EDITORIAL BOARD

Chairman : Air Marshal R Vaidya, VSM

Director General Medical Services (Air)

Chief Editor : Brig Vijay Kumar Bhatti

Professor and Head, Department of Community Medicine
Armed Forces Medical College, Pune

Associate Editor : Col Harpreet Singh

Associate Professor, Department of Community Medicine
Armed Forces Medical College, Pune

Technical Editor : Col Swati Bajaj

Professor, Department of Community Medicine
Armed Forces Medical College, Pune

Joint Editors : Col DS Faujdar

Commanding Officer, 329 Field Hospital
Ex Professor, Department of Community Medicine
Armed Forces Medical College, Pune
Surg Capt Saurabh Bobdey
Professor, Department of Community Medicine
Armed Forces Medical College, Pune

Editorial Assistants : Sqn Ldr Surjit Singh Gangwar, Resident, Department of Community Medicine
Armed Forces Medical College, Pune
Sqn Ldr Priyanka Sharma Michael, Resident, Department of Community Medicine
Armed Forces Medical College, Pune
Maj Chandan K Panigrahi, Resident, Department of Community Medicine
Armed Forces Medical College, Pune
Maj Needhi Rana, Resident, Department of Community Medicine
Armed Forces Medical College, Pune
Maj Manish Kumar, Resident, Department of Community Medicine
Armed Forces Medical College, Pune
Sqn Ldr Aditya Pasumarthy, Resident, Department of Community Medicine
Armed Forces Medical College, Pune

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 CONTRIBUTORS
Authors and Reviewers from Department of Community Medicine
Air Vice Marshal Renuka Kunte Dr (Mrs) Rina Tilak
Principal Medical Officer, Scientist ‘G’ (Entomology) (Retd),
Maintenance Command, Indian Air Force Department of Community Medicine,
Ex Professor and Head, Department of Community Medicine Armed Forces Medical College, Pune
Armed Forces Medical College, Pune
Mr Dashrath R Basannar
Brig SK Kaushik Scientist ‘F’ (Biostatistics) (Retd),
Deputy Commandant, Command Hospital (NC) Department of Community Medicine,
Ex Professor and Head, Department of Community Medicine Armed Forces Medical College, Pune
Armed Forces Medical College, Pune
Dr Seema R Patrikar
Col Saibal Adhya (Retd) Senior Lecturer (Biostatistics & Demography),
Ex Professor, Department of Community Medicine Department of Community Medicine,
Armed Forces Medical College, Pune Armed Forces Medical College, Pune
Surg Capt Shabeena Tawar Mr Ankit
Professor, Department of Community Medicine, Scientist ‘C’,
Armed Forces Medical College, Pune Department of Community Medicine,
Col Chetna Arora Armed Forces Medical College, Pune
Associate Professor, Department of Community Medicine, Maj Mandeep Kaur
Armed Forces Medical College, Pune Ex Clinical Tutor,
Col Ayon Gupta Officer Commanding,
Assistant Professor, Department of Community Medicine, Station Health Organization, Ambala
Armed Forces Medical College, Pune Maj Sumeet Singh
Wg Cdr Amol Dileep Nath Clinical Tutor,
Assistant Professor, Department of Community Medicine, Department of Community Medicine,
Armed Forces Medical College, Pune Armed Forces Medical College, Pune

Authors and Reviewers from Other Units of Armed Forces Medical Services

Brig Kunal Chatterjee Col Puja Dudeja, VSM

Brigadier (Medical), Food Inspections, Colonel Medical (PS), Office of Director General Medical
Office of Quarter Master General, IHQ of MoD (Army) Services (Army), IHQ of MoD (Army)
Surg Cmde Saugat Ray Surg Capt Kiran Maramraj
Principal Medical Officer, Naval Dockyard, Mumbai Captain Medical Services (Health),
Office of Director General Medical Services (Navy)
Brig Vani Suryam
Commandant Military Hospital, Ahmednagar Gp Capt Nilakantan Anand
Deputy Principal Medical Officer,
Brig Vikram S Grewal
South-Western Air Command, Indian Air Force
On NDC Course, Ex Deputy Assistant Chief Integrated
Defence Staff (Medical), Headquarters Integrated Col Seema Sharma
Defence Staff Senior Registrar & Officer Commanding Troops,
151 Base Hospital
Gp Capt Manohar Dutt
Group Captain Medical Services (Health), Col Ravi Nimonkar
Office of Director General Medical Services (Air) Officer Commanding,
Station Health Organization, Pune
Col Shubhodeep Ghosh, VSM
Colonel Armed Forces Medical Services (Health), Lt Col Vipra Mangla
Office of Director General Armed Forces Medical Services, Officer Commanding,
Ministry of Defence, New Delhi Station Health Organization, Lucknow

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Surg Cdr Kaushik Roy Wg Cdr Aniket A Kulkarni
Commander (Medical Staff) Health, Senior Medical Officer, 11 Wing, Tezpur
Office of Director General Medical Services (Navy)
Lt Col Manjunath SR
Lt Col Kapil H Pandya Deputy Assistant Director Health, 54 Infantry Division
Assistant Director Health, Dakshin Bharat Area
Maj Ayush Khajuria
Lt Col Shilpa Katoch Officer Commanding,
AAG, Armed Forces Medical Services (Health),
85 Field Health Organization
Office of Director General Armed Forces Medical Services,
Ministry of Defence, New Delhi Sqn Ldr Mayuri Verma
Lt Col V Mopagar Officer in Charge,
Technical Editor, Medical Journal Armed Forces India Station Health Organization, 2 Wing, Lohegaon

Wg Cdr Gurpreet Singh Maj Suraj Kapoor

Senior Medical Officer, 28 Wing, Hindon Deputy Asst Director Health, 33 Armoured Division

CONTRIBUTORS
Authors and Reviewers from Sister Departments and Institutes
Brig ID Roy Surg Cdr Gurpreet Kaur
Deputy Commandant, Command Military Dental Centre, Associate Professor, Department of Pathology,
Lucknow Armed Forces Medical College, Pune
Col Sameer Mehrotra Lt Col SN Panda
Senior Advisor (Hosp Adm), Army Hospital, Associate Professor, Department of Psychiatry,
Research & Referral Armed Forces Medical College, Pune
Col Kanwaljit Kaur Lt Col Aditya Pawar
Classified Specialist (Path & Micro), Assistant Professor, Department of Surgery,
Base Hospital, Delhi Cantt Armed Forces Medical College, Pune
Lt Col Deepti Sahran Lt Col Kundan Tandel
Associate Professor, Department of Hospital Administra- Professor, Department of Microbiology,
tion, Armed Forces Medical College, Pune Armed Forces Medical College, Pune

ASSISTANTS
Residents of Department of Community Medicine
Surg Cdr Ajith Mohan Maj Suman Chatterjee
Surg Lt Cdr Pooja Maj Amreen Begum
Sqn Ldr Rahul Nayak Sqn Ldr Ashita Mathur
Maj Jyoti Arya Sqn Ldr Damini
Sqn Ldr Apoorva Vineeth Dsouza Maj Manu Mohan
Maj Siddartha Tekuru Maj Onam Gupta
Maj Kiran B Rajput Dr (Maj) Shekhar D Bajpayee
Maj Barinderjot Kaur Dr Aditi Yadav
Surg Lt Cdr Robinson V Thomas Dr Mitesh Modi

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 ABBREVIATIONS

ABC-AR Animal Birth Control and Anti rabies AMC Army Medical Corps

ABER Annual Blood Examination Rate AMDR Acceptable Macronutrient Distribution

Range
ABPMJAY Ayushman Bharat Pradhan Mantri Jan
Arogya Yojana AME Annual Medical Examination

ABSULS ASHA based Surveillance for Leprosy AMS Acute Mountain Sickness
Suspects ANM Auxiliary Nurse Midwife
ACF Active Case Finding ANMOL Auxiliary Nurse Midwife On Line
ACO AIDS Control Organization ANTU Alpha-Naphthyl Thio Urea

ACP AIDS Control Programme AOD Anganwadi on Demand

ADS Alcohol Dependence Syndrome APC Armoured Personnel Carrier

ADS Advanced Dressing Stations APHA American Public Health Association

AEFI Adverse Events Following Immunization API Annual Parasite Incidence

APT Alum Precipitated Toxoid

AFB Acid Fast Bacilli
ARB Angiotensin Receptor Blockers
AFCESC Armed Forces Central Epidemiological
Surveillance Center ARI Acute Respiratory Infections

AFD Accelerated Freeze Dried ARSH Adolescent Reproductive and Sexual

Health Programme
AFHSC Armed Forces Health Sub Committee
ARWSP Accelerated Rural Water Supply
AFI Annual Falciparum Incidence Programme

AFMRC Armed Forces Medical Research ASC Army Service Corps

Committee
ASHRAE American Society for Heating,
AFMS Armed Forces Medical Services Refrigerating and Air-conditioning
Engineers
AFMSF Armed Forces Medical Services Form
ASI Air Staff Instructions
AGS Anti-G Suit
AT Animal Transport
AGSM Anti-G Straining Manoeuvre
ATA Atmosphere Absolute
AHR Army Health Regulation ATC Air Traffic Control
AIDC Apex Immunodeficiency Centres ATS Anti Tetanus Serum
AIDS Acquired Immunodeficiency Syndrome ATV All Terrain Vehicles

AMA Authorised Medical Attendant AUA Aid Under Attack

AMB Attributability Medical Board AUFI Acute Undifferentiated Febrile Illness

AMB Anaemia Mukt Bharat AWW Anganwadi Worker

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AZT Zidovudine CDSCO Central Drugs Standard Control
Organization
BCC Behaviour Change Communication
CEB Crisis Expansion Beds
BFNA Battlefield Nursing Assistants
CLIA Chemiluminescence Immunoassay
BGT Black Globe Thermometer
CLL Central Light Loss
BMR Basal Metabolic Rate
CMO Chief Medical Officer
BMW Bio Medical Waste
CMS Chronic Mountain Sickness
BOD Biochemical Oxygen Demand
CNS Central Nervous System
bOPV bivalent Oral Polio Vaccine
CO Commanding Officer
BP Blood Pressure
COD Chemical Oxygen Demand
BPET Battle Physical Efficiency Test
COPRA Consumer Protection Act
BPL Beta-Propio Lactone
COTPA Prohibition of Advertisement and
BSA Bile Salt Agar Regulation of Trade and Commerce,
Production, Supply and Distribution
BSR Basic Four Hour Sweat Rate
CP Car Post
BURP Backward-Upward-Rightward Pressure
CP Continuation Phase
BV Biological Value
CPCB Central Pollution Control Board
CAD Coronary Artery Disease
CRESS Consciousness level, Respiratory
CBMWTF Common Bio-Medical Waste Treatment
pattern, Eyes, Secretions and Skin
Facility
CS Campbell-Stokes
CBRN Chemical, Biological, Radiological and
Nuclear CSF Cerebrospinal Fluid
CBRNE Chemical, Biological, Radiological and CSIR Council of Scientific and Industrial
Nuclear Explosives (E) Research
CBT Cognitive Behaviour Therapy CTF Colarado Tick Fever
CBWTF Common Biomedical Waste Treatment CUF Care Under Fire
Facility
CVT Cerebral Venous Thrombosis
CCB Calcium Channel Blockers
CVT Continuous Vaccination Teams
CCHF Crimean Congo Haemorrhagic Fever
CWMI Composite Water Management Index
CCP Casualty Collection Point
DALY Disability Adjusted Life Year
CCPA Central Consumer Protection Authority
DAT Department of Aviation Toxicology
CCV Cell Culture Vaccines
DB Dry Bulb
CDC Centers for Disease Control
DBT Dry Bulb Temperature
CDL Clean Dirty Line
DBT Direct Benefit Transfer
CDRC Consumer Disputes Redressal
Commission DCI Decompression Illness

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DCS Decompression Sickness ECLSS Environmental Control and Life
Support System
DDT Dichlorodiphenyltrichloroethane
ECS Environmental Control System
DDWS Department of Drinking Water Supply
EEE Eastern Equine Encephalitis
DEET N,N-diethyl-meta-toluamide
EIA Enzyme Immuno Assays
DEIC District Early Intervention Centre
ELISA Enzyme Linked Immunosorbent Assay
DEPA Diethyl Phenyl Acetamide
EM Electro-Magnetic
DFA Direct Fluorescent Antibody Assay
EMT Emergency Medical Treatment
DFS Double Fortified Salt
ENAP Every Newborn Action Plan
DGAFMS Director General Armed Forces Medical
Services EPR Extended Producer Responsibility

DGST Director General of Supplies and EPRP Emergency Preparedness and

Transport Response Plans

DH District Hospital EPS Expanded Poly Styrene foam

DHF Dengue Haemorrhagic Fever EPT Effective Performance Time

DHMOSH Division of Health Management and EPTB Extra Pulmonary Tuberculosis

Occupational Safety and Health
ER Extraction Rate
DIAAS Digestible Indispensable Amino Acid
Score ERIG Equine Rabies Immunoglobulin

DLHS District Level Household Surveys ESI Employees’ State Insurance Act

DMA Disaster Management Act ESIC Employees State Insurance Corporation

ET Eustachian Tube
DOTS Directly Observed Treatment Short
course ET Endotracheal Tube
DPT Diphtheria, Pertussis and Tetanus ETS Exposure to Toxic Substances
DRDO Defence Research & Development EVA Extra Vehicular Activity
Organization
EVD Ebola Virus Disease
DT Diphtheria Tetanus
EWC European Water Closet
DTL Deep Trench Latrine
FDA Food and Drug Administration
DTP Diphtheria–Tetanus–Pertussis
FEMS Fast Erectable Modular Shelters
DVT Deep Vein Thrombosis
FHTC Functional Household Tap Connection
EAA Essential Amino Acids
FIDC First Line Immunodeficiency Centres
EAR Estimated Average Requirement
FIVE Familial Isolated Vitamin E
ECC Extreme Climatic Condition
FMO Force Medical Officer
ECG Electrocardiography
FRU First Referral Units
ECL Electrochemiluminescence
Immunoassay FSC Forward Surgical Center

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FSD Focus patient Surface Distance HBO Hyperbaric Oxygen

FSO Food Safety Officer HBOT Hyper-Baric Oxygen Therapy

FSSAI Food Safety and Standards Authority HBV Hepatitis B virus

of India
HCW Health Care Workers
FSW Female Sex Workers
HDCV Human Diploid Cell Vaccine
FT Formal Toxoid
HDL High Density lipoprotein
FW Forced Whisper
HEICS Hospital Emergency Incident Command
FWC Family Welfare Centres System

FWEE Family Welfare Extension Educator HHV Human Herpes Virus

GATS Global Adult Tobacco Survey HI House Index

GAVI Global Alliance for Vaccines and HIV Human Immuno deficiency Virus
Immunizations
HL Health Literacy
GEB Gum Elastic Bougie
HMIS Health Management Information
GFATM Global Fund to fight AIDS, Tuberculosis System
& Malaria
HMOD Hypertension Mediated Organ Damage
GII Gender Inequality Index
HMP Hexose Mono Phosphate
GISRS Global Influenza Surveillance and
HPHC High Performance Human Centrifuge
Response System
HPNS High Pressure Nervous Syndrome
GMO Guide to Medical Officers
HPS High Performing States
GRP Glass Fibre Reinforced Plastic
HPV Human Papilloma Virus
GSW Gun Shot Wounds
HRC Health Record Card
GUD Genital Ulcer Disease
HRG High Risk Groups
GWG Gestational Weight Gain
HRI Heat Related Illness
HAA High Altitude Area
HRIG Human Rabies Immunoglobulins
HACE High Altitude Cerebral Edema
HSV Herpes Simplex Virus
HADR Humanitarian Assistance and Disaster
Relief HTH High Test Hypochlorite
HAI High Altitude Illness HVA Hazard Vulnerability Analysis
HAPE High Altitude Pulmonary Edema HVR Hypoxic Ventilatory Response
HAPH High Altitude Pulmonary Hypertension HZ Herpes Zoster

HAPO High Altitude Pulmonary Oedema IAF Indian Air Force

HAV Hepatitis A Virus IAM Institute of Aerospace Medicine

HBI Human Blood Index ICAO International Civil Aviation Organization

HBIG Hepatitis B Immunoglobulin ICD International Classification of Diseases

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ICDS Integrated Child Development Service IRSR Interim Reference Sunshine Recorder

ICMR Indian Council of Medical Research ISAS International Standard Atmospheric

Scale
ICRU International Commission on Radiation
Units ITBN Insecticide Treated Bed Nets

IDC Immunodeficiency Centres IVM Integrated Vector Management

IDD Iodine Deficiency Disorders IVR Interactive Voice Response

IDS Integrated Defence Staff IYCF Infant and Young Child Feeding

IDSP Integrated Disease Surveillance JE Japanese Encephalitis

Programme
JJM Jal Jeevan Mission
IDU Injecting Drug Users
JSSK Janani Shishu Suraksha Karyakram
IEC Information, Education and
Communication JSY Janani Suraksha Yojana

IED Improvised Explosive Devices KE Kinetic Energy

IFA Immunofluorescence Assay KFD Kyasanur Forest Disease

IFA Iron and Folic Acid KIA Killed in Action

IFG Impaired Fasting Glucose LAIV Live Attenuated Influenza Vaccine

IGT Impaired Glucose Tolerance LARES Large Analysis and Review of

European housing and health Status
IHD Ischemic Heart Disease
LDL Low Density Lipoproteins
IHR International Health Regulations
LF Lymphatic Filariasis
ILI Influenza-like Illness
LHV Lady Health Visitor
ILMA Intubating Laryngeal Mask Airway
LIC Low Intensity Conflicts
ILR Ice Lined Refrigerator
LLIN Long Lasting Insecticide Nets
IMB Invaliding Medical Board
LMA Laryngeal Mask Airway
IMEP Intensified Malaria Elimination Project
LMC Low Medical Category
IMNCI Integrated Management of Neonatal
and Childhood Illness LOC Line of Control

IN Indian Navy LPS Low Performing States

INAP India Newborn Action Plan LSI Life Saving Interventions

INBR Indian Naval Book of Reference LSM Larval Source Management

INSTI Integrase Strand Transfer Inhibitor LSS Life Support System

IP Intensive Phase LTBI Latent Tuberculosis Infection

IPE Individual Protective Equipment MAA Mother’s Absolute Affection

IPV Inactivated Polio Vaccine MARPOL Marine Pollution

IRS Indoor Residual Spray MB Multibacillary

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MBBR Moving Bed Biofilm Reactor MSW Municipal Solid Waste

MBR Membrane Bioreactor MT Mechanical Transport

MBT Mean Body Temperature MTP Medical Termination of Pregnancy

MC Motor Cycle MUFA Monounsaturated Fatty Acids

MCTS Mother and Child Tracking System MVA Manual Vacuum Aspiration

MDA Mass Drug Administration MVE Murray Valley Encephalitis

MDR Multidrug Resistant NA Nursing Assistants

MDT Multi Drug Therapy NAAT Nucleic Acid Amplification Test

MEA Monoethanolamine NACO National AIDS Control Organisation

MES Military Engineering Services NACP National AIDS Control Programme

MET Metabolic Equivalent NAPDDR National Action Plan for Drug Demand
Reduction
MF Microfiltration
NBC Nuclear Biological and Chemical
MIP M. Indicus Pranii
NBCC Newborn Care Corners
MISO Management Information System
Organization NBCD Nuclear Biological Control Defence and
Damage Control
MJ Mega Joule
NBSU Newborn Stabilisation Unit
MMDP Morbidity Management and Disability
NCB Narcotics Control Bureau
MO Medical Officer
NCCMIS National Cold Chain Management
MODS Multiple Organ Dysfunction Syndrome Information System

MOHFW Ministry Of Health and Family Welfare NCD Non Communicable Diseases

MOPP Mission Oriented Protective Posture NCDC National Centre for Disease Control

MPL Monophosphoryl lipid A NDMA National Disaster Management

Authority
MPN Most Probable Number
NDRF National Disaster Response Force
MPW Multipurpose Workers
NDWM National Drinking Water Mission
MR Measles-Rubella
NEA Non Enemy Action
MRE Meal, Ready-to-Eat
NEC National Executive Committee
MRSF Measles and Rubella Strategic
Framework NEERI National Environmental Engineering
and Research Institute, Nagpur
MRT Milk Ring Test
NF Nanofiltration
MSAC Medical Services Advisory Committee
NFME National Framework for Malaria
MSL Mean Sea Level Elimination
MSM Men having Sex with Men NGS Next Generation Sequencing
MST Mean Skin Temperature NGT National Green Tribunal

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NHE Nutrition and Health Education OCV Oral Cholera Vaccine

NHM National Health Mission ODF Open Defecation Free

NIAD Noise Induced Acoustic Disorders OEF Operation Enduring Freedom

NID National Immunization Day OFWS Organophosphate Fluoride Wormer

NIHL Noise Induced Hearing Loss OFWST Outfit Water Sterilizing Tablets

NIN National Institute of Nutrition OGA Oxygen Generation Assembly

NIS National Immunization Schedule OIF Operation Iraqi Freedom

NITI National Institution for Transforming OPTRAM OPerational Training in Aerospace

India Medicine

NLCP National Leprosy Control Programme OR Other Ranks

NLEP National Leprosy Eradication ORS Oral Rehydration Solution

Programme
ORT Oral Rehydration Therapy
NMBA Nasha Mukt Bharat Abhiyaan
OSHA Occupational Safety and Health
NOK Next Of Kin Administration

NPA Nasopharyngeal Airway OT Orthotolidine Test

NPHCE National Programme for the Health OTA Orthotolidine Arsenite Test
Care for the Elderly OTC Over the Counter
NPPMTBI National Programme for Prevention OVP Open Vial Policy
And Management of Trauma and Burn
Injuries PA Public Address

NPU Net Protein Utilization PAC Polyaluminium Chloride

NPY Nikshay Poshan Yojana PAH Polycyclic Aromatic Hydrocarbons

NRC Nutritional Rehabilitation Centre PAHO Pan American Health Organization

NRDWP National Rural Drinking Water PAIR Puncture, Aspiration, Injection, Re-
Programme aspiration

NSAIDS Non-Steroidal Anti-Inflammatory Drugs PAL Physical Activity Level

NSDP National Skill Development Program PAR Physical Activity Ratio

NSP National Strategic Plan PAWS Pain management Antibiotics Wounds

Splinting
NTCP National Tobacco Control Programme
PB Paucibacillary
NTEP National Tuberculosis Elimination
Programme PCECV Purified Chick Embryo Cell Vaccine

NTU Nephelometric Turbidity Units PCPNDT Pre Conception and Pre-Natal

Diagnostic Techniques (Prohibition of
NTV Neural Tissue Vaccine Sex Selection) Act

NUDWM National Urban Drinking Water Mission PCR Polymerase Chain Reaction

NVD Night Vision Devices PCV Pneumococcal Conjugate Vaccine

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PDEV Purified Duck Embryo Vaccine PVA Polyvinyl Isopropyl Alcohol

PDK Personal Decontamination Kits PVRV Purified Vero Cell Rabies Vaccine

PEL Permissible Exposure Limit PWT Peptone Water Tellurite

PEP Post-Exposure Prophylaxis QF Quality Factor

PFU Plaque Forming Unit QMG Quartermaster General

PHVO Partially Hydrogenated Vegetable Oil QRMT Quick Reaction Medical Teams

PID Pelvic Inflammation RABV Rabies Virus

PKDL Post Kala azar Dermal Leishmaniasis RAMB Re-assessment Medical Board

PLHIV Persons Living with HIV RAP Regimental Aid Post

PLL Peripheral Light loss RAT Rapid Antigen Testing

PMAY-G Pradhan Mantri Awas Yojna - Gramin RBE Relative Biological Effectiveness

PMB Periodic Medical Board RBP Retinol Binding Protein

PME Periodic Medical Examination RBSK Rashtriya Bal Swasthya Karyakram

PMMVY Pradhan Mantri Matru Vandana Yojana RCA Riot Control Agents

POW Prisoner of War RCH Reproductive and Child Health

PPB Positive Pressure Breathing RDA Recommended Dietary Allowance

PPE Personal Protective Equipment RDF Refuse Derived Fuel

PPGI Pre-painted GaIvnized Iron sheet RDT Rapid Diagnostic Tests

PPP Public Private Partnerships RGSEAG Rajiv Gandhi Scheme for

Empowerment of Adolescent Girls
PRAI Planning, Research and Action Institute
RH Relative Humidity
PRO Public Relations Officer
RIG Rabies Immunoglobulin
PRPMAT Performance Related Post-Mortem
Aviation Toxicology RKSK Rashtriya Kishor Swasthya Karyakram

PSP Personal Survival Packs RMB Release Medical Board

PST Proportionate Sensitivity Testing RME Release Medical Examination

PTAH Purified Toxoid Aluminium Hydroxide RMNCAH Reproductive, Maternal, Newborn,

Child, Adolescent Health “Plus”
PTAP Purified Toxoid Aluminium Phosphate Nutrition Strategy

PTB Pulmonary Tuberculosis RMNCH Reproductive, Maternal, New-born,

Child and Adolescent Health
PTE Pulmonary Thromboembolism
RMO Regimental Medical Officer
PTSD Post Traumatic Stress Disorder
RMSAF Regulations for the Medical Services
PUD Peptic Ulcer Disease for the Armed Forces
PUF Polyurethane Foam RMSF Rocky Mountain Spotted Fever
PUFA Polyunsaturated Fatty Acids RNA Ribonucleic Acid

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RNP Ribonucleoprotein SMR Sterile Male Release

RNTCP Revised National Tuberculosis Control SNHL Sensory Neural Hearing Loss
Programme
SOD Super Oxide Dismutase
RO Reverse Osmosis
SOP Standing Operating Procedures
RPR Rapid Plasma Reagin
SPIT Sedate, Paralyze, Intubate and then
RR Rifampicin Resistance Transported

RRT Rapid Response Team SPR Slide Positivity Rate

RSBY Rashtriya Swasthya Bima Yojana SR Sweat Rate

RSI Rapid Sequence Intubation SRP Sector to Reform Project

RSMB Re-survey Medical Board SRS Scales of Rations and Supplies

RT Radio-Telephone SS Stainless Steel

RTA Road Traffic Accidents SSPE Subacute Sclerosing Panencephalitis

RTPCR Reverse Transcriptase Polymerase STD Sexually Transmitted Disease

Chain Reaction
STH Soil Transmitted Helminth
RVC Remount Veterinary Corps
STI Sexually Transmitted Infections
RW Rideal-Walker phenol coefficient
STITC Sexually Transmitted Infections
SAGE Strategic Advisory Group of Expert Treatment Centre

SAMS Sub Acute Mountain Sickness SWM Solid Waste Management

SAR Search and Rescue SY Sieverts

SARI Severe Acute Respiratory Infections TACO Tarpaulin Assisted Cooling Oscillation

SAS Space Adaptation Syndrome TAF Toxoid Antitoxin Flocculus

SBM Swachh Bharat Mission TB Tuberculosis

SBP Systolic Blood Pressure TBE Tick Borne Encephalitis

SCBA Self Contained Breathing Apparatus TCCC Tactical Combat Causality Care

SD Spatial Disorientation TCV Typhoid Conjugate Vaccine

SDG Sustainable Development Goals TDF Tenofovir Disoproxil Fumarate

SDR Single Dose Rifampicin TDS Total Dissolved Solids

SEAR South East Asian Region TEE Total Energy Expenditure

SEMO Senior Executive Medical Officer TEFS Tent Extendable Frame Supported

SES Socioeconomic Status TFR Total Fertility Rate

SFA Saturated Fatty Acids TG Transgender

SLAC Sparsh Leprosy Awareness Campaign THM Trihalomethanes

SMO Senior Medical Officer TIC Toxic Industrial Chemicals

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TIG Tetanus Immunoglobulin VL Visceral Leishmaniasis

TLR Toll Like Receptor VOC Variant Of Concern

TOT T.O. Thompson VOI Variant Of Interest

TPP Thiamine Pyro Phosphate VR Venkatraman-Ramakrishnan

TPT Tuberculosis Preventive Therapy VT Venous Thrombosis

TRT Taste Removing Tablets VUM Variant Under Monitoring

TSH Thyroid Stimulating Hormone VVM Vaccine Vial Monitor

TST Tuberculin Skin Test VZIG Varicella Zoster Immune Globulin

TTCV Tetanus Toxoid Containing Vaccine WASH Water, Sanitation and Hygiene

TUC Time of Useful Consciousness WB Wet Bulb

TWA Time Weighed Average WBGT Wet-Bulb Globe Temperature

TXA Tranexamic Acid WC Whole-Cell Only Vaccines

UF Ultrafiltration WHA World Health Assembly

UHC Universal Health Coverage WHO World Health Organization

UIP Universal Immunization Program WIFS Weekly Iron and Folic acid
Supplementation
ULB Urban Local Bodies
WMD Weapon of Mass Destruction
ULN Upper Limits of Normal
WMO World Meteorological Organization
ULV Ultra Low Volume
WN West Nile
UN United Nation
WP White Phosphorus
UNHCR United Nations High Commissioner for
Refugees WPA Water Processor Assembly

UNICEF United Nations International Children’s WPDK Water Poison Detection Kit
Emergency Fund
WPV Wild Poliovirus
UPA Urine Processor Assembly
WRD WHO Recommended Rapid Diagnostic
US United States Test

UT Union Territories WSP Water Sterilizing Powder

UV Ultraviolet WWCP Walking Wounded Collection Post

VBD Vector Borne Diseases YEP Yaws Eradication Programme

VBM Variants Being Monitored n

VDRL Venereal Disease Research Laboratory

VDU Video Display Units

VE Vaccine Effectiveness

VHSNC Village Health Sanitation and Nutrition

Committees

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 LIST OF TABLES IN RED BOOK

Table
Chapter Title Page No.
No.
Section I - Introduction to Military Health
1.1 Historical Trend of Morbidity Due to Communicable & Non-Communicable 5
Diseases
1.2 Leading Causes of Morbidity in Armed Forces (2020) 6
1.3 Leading Causes of Mortality in Armed Forces (2020) 6
1.4 Disease Burden of COVID-19 among Armed Forces Personnel in 2020 11
I
1.5 Decadal Trend in Hospital Admissions for Injuries Due to Non-Enemy-Action 12
(Rates Per 1,000)
1.6 Breakdown of Battle & Non-Battle Casualties in Past Conflicts (Annual Rates 12
Per 1,000)
1.7 Decadal Hospital Admission Rates – All Causes (Rates Per 1,000) 13
2.1 Pollutants, Their Source and Their Impact on Health 16
2.2 Single Living Accommodation for Service Officers and Nursing Officers 21
2.3 Single Living Accommodation for JCOs, NCOs or / and Their Equivalents in 21
Other Services and NCS (E) of IAF
II
2.4 Married and Separated Family Accommodation for Service Officers and 23
Nursing Officers
2.5 Married and Separated Family Accommodation for JCOs, Havildars or / and 24
Their Equivalent in Other Services
3.1 Approximate Ranges of Thermal Insulation Values of the Three Components of 30
Thermal Barrier Between Human Body and its Surroundings
3.2 Metabolic Rates for Various Activities 31
III 3.3 Clothing Insulation (Clo) Required for Prolonged Comfort in Outdoor Exposure 32
to Dry Cold
(Sun 45° from Zenith)
3.4 Physical Requirements of Clothing under Various Climatic Conditions 39
IV — — —
V 5.1 Characteristics of Deep Well and Shallow Well 54
5.2 Pollutants of Water 58
5.3 Disease Related to Water Supply Caused by Biological Agents 58
5.4 Rapid and Slow Sand Filters 65
5.5 Classification of Hardness of Water 75
5.6 Bacteriological Quality of Drinking Water 83
5.7 Drinking Water Specifications : Bureau of Indian Standards. 84
5.8 Sample of Water and their Interpretation 85
5.9 Poisons in Water and their Detection Limit 86
5.10 Comparison of Ordinary and Field Methods 90
5.11 Colony Counts in Water 91
5.12 Personnel for Water and Sanitation Duties 95

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 Table
Chapter Title Page No.
No.
5.13 Scale of Water Consumption (Liters Per Head Per Day) 102
Section II - Environments Specific to Armed Forces: Health Hazards, Diseases and Prevention
6.1 Relative Humidity (Percent) 118
6.2 Relative Humidity (Percent) 119
VI 6.3 Wavelength of Various Component Rays in The Solar System 128
6.4 Altitude, Pressure, Temperature, Oxygen, Partial Pressure and Equivalent 150
Oxygen Percentage
VII 7.1 Commonly Observed Health Problems among Troops During Movement 158
VIII — — —
IX 9.1 Oxygen Recompression Therapy (For Mild Cases) 181
9.2 Oxygen Recompression Therapy (For Severe Cases) 182
9.3 Air Diving Table 182
9.4 Modified Air Recompression Therapy 187
9.5 Symptoms of Carbon Monoxide (CO) Poisoning 188
X 10.1 Adult Water Requirement As Per Temperature 207
XI 11.1 Pressure, Density and Temperature Variations in the Atmosphere 211
11.2 Acceptable G Tolerance Standard for PLL, CLL and LOC 216
11.3 Equations Used for Determining the Time of Decompression 225
11.4 Stages of Hypoxia with PaO2 (mm Hg) and Percentage Saturation of 229
Haemoglobin
11.5 Clinical Features of Hypoxia during Disturbance Stage 230
11.6 Equivalent Lung Altitudes 231
11.7 TUC at Different Altitude 232
11.8 Supplemental Oxygen Requirements at Altitude to MaintainSea Level Air 233
Equivalence
11.9 PRICE Checklist 234
11.10 Values for Alveolar Gas Compositions 242
11.11 Anthropometric Range for Aircrew Aircraft Compatibility 254
11.12 Specimens for Toxicological / Biochemical Examination 259
11.13 Permissible Noise Exposure Limit (NIOSH). Combinations of Noise Exposure 265
Levels and Durations That No Worker Shall Equal or Exceed
11.14 Casualty Classification 267
11.15 Casualty Carrying Capacity of Various IAF Aircrafts 279
XII 12.1 Meteorological Parameters 285
XIII 13.1 Environmental Stressors at High Altitude 287
13.2 Comprehensive List of Altitude-Related Medical Problems 288
13.3 Lake Louise Scoring System 290
13.4 Clinical Diagnosis of HAPE 294
13.5 Grades of HAPE 294
13.6 Acclimatization Schedule for High Altitude 300
XIV 14.1 International System of Units 305
14.2 Acute Whole-Body Exposure 307
14.3 Triage Categories in The CBRN Scenario 326

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14.4 Abbreviated ‘Quick Look’ For Selected CBRN Agents and Drugs 327
XV 15.1 Permissible Exposure Limit (Pel) of Gases and Vapours (Factories Act 1948 as 340
Amended 2016)
15.2 (a) Aetiology of Industrial 341
(b) Prevention of Industrial Accidents 342
15.3 Categories of Lead Absorption 346
15.4 Manifestation of Lead Poisoning 346
15.5 Method of Dust Control 356
15.6 Prevention of Occupational Cancer 358
15.7 Personal Protective Equipment 362
Section III - Waste Disposal in Armed Forces Environment
XVI — — —
XVII 17.1 Classification of Biomedical Waste 416
17.2 Categories of Biomedical Waste & Their Disposal 417
17.3 Organizational Set up of Bio-Medical Waste Mgt in Armed Forces 419
Section IV - Nutrition and Food Safety
XVIII 18.1 Summary of RDA for Indians- ICMR-NIN, 2024 (Source: RDA and EAR, Report 444
of Expert Group, NIN (ICMR) 2020, updated 2024)
18.2 Major Sources of Proteins and Their Protein Contents (g / 100 g) 445
18.3 RDA and EAR for Proteins 446
18.4 Fat Content in Various Food Sources 447
18.5 Approximate Fatty Acid Contents of Common Oils (g / 100 g) 448
18.6 Recommendations of Dietary Fat Intake in Indians 450
18.7 Major Sources of Carbohydrates (Per 100 g) 451
18.8 Major Food Sources of Fiber 453
18.9 Dietary Fiber Content of Common Foods 454
18.10 Vitamin Content of Selected Food Items (per 100 gms) 460
18.11 Comparative Summary of Different Vitamins 460
18.12 Cutoff Llevels for Diagnosis of Anaemia 463
18.13 Functions, RDA, EAR, Deficiency and Sources of Various Macrominerals 467
18.14 Equations for Calculating BMR (kcal / 24hr) 469
18.15 Computation of Energy Expenditure of an Adult Indian Population 469
18.16 (a) Energy Requirements of Indian Men, Women at Different Ages, Body 470
Weights and Activities (Source: RDA and EAR, Report of Expert Group, NIN
(ICMR) 2020, updated 2024)
(b) Energy Requirements of Indian Women at Different Ages, Body Weights 471
and Activities to Maintain Normal BMI
18.17 Energy Requirements of Reference Indian Man and Woman 473
18.18 Estimation Of Fluid Requirements for Indian Troops Based on Their Energy 473
Expenditure under Different Environments and Training
18.19 Fluid Replacement And Work / Rest Guidance for Warm Weather Training 474
Conditions and Refill Frequency for 3l Collapsible Drink System

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18.20 Percent Total Energy From Different Macronutrients Acceptable Macronutrient 475
Distribution Range (AMDR)
18.21 Balanced Diet for Sedentary Man 476
18.22 Balanced Diet for Moderately Active Man 477
18.23 Balanced Diet for Sedentary Woman 478
18.24 Balanced Diet for Moderately Active Woman 479
XVIX 19.1 Constituents of Flour of Different Percentages of Extraction 485
(Values in Per 100 gms)
19.2 Examples of Food Fortification 492
19.3 For Children, the Following Scales are Adopted 494
XX 20.1 Diseases Conveyed Through Milk 519
Section V - Healthcare in Armed Forces
XXI 21.1 The Relevant Army / Navy / Air Force Orders Give the Desirable Weights for 571
Various Ages and Heights for Men & Women
21.2 FWCs - Classification, Staffing Pattern and Services Offered 573
XXII 22.1 Venue, Investigations and Schedule of AME in Army 588
22.2 Age-wise Schedule of AME for Officers and Sailors 588
22.3 Timing of AME 589
22.4 Age-wise Schedule of PME in Army and Navy 590
22.5 Approving and Perusing Authorities for PME of Army Officers and JCOs 591
22.6 Medical Classification System in Armed Forces 592
22.7 Equivalence of Medical Categorisation system in Armed Forces 592
22.9 Medical Classification System: Navy (Auth: Para 22 of NO 7 / 2014) 592
22.8 Medical Classification System: Air Force (Auth: IAP 4303 5th Ed) 593
22.10 Grades Based on the Functional Capability 595
22.11 SHAPE Classification System for Medical Categories for Officers 595
22.12 Examples of LMC and Disability Profile 597
22.13 COPE Coding Matrix 598
22.14 SHAPE Classification System and Employability Restrictions for JCOs / OR 599
22.15 Approving and Perusing Authority for Classification / Re-Classification Medical 602
Board of Officers
22.16 Competent Authority to Grant Sick Leave to Officers of Army 604
22.17 Competent Authority for Providing Sanction for Delayed AME for Officers 606
22.18 Competent Authority for Providing Sanction for Delayed PME for Officers 606
22.19 Competent Authority for Sanctioning Delayed AME / PME / Re-Classification 607
Medical Board for JCOS / OR
22.20 COPE Coding for Diabetes Mellitus 609
22.21 COPE Coding for officers with Hypothyroidism. 609
22.22 COPE Coding for Officers with Hypertension 609
22.23 LMC and COPE Coding for Officers with Backache, PIVD, Spondylosis, Ailments 610
of Musculoskeletal System of Axial Skeleton
22.24 LMC and COPE Coding for CAD 612

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22.25 The Venue for RMB / IMBs in Respect of General / Flag / Air Officers of Armed 614
Forces
22.26 Channel for Approval / Confirmation and Acceptance of IMB 614
22.27 Sanction for Delayed RME / RMB: Officers / JCOs / OR 617
22.28 Composition of Original and Duplicate Set FCDs 620
22.29 Responsibility of Preparing and Processing of FCDs 621
22.30 Channel of Submission of FCDs 621
22.31 Disposal of Non-fatal Cases 622
XXIII 23.1 Vaccines – Milestones 624
23.2 Types of Immunity 628
23.3 Difference Between Innate Immunity and Acquired Immunity 628
23.4 Comparison Between Active and Passive Immunity 629
23.5 Types of Vaccine 630
23.6 Human Vaccine Adjuvants 631
23.7 Cause-specific Categorization of AEFIs 632
23.8 Sensitivity of Vaccines to Heat, Light and Freezing 635
23.9 Technical Specifications of Cold Chain Equipment 636
23.10 Do’s and Don’ts for ILR Use 638
23.11 Do’s and Don’ts for Deep Freezer Use 639
23.12 Do’s and Don’ts in Using Ice Packs 641
23.13 Do’s and Don’ts in Cold Chain and Vaccine Sensitivities 643
23.14 Do’s and Don’ts in Using a Vaccine Carrier 644
23.15 Register of Vaccination and Inoculation 646
23.16 Armed Forces Immunization Schedule for Serving Personnel 646
23.17 Comparison of Armed Forces Immunization Schedule with UIP for Infants, 647
Children and Pregnant Women
23.18 Dosage of Tetanus and Diphtheria Vaccine 652
23.19 Dosage of Cholera Vaccine 653
23.20 Dose Schedule of Influenza Vaccine 658
23.21 Cell Culture Vaccines 660
23.22 Validity of International Certificate of Vaccination 661
XXIV — — —
XXV 25.1 Type of Wounds Based on Quantum of Energy Transfer 686
25.2 Types of Shock Waves 687
25.3 Casualty Burden from Various Modalities in Combat 690
25.4 Trimodal Distribution of Death 691
25.5 Criteria for Torniquet Conversion in Field 694
25.6 Components of Early Reasonable Exposure 697
25.7 Objective Signs of Airway Obstruction 698
25.8 Objective Signs of Inadequate Ventilation 698
25.9 Need for Definitive Airway Management 701
25.10 Signs and Symptoms of Tension Pneumothorax 703

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25.11 Difference between Tension Pneumothorax and Massive Haemothora 706
25.12 Patho-Physiological Classification of Haemorrhagic Shock 706
25.13 Evaluation of Signs of Internal Bleed in a Patient with Shock 707
25.14 Classification of Patients on the Basis of Fluid Challenge 708
25.15 Management of Combat Casualty in Haemorrhaging Shock 710
25.16 Glassgow Coma Scale 713
25.17 Secondary Survey in Trauma Patients 716
25.18 Priority Scheme for Transfer to Higher Echelon 718
25.19 Template for Communication to Higher Echelon 718
25.20 Chain of Evacuation 720
25.21 Casualty Carrying Capacity of Various Aircrafts 723
Section VI - Epidemiology & Biostatistics
XXVI 26.1 Different Types of Study Designs 726
26.2 r by c Contingency Table 756
26.3 Criteria of Classification for Chi Square Distribution 757
Section VII - Communicable Diseases in Armed Forces: Epidemiology and Prevention
XXVII 27.1 Modes of Transmission of Diseases 764
27.2 Levels of Prevention 767
27.3 Notifiable Diseases in the Armed Forces 769
27.4 Recommended Dilution of Chlorine Releasing Compounds 781
27.5 Non-Chlorine Releasing Compounds (Used for Disinfection of Items which are 781
Adversely Affected upon by Chlorine)
XXVIII 28.1 Type of Contact, Exposure and Recommended Post-Exposure Prophylaxis (PEP) 788
28.2 Wound (s) Management 789
28.3 Immunization Schedule for Rabies Prophylaxis 790
XXIX 29.1 Classification of Helminths 810
29.2 Assessment of Worm Load (Chandler’s Index) 814
XXX 30.1 Types of Shigella 828
30.2 Composition of Reduced Osmolarity Oral Rehydration Solution (ORS). 829
30.3 Difference between Classical and El Tor Vibrio Cholerae 831
30.4 Summary of Food Poisoning 837
30.5 Difference between Food Poisoning and Cholera 839
30.6 Calculation of Food Specific Attack Rates 840
XXXI 31.1 Reporting of Smears 856
31.2 Regimen for Drug Sensitive TB 858
31.3 Grouping of Medicines Recommended for Use in Longer MDR-TB Regimens 858
31.4 Oral Bedaquiline-Containing MDR / RR-TB Regimen 859
31.5 Shorter Injectables Containing Regimen 859
31.6 H Mono / Poly DR-TB Regimen Lfx - Levofloxacin, R - Rifampicin, 859
Z - Pyrazinamide, E - Ethambutol
31.7 Drug Dosages for First Line Anti TB Drugs 860
31.8 Daily Dose Schedule for Adults as per Weight Bands 860

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31.9 Drug Dosage for Paediatric TB 861
31.10 Adverse Drug Reaction of Anti TB Drugs 862
31.11 Possible Adverse Events Associated with TPT Drugs 862
31.12 Chemoprophylaxis for Close Contacts of Meningococcal Meningitis Cases As 876
Per CDC Guidelines
31.13 WHO Variants of Concern (VOC) 878
31.14 Various SARS-CoV-2 Variants Being Monitored (VBM) 878
31.15 Types of Vaccines 880
31.16 Dose of Oseltamivir for Infants <1 Year of Age 884
31.17 Dose of Oseltamivir for Infants > 1 to 12 Year Age 884
31.18 Chemoprophylaxis Dose for Pandemic Influenza A (H1N1) 2009 885
XXXII 32.1 Dosage of Single Dose Rifampicin in Preventive Treatment 917
32.2 Differences between Disease Arrest & Inactivity in Cases of Leprosy 918
32.3 Assessment of Disablement for Amputation of Fingers 919
32.3 Assessment of other Manifestations of Leprosy 919
32.4 Stages of Rash in Monkey Pox 921
32.5 WHO Global Incidence of the Diseases 924
32.6 Classification of STDs Agents 924
32.7 Syndromic Approach 925
32.8 STIs Treatment Guidelines 926
32.9 Treatment Options for STIs 928
32.10 Symptoms for Gonorrhoea 929
32.11 Symptoms for Chlamydia 929
32.12 Factors Increasing the Risk of Acquisition of HIV 937
32.13 Major and Minor Symptoms of HIV 938
32.14 WHO Classification of Clinical Stages for HIV / AIDS 939
32.15 Generation of Anti-HIV Antibody Tests 940
32.16 Pre-Test and Post-Test Counselling 943
32.17 First Line ARV Drugs Toxicities 944
XXXIII 33.1 Paediatric Age Group - Recommendation for Volume of Blood Collected for 960
Culture
33.2 Minimum Quantities of Food Items Required for Examination 963
33.3 Details of Viscera to be Sent for Chemical Examination in Fatal Cases 964
XXXIV 34.1 Arthropod Borne Diseases 975
34.2 Major Malaria Vector Species Prevalent in Different Ecosystems in India 979
34.3 Important Differences Between Anopheline and Culicine Mosquitoes 982
34.4 Decadal Incidence of Malaria by Category of Personnel 2010 To 2020 (Rate 986
Per 1000)
34.5 Breeding Habits of Anopheline Mosquitoes 990
34.6 Species Distribution of Anopheles in India 991
34.7 Human Filarial Infections 996
34.8 Difference between Microfilariae of W. bancrofti and B. malayi 997
34.9 Classification of Rickettsial Infections 1021

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34.10 Some Selected Arboviral Infections 1028
34.11 WHO Clinical Classification of DHF 1032
34.12 Insecticides for Indoor Residual Spray 1071
34.13 Insecticides for Indoor Space Spray 1072
34.14 Insecticides for Outdoor Fogging 1072
34.15 Larvicide Formulations and Dosages 1072
Section VIII - Non-Communicable Diseases
XXXV 35.1 Decadal Trend of Hospital Admissions for IHD (Rate Per 1000) 1084
35.2 Modifiable Coronary Risk Factors 1088
35.3 Preventive Strategies for IHD 1089
35.4 Decadal Trend in Hospital Admission for Hypertensive Diseases 1092
(Rate Per 1000)
35.5 Decadal Trend in Hospital Admissions for Diabetes Mellitus (Rate Per 1000) 1097
35.6 Diagnostic Criteria for IGT And IFG 1098
35.7 Asian Classification of BMI 1101
35.8 WHO Classification of Weight As Per BMI 1102
35.9 Decadal Trend in Hospital Admission Due to Peptic Ulcer (Rate Per 1000) 1106
35.10 Decadal Trend in Hospital Admissions for Malignant Neoplasms 1111
(Rate Per 1000)
35.11 Ranking Order by Site of 8 Selected Cancers 1112
35.12 Decadal Trend in Hospital Admissions for Injuries NEA (All Forms) (Rate Per 1117
1000)
35.13 ‘Rule of Nines’ 1121
XXXVI 36.1 Decadal Trend Of Hospital Admission For Psychiatric Disorders Incl Psychosis, 1128
Neurosis (Rate Per 1,000)
XXXVII 37.1 Dentition Schedule 1138
Section IX - National Health Programmes & Public Health Legislations
XXXVIII 38.1 Classification of States / UTs based on API as Primary Criteria 1150
38.2 Specific Objectives and Key Interventions in Elimination Phase (Category 1) 1151
38.3 Specific Objectives and Key Interventions in Intensified Control Phase 1152
(Category 3)
38.9 Indicators of NTEP 1157
38.10 Evolution of the National HIV / AIDS Response 1160
38.11 Causes of blindness in India: 2015-19 National Survey on Blindness 1163
38.13 Package of Services. 1170
38.14 Services Provided under ICDS Scheme 1172
38.15 Population Norm for Setting Up of AWCs and Mini AWCs 1173
38.16 Urban Health Infrastructure 1178
38.17 Scale of Assistance under JSY 1186
38.18 6 x 6 x 6 Strategy under AMB 1187
38.19 Selected Health Conditions for Child Health Screening and Early Intervention 1190
Services
XXXIX 39.1 General Penalty for Offences 1197

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39.2 Penalty and Procedures under FSSAI, 2006 1204
39.3 Provisions under the Act of 1971 1206
39.4 MTP Act 1971 Vs MTP Amendment Act 2021 1206
39.5 Important Rules under MTP Act 1971 1207
39.6 Important Rules under MTP Act 1971 1207
39.7 Provisions of PCPNDT Act 1208
39.8 Offence and Punishments under PCPNDT Act 1209
39.9 Offences and Penalties under THOA 1210
39.10 Offences and Penalty under Human Immunodeficiency Virus And Acquired 1212
Immune Deficiency Syndrome (Prevention And Control) Act, 2017
Section X - Miscellaneous Aspects of Health & Preventive Medicine
XXXX 40.1 Prevalence and Estimated Numbers of Alcohol and Drug Users in India 1221
40.2 Strategies Under Family Planning Programme in India 1223
40.3 Contraceptive Services Provided at Various Levels of Public Health Sector 1224
Facilities
XXXXI 41.1 Short-Term Effects of Disasters 1235
41.2 Site Planning Norm 1237
41.3 Dosage of Water Sterilizing Tablet, Bleaching Powder or Liquid Disinfectant 1238
41.4 Composition of Disaster Management Committee 1247
41.5 Activation Plan 1250
41.6 Staffing Pattern for Disaster Plan in Hospital 1252
41.7 Area Demarcation for Various Activities in the Event of Disaster 1253
XXXXII 42.1 Phases of Influenza Pandemic 1271
XXXXIII — — —

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 LIST OF FIGURES IN RED BOOK

Figure Page
Chapter Title
No. No.
Section I - Introduction to Military Health
1.1 Morbidity Patterns of the Allied Troops in Southeast Asia 1943-45 1
1.3 Indian Army Operating in Siachen Glacier 2
I 1.2 Indian Army Operating in Desert 2
1.4 Indian Army Operating in Jungle 3
1.5 Decadal Trend of Hospital Admissions All Causes in Armed Forces (Per 1000) 4
2.1 Method for Optimizing Floor Space Utilization 20
2.3 Prefabricated Structures 25
2.2 Insulated Sandwich Panels 25
II
2.4 Complex Earth Blocks 26
2.5 Solar Heated Insulated Ladakhi Shelters 27
2.6 Fast Erectable Modular Shelters 27
3.1 Air Insulation in Relation to Wind Speed and Altitude 30
3.2 Total Insulation (Clothing + Air) Required for Prolonged Comfort in Relation to 32
Air Temperature (Shade and Metabolic Rate of Heat Production)
3.3 Tolerance Time Prediction Chart At 1.5 Met (Light Activity) for an Average Soldier 33
in Relation to Air Temperature and Total Insulation (Clothing Air) in Shade
3.4 Extreme Climate Clothing for HAA 36
3.5 Parka Coat and Trousers 37
3.6 Bag Sleeping 37
III 3.7 Blanket. 37
3.8 Helmet Combat 37
3.9 Combat Boot for HAA 38
3.10 Diving Clothing 40
3.11 Air Ventilated Suits 40
3.12 Fire Fighting Clothing 41
3.13 Protection Against High Intensity Thermal Radiation 41
3.14 Ballistic Resistant Clothing (Armour Clothing) 41
IV — — —
5.1 Slow Filtration of Tank Water 53
5.2 Underground Water 55
5.3 Sanitary Well 56
5.4 Slow Sand Filter 62
5.5 Cleaning of the Slow Sand Filter 63
V
5.6 Rapid Sand Filtration Plant 64
5.7 Mechanical Filter (Stellar Filter) 65
5.8 Membrane Process for Water Disinfection 74
5.9 Nalgonda Technique 77
5.10 General view of the WPDK 87

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5.11 Schematic view of the WPDK kit 87
V 5.12 Rainwater Harvesting 92
5.13 Layout of Water Points 99
Section II - Environments Specific to Armed Forces: Health Hazards, Diseases and Prevention
6.1 Campbell Stokes Sunshine Recorder 114
6.2 Solar Radiation Thermometer 114
6.3 Pyranometer & Its Components 115
6.5 Stevenson Screen 115
6.4 Black Globe Thermometer 115
6.6 Dry Bulb 117
6.7 Rain Gauge 120
6.8 Kata Thermometer 120
6.9 Anemometer 121
6.10 Automated Weather Station 121
6.11 Thermal Balance of Human Body 123
VI 6.12 (a) Corrected Effective Temperature (C.E.T.): Normal Scale 126
(b) Corrected Effective Temperature (C.E.T.): Basic Scale 126
6.13 Basic four Hourly sweat Rate (BSR) and Temperature 127
6.14 Schematic Summary of Extreme Hot Climate 134
6.15 Normal Body Fluid Compartments 135
6.16 Pure Water Depletion 136
6.17 Pure Salt Depletion 136
6.18 Humidity and Training 138
6.19 Wind Chill Chart 142
6.20 Relationship between Altitude and Atmospheric Pressure 149
6.21 Relationship between Alveolar and Arterial Oxygen Saturation with the Hypoxia at 151
Altitude
VII — — —
VIII 8.1 Personal Protective Equipment in Jungle 167
IX 9.1 Underwater Vision 179
9.2 Chart for the Aid of Divers to Prevent Decompression Sickness 180
9.3 Sinus Barotrauma 184
9.4 Aural Barotrauma 185
X 10.1 (a) Twenty-Five Men Life Raft 201
(b) Types of Life Raft 202
(c) Life Raft In Storage Container Onboard Ship 202
10.2 (a) Heliograph 203
(b) Way To Use Heliograph 204
10.3 Morse Code Lamp 204
10.4 Newer Modalities To Send Distress Signals 205
10.5 Contents In Survival Pack of Life Raft 206

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XI 11.1 Atmospheric Pressure Variation with Altitude 211
11.2 Temperature Based Classification of Atmospheric Layers 212
11.3 High Differential Cabin Pressure 223
11.4 Pressure Changes in Passenger and Combat Aircraft Cabin 224
11.5 Typical Pressurization Schedule for Pressure Cabins in Combat 224
11.6 Cabin Altitude Control 225
11.7 Oxygen Cascade 228
11.8 Bubble – Blood Interaction 237
11.9 Pathophysiology of Bubbles 238
XII — — —
XIII 13.1 CT Scan in a Patient of HACE Showing Absence of Sulci, Small Ventricles, and a 296
Diffuse Low-Density Appearance of the Entire Cerebrum
13.2 Portable Hyperbaric Chamber (One Man HAPO Bag) 301
13.3 Hyperbaric Chamber in a Hospital 302
XIV 14.1 CDC Classification of Biowarfare / Bioterrorism Agents 319
14.2 Timeline of Medical Effects Following CBRN Event 321
14.3 Appropriate Public Response in a Nuclear Power Plant Emergency 323
14.4 Modified CBRN Triage Sieve by First Responders at Site of Incident 328
14.6 Layout of Casualty Decontamination Centre 331
XV 15.1 Occupational Dermatitis 350
15.2 Work Station Ergonomics (a) & (b) 368
Section III - Waste Disposal in Armed Forces Environment
XVI 16.1 Sanitation Barrier 372
16.2 Water Seal 373
16.3 Aqua Privy 374
16.4 Shallow Trench Latrine 375
16.5 Incinerator Latrine 375
16.6 Deep Trench Latrine 377
16.7 Built-up Deep Trench Latrine 378
16.8 Trough Urinal 379
16.9 Standard Funnel Urinal 379
16.10 Tulip Funnel Urinal 380
16.11 Urinoil 380
16.12 Ghee Tin Urinal 381
16.13 Standard Funnel Urinal 381
16.15 Relief Tube 382
16.14 Four Funnel Urinal 382
16.16 Male and Female AMXDmax Systems (Harvie, 2016) 383
16.17 Functioning of a Bio-Toilet 384
16.18 Flow Diagram of a Modern Sewage Treatment Plant 385
16.19 Percolating Filter 386
16.20 Conventional Activated Sludge Process 387

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No. No.
16.21 Oxidation Pond 389
16.22 Intermittent Oxidation Ditch 390
16.24 Flow Diagram for Sludge Handling (Arrows Indicate Possible Flow Paths) 392
16.23 (a) - (e) Typical Flow Diagram for Treatment Process and Quality of Resulting 392
Effluent
16.25 Tight Packing of Manure Using a Trench 396
16.26 Gobar or Bio-Gas Plant 396
16.27 Closed Beehive Incinerator 402
16.28 Cold Water Grease Trap 406
16.29 Strainer Grease Trap 406
16.30 Soakage Pit for Kitchen Sullage 407
16.31 FOG Separators – (a) Underground, (b) Free Standing 408
XVII 17.1 Autoclave 425
17.2 Microwave 425
17.3 Incinerator 425
17.4 Biohazard Symbol 426
Section IV - Nutrition and Food Safety
XVIII 18.1 Graph Explaining the Difference between RDA and EAR 443
18.2 Blood Glucose Levels Based on Gi of Food Items 452
18.3 Food Guide Pyramid 475
XVIX — — —
XX 20.1 Formulation of DFS 505
Section V - Healthcare in Armed Forces
XXI — — —
XXII 22.1 LMC for Individuals with Seizures / Epilepsy 611
22.2 Channel of Processing of IMB Documents in Non Appeal Cases 615
22.3 Channel of Processing of IMB Documents in Appeal Cases 615
22.4 The Process of Initial Adjudication of RMB / IMB Documents 617
XXIII 23.1 Immune System of the Body 627
23.2 Cold Chain System 634
23.3 Cold Chain Equipment 636
23.4 Cold Chain Room 637
23.5 Storing Vaccines in ILR 637
23.6 Freezing Ice Packs in the Deep Freezer 638
23.7 Brick Layered Ice Packs in Deep Freezer 639
23.8 Storage of Vaccines in Domestic Refrigerators 640
23.9 Packing a Cold Box 640
23.10 Ice Packs 641
23.11 Conditioning of Ice Packs 642
23.12 Different Stages of Vaccine Vial Monitor 642
23.13 (a) Shake Test Passes Vaccine Usable 643
(b) Shake Test Failed– Don’t Use Vaccine 643

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23.14 Correct Packing of a Vaccine Carrier 645
23.15 Placement of Vaccines when at RI Session Site 645
XXIV — — —
XXV 25.1 Effect of High Velocity Missile on Tissue 686
25.2 Blast Injury Hand 688
25.3 Gun Shot Wound Injury Groin 688
25.4 Anti-personnel IED Explosion Injury Foot 688
25.5 Distribution of Organs Affected in Military Trauma 690
25.6 Trimodal Distribution of Death 691
25.7 Zones of Engagements 692
25.8 COMBAT Acronym 692
25.9 COMBAT Flow Chart 693
25.10 Airway Management Flow Chart in AUA 694
25.11 Flowchart on Tactical Evacuation of Casualty under Fire 695
25.12 Dragging 695
25.14 Fireman’s Lift 695
25.13 Sledging 695
25.15 Mobile Casualty Evacuation 695
25.16 REACT NOW Acronym 696
25.17 Evaluation of ‘Response’ Flow Chart 696
25.18 Sequential Flowchart for Airway Management in Combat Trauma 698
25.19 Chin-lift Manoeuvre 699
25.21 Nasopharyngeal Airway 699
25.22 NPA Selecting Correct Size 699
25.20 Jaw Thrust Manoeuvre 699
25.23 Oropharyngeal Airway 700
25.24 Inserting a Laryngeal Mask Airway 700
25.25 Steps of Endotracheal Intubation 701
25.26 Anatomy of Crico-thyroid Membrane 702
25.27 Steps of Surgical Cricothyroidotomy 702
25.28 Anatomical Location for NCD 703
25.29 Performing a NCD in Tension Pneumothorax 703
25.30 Anatomical Boundaries of Triangle of Safety 704
25.31 Steps of Performing Tube Thoracostomy 704
25.32 Vented-Triple Seal 705
25.33 Stepwise Evaluation for Site of Haemorrhage 707
25.34 Cardiac Tamponade and its Clinical Signs and ECG Changes 711
25.35 Paradoxical Respiratory Movements in Flail Chest 711
25.36 Xray Findings in Aortic Disruption 712
25.37 Evaluation and Management Scheme for Head Injury in Field Etting 713
25.38 Evaluation and Management Scheme for Spinal Injuries in Field Setting 714
25.39 AMRAT Acronym for Drugs to be Administered in Field Setting 715

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Section VI - Epidemiology & Biostatistics
XXVI 26.1 Different Types of Epidemic Curves 729
26.2 Design of Case-Control Study 730
26.3 Design of a Cohort Study 730
26.4 Design of a Cross Sectional Study 731
26.5 Design of Experimental Study (RCT) 731
26.6 Levels of Evidence Pyramid 732
26.7 Epidemiological Triad 733
26.8 Organization of An Epidemiological Surveillance System 734
Section VII - Communicable Diseases in Armed Forces: Epidemiology and Prevention
XXVII 27.1 Serbian Barrel 774
27.2 TOT Disinfector 775
27.3 Disinfector Portable Field 776
XXVIII — — —
XXIX 29.1 Life Cycle of Ascaris lumbricoides 812
29.2 Life Cycle of Ancylostoma Duodenale / Necator Americanus 816
29.3 Life Cycle of Taenia saginata 819
29.4 Life Cycle of Taenia solium 819
29.5 Life Cycle of Echinococcus granulosus & E. multilocularis 820
29.6 Life Cycle of Dracunculus medinensis 822
29.7 Life Cycle of Schistosoma spp 824
29.8 Life Cycle of Fasciolopsis buski 825
XXX — — —
XXXI 31.1 Diagnostic Algorithm for Pulmonary Tuberculosis 854
31.2 Diagnostic Algorithm for Extra Pulmonary Tuberculosis 854
31.3 Diagnostic Algorithm for Paediatric Pulmonary Tuberculosis 855
31.4 Management of MDR-TB Patients during Pregnancy 859
XXXII 32.1 Sarcoptes Scabiei 908
32.2 Diagrammatic Representation of Itch Mite in a Burrow made in the Skin 909
32.3 Organization of HIV-1 Virion 934
32.4 HIV Replication Cycle 936
32.5 Tests Used for HIV Diagnosis in Individuals above 18 Months of Age 940
32.6 Strategy 1 for Blood Transfusion / Transplant Safety 941
32.7 Strategy 2A for Sentinel Surveillance 941
32.8 Strategy 2B for Symptomatic Patients 942
32.9 Strategy 3 for Asymptomatic Patients 942
XXXIII 33.1 Triple Packaging System 971
XXXIV 34.1 Anopheles Mosquito 979
34.2 Culex Mosquito 980
34.3 Morphological Difference between Ae. albopictus and Ae. aegypti 981
34.4 Mansonia Adult with Wing Depicting Typical Salt & Pepper Appearance 981
34.5 Life Cycle of The Malaria Parasite 988

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 Figure Page
Chapter Title
No. No.
34.6 Sand Fly - Morphology and Life Cycle 1002
34.8 Life Cycle of House Fly 1006
34.7 Musca domestica 1006
34.10 Flea Life Cycle 1009
34.9 Adult Rat Flea 1009
34.11 Body Louse 1014
34.12 Head Louse 1014
34.13 Hard Tick-Dorsal and Ventral Aspect 1016
34.14 Soft Tick-Dorsal and Ventral Aspect 1016
34.15 Adult Trombiculid Mite 1018
34.16 Black Fly 1035
34.17 Classification of Insecticides As Per Chemical Composition 1044
34.18 Biorational Insecticides Used in Vector Control 1048
34.19 Diagrammatic Representation of Mode of Action of BTI 1048
34.20 Protective Clothing 1053
34.38 Hand Held Thermal Fogger 1059
34.39 Hand Carried Cold Fogging Equipment 1059
34.40 Spray Application Route Relative to Wind Direction 1061
34.41 Gambusia affinis 1064
34.42 Poecilia reticulata 1064
34.43 Mode of Action of Romanomermis Against Mosquito Larvae 1065
Section VIII - Non-Communicable Diseases
XXXV 35.1 Mechanism Type-1 Diabetes Mellitus 1098
35.2 ‘Rule of Nines’ 1121
XXXVI — — —
XXXVII 37.1 Healthy Tooth 1137
Section IX - National Health Programmes & Public Health Legislations
XXXVIII 38.1 Proposed Structure of VISION 2020: The Right to Sight 1164
XXXIX — — —
Section X - Miscellaneous Aspects of Health & Preventive Medicine
XXXX — — —
XXXXI 41.1 Disaster Management Framework in India 1230
41.2 National Disaster Management Institutional Mechanism 1230
41.3 Disaster Risk and Vulnerability 1232
41.4 Stages of Disaster 1232
41.5 Disaster Management Cycle 1234
41.6 Triage at Disaster Site 1242
41.7 Hospital Emergency Incident Command System (Organogram) 1243
41.8 Components of Disaster Management Committee 1244
41.9 Flow of Causalities 1255
XXXXII 42.1 History of Pandemics 1271
XXXXIII — — —
n

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 INDEX

Section Chapter No. Topic Page No.

1 Introduction to Military Health

I Review of Military Hygiene and Health 1

II Accommodation 15

III Clothing 28

IV Assessment of Health & Sanitation 42

V Water Supply 50

2 Environments Specific to Armed Forces: Health Hazards, Diseases and Prevention

VI Introduction to Climate and Health 105

(Including Adverse Effects of Different Climates / Weathers)

VII Health Problems during Move & Training 157

VIII Health Problems in Jungle Warfare 164

IX Naval Health 171

X Survival at Sea 200

XI Aero-space Medicine 210

XII Survival in Desert 281

XIII Survival in HAA & Antarctica 286

XIV Medical and Other Aspects of NBC Warfare 303

XV Occupational Health 334

3 Waste Disposal in Armed Forces Environment

XVI Environmental Sanitation 369

XVII Bio-Medical Waste Management 416

4 Nutrition and Food Safety

XVIII Introduction to Nutrition 442

(Including Various Food Constituents, Macro & Micronutrients, Their Role
& Function, Deficiency Diseases & Conditions)

XIX Ration Scales in Armed Forces & Their Importance 482

XX Food Safety and Inspection of Food Items Production, Handling & 504
Eating  / Catering Establishment

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Section Chapter No. Topic Page No.
5 Healthcare in Armed Forces
XXI Health Care & Health Administration 556
(Including Family Health Services & ECHS)

XXII Medical Boards: AME, PME, Cl & Re-Cl RMB & IMB with Relevant Orders 587
& Policies
XXIII Immunization (Including Armed Forces Immunization Schedule) 624
XXIV Health Guidelines for UN Missions 663
XXV Combat Medical Care 685
6 Epidemiology & Biostatistics
XXVI Epidemiology and Statistical Methods 725
7 Communicable Diseases in Armed Forces: Epidemiology and Prevention
XXVII General Principles of Prevention & Control of Communicable Diseases 764
(Including Notification, Disinfection Methods & Practices)
XXVIII Animal Borne Diseases (Zoonoses) 782
XXIX Helminthiasis 810
XXX Excremental Diseases 827
XXXI Air Borne Diseases 851
XXXII Contact Diseases (Including STIs) 900
XXXIII Collection of Specimens for Lab Investigation 953
XXXIV Entomology (Including Vector Borne Diseases) 974
8 Non-Communicable Diseases
XXXV Non-Communicable Diseases 1082
XXXVI Mental Health 1125
XXXVII Dental and Oral Health 1137

9 National Health Programmes & Public Health Legislations

XXXVIII National Health Programmes 1146
XXXIX Public Health Legislations (Including relevant Armed Forces Policies) 1195

10 Miscellaneous Aspects of Health & Preventive Medicine

XXXX Important Medico Social Problems and Population Control 1214
XXXXI Disaster Management (Including HADR Activities) 1227
XXXXII Pandemic Management 1270
XXXXIII SOP for Embalming & Transportation of Dead Bodies 1277

Additional Information 1282

Index 1289

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 HISTORY OF MILITARY HEALTH

Chapter
I
HISTORY OF MILITARY HEALTH

1.1 Introduction.
Mathematician philosopher Bertrand Russell had stated that man is continuously engaged in three kinds of
conflicts - Man and Nature; Man and Man; and Man and Himself - in that order. A study of history of mankind
confirms this view. Men come closer to each other when pitted against nature, be it natural calamities like
earthquakes, floods, etc. or day to day individual struggles against nature in finding food, clothing and shelter.
Once he has conquered nature, he turns his aggression against fellow human beings the extreme spectrum of
which is war. Once he has vanquished his mortal enemy, he turns to self-indulgence to avoid boredom giving rise
to the modern lifestyle diseases of overindulgence.
What took mankind centuries to experience is experienced by a soldier in a single lifetime, either in combat or
preparing for combat. Deployments in alien and hostile environments, be it the Siachen glacier, the deserts of
Rajasthan or the jungles of North-East, take their toll in form of injuries and diseases due to hostile environment
manifesting in cold injuries and effects of high altitude in the glacier, effects of heat in the desert and arthropod-
borne diseases like malaria in the forests of North-East and these outnumber battle casualties. Once he survives
these vagaries of nature and the uncertainties of battle, he faces periods of inactivity and perhaps loneliness,
leading to ennui under stress of which some men lose their morale leading to psychiatric morbidity and incidence
of sexually transmitted infections among other diseases.
Among all the three adversaries, nature still reigns supreme. Deserts, jungles, severe cold, severe heat and other
unhealthy environments still account for most of the morbidity and mortality among the Armed Forces personnel.
Any terrain is strategically and tactically disadvantageous if disease conditions are harmful to the troops operating
in it.
Unit effectiveness is greatly dependent upon the health of its soldiers. Military units are unable to carry out their
missions when the soldiers are weakened by disease. The success or failure of an Army, the outcome of a war
and the fate of a nation may, therefore, rest upon how well diseases are prevented through effective preventive
medicine practices in the units. Historical records of armies in the field are replete with accounts of failures for
which disease was a major contributing factor. This was true of Napoleon in his retreat from Moscow in 1812.
Confronted with cold weather and louse borne typhus, his elite army was almost completely decimated.
Napoleon’s loss is understandable in view of his lack
of knowledge concerning the medical threat. But 1200
modern armies have also experienced great losses from
1000
preventable diseases. Arthropod- borne diseases alone
were responsible for the loss of 1,65,76,100 man-days 800
among United States Armed Forces during World War
II. The entire Asia-Pacific campaign in World War II was 600
seriously threatened by the debilitating effects of malaria.
400
During the talk of strategy of the South-East Asian
Campaign, Admiral Mountbatten stated, “More serious 200
than the monsoon, however, was the incidence of tropical
diseases. The jungles of Burma are infested with malaria 0
1943 1944 1945
mosquitoes, the scrub typhus mites and the bacteria and
amoebae of dysentery. Between them they presented a Enemy action Sickness
more redoubtable enemy than the Japanese themselves.
Fig 1.1 : Morbidity Patterns of the Allied Troops in
I, therefore, set up at once an inter-service, inter-Allied
Southeast Asia 1943-45
medical advisory division to help the research and to

1
 INTRODUCTION TO MILITARY HEALTH

organize an offensive drive against disease to be waged by the medical services. In 1943, for every man who
was admitted to hospital with wounds, there had been 120 who were casualties from the tropical diseases. By
1944, these 120 men had been reduced to 20, although hospital admission still reached between 14 to 15 per
thousand per week in peak periods. By 1945, the rate had dropped to ten men sick for one battle casualty and
during the last six weeks of the war, these ten had been reduced to six (Fig 1.1). The enemy had no medical
advisory division and appears to have made no advance in medical research. As our troops became more
immune from circumstances against which the Japanese had no remedy. I was determined to enlist disease as
an additional weapon on our side and deliberately chose unhealthy areas in which to fight”.

1.2 Factors Affecting Health of Troops.

The impact of casualties caused by preventable diseases upon military campaigns has been a prominent and continuous
feature of military operations. From the beginning of recorded history up to the present time, armies have had immense
problems with heat, cold and communicable diseases. It was realized in the past, as it is universally agreed today that
losses of men in war from sickness exceed the losses due to battle wounds. Frederick of Prussia said, “Fever cost me
as many men as seven battles” and that saying was as true in the SE Asia Campaign during the Second World War
as when said almost 150 years ago. The ultimate objective of a military force, success in battle, demands that troops
be maintained in a constant state of good health. Among the many health hazards, there are four major components
of the health threat to field forces:
(a) Heat.
During the 1967 Arab Israeli conflict, the Israelis enveloped the
Egyptians, severing their lines of support. The Egyptians suffered a
total of 20,000 deaths, mostly due to heat while the Israelis had no
deaths due to heat and only 128 cases of heat injury. The Israelis
demonstrated that health hazards, such as heat, could be as effective
as tactical weapons in securing success on the battlefield. Our troops
operating in the deserts of Rajasthan (Fig 1.2), also need to be
protected from the ill effects of extreme heat.
(b) Cold.
In World War II, during the winter of 1944-45 in the European theatre,
over 54,000 US soldiers were admitted to hospitals with cold injuries
and over 90,000 US soldiers were admitted with cold injuries throughout
the war. In the twenty-four days the British were in combat on the
Falkland Islands, they sustained 777 total casualties, 109 (or 14%)
were cold injuries. When the British had the Argentinians surrounded Fig 1.2 :
at Port Stanley, they could have waited until the Argentinians exhausted Indian Army Operating in Desert
their food and water. But they were forced by the adverse environment
to attack, thus sustaining additional combat casualties. Our troops
deployed in the Siachen Glacier (Fig 1.3), are engaged more in the day-to-day battle against a bitterly cold,
high-altitude environment rather than frequent engagements with the enemy. The respiratory group of ailments
has also increased due to these adverse environmental conditions.
(c) Arthropods.
There are many species of arthropods that transmit diseases,
which seriously affect military operations. Napoleon’s Le Grand
Army numbered over 6,00,000 when it crossed the Russian
border in June of 1812. Although he succeeded in taking Moscow,
Guerrillas, disease and cold injury decimated his troops, forcing
his retreat. Only 1,00,000 men returned to France. There were
70,000 combat losses versus 4,30,000 losses due to disease.
Of these, over 100,000 of Napoleon’s soldiers were lost to louse
borne typhus. In our conflicts with China and Pakistan, the same
Fig 1.3 : experience was repeated. The areas were infested with malaria
Indian Army Operating in Siachen Glacier mosquitoes and scrub typhus mites, which caused at least 500

2
 HISTORY OF MILITARY HEALTH

casualties in a vital combat sector (Fig 1.4). It is extremely

unfortunate that valuable lessons learnt during wars are so
quickly forgotten after the combat is over.

(d) Diarrheal Diseases.

These can be contracted from contaminated water or food, but
in either case it can have a catastrophic impact on a fighting
force as illustrated by Rommel’s predicament in North Africa.
Not one of Rommel’s original highly successful generals was
available to help him when he needed them most at El Alamein.
They had all, over time, been medically evacuated for illness.
Rommel himself was not present when the battle began, he was
in Germany recovering from hepatitis. His Chief of Staff and his
Intelligence Officer were evacuated just prior to the battle and
his Operations Officer was evacuated during the battle, all three
for amoebic dysentery. In 1980, during Operation Bright Star,
the US commander rewarded his troops for a job well done by
allowing them to go into town the evening prior to redeployment. Fig 1.4 : Indian Army Operating in Jungle
Thirty percent of his command contracted shigellosis and were
sick with gastroenteritis on the flight back to the States.

1.3 Factors Affecting Vulnerability of Soldiers in Field Deployment.

(a) Environment.
The harshness of the environment and the tactical situation, often   requiring them to go into places, good

sense tells one to avoid. The environment may be mosquito- infested jungles; sandfly infested villages; hot, dusty
deserts; or cold windy plains and high-altitude area. Our soldiers and their leaders must be prepared to live and
fight in such places.  
(b) The Disruption of the Body’s Natural Defences.
The human body has an excellent capacity to protect itself against disease and climatic injury. But the efficiency
of these mechanisms is dependent upon one’s overall well-being. If soldiers are deployed around the world (as
in UN Peace Keeping Missions), there may be disruption in their circadian rhythms. Added to this, exposure to
extremes of heat or cold, meals at irregular hours and deprivation of sleep, will result in troops who are more
susceptible to illness and combat stress.
(c) Breakdowns in Basic Sanitation.
Potable water and proper waste disposal are examples of things taken for granted in a garrison. But even using
the latrine or changing socks becomes a challenge for the soldier when living in a muddy foxhole and similar
other deployment situation.

1.4 The Individual in a Field Environment.

Ordinarily, a soldier maintains a high standard of personal hygiene in a peacetime environment with convenient facilities.
In the field, however, where proper sanitation requires coping with the elements of nature, problems arise; the soldier
is suddenly faced with inconveniences. In a peacetime garrison, an individual follows a set course after rising in the
morning. Routine acts of personal hygiene are performed in a conveniently located toilet and bathroom that is warm and
has hot and cold water. However, upon arising in the field, one may feel too cold & challenged to take care of personal
hygiene. There may be insufficient water to enable every soldier to have a daily bath and wash his undergarments. The
toilet in the field is not as convenient and hygienic as the one in the garrison. An ordinarily well-groomed individual
may become dirty and unkempt in such an environment. Filth and disease go hand in hand. Dirty, sweaty socks may
cause the feet to be more susceptible to disease. Dirty clothing worn for a prolonged period of time and unwashed hair
are open invitations to lice. Inadequate individual personal hygiene in the field is one of the most difficult problems
to overcome, because it requires a sense of responsibility on the part of each individual to try to maintain his health
regardless of the difficulties encountered. This also includes the difficulty of ensuring personal prophylactic measures

3
 INTRODUCTION TO MILITARY HEALTH

such as use of mosquito repellents for prevention of malaria so vital during night operations/exercises particularly
when most vectors may be resting outdoors as is common in forested areas.
Reference in respect of camp sanitation is found in Sushruta’s works, where it was enjoined on medical men that they
should be aware of the possible harmful effects to the health of troops and animals through shelter, water, food, fuel
and fodder and to constantly protect the commander and his forces by taking all possible preventive measures against
any harm to their health. In Chapter 7 of Mahabharata (600 BC) Karna, the Commander-in-Chief of Kauravas warned
that prevalence of fly nuisance, appearance of swarms of crows and vultures and epidemics of intestinal diseases were
sure precursors of defeat. In respect of establishment of camps for troops, it is stated in Kautilya’s “Artha Shastra”
(350 BC) Chapter 129, section 10, that camps should be sited by a survey party comprising of a surveyor, a combatant
officer, an engineer and a meteorologist. The duties of the survey party consisted in the selection of a site with due
consideration to the nature of the terrain, character of the soil, meteorological conditions such as the temperature and
humidity variations, shelter from strong wind and sun to ensure its suitability appropriate to the arm or service whether
at rest or in action. In the Mahabharata, Chapter 7, instructions were issued on mobilization of Army, in respect of
selection, establishment and siting of water points at such places not liable to contamination. Kautilya warned that
in the field, where water is likely to be scarce, importance of pure water carried in a water cart or by each soldier
in-person was not to be forgotten.
Caesar paid the utmost attention to physical fitness of his men, particularly to their bathing and to camp sanitation.
Marlborough concentrated on clothing and feeding and his Army was the best fed and clothed of its day in Europe. In
Mahabharata, reference exists in respect of large stocks of provisions made available for sale to troops at controlled
rates e.g., honey and ghee, in order to maintain the nutrition of the soldier. Parkes, Professor of Hygiene at the British
Army Medical School, later R.A.M. College, was the first scientific military hygienist. He lived from 1819 to 1876 and
his efforts to improve the living conditions of the soldier had such a remarkable and world-wide effect that, when he
died, Von Moltke said; ‘Every Regiment in Europe ought to parade on the day of Dr. Parkes’s funeral and present arms
in honour of one of the greatest friends a soldier ever had’.
Reference in respect of naval hygiene also exists. Capt. Cooke, the Commander of Ships scanning the South Pacific,
found the good effects of citrus fruits especially lemon in the health of the sailors. In fact, the first vitamin to be
described i.e., vit C has been named after the first alphabet of his name. Nelson interested himself in the prevention
of scurvy and introduced the issue of lemon in the Royal Navy, which caused the Royal Mariner (and later all British
sailors) to be nicknamed “LIMEY”. James Lind, a naval surgeon, who lived from 1716 to 1765, had ideas a century and
half ahead of his time. He recommended the delousing of sailors and baking of their infested clothing as a means of
preventing typhus. He knew as much about scurvy as we do today and his recommendation for the introduction of lemon
juice in the Navy as a daily issue contributed materially to naval victories during the time of Nelson. He introduced the
sand filtration of water and the production of drinking water by distillation from seawater.

1.5 Changing Pattern of Morbidity in the Armed Forces.

Admissions to hospitals per 1,000 of strength at
present in Indian Armed Forces are approximately
one eighth of what they were 100 years ago. In
1870, when there was no military operational activity
in India, the admission rate per 1,000 of strength
was 1650 and in 1976 the rate dropped down to
200.77, in 2001 it was 102.95 per 1,000 and in
2020, admissions due to morbidities decreased to
75.98 per 1000 as per AHR 2020 (Fig 1.5). Besides
the rate, changes in morbidity pattern in the Armed
Forces over the last 100 years or so is interesting
to study as it reflects changes occurring throughout
the world, both in developed and developing nations.
For the developed nations, the evolution of patterns
of disease spanned more than a century and fall
into three fairly distinct stages. The first, marked
by infectious diseases associated with poverty,
malnutrition and poor environmental sanitation and Fig 1.5 : Decadal Trend of Hospital Admissions All Causes
in Armed Forces (Per 1000)

4
 HISTORY OF MILITARY HEALTH

personal hygiene, gradually gave way thanks to better housing and sanitation, greater availability to safe drinking water
and vaccination services. In the second stage. degenerative diseases such as heart disease, cerebrovascular accidents
and cancer gradually began to replace infectious diseases as the leading causes of morbidity and mortality. Finally,
the third stage reflects a growing concern with health problems caused by rapid urbanization and to changing social
conditions in families, communities and the workplace which foster stress manifested by increasing violence, alcohol
abuse and drug addiction.
One of the distinguishing features of the health situation in developing countries is that, whereas developed nations
went through all three stages in more than a century, developing nations must face all three at once-consequently
health conditions in these countries have become a veritable “epidemiological mosaic.” The man in uniform is not
insulated from these developments. Changes have been observed in the Armed Forces as well, where on one hand
communicable diseases are still a priority (particularly in the field and operational areas) and on the other hand there
is increasing trend in non-communicable diseases and injuries with exception of COVID-19 pandemic in the year 2020
(Table 1.1 & Table 1.2).
Table 1.1 : Historical Trend of Morbidity Due to Communicable & Non-Communicable Diseases
Morbidity “All Communicable Diseases Non-Communicable Diseases
Year Causes” Rates % of “All % of “All
Per 1,000. Rates Per 1,000 Rates Per 1,000
Causes” Causes”
1877-79 1,322 989 75 333 25
1895-99 777 523 67 254 33
1915-19 788 515 65 273 36
1920 762 489 64 273 36
1930 453 272 60 181 40
1940 549 323 58 226 42
1950 352 156 44 196 56
1960 233 83 36 150 64
1970 203 64 31 139 69
1976 198 59 29 139 71
1989 125 27 22 97 78
1999 133 26 19 108 81
Overall morbidity rate per 1,000 of strength decreased from 1,322 in 1877-79 to 133 in 1999 as per AHR 2020.
Incidence of communicable diseases came down significantly and made a major contribution towards the improvement
of overall morbidity incidence. Non-communicable diseases also decreased but as compared with the spectacular fall
in the incidence of communicable diseases, the incidence of non-communicable diseases showed a more modest fall
during the same period. Similarly. the proportionate morbidity due to communicable disease decreased but that due
to non-communicable disease increased during the past 120 years. Social, environmental and economic improvements
have failed to control the impact of non-communicable diseases. In fact, these very socio-environmental changes have
promoted them by encouraging lifestyles involving lesser physical activities coupled with the stress of modern living
and increasing aspirations. Increased motorized transport also contributes to increasing incidence of Injuries due to
NEA which heads the list for causes of morbidity and mortality in the Armed Forces today.
Reduction in incidence of communicable disease through general improvement in the environment by exogenous
methods may reach its limit in near future. Further improvement in morbidity due to both communicable and non-
communicable diseases will need conscious efforts on the part of the people themselves. Health education of service
personnel and their families is, therefore, of utmost importance in addition to continuance of assiduous efforts to
further improve their environmental condition. Of the non-communicable diseases, ‘Injuries’ (non-enemy action) is one
single cause of high morbidity (24 per 1,000 in 1999 & 7.8 per 1,000 in 2020) and mortality (0.32 per 1,000) (Table
1.3). The other group, which has been causing concern, is the group called ‘stress diseases’.

5
INTRODUCTION TO MILITARY HEALTH

Table 1.2 : Leading Causes of Morbidity in Armed Forces (2020)

S. Rate Per 1,000
Diagnosis ICD No
No. 2020
1. COVID-19 U 07.1 & U07.2 25.17
2 Injuries (Non enemy action) (Accidents, falls, V, W X00-59, 64-84, 85-Y09, Y10-34 7.80
fire, bites, drowning, intentional self-harm,
homicides and others)
3. Acute Respiratory Infections incl Pneumonias J00-06,20-22 2.99
4. Disease of Urinary System NOO-12,17-19,20,21 2.26
5. Hypertensive disorder I10,15,111-13 1.87
6. ADS & Drug Abuse F10.X,F11.X-1.09-F19.X,F10.2,F12-19 1.09
7. Acid Peptic Disease K25,26,29,30 1.04
8. Psychiatric Disorders F20-69&F99 1.03
9. Diseases of Eye A71,H00-59 0.82
10. Skin infections B 35,36,86, L01,L02 0.74
11. Disease of Gall Bladder, Liver, Pancreas and K72,74,75,76,80-83,85-86,90 0.74
Intestine
12. Neoplasms C00-79,D00-48 0.70
13. Other mosquito borne illnesses B74,A83,A90-A92 0.65
14. Diseases of the Ear H60-95 0.65
15. Intestinal infections (excluding enteric fever, A03-04 &06-A09 0.60
cholera)
16. Metabolic Disorders incl Obesity E40-64, E66, M10.9, D50-64 0.58
17. Diabetes Mellitus E10-E14 0.58
18. Chicken pox B01 0.56
19. Enteric group of fevers A01-02 0.51
20. Malaria B50-54 0.50
21. Ischemic Heart disease I00-I09.9, I20-27, I30-52 0.48
Table 1.3 : Leading Causes of Mortality in Armed Forces (2020)
S. Rate Per 1,000
Diagnosis ICD No
No. 2020
1. Injuries (Non enemy action) (Accidents, falls, fire, bites, V, W X00-59, 64-84, 85-Y09, 0.32
drowning, intentional self-harm, homicides and others) Y10-34
2 Neoplasms C00-79, D00-48 0.08
3. Injury Enemy Action (Incl BC) Y 36 0.06
4. COVID 19 U 07.1, U 07.2 0.06
5. Ischemic Heart disease I 20-25 0.04
6. Desease of Gall Bladder, Liver, Pancreas and Intestine K 72, 74, 75, 76, 80-83, 85- 0.03
86, 90

6
 HISTORY OF MILITARY HEALTH

Effects of hot climate have been with us for a considerable long time, but effects of cold climate and high attitude
are the new conditions of concern consequent to the necessity of deployment of troops in the Northen and Eastern
India. Among the communicable diseases, sexually transmitted diseases including HIV /AIDS had assumed major
significance in view of the global pandemic of HIV/AIDS and increasing commitment of our troops both in stressful
internal security duties and overseas deployments for UN Peace Keeping Missions. However, intensive efforts through
preventive strategies including Behaviour Change Communication (BCC) and Information, Education and Communication
(IEC); the incidence has reduced drastically.

1.6 Infectious Disease Morbidity.

(a) Dysentery and Diarrhoea.
These are essentially the diseases of active service and have been present in every campaign, often with
devastating results. Experience obtained during the two World Wars indicates that the only way to reduce the
incidence is by the application of the principles of general sanitation. Over the years, because of better awareness
among the rank and file, the incidence of diarrhea and dysentery has declined in the Armed Forces. The incidence
of admission due to intestinal infectious diseases (excluding cholera and food poisoning) in the year 2001 was
3.27 per 1,000 in the Army, 0.98 per 1,000 in the Navy and 0.87 per 1,000 in the Air Force and in the year
2020 it decreased to 0.52 per 1,000 in Army, 0.45 per 1,000 in the Navy and 0.44 per 1,000 in the Air Force.
However, sporadic outbreaks of food poisoning among troops are reported from time to time. This calls for
continuous efforts to maintain high degree of food and water hygiene.
(b) The Enteric Group of Fevers.
These played havoc amongst the armies in the past. It is difficult to know its true incidence in the earlier wars
of history, but its incidence was 100 per 1,000 in the S. African war of 1899-1902. In India between the years
1890-1898, the incidence rose from 18.5 per 1,000 per annum in 1890 to 36.9 per 1,000 per annum in
1898. Due to its rising incidence a medical organization was set up with two objectives in view, firstly to institute
bacteriological inquiries in connection with enteric fevers and secondly to undertake detailed inspection of
sanitary conditions existing in unit lines. In July 1899 the importance of examining water supplies and ensuring
their purity and protection was realized.
Prophylactic inoculation for Enteric fever first invented by Prof. Arlmoth Wright of St. Mary’s Hospital London was
introduced for mass immunization of troops. Later, bleaching powder was introduced for purification of water by
Horrocks. These preventive measures resulted in an appreciable decline. In 1907, the incidence came down to
13 per 1,000 per annum and during the World War I, the incidence did not go higher than 5 per 1,000 in the
various theatres of operations.
The incidence of enteric fever in the Indian Army during the post-war period of 1919-33 remained between 3
and 4 per 1000. At about that period, the quality of TAB vaccine which hitherto had been prepared from the
old classical strains of bacilli, was further improved by ensuring that only virulent organisms which had fulfilled
certain tests, were employed in its preparation. Since the introduction of this more potent vaccine, the incidence
of enteric fever in the Army 1941 came down to approximately 1 per 1,000, 0.13 per 1,000 in 1950 and less
than 0.10 per 1,000 thereafter.
The superiority of this improved vaccine was clearly demonstrated during the N. African campaign of the last
world war. The incidence of enteric fever among Axis troops who were still being protected with the old type of
vaccine prepared from classical strains of doubtful virulence, was much higher than that among allied troops
and assumed almost epidemic proportions among the large number of prisoners of war taken at El Alamein.
Re-inoculation with stocks of captured vaccine, failed to check the spread of the diseases but as soon as
stocks of the potent vaccine became available the epidemic was quickly brought under control. On the other
hand, although ideal conditions existed for the spread of enteric fever among the British and Indian prisoners of
war in enemy hands, to the great surprise of the Axis medical authorities, very few cases of enteric fever were
encountered, although the sanitary conditions of these prison camps were primitive. Improved sanitation, control
of water supplies and care of food, both in Cantonments and in the field, had also contributed to the lowering of
incidence of enteric fever. But from the above-mentioned facts it seems obvious that this remarkable reduction
in its incidence had been mainly achieved by enforcement of the routine practice of prophylactic inoculation with
the potent TAB vaccine. This fact is also corroborated with the study of the morbidity tables of Burma campaign
during the last war when malaria, dysentery, viral hepatitis and typhus were responsible for high sick rate, but

7
 INTRODUCTION TO MILITARY HEALTH

enteric groups of fevers were at no time a serious problem.

In recent years, there has been a slow but steady increasing trend in the incidence of enteric fever in the Armed
Forces. In the Army, it has risen from a rate of 0.40 per 1,000 in 1991 to 0.87 per thousand in 2001; in the
Navy from 0.50 per 1,000 in 1991 to 1.19 per 1,000 in 2001; and in the Air Force form 0.30 per 1,000 in
1991 to 0.51 in 2001. In 2020, it was found to be 0.52 per 1,000 in Army, 0.45 per 1,000 in Navy and 0.44
per 1,000 in Air Force. Continuous endemicity indicates some deficiency in the food and water sanitation as
well as probable effect of advent of drug resistant strains of S typhi. Another reason may be that our troops are
now less insulated from the civil environment and eateries. It also raises doubts about the complete efficacy/
coverage by vaccination. The feasibility of introducing the newer oral vaccines against enteric fever and monitoring
their efficacy in military setting also needs to be explored.
(c) Malaria.
In addition to its specific role as a major global public health problem, malaria as a military medical problem
goes back into antiquity. Malaria has the potential of incapacitating such a large number of troops that military
operations may be jeopardized. In India, the Vedic medical literature recognized it as the “King of Diseases”.
The incidence of malaria in 2001 in Army was 4.08 per 1,000, in the Navy 5.89 per 1,000 and in the Air Force
2.32 per 1,000 and in 2020 it was 0.33 per 1,000 in Army, 3.66 per 1,000 in Navy and 0.30 per 1,000 in Air
Force.
With increasing deployment of our troops overseas in UN Peace Keeping Missions particularly in some of the
worst malaria affected regions of the world such as the African Continent. It is important that global intelligence
not only of the prevalence of various parasites and vectors of malaria be known to our medical officers but also
the different drug resistance patterns including recommendations for treatment and prophylaxis in different parts
of the world. These should be ascertained before deployment and adequate provisions of hygiene chemicals
(including repellents and synthetic pyrethroids for impregnation of mosquito nets) and appropriate antimalarial
drugs should be catered for and procedure of chemoprophylaxis to be undertaken meticulously.
Enforcement of the use of preventive measures is a command function. The appearance in a unit of cases of a
specific disease that should have been prevented by the application of the command directed preventive measures
(e.g. cases of malaria that should have been prevented with the prescribed chemoprophylaxis) should bring
about an epidemiological investigation to determine if the outbreak is due to failure of the prescribed preventive
measures to prevent the cases (e.g. the malaria parasites are resistant to the prescribed chemoprophylaxis) or
the result of command failure to enforce the preventive measures (e.g.. the soldiers are not taking the drug).
If the investigation shows that the cases are due to failure of the prescribed preventive measures, then better
methods must be decided upon and put in place quickly. If due to the latter, disciplinary action may be warranted.
In this connection, Field Marshall Sir William Slim, commander of the British Army in Burma in World War II, in
his personal diary of the period stated: “Good doctors are no use without troop discipline. More than half the
battle against disease is fought, not by doctors, but by the regimental q-officers.... When mepacrine was first
introduced .... often the little tablet was not, swallowed. An individual medical test in almost all cases will show
whether it has been taken or not.... /, therefore, had surprise checks of whole units, every man being examined.
If the overall result was less then ninety five percent positive, I sacked the commanding officer: I only had to
sack three; by then the rest got my meaning.”
(d) Dengue.
Dengue is an arbovirus, which spreads through bite of an infected female Aedes mosquito. There is an increasing
trend of reporting of Dengue case in Armed Forces. Around 1942 Dengue cases were reported in 2013 which
increased to 4,846 cases in the year 2019. In 2020, Armed Forces reported 998 cases only. However, the
dengue cases are on the rise across the country and our troops also remain at an increased risk of dengue
infection.
(e) The Rickettsial Group of Fevers.
Two common forms of typhus fever have been associated with the morbidity amongst    troops and these are
epidemic typhus fever and the scrub typhus.
(i) Epidemic Typhus Fever. It was a scourge of armies and the navies up to and including World War
I known as ‘Jail Fever’, ‘Ship Fever’, ‘Camp Fever’ and ‘Barrack Fever’. This was associated with louse

8
 HISTORY OF MILITARY HEALTH

infestation and overcrowding concomitant with wars and famines. During the World War II, outbreaks were
recorded at Naples among captured German and Italian troops in 1943 and in Middle East amongst Polish
refugees. The epidemiology and aetiology were studied. It made their control easier and added a great
deal of knowledge for the classification of fevers in this group. With improved knowledge in the dynamics
of disease process, better experience of organization of refugee and POW camps and better methods of
disinfestation, this disease is unlikely to become a major problem again.
(ii) Scrub Typhus. During the Second World War there were large outbreaks of Scrub typhus with a high
mortality rate in the Assam and West Bengal. The problems became so serious that special research teams
were established to elucidate the epidemiology. With the institution of rational preventive measures e.g., use
of mite repellents and avoidance of mite infested areas along with large scale use of modern insecticides,
the hazard of this disease was reduced to a great extent. However, the lessons learnt were soon forgotten
and during and after the operations in J & K from 1947 to 1953 there were serious outbreaks. In 1965,
Indian troops occupying the Pakistan territory adjacent to Jammu and Amritsar suffered heavy casualties
due to scrub typhus which could have been averted. It is observed that the incidence shoots up whenever
troops are deployed for operational purposes and they fail to observe preventive measures. The incidence
in 1971 and 1972 during and after Indo-Pak War was 0.12 and 0.04 per 1,000 respectively. However, scrub
typhus need not always be associated with operations. Time and again there have been focal outbreaks
during peacetime including in a training academy where after outdoor training few officer cadets contracted
scrub typhus.
(f) Plague.
Horner, 3,000 years ago, described the first outbreak among the Greeks at the siege of Troy. The relationship
between what is now known as epizootic plague and the human plague had been appreciated in Bhagavata
Purana written sometime between 700 to 500 BC. The people were warned to ‘desert their homes when rats fall
from the roof above, jump about and die’. The earliest official record of plague was made by Emperor Jehangir
in 1612. The first serious outbreak was in Bombay in 1896 having probably been imported from Hongkong and
thence it spread to Kolkata and subsequently throughout India. A plague commission appointed to investigate
into the various factors involved in the epidemiology of plague completed the report in 1904 and rationally
established the role played by the rat and the rat flea in its transmission. Plague accompanied armies all over
Europe from Norman days to the end of the 17th century. It was essentially a disease of the base and Comm
Z area, of besieged cities and towns but not of troops on the move. ln any case, plague has never been a
disease of military camps, even when the Cantonments were too close to the infested towns. The disease
made a comeback in India in September 1994 after a gap of almost 30-years (after 1966), when 4 persons
tested positive for bubonic plague in Beed (Maharashtra) followed by an outbreak of pneumonic plague in Surat
(Gujarat). Cases were also reported from Delhi, Mumbai, Kolkata and some other places. 4,780 suspected cases
were reported, out of which 167 tested positives for plague and 53 deaths were reported in 1994. More recently,
16 cases of pneumonic plague were also reported from Shimla district, Himachal Pradesh in 2002. With the
present knowledge of its epidemiology and control measures based on rodent and flea control, judicious use of
residual insecticides and efficient vaccine in prevention, drugs and antibiotics for its treatment, it is extremely
unlikely that our troops will ever be seriously menaced by plague.
(g) Cholera.
In the past cholera has always been present among the troops both in the field and in the barracks. Cholera
had been endemic in certain parts of India for a long time and had assumed epidemic proportions from time to
time due to well-known causes. Troops were thus liable to contract infection in the field and in garrison towns.
High mortality and ignorance of its causation created scare. Considerable research on cholera has been carried
out in India and its epidemiology has been understood to a great extent. It used to be said that ‘you can eat
cholera; you can drink cholera, but you cannot catch cholera’. Outbreaks of cholera occurred in the war 1914-
18 in Austria, Germany, Russia, Turkey, Palestine and Mesopotamia. Localized outbreaks have occurred in the
Army from time to time.
A new strain of cholera, code named 0139, emerged in India in 1992. It spread westwardly to Pakistan and in
the East to Bangladesh. In the early months of 1993, cholera caused estimated one-lakh cases and 10,000
deaths in southern Bangladesh. Although it has not spread that rapidly since then, it remains a threat.
Cholera is now commonly due to El Tor biotype. Most of the cases nowadays are mild or asymptomatic.

9
 INTRODUCTION TO MILITARY HEALTH

Epidemiological studies have shown that cholera is responsible for about 5-10% of all acute Diarrhoea cases in
a non-epidemic situation. Global experience of the ongoing pandemic has shown that cholera can get introduced
into any country but can create problem only in areas where other acute enteric diseases are endemic signifying
defective sanitation and unsafe water supply.
(h) Smallpox (Obituary).
There was a time when the prevalence of the disease was very high. As a result of successful vaccination
drive, surveillance and containment, it has been possible to achieve global eradication of the disease on
29th Oct 1979 with the active support of WHO. India reached the goal of smallpox eradication in April 1977.
(j) Brucellosis.
Undulant fever was responsible for causing a high sick rate amongst the naval and military garrisons in Malta.
David Bruce discovered the causative organism in 1884 but it was not until 1905 that a committee under the
chairmanship of Bruce found goat as the reservoir of infection. The knowledge of aetiology of this disease helped
in its elimination from the Army and Navy. Sporadic cases of brucellosis, both Malta fever and abortus fever,
have been reported amongst the troops in India. Improved management of dairy farms under veterinary and
medical supervision, pasteurization and the popular custom of boiling milk are responsible for the low incidence
of brucellosis amongst our troops.
(k) Sexually Transmitted Diseases (STD).
In 1898, incidence of sexually transmitted diseases was 30.5 per 1,000 per annum in the Army which rose to
60.5 per 1,000 per annum in 1920. However, it dropped to 7.5 per 1,000 in 1938. During World War II there
was a steep rise in the incidence of STD and reached its peak in 1943 with a rate of 49.3 per 1,000. As
mentioned earlier stress of war affects people in different ways; for some there is breakdown in morale leading
to war psychosis, while in others it is the breakdown of morals leading to increased incidence of STDs. Both
call for effective military leadership.
The post war decline in STDs began in 1946, when the admission rate was 46.6 per 1,000. further coming
down to 10.5 per 1,000 in 1951. Since 1956, the incidence has been below 4,000 and this downward trend
continues to date. In the year 2001, the incidence of hospital admission for STDs in the Army was 0.19 per
1,000, in the Navy 0.64 per 1,000 and in the Air Force 0.04 per 1,000.
(l) HIV Infection and AIDS.

Fig 1.6 : Decadal Trends in HIV among Armed Forces Personnel

There was a gradual increase in the incidence of HIV infection in the Armed Forces since the first case of HIV
was detected in the services in the year 1986.HIV infections were rising in Armed forces till about year 2000
but with an intensive preventive program it remained constant for few years and finally began to fall by 2008

10
 HISTORY OF MILITARY HEALTH

(Fig 1.6). In the year 2020, the rate per 1,000 for the Army was 0.01, for the Navy 0.05 and 0.01 in the Air
Force. Most of those infected (80.75%) have reported the source of infection as unknown.
Besides, the problem in the Armed Forces has to be seen in the context of the Global and National Scenario
since with increasing commitments of our forces both within the country and internationally (UN Peace Keeping
Missions), there is increasing interface between the civil and military populations. Globally there are over 30
million HIV positive persons in the world and some of the worst affected continents are Africa and Asia (these
are the very places our troops are deployed during peace keeping missions). In India most of the big cities such
as Mumbai, Chennai, Pune, Delhi, Kolkata, Goa and the Northeast are pockets of intense HIV transmission.
Military service provides a disciplined highly organized environment in which HIV/AIDS prevention and education
can be provided to a large audience. In some ways, such efforts fit perfectly well with the ethos of a profession
that places a high value on loyalty to comrades amid the tradition of officers looking after the welfare of troops
under their command.
(m) Covid 19 and its Impact on the Armed Forces.
Corona Virus Disease-2019 (COVID-19) was declared as Pandemic by WHO on 11th Mar 2020 with India reporting
its first case on 30th Jan 2020. COVID-19 was the leading cause of morbidity (25.17 per 1,000) and fourth
highest cause of mortality (0.06 per 1,000) amongst Armed Forces in the year 2020 as per AHR 2020. Overall
Case Fatality rate for COVID-19 in the year 2020 was 2.42 (Table 1.4).
Table 1.4 : Disease Burden of COVID-19 among Armed Forces Personnel in 2020
Cases Reported (Absolute Numbers) Rate
Category
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total (2020)
Morbidity 0 0 12 63 389 2,149 5,289 9,124 10,723 5,735 3,830 2,298 39,612 25.17
2.42
(Case
Mortality 0 0 0 0 9 4 9 13 20 16 13 12 96
Fatality
Rate)

1.7 Non-Infectious Disease Morbidity.

(a) Nutritional Deficiency.
The task of feeding sailors and soldiers in war has always been a difficult one. Scurvy was for centuries the dread
of mariners. In planning military nutrition in India, one must bear in mind two facts viz. the supply of food to
large bodies of troops in the field may pose a logistic problem and secondly the nutritional state of recruits on
enrolment. It should be our endeavor that the troops are supplied with rations not only to subsist but also for
promotion of positive health. Sometimes, it is not possible to deliver these rations and as a result, the nutrition
of the troops may suffer. Ration scales now cater for different requirements e.g., at high attitude and deserts.
Vitamin C and compound vitamin tablets can be issued to the troops in emergency to prevent deficiency diseases
whenever they have to subsist on freeze dried rations. Morbidity due to Nutritional Deficiency has been negligible
in recent years.
(b) Stress Diseases.
The group of illnesses called ‘stress diseases’ is gradually emerging in the list of important diseases. Modern
civilization with its accelerated tempo of life has brought in its wake stimuli which hitherto were absent or were
of such low impact that they did not stimulate the chain of psycho-physical reactions enough to cause manifest
effects. Age of ‘infections’ is gradually passing to an age of ‘stress’. Stress constitutes a chain of psycho-physical
reactions which, when generated in excess of or for longer periods than necessary for physiological functions,
creates manifestations of ‘stress diseases’. This group broadly a risk factor for psychiatric diseases, hypertension
and ischemic heart disease. Stress diseases has shown a steady increase in incidence in the past three decades
and unlike communicable diseases seems refractory to preventive measures.  
Even in peacetime, the occupation of the soldier exposes him to certain stressful conditions peculiar to military
service. Increasing demands made on the military for internal security duties, CI Ops, Low-intensity Conflicts (LIC),
aid to civil authorities, etc. together with the harsh deployment condition of the soldier and unsettling family life
may increase stress among servicemen.

11
 INTRODUCTION TO MILITARY HEALTH

(c) Injuries (Non-Enemy Action).

Like the stress diseases, the incidence of injuries (non-enemy action) also has maintained a steady trend in
the past three decades and appears refractory to control measures (Table 1.5). Injuries cause great wastage
of man-days and manpower. Moreover, the money spent on their treatment and rehabilitation has increased
the importance of prevention of injuries. Injuries may be sustained on roads by mechanical transport accidents,
workshops, during training, during operational and tactical maneuvers in daily routine tasks due to poor training,
unsafe and careless working methods, at homes, during organized games and sports. All have their definite
epidemiology and preventive aspects. It is also among the leading cause of’ death in all the three services with
highest rate among cadets.
Table 1.5 : Decadal Trend in Hospital Admissions for Injuries Due to Non-Enemy-Action (Rates Per 1,000)
Year Army Navy Air Force Armed Forces
2010 19.50 12.03 19.34 17.85
2011 18.23 4.99 18.26 17.31
2012 17.90 6.57 16.06 16.84
2013 17.00 6.16 18.60 16.91
2014 17.11 5.39 17.82 16.86
2015 19.07 4.51 16.24 18.04
2016 17.77 4.61 9.95 16.38
2017 17.67 1.66 3.64 15.62
2018 17.65 0.87 7.35 15.87
2019 15.88 0.97 10.12 14.55
Avg of 10 years 17.78 4.77 13.73 16.62
2020 8.58 0.50 4.99 7.80

1.8 The Past and the Present.

A study of the past campaigns shows that more men are lost by sickness than by enemy action and that the majority
of the diseases are preventable even during active warfare. Diseases have decimated armies even before reaching
the scene of operations and expeditions have been abandoned owing to the ravages of diseases in camps. Table 1.6
shows the breakdown of battle and non-battle casualties in some past conflicts.
Table 1.6 : Breakdown of Battle & Non-Battle Casualties in Past Conflicts (Annual Rates Per 1,000)
Non-Battle
Battle Cas Breakdown of NBC
Casualty
Periods to
Killed in Action/

Death Incl BID

Malaria

Mental Illness
Adm to Hosp

Adm to Hosp

Minor Sepsis

Theatre of which the

Injury (NEA)
STDs (VD)

All Others
Dysentery

Influenza
Diarrhea

War Figures
Cold
BID

TB

Relate

Indo-Burma 1942-Sep 21 8.5 8.33 4 311 41 41 28 31 26 27 1 4 2 315

45
Ceylon Army 1942-45 1 - 716 2 156 42 51 40 22 20 15 5 4 1 362

Egypt/ 1939-45 17 6 433 2 27 20 51 26 16 13 15 2 4 1 258

Palestine/
Cyprus/
BNAF

12
 HISTORY OF MILITARY HEALTH

Non-Battle
Battle Cas Breakdown of NBC
Casualty
Periods to

Killed in Action/

Death Incl BID

Malaria

Mental Illness
Adm to Hosp

Adm to Hosp

Minor Sepsis
Theatre of which the

Injury (NEA)
STDs (VD)

All Others
Dysentery

Influenza
Diarrhea
War Figures

Cold
BID

TB
Relate

Sudan/ 1940-43 48 22 259 1 25 33 22 11 13 10 7 1 2 0 135

Eritrea
Iran/Iraq/ 1939-45 1 14 550 3 79 49 43 33 18 15 24 2 3 1 284
PAI Force
Aden & 1940-45 1 0 553 2 55 47 53 31 22 14 19 5 1 0 316
Scotra
Indo China 1962 1.29 NA 223 0.95 0.91 3.04 24.3 NA 3.8 5.1 14.5 1 0.2 - 167
Conflict (Sep-Dec)
Indo Pak 1965 (Apr 19 477 246 0.7 0.6 4.1 37.7 NA 5.0 5.7 6 1.3 3.4 - 188
conflict -Sep)

Indo Pak 1971 11 NA 193 NA 0.05 3.9 29.5 17 4.1 4.7 3.7 1.6 4 - 133
conflict (Dec)
The hospital admission rates among Armed forces personnel in the decade 2010-2019 is shown in Table 1.7. Injuries
(NEA), diseases of musculoskeletal system and connective tissue, ARIs, diseases of urinary system, psychiatric illnesses
and COVID-19 (in 2020) are the major causes of morbidity in this decade.
Table 1.7 : Decadal Hospital Admission Rates – All Causes (Rates Per 1,000)
Year Army Navy Air Force Armed Forces
2010 117.10 161.83 121.18 120.82

2011 107.98 152.39 118.20 112.58

2012 104.95 128.21 117.50 108.41

2013 102.53 136.64 106.29 105.46

2014 100.77 143.59 99.39 103.56

2015 109.65 120.50 91.41 108.28

2016 102.41 127.05 89.97 102.42

2017 93.13 115.21 87.88 93.69

2018 90.44 125.63 96.95 92.77

2019 90.07 121.20 114.47 94.03

Avg of 10 years 101.90 133.23 104.32 104.20

2020 70.42 117.07 101.75 75.98

1.9 Future Challenges.

The end of the cold war has substantially altered the nature of the threat to global security. and along with it the
military strategic responses of the nations of the world. Military forces were formerly preoccupied with the potential for
large scale, high intensity armed conflicts. The primary strategic concern now seems to have shifted to the containment
of various regional ethnic and religious conflicts and to the prevention of terrorist attacks against national interests,

13
 INTRODUCTION TO MILITARY HEALTH

both at home and abroad. The use of weapons of mass destruction (biological, chemical and nuclear) among warring
factions or by terrorists against national targets is regarded as a distinct possibility. The effect of these trends has
been to increase the mission diversity of our Armed Forces to include not only fighting war, but also peacekeeping,
humanitarian assistance and disaster relief missions, which, in turn, require the medical capacity to provide highly
flexible and mobile support over long distances and in widely diverse environments. To meet these challenges, Military
Medical Officers, besides being well-versed in general preventive medicine, should also be conversant with the following
subspeciality areas of military preventive medicine.
(a) Aviation medicine, (b) Marine medicine, (c) Occupational medicine, (d) Sanitary engineering, (e) Environmental
science, (f) Entomology, (g) Parasitology, (h) Veterinary sciences, (j) Basic epidemiological and statistical methods,
(k) NBC Warfare.

1.10 Conclusion.
Preparedness of Armed Forces for war depends largely on its training, equipment and its physical fitness. Physical
fitness is largely the outcome of good nutrition, physical training and absence of illness. Therefore, prevention of
illness and injuries occupy a prominent position in the life and efficiency of the Armed Forces in a country. It is amply
proved from the campaigns described earlier that prevention of diseases in peace and war time would pay dividends.
Hence importance of prevention of illness. knowledge of theory and practice of preventive medicine at all levels and
education of troops in all spheres cannot be overemphasized. Most communicable ailments can be totally prevented
by rigid attention to environmental control, personal care, immunization and health education of troops. Comprehensive
medical care starts with preventive aspects and ends with rehabilitation.

Suggested Reading.
1. Allen B. Distribution Statement Approved for Public Release the Effects of Infectious Disease on Napoleon’s
Russian Campaign, A Research Report Submitted to the Faculty in Partial Fulfilment of the Graduation Requirements
[Internet]. 1998 [Accessed 2024 Apr 1]. Available from: https://apps.dtic.mil/sti/pdfs/ADA398046.pdf.
2. Annual Health Report of the Armed Forces 2020, Office of the DGAFMS, Ministry of Defence
3. Banerjee A. Resurgence of MT Malaria in the Northeast: The Dilemma of Chemoprophylaxis. Med J Armed Forces
India. 1996 Oct;52(4):274, Doi: 10.1016/S0377-1237(17)30891-2. PMID: 28769420; PMCID: PMC5530784.
4. Viscount Mountbatten, Viscount Alan Brooke, The Strategy of the South-East Asia Campaign, Royal United Services
Institution. Journal, 91(564), 469-484, DOI: 10.1080/03071844609433961.
5. Banerjee A, Nayak B. Epidemiological And Entomological Correlation of Malaria Transmission in an Air Force
Station. Med J Armed Forces India. 2001 Jul;57(3):191-3. doi: 10.1016/S0377-1237(01)80040-X. PMID: 27365601;
PMCID: PMC4925055.
6. Bruce D. Prevention of Disease. Science [Internet]. 1924 [Accessed on 2024 Apr 1];60(1545):109–24. Available
from: https://www.jstor.org/stable/1650338.
7. Watt JR, Saving Lives in Wartime China: How Medical Reformers Built Modern Healthcare Systems Amid War
and Epidemics, 1928-1945 [Internet]. brill.com. Brill; 2014 [Accessed 2024 Apr 1]. Available from: https://brill.com/
display/title/20235?language=en
n

14
 ACCOMMODATION AND SHELTER

Chapter
II
ACCOMMODATION AND SHELTER

2.1 Introduction.
Accommodation and shelter are a basic human need. However, a ‘house’ means more than a roof over one’s
head: It means to have a home, a place that protects privacy, contributes to physical and psychological well-being
and supports the development and social integration of its inhabitants a central place for human life.

2.2 The WHO Approach to Housing and Healthy Housing.

‘Housing’ is a comprehensive concept considering various factors contributing to the quality of housing and housing
environment. The Habitat Declaration, Istanbul (1996), defines the characteristics of an ‘adequate shelter’ as “Adequate
shelter means more than a roof over one’s head. It also means adequate privacy, adequate space, physical accessibility,
adequate security, security of tenure, structural stability and durability, adequate lighting, heating and ventilation;
adequate basic infrastructure, such as water supply, sanitation and waste-management facilities; suitable environmental
quality and health related factors; and adequate and accessible location with regard to work and basic facilities...”
Healthy housing is a complex construct that cannot be represented merely by the physical structure of the home. The
WHO understanding of ‘Healthy Housing’ is, therefore, based on a four-layer model of housing, taking into consideration
the physical structure of the dwelling, the extent to which it enables physical health, the external dimension of the
immediate housing environment and the local community with all neighbours.
There is considerable evidence that housing conditions affect health status. Nevertheless, we are still left with the
question, “what is healthy housing?” Housing is the conjunction of the dwelling, the home, the immediate environment
and the community. The role of public health is to facilitate circumstances under which people can be healthy.

2.3 Housing as a Determinant of Health.

An increasing body of evidence has associated housing quality with morbidity from infectious diseases, chronic ailments,
injuries, poor nutrition and mental disorders. Some of the health effects of housing are summarized below.
(a) Infectious Diseases.
Poor housing standards and lack of basic hygiene facilities like lack of safe drinking water, lack of water for
maintaining personal hygiene, inefficient or absent waste disposal systems, easy access to disease vectors and
rodents, have long been associated with spread of infectious diseases. Overcrowding and poor ventilation are
associated with the spread of respiratory diseases and tuberculosis.
(b) Chronic Diseases.
While inadequate housing conditions and infectious diseases have long been associated, epidemiological studies
in more recent years have shown the relationship between improper / substandard housing conditions and risk
of chronic ailments. For example, damp, cold and mould infested houses are associated with asthma, allergies
and other chronic respiratory diseases.
Living in cold houses has been associated with a generalized lower health status and increased utilization of
health services. Recent studies have shown that deviation of indoor ambient temperature beyond a relatively
narrow range may be associated with increased risk of cardiovascular diseases. Exposure to toxic substances
found in homes can result in chronic health problems (Table 2.1). Exposure to Environmental Tobacco Smoke
(ETS) and its myriad ill effects are well documented. Volatile Organic Compounds (VOC) emitted by numerous
household cleaning and disinfectant agents, floor coverings, etc. may be associated with several adverse health
effects including asthma and Sick Building Syndrome. Some of the VOCs are known carcinogens. The relationship
between lead exposure and neurodevelopment abnormalities is well established, now additional evidence suggests
an association with hypertension.

15
 INTRODUCTION TO MILITARY HEALTH

Table 2.1 : Pollutants, Their Source and Their Impact on Health

Pollutant Sources / Types Health Hazard
Respirable particles Tobacco smoke, smoke, stoves, Respiratory tract disorders
biomass fuel, etc.
Carbon monoxide, Nitrogen dioxide, Combustion Respiratory tract disorders
Sulphur dioxide, Carbon dioxide

Volatile organic compounds Cleaning materials & solvents Asthma, allergies, mucosal irritation,
carcinogens
Types: Formaldehyde, benzene,
toluene
Radon and its decay products Building material Carcinogens
Asbestos Insulation, fireproofing Asbestosis, Carcinogens
Biological hazards Bacteria (Legionella, Airborne infections, asthma,
Mycobacterium), viruses and fungi infections
(moulds),
pests (cockroaches, mites, bedbugs,
rats)
(c) Injuries.
Unintentional home injuries are a serious health problem. Dwelling design and maintenance is an important
factor related to such injuries. Houses contain physical dangers like gas, electrical fittings, steps, stairs, balconies,
breakable glass window panes, unprotected upper storey windows, low railings, etc. which pose imminent risks
for domestic accidents.
(d) Mental Health.
Data gathered from the WHO LARES (Large Analysis and Review of European housing and health Status) shows
that people are significantly more depressed and more anxious when they live in a dwelling that is overcrowded,
has inadequate ventilation, does not offer adequate protection from noise, dampness, moulds, etc. Studies
have demonstrated a consistent association between mental disorders and urban living conditions. Though
alcoholism, vandalism, adolescent delinquency, schizophrenia, etc, may not be caused by bad housing alone
and are symptoms of more complex social pathology, it is also accepted that stressful housing conditions can
aggravate pre-existing psychiatric pathologies. Finally, indoor exposure to toxic compounds (i.e. heavy metals,
solvents) may lead to neuropsychiatry disorders.
(e) Neighbourhood Health Effects.
Besides the conditions of the housing unit, the immediate neighbourhood is also documented to have health
effects on the inhabitants. These include increased rates of intentional injuries, poor birth outcomes, cardiovascular
diseases, STD, depression, physical inactivity and obesity. Several features of the neighbourhood may contribute
towards ill health. The air quality may be poor due to proximity to major highways or roads, improper waste
disposal in the neighbourhood, absence of green spaces and walking areas may promote physical inactivity and
obesity. Several social dimensions of neighbourhoods also affect the health of the inhabitants.
(f) Built Environment and Health.
The built environment encompasses all buildings, spaces and products that are created or modified by people.
It includes our homes, schools, workplaces, parks, industrial areas, farms and roads. The built environment not
only impacts indoor and outdoor physical environments (e.g., climatic conditions, indoor and outdoor air quality),
but it also affects social environment and subsequently our physical health and quality of life. Recent research
has explored the effect of built environment on physical activity, asthma, obesity, cardiovascular diseases, cancer
and mental health. These complex diseases are attributable to an interaction of genetic and environmental
influences and many of the later can be directly connected to the built environment.

16
 ACCOMMODATION AND SHELTER

2.4 Housing in Special Situations.

The criteria of healthy housing have been laid down by several agencies and are updated from time to time. Housing
and health; APHA (American Public Health Association) - CDC recommended minimum housing standards’ which specify
standards related to basic facilities and equipment. The ‘WHO Health Principles of Housing’ throws light on the wide
range of behavioural factors that can influence health in relation to housing conditions. In India certain standards have
been laid down for affordable housing and have been enunciated in the recent document of Pradhan Mantri Awas
Yojna - Gramin (PMAY-G). However, none of these standards are legally enforceable and can only be used as guidelines.
(a) Housing in Urban Slums.
In the last few decades with increasing urbanization, there has been a great increase in the number of people
staying in peri-urban or urban areas in slums or shanties. These dwelling are not only highly substandard, but
they often lack basic sanitation, access to clean water supplies, medical care and other basic services. The
proportion of people residing in such situations ranges from 20 to 80 percent in most cities throughout developing
nations like in South, South-east and South-west Asia, Africa and Latin America.

2.5 Housing in the Armed Forces.

Housing in the Armed Forces has its special considerations for the reason that the forces tend to be frequently
on the move and may require to leave one area to occupy another or may at times have to reside in inhospitable
terrains for prolonged periods. Quartering of the service personnel should be analysed with respect to permanent
accommodation in family stations and accommodation in field areas. While guidelines and recommendations on
standards of housing may be adhered to for the living accommodation in peace / family areas, the same may not
be possible during operations / exercise locations. During operations / exercise / move etc, priority is given to safety of
troops. Improvisations for comfort only follow after ascertaining the safety from operational point of view. Often, due to
operational requirements troops have to stay in compromised living conditions. It is the duty of the medical authorities
to point out to the commander the dangers to the health, which may follow if the standards and rules for healthy
living are violated. If in spite of such advise the commander decides to quarter the troops in unhygienic conditions
for tactical or strategic reasons, the medical authorities must be vigilant and recommend measures to minimize risk
to the health of the troops.
(a) Temporary Accommodation for Troops.
Accommodations for troops when they move out of their military camps usually include the following: Bivouacs,
trenches, dug outs, bunkers and tents. While most of them are meant as a temporary measure, however at
times, troops may have to occupy these for longer periods.
(i) Bivouac.
A bivouac is a temporary, overnight shelter used during emergency, when troops are on the move  / in
an operational area. These provide very scanty shelter, usually in the form of a ground sheet stretched
overhead.
(ii) Trenches, Dugouts, Bunkers.
These are defensive fortifications. Bunkers are mostly below the ground. In certain areas massive bunker
complexes were built to house strategic infrastructure as well as troops and stores. There are several types
of bunkers like the trench bunker, pillbox bunker, industrial bunker and personal shelter bunker. The basic
plan of a bunker is to provide a structure that can withstand physical compression. A bunker should deflect
blast waves from explosions to prevent internal injuries to people sheltering in the bunkers. In the present
scenario of nuclear warfare, the bunkers must also provide radiation protection. Technical expertise is
provided by the Corps of Engineers during construction of these bunkers. However, factors which influence
the health of the troops, like ventilation, protection from heat, cold, wind, snow etc, must be given due
consideration. Prolonged occupation and maintenance of sanitation in bunkers, trenches and dug outs
present difficult problems and are tiring for the physical and mental health of the troops.
(iii) Camps.
These are much healthier than bivouacs. Camps can be ‘permanent’, ‘semi-permanent’, ‘temporary’ and
‘standing’ or ‘perimeter camps’. The ‘standing camps’ are in fact temporary or semi-permanent camps used
mainly for administrative, tactical or strategic concentration on the LOC or in concentration zones. They may

17
INTRODUCTION TO MILITARY HEALTH

be occupied for a month or so for which huts or barracks would be normally provided if a prolonged stay
becomes necessary. ‘Temporary camps’ are those occupied for a duration of not more than a week, during
exercise, manoeuvres, artillery practices or for resting on the line of march to the cone area or destined
location. ‘Permanent camps’ are those which are in occupation for more than a year and where the living
accommodation and all ancillaries and sanitary facilities must conform to the standards laid down as soon
as possible. Such camps are found in the field areas at the corps or divisional bases and also on the LOC
or communication zones.
(aa) Selection of Site.
The selection of a campsite, particularly for a temporary camp, is usually determined by the facilities
which exist for obtaining water. The comfort and convenience of troops and their health should be
the guiding consideration in selecting the campsite, specially for selecting sites for semi-permanent
and permanent camps. In hostile country, however, military exigencies govern the selection of the
site. Often. however, there are alternative sites. which may make all the difference to health, but
the selecting officer may not realize this unless pointed out. The senior medical officer should point
out the most healthy of the alternative sites, particularly in relation to malaria, typhus and other
preventable diseases in which the ‘Landscape epidemiology’ plays the important role. Advice should
be given before selection has been made because a change after settling down is often not possible
and medical objection at this late stage may be resented.
(ab) Layout.
Camps should be located on high grounds. Marshes, irrigated lands and vicinity of villages should be
avoided. Rocky ground and land where the subsoil water may be expected to be high, i.e. the dry beds
of water course and low-lying ground at the mouths of the river, ploughed and dusty areas, abandoned
camping grounds and land in the vicinity of intensive agriculture should be avoided as sudden storms
and the resulting spates are liable to sweep everything off such an area. Malaria and scrub typhus
risk in such an area is also high. Dangers of aerial attack might alter entirely the requirements as to
the size and layout of all types of camps. The necessity for camouflage, dispersion and concealment
will affect the distances between sub-divisions of unit, kitchen, bathhouses, latrines and so on and the
provision of sufficient water may become an additional problem. Sanitary arrangements and various
sections / departments should be organized taking into account all such unforeseen contingencies,
the expected length of stay and facilities available. The general layout of a camp should be planned
after taking the following points for guidance. Modifications will often have to be made because of
the physical configurations of the ground, approach from the road, necessity of concealment from
the air and so on.
O Any sector of the camp should be at least one kilometre away from any village or local
habitation and from any collection of water likely to breed mosquitoes.
O It is necessary to forbid troop movement towards villages and to place the village ‘out
of bounds’ for troops from dusk to dawn as an extra precaution against contracting mosquito­
borne, excremental and sexually transmitted diseases.
O Direction of the prevailing wind should not be from the village or breeding places of
mosquitoes towards the camp.
O The camp and all its sub-units and sectors should be on high ground.
O The front of the camp should face the prevailing wind (except at high altitude where wind­
chill is a hazard).
O Sleeping accommodation should be in front with cooking and messing accommodation
nearby on one side.
O The bathing area and water point should be at one side, well away from the conservancy
area and with drainage so arranged as to prevent waterlogging in the camp.
O The conservancy area should be concentrated to the lee-ward side, not more than
200 meters from the most distant sleeping place and not in a place likely to pollute water supplies.
O Transport lines for vehicles and animals should be concentrated in special areas in the

18
 ACCOMMODATION AND SHELTER

rear. This applies particularly to composite camps for several units, where the establishment of
one single animal picketing ground for all units has a marked effect in reducing fly prevalence.
O Camp roads should be so arranged that vehicle and animal traffic does not cover the
cooking and messing areas with dust.
O The camp should be provided with surface drainage.
(iv) Tented Camps.
Tented camps are usually of a temporary nature, but due to tactical, administrative, logistic and economic
reasons, they may be protracted over longer durations. Various improvisations may have to be introduced to
decrease the discomfort and health hazards to the troops. Ventilation, overcrowding are problems commonly
associated with tented accommodation. Presently, use of TEFS (Tent Extendable Frame Supported) is
common in the Armed Forces. After first appearing during the Second World War, these tents have through
the years evolved into Extendible Modular types that have become widely acknowledged the world over as
the most practical alternative shelters in times of unrest. Furthermore, TEFS can today adapt many special
requirements such as vehicle maintenance, field kitchens and mobile hospitals to the original standard
modular tents. As far as possible, only authorized strength of persons should use the tents, four persons
in the four- man tent and two men in the two-man tent. Modular shelters, fiberglass huts and various other
prefabricated shelters are now in use. However, in all such shelters, problems of overcrowding and improper
ventilation continue to worry the medical authorities. Risk of carbon monoxide poisoning and fire hazard
are relevant concerns in high altitude living arrangements.
(b) Permanent Accommodation.
In cantonments, garrison stations and in peacetime, accommodation for single men is provided in permanent
barracks. The primary consideration here is ‘the health and comfort of troops’ and this outweighs any other
consideration. In general, married accommodation available for troops falls short of requirement. The commanding
officer should ensure equitable allotment of such accommodation at his disposal so as to permit the personnel
to bring their families by turn. Due to the shortage of married accommodation in most of the military stations,
outliving or living under own arrangements (or CILQ) is usually resorted to, to enable the soldier to live with his
family. The commanding officer of the unit is responsible for ascertaining that the hygiene, sanitation and other
aspects of the accommodation proposed to be used by the service personnel is satisfactory and periodic checks
are also ensured by the unit rep to ascertain the living conditions from time to time. Scales of accommodation
for the various ranks in the Armed Forces is given in Table 2.2 to Table 2.5.
(i) Minimum Prescribed Standards.
The housing for single men in the Armed Forces is unique in that a large number of people share the
accommodation and are in close contact for a large period of time. Prevention of infections and diseases
in such setting prompts the requirement for prescribing certain standards for ‘healthy living space’. These
standards may also prove to be useful in other circumstances where people may have to live in close
contact like refugee camps, prisons, correctional centres, boarding schools, tourists or pilgrim’s camps etc.
It may be in barrack, hut, bunker, basha or tent; principles applicable to one are applicable to all types of
accommodation.
(ii) Per Person Space Requirement.
The space allowed per individual in a barrack is a minimum 2 metres of linear wall space, 5 metre2 of floor
area and 18 metre3 of air space with the exclusion of any height above 3.6 metres. The distance between
centres of two adjacent beds / bunks should not be less than 1.8 metres, but during exigencies of service,
these scales may have to be reduced after a medical review. The US Army in its technical bulletin on non-
vaccine recommendations for prevention of acute infectious respiratory diseases among army personnel
staying in close quarters has recommended 72 sq. ft. of floor space per person with at least 3 feet between
adjacent beds to minimize disease agent transmission. In all forms of accommodation, whether permanent,
temporary or even in tents, this minimum space should be ensured. At times, overcrowding in the barracks
becomes inevitable, as is usually seen in some regimental centres. Given below in an illustration of a
method of optimizing floor space utilization, while allowing maximum space between the beds (Fig 2.1).

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INTRODUCTION TO MILITARY HEALTH

Fig 2.1 : Method for Optimizing Floor Space Utilization

(iii) Ventilation Standards
Various standards of ventilation have been prescribed by different workers. Ventilation is usually measured
in cubic space, air change or floor space. The accepted standards are 1,000 to 1,200 cubic feet space
per person and 50 to 100 sqft floor space per person. However more subjectively, it is usually said that
at 0300 h in the morning, if no musty or unpleasant odours are perceived inside the barrack / room, the
ventilation is satisfactory. For ensuring adequate ventilation, the total window space should not be less
than 1/10th of the total floor space and cross ventilation should be maintained.
(iv) Temperature and Humidity.
Though temperature and humidity are both perceived to be matters of personal comfort, both these factors
are associated with health symptoms. High humidity can support the growth of fungus, moulds, mites,
etc. The U.S. Occupational Safety and Health Administration (OSHA) recommends maintenance of indoor
temperatures in the range of 68-76°F and humidity levels of 20-60%.
(c) Scale of Accommodation.
It is given in “Scales of Accommodation 2022” published by MES (Military Engineering Services), Engineer-
in-Chief’s Branch of Integrated Headquarters of Ministry of Defense. It provides authorization for creation of
Infrastructural facilities (operational, functional, training, administrative, living and recreational) for the tri-services
and allied forces. It has incorporated Government policies on green buildings, renewable energy, reduction in
carbon footprints, etc.

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 ACCOMMODATION AND SHELTER

Table 2.2 : Single Living Accommodation for Service Officers and Nursing Officers
S. Plinth Area Special
Description of Items Planning Notes
No. (Sqm) / Scale Facilities
1. Main Unit of Accommodation (a) Staircase of 5.02 Sq m to
be provided for double or multi-
(a) Major and above and equivalents 66 storey construction.
(b) Sleeping out balcony of
8.0 Sq m area may be provided
(b) Lt / Captain and equivalents 56 for all officers.
(c) Box room and orderlies
room @ 1.0 Sq m FA per officer.
2. Servant Quarters
a) Major and above and equivalents 18.58 Staircase of 4.65 Sq m to be
provided for double or multi-
storey construction.
To be provided at 75% for Major
and above and equivalents.
(b) Lt / Captain and equivalents 18.58 To be provided at 50% for
Lt / Captain and equivalents.
3. Garages / Parking (may be provided as
stilt / basement parking)
(a) Major and above and equivalents 21 To be provided at 100%.
(b) Captain and equivalents 21 To be provided at 100% as open
common shed.
(c) Lieutenant and equivalent. 21 To be provided at 100% as open
common shed.
Note. The scales of staircase given above are on the basis of one brick wall construction. If stone masonry construction
is adopted 16% additional plinth area will be allowed. For 1½ brick wall construction the plinth area may be increased
by 12.5%.
Table 2.3 : Single Living Accommodation for JCOs, NCOs or /
and Their Equivalents in Other Services and NCS (E) of IAF
Plinth Area
S. No. Description of Items Special Facilities Planning Notes
(Sq m) / Scale
Single Living Accommodation per JCO
1. Living Accommodation 41.2 Desert Cooler in hot Staircase of 5.02
(Plinth Area) climate @ one per JCO. Sq m to be provided
for double or multi-
storey construction
2. Scooter Shed 6 To be provided
(Plinth Area) @ 50% as open
common shed.
3. Car Parking 12 50% be provided as
(Plinth Area) open common shed.

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INTRODUCTION TO MILITARY HEALTH

Plinth Area
S. No. Description of Items Special Facilities Planning Notes
(Sq m) / Scale
Single Living Accommodation Havildars / OR and NCs(E) of IAF
4. Living Accommodation 13 (a) Notice board
per Havildar in entrance hall or
verandah.
(b) Full length mirror in
verandah.
5. Living Accommodation 10
per OR and NCs(E) (c) Clothes lines
of IAF for hanging clothes
outside the barracks
and retractable ceiling
pulley clothing line
in verandah for wet
weather drying.
(d) A writing shelf with
chair and in-built book
shelf – one per two
ORs.
(e) Lines for mosquito
nets may be provided
as required.
(f) Desert Cooler in hot
climate in stations at
Appendix A at the rate
of one per six ORs.
(g) One fan for two
individuals.
6. Common Room 0.50 Sq m per man Pelmet with curtain To be provided
rods or curtain runners. at company or
equivalent level.
7. Study Room 0.25 per man Pelmet with curtain To be provided
rods with required at company or
accessories or curtain equivalent level.
runners.
8. Store Room 0.25 per man Cabinets / shelves.
Facility for installation
of washing machine.
9. Verandah 2.4 m wide To be provided on
one side. May be
provided on both
sides at stations
where at certain
times of the year
it is preferable for
troops to sleep
outside.

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 ACCOMMODATION AND SHELTER

Plinth Area
S. No. Description of Items Special Facilities Planning Notes
(Sq m) / Scale
10. Sanitary Block

(a) Baths 25% of authorised strength (a) Glazed ceramic tile Minimum 03 Nos
dado upto ceiling level.
(b) WCs 33% of authorised strength Minimum 04 Nos
(b) Counter with
(c) Trough type WHB 33% of authorised strength stone slab with Minimum 03 Nos
single / multiple oval
(d) Urinals 12.5% of authorised strength type / WHB and single Minimum 02 Nos
large mirror with border
covering entire width of
slab.
(c) Hot water supply in
each bath.
(d) Storage tank of
capacity as per NBC
2005. Provision of
separate tank for WC.
11. Car Sheds 12 Sq m To be provided
(Plinth Area) @ 20% as open
common shed.
12. Scooter Shed 06 Sq m 80% be provided as
(Plinth Area) open common shed.
Note.
1. The scales of staircase given above are on the basis of one brick wall construction. If stone masonry construction
is adopted 16% additional plinth area will be allowed. For 1½ brick wall construction the plinth area may be increased
by 12.5%.
2. Covered parking may be provided in lieu of Scooter sheds, if required.
Table 2.4 : Married and Separated Family Accommodation for Service Officers and Nursing Officers
Plinth Area (Sq m) / Scale
S. Separated Planning
Description of Items Married Special Facilities
No. Family Notes
Accommodation
Accommodation
1. Main unit of Accommodation
(a) Major General and above 198.00 (a) Balcony - 11.00 Sq m
and equivalent
(b) Staircase - 6.00 Sq m
(b) Major to Brigadier and 139.35 (a) Balcony – 4.925 Sq m
equivalent
(b) Staircase - 6.04 Sq m
(c) Captain and below and 83.61 (a) Balcony – 3.90 Sq m
equivalent
(b) Staircase - 6.04 Sq m
2. Servant Quarters
(a) Major General and above 25.00 (a) Balcony - 5.00 Sq m
and equivalent
(b) Staircase - 4.50 Sq m

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 INTRODUCTION TO MILITARY HEALTH

Plinth Area (Sq m) / Scale

S. Separated Planning
Description of Items Married Special Facilities
No. Family Notes
Accommodation
Accommodation
2. (b) Major to Brigadier and 22.30
equivalent
(c) Captain and equivalent 22.30
(d) Lieutenant and below and ---
equivalent
3. Garages
(a) Major General and above 20.90
and equivalent
(b) Major to Brigadier and 18.00
equivalent
(c) Captain and equivalent 18.00
(d) Lieutenant and below and 18.00
equivalent
Notes.
1. These scales will be considered for New Accommodation only.
2. These Norms and Scales will be revised as and when revised norms / scales are issued by MoHUA / MAP.
Table 2.5 : Married and Separated Family Accommodation for JCOs, Havildars or /
and Their Equivalent in Other Services
Plinth Area (Sq m) / Scale
S. Separated
Description of Items Married Special Facilities Planning Notes
No. Family
Accommodation
Accommodation
1. Main unit of Accommodation
(a) JCOs and equivalent 78.535 (a) Balcony - 3.715 Sq m (a) Electric circuit
(b) Staircase - 5.50 Sq m for inverter.

(b) Havildars / NCOs / OR 55.835 (a) Balcony - 3.715 Sq m (b) One EWC to
and equivalent be provided.
(b) Staircase - 5.50 Sq m
2. Car / Scooter Shed
(a) JCOs and equivalent 16.00 for car JCOs @ 75% for
Car / 25% for
6.00 Sq m for scooter
Scooter Shed.
(b) Havildars / NCOs / OR 16.00 for car ORs @ 50% for
and equivalent Car / 50% for
6.00 Sq m for scooter
Scooter Shed.
3. Space for washing 05 Sq m (a) Power point.
machine (Dry Balcony) (b) Water
connection.
(c) Drain out
pipe.

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 ACCOMMODATION AND SHELTER

Notes.
1. Scooter sheds for JCOs and equivalents should be so designed and constructed that if these are to be converted
in to garages either at the time of construction for use on shared basis or later for using as garages if the authorised
percentage of garages is enhanced, it would be possible to combine them.
2. Covered parking areas may be provided in lieu of scooter sheds, if required.
3. These scales will be considered for New Accommodation only.
4. These Norms and Scales will be revised as and when revised norms / scales are issued by MoHUA / MAP.

2.6 Modification of Shelters in Armed Forces and Recent Advances.

(a) Construction of Shelters in High Altitude Area
(i) Insulated Sandwich Panels.
Insulated sandwich panels are
composite structures commonly
used for providing excellent
thermal & acoustic insulation
properties. Insulated sandwich
panels consisting of an insulating
layer of rigid core sandwiched
between two layers of structural
board, used as a building material.
The board can be made of Pre- Fig 2.2 : Insulated Sandwich Panels
coated GI sheet (PPGI), Stainless Steel (SS), cement fibre board or Aluminium Composite Panel (ACP). The
insulation core material is made of one of Expanded Poly Styrene foam (EPS), Polyurethane Foam (PUF),
rock wool or glass wool. Insulated sandwich panels is a cost-efficient alternative to conventional building
masonry construction designed for various applications (Fig 2.2).

(ii) Prefabricated Structures.

Prefabrication is the practice of assembling components of a structure in a factory or other manufacturing
site and transporting complete assemblies or sub-assemblies to the construction site where the structure
is to be located. Prefabricated structures are light weight, durable, economical, relocatable and energy-
efficient, making them a preferred alternative to conventional concrete building. Sturdy construction and
innovative design capabilities make these buildings earthquake-resistant, leak-proof and able to withstand
any adverse environmental conditions without compromising on building aesthetics (Fig 2.3).

Fig 2.3 : Prefabricated Structures

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INTRODUCTION TO MILITARY HEALTH

Important aspects of prefabricated shelters are as follows:

(aa) Thermal and acoustic insulation properties help in maintaining a temperature difference of
5°-7°C from outside temperature.
(ab) Being relatively lightweight, these structures are easy and quick to install without any additional
cost.
(ac) Cladding options are customizable for better thermal insulation and aesthetic finish, like PPGI,
SS, Cement fibre board, ACP.
(ad) Low thermal conductivity helps in higher energy savings and maintains a desired temperature.
(ae) Walls and ceilings can be made strong enough to bear the load of AC’s, LED’s, projectors,
smoke detectors.
(af) Structures are disaster resistant.
(ag) They require absolutely little or no maintenance in the long run.
(iii) Compressed Earth Blocks (CEB).
The traditional masons in Ladakh region construct safe, durable and thermostatic structures by utilizing
the compressive strength and binding properties of mountain soil, that work better when dry and does
not require water which is a scarce resource in the area. The locals use a mixture of soils from different
villages with varying proportion of clay and small amounts of cement and water for making the perfect
earth blocks. Although not a preferred option for rapid accommodation of troops in a camp setting, these
blocks are often used in construction of underground bunkers for soldiers and civilians who reside at areas
of shellfire due to their disaster-resilient nature (Fig 2.4).

Fig 2.4 : Complex Earth Blocks

(iv) Solar Heated Insulated Ladakhi Shelters Launched in Leh for Army Jawans.
The shelter is designed to meet the extreme climate condition in the Eastern Ladakh region and help keep
the soldiers warm in cold weather by maintaining a temperature of +14 to 22°C, while the temperature
outside the shelters falls up to -30°C on some days. The shelter does not use any fuel or electric heating
appliances and further harnesses ambient sunlight and eco-friendly construction material like Ladakhi bricks
made up of biowaste, clay and hay to act as insulators and the utilisation of non-biodegradable waste
substances such as disposed of plastic bottles (Fig 2.5). A prototype of ‘Ladakh Solar Tent’ for keeping
inhabitants warm in sub-zero temperatures is also under development and user trials. The structure being
solar-powered does not require any fuel for heating purposes.

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 ACCOMMODATION AND SHELTER

Fig 2.5 : Solar Heated Insulated Ladakhi Shelters

(v) Fast Erectable Modular Shelters (FEMS).
FEMS consist of prefabricated insulated panels which can be erected in a week’s time and can accommodate
8-40 personnel during extreme winters when temperatures fall to minus 35-40°C (Fig 2.6).

Fig 2.6 : Fast Erectable Modular Shelters

Suggested Reading.
1. Scales of Accommodation, Jun 14, 2022, Military Engineer Services, E in C, Integrated HQ of MoD (Army).
2. Fon FL. Ayuk-Nkem AM. Housing Standards, Household Health and Disease Nexus in the Buea Municipality.
Journal of Sustainable Development. 2014 Jul 31;7(4). 262-267.
3. Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health. 2002
May;92(5):758-68, Doi: 10.2105/ajph.92.5.758. PMID: 11988443; PMCID: PMC1447157.
4. Smith IFC, SpringerLink (Online Service. Intelligent Computing in Engineering and Architecture: 13th EG-ICE
Workshop 2006, Ascona, Switzerland, June 25-30, 2006, Revised Selected Papers. Berlin, Heidelberg: Springer Berlin
Heidelberg; 2006.
n

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 INTRODUCTION TO MILITARY HEALTH

Chapter
III
CLOTHING

3.1 Introduction.
Troops are exposed to a wide range of environmental stresses which, in our country, vary from hot dry desert
and hot humid jungle conditions to dry cold and wet cold environments of the Himalayas. The human body is
endowed with an excellent thermoregulatory system for maintaining thermal balance with the environment and for
keeping its core or “deep body” temperature at a level determined by the grade of physical activity. This control
mechanism is, however, effective only over a limited range of environmental conditions and activity depending on
the degree of training and acclimatization. Beyond this range over­heating or over-cooling of body will take place,
unless it is protected by means of suitable clothing, which is a major factor that helps a man to maintain optimal
efficiency and morale. Importance of scientific study of the subject and its application to military clothing was
first appreciated during World War II. Great advances in mechanical technology in various fields such as aviation,
submarine navigation, specialized land transport and combat vehicles and in industrial fields have necessitated
suitable modifications and reinforcements in clothing and designing of specialized functional clothing.

3.2 Functions of Clothing.

Functions of clothing besides protection against climatic extremes and vagaries, include a number of other functions
which are summarized as under.
(a) Physiological.
The principal function of clothing is to enable the individual to achieve comfort by thermal conditioning of intimate
microclimate around the body.
(b) Physical.
To protect against.
(i) Intense solar radiation, wind, snow, rain etc.
(ii) Climatic severity
(iii) Mechanical injury
(iv) Insect bites
(v) Bacterial and parasitic infections
(vi) Chemicals, either liquid or gaseous
(vii) Ionizing radiations
(viii) Effects of “G’ acceleration and high-altitude hypertension in aviation
(c) Aesthetic.
Clothing is also necessary for personal adornment and this decorative function cannot be ignored because the
soldiers, sailors and airmen should look smart.
(d) Camouflage.
In the Armed Forces, the camouflage aspect of clothing is also important and terrain specific i.e. pattern specific
to ops in jungle, deserts etc.

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 CLOTHING

3.3 Factors Influencing Requirements of Clothing.

(a) Clothing as a Thermal Barrier.
The process of heat exchange between man and his environment is considerably modified and complicated by
clothing. Strictly speaking, man lives and works in his individual micro-environment made up of.
(i) The external environment determined jointly, by air temperature, humidity, air movements and radiation.
(ii) The heat produced by human body depending on its level of physical activity.
(iii) The heat lost in evaporation of moisture in the respiratory passages and in the form of perspiration,
sensible or insensible.
(b) The thermal barrier between deep regions of the human body and its external environment. Much of this
thermal barrier has been provided by nature in two ways as under.
(i) Firstly, there is a layer of peripheral tissues on the surface of the body supplied with a network
of capillaries, through which the flow of blood can be regulated within wide limits by processes of
vasoconstriction and vasodilatation. The skin layer, therefore, has a variable thermal resistance, which can
be adjusted within a certain range according to the demands of the thermal economy of the body.
(ii) Secondly, sticking to the body surface, there is a relatively still layer of air whose effective thickness
is determined by the prevalent air movement. Air being one of the poorest conductors of heat, this layer
provides efficient insulation between the human body and its surroundings, although its effectiveness is
diminished up to a certain limit by increasing air movement. What is usually known as clothing, is from a
scientific point of view, an additional layer or layers of thermal insulation innovated by man, which serves
to supplement, though in a much less efficient way, the two layers of insulation provided by nature.

3.4 Units of Thermal Insulation.

Environmental physiologists, bioclimatologists and clothing scientists usually express heat flow in Kcal / m2 / h. The
thermal resistance or insulation of a layer of material is measured by the ratio of temperature difference across the
layer and is the rate of heat transfer across unit area, therefore expressed as:
0°C
Kcal/m2/h

However, these units make little sense from the point of view of the users of protective clothing and equipment. A
practical unit of thermal insulation, known as the “Clo” was, therefore defined as equal to the insulation provided by
an ordinary business clothing which keeps a resting man comfortable with a mean skin temperature of 33.3°C in a
room at 21.1°C with still air (20 ft / min or 0.1 m / s). A Clo value of 1 is equal to the amount of clothing required by
a resting human to maintain thermal comfort at a room temperature of 21°C. A value of 1 Clo is based on a typical
business suit including a shirt, undershirt, trousers and a suit. Higher the Clo value, more the insulating value provided
by the clothing in question. For example, a pant with long legs will have Clo value of 0.1, thick fabric trouser will be
0.24 and coat Parka 0.70.
Subsequently another unit, the “tog” was introduced, which was taken as.
0°C
1 tog = 0.116 = = 0.645 Clo
Kcal/m2/h

So that 1 Clo =1.55 tog. However, clothing scientists in India prefer to use the ‘Clo’ unit of insulation, which has also
been accepted internationally.

3.5 Thermal Insulation of Clothing.

Studies in clothing science have revealed that the insulation of clothing is mainly determined by its thickness, irrespective
of the material. This is because insulation is chiefly due to immobilized air in clothing and in between its layers, since
air has the maximum insulation value (about 2.9 Clo / cm or 4.5 tog  /  cm at 0°C). The conductivity of air increases by
about 0.23% per °C rise in temperature. Therefore, insulation of still air decreases with increasing air temperature at
the rate of 0.23% per °C. However, it may be noted, , that transfer of sensible heat from the skin to the outer surface
of clothing is rather complicated, since apart from pure conduction, internal convection and radiation processes in the

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 INTRODUCTION TO MILITARY HEALTH

air spaces in clothing are also involved. For practical purposes, therefore, a standard value of 4 Clo / inch (1.57 Clo / cm
or 2.44 tog / cm) has been internationally agreed upon. Accordingly, a 0.63 cm thickness of clothing is roughly equal
to 1 Clo of thermal insulation. The insulation value of the heaviest arctic clothing assembly does not exceed 5 Clo.

3.6 Thermal Insulation of Ambient Air.

Thermal insulation of the ambient
air is due to relatively still layer of
air sticking to the clothing / body
surface, whose effective thickness
decreases with increasing air
movement. As a matter of fact,
air insulation (I) depends on the
product of wind speed and air
density, the latter decreasing with
decreasing atmospheric pressure
and hence with increasing
altitude. At a given altitude (a),
higher the wind speed, lower will
be the air insulation. The effects
of wind speed and altitude on air
insulation, Ia are shown in Fig
3.1, from which one can readily
estimate Ia for given values
of wind speed and altitude.
Thermal insulation is currently
also measured by R-value which
is a measure of how well a layer
of insulation resists conductive
flow of heat. It is the temperature
difference per unit of heat flux
needed to sustain one unit of heat
flux between warmer surface and Fig: 3.1 : Air Insulation in Relation to Wind Speed and Altitude
colder surface of a barrier under steady-state conditions. For example, one inch of solid wood has an R-value of 1.
Dry, absolutely still air has R-value of 3.6 per inch of air.
(a) Practical Ranges of Thermal Insulation.
It is now evident that there are three components of the thermal barriers between the deep regions of the human
body and its surroundings, viz., peripheral tissues, clothing and air. Approximate Clo ranges of these components
are given in Table 3.1.
Table 3.1 : Approximate Ranges of Thermal Insulation Values of the Three Components of Thermal
Barrier Between Human Body and its Surroundings
Resistance Element Range in ‘Clo’ Units Cause of Variation
Peripheral tissues 0.15-0.80 Vasomotor action
Air 0.15-0.80 Air Movement
Clothing 0.5-5.0 Choice of clothing
(a) (b)
Note. (a) Lightest summer clothing (b) Heaviest arctic clothing

3.7 Effects of Moisture Inside Clothing.

It should be noted that the insulation of clothing as discussed earlier pertains to dry clothing. Presence of moisture
in clothing drastically reduces its insulation value since thermal insulation of water is only about 0.11 Clo/cm. In

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 CLOTHING

comparison, the insulation value of dry clothing, as mentioned earlier, is about 14.4 times that of water. This is an
important consideration in respect of a clothed man working in a hot humid environment when a man wearing clothing
adequate for static duties is called upon to perform heavy manual work, unless the clothing system is so designed as
to permit variation in its thermophysical characteristics.

3.8 Body’s Defence against Heat Stress.

As soon as a man is exposed to a hot environment, his thermoregulatory system gets busy with the job of maintaining
thermal balance with his surroundings, keeping his core temperature at a level determined by his physical activity. The
control centre is located in the hypothalamus in the brain, which is responsible for the following two types of adjustments.
(a) Vasomotor Control.
It regulates blood supply to the skin. This acts by vasodilatation of the peripheral blood vessels. The increased
cutaneous circulation increases convective transport of heat from interior of the body to the surface. At a low
level of heat stress this mechanism is sufficient to maintain heat balance and is, therefore,known as the first
line of defence.
(b) Sudomotor Control.
It acts by initiating sweat gland activity and dissipation of heat is achieved by evaporation of sweat. The sweating
capacity, however, depends on the individual’s degree of acclimatization to heat and work. The sweat glands
also get fatigued after working at full capacity for some time in very hot environment.

3.9 Internal or Metabolic Heat.

While resting, an average adult produces heat at the rate of about 50 Kcal / m2 / h of body surface. This rate is
increased to 5 times or more in heavy manual work. For convenience of presentation of data, a practical unit known
as the Metabolic Equivalent (MET) has been chosen to represent the standard metabolic rate of 50 Kcal / m2 / h”.
Table 3.2 gives approximate values of metabolic rate for various activities.
Table 3.2 : Metabolic Rates for Various Activities
Metabolic Rate
Activity
K cal/m2/h MET
Basal State 40 0.8
Sitting resting 50 1.0
Light activity 75 1.5
Moderate work 150 3.0
Moderately heavy work 200 4.0
Heavy work 250 5.0

3.10 Thermal Insulation Required for Prolonged Exposure in Dry Cold.

Extreme cold is necessarily dry even at 100 percent relative humidity, because water vapor content of the atmosphere
is quite low, vapor pressure not exceeding 10 mm Hg. Humidity assumes a major role only in heat and within the range
of so called wet-cold conditions between the approximate limits of -6°C and +10°C. Under out-door conditions, the
air insulation can vary roughly from 0.6 Clo to 0.2 Clo from very calm wind (about 1 km / h) to strong breeze (about
25km / h). In the high-altitude region of Western Himalayas (particularly Ladakh) which is mostly arid, temperatures below
-20°C are not infrequent during the day in winter, but direct insulation at the same time is very high, often exceeding
1.7 cal / cm2 / min at normal incidence under clear sky conditions. To this may be added diffuse sky radiation and
radiation reflected by the terrain, which is considerable in snow bound areas. A man in the erect posture receives
maximum solar energy when the sun is 45°C from zenith and its magnitude under the above conditions may be as high as
200 KCal / m2 / h or 4 Met, of which 3 Met will be absorbed by olive green uniform. Result of simple calculation are
presented in Table 3.3, roughly indicating the clothing insulation required for prolonged comfort in out-door exposure
to dry cold. It has been assumed that the clothing is sufficiently wind proof, the extremities have been adequately
protected and heat leakage due to bellow action has been minimized.

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 INTRODUCTION TO MILITARY HEALTH

Table 3.3 : Clothing Insulation (Clo) Required for Prolonged Comfort in Outdoor Exposure to Dry Cold
(Sun 45° from Zenith)
Moderate Cold Temp 0°C Very Cold Temp -20°C
Light Activity Moderate Activity Light Activity Moderate Activity
1.5 MET 3 MET 1.5 MET 3 MET
Sky overcast Calm wind
2.4 0.9 4.3 1.9
Ia = 0.6 Clo
Shade Strong breeze
2.8 1.3 4.7 2.3
Ia = 0.2 Clo
Clear Sky Calm wind
0.8 0.1 2.7 LI
Ia = 0.6 Clo
Bright sunshine Strong breeze
2.3 1.0 4.2 2.0
Ia = 0.2 Clo
The above table illustrates the importance of variables like wind speed, solar radiation and grade of activity, apart from
air temperature in influencing clothing requirement for dry-cold. The effect of solar radiation is most pronounced in
calm wind but is of little importance in strong breeze. Further, change from calm wind to strong causes only a slight
increase in clothing requirement in shade, but quite a large increase in the sun. In moderate cold (0°C), with calm
wind, little clothing is required under bright sunshine. Prolonged marching even in the lightest cold weather clothing
(about 1.5 Clo) may be quite hazardous. Only a strong breeze can provide relief in case clothing cannot be removed.
In general, there is a large reduction in clothing requirement when activity is changed from light to moderate, both
in sun and shade, particularly under very cold conditions. Fig 3.2 gives total insulation required (clothing plus air) for
prolonged comfort in relation to air temperature (shade) and metabolic rate of heat production. The clothing insulation
required is found by subtracting air insulation as given by Fig. 3.1.

Fig 3.2 : Total Insulation (Clothing + Air) Required for Prolonged Comfort in Relation to
Air Temperature (Shade and Metabolic Rate of Heat Production)

3.11 Safe Exposure with Inadequate Clothing.

It may be noted that prolonged comfort stands for an indefinite period. In actual practice continuous out-door exposure
rarely exceeds a certain period, ranging from a few minutes to several hours, for which insulation requirement is
certainly less than what is indicated in Fig 3.2 The mean skin temperature is generally accepted as the best single

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 CLOTHING

index of thermal comfort in cold environments. It is about 33.3°C for optimum comfort and about 30.0°C as the
average tolerance limit, which brings the subject to the point of uncomfortable cold, usually with definite shivering. Fig
3.3 indicates safe duration of exposure as a function of air temperature (shade) and total insulation (clothing plus air)
for light activity (1.5 Met). It may be noted that the figure is applicable to the average soldier. As a matter of fact, the
tolerance time is proportional to body weight per unit area of body surface, which may be regarded as a “body shape
factor”. This means that a stocky and heavily’ built person can stand cold exposure better than a lean and thin person.
Also, a subject with a lower tolerance limit of mean skin temperature has a higher tolerance time. This criterion together
with the “body shape factor” may be used with advantage for selection of personnel for high altitude operations.

Fig 3.3 : Tolerance Time Prediction Chart At 1.5 Met (Light Activity) for an Average Soldier in Relation to Air
Temperature and Total Insulation (Clothing Air) in Shade

3.12 The Problem of Wet Cold.

So far, dry-cold conditions only have been considered, which do not as a rule significantly affect the insulative properties
of clothing. Even then, the effect of moisture from internal sources, namely, sweating during periods of strenuous
activity, plays a considerable role in modifying the heat exchange processes between man and his surroundings.
The situation becomes much more complicated in a wet-cold climate, roughly defined as between -6°C and +10°C
(dry-bulb temperature), with the presence of high humidity (80%). In fact, the problem of protection against wet-cold
is far more difficult than protection against much lower temperatures under dry cold conditions.
The difference is almost entirely due to the effect of moisture from both internal and external sources and the presence
of clothing, paradoxically enough, adds to the complications. In a wet-cold climate, the actual vapor pressure in the
atmosphere is quite low, usually between 4 mm and 9 mm Hg, whereas the average vapor pressure at the skin
surface is rarely below 10 mm Hg, but can rise up to about 40 mm Hg, during periods of severe activity even in a
very cold climate. Thus, there exists a temperature gradient and a vapor pressure gradient across the thickness of the
clothing layers. Since saturation vapor pressure of water is almost exponentially related with absolute temperature, it
can be seen that with decreasing temperature it decreases more steeply in the initial stage than in the latter. Relative
humidity, being the ratio of actual vapor pressure to the saturation vapor pressure, should therefore rise from skin
surface outwards, reach a peak somewhere within the clothing layer and then decrease finally to the ambient humidity

33
 INTRODUCTION TO MILITARY HEALTH

at the clothing surface. It is quite possible, under favourable conditions, that this peak exceeds 100% resulting in
condensation of moisture in those zones which in turn reduces the clothing insulation in proportion to amount of dry
air replaced by condensed water vapor.
The principles underlying the clothing problem in a wet-cold environment may be summarized as below.
(a) The diffusion of moisture from the body surface cannot be prevented without serious physiological
consequences.
(b) The accumulation of any appreciable amount of water within the clothing from external sources should be
prevented.
(c) Water vapor diffusing into the clothing from the body should not be allowed to accumulate as moisture
within the clothing layers.
To satisfy simultaneously all the three conditions mentioned above, which are apparently contradictory, is the major
problem confronting research workers engaged in the development of clothing for wet-cold.

3.13 Developments in Cold Weather Clothing.

(a) General Requirements.
The major factors involved in protecting a man in a cold environment, assuming he has no recourse to warm
shelter or auxiliary heating are.
(i) Metabolic heat output
(ii) Wind chill
(iii) Thermal insulation air
(iv) Moisture vapor permeability.
If the sum of heat loss arising from factors (ii) (iii) and (iv) exceeds the gain from factor (i) he goes into heat
debt and will eventually collapse. If it is the other way round, he must get rid of the excess heat by ventilation
or other means.
(i) Metabolic Heat Output.
As already brought out in para 3.9, the metabolic heat production can vary over a wide range, from
0.8 MET (basal) to more than 5 MET in heavy physical work. The clothing system developed must, therefore,
be capable of sustaining the individual in thermal comfort at the lowest level of metabolic heat production
and also be capable of being adjusted to allow excess metabolic heat to be dissipated when necessary.
(ii) Wind Chill.
The effect of wind is, of course, to cause compression of under lying fabrics and to disturb the entrapped air
by penetration through the outer fabric. This effect is negligible at low wind speed (8 km/h), but becomes
significant at higher wind speed depending on the air permeability of the outer fabric. Thus, in windy conditions,
a wind proof outer fabric is necessary for maintaining the thermal insulation value of the clothing system.
(iii) Thermal Insulation.
The thermal insulation of any clothing system is the sum of the insulation values of the clothing layers, the
layer of air next to skin and the layers of air trapped between various layers. Air is the cheapest and the
best insulating material available. Its thermal conductance is about 1/10th of that of most fibres and about
1/6th of that of most fabrics. The greater the volume of air entrapped in a fabric. i.e., the greater the loft
of a fabric for a given weight, the greater its thermal insulation. A good wool blanket, for example, contains
about 80% by volume of air and 20% fibre, while a polyurethane foam such as is used in the production
of laminates for clothing, contains about 98% of air by volume. However, the insulation is considerably
reduced by compression and by disturbance of the air layers (convection). The simple act of walking has
been found to reduce thermal resistance of arctic clothing by 50%.
(iv) Air and Moisture Vapor Permeability.
The importance of an impermeable outer fabric has been mentioned above. Moisture vapor, however, passes

34
 CLOTHING

through permeable fabric by a different mechanism. Whereas air can pass only through the interstices of
fabrics, moisture vapor also passes through the fibre itself. Hence a range of fabrics is possible with very
low air permeabilities but with low to high moisture vapor permeability. If the moisture vapor permeability
of the clothing system is low, excess moisture accumulates in the clothing, causing progressive reduction in
thermal insulation and eventually condensation and wetting. As activity ceases, freezing occurs leading to
after exercise chill and if the temperature is low enough, frostbite will occur. The golden rule is, therefore,
to avoid excessive sweating at all costs in extreme cold. Gradual wetting, loss of insulation and increasing
weight of clothing and sleeping bags is a major problem of extreme cold since facilities to dry them out
are lacking in forward areas and the overall combination of wind, wetting and disturbance of entrapped
air can reduce the insulation value of a clothing system by as much as 90%.
(b) Desirable Characteristics.
While designing cold weather protective clothing systems, the following characteristics should be incorporated
as far as practicable.
(i) High wind resistance.
(ii) High thermal insulation.
(iii) High moisture vapour permeability.
(iv) Resistance to wetting.
(v) Smooth surface to shed snow
(vi) Means of varying insulation.
(vii) Means of varying ventilation.
(viii) Compressibility.
(ix) Minimum restriction of movement.
(x) Durability.
(xi) Minimum weight.
(xii) Minimum bulk.
(xiii) Ease of donning.
(xiv) Ease of doffing.
(xv) Cost.
At high altitudes, by far the most important consideration is that of weight and bulk of the clothing assembly.
(c) Protection of Extremities.
Despite the problems mentioned and the formidable list of design requirements, the challenge is that what is
needed can be accomplished for 90-95 percent of the body only. The parts which offer and will continue to
offer difficulty, are the hands and the feet. The surplus metabolic heat generated is distributed to the hands and
feet through blood flow. In extreme cold this decreases from about 100 ml/min for the active soldier to about
1 ml/min for the inactive soldier at extremities as he becomes cold. Circulatory heat input to the hands and feet
of the resting soldier is, therefore, negligible. According to the general theory of heat transfer, the effective thermal
insulation provided by a given thickness of material decreases with decreasing diameter of the cylinder. Fingers and
toes may be regarded as small cylinders. It is, therefore, almost impossible to provide adequate practical insulation
for the fingers and toes at ambient temperature below about -30°C. The practical upper limit of glove insulation,
consistent with reasonable dexterity is obtained by five mm thickness of fabric. To reduce the surface of fingers
covered by thick fabric so as to permit maximum finger mobility and yet cover enough area so as to decrease heat
loss, mittens are preferred. When use of fingers is not called for, glove made of thick wool fabric with meshes or
leather glove with woollen lining, slung round the neck, in order to permit intermittent insertion, are preferable.
(d) Protection of Head and Face.
Protection of head and face also presents special problems. In cold environment, heat from the entire body

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 INTRODUCTION TO MILITARY HEALTH

flows rapidly out from the face and head as the homeostatic vasoconstricting mechanisms of these regions act
poorly. Exposure of the head accounts for a large percentage of body heat loss. So, when the head and face
are given adequate protection, more heat is retained in the body and warm blood diverted to the extremities
keeps them warm. It is, however, difficult to cover the entire head and face conveniently without interfering with
hearing, vision, breathing, smell or speech. Two third of the head can be covered conveniently by a cap and a
muffler or by a knitted woollen garment such as cap balaclava leaving the nose, mouth and eyes exposed. Such
headgears should be provided with adequate venting for active men/women to avoid overheating of the face.
Goggles must be used for protection of eyes.

Fig 3.4 : Extreme Climate Clothing for HAA

3.14 Developments in Clothing.

Rapid scientific and technological advances made in the last few decades have revolutionized the very concept of war,
the natural barriers which were once thought of as affording protection from attacks, have now become vulnerable and
have been scenes of action. For such regions and for high altitudes, there is an ever increasing need to reduce the
weight and bulk of personal clothing and equipment carried by the infantry soldiers, without sacrificing their functional
properties. This has been achieved to a large extent, due to indigenous availability of some of the synthetic fibres,
resins and chemicals, coupled with the acquisition of improved technical know-how in process engineering. The threat
posed by thermonuclear, bacteriological and chemical warfare calls for radical changes in the design of stores as well
as the development of new materials. Emphasis should be put on development of multipurpose as well as disposable
material. Achievements made so far in reducing the weight and bulk of personal clothing and equipment of an infantry

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 CLOTHING

soldier are summarized below in respect of some of the major items.

(a) Parka Coat and Trousers.
The reduction in weight of the Coat and Trousers Parka without affecting their
thermal insulation was achieved by the use of stabilized polyester batting which
replaces the pile fabric used earlier. This has brought down their respective
weights to 2.2 kg and 1.0 kg as against 2.8 kg and 1.5 kg respectively.

(b) Bag Sleeping.

So far as is known, only downs provide high thermal insulation with the least
pack volume. Hence these were used as the insulating medium. The weight
of the bag was further reduced by using polyurethane coated lightweight nylon
fabric as the basic fabric in place of closely woven cotton fabric. The weight of
Fig 3.5 : Parka Coat and Trousers
this bag is 2.37 kg as against 4.60 kg of the earlier bag made out of cotton
fabric with Kapok as the insulating medium. The pack volume was also reduced
to only 0.023 m3 as against 0.048 m3 of the Kapok filled bag.

(c) Blanket Barrack.

The new blanket manufactured from cotton warp and woolen weft in double texture
design is as durable as the earlier one but is thicker with higher insulation value.
Only three of these blankets provide the same thermal insulation as provided
by four of the earlier ones. The weight of each new blanket is 1.9 kg as against
2.2 kg of the earlier one. This alone has thus reduced the personal load of the
infantry soldier at high altitude by more than 3 kg.

(d) Cape Waterproof.

Fig 3.6 : Bag Sleeping Improved version of the cape using superior basic material with high resistance
to rain weighs 1.7 kg, as against 2 kg of the earlier version and provides better
protection against heavy rains encountered in the eastern region of the country.

(e) Web Equipment.

New web equipment is made of lightweight webbings and aluminium metal fittings
with additional space for extra ammunition and suitable arrangement for fixing
pick/shovel. Its weight is 2.08 kg as against 2.69 kg of the earlier pattern.

(f) Water Bottle.

Fig 3.7 : Blanket
With the availability of plastic suitable for food containers, light weight water
bottles have been developed which weigh only 375 g as against 565 g of the
earlier enamelled bottles.

(g) Helmet Combat.

Certain plastic when reinforced with high tenacity fibres exhibit a high degree
of resistance to stresses and strains. They also provide ballistic resistance
equal to or more than that of armour steel. The new design of helmet combat
utilizes Glass Fibre Reinforced Plastic (GRP). It weighs 1.05 kg as against the
earlier steel helmet weighing 1.37 kg. Moreover, the higher thermal insulation
provided by the new design causes much less discomfort in extreme cold.
Fig 3.8 : Helmet Combat

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 INTRODUCTION TO MILITARY HEALTH

(h) Boot Combat.

Reduction in the weight of Boot Combat has been achieved by using
light weight insulating material and the developed boot weights 1.8 kg
as against 2.6 kg of the earlier version. The new boot has also been
provided with a better sole for improved grip in mountainous and snowy
regions, which results in less fatigue to the user.
(j) Ground Sheet.
The reduction in the weight of the ground sheet has been made possible
due to the development of a lighter basic fabric of special construction
that retains its durability and resistance of wear and tear. It weighs
only 900 g as against 1.4 kg of the earlier model. As a result of these
developments the maximum personal load of the infantry soldier has
been brought down to very nearly the desired level of 25 kg. Since this
pertains to near-sea level conditions, a further reduction in weight is
desirable for soldiers operating at high altitude. Fig 3.9 : Combat Boot for HAA

3.15 Scope for Future Developments.

With the advent of newer material such as fibres of high tenacity, reinforced plastics, polycarbonates and low-density
materials (polypropylene), further reduction in the weight of the personal load and equipment of the infantry soldier
is possible. The only hindrance in the use of such materials is their high cost and non-availability indigenously. It is
hoped that such obstacles will be overcome in the near future. New approaches, such as use of spacers for providing
thermal insulation to snow clothing and equipment, inflatable items of sleeping gear, auxiliary heating devices working
on light weight, highly efficient batteries / solar cells and use of exhaled air for heating the sleeping gear, are to be
investigated in detail. These may go a long way in reducing the weight of the personal clothing and equipment.

3.16 Training of Troops.

Over the past two decades, mountain and arctic warfare equipment has changed considerably. This is because it became
clear that the old equipment was too heavy and in many cases, not quite satisfactory. This is of particular importance for
high altitude environments. Considerable success could be achieved because of many new developments in light-weight
materials. Despite these advances, the human factor remains of paramount importance. Proper working of a clothing
system depends entirely on man being prepared to make the effort to adapt the system at best to meet his needs in
any given situation, either by venting or donning or doffing layers as the case may be. It is challenging to have to do
this, more so in adverse weather, but it is only by doing so that he will able to keep himself tolerably comfortable over
a wide range of temperatures. Training to achieve maximum comfort out of what he has got is absolutely essential.
Proper use of protective clothing and equipment in extreme cold in relation to level of physical activity can bring down
the incidence of cold injuries by 60-80 percent. In this connection the letters of the word ‘COLD’ symbolize several
cardinal points which are as follows.
(a) ‘C’ signifies that the clothing should be kept ‘Clean’ so that it will not become cloggy, greasy or will not
cling, mat down or destroy insulation.
(b) ‘O’ should remind the active soldier to ‘Open up’ his clothing before he becomes overheated and to avoid
sweating.
(c) ‘L’ should remind him to wear his clothing ‘Loose’ and in ‘Layers’.
(d) ‘D’ should remind him to keep his clothing ‘Dry’.

3.17 Clothing for Hot Climates.

(a) General Requirements.
When the ambient temperature exceeds body temperature, the body gains heat from its surrounding which is
added to the metabolic heat production determined by the level of activity. Thermal balance can be achieved
only by evaporation of sweat. In a hot dry environment, the problem is not so serious since evaporation of sweat
can take place even through clothing, provided cool drinking water is available and the men possess efficient
sweating capacity. In a hot-humid environment, on the other hand, ambient temperature rarely exceeds the body

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temperature, but evaporative capacity of the environment becomes the limiting factor because of high humidity
and low wind speed. Therefore, there are important differences in clothing requirements for hot-dry and hot-humid
climates and also for tropical rains. The requirements are summarized in Table 3.4; Present authorized clothing,
more or less meets the requirements to a reasonable extent. It may be noted, however, that in a certain range of
hot humid climates, particularly with low air movements, heavy physical activity may have serious consequences.
(b) Footwear.
Footwear for hot weather presents no great problem except for marching on very hot sandy terrain of the desert.
It must protect the sole from the heat of the ground and the foot from injury. It has also to permit evaporation of
sweat which is mostly achieved through air movements caused by the bellows action of the boot and the moisture
vapor permeability of the boot upper. The boot-upper should also have sufficient accommodation for increased
volume of the foot due to vasodilatation. In a hot wet climate, the boot-upper must also afford protection against
water ingress, leaches and insect bites. Gum boots and jungle boots with high boot uppers have proved useful.
(c) Headgear.
Headgear should afford protection from direct solar radiation without impeding heat dissipation from the scalp.
An important principle in designing headgear is that an air space should be provided between the vault of the
hat and the top of the head to minimize conductive heat gain from outside and also air circulation must be
maintained in the space by providing vents. The peak of the hat protects eyes from direct or reflected gear. The
Gorkha type felt hat and jungle hat almost fulfil these requirements. The turban, which scatters radiant energy
and provides thermal insulation, provides effective protection in dry desert heat. In humid heat however it loses
its effectiveness & causes discomfort since it restricts air circulation over the head and diminishes evaporative
heat loss. Headgear should not be tight fit nor should it be too loose.
Table 3.4 : Physical Requirements of Clothing under Various Climatic Conditions
Climatic Ventilation (Design Permeability to Water
Colour Conductivity Insulation
Condition and Texture) Water Vapour Repellence
Wet cold - Designed to have Low Clothing Inner water High: outer
controlled vents assembly vapour barrier external
at neck, wrists should be to prevent the covering
and waist. Texture thick but the diffusion of detachable
loose so that air air space water vapour
can be trapped in between layers into clothing
the clothing and should not
from the skin.
in between layers, exceed 0.9
water repellent outer cm.
covering.
Dry cold - -do- -do- -do- -do- Immaterial
Cold and As dark as As above, but there -do- -do- -do- -do-
high velocity possible so that should be an outer
winds the outer radiant detachable “wind
heat is absorbed break” covering,
made of tightly
woven material
Hot dry heat As light as is Designed to have High Material to be Moderate to -do-
with strong compatible minimum number of moderate high
radiation with camou- of openings and thickness,
from flage require material of close thicker
sun and ments so that texture material
surrounding the maximum required if
objects and amount of heat wind velocities
occasional is reflected. are high
high wind
velocities

39
 INTRODUCTION TO MILITARY HEALTH

Climatic Ventilation (Design Permeability to Water

Colour Conductivity Insulation
Condition and Texture) Water Vapour Repellence
Hot humid Immaterial Designed to have -do- Thin High Moderate
minimum opening
material
and the material to
be of open texture
Tropical rain Immaterial Designed to -do- Thin As high as in High
have maximum consistent with
openings facing water exclusion
downwards and the
material should be
impermeable to
water

3.18 Special Protective Clothing.

(a) Diving Clothing.
Exposure waterproof suits are used during immersion in water to
provide protection against cold seawater. In a hot climate, such suits
may increase heat stress. This defect has been corrected to a certain
extent by the development of a fabric by producing minute pores in
a laminated “aerobond”. This permits passage of water vapor but not
water. This has been enhanced by reinforcing the fabric by finely divided
particles of hydrophobic silica aerogel. The particles are held between
two layers of thin fabric by natural latex or synthetic latex. Aero bond
fabric is a great advancement for use in deep sea diving. It provides
warmth, buoyancy, water resistance and vapor permeability.
(b) Water Repellent Clothing.
Water repellent clothing is meant for use where rainfall and snow fall
are almost continuous. It is not completely waterproof or impermeable
to water vapor and therefore permits evaporation of sweat. Men should Fig 3.10 : Diving Clothing
be able to wear it comfortably in any type of climate where protection
from rain and snow is essential. Water repellent clothing should also
dry up quite rapidly. This, however, may not be adequate to meet the
requirements of continuous heavy rains in which case waterproof over
garments must be used.
(c) Air Ventilated Suits.
Air ventilated suits are designed for use under extreme temperature
conditions such as those met within the cockpits of a jet aircraft.
Ventilation is achieved by free circulation of air between the clothing
and the skin. Such clothing apparels are in the form of overalls which
have layers completely canalized through which hot or cold air, supplied
through a master tube from a cylinder, can be circulated to provide air
at a suitable temperature for the trunk and limbs and regulated as
required by the pilot.
(d) Fire Fighting Clothing.
Clothing against exposure to very high temperature are available for use Fig 3.11 : Air Ventilated Suits
during and after air raid, firefighting and in boiler rooms. Most open
fires have temperatures ranging from 500°C to 1000°C and glowing
metals may reach even 3000°C. In addition to physiological stress under such condition, burn, injuries to the
eyes and damage to the respiratory system through inhalation of hot air must be expected. Cotton can be

40
 CLOTHING

brought to ignition at about 225°C. Nylon melts but does not burn; glass fabrics can withstand 600°C or more.
Asbestos can stand 1150°C. Ignition is also related to fresh air supply in pores of the fabric and therefore,
its impregnation with metal reduces the danger of ignition. Protective outer garments can be impregnated with
aluminium. Garments made of such flameproof fabrics afford effective protection against rapidly developing fire
and high intensity radiation. A flame-resistant treatment of the combat suit has also been devised. Protection
for the eyes, face and hands is similar to nuclear heat flash protection.
(e) Protection Against High Intensity Thermal Radiation.
The multilayer clothing assembly offers some degree of protection against high intensity thermal radiation
from nuclear explosion. Colour of the clothing also plays an important role. Brightly coloured textile and metal
impregnated suits such as aluminium suits, are quite useful. It is thought that glass fabric impregnated with
aluminium may give better results. Exposed parts of the body may be given protection with heat barrier creams,
head cover (‘yashmak’), suitable gloves and welders goggles. Special clothing is essential to protect personnel
exposed to microwave radiation in radar fields. Protection can be provided by a knot mesh of silvered, copper
or an aluminized fabric suit constructed either as a one-piece garment similar to a boiler suit or as two-piece
smock and trousers; gloves and boots are lined with aluminized fabric. Use of spacers in clothing and increasing
reflecting power of the surface of clothing are likely to afford considerable protection against high-energy radiation.
(f) Ballistic Resistant Clothing (Armour Clothing).
This is a special clothing garment for protection of all vital areas of the body against high-speed grenade, mortar
or mine fragments, as well as bullets from a pistol or a rifle. It is likely to prevent 60 to 70 percent of chest
and abdominal wounds from fragments or missiles. It is made from a classified combination of synthetic fibres
and lightweight metal.

Fig 3.12 : Fire Fighting Clothing Fig 3.13 : Protection Against High Fig 3.14 : Ballistic Resistant
Intensity Thermal Radiation Clothing (Armour Clothing)

Suggested Reading.
1. J. V. MORRIS, Developments in Cold Weather Clothing, The Annals of Occupational Hygiene, Volume 17, Issue
3-4, February 1975, Pages 279–294.
2. Buettner K. Effects of Extreme Heat on Man: Protection of Man Against Conflagration Heat. JAMA. 1950;144(9):732–
738. doi:10.1001/jama.1950.02920090006003.
n

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 INTRODUCTION TO MILITARY HEALTH

Chapter
IV
ASSESSMENT OF HEALTH & SANITATION
IN ARMED FORCES
4.1 Introduction.
The medical officer providing medical cover to the unit is an important person for provision of health cover.
He is required to bring to the notice of the commanding officer any conditions considered responsible for the
deterioration in health or likely to adversely affect the health, morale and welfare of the personnel of the unit. The
further responsibility for rectifying such conditions rests with the Commanding Officer (CO) under the Authorised
Medical Attendant’s (AMA) advice. In order to fulfil these duties, the AMA has to carry out.
(a) Assessment of the environment, living and working conditions of the personnel by regular periodical
inspections of the unit lines.
(b) Assessment of their health by regular periodical health inspections and examinations of the men
under his/her medical care.

4.2 Unit Inspection.

The AMA should make frequent inspections of the unit, which should include the entire camp, hutments, barracks, all
annexes and family quarters in the area or under administrative control of the unit. These inspections should not be
concerned only with the environmental sanitation. The inspections must include all the factors which play a role in the
soldiers living and working environments and determine his / her physical and mental efficiency, health and sickness,
morale and welfare and above all his/her fighting fitness. The unit hygiene inspections by the AMA are of four kinds.
(a) The periodic routine inspections
(b) Rectifying check inspections
(c) Special inspections on occurrence of any disease in epidemic/outbreak form
(d) Inspection for siting and locating the unit and its sub divisions when on the move into a new area.

4.3 General Principles.

Para 114 of Regulations for Medical Services in the Armed Forces (Revised-2010) lays down that the AMA should visit
every part of the barracks and camp at least once a month. This does not mean that only one day during a month
should be set aside for complete unit inspection. Indeed, such an inspection thoroughly carried out would occupy
the whole day. It is much better to hold weekly inspections so planned that every part of the unit is covered once a
month. A set day and a set time each week should be allotted to the inspection. This procedure has been contended
to be faulty on the grounds that it removes the element of surprise, which enables the medical officer to see the
conditions as they always are rather than when specially prepared for inspection. The advantages of fixing date and
time outweigh this objection. Firstly, this procedure ensures that such officials as the second in command, messing
officer and quartermaster accompany the AMA on his round. Secondly, it guards against the possibility of the medical
officer missing the inspection in a particular month and finally, it has an educative value of teaching all personnel how
the conditions should ideally exist.
A definite scheme should be drawn out in detail and closely followed to ensure that nothing is overlooked. The plan
will naturally depend upon the topography of the camp. After taking over medical charge the AMA should obtain or
make a map of the camp and unit showing the location of all departments, buildings, huts, roads, latrines and so
on. This should be studied and closely followed during the first few weekly inspections until the AMA becomes fully
conversant with the location of every part of the unit and camp, including the water supply and drainage system. It is
also important for him/her to know from the study of the previous reports and the sanitary diary, the sanitary problems,
which had arisen in the past and the way they had been handled.

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 ASSESSMENT OF HEALTH & SANITATION IN ARMED FORCES

The medical officer should always be accompanied on his inspection by the quartermaster, the messing officer (on days
when the messing arrangements are being inspected), unit sanitation and anti-malaria officer and any other individual
specially required. If feasible, the second in command should accompany the medical officer. This practice is of great
value and should always be encouraged. Prior to starting the inspection, the medical officer should always visit the
CO. This offers an opportunity for discussing important points having bearing on the health and welfare of personnel.
During the inspection minor defects should be commented upon verbally and not included in the written report. The
more serious defects may, however, be noted for subsequent report to the CO in the sanitary diary. The inspection
should be carried out systematically. The places to be seen are.
(a) Living barracks, huts, tents (n) Gymnasium
(b) Cook houses (o) Guard rooms
(c) Dining halls (p) QM stores
(d) Ration stores (q) School
(e) Officers’ and JCO’s messes (r) MI Room
(f) Barber shop (s) Bath houses
(g) Water supply point (t) Latrine area
(h) Washing places (u) Rubbish and waste matter disposal area
(j) CSD canteen (v) Animal lines
(k) Wet canteen (w) Aerated water factory
(l) Recreation and Information room (x) Slaughter houses (if existing)
(m) Regimental school (y) Family lines

4.4 Living Accommodation.

The requirements of ventilation and lighting have been described in “Scales of Accommodation 2022” published by MES
(Military Engineering Services), Engineer-In-Chief’s Branch of Integrated Headquarters of Ministry of Defense. Compliance
with all the requirements, including the state of general hygiene should be scrutinized. The general cleanliness of the
place should be meticulously maintained. Floors, walls and ceiling should be in good state of repairs to avoid harborage
of vermin. Daily sweeping and /or mopping should be encouraged. The unit sanitation and antimalarial squad should
carry out their duties efficiently and regularly; their work in respect of spraying insecticides in all barracks should be
checked from time to time. Every barrack, hut or tent should display on the wall the record of residual insecticide
spraying.
The AMA should inspect the arrangements for fixing mosquito nets, stringing of charpoys, cleanliness of beds, bug
infestation and so on. A few dining plates should be inspected for cleanliness. Bungs of water bottles should be checked
for fungus, mold and cleanliness. A few mosquito nets must be randomly examined for tears and proper repairs by
patching (and not stitching or tying). Barrack inspection thus provides an opportunity to go into many details of the
living conditions of troops. In areas where impregnation (insecticide treatment of mosquito nets) is being done, the
AMA has a duty to check that the impregnation with synthetic pyrethroids is properly done on the mosquito nets.

4.5 Messing Arrangements.

Adequacy and suitability of space, ventilation, lighting must be considered during inspection and all those standards
should be taken into account. In general, the inspection can be grouped into cookhouse unit and dining hall unit. The
under mentioned points should be observed.
(a) Structural repairs, necessary hygienic standards, fly and rat proofing, measures for avoiding cockroach
nuisance, ventilation, lighting, smoke free and so on.
(b) Inspection should be carried out of the preparation of raw foodstuff, especially the fresh items and
their cooking from the point of view of any loss of nutritional values, digestibility, acceptability and possible
contamination or deterioration of cooked food.
(c) Inspection of personnel working in cookhouse and handling food for personal hygiene, especially cleanliness

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 INTRODUCTION TO MILITARY HEALTH

of clothing and hands, personal cleanliness, trimmed finger nails, clipped hair and any skin conditions.
(d) Inspection of food for taste, flavour, palatability and acceptability in general. Food should be tasted to
ascertain these points.
(e) Availability of fresh water supply and its protection.
(f) Inspection of dining hall from the point of view of adequacy of space comfort, fly and rat proofing, seating
and eating arrangements and plate washing arrangement.
(g) The following documents should be checked.
(i) Cook house rules.
(ii) Nominal roll of food handlers and their monthly medical examination and immunization records.
(iii) Bill of fare.
(h) Store room for ration from point of view of general hygiene, fly and rat proofing. storage facilities especially
for fresh rations.
(j) Sample of food preparation served in messes should be preserved in refrigerator wherever the facility exists
for at least 24 hours and the containers should be properly marked.
(k) Officers’ and JCOs Mess.
It is often said, with some truth, that the kitchens of officers’ and JCO’s messes are far below the standard
demanded of the men’s cookhouse. These messes should neither be overlooked nor any lower standard be
accepted.

4.6 Barber Shop.

This can become a focus for dissemination of HIV, skin infections like sycosis barbae, Tenia barbae or Tenia capitis
and respiratory infections to the personnel due to close contact, which is unavoidable during shaving or hair cutting.
During inspection the following points should be checked.
(a) The shop, furniture and equipment should be always kept clean.
(b) No bedding or unauthorized clothing should be kept therein.
(c) A nominal roll of all employees showing the date of monthly medical examination and vaccination under
the signature of the medical officer should be displayed in the barbershop.
(d) Arrangements for frequent washing of hands of the barbers and adequate water supply.
(e) All barbers to wear clean overalls and aprons when at work.
(f) Shaving or hair cutting of men suffering from skin disease should be prohibited.
(g) Clean towels and sheets are used in the shop.
(h) If a ‘barber’s chair’ is provided, its headrest should be protected by clean paper: a fresh piece being used
for everyone.
(j) A bucket / a tin / dustbin is provided for used cotton wool and clipped hair. The tables are provided with
sun mica, zinc sheet or marble top and kept clean.
(k) Combs, razors and clippers are kept immersed in 2.5 percent cresol, dettol or chlorosol solution when not
in use during working hours. Before use they are washed with clean water. The rest of the time they are cleaned
and protected with Vaseline except combs which are cleaned and washed with soap and dried. Shaving brushes
after each shave are washed in a solution of Savlon/Dettol and then rinsed in clean water. Razors are wiped
on a clean towel. Only fresh changeable blade razors should be used. These blades should be used once and
then disposed off. The used blades should be disposed off by deep burial. In general shaving by barbers should
be discouraged wherever possible.
(l) All cuts should be swabbed with tincture of Iodine / Dettol / Savlon.

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 ASSESSMENT OF HEALTH & SANITATION IN ARMED FORCES

4.7 Washing and Bathing Arrangements.

Inspection should be carried out to see the adequacy, cleanliness, surroundings, disposal of wastewater, shelter from
cold wind, arrangements for drying and arrangements for provision of hot water.
(a) Bathing Arrangements.
Each unit should have a definite arrangement for providing personnel a daily bath and at least two hot baths a
week during winter. The unit medical officer should make himself/herself familiar with the system of bathing of
the personnel of his/her unit and should make it his / her duty to see that it is adequate.
(b) Dhobi Ghat and Shop/Laundry.
Arrangements should exist for washing of the clothes of the personnel. These should be established as far as
possible near the unit lines. Washed and unwashed clothes should not be allowed to be mixed. Washing water
should be clean and no waterlogging should be permitted. Wastewater should be drained well away from the
place after removal of the soapy scum.

4.8 Water Supply.

Chapter V on water supply describes methods of provisioning of safe and wholesome water to troops. Details must be
always known to the AMA. Where water supply is piped to the unit water samples at various point of delivery in the
unit and sub-units should be examined for the presence of free chlorine at frequent intervals and not only at the time
of the monthly unit inspection. If chlorination is not done centrally at the water point or in the unit after getting it, the
method of chlorination at sub-unit levels should be checked, not only during monthly inspection but more frequently and
records maintained. Any likelihood of pollution at any stage before its consumption should also be ascertained. Random
samples should be taken for checking the presence of free chlorine and the record of daily chlorination maintained by
water duty personnel at various sub-units should be scrutinized during the monthly round.

4.9 Canteen.
The wet canteen should be inspected exactly in the same way as or preferably with more detailed scrutiny than the
cookhouse. Sanitary control of canteens is extremely important.

4.10 Recreation and Information Rooms.

The standards recommended for space, ventilation, lighting and furniture should be ensured. Overcrowding in a recreation
room is as dangerous as it is in living barracks. Therefore, space and ventilation are important factors. Moreover, the
rooms should be adequately warm in winter and cool in summer. The function of the recreation room is to provide
healthy recreational facilities in order to promote mental well-being, to break the boredom and divert attention from
the temptation of visiting out of bond areas, high risk behaviour, etc. Attention should be paid to general cleanliness
of the premises, particularly to ventilation and lighting.

4.11 Regimental School.

Regimental school is for the soldiers and is different from the school for children. Adequacy of space. ventilation,
lighting and general cleanliness should be examined. The seating arrangements and the relative position of black
board and teacher must be checked.

4.12 Office Rooms, Guard Room and QM Stores.

These places also require inspection for ensuring adequacy of accommodation, maintenance, lighting. heating/cooling
and ventilation from the point of view of health. Clothing and ration stores must be examined for rat and fly proofing.
Working comfort of the staff in office and living comfort in guardrooms are also important and must be ensured.

4.13 Family Lines.

These should be included in the inspection as the health and hygiene of families and their living standards also influence
the soldiers’ health. Their health is as much the responsibility of the CO as the health of personnel. The same uniform
high standard in the ordinary married quarters as in the men’s’ barracks cannot be expected. Everything possible
should be done to raise the level of living conditions of the soldier’s family by lectures and talks at regular intervals.
The attitude of helpfulness should be adopted during these inspections. It should be realized that the average soldier’s

45
 INTRODUCTION TO MILITARY HEALTH

wife with duties of house-keeping and care of the children has her hands full in keeping her home even reasonably
clean. The important points on which to lay stress are the condition of the food storage, water supply, waste disposal
and drainage, the ventilation and general cleanliness of the house.

4.14 Family Welfare Centre.

One of the duties of the AMA is to supervise the family welfare centres of his/her unit and to remain acquainted with
the health of the families. Often a full time or a part time lady MO is appointed by large units for day-to-day work
under the overall supervision of the AMA / SEMO.

4.15 Children’s School.

It should be inspected once a month. General cleanliness, adequacy and the state of sanitary conveniences, water
supply arrangements, programme for health and physical education and the general state of health of the children
should be checked.

4.16 Aerated Water Supply.

Many units run their own aerated water factories. Sometimes, the natural desire to bring down the production cost
tends to a lowering of the hygienic standards of production. As a principle, the hygienic standards of the aerated water
should be the first criterion in its manufacture and low cost, although desirable, should be of secondary considerations.
The premises in which the factory is located should have concrete floor and impervious walls. The personnel employed
in the factory should be directly under the unit medical control and supervision. Special clothing for use during working
hours should be supplied to all workers. Piped chlorinated water from a central water works can be used. When such is
not obtainable, clarified water should be chlorinated and used after half an hour of chlorination. Strict attention should
be paid to the cleanliness of the bottles and the method of washing them. The satisfactory method of washing bottles
is first to scrub them inside and outside with a brush, then steep them for 15 min in bleaching powder solution (one
scoopful in 1 to 5 litres of water) and then in running chlorinated water and finally allow them to dry on a draining
board without wiping with cloth. The method of preparing and storing the syrups and flavouring agents for lemonade,
ginger beer and other sweetened aerated water should be hygienic.
These products are attractive to flies and the possibility of contamination by this means should be guarded against.
From time to time, samples of all types of aerated water made in the factory should be sent to the laboratory for
bacteriological examination. The health standards expected of personnel employed in the factory are the same as those
for cooks of unit kitchen. All concentrates should be FSSAI approved.

4.17 Abattoir.
Frozen meat/chicken is being provided as part of rations. However, when slaughtering of animal is carried out under
unit arrangements, the AMA should inspect abattoir thoroughly for hygienic standards, as it becomes a source of health
hazard to the personnel. Fly breeding and contamination of meat are the two hazards. Special notice should be taken
of the floor and general cleanliness of places where the carcasses are dressed. Floor should be of impervious concrete
and interior wall of smooth concrete, which should be lime washed frequently. Concrete channels should drain all liquid
manure from the lairs and the slaughter room to a place of disposal outside, semisolid manure should be dealt with
in the same way as manure from a dairy. The slaughter room should be fitted with scaffolding, having chrome plated
hooks for dressing animals, be fly proof, have an adequate water supply and be provided with a suitable means of
dealing with blood, offal and waste animal products. All liquid waste should be treated in effluent treatment plant prior
to discharge into a water carriage sewer and all solid refuse should be burnt in an incinerator. Above measures, however,
are rarely possible because slaughtering under unit arrangements is usually necessary in the field when meat-on-hoof
is supplied. The best method of disposal then is daily burning of all refuse and offal in the beehive incinerator. On
rare occasions when burial is adopted, the pits should be well limited and covered with rammed oiled earth. Special
covered receptacles for holding blood and offal pending incineration or burial should be provided. The carcass hanging
room should be well ventilated and fly proof.

4.18 Animal Lines.

The chief sanitary problem of the animal lines is the collection and disposal of animal litter in such a way as to prevent
fly breeding. Therefore, a visit should be paid frequently to the animal lines for maintaining vigilance on the method of
removal and storage of animal litter pending final disposal as it is a potential fly-breeding place in a unit. The floors of

46
 ASSESSMENT OF HEALTH & SANITATION IN ARMED FORCES

animal standing and for their litter should be made of sound concrete; otherwise, it is difficult to deal with fly menace.
The method of ultimate disposal of animal litter is described in chapter XVI. The medical officer should satisfy that at
no place in the system of removal and disposal of animal litter there is any possibility of fly breeding. Before leaving
the animal lines, grain stores should also be examined. The grain stores should be in permanent camps and always
be rat-proof.

4.19 Disposal of Waste.

This should be inspected at the end of the tour. The methods of waste disposal are described in Chapter XVI.
The RMO should proceed as follows to ensure the efficiency of methods adopted.
(a) Excreta Disposal.
If a water carriage system connected to main municipal drainage is in use, very little attention is needed except
to ensure that the latrines and urinals are clean, the flushing system is working efficiently and that there are
no leakages, breakages and blockages in the whole system. In cantonments, garrison stations and permanent
camps this is the method of choice. The medical officer should carry out an occasional inspection of the water
closets and urinals. Military sewage disposal works in large stations are under central control; in small stations
a sewage disposal plant may come under the unit’s sanitary control and should be inspected by the RMO for
its efficiency. Wherever septic tanks are used their efficacy and maintenance should be checked. If the ultimate
disposal of faeces is by trenching or composting, very close supervision is necessary, whenever possible it
should be substituted by deep trench latrines or by a partial water-carriage system connected with septic tanks.
In camps where deep trench latrines are in use it is essential that they must be always maintained in a state
of maximum efficiency.
Conservancy utilisation for disposal of faeces manually should not be allowed. If excreta are to be disposed off
away from the camp, it is most important to ensure that there is no spillage during removal and that the excreta
is taken at least two km away from the barrack for ultimate disposal.
(b) Refuse Disposal.
Control should be kept over refuse collection and disposal in a similar manner. Unit hygiene and sanitary squads
must be properly trained to construct and maintain the sanitary appliances. Dry waste and refuse are not to be
burned. They should be disposed off by waste to energy process, plastic to road construction, recycling, pyrolysis,
gasification. However, feasibility of modalities (Incineration/waste to energy process/burial) in Op scenario / field
condition must be explored for dry waste disposal. The beehive incinerator is ideal for any camp except in
purely temporary camp in which proper drum incinerators should be used. Care to burn all cook house refuse
should be taken as it is a source of fly nuisance. Burial as a method of refuse disposal is inferior to burning
and should not be adopted except as a last and temporary resort. It attracts rats and flies, breeds cockroaches
and creates general unhygienic conditions around kitchen and other bio­ degradable refuse may be disposed by
vermicomposting.
(c) Sullage Disposal.
In permanent camps, garrison stations and cantonments, underground drainage connected with the main sewage
system is ideal; otherwise disposal in large streams or soakage pits should be resorted to. In every case grease
traps and gully traps should be properly constructed and maintained.
(d) Animal Litter.
It should be disposed off by trenching, composting, tight packing or incineration according to the facilities
available, amount of litter and duration of the camp as described in Chapter XVI.

4.20 Action after the Unit Inspection.

After the inspection, the CO of the unit inspected should be given a verbal report mentioning all defects and measures
advised for their rectification. A severely critical written report on matters not discussed verbally with CO should, except
in very exceptional circumstances, be avoided as this usually leads to misunderstanding and defeats its own objective
which is to improve hygiene and habitability conditions of the unit. The written report in the sanitary diary should be
submitted to the CO as soon as possible after the inspection. The sanitary diary should be a large book, which is
not likely to be lost and which allows a record of the sanitary sate of the unit to be maintained over a long period.

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 INTRODUCTION TO MILITARY HEALTH

The up-to-date maintenance of sanitary diary is the unit’s responsibility. The pages should be ruled into four vertical
columns headed ‘Observations of RMO’, ‘Recommendations’, ‘Orders of the Commanding Officer ‘ and ‘Action taken’.
The report should begin with a statement ‘I carried out my weekly/monthly inspection of (unit/sub-unit) on (date)...’
The general sanitary condition of the camp should then be summarized as, for example. ‘excellent’, ‘good’, ‘fair’ or
‘poor’. This should be followed by detailed observations and recommendations recorded in their proper grouping e.g.
the accommodation, messing arrangements, regimental institutes, refuse disposal, arrangements for personal hygiene
and so on.
Comments should always be constructive and the observation of a defect should invariably have a concrete
recommendation for its rectification. Suggestion must never be impracticable, fanciful or ill­ considered, but always
fully thought out and well-reasoned, with due weight being given to the feasibility, cost and labour involved in structural
alterations. The tone of the report should be sober and moderate, strongly worded criticisms being avoided, however,
correct they may be, the motive of unit inspection being to achieve a progressive improvement in environmental
conditions for maintenance of high standards of health and battle-worthiness of the unit at all times. The inspection
note should provide a valid guide to the CO for assessment of the health of troops, their morale and hygiene conditions.
After the CO has scrutinized it and rectification recommended are carried out by the regimental officers concerned or
the reasons for not carrying them out are given, the sanitary diary should be forwarded by the unit to the SEMO. This
serves as a guide for the SEMO to further advise the CO of the unit and keep the formation commander informed.
Therefore, difficulties experienced by the unit also should be mentioned. The RMO should whenever necessary, obtain
advice and help from the DADH and local OC Station Health Organisation.

4.21 Provision of Medical Inspection Room or Regimental Aid Post.

Promotion and maintenance of health of troops being the concern of the CO of the unit and illness being the most
important index giving an indication of the state of health of personnel, it is incumbent upon the unit administration
to make provision for a suitable, centrally located, unit Medical Inspection Room (MI Room) / Regimental Aid Post (RAP)
to detect illness and have adequate treatment facilities. The MI Room and the RAP should be such that the medical
officer will be able to carry out his/her duties conveniently and comfortably. It should be clean, neat and tidy. It should
be well equipped with all the medical and ordnance equipment as authorized; the work should be well organized and
all equipment should always be in working condition.

4.22 SEMO / SMO Visit.

He/She visits the units with the objective of assessing the following.
(a) The living and working environments.
(b) The general state of health, morale and health education of troops and their families.
(c) Checking health documents maintained in the unit.
(d) The earnestness with which all the health programmes are carried out and the efforts with which the orders
and instructions regarding maintenance of health and prevention of illnesses are observed.
(e) The difficulties experienced by the unit and AMA in carrying out and observing health rules, administering
health programme and in general maintaining the health and morale of troops and their families at a high
standard.
(f) The state of unit medical equipment, its adequacy and maintenance.
(g) The AMA’s work, his medical administration, professional knowledge. efficiency, tact, resourcefulness and
the cooperation he receives from officers and men of the unit.

4.23 Assessment of Health.

The AMA gets some idea of the state of health (or extent of ill health) and morale of personnel in the unit under his
medical care from the daily sick report. But the thoroughly carried out, regular, periodical medical inspections are often
more revealing. This is a reliable method of keeping himself/herself informed of the state of health of unit personnel.
The AMA is required to carry out medical inspection of.
(a) All food handlers once a month.
(b) Personnel newly posted to the unit.

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 ASSESSMENT OF HEALTH & SANITATION IN ARMED FORCES

(c) Personnel before proceeding on and returning from courses of instruction / leave / temporary duty.
(d) Recruits posted to the unit.
(e) Personnel joining their units after serving abroad.
(f) All unit personnel yearly.
Such medical inspection enables the AMA to detect a disease in an individual and the rising incidence of any disease
in the unit, early enough to enable him to take prompt action and to advise the CO on the control measures to be
adopted.
Yearly medical inspection of all personnel implies a thorough inspection of a person for fitness. A detailed record is to
be maintained of such inspections and the health record card filled up.

4.24 Medical Inspection of Civilians.

In order to protect the health of service personnel, as few civilians as possible should be employed or allowed into
the unit lines. Vendors and hawkers of food articles should not be allowed in the unit area. All civilians employed or
permitted to enter unit lines should be under strict medical supervision. The following precaution must be taken to
ensure that no civilian entering unit lines transmits an infection to personnel.
(a) Before any civilian is employed he/she should be medically examined by the unit medical officer.
(b) Each civilian employed should be given a pass on which his name, address, age, date of employment,
dates of medical inspections and vaccination should be recorded. The pass should also bear the photograph
and finger imprints of the person to whom it is issued.
(c) All civilians employed in the unit should be regularly inspected once a month.
(d) Before a civilian returns to duty after an absence for any cause, he should be medically examined; and if
the absence has been due to illness, this should be kept in mind before declaring him/her fit for returning to
his/her work.
(e) If for any reasons hawkers are permitted, they should be subjected to exactly the same control, as other
civilians including medical inspection.
(f) Civilians in canteens, cookhouses, messes, butcheries (if any) and barber’s shop should be employed on
a permanent or long-term tenure and always more thoroughly examined.

4.25 Inspection of School Children.

The inspection of the school buildings should be carried at least once a quarter, a general survey should be made of
the children in the classrooms. The points to note are the general appearance and demeanour of each child and their
cleanliness. Generally, speaking a clean happy looking child is healthy. The teacher in charge of each class should be
invited to give his/her opinion on the general welfare of the children. Any child considered by him / her to be suffering
from any defect should be carefully examined afterwards. Particular attention to the teeth, tonsils and adenoids,
intelligence and personal cleanliness of the child should also be looked into. It is not suggested that a complete
medical examination should be done once a quarter of each child. But all children detected in the general survey of
the whole class as having some defect or reported by the teacher as having some defect, should be thus examined.
In addition to the survey, a complete examination should be made of all children once a year.

Suggested Reading.
1. Army Order – AO 10/2020/DGMS, Prevention of Food and Water Borne Diseases.
n

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Chapter
V
WATER SUPPLY

5.1 General Considerations.

Water is a vital resource for sustainable development. It not only fulfils basic human needs, but also plays a key
role in energy production, agriculture, industry and transport. However, fresh water, a renewable yet finite resource,
is facing increasing pressure from population growth, economic development and changing consumption patterns.
According to the UN World Water Development Report 2021, water demand already exceeds supply in many parts
of the world and is projected to increase by 20 to 30% above the current level by 2050.
Water can also become a vehicle for transmission of faeco-oral group of infections, because the faecal
contamination of water is extremely common and its avoidance and subsequent purification is very difficult.
These microorganisms can cause a variety of diseases, including diarrhoea, cholera, typhoid fever and hepatitis
A. Therefore, a strict water vigilance and control is to be maintained at all times. Water can also be contaminated
with chemicals, such as lead, arsenic and fluoride. These chemicals can cause a variety of health problems,
including neurological damage, cancer and kidney disease. Lead contamination is a particular concern in older
homes, where lead pipes may be used to deliver water. Arsenic contamination is a problem in some parts of the
world, where it is naturally present in the soil and water. Fluoride is added to water in some areas to prevent
tooth decay, however, excessive fluoride can also be harmful and it can cause skeletal fluorosis, a condition that
can lead to pain, stiffness and other health problems.

5.2 Global Situation.

The escalating demand for water is imposing pressure on water resources potentially leading to water scarcity, water
pollution and conflicts. Water scarcity is already a problem in many parts of the world. In 2020, 2.2 billion people lived
in areas with severe water scarcity. By 2050, it is estimated that up to 7 billion people could be living in water-stressed
regions. Water scarcity can lead to a number of problems, including food insecurity, economic losses and conflicts.
Water contamination is another major problem that is affecting people around the world. Every year, millions of people
get sick from drinking contaminated water. According to the World Health Organization, diarrheal diseases caused by
contaminated water are responsible for the deaths of 8,42,000 children under the age of five every year.
To address these challenges, the international community has launched several initiatives, such as the United Nations’
Sustainable Development Goal 6, which aims to ensure access to water and sanitation for all by 2030. The World
Bank’s Water Global Practice supports countries in their efforts to manage water resources sustainably and improve
access to water and sanitation services. The WHO’s Water, Sanitation and Hygiene (WASH) program also aims to improve
water and sanitation services in healthcare facilities, which are critical for preventing healthcare-associated infections.

5.3 National Situation.

India has about 4% of world’s freshwater resources ranking it among the top ten water rich countries. Despite this, India
is designated a ‘water stressed region’ with current utilisable freshwater standing at 1,122 cubic meter (cu m) per year
and per capita compared to international limiting standards of 1,700 cu m. In future, it is expected that India will be
termed a ‘water scarce region’ as utilizable freshwater falls below the international standard of 1,000 cu m per year
and per capita. Water scarcity is already a problem in many parts of India and it is expected to worsen in the coming
years. The states of Maharashtra, Gujarat, Rajasthan and Madhya Pradesh are particularly vulnerable to water scarcity.
According to the National Institution for Transforming India (NITI) Aayog report (2018), around 600 million Indians are
facing high to extreme water stress and 21 cities in the country were likely to run out of groundwater by 2020.
Contaminated water is a major cause of waterborne diseases in India, including cholera, typhoid and hepatitis A. The
lack of access to clean water and sanitation facilities is also a significant concern, particularly in rural areas. According
to a report by WaterAid India, 163 million Indians lack access to clean water and 732 million do not have access to

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 WATER SUPPLY

basic sanitation facilities.

To address these challenges, the Indian government has launched several initiatives, such as the Jal Shakti Abhiyan,
which aims to provide safe and adequate drinking water to every rural household by 2024. The Swachh Bharat Mission
(Clean India Mission) is also working to improve access to sanitation facilities across the country, with a target of
achieving a Swachh Bharat (Clean India) by 2019.
In addition, the National Rural Drinking Water Programme (NRDWP) and the National Urban Drinking Water Mission
(NUDWM) are working to provide safe and adequate drinking water to rural and urban areas, respectively. The NITI
Aayog has also launched the Composite Water Management Index (CWMI) to assess and improve water resource
management across states in India.

5.4 Safe and Wholesome Water.

Drinking water should be safe as well as wholesome. The term ‘safe and wholesome means that the drinking water
should be.
(a) Free from pathogenic organisms.
(b) Free from harmful chemical substances.
(c) Acceptable to taste and appearance.
(d) Usable for domestic purposes.
Such water is also termed as potable water. Water is called polluted when it contains infective and parasitic agents,
poisonous chemicals, industrial and other wastes or sewage.

5.5 Uses of Water.

Water is essential for the total development of a community i.e., economic. social and cultural. The uses of water may
be broadly classified as follows.
(a) Domestic Uses.
For drinking, cooking, bathing and washing, flushing of toilets, gardening etc.
(b) Public Purpose.
For firefighting, street washing, watering of public gardens, swimming pools and numerous other civil activities.
(c) Industrial and Commercial Purposes
(d) Agricultural and Animal Husbandry Purposes.
To raise food, fodder, livestock and other raw materials.

5.6 Sources of Water.

The ultimate origin of all sources of water is rainfall. The water in streams and rivers finally flows into the sea.
Groundwater is the source of water in wells and springs that feed streams, rivers and lakes. The quality of water varies
greatly depending on the source of water and the medium through which it flows. Surface waters generally contain
larger quantities of turbidity and bacteria than ground water, but groundwater has higher concentration of dissolved
chemicals. There are three main sources of water.
(a) Rainwater
(b) Surface Water.
impounding reservoirs, lakes, ponds, tanks, rivers, streams and sea water
(c) Underground Water.
shallow wells, deep wells, tube wells, artesian wells, step wells and springs
(a) Rainwater.
Rainwater is the purest form of water. It is usually soft, plumbosolvent and mildly acidic due to its reaction with

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INTRODUCTION TO MILITARY HEALTH

carbon dioxide in the atmosphere to form carbonic acid. Physically, it is clear, bright and sparkling. Chemically,
it is very soft water containing only traces of dissolved solids (0.0005%). Being soft it has a corrosive action on
lead pipes. Bacteriologically, rainwater is free from pathogenic agents.
Rainwater is used as a direct source on islands in salt water, such as Bermuda, where the rain is collected and
led into cisterns to serve as the only available water supply. Catchment areas for direct capture of rainwater are
also useful for individual households as in Southwest USA or small communities as in Gibraltar where paved
catchments are used.
Acid rain is a result of air pollution, which occurs when oxides of Sulphur and nitrogen combine with atmospheric
moisture to yield sulphuric and nitric acids, which may then be carried long distances from their source before
they are deposited by rain. The pollution may also take the form of snow or fog or be precipitated in dry forms.
The problem of acid rain originated with the Industrial Revolution and it has been growing ever since. The
widespread destructiveness of acid rain, however, has become evident only in recent decades as it has been
found to erode buildings and other structures, injure crops and forests and threaten or deplete life in lakes.
(b) Surface Water.
Surface water usually originates from rainwater. It includes rivers, streams, impounding reservoirs, lakes, irrigation
canals, ponds, sea water and wastewater after treatment. Surface water is moderately soft and contains variable
degree of pollution from human and animal excreta. The extent of contamination at a particular time and place
will depend upon the pollution of water from the feeding streams, upstream or springs, extent of stagnation or
outflow over a given time and extent of natural self-purification.
(i) Impounding Reservoirs.
These are the artificial lakes constructed usually of earth work, concrete or masonry in which large quantities
of surface water is stored. Dams built across the rivers and mountain streams also provide large reserves
of surface water. During storage, sedimentation takes place and the number of fecal coliforms and fecal
streptococci are considerably reduced. Destruction of organic matter by atmospheric oxygenation, solar
radiation and aquatic flora and fauna also occur. Algal growth and loss of water through evaporation are
the chief drawbacks. Storage in reservoirs and lakes may degrade water quality through eutrophication and
thermal stratification. Eutrophication (over-nourishing) occurs due to the influence of nutrient materials,
particularly phosphorus and nitrogen which support the growth of algae. These nutrients accumulate in
algae, promoting algae growth and contributing to the degradtion of water quality. The increasing amounts
of algae impart unpleasant taste and odour to water.
During summers, warm water accumulates at the top and the density difference prevents mixing.
Microorganisms tend to accumulate at the thermocline- the zone of rapidly changing temperature and
density that separates upper and lower layers.
(ii) Lakes.
Lakes are increasingly becoming vulnerable to pollution as they are quite accessible for human activities.
Eutrophication of lake waters is also common due to runoffs of chemical fertilizer from cultivated fields. The
process of eutrophication can produce aesthetic problems such as bad taste, odour and unsightly green scums
of algae, dense growth of rooted plants, oxygen depletion in the deeper waters and bottom sediments of lakes
and other chemical changes such as precipitation of calcium carbonate in hard water. Another problem, of
growing concern in recent years, is acid rain, which is leaving many lakes totally devoid of life.
(iii) Ponds.
Surface ponds without inflow of fresh water from upland streams or natural springs are stagnant. The degree
of pollution and contamination is very high due to surface inflow and seepage from the surroundings. The
concentration of pollution increases as water evaporates. The degree of self purification is negligible and
the amount of pollution added to it each day is unpredictable. Water from fresh water lakes, which are
properly protected, fenced and patrolled is generally pure and can be made potable whereas that from a
pond is never recommended for human consumption. Unfortunately, it constitutes one of the main sources
of water supply in the rural areas of our country.
(iv) Tanks.
Tanks are large excavations in which surface water is stored. They are an important source of water supply

52
 WATER SUPPLY

in some Indian villages. They are contaminated with silt and colloidal matter, especially immediately after
the rains. They are often used for washing clothes, cattle and for defecation purposes at its edges which
will be washed into the tank at the next rain. They are thus highly dangerous as a source of drinking water
and basic techniques of modifying a part of it into a filter bed should be applied. The filtered water is then
drawn into gravity fed well and finally chlorinated before supply (Fig 5.1).

Fig 5.1 : Slow Filtration of Tank Water

(v) River and Streams.
These are natural drainage channels of the land. The quality of river water depends upon the geological
strata through which it has travelled, seasons of the year and amount of pollution that has occurred during
its course. River water is turbid during rainy season and it may be clear in other seasons. Clarity of water
is no guarantee that the river water is safe for drinking. Generally, it is moderately hard and holds organic
and inorganic pollutants. It contains dissolved and suspended impurities. These impurities are derived from
surface washings, sewage and sullage water, industrial and trade waste, drainage from agricultural areas,
carcasses and human dead bodies. In dry periods, river flow is less and the load of dissolved solids is more
concentrated. In wet periods, water in rivers and streams may be low in dissolved solids content but has
high turbidity. The Central Pollution Control Board (CPCB) in 2018 identified 351 polluted river stretches in
India. The assessment of water quality for identification of polluted river stretches found that 31 states and
Union Territories (UT) had rivers and streams that did not meet the water quality criteria. Maharashtra has
the highest number of polluted river stretches (53), followed by Assam (44), Madhya Pradesh (22), Kerala
(21), Gujarat (20), Odisha (19) and West Bengal and Karnataka (17).
Rivers, however, have considerable powers of self-purification through the physical and biological processes.
The degree of self-purification depends upon the length, breadth and depth of the river, velocity of the
water, nature of riverbed, presence of saprophytic organisms, volume of water, presence of aquatic and
animal life and exposure to sun rays. It should be ensured that water supply is protected upstream and the
industrial and other effluents discharged into a river downstream conform to the laid down standards. The
inadequacy of traditional methods of water treatment to tackle gross river water pollution may be indicated
by the outbreaks of viral hepatitis in New Delhi in 1955-56, when there were 30,000 cases.

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 INTRODUCTION TO MILITARY HEALTH

(vi) Sea Water.

Sea water contains 3.5% of salts in solution. Off-shore water of oceans and seas have salt concentration
of 30-36 g / L of dissolved solids including 19 g / L of Chloride, 10.6 g / L of Sodium and 1.27 g / L of
Magnesium. The most appropriate method for desalination of sea water is thermal distillation as done in
the Middle East and West Indies. Several different processes, including electrodialysis, reverse osmosis
and direct-freeze evaporation, have been developed for this purpose. With brackish water, where the salt
content is much less than that of sea water, reverse osmosis or electrodialysis may be used. An additional
problem is that with almost 80 percent of the planet covered by oceans, people have long acted as if these
water bodies can serve as a limitless dumping ground for wastes. Raw sewage, garbage and oil spills have
begun to overwhelm the diluting capabilities of the oceans and most coastal sea waters are now polluted.
(c) Underground Water.
Rainwater percolating through the ground and reaching permeable layers form underground water. This water is
of major importance to civilization, because it is the largest reserve of drinkable water in regions where humans
can live. The advantages of underground reservoirs are as follows.
(i) They do not lose water through evaporation.
(ii) Their quality is not so likely to be affected by natural, urban or industrial pollution.
(iii) They do not require expropriation of large areas of land.
(iv) They may be located nearer to the points of use than are surface impoundments.
Although groundwater is a renewable resource, reserves are replenished relatively slowly. Because groundwater
is recharged and flows so slowly, once polluted it will remain contaminated for extended periods. Contamination
arises from leaking underground storage tanks, poorly designed industrial waste ponds and seepage from deep-
well injection of hazardous wastes into underground geological formations. Due to this, some villages do not
have access to safe water resulting in occurrence of ‘problem village’.
The usual groundwater sources are wells and springs. Springs occur due to the emergence of groundwater to
the surface. Wells can be classified according to the construction process into dug wells, bore wells and step
wells. They can also be classified into shallow and deep wells and artesian wells depending on the depth and
the layer of water table. The characteristics of deep well and shallow well are described in Table 5.1.
Table 5.1 : Characteristics of Deep Well and Shallow Well
Criteria Shallow Well Deep Well
Definition Taps water from above the first Taps water from below the first
impervious layer impervious layer
Chemical quality Moderately hard Much hard
Bacteriological quality Usually grossly contaminated Good
Yield Low, usually dries in summer, about High (about 100 gpm)
1 gallon per minute (gpm)
(i) Shallow Wells.
These wells tap the ‘superficial water table’ above the first impervious layer in the ground. They yield limited
quantities of water which usually dries up in summers. The yield of water from shallow wells of moderate
depth and diameter in hard rock is expected to be 1 to 50 gallons per minute (1 gpm = 1440 gpd), whereas
similar wells in coarse sand, gravel and coarse sandstone is 50 to 500 gpm. In India, most of the wells are
of shallow type. The quality of water from shallow wells is unpredictable and depends upon the geological
formation and degree of pollution by seepage from the adjacent area. These wells are, therefore, inferior
to deep wells as sources of water for human consumption.
The Cholera outbreaks in Delhi in 1988 were due to contamination of shallow wells. For improvement of the
existing shallow wells which are usually ‘kutcha’ and are most commonly used in rural areas, the Planning,
Research and Action Institute (PRAI) Lucknow has developed a modification plan at nominal cost. Such a
well can be made sanitary by deepening the bottom, installing a handpump with screen and then filling the

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 WATER SUPPLY

well with coarse sand upto water

level. Clay is then put over sand till
it reaches a little above the surface
level and then left for consolidation.
When the material used for filling
is consolidated a platform and
drainage is constructed. Samples
of water from such wells is found
to be satisfactory.
(ii) Deep Wells.
These wells tap the deep-water
table lying between the two
impermeable strata and their yield
is constant. Wells in deep aquifers
may yield 100 gpm or more in
favorable circumstances. These
wells are usually machine dug and Fig 5.2 : Underground Water
are several hundred meters deep.
Water from deep well is usually
cool, pure and sparkling but is likely to have a lot of mineral contents. Normally it forms a very good
source of water supply if it is well protected. A deep well is also liable to pollution if there are cracks in the
impermeable layer especially in chalky strata. Faulty staining also makes them liable to surface pollution
as in the case of shallow wells.
An ideal deep well is the one which is sunk to a sufficient depth below the first impermeable geological
stratum, well stained with stones or bricks set in cement concrete provided with a covered parapet with a
coping or sloped platform around and fitted with a pump. The depth of water should be sufficient to ensure
an adequate quantity and sedimentation (Fig. 5.2).
(iii) Sanitary Well.
A sanitary well is a well which is properly located, well-constructed, is protected against contamination and
yields safe water supply. A sanitary well has the following features (Fig 5.3).
(aa) Location.
It is located at least 15 metres (50 feet) away from the likely source of contamination. It should be
located on a higher elevation with respect to the possible source of contamination and the distance
from consumers should not be more than 100 metres.
(ab) Lining.
The lining of the well is built with bricks or stones and cement upto a depth of 6 metres (20 feet) so
that water enters from the bottom and not from the sides of the well. The lining should be around
60-90 cms above the ground level.
(ac) Parapet.
The well should have a parapet wall up to a height of 70-75 cm above the ground.
(ad) Platform.
There should be a cement-concrete platform around the well extending at least one metre in all
directions. The platform should have a gentle slope outside towards the drain built around the edges.
(ae) Drain.
A cemented drain should be made around the platform to drain storm water and spilled water to the
main drain or soakage pit constructed beyond the cone of filtration.
(af) Covering.
The top of the well should be covered providing some gaps for aeration and ventilation. The gaps

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INTRODUCTION TO MILITARY HEALTH

should however, not allow the impurities to go inside the well.

(ag) Handpump.
A manual or electric pump should be connected to draw water hygienically from the well.
(ah) Consumer responsibility.
Strict cleanliness should be enforced in the vicinity of the well. Personal ablutions, animal droppings,
washing of clothes and animals, bathing etc should be prohibited. Ropes and buckets from individual
homes should not be used for drawing water from the well.
(aj) Water stagnation.
Water should not be allowed to stagnate near the well to prevent breeding of mosquitoes.
(ak) Quality.
The physical, chemical and bacteriological quality of water should be as per the acceptable standards
of quality of safe and wholesome water in rural areas.

Fig 5.3 : Sanitary Well

(iv) Tube Wells.
These wells are made by boring into the ground. These wells can be shallow or deep. A lot of emphasis is
presently being given nationally as well as internationally to provide safe water through tube wells in rural
areas. Tube wells can be drilled to over 200 meters deep, even through hard rock. The tube well consists
of a pipe made of galvanized iron that is sunk into the water bearing stratum. The pipe is fitted with a
strainer at the bottom and a handpump is connected at the top. Boring and inserting a tube and fitting a
pump are works of some magnitude. The hand pumps are so constructed that their levers can withstand
reasonable degree of rough handling.
The yield of tube wells is usually very high and does not depend on rainfall in the vicinity. The capacity of
tube wells varies over a wide range, from less than 1 liter / sec for shallow small-diameter wells in fine sand
aquifers, to over 100 liters / sec for large diameter deep wells in coarse sand or sedimentary rock deposits.
Bacteriologically, water is safe and is an economical source of water in comparison to other water sources.
Chandigarh derives its most of the water supply from tube wells. The difficulty in installing tube well lies
in the apparatus required for its construction, which require complicated mechanical drilling equipment
and skilled engineering directions. The life of a tubewell may last for a period of 5-10 years. However, in
certain cases they have given satisfactory service even after 30 years. Also, there may be a uncertainty

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regarding striking water and if found, it's suitability in terms of water quality. At times, water obtained may
be brackish or heavily charged with magnesium salts.
(v) Artesian Wells.
The name is derived from French province of Artois, where such wells were first drilled in modern times.
They contain groundwater under positive pressure. This pressure arises because water is confined between
impermeable rocks or clay. The water level in the well rises to a point where hydrostatic equilibrium is
reached. Sometimes, water level reaches to the surface when the natural pressure is high. Artesian wells
are not common in India.
(vi) Step Wells.
These are a kind of ‘pucca’ wells where steps are constructed leading to these wells to fetch water. There
is considerable contact between the user and water. Guinea worm infestation was a public health problem
in areas having such wells. These wells are now becoming obsolete.
(vii) Driven Wells.
Driven wells are essentially suitable for soft, sandy formations, which are readily penetrated by the well
point. They are usually limited to shallow wells of less than 10-15 meters depth. The diameter is also about
5-10 cm only. The yield is only about 0.1 to 1.0 liter / sec.
(viii) Springs.
These are natural wells formed when for some reason the underground water over flows upon the surface
where the geological formation is favorable for an outcrop. Springs can be ‘shallow springs’ and ‘deep
springs’ depending upon whether the water comes from the superficial or deep-water tables. They may be
intermittent or constant. Intermittent springs are merely the reappearance of upland surface water, which
has temporarily passed underground.
Springs are prone to contamination. Until it is made certain that the water is from deep spring, its purity
should be viewed with suspicion. Water from a deep spring is generally hard and less suitable for washing
and cooking but can be used for drinking. Deep springs can be turned into well like reservoirs by building
parapets around them.

5.7 Water Availability and Requirements.

The amount of water in the world is fixed, around 1,500 million km3. The amount of fresh water is less than 3%, about
two-thirds of which is locked in ice caps and glaciers. Most of the liquid fresh water is underground, around 6 million
km3 of groundwater is 50 meters deep and a further 2 million km3 at greater depth. The amount of fresh water in
lakes, rivers and streams is small, about 0.2 million km3. The atmosphere contains 13,000 km3 of water. The supply
of water must be satisfactory in quality, adequate in quantity, readily available to the user, relatively cheap and easily
disposed after it has served its purposes.
Water requirement depends upon climate, extent of physical activity, its availability, standard of living and habits of
the people. In an urban area having water carriage system of sewage disposal, about 150 to 200 liters per head per
day supply is considered adequate.

5.8 Water Pollution.

Natural water, from a chemical point of view, is never pure. The impurities could be either natural, derived from
atmosphere or catchment area and soil or due to human activities. NITI Aayog report (2018) titled “Composite Water
Management Index”, mentions that India is undergoing the worst water crisis in its history and nearly 600 million
people are facing high to extreme water stress. The report further mentions that India is placed at 120th amongst 122
countries in the water quality index, with nearly 70% of water being contaminated.
Water pollution may come from point or nonpoint sources. Point sources discharge pollutants at specific locations, for
example, from factories, sewage treatment plants or oil tankers. Technology is available for point sources of pollution
to be monitored and regulated. Nonpoint sources, for example, run off water containing pesticides and fertilizers from
areas of agricultural land are much more difficult to control. Pollution arising from nonpoint sources accounts for most
of the contaminants in streams and lakes. The pollutants may be classified as under (Table 5.2).

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Table 5.2 : Pollutants of Water

Natural Pollutants Manmade Pollutants
Dissolved gases: Carbon dioxide, Sewage and other oxygen-demanding wastes (largely carbonaceous organic
ammonia. hydrogen sulphide and material, the decomposition of which leads to oxygen depletion) and
nitrogen infectious agents
Dissolved minerals: Salts of Plant nutrients, including fertilizers, that can stimulate the growth of aquatic
calcium, magnesium and sodium plants, which then interfere with water use and when decaying, deplete the
dissolved oxygen and produce disagreeable odours
Suspended impurities: Clay, silt Exotic organic chemicals, including pesticides and herbicides, various
and mud washed by storms industrial products, surface-active substances in detergents and the
and floodwater from croplands, decomposition products of other organic compounds
unprotected soils, strip mines,
roads and bulldozed urban areas
Microscopic plants and animals: Petroleum, especially from oil spills
Plankton, algae, saprophytes and
Inorganic minerals and chemical compounds, metal salts and synthetic
insects
organic chemicals
Radioactive substances from the wastes of uranium and thorium mining
and refining, from nuclear power plants and from the industrial, medical
and scientific use of radioactive materials
Heat may also be considered a pollutant when increased temperatures in
bodies of water result from the discharge of cooling water by factories and
power plants

5.9 Health Hazards due to Consumption of Impure Water.

Health may be affected either directly by consuming contaminated water or indirectly through food chain and also by
use of water for recreational, agricultural, trade and other purposes. The health hazards of water pollution may be due
to biological, chemical and radioactive substances / agents.
(a) Biological.
The diseases related to water supply and caused by biological agents are as follows (Table 5.3).
Table 5.3 : Disease Related to Water Supply Caused by Biological Agents
Group Diseases
Water borne diseases: Diseases transmitted by water Cholera, typhoid, bacillary dysentery, viral hepatitis,
where water acts as a passive vehicle for infecting leptospirosis, giardiasis, gastroenteritis
agent. All these depend also on poor sanitation
Water washed diseases: Scabies, skin sepsis & ulcers. yaws. leprosy, lice,
typhus, trachoma, conjunctivitis. bacillary and amoebic
Diseases due to lack of water. Poor personal hygiene
dysentery, salmonellosis, worm infestations
favors spread. Intestinal infections depend on lack of
proper human waste disposal.
Water based diseases: Schistosomiasis, dracunculiasis
Infecting agents spread by contact or ingestion of
water. An essential part of life cycle of agent takes
place in aquatic animal.
Water related vectors: Transmitted by insects living Yellow fever, dengue, encephalitis, filariasis, malaria,
close to water Onchocerciasis, sleeping sickness
Faecal disposal diseases: Caused by infecting agents - Clonorchiasis, Diphyllobothriasis, Fasciolopsiasis,
by eating uncooked fish and other food. Paragonimiasis

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(b) Chemical.
These pollutants are of diverse nature and are derived from industrial, trade and agricultural wastes that are being
discharged increasingly into water bodies. The chemical pollutants include detergents, solvents, cyanides, heavy
metals, minerals, organic acids, nitrogenous substances, dyes, pigments, bleaching agents, sulphates, ammonia
and other toxic substances. Acute toxic effects on human health by these pollutants presently are presumably of
less concern than their long-term low-level exposures. Some of these substances are either known or suspected
of having carcinogenic, mutagenic or teratogenic effects. Deficiency of some substances such as iodine and
fluorine may cause goitre and dental caries respectively. Excess of some of them may also cause harmful effects;
excess fluorides may cause fluorosis; excess of nitrates and nitrites may cause methemoglobinemia in infants.
(c) Radioactive Substances.
In modern world with radioactive substances being used in wide range of fields, extending from peaceful use
such as medical diagnostics and treatment to it's wide used in energy production and other sectors. In future
these substances may pose a major health hazard due to water contamination by its residues.

5.10 The Water (Prevention and Control of Pollution) Act 1974 (Amended in 1988)
This Act was passed by the Parliament in 1974 to counter and contain ever growing pollution of natural water resources.
This Act is comprehensive in providing legal basis for prevention and control of water pollution, maintenance and
restoration of wholesomeness of water sources in the country. To execute the aforesaid purposes, the Act provides for
the constitution of Central, State and Joint Boards having prescribed powers and functions.
The main function of the Central Board shall be to promote cleanliness of watercourses in different areas of the States.
The Board has been conferred the power to perform several functions i.e. advisory to the Central Govt; coordinating
the activities of the State Boards, provide technical assistance and guidance to the state board, carry out and sponsor
investigations and research relating to problems of water pollution and their abatement; plan and organize training of
persons engaged or to be engaged in programs for prevention and control; collect, compile and publish technical and
statistical data related to the subject; to lay down, modify or annul the standards for a water course, plan and ensure
implementation of nationwide programme. The Board may establish or recognize laboratories to enable it to perform
its functions including the analysis of samples of water, sewage or trade effluents.
The State Boards, under the guidance of Central Board, are similarly responsible to plan and execute comprehensive
programmes in their respective territories. They have also been conferred the powers of entry into any premises after
giving due notice to the owner and collect samples of water, sewage and trade effluents for analysis and recommend
necessary legal steps. The State Governments, under advice from the Board, are also authorized to take emergency
measures when pollutants have entered or threatened to enter the watercourse due to accidental or unforeseen event
or act of omission or commission.
A Joint Board is set up on subjects of common interest by mutual agreement either between adjacent states or between
the states(s) and the Central Govt. when the latter has been appointed as the executing agency for the Union Territories.

5.11 Selection and Protection of Water Sources.

To obtain purified and safe water supply for human consumption, proper source and tapping site should be selected
keeping in view the vulnerability and degree of pollution, power of self-purification, daily yield, availability duration,
wholesomeness of water and accessibility to the area.
(a) The area around the source, tapping point and delivery point should be protected against pollution by
fencing and prohibiting entry of animals and unauthorized men, bathing and washing.
(b) No sanitary installation should be allowed in the vicinity.
(c) Water pumped out of wells, when that is the source of water, should be received in a reservoir and
chlorinated. The storm water should be led away by a channel constructed around the outer platform to a garden
or a large soakage pit. The well should be fenced and no unauthorized persons should be allowed into the area.
Periodic inspection, repairs and desilting of the well should be carried out.
(d) Springs should also be provided with a coping and parapet. They should be fenced and bricked in. The
surface storm water should be diverted away by means of channels dug around the spring.
(e) Water from streams and lakes should be drawn from the upstream side of the township and as far from

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the banks as possible and pumped into the treatment tanks.

(f) In the field, several alternative sources and sites should always be examined and the best of them selected
for immediate use. The others should then be graded according to merits and improved upon for use in an
emergency. When there is no freedom of choice, the only available source and site should be improved upon.
Personnel attending to the water treatment / distribution should be protected against typhoid and medically
inspected.

5.12 Water Purification.

(a) Aim.
The aim of water purification is to diminish organic and inorganic suspended matter, pathogenic organisms and
deleterious salts and poisons in solution. Clarification followed by sterilization by various methods generally renders
water safe for human consumption. Clarification removes suspended matter and sterilization kills pathogenic
organisms. The elimination of deleterious salts is a difficult problem and no simple practicable method has yet
been devised for employment in the field. Sterilization without clarification may be practiced if water is beyond
any doubt of pollution and is visibly clear or under extreme urgency.
(b) Purification of Water on Large Scale.
Water purification may be required to be carried out at large scale or small scale. The components of a typical
water purification system comprise of one or all of the following measures.
(i) Pre-treatment.
(ii) Filtration.
(iii) Disinfection.
The conventional treatment of water includes pre-chlorination, aeration, flocculation (rapid and slow mixing) and
sedimentation, rapid gravity filtration and chlorination to render water safe for consumption. Clarification refers
to sequence of operations used to remove suspended solids (minerals and organic) from raw water together
with the proportion of dissolved organic matter (flocculating fractions). It consists of four phases- coagulation,
flocculation, sedimentation and filtration. Efficient clarification besides eliminating the suspended matter, also
removes harmful organisms, cysts, ova, mollusc and Cyclops. This thus reduces the chlorine demand of water.
Out of the two processes- sedimentation and filtration, filtration is superior to sedimentation provided that the
suspended matter is not too dense. Sedimentation requires more time (several hours) than filtration and the
amount of water that can be dealt with is limited by the size of tanks available. Sedimentation less efficiently
eliminates ova and cysts than filtration. However, efficient sedimentation prior to filtration definitely results in a
better clarity of water and relieves the filters of the clogging debris.
(i) Pre-treatment.
It includes storage, coagulation, rapid mixing, flocculation and sedimentation.
(aa) Storage.
This process involves allowing water to stand in concrete masonry or canvas tank over a variable
period (2-6 hours) for settling the coarse suspended matter. This process can be improved in quality
and fastened by coagulation and flocculation which precipitates particulate and colloidal matter.
Storage is a natural purification process which acts in following ways.
O Physical.
Approximately 90% of suspended impurities settle down in 24 hours by gravity which renders
the water to become clear and pure.
O Chemical.
The aerobic bacteria oxidise the organic matter present in water with the help of dissolved
oxygen. This results in reduction in content of free ammonia and increase in nitrates.
O Biological.
Significant reduction in the number of bacterial counts by first 5-7 days.

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(ab) Coagulation.
This process involves addition of chemical coagulants such as pure aluminum sulphate (alum) or
more commonly alumino ferric which is an impure form of alum containing about 1 percent of ferric
sulphate. Both salts are readily soluble in water and being acidic in nature, tend to lower the pH of
water in which they are dissolved. When either is added to water with a pH of not less than 6, a
precipitate of aluminium hydroxide is formed which engulfs and precipitates with it the minute particles
of suspended matter. If pH is less than 6, no precipitate forms and if it is above 8 the precipitate
becomes too gelatinous and sedimentation is delayed. The optimum reaction for rapid and efficient
sedimentation occurs at pH 7 at which addition of 35 g of alum or aluminoferric per 1,000 L will
rapidly clarify water but not turbid water. If water is exceptionally turbid, around 70 g per 1,000 L
may have to be used.
Generally large sludge volumes are produced with alum which requires frequent desludging operations
at the treatment plants causing increased wastage of water. There is also the possibility of aluminium
carry over in water treated with alum. High levels of aluminium in potable water have reported to
cause Alzheimer’s disease. However, at present there is no clear evidence to suggest a link between
aluminium and Alzheimer’s disease (Cole, 1990). Polyaluminium Chloride (PAC) has been developed
as an alternative coagulant for alum by an Indian manufacturer. PAC hydrolyzes with great ease as
compared to alum, emitting polyhydroxides with long molecular chains and greater electrical charge in
the solution, thus contributing to maximize the physical action of the flocculation. Better coagulation
is obtained with PAC as compared to alum at medium and high turbidity waters. Floc formation with
PAC is quite rapid. The sludge produced by PAC is more compact than that produced by alum.
(ac) Flocculation.
It is the process of gentle and continuous stirring of coagulated water for the purpose of forming flocs
through the aggregation of the minute particles. After coagulation, individual floc particles are easily
observed by the naked eye, being of the order of 1-2 mm in diameter. ln practice, the velocities in
flocculation tanks vary from 1 m / s at the entrance, decreasing to about 0.2 m / s near the outlet,
with a retention time of 30 minutes. Slow mixing is a hydrodynamic process which makes the particles
colloid and agglomerate resulting in the formation of large and readily settleable flocs of aluminium
hydroxide, which can subsequently be removed in settling tanks and filters. The mechanical type of
flocculator is widely used in which paddles rotate at 2-4 rpm.
(ad) Sedimentation.
This process involves separating suspended particles from water by gravitational settling down. The
coagulated water is led into sedimentation tanks where it is detained for 2-6 hours. The flocculant
precipitate settles down in the tank together with impurities and bacteria. The precipitate or sludge
that settles at the bottom is removed from time to time without disturbing the tank’s operation.
For very turbid water, sedimentation may be better carried out in two stages: initial settling of the bulk
of coarse debris followed by chemical flocculation. Leading the flow of water through long tortuous
broad channels at slow velocity and storage in large reservoirs before its entry into the sedimentation
tanks helps to achieve better sedimentation.
The sedimentation process also exposes water to the natural purifying effects of the sun’s rays and
fresh air and the biological effect of minute aquatic fauna and flora. These processes render the
water highly suitable for filtration and bring down the bacterial content of water considerably.
(ii) Filtration.
This process involves separation of suspended and colloidal impurities from water by passage through
a porous media. It is almost universally adopted in a large-scale purifying process of water in municipal
cantonment, garrison or base areas where permanent water works exist. Storage and sedimentation with
or without flocculation depending upon the quality of water, almost always precede the process of filtration.
Filters are slow and rapid sand filters and mechanical filters. Sand filters have been used widely as sand
is readily available, is cheap and effective in removing impurities. The driving force for overcoming the
fractional resistance encountered by the flowing water can be either – the force of gravity or the applied

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pressure. Depending on the flow rates, the filters are classified into Slow sand or biological filters and Rapid
sand filter.
(aa) Slow Sand or Biological Filters.
These are large masonry tanks 2.5 m to 4 m deep containing sand supported on gravel and the water
is passed through them slowly from above downwards (Fig 5.4). As the filter plants need extensive
tracts of land these are usually situated on the outskirts of town located on the bank of a river.
To avoid choking of the media preliminary sedimentation is necessary, chemicals may be used for
hastening up clarification if the water is too turbid.
The filter beds are usually rectangular in shape, arranged side by side in rows and may be either
open on top or covered. Each bed usually covers an area from one tenth of an acre to one acre land.
The filter bed from top to bottom consists of the following layers.
O Supernatant water layer: 1-1.5 m
O A bed of filter medium: Sand bed 1-1.2 m, graded gravel 0.3-0.5 m
O Underdrainage system: 0.16 m
O A set of control valves and appurtenances
The supernatant provides the driving force or constant head of water to overcome the resistance of
filter beds and provides a waiting period of some hours for the raw water to undergo sedimentation,
oxidation and particle agglomeration. A layer of graded gravel of about 0.3-0.5 m thickness is placed
over the perforated pipes. Above the gravel is the sand bed having a thickness of about 1.2 m, the
sand grains have an effective diameter of 0.2 to 0.3 mm. The underdrainage system is about 16 cm
in depth, it consists of porous or perforated pipes which serves the dual purpose of providing an outlet
for filtered water and supporting the filter media above. A system of controlled valves facilitates the
regulation of filter weight and adjustment of water level in the filter. An important component of the
regulation system is the Venturi meter or V notch, which measures the flow of water or bed resistance
or ‘loss of head’. When the bed resistance builds up, the operator opens the regulating valve so as
to maintain a steady rate of filtration. When the ‘loss of head’ exceeds 1.3 m, it is uneconomical to
run the filter.

Fig 5.4 : Slow Sand Filter

Mechanism of Action of Slow Sand Filters.
In a slow sand filter, water is subjected to various purifying influences as it percolates through the
sand bed. The filter primarily acts biologically by forming a slimy ‘zoogleal’ or vital or Schmutzdecke
layer containing algae, plankton and other minute plants and protozoa formed in two or three days’

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time over the surface of the sand bed. Vital layer is also called as the ‘heart of the filter’ and till this
layer is fully formed, the filtrate is run to waste. To obviate cracks in the vital layer, the rate of filtration
should not exceed 100 m2 of filter surface per hour. Trouble free operation is only possible when
the average turbidity of the raw water is less than 5 Nephelometric Turbidity Units (NTU). However,
occasional peak values below 20 NTU is permissible.
Removal of impurities is brought about by different processes such as straining, sedimentation,
adsorption and most importantly biochemical and microbial actions. In straining, suspended particles
that are too large to pass through the pores are retained at the surface or top layer of the filter. In
the upper part of the filter-bed, sedimentation of fine suspended solids also takes place. Settling
efficiency is very high due to the large surface area (10,000 to 20,000 sqm per cum of the filter
sand) and slow rate of filtration. Most of the remaining suspended solids with colloidal and dissolved
impurities are removed by adsorption onto the sticky gelatinous coating formed around the sand
grains or through physical mass attraction and electrostatic attraction. Clean quartz has a negative
charge and so are the particles of bacteria and colloidal material. Initially positively charged ions are
adsorbed over the sand grains and over saturation occurs after which negatively charged ions are
adsorbed after ripening of filter bed. Then, there is a varied series of negative and positive charged
grains that are able to adsorb most impurities from the passing water.
The biochemical and microbial actions of vital layer remove organic matter, holds back bacteria,
oxidizes ammoniac nitrogen into nitrates (simple harmless substances) and helps in yielding bacteria
free water. The filter is capable of reducing the E. coli content by a factor of 100 to 1,000 and total
bacteria count by a factor of 1,000 to 10,000. It also removes protozoa such as E.histolytica and
helminths such as S.haematobium and A.lumbricoides. Since the organic matter is limited, there will
be a simultaneous die-off of bacteria releasing organic matter. Gradually, the organic matter is broken
down and transformed to inorganic compounds like carbon dioxide, nitrates, sulphates and phosphates
which are released with filter effluent. In practice, it is seen that full bacterial activity extends for
a depth of about 0.6 m of filter-bed. For intestinal bacteria, the filter-bed provides unfavourable
conditions because the water is generally colder than their natural habitat and usually does not
contain sufficient organic matter of animal origin for their living requirements. The microorganisms in
the filter also produce antibiotics and other agents that kill or at least inactivate intestinal bacteria.
Cleaning of the Filter.
Normally the filter may run for weeks to months even without cleaning. After several months of running
of the filter when the bed resistance increases to such an extent that the regulating valve has to be
kept fully open, then the filter bed necessitates cleaning. This is done manually by scraping the top
portion of the sand layer upto a depth of 1-2 cm. This operation can be carried out by an unskilled
worker using simple hand tools or by mechanical equipment. After several years of operation when
the thickness of the sand bed reduces to about 0.5 to 0.8 m, the plant is to be closed and a new
bed is to be constructed (Fig 5.5).

Fig 5.5 : Cleaning of the Slow Sand Filter

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(ab) Rapid Sand Filters.

Rapid sand filters are of two types ‘gravity type’ (Paterson’s filter) and the ‘pressure type’ (Candy’s
filter). While the former is usually used in large installations, the latter is used in smaller installations
such as swimming pools. The parts and functions of the rapid sand filter are as follows.
O Filter Bed.
The filter bed is a watertight rectangular chamber with a surface area of about 90 m2. The
depth of the sand bed is usually 1 m and the sand particle size is bigger than that used in
slow sand filters.
The various steps in the working of a gravity type rapid sand filter are as mentioned below (Fig
5.6).
O Coagulation.
The raw water is first treated with calculated dose of alum or aluminoferric which varies from
5 to 40 mg / L depending on the turbidity, colour, temperature and pH value of water.
O Rapid mixing.
This water is then subjected to violent agitation in a mixing chamber for a few minutes. This
allows quick and through dissemination of alum throughout the bulk of water.
O Flocculation.
The water is then allowed to move gently for half an hour in a flocculation chamber by
mechanically operated paddles which rotate at 2 to 4 rpm. A thick floc is formed which entangles
suspended matter and bacteria.
O Sedimentation.
The coagulated water is then taken to sedimentation tank where it is detained for 2-6 h. When
floc settles down, about 95 percent of floc is removed and then the partly clarified water is
taken to the filter bed.
O Filtration.
The partially clarified water is then subjected to rapid sand filtration. The rapid sand filter bed
is a watertight rectangular chamber with a surface area of about 90m2. The depth of the sand
bed is usually one meter having sand particles whose sizes are bigger (0.4–0.7 mm) than the
ones used in slow sand filters. Below the sand bed is a layer of graded gravel of about 40 cm
thickness. The under drainage is below the graded gravel layer. The supernatant water height
is about 1 to 1.5 m. The alum floc makes a tough slimy layer (chemical layer) over the sand
bed, which acts mechanically. In this system, there is no time wasted for ripening of the bed.
The rate of filtration in a rapid sand filter (200 million gallon per acre per day) is about 100
times faster than that of slow sand filter (2 to 3 million gallon per acre per day)
O Backwashing.
When the filter bed gets clogged after use for a day or so, it is cleaned by back washing by
reversing the flow of filtered water. Backwashing is usually preceded by loosening of the sand
bed by passing compressed air through it. After backwashing, the filter bed is put to use
immediately and not after 24 hours or so as is required for the formation of biological film in
a slow sand filter.
CHLORIENE

RIVER CLEAR
MIXING FLOCULATION SEDIMENTATION
TANK FILTERS WATER CONSUMPTION
CHAMBER CHAMBER STORAGE
ALUM

Fig 5.6 : Rapid Sand Filtration Plant

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O Comparison of Rapid and Slow Sand Filters.

The comparison of rapid and slow sand filters is as tabulated in Table 5.4.
Table 5.4 : Rapid and Slow Sand Filters
Rapid Sand Filter Slow Sand Filter
Space requirement Occupies very less space Occupies large space
Preliminary treatment Chemical coagulation, sedimentation Plain sedimentation
Effective size of sand 0.4-0.7 mm 0.2-0.3 mm
Operation Requires highly skilled workers Require less skilled workers
Rate of filtration 200 million gallon per acre per day (m.g.a.d) 2-3 m.g.a.d
Quality of filtered water
(i) Removal of turbidity Good Good
(ii) Removal of colour Good Fair
(iii) Removal of bacteria 98-99% 99.9-99.99%
Washing of filter bed Easy, by backwashing By scraping the sand bed
Loss of head allowed 6-8 feet (2-2.5 m) 4 feet (1.5 m)
(ac) Mechanical Filter.
Mechanical filters are used in small,
more sophisticated water plants and
in water tank, trucks and trailers.
It consists of a cylindrical metal
chamber surmounted by a filter
head. Into the undersurface of the
filter head are screwed four to six
filter elements (candles). There are
two types of filter candles used in
the Armed Forces-meta filter and
stellar filter. The meta filter consists
of thin Monel metal discs with
embossed faces. When these discs
are superimposed on each other
and held in position by clamping
rods they form a column of a candle.
Each disc has a central hole. As the
discs lie on one another, a central
channel through the column is
formed. The embossed faces leave
a space of 8 mm in between each
pair of discs. The stellar filter candle,
on the other hand, consists of brass
former with a central channel and
a spiral thread on its outer surface
round which a monel metal wire is
wound so as to allow a space of 8 Fig 5.7 : Mechanical Filter (Stellar Filter)
mm between the adjacent coils of
wire. Water from outer side of the
metal or stellar filter candles can only pass through the interstices. To increase the filtering efficiency
and to reduce chocking of interstices, filter powder is introduced to form a filter bed around the filter
candles in the chamber. The powder is mixed in water and then poured onside the filter chamber.

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Water is then pumped by using engine power of the water tank truck or trailer into which these filters
are mounted. Under field conditions when regular water points cannot be established, these filters
can be used as mobile water plants (Fig. 5.7).
(iii) Disinfection.
Disinfection of water is carried out after pretreatment and filtration. It means making water fit for drinking by
destroying all pathogenic organisms that may be present in it. The disinfection of water can be carried out
by following methods - Physical methods (Thermal treatment, Ultrasonic waves), Chemical methods (Use of
oxidizing chemicals such as Chlorine, Iodine, Ozone, etc.) and Radiation (Ultraviolet rays, gamma rays, X–rays).
(aa) Criteria for Ideal Disinfectant.
The ideal disinfectant must possess the following properties.
O It must destroy bacteria, viruses and amoebic cysts in water within a reasonable time
despite all variations in water temperature, composition and concentration of contaminants.
O It must not be toxic / unpalatable to humans and domestic animals.
O It must be reasonable in cost and safe and easy to store, transport, handle and apply.
O Its residual concentration in the treated water must be easily and preferably automatically
determinable.
O It must be sufficiently persistent so that the disappearance of the residual would be a
warning of recontamination.
(ab) Chlorination.
In water treatment and purification process, the term disinfection is almost synonymous with
chlorination. Disinfection of water is usually carried out with chlorine. Chlorine has been found to
be very efficient and fulfills all the criteria of ideal disinfectant. When chlorine is added to water it
forms hydrochloric acid and hypochlorous acid (Cl2 +H2O = HCl + HOCl). The hypochlorous acid further
ionizes to H+ and OCl- (hypochlorite ion). The disinfection action of chlorine is mainly by hypochlorous
acid and partly by hypochlorite ion. Chlorine acts best when pH of water is around 7 because of
predominance of hypochlorous acid. When pH exceeds 8.5 hypochlorite ion mostly acts. Fortunately,
most waters in India have pH between 6 to 7.5. Organic matter or reducing salts deviate chlorine
which results in uncertainty of its action. Therefore, for efficient action of chlorine, freedom from such
organic matter, resistant organisms and reducing salts is essential. Efficient clarification is therefore,
necessary to render the results predictable and certain, to economize chlorine expenditure and to
estimate the quantity of chlorine needed for water disinfection.
If the distribution system is long and complex, then it can be difficult to maintain free residual
chlorine concentration of 0.2 to 0.5 mg / L at the farthest end. The maintenance of the required
residual concentration in such cases can be accomplished by a stage wise application of chlorine
in the distribution system. This is called as re-chlorination. It is carried out in service reservoirs or
booster pumping station or at the point where the main supply to distribution zone occurs.
(ac) Chlorine Demand.
Chlorine and its compounds have oxidizing power and is consumed by inorganic and organic matter
present in water before the disinfection action of chlorine in water starts. It is therefore, essential
to provide a sufficient dose of chlorine for adequate time to satisfy the needs of various chemical
reactions and leave some amount of unreactive chlorine as residual chlorine (in form of free or combined
chlorine) that is adequate for killing the pathogenic organisms. The persistence of free chlorine in
water is essential as a safeguard against any incidental entry of pathogenic bacteria prior to its actual
consumption. The difference between the amount of chlorine added to water and amount of residual
chlorine after specified contact period (usually 30 minutes) at the given temperature and pH of water
is defined as the chlorine demand. The point at which the chlorine demand of water is met and free
residual chlorine appears after the entire organic impurities have been completely destroyed is called
as ‘breakpoint chlorination’. If chlorine is added further, it only increases free chlorine.
Chlorine demand is estimated by the Horrock’s test. A high chlorine dose creates unpleasant chlorinous

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taste in water, 0.5 ppm of free chlorine in water is imperceptible. Over 0.5 ppm the chlorine taste
becomes faintly noticeable while above 1 ppm a definite chlorine odour and taste are apparent.
Chlorinous taste can be prevented by.
O Careful selection of good source of water, which should remain qualitatively constant.
O Efficient clarification.
O Administration of minimum ‘disinfecting dose’ adequate to permit the desired free residual
chlorine.
(ad) Dosage of Chlorine.
Under conditions assuring efficient clarity of water a minimum 30 min of contact with the ‘disinfecting
dose’ and persistence of 0.2 to 0.5 parts of free chlorine per million parts of water is considered
adequate to achieve health safety with freedom from chlorinous taste. On active service in the field
or under less efficient conditions, however, persistence of 1 ppm of free residual chlorine after
30 min of chlorination is considered as a safe standard.
(ae) Superchlorination.
In the presence of actual or potential danger of outbreak of intestinal infections or when the water is
heavily polluted or quality of water fluctuates rapidly, large dose of chlorine is added to water. Also,
sporing organisms like the welchii group, protozoa cysts like E. histolytica, helminth ova, moluscs,
cercariae and viruses of infectious hepatitis and poliomyelitis in water require a higher concentration
of chlorine maintained over a long time. This is called as super chlorination. The dose of chlorine
may be as high as 10-15 mg / L with contact period of 30 minutes. The free residual chlorine to be
achieved in superchlorination is 2 ppm. When super chlorination is resorted to, dechlorination should
be carried out before consumption of water.
(af) Dechlorination.
When superchlorination is employed, water contains excess of free residual chlorine and has chlorinous
taste, which must be removed before water can be consumed. This is called as dechlorination. It is
done by adding 2 tablets of 0.5 g each of sodium thiosulphate (Taste Removing Tablets or TRT) per
500 L of water. During superchlorination, contact with chlorine for a minimum of 30 min should be
allowed before dechlorinating, but preferably contact time should be prolonged as long as possible.
The danger of a premature use of TRT and its use in un-superchlorinated water must be appreciated
and guarded against. Other methods used for dechlorination include use of activated carbon filtration,
UV dechlorination, Reverse Osmosis, filtration media and aeration, etc.
(ag) Methods of Chlorine Application.
Disinfection of large quantities of water with chlorine may be achieved by one of the following chlorine
preparations.
O Diluted solution of chlorine prepared from bleaching powder, High Test Hypochlorite
(HTH), etc. for disinfecting small to medium quantities of water. It is simple, does not require
electricity and is relatively safe but instability of bleaching powder, its hygroscopic nature and
low percentage of available chlorine makes it difficult to attain the desired level of free chlorine.
O By adding diluted solution of chlorine prepared by electrolysing brine solution. This requires
electrochlorinators, which is still an emerging technology.
O By adding chlorine, either in gaseous form or in form of solution made by dissolving
gaseous chlorine in small auxillary flow of water: chlorine gas is obtained from pressurized
chlorine containers. This is the common practice for medium to large scale water supplies. This
however, requires elaborate safety practices and use of chlorinators and auxillary equipments.
(ah) Chlorine Agents used for Disinfection.
O Chlorine Gas.
Chlorine is an irritant to the eyes and is poisonous, so, it is applied through chlorinating
equipment only. In the modern water works application of gaseous or liquid chlorine is carried

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out with the help of mechanical injector called ‘Chloronomes’. Paterson chloronome is used
for adding gaseous chlorine. In this process, the charging of the water supply with chlorine,
ascertaining persistence of free chlorine content are all carried out automatically. The standard
of chlorination to be aimed at when chlorinating through chloronomes is the persistence of
0.2 ppm free chlorine at the consumers end. This can be achieved by ensuring 0.5 ppm of free
chlorine at the plant provided that the delivery of water is not delayed for more than 6 hours.
If quantity of water to be treated is more than 5,00,000 litres per day, chlorine gas has been
found to be the most economical.
O Chloramines.
Chloramines are loose compounds of chlorine with ammonia. They impart less chlorinous taste
in water and give more persistent type of residual chlorine. This prolonged residual effect confers
prolonged resistance to contamination during the flow of water through the pipe system. This can
hence be advantageously used in large urban water plants where the pipeline runs for several
million meters. Their drawback is that they have slower and inferior action than chlorine.
O Bleaching Powder.
In less developed urban areas or rural areas or under field service conditions, use of bleaching
powder for sterilization of water is resorted to. Bleaching powder also known as chlorinated
lime (CaOCl2) was first introduced for sterilization of water by Horrocks in 1914. It is a white
amorphous powder with pungent smell of chlorine. When freshly made it contains about 33
percent of available chlorine. It is, however, very unstable and its chlorine is readily set free
by the action of moisture, carbon-di-oxide, heat, light and possibly even by continued vibration
sustained during long journeys. As a result, it has been frequently delivered in the field with
very scanty chlorine content. Estimations to determine the amount of available chlorine in
each tin of bleaching powder has to be made before dosing the water involving considerable
labour and much error. Bleaching powder is also difficult to introduce in accurate doses into
large quantities of water, leading to further error in the dosage. Bleaching powder is stored
in corrosion free containers made of wood, ceramic or plastics. It is generally made into thin
slurry with water and the supernatant is applied to water.
O Water Sterilising Powder (WSP).
Bleaching powder is considerably improved in its keeping quality by the addition to quicklime
in the proportion of 80:20. The mixture is known as water sterilising powder. Its available
chlorine should not be less than 25 percent. It is usually used for disinfection of water under
field service conditions. It is an Ordnance store item and is supplied in packs of 50 g, 100 g,
¼ kg, ½ kg, 1 kg and 25 kg. WSP is soluble in about twenty times its weight in water yielding
an insoluble precipitate consisting mostly of Calcium Hydroxide Ca(OH)2, silica etc. This settles
quickly, if too thick a paste is not made; otherwise a gelatinizing action takes place and great
difficulty in settling is encountered. It is not necessary or desirable to grind or break up the
lumps thoroughly and too much agitation is detrimental to prompt settling. 500 g of WSP mixed
with 5 lit water contains approximately 2.5 percent of available chlorine if the powder is of 25
percent strength. This chlorine solution of 2.5% strength can also be written as 25,000 ppm
or 25,000 mg / L. Chlorine solution can maintain its strength for weeks if properly corked in
brown bottles.
O Perchloron.
Perchloron, also known as HTH (High Test Hypochlorite), is a chemical compound primarily
composed of calcium hypochlorite (Ca(ClO)2). The available chlorine content in Perchloron typically
ranges from 60% to 70%. This means that for every 100 grams of Perchloron, approximately
60 to 70 grams of the compound can release chlorine to disinfect water or surfaces. Calcium
hypochlorite can be fed in either the dry or solution form while sodium hypochlorite as solution.
Perchloron / HTH is widely used in various applications, including water treatment for swimming
pools, spas and drinking water systems. Corrosion resistant materials such as Ceramic, glass,
plastic or special rubber should be used while handling hypochlorite solution.

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O Altoch GP.
Calcium Hypochlorite granules (65 to 70% of available chlorine)
O Chlorine Dioxide.
Chlorine dioxide (as a gas) exhibits high reactivity and becomes explosive under pressure,
making it unsuitable for storage, transport or direct use. Instead, it is generated on-site as a
solution when needed. In contrast to chlorine, which forms hypochlorous acid upon contact
with water, chlorine dioxide dissolves in water without undergoing any chemical reactions. The
formulation Chlorine dioxide SCS-10K, approved by MES, is a mixture of two compounds that
produce chlorine dioxide gas when introduced to water (40 gm of Chlorine dioxide SCS-10K in
1 L of water yields 10,000 ppm of Chlorine Dioxide). It is more effective as a disinfectant than
chlorine at higher pH (above 7) but similar at lower pH (below 6). As chlorine dioxide does not
react with water, ClO2 is readily expelled from water solutions by passing air or by vigorous
stirring of the water. It is degraded by UV light to produce chlorite and chlorate as a byproduct,
so treated water needs to be protected from sunlight. Both chlorite and chlorate can oxidize
haemoglobin resulting in methaemoglobin and reduced oxygen carrying capacity. Chlorite is a
haemolytic agent and may initiate haemolytic anaemia in susceptible individuals at the levels
found following disinfection. It is a highly effective disinfectant against bacteria, viruses and
Giardia, especially more effective against Giardia compared to chlorination. Unlike chlorine (Cl2),
the efficiency of ClO2 remains relatively stable in the pH range of 6-9, whereas the performance
of Cl2 decreases with increasing pH. However, ClO2 does not chlorinate organic compounds,
leading to a significant reduction in the formation of Trihalomethanes (THMs) compared to
chlorination.
(aj) Tests for Chlorine Demand of Water.
Before disinfecting any source of water, chlorine demand of water source should be calculated, which
would give adequate disinfection and the desired level of free chlorine. The test used for calculation
of chlorine demand of water is called as Horrock’s Test.
The objective of this test is to determine the quantity of the particular sample of WSP required
to sterilize a particular sample of water. The test is carried out by means of ‘case water testing
sterilization’ (Horrock’s Box). The Horrock’s box contains six white cups of 200 ml capacity each
and one black cup of 240 ml capacity; two metal scoops, each of which holds 2 g of WSP when
filled level with the brim; a bottle of stock cadmium iodide-starch solution; a bottle containing
85 ml of 50% glacial acetic acid; 25 tablets of sodium thiosulphate (100 mg each); seven glass
stirring rods; one pipette and two droppers. The test should be carried out on the same water that
is to be chlorinated later.
(ak) Procedure of Horrock’s Test.
O A standard solution of the particular sample of WSP is prepared in the black cup. First a
thin paste with one level scoopful of WSP and a little clarified water is made and then gradually
more water is added up to the mark on the inside of the cup and the mixture is stirred with
a clean glass rod. The lime in suspension gradually settles down. This is known as the stock
solution.
O The six white cups are then filled with clarified water to within half a centimeter from its
top.
O Drops of the standard WSP solution from the black cup are added to each of the white
cups by the pipette, so that the first cup receives one drop; the second cup receives two drops
and so on serially increasing until finally the sixth cup receives six drops. One drop represents
one part of chlorine in a million parts of water when added to the white cup filled with water.
The pipette must be held vertical when delivering the drops.
O The contents of each cup are stirred with a separate clean stirring rod, starting with the
first cup and allowed to stand for half an hour, shading them from sunlight.
O After this, three drops of the starch-cadmium iodide indicator solution is added to each cup

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from the drop bottle and stirred with a clean stirring rod. The starch-cadmium iodide indicator
solution is made by first preparing a uniform paste of 1.5 g of starch in 25 ml of distilled water
and then adding it slowly to 75 ml of boiling distilled water and continually stirring it while,
still boiling for the subsequent 15 min. After cooling, 7.5 g cadmium iodide is added to the
mixture and dissolved by shaking. In an emergency situation, potassium iodide may be used
if cadmium iodide is not available. The solution should be stored in a well-corked dark brown
bottle in a dark and cool place. The keeping quality of the solution is enhanced by the addition
of 1 ml formalin to this solution.
O Some of the cups will show a blue colour. This indicates that the water in those cups
contain one or more parts of chlorine per million parts of water. The blue colour indicates the
presence of free residual chlorine.
O The serial number of the first cup showing definite blue colour indicates the number of
scoopfuls of that particular sample of water sterilizing powder required to sterilize 500 L of
water and to leave 1 ppm of free residual chlorine after chlorine demand of that sample of
water is satisfied during half an hour contact with chlorine. For example, if cups 3, 4, 5 and 6
show a definite blue colour, then three scoopfuls or WSP are required to sterilize 500 L of the
particular water sample and leave 1 ppm residual free residual chlorine after contact for half
an hour contact period. If superchlorination is indicated one more scoopful of WSP per 500 L
of water is required to be added. This will give 2 ppm of free chlorine in water after 30 min
contact period. In the example given above a total of 4 scoopfuls of WSP per 500 L will be
needed for superchlorination. The WSP used for chlorination or super chlorination should be
from the same tin from which the WSP for Horrock’s test was used. If cup 5 and 6 or only 6
show definite blue colour, then water has high contamination and preferably some other source
of water should be tried.
(al) Tests for Adequacy of Chlorination.
Adequate control on chlorination should be maintained by conducting regular examination of the
treated water to ensure that requisite amount of free chlorine has persisted in water for the requisite
time.
O Orthotolidine Test (OT test).
In this test, 10 ml of chlorinated sample of water is taken after the required contact period, in
a glass tube. To this 0.1 ml of orthotolidine solution is added. The colour formed is observed
after 5 minutes. The formation of yellow colour normally indicates the presence of chlorine
(either combined or free) in the water. The more yellow the colour, the greater, is the chlorine
residual. The amount of residual chlorine can be ascertained by comparing the colour developed
in the glass tube with the standard colours. This test, is therefore, very simple and does not
require much technique or time. Under normal conditions, a lemon-yellow colour is satisfactory
for public water supply. The orthotolidine test will normally gives the total residual chlorine
present in water. However, it may be adjusted so as to give separately the quantities of free
residual as well as combined residual of chlorine. The free residual chlorine forms the yellow
colour during the first 5 seconds of the addition of orthotolidine, while the combined residual
chlorine goes on forming the colour for about 5 minutes. Hence, the colour after 5 seconds will
give the quantity of free residual chlorine and the colour after 5 minutes will give the free and
combined chlorine. The difference in value between the two values is the combined chlorine. The
orthotolidine test, however, is not accurate, because the impurities such as iron, manganese,
nitrate, etc. are likely to cause a false yellow colour and indicating wrong and increased chlorine
residual.
O Orthotolidine Arsenite Test (OTA).
To overcome the problem of interfering ions in OT test, Orthotolidine – Arsenite (OT A) test is
carried out. Sodium arsenite is added to the chlorinated sample of water. This will dechlorine
the sample and orthodolidine is then added. The colour formed (X1) now is only the intensity
of colour caused by interfering agents like nitrates, iron, manganese etc. Now another sample
is taken in another test tube and orthotolidine solution is added first and just after 5 seconds,

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sodium arsenite is added. The sodium arsenite will arrest the colour to be formed by the
combined chlorine. Hence, the colour observed at the end of the experiment (X2) will be due
to the free residual plus due to the interfering colour causing compounds of iron, manganese
etc. Then, a third test is conducted on a third sample of water. In this, only the orthotolidine
solution is added to the given sample of water and the colour is noted after 5 minutes. The
noted colour (X3) will evidently be due to the free and combined chlorine plus due to interfering
colour causing compounds. Now the different chlorine residuals can be easily determined as
follows:
O Free residual chlorine = (X2) – (X1)
O Combine residual chlorine = (X3) – (X2)
(am) Test for Chlorination Control.
A control must be kept on chlorination by regular examination of the treated water to make sure
that the requisite amount of free chlorine has persisted in water for the requisite time. This can be
done by means of starch-iodide, thiosulphate with starch-iodide, orthotolidine, orthotolidine arsenite
or neutral red.
O Colour Test.
Fill a white cup with chlorinated water to be tested and stir into it 10 drops of fresh cadmium­
iodide-starch indicator solution. If there is > 1 ppm of free residual chlorine in water a blue
colour will appear. In this test the residual chlorine replaces iodine and combines with cadmium
radicle; iodine so released combines with starch and turns it blue.
O Thiosulphate Test.
Make a solution of 300 mg of sodium thiosulphate (3 tablets of 100 mg each) in a white cup
full of clarified but unchlorinated water. Add this solution drop by drop with a glass pipette
to the cup and continually stir until the blue colour just disappears. The number of drops of
thiosulphate solution required divided by 10 gives approximate part of free chlorine in a million
part of the chlorinated water.
O Neutral Red Test.
This reagent can be used as a tablet or as a 0.03 percent solution in 50 percent glacial
acetic acid. This has a purple red colour. This colour is bleached to a light-yellow tinge by a
chlorine concentration of 2 ppm in water. The method therefore only indicates superchlorination.
Superchlorination by the ‘fixed dose’ method without Horrock’s test is resorted to when this
reagent is employed. It does not indicate the extent of chlorine demand of a sample of water
or available chlorine in WSP, as is done by the Horrock’s test. The actual method is as follows.
− Add 4 scoops of WSP per 500 L of water, stir well and wait for 15 min.
− Fill the white cup with chlorinated water and crush one neutral red tablet or add
one scoop of solution to it.
− If the water becomes colourless or yellowish after one minute, it is safe for drinking.
If it is still red, add 2 more scoops of WSP per 500 L and repeat the test after 15 min.
Repeat the process until the test shows bleaching of neutral red.
− Add 4 taste removing tablets for every 500 L of water before consuming.
(an) Agents Other than Chlorine.
O Heat.
Boiling of water can disinfect it but the method cannot be used to disinfect large scale supplies.
It can be used in emergency for individuals or household drinking water.
O Ozone.
It is a powerful oxidizing agent. It removes undesirable odour, taste, colour and organic matter.
It even inactivates viruses in a few seconds and hence can be used most advantageously

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for destruction of enteropathogenic viruses. Since ozone decomposes and disappears within
short time there is no residual germicidal effect. Hence, a minimal dose of chlorine may be
added to the ozonised water before distribution. In this combined treatment, the two methods
complement each other. The ozone dosage required for potable water treatment varies from
0.2 to 1.5 mg / L. Ozonisation of water is presently practiced in the advanced countries. The
combination of ozone for pretreatment while providing some disinfection to be followed by
chlorination, has become a popular sequence in Europe and is beginning to be used in USA to
reduce the level of trihalomethanes in treated water.
The disadvantages of ozone treatment are high cost of production, inability to provide residual
protection against recontamination and onsite degeneration due to instability.
O Ultraviolet Irradiation.
UV radiation may kill a cell, retard its growth or change its heredity by gene mutation. Radiation in
the wavelength region of 220-260 nanometre units is recommended for maximum destruction of
cell. However, germicidal effect of this method is limited due to its expense, non-residual germicidal
effect and its somewhat lesser effect in presence of turbidity. A mercury vapour arc lamp emitting
invisible light of 250 nanometre units is used for disinfection of water in Russia. The advantages
of UV radiation include that exposure is for short duration, no foreign matter is actually introduced
and no taste or odour is produced. Overexposure does not result in harmful effects.
O Other Halogens.
In view of the formation of organochlorine compounds by chlorine which are either known or
suspected carcinogens, many chlorine alternatives such as bromine and iodine substances are
receiving renewed interest. However, these substances do not seem to be a viable alternative
to chlorine.
(iv) Membrane Processes.
Membrane processes in water purification have revolutionized the way we treat and provide safe drinking
water. These processes have traditionally applied to the production of water for industrial or pharmaceutical
applications, but are now being applied to treatment of drinking water. These processes utilize specialized
membranes to effectively remove contaminants, particles and impurities from water, resulting in cleaner
and healthier water for consumption. The common membrane processes used in water purification are
divided as high pressure processes e.g., reverse osmosis and nanofiltration and low pressure processes
e.g., ultrafiltration and microfiltration (Fig 5.8).
(aa) Reverse Osmosis (RO).
Reverse Osmosis (RO), a water purification method employing a semi-permeable membrane,
distinguishing itself from conventional filtration techniques. Reverse Osmosis technique can
effectively eliminate various molecules and ions from solutions, finding applications in industrial
processes and potable water production. Its most notable application lies in the purification of
drinking water from seawater and areas prone to contamination by viruses and chemicals such
as metal ions, lead, arsenic, fluoride, radium, sulphate, magnesium, potassium, nitrate, fluoride
and phosphorus.
O Operation of RO (Reverse Osmosis).
RO operates by utilizing a high-pressure pump to elevate the pressure on the salt side of
the system, compelling water through the semi-permeable membrane and leaving behind
nearly all dissolved salts in the reject stream, typically around 95% to 99%. The requisite
pressure correlates with the salt concentration of the feed water; higher concentrations
demand greater pressure to overcome osmotic pressure. The resultant desalinated
water or de-mineralized water is termed permeate or product water. The stream carrying
concentrated contaminants that failed to traverse the RO membrane is termed the reject
or concentrate stream. Typically, 40-60% of water is rejected during the RO process.
The Reverse Osmosis membrane features a dense pore structure (less than 0.0001
micron), effectively eliminating up to 99% of contaminants and impurities such as total

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dissolved solids, chemicals, bacteria and viruses from drinking water. Anti-microbial and
carbon filters integrated into Reverse Osmosis systems aid in eliminating unwanted odors,
colours and tastes from water. In comparison to other systems, RO systems exhibit high
efficacy in removing protozoa, bacteria and viruses. Additionally, RO systems can reduce
the concentration of common chemical contaminants such as metal ions and aqueous
salts, including sodium, chloride, copper, chromium and lead etc.
In military settings, there is a growing trend towards allowing private vendors to operate
RO plants in garrisons or cantonments under the guise of enhancing welfare, even when
the mineral content of water falls within normal limits. Subjecting water with normal TDS
levels to demineralization / reverse osmosis further depletes its mineral content, rendering
it soft.
The National Green Tribunal (NGT), in its ruling on May 20, 2019, directed the Ministry
of Environment and Forests (MoEF) to issue a notification banning RO in areas where the
Total Dissolved Solids (TDS) in water supply are less than 500 ppm.
O Health Risks from Consumption of Demineralised or Low-Mineral Water.
A WHO report outlines potential adverse consequences of consuming water with low
mineral content, including direct effects on intestinal mucous membranes, metabolism,
mineral homeostasis and other bodily functions. Additionally, low mineral water intake
may result in inadequate intake of calcium, magnesium and other essential elements
and microelements.
O Recommendation.
Demineralized water or water with low mineral content, due to its substantial lack of
essential minerals, is not deemed ideal for drinking and regular consumption may not
provide sufficient levels of essential nutrients. Given the available evidence, the use
of RO should be discouraged in military stations where the TDS value is less than
500 ppm. Medical authorities should advocate against the installation of desalination / RO
plants based on ill-informed demands or in the name of welfare, without scientific basis,
to protect individuals from chronic diseases. The necessity for such installations should
be evaluated considering geological parameters and chemical reports of available water
sources and installations should be conducted through authorized agencies with built-in
mechanisms for quality control, monitoring and evaluation to safeguard personnel health
in the long term.
(ab) Nanofiltration (NF).
Pore size is typically 0.001 to 0.01 micrometre. Operating pressure is about 5 bar. Nanofiltration
membranes have smaller pore sizes compared to UF and MF membranes but larger than RO
membranes. NF can remove divalent ions, organic matter and some multivalent ions. It is often
used for water softening, color removal and the removal of specific contaminants like pesticides
and pharmaceuticals.
(ac) Ultrafiltration (UF).
Ultrafiltration membranes have relatively larger pore sizes compared to RO membranes. UF can
effectively remove suspended solids, colloids, bacteria, viruses and some macromolecules from
water. It is commonly used as a pre-treatment step to remove larger particles before RO or as
a standalone process for producing drinking water.
(ad) Microfiltration (MF).
Microfiltration membranes have even larger pore sizes than UF membranes and can effectively
remove suspended solids, bacteria and some larger particles. MF is commonly used in water
treatment for turbidity reduction, particle removal and disinfection. The pore size of the
membrane is smallest in RO and is in the following order: RO < Nano filter < Ultra filter <
Micro filter

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Fig 5.8 : Membrane Process for Water Disinfection

5.13 Purification of Water on Small Scale.

Household purification of water can be carried out by the methods stated below.
(a) Boiling.
It is a very effective method and kills all bacteria, viruses, spores, cysts and ova when water is boiled for 5 to
10 min, called as ‘rolling boil’. This method also removes temporary hardness by driving off carbon-di-oxide and
by precipitating calcium carbonate. The taste of water is, however, altered. Boiled water has also no residual
protection against subsequent contamination and hence care to be taken to avoid contamination during storage.
(b) Chemical Disinfection.
It may be carried out with either chlorine solution, bleaching powder, WSP, perchloron, chlorine tablets or iodine
solution. The chlorine tablets manufactured by the National Environmental Engineering and Research Institute,
Nagpur (NEERI) are about 15 times more potent than ordinary halogen tablets and are available in the market.
A single tablet of 0.5 g is sufficient to disinfect 20 L of water. The tablets are mostly used by travellers or by
soldiers in field areas. Potassium permanganate is no longer recommended, as it is not a satisfactory water
disinfecting agent although it is a powerful oxidizing agent. It has other drawbacks such as alteration of colour,
smell and taste of water.
(c) Filtration.
It is done through ceramic filters such as Pasteur Chamberland, Berkefeld and Katadyn filters. The essential part
of a filter is the candle, which is made of unglazed porcelain in Pasteur Chamberland type and of Kieselguhr in
Berkefeld type. The surface of the candle in Katadyn filter is coated with a sliver catalyst. The bacteria coming
in contact with filter candle get killed by the oligo-dynamic action of silver ions. Filter candles are liable to be
clogged. These are to be cleaned by scrubbing with a hard brush under running water. The candles should be
boiled at least once a week. Relatively clean water should be used with ceramic filters. Filter candles removes
bacteria, however, do not remove filter-passing viruses.
(d) Reverse Osmosis (RO).
This process has already been discussed above.

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5.14 Removal of Deleterious Salts.

Hardness of water may be defined as its soap destroying power. It is due to presence of bicarbonates, sulphates,
chlorides or nitrates of calcium and magnesium in water. Hardness is undesirable because it wastes soap and large
amounts of soap is required to produce lather. It retards washing, causes encrustation of water carrying system (pipes
and fixtures) and heating utensils resulting in wastage of fuel and even explosion of boilers, although rarely. Vegetables
cooked in very hard water may be less digestible. It reduces the life of fabrics also. The hardness of water is mainly
caused by four dissolved compounds: Calcium bicarbonate, Magnesium bicarbonate, Calcium sulphate and Magnesium
sulphate. The presence of any of these compounds renders water hard. However, generally in small amounts, chlorides
and nitrates of calcium and magnesium can also cause hardness of water.
Hardness is expressed in terms of milliequivalents per litre (m Eq / l). One m Eq / l of hardness producing ion is equal
to 50 mg (CaCO3) (50 ppm) in one litre of water. Based on this scale the degree of hardness of water is classified as
follows (Table 5.5).
Table 5.5 : Classification of Hardness of Water
Classification Level of hardness (m Eq. / l)
Soft <1 (<50 mg / L)
Moderately hard 1-3 (50-150 mg / L)
Hard 3-6 (150-300 mg / L)
Very hard > 6 (> 300 mg / L)
Drinking water should be moderately hard. Softening of water is recommended when hardness exceeds 3 m Eq / L. It
has been observed that in some localities supplied with soft drinking water, death rates due to arteriosclerotic heart
diseases and Ischaemic Heart Diseases were higher. Depending on the interaction of other factors, such as pH, water
with a hardness above 200 mg / L may cause scale deposition in the distribution system and may result in excessive
soap consumption. On the other hand, water with a hardness of less than 100 mg / L has a low buffer capacity and
is corrosive for water pipes.
(a) Carbonate Hardness (Temporary Hardness).
It is due to the presence of bicarbonates of calcium and magnesium which can be removed by boiling that
drives out Carbon dioxide and precipitates carbonates or by the addition of 60 g of quick-lime to 1,000 litres
of water for each degree of hardness (Clark’s process). If hardness is due to Magnesium bicarbonate, double
of this dose is required, thorough mixing and filtration are necessary, as complete sedimentation may not occur
even after 12 hours. The methods of removing temporary hardness are as follows:
(i) Boiling.
(ii) Addition of lime.
(iii) Addition of sodium carbonate.
(iv) Permutit process.
(b) Non-Carbonate Hardness (Permanent Hardness).
This is due to sulphates, chlorides and nitrates of calcium and magnesium, which are removed by the addition
of calculated amount of sodium carbonate (Soda ash). In case of water, which contains temporary as well as
permanent hardness, use of lime and sodium carbonate will remove both. This is followed by sedimentation and
filtration. Base exchange silicious zeolites are used for removing permanent hardness in large establishments.
Zeolite is a mineral having a complex formula of Sodium Aluminum Silicate. It exchanges sodium cation for
calcium and magnesium ions of water. When hard water is passed through Zeolite, calcium and magnesium ions
are entirely removed by sodium ions of Zeolite. As the filtered water has zero hardness, it is mixed in appropriate
proportion with hard water before its supply. Regeneration of Sodium Zeolite takes place when the so formed
Calcium and Magnesium Zeolite is washed with sodium chloride. The methods of removing permanent hardness
are as follows:
(i) Addition of Sodium Carbonate.

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(ii) Base Exchange Process.

(c) Removal of Hardness.
Removal of harness of water can be done by the following methods:
(i) Boiling.
It removes the temporary hardness by expelling Carbon dioxide and precipitating the insoluble calcium
carbonates. It is an inexpensive method to soften water on a large scale.
Ca (HCO3)2 CaCO3 + H2O + CO2
(ii) Addition of Lime.
Lime softening not only reduces total hardness but also accomplishes magnesium reduction. Lime absorbs
carbon dioxide and precipitates the insoluble calcium carbonate. In the Clark’s method of softening water,
one ounce of quick lime is added to every 700 gallons of water for each degree of hardness.
Ca(OH)2 + Ca (HCO3)2 CaCO3 + 2H2O
(iii) Addition of Sodium Carbonate.
Sodium carbonate (soda ash) removes both temporary and permanent hardness, as shown below.
Na2CO3 + Ca (HCO3)2 2NaHCO3 + CaCO3
CaSO4 + Na2CO3 CaCO3 + Na2SO4
(iv) Base Exchange Process.
In the treatment of large water supplies, Permutit process is used. Sodium permutit is a complex compound
of sodium. Aluminium and silica (Na2 Al2 Si2O H2O). It has the property of exchanging sodium cation for
calcium and magnesium ions in water. When hard water is passed through the permutit, Calcium and
Magnesium ions are entirely removed by base exchange and the sodium permutit is finally converted into
calcium and magnesium permutit. By this process, water can be softened to zero hardness. Since water
of zero hardness is corrosive, a part of raw water is mixed with softened water to secure the desired
hardness. After permutit has been used for sometime, it loses its effectiveness but it may be regenerated
by treating with concentrated solution of sodium chloride of brine and washing away the soluble calcium
and magnesium chloride formed. Permutit process removes both temporary and permanent hardness.
(d) Sodium Chloride.
Many waters in the desert and elsewhere contain excessive salt making it undrinkable. Below 1,000 ppm of
salt, taste is not appreciable. Sodium chloride can be eliminated from water by condensation, reverse osmosis
or by ion exchange demineralization process. The condensed water should then be blended with brackish water
in such proportion that the salt content of the mixture falls below 1,000 ppm.
(e) Bitter Aperient.
Water having bitter aperient can be treated by the gradual addition of lime at the scale of 2 to 3 kg per
1,000 litres of water and stirring vigorously. From time to time, a small quantity is filtered in a cup and few
drops of silver nitrate solution are added to the filtrate. If a brown colour appears, the process is stopped. 50
litres of raw water are added to precipitate excess lime. After complete settling of lime, water becomes free
from aperient action.
(f) Iron.
A trace of iron is almost always present in water. Iron upto 0.3 mg / L is acceptable. Above that it causes
constipation, colic and results in colouration of vegetables while cooking and staining of linen. It also causes
deposits in the distribution mains and reservoirs and leads to the growth of iron bacteria. Iron in water is
commonly found as bicarbonates and rarely as oxides and sulphates. Exposure to air causes oxidation of ferrous
salt, which makes the water opalescent, discoloured and produces a deposit. The usual clarifying processes and
Clark’s lime process of softening water removes iron to a certain extent. A special Manganese Zeolite removes
iron more efficiently.

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(g) Fluoride.
Its removal is necessary when the concentration in drinking water is more than 1.5 ppm. The optimum
concentration in countries like India where people consume a lot of water should be between 0.5 to 0.8 ppm.
If fluoride content of water is less than 0.5 ppm, fluoridation is necessary for prevention of dental caries. On
the other hand, fluoride concentration over 1.5 ppm causes dental fluorosis. A still higher concentration causes
skeletal fluorosis. The excess quantity of fluoride in water is removed by ‘Nalgonda technique’ (Fig 5.9). Nalgonda
technique is a simple and economical technique evolved by National Environmental Engineering Research Institute
(NEERI), Nagpur. The technique involves addition of aluminium salts, lime and bleaching powder followed by rapid
mixing, flocculation, sedimentation, filtration and disinfection. Aluminium salts are added as aluminium sulphate
(alum) or aluminium chloride. Aluminium is responsible for removal of fluorides from water. The dose of aluminium
salt increases with increasing fluoride and alkalinity level of raw water. Lime facilitates formation of flocs for rapid
settling of insoluble fluoride salts. The dose of lime is 1 / 20th of that of aluminium salts. Bleaching powder is
added to raw water at the rate of 300 mg / L for disinfection. The technique is very effective in India to achieve
the fluoride content of <1 mg / L in various settings such as large communities, fill and draw technique for small
communities, fill and draw deflouridation plant for rural water supply and for domestic deflouridation.

Fig 5.9 : Nalgonda Technique

5.15 Swimming Pool.

(a) A swimming pool is an artificial structure where water volume per swimmer is relatively small. The water
is thus exposed to contamination by ammoniacal and other organic substances as well as organism from skin,
nasopharynx and other orifices of the swimmer. The health hazards associated with swimming in these pools
are usually fungal, viral and bacterial infections of the skin, eye, ear, nose, throat, upper respiratory tract and
intestinal tract. Proper maintenance of pools is, therefore of vital importance. The health hazards associated
with swimming pools are as follows.
(i) Viral and fungal infection of the skin including epidermophyton and trichophyton species which
produces “athlete foot”. The papilloma virus causes plantar warts.
(ii) Infection of eyes, ear, nose & throat.
(iii) Infection of upper respiratory tract.
(iv) Intestinal infection.
(v) Accidents.

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(b) Sanitation Measures for the Swimming Pool.

(i) Recommended area: 2.2 square meter (24 sq ft) per swimmer is recommended.
(ii) Rules and regulations governing the use of pools should be posted in noticeable areas for the
information of users. Following points should be included.
(aa) Persons suffering from skin diseases, sore throat, fever, nasal or ear discharge or other
communicable diseases should not be allowed into the swimming pool.
(ab) All bathers should be strictly instructed to empty the bladder and if necessary, use toilets.
(ac) A cleansing shower bath in the nude with soap and water should be mandatory before entering
the swimming pool.
(ad) Spitting, spouting of water and blowing of nose should be prohibited.
(ae) The surrounding areas of swimming pool including shower rooms, walkways and decks should
be properly disinfected to destroy contagious microorganisms.
(iii) A continuous inflow or daily change of water, though ideal, is usually not feasible. The modern pools are
equipped with continuous filtration and chlorination system. The “fill and empty” system is also encountered.
Considerable attention is thus necessary to ensure that water is maintained continuously in a pure state
in such pools. If the water is turbid, provision for sedimentation in a separate settling tank may become
inescapable. Water must be renewed at least once a week and 10-15% of water should be replaced by
fresh daily inflow. Water replacement leads to removal of solutes consisting of ammonia, albuminoids,
organic and nitrate derived from the bathers. These solutes have the capacity to reduce bactericidal activity
of chlorine. When the pool is emptied, floor and sides should be thoroughly scrubbed and lime washed.
Addition of copper sulphate 2 g per 1000 L once a week will prevent algal growth and accumulation of
slime.
(iv) Chlorination of the pool is carried out by injecting gaseous chlorine by the use of chloronome.
Continuous maintenance of 1 ppm of free residual chlorine provides adequate protection against bacterial
and viral agents. When chloronomes are not installed or not functioning, the required amount of WSP as
calculated by Horrock’s test is first made into a thin mixture and distributed evenly over the surface of water.
Water is then stirred with paddles. Subsequently, each day until the next filling, half that amount of WSP
should be added half an hour before the swimming time. Tests for free residual chlorine is to be carried
out daily half an hour after adding WSP. It is ideal to keep pH of water between 7.4 to 7.8 as irritation
of eyes due to chloramine formation will be minimum. In a swimming pool the process of chlorination
preferred is ‘breakpoint’ chlorination. When chlorine is added to water, it immediately forms chloramines with
ammonia, which is always present. The process continues till all the ammonia present is used up and the
concentration of chloramines reaches its peak. Chloramines are, however unstable and react with excess
free chlorine present in water and get oxidized completely to nitrogen and thus water no longer contains
free chlorine. Break point is said to have been reached when water no longer gives ‘flash’ reaction of free
chlorine. Any further addition of chlorine hereafter causes a proportionate rise in free residual chlorine,
which acts as efficient germicidal agent. The bacteriological quality of swimming pool water should reach
as nearly as possible the standard of drinking water. The bacteriological test of swimming pool should be
carried out weekly.

5.16 Disinfection of Wells.

It is sometimes necessary to carry out disinfection of wells especially during epidemics of cholera and other
gastrointestinal infections. Chlorination with bleaching powder is the most effective and cheapest method for this
purpose.
(a) Steps of Well Disinfection.
(i) Firstly, the volume of water in well is calculated.
3.14 × d2 × h × 1000
Volume of water in circular well (in litres) =
4
Volume of water in rectangular well (in litres) = l x b x h x 1000

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where d: diameter of well (in metres)

h: depth of water column (in metres)
l: length of the well
b: breadth of the well
One cubic metre = 1000 L of water
(ii) Then the amount of WSP required for disinfection is estimated by Horrock’s test. Roughly 2.5 grams
of good quality bleaching powder is required to disinfect 1,000 L of water. This gives approximate dose of
0.7 mg of applied chlorine per litre of water.
(iii) The required quantity of bleaching powder is then made into a thin paste with little water in a bucket
(not more than 100 g in a bucket). The bucket is filled three-fourth with water stirring all the time. About 5
to 10 min time is allowed for the chalk to settle down. The supernatant clear solution is then transferred
to another bucket and chalk is discarded. The lime sediment should not be poured into the well as it
increases the hardness of well water.
(iv) Delivery of chlorine solution into the well.
The bucket containing clear chlorine solution is lowered some distance below the water surface and the well
water is agitated violently both vertically and laterally. This should be done several times so that chlorine
solution mixes intimately with the well water.
(v) Contact Period.
After half an hour contact, Orthotolidine test is carried out. If fresh residual chlorine is less than 0.5 mg / L,
additional quantities of WSP will have to be added. Wells are best disinfected at night after the day’s draw
off. During epidemics, wells should be disinfected every day.
(b) Double Pot Method.
In cases of emergency, it is desirable to ensure constant dose of chlorine in well water. For this purpose, a
simple effective method such as the double pot method devised by National Environmental Engineering Research
Institute (NEERI), Nagpur has been devised. In this method, two cylindrical pots are used- one pot placed inside
the other. The height and diameter of outer pot are 30 cm and 25 cm respectively. A hole of 1 cm diameter
is made in each pot- the hole is in the upper portion near the rim of inner pot and is 4 cm above the bottom
of outer pot. A mixture of 1 kg of bleaching powder and 2 Kg of coarse sand (sand size: 2 mm diameter) is
prepared and slightly moistened with water. The inner pot is filled within mixture upto 3 cm below the level
of the hole. The inner pot is introduced into the outer one and mouth of the latter is closed with polyethylene
foil. The use of two pots makes it possible to have larger holes and prevents the risk of over chlorination. The
double pot is lowered into the well by a rope attached to the well kerb. The pot is immersed at least 1 metre
below the water level to prevent damage by buckets used for drawing water. The double pot method provides
adequate disinfection for 2-3 weeks in household wells containing about 4,500 L of water with draw off rate of
360-450 L / day.

5.17 Examination of Water and its Sources of Supply.

Water should be both safe and wholesome. It should be free from physical, microbiological and radiological impurities
(safe) and should also be pleasant, acceptable to taste, appearance and smell (wholesome). In addition, the quantity
should also be adequate because if quantity is not adequate, then the community will get water for their basic needs
even from unsafe sources, thereby increasing the hazards of disease. Moderately contaminated water may sometimes
be quite palatable and sparkling. The laboratory assessment of water quality comprises of physical, microbiological
and chemical examinations; each having its own usefulness.
On active service in field, the quality of raw water is judged mainly by purity at its source and sanitation of surroundings
of source and appearance of water. The source of water and its surroundings offer indications of the extent of pollution
and purity of water at its source and procedure to be adopted to maintain purity and enhance safety until it is delivered
for consumption. Frequent examination by Horrocks’ test and efficient chlorination are relied upon to further safeguard
water supply. Bacteriological examination in field assumes the role of field test to judge efficacy of methods of purification
rather than purity of raw supply. In any case full laboratory examinations are not always feasible as a routine measure

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in the field. They are, however, essential when the establishment of permanent or semi-permanent water points are
contemplated, while investigating outbreaks of water related diseases and for routine check on supplies in townships,
garrisons and cantonments.

5.18 Hygiene Inspection.

The hygiene inspection of source, surroundings and site of water supply is carried out by making a plan and following
it systematically. The inspection should include presence of habitation on the banks of stream or near the water
source; presence of water-logging nearby, sanitation of surroundings; presence of waste disposal area, latrines or
urinals; presence of cattle sheds or horse stables in the vicinity; seepages or surface pollution especially of human and
animal waste products and industrial effluents affecting the potability and purity of water; amount of vegetation in the
vicinity, in water course or reservoir; use of source by local inhabitants and their health status including presence of
enteric fevers, viral hepatitis type A and gastrointestinal flux; amount of flow of water and factor of dilution of pollution
in water. The presence of living and actively multiplying fish generally indicates low pollution and absence of disease
among the inhabitants consuming water indicates its general wholesomeness. Quick filling power indicates presence
of fresh springs in lakes and wells. Good yield occurs in case of a stream, however, the likelihood of seepages from
surroundings may also cause increased yield and should be guarded against. The site for obtaining water for human
consumption from the selected source should also be properly examined before final selection. A sanitary survey is
an on-site inspection and evaluation by a qualified person of all the conditions, devices and practices in the water
supply system which pose a danger to the health and well being of the water consumer. No bacteriological or chemical
examination can take the place of sanitary survey as the pollution is often intermittent and may escape laboratory
testing. Surveys should be undertaken when majority of samples should be from problem areas i.e., those with poor
results in the past, low pressure zones, areas with high leakage, densely populated areas with inadequate sewerage,
dead ends on pipelines, areas far away from waterworks etc.
(a) A new source is contemplated.
(b) Laboratory analysis indicates hazard to health.
(c) An outbreak of waterborne diseases occur in the area.
(d) To interpret bacteriological, chemical and physical analysis of samples.
(e) When any change takes place that can affect water system e.g., industries coming up in watershed.
(f) On a regular basis depending on size and available staff and resources and population / area under
coverage.

5.19 Water Quality Standards.

Prevention of pollution of drinking water, though ideal, is beyond achievement even with the best of efforts. Hence to
minimize all the known health hazards, governments or appropriate authorities have adopted specific drinking water
standards. These standards are the exposure limits for bacterial, viral, chemical and physical agents. World Health
Organisation (WHO) in 1993 and 2011, has published volumes 1 and 2 respectively, of fourth edition of “Guideline
for Drinking Water Quality” for use by countries to develop their own standards, keeping in view the environmental,
social, economic and cultural conditions prevailing there. The standards of water quality are, however, by no means
static; these are constantly under review in the light of new knowledge. The four aspects of water quality which the
guidelines deal with are:
(a) Acceptability Aspects
(b) Chemical Aspects
(c) Microbiological Aspects
(d) Radiological Aspects
(a) Acceptability Aspects include physical parameters such as taste, odour and appearance The physical
parameters for wholesomeness and acceptability of drinking water is as follows.
(i) Turbidity.
The acceptable limit for turbidity is 1 NTU, however on aesthetic grounds, drinking water with obvious
turbidity, i.e., turbidity above 5 NTU, becomes unacceptable to the consumer. Turbidity indicates incomplete

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treatment of water and also interferes with disinfection of water.

(ii) Colour.
The acceptable limit for colour in drinking water is 5 True Colour Units (TCU). Colouration of water may be
due to presence of organic matter such as peat, metals like iron and manganese or due to industrial wastes.
(iii) Taste and Odour.
Even though no guideline limit value has been laid down, water with significant degree of taste and odour
is unacceptable to the user. Taste and odour may be due to mineral matter, presence of organic matter
and occasionally due to excessive residual chlorine in treated waters.
(iv) Temperature.
Cool water is generally more palatable and no guideline value is recommended for temperature since its
control is usually impracticable.
(b) Chemical Aspects.
Chemical analysis of water is assuming greater importance due to ever increasing chances of industrial and
agricultural pollutants finding their way into the sources of raw water. In the Armed Forces, the test is carried
out prior to establishment of water works / permanent water point. The existing sources are also subjected to
test annually once or as frequently as desired. When chemical examination is indicated by the presence, type
and quantities of hardness and inorganic salts acquired from geological strata; chlorides, nitrites, ammonia and
‘oxygen absorbed’ estimates to determine the extent of pollution are required to be ascertained. Estimation of
iodides, fluorides and calcium are required under special circumstances when subnormal or abnormal quantities
of these in water are suspected. A complete chemical examination also includes analysis for toxic metals,
pesticides, persistent organic chemicals and radioactivity. Potable water from a chemical standpoint alone,
is not adequate as the chemical constituents cannot be relied upon to detect minute quantities of sewage
contamination. For this, bacteriological examination is needed.
The organic matter increases the chlorine demand of water. Ammonia interferes in the process of chlorination due
to the formation of chloramines. High salinity adversely affects taste and consumption of water. On decomposition
of nitrogenous organic matter, carbon dioxide and ammonia are produced. Ammonia is oxidised to nitrites and
then to nitrates. In recently polluted water, ammonia and nitrites are found in larger quantities than nitrates.
The interpretations of some of the usual chemical contents of water are as given below.
(i) Inorganic Constituents.
(aa) Total Dissolved Solids (TDS).
Amount of TDS in water has an important effect on its taste. Water with very low concentration of
TDS, such as rain water is not relished by consumer because of flat, insipid taste. The palatability
of water with TDS levels below 500 mg / L is considered to be good and those above 1,200 mg / L
becomes unpalatable and objectionable due to scale formation in pipes, heaters and household
appliances. The guideline value for TDS is below 500 mg / L.
(ab) pH.
The guideline value for pH of water is 6.5 to 8.5. Water with pH levels below this range may corrode
pipelines, resulting in increased levels of certain chemical substances, such as lead, in water. At pH
levels above this range, the efficiency of disinfectant action of chlorine is reduced.
(ac) Hardness.
Depending on the interaction of other factors, such as pH, water with hardness above 200 mg / L,
may cause scale deposition in the distribution system and result in excessive soap consumption. On
the other hand, water with hardness of less than 100 mg / L has low buffer capacity and is corrosive
for water pipes.
(ad) Dissolved Oxygen.
Even though no health-based guideline value has been laid down, depletion of dissolved oxygen
content in water encourages microbial reduction of nitrates and sulphates to nitrites and sulphides

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respectively, with consequent odour problems. It will be absorbed as long as there is oxidisable matter
in water. Some streams may be so heavily polluted with crude sewage that all dissolved oxygen is
removed from water and aquatic animals may die.
O When acidic potassium permanganate is used as an oxidizing chemical agent, ‘oxygen
absorbed’ value after 15 min indicates the amount of reducing inorganic substances such as
nitrites and ferrous salts, but at the same time it may indicate the presence of certain rapidly
oxidisable substances in sewage. Examination of other figures in the analysis and absence of
iron will assist in forming an opinion.
O Oxygen absorbed value after 4 hrs gives an indication of total oxidisable matter present
in water, organic matter mainly vegetable (co-related with albuminoid) and also to some small
extent sewage.
O If the difference between the two oxygen absorbed figures is high i.e. 0.8 or more, probably
vegetable pollution is present, but this must be confirmed by noting if albuminoid ammonia is
also high and free and saline low and whether water is acidic and soft or peaty.
(ae) Hydrogen Sulphide.
The presence of hydrogen sulphide in poorly oxygenated, stagnant waters is easily noticed by the
consumer by its characteristic ‘rotten egg’ odour. The guideline value for hydrogen sulphide is
0.05 mg / L.
(af) Ammonia.
Ammonia in water is an indicator of possible bacterial, sewage and animal waste pollution. It may be
present in a non-ionised or ionised form. Ammonia retards the efficiency of treatment processes including
disinfection and may also give rise to taste and odour problems. The guideline value is 1.5 mg / L.
(ag) Sodium.
The taste threshold of sodium depends on the associated anion and temperature of water. The
guideline value is 200 mg / L.
(ah) Chlorides.
The guideline value for chloride is 250 mg / L even though the maximum permissible level is kept at
600 mg / L. Chloride content of water varies a lot from place to place and tends to be high in the
neighborhood of sea. Any sudden increase in background levels of chlorides in water from a place
should raise suspicion of contamination of water.
(aj) Nitrites / Nitrates
These are the first stage in oxidation of ammonia and indicate recent pollution. They can also be
present in water from green sand strata due to reduction of nitrates. Nitrites should be zero in potable
water unless it comes from green sand stratum. Ingestion of water containing nitrates in excess of
45 mg / L may give rise to methemoglobinemia in infants. The guideline value of nitrates and nitrites
is 50 mg / L and 3 mg / L respectively.
(ak) Fluorides.
Optimum recommended concentration is 1 ppm (0.5 to 0.8 ppm in India).
(ii) Organic Constituents.
(aa) Polyaromatic hydrocarbons (PAHs).
Most PAHs found in environment are formed by combustion and pyrolysis processes. Some of these
are known to be carcinogenic. Their concentration should not exceed 0.2 g / L.
(ab) Pesticides.
Chlorinated hydrocarbons and their derivatives, herbicides, soil insecticides and pesticides that leach
out from the soil are important in determining the quality of water. The upper limit of Aldrin is
0.03 mg / L, for DDT and hexachlorobenzene the limits are 2 and 1 mg / L respectively.

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(c) Microbiological Aspects.

These are the standards relating to the presence of bacteria and viruses in drinking water.
(i) Standards of Bacterial Quality.
(aa) Treated Water.
Ideally all samples taken from the distribution system should be free from coliform organisms. In
practice, this standard is not always attainable and the following standard for water collected in the
distribution system is therefore recommended throughout the year. 95 percent of water samples
should not contain coliforms in 100 ml, no sample should contain E. coli in 100 ml and coliforms
should not be detected in 100 ml of consecutive sample (Table 5.6).
(ab) Individual or Small Community Supplies.
The standards outlined above may not be attainable in case of water from wells and springs. In
these waters, coliform count should be less than 10 per 100 ml. Persistent failure to achieve this,
particularly if E. coli is found repeatedly calls for rejection of water supply
Table 5.6 : Bacteriological Quality of Drinking Water
S. No. Organisms Requirements
1. All water intended for drinking :
a. E. coli or thermotolerant coliform bacteria Shall not be detectable in any 100 ml sample
2. Treated water entering the distribution system :
a. E. coli or thermotolerant coliform bacteria Shall not be detectable in any 100 ml sample
b. Total coliform bacteria Shall not be detectable in any 100 ml sample
3. Treated water in the distribution system :
a. E. coli or thermotolerant coliform bacteria Shall not be detectable in any 100 ml sample
b. Total coliform bacteria Shall not be detectable in any 100 ml sample
(ii) Standards of Viral Quality.
As stated earlier, water free of faecal coliforms need not necessarily be free of viruses. Enteroviruses,
reoviruses and adenovirus have all been detected in water. As per the WHO standards, not more than one
Plaque Forming Unit (PFU) per litre of water is considered potable. There should also be complete absence
of enteropathogenic viruses and faecal bacteriophages.
(d) Radiological Aspects.
There is an increasing hazard of pollution of water supplies by radioactive substances. The radioactivity of water
is measured in picocuries per liter (pCi / l). WHO has proposed the following limits of radioactivity as acceptable.
(i) Gross alpha activity: 3 pCi / l
(ii) Gross beta activity: 30 pCi / l

5.20 Drinking Water Specifications.

The drinking water specifications as per the Bureau of Indian Standards are as mentioned below (Table 5.7)

5.21 Interpretation for Different Samples / Sources of Water.

The above standards are not hard and fast dividing lines above which water is to be immediately condemned or below
which it is safe to drink. The following table gives samples of some water analysis and their interpretation (Table 5.8).

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Table 5.7 : Drinking Water Specifications : Bureau of Indian Standards

Requirement Permissible Limit in the
S. No. Characteristic
(Acceptable Limit) Absence of Alternate Source
1. Colour (Hazen units) 5 15
2. Odour Agreeable Agreeable
3 pH value 6.5-8.5 No relaxation
4. Taste Agreeable Agreeable
5. Turbidity (NTU) 1 5
6. Total dissolved solids (TDS), mg / L 500 2,000
7. Total hardness (as CaCO3) 200 600
8. Aluminium (Al), mg / L 0.03 0.2
9. Ammonia (Total Ammonia-N) 0.5 No relaxation
10. Chloride (Cl), mg / L 250 1,000
11. Copper (Cu), mg / L 0.05 1.5
12. Fluoride (F) mg / L 1.0 1.5
13. Free residual chlorine, mg / L 0.2 1
14. Iron (Fe), mg / L 0.3 No relaxation
15. Magnesium (Mg), mg / L 30 100
16. Manganese (Mn), mg / L 0.1 0.3
17. Nitrate (NO3), mg / L 45 No relaxation
18. Cadmium (Cd), mg / L 0.003 No relaxation
19. Lead (Pb), mg / L 0.01 No relaxation
20. Mercury (Hg), mg / L 0.001 No relaxation
21. Arsenic (As), mg / L 0.01 0.05
22. Cyanide 0.05 No relaxation
23. Selenium 0.01 No relaxation
24. Chromium (Cr), mg / L 0.05 No relaxation
25. Alpha emitters Bq / l 0.1 No relaxation
26. Beta emitters Bq / l 1.0 No relaxation
(i) Rain Water.
Free (F) and Saline (S) ammonia very high (from air), Albuminoid (Alb) ammonia absent and very low oxygen is
absorbed. In pure rainwater, there is absence of nitrites or nitrates, very low chlorides, hardness and total solids.
(ii) Peat Surface Water.
Acidic brown colour, F and S ammonia very low, very high Alb ammonia and oxygen absorbed. Nitrites and nitrates
are absent. Chlorides is about normal for surface water, very low hardness and total solids and Iron is present.
Soft water presumably plumbosolvent not showing signs of animal pollution, either recent or remote.
(iii) River Water derived from Chalk Springs.
F and S ammonia low; Alb ammonia and oxygen absorbed very low. Nitrites absent, nitrates and chlorides higher

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than normal for clean surface water. Temporary hardness is high whereas permanent is low. A good river water
but showing some evidence of past animal pollution (nitrates and chlorides).
(iv) River Water derived from Chalk Springs after Receiving Sewage.
Turbidity and colour changes from blue to brown. F and S ammonia very high, Alb ammonia low, oxygen absorbed
high. Nitrites present, Nitrates and chlorides rather high. Increase in permanent hardness probably due to
sulphates in sewage. A very impure water showing evidence of recent animal pollution.
(v) Water from Pond Receiving Sewage.
A turbid brown unpleasant smelling water. F and S and Alb ammonia and oxygen absorbed all very high. Nitrites
present, nitrates and chlorides very high. Permanent hardness probably due to sulphate from sewage. The quality
of water is poor and shows marked evidence of recent animal and vegetable pollution.
(vi) Water from Well without Surface Protection.
F and S ammonia high, Alb ammonia and oxygen absorbed very high. Nitrites nil but nitrates rather high. Chlorides
high (around 2,000) temporary and permanent hardness high. The quality of well water is poor and is certainly
contaminated by surface washings.
Table 5.8 : Sample of Water and their Interpretation
A B C D E F
Physical Characteristics
pH 6.0 5.3 Alk Alk Alk Alk
Turbidity Nil Nil Nil Slight Turbid Nil
Slight Green
Colour Nil Brownish Brown Nil
Brown Blue
Odour Nil Nil Nil Nil Unpleasant Nil
Chemical Characteristics (In Parts Per Million)
Ammonia F & S 0.49 0.008 0.014 0.122 4.5 0.6
Ammonia Alb Nil 0.160 0.020 0.098 4.7 1.1
Oxygen absorbed 15 minutes 0.03 1.03 0.05 0.42 6.9 5.0
Oxygen absorbed 4 h 0.05 l.80 0.52 l.46 2.9 8.4
Nitrites Nil Nil Nil Present Present Nil
Nitrates Nil Nil 3.1 3.6 8.0 6.0
Chlorides 1.5 11 16 19.0 6.25 4.5
Hardness temporary 2 8 228 196 20 150
Hardness permanent Nil 8 14 180 50 100
Total solids 23 40 284 296 267 400
Metals Nil Iron Nil Nil Nil Nil
A: Rain Water, B: Peat surface water, C: River water derived from chalk springs; D: River water derived from chalk
springs after receiving sewage, E: Water from pond receiving sewage, F: Water from well without surface protection.

5.22 Detection of Poison in Drinking Water.

Water is the most vital source of all kinds of life on this planet. There is every possibility of sabotage of drinking water
source by the enemy / militants. It must be ensured that water is free from poisons before it is declared potable. Testing
of poison in drinking water requires elaborate laboratory facilities, which are not possible in remote areas. A kit has
been developed by DRDE Gwalior and marketed by Hindustan Metal Industries, Nai Sarak, Gwalior, Madhya Pradesh

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keeping in view the above requirement and facilitated testing of most commonly present poisons such as Sulphur
mustard, nerve agent and microbial contamination (Table 5.9).
Table 5.9 : Poisons in Water and their Detection Limit
S. No. Poisons Detection Units (mg / L)
1. Nerve agents 0.01
2. Sulphur mustard 2.0
3. Cyanide 0.05
4. Mercury 0.5
5. Arsenic 0.2
6. Lead 0.001
7. Manganese 0.2
8. Copper 1.5

9. Microbial contamination 1-3 coliform in / 100 ml

(a) Description.
The Water Poison Detection Kit (WPDK) is housed in aluminum container having shoulder strap to carry for
field use. The kit is provided with the reagents / material, sufficient for testing poisons 50 times. Each of the
consumable reagents / material are quite stable and are replenishable. The field kit is for the detection of poisons
in drinking water. WPDK tests are specific and can be performed systematically within 30 minutes, excluding
the test for microbial contamination which takes 18 hours alone.
(b) Warning.
The following points should be considered before performing the tests.
(i) The sample of water should not be chlorinated. If chlorinated, water can be dechlorinated by adding
sodium thiosulphate.
(ii) Water sample should be made clear by filtering if turbidity is observed.
(iii) pH of water sample should be close to 7.
(iv) Deionised water may be used in lieu of distilled water. Deionised water can be prepared by shaking
water (50 ml) with four scoopfuls of resin from bottle No 3 for 5 minutes, supernatant of which can be
used.
(c) WPDK (Field Kit for Detection of Poisons in Drinking Water (WPDK).
This kit is developed by Defence Research & Development Organization (DRDO). User handbook cum part
identification list and a pic of test kit with its schematic internal diagnosis (Fig 5.10 & 5.11) is reproduced
below for the ease of executing the tests.
(i) Size of the Kit: Length: 317 mm, Width: 270 mm, Height: 100 mm
(ii) Capacity of the Kit: 50 tests for each poison and 5 test each for nerve agents and microbial
contaminants.
(d) Procedure of Detection.
(i) Nerve Agents.
(aa) Take the sample of water more than half in the small glass bottle (24)
(ab) Break the big ampule followed by small by means of clean glass plunger (25)

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6 23 23 23 23 23 7

13 24 24 24 24 24 21
5 8
15 17 18
4 9
26 26 26 26 25 25 29 28
3 10
20
14 15
2 22 32 11

1 19 12

Fig 5.10 : General view of the WPDK Fig 5.11 : Schematic view of the WPDK kit
(ac) Observation.
The colour of water sample will turn blue, wait for 5-8 minutes. Blue colour will disappear. It shows
that the sample under test is free from nerve agents. If blue colour of water does not disappear even
in 10 minutes, it shows the presence of Nerve agents.
(ii) Sulphur Mustard.
(aa) Open the cap of chemical heater assembly (19) and take out the metallic part.
(ab) Add approximately 30 drops of distilled water / deionised water in the plastic container of the
chemical heater assembly. Then add one crushed tablet and put metallic part in it.
(ac) Place one mustard test paper (18) over the pre-heated metallic platform of the heater.
(ad) Add 1-2 drops of catalyst solution (22)
(ae) Add slowly 10 drops of water sample drop by drop and wait for 2 minutes.
(af) Add 1 drop of reagent No (21)
(ag) Observation.
Appearance of purple blue colour will indicate the presence of sulphur mustard. Intensity of colour
will vary from light blue to purple blue depending upon the concentration of Sulphur mustard.
(iii) Cyanide.
(aa) Take 15 drops approximately of distilled water / deionised water in test tube.
(ab) Add one tablet each of (11) and (4) together.
(ac) Shake the test tube till it makes suspension, then add two drops of suspension on the filter
paper (17).
(ad) Now take 100 ml sample of water in a polythene bottle (14) add to it one tablet (12) and add
one scoopful of (2).
(ae) Quickly put the paper from step (ac) upside down directly on the mouth of the polythene bottle,
prepared as step (ad)
(af) Wait for 5 minutes.
(ag) Caution.
Cork of the plastic bottle may be put over filter paper in order to minimize the escape of gas evolved
through the sides of filter paper.
(ah) Observation.
A distinct bluish green colour will appear on the filter paper indicating the presence of Cyanide.

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(iv) Mercury.
(aa) Take a mercury test paper (16).
(ab) Add slowly fifteen drops of water sample by means of dropper on the centre of paper allowing
the drop to be soaked completely before adding the next drop.
(ac) After adding all the drops, wait for 2 minutes.
(ad) Observation.
Appearance of brick red / orange colour will indicate the presence of Mercury. For better visibility see
colour against white background. Any other colour has no significance.
(v) Arsenic.
(aa) Take a filter paper (17) and add two drops of reagent (13).
(ab) Now take 100ml water sample in a polythene bottle (15) and add one tablet (5).
(ac) Add one scoopful of (2).
(ad) Quickly put the above filter paper to which the reagent is already added, directly on the mouth
of polythene bottle, facing water.
(ae) Wait for 10 minutes
(af) Observation.
Pink / violet stain will appear on the filter paper facing water indicating the presence of Arsenic. Yellow
stain has no significance.
(vi) Lead.
(aa) Take 100 ml of sample of water in polythene bottle (15). Add one scoopful of (No 1). After 5 minutes
shake the bottle gently up and down for two minutes, then allow to settle the resin, reject the supernatant
liquid. Add another 100 ml sample and repeat as above till one litre of sample is extracted.
(ab) Take the extracted resin on a filter paper to remove excess water. Transfer the resin thus dried
in the test tube.
(ac) Add 15 drops approximately distilled / deionised water in the test tube, crush and add one tablet
each of (6) and (7) together in the test tube.
(ad) Shake vigorously for 5-10 minutes. The solution will become turbid.
(ae) Add five drops of turbid solution on a fresh filter paper (17).
(af) Take 5-6 crystals of (8) in another test tube and add 30 drops distilled / deionised water to make
solution. Add 5 drops of this solution over the filter paper where turbid solution has already been added.
(ag) Observation.
A distinct dark violet stain will develop to indicate the presence of Lead.
(vii) Manganese.
(aa) Put one tablet (9) on filter paper (17)
(ab) Add 10 drops of water sample very slowly by means of dropper.
(ac) Wait for two minutes.
(ad) Observation.
A distinct bluish green colour will appear on the filter paper indicating the presence of Manganese
in water.
(viii) Copper.
(aa) Put one tablet (10) on a filter paper (17).

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(ab) Add slowly 10 drops sample of water on the tablet.

(ac) Wait for two minutes.
(ad) Observation.
Olive green colour will appear on the filter paper indicating the presence of Copper.
(ix) Microbiological Contamination.
(aa) Take a bottle (23), unscrew it and immediately fill the sample of water up to the mark
(ab) Shake the bottle for one minute.
(ac) Keep the bottle at room temperature preferably at 30°C for 18 hours.
(ad) Observation.
After 18 hours, see the colour of water. If it turns jet black, it confirms the presence of heavy biological
contamination and if it is less means less contamination. Temperature will play an important role in
the development of colour, if sample of water is contaminated.

5.23 Surveillance of Drinking Water Quality.

Surveillance is an important element in the development of strategies for incremental improvement in the quality of
drinking water supply services. Strategies for implementing surveillance, collating, analysis, summarizing data and
reporting and disseminating the findings accompanied by recommendations for remedial actions. The activities that
should be included in the surveillance function are.
(a) Approval of new water source including private owned supplies.
(b) Watershed protection.
(c) Approval of construction and operating procedure of water works including
(i) Disinfection of the water plant and distribution system after repair or interruption of supply.
(ii) Periodic flushing programmes and cleaning of water storage facilities.
(iii) Certification of operators.
(iv) Cross-connection control, backflow prevention and leak detection control.
(d) Sanitary survey.
(e) Water monitoring programmes including provision for central and regional analytical lab services.
(f) Development of codes of practice for well construction, pump installation and plumbing.
(g) Inspection quality control in bottled water and ice manufacturing operation.
The component steps for establishing water quality surveillance system are as follows.
(a) Sanitary Survey.
It is the onsite inspection and evaluation by a qualified person of all the conditions, devices and practices in
the water supply system that pose a danger to the health and wellbeing of the water consumers.
(b) Sampling.
Sampling of water should be done with strict aseptic precautions and should be carried out by competent and
trained personnel in accordance with the methods and frequency of sampling prescribed in the WHO guidelines
for drinking water quality.
(c) Bacteriological Surveillance.
The WHO recommends the measurement of E. coli in drinking water samples as the best indicator of water
quality. The WHO guidelines for potable water is less than one E. coli per 100ml of drinking water. The multiple
tube fermentation and membrane filtration test measures total coliforms and are standard methods for water
quality assessment. Following tests are conducted for bacteriological surveillance of drinking water.

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(i) Presumptive Coliform Test.

(aa) Multiple Tube Method.
This test is based on estimating the Most Probable Number (MPN) of coliform organisms in 100 ml
of water. The test is carried out by inoculating measured quantities of sampled water (0.1, 1, 10,
50 ml) into tubes of Mc Conkey’s Lactose Bile Salt broth with bromocresol purple as an indicator.
Bottles containing McConkey’s broth, sample of water and a small inverted tube are incubated for
24 to 48 h at 37°C. The multiplication of faecal organisms present in water under test produces
acid and gas. From the number of samples turning acidic, as shown by the pink colour of mixture
and gas as seen in the inverted tubes, an estimate of MPN of the coliform group of organisms per
100 ml is ascertained from the standard tables. The estimates are therefore ‘presumptive’ and not
actually existing. There are two methods usually employed in the laboratories: the ‘ordinary method’
and the ‘field method’.
The water samples are collected in 180 ml sterilised bottles with all necessary precautions. If possible,
the bottle should contain culture medium and be inoculated on the spot. If not, they should be packed
in ice and sent expeditiously to the laboratory.
(ab) Ordinary Method.
This method is used while examining water from urban water works. Two series of bottles are put
up. Series 1 is used for the samples that are likely to be satisfactory and series 2 when water is
obviously unsatisfactory. Samples showing upto 2 presumptive coli in 100 ml are considered ‘good’
while those showing above 10 are ‘bad’; the intermediate grade samples from an otherwise good
source may be acceptable in an emergency, provided that efficient clarification and chlorination show
no presumptive E. coli in 100 ml (Table 5.10).
(ac) Field Method.
This method gives rapid results enabling one to take quick decision in the field about the comparative
merits of two or more water sources. Five bottles containing inverted tubes and 10 ml double strength
Mc Conkey’s broth are inoculated with 10 ml of sample of water on the spot and incubated for
24 h after which none of the bottles should show gas or acid.
Table 5.10 : Comparison of Ordinary and Field Methods
No. of Quantity Single Broth ml
Method Series Quantity of Water
Bottles Strength Double Strength
Ordinary 1 1 50 - 50
5 10 - 10
5 1 10 -
2 5 10 - 10
5 1 10 -
5 0.1 10 -
Field 5 10 - 10
(ii) Confirmatory Test.
The next step is to confirm the presence of coliform organisms in each tube showing a presumptive positive
reaction. Such conformation is usually not required in case of unchlorinated water but is required in case
of chlorinated water. Confirmation is done by subculturing each presumptive positive tube in two tubes of
brilliant green bile broth, one of which is incubated at 37°C for upto 48 hrs for confirmation of the presence
of coliforms. The other tube is incubated at 44°C and inspected after 6 and 24 hrs to decide whether
E. coli is present or not. E. coli is the only coliform which can produce gas from lactose at 44°C. Further
confirmation of presence of E.coli can be done by testing for indole formation at 44°C.

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(iii) Membrane Filtration Technique.

In some countries, membrane filtration technique is used as a standard procedure to test for the presence
of coliform organisms. A measured value of water sample is filtered through a membrane made of cellulose
ester. Bacteria present in water are retained on the surface of membrane. The membrane is then directly
inoculated face upwards on suitable media at appropriate temperature. Within 20 h, the colonies grow and
can be counted.
(iv) Faecal Streptococci and Clostridium perfringens Detection.
They regularly occur in faeces, but in much smaller numbers than E. coli; in doubtful cases, the finding of
faecal streptococci and Clostridium perfringens in water is regarded as important confirmatory evidence of
recent faecal pollution of water. Streptococci are highly resistant to drying and may be valuable for routine
control testing after laying new mains or repairs in distribution systems or for detecting pollution by surface
run-off to ground or surface waters and Cl. perfringens spores can survive in water for a longer time than
organisms of the coliform group and usually resist chlorination at the doses normally used in water works
practice. The presence of spores of Cl. perfringens in a natural water suggests that faecal contamination
has occurred and their presence, in the absence of the coliform group, suggests that faecal contamination
occurred at some remote time. Its presence in filtered supplies may indicate deficiency in filtration practice
(v) Colony Count.
The colony count on nutrient agar at 37°C and 22°C provide an estimate of the general bacterial content
of water. A single count is of little value but counts from the same source at frequent intervals are of
considerable value. A sudden increase in the count serves as the earliest indicator of contamination and
hence this test is gainfully used in the public water works. The recommended plate counts are (Table 5.11).
Table 5.11 : Colony Counts in Water
Water at the Point of Consumption Plate Count after 2 Days at 37°C Plate Count after 3 Days at 22°C
Disinfected 0 20
Not disinfected 10 100
Plate count on yeast extract agar at 22°C for 7 days is even a better indicator due to the absence of
chlorine residuum when there is uninhibited bacterial growth.
(d) Biological Surveillance.
Water may contain planktons i.e. microscopic organisms such as algae, fungi, yeast, protozoa, rotifers, crustaceans,
worms etc. The presence of planktons is an index of pollution and they produce objectionable taste and odour
in water. The degree of pollution is assessed qualitatively and quantitatively by noting the type and number of
organisms present in water.
(e) Chemical Surveillance.
Tests for pH, colour, turbidity, chlorides, ammonia, chlorine demand, free residual chlorine are carried out under
chemical surveillance of drinking water. Tests for iron, manganese are required when these substances are
present in raw water in sufficient quantities.

5.24 Water Conservation.

Water conservation or saving water includes all policies, strategies and activities to sustainably manage natural resource
of fresh water to meet the current as well as the future demand of humans. In industrial and agricultural countries,
factors such as climate change has increased pressure on natural water resources. The goals of water conservation
include.
(a) Ensure availability of water for future generation where withdrawal of fresh water from an ecosystem does
not exceed its natural replacement rate.
(b) Energy conservation as water pumping, delivery and wastewater treatment facilities consume significant
energy.
(c) Conservation of ecosystem and leaving enough water bodies for migratory and water dependent birds.

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The key activities in water conservation include.

(a) Reduction in water loss, water use and waste of water resources.
(b) Avoiding damage to water quality.
(c) Improving water management practices that reduces the wastage of water.

5.25 Rain Water Harvesting.

Water conservation can be undertaken by
several ways. Rain water harvesting is one
of the most commonly used method. In this
method, rainwater is accumulated and stored
for reuse onsite rather than allowing it to
run off. Rainwater is collected from roofs or
many a times water collected is redirected to
a deep pit such as well, shaft or borehole, a
reservoir with percolation or collected from
dew or fog with nets or other tools. This
collected water is used for gardens, livestock,
irrigation or domestic purpose after proper
treatment. The harvested water can also be
used as drinking water, for long term storage,
ground water recharge etc. Wire meshes
or inlet filters are placed over the top of
downpipes to prevent leaves and debris from
entering storage containers and are cleaned
regularly to prevent clogging. Storage tanks
can become mosquito breeding sites and this
should be prevented by covering the tanks
with fine metallic mesh to prevent entry of
mosquitoes (Fig 5.12). Fig 5.12 : Rainwater Harvesting

5.26 The International Drinking Water Supply and Sanitation Decade 1981-1990.
The ‘Decade’ was launched at a special meeting of the United Nations General Assembly on 10th November 1980
following the recommendation of the UN Water Conference at Mar del Plata in 1977. The above conference gave priority
to the provision of safe water supply and sanitation. This was influenced by the joint report of WHO and World Bank
which showed that in 1975, 1,230 million people were still without safe water supplies and 1,350 million people had
lack of adequate sanitation facilities. Among the rural populations of developing countries, only 22 percent had access
to reasonable safe water and only 15 percent had facilities for excreta disposal. The Mar del Plata action plan also
urged the individual countries to establish goals for 1990, to match the global target of the decade.
(a) Preparatory Phase.
The period from 1977-1980 was declared as the preparatory phase during which the countries were urged by UN
action plan to prepare realistic plans and programmes for the decade. The United Nations system also urged to
strengthen cooperation with countries, international organization and external sources of technical and financial
support for promoting the decade’s success.
(b) Steering Committee.
To initiate necessary action a steering committee composed of representatives of the various organizations within
the UN system was set up. The objectives of steering committee were to provide regular forum for policy review
and developments to adopt coordinated approach to the orientation and management of individual programmes
and to arrange for consultative meetings with donors and financing agencies. The UNDP resident representative
is to act as the focal point at the country level for coordinating technical support desired by government from
the organizations of UN system.

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(c) Rapid Assessment Exercise.

Following the Mar del Plata conference, more than 100 countries including India, launched a rapid countrywide
assessment exercise to review the status of drinking water and excreta disposal sector and how existing national
programmes should be adjusted to the goal of the decade. Though the constraints to the rapid assessment
exercise were many, the positive response of the government is considered very encouraging.
(d) Joint Consultative Meetings.
A joint consultative meeting of the representative of the bilateral agencies and regional banks as well as of the
cooperating UN agencies was convened at Geneva in November 1978 by the administration of UNDP and Director
General of WHO. The meeting reached a consensus on wide range of question including the need to ensure
coordination at national level, role of UNDP resident representative, priority to be given to poor populations in both
rural and urban areas, encouragement of community participation, technical co-operation amongst developing
countries, need to ensure effective use of resources etc. A second consultative meeting was held in 1980 in
which the member governments were also invited.
(e) Task Forces.
As per agreement reached, two task forces were set up for exchange of information and formulation of projects
in the sector. The donor agencies, international banks and non-governmental organizations are represented on
the task forces.
(f) Target of the Decade (1991-2000).
The targets fixed by the Indian Government for the decade were.
(i) 100% urban and rural supply
(ii) 50% urban sanitation
(iii) 25% rural sanitation
The Guinea worm eradication programme was linked with this decade. In 1986, the National Drinking Water
Mission (NDWM) popularly unknown as Technical Mission was launched in order to provide scientific and cost-
effective content to the centrally sponsored Accelerate Rural Water Supply Programme. In 1987, National Water
Policy was announced that gave high priority to drinking water.

5.27 National Programme for Supply of Drinking Water and Sanitation.

The Ministry of Drinking Water and Sanitation, Government of India formerly under the Ministry of Rural Development as
Department of Drinking Water and Sanitation is presently headed by a Cabinet Minister, Drinking Water and Sanitation.
The Accelerated Rural Water Supply Programme (ARWSP) was the first major sanitation in water sector that started
in 1972-1973. To accelerate coverage, technology mission on drinking water was launched in 1986. In 1991-92, this
mission was renamed as Rajiv Gandhi National Drinking Water Mission and in 1999, the Department of Drinking
Water Supply (DDWS) was formed under the Ministry of Rural Development for focused attention on drinking water
and sanitation. The first major sector to reform project (SRP) was started the same year and was later renamed as
Department of Drinking Water and Sanitation in 2010 and in 2011, ministry status was conferred to it. Keeping in
view, extreme importance given to sector by ruling government. It is the nodal ministry for policy formulation, planning,
funding and coordination for two flagship programmes of Government of India namely, National Rural Water Drinking
Programme for rural drinking water supply and Swachh Bharat Mission (Gramin) SBM (G) for sanitation of the country.
(a) National Rural Drinking Water Programme.
The National Rural Drinking Water Programme (NRDWP) is a centrally sponsored scheme aimed at providing
every person in rural India with adequate safe water for drinking, cooking and other basic domestic needs on
a sustainable basis. Safe water is to be readily and conveniently accessible at all times and in all situations
and therefore, the scheme focusses on the creation of the infrastructure. This has resulted in the provision of
significant additional resources to the sector, development of infrastructure and capacities for the successful
operation of drinking water supply schemes in the rural areas.
(b) Jal Jeevan Mission (JJM).
The centrally sponsored scheme of the Department of Drinking Water and Sanitation-National Rural Drinking

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Water Programme (NRDWP), was restructured and subsumed into Jal Jeevan Mission (JJM) to provide Functional
Household Tap Connection (FHTC) to every rural household i.e., Har Ghar Jal, by 2024. Jal Jeevan Mission is
envisioned to provide safe and adequate drinking water through individual household tap connections by 2024
to all households in rural India. The programme will also implement source sustainability measures as mandatory
elements, such as recharge and reuse through grey water management, water conservation, rain water harvesting.
The Jal Jeevan Mission is based on a community approach to water and include extensive information, education
and communication as a key component of the mission. JJM looks to create a nationwide campaign (Jan Andolan)
for water, thereby making it everyone’s priority.
(c) Swachh Bharat Mission.
To accelerate the efforts to achieve universal sanitation coverage and to put focus on sanitation, Swachh Bharat
Mission was launched on 2nd Oct 2014. The mission was implemented as nationwide campaign which aimed at
eliminating open defecation in rural areas during the period 2014 to 2019 through mass scale behaviour change,
construction of household-owned and community-owned toilets and establishing mechanisms for monitoring toilet
construction and usage. Under the mission, all villages, Gram Panchayats, districts, States and Union Territories
in India declared themselves “Open-Defecation Free” (ODF) by 2nd October 2019, the 150th birth anniversary of
Mahatma Gandhi, by constructing over 100 million toilets in rural India.
(d) Namami Gange Programme.
It is an integrated conservation mission, approved as ‘Flagship Programme’ by the Union Government in June
2014 with budget outlay of ₹ 20,000 crore to accomplish the twin objectives of effective abatement of pollution,
conservation and rejuvenation of national river Ganga. Main pillars of the Namami Gange Programme are.
(i) Sewerage treatment infrastructure (v) Afforestation
(ii) River-front development (vi) Public awareness
(iii) River-surface cleaning (vii) Industrial effluent monitoring
(iv) Bio-diversity (viii) Ganga Gram

5.28 Provision & Monitoring of Water Quality in Armed Forces.

Since Armed Forces personnel are particularly vulnerable to the danger of water related diseases because of the nature
of their duty under adverse conditions beyond their control, strict water vigilance and control is to be maintained at all
times. The provision of adequate and safe water supply for use of Armed Forces personnel is an important responsibility
of every Commander as it is important in the maintenance of health and fighting efficiency of troops.
The Engineers are responsible for the supply of wholesome water and the Medical Services for the advice as to its
safety and procedure to render it safe for consumption. In the field, all untreated water should be regarded as polluted
but practically water from any source can be made safe by modern methods. However, better the initial supply source
of water, better is the result. In every instance it must always be properly treated to render it fit for drinking.
MES authorities are supposed to get all water sources in a Stn tested for all physical, chemical, radiological and
microbiological parameters from a central public health lab every 6 monthly. The same should be ensured by PSM
spl in Stn.
(a) Monitoring of Water Quality by Med Auth in Stn.
(i) SEMOs / SMOs / OCs SHOs and FHOs / local Med auth will meticulously monitor the quality of water
including sanitary conditions of water supply system and immediately advise the Cdrs and MES / Engr auth
for rectification of defects.
(ii) Unit Nursing Asst / Hygiene & Sanitation squad will check for free chlorine levels in MES / Engrs water
supply daily during supply hours and a register on the same will be maintained. Following steps will be
taken by Med authorities and record will be maintained.
(aa) Daily check of free residual chlorine at randomly selected consumer end points, in rotation to
ensure that all areas of the Stn / Fmn / Units are covered in a week.
(ab) Checking of Chlorination process at all pump houses / supply sources.
(ac) Regular Bacteriological analysis of water in entire Stn / Fmn / Unit at frequent intervals in rotation

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so as to cover each water source once every qtr.

(ad) Physical, chemical and bacteriological analysis at the time of commissioning of new water points
(surface water, bore wells etc) and once in a year for all water points will be carried out under the
arrangements of MES / Engrs / Stn Cdr and result intimated to SEMO / SMO.
(ae) On ground check of water supply pipes for any leakages / cross connections with sewage system or
of potential of cross contamination of water supplies with excreta. This action will be undertaken jointly
by the MES / Engrs and Med auth in a way that entire Stn / Fmn / Unit is covered once in a month.
(af) In field areas, med auth will assess the requirement of bleaching powder to be added to water
for chlorination / super chlorination and advice the Engrs / Units accordingly. They will also render
advice regarding the siting and hygiene of water points / water sources to ensure the supply of potable
water by Engrs.
(b) Range for Chlorine Concentration at Source and Consumer end point.
A minimum level of 0.2 ppm of free residual chlorine is always available at consumer end points and 0.5 to
1.0 ppm level is available at the pump house / supply source. In a case of suspicion / impending outbreak or
if considered by the Med auth, Super chlorination will be undertaken so as to ensure 1.0 ppm free residual
chlorine at the consumer end points and 2.0 ppm at the source. In emergent situations med auth may also
advice boiling the water before consumption.
(c) Responsibility of providing potable water rests with the MES / Engrs auth. However, instances where Reverse
Osmosis (RO) plants are being planned / used the following will be kept in mind.
(i) RO purified water will be discouraged in places where the TDS of ground water is less than 500 ppm.
(ii) RO plant storage tanks / coolers / dispensers will be emptied completely and cleaned at least once a
week.
(iii) Waste water drains should be provided near it for ease of drainage.
(iv) Membrane filters of each RO unit will be changed at regular intervals along with maintenance checks
and a register for the same will be maintained by NCO I / C.
(v) RO plant waste water should be used for environmental management and water harvesting.
(d) All units are responsible to train certain number of personnel in water and sanitation duties (Table 5.12).
These personnel will work under the supervision of the unit Quarter Master. Their duties consist of.
(i) Sanitation of source / storage of water supplies.
(ii) Supervision of sanitation within the unit lines.
(iii) Sanitation of cook houses and canteen.
(iv) Disinfection.
(v) Anti-fly, anti-mosquito and anti-rodent measures. Men previously trained are required to be sent on
refresher courses annually. Necessary courses for the training of personnel are organized and conducted
by RMOs / SEMOs / SHOs / Fd Hospitals.
Table 5.12 : Personnel for Water and Sanitation Duties
Water and Sanitation Duties
Unit
NCO OR
Major units commanded by Lt Col and above 4 6
Plus 100% as reserve
Minor units commanded by Major and below 2 3

5.29 Chlorination of Water in Field Service.

Practice of sterilizing water adopted in field service and in some semi-permanent or even a few permanent camps
where chloronomes are not available, is by use of WSP, added manually or by dosers. The standard procedures used
in the field are ‘chlorination’ and ‘super chlorination’.

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(a) The ‘chlorination’ aims at obtaining 1 ppm of free residual chlorine in water after half an hour’s contact.
The quantity of water sterilizing powder required is estimated by Horrocks’ test. The number of scoopfuls (of two
grams) of water sterilizing powder required to chlorinate the given quantity of water is calculated and added to
water. Water must be allowed to stand at least 30 min after addition of the requisite amount of WSP before it
is taken into use.
(b) ‘Super chlorination’ of water aims at obtaining the free residual chlorine of 2 ppm in water. This is achieved
by adding one scoopful of water sterilising powder per 500 L of water more than that required for ‘chlorination’.
A contact period of 30 min is allowed. This method of treatment is adopted when efficient clarification is not
possible; safety of source and initial purity of water is doubtful; outbreak of any water-borne disease is threatened;
or water is required for use in a very short time. Super chlorination by a ‘fixed dose’ of 4 scoopfuls of WSP per
500 L of water is carried out when the clarity of water is doubtful and the Horrocks box is not available.
In all these processes the required amount of water sterilising powder is first mixed in little water and made into
strong solution in a bucket and then this solution is evenly added to whole bulk of water to be treated and mixed
thoroughly. The cadmium iodine starch colour test is then carried out at the end of 30 min for chlorination and
15 min for superchlorination. If blue colour is not obtained, one scoopful of WSP per 500 L for chlorination and
two more scoopfuls per 500 L for superchlorination must be further added to water. After mixing and allowing for
30 min or 15 min lapse as the case may be, the colour test is repeated. Except in water containing schistosome
or cercariae, these doses should not be exceeded.
Dechlorination may become necessary to remove chlorinous taste after superchlorination. Sometimes rain water
or water recently polluted with organic matter contains ammonia, which forms chlorarmines on addition of water
sterilizing powder. Chloramines are not deviated by organic matter as chlorine is and hence gives blue colour even
in the presence of oxidisable organic matter, when cadmium iodide starch indicator solution is added. Moreover,
there will be a lag in disinfection owing to the slower bactericidal action of chloramine. Therefore, while super
chlorinating water of this nature it is better to extend the contact time to a minimum of 30 min or even more.
(c) Pre-chlorination and Re-chlorination.
Sometimes prechlorination has to be employed before filtration of water by a water tank truck in order to
decrease the organic matter load on the filters and to reduce its subsequent chlorine demand especially in
a newly occupied area in field service. At times the chlorinated water obtained from local civil sources needs
to be rechlorinated before consumption by troops, if there is a longer lapse of time between chlorination and
consumption.
(d) Chlorine Content in WSP.
The chlorine content of WSP sample is determined by either Penot’s arsenite test or by thiosulphate test. A
mixture of 10 ml of 1 percent WSP solution and 10 drops of fresh cadmium-iodide­ starch indicator solution is
taken in a beaker. The neutralizing reagent is then slowly run into it from a burette. The neutralizing reagent
in Penot’s test is a 0.5 percent sodium arsenite solution which is prepared by dissolving 0.5 g of arsenious
acid (As2O3) and 2.5 g of sodium carbonate (Na2CO3) in 100 ml of distilled water. In the thiosulphate test,
2.48 percent sodium thiosulphate solution is used. The ml of neutralizing reagent required to decolourise the
blue WSP indicator solution mixture multiplied by 3.55 indicates the percentage of chlorine in WSP sample
under test. These tests require well-equipped laboratories and therefore cannot be carried out in field service.
A rough and ready field test can be carried out by the use of Horrock’s box. WSP solution is made by mixing one
level scoopful of WSP powder to be tested in black cupful of clarified water. One scoopful of this solution is mixed
with a scoopful of cadmium-iodide indicator solution in a white cup and a tablet of acid sodium bisulphate is
added to it. 0.05 percent of neutralising reagent is prepared by dissolving 100 mg tablet of sodium thiosulphate
in a white cupful of water. Scoopfuls of this solution are added to blue mixture of indicator-WSP solution and
stirred. The number of scoopful of thiosulphate solution added until the blue colour first disappears indicates
percentage of chlorine in WSP under test.

5.30 Water Supply in Armed Forces.

The water supply for the Armed Forces is organized at various levels of echelons according to facilities available, with
various grades of refinements in clarification and chlorination depending on the situation and availability of resources.
All efforts should be made to avoid deficiencies in supply, such as the following.

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(a) Pollution of the source.

(b) Inadequate treatment.
(c) Cross connections with sources of contamination.
(d) Inadequate capacity resulting in low pressure.
(e) Inadequate operation of the facilities including.
(i) Inadequate disinfection.
(ii) Failure to provide standby facilities in the event of power or other equipment failure.
After floods, when water supply distribution system remains intact, pressure in the pipelines should be raised so as to
prevent polluted water from entering the pipes. Superchlorination is also an additional measure. Pipelines are routed
alongside roads or public ways to facilitate inspection (for detecting leakage, unoperative valves, damage etc.) and to
provide ready access for maintenance and repair. The most common pipe materials used are made of cast iron, ductile
iron, steel, asbestos cement, polyvinyl chloride and high-density polyethylene.

5.31 Cantonment Water Supply.

In military cantonment and permanent garrisons, well established permanent water works function under the
management of State or Central PWD. In some permanent garrisons where Cantonment Boards do not exist, similar
water plants are established under the jurisdiction of the MES. Usually the sources of water supply are streams or deep
wells. Clarification of water is carried out by sedimentation, first without and later with flocculation. followed by filtration.
Large reservoirs for holding raw water, masonry or concrete settling tanks, slow or rapid sand filters and high level
reservoirs for holding finally treated and chlorinated water ready for delivery is created. Chlorination or chloramination
is carried out with gaseous or liquid chlorine by chloronomes. Delivery of treated water from the overhead or high
level reservoirs is through pipes. Quality control is maintained by regular chemical and bacteriological examination and
automatic orthotolidine testing and recording. The delivery of water to Armed Forces units may occasionally be through
the unit or centralized station transport.

5.32 Garrison Water Plants.

In semipermanent camps in Corps HQ or Command Zone bases in field areas, MES establishes central water points.
Generally, sedimentation with flocculation is carried out in masonry tanks. Chlorination by gaseous or liquid chlorine is
usually the method of choice but sometimes it is carried out by either bleaching doses or manual application of WSP
depending on the nature and duration of stay of the garrison. The sources of water have to be much more carefully
selected as filtration is not usually possible. Quality control is ensured by initial chemical and bacteriological examination
repeated whenever the quality of raw water is likely to change. The Horrock’s test is regularly carried out to assess the
WSP requirements. Orthotolidine testing of water and recording is carried out every time the fresh quantity of water is
chlorinated. Delivery of water may be through pipes, but quite commonly it is through unit or station transport.

5.33 Central Field Water Points.

In forward areas, MES or Corps of Engineers establishes various grades of ‘central water points’ at the Divisional
and Brigade levels. The sources are most meticulously selected from the hygienic point of view and for the initial
clarity of water. Purity of water and protection is ensured by fencing, policing and imposing strict prohibitory orders
against the entry of unauthorized persons. The sources are streams, deep wells or natural springs. For clarification
and chlorination, masonry tanks can be constructed at the Divisional levels but usually the canvas tanks are used.
Filtration is normally not feasible and only the sedimentation with flocculation is relied upon. If for any reason e.g. in
mobile warfare it becomes impossible to establish a static water point, only the filtration without sedimentation may
be carried out centrally, provided that the water tank trucks fitted with large size stellar or meta filters are available.
Chlorination is carried manually with WSP after determining the quantity required. Horrock’s test is mostly carried out
daily. Quality control is maintained by color test but cadmium iodide-starch solution or Orthotolidine test (OT test) is
carried out every time the delivery tank is filled and chlorinated, but not earlier than half an hour after chlorination.
Water is collected by units in water tanks or lorries with metal or improvised canvas tanks hoisted on them. Chlorination
may be carried out at the units instead of at the central water point. If the quality of raw water shows wide fluctuation,
super chlorination is preferable with dechlorination carried out just before consumption but not earlier than 30 minutes
after adding WSP.

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5.34 Unit Water Points.

When central (Divisional or Brigade) water points are not feasible or when units are located at a long distance from
such water points, water is collected, clarified and chlorinated under unit arrangements. Normally springs, wells or
streams are used as sources. The selection of source and collecting point has to be on much more rigid standards.
The Medical Officer is required to exercise utmost caution in accepting the particular source. Checks on alternative
sources should also be carried out. If water tanks with meta or stellar filter are available, they are used to collect and
filter water. Otherwise, water is clarified in canvas tanks or CGI drums by flocculation. Chlorination is carried out by
WSP after daily assessment of the required WSP dose. Quality control requires strict supervision and is carried out
by color test or Orthotolidine test.

5.35 Sub Unit Arrangements.

When such unit water points are too remote e.g., detachment and piquets, water is collected from clear reliable sources
such as springs or wells in small containers like pakhals, drums or canvas tanks and manually superchlorinated after
the Horrock’s test or by ‘fixed dose method’ if Horrocks’ box is not available and is tested by color test. Dechlorination
is carried out just before consumption. Training needs to be given to personnel in its adoption.
(a) Individual Water Sterilization.
When troops have to rely solely on individual resources on piquets, patrols, reconnaissance or trekking, water
from as clean a source and spot as possible is taken in water bottles, chaggals or buckets and superchlorinated
with WSP by fixed dose method or by use of individual water sterilizing outfit.
(b) Arrangements While on March.
On a long march when a long halt is contemplated, a staff officer accompanied by an engineer officer and
water duty personnel, medical officer and sufficient regimental police personnel should be sent forward to select
halting grounds near the good source of water. They should arrange for purification and chlorination of water
supply and take measures for its protection until the main body arrives. Thereafter, systematic distribution to
units / sub-units should be arranged. In movements by rail, troops must not use water supply without authority
from Railway Transport Officer.
(c) Field Water Point.
On active service in the field, water points are organized under the administration of Corps of Engineers. The
medical services in field collaborate with field engineers in the selection of proper water source and water
collecting point. The responsibility of ensuring initial quality of raw water, recommendation on processes to be
adopted for clarification and dose of chlorination required is that of Medical Services while the achievement
of medical recommendations and quantity to be provided rests with the Engineers. Medical services are also
responsible to check quality of water and standard of chlorination from time to time and advise on measures to
be adopted for achievements and maintenance of quality of water. The field water points is organized as under.
(i) The sources of supply are usually a stream or well. The banks of streams or lakes should be suitably
earmarked for drawing water for various purposes and indicated by different flags e.g., white for drinking-
water, blue for watering animals and red for bathing or washing of clothes and animals in that order from
upstream downwards.
(ii) If water is obtained from springs, they should be bricked in and trapped. If a well is used as a source
of water it should be properly constructed and maintained.
(iii) Methods of water treatment adopted at the field water point are sedimentation followed by chlorination
or superchlorination. The processes are generally carried out in 6,000 litres canvas tanks.
(iv) The tanks should be raised on a properly laid gravel, clinker or stone base, which is properly drained.
(v) Raw water is either pumped or led by gravity into one or more canvas cisterns for sedimentation.
(vi) Entry and exit roads, adequate drainage, fencing to protect tank area and military police or guards
should be provided. Protection and policing of whole water supply area from the moment the campsite is
selected is absolutely essential.
(vii) Treated water is delivered into unit water tanks or receptacles by hand or mechanical pump (Fig 5.13).

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Fig 5.13 : Layout of Water Points

(viii) The process of purification of water should be efficiently carried out under the constant supervision
of a trained officer / JCO of Corps of Engineers and checked by AMC officer. Horrocks’ test and colour test
(Orthotolidine test) should be carried out by AMC NCO trained and deputed specially for this purpose. Water
duty personnel of Field Coy Engineers or other unit organizing the water point must also be specially trained.
(ix) Details of process of water treatment is as under.
(aa) The first cistern of each set is filled with water to within 8 cm of brim by a pump. For flocculation,
35 g alum or alumino ferric per 1,000 litres of water is added as a coagulant. This is first dissolved
in a bucket of water and the solution is distributed evenly throughout water in the cistern. If water
is very turbid, upto 70 g per 1,000 litres of coagulant may be necessary. Alternatively, a sandbag
containing the requisite amount of crushed coagulant may be tied over the mouth of delivery pipe
so that water flows into the cistern through the bag.
(ab) The contents of cisterns are then well stirred for a few minutes and allowed to stand for two to
four hours or until the suspended particles have settled to the bottom leaving the supernatant water
clear. If flocculation does not begin within a few minutes, addition of lime (half the quantity as that
of alumina ferric) is added to produce flocculation and sedimentation.
(ac) The clarified water is then transferred to next cistern either by pumping or by siphoning, care
being taken not to disturb the sludge at the bottom of setting cistern. A simple plan is to lash the
hose pipe of pump or siphon to a post near the cistern so that the intake end of the hose pipe is
15 cm above the floor of cistern or tie an empty sealed tin to it so as to serve as a float.
(ad) A sample of clarified water should be taken and Horrocks’ test started just as the clarified water
starts pouring into the tank.
(ae) The amount of WSP required is made into a thin paste with a litre or so of clarified water in
a bucket and more water gradually added until the bucket is full of an even solution of WSP. This is
then evenly added to clarified water in the second cistern. If superchlorination is desired one more
scoopful of WSP is added per 500 litres of water.
(af) Water is well stirred and allowed to stand for half an hour or fifteen minutes if superchlorination

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has been carried out.

(ag) At the end of this time, a sample of chlorinated water is tested by colour test in a white cup.
If blue colour does not appear, water is not safe to drink until sufficient additional WSP has been
added to give blue color after a further half an hour.
(ah) Dechlorination is carried out by adding two taste removing tablets per 500 litres before
consumption of water.
(x) Delivery of water to units should be made in their unit transport by pumping it in and not by manual
lifting. The approach and exit to water point should be free from dust and slush and made hard by coping
or paving the paths. The water tank fitted in lorry should be always cleaned and washed before receiving
water in it and periodically sterilized by chlorine.

5.36 The Water Tank Truck.

The water tank trucks, lorries or trailers equipped with mechanical filters are used in forward areas by formations and
units whenever central water points cannot be established under the arrangement of field engineers. By the judicious
use of water truck, water from otherwise satisfactory local sources can be easily purified instead of obtaining it form
central water point situated several miles away. The essential functional parts and equipment on the truck or lorry
are water tank of varying capacity; mechanically (or sometimes manually) operated pump; a pair of mechanical filters
equipped with meta or stellar filter candles; waterproof and leak-proof suction hoses on the farther end of which are
carried the float and strainer. The filters are the most important equipment fitted one on each side of the front of
tank and connected to the pump.

5.37 Chlorination in Small Containers in the Field.

When detachments are separated from the main bodies, clarification of water to great extent will not be possible.
After short period of sedimentation by flocculation if possible, in small containers, it is chlorinated or more commonly
super chlorinated as under.
(a) In Pakhals, Buckets, Petrol Tins.
The number of scoopfuls of WSP as indicated by the Horrocks’ test should be mixed with clarified water in the
black cup from Horrocks’ box. For super chlorination, one extra scoopful of WSP should be added. The cup is
filled with water upto the mark, stirred and allowed to stand until the chalk powder in suspension settles. One
scoopful of this stock solution per 5 litres of water will be required. The treated water is allowed to stand for
30 min before consumption. When super chlorination is carried out, dechlorination may be carried out before
consumption but not earlier than 15 min contact. For this purpose, thiosulphate solution is prepared by dissolving
two taste removing tablets (1 g) in the black cup which is filled to the mark. One scoopful of this solution per
5 litres of super chlorinated water is added. When Horrocks’ box is not available, stock solution of 16 scoopful
of WSP should be made in a water bottle. One scoopful of this stock solution to every 5 litres is required. For
dechlorination, dissolve 16 thiosulphate tablets in another water bottle full of water. One scoopful per 5 litres
of this is added after it has had 30 min contact with chlorine or just before consumption.
(b) ln Water Bottles.
(i) By Individual Water Sterilizing Outfit.
This aims at achieving super chlorination by a fixed dose. In the tin, there are two bottles. 50 sterilizing
white tablets, each containing 0.2 g of mixture of 7.5% halogen (para-sulphondichloramino-benzoic acid),
10.5% anhydrous sodium carbonate and 82% anhydrous sodium chloride, are continued in one bottle. 50
taste removing blue tablets, each containing 0.1 g of mixture of 85% sodium chloride and 15% anhydrous
sodium thiosulphate, are contained in another bottle. The bottles should be kept tightly corked when not
in use and tablets should only be taken out of the bottle when actually required for sterilizing water. One
sterilizing tablet added to full water bottle ensures 4 ppm of chlorine in water. A minimum of 30 min contact
is necessary to ensure sterilization. The longer the period of contact better it is. The water bottle should
be well shaken 2-3 times during this period. One taste removing tablets may be added to the bottle and
the bottle well shaken before consumption of water but not earlier than 30 min after the addition of white
tablets.
(ii) When the ‘Individual Water Sterilizing Outfit, is not available, stock solution of WSP should be made by

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adding number of scoopful of water sterilizing powder as indicated by the Horrock’s test to water contained
in a bottle. For super chlorination, add one scoopful more WSP than indicated by Horrock’s test to the stock
solution. If the Horrock’s box is not available, fixed dose of 4 scoopful of WSP should be used to make
stock solution in water bottle. One scoopful of this stock solution should be added to each water bottle. At
least 30 min contact should be allowed before consumption. For dechlorination after super chlorination,
one scoopful of taste removing solution made by adding 4 TRT to the water bottle should be added to
each water bottle before consuming water.
(iii) Aquatabs.
Recently, aquatabs (Bayer) have been included in the hygiene chemicals. The active ingredient is Sodium
Dichloroisocyanurate (Na DCC) (3.5 mg tablet). One tablet is added to the water bottle of capacity 1 litre
and takes 30 minutes for the effect to build up. These tablets release a limited amount of chlorine in
the form of HOCl depending upon the level of contamination and hence always maintain a basic level of
residual chlorine in water.

5.38 Summary of Field Appliances.

(a) Water Bottle.
Its capacity is 1.14 litres.
(b) Chagul.
It is a bottle shaped receptacle of 4.5 or 9 litres capacity. It should be well soaked before use. Water in Chagul
is cooled by evaporation from its surface.
(c) Pakhal.
It is a zinc or zinc coated, metal tank with a large brass screw on cover. It is oblong in shape and is covered
with felt, which can be soaked for cooling the contents. Over the felt is a stout net and it is designed essentially
for pack transport. Mule pakhal (cistern mule) has about 30 litres capacity. Camel pakhal (cistern camel) has
a capacity of about 60 litres.
(d) Canvas Cisterns (225 and 450 litres).
These are cubical shaped with a lid and a tube delivery pipe. The cistern is usually supported in a collapsible
wooden iron frame. They are most useful for small units and detachments.
(e) Iron Cistern (1,820 litres).
This is a normal size water cistern for small storage made of 5 sections of standard square steel plates.
Larger sizes are made by adding more standard sections as required. Such tanks are usually painted red for
preservation. For cooling, they should be painted white or heavily white washed on the outside.
(f) Galvanized Cistern (225 and 450 litres).
These are cubical cisterns, which may or may not be fitted with a lid and / or a draw-off cock.
(g) Canvas Cistern (6,000 litres).
These are used for water points in the field. In dusty areas, covers should be provided. The normal method is
to use these tanks in pairs, one for sedimentation and the second for chlorination of clarified water siphoned
from the first. A third one may be used either for storing chlorinated water pending delivery or for initial gross
sedimentation before flocculation is carried out in the second sedimentation tank.
(h) Circular Canvas Cisterns.
These are of 5,500 litres capacity with a kapok collar which rises as the cistern fills.
(j) Water Tank Truck.
This consists of a 9,900 litres (working capacity 9,000 litres) tank mounted on a standard motor truck, provided
with a mechanical force pump driven from the truck engine. Water is clarified by means of mechanical filter
(Meta or stellar filters) aided by alum or keiselguhr coagulant. Disinfection is carried out by chlorination or super
chlorination.

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5.39 Estimation of Yield.

(a) Well (circular) - depth of water in meters x square of diameter x 785 = liters of water in the well.
Well (rectangular) - depth of water x length x breadth x 1000 = liters of water in the well.
Yield per hour = Lower the water level rapidly by pumping out; measure water level from top of the well in meters;
after a few measured hours, measure the water level from the top again: difference in two levels x square of
diameter x 785 divided by the number of hours= yield of water in liters per hour. This multiplied by 24 will show
the output of water per day.
(b) Stream.
Select 100 m length where the channel is uniform and where there are no eddies. Take the average breadth
and depth in three or four places. Drop a chip of wood and calculate time (in seconds) it takes to travel a
measured distance which when divided by time (in seconds) gives the surface velocity per second. 4 / 5 of this
is the mean velocity of the stream. This multiplied by the sectional area in meters x 1000 gives the yield per
second in liters.
The scales of water consumption for the Armed Forces personnel are given in Table 5.13 below.
Table 5.13 : Scale of Water Consumption (Liters Per Head Per Day)
Married Single Military Area
With Water Without Add for Garden
Class No. of Servants Borne Water Borne Conservancy
Family and No. Servant Sanitation Sanitation (L / day)
Members Families
Plains Hills Plains Hills
225 litres per
married officer
Officers Mil / Civilians 5 5 1 1 225 160 160 90 and 135 litres
per single
officer
115 litres per
JCO and equivalent in married JCO
5 - 1 - 205 145 145 80
Navy & Airforce and 70 litres
per single JCO
45 litres each
NCO & equivalent 5 - 1 - 205 145 145 80 for married &
single
OR & equivalent 5 - 1 - 205 145 145 80 -
Followers (Non-
5 - 1 - 205 145 145 80 -
combatants)
Regimental shops - - - - 7 45 45 45 -
Wet canteen - - - - 1135 910 910 680 -
Animals - - - - - - - - 70
Labour employed in
- - 1 - 45 15 35 15 -
depots / installations
Office / schools with
- - 1 - 45 25 25 15 -
water borne sanitation

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5.40 Eqpt which should be Available at the level of OC SHO / FHO.

(a) pH Meter.
The pH meter plays a crucial role in safeguarding public health through its ability to accurately measure the
acidity or alkalinity of various substances, including water and bodily fluids. In public health, pH meters are
indispensable tools for monitoring the quality of drinking water, ensuring it meets the required standards for
safe consumption. By testing the pH levels, health officials can identify potential contaminants or issues such
as high acidity that may indicate corrosion of pipes, which can lead to harmful metal leaching into the water
supply.
(b) TDS Meter.
The Total Dissolved Solids (TDS) meter plays a vital role in public health by providing valuable insights into the
quality of water, which is essential for various purposes, including drinking, agriculture and industrial use. In
public health, TDS meters are particularly important for assessing the mineral content of drinking water sources.
High TDS levels can indicate the presence of dissolved substances such as salts, minerals, metals and organic
matter, some of which may pose health risks if present in excessive amounts. Monitoring TDS levels helps in
identifying potential contaminants, such as lead, arsenic or nitrates, that can have adverse effects on human
health. By regularly testing water sources with TDS meters, public health officials can ensure that drinking water
meets the required quality standards, minimizing the risk of waterborne diseases and other health hazards.
Additionally, TDS meters are used in wastewater treatment plants to monitor the effectiveness of purification
processes, ensuring that discharged water is safe for the environment and public health. Overall, the role of TDS
meters in public health is crucial for maintaining safe and healthy water supplies for communities.
(c) Chloroscope.
The Chloroscope is a device utilized for assessing residual chlorine levels in drinking water. In this procedure,
a sample of chlorinated water is collected in a glass tube following the designated contact duration. A specific
amount of chemical reagent is then introduced to the sample. The resulting coloration is observed after a
5-minute interval. Typically, the presence of chlorine (whether combined or free) is indicated by the formation
of a yellow hue. A deeper yellow color corresponds to a higher residual chlorine concentration. Comparing the
color in the glass tube with standard color chart allows for the determination of the residual chlorine level. This
method is straightforward, requiring minimal technical skill or time.
(d) Nephelometer.
The Nephelometer serves a significant role in public health by providing a means to measure the turbidity of
water, which is a key indicator of water quality. Turbidity refers to the cloudiness or haziness of a fluid caused by
suspended particles, such as sediment, silt or organic matter. These are essential tools for monitoring drinking
water sources and ensuring their cleanliness and safety for consumption. High levels of turbidity can indicate the
presence of pathogens like bacteria, viruses and parasites, as well as other contaminants that may be harmful
to human health. Turbidity measurements are also crucial in monitoring the effectiveness of water treatment
processes, such as filtration and disinfection. Properly functioning nephelometers help in ensuring that these
treatment methods are efficiently removing suspended particles and pathogens from the water supply. Moreover,
nephelometers are used in environmental monitoring to assess the impact of human activities on water bodies.
For instance, they are employed to measure the turbidity of rivers, lakes and coastal waters, providing valuable
data for managing and protecting these ecosystems.
(e) Field Water Test Vials.
Field water test vials are essential tools used in various industries, including environmental monitoring, public
health and water treatment. These vials are designed to carry out on-site assessments of water quality quickly
and conveniently. They come in a variety of types, each containing specific reagents or indicators tailored to
detect various parameters such as pH, chlorine, nitrates and more. Field water test vials are portable and easy
to use, making them ideal for fieldwork, disaster response and routine water quality checks in remote areas or
locations lacking sophisticated laboratory facilities. With simple instructions, users can add a water sample to
the vial, introduce the appropriate reagent and observe the color change or reaction that indicates the presence
and concentration of the target parameter. This rapid testing capability allows for immediate assessment of water
safety, enabling timely decisions to be made regarding treatment, consumption advisories or further investigation.

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(f) Life Straw Bottles.

LifeStraw bottles are innovative and life-saving tools designed to provide safe drinking water in various
environments, particularly in situations where clean water access is limited or compromised. These bottles
are equipped with advanced filtration technology that can remove bacteria, parasites, microplastics and other
contaminants from water, making it safe for consumption. The built-in filter works by trapping harmful particles
and microbes while allowing clean water to pass through, offering a convenient and reliable solution for travelers,
hikers, emergency responders and communities facing water scarcity. LifeStraw bottles are not only portable and
easy to use but also environmentally friendly, reducing the need for single-use plastic bottles. Their durability and
effectiveness make them invaluable for outdoor adventures, disaster relief efforts and everyday use in regions
where waterborne illnesses are prevalent. By providing a simple yet powerful way to access clean water on the
go, LifeStraw bottles play a crucial role in promoting public health, hydration and sustainability worldwide.

Suggested Reading.
1. Sharad K. Jain, Pushpendra K. Agarwal, Vijay P. Singh, Vijay P. Singh. Hydrology and Water Resources of India.
1st ed. Springer Dordrecht; 2007.
2. Ministry of Jal Skahti, Department of Drinking Water and Sanitation | GoI [Internet]. Mdws.gov.in. 2024 [Accessed
2024 Apr 7]. Available from: https: // www.mdws.gov.in /
3. Water quality standards. Ministry of Environment, Forest and Climate Change (MoEFCC), Central Pollution Control
Board (CPCB) [Internet], [Accessed on 2024 Apr 7]. Available from: https: // cpcb.nic.in / wqstandards /
4. WHO. Guidelines for drinking-water quality: fourth edition [Internet]. WHO. 2022 p. 1–614. Available from:
https: // iris.who.int / bitstream / handle / 10665 / 352532 / 9789240045064-eng.pdf?sequence=1
5. WHO, Guidelines for drinking-water quality: Small Water Supplies [Internet]. 2024 p. 1–220. Available from:
https: // iris.who.int / bitstream / handle / 10665 / 375822 / 9789240088740-eng.pdf?sequence=1
6. Bureau of Indian Standards (BIS), Indian Standard Drinking Water — Specification Second Revision [Internet].
CPCB. 2012 p. 1–16. Available from: https: // cpcb.nic.in / wqm / BIS_Drinking_Water_Specification.pdf
n

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 CLIMATE AND HEALTH

Chapter
VI
CLIMATE AND HEALTH

6.1 Introduction.
Climate has a profound influence on health, incidence of diseases, their epidemiology and endemicity. Man
gets acclimatized to a particular environment by the complex physiological and psychological processes through
prolonged interplay of external stimuli and homeostatic mechanisms. Individual de-acclimatization rapidly occurs on
cessation of acclimatizing stimuli. Both acclimatization and de-acclimatization show individual variations according
to the individual phenotypic plasticity and the range of homeostatic capacity. For instance, a European may be
more physically fit than an Amazonian Indian, yet the latter proves to be better adjusted to hot and humid tropical
climate of Amazon basin and many prevalent diseases of that zone.
Another unique feature of human ability to adapt in a particular environment is intelligence, which endows humans
to apply their skills to protect themselves from the effects of adverse environmental conditions by use of artificial
means.
The environment comprises of physical, biological and social aspects. Physical environment constitutes the varying
ranges of natural factors like atmosphere, climate, soil, topographical features and so on. It also includes artificial
innovations as aids to adaptation to natural environment e.g., housing, clothing, air conditioning, artificial heating,
cooling and so on. Social factors apart from biological factors like pathogenic organisms, disease producing
ectoparasites, arthropod vectors and animal reservoirs of infections are significantly influenced by climatic factors
which exert their influence on health in multiple ways.
The subject of biometeorology, an interdisciplinary off-shoot of ‘ecology’ and ‘meteorology’ concerns itself with
the effect of physical and chemical factors of atmospheric environment on the ecological aspects of living things
on one hand and their influence on biological systems of living beings on the other. ‘Biological success’ of an
organism including man, depends on its adaptability to such influences.
ln view of the above, a study of the interrelationship between Climate and Health assumes special significance,
particularly in the Armed Forces because of frequent movement of troops from one climatic zone to other at
short notice or due to induction of troops into hostile climatic zones for prolonged durations. On both occasions,
careful health planning is an inescapable need, since more often such personnel are not well acclimatized to
the new environment.

6.2 The Static Atmosphere.

An envelope of atmosphere surrounds the earth for about 100 km above it. This envelope has three zones; the innermost
extending up to 11 km is called ‘troposphere’, the middle zone from 11–50 km is the ‘stratosphere’, then from
50-85 km is the Mesosphere and the outermost is the ‘Thermosphere’ which ranges from 85-800 km. The narrow belt
between the troposphere and the stratosphere is called the ‘tropopause’, which almost completely separates these two
zones having contrasting characteristics as described below.

6.3 Physics of Atmosphere.

Temperature in the troposphere decreases with altitude, at a rough rate of 0.65°C per 100 m until it goes down to
about -55°C. Beyond the tropopause and up to 32 km, it is almost constant with a gradual rise thereafter, so that at
altitude between 50 to 60 km it is more than that at the sea level. The troposphere contains 80% of the total bulk of
the air and almost all the moisture and terrestrial dust of the atmosphere. The tropopause does not permit dispersion
of air from troposphere into stratosphere. In the troposphere there are zones of eddies and turbulences which produce
vertical air currents causing cloud formation and rainfall. The stratosphere is very calm and clouds do not rise above
tropopause. All ultraviolet radiation below 290 nm (2,900 A°) is absorbed by ozone above the tropopause which also
minimises electrical storms that are common in the stratosphere. The tropopause thus acts as an insulating blanket

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 ENVIRONMENTS SPECIFIC TO ARMED FORCES: HEALTH HAZARDS, DISEASES AND PREVENTION

and barrier which keeps the envelope of gaseous troposphere confined within its bounds without being disturbed by
cosmic events, harmful radiation and electric storms of outer space or getting lost in the void of outer space.

6.4 Composition of Air.

As we ascend, air becomes rarer and rarer and the air pressure progressively decreases, faster at lower heights and
slower at the higher regions. At 5,500 m altitude (18,000 ft) it is half that of sea level; at 50 km height it is 1/1,000
that at sea level and at 100 km it is 1/1,00,000 that at sea-level. Half of the quantity of total air in the atmosphere
is below 5.8 km and 80% below 11 km. Life ceases instantaneously above 10,000 m. Atmosphere contains air, water
vapor, radiation and terrestrial dust.
(a) Gases.
The air in its dry state has 78% nitrogen and 21% oxygen; the remaining 01% is hydrogen, CO2, ozone and a mixture
of inert gases such as argon, neon, krypton, xenon and radon. Oxygen is the ‘vital’ constituent of atmosphere,
as without it no life could exist on earth. However, without the dilutional effect of nitrogen, pure oxygen would
oxidize and eradicate all living matter. Nitrogen is also utilized by plants to build up their cellular structure. CO2
emitted in the atmosphere by all living beings as metabolic waste is necessary for plant metabolism. Ozone is
mostly concentrated in the upper atmosphere and acts as an umbrella against the dangerous radioactive and
photochemical solar radiation.
(b) Water Vapour.
Atmospheric water which exists in vapour form, also condenses in the form of rain, snow and ice. Extremely dry
air is not suitable for respiration as it interferes in the normal Oxygen - CO2 exchange in lungs by desiccating
alveolar epithelium. Moreover, without water vapour, rains would not be possible and no life would exist. The
plants which constitute the fundamental nutrient of all living beings would not be able to draw their nutrition
from the earth’s crust without water acting as a solvent. All living beings contain approximately 70% water by
weight.
(c) Radiation Energy.
Both terrestrial and extra-terrestrial sources (sun, cosmic rays) contribute to radiation energy around the earth
and ranges from the shortest radioactive waves, ten-thousandth of a micrometre to long radio waves of one
meter length. Atmosphere is, however, impenetrable to a vast majority of them due to ozone in the outer
atmosphere and dust and water vapor in the inner atmosphere. The harmful radioactive and photochemical short
ultraviolet rays below 2,900 A° (290 nm) are filtered out by ozone and oxygen while the thermal waves above
30,000 A° (3000 nm) are absorbed by water vapor and terrestrial dust in the atmosphere. Only ultra-violet
radiation between 2900 and 3,900 A°, the visible spectrum from 3,900 to 9,500 A° and some of the infra-red
rays up to 30,000 A° penetrate the astrosphere. Terrestrial dust and water vapor also scatter the radiation.
Photochemical, thermal and luminant effects on biological organisms can be produced by solar, terrestrial,
celestial and ambient radiation. Photochemical action enables plants to anabolize their carbohydrate reservoir
out of carbon and water absorbed through leaves and roots, warmth required for all vital and metabolic activities
of living things is provided by long wave solar radiation and illumination by the middle spectrum.

6.5 The Dynamic Atmosphere.

The atmospheric dynamism creates weathers and climates, breeze, gales and storms, rains, snow and hail. The
meteorological factors conferring dynamism are varying atmospheric temperature, pressure, humidity and its
condensation in rainfall.
(a) Fundamentally, air is heated mainly by radiation from the earth which acquires it from solar radiation.
Although little of the solar radiation is directly absorbed by the air, the thermal stock of the earth’s surroundings
depends upon its intensity and duration.
(b) Heated air next to the earth rises up and the low-pressure pockets created thereby are filled in by the cooler
air rushing in from the surroundings. Vertical and horizontal air movements are thus created producing breeze,
gale and storms. Atmospheric pressure and temperature profoundly affect atmospheric movements. Variations
in these meteorological factors result in cyclones or depressions, in low pressure systems or anticyclones in
high pressure systems. The atmospheric pressure depends upon altitude of the place, the temperature of the
air and the amount of moisture it contains.

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(c) Water has a higher specific heat than the earth’s crust. Therefore, oceans absorb more heat from solar
radiation, retain it longer and release it more slowly than the earth. The temperature during the day is, therefore,
always higher on land than in the oceans. This keeps a difference in temperature on land and sea and produces
air movements from sea towards land and vice versa.
(d) The moisture laden winds from oceans blowing towards land subsequently rise up and form clouds which
condense as rain. Earth’s rotation around its axis gives winds their horizontal directions. Clouds, rain, hailstones,
snow, fog, mist and dew are all the different gradations of condensation of atmospheric moisture when the
moisture laden air is cooled. Its contact with the cooled earth’s surface produces mists, while its adiabatic
cooling below dew point, high up in the troposphere forms clouds. Air cools down about 1°C with each 100 m
of ascent. The mass of clouds depends upon the amount of moisture in the air and fall in temperature. As the
condensation in the cloud further increases, discrete drops of water begin to form and gradually increase in size
by coalescence.
(e) When the condensed particles within the clouds are violently pushed up and down by strong convection
currents, each droplet abruptly breaks up into a number of tiny drops. Each of this, immediately collects more
moisture until each in turn attains a diameter of 5.5 mm and again splits up into minute particles. This process
repeats itself a number of times. Electric energy is released when droplets split. They become positively charged
while the air is negatively charged. The tremendous difference of electric potential thus produced results in
flashes of lightning and peals of thunder.
(f) Hail is usually produced due to several factors. Some of these are: freezing level altitude below 3,400 meters,
dry air moving into strong thunderstorms and cloud elevation should be 6,100 meters and above due to very strong
upward convection current. Snow is formed when water vapor freezes directly into solid flakes without having gone
through the intermediate state of water drops.

6.6 Weather, Climate and Seasons.

(a) Weather.
The results of dynamic meteorological events like low or high barometric pressure waves, gales, storms, clouds,
rainfalls, hailstorms and snowfall typify the weather of a place. The fundamentals which determine these events
at a place, are the meteorological factors and the topographical factors. The meteorological factors are the
intensity and duration of solar radiation, ambient temperature, air movement and the atmospheric humidity.
The topographical factors are geographical position in the continent, altitude and latitude, geophysical features,
distance from oceans and the presence and direction of ocean currents. Each of the meteorological factors
modifies all others and all are influenced by the topographical features. The overall results of the combination of
all these factors over a definite period constitute weather. Its effect on humans depends not upon each individual
factor but upon the resultant combination of all of them and the final effect on human sensation is produced by
the most dominant of meteorological factors. Thus, weather is described as ‘warm’, ‘chilly’, ‘rainy’ or ‘just fine’,
‘lousy’ or ‘miserable’. These adjectives describe the human sensations created by particular weather condition
rather than weathers itself or the meteorological events.
(b) Climate.
Continuous confluence of weather events over long periods constitute climate. Weather is thus a single event in
the series of events, which make up the climate. The character of climate is determined by the most frequently
occurring or most prolonged weather events. It is, therefore, described in fewer terms than weather and the
description is more related to geographical description of places where the particular type of weather prevails
or in the degree of thermal sensation. Thus, we describe climates as ‘tropical’, ‘temperate’, ‘insular’, ‘maritime’
or ‘equable’, ‘continental’ or ‘extreme’, ‘mountain climate’ or ‘high altitude climate’ or ‘just hot or cold climate’.
Sometimes, the final descriptive terms of weather are also applied to climates. However, in respect of all these
descriptive terms of weather and climate, the final feeling of any weather or climate is as perceived by humans,
referable to thermal sensation as hot or cold, necessitating physiological adjustment.
(c) Season.
Seasons are cyclically recurring sets of weather conditions during a particular period each year, in specific order
in particular geographical areas of the world. The seasons are caused mainly due to the 23½° tilt of earth’s axis
to the orbit of its revolution around the sun. Seasonal variations occur more markedly as the latitude increases

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especially up to 66½° latitude. After this, the variation decreases just as it does below 23½° latitude. The
seasonal variations are widest between 20° to 50° especially in the Northern Hemisphere; in the Southern
Hemisphere the effect of oceans narrows down the variations. The seasons and seasonal variations are influenced
by factors which influence weather and climate described above.

6.7 Adaptation to External Environment.

(a) Internal Environment.
External environment described above surrounds all living organisms. Cells, tissues and organs constituting the
organism itself remain bathed in ‘internal environment’, the ‘milieu interieur’ of Claud Bernard. Heterogeneous
raw materials drawn from the external environment are transformed into homogenous biochemical solutions of the
internal environment. Preservation of life, structure and function of cells and maintenance of health of tissues,
organs and the organism depend upon the maintenance of constancy of physical and chemical properties of the
internal environment. Its qualitative and quantitative normality must be maintained within very narrow limits in
the face of the widely ranging external environment. However, the ‘state of normality’ is not a fixed state but a
flexible state; wide deviations from the extreme limits of the flexible normality herald disease conditions unless
resisted by the body. The precision regulation system which enables the body to resist this and maintain internal
environment within limits of normality in the face of external environmental variation is called ‘HOMEOSTASIS’.
(b) Homeostasis.
Mechanisms of homeostasis are the constantly exercised, automatically functioning physiological processes
occurring as chain reactions from a series of stimuli and responses. Response to external stimuli induced by
environmental changes is the initiator of homeostatic mechanism. These initial external stimuli are sensed by
the peripheral receptors like cutaneous nerve endings of special sense organs. Internal stimuli are the minute
deviations from normality in internal environment sensed by the autonomous nerve centres. Further processes
concerned with homeostatic regulation are the physiological functions mainly proceeding through nervous and
endocrine channels. The chain of reactions is channeled through the cortical perceptual centers, subcortical
autonomous centers, endocrine system and the medullary and spinal reflex centers to the cardiovascular,
respiratory, excretory, perspiratory, volitional and other functional systems and organs.
The complexity of the process in which the external environmental changes set the homeostatic mechanisms
in motion can be illustrated by an example; when external temperature increases, the immediate need of more
heat dissipation from the body is fulfilled by increased production and evaporation of sweat, which causes the
body to lose water. In order to conserve water, the kidneys through the hypothalamic and pituitary axis produces
concentrated urine, thereby not compromising the excretion of metabolic waste, but reducing the volume of water
lost. Concurrently, a feeling of thirst for increasing water intake is created and the pH concentration of body
fluids is also maintained. Homeostatic mechanism thus keeps the body temperature constant, conserves water
and electrolytes, keeps the pH concentration of body fluids constant, excretes metabolic wastes and creates
thirst which acts as stimulus for the intake of water. This is an over simplified scheme. The internal chain of
reactions is much more complex to keep the physical and chemical properties of internal environment within
normal limits under widely varying extremes of atmospheric, climatic and other environmental conditions.
The range of fluctuations in the internal normality tolerated by an organism determines the state of its adaptation.
This range is determined by the continued efficiency of homeostasis. Constantly exercised successful homeostatic
mechanisms for prolonged periods increases this range of tolerance and confers upon the individual the power
of adaptation resulting in acclimatization. Progressive adaptation of a race is determined by a development of
the wider range of tolerance by its members. This is hereditarily transmissible. Homeostasis is thus the basis
of the acquired and genetic adaptability to external environs and finally that of the biological fitness of the race
under adverse and widely varying environmental conditions.
(c) Acclimatization.
Acclimatization is the process by which adaptability against the vagaries and extremes of external environs is
established in response to prolonged exposure to adverse conditions. All living beings have some capacity of
acclimatization, but man is unique as regards the range of homeostasis and power of final adaptability. Although
humans have some natural disadvantages against climatic variability as compared with other living beings,
they have well developed acarine sweat glands and a highly flexible respiratory and cardiovascular system. The
range of tolerance and the biological flexibility are much more profoundly developed in humans than in animals

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and confer upon the human race the superior power of adaptability. Owing to this higher power of adaptation
humans have surpassed all other animals in taking advantage of varying climatic conditions. Thus, in many
uncongenial parts of the earth some races and tribes live and thrive, not because that climate is best suited
to them, but because over long periods of time, they have gradually evolved successfully to adapt to these
particular environments. For example, the Eskimo successfully maintains his race in the Arctic Circle, the Dyak
on the Equator, the Tibetan at high attitude and Arab in the arid Sahara. This does not mean that these races
would not thrive better in other climatic conditions. The velocity of the breeze, rainfall, sunshine, cosmic rays and
even snowfalls and hailstorms within limits have invigorating effects of life. Climatic dynamism activates human
physiological dynamism, produces beneficial effects on human activity and gives rise to biological and intellectual
evolution. A dynamic climate and human adaptability are the two most important factors leading to human
progress. Stagnant and static climates have retarded human evolution. Climate as well as geography determine,
to a large extent, the culture, mode of living, temperature, beliefs, dietary habits, customs and manners, power,
endurance and functional ability in the evolution of human races, clans, communities and nations.
Individual acclimatization is a complex physiological and psychological active process of adaptation through
prolonged continuous successful functioning of the homeostatic mechanisms. Individual acclimatization is,
however not a permanently acquired state; de-acclimatization rapidly occurs by cessation of acclimatizing stimuli.
Both acclimatization and the de-acclimatization show individual variations according to individual phenotypic
plasticity and range of system variability and neither have a correlation with the physical fitness in its ordinary
sense. A medically or physically fit person does not necessarily adjust himself better to adverse climatic conditions
than the others. However, medical and physical fitness, nutritional state, skin color, body surface area, tolerance
to physical activity, state of cardiovascular system, motivation, mental attitude and in general the physical and
mental health are important factors for successful and rapid acclimatization. They enable the homeostatic
mechanisms to function continuously and stretch maximally with the physiological process breaking down under
the stress of climatic extremes.
Another unique feature determining human adaptation to environment is that while all other organisms must be
entirely dependent upon natural biological endowments for adaptation to environment, humans have, in addition
to these qualities, ‘intelligence’ which enables them to profoundly modify their immediate environment. In the
event of a vast change in environmental conditions beyond their biological capacity, animals have to migrate to
more congenial environs to which they either adapt or perish: but humans can survive and prosper by artificially
changing their environs through technical innovations such as clothing, shelter, environmental conditioning and
dietetic variations, at their will.
(d) Biometeorology.
This is the recently evolved branch of science, which studies the effects of climate on organisms. The branch of
biology which deals with the inter-relationship of living organisms with their environment, inclusive of earth, water,
atmosphere, radiation, plants and other living organisms is called ‘ecology’. Atmosphere is but one component
of the total environment on which existence of whole panorama of nature depends. The science concerned
with atmosphere, weather, climate and the interrelationship between the components of atmosphere is called
‘meteorology’. Biometeorology is an interdisciplinary offshoot formed by the fusion of ‘ecology’ and ‘meteorology’
and concerns itself with the effects of physical and chemical factors of atmospheric environment on ecology of
living beings, plants, animals and humans. It conjoins biology, particularly ecology and meteorology in study of the
system in which organisms and atmospheric component of the total environment interact. Favourable reactions
maintain the internal normality and lead to adaptation and biological success of the organisms; unfavourable
reactions lead to internal imbalance, non-adaptation of the organism and its biological defeat leading to disease
processes. Biometeorology has three sub-divisions, the plant, animal and human biometeorology.
By virtue of the unique power of biological adaptability and intellectual capability of human race, human
biometeorology is a specially developed, highly specialized branch of biometeorology and not merely an extension
of animal biometeorology. It has two aspects to study; the first aspect is biological events, variations and
adaptability in response to external variations; the second aspect is human ability to modify the environs and
study of the innovations which enables them to affect such modifications. The first aspect embraces study on
inherent adaptability and acquired power of acclimatization: the beneficial effects of climate and tolerance to
variations in climatic conditions, the study of comfort zones for various human functions and activities; the
deleterious effects of their vagaries and extremes on unacclimatized or nonadaptable individuals; prevention of
such effects by biological measures and treatment of casualties occurring due to excessive exposure to such

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extremes of vagaries. The second aspect embraces study of influence and application of man-made artificial
innovations such as various types of clothing, structures, shelters, thermal and air conditioning and the study of
effects of artificially created atmosphere as in industrial environs or in submarines and satellites. Its extension
in human pathology is to study the influence of atmosphere, weather and climates in causing progression or
regression of various human ailments or what is called ‘Meteor tropism of diseases’ and in the fields of climatic
therapy for various diseases.

6.8 Influence of Climate on Human Health.

The beneficial effects on health, well-being and progress of mankind derived from acclimatization have been mentioned
in the preceding paragraphs. Even after acclimatization the physical, physiological, psychological and functional abilities
of human beings are maximum within a certain range of atmospheric and climate conditions. Beyond that range is
a zone in which efficient homeostatic mechanisms maintain the ‘physical and psychological’ comforts and functional
ability at its optimum level. Further beyond that lies a zone within which the physical and psychological comforts may
be strained without disturbing the functional efficiency or internal ‘steady state’ by homeostatic mechanisms working
at their maximum range. However, when this range is also crossed, these homeostatic mechanisms may be put under
stress, manifesting the stress-syndromes and diseases. Thus, there are comfort zones, the limits of tolerance, range of
homeostatic extremes and the biological extremes. Limits of these zones may vary, within limits, in different individuals.
A process of acclimatization can stretch them further and conditions can be modified by artificial means like clothing,
accommodation and dietary and environmental conditioning to the individual and their functions.
Climate determines the energy level of humans in a given environment. In tropical climate, to counteract the difficulty
in heat loss, man has adopted a lower rate of heat production. Vital capacity in healthy young adults living near the
equator is only a little more than half the vital capacity in similar individuals living in a temperate climate. A definite
inverse relationship between tissue combustion and external temperature exists. Sub-tropical and temperate climates
are best suited to man’s fullest efficiency as moderate variations maintain the vigor of developmental progression.
In the tropics, lowered general tissue vitality from sluggish cellular combustion keeps human development quiescent.
Though much of this insalubrity is due to poor environmental hygiene, yet the climatic environment also plays an
important role by influencing physiological functions of healthy persons. It is however, not easy to analyze the effects
of atmospheric factors, daily weather fluctuations or climate in isolation.

6.9 Adverse Effects.

Climate adversely influences human health directly through its vagaries and extremes and indirectly by influencing
metabolism or defensive mechanism and remotely through environmental modification.
(a) Causes.
The direct adverse effects are caused when humans are exposed to climatic extremes and if the homeostatic
mechanisms fail, either due to rapidity or severity of or prolonged exposure or non-adaptability to the extremes
encountered or due to physiological dysfunction. This produces conditions like heatstroke, heat exhaustion, cold
injuries, general hypothermia and high-altitude hypoxia. Being of special importance to Armed Forces personnel, such
direct effects on health are described in detail in the subsequent paragraphs. The fact that the while adverse effects
of extremes of climate is apparently given the place of importance, does not in any way belittle the importance of
indirect and remote influences. In some instances, described below, such influences are even more important and
numerous but less obvious than the direct influences. Incidence of infection and illness, devitalization, functional
deficiency or inefficiency caused by them are often commoner than those due to the direct influences.
(b) The direct effects are caused either through endogenous or through exogenous channels. They are termed
the ‘Meteor tropism of diseases’.
(i) The endogenous channel influences human physiology thereby either favouring the · ecology of
invading pathogenic microorganisms or disturbing human metabolism and immune response. Thus, some
diseases more commonly occur during the particular seasons or under particular weather conditions or in
areas with particular climatic type.
(ii) The exogenous channel does not influence the human physiology but influences his biological
environment. For example, insect borne diseases occur during specific seasons when arthropods breed
and actively propagate the disease.
(c) The remote mode of causation of disease is through changes caused in the external environment which

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affects human health. Thus, prolonged paucity of water in areas with low rainfall may be associated with
incorrect household water storage practice leading to mosquito breeding and resulting in outbreak of mosquito
borne diseases like Dengue, Zika Virus disease etc. Meteorological changes also bring about the evolution and
devolution of disease either by direct influence on the pathogenic organisms and epidemiological dynamism or
indirectly through change in the socio-economic and cultural patterns of the community.

6.10 Mechanism.
Climate exerts influence on the body at three levels. The first ‘physical’ level is at the surface where general homeostatic
mechanisms are not activated and only local tissue reaction is effective. The local effects of direct solar radiation on the
skin and the eyes are examples. The second ‘Physico­physiological’ level is at the deeper tissues where local homeostatic
mechanisms and the response of the cardiovascular system to counteract the effects of climatic extremes need to be
active; the results of their failure are manifested by frostbite, trench-foot and chilblain. The third, the ‘physiological’
level is where the higher degree of homeostatic mechanisms have to be active in order to maintain the steady state of
internal cellular and tissue metabolism within tolerable limits; heat stroke, heat exhaustion, pathological hypothermia
and effects of high-altitude hypoxia are the examples.
Three types of reactions occur in response to exposure to climatic extremes. The first type occurs when homeostatic
mechanisms inadequately meet the challenge of climatic vagaries and extremes in an inadequately acclimatized
individual; the second type occurs when the homeostatic mechanisms are quite adequate but the external conditions
themselves are too severe or prolonged; the third type occurs when the homeostatic mechanisms fail, because they
are stretched beyond normal tolerable critical limits and the failure of ‘general adaptation’ mechanisms and general
collapse results. The pathogenesis of the effect of climatic extremes thus has three fundamental aetiologies: the
‘intrinsic’. corresponding to the first type of reaction; the second ‘extrinsic’ corresponds to the second type of reaction;
and the third ‘aetiology’ arises out of the combination of both the severity of extrinsic and inadequacy of intrinsic factors.

6.11 Description of Climates.

(a) Classification.
Climates are roughly classified into certain belts or zones arranged as per geographic latitudes. The five familiar
zones on either side of the equator are the tropical, sub-tropical, temperate, sub-arctic and arctic zones. Each
may be considerably modified by an insular, coastal or continental situation and by the altitude and longitude.
(b) Tropical.
The tropical belt lies between the tropics of Cancer and Capricorn at 23½° North and South of the equator
respectively. The characteristic tropical climate however occurs between 18° N and 15°S of the equator, but most
typically in a narrow belt 8° North and South of the equator. The temperature is rarely higher than 35°C and
usually ranges between 27°C and 32°C with remarkable diurnal and seasonal uniformity with a maximum mean
annual range of 5°C. The seasons are not classified according to temperature but according to rainfall which is
usually heavy, with daily rainfall in some parts. The atmospheric humidity is high (90 to 100%). Vegetations and
lower forms of animal life are well suited to this steamy hot-house atmosphere and grow and flourish luxuriantly.
Towards the fringe of this zone, seasons appear. Vegetation shows a tropical character. This type of climate exists
in India as far North as the foothill regions of the Eastern Himalayas.
(c) Subtropical.
The subtropical belt generally starts at 18°N and 15°S without any sharp geographical or meteorological dividing
line but each merging gradually into other and extending up to 35° in the Northern and 30° in the Southern
hemispheres. As the distance from the equator increases, the climate tends to become less tropical and gradually
assumes the characteristics of the subtropics. The subtropical climate shows greater variations between diurnal
maximum and minimum and between mean summer and mean winter temperature than the tropical climates.
The seasons are well marked with the seasonal climatic variations with varying relative lengths of days and
nights. The annual maximum temperature is considerably lower than in the tropics. Summer may be extremely hot
and winter may be quite cold with variable summer rainfall depending on the geographical location. Vegetation
shows grassy characteristics of the savanna, prairies and steppes.
(d) Desert.
Between 20° to 30° North and South of the equator, especially on the western side of the continent, there

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are extensive deserts with hot and dry climates. A dry bulb temperature of 45° is quite frequent and may also
often rise above 50°C. Humidity is less than 20% and there is practically no rainfall in these areas. Under such
climatic conditions, the body is directly heated by radiation, hot breeze and also to some extent by conduction.
Nights are cooler as the sky is generally clear. On the North-West shoulders of these deserts, the ‘Mediterranean
climates’ occur with mild summer and winter rainfall. These areas are the orchards of the world.
(e) Temperate.
Temperate climates prevail between 35° to 65° latitudes. The average daily temperature varies between 0°C to
10°C but the maximum temperature may at times go up to 20°C. Winds, gales and hurricanes, fog, mist and
rain are common and snow is also encountered. Summer and winter are of equal duration. The vegetation is
that of the deciduous type.
(f) Sub-arctic.
Sub-arctic climate lies between 50° to 70° where the summer is short and winter is very cold and long. The
average summer temperature ranges from 10°C to freezing point and often below freezing point. The winter
dry bulb temperature ranges between minus 10° and minus 35°C. Such climatic conditions are encountered
above the altitude of 2,500 m in the Western and 3,000 m in the Eastern Himalayas. The vegetation shows a
coniferouscharacter. In summers the melting snow gives rise to slushes.
(g) Arctic.
It has a very short summer and a very long, intensely cold gloomy winter. Temperature is always below freezing
point and may go down to minus 50° C. Coniferous forests are common on the Southern fringe, but beyond that
very scanty vegetation is seen. The snow is perpetual at higher latitudes (or altitudes) and there is no slush.
Such a climate is common above 4,000 m in the Eastern and 3,500 m in the Western Himalayas.

6.12 Climates in India.

India exhibits great diversity in its climate and weather, with heat and monsoon as the predominant features. During
first half of the year, temperature rises and during the second half it steadily decreases. Annual variation is small in
the extreme South and very high in the North. It is twice as great in Central India in comparison to Mumbai or Malabar
and is greatest in the most inland or drier tracts of Punjab and Rajasthan.
Although in some parts of upper India, winter, spring, summer and autumn seasons of the temperate zones can be
differentiated, alteration of summer, monsoon and winter seasons is the predominant character of seasons in India.
During winters, the general flow of air is from land to sea, hence it is a season of dry weather over nearly whole of India,
except in the southern Peninsulas and East, which often have rains at this time. This phenomenon causes winter from
December to February, summer from March to June, monsoons up to September and post South-westerly monsoons
with high atmospheric humidity, clouds and rain. However, these seasons do not uniformly occur in every part of India.
For example, in the South, (tropical areas) there is practically one season of continuous heat and humidity throughout
the year. In the hill stations in Himalayas and Western Ghats in the Peninsula, the climate is cooler and damper than
that of neighbouring plains. Himalayas have great annual vicissitudes of heat, cold, dryness and dampness. Climate
in southern India is comparatively equable, the summer season is shorter than in the northern parts and not so dry.
Hill stations in the Himalayas may be shrouded in clouds for days together in September with humidity of 100%, but
in November they are clear with low humidity.
In general, the Indian climate in different areas falls within one of the six broad groups viz. hot, hot- humid, equable
or insular, continental, hot-arid, cold-dry and cold-wet.
(a) Hot Humid.
A hot-humid environment is typified by the Dooars (alluvial floodplains), Arunachal and North-Eastern plains.
Annual rainfall is high, above 2,500 mm (maximum 2,500 mm and average 500 mm). ln Arunachal most of it
is during monsoons with a mean temperature of 30°C and relative humidity above 80% during the hot season
with winds going to gale strength during storms, cloudy to overcast skies during monsoon months and clear
to cloudy otherwise. The landscape is flat or undulatory having marshes and jungles with thorny bushes and
exuberant undergrowth infested with leeches, snakes, mosquitoes and other insects.
(b) Equable/Insular.
This climate prevails along the Eastern and Western coastal regions. This gradually merges into drier peninsular

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climates of the Deccan trap, which in turn gradually transforms up north into climates of the lndo-Gangetic
plains. Rainfall is moderate between 1,250 to 2,500 mm and the diurnal and seasonal range of temperature
is moderate in spring with wide variations in winter and summer.
(c) Continental.
Continental climate prevails over most of the sub-continent till about 20°N. As we approach the Indo-Gangetic
plain of Northern India, the seasonal variations become marked with variable wide ranges in diurnal and seasonal
temperature, except during monsoons. Rainfall varies between 600 mm in the Western regions to 2,500 mm in
the Eastern regions.
(d) Hot-arid.
This is present in the Punjab plains and Rajasthan deserts. Annual rainfall is not more than 500 mm, about
3/5th of which is during the monsoon period and the remainder during winter. The diurnal and seasonal range of
temperature is very wide. Temperature approaches to 0°C in winter and touches 50°C during summer months.
Relative humidity, except during rains, is not more than 30% with light to moderate breeze except during dust/
sandstorms which occur during monsoon and winter months. The landscape is flat, cultivated, interspersed with
rivers and canals. The day-time ground temperature is fairly high during summers. Mosquito breeding occurs
during and after rainy season. A similar climate with much milder winters is seen in the Deccan-trap, mainly in
the rain shadow areas or the Eastern side of the Western ghats.
(e) Cold-dry.
This climate is typical in the Western Himalayan region of Ladakh, 3,000 m above sea level. Very little rain/
snow fall occurs during summer and relative humidity is very low. Annual mean temperature varies between
5°C and minus 10°C. Minimum temperature in winter may touch minus 40°C. Winds are moderate to blizzard
strength with biting cold during winter months; hill tops and slopes at lower altitudes are covered with snow
during winter and perpetually above 5,000 m, otherwise the ground surface is loose, interspersed with rock
and slush, especially at lower heights. Ground is frozen hard during subzero temperatures of winter and permits
no forests. Vegetation is sparse except in the valleys. At these altitudes the unfiltered sunrays are exceptionally
strong and have a pronounced thermal effect on clear calm days.
(f) Cold-wet.
This climatic condition is encountered in Kashmir Valley and more so in Sikkim and Arunachal Pradesh. Minimum
temperature recorded is higher than that of cold dry climate of Ladakh, but humidity is much more. This high
humidity makes the cold season very unpleasant. There are abundant pine forests, particularly on the Southern
slopes. The ground is extremely slushy in summer as in the subarctic region when the snow melts. Cultivation
and vegetation are plentiful in the valleys.

6.13 Assessment of Environmental Conditions.

(a) Forecasting of Weather.
Weather forecasting helps us in planning for agricultural, navigational, aviation and other such activities which
are influenced by weather conditions. It is also desirable to know the usual weather and climate conditions
for planning prevention and control of diseases, predict the level of human efficiency, fore-assess the dangers
of climatic extremes and vagaries on men and plan for the prevention of their effects. Weather forecast and
knowledge of climate conditions at particular places in particular periods of the year are necessary for the Armed
Forces Medical Officers to advise the commanders on preventive aspects and also plan control and therapeutic
measures for diseases that occur during these conditions. They are also important from administrative, tactical
and operational points of view in the Armed Forces. Forecasting of weather and climate is done by correlating
the contemporary and antecedent meteorological observations with norms observed over considerably long
retrospective periods i.e., the ‘climatic habits’ of the place. The anticipated prospective meteorological trend
is thereby forecast. Difference between the predicted meteorological events and subsequently observed data
are correlated and finally by correcting the hypothesized trend, more and more accurate forecast is made for
subsequent periods thereafter. Forecasting is thus a syncytial process. The important data required to be collected
for weather forecasting are atmospheric temperature, atmospheric humidity (wet bulb reading), barometric
readings, directions and velocities of wind, presence, type and direction of movements of clouds, rainfall or
snowfall and solar radiation. Of these, atmospheric temperature and pressure are the most valuable data for

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weather forecasting. If speedy, exact and reliable information over a large area is available, a remarkable degree
of accuracy can be achieved in weather forecasting.
Environmental conditions are the product of primary solar radiation aided by terrestrial, celestial and ambient
secondary radiations, influenced and modified by atmospheric movements. Various instruments are used to
measure these meteorological factors; various modes of expressing the quantitative degree and qualitative types
of these factors have been evolved; and various scales expressing their effect on human sensation have been
innovated. These are briefly described in the succeeding paragraphs.
(b) Measurement of Solar Radiation.
(i) Campbell-Stokes Sunshine Recorder.
The number of hours of sunshine per
day is estimated by the Campbell-
Stokes Sunshine Recorder (Fig 6.1) in
which sunrays are brought to focus on
a charted paper by means of a glass
globe. The charred line gives the total
number of hours of sunshine.
In 1853, J. F. Campbell created the
first sunshine recorder, a pivotal tool
in measuring hours of bright sunshine
worldwide since the 1880s. The Campbell-
Stokes (CS) recorder, his invention,
leaves burn marks on specially treated
cards to measure direct solar radiation.
This method has greatly contributed to Fig 6.1 : Campbell Stokes Sunshine Recorder
our understanding of climate change. By
1962, the World Meteorological Organization (WMO) endorsed a standardized version, the Interim Reference
Sunshine Recorder (IRSR), ensuring consistent data collection across various locations globally.

(ii) Solar Radiation Thermometer.

The intensity of solar radiation is measured by a solar radiation thermometer (Fig 6.2). It is a black bulb
thermometer enclosed inside a glass shield, devoid of air. The difference between the black bulb reading
taken when exposed to sun rays and the maximum thermometer reading taken inside Stevenson Screen
denotes the intensity of solar radiation.

Fig 6.2 : Solar Radiation Thermometer

(iii) Pyranometer.
Pyranometer (Fig 6.3) is a type of actinometer (an instrument for measuring the intensity of radiation,
especially UV radiation) used to measure irradiance of solar energy within the preferred location as well
as flux density of solar radiation. The range of solar radiation extends between 300 & 2,800 nm.

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Fig 6.3 : Pyranometer & Its Components

The working principle of the pyranometer mainly depends on the difference in temperature measurement
between two surfaces like dark and clear. The solar radiation can be absorbed by the black surface on
the thermopile whereas the clear surface reproduces it, so less heat can be absorbed.
Pyranometer Applications.
(aa) The solar intensity data can be measured.
(ab) Climatological & Meteorological studies
(ac) Locations of the greenhouse can be established.
(ad) Expecting the requirements of insulation for building structures
(c) Black Globe Thermometer.
A black globe thermometer (Fig 6.4) records the mean radiant temperature of
the environment. It consists of a hollow copper globe of 15 cm diameter whose
outer surface is coated with Matt black paint, absorbing radiant heat from the
surroundings. If the place is windy, a black globe with 20 cm diameter should be
used. The sphere has circular opening through which a mercury thermometer is
inserted into the globe. Instrument is placed in the environment for about 20 min
and temperature is recorded. Mean Radiant Temperature (M.R.T.) is calculated
from the chart provided.
The Black Globe Thermometer (BGT), devised by H.M. Vernon in 1932, serves as a
tool to gauge the combined impact of air temperature and radiation on individuals.
It measures the black globe temperature (Tg), defined as the temperature at the
center of a black-colored, thin-walled sphere. The thermometer’s range spans
from 20 to 120 degrees Celsius, utilizing a non-
standardized temperature sensor. Within this range, it Fig 6.4 :
boasts an accuracy of ± 0.5 degrees Celsius between Black Globe Thermometer
20 and 50 degrees Celsius and ± 1 degree Celsius
beyond 50 degrees Celsius. Tg forms a crucial component in calculating the Mean
Radiant Temperature (MRT), in conjunction with air temperature, relative humidity
and air velocity. These factors collectively influence human responses to thermal
environments.
(d) Measurement of Atmospheric Temperature.
(i) Stevenson Screen.
To ensure free access of air to the dry and wet bulb thermometers and their
protection from sun and rain, the thermometers are mounted in a box of
approved pattern called ‘Stevenson Screen’ (Fig 6.5). It is a double louvered
box, whose internal dimensions are, length 76 cm, width 45 cm and height
48 cm. It has a double roof, the upper one projecting 5 cm beyond the sides
Fig 6.5 : Stevenson Screen of the box and sloping from front to back and has an open base. At the front

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is a hinged door opening downwards. The box is mounted on four posts with its door opening to the North
(South in the Southern hemisphere), at such a height that the bulbs of the thermometers are 138 cm
from the ground and at least 6 m away from buildings, large trees and other obstructions to the prevailing
wind. The thermometers are hung up inside the box so that they can be read without being touched and
moved and arranged in such a way that no bulb comes within three inches of the roof or sides.
(ii) Maximum Thermometer.
It records the highest temperature attained at any given time of observation. It is hung up almost horizontally
with the bulb end slightly lower than the other end. Maximum thermometer is a mercury thermometer, in
the capillary stem of which there is a small metal indicator which is pushed up along with the rising level
of mercury and fits tightly enough to remain behind when mercury recedes. Lower end of the indicator gives
the highest temperature reached during the period of observation. To reset the instrument, the indicator
is pulled down by means of a magnet until it comes in contact with the mercury.
The design of this thermometer incorporates a unique mechanism: a small air bubble isolates a portion of
mercury within the main column. Positioned horizontally, this setup allows the detached mercury to stay in
place while the rest of the column contracts, indicating the maximum temperature reached.
In essence, the maximum thermometer comprises a glass bulb linked to a slender capillary tube. Within the
bulb resides a liquid, typically mercury or colored alcohol. As temperatures rise, the liquid expands within the
bulb, causing the column in the capillary tube to move accordingly. Conversely, when temperatures decrease,
the liquid contracts, leaving a marker at the peak temperature attained. This ingenious design provides a
visual record of the maximum temperature experienced, eliminating the need for constant monitoring.
(iii) Minimum Thermometer.
It is a spirit thermometer with a small metal pin-shaped indicator, which lies free in a column of spirit in
the stern. To set the thermometer it is held with the bulb-end uppermost so that the indicator runs down
the stem until stopped by surface tension of the spirit. It is hung up similarly as the maximum thermometer
without disturbing the indicator. As temperature falls, the indicator is dragged down by the contracting spirit;
but when it rises the spirit flows past the indicator. At the end of any period of observation the position of
the end of indicator farthest from the bulb shows the lowest temperature reached during the period.
(iv) Combined Maximum and Minimum Thermometer.
This is available in several types. Commonest of these is James Six’s Thermometer. This instrument consists
of a glass tube bent into three limbs and combines the principles of maximum and minimum thermometers
described above. It is convenient for routine purposes, but it is not accurate enough for exact meteorological
observations.
(e) Scale of Temperature.
Two scales of temperature measurement are in common use. Fahrenheit is in general use in almost all the
Commonwealth countries and in the United States of America, while Centigrade is used in scientific work globally
and is also in general use in Europe; India has adopted this latter scale. Freezing and boiling points of water in
centigrade scale are 0°C and 100°C respectively and in Fahrenheit scale are 32°F and 212°F respectively. To
convert the reading of Fahrenheit to centigrade scale deduct 32 from the degree of temperature read in that
scale and multiply by 5/9 and to convert centigrade scale into Fahrenheit scale multiply by 9/5 and add 32.
(f) Means of Temperature.
To convey a proper idea of prevailing warmth of a locality, full range of ‘normal’ data for the whole year and
extending over a number of years should be given. They are as under:
(i) Daily Mean Temperature.
It is the mean of maximum and minimum temperatures recorded during the day or at stations equipped
with self-recording instruments for temperature, the mean of the twenty-four-hour values from midnight to
midnight.
(ii) Weekly Mean Temperature.
It is the mean of seven consecutive daily mean temperatures.

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(iii) Monthly Mean Temperature.

It is the mean of daily mean temperature of the number of days in the month in question.
(iv) Yearly Mean Temperature.
It is the mean of 12 monthly means.
(g) Diurnal Range of Temperature.
It is the difference between the maximum and minimum temperatures of any day. The mean weekly, monthly
and annual ranges of temperatures are obtained in the same way as the mean daily range of temperature.
(h) Measurement of Atmospheric Humidity.
Vapour in the air is expressed as ‘vapour pressure’, as ‘absolute humidity’ or as ‘relative humidity’. Vapour
pressure is expressed in millibars and is calculated by formulae based on wet and dry bulb temperatures,
atmospheric pressure and latent heat of evaporation. Absolute humidity is the amount of water vapour actually
present in air expressed as grams per litre of air, as estimated by absorption hygrometers. Relative humidity is
the ratio of amount of water vapour actually present in air at any given temperature to the amount that would be
present in air, if the air was saturated with water vapor at the same temperature. It indicates the percentage of
saturation. Amount of water vapour necessary to cause saturation of air varies directly with temperature; higher
the temperature of air more the water vapour it can hold before saturation point is reached. When atmospheric
saturation is reached, evaporation ceases altogether. If air at a certain temperature holds 6g of moisture in each
litre but if at that temperature it would not become saturated until it held 8 g/l, it is obviously 3/4 saturated:
i.e., its relative humidity is 75%. For sake of brevity, it is generally spoken of as ‘the humidity’. Relative humidity
can be estimated by first finding out dry and wet bulb temperatures by means of a self-recording hygrometer
and then by calculating RH from the standard tables (see Table 6.1). Mason’s Hygrometer and Whirling or Sling
Psychrometer are used for this purpose.
(i) Mason’s Hygrometer.
It has two mercury thermometers mounted side by side on a frame in the Stevenson Screen. Dry bulb is
exposed in the ordinary way and wet bulb is covered with muslin kept moist by a cotton wick, which dips
in distilled water. Wet bulb thermometer records air temperature as influenced by rate of evaporation from
the muslin cloth. Drier the air, greater the rate of evaporation and lower will be the wet bulb readings. In
a saturated atmosphere, the readings of dry and wet thermometers coincide. The difference between dry
and wet bulb readings, known as ‘depression of the wet bulb’ is inversely proportional to the amount of
atmospheric moisture. Hygrometric tables enable the relative humidity, vapour and dew point to be read
directly for any reading of Mason’s hygrometer. This hygrometer is used for meteorological purpose at
permanent meteorological stations.
(ii) Whirling or Sling Psychrometer.
It has dry and wet bulb
thermometers mounted side by
side on a metal strip, which
is pivoted to a frame with a
handle. A small cylindrical water
container is provided for soaking
the piece of a wick. This is whirled
by hand until wet bulb reaches
the lowest value. Successive
observations are made to get
a constant reading. Wet bulb
reading should be taken first.
An aspirating psychrometer is Fig 6.6 : Dry Bulb
rotated by a motor. This is more
accurate but is expensive. For the purpose of physiological studies in enclosed places, these psychrometers
are used and not the Mason’s hygrometers. A whirling psychrometer is also used at the temporary field
meteorological stations (Fig 6.6).

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Table 6.1 : Relative Humidity (Percent)

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 Table 6.2 : Relative Humidity (Percent)
Difference between the Dry and Wet Bulb Thermometers (Below 1500 ft ASL)

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(j) Measurement of Atmospheric Pressure.

Atmospheric pressure is estimated by use of a mercury barometer of which there are several types or by an
aneroid barometer which, however is not so accurate as the mercury barometers. Pressure observations are
expressed in inches or millimetres of mercury or more correctly as millibars. Barographs are also available
which can make continuous records of barometric pressure during a 24-hour period. The instrument is supplied
complete with recording device and spare recording charts. Highly sensitive barographs are also available which
are called microbarographs. Working of this apparatus is simple but for field work, aneroid barometers are
the instruments of choice. They should, however be calibrated with a standard mercury barometer at frequent
intervals.
(k) Measurement of Rainfall.
Rainfall is expressed in terms of inches or millimetres.
A rain gauge consists of a collecting funnel, a receiving
vessel and measuring glass. The funnel, which is made
of copper, is cylindrical in its upper part with a diameter
of 20.3 cm; in some instruments it is 12.7 cm. The
receiving vessel is a small copper can, which fits inside
an outer casing. A measuring glass graduated for the
particular instrument is provided with each gauge. To
take an observation, outer casing of the instrument with
receiving vessel and collecting funnel in situ, is sunk
into the ground in an open space so that top of the
receiving funnel is about one foot above the ground.
After desired time has elapsed, the collecting funnel
is removed, the receiving vessel is lifted out and its
contained water poured carefully into the measuring Fig 6.7 : Rain Gauge
glass and read off. Snowfall is also measured using
similar apparatus and method (Fig 6.7).
(l) Measurement of Air Movement.
Instruments that can be used include the kata-thermometer, rotating vane or propeller anemometers, thermo-
anemometer and hot wire anemometer.
(i) Kata-thermometer.
The standard silvered kata-thermometers are of three types with appropriate cooling ranges:
(aa) The standard Kata (Red coloured) – Cooling range between 100°F - 95°F.
(ab) The high temperature Kata (Dark blue coloured) – cooling range between 130°F - 125°F.
(ac) The extra high temperature Kata (Magenta coloured) – cooling range between 150°F - 145°F.
Kata thermometers are alcohol thermometers with a glass bulb 4 cm long and 1.8 cm in diameter (Fig 6.8).
Kata thermometers are useful for measuring air velocities up to 250 cm per sec. Each kata-thermometer
has a given Kata-Factor and is provided with standard charts with instructions for use. First, the silvered
bulb of the thermometer is immersed into a flask containing hot water. Coloured fluid from the bulb will rise
into the stem up to the small upper bulb. The Kata-Thermometer is removed from the flask and suspended
on a stand 60 cm away from the observer

Fig 6.8 : Kata Thermometer

so that his respiratory air current does not vitiate the result. Wipe out all moisture from the surface of the

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thermometer with a clear chamois leather piece. Note with a stopwatch the time in seconds for the fluid
column to traverse the marked distance while cooling. Take five readings and estimate the mean value.
Wind velocity is calculated from Kata-Factor and Kata-Charts available with instruments.
(ii) Anemometer.
Anemometer (Fig 6.9) of the rotating vane or propeller type are used for
recording the speed of a unidirectional air current. For low air velocities
and for measuring combined air movement of eddies, kata-thermometer
is preferable. Moreover, for biometeorological studies omnidirectional air
movement is more important than unidirectional air current.
(iii) Thermo-anemometer and Hot Wire Anemometer.
These are used in laboratories for precision experimental work:
(aa) A thermo-anemometer is a mercury thermometer with an
electrically heated metallic coil round its bulb. A rheostat regulates
voltage. The velocity of air can be measured up to 5,000 cm per sec
or more by using suitable voltage and a calibration chart.
(ab) A hot wire anemometer is made of three pieces of electrically
heated fine platinum wires. The change in resistance produced by
cooling effect of air current is measured by a potentiometer or a
galvanometer. This instrument is sensitive to very low air movements
below 100 cm per sec.
Fig 6.9 : Anemometer
(iv) Automated Weather Station.

Fig 6.10 : Automated Weather Station

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An automated weather station (Fig 6.10) is an integrated system of components that are used to measure,
record and often transmit weather parameters such as temperature, wind speed and direction, solar
radiation and precipitation. Weather stations are used on land and sea for a variety of operational and
research purposes.
An automatic weather station works by measuring atmospheric conditions and transmitting them to a
network, forecaster or display. Automatic weather stations have
(aa) Thermometer for measuring temperature
(ab) Anemometer for measuring wind speed
(ac) Wind vane for measuring wind direction
(ad) Hygrometer for measuring humidity
(ae) Barometer for measuring atmospheric pressure
An automatic weather station is widely used in many fields such as meteorology, agriculture, ecology and
transport.

6.14 Thermoregulatory Response to Climate Variations.

Study of the effects of ‘Environmental stresses’ on man is never possible without the consideration of relationship
between physical factors as enumerated above which act like ‘Stressors’ and the physiological reactions that follow.
Various combinations of the above factors are encountered in different environmental conditions. It therefore becomes
extremely difficult to ‘compare’ (in terms of stress) one environmental condition with that of the other. To obtain a
reasonably comprehensive idea about the ‘total environmental effect’ and its relative magnitude, several parameters
are in use which can be broadly classified as under:
(a) Biophysical
(b) Physiological
(c) Subjective feeling
For all the aforesaid parameters, the main reference is the ‘man’ and his physiological reactions to the environmental
conditions both in terms of comfort and/or tolerance. Different sets of environmental conditions which produce the same
degree of physiological stress or reactions are similar. Based on this premise, several environmental ‘standards’ have
been laid down based on laboratory/field studies with a view to serve as guidelines for optimum conditions for outdoor
exercise, rest, comfort, types of protective measures required under adverse conditions and so on. Description of these
standards follows in subsequent paragraphs. But before considering these standards it is necessary to understand the
physiological mechanism of thermal homeostasis and the influence of environmental conditions on it.
Heat is constantly produced by basal metabolism in the deeper tissues at the rate of 75 kcal per hour with muscular
activity producing five times more and the specific dynamic action of food adding about 10% of BMR. The homeostatic
physiological thermoregulatory mechanisms aided by the physical laws of environmental heat exchange maintain the
internal body temperature close to 37°C by balancing heat production and heat loss. The range of external temperature
within which the homeostatic mechanisms of thermoregulation are not stressed and within which the resting heat-
production rate is at its minimum, is called the zone of ‘thermoneutrality’ (Fig 6.9). This zone in a resting person is
2° on either side of 29°C. depending on whether he is clad or unclad. Deviation from this zone sets the homeostatic
thermoregulatory mechanisms in action. On the hotter side of the zone, heat loss is increased while on cooler side,
heat conserving mechanisms are stimulated. The external physical laws of thermal exchange, which influence the body
heat balance are conduction, convection, radiation and evaporation from the body surface.
(a) Thermal Balance of Human Body.
Body temperature is a function of two processes viz., heat gain and heat loss. In any study of man in relation to his
environment, wherein effect of clothing has to be taken into account, heat balance is an important consideration.
Heat balance equation can be expressed as:
M ± Cv ± Co ± R - E = ± S
Where,

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M = Metabolic heat production

S = Storage heat
Cv = Heat lost or gained by convection
Co = Heat lost or gained by conduction
R = Heat lost or gained by radiation
E = Heat lost by evaporation.

Fig 6.11 : Thermal Balance of Human Body

When the value is 0, there is neither heat gain nor loss. Depending upon environmental conditions, the body
either gains or loses heat. Body always loses heat by evaporation of sweat when the environmental temperature is
higher than mean body temperature, provided the evaporative conditions like relative humidity and air movements
are favourable (Fig 6.11).
(b) Heat Dissipation.
It is common knowledge that with high relative humidity, sweat instead of evaporating, trickles down, particularly
when the air movement is negligible. It is the evaporative loss of water (as sweat) that has the coolant effect
based on the principle of latent heat of vaporization, viz., with each gram of sweat evaporated, the body loses
0.58 Kcal of heat. Any hindrance to evaporation of sweat either due to high RH, still air or wearing of impervious
layer of clothing (as in the case of pilots), therefore, hinders heat dissipation mechanism resulting in rise of
‘storage heat’ of the body(S). The core temperature, recorded in human subjects as oral, rectal, oesophageal or
from tympanic membrane, correspondingly rises with accumulation of heat in the body.
On the higher scale of environmental temperature i.e., above 29°C, a lightly clad individual starts sweating in
order to dissipate extra accumulated heat. A subject start sweating when the environmental temperature reaches
31°C corresponding to mean skin temperature of 34°C. Sweating reaches its maximum peak at environmental
temperature of 35°C. From then on, it is the amount of sweat evaporation and its cooling effect that becomes the
sole means of heat dissipation. Storage heat(S) of the heat balance equation becomes positive and mean body
temperature (MBT) starts rising proportionately if heat gain exceeds dissipation due to shortfall in evaporative
cooling. This initiates the progress of heat strain. Therefore, the degree of strain is proportional to the rate of

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build-up as well as the quantity of storage heat (S) at a given moment.

Cv, Co and R of heat balance equation largely (with minor variations) depends upon vasomotor regulation
controlled by the hypothalamic center. With rise of body temperature (MST - Mean Skin Temperature or Core
temperature or both) peripheral blood vessels, notably those on the skin dilate several times diverting bulk flow
of blood to the periphery thus facilitating dissipation of heat. However, it should be borne in mind that heat
loss from the body surface is only possible by the above processes when environmental temperature is lower
than body temperature particularly MST, otherwise body instead of losing, gains heat by conduction, convection
and radiation when the environmental temperature is higher than the body temperature. Hence, in heat balance
equation, the sign of + appears before Cv, Co and R. In fact, under conditions of high environmental heat load,
vasodilatation of the skin serves only one useful purpose i.e., to help in the increased production of sweat which
plays the main role of heat dissipation.
(c) Heat Conservation and Heat Production.
Vasomotor regulation occurs in the range of environmental temperature between 25°C and 29°C. by simply
adjusting the blood flow within this range of environmental temperature fluctuations. Below 25°C environmental
temperature, vasomotor adjustment in a nude subject proves to be insufficient. “Shivering” or extra generation
of metabolic heat, again regulated by hypothalamic centre, serves as an immediate source of supplemental heat
which in turn pushes up the value of M of heat balance equation and thus tries to maintain thermal homeostasis.
“Non shivering” thermogenesis as a result of activation of adrenal cortex, medulla and thyroid play a contributory
role in augmenting metabolic heat (M) notably in well acclimatized subjects. However, below 10°C environmental
temperature it is not possible for a nude subject to maintain heat balance indefinitely (despite acclimatization)
without clothing protection. Under cold exposure like survival condition, this factor assumes great importance.
(d) Storage Heat (S).
Heat is said to be stored if the body gains heat faster than it can lose. The total heat in the body acts like a
buffer against thermal demands. In effect it thus provides a means by which the regulatory changes (vasomotor,
shivering or sweating) are not strained unduly. The amount of heat stored in the body depends on its mass and
its specific heat as stated earlier. Heat stored is held by body’s water content which has high thermal capacity.
Therefore, a man weighing 70 kg with a specific heat of 0.83 would have a water equivalent of (0.83 x 70) =
58 kg. Rise of temperature of 1°C in his case would result in storage of 58 Kcal of heat.
The rise in body temperature refers to MBT.
Therefore, Heat content = 0.83 W (0.65 Tr + 0.351 Ts)
Where,
W = Weight
Tr = Temperature rectal
Ts = Temperature skin
The interplay of environmental thermal stress and the capacity of physiological regulatory controls ultimately
determine the amount of storage heat. The latter in turn, depending upon its magnitude, influences the various
systems in different ways.
Following is the sequence of reactions which records body heat balance, as the external temperature (or internal
thermogenesis) increases:
(i) Within the thermoneutral zone, heat from the body core is conducted through the cutaneous tissues
to a cooler surface of the body, exhibiting a descending thermal gradient from within outwards. Heat from
the body surface is dissipated by radiation to the cool environment, atmosphere, buildings, walls, furniture
and so on.
(ii) When external environmental temperature rises above the thermoneutral zone, the thermal gradient
in the body is gradually flattened. Immediate homeostatic response for increasing heat loss produces
peripheral vasodilatation, increasing blood flow through peripheral capillary bed, thus permitting more heat
to be brought to surface from the internal body core. Radiation is now aided by convectional air currents
which removes the warmer humid air enveloping the body surface and replaces it with cooler drier air.

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(iii) Vasodilatation adequately affects the thermoregulation until the environmental temperature approaches
about 32.8°C. Thereafter, vasodilatation alone cannot cause efficient cooling of the body; perspiration and
its evaporation accelerate heat loss. The stimuli to sweat glands also arrive through the same channel as
those for vasodilatation.
(iv) To begin with, perspiration is insensible, but as the environmental temperature rises, it becomes more
profuse. Stronger convectional currents are thereafter required for evaporation to carry out effective body
cooling.
(v) For evaporation of one gram of sweat, 537 Cal, extracted from the body, is required. Heat loss after
environmental temperature exceeds 35° C, entirely depends upon the following:
(aa) Capacity of the body to produce perspiration, which depends upon the presence of efficient
sweat glands, quantity of water in the body and the efficiency of homeostatic thermoregulating
mechanism achieved by acclimatization.
(ab) Evaporating power of atmosphere, which depends upon humidity and air movement. Higher the
humidity and lower the air movement, lower is the evaporating power; lower the humidity and higher
the air movement, higher is the evaporating power.
Mechanism for conserving body heat and preventing its loss which becomes operative below the thermoneutral
zone, has the following sequence:
(i) Immediate response is that of peripheral vasoconstriction brought about through the medullary
thermoregulatory and vasomotor centres. Heat loss through convection and radiation from the skin surface
is thus restricted.
(ii) Rate of heat lost through convection and radiation below the thermoneutral zone is directly proportional
to the difference in body temperature and ambient temperature. Therefore, as the difference increases,
vasoconstriction does not adequately conserve body heat. Production of body heat is increased by:
(aa) Reflex involuntary rhythmic contraction of skeletal muscles producing shivering.
(ab) Voluntary bodily activity may also be undertaken by the individual unwittingly.
(ac) Accompanying these vasomotor and muscular activities, the circulating blood volume decreases
through movement of its fluid portion to the extra-cellular interstitial tissue spaces.
(ad) Endocrinal adjustments counteract stress; and increase in the metabolism occurs by extra
activity of the pituitary-adrenal axis and thyroid gland.

6.16 Measurement and Expression of Thermal Comfort.

In the study of physiological response to heat or of effects of heat on working efficiency, comfort or general well-being,
it is necessary to clearly express numerically the ‘warmth of the environment’. If the thermal value of environment is
to be completely specified to indicate the combined effect of various meteorological factors of human comfort, it is
necessary to evolve a method, which can express it as a single index. Various attempts to integrate two or more of
the meteorological variables into a single index by devising instruments and nomograms, on a theoretical or empirical
basis, have been made.
(a) Effective Temperature (E.T.)
This scale, described as a ‘sensory scale of warmth’, indicates comfort value of the combination of temperature,
humidity and air velocity, but does not take the effect of radiant heat into consideration. It is compiled from
the reading of wet and dry bulb thermometers and air speed. The standard of reference is the temperature
of still air saturated with vapor, which induces the same sensation of warmth as that experienced under the
given condition. Thus, any weather condition for which Effective Temperature is 60°F, feels as warm as still and
saturated air does at a temperature of 60°F.
(b) Corrected Effective Temperature (C.E.T.)
This includes an adjustment for radiant heat. It is calculated from Globe Thermometer, Wet Bulb Thermometer
and air velocity readings, obtained by using Kata Thermometer for estimating wind velocity. There are two CET
scales, the ‘Normal Scale’ which is applicable to persons with winter indoor clothing as used in U.S.A. and the

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‘Basic scale’ applicable to persons wearing trousers, socks and shoes. CET for both these scales is calculated
from the given data by consulting separate nomograms [Fig 6.12 (a) & 6.12 (b)].

Fig 6.12 (a): Corrected Effective Temperature (C.E.T.): Normal Scale

Fig 6.12 (b) : Corrected Effective Temperature (C.E.T.): Basic Scale

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(c) Predicted Four Hourly Sweat Rate (P4 SR).

The scales described above are applicable to sedentary conditions and not for conditions involving physical
activity. They do not clearly reflect bad effects of low air velocity when a man is working in hot humid climate;
they exaggerate the stress imposed when velocity of air is 100 metres or more per min and dry bulb temperature
is high; and finally, they lay more stress on dry bulb reading than on wet bulb reading. Therefore, a scale called
the Predicted Four Hourly Sweat Rate (P 4.S.R.) has been evolved recently to indicate maximum degree of warmth
during various degrees of activities and wearing various types of clothing. This is a true index of physiological
stress based on sweat loss.
First, the Basic Four Hour Sweat Rate (BSR) (Fig 6.13) is calculated from nomogram, on the basis of atmospheric
readings by reference to nomograms and P4SR equations. This shows quantity of sweat in litres produced in 4
hours by a young, fully acclimatized person sitting, wearing shorts without any physical activity. The value of P4SR
is then calculated by making mathematical adjustments to BSR for various types of clothing and activities from
standard formulae and nomograms. This scale is a better index for estimating thermal comfort and water and
salt requirement in a given hot environment, especially in industry. It also can be taken as a limit of tolerance
for a fairly acclimatized young man. The level of efficiency can be maintained if conditions are kept under control
so that maximum value of P4SR level viz. 4, is not reached.
Wet Bulb Globe temperature Index (WBGT): The WBGT index is calculated as:
Outdoor = WBGT = 0.7 tnwb ± 0.2 tg ± 0.1 tdb
Indoor = WBGT = 0.7 tnwb + 0.3 tg.
Tnwb = Natural Wet Bulb Temperature
Tg = Globe Thermometer temperature
Tdb = Dry Bulb Temperature
All outdoor temperatures are recorded in the shade and in degree Fahrenheit. When theWBGT reaches 88°F, it
is advisable to suspend outdoor work, which involves heavy exercises. Well acclimatized subjects, however, may
not find this condition unbearable.

Fig 6.13 : Basic four Hourly sweat Rate (BSR) and Temperature

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(d) Oxford Index (Wet Dry Index).

Information regarding tolerance time of working men (like soldiers) in different work environments of heat
stress needs some special attention. Main difficulty encountered in all such assessment is to find comparable
“equivalent” stressful situations in widely varying combinations of Dry and Wet Bulb temperatures and wind
speed. While C.E.T. scale and to a certain extent P4SR index (described above), serve as useful guidelines in
lower range of heat stress, they fail to provide an answer when the DB and WB conditions are high. A series of
experiments carried out by a group at Oxford (England) finally established that it was possible to relate climates
with similar tolerance times with sufficient accuracy for the practical purpose by simply assigning “weightage”
to DB and WB combinations as below:
WD = 0.15 d + 0.85 W
Where,
WD = Oxford Index = Weighted value of the combined DB and WB
d = Dry bulb temperature reading (actual)
W = Wet bulb temperature reading (actual)
“Oxford Index” as a stress index of heat, merits consideration for its simplicity and ready applicability.
(e) Comfort Zones.
There is still considerable diversity of opinion as to what constitutes a comfortable environment. Feeling of comfort
is related to environment, degree of physical activity, racial habits, type of clothing and state of acclimatization.
It also varies with seasons, with considerable range of individual variations. In temperate zones, an effective
temperature of 64°F to 69°F has been suggested. The American Society for Heating, Refrigerating and Air-
conditioning Engineers (ASHRAE) suggest effective temperature of 60°F to 73°F as the Comfort Zone. Data
collected by the Defence Research Laboratories indicate that the upper limit of comfort zone for hot weather
(with humidity below 75%) appears to be within 76°F to 80°F Corrected Effective Temperature (C.E.T.). Within
the range of 70° to 76°F C.E.T. men feel comfortable and pleasant (Lower limit of comfort zone); C.E.T. below
72°F is cool and stimulating, while below 69°F C.E.T., a definite feeling of cold is experienced in cotton clothing.
The range of winter comfort zone, with normal woollen clothing is considered to be within 57° to 63° F effective
temperature in other countries, but in India, the upper limit for winter comfort zone in service battle dress
appears to be around 68°F C.E.T. Subjects wearing battle dress start feeling warm above 70°F C.E.T.

6.17 Effects of Intense Solar Radiation.

Solar radiation profoundly affects the health directly and indirectly. The direct effects occur mainly through two avenues
viz., the eye and the skin. Various wavelengths of component rays in the solar spectrum, which penetrate the atmosphere,
cause biochemical, luminous and thermal effects are as under in Table 6.3.
Table 6.3 : Wavelength of Various Component Rays in The Solar System
Rays Effects Angstrom units
Ultra-violet 1,000-3,900
Violet Biochemical 3,900-4,300
Blue 4,300-5,000
Green 5,000-5,600
Yellow Luminous 5,600-5,900
Orange 5,900-6,200
Red 6,200-7,700
Thermal
Infra-red 7,600-10,00,000
The combined effect of solar radiation is to provide radiant thermal energy to warm the skin, stimulate metabolism, to
provide luminosity and to produce a biochemical effect on living organisms and plants. In temperate climates, sunshine

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promotes a feeling of comfort, cheerfulness and physical wellbeing. Moderate exposure to sunrays is beneficial even
during hot weather when it simulates adaptive mechanisms. 40% of solar radiation is reflected away from unclad skin
reducing the thermal heat load to a great extent. Moreover, clothing reduces penetration of solar radiation. Very little
of ultraviolet and longer infra-red rays are reflected from the skin surface and therefore they are absorbed in the horny
layer of skin. Infra-red portion, which penetrates beyond the epidermis, causes heating in the dermis and the deeper
layers. Photochemical ultra-violet rays around 3,000 A° units produce Vit D and destroy microbes. The other beneficial
effects cannot be shown by exposure, but lack of exposure may show various defects of metabolism not yet identified.
In the tropics, too much sunshine is uncomfortable, irritating, enervating and dangerous to health. However, harmful
effects of exposure to sun are usually exaggerated and over-estimated. Although the direct rays of sun without doubt
become harmful after prolonged exposure, the myth of the ‘actinic rays’, of the sun striking through the human skull
‘like a poleaxe’, has been discredited. The exposure of bare shaven head of a rabbit to an intensely hot sun causes
cerebral trauma only when its body is also superheated but is harmless if the body is kept cool. Constant exposure to
the intense glare from sun is irritating to the point of causing distress, headache, mental irritation and actual exhaustion.
(a) Skin Manifestations.
These are not heat effects but are radiation effects and may occur in the tropics, sub-tropics, at high altitude
or even in the arctic zone.
(i) Tanning.
It is the normal adaptation of skin to sunlight, caused by repeated exposure of the body to small doses of
sunrays. Moderate sunshine causes keratinization of the horny layer in addition to pigmentation. Pigment
absorbs excessive radiation which might be otherwise harmful to the underlying tissues. This is, therefore,
a defensive mechanism.
(ii) Erythema.
After an acute or subacute exposure to intense direct sunshine, the un-adapted non-pigmented skin shows
erythema within twenty minutes and reaches its maximum within two hours.
(iii) Solar Dermatitis.
Larger doses produce painful erythema, turgescence, oedema, blisters or bullae leading to clinical syndromes
of acute or subacute sunburn and solar dermatitis which are gradations of the same condition, depending
upon the dose of exposure. Sunburns under nose, chin, cheeks and pinna of the ears occur due to reflected
rays from snow. These are all initially characterized by peeling of the epidermis followed by dermatitis with
erythema and oedema and later by extensive desquamation. These reactions are due to photochemical
reaction to ultraviolet energy in the spectral range of 2,900 A° to 3,200 A° The important factors which
determine the degree of reaction are duration and intensity of exposure to direct solar radiation, individual
and topical susceptibility, thickness of horny layer and amount of pigment in the skin.
(iv) Long Term Effects of Solar Radiation.
The long-term effects of exposure to intense unfiltered sunshine like at high altitude or in arid tropical and
subtropical zones are ageing of the skin with wrinkling and loss of elasticity. In the long run. Rodent ulcers
and even skin cancers may be caused by prolonged exposure. Sunrays in the tropics are more direct than
in temperate zones and therefore produce their effect with greater intensity. Sunrays at high altitude are
unfiltered of its short ultra-violet portion and hence cause deleterious effects. Similar effects are seen in
those parts of the world where sunrays are comparatively unfiltered due to paucity of terrestrial dust and
water vapour e.g. in Australia and New Zealand where rodent ulcers are common.
(v) Prophylaxis for Skin Manifestations.
Clothing cuts out a large portion of the ultra-violet rays. Prevention should be based on the fact that
skin pigmentation is increased by rays of wave lengths different from those, which produce sunburn and
dermatitis. Protective devices should therefore filter out the shorter wavelengths but allow longer pigment
forming portion of ultra-violet rays to pass through. Applications should be such that these can be applied
evenly, should be sufficiently adhesive and can be washed from the skin easily. These should not impair
sweat secretion and should not have irritating effects on the skin. If a preparation is to be used in a cold
climate, the composition should be such that it should not freeze. A 10% solution of tannic acid in alcohol
to which some castor oil has been added is usually recommended. 10% suspension of benzyl salicylate

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in castor oil gives very good screening by filtering out the sunburn producing rays without affecting the
protective phenomenon of tanning by pigment production. Application of calamine lotion (or cream) is the
first aid measure for sunburn and solar dermatitis.
(b) Eye Manifestations.
The direct or indirect reflected solar radiation causes thermal or photochemical effects on the conjunctiva, cornea,
lens and retina. Absorption and scattering of rays shorter than 3,900 A° units and longer that 9,500 A° units
normally occurs in the lens and the vital structures of the eye are saved. Hyperaemia of the superficial tissues
occurs on acute exposure causing irritation of conjunctiva and oedema, but prolonged exposure to intense
infrared rays (in solar, terrestrial or industrial radiation) causes posterior polar cataract. Retina may suffer from
foveal oedema or burn. Harmful and disagreeable effects of solar radiations on eyes and eyesight are caused by
the entire spectrum of solar radiations penetrating the atmosphere viz. Ultra-violet, infrared and visible spectrum.
(i) Ultra-violet Radiation.
The intensity of ultra-violet radiation is greatly reduced by ozone in the atmosphere. However, at altitudes
above 3,000 m, the direct solar radiation is less filtered than at lower altitudes. Also, their refraction through
snowflakes and particles in the air and reflection from snow exposes the eye to ultra-violet radiation. Photo-
chemically the most active zone is 2,900 A° to 3,100 A° units. Effects are practically limited to the external
structures of the eye resulting in photochemical conjunctivitis, keratitis producing photophthalmia or snow
blindness. The symptoms are intense pain, photophobia, lacrimation and intense circumcorneal injection.
(ii) Infra-red Radiation.
The concentration of infra-red rays is also more at high altitude due to paucity of water vapor and atmospheric
dust. This produces a transient conjunctivitis but if exposure is continued, it may cause the development of
cataract. The most damaging effect of heat radiation is seen in ‘eclipse scotoma’, a retinal burn produced
by radiant energy of the sun when the unaided eyes are exposed to the sun.
(iii) Visible Spectrum.
The undesirable effects are due to glare, which may be defined as ‘brightness’ within the visible spectrum
of the sunrays, causing visual discomfort or interference with visual functions. Control of glare hence is of
the greatest importance in selection of absorptive filters for sun goggles.
(iv) Prophylaxis and First Aid for Eye Manifestations.
The best prevention is afforded through wearing of authorized goggles by troops and air crew when exposed
to radiation reflected from snow or refracted through the snowy atmosphere at high altitudes. Coloured
glasses and plastic filters can absorb most of the ultra-violet components of actinic rays. In advising
sunglasses, all the three regions of the spectrum have to be considered. The best glasses are ordinarily of
green or rose smoke colour as infrared transmission through them is slight, but they completely filter out
the harmful portion of ultra-violet spectrum and transmit 15 to 20% of visible radiation. ‘Slit-masks’ made
from cardboard or thick paper with a slit to look through may be used in an emergency. Cold compresses,
pad and bandage with antibiotic drops for 24 hours and oral analgesics if pain is intolerable will heal most
cases within 24 to 48 hours and same should be carried out in forward posts. If the cornea is involved,
atropine ointment should be given. The individual should not expose his eyes to sunshine for at least a
week after the initial treatment.

6.18 Hot Climate.

(a) Epidemiology.
Deleterious effects of heat are widespread in the subtropics during the summers. They occur much less
commonly in the tropics than is generally expected. The primary areas where such conditions are common
are shores of the Persian Gulf and plains of Central and North Western India. Broadly speaking, the incidence
of effects of heat in India is commonest in an area above the line drawn horizontally through Nagpur, with
its Eastern limit marked by a line drawn vertically along the western border of West Bengal through Asansol,
excluding the coastal areas. The great majority of cases occur in Punjab; but there is hardly a place in the
plains of Northern and Central India where they have not occurred at one time or another. Most cases occur
during a week or two prior to the onset of South West monsoons and during ‘breaks’ in the monsoons when

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atmospheric temperature and humidity are very high. In the North and West, the dangerous period is towards
the end of June or even later. In the Central India it is mid-June, while in the South and Eastern India, May
and early June are critical periods.
(i) Environmental Factors.
(aa) High Atmosphere Temperature.
It is the most important primary cause. The final effect is, however determined by the period of
exposure and adaptability or state of adaptation of the individual. Fit acclimatized men can withstand
temperature of even 43°C in dry weather. As the ambient temperature approaches 46°C or so,
especially in the presence of wind velocity of more than 32 km per hour, the danger point approaches
and heat stroke may occur.
(ab) Sun Glare.
Direct exposure to sunrays increases the body heat load further and may precipitate the attack.
Constant exposure to the sun glare is irritating to the point of causing distress. headaches, mental
irritability and actual exhaustion.
(ac) High Atmospheric Humidity.
It is as important a factor as high ambient temperature in the causation of adverse effects of heat,
since upon it depends on the capacity for evaporation and hence the body heat loss. A high ambient
temperature can be borne with comparative comfort if the weather is dry enough, but as humidity
increases, it becomes unendurable. In a humid environment, though the body may produce ample
sweat, heat effects may ensue even at a temperature as low as 38°C, if the relative humidity is 85%
or more. In the equatorial belt, the temperature in summer rarely exceeds 35°C but the humidity
is often 35-90%. This combination contributes a much greater heat load to the body and produces
greater discomfort than the hot-dry climate with a temperature of 53°C and relative humidity of 20%
as seen in Punjab.
(ad) Air Movement.
It is the third important environmental factor which determines the human thermal comfort.
Atmospheric inertia increases the liability to heat effects, especially in humid conditions. Moderate
air movements increase convectional loss of body heat. Wind velocity up to 32 km thus helps the
body to lose heat even in dry environment with temperatures as high as 46°C. But above that velocity,
while doing no harm, it does not do any extra good. With a very dry and hot atmosphere above 46°C,
the wind velocity over 32 km per hour becomes dangerous as it causes reversed convection and
excessive increase in body heat load. Such a combination is found in deserts.
(ae) Overcrowding.
It raises the temperature and humidity of a room. Bad ventilation aggravates these conditions.
(ii) Host Factors.
(aa) Age.
Advancing age is associated with decreased efficiency of the sweating mechanism and greater
incidence of cardiovascular diseases. Unsupervised physical labour is undesirable for persons above
40 years of age.
(ab) Body Build.
Obese persons take a very long time to acclimatize to hot environment.
(ac) Sex.
Women are more susceptible to adverse effects of heat. This is due to thicker subcutaneous fat
covering and an altered threshold for sweating due to female sex hormones.
(ad) Medical Conditions.
Miscellaneous conditions like diabetes, vomiting, gastrointestinal disturbances, hyperthyroidism etc.

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make the individual more susceptible to the adverse effects of heat.

(ae) Fluid Loss.
Fluid loss in excessive sweating affects subsequent cooling capacity. In the plains of India in hot
weather, the minimum water loss in sweat and urine by a man doing moderate work is 8 L per day
and that by a man doing hard work, e.g., 35 km route marching is about 14 L or more of water and
15 g of sodium chloride a day.
(af) Severe Exertion.
Long forced marches or camp work in hot, humid, still weather imposes an increased strain on
the heat regulating mechanism of the body. Fit men can, however, withstand a surprising amount
of exertion if acclimatized, provided with ample water, suitably clothed and not overburdened with
equipment. Prolonged work in close places is more harmful than in the open.
(ag) Acclimatization.
Non-acclimatization and inadaptability have always provided fertile soil for causing adverse effects of
heat. Combined with this, ignorance of safety precautions is also a precipitating factor.
(ah) Rest.
Lack of rest and sleep are predisposing factors.
(aj) Personal Hygiene.
Dirty skin covered with epidermal debris, finely plastered dust and the decomposition products of
sweat predispose to prickly heat, cause insufficiency in sweating and its evaporation.
(ak) Prickly heat.
Severe prickly heat, mechanically decreasing the area of healthy sweat pores also interferes with
effective sweating.
(al) Clothing.
Unsuitable, cumbersome and heavy clothing and equipment impede heat loss and produce extra
internal heat. Tight clothing becomes particularly harmful by aggravating prickly heat.
(am) Food Consumption.
Food requirements of men in hot weather are the same to which they are accustomed. The fit
soldier who consumes adequate food is much less likely to develop adverse effects of heat than
one with a feeble appetite. Loss of appetite itself is often an early symptom of heat exhaustion.
It is wrong to reduce protein intake on the theoretical grounds of their thermogenic effect or any
other considerations. Water soluble vitamins B and C are excreted in the sweat. ‘Heat stress’
would cause an increased demand on cortisone; and vitamin C is a sparer of the ketosteroids. It
is therefore possible that vitamin C may be helpful in combating heat stress in consideration of
the concept of ‘General Adaptation Mechanism’. Excess intake of vitamins, however, has no extra
beneficial effect.
(an) Health Status.
Previous ill health predisposes a person to the effects of heat. An unfit or convalescing man should
not be made to do heavy work in hot humid weather. On the other hand, adverse heat effects may
occur in apparently fit and healthy soldiers. Febrile illnesses upset the heat regulating mechanism
of the body. Possibility of this occurring in areas where febrile diseases are endemic and in hospital
patients, especially in the non-air-conditioned operation theatres must be borne in mind. Pathological
conditions of the skin may also produce the same result by interfering with sweat secretion.
(ao) Mental Disposition.
An unstable and easily excitable temperament predisposes a person to the heat effects; worry and
apathy leads to neglect of precautions.

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(ap) Alcohol.
Habitual consumption of alcohol makes heat effects noticeably common; rapid consumption of alcohol
in large quantities may precipitate the attack.
(aq) Task Factors.
The effect of heat on body is modified many times by task factors. Complexity of tasks, prolonged
duration of task, strenuous physical tasks, tedious mental workload including perceptual and motor
loads and tasks involving higher skill also makes a person liable to suffer from adverse effects of
heat.
(b) Effects of Extreme Hot Climate.
At progressively increasing ambient temperatures, the mild failure of the homeostatic control and evaporative
regulation causes apathy, lassitude, sleeplessness and cramps. More advanced severe imbalance or failure leads
to hyperthermia causing heat stroke or dehydration causing heat exhaustion. The two syndromes are clinically
distinguishable and require different therapeutic measures. However, sometimes there may not be clear-cut
clinically distinguishable features and ‘heat exhaustion’ may proceed or progress to ‘heat stroke’, depending
upon whether the dehydration or hyperthermia is predominant.
(i) Heat Stroke.
This condition occurs as a result of an excessive rise in the body temperature. When perspiration and
its evaporation are adequate, the resultant thermal loss maintains the thermal balance of the body and
continues to do so till water replenishment is maintained. The thermoregulatory mechanism may fail if
internal conditions are adverse viz., there is relative deficiency of water in the body or the internal (febrile)
thermogenesis is excessive or if the external conditions are unbearable under intense solar radiation, high
ambient temperature or very hot winds. The heat load imposed upon the body by such severe conditions
may be about 200 Kcal per square metre of body surface area per hour i.e. 3,000 to 4,000 Kcal per hour,
which is equivalent to the metabolic output of very strenuous exercise. Under such conditions, when the
heat regulating mechanism of the body fails to keep the body temperature below critical level, hyperpyrexia
develops. There may be prodromal signs like defective sweating, exhaustion, giddiness, anorexia and
frequency of micturition. On the other hand, individuals in apparently good health may suddenly become
unconscious and get rapid rise in temperature above 40°C. The cardinal signs of heat stroke are - hot dry
skin, which may be red and mottled, hyperthermia with rectal temperature more than 40.6°C and central
nervous system disturbances.
(aa) General Manifestations.
Body temperature is more than 40°C, skin is dry and hot due to lack of sweating. Breathing is rapid
(more than 30/ min) and may become acidotic or Cheyne Stokes type later. Face is congested, eyes
are suffused and pulse is full and bounding.
(ab) Neurological Manifestations.
These are altered consciousness, somnolence, stupor, delirium or coma. Two-thirds of cases may
develop convulsions. Ataxia and dysarthria may appear due to cerebellar damage. Rarely one may
come across neck rigidity, extensor planters, decorticate posturing and pupillary abnormality. CSF
examination is always normal.
(ac) Cardiovascular Manifestations.
High output failure may occur due to peripheral vasodilatation, but low BP, tachycardia and shock
invariably follow later. ECG may show arrhythmias, bundle branch block and T-wave changes. Effects
of hyperkalaemia may also be seen.
(ad) Renal Manifestations.
Raised blood urea, proteinuria, pyuria and casts (granular and hyaline) are common findings. Rarely
acute tubular necrosis may occur presenting as anuria or oliguria.
(ae) Hepatic Manifestations.
Hepato-cellular dysfunction is manifested by jaundice appearing in 2-3 days and disappearing in 2-3

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weeks. Biochemical tests reveal raised hepatic enzymes and serum bilirubin and sometimes a fall in
serum albumin.

High Environmental Temperature

Lack of sweating Efficient sweating

Adequate evaporation of sweat

Increased thermogenesis and adequate replenishment of Insufficient evaporation and /
water and salt or inadequate replenishment
and / or break down of heat
regulating centre. of water & salt

Efficient body thermal regulation

Severely hot environment

rendering thermoregulatory
body mechanism and / or
Stable level of sweatingand salt body stock of water and salt
economy short of requirement.

Perfect adaptation to heat

Dehydration

Acclimatisation
Heat Exhaustion

Fig 6.14 : Schematic Summary of Extreme Hot Climate

(af) Haematological Reactions.
Polymorphonuclear leucocytosis is common. Haemorrhages may occur due to increased capillary
fragility, thrombocytopenia, decreased prothrombin level and increased fibrinolytic activity. Mortality
in heatstroke is roughly proportional to temperature recorded at admission. Recovery, however, is
recorded even with rectal temperatures more than 45°C.
(ii) Heat Exhaustion.
This occurs more commonly than heatstroke. In the clinical syndrome of heat exhaustion, the main effects

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are not due to hyperthermia but are rather the result of water and salt depletion due to excessive sweating.
The pathogenesis is briefly as follows:
(aa) Very high ambient temperature causes excessive sweating. High ambient temperature and very
high atmospheric humidity or stagnant air retard efficient evaporation of sweat which just drips off
the body as useless perspiration’ without causing body cooling.
(ab) Requirement of water intake, which is high in hot weather, if reduced with consequent reduced
excretion, results in the production of concentrated urine through which toxic metabolites are removed.
(ac) Excessive sweating also causes salt loss. Normally about 15 g of salt intake is adequate. Any
salt consumed over this daily requirement is excreted in urine. If the intake is reduced or excretion
in sweat is increased, salt is conserved by diminishing its excretion in the urine.
(ad) Water constitutes 70% of body weight or about 50 L; about 30% of it or about 15 L is extracellular
and 70% or about 35 L is in intracellular compartments. 75% of extracellular fluid or about 11 L
exists as tissue fluid and 25% or about 3-4 L as circulating plasma. Maintenance of the fluid balance
and its relative distribution in the three compartments is of profound importance for the health of
the cells and tissues and is kept constant by the relative osmotic pressures (Fig 6.15).

Fig 6.15 : Normal Body Fluid Compartments

(ae) The long term steady osmotic state is controlled by colloids but the short term or immediate
osmotic state is controlled by water and salt concentration. Changes in the tissue fluid tonicity due to
water and electrolyte loss causes a change in osmotic pressure and consequently the accumulation
or withdrawal of water from the cells.
(af) Consequently, the tissue water balance, the electrolyte balance, pH concentration, osmotic
pressure and chemical composition of fluids are all disturbed causing profound physiological
breakdown. The hormonal activity, especially mineralocorticoid, attempts to restore the electrolyte
and water balance and the kidneys try to conserve water and salts while keeping the excretion of
metabolic wastes constant. Eventually, however, oliguria occurs which retards excretion of tissue
metabolites and gives rise to toxaemic (uraemic) symptoms. Excessive water and salt excretion in
sweat beyond a critical level thus causes dehydration, homeostatic exhaustion, metabolic disruption
and failure of the general adaptation mechanism. Thus sweating, which is essential for maintaining
thermal balance becomes a threat to the body.

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Dehydration may arise from pure water depletion, pure salt depletion or combined salt and water
depletion (Fig 6.16 and 6.17).
(iii) Pure Water Depletion.
In pure water depletion, initially the extracellular fluid becomes hypertonic due to water loss without a
parallel salt loss. Intracellular water is withdrawn to restore the extracellular fluid volume resulting in
intracellular dehydration. The sodium and chloride content of plasma rise along with blood urea. There is
hardly any change in plasma volume or in haematocrit value. Increasing thirst with dry mouth and tongue
occurs early. There is oliguria and progressive weakness and the face becomes ashen grey. Temperamental
characteristics may be exaggerated. Mentation may be affected, evidenced by confusion and hallucinations.

Fig 6.16 : Pure Water Depletion

(iv) Pure salt Depletion.
In pure salt depletion, the extracellular fluid becomes hypotonic. As the body cannot retain water in the
absence of salt, kidneys excrete more water and extracellular fluid volume falls. Therefore, pure salt depletion
causes extracellular dehydration. This produces a fall in plasma volume; but because of the osmotic action
of the intravascular plasma proteins, water loss is greater in the tissue compartment than in the vascular
compartment. There may be changes in the body’s acid-base equilibrium. Extreme lassitude and apathy
may be present and may progress to stupor. There may be muscular weakness, cramps and postural
hypotension. The latter manifests as giddiness and fainting on assuming erect posture. There is absence
of thirst. After drinking water, the urine volume increases but diuresis may not develop for several hours.
There may be anorexia, nausea and even vomiting. The skin is often dry and inelastic.

Fig 6.17 : Pure Salt Depletion

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(v) Combined Salt and Water Depletion.

In combined salt and water depletion, which is the usual occurrence in heat exhaustion syndromes,
dehydration is more universal and shows a mixed picture. The patient appears dehydrated with a pinched
appearance and complains of thirst. There is oliguria and hypotension, reduced urinary salt excretion, raised
blood urea and haemoconcentration.
(c) Clinical Spectrum of Cases.
Cases of one type of heat exhaustion occur in the first half of summer at the peak of external temperature before
acclimatization occurs. Patients usually suffer from collapse, vomiting and cramps. Pulse rate and systolic blood
pressure are normal when a person is lying down; the diastolic pressure is high. On standing, the pulse becomes
very fast, the systolic pressure falls and syncope occurs. These cases have a reduced plasma volume, grossly
reduced plasma chlorides and oliguria. Biochemically, this type is salt depletion dehydration and is caused due
to excessive loss of salt during sweating and improves rapidly with replacement of salt and water. It predisposes
the subject to adverse effects of excessive heat. and predisposes to heatstroke. The second type of cases occur
towards the second half of the summer among men who have already been through the hottest part of summer
and can be considered to be fairly acclimatized. The symptoms are dizziness, palpitation, dyspnoea and lack
of sleep. Inadequate sweating and prickly heat accompany these symptoms. There is marked polyuria, the total
chloride output of urine being within normal limits. Plasma chlorides are moderately reduced. General picture
suggests a breakdown of the body defence mechanism against heat and that of water depletion.
(d) Other Effects of Heat.
(i) Heat Cramps.
This occurs due to intra-cellular over-hydration and diminution of chlorides in the tissue fluid. Subsidiary
factors are fatigue and non-acclimatization. Any muscle may go into cramp but the fatigued muscle is more
susceptible. The acclimatized individual is less liable to get cramps as he is less easily fatigued, loses less
salt in sweat, thus conserving plasma chlorides and becomes more tolerant of cramp-producing conditions
produced in his muscles.
(ii) Prickly Heat.
It occurs due to hyperactivity of acarine sweat glands, irritation of skin by clothing soaked in sweat, blocking
of sweat ducts by epidermal debris, desquamation due to soddening effect of sweat and its decomposition
product and salt crystals in sweat. Unclean skin increases the liability to suffer from prickly heat and also
from secondary infection causing furunculosis.
(e) Prevention of Effects of Heat.
(i) Acclimatization.
It is the most valuable and important prophylactic measure against effects of heat. It includes conditioning
of all ranks and education of unit commanders in common precautions. The ability to do hard work in hot
climate can be achieved in about two weeks by a gradual acclimatization procedure. Initially, men should
be exercised for short periods every day, sufficient to promote vigorous sweating, but not so severe as to
cause exhaustion. After a week, the duration of such exercises and their frequency should be lengthened
and the process continued until the men can work for several hours without distress. During the period of
acclimatization, constant vigilance is necessary to ensure that the preventive routine has been thoroughly
mastered and that exhaustion or deleterious effects do not occur. During the first fortnight, exertion to the
point of exhaustion is most dangerous and severe tests of endurance should be avoided.
(ii) Fluid Intake.
It should be enough to produce sweat and compensate for water loss. Provision of ample supplies of cool
water should be ensured. Water consumption is likely to be inadequate if it is not cool enough to quench
thirst. Moderate work in hot weather may need 8 to 12 litres a day per man and for men on long route
marches/strenuous physical work, even up to 16 litres a day may be needed.
(iii) Salt Intake.
Intake of salt should compensate for its excessive loss in sweating. In the ordinary rations 20 g of salt
evaporated per day is supplied and is adequate.

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(iv) Training.
Exertion should be judicious. While it is definitely beneficial for troops to be employed on light work throughout
the day in the shade, it is not wise to engage them on excessively hard work under the open sun for long
periods. It is not advisable to allow strenuous games before 1700 hours, but daily morning collective exercise
in open air is beneficial. Although seasoned troops can perform a surprising amount of hard work without ill
effects even in the hottest weather, they should not be engaged, as far as possible, in route marches, physical
training and such exhausting work after mid-day in extremely hot weather. During the critical heatstroke period,
training programs of work should be drawn up in consultation with the medical authorities.

Fig 6.18 : Humidity and Training

(v) Rest.
The cumulative effect of inadequate sleep predisposes to the ill effects of heat. Rest and sleep therefore
should be adequate, as the recovery must compensate for the activity. The day’s programme should
be arranged to achieve this aim. The early limit for reveille should, when possible, not be earlier than
0530 hours, because the best period for the most satisfactory and restful sleep is during the coolest 3
or 4 hours before dawn. Troops should be allowed and provided facilities to have an afternoon rest after
meals when the heat is oppressive.
(vi) Bathing.
A daily bath must be ensured. Improvised shower baths are of great value. An active healthy clean skin is
an important agent for dissipation of heat through radiation, convection and evaporation.
(vii) Clothing.
It should be light and loose and permeable to water vapour and air.
(viii) Food.
Men should be provided sumptuous, wholesome and well-cooked meals. They should be encouraged to
eat their full normal rations with adequate amount of water. Dining halls should be cool and comfortable
as no one can be expected to take full meals under hot and humid conditions.

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(ix) Living Accommodation.

The living quarters must be spacious, well-ventilated and cool. A large proportion of heatstroke cases occur
in congested, ill ventilated, stuffy and crowded barracks, rooms, huts or tents.
(x) Medical Examination.
All men who are physically below par should be carefully excluded from all route marches and other hard
work or exercises. Men who have once suffered from effects of heat or who have recently been discharged
from hospital after any illness require special observation.
(xi) Health Education.
Simple talks should be given to all ranks regarding effects of heat and measures for their prevention.
They should be educated to recognize the early symptoms of adverse effects of heat such as weakness,
headache, giddiness, absence of thirst, anorexia and apathy.
(xii) Rail and Road Moves.
Additional precaution as described in chapter on health problems during move should be observed during
the move by marches, road transport and rail in hot weather.
(xiii) First Aid and Early Treatment.
This is necessary to prevent complications including loss of life in affected pers. All MOs must be prepared
to act expeditiously. Temperature should be rapidly reduced by spraying cool (not ice cold) water and fanning;
thirst is quenched by giving cool water, in quantities as required to quench thirst. The rectal temperature
is observed every 10-min; cooling is reduced when it falls to 39°C and patient is removed to the heat-
stroke centre. Dehydration is treated by the optimum administration of fluids and electrolytes. Cases of
pure water loss should be given water only, while those with salt and water loss, which is commoner,
should be treated by isotonic saline infusions until at least half a pint of urine is passed every six hours.
This enables the body to perform the essential functions of excreting 33 g of endogenous wastes a day.
In water deficit, if there is only thirst, approximate deficit may be up to 1 to 2 L; if there is thirst with a
dry mouth, oliguria and weakness, an approximate deficit of 4 L may be assumed; in very severe cases
with considerable impairment of mental and physical capacity there may be a deficit of 5 to 10 L. In salt
depletion, if there is lassitude, giddiness and fainting on standing, there may be an approximate deficit of
4 L; if urinary chlorides are absent and if there is anorexia, nausea and vomiting with the systolic blood
pressure of 90 mm of mercury, there may be a deficit of 5 L; if systolic blood pressure is less than 90
mm there is an approximate deficit of 8 L.
(aa) First Aid Measures at BFNA/ Nursing Assistant Level.
O Try and move patient to a cooler, shaded place.
O Remove the clothes.
O Spray skin with tap water (at 25° to 30°C) or wrap the patient in a sheet soaked in water.
O Continue fanning manually or with an electrical fan.
O Keep vigorously massaging the skin to prevent constriction of blood vessels during cooling.
O Place ice packs or towel soaked in cold water around the neck, axillae and groin.
O Nurse in the comatose position; clear oral secretions.
O Quickly transport to the Ml Room (cool room) /Hospital (Heat stroke Centre) as an emergency.
(ab) First Aid Measures at RMO/MI Room Level.
O Initiate measures outlined under first aid mentioned above, if not already initiated.
O Record Rectal (Core) temperature. The same can be easily done with present day digital
thermometers. If it is not possible to record rectal temperature, record oral temperature and
add 0.5°C.
O Establish Intra Venous line; take blood sample for investigations.

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O Start normal saline (or Ringer lactate) drip at 20-25°C. Give a challenge of 1 liter fluid in
15 to 30 minutes. Add other electrolytes such as K+, as guided by subsequent investigations.
O In case of seizures, give IV Diazepam 5-10 mg over 10 min.
O If facilities are available, intubate the patient and initiate ventilator support.
O If rectal temperature is not coming down or there is evidence of cerebral, hepatic or renal
complications, transfer the patient to a hospital with intensive care facilities.
(f) Heatstroke Room for Emergency Management of Severe Heat-Related Illnesses (HRI) (For Community
Health Centre and District Hospitals).
The heatstroke/cool room in Armed Forces are authorised medical equipment as per ME Scale AMC-72. The
authorisation of heat stroke room, given in scales of accommodation 2022 is as follows:
(i) Floor area (Sq m): 14 sq m for strength of upto 1,000, thereafter additional 14 sq m for 1,001–2,500,
2,501–5,000 & 5,001–10,000 each.
(ii) Special facilities like built in cupboard with top half for hanging and bottom half shelved with shoe
rack and mirror inside; WHB with peg set and towel rail; Glazed ceramic tiles dado upto lintel height.
(iii) One attached toilet from the overall authorisation, air-conditioner to be provided.
(g) Logistic Requirements Setting up Heatstroke Room in Health Facility.
(i) Dedicated heat stroke room (at least 2 beds, 14’ X 16’) (with cooling equipment: AC/ cooler/ fans/
water sprinkler/ refrigerator / ice packs)
(ii) Selecting a heatstroke room: A room in the health center be designated where the ambient temperature
could be maintained optimally with appropriate natural shading and ventilation and should have continuous
electricity supply or functional generator back up. It should not be on the top floor and can be cooled
effectively with fans and desert coolers wherever air conditioning is not available. This room should contain
a refrigerator, ice box, ice packs, ice cool water, cool blankets, wet linens, garden sprayer round the clock.
(iii) Thermometer/ Rectal Thermometer/ Rectal Probe/ Multipara monitor/ Stethoscope / BP apparatus/
ET tube and laryngoscope.
(iv) Disposable waterproof zipper body bags for immersion cooling.
(v) High flow oxygen.
(vi) ECG equipment: ECG machine, Gel, electrodes, ECG paper.
(vii) Glucometer and testing strips.
(viii) Ryle’s tube.
(ix) Multifunction monitor, cardioversion/defibrillator facility.
(x) Medicines: Lorazepam, Diazepam, IV antiseizure medicines like phenytoin and valproate cold IV normal
saline (0.9%), dextrose 50% in water solution (D50W), Dopamine, dobutamine.
(xi) Trained Staff.
(xii) Treatment protocol on walls.
(xiii) IEC Material
(h) Logistic Requirements Setting up for Heatstroke Facilities in Ambulance Transport.
(i) Air conditioning with ice box.
(ii) Thermometer/ Rectal Thermometer, Stethoscope, BP apparatus, ET tube and laryngoscope and High
flow oxygen.
(iii) Ice packs, Cold towels, ORS, small/hand fans, Tarpaulin.
(iv) IV catheters, drip set, cold IV normal saline (0.9%), dextrose 50% in water solution (D50W).

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(v) Glucometer and testing strips.

(vi) TACO (Tarpaulin Assisted Cooling Oscillation) method (depending on feasibility and training)

6.18 Cold Environment

(a) Introduction.
Deleterious effects of extreme cold are inherent not only at high altitude areas but may also occur at low altitudes
in the plains of Northern India. However, it is the increased operational deployment of troops at high altitude,
where effects of cold climate become more complicated and aggravated due to hypoxia, that has made the
study of effects of cold more important for the Medical Officers of the Armed Forces. Sub Zero temperature is
accompanied by very low humidity as in Ladakh, Rajasthan or Punjab or with high humidity and rainfall as in
Sikkim, Kashmir and Arunachal or with moderate humidity as in the North Indian Plains. It may alternate with
very hot summers in the plains or with mild summer as in the mountains. The exact nature of the effects of
cold may vary from one type of cold environment to another as under:
(i) Altitudes above 3,000 m in the Western and 4,000 m in the Eastern Himalayas represent the same
climatic conditions as in the arctic region. The temperature in winter ranges between minus 20°C to minus
50°C. There is not much of vegetation except for lichen and moss; the cold is dry cold and is accompanied
by severe winds and blizzards with snow particles wafting in the air and deep snowdrifts are common. In
summer melting snow creates avalanches and slush. The sun is extremely bright, scorching and distressing.
Frostbite and snow blindness are common hazards.
(ii) Below that altitude and above the winter snow line at about 2,000 m in the Western and 2,500 m in
the Eastern Himalayas, subarctic conditions prevail. Melting snow in summer produces slush. Winds are cold
but less severe because of the protection given by coniferous forests and scrub. Atmospheric temperature
is usually quite low but rarely goes below minus 10°C and the region has pleasantly cool summers. Though
snowstorms are frequent and frostbite may occur, trench foot is a much more frequent risk. Chilblain is
the commonest hazard in this region.
(iii) Below the altitude of winter snowline, the conditions are similar to higher temperature zones with
deciduous forests. Cold is severe in winter but not so severe as to produce frostbite or trench foot; chilblain
is quite common in susceptible persons. Summers are pleasant. In Western parts winter rains occur.
(iv) In foothills up to about 1,000 m height the climate is humid and warm in summer with high rainfall
in the monsoon and mild winters.
(b) Epidemiological Factors of Cold Injuries.
(i) Environmental Factors.
(aa) Severity of Cold.
Severity of atmospheric cold and its abrupt occurrence increases the liability of incidence of cold
injuries among non-acclimatized, non-resident individuals.
(ab) Duration of Exposure.
It is an important factor determining the final injury. Average 10 hours exposure to -10°C is needed
to cause the cold injury but may occur before that in in lower temperatures.
(ac) Moisture.
Moisture is a good thermal conductor and its presence in contact with skin interferes with the
natural insulating action of greasy sebaceous material on the skin. Presence of moisture-in the
clothing increases its thermal conductivity and obliterates air-containing meshes, thereby decreasing
its insulating action and extracts body heat by evaporation. Moisture enhances the effect of cold
climate through influencing ‘super-cooling’ caused by decreasing the aid given by sebaceous material
on skin surface.
(ad) Hypoxia.
High altitude hypoxia deprives cardiac muscles of oxygen and thereby decreases the minute cardiac
output, lowering the peripheral blood and oxygen tension and reducing the tissue oxygen saturation.

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Hypoxia also devitalizes the capillary endothelium and increases exudation into tissues. All these increase
the proneness of extremities to cold injuries; skin, being the least vital organ, is affected the most.
(ae) Wind Movements.
This hastens tissue cooling. The combination of ambient low temperature and wind movement is
termed the ‘wind-chill’ factor. The power of the climate to cause cold injuries is directly proportional
to the ‘wind-chill’ factor rather than its temperature alone. Increased wind velocity by increasing the
‘wind-chill’ factor increases chances of frostbite. This is well illustrated in the wind-chill chart as in
Fig 6.19 below:
Minutes to frostbite for the 5% most susceptible segment of the population

Fig 6.19: Wind Chill Chart**

Note: If the individual is exposed to a temperature of –40°C with wind velocity of 10 km/h it will
take 8 min for frostbite to develop. Whereas if the wind speed is 80 km/h at the same temperature
it would take just 2 min for the same.
** wind chill chart used by the US Armed Forces.
(ii) Host Factors.
(aa) Circulatory Stagnation.
Local circulatory stagnation leads to lowering of local temperature, increases liability of exudation
through the already damaged vascular endothelium and deprives the tissues of nutrition and oxygen,
causing devitalization. This may be caused by forced immobility due to being pinned down to trenches,
cramped conditions in winter cut-off posts, in vehicles during a siege or in defensive battle. Tight
fitting clothes, putties or boots or socks may also cause constriction.
(ab) Physical Inactivity.
It increases risk of cold injuries primarily due to circulatory stagnation. Activity decreases the liability
to sustain them and is an important prophylaxis against cold injuries.
(ac) Nutrition.
It plays an important part in resisting adverse effects of cold and malnutrition predisposes a person
to cold injuries. Vitamin A deficiency increases risk of infections especially in mucous membranes.
Vitamin C deficiency increases capillary permeability and decreases healing capacity of tissues. As a
sparer of ketosteroids it also plays a part in ameliorating cold stress and help the general adaptation

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mechanism against its effect. The presence of moderate sub-cutaneous fat increases tissue protection
against cold.
(ad) Physical Health.
Intercurrent or chronic diseases or convalescence state and physical exhaustion decrease the general
tissue vitality, physical activity and also capability to acclimatize and hence increases the liability to
cold injuries.
(ae) Mental Health.
Mental apathy, fatigue, fear and anxiety which are common in extreme cold environment, especially
under hypoxic conditions at high altitude cause neglect of precautions and increase physical inertia,
thereby increasing liability to cold injuries.
(af) Local Conditions.
Local injury or skin infection predisposes the particular part to cold injuries.
(ag) Tobacco.
Use of tobacco increases risk of frostbite due to vasospasm induced by it and aggravates the injury
itself on occurrence.
(ah) Alcohol.
Alcohol consumption in large quantities followed by exposure to cold, excessive physical activity or
lethargy increases the risk of general hypothermia and also local cold injuries.
(aj) Cold Adaptation.
Adaptation to cold, although not as effective as acclimatization to heat, is nevertheless an important
factor determining individual vulnerability to cold injuries.
(c) Local Effects of Severe Cold Climate.
Tissues may get injured on exposure to cold producing frostbite, immersion foot or hand or chilblains, depending
upon intensity of cold, duration of exposure and presence or absence of moisture.
(i) Frostbite.
(aa) Introduction.
Freezing of tissues causes this effect. More exposed or distal areas like nose, earlobes, cheeks,
hands and feet are the usual sites of these injuries. Freezing damages tissues by disrupting enzyme
functions, denaturing proteins and crystal formation in extracellular fluid which consequently become
hyperosmotic with respect to intracellular fluid and causes cellular desiccation. Intracellular crystal
formation can further disrupt cellular integrity. Prolonged cooling with or without freezing causes
ischemic injury through vasospasm and microvascular stasis. A train of events follow in tissues
successively producing arterial and arteriolar constriction, venular and capillary dilatation, capillary
leakage, arteriovenous shunts, platelet, fat and RBC aggregation and thrombosis in small veins.
Depending upon the magnitude and duration of exposure, the tissue changes may be confined from
very superficial localized areas to entire thickness of distal portion of digits, which may get devitalized.
Clinically, frostbite begins insidiously with paraesthesia and numbness. When freezing extends just
into epidermis, a shallow blanched wheal formation may take place. This is called frostnip or incipient
frostbite. Freezing that penetrates deeper, results in any one of the four grades of injury.
O First Degree.
This consists of oedema and redness of part without necrosis. If further freezing is arrested,
it resolves fully. Cold sensitivity may be expected for a few weeks after recovery.
O Second Degree.
It is characterized by partial skin thickness involvement of skin with formation of blisters. An
eschar forms in 2-3 weeks which separates in about 4 weeks revealing poorly keratinized skin.
Late sequelae of this degree of frostbite are paraesthesia, tingling pain, hyperhidrosis and

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reactive vasodilatation.
O Third Degree.
There is complete necrosis of skin. To begin with, the part appears lifeless and pale with no
sensation. Pain and swelling appear after a few hours. A thick gangrenous eschar forms in
about two weeks. Healing takes place by granulation. There is inevitably loss of some tissue.
O Fourth Degree.
This involves entire thickness of skin and varying depth of deeper tissues. Individual may have
a complete loss of toes, fingers hand or foot. Demarcation between dead and living tissues
take about one month and spontaneous amputation is usual in another two weeks.
(ab) Treatment of Frostbite.
The principles of treatment of frostbite are as under:
O General.
Prevent further injury to the part and take measures to prevent the continuation of cold stress.
General body warmth should be restored.
O Rewarming.
Rapid rewarming of the part by immersing it in water bath at 42°C for 20 min or until there
is erythematous flushing. It is not recommended to continue rewarming for more than 30 min
as no useful purpose is served after this period. During rewarming there may be excruciating
pain requiring management with analgesics.
O Smoking.
It is absolutely prohibited.
O Drug Therapy.
Administration of intravenous low molecular dextran (Lomodex) is beneficial.
O Local Treatment.
The affected part is covered with sterile cotton lightly. Whirlpool treatment with dilute lukewarm
antiseptic solution should be started early and done twice a day. It reduces risk of infection
and aids debridement.
O Physiotherapy.
It is initiated early to improve the functionality of affected part and improve blood supply.
O Surgical Treatment.
Amputation, excision or skin grafting is always delayed until there is complete demarcation and
separation of gangrenous tissues. Sympathectomy has a role only in late troublesome oedema,
hyperhidrosis and pain associated with vasospasm.
(ii) Trench Foot.
It develops above the critical tissue temperature in combination with dampness. Owing to circulatory
stagnation, catabolites collect in the tissue spaces during the process of cooling and thawing, which
alternate with each other as the external temperature fluctuates frequently. The capillary damage caused
by this process results in extensive transudation in the tissues on thawing. In severe cases this transudate
may become haemorrhagic and there may be blisters and blebs on the skin. There is tissue devitalization.
Clinical manifestation depends upon the degree of pathological changes. The onset is insidious and may
be painful. In the event of nerve involvement, the affected part may be relatively insensitive. Slight trauma
at this stage may pass unnoticed with serious consequences later. The affected part is characterized by
swelling with dusky blue colour followed by an intense flush and severe pain when thawed. There is some
superficial desquamation; paraesthesia may persist for some time. In severe cases the swelling is more
marked, blisters are formed and a portion of the skin may become gangrenous. In more severe cases there

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is intense swelling and the part becomes dark blue in colour. The swelling extends upwards to the leg and
one or more toes become gangrenous. The affected feet are very prone to infection and tetanus. Healing
is very slow and complete recovery is rare. Restriction of joint movements and paraesthesia may remain
permanent.
(iii) Chilblains.
These are localized inflammatory lesions which arise as a result of an abnormal reaction to cold. The
parts involved, which are usually the hands and feet, become red with intense irritation, especially when
warming is attempted. The redness is gradually replaced by a cyanotic tinge and irritation followed by
pain. Desquamation may supervene and bullae or ulceration may develop. These are usually self-limiting.
Therapy is empirical. Prophylaxis by use of warm clothing and gloves is important. Drugs which are not of
proven benefit are calcium, vasodilators and Vitamins B complex, C and K. Ultraviolet light is a time-tested
remedy. Some individuals derive benefit from three weekly doses of ultraviolet light at the beginning of
winter, of sufficient dosage to produce erythema. Cases of resistance to therapy may require change of
climate to warmer zones. Once chilblains appear, treatment is only symptomatic along with antipruritic
local application. When skin is intact, a paint containing 50% menthol in compound tincture of benzoin
as an ointment containing 3% camphor and 0.5% phenol in Lanolin paraffin mixture (equal parts) should
be rubbed gently onto to the affected parts every night and morning after immersing in warm water and
drying them carefully. Sympathectomy has been advocated in cases of crippling severity, not responding to
any other therapy.
(d) Effect of Extreme Cold Climate.
(i) Hypothermia.
(aa) Introduction.
Hypothermia may manifest itself either as accidental hypothermia or hypothermia secondary to acute
illness. Accidental hypothermia develops due to lowering of body core temperature following exposure
to severe cold. On the other hand, hypothermia secondary to acute illness is never accompanied
by history of exposure to cold. Normally the body core temperature is relatively constant at 37°C,
although the body surface temperature in the extremities may be considerably below 37°C in extreme
cold environment. An individual is stated to be suffering from accidental hypothermia, when his rectal
temperature falls below 34°C. This condition occurs when troops are exposed to very severe cold
with high velocity winds in the snow bound areas of high altitude while on patrols or treks. Not only
is acute exposure important, but also the duration of exposure determines severity of accidental
hypothermia. Injury, blood loss, shock, fatigue, anxiety, ingestion of drugs (especially alcohol)
predisposes to this condition. Systemic disorders such as myxoedema, pituitary insufficiency, Addison’s
disease, hypoglycaemia, cerebrovascular accident, myocardial infarction, cirrhosis and pancreatitis
also predispose to accidental hypothermia. This condition is rapidly progressive and if not recognized
early, is fatal. Early recognition and prompt therapy is lifesaving. Recovery is usually complete, but
super-imposed infections especially pneumonia and irreversible cardiopulmonary dysfunction may
occur. The clinical features depend upon the severity and speed or progress of hypothermia and
do not occur in any particular order. Hypothermia may be divided in to mild, moderate and severe
hypothermia.
O Mild.
When the rectal temperature is between 32.2°C and 45.0°C, shivering becomes intense with
loss of fine manual dexterity. Gradually, the individual becomes apathic with poor judgement,
memory lapses, dysphasia, dysarthria and ataxia. If patient can be protected from further heat
loss, the hypothermia is reversible.
O Moderate.
When rectal temperature falls below 32.2°C and up to 27.8°C, shivering is replaced by marked
muscular rigidity and stiff distal movements. Confusion progresses to stupor. The individual may
have a glassy stare. Blood pressure may not be detectable with arm cuff of sphygmomanometer.
Breathing becomes shallow and irregular. Cardiac rhythm irregularities appear with tachycardia,
supraventricular arrhythmias, ventricular extrasystoles and T wave inversion in ECG.

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O Severe.
When rectal temperature is below 27.8°C, deep coma and rigidity develop. ECG may show
classic J wave or Osborne wave notching at end of QRS complex. Pulmonary oedema can occur.
There is great risk of ventricular fibrillation resistant to cardioversion. Lethal temperature can
be highly variable and survival has been recorded with core body temperature as low as 20°C.·
(ab) Treatment of Hypothermia.
Once hypothermia is recognized, treatment must be prompt as under:
O Prevent further heat loss. Remove any wet clothing and cover patient with warm dry
blankets. Protect the victim against wind and weather by a good mattress and cover, which
may be improvised in the field from ground sheets, blankets and polythene sheet. The patient
should be promptly removed to an area where wind effect is minimal. Rewarming can be started
by application of external heat sources.
O If patient is conscious, hot drinks may be given, but alcohol should be avoided.
O During evacuation, attention is especially given to protective clothing, prevention of any
further heat loss, airway maintenance and continued resuscitation.
O There are various rewarming methods once the patient reaches a hospital or a place
where treatment can be given. Rapid rewarming may produce circulatory collapse or “rewarming
shock” which probably is a combination of lactic acidosis, hypoxemia, dehydration, increased
functional demands on heart during rewarming in face of myocardial glycogen depletion.
Rewarming should, therefore, be gradual. When core temperature is below 30°C, internal
rewarming is considered safer. It is done by isotonic peritoneal dialysis with fluid at 100°F,
the fluid being exchanged at the rate of 2 L every 20-30 min, with the intention of raising the
rectal temperature to 30°C as early as possible. Once the rectal temperature exceeds 30°C,
warm water bath can be used to raise body temperature not in excess of 1°C per hour. During
this phase there may be persistent bradycardia, atrial arrhythmias, hypertension and oliguria
which are appropriate to metabolic state of the human body at low temperature. They usually
correct spontaneously with rewarming. Use of diuretics, vasoactive drugs or stimulants like
adrenaline should be avoided.
(e) Prevention of Cold Injuries.
(i) Primary Prevention.
(aa) Health Promotion.
O General Hygiene.
Personal cleanliness, dry clothing, ventilated shelter without drought, a warm bed and adequate
recreational activities are helpful. At least two or three hot baths in a week in snowbound
and cold environs are necessary. Bathing places should be sheltered from wind and snowfall.
However, too frequent use of soap is not good as it removes the greasy sebaceous material
from the skin and decreases insulation.
O Nutrition.
Energy requirement in cold is more due to higher basal metabolic rate. Therefore, to maintain general
heat of the body, energy value of food has to be adequate. Provision of adequate hot and appetizing
meals should also be ensured. Well cooked, nourishing hot food and drinks increase resistance
to cold, promote mental and physical well-being and fortify the body against infection, fatigue and
hazards of privations and climatic extremes. Vitamin C is also necessary for cellular reformation,
vascular endothelial integrity and as steroid sparer. It may be given in the form of multivitamin
tablets. In trenches and pickets frequent hot meals and hot drinks should be provided.
O Exercise.
Regular moderate exercise to maintain circulation without causing any exhaustion or excessive
sweating should be undertaken frequently. When operational or tactical situations do not permit

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movement in the open, static physical activity by frequent vigorous movements of limbs from
time to time and wriggling of toes and moving of fingers should be continuously practiced.
Facial muscles should be wrinkled to keep up the circulation.
O Alcohol.
It should never be consumed in excess over a short duration and none when likely to be exposed
to cold wind, required to undertake excessive exertion, marches or patrol, while in combat or
when proper shelters to sleep are not likely to be available after its consumption.
O Smoking.
It is advisable not to smoke at all. Those who cannot avoid smoking should do so in moderation.
It should be definitely prohibited in persons who have sustained cold injury.
(ab) Specific Protection.
O Shelter.
Shelter from strong wind is essential, especially when resting or sleeping and improvisation
should not be difficult. Facilities for drying clothes should be available in each camp.
O Clothing.
Clothing should be loose and worn in several layers. The outer layer should be impervious and
wind proof. Boots, socks, gloves and headgear should not be tight. Snow clothing should be worn
wherever authorized and training for its proper use should be given to all personnel. Head and
face lose 30% of the body heat due to poor vasomotor control and therefore should be properly
covered. Damp clothing should be immediately changed. Gloves should be slung around the
neck so that hands can be readily withdrawn for essential duties and easily reinserted without
losing the gloves in haste or darkness.
O Boots.
In cold weather, when two pairs of socks are worn, boots become tight and this may compel
the individual to discard them altogether. Therefore, boots should be loose fit, kept soft and
waterproof with dubbin and every person should have an extra dry pair of socks and boots
to change into, if his feet get wet. If persons must work in water or slush, gumboots are of
advantage. Boots moccasin, combat boots or snow boots are issued with cold clothing. Boots
should always be issued after the individual has tried them out with thick woollen socks and
by walking a few paces.
O Socks.
These should not be tight. Every man exposed to intense cold should have four good pairs
of woollen socks all the time. Regular inspection is essential. Badly darned socks become
dangerous by adding an element of trauma. Damp socks should be changed immediately.
O Foot Hygiene.
The feet should be inspected before going to bed every night utilizing the buddy system for
inspecting each other’s feet. Feet must be washed with warm water, thoroughly dried and
smeared with a little Vaseline, before sleeping. This aids ‘supercooling’ and avoids frostbite. An
individual with ulcers and abrasions should be excused duty until they are healed. Foot powder
should be used before wearing socks in the morning to decrease dampness during exertion
and reduce friction with socks.
O Venous Congestion.
Men should not sit for long periods cramped up in vehicles, trenches, enclosed places or upon
the railing with feet hanging down and especially over the edge of seats as this leads to venous
congestion. Too tight clothing also causes venous stagnation.
O Buddy System.
Buddies should observe each other’s face for any early tissue damage. lf the tip of nose,

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earlobes or cheeks of one are affected, the other draws attention and first aid is given.
O Re-exposure.
Persons who have once suffered from cold injury should not be exposed to a similar risk again.
(ii) Secondary Prevention.
Early diagnosis, first aid and prompt treatment are aimed at prevention and arrest of tissue damage. The
treatment of frostbite is directed toward reversing the pathologic effects of ice-crystal formation, vaso-
constriction and the release of inflammatory mediators; therefore, rapid rewarming and anti-inflammatory
agents are still the main components of treatment protocols. As rewarming followed by refreezing can
be more harmful to the extremity than a delay in rewarming, protecting involved extremity and avoiding
rewarming until correct procedures can be performed is recommended. The following actions should be
taken as soon as a case of cold injury is seen.
(aa) All cold injury cases must be treated as lying cases. The patient should be removed to a
sheltered place in warm surroundings with the temperature not exceeding 38°C and given extra
clothing and blankets. At high altitude, oxygen should be given through BLB mask. All constricting
clothing should be loosened and boots removed. The affected part should be kept at absolute rest,
gently but thoroughly cleaned and wrapped in sterile dressing. Blisters should not be opened.
(ab) Normal body temperature should be restored before treating the local injury. The preferred
initial treatment for frostbite is rapid rewarming in a water bath at a temperature of 39-42°C
(102.2-107.6°F). The limb must be kept constantly warm for a long time after thawing. Therefore,
rewarming on the line of march should be avoided, as the aforesaid protocol cannot be adhered to.
Rubbing, massaging, warming by fire, application of hot water bottles or baths above 45°C should
not be used for re-warming since the stagnant circulation in the affected parts cannot carry away the
heat and will produce considerable local tissue damage and oedema. The practice of rubbing snow
on the affected part is unscientific and should never be resorted to.
(ac) Rest, nourishing diet and sleep are essential. Hot nourishing fluid and meals are helpful in
restoring morale and health. Vitamin C and K are often helpful when given before the onset of
the gangrene. Nicotinic acid 100 mg thrice a day increases peripheral circulation by vasodilatation
and reduces tissue destruction. Alcohol is contraindicated as it causes heat loss due to peripheral
vasodilatation. Smoking should be strictly prohibited as it increases vasospasm.
(ad) No hypnotic, analgesic or pain relievers are necessary or indicated except Ibuprofen. Heparin
100 mg may be added only if no other wounds are present. Low molecular weight dextran
0.5-1.0 L, given shortly after injury is also effective in reducing residual tissue damage. Other measures
include elevation of the injured part and early institution of physiotherapy. Regional sympathectomy
performed 24-48 h after thawing significantly reduces residual damage. Intra-arterial reserpine has
effects like sympathectomy.
(ae) A booster dose of 0.5 ml of tetanus toxoid must be given to preimmunized persons and tetanus
antitoxin 3000 units to all who are not pre-immunized. Infection must be prevented and combated
with antibiotics.
(af) Ordinary cases showing hyperaemia with subsequent desquamation of the epidermis will not
require any particular treatment except rest, hot food and drinks, warmth, Ibuprofen and supervision
for 48 h in warm environment. When necrosis extends through the whole diameter of the digit or
limb, surgical treatment should be urgently considered. Signs of progressive sepsis or gangrene is
an indication for amputation as a life-saving measure.
(f) Adaptation to Cold.
Adaptation to cold is slower and less efficient than acclimatization to heat. It is automatically affected when
troops are inducted to cold areas in summer and stay on over one or two winters or gradually taken up the
mountains in stages. However, when they are suddenly inducted to cold areas in winter, the adverse effects
of cold may appear in a large number of persons. Systematic acclimatization to cold can be carried out under
such circumstances by exposing newly inducted troops to the ambient temperature of 0°C to 5°C for three or
four hours a day for three consecutive weeks in accordance with the following procedures.

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(i) During the first week troops should be dressed in vest cotton, shirt Angola drab (sleeves rolled down),
jersey pullover woollen, trousers battle dress, cap comforter, gloves knitted, boots worn with only one pair
of socks woollen. Outside the exposure hours, troops can wear the normal snow clothing authorized. During
the next two weeks jersey pullover should be removed.
(ii) Site selected for exposure should be sheltered from wind. If there is any wind or breeze, troops should
wear the outermost wind proof layer of coat parka without its inner lining or pile layer.
(iii) Physical exercise warms the body and hence impedes the acclimatization process. During the hour of
exposure, physical exercise should not be allowed but normal sedentary military duties such as educational
classes, lectures, training classes etc which do not involve much physical activity may be carried out.
Exposure programme can be conveniently carried out while acclimatizing for high altitude as per A° 110/80
and DG Memorandum no 189, during the periods of relaxation during its course.
(iv) Troops should be reassured that exposure to cold for cold acclimatization will cause no harm. A very
small number of personnel may not be able to stand exposure for three hours in the early stages. If any
complaint like rhinitis, pharyngitis, fever, excessive shivering or cramps are noticed, the exposure should
be discontinued for the day or until cured. It can be restarted and gradually increased day by day when
the individual has recovered.

6.19 Effects of High Altitude.

ALTITUDE IN METERS (IN HUNDREDS)
780
760 15 50 75 100 125 150 175 200 225 250
720

640

560
BAROBETRIC PRESSURE (MM HG)

480

460

320

240

160

80

0
0 8 16 24 32 40 48 56 64 72 80
ALTITUDE IN FEET (IN THOUSANDS)

Fig 6.20 : Relationship between Altitude and Atmospheric Pressure

(a) Environment.
Effects of high altitude are encountered in aviation and by troops deployed at high altitudes. The environmental
conditions at high altitudes which influence physiological processes are low atmospheric pressure and partial
pressure of oxygen, low temperature and humidity, increased intensity of sunshine and cosmic radiation and
isolation under monotonous mountain conditions. The chief hazards on health primarily arise from the low
atmospheric pressure, coupled with low partial pressure of O2 in the alveolar air leading to low oxygen tension
in the blood and low ambient temperature both decreasing, as the altitude increases (Fig 6.20 & Table 6.4).
Effects of hypothermia have been described in the preceding paragraphs. There is no difference in their aetiology,
manifestation, prevention and first aid at high altitude, except that they are aggravated due to atmospheric and
tissue hypoxia.

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Table 6.4 : Altitude, Pressure, Temperature, Oxygen, Partial Pressure and Equivalent Oxygen Percentage
Altitude Pressure Temperature Oxygen Partial Equivalent
Pressure Oxygen
Feet Meters (mm Hg) °C Decrease °C (mm Hg) Percentage
0 0 760.0 15 0 159.2 20.96
1,000 305 733.0 13 -2 153.6 20.18
2,000 610 706.6 11 -4 148.1 19.46
3,000 914 681.0 9 -6 142.7 18.76
4,000 1,219 656.4 7 -8 137.5 18.07
5,000 1,524 632.4 5 -10 132.5 17.41
6,000 1,829 609.0 3 -12 127.6 16.77
7,000 2,134 586.4 1 -14 122.9 16.15
8,000 2,438 564.4 -1 -16 118.2 15.54
9,000 2,743 543.2 -3 -18 113.8 14.96
10,000 3,048 522.6 -5 -20 109.5 14.39
11,000 3,353 502.6 -7 22 105.3 13.84
12,000 3,658 483.2 -9 -24 101.2 13.31
13,000 3,962 464.6 -11 -26 97.3 12.79
14,000 4,267 446.4 -13 -28 93.5 12.29
15,000 4,572 428.8 -15 -30 90.5 11.81
16,000 4,877 411.8 -17 -32 86.3 11.34
17,000 5,182 395.4 -19 -34 82.8 10.89
18,000 5,486 379.4 -21 -36 79.5 10.45
19,000 5,791. 364.0 -23 -38 76.2 10.02
20,000 6,096 349.2 -25 -40 73.1 9.61
(b) Physiological Adaptation.
(i) The lowered partial pressure of oxygen at high altitude causes alveolar and arterial hypoxia leading
to tissue hypoxia (Fig 6.21). Tissue oxygen demand at high altitude is the same as that at sea level and
oxygen requirement for a given task remains almost constant at different altitudes. In order to meet the
tissue oxygen demand at high altitude the cardiac output per minute has to increase and in order to
ensure adequate oxygenation of blood, pulmonary ventilation has to increase. These requirements are
initially achieved by hyperpnea and tachycardia arising out of hypoxic drive. As the stay at high altitude
continues, the increased heart and respiratory rates are replaced by increased amplitudes. A series
of further physiological adjustments take place depending on the rate of ascent, altitude attained and
period of stay at that altitude, by adaptation of the haemopoietic, cardio-vascular, respiratory and nervous
systems. The haemochemistry and haemodynamics undergo change and rapid cardiovascular functional
modification occurs. Glucocorticoids and vasopressin are released in the bloodstream to counteract stress
of hypoxia. The number of circulating RBCs, haemoglobin concentration in RBC, size and volume of red
cells, pulmonary ventilation, vital capacity, pulse rate, circulating blood volume, circulation rate and cardiac
output all undergoes changes.

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ALTITUDE IN MEETERS (IN HUNDREDS)

15 30 45 60 75 90
160

140

120

100
OXGEN TRANSITION (MM HG)

80

60 100

PIO2
SaO2 (in Percent)

40 80
PAO2
SaO2
20 60

0 40
5 10 15 20 25 30
ALTITUDE IN FEET (IN THOUSANDS)

Fig 6.21 : Relationship between Alveolar and Arterial Oxygen Saturation with the Hypoxia at Altitude
(ii) Circulatory and haemopoietic adjustments are variable and do not normally occur to an appreciable
extent among Indians up to an altitude of 2500 m. Beyond that altitude, the variation in haemodynamic
and concentration of available RBCs in the peripheral circulation appear first; the increase in the respiratory
and heart rate closely follows; haemopoietic response brought about by erythropoietin occurs next; and
finally, the increased amplitude of respiratory and cardiac movements gradually replaces the increased rate.
This completes the early process of adaptation. Interstitial fluid is diverted to the vascular compartment
which causes hypervolemia, overloading the pulmonary circulation and cardiac function. Due to increased
pulmonary ventilation, tissue CO2 is washed out, alkalosis occurs and the CO2 tension in the blood
is decreased. Hypocapnia (lowered CO2 tension in the blood) due to hyperventilation leads to shifting
the oxygen dissociation curve to the left and decrease in cerebral and coronary flow, leading to other
complications. Altered pH (alkalosis) of the blood is partially rectified by increased excretion of alkaline
urine, thus restoring the left shift of oxygen dissociation curve as the acclimatization process continues.
But the major readjustment in respiratory system is brought about by increased 2-3-diphosphoglycerate of
RBC which in turn offsets the effects of left shift of Oxygen Dissociation Curve and thus restores oxygen
delivery to the tissues. The cause for pulmonary hypertension which is a common observation in high
altitude is not known. During initial phase it is relieved by oxygen inhalation.
(iii) Stimuli for adaptation becomes operative when the atmospheric pressure decreases by 30%, which
occurs at the height of 2,500 m. These mechanisms are usually uneventful and insensible up to about
3,000 m. Beyond such altitude, when pronounced physiological mechanisms are activated, the symptoms
of ‘early mountain sickness’, which in reality are the symptoms of ‘rapid acclimatization’, become manifest.
If acclimatization is inadequate or if the ascent to higher altitude is too rapid, the essentially beneficial
adaptive responses are minimized leading to adverse clinical manifestations.
(iv) The factors determining the magnitude of physiological responses are the rapidity of exposure to
low atmospheric pressure, severity and duration of exposure to reduced partial pressure of oxygen and
the general physical condition of the individual. The various symptoms of high-altitude sickness essentially
arise from the lag in adjustment of the body to increasing hypoxia and partial lack of cardiopulmonary
co-ordination to meet the challenge of tissue hypoxia in the face of atmospheric hypoxia coupled with the

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altered haemodynamic. Symptoms are, therefore, more severe and frequent during rapid ascent and also at
nighttime due to an increased blood volume in the lungs caused by horizontal posture and nonequilibrium
of the forward force of and venous return to the heart. Cerebral hypoxia causes mental symptoms.
(c) Clinical Syndromes.
The most frequent and important clinical problems encountered at high altitude are as under:
(i) Acute mountain sickness.
(ii) Acute pulmonary oedema.
(iii) Chronic Pulmonary Hypertension
(iv) Coronary and Cerebrovascular insufficiency and congestive cardiac failure
(v) Seroche-Monge’s disease
(vi) Flare up of pre-contracted infections.
(vii) Worsening of Diabetes Mellitus
(viii) Psychological effects
(d) Acute Mountain Sickness.
Depending on the altitude, an individual may suffer from mild to severe symptoms. Between 3,350 and 4,300 m
of height, headache, insomnia or disturbed sleep, occasional palpitations, nausea and rarely vomiting are common
symptoms. Above that height, severe headache, giddiness, disinclination to work, depression and persistent
insomnia commonly occur. Loss of appetite, nausea and vomiting may occur in more severe cases which may
progress to breathlessness and Cheyne-Stoke’s respiration. Muscular weakness and fatigue occur at a later
stage. At heights greater than 4,300 m, headache, depression, apathy and drowsiness are marked. On the other
hand, there may be excitement, general loss of emotional control with exhibit of dangerous behaviour. Memory
is impaired, appreciation of time altered and danger goes unheeded. Above 4,500 m these symptoms become
more common, severe and persistent. Breathlessness at rest, palpitation, muscular weakness and fatigue may
supervene thereafter. Hallucinations, mental irritability, lack of concentration and weight loss may occur among
some individuals after variable periods of stay in high altitude. Persistent cough, severe breathlessness on slight
or no exertion and pain in the chest herald the most severe of all the hazards i.e., ‘Pulmonary Oedema’.
Normally very few symptoms in individuals below 3,300 m if the ascent is gradual. But on rapid ascent,
breathlessness occurs almost universally. The incidence of symptoms increases with the altitude of deployment.
However, all symptoms do not affect every individual; most individuals are symptomatic for a short duration
and recover spontaneously without any intervention. In some individuals however, an initial phase, in which the
symptoms are relieved with oxygen, is followed by a more resistant phase, which does not readily respond to
such measures or acclimatization and necessitates transferring the individual to a lower altitude. Re-induction of
such persons necessitates prolonged acclimatization at all stages. Some individuals repeatedly fail to acclimatize
and should not be re-inducted after the second or at the most, third failure.
The following measures should be taken for amelioration of symptoms:­
(i) Thorough acclimatization as mentioned in A° 110/80, discussed in detail in chapter XIII.
(ii) Ample intake of fluids in the form of tea, coffee or malted drinks at frequent intervals.
(iii) Avoidance of smoking, alcohol and late dinners.
(iv) Aspirin for relieving headache and mental irritability.
(v) Men should be encouraged to report sick if feeling unwell. Such individuals should not be left
unsupervised.
(vi) In case the symptoms persist, they should be moved to a lower camp for 2-3 days. They can be
brought up again when the symptoms clear.
(e) Acute Pulmonary Oedema.
Pulmonary oedema is the most important and serious effect of rapid exposure to high altitude and may occur at

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any altitude above 3,000 m. It progresses rapidly and may be fatal if not recognized early and treated promptly.
Susceptibility is high in individuals who have had prior episodes of high-altitude pulmonary oedema or in well
acclimatized individuals returning to high altitude areas after staying for a few weeks at sea level, young males
under 20 and any individual who rapidly ascends above 3,000 m and engages in vigorous physical activity
immediately. Viral infections of the respiratory tract, previous episode of ischemic heart disease and hypertension
may also predispose.
Symptoms appear within three or four days or earlier after arrival at high altitude, especially if associated with
immediate physical activity and consists of dyspnoea, cough, nausea, vomiting, chest discomfort and pink,
frothy sputum. Physical signs include cyanosis, tachycardia, hypertension and pulmonary rales, but there is no
evidence of pneumonia, cardiac enlargement or heart failure. Clinical evidence of infection such as chills, high
fever, leucocytosis, increased ESR or purulent sputum is infrequently encountered in cases of pulmonary oedema.
The oedema clears rapidly with bed rest and oxygen or removal to lower altitudes. X-ray chest reveals pulmonary
vascular congestion and patchy pulmonary densities, most marked in the middle and upper 1/3 zones and more
on the right than the left side; the lower zone may be relatively clear. Autopsy shows congestion of pulmonary
circulation as the most constant finding and weight of the lungs is increased due to oedema, which may be
extensive or only noted microscopically. Dilatation of the right ventricle may be present but the left ventricle is
normal. Thorough acclimatization and avoidance of physical exertion during immediately on the arrival in high
altitude can prevent acute pulmonary oedema. Persons suffering from nose and throat infections should be
advised not to go to high altitude by air.
Acute mountain sickness and high-altitude pulmonary oedema seems to be clinical variants of the same disorder,
because pulmonary adventitious sounds are often found in severe acute mountain sickness without the clinical
picture of frank pulmonary oedema. An individual may suffer from either or both illnesses. A definite time lag
exists between arrival at high altitude and onset of these illnesses. During this period, oliguria develops and
induced diuresis ameliorates the symptoms of both conditions. In both these conditions, the normal immediate
hyperpnea response to a fall in the alveolar oxygen tension fails to develop and the respiratory rate does not
increase. There may be irregular breathing and breathlessness on slight exertion, Cheyne-Stoke’s breathing,
fullness, discomfort or pain in the chest in both conditions. Crepitations appear over the lungs in about one-third
of the cases of acute mountain sickness and the expiratory peak flow is significantly diminished. Pulmonary
oedema, oliguria and many of the symptoms of acute mountain sickness are due to lack of respiratory adjustment
and rapid increase in pulmonary blood volume. The underlying mechanism causing the increase in pulmonary
blood volume is complex and unclear.
(f) Chronic Pulmonary Hypertension.
A certain degree of pulmonary hypertension is inevitable after about 6 months stay above 3,600 m. Individuals who
have had high altitude pulmonary oedema and have returned to high altitude after staying at sea level for some time
are particularly predisposed. The cause of pulmonary hypertension is also not exactly known but hypoxia does not
appear to be a direct cause as oxygen therapy has variable effect on it. Long persistence of this condition results in
fibrin deposits in alveolar capillaries and branches of the pulmonary arteries which cause obstruction to the blood
flow resulting in pulmonary hypertension. Similar fibrin thrombi are observed plugging the glomerular and peritubular
capillaries of the kidneys and sinusoids of the liver. Additionally, there is intra alveolar deposition of fibrin, aggregated
in places to form typical hyaline membrane, akin to those found in various types of juvenile pulmonary lesions. This
may occur without polycythaemia and may persist for long after the red cell count becomes normal on return to sea
level. At high altitude, there may be a breakdown of the fibrinolytic enzyme system upsetting the equilibrium between
fibrin formation and fibrin dissolution, involving both veins and arterioles. The result of increased pulmonary vascular
resistance is right ventricular hypertrophy, which leads to failure.
However, a majority of personnel get only mild hypertension and its mere presence does not always reflect
adversely on the physical fitness of the affected individual. Only a small proportion of those who get pulmonary
hypertension become unfit for retention locally on account of diminished performance and need evacuation to
sea level. After arrival at sea level, it usually regresses within three weeks. Evacuation to sea level becomes
necessary if the individual is dyspnoeic, having chest pain of anginal type, a split second pulmonary sound
especially associated with a pulmonary systolic murmur, a prominent pulmonary artery on X-Ray examination and
any or all of the following E.C.G. changes; Grade 1 right ventricular hypertrophy (dominant R in VI or dominant
S in V5); right ventricular strain (T inversion in V1-V4) and QRS above 0.10.
Coronary Insufficiency, Congestive Cardiac Failure and Cerebrovascular Insufficiency: The dual stress of hypoxia

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and cold may predispose a susceptible individual to these conditions. The susceptibility is possibly related to
asymptomatic atherosclerosis that existed before the individual was inducted to a high-altitude area.
(g) Other Effects.
(i) Individuals who had contracted viral or amoebic hepatitis infections prior to induction in high altitude,
run a considerable risk of a more fulminant clinical course on exposure to high altitude.
(ii) Prolonged exposure to hypoxia after acclimatization may produce other minor health effects insidiously
after a long latent period.
(iii) Dimness of vision, loosening of teeth, progressive diminution of work capacity, loss of weight, flatulence,
indigestion, thyroid deficiency and increased severity of infections may be encountered.
(h) Prevention of Effects of High Altitude.
(i) Individual tolerance to hypoxia varies and has no correlation with physical fitness in its ordinary sense.
Complacency or bravado, which in itself is one of the symptoms of hypoxia, encourages excessive physical
activities without proper and adequate acclimatization. Rapid ascent without acclimatization followed by
physical activity increases the risk of effects of hypoxia. Even after acclimatization, the capacity for physical
activity of even the most robust persons is lesser at high altitude than in the plains. Therefore, commanders
may be reminded that more man-hours or more personnel are required to perform similar physical tasks at
high altitude than in the plains. Lack of appreciation of this fact can result in men over-exerting themselves
to complete allocated task and often incurring casualties in the bargain.
(ii) Acclimatization.
It is important that troops when posted above 2,700 m should be systematically acclimatized. Procedure
and schedule of acclimatization have been discussed in chapter XIII on survival in HAA and Antarctica.

6.20 Global Warming & Ozone Attenuation.

(a) Mechanism.
Earth’s climate and atmospheric composition have been changing throughout its 4 billion years of existence.
Population explosion and rapid industrialization have affected the entire ecosystem. Within a short span of time
(taking into account the evolutionary period of earth) from 1900 AD to 2023 AD the population has increased by
almost 5 times (1.6 billion to 8.1 billion). Increased human activity inclusive of rapid industrialization, urbanization
and increased burning of fossil fuels coupled with deforestation has led to Global warming affecting the earth’s
ecosystem through changing climatic & environmental conditions. The earth’s mantle of atmosphere consisting
of various gases acts like a Green House allowing the passage of short wavelength solar radiation into the
biosphere, trapping longer wavelength infrared radiations. The presence of these atmospheric gases acts like
an insulator for the earth and prevents excess of heating and cooling during the day and night respectively. This
phenomenon is known as the Green House Effect. There are two types of greenhouse gas effects: natural and
enhanced. The natural greenhouse effect is driven by natural levels of greenhouse gases, playing a crucial role
in sustaining life on Earth. Without the natural greenhouse effect, the Earth’s surface would be approximately
33°C colder. On the other hand, the enhanced greenhouse effect refers to the additional radiative forcing
caused by elevated concentrations of Green House Gases (GHGs) resulting from human activities. The primary
GHGs experiencing increasing atmospheric concentrations include carbon dioxide (CO2), methane (CH4), nitrous
oxide (N2O), Hydro Chloro Fluoro Carbons (HCFCs) and Hydro Fluoro Carbons (HFCs). These main GHGs tend to
accumulate in the atmosphere due to their extended lifetimes. As per the data of NASA Earth Observatory, the
average global temperature on Earth has increased by at least 1.1°  C (1.9° F) since 1880. The majority of the
warming has occurred since 1975, at a rate of roughly 0.15 to 0.20°C per decade.
Increased combustion of petroleum fuels through ever increasing automobiles, accelerated by global industrial and
commercial development are adding several polluting gases to the atmosphere in large quantities. Globally, About
35 billion tonnes of carbon dioxide are being added to the atmosphere annually. Tropical rain forests, an important
carbon sink is being rapidly depleted due to human activities. The population of unicellular phytoplankton in
sea, another carbon sink is steadily declining due to increased ultraviolet radiation flux caused by depletion of
stratospheric ozone. These are resulting in increased concentration of carbon dioxide within the greenhouse
which would trap more solar radiation in the biosphere leading to Global Warming. It is predicted that the mean
global temperature might increase by 1°C to 3.5°C in the twenty first century with all its adverse effects.

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Ozone (O3) is formed through the combination of an O2 molecule with an oxygen atom under the influence of
solar radiation. The average concentration of ozone is about 300 parts per billion by volume in the atmosphere,
of which 90% is present in stratosphere. Ozone even in such quantities plays a vital role in supporting life on
earth. The conversion of Ozone to oxygen molecules and reforming into ozone under the influence of solar
radiations helps in conversion of solar energy to heat. Ozone exerts its protective effect by absorbing ultraviolet
radiation of wave lengths from 290 to 315 nm. Each molecule of Chloro Fluoro Carbons (CFCs) which are used
in the refrigeration industry, as propellants in aerosol sprays, blowing agents for plastic foam and as cleansers in
electronic industry can destroy 10,000 ozone molecules. Other compounds like halocarbons, oxides of nitrogen
etc can also destroy ozone. Reduction in ozone concentration would permit unhindered passage to Ultraviolet
radiation with its consequent harmful effects.
(b) Effects of Exposure to Ultraviolet Radiation are as under:
(i) Skin Conditions.
Skin lesions vary from simple sunburn like lesions to cancers (squamous cell & basal cell carcinomas and
other malignancies).
(ii) Eye Lesions.
Keratitis and cortical/subcapsular cataracts.
(iii) Immunity.
Excess UV radiation can cause lowering of general immune response.
(iv) Aquatic Ecosystem.
Exposure to excessive UV radiation can lead to impaired larval development, decreased reproductive capacity
in some amphibians, shrimp & fish and also damage phytoplankton communities.
(v) Plants.
The response to excessive UV radiation varies widely among species, in the form of timing of developmental
phases or the allocation of biomass to the different parts of the plant.
(c) Effects of Global Warming.
The effects of global warming on human health are both direct and indirect which include the following:
(i) Heat Stress.
An increase in average global temperature will result in experiencing irregular heat waves at mid latitude
levels. Minimum temperatures at night and winters would increase more rapidly than average temperatures.
A warmed atmosphere holds more water vapor (6% more for each degree Celsius) resulting in increased
humidity and heat waves.
(ii) Weather Disasters.
Global warming would result in frequent & more severe storms with heavy precipitation and flooding, mainly
in coastal areas.
(iii) Rising Sea Levels.
The rate of Global Mean Sea Level (GMSL) rise from 1993 to present has been measured at 3.4 millimetres
per year. This is attributed to thermal expansion of oceans, melting of glaciers and ice caps. Mainland
coastal regions and islands are the worst affected. In addition, adjacent land would be rendered unfit for
agriculture by the rising salinity of water table.
(iv) Climate Change & Infectious Diseases.
Outbreaks of vector borne diseases which are dependent on climatic factors would be common as
temperatures coupled with increased humidity would help enhance vector breeding and survival.
(d) Recent Updates.
In an effort to tackle the effects of global warming following advances has been made globally and at national
level:

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(i) Conference of Parties (COP 28).

Nearly 200 countries agreed to a new climate deal at the COP28 held in Dubai in December 2023,
urging the countries to move away from fossil fuels, the main driver of the climate crisis, some experts
declaring that it signals the beginning of the end of the fossil fuel era. The signatories to the agreement
are committed to “contribute” to global efforts to reduce carbon pollution and actions that can be taken,
including “transitioning away from fossil fuels in energy systems, accelerating action in this critical decade,
to achieve net zero carbon pollution by 2050. The agreement also entails for tripling of renewable energy
capacity and a doubling of energy efficiency by 2030. The Global Cooling Pledge for COP 28 includes 66
national government signatories committed to working together with the aim of reducing cooling-related
emissions across all sectors by at least 68% globally relative to 2022 levels by 2050. 37 nations have
agreed to the Mutual Recognition of Certification Schemes for Renewable and Low-Carbon Hydrogen and
Hydrogen Derivatives will seek to work towards mutual recognition of their respective certification schemes
on low-carbon hydrogen and hydrogen derivatives.
(ii) National Green Hydrogen Mission.
India has set goals of becoming energy independent by 2047 and reaching Net Zero by 2070. To realize these
objectives, a pivotal focus of India’s Energy Transition involves promoting the increased use of renewable
energy across various economic sectors. Green Hydrogen is seen as a promising solution to facilitate this
transition. Its applications include long-term storage of renewable energy, substituting fossil fuels in industrial
processes, supporting clean transportation and potentially contributing to decentralized power generation,
aviation and marine transport. The National Green Hydrogen Mission, aims to achieve the following objectives:
(aa) Making India a leading producer and supplier of Green Hydrogen in the world.
(ab) Creation of export opportunities for Green Hydrogen and its derivatives.
(ac) Reduction in dependence on imported fossil fuels and feedstock.
(ad) Development of indigenous manufacturing capabilities.
(ae) Attracting investment and business opportunities for the industry.
(af) Creating opportunities for employment and economic development.
(ag) Supporting R&D projects.
(iii) Pradhan Mantri Suryodaya Yojana.
Pradhan Mantri Suryodaya Yojana aims to provide electricity to low and middle-income individuals through
solar rooftop installations, along with offering additional income for surplus electricity generation. Massive
national campaign to be started to mobilize residential segment consumers to adopt rooftop solar in large
numbers and installing rooftop solar on one crore houses.

Suggested Reading.
1. Cg, Warner. “Measurement of the Thermal Environment in Industry.” Occupational Medicine, vol. 15, no. 1, 1 Jan.
1965, pp. 83–88, academic.oup.com/occmed/article-abstract/15/1/83/1421438?redirectedFrom=fulltext, https://doi.
org/10.1093/occmed/15.1.83. Accessed 2 Apr. 2024.
2. “HOT ENVIRONMENTS—MEASUREMENT and TOLERANCE ESTIMATION*.” The Annals of Occupational Hygiene,
Feb. 1975, https://doi.org/10.1093/annhyg/17.3-4.255. Accessed 9 Oct. 2021.
3. Hultgren, Herbert N. “High Altitude Medical Problems.” Western Journal of Medicine, vol. 131, no. 1, 1 July 1979,
pp. 8–23, www.ncbi.nlm.nih.gov/pmc/articles/PMC1271618/.
4. Johnson, L. A. “Accidental Hypothermia: Peritoneal Dialysis.” JACEP, vol. 6, no. 12, 1 Dec. 1977, pp. 556–561,
pubmed.ncbi.nlm.nih.gov/926514/, https://doi.org/10.1016/s0361-1124(77)80428-0. Accessed 2 Apr. 2024.
5. Marriott, H. L. “Water and Salt Depletion: Part II.” Br Med J, vol. 1, no. 4496, 8 Mar. 1947, pp. 285–290, www.
bmj.com/content/1/4496/285, https://doi.org/10.1136/bmj.1.4496.285. Accessed 2 Apr. 2024.
6. Singh, Inder, et al. “HIGH-ALTITUDE PULMONARY HYPERTENSION.” The Lancet, vol. 286, no. 7404, July 1965,
pp. 146–150, https://doi.org/10.1016/s0140-6736(65)90229-1. Accessed 4 Oct. 2020.
n

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Chapter
VII
HEALTH PROBLEMS DURING MOVE & TRAINING
“A camps’ situation should be strong by nature and there should be plenty of wood, forage, and water. If the
army is to continue in it for any considerable time, attention must be paid to the salubriousness of the place.
The camp must not be commanded by any higher grounds from where it might be insulted or annoyed by the
enemy, nor must the location be liable to floods which would expose the army to great danger. The dimensions of
the camps must be determined by the number of troops and quantity of baggage. The health of troops depends
on the choice of situation and water, on the season of the year, medicine, and exercise. As to the situation, the
army should never continue in the neighborhood of unwholesome marshes any length of time, or on dry plains
or eminences without some sort of shade or shelter. In the summer, the troops should never encamp without
tents. And their marches, in that season of the year when the heat is excessive, should begin by break of day
so that they may arrive at the place of destination in good time. Otherwise, they will contract diseases from the
heat of the weather and the fatigue of the march. In severe winter they should never march in the night in frost
and snow or be exposed to want of wood or clothes. A soldier, starved with cold, can neither be healthy nor
fit for service. The water must be wholesome and not marshy. Bad water is a kind of poison and the cause of
epidemic distempers.”
— R. Flavius Vegetius. De re militari  
   (4th Century C.E.)

A soldier, who is well nourished, physically & mentally fit and well rested, is better able to withstand the rigors of
deployment, perform at a higher level, be more resistant to the effects of the existing environmental & occupational
health threats and more resilient in overcoming any adverse effects. This was evident to Vegetius when he wrote about
the health of the Roman legions in the 4th century. It remains just as relevant to modern militaries. Medical authorities
at all levels therefore need to be aware of the spectrum of preventive health measures about move and deployment
of troops and be able to implement interventions customized to the local situation.
During military deployments, there is a combination of social, physical, psychological and environmental factors which
can result in adverse health effects for troops. Troops must be guarded against preventable and foreseeable health
issues which are unique to each terrain and mission.

7.1 Risk Assessment.

Medical officers on staff appointments at administrative headquarters must keep themselves abreast of the tactical
and strategic objectives of the planned move. They must work closely with logistics department (Q branch) to draw up
a detailed blueprint of the planned move. The nature of the move (road, rail, air or on foot), number of troops involved,
number of vehicles, duration of the move, proposed route, prevailing weather conditions and prevalent disease burden
at intended destination are all factors which may affect the health of troops. A deliberate risk assessment exercise
must be subsequently carried out taking the above-mentioned factors into consideration. It must be kept in mind that
risk analysis is uncertain and open to revision given change in any of the determining factors or emergence of new
information. It is also important to distinguish between the likelihood of a risk being realized, the severity of the risk if
it is realized and the time of onset and duration of the harm if it is realized. Risk analysis for each component factor
must be calculated as range of values. The risk analysis exercise must conclude with a discussion with commanders
at higher headquarters as well as battalion level to arrive at an acceptable level of risk by adjusting the influencing
factors. The acceptability of risk for moving troops to deny strategic gains by enemies will be different to that for a
training or administrative move.

7.2 Risk Communication.

Adoption of healthy behaviours by troops is the most important factor leading to success of preventive health activities. While
trained military personnel are used to following orders, the implementation of health-related orders is improved if troops
are aware of what risks these orders are meant to mitigate. Adherence to orders prohibiting climbing on roof of military

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vehicles / railway wagons while loading / unloading military trains is likely to improve if troops are made aware of the risks
of electrocution from overhead power lines. Knowledge of the high incidence of heat stroke cases at the destination station
is a motivating factor for individuals to be meticulous about hydration and sub-unit commanders to plan work schedules with
adequate rest breaks. The challenge for medical authorities and commanders is to decide what level of risk to communicate
and the chosen medium for the communication. Some risks are likely to lead to harm, some are unlikely to lead to harm,
and some fall between these extremes. While some risks may be addressed in daily briefings by sub-unit commanders at
their level, some others may require the commanding officer to issue special orders.  
Some of the commonly observed health problems among troops during movement of unit or formation in various
environments are depicted in the Table 7.1.
Table 7.1 : Commonly Observed Health Problems among Troops During Movement
Problems Illness
All moves Road traffic accidents, Injuries
High ambient temp Prickly heat, Heat exhaustion, Heat cramps, Heat syncope, Heat stroke
Cold climatic conditions Respiratory group of illness, xanthematous skin conditions, frostbite, Trench
foot, chillblains, hypothermia.
Mountains Acute Mountain Sickness, Pulmonary edema, Cerebral edema
Solar radiations Skin tanning, Skin burns, Snow blindness, Solar dermatitis.
Dust Chronic eye infections, Irritation of eyes, Aggravation of pre-existing respiratory
illness like bronchial asthma
Vector borne diseases Malaria, Dengue, Scrub typhus
Food and water borne diseases Diarrhea / dysentery, Viral hepatiis, Typhoid, Worm infestations, Food poisoning
Local flora and fauna Allergic manifestations, Snake / scorpion bites
Poor personal hygiene Skin infection, Scabies, Dandruff

7.3 Accident and Injury Prevention.

During mobilization / exercise, there is always an increased risk of accidents, particularly road traffic accidents.
Causation is multifactorial. Injuries result from an interplay of sub-optimal physical conditioning, weather & terrain
factors, inadequate rest & recovery, heavy or unwieldy loads and defective equipment including clothing and footwear.
Local commanders must demand and ensure peak physical conditioning of troops. A scientifically structured and graded
training program to improve physical fitness must be scheduled well in advance of any impending move. Buddy pair
supervision of personal equipment and load preparation should be ensured. Details of the move, specifically weather
conditions enroute and terrain factors must be intimated to the troops in advance allowing them adequate preparation
time. Any positive feedback from troops must be given due weightage and if required move schedules may be altered
to allow for adequate rest and recovery.
The common causes of road accidents are excessive speed, poor road conditions, unusual behaviour of men & animals,
disregard of road signs, defective vehicles, fatigue amongst drivers, alcoholism & drug addiction in drivers, poor physical
health of drivers incl vision / hearing defects & other physical defects, low intelligence & accident proneness, anger, fear,
worry & stress amongst drivers, the overconfidence of drivers and lack of training / practice of driving, particularly in hilly
terrain. A regular schedule of refresher training must be devised and implemented for all drivers. In addition, drivers must
be briefed about road safety measures before the planned move. Drivers must ensure the roadworthiness of vehicles before
driving out of MT and maintain strict road discipline during movement. Subunit commanders must ensure:
(a) No issue of alcohol two days before movement.  
(b) Org and conduct training including mock drills for move.
(c) Prepare proper load tables before movement.  
(d) Use of protective equipment like helmets, goggles, gloves etc by troops while managing heavy & dangerous
equipment.

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(e) Supervision of loading and unloading of stores / equipment.  

(f) Drivers are given adequate rest.  
(g) Enabling an environment which encourages individuals to identify and report potential hazards.

7.4 Camp Selection and Layout.

When occupying a new or unimproved area, commanders must plan for and procure field hygiene and sanitation facilities
and equipments. These facilities and equipments include DTLs, bathing, hand washing and laundry facilities. Planning
considerations should include the type and number of facilities needed to meet per authorization and requirements
of the organization. Operational exigencies override other considerations, but the following guidelines are suggested
for the siting of camps:
(a) Campsite to be at least 1 km away from civilian habitation, refuse dump and stagnant water body.
(b) Camp to be located on high ground but with adequate wind protection.
(c) Camp should be sited as near as possible to potable water source.  
(d) Occupy areas away from insect and arthropod breeding areas such as natural bodies of water or densely
vegetated patches.  
(e) Deep Trench Latrines (DTLs) must be on the lee ward side not more than 200 m from living quarters.
(f) Latrines should be sited away from waterpoints.  
Daily cleanliness inside and outside the camp is to be ensured. Drainage system near water / bathing point to be
made. All drains must lead to a soakage pit to prevent water stagnation. Nearby village / civil habitation to be made
‘out of bounds’ for troops. Make adequate storage arrangement for water, both for drinking and washing. Make snake
trench (60 cm x 60 cm) all around the living accommodation. Necessary arrangements for putting up mosquito net
inside the tents also to be made.  

7.5 Excreta & Waste Disposal and Fly Control.

Housefly nuisance is imminent in operational areas if preventive measures are not observed with diligence. DTLs at
the scale of 15% and funnel urinals at the scale of 4% of the troop’s strength must be carried along. The same may
be demanded well in advance from formation Engineer support. While establishing the camp, select a suitable site for
DTLs and establish DTL as per the specifications. Regular maintenance of DTLs must be ensured by cleaning by daily
scrubbing & drying of the superstructure. Daily spray with pyrethrum / Baygon around the DTLs to prevent fly breeding
and educate troops not to throw plastic bottles or refuse in DTLs. DTL must not be established far away from the
sleeping area so as to prevent open air defecation. Troops should be educated to avoid open-air defecation.  

7.6 Plan for Safe Water.

Commanders must plan for the provision of safe drinking water supply enroute by knowing the location of approved
water distribution points and ensuring adequate supply. Selection of water points and provision of water to units in
operational areas is the responsibility of Engineers. Medical authorities must monitor the quality of water. Chlorine
demand in each water point should be calculated using Horrock’s Apparatus and communicated to the engineers
for strict compliance. Preferably select groundwater for the establishment of water points. Water Point should be
100 meters away from cesspools / DTLs. Ensure 2 ppm of chlorine at the source after 30 min of the contact period.
The free chlorine levels can be raised to 4 ppm if the water source is doubtful / during an outbreak of waterborne
disease. Maintain a record of chlorination at each water point. Ensure water is collected from authorized sources only.
If a unit is in a remote / isolated location, a separate water point may be considered in consultation with Engineers
& AMA. The water supply in field locations may be through water bowsers which involves direct handling of water at
the source and at the consumer end thereby increasing the risk of waterborne diseases. Following guidelines must be
complied with by all the units to keep the water supply safe through water trucks and trailers:
(a) Earmark separate bowser for drinking water.  
(b) Improvised water trucks must be covered to prevent contamination in transit.
(c) The tanks must have a pipe / tap at the bottom for distribution of water. The pipe should not be in contact
with the ground or be soiled.

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(d) Individual water bottles and improvised containers should never be dipped directly into water tanks.
(e) In case water is collected from an untreated source, Water Sterilizing Powder (WSP) / bleaching powder will
be added as per guidelines. WSP is to be added with a contact period of at least half an hour before distribution.
Drivers / co-drivers of water bowsers must be educated to this effect.
(f) The WSP / bleaching powder must be kept in an airtight dark container, away from sunlight and should be
always dry to maintain its efficacy.
The water tanks should have drinking water / graded water stenciled on them along with the date of the last cleaning
carried out and consumers informed about the same. Ensure daily check of chlorine at the Regimental Post gate. Instruct
troops to use water from authorized sources only. Once the water reaches the camp, prevent further contamination
at the company level by proper handling and storage. Ensure strict water discipline and avoid water wastage. Store
drinking water separately. Use containers with a tap at the bottom for distribution. Alternatively, long-handled ladles
may be used for drawing water from containers. Maintain adequate stock of Outfit Water Sterilizing Tablets (OFWST).
Commanders must ensure troops carry OFWS tablets (1 Kit for everyone) and ensure water trailers & tankers are
inspected by the unit hygiene and sanitation squad / AMA regularly.

7.7 Cook House Sanitation and Plan for Safe Food.

Units must identify a suitable place for the establishment of cook house (preferably in the shade) during rest halts.
Adequate quantity of water for cooking, washing and drinking will determine the choice of location for the establishment
of the cookhouse. Mess commander should supervise hygienic disposal of kitchen waste and ensure the provision of
utensil washing points & hand washing facilities for food handlers & diners. He must inspect food service personnel
daily and those who are ill or have skin infections are to be referred for medical evaluation. Only hot-cooked food is
recommended to be served to troops on the move. Serving raw vegetables as salad or cut fruits in less-than-ideal
conditions increases the risk of food-borne disease transmission. It must be ensured that all troops consume the
freshly prepared food while it is still hot. On no account should leftovers from one meal be carried over to the next.
Indiscriminate disposal of kitchen waste is prohibited. It should be disposed of by burying in well-covered garbage pits
or if there is a paucity of space by burning it. An adequate number of flyproof receptacles must be provided for the
storage of food waste pending disposal. For disposal of wastewater, a soak pit must be established. The drains from
the cook houses should lead to the soak pit, through a grease trap. Space spray in the cook house by Cyphenothrin
5% EC / Propoxur 20% EC (appropriately diluted) will minimize housefly nuisance. It is recommended to spray the above
chemicals every fortnightly in cook house / dining area 30 min after breakfast has been eaten by everyone and again
30 min before starting preparation for lunch. All food items, fresh or dry and raw or cooked, should be meticulously
covered before spraying. All doors and windows should be closed before, during and till 30 minutes after spraying.

7.8 Plan for Arthropod, Rodent and Animal Threats.

Units must plan for arthropod, rodent and animal threats by obtaining information on these from past experiences and
consult health authorities posted at formation headquarters enroute and at destination station. Risk communication
measures must be instituted well in advance for preventive precautions against these pests and illnesses. Health
authorities must monitor whether adequate quantity of appropriate hygiene chemicals is being carried during the
move. Commanders must ensure serviceability of their spray equipment prior to move. It is recommended that troops
be issued with Insecticide Treated bed Nets (ITNs) prior to move and instructed to ensure use of the same during the
move. Risk of malaria & other arthropod-borne illnesses and snakebites and the role of ITNs in mitigating the same
should be communicated prior to move. Troops should be immunized against illnesses specific to the destination or
the region they are transiting. (e.g., Yellow fever, Japanese Encephalitis) Chemoprophylaxis (for example, antimalarial
tablets) must be available for issue as required.
Officers / JCOs must undertake surprise checks for the use of mosquito nets by troops. Spray the inner layer of tents
with chemicals under the arrangement of the unit anti-malaria squad. While on sentry / guard duty during the night, use
Odomos / Mosfree and re-apply after every 4 hrs. Instruct individuals to avoid handling insects, arthropods, snakes and
animals to prevent bites or injury. Before proceeding in Scrub Typhus endemic areas, all uniforms must be treated with
DEPA 50% as a drill. Assistance from a preventive medicine specialist must be sought (through medical or command
channels) when control of biting arthropods, rodents, or animals is beyond the capabilities of the unit.

7.9 Plan and Prepare for Hot Weather Operations.

During summer the raised atmospheric temp and high humidity can result in adverse effects of heat and sometimes

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fatalities. Units moving through hostile terrain (deserts, jungles) with high ambient temperatures and scarce water
resources are at increased risk of suffering adverse effects of heat amongst troops. Before deployment, units must
plan for hot weather operations by maximizing physical fitness and heat acclimatization opportunities. Hydration must
be emphasized and arrangements made to provide adequate cool drinking water during the move. Rest halts must
be made at areas with sufficient shade. In summer, moves should be planned in the early hours of morning or late
afternoon, night to mitigate adverse effects of heat.

7.10 Plan and Prepare for Cold Weather Operations.

Commanders must understand that cold injuries can and do occur in non-freezing temperatures. Hypothermia can
occur in mildly cool weather and can lead to permanent disability, just like frostbite. Commanders must identify special
conditions that place soldiers at high risk of cold injuries. These special considerations includes -
(a) Fatigue and Sleep deprivation.
(b) previous trench foot or frostbite.  
(c) Use of alcohol.  
(d) Significant injuries.  
(e) Poor nutrition.  
(f) Use of medications that cause drowsiness.
(g) Little previous experience in cold weather.  
(h) Immobilized or subject to greatly reduced activity.
(j) Soldiers wearing wet clothing.  
The effects of cold among troops can be prevented by experienced leadership, training, discipline, adequate
and nutritious food, and proper clothing.
(a) Preventive Clothing.  
Cold and wind are the main causative factors of cold injuries. Therefore, suitable clothing is necessary,
which should be loose and worn in many layers. The outer layer should be water and wind-proofed and
the inner layers should be of insulating material e.g., Wool. ECC clothing, Boot RI, Coat Parka, Leather
gloves or mittens etc. should be provided to all ranks. Socks and boots should be dry. A spare pair of
boots and socks should always be available with everyone during the move.
(b) Accommodation and Shelter.
Adequate weatherproof tents should be provided. Windbreaks should be erected in front of living
accommodations in cases where there is no natural feature to mitigate windchill effects. Stove
heating / Bukharies are useful to warm up the shelter / accommodation but must be used with caution
given the inherent risk of fire.
(c) Care in Holding Cold Objects.
Contact with cold objects should be avoided. Cold metal parts like rifle triggers, metal frames of spectacles
should be wrapped with tape. Forks, spoons and plates should be warmed before use.
(d) Nutrition.
Appetizing hot meals and hot drinks to provide adequate calorie requirements in the cold should be
served as far as possible.
(e) Personal Hygiene.
Attention should be paid to the personal hygiene of all ranks. Hot baths are essential in cold climates.
Wear clean undergarments.
(f) Motivation.
Educate troops to remain cheerful and develop a healthy and happy attitude towards life during their
stay in extreme cold climates. They must take regular gradual physical exercise. Encourage them to

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move their toes, fingers and facial muscles when unable to move out. Troops must relax and make use
of recreational facilities to the utmost during off time. Educate them to put on gloves and boots while
moving outside and use snow goggles when going out over the snow.

7.11 Plan for and Enforce Preventive Measures for Carbon Monoxide Poisoning and Fire Prevention.
Carbon monoxide is a colourless, tasteless and odourless gas and is produced by the incomplete combustion of fuel
and carbonaceous materials like wood, coal and kerosene oil. It has specific chemical action on the blood and interferes
with tissue oxidation. It is toxic to personnel who are exposed to it for a moderate period. if present in the atmosphere
even in very small amounts at high altitudes and in cold environments, there is always danger of its poisoning amongst
the troops. Exposure to an atmosphere containing sufficient concentration of carbon monoxide causes giddiness, severe
headache, sense of compression in the chest, mental confusion, unconsciousness and eventful death.
The commonest cause is the burning of ‘ANGITHIS’ inside ill-ventilated rooms where the tendency amongst the troops
is to keep ‘ANGITHIS’ on and going to sleep which must be prevented. The danger of carbon monoxide poisoning is
present when sigree, kerosene oil heaters, stove oil wickless, gas cookers etc. are used in confined areas. It may also
occur when MT engines are run in the garage with doors closed and through lack of back draught in the Bukhari
and other room heating devices. Stove oil wickless portable produces high percentage of carbon monoxide due to the
small distance (1/2 inch) between the burner top and the bottom of the cooking utensil. The effects of the circular
corrugated metal stove top, which when the cooking utensil is on the stove, restricts the supply of air to the flame and
thus prevents complete combustion of the fuel from taking place.
(a) Prevention Measures Against Carbon-Monoxide Poisoning.
The following important preventive measures against this condition to be taken by all ranks during the mission:
(i) Places where stove oil wickless, sigrees, gas cookers, kerosene oil heaters or any other device
using fuels or carbonaceous material are used should be as well-ventilated as possible. If it is used in
the tents the flaps should be opened at intervals to give a thorough draught of air.
(ii) It should be ensured that there is no leak in BUKHARIES or its ventilation pipes.
(iii) Test running of engines should be carried out in the open, and if it is done in the garage, the
doors should be kept open, and the exhaust should face the open door.
(b) First Aid against Carbon-Monoxide Poisoning.
A person showing the first symptoms of carbon monoxide poisoning should proceed into the open air at once
where the symptoms will quickly disappear. In case, any person is found unconscious in a place where there
is a danger of carbon monoxide poisoning, the person or the party should hold their breath before entering
the room and quickly open all doors and windows, bring the unconscious person out in the open air and start
artificial respiration as an emergency first aid. Evacuate the person to the nearest medical aid post as early
as possible for further treatment and management by the MO / RMO.

7.12 Plan for Personal Hygiene.

Cleanliness is the hallmark of perfect standards, discipline, purity, clarity and ethos of the unit. It must be taught as
an indispensable drill at each stage of a soldier’s life. Sub-unit commanders must inspect soldiers’ personal equipment
and ensure they have:
(a) Sufficient personal hygiene supplies like soap, washed cloths, towels, toothbrushes, dental floss, fluoride
toothpaste, razor and razor blades (females should have sanitary napkins or tampons).  
(b) Undergarments are made up of cotton (not silk, nylon, or polyester).  
(c) Uniforms fit properly.  
(d) Soldiers have several pairs of issue boot socks; the number will depend on the type and length of the
mission.  
(e) Annual and Periodic Medical examinations done religiously.  
(f) Ensure soldiers bath at least once a day. Keep the hair and nails trimmed. Wash hands every time
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(g) Change undergarments regularly.

(h) Do not defecate in open.

7.13 Plan for and Enforce Sleep Discipline.

Sleep is a biological need, critical for sustaining the mental abilities needed for success on the battlefield. Soldiers require
seven to eight hours of good-quality sleep every 24 hours to sustain operational readiness. Soldiers who lose sleep will
accumulate a sleep debt over time that will seriously impair their performance. The only way to pay off this debt is by
obtaining the needed sleep. The demanding nature of military operations often creates situations where obtaining sleep
may be difficult or even impossible for more than short periods. While essential for many aspects of operational success,
sheer determination or willpower cannot offset the mounting effects of inadequate sleep. This concept is applicable for all
levels of military operations including basic training and in all operational environments. For this reason, sleep should be
viewed as being as critical as any logistical item of resupply like water, food, fuel and ammunition. Commanders need to
plan proactively for the allocation of adequate sleep for themselves and their subordinates.  
(a) Ways To Overcome Performance Degradation Include.
(i) Find time to nap, change routines or rotate jobs (if cross-trained) upon signs of diminished performance.  
(ii) Have the soldiers execute a task as a team, using the buddy system.  
(iii) Do not allow soldiers to be awakened for meals while on flight to a new location, especially if the
time zone of the destination is several hours different than that of the point of departure.  
(iv) Encourage soldiers to empty their bladder before going to bed. Awakening to urinate interrupts
sleep and getting in and out of bed may disturb others and interrupt their sleep.  
(v) Allocate sleep by priority. Commanders, on whose decisions the mission success and unit survival
depend, must get the highest priority and largest allocation of sleep. Second priority is given to Soldiers
who have guard duty and to those whose jobs require them to perform calculations, make judgments,
sustain attention, evaluate information and perform tasks that require a degree of precision and alertness.

7.14 Minimize Exposure to Poisonous Plants and Toxic Fruits.

Units can minimize exposure to poisonous plants and toxic fruits by obtaining information on indigenous poisonous
plants & toxic fruits through natives and past experiences. Seek help of health authorities if required.  

7.15 Promote Unit Cohesion and Bonhomie.

Unit cohesion is an integral element and ethos of soldierly life. It is achieved with the integration of new members and
rapid familiarization through equipment drills, physical fitness training, team sports and field stress training to stimulate
mutual reliance and closeness. Honouring the historical examples of initiative, endurance, resilience, overcoming heavy
odds and of self-sacrifice will motivate troops to achieve the objectives in a defined time.

Suggested Reading.  
1. FIELD HYGIENE AND SANITATION Headquarters, Department of the Army [Internet]. 2015. Available from: https://
armypubs.army.mil / epubs / DR_pubs / DR_a / pdf / web / tc4_02x3.pdf
2. Allmand C, editor. The legacy: the De re militari in medieval military thought and practice [Internet]. Cambridge
University Press. Cambridge: Cambridge University Press; 2011 [cited 2024 Mar 9]. p. 249–50. Available from: https://
www.cambridge.org / core / books / abs / de-re-militari-of-vegetius / legacy-the-de-re-militari-in-medieval-military-thought-
and-practice / 6A156752AEC20D217C0B1D6FD9B3F9DF
3. Renatus FV. De re militari opera [Internet]. Google Books. Maire; 1633. Available from: https://books.google.
com.bd / books?id=Wcc9AAAAcAAJ&printsec=frontcover#v=onepage&q&f=false
4. DGAFMS/DG-3A letter no. 25514/19(ii)/Hyg chem/DGAFMS/DG-3A dt 08 Mar 2022.
5. DGAFMS Medical Memorandum No. 211.
6. DGAFMS Medical Memorandum No. 158.
n

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Chapter
VIII
HEALTH PROBLEMS IN JUNGLE WARFARE

8.1 Introduction.
Soldiers must understand that the environment affects everyone. The degree to which soldiers are trained to live
and fight in harsh environments will determine their unit’s success or failure. There is very little to fear from the
jungle environment. Fear itself can be an enemy. Soldiers must be taught to control their fear of the jungle and
must learn to keep calm.  
There is no standard jungle. It may be a tropical rain forest, which is the popular conception or a dry open scrub
country. Jungle vegetation depends on climate and to a large extent, the influence of men through the centuries.
Tropical trees take over 100 years to mature and are fully grown only in untouched primeval virgin forests. This
is a “Primary” jungle and is easily recognized by its abundance of giant trees. The tops of these trees form a
dense canopy over 100 feet from the ground, under which there is little light and underbrush. Land in this type
of jungle is difficult but not impossible to traverse.
Primary jungle growth has been cleared in many areas of the world to allow cultivation. This land is later left idle
and jungle growth reclaims it, making it a sea of dense underbrush and creepers. This is a “secondary” jungle
and is much harder to traverse than the primary jungle.
The tropical rain jungle, whether secondary or primary, is an unpleasant land to live in and travel through. The
soil is covered with decaying vegetation over which countless millions of loathsome and bothersome leeches
and insects abound. In secondary forests sometimes impenetrable undergrowth bars travel. Open space, over
the undergrowth and beneath the jungle tree tops, where other trees, vines and creepers grow in primary jungle.
Birds and small animals are often found in this area. High among the treetops of primary growth may be found
birds, bees and monkeys.
The dry scrub country is more open than the wet jungle but is difficult to travel because of its lack of topographical
features, population and tracks. It is to be traversed with the use of a compass, patience and common sense.

8.2 Peculiarities of Jungle.

(a) Climate.
The climate is normally hot, wet and humid with little daily variation. Rainfall is heavy, especially during the
monsoons. In some regions, one expects a regular wet season and dry season. Nights are quite cold.
(b) Humid Conditions Sap Vitality.
In battle, morale and resistance to disease quickly drop. The constant dampness and humidity affect radio sets,
equipment and food.
(c) Terrain.
The country varies from region to region. Though jungle regions have great varieties of terrain and vegetation,
features common to all are good cover, limited visibility and difficulties of movement.
(d) Communications.
Where existing, roads are narrow and often unmetalled. The road network will not usually support heavy-tracked
vehicles or continuous military traffic. Vehicle movement off the roads will only be possible in limited areas and
only at certain times of the year. Building air strips and helipads takes time in this sort of terrain and, even in
drier weather, frequent maintenance is necessary.

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8.3 Tactical and Operational Considerations.

Due to the peculiar features of the terrain and lack of roads and tracks, the operations undertaken will have the
following peculiarities:
(a) The size of the forces which can take part in the operations is limited. Operations will usually be undertaken
by brigade groups deployed on widely dispersed axs. Long-range patrolling will be a regular feature.
(b) Only lightly equipped formations, supported by new small vehicles, porters, helicopters and animal transport
can retain true mobility in these conditions.
(c) Administration imposes severe limitations of operations, though logistic support by air can reduce this.

8.4 Administration and Logistics in Jungle Welfare.

In undeveloped jungle countries where communications are poor or non-existent, administrative problems are so great
that they may well dictate the whole course of planned operations. For this reason, every endeavour should be made
to build up reserves of supplies, material and personnel as far forward as possible, so that breaks in the maintained
communications will have the minimum effect on operations.
(a) Deployment of Units.
Medical posts must be kept as much as possible, particularly those established on jungle tracks. Camouflage
and concealment should take preference over reliance on general medical corps marking, like the Red Cross, for
protection from enemy attacks. Tying bits of cloth onto branches, marking trees and knotting shrubs are helpful
to trace casualties and assist in the identification of paths.
(b) Water.
Water is vital in the jungle and is usually easy to find. Animal trails often lead to water. However, water from
natural sources should be considered contaminated. Water purification procedures must be taught to all soldiers.
The water from clear, swift-flowing streams containing boulders is a good source for drinking and bathing. But
before drinking, purify it by boiling or chemical means using OFWS tablets. Water from tropical streams, pools,
springs and swamps is safe to drink only after it has been purified. Coconuts, particularly when green, supply
milk which is both pleasant and nourishing. A sugary sap can be obtained by cutting the flower spikes. Nuts are
available throughout the year. Soldiers can prevent waterborne diseases by:  
(i) Obtaining drinking water from approved engineer water points.  
(ii) Using rainwater; however, rainwater should be collected after it has been raining for at least 15 to
30 minutes. This lessens the chances of impurities being washed from the jungle canopy into the water
container. Even then the water should be purified.
(iii) Assuring that all drinking water is purified.
(iv) Not swimming or bathing in untreated water.
(v) Keeping the body fully clothed when crossing water obstacles.
(c) Food.
There is an abundance of food in the jungles, but few are poisonous. Any food eaten by a monkey or a bird is
generally safe for human consumption. To be safe, cook all vegetables before you eat them. Be sure to protect
your food from flies, because they can re-infect it after it has been cooked. Certain itchy and poisonous plants
like White mangrove, Physic nut, Thorn apple/Datura/Jimson weed, Nettle trees and Castor oil plants should be
avoided.  
The composite pack / ready to eat rations provide food of adequate variety and nutritive value which does not
require cooking and is packed in a manner to facilitate easy handling. Their principal use is in the operations,
‘between the initial assault and the establishment of a normal chain of supplies and cooking facilities, in
jungle operations or for air dropping. The type ‘A’ ration pack is meant for meat eaters and type B contains
cooked dal for vegetarians. These rations are not to be used when basic rations can be provided. The use of
Composite Rations will be restricted to a maximum period of two weeks at a stretch. The present container has
5 men’s ration for one day. Another type of pack ration is “Meals Ready to Eat” (MRE) for individual persons.
Each pack weighs approximately 2.32 Kg and contains one person’s breakfast, lunch and dinner. It contains

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ready-to-eat suji halwa (300 g), veg pulao (300 g), veg peas and mushrooms curry (300 gm) dal makhani
(330 g), chapatis or parathas (320 g), tea mix (tea, sugar and dairy whitener), soft bar (110 gm), hexamine
cooker and tablets, matchbox, paper plates etc These packs are stocked in selected supply depots to be issued
to troops when necessary and as ordered by the authorities. The shelf life of the ration is 12 months under
ambient condition. The total caloric value of the ration is 3,300 Kcal and meets the immediate nutritional
requirement during operation.
(d) Clothing.
Unless completely covered, the body is vulnerable to leeches, insects, scratches, bruises and cuts. Soldiers
should have clothing:
(i) Loose enough to be tucked into gloves and socks.
(ii) Strong enough to withstand wear & tear.
(iii) Mosquito head nets and thorn-resisting gloves.
(iv) Plenty of pockets for carrying emergency items such as maps, compasses and matches.
(v) Combat boots - These are the best jungle footwear.
(e) Travel.
Troops should keep the following things in mind while traveling through Jungles.  
(i) Pinpoint position as accurately as possible to determine a general line of safety travel. If a compass
is not available, use the sun in connection with a watch as an aid to direction.
(ii) Take stock of your water supply and rations.
(iii) Move in one direction but not in a straight line. Avoid obstacles, don’t fight them. In enemy territory,
take advantage of natural cover and concealment.
(iv) Turn your shoulders, shift your hips, bend your body and shorten or length, increase or decrease
your pace as required. There is a technique for moving through jungle: blundering only leads to bruises
and scratches.
(v) Be alert.
(vi) Check your bearing often.
(f) Shelter.
Jungle shelters are used to protect personnel and equipment from the harsh elements of the jungle. Shelters are
necessary while sleeping, planning operations and protecting sensitive equipment. The following things should
be kept in mind while selecting a camp site:
(i) Try to pick a campsite on a knob or high spot of ground in an open place, away from swamps, so as
to be less bothered by mosquitoes. The ground will be drier and there will be more chance for a breeze.
(ii) Don’t build under large trees with dead limbs as they may fall, don’t place your shelter under a
coconut tree.
(iii) In mountain jungles, the nights are cold. Get out of the wind.
(iv) Avoid dry riverbeds as they can be flooded in a few hours by rains that have occurred in a distant
location from you, that you are not aware of.
(v) If camping during the day and moving at night, the shady borders of rivers supply the best sites.
(vi) Don’t sleep on the ground.

8.5 General Health.

The climate in tropical areas and the absence of sanitation facilities increase the chance that soldiers may contract a
disease. The disease is fought with good sanitation practices and preventive medicine. In past wars, diseases accounted
for a significantly high percentage of casualties. The evenness of temperature and the excessive humidity sap man’s

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vitality. This affects battle efficiency and also reduces resistance to tropical disease. The climate is also conducive to
the existence of a variety of insects and other organisms, causing common diseases like malaria, diarrhea, dysentery,
scrub typhus, trench foot, hookworm infestation and jungle sores. Animals used for transportation are also subject to
a variety of diseases. Some features of the jungle that involve special medical precautions:
(a) High by day and marked drop in temperature by night.
(b) Higher humidity and diminished capacity for physical exertion.
(c) The presence of disease-carrying insects, poisonous reptiles and plants.
(d) Poor sanitary habits of local inhabitants.  

8.6 Diseases.
Sickness causes more casualties than the enemy and in particular raw troops become nervous and depressed due to
the strain of continuous alertness in the jungle. During the talk of the strategy of the Southeast Asian Campaign, Admiral
Mountbatten stated, “More serious than the monsoon, however, was the incidence of tropical diseases. The jungles
of Burma are infested with malaria mosquitoes, the scrub typhus mites and the bacteria and amoebae of dysentery.
Between them they presented a more redoubtable enemy than the Japanese themselves. I, therefore, set up at once
an inter-service, inter-allied medical advisory division to help the research and to organize an offensive drive against
disease to be waged by the medical services. In 1943, for every man who was admitted to the hospital with wounds,
there had been 120 who were casualties from the tropical diseases. By 1944, these 120 men had been reduced to
20, although hospital admission still reached between 14 to 15 per thousand per week in peak periods. By 1945,
the rate had dropped to ten men sick for one battle casualty and during the last six weeks of the war, these ten had
been reduced to six. The enemy had no medical advisory division and appears to have made no advance in medical
research. As our troops became more immune from circumstances against which the Japanese had no remedy, I was
determined to enlist disease as an additional weapon on our side and deliberately chose unhealthy areas in which to
fight”.
In order to ensure preventive measures against health hazards, a detailed health appreciation of the problems involved
be carried out by the medical staff. Based on the appreciation, a comprehensive directive on preventive measures
applicable in the area of operations should be issued though the staff channel for strict compliance. Failure in this
respect will result in heavier casualties from diseases rather than enemy action leading to great strain on medical
resources and unnecessary wastage of trained manpower. Before going into a jungle area, leaders must:
(a) Make sure troops are immunized for Typhoid, Tetanus Toxoid, Japanese Encephalitis etc. as applicable.
(b) Start chemoprophylaxis for diseases peculiar to the region on consulting medical authorities.
(c) Instruct soldiers in personal hygiene.

Fig 8.1 : Personal Protective Equipment in Jungle

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(d) Get soldiers in top physical shape.

(e) Take stock of hygiene chemicals, Composite packs containing multivitamin tablets, matchboxes, hexamine
cooker and water sterilizing outfit, tin opener & “Meals Ready to Eat”
Following are the some common diseases/ health hazards that are normally encountered in the jungle terrain for
which soldiers need to be aware of  
(a) Malaria.
Malaria-carrying mosquitoes are probably the most harmful of the tropical insects. Soldiers can contract malaria
if proper precautions are not taken. Mosquitoes are most prevalent early at night and just before dawn. Soldiers
must be especially cautious at these times. Malaria is more common in populated areas than in uninhabited
jungle, so soldiers must also be especially cautious when operating around villages.
(b) Gastrointestinal Diseases.
Caused by polluted food or drinking water. All precautions as mentioned in para 8.4 should be undertaken to
prevent gastrointestinal diseases.
(c) Typhus.
There are several types of typhus to be found in tropical areas among which are the flea-borne, louse-borne
and mite-borne varieties. The general symptoms are severe headaches, weakness, fever and generalized body
aches. The victims usually have a dusky complexion and may or may not develop a pink mottled or splotchy
rash. Typhus of all types will likely prove fatal without medical attention. Strict attention to personal hygiene,
avoidance of contact with lice or flea ridden rodents and avoidance of mite-infested grassy areas is essential.
Inoculations for the louse-borne typhus infection are effective. Keep them current.
(d) Fungus Diseases.
These diseases are caused by poor personal health practices. The jungle environment promotes fungus and
bacterial diseases of the skin and warm water immersion skin diseases. Bacteria and fungi are tiny plants that
multiply fast under the hot, moist conditions of the jungle. Sweat-soaked skin invites fungus attack. The following
are common skin diseases that are caused by long periods of wetness of the skin:
(i) Warm Water Immersion Foot.
This disease occurs usually where there are many creeks, streams and canals to cross, with dry ground
in between. The bottoms of the feet become white, wrinkled and tender. Walking becomes painful.  
(ii) Chafing.
This disease occurs when soldiers often wade through water up to their waists and the trousers stay wet
for hours. The crotch area becomes red and painful to even the lightest touch.  
Most skin diseases are treated by letting the skin dry. To prevent these diseases, soldiers should:
(aa) Bathe often and air or sun-dry the body as often as possible.
(ab) Wear clean, dry, loose-fitting clothing whenever possible.
(ac) Not to sleep in wet, dirty clothing. Soldiers should carry one dry set of clothes just for sleeping.
Dirty clothing, even if wet, is put on again in the morning. This practice not only fights fungus, bacterial
and warm water immersion diseases but also prevents chills and allows soldiers to rest better.
(ad) Not wear underwear during wet weather. Underwear dries slower than jungle fatigue and causes
severe chafing.
(ae) Take off boots and massage feet as often as possible.
(af) Dust feet, socks and boots with foot powder at every chance.
(ag) Always carry several pairs of socks and change them frequently.
(ah) Keep hair cut short.

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(e) Heat Related Illnesses.

During summer season, the raised atmospheric temp and high humidity can result in adverse effects of heat
like heat stroke, heat exhaustion, heat cramps and prickly heat. Sometimes, this can be fatal also. The following
factors predispose to the development of effect of heat:
(i) Severe exertion.
(ii) Fluid loss in body resulting from excessive sweating on the one hand and inadequate drinking of
water on the other hand.
(iii) Lack of adequate rest and sleep.
(iv) Humidity and poor ventilation in thick jungles.
(v) Inadequate bathing leads to unhealthy skin.
(vi) Unsuitable, cumbersome and heavy clothing.
(vii) Previous illness and febrile conditions.
Soldiers should be educated to keep themselves hydrated and observe the urine color which indicates hydration
status. The buddy system should be adhered to monitor symptoms and signs of heat related illnesses.
(f) Insects.
The larger centipedes and scorpions can inflict stings which are painful but not fatal. They like dark places, so it
is always advisable to shake out blankets before sleeping at night and to make sure before dressing that they
are not hidden in clothing or shoes. Spiders are commonly found in the jungle. Their bites may be painful but
are rarely serious. Ants can be dangerous to injured men lying on the ground and unable to move. Wounded
soldiers should be placed in an area free of ants.
(g) Leeches.
These are common in many jungle areas, particularly throughout most of the Southwest Pacific, Southeast Asia
and the Malay Peninsula. They are found in swampy areas, streams and moist jungle country. They are non-
poisonous, but their bites may become infected if not cared for properly. The small wound that they cause may
provide a point of entry for the germs which cause tropical ulcers or “jungle sores”. Soldiers operating in the
jungle should watch for leeches on the body and brush them off before they have had time to bite. When they
have taken hold, they should not be pulled off forcibly because of the risk of breaking and leaving behind its
suction apparatus which is liable to cause inflammation and suppuration. Gum boots or jungle boots protect
one from leech bite. Salt, vinegar or a tobacco infusion application or a touch of the lighted end of a cigarette
induces the leech to relinquish its hold. Subsequently, tincture of iodine should be applied to the bitten spot
and a piece of adhesive plaster may be applied to the bitten spot. Repellents DEET & DEPA can be used to
provide protection. The repellents can be applied on the clothing as well as topical application. At night a properly
adjusted mosquito net, preferably treated variety affords good protection. Aquatic leeches can be removed from
drinking water by filtering through a sieve or a piece of muslin.
(h) Snakes.
A soldier in the jungle probably will see very few snakes. When he does see one, the snake most likely will be
making every effort to escape. If a soldier should accidentally step on a snake or otherwise disturb a snake, it
will probably attempt to bite. The chances of this happening to soldiers traveling along trails or waterways are
remote if soldiers are alert and careful.
(j) Wild Animals.
All movements of animals and men are marked by tracks and signs. Soldiers must learn to read signs left
in soft ground, in streambeds, on roads & trails and near watering places & salt licks. Animals seldom move
without a reason, a few fresh tracks supply information about their maker, his direction and probable intentions.
Animals avoid man. The animals, their tracks and their behaviour can reveal whether or not men are in the
area. Jungle fighters can listen to the cries of animals and learn to recognize their alarm calls. The ability to
track and to recognize signs in the jungle are valuable skills. Throughout the soldier’s time in the jungle, he
should practice these skills. In areas where the wild animals are not protected, they are shy and seldom seen.
When encountered, they will attempt to escape. All large animals can be dangerous if cornered or suddenly

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startled at close quarters. This is especially true of females with young. Ordinarily, these will not attack a man
unless they are cornered or wounded. Certain jungle animals, such as water buffalo and elephants, have been
domesticated by the local people. Soldiers should also avoid these animals. They may appear tame, but this
tameness extends only to people the animals are familiar with.
Conclusion.
Preparedness of Armed Forces for war depends largely on its training, equipment and its physical fitness. Physical
fitness is largely the outcome of good nutrition, physical training and absence of illness. Therefore, prevention
of illness and injuries occupy a prominent position in the life and efficiency of the Armed Forces in a country.

Suggested Reading.  
1. FM 90-5 Chptr 2 Life In The Jungle [Internet]. www.globalsecurity.org. [cited 2024 Mar 9]. Available from: https://
www.globalsecurity.org/military/library/policy/army/fm/90-5/Ch2.htm#s2
2. United States. War Department. General Staff. FM 72-20 Jungle Warfare, 1944 [Internet]. Internet Archive.
Washington; 1944 [cited 2024 Mar 9]. Available from: https://archive.org/details/Fm72-20/page/n3/mode/2up
3. The Strategy of the SouthEast Asia Campaign. Royal United Services Institution Journal [Internet]. 1946;91(564):469–
84. Available from: https://doi.org/10.1080/03071844609433961
n

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Chapter
IX

NAVAL HEALTH

9.1 Introduction.
Oceans and seas cover nearly 71% of the earth’s surface and encompass various unique ecosystems depending
on their size, location and weather patterns. The requirements of life at sea are different from those on land.
Man has evolved to live on land and water is not its natural habitat. Hence, seafaring presents a plethora of
distinctive challenges.
Navy is a sea going force and operates in white (coastal) and blue (beyond coastal) waters by deployments onboard
ships, under water vessels (submarines) and aircrafts. Life in Naval ships and submarines demands high degree of
professionalism and endurance as work and living spaces are restricted, machinery spaces are hazardous, there is
substantial risk of injuries, limited resources and rations present onboard, sea sickness compromising functioning,
close community life without privacy, restricted communication and separation from family. Naval personnel have
to negotiate these challenges on a daily basis and it has an effect on the physical and psychological bearing.
The Sickbays constitute the centres of all medical activities on board the afloat platforms. Aircraft carriers have a
large sickbay with Operation Theatre with a complement of surgical team and Dental Officer along with superior
facilities like X-Ray, auto-analyzers and other equipment to render complete and definitive medical care. Majority
of the afloat platforms (all big ships) have Medical Officers posted in them along with a dedicated sickbay with
basic facilities for treatment along with few non-dieted beds. In a submarine or in small surface ships, Medical
Officers are sent on temporary duty once they sail for prolonged duration and daily medical care is rendered by
a Sick Berth Assistant (Medical Assistant) with a basic equipment and supplies.
The planning and arrangement of sick bays in Naval vessels is dependent on the ship’s design, complement of
crew, role of the vessel, possibility of air operations or evacuation and medical requirements. The practice of
medicine on board the ship does not materially differ from that practiced ashore. But due to shortage of storage
space, careful planning is necessary in ensuring the safety and storage of medical stores and equipment. The
medical stores and equipment are authorized as per the class of afloat platforms. It is the responsibility of the
Medical Officer to stock adequate amount of medicines and essential medical equipment before proceeding for
any deployment.
The duties of the Medical Officer are principally the same at sea as on land except that at sea the Medical Officer
is the sole adviser to the Commanding Officer on all medical and health matters without aid or consultation.
Casualty evacuation often compromises missions and the entire ship or submarine needs to be brought to a
location from where it can be undertaken. Though, with the provision of satellite-based telemedicine services,
the Medical Officer in afloat units will also be able to consult the concerned Specialists at hospitals in real time
and undertake advanced diagnostics such as Ultrasound.
The health of the ship’s company is the overall responsibility of the Commanding Officer but he looks up to the
Medical Officer for all issues about physical and mental health. Medical Officers also needs to highlight and
address the peculiar hazards that the personnel of each trade confront. Hence, the role of medical staff (Medical
Officer and medical sailors) onboard these platforms becomes extremely important. Knowing the layout of the ship
or submarine, as well as being conversant with it’s daily routine and administration is paramount for effective
performance of duty. This chapter will cover the specific health issues unique in the afloat platforms.

9.2 Naval Health Problems.

General principles of hygiene and sanitation for maintenance of health and prevention of disease afloat are similar
to those on land. The Medical Officer is expected to have basic knowledge about the various health issues that is
expected in ships, submarines and naval aviation. Apart from routine treatment of patients, other health issues also
needs to monitored and addressed. They are as follows.

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(a) Naval Health Concerns.

(i) Habitability conditions.
(ii) Submarine microclimate.
(iii) Diving illnesses.
(iv) Survival on abandoning ship and death at sea.
(v) Problems of Naval Aviation.
(vi) Entering foreign ports, quarantine rules and compliance of International Health Regulations.
(b) Other Common Health Concerns.
(i) Potable Water supply.
(ii) Food safety.
(iii) Disposal of refuse and sanitation.
(iv) Pest menace.
(v) Prevention of communicable disease.
(vi) Maintenance of mental health.

9.3 Habitability Conditions of Ships.

The ship or submarine design should provide comfortable and habitable conditions in terms of maintenance of
temperature, humidity, air movement and heat radiation and are provided with centralized monitoring system for the
same. The corrected effective temperature and the comfort zones provide a guide for assessment.

9.4 Ventilation.
The supply of fresh and cool air in a warship with watertight compartments without weakening the floatation of the
ship needs engineering ingenuity.
(a) Health Effects.
Poor ventilation results in rise in ambient temperature of a chamber which may cause body temperature and
pulse rate to rise even while resting. Urgent remedial action is called for when this happens. The environment
onboard must maintain the proper body heat balance, must not contain any harmful gases and provide a constant
and sufficient supply of oxygen.
(b) Prevention.
The different types of ventilation systems utilized onboard vessels are mentioned below.
(i) Positive Ventilation.
Modern afloat platforms have central air conditioning systems with compartment wise distribution system
with blowers to maintain temperature, humidity and air movement. The plant air-conditioning also cleanses
the air by filters as required.
(ii) Negative Ventilation.
Heat and noxious gases from the machinery, engine spaces in the sealed hull area and galleys are also
removed by the exhaust ventilation system to maintain the overall temperature of the vessel. Oxygen
depletion and built up of noxious gases may occur in closed spaces. All such closed spaces should be
identified and thoroughly ventilated before entering to prevent mishaps. The oxygen apparatus should be
kept ready in such situations and a ‘lifeline’ should be attached to the person entering such a compartment.
(iii) Spot Cooling.
It is used in certain hot places, where it is difficult to provide sufficient fresh air to maintain satisfactory
temperature in the compartment. Areas of cool air is created by directing a high velocity blast of cool air.
These air duct terminals must be located to the best advantage of the occupants of the chamber. This

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system is effective even outdoors in high ambient temperature.

9.5 Lighting.
Adequate lighting on board ship is essential for efficiency and safety. Good lighting is important, especially in the engine
room, galley, chartroom and companionways.
(a) Health Effects.
Fatigue and eyestrain develop rapidly in poor illumination. Work performance is reduced, accidents increase and
the individual’s morale deteriorates.
(b) Prevention.
In the engine-room, high-level illumination free from glare is desirable. Lights should be located so that
crewmembers will cast the least possible body shadows upon their work and equipment will not create pools
of darkness. Adequate illumination in the areas where food is served and prepared is essential for proper food
handling and for the maintenance of adequate standards of sanitation.

9.6 Effects of Noise, Vibration and Non-ionizing Radiation.

Exposure to noise, vibration and radiation occur on afloat platforms can pose significant health hazards. Safe levels
and protective measures have also been identified based on extensive studies in commercial ships and Navies. The
Medical Officer is responsible to advise the Commanding Officer and Engineering Officer on these matters and for
conduct of health education.
(a) Noise.
(i) Source.
Ships and submarines are both the living quarters and workplace for in-living personnel even when the
platforms are in harbour. In addition, the entire crew is subjected to the ill effects of noise onboard during
sailing or deployment. Noise is created in engine and machinery spaces, during flying operations and regular
announcements on public address system. Personnel are exposed to the noise twenty-four hours a day.
(ii) Health Effects.
Noise can have a widespread effect, both aural and non-aural Noise Induced Acoustic Disorders (NIAD),
depending upon the type of noise and duration of exposure.
(iii) Prevention.
As there is no treatment for Noise Induced Hearing Loss (NIHL), it is imperative that education, proper
monitoring, adequate training and preventive measures are instituted on board. All noise danger zones
should be marked with a signboard ‘Noise Danger Zones - Use Ear Protectors’. Ear protectors are of three
types.
(aa) Plug type
(ab) Muff type
(ac) Flight deck helmets or ear defenders
(b) Vibration.
(i) Source.
Vibration is the transmission of oscillation energy from one source to another object. It can enter the body
at the hands, feet, seat or the back. The personnel most commonly exposed to vibration are engine room
and electrical sailors as well as shipwrights and seamen using pneumatic tools.
(ii) Health Effects.
Vibration can have localized effects on the circulatory system, bones and joints; nerves and muscles or it
can have generalized effects on the whole body as such.

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(iii) Prevention.
To prevent the deleterious effects of vibrations it is necessary to redesign ships by applying proper ergonomics
and instituting regular health education.
(c) Non-Ionizing Radiation.
(i) Source.
Non ionizing radiation is part of electromagnetic band and extends from ultra violet radiations through
the visible range up to the infrared range and the radio frequency cum microwave radiation zone. These
radiations are present in varying amounts onboard. Emissions of particular concern are from sunlight while
working on outer decks while at sea and from radar and Video Display Units (VDUs) indoors. UV radiation
is released from black lighting, electric arcs like fly killers and welding flashes.
(ii) Health Effects.
Personnel onboard ships and submarines are exposed to low levels of non-ionizing radiation every day.
They do not cause nuclear changes in the cells but exposure to intense amount of and direct non-ionizing
radiation may result in damage to tissues due to heat. UV radiation is known to cause skin burns, premature
ageing of skin, eye damage and skin cancer.
(iii) Prevention.
Preventive measures are generally restricted to education, proper sign posting and use of protective
equipment. In the long term, equipment modification may prevent exposure.

9.7 Submarine Microclimate.

The temperature within a submarine is often extremely high, especially in the tropics. While cruising submerged,
some cooling is obtained through the hull’s contact with the cooler sea water. Relative humidity in submarine
often approaches the saturation point during an extended submerged run from the moisture given off by the
occupants, by the process of cooking and from the batteries, causing considerable discomfort to the crew. It
causes the bulkheads to drip, moistens all clothing, mattresses etc. making them continually damp, thus adding
to the health hazards amongst the crew.
The habitability of the submarine from the point of atmospheric conditions depends upon pressure, movement,
temperature, humidity and constituents of the air. The air conditioning unit can control the temperature and
humidity as well as the air circulation.
(a) Ventilation in Submarines.
The ventilation system in a submarine is critical for maintaining acceptable conditions of habitability for the crew.
The ventilation is particularly difficult during submerged cruising, when air has to be recirculated. Depletion of
oxygen, increase of carbon dioxide and moisture vitiate the air. In addition, heat produced by the machinery and
gases produced from cooking and batteries including chlorine makes maintenance of microclimate extremely
challenging. Close watch is therefore necessary when the submarine is cruising submerged. The whole ventilation
system is balanced with the combination of the plenum and exhaust ventilation. In addition, the ventilation
system has two other roles.
(i) It provides sufficient air for the engines when they are operating.
(ii) It also meets the battery ventilation requirements under various conditions of battery operations.
In a submarine, air for the engine enters through the main air induction valve located in the conning tower
and through outboard piping to the engine room via hull valves. The air supply for ventilation enters through
the hull air induction valve, also located in the fin through a separate outboard valve to the hull supply
fan. Air is then distributed by the hull supply fan within the submarine through the main ducts running the
entire length of the ship and branching in each compartment. Forced draft blowers take air through the
main supply duct and distribute it to the various compartments. Exhaust is delivered to the engine room to
be discharged through the engines when they are running and overboard when they are static. When the
vessel is submerged, the air is not exhausted through the engines but is returned to the supply system
through the air-conditioning unit, which filters, cools and dehumidifies it. For the purpose of recirculation of
air, cross connection is provided between exhaust fan discharge and the supply fan intake. These methods

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of air movement are supplemented by the use of compartment electric fans and portable blowers.
(b) Atmospheric Gases in Submarines.
(i) Oxygen.
(aa) Causes for Depletion.
Oxygen is rapidly utilized during respiration by the crew. In addition, oxygen leak also occurs from
oxygen propelled torpedoes.
(ab) Health Effects.
Oxygen concentration is maintained above 17% to prevent symptoms of anoxemia such as weakness,
vertigo, cyanosis, nausea and unconsciousness.
(ac) Prevention.
Oxygen level in the torpedo compartment need to be measured periodically at least every half an
hour by central monitoring system or by using portable analyzers. If the level of oxygen falls to
19-18%, then oxygen is to be released from oxygen banks or by using regeneration chemicals like
Sodium / Potassium Peroxide or by hydrolysis of water.
(ii) Carbon Dioxide.
(aa) Source.
A submarine carrying a normal complement of its crew may safely operate submerged for about 20
hours without requiring to release oxygen or absorb Carbon Di-Oxide. The Carbon Di-Oxide production
is 20 Liters per man per hour. Additional amount of Carbon Di-Oxide is produced from galley oxidation
of Carbon Mono-Oxide and leakage from engine exhaust particularly after a crash dive or during
snorting.
(ab) Health Effects.
The health effects of Carbon Di-Oxide are directly proportionate to its partial pressure. In general,
Carbon Di-Oxide tension of 3% causes mild symptoms; between 3-6% causes headache, discomfort
and deep breathing; between 6-9%extreme distress. panting and collapse may be caused and
concentration above 9% is fatal. Increasing the oxygen tension has no beneficial effect unless the
excess of Carbon Di-Oxide is removed.
(ac) Prevention.
The removal of Carbon Di-Oxide is accomplished by the use of Carbon Di-Oxide absorbents like Sodalime
(NaOH), regeneration chemical (Na202) which absorbs Carbon Di-Oxide and releases Oxygen and MEA
(Monoethanolamine) which absorbs Carbon Di-Oxide when cooled and releases it when heated.
(iii) Carbon Monoxide.
(aa) Source.
It is produced by the incomplete combustion of any kind of fuel and is a constituent of the exhaust
gases from engines. It is also found after fires or explosions in closed compartments where there is
an insufficient supply of oxygen to afford complete combustion.
(ab) Health Effects.
Symptoms are produced due to hypoxia resulting from carboxy-haemoglobin and include exhaustion
with breathlessness, nausea, increasing weakness, dizziness, vertigo and unconsciousness. On
examination, there is pink tongue and pallor.
(ac) Prevention.
First aid treatment for carbon monoxide poisoning constitutes breathing fresh air or oxygen and giving
artificial respiration. If the presence of this gas suspected in a compartment, no one should be allowed
to enter without appropriate respirator. Prevention is by using absorbent filters in ventilation system,
which helps in reducing carbon monoxide in the compartment air.

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(iv) Hydrogen.
(aa) Source.
In a submarine Hydrogen is produced by electrolysis within the storage batteries, particularly during charging.
Hydrogen gas is chemically active. An air mixture containing 4.1% hydrogen is inflammable and percentages
higher than this may be explosive.
(ab) Health Effects.
Hydrogen is physiologically harmless but increase in concentration reduces the partial pressure of Oxygen
and CO2. Sometimes it may be a fire hazard onboard submarines.
(ac) Prevention.
Separate ventilating system is provided for the batteries and the air is discharged outboard during surface
runs and inboard during submerged runs. Hydrogen burners located in battery compartments continuously
burns the hydrogen evolved from batteries and also oxidises carbon monoxide and hydrocarbons. Each
battery compartment contains hydrogen detectors for determining the percentage of Hydrogen gas
continuously and an alarm alerts the watch keeper if Hydrogen levels exceed more than 4%. The maximum
permissible amount in the battery ventilating system is 3%.
(v) Chlorine.
(aa) Source.
In a submarine, Chlorine is produced when seawater comes in contact with Sulphuric Acid present in the
batteries. It is two and half times heavier than air and remains close to the deck unless disturbed by air
currents.
(ab) Health Effects.
A concentration of 1 ppm causes coughing, 10 ppm is dangerous if inhaled for half an hour; and
100 ppm may be fatal within a few minutes.
(ac) Prevention.
Battery compartments have monitors which raise alarm when Chlorine gas is detected. Exhaust ventilation
from the sealed compartment is used to discharge the gas from submarines.
(vi) Tobacco Smoke.
(aa) Health Effects.
The ill effects are due to the nicotine consumption through indirect inhalation especially among personnel
not habituated to tobacco and the associated foul odour in closed compartments. Nicotine generally causes
acceleration of the pulse rate, reduced cardiovascular tolerance and confusion. In some cases, it may also
cause irritation of the eyes and the respiratory tract.
(ab) Prevention.
Tobacco use is forbidden in submarines.
(vii) Other Pollutants.
(aa) Source.
In closed atmosphere where there is no dispersion of gases, even limited amounts of pollutants such as
acrolein, sulphur dioxide, hydrogen sulphide & ammonia may get accumulated and cause ill health. Carbon
monoxide, Cardon dioxide, Acrolein etc. are produced during toasting and frying in galley. In washrooms
and latrines foul odours are created due to release of sulphur dioxide, hydrogen sulphide and ammonia.
(ab) Prevention.
These pollutants are absorbed by using Hopcalite and activated carbon filters present in the ventilation system.
(c) Effects of Increase in Air Pressure.
The air pressure in a submarine is normally equal to the atmospheric pressure. While diving, the pressure

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increases slightly due to the compression of the hull and venting (blowing) of the tanks inboard. During ‘submarine
escape’ from a sunken submarine, the air pressure inside the flooded compartment must exceed the pressure
of the outside seawater prior for opening the escape hatch. The detailed effects of pressure are covered in
section of Diving Illnesses.
(d) Noise and Vibration in Submarines.
(i) Noise Pollution.
An average noise level in a submarine is around 80 to 90 decibels. The noise levels may be as high as
100 to 110 decibels in the engine room. Continuous exposure to noise of high intensity may cause auditory
effects like hearing loss and non-auditory health effects like fatigue and confusion, etc.
(ii) Vibration.
The vibration level in submarine is 2 to 3 times higher than the safe physiological limits. Whole-
body vibration can cause motion sickness, fatigue, stomach problems, headache, loss of balance and
shakiness in legs. Excessive exposure of vibration in hands can affect the nerves, blood vessels, muscles
and joints of the hand, wrist and arm causing Hand-Arm Vibration Syndrome.
(iii) Preventive Measures.
Planning of proper living and working conditions in the submarine right from the design to construction
stages is essential to provide optimum hygienic living conditions based on ergonomic principles.
(e) Effect of Submarine Sailing on Crew.
(i) Emotional and Psychological Stress.
(aa) Causes.
Due to limitation of men in submarines, every submariner in addition to his primary task also performs
additional responsibility. Additional workload in confined and shared spaces in challenging environment
may create emotional stress. In addition, separation from families with limited information about them
enhances the emotional turbulence.
(ab) Preventive Measures.
Submariners are selected after detailed health examination including psychological examination.
(ii) Effects on Central Nervous System.
Prolonged submarine cruise may cause headache, irritability, sleep disorder or depression, etc. It may also
lead to digital and eyelid tremors, unequal tendon reflexes and impaired thermal and pain sensitivity. In
extreme cases, there is reduction in the mental capacity, affecting professional activity.
(iii) Effects on Sensory Organs.
(a) Eyes.
Submarine cruise affects the dark adaptation and may also temporarily reduce visual acuity. Prolonged
underwater sailings may reduce field of vision. This may be due to over-fatigued ciliary muscles due
to close viewing of objects in dim lights for a long time.
(b) Ears.
The leading specific factors, that influence the auditory organs, are the level of noise and to a lesser
degree the pressure changes. Problem of deterioration of acuity of hearing in engine room crew is
also important. Prolonged underwater sailing will reduce both air and bone conductivity. Some have
even noticed increased incidence of neuritis of auditory nerve among submariners.
(iv) Effects on Cardiovascular and Respiratory Systems.
Prolonged submarine cruise may cause pain in the precordium, palpitation, oedema of lower extremity
and dyspnoea on exertion. Clinical examination may reveal tachycardia, rise in systolic pressure and fall in
diastolic pressure leading to an increased pulse pressure. Correspondingly, the respiratory rate may increase
and reduce the vital capacity as an adaptation to increased carbon dioxide level.

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(v) Changes in Digestive System.

The changed working conditions and food habits may cause loss of appetite, belching, heart burn and
constipation etc.

9.8 Diving Illnesses.

Unlike submariners who are protected from effects of pressure by the hull of the submarines, divers are directly exposed
to effects of water and air pressures when they go underwater or live in submersibles. This calls for physiological
adjustment and supplementation with specialized equipment.
(a) Physics of Diving.
(i) Air Pressure and Pressure by Water Column.
(aa) Concept of Atmosphere Absolute.
The earth is surrounded by atmosphere, which exerts a pressure which has been standardised as
760 mm of Hg measured at sea level or 01 Atmosphere Absolute (ATA). Instead of mercury column if
seawater is used, the barometer would show 01 ATA as shows 10 meters. Hence, 01 ATA is equal to
760 mm of Hg or 10 meter of sea water or 1 Kg / cm2 or 01 Bar of pressure. Therefore, Commercial
divers working at depth of 600 meters would be exposed to 61 Kg / cm2 or 61 ATA, i.e. 60 ATA water
column + 01 ATA atmosphere.
(ab) Body Physiology and Gas Laws of Physics.
The diver is able to sustain and work under such great pressure because the human body contains
75% liquid and 25% solids, which are not compressible as per Pascal’s law. The effects of diving on
the human body are caused by the gas present in the body both in physical and dissolved forms,
which obeys the physical laws viz. Boyle’s law, Dalton’s law and Henry’s law, etc.
(ii) Buoyancy.
As per the Archimedes principle whether an object floats or not depends upon the relative magnitudes of
the weight and upthrust which is equal to the weight of liquid displaced. Hence, there are three possible
cases, i.e. negative, positive or neutral buoyancy.
(aa) Ballast Weights.
Under normal conditions a diver in the water is positively buoyant. It is necessary to increase his weight
by the addition of ballast weights in order to bling him to a state of neutral or negative buoyancy
when totally immersed. The weight required varies depending on the type of equipment being used,
amount of underclothing, area of operation and the density of the water.
(ab) Change of Buoyancy with Depth.
A self-contained diver is buoyant because of the air in his lungs and air trapped in the dress. To
assist his descent, the diver vents the diving suit at the surface before swimming down. As the water
pressure increases and compresses the air in the dress, displacement is reduced, making it more
negatively buoyant and increasing the speed of descent.
(ac) Suit botion and Dangers of Blow-Up.
If a diver at the bottom has slight negative buoyancy, then he inflates the dress to displaces a
greater amount of water and assumes positive buoyancy, thus increases the speed of his ascent to
the surface. The diver has means of deflating the dress by releasing air from his cuff for controlling
the speed of ascent. A diver must take appropriate actions quickly, otherwise there is a danger of
being ‘blown up’ to the surface (rapid ascent with lung and bone complications).
(iii) Underwater Vision.
Even in the cleanest ocean water, 20% of the incident light reaches a depth of 10 meters and only 01%
reaches 85 meters. Coastal waters with more suspended material scatters the light and restricts the vision.
In water, refraction at cornea-air interface and air-glass-water boundary increases the apparent size of
objects by about 30% (Fig 9.1). This makes objects appear closer than they are. Face masks also restrict

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vision by narrowing the peripheral fields and distorting objects.

Fig 9.1 : Underwater Vision

(iv) Underwater Sound.
In air, sound travels at about 335 metres per second. In water, sound travels more than four times as
fast as in air, i.e. in the range of 1,000 to 1,400 meters per second, depending on the salinity and depth
(density) of water. Human ear is not adapted to such environment and it makes it almost impossible to
pinpoint a source of sound underwater. It is only possible to obtain a general idea of the direction of
sound. In addition, sound energy is lost when being transmitted from air to water. Therefore, for divers to
hear sounds from the air above them, the sounds must originally be very loud. The telephone lines going
underwater to communicate with divers have gases at increasing pressures and densities as the depth
increases. The speed of sound is different in gases of different densities. Hence, at depths of around
1,000 meters, the voice becomes so distorted that telephone communication is almost impossible. In
addition, breathing oxygen-helium gas mixture or air at high pressures changes the voice to a higher pitch.
The higher the partial pressure of helium, the greater is this effect.
(v) Effects of Pressure on Human Body.
Effects of pressure on human body during a dive are as mentioned in the succeeding paragraphs.
(aa) Direct Physical Effects or Barotraumas.
The physical effect is due to a direct effect of increased pressure by a column of water on the human
body. It causes changes in the volume of air in the various air containing cavities of the body like
lungs, ears, GIT, etc. and may profoundly change the respiratory dynamics.
(ab) Indirect Biological Effects.
The biological effects are indirect in nature and are due to change in partial pressure of the gases
inhaled and depend on the saturation / desaturation of the tissues with dissolved gases like oxygen
toxicity, nitrogen narcosis, etc. and changes in the body functions by abnormal gas tension like
decompression sickness, dysbaric osteonecrosis, air embolism, etc.
(b) Classification of Diving Medical Problems.
Medical problems encountered by the divers may be classified according to the phases of diving.
(i) Phase of Ascent to Surface and Thereafter.
(aa) Decompression Sickness.
(ab) Pulmonary Barotrauma.
(ii) Phase of Descent to Bottom.
(aa) Otitis or sinus or dental barotrauma.
(ab) Face or thoracic body squeeze.

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(ac) Acute Hypoxia.

(ad) Hyperbaric Arthralgia.
(ae) High Pressure Nervous Syndrome (HPNS).
(iii) Phase of Staying at Bottom.
(aa) Respiratory problems at depth.
(ab) Oxygen, CO2, CO toxicity.
(ac) Inert gas / Nitrogen Narcosis.

9.9 Decompression Sickness.

Decompression sickness is also known as Caisson disease or Bone Bends and is produced by the sudden release of
nitrogen gases dissolved in blood in form of bubbles into the body fluids and tissues during the phase of rapid ascent.
(a) Aetiology.
Liquids like blood while under pressure (eg. staying underwater at depths of more than 60 meters for prolonged
period), absorbs / dissolves excess gases in comparison to when at sea level, in accordance with Henry’s Law.
Body tissues also while under pressure take up gases in accordance with the solubility of these gases. For
example, fatty tissues take up five times more nitrogen than other tissues in the body. If the pressure is suddenly
released (eg. in case of rapid ascent to surface), the excess gases dissolved in blood is released in the form of
bubbles in body fluids and tissues causing Decompression Sickness. The release of bubbles can be managed
without producing Decompression Sickness till some distance of ascent / release of pressure and these findings
have been used to produce charts for the aid of divers (Fig 9.2). Inert gas such as nitrogen is generally responsible
in formation of bubbles, as oxygen is metabolically active and is rapidly consumed in tissues.

TIME IN MINUTES
0 20 40 60 80 100 120 140 160 180
0
20
40
SAFE
60

80
100 LIMITS OF TIME AND DEPTH
FROM WHICH A DIVER MAY BE
DEPTH IN FEET

120 DIRECTLY BROUGHT TO THE

140 SURFACE WITHOUT RISK OF
DECOMPRESSION SICKNESS
160 WHEN BREATHING AIR
180

200
220
240
260

280
300

Fig 9.2 : Chart for the Aid of Divers to Prevent Decompression Sickness
(b) Pathology.
(i) Acute Vascular Occlusion of Micro-vessels.
The main pathological lesions are secondary to vascular occlusion by inert gas / nitrogen bubbles and any
organ can be affected in this process. Some common examples are Air Embolism in pulmonary system,

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Embolic Stroke due to occlusion of the vessel in cerebral circulation and Myocardial Ischemia due to
occlusion of coronary arteries.
(ii) Delayed Effects - Coagulation Dysregulation and Bone Necrosis.
Gas bubbles also act as foreign surfaces, which attract platelets and activate Hageman factor to trigger off
the coagulation system. This process leads to formation of micro thrombi. There is evidence to suggest that
Fat Emboli are released into the circulation which may have delayed manifestations in the form of Aseptic
Bone Necrosis of long bones and generalised degeneration of neurons of the central nervous system.
(c) Signs and Symptoms.
Generally, the shorter the time interval in onset of symptom after surfacing from a dive, the graver are the
symptoms. By and large symptoms which appear after one and half hours after surfacing are of the milder
variety. But Decompression Sickness is known to occur upto a day after surfacing from a dive.
(i) Severe Decompression Sickness.
The fatal symptoms are produced because of gas emboli in the pulmonary, CNS or Coronary vasculature.
The patient has severe dyspnea, paresis or paralysis, speech disturbance, cerebellar disturbance, mood
disturbance, convulsions and disturbance of consciousness.
(ii) Mild Decompression Sickness.
It usually comes after an interval of minutes or hours of surfacing from a dive. It manifests as pain in a
joint or as an itchy skin rash. These symptoms may also be a part of severe Decompression Sickness.
(d) Treatment in Recompression Chamber.
Instructions for treatment are contained in Articles 5502 to 5523 of Indian Naval Book of Reference (INBR) 2806,
which is the Diving Manual for the Indian Navy. These references should always be made available at diving sites.
However, most Decompression Sickness encountered in diving at less than 70 meters of depth can be effectively
treated by following the instructions in oxygen tables Table 9.1 and 9.2) and use of Recompression Chamber. If
symptoms appear then, the diver should be immediately repressurized without wasting time for investigations.
(e) Treatment in Absence of Recompression Chamber.
In the absence of Recompression chamber, the patient should be administered 100% Oxygen by oronasal mask
and administered plasma expanders like Dextran to prevent sludging of RBC and haemo-concentration. Analgesics
(Aspirin) may be given for symptomatic relief from limb bends. In extreme cases, Heparin 7,500 IU stat and
5,000 IU may be administered every 06 hours.
(f) Air Evacuation of Diving Casualty.
Diving casualties may be transported in aircrafts, which can maintain a cabin altitude of 500 to 1,000 feet or
in helicopters at a height of 500 feet.
Table 9.1 : Oxygen Recompression Therapy (For Mild Cases)
Gauge Depth Rate of Ascent
Stoppages Elapsed Time
(Meters) (Meters / Minute)
18 20 (O2) 0000-0020 -
18 5 (Air) 0020-0025 -
18 20 (O2) 0025-0045 -
18-9 30 (O2) 0045-0115 03 meters in 10 mins
9 5 (Air) 0115-0120 -
9 20 (O2) 0120-0140 -
9 5 (Air) 0140-0145 -
9-0 30 (O2) 0145-0215 03 meters in 10 mins

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Table 9.2 : Oxygen Recompression Therapy (For Severe Cases)

Gauge Depth Rate of Ascent
Stoppages Elapsed Time
(Meters) (Meters / Minute)
18 20 (O2) 0000-0020 -
18 5 (Air) 0020-0025 -
18 20 (O2) 0025-0045 -
18 5 (Air) 0045-0050 -
18 20 (O2) 0050-0110 -
18 5 (Air) 0110-0115 -
18-9 30 (O2) 0115-0145 03 meters in 10 mins
9 15 (Air) 0145-0200 -
9 60 (O2) 0200-0300 -
9 15 (Air) 0300-0315 -
9 60 (O2) 0315-0415 -
9-0 30 (O2) 0415-0445 03 meters in 10 mins

(g) Prevention.
(i) Decompression Sickness can be prevented by the strict adherence to diving schedules given in
diving manuals. The air diving table followed in the Indian and Royal British Navy is given in Table 9.3 for
reference. Diving at high altitudes and in extreme cold conditions can predispose to Decompression Sickness
due to low ambient pressure. Recompression Tables are modified for these areas. As fatty tissues take up
considerable amount of excess gas, obese people should not be allowed to dive.
Table 9.3 : Air Diving Table
Stoppages at Different Depths Total Time
Depth upto for Decom-
Bottom Time
(Meters) 25 m 20 m 15 m 10 m 5m pression
(Minutes)
9 Nolimit - - - - - -
10 230 - - - - - 01
420 - - - - 05 05
480 - - - - 10 10
15 80
- - - - - 01
85 - - - - 05 05
90 - - - - 10 10
100 - - - - 15 15
110 - - - - 25 25
120 - - - - 30 30
20 45 - - - - - 1½
50 - - - - 05 05

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Stoppages at Different Depths Total Time

Depth upto for Decom-
Bottom Time
(Meters) 25 m 20 m 15 m 10 m 5m pression
(Minutes)
55 - - - - 10 10
60 - - - - 15 15
65 - - - - 25 25
70 - - - - 30 30
25 25 - - - - - 02
30 - - - 05 05 10
35 - - - 05 10 15
40 - - - 05 15 20
45 - - - 05 20 25
30 20 - - - - - 02
25 - - - 05 05 10
30 - - - 05 10 15
35 - - - 05 20 25
35 15 - - - - - 2½
20 - - - 05 05 10
25 - - - 05 15 20
30 - - - 05 25 30
40 11 - - - - - 03
15 - - - 05 05 10
20 - - - 05 10 15
25 - - - 05 25 30
45 09 - - 03
15 05 10 15
20 05 10 25
50 07 - - - - - 03
10 - - - 05 10 15
15 - - - 05 20 25
55 06 - - - - - 04
10 - - - 05 05 10
15 - - 05 05 15 20
60 05 - - - - - 04
10 - - - 05 10 15
15 - - 05 05 20 30

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Stoppages at Different Depths Total Time

Depth upto for Decom-
Bottom Time
(Meters) 25 m 20 m 15 m 10 m 5m pression
(Minutes)
65 10 - - - 05 10 15
15 - - 05 10 30 45
70 10 - - - 05 15 25
15 - 05 05 10 50 65
75 10 - - - 05 15 25
15 - 05 05 10 50 65

9.10 Barotrauma.
Barotrauma is defined as tissue damage resulting from the expansion or contraction of enclosed gas spaces and is the
direct effect of gas volume changes causing tissue distortion. It is the most common occupational disorder in divers.
Changes in volume in air filled cavities like sinuses, ears, lungs, etc. due to change in outside pressure are greater
near the surface / sea level in accordance with Boyle’s Law. A pressure difference as small as 0.05 Kg / cm2 between
the inside and outside of a body cavity can cause damage to body tissue.
(a) Sinus Barotrauma.
(i) Pathology.
The sinus cavities are lined with a mucous membrane similar to that in the nose. Bony canals provide
means of equalisation of pressure between the cavities and the mouth. Normally, there is a free flow of
air to the sinuses from the back of the nose and throat. However, if the canal through the bone becomes
blocked by mucus or swelling of the tissues, the air flow will not occur. The volume of air in the sinuses
contracts on increase in external pressure causing lining wall bulging and blisters in sinuses. On ascent,
the air in the sinuses will expand and may force the accumulated blood in blisters out through the canal
(Fig 9.3).

Fig 9.3 : Sinus Barotrauma

(ii) Symptoms.
Local pain or headaches may occur if sinus lining is damaged. The sinus mucous lining may burst causing
the cavities to fill with blood with relief in pain. However, after ascent there may be a nose or mouth
bleed.
(iii) Prevention.
Diving should be avoided when suffering from a cold, catarrh or throat infection or in other cases where
the sinuses are blocked.

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(b) Aural Barotrauma.

(i) Pathology.
The Eustachian Tube (ET) usually opens in the healthy individual during the act of swallowing to allow air
in or out of the middle ear for maintaining pressure balance. However, under large pressure differences,
ET does not open freely and discomfort is felt as the drums are stretched. During ascent the air escapes
on its own and clearing is not usually necessary. Middle ear barotrauma is the most common occupational
disorder of divers. If the Eustachian tube is blocked by swelling or mucous as in the upper respiratory
tract infection, the pressure equilisation between middle ear and external ambient atmosphere will not
take place (Fig 9.4).
(ii) Symptoms.
There is an inward bulging of eardrum with stretching pain, haemorrhage which may lead to perforation
of the eardrum.

Fig 9.4 : Aural Barotrauma

(iii) Prevention and Treatment.
(aa) Prevention includes pre-dive ENT examination and avoidance of diving with nasal or ear
infections. Slowing the pace of descent rate also prevents aural barotrauma.
(ab) Discomfort during descent is overcome by forceful opening of the ET by swallowing, yawning
or by Valsalva manoeuvre. The relief is evident either as ease of pain / stuffiness or as an audible
click in the ear. The clearing of ears is required at the pressure of 2.2 meters, 4.4 meters and

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7.3 meters, 10.8 meters and so on.

(ac) Treatment includes pain relief by taking Disprin / Brufen and antibiotics to stop infection.
(c) Pulmonary Barotrauma.
For an average person the Lung Capacity is about 06 litres and Residual Capacity is about 1.5 litres. During
diving, these gases are subjected to contraction or expansion in accordance with Boyle’s law causing Pulmonary
Barotrauma. This is the most serious form of the Barotrauma.
(i) Lung Squeeze during Descent.
(aa) Pathology.
When a diver descends, the increase in pressure of water column (outside pressure) causes
a decrease in volume of the air in the lungs. At about 30 meters depth, the volume of lungs
decreases to about 1.5 liters, i.e. nearly the Residual Capacity. On further descent, the chest
and lungs cannot contract any more. So, fluid and tissues are forced into the chest and lung air
spaces as the external pressure continues to rise. In extreme cases, the ribs may crack and the
chest cave in. This phenomenon is known as lung squeeze.
(ab) Prevention.
It is prevented by supplying pressurized breathing gas to the diver at the same pressure as the
surrounding water.
(ii) Burst Lung and Embolism During Ascent.
(aa) Incidence and Mortality.
The incidence of burst lung and embolism during ascent among Naval divers is 1 in every 3,000
free ascents with fatality rate as 1 in every 50,000 free ascents.
(ab) Pathology.
Decreasing external pressure of even 0.035 bar during ascent causes the gases in lungs to expand
by twofold. If the gas is not allowed to escape, the alveoli may rupture due to over distention
causing damage to the pulmonary tissue. Gas may enter the blood stream through the ruptured
alveoli which would tend to expand as pressure further decreases. These gas bubbles may block
the blood supply to vital organs such as the brain and heart. Air may also escape from the
lungs into the chest cavity, causing partial collapse of the lungs. Voluntary breath holding during
ascent, inadequate exhalation caused by panic, sudden blow to the breathing bag resulting in back
pressure, obstruction in the pulmonary airways as in asthma, tuberculosis, cysts, lung infections,
etc. prevents the escape of gases from lungs during ascent.
(ac) Symptoms.
Haemoptysis and chest pain on deep inspiration are early symptoms. Air embolus may cause
disruption of blood supply to vital organs. In extreme cases, Pneumothorax may occur, further
causing dyspnoea. Pneumomediastinum and Surgical Emphysema may occur due to tracking of
respiratory gases along the air passages resulting in dyspnoea, dysphagia, left recurrent laryngeal
nerve palsy and brassy tone due to compression on the voice box. If the symptoms are not treated
early, then it rapidly progresses to unconsciousness and death.
(ad) Prevention.
Personnel with pulmonary disease should not be allowed to dive. It is essential to breathe out on
a free ascent when using breathing apparatus and observing the correct drill to keep the airway
patent during ascent.
(ae) Treatment.
Immediate treatment is by recompression to 50 meters for 30 minutes after which the patient is
decompressed according to the recompression table (Table 9.4). If required resuscitation measures
should continue in the recompression chamber while re-pressurisation is going on. Ancillary
measures such as needle drainage for pneumothorax should be done.

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Table 9.4 : Modified Air Recompression Therapy

Gauge Depth Stoppages Ascent Elapsed Time Rate of Ascent
(mtrs) (min) (Hours) (Meters/Min)
50 30 (Air) 0000-0030 -
50-18 4 (Air) 0030-0034 8 m/min
18 20 (O2) 0034-0054 -
18 5 (Air) 0054-0059 -
18 20 (O2) 0059-0119 -
18 5 (Air) 0119-0124 -
18 20 (O2) 0124-0144 -
18 5 (Air) 0144-0149 -
18-9 30 (O2) 0149-0219 03 m in 10 min
9 15 (Air) 0219-0234 -
9 60 (O2) 0234-0334 -
9 15 (Air) 0334-0349 -
9 60 (O2) 0334-0449 -
9-0 30 (O2) 0449-0519 03 m in 10 min
Surface 0519

9.11 Breathing Gas Problems.

The problems associated with breathing gas are dependent upon the partial pressure of oxygen, nitrogen and carbon
dioxide in the breathing gas mixture.
(a) Hypoxia.
(i) Causes.
It may occur due to wrong preparation of gas mixture, empty air cylinder, malfunctioning of reducers,
accumulation of foul gases in breathing bag.
(ii) Pathology.
Breathing gas with less than 17% oxygen concentration results in hypoxia.
(iii) Symptoms.
Symptoms are difficult to detect in early stages and the first symptom is false sense of wellbeing and
over confidence. If partial pressure of oxygen falls continuously, the diver may become unconscious.
(iv) Prevention.
Meticulous checks of the partial pressure of oxygen in the breathing gas and ensuring the correct flow
of gas mixture are to be ensured by the diving coordinator. In addition, checks are to be instituted for
periodic clearing of carbon dioxide and other gases i.e. to counter lung to prevent dilution hypoxia.
(b) Oxygen Toxicity.
(i) Causes.
When breathing pressurized gas mixture beyond 20 meters, symptoms of acute oxygen poisoning may
occur. Breathing of oxygen under pressure in excess of 0.6 ATA for prolonged periods can produce chronic
oxygen toxicity.

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(ii) Symptoms.
This may be experienced as twitching of lip and other facial muscles, dizziness, vertigo, nausea and
unusual tiredness. The breathing pattern may be disturbed and cause onset of dyspnoea, hyperpnoea
or apnoea. In extreme cases, euphoria, tunnel vision, unconsciousness and generalised convulsions may
manifest. The diver may lose his mouthpiece or mask during loss of consciousness and convulsions,
leading to drowning. Delayed manifestation is transient loss of memory. Chronic oxygen toxicity manifests
as pulmonary oedema, hemorrhages and fibrosis.
(iii) Prevention.
Depth should be restricted to 08 meters for free swimming and 10 meters for light work, while using
100% oxygen during diving. The partial pressure of oxygen in the breathing gas mixture may be limited
to 02 bars absolute.
(iv) Treatment.
If symptoms are detected then, resurface the diver and remove the breathing apparatus and suit
immediately. The diver should be allowed to breath normal air to recover. Convulsion precautions are to
be taken. The diver must be kept under observation for at least 12 hours.
(c) Inert Gas Narcosis.
(i) Causes.
When gases like nitrogen, helium, neon, hydrogen, argon, krypton, etc. are inhaled, they dissolve in the body
and produce narcotic effect as that of anaesthetic gases. Helium, neon and hydrogen are least narcotic,
whereas krypton and xenon are highly narcotic. Narcotic effect is depth related, i.e. it occurs immediately
on reaching the depth and independent of time. In fact, the diver develops acclimatisation after prolonged
stay.
(ii) Symptoms.
The symptoms are similar to that of alcohol intoxication. 01 ATA of air produces the narcotic effect
equivalent to intoxication of consuming of 30 ml of Martini wine. Euphoria, talkativeness and laughter
may manifest till depth of 50 meters. Beyond this depth, delusions, stupefaction and unconsciousness
may occur.
(iii) Prevention.
Air as breathing medium should not be used during diving beyond 50 meters of depth.
(d) Carbon Monoxide (CO) Poisoning.
(i) Causes and Symptoms.
This occurs due to charging of air bottles in polluted atmosphere or near engine exhausts. Symptoms
are mentioned in Table 9.5.
Table 9.5 : Symptoms of Carbon Monoxide (CO) Poisoning
CO in Air Percentage of
Symptoms
(As PPM) Carboxy-Haemoglobin
400 7.2 Nil
800 14.4 Headache, nausea, dizziness, breathlessness
Confusion, visual disturbance, increasedpulserate,
1,600 29
increased respiration, collapse
3,200 58 Unconsciousness, intermittent convulsions
4,000 72 Profoundcoma,cardiovascularand respiratoryfailure
4,500 81 Death

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(ii) Treatment.
The diver should not be exposed any further to the polluted breathing gas and provided 100% oxygen
to wash of the effects. In extreme cases, the diver may be resurfaced and administered Hyper-Baric
Oxygen Therapy.
(e) Carbon Dioxide Toxicity.
(i) Causes.
During diving, Carbon Dioxide retention occurs mainly because of the malfunctioning of the breathing
sets, i.e. non-functioning of valves of the air bottles, inefficient Carbon Dioxide removal or accumulation
of foul gases in the breathing bag. Excess Carbon Dioxide also may be produced due to over exertion.
In chronic form of poisoning there is a stage of compensation, which is followed by decompensation and
ultimately failure. In acute form, the stage of compensation may be totally absent.
(ii) Symptoms.
(aa) Latent Hypercapnia (0.2-0.5% Carbon Dioxide).
Perception of smell improves along with sense of euphoria, but there is a feeling of stiffness.
(ab) Compensated Hypercapnia (0.5-3% Carbon Dioxide).
The diver starts to hyperventilate at this concentration. Attention and memory get affected. Acidic
secretions of stomach increase as well as the urine and sweat becomes acidic. Hypotension may
develop after prolonged exposure, i.e., after 03 to 04 days.
(ac) Marked Hypercapnia (3-6% Carbon Dioxide).
There is a sharp deterioration of general condition, lack of confidence and self-control including
lack of orientation in space and time. Euphoria is enhanced and there is a deterioration of critical
judgement.
(ad) Uncompensated Hypercapnia (6-10% Carbon Dioxide).
There may be drowsiness, loss of consciousness, constriction of pupils, convulsions and depression
of adrenal cortex leading to collapse.
(ae) Narcotic Stage (>10% Carbon Dioxide).
Deep narcosis with respiratory depression leading to death.
(iii) Treatment.
On detection of symptoms, the diver must flush through the counter lung and breathe deeply or signal
for more air, according to the equipment in use. If this brings no relief, the diver must surface and be
administered fresh air or oxygen.
(iv) Prevention.
Carbon Dioxide absorbent in the canister must be checked if it is fresh, dry, dust free and correctly
packed. Endurance of the canister must not be exceeded. Correct breathing technique should be used
by divers, i.e. intake of long and deep breaths. Periodically, the stale air in the Bell / Chamber must be
replaced with fresh air without causing a change of pressure.

9.12 Hyper-Baric Oxygen Therapy (HBOT).

(a) Physiology.
Breathing 100% oxygen at more than 01 ATA in a pressurized chamber is called Hyper-Baric Oxygen Therapy.
Breathing of pure oxygen at 3 ATA pressure ensures availability of 06 ml of oxygen per 100 ml of blood in
the form of physical solution, which is adequate to meet the oxygen requirements of body without dissociating
oxyhaemoglobin.
(b) Benefits.
This soluble oxygen readily diffuses into tissues and reverses hypoxia, reduces oedema, improves blood

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circulation through neo-vascularisation and enhances wound healing by collagen matrix formation. The oxygen
radicals are powerful bactericidal and controls anaerobic and partly aerobic infections.
(c) Indications.
(i) Accepted Indications.
(aa) Decompression Sickness
(ab) Gas Embolism
(ac) Gas Gangrene
(ad) Carbon monoxide poisoning
(ae) Osteomyelitis and Osteonecrosis
(af) Wound Healing
(ii) Possible Indications.
(aa) Adjuvant to Radio therapy
(ab) Burns injury
(ac) Cerebral Oedema
(ad) Vascular Insufficiency
(ae) Tuberculosis
(af) Leprosy
(ag) Actinomycosis
(d) Contraindications.
(i) Air trapping respiratory disorders viz. pneumothorax, emphysema, asthma, fibrosis, tumours, cysts
and thoracic surgery.
(ii) Eustachian blockage due to upper respiratory infections, allergy and polyps.
(iii) Uncontrolled high fever.
(iv) Pregnancy
(e) Complications.
(i) Middle ear, sinus and pulmonary barotraumas
(ii) Myopia and cataract
(iii) Oxygen seizures
(iv) Claustrophobia
(f) HBOT Protocol.
Giving pure oxygen at 2.8 ATA for 60 minutes / day for 01-02 weeks is sufficient for the above indications.
However, severe infections like Gas Gangrene requires 02 sessions on first 03-04 days. In a hyperbaric chamber
simulated for depth of 18 meters, convulsions may occur while treatment. In such cases, oxygen mask should
be removed and the patient be allowed to breathe chamber air. The pressure should thereafter be reduced
to 12 meters to restart therapy.

9.13 Hypothermia.
The Indian Naval personnel are not usually subjected to cold weather and waters. They may sometimes suffer from
hypothermic reactions following the diving operations in cold water with temperature below 15ºC. The initial defensive
response produces a constriction of blood vessels, increased heart rate and blood pressure, shivering, increase in
metabolism and hypoglycemia. Generalised pathological hypothermia with a dynamic phase occurs, when the core body
temperature falls below 33ºC resulting in hallucinations, delusions and cardiac arrythmias. When the core temperature

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falls below 30ºC, paralytic phase sets in, which manifests as unconsciousness, stoppage of heart and respiration.

9.14 Drowning.
Drowning is asphyxia due to immersion in water. Hypothermia is a common cause of drowning in colder waters. The
victim both inhales and swallows water. However, in the most cases very little water enters the lungs due to spasm
of larynx causing ‘dry drowning’. Drowning causes congestion of the lungs and failure of oxygen transfer in alveoli.
(a) Clinical Features.
The main clinical feature is difficulty in breathing with increased rate and depth. There is frothing from mouth,
blueness of lips and fingertips, confusion, unconsciousness and finally death if not rescued within about 08
minutes.
(b) First Aid.
The victim should be laid on a flat surface and obstructions in the mouth removed. Artificial respiration
and cardiopulmonary resuscitation should be started immediately if indicated. Victims tend to swallow large
quantities of water distending their stomach. The victim may be placed in a head downward position and lifted
under the stomach with the rescuer’s hand to force out the water.

9.15 Hazardous Marine Animals.

Certain forms of marine life pose a threat to humans. Generally Naval personnel get hurt during self-defense when
encountered by sea creatures.
(a) Biting Group.
Sharks are the most feared sea creatures. Flesh, blood, noise and irregular vibrations commonly attract
sharks, like after a ship wreck. These predators are most vicious when in the ‘feeding frenzy’ mood. Preventive
measures are by avoiding known shark infested water and avoiding water in which food and animal products
has been thrown. Divers and marine commandos often carry shark repellants during operations. Treatment
is required for hemorrhage and secondary infection. Bites by other sea predators like Barracuda, Moray eel,
killer whale and grouper fish are rarely encountered in Indian waters.
(b) Venomous Group.
(i) Sea Snakes.
Out of the 40 species of sea snakes in Indian waters, 39 species are poisonous. Sea snakes are two
to ten times more poisonous than that of Cobra. However, due to it’s poorly developed fangs, it can
deliver only 25% of the poison. The venom is both neuro and myotoxic and also causes tubular damage
of kidneys.
(ii) Fish.
Catfish stings are common and painful. Sting Rays are found in mud and can deliver a fatal sting.
Scorpion and Stone fish stings can also be lethal but are uncommon. Numbness at bite site, nausea,
vomiting, dizziness and respiratory paralysis may occur if left untreated. Myonecrosis is a common delayed
complication.
(iii) Sea Wasp and Jelly Fish.
The sea wasp is the most venomous animal in the sea and it’s poison can kill within five to ten minutes.
The sting causes a line of wheals on the skin and can cause both local paralysis and respiratory paralysis.
Cone-Shell fish and Octopus sting may be lethal. The Jelly fish normally cause painful pruritic local lesions.

9.16 Investigation of Diving Accidents.

Diving accidents are not uncommon and they should be investigated thoroughly to prevent their recurrence. Almost all
of the diving accidents are preventable and majority of them are due to human error. High standard of physical fitness,
following detailed SOPs and periodic training of the diver are essential for safe diving.
On reporting of diving accident, the diving set is inspected meticulously. The position of all the valves, pressure gauges
and the external appearance of the set are examined and noted down. Gases filled in the cylinder / breathing bag are

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sent for analysis including Carbon Di-Oxide absorbent cannisters. Statements of the diver and diving attendant are also
taken. All this information when analyzed together often leads to the cause of the accident. In cases of fatal accident,
postmortem examination of the body is mandatory. In addition, the Medical Officer should provide full assistance to
the diving supervisor in the investigations.

9.17 Survival at Sea

For further details on Survival at Sea refer Chapter X.

9.18 Health Problems in Naval Aviation.

Health problems of aircrew and supporting ground crew of Naval Air Arm are the same as for those of other Naval
personnel. Aircrew face the same problems as encountered in aviation by the Indian Air Force as covered in Chapter XI.

9.19 Medico-Legal Aspects of Death at Sea.

(a) Post-Mortem Examination.
In case of a sudden or unnatural death onboard ship or submarine while at sea, where circumstances do not
permit the assistance of shore authorities for the postmortem and the body cannot be preserved until arrival
of the ship in harbour, the Medical Officer may under written orders from the Commanding Officer, conduct the
postmortem examination to ascertain the cause of death. Should there be any suspicion, the Medical Officer
should retain evidence in accordance with the medico-legal requirements and DGAFMS Medical Memorandum
176. The Medical Officer shall also inform the Commanding Officer of this suspicion. The Commanding Officer
shall thereupon take appropriate steps to investigate the case and report the same to the senior administrative
authority who shall thereupon convene a Board of Inquiry.
(b) Preservation of Dead Body.
If facilities are present onboard, then all measures may be taken to preserve the body and bring it ashore for
handing over to civil police / next of kin.
(c) Disposal at Sea.
If the dead body cannot be preserved due to any reason, then it should be packed and sealed in the manner
as to ensure it’s immediate sinking.
(d) Inquest.
If the ship is near an Indian port, the Commanding Officer if considers it necessary, may inform the coroner
or other appropriate civil authority for conduct of Inquest. In case the death occurs at a place outside India,
unless the local law requires, it is not necessary to inform the local civil police and the Inquest may be held
by the Commanding Officer. Upon bringing the dead body or human remains of persons who have died of
Yellow Fever, Plague, Anthrax or Glanders the Central government may be notified.

9.20 Prevention of Communicable Diseases.

The scientific principles for prevention and control of infectious diseases afloat are similar to those on land. Ships,
however may call at ports of the countries where specific infectious diseases may be prevalent. Due to intense mixing of
crew within confined spaces with shared ventilation system, the chances of spread of communicable diseases especially
airborne diseases is greater on ships. Therefore, the Medical Officer has to be constantly on guard to prevent any
importation of such diseases on board the ship from foreign ports and thereby to the country. The control of infectious
diseases is described in chapters XXVII to XXXIV.

9.21 International Health Regulations (IHR).

The objective of IHR is to prevent infection spread via international traffic of person and goods from countries where
it exists and by containing it upon arrival, while causing minimal disruption of international traffic. IHR was formulated
by the World Health Organisation and are binding on all member states. The provisions include creation of health
organisation at the frontiers like Port and Airport Health Organisations, notification of diseases, enforcing quarantine
and isolation. Plague, Cholera and Yellow Fever are designated as ‘quarantinable diseases’. International traffic and
vessels are mandated to undertake sanitary measures and participate in health formalities without delay before and

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after arrival at both foreign and domestic ports. This includes production of Bill of Health, Pratique and certificates for
disinfection, disinfestation and other health operations.
(a) Bill of Health.
The Port Health Authorities takes all practicable health measures to prevent the departure of any infected
person or a person suspected to have been in contact with such a person. The aim is to prevent the introduction
of a possible infectious agent or disease vector onboard a ship. This includes mandatory vaccination, medical
examination of crew, disinfection and disinfestation. To this effect a certificate is rendered by Port Custom
Authorities to the Captain of the ship, where it is certified that no notifiable disease is present at the time
of departure from port. This certificate is known as the ‘Bill of Health’. This certificate is mandatory for any
international voyage and is checked by the pilot of the foreign port before entering the same.
(b) Pratique.
Any vessel coming from an infected port or with an infectious case on board, is mandated to fly the yellow
quarantine flag to inform the Port Health Authorities. Such ships are directed to anchor at the quarantine
anchorage and withhold interaction with shore or other ships. All activities as per regulations for prevention of
the particular disease are undertaken and then the ship is declared as free from a communicable disease by
the Port Health Authorities. This certificate is known as ‘Pratique’. For obtaining ‘Pratique’, the ‘Bill of Health’
from the previous port of call needs to be produced. In recent times, pratique is issued for all vessels after
arrival at foreign port, after examination of the vessels, the crew and undertaking preventive heath measures,
if required.
(c) Preventive Measures prior to Departure to Foreign Port.
Prior to proceeding on an international vouge, the incidence of infectious diseases at various ports of call
should be studied. If cases of cholera, plague or influenza are notified at the ports of call then, it is better
to avoid the infected port. If the voyage has to done with these risks, then visiting the port should be out of
bounds and all shore leaves must be stopped. Preventive vaccination as per IHR for all crew is mandatory, if
visiting countries with endemic notifiable diseases.
(d) Health Measures on Arrival at Port.
The Port Health Authority is empowered to conduct medical examination of crew of any ship on arrival after
international voyage. It is done to determine the health measures which need be applied, before allowing the
ship to dock.
(i) Isolation.
An infected person on board can be removed and isolated.
(ii) Quarantine.
Any person on an international voyage from an infected area can be placed under surveillance, until the
end of the incubation period of the disease. However, they are not isolated unless the health authorities
consider the risk of transmission of infection by the suspect to be exceptionally serious.
(iii) Disinfection and Dis-Infestation.
Health measures like disinfection and dis-infestation are normally not repeated at a subsequent port
unless, an incidence of epidemiological significance warranting further applications of health measures
has occurred during the voyage or were not effective in the previous port. If a port is not equipped for
applying these health measures, then it may advise the ships to proceed at their own risk to the nearest
suitable and convenient port.
(iv) Contact with Infectious Person at Foreign Port.
If a crew member comes in contact with a person suffering from an infectious disease, in accordance
with the Naval regulations, the person is required to report this fact at once to his Commanding Officer.
If the infectious disease assumes an epidemic proportion on board the ship, in addition to the routine
preventive measures, the following special precautions may have to be undertaken.
(aa) Stoppage of leave.

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(ab) Prohibition on mixing of the ship’s company.

(ac) Stoppage of visitors to the ship.
(ad) Disinfection of outgoing correspondence and laundry.
(ae) Disinfection of the ship as described in article 1106 clause 2 and article 1109 clauses 5
and 7 of the Regulations of Indian Navy.

9.22 Other Health Concerns.

(a) Management of the Mentally Unfit Crew on-board Ship.
Medical Officers should be alert to notice the incipient cases of maladjustment and mental disorders among
Naval personnel. Special lookout should be established for early pickup of crew who are likely to breakdown.
The Divisional Officers and Divisional Chiefs in charge of such personnel must be apprised of the situation.
Anyone showing a such symptoms should at once be evacuated to a hospital as they may cause harm either
to self or others in a weaponized and stressful situation.
(b) Sea Sickness.
(i) Causes.
This is an acute illness encountered during sailing and the principal factors are visual and kinesthetic
mismatch. Kinesthetic response for balance is received from proprio-sensation and vestibular sensation.
Sea sickness is worsened by psychological stress and hypoglycaemia.
(ii) Symptoms.
It is characterised by heaviness of head, mild headache, nausea, dizziness and vomiting. Severe cases
may have blood-stained vomiting. The psychological effects of this illness are high in rough seas as it can
temporarily incapacitate a large percentage of the crew members. Those who are prone to hypoglycaemia
have a history of attack in an empty stomach.
(iii) Prevention.
In affected individuals, generally acclimatisation of the body response with movement of the ship occurs
within 48 to 72 hours. Reassurance and administration of antihistamines is required in this period.
Promethazine or Phenergan tablets are quite effective in warding off sea sickness provided such tablets
are administered 6 to 12 hours prior to exposure to the risk. The drug prescribed should be continued
at 12 hourly intervals, as long as the ship remains in the risk zone. Preventive drugs if instituted in time
is quite effective, but once sea sickness sets in, resolution becomes difficult. It is advisable to maintain
a list of susceptible crew members and administer the antihistaminic prophylaxis as a routine prior to
sailing. Small feeds prior to sailing may be helpful.

9.23 Safe Water Supply.

(a) Responsibilities.
The Engineering Officer is responsible for supply of safe water and the Medical Officer is responsible to monitor
potability of water and advise on the water treatment to render it fit for human consumption.
(b) Sources.
Safety of water supply is important for the prevention of waterborne diseases. The source of potable water
supply on Naval vessels is mostly from potable water systems ashore or by distillation of seawater. Potable
water must be provided for drinking and cooking purposes. As far as possible it should also be available for
washing, bathing and laundering. However, due to storage difficulties afloat, it is not possible to supply water
at the same scale as on shore. Sea water is normally utilised for firefighting, flushing systems and cleaning
of decks.
(i) From Shore.
Before accepting any fresh water from shore, it is good to know the source of supply. If time permits, Ortho-
Toludine Test and Bacteriological Examination of the port water should also be carried out. Information

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regarding quality of the water is generally available with local Port Health Authority. Water for ship’s
supplies is chlorinated and the Port Health Authorities all over the world conform to the international
requirements of the quality of water. Therefore, if proper precautions for transportation, storage and
distribution are taken, there is little danger of waterborne diseases. Re-Chlorination of water supply
onboard the ship ensures added safety, especially when water is of doubtful purity or when it is likely to
get contaminated during the process of transportation. The following precautions should be taken while
loading water.
(aa) Generally, potable water is available from a common source of supply ashore for both
domestic purposes as well as for firefighting and flushing systems. In some ports there is a dual
system and unfiltered water is supplied for firefighting and in flushing system. The hydrant should
be properly identified, specifically when they are not distinctly marked. This information must be
passed to the individual who makes the connection between the shore supply and the ships
system and operates the hydrants
(ab) The fresh water hose should always be kept separate from others. When taking it to shore
for attachment to hydrants, precaution must be taken to ensure that no part of the hose falls into
the harbour water. The hose should be thoroughly flushed with fresh water before it is connected
with the water system of the ship. After the operation of loading is completed, the hose should
be disconnected, drained and washed and stored away.
(ac) It is necessary to test the water for the residual free chlorine by the Ortho-Toludine Test.
(ad) While filling the freshwater tanks, it should be ensured that no cross connections exist
between the fresh water system and fire-fighting or flushing systems.
(ii) Water Tankers and Barges.
Sometimes the water is transferred from a water ship or a tanker. This water may have been purified
before loading at the base or might have been distilled on board the ship. Arrangements for chlorination
often exist in such vessels. If not, it will have to be carried out after receiving the delivery. Water
barges are also sometimes used for transportation of shore water to the ship specially in harbour. The
precautions mentioned above must be observed in transferring water from these vessels.
(iii) Distilling Water and Reverse Osmosis Plants Onboard Ships.
(aa) Distilling plants of various types for fresh water and boiler feed water are provided on certain
Naval vessels. The distillation of sea water often leaves a considerable quantity of ammonia in the
water, resulting in deviation of a considerable amount of chlorine. An adequate quantity of free
chlorine is thus not available for sterilising purposes. Free chlorine in water should be estimated
by the Ortho-Toludine Test.
(ab) Most ships are fitted with Reverse Osmosis Plants, the purpose of which is to convert sea
water to fresh water. They drastically reduce requirements of water storage onboard during long
sailings. If saline content is more, then the permeate is recycled to further reduce the saline
content till it reaches acceptable limits.
(iv) Overboard Water.
The water in harbours or off-shore near habitations and around fleet concentrations is highly contaminated
and should not be used for any purpose. At times overboard water has to be used in the laundry, showers
and washing of decks. This source should only be used when it is approved by the medical officer and
when out at sea away from shore.
(c) Storage of Fresh Water.
From water safety point of view, detached tanks for storage of fresh water are ideal. In order to fully utilise
the hull space, fresh water is often stored in the inner bottom and outer shell tanks. The ship’s bottom is
subjected to maximum external pressure and can also get damaged from under-water explosions or when
grounded. Should the tank develop a leak, there is likelihood of the contamination of the fresh water in such
tanks.
(i) Periodic monitoring, care and regular maintenance are essential to keep the water tanks free from

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contamination.
(ii) Use of sounding rods for gauging the depth of water in storage tanks can be a source of
contamination. Their use should be restricted and strictly monitored.
(iii) All tanks should have watertight covers, which are to be kept locked at all times.
(iv) Only hose lines reserved for fresh water should be used and all cross connections to other systems
eliminated while filling the tanks.
(d) Cleaning of Fresh Water Tank.
When it is absolutely necessary to enter the tanks for repair and maintenance, then these should be properly
disinfected before being taken back into use.
(i) All personnel employed for cleaning the tanks should be free from infectious diseases and are
required to bath and wear clean clothes before entering the tanks.
(ii) Water tanks are cleaned by scrubbing and brushing.
(iii) Water tanks should be painted only with authorised paints, otherwise there may be a risk of
unpleasant taste and odour or even poisoning by toxic chemicals.
(iv) Thereafter, super chlorinated water is prepared by adding 60 grams of Water Sterilizing Powder
(WSP) to every 1,000 liter of water. The total amount of WSP is first made into a thin paste, by mixing
one kilogram of WSP in 10 liters of water. It is added to a full tank and thereafter the water is circulated
through the pump back and forth.
(v) Taps and outlets nearest to the tank are allowed to flow until the super-chlorinated water appears
in them. This process is continued outward from the tank until all outlets have been flushed.
(vi) The outlets are then closed and after one hour of contact period, the water is let out.
(vii) The system is then washed and filled up with potable water.
(e) Monitoring of Water Quality.
The Medical Officer should see that potable water onboard the ship has at least 0.2 ppm of free chlorine at
all times. Sterilisation of water with chlorine may be carried out when necessary. In large ships, chlorine gas
in solution is used when automatic chloronome is available but in most of the smaller ships field methods
are employed with help of Horrocks’ box. Free and combined chlorine can be estimated easily by the use of
a Chloroscope (Lovibond comparator).
(f) Protection of Water Distribution System.
The fresh water distribution system delivers potable water to galleys, sculleries, pantries, sick bays, laundries,
deck showers and to drinking water taps throughout the ship. The fresh water and salt water systems are
generally independent of each other. There is an additional and exclusive water system for engine room. The
following general rules should be observed as precautions.
(i) Prevention of Cross Contamination.
(aa) In order to trace and identify the various water and other pipe systems and to prevent
improper connections, all pipes are stencilled with the name of the fluid carried or are painted
with distinguishing colours.
(ab) The identification colours used are light blue for potable or drinking water, orange for
sanitary water and red for fire services.
(ac) All faucets, hydrants and other outlets on any system not carrying potable water should be
clearly marked as ‘Unfit to Drink’.
(ad) Cross-connection and back siphonage between other water distribution systems and the
potable water system ashore should not be permitted.
(ii) The fresh water tanks and all parts of the fresh water system must be disinfected at least annually
or whenever there are reasons to suspect contamination.

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(iii) The fresh water tank must always be filled from drinking water hydrants and never from fire main.
(iv) When fresh water is introduced into any piece of equipment that may contain contaminated water,
it should only be admitted through a non-floodable air gap.
(v) The air gap protection should be provided for galley and pantry sinks, scullery equipment, laundry
machines, lavatories, hospital sterilisers and fixtures of all types.
(vi) All drainage outlets to sewers, drains or the bilge, should be protected from flooding by the use
of air gaps.
(vii) As an added factor of safety, water stored in fresh water tanks should be re-chlorinated specially
when the ship is operating in polluted waters.
(g) Water Requirements.
The minimum allowance of fresh water for all purposes on a Naval vessel is about 55 liters per person per day,
out of which about one fifth is required for drinking and cooking. Economy in the use of water is essential. In
smaller ships with small water storage tanks and no method to treat saltwater, drastic restrictions in the use
of fresh water are enforced during sailing. But even under these circumstances an allowance of 10 liters per
person per day is considered minimum.
(h) Use of Salt Water.
Seawater on board ships is used primarily for fire-fighting and sanitary purposes (for flushing of toilets, etc).
Seawater is also used in condensers (heat exchangers) for cooling of machinery, for anchor cleaning and for
pumping out oil and grease bilge eductors. In the event of a Nuclear Biological Control Defence and Damage
Control (NBCD) fall out, certain types of ships have a sprinkling system on upper decks which form a water
curtain to prevent against such biohazards from contaminating the ship.
(j) Emergency Water Supply.
A 1,000 liter tank is provided for vessels with a crew complement of over 500 personnel and a 500 liter tank
for vessels with a total complement of 300 to 500 crew members. It is generally located in the forward section
after the battle dressing stations. Destroyers and other similar ships have a 200 liter tank. Arrangements for
emergency drinking water should be made in turrets and other action stations. Lifeboats and rafts must at all
times carry a supply of drinking water. All emergency supplies should be regularly examined in order to ensure
that safe water is available at all times.

9.24 Storage and Preservation of Fresh Rations and Food Inspection.

A typical problem encountered afloat is the preservation of large quantities of fresh rations carried during prolonged
sailing. Most Naval ships are equipped with Cold Rooms for preserving meat and fish, but only some ships have a
separate Cool Room for storage of fresh fruits and vegetables. Fish should always be stored in containers to prevent
fishy smell in entire Cold Room. Power failure or a mechanical breakdown of the cooling plant for a prolonged duration
is rare and may cause putrefaction of meat and fish. The thawing of the meat should be done gradually. Tinned milk
may be issued onboard in lieu of fresh milk. A daily inspection of fresh rations issued to the galleys is necessary.
Arrangement for cooking and serving of food should be on the same hygienic lines as on shore.

9.25 Sewage Disposal.

(a) Ships.
In most instances ships discharge their sewage over the side without treatment. Disposal by this method
presents little problem when a ship is sailing, except that of providing adequate seawater to ensure flushing
of the troughs and the effluent line. For this purpose, dilution ratio of one to fourty parts is ensured. On some
vessels, the construction is such that drainage from the plumbing fixtures cannot be discharged overboard by
gravity flow because they are below the level of the waterline or because openings would weaken the armour
of the ship. In such instances the liquid wastes flow into a sump tank equipped with a float-device which, when
the sewage rises to a certain level, automatically starts a pump that lifts the sewage up and over the side.
Inspections must be made to ensure that the pump is in working order and there is no leakage or overflow.
The tanks should be cleaned, scraped and painted when the ship is in port for regular overhaul or refit.

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(b) Submarines.
Disposal of wastes from submarines when operating under water is achieved by forcing them out by use of
compressed air. The wastes are collected in a tank and ejected at specified intervals. This method requires special
equipment and education of personnel in it’s use to avoid blowing the wastes back into the ship’s compartment.
Tanks require periodic cleaning, scraping and testing during dockyard overhaul periods to prevent fouling and
leaking. Because of necessity, fresh water, salt water and flushing system lines are located in close proximity
to one another. Cross-connection presents a problem due to the frequent variation of the water pressure and
the subsequent back siphonage created, especially in the fresh water system. These conditions require special
attention to prevent any accidental contamination of the fresh water supply. Under such conditions the lines must
be marked distinctly and frequent inspections should be made to address leaks.

9.26 Pest Control.

(a) Rodents.
In modern ships burrowing by rodents from one compartment to another is impossible, but they can always
find enough of hiding and nesting places in ducts and panels. Rodents multiply rapidly and entry of even a
couple of rodents onboard, soon leads to infestation. Knowledge of habits and characteristics of rodents is
helpful in instituting the control measures. Anti-rodent measures are described in Chapter XXVIII. In general,
rodent control on ships is achieved by denying them access to the ship, denying food, water and shelter for
them and active destruction by trapping, poisoning and fumigation.
(i) Prevention of Access to Rodents.
Rodents gain access to the ships from the shore lines, gangways, cargo nets, electric and water lines,
cargo or from other ships alongside. Port Health Authorities normally enforce the regulations regarding
the use of Rat Guards and these must be complied with.
(aa) All lines connecting ship with decks should be protected with Rat Guards in such a manner
as to prevent rats travelling from line to line.
(ab) The lines should completely fill the central hole of guards so that no gap is left for rats to
pass through.
(ac) If several lines are enclosed by any one guard, they should be lashed together and the
left-over spaces stuffed with cloth.
(ad) Rat Guards should not be placed too close to the docks, i.e. less than one meter as rats
can jump from the dock on the Rat Guard or to the line beyond the Rat Guard.
(ae) When the lines of different ships cross each other, the guards should be placed in such
a way that they cannot be bypassed by the rodents.
(af) Rat Guards should not be less than one meter in diameter. There should be no sagging as
this reduces their effective diameter.
(ag) Rat Guards with small central openings should not be placed on several lines as there is
a tendency for the seams to gape and thus allow access to rats.
(ah) Bow, stern and spring lines should be illuminated during the hours of darkness.
(aj) All landing ramps and gangways not in use should be removed and those in use should
have adequate lighting between the hours of sunset and sunrise.
(ak) Cargo nets should be lifted on board the ship when cargo is not being transferred.
(ii) Rat Proofing.
By rat proofing a ship, the rodents are deprived of their biological necessities for existence like place
for hiding, nesting, breeding and access to food. Under conditions of food and water scarcity, rats even
kill each other and it is easy to trap or poison them.
(aa) Store Rooms.
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pipes and conduits with metal sheeting and by screening other openings. The proper turnover of
the stores every month reduces rat infestation. Food stuff should be stored in rat proof containers.
(ab) Waste Disposal.
Refuse and food scraps from galleys and mess decks must be deposited in raptor containers
pending disposal. All cooked and left over food must be stored in proper rat proof bins.
(iii) Rodent Control.
Active rodent control measures should be adopted at docks and harbours. Rat control by trapping and
poisoning should be practiced onboard also.
(iv) Trapping.
Rat traps are not scaled items and may be obtained on loan from Station Health Organisation. Traps are
effective for the first three days, provided sufficient number of traps are laid. Rat traps are laid at ninety
degrees on the rat runs, which are usually along the borders of the cabin spaces and the air trunkings.
Thereafter rats become aware of the traps and avoid them. Rat glue pads can be utilised as well.
(v) Poisoning.
Zinc Phosphide mixed in the proportion of one part to nineteen parts of atta is used as bait. Tinned
fish can be added to the bait mixture for release of smell to attract rodents. Other poisons used are
anticoagulants like Bromadiolone and Coumatetralyl. Ships should liaise with Station Health Organisation
for carrying out deratting onboard on a regular basis, i.e. at least once every three to six months.
(b) Cockroaches.
Good sanitation and housekeeping in kitchens, larders and dining places prevents cockroach breeding. Control
is by use of chemicals like 1% Baygon or Propoxur, Malathion-pyrethrum mixture, 10% Boric Acid paste or 0.05%
Fipronil gel. These chemicals are generally procured by Station Health Organisations and de-cockroaching is
done periodically by SHO staff or as required by ships on raising the demand / request
(c) Bed Bugs.
Bed bugs live in cracks, crevices and holes in furniture, walls and floors. They are also found in seams of
bed linen and folds of clothing. They remain hidden during the day and emerge at night for and live solely
on the blood. Bedbug nuisance is common onboard ships and submarines. Control is by filling or cleaning
of cracks and crevices, application of heat, replacement of broken furnishings, air bedding of mattresses in
sun, washing of linen and chemical control. 50% Malathion, 2.5% Propoxur and 0.1% Pyrethrum are known
to destroy bedbugs, but not their eggs.

Suggested Reading.
1. Manual of Medical & Dental Administration 2013. Integrated Headquarters Ministry of Defence (Navy).
2. Lambo TA, Day SB. Issues in Contemporary International Health. Springer eBooks. 1990.
3. Edmonds C. Diving and Subaquatic Medicine. 2015.
4. Edmonds C, Thomas RL. Medical aspects of diving--3. The Medical Journal of Australia [Internet]. 1972 Dec 2
[accessed 2024 Feb 22];2(23).1300–4. Available from. https://pubmed.ncbi.nlm.nih.gov / 4405432 /
5. Edmonds C, Bennett M, Lippmann J, Mitchell S. Diving and Subaquatic Medicine, Fourth Edition. CRC Press
eBooks. 2001.
6. Schulte JK. Sealed Environments in Relation to Health and Disease. 1964 Mar 1;8(3).438–52.
7. Hamilton RW, Heimbach RD, Bove AA. Abnormal Pressures. Hyperbaric and Hypobaric. Patty’s Toxicology. 2001
Apr 16;
8. Jain KK. Effects of Diving and High Pressure on the Human Body. Textbook of Hyperbaric Medicine. 2017;23–31.
n

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Chapter
X

SURVIVAL AT SEA

10.1 Introduction.
A situation may arise during operations, routine sailings or training exercises when personnel need to abandon the
afloat platform (ship or submarine) and fend for themselves for survival at sea. Sometimes air accident survivors
may also get stranded at sea. It requires courage, patience and a strong will to overcome the challenges in such
adverse circumstances. Commonsense, awareness of basic survival skills and familiarity of the use of safety
equipment increases the likelihood of survival. As per available data on shipwrecks, most (70%) occur in Atlantic
Ocean followed by Indian Ocean (24%) and is similar to the pattern of sea traffic. Drowning and hypothermia are
the leading causes of death during shipwrecks in temperate and Arctic waters, whereas in tropical waters, it is
drowning and dehydration.  

10.2 Principles of Survival.

Successful survival depends on many conditions prevailing at the time of abandoning the ship viz. day or night,
temperature of water, visibility, calm or stormy sea, presence or absence of enemy forces or friendly ships in the vicinity,
the preparedness of the crew and their ability to lower the boats and rafts quickly. Statistics show that staying near
the shipwreck site increases chance of survival viz a viz getting adrift.
Three most important principles of survival are as under.
(a) The Will to Survive.
When the situation demands, one should help himself and his fellow crew and take them to safety by taking
following actions.
(i) Abolish all fears of mind.
(ii) Decide on a course of action.
(iii) Check all safety equipment.
(iv) Avoid over exertion.
(v) Start rationing of resources.
(b) The Knowledge of Expected Hazards and Use of Common Sense.
All seafarers including people embarking ships for travel should have the basic knowledge of the hazards at sea
and be prepared to negotiate them when needed. Regular seafarers should be periodically trained on survival
skills. The crew should also be briefed on the location of safety equipment and life rafts. Drills to familiarize the
escape routes in the ship should be conducted at least once a year.  
Improvisation and use of commonsense is needed when stranded at sea. Knowledge of the following are crucial
in survival of self and others.
(i) First Aid.
Knowledge of basic first aid is essential as minor trauma is common in shipwreck survivors. If they are
not attended soon, then chance of infection or sepsis increases. First aid items are available in life-rafts.
For stabilizing fractures, splints may be improvised from nearby floating debris.
(ii) Protection from Weather.
Finding suitable shelter like life-raft or large floating substances is key for negotiating drowning and
hypothermia. On finding suitable shelter, clothing may be adjusted to prevent heat loss like discarding wet

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clothes. Huddling up of survivors also prevents heat loss.  

(iii) Location.
On receiving SOS message from distressed ships at sea, several modalities are adopted to find and rescue
the crew, including deploying ships and aircrafts. Early location of the survivors increases chance of survival.
Hence, the survivors should also assist in Search and Rescue (SAR) operations by using the items in survival
pack and any natural resources available.  
(iv) Water and Food.
Both water and food are vital for survival. Knowledge about what to drink and eat and in how much quantity
is essential for survival. Detailed description is provided in sections below.
(c) Effective use of Safety and Survival Equipment.
(i) The Life Raft.
Life rafts are scaled items and provided on ships as per the number of crew. Life rafts are available in
capacity of 6, 10, 15, 20 and 25 persons and are designed to function in adverse sea conditions. They
are placed on the outer decks near the rails of the ships. The life rafts open by itself once it is dropped
from the ships into water. The life raft is made from gas-tight, rubber proofed, high strength fabric, rings,
the floor, the anchor column supporting the canopy and the canopy itself [Fig 10.1 (a), 10.1 (b), 10.1 (c)].
The canopy stays up even if one of the buoyancy rings is damaged or deflated.  

Fig 10.1 (a) : Twenty-Five Men Life Raft

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Fig 10.1 (b) : Types of Life Raft

  
Fig 10.1 (c) : Life Raft In Storage Container Onboard Ship
(ii) The life raft should be handled as follows:
(aa) In-Charge of the Raft.
One person should be nominated to be in-charge of the raft and to oversee safety, maintenance
of rations and resources, division of duties, etc. All survivors must follow his directions and act as
a team. This person-in-charge must maintain a log over the entire period spent in the raft. Basic
writing material is present in the survival kits of the raft, for this purpose. The first entry must include
the details of the accident e.g. date, time and position of the wreck, names of survivors, weather
conditions, details of rations available, etc. Later entries must cover details of stay in the raft including
the physical condition of stay, weather, rations log, sighting of ships and airplanes, morale of the
people, etc. The survival pack is likewise to be in the personal care of the person-in-charge who
should personally distribute water, rations, medicines, etc.

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(ab) Co-operation and Confidence.

The inmates of the raft should never lose hope. The raft offers excellent protection. It is important
to keep the will to live and to maintain discipline.
(ac) Safety of Raft.
All parts of the life raft must be checked regularly. From time to time the pressure in the buoyant
rings, arches or column should be checked manually. In newer variants of life-rafts, a handheld, battery
operated pump is provided in the maintenance kit of the raft. Under no circumstances should the
deflation valves be interfered with.
(ad) Maintenance.
Any leaks in the raft should be plugged with leak stoppers provided in the survival kit. Thereafter
they should be repaired properly at the first opportunity.
(ae) Routine Duties.
Routine duties include checking of the raft periodically (every hour or so), collection of rainwater, food
items, care of the injured, lookout for rescue ships/ airplanes and maintenance of logs. All personnel
must take turns to do these duties. This also ensures adequate period of rest for all survivors which
will allow conservation of body water and energy.
(af) Watch-Keeping and Lookouts.
Two lookouts per watch must be kept to spot rescue ships/ airplanes. Based on the number of
survivors in the raft, lookouts may be scheduled in shifts of two to four hours. The watches must
be maintained throughout the 24 hours without a break. One of the lookouts should be responsible
for collection of water in case it rains. In earlier times, Heliographs [Fig 10.2 (a) and (b)] and Morse
Lamps [Fig 10.3] were used to send distress signals on spotting ships/ airplanes, which have now
been replaced by torches, pyro-technique flares and LED light items [Fig 10.4]. They should always
be kept within the reach of lookouts.

Fig 10.2 (a) : Heliograph

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Fig 10.2 (b) : Way To Use Heliograph

Fig 10.3 : Morse Code Lamp

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SIGNALLING TORCH PYROTECHNIQUE DEVICES LED FLARES

Fig 10.4 : Newer Modalities To Send Distress Signals

(ag) Weather Protection.
In hot weather and in daytime, the floor of the raft is to be kept deflated for allowing cooling from
below. In cold weather and at night, the floor of the raft must be kept inflated to prevent loss of heat
to water. The canopy should always be kept up to protect from sun, wind and rain.
(iii) Survival Pack.
The items described below are provided in Survival packs in rafts [Fig 10.5].  
(aa) Drinking Water.
Water is supplied in cans or plastic bottles. In addition, desalination tablets are provided for preparing
drinking water from sea water.
(ab) Food.
Barley, sugar or glucose and rations in concentrated form providing a total of 2,500 calories food
value per person.
(ac) Calibrated mugs for measuring water rations for each person.
(ad) Can openers for opening water and food cans.
(ae) Fishing tackle consisting of fishing line and hooks.
(af) Distress signal equipment.
Two parachute flares (Pyrotechnics), six hand flares (red), a radar signal reflector, a buoyant smoke
flare, a Signalling Whistle, Signalling Torch (for morse code), Signalling Mirror and instructions
(signalling in day) – to attract the attention of people in water or on other rafts or ships/ aircrafts
for signalling for help
(ag) First aid kit.
(ah) Sea sickness bags and anti-sea sickness tablets.
(aj) Repair Equipment.
A repair kit, a hand-held battery-operated pump, torch, spare bulb and batteries, two paddles, rescue
quoit and line, two drogues (a funnel-shaped device deployed to help control the craft) and 30 m of
nylon rope.
(ak) Two paddles.
(al) Bailers (for bailing out water) and two sponges for drying the raft.
(am) Thermal protective clothing.

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Fig 10.5 : Contents In Survival Pack of Life Raft

10.3 First Aid Measures.

The following first aid measures should be adopted on finding survivors:
(a) Drowning or Unconscious Person.  
(i) Initiate CPR by Clearing the Respiratory Tract.
Remove loose fitting sets of artificial teeth, if any. Then turn the head of the patient to one side and with
the index finger covered with a piece of clean cloth, force open the mouth and clean the froth, blood and
foreign bodies.
(ii) Artificial Respiration.
If breathing has stopped, attempt should be made to revive respiration by blowing with the mouth into the
nose or mouth of the unconscious person.
(iii) Removal of Constrictions.
Loosen all constricting garments such as ties, collars, belts and the like. Do not waste time in removing
garments.
(b) Shock/Chill.
Some of the survivors might be suffering from shock or chill indicated by shivering and low body temperature.

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The patient should be warmed by removing wet clothes and by providing additional clothing, covering the head
and possibly by body heat by huddling. The legs of the affected person must be kept raised to treat shock.
(c) Bleeding.
Bleeding can generally be stopped by firm application of compresses and by putting direct pressure on the
wound. Raising the injured limb may help to stop bleeding.
(d) Injuries and Burns.
Wound should be bound with sterile bandages. Burn blisters should be dressed and not be burst. In a shoulder
or arm fracture, a triangular cloth sling maybe applied and the arm tied in front of the chest. For a fractured
leg, suitable floating shipwreck debris may be used for splinting. In case there is no suitable object to make a
splint, then the healthy leg may be used as splint.

10.4 Eating and Drinking.

Drinking water is a more vital item than food since one can stand hunger for three weeks, whereas lack of water can
be dangerous in even a few days.
(a) Water.
(i) First 24 Hours.
No water should be given to healthy people in the first 24 hours; their bodies still have sufficient fluid and
water consumed additionally would only be eliminated as urine. Sick and injured persons may be given
water in the first 24 hours, if they are thirsty. Thirst can be allayed by increasing saliva e.g. by sucking on
a piece of cloth or a button.
(ii) Scale for Water Rationing.
The daily ration of water must be given in several small portions with the help of measuring cups in the
survival kit. Daily water requirement in a healthy adult range from 1.3 to 3 ltrs and is dependent on the
temperatures (Table 10.1)
Table 10.1 : Adult Water Requirement As Per Temperature
Temperature 50ºC 41.5ºC 38.8ºC 33.1ºC 27.8ºC 22.1ºC
Minimum Requirement of Water/Day in Ltrs. 2.92 1.89 1.56 1.42 1.32 1.28
(iii) While drinking, the lips must be moistened, mouth and throat must be wetted by rolling the water
around before swallowing; drinking should be slow and in sips.
(iv) Rainwater.
Rainwater should be collected in clean objects with every opportunity, even if it is in very small quantities.
Plastic bags in the survival pack and empty water cans can be used for this purpose. Even if abundant
rainwater has been collected, still the water must be rationed and consumed slowly and prudently. Excessive
drinking of water in such situations may cause vomiting, and loss of more water from the body.
(v) Sea Water.
Drinking sea water even in short quantities and for a short time may become fatal. Seawater even if diluted
with fresh water should never be drunk as this leads to addition of salts in the body. The body needs
large quantities of water to dissolve this salt and the excess water is eliminated with urination, leading to
dehydration.
(vi) Water may be preserved in the body by proper sleep and rest avoiding alcohol, smoking and highly
proteinaceous food.
(b) Food.
(i) Scale of Rationing.
In the first 24 hours, no rations should be issued. The rations should be issued sparingly and judiciously
on subsequent days. If drinking water is limited, then less food should be consumed, otherwise the feeling

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of thirst would be too painful.

(ii) Sea Weeds.
Some types of sea weeds are edible. Fresh good seaweed is odourless and feels smooth and firm. However,
algae growing on the seaweed should be removed by washing in sea water, before it is eaten. Long seaweeds
of a fibrous nature should not be eaten as they may cause inflammation or irritation. Sea weeds contain
salt and may be eaten only if sufficient water is available to dissolve the salt.
(iii) Sea Fish.
Sea fish are generally edible and angling should be done as much as possible, with the fishing hooks
provided in the survival pack. Fishing may keep the morale of survivors high. Fish contains some salt,
hence if it is eaten, additional drinking water should be consumed. In temperate waters, all fish are edible.
In tropics, fish caught in the open sea outside the sight of land are generally edible. However, in shallow
tropical waters, there are some poisonous species of fish like fishes with spikes and those which smell. Fish
with brushes or spikes but no scales have lethal neuro and myo-toxins and should not even be touched.
When catching or handling fish, hands must be protected otherwise the small injuries may later lead to
inflammation.
(iv) Sea Birds.
All sea birds may be eaten, even raw. However, they have an oily taste.

10.5 Preventive Measures.

Preventive measures against common ailments are as follows.
(a) Dehydration.
Perspiration should be avoided as far as possible, especially when stranded in tropical water with bright sunlight.
Body movements must also be cut down to a minimum. In addition, the body should be protected from sun by
staying under the canopy and if necessary, by application of wet clothing.
(b) Sea Sickness.
It can become dangerous if sea sickness continues over a long period, as it causes loss of body fluids by repeated
vomiting. Anti-sea sickness tablets are provided in the survival pack of rafts.
(c) Frost Bite.
It is caused by intense cold or icy wind and appears mostly on the face. digits and ears. Presenting symptoms
are numbness and intense pallor of the parts affected. The affected parts should be covered with protective
clothing and should not be rubbed or exposed to sudden heat.
(d) Sea-Water Injuries.
If the skin is covered with salt leftovers of the sea water and the pores get blocked, then there is a chance of
having skin inflammation. Such areas should be covered with ointment and loosely wrapped in bandage.
(e) Sunburn.
Sunburns should be prevented by protecting the body from the direct rays of the sun which might result in boils
and later on inflammation. Ointment and most clothing is useful in treating the sunburns.

10.6 Attracting Attention.

In clear weather, pyrotechnic distress signals can be visible at a distance of 25 sea-miles. For rescue ships, a life-raft
may be seen with the naked eye from a distance of 4 sea miles in a good weather and, it can be picked up by radar
at about 2 sea miles. The following instructions must particularly be observed to increase chances of being spotted
by rescue vessels.
(a) Pyro-Technique Signal.
Distress signals should be fired only when a ship is spotted at distance to draw its attention when it is not
coming any nearer. If it is seen approaching, the distress signal should be fired when it can be seen from the

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ship. For airplanes, the distress signals can be fired in the daytime on spotting them. The distress pyro-technique
signal should be fired with the wind.
(b) Heliograph.
The mirror heliograph may also be used in daytime to indicate one’s position and light signals from heliographs
or mirrors can be seen for up to 20sea-miles depending on the sunshine and atmospheric conditions.  
(c) Signalling Torch.  
At night the waterproof signalling torch can be used to send blink signals or messages by morse code.

10.7 Rescue
The rescue teams generally follow the below mentioned protocol for rescue.
(a) Aid by Airplanes.
(i) If the raft is sighted by an airplane, rescue by nearby ships is coordinated as per MARPOL guidelines.
The airplane will indicate by circling round, that the raft has been noticed, and callup a ship or helicopter
to pick up the survivors.
(ii) Some search planes are equipped with Rescue-Supply kit which is air dropped into the sea near
the raft to keep the survivors supplied until their final rescue. The kit consists of a number of containers
connected to one another. To mark the life-raft and also ascertain wind direction, the search plane first
sends out a smoke signal. The plane then flies at fixed height, obliquely to the wind over the raft and throws
out the container. When the containers strike the water, a sea-anchor is released automatically from each
one of them and the life-raft in the middle container inflates rapidly. The other containers hold drinking
water, food, clothes, medicines etc.
(iii) The raft with survivors should then take in its sea-anchor and move towards the life-raft dropped
from the plane. Some of the survivors should then board the air dropped raft, distribute the water, food,
etc. and then wait for nearby ships to come for their rescue.
(b) Rescue by Helicopter.
(i) The survivors are fished up from the water by a net, rescue sling or winch by helicopters. The sling is
pulled over the body of the man and lies against the small of the back and under the armpits. The distance
between the hoisting point and the chest of the person being lifted is adjusted by a safety slipknot. If a
survivor cannot help himself, a member of the helicopter crew maybe let down and then the survivor can
be helped into the sling for hoisting up.
(ii) The survivors must leave the raft and get into the water first, and care should be taken that not all
the inmates of a raft leave at the same time. Generally, the weakest ones should be sent first, as it will
then be possible for the others to give them assistance.
(c) Rescue by Ship.
(i) If a live raft is sighted by a ship, rescue is immediate and the survivors are picked up. The rescue
ship comes as close as possible to the raft and makes lee. As a result of the ship’s height, which catches
the wind, its drift is greater than that of the life-raft and it can therefore come quickly up to the raft. Care
must be taken that the sea-anchor of the raft does not tangle with any part of the ship e.g. the propellers.
If necessary, take the anchor in.
(ii) A line is thrown from the ship to the raft and tied fast to the painter or the mooring of the life-raft.
Thereafter, instructions given by the rescue ship should be followed. If necessary, a lifeboat is sent and
the rescue action are directed from it.
(iii) After the survivors have been rescued, the raft can be taken on board the rescuing vessel and
deflated.

Suggested Reading.
1. Manual of Medical and Dental Administration- Integrated Headquarters Ministry of Defence (Navy). 2013.
n

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Chapter
XI
AEROSPACE MEDICINE

11.1 Introduction.
Aviation Medicine deals with the medical problems of human beings in the alien flight environment. The first
scientific paper on the subject was published in 1907. The development of Aviation Medicine into a well-organized
science occurred during World War I. The development of high-performance aircraft in 1930s gave a boost to
the newly discovered science to study the effects of high altitude, high speed and extended range of flights on
the human organism and methods of neutralizing or eliminating factors detrimental to the efficiency, health
and safety of flying personnel. The phenomenal progress in military and civil aviation following World War II has
greatly increased the complexity of medical problems imposing heavy physical, physiological and psychological
demands on the human operator. In the complex man-machine system, man is the weakest link and must be
fully supported to achieve mission accomplishment with safety. In modern flying, the flier is exposed to various
stresses like hypoxia, pressure changes, acceleration, extreme temperatures, noise, vibration, visual disturbances,
disorientation and problems of survival after ejection from a disabled aircraft etc. Awareness and recognition of
these stresses for adapting preventive and remedial action are not only essential for mission accomplishment but
are vital for the very survival of the aircrew. Thus, the primary aim in Aviation Medicine is to maintain optimum
efficiency of the flying personnel.
Aviation Medicine not only caters for the health and efficiency of aircrew but also covers the problems of ground
crew, Air Traffic Control (ATC) personnel and all others associated with the conduct of safe flight. Aircraft accidents
are seldom caused by one single factor. Careful investigation always reveals some contributory factors converging
to a situation and precipitating accident.

11.2 Physics of Atmosphere

(a) Introduction.
A gaseous envelope called the atmosphere surrounds a planet. The gaseous atmosphere on Earth is essential to
life since it provides oxygen for our living and carbon dioxide for plant life. It stores up heat to make our survival
possible and at the same time acts as a filter to solar radiation, allowing long-wave radiation and absorbing
most of the harmful ultraviolet and X-Ray radiation. It diminishes the intensity of cosmic radiation so that only
minute amounts are observed at the earth’s surface. Earth’s atmosphere is the environment in which flying is
undertaken. Therefore, understanding the form and function of the atmosphere is very important from the point
of view of Aerospace Medicine.
(b) Physical properties of Atmosphere: Pressure, Density and Temperature Variations.
The total mean mass of the atmosphere has been estimated to be 5.2 x 1018 Kg and about 10.6 times the
mass of the earth. The atmosphere, owing to the pull of the gravitational field, is compressed so that it is denser
at the surface of the earth. With the increase in altitude, the atmospheric pressure (force / area) and density
(mass / volume) fall rapidly in the beginning and more slowly later, until it becomes a vacuum at the outer limit of
the atmosphere. The gradients of pressure and density are not linear. The pressure on the surface of the earth
is 1 ATA (Atmosphere Absolute) or 760 mm of Hg (or 29.92 inches of Hg) or 1.02 Kg / cm2 or 14.7 psi (Pounds
per square inch) or 1013 milli bars or hectopascal. Fig 11.1 gives the pressure variations in the atmosphere.
(c) Atmospheric Temperature.
Atmospheric temperature is a measure of temperature at different levels of the Earth’s atmosphere. It is governed
by many factors, including incoming solar radiation, humidity and altitude. Solar radiation reaching the earth is
absorbed by the Earth’s surface, which in turn radiates back to the atmosphere. The atmospheric temperature
also varies with altitude. Air temperature falls steadily with altitude at an average rate called the temperature
lapse rate, which is equal to 1.98º  C per 305 m (in troposphere), up to an altitude of 10,973 m. Then there is a

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layer of constant temperature till 21,336 m above which temperature rises again. Table 11.1 gives the pressure,
density and temperature variations in the atmosphere.

Fig 11.1 : Atmospheric Pressure Variation with Altitude

(d) Gaseous Composition.
Atmospheric air is a mixture of various gases, the principal ones being Nitrogen (N2), Oxygen (O2) Argon (A),
Carbon-dioxide (CO2) and water vapour. The other atmospheric gases occur in insignificant amounts, some of
them being only in trace forms. The composition of dry air remains constant to its principal constituents up to
a height of about 20 to 25 km. Below 9,144 m (30,000 ft), air contains a variable amount of water vapour.
Table 11.1 : Pressure, Density and Temperature Variations in the Atmosphere
Altitude Pressure Density Temp
Newton /
Meter Feet mm Hg Psi Kg / m3 º  C
m2 × 104
0 0 760 14.70 10.132 1.2250 +15
1524 5000 632 12.23 8.43 1.0138 +5.1
2438 8000 565 10.92 7.526 .9629 -0.9
3048 10,000 513 10.11 6.968 .9047 -4.8
7620 25,000 282 5.46 3.767 .5518 -34.5
10,973 36,000 155 3.30 2.274 .3652 -56.3
12,191 40,000 141 2.72 1.875 .3017 -56.5
15,240 50,000 87 1.68 1.160 .1866 -56.5
18,288 60,000 54 1.04 .716 .1163 -56.5
24,384 80,000 21 .401 .273 .0439 -52.1
30.480 100,000 8 .158 .100 .0162 -46.0

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Atmosphere is not homogeneous throughout. The atmosphere is divided into many layers differing in composition,
temperature and temperature variation, electrical properties and other physical characteristics. The contrast
between these layers is conspicuous in the vertical distribution of temperature.

Fig 11.2 : Temperature Based Classification of Atmospheric Layers

(e) Classification of Atmosphere.
Based on temperature, the atmosphere is divided into concentric layers as given below [Fig 11.2 refers]:
(i) Troposphere.
The troposphere, where most of the flying takes place lies in contact with the earth’s surface. It is characterized
by weather and a constant decrease in temperature with increasing altitude. It has an average thickness of
11 km and is thicker at the equator (16,764 m or 55,000 ft) and thinner at the poles (7,315 m or 2,400
ft). The outer boundary of the troposphere is known as tropopause, which lies at about (10,973 m or 36,000
ft) 11 km at a latitude of 40º N. The tropopause height is variable with latitude.
(ii) Stratosphere.
The Stratosphere extends from 11.50 km and lies above the troposphere. It is characterized by a constant
temperature of 56.5º  C up to an altitude of 20 km. The temperature thus remains constant between
tropopause and up to about 20 km. Ozone is formed in the stratosphere by the action of solar ultraviolet
radiation on molecular oxygen. It is formed at altitudes between 15,240 m (50,000 ft) and 42,672 m
(1,40,000 ft) with maximum concentration of about 10 parts per million air particles at an altitude of 25-
30 km (Ozonosphere). It is highly unstable and changes into oxygen by heat. Thus, it is largely destroyed
by heat as the air passes through the engine compressor. Air, which is used for cabin pressurization, thus
does not expose aircrew to the toxic effects of ozone.
(iii) Mesosphere.
The mesosphere is characterized by a rapid fall in temperature. Temperature changes from -3º  C to about
-110º  C at an altitude of 2,90,000 ft. It is the coldest layer of the atmosphere.
(iv) Thermosphere.
Thermosphere is characterized by continuous increase in temperature. Temperature goes up to 1700º  C during

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days of maximum solar activity. The air has low density. Most of the particles within this layer are charged
and is also known as the Ionosphere. The structure of the ionosphere depends on the energy input from
the sun. It is affected markedly by the 11 years cycle of solar flare activity. It acts as a reflector for the long
wave Electro-Magnetic (EM) radiations used for radio communication between distant points on Earth.
(v) Exosphere.
Exosphere is the edge of the atmosphere and the beginning of the true space. No pause at the upper
reaches of this sphere. And it progressively merges in space. Principal components of this layer are H and
He and present at very low concentrations.
(f) Radiation in the Earth’s Atmosphere.
Practically all the energy that is available, in the atmosphere comes from the sun in the form of electromagnetic
radiation. The other sources of terrestrial energy are stellar radiation and cosmic radiation. High energy and
biologically harmful radiation, which can cause ionization, is either absorbed or highly attenuated at the upper
atmosphere. Thus, what is available at the earth’s surface and at flying an altitude of up to 60,000-70,000 ft is
non-harmful solar and cosmic radiation. It has been seen that for aircraft operating at high altitudes, the amount
of radiation that an aircrew is likely to receive is very small and does not present any hazard. Even with 1000 hrs
flying per year at 16,764 m (55,000 ft) the radiation dose will be less than half of which is considered safe for
an industrial worker.
(g) Standard Atmosphere and Its Ideal Assumptions for Atmospheric Parameters. (As per International Civil
Aviation Organization (ICAO) – 1964).
There is a relationship between barometric pressure and altitude. A number of pressure measuring instruments
are used to indicate the altitude of aircraft above the ground. It is necessary to standardize the relationship
between barometric pressure and altitude for calibration of flight instruments and also to make comparison
between performance of aircraft and aircraft systems.
ICAO standard Atmosphere closely represents the physical characteristics of the real atmosphere at latitude of 45º
North. Based on its assumptions, relationship between the pressure and altitude, Mean Sea Level (MSL), density,
gravity, temperature and lapse rate in Earth’s atmosphere is standardized. Ideal assumptions of this standard are:
(i) The air is dry, devoid of dust and has a stated composition.
(ii) The atmospheric pressure at mean sea level is 760 mm Hg.
(iii) The atmospheric density at mean sea level is 1.225 kg / m3.
(iv) Acceleration due to gravity is 9.8 m / s2 and is constant.
(v) The temperature at mean sea level is 15º  C.
(vi) Mean temp lapse rate is 1.98º per 1,000 m from sea to 36,000 ft.
(vii) Height of troposphere is 36,000 ft.
(viii) The temperature of the isothermal layer of stratosphere from 36,000-65,000 is 56°C.
(h) Summary.
Earth’s atmosphere is a gaseous envelope that surrounds Earth. Its composition has about 78% of N2 and
21% of O2. The composition remains constant up to 25 km. Pressure and density decrease with altitude but
with greater gradient in the lower atmosphere. Classification of atmosphere is mainly based on the temperature
variation. It is in this atmosphere that the aircraft operates. Troposphere is of maximum concern to aviation
and its average temperature lapse rate is in 1.98º  C per 1,000 ft. Radiation in Earth’s atmosphere is primarily
because of sun and trapping of charged particles by magnetic field. At active flying station, details of weather
and weather forecast are taken periodically before each flying session. Atmosphere influences the performance
of aircrew and aircraft. It is also responsible for potential operational hazards, for which an aircrew rating system
is followed in all military flying towards optimization of safe flying operations. Therefore, understanding form and
functions of the atmosphere is crucial to the development of aircraft and life support equipment.

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11.3 Acceleration Physiology.

(a) Introduction.
The term “G” or “G-force”, which is most commonly used in the field of aviation is an abbreviation for gravity.
G-force is a measure of acceleration or deceleration. One experiences one G of force, that is acceleration due
to gravity. On the commercial flight passengers generally experience not more than 1.3 G and not less than
0.7 G on their body. Put another way, the typical passenger will feel a maximum of up to 30% heavier or 30%
lighter for brief moments depending on whether the aircraft is accelerating, decelerating, climbing, descending or
turning. In general, most people will barely notice these forces. While commercial flights exert only very minimal
positive and negative G-forces on passengers, several orders of magnitude greater are the G-forces experienced
by astronauts, Fighter pilots and stunt pilots. These types of pilots can experience brief periods of extreme forces
of 9 G and 10 G. Without highly specialized training and equipment, this level of force would have an extreme
effect on the average person within a few seconds. For example, as significant downward G-forces are applied
to the human body, blood is forced from the head to the lower extremities, quickly overwhelming the heart’s
capacity to pump it to the brain. On the other hand, extreme negative or upward G-forces force blood from the
extremities up toward the head. Type, duration and axes of acceleration are the key factors for adverse health
effects due to G-forces. Human tolerance to short duration acceleration is determined by the structural strength
of the body, whereas physiological changes set the limit for the long duration acceleration.
(b) Types of Acceleration.
(i) Linear Acceleration.
Change in magnitude of speed only. e.g., Take-off, landing, ejection, parachute opening shock. Linear
acceleration = v / t, where v = velocity and t = time.
(ii) Radial Acceleration.
Change in direction but no change in magnitude of velocity: e.g. loop, pulling out of a dive. Radial acceleration
= v2 / R, where v = velocity, R = radius of turn.
(iii) Angular Acceleration.
Change in both, the direction and magnitude of velocity: e.g. spin spiral.
(c) Duration of Acceleration.
(i) Short.
duration 1 second or less; e.g. ejection.
(ii) Intermediate.
duration 0.5–2 sec.; e.g. deck landing.
(iii) Long.
duration more than 2 sec may last to several minutes, e.g. aerial combat maneuvers, space launch and
re-entry.
(d) Axes of Acceleration.
(i) Gx : Acceleration Acting in Antero-posterior Axis.
+ Gx = when inertial force acts from front to back
– Gx = when inertial force acts from back to front
(ii) Gy: Acceleration Acting in Side to Side Axis.
+ Gy = when inertial force acts from left to right
– Gy = when inertial force acts from right to left
(iii) Gz : Acceleration Acting in Head to Feet Axis.
+ Gz = when inertial force acts from head to feet

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– Gz = when inertial force acts from feet to head

G is the ratio between a given acceleration and the acceleration due to gravity. It has no units. The term
G force is used sometimes to describe a force, which produced acceleration, which is a multiple of the
acceleration due to gravity (9.81 m / sec / sec). Thus, an acceleration of 98.1 m / sec / sec / would be 10 G.
(e) Factors influencing Effects of Acceleration on Body.
(i) Magnitude.
Higher the magnitude, more the effects.
(ii) Duration.
Shorter the duration, lesser the effects.
(iii) Rate of Onset / offset; gradual onset - CVS reflexes effective.
O Rapid onset - CVS reflexes bypassed. Slow offset - longer to recover.
O Faster offset - shorter time to recover.
(iv) Site of Application.
If force is dissipated over larger area, there is less distortion of tissue.
(v) Direction.
Least tolerance in Gz and maximum tolerance in Gx.
(f) Effects of Acceleration on Body.
+Gz is the commonest type of acceleration encountered in aviation and the human tolerance to +Gz is low. The
effects of +Gz are:
(i) Apparent increase in body weight.
(ii) Heaviness of limbs.
(iii) Helmet-head limitation.
(iv) Difficulty in getting up from the seat.
(v) Viscera are pushed caudally.
(vi) Disturbance in the mechanics of breathing.
(vii) Drop in hydrostatic pressure above the level of heart.
(viii) Increase in hydrostatic pressure below the level of heart.
(ix) Pooling of blood in lower limbs, reduced venous return.
(x) Reduced cardiac output.
(xi) Visual changes (Greyout, blackout).
(xii) G-LOC (G-induced Loss Of Consciousness).
The effects of +Gz on CVS are the most important and determine the tolerance to +Gz exposure. Immediate
circulatory changes occur due to hydrostatic effects, which in turn evoke reflex compensatory changes
mediated through baroreceptors.
(g) Tolerance to +Gz: Haemodynamic Concept.
The hydrostatic pressure of a column of fluid depends upon the height of column (h), density of fluid (d) and
acceleration to which it is exposed (G), i.e.,
Hydrostatic pressure = h x d x G
This pressure under acceleration is directly proportional to the values of G provided h and d are constant. The
positive acceleration increases the weight of the blood column above and below the heart resulting in reduced
vascular pressure above the heart and increased vascular pressure below the level of heart. For a column of

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blood having a height of 30 cm at 1 G, the pressure exerted is 22 mm of Hg. Thus, if Mean Arterial Pressure
(MAP) at heart level is 100 mm Hg, it will be reduced to 78 mm of Hg at cerebral level at 1 G and at 4.5 G,
the reduction will be by 99 mm of Hg, resulting in only 1 mm Hg of MAP in cerebral circulation. The pressure
levels below the heart are increased concomitantly leading to pooling and extravasation of fluid. The net result
is reduction in the circulating volume of blood in the head and neck area leading to features of Greyout, Black
out and Loss of Consciousness (LOC).
(h) Tolerance to +Gz: Physiological Criteria.
Visual symptoms of Greyout, which include tunneling of vision, veiling of vision is referred as Peripheral Light loss
(PLL) and Black out as Central Light Loss (CLL). Both are due to disturbances in retinal circulation. Subsequently,
cerebral circulation gets compromised leading to loss of consciousness, which is also called G-LOC. Tolerance
to +Gz is determined for PLL, CLL and LOC. The accepted tolerance standard are depicted in Table 11.2.
Table 11.2 : Acceptable G Tolerance Standard for PLL, CLL and LOC
Criteria Mean-G SD G-range
PLL 4.1 +0.7 2.2-7.1
CLL 4.8 +0.8 2.7-2.8
Unconsciousness 5.4 +0.9 3.0-8.4
In military aircrew in India, tolerance point for +Gz is taken, as a level at which there is a PLL of 52º to 56º .
This is objectively confirmed by disappearance of Doppler audio signals. It is seen that the average relaxed G
tolerance of IAF Fighter pilot population is 4.7 + / - 0.7 G. It increases with experience. The G tolerance of non-
Fighter aircrew or ground crew is little less. However, it must be realized there are large individual variations in
G tolerance and even in the same individual tolerance may vary at different times.
(j) Factors Affecting Tolerance to +Gz.
(i) Hypoglycemia.
Hypoglycemia reduces tolerance to Gz.
(ii) Heat Stress.
Heat stress reduces tolerance to +Gz due to reduced effective circulatory volume caused by sweating and
peripheral vasodilatation.
(iii) Alcohol.
Ingestion of Alcohol reduce the tolerance to positive acceleration.
(iv) Hyperventilation.
Hyperventilation markedly reduces tolerance to +Gz. This is due to accentuation of reduced cerebral blood
flow due to hypocapnea.
(v) Gastric Filling.
Filling of stomach minimizes the descent of diaphragm and also heart. Ingestion of 1.5 litre of water could
increase Gz tolerance by 0.6G.
(vi) Hypoxia.
Hypoxia reduces tolerance to +Gz.
(vii) Fatigue.
Fatigue due to any cause e.g., excessive flying, sleep deprivation etc will reduce tolerance to +Gz.
(viii) Psychological Factors.
Motivation, fear etc. change an individual’s tolerance to +Gz.
(ix) Minor Disablements.
Mild rise in body temperature and intercurrent infections reduce tolerance to +Gz.

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(x) Flying Currency.

Even a one-week period off flying can reduce Gz tolerance.
(k) G-LOC Syndrome.
G-LOC was earlier defined as “A state of altered perception, where one’s awareness of reality is lost as a
result of sudden critical reduction of cerebral blood flow under high positive acceleration”. G-LOC involves more
than just alteration of the highest central nervous system function supporting consciousness. Loss of vision,
consciousness, postural muscular control and memory with induction of myoclonic convulsions and dreamlets
together constitute a symptom complex that has been defined as the G-LOC syndrome. Various symptoms of the
G-LOC syndrome signify the limits of CNS tolerance to +Gz stress. These symptoms are not the result of abnormal
CNS function; they are normal responses of segments of the CNS affected differentially by specific patterns of
+Gz induced ischemia / hypoxia. The underlying theory of the G-LOC syndrome is related to G-induced ischemia
affecting the cephalic areas of the nervous system. G-LOC in prolonged low G exposure is due to vasovagal
syncope due to reduced venous return resulting from peripheral pooling. Centrifuge research has quantified
and kinetically related the symptoms of the G-LOC syndrome. Symptoms following G-LOC have been identified
and are grouped as physiological and psychological symptoms. Physiological symptoms include convulsive (flail)
movements, tingling in the extremities and face, impaired motor coordination, amnesia, dream like state and a
sense of falling asleep. Psychological symptoms include suppression of self-esteem and self-image, denial, lack
of self-trust, embarrassment or ashamed of losing self-control, dissociation, euphoria (false sense of well-being,
anxiety, fear (basal survival instinct), antagonism towards other flying personnel & situations and give-up attitude.
The most important of these symptoms are amnesia, impaired motor coordination, confusion, disorientation and
denial. Amnesia and denial would reduce the number of reported G-LOC incidences, thereby artificially reducing
the perception of the hazard. Retrograde amnesia, however, does not appear to be a feature. Impaired motor
coordination and mental confusion extend the length of recovery and therefore increase the hazard of G-LOC.
The pilot may suffer from convulsions during last 4 secs of absolute incapacitation. These convulsions are
described as either slight or severe clonic seizures, with brief tonic episodes involving the extremities, face,
neck and trunk. There are neck and trunk extension with arms extended in pronation and legs flexed. Usually,
violent jerks terminate the seizures in 2 to 5 sec and the ECG remains in delta rhythm throughout the absolute
incapacitation.
Dreamlets possibly occur towards the end of the absolute incapacitation period and the beginning of
the convulsions. It is memorized as the cerebral cortex regains function and terminates with the return of
consciousness.
The overall or total incapacitation associated with a G-LOC episode can be divided into two periods: (i) absolute
incapacitation or the period during which the pilot is unconscious; this is followed by (ii) relative incapacitation
or the period during which the pilot is confused / disoriented. A pilot is unable to maintain aircraft control during
either of these periods.
The incidence of in-flight G-LOC in IAF is around 10-11% while the incidence in USAF is 12% and in RAF 19%.
Worldwide, G-LOC is documented as the cause of several Fighter aircraft mishaps.
(l) Protection Against +Gz.
Protection against +Gz and increase in +Gz Tolerance is gained principally by:
(i) Avoidance of factors that reduce G tolerance.
(ii) Prevention of blood pooling in lower parts of body and enhancement of venous return.
(iii) Reduction of height of hydrostatic column above heart i.e. reduced heart-to-brain distance.
(m) Various Anti G Countermeasures.
(i) Physiological Measures.
Anti-G Straining Maneuver or AGSM is the single most cost-effective means of increasing G-tolerance. AGSM
has two components; muscle tensing and breathing out against a closed glottis (L-1) or with a semi closed
glottis (M-1). Timing of the breathing components is very important. The inspiration should be sharp, as a
gasp, lasting 0.5 to < 1 sec followed by expiration over next 3 seconds. A well-performed AGSM can increase
a pilot’s tolerance by 4 G. AGSM training can be performed safely in the simulator (human centrifuge).

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Presently, such training is conducted at Institute of Aerospace Medicine (IAM).

(ii) Anti-G Suit (AGS).
AGS is a special garment and generally takes the form of tightly fitting trousers, which fit either under or
over (depending on the design) the flight suit worn by the aircrew. The trousers are fitted with inflatable
bladders which, when pressurized through a G-sensitive valve in the aircraft, press firmly on the abdomen
and legs, thus restricting the draining of blood away from the brain during periods of high acceleration. In
addition, in some modern very high-performance Fighter aircraft, the protective effect is augmented by a
small amount of pressure applied to the lungs (positive pressure breathing), which also enhances resistance
to high G. Various designs of AGS have been developed. They first used water-filled bladders around the
lower body and legs. Later designs used air (pneumatic) under pressure to inflate the bladders. These
G-suits were lighter than the liquid-filled versions and are still in extensive use. An AGS should ideally be
worn directly over the skin, but for convenience, most aircrew wear it over the flying overall. A well-fitting
AGS gives a protection of 1.0 to 1.5 G.
(iii) Reclining Seat with Heel Elevation.
Such a seat system is designed to decrease heart-brain distance and also reduce venous pooling in the
lower limbs. Such a seat with 30 degree tilt-back has been introduced in F-16 aircraft and is reported to
give protection of 1G.
(n) Negative Gz (-Gz).
It is a form of radial acceleration where the inertial force acts from feet to head. This is experienced during a
‘bunt’ maneuver, inverted flying or during an inverted spin. However, negative G maneuvers are often deliberately
not performed because, (i) Human tolerance to -Gz is very low and (ii) Aircraft structure is not designed to tolerate
high -Gz forces.
The physiological effects are mainly due to the pooling of blood in the head and neck region and give rise to
symptoms like heaviness to feeling of bursting in the head, throbbing and intense headache. ‘Halos’ may be
seen around brightly lit objects with general dimming of vision. This occurs because of increased intra ocular
pressure. Red Out may occur at about - 3.0 G. The feeling is like viewing through a red filter. It occurs because
the congested lower lid gravitates over the eye. Telltale signs of a pilot having undergone -Gz could be petechial
hemorrhages to large hemorrhages in the soft tissue of head and neck. Sub-conjunctival haemorrhages may
also occur at -Gz of 2.5-3.5. Bradycardia and various forms of arrhythmias may occur due to reflex vagal action,
set up by increased blood pressure in the area above the level of heart through the baroreceptors.
(o) Conclusion.
All Fighter pilots have been faced with situations wherein during combat when going in for the crucial kill have
had to ease out due to ‘grey out’. So, in the heat of a battle one has to constantly remind oneself to pull at
the stick slowly, to avoid any G-related problems.
Some pilots, whom we have spoken to, mention that they never pull high Gs in the squadron and such high
levels of G are unrealistic. Yet combat HUD videos from the Iraq war tell us a different story. Whether it is air-
to-air combat or missile jinking, the USAF pilots appear quite comfortable at high G levels. Other Air Forces in
the world are also trying to expand their G envelopes to levels as high as 12 G. Pilots wearing newer anti-G
suits (like ‘Libelle’ suit) have been able to hack off 15 G in the centrifuge.
G tolerance is, therefore the most critical issue that needs to be addressed, to improve a pilot’s efficiency in
combat. AGSM is a cost-effective method to enhance G tolerance (as is evident from the review of literature
worldwide). Physical conditioning is known not only to increases G tolerance by improving efficacy of AGSM, but
also prevent injuries to the neck and back. The USAF started an anti-G and exercise training programme almost
20 years ago. Other NATO Air Forces followed suit within the next few years.
Keeping in tandem with the worldwide practice, the Indian Air Force also started centrifuge training in 1993, to
enhance pilot’s G withstanding capability. With the induction of new High Performance Human Centrifuge (HPHC)
and other state-of-the-art simulators, this training has now taken a new “form” - OPTRAM. OPTRAM is an acronym
that stands for “OPerational Training in Aerospace Medicine”. The thrust of the course is on high G training and
Spatial Disorientation (SD) countermeasures. Other important issues such as oxygen management, Night Vision
Goggles and Survival are also addressed in the course. It is therefore, important that as a medical officer of all

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frontline combat squadron, one to have the knowledge about the subject to understand the problem better and
guide the crew towards honing and enhancing their combat skills.

11.4 Spatial Disorientation.

(a) Introduction.
Spatial Disorientation (SD) has been and remains the ‘Numero-Uno’ of all aeromedical stresses. This indeed is a
matter of great concern to all those related to aviation, both in the civil and military fields. The most important
consequence of SD is the orientation error accident, which claims every year lives of aircrew and passengers
and is also responsible for loss of costly aircraft. SD is a worldwide problem in aviation especially in military
aviation. With introduction of superagile, super maneuverable aircraft, this issue is only getting worse. 4-26% of
all aircraft accidents are documented to be due to SD. 6% of all major mishaps and 10-30% of all fatal mishaps
in USAF whereas 2.5% of all class-I mishaps and 18% of all fatal mishaps were due to SD.
(b) Definition.
SD is defined as a state characterized by an erroneous orientation percept, that is, an erroneous sense of
position, altitude and motion of oneself or one’s aircraft in relation to a fixed, three-dimensional co-ordinate
system defined by the surface of the earth and the gravitational vertical. This phenomenon is also understood
as the error of perception by the aviator of his position, motion or attitude to his aircraft or of his own aircraft
relative to other aircraft. Operationally, it is an erroneous sense of the magnitude or direction of any of the
control or performance flight instruments.
(c) Types.
SD has three types. In Type-I or “Unrecognized SD”, pilot gets disoriented, but does not recognize it till the
aircraft meets an accident due to corrective action is not taken. In type-II or Recognized SD pilot can identify
and therefore takes corrective actions. Type-III SD is a recognized SD where pilot fails to take any corrective
action due to profound incapacitation, which could be psychological, physiological or physical in nature.
(d) Mechanisms.
Man’s ability to sense or more correctly perceive orientation in three-dimensional space depends on his learned
interpretation of the continuous input of signals from many sensory receptors. Some of these receptors are
grouped to form specialized sense organs like the eye and the vestibular apparatus of the inner ear. Others are
more generally distributed in the body and are found in the skin, the capsules of joints and supporting tissues.
Together they form the triad of orientation. This visual system is responsible for 90% of all orientation cues,
vestibular system gives 5% and rest 5% comes from the proprioceptive system. Illusions are the erroneous
sensations that arise from any of these orientational cues leading to SD.
(e) Visual Illusions.
(i) Shape Constancy.
The pilot uses the shape of various objects, e.g., the runway to get a perspective of his position in space
above the runway. If the shape of the runway is different, this perspective gets wrapped. For example, when
landing on the parallel taxi track, which is much less broad than the runway, the pilot tends to come in a
low approach to make the taxi track look as broad as the runway and thus undershoots.
(ii) Size Constancy.
Size constancy is extremely important in judging distances. During combat, in a rapidly changing scenario,
distances between aircraft are gauged by the size of the retinal image of other aircraft. Consider a pilot
used to flying a large aircraft like a SU-30. He is used to seeing an aircraft of a particular size at a distance
of 3km. This pilot, during dissimilar combat with a MiG-21, is likely to come in extremely close, expecting
the MiG to look the same size as a Su-30.
(iii) Visual Auto Kinesis.
The apparent wandering of an object or a light when viewed against a visually unstructured background
or dark background is called auto kinesis. This is a result of the pursuit tracking movement of the eyes
especially if there is little to focus upon. A bright star may be seen as moving in a circle or moving linearly.
During night formation flying, when only one wandering light of the lead aircraft is seen, other pilots may

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have trouble distinguishing the real movements of the aircraft. The pilot should avoid staring at solitary
lights for more than a few seconds and establish a reliable reference to some structure in the aircraft,
such as the canopy bow.
(iv) Linear and Angular Vection.
If a large structure nearby moves forward, there is an illusion that one is slipping backwards. The most
familiar situation occurs when one is in a train and an adjacent train moves forward. A false impression is
created that your train has started moving in the opposite direction. A person may also perceive a rotational
sensation when an image rotates in the surrounding background.
(v) The Black Hole Approach.
The black hole illusion is produced during night landings, when there are no references except for the
runway lights. This situation may be worsened when the lights of city in a up sloping terrain at the end of
the runway make the approach look high and the horizon is not distinct. A natural tendency to lower the
aircraft nose may cause a crash short of the runway.
(vi) False Horizon or Sloping Cloud Deck.
A sloping cloud deck may cause the pilot to adjust the aircraft’s attitude to what is perceived as the real
horizon. There is a strong tendency to accept the level appearance of the clouds as the true horizon,
especially if the horizon is indistinct. An unperceived angle or bank will lead to loss of altitude, if it is not
corrected. This is particularly hazardous when flying near mountainous terrain.
(vii) Lean on the Sun Illusion.
Terrestrial creatures are accustomed to seeing the brighter part of the horizon above and the darker ground
below. This may be reversed, especially when flying in weather or at high altitudes above clouds. In such
circumstances, basing ones decision on such an assumption may result in an accident.
(f) Vestibular Illusions Due to Otolith Organs.
(i) Somatogravic Illusions.
During flying, sudden acceleration of the aircraft may give a climbing sensation and during deceleration, one
may get a nose down sensation. Usually, this sensation is ignored with experience or wherever adequate visual
cues are available. However, when both these are lacking, it may lead to problems in maintaining orientation.
(ii) The Oculogravic Illusion.
This illusion results in the perception, that instrument panel has moved upward or downward during
acceleration or deceleration respectively.
(g) Vestibular Illusions Due to Semicircular Canals.
(i) Somatogyral Illusion.
During angular acceleration (bank to right or left side) or deceleration (correction of bank), pilot may not feel
the rotation correctly and get disoriented especially during a roll or a spin and fail to recover the aircraft.
(ii) The Oculogyral Illusion.
The subject perceives that an object, which is actually stable in front, is rotating in the opposite direction
and this confirms the perception of the subject’s own rotation.
(iii) The Coriollis Illusion.
It is an abnormal bizarre sensation or sensation of tumbling. For example, if a pilot in a right-sided roll
moves his head forward he gets a sensation of yaw to the left, though actually he is in a roll. Accidents
may occur due to this sensation.
(iv) The Leans.
It is the most common vestibular illusion. This phenomenon is basically an illusion of bank when one is
straight and level. The pilot resolves this situation by leaning in the opposite direction and flying the aircraft
like that.

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(v) Pressure Vertigo.

Due to sudden changes in the middle ear pressure during sudden ascent or descent a turning sensation
may be felt due to vertigo.
(h) Conditions Conducive to SD.
Several situations / scenarios encountered in flying contribute to occurrence of SD. Flying in the absence of visual
cues (cloud flying, night flying, glare and dazzle), in a state of physiological compromise (hypoxia, alcohol / drugs,
fatigue, illness, etc.), involved in violent aircraft maneuvers or unnecessary head movements, apart from a
psychological state like anxiety, preoccupation, inattention and emotional stresses, etc. are some of the important
preconditions of SD.
(j) Prevention of SD.
It is a multipronged approach targeting aircrew, aircraft and air operations.
(i) Aircrew Factors.
(aa) Selection.
Selecting out the student pilots / cadets having abnormal vestibular, visual or neural problem.
(ab) Health and Medication.
Aircrew are advised to maintain both physical and mental health. Also, they need to adhere to
existing orders, which prevent them from undertaking flying duties if found under influence of alcohol,
drugs / medication, stress or fatigue.
(ac) Indoctrination and Proper Training.
Aircrew are indoctrinated to the different types of illusions by appropriate didactic lectures, practical
demonstration / experience in the SD simulators.
(ii) Aircraft Factors.
Various modifications in the aircraft design and display should be brought in, to decrease the incidence of
SD in flight. Good cockpit layout, Head-up display, Inside-out & outside-in display and Autopilot are such
technical initiatives.
(iii) Operational Factors.
(aa) In-flight Procedures.
Only “Instrument rated” aircrew are permitted to fly in bad weather conditions.
(ab) Break in Flying.
After coming back from leave or long absence from flying, all aircrew are advised to fly the first sortie
under supervision.
(h) Practical Advice for Pilots.
When spatial disorientation strikes:
(i) Make a positive effort to redirect attention to instruments. Believe in your instruments.
(ii) Do not try to analyze the situation. This wastes valuable time. Try to make your instruments read
right.
(iii) Maintain instrument scan pattern.
(iv) Do not attempt to mix instrument flying and flying by visual reference only.
(v) Seek help. Hand over controls to co-pilot if available.
(vi) Talk. Tell people that you are disoriented. They may be able to help.
(vii) Engage autopilot.
(viii) If nothing else works – abandon aircraft.

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11.5 Motion Sickness.

(a) Introduction.
Motion sickness is a condition characterized primarily by nausea, pallor, cold sweating and vomiting that occurs
when a man is subjected to real or apparent motion stimuli with which he is unfamiliar and hence unadapted.
Despite an origin about sea-sickness, the term encompasses symptoms induced by any motion and hence
seasickness, airsickness, simulator sickness, space motion sickness etc. The symptoms may occur in the absence
of motion (simulators) and the affected person may not be sick in a colloquial way, hence the term Motion
Maladjustment Disorder has been suggested to replace the earlier one. Airsickness is an entity under the rubric
of Motion Sickness, the discord in spatial integration being caused by conflicting positional and motion cues
afferent to the integrating centers. However, flying being a motion where a complete effort is a necessity at all
times and decisions are more time-critical, it achieves a special relevance. Also, it results in a wastage of flying
time, effort, cost of training and loss of manpower.
(b) Incidence.
It was estimated that 10 to 11% of trainee pilots became airsick during 1st 10 flights and 1-2% were eliminated
from flying; among non-pilots, the incidence was up to 50%. Recent figures of incidence are around 40%, 15
to 18% of whom are severe enough to compromise aircraft control. Of these, only 1% is finally eliminated from
flying (indicative of adaptation). 50% of cosmonauts have Space motion sickness on reasonable provocation. An
incidence of 8.9 (+3.1) has been reported among student pilots in India.
(c) Clinical Features.
The chief symptoms are nausea, vomiting, cold eccrine perspiration, pallor and other less common ones like
drowsiness, headache / buzzing, anxiety, apathy, general discomfort, stomach awareness and increased salivation.
The symptoms occur in fixed order over a varying period of time depending on the aircrew susceptibility, severity
and the provocative motion stimulus (Benson 1973, Kennedy et al 1968).
(d) Management.
(i) Pharmacological.
Medicines like antiemetics, scopolamine-amphetamine combinations are frequently used to prevent and
treat motion sickness, but they are not permitted for flying duties.
(ii) Non-pharmacological.
Apart from adapting few techniques like postural correction, restriction of head movement, ensuring
adequate vision during flying, Desensitization and Biofeedback are frequently used. Psychological techniques
like Cognitive Behaviour Therapy (CBT) and Modified Jacobson’s Progressive Muscle Relaxation Therapy are
also used in conjunction with adaptation therapy. Selected yogic exercises are also tried to treat motion
sickness. It has been found that the combined yogic exercise and CBT has significant increment of motion
tolerance, decrement in symptoms and associated anxiety. Reflighting rates of 80% and above have been
reported.
(e) Conclusion.
The management of Air sickness is an important issue because of its implications to the aircrew personally
(whose career is at stake!), to the training staff (the man hours spent) and to the nation (the monetary
brunt!). The management with drugs is not feasible for the aircrew in view of adjuvant side / adverse effects.
The desensitization techniques are the optimal management strategies of today. Probably with the clearer
understanding of the etiopathogenesis of the condition, physio-anatomical correlates of the integrating system
and drugs without CNS side effects, it may be possible to tame this entity.

11.6 Cabin Pressurization.

(a) Introduction.
Pressurization is artificially raising the pressure at higher altitudes. Cabin pressurization is the active pumping
of air into an aircraft cabin to increase the air pressure within the cabin at a higher aircraft altitude. It is an
effective way of protecting so that the physiological effects of high altitude should be reduced to a minimum. It
is required when an aircraft reaches high altitudes, because the natural atmospheric pressure is too low to allow

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people to absorb sufficient oxygen, leading to altitude sickness and ultimately hypoxia. The absolute pressure
in the cabin is stated in accordance with International Standard Atmospheric Scale (ISAS). Cabin pressurization
system nowadays is also called as cabin Environmental Control System (ECS) as it also includes maintaining
temperature and quality of air.
It would seem to be very convenient to maintain sea-level conditions throughout the flight envelope of the aircraft.
However, there are associated problems consequent to corporating such a design. The following would be the
penalties associated with keeping the cabin pressure at one atmosphere:
(i) A very powerful system requirement and increase in aircraft weight.
(ii) Increased load on pumps and fuel requirement.
(iii) Reduced aircraft life and performance.
(iv) Very large pressure differentials across the walls cabin.
(v) Compromising on safety.
(b) Cabin Pressurization: Physiological Consideration.
The following four factors are important while designing the cabin pressurization system of an aircraft.
(i) Maximum Acceptable Cabin Altitude.
The maximum acceptable cabin altitude ranges from 7,000-9,000 ft. With cabin altitude at 10,000-12,000 ft,
significant hypoxic condition arises. An occupant may suffer from GI tract gas expansion, difficulty in venting
and task performance. At an altitude increase of 18,000 ft and above, effects of decompression can be
seen. At 22,000 ft, severe hypoxic conditions can be seen and 44,000 ft requires supplemental oxygen. The
physiological changes at 7,000-9,000 ft are slow, with only mild hypoxia possibility.
(ii) Maximum Acceptable Rate of Change.
During the ascent and descent, the rate of change of cabin pressure is kept within acceptable limits keeping
in mind the ventilation of middle air cavities and the paranasal sinuses. The descent rate is generally kept
slower than the ascent rates. The rate of ascent can be around 11 kPa / min and that of descent about 1
kPa / min.
(iii) Effect of Sudden Cabin Failure.
To reduce the effects of sudden cabin failure the ratio of the maximum size of defect that could occur in
the wall (ie loss of window) to the volume of the cabin is as small as possible.
(iv) Quality of Air.
Other than the pressure control; the temperature, physical and chemical property of air to be maintained
in the cabin. The cabin should be properly ventilated, free of toxic gases and dust free.
(c) Cabin Pressurization Schedule.
In a relationship between cabin altitude and aircraft altitude, following two pressurization schedules are followed:
(i) High Differential Pressure.
In this case, the difference between the
altitude of the cabin and the aircraft
altitude is very high. This kind of cabin
pressurization is used in passenger
aircraft. In the case of passenger aircraft
the pressure is kept close to the sea level.
The fatigue-free environment and comfort
of the passengers is priority. In these
passenger cabins occupants can move
freely without oxygen masks. The risk of
structural failure and cabin decompression
is low Fig 11.3.
Fig 11.3 : High Differential Cabin Pressure

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(ii) Low Differential Pressure.

The pressure difference between the cabin and aircraft altitude is low. This type is mostly used in combat
aircraft. The aircrew is provided with Life Support System (LSS). The aircraft weight and cabin system are
speed and performance oriented. The aircraft has lesser weight requirements and is ready for decompression
[Fig 11.4].

Fig 11.4 : Pressure Changes in Passenger and Combat Aircraft Cabin

Fig 11.5 : Typical Pressurization Schedule for Pressure Cabins in Combat

In the graph shown above, it is very evident that in tactical aircraft the pressurization commences at higher
altitudes and is maintained at the given level till max pressure differential is reached. From this point, a
further increase in altitude is associated with an increase in cabin altitude at the given pressure differential
and passenger aircraft [Fig 11.5].
In commercial aircraft the pressurization commences at lower altitudes and cabin altitude is maintained
till the ceiling of the aircraft. There are other methods of pressuring cabins. For example, space vehicles
carry their own source of pressurization, which may be 100% oxygen (stored in liquid form) or a mixture

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of oxygen and an inert gas. It is advantageous to use an oxygen / inert gas mixture for reasons of safety.
Cabin Altitude Control. The cabin pressure or cabin altitude can be controlled in three different ways. In
isobaric control the cabin pressure is maintained constant. In differential control, the ratio of cabin and
aircraft altitude is kept constant. In intermediate control, the pressure is changed slowly using both the
previous options.

Fig 11.6 : Cabin Altitude Control

(d) Factor Governing Rate of Decompression.
There are three main factors, which govern the rate of decompression, viz.
(i) The volume of the pressure cabin.
(ii) The size of the cabin defect.
(iii) The pressure ratio between the cabin and the outside atmosphere.
The larger the pressure cabin, the longer it will take for the air to escape during the decompression and
conversely, small cabins will experience much more rapid decompression (time taken for decompression and
equalization of cabin and ambient pressure is less) for a given size of the defect. It is for these reasons that
small Fighter type cockpit has been designed with low differential cabins. The larger the cabin defect, the more
rapidly will a decompression occur since a greater volume of air can escape and thus the time of decompression
will be shortened. Two equations are used to determine the time decompression is given in Table 11.3.
Table 11.3 : Equations Used for Determining the Time of Decompression
Fliegner’s Equation Haberand Clamann Formula

V P–B
t = 0.22 t = tC × Pf
A B

t = Time of decompression in second, tc = V / vs *A, Pf = Pi/Pa

V = Volume of cabin in cubic ft3 V = Volume of cabin Pi = Initial pressure
A = Cross sectional area of defect in sq inch A = Cross sectional area of defect Pa = Ambient pressure
Pc = Initial cabin pressure in sqr inch
Pa = Ambient pressure vs = Local sound velocity

(e) Advantages and Disadvantages of Cabin Pressurization.

The pressure cabin is an essential part of the modern high-performance aircraft, without which it would not have
any useful high-altitude capability. Without pressurization, aircrew would only be able to carry out high altitude
flying by the continuous use of personal oxygen equipment. The pressurized cabins give comfort and fatigue
free environments. There is a reduced need for supplementary oxygen. The environmental control systems keep
pressure changes within physiological limits. There is no movement restriction in the cabin. However, with cabin
pressurization the structural weight of the aircraft increases and also the requirements of additional pressure

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controllers and power systems adding to maintenance. The risk in case of cabin failure is high.
(f) Loss of Cabin Pressure.
Loss of cabin pressure can vary from a slow leak, due to some minor mechanical fault such as a failure of the
canopy seal, to a rapid or even explosive decompression due to rupture of the cabin wall or loss of the canopy
or window.
The occurrence of rapid decompression is readily indicated by a loud noise due to the sudden release of pressure.
The compressed air within the cabin rushes out of the defect at a velocity near the speed of sound until the
cabin pressure reaches that of the surrounding air. As this air leaves the cabin, the remaining gas expands;
causing the temperature of the air within the cabin to drop to its dew-point and water condenses out as a mist
which can be so dense that it interferes with the occupant’s vision. The loud noise plus misting often leads the
crew to believe that their aircraft is severely damaged and on fire.
In the case of a slow leak, there is no such dramatic indication. The first sign is either the sound warning of the cabin
pressurization failure, the illumination of the appropriate warning light or a cabin altimeter indication depending
upon the aircraft instrumentation. The effect of decompression on cabin occupants depends on three major factors
i.e. rate of decompression, pressure change during decompression and pressure in the cabin after decompression.
(g) Hazards of Rapid Decompression.
The physiological effect of decompression depends upon the pressure differential, the duration of decompression
and the final cabin altitude. During decompression, the potential ill effects are associated with the rapid expansion
of gas within the body, which is governed by the pressure differential, duration of the decompression and
ambient aircraft altitude at the time of decompression i.e. explosive (< 1 second), rapid decompression (>1
second < 20 seconds) and fast (20-30 seconds). The dangers of rapid expansion of gases in semi-closed cavities
are remarkably rare under normal conditions of flight and pressurization.
(i) Hypoxia.
The most severe hazard associated with a rapid decompression to high altitude is hypoxia. If the final cabin
altitude is very high i.e. above 10,000 m or 33,000 ft, the time of useful consciousness for the various crew
members breathing air may be reduced by as much as one-third from the figures which would normally be
expected for that ambient altitude. This is due to the fact that during the escape of gas from the lungs, the
partial pressure of oxygen in the alveoli is reduced to below 40 mm Hg which is the approximate value for the
oxygen tension in the venous blood. There is an actual reversal of the oxygen diffusion gradient across the
alveolar membranes and oxygen passes back into the lungs from the venous blood. Immediately following
a rapid decompression to these very high altitudes, therefore, the arterial blood leaving the heart would
be carrying a little or no oxygen and the onset of hypoxia would be very rapid. This shows the advantage
of having the pilot or one of the pilots on oxygen the whole time when ambient aircraft altitude exceeds
8.5 Km (30,000 feet).
(ii) Decompression Sickness (DCS).
After decompression accident, if for any reason there is a need to continue the flight at a cabin altitude
greater than 7,500 m (25,000 ft), the crew may be faced with the possibility of developing DCS. In certain
susceptible individuals, it might even develop at an altitude as low as 5,500 m (18,000 ft).
(iii) Cold.
Depending upon the size and position of the defect in the cabin structure, cold may also limit sustained
flight at altitude after a rapid decompression. If for example, the canopy has been lost or the windscreen
shattered, the wind chill effect would be very large and force the crew to descend.
(iv) Aerodynamic Suction Effect.
The violent outrush of air through a hatch or window opening could endanger aircraft occupants who are
not strapped in. They can be pulled out of their seats and even out of the aircraft, depending upon the
severity of the decompression and their position in relation to the defect in the aircraft structure.
(h) Procedure after Loss of Pressure.
Immediate steps must be taken to prevent hypoxia. The action necessary will be to commence emergency

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descent to safe altitude. In Fighter aircraft, if the resultant cabin altitude is greater than 12,000 m (40,000 ft)
the subsequent action will depend upon the type of positive pressure breathing assembly being used. A pressure
suit, which provides the wearer with the capability of staying at altitude and which is functioning correctly,
will remove the danger of hypoxia. If on the other hand, a partial pressure assembly with only a get-you-down
capability is being worn, an immediate descent at a maximum rate will be necessary, through 12,000 m (40,000
ft). In either case, the remainder of the sortie should be planned according to the circumstances, bearing in
mind operational necessities, the fuel state of the aircraft, the effect of low cabin temperatures on both the
occupants and their equipment and the possibility of the onset of decompression sickness.
(j) Conclusion.
The pressure cabin is an essential part of the modern high-performance aircraft, without which it would not have
any useful high-altitude capability. Without pressurization, aircrew would only be able to carry out high altitude
flying by the continuous use of personal oxygen equipment. At very high altitude, this would be cumbersome and
have an adverse effect on their efficiency and performance during the flight. Therefore, in an operational role,
modern combat aircraft possess a risk of rapid decompression following cabin damage resulting in an immediate
need for a suitable personal oxygen assembly to prevent hypoxia.

11.6 Hypoxia.
(a) Introduction.
Since the early days of flying till today, hypoxia has remained a constant hazard during flights. With the advent
of modern technology, the aircraft started flying higher and faster. Thus, the need to prevent in-flight hypoxia
was felt more acutely. The Aircraft Oxygen System was developed parallelly to match the aircraft’s performance
and its ever-increasing agility. Considerable research and effort have gone into the evolution of aircraft Oxygen
systems as a means to combat in-flight hypoxia. The present systems are very versatile, mature and completely
automatic. Despite the existence of such well evolved and advanced systems, in-flight hypoxia still keeps occurring
although the frequency of such events has drastically reduced. With sound knowledge of the subject, medical
officer plays a key role in preventing this physiological aberration and thereby, contribute to saving lives, aircraft
and missions.
(b) Definition.
Hypoxia is a syndrome that results from an absence of an adequate supply of oxygen to the tissues, whether
in quantity or in molecular concentration. This oxygen lack is manifested through the myriad of physical and
mental dysfunctions due to deranged energy production. In aviation, these manifestations are usually acute and
profoundly compromise the ability of the pilot to effectively fly an aircraft.
(c) Pathophysiology: Oxygen Cascade.
The transfer of oxygen from the external environment to its ultimate destination in the mitochondria of the cells
can be envisaged as a stream cascading over five successive steps which gradually attenuate the pressure
of oxygen available for diffusion in the tissues. The concentration of oxygen keeps falling from 160 mm Hg in
inspired air to 103 mm Hg at alveolus, 100 mm Hg at artery, 51 mm Hg capillary and remains between 1 to
10 mm Hg at mitochondria [refer to Fig 11.7].
In clinical practice, a deficiency in any of the following can lead to a decreased oxygen concentration at tissue
level:
(i) Degree of Oxygenation of Blood Due to Any Cause.
(aa) Reduction in the Haemoglobin levels thereby decreasing the oxygen carrying capacity of the
blood.
(ab) Inadequate blood flow at tissue level.
(ac) Decreased / non-utilization of oxygen by the body tissues.
(ii) Capacity of blood to carry oxygen.
(iii) Reduction of blood flow at tissue level.
(iv) Ability of tissue to utilize available oxygen.

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Fig 11.7 : Oxygen Cascade

(d) Classification of Hypoxia.

On the basis of the above, Hypoxia is classified by modified Barcroft’s Classification, as under:
(i) Hypoxic Hypoxia.
Hypoxic hypoxia can occur when any of the following occur:
(aa) Reduction of a partial pressure of oxygen in the inspired air e.g. on exposure to altitude,
breathing in closed space, breathing oxygen poor gas.
(ab) Reduction in alveolar ventilation or hypoventilation e.g. Airway obstruction, paralysis of respiratory
muscles, depressed respiratory center, increased airway resistance etc.
(ac) Alveolar capillary diffusion block e.g., pneumonia, pulmonary haemorrhage, blast injuries etc.
(ad) Ventilation perfusion defects e.g. Emphysema, atelectasis, cyanotic heart disease etc.
(ii) Anaemic Hypoxia.
Anaemic hypoxia results when there is a reduction in oxygen carrying capacity of the blood; consequent
to decreased haemoglobin content. Carbon monoxide, nitrates, sulfa drugs etc. also cause some type of
hypoxia by forming stable compounds with haemoglobin and reducing the amount of haemoglobin available
to form oxy-haemoglobin.
(iii) Stagnant or Hypokinetic Hypoxia.
This form of hypoxia is due to malfunction of the circulatory system where the oxygen carrying capacity
of the blood is adequate but there is an inadequate circulation of the blood. Conditions such as heart
failure, arterial spasm, occlusion of blood vessel, In aviation, the venous pooling encountered during +Gz
maneuvers would predispose to stagnant hypoxia.
(iv) Histotoxic Hypoxia.
Histotoxic Hypoxia occurs when the utilisation of oxygen by the body tissues is interfered with. Alcohol,

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narcotics and certain poisons such as cyanide, interfere with the ability of the cells to make use of the
oxygen available to them even though the supply is normal in all respects. In histotoxic hypoxia the venous
haemoglobin saturation with oxygen is higher than normal because the oxygen is not being unloaded to
the tissues and tissues are unable to metabolize the delivered oxygen.
All these types of hypoxia may be encountered in flight, but the most frequent and important type of hypoxia
encountered in aviation is that of hypobaric hypoxic hypoxia (caused by breathing air at altitude). The partial
pressure of oxygen in the inspired air progressively reduces as compared to breathing air at sea level. The
principal causes of inflight hypoxia are ascent to altitude without supplemental oxygen, failure of personal
breathing equipment and decompression of the pressure cabin.
(e) Causes of Hypoxia During Flying.
In a study of hypoxia and related incidences in the past, the main causes for in-flight hypoxia were identified as
the following:
(i) Failure of the regulator to deliver correct concentration of oxygen.
(ii) Inadequate seal of mask to face.
(iii) Decompression of the pressure cabin.
(iv) Inadvertent break of connection of the hose between mask and regulator.
(v) Failure to turn on the oxygen supply.
(f) A study conducted in a Royal Air Force base to Analyze the Different Incidents of Hypoxia Revealed the
Following:
Stages of Hypoxia.
Depending upon the altitude of exposure, there are four well-delineated stages of hypoxia. The different stages
of breathing normal air and their equivalent altitude of breathing 100% oxygen are given in Table 11.4 below.
Table 11.4 : Stages of Hypoxia with PaO2 (mm Hg) and Percentage Saturation of Haemoglobin
Cabin Altitude PaO2 (mm Hg) and Percentage
Stages of Hypoxia
Breathing Air Breathing 100% Oxygen Saturation of Haemoglobin

0-3,30 m 10,300-12,000 m 60-104 mm Hg

Indifferent
0-10,000 ft 33,000-40,000 ft 90-97%
3,030-4,500 m 12,000-13,000 m 42-60 mm Hg
Compensatory
10,000-15,000 ft 40,000-42,500 ft 80-90%
4,500-6,000 m 13,000-13,500 m 42-35 mm Hg
Disturbance
15,000-20,000 ft 42,500-45,000 ft 70-80%
6,000-7,000 m 13,500-13,800 m 35-30 mm Hg
Critical
20,000-23,000 ft 45,000-46,000 ft 60-70%
The manifestations of bodily dysfunctions in hypoxia are the result of the interplay of intensity of the hypoxic insult
and reactions of the body in a bid to overcome it. During the Indifferent stage, the intensity of hypoxia is mild
and body is indifferent to it . Hence, the symptoms are very mild and generally not recognized. The compensatory
stage is characterized by body’s attempt to compensate for the oxygen lack by adjusting its functions. During
disturbance stage overt bodily dysfunctions are manifested heralding an impending surrender of the body to
intense hypoxic insult. The critical stage is marked by total surrender and the triumph of hypoxia over the body
and mind and if allowed to continue and oxygen is not provided, death ensues. Operationally, these stages are
very important and no hypoxic insult should be allowed to worsen beyond indifferent stage if effective flying
ability is to be preserved. The different clinical manifestations during the various stages are enumerated below.
(i) Indifferent Stage.
Dark adaptation gets affected early. Night vision may be lost by 5-10% at 5,000 ft. (14,505 m) and may be
compromised by 25% at 12,000 ft (3,400 m). Though this deterioration may not be operationally significant,

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all Fighter aircrew during night flying are advised to take oxygen from ground level. Increased pulse rate and
alveolar ventilation may be observed during this stage.
(ii) Compensatory Stage.
During this stage, the circulatory and respiratory systems can provide some defence against hypoxia. This
happens due to increased heart rate and more productive pumping of blood leading to enhanced circulation
and increased depth and rate (mild) of respiration. Although these responses occur automatically, one
should not depend on recovering without taking conscious corrective action. At 12,000 to 15,000 ft (3,4000-
45,000 m) the effects of hypoxia on the nervous system can become increasingly incapacitating. As time
spent at this altitude continues (as little as 10-15 min) impaired skills are very evident. What is dangerous
is the feeling of well-being and euphoria. Other symptoms that may appear are drowsiness, poor judgment
and frequent subtle errors in flying.
(iii) Disturbance Stage.
In this stage, the physiological compensations do not suffice to provide adequate oxygen for the tissues.
Subjective symptoms may include fatigue, lassitude, somnolence, dizziness, headache, breathlessness and
euphoria. Occasionally there are no subjective sensations up to the time of unconsciousness. Physiological
systems that get affected are tabulated in Table 11.5.
(iv) Critical Stage.
This is the stage in which consciousness is lost. This may be the result of circulatory failure (fainter) or
central nervous system failure (non-fainter) where unconsciousness happens even with maintenance of
blood pressure. The former is more common with prolonged hypoxia, the latter with acute hypoxia. With
either type there may be convulsions and eventual failure of the respiratory centre.
Table 11.5 : Clinical Features of Hypoxia during Disturbance Stage
Special Senses Mental Process Personality Trait Psychomotor Function
Vision Intellectual impairment Euphoria Muscular incoordination
— Peripheral & Central Unable to perform delicate &
Slow Thinking Elation
Vision fine motor activities
— Visual acuity Unreliable Calculation Overconfidence Stammering
— Extra ocular muscles
Faulty Memory Loss of self-critique Illegible handwriting
— Accommodation
Touch & Pain sensations Poor Judgement Loss of inhibition Poor coordination
Release of basic Difficulty in keeping station
Hearing Delayed reaction time
personality trait during formation flying
(g) Factors Affecting Onset and Severity of Hypoxic Effects.
(i) Altitude.
Higher the altitude, lower is the partial pressure of alveolar oxygen and hence shorter the latent period
and greater the severity of effects.
(ii) Rate of Ascent.
The greater the rate of ascent the more rapid the onset of signs and symptoms of hypoxia.
(iii) Duration at Altitude.
The effects of hypoxia are more severe the longer the duration at altitude. This is due to the fact that the
effects of hypoxia are cumulative.
(iv) Ambient Temperature.
High or low environmental temperature favours the development of symptoms.
(v) Physical Activity.
Exercise at altitude raises the demand for oxygen and hence the symptoms of hypoxia are more severe,

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with a greater degree of activity.

(vi) Individuals differ considerably in their ability to withstand hypoxia.
(vii) Physical Fitness.
A high standard of physical fitness is conducive to a better tolerance of hypoxia. Physical training exercise
improves the hypoxia tolerance of individuals.
(viii) Smoking.
Heavy smoking makes an individual more liable to suffer from hypoxia due to the binding of haemoglobin
with the carbon monoxide in the smoke.

Actual Altitude (ft) Non-Smoker Apparent Altitude (ft) Smoker

Sea Level 7,000 ft
10,000 ft 14,000 ft
20,000 ft 22,000 ft
(ix) Organic Diseases.
Effects of hypoxia are more severe in those with disease of the heart, lungs or blood which interfere with
the normal oxygenation and circulation to prevent adequate physiological compensation.
(x) Emotional State.
Apprehension and anxiety make an individual more susceptible to the effects of hypoxia.
(xi) Acclimatization.
Acclimatization by residing at high altitude raises the individual’s ability to withstand hypoxia.
(h) Concept of Equivalent Lung Altitude.
Breathing air at a sea level is associated with a certain partial pressure of oxygen in the lungs (104 mm Hg).
By breathing 100% oxygen, the same partial pressure is brought about at a much greater altitude, in this case
33,000 ft. Table 11.6 given below shows the various equivalent lung altitudes.
Table 11.6 : Equivalent Lung Altitudes
Breathing air Oxygentension mm Hg Breathing 100% Oxygen
Sea level 104 mm Hg 33,000 ft
10,000 ft (3,030 m) 60 mm Hg 39,000 ft (12,000 m)
12,500 ft approx. 50 mm Hg 45,000 ft
(j) Concept of Time of Useful Consciousness (TUC).
Time of Useful Consciousness (TUC) or Effective Performance Time (EPT) is the period of time from the interruption
of the oxygen supply or exposure to an oxygen-poor environment, to the time when capability to perform useful
function is lost. It has enormous operational significance in flying. Beyond this time in a given altitude, an
individual is no longer capable of taking proper corrective and protective action to undo his predicament. It is
not the time to total unconsciousness but the time for a measurable decrement of performance.
The TUCs are for an individual at rest. Any exercise will reduce the time considerably. For example, usually
upon exposure to hypoxia at 25,000 ft, an average individual has a TUC of 3 to 5 min. The same individual,
after performing 10 deep knee bends, will have a TUC in the range of 1 to 1.5 min. It is reduced drastically
by rapid decompression. There are many individual variations and there may be variations in the same person.
The Effective Performance Time or Time of Useful Consciousness at different altitude is tabulated in Table 11.7.
These times have been calculated from observations over a period of years.

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Table 11.7 : TUC at Different Altitude

Altitude
Effective Performance Time
Mtr Ft
5,500 18,000 20 to 30 min
6,700 22,000 10 min
7,600 25,000 3 to 5 min
8,500 28,000 2.5 to 3 min
9,100 30,000 1 to 2 min
10,700 35,000 0.5 to 1 min
12,200 40,000 15 to 20 sec
13,100 43,000 9 to 12 sec
15,200 50,000 9 to 12 sec
The variation in TUC is the reflection of the influence of many factors which include physical fitness, age, degree
of training and previous experience of hypoxia The last two factors highlight the beneficial effect of hypoxia
indoctrination training of aircrew.
(k) Prevention of Hypoxia.
Ensure the individual has sufficient oxygen to maintain alveolar PO2 between 60 and 100 mm Hg for preventing
hypoxia. This can be achieved in aircraft by an oxygen system, cabin pressurization or a combination of the two.
Cabin Pressurization.
The most efficient method of circumventing the physiological effects of Hypoxia is by providing an aircraft
pressurization system. This ensures that the occupants of the aircraft are never exposed to pressures outside
the physiologic zone. In practice there exist two pressurization schedules:
(i) Isobaric System.
The system maintains a constant cabin pressure as the ambient pressure decreases. The cabin altitudes
are maintained between 610 to 2,500 meters (2000 to 8,000 ft). This pressurisation increases the comfort
and mobility of the occupants.
(ii) Isobaric Differential System.
Tactical military aircraft are not equipped with isobaric pressurization because the added weight penalty
would severely affect the range of the aircraft. In this system the pressurization commences at a given
altitude and cabin altitude is maintained at this value till a preset pressure differential is reached. With
continued ascent, the differential is maintained. In aircraft provided with this kind of system, an Oxygen
supplement is mandatory.
Supplemental Oxygen.
Provision of supplemental oxygen in the aircraft ensures that the occupant receives increasing quantities of
oxygen in the inspired air. The oxygen system (regulator assembly) is responsible for the correct percentage
of oxygen that is added to the inspired air to maintain lung Pa O2 at 103 mm Hg.
Pressure Breathing.
During acute, unintentional exposures to high altitudes (40,000 feet or above) Positive Pressure Breathing
(PPB) is used to prevent the occurrence of hypoxia. In a specially designed oxygen system, 100% oxygen
at greater than ambient pressure is delivered. In order to maintain total pressure within the lungs at the
minimum acceptable level, of 141 mm Hg (40,000 equivalent), the magnitude of PPB delivered must
increase progressively with altitude. For example, at 45,000 feet where PB = 111 mm Hg, PAO2 = 39 mm
Hg, PAH2O = 47 mm Hg and PACO2 = 25 mm Hg, a positive pressure of 30 mm Hg [141 - (39 + 47 + 25)]
is required. Even higher levels of pressure breathing are needed as altitude further increases.

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Table 11.8 : Supplemental Oxygen Requirements at Altitude to Maintain

Sea Level Air Equivalence
Altitude BAROMETRIC OXYGEN REQD
Meters Feet (mm HG) (%)

Sea level Sea level 760 21 %

1,515 5000 632 25 %
3,030 10,000 532 31 %
4,545 15,000 429 40 %
6,060 20,000 329 49%
7,575 25,000 282 62%
9,090 30,000 225 81%
10,300 34,000 187 100%

Pressure Breathing with Chest Counterpressure.

Above 50,000 feet, pressure breathing is of little value since it is impossible to tolerate the amount of
positive pressure necessary to prevent severe hypoxia without counterpressure. It is for this reason that all
individuals flying in aircraft above 50,000 feet are required to wear a counterpressure suit.
Pressure Suits.
Pressure suits are designed to provide protection against hypoxia at altitude above 50,000 feet as a
backup protection for the pressurization system. High breathing pressures can be tolerated in a pressure
suit because of the counterbalance effect of the pressure suit and helmet. The two basic types of pressure
suits are the partial pressure suit and full pressure suit. The former applies counterpressure directly to the
body surface by means of mechanical squeeze and the latter by surrounding the body with an envelope of
air or oxygen. The full-pressure suit, helmet and gloves surround the body with a pressurized gas envelope
to provide counterpressure. Pressure suits do not protect against decompression sickness or the effects
of trapped gases in the body.
(l) Recovery from Hypoxic (Altitude) Hypoxia - Oxygen Paradox.
Recovery from Hypoxia usually occurs within seconds after re-establishing a normal alveolar partial pressure.
Nevertheless, mild symptoms, such as headache or fatigue, may persist after the hypoxic episode. The persistence
of symptoms seems to have a higher degree of correlation with the duration of the episode than with its severity.
In some instances, following the sudden administration of oxygen to correct the hypoxic insult, the individual develops
a temporary increase in the severity of symptoms, known as oxygen paradox. The subject may lose consciousness or
develop clonic spasms for a period lasting up to a minute. Accompanying symptoms are mental confusion, deterioration
of vision, dizziness and nausea. Initially, the arterial blood pressure falls and the rate of blood flow decreases.
The hypotension produced by the sudden restoration of oxygen is probably due to vasodilatation, which occurs
in the pulmonary vascular bed and is brought about by the direct action of oxygen on the pulmonary vessels.
The hypocapnia produced by hypoxia and the decrease in blood pressure, which follows re-oxygenation, act
together to reduce cerebral blood flow. This reduction in blood flow probably intensifies the cerebral hypoxia for
a short period until the cardiovascular effects have passed and the carbon dioxide tension returns to a normal
range. Once the PaCO2 returns to a normal value, it will stimulate the respiratory centre to resume ventilation
and resolve the cerebral hypoxia.
(m) Prevention of Hypoxia in Aircrew.
Pre-flight checks. Conscientious pre-flight checks would go a long way in decreasing the incidence of hypoxia.
Before every flight, the pilot should perform the “PRICE” check on the oxygen equipment. The acronym PRICE
is a checklist memory-jogger that helps pilots and crew members inspect oxygen equipment.

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Table 11.9 : PRICE Checklist

Pressure Ensure that there is enough oxygen pressure and quantity to complete the flight.
Inspect the oxygen regulator for proper function. If you are using a continuous-flow system,
Regulator
make sure the outlet assembly and plug-in coupling are compatible.
Most oxygen delivery systems indicate oxygen flow by use of flow indicators. Flow indicators may
Indicator be located on the regulator or within the oxygen delivery tube. Don the mask (or nasal cannula)
and check the flow indicator to assure a steady flow of oxygen.
Ensure that all connections are secured. This includes oxygen lines, plug-in coupling and the
Connections
mask (or nasal cannula).
Have oxygen equipment in the aircraft ready to use for those emergencies that call for oxygen
Emergency (hypoxia, decompression sickness, smoke & fumes and rapid decompressions.) This step should
include briefing passengers on the location of oxygen and its proper use.
(n) Hypoxia Indoctrination Training.
The crewmembers’ last line of defense against incapacitation from altitude hypoxia, regardless of its cause
(mechanical failure of pressurization or other equipment, etc.), is to recognize their own symptoms of exposure to
hypoxia. Hypoxia training in the “Altitude Chamber” permits the aircrew to experience and identify their individual
symptoms of hypoxia under safe and controlled conditions. Individuals will experience their own symptoms
or combination of symptoms, which will vary with age, physical condition, temperature and the degree of
apprehension. Once experienced, these symptoms of hypoxia can be classified as either objective signs perceived
by the observer or subjective symptoms perceived by the subject. Whenever exposed to hypoxia, one experiences
similar set of signs & symptoms. This phenomenon is called “Hypoxia Signature”. An aircrew if aware about
his / her own hypoxia signature is capable of recognizing inflight hypoxia during actual flying.
(o) Role of a Squadron Medical Officer Trained in Aviation Medicine.
The squadron medical officer trained in Aviation Medicine plays an important role in giving proper guidance on
day-to-day problems of aircrew related to hypoxia, oxygen systems and personal protective clothing.

11.7. Hyperventilation.
(a) Introduction.
Various inflight factors may increase the respiration rate among the piloting aircrew and could increase the risk
of hyperventilation. These potential contributing factors include high altitude, low humidity, high carbon dioxide
concentration, specific pollutants and situational stress (e.g., mechanical problems, weather and increased
terrorist threats). Hyperventilation can affect brain function, judgment and visuomotor performance. These factors,
coupled with other environmental stressors specific to flying, could pose a potential problem for air safety.
(b) Pathogenesis.
Hyperventilation is a condition in which pulmonary ventilation is greater than that required to eliminate the
carbon dioxide produced by the tissues. There is an excessive rate or depth of breathing flushing out carbon
dioxide. The consequent excessive removal of carbon dioxide from the alveolar gas, the arterial blood and the
tissues results in a reduction in the tension of carbon dioxide throughout the pathway.
There is a close relationship between carbon dioxide tension and hydrogen ion concentration in the blood and
tissues, since these substances are in equilibrium according to the equation:
CO2 + H2O  H2CO3  H+ + HCO3–

Under normal circumstances, the direction of the equation is towards right producing adequate H+ and maintaining
the acidity. A reduction in carbon dioxide tension will reverse the direction and drive the equilibrium towards the
left. Consequently, there is a fall in hydrogen ion concentration, i.e. a rise in pH. Thus, hyperventilation causes
an increase in the pH of blood and tissues in other words, results in development of respiratory alkalosis.
Normal blood PaCO2 ranges between 36 mm Hg and 44 mm Hg; hyperventilation brings it to less than 36 mm
Hg. Hyperventilation lowers the PaCO2 and increases the pH. The lower the PaCO2, the worse are the symptoms.

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Respiratory alkalosis is the result of hyperventilation leading to abnormally low levels of carbon dioxide in the
blood (< 36 mm Hg).
(c) Causes of Hyperventilation in Aviation.
The causes that can lead to hyperventilation in aviation are:
(i) Hypoxia.
Hyperventilation is a normal response to Hypoxia and sets in whenever Alveolar Oxygen tension is < 55 mm
of Hg to 60 mm of Hg.
(ii) Positive Pressure Breathing.
The mechanics of respiration get reversed during positive-pressure breathing. Inspiration becomes passive
and expiration becomes active. The force that the individual has to exert in exhaling against the applied
pressure results in an increase in the rate and depth of breathing.
(iii) Anxiety.
More commonly, the condition is produced by emotional stress, particularly anxiety, apprehension and fear.
A significant proportion of student pilots undergoing training exhibit gross hyperventilation in flight. It has
been claimed that 20–40% of student aircrew suffers from hyperventilation at some stage during flying
training. The condition is also seen in experienced aircrew when, for example, they are exposed to the
mental stress of a sudden in-flight emergency or when they are being trained to operate a new aircraft
type. Aircraft passengers who are afraid or anxious frequently hyperventilate. Hyperventilation can also be
seen amongst individuals undergoing Hypoxia Indoctrination in the Hypobaric (Altitude) Chamber.
(iv) In-flight Conditions.
Apart from flying stress, pain or discomfort due to any reasons, air sickness, thermal discomfort and even
vibration at 4–8 Hz produced by air turbulence can cause hyperventilation.
(v) Pharmacological Stimuli (uncommon in aviation).
The major groups of drugs that cause hyperventilation are salicylates, female sex hormones, catecholamines
and analeptics.
(d) Physiological Features of Hyperventilation.
(i) CVS.
Hypocapnia induces a marked vasoconstriction of the cerebral arterioles and the vessels of the skin, while
blood flow through skeletal muscle is increased.
(ii) CNS.
Deterioration in performance, appearance of slow-wave activity in the electroencephalogram and loss of
consciousness, are usually due to a combination of hypoxia and alkalosis in the cerebral tissues.
(iii) Psychomotor Tasks.
Reduction in the arterial carbon dioxide tension to below 25 mm Hg causes a significant decrement in the
performance of psychomotor tasks, such as tracking and complex coordination tests. The reaction time at
a two-choice task is increased by about 10% by such a fall and is increased by 15% at an arterial carbon
dioxide tension of 15 mm Hg. The ability to perform complex mental tasks, such as mental arithmetic, is
compromised by a reduction in carbon dioxide tension to below 25–30 mm Hg. Steadiness of the hands
is also impaired by a reduction in arterial carbon dioxide tension to 25 mm Hg. The ability to perform
manual tasks is affected markedly by the muscle spasm that occurs if arterial carbon dioxide tensions fall
below 20 mm Hg. Reduction of carbon dioxide tension below 10–15 mm Hg produces gross clouding of
consciousness and then unconsciousness.
(iv) Neuromuscular Effects.
Sensory disturbances, such as paraesthesia in the face and extremities and motor disruption cause muscle
spasms (tetany).

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(e) Clinical Features of Hyperventilation.

Moderate and severe hyperventilation produces a general deterioration in mental and physical performance,
which is followed by impairment of consciousness and finally unconsciousness. Few other clinical features can
be described based on arterial CO2 tension:
(i) PaCO2 of 20–25 mm Hg.
Feelings of light-headedness, dizziness, anxiety and a superficial tingling (paresthesia) in the extremities
and around the lips.
(ii) PaCO2 of 15-20 mm Hg.
Muscle spasms, particularly of the limbs and of the face, Contraction of muscle groups in the wrist and
hand and the ankle and foot give rise to carpo-pedal spasm.
(iii) PaCO2 < 15 mm Hg.
The whole body becomes stiff as a result of general tonic contractions of skeletal muscle (tetany).
Symptoms of hyperventilation are often confused with those of hypoxia. Light-headedness, paresthesia and
apprehension seen during acute hypoxia in a subject breathing air at altitudes between 15,000 and about
20,000 feet are due to the concomitant hypocapnia. Thus, hypoxia should always be suspected when symptoms
or signs of hypocapnia occur at altitudes above about 12,000 feet and the corrective procedures must be based
on the assumption that the condition is caused by hypoxia until proven otherwise.
(f) Diagnosis of Hyperventilation.
Diagnosis of hyperventilation in aircrew is clinched by:
(i) Statement of individual / colleague / instructor in a training sortie wherein the individual is noted to
breathe rapidly before manifesting classical signs and symptoms.
(ii) Observing the oxygen flow rates by Doll’s Eye in the cockpit.
(iii) Post-sortie urine sample may be alkaline.
(g) Common Symptoms and Signs of Hyperventilation.
The most common symptoms of hyperventilation are, numbness, tingling of the hands, feet and face, muscular
in-coordination, giddiness, visual disturbances and fainting spell, increased rate and depth of breathing, muscle
twitching and tightness, paleness, cold clammy skin and muscle spasms.
(h) Differences between Hyperventilation and Hypoxia.
Though the etiology of hypoxia and hyperventilation are distinct, the symptoms are similar making it difficult to
distinguish between them. There are few distinctive differences in the two syndromes. In hyperventilation, the onset
is gradual, with the presence of pale, cold, clammy skin and development of muscle spasms and tetany. In hypoxia,
the onset of symptoms is usually altitude-dependent, with the development of flaccid muscles and cyanosis. The
symptoms of hyperventilation may persist even on switching over to 100% oxygen while that of hypoxia will be relieved.
(i) Treatment of Hyperventilation.
Hypoxia and hyperventilation are similar and both can quickly incapacitate. The treatment is aimed at correcting
both problems simultaneously. There are five steps for the treatment inflight hyperventilation syndrome.
(i) Switch over to 100% oxygen if not already on it.
(ii) Check oxygen equipment to ensure proper functioning.
(iii) Control breathing-reduce the rate and depth.
(iv) Descend below 10,000 feet where hypoxia is an unlikely problem.
(v) Communicate the problem to ground control.
(j) Conclusion.
Though the reporting of hyperventilation syndrome is rare among military aircrew, the occurrence of this

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physiological aberration is a matter of concern due to its possible implications for flight safety. All squadron
medical officers must educate the aircrew through necessary awareness programs so that the issue is recognized
early and managed effectively.

11.8 Decompression Sickness.

(a) Introduction.
Decompression sickness is the name given to a group of symptoms which may occur as a result of exposure
to reduced atmospheric pressure, excluding those which are due to hypoxia or the expansion of gas contained
in the hollow cavities of the body. It is sometimes referred to as bends, a term which is used to describe the
commonest symptom of decompression sickness, namely, pain the muscles or joints. The term dysbarism is
also used to describe the effects. Other terms, which are sometimes used, are aero- embolism (gas bubbles
in the blood vessels) and aero-emphysema (gas bubbles in the tissues). The term Decompression Sickness
has been replaced with Decompression Illness (DCI). DCI includes the effects produced by gas bubbles in the
circulation. Under the umbrella of DCI, signs and symptoms of arterial gas embolism are included. Two variants of
decompression sickness are recognized: (a) Caissons disease of Divers and (b) Sub atmospheric decompression
sickness.
Synonyms: Bends, aeropathy, creeps, dysbarism.
(b) Pathophysiology.
There are many theories put forward to explain the effect of lowered atmospheric pressure on the body and the
most likely cause is based on one of gas laws viz. Henry’s Law, states that the amount of gas that will dissolve
in a solution and remain in solution, is directly proportional to the pressure of the gas over the surface of the
solution. The basic mechanism is the super-saturation of the tissues with Nitrogen (N2).
Super-saturation of Tissues.
When the rate of decompression exceeds the rate at which inert gas viz. N2 is offloaded super-saturation results.
Super-saturation Ratio.
It refers to the ratio of the tension of the inert gas in tissue to the ambient pressure. The Super-saturation ratio
= PN2 / Pbarometric. Chances of DCS developing are nil when this ratio is < 2 (if pressure change is less than 50%,
DCS not observed). Under certain conditions, super-saturation results in the formation of bubbles.
Bubble Formation.
The process starts with the formation of bubble nuclei in the areas of negative hydrostatic pressure (Vessel Bifurcation).
Bubble nuclei are microscopic masses of gases attached to irregularities in the walls of a cavity. These develop in
areas of negative hydrostatic pressure. Distribution of the nuclei may account for the sites at which disturbances
occur in DCS. Bubbles have to grow to a certain size before they cause deformation and produce effects.
At reduced atmospheric pressure, bubble formation is influenced by factors such as movement of the tissues
(which explains the significance of exercise as a predisposing factor), alterations in the circulation of body fluids
and rapid changes in gas pressure, bubbles appear in those areas around joint capsules and the insertions of
tendons and ligaments; tending to be released in fatty tissues where there is the least blood supply and the
greatest amount of dissolved nitrogen.

Bubble - Blood interaction: Platelet aggregation

Release PF3 increased clotting & increased Release Histamine, 5-HT, Epinephrine
circulatory embarassment
(i) Vasocostriction
trans capillary fluid loss (ii) increase permeability
Increased Haemoconcentration Fluid shift intra vasc. to
extra vasc.

Circulatory embarassment
Fig 11.8 : Bubble – Blood Interaction

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Increased Haemoconcentration

Trans capillary fluid loss Mech. effect

Increased
surface
activity
bubble
post Increase Lymph.
capillary Plasma vol. obstruction
resistance Increased Resistance
Increased Viscosity to flow
blood
Decreased Decreased CO
blood flow
Increased
Haematocrit
Fig 11.9 : Pathophysiology of Bubbles
(c) Symptoms of Decompression Sickness.
Decompression sickness can occur in apparently normal individuals who have no predisposing disease and there
is a wide individual variation in susceptibility. The symptoms of decompression sickness are:
(i) Bends.
This is the most common symptom of decompression sickness and consists of pain in the muscles or
joints which may be mild or severe. Mild pain very commonly becomes severe or agonizing if altitude is
not reduced and an individual may ultimately collapse; rarely bends pain may disappear without becoming
severe. The commonest sites for the pain are: the upper part of the arm (near the shoulder), the knee, wrist
and ankle; and more than one of these areas may be affected at the same time. The pain usually starts
as a mild ache, not unlike the after-effects of unaccustomed exercise, but if it is allowed to continue it may
become a deep pain spreading along the limb causing weakness and eventually complete disablement of
the limb. When the pain is mild, the sufferer is inclined to rub the affected part to gain some relief but
this action only makes matters worse. The symptoms usually pass of during descent, somewhere between
8,000 m (26,000 feet) and 6,000 m (20,000 feet). Some residual stiffness and even a mild ache may
persist for some time. Re-exposure to altitude causes immediate recurrence of the pain.
(ii) Skin Effects.
Pricking or tingling sensations in the skin frequently occur but they are usually transient. Localized skin
rashes are sometimes visible.
(iii) Chokes.
This is the name given to respiratory disturbances, which occur as a symptom of Decompression Sickness.
The term is a misnomer, as the subject does not choke. This symptom refers to a sore burning feeling in
the center of the chest, associated with pain on inspiration; there are also repeated paroxysms of coughing.
It is not a common symptom of Decompression Sickness. The appearance of symptoms must be taken
very seriously and descent should be initiated as soon as possible preferably to below a height of 5,000 m
(16,000 ft) or collapse may result. Although the condition is relieved by descent, (recompression) a residual
soreness may remain. Chokes may be preceded by bends pain in some cases.
(iv) Neurological Symptoms.
The effects on the central nervous system are very varied. A temporary defect in the field of vision is a
fairly common symptom. Frequently, there is a feeling of uneasiness or inability to concentrate. Following
descent a severe headache may develop. It is rare for numbness and paralysis to occur at altitude, but
they may arise as a complication of secondary collapse. Development of neurological symptoms should be
taken /  treated seriously.

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(v) Collapse.
A person who is suffering from Decompression Sickness may collapse with or without any other symptom
being present. Collapse occurs in 1 in 2,500 exposures to altitudes > 30,000 feet. This collapse is a
typical faint characterized by pallor, sweating, nausea, giddiness and then unconsciousness. The entity of
Post Decompression Collapse may occur after return to ground level and in a few cases up to 6 hours or
longer after landing. This type of collapse is generally preceded by some of the above-mentioned symptoms
of Decompression Sickness. The clinical picture is very variable. Typically, the patient becomes anxious,
develops a frontal headache and feels sick. The important signs are:
(aa) Facial pallor.
(ab) Cold clammy extremities.
(ac) Peripheral cyanosis.
(ad) Increase in the haematocrit.
(ae) Focal signs such as weakness of the limbs, scotomata and apraxia.
In view of this, individuals who have had symptoms of Decompression Sickness at altitude are placed under
medical surveillance as soon as possible for at least 12 to 24 hours.
(d) Factors Which Predispose to Decompression Sickness.
There are several factors which influence the incidence of decompression sickness:
(i) General Factors.
(aa) Altitude.
There is considerable evidence that the altitude threshold for decompression sickness is 5,500 m
(18,000 feet) although in fact, it occurs only rarely below 6,000 m (20,000 feet) The frequency
increases with altitude, particularly above 8,000 m (26,000 feet).
(ab) Rate of Ascent.
The rate of ascent is of little significance.
(ac) Duration of Exposure.
It takes between 5-20 minutes of exposure for DCS to occur and manifest.
(ad) Exercise.
Exercise at altitude, is one of the most important factors influencing the susceptibility to this condition,
it is for this reason that both rubbing and repeatedly flexing the affected part are maneuvers that
will aggravate, rather than alleviate, the condition.
(ae) Re-exposure.
Re-exposure to altitude within a period of 48 hours increases an individual’s susceptibility to
Decompression Sickness.
(af) Temperature.
There is some evidence to suggest that low temperature increases the incidence.
(ag) Skin / SCUBA Diving.
Underwater during the 24 hours before flight, may facilitate development of Decompression Sickness
or worsen decompression sickness in the air.
(ii) Personal Factors.
(aa) Age.
There is highly significant increase in susceptibility with age. For example, individuals in their mid-
thirties are about three times more susceptible than those in their early twenties.

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(ab) Body Weight.

Obesity predisposes an individual to decompression sickness.
(ac) Recent Injury.
Recent joint and limb injuries increase the local susceptibility to bends pain.
(ad) State of Health.
The after-effects of alcohol ingestion and inter-current infection both increase susceptibility.
(e) Prevention of Decompression Sickness.
Decompression sickness is only encountered when there is failure of the pressure cabin at high altitudes (above
25,000 ft). The incidence of decompression sickness in Aerospace operations is very small as compared of
incidence of DCS amongst those in the diving fraternity. To reduce the chances of developing decompression
sickness in the eventuality of failure of the pressure cabin, the following are to be done by the pilot:
(i) Commence immediate rapid descent to altitudes below 18,000 feet. He should prepare for an
emergency landing.
(ii) Once on the ground, the aviator should be taken to the MI Room for medical surveillance.
(iii) To reduce the likelihood of developing DCS the aviator must ensure the following:
(aa) Maintain High Standard of Physical Fitness.
An individual who is not in peak physical condition is more prone to developing DCS. There is a
greater risk of Decompression sickness in the obese / overweight personnel.
(ab) Not to Fly under Influence of Alcohol.
Alcohol ingestion and the presence of infection increase the susceptibility to DCS.
(iv) Avoid Flying after Diving.
This would be more applicable to the Naval aviators. Aircrew are advised not to fly at least for 24 hr after
diving.
(v) Delayed DCS.
DCS can occur even after several hours of decompression. The signs of delayed DCS are:
(aa) Severe weakness.
(ab) Feeling excessively drowsy.
(ac) Excessive sweating.
(vi) Factors Increasing the Susceptibility to DCS.
Re-exposure to altitude, where an episode of DCS has occurred earlier. High altitude hypoxia and low
environmental temperature increase the incidence / risk.
(f) Treatment of Decompression Sickness.
Rapid recompression Therapy, in which the individual is compressed to pressures greater than 1 Atmosphere in
order to promote dissolution of the Nitrogen bubbles. In the aviation environment, rapid descent achieves this to
a great extent. After landing the aviator is to be kept under surveillance of the medical authorities for a period of
observation for 12-24 hours. This period is essential, as most cases of post-decompression collapse manifest in
this period. If the symptoms / signs persist, recompression therapy in a Rapid Recompression Chamber (RRC) is
indicated. Individuals should be evacuated to the nearest RRC facility by means of Heptr / Tpt aircraft ensuring
that the cabin altitude is not allowed to exceed 300 m (1,000 ft) of the base altitude during the entire sortie.
Recompression protocol in the lines of the standard US Navy Diving table No. 6, 6A or 7 is to be followed.
(g) Conclusion.
Decompression sickness is a potentially serious condition, which is associated with flying at cabin altitudes above
7,500 m (25,000 ft) (lower in some cases). This condition must be kept in mind after loss of cabin pressure.

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Cases of decompression sickness should be treated energetically and placed under medical surveillance as soon
as possible.

11.9 Hyperbaric Medicine.

(a) Introduction.
The need for air as one of the prime requisites for maintenance of life of all living beings was recognized many
years back. In 1662, Henshaw designed a chamber in which acute disease could be treated with increased
pressure of air. Priestley isolated oxygen in 1775.
Interest in using increased pressure of air for treatment hastened as technical progress provided means by which
man could work under increasing pressures in caissons, tunnels and diving bells. Scores of chambers were built
in Canada, Europe and the United States in early part of this century. Oxygen did not qualify for therapeutic use
until 1920‘s simply because it was not available in sufficient quantity. The role of oxygen when administered at
increased pressure conditions is only now well understood.
It was in the mid 50‘s that Hyperbaric Oxygen (HBO) was introduced in clinical practice after the pioneering
efforts by Borema (in Holland) and Illingworth in UK. Since 1955, there has been widespread use of oxygen
under pressures greater than 1 atmosphere as therapeutic adjuvant for many clinical conditions.
The use of high oxygen pressures in cardiac surgery was also proposed in 1955 on the principle that drenching
patients with oxygen should prolong the tolerance of the myocardium muscle and brain to circulatory arrest. The
concepts of using HBO initially arose from the fact, that by this procedure, one could provide a larger amount
of oxygen to the affected tissues, due to the increased volume of oxygen dissolved and the increased oxygen
tension in the blood. Hence, its use was mainly for those diseases consequent to ischemia. The constraints
of cost, specialized equipment and hazards have been the limitations in its use. It was started at the IAM IAF,
Bangalore in 1967 and a second center followed shortly thereafter in Mumbai, (INHS Asvini).
(b) Physical and Physiological Basis of Hyperbaric Therapy.
The actual mechanisms of HBO are varied and include the following:
(i) Effects due to increased pressure.
(ii) Effects due to increased Oxygen in the blood stream, tissues and cells.
Effects due to increased pressure are best used in disorders resultant from pressure inequality, where pressure-
volume changes of gases are of paramount importance in treatment e.g. DCS, Air Embolism. The physiological
basis for HBOT is a combination of various fundamental responses to Oxygen at increased pressures. Three
areas need consideration because important reactions take place in these regions. These are:
(i) The lungs.
(ii) The blood.
(iii) The tissues.
The three gas laws, which control and influence these reactions, are:
(i) Boyle‘s Law which relates gas volume inversely to pressure.
(ii) Dalton‘s Law defining the partial pressure of a constituent gas in a mixture of gases.
(iii) Henry‘s Law, which quantifies the volume of gas going into solution.
These laws provide the physical basis of Hyperbaric Oxygen Therapy. By themselves, they do not explain the
elevation of oxygen tension in the whole body. The increased oxygen-carrying capacity of blood is affected by:
(i) Factors affecting lung diffusion.
(ii) Properties of haemoglobin.
(iii) Rates of oxygen uptake and blood flow.
(iv) Uncertainties concerning the diffusion of oxygen from capillaries into tissues.
(v) Alveolar Oxygen Pressure.

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Sea level atmospheric pressure = 760 mm Hg, PH2O at 37º  C is 47 mm Hg, PACO2 = 40 mm Hg. If one were
to breathe 100% O2 at sea level then the alveolar partial pressure of oxygen (PAO2) would be 673 mm Hg.
(c) Alveolar Gas Tension of Oxygen when Breathing 100% Oxygen at Increasing Pressures.
In the alveoli, pulmonary capillary blood removes oxygen and adds carbon dioxide in amounts governed by the
metabolic activity of the body. With normal ventilation, the partial pressure of oxygen is 103 mm of Hg, PCO2
being 40 mm Hg and the PN2 being 570 mm of Hg. While breathing at one atmosphere, on switching over to
100% oxygen, there is a rapid rise in the alveolar partial pressure of oxygen. Initially, nitrogen washout takes
place at an exponential rate dropping alveolar nitrogen pressure to negligible levels. The values for alveolar gas
compositions while breathing 100% O2 at 1 atmosphere, 2 atmospheres and 3 atmospheres are given in Table
11.10.
(d) Oxygen Uptake in Lungs.
Oxygen Uptake. With increasing alveolar PAO2 oxygen transfer gets affected i.e. the process is limited by the
process of auto regulation. This limitation in oxygen transfer, results in larger Alveolar-Arterial PO2 difference
reaching as high as 100 mm of Hg at 3 to 4 atmospheres of inspired oxygen pressure. This is responsible for
the smaller than expected rise in arterial oxygen content. The reasons forwarded for such limitations of oxygen
uptake are:
(i) As the PAO2 increases there is a greater amount of blood that is shunted in the bronchial vessels.
(ii) V / Q i.e. Ventilation perfusion inequality increases decreasing diffusion.
(iii) Probable Atelectasis of the small lung units develops.
With rise in pressures of inspired oxygen from 1 to 5.5 ATA, a progressive decrease in pulmonary diffusion
becomes evident (as revealed by lowered diffusion constant for CO and Hb under high oxygen tension) but this
fact does not in itself explain the observed interference with trans-pulmonary oxygen uptake.
Table 11.10 : Values for Alveolar Gas Compositions
Breathing Air Breathing Oxygen
1 ATA 1 ATA 2 ATA 3 ATA

PN2 570 0 0 0

PH2O 47 47 47 47

PCO2 40 40 40 40

PO2 103 673 1433 2193

PB (Total) 760 760 1480 2280
PSIg 0 0 14.7 29.4

Alveolar gas tension (mm of Hg) at 37º  C

Feet (sea depth) from the surface 33 ft = 1 atmosphere, 66 ft = 2 atmospheres etc.
(e) Oxygen Transport in Blood.
One gram of haemoglobin can combine with 1.37 ml of oxygen. The usual O2 carrying capacity of blood (taking
15 gm Haemoglobin as normal) is 20 ml of oxygen / 100 ml of blood (usually expressed at 20 volume percent).
Oxygen in solution = 0.0237 ml / ml of blood = 0.3 ml / dl.
By increasing the partial pressure of oxygen the quantity of oxygen in the dissolved form increases. Thus
at 3 Atmospheres the amount of oxygen dissolved increases to 6.4 ml / dl. This aspect of oxygen carriage is
made use of extensively in Hyperbaric Oxygen Therapy (HBOT). In clinical conditions characterized by severe
compromise of tissue perfusion / derangement in capability to use oxygen, HBOT becomes very useful as the
primary modality / adjunct.
At normal arterial PO2 of about 100 mm of Hg Haemoglobin is approximately 97% saturated. Increasing the

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PO2 of blood beyond 100 mm of Hg increases oxygen saturation of the Haemoglobin - adding about 0.6 Vol.
% by the time of O2 of approx. 200 mm of Hg is reached. (The accepted co-efficient of solubility for oxygen in
normal whole blood at 37°C is 0.0237 ml of O2 / ml blood / 760 mm of Hg, that is 2.37 ml of O2 / 100 ml of
blood / 760 mm of Hg PO2. i.e. 0.0031 vol. % / mm of Hg). The amount of dissolved oxygen increases linearly
with increasing pressure and at 3 ATA can reach 6.4 vol. %.
(f) Hyperbaric Oxygen Therapy is thus based on the following principles.
(i) Volume of oxygen per unit of blood is increased.
(ii) Increased O2 tension in plasma and thereby in the tissue fluids around the vessels.
(iii) O2 tension gradient from the capillary blood to the metabolizing cells is raised.
(iv) Volume rate oxygen flow (i.e. the amount of O2 perfusing the tissue per min) is raised.
(g) Tissue Oxygen Tensions.
Oxygen molecules reach and enter all body cells and fluids from the capillary blood solely by diffusion and the
difference in PO2 between regions can be viewed as the driving force of diffusion. The number of oxygen molecules
reaching the most distant cells may be barely sufficient for their needs under normal conditions and anything
that reduces the number available, the driving force of diffusion or the effective diffusion distance may produce
cellular hypoxia. Administration of oxygen at high pressure not only increases the number of O2 molecules in the
blood, but the corresponding increase in PO2 greatly increases the ability of O2 to diffuse from the capillaries to
distant cells.
(h) Compression and Absorption of Gas under High Pressure.
One of the oldest applications of high pressure is its use to reduce the volume of gas bubbles in decompression
sickness and air embolism. Recompression is an effective treatment for such cases because high pressure
reduces the size of the bubble, but also aids to their absorption and disappearance.
(j) Oxygen Toxicity.
Inhalation of oxygen at high partial pressure can be harmful if the duration of exposure is more than the latent
period for development of a form of oxygen toxicity. The safe latent period becomes shorter as oxygen pressure
is raised.
(i) Lorraine-Smith Effect (Lung Toxicity).
It is a dose and duration relationship. Oxygen breathed at 250 mm of Hg for periods of up to 30 days in
space has shown no adverse effects. Exposure to 1 atmospheric pressure of 100% oxygen for 24 hours
leads to pulmonary, nasopharyngeal and conjunctival irritation. On the second day, there occurs a reduction
of vital capacity followed by symptoms of bronchiolitis and pain behind the sternum. There is a reduction
in diffusion capacity of lungs of 80% after 48 hours O2 breathing.
(ii) Toxicity on CNS (Paul Bert Effect).
Two types of crises have been described:
(aa) Minor Crisis.
It is characterised by facial pallor, twitching of eye lids and alae nasi, sweating, bradycardia nausea,
dizziness, vertigo, dimness of vision and minor changes in behavior.
(ab) Major Crisis.
It is preceded by minor crisis leading to vertigo, convulsion and collapse. The convulsions are Grand
Mal type. The tonic phase which may last for about 30 seconds is followed by clonic movements for
about one minute.
There are wide individual variations in tolerance to HBO. O2 at 2 ATA for periods up to 3 hours
produces no fits. In one study, convulsions were seen in 2 out of 4 cases on breathing 100% oxygen
for 44 min. at 3 ATA. Oxygen at 5-7 ATA causes convulsions in 4½ min.

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(iii) Mechanism.
Hyperbaric Oxygen exposures are well known to cause toxic effects. The mechanisms of Oxygen toxicity
have been proposed to involve:
(aa) Increased production of intracellular reactive oxygen species.
(ab) Alterations of oxidative process.
(ac) Inactivation of intracellular enzymes.
(ad) Changes in the cortical amino acid and ammonia levels.
These changes are generally attributed to the reaction between the Free Radicals of Oxygen (FRO) and
cellular components. A free radical is defined as an atom, an ion, a molecule with an unpaired electron
in the outer orbit and oxygen free radicals are products resulting from the normal oxireductive process
of the cell. When one, two or three electrons are added to oxygen the resulting species are superoxide
anion (O2–), hydrogen peroxide (H2O2) and hydroxyl radical (OH) respectively. Of these, the first and third
are free radicals and the second can react to generate radicals. In hyperoxic condition their production
notably increases. Most free radicals are highly reactive, due to their tendency to add an electron to the
unpaired one. These highly reactive metabolic products of oxygen may inhibit cellular enzymes, damage
DNA or destroy lipid membranes causing oxidative injury.
Free radicals are continuously produced in the cells that use oxygen, so these cells must possess an
adequate defense system. The defense system consists of first line enzymatic mechanism and second line
non-enzymatic mechanism. In addition to this enzymatic defense system, cells contain substances that are
capable of breaking the free radical chain reaction. Such agents called Scavengers encompass vitamin E
(Tocopherol), vitamin C (Ascorbic acid), vitamin A (Beta carotene) and glutathione. These can eliminate both
oxygen and non-oxygen free radicals.
(iv) Enzymatic Defence Mechanism.
(aa) Enzyme Super Oxide Dismutase (SOD) and several subtypes of SOD Catalase. H2O2 is reduced
by catalase to water and oxygen molecule.
(ab) Selenium containing enzyme glutathione peroxidase. The small quantity of H2O2 formed in the
cytoplasm is reduced by Selenium containing enzyme glutathione peroxidase that converts reduced
glutathione to oxidized glutathione.
(v) Secondary Defenses.
(aa) Phospholipase mediated removal of damaged fatty acid moieties.
(ab) Proteolytic enzymes mediated removal of oxidatively altered proteins. This process prevents the
accumulation of altered and damaged proteins in the cell.
(vi) Simple Monosaccharide Radicals and Other Defenses.
(aa) Vitamin E.
(ab) Vitamin C - Functions in an aqueous environment. It is a reducing and antioxidant agent. It
reacts with O–2 and OH and various lipid hydro-peroxides. It restores antioxidant property of oxidized
Vitamin E. Thus, major function of Vitamin C is to recycle Vitamin E radicals. As an antioxidant Vitamin
C exerts a sparing effect on the antioxidant actions of Vitamin E and Selenium.
(k) Indications of HBO Therapy.
The role of HBO therapy in such acute conditions like Decompression Sickness, Carbon Monoxide poisoning, Air
embolism and Gas gangrene are well documented. Beneficial results have also been noted in cases of acute
ischaemia of limb, myocardial infarction, ischemic strokes, sudden deafness and cerebral oedema following
head injury. The chronic ailments where HBO therapy has been found useful include peripheral vascular disease,
indolent ulcer, chronic osteomyelitis, diabetic gangrene radionecrosis, malignancy and neurological disorders. The
beneficial use of HBO therapy in chronic diabetic ulcers and multiple sclerosis have been reported.
The action of HBO is direct as well as indirect. The increased oxygen content in the affected tissue may be
beneficial directly as in many cases of peripheral vascular disease. Increase PO2 can bring about improvement

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in infections, especially of anaerobic etiology. Elevated tissue PO2 in tumor cells following HBO enhances the
effects of chemotherapy and radiation therapy.
The observation that HBO increases fibroblastic and osteoblastic activity, neovascularisation, formation of
granulation tissue and epithelialization, has been the reasons for its use in chronic skin ulcers, refractory
osteomyelitis, certain fractures and radionecrosis.
Some of the beneficial effects are not so direct but are results of changes brought about either in metabolism
or immunological status. It has been noted that HBO has an immuno-suppressive effect. Experimental work on
animals has shown depression of macrophages, cell mediated immunity and reduction in circulating leukocytes,
similar findings in human beings, however has not been conclusively proved.
(l) Currently Accepted Applications of HBO Therapy are as Follows.
(i) HBO is used commonly as major therapy compound in the treatment of
(aa) Decompression sickness.
(ab) Gas embolism.
(ac) Carbon Monoxide poisoning.
(ii) HBO is used as an adjunctive treatment in:
(aa) Gangrene / Necrotizing fasciitis.
(ab) Non healing ulcers.
(ac) Cyanide poisoning.
(ad) Peripheral vascular disease.
(ae) Frost bite.
(af) Crush injuries.
(ag) Tissue infection.
(ah) Compromised skin grafts.
(aj) Selected wound healing enhancement.
(ak) Soft tissue necrosis.
(al) Acute and refractory cerebral oedema.
(am) Selected thermal burns.
(iii) Research is on to determine potential positive effects of HBO when treating a variety of other conditions:
(aa) Spinal cord injury.
(ab) Non-irradiated bone grafts.
(ac) Acute cerebro - vascular accidents.
(ad) Hansen‘s disease.
(iv) A few important indications are discussed:
(aa) Carbon Monoxide Poisoning.
HBO appears to be the treatment of choice, if available. Oxygen administered at 2.5 to 2.8 ATA reduces
the amount of tissue hypoxia mainly by increasing the dissolved oxygen in plasma. High oxygen tension
also increases the CO (carbon monoxide) elimination. Cardiac arrhythmia and sequelae are rare after
HBO therapy. Oxygen treatment should be started as soon as possible after intoxication.
(ab) Gas Gangrene.
HBO is a valuable adjunct to antibiotic, supportive measures and surgery. Advantages are seen
in saving both life and tissue when compared to conventional treatment and this fact has been

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consistently reported. Important effects noted are:

O Alpha toxin production is suppressed.
O PO2 levels of 1400 mm Hg are bacteriostatic and prevent spread of infection in tissues.
A multi-place chamber could be of advantage where a surgeon - anesthesiologist - nurse team could
render comprehensive care simultaneously with HBO therapy. It is advisable to have the first exposure at
the earliest. The protocol of therapy is: First 24 hours to 48 hours – two / three exposures of HBO at 2.8
ATA for 90 minutes. Thereafter, HBO at 2.8 ATA for 90 minutes daily / twice daily depending on response.
A total of 10-12 exposures are given. This will improve the general condition and suppress the
production of the toxins. Surgical toilet should be undertaken thereafter 2 exposures a day.
(ac) Decompression Sickness and Aero Embolism.
HBO is treatment of choice in all types of Decompression Sickness. Decompression Sickness
manifesting with neurological signs and symptoms needs immediate compression to 6 ATA. Various
compression schedules are available depending on the severity of illness; US Navy diving schedules
for DCS Tables 6, 6a and 7 are used.
(ad) Burns.
HBO reduces oedema and plasma loss. Secondary infection is controlled and healing is accelerated.
Graft failures are minimized. HBO should be given before and after the graft. HBO at 2.5 ATA daily
for 90 minutes for 15-20 exposures (till the graft takes up) is the usual schedule.
(ae) Tetanus.
HBO restricts the growth of Clostridium tetanii and reduces its number. Some claim that it also helps
in neutralizing toxin fixed to anterior horn cells. In the chamber, the number of spasms decreases
and the gap between convulsions increases. The amount of exhaustion is also reduced.
(af) Peripheral Vascular Disease.
HBO helps in carriage of oxygen. Enhanced oxygen carriage through tissue fluids and blood, to distant cells,
ameliorates the condition. Individuals treated with vasodilators and lumber sympathectomy improves with
HBO. Many patients having rest pains, intermittent claudication, venous ulcers and gangrenous changes
have been treated using HBO with beneficial results. With HBO, the following have been documented:
O Venous and other ulcers healed.
O Patients report an increase in the claudication distance.
O Improvement is noticed in temperature gradient in the affected limb. Therapy with HBO
usually involves exposure to 2.5 ATA for 90 minutes for a minimum of 10 days.

11.10 Flying at High Altitude.

(a) Introduction.
High altitude (HA) areas are defined as areas at altitudes equal to or greater than 2,700 meters above mean
sea level. At this altitude and beyond, alterations in human physiological function become apparent. The alveolar
partial pressure of oxygen (PaO2) at 2,700 meters is about 60 mm Hg and the corresponding arterial oxygen
saturation (SaO2) is 90%. An estimated 30 million people worldwide are permanent residents at altitudes
greater than 2,700 meters. The HA environment presents a number of challenges to the human body. Recent
evidence indicates that High Altitude Pulmonary Oedema (HAPO) at moderate altitudes (1,400 to 2,400 m) is
more frequent than usually reported. Among the important HA induced illness are Acute Mountain Sickness
(AMS) and High Altitude Pulmonary Oedema (HAPE), while High Altitude Cerebral Oedema (HACE) is relatively
rare. Ref chapter XIII for effects of high Altitude, pathophysiology and prevention of these conditions.
(b) Operating Schedules for Aircrew for High Altitude Operations.
(i) Operating Schedule from High Altitude for Aircrew for Exposure < 06 Hours (Transiting Aircrew).
(aa) Physical exertion to be barest minimum.

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(ab) Aircrew to breathe 100% oxygen from base altitude to high altitude.
(ac) Aircrew to breathe 100% oxygen the moment he sits in the cockpit for take-off from high
altitude airfield.
(ad) Aircrew to be transported from aircraft to restroom and back by aircrew van.
(ae) Availability of oxygen at aircrew room for breathing oxygen whenever possible during waiting
period of maximum of 06 hours.
(af) Drink water  / fluids and small meals  / fruits during period of transit.
(ag) Plan take off from high altitude to lower altitudes within 6 hours period at altitude.
(ah) Report to MO if any abnormal symptoms are felt like fatigue, breathlessness, cough,
headache, nausea or any type of illness.
(aj) If delayed at altitude by more than 06 hours follow Schedule for detachment aircrew.
(ii) Operating Schedule from High Altitude or Fighter  / Transport / Helicopter Aircrew on Detachment
(Altitude Exposure of > 6 H).
(aa) No flying to be undertaken for the first 48 hours and aircrew to take maximum rest.
(ab) After 48 hours:
O Aircrew to fly familiarization sorties.
O Aircrew to breathe 100% Oxygen from ground and for duration of the sortie.
O Aircrew be transported to the aircraft by aircrew van.
O Physical exertion to be barest minimum.
(ac) Report to MO if any abnormal symptoms are felt like fatigue, breathlessness, cough,
headache, nausea or any type of illness.
(iii) Operating Schedule for all Aircrew for Long Duration Stay in High Altitude Areas.
Aircrew arriving at high elevation bases for detachment or posting are not to fly for first 48 hours. They
are to report for and be cleared by a pre-flight medical examination prior to commencement of flying.
When such aircrews return to air bases at a lower level, their acclimatization is valid for 7 calendar
days i.e. aircrew returning to high altitude within 7 calendar days need not to go through the 48 hours
of acclimatization mentioned above, unless High Altitude Sickness symptoms are noticed.
(c) Conclusion.
To conclude, adherence to acclimatization procedure, avoiding rapid ascent to altitude, maintaining a high degree
of clinical suspicion especially in individuals with pre-existing upper respiratory tract infection and previous history
of HA illness will not only enable reduction in the incidence of HA illnesses but also decrease the morbidity and
mortality due to these disorders.

11.11 Aviation Fatigue.

(a) Introduction.
Fatigue is the state of “Tiredness” that is associated with long hours of work, lack of quality and duration
of sleep or the requirement to work at times that are out of phase with the circadian rhythm of the body.
International Civil Aviation Organization (ICAO) has defined fatigue as a physiological state of reduced mental or
physical performance capability resulting from sleep loss or extended wakefulness, circadian phase or workload
(mental and / or physical activity) that can impair a crew member’s alertness and ability to safely operate an
aircraft or perform safety related issues.
The global economy, societal factors and technological advancements have made the issue of aircrew fatigue
more important than ever before in the aviation community & in the military aviation community. Also, there
is the extension of time of operation, range; owing from advancements in technology like air-to-air refuelling,
use of Night Vision Devices (NVD); mainly to keep the enemy under pressure round the clock, especially in

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theatres far away from one’s home base.

Though fatigue plays a major role in causation of aircraft accidents, the percentage of accidents attributable
to sleep loss / fatigue remains uncertain. It is estimated that fatigue may be involved in 4-7% of civil aviation
mishaps. In the military, the percentage of aircraft accidents arising from Fatigue / Sleep loss is not available
in open forum due to sensitive nature of such information. However, a study of the USAF Safety Centre states
that 25% of the USAF’s Night Tactical Fighter Class A accidents between 1974 and 1992 were attributed
to fatigue and 12.2% of the USN accidents between 1977 to 1990 were fatigue related. Data published in
open scientific literature make it clear that aircrew are susceptible to fatigue because of a variety of factors
including extended duty periods, circadian disruptions, rotating work / rest schedules and travelling across time
zones, unfriendly sleep environment, short lay overs, use of stimulants like caffeine, sustained operations in
the military set up augmented by pharmacological aids if it is not used judiciously.
(b) Effects of Fatigue.
Effective fatigue management requires a sound knowledge of the signs, symptoms and effects of sleep loss
and fatigue.
(i) Physical Signs.
Extreme fatigue leads to physical deterioration. Major physical signs of fatigue and chronic sleep loss
are tiredness, difficulty in keeping the eye open, heaviness of eyelids, watering and frequent blinking,
feelings of sand in eyes, blurring of vision, irresistible sleep, grogginess, slurring of speech, swaying or
postural instability, slower motor response, stiffness & muscle cramp, loss of manual dexterity, difficulty
in making fine motor movement.
(ii) Degraded Mental Processes.
Fatigue disrupts mental processes through confusion, poor concentration, narrowed perception, general
cognitive slowness and forgetfulness. The deterioration in working memory, sensory acuity and motor
speed, which are characteristic of fatigue, may combine to cause degraded vigilance and slowed
responsiveness and prevent reactions demanded by a change in situation.
(c) Non-Pharmacological Countermeasures.
(i) Sleep.
The non-pharmacological countermeasures against fatigue are aimed at ensuring sufficient quality sleep
daily. Sleep hygiene is very important in getting adequate natural sleep. This is the best way to maintain
on-the-job alertness and ensure optimal judgment and concentration.
(ii) Napping.
Well-planned naps can serve maintenance or a recuperative function to attenuate the effects of fatigue
on performance until normal sleep is again possible. This is the best fatigue countermeasure for fatigue
next to 8 hours of consolidated restful sleep. Although napping exerts little or no effect on the circadian
component of sleepiness or fatigue, it can mitigate the general impact of fatigue during circadian “low
points” by reducing overall sleep pressure.
(iii) Rostering.
Schedulers need to set up shift rotations that offer personnel the best possibility for adjusting to new
work / sleep times. Whenever possible, forward or clockwise rotations should be used. This means starting
from morning shift to day shift, evening shift then through to night shift and not the other way around.
This is much easier because such scheduling takes our natural ability to delay sleep until later than
usual as opposed to our fighting our natural inability to fall asleep earlier than usual. This is the reason
why we are able to readjust to westward time zone change than eastward time zone change.
(iv) Behavioral Interventions.
When fighting shift lag or jet lag, it is essential to adjust meal timings, activity and sleep times to the
new schedule. Adjust the timing of sunlight exposure to the new schedule. Try to make sleep environment
congenial for sleep. Do not consume heavy meal or caffeine before going off to sleep. Try exercising
yourself and go for a hot bath prior to retiring to bed.

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(v) Bright Light.

The use of bright light may help to minimize some of the problems associated with schedule changes by
promoting more rapid re-synchronization of the body’s clock to new routines. There is growing evidence
that even bright room lighting (150-300 Lux) can be beneficial.
(vi) Exercise and Diet.
Exercise has been demonstrated to facilitate circadian adaptation. The discomfort associated with being
hungry or having eaten too much may interfere with falling asleep. If one is hungry or thirsty at bedtime,
a light snack or a small drink is preferable. It has been suggested that food rich in carbohydrates (eg.
Legumes, pastas, potatoes) may induce sleep by elevating serotonin levels. Conversely, food high in
protein (eg. Meat, dairy products, eggs) and certain amino acids are likely to produce wakefulness by
enhancing catecholamine activity.
(d) ‘Go’ ‘No Go’ Pills in Indian Air Force.
After prolonged trials regarding the use of stimulants and sedatives, the IAF has authorized the use of
pharmacological compounds (Modafinil and Zolpidem) in the management of alertness and sleep in aircrew
in uncommon, rather exceptional situations wherein the other (non-pharmacological) methods are not feasible.
The relevant Air Staff Instructions (ASI) describes in detail the use of Go pills and No Go pills in the IAF. The
salient features of this instruction are reproduced below:
Indications for Pharmacological Management of Alertness.
(i) During periods of continuous wakefulness exceeding 16 hrs.
(ii) During (planned) Fighter missions longer than 8 hrs.
(iii) During shift work, when a sleep window of 8 hrs has not been made available and the aircrew is
feeling unduly sleepy.
(iv) At the discretion of the Commander in consultation with the Senior Medical Officer (SMO) and
Aviation Medicine Specialist.
‘Go’ Drug (Modafinil).
(i) Modafinil
200 mg is permitted for management of alertness. If required a second dose may be administered after
6 hrs. Not more than 2 such doses are permitted in a week.
(ii) Special Precautions.
Caution is to be exercised by the SMO / Aviation Medicine specialist for aircrew having existing
cardiovascular conditions. Pregnancy is a contraindication for intake of this drug.
(iii) Actions to be Observed Post Flying.
Administration of Modafinil in the above doses will have significant negative effect on the propensity of
the aircrew to go to sleep and also on the quality of sleep. This may affect their further deployment. A
minimum of 12 hrs rest is to be provided before next mission if two doses of Modafinil are administered.
“No-Go’ Drug (Zolpidem).
(i) A single dose of the drug Zolpidem 10 mg is permitted for management of Sleep. For lady pilots
the dose approved is 5mg since higher doses are known to produce untoward side effects in women.
Not more than 2 such doses are permitted in a week.
(ii) Grounding after Zolpidem.
Minimum grounding period of 10 hrs is to be observed following ingestion of Zolpidem.
(iii) Special Precautions.
Aircrew should be advised to observe caution not to mix both the medications and not to carry Zolpidem
in the cockpit. Zolpidem is not to be used concomitantly with alcohol.

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Indications for No-Go Pills.

(i) At times when sleep is difficult to obtain, such as during daytime, prior to a mission, noisy conditions
or when sleeping conditions are less than optimal due to any other reason.
(ii) After operations especially when the aircrew has used Modafinil for alertness management.
(iii) At the discretion of the Commander in consultation with the Senior Medical Officer (SMO) / Aviation
Medicine Specialist.
Authorization & Consent.
For use of any / both the medications i.e. Modafinil and Zolpidem, written authorization by the Commander, in
consultation of the SMO / Aviation Medicine specialist, is mandatory along with consent of the aircrew. After
filling up the authorization and consent forms, this form along with Medical Case Sheet (AFMSF-7) is stored
in the aircrew’s medical records (AFMSF-1). Before administration of these medications, the aircrew is to be
indoctrinated about these medications and ground trial is to be carried out. In case, an individual develops any
adverse reactions or demonstrates any side effects to these drugs during the ground trials, he or she will not
be administered these drugs even for operational requirements.

11.12 Effect of Spaceflight on the Human Body.

(a) Physiological Effects.
Many of the environmental conditions experienced by humans during spaceflight are very different from those
in which humans evolved; however, technology is able to shield people from the harshest conditions, such as
those offered by a spaceship or spacesuit. The immediate needs for breathable air and drinkable water are
addressed by a life support system, a group of devices that allow human beings to survive in outer space.
The life support system supplies air, water and food. It must also maintain temperature and pressure within
acceptable limits and deal with the body’s waste products. Shielding against harmful external influences such as
radiation and micro-meteorites is also necessary. Of course, it is not possible to remove all hazards; the most
important factor affecting human physical well-being in space is weightlessness, more accurately defined as
Microgravity. Living in this type of environment impacts the body in three important ways: loss of proprioception,
changes in fluid distribution and deterioration of the musculoskeletal system.
(b) Space Environment.
The environment of space is lethal without appropriate protection: the greatest threat in the vacuum of space
derives from the lack of oxygen and pressure, although temperature and radiation also pose risks.
(i) Vacuum.
Humans and other animals exposed to vacuum lose consciousness after a few seconds and die of
hypoxia within minutes, but the symptoms are not nearly as graphic as the imagery in the public media
suggests. Blood and other body fluids do boil when their pressure drops below 6.3 kPa (47 Torr), the
vapor pressure of water at body temperature. This condition is called ebullism. The steam may bloat
the body to twice its normal size and slow circulation, but tissues are elastic and porous enough to
prevent rupture. Most spacesuits have internal pressure which is high enough to prevent ebullism and
decompression sickness.
(ii) Temperature.
In a vacuum, there is no medium for removing heat from the body by conduction or convection. Loss of
heat is by radiation from the 310 K temperature of a person to the 3 K of outer space. This is a slow
process, especially in a clothed person, so there is no danger of immediately freezing. Rapid evaporative
cooling of skin moisture in a vacuum may create frost, particularly in the mouth, but this is not a
significant hazard.
(iii) Radiation.
Without the protection of the Earth’s atmosphere and magnetosphere astronauts are exposed to high
levels of radiation. A year in low-earth orbit results in a dose of radiation 10 times that of the annual
dose on Earth. High levels of radiation contribute to the lowered immunity experienced by astronauts.
Radiation has also recently been linked to a higher incidence of cataracts and chance of cancer in

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astronauts. Solar flare events (though rare) can give a fatal radiation dose in minutes. It is thought that
protective shielding lowers the risks to an acceptable level.
(iv) Weightlessness.
Following the advent of space stations that can be inhabited for long periods of time, exposure to
weightlessness has been demonstrated to have some deleterious effects on human health. Humans are
well-adapted to the physical conditions at the surface of the earth and so in response to weightlessness,
various physiological systems begin to change and in some cases, atrophy. Though these changes are
usually temporary, some do have a long-term impact on human health.
(v) Motion Sickness.
The most common problem experienced by humans in the initial hours of weightlessness is known
as Space Adaptation Syndrome (SAS), commonly referred to as space sickness. It is related to motion
sickness and arises as the vestibular system adapts to weightlessness. Symptoms of SAS include nausea
and vomiting, vertigo, headaches, lethargy and overall malaise. The first case of SAS was reported by
cosmonaut Gherman Titov in 1961. Since then, roughly 45% of all people who have flown in space have
suffered from this condition. The duration of space sickness varies, but rarely has it lasted for more than
72 hours, after which the body adjusts to the new environment.
(vi) Bone and Muscle Deterioration.
A major effect of long-term weightlessness involves the loss of bone and muscle mass. Without the
effects of gravity, skeletal muscle is no longer required to maintain posture and the muscle groups used
in moving around in a weightless environment differ from those required in terrestrial locomotion. In
a weightless environment, astronauts put almost no weight on the back muscles or leg muscles used
for standing up. Those muscles then start to weaken and eventually get smaller. Consequently, some
muscles atrophy rapidly and without regular exercise, astronauts can lose up to 20% of their muscle
mass in just 5 to 11 days. Advances in research on exercise, hormone supplements and medication
may help maintain muscle and body mass.
Bone metabolism also changes. Normally, bone is laid down in the direction of mechanical stress.
However, in a microgravity environment, there is very little mechanical stress. This results in a loss of
bone tissue of approximately 1.5% per month especially from the lower vertebrae, hip and femur. Due
to microgravity and the decreased load on the bones, there is a rapid increase in bone loss, from 3%
cortical bone loss per decade to about 1% every month the body is exposed to microgravity, for an
otherwise healthy adult. The rapid change in bone density is dramatic, making bones frail and resulting
in symptoms that resemble those of osteoporosis. To prevent some of these adverse physiological effects,
the International Space Station is equipped with two treadmills (which enable various weight-lifting
exercises that add muscle but do nothing for bone density and a stationary bicycle; each astronaut
spends at least two hours per day exercising on the equipment. Astronauts use bungee cords to strap
themselves to the treadmill.
(vii) Fluid Redistribution.
The second effect of weightlessness takes place in human fluids. The body is made up of 60% water,
much of it intra-vascular and inter-cellular. Within a few moments of entering a microgravity environment,
fluid is immediately re-distributed to the upper body resulting in bulging neck veins, puffy face and
sinus and nasal congestion which can last throughout the duration of the trip and is very much like
the symptoms of the common cold. Orthostatic intolerance results in astronauts returning to earth after
extended space missions being unable to stand unassisted for more than 10 minutes at a time without
fainting. This is due in part to changes in the autonomic regulation of blood pressure and the loss
of plasma volume. Although this effect becomes worse the longer the time spent in space, as yet all
individuals have returned to normal within at most a few weeks of landing.
(viii) Disruption of Senses.
(aa) Vision.
Because weightlessness increases the amount of fluid in the upper part of the body, astronauts
experience increased intracranial pressure. This appears to increase pressure on the back of the

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eyeballs, affecting their shape and slightly crushing the optic nerve. This effect was noticed in
2012 in a study using MRI scans of astronauts who had returned to Earth following at least one
month in space.
(ab) Taste.
One effect of weightlessness on humans is that some astronauts report a change in their sense of
taste when in space. Some astronauts find that their food is bland, others find that their favorite
foods no longer taste as good (one who enjoyed coffee disliked the taste so much on a mission
that he stopped drinking it after returning to Earth); some astronauts enjoy eating certain foods
that they would not normally eat and some experience no change whatsoever. Multiple tests have
not identified the cause and several theories have been suggested, including food degradation and
psychological changes such as boredom. Astronauts often choose strong-tasting food to combat
the loss of taste.
(ix) Stress.
There has been considerable evidence that psychosocial stressors are among the most important
impediments to optimal crew morale and performance.
(x) Sleep.
The amount and quality of sleep experienced in space are poor due to highly variable light and dark
cycles on flight decks and poor illumination during daytime hours in the spacecraft. Even the habit of
looking out of the window before retiring can send the wrong messages to the brain, resulting in poor
sleep patterns. These disturbances in circadian rhythm have profound effects on the neuro-behavioural
responses of crew and aggravate the psychological stresses they already experience.
(c) Environment Control and Life Support System in Spacecraft.
The Environmental Control and Life Support System (ECLSS) for the Space Station performs several functions:
(i) Provides oxygen for metabolic consumption.
(ii) Provides potable water for consumption, food preparation and hygiene uses.
(iii) Removes carbon dioxide from the cabin air.
(iv) Filters particulates and microorganisms from the cabin air.
(v) Removes volatile organic trace gases from the cabin air.
(vi) Monitors and controls cabin air partial pressures of nitrogen, oxygen, carbon dioxide, methane,
hydrogen and water vapor.
(vii) Maintains total cabin pressure.
(viii) Maintains cabin temperature and humidity levels.
(ix) Distributes cabin air between connected modules.
(d) Evolution.
Earth’s natural life support system provides the air we breathe, the water we drink and other conditions that
support life. For people to live in space, however, these functions must be done by artificial means. The life
support systems on the Mercury, Gemini and Apollo spacecraft in the 1960s were designed to be used once
and discarded. Oxygen for breathing was provided from high pressure or cryogenic storage tanks. Carbon
dioxide was removed from the air by lithium hydroxide in replaceable canisters. Contaminants in the air were
removed by replaceable filters and activated charcoal integrated with the lithium hydroxide canisters. Water
for the Mercury and Gemini missions was stored in tanks, while fuel cells on the Apollo spacecraft produced
electricity and provided water as a byproduct. Urine and waste-water were collected and stored or vented
overboard. The Space Shuttle is a reusable vehicle, unlike those earlier spacecraft and its life support system
incorporates some advances. But it still relies heavily on the use of consumables, limiting the time it can stay
in space. The International Space Station includes further advances in life support technology and relies on
a combination of expendable and limited regenerative life support technologies.

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(e) Water (Water Recovery System).

The Water Recovery System provides clean water by reclaiming wastewater, including water from crewmember
urine; cabin humidity condensate; and Extra Vehicular Activity (EVA) wastes. The recovered water must meet
stringent purity standards before it can be used to support crew, EVA and payload activities. The Water Recovery
System is designed to recycle crewmember urine and wastewater for reuse as clean water. The Water Recovery
System consists of a Urine Processor Assembly (UPA) and a Water Processor Assembly (WPA). A low-pressure
vacuum distillation process is used to recover water from urine. The entire process occurs within a rotating
distillation assembly that compensates for the absence of gravity and therefore aids in the separation of
liquids and gases in space. Product water from the Urine Processor is combined with all other wastewaters
and delivered to the Water Processor for treatment. The Water Processor removes free gas and solid materials
such as hair and lint, before the water goes through a series of multi-filtration beds for further purification.
Any remaining organic contaminants and microorganisms are removed by a high-temperature catalytic reactor
assembly. The purity of product water is checked by electrical conductivity sensors. Unacceptable water is
reprocessed and clean water is sent to a storage tank, ready for use by the crew.
(f) Oxygen Generation System.
The Oxygen Generation System produces oxygen for breathing air for the crew and laboratory animals, as well
as for replacement of oxygen lost due to experiment use, airlock depressurization, module leakage and carbon
dioxide venting. The system consists mainly of the Oxygen Generation Assembly (OGA) and a Power Supply
Module. The heart of the Oxygen Generation Assembly is the cell stack, which electrolyzes or breaks apart,
water provided by the Water Recovery System, yielding oxygen and hydrogen as byproducts. The oxygen is
delivered to the cabin atmosphere while the hydrogen is vented overboard. The Power Supply Module provides
the power needed by the Oxygen Generation Assembly to electrolyze the water. The Oxygen Generation System
is designed to generate oxygen at a selectable rate and is capable of operating both continuously and cyclically.
Carbon Dioxide Reduction Assembly (CReA) will cause hydrogen produced by the Oxygen Generation Assembly
to react with carbon dioxide removed from the cabin atmosphere to produce water and methane. This water
will be available for processing and reuse.
(g) Future.
Ultimately, expendable life support equipment is not suitable for long-duration, crewed missions away from low
earth orbit due to the resupply requirements. It is expensive to continue launching fresh supplies of air, water
and expendable life support equipment to the Station and returning used equipment to Earth. On deep space
missions in the future, such resupply will not be possible due to the distances involved and it will not be possible
to take along all the water and air required due to the volume and mass of consumables required for a voyage
of months or years. Regenerative life support hardware, which can be used repeatedly to generate and recycle
the life sustaining elements required by human travelers, is essential for long duration trips into space.

11.13 Anthropometry in Aviation.

(a) Definition.
The science of human measurements, includes measurement of the body dimensions and other physical
characteristics of the body like volumes, center of gravity, inertial properties and mass of body segments.
(b) Types of Anthropometry.
(i) Static (Anatomical).
It concerns the measurement of the fixed structural dimensions of the body and it is made between two
specific anatomical landmarks. It measures skeletal dimensions- like height, contour dimension- biceps
girth.
(ii) Dynamic (Functional).
Dimensions are taken under conditions in which the body is engaged in some activity e.g. clearance,
reach, range of movements, of joints and strength of various actions.
(c) Application of Anthropometry in Aviation.
(i) Selection of right candidate for pilot training keeping in view aircrew–aircraft compatibility.

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(ii) Designing of cockpit.

(iii) Cockpit evaluation of aircraft procured from other countries.
(iv) Designing of ejection systems and instrument panels.
(v) To improve comfort and convenience of aviation related personnel.
(vi) For improving logistic efficiency.
(vii) Aircraft accident investigation - Identification of body.
(viii) To measure the range and force of movements of different joints for cockpit operations.
(ix) Evaluation of orthopedic disability and determined employability.
(x) Design of the correct-sized flying clothing for aircrew.
(d) Reaches and Clearances.
Anthropometry plays a key role in determining reaches and clearances during aircrew-aircraft compatibility
assessment. For the larger percentile aircrew, clearances from all cockpit structures are of vital importance,
keeping in view the possibility of injuries during assisted escape.
Smaller percentile pilots should be able to reach all aircraft controls while harnessed and should also have
an adequate over-the-nose vision to enable safe operations during all stages of flight.
(e) Current Practice of Anthropometry in IAF.
Presently 57 different measurements are taken by IAM developed anthropometric platform. Of them, four are
crucially important for selection of pilots to ensure aircraft-aircrew compatibility.
Table 11.11 : Anthropometric Range for Aircrew Aircraft Compatibility
Min in cms Max in cms
Standing Height 162.50 --
Sitting Height 81.50 96.00
Leg Length 99.00 120.00
Thigh Length -- 64.00

For officers and airmen who apply for aircrew duties, other than F(P), FTE duties and System Operators of Su
30, the minimum height will be 157.5 cm. Any relaxation of other anthropometric variables in aircrew will be
strictly by waiver of DGMS (Air).
For female candidates, the minimum height acceptable for various branches is as follows:
(i) Flying Branch - 162.5 cm.
(ii) Other Branches - 152 cm.

11.14 Aviation Pathology in Accident Investigation.

(a) History of Aviation Accident Pathology.
In 1908 Lt Thomas Selfridge was killed in an air accident. The autopsy revealed the death was due to a head
injury, subsequent to which the use of helmet in aviation started. This was the first application of aviation
accident pathology. In 1943, for the first-time medical professionals were included as a part of the investigation
of air crashes. Teare in 1951 published a report on autopsy findings of 28 persons killed in a Viking aircraft
accident. He carried out the reconstruction of events within the passenger compartment and appraisal of
safety equipment available on board. In 1955 Armstrong investigated the Comet disaster and concluded that
the deaths of passengers were due to sudden decompression. This was further compounded by the engineer’s
team, who found a technical fault in the windows of the aircraft leading to structural modification in the aircraft.
Hence aviation pathology plays a vital role in improving flight safety.

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(b) Development of Aviation Pathology in India.

Aviation Pathology cell was established as a part of Department of Pathology, AFMC, Pune in 1959 and
later moved to Institute of Aviation Medicine, then called School of Aviation Medicine, IAF in 1968 and The
Department of Aviation Pathology was started.
(c) Objectives.
Squadron / Unit Medical Officers in IAF have additional responsibility for aircraft accident investigations to
promote flight safety. The paragraphs given below are aimed to apprise MOs on various aspects of Aviation
Pathology, their role in accident investigation, investigating procedure of fatal aircraft accidents, collecting as
much evidence / information as possible, carrying out correct and detailed documentation, help pathologist
during autopsy, collect and dispatch specimens for histological and biochemical / toxicological examination.
(d) Purpose of Aircraft Accident Investigation.
(i) Primary Purpose.
(aa) Prevent future accidents.
(ab) Prevent future injuries.
(ac) Prevent future fatalities.
Hence, a thorough investigation of injuries sustained and circumstances of mishap is a must.
(ii) Secondary Purpose.
(aa) Identification.
(ab) Ruling out sabotage.
(ac) Documentation.
(ad) Ensuring smooth and efficient interstate movement.
(e) Definition of Aviation Pathology.
The comprehensive study of all Aviation fatalities whereby medical history of the casualty and the findings at
postmortem can be correlated with the environmental factors; structural and other damages to aircraft; use or
abuse of equipment; role of pre-existing sub clinical disease if any so that a complete picture of the accident
may be formed. The main object is the reconstruction of fatal accidents.
(f) Autopsy in Fatal Accident.
The aim of an autopsy in a fatal aircraft accident is to correlate the findings with the medical history / environmental
factor / structural damage. It should be carried out without delay before decomposition.
(g) Authority for Holding Autopsy.
The authority to order an autopsy is vested in the Stn Cdr / Sqn Cdr of the unit of the deceased. There is no
requirement for an inquest from police. The Govt of India, authority dispensing away with the requirement of
a police inquest to be handed over to the police. A copy of this letter is given in IAP 4305.
(h) Who should Perform Autopsy.
(i) Aviation pathologist.
(ii) Service pathologist.
(iii) Civilian pathologist.
Ideally, it should be carried out by an Aviation Pathologist or a Service pathologist in the local service hospital.
If either of the two is not available, the civil surgeon must carry out the autopsy. However, in all such cases an
Air force medical officer must be present during the autopsy to guide the pathologist about the requirements
of Air Force. Details are given in IAP 4305.
(j) Where Should Autopsy be Carried Out.
After collection of evidence at the accident site and photographic records have been taken, the human remains

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have to be shifted to the nearest Armed Forces or civil hospital mortuary.

(k) Information Required by the Pathologist.
The pathologist requires certain information to make meaningful inferences from his autopsy findings. The
information generally pertains to the man, the machine and the mission.
Man. Aircrew category / age of aircrew / past illness / medical category / experience etc.
Machine. The type of aircraft flying, the track record of the performance of aircraft. Servicing history, snag
history and the capabilities of the aircraft.
Mission. The type and nature of mission sortie and the likely effects of the ac maneuvers on the pilot.
Information about the weather can also be useful.
Aims of Postmortem.
(i) Reconstruction of an accident.
(ii) To establish cause of crash.
(iii) To evaluate effect of environmental stress.
(iv) To evaluate Injuries - Ante mortem / post-mortem.
(v) To ascertain presence / absence of pre-existing disease.
(vi) Examination of clothing / personnel equipment.
(vii) To assess presence of burns / foreign bodies.
(m) Correlation of Medical History of Casualty and Autopsy Findings.
It is important for the pathologist and the aviation medicine specialist to collate the evidence garnered from
the accident site as well as the evidence given by the witnesses and the findings on the autopsy table. The
important correlations to look for are:
(i) Environmental factors e.g. Hypoxia, carbon monoxide exposure, toxic fumes, decompression etc.
(ii) Correlation of injuries vis-à-vis structural and other damage to aircraft.
(iii) Correlation of injuries vis-à-vis use or abuse of safety equipment e.g. Ejection seat, protective
helmet, harness etc.
(iv) Role of pre-existing sub-clinical disease if any.
Apart from the postmortem examination, a complete photographic record has to be maintained along with an
X-ray of whole body to assess fractures and foreign bodies. The personnel clothing / equipment after examination
is to be sealed in a plastic bag and handed over to the Unit authorities  /  COI.
(n) External Examination of Body.
(i) Size / location of injuries- abrasion / laceration.
(ii) Imprints of harness / straps.
(iii) Burns- percentage of burns, degree of burns.
(iv) Helmet / shoes- examination.
(o) Internal Examination Body.
Head & Neck.
(i) Fractures  /   injuries  /   pre-existing disease, cerebral aneurysm.
(ii) Ante-mortem subconjunctival hemorrhage.
(iii) Fracture around foramen magnum.
(iv) Burns, explosive fracture of skull.

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Neck & Thorax.

(i) Vertebral & rib fractures- ejection landing.
(ii) Fracture sternum-posterior aspect - hyper flexion.
(iii) Heart
(aa) Posterior laceration-deceleration.
(ab) Infarcts.
(ac) Coronaries.
(ad) Septal defects.
Burns.
(i) Larynx, tracheobronchial tree: soot.
(ii) Larynx- oedema- inhalation of toxic fumes.
Abdomen.
Tear of mesentery / contusion of bowel - lap belt injury.
Stomach.
(i) Laceration  /   ulceration.
(ii) Pre-existing pathology in organ.
Pelvis.
(i) Dislocation of symphysis pubis-wind blast.
(ii) Fracture ischial tuberosity-ejection.
Extremities.
Fractures- direction of force.
Hands.
(i) Contusion of thenar muscles & injuries to metacarpophalangeal joints especially to index finger.
(ii) Pilot still holding controls at time of crash.
Once the autopsy is completed and after extensive photography has been taken, the body is stitched and
handed over to the necessary authorities.
(p) Collection Preservation Storage & Dispatch of Postmortem Specimens.
Generally 1 cm thick pieces - weighing 100 gm to be collected
Brain.
(i) Cerebrum - Coronal section.
(ii) Cerebellum - Coronal section.
(iii) Mid-brain including medulla oblongata.
(iv) Pituitary.
Respiratory Tract.
(i) Pieces of trachea / pieces of bronchi - to be sent whole in case bodies are associated with burns.
(ii) Pieces from each lobe of lung - 5 pieces.
Aorta, Heart and Thyroid. As a whole-open chambers.
Skin. In case of burns.

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Abdomen.
(i) Pieces of stomach
(ii) Pieces of intestines
(iii) Liver
(iv) Kidney
(v) Adrenals
(vi) Pancreas
(vii) Spleen
Container.
0.005 gauge polyethylene plastic bags 40 cm × 25 cm
Preservation.
5-10 times the volume of formalin added
40 ml formalin + 3.6 gm NaCl + 360 ml tap water – 10% soln
Dispatch.
Each bag placed in another bag - proper label attached to each bag giving personnel details, Organ and Date
of collection. All bags are placed in a cardboard box.
Dispatch Sent to.
Dept. of Aviation Pathology IAM, Vimanapura Bangalore - 560017
Remember.
Never send by Post / SDS. To be send with escort.
Copy of detailed autopsy report must accompany specimen.
(q) Aviation Toxicology.
The flying process involves the interaction between man and the machine and it is not only the equipment
failure, but also the performance impairment and / or abnormal behaviour of aviators that might contribute to
an accident. The performance / behaviour-related changes in aviators may be because of the presence of foreign
substances in their system. The detection of such performance-impairing substances in the pilot blood, urine
or tissue is called Aviation Toxicology. Internationally this stream is called as Performance Related Post-Mortem
Aviation Toxicology (PRPMAT). The Department of Aviation Toxicology (DAT) caters to Aviation related samples
for accident investigation. The protocols of all the drugs have been standardized, validation of protocols on
clinical samples and evaluation of autopsy samples is being done.
(r) Conclusion.
The availability of crucial material evidence to establish cause(s) in a fatal aircraft accident is of paramount
importance. Correlation of autopsy findings with a medical history of the aircrew, environmental factors,
structural damage of the aircraft and use and abuse of safety equipment provided in the aircraft is an integral
part of the aircraft accident investigation. The Toxicology Lab at IAM Bangalore is the only centre where such
an analysis is done in IAF. It is therefore important that the samples collected after conduct of autopsy are
preserved and transported under ideal conditions so that the tissue does not deteriorate and result in the loss
of important material evidence to the investigation. Station authorities as mentioned in this guideline must
coordinate all activities as entrusted to them and integrate them with SOPs in their post-accident plans.

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Table 11.12 : Specimens for Toxicological / Biochemical Examination

Anticoagulant / Storage &
Study Sample Quantity
Preservative Dispatch
Toxicological
Carbon monoxide (i) Blood 5 ml NaF 10 mg/ml/EDTA 2-8º  C
(ii) Muscle 150-200 gm Frozen
Ethanol (i) Blood 5 ml NaF 10 mg/ml 2-8º  C
(ii) Urine 5 ml Nil 2-8º  C
(iii) Vitreous Humour 2-3 ml Nil 2-8º  C
(iv) Liver 500 gm Nil Frozen
(v) Spleen 150 gm Nil Frozen
(vi) Kidney 100 gm Nil Frozen
Drug Assay (i) Blood 25 ml NaF 10 mg/ml 2-8º  C
(ii) Urine 5 ml Nil 2-8º  C
(iii) Liver 500 gm Nil Frozen
(iv) Spleen 150 gm Nil Frozen
(v) Kidney 100 gm Nil Frozen
Biochemical
Lactic acid estimation (In case (i) Brain 150-200 gm Frozen
where hypoxia is suspected)
(ii) Plasma# 2-5 ml NaF 10 mg / ml 2-8º  C
Blood glucose (in case where (i) Blood 5 ml NaF 10 mg / ml 2-8º  C
hypoglycemia is suspected) (ii) Vitreous Humor 2-3 ml Nil 2-8º  C
[Note 1: # Blood collected in NaF is to be centrifuged at 3000 rpm for 10 min and supernatant plasma separated
and sent at 2-8º  C.
Note 2: Blood, urine and vitreous should not be frozen]

11.15 Airline Hygiene.

Commercial aviation with its ever-expanding sphere has become an integral part of modern life and with it, has come
the importance of flight safety arising out of ‘Airline Sanitation’. The ‘Airline Sanitation and Air Safety,’ can be divided
into three basic divisio as regard to mode of spread of infection, namely:
(i) Food-borne & water-borne (i.e. Food sanitation)
(ii) Disposal of waste (i.e. food waste, dry waste & human waste)
(iii) Transmission of infection by flying insects & rodents (pest control)
Food-borne illness is the most important aspect of civil airline hygiene regarding the severity and legal implication,
along with subsequent fallout to the civil airliner.
(a) Air Safety & Food Sanitation.
A paraphrase of Article 14 of the International Health Regulation (1969) requires every airport to be provided
with pure drinking water and wholesome food supplied from sources approved by the Health Administration
for public use and consumption, either on the airport premises or on-board aircraft. The food shall be stored
and handled in such a manner as to ensure protection against contamination. The Health Authorities are also

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required to conduct periodic inspections of equipment, installations and premises and the Article also requires
every airport to be provided with an effective system for the removal and safe disposal of excrement, refuse
waste of condemned food, etc. The purpose of Article 14 is, of course, to protect travelers, whether passengers
or crew, against the possibility of food or water-borne diseases and to ensure maximum security against the
possibility of the International spread of such diseases, in accordance with the principles and aims of the
World Health Organization. Food-borne illnesses are the most important element of airline hygiene merely by
virtue of the large quantities of food, which have to be provided daily on a worldwide basis.
There are several ways in which poor food hygiene or unsatisfactory disposal of food waste may influence
airline safety, either directly or indirectly:
(i) Sudden Incapacitation or collapse of a member of the operating crew with a short incubation
fulminating type of food poisoning due to bacterial toxins as seen in some staphylococcal infections.
(ii) Subtle incapacitation in one member of the aircrew at a critical phase of flight, as may occur in
cases where there is toxemia prior to the onset of gastrointestinal symptoms, as may occur in cases
where there is toxemia prior to the onset of gastrointestinal symptoms, as may occur in food poisoning
with some marine organisms or biotoxins.
(iii) Bird strikes or jet ingestion of birds at the time of landing or take-off, these scavenger birds having
been attracted to the airfield by insufficient or unhygienic disposal of aircraft wastes.
(iv) Rats may also be attracted by insufficient disposal of aircraft wastes and irrespective of their
ectoparasites being vectors of diseases, rats may gain access to aircraft and damage electrical or control
conduits.
(v) An acute outbreak of food poisoning affecting a significant number of passenger loads, while in
itself an acutely embarrassing situation may influence the operating aircrew to divert to an alternative
airfield to which they may not be accustomed or where the landing aids are not up to the normal high
standard.
(vi) Where there is open food waste or garbage, flies are attracted and they may contaminate food
being prepared for use in aircraft or in airport restaurants, where crew and passengers take refreshments.
(vii) The International Civil Aviation Organization has also included in their recommended practices,
16th edition, Annex 9 (Facilitation), that the preparation, handling, storage and serving of food for aircraft,
must be hygienically carried out in accordance with the WHO recommendations and the disposal of food
wastes must be of a high standard. Various authorities are concerned with these responsibilities. State
Health Administrations, local health authorities, airport authorities, aircraft caterers, airlines and even
aircraft manufacturers and catering equipment manufacturers.
(b) Importance of Safety Considerations of Food Sanitation in Flight Safety.
(i) Delays to aircraft may occur in transit while any case of suspected food poisoning or communicable
disease is being investigated and this may introduce a fatigue factor, if flight limitations are exceeded.
(ii) To prevent the remote possibility of both pilots being incapacitated at the same time, it is important
that they should have different meals, not only at hotels before reporting for duty but also at airport
restaurants and actually on board the aircraft, as far as this is practicable.
(iii) In addition, it is advisable that certain types of food, which are particularly liable to cause acute
gastrointestinal symptoms, should be avoided, e.g. shell fish.
(iv) Where there is any doubt regarding food requirements, only hot, freshly prepared meals should
be provided. Airline catering is essentially mass catering which requires supply of ready-to-eat food for a
large number of people at the same time or within a short period of time in relation to the number of
people to be fed (WHO 1983). In addition, the following other specific areas are of concern in association
with such catering:
(aa) The food is prepared and stored for varying periods before it is consumed.
(ab) It may be exposed to varied temperatures conducive to bacterial growths.
(ac) The food component may not possess H+(acidity) and AW (water) content that are prohibitive

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to bacterial growth.
(ad) Such food does not necessarily contain chemicals prohibitive to bacteria.
As (iii) and (iv) cannot be controlled properly, the microbiological hazards of catering must be controlled
primarily by product formulation, temperature control, food handlers training and supervision. Further, the
layout of the catering establishment and cleaning and disinfecting procedures have to be scientifically
standardized.
(i) All food handlers employed in aircraft catering units or in airport restaurants or transit
hotels where crew or passengers are accommodated should be medically screened prior to return
to duty after sickness, indoctrinated in elementary food hygiene and comply with any statutory or
other requirements of the state health administration affecting food handlers or food premises.
(ii) Top management of all catering units supplying to air operators should equally be
indoctrinated in the importance of food hygiene. They should enforce kitchen discipline, which
should be geared to the principle that even if a carrier of disease is inadvertently employed as
a member of catering staff, the hygiene measures enforced should be such to ensure that there
is no possible danger to passengers or crew from food poisoning organisms or toxins. Caterers
should be encouraged to set up their microbiological testing programme rather than relying on
the airline.
(iii) Food to be prepared for aircraft meals should be subjected to quality control from the
raw materials to the finished product and samples of prepared meals and water supplies should
be regularly sent for bacteriological and chemical analysis. To avoid growth of food poisoning
organisms cold meals should be stored at room temperature below 10º  C and hot meals above
63°C if maintained hot from the point of cooking to service. Alternatively, hot meals can be blast
chilled to a temperature below 5º  C and then handled as a cold meal. The cold chain must be
continued from the flight kitchen to the aircraft and followed up on board by the storage of food
at room temperatures ranging from 2-7º  C until served. Ovens in the aircraft should be able to
raise the temperature of chilled meals to at least 73º  C.
(iv) Transportation of food to the aircraft could be by using refrigerated lorries or refrigerating
the aircraft trolleys by using solid carbon-di-oxide (dry ice) as slabs, pellets or snow. Hot meals are
delivered to the aircraft either as pre-heated items for smaller aircraft without ovens or as chilled
items to be reheated in electric convection ovens. Safe transportation of pre-heated foods may be
jeopardized should the aircraft departure time is delayed, even though such food would normally
be in polyurethrine boxes which help to maintain the temperature. Samples for microbiological
examination should be taken initially from the end product and then where necessary from raw
materials or from products during processing and handling.
(v) The airlines or health authorities should ensure that there are regular inspections of all
such food premises by hygiene or sanitation officers to ensure compliance with statutory and other
recommendations.
(vi) All cabin staff, as food handlers should be medically screened before employment and after
sickness.
(vii) Should there be passenger or crew complaint regarding any item of food, samples of the
suspect dish should be retained for analysis in a food hygiene laboratory.
(viii) To ensure that any such complaint regarding food is fully investigated, cabin staff in their
voyage reports should make inquires in accordance with a specific questionnaire, so that all
sources of food taken during the previous 24 hrs can be investigated. In this respect, it is most
unusual for only one or two passengers to be affected by food poisoning, if an aircraft meal or
meals provided on the ground are suspect.
(ix) To prevent attracting birds, rats, flies or pariah dogs, every airport or local authority should
ensure the efficient disposal of refuse and food waste.
(x) Aircraft toilet fluids should remain bactericidal at maximum dilution, be constant in
formulation, deodorant, nontoxic and noncorrosive and not interfere with sewage plants. Special

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buildings with soak-aways into the public sewage system should be installed at all airports.
(xi) Ice served to be used in drinks on aircraft or at airport restaurants must be made from
pure chlorinated or chloraminated water and should be hygienically removed from ice machines
by sterile scoop and sealed in cellophane containers prior to use.
(xii) Similarly, all water supplied to aircraft should be potable, so that safe, wholesome water
will be obtained from any cold-water source on board the aircraft.
(xiii) Drinking water on a modern aircraft is stored in stainless steel or reinforced fiberglass tanks,
which are built into the aircraft structure and from which the water is fed by gravity or pumped to
the galleys, sink taps, wash hand basins and drinking points. The water is supplied via a fill point
on the belly of the plane and is fed directly from the main supply by hosepipe or more often by
self-propelled tanker. To avoid infection by contaminated water it is essential that the water supply
point be maintained in a sanitary condition. It must be kept covered and locked away when not
in use and labeled: ‘For aircraft drinking water use only’. Water supply should be purified, with a
system which can readily detect contamination and is simple to use. A treatment with chloramines
is preferable than chlorine as it is more stable and has a longer life than chlorine. Water servicing
is normally be carried out by maintenance engineer and should follow a detailed code of practice.
This requires the regular sterilization of the water bowsers, aircraft tanks and pipelines by hyper
chlorination using residual chlorine at 15 mg per liter of water. Regular microbiological checks of
the water should be carried out.
(c) Airline Food Catering in India.
Different airlines lifts food from various establishments on its worldwide network. Of these, the two Chef Air
Flight Kitchens, one each at Delhi and Bombay are at India. The airline’s Medical Services Department directly
supervises the Chef Air Flight Kitchens: periodic examination of food handlers is carried out stringently as
per WHO recommendations. Every aspect of catering, its storage, preparation and dishing out, is also closely
monitored to achieve the highest standards of food hygiene. The premises of outside agencies’ agents are also
checked by the airlines at random. Food analyses reports are regularly obtained every station from where food
is lifted. APHO has its own highly developed Microbiology laboratory, which follows standard microbiological
methods recommended by WHO and American Society for Microbiology. The food sampling methods are those
recommended by WHO and American Society for Microbiology. The food samples analyzed here in the last few
years show 99-100% acceptability of both raw and prepared food.
(d) Disposal of Waste.
Aircraft waste can be considered as:
(i) Food Waste.
(ii) Dry Waste.
(iii) Human waste.
Food waste leaves the aircraft on the meal trays to ultimately to the flight-catering unit, where it is stripped
and disposed of (e.g. incineration, i.e. whichever the way the local regulation demand). During transportation
to the catering unit and subsequent disposal it should be covered to avoid attracting pests.
Dry waste (paper, peanuts etc.) which is deposited in the passenger cabin during the flight, is collected by
the aircraft cleaners at the end of each sector travel, they are then placed in polythene sacks and disposed
of through the normal airport system of waste product removal procedure.
Human waste is contained in tanks on board the aircraft and the toilets are serviced at each stop. The
tanks are emptied, flushed and refilled to a predetermined level with a mixture of water and an aromatic &
coloured chemical, this is to camouflage the toilet contents. Vacuum toilets now replace large self-contained
toilets of older aircrafts. In these vacuum toilets, which are situated in the tail of the aircraft, making use of
the pressure differential outside the aircraft carries out the flushing. The flush handle on the toilet operates
a valve which causes a vacuum and the toilet contents are sucked down a pipe to the holding tank at the
rear, the small quantity of water, which are added during the flushing processes is mainly to make the whole
procedure aesthetic. Waste is disposed of by discharge into the airport drainage system at a disposal block
provided with wash down facilities and a macerator or coarse screen to remove solids.

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(e) Pest Control.

Rodents like mice, rats and then insects and mosquitoes not only carry disease processes but also cause
damage to the aircraft fabric. The prevention of transmission of illness by insects carried on board the aircraft
is by disinfection of aircraft, as laid down in the International Health Regulation 1969, amended and published
by the World Health Organisation. Regulations states that ‘every aircraft leaving an airport situated in an area
where transmission of vectors borne diseases are occurring or where insecticide resistant mosquito vectors
of the disease are present, shall be disinfected. Two methods of disinfections are currently in use:
(i) Blocks Away
(ii) Residual Insecticide Film
‘Blocks Away’ is a method where disinfecting of the passenger cabin and all other accessible interior space
of aircraft are done except the flight deck, by spraying the cabin space of the aircraft after the doors have
been secured following embarkation and prior to take off. The flight deck, the cargo hold and external areas
such as the wheel wells are to be sprayed by ground personnel before departure of aircraft, with the used
cans again being retained for inspection by the Port Health Authority.
Disinfections by application of Residual Insecticide Film are carried out as part of an engineering procedure
at the base airport of the airline in question. It is designed to provide a film of insecticide covering all internal
surfaces of the aircraft. Any insect coming in contact with this treated surface will subsequently die. Permethrin
is the insecticide generally used. The procedure has been laid out by the World Health Organization and is
based on discussions held in Geneva in November in 1984 and subsequently published in the Epidemiological
Record on 8th November 1985. The present guidelines were reviewed and recommended by the Ninth WHOPES
Working Group Meeting, held at WHO-HQ in Geneva, Switzerland, on 5–9th December 2005 (WHO, 2006). It
is aimed at producing an even deposit of 0.5 gm per square meter of Permethrin on carpets and 0.2 gm on
other interior surfaces. Electrically sensitive areas e.g. the flight deck can also be treated using 2% Permethrin.
(WHO aircraft disinsection on methods and procedures-2021).
Opening and clearing all areas and drawing all window blinds prepare the aircraft. Carpet covers must be
removed. All surfaces of the passenger, crew and cargo compartments are sprayed including toilets, galleys
and wall areas behind curtains. Both sides of the doors and locker lids are sprayed at the end of the operation
and the carpets are resprayed. After spraying the air-conditioning must be operated for at least an hour to
clear the air of volatile components. The aircraft must be resprayed at intervals not exceeding eight weeks,
but a weekly treatment schedule has to be adopted for interior areas subject to regular cleaning and areas
receiving deep cleansing have to be given a supplementary spray. After treatment, a ‘Certificate of Residual
Disinfection’ is issued and carried on board as part of aircraft paperwork.
Rodents e.g. rats, mice carrying diseases like rabies, gain access to aircraft directly from infested terminal
building or from the cargo. Rodents can also crush into many moving parts of an aircraft and can also damage
the plastic coating of many cables. Aircraft should be taken out of service and disinfested, as soon as presence
of rodents in the aircraft is suspected. This is best achieved by fumigation by authorized experts using Methyl
Bromide applied at a dosage rate of 8 oz per 1,000 cubic feet of airspace in the aircraft, for a period of four
hours. Methyl bromide being heavier than air tends to get deposited in the bottom of the aircraft and the
aircraft must be checked after fumigation and ventilation to ensure that no trace of the gas remains.

11.16 Noise in Aviation.

(a) Introduction.
Aircraft, both rotary and fixed wing, produce perhaps the most severe form of noise. Aviation personnel working
in various occupational posts are exposed to high ambient noise. Excessive exposure to noise may interfere
with routine living activities, induce annoyance, degrade voice communication, modify physiological functions,
reduce the effectiveness of performance and cause Noise-Induced Hearing Loss (NIHL). To shield against the
deleterious effects of noise and vibration, it is imperative that the aircrew and ground crew must adhere to
the preventive measures.
(b) Effects of Noise.
Effects of noise on man can be broadly classified as physiological and psychological. The physiological response
of human body to noise is further subdivided into auditory and non-auditory effects. Effects of noise that are

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confined only to the hearing organ are termed auditory effects. Prolonged exposure to various levels of noise
can cause different degrees of hearing loss (or threshold shift) over time. These are caused by slow and
progressive degeneration of the sound-sensitive cells in the inner ear. The shift in threshold brought about by
noise may be temporary or permanent in nature and is termed noise-induced threshold shift or noise-induced
hearing loss. Temporary threshold shift refers to a loss of sensitivity of one or both ears, which returns to
normal or pre-exposure hearing levels within a reasonable time, on cessation of the noise exposure while
permanent threshold shift is a loss of hearing that persists, with no recovery of sensitivity, regardless of the
time away from the noise exposure. Even a single or intermittent noise can cause ringing in the ear (tinnitus) or
temporary / permanent threshold shift, if the intensity is sufficiently high. The extent of threshold shift depends
upon the frequency, intensity and duration of noise exposure. The time taken for recovery from such a threshold
shift is directly proportional to both intensity and duration of the exposure. High frequency sound is found to
be more damaging than low frequency as the sensitivity of the ear is higher at high frequencies.
Noise-induced hearing loss is different from age-related hearing loss. Noise-related hearing loss first appears
in the region of 4,000 Hz and is characterized by a dip in the threshold of hearing while age-related hearing
loss shows a general overall loss of hearing across most frequencies.
Non-auditory physiological responses may be manifested in the form of fatigue, loss of appetite, sleep
interference, startle etc. whereas psychological effects may be seen as distraction, irritability and annoyance,
interference with communication particularly speech and effect on task performance.
(c) Protection Against Harmful Effects of Noise.
To protect human beings against the harmful effects of noise, ear protective devices are used very effectively;
earplugs, earmuff and helmets are the commonly used devices for this purpose. Earplugs are either inserted
in or held against the entrance to the external ear canal whereas earmuffs are used to enclose the external
ear completely by means of a pair of ear cups. The earmuffs fit closely to the side of the head by means of
a soft cushion, which forms an effective acoustic seal around the earlobe. Helmets, in addition to providing
protection against crash / impact forces, are excellent means of personal protection from the standpoint of noise.
The degree of attenuation offered by ear protectors varies from one type to another. However, when the ear
protective devices are used in combination, they give an additional protection of up to 15 dB approximately.
(d) Hearing Conservation Program in Flying Stations.
The National Institute for Occupational Safety and Health (NIOSH) recommends that workers shall be required to
wear hearing protectors when engaged in work that exposes them to noise that equals or exceeds 85 dBA. Hearing
protection by using an appropriate Hearing Protection Device (HPD) is mandatory for all personnel working in such
noise risk zones. Either earplugs or earmuffs are to be used in the areas where the noise level is between 85
to 100 dBA. Both in combination (Double Protection) are to be used in the areas where noise level exceeds 100
dBA. For the posts recording the noise 100 and more, double protection with crew rotation is advised. Following
administrative actions are required to be taken for an effective hearing conservation program:
(i) Recording the “Noise Signature” of all types of aircraft those are operating in an air station.
(ii) “Noise Mapping” of air stations by using an appropriate Sound Level Meter (SLM) and identifying
the High-risk (>100 dBA), Potential risk (86-100 dBA) and Minimal risk (<85 dBA) areas with large sign
boards having appropriate colour codes and warning signs.
(iii) Issuing orders on use of HPDs for all individuals entering noise hazardous areas in the air stations.
(iv) Individuals not concerned with aircraft operations should not be permitted to or remain in the
High / Moderate risk areas.
(v) All individuals on completion of their task on aircraft must shift to a No-risk areas.
(vi) All ground run and engine testing should be carried out at the appropriate place away from the
inhabited / office areas.
(vii) Hanger door facing the source of noise should remain closed during the operation of the aircraft.
(viii) The door and windows of various offices in the squadron should be kept closed during the operation
of the aircraft. This will reduce the indoor noise level by about 10-15 dBA.
(ix) Sound proofing of existing as well as new construction of building meant to house personnel in or

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near the high and potentially risk zones is to be undertaken under the guidance of acoustic professionals.
(x) Wide publicity about the hazardous effects of noise and preventive strategies should be given in
all possible aviation forums.
Following administrative actions are required to be taken under the guidance of the medical officer:
(i) Identifying the personnel at risk and stratifying them into various protection categories like High-
risk (>100 dBA), Potential risk (86-100 dBA) and Minimal risk (<85 dBA) groups.
(ii) Selection of HPD is to be done by subtracting 7 from the NRR (Noise Reduction Rating) provided
by the manufacturer. Subtract remainder from the average sound level (8-hour time-weighted average)
recorded in the noise risk zone to obtain the estimated protection required.
(iii) If estimated protection is less than the level of noise in an occupational post, duration of protection
is to be told to the worker by referring the Permissible Noise Exposure Limit (NIOSH) Table 11.13 so that
better HPD is used or Crew Rotation strategy can be employed.
Table 11.13 : Permissible Noise Exposure Limit (NIOSH). Combinations of Noise Exposure Levels and
Durations That No Worker Shall Equal or Exceed
Exposure Duration, T Exposure Duration, T
Level, L Level, L
(dBA) Hours Minutes Seconds (dBA) Hours Minutes Seconds

80 25 24 - 106 - 3 45
81 20 10 - 107 - 2 59
82 16 - - 108 - 2 22
83 12 42 - 109 - 1 53
84 10 5 - 110 - 1 29
85 8 - - 111 - 1 11
86 6 21 - 112 - - 56
87 5 2 - 113 - - 45
88 4 - - 114 - - 35
89 3 10 - 115 - - 28
90 2 31 - 116 - - 22
91 2 - - 117 - - 18
92 1 35 - 118 - - 14
93 1 16 - 119 - - 11
94 1 - - 120 - - 9
95 - 47 37 121 - - 7
96 - 37 48 122 - - 6
97 - 30 - 123 - - 4
98 - 23 49 124 - - 3
99 - 18 59 125 - - 3
100 - 15 - 126 - - 2
101 - 11 54 127 - - 1
102 - 9 27 128 - - 1
103 - 7 30 129 - - 1
104 - 5 57 130-140 - - <1
105 - 4 43 - - - -

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11.17 Disaster Management in Aviation Accidents.

A disaster is usually taken as a great and sudden misfortune. In aviation, accidents have been occurring since the
very inception of aeronautics. An accident is an unexpected and unforeseen mishap, which remains an inevitable part
of aviation all over the world. Aviation accidents are marked by their extreme suddenness, violent and destructive
nature often associated with extensive injuries, with or without individual or mass fatalities. Unlike other disasters on
the ground, the number of fatalities involved rarely guides the definition of an aviation disaster. More often than not,
it is the failure to cope up with an accident within available communication, rescue, medical, logistic and manpower
resources irrespective of number of casualties. The major concern in civil aviation is the occurrence of mass casualties
that may rapidly overwhelm the local resources even at large airports, where nearly 80% of aviation accidents occur.
(a) Pre-accident Plan (Medical and Rescue Services).
Each aircraft accident is unique in its presentation and survivability of occupants. The uncertain outcome
may range from surprise survivals to mass fatalities. The rescue requirements are challenging considering
the suddenness of the accident, negligible pre-warning and rapid progression of pre and post-crash events,
which leave no scope for delays or confusion. The rescue teams need to have quick day and night deployment
capabilities, high physical endurance, the ability to function within restricted and deformed aircraft body and
survive in inhospitable off-base accident sites over diverse terrain. A rescue team of which a doctor could be a
member, involves extrication of victim to safe area with aim of early resuscitation and treatment for preservation
of limb and life. In off-base accidents, often requires innovative use of natural resources. Evaluation reports
of various air accidents indicate a high occurrence of multiple lacerations and contusions, burns, cervical and
lumbar spinal fractures, facial injuries including fractures, pleural effusions, pneumothorax, fracture clavicle
and pelvis, ruptured spleen, severe head injuries and occasional abortions. On the spot medical aid aims at
active maintenance of airways, endotracheal intubation, oxygen administration, treatment of carbon monoxide
poisoning, circulatory stabilization, application of bandages and splints, immobilization of head and spine,
etc. It may have to be carried out in a very restricted space of a deformed cabin where only less than 19
inch stretcher could be accommodated. A large majority of wounded need manual lifting at the start and may
require subsequent staging where the nearest hospital is located at distance. Careful evacuation by itself can
substantially change the outcome in the survivors. The emergency medical equipment must be designed to
cater to mentioned medical conditions.
The main purpose of pre-accident plan is to lay down procedures and delegate responsibilities ensuring the
quickest and prudent rescue and lifesaving operations. Due to differences in rescue methodology and the
rescue operations, the pre-accident plan is designed separately for On-base, in the vicinity of base and Off-
base air accidents. It is usually general in nature and not all encompassing. Each airline in addition develops
its own contingency plan, which is operable under overall control of local airport authority. At various domestic
airports under primary control of armed forces, such contingency plans may be developed as joint plans.
(b) Rescue Responsibilities at National and International Airports.
Barring a few international airports in India, most of the airports are primarily being operated by defense
services. Station Flight Safety Officer who works under directions of Chief Operation Officer of that base
conducts the rescue operations at these airbases. Any rescue assistance can be requested through him. The
civil airports are governed by Airport Authority of India, which carries out the primary rescue. If the situation
demands, the individual resources of each airline and those of adjoining civil and military services can be
requested for a combined rescue effort. At civil airports the emergency medical arrangements and conduct of
periodic mock-up drills come under the purview and jurisdiction of Airport Authority.
(c) Airport Rescue Services and Procedures.
Rescue operations involve a number of supporting sections mainly the crash crew, transport, medical, security
and Search And Rescue (SAR) crew, station fire section and administration in general. At civil airports, additional
information cell, commercial extension counters, reception units for the relatives of those involved in accidents
and press is established. National and international agencies become involved in the accidents of foreign
aircraft or over foreign airspace. Medico-legal and insurance aspects go by the laid down rules in the individual
country. DGCA in India or its equivalent in foreign are the governing bodies in such instances.
(d) Disaster Rescue Operations.
On an immediate confirmation of an accident by Air Traffic Control, the Pre- accident Plan comes in to force

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and continues till all rescue efforts are over and accident investigations commence. Flight Safety Officer is the
overall in-charge.
(e) Emergency Call-Up Procedure.
(i) Immediately, the Air Traffic Control activates Primary Alarm by the fastest means of communication
to all those who are directly involved in fire fighting, rescue, medical and administrative support. The
exact location of the accident is passed along with the primary alarm and they all follow the preplanned
sequence of action.
(ii) The director of Aerodrome takes over full control of situation. A command / co-ordination post
is established at the site. The Operation Manager activates Secondary Alarm. Standby reinforcements
of each major service are kept in readiness. For On-base accidents, Duty Air Traffic Officer dispatches
rescue, medical and supporting vehicles.
(iii) For “In the Vicinity” air accidents other set of rescue vehicles are sent.
(iv) For “Off Base” accidents, SAR (Search And Rescue) helicopter is requested and sent.
(v) For an accident abroad, a relief aircraft under aegis of DGCA is sent.
(vi) Disaster Site Triage
On receipt of primary alarm the duty medical officer would immediately proceed to Crash Bay along
with medical assistant / assts. On further instructions he would proceed to the site and attend to the
casualties, awarding following categories:
Table 11.14 : Casualty Classification
Category Priority Significance
Black Zero Dead
Red I Immediate care
Yellow II Delayed care
Green III Minor care

He keeps track of all the casualties evacuated to various hospitals and disposal of the dead. In event
of mass casualties, a temporary morgue in a protected area such as hanger is established. Short-term
holding and resuscitation are carried out in the Emergency Medical Room, located near the Crash Bay.
(vii) Duties And Responsibilities of Doctors on Emergency Panel:
(aa) Supplement the medical aid requirements at the crash site.
(ab) Organize reception of casualties at the casualty center.
(ac) Establish a mini-morgue in one of the rest rooms  /  courtyards of fire station.
(ad) Contact the Coroner guard  /   Police surgeon   /  Inspector of accident for postmortem / disposal
of dead bodies.
(ae) Maintain record of casualties, types of treatment given.
(af) Categorization of casualties.
(ag) To alert the receiving hospitals.
(h) Rescue Operations before the Arrival of Rescue Teams at Off Base Locations.
The department of Police initiates the rescue operations even before the arrival of airport rescue team, safety
officer / inspector of accident / officer in-charge nearest aerodrome or any officer of civil aviation department.
(j) Air Accidents in Foreign Countries.
The concerned airline is to depute a relief aircraft in consultation with DGCA. Some mega-airlines have the
capabilities of launching such an aircraft within three hours of call-up.

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11.18 Drugs and Flying.

(a) Introduction.
Flying personnel may be treated by any physician whether civilian or military and whether in office, emergency
room or in and outpatient clinic. Frequently non-aviation medicine qualified physicians are unaware of the
hazards associated with taking medications while flying. Therefore, they may fail to warn the aviator of the
dangers, ground him and label the prescriptions with appropriate warnings.
The proper course is to ground flying personnel until their illness and their need for medication have passed.
Any physician may recommend grounding of flying personnel. Only an Aviation Medicine qualified medical
examiner can recommend clearance to fly. It imposes upon him a corresponding special responsibility.
(b) Objectives.
Drugs when selected should be so as to produce, if possible, a fast, permanent cure, do no harm and have
the fewest possible side effects. The benefits of this approach for the patient are to keep him comfortable
during the healing process, to restore him to health and to preserve and prolong his career.
(c) Effects of Drugs.
Perhaps the most important factor to be considered when deciding whether to ground an aviator for taking
medication is not the medication itself, but rather the disease for which the medication was prescribed.
Normally, any illness significant enough to bring flying personnel to the doctor or to prompt the doctor to
prescribe drugs is sufficient in and of itself to warrant consideration of grounding the aviator. If either the
disease or the drug has effects or side effects which would impair the physical, mental or emotional functioning
of the individual then grounding should be considered.
In deciding whether to ground an aviator taking medication it is important to analyse the effects of the drug and
then relate these effects to the mission and to the individual’s role in the mission. For instance, gastroenteritis
in a radar operator could be handled in a much different way from the same disease in the pilot of a single-seat
aircraft. In the latter instance, disease alone might ground the pilot. When the effects of the drug compromise
an individual’s ability to perform effectively and safely and when they decrease his ability to withstand the
stresses of flight or a survival situation grounding of the aviator should be considered. On the other hand,
when prior testing has shown the drug to accomplish its purpose and to produce no adverse side effects the
doctor may decide to prescribe the drug for use in flight when it is necessary for accomplishment of a mission.
Such an example might be the prescribing of anti-motion sickness drugs for student pilots accompanied by
an instructor for their first few flights or their first aerobatic flights.
In analysing whether to allow an aviator to use drugs in flight, all effects of the drugs should be considered.
Many drugs have more than one effect - some are desirable and intended and others are unwanted side
effects. The latter are further subdivided into predictable physiological responses, unpredictable physiological
responses and idiosyncratic reactions. Examples of drugs, which might demonstrate these side effects
are atropine and other anticholinergics. The intended physiological response might be suppression of acid
production or gastrointestinal motility. A predictable, unwanted side effect might be pupillary dilation and
decreased accommodation. An unpredictable, unwanted, physiological side effect might be the degree to which
an individual’s heart rate response to the G-forces of flight is compromised. An idiosyncratic reaction might be
a rash or precipitation of glaucoma. Other drugs should be analysed similarly.
Basic to the analysis of a drug’s applicability in flying personnel is the requirement that the physician know all
the effects and side effects of the drug (even if this requires going back to the books to find them). Information
on the side effects of drugs is available from many sources. The doctor must then analyze those actions as
they relate to aviation safety. The following listing gives some of the factors to be considered.
(d) Interference with Normal Bodily Functions.
(i) Vision.
Does the medicine cause pupillary dilation or photophobia? Does it decrease accommodation and cause
blurring of vision or decreased visual acuity, etc.
(ii) Cerebration.
Does the medicine produce drowsiness, confusion, illusions, hallucinations, disorientation, psychosis.

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(iii) Cardiovascular Effects.

Does the medicine affect any of these factors in such a way as to cause hypotension, significant
hypertension, arrhythmias or alter the body’s normal reaction to stress
(iv) Temperature Control.
Does the drug affect the central thermal regulatory centers or the peripheral mechanisms (sweating,
vasodilatation, etc) involved in temperature control? How will this affect an aviator if he is sitting in a
cockpit, which has a “greenhouse effect,” or if he is down at sea in cold water?
(v) Oxygenation.
Does the drug affect the rate or depth of respiration? Does it alter the chemical ability of the blood to
become oxygenated or to release oxygen to the tissues? Will the drug cause anemia?
(vi) Comfort.
Will the drug cause distracting, uncomfortable side effects such as dry mouth, itching, flushing, etc.?
(vii) Gastrointestinal Function.
Does the drug cause nausea, stomach cramps, diarrhoea, constipation, etc.? Will it interfere with motility
and cause trapped-gas problems?
(viii) Vestibular System.
Does the drug cause vertigo or decreases the individual’s threshold for motion sickness? Will it in any
way increase his susceptibility to disorientation?
(ix) Homeostasis.
Does the drug cause chemical derangement of the body? Does it alter the body’s capacity to respond
to changes in fluid intake, etc?
(x) Musculoskeletal.
Does the drug limit the motion of any extremity or the spine? Does it cause unwanted, involuntary movements?
(e) Ability to Withstand Stress.
(i) Hemorrhage.
Does the drug cause bleeding? Will it adversely affect the body’s ability to cope with bleeding if injuries
are sustained?
(ii) G-forces.
Will the drug decrease an aviator’s ability to cope with G-forces during aircraft maneuvering or ejection?
(iii) Heat.
Will the drug predispose to heat stroke? What will its effect be on an aviator waiting at the end of the
runway for takeoff in a cockpit with a “greenhouse” effect?
(iv) Dehydration.
Does the drug cause Diuresis, decrease fluid intake, increase insensible fluid loss or sweating?
(v) Survival Situation.
Will the drug decrease an aviator’s chances of survival in case of a crash or ejection? Does it sensitize
the myocardium to arrhythmias with exposure to cold water? Will he be able to survive without injury in
a survival situation if he does not take the medicine?
(vi) Change in Barometric Pressure.
Does the drug cause mucosal swelling, which might block the sinus ostia or the Eustachian tubes? Does
it delay gas transport in the intestines and lead to trapped gas problems, etc?

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(vii) Hypoxia.
Does the drug tend to cause hypoxia? Does it change the body’s response to hypoxia? Does it obscure the
pilot’s ability to recognize hypoxia? Does the action of the drug change in the presence of hypoxia, etc?
(f) Risk of Incapacitation.
(i) Sudden.
What are the chances that the disease will cause sudden incapacitation? If the disease doesn’t, could
the drug suddenly render an aviator incapable of performing his duties? Could it cause unconsciousness,
severe pain, tetany, vertigo, decreased visual acuity, etc? Any drug or disease that could cause interference
with an aviator’s ability to function effectively should be considered a cause for grounding.
(ii) Insidious.
Insidious incapacitation is sometimes much harder to identify or predict than sudden incapacitation and
is thus much more dangerous. The pilot who gets vertigo and faints due to orthostatic hypotension as a
side effect of a drug will probably ground himself. However, the same pilot taking a sleeping pill because
of domestic problems may not even recognize the decrement in his performance which persists for hours
the next day, even after the obvious soporific drug action has worn off. Problems such as potassium
depletion from some diuretics may not manifest themselves until the patient has been on the drug for
a long period of time. Even then, additional stress, such as dehydration, may be necessary to make the
condition manifest. The time interval from an aviator’s starting a drug until he could be considered safe to
fly, must be long enough for any cumulative effects to manifest themselves. It must also be long enough
for an aviator to experience all the side effects of the drug and to learn to recognize those side effects.
(g) Modification of Drug Action Due to Flying.
The doctor must consider all the stresses imposed on an aviator by flying and how these stresses will interact
with the effects and side effects of the drug. As an example, hypoxia is dangerous enough by itself. A borderline
case of hypoxia that might not have resulted in fatality might be converted into a sudden catastrophe if an
aviator is taking systemic decongestants or using nasal spray for a cold. Adrenergic drugs and sympathomimetics
sensitize the myocardium to the effects of hypoxia and can cause dangerous, suddenly incapacitating cardiac
arrhythmias. Another example is the lack of alertness, which can result from the additive effects of fatigue
and drowsiness from antihistamines. Many similar examples will be apparent to the concerned Flight Surgeon.
(h) Specific Drugs.
Antibiotics.
Antibiotics prescribed for use by an outpatient are multiple and the chance that aviators will need them is always
present. In addition to individual-specific side effects, some general side effects or reactions deserve comment.
(i) Allergic reactions to antibiotics, especially penicillin, are not infrequent. Immediate, sudden
incapacitation may occur with anaphylaxis, angioneurotic edema or asthma. Less dramatic but still
potentially dangerous skin rashes, photosensitivity reactions and urticaria occur with regularity.
(ii) Ototoxicity occurs primarily with the polypeptide or aminoglycoside group of antibiotics which are
ordinarily reserved for more severe infections. Nevertheless, aviators will receive them occasionally. Either
hearing loss or disequilibrium may result and disable an aviator.
(iii) Other possible side effects are multiple and require consideration.
Non-narcotic Analgesics.
Two general types of analgesics are in common usage, the salicylates and aniline derivatives. Due to their
extremely common use, there is a tendency to forget that they do have adverse effects. Among these are
gastritis, tinnitus, loss of hearing and methemoglobinemia.
(i) Sulfonamides.
Sulfonamides are frequently used for the treatment of urinary tract infections. Among their adverse
effects are methemoglobinemia, decreased depth perception, accentuation of phorias, nausea, vomiting,
dizziness, dermatitis, agranulocytosis and hepatitis

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(ii) Topical Medications.

In general, most topical preparations are safe to use with flying. However, some ointments that are
petroleum based may oxidize rapidly in the 100% oxygen environment of an aviator’s mask and probably
should not be used around the face.
(j) Drugs Commonly Permitted with Flying Duties in India.
With more data being accumulated over time for effects of various drugs, more and more drugs are considered
to be compatible with flying duties. Common examples are Diuretics except loop diuretics, Cardio-selective
beta blockers e.g. Metoprolol, Atenolol etc, ACE inhibitors eg Enalapril, Angiotensin Receptor Blockers (ARBs),
Calcium Channel Blockers (CCB) e.g. Amlodipine, Statins, Aspirin, Metformin, DPP4 inhibitors. Patients should
be initially grounded and observed on ground for reasonable duration to assess adverse effects of drugs before
resuming observed flying with a copilot. Every case should be assessed individually and disposal of the cases
given according to current military / civil regulations in practice.

11.19 Survival.
(a) Introduction.
The term “survival” is used to express the actions and attitudes which help an individual to continue to live
in spite of adverse circumstances to improve his situation and to increase the possibility of eventual rescue.
In the SAR system “survival” is defined in terms of time factors with respect to the probability of locating
survivors and the probability of their remaining alive until rescue can be affected. In the present-day aviation
environment, there is a high probability that aircrew and passengers of ill-fated aircraft will survive the crash.
The present-day escape system in both military and commercial aircraft offers dedicated efforts to prevent
traumatic consequences in the event of an inevitable crash or abandoning of the aircraft.
The time period between appearance of an emergency on board the aircraft leading to the crash of the aircraft
and rescue of the survivors by the SAR team, is quite crucial. The term “survival” denotes gamut of actions,
which may be taken in this period for the prevention / curtailment of sequelae of the crash / abandonment of the
aircraft. This period poses peculiar problems, which need to be understood and addressed by the aeromedical
community. Indoctrination of aircrew and passengers on various sound principles of survival will further be of
great help in improving the chances of survival.
It is an established fact that SAR planning and execution in our scenario, does not compare well with the
high standards of preparedness in such tasks available in the developed countries. This makes it the entire
imperative that we do everything possible to improve the chances of survival. In this chapter, we shall cover
all aspects of survivability including psychological and physiological factors, training as well as tools and
equipment, which will improve the chances of survival.
It is obvious that the chances of survival of the escapee(s) are inversely proportional to the time in which they
are rescued. The efficacy of the SAR operations therefore also has a bearing on the survival. There are also
problems of psychological and physical nature following the traumatic event of the escape from the aircraft.
The chances of survival are determined by a variety of other factors, which fall within the domain of the
aeromedical purview. This chapter attempts to cover the basic definitions, concepts, facilities (survival packs)
and training related aspects.
(b) Psychological and Physiological Factors.
The factors which directly affect the survivability of an individual, are those, which physically or psychologically
tend to hinder the activities of survival. These are as follows:
(i) Pain.
Pain arising out of the injuries sustained during the event of escape / crash can weaken the will to survive
as well as the physical ability to counter the threats affecting survival.
(ii) Cold / heat.
The environmental conditions existing at the site of survivable may be in the extremes of ranges not
conducive to humans physiologically. A large part of metabolic effort would be expended in countering
these extremes of temperature ranges thereby threatening survival.

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(iii) Thirst.
Minimal amount of water loss leading to thirst can reduce the mental ability to concentrate on the task
of survival. Moreover, the body continues to lose water through metabolic requirements and by the
insensible perspiratory losses. The problem of water deprivation is more critical in the areas of high
environmental temperature such as the deserts and the tropics and the areas of high humidity such as
in sea survival in daytime in tropics.
(iv) Hunger.
Hunger reduces mental ability for rational thinking and activities and also causes a reduction in tolerance
for other concomitant stresses such as cold, heat, pain and fear.
(v) Fatigue.
Fatigue can make a survivor less motivated and careless. The fatigue may be due to the stress of the events
of the recent past, which the survivor undergoes rapidly after the crash/escape. Fatigue may represent
an escape mechanism from the situation that has in the mind of the survivor become too difficult to cope
with. It may also arise out of a lack of goal, frustration or increasingly difficult environmental conditions.
(vi) Boredom and Loneliness.
In a single survivor situation, this factor sets in if the initial actions of survival are carried out and there
is no immediate danger to the survivor but the rescue is still not forthcoming.
(vii) Fear.
This is the worst enemy of survival as it sets psychological barriers in the assessment of the threat
by the survivor. Fear sets in a process of panic in which the survivor tends to perceive magnification
of the threats to his existence thereby resulting in inappropriate actions. Optimal fear is essential for
optimization of resources but excess of fear is highly detrimental to the chances of survival. Accepting
fear as a natural reaction to the threatening situation is conducive to the purposeful activity but its
exaggerated form is incapacitating in the scenario.
The probability of survival diminishes rapidly after the escape / crash particularly in hostile environmental
conditions of air temperature, wind velocity, water temperature, humidity etc. It is estimated that successful
survival is to the order of 60%-80% after the first 24 hours with rapid decline after 3 days.
The pattern of activities in the event of a survival situation is determined by the urgency of the need to
carry out a given activity. Certain activities need to be initiated early in the survival situation to ensure early
safety and to ensure subsequent activities can be undertaken safely. In a survival situation, the survivor
hence has to prioritize his actions in the order of their need and then execute them. The following is the
sequential order of activities that a survivor needs to do as revealed from the histories of survival situations.
Depending on the space available in a given aircraft, the type of the aircraft and the number of likely
survivors determined by the number of crew / passengers on board, the survival packs are provided with
items of various shapes / sizes and contents. The items provided in the Personal Survival Packs (PSPs)
are broadly classified in terms of their utility and are classified as follows:
(i) Protection Aids.
These aids are provided with a view to protect the survivor(s) from external environmental threats.
The threats may be from extremes of temperatures, snow, sea, deserts, wild animals etc. Depending
on the area and terrain of the survival. Protection against enemy in escape / crash in the enemy
territory in the combat scenario is also included in this group.
(ii) Location Aids.
These groups of items can enhance the early location of the survivors by the SAR teams. The
survivors can be better located if they use provided visual attention-seeking techniques or by
establishing emergency radio communication. Various visual attention enhancement items
provided include sea marking dye (uranine), Heliograph, orange colour of the parachute / life
vest / dinghy / overalls, the wreckage site itself, ground to air indication codes and pyrotechnique
devices (signal miniflares). The radio communication aids include devices such as SARah (Satellite-

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based Radar Reconnaissance System) / SARBE which emit radio frequencies when activated
automatically / manually after escape / crash and act as a non-directional beacon signaler to the
rescue team. Radio equipment with press to talk facilities are also available. The radio equipment,
however, are useful only in the open spaces for the wave transmission to occur.
(iii) Water.
Water requirements during survival situation are determined by the environmental conditions, type
of terrain and status of hydration of the survivor(s) prior to the event of escape/crash. Deprivation
of water i.e. Dehydration also leads to loss of electrolytes from the body. Water is hence provided
in the survival packs. With no need to consume on Day 1, the recommended intake of water on
Day 2, 3, 4 is 420 cc. 60 cc is recommended on Day 5 and thereafter. The personal survival packs
carried in the single crew aircraft (Fighters) cater for 1,500 cc for the survivor to be consumed over
3 days. The quality of such potable water stored in the PSPs in terms of taste, palatability, bacterial
counts etc. needs to be maintained. It is advisable to consume the water by sipping to conserve it
and to supplement the same with natural sources as and when found.
(iv) Food.
Food consumed also varies the water requirements and hence food with high fat content, which
takes higher molecules of water for metabolism are best, avoided. The food is provided in the
PSPs in form of compact bars of chocolates made of carbohydrates and proteins with traces of fat
added for improved satiability and taste. The percentages of various components recommended for
survival food are Carbohydrates - 80-90%, Proteins - 10-20%, Fats - trace. The daily recommended
calorie intake is 1800 calories. The food supplements available in the area of survival may be
used. e.g. Fruits in jungles, fish in the sea, edible barks etc.
(v) First Aid.
Medicines and bandages are required to counter the immediate threat from injuries and is provided
as part of the PSPs. The number of likely survivors and casualties again determines the amount of
the store provided. Instructions for the use of the items provided are given and these instructions
indicate the treatment to be taken by the survivor for a variety of symptoms.
(vi) Miscellaneous Aids.
Other items of comfort may be provided in the PSP for the comfort of the survivor e.g. Provision
of cigarettes, fire-making devices, fishing snare etc.
(c) Survival Situations.
Snow Survival.
The abandoning of the aircraft in the snow-bound area would expose the survivors to the following additional
environmental / climatic challenges:
(i) Cold temperature effects (frost bite / chilblains)
(ii) Wind chill effects
(iii) Avalanches
(iv) Snow glare effects
(v) Lack of natural food availability
(vi) Non-availability of shelter
The survivor can be better located in the snow as there are no visual obstructions to locate him. He can follow the
streams formed from the snow and navigate to lower altitudes where he is likely to find inhabitation. Location can
be enhanced by making markings in the snow, which can be detected by the rescue aircraft the survivor must make
shelter on the leeward side of the mountain to get protection from winds. No metallic parts of the aircraft wreckage
should be touched with bare hands to avoid frostbite. The parts of aircraft such as the left-over fuel, upholstery etc.
should be used for protection. Excessive loss of body energies should be avoided to conserve the energy required
to keep the body warm. Melted snow can be used as a source of water.

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Desert Survival.
The additional sources of stresses in the desert include the following:
(i) High temperatures
(ii) Exposure to sun
(iii) Mirages
(iv) Loss of navigational cues due to shifting sands
(v) Shortage of natural sources of water and increased loss of body water
The survivor should protect himself from exposure to the sun by constructing a shelter. Water should be further
conserved to reduce the daily intake to 240 cc daily till last 240 cc is left which can be had in the last 2
days. Unnecessary physical activity, which tends to increase the water requirement, should be avoided.
Sea Survival.
The immediate hazard is of drowning and a failure to separate the parachute from the survivor will tend to
drag the parachute-survivor combination to be dragged with the waves thereby causing injuries. Additional
factors specific to the sea environment include the following:
(i) High humidity leading to body water loss by evaporation
(ii) Hypothermia if the temperature of the water is low
(iii) Sharks
(iv) Non-availability of fresh water for drinking
(v) Skin maceration
(vi) Rough sea
The sea survivors can be located easily due to the easy visual accesses. The contrasting colours of the flying
clothing and the survival equipment against the blue background of the sea, sea-marking devices and high
chances of being located by ships  /  boats in the vicinity are all contributory. The survivor can overcome the
problem of drinking water by collecting rainwater or by using desalination kits if available. Shark repellent dyes
are available to protect the survivor from the sharks. Dinghies are provided for all aircraft overflying the sea
to accommodate the expected number of casualties.
Jungle Survival.
The survival situation in the jungles mainly demands effective use of protective and location aids. Immediate
protection is required against the wild animals, mosquitoes, leeches etc. The location aids based on radio
communication are less effective and navigation in the thick jungles is difficult. Food and water may be in
abundance, but the survivor may need to identify carefully the edible and safe food and water sources to
avoid poisoning by certain naturally growing substances. The survivor is provided with knife, fire-making tablets,
mosquito veils and repellent cream etc. to counter the same.
(d) Survival Packs.
The survival packs can be classified based on the aircraft they are likely to be used. The type of aircraft
indicates the number of occupants of the aircraft which in turn would determine the number of likely survivors
it would cater for. Thus a single crew PSP would cater for the survival of the lone occupant of the aircraft (i.e.
In Fighters), where as a transport aircraft PSP would cater for the aircrew as well as the predicted number of
occupants on board.
The survival packs have also been classified according to the terrain in which it is likely to be used i.e. the
terrain over which the aircraft is likely to be flying. The various items required in a specific type of terrain are
of no use in other type of terrain. E.g. Mosquito veil and repellent cream would be of no use in the snow
survival situation. The terrain specific survival packs thus cater for the specific stressors expected in the given
terrain thereby allowing inclusion of more stressor specific aids in lieu of the items not required in that terrain.
The packs can hence be classified as follows:

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(i) Composite packs

(ii) Sea variant
(iii) Desert variant
(iv) Snow variant
(v) Jungle variant
The logistic importance of the terrain specific survival packs can be appreciated in overseas operational
scenario like the Gulf war wherein the pilots were flying in totally alien terrain.

11.20 Casualty Evacuation.

The transport of critically ill and injured is an increasingly important health care adjunct. Transportation could be from
a remote area where no facilities exist or may be an inter facility transfer. Safe, efficient and expert care by trained
personnel is a crucial element in delivering health care in the unpredictable environment of airplanes, helicopters and
ambulances. Unlike the controlled environment of a medical facility, an aviation environment offers the challenge of
delivering standardized medical practice in a confined unstable space with limited equipment and personnel.
(a) Altitude Physiology.
Dalton’s law of partial pressure states that a decrease in atmosphere pressure with an increase in altitude
results in a decrease in the partial pressure of O2 in the atmosphere. The physiological significance is hypoxia. In
the compromised patient this shift in oxygenation may contribute to in-flight deterioration, therefore all patients
must be placed on supplemental oxygen regardless of there clinical condition. Time of Useful Consciousness
(TUC) is reduced by 50% in rapid decompression of the aircraft. PaO2 is less than 60 mm Hg at altitudes higher
than 10,000 feet; 30 mm Hg at altitudes higher than 20,000 feet. Threshold Altitude (TA) is the altitude at
which symptoms of hypoxia are likely to develop. Normal TA is 10,000 to 12,000 feet. In the elderly or those
with chronic diseases or in compromised physical conditions, the TA could be as low as 2,000 feet. Neonates
can have an even lower TA due to greater alveolar to arterial gradient.
Another concern is the physiologic implications of Boyle’s law. Simply stated, gases expand as altitude increases
and vice-versa. The significance of this law is seen with the expansion of gases trapped within the body,
effecting hollow organs and cavities. This particularly applies to the ears, sinuses, hollow organs and GI
tract. Therefore, aeromedical crews must give special attention to patients with pneumothorax, penetrating
head or eye trauma and bowel obstruction. Preflight physiological decompression should be considered for
pneumothorax, bowel obstruction and gastric distention. In certain clinical conditions where altitude is a major
concern, the aeromedical crew should ask the pilot if they can fly non-pressurized aircraft at lower altitude or
reduce the cabin altitude in pressurized aircraft.
Failure to ventilate the middle ear cavity during aircraft descent would lead to fullness followed by pain in the
ear and further lead to perforation of tympanic membrane- otitic barotrauma. Chronic Eustachian tube blockage
is the cause, which prevents ventilation of the middle ear during descent. Chronic Eustachian tube obstruction
is usually secondary to a pathologic process in either the nose or nasopharynx. Sleeping and unconscious
patients are more prone to otitic barotrauma. Passengers and crewmembers should at minimum take preflight
doses of pseudoephedrine and use topical nasal vaso-constrictors, which will promote sinus drainage without
the CNS side effects. Similarly, expansion of gases during ascent of aircraft in conditions when ventilation of
sinuses is restricted, for e.g. allergic rhinitis can be a cause for concern.
Accelerative and decelerative forces encountered during the take-off, landing and turns are of minimal significance
in a sitting patient, in case of a lying patient, forces during take-off and landing act along the long axis of the body
and can adversely affects the patient’s condition. For instances in a patient with circulatory compromise, if the
patient’s head is towards the front end of aircraft, during take off, there would be significant pooling of blood in
lower limbs resulting in compromised cardiac output. Coning of the brain stem could occur in-patients with raised
intracranial pressure with head towards front end, during take-off, because footward ‘G’ forces.
(b) Important Considerations.
The major questions faced and which must be answered prior to evacuation of casualty by air are:
(i) Is the risk to the patient being transferred less than the risk of not being moved?

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(ii) Is the patient adequately stabilized?

(iii) Do the benefits of the move justify the clinical and fiscal costs?
(iv) Is the move medically necessary or driven by emotional or family-based concerns?
(c) Priorities for Evacuation.
Whenever large numbers of casualties have been incurred and they are required to be transported by air, the
order in which they should be evacuated, is based on the following priorities:
Priority 1. Patients whose transfer by the quickest possible means are necessary as life saving measure
or to avoid serious permanent damage.
Priority 2. Patients whose condition are likely to be adversely affected unless they are speedily evacuated
or patients who need early-specialized treatment, which are not available locally.
Priority 3. Patients whose immediate treatment requirements are available within his local medical units
but whose prognosis would benefit if transported by air rather than by surface transport.
Priority 4. Patients for whom movement by air is a matter of convenience rather than a medical
requirement.
(d) Medical Documentation.
All relevant medical documents must accompany the patients being evacuated. These documents should be
handed over to the medical authority responsible for in-flight nursing. Separate reports in duplicate for each
patient should be handed over showing the following details:
(i) Condition of patients
(ii) Classification of patients
(iii) Priority of evacuation
(iv) In-flight treatment required
In-flight nursing personnel are to record the in-flight condition of the patient and any medication given. The
original copy of the report is to be forwarded with the case sheet and relevant documents to the receiving
medical unit. The duplicate is retained by the IAF medical authority responsible for in-flight nursing.
(e) Preflight Procedure Prior To Air Casevac.
(i) The doctor of the dispatching airfield is responsible to:
(aa) Prepare loading plan and decide fitness of patients for evacuation
(ab) Ensure in-flight medical / nursing equipment, clothing and stores (including O2) are catered
for patients.
(ac) Ensure patients are adequately prepared and briefed.
(ad) Ensure suitable arrangements are made at intermediate and destination airfields for
reception, care and welfare of the patients.
(ae) Brief captain of the aircraft on the following points:
O Height restriction, cabin altitude etc.
O Precautions to be taken in transportation of neuropsychiatry or other special cases.
(ii) The captain of the aircraft should ensure:
(aa) Aircraft casualty evacuation fittings are in order and are properly rigged e.g. litter straps,
ring clamps.
(ab) Brief the senior member of the in-flight nursing team on:
O Weather condition and operational limitations
O Duration of the flight

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O Intermediate halts if any,

O Expected time of departure and arrival at destination.
(f) Merits and Limitations of Air Casevac.
The advantages of air casualty evacuation are as follows:
(i) Morale.
Early evacuations of casualties from the theatre of war to a center with specialized medical facilities
boost the morale of the casualties as well as the troops.
(ii) Speed of Evacuation.
Fastest mode of evacuation. Enables removal of ineffective personnel in war expeditiously from the
battlefield, which is a tactical necessity. Also saves to decongest the field medical unit’s resources.
(iii) Reduces incidence of Infection.
(iv) Overcomes Adverse Terrain.
Conventional modes of transportation are ineffective when difficult terrain is to be surmounted. For e.g.
Earthquakes, sea, jungle, hills. Air transportation alone can overcome these natural obstacles.
(v) Enables institution of early and definitive treatment.
(vi) Centralization of Trained Medical Expertise.
Specialist medical personnel can be based in the hospitals which are well equipped instead of dispersing
to the field, where their skill and efficiency is compromised because of lack of facilities in terms of
equipment, instrument and drugs.
(vii) Keep the Communication Lines Free.
Air evacuation reduces the number of personnel vehicles and ambulance trains that would be required
to transport invalids by conventional means of transportation.
(viii) Comfort.
Since the duration of journey is short, it is more comfortable to the casualty being airlifted.
(ix) Safety.
When air superiority exists, evacuation by air from theatre of war is much safer.
(x) Economy.
Evacuation of casualties is economical viz a viz other means of transportation in terms of manpower,
time and money.
(g) Limitations of Case Evac.
(i) Air Superiority.
Enemy air action is a serious disadvantage in deployment of aircraft for patient evacuation. Casualty
evacuation by air is possible when air superiority is established in the theatre of war, from where
casualties are to be evacuated.
(ii) Landing Grounds.
Suitable airfield / helipads with facilities for communication, fuel and servicing are required for operation
of aircraft.
(iii) Aircraft Availability.
Availability of aircraft is variable factor which will limit the scope of casualty evacuation.
(iv) Regularity of Sorties.
Air sorties may be delayed or cancelled due to operational reasons; resulting in long and infructuous

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delay in evacuation.
(v) Weather.
Weather conditions including fog, snow, low ceiling may restrict medical operations.
The non-availability of dedicated aircraft for the roles of air ambulance compels the retention of the
existing organization for casualty evacuation overland routes. Air evacuation, though most effective and
desirable plays an ancillary role of conventional modes of transport operation. Casualty carrying capacity
of various Indian transport aircraft is given at Table 11.15.
(h) Certain Medical Conditions, which would Warrant Special Precautions.
(i) Cardiovascular Diseases.
Patients with cardiovascular compromise who require supplemental O2 at ground level would definitely
require supplemental O2 in flight. The percentage of O2 required will have to be titrated upwards as
cabin altitude increases. Ischaemic / hypoxic myocardium equals potential for in-flight cardiac catastrophe
and arrhythmia. In a fully compensated cardiovascular condition, a cabin altitude off 10,000 feet is well
tolerated, but in borderline cases, supplemental O2 will be required whenever cabin altitude rises above
4,500 feet. Patients suffering from acute myocardial infarction should ideally not be evacuated by air
for at least 06 weeks. If cardiopulmonary resuscitation is required enroute, patient must be placed on
CPR board. Standby oxygen must always be available in-flight for the evacuation of all cardiac patients.
(ii) Respiratory Diseases.
Patients with obstructive pulmonary diseases would require careful evaluation, to determine the cabin
altitude to be maintained and % of supplemental O2 which will be required to be given to the patient
in flight. Patients who have undergone pulmonary surgery should have had an adequate period of
convalescence prior to being evacuated by air. Untreated pneumothorax is an absolute contraindication
unless there is no respiratory embarrassment and the cabin altitude in flight, can be maintained at
ground level, that at the point of origin. A chest tube with an unbreakable water seal assembly must be
inserted prior to air evacuation. In pneumonia, gaseous exchange in alveoli is disturbed. Supplemental
O2 will be required from ground level itself.
(iii) Neurological Considerations.
Patients with increased intracranial pressure should be given supplemental oxygen to eliminate the risk
of minimal hypoxia. Also, patients with cerebral injury are exceedingly sensitive to forward acceleration,
like the one experienced during take-off. Therefore, patients with cerebral injuries should be positioned
with their head toward the rear end of the aircraft. CSF leak from either the nose or the ear is a
relative contraindication due to the danger of sucking in air, contaminated with bacteria, during descent.
Therefore, cabin pressurization to maintain cabin altitude at point of origin is mandatory. Patients with
seizures may be susceptible to recurrence in flight, induced by hypoxia. In such cases, supplemental
O2 must be given in-flight. For Patient with head trauma and combativeness should be SPIT (Sedate,
Paralyze, Intubate and then Transported) should be followed / ensured.
(iv) Burns.
Prior to air transportation, in all cases of burns, it must be ensured, whether they have pulmonary burns.
This is because often, it is seen that survivable surface burns, are fatal as a result of pulmonary burns.
Therefore, a preflight chest radiograph is important to assess the presence or absence of pulmonary
burns. Stabilization in burns patient, includes maintenance of patency of airway, adequate ventilation,
oxygenation and fluid resuscitation.
(v) Gastro-Intestinal Cases.
In-patients, who have undergone abdominal surgery recently, gas, may remain trapped in the abdominal
cavity. Also, trapped gas in a hernia or volvulus can expand in-flight causing pain and in some cases
compromise the circulation of the bowel.

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(vi) Neuropsychiatric Cases.

Table 11.15 : Casualty Carrying Capacity of Various IAF Aircrafts
Aircraft Sitting Cases Lying Cases In Addition to Lying
MI-8, 23 OR 12 (+2 Sitting) without Internal Auxiliary tank
MI-17 15 OR 06 (+4 Sitting) without Internal Auxiliary tank
MI-26 82 OR 60 +03 Sitting Cases
AVROHS-748 48 OR 21 +03 Attendants
AN-32 50 OR 24
IL-76
Version-1 38 +72 +4 medical attendants (total 114)
Version-2 7 +80 +3 medical attendants (total 90)
Version-3 12 +32 +1 medical attendants (total 45)
CHETAK 03 OR 02 +1 medical attendant
CHEETAH 03 OR 01 +1 medical attendant,co-pilot seat has to be removed to
accommodate stretcher.
(aa) Prior to transportation by air, neuropsychiatric patients are to be observed for a sufficient
period of time to establish whether they are amenable to routine nursing discipline or that some
additional form of control will be needed in flight.
(ab) The doctor at the dispatching hospital must classify the patient on the advice of the
specialist in psychiatry, where available, not more than three days prior to boarding the aircraft.
(ac) When necessary, neuropsychiatric patients are to be kept adequately sedated before and
during flight. Equipment for restraint is to be carried for these patients.

Suggested Reading.
1. Human Physiology | Aviation Medicine :: Aerospace Medicine [Internet]. [accessed 2024 Feb 20]. Available from:
http: /  / www.avmed.in / category / human-physiology /
2. Atmosphere [PDF] [4b6vpmv9qbg0] [Internet]. vdoc.pub. [accessed 2024 Feb 20]. Available from: https: /  / vdoc.
pub / documents / atmosphere-4b6vpmv9qbg0
3. Mehta S, Chawla A, Kashyap A. Acute Mountain Sickness, High Altitude Cerebral Oedema, High Altitude Pulmonary
Oedema: The Current Concepts. Medical Journal Armed Forces India. 2008 Apr;64(2):149–53.
4. (PDF) Hyperbaric Oxygenation - British Journal of Diseases [Internet]. research.amanote.com. [accessed 2024
Feb 20]. Available from: https: /  / research.amanote.com / publication / J6lSAnQBKQvf0BhikH0h / hyperbaric-oxygenation
5. Cowl CT. Justifying Hyperbaric Oxygen Delivery for Carbon Monoxide Poisoning. Chest. 2017 Nov;152(5):911–3.
6. Yu BP. Cellular defenses against damage from reactive oxygen species. Physiological Reviews. 1994 Jan
1;74(1):139–62.
7. Campbell RD, Bagshaw M. Human Performance and Limitations in Aviation. 2002 Feb 22
8. https: /  / www.researchgate.net / publication / 264047001_Hypoxia_and_hyperventilation
9. Indian Society Of Aerospace Medicine [Internet]. www.isam.in. [accessed 2024 Feb 21]. Available from:
https: /  / www.isam.in / Flying-Clothing.html
10. Jain KK. Textbook of Hyperbaric Medicine. Springer eBooks. Springer Nature; 2017.
11. Mathieu D, editor. Handbook on Hyperbaric Medicine. Dordrecht: Springer Netherlands; 2006.
12. Ernsting’s Aviation Medicine, 4E. CRC Press eBooks. 2006.
13. Kelly M. Control of infection in an international airline. Occupational Medicine. 1993;43(2):91–4.

279
 ENVIRONMENTS SPECIFIC TO ARMED FORCES: HEALTH HAZARDS, DISEASES AND PREVENTION

14. Juurlink DN, Buckley NA, Stanbrook MB, Isbister GK, Bennett M, McGuigan MA. Hyperbaric oxygen for carbon
monoxide poisoning. The Cochrane Database of Systematic Reviews [Internet]. 2005 Jan 25 [accessed 2024 Feb
21];(1):CD002041. Available from: https: /  / pubmed.ncbi.nlm.nih.gov / 15674890 /
15. Yu BP. Cellular defenses against damage from reactive oxygen species. Physiological Reviews. 1994 Jan
1;74(1):139–62.
16. Deulofeu R, Parés A, Rubio M, Gassó M, Román J, Giménez A, et al. S-adenosylmethionine prevents hepatic
tocopherol depletion in carbon tetrachloride-injured rats. Clinical Science (London, England: 1979) [Internet]. 2000 Oct
1 [accessed 2024 Feb 21];99(4):315–20. Available from: https: /  / pubmed.ncbi.nlm.nih.gov / 10995597 /
17. Ranjan CK, Renjhen P. Casualty Air Evacuation: Sine quo non of combat casualty. Medical Journal Armed Forces
India. 2017 Oct;73(4):394–9.
18. Meijne NG, Mellink HM, Kox C. The main present-day indications for clinical treatment in a hyperbaric chamber.
Lung. 1973 Dec 1;149(3):173–80.
19. Kumar A, Nataraja M, Sharma V. Analysis of G-induced Loss of Consciousness (G-LOC) and Almost Loss of
Consciousness (A-LOC) incidences in high-performance human centrifuge at Institute of Aerospace Medicine Indian Air
Force. Indian Journal of Aerospace Medicine. 2020 Oct 3;63:53–60.
20. Gander PH. Evolving Regulatory Approaches for Managing Fatigue Risk in Transport Operations. Reviews of Human
Factors and Ergonomics. 2015 May 28;10(1):253–71.
21. Concise Encyclopedia of System Safety: Definition of Terms and Concepts | Wiley [Internet]. Wiley.com.
[accessed 2024 Feb 21]. Available from: https: /  / www.wiley.com / en-ae / Concise+Encyclopedia+of+System+Safety:+
Definition+of+Terms+and+Concepts-p-9781118028667
22. Seedhouse E. Tourists in Space. Springer eBooks. 2014.
23. Design of an optimum anti-G suit controller using an adaptive feedforward control scheme | IEEE Conference
Publication | IEEE Xplore [Internet]. ieeexplore.ieee.org. [accessed 2024 Feb 21]. Available from: https: /  / ieeexplore.
ieee.org / document / 112882
24. Young TM. Performance of the Jet Transport Airplane: Analysis Methods, Flight Operations and Regulations. 2017
Nov 3;
25. Pisacane VL. The Space Environment and Its Effects on Space Systems. 2008 Aug 22;
26. Bagshaw M, Cheng IC, Bor R. Aviation and travel medicine. 2015 May 15;241–56.
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Chapter
XII
SURVIVAL IN DESERT

12.1 Introduction.
Deserts around the world present a peculiar set of environmental conditions which are characterized by dry weather
and high temperatures, especially during the summers. Diurnal temperature variation is high and is characteristic
of deserts. Such environmental conditions put increased stress on human physiology. The human body has to
adapt over a period of time to desert conditions. Inappropriate acclimatization and prolonged stay in the desert
cause deleterious effects on the health & efficiency of individuals.
In India, the arid zone occupies nearly 12 percent of the total area. This includes 0.32 million sq km of hot desert
mainly in Rajasthan, Gujarat and Haryana. Western Rajasthan, a part of the Thar desert, is covered by wind-blown
sand and dunes. This area is characterized by conditions of high aridity with low average annual rainfall. The
data generated by Central Arid Zone Research Institute, Jodhpur reveals that there is an upward trend in average
rainfall and relative humidity over the past decade. The range of annual rainfall is 192 mm and 392 mm, with
a relative humidity of 30% in Jaisalmer to 20% in Jodhpur respectively.
The Indian desert is one of the most densely populated deserts in the world. The population can be roughly divided
into two major categories, namely, a diffuse and scattered population living in the hinterlands and a concentrated
population living in the cities / towns. Working in a desert area is beset with medical problems due to adverse
environmental conditions and terrain.

12.2 Desert Ecology.

The zone is also characterized by high-temperature variation from less than Zero degrees centigrade in winter night
to more than 50°C in daytime in summer. Relative humidity varies around 30% and sandstorms are common during
Apr-Jun. Vegetation is sparse with few trees in between. Full-grown trees are still less though the ecology is changing
fast. Drinking water scarcity compounds the problem.

12.3 Zone of Thermoneutrality and Human Physiology.

The external temp with which the homeostatic mechanism of thermoregulation is not stressed and the resting heat
production rate is at its minimum is called the zone of thermoneutrality. In a resting person, this is 2°C on either side of
29°C depending on whether the person is clad or not. Deviation from this zone sets the homeostatic thermoregulatory
mechanism in action on the hotter side, the heat loss is increased while on the cooler side, the heat conservation
is stimulated. The body loses and gains heat by conduction, convection and radiation. By evaporation, the body only
loses heat.
As the temperature rises beyond the thermoneutral zone, the immediate response is to cause vasodilatation in the
periphery to divert heat from the core to the periphery. This results in a fall in BP and a rise in heart rate. Dehydration
further aggravates this phenomenon. During exercise, blood is shunted to working muscles. In unacclimatized individuals,
this can lead to cardiovascular instability. Heat tolerance can be achieved by daily normal physical work. The adaptive
processes rapidly develop over 3-4 days and is complete in 10 days and last up to 2 weeks after leaving the area.

12.4 Acclimatization in the Desert.

Over a longer period of stay in a desert, the body achieves a more efficient mechanism of heat loss by setting in a
few physiological changes like:
(a) Increased.
(i) Circulatory volume
(ii) Cardiac output

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(iii) Aldosterone production

(iv) Renal retention of sodium
(v) Responsiveness of sweating
(vi) Fluid requirement
(b) Decreased.
(i) Heart rate
(ii) Volume of sweating
These changes constitute what is called acclimatization to heat and remain in place till the individual stays in
a desert area.

12.5 Problems in Desert Area.

(a) Water Supply.
In desert areas, ensuring compliance with water quality standards remains an ongoing struggle, because of the
natural scarcity and vulnerability of water sources. The dry climate and minimal rainfall increase the chances of
water resource contamination and depletion. Common issues in desert regions, such as elevated levels of Total
Dissolved Solids (TDS), salinity, chloride and nitrate, often exceed acceptable water quality standards. These
contaminants not only affect the potability of water but also pose significant risks to agricultural activities and
ecosystem health.
As per State Groundwater Quality Report 2022, Rajasthan (BIS-10500,2012), only 09 percent of the groundwater
in Rajasthan conforms to normal standards of drinking water, i.e., containing less than 500 mg / L (TDS). In
western, central and some eastern parts of the state high Chloride (Cl) values (>1,000 mg  / L) have been
observed thus making the groundwater bitter in taste and non-potable. In western, northwestern, southern and
some eastern parts of the state high nitrate values (> 45 mg / L) have been observed... In some areas, the
fluoride content of groundwater is also high. However, no toxic elements are detected in the waters of Western
Rajasthan. It can thus be seen that this water deficit area has an acute problem of saline ground waters, which
is not potable and hinders bathing, washing and other community utilities. Such a situation gives rise to a high
incidence of gastrointestinal disease including viral hepatitis and skin diseases.
(b) Adverse Environmental Conditions.
During winter, there is a great drop in temperature after sunset which gives rise to the respiratory group of
illnesses. During the day, especially during summer, high temperature account for a higher incidence of effects of
heat like heat exhaustion, heat stroke and prickly heat. The sand and dusty environments lead to an increased
incidence of foreign bodies in the eyes, conjunctivitis and trachoma. Desert sores are common and may develop
from minor abrasions and they heal slowly.
(c) Endemic Diseases.
Malaria, excremental diseases including viral hepatitis and skin diseases have a higher prevalence in desert
areas. Sand flea infestations (Tunga penetrans) of the skin are common.
(d) Local Fauna.
Desert areas are infested with poisonous snakes and scorpions. Cases of snake bites in summer and scorpion
bites in winter are common occurrences.
(e) Housing and Sanitation.
Sources of water in desert areas are scarce and hence, people gather around such areas leading to overcrowding,
unhealthy housing and a fall in the standards of sanitation. There is a problem of wastewater and sewage
disposal in desert areas which may cause outbreaks of fly-borne and excremental diseases.
(f) Disposal of Waste.
Disposal of dry and liquid waste problem in desert areas due to caving in of the trenches / DTLs.

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(g) Classification of Medical Problems in Desert.

There is no universally acceptable classification of medical problems in the desert. These medical illnesses
are also present in other parts of the country but get exaggerated under desert conditions. Hence, a tentative
classification is as under:
(i) Illnesses Due to High Ambient Temperature.
(aa) Heat exhaustion
(ab) Heat cramps
(ac) Heat syncope
(ad) Heat stroke
(ii) Illnesses Due to Solar Radiations Exposure.
(aa) Skin tanning
(ab) Solar dermatitis
(ac) Solar erythema (sunburn)
(ad) Ageing of skin
(ae) Rodent ulcer
(af) Cataract
(ag) Retinal degenerative changes
(ah) Pterygium
(iii) Illnesses Due to Dust.
(aa) Chronic conjunctivitis
(ab) Hyperaemia of sclera
(ac) Trachoma
(ad) Pneumoconiosis (mainly in local inhabitants)
(iv) Miscellaneous.
(aa) Prickly heat
(ab) Fluorosis
(ac) Gastro-Intestinal illnesses
(ad) Snake bite & scorpion bite
(h) Preventive Measures.
It is imperative that adequate preventive measures be adopted to keep the wastage of adequate manpower due
to sickness to a minimum. Guidelines to minimise the health hazards are given in the succeeding paragraphs.
(i) Acclimatization.
(aa) The most important prophylactic measure. Two weeks of gradual acclimatization is recommended.
(ab) Initially, troops should exercise for short durations and after a week, the duration can be
increased. After acclimatization, the troops can work and stay well in hot conditions provided an
adequate intake of water and salt is maintained.
(ii) Fluid Intake.
(aa) Moderate work in desert conditions may require 8-12 litres of water per day. During long
marches and strenuous exercises, the requirement can go up to 16 litres / day.
(ab) Water should be cold enough otherwise it will not be consumed in the right quantity. Fluids

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should preferably be taken at regular intervals in moderate quantities rather than large amounts at
one time.
(ac) Salt intake should be sufficient to compensate for loss in sweat.
(iii) Prevention of Effects of Heat.
(aa) Training of the troops should be restricted to the cooler hours in the morning and evening.
(ab) Sleep should be a minimum of 8 hours and preferably in the cooler hours of the morning.
Reveille generally should not be before 0530 hrs. As far as possible troops should be allowed for
afternoon rest.
(ac) Light and loose clothing should be worn to allow maximum circulation of air
(ad) Adequate bathing facilities should be provided for troops to maintain optimum personal hygiene
(ae) Adequate calories must be consumed by tps as contained in their ration. Dining halls should
be airy, cool and comfortable.
(af) The living area must be spacious well-ventilated and cool.
(ag) Medical examination must be thorough and regular to detect early symptoms of the effects of
heat.
(ah) Health Education of troops, including officers and JCOs on preventive measures against the ill
effects of heat should be carried out.
(aj) Cool rooms / Heat stroke Centres should be established at the various MI Rooms / Medical Units
as per the advice of SEMOs / SMOs.
(ak) Special precautions should be observed during operation / recce missions to prevent dehydration
and adverse effects of heat, by proper planning for the provision of adequate supplies of potable
water.
(iv) Hygiene and Sanitation.
It is essential to maintain strict hygiene / sanitation in camp, especially when troops are deployed for a short
duration in field conditions. In temporary camps, apart from a chlorinated water supply, the organic waste
should be promptly disposed in small pits, ensuring it is covered with sand to avoid fly nuisance, which is
usually heavy in desert conditions resulting in diarrhoea / dysentery. Kitchen waste should be disposed by
deep burial. Modified soakage pits are required for liquid waste. DTLs should be used in semi-permanent
camps. Riveting of DTLs should be done to prevent collapse. For shorter periods of stay, incinerator latrines
may be used.

12.6 Battle Physical Efficiency Test (BPET).

It has been observed that a number of casualties due to the effects of heat occur when troops are taking part in
BPET. This can be avoided by strict observation of preventive measures laid down in AO 7 / 80. The salient measures
are enumerated below:
(a) Only those troops should be permitted to take part who have been acclimatized.
(b) Attention must be paid to the time for the conduct of BPET during months from Apr to Sep when the test
must be completed before 0700 hrs.
(c) Pers taking part in BPET should be medically examined a day before the test. Individuals with any ailments
especially fever or those who feel exhausted should not be allowed to undergo the test.

12.7 Publication of Station Order.

A station order can be published to sensitise all concerned. A rough guide for outdoor Exercise based on Dry Bulb
Thermometer (DBT) reading and Relative Humidity (RH) is provided below in Table 12.1:

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Table 12.1 : Meteorological Parameters

Moderate Risk of Heat Effect High Risk of Heat Effect
Dry Bulb Temp (DBT)°C
Relative Humidity (%) Relative Humidity (%)
29.5°C 100% -
32.3°C 70-99% -
35.0°C 50-70% > 80%
37.8°C 40-50% 60-80%
40.6°C 20-40% 50-60%
43.3°C 10-30% 40-50%
46.1°C 10-20% 30-40%
48.9°C 1-10% 20-30%
Note. These meteorological parameters should be recorded as near the place of outdoor exercise as possible and
around the same time.

Suggested Reading.
1. Desert Survival Team Building Exercise [Internet]. Human Synergistics. [cited 2024 Apr 9]. Available from: https://
www.humansynergistics.com/change-solutions/change-solutions-for-groups-and-teams/team-building-simulations /
survival-series/desert-survival-situation /
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Chapter
XIII
SURVIVAL IN HAA & AND ANTARCTICA

13.1 Introduction.  
With the present body of knowledge, there is no clear demarcation as to what height above sea level constitutes
“High Altitude”. The general opinion varies and is dependent on the altitude at which definite manifestations
of high-altitude illness are likely to occur in a noteworthy proportion of the subjects. Generally, an altitude of
2,700 m and above is defined high altitude, with increasing grades of high altitude as 2,700 m to 3,600 m,
3,601 m to 4,500 m and 4,501 m to 5,400 m. Altitudes above 5,400 m are often referred to as “extreme
high altitude” wherein permanent successful acclimatization becomes very difficult.  
Around 140 million people all over the globe live permanently at altitudes of over 2,500 m and approximately
another 40 million enter high-altitude areas every year for reasons of occupation, sport or recreation. Miners in
South America go for work to altitudes as high as 6,000 m, while Indian soldiers are deployed at even higher
altitudes. Persons who are at an increased risk of being affected by high altitude illness include Native highlanders
who re-enter high altitude after staying at lower altitudes; Mountaineers; Soldiers; Trekkers; Adventurers; Miners
at high altitude; Pilgrims and porters.

13.2 The High-Altitude Environment.

Effects of high altitude are encountered among troops deployed at high altitudes and in high-altitude aviation. The
environmental conditions at high altitudes which influence physiological processes are low atmospheric pressure, low
partial pressure of oxygen, low temperature and humidity, increased intensity of sunshine and cosmic rays and isolation
under monotonous mountain conditions. The chief hazards to health, however, arise from the low atmospheric pressure,
coupled with low partial pressure of oxygen in the alveolar air leading to low oxygen tension in the blood and low
ambient temperature, all of which worsen as the altitude increases.  
The main problem with high altitude terrestrial environment is, in fact, the declining atmospheric pressure. For instance,
the atmospheric pressure which is 760 mm Hg at sea level drops down to only approximately 500 mm Hg at Leh, which
is at around 11,000 feet above Mean Sea Level (MSL). Boyle’s Law states that the partial pressure of a mixture of
gases is equal to the sum of the partial pressure of these gases and the partial pressure of these individual gases is
proportional to their concentration in the gaseous mixture. For all practical purposes, air is mainly a mixture of nitrogen
and oxygen in the proportion of 80% and 20% respectively. Thus, the partial pressure of nitrogen will be four-fifth and
that of oxygen will be one-fifth that of the atmospheric pressure at a given location. Hence, at sea level, where the
atmospheric pressure is 760 mm Hg, the partial pressure of nitrogen is 608 mm Hg (4/5th of 760 mm Hg) and that
of oxygen is 152 mm Hg.
Now as the atmospheric pressure drops with ascent from sea level (by very roughly, 25 mm Hg for every 1,000 feet
ascent), at Leh (11,000 feet) it would be approx. 500 mm Hg; and, by Boyle’s law, at this height, the partial pressure
of nitrogen would be (4 / 5th of 500) i.e., 400 mm Hg and that of Oxygen will be 100 mm Hg. It is this progressive
decline in partial pressure of oxygen in ambient air (commonly referred to as “thinning of air” or “rarefied air’) that
results in the reduction of alveolar oxygen pressure, with all the resultant pathological issues of high altitude. Thus,
though the concentration of oxygen in atmospheric air at high altitudes is still one-fifth, the net result of such reduced
partial pressure of oxygen is akin to a lack of oxygen in the air. Thus, at 11,000 feet altitude in Leh, the availability
of oxygen in the air is 13.8%, instead of 21% at sea level. The details are depicted in Table 13.1 This is the basic
environmental issue that triggers a massive cascade of physiological responses, intended to be protective, once a
human being is inducted into high altitude.

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Table 13.1 : Environmental Stressors at High Altitude

Hypobaric Hypoxia Barometric pressure falls with increasing altitude, reducing the partial
pressure of oxygen in ambient, inspired and alveolar air. (Note that there is
no change in the concentration of oxygen in air
Low Ambient Temperature Atmospheric temperature falls by 1°C per 150 m (500 ft) ascent. Perceived
temperature is further low due to frequent winds (wind chill factor)
Low Absolute Humidity Low atmospheric humidity increases the insensible water loss from the body
during respiration. This predisposes to dehydration
Increased Solar and Ionizing Ultraviolet radiation increases by 4% for every 300 m (1,000 ft) ascent. This
Radiation causes damage to cutaneous and ocular tissues

13.3 Physiology of the Adaptation Process.

The low partial pressure of atmospheric oxygen at high altitudes causes alveolar and arterial hypoxia leading to tissue
hypoxia. As described earlier, the oxygen partial pressure in alveoli is decreased at high altitudes and hence, to
compensate for this, more blood must flow into the alveolar capillary bed in each unit of time. Also, more air needs to
be sucked in by the lungs in each unit of time, as compared to sea level. Cardiac output per minute and pulmonary
ventilation increases to ensure adequate oxygenation of the blood. These responses are initially achieved by hyperpnoea
and tachycardia arising out of hypoxic drive.
As the stay at high altitude continues, the increased pulmonary and cardiac frequencies are replaced by increased
amplitudes. A series of further physiological adjustments take place depending on the rate of ascent, the altitude
attained and the period of stay at that altitude, by adaptation of the haemopoietic, cardiovascular, respiratory and
nervous systems. Glucocorticoids and vasopressin are poured into the bloodstream to counteract the stress of hypoxia
(Table 13.1). The number of circulating RBCs, haemoglobin concentration in RBC, the size and volume of red cells,
pulmonary ventilation, vital capacity, pulse rate, circulating blood volume, circulation rate and cardiac output all change.
Circulatory and haemopoietic adjustments are variable and do not normally occur to an appreciable extent among
Indians up to an altitude of 2,500 m. Further high, variation in haemodynamic and concentration of available RBCs in
the peripheral circulation are the first to appear. This is followed by an increase in respiratory and cardiac rhythm; a
haemopoietic response brought about by erythropoietin (secreted from kidneys) comes next; and finally, the increased
amplitude of respiratory and cardiac movements gradually replaces the increased frequency. This completes the early
process of adaptation.
Interstitial fluid is diverted to the vascular compartment which alters the hemodynamic and causes hypervolaemia,
thereby overloading the pulmonary circulatory system and cardiac function. Due to increased pulmonary ventilation,
the tissue CO2 is washed out, alkalosis occurs and the CO2 tension in the blood is decreased (hypocapnia). This leads
to the shifting of the oxygen dissociation curve to the left and a decrease in cerebral and coronary flow thus leading
to other complications. Alkalosis in the blood is partially corrected by increased excretion of bicarbonate in the urine,
thus restoring the left shift of the oxygen dissociation curve with ongoing acclimatization.  
But the major readjustment in the respiratory system is brought about by increased 2-3-diphosphoglycerate of RBC
which in turn offsets the effects of the left shift of oxygen dissociation curve and thus, restores oxygen delivery to the
tissues, increased sensitivity of respiratory centre to hypocapnia and by increased diffusion coefficient of oxygen at
the alveolar level. Pulmonary hypertension is a common occurrence at high altitudes, the cause of which is not clear.
In the initial phase, it is relieved by oxygen inhalation.  
Adaptive responses are triggered when atmospheric pressure reduces by 30% or at altitudes above 2,500 m. These
mechanisms are usually insensible for human beings up to about 3,000 m. However, as one ascends higher, pronounced
physiological mechanisms swing into action and symptoms of early mountain sickness manifest. In other words, these
are the initial symptoms of rapid acclimatization. When acclimatization is inadequate and the ascent is rapid, these
protective responses derange and pathogenesis begins. The severity of symptoms of altitude illnesses depends on the
rapidity of ascent, severity of hypoxia, duration of exposure and individual susceptibility. There are no specific markers
to predict susceptibility but those with poor Hypoxic Ventilatory Response (HVR) are at greater risk. Severe forms of
illnesses are commonly seen with rapid ascent to altitudes above 3,000 m by obese individuals with cardiopulmonary
comorbidities. Symptoms frequently occur during nights when an individual lies in a supine position and venous return
increases.

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13.4 Clinical Syndromes at High Altitude.

High Altitude Illness (HAI) is a collective term used to denote the group of acute clinical syndromes resulting from
exposure to high altitude environment. HAI manifest either as a progressive spectrum from mild to severe depending
on progressive exposure to hypoxia or as direct effects of severe hypoxia on unacclimatized persons. Apart from the
hypoxic effects of altitude, the mountain atmosphere is also rendered hostile by cold climate. Frostbite and chilblains
occur more frequently at high altitude than on the plains. The magnitude of occupational exposure to cold is higher
among Indian soldiers who undertake several operational commitments in the Himalayas. The effects of cold climate
are explained in a chapter VI.
For further discussion, only the effects of hypobaric hypoxia are dealt with in detail in this chapter. High-altitude illnesses
can be grouped under acute, sub-acute and chronic illnesses (Table 13.2).
Table 13.2 : Comprehensive List of Altitude-Related Medical Problems
High Altitude Illness (HAI)
Acute Acute Mountain Sickness
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Sub-acute High Altitude Pulmonary Hypertension (HAPH)
Chronic Chronic Mountain Sickness (CMS) (Monge’s Disease)
High Altitude Pulmonary Hypertension (HAPH)
Miscellaneous Altitude-related Health Problems
Thrombotic events (Venous & arterial thrombosis)
Hypertension at High Altitude
Cold injuries
Gastro-intestinal problems
Dermatitis
HA Retinopathy & Other Eye illnesses at High Altitude
Sleep impairment at High Altitude
Neuro-psychiatric effects of High Altitude stay
Altitude Exacerbated Health Problems
Sickle cell disease and trait
Coronary Artery Disease
Primary and secondary pulmonary hypertension
Decompensated congestive heart failure and COPD
Bronchial asthma
Other pre-existing circulatory, hematologic and metabolic disturbances

13.5 Acute Mountain Sickness (AMS).

(a) Etiopathogenesis.
AMS is caused by hypoxic damage to the blood-brain barrier. It is hypothesized that AMS is at one end of the
clinical spectrum of effects of cerebral hypoxia with the most severe form being High Altitude Cerebral Edema
(HACE).  

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(b) Risk Factors.

(i) Age.
Younger persons are more susceptible to AMS than older persons simply because of relatively higher
physical activity undertaken by the younger population. Relative preponderance among younger age groups
has been observed in various studies across different mountain ranges.
(ii) Gender.
No clear gender predisposition of AMS has been discovered so far. However, independent studies by Kayser
and Basnyat reported increased incidence among women as compared to men. The possibility of a bias
resulting from women reporting their symptoms earlier than their males cannot be underestimated.  
(iii) Obesity.
AMS occurs more frequently among obese individuals because of the direct effect of body weight on
cardiopulmonary function.
(iv) Altitude Reached.
Symptoms of AMS are found to occur at heights more than 4,000 m above sea level. There is a direct
association between altitude and incidence of AMS. Even the native mountainous tribes who return to their
homes at high altitude after an interval spent in the plains are susceptible to AMS.  
  (v) Speed of Ascent.  
AMS is found to occur more frequently among individuals who go too fast and too high. Air travellers are at
a higher risk than those who travel by road. Acclimatization by the prevalent norms prescribed by medical
authorities is key to the prevention of AMS. At a given high altitude, unacclimatized travellers who reach
too high by air (rapid induction) are always found to be at greater risk of developing AMS than those who
undertake a long journey by road to the same destination, with adequate rest at regular intervals.
(vi) Exercise.
Studies have shown that AMS was associated with individuals who undertook strenuous physical activity
on the day of ascent or the following days. The incidence of AMS is low among groups who undertake rest
after ascent.
(vii)   Dehydration.
Higher fluid intake has been found to reduce the incidence of AMS. At present, an evidence-based
recommendation is not available on this factor. Nevertheless, a scientific practice would be to ensure proper
hydration, in view of the various other physiological benefits it provides in comparison to a dehydrated state.
(viii) Smoking.
It has been observed that smokers tend to have fewer symptoms than non-smokers. This might be because
smokers tend to be habituated to a pre-existing, modest level of carboxy-haemoglobin and hence, may be
having a physiological state equivalent to “pre-acclimatization”. In any case, smoking is to be discouraged,
because of additional risks of thrombotic disorders and other documented adverse effects of smoking.
(c) Clinical Features.
The symptoms of AMS typically develop within six to ten hours of ascent but are invariably found to occur within
one to three days of exposure to altitude hypoxia. Onset tends to be earlier with rapid ascents, higher altitudes
and individuals predisposed to HAI by prior exposure or cardiovascular illnesses. AMS is usually a self-limiting
illness and can be managed conservatively.
(d) Diagnosis.
AMS is diagnosed by the clinical presentation based on typical symptoms in the backdrop of recent ascent to
high altitude. Symptoms of AMS include headache, light-headedness, fatigue, nausea or vomiting, poor appetite
and sleep disturbances. Physical examination and blood investigations are usually normal. Sometimes, these
symptoms may progress into wobbly gait, confusion and impaired consciousness. In such a situation, HACE is
to be suspected, it requires management in an intensive care unit.

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The Lake Louise Consensus scoring system (Table 13.3) is often used to aid diagnosis and therapeutic response.
The patient or the healthcare provider can fill out the questionnaire. A score is assigned to each of the five
symptoms. The total AMS score is the total of the symptom scores. AMS is diagnosed if there is a headache
and any one of the following symptoms and the total score is three and above, in the setting of a recent gain
in altitude.  
Table 13.3 : Lake Louise Scoring System
Symptom Score  
Headache
None   0
A mild headache 1
Moderate headache 2
Severe headache, incapacitating 3
Gastrointestinal symptoms
Good appetite, no GI symptom 0
Poor appetite and / or nausea 1
Moderate nausea and / or vomiting 2
Severe nausea and / or vomiting, incapacitating 3
Fatigue and / or weakness
Not tired or weak 0
Mild fatigue / weakness 1
Moderate fatigue / weakness 2
Severe fatigue / weakness, incapacitating 3
Dizziness / light-headedness
None 0
Mild 1
Moderate 2
Severe, incapacitating 3
Difficulty in sleeping
Slept as well as usual 0
Did not sleep as well as usual 1
Woke many times, poor night's sleep 2
Could not sleep at all 3
Total score (Lake Louise Score): Total of symptom scores
Mild AMS: 3-5
Moderate to severe AMS: ≥ 6

13.6 High Altitude Pulmonary Edema (HAPE).

(a) Epidemiology.
The first scientific description of HAPE, in the English language, was provided in 1960 by Houston. However,
there are earlier descriptions too, though the terminology was not identified. For instance, the description of the

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death of a doctor at an altitude of 15,000 feet during a rescue mission was likely to be due to HAPE. Similarly,
Ravenhill’s description in 1913 of cases of cardiac failure at high altitude would have been cases of HAPE. It
is also likely that the experiences of Hultgren and Spickard in Peru, in 1959, of cases of pulmonary edema
referred to description of HAPE. Since then, the condition has become widely recognized. Pioneering work in this
field has been undertaken by Medical Officers of the Indian Armed Forces, especially after the rapid induction
of thousands of troops into high-altitude areas following the Sino-Indian war of 1962 and subsequently during
the Indo-Pak conflict on Siachen Glacier – the highest battlefield in the world.
(b) Incidence.
In general, the incidence of HAPE can be estimated to be in a range of 0.1 to 4%. Bhalwar et al reported an
incidence rate of 5.7 per 1,000 inductions to high altitude. A higher incidence of 3.4% was reported by a Western
study by Hultgren et al, 2.5% among trekkers to Nepal and 5% among pilgrims to Nepal by Basnyat et al.
(c) High-risk Groups.
Any person irrespective of age, gender or race, who enters a high-altitude terrestrial environment, is at risk
of HAPE, including native highlanders who return to high altitude after a stay in lowlands. However, certain
groups seem to be at a higher risk due to socio-behavioural or occupational reasons. These include soldiers,
mountaineers, trekkers, adventurers, mountain sportspersons, miners working at high altitude, porters and land
pilgrims to high-altitude shrines.
(d) Time of Onset Since Induction.
The ‘latent period’ or ‘induction time’ (period elapsing from entry into high altitude to the onset of the first
manifestation of HAPE) is usually between six to 96 hours. Onset beyond this range is quite uncommon. Bhalwar
et al found the induction time among soldiers at 3,600 m, to be six to 96 hours with a median of 54 hours.
Similarly, in the case series by Menon, Singh et al and Kleiner, it was observed that a large majority of cases
occurred within three days of entry into high altitude. Following exposure to high altitude, when a subject returns
to low altitude within six hours, the risk of HAPE would be quite low. Also, the period of initial 48 hours following
ascent is most crucial for enforcing preventive measures regarding acclimatization, especially restricting physical
activity (except for self-care activities of a routine nature). It may be noted that rare cases can occur as late as
ten days also.  
(e) Recurrence Rate.
HAPE tends to recur multiple times in the same individual who has already had a prior attack during the last
exposure. The recurrences are found to be more severe than the previous episode. The recurrence rate of
HAPE in a subject who has suffered from HAPE earlier, over a follow-up period of 18 months, was worked out
by Bhalwar et al, based on a well-established and scientific central registry. The workers reported that out of
152 cases that had the first attack and followed up for 12-18 months duration, a total of five cases occurred
for the second time during the follow-up. giving a cumulative incidence of 3.29% and incidence density of 1.83
per 1,000 person-months of follow-up. The period between the first and second attack was 115 to 208 days.
All these five cases of recurrent HAPE occurred within 48 hours of entry into high-altitude areas.
(f) Risk Factors for HAPE.
(i) Age.
Younger individuals are more prone to develop HAPE than older adults. However, this may not represent
a true cause-effect relationship. Younger people tend to visit the mountainous areas more often, besides
being more inclined to perform moderate-intensity physical activities after arrival at high altitude. In fact,
in their nested case-control analysis, Bhalwar et al did not observe any significant association between
age and HAPE. However, their study participants belonged to the age group of 20-40 years. Also, there is
no evidence to indicate that children are protected; Heath and Williams reported that children up to four
years of age are at considerable risk.
(ii) Gender.
Basnyat et al observed that at an altitude of 4,300 m, women had a higher risk of HAPE as compared to
healthy male counterparts. However, as pointed out by Heath and Williams, it is the young male who is at
higher risk. It is possible that males are more likely to perform moderate-intensity physical activities soon
after arrival at high altitude, thus making them more vulnerable. With the present body of knowledge, it

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may not be possible to comment authoritatively about the gender differences unless a comparison of proper
cumulative incidence rates between men and women, with control for potential confounders, is undertaken.
(iii) Ethnic and Racial Factors.
There does not seem to be any ethnic or racial group which is specifically predisposed to or protected from
HAPE. HAPE has certain complex genetic risk factors that determine the expression of specific proteins in
pulmonary vasculature. This genetic model of HAPE is being extensively studied by modern researchers
who argue that the pulmonary capillary response to hypoxia has its basis in adaptation to high-altitude.
Such adaptation is a long and evolutionary process that is inherited by generations of children born to the
natives of mountainous terrain and it is an ongoing process. No individual can achieve total adaptation to
high altitude.
(iv) Number of Repetitive Exposures to High Altitude.
Repeated exposures to high-altitude environment have been described to be an important determinant of
HAPE. In the study by Menon, most of the cases had a prior history of exposure to high altitude environment
before the latest one, while only a smaller proportion of cases were those who had come to high altitude for
the first time. Similar findings were observed by Hultgren and Marticorena. However, it needs to be appreciated
that case series are not a reliable study design from an epidemiological point of view. Case series just describe
numbers and do not compare incidence rates. It is not unlikely that in general, the individuals who are first
exposed to high altitude make a smaller group (fresh inductees) than those who are on their second or third
visits (re-inductees). In fact, Bhalwar et al did not find any significant difference in incidence rates between
fresh inductees and re-inductees. Even native highlanders have developed HAPE when they revisited their
homes after a brief sojourn to the plains. Previous acclimatization to high altitude does not confer protection
during subsequent exposures. Re-entry, even after visiting low altitude for a few days, may predispose to HAPE
and a complete acclimatization schedule must be undertaken if a person has gone down for more than four
weeks. As per the acclimatization norms of the Indian Army, if the absence from high altitude has between 11
to 28 days, acclimatization should still be undertaken. Native highlanders are also recommended to adhere to
a similar acclimatization procedure as that for the residents of low altitude.
(iv) Tobacco and Alcohol Use.
Tobacco smokers do not seem to be at any significant risk. Similarly, moderate consumption of alcohol
after entry into high altitude does not seem to increase the risk. However, keeping in view the other health
hazards, avoidance of tobacco and alcohol use must be emphasized.
(v) Genetic Factors.
There are some indications that susceptibility to HAPE may be determined by genetic factors to some extent.
In a study by Hanoka et al, an association was observed between HAPE and certain HLA types, notably
HLA-DR6 and HLA-DQ4. Morrell et al also observed an association between pulmonary hypertension and
‘D’ allele of ACE genes among native highlanders of Central Asia. This aspect of HAPE is currently being
extensively researched. Candidates for further studies in this field include endothelial nitric oxide synthase
gene polymorphisms, angiotensin-converting enzyme gene polymorphisms and genetic determinants of
primary pulmonary hypertension.
(vi) Previous History of High-altitude Illnesses.
Persons who have suffered from an episode of AMS, HAPE or HACE during their earlier sojourns to high
altitude seem to be at a slightly higher risk of HAPE during subsequent exposures. Also, a previous history
of AMS as well as physical exertion undertaken within 24 hours of entry into high-altitude are two factors
that tend to interact with each other, thereby multiplying the risk of HAPE. As such, a history of AMS during
previous exposures significantly increases the risk of HAPO.
(vii) Cold Weather.
Observations based on case series indicate that cases are more common during the cold weather, particularly
in January. While the exact reasons are unclear, some believe that this is because most of the roads leading
to the mountains are blocked during winters and people get rapidly exposed to high altitude by air travel.
Rapid ascents predispose individuals to develop HAPE. Also, volitional physical activity may increase in cold
weather, thereby causing an increased incidence of HAPE during winters.

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(viii) Co-existing Cardiopulmonary Morbidities.

Pre-existing diseases of the cardiopulmonary system including emphysema, bronchial asthma and heart
failure are found to worsen the clinical presentation of HAPE. It is to be noted that predominantly, the
persons reaching high-altitude are young and of athletic disposition. Very often, they also undergo a
mandatory clinical examination before entering high altitude areas, which helps to screen off those with
such comorbidities. However, there is no validated predictive tool to calculate the risk of developing HAPE or
AMS due to the complex interplay of several physiological, behavioural and genetic factors in their causation.
(ix) Physical Activity at High-altitude.
Physical exercise, even of moderate intensity, undertaken within 72 hours of arrival at high altitude is an
important determinant of HAPE and is almost universally recognized by experts in high-altitude medicine,
from across the world, with a strong and significant association. In addition, physical exercise during the
first 24 hours was also strongly and significantly associated with the severity of HAPE. Singh, Kliener and
co-workers, through their independent research work in different mountainous terrains, agreed that the
majority of cases have a history of undue physical exertion within three days of arrival at high altitude. Thus,
it seems that physical exertion in the first 72 hours of arrival at high altitude determines the chances of
developing HAPE, the first 24 hours determines the severity of the illness. It is also noteworthy that HAPE
can occur even among persons who have exerted relatively less than others and even during sleep. In such
cases, there is always a history of rapid exposure to high altitude by air travel.
(x) Acclimatization.
HAPE commonly affects subjects who have not adequately acclimatized themselves to high altitude
environment soon after arrival. Acclimatization is the total of physiological responses to the hypoxia and
hypobaria of a high-altitude environment. In general, acclimatization is undertaken by one to two days of
complete rest, followed by gradual resumption of physical activities over the subsequent two to four days
at a particular altitude. This process should be repeated for every 900 m (3,000 feet) gain in altitude.
The acclimatization schedule prescribed by the Indian Armed Forces is described in a later section in this
chapter.  
(xi) Altitude of Ascent.
The “critical altitude” at which the risk of developing HAPE has been reported is 3,350 m in the Himalayas,
3660 m in the Andes and 2,590 m in the Rocky Mountains of North America. In the context of the Indian
Armed forces, an altitude above 2,700 m (9,000 feet) is considered as high-altitude.  
(xii) Rate of Ascent.
The speed with which an individual reaches high altitude is an important determinant in causing high
altitude illness. Observations have shown that among tourists who reach high-altitude areas by air where
ascents of 3,000 m and more are reached in less than an hour, the incidence rates are higher than among
those who reach the same location by road transport over a span of three to four days. Such slow gains of
altitude by road over days to weeks may permit some acclimatization. Gradual ascent with acclimatization
enroute is the key strategy in prevention. In general, at heights greater than 3,000 m, it is recommended
that the nights be spent at an altitude of not more than 300 m above the previous night’s altitude, with
one day’s rest after every two to three days’ climb (or, for every 1,000 m ascent). In certain situations, this
rate of ascent may seem slow and unrealistic. In such situations, the trip can be modified in such a way
that the altitude difference between two consecutive “sleeping sites” should not be more than 600 m per
day. Work high and sleep low is the thumb rule for a healthy ascent. Often, it is permissible to gain more
than the recommended daily altitude if daily descents are made for sleeping. Spending up to eight hours
sleeping at a low altitude is also likely to aid in the acclimatization process.
(xiii) Other Risk and Protective Factors.
There is some evidence that neck irradiation, surgery and pre-existing respiratory tract infections may act
as potential risk factors for HAPE. Consumption of antioxidant vitamins prior to induction may reduce the
severity and incidence of high-altitude illnesses. The role of Gingko biloba consumed five days before ascent
also seems to be useful by virtue of its antioxidant properties. The role of sildenafil as a preventive remedy
has also been postulated. However, tablet acetazolamide (250 mg BID orally, starting from one day before

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ascent) and dexamethasone 8mg per day in divided doses in prophylaxis for AMS have shown promising
results in the prevention and management of high-altitude illnesses.
(g) Clinical Criteria for Diagnosing High Altitude Pulmonary Edema (HAPE).
HAPE can be clinically diagnosed by typical symptoms (Table 13.4) with a history of recent ascent.
Table 13.4 : Clinical Diagnosis of HAPE
History of recent gain in altitude along with any two of Cough
the following symptoms
Dyspnoea at rest
Chest discomfort
Weakness / fatigue
                                                                 AND
Any two of the following signs Crackles / wheeze at least one lung field
Central cyanosis
Tachycardia
(h) Classification of HAPE Based on Severity.
The severity of symptoms, heart rate, respiratory rate and chest radiograph findings are used to grade the severity
of HAPE (Table 13.5).
Table 13.5 : Grades of HAPE
Respiratory
Heart Rate
Grade Symptoms rate Chest X-ray
(beats / min)
(breaths / min)
Mild   Dyspnoea on moderate exertion, < 110   < 20 Minor opacities involving < ¼
Able to perform light activity of one lung field

Moderate   Dyspnoea at rest, 110 – 120   20 – 30 Opacities involving at least

Weakness, half of one lung field
Fatigue on slight effort,
Inability to perform light activity,
Headache with cough
Serious Severe dyspnoea, 121 – 140 31 – 40 Opacities involving
Loose recurrent productive cough, at least half of each
Wheezy difficult respiration, lung field or unilateral
Obvious cyanosis, exudates involving all of one
Weakness, lung field
Headache,
Nausea at rest
Severe   Clouded consciousness, > 140   > 40 Bilateral opacities
stupor > coma, involving > ½ of each lung
Unable to stand > walk, field
Severe cyanosis,
Bubbling rales,
Copious bloody sputum,
Severe respiratory distress
(j) Management of HAPE.
HAPE is treated by immediate descent or simulated descent if the former is not possible. Supplemental oxygen
and pharmacotherapy with nifedipine are used to manage a case of HAPE.

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(k) Prognosis.
Severe HAPE is one of the common causes of mortality at high-altitude. When treatment is not taken or delayed,
it can be life-threatening due to worsening pulmonary oedema. Individuals who develop HAPE during the first
visit to high-altitude are at higher risk of developing a more severe illness during subsequent visits.  

13.7 High Altitude Cerebral Edema (HACE) and Other HAIs.

HACE was first described in 1913 by Ravenhill, but it was only after half a century that the clinical importance of this
condition was recognized. The risk factors for HACE are similar to the ones for AMS and HAPE. However, it seems
difficult to predict the likelihood of developing HACE among a cohort of individuals travelling to high altitude.
(a) Definition and Epidemiology.
HACE is a potentially fatal condition that is diagnosed clinically as per the Lake-Louise consensus criteria as the
presence of ataxia with or without altered consciousness in an individual who may or may not have AMS or HAPE.
HACE can present within one week of arrival to elevations as low as 2,700 m (9,000 ft). HACE may occur within
a shorter time frame during rapid ascent to greater altitudes and thus the features of preceding AMS may be
masked and absent. The incidence of HACE varies principally with the rate of ascent and the sleeping altitude
attained during a particular ascent. It has been reported as less than 0.1% in Indian troops at high altitude. Up
to 14% of cases of HAPE are known to have concomitant HACE, probably a result of the accentuated hypoxia
consequent to HAPE.
(b) Etiopathogenesis.
The exact pathophysiological basis of HACE is not well established. Some of the postulated mechanisms are
increased capillary permeability coupled with increased cerebral blood flow and capillary hydrostatic pressure
seen in the early days at high-altitude. It is also hypothesized that fluid retention may have a role to play in the
development of HACE.
(c) Clinical Features.
Altered mental status and truncal ataxia are the diagnostic clinical features of HACE. Mental status changes
may range from irrational behaviour progressing rapidly to lethargy, depressed sensorium, hallucinations and
coma. Associated findings may include papilledema, retinal haemorrhages, cranial nerve palsies and abnormal
reflexes. Focal neurological deficits are rare.
(d) Diagnosis.
HACE is diagnosed clinically. The presence of altered mental status or ataxia in an individual showing features
of AMS or the presence of an altered mental status and ataxia in the absence of features of AMS, in individuals
within three to five days of ascent to high altitude is HACE unless proved otherwise. Several conditions can
mimic HACE and the evidence for these must be sought when the symptoms occur without a history of recent
gain in altitude, absence of a precipitating factor such as unusual exertion, failure to respond to therapy or an
unusually rapid response to therapy.
(e) CT Imaging in HACE.
Where CT imaging is available in severe HACE it may reveal nonspecific findings of diffuse cerebral edema, such
as the absence of sulci, small ventricles and a diffuse low-density appearance of the entire cerebrum (Fig 13.1).
Diffusion-weighted MR imaging is the most reliable diagnostic modality available. T2-weighted MR imaging reveals
reversible white matter edema, especially in the splenium of the corpus callosum and the centrum semiovale,
without involvement of the grey matter.
(f) Treatment in the Field Setting.
HACE is a medical emergency requiring immediate descent to a lower altitude. Symptoms are typically seen
to resolve with a descent of 300 m to 1,000 m (1,000 to 3,300 feet). Where actual descent is not possible,
simulated descent using recompression chambers is lifesaving. Portable recompression chambers can generate
pressures up to 130 mm Hg simulating a descent of about 6000 feet. Supplemental oxygen, oral or parenteral
Dexamethasone (8 mg stat followed by 4 mg 6-hourly) and tablet Acetazolamide (250 mg 12-hourly) should be
started if available and continued till symptoms resolve. This should be quickly followed by institutional care in
a hospital with supplemental oxygen, decongestive measures to lower intracranial pressures, hyperbaric therapy

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(if available), dexamethasone, intravenous mannitol or oral glycerol and other supportive measures for the care
of a comatose patient. A recompression chamber may be used to simulate a descent to sea level, if available.  

Fig 13.1 : CT Scan in a Patient of HACE Showing Absence of Sulci, Small Ventricles,
and a Diffuse Low-Density Appearance of the Entire Cerebrum
(g) Complications.
HACE can be fatal if not managed as a medical emergency.
(h) Prognosis and Prevention.
The mortality is often as high as 25% even with prompt institution of therapy. Prevention of HACE is achieved
by the same means as for AMS. Individuals who have had an episode of severe AMS or HACE are at a higher
risk of life-threatening High-altitude illnesses (HAIs) on their later visits to high-altitude.

13.8 Chronic Mountain Sickness (CMS) and Sub-Acute Mountain Sickness (SAMS).
(a) Introduction.  
SAMS is characterized by pulmonary hypertension, right ventricular hypertrophy with or without failure, either
among infants or among adults who have stayed at a high-altitude for a few months. CMS is characterized by
excessive erythrocytosis and hypoxemia that is reversible on descent, among people who have stayed at high
altitude for long periods of time. Reliable data is not available on the epidemiological aspects of CMS and SAMS
except for isolated case reports and few case series. The occurrence of infantile SAMS was well known to the
Spaniards who first colonized the Andes Mountain ranges. Knowing that their infants would not thrive if born at
high-altitude, the children were delivered at low altitude and they were not brought to high-altitude till they were
one year old. Sui et al reported a case series from Tibetan region of fifteen infants, who died of the condition.
The majority of these infants were born at low altitude. There is a strong possibility of genetic determinants
since infants of highlanders seem to be relatively protected, while children of lowlanders born at high altitude
or born at low altitude but moving to high altitude during their infancy seem to be at particular risk.
Epidemiological descriptions of the adult form of SAMS have been provided in the form of case series among
Indian Army personnel who had stayed at extreme altitudes for prolonged periods of many months. A similar
condition known as Brisket disease among cattle manifesting as oedema in the dependant part of the neck
has been described. Adult SAMS could be the human counter part of Brisket disease. The condition manifests

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as pulmonary hypertension, right ventricular hypertrophy with or without failure and dependent oedema.
Chronic Mountain Sickness (CMS) was first described in 1925 by Monge, followed by a case series in 1928. It is
also known as Monge’s Disease. Another case series was reported by Hurtado. Descriptions from Tibet indicate
that lowlanders migrating to high altitude are at much higher risk vis-à-vis the native highlanders. Males and
tobacco-smokers are likely to be at higher risk. However, the condition is now being reported among the native
Tibetan highlanders too. Among the native highland populations, it seems that the native Tibetan highlanders
have lower haemoglobin values and are less likely to be at risk of CMS as compared to the native Andean
highlanders, possibly due to certain genetic determinants.
(b) Flare-up of Previous Infections.
Viral and amoebic hepatitis in individuals who had contracted the infections at lower altitudes run the risk of a
more fulminating course with increased fatality, at high altitude. The course is otherwise prolonged, resolution
seems to be difficult and unless evacuated to sea level, chronic protracted hepatitis may result. However, liver
function is not altered in normal individuals located at high altitude. Glucose tolerance may be slightly impaired
and a lag curve may be seen. Cases of amoebiasis, that have been successfully treated by all measures even
before five years, may flare up to frank amoebic hepatitis within weeks of their arrival at high-altitude. An abscess
may form without evidence of liver tenderness, fever or leucocytosis and may even rupture before the patient
reports sick. The clinical cure is often difficult in patients treated at high altitude. An acute hyperglycaemic
episode may be precipitated at high altitude, among diabetic patients who are stable at sea level. The condition
remits completely within a few days of return to sea level.  
(c) Other Effects.
Prolonged exposure to hypoxia may produce other minor effects insidiously after a long latent period. Diminution
of vision (cataracts), loosening of teeth, progressive diminution of work capacity, loss of weight, flatulence,
indigestion, loose bowels, anaemia, thyroid deficiency and increased severity of infections may be encountered.
Most of these symptoms usually disappear within a month of descent to the plains. Long stays at high altitude
can sensitize tissues to low oxygen tension to some extent but increases tissue metabolism. A high-protein diet
is thus essential. The atmosphere is cold and the air has very low atmospheric moisture content. The exhaled air
on the other hand is at body temperature and hence contains more moisture. Water is thus lost from the body
through expired air. Lack of interest, irritability, insubordination, irrational reaction and lengthening of reaction
time may occur. There is no increased incidence of frank psychiatric disease at high altitude in comparison
with the plains. However, altered mentation should raise suspicion of cerebral venous thrombosis. Lack of
concentration and mental impairment, which may occur on arrival at high altitude, as part of acute mountain
sickness, usually subsides within a few days. Some individuals may take a few weeks to acclimatize. In general,
there is no scientific evidence to indicate that a long-term decline in memory or decrease in libido would occur
either during stay at high altitude or after return to sea level.  

13.9 Miscellaneous Altitude-related Health Conditions.

(a) Thrombosis at High Altitudes.
Both venous and arterial thrombotic events have been reported to have greater prevalence amongst lowlanders
at high altitudes.
(b) Venous Thrombosis.
Isolated Venous Thrombosis (VT) at high altitude has been frequently reported with various case reports of
Cerebral Venous Thrombosis (CVT), Pulmonary Thrombo-embolism (PTE), Mesenteric Vein Thrombosis and Deep
Vein Thrombosis (DVT) in apparently healthy individuals at high-altitude. In the last decade, few case series
based on the Indian Army’s experience in Ladakh have highlighted the issue of increased incidence of venous
thrombosis at high-altitude. An increase in risk of venous thrombosis up to 30 times higher, in sojourners at high-
altitude as compared to the plains has been suggested. Several cases of thrombosis continue to be diagnosed
regularly amongst our troops at high-altitude. Interestingly, many of these patients are under 40 years, healthy
individuals and thrombosis occurs within days to months after they arrive at high-altitude, at altitudes ranging
from 3,300-6,000 m (11,000-20,000 feet), at unusual sites (cerebral, mesenteric, etc.) and in varied ethnic
groups.

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(c) Mechanism and Pathogenesis.

Physical and environmental factors may cause a pro-thrombotic milieu at high-altitude. Hyper-viscosity of blood
due to elevated haemoglobin may be compounded by dehydration arising from low ambient humidity especially
when an individual exerts and loses water by hyperventilation. Thirst mechanisms are known to be restricted
by ambient cold. Immobility due to reduced daily activity especially when bad weather supervenes and tight
poorly fitting clothing and accessories may further contribute to sluggish venous flow. Thus, the changes of
acclimatization coupled with environmental factors may precipitate a situation ideal for venous clot formation.
This risk is intensified in patients predisposed to thrombosis by inherited thrombophilias such as Factor V Leiden
mutation, protein C, protein S and anti-thrombin deficiency. Studies of the coagulation cascade and fibrinolytic
pathway have failed to provide convincing evidence of a pro-coagulant profile but are constrained by weak study
designs or underpowered sample sizes. Platelet number and activation patterns may have a role to play as may
endothelial dysfunction at high-altitude. However, the contribution of these mechanisms at high-altitude has not
been convincingly demonstrated yet.
(d) Diagnosis and Management.
A high index of suspicion of thrombotic ailments is required to make an early diagnosis. The occurrence of HAPE
or HACE in unusual settings such as late during stay at a given altitude, must arouse suspicion of PTE or CVT.
Initiation of oxygen therapy and evacuation to lower altitudes are the two most important therapeutic measures
at the forward post. The patient must be evacuated to a higher care centre at the earliest possible time for
further management. In the higher centre, the diagnosis must be confirmed by appropriate imaging modalities
such as Doppler scan for lower limb and abdominal veins, MRV or CECT for cortical veins and CT angiography
for pulmonary vessels and specific therapy instituted. All patients need to be started on anticoagulation with
heparin. Anti-coagulation is usually continued for at least three months for distal thrombosis such as involvement
of calf veins and up to six months for proximal veins such as popliteo-femoro-iliac or IVC thrombosis. Long-term
anti-coagulation must be administered for thrombotic episodes such as PTE, CVT and thrombosis at other unusual
sites. All cases with a strong family history of thrombosis, recurrent venous thrombosis or thrombosis occurring
at atypical sites should be evaluated for underlying inherited procoagulant state and managed accordingly.
(e) Arterial Thrombosis.
Arterial thrombosis is a recognized peril of high-altitude travel. Dehydration, haemoconcentration, cold,
prothrombotic milieu have been elucidated as aetiologies for vascular thrombosis in high-altitude, but evidence
thus far is limited, albeit conflicting. Arterial thrombosis in high altitude has been reported in relation to cardiac,
brain, mesenteric and limb ischemia. In patients with stable Ischemic Heart Disease (IHD) at high altitude,
signs of myocardial ischemia occur at similar or slightly reduced cardiac work and left ventricular contractility
is unaffected despite a possible reduction in coronary blood flow, suggesting that myocardial oxygenation is
sufficient at least after a few days of acclimatization.  
Studies have shown that the incidence of cerebrovascular complications in patients under 45 years is at least
10-12 times higher in high altitude. The risk of thrombotic events persists for quite some time even after the
individual leaves high altitude area. Hence it is recommended that the patients be followed up even after they
have left the mountains. Since sufficiently powered trials are lacking, the exact duration of follow-up cannot be
recommended with certainty.
(f) Hypertension at High-Altitude.
Several soldiers, during their fitness medical examinations after ascent to high-altitude, are found to have blood
pressure values in the hypertensive range of more than 140 / 90 mm Hg. The reasons for this may be either an
increase in blood pressure upon ascent to high altitude or a diagnosis of pre-existing hypertension during medical
examination at high altitude. In an unpublished study on retrospective records from years 2015 to 2018, incidence
rate of up to 12% was observed among a normotensive cohort of healthy Indian soldiers. An increase in blood
pressure consequent to the stressors of high-altitude sojourn such as hypobaric hypoxia, cold, apprehension etc.
may lead to hypertension, especially among the pre-hypertensives at near sea-level. The elevation in BP seen
at high altitude may be due to increased sympathetic discharge and fluid retention in the initial weeks at high
altitude reported by some workers. The sympathetic discharge is believed to settle within three months of stay
at a high altitude. Few studies have examined blood pressure fluctuations over a three-month period at high
altitude but emerging evidence from longitudinal studies suggests a decrease in blood pressure by three months
of stay after an initial increase in the first three to six weeks of stay. The effect of long-term stays for months to

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years at high altitude on systemic blood pressure has not been studied extensively. Keeping in mind the likely
effect of high-altitude on endothelial function, the possibility exists that systemic hypertension may develop or
be accelerated by high-altitude exposure. Long-term longitudinal studies need to be conducted before this issue
is set to rest.
(g) Prevention of High-Altitude Illnesses (HAIs).
Individual tolerance to hypoxia varies and cannot be correlated entirely with one’s physical fitness. Rapid ascent
without acclimatization followed by undue physical exertion increases the risk of effects of hypoxia. As discussed
earlier, acclimatization cannot always help even robust persons. Therefore, commanders may be reminded that
more man-hours of work or more working hands are required to perform similar physical tasks at high altitude
than in the plains. Acclimatization is the cornerstone of the prevention of hazards of high-altitude. It needs
to be noted that even after complete and successful acclimatization, the capability to perform an exercise or
physical task will be reduced at high-altitude in comparison to lower altitudes. This was evident during the
Mexico Olympics of 1968, held at an altitude of 2,300 m wherein most of the world-class athletes experienced
as much as 13% reduction in their performance. Evidence also suggests that for healthy acclimatized subjects,
the physical capability will reduce to 70 to 75% at an altitude of 3,100 m when compared to capability at sea
level and would be about 50 to 60% at 4,000 m. Care should be taken, therefore, by all subjects moving to
high altitude, to make realistic adjustments in their expectations regarding task performance. Medical officers of
armed forces should also impress this aspect on their respective commanders so that they can make realistic
judgments of requirements of manpower for a given operational task at high altitude. Following measures to be
taken to prevent adverse effects of high altitude:
(i) Ensure a strict acclimatization schedule.
(ii) Take precautions against cold injuries.
(iii) Education and motivation of all ranks about benefits of acclimatization and planning of manpower
for given tasks.
(iv) Avoidance of tobacco and moderation of alcohol.
(v) Good hydration.
(vi) Hot palatable meals.
(vii) Warm and comfortable shelter.
(viii) Maintain morale and psychological well-being.

13.9 Acclimatization.
(a) Introduction.
It is important that soldiers posted above 2,700 m should be systematically acclimatized. Individuals working
at a higher altitude should sleep at a lower altitude during the period of acclimatization. When the troops have
acclimatized to a certain height, they can operate at those heights or even at slightly higher heights without any
increased risks. This initial acclimatization is enough if the individuals do not go beyond 3,600 m. If they are
required to be stationed at a height of more than 3,600 m, they will require further spells of acclimatization.
For individuals who return to high altitude after a period of stay in plains for more than ten days at a time,
acclimatization is necessary on their return to high-altitude area. The tenure of stay should be such that an
individual remains in an excellent state of health and physical fitness during his stay. It has been found that
the desirable maximum period of stay should be 24 months between 2,700-4,200 m and 12 months above
4,200 m but below 4,800 m and about two months at a stretch for staying at altitudes beyond 4,800 m.
However, these recommendations need to be guided by operational requirements. Doctors of armed forces should
advise the commanders regarding needful rotation of personnel, with a view to maximize the performance and
minimize hazards.  
(b) Staging Schedule in Indian Armed Forces (Army Order 110 / 80).
Considering the need to prevent or reduce the occurrence or severity of acute HAIs and the existing topographical,
logistic and operational constraints, a staged ascent schedule to high altitude is practised. This is referred to as
the “acclimatization schedule” (Table 13.6). However, “staging schedule” is a better term since acclimatization

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carries on for several weeks to months after arrival at a high altitude. The importance of the staged ascent
schedule employed by the Indian Army has been proven over more than three decades of use with incidence
rates of serious acute HAI such as HAPE and HACE being lower than the internationally reported figures. It is
done in three stages. Considerable inter-individual variability exists in the response to acclimatization. Adherence
to acclimatization schedule neither implies a return of exercise capacity to sea-level values at the end of any
stage or during any time of stay in high-altitude nor absence of the likelihood of acute High Altitude Illness
(HAI) if precipitating factors such as subsequent ascent, unusual exertion or concurrent illness occurs. If an
individual is directly taken to a higher stage, complete acclimatization as applicable for the first stage should be
recommended. For example, if a person is inducted by air, from the plains, directly to a height of 14,000 feet
(4,200 m), he should have six days of first-stage acclimatisation (and not only four days of schedule normally
recommended for this height, for second stage). For individuals who travel through the Pathankot-Manali-Upshi-
Leh, specific instructions are laid down by HQ Northern Command regarding acclimatization for soldiers entering
Leh. Acetazolamide and ascorbic acid are often recommended for prophylaxis.
Table 13.6 : Acclimatization Schedule for High Altitude
Acclimatization Schedule (As Per AO 110 / 80)
This is for individuals arriving at heights between 2,700 m to 3,600 m (9,000 feet to 12,000
feet). The staging period is for six days as under:
First and second day   Rest, except for short walks in the unit lines only, not involving any
Stage 1 climbs
Third and fourth day Walk at slow pace for 1.5 to 3 km. Avoid steep climbs
Fifth and sixth day Walk up to 5 km and climb up to 300 mtrs at a slow pace
On ascent to altitudes above 3,600 m and up to 4500 m (12,000 feet to 15,000 feet) after
completion of Stage 1. This is carried out for four days as under:

Stage 2 First and second days   Slow walk for a distance for 1.5 to 3 km; avoid steep climbs
Third day Slow walk and climb up to 300 m
Fourth day Climb 300 m without equipment

On further ascent to altitudes above 4,500 m (15,000 feet) after completing stages 1 & 2 of
Stage 3
ascent protocol. This also lasts for four days and is on the same lines as second stage

Acclimatization Schedule for Re-entry to High-altitude

AO 110 / 80 also lays down the entry schedule for soldiers returning from the plains after ten days of absence
but less than 28 days absence from high-altitude as follows:
First and second day Rest, except short walk
Third day Walk at slow pace for 1 to 2 km. Avoid steep climb
Fourth day Walk for 1 to 2 km, climb up to 300 m
This schedule is to be followed at every stage of ascent i.e. 2,700 to 3,600 m (9,000 feet to 12,000 feet), 3,600
to 4,500 m (12,000 feet to 15,000 feet) and > 4,500 m (15,000 feet)
If the individual has been in the plains for more than four weeks, then the entire acclimatization schedule must
be repeated as for a fresh visit to high-altitude.
(c) Simulated Descent.
Adverse effects of high altitude, particularly HAPE and HACE should be managed as medical emergencies; prompt
first aid and evacuation would be lifesaving. Medical officers should be familiar as to how to distinguish between
AMS on one hand and HAPE or HACE on the other; Unnecessary evacuation in case of AMS may deplete the
manpower while not evacuating a case of HAPE or HACE to a higher echelon could be disastrous for the patient.
If this is not possible, artificial recompression in a “Portable HAPO Bag” or else in a recompression chamber
at the dependent hospital should be undertaken (Fig 13.2 & 13.3). At the level of RMO or Nursing Assistant at

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the periphery, the essentials of first aid are outlined as below:

(i) Reassure the patient
(ii) Complete rest; no physical activity; manage as stretcher case
(iii) Oxygen inhalations 4-5 ltrs / min
(iv) Establish intravenous line
(v) Call for evacuation
If evacuation is not possible, a viable alternative is to place the patient in a recompression chamber which
virtually de-inducts the patient to lower altitudes. The pressure is maintained at 1 atmosphere. Hyperbaric
pressure above 1 atmosphere is not indicated. Severe cases of HAPE and patients with evidence of cerebral
oedema must be treated in a recompression chamber, if not evacuated to sea level. The average duration of
treatment in a recompression chamber is 16 hrs. In forward areas where a portable one-man recompression bag
is available, all measures should be taken to stabilize the patient using available resources on-site and attempt
to consult the specialist at tertiary care centre via telemedicine node if available and then evacuate the patient
in a fit-to-evacuate condition.

Fig 13.2 : Portable Hyperbaric Chamber (One Man HAPO Bag)

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Fig 13.3 : Hyperbaric Chamber in a Hospital

Suggested Reading.
1. “Clinical and Echocardiographic Predictors of in–Hospital Mortality in St Elevation Myocardial Infarction in a
Territory Care Center., IJSR - International Journal of Scientific Research (IJSR), IJSR | World Wide Journals.” Www.
worldwidejournals.com, www.worldwidejournals.com/international-journal-of-scientific-research-(IJSR)/article/clinical-
and-echocardiographic-predictors-of-in-hospital-mortality-in-st-elevation-myocardial-infarction-in-a-territory-care-center/
MjQwMTU=/?is=1&b1=29&k=8. Accessed 2 Apr. 2024.
2. Dehnert, Christoph and Peter Bärtsch. “Can Patients with Coronary Heart Disease Go to High Altitude?” High
Altitude Medicine & Biology, vol. 11, no. 3, Oct. 2010, pp. 183–188, https://doi.org/10.1089/ham.2010.1024. Accessed
9 Apr. 2020.
3. Jha, Sudhir Kumar, et al. “Stroke at High Altitude: Indian Experience.” High Altitude Medicine & Biology, vol. 3,
no. 1, Mar. 2002, pp. 21–27, https://doi.org/10.1089/152702902753639513. Accessed 22 Jan. 2022.
4. Mehta, SR, et al. “Acute Mountain Sickness, High Altitude Cerebral Oedema, High Altitude Pulmonary Oedema:
The Current Concepts.” Medical Journal Armed Forces India, vol. 64, no. 2, Apr. 2008, pp. 149–153, https://doi.
org/10.1016/s0377-1237(08)80062-7.
5. Oommen Savina George, et al. “Proof of Concept Study – Alternative Pharmacoprophylaxis for High-Altitude
Pulmonary Edema: A Hospital-Based Randomized Controlled Trial.” Medical Journal Armed Forces India, 1 Oct. 2023,
https://doi.org/10.1016/j.mjafi.2023.07.015. Accessed 27 Mar. 2024.
6. Ramchandani, Rashi, et al. “A Systematic Review of Electrocardiographic Changes in Populations Temporarily
Ascending to High Altitudes.” Current Problems in Cardiology, vol. 48, no. 5, 1 May 2023, pp. 101630–101630, https://
doi.org/10.1016/j.cpcardiol.2023.101630. Accessed 2 Apr. 2024.
7. Sharma, Poornima, et al. “A Study of Survival Strategies for Improving Acclimatization of Lowlanders at High-
Altitude.” Heliyon, vol. 9, no. 4, 1 Mar. 2023, pp. e14929–e14929, https://doi.org/10.1016/j.heliyon.2023.e14929.
8. West, John B. “High-Altitude Medicine.” American Journal of Respiratory and Critical Care Medicine, vol. 186,
no. 12, 15 Dec. 2012, pp. 1229–1237, https://doi.org/10.1164/rccm.201207-1323ci.
n

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Chapter
XIV
MEDICAL AND OTHER ASPECTS OF NBC WARFARE

14.1 Nature of Radiation and its Action on Living Cells.

Transfer of energy from sun to earth by radiant heat and light is a well-known phenomenon. This radiant heat and
light can be stopped by opaque objects, which are interposed in the path of these radiations. These radiations
form only a small region of the whole spectrum of electromagnetic radiations, ultraviolet, visible light and infrared
region. More than 90 percent of the ultraviolet radiation, which is incident on the earth’s atmosphere is absorbed
by the ozone layer surrounding the earth. So the presence of the ozone layer is important for the living beings
on the earth.
The knowledge of the biological effects of radiation has been built over the past through experience in the fields
of early X-ray workers, luminous dial painters, patients who have been administered radium salts and high doses
during radiation, uranium miners, atomic bomb survivors in Japan, victims of reactor accidents and children of
mothers who is received radiation exposure during pregnancy.

14.2 Types of Radiation.

Several kinds of penetrating radiations are known of which common types are the following:
(a) Alpha Particles.
These nuclei of helium atom are swiftly moving particles of high energy, carrying a positive electric charge. They
have little power of penetration, passing into soft tissue upto only fraction of a millimeter and thus irradiation of
the body from outside with alpha particles is of little significance. However, they may affect living tissues when
released by radioisotopes within the body.
(b) Beta Particles.
These are fast moving energy carrying particles (electrons) of very small mass with a negative charge. The amount
of energy carried varies and their penetrating power will also vary accordingly. In general beta particles are more
penetrating than alpha particles and can traverse distances up to a centimetre or more in soft tissues. For this
reason, these are valuable therapeutically and radioactive substances emitting beta radiations are used for the
destruction of superficial tumours. However, heavy doses from outside the body can damage the superficial
tissues and if beta emitting substances are ingested, destructive effects within the body may be produced.
(c) Gamma Rays.
These are electromagnetic radiations of high energy emitted by atomic nuclei. Like alpha and beta particles,
these are produced in the process of natural or artificially induced atomic disintegration. Gamma rays have great
penetrating power in comparison with alpha & beta particles and the more energetic gamma rays can traverse
the whole body with relatively little absorption. As a result almost the whole thickness of the body may be
irradiated by gamma radiation and this is the deciding factor in producing the general illness, which may follow
this type of irradiation. The properties of gamma rays are essentially similar to those of x-rays but in general
gamma rays have more energy and penetrating power compared to x-rays.
(d) X-rays.
These are also electromagnetic radiations, which are usually produced artificially by electrical machines and their
origin is from the electronic structure of the atom. These are widely used both diagnostically and therapeutically
in medicine, varying considerably in their penetrating power according to the electrical potential used in their
production. The biological effects of x-rays are brought about by high-energy electrons, which are liberated in
the tissues during the passage of the rays, thus the biological action of x-rays and beta particles is essentially
the same.

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(e) Neutrons.
These are primary constituents of atomic nuclei and may be liberated with considerable energy. These carry no
electrical charge and are therefore not repelled by the charged nuclei of atoms. These enter into the atomic
nuclei to build up unstable structures, which often disintegrate with the production of artificial radioactivity. Fast
neutrons act mainly by collision with the hydrogen of water and of other compounds which the tissues contain,
the resultant recoiling hydrogen nuclei are called protons. The fast neutrons are gradually slowed down in the
tissues and may then bring about biological effects by interaction particularly with nitrogen. They may also be
captured by the hydrogen nuclei, thereby releasing energetic gamma radiation.

14.3 Ionization.
Ionizing radiation loses its energy in the medium by knocking out an electron and sharing part of its energy with the
electrons. This results in a number of electrically charged atoms, molecules and electrons along the path of ionising
radiation, which are called ions. For this reason, this is called ionising radiation. Every radiation is characterised by the
power of penetration as well as the ionizing capacity. It is the production of these electrically charged particles or ions,
which is mainly responsible for initiating the physicochemical changes in the living tissue that lead to the production
of radiation damage or biological effects.
The biological effects of radiation are closely related to its dose, the period of exposure and the type of radiation. The
intensity of a beam of x-rays or gamma rays is simply the measure of quanta striking a particular area in a given time,
the radiation being regarded as consisting of small units of energy called quanta. The radiation dose may be described
as the energy, which is absorbed in the small mass of tissue upon which the radiation impinges. Living tissues are
not inert. After damage by radiation, repair processes take place and the rate at which the dose of radiation is given
becomes an important factor in determining the biological effects. Thus, if a dose of radiation is spread out over
many years, the response may be very much smaller than or even quite different from that which would occur if the
same amount of radiation were given in a very short time. On the other hand, with some forms of biological damage
produced by radiation (like gene mutations) recovery does not occur.

14.4 Measurement of Radioactivity.

Biological effects of radiation depend upon the amount of energy absorbed in the tissues. An atom emits certain amount
of energy in the process of disintegration. The total rate at which the tissues are in-adiated therefore depends upon the
rate of disintegration. In assessing the effects of radioactive material within the tissue, the use of radioactivity units,
which depend upon the number of atomic disintegrations per second, is necessary. Based originally on the rate of
atomic disintegration of radium, the unit of radioactivity is called the Curie and represents the amount of an element
in which 3.7 x 1010 disintegrations occur per second. This is too large an amount of radio- activity for most biological
work and it is customary to measure the amount of radioactivity in the body in microcuries i.e. 3.7 x 104 disintegration
per second. The present SI Unit is “Becquerel”. The conversion factor from SI Unit to present unit is 2.703 x 10-11 and
present unit is 37 kilo Becquerel = 1 microcurie.
The method of measuring the disintegration of a radioactive substance is in terms of half-life. The time taken for
activity to decrease to half its original value is known as half-life and is also called physical half-life (Tp). When isotope
is administered into man, it is excreted out. The time required by the administered activity to excrete to half is termed
as biological half-life (Tb). The effective half- life of radioactive substance in the body is as follows:
Teff
= Tp x Tb
Tp + Tb

14.5 Measurement of Dose.

Roentgen is a unit of measure of exposure. It was only in 1951 that International Commission on Radiation Units (ICRU)
clarified that Roentgen is the unit of exposure dose. Exposure at a point is a measure of the radiation at that point based
upon its ability to produce the ionisation in air. Thus, the unit Roentgen (R) is defined as the quantity of x or gamma radiation
such that the associated corpuscular emission per 0.001293 gram of air (i.e. 1 cc of air at NTP: Normal Temperature &
Pressure) produces ions carrying one electrostatic unit of quantity of electricity of either sign. In the matter of assessment
of biological effects, the energy absorbed by the medium • from the exposure of radiation is an important factor. One
Roentgen corresponds to the absorption of 87.7 ergs /gm of air. The Roentgen is unit of exposure, which applies only to
x- or gamma radiations with air as medium. SI Unit for exposure is measured in coulombs per kg.

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(a) Rad.
As mentioned earlier, Roentgen is a measure of exposure and is used in assessing the biological effects in tissues
due to radiation exposure. The measurement of the energy absorbed in the tissue has become a necessity, which
is called absorbed dose or simply dose. A measure of dose is called rad (radiation absorbed dose). This measure
of dose includes all types of radiation irrespective of particulate or nonparticulate matter. The rad is defined as
an energy deposition of 100 ergs per gram. This was first defined by ICRU in 1954. SI Unit for absorbed dose
is Gray with 1 gray equal to 100 rad.
(b) Kerma.
Kerma (Kinetic Energy Released in Matter) is a unit just like Roentgen which is meant for all media and includes
all indirect ionizing radiation (x-rays, gamma rays and neutrons). It is measured in energy/ unit mass.
(c) Rem.
Even though rad is a useful unit, it transpires that in biological system the same degree of damage is not
necessarily produced by the same absorbed dose of different types of radiation. In order to account for this,
a factor known as Relative Biological Effectiveness (R.B.E) or Quality Factor (Q.F.) has been introduced, which
reflects the ability of the particular type of radiation to cause damage. The quantity obtained when absorbed
dose is multiplied by R.B.E. or Q.F. is known as Dose equivalent, the unit of which is rem.
(d) Relative Biological Effectiveness.
Relative Biological Effectiveness depends upon the density of ionisation caused by radiation. The values of RBE
or QF for different types of radiation are given below:
Types of Radiation QF or RBE
X-Ray or B 1
Thermal neutrons 3
Fast neutron 10
In Sl units of dose, equivalent is measured in Sieverts (SY). One Sv = 100 rem.
Certain measurements, which were preferred in exposure quantity and expressed in its special unit the roentgen,
have now been replaced by air kerma measured in free air. An exposure of 1 roentgen is equivalent to an air
kerma of 8.7 milligray (mGy). Specific gamma ray constants are now replaced by air kerma rate constants,
expressed in units such as wGy h-1. GBq-1. at 1 meter. (Table 14.1)
Table 14.1 : International System of Units
S. No. Radiation Quantity SI Unit Special Unit
1. Adsorbed dose 1 gray (Gy) 100 rad
1 Centigray (Cgy) 1 rad
2. Dose equivalent 1 Sievert (Sv) 100 rem
10 millisievert (mSv) 1 rem
10 microsievert (µSv) 1 millirem
3. Radioactivity 1 becquerel (Bq) 1 disintegration per second (dps)
37 Kilobecquerel (K Bq) 1 microcurie (µCi)
37 megabecquerel (M Bq) 1 millicurie (mCi)
37 gigabecquerel (G Bq) 1 Curie (C)

14.6 Action on Living Tissues.

The radiation acts primarily upon the cell and its constituents and upon the complex chemical processes occurring
in these, rather than upon the fluids in which the cell is bathed. The processes associated with the formation of ions
during the passage of radiation lead to changes in some of the highly organised molecular systems within the cell.
These changes are probably brought about by highly reactive chemical intermediates liberated within the cell subsequent

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to the physical process of ionisation.

All living tissues are killed when exposed to large doses of radiation. Different types of organisms, tissues and cells vary
greatly on the amount of radiation, which they can withstand. Among the mammals, the dose of x-rays to the whole
body, which will kill 50 percent of an animal species varies from 200-1000 R-(2-1O Gy) depending on the species (for
man it is thought to be between 400 and 500 R (4-5 Gy) There is also a wide variation in sensitivity between different
animal tissues. For instance, in man, the most sensitive tissues include the lymphatic glands, the epithelium of small
intestines and bone marrow whereas adult nerve and muscle tissues are less sensitive. Variations in the sensitivity
also occur at different stages in the life cycle of a cell; for example, cells about to divide are often more sensitive
than those in the resting stage.

14.7 Repair Processes.

In case tissue damage is less, the situation is modified by a process of repair, but a distinction must be drawn between
true recovery in which the damaged cells return to normal form and function and the replacement of injured cells by
those coming from outside the field of radiation. The latter is a more conspicuous form of repair after heavy radiation
damage in the higher animals and leads to the original tissues being replaced by simpler and unspecialised material
or scar tissue. Repair processes within the individual cell are not yet well understood and still a matter of speculation.
An understanding of such repair processes plays an important role in low-level radiation effects.

14.8 Effects of Radiation on Health.

The effects of ionizing radiations on human beings are based on four main sources; uses of x-rays and radium in
the treatment of disease, mainly concerning knowledge of occupational hazards of medical radiologists, workers in
luminising industry and miners of radioactive ores; study of the victims of atom bomb explosions and from animal
experiments. Observation of patients receiving radiotherapy has yielded information on the general effects of radiation
and on the effects produced in different tissues by external radiation and the therapeutic use of radioactive isotopes
has provided data on the effects of radioactivity within the body i.e. internal exposure. The other sources of data on
effects of radiation include:
(a) Radiological worker exposed to external radiation, by x-rays and gamma rays leading to skin cancer or bone
marrow damage resulting in blood dyscrasias.
(b) Luminising dial painters who used radium, mesothorium and radiothorium in paints, developed bone
tumours. This is due to their ingestion and retention in the skeleton.
(c) Miners who worked in an atmosphere containing high concentration of radon developed lung cancer. The
study of different hazards has contributed to the knowledge of harmful effects of radiation and has helped to
formulate safety standards. Atomic bomb explosions over Hiroshima and Nagasaki brought wide spread destruction
to both the cities. About 15 to 20 percent casualties were caused by the gamma and neutron radiation emitted
during the explosion. The observations of these casualties regarding immediate and delayed effects of radiation
have given baseline information on this subject.
Radiation hazards may be external or internal. The external hazards arise from the exposure of the whole body or its
parts to penetrating radiations (like gamma ray or x-ray or neutrons) from sources outside the body. Alpha ray emitters
are not an external hazard since alpha rays cannot penetrate even a fraction of a millimetre into the tissue. Beta
rays will not normally be a significant external hazard since clothing will act as a barrier but beta emitters in contact
with the skin can produce some harmful effects like loss of hair and skin burns. Internal hazards originate through
the incorporation into the body of radioactive materials. This may arise through inhalation of radioactive dusts and
vapours, from ingestion of active material through eating and drinking or through cuts and wounds. Depending upon
the nature of the isotope, the radiation it emits, its half-life-physical as well as biological, the critical organ in which
the isotope concentrates etc., even extremely minute amounts of internally deposited radioisotopes may be hazardous.
The effects also depend upon the rate at which the radiation dose is received. ‘Acute’ exposure (received in a short
period) is more injurious than protracted or chronic exposure. This is because cells have a certain capacity for repair
and recovery from the radiation injury. Thus, a whole-body exposure to 600 R (6 Gy): would be lethal if received as a
single exposure. The same dose spread over a period of 20 years should not cause appreciable clinical effects.
Biological effects can be classified as somatic and genetic. Somatic effects are manifested in the person exposed to
radiation. These may be manifested soon after exposure (within a few days) while certain other effects exhibited after
a latent period of several years. Genetic injury does not affect the exposed persons but their progeny. The exposure to

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radiation of sex cells of a person damages the genetic material causing “gene mutations.” During reproduction one of
the damaged cells may take part in the fertilization process, the fertilized cell carrying the defect and repeating itself
during successive divisions. This leads to a defective offspring. Biological effects can also be classified into immediate
and delayed effects. Immediate effects are mainly due to acute exposure whereas the delayed effects are due to
chronic low exposures. Direct relationship between the effect and radiation dose depends upon the threshold of a
person. These are called non-stochastic effects. In the low dose irradiation range, there is no threshold dose where the
effects could be observed. These are called stochastic effects like induction of cancer, leukaemia and genetic effects.

14.9 Immediate Effects of Radiation.

A summary of the immediate effects in human beings related to radiation dose when the exposure is acute and to
the whole body is given in Table 14.2.
Table 14.2 : Acute Whole-Body Exposure
Acute Dose Effects
5,000 R (50 Gy) Immediate and persistent non-effective mass until death
1,000 R (10 Gy) Initial sickness appears in 1 hour or less. There may be no latent period. No survivors are
expected.
650 R (6.5 Gy) Initial sickness appears in all personnel within 4 hours and lasts for about one day. The
latent period is one week. Death ensues in about 2 weeks in about 95 percent of the
cases. Survivors are non-effective for 6 months.
450 R (4.5 Gy) Initial sickness appears in all personnel during first day. The latent period is 2 weeks.
About 50 percent deaths may be expected but can be reduced by giving adequate medical
treatment. Survivors are non-effective for six months.
300 R (3 Gy) Initial sickness during first day in all personnel. After about 3 weeks of latent period, about
25 percent deaths may be anticipated but this may be reduced by giving adequate medical
treatment. Survivors are non-effective for 3 months.
200 R (2 Gy) Initial sickness during first day in about 50 percent of personnel. Second period of sickness
appears after about 3 weeks and lasts for 1 to 2 weeks. No deaths anticipated unless
recovery is complicated by poor health. other injury or infection.
100 R (1 Gy) Initial sickness in about 2 percent of personnel. All are able to perform duty.

14.10 Acute Radiation Effects on Individual Systems.

(a) Central Nervous System.
An acute dose of 1600 R (16 Gy) or more will cause brain damage with severe oedema causing unconsciousness
within three to four days followed by certain death. The higher the dose, the more rapid is the onset of
unconsciousness. Loss of sphincter control may be a sign of central nervous system involvement.
(b) Gastrointestinal Tract.
A dose of 400 R and higher will cause radiation sickness with nausea, vomiting and diarrhoea. The higher the
dose the more quickly the symptoms appear. Where vomiting comes on immediately and persists for several days
without interruption, the dose received will probably prove lethal. Vomiting may also be induced by psychogenic
factors. Denudation of gastro-intestinal tract with haemorhages will follow doses of 900-1000 R (9-10 Gy) and is
lethal within one or two weeks. The G-I tract is hyperactive initially but later on atony sets in.
(c) Bone Marrow.
Depression of the haemopoietic activity of the marrow will be caused by doses as low as 200 R (2 Gy). Even
after 200 to 300 R (2-3 Gy) improvement may occur without any symptoms, unless complications such as pre-
existing illness, pregnancy, trauma and thermal burns are also present. Doses of 400 to 600 R (4-6 Gy) may
result in total aplasia of the bone marrow. Restoration may occur spontaneously by proliferation of primordial
cells, provided the period of acute cellular depletion of the blood is tided over. Irreversible aplasia results from
doses of 700 to 900 R (7 to 9 Gy).

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(d) Lymph Nodes.

The lymph nodes become atrophic and depleted of cells after doses of 400 to 500 R (4-5 Gy). This condition
becomes irreversible if 700 to 900 R (7-9 Gy) have been received.
(e) Skin.
Following 400 to 500 R (4-5 Gy) hair will usually be lost in bunches within 12 to 14 days. Alpha particles
cause damage only if inhaled or ingested.

14.11 Delayed Effects of Radiation.

Delayed effects of exposure to radiation may occur at any time after the end of the second month. Disorders of the
skin and underlying soft tissues and bones may occur. There may be subsequent development of cancer. Cataracts,
severe anaemia and leukaemia have been caused. There is evidence from animal experiments that exposure to radiation
may cause death at a prematurely early age. There may be inhibition of immune response. Radiation exposure may
be harmful to the genetic material, which may be transferred from one generation to the other.

14.12 Leukaemia.
Leukaemia is a disease in which there is an uncontrolled over production of white blood corpuscles. Experiments on
animals have shown that the incidence of leukaemia is increased by irradiation. Clear evidence that the same is true
of the man, comes from two main sources; a study by the Atomic Bomb Casualty Commission of the incidence of
leukaemia in Hiroshima and Nagasaki and a survey of the incidence of leukaemia among patients treated by radiation
for ankylosing spondylitis. The latent period, that is the average length of the period between exposure and the first
appearance of symptoms of leukaemia was about six years. The conditions of exposure to radiation in Hiroshima and
Nagasaki and in the treatment of ankylosing spondylitis are not comparable with the irradiation in small doses over
long periods which might be received by persons engaged in work with a possible radiation hazard i.e. in radiologists
mainly. Some evidence has been presented suggesting an increased death rate due to leukaemia among radiologists.
All evidence indicates that the incidence of certain types of Leukaemia increases in children as a result of prenatal
irradiation at high dose rate of 5-50rads (5.50 cGy). Radiation induced leukaemia’s tend to occur most frequently
within a few years (six years) after exposure, and, after 25 years, the frequency tends to return to levels expected in
the absence of irradiation.

14.13 Cancer.
Two characteristics of cancer induced by radiation are noteworthy: (i) the tendency of tumours to arise in tissues already
severely damaged by radiation and (ii) the long latent period, 20 years or more, before they appear.
Studies of people exposed to internal irradiation include workers and patients contaminated with radium, mesothorium,
plutonium and radioactive strontium and also miners exposed to radon gas. Radium, plutonium and strontium are
accumulated and retained in the bone thereby irradiating bone-forming cells continuously at a decreasing rate for
decades after being absorbed into the body and give 1ise to bone tumours.
Studies of pitchblende miners suggest that the inhalation of the radioactive gas radon may lead to cancer of the
lung. The frequency appears to rise in proportion to the level and duration of exposure. The latent period has been
about 20 years and the dosage to lungs over this period may be about 1000 rads (10 Gy) due to alpha radiation.
Lung dosimetry is extremely difficult and the role of other carcinogenic factors such as smoking habits is very difficult
to assess. In theory, the inhalation of radioactive particles in the fallout from atomic explosions or in the vicinity of
nuclear reactors could also lead to cancer of lung. But the hazard due to fallout from atomic explosions in peacetime is
extremely unlikely and steps are always taken to ensure that such incidents do not occur. Lung cancers appear to have
been induced at Hiroshima by doses estimated on the basis of crude assumptions to be equivalent to some 30 rads
(30 cGy) of external gamma radiation and to have increased with dose upto about 100 rads (1 Gy). The data indicates
that from 10 to 40 cases of cancer per rad (cGy) per million exposed (at 200 rad to 300 rad (2-3 Gy) respectively)
will develop during the first 25 years after exposure to high dose of gamma radiation.
Information is also available on the induction of thyroid and breast cancers. Breast cancer mortality at Hiroshima
suggests a risk of 6-20 cases per million per rad (cGy) in the first 25 years after irradiation among women exposed
to between 60 and 400 rads (0.6 and 4 Gy). This is probably an underestimate of the situation. For thyroid cancers,
an average of about 40 cases per million in the same range of irradiation over the same period of time is obtained.

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The estimate has large uncertainties due to small number of cases observed. Cancer of the thyroid gland in children
has been a sequel to irradiation of neck for enlargement of the thymus gland. This form of cancer is distinguished
by its short latent period (about 7 years) and comparatively low dosage of radiation required to induce it. There is a
possibility of other factors also involved in addition to the direct effects of irradiation.
Cancer of the skin was the earliest form of radiation-induced tumour to be described in man. By 1911, before the
adoption of proper safeguards, fifty-four cases have been described among the pioneers of radiology. The doses of
radiation which have led to the formation of skin cancers must have been high--in the order 1000 rad (10 Gy) and
above (partial body exposure).

14.14 Other Delayed Effects.

There may be other delayed effects like aplastic anaemia, cataract formation and temporary loss of hair. Miscarriage
and stillbirth may be a consequence of irradiation during pregnancy. But they do not constitute a problem unless the
dose of radiation is large. A number of different developmental abnormalities have been described in the children
whose mothers were treated by irradiation during pregnancy, the most conspicuous defect being microcephaly, a partial
failure of the development of the brain. Number of cases so classified are recorded in children with irradiation, before
birth in Hiroshima and Nagasaki.

14.15 Genetic Effects of Radiation.

The genetic material consists of chromosome (microscopically visible structures within cell nuclei) and genes (functional
units being the chromosomes, which cannot be distinguished microscopically). These structures are present in all the
body cells. But only those in the reproductive cells me transmitted to the fertilized ovum. Where the reproductive
cells are irradiated, changes may be produced in the genes or in the chromosomes of these cells and subsequently
transmitted to the descendants of the individual. These genetic changes are of different kinds:
(a) Gene-mutation i.e. alterations in the function of individual gene.
(b) Chromosomal aberrations resulting from breakage and reorganisation of chromosomes, and
(c) Changes in the number of chromosomes. Some of these changes result in offspring suffering from
abnormalities, which may range from mildly detrimental to severely disabling lethal disorders.
Spermatogonia in the male and oocytes in the female are the two reproductive cell stages, which are most important
for assessment of genetic risks. At high acute doses of radiation, the risk of mutation in females conceiving shortly
after radiation exposure will be about twice as high as in males, whereas at low doses, the risk will be reduced to
one third and with chronic exposure to about one twentieth of that expected after acute exposure to high doses. If the
human ovary responds to irradiation as it does in that of mouse, which is by no means certain, it can be expected
that, if conception occurs after a sufficient interval following in-adiation, the resulting frequency of mutations in the
descendants of irradiated females might be zero. Dominant gene mutations are expressed in the first generation of
an irradiated population.

14.16 Chromosomal Aberrations.

Spontaneously occurring chromosome aberrations are a source of considerable hardship since they are responsible
for a large fraction of all spontaneous miscarriages, congenital malformations and mental and physical defects. The
possession of an additional chromosome (Number 21) leads to Down’s syndrome which is associated with severe
mental retardation.
Another type of aberration is known as translocation. This involves the exchange of parts between two different
chromosomes. This may lead to malformations similar to those· associated with the presence of additional chromosomes
or may lead ‘to early pre-natal death.
These effects are· associated with the presence of translocation in the unbalanced form, in which there may be loss of
one of the exchanged segments and gain of the other. In its balanced form, a translocation usually has no detrimental
effect for the persons carrying it, but half of his or her offspring are likely to have the translocation in unbalanced form.
Many of these unbalanced zygotes will die at such an early stage in pregnancy that they will lead to a missed menstrual
period. The proportion surviving will be abnormal babies. An estimation of such abnormal babies is very difficult.
There may be other forms of aberration in chromosomes. For instance, there may be gain or loss in chromosomes
in addition to translocation. Very few of these aberrations are transmitted to the next generations after irradiation

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of the male because the reproductive cells carrying them will be eliminated before they mature. In female, some
are transmitted. Most of these cases will die before birth. Those surviving will be sterile and will have certain other
symptoms (Turners’ syndrome).
Genes on chromosomes form an important component of the human genetic burden. Gene mutations are induced
at higher frequencies than chromosomal aberrations. Furthermore, chromosome aberrations will be eliminated after
a few generations whereas gene mutations may permeate through many more generations thereby ‘affecting a larger
number of individuals.

14.17 Changes in Immune Response.

Immune system provides the main defence mechanisms of the body against infective agents or their products. The
system recognizes what is foreign to the body and responds by destroying or neutralizing it whereas it does not
distinguish between “foreign good” and “foreign bad”. It can stand in the way of medically desirable objectives, such
as the acceptance of needed tissues or transplants. Some net effects of immune reaction are themselves undesirable,
as in allergic and other immunological disorders where the system reacts to body’s own components producing auto-
immune diseases.
Because of the many values associated with the immune system, affecting it by irradiation has great human significance
in numerous contexts. For example, depressing immune responsiveness by irradiation reduces the ability to acquire
resistance to bacterial, rickettsial and parasitic infections or to neutralize bacterial toxins and is therefore an undesirable
effect of radiation. This is the situation in atomic warfare.
Depressing immune responsiveness by some means is desirable, even necessary, if organ transplants are to be
accomplished. Suppressing or controlling allergy, hypersensitivity, immunopathological disorders and autoimmune
diseases are other important medical objectives.
In cancer, the malignant cells are recognised as foreign by the individual’s own immune system and the lymphocytes
in the host may be directed against tumour cells. The existence of specific serum factors, which react with cancer
cells has also been recognised and in some instances, these may protect cancer cells from the action of potentially
lethal lymphocytes. In some situations, 1t is clearly observed that radiation induced immune depression permits an
increased rate of growth of cancer. A more critical question arises as to whether immune suppression may be an
important factor in radiation-induced cancer.
The immune system has large built-in factors of safety so that it can withstand substantial injury and recover from
damage. Even then effects on human lymphocytes in culture have been noted at doses of 10 rads (cGy). The observable
damage to the immune systems such as changes in antibody formation resulting from the whole-body dose of the
order of tons of rads is unlikely to be the effect causing the greatest concern. A dose in the range of 100 rads (1 Gy)
to the whole body and damage to the immune system leads to an increase in susceptibility to infection. When whole
body doses approach and exceed 200 rads (2 Gy), it leads to increased risk of mortality from infection.

14.18 Social and Mental Health Aspect of Radiation.

The large-scale use of atomic power in the field of industry, medicine and agriculture is inevitable and more people
will have to live and work in intimate contact with ionizing radiation. The prospects of dangers to health of the people
and genetic effects on their descendants would cause apprehension and since dangers of radiation cannot be seen or
felt emotional unrest and confusion are bound to occur in course of time. This new technological advance is therefore,
bound to create a number of social and mental health problems involving the industrial and scientific workers and
also the population in general. Added to these the real and imagined horrors of the nuclear bomb and weapons hang
like the ‘sword of Damocles’. A better understanding of these problems by the people and more so by the medical
profession, is necessary in order that they get a clear perspective of the real hazards and know the efficient preventive
and remedial measures that can be taken when need arises so that the people are confident of the preparedness of
the medical profession to do so. The social and mental health problems can be divided into the ones that may occur
among workers and the ones that may occur among the general population.
(a) The mental health problems that may occur among workers in atomic reactors, chemical plants and allied
nuclear industries are of immediate importance. Under vigilant management, the occupational hazards will not
actually affect most workers; but a certain extent of fear and anxiety will be present in them. Radiophobia may
arise in certain neurotic workers who may suffer from irrational and groundless fears of over exposure and
may produce a serious mental derangement, which may also influence others around. The usual prevalence

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of anaemia, leukaemia, cancer, psychosexual aberrations such as impotency and male sterility, abortions,
fetal abnormalities, sterility in women workers and so on, may all come to be ascribed to the occupational
radiational exposure. In the event of an accident in the reactor, a few may be actually exposed to an overdose
of radiation, although no immediate illness may occur, but some of the others actually not exposed to an
overdose may constantly be haunted by the fear of development of late effects of radiation. A regular periodical
medical examination is an excellent method of restoring confidence and removing anxiety and fear. Industrial
Physicians will be able to remove and rationalise many of the apprehensions by explanation and assurance.
(b) Concern, misgivings and anxiety may also arise in the minds of the people living in the vicinity of the
reactors. The workers in the reactors knowingly and willingly submit themselves to the occupational nuclear
hazards for vocational, financial or scientific interest. These factors, a correct knowledge of the real hazard and
observance of and confidence in precautionary measures help to maintain their mental balance and health.
The people in the vicinity of a reactor on the other hand have no knowledge or interest in the reactor and have
apprehensions. The usual incidence and outbreaks of disease may come to be attributed to radioactivity. A
reactor accident, should it happen, may constitute a hazard to a wide area and may necessitate evacuation of
people. This may lead to anxiety and tension in the population and resentment against the authority responsible
for locating the factory in their vicinity. The education of the people regarding radiation, its hazards and the
observance of safety precautions may rationalize their attitude. An organisation to carry out monitoring of the
surrounding areas of the reactor and to reassure the population regularly should be established and doctors and
nurses will have to check the health of the surrounding population from time to time and inspire confidence.

14.19 Food and Water Contamination by Radioactive ‘Fallout’.

Food and water are not spoiled by radiation, but contamination by radioactive material from accidents in a reactor or
fallout from nuclear bursts makes them dangerous for consumption. The crops in areas highly contaminated with fallout
build up radioactivity. The animals grazing on contaminated herbage pick up radioactivity. This when excessively absorbed,
may cause hypothyroidism or the bone seeking isotopes such as strontium-90 may cause leukemia and anaemia. The
edible parts of the animals do not concentrate radioactive materials to the same extent as the thyroid and ash bone,
except that the milk may contain radioactivity. Consumption of such milk and its products will introduce strontium-90
inside the human body resulting in the possibility of bone cancer and leukemia. Fish from water contaminated by a
fall out, meat from exposed slaughterhouses, fresh vegetables from fields, contaminated with fallout, cereals from
such crops, flour and bread from such cereals and also when directly exposed are dangerous for consumption. When
water in lakes and reservoirs contaminated by a radioactive fallout is consumed, the gastrointestinal mucosa may be
ulcerated and on absorption the contained radio-active material may get deposited in the bone, liver, muscle etc. and
produce internal irradiation like strontium-90, causing bone tumor’s and leukaemia. Casualties, however, may not result
immediately from drinking moderately contaminated water.

14.20 Protection Against Radiation Hazards.

An Increasing use of diagnostic X-rays and fluoroscopy has resulted in an increasing radiation level to mankind causing
concern and awareness of possible schostic and non-­ schostic effects to patients, medical and paramedical workers
and to the population. Adequate protection against X-rays and teletherapy units can be ensured by its intelligent use.
Some of the important precautions are as under:
(a) During radiographic exposure, no person other than operator should be present inside the room and
operator should stand behind protective barrier.
(b) The patient should not be held by a worker. Either immobilisation devices should be used or relatives
of the patient be asked to hold the patient.
(c) Lead-rubber apron, gloves and film badge should be used by the worker.
(d) Fluoroscopic procedures are more hazardous than radiographic ones because of longer exposure and
proximity of personnel to the machine. The tabletop dose should not exceed l0 R (cGy)/min and if it exceeds,
the dose should be brought down either by reducing tube current, increasing filtration, increasing the Focus
patient Surface Distance (FSD) or by providing screens.
(e) The time of examination should be reduced to minimum.
(t) The eyes of the radiologist should be sufficiently dark adapted to reduce his exposure.

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(g) Radiologist should make use of protective clothing, palparium spoon and fluoroscopic chair.
(h) If any helper is required during examination, he should be asked to position himself behind the protective
barrier.
(j) Gonadal dose of the patient should be reduced by using gonadal shields.
(k) Examination should be restricted to those cases in which it is of established value and absolutely
essential. This should be avoided if not clearly indicated especially the repetition of identical examinations,
particularly of female pelvis, hip joints, lumbar vertebrae and most definitely the gonads or the foetus if they
lie in the direct beam of radiation.
(l) In dental units, the dose rate can be quite high because of short FSD. The same rules mentioned above
apply here.
(m) In particular, nursing staff should not hold the film or the tube housing
(n) Mobile fluoroscopy is carried out generally in wards. It should be ensured that neither staff nor other
patients are too near the X-ray unit.
(o) In teletherapy, nurse should not enter the room when the machine is on. She should not sit near the
hole from where the cables have been taken.
(p) In sealed source Brachy therapy (Interstitial and Intracavitary), radium-226 and cobalt-60 in the form
of needles or tubes, gold-199, radon-222, vitrium-90 in the form of seeds and tantalum I82 and ilidium-192
wires are used. Of these, radium is most hazardous because of its high toxicity and long life. Radiation hazards
exist at every stage, viz.
(i) Storage.
(ii) Preparation
(iii) Transport
(iv) Application
(v) Hospitalization and nursing of patients.
(vi) Removal from patient.
(vii) Transfer
(q) Nursing Staff should not be allowed to stay unnecessarily near the storage safe, preparation room and
operation theatre during insertion.
(r) Radioisotope should be transported to lead container quickly.
(s) Relatives of the patients should not be allowed in wards in which the patients containing interstitial
sources are kept.
(t) Film badges and dosimeters should be used for monitoring.
(u) A periodical examination of the radiologists, radiographers, technicians and other workers is carried out
when considered necessary. This includes a complete blood examination.

14.21 Safety Measures in Handling Radioisotopes.

The use of radioisotopes in medicine for diagnostic and therapeutic purpose is increasing rapidly and hence one should
take appropriate precautions in safe handling of radioisotopes. Two types of hazards can arise due to radioisotopes viz.
external hazards and internal hazards. The external hazards arise from source of radiation outside the body and when
radiation source gets inside the body it gives internal hazards. The external hazards can be controlled by observing
distance, time and shielding principles. The exposure from radiation obeys inverse square law, so one must keep
maximum possible distance from the radiation source. Exposure is directly proportional to time spent in the vicinity
of radiation, so spend minimum possible time. Thirdly, the electromagnetic radiations get attenuated while traversing
through the material, hence sufficient shielding should be provided to reduce the external exposure. The following
is a brief guide to general precautions, which should be taken in radioisotope laboratory for controlling internal and
external hazards:

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(a) Unpacking.
Before opening a radioactive package received from the supplier. the user(s) must familiarize themselves with
details in respect of packaging around the source, safe closing/opening instructions and other precautions to
be observed at the time of unpacking.
(b) Storage.
Storage area must be lined with sufficient quantities of absorbent material to absorb the entire contents in
case of spillage.
(c) Handling.
Trial runs with non-active materials must be conducted before introducing radioactivity in new operations.
Predetermined safe handling procedures should be adopted.
(d) Protective Clothing.
Personnel must wear laboratory coats in the radioisotope laboratory. Whenever necessary, lead rubber aprons
and other protective clothing should also be used. These coats/clothing’s must not be used outside the active
laboratory.
(e) Protective Gloves.
Surgical gloves must be used during work with radioactive material or while nursing of active patients. Hands
must be monitored immediately after removal of gloves for possible contamination.
(f) Receptacles and Trays.
All manipulations involving radioactive material should be conducted in nonporous double trays provided with
a layer of absorbent material backed by disposable lining such as polythene. All breakable containers for
radioactive solutions, must be kept in non-breakable receptacles.
(g) Special Containers.
Use of hermetically sealed rubber stupider vials for handling radioactive liquids & aid of needles and syringes
should be preferred to open top containers.
(h) Unsafe Practices.
Mouth pipetting or any such oral operation must never be done in radioisotope laboratory. Any person with
open wounds must not work with open sources. Eating, drinking or using cosmetics inside the radioisotope
laboratory must be strictly forbidden.
(j) Precautions for Imaging Personnel.
Minimum patient handling time, maximum distance from the patient should be employed.
(k) Dynamic Function Studies.
These must be performed with due care, to avoid contamination of counting room. A specifically identified
area in the room should be used for handling radioisotope for such studies.
(l) Persons under Training.
They shall work under direct supervision of qualified personnel.
(m) Control of Visitors.
Only those workers and patients should be allowed in the radioisotope laboratory whose presence is necessary.
(n) Therapeutic Procedures.
The following additional safety precautions must be observed while undertaking therapeutic procedures:
(i) Dispensing Therapeutic Doses.
Preparation of therapeutic amounts of radionuclide for direct administration must be done in a fume
hood, employing automatic dispensing devices.

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(ii) Admission of Patients Administered with Therapeutic Doses of Radionuclide.

Normally a patient administered with a therapeutic dose of more than 500 mBq should be hospitalized.
(iii) Care of’ a Patient.
The nursing of patients administered with a therapeutic dose must be kept to the basic minimum. Entry
of visitors in the radiation wards must be regulated. Children and pregnant woman must not be permitted
in these wards.
(iv) Placards & Symbols in Wards.
Beds of patients administered with therapeutic doses must display a placard showing a radioactive
symbol, details of patient, date, time and amount of radioisotope administered.
(v) Discharge of’ in-patients.
Patients administered with radioisotopes and hospitalized in the wards must not be permitted to leave
their wards without approval of concerned medical staff in charge of wards.
(vi) Autopsy.
Autopsy is inadvisable and should invariably be restricted to the minimum.
In addition to above certain special devices, which may be required for certain specific application of radioisotopes,
secondary storage and transport containers are provided whenever it is required to carry radio isotopes from
place to place within the laboratory / hospital. The containers should be marked so that the isotope inside
may be easily identified. Lead bricks should be available in sufficient number for storage of gamma emitting
radioisotopes and for emitters Perspex may be used for their storage. Sufficient number of remote-control tongs,
pipettes, forceps, bottle openers, rubber gloves, paper handkerchief, absorbent paper, polythene sheets, enamel
trays, wash bottles and brushes must be available for safe handling of radio- isotopes. Detergents, E.D.T.A., dilute
acid, Teepol, KMn04 must be made available to facilitate decontamination procedure in case of spillage.
Apart from this, various registers and reports required to be kept either because of statutory obligation or in
accordance with codes of practice, are:
(a) The health register-to record all medical examinations of radiation workers.
(b) The source register-to record information of all radioactive sources and the dates and results of all
leakage tests.
(c) Radiation dose records are required to be kept in respect of radiation worker.
(d) Survey Report Record Register.
(e) Waste disposal record register showing the activity of burial of solid waste.
According to Radiation Protection Rules (1971) there should be a Radiological Safety Officer in every radiological
installation to advise on all matters relating to radiation protection and ensure that safety standards are being adhered
to fully.

14.22 Monitoring Techniques.

For ensuring that the precautions taken are adequate, monitoring should be done by ascertaining from time to time the
total dosage to which workers have been exposed to in a given period. Personal monitoring with a pocket dosimeter
or film badge gives better assessment of the total dose received by the workers than the routine six monthly blood
examination. Because the minimum exposure of 25 rem (250 mSV) required before effects on the blood count are
noted, it occurs only as a result of an accident or gross negligence and rarely occurs in a radioisotope laboratory.
(a) For external radiation, monitoring is done by studying the TLD, dosimeter or the film badge, which is
continuously worn on the front of the body, on the breast pocket or attached to a finger ring or wrist by each
person exposed to radiation. Intensity of radiation incident on the badge is shown by a proportionate blackening
of film on its development. A fountain pen type dosimeter can be read by the wearer himself at any time but
it requires expert maintenance. The developed film badge serves as a permanent record of the individual’s
exposure (physical monitoring).

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(b) If an internal hazard is suspected, testing of urine, faeces, nasal smear or sputum may be helpful
depending upon the metabolism of the particular element involved (Biological monitoring).
(c) Measurements over the thyroid may be used to estimate the body burden of radioiodine where it is being
used. A monthly thyroid ivestigation of the workers would show whether the radioisotopes have been inhaled
or ingested.
(d) Hands and shoes, floors, tabletops, gloves and other items are checked for contamination by the Gieger-
Muller portable survey instruments.
(e) For larger radioisotope units, a ‘count rate’ meter is also essential according to the nature of the radiation
exposure.
(f) Intensity of radiation due to radioactive materials, which have entered the body by inhalation, ingestion
or through skin can be estimated through biological monitoring by a ‘scintillating counter’.
(g) The total body burden can be estimated by assaying the amount of radioactivity excreted in the mine,
faeces or exhaled air and by a direct measurement of radiation from the ‘critical organ’.

14.23 Protection of Workers in Industry.

In addition to the various measures described earlier, general protection is provided by measures described as under,
the actual details varying with the nature of the hazard.
(a) Protection Against External Radiation.
All techniques used for providing protection against the exposure to external sources aim at increasing the
distance of the subject from the source of exposure, decreasing the exposure period, shielding from exposure
and use of various remote-control devices. The tissue-penetrating gamma-rays obey the inverse­square law just
like light. Therefore, if the distance from the source is doubled, the intensity of radiation falls to a quarter. When
it is necessary to work in fields of intense radiation, the dose received can be reduced by limiting the period
of exposure and shielding the subject from exposure to radiation. The thickness of the shield is determined by
types and intensities of radiations and the rate at which the shielding material attenuates the radiation. Alpha
radiations are stopped even by a sheet of paper, clothes on the body and by horny layer of human skin. Beta
rays penetrate into the tissues ‘for about 3 mm and can be stopped by an aluminium foil, thick clothing or
plastic overalls. For protection of hands, plastic or rubber gloves are enough. The use of protective clothing made
of serial materials like plastics, aluminium, fabric or other synthetic fabric are important protective measures.
Gamma rays are however, highly penetrating and can only be attenuated by lead and cement concrete. The
shielding power against gamma rays is proportional to the specific gravity of the material. Therefore, 2.5 cm
thickness of lead, which is about 4 times as dense as aluminium has the same shielding as 10 cm thickness
of aluminium. In addition to shields of lead-bricks, a variety of ‘remote control’ implements are used while
dealing with high intensity radio- active matter in industry and the working is reduced so that the permissible
radiation exposure limit is not exceeded.
(b) Protection Against Internal Radiation.
Smoking, drinking, chewing, taking snuff or eating in areas where there is a possibility of contamination and
pipetting of radioactive solutions by mouth is forbidden;·rubber bulbs for aspiration are used for this purpose.
Rubber or plastic gloves are worn for handling radioactive material. When a risk of air­borne contamination
is present, appropriate devices to mechanically suck and carry the fumes, mists, dusts or vapours away from
the worker and respirators or special hoods are used. Fixed radioactive contamination is not a source of
internal hazards as it cannot be inhaled or ingested, but loose contamination leads to hazards. The scrupulous
cleanliness, protective clothing, washing of hands and mouth, prohibition of eating, drinking, smoking or
application of cosmetics in work rooms will give considerable protection against internal radiation hazards.
For ensuring that the precautions taken are adequate, monitoring should be done by ascertaining from time
to time the total dosage to which workers have been exposed in a given period.
(c) Prevention of Exposure to Radioactive Material.
In industries such as radium dial painters where the material comes in intimate contact is prevention of
exposure affected by providing the workers with:
(i) Glass screen booths and efficient exhaust ventilation.

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(ii) Adequate facilities for washing hands before meals.

(iii) Wearing of rubber aprons.
(iv) Use of paper handkerchiefs, which are collected daily and destroyed. Workers should not use their
own handkerchiefs.
(v) Special separate rooms for eating and smoking. Food, tobacco, drinks and cosmetics must never
be introduced into workrooms.
(vi) Special solvents to remove paints should be rubbed on the hands and removed with soap and
water. The hands after drying thoroughly must be examined in a darkened room under ultraviolet light,
which may reveal some residual luminescent material. Electroscope and Geiger-Muller counters can more
accurately detect radioactive substances. A breath radon estimation may also be helpful, if facilities are
available
(vii) Cleaning of floors must be done by employing the wet methods.
(viii) Mechanical painting process should be employed and brushes must not be licked for pointing.
(ix) Employees should be medically examined within seven days of employment and thereafter at
monthly intervals. The first sign of finger damage is a reddened glazed appearance of the finger tips
commencing with the erasure of the finger impressions, followed by cracking of the nails. At this stage
with complete stoppage of exposure, the fingers will revert to normal. A total WBC count below 4,500
with reduction of polymorphs and relative lymphocytosis shows ingestion of large doses.
(d) Medical Examination.
(i) A preplacement medical examination is necessary to eliminate individuals, physically and mentally
or temperamentally unsuitable to work with radiation and also to get basic blood counts for future
comparison during the employment. The preplacement medical standards are laid down in the ILO
publication on ‘Protection of Workers against Radiation’.
(ii) Periodical medical checks of persons who are continuously exposed to ionizing radiations are
necessary. A complete medical record of such periodic or special examinations should be maintained.
This should include information regarding preplacement state of health, the radiation hazards exposed
to, details of clinical examination and any special investigations relating to the critical organs or tissues.
(iii) Examples of special investigations are: haematological examination in case of external whole-
body irradiation; skin examination in case of external irradiation or contamination; ophthalmological
examination in case of exposure to neutrons and to heavy corpuscular radiations; examination of the
‘body burden’ in case of an internal radiation hazard; pulmonary examination in the case of inhalation
of radioactive aerosols and gases.
(iv) Haematological examinations should include RBC, WBC and thrombocyte counts, a search for
abnormal cells, haemoglobin estimation and an assessment of the bleeding and the coagulation time.
The skin examination should be carried out for detection of epilation, dermatitis, cancer and also slight
changes such as the disappearance of the finger ridge details. The ophthalmological examination should
be done for changes in the crystalline lens. The ‘body burden’ examination should define the nature
and degree of the internal contamination assessed by means of measurement or analysis directly on
the body or indirectly on the excreta, urine, faeces, inhaled air and so on. The pulmonary examination
should be done for detection of the complex effects (mechanical, chemical and radioactive) of radioactive
aerosols and gases.
(e) Health Education to Workers exposed to ionizing radiations and internal changes should be watched for.
Precautions should be taken where necessary as carelessness may lead to harm to themselves and others.
They should immediately report to their doctor if any abnormal signs detected on the skin or any other unusual
ailment develops, without becoming unduly alarmed. However, exposure beyond a permissible level can occur
for a long time before any significant change in the blood count becomes evident. In planning protective
measures, the emphasis should be much more on the instrument and film badge monitoring of radiation
exposure than on blood counts.

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14.24 Responsibilities of Employers.

The responsibilities of the employer can be summarized as follows:
(a) Choice of Staff.
All workers would not be suitable for radiation work. temperament of the candidate should be considered.
Medical suitability should rank very high in the choice of the staff. All new employees in radiological work
should have a pre-placement blood count, family history, occupational history and previous exposure either
because of work with radiation or due to diagnostic x-ray examination. Periodical medical examinations will
also be carried out. generally, once in a year to assess their continuing fitness.
(b) Provision of Facilities.
It is the duty of the employer to provide adequate facilities for work e.g. protective clothing, film badges etc.
For high level work, it would be essential to provide the necessary protective equipment, glove boxes, lead or
concrete protective shields for gamma radiation.
(c) Training Scheme.
The legislation and codes of practice require that all persons exposed to radiation in the course of their work
be given training in safeguarding against the hazards. This may vary from a short talk on the functions of a
film badge and an outline of local rules to a detailed course in Health Physics.

14.25 CBRN.
CBRN is the internationally accepted acronym for chemical, biological, radiological and nuclear agents. These agents
include material from nuclear fission or fusion or other radioactive material with the potential to affect human health;
biological agents causing infection or disease; and toxic chemicals that can cause poisoning. They are hazardous
materials, either naturally occurring or artificially produced, which can have significant adverse effects on human
health, including severe illness and death, depending on the nature of the agent and the circumstances of exposure.
The differences between nuclear agents and radiological agents relate to their different origins. Nuclear agents are
radioactive material generated from nuclear fission or fusion, such as those produced by detonation of a nuclear weapon
or releases from damaged nuclear power plants. Radiological agents are radioactive material generated as by-products
and waste from the mineral processing industries, produced for use in industrial applications and medical therapy or
occurring naturally in the environment. The term CBRN is sometimes expanded to CBRNE to incorporate certain high-
yield explosives (E) into the nomenclature. This signifies the potential for the use of high-yield explosive materials that
rapidly release large amounts of energy and produce a pressure shock wave during detonation. They may be used in
conjunction with any of the CBRN agents as a Weapon of Mass Destruction (WMD) by state or non-state actors.
Biological agents have been used since antiquity. The earliest documented incident of intentional biological weapons
usage is from Hittite texts of 1,500–1,200 BC, which record victims of tularemia being driven into enemy lands,
causing an epidemic. During the French and Indian War in North America in the 18th century, British officers gave
the Native Indian tribes smallpox-infected blankets which subsequently caused an outbreak. The first large-scale use
of chemical agents in warfare can be traced to World War I where chlorine gas was extensively used to break the
stalemate of trench warfare. The atomic bombing of Hiroshima and Nagasaki in World War II heralded the dawn of the
nuclear age. Examples of the recent use of CBRN agents include wars (Iran-Iraq War), ethnic conflict (chemical weapon
use against the Iraqi Kurds and in Syria), terrorism (release of sarin in the Tokyo underground, US anthrax letters)
and targeted political assassinations (ricin, polonium-210, novichok). The deliberate use of biological agents, toxins
and chemical agents in warfare is prohibited internationally by the Biological Weapons Convention and the Chemical
Weapons Convention. However, CBRN events have also included accidental releases (Bhopal, Chernobyl) of these agents.

14.26 Characteristics of CBRN Agents.

Although there may be similarities between events leading to the delivery or dispersal of CBRN agents, they are very
different in the ir physical and chemical nature, their origin and their properties. There are also significant differences
in the type of injury or illness they produce and the period of time between exposure and the appearance of signs
and symptoms.
Nevertheless, CBRN agents have four key properties in common, which influence the overall approach to treating
adverse health effects and managing CBRN events:

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(a) Toxicity.
It is a measure of the ability of a toxic substance to cause harmful effects or death. Toxicity is generally
used to describe chemical agents, whereas the terms ‘morbidity’ (incidence of disease) and ‘mortality’ or
‘lethality’ (number of deaths) are more commonly used for biological agents. For nuclear and radiological
agents, ‘deterministic effects’ refer to immediate damage linked to levels of radiation exposure; ‘stochastic
effects’ are chance effects that appear at a later date (e.g. cancer). All these terms describe the ability to
cause injury or death according to the level of exposure.
(b) Latency.
It is the interval between exposure to a CBRN agent and the first signs and symptoms of illness or disease.
The time of onset depends on a number of factors including the type of agent, its concentration, the amount of
exposure and the individual’s response. For biological agents, the latency period is often called the ‘incubation
period’. A related factor is the time window for medical treatment. Where this falls entirely within the latency
period it may not be possible to deliver effective treatment.
(c) Persistence.
It is the capacity of a CBRN agent, once released, to remain capable of causing significant harm for a prolonged
period of time. This characteristic depends on two main factors: the inherent physical or chemical stability of
the agent and its propensity to degrade in line with certain environmental conditions, such as temperature,
moisture and ultraviolet radiation (i.e. sunlight) levels. The persistence of nuclear and radiological agents will
depend on the physical half-life of the radioactive material and its biological half-life once ingested or inhaled.
The persistence of biological and chemical agents varies with the type of agent used, its propensity to degrade
in the environment and the context of dispersion.
(d) Transmissibility.
It is the term used to describe whether an agent can be transmitted from one person to another. The main means
of transmission of CBRN agents are cross-contamination and direct physical contact. However, transmissibility is
understood differently for certain infectious biological agents, which can be transmitted from person to person
directly but without contact (e.g. through the air) or indirectly (e.g. through insect vectors).
Toxicity and latency are the main properties to be considered when treating patients who have been exposed
to CBRN agents, while persistence and transmissibility are key considerations when managing CBRN events,
including assessment of contamination risks for first responders and how to prevent further casualties.

14.27 Classification of CBRN Agents.

(a) Chemical agents.
The main classes of chemical agents are
(i) Nerve agents (organophosphorus compounds)
(ii) Blistering agents (vesicants) agents.
(iii) Cyanides (also known as blood agents).
(iv) Pulmonary agents (choking or lung damaging agents).
(v) Incapacitants (mental and physical).
(vi) Toxic Industrial Chemicals (TICs). While this class of agent is used, there is significant overlap with
other classes of chemical agents especially cyanides and pulmonary agents.
(vii) Riot Control Agents (RCAs). These agents used by law enforcement agencies are not prohibited
by international conventions but may still have harmful effects.
(viii) Pharmaceuticals. This class includes illicit and commercial drugs usually at supra-therapeutic or
toxic doses.
(b) Biological agents.
The two classes of biological agents are

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(i) Live agents such as bacteria including rickettsia and chlamydia, viruses and fungi
(ii) Toxins – chemical agents that are of biological origin and include those derived from bacteria,
fungi, plants and animals (venom)
(iii) The Centers for Disease Control (CDC) have classified biological agents into three classes (Fig
14.1) assessed as per their potential threat to national security based on transmissibility, lethality and
ease of production/dissemination.
CRITERIA EXAMPLES

High mortality, Bacillus, anthracis, Yersiia

disseminate pestis, Variola major,
Category A Francisella tularensis,
easily, needs
special action Filoviruses & Arenaviruses
family

Brucella species,
Moderately easy
Salmonella species,
to disseminate,
Category B Escherichia coli 0157:H7,
moderate
Vibrio cholerae
morbidity
Alphavirues family

Easily produced, Mycobacterium

potential for tuberculosis* Nipah virus,
Category C
high morbidity Hantavirus
and mortality

Fig 14.1 : CDC Classification of Biowarfare / Bioterrorism Agents

(b) Nuclear and Radiological Material.
This hazard can be classed by the type of ionizing radiation present:
(i) Alpha – a relatively large subatomic particle (similar to a helium nucleus) with a limited range in
air (millimetres) but significant damaging effects.
(ii) Beta – a small subatomic particle similar to an electron with a range in air of centimetres.
(iii) Gamma / X-ray – high-energy photons with no mass but highly penetrating
(iv) Neutrons – normally associated with nuclear material and the fission (nuclear) process which are
highly penetrating and have variable damaging effects.

14.28 Indication of Possible CBRN Event.

First responders must be aware of and be alerted to the possibility of a recent or imminent CBRN event in case they
observe:
(a) Suspicious munitions, devices or packages (boxes with wiring, compressed air cylinders with tubing,
containers with powders, liquids or aerosols, etc.).
(b) Unusual liquid sprays or vapours in the air, falling on the ground or on exposed surfaces.
(c) Unauthorized, unexplained or out-of-season overhead spraying in the area.
(d) Unexplained odours (e.g. smell of bitter almonds, peach kernels, mown hay, cut grass).
(e) Cases of nausea, difficulty in breathing, convulsions, disorientation or patterns of illness inconsistent
with natural disease reported or confirmed by local public health agencies.
(f) An abrupt spike in the rate of death among birds and animals in the area.
(g) Low-lying clouds or fog unrelated to weather, clouds of dust or of suspended, possibly coloured, particles.
(h) People dressed unusually (long-sleeved shirts or overcoats in warm weather) or wearing protective masks,

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particularly in crowded areas such as subways or stadiums.

14.29 Health Impact of CBRN Agents.

The health impact of a CBRN event varies according to the delivery system, route of exposure and persistence in the
environment. Health system must be geared to deal with a variety of challenges which may include:
(a) The initial (immediate, acute and delayed onset) health effects of CBRN agents.
(b) The long-term (late-onset or chronic) health effects of CBRN agents.
(c) The secondary exposure risk to medical personnel due to either contamination or a contagious illness.
(d) The requirement to carry out casualty hazard management that may include decontamination, isolation
and quarantine.
(e) The implementation of wider public health reporting and travel restrictions for transmissible biological agents.
(f) The potential impact on the health of individuals due to the use of CBRN personal protective equipment,
including heat illness and psychological stress.
(g) The potential impact on the healthcare system to implement pre-exposure or post-exposure prophylaxis.
(h) The management of any casualty, including trauma, in a CBRN environment.
(j) The presence of combined (CBRN and conventional) injury.
(k) The traumatic effects of a nuclear detonation.

14.30 Medical Effects of CBRN Agents.

The medical effects of CBRN agents depend on a number of factors including route of exposure, type of agent and
severity of effects.
(a) Route of Exposure.
The routes of exposure/absorption are important both for predicting and modelling the medical effects of
agents and the provision of protective equipment specific to that route. The routes of exposure are:
(i) Inhalation.
This route may present the greatest risk of multiple casualties due to an airborne hazard such as gas,
vapour, aerosol, droplets (in close proximity) or smoke. Protection is by mask, respirator or Self Contained
Breathing Apparatus (SCBA).
(ii) Ingestion.
This route is less likely to cause mass fatalities due to the dilution of any chemical agent or destruction
by the cooking process or digestion. It may, however, be a significant route for the introduction of live
biological agents with high infectivity. This route may be used for the targeting of individuals or small
numbers. Protection is provided by water and food security and the restriction of eating and drinking
during and post-attack.
(iii) Skin (Percutaneous).
There are three methods for CBRN agents to pass through the skin:
(aa) Intact Skin (Transcutaneous).
Although the skin is protective against many CBRN agents, some agents may directly damage the
skin (vesicants) or have chemical properties (fat-soluble) to allow penetration.
(ab) Inoculation.
This is the intentional break in the skin in order to introduce a CBRN agent causing minimal trauma.
(ac) Wounds.
This is the gross loss of skin integrity allowing for the opportunistic entry of CBRN agents into the
body.

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(iv) Mucous Membranes.

Although skin provides significant protection to biological agents, mucous membranes, which form the
lining of internal cavities such as the mouth and rest of the gut, are more permeable and may allow
an effective dose to be absorbed. Moisture on mucous membranes may also be reactive with some
chemical agents such as chlorine causing immediate effects.
(v) Eyes.
While eyes are not a good route for absorption, there are significant local effects on the eyes and
conjunctiva. An example is the pinpoint pupils (miosis) associated with nerve agent vapour.
(b) Type of CBRN Agent will define the type of effects seen following an exposure, these are:
(i) Intoxication.
Due to a chemical (and toxin) exposure.
(ii) Infection.
Due to a live biological agent exposure.
(iii) Irradiation.
Due to ionising radiation exposure.
(iv) Injuries.
Due to exposure to trauma or climatic stress (heat) either in isolation or as a combined injury (CBRNE).
The delivery method of the CBRN agent may cause trauma as well as physical degradation from Individual
Protective Equipment (IPE) use (heat injury).

Fig 14.2 : Timeline of Medical Effects Following CBRN Event

Adapted from Bland SA. AMedP-6: NATO Management of CBRN Casualties Manual.

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The onset of symptoms is important in the recognition and establishment of causation of a CBRN or exposure.
However, a delay in symptom onset due to a latency period may be misleading in an epidemiological investigation.
For live biological agents, the latency period is called the incubation period. In some cases, such as certain
live biological agents and acute radiation syndrome, there is a significant period of non-specific symptoms and
signs (e.g. fever and muscle aches) that precede a more recognisable syndrome (or toxidrome); this is called
a prodromal stage. A toxidrome is a pattern of symptoms and signs (syndrome) due to exposure to a toxic
substance. Notable toxidromes are those for nerve agent intoxication and opioid overdose. Fig 14.2 provides
a summary of the latency and incubation periods for certain CBRN agents.
Apart from the specific symptoms and injuries caused by various agents, CBRN agents may cause a variety
of psychological effects. Some effects may be appropriate to the hazard (i.e. acute stress reaction) and may
even enhance the response to an incident. Other effects will cause mental incapacitation with symptoms
ranging from anxiety (acute stress disorder) to acute psychosis or delirium. Symptoms can occur at any time
and include Post Traumatic Stress Disorder (PTSD). Psychological effects due to CBRN agents may be direct,
indirect and psychogenic.
(c) Other Delayed Effects.
There may be other delayed effects like aplastic anaemia, cataract formation and temporary loss of hair.
Miscarriage and stillbirth may be a consequence of irradiation during pregnancy. But they do not constitute a
problem unless the dose of radiation is large. A number of different developmental abnormalities have been
described in the children whose mothers were treated by irradiation during pregnancy, the most conspicuous
defect being microcephaly, a partial failure of the development of the brain. Number of cases so classified
are recorded in children with irradiation, before birth in Hiroshima and Nagasaki.

14.31 Keys to CBRN event response.

In responding to a CBRN event, the primary objective is to reduce the risk of injury to individuals or groups from
exposure to CBRN agents. The three key steps to take in order are:
(a) Avoid or minimize exposure.
(b) Remove agents from exposed skin, hair and clothing
(c) Seek medical attention.
IEC activities and periodic drills should be conducted to enhance public awareness of appropriate response. An example
of a poster campaign for response in a nuclear emergency is depicted in Fig 14.3.
(i) Time spent in areas of potential exposure should be minimized
(ii) Distance from areas of potential exposure should be maximized
(iii) Shielding, that is employing a physical barrier against CBRN agents, should be used.
This will depend on an assessment of risks in the particular situation, which may lead to a decision to evacuate,
shelter, temporarily relocate or continue operations using appropriate protective measures. Until the risks have been
established, the objective should be to immediately move or stay away from areas of potential exposure or to seek
shelter if unable to leave the affected area.
Evacuation or temporary relocation may be effective if there is a safe location in the immediate area or if there is
safe transport available to a more distant safe location. The suitability of a safe location will depend on the nature
of the event, the type of CBRN agent involved and the possible extent of its dispersal. Seeking shelter in a building
or another protective structure will provide a barrier to agents dispersed on the ground or in the outside air but even
clothing may provide a basic form of shielding to protect skin from contamination. If sheltering is in place (which refers
to taking cover in a designated shelter in the event of a suspected release of CBRN agent) the location should be
above ground level but not on the roof. Basements or cellars should never be used for shelter as many CBRN agents
are heavier than air and tend to concentrate in such places.
In case a specific population is at risk of exposure to CBRN agents and especially when the event has yet to affect a
wider area or region actions should be taken to scale down operations and relocate anybody who is not required to
remain. This will be effective in reducing the number of people at risk and enabling those remaining to take maximum
advantage of available protective measures.

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Fig 14.3 : Appropriate Public Response in a Nuclear Power Plant Emergency

Distribution and use of specialized Personal Protective Equipment (PPE) would normally be limited to those trained
in the use of this equipment, such as first responders and Quick Reaction Medical Teams. For individuals for whom
PPE is not available, ordinary clothing may provide a suitable temporary barrier to skin contamination. The approach
is to minimize areas of exposed skin, for example, wearing long- sleeved shirts, long trousers and a head covering. If
available, a simple face mask should be worn to reduce the risk of inhaling airborne agents or an improvised mask
made from a moistened cloth held over the mouth and nose.
To avoid or minimize exposure to CBRN agents, the basic principles are time, distance and shielding:
If exposure to CBRN agents is unavoidable, all possible efforts should be made to remove agents from skin, hair and
clothing. Simple actions can be effective, such as:
(a) Removing any agent on exposed areas of skin by scraping, wiping with a damp cloth or disposable towel or
washing thoroughly. Care should be taken not to rub the agent further into the skin. Personal decontamination
kits (PDK 1, PDK 2) may be used if available. These are used at individual, unit or formation level. These are
(i) Personal Decontamination Kit – PDK No. 1
(aa) Characteristics.
It effectively decontaminates all types of chemical warfare agents and also for immediate
decontamination of human skin exposed to a chemical attack.
(ab) Description.
It consists of pads filled with an inert, non-irritating strong absorbent powder. Each pad is sealed
in polythene laminated aluminium paper bag to protect it from moisture and contamination.
(ac) Procedure.
Quickly blot affected parts of skin with the pad then dap the pad lightly on the skin to cover the

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area liberally with powder. Remove excess powder with a fine towel to be thrown away or destroyed.
(ad) Packing.
It consists of four bags (containing powder pads) wrapped and sealed in polythene coated paper
folder.
(ae) Precautions.
It should be stored in a dry place & used as survival kit in an emergency to be followed by medical
treatment. Always be alert to the development of symptom even after decontamination.
(ii) Personal Decontamination Kit-PDK No. 2
(aa) Characteristics.
PDK No. 2 effectively decontaminates all types of chemical warfare agents. It is used for the
decontamination of clothing, equipment and small arms.
(ab) Description.
It is puffing bottle with a mixture of absorbent powder and chlorinated lime. Presence of chlorine
helps in fast neutralization of mustard and VX agents in addition to the absorption properties.
(ac) Procedure.
Press puff bottle repeatedly. Spray powder to spread all over the contaminated surface, dab the
surface briskly and then wipe off the excess powder.
(ad) Packing.
Its puff bottle contains 80 gms of powder.
(ae) Precautions.
It should be stored in a dry place and used for decontamination of skin. It is also used as field
kit by the individual in an emergency.
(b) Showering and washing hair to remove any agent lodged on the body. Start by leaning forward into the
stream of water to remove contamination from the hair and headfirst to minimize the spread of contamination
further down the body.
(c) Changing into a clean set of clothing and discarding or sealing contaminated items in a disposable bag.
If exposure to CBRN agents occurs or cannot be excluded with certainty, medical attention or advice should
be sought as soon as possible. Some agent-specific protective measures and medical treatments exist but
they may not be available for all agents. Examples include:
(i) Prophylactic (preventive) use of KI is recommended as a medical countermeasure to protect the
thyroid from radioactive iodine in people under 40 and pregnant or breastfeeding women in a nuclear
or radiological event involving the release of substantial amounts of radioactive iodine to prevent an
increased risk of thyroid cancer in later life.
(ii) Vaccines, antibiotics and antidotes to prevent or counteract the effects of certain viral, bacterial
and toxin biological agents.
(iii) Antidote treatment to counteract the effects of certain toxic chemical agents. (e.g. Atropine)
If a definitive diagnosis cannot be made of CBRN agent exposure, symptomatic treatment will be required that
is directed by medical assessments based on patient history, physical examinations and laboratory investigations
where available.

14.32 Principles of CBRN Casualty Management.

The principles of CBRN casualty management are:
(a) Recognition (detection & diagnosis)
(b) Safety (personal and collective)

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(c) Self-aid/first aid

(d) Triage
(e) Casualty assessment – ‘quick look’
(f) Life-saving interventions
(g) Casualty hazard management
(h) Supportive treatment
(j) Definitive treatment
(k) Rehabilitation
The provision of CBRN casualty care starts from the Point of Exposure (PoE) and may continue to rehabilitation. The
ability to provide care from PoE to hospital depends on the limitations imposed by the operational environment due
to the persistence of the CBRN agent. Care within contaminated areas is limited to first aid and Emergency Medical
Treatment (EMT). In military operations with embedded medical support, the level of care for casualty is decided on
a zonal basis as under:
(a) Hot zone (non-permissive) management.
The hot zone is a non-permissive area where there is a direct hazard from the environment (firearm, explosive
hazard or CBRN). This zone is sometimes referred to as the exclusion zone especially where PPE does not
mitigate the hazard such as in the case of explosives or high-dose radiation. Casualty care in a non-permissive
environment is limited by the direct risk to the responder and the protective measures or actions required
(individual protective equipment, return of fire).
This level of care is sometimes described as “Care under Fire (CUF)” with hazards including CBRN (primary
exposure), an explosive device, effective fire or environmental. Management is limited to:
(i) Self- and first aid
(ii) Triage
(iii) Casualty assessment (‘quick look’ includes a trauma primary survey)
(iv) Life-saving interventions (T1 casualties) for CBRN and trauma
(v) Evacuation to the Casualty Collection Point (CCP)
(b) Warm zone (semi-permissive).
The warm zone is a semi-permissive (buffer) area setup usually due to a continuing contamination hazard
from casualties or equipment coming out of the hot zone. This zone is also referred to as the decontamination
zone and is demarcated by a Clean Dirty Line (CDL). Casualty care is limited due to the risk of secondary
hazards from casualties or equipment (contamination, contagious disease) and personal protective equipment.
This level of care is sometimes called “tactical field (medical) care” and may take place at the CCP before
decontamination or during the decontamination process. It is limited to:
(i) Triage
(ii) Casualty assessment (‘quick look’ including Trauma Primary Survey)
(iii) Life-saving interventions
(iv) Casualty hazard management, e.g. decontamination
(v) Wound management
(vi) Evacuation to a definitive care facility.
(c) Clean Zone (permissive).
Casualty care beyond the CDL allows optimal access to the patient, although treatment may still be limited by
PPE due to wound contamination or contagious disease. Advanced medical care at this level is divided into:

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(i) Supportive Care.

During CBRN casualty management, the causative agent may not be known. Treatment may still be
effective by adequate supportive treatment focused on managing observed effects such as hypoxia
and hypotension. Even when the agent is known, there may be no definitive treatment and treatment
remains supportive throughout the continuum of care including critical care with advanced respiratory
and circulatory support.
(ii) Definitive Care.
Definitive treatment is the final level of care provided to return the patient to the highest degree of mental
and physical capability possible. It includes further antidote treatment, replacement therapy, surgery
and burns management. After definitive treatment, the casualty may undergo rehabilitation before being
returned to duty.

14.33 CBRN Emergency Medical Treatment (EMT).

The provision of prehospital medical support to CBRN casualties including trauma in a CBRN environment is described
as EMT. Specially constituted and trained Quick Reaction Medical Teams (QRMT) provide EMT in a pre-hospital CBRN
setting. The constitution, deployment and equipment of QRMTs in the Armed Forces are available in HQ ARTRAC note
on the subject accessible through respective Command HQ Medical Branch. EMT consists of:
(a) Triage
(b) Casualty assessment (‘quick look’)
(c) Life-saving interventions (LSIs)
(d) Casualty Hazard Management.
Contaminated casualties are a hazard to themselves; to other casualties and to medical / rescue personnel thus
decontamination continues concurrently with treatment, but it should not be prioritized over life-saving interventions
(LSIs).
(a) Triage in CBRN scenario.
A major CBRN / CBRNE event is likely to result in mass casualties with the added complication of assessing and
treating a large number of contaminated casualties. As in conventional injuries, objective triage of casualties
offers the best option for optimal casualty management with finite resources. Triage categories are used for:
(i) The prioritisation for treatment
(ii) The prioritisation for decontamination
(iii) The Prioritisation for Casualty Evacuation (Transport).
In a CBRN scenario, four priority classes are assigned as against three in conventional disasters.
They are given in Table 14.3. Triage is a dynamic process and casualties should be re-assessed and
triaged at multiple points in the evacuation chain. A triage sieve (Fig 14.4) using basic easily assessed
parameters may be used for primary triage, at the scene and patients re-triaged using a Triage Sort
using a standardised trauma score at a forward casualty collection point.
Table 14.3 : Triage Categories in The CBRN Scenario
S. No. Priority Class Requirement of Resuscitation / Surgery Proportion of Total Case
1. T-I (Immediate) Immediate resuscitation and urgent surgery/management 20%
2. T-II (Urgent) Possible resuscitation, early surgery/management and 20%
hospitalisation
3. T-III (Delayed) Minimal immediate treatment and delayed evacuation 40%
4. T-IV “T1 hold”; supportive / palliative care; poor prognosis 20%
(Expectant)
Note. 30% of total casualties are likely to constitute the surgical load

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(b) Casualty assessment (‘Quick Look’).

The ‘Quick Look’ is a rapid focused initial assessment of a casualty for signs of trauma and intoxication. In
the context of trauma, the assessment is for any catastrophic haemorrhage or respiratory distress due to an
airway or breathing problem. Recognition of chemical casualties may be based on the clinical signs of certain
chemical agents using Consciousness level, Respiratory pattern, Eyes, Secretions and Skin (CRESS).
An abbreviated Quick Look for important CBRN- related agents and drugs is depicted in Table 14.4 Casualty
assessment of life-threatening infections and sepsis after biological agent use is vital for life-saving treatment.
Septic shock is a life-threatening condition and fluid resuscitation should be started within 10 min of diagnosis
in the warm zone/CCP.
(c) Life-Saving Interventions (LSIs).
LSIs are actions that can be performed by any appropriately trained person to reverse life-threatening conditions
or prevent deterioration due to a CBRN agent and/or trauma. A generic approach can be applied to both
CBRNE and trauma events using the following priorities for treatment:
(i) Catastrophic haemorrhage.
(ii) Airway management and antidotes.
(iii) Breathing.
(iv) Circulation.
(v) Decontamination and disability.
(vi) Evacuation to a more permissive environment.
Note. Decontamination is NOT prioritized over basic LSIs.
Table 14.4 : Abbreviated ‘Quick Look’ For Selected CBRN Agents and Drugs
Nerve Agent Cyanide Opioid Atropine Sepsis
Consciousness Seizures/ Decreased/ Decreased/ Increased Normal /
Decreased unconscious unconscious decreased
Respiration Increase Increased / Decreased Normal / Increased
Decreased Increased
Eyes (Pupils) Pinpoint/ Normal/large Pinpoint/ Large Normal
constricted constricted
Secretions Increased Normal Normal Dry/Decreased Normal/ Sputum
Skin Sweaty Pink/ Blue Normal/ Blue Warm/Dry Sweating / pale
Others Diarrhoea / Sudden onset High temperature
Vomiting,
bradycardia

LSIs should only be performed on the most severe casualties (T-I) with immediate life-threatening conditions and include:
(i) Removal from the hazard (self-extraction or rescue)
(ii) Application of tourniquet(s) (C)
(iii) Application of pressure dressing and haemostatic agents (C)
(iv) Basic airway management including suction (A)
(v) Early medical countermeasures /antidote administration including anticonvulsant (a)
(vi) Ventilation (as resources allow) (B)
(vii) Administration of oxygen (B)
(viii) Management of tension pneumothorax, such as needle decompression (B)

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(ix) Management of sucking chest wound, such as application of dressing with valve (B)
(x) Fluid resuscitation (trauma, sepsis or combined injuries) (C)
(xi) Management of severe sepsis and septic shock (fluids, oxygen and antibiotics) (C)
Hot zone casualty care is limited to the management of T-I casualties with catastrophic haemorrhage, airway problems,
antidote administration and management of sucking chest wound and/or tension pneumothorax (breathing problems)
followed by evacuation to the warm zone and the forward Casualty Collection Point (fwd CCP). These measures have
the acronym CAaBE. The fwd CCP is a key ad hoc point in the casualty evacuation chain where medical management
rather than first aid can take place as the casualty starts to be decontaminated. In many circumstances, evacuation
“scoop and run” to a more permissible environment may be a more effective intervention than “stay and play” in the
hot zone.

Fig 14.4 : Modified CBRN Triage Sieve by First Responders at Site of Incident
(d) Casualty Hazards Management.
Casualty hazard management is the decision-making process for the handling of casualties with a secondary
exposure risk due to either contamination or a contagious illness (Fig 14.5). LSIs take priority over casualty
hazard management although the removal of chemical contamination may reduce further exposure to the
casualty and the responder and are lifesaving also. The components of casualty hazard management are:

(i) Containment
(ii) Decontamination
(iii) Isolation
(iv) Quarantine
(v) Public health control measures

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(i) Containment.
It is the immediate on-scene action to limit further spread. Containing the scene and exposed persons allows
the Incident Commander to assess the risks of secondary spread and the requirement for decontamination.

CBRN INCIDENT?
Consider PPE
Consider containment

Containment
Establish cordons
(Hot / warm & cold zones)

PROVIDE EMT
Triage
Life Saving Interventions*

TYPE OF HAZARD?

Contaminated Contagious
(CBRN) (B only)

DECONTAMINATE ISOLATE
Remove clothing Consider contact tracing
Wet or dry decon method and quarantine
* includes remove from hazardous area
Fig 14.5 : CBRN Casualty Hazard Management
(ii) Decontamination.
This can be divided into external, internal and wound decontamination. External methods include
(aa) Physical Removal.
This is the mechanical removal of persistent chemical, biological and radiological contamination.
The most common mechanical methods used alone or in combination are:
O Removal of clothing.
O Irrigation with copious amounts of water.
O Dry adsorbents. Adsorbents draw in liquid contaminants and examples include fullers’
earth (PDK-1, PDK-2). It should be noted that the agent is not destroyed and an off-gassing
hazard remains after dry decontamination.
(ab) Chemical destruction.
This method involves the deactivation of an agent by altering its structure. This can be achieved
by chemical reactions such as hydrolysis, oxidation and active decontaminants.
(ac) Wound Decontamination.

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The management of wounds and the use of tourniquets and dressings mean that the potential
for external contamination exists and all dressings and tourniquets must either be replaced or
covered in a clear well-marked protective dressing or wrap. Copious water or weak hypochlorite
solution is recommended for initial wound irrigation. Skin decontaminants such as Fuller’s Earth
and some active decontaminants should be avoided in wounds due to complications and potential
delayed wound healing. Surgical management of any traumatic injury should include a wide
debridement (removal of dead tissue), whether CBRN or conventional. There is a theoretical risk
that contaminated wounds (munitions fragments or impregnated clothing) may pose a threat to a
surgical team. Standard surgical procedures including the use of aseptic technique and surgical
instruments, such as forceps, will minimise any risk. Research has demonstrated that a single pair
of latex surgical gloves may not provide adequate protection from some chemical agents where
there is direct contact, i.e. wound probing and therefore double nitrile gloves, which have greater
chemical resistance, are the minimum requirement.
(iii) Isolation and Quarantine.
In the context of CBRN casualty hazard management, isolation refers to the separation of casualties
with an illness due to a suspected transmissible (contagious) biological agent. The principles of isolation
include physical protection and hazard management. Isolation will generally use negative pressure and
barrier nursing methods will be used and supported by the infection prevention and control nurses. Where
there is more than one casualty with the same illness, a cohort facility or ward should be considered
to reduce staffing and logistical demands. In the context of CBRN casualty hazard management and
endemic disease, quarantine refers to the separation and observation over a period of time (usually the
latency or incubation period) of a well person who may have been exposed to a suspected hazard or
have an epidemiological link to a probable or confirmed case.
(iv) Casualty Decontamination Centre (CDC).
The requirement and level of casualty decontamination depends on the hazard present (hot/warm zone),
the persistence of the agent, the protective equipment the casualty was wearing and the decontamination
method available (dry versus wet decontamination). The staffing at the CDC is provided by personnel of
the affected unit who have undergone basic CBRN training. Elements of a CDC (Fig 14.6) include:
(aa) Commander (Officer or NCO)
(ab) Casualty Collection Point
(ac) Triage
(ad) Ambulatory channel(s)
(ae) Stretcher channel(s) with provision for EMT
(af) Body handling area
(ag) Expectant (T4) area, as required
(ah) Equipment decontamination
(aj) Logistic support, as required
(ak) Miscellaneous, including scribes (clerks) and runners
The Clean Dirty Line (CDL) is the cordon at which point full decontamination (casualty, personnel
and equipment) has taken place. For casualty management, this may be the first point that casualty
documentation may have been generated and a formal handover of care should take place. The handover
should include as much information as possible and the minimum (AT-MIST) is:
(aa) Age (if known)
(ab) Time of exposure/injury and duration
(ac) Mechanism of exposure, i.e. type of incident
(ad) Injuries, intoxication, infection and irradiation suspected

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(ae) Symptoms and signs

(af) Treatment including antidotes and antibiotics given
A sample casualty first aid and triage card is attached as Appendix A.

Fig 14.6 : Layout of Casualty Decontamination Centre

14.34 Post-CBRN Event Actions.

(a) Occupational Medical Advice.
Following a CBRN incident, medical personnel may need to provide advice on measures including:
(i) Post-exposure prophylaxis of responders that may have been exposed during the incident such as
vaccination, antibiotics or anti-radiation countermeasures.
(ii) PPE to limit exposure of recovery workers.
(iii) Monitoring of the health aspects of working in a hazardous environment and PPE including heat
illness.
(iv) Advice and monitoring hazard management measures such as limiting working times.
(v) Pre-exposure prophylaxis of recovery workers to CBRN and other occupational exposures including
hepatitis A and B.
(vi) Recording any medical countermeasure use and potential exposures.
(b) Health Surveillance.
There may be a requirement to start appropriate health surveillance by using health registries. Registries may
be based upon a cohort of the population that share the same potential or confirmed exposure to a hazardous
substance or environment or the same symptoms, syndromes or specific illness.
Members of the register are either casualties that have been entered into the registry by the receiving hospital
or other potentially exposed persons that volunteer to be added to the register. The benefit of this is to:

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(i) Identify any delayed or long-term health effects including mental health.
(ii) Communicate rapidly between exposed persons and health organisations.
(iii) If there are no observed health effects, reassure the exposed population.
(iv) Mitigate any delayed health effects as they are identified in other members of the cohort.
(v) Comply with potential health and occupational regulations.
(c) Aftercare of Responders.
Debriefing should be carried out after standing down of responders. All responders should be checked to ensure
there are no injuries or acute effects following any potentially hazardous exposure. All responders’ details should
be logged and kept for follow-up and any likely investigations into the incident and its response. Where there
is a known exposure, responders should be given advice on symptoms to look out for and where necessary
primary or preventive health care informed. Following any significant incident, especially where there may have
been multiple casualties and/or CBRN, stress is likely to have a number of effects on an individual and this
is to be expected. The management of psychological stress should be managed by the team in a supportive
way that initially is independent of any medical interventions. Many post-incident stress management systems
use a series of escalating interventions and these may be of benefit:
(i) Voluntary team debriefings
(ii) Unit commander risk assessment of individual
(iii) Unit level counselling
(iv) Referral for formal counselling
(v) Formal medical referral and interventions

Suggested Reading.
1 Croddy, Eric, et al. “Biological Warfare: A Brief History.” Chemical and Biological Warfare, 2002, pp. 219–236,
https://doi.org/10.1007/978-1-4613-0025-0_8.
2 Chemical Weapons: Protect Integrity of Global Ban [EN/AR] - World | ReliefWeb.” Reliefweb.int, 15 May 2023,
reliefweb.int/report/world/chemical-weapons-protect-integrity-global-ban-enar. Accessed 28 Mar. 2024.
3 Bland, Steven A. “Chemical, Biological, Radiological and Nuclear (CBRN) Casualty Management Principles.”
Conflict and Catastrophe Medicine, 22 Nov. 2013, pp. 747–770, www.ncbi.nlm.nih.gov/pmc/articles/PMC7121337/,
https://doi.org/10.1007/978-1-4471-2927-1_46.
4 “a History of Warfare [PDF] [1is9h43gqr10].” Vdoc.pub, vdoc.pub/documents/a-history-of-warfare-1is9h43gqr10.
Accessed 28 Mar. 2024.
5 Yurkovsky, Savely and Internet Archive. Biological, Chemical and Nuclear Warfare : Protecting Yourself and Your
Loved Ones : The Power of Digital Medicine. Internet Archive, Chappaqua, N.Y. : Science of Medicine Pub., 2003,
archive.org/details/biologicalchemic0000yurk. Accessed 28 Mar. 2024.
n

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Appendix A

CBRNe Casualty Triage Card

Name: Date: / / Sex: Male / Female Age:
DOB: / / or
Nationality: Rank: Service No:
Location: Incident time (if overt): : Time of Symptom onset: : Arrival Time: :
Chemical [suspected agent ] Biological [suspected agent ] Radiological Nuclear
Type of
Trauma [Type ] Other [ ]
Incident:
CBRN Suspected Probable Confirmed DIM equipment used [ ] Reading [ ]
Physical Protection: Respiratory [CBRN /Particulate / Other ] Gloves Protective suit Other [ ]
Pre-Exposure MedCM: Chem [ ] Bio [ ] Red [ ]
INJURIES & CONTAMINATION: QUICK LOOK – CBRN
Alert Verbal Pain
Conscious Unconscious Fitting
Normal Abnormal
Respiratory Asymmentrical Absent / min

Eyes
Pinpoint Normal Wide
Secretions Normal Secretions Dry
Normal Sweaty BURNS
Skin Cynosed Pink Chemical
Purpuric rash Thermal
Temp °C /°F ( Core Peripheral)
Pulse Rad Fem Carotid
ECG Sinus Rate / min Abnormal
Other

Radiation:
Vomitting or Diarrhoea onset [ : ]
EMERGENCY MEDICAL TREATMENT AND HAZARD MANAGEMENT:
INITIAL HAZARD: Gas / Vapour Liquid Dry / particulate Wound Unknown Contagious (Suspected)
TRIAGE T MANAGEMENT: Removal of clothing Dry contamination Rinse Full wet contamination isolation
Catastrophic Site(s) : [ ] [ ][ ] [ ]
Haemorrhage: CAT Appled Time [ : ] Haemostatic Time: [ : ] FPD Site (s) : [ ] [ ]
Airway: OPA/NPA Size: [ ] LMA Size: [ ] ETT Size: [ at ] RSI Time: [ : ] Surgical Airway
ComboPens Number given: [ ] Oxime: [ ] Total [ ] Atropine Total: [ ]
Antidotes / MedCMs Benzodilazepine: [ ] Social [ ] Naloxone Total: [ ]
& other therapy:
Amyl nitriate Dicobalt odetate 300 g 600 mg Glucose Sodium nitrate Sodium thiosulphate
ANTIBIOTIC(S): [1: ] dose [ ] [2: ] dose [ ] [3: ] dose [ ]
OTHERS: Morphine total [ ] Fentanyl total [ ] Ketamine toal [ ] Ondansetrone dose [ ]
[1: ] dose [ ] [2: ] dose [ ] [3: ] dose[ ]
Breathing: Oxygen BVM Needle decomposition L R Thoracostomy Chest drain L R
IV/VO Site [ ] Size: [ ] IV/VO Site [ ] Size: [ ] CPR duration [ /mins]
Circulation: FLUIDS: Crystalloid [ ] Volume [ ] Blood [ ] Volume [ ]

Other interventions
and comments:

COLD ZONE Casualty Clearing Station Survivor Reception Centre RTU / Home
TRIAGE CAT T OUTCOME MTF / Hospital Name: [ ] Mortuary Other: [ ]
CDL Handover Time: : Completed by:

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Chapter
XV
OCCUPATIONAL HEALTH

15.1 Introduction.
Industrial productivity is closely related to the mental and physical well-being of the worker. His well-being is
often influenced by the peculiar physical, chemical, biological, mechanical and psychosocial factors to which he is
exposed during his work. He is entitled to the same comprehensive medical care as the community of which he
forms a part. Factory workers often live under unsanitary conditions, which are favourable for the propagation of
diseases. From this point of view, the general principles of environmental sanitation are also equally applicable to
them. However, factories have their peculiar environments created by conditions arising out of various industrial
processes. Occupational health is thus a comprehensive subject comprising the health, safety and welfare of the
workers in the ‘workplace’ and ‘off-work’ environments. Consequently, in occupational health, the teamwork of
several disciplines such as medicine, engineering, administration, physics, nutrition, etc., has to be integrated for
high industrial production and the well-being and contentment of the workers.

15.2 Role of Medical Officers.

Medical officers are frequently required to extend medical supervision to ordnance factories, Armed Forces workshops,
unit workshops and other mechanical units and to provide medical care to the personnel working there. Moreover,
Air Force and Naval MOs must deal, in their day-to-day duties, with personnel who are virtually industrial workers, as
they are to function under similar circumstances. The following paragraphs may serve as a guide to them when called
upon to carry out inspections of such places and extend medical supervision and care to workers in these units and
establishments.

15.3 Occupational Health and the Armed Forces.

The Armed Forces, by virtue of its diverse role in varying climatic conditions, terrain and often the uncongenial psycho-
social environment, are exposed to peculiar physical, chemical, biological, mechanical and psychosocial factors in the
workplace and off it. Occupational health is thus of prime importance for optimizing the efficiency, well-being and
contentment of the personnel of our three services. Occupational health aspects peculiar to the Navy and Air Force
have been dealt with separately in this manual. The focus of our discussion in the succeeding paragraphs will pertain
to the occupational health problems of the Army.
The occupational health hazards that are common to all Arms and Services of the Army may be grouped into:
(a) Physical Hazards.
(i) Effects due to heat and cold.
(ii) Effects due to altitude.
(iii) Effects of noise especially during the firing of heavy weapons.
(iv) Mechanical factors - Injuries, accidents.
(v) Effects of excessive glare.
(vi) Effects of ultraviolet radiation especially in high altitude and snow-bound areas - Snow blindness.
(b) Chemical Hazards.
(i) Ingestion of water from varied sources often with high mineral content especially fluorides and
chlorides.
(ii) Dusts especially while travelling through unmetalled desert tracks.

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(c) Biological Hazards.

(i) Vector-borne diseases especially malaria and zoonosis due to frequent movements and living outdoors.
(ii) Fungal infections due to prolonged use of uniform and boots.
(iii) Potential for rapid spread of airborne infections due to living in barracks.
(iv) Common source food and water-borne disease outbreaks.
(v) STD/HIV infection - increased chances of personnel visiting CSWs as they stay for long without their
families.
(vi) Nosocomial infections in health workers.
(d) Psychosocial Hazards.
(i) Long periods of deployment in operational situations away from families may result in heightened
emotional stress, frustration, alcoholism, hostility, anxiety, depression and psychosomatic disorders.
(ii) Long periods of isolation in high altitude or other areas result in psychosomatic problems.
(e) Hazards due to Warfare.
(i) Conventional warfare deaths/injuries due to bullets, shells, bombs, mines etc.
(ii) Psychological problems - shell shock

15.4 Specific Occupational Hazards: Services/Corps Related.

The occupational hazards specific to certain Arms and Services of the Army are discussed in the succeeding paragraph.
However, it may be kept in mind that since certain trades are common to all Arms and Services, the occupational
hazard discussed under a particular trade may be applied to a similar trade in another Arm / Service.
(a) Army Service Corps (ASC).
Personnel from this service are employed in supply, transport and clerical duties. The peculiar hazards of
occupation are:
(i) Drivers.
Inadequate ergonomics in vehicles can contribute to diverse musculoskeletal disorders, particularly
backaches, while extended periods of driving may elevate the risk of eye strain, mental exhaustion and
physical fatigue, thereby increasing susceptibility to accidents. Furthermore, exposure to vibration can lead to
conditions such as Raynaud’s phenomenon. Additionally, prolonged separation from families during extended
driving durations may raise the risk of acquiring Sexually Transmitted Diseases (STDs), potentially due to
an increased likelihood of seeking the services of Commercial Sex Workers (CSWs).
(ii) Clerks.
Extended periods of working with computers may result in musculoskeletal disorders, such as backaches, as
well as Repetitive Strain Injuries (RSI) from typing and desk duties. Additionally, prolonged computer use may
contribute to eyestrain, often caused by glare and expose individuals to other potential effects of radiation.
(b) Medical Personnel [Army Medical Corps (AMC) and Equivalent in Navy & Air Force].
Healthcare professionals face an elevated risk of contracting infections, including Hepatitis B and HIV, due to
accidental needle stick injuries and exposure while handling biological samples and waste. Prolonged periods
of standing during surgeries, dental procedures and other medical interventions may lead to the development
of varicose veins. The risk of acquiring various infections, particularly airborne infections, is heightened during
patient care activities. Personnel working in radiology and radiotherapy may experience adverse effects due to
radiation exposure. Improper handling of cytotoxic and biomedical wastes poses a contamination hazard, while
lab workers dealing with blood and body fluids are at an increased risk of infections. Additionally, psychological
issues and stress associated with shift work contribute to the overall challenges faced by healthcare professionals.
(c) Corps of Electronics and Mechanical Engineers (EME).
(i) Effects of high noise levels in the workshop floor resulting in deafness.

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(ii) UV radiation effects due to arc welding leading to blindness.

(iii) Effects due to inhalation of various fumes and gases.
(iv) Irritant dermatitis due to repeated exposure to various chemicals like grease, oil etc.
(v) Musculoskeletal disorders amongst vehicle mechanics due to awkward postures and excessive bending
at work.
(vi) Effects due to prolonged exposure to vibration.
(vii) Injuries during handling of various types of machinery.
(viii) Electrical injuries.
(d) Engineers.
(i) Injuries during blasting, mine-laying/removal and construction work.
(ii) Effects of prolonged exposure to vibration during drilling and handling of heavy machinery.
(iii) Injuries during handling of heavy equipment like earth moving and bridging.
(iv) Drowning while assisting in river crossings
(e) Armoured Corps and Mechanized Infantry.
(i) Claustrophobia due to cramped spaces in armoured vehicles.
(ii) Effects of excessive heat inside their vehicles.
(iii) Effect of noise due to firing of guns.
(iv) Effect of dust.
(f) Artillery.
(i) Effects of high levels of noise generated during firing of artillery guns may lead to rupture of the
tympanic membrane and conductive deafness.
(ii) Injuries during handling of heavy equipment.
(iii) Effect of dust.
(g) Remount Veterinary Corps (RVC).
(i) Risk of acquiring zoonosis.
(ii) Animal bites.
(h) Signals.
(i) Injuries among linemen due to falls from telephone poles.
(ii) Long hours of work under the sun especially among linemen resulting in heat stress disorders.
(j) Infantry.
Infantry face numerous health hazards due to the nature of their duties, which often involve physically demanding
tasks, exposure to harsh environmental conditions and combat-related risks. Some of the primary health hazards
for infantry units include:
(i) Injuries such as gunshot wounds, shrapnel injuries, fractures, sprains and strains due to combat
operations and carrying heavy equipment over rugged terrain.
(ii) Heat and Cold Injuries as infantry units often operate in extreme temperatures.
(iii) Musculoskeletal Injuries due to carrying heavy loads, engaging in prolonged marches and performing
repetitive tasks.
(iv) Exposure to dust, smoke, pollutants and chemical agents in combat zones can increase the risk of
respiratory problems.

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(v) Infectious Diseases due to crowded living conditions, poor sanitation and exposure to contaminated
water sources in field environment.
(vi) Psychological Stress due to repeated tenure in CI Ops and the pressure of combat operations
(k) Recruits/Regimental Training centre.
(i) Stress fractures.
(ii) Psychological stress
(iii) Overcrowding has the potential for explosive disease outbreak like meningococcal meningitis,
exanthematous fever, etc.
(iv) Common source outbreak – food poisoning, viral hepatitis, etc.
(l) Troops on Foreign Mission.
The specific hazards are discussed in a separate Chapter XXIV on UN Mission.

15.5 The Factories Act 1948.

(a) Introduction.
Society has an obligation to protect the health of the workers engaged in diverse occupations. Factory laws have
thus been framed in every country to govern the conditions in industry and to safeguard the health and welfare
of the workers. The Factories Act was enacted by the Parliament of India in 1948 and since then it has been
revised and amended from time to time, the latest being the Factories (Amendment) Act, 2016.
(b) Scope of the Act.
The Act defines “factory” as an establishment employing 10 or more workers where power is used and 20
or more workers where power is not used. The term “Worker” includes within its meaning contract labour
employed in the manufacturing process. The Act applies to the whole of India. Under the provisions of the Act,
the State Governments are authorized to appoint besides the Chief Inspector of Factories as many Additional
Chief Inspector of Factories, Joint Chief Inspectors, Deputy Chief Inspectors and Inspectors as they think fit to
enforce the provisions of the law.
(c) Health and Safety.
Elaborate provisions have been made in the Act under Chapters III, IV and IV A with regard to the health and
safety of workers. These chapters deal with laws pertaining to such matters as cleanliness, lighting, ventilation,
treatment of workers, effluents and their disposal. elimination of dust and fumes in the workplace, provision
of spittoons, control of temperature, supply of cool drinking water and the employment of cleaners to keep the
water closets clean. A minimum of 350 cu feet of space for each worker for factories installed before 1948 and
500 cu feet for factories installed after 1948 has been prescribed by the government not taking into account
space more than 14 feet above ground level. The Act also prescribes in detail provisions relating to the safety of
workers. Section 40B provides for the appointment of “Safety Officers” in every factory wherein 1,000 or more
workers are ordinarily employed. The State Government is empowered to prescribe maximum weights, which
may be lifted or carded by men, women and children. Some of the other safety provisions relate to caring of
machinery, devices for cutting off power, hoists and lifts, protection of eyes and precautions against dangerous
fumes, explosive and inflammable materials.
(d) Welfare.
Chapter V of the Act relates to welfare measures for the worker. The Act specifies that wherein more than 250
workers are ordinarily employed, a canteen shall be provided. In every factory, wherein 30 or more women
workers are ordinarily employed, a crèche should be provided. Provisions have been made under the Act to
ensure adequate washing facilities, facilities for storing and drying clothes, sitting, first aid appliances, shelters,
rest rooms and lunchrooms. There should be a welfare officer for every factory employing more than 500 workers.
(e) Employment in Hazardous Processes.
Chapter IV A, incorporated by the Factories (Amendment) Act, 1987 relates to hazardous processes. A Site
appraisal committee consisting of Chief Inspector and other members, not more than 14 in number, is to be

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constituted to submit recommendations on the siting of factories using hazardous processes. Provisions have
been made for workers and participation in safety management in industries involving hazardous processes.
(f) Hours of Work.
The Act has prescribed a maximum of 56 hours of work (60 hours including overtime) per week with a maximum
spread over of work up to 12 hours per day (including rest interval of 30 minutes after every 5 hours of work.
For adolescents, the maximum hours of work per day have been restricted to 4½ hours.
(g) Employment of Young Persons and Women.
The Act prohibits employment of children below 14 years of age. Persons between the ages of 15 and 18 years are
to be duly certified as adolescents by “Certifying Surgeons” and also deemed fit to work. Adolescent employees
and women are restricted from employment in certain dangerous occupations and hazardous processes and are
allowed to work between 6 AM and 7 PM.
(h) Leave with Wages.
The Act lays down that besides weekly holidays, every worker will be entitled to leave with wages after 12 months
of continuous work at the rate of one day for every 20 days of work for adults and one day for every 15 days
of work for adolescents.
(j) Notifiable Occupational Diseases.
Schedule III (Section 89) of the act gives a list of 29 notifiable conditions. It is obligatory on the part of the
factory management to give information regarding specified accidents, which cause death or serious bodily injury
and regarding occupational disease. Provisions have also been made for safety and occupational health surveys
in the factories.
(k) Components of Occupational Health Care.
(i) Work environment
(ii) Machinery
(iii) Materials used or manipulated
(iv) Method and process of work
(v) Worker

15.6 Work Environment.

(a) Design of Building.
All buildings, permanent or temporary should be structurally safe and sound to withstand the stress and strain of
machinery. Single-story construction is the usual rule as it allows flexibility of layout. Any intensity of natural light
can be obtained in it by a combination of wall and roof lighting and it is easier to manage natural ventilation.
By careful orientation, direct exposure to the tropical sun can be avoided. Protection from conducted heat can
be achieved by a choice of suitable material. The asbestos lining of the walls and ceilings will reduce the noise
or machines by controlling the reverberation, resonance and sympathetic vibrations. This will also make the
building fireproof.
(b) Space Requirement.
A floor area of 3.8 m2 and 14.2 m3 of space per worker should be provided. The height of the work rooms
should not be less than 3 m in calculating the space, no deduction should be made for furniture, machines
and material, but a height above 4.2 meters should be excluded. The floor should, however, not be crowded
with machinery. Individual machines or process units should have sufficient space around them to permit safe
operation.
(c) Lighting.
Workrooms should be adequately provided with natural and/or artificial lighting. Any special type of work should
have special, extra or spot lighting suitable for the operations. In all places where persons work or pass through,
enough diffuse background lighting should be ensured. Natural lighting is ensured by the provision of skylight

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and windows located and spaced with devices to avoid glare. Artificial lighting should be provided where the
daylight illumination is insufficient. It should be uniform and free from sharp and contrast shadows and direct or
reflected glare. Supplementary lighting specifically designed for visual tasks should be so arranged as to avoid
glare, flicker or after­image. Emergency lighting should be provided in all important stairway exits and passages,
to and from workplaces and windowless buildings.
(d) Ventilation.
The modern concept of ventilation requires the replacement of vitiated air with a supply of fresh outdoor air. The
quality of the incoming air should be such that its temperature, humidity and purity are conducive for healthful
working. Clean fresh air should be supplied to enclosed workplaces and it is recommended that in work rooms
and assemblies, there should be 4 to 6 air changes in one hour. If the air is changed more frequently, i.e.
more than 6 times in one hour, it is likely to produce a draught which should be avoided. Where an adequate
supply of fresh air cannot be obtained by natural ventilation, mechanical ventilation should be provided. All
dust, fumes, gases, vapors or mists generated and released in industrial processes should be removed by local
exhaust ventilation at their point of origin.
(e) Thermal Comfort.
Temperature and humidity should be maintained in enclosed workplaces suitable to the kind of work performed.
In localities subject to high or low seasonal temperatures appropriate means such as heat insulation of roofs,
walls and floors and even of doors and windows should be adopted. All employees should be protected against
radiant heat and excessive temperature from heated machines or hot processes by heat insulation of the
equipment and/or by suitable protective clothing. In industries involving exposure of workers to high or low
temperatures, ‘transition rooms’ should be provided so that the workers can gradually adjust themselves to
the external climatic environments. Roof-shelters and windbreakers should be provided for yard-workers where
necessary. Measurement and indices of thermal comfort have been dealt in detail in Chapter II.
(f) Working Comfort.
Seats and workbenches of suitable shape and height should be provided for workers. The seats should be so
placed that working material can be reached easily without strain or having to bend forward unduly. Seats should
also be provided for all workers who must work in a standing position, for occasional resting purpose.
(g) Sanitary Conveniences.
These should be conveniently located:
(i) Latrines.
The scale is of 4 for the first 100 workers and 2 for the subsequent 100 workers or part thereof.
(ii) Urinals.
Two urinals for every 100 workers up to 500 and thereafter one for 100 workers are to be provided. For
female workers separate sanitary conveniences are to be provided.
(iii) Wash Basins.
Adequate hand washing facilities should be provided. For persons whose work involves contact with any
injurious substances, there should be at least one tap for every 15 workers.
(iv) Bathrooms.
An adequate number of bathrooms for bathing and washing of clothes should be provided.
(v) Spittoons.
Enough spittoons should be placed at convenient places.
(vi) Cloak Rooms.
Well-ventilated rooms with individual lockers are provided for dressing purposes and storage of personal clothing.
(h) Drinking Water.
An adequate supply of cool and safe drinking water should be provided in a readily accessible place. Water

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coolers are ideal and most hygienic. Proper precautions to prevent contamination of water in tanks, pails and
other containers must be enforced, Section l 8 of the Factories Act lays down that every factory having more
than 250 workers will provide cool drinking water during hot weather.
(j) Housekeeping.
It implies general cleanliness and orderliness of the plants, the tools and the products. Cleaning and sweeping
should be done during non-working hours; vacuum cleaning or wet mopping should be adopted. Effective drainage
should be maintained where wet processing is carried out. False floors, platforms, mats or other dry-standing
places along with suitable footwear should be provided in oily and greasy places. However, ‘house-keeping’
means much more than merely keeping the working places clean, it also encompasses the fact that there is
a place for everything and everything is in its right place and this is a tried-and-true axiom of industrial safety.
Stumbling and tripping due to improper house- keeping is another potential cause of accidents.
(k) Miscellaneous Requirements.
Infestation with rodents, insects and vermin should be eliminated by suitable measures. Workrooms and
workplaces should not be used as living or sleeping quarters. No food, drink, betel nut or leaves or tobacco
should be consumed or brought by any worker into any workroom in which dangerous and obnoxious materials,
particularly lead and radioactive substances, are in use. Anyone suffering from communicable diseases should
be isolated and preventive and control measures instituted.
(l) Machinery Accident.
The most important industrial hazard due to machinery is accidental injury. Accidents in industrial environments
are due to various causes. Bad housekeeping, faulty and unguarded machinery, faulty work methods, carelessness,
ignorance, physical and mental illness, accident-proneness and slackness in the maintenance of machinery or
the formation of an accident prevention organization, are the important factors. The components of machinery
are the main causes of accidents. Though the loss of productive capacity due to accidental disabilities major
and minor and even deaths cannot be measured, it is obviously of the same magnitude, as judged by the man-
days or working time lost. Practical preventive measures are therefore essential to safeguard the workers against
accidents. The safety officer must investigate all accidents with a view to ascertaining the cause, adopt safety
measures against recurrence and train personnel in accident prevention. Most of the accidents are preventable
by the close collaboration of the factory engineer, safety officer, welfare officer, chemist, industrial hygienist and
medical officer. The worker plays an important role in the prevention of accidents. Some industries, occupations
and processes cause particular types of injuries on particular parts of the body. Therefore, he must be educated
and trained in various processes and handling of different types of machines. The Table 15.2 (a) and 15.2 (b)
shows the general causes and give a broad outline of preventive measures against them.
(m) Permissible Exposure Limit (PEL).
It is defined as exposure to a maximum Time Weighed Average (TWA) of concentration of a toxicant for an 8-hour
work. The PELs of some important substances as recommended by the Factories Act 1948 (modified in 2016)
are given in Table 15.1.
Table 15.1 : Permissible Exposure Limit (Pel) of Gases and Vapours (Factories Act 1948 as Amended 2016)
Substance PPM of Air by Volume Substance PPM of Air by Volume
Acetone 750 Nitrogen dioxide 3
Ammonia 0.25 Phenol(skin) 5
Arsine 0.2 mg/m 3 Phosgene 0.1
Benzene 10 Pyridine 5
Bromine 0.1 Sulphur dioxide 2
Carbon disulphide (skin) 10 Toluene 100
Carbon monoxide 50 Trichloroethylene 50
Formic acid 5 Vinyl chloride 5
Hydrogen cyanide(skin) C10 Xylene 100

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 Table 15.2 (a) : Aetiology of Industrial

Aetiology of Industrial

Agent factors Host factors Environment factors

Improper planning and construction of factories Age

Faulty design Sex Physical Social Lack of social
Lack of guards and fencing Experience and education environment environment environment
Lack of maintenance Physical defects
Entanglement of loose clothes and hair Concomitant disease
Transmission of machinery Psychological factors Bad housekeeping At work place
Speed of work Personality traits Overcrowding Domestic
Processes Emotional stability Defective lighting Relationship

341
Faulty planning Industrial fatigue Temperature between
Boiler explosion Accidental falls workers and
Ventilation
management
Dust explosion Wearing unsuitable shoes Humidity
Corrosive materials Carrying improper loads Radiaons from
Molten metal and hot liquids Faulty stepping surroundings
Flying solid particles Habits Atmospheric
Metal grinding, Stone dressing Carelessness pressure
Riveting Negligence Noise
Chipping metal Not using persoal Vibrations
Electricity protective measures Ionising radiations
Gassing Slippery floors
Hand tools, Hammer, Chisel, Cutting instrments Uncovered drains
Falling objects in maintained roofs
Transport, trolleys, cranes, locomotives
Poor human engineering (ergonomics)
OCCUPATIONAL HEALTH
 Table 15.2 (b) : Prevention of Industrial Accidents

PREVENTION OF INDUSTRIAL ACCIDENTS

Primary Prevention Secondary Prevention Tertiary Prevention

Early Diagnosis Disability Limitation
Prompt treatment Rehabilitation
Well organised health department

Health promotion Specific As early as Therapeutic Evaluation Physiological Vocational Guidance

Health education protection possible facilities and of disability rehabilitation training Counselling for
physiotherapy placement adjustment to

342
Personality development
family
Role of voluntary bodies
Workers participation
(Suggestion awards)
Healthy competition in
different departments
Wrokers cooperation
ENVIRONMENTS SPECIFIC TO ARMED FORCES: HEALTH HAZARDS, DISEASES AND PREVENTION
 Table 15.2 (b) : Prevention of Industrial Accidents contd.

Planning Role of Good working Processing Machines Role of ILO Personal Industrial Mo and Foreman and Legilation
1. Design and management environments 1. Precaution 1. Guards 1. Collection protection saftey safety 1. Law
Construction of 1. Clear policy 1. Lighting against toxic & utilization of 1. Clothing 1. Medical 1. Proper training
2. Painting 2. Safety
factory fume, gases, information of examination
2. safety 2. Thermal of dangerous 2. Dust 2. Supervision codes
2. Collaboration dust vapours adjacent study of
committee comforts parts 2. Psychological
special dangers in 3. Masks 3. Education of
O Industrial 2. Substitution test/Physical check
3. Job analysis 3. Noise industry workers on shop
Mo 4. Respirator of environments
of each worker Control 3. Segregation floor
O Safety 2. Methodological 5. Proper weight 3. Statistics of
officer 4. Supervision 4. Vibration 4. Exhaust investigation of 4. Accident
lifting acciedents help
Control Ventilation physical and Investigation
O Chemist 5. training
psycological cause 4. Engineer
O Industrial of new 5. Radiation 5. Periodic 5. Research
& standardization designing / setting
hygienist worker / trainee Control MAC checks of
of statistics 6. Engineering
equipment 5. Investigation of
O Supervisor 6. Industrial 6. Precautions
3. Prescribing accidents 7. Medical
O Engineer fatigue against fire and O Preventing
electrocution boredom safety by laws 6. Health 8. Human
O Personnel O Avoid long
O Recreation 4. Research education behaviour training
Officer hours 7. Good house
welfare publicity material 9. Personal
O Welfare O Rest keeping
O services 5. Encourage protective
Officer O Pauses
safety measures equipment
O Union O Posture

343
leader O Preventing
O Social
boredom
worker O Recreation
welfare
O services
OCCUPATIONAL HEALTH
ENVIRONMENTS SPECIFIC TO ARMED FORCES: HEALTH HAZARDS, DISEASES AND PREVENTION

(o) Materials handled Toxicology.

Industry uses and manufactures a wide variety of substances, which are either known or suspected to cause toxic
effects in the persons working with them. Industrial toxicology is concerned with the study of various substances
used in industry either as media for processing some other materials or as raw materials or the finished product.
(p) Prevention.
General rules for the prevention / reduction of hazards from dangerous and obnoxious substances are as under:
(i) Substitution.
Wherever practicable, the use of offending substances should be prohibited. If this is not possible, a
harmless substance should be substituted for the harmful one. For example, in the match industry, yellow
phosphorus can be substituted by phosphorus sesquisulphide. Similarly, sand-blasting may be replaced
with shot blasting and acetone may be used instead of benzol as a solvent.
(ii) Total Enclosure.
Through airtight enclosure, personal contact with harmful substances such as dust, fibres, fumes, gases,
mists or vapours would be prevented.
(iii) Local Exhaust Ventilation.
Where an airtight apparatus cannot be used, the harmful products should be removed at or near their point
of origin by means of fume chambers or suction hoods properly connected to efficient exhaust systems.
(iv) Dust Suppression.
Where practicable the materials should be used in a moist or wet state to prevent the evolution of dust
e.g. lead.
(v) Personal Protective Measures.
Where necessary personal protective clothing/equipment (respirators and breathing apparatus particularly)
should be worn. The skin may be protected by means of a ‘barrier’ or protective creams.
(vi) Disinfection.
Material infected with bacteria should be disinfected e.g. raw hides against anthrax.
(vii) Duration of Exposure.
Limitation of the duration of exposure or employment should be compulsory in certain trades e.g. in
radioactive processes.
(viii) Restriction of Employment.
Children below 14 yr. are not permitted to work in any industry. Women and young persons between 15-
18 years are prohibited from working in hazardous industries. Women are prohibited from working
underground in a mine.
(ix) Personal Hygiene.
Provision of adequate washing facilities and insistence on washing/bathing e.g. for workers in lead, chromes
and radioactive processes. Prohibition of the preparing or taking of meals and smoking in workrooms.
(x) Environmental Monitoring.
The atmosphere of workrooms should be tested periodically to ensure that the concentration of irritating
or toxic dust, fibres, fumes, gases, mists or vapours is kept within safe limits.
(xi) Health Education.
By far the most important safety factor is the co-operation of the worker in obeying the given safety orders
and instructions. Too often, the safety notices / posters are couched in purely negative terms; the worker
is exhorted not to perform one or other action and is left in doubt as to the reason for the prohibition. A
positive approach has been found to be more effective. If the notices give an indication of the nature of
the hazards to which the workman would be exposing himself, there could be less temptation for disobeying

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the restrictions.
(xii) Notifiable Diseases.
Occurrence of any of the diseases listed hereunder should be notified under “The Factories Act, 1948 as
amended in 2016”.
(aa) Lead poisoning including poisoning by any reparation or compound of lead or its sequelae.
(ab) Lead tetraethyl poisoning
(ac) Phosphorus poisoning or its sequelae
(ad) Mercury poisoning or its sequelae
(ae) Manganese poisoning or its sequelae
(af) Arsenic poisoning or its sequelae
(ag) Poisoning of nitrous fumes
(ah) Carbon bisulphide poisoning
(aj) Benzene poisoning including poisoning by any of its homologues, their nitro or amino derivatives
or its sequelae
(ak) Chrome ulceration or its sequelae
(al) Anthrax
(am) Silicosis
(an) Poisoning by halogens or halogen derivatives of the hydrocarbons of the aliphatic series
(ao) Pathological manifestations due to radium or other radioactive substances and X-rays
(ap) Primary epitheliomatous cancer of the skin
(aq) Toxic anaemia
(ar) Jaundice due to hepatotoxic substances
(as) Oil acne or dermatitis due to mineral oils and compounds containing mineral oil base
(at) Byssinosis
(au) Asbestosis
(av) Occupational or contact dermatitis caused by direct contact with chemicals and paints. These
are two types, that is, primary irritants and allergic sensitizers
(aw) Noise-induced hearing loss (exposure to high noise levels)
(ax) Beryllium poisoning
(ay) Carbon monoxide poisoning
(az) Coal miners’ pneumoconiosis
(ba) Occupational cancer
(bb) Isocyanates poisoning
(bc) Toxic nephritis
(bd) Phosgene poisoning
(xiii) Medical Examination.
A proper pre-placement medical examination followed by periodical medical inspections at appropriate
intervals for workers exposed to hazardous occupations should be enforced.

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 ENVIRONMENTS SPECIFIC TO ARMED FORCES: HEALTH HAZARDS, DISEASES AND PREVENTION

15.7 Common Occupational Hazards.

(a) Lead.
Lead is ubiquitous in industry and poisoning due to absorption of lead and its compounds is still common.
Hazardous processes are lead smelting, burning and making paint, painting, welding, riveting, battery manufacture
and lead baths connected with heat treatment of metals, especially when carried out in confined spaces. Inhalation
of lead dust and fumes is the chief route of poisoning; the next common route is ingestion; cutaneous absorption
is rare. It is rapidly absorbed into general circulation when inhaled and produces ill effects much more rapidly
and probably in a more severe form than when ingested. Young persons are more prone to lead poisoning than
adults. Lead concentration in the working atmosphere should be kept below 2.0 mg per 10 cum of air.
(i) Symptoms.
The commonest manifestations of lead poisoning are blood changes and lead palsy. Lead makes the
RBC fragile and causes haemolysis, which results in anaemia with compensatory stimulation of the bone
marrow. So immature RBC or reticulocytes appear in the blood and the RBC count is generally below
3 million with haemoglobin under 70 percent (Sahli). In ‘Lead palsy’ there is a typical degenerative neuritis
and subsequent fibrosis. In acute lead encephalopathy, there is involvement of the meninges with oedema
and increased intracranial pressure. There, maybe some capillary damage as well. The lead line showing
blue discoloration of the margins of the gums is a classical sign. A diagnosis of lead poisoning should
be based on clinical findings, biochemical evidence of excessive lead absorption and evidence of unusual
exposure. Table 15.3 lists biochemical tests for estimating the degree of lead absorption and Table 15.4
shows manifestation of lead poisoning.
Table 15.3 : Categories of Lead Absorption
Excessive Absorption in
Acceptable Absorption
Test Normal Population Occupation with Signs &
in Occupation
Symptoms

Blood lead 10 ug / dl 10-80 ug / dl >80 ug / dl

Urinary lead 10-65 ug / g Cr upto-150 ug / g Cr >150 ug / g Cr
Zinc protoporphyrin 16-35 ug / dl Upto 100 ug / dl >100 ug / dl
Urinary delta
5 mg / g Cr 6-20 mg / g Cr >20 mg / g Cr
aminolaevulinic acid
Table 15.4 : Manifestation of Lead Poisoning
Evidence of
System Evidence of Absorption Evidence of Definite Poisoning
Incipient Poisoning
General Restive, moody, easily Pallor, lead line, Anaemia, lead line, jaundice,
excited, emotional, lead line. jaundice.
appearance Emaciation, “premature ageing”.
Digestive Persistent metallic taste, Metallic-taste, Definite Metallic taste, increasing anorexia,
slight anorexia, slight anorexia, slight colic, nausea and vomiting, marked colic,
System
constipation. constipation. rigid abdomen marked constipation,
blood in stool.
Nervous system Irritability, Slight headache, Severe headache, increased
uncooperativeness. insomnia, slight insomnia, increased dizziness,
dizziness, palpitation, ataxia, confusion, marked, Reflex
increased irritability, changes, tremors, fibrillary
increased reflex. twitching, neuritis, visual
disturbances, encephalopathy
hallucinations, convulsions, coma,
paralysis.

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 OCCUPATIONAL HEALTH

Evidence of
System Evidence of Absorption Evidence of Definite Poisoning
Incipient Poisoning
Miscellaneous Muscle soreness, easily General weakness, arthralgia,
fatigued. hypertension.
Urine examination Abnormal lead content Abnormal content, cast Abnormal lead content, albumin,
cast, porphyrinuria, haematiria
Blood Polycythaemia, Normal red cell counts Decrease in haemoglobin, decrease
polychromatophilia, and haemoglobin, in RBC, increase in cells showing
Changes
increased platelets, reticulocytosis, 50- basophilia. anisocytosis and
reticulocytosis, abnormal 100 stippled cells poikilocytosis, decreased platelets,
blood lead. per 1,00,000 RBC, increase in blood lead.
abnormal blood lead.
(ii) Prevention.
It depends on good housekeeping, personal protection and education of workers and medical supervision
for the detection of hazards before the occurrence of poisoning followed by its rectification.
(aa) Exhaust ventilation measures so arranged that whatsoever position the worker assumes the
lead dust and fumes are drawn away from his face.
(ab) Strict periodical inspection of the exhaust system; all ducts and their angles should be cleaned
periodically.
(ac) Avoidance of crowding in the workrooms where metallic lead is heated.
(ad) The floor should be impervious to water and smooth so that no lead dust can accumulate.
(ae) The floor should be constantly kept wet and swept before and after the day’s work with a
vacuum cleaner.
(af) Workers should wear special work clothes which should be removed before leaving the factory
and deposited in specially provided lockers in order to ensure the prevention of contamination of
private clothes.
(ag) Suitable respirators against lead dust and fumes should be used and inspected regularly.
(ah) No food, drink or tobacco should be taken in a place where there is a risk of lead poisoning;
special rooms should be provided for this in factories.
(aj) Personal cleanliness should be ensured by providing bathing and washing facilities.
(ak) Health education to avoid dust and fumes of lead being inhaled or ingested.
(al) Medical Surveillance.
Pre-employment medical scrutiny of the prospective workers in the hazardous process should include
the history of previous exposure to lead and the elimination of those with a positive history of
symptoms of lead poisoning. Quarterly medical examination during employment with attention paid to
the loss of weight, gastro-intestinal symptoms, weakness of wrist muscles and blood picture. Removal
from exposure should be followed by active treatment
(iii) Treatment.
When lead poisoning is diagnosed, the further exposure should be discontinued. The use of penicillamine
and Ca- EDTA, chelating agents, helps in bringing down the blood lead levels by promoting lead excretion
in urine. A saline purge will help to remove unabsorbed lead from the gut and also will relieve constipation.
(b) Tetraethyl Lead.
Historically, tetraethyl lead which was used in leaded petrol was responsible for an acute form of lead poisoning
(local encephalopathy). However, it has been banned in India since Mar 2000, because of its serious health
effect following exposure.

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ENVIRONMENTS SPECIFIC TO ARMED FORCES: HEALTH HAZARDS, DISEASES AND PREVENTION

(c) White Phosphorus (WP) Burns.

White Phosphorus (WP) is being used in smoke-producing ammunition. After white phosphorus exposure burnt
skin is washed with 5% sodium bicarbonate and 3% copper Sulphate in 1% hydroxyethyl cellulose. Phosphorus
particles become coated with black cupric phosphide allowing easy identification. Copper Sulphate also decreases
the rate of oxidation of phosphorus particles, limiting damage to underlying tissue. Since blackened particles
continue to elicit tissue injury, they can be removed. Of late, copper Sulphate is found to be toxic and systemic
copper poisoning can manifest as vomiting, diarrhoea, oliguria, haematuria, hepatic necrosis and cardio-
pulmonary collapse. Thus, presently the following treatment is followed:
(i) Self-Aid.
(aa) If burning particles of WP strike and stick to clothing, take off the contaminated clothing.
(ab) If burning WP strike the skin, smother the flame with water  / a wet cloth. Keep the WP covered
with wet material to exclude air until the particles can be removed.
(ac) Try to remove the WP particles with a knife, stick or available object. It may be possible to
remove some particles with a wet cloth.
(ii) Treatment.
(aa) At the earliest opportunity, all WP particles must be removed.
(ab) The affected area is bathed in a bicarbonate solution to neutralize phosphoric acid which will
then allow removal of visible WP particles. In dark surroundings, fragments are seen as luminescent
spots.
(ac) Do not apply oil-based ointments until it is certain that all WP has been removed as WP is readily
soluble in oil. Following the complete removal of the particle, treat the lesion as a thermal burn.
(ad) If an eye is affected, treatment must be started immediately. The most effective treatment is
to neutralize any phosphoric acid by irrigating with a 5% bicarbonate solution. Continue irrigating for
10-15 min with copious amounts of normal saline or water at room temperature. On completion of
irrigation, a wet dressing/cloth should be applied to stop WP burning by depriving it of oxygen. All
WP particles easily accessible should be removed promptly. The lids must be separated and a local
anaesthetic instilled to aid the removal of embedded particles. Once all particles have been removed
from the eye, atropine eye ointment should be put and the patient be transferred to the care of an
Ophthalmologist as early as possible.
(d) Mercury Fulminate.
It is brownish-yellow, heavy, crystalline solid prepared by the action of alcohol on mercuric nitrate. The chief
hazard is dermatitis affecting those who are employed in filling operations where a fine dust is raised, which
comes in contact with the naked skin. The susceptibility of some individuals may not enable them to withstand
exposure even for a day. The exposed parts of the body become erythematous accompanied by violent itching,
swelling and oedema of the face, eyelids, ears, neck and forearms. Teeth become black owing to the formation
of mercuric sulphide. Cleanliness of the plant is important. All precautions as for a lead factory should be taken.
Exhaust ventilation should be fitted and all persons should be provided with well-fitting overalls, aprons, rubber
gloves and if necessary, respirators as well. Additional hand washing facilities should be provided.
(e) Chromium.
Chromic acid and bichromates of sodium and potassium are used in chromium plating of metals, manufacture
of explosives and for tanning of leather. Characteristic chrome ulcers occur on nail beds and the nasal septum.
They are small, deep ulcers varying in size from the head of a matchstick to the end of a lead pencil. The tissues
around the ulcers are heaped up and are covered by crusts. They may cause perforation of the nasal septum.
The ulcers are as a rule not painful but heal very slowly.
(i) Prevention.
Mechanical lateral exhaust ventilation should be provided for the removal of the vapour and spray at the
point of origin. The floor of rooms containing chrome baths should be impervious, maintained in good
condition and flushed out daily. Suitable rubber gloves, aprons and other protective clothing should be

348
 OCCUPATIONAL HEALTH

provided and maintained properly. Water taps should be installed in workplaces, to enable the workers
to wash their hands frequently. A shower bath and a change of clothing should follow the day’s work. All
cuts, abrasions and other injuries on hand and forearm should be protected by adhesive strapping before
starting work. The hand and forearm should be inspected twice a week and any breach of continuity of
the skin should be immediately reported to the factory doctor. A protective ointment should be applied in
the nostrils.
(ii) Treatment.
Chrome holes are only slightly painful and tend to heal spontaneously but may be troublesome if secondarily
infected. They can however be treated adequately with a 10% solution of Calcium EDTA. For ulceration of
the nasal septum use of liquid paraffin on plugs of cotton wool is enough. The man should be removed
from the exposure until completely cured.
(f) Metal Fume Fever.
It is an acute transient illness and is commonly known as ‘Brass Founders Ague’, ‘Zinc Fever’ or ‘Metal Chill’.
It follows the inhalation of high concentrations of finely dispersed zinc or brass fumes, usually in the form of
oxides. After heavy exposure, the nose and throat feel dry and sore giving rise to a dry cough. In a few hours, the
symptoms appear. There is shivering which may last for some time and this is followed by profuse perspiration,
the picture simulating that of an attack of malaria. Considerable prostration follows the attack, but by the next
morning, recovery is almost complete. Some degree of insusceptibility is produced by low-grade inhalation but
is lost in 48 hours. Workers, therefore, are likely to suffer more on Monday mornings. Metal fumes should be
eliminated by proper exhaust ventilation. When conducting replacement or transfer medical examinations, cases
with a history of chronic bronchitis, asthma or any other respiratory trouble should be withheld.
(g) Mineral Oils.
Mineral oils are insoluble and soluble. The insoluble ones are used mainly as lubricants for cutting tools and
the soluble ones are used as cooling agents. Cutting oils have the property of defattening the skin. They also
plug the pores of the skin and form comedones. After some days of use, they may contain steel slivers, which
may injure the skin and thus start dermatitis affecting the forearm and thigh. Small blackheads due to blocking
of the sebaceous glands appear in these areas.
(i) Prevention.
Cleanliness of persons, their clothes and machines should be ensured by the provision of adequate washing
and shower bath facilities. Suitable industrial cleaners should be placed at convenient locations in the
washroom. Clean rags or cotton waste free from sliver should be provided. Time should be allowed for
workers to carry out thorough cleansing, change of clothes and dressing. Those who have a previous history
of dermatitis should be excluded by preplacement examination. Persons suffering from seborrhoea, acne
and excessive sweating should be prohibited from employment in such jobs (Fig 15.1). If the dermatitis
occurs or comedones appear, the person should be temporarily withdrawn from the process and re-employed
when the skin condition clears up.
(ii) Treatment.
The treatment is usually by soothing lotions or creams like calamine. Barrier creams may help in getting
the skin of beginners slowly conditioned to the contact with cutting Occupational Dermatitis oils but cannot
serve as a permanent protective measure for persons whose skins are excessively sensitive.
(h) Benzene.
This is a colourless aromatic hydrocarbon with a characteristic pleasant smell. It is extensively used as a solvent
and as a starting material in the synthesis of numerous chemicals.
(i) Acute Poisoning.
Clinically, acute poisoning is of three general types, depending upon the severity of its anaesthetic effects
on brain centres. Very high concentrations of benzene inhalation may result in unconsciousness, followed
by death from respiratory failure. With somewhat, lower concentrations there may be dizziness, weakness,
apprehension, collapse and unconsciousness. Death may occur from respiratory failure. In the third type
of poisoning, death occurs in several days usually without recovery from a coma.

349
 Occupational Dermatitis

Predisposing Machine Physical Chemical Biological Preventive

Factor Causes Causes Causes Causes measures

Type of Skin Repeated friction Heat Bacteria Selection of workers

Age Sand, dust, coal Humidity Parasite (Mite) Health education
Personal hygiene particles Sunburn Plants (Liliaceae) Periodic inspection
Weather Metal particles Radiation Vegetables Plant design
conditions Glass fibres (U.V. Rays, X-rays) (A sparagus, spinach, Substitution
Pre-employment Fish scale / bone Constant beans, pyrethrum) Personal protection
conditions of skin exposure to water fruit (Orange, lemon,
pricks Thermal comforts
tulip)
Nutritional state Barrier cream
Environmental Keeping up morale
conditions

350
of workers
Protective
clothing
Mechanical
factors Primary Irritants Cutaneous Sensitisers
Excessive sweat
Emotional status
Alkali soap (Dissolve keratin) Combine with tissue proteins and forms complex
ENVIRONMENTS SPECIFIC TO ARMED FORCES: HEALTH HAZARDS, DISEASES AND PREVENTION

Organic solvents (Dissolve fats) antigens

Inorganic acids (Dehydrate tissues) Acridine compounds (acriflavin, mepacrine)
Heavy metal salts (Precipitate proteins) Dyes (Diamine, Rosamine, Chrysodine)
Chromates and bleaches (oxidation of tissue) Solvents (Petrol, TNT)
Coal tar and petroleum (Keratogenic action) Developers (Metol, hydroquinone)
Antioxidants (Guanidine)
Resin, perfumes, waxes
Miscellaneous group (fluorides, mercury fulminate,
bichromates,
insecticides, fungicides, streptomycin, penicillin

Fig 15.1 : Occupational Dermatitis

 OCCUPATIONAL HEALTH

(ii) Chronic Poisoning.

The haemopoetic system is mostly affected but degenerative changes are also observed in the kidneys and
heart. There is weakness, dizziness, rapid pulse, persistent headache, malaise, loss of appetite, shortness
of breath, undue fatigue, decreased resistance to infections and ulcers in the throat. Due to a decrease in
platelets, there is bleeding from the mucous membrane and haemorrhage in tissues. Macrocytic anaemia
gives a more reliable indication of the poisoning than leucopenia, especially in the early part of the disease.
(iii) Prevention.
The ventilation of the workroom should be improved by mechanical exhaust ventilation. A monthly
examination of the employees should be carried out including a complete blood count and findings recorded
in a special register. There should be a rotation in duties of the personnel. Workers showing an altered blood
picture should be removed from exposure. They should report for medical examination if bleeding from the
nose, gums or other mucous membranes is noticed. Toluene, xylene, cyclohexane or trichloroethylene can
be used as comparatively safer and satisfactory substitutes for benzene.

(iv) Treatment.
Penicillin should be given in adequate doses if infection is suspected. Repeated blood transfusions may be
necessary. Since anaemia is frequently of the macrocytic type-folic acid and vitamin B12 should be given.
The diet should be rich in protein, especially animal proteins and in vitamin C and Vitamin B group.
(j) Trinitrotoluene (TNT)3.
It is a yellowish crystalline solid, which looks like brown sugar. It is used extensively as an explosive. TNT is
mainly absorbed by the skin and to a certain extent by inhalation. It forms methaemoglobin, which decreases
the oxygen-carrying capacity of the red blood corpuscles. It has a deleterious action on the bone marrow and can
also cause massive necrosis of the liver. Breathlessness, cyanosis and dermatitis of the hands and forearms are
the early symptoms of poisoning which appear 7 to 14 days after exposure. Later jaundice and aplastic anaemia
may develop. Control of the dust at the point of generation and dissemination by local and general exhaust
ventilation and dilution with uncontaminated air by the plenum system of general ventilation together with good
housekeeping reduce the danger of TNT poisoning. Workers should be subjected to a rigid pre-placement medical
examination. Habitual alcoholics, mouth breathers and particularly persons showing any indication of anaemia
and those with liver, kidney and chronic respiratory and skin diseases should be eliminated. After employment
they should be examined at monthly intervals with special attention paid to the blood picture. If anaemia develops,
a repeated blood transfusion might be needed in addition to a high-protein diet and anti-anaemia therapy.
(k) Tetryl.
It is a light-yellow crystalline powder used as an important propellant in conventional military missiles. It causes
dermatitis, beginning on the face. There may be blisters on the skin and eyes may become oedematous. Hands or
the parts of the body coming in contact are discoloured yellow. As a rule, there are no constitutional disturbances.
Exhaust ventilation, protective clothing, barrier ointments and personal cleanliness reduce the incidence. Sodium
sulphate incorporated in soap quickly removes the stain caused by tetryl.
(l) Nitroglycerine.
Nitro-glycerine is prepared by adding glycerine to a mixture of nitric and sulphuric acids. It is principally used
for making dynamite. It is absorbed mainly by inhalation and to a lesser degree through the skin. It is a strong
vasodilator. The symptoms of poisoning are flushing of the face, throbbing in the head, intense headache,
palpitation, nausea, vomiting and fainting. All operations where nitro-glycerine is washed and neutralized should
be enclosed as completely as possible and exhaust ventilation should be provided. Since it is also absorbed
through the skin, special attention must be paid to housekeeping (cleanliness of workshops) and personal
hygiene, which should include changing working clothes daily, washing hands and wearing protective clothing
as described above.
(m) Trichloroethylene (Trilene).
It is a colourless liquid with chloroform-like odour. It is largely used in the metal industry as a degreaser. When
the exposure is sudden, the worker may die and the post­ mortem examination may reveal oedema of the lungs

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and petechial haemorrhages. Fatty degeneration of the liver, kidneys and heart is present if death is delayed.
Repeated exposure affects the central nervous system leading to paralysis of the hypoglossal nerve, sensory
fibres of the fifth nerve, second cranial nerve and polyneuritis in the limbs. Mild poisoning may cause various
grades of unconsciousness as occurred in the past in laundry workers. Trichloroethylene should be used only in
closed systems or in rooms with a downward exhaust ventilation system. Workmen with dry and fissured skin
should not be permitted to handle the chemical_. Inhalation of a mixture of 95 percent carbon dioxide is of
great value in the treatment of poisoning. Artificial respiration may be necessary.
(n) Carbon-Monoxide.
It is a colourless and odourless gas formed from the incomplete combustion of materials containing carbon. It
is encountered in various industries such as foundries, gasworks, coke ovens, blast furnaces and in automobile
garages. It is a chemical asphyxiant. It forms a relatively stable compound, carboxyhaemoglobin when it combines
with haemoglobin, as its affinity for the haemoglobin is about 300 times that of oxygen.
(i) Symptoms.
Acute poisoning causes a sudden onset of unconsciousness, rapidly developing cyanosis and death. Initial
symptoms of subacute carbon monoxide poisoning, which are more likely to be encountered in the industry
than acute poisoning are shortness of breath and palpitation on exertion accompanied by slight headaches
which tend to increase in severity. With the increased concentration of this gas in the blood, judgement
becomes fogged and the affected individual may not realize his danger. If the exposure continues mental
aberration is followed by unconsciousness resulting in death from respiratory failure. Chronic poisoning
shows all these symptoms coming on gradually and then continuing for longer periods.
(ii) Prevention.
Minimizing its leakage by ensuring efficient ventilation and finally by observing the rules of personal protection
can prevent carbon monoxide poisoning. No person should be allowed to work single-handed in a place
where there is a danger of production of this deadly gas. No workman should enter or approach a place
until the gas has been flushed out by fresh air and a suitable breathing apparatus is used. Safety posters
in common languages should be displayed at strategic points explaining the deadly nature of symptoms of
poisoning and means of rescue and first aid. Workmen should be given practice drills in rescue operations,
artificial respiration and resuscitation. A cylinder containing a mixture of 95 percent oxygen and 5 percent
carbon dioxide with a close-fitting mask, should be available at all times for immediate use.
(iii) Treatment.
The victim should be removed immediately into fresh air and should not be made to walk even if he is
conscious. The oxygen and carbon dioxide mixture should be administered or oxygen should be administered
under positive pressure if available. If the breathing has stopped or is shallow. Artificial respiration must be
started and continued until normal breathing returns. If the heart has stopped beating, cardiac massage
and stimulants should be given. Absolute rest in bed and warmth are essential. A close vigil should be
maintained because of the tendency to relapse. Artificial respiration administration of oxygen-CO2 mixture
and cardiac massage should not be stopped until it is quite certain that the heartbeat cannot be revived.
(o) Hydrogen Cyanide.
It is a colourless gas, with a penetrating bitter almond odour. Sodium and potassium cyanide baths used in the
heat treatment of steel and iron are potential health hazards.
(i) Symptoms.
Hydrogen cyanide like carbon monoxide is a chemical asphyxiant and prevents the tissue from using the
oxygen carried in the blood. When inhaled in high concentration it causes sudden collapse and almost
immediate death. In lower concentration symptoms are delayed; the patient complains of headache.
Dizziness, vomiting, general weakness; slow and irregular respiration and pulse is almost imperceptible.
There is a smell of bitter almonds in the breath. And if inhalation continues for some time coma supervenes,
followed by death from respiratory failure.
(ii) Prevention.
Efficient plenum and exhaust ventilation, respiratory devices. Protective hoods and respirators ensure safety.

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(iii) Treatment.
Immediate first aid measure comprises removing the patient to fresh air keeping the patient warm and at
rest and removing contaminated clothing contaminated skin is washed well with water. Treatment consists
of inhalation of amyl nitrite for 15-20 secs every 2-3 mins along with Oxygen inhalation and artificial
respiration. If a patient is comatose or becomes drowsy then Dicobalt edetate (300 mg in 20 ml glucose
sol) should be given by slow IV injection over 3-4 mins. If there is no return to consciousness, then give
Sodium thiosulphate (12.5 gm in 25 ml of 50% sol) IV over 5-6 mins. If the symptoms reappear or persist,
half the dose of the antidotes should be repeated one hour later. If cyanide has been swallowed, gastric
lavage is essential.
(p) Nitrous Fumes.
The chief constituents of nitrous fumes are nitrous oxide, nitric acid and two forms of nitrogen dioxide, NO2 and
N2O4; the last two lend a brown colour to the fumes. Nitrous fumes are present in industries where sulphuric
and nitric acids are manufactured. And in the manufacture of explosives. The fumes are also a hazard in certain
operations e.g. welding. Metal cleaning and electroplating. Toxicologically nitrogen dioxide (NO2) is the most
important of the oxides of nitrogen.
(i) Symptoms.
The principal symptoms of nitrogen dioxide poisoning are vertigo, headache and tightness in the chest,
nausea and cough. In high concentrations it may produce bronchitis, pulmonary oedema and death. It is
one of the most insidious hazards in industry. When a workman happens to inhale some fumes, for a time
he is a little inconvenienced. He goes home and has his meal, still suffering from no ill effects. During the
night, pulmonary oedema develops and he may be dead by the next morning or noon.
(ii) Prevention.
The fumes should be controlled at the point of origin by efficient general ventilation and by local exhaust
ventilation. Isolation of the offending operation is helpful where the process does not yield readily to the
above measures of control. Respiratory protective devices such as chemical filter respirators are justified
as a last resort when all other measures of control have proved ineffective. These masks need periodical
examination and proper maintenance. The education of the worker in the use of the respirator is of utmost
importance.
(q) Alkalies.
The alkalies used in industry are chiefly ammonia, potassium and sodium hydrates. The industrial hazard from
ammonia is invariably due to the accidental escape of the liquid or gas. It is very irritating to the upper respiratory
passages and may give rise to pulmonary oedema. Burns may follow the splashing of ammonia and other alkalies,
especially in the eyes. Prevention is achieved by taking precautions to obviate the escape of ammonia and the
use of goggles or eye shields. If splashing occurs, frequent irrigation of the eyes by a 4 percent solution of
ammonium chloride should be ensured to reduce the fixed alkalies. Penicillin drops or ointment should follow
irrigation.
(r) Acids.
The common acids used in industry are sulphuric, nitric and hydrochloric acids. When splashed into the eyes
they cause severe burns of the cornea and conjunctiva. Prevention of splashing by protective devices, training
of workers in work methods and personal protection are important precautions. Tubs full of water, ‘plunge
baths’ should be kept in the sections which involve the risk of chemical burns so that the affected individual
can immediately plunge into it to wash the chemical without vigorous rubbing. In cold weather, the bath water
should be kept at 38°C (about the body temperature) during working hours. A number of undines containing 3
percent boric acid solution should be placed in strategic places and workmen should be taught how to irrigate
the eyes immediately. Splashing clean water into the eyes is also helpful. Arrangements should be made for the
mechanical transport of carboys containing acids covered with baskets and handled as little as possible.
(s) Physical Hazards.
Physical hazards arise from poor working conditions such as:
(i) Extremes of temperature especially in hot working environments may lead to causation of heat effects.

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(ii) High humidity contributing to thermal discomfort.

(iii) High or low barometric pressure.
(iv) Radiant energy producing harmful effects (see next chapter).
(v) Noise and vibrations.
(vi) Poor ventilation and lighting.
(vii) Overcrowding of men, machine and equipment, which are important agents for causing accidents.
(viii) Improper seating arrangements producing postural defects in the workers.
(ix) Lifting heavy loads or incorrect technique of carrying loads.
(x) Industrial accidents arise from various causes.
The effects of each of these hazards can either be eliminated or reduced by a careful study of working conditions
and planned action. A close collaboration of the factory engineer and supervisory staff is essential to guard
against such health hazards.
(t) Welding Hazards.
Welding is employed to join metal parts while the edges are in a molten state. There are mainly two methods
of welding, oxyacetylene welding and electric welding. Excessive exposure will produce ultraviolet conjunctivitis,
‘Arc-Eye’ or ‘Welder’s Eye’ which causes swelling of the eyelids, photophobia, a feeling of ‘sand in the eyes’ and
conjunctival injection. Infrared radiation can also cause ‘heat cataract’. The unprotected skin around the neck
and face may receive burns from the ore or the molten metal. Carbon monoxide, nitrous and metal fumes are
produced which can be prevented from toxic effects by the use of a respirator. Screening by coloured glass in the
form of very dark goggles, hand shields or shields fixed on the working benches or helmets prevents exposure
of the eyes to injuries. Good work method training is essential.
(u) Silicosis.
Silicosis is a disease caused by breathing air containing silica in its free state, such as quartz (SiO2). The
pathological result is a generalized fibrotic change and development of military nodules of variable sizes in both
lungs. The clinical manifestations are shortness of breath, decreased chest expansion, a lessened capacity for
work and chronic bronchitis with the absence of fever and characteristic X-ray findings. There is an increased
susceptibility to tuberculosis. The diagnosis of the disease mainly depends upon occupational history, symptom
complex and radiological findings. The pathological process starts only when the dust particles, which contain
silica in a free state such as quartz (SiO2), reach the alveoli. Most of the dust inhaled is expelled by the ciliated
epithelium and some part is eliminated by phagocytosis, which brings up the particles and discharges them to
the ciliated epithelium and the cough mechanism expels them. However, when fine particles are present in the
atmosphere in a large quantity, some find their way to the finer air passages. They first cause the inflammation
of the ciliated epithelial cells with their subsequent destruction, reducing the first line of defence. Epithelial cells
crowded with silica dust get aggregated into definite clumps around which fibrosis occurs. This damage produced
in the lung is permanent. It is liable to activate the pre-existing tubercular focus and develop tuberculosis. The
disease finally produces emphysema and cor-pulmonale.
(i) The factors of importance in the causation of the disease are dependent upon the nature of the
work process and the environmental working conditions. They are as under:
(aa) The dust must contain silica in a free state as quartz (SiO2) and the particles must be of
respirable size.
(ab) These must be present in sufficient concentration in the atmosphere and must be breathed
for long periods.
(ac) The larger particles tend to flocculate and settle out of the atmosphere. Particles of 0.5 to
5 microns are dangerous as they are capable of getting into the lungs.
(ad) Therefore, the dust, which cannot be seen by the naked eye, is much more dangerous than
the dust, which is visible.
(ae) The work in enclosed places is more dangerous than in open places.

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(af) Wet processes carry less risk or none at all but dry processes are dangerous.
(ag) It is generally held that 10 years or longer is necessary for the development of a significant
degree of silicosis; but in more severe exposures, such as in sandblasting and rock drilling under
ill-ventilated conditions, it may occur early.
(ii) Prevention.
Very little can be done once the disease has set in and, therefore, prevention is most important. Dust
control is the most important engineering procedure to reduce risk as shown in Table 15.5.
(v) Asbestosis.
Asbestos is a fibrous material. These are silicates; silica combined with bases like magnesium, iron, calcium,
sodium and aluminium. These are of two types-serpentine and amphibole. However, 90% of production is of
serpentine variety. Asbestos is used in the manufacture of asbestos cement, fireproof textiles, roof tiling, brake
lining, gaskets and such other items. Asbestos fibres are inhaled and fine dust gets deposited in the alveoli.
These are insoluble and cause chronic irritation resulting in pulmonary fibrosis of the lungs. It can also cause
carcinoma of the bronchus and mesothelioma of the pleura and peritoneum (more due to amphibole variety).
These possibilities are more when exposure is coupled with smoking. The disease appears after an exposure
of 5 to 10 years. The fibrosis is peri-bronchial, diffuse and more near the bases in contrast to fibrosis due to
silicosis. Clinically, a patient gets a cough, pain in the chest and dyspnoea disproportionate to the clinical signs
in the lungs. In advanced cases there may be clubbing of fingers, cardiac failure and cyanosis. Sputum shows
asbestos fibres coated with fibrin called asbestos bodies. X-ray chest shows a ground glass appearance in the
lower parts of lungs. The disease is progressive even after removal from exposure.
(i) Prevention.
(aa) Adopt all measures for dust control.
(ab) Substitute it with safer materials like glass fibres, calcium silicate, plastic foam etc. where
feasible.
(ac) Use safer varieties of asbestos (chrysotile and amosite).
(ad) Periodic medical examination of workers and elimination of susceptible from the workforce.
(ae) Use of personal protective measures.
(af) Health education of the workers.
(ag) Continuing research to find out safer substitutes.
(w) Noise.
It has already been realized that noise is a great hazard to human health. The whole world is getting increasingly
conscious of noise pollution. Excessive and unwanted noise is always disliked by people and more so, it adversely
affects the safety and working efficiency of workers in industries. Noise is a discordant sound resulting from
non-periodic vibrations of air.
(i) Sources.
The common sources of noise are military operations, aviation, submarines, automobiles and factories like
- boiler factories, steel mills, textile plants, can factories, shipyards, aeroplane factories and various other
workshops. Domestic exposure occurs due to TV, radio, home theatre, blue tooth speaker and so on.
(ii) Effects.
The loudness of sound depends on intensity and frequency. The human ear perceives, sounds of 20 to
20,000 cycles per second (Hz). The sensitivity of ear changes at different frequencies. Most sensitive
frequencies are from 500 to 5,000 Hz. Prolonged exposure to sound levels of 90 decibels (dBs) and above
cause permanent deafness. Very high-intensity sounds (160 dBs and above) may produce damage in a
single exposure. Noise can produce auditory effects and non-auditory effects.

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 Table 15.5 : Method of Dust Control

Method of Dust Control

Medical Control Environmental Control Personal Control

(i) Proper selection of

persons for dusty trades
Prevention of Respiratory protection
(ii) Periodic medical Dust Control at
escape of dust in Personal hygiene
examination the Source - Dust respirator
to atmosphere
(iii) Epidemiological analysis - Air Mask
(supplied with air)

356
Change in Process Control by substition Control by wetting (i) Segregation
(i) Rotary diamound drills (i) Silica carbide/ (i) Wet drilling. (ii) Proper enclosure
in place of pneumatic drills (in aluminum grinding wheels
(ii) Additional wet mining (iii) Ventilation general & exhaust
mines). instead of sand stone sheel.
method (coal mines)
(iv) Reduce magnitude of air
(ii) Use of permanent (ii) Ground flint replaced
(iii) Moistened flint in displacement by review of design of
ENVIRONMENTS SPECIFIC TO ARMED FORCES: HEALTH HAZARDS, DISEASES AND PREVENTION

mould in foundry. by non-silica substitute in

potteries process equipement
pottery making.
(iii) Use of plastic sand
(iv) Wet abrasive (v) Plant layout
mixture to form moulds in (iii) Silica free parting
foundry. compounds in iron and steel (v) Water sprays in mines (vi) Segregating of dust and non-
industry. dusty operations.
(iv) Use of dust free flint in (vi) Wetting agents
glaze of potteries in place of (Iv) Abrasive blasting (vii) Dust free rooms for rest
(vii) Lead in form of paste.
quartz mixture. replaced by wheel shot periods.
blasting.
(v) Wet grinding of washing (viii) No crowling.
quartz sand in potteries.
(ix) Mechanization
(x) Good house keeping
 OCCUPATIONAL HEALTH

(aa) Auditory Effects.

O Masking Effects.
Excessive noise leads to a masking effect, which makes it impossible to hear normal speech.
O Acute Severe Exposure.
Sound above 160 dBs may rupture the tympanic membrane and may cause bleeding through
the ear. This leads to temporary deafness, which recovers after the healing occurs. This deafness
is in all frequencies and is present only in the affected ear.
O Auditory Fatigue.
Sound level exposures above 90 dBs and 4,000 Hz over a prolonged period lead to auditory
fatigue which is associated with whistling and ringing in the ears.
O Occupational Deafness.
This is the most serious effect of noise and can be temporary or permanent. Temporary Deafness
(Temporary Threshold shift) occurs due to exposure to noise at 4,000-6,000 Hz in the initial
period and it may recover if the worker is withdrawn from exposure for a sufficient length of
time. Permanent Deafness (Permanent Threshold shift) occurs due to prolonged exposure to
sound levels of 90 dBs and above. The victim is usually unaware of the damage initially. The
extent of damage depends on intensity, frequency and duration of exposure and individual
susceptibility to noise levels. Audiogram shows hearing loss at frequencies above 2,000 Hz but
there is a typical dip (c5 dip) at 4,000 Hz. Hearing loss is gradual and progressive. A worker
is unaware of his deafness until it is severe. The first symptom is an inability to converse in
which many people take part followed by tinnitus, buzzing and ringing & whistling sounds in the
ears. This is bilateral, periodic and transitory. Vertigo and ear pain is rare. There is a repetition
of sounds heard at workplace, during the night when away from work (acoustic after-images).
The audiogram shows bilateral hearing loss with a typical-c-5 dip.
(ab) Non-auditory Effects.
Excessive noise reduces general efficiency and increases fatigue. Sudden noise increases BP and
intracranial pressure. It leads to giddiness, nausea. Insomnia, tachycardia and tachypnea. Irritation,
annoyance and neurosis may ensue.
(iii) Prevention.
(aa) Control at Source.
To ensure a conducive work environment, it is essential to monitor sound levels for frequencies and
intensities, taking proactive measures such as segregating noisy machines, applying sound mufflers
to equipment, enclosing noisy processes and implementing suitable design changes when necessary.
(ab) Control of Transmission.
Enhance the architectural designs of noisy buildings by implementing effective soundproofing measures
for walls, ceilings and floors.
(ac) Protection of Workers.
In order to mitigate the impact of noise in the workplace, consider implementing measures such as the
use of ear defenders like ear plugs and ear muffs, ensuring a rapid turnover of workers, conducting
preplacement and periodic medical examinations, providing health education for the management,
staff and workers and establishing legal protections for workers against noise-induced deafness.
(x) Occupational Cancer.
(i) It has the following sequences:
(aa) Exposure to a carcinogenic agent or factor.
(ab) Long latent period during which continuous or interrupted application of the carcinogenic agent
continues.

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(ac) Manifestation of precancerous conditions.

(ad) Appearance of a state of malignancy.
(ae) Appearance of invasive and metastatic carcinoma.
(ii) Carcinogenic Agents.
In the complex landscape of carcinogenesis, numerous chemical groups, a variety of physical factors
and diverse viral agents contribute to the development of cancer, each exhibiting distinct features and
characteristics. The challenge lies in assessing the relative impact of individual components, especially
considering that many of these agents often coexist in combinations. Currently, the recognized groups
encompass a wide range, including carcinogens acting through different modes such as skin contact,
respiratory exposure, oral ingestion and systemic effects. This intricate interplay of factors underscores the
complexity in understanding and evaluating the risks associated with carcinogenic agents.
(iii) Affected Sites.
Occupational cancer often affects the skin, lungs, bladder and blood-forming organs, with its characteristics
including manifestations after prolonged exposure to specific factors, a latency period of 10 to 20 years,
persistence post-exposure cessation, an earlier age of incidence compared to other cancers and consistent
tumour localization within particular occupations.
(iv) Prevention.
This involves the elimination or substitution of any carcinogenic factor including promulgation of legislation,
protection of those exposed to risk by suitable engineering measures and education and training (Table
15.6). Owing to the complexities of industrial carcinogenesis, however, there are difficulties in the application
of all these methods. It is unusual to accept evidence of carcinogenicity in animals alone as justifying
legislative action, which requires long-connected evidence of carcinogenicity in man. When there is
epidemiological evidence that an industrial substance is carcinogenic, combined with experimental proof
of its carcinogenicity in animals. The manufacturers should be advised of its hazards and coerced to stop
its manufacture, eliminate or substitute the process or material with a safe one or institute measures
necessary to prevent contact of the worker.
Table 15.6 : Prevention of Occupational Cancer
Technical Personal Legal Medical
Engineering Process control Personal Notification Preplacement Medical Examination
protective
Building Substitution Cancer registry Periodic examination
equipment
isolation Acts and Rules
General Mass screening of vulnerable group
of harmful Barrier creams
ventilation Forbidding use of
process Analysis of medical records
Bathing & harmful chemicals
Local exhaust
Maintenance washing Periodic checks by Health education
system Plant
of plant factory inspectors
equipment Limitation of Early diagnosis and treatment
equipment Licensing
exposure
design Special cancer clinics
Dust control Certifying
Personal health
Mechanization surgeon’s Training of cytopathologists
Environmental habits
Monitoring Compensation
Good Avoidance of
physical and housekeeping repeated trauma
chemical & tar bums
waste disposal Protection against
ionizing radiations
The manufacture of b-napthylamine - a proven bladder carcinogen was stopped in many countries through
voluntary action by the dye manufacturers. Where a risk of such substances has been proved beyond doubt
the law places a basis for claiming compensation of the hands of the worker and gives a warning to the
employer and finally prohibits the use of such material, process or manufacture of the product. The industrial

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materials proved to be highly carcinogenic both in animal experimentation and epidemiological studies in
man, include β naphthylamine benzidine, 3-3-dichlorobenzidine, 4-arninobiphenyl (xenylamine), polycyclic
hydrocarbons, dimethylnitrosamine, nitrosomethy­ lurethane, b-propiolactone, diazomethane, trinitrotoluene,
beryllium salts. Oxides, mineral oil, pitch, tar, 3:4 benzpyrene, radioactive substances, nickel, arsenic and
asbestos besides elimination, substitution and engineering devices of safety, the principles which protect
workers exposed to risk from industrial carcinogens are the segregation of processes, mechanical handling
and enclosure of processes. Exhaust removal, chemical monitoring, dust control, use of protective clothing.
Provision of washing facilities, medical surveillance and education of the workers.
Workers require a clear exposition of the risks to which they are exposed and of the reasons why protective
measures and codes of hygiene are so important, of how these measures are to be carried out, combined
with a warning of the possible consequences if they do not adhere to; and with advice to report any health
abnormality, however trivial, to the factory doctor.

15.8 Worker.
The worker is the most important component of the industrial set-up. It is imperative that the worker remains in an
optimal state of physical, mental and social health. To achieve this, it is of prime importance to fit the worker’s skill to
the job and the job to his skill. Therefore, from the medical point of view, a judicious preplacement medical examination
should be carried out taking into consideration the hazards which factory life will impose on the individual. It should,
however, be realized that every factory job does not require the highest physical standard of health. Even a disabled
person could be accepted in certain jobs where the partial disability of the individual will not in any way interfere with
the efficient performance of his duties in that particular job. In other words, a disabled person should be viewed not
as to how much he cannot do, but how much he really and safely can do. In addition to assessing his disability, his
residual ability should also be assessed. For instance, a few blind ex-soldiers have been employed in an optical factory
and it has been found that their output has been more than that of normal men. They work through the sense of
touch which evidently they have developed in themselves to an extraordinary degree of proficiency and also perhaps
the blindness in their case has actually helped greater concentration on work by excluding visual distraction. Having
ensured basic fitness, it would be important to watch, through periodic medical examinations, the progress of the worker
under the impact of his occupational environment. After selection and placement, it is the duty of the management
to provide adequate safeguards to protect him from accidents, toxic and other occupational hazards, not only to fulfil
the employers’ obligations under the Factory Act, but also to ensure maximum individual and collective protection. It is
then necessary to train him in work methods and self-protection against all possible occupational hazards. If in spite
of all these precautions the person does become a victim, the management should offer remedial measures, social
security and alternative placement rehabilitation.

15.9 Clothing.
They should fit well; there should be no loose flap or string and even shoelaces should be tied tight. Persons exposed
to inflammable, explosive or toxic dust should not wear clothing having pockets, cuffs and turn-ups that might collect
such dust. Loose, torn or ragged garments, neckties, mufflers or headdresses and key or watch chains should not be
worn near moving parts of a machine. Shirts with short sleeves should be worn in preference to rolled-up sleeves and
pockets, if any, should be few and as small as practicable in all clothing. When the operation involves a danger of
explosion or fire, wearing of articles such as collars, eye shades, cap visors and spectacle frames made of celluloid
or other inflammable materials should be prohibited during working hours. Sharp or pointed objects and explosive
substances or Inflammable liquids should not be carried in pockets. The material and shape of special protective overalls
should vary with the substances involved e.g. liquid-proof or gas-proof against corrosive and irritant liquids / gases;
asbestos suits complete with a helmet, gloves and boots against risks of excessive heat and fire; against radio-active
substances washable material so designed as to cover other clothing at the neck and wrists. Washing of working
clothing is necessary at least once a week as prevention against contamination of other clothing.

15.10 Head Gear.

Well-fitting helmets made of aluminium; fiberglass or steel should be worn as protection against falling or flying objects
and blows on the head. For the protection of hair from overhead moving belts, well-fitting caps of washable and non-
inflammable material should be used.

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 ENVIRONMENTS SPECIFIC TO ARMED FORCES: HEALTH HAZARDS, DISEASES AND PREVENTION

15.11 Eye and Ear Protection.

Workers with errors of refraction should have the error corrected. Glasses or transparent plastic materials for goggles
and windows of protectors should be free from striae and air bubbles. All goggles intended for mechanical protection
should be splinter proof. Goggles and shields for workers engaged in welding, furnace work or any other operation where
their eyes are exposed to glare should have filter lenses or windows of standard absorption value against ultraviolet
and heat rays. Non-flammable, transparent visors, free of scratches should be provided for protection against glare and
sparks. Goggles, when not in use should be kept in special closed containers protecting them from mechanical damage
and should be inspected at regular intervals once a month and all defective parts should be replaced immediately.
Earmuffs and earplugs should be used for protection against noise. Each of these reduce the sound level exposure
by about 20 dB each.

15.12 Hand and Arm Protection.

Gloves for workers handling sharp-edged or abrasive objects should be made of tough material and where necessary
provided with special reinforcements of leather pieces or even a metal piece over the palm. Gloves should also be
made of steel mesh for use in the cutting process. Gloves and sleeves for workers handling hot metals could be made
of asbestos or other heat-resisting material. Gloves with sleeves made of rubber capable of withstanding voltage of
10000 or more should be used for electrical workers. Gauntlets made of natural synthetic rubber or pliable plastic
material should be used when handling corrosive liquids. Close-fitting gloves should be used to avoid exposure to toxic
fumes and infectious agents.

15.13 Barrier Cream.

It prevents penetration of irritant substances into the skin. Ideally, a barrier cream should be non-irritating, non-
sensitizing and insoluble in the substance against which being used. Easily removable and cosmetically agreeable.

15.14 Foot and Leg Protection.

Leggings for workers handling molten metals should be made of asbestos or other suitable heat-resisting material,
extending to the knee. At the lower end, they should also cover eyelets of footwear. Metal toe guards or safety boots or
shoes should be worn in operations where heavy objects are handled. Footwear for workers handling corrosive liquids
should be of rubber, specially treated leather, wood or other suitable corrosion-resisting material. Footwear for electrical
workers should have non-conductive soles.

15.15 Respirators.
The cardinal principles governing the choice of a respirator are the process and conditions that create the exposure; the
chemical, physical, toxic or other hazardous properties of the substance from which protection is required; the nature
of the duties performed by the persons wearing the equipment and the encumbrance or restriction of movement in
the working area; and the facilities for maintenance, upkeep and supervision of use. Finally, all respiratory protective
equipment should be capable of fitting various types of facial contours without leaking. The following are a few types
of respirators used in various industrial processes and environments. These should all be inspected and tested at
regular intervals by responsible trained persons.
(a) A mechanical filter respirator can only filter the suspended atmospheric impurities. A wide variety of
impressive patterns and designs are available. None afford protection against solvent vapours, injurious
gases or atmospheres deficient in oxygen and are essentially dust and fume filters in an otherwise healthy
atmosphere. The simplest example of such a type of respirator is the common surgical gauze mask. By
introducing a thin layer of wet cotton wool in between the layers of gauze, it may be worn as a protection
against coarse particles, such as fibres or sawdust. Their efficiency against fine particulates, such as those of
silica dust, will depend upon the quality of the filtering medium. Over time, these, filters become clogged and
there is increased resistance to breathing. The filters should then be washed or changed. Everybody should
be supplied with a personal mask.
(b) Chemical cartridge respirators and canister masks ensure the purification of air, which passes through the
canisters containing specific neutralizers against specific toxic gases. The canisters have a particular coloured
design painted on them indicating the specific toxic gases against which they afford protection; e.g. an orange-
coloured canister indicates that it is meant to be used against nitrous fumes. The user has to depend upon
the oxygen content of the atmosphere; therefore, such respirators should not be worn in confined or poorly

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ventilated places or where the concentration of the offending gases is high. The canister should be changed
after each use and if not in use, at an interval not exceeding one year or such other period as specified by
the manufacturer. These should be properly maintained and all defective parts replaced.
(c) Breathing apparatus (supplied-air-respirators or hose masks). The term ‘supplied-air-respirators’ means
a respirator equipped with a hose line, through which fresh air is supplied under positive pressure whereas
through hose masks the wearer can inhale air at atmospheric pressure. The length of the hose in the former
should not exceed 45 m and in the latter, it should not be more than 75 m. For the hose mask, the inside
diameter of the hose should not be less than 2.5 cm and the hose should be of a non-collapsible type. These
are also used when the canister for the cartridge respirator cannot be used due to high concentrations of
dangerous gases or fumes. The body harness should be comfortable and should allow free movement of the
wearer and also all parts should withstand a pull of at least 115 kg.
(d) An oxygen breathing apparatus consists of a face piece with a corrugated tube connecting it to an
oxygen tank or cylinder. This is used by workers engaged in firefighting, rescue or repair work in atmospheres
containing high concentrations of gases or which is deficient in oxygen or sufficient pure air supply.
(e) A self-generated oxygen mask is a new type of oxygen breathing apparatus fitted with a small canister
containing a chemical. Moisture from the inhaled air starts a chemical reaction, which liberates oxygen.

15.16 Accident Prevention Strategies.

The first step in any accident prevention program is the elimination of various hazards whilst designing the process. If
this is not possible, the next best step would be to control the physical, mechanical and chemical hazards in a work
environment by suitable engineering design. But when this also is not possible or is not able to give full protection to
workers the third line of defence has to be resorted i.e., the personal protective equipment. This protective equipment
cannot eliminate a hazard or stop an accident from taking place. These equipment’s merely set up a barrier against
the hazards thereby preventing or minimizing an injury. In selection of these equipment’s, the following points are to
be borne in mind:
(a) Type of hazard to be faced.
(b) Selection of 1ight type of personal protective equipment.
(c) Availability of correct equipment in good condition at the work spot.
(d) Training of workers to use the equipment.
(e) Convincing the workers that the equipment if used will protect them from hazards.
(f) Making it a habit with the worker to use the equipment.
(g) The degree of protection needed.
(h) Ease & comfort with which it can be used and freedom of movement with equipment should not
hamper performance of the worker.
(j) Maintenance of these equipment.
(k) Periodical check-up
(l) Good earthing

15.16 Personal Protective Equipment (PPE).

Personal protective equipment generally provided in factories for protection against various hazards is given below in
Table 15.7 the provision of PPEs does not enable an individual to take liberties against the hazard, as it is not full proof.
Hence, emphasis should be directed at the prevention of hazards by making the system full proof. At the same time,
individuals who have been provided PPEs should use the same although there may be some difficulty and discomfort
initially. Gradually the wearer shall get accustomed to the same and discomfort will vanish.

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Table 15.7 : Personal Protective Equipment

S. Part of Body
Hazards PPE Recommended IS. No.
No. Protected
1. Chemicals Chest/ Apron Rubber Acid & Alkali IS-4501-1981
Abdomen Proof 30” wide x 40 long
2. Chemicals Full body Acid Protective suit with -
Coat, Pant, Hood, PVC welded
3. Falling objects Head PVC Helmet IS-2925-1984
4. Welding rays Eyes Goggles blue IS-5983-1980
5. Gas cutting / Welding rays Eyes Goggles green IS-5983-1980
6. Chemicals Eyes Goggles cup type IS-5983-1980
7. Flying particles Eyes Goggles impact IS-5983-1980
(Grinding)
8. Flying particles (Grinding) Face/Eyes Face shield plastic transparent with IS-8521
adjustor head band Type-I of 1977
9. Hot metal Hand Gloves Mitten Gunny -
10. Handling of material having Hand Canvas Gloves 12” long IS-994
sharp edges Type -XV

11. Handling of Hand Cotton drill gunny pattern (blue) gloves IS-6994
Material having sharp edges Type-XV

12. Thin gauge stlip inspection Hand Shingler coloured hosiery hand gloves -
13. Handling hot components Hand Asbestos hand gloves16” long -
with cotton lining
14. Welding Hand Leather Gauntlets for welders 16” long IS-2573 (Type-I)
15. Handling Hand Rubber Gauntlets -
Acid & Alkali proof 16” x 8” long
(without internal lining)
16. Working on Electrical lines Hand Rubber gloves for Electrical purpose IS-4770
working voltage 4000V Type-IV
17. Dust Respiratory Permacal face mask “Swasthya” -
18. Fumes/Mist Respiratory Chemical respirators IS-18522
19. Noise Ear Foam Ear plugs IS-9167-1979
20. Noise Ear Rubber Ear plugs -do-
21. Fall from height - Safety belt IS-3521 (Type-2)
22. Toxic gas Respiratory Canister gas mask IS-8523-1977
23. Chemical Foot Industrial vulcanized rubber BS-5145
knee high boots 1984
24. Fall of heavy objects Foot Leather safety shoes for heavy metal IS-1989 of 1978
Industry

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15.17 Safety Audit.

(a) Objectives of Safety Audit.
(i) Critically evaluate the safety programme.
(ii) Evaluate the systems to identify and control hazards.
(iii) Check that the above system meets the statutory standards and codes of practice.
(b) Benefits of Safety Audit System.
(i) Strengthening of the Organization’s safety standard and program.
(ii) Improve the skills and performance of employees and managers.
(iii) Helps to create group and self-awareness and provides motivation.
(iv) Identifies specific deficiencies in the safety program.
(v) Provides timely information before any injury-producing incident occurs.
(c) Corporate Safety Audit System.
Safety audits shall be carried out at three levels in the Ordnance Factories.
(i) Level-I.
Internal Audit Inspection by Safety Officers from within the factory once every three months.
(ii) Level-II.
Audit Inspection by a group comprising 3 officers of the factories in the concerned group, once in a
period of six months.
(iii) Level-Ill.
Annual Audit Inspection by the Regional Controller of Safety/O.F. Board.
(d) Scope of Safety Audit.
The Audit is necessarily very wide-ranging in scope and covers all aspects of a company’s operations. Some
of the broad areas to be covered for the Safety Audit are appended below:
(i) Safety Policy.
Involvement of Top Management, assignment of responsibility and accountability, workers participation
through involvement.
(ii) Process Safety.
Identification and control of hazards.
(iii) Fire Safety.
Fire prevention and protection.
(iv) Hazards and Their Control.
Covering ventilation and exhaust system, work environment monitoring, personal protective equipment
and emergency showers.
(v) Pollution Control.
Air, Water, Noise.
(vi) Review of Procedures.
Operating, Maintenance, Start-up & shut down, permits to workers etc.
(vii) Machine guarding.
(viii) Housekeeping.

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(ix) Material Handling System.

(x) Safety.
(xi) Training of workers/Supervisory staff and Management personnel.
(xii) Accident reporting, investigation & Analysis.
(xiii) Emergency preparedness.
(xiv) Health, First Aid and Periodical Medical Examination.

15.18 Accident Investigation.

All accidents shall be investigated by the concerned Heads of Sections and an unambiguous report sent in Form
No 20/20A. The safety section shall investigate selected accidents involving plants / machineries/chemicals where
accidents are due to unsafe conditions. In case of all serious accidents, a Board of Enquiry to investigate the accident
shall start investigation immediately upon receipt of intimation by visiting the accident spot so that the evidence is
not tampered. Photographs may be taken if necessary. The investigation should be towards fact-finding and not fault-
finding. The concerned sections shall not disturb the site until it is cleared by the Board of Enquiry or Safety Officer.

15.19 Accident Returns.

The accident statistics indicating details of accidents, man-days lost and man-hours worked are compiled quarterly. A
monthly report on the accidents taking place during the preceding month is also compiled.

15.20 Accident Analysis.

The accidents taking place in the factory shall be analysed by the Safety Section, Department-wise and as per IS-
3786-1983 as follows:
(a) Unsafe material or physical condition (e) Agency of Injury
(b) Unsafe act (f) Nature of Injury
(c) Unsafe personal factor (g) Location of Injury
(d) Type of Accident

15.21 Occupational Psychology.

Occupational psychology enables the study of psychological fitness for employment and investigation into the causes
of a psychological breakdown due to stress and strain in certain occupations. This includes investigations into aptitude
for different kinds of work and into the causes of industrial fatigue. This wider aspect of industrial psychology includes
vocational guidance, personal supervision, management and the quality and nature of human relationships in industry.
There are many psychological factors involved in occupational morbidity, work may be dull, monotonous, repetitive or
otherwise un-suited to persons of certain temperament or character.

15.22 Preplacement Medical Examination.

(a) All workers should undergo a medical examination before entering industrial employment for the first
time (engagement or preplacement examination) or within 15 days of employment.
(b) Those under 14 years of age should not be employed except in technical schools, special training shops
or apprenticeship courses.
(c) Section 34 of the Factories Act states that no woman or young person unaided by another person, lifts,
carry or move by hand or on the head, any material, article, tool or appliance exceeding the following limits:

Adult Adolescent Child

Male - 29.5 kg 16 kg
Female 29.5 kg 20 kg 13.5 kg
(d) Medical services should collaborate closely with the technical services of industrial establishments

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to ensure as perfect a selection of workers as possible from the standpoint of physical, physiological and
psychological suitability and also from that of the worker’s skill.
(e) The pre-placement medical examination should consist of a general clinical examination and special
investigation, where indicated. Diagnosis made on these medical examinations should be strictly confidential.
Persons suffering from unsafe traits, such as, ‘accident-proneness’ should not be employed.
(f) Proper job analysis should be done for all the jobs and each person should be placed in such a way that
he fits in the job and the job fits him.

15.23 Periodical Medical Examination.

(a) Periodical medical examination should be carried out at regular intervals (monthly, quarterly, yearly)
depending upon the hazard to which a worker is exposed.
(b) In addition, medical examinations of workers should be carried out on their returning from sick leave
and those seeking a change of employment.
(c) The clinical examination should be supplemented by special investigations where indicated.
(d) The date and results of such examination should be recorded in special registers maintained for this purpose.

15.24 Medical Records.

Meticulous attention should be paid to the maintenance of all statistical records/documents. These should be carefully
studied and analysed for correct evaluation. These records will help in the planning, development and efficient operation
of the occupational health service. Graphs should represent ratios per 1,000 and not actual figures. The latter are
fallacious and of no comparative value. Amongst other documents / records and ‘Absentee register’ is of special
importance and gives an indication for taking appropriate measures for the improvement of industrial safety and
hygiene in the factories.
(a) Analysis of sickness or morbidity.
Total sickness absence is expressed as the average number of days lost per worker employed during the period
and is calculated as:
Average days lost = Total number of days lost per person divided by no. of Persons employed.
Note. With a view to obtain more accuracy with regard to low figures of small factories, cases of ‘sickness
absence’ may be divided into the ‘long term’ and ‘short term’ absence (over or under 30 days respectively).
(b) Analysis of Accidents.
The higher risk of accidents is greater in certain occupations than in others. In order to compare the frequency
and the severity of accidents in a given period, the International Labour Office has standardized the following
ratios for each million man-hours worked:
(i) Frequency rate: E/C x 1,000,000
(ii) Severity rate: F/C x 1,000,000
Note. E = Number of accidents causing loss of working time in the given period.
C = Total man-hours worked in the given period.
F = Total hours lost through accidents occurring in the given period.

15.25 Hazards to Population.

(a) Causes.
The industry not only presents hazards to workers but also creates hazardous, obnoxious or annoying conditions
for the residents in the vicinity or the township. Some of the principle hazards are owing to:
(i) The atmospheric pollution by smoke and poisonous gases, fumes and dust
(ii) Soil pollution by industrial wastes or unhygienic habits of workers

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(iii) Water pollution by industrial effluents

(iv) Noise pollution by machinery, work processes and other conditions
(v) Consumption or use of hazardous finished products
(b) Air Pollution.
In recent years, air pollution by smoke and noxious gases, dust and fumes has become an important public
health problem. Turbulence in the air usually ensures that the pollutants put into it are rapidly removed.
This process, however, may not be adequate to deal with the exorbitant amount of pollutants. Moreover,
due to temperature inversion in still weather, cold air near the ground comes to underlie the warm air and
the pollutants accumulate near the earth’s surface the most important air pollutant is smoke resulting from
incomplete combustion of solid, liquid and gaseous fuels. The use of fuel is associated with all aspects of
our life but industrial uses are the most important sources of smoke in the atmosphere. Besides industry,
shipyards, rail and road transport, thermal power stations and household activities also pollute the atmosphere
with smoke. Smoke is often mixed with dense fog, which has come to be termed as ‘smog’.
Most coals, cokes and heavier oils contain sulphur compounds, which on burning emit sulphur dioxide.
Combustion of gasoline yields carbon monoxide and the irritating hydrocarbon known as olefin. Other volatile
organic compounds present in polluted air in big cities are cresol, phenol, toluene, xylene, 3:4 benzpyrene,
aldehydes and soot and tar compounds. Industrial contaminants specific to some industries are, sulphur dioxide
from smelting operations, chemical plants and oil refineries; sulphuric acid mist from acid-producing plants;
fluoride compounds emitted by aluminium plants, phosphate from fertilizer plants and refinery processes; radio-
active wastes from atomic reactors; suspended matter from pulp and paper mills, steel plants and tanneries
and so on. Dust is a special hazard from industries like Portland cement manufacturing.
(c) Ill Effects on Health.
Air polluted with sulphur dioxide and sulphuric acid can produce acute respiratory irritation and distress. This
may prove to be a final burden for the persons suffering from respiratory and/or cardiac disease and allergic
disorders of the respiratory tracts, the aged and premature infants. The other ill effect attributed to air pollution
is the increased incidence of lung cancer. Unpleasant odours of polluted air may cause perpetual anorexia and
gastric troubles. Interference with visibility may be a contributory factor towards increasing the frequency of
road accidents. Eye troubles also increase in a smoky atmosphere. In any case, it is very depressing to work
and move in smoky and smog environments. Silicosis and pneumoconiosis occur due to pollution with dust.
(d) Trade Effluents.
Indiscriminate discharge of untreated liquid wastes into a stream makes the water unpotable, destroys fish and
renders it unfit for bathing and recreation purposes. Livestock and dairy cattle may get poisoned by drinking
water contaminated with industrial wastes like insecticides and mineral oil etc. or give an unpleasant flavour
to milk. Anthrax is known to be transmitted by using water polluted with slaughterhouse or tannery wastes.
Wastewater from chemical and ammunition factories contains untreated compounds like arsenic, cyanides
etc., which are toxic to plant, animal and human life. Untreated trade effluents discharged into a sewer make
the final disposal of sewage unsatisfactory. Trade effluents from gas works give an offensive taste and smell
to water. The indiscriminate discharge of wastewater on land may cause water logging, infertility of soil and
even destruction of standing crops.
(e) Control Measures.
(i) Effective legal provisions for the control of water and soil pollution by proper disposal of trade
effluents should be provided. A technical organization to assess the nature and magnitude of water
pollution is required. Water (Prevention and Control of Pollution) Act, 1974 & Environmental Protection
Act 1986 refers.
(ii) Similarly, legislative procedures for the control of smoke nuisance coupled with regular monitoring
of air pollutants and rigid enforcement of these provisions are the chief measures for controlling smoke
pollution of the atmosphere. Standards for the sulphur content of coal and smoke in the air must be
laid down. Air Pollution Control Act 1981 & Environmental Protection Act 1986 refers.
(iii) A technical organization to monitor the water, soil and air pollution, advice on methods of treatment
and determine suitable standards for disposal should be established.

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(iv) Administrative machinery to enforce legal provisions with representatives from the state health
department, factory inspectorate and public health engineering should ensure that these essential
requirements are fulfilled.
(v) The proper siting of residential and industrial areas by sound town planning is important to reduce
the hazards from air pollution.
(vi) Smoke nuisance from railway locomotives, ships and also the industry can be eliminated by a
changeover to diesel fuel or electric power.
(vii) The active cooperation of industrialists who must recognize their responsibility in this matter plays
a vital role in the control of air pollution and disposal of effluents.
(viii) The education of legislators, industrialists and workmen is important to make them appreciate
the problem and their respective role in minimizing the hazards.
*Note. the details of legislation in relation to occupation health has been covered in chapter XXXIX on
Public health legislations.

15.26 Hazard & Risk Assessment at Work.

Hazard refers to a substance, agent or physical situation with a potential for harm in terms of injury or ill health,
damage to property, damage to the environment or a combination of these. Hazards can be physical, chemical,
biological, ergonomic or psychosocial in nature. Risk is the likelihood of the harm or undesired event occurring and
the consequences of its occurrence. It is the probability that the substance or agent will cause adverse effects under
the conditions of use and/or exposure and the possible extent of harm. It is thus a function of both exposure to the
hazard and the likelihood of effects on health from the hazard.
Risk assessment is the process of estimating the magnitude of risk and deciding if the risk is tolerable or acceptable.
A tolerable risk may not always be acceptable. It is the willingness to live with a risk to secure certain benefits and
in the confidence that the risk is being properly controlled. The levels of tolerability of risk are different for different
countries and in different working populations and the general public views on tolerability depend to a large extent
on the populations that might be affected by the risk. Risk assessment and risk management must take into account
both routine and non-routine activities and conditions, including foreseeable emergency situations. Hazards intrinsic
to these situations or generated by such activities should be recognized and the exposed people should be identified,
including non-employees and those who are susceptible and therefore at higher risk because of illness or other medical
conditions. As part of this assessment, any existing control measures also need to be evaluated. Such a process
requires a team effort, involving the workers themselves as well as personnel with the relevant expertise. It is important
to inform workers of the hazards, risks and appropriate measures that have been and can be taken to protect them.
(a) Ergonomics.
Ergonomics is a branch of occupational health that focuses on the design and arrangement of products, systems
and environments at workplace to optimize human well-being and performance. It aims to create a harmonious
relationship between humans and their surroundings, taking into account their physical abilities and limitations.
The word “ergonomics” is derived from the Greek words “ergon” (work) and “nomos” (laws). It encompasses several
disciplines, including human anatomy, psychology, engineering and design. The main objective of ergonomics is to
improve human efficiency, comfort and safety by adapting products and workspaces to fit the individual rather than
forcing the individual to adapt to them. One of the fundamental principles of ergonomics is anthropometry, which
is the study of human body measurements. By understanding the diverse dimensions and physical capabilities
of individuals, designers can create products that accommodate a wide range of users, promoting inclusivity
and accessibility. For instance, adjustable chairs and desks in office settings are the result of anthropometric
research, allowing people of different heights and body types to work comfortably.
Ergonomics is not limited to workplace design. It extends to various domains, such as product design,
transportation and digital interfaces. A well-designed computer mouse (Fig 15.2), for example, reduces strain
on the wrist and enhances productivity during long hours of computer use. Incorporating ergonomic principles
in the workplace can lead to several benefits. By providing ergonomic furniture and equipment, employers can
reduce the risk of musculoskeletal disorders and repetitive strain injuries among their workforces. Healthy and
comfortable employees are more productive and satisfied, resulting in reduced absenteeism and higher job
performance.

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Furthermore, ergonomics plays a crucial role in the design of consumer products. User-friendly gadgets and
appliances simplify daily tasks, making technology more accessible to people of all ages and abilities. For
instance, smartphone interfaces with intuitive touch gestures cater to a wide audience, including the elderly and
individuals with disabilities. Ergonomics also extends its influence to the realm of interior design and architecture.
By considering factors such as lighting, acoustics and spatial layout, designers can create environments that
enhance comfort, concentration and overall well-being. Whether it is a factory, office, classroom or hospital, a
well-designed space can create products, workspaces and environments that prioritize human comfort, safety
and efficiency leading to healthier and more productive individuals, fostering inclusivity and enhancing the
overall quality of life. All efforts should be made to create an ergonomically sound working environment.

Fig 15.2 : Work Station Ergonomics (a) & (b)

Suggested Reading.
1 Internet Archive. Work and Health: An Introduction to Occupational Health Care. Internet Archive, London: Chapman
& Hall, 1995, archive.org/details/workhealthintrod0000unse. Accessed 27 Mar. 2024.
2 World Health Organization. “Occupational Health.” Who.int, World Health Organization: WHO, 17 Sept. 2019,
www.who.int/health-topics/occupational-health.
3 Occupational Health (Occupational Safety and Health).” Ilo.org, 2019, www.ilo.org/safework/areasofwork/
occupational-health/lang--en/index.htm.
4 Koh, David and Wee Hoe Gan. “Occupational Health.” Oxford University Press EBooks, 1 Nov. 2021, pp. 457–
472, academic.oup.com/book/36249/chapter-abstract/316169801?redirectedFrom=fulltext, https://doi.org/10.1093/
med/9780198816805.003.0055. Accessed 27 Mar. 2024.
5 “Importance of Occupational Health and Safety Procedure | PDF | Hazards | Occupational Safety and Health.”
Scribd, www.scribd.com/presentation/597170882/Importance-of-Occupational-Health-and-Safety-Procedure. Accessed
27 Mar. 2024.
6 Jindal, A. K., et al. “Study of Occupational Risks to Personnel in an Air Force Station.” Indian Journal of Aerospace
Medicine, vol. 57, no. 2, 31 Dec. 2013, pp. 1–8, indjaerospacemed.com/study-of-occupational-risks-to-personnel-in-an-
air-force-station/. Accessed 27 Mar. 2024
7 IS 3786 (1983): Methods for computation of frequency and severity rates for industrial injuries and classification
of industrial accidents.
n

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Chapter
XVI
ENVIRONMENTAL SANITATION

16.1 Introduction.
Environmental Sanitation is defined as “the control of all those factors in the physical environment which may
exercise a harmful effect on human beings’ physical development, health and survival”. Poor sanitation is linked
to transmission of diarrheal diseases such as cholera and dysentery, as well as typhoid, intestinal worm infections
and polio. It exacerbates stunting and contributes to the spread of antimicrobial resistance. Globally over 1.5 billion
people still do not have basic sanitation services, such as private toilets or latrines in 2022. Of these, 419 million
still defecate in the open, for example in street gutters, behind bushes or into open bodies of water. Poor sanitation
reduces human well-being, social and economic development due to impacts such as anxiety, risk of sexual assault
due to women being forced to practice open defecation in fields and other secluded areas and lost opportunities
for education and work due to morbidity caused by poor sanitation.
Lemuel Shattuck, in the mid-19th century, spearheaded the landmark “Report of the Sanitary Commission of
Massachusetts,” a watershed moment that advocated for organized public health measures. Simultaneously across
the Atlantic, Edwin Chadwick championed the cause of sanitation and public health in England through his famous
“Report on the Sanitary Conditions of the Laboring Population of Great Britain.”. His impassioned advocacy led
to the pivotal Public Health Act of 1848, emphasizing the connection between unsanitary living conditions and
disease outbreaks, transforming the landscape of public health in Britain.
With his consistent application of the experimental method to public health, Max Von Pettenkofer (1818-1901) helped
the discipline of hygiene to provide precise and reliable answers to sanitary questions. He established in 1879, the
first centre of competence for hygiene and environment in the world, opening a new era of environmental observation.
He combined medical expertise with physics, chemistry, technique and statistics, this “crossover-thinking” made
Environmental Hygiene and Sanitation the first interdisciplinary medical field.

16.2 Scope of Environmental Sanitation.

The scope of environmental sanitation includes:
(a) Waste Disposal.
Methods for the adequate and safe disposal of excreta, sewage and community wastes.
(b) Water Supply.
To ensure that drinking water is pure and wholesome.
(c) Housing.
To ensure that it is of a character likely to:
(i) Provide as few opportunities as possible for the direct transmission of disease, especially respiratory
infections and
(ii) Encourage healthful habits in the occupants.
(d) Milk and Other Food Supplies.
To ensure that they are safe (the question of their nutritive quality being excluded from consideration)
(e) Pers Hygiene.
Personal habits of cleanliness and of good public taste in relation to disease.

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(f) Vector Control.

Elimination of arthropod, rodent and mollusc infestation or other alternative hosts of human disease.
(g) Atmospheric Conditions.
To ensure that the external atmosphere is free from deleterious elements and that the internal conditions of
workshops, houses, etc. are suitable for the occupations undertaken in them.
(h) Factories, Workshops, Dwellings, Streets and the General Environment.
to ensure freedom from risk to health whether mechanical, chemical or biological and to provide the best working
and living conditions.
However, this chapter focuses mainly on the different types of waste and management of waste. All the other components
mentioned above are discussed in detail in other chapters of this book.

16.3 Waste.
According to the Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and Their Disposal
of 1989, Art. 2 (1), ‘Wastes’ are substances or objects, which are disposed of or are intended to be disposed of or are
required to be disposed of by the provisions of national law”. Waste is an unwanted or discarded material that may
not be of any use to an individual who is discarding it, but it may be of use to someone who may reuse it or recycle
it. Though waste is a physical object, its generation is a physical and psychological process.
(a) Significance of Waste Disposal.
Swachh Bharat Mission, the world’s largest sanitation initiative was launched by the Government of India in
2014 to achieve an Open Defecation Free India by October 2, 2019. The program led to the construction of
over 10 crore individual household toilets, taking sanitation coverage from 39% in 2014 to 100% in 2019
when around 6 lakh villages declared themselves Open Defecation Free (ODF). Despite the progress achieved
through “Swachh Bharat” and “Swachh Bharat 2.0 (Urban)” India still has much scope for improvement in the
field of environmental sanitation. Many cities and towns in India are characterized by over-crowding, congestion
and inadequate facilities for disposal of waste. To maintain adequate environmental sanitation, governmental
authorities and the community need to work together.
Waste collection and disposal assume significance primarily on two fronts: public health and socioeconomic aspects.
(i) Public Health Aspects.
A World Health Organization (WHO) study estimates that 1.4 million deaths could be prevented each year
through improving access to safely managed water, sanitation and hygiene services (5). Human excreta
is the principal source of pathogenic organisms. Diseases of public health significance such as the
enteric group of infections including cholera, typhoid, dysentery, diarrheal diseases and viral infections
are still causing considerable morbidity and mortality in low- and middle-income countries. Inadequate
environmental sanitation can pave the way for several communicable diseases like, food crop contamination
through unsanitary irrigation practices and soil contamination by helminths including Ascaris, Enterobius and
Hook worm result in many morbid conditions. Breeding of Culex in standing pools of wastewater causing
widespread filariasis is a serious hazard. Apart from waste generated through human habitation, pollution
of natural resources due to ever growing industrialization has become a major threat. About 54 million
tons of e-waste, such as TVs, computers and phones, are created annually with an expected increase to
75 million tons by 2030. Exposure to improperly managed e-waste and its components can cause multiple
adverse health and developmental impacts especially in young children.
(ii) Socio-Economic Aspects.
A WHO study calculated that for every US$ 1.00 invested in sanitation, there was a return of US$ 5.50 in lower
health costs, more productivity and fewer premature deaths. The general development of hygienic conditions
promotes a state of wellbeing in the population, which is conducive to its social development. The provision of
organized sanitary facilities, such as potable water supply, leads to a considerable saving of time and labour
which would otherwise be lost due to disease and this becomes available for productive work in any economy.

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(b) General Principles of Waste Management in the Armed Forces.

Disease occurrence, especially gastro-intestinal infections in military operations are inversely proportional to the
efficacy of waste disposal. Hence sanitary disposal of wastes assumes great importance in keeping the troops
fighting fit. The methods of waste disposal on active service must be simple, practical and standardized. Multiplicity
and over-elaborations in design should, as far as possible, be avoided. Modifications are to be permitted only on
grounds beyond control such as climate, type of terrain or type of campaign. The actual methods to be employed
depend on the length of stay in any place. For convenience, Armed Forces camps are grouped as:
(i) Permanent Camps.
Occupied for a year or longer; they include cantonments, garrisons. base camps, large camps on the Comn
Z and so on.
(ii) Semi-permanent Camps.
Occupied for less than a year and more than six days.
(iii) Temporary Camps.
Occupied for six days or less.
This grouping serves only as a guide, no hard and fast rules can be laid to distinguish the various kinds of
camps. It should always be kept in mind that a particular camp can be required to be occupied for a more
prolonged period than initially expected. Thus, a temporary camp can become a permanent camp and a semi-
permanent camp can become a permanent camp, garrison or even a cantonment. Generally, in permanent
camps, cantonments and in garrison stations where water carriage system of faeces disposal or other efficient
systems of conservancy, sullage and refuse disposal exist, latrines and other sanitary conveniences are usually
located from the point of view of users’ convenience. In semipermanent and temporary camps, latrines and refuse
disposal should be concentrated in a well-defined circumscribed sanitary disposal area even at the expense of
the convenience of the users to some extent. However, the latrines should be as close as possible to living
quarters, commensurate with the need for efficient supervision and working.
The sanitary area should be:
(i) Clean and tidy.
(ii) On the leeward side of the camp.
(iii) Away from the water supply points and cook houses.
(iv) Protected from rains.
(v) Allotted according to the existing scale to units and subunits.
(c) Responsibilities.
The local Commander is responsible for the health and comfort of his men. Maintenance of the latrines and
all other sanitary installations and appliances, detection and rectification of sanitary defects. and obedience of
orders regarding sanitation are, therefore, important responsibilities of the unit administration. The unit sanitary
squad should carry out all these duties under the supervision of the unit hygiene and sanitation officer. The unit
orderly officer should make a routine inspection at least once a day. Advising the local Commander on matters
of health of the troops, prevention of ill health and healthy living and working conditions is the responsibility of
the medical officer. These duties should therefore oblige him to conduct a sanitary round once a month to the
latrine areas and unit lines and observe the state of unit sanitation and hygiene and make recommendations
to improve them. He is also responsible for training and guiding the unit hygiene and sanitation officer and the
sanitary squad. For this purpose, he can get assistance from the sanitary staff of the medical organization and
the technical staff officer at the formation HQ.
(d) Classification of Waste
For convenience of disposal, wastes may be grouped as under:
(i) Human excreta - faeces and urine.
(ii) Stable litter - cattle and horse dung.

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(iii) Dead animals, carcasses and offal of slaughtered animals.

(iv) Offensive trade wastes.
(v) Solid waste - Dry refuse and garbage-household, municipal, industrial and agricultural.
(vi) Liquid waste - household sullage, municipal and industrial effluent.
(vii) Electronic waste.
(viii) Biomedical Waste.

16.4 Excreta Disposal.

Excreta, also known as Nightsoil, should not be disposed along with solid waste or any other kind of waste as it has
several health hazards specific to it, unlike the other types of waste. In developing, underdeveloped countries and
our country as well, excreta is found mixed with other kinds of waste and efforts should be made to ensure that the
excreta is not mixed with other wastes for disposal.
(a) Sanitation Barrier.
Sanitation barrier refers to segregation of excreta in such a way as to break the disease transmission cycle (in
case of fecal borne diseases)
Faeces should not be allowed to come in contact with the food, fluids, food, flies, fields and fingers

SANITATION BARRIER FOOD

FLIES

FAECES FIELDS

FLUIDS

FINGERS

Fig 16.1 : Sanitation Barrier

This can be ensured through proper collection and disposal of human excreta.
(b) Excreta Disposal Systems.
The transport system of excreta is by far the most expensive part of the overall system and is related to the
type of ultimate disposal envisaged. Basically, there are four alternatives:
(i) Water Carriage System.
(ii) Air Carriage System.
(iii) Conservancy System.
(iv) On spot Disposal System.
A detailed description of all these methods of excreta disposal, which are in practice in different parts of the world,
is beyond the scope of this manual. Only those ones, which are in vogue in the Armed Forces establishments
in India, will hereafter be briefly discussed. Standard textbooks should be consulted for details.
(i) Water carriage System.
In this system human excreta and waste from residential, commercial and industrial areas are carried away
by a network of underground pipes called sewers to the place of ultimate disposal. This is the method of
choice for urban areas having piped water supply. There are two types of sewerage system, the combined
and the separate systems. The combined system carries both sewage and storm water. ln the separate
system surface water is not admitted into the sewers. The latter is the system of choice. The main problems
are lack of funds, piped water supply, skilled manpower and low priority accorded to its construction.

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(aa) Components of Water Carriage System.

O Household Sanitary Fittings.
These include water closets, urinals, washbasins, bathtubs along with their plumbing systems.
O Soil Pipes.
These are pipelines, which carry excreta from the water closets to the house drain. They are
fitted with outlet ventilators for the escape of foul gases and hence are placed outside along
rear walls of the houses and are carried above the roof tops.
O House Drain.
It is an underground galvanized iron (GI) or stoneware pipe usually of 10 cm diameter and
is laid in the courtyard 15 cm below the ground level on a bed of cement concrete mix with
sufficient gradient towards the public sewer. It carries away the discharges from the household
sanitary fittings to the street sewers.
O Public Sewer.
It is a network of underground pipelines varying in diameter from 22 cm to 3 m for carriage
of sewage from domestic, industrial and commercial areas to the place of final disposal. While
laying the pipelines sufficient gradient is to be ensured for self- cleansing velocity of sewage.
This velocity varies from 60 cm to 90 cm per second.
O Sewer Appurtenances.
These are manholes and traps installed in the sewerage system:
- Manholes.
These are opening built in the sewers for the purposes of repairs and cleaning. They are
placed wherever there is change in the direction of sewers, at the junction of two or more
sewers and at a distance of 100 meters in the long, straight run of the sewers. Workers
entering manholes are liable to sewer gas poisoning (H2S, CO2, CH4, NH3, SO2, biological
organisms, water vapor and other chemicals) and asphyxiation unless due precautions
are taken.
- Traps.
These are devices designed to prevent the entry of foul gases inside the house and to
remove sand, grit, grease etc. from sewage. Traps are placed at three points under the
water closet, at the junction of the house drain and the street sewer and where the
surface water enters the sewers. There are several designs of traps. The simplest one is
a bent pipe containing water as a seal (Fig 16.2). The water seal in a trap is the distance
between the highest level of water in the trap and the lowest point of the trap’s concave
upper surface.

Fig 16.2 : Water Seal

(ii) Air Carriage system (Vacuum flush system).
The modern air transport, maritime transport and some road transport and some high-rise buildings use
vacuum flush technology to eliminate solid and liquid residue. The system is mostly water free, clearing

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the non-sticky bowl with suction. When the flush button is pressed, a valve at the base of the toilet opens
and the contents are sucked out of the bowl by suction due to sufficient differential pressure. The contents
along with a small amount of disinfectant flow through the pipes to large, sealed tanks for storage and are
emptied either by tanker or pumped into an underground sewage system.
(iii) Conservancy System (Pan System).
This system is to be relegated to pages of history. In this system the collection and removal of night soil
from the bucket and or pail latrines were carried out through human agency and hence termed conservancy
system or service type. The employment of human labour for collection of nightsoil is highly inconsistent
with the concept of human dignity. As per Section 2 (1) (g) of the Prohibition of Employment as Manual
Scavengers and their Rehabilitation Act, (MS Act 2013) manual handling of human excreta is banned and
this practice is a cognizable offence in our country.
(iv) Onspot Disposal System.
(aa) Aqua Privy.
It is a satisfactory method of on spot disposal system, which may be used, in small garrisons
having no piped water supply. This system, however, is more suitable for semipermanent camps and
individual dwelling units in rural/semiurban areas. Use of PVC pipes is advised in temporary and
semi-permanent camps. This consists of an underground concrete septic tank with the latrine seat
and faeces receptacle incorporated in the cover of its digestion chamber. The 25 to 30 cm long soil
pipe is submerged 5 cm below the water level in the rank. The digestion and aeration chambers
intercommunicate by one hole in the centre of the partition wall for the discharge of half-digested
night soil and the other above the water level for the escape of gases into the aeration chamber. The
aeration chamber is subdivided into 3 or 4 compartments by means of baffles, which remain 15 cm
short of the tank cover and 10 cm above the water level. These compartments intercommunicate by
means of apertures of 8 cm diameter, placed alternatively near the top and bottom of the baffles
to slow down the flow of the sewage for its effective liquefaction. The ventilation shaft is at the
proximal end of the aeration chamber. The effluent discharge pipe should be fixed 6 cm above the
level of the lower end of the soil pipe and 10 cm below the level of the upper edge of the baffles i.e.
25 cm below the tank cover. The excreta undergo disintegration by ‘septic tank action’ in the digestion
chamber. The disintegrated particles are carried into the next compartment with fresh addition of
excreta and ablution water. Subsequent disintegration and dilution of the particles continues during
their passage through the successive compartment resulting in a clear and inoffensive effluent, which
can be disposed of by any of the recognized methods. Aqua privy cannot be usually used as universal
method in large stations but may be used in small garrisons of a semipermanent nature.

Fig 16.3 : Aqua Privy

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16.5 Disposal of Excreta within the Armed Forces Based on the Nature of Deployment.
Within the armed forces, the choice of final disposal system can be divided into 4 categories based on the terrain and
operational requirements:
(a) Temporary.
Shallow trench latrine, sanitary latrine based on improvised and removable Indian type sanitary water closet,
incinerator latrine.
(b) Semi-permanent.
Deep trench latrine, improvised deep trench latrine, dug well latrine, ventilation improved pit latrine, Pour flush
water seal latrine.
(c) Permanent.
Sewerage system, Combination of septic tank and soakage pit/subsoil irrigation, oxidation pond, bio-latrine, aqua
farming.
(d) High Altitude.
Temperature-controlled bio-digester, chemical closet.
(a) Temporary camps.
(i) Shallow Trench Latrine.
These are used strictly as a temporary measure only when the deep trench latrines cannot be constructed.
Each trench is 90 cm long, 30 cm wide and 60 cm deep. Trenches are dug in parallel with an interval of
at least 60 cm in between two trenches. The earth removed should be neatly piled at its head end (Fig
16.4). The trench is used by squatting astride it, with a foot on either side and not both feet on the same
side. After defecation, the excreta must be covered by earth with a scoop. Fly breeding occurs if this is
neglected. The latrine area must be policed by a member of the unit sanitary squad to ensure that each
user carries out these instructions. After 24 hours, faeces should be covered with a 3 cm layer of slaked
lime and trenches should be filled with earth. A new row of trenches is immediately dug in front of the
previous day’s row. While leaving the camp, the earth should be well rammed down, sods should be replaced
on the trenches, the whole area and the ground up to to 1 m all round sprayed with the insecticides and
the area suitably marked ‘L’ to indicate the ground as unusable by any unit camping thereafter.

Fig 16.4 : Shallow Trench Latrine Fig 16.5 : Incinerator Latrine

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(ii) Incinerator Latrine.

It may be used in sandy desert, loamy or arid lands by small detachments for short periods. A shallow
trench with dimensions as given in (Fig 16.5) is dug. Ghee tin ‘A’ has its bottom perforated top removed
and corners cut and the sides bent outwards so as to receive the bottom of tin ‘B ‘. The tin ‘B’ with its top
and bottom removed is then placed in position projecting 15 cm above the ground level. The remainder
of the trench is filled up to the level of the base of tin ‘B’ with stones Tin ‘C’ with its bottom perforated
and the top 15 cm of its side adjacent to tin ‘B’ cut way is then placed in position. The top 15 cm of the
side of tin ‘B’ adjacent to tin ‘C’ is cut and bent over to grasp the cut side of tin ‘C. A fly proofed wooden
seat battened with strips of wood on its under surface is then placed in position to fit tightly over the tins
BC. Faeces fall into tin AB and urine into ‘C’ to soak into the small soak pit beneath. The seat must be
kept clean. The faeces are burnt twice a day by pouring a small quantity of mixture of petrol. kerosene
and sump oil and igniting after removing the seat. This latrine lasts for a fortnight for ten men. When the
contents are 15 cm from the top, the seat is removed the final burning is carried out. A sandbag soaked
in oil is placed on top, the flap of tin ‘B’ is bent backwards and the remainder of tin ‘B’ is then filled with
sand/earth and well packed. No flies can either enter or emerge and any egg deposited in the faeces will
be destroyed.
(b) Semipermanent Camps.
(i) Deep Trench Latrine (DTL).
The Deep Trench Latrine (DTL) is the standard method of faeces disposal in a semi-permanent camp. In
this latrine, the faeces are deposited and directly disposed of in the deep trench over which a flyproof
superstructure with several squatting or sitting seats is fixed. Faeces get disintegrated; the liquid effluent
of disintegration, ablution water and urine are absorbed; and the solid residue, greatly reduced in quantity,
deposits at the bottom of the trench. If properly maintained the trench lasts for six months or more and
is free from any danger of either fouling the surroundings or fly breeding. Normally 5 seats per latrine are
constructed at the scale of 10 percent of the strength of unit / subunit. It is better to provide a duplicate
trench for use when the first one is sealed. Used alternatively, a pair of trenches can last up to four years.
The advantages of the DTL over the conservancy system are many. Since it is one of the methods of the
spot disposal system, it dispenses with the services of conservancy staff, use of receptacles and carts.
There is no fouling of the ground and no pollution of the water supply. Fly breeding is minimum.
Construction details of Deep Trench Latrine.
Broad details of the construction of DTL and its maintenance are given hereunder step by step. Unit sanitary
personnel should be trained in proper construction and maintenance of the DTL with understanding of the
rationale (Fig 16.6).
(aa) The standard trench is 1m wide, at least 2½ m deep and 3 m length or of the length of the
superstructure available. If any danger of sides collapsing is envisaged, they should be riveted with
bamboo, sandbags or wire netting. If sandbags are used the width should be 1.3 m. It should not
reach the subsoil water level for chances of contamination of subsoil water level. If the subsoil water
level is high, an increased depth may be obtained by building a mud bank upto one meter high all
around the trench (Fig 16.7). This bank is riveted on both its internal and external faces with interlaced
bamboo.
(ab) The ground up to one meter around the trench is then dug to a depth of 10 cm and the
loosened earth is removed. Strips of oil-soaked sacking, each 1½ m wide, are then spread over this
dugout area with the inner edges hanging down to 15 cm over the sides of the trench and secured
in position with small wooden pegs. The outer edges are sunk into the ground along the outer edge
of the dugout area.
(ac) Required number of joists (4 or 5) are placed over the trench, overlapping its edges by 60 cm
to support the superstructure.
(ad) The fly proof wooden superstructure made as described below is then placed over the joists
so as to overlap the edges of the trench by 10 cm.
(ae) The squatting type of superstructure should be flat as a tabletop, made of tongued and grooved

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timber and it’s under surface completely covered by a double thickness of oiled sacking snugly tucked
to the wood, except at the lidded squatting apertures.
(af) Each aperture should be 36 x 25 cm, with a distance of 30 cm from the next one and fitted
with a hinged lid.
(ag) The lid should overlap the aperture by 5 cm all round. It should be covered on the under surface
with a double layer of oiled sacking. A device for opening without touching it with hands should be
provided.
(ah) The loose soil removed from around the trench is then mixed with heavy oil, replaced in the
dug-out area around the trench on the top of the sacking and joists and rammed down to form a
hard impervious layer. Flies likely to hatch out inside the trench are trapped beneath the sacking
while trying to reach the surface after emergence from their pupal cases.
(ai) A flytrap may be constructed at one end of the trench.
(aj) A shallow drain with a soak pit at its end to stop storm water from entering the trench is made
all round the latrine.
(ak) An overhead shelter must be provided as protection against rain and the sun. Partitions should
be interposed between seats.

Fig 16.6 : Deep Trench Latrine

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(al) Maintenance should be carried out as under:

O The superstructure must be maintained always fly proof by replacing all wrapped lids, by
caulking all cracks with oiled sacking and by replacing all torn sacking.
O The lids must always be kept closed when the latrine is not in use.
O It is unnecessary and even harmful to throw any disinfectant into the trench.
O Oiling of superstructure or seats is unnecessary; they should be scrubbed daily and
washed and always kept dry.
O Tins, bottles or other extraneous matter must not be thrown in.
O Insecticide spray should be carried out on a fixed day once a week on the superstructures
and 2 m all around the latrine.

Fig 16.7 : Built-up Deep Trench Latrine

(ii) Improvised Deep Trench Latrine.
An improvisation of DTL may be carried out by placing the seat fitted with modified water closets, a meter
and half in front of the long edge of the trench. The excreta are flushed through sewage pipes into the
trench with small quantity of water. It is similar in principle to the hand flushed water seal latrine evolved
by the Planning, Research and Action Institute (PRAI) of the Ministry of Health, Government of India. The
water seal performs two important functions prevents access to flies by sealing off the night soil and escape
of foul gases. This type of latrine, therefore, is more hygienic and acceptable. For a detailed description
and functioning of the PRAI and RCA types of latrines, which have been found highly suitable for the rural
masses in this country, standard texts may be consulted.
(c) Permanent Camp: The method of excreta disposal in a permanent camp depends on the existence of
sewerage system. If sewerage system does not exist and or not to be constructed, then aqua privy is the method
available. The water carriage system with final disposal either to sewage works or to septic tanks or to oxidation
ponds should always be preferred than aqua privy. It is desirable from aesthetic, health, labour saving and
cost effectiveness points of view. If a nearby municipal sewerage system exists, then the question of adopting
other systems should not arise. Lead pipes should not be a part of the disposal system as it can be severely
detrimental to nature.
(d) High Altitude.
(i) Chemical Closet.
In the Armed Forces, when troops are deployed in certain areas like the high-altitude terrain where no

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other methods of excreta disposal could be found practicable, chemical closets have proven to be effective.
The closet consists of a metal tank containing mainly a solution of caustic soda. The toilet paper is to be
used. If water is allowed to enter the tanks, the chemical gets diluted and hence loses its functioning. This
system works by chemical liquefaction and sterilization of excreta. After a few months of operation, the
chemicals are to be replaced. It is expensive and hence of limited use restricted to inhospitable terrain.

16.6 Disposal of Urine within the Armed Forces Based on the Nature of Deployment.
(a) Permanent Camp.
In a permanent camp having water carriage system, porcelain, cement or masonry, trough urinals connected to
the sewers should be insisted upon. If the water carriage system does not exist, the urinals should be drained
to a covered soakage pit. Trough may be improvised from corrugated or plain galvanized iron sheet (Fig 16.8). It
should slope gently towards one end from which a vertical drainpipe runs down to the soakage pit. The front lip
of the trough should normally be 70 cm. Both the end faces of the trough are occluded by a semi-circular disc of
wood covered with tin. Two troughs, each 2 m long, are sufficient for coy strength. The ground beneath the trough
and for 1 m all rounds should be covered with concrete. A bored hole may be substituted for the soakage pit.

Fig 16.8 : Trough Urinal

Fig 16.9 : Standard Funnel Urinal

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Fig 16.10 : Tulip Funnel Urinal

(b) Semi-Permanent Camp.
In a semi-permanent camp, the standard type of funnel urinal described below should always be insisted upon.
A masonry or corrugated iron sheet trough constructed as described above may also be used. ‘Urinoil’ is a
modified funnel urinal in which a layer of heavy oil is used as a barrier against flies and bad odour.

Fig 16.11 : Urinoil

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(c) Temporary Camp.

In a temporary camp improvised tin urinal placed over soakage pit may be used. A ghee tin with perforated
bottom and half buried in a soak pit is the simplest of these types. A trench half a meter broad, 4 to 5 m long,
dug down to 15 cm to 18 cm filled with brickbats or stones may be used in camps on the line of march. At
the time of closing of the camps, the trenches should be filled with earth and layer of slaked lime spread over
these.
(i) Funnel Urinal.
The standard one can be made from three ghee tins. The entire length of the urinal is 105 cm, of which
the shaft is 85 cm and the funnel top in its central axis is 20 cm. The diameter of the funnel top is
35 cm, which tapers gradually to 5 cm where it joins the shaft. The outer surface of the entire urinal and
the inner surface of the shaft should be treated with coal tar. The inner surface of the funnel may be
painted white for easy visibility at night. A strainer of 5 cm diameter and made of a perforated tinplate is
soldered inside at the junction of the funnel with the shaft The urinal should be installed over the soakage
pit so that 30 cm of the shaft is buried. That will leave 55 cm of the shaft and the funnel top above the
ground. The urinal should be fixed inclined in such a way that the user can stand just outside the soakage
pit. This is ensured by placing the shaft at an angle of 25° to 30° with the vertical axis. The edge of the
funnel should not be less than 60 cm nor more than 75 cm above the ground. Naphthalene balls should
be left ·in the funnel to minimize bad odour. A hessian cloth enclosure will ensure privacy.

Fig 16.12 : Ghee Tin Urinal

Fig 16.13 : Standard Funnel Urinal

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Fig 16.14 : Four Funnel Urinal

(ii) Relief Tube.
During World War II, certain fighter aircraft were fitted with devices known as ‘relief tubes. These consisted
of a funnel attached to a hose that led to the outside and which could be used for urination. These devices
were awkward to use and could become frozen and blocked in the intense cold of the high altitude.
Such devices are still sometimes fitted
to modern military aircraft undertaking
extended soaring.
In early aircraft, the amount of fuel the
aircraft could carry usually determined
how long it could stay in flight. Today,
with aircraft being able to air refuel,
the time they can stay aloft is based
more on human needs, one being waste
management. Voiding urine in a single-
seat ejection seat aircraft has been an Fig 16.15 : Relief Tube
issue for male pilots in the past, but with
the increasing numbers of female pilots in single-seat aircraft, finding a solution has intensified. The recent
developments in this field are, Piddle packs, female relief systems like The Lady-J, The Go-Girl Urination
Director, Vacuum Assisted Relief System. Of all the methods used by aircrew over the years, the AMXDmax
system appears to be the only solution currently available that allows a pilot to remain fully hydrated,
secured in the ejection seat and flight gear and on-mission for the duration of a sortie.

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Fig 16.16 : Male and Female AMXDmax Systems (Harvie, 2016)

16.7 Other Recent Developments in Urine and Excreta Disposal.

(a) Sulabh Shauchalaya.
The concept was introduced by Dr. Bindeshwar Pathak. He modified the standard hand flush latrine to suit rural
Indian community. It consists of a specially designed pan and a water seal trap. It is connected to a pit 3  x  3  x  3
feet. Minimal water is needed in the process. The excreta get decomposed to manure in the pit. This provides
clean and sanitary toilets for the users at a minimal cost. These are also maintained by the Sulabh International
society.
(b) Bio-Toilet.
DRDE has developed a “bio-toilet” which can be used in the plains of permanent and semipermanent settlements`.
It is also being used in the Indian railways currently. The advantages of a bio-toilet over the traditional waste
disposal systems are:
(i) An eco-friendly, customizable, maintenance-free technology for human faecal matter digestion, for use
in plains.
(ii) Smaller than conventional septic tank system.
(iii) Composed of Specially designed digester (Biotank), a consortium of bacteria & their attachment
matrix.
(iv) A consortium of bacteria degrades organic waste into water and gases. Biogas generated can be
harnessed.
(v) No-slurry system, thereby reducing maintenance (no manual scavenging/cesspool emptying required).
(vi) Reduced sewage load and pathogen.
(vii) Secondary treatment of effluent water (use of Reed bed) for quality augmentation.
(viii) Treated water can be reused for flushing, gardening etc.

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Human Waste

Anaerobic bacteria Co2 + Methane gases

(Liquid bacteria) released to atmosphere

Liquid Waste

Chlorination

Disinfected liquid
discharged to track

Fig 16.17 : Functioning of a Bio-Toilet

16.8 Disposal of Sewage.

Sewage consists of wastewater discharged from residences and from commercial, institutional and public facilities
that exist in the locality. Sub-types of sewage are greywater (from sinks, bathtubs, showers, dishwashers and clothes
washers) and blackwater (the water used to flush toilets, combined with the human waste that it flushes away). Sewage
is 99.9 percent water and 0.1 percent solids, which is partly organic and partly inorganic. Sewage is teeming with living
organisms, some of which may be pathogenic. The strength of the sewage may be expressed in terms of biochemical
oxygen demand, chemical oxygen demand and suspended solids.
Biochemical Oxygen Demand (BOD)
It is defined as the amount of oxygen absorbed by a sample of sewage during a specified period, generally 5 days at
a specified temperature, usually 20°C for aerobic digestion. This is the most important test carried out on sewage. A
sewage with a BOD value of 300 mg/L (300 ppm) or above is termed strong while that of 100 mg/L (100 ppm) or
below is termed weak.
Chemical Oxygen Demand (COD).
COD is the amount of oxygen required to oxidize organic matter by use of dichromate in an acid solution and to convert
it to carbon dioxide and water. The value of COD is always higher than that of BOD because many organic substances
can be oxidized chemically but cannot oxidize biologically. Commonly, BOD is used to test the strength of untreated
and treated municipal and biodegradable industrial wastewaters. COD is used to test the strength of wastewater that
is either not biodegradable or contains compounds that inhibit activities of microorganisms.
Suspended Solids.
If the number of suspended solids is 100 mg/L or more, it is termed strong.
(a) Sewage Purification.
The aim of sewage treatment is to convert an offensive and potentially dangerous mixture into an inoffensive
effluent and sludge which can be disposed of safely and without causing nuisance into rivers, into the sea or
on land and should even be capable of being reused to replenish non-potable water supplies and to provide

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water useful for agriculture in suitable circumstances and with due safeguard. The conversion of the complex
organic matter in the sewage to simpler substances takes place by two processes, viz aerobic and anaerobic.
The aerobic method requires a continuous supply of free dissolved oxygen for the aerobic microorganisms to
breakdown the organic matter into simpler substances such as carbon dioxide. ammonia, water, nitrite, nitrate,
sulphate etc. The anaerobic process is highly effective where the sewage is highly concentrated and contains
plenty of solids. Hence, this method is usually gainfully used for digestion of sludge in sewage works. The end
products of anerobic decomposition are methane, ammonia, carbon dioxide. hydrogen etc.
(b) Modern Sewage Treatment.
The main processes comprise of physical treatment to remove solids from the liquid and biological treatment
brought about by aerobic and anaerobic bacteria. While the physical treatment is often referred as primary
treatment, the biological treatment process is called secondary treatment. Treatment rendered in addition to
the conventional secondary treatment for improving further the quality of effluent is termed ‘tertiary treatment’
or advanced waste treatment process. The sludge is also given treatment for stabilization and dewatering.
Chemical treatment by the addition of coagulants may be used to assist sedimentation and sludge treatment.
Flow diagram of a modem sewage treatment plant is shown in (Fig 16.18).

PRIMARY TREATMENT SECONDARY TREATMENT CHLORINE

PRIMARY FINAL
GRIT BIOLOGICAL
SCREEN SEDIMENTATION SEDIMENTATION
CHAMBER TREATMENT EFFLUENT
TANK TANK

SLUDGE
METHANE SLUGE
GAS DIGESTOR

SLUDGE DRYING BEDS

Fig 16.18 : Flow Diagram of a Modern Sewage Treatment Plant

(i) Primary Treatment.
(aa) Screening.
It is the first step in the sewage treatment for removing the larger solids. The raw sewage is passed
through bar-screens with openings of 8 to 10 cm between the bars placed across the inflow channels.
The screenings can be manually raked from the screens and buried. In larger works, the mechanical
rakes or brushes are used and screened out solids shredded by mechanical shredders and returned
to the raw sewage flow for sedimentation. A device in which a slotted drum rotates in the sewage
flow to cut and screen the solids in one operation is used in the comminutor.
(ab) Grit Removal.
In the next step, combined sewerage systems carry grit from roads or other debris from general sullage
and fine granular inorganic material. This material which otherwise causes heavy wear in pumps and
tends to settle out and cause difficulty in later treatment processes must be removed in grit chambers
and channels. The sewage is allowed to flow in a channel at a controlled velocity of about 30 cm/s,
which is slow enough for the heavy non-organic solids to settle down but fast enough to carry the lighter
organic solids forward. The grit is removed periodically, washed free of organic matter and dumped on
waste land for reclamation or to fill excavations and quarries without causing nuisance.

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(ac) Sedimentation.
It is the third step to remove as much of the organic solids as possible from the liquid sewage. The
same principles as those for the treatment of water are employed. Sedimentation tanks may be
rectangular with a horizontal flow, hopper-shaped with vertical flow or circular with radial centrifugal
flow. Slow moving paddles to encourage flocculation of solids and increased settling velocities may be
incorporated. The sewage is retained in sedimentation tanks for 4 to 12 hours. The process removes
50-60 percent of the suspended solids and about 40 percent of the BOD of the sewage. The settled
sludge is removed by mechanical scrapers to hoppers from which it is drawn off either continuously
or at frequent intervals to prevent it from becoming septic. The sewage is then treated biologically.
(ii) Secondary Treatment.
The secondary or biological treatment of sewage essentially involves the oxidation of suspended and dissolved
organic matter by aerobic bacteria. Carbonaceous matter is converted to carbon dioxide and water and
nitrogenous material to ammonia, nitrites and nitrates. Fungi, algae, ciliate protozoa, insects and worms
supplement the bacterial digestion. The main processes employed for biological treatment are as under:
(aa) Land Treatment.
This is the earliest form of biological treatment, which is still practiced. This is carried out by passing
sewage, after primary settling over the land. Besides purifying the sewage, this provides water and
nutrients for growing crops. However, stringent precautions are necessary to prevent pollution of water
and any nuisance. Land treatment requires large areas. Difficulties may be confronted in wet weather.
Reserve areas must be available to permit resting for the ‘sewage sick’ grounds. To concentrate this
process on smaller areas, intermittent filtration and treatment in contact beds was introduced. These
processes have been superseded by treatment by percolating filters.
(ab) Percolating or Trickling Filters.
These consist of beds 1½ to 2 m depth, made of stone, cinders, slag or brick pieces, other impervious
material generally from 3 to 8 cm in size over which effluent from primary sedimentation tanks
brought in through a central pipe is intermittently percolated. The beds are usually circular with
rotating distributors or rectangular with horizontally gliding distributors and sometimes irregular in
shape with fixed spraying nozzles. A slimy ‘zoogleal’ film of aerobic bacteria and other organisms
develops on the surface of the stones. In trickling downward through the bed, the sewage donates its
organic content to the vital zoogleal film for its nutrition and in return receives soluble organic salts
produced by oxidation. Access of air through the filter is essential for the zoogleal fauna to oxidize
the organic matter. Percolation is followed by final settling in humus tanks to remove the particles of
the zoogleal matter and innocuous debris. The humus is separately disposed of or can be returned
to the primary sedimentation tanks from which it is removed for treatment with primary sludge as
described below. A competent percolating filter plant reduces the BOD of the raw sewage by 85 to
95 percent. A higher rate of treatment can be achieved by returning some of the filtered effluent to
mix with the influent and reapplying it on to the filter or by ‘alternating double filtration’, in which
the sewage passes through two filters in series, their orders being reversed daily. Deep enclosed
filters aerated by forced draught can also treat sewage at two or three times the normal rate while
maintaining a high-quality effluent (Fig 16.19).

Fig 16.19 : Percolating Filter

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(ac) Activated Sludge Process.

In this process of biological treatment of sewage, the high BOD of the raw sewage from the primary
sedimentation tank is satisfied by aerating it after intimately mixing with some of the sludge collected
from the final sedimentation tank. The sludge from the final tank is called ‘activated sludge’ as
it contains active aerobic bacteria. The mixture is called ‘mixed liquor’. In the presence of ample
oxygen, the aerobic bacteria utilize the unstable oxygen demanding solids in the raw sewage such as
food materials and convert them into stabilized, odorless compounds having nil or very little oxygen
demand. The process requires air supply and thorough mixing which brings about intimate contact of
the organic solids with oxygen and aerobic bacteria. First the effluent from the primary sedimentation
tank is mixed for 1-2 hours with the activated sludge returned from the final sedimentation to form
the ‘mixed liquor’, then the oxygenation of the mixed liquor is carried out by 4 to 6 hours aeration
by one or more of the methods described below. The plant consists of a long channel or of a series
of chambers through which the sewage passes while aeration proceeds. The aeration is followed
by settling in tanks. The sludge is removed and the clear purified final effluent flows out for safe
discharge. Most of the sludge is returned to be mixed with the sewage from the primary settling
tanks as described above. Thus, there is a continuous circulation of activated sludge carrying aerobic
bacteria and protozoa, which are kept active by the constant replenishment of organic food and oxygen
(Fig 16.20). The common methods of aeration employed in the activated sludge process are:
O Diffused Air System.
Compressed air is blown through porous plates, domes or pipes fixed at the bottom of aeration
channels.
O Simple Surface Aeration.
Motor driven propellers are used to mix and break up the sewage into fine spray, bring it in
contact with air and induce circulation in hopper- bottomed chambers.
O Kessenger Process.
The process involves the use of a rapidly rotating brush mounted just above the surface of the
sewage.
O Haworth System.
It is also called the Sheffield system. In this motor driven paddles circulate the sewage along
a continuous zig-zag channel.

FINAL
SETTLING
AREATION
PRIMARY TANK
SEDIMENTATION
6-8 HOURS
DETENTION ALTERNATE
SLUDGE
EXCESS
TO
SLUDGE TO
DIGESTER
DIGESTER OR
THICKENER
EXCESS RETURN AND
EXCESS SLUDGE SLUDGE 20-30% EXCESS SLUDGE

Fig 16.20 : Conventional Activated Sludge Process

Newer techniques.
(ad) Sequential Batch Reactor.
The biological stage of the sewage treatment plant is designed as a “Sequenced Batch Reactor”(SBR).

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WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

The process takes place in one or more SBR-reactors, depending on the chosen plant design with
each SBR-reactor operates according to the activated sludge process, but with a modified operation-
concept, which uses the reactor as an aeration tank as well as a clarification system. Due to the
SBR process, extensive removal of dissolved organic substances from the waste sewage water can
be achieved by nitrification and denitrification as well as by the removal of phosphorus. The special
characteristic of the SBR process is since the individual process phases of an activated sludge plant
(aerobic, anoxic and anaerobic, mixture as well as sedimentation) run along the time axis in one
single tank. Thus, the times of the individual process stages are adapted to the load and thus the
required effluent parameters can be maintained with security.
(ae) Membrane Bioreactor (MBR).
It is the combination of a membrane process like microfiltration or ultrafiltration with a biological
wastewater treatment process, the activated sludge process. It is now widely used for municipal
and industrial wastewater treatment. Membrane Bioreactor or MBR Sewage treatment plant is an
innovative wastewater treatment method. As the name suggests, it combines two technologies
membrane filtration and the biological treatment and gets rid of pollution through sedimentation, bio-
reaction and membrane separation. In a Membrane Bioreactor sewage treatment plant, wastewater
is first fed into a vessel filled with microorganisms that break down organic substances.
The MBR Sewage Treatment system is for very small to medium sized sewage treatment plants.
‘Membrane Bioreactor’ (MBR) is generally a term used to define wastewater treatment processes
where a perm-selective membrane, e.g., microfiltration or ultrafiltration, is integrated with a biological
process − specifically a suspended growth bioreactor. MBRs differ from ‘polishing’ processes where
the membrane is employed as a discrete tertiary treatment step with no return of the active biomass
to the biological process. Almost all commercial MBR processes available today use the membrane
as a filter, rejecting the solid materials which are developed by the biological process, resulting in a
clarified and disinfected product effluent.
(af) Moving Bed Biofilm Reactor (MBBR).
A moving bed biofilm reactor is a biological process for treating wastewater, with some unique
characteristics that make it a beneficial alternative to traditional methods such as activated sludge
or trickling filter. Most of the modern STPs these days use MBBR technique for sewage treatment.
The various components of this technique are as follows:
O Aeration Tank.
The MBBR process takes place in an aeration tank. The size of this receptacle depends on
the filtration needs of a particular plant. Influent enters this tank for treatment. MBBR aeration
tanks are open at the top, exposing the water to the open air, which makes this an aerobic
process of filtration.
O Media.
The Aeration tank is full of thousands of small plastic chips, called media or carriers. These
media may occupy as much as 50 to 70% of the tank. Their design maximizes the surface
area they provide for biofilm to grow on them.
O Aeration Grid.
This helps the media move effectively throughout the tank in an aeration grid. This device
is essentially a fan located at the bottom of the reactor tank. The aeration grid helps keep
carriers on the move so they can meet all the waste present and efficiently decompose it and
it introduces more oxygen into the tank.
O Sieve.
The mesh material attached to the tank allows water to pass through but keeps the plastic
carriers inside the basin.
(ag) Oxidation Ponds.
Also known as ‘Redox Pond, Sewage lagoon and Waste Stabilization Pond’. These are simple ground

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 ENVIRONMENTAL SANITATION

level non-porous and leak proof tanks which provide an economical and efficient means of treating
sewage from a small community, when ample space and sunshine is available. After sedimentation,
the sewage flows to one or more of the tanks, each of which is about one meter deep and contains
algae. In this process an active symbiosis of the aerobic bacteria and algae are made use of. The
aerobic bacteria in the presence of dissolved oxygen convert the decomposable organic matter to stable
products liberating carbon dioxide. The algae utilize this carbon dioxide and through photosynthesis
produces surplus oxygen required for aerobic bacterial action. The highly putrescible and hazardous
sewage is thus converted into the highly stable and nonpathogenic sludge and effluent if the algae
can provide excess oxygen required by the aerobic bacteria to degrade the organic matter. If sufficient
oxygen is not provided, aerobic or facultative bacteria will obtain the required oxygen from chemical
compounds and produce organic acids, alcohols and so on. A fermentation process will produce
less oxidized products such as methane. Oxidation ponds may thus develop into varying degrees of
combined aerobic anaerobic treatment units. However, in most of the ponds aerobic conditions are
maintained up to considerable depth under conditions favoring good algal growth. The factors which
affect the growth and metabolism of algae are temperature, sunshine and organic nutrients, which
are all available in the tropics and subtropics. The land should be relatively level and the soil should
be free from sand, gravel or other impervious material to prevent leakages. Rock, especially limestone
or any consolidated rock requires excavation (Fig 16.21). When the ponds are properly maintained
there is no odour nuisance. Mosquito nuisance can be avoided by keeping weed growth around the
ponds to a minimum and the waterline free from marginal vegetation.

Fig 16.21 : Oxidation Pond

(ah) Oxidation Ditch/Aerated Lagoon.
This process makes use of mechanical rotors for extended aeration and thus minimizes the
requirement of land area. The land requirement in this method is barely one tenth of oxidation pond
(Fig 16.22). In primary sedimentation, a reduction of 30-40% in the number of coliforms is obtained,
while in most full biological treatment processes the reduction is between 90 and 95%. Stabilization
ponds with a 30-day retention period have shown reductions from 99% to 99.9%. Most vegetative
bacterial pathogens appear to be removed in the same proportion as coliforms. Certain helminthic
eggs may be effectively removed by primary sedimentation and even more effectively by stabilization
pond treatment of 5-7 days duration; viruses are less effectively removed. Coagulation and filtration
remove 98 to 99.9% of viruses. High standards (< 100 coliforrns / 100 ml in 80% of samples) can
often be obtained after complete biological stabilization, followed by heavy and carefully controlled
chlorination (15-20 mg/L of chlorine with contact periods of 1-2 hours). The treatment was also
effective in inactivating amoebic cysts. When treating a sewage of normal characteristics, the overall
reduction of BOD and suspended solids to be expected from a conventional combination of primary
and secondary treatment will be 85-95%. In a properly designed and operated pond, well over 90%

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WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

of the polluting matter (in terms of its BOD) can be removed and the number of microorganisms
much reduced. Ponds have the advantage of providing a high degree of treatment at a relatively low
cost, with little call for equipment or skilled operators.

INFLOW

AERATION ROTOR

DEVIDING STRIP
OR WALL

OUTFLOW

Fig 16.22 : Intermittent Oxidation Ditch

(iii) Tertiary Treatment.
The secondary waste-water treatment process removes at its best about 85 to 95 percent of organic matter
and has practically no effect on dissolved solids and algal nutrients such as nitrogenous and phosphatic
compounds. Where the receiving stream is small or where the demand of water from this stream is great,
additional treatment may then be required. The discharge of secondary effluents into lakes or estuaries
may also stimulate algal bloom and thereby severely interfere with their usefulness for other purposes. In
water shortage areas, wastewater after treatment constitutes a valuable resource. Thus, to make wastewater
suitable in quality for direct reuse for irrigational, industrial, recreational or even as a source of potable
water supply, calls for additional treatment. This is how the tertiary treatment process has evolved. If the
receiving body of water requires a higher degree of treatment than the secondary process can provide or
if the final effluent is intended for reuse, advanced wastewater treatment is necessary. The term tertiary
treatment is often used as a synonym for advanced treatment, but the two methods are not the same.
Tertiary or third-stage, treatment is generally used to remove phosphorus, while advanced treatment might
include additional steps to improve effluent quality by removing refractory pollutants. Processes are available
to remove more than 99 percent of the suspended solids and BODS. Dissolved solids are reduced by
processes such as reverse osmosis and electrodialysis. Ammonia stripping, denitrification and phosphate
precipitation can remove nutrients. If the wastewater is to be reused, disinfection by ozone treatment is
considered the most reliable method other than breakpoint chlorination. Application of these and other
advanced waste­ treatment methods is likely to become widespread in the future in view of new effects to
conserve water through reuse.
Tertiary treatment may be intended primarily for ‘polishing’ i.e., to increase the extent of removal of
suspended matter from secondary plant effluents. In many situations, polishing may not be sufficient
and processes are required that will remove specific constituents such as phosphates, nitrogen, metals
or the salts that may accumulate with recycling. Treatment processes to eliminate specific constituents
may include coagulation and sedimentation, adsorption, electrodialysis, biological denitrification, reverse
osmosis, foam separation, ion exchange, multimedia filtration, distillation and so on. In general, tertiary
treatment requires considerable sophistication in design, construction and operation; hence, its large-scale
adoption in developing countries is limited. Nevertheless, there may be one or two specific situations
where tertiary treatment may be necessary because of intensive industrialization, high population density
and limited water resources [Fig 16.23 (a)-(e)]. In India, the first tertiary treatment plant for purifying
municipal effluent was put into operation to supply cooling and process water to an industrial plant in
1970. The effluent flow of 4,500 cubic meters per day is treated biologically and chemically, filtered through

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 ENVIRONMENTAL SANITATION

sand, softened. chlorinated and used in the plant. The simple processes by which the suspended solids
in a secondary effluent can be reduced to 5-10 mg/L are tube settlers consisting of tubes of various
cross-sectional configurations inclined at 450-600 to the horizontal, in which suspended solids settle;
sand filtration; micro straining or micro-screening and irrigation over grassland followed by retention in
maturation ponds. Phosphates are readily removed during treatment with aluminum of ferric salt or with
lime. Activated carbon is generally efficient in adsorbing aromatic hydrocarbons, chlorinated pesticides
and similar classes of compounds. Hypochlorous acid kills coliform bacteria in a few minutes but takes an
hour to kill some viruses. In the presence of an excess of chlorine, the ammonia is destroyed, but each
part of nitrogen present as ammonia requires for its destruction nearly 10 parts of chlorine. 0.4 mg/L of
free ozone in 4 minutes is sufficient to inactivate viruses. Enteric viruses in general and hepatitis viruses,
require much more treatment than most bacteria, but the recommended contact period of one hour will
provide a margin of safety.

SEWAGE SCREENING
PRIMARY SECONDARY
COMMUNICATION AERATION
CLARIFICATION CLARIFICATION
AND GRIT REMOVAL

SLUDGE
THICKENING DISINFECTION

SLUDGE DISPOSAL

Fig 16.23 (a)

SECONDARY
EFFLUENT
SURGE POND SAND FILTERATION DISINFECTION

PRODUCT
WATER

Fig 16.23 (b)

SECONDARY
EFFLUENT CARBON FILTERATION
SURGE POND DISINFECTION
AND ABSORPTION

PRODUCT
WATER

CARBON
REGENERATION

Fig 16.23 (c)

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WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

SECONDARY
EFFLUENT SURGE LIME AMMONIA CARBON FILTERATION
DISINFECTION
POND TREATMENT STRIPPING AND ABSORPTION

PRODUCT
WATER

LIME CARBON
CARBON
RECALCINING DIOXIDE REGENERATION

Fig 16.23 (d)

SECONDARY
EFFLUENT SURGE CARBON FILTERATION ELECTRO
DISINFECTION
POND AND ABSORPTION DIALYSIS

SULPHURIC

DISPOSAL
PRODUCT

BRINE
WATER

ACID
CARBON
REGENERATION

Fig 16.23 (e)

Fig 16.23 (a) - (e): Typical Flow Diagram for Treatment Process and Quality of Resulting Effluent
(c) Sludge Treatment.
The sludge from primary or final sedimentation tanks contains 90 to 95
percent water. This high-water content needs to be reduced for converting
the sludge to a solid condition in which it may be used or disposed of
harmlessly. Possible methods of dealing with sludge of which one or more CONCENTRATION
or even all may be utilized in any given situation (Fig 16.24). The most
profitable sludge treatment is anaerobic digestion. The sludge is pumped
daily into enclosed digestion tanks in which anaerobic fermentation DIGESTION
proceeds with the production of gas comprising about 70 percent
methane and 30 percent carbon dioxide. This sludge gas is a valuable
fuel to supply all power needs for pumping, air compression, electricity DEWATERING
generation and heating on the activated sludge plants. The gas may also
be compressed and used as vehicle fuel. For most effective digestion
and gas production, the digestors are heated to about 32°C. Digestion
converts much of the organic solids to gas and soluble matter and so DRYING
reduces the quantity of solids to be handled eventually. Digested sludge
is a black liquid with a tarry odour and is more amenable to subsequent
de-watering than undigested sludge. Apart from digestion, the main object INCINERATION
of sludge treatment is to de-water it so that it can be handled as relatively
compact, moist solid rather than as a much greater volume of liquid with
a low solid content. The following processes are used for de-watering the
sludge and may be applied to either raw or digested sludge. DISPOSAL
(i) Air Drying. Fig 16.24 : Flow Diagram for
Liquid sludge, after digestion, is placed on sand beds for air drying. Sludge Handling
(Arrows Indicate Possible Flow Paths)

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 ENVIRONMENTAL SANITATION

Percolation into the sand and evaporation are the chief processes involved in the dewatering process. Air
drying requires dry, relatively warm weather for greatest efficiency and some plants have a greenhouse-like
structure to shelter the sand beds. The semisolid sludge, which is left, is lifted manually or mechanically.
Dried sludge in most cases is used as a soil conditioner; sometimes it is used as a fertilizer because of
its 2 percent nitrogen and 1 percent phosphorus content.
(ii) Lagooning.
Sludge is stored in an open basin, a few meters deep to allow settlement of solids. Clarified liquid may be
drawn off and the solids are eventually dug out.
(iii) Filter Pressing.
In this, moisture is squeezed out through a filter cloth by mechanical pressure.
(iv) Vacuum Filtration.
Water is extracted by applying a vacuum to the inside of a filter drum, rotating partially submerged in a
trough of the sludge.
Sewage sludge contains useful nitrogen and phosphorus, although rather deficient in potassium. It forms
a moderately good fertilizer. Undigested primary sludge and undigested activated sludge are easier to
apply to land and their humus content improves the soil. In suitable circumstances, sewage sludge may
be composted with municipal refuse. Where sludge cannot be used either as a fertilizer or for composting.
or, in a few cases, for recovery of byproducts, it is usually tipped for land reclamation and dumped at sea
or incinerated.
(d) Disposal of Effluent.
The effluent after treatment is usually discharged on land or into bodies of water:
(i) Disposal on Land,
If suitable land is available, the effluent can be used gainfully for irrigation purposes. Over the recent
past, there has been a considerable revival of interest in the use of wastewater for crop irrigation in arid
and semiarid regions because of the scarcity of alternative water supplies and the need to increase food
production. Reuse of treated effluent for the irrigation of crops and urban ‘green spaces’ (such as parks and
golf courses) has expanded significantly in many countries. The viability of organisms in the soil or on crops
irrigated by wastewater depends on the type of organism and its resistance to environmental factors such
as climatic conditions, soil moisture and the amount of protection provided by crops. Enteric viruses appear
to be particularly persistent under natural conditions. Sewage farming or the spread of treated effluent on
farms is still used in many countries, particularly those having low rainfall and high temperatures. In wetter,
cooler climates, the area of land required may become prohibitive. Enteric viruses have been found in raw
sewage in concentrations of 1-10 per ml in various countries. Limited studies have shown that ingestion
of 1 TCID of poliovirus can cause infection in man, but it is not known as to what percentage of persons
would become infected with such a low dose or what size of infective dose would be needed for other
enteric viruses. Only if water has been treated to such a degree that essentially all ammonia and nearly
all residual organic matter has been removed, is it possible to achieve the free chlorine concentration
of 0.5 mg/L for one hour recommended by WHO for effective inactivation of enteric viruses. It has been
reported from India that hookworm and other enteric infections are much commoner among workers on
sewage farms than among the farming population in general. The local custom of walking barefoot is a
major contributing factor in the spread of some of these diseases.
(ii) Disposal by Dilution.
Discharging the effluent into bodies of water such as rivers, streams. lakes and sea for the purpose of
dilution as well as oxidation of the impurities by the dissolved oxygen in water is termed” disposal by
dilution”. The BOD content of the effluent and diluting capacity of the bodies of water are the important
considerations. The BOD standards of effluent are laid down as per The Environment (Protection) Rules,
1986. Consequently, the effluent may contain toxic substances, which may be harmful to man either directly
or indirectly through the aquatic flora and fauna. When rivers contain a high proportion of effluents, the
production of water from them should be regarded as analogous to the direct recovery of water from a

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sewage or industrial effluent and safeguards appropriate to this situation should be imposed. Some rivers
carry such a high proportion of treated and untreated wastewater that their use as a water source can be
considered essentially wastewater reuse.
(e) Septic Tank System.
The efficiency of a septic tank system is certainly inferior to the sewage works but the former is satisfactory for
disposal of excreta and liquid wastes from individual houses, groups of houses and institutions having adequate
piped water supply but lacking the facilities of a public sewerage system. It is much cheaper, quicker and easier
to provide and maintain than sewage works. Hence it is often favoured in the Armed Forces permanent camps.
Septic tanks are commonly used for individual households in low density residential areas.
(i) Construction.
It consists of an underground concrete tank, usually double chambered. A tank with more than two
chambers is expensive and has no additional advantage. Even a single chambered tank has been found
satisfactory for a small installation. The latrines should preferably be grouped together with one or more
tanks placed close to a group. The sewers leading from the latrines to the tanks should have manholes at
every 100 m and at every change of direction. Two or more medium sized tanks arranged in parallel instead
of one large tank are preferable as these facilitate removal of sludge without disturbing the functioning
of the system. The capacity of the tank should be at the scale of 13 /12 users with a minimum size of
3m x 3m. The length of the tank should be a minimum air space of 30 cm above liquid level. The septic
tank is covered by a concrete slab with a manhole in it. The aeration chamber should be ventilated by one
or more shafts, the opening of which should be screened with wire gauze. The inlet and exit pipes to the
tank should be trapped. Agricultural drains are laid from the exit pipe at a suitable fall in a herring-bone
pattern, 30 to 60 cm below the surface of the soil. The length of the agricultural drains per user should
be 60 cm. Alternatively the effluent may be disposed into a soak well. Septic tanks are commonly used for
individual households in low density residential areas. The guiding principles in designing a septic tank are:
(aa) Provide sufficient retention time for the sewage in the tank to allow separation of solids and
stabilization of liquid.
(ab) To provide stable, quiescent, hydraulic conditions for efficient settlement and floatation of solids.
(ac) To ensure that the tank is large enough to store accumulated sludge and scum
(ad) To ensure that no blockages are likely to occur and that there is adequate ventilation of gases.
(ii) Functioning.
The action in a septic tank is by the biological process of anaerobic and aerobic digestion. The crude
sewage on entry to the anaerobic chamber is allowed to stand for 2 to 3 days and is acted upon by the
anaerobic micro-organisms. A colloidal solution is formed which is only partially digested and hence has
an offensive smell. The complete oxidation and mineralization of the colloidal matter is carried out by the
aerobic micro-organisms in the aerobic chamber and or in the agricultural drains. Though most of the
pathogens, after having undergone aerobic treatment, die but the cysts and ova of the intestinal parasites
survive. The effluent, however, loses most of its offensive smell. The minerals are absorbed from the soil
by the plants. Many of the problems of septic tanks arise because inadequate consideration is given to
the disposal of the tank effluent. A principal aim of septic tank design is to achieve hydraulically quiescent
conditions within the tank to assist the settlement by gravity of heavy solid particles. Large surges of flow
entering the tank may temporarily cause a high concentration of suspended solids in the effluent owing
to disturbance of the solids, which have already settled out. Grease, oil and other light materials float
up, forming a layer of scum, which can become quite hard. The liquid moves through the tail sandwiched
between the scum and sludge. The use of ordinary household soap in normal amounts is unlikely to affect
the digestion process of a septic tank. The wastewater to septic tanks may be waste from toilets only or
may also include sullage. After desludging, the effective liquid retention time is greater because liquid
then occupies the regions previously full of sludge and scum. The shape and size of septic tank should
be such that there is achievement of even distribution of flow so that there are no dead areas and no
“short-circuiting”, i.e., the incoming flow shooting through the tank in less than the designed retention time.
Surges and turbulence reduce the efficiency of settlement and can cause large amounts of solid matter to
be carried out in the tank effluent.

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 ENVIRONMENTAL SANITATION

(iii) Maintenance.
The operation and maintenance of a septic tank is simple. To commission a septic tank, it must be first filled
with water and then seeded with a bucketful of sludge from another tank or a DTL. Not less than 25 L of
water per day per user must enter the tank. Use of soap water and chemicals should be avoided. Sludge
from the tank is to be bailed out once a year or two. The tank cover or roof, which usually consists of one
or more concrete slabs, must be strong enough to withstand any load that will be imposed. Removable
cover slabs should be provided over the inlet and outlet. Circular covers, rather than rectangular ones, have
the advantage that they cannot fall into the tank when removed. Routine inspection is necessary to check
whether desludging is needed and to ensure that there are no blockages at the inlet or outlet. A simple
rule is to de-sludge when solids occupy between one-half and two-thirds of the total depth between the
water level and bottom of the water tank. The most satisfactory method of sludge removal is by vacuum
cleaner.
(j) Excreta Disposal During Operations of War.
Satisfactory waste disposal is difficult on the line of march in mobile warfare. At short halts all that can be
practiced is ‘cat’ s hygiene’. Each man should excavate a shallow hole on the ground and cover it with earth
after use. At longer halts shallow trench latrines should be used. When an existing building is to be modified for
billeting, arrangements should be made for adequate sanitation facilities. If water carriage system is already in
existence, additional WCs should be constructed and connected to the sewers. DTL should serve the purpose if
sewerage facilities do not exist. The latrines should be grouped together in areas fairly adjacent to the billets.
No man should be expected to walk more than 200 m to use the facilities provided. Signposts should indicate
the path.

16.9 Disposal of Stable Litter.

Stable litter, by virtue of its enormous potential for fly breeding and great nuisance value, must be disposed off
hygienically. It contains mainly animal dung and to a small extent leftover feed. The animal dung may be that of cattle,
horses, mules and camels. Dung is in a semi-formed state. Cattle shed thus must be smooth and impervious, preferably
made of concrete; horse or mule shed, at times may be allowed to be made of mud heavily mixed with oil and well
rammed. Removal of dung from the shed in both groups must be at least once a day and taken away directly to the
disposal site. If direct disposal is not feasible, a concrete collecting platform with 30 cm high wall with corners rounded
may be constructed for keeping the litter pending disposal. However, under no circumstances, dung may be left in the
collecting platform for more than 24 h. Removal of dung to the disposal site must be carried out hygienically either
in galvanized iron wheelbarrows or receptacles. If the litter is removed under contractor’s arrangements, it must be
carried out daily in a suitable vehicle and in a manner approved by medical authorities. The disposal site should be
situated at least 2 km away from any military installation. Final Disposal may be carried out by tight packing, disposing
in biogas plants (popularly known as gobar gas plants), composting, trenching or incineration.
(a) Tight Packing.
In this method, the animal excreta are tightly packed into an oblong mound and covered by patting mud over
it to prevent entry of flies. The temperature in the interior of a tightly packed manure heap rises to 70°C at
which the fly larvae are rapidly killed. A flat piece of ground 3 m wide and of required length is prepared by
digging down to a depth of 10 cm, mixing the loosened earth with heavy oil and then pounding the earth
hard. Dung is piled starting from the farthest end on this prepared area and beaten well down during packing.
When a height of 1½ m has been reached, the top is flattened. The sides at starting end of the heap are
sloped abruptly down to the ground, well moistened with water and beaten hard. A trench 45 cm wide and 45
cm deep is then dug round the pack. The trench is treated with heavy oil sprayed with a knap-sack sprayer.
The earth removed from the trench is plastered all over the pack except at the advancing end to form a layer
15 cm thick, patted hard and allowed to dry. Fresh additions of dung are made at the advancing end daily,
rammed and covered with puddled clay. The trench around is also extended and oiled daily. When the pack
reaches a length of 20 m or when the camp site is changed, a trench is dug across the open and which is then
closed and the whole dump is left until fermentation ceases. Fresh dung should never be left uncovered for more
than 48 hours. There should only be one tight pack for every 2,000 animals and it should, where possible, be sited
at least 400 m outside the camp. Success in this method is ensured by a well damped and well rammed pack,
on a basis unsuitable for larval penetration and a thick firm covering of clay to retain heat throughout the pack
(Fig 16.25).

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Fig 16.25 : Tight Packing of Manure Using a Trench

(b) Disposal in Biogas Plant (Gobar Gas Plant).
In view of the increasing energy crisis, this method is gaining rapid popularity, particularly in countries having large
cattle population. In this method the dung gets converted into good quality manure under hygienic conditions
and there is also generous liberation of biogas energy. This can be used as fuel in the kitchen, for running
engines, lighting and other purposes. A biogas plant is cheap, simple in construction, easy to handle and can be
made locally from indigenous materials. The digester is partly an underground masonry tank with an incomplete
partition in the middle (Fig 16.26). It has an inlet and an outlet pipe. Dung mixed with water in equal proportion
is put inside through the inlet. In the plant, excreta are often mixed with straw or other vegetable waste and
equal quantities of water are added to make a slurry which is fed to the inlet side of the chamber. Effluent
slurry is removed after a retention time of 30-50 days. Biogas production is greater at higher temperatures. At
300°C the rate of generation of gas is about twice that at 250°C and little gas is produced if the temperature
is below 150°C. A few hookworm eggs survive and there is high survival of roundworm eggs. Many pathogens
including schistosome eggs are killed.

Fig 16.26 : Gobar or Bio-Gas Plant

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(c) Trenching and Composting.

These are carried out in the same manner as for and often in conjunction with solid waste and night soil.
(d) Incineration.
This as a method of dung disposal is considered a wastage of bioenergy resources. Hence, under normal
circumstances, it should not be recommended.

16.10 Solid Waste Disposal.

(a) Composition.
Solid waste includes all unwanted or discarded material of domestic, street, commercial, industrial and
agricultural origin. It consists of garbage and swill from cook houses and dining halls; house and street rubbish
like waste papers, rags, glass pieces, ferrous and nonferrous metals, plastics, dried leaves, pieces of wood,
ferrous and nonferrous metals, plastics, ashes, cinders, brick bats and commercial and industrial wastes of all
types. Generally, wastes of animal and vegetable origin are very attractive to flies, cockroaches, rodents and
other pests and therefore must be disposed of hygienically, as early as possible. Solid wastes can be organic
or inorganic and can be further classified as follows:
(i) Garbage: decomposable wastes from food.
(ii) Rubbish: non-decomposable wastes, either combustible (such as paper, wood and cloth) or non-
combustible (such as metal, glass and ceramics).
(iii) Ashes: residues of the combustion of solid fuels
(iv) Large wastes: demolition and construction debris and trees
(v) Dead animals
(vi) Sewage-treatment solids: material retained on sewage-treatment screens, settled solids and biomass
sludge.
(vii) Industrial wastes: such materials as chemicals, paints and sand
(viii) Mining wastes: slag heaps and coal refuse piles
(ix) Agricultural wastes: farm animal manure and crop residues.
(x) Plastic wastes: plastic containers, bags and bottles.
(b) Collection.
Suitable receptacles are to be provided at convenient places for collection of all rubbish awaiting disposal.
Metal, fly proof receptacles, big enough to hold 24-hour collection, must be provided for storage of garbage
and swill in the cook houses and dining halls. General camp refuse and house refuse other than garbage
which is not so attractive to flies may be collected separately. In a permanent camp, sanitary bins made of
GI sheet are usually provided. In other types of camps receptacles having well fitted lids may be improvised
from empty cresol drums, oil drums and ghee tins.
(c) Segregation.
Throwing waste in the bin is a good habit. However, it is not where the process of managing waste ends,
but where it begins. Segregation is the first step of waste management. While most of us think that it starts
once the waste reaches the dustbin vans or the dumping grounds, it really starts right at our house. It can
be separated in to two categories. Both need to be disposed and recycled differently. Remember that wet
waste is organic and dry is not. According to Solid Waste Management Rules (SWM), 2016, it is required to
segregate household waste into three categories:
(i) Wet Waste.
It includes cooked and uncooked food, waste from fruits and flowers, fallen leaves, dust from sweeping
and other similar things.

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(ii) Dry Waste.

It includes cloth rags, glass, leather, metals, paper, plastic, rubber, wire and related things etc.
(iii) Domestic Hazardous Waste.
It includes old medicines, paints, fluorescent tubes, batteries, spray cans, fertilisers, shoe polish, razors, etc.
Segregation at source level is the need of the hour as the waste being produced in the present day has
negative impact on environment. It is the first step towards proper disposal of all categories of waste.
Bits of plastic are dry waste components which if not disposed properly can become an environmental
hazard. It is advisable to keep one more bin for toxic wastes such as medicines, batteries, dried paint,
old bulbs and dried shoe polish. Segregation of waste is basic need for channelizing the waste to wealth
by reduce-reuse-recycle and recover strategy.
(d) Disposal.
Disposal of Solid Waste is governed by Solid Waste Management Rules, 2016 which came into force on
08th April 2016. These rules apply to every urban local body including all defense establishments, airbases,
Ports and harbors, etc.
(e) Criteria for Selection of Waste Processing Technology.
For planning and designing a waste management plan, a preliminary survey should be carried out. If the quantity
of waste is found to be less than required for treatment, a regional plan may be prepared for clusters of towns
to gather the desired quantity of waste. In case of excessive generation of waste, the waste can be reduced
by adopting decentralized treatment process (vermin-composting/Biogas) in pockets within garden premises,
large residential complex, etc. However, Integrated waste processing plants are capable of processing both
organic and incinerable wastes.
The primary criteria for selection of waste processing technologies are as under:
(i) Quantity of waste generation
(ii) Characteristics of waste (Physical and chemical property)
(iii) Based on land availability
(iv) Prevailing environmental conditions
(v) Climatic condition and terrain
(vi) Social acceptance
(vii) Market for the products
(viii) Capital investment
(ix) Siting criteria
(x) Environmental norms
The available solid waste processing technologies can be broadly divided into two categories:
(i) Biological treatment
(ii) Thermal treatment.
(i) Biological Treatment.
The Biological treatment process is accomplished by allowing micro-organisms to degrade waste components by
creating conducive environment for growth of microbial organisms. In the biological process, the biodegradable
organic portion of waste is broken down into gaseous products (CO2, Methane gas, etc.) and water molecules
leaving behind carbon rich byproduct called compost. The biological activities depend upon several criteria-
C/N ratio, pH value, moisture content, supply of oxygen, etc. Biological processes for waste treatment can be
further divided into two categories:
(aa) Aerobic treatment (in presence of Oxygen)

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(ab) Anaerobic treatment (absence of Oxygen)

(ii) Thermal Treatment.
The thermal process of treatment is applied to destroy the harmful potential of waste together with
energy recovery. In this process, the waste components are incinerated in controlled oxygen supply so
that maximum heat energy can be recovered without causing air pollution. During incineration, the waste
undergoes chemical changes to release gaseous byproduct, water vapour along with heat energy. The
heat energy can be utilized for generating electricity through a boiler. The efficiency of heat recovery
depends upon the calorific value of incinerated waste.
(f) As far as the Armed Forces camps are concerned, the removal of solid waste by the local civil organization
or by a contractor is usually resorted to. The final disposal by these agencies is normally carried out by dumping,
trenching or composting. Incineration is the method of choice if removal by such agencies is not possible,
particularly for camps of short duration. Burial in such camps may be permitted only where incineration is
impossible. If, however, the camp is occupied for more than 6 days, burial is not to be permitted. Details of
the available technologies are discussed below:
(i) Aerobic Composting.
Composting is the process of aerobic decomposition of biodegradable organic matter in a warm, moist
environment by the action of bacteria, yeasts, fungi and other organisms. Municipal Solid Waste (MSW)
in India has an initial C/N ratio of around 30:1, ideal for decomposition. The organisms involved in
stabilization of organic matter utilize about 30 parts of carbon for each part of nitrogen. Compositing
requires approximately 25 m2 area per ton of MSW (only for windrow formation for 21 days composting
and maturity yard for 30 days stabilization). The additional area required is for machinery, packing and
storage. Facilities are also required for recycling and treatment of effluent (leachate) and sanitary landfill
for rejects (inert materials, sludge from ETP). The compost products should comply with the standards
prescribed in the SWM Rules, 2016.
This method is superior to trenching, which is a modification. It is usually employed for the combined
disposal of solid wastes, stable litter, night soil and sludge. It entails proper preliminary construction,
higher initial expenditure, running cost, efficient organization and supervision. This method in the Armed
Forces is, therefore, suitable only for cantonments and permanent stations. The organic matter in this
method breaks down under microbial action into relatively stable humus like substance called compost.
which has considerable manurial value. The principal by-products are carbon dioxide. water and heat.
The heat produced during composting rises to 60°C or higher which is retained over a period of several
weeks. The eggs and larvae of flies and pathogens are destroyed by the heat. The end-product compost
is a good soil builder and can be sold to recover part of the running cost.
The following methods of composting are now a days used Bangalore method (anaerobic method),
mechanical method (aerobic method) and vermicomposting (aerobic method).
(ii) Bangalore Method (Hot Fermentation Process).
This method of anaerobic composting was evolved under the auspices of The Indian Council of Agricultural
Research at the Indian Institute of Science, Bangalore and hence termed Bangalore method. Long trenches
are dug, each having a depth of 1m and breadth of 1.5 to 2.5 m. Depths greater than 1 m are not
recommended because of slow decomposition. First a layer of refuse 15 cm thick is spread at the bottom.
Over it, a layer of night soil of 5 cm thickness is added. The alternate layers of refuse and nightsoil are
added in the proportion 15 cm and 5 cm respectively till the heap rises 30 cm above the ground level. The
top layer of refuse should be at least 25 cm thickness. The heap is then covered with excavated earth. If
properly laid, a man’s leg will not sink when walking over it. Within 7 days, considerable heat is generated
in the mass. The heat persists for 2 to 3 weeks. At the end of 4 to 6 months, the mass is ready to be
taken out as manure. During decomposition of faeces and urine. the following processes take place:
(aa) Complex organic compounds such as proteins and urea are broken down into simpler and
stable forms.
(ab) Gases such as ammonia, methane, carbon dioxide and nitrogen are produced and released
into the atmosphere.

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(ac) Soluble material is produced which may leach into the underlying or surrounding soil or be
washed away by flushing water or ground water.
(ad) Pathogens are destroyed because they are unable to survive in the environment of the
decomposing soil.
The decomposition is mainly carried out by bacteria although fungi and other organisms may assist.
Aerobic or anaerobic activity may take place. In some situations, both may apply in turns. When all
available oxygen has been used by aerobic bacteria, facultative bacteria capable of either aerobic or
anaerobic activity take over and finally anaerobic organisms commence activity. During composting of a
mixture of faeces and vegetable waste under fully aerobic conditions, the temperature may rise to 700°C,
which is too hot for the survival of intestinal organisms. Pathogens may also be attacked by predatory
bacteria and protozoa or may lose a contest for limited nutrients. Aerobic bacteria combine some of the
carbon in organic matter with oxygen in the air to produce carbon dioxide, releasing energy. Some energy
is used by the bacteria to reproduce; the rest is converted to heat, often raising the temperature to
more than 700°C. At high temperatures, there is rapid destruction of pathogenic bacteria and protozoa,
worm eggs and weed seeds. All faecal microorganisms, including enteric viruses and roundworm eggs,
will die if the temperature exceeds 460°C for one week. Fly eggs, larvae and pupae will also be killed at
these temperatures. No objectionable odour is given off, if the material remains aerobic. In the absence
of oxygen, nitrogen in organic matter is converted to acids and then to ammonia; carbon is reduced to
methane and sulphur to hydrogen sulphide. There is a severe odour nuisance. Complete elimination of
pathogens is slow, for example, taking upto twelve months for roundworm eggs. Too much moisture in
a heap of composting material fills the spaces between particles, preventing air from getting in. On the
other hand, bacteria do not flourish if the material is too dry. The optimum moisture content is 40-60%.
Moisture content can be increased by spraying a compost heap with water and can be decreased by
adding dry straw or sawdust. Frequent turning allows a heap to dry naturally by evaporation. For optimum
value to plants, the ratio of available C:N ratio in compost should be about 20. In the composting process,
carbon is used by the bacteria, so the best raw material for composting has a higher C:N ratio, say, about
30. The C:N ratio of nightsoil is about 6, of fresh vegetable waste around 20 and of dry straw, over 80.
The ratio of mixed household refuse is often in the range of 30-50, but it may be higher if there is a
high paper content. The desirable ratio of 30 can sometimes be obtained by judicious mixing of incoming
waste, for example, by adjusting the proportions of nightsoil or sludge and vegetable waste. A good
operator learns to judge what mix of materials will produce the best compost. During composting, the
volume is reduced by 40-80% and the weight by 20-50%. The major plant nutrients (nitrogen, phosphorus
peroxide and potassium oxide) are likely to be about 3% by weight in compost derived from nightsoil or
sludge, i.e., three times the concentration in compost derived from municipal refuse. As excreta become
decomposed, they are reduced in volume and mass due to:
(aa) evaporation of moisture.
(ab) production of gases which usually escape into the atmosphere.
(ac) leaching of soluble substances.
(ad) transport of insoluble material by the surrounding liquids and
(ae) consolidation at the bottom of pits and tanks under the weight of superimposed solids and
liquids.
(iii) Mechanical Composting.
In this method, compost is manufactured on a large scale out of raw materials within a very short time.
The refuse first undergoes a process of mechanical sorting for items like rags, bones, metal pieces and
glass which otherwise are likely to interfere with grinding operation. The entire mass is then pulverized in
mechanically operated pulverizing equipment. The pulverized refuse is then mixed with night soil, sewage
or sludge in a rotating machine and incubated under controlled temperature, pH, carbon-nitrogen ratio
and aeration. The final product compost is ready in 4 to 6 weeks. This method of composting is in vogue
in developed countries. A few of the Indian cities with a population of more than 3 lakhs are presently in
the process of installing such plants. The waste is degraded biologically to a humus with a total nitrogen,
phosphorus and potassium content of 1 to 3 percent, depending on the material being composted.

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Afterwards, the product is ready for curing and blending with additives, bagging and marketing.
(iv) Vermi-composting.
Vermi-compost is the end-product of the breakdown of organic matter by a particular species of earthworm.
Vermi-compost is a nutrient-rich, natural fertilizer and soil conditioner, cultured on a specially made
vermi-bed. The earthworm species most often used are Eudrillus eugineae, Eisenia foetida or Lumbricus
rubellus. It can treat any organic waste, not appreciably oily, spicy, salty or hard and that do not have
excessive acidity and alkalinity. The C/N ratio preferred is 30:1 where carbon matter comes from brown
matter (wood products, saw dust, paper, etc) and nitrogen from green matter (food scraps, leaves,
etc). Overabundance of greens generates ammonia. The moisture content of 40-55% is preferable and
maintained by covering the tank with wet sack and sprinkle water as required. Vermi-compositing can be
done in tank with size of 4 m x 1 m x 0.5 m for waste input of 10 kg/day of semi decomposed waste.
It is an eco-friendly method of disposal of bio-degradable waste from kitchen, dining places, etc. which
mostly contain organic food wastes, peels and serves the dual purpose of disposing off garbage and at
the same time mustering the environment.
(aa) Principles of Process.
O Proper aeration of organic material
O Inoculation of required bacteria
O Spraying of fresh cow dung.
O Keeping pH around 7
O Maintaining moisture at 50%
(ab) Method.
A rectangular bed of earth of suitable size bound by a brick wall 2-3 ft high will serve the purpose.
A few hundred earthworms are introduced on which waste can be dumped and water sprinkled
daily. Agriculturally useful compost is formed in 2-3 months which can be periodically removed.
(ac) Advantage.
O The end product is value added bio-fertiliser (manure) and can be used in agriculture
and organic farming.
O Process converts the project site into a green patch.
O Organic agriculture produces a recurring output, making it sustainable and viable.
O The process does not generate methane gas nor contaminates ground water by leaching.
O The process enriches the organic matter in the soil with bacteria and deep burrowing
earthworms.
(v) Bio methanation /Bio-waste Derived Fuel.
It is a process based on anaerobic digestion of organic matter in which microorganisms break down
biodegradable material in the absence of oxygen. The process is widely used to treat wastewater sludge
and organic wastes because it provides volume and mass reduction of the input material. It produces
methane and carbon dioxide rich biogas suitable for energy production and hence, is a renewable energy
source. The nutrient-rich solids left after digestion can be used as a fertilizer. It generally treats sorted
organic fractions only (highly putrescible) for better gas yield. Fibrous organic matter is undesirable as
the anaerobic microorganisms do not easily break down woody molecules such as lignin, cellulose,
hemicelluloses, etc. The preferred C/N ratio is 25-30. Moisture content should be >50% which implies
feed, gas production, system type and system efficiency. The area requirement for bio-methanation is
approximately 25 m2 per ton of Municipal Solid Waste. Extra area required for machinery, gas-containing
and storage facilities.
(vi) Incineration.
The incineration of Municipal Solid Waste (MSW) involves the combustion of waste leading to volume

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reduction of 90-95%. It is a furnace for burning waste and converting MSW into ash, gaseous and
particulate emissions and heat energy. The efficiency of the technology is linked to the waste characteristics
and their properties such as moisture content and calorific values. It requires a high temperature of
the order of 800-1,000°C and sufficient air and mixing of gas stream. The minimum temperature for
burning carbonaceous wastes to avoid the release of smoke and prevent emissions of dioxin and furans
is 850°C. Depending on the nature of wastes and the operating characteristics of the combustion
reactor, the gaseous products derived from the combustion of MSW may include carbon dioxide (CO2),
water (H2O, flue gas), oxygen (O2), nitrogen oxides (NOx), sulphur dioxide (SO2) and minimum moisture
content should be <45%. The calorific value should be as high as possible > 1500 kcal/kg. Incineration
of chlorinated plastic should be avoided as far as possible. The emission standards are prescribed in
SWM Rules, 2016.
This is a hygienic method of waste disposal. Many developed countries use incinerators, which are
complete with air pollution controls and heat recovery process. However, incineration is not considered
very suitable in this country because the waste contains a high proportion of fine ash, which makes
burning refuse difficult. Besides it involves heavy initial cost on installation and recurring expenditure
on fuel and maintenance. It also requires strict supervision and manpower management. With the
present-day energy crisis, incineration of community waste may be considered as a loss to the country.
Incineration at times is resorted to in some of the Armed Forces permanent installations where there is
no contractor or service provider who can treat this waste in proximity. The common types of incinerators
used in the services are described below:
(aa) Beehive Incinerator.
The beehive incinerator is constructed preferably with fire bricks, over a concrete platform. They
must be sited near the latrines and protected from the weather (Fig 16.27). For an efficient working
of the incinerator, the personnel must be skilled, properly trained and permanently employed.
An adequate supply of readily combustible material such as dry camp refuse, dry leaves, paper,
cinders or dried horse manure must be ensured. At least 15 kg of wood or coal each day will be
needed in addition to the camp refuse. Coal or wood at the scale of 75 kg per 1,000 men per
diem or an equivalent quantity of oil, may be necessary if camp refuse is not adequately available.
A fire is first started with paper and other inflammable camp refuse. The faeces manure and camp
refuse are mixed to form sizeable lumps on the platform. When the fire has turned up brightly,
the mixed mass is slowly tipped into the incinerator taking care not to overload the fire. Between
the charges, camp refuse is added in small quantities to keep up the fire. The incinerator must
be stoked carefully, otherwise the material will fall as a cake to the bottom of the fire. When the
incinerator is working properly, all the smoke is consumed in the vault below the chimney. To keep
the fire alive overnight, the air inlets should be blocked.

Fig 16.27 : Closed Beehive Incinerator

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(ab) Open Brick Incinerator.

This is circular, about 1½ m high, with a uniform diameter of 1 to 1½ m. Its floor is composed
of several iron bars, laid across 5 cm apart from each other, grid iron fashion, 30 cm above the
ground level. They are not built in the walls but laid loose. Four funnel shaped square or round
inlets are made opposite each other in the wall immediately below the fire bars with an outer
dimension of 15 cm square. A raking window 45 cm wide by 22 cm is made immediately above
the fire bars. When not in use, it is closed by an iron sheet. Similar incinerators can be improvised
out of mud or ghee tins filled with earth.
(ac) Drum Incinerator.
An incinerator can be cut out from 160 L or 200 L drum. To make this, the top and bottom of
the drum are removed. Four ventilating windows, 18 cm2 each, are cut out 25 cm above the
bottom rim of the drum but leaving the upper margin of the flaps attached to the drum. These
flaps are turned inside to form rests to support the burning plate. This is made by fenestration of
the removed drum bottom and fixing it inside over the in-turned flaps. The removed top can be
used as a cover to protect the fire from rain. This can be supported by 25 cm metal strips cut
out from the top portion of the drum and turned up.
(ad) Modern Incinerators.
In incinerators of conventional design, refuse is burned on moving grates in refractory-lined
chambers; combustible gases and the solids they carry, are burned in secondary chambers.
Combustion is 85 to 90 percent complete for the combustible materials. In addition to heat, the
products of incineration include the normal primary products of combustion-carbon dioxide and
water-as well as oxides of sulphur and nitrogen and other gaseous pollutants: nongaseous products
are fly ash and unburnt solid residue. Emissions of fly ash and other particles are often controlled
by wet scrubbers, electrostatic precipitators and bag filters.
Resource Recovery.
Numerous thermal processes recover energy in one form or another from solid waste. These
systems fall into two groups: combustion processes and pyrolysis processes. Several companies
burn in-plant waste in conventional incinerators to produce steam. A few municipalities produce
steam in incinerators in which the walls of the combustion chamber are lined with boiler tubes.
The water circulated through the tubes absorbs heat generated in the combustion chamber
and produces steam. Pyrolysis, also called destructive distillation, is the process of chemically
decomposing solid wastes by heat in an oxygen-reduced atmosphere. This results in a gas stream
containing primarily hydrogen, methane, carbon monoxide, carbon dioxide and various other gases
and inert ash, depending on the organic characteristics of the material being pyrolyzed.
(vii) Plasma Pyrolysis.
Plasma pyrolysis or plasma gasification is a waste treatment technology that gasifies matter in an
oxygen-starved environment to decompose waste material into its basic molecular structure. The process
demands high electrical energy for creating high temperature by an electrical arc gasifier. It does not
combust the waste as incinerators do. In a plasma converter, the arc breaks down waste primarily
into elemental gas and solid waste (slag). The objective of the process is to generate net electricity,
depending upon composition input wastes and to reduce the volumes of waste being sent to landfill
sites. Relatively high voltage, high current electricity is passed between two electrodes, spaced apart,
creating an electrical arc where temperatures as high as 13,871°C is reached. The temperature from
one meter arc can reach up to ~4,000°C. At these temperatures, most types of waste are broken into
basic elemental components in a gaseous form and complex molecules are atomized - separated into
individual atoms. Depending on the input waste (plastics tend to be high in hydrogen and carbon), gas
from the plasma containment can be removed as Syngas and may be refined into various fuels at a
later stage. There has been issues of plasma systems regarding high temperatures requirement and
short life of liners which are highly susceptible to both chlorine attack and to local variability in such
high temperatures, not likely to last more than a year in service.

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(viii) Palletization /Production of Refuse Derived Fuel (RDF).

It is basically a processing method for mixed MSW, which can be very effective in preparing an enriched fuel
feed for thermal processes like incineration or for use in industrial furnaces. It is a fuel produced by shredding
MSW and steam treatment for reducing moisture content. RDF consists largely of organic components
of municipal waste such as plastics and biodegradable waste, which are compressed into pellets, bricks
or logs. Non-combustible materials such as glass and metals are removed during the treatment process
with an air blow or other mechanical separation processing. The MSW collected for disposal is tested for
its moisture content and when the moisture content is more than 35-40%, it requires drying to produce
fuel pellets with reasonable calorific/heating values. The reduction in moisture can be done artificially
or by natural sun drying. The sun-dried garbage is then uniformly fed into a rotary drying system i.e. Hot
Air Generation burning oversized garbage or other fuel to further bring down the moisture level to about
10-12%.
(ix) Dumping.
In this method, waste is simply dumped in low-lying areas. As the waste is kept lying loose it creates
nuisance, pollutes the surrounding water and soil and encourages the breeding of flies, rodents and
other pests. Dumping, as a method of waste disposal, should be avoided.
(x) Controlled Tipping (Sanitary Landfill).
This is a satisfactory method if suitable land is available. This method is popular with local bodies and
cantonments. It differs from dumping in that the material is placed in trenches or other prepared areas
adequately compacted and covered with earth. Hence it minimizes the problem of offensive odour,
unsightly appearance, pollution of the surrounding soil and water and pest and vermin infestation. The
size selected should be away from the habitation. A hollow low-lying ground or an abandoned quarry or
a swampy area is generally selected; otherwise, broad trenches are dug on flat low-lying ground. Long
trenches are usually dug out, each having a depth of 2 to 3 m and breadth of 3 to 10 m. Filling of
waste is to take place from the farthest end. At the end of the day’s work, it is covered with earth and
compacted well. The method of controlled tipping has been revolutionized by mechanization. The bulldozer
achieves the tasks of spreading, compacting and leveling the top. After this operation, the top is covered
with clinkers or sweet earth and fast-growing shrubs may be planted. Pollution of surface and groundwater
is minimized by lining and contouring the fill, compacting and planting the cover, selecting proper soil,
diverting upland drainage and placing waste in sites not subject to flooding or high groundwater levels.
Gases are generated in landfills through anaerobic decomposition of organic solid waste. If a significant
amount of methane is present it may be explosive, hence proper venting is mandatory to eliminate this
problem.
(xi) Burial.
This is allowed in only temporary camps where incineration cannot be undertaken. Fly proof pits
constructed exactly like an Otway’s pit may be used for the purpose. Refusal not attractive to the flies
may be buried in deep pits.
(xii) Salvaging.
This method of refuse disposal can be profitably used in metropolitan areas. Wastepaper, polythene bags,
wood pieces, glass pieces, tinkers, cigarette packets, tinfoil, rag and even the garbage and swill can
be salvaged for economic gain before the unsuitable remnants are sent for disposal. The garbage and
swill can be processed for use as chicken and hog feed. Rags and papers can be recycled. Metals both
ferrous and non-ferrous, could be salvaged for gainful use. Today, recyclable materials are recovered from
municipal refuse by several methods, including shredding, magnetic separation of metals, air classification
that separates light and heavy fractions, screening and washing. Another method of recovery is the wet
pulping process: incoming refuse is mixed with water and ground into a slurry in the wet pulper, which
resembles a large kitchen disposal unit. Large pieces of metal and other non-pulpable materials are
pulled out by a magnetic device before the slurry from the pulper is loaded into a centrifuge called a liquid
cyclone. Here the heavier non-combustible such as glass, metals and ceramics are separated out and
sent on to a glass­ and metal-recovery system; other, lighter materials go to a paper-fiber-recovery system.
The final residue is either incinerated or is used as landfill. In the developed nations, municipalities and

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private refuse-collection organizations require to keep bottles, cans, newspapers, cardboard and other
recyclable items separate from other waste. Special trucks pick up this waste and cart it to transfer
stations or directly to recycling facilities, thus lessening the load at incinerators and landfills.

16.11 Disposal of Liquid Waste.

(a) Composition.
This includes wastewater from bathrooms, ablution places, washing places, sullage from cook house and
dining halls and industrial effluents. The effluents from septic tanks and sewage works are also included
in this. The main aims of liquid waste disposal are aesthetic considerations, prevention of water and soil
pollution, prevention of water logging of grounds, prevention of mosquito, fly, sandfly and cockroach breeding
and protection of aquatic flora and fauna. Sullage is also called grey water to distinguish it from black water,
which describes wastes containing human excreta. There are various reasons for keeping sullage separate
from excreta as:
(i) There may be a system for on-site disposal of excreta that cannot accept large volumes of water.
(ii) The sullage may be transported away from the site by a small-diameter pipe that could not handle
faeces.
(iii) May be to reduce the hydraulic loading on a septic tank by diverting the sullage away from it.
If a particular area is always used for tipping sullage on the ground; the continual moistness will favor the
survival of helminths such as hookworms and the breeding of flies and mosquitoes. If the greater availability
of water causes the creation of pools of stagnant sullage (because sullage disposal has not been carefully
considered), then the improved water supply could have a negative effect on the health of the community. The
disposal of sullage is a particular problem at community water points. A simple cross­ section of drain designed
only for stormwater would conduct the sullage away at a very low velocity, leaving the solids suspended in
the sullage in the bottom of the drain. The circular channel in the invert of a compound cross-section allows
small flows to move at a higher velocity.
(b) Disposal.
If a water carriage system exists, all liquid wastes can be conveniently discharged into the sewerage system.
If this is not available, the most common method of disposal of these liquid wastes is into soakage pits or
streams. The sullage from the cookhouses and dining halls, however, needs pretreatment before disposal due
to its high fat content. Even with the most porous soil, fat, grease and soap form an impervious coating on the
surface, which prevents percolation. When discharged into a stream untreated, it can harm the aquatic flora
and fauna by hampering oxidation. The simplest method of removal of grease from the sullage is by passing
it through grease trap.
(i) Cold Water Grease Trap.
When warm wastewater passes into a sufficient quantity of cold water, the contained fat solidifies and
rises to the surface and the clear water runs into soakage pits or into a stream. Cold water runs into
soakage pits or into a stream. A cold-water grease trap is used in semipermanent and permanent camps
(Fig 16.28). It is only useful for cookhouse sullage but not for bathroom water because the soap does
not form float scum. The construction and maintenance are as under:
(aa) Construction.
Grease traps for permanent camp should be made of cement concrete or masonry while those
for a semi-permanent camp may be made of wood. The quantity of water in a trap should be at
least five times the peak-hour quantity of wastewater entering it, otherwise, the wastewater will not
be adequately cooled for the grease to solidify. The normal cookhouse wastewater yield is about
3 L per head at the peak hour. Therefore, a trap for a coy cookhouse serving 100 to 130 men
should be 1m long, 0.5 m broad and 0.65 m deep. This will hold about 300 L of cold water. The
trap is divided into three compartments with two baffle plates placed at about 25 cm distance
each from the entrance and exist. They are deficient for about 16 cm at the bottom, hanging in
the trap without touching its floor. The middle compartment holds the scum of grease floating.
A third baffle plate about 20 cm broad is fixed in the center of this grease compartment resting

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vertically on the bottom of the trap to stop the sludge. A strainer made of galvanized iron or tin
may be interposed between the inflow and the first compartment to hold back any gross pieces of
garbage. The water entering the trap gravitates down due to the force of flush and finding its way
under the first baffle enters the second compartment wherein the cold water freezes the grease
in it. The sludge accumulates at the middle baffle.

Fig 16.28 : Cold Water Grease Trap

(ab) Maintenance.
Surface grease should be removed daily with a ladle and burnt in an incinerator. The grease trap
should be emptied once a week, all sludge removed from the bottom and buried; and the sides,
bottom and baffles scraped and scrubbed before refilling with cold water.
(ii) Strainer Grease Trap.

Fig 16.29 : Strainer Grease Trap

These are used in temporary camps (Fig 16.29). The standard type of strainer grease trap is made from
ghee tin or cresol drum with perforated bottom. The tin is then filled from below upwards with 7 cm
layer each of gravel, coarse sand and fine sand. Over this is placed a 15 cm thick layer of hay or straw.
A shallow tin strainer is placed over this grease trap and the sullage water is led into this tin strainer.
Percolating downwards the sullage water deposits grease on the straw and top layer of fine sand. A

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soakage pit is prepared, the strainer grease trap is fixed directly over its centre and wastewater is led
to it through drain from the outfall of water from the kitchen. The straw should be burnt daily. Sand and
gravel need replacement twice or thrice a week and the greasy material is burnt or buried.
The effluent may be run into the existing drainage system, a septic tank or into a stream at point where
it does not pollute any source of domestic water supply or into a soakage pit or soak well. The usual
method of disposal in the Armed Forces units is to a soakage pit.
(iii) Soakage Pit.
It is made by digging a 1.25 m3 pit (Fig 16.30). The pit is then filled with stones and brick bats in a
graded fashion. The final top layer is made of coarse gravel or sand. The pit is then covered with bamboo
matting except at the center for fixing the strainer grease trap over the pit or over an area of required
dimension to receive the channel from the cold-water grease trap. Heavily oiled hessian cloth is put over
the bamboo matting extending up to 0.5 m all around. The soakage pit functions by physical as well
as biological process. The physical process involves soakage and evaporation. The biological process is
due to the action of the ‘Zoogleal’ that grows on the surface of the stones and brick bats. The stones
not only provide a surface for growth of the ‘Zoogleal’ but also help in evaporation by providing a large
surface area. Soakage pits are however, liable to clogging even with the use of efficient mechanical traps
as some grease and soap from sullage will be left in the effluent and form an impermeable coating on
the walls and floor of the pit. Spare pits are thus to be kept in readiness. The water-logged pit is dug
out scraped and left open for drying and subsequently rearranged. Weekly insecticidal spraying is to be
carried out around the pits.

Fig 16.30 : Soakage Pit for Kitchen Sullage

(iv) Lagoon Pans.
These are suitable in a very dry climate where the soil is porous. The effluent is allowed to flow over
the surface for percolation and evaporation. The ground is usually divided into seven areas called the
‘lagoon pans’, Each pan receives one day’s effluent in turn: the largest area is reserved for Sunday. A
central channel with three parallel channels running across the central channel is cut. The effluent is
diverted into these by rotation for filling up the required pan. The channel could also be modified in the
pattern of ‘Herring bone’ system for better functioning. Periodic scrapping of the pans and the channels
is to be undertaken. Flowering or vegetable plants may be grown advantageously in the pan areas.
(v) Wastewater Reclamation.
Water is used as a means of transporting pollutants, but in areas short of water, it is uneconomic to

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throw away 999 tons of water to dispose off 1 ton of pollutants. “Conservation” consists in making the
best use of existing water resources and preserving them from deterioration. “Reclamation” is the act of
restoring used water as nearly as possible to its previous quality. By judicious reclamation, it is possible
to reserve first class water sources for first class uses for example, for drinking, cooking and washing.
The demand for second-class water being met from reclaimed water, used for toilet flushing, gardening
and car washing. In 1958, UNESCO stated: “No higher quality of water unless there is a surplus of it,
should be used for a purpose that can tolerate a lower grade”. Further treatment of secondary effluents
is regarded as “advanced waste treatment” or “water reclamation”. Rapid urbanization and population
growth worldwide have intensified the demand for water, leading to common water shortages exacerbated
by pollution. In the past, natural processes sufficed, but increased population and industrialization
demands wastewater treatment to maintain stream quality. Treated wastewater becomes an additional
resource, saving clean water supplies when repurposed for non-drinking purposes. Industries, producing
numerous persistent chemicals, contribute to water pollution, challenging conventional treatment
methods. Wastewater reclamation, crucial in arid regions, should be integrated into sewerage projects.
Wastewater treatment requires qualified personnel and advanced tools for effective monitoring. Automatic
measurements of various parameters are feasible, though toxicity measurement methods are lacking.
Tailored purification is essential based on reuse, from minimal treatment for irrigation to comprehensive
processes for unrestricted use. While complete renovation is costly, reclaiming wastewater for non-potable
purposes conserves natural potable water for essential consumption, promoting sustainability.
(vi) Newer technologies: FOG separator.
FOG (Fats, Oils and Grease) comprises fats, oils, grease created by food debris, fats and oils used in the
cooking process, washing of food vessels/equipments, crockery etc. Different types of FOG separators
can be utilized in permanent camps for the cookhouses depending on size of cookhouse, type of food
being prepared, no. of equipments used for cooking and density of the FOG produced.
There are primarily two types of FOG separators-
(aa) Underground separator- mainly used for space constraint reasons and are installed outside
the building.
(ab) Free standing- installed above the ground and are easy to access and maintain.
Advantages-
O Made of polyethylene with integrated sludge trap
O Odourproof cover
O Low weight
O Easy installation and maintenance

(a) (b)
Fig 16.31 : FOG Separators – (a) Underground, (b) Free Standing

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16.12 Offensive Trade Waste.

Offensive trades are those which may act as sources of nuisance and health hazard to the workers and the surrounding
population because of the smell and effluvia generated by these trades and parties on account of the materials and
processes employed therein. These trades, as far as possible, should be discouraged in the cantonment area or the
vicinity of Armed Forces Camps. If, however, these trades are already in existence, adequate precautionary measures
are to be ensured. A brief description of some of these trades, including measures recommended for safeguarding the
health and aesthetic considerations of the public as well as the workers, are given below:
(a) Animal House.
When animals are kept in crowded, ill-ventilated and poorly drained localities, they become a source of nuisance
and health hazard. The animal houses may often create a nuisance from the storage of straw, grains and
other foodstuffs in a wet state and accumulation of dung and urine into the ground owing to defective flooring.
Pig sites, in particular, may create a serious nuisance from the smell of sour and decomposed food and rice
on which pigs are fed. Keeping poultry may also cause some nuisance and should, therefore, be discouraged
in individual houses. Cowsheds and stables should be properly constructed. Dung should be removed and
disposed of hygienically. The shed should be cleaned and washed regularly.
(b) Slaughterhouse.
It may be private or public. The private ones must be closed as they are not only a source of very serious
nuisance but also facilitate the slaughter of the diseased animals. Nuisance in a slaughterhouse usually
arises from the unhygienic way the animals are kept and from delayed removal of decomposed carcasses
and garbage. Filthy slaughterhouses are always a menace to the public health due to large collection of offal
undergoing putrefaction and the continuous flow of blood, urine and faecal matter in the surrounding areas.
Thus, for proper sanitary control, all slaughtering should be carried out in licensed public slaughterhouses
(abattoirs). The hygienic rules for the slaughterhouses must be followed strictly. The slaughterhouse should
be built with brick and concrete and well protected against rodents, cats and dogs. The employees must wear
clean clothing, be free from communicable diseases, be periodically examined and protected by immunization.
All refuse, blood, manure and offal must be kept in proper wastebins made of non-absorbing material with
close fitting lids immediately after slaughter and removed as early and possible for hygienic disposal.
(c) Blood Products.
Blood collected from slaughterhouses is utilized for making blood albumin and manure, refining of sugar and
other purposes. Blood is usually boiled with sulphuric acid and then dried. The process gives off a sickening
smell, hence they should be situated away from inhabited places.
(d) Bone Crushing.
This is carried out for preparing natural phosphate manure. Storage of raw bones during rainy seasons may
give off foul odour. Bone crushing should be carried out without creating any dust nuisance in the locality.
(e) Gut Scraping.
This process is undertaken for the purpose of making catguts from the small intestines of swine and sheep.
The intestines are first washed, cleaned, softened by soaking in salt for days and then scraped till a thin layer
of muscle with peritoneal covering is left. These are finally washed and dried.
(f) Fat and Tallow Melting.
Fat and tallow obtained from the dealers is utilized for making candles, soaps and leather dressing. In the
manufacturing process, nuisance may be caused from improper conveyance of storage of materials, storage
of residue, general filthiness and harmful vapours.
(g) Fell Mongering.
It means processing of fresh or old skin for leather dressing. The process of tanning is very offensive. In this
process, putrescible hides are converted into non-putrescible and flexible materials known as leather. Tanneries
when conducted in modern method do not cause much nuisance. However, on account of the offensive odours
given off, they should be located on the outskirts of the town. The wastewater from the tannery must be treated
before discharge.

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(h) Paper Making.

The raw materials such as cotton, linen, rags, waste papers, straw, bamboo, grass and baggage are first
cleaned, washed, made into small pieces and when bleached. It is then reduced to pulp by boiling with
concentrated alkali. The nuisance is mainly due to discharge of the alkali waste into a stream. The vapors
given off during processing are also offensive and should be conducted by a flue to a tall chimney. The basic
measures of proper housekeeping are also equally important.
(j) Oil Mills.
The smell evolved may cause discomfort to the public in the locality. So, these mills should be sited away from
the locality.
(k) Rice Mills.
The wasted water coming out of parboiling of the paddy is dark reddish brown and undergoes putrefaction giving
off offensive odour. This liquid should not be allowed to run into a drain, tank or a stream without being treated
first with chlorinated lime. Nuisance also arises during the process of winnowing from the accumulation of large
quantities of husk and dust. These should be removed as quickly as possible and hygienically disposed of.

16.13 Disposal of Dead Animals.

Incineration is the best method of disposal of a carcass of animal died of an infection. It requires 40 kg of wood and
10 L of kerosene to ensure complete combustion of a mule in an efficient destructor. For an ordinary non-infectious
carcass burial is suitable. A mule or horse carcass needs a 4 x 2 x 2 m pit. Before the carcass is placed in the pit,
its belly and intestines should be opened to permit the gases of decomposition to escape. Otherwise, the belly swells
enormously and often force open the grave. Burial places should always be remote from any campsite or source of
water supply. Charring can precede the burial. A pit is dug beside the disemboweled carcass. The viscera are buried.
The carcass is then dragged over the buried viscera and blood saturated soil. 20 kg of dried grass or litter soaked
with 2 L of kerosene oil is spread over the carcass and ignited. The aim is to sterilize the surface by chaffing and not
to incinerate. The charring should be done early after the death of the animal so that the saprophytic organisms have
no time to penetrate tissues. The exposed surface affords attraction to flies. A disinfectant fluid consisting of 1 part
of coal tar-creosote-oil with 14 to 18 percent tar acids and 5 parts kerosene prevents smell and fly breeding. This
can be sprayed over the carcass or injected into its carotid artery. Ten liters per horse are necessary. A spray of five
percent cresol is also used. Slaked lime should be sprinkled over the carcass, in the grave and over the area. Animals
slaughtered for rations and found unfit for consumption should be disposed of on similar lines.
If it is not possible to incinerate the carcass of animal died of anthrax or suspected anthrax, the carcass may be
buried. It, however, must not be cut open. If it is necessary to take a sample of blood for bacteriological diagnosis,
an ear is cut off and sent to the laboratory wrapped in gauze well soaked in 5 percent cresol solution and covered
by sacking. The blood or discharges of the animals should not contaminate the ground. All orifices should be plugged
with gauze tow soaked in 5% percent cresol and the body wrapped in sacking similarly soaked. The carcass placed
in the pit should be surrounded from all sides with quick lime. The byres should be disinfected with 5 percent cresol,
using long handled brushes and then treated with freshly chlorinated limewash. Overalls and gloves should be worn
throughout the operation.
The requirements for disposal of carcasses and other potentially contaminated fomites in case of infectious and
contagious diseases are provided in the Prevention and Control of Infectious and Contagious Diseases in Animals Act,
2009 and Prevention and Control of Infectious and Contagious Diseases in Animals (Form of Vaccination Certificate,
Manner of Postmortem Examination and Disposal of Carcass) Rules, 2010. Proper disposal of the carcass is mandatory
as per the Act and the destruction and disposal of the animals and material shall be documented by the Animal
Husbandry Department officials. States may also follow the provisions of India Code Disposal of Dead animals and may
involve NGOs and cooperatives. Advance cooperation between the Veterinary Service and other relevant government
bodies is necessary for proper disposal of dead animals.
Different methods for disposal of dead animals and related materials are as under:
(a) Burial.
From a biosecurity point of view, burial is a viable option, but groundwater contamination needs to be checked.
Burial site selection should be away from water courses, drainage etc. The record of all burial pits shall be
maintained. The process of burying should be as follows:

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(i) The site should not be in a drinking water catchment area and near to the coast and should
be away from towns, dwellings, roads and free from underground pipelines, power and telephone lines
(local bodies and pollution authority should be consulted). For proper management, pits should be dug
on common land within the infected zone in limited numbers.
(ii) The site should be on soils of low permeability with significant clay content (lining pits with clay
soil may be considered). The pits should not be on a slope greater than 6 degrees and digging to a
5-meter depth is possible.
(iii) The groundwater table level should be a minimum of 6 meters below the lower level of deep burial
pit.
(iv) The watercourse should be away from the burial sites such as lakes (1,000 ft), rivers (400 ft),
tube well (200 ft).
(v) Pit should be 2 meter deep and half filled with waste, then covered with lime within 50 cm of
the surface, before filling the rest of pit with soil. On each occasion when waste is added to the pit, a
layer of 10 cm soil shall be added to cover the waste.
(vi) Burial pit/trench should be at least 2.3 meter (not more than 3 meter) wide and 3 meters deep
(7 x 9 ft). The length should be as per the number of carcasses.
(vii) A floor space of 1.3 m2 (15 ft2): May accommodate mature bovine/equine carcass, 5 mature pigs/
sheep, 100 mature chickens/40 mature turkeys. For each additional meter (3 ft) in depth, the number
of animals per 1.3 m2 of floor space may be doubled. The weight of dead animals in the pit should not
exceed 2500 kg.
(viii) Land requirement of 1.5 cubic meters for adult cattle carcass, 0.3 cubic meter for pig/sheep
carcass and 1.0 cubic meter for 200 chickens may be considered.
(ix) The carcasses should be covered with at least 400 mm soil with an unbroken layer of slaked lime
-Ca (OH)2 (avoid lime in Anthrax carcass). Lime should not be placed directly on carcasses, because in
wet conditions it slows and may prevent decomposition.
(x) The burial pit should be covered with at least 2 m (6 ft) soil. Soil should not be compact. During
closing the pit surplus soil should be heaped over it as overfill. Lime should be added to pits, to prevent
earthworms from bringing contaminated material to the surface after pit closure.
(xi) No person should enter the trench more than 1.5 m deep without stabilizing the sides.
(xii) All the remnant feed and soil up to 2 inches deep must be disposed-off along with the carcass.
(xiii) The buffer zone with green belt should be maintained in consultation with local bodies and
pollution authorities.
(xiv) The pit sites should be fenced and permanent warning signboards should be fixed in all the pit
sites. The pits should be monitored at regular intervals to check for any sinking, water accumulation etc.
and if necessary, steps be taken as mentioned above.
(xv) There should be no accumulation of water during rainy season at the disposal site.
(xvi) No crop should be grown further for at least one year on the pit site.
(xvii) All the pits should be dug one day in advance of the disposal and while digging pits, it should be
ensured that no water is oozing out of the pit.
(xviii) After the operation clean and disinfect all equipment and area.
(xix) Stabilize the surface of the excavated area in accordance with local requirements and ensure
regular inspections for maintenance.
(xx) Monitor ground water quality and fence the area with visible sign of restricted entry.
(b) Landfills/Subsurface Disposal.
This is similar to burial. Carcasses are layered between compacted soil and solid waste materials. Established
sites should have minimal potential risks to groundwater, surface water and other environmentally sensitive

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areas. Landfill design incorporates liners, leachate containment systems and gas collections systems to minimize
environmental impacts. May require 3-5 cubic yards of cover materials per 1,000 carcass. The recommended
height for a pile is 5-7 feet. The points to be taken into consideration are:
(i) Monitor frequently and the initial core temperature should be between 135-140°F.
(ii) On-site biosecurity risks associated with transport should be controlled.
(iii) Affected by weather and ambient temperature and therefore need to be protect from wind, rain,
drying conditions and scavengers.
(c) Incineration.
Incineration is thermal destruction of carcass by using high-temperature (>8,500°C) combustion (by using fuels
like diesel, natural gas, electric energy) to convert carcasses to inert gases and sterile ash as well as deactivate
pathogens. Incineration shall be practiced only on-site by agencies and institutes that have adequately trained
manpower in operating the rendering plant.
(d) Burning.
Burning of carcasses within a farm on pyres is also a common waste treatment practice that involves combustion
of organic substances contained in waste material. It is not suitable for large volumes of material. Following
are some important things to be taken care of:
(i) Should be approved by appropriate authorities.
(ii) Burning should be away from public view and on flat, open ground with legal approvals.
(iii) Fire bed burning should be at a right angle to the prevailing wind.
(iv) Remove all vehicles, personnel and other equipment well away from the fire bed.
(v) Burning space: 8 x 3 ft. for each mature cattle/horse, 5 mature pigs/sheep, 100 mature chickens
and 40 mature turkeys. Also at least 1 meter fire bed length may be assumed for 1 adult cattle carcass/5
swine/sheep carcass/200 chickens.
(vi) In pyre burning: Place carcasses on top of solid fuel with sufficient airflow, on their backs lower
and alternating head to tail. Approximately one cord of wood (128 cubic feet or 3.4 m3 ) is required per
500 kg of carcass.
(vii) Burn pit: The pit should be 0.5 m deep and extended 0.75 m beyond each end of pyre. The
pit should be 25 cm wider than the pyre on each side. The bottom of the pit should be covered with
accelerant (diesel, kerosene etc. in less quantity to avoid contamination), soaked wood, hay, straw, etc.
Solid fuels should be used to maintain combustion. Pieces of heavy timber are placed across the pit to
support the pyre.
(viii) Two goats, sheep or swine carcasses may be placed on top of each bovine carcass.
(ix) The trench should be filled with mud after the entire carcass is burnt.
(x) Do not use tires, rubber, plastic and similar materials for burning.
(xi) Handlers and supervisor should use PPE.
(xii) Firefighting equipment should be readily available.
(xiii) After the operation, clean and disinfect all equipment.
(xiv) Dispose off ash in accordance with legal requirements.
(xv) Anthrax carcass can also be disposed of by burning (if incinerator is not available). All vessels
and instruments should be disinfected with 3% solution of sodium carbonate.
(e) Composting.
Composting is a natural biological process that transforms organic material in a predominantly aerobic
environment into a useful and biological end product. It destroys nearly all pathogenic viruses, bacteria, fungi,
protozoa and helminth except endospore forming bacteria (B. anthracis) and prions (including BSE). The points

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to be taken into consideration are:

(i) Composting should be at least 100 meters away from water sources and residence and
300 meters away from roads.
(ii) It involves layering/mixing carcass with co-compost material (sawdust, silage etc.) with at least
60 cm covering of composting material.
(iii) Material should be removed from the compost pile after the carcass/related material is completely
composted with minimum odour.
(iv) Compost piles kill most pathogens in 10-14 days in case of small carcasses, longer in large
carcasses.
(v) Assume land area as 17 square meters for cattle carcasses, 3.5 square meter for pig/sheep
carcass and 8.7 square meter for 100 chickens. The site should be 120 cm above seasonal high-water
level and at least 1 meter above bed rock. The site should not be located on flood plains.
(vi) On the base of litter, the carcass and related material along with bulking agent are added in layers
so that the carbon-to-nitrogen ratio is in the range of 15:1 to 35:1 (optimal 23:1).
(vii) Necessary measures should be taken to minimize odour, flies, rodents, bird menace and fire
hazard.
(viii) Leachate should be re-circulated in the compost plant for moisture maintenance.
(ix) Turning piles may increase the rate of decomposition. The first stage of composting normally
completed within about 3 weeks for poultry, 12 weeks for large animals. Second stage composting takes
an additional 3 weeks for poultry and up to about 8 months for large animals.
(x) The volume of dead animal(s) in the compost pile must not exceed 25% of the total volume of
the compost pile.
(xi) Break eggs prior to composting.
(xii) Finished products can be recycled, stored or added to the land as a soil amendment subject to
the fulfillment of standards prescribed by Fertilized Control Orders.
(xiii) Clean and disinfect all the equipment and area.
(xiv) The operation should be under expert care for proper composting.
(f) Rendering.
Rendering is a process that uses heat to convert animal carcasses into safe, pathogen free feed protein, meat
and bone meal, fat or tallow and other final products and by products. Some facilities can efficiently transport
and process one million or more pounds of raw animal per day. Not recommended for anthrax carcasses.

16.14 E-Waste Disposal.

Electrical and electronic waste (e-waste) is one of the fastest growing waste streams in the world. “The increasing
market penetration” in developing countries, “replacement market” in developed countries and “high obsolescence rate”
make e-waste as one of the fastest growing waste streams. Environmental issues and trade associated with e-waste
at local, trans-boundary and international level has driven many countries to introduce interventions.
E-waste comprises of wastes generated from used electronic devices and household appliances which are not fit for
their original intended use and are destined for recovery, recycling or disposal. Such wastes encompass a wide range
of electrical and electronic devices such as computers, handheld cellular phones, personal stereos, including large
household appliances such as refrigerators, air conditioners etc. E-wastes contain over 1,000 different substances
many of which are toxic and potentially hazardous to the environment and human health if these are not handled in
an environmentally sound manner.
(a) Guidelines For Environmentally Sound Management for E-Waste.
E- Waste (Management & Handling) Rules, 2011 were notified in 2011 and came into force wef 1st May 2012.
To ensure effective implementation of E-Waste Rules and to clearly delineated the role of producers in EPR,

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MoEF & CC, Government of India in supersession of E-Waste (Management and Handling) Rules, 2011 has
notified the E-Waste (Management) Rules, 2016 vide G.S.R. 338 (E) dated 23.03.2016 which came into effect
from 01.10.2016. These rules are applicable to every producer, consumer or bulk consumer, collection center,
dismantler and recycler of e-waste involved in the manufacture, sale, purchase and processing of electrical
and electronic equipment or components specified in schedule – I of these Rules. The main feature of these
rules is Extended Producer Responsibility (EPR). There are two categories of electrical and electronic equipment
covered under these rules, namely:
(i) IT and Telecommunication Equipment and
(ii) Consumer Electricals and Electronics such as TVs, Washing Machines, Refrigerators, Air Conditioners
including fluorescent and other mercury containing lamps
(b) E-Waste Composition and Recycle Potential.
The consumption of e-waste and its recyclable potential is specific for each appliance. To handle this complexity,
the parts/materials found in e-waste may be divided broadly into six categories as follows:
(i) Iron and steel, used for casings and frames.
(ii) Non-ferrous metals, especially copper used in cables and aluminum.
(iii) Glass is used for screens and windows.
(iv) Plastic is used as casing, in cables and for circuit boards.
(v) Electronic components.
(vi) Others (rubber, wood, ceramic etc).
(c) Recycling, Reuse and Recovery Options.
The Environmentally Sound Technologies for e-waste treatment involve complex treatment rationale driven by
“Material Flow”. This is compared with the best available technology and e-waste treatment technology currently
used in India.
The composition of e-waste consists of diverse items like ferrous and non-ferrous metals, glass, plastic,
electronic components and other items and it is also revealed that e-waste consists of hazardous elements.
Therefore, the major approach to treating e-waste is to reduce the concentration of these hazardous chemicals
and elements through recycling and recovery. In the process of recycling or recovery, certain e-waste fractions
act as secondary raw materials for the recovery of valuable items. The recycling and recovery include the
following unit operations:
(i) Dismantling.
Removal of parts containing dangerous substances (CFCs, Hg switches, PCB); removal of easily accessible
parts containing valuable substances (cable containing copper, steel, iron, precious metal containing
parts, e.g., contacts).
(ii) Segregation of ferrous metal, non-ferrous metal and plastic. This separation is normally done in
a shredder process.
(iii) Refurbishment and reuse: Refurbishment and reuse of e-waste have potential for those used
electrical and electronic equipment that can be easily refurbished to put to its original use.
(iv) Recycling/recovery of valuable materials. Ferrous metals in electrical furnaces, non-ferrous metals
in smelting plants and precious metals in separating works.
(v) Treatment/disposal of dangerous materials and waste. Shredder light fraction is disposed of in
landfill sites or sometimes incinerated (expensive), CFCs are treated thermally, PCB is incinerated or
disposed of in underground storages, Hg is often recycled or disposed of in underground landfill sites.

Suggested Reading.
1. https://iris.who.int/bitstream/handle/10665/38919/WHO_TRS_10.pdf?sequence=1&isAllowed=y
2. https://www.who.int/news-room/fact-sheets/detail/sanitation

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 ENVIRONMENTAL SANITATION

3. https://www.basel.int/Portals/4/Basel%20Convention/docs/text/con-e-rev.pdf
4. Swachh Bharat Mission - Gramin, Department of Drinking Water and Sanitation [Internet]. [cited 2024 Jan 14].
Available from: https://swachhbharatmission.gov.in/sbmcms/index.htm
5. Gordon B, Boisson S, Johnston R, Trouba DJ, Cumming O. Unsafe water, sanitation and hygiene: a persistent
health burden. Bull World Health Organ. 2023 Sep 1;101(9):551-551A.
6. https://cdn.who.int/media/docs/default-source/who-compendium-on-health-and-environment/who_
compendium_chapter4_v2_01092021.pdf?sfvrsn=b4e99edc_5
7. https://iris.who.int/bitstream/handle/10665/331057/WHO-CED-PHE-EPE-19.12.09-eng.pdf?sequence=1&is
Allowed=y
8. https://iris.who.int/bitstream/handle/10665/75140/WHO_HSE_WSH_12.01_eng.pdf?sequence=1
9. Schultz MC, Schultz JT, Schultz JJ. Female Relief Systems in U.S. Military Fighter Ejection Seat Aircraft. J Aviat
Technol Eng. 2022 Jan 13;10(2):1.
11. Compendium on IR-DRDO Bio-toilets for Indian Railways
12. DRDO Biotoilet for plains | Defence Research and Development Organisation - DRDO, Ministry of Defence,
Government of India
13. Sperling M von. Wastewater characteristics, treatment and disposal. London: IWA Publ. [u.a.]; 2007. 292 p.
(Biological wastewater treatment series).
14. https://cpcb.nic.in/GeneralStandards.pdf
n

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Chapter
XVII
MANAGEMENT OF BIOMEDICAL WASTE

17.1 Introduction.
The term Bio Medical Waste (BMW) means, any waste which is generated during the diagnosis, treatment or
immunisation of human beings or animals or research activities pertaining thereto or in the production or testing
of biologicals or in health camps. In addition, it includes the same types of waste originating from minor and
scattered sources, including waste produced in the course of health care undertaken in the home (e.g. home
dialysis, self-administration of insulin, recuperative care etc.)
Globally, approximately 16 billion injections are administered each year, posing a disposal challenge for healthcare
waste, especially in low-income countries. High-income countries generate about 0.5 kg of hazardous waste per
hospital bed daily, while low-income countries, facing issues with waste separation, likely produce more hazardous
waste than estimated. This underscores the urgent need for improved global healthcare waste management.
In India total, 764 tonnes of Bio Medical Waste (BMW) are generated daily, with 721 tonnes effectively treated
and disposed off through 215 operational Common Biomedical Waste Treatment Facilities (CBWTFs) and other
healthcare facilities. However, there remains a notable gap between BMW generation and its treatment and
disposal, particularly in states such as Assam, Bihar, Himachal Pradesh, Jharkhand, Karnataka, Madhya Pradesh,
Nagaland and Tripura.

17.2 Classification of Biomedical Waste.

Biomedical waste has been classified into various classes based on the type of waste. The same are summarized in
Table 17.1 alongwith suitable examples.
Table 17.1 : Classification of Biomedical Waste
Waste Category Descriptions and Examples
Sharps waste Used or unused sharps (e.g. hypodermic, intravenous or other needles, auto-disable
Syringes, syringes with attached needles, infusion sets, scalpels, pipettes, knives, blades,
broken glass)
Infectious waste Waste suspected to contain pathogens and that poses a risk of disease transmission (e.g.
waste contaminated with blood and other body fluids, laboratory cultures and microbiological
stocks; waste including excreta and other materials that have been in contact with patients
infected with highly infectious diseases in isolation wards)
Pathological waste Human tissues, organs or fluids; body parts; foetuses
Pharmaceutical Pharmaceuticals that are expired or no longer needed, items contaminated by or
waste, cytotoxic
containing pharmaceuticals
waste
Cytotoxic waste containing substances with genotoxic properties (e.g. waste containing
cytostatic drugs – often used in cancer therapy, genotoxic chemicals
Chemical waste Waste containing chemical substances (e.g. laboratory reagents, film developer,
disinfectants that are expired or no longer needed; solvents, waste with high content of
heavy metals, e.g. batteries, broken thermometers and blood-pressure gauges)
Radioactive waste Waste containing radioactive substances (e.g. unused liquids from radiotherapy or laboratory
research; contaminated glassware, packages or absorbent paper, urine and excreta from
patients treated or tested with unsealed radionuclides; sealed sources)

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Waste Category Descriptions and Examples

Non-hazardous or Waste that does not pose any particular biological, chemical, radioactive or physical hazard
general health- (e.g. newspaper, cardboxes, plastic water bottles, aluminium cans of soft drinks, etc.)
care waste

17.3 Categories of Bio Medical Waste.

The BMW has been categorized into four categories based on colour code and segregation pathway i.e. Yellow, Red,
White (Translucent) and Blue for ease of management and monitoring under the provisions of Biomedical Waste
Management Rules, 2016. The categories of biomedical waste alongwith their disposal is given below in Table 17.2.
Table 17.2 : Categories of Biomedical Waste & Their Disposal
Type of Bag or
Category Type of Waste Container To Be Treatment and Disposal
Used
YELLOW (a) Human Anatomical Waste. Yellow coloured Incineration or Plasma Pyrolysis or
Human tissues, organs, body parts and non-chlorinated deep burial
fetus below the viability period (as per plastic bags
the Medical Termination of Pregnancy
Act 1971, amended from time to time).

(b) Animal Anatomical Waste.

Experimental animal carcasses, body
parts, organs, tissues, including the
waste generated from animals used
in experiments or testing in veterinary
hospitals or colleges or animal houses.
(c) Soiled Waste. Incineration or Plasma Pyrolysis or
Items contaminated with blood, body deep burial.
fluids like dressings, plaster casts, In absence of above facilities,
cotton swabs and bags containing autoclaving or microwaving/
residual or discarded blood and blood Hydroclaving followed by shredding
components. or mutilation or combination of
sterilization and shredding. Treated
waste to be sent for energy
recovery.
(d) Expired or Discarded Medicines. Yellow coloured Expired cytotoxic drugs and items
Pharmaceutical waste like antibiotics, non-chlorinated contaminated with cytotoxic
cytotoxic drugs including all items plastic bags or drugs to be returned back to
contaminated with cytotoxic drugs containers the manufacturer or supplier or
along with glass or plastic ampoules, common biomedical waste facility
vials etc. for incineration at temperature
>1,200°C.
Encapsulation or plasma pyrolysis
at >1,200°C. All other discarded
medicines shall be either sent
back to manufacturer or disposed
by incineration.

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WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

Type of Bag or
Category Type of Waste Container To Be Treatment and Disposal
Used
(e) Chemical Waste. Yellow coloured Disposed of by incineration or
Chemicals used in production of non-chlorinated Plasma Pyrolysis or Encapsulation
biological and used or discarded plastic bags or in hazardous waste treatment,
disinfectants. containers storage and disposal facility.
(f) Chemical Liquid Waste. Separate collection After resource recovery, the
Liquid waste generated due to use of system leading chemical liquid waste shall be pre-
chemicals in production of biological to effluent treated before mixing with other
and used or discarded disinfectants, treatment system wastewater.
Silver X-ray film developing liquid, or yellow container The combined discharge shall
discarded Formalin, infected (recyclable liquid conform to the discharge norms
secretions, aspirated body fluids, chemical) given in Schedule-III.
liquid from laboratories and floor
washings, cleaning, house-keeping and
disinfecting activities etc.
(g) Discarded linen, mattresses, Non-chlorinated Non- chlorinated chemical
beddings contaminated with blood or yellow plastic bags disinfection followed by
body fluid, routine mask or gown. or suitable packing incineration or Plasma Pyrolysis or
material for energy recovery.
In absence of above facilities,
shredding or mutilation or
combination of sterilization and
shredding. Treated waste to
be sent for energy recovery or
incineration or Plasma Pyrolysis.
(h) Microbiology, Biotechnology and Autoclave safe Pre-treat to sterilize with non-
other clinical laboratory waste. plastic bags or chlorinated chemicals on-site
Blood bags, Laboratory cultures, stocks containers as per National AIDS Control
or specimens of microorganisms, live Organisation or World Health
or attenuated vaccines, human and Organisation guidelines thereafter
animal cell cultures used in research, for Incineration.
industrial laboratories, production of
biological, residual toxins, dishes and
devices used for cultures.
RED Contaminated Waste (Recyclable). Red coloured non- Autoclaving or microwaving/
Wastes generated from disposable chlorinated plastic hydroclaving followed by shredding
items such as tubing, bottles, bags or containers or
intravenous tubes and sets, catheters, mutilation or combination of
urine bags, syringes (without needles sterilization and shredding. Treated
and fixed needle syringes) and waste to be sent to registered or
(vaccutainers with their needles cut) authorized recyclers or for energy
and gloves. recovery or
plastics to diesel or fuel oil or
for road making, whichever is
possible.
Plastic waste should not be sent
to landfill sites.

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Type of Bag or
Category Type of Waste Container To Be Treatment and Disposal
Used
WHITE Waste sharps including Metals. Puncture proof, Autoclaving or Dry Heat
(TRANSLUCENT) Needles, syringes with fixed needles, leak proof & Sterilization followed by shredding
needles from needle tip cutter or tamper proof or mutilation or
burner, scalpels, blades or any other containers encapsulation in metal container
contaminated sharp object that or cement concrete; combination
may cause puncture and cuts. This of shredding cum autoclaving;
includes both used, discarded and and sent for final disposal to
contaminated metal sharps iron foundries (having consent to
operate from the State Pollution
Control Boards or Pollution Control
Committees) or sanitary landfill or
designated concrete waste sharp
pit.
BLUE (a) Glassware. Puncture proof, Disinfection (by soaking the
Broken or discarded and contaminated leak proof blue washed glass waste after cleaning
glass including medicine vials and boxes or cardboard with detergent and Sodium
ampoules except those contaminated boxes with blue Hypochlorite treatment) or through
with cytotoxic wastes. colored marking autoclaving or microwaving or
hydroclaving and then sent for
recycling.
(b) Metallic Body Implants. Puncture proof,
leak proof blue
boxes or cardboard
boxes with blue
colored marking

17.4 Management and Handling of BMW in Armed Forces.

The organizational set up of biomedical waste management and its’ brief functions are outlined in the Table 17.3.
Table 17.3 : Organizational Set up of Bio-Medical Waste Mgt in Armed Forces
ORGANIZATIONAL SET-UP
Level Type of Committee Functions
Office of DGAFMS Advisory Committee. (i) To lay down the general policy to be followed for
(i) Chairman: DGHS (AF) implementation of the Rules in the armed forces
(ii) Representative from MOD/D (ii) To assist the DGAFMS in effective mgt of BMW in
(Med) Armed Forces HCEs
(iii) Representative from MOE & F (iii) To meet periodically (once in six months) to
discuss BMW management in the Armed Forces
(iv) Representative from
MOH&FW (iv) To scale, all consumables including chemicals for
management of BMW required at each level
(v) Representative from CPCB
(v) Periodical revision of scales and their
(vi) Member Secretary: Col/Gp
authorization in ME scale
Capt /Surg Capt AFMS (H)

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 WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

ORGANIZATIONAL SET-UP
Level Type of Committee Functions
Office of DGsMS BMW Management Committee. (i) It will assist the DGMS in the implementation
(i) Col Med (Health) or of the BMW Management Rules in the HCEs of the
equivalent in Air Force & Navy /Jt respective service
Dir (Health) or equivalent / Officer (ii) Compile and analyze reports & returns received
detailed by the DGsMS. from commands and ensure timely submission of all
(ii) Two officers designated by the reports and returns to DGAFMS/DG-3A
DGMS. (iii) Disseminate info and instructions pertaining to the
Rules to lower formations
(iv) Ensure implementation of all orders pertaining to
BMW by units under their jurisdiction
Command/ Command: MG (Med)/CMO/PMO (i) Will analyse critically that all the orders pertaining
Corps/Div/ Area/ Commands to BMW are implemented and followed in true spirit
Health Care and (ii) Will inspect BMW Management facilities in all the
Non-Medical Health Care Establishments during technical inspection
Establishment
(iii) Will designate an officer to assist him in effective
implementation of BMW management and handling
rules
Command: Designated Officer by (i) Will assist the MG (Med)/CMO/PMO in the
MG (Med)/CMO/PMO implementation of the BMW management and handling
Rules in the HCEs in the command
(ii) Will visit HCEs at least once a year and will
ensure satisfactory functioning of all equipment
(iii) Will ensure timely submission of all reports and
returns to the service Dte
(iv) Disseminate information pertaining to the Rules to
the lower formations
Health Care BMW Management Committee. (i) Segregation of the waste at source
Establishment (i) Senior Registrar/ Registrar - (ii) Collection storage, labelling, transportation of the
(HCE) O/IC waste to the site of treatment and final disposal
(ii) Specialist Pathology, (iii) Make an inventory of waste; weight wise and
(iii) Principal Matron, category wise
(iv) QM/Adm Offr, (iv) Maintain a record of generation, collection,
reception, storage, tpt, treatment, disposal, handling by
(v) OC SHO/ Specialist in PSM
using appropriate forms and make the same available
(vi) Rep of MES for inspection by the prescribed authority (all data
(vii) JCO I/C sanitation should be provided in Kg).
(Equivalent in Navy and Air Force) (v) Increasing the awareness of the rules amongst all
(viii) Senior most safaiwala/ pers and bring about an Attitudinal and Behavioural
safaiwali change among the HCE staff for observance of
(ix) Any other member as universal precautions and practices on BMW.
deemed necessary (vi) Ensure use of protective clothing
(vii) Ensure education of the health staff and the
handlers by holding courses at least twice a year
(viii) Committee should meet at least once in six
months and minutes submitted with Annual report

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17.5 Bio-Medical Waste Management Rules 2016.

Biomedical Waste (BMW) regulations in India have evolved since 1998, with updates in 2000, 2003 and 2011. The
Ministry of Environment introduced the current rules in March 2016 under the Environment (Protection) Act, 1986. These
rules focus on the proper management of BMW, covering key aspects like characterization, quantification, segregation,
storage, transport and treatment reflecting ongoing efforts to enhance biomedical waste disposal practices in the
country.
(a) Salient Features of Bio-Medical Waste Management Rules, 2016.
(i) The ambit of the rules has been expanded to include vaccination camps, blood donation camps,
surgical camps, first aid rooms in schools or any other healthcare activity.
(ii) Phase-out the use of chlorinated plastic bags, gloves and blood bags.
(iii) Pre-treatment of the laboratory waste, microbiological waste, blood samples and blood bags through
disinfection or sterilisation on-site in the manner as prescribed by WHO or NACO.
(iv) Provide training to all its health care workers and immunise all health workers regularly.
(v) Establish a Bar-Code System for bags or containers containing biomedical waste for disposal.
(vi) Report major accidents.
(vii) Existing incinerators to achieve the standards for retention time in secondary chamber and Dioxin
and Furans. The new rules prescribe more stringent standards for incinerators to reduce the emission of
pollutants in the environment.
(viii) Bio-medical waste has been classified in to 4 categories instead of 10 categories to improve the
segregation of waste at source.
(ix) No occupier shall establish on-site treatment and disposal facility if a service of ‘Common Bio-medical
Waste Treatment Facility’ is available within a distance of seventy-five kilometres.
(x) Operator of a Common Bio-Medical Waste Treatment And Disposal Facility to ensure the timely
collection of bio-medical waste from the HCFs and assist the HCFs in the conduct of training.
(b) BMW Management Rules 2016, does not apply to (As they are covered under different legislations).
(i) Radioactive active waste
(ii) Municipal solid waste
(iii) Hazardous chemicals
(iv) Lead acid batteries
(v) E-waste
(vi) Hazardous microorganisms, genetically engineered microorganisms and cells

17.6 Bio-Medical Waste Management.

The essence of effective Bio-Medical Waste (BMW) management lies in the 3Rs: reduce, recycle and reuse. The focus
is on minimizing waste generation and maximizing recovery, rather than simply disposing of it. The preferred BMW
disposal methods prioritize prevention, reduction, reuse, recycling, recovery, treatment and finally, disposal. Segregation,
collection, pre-treatment, intramural transportation and storage is the exclusive responsibility of HCF. The treatment
and disposal steps are mainly handled by Common Biomedical Waste Treatment Facility (CBWTF) except for lab and
highly infectious waste, which is required to be pretreated by HCF.
(a) Segregation, Packaging of waste.
(i) No Mixing of Untreated Bio-medical Waste.
Untreated bio-medical waste must not be combined with other types of waste.
(ii) Segregation at Point of Generation.
Bio-medical waste should be segregated into containers or bags at the source, following the guidelines as

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given in Table 17.2.

(iii) Labelling of Containers or Bags.
Containers or bags used for bio-medical waste must be labelled according to the specifications.
(iv) Introduction of Bar Code and GPS.
Occupiers and common bio-medical waste treatment facilities are required to add bar codes and global
positioning systems.
(v) Transportation Requirements.
Vehicles used for transporting bio-medical waste must adhere to labelling specifications.
(vi) Compliance with Regulations.
Vehicles transporting bio-medical waste must comply with conditions set by the State Pollution Control
Board or Pollution Control Committee, in addition to Motor Vehicles Act, 1988 and its rules.
(vii) Pre-treatment of Microbiology and Laboratory Waste.
Microbiology and clinical laboratory waste must undergo pre-treatment by sterilization or disinfection following
WHO guidelines before being sent to the common bio-medical waste treatment facility.
(b) Storage.
(i) Time Limit for Storage.
Untreated anatomical and biotechnology waste should not be stored for more than 48 hours. If necessary
to exceed this limit, measures must be taken to prevent adverse effects, with notification to the prescribed
authority.
(ii) Designated Collection Sites.
Large containers with a uniform colour code should be placed at designated kerb sites for collecting waste
bags from wards / departments before final treatment / disposal.
(iii) Storage Area Specifications.
The storage area must have an impermeable, hard-standing floor with good drainage, facilitating easy
cleaning and disinfection. It should be easily accessible for waste collection vehicles.
(iv) Water Supply for Cleaning.
A water supply should be available for cleaning purposes within the storage area.
(v) Security Measures.
The storage area should be easily accessible for staff handling waste and equipped with a proper locking
mechanism to prevent unauthorized access.
(c) Transportation.
(i) Covered Transportation.
Waste is transported from the point of generation to the Kerb Collection Area using covered hand trolleys,
which are properly labeled and exclusively designated for this purpose.
(ii) Protective Measures for Staff.
Designated staff, equipped with protective gear, will carry the labelled trolleys during transportation.
(iii) Responsibility of Treatment Facility Operator.
The operator of the common bio-medical waste treatment facility is responsible for transporting bio-medical
waste from the occupier’s premises.
(iv) Compliance with Regulations.
Vehicles used for transportation must adhere to conditions set by the State Pollution Control Board or

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Pollution Control Committee, in addition to complying with the Motor Vehicles Act, 1988 and its rules for
the transportation of infectious waste.
(d) Treatment and disposal.
(i) Treatment and Disposal Compliance.
Bio-medical waste must be treated and disposed of in accordance with Guidelines for Management of
Healthcare Waste as per Biomedical Waste Management Rules, 2016.
(ii) Safe Storage Provision.
Within the premises, healthcare facilities should designate a safe, ventilated and secure location for the
storage of segregated biomedical waste in coloured bags or containers.
(iii) Handover to Common Treatment Facility.
Occupiers are required to hand over segregated waste, to common bio-medical waste treatment facilities
for processing and final disposal.
(iv) Restriction on On-Site Facilities.
No occupier is allowed to establish on-site treatment and disposal facilities if a common biomedical waste
treatment facility is available within a 75 kilometer distance.
(v) Setting Up Treatment Equipment.
In cases where a common bio-medical waste treatment facility is not available, occupiers must set up the
necessary biomedical waste treatment equipment.
(vi) Approval for New Technologies.
If an occupier intends to use new technologies for the treatment of bio-medical waste not listed in guidelines,
the case must be submitted to the prescribed authority for sanction.
(vii) Recycling of Treated Waste.
Recyclables from treated bio-medical waste, such as plastics and glass, should be given to authorized
recyclers in the vicinity. Records of this activity must be maintained and submitted as part of the annual
report to the prescribed authority.
(viii) Special Treatment for Microbiology and Clinical Laboratory Waste.
Microbiology and clinical laboratory waste must undergo pre-treatment, either by sterilization to Log 6 or
disinfection to Log 4, as per World Health Organization guidelines. Highly infectious bio-medical waste
generated in labs should be pre-treated using equipment like autoclaves or microwaves.
(ix) Handling of Mercury and Lead Waste.
The handling and disposal of all mercury and lead waste must comply with respective rules and regulations.
(x) Deep Burial Disposal.
Deep burial disposal is permitted only in rural or remote areas without access to common bio-medical waste
treatment facilities. Prior approval from the prescribed authority is required and disposal must follow the
standards specified in guidelines.
(e) On-site treatment.
(i) Prohibition of On-Site Treatment.
On-site treatment of biomedical waste is no longer permitted as per the notification. Waste must be
outsourced to common facilities, initiating a gradual shift in BMW management as required by the gazette.
(ii) Exception for Non-Existing CBMWTF.
In areas where a Common Bio-Medical Waste Treatment Facility (CBMWTF) is non-existent within a 75 km
radius, on-site facilities may be installed.

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 WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

(iii) Standards for Treatment Methods.

Standards for various treatment methods such as incineration, plasma pyrolysis or gasification, autoclaving,
microwaving, deep burial, chemical disinfection, dry heat sterilization and liquid waste have been specified.
It is imperative to consistently adhere to these prescribed standards.
(iv) Responsibility of the Occupier/Hospital.
The occupier or hospital is obligated to establish, upgrade and maintain equipment following the specified
standards for on-site treatment.
(v) Exploration of Maintenance Options.
In-house maintenance by Military Engineering Service (MES) staff or third-party maintenance through annual
maintenance contracts should be explored for the upkeep of on-site treatment equipment.

17.7 Implementation of Biomedical Waste Mgt Rules 2016 in Armed Forces.

The Biomedical Waste Management Rules are implemented in the Armed Forces under the aegis of DGAFMS who is
the prescribed authority under the 2016 rules. The Biomedical Waste Management Rules In Armed Forces have been
implemented vide O/o DGAFMS Letter No 354811(d)/ BMW/ DGAFMS/DG-3A dated 10th Dec 2016 & 15th May 2017.
The organizational set up for Biomedical Waste Management in Armed Forces has been described in Table 17.3. The
responsibilities, implementation and submission of reports and returns as per rules in armed forces are outlined below:
(i) Commanding Officer of the HCE is responsible for the implementation of the various provisions under the
rules in his/her establishment. His/her functions are:
(a) To make an application for authorization in Form-II for initial auth and subsequent renewal of auth
to the prescribed auth. (att as Appx B)
(b) To submit Annual Report in Form-IV by 31 Jan each year. To be forwarded through channel to respective
DGsMS. The same is to be consolidated at O/o DGMS and forwarded to O/o DGAFMS.
(c) To report any major accident in his establishment in Form I (att as Appx A).
(d) To appoint a BMW Management Committee.
(e) Procure all consumables required for the system through local purchase under existing procedures,
if the central supply does not materialize.
(f) Authorisation.
Every occupier or operator (CO / Comdt) handling bio-medical waste, irrespective of the quantity shall make
an application in Form II. Bedded Health care est also submit inspection report in duplicate to the prescribed
authority (DGAFMS) for new/ renewal of authorization. Authorization is done on Form - III by O/o DGAFMS.
Authorization is valid for a period of five years. Authorisation for non-bedded occupiers is one time and the
authorisation in such cases is deemed to have been granted, if not objected by the prescribed authority.
Such applications are submitted to respective DGsMS through MG (Med) or equivalent in Navy or Air Force.
The various forms are appended at the end of the Chapter.
(ii) BMW Management Committee.
BMW Mgt committee should be formed in each HCE & function under the supervision of Commanding Officer.
The committee should perform all functions as outlined in the Table 17.3.
(iii) Non-Med Establishments.
The OC unit/Stns will be responsible for implementation of all provisions under the BMW Management Rules.
He/she are assisted by SMO/RMO and equivalent in Navy and Air Force.
(iv) Special points for Armed Forces.
(a) Untreated human anatomical waste, animal anatomical waste, soiled waste and, biotechnology waste
shall not be stored beyond a period of forty-eight hours.
(b) As per the rules no occupier shall establish on-site treatment and disposal facility, if a service of

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common biomedical waste treatment facility is available at a distance of seventy-five kilometer.

(c) Disposal by deep burial is permitted only in rural or remote areas where there is no access to common
bio-medical waste treatment facility. This will be carried out with prior approval from the prescribed authority
and as per the Standards specified in Schedule-III of Biomedical waste management Rules, 2016.
(d) Scaling of Biomedical Equipment.
In places where the CBMWTF are not existing and there is a need to have in-house treatment facility, the
scaling of equipment is governed by DGAFMS–DG-3A policy dated 08th Jul 2003 and 27th Feb 2008.

17.8 Technologies for Waste Treatment.

Some of the technologies being used for waste treatment are as under:
(a) Autoclave.
An autoclave is an instrument, which uses steam at high temperatures
to kill all microbes. There are two types of autoclaves:
(i) Gravity Displacement Autoclaves.
In this system, the air within the autoclave is pushed out by entering
steam. This process has a problem. There may be air pockets left
within the waste, which is being autoclaved. This reduces the
temperature of the waste and therefore reduces the efficiency of
the system.
(ii) Pre-vacuum Autoclaves.
Fig 17.1 : Autoclave
Once the waste is put into the autoclave, a vacuum is created within
the autoclave (all the air from the chamber is removed). Steam,
which enters the chamber, is able to penetrate the entire waste.
Absence of air pockets ensures that high temperature is achieved
within the waste, rendering it harmless (Fig 17.1).
(b) Microwave.
A microwave system uses high-frequency waves. These waves cause the
molecules within the waste material to vibrate. This generates heat from
within the matter itself. The heat generated is high enough to ensure
that all microbes are killed (Fig 17.2).
(c) Chemical Disinfection.
(i) Chemical disinfection is cost-effective and does not require
large investments. In this form of disinfection, a chemical is used
to destroy the pathogens.
(ii) Not all medical waste should be treated in this way. Only Fig 17.2 : Microwave
plastic, rubber and metals should be disinfected. It is not advisable
to chemically disinfect cloth-based medical waste because it is
difficult to handle wet waste and it also adds to the weight and
volume of the waste.

(d) Incineration.
Incineration is the process of burning solids at very high temperature
in a furnace. The temperature in these furnaces is usually high enough
to burn even the metals. The furnace is connected to a cline so that
the smoke does not pollute the surrounding environment (Fig 17.3).
The incineration area must be out of bounds for everyone except those
working there.
Fig 17.3 : Incinerator

425
 WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

(e) Hydroclave.
Hydroclaving is a steam sterilization technology. Hydroclave is a double walled container, in which steam is
injected into the outer jacket to heat the inner chamber containing the waste. Moisture contained in the waste
evaporates as steam and builds up the requisite steam pressure which sterilizes the waste. The waste material
gets dehydrated and reduced in volume.
(f) Plasma Torch Techniques.
The waste is pyrolyzed (heated without air) at temperatures beyond 1,150°C, producing combustible gases and
vitreous or glass like rock substance by deploying plasma technology. The residue is suitable for concrete and
asphalt construction and the gases may serve as a source of energy.

17.9 Biohazard Symbol.

The biohazard symbol to be used as labels on all containers/ bags and vehicles
meant for storage/transportation of BMW is shown in the figure (Fig 17.4).

17.10 Conclusion.
With the recent Gazette Notification, all healthcare facilities are now mandated to
have effective bio-medical waste management and handling facilities aligned with
prescribed standards and schedules. While achieving all standards simultaneously
may be challenging, the focus is on making incremental improvements and
transitioning towards a sustainable system for a healthier environment, both
mentally and physically. It is time that our service hospitals, who are eminently
Fig 17.4 : Biohazard Symbol
known for their high standards of hygiene, good maintenance and excellent
administration, should take a lead in this vital area of health care.

Suggested Reading.
1. Guidelines for Management of Healthcare Waste as per Bio Medical Waste Management Rules, 2016.
2. Ref of DGAFMs policy note No. 3548/1(d)/BMW/DGAFMS/DG-3A dt 10 Dec 2016 ‘guidelines for management
and handling of Bio Medical Waste (BMW) in the Armed Forces.’ and DGAFMs note No. 3548/1(d)/BMW/DGAFMS/
DG-3A dt 21 Aug 2018.
3. DGAFMs note No. 3548/1(d)/DGAFMS/DG-3A dated 11 Sept, 9 Oct & 29 Oct 2019.
4. Environmental Information System,CES,Indian Institute of Science, Bangalore [Internet]. wgbis.ces.iisc.ac.in.
Available from: https://wgbis.ces.iisc.ac.in/
5. Datta P, Mohi G, Chander J. Biomedical waste management in India: Critical appraisal. Journal of Laboratory
Physicians [Internet]. 2018;10(1):6. Available from: http://www.jlponline.org/article.asp?issn=0974-2727;year=2018;vo
lume=10;issue=1;spage=6;epage=14;aulast=Datta
6. Bhalla GS, Bandyopadhyay K, Sahai K. Keeping in pace with the new Biomedical Waste Management Rules:
What we need to know! Medical Journal Armed Forces India. 2019 Jul;75(3):240–5.
7. Kothari R, Sahab S, Singh HM, Singh RP, Singh B, Pathania D, et al. COVID-19 and waste management in Indian
scenario: challenges and possible solutions. Environmental Science and Pollution Research. 2021 Aug 30;28(38):52702–
23.
8. Sheth JK. Salient Features of Bio-Medical Waste Management Rules, 2016. Indian Journal of Community Health.
2017 Mar 31;29(1):05–9. Fundamentals of Immunity. Springer eBooks. 2007 Jan 1;27–38.
9. Padmanabhan KK, Barik D. Health Hazards of Medical Waste and its Disposal. Energy from Toxic Organic Waste
for Heat and Power Generation [Internet]. 2019;99–118.
10. Meet Fatewar, Vaishali. COVID-19: An Opportunity for Smart and Sustainable Cities in India. Springer eBooks.
2021 Jan 1;1–30.
n

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 MANAGEMENT OF BIOMEDICAL WASTE

Appx ‘A’

FORM - I

ACCIDENT REPORTING

1. Date and time of accident :

2. Type of Accident :

3. Sequence of events leading to accident :

4. has the Authority been informed immediately :
5. The type of waste involved in accident :
6. Assessment of the effect of the accidents
on human health and the environment :

7. Emergency measures taken :

8. Steps taken to alleviate the effects of accidents :

9. Steps taken to prevent the recurrence of such an accident :

10. Does you facility has an Emergency Control policy?

If yes give details :

Date : Signature :
Place : Designation :

427
WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

Appx ‘B’

FORM - II
(See rule 10)

APPLICATION FOR AUTHORISATION OR RENEWAL OF AUTHORISATION

(To be submitted by occupier of health care facility or common bio-medical waste treatment facility)

To
The Prescribed Authority (DGAFMS)
1. Date and time of accident :
(i) Name of the Applicant :
(In block letters & in full)
(ii) Name of the health care facility (HCF)
or common bio-medical waste treatment facility (CBWTF) :
(iii) Address for correspondence :
(iv) Tele No., Fax No. :
(v) Email :
(vi) Website Address :
2. Activity for which authorization Is sought

S.No. Activity Please tick

1 Generation, segregation
2 Collection
3 Storage
4 Packaging
5 Reception
6 Transportation
7 Treatment or processing or conversion
8 Recycling
9 Disposal or destruction
10 Use
11 Offering for sale, transfer
12 Any other form of handling
3. Application for fresh/renewal of authorisation (please tick whatever is applicable) :
(i) Applied for CTO/CTE Yes / No
(ii) In case of renewal previous authorisation number and date :
(iii) Status of Consents :
(a) under the Water (Prevention and Control of Pollution) Act, 1974
(b) under the Air (Prevention and Control of Pollution) Act, 1981 :

428
 MANAGEMENT OF BIOMEDICAL WASTE

Appx ‘B’

FORM - II (Contd...)

4. (i) Address of the health care facility (HCF)

(ii) GPS coordinates of health care facility (HCF) or
common bio medical waste treatment facility (CBWTF) :
5. Details of health care facility (HCF) or common bio-medical waste treatment facility
(CBWTF) : (Strike off whichever is not applicable)
(i) Number of beds of HCF :
(ii) Number of patients treated per month by HCF :
(iii) Number healthcare facilities covered by CBMWTF :
(iv) No. of beds covered by CBMWTF :
(v) Installed treatment and disposal capacity of CBMWTF : ____ Kg / day
(vi) Quantity of biomedical waste treated or disposed by CBMWTF : ____ Kg/day
(vii) Area or distance covered by CBMWTF :
(viii) Quantity of Biomedical waste handled, treated or disposed :

Quantity Method of
Category Type of Waste Generated or Treatment and Disposal
Collected, kg/day (Refer Schedule-I)
Yellow (a) Human Anatomical Waste :
(b) Animal Anatomical Waste :
(c) Soiled Waste :
(d) Expired or Discarded Medicines :
(e) Chemical Solid Waste :
(f) Chemical Liquid Waste :
(g) Discarded linen, mattresses, beddings
contaminated with blood or body fluid.
(h) Microbiology, Biotechnology and other
Red Contaminated Waste (Recyclable)
White Waste sharps including Metals :
(Translucent)
Blue Glassware :
Metalic Body Implants

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WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

Appx ‘B’

FORM - II (Contd...)

6. Brief description of arrangements for handling of biomedical waste (attach details) :

(i) Mode of transportation (if any) of bio-medical waste :
(ii) Details of treatment equipment (please give details such as the number, type & capacity of each unit)

S.No. Activity No. of units Capacity of each unit

1 Incinerators
2 Plasma Pyrolysis
3 Autoclaves
4 Microwave
5 Hydroclave
6 Shredder
7 Needle tip cutter or destroyer
8 Sharps encapsulation or concrete pit
9 Deep burial pits
10 Chemical disinfection
11 Any other treatment equipment :

7. Contingency plan of common bio-medical waste treatment facility (CBWTF) (attach documents) : (To be
sought from CBMWTF)
8. Details of directions or notices or legal actions if any during the period of earlier authorization.
9. Declaration
 do hereby declare that the statements made and information give above are true to the best of my
knowledge and belief and that I have not concealed any information.
 do also hereby undertake to provide any further information sought by the prescribed authority in
relation to these rules and to fulfill any conditions stipulated by the prescribed authority.

Date : Signature of CO/Commandant

Place :

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 MANAGEMENT OF BIOMEDICAL WASTE

Appx ‘C’
FORM - III
(See rule 10)
AUTHORISATION
(Authorisation for operating a facility for generation, collection, reception, treatment, storage,
transport and disposal of biomedical wastes)
1. File number of authorisation and date of issue
2. M/s an occupier or operator of the facility located at
is hereby granted an authorisation for;
Activity Please tick
Generation, segregation
Collection,
Storage
Packaging
Reception
Transportation
Treatment or processing or conversion
Recycling
Disposal or destruction
Use
Offering for sale, transfer
Any other form of handling
3. M/s is hereby authorized for handling of
biomedical waste as per the capacity given below;
(i) Number of beds of HCF :
(ii) Number healthcare facilities covered by CBMWTF:
(iii) Installed treatment and disposal capacity: Kg per day
(iv) Area or distance covered by CBMWTF:
(v) Quantity of Biomedical waste handled, treated or disposed :
Type of Waste Category Quantity permitted for Handling
Yellow
Red
White (Translucent)
Blue
4. This authorisation shall be in force for a period of Years from the date of issue.
5. This authorisation is subject to the conditions stated below and to such other conditions as may be
specified in the rules for the time being in force under the Environment (Protection) Act, 1986.
Date : Signature
Place : Designation

Terms and conditions of authorisation*

1. The authorisation shall comply with the provisions of the Environment (Protection) Act, 1986 and the rules made
there under.
2. The authorisation or its renewal shall be produced for inspection at the request of an officer authorised by the
prescribed authority.
3. The person authorized shall not rent, lend, sell, transfer or otherwise transport the biomedical wastes without
obtaining prior permission of the prescribed authority.
4. Any unauthorised change in personnel, equipment or working conditions as mentioned in the application by the
person authorised shall constitute a breach of his authorisation.
5. It is the duty of the authorised person to take prior permission of the prescribed authority to close down the
facility

431
WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

Appx ‘D’

Form - IV
(See rule 13)
ANNUAL REPORT
1. Particulars of the Occupier
Particulars
(i) Name of the authorised person
(occupier or operator of facility)
(ii) Name of HCF or CBMWTF
(iii) Address for Correspondence
(iv) Address of Facility
(v) Tel. No, Fax. No
(v) E-mail ID
(vii) URL of Website
(viii) GPS coordinates of HCF or CBMWTF
(ix) Ownership of HCF or CBMWTF (State Government or
Private or Semi Govt. or any other)
(x) Status of Authorisation under the Authorisation No.:
Bio-Medical Waste
(Management and Valid up to:
Handling) Rules
(xi) Status of Consents under Water Valid up to :
Act and Air Act
Act

2. Type of Health Care Facility

Particulars
(i) Bedded Hospital No. of Beds:.....
(ii) Non-bedded hospital
(Clinic or Blood Bank or Clinical
Laboratory or
Research Institute or Veterinary
Hospital or any other)
(iii) License number and its date of expiry
3. Details of CBMWTF
Particulars
(i) Number healthcare facilities covered by
CBMWTF
(ii) No of beds covered by CBMWTF
(iii) Installed treatment and disposal capacity of
CBMWTF:
(iv) Quantity of biomedical waste treated or
disposed by CBMWTF

432
 MANAGEMENT OF BIOMEDICAL WASTE

Appx ‘D’

Form - IV
(See rule 13)
ANNUAL REPORT (CONTD)
4. Quantity of waste generated or disposed in Kg per Annum (on monthly average basis)
Particulars
(i) Name of the authorised person
(occupier or operator of facility)
(ii) Name of HCF or CBMWTF
(iii) Address for Correspondence
(iv) Address of Facility
(v) Tel. No, Fax. No
(v) E-mail ID
5. Details of the Storage, treatment, transportation, processing and Disposal Facility

(i) Details of the on-site storage Facility Size:

Capacity :
Provision of on-site storage:
(cold storage or any other provision)

(ii) Disposal Type of treatment No of Capacity Quantity

facilities equipment units Kg/day Treated or
disposed in
kg per annum
Incinerators
Plasma Pyrolysis
Autoclaves
Microwave
Hydroclave
Shredder
Needle tip cutter or destroyer
Sharps
encapsulation or concrete pit
Deep burial pits
Chemical disinfection
Any other treatment equipment :

433
WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

Appx ‘D’

Form - IV
(See rule 13)
ANNUAL REPORT (CONTD)

(iii) Quantity of recyclable wastes sold to

authorized recyclers after treatment Red category
in kg per annum.
(iv) No of vehicles used for collection and
transportation of biomedical waste
(v) Details of incineration ash and Quantity Where
ETP sludge generated and generated disposed
disposed during the treatment of
wastes in Kg per annum Incineration
Ash
ETP Sludge
(vi) Name of the Common Bio- Medical
Waste Treatment Facility Operator through
which wastes are disposed of
(vii) List of member HCF not handed over
bio-medical waste.

6 Do you have bio-medical waste management committee? If yes, attach minutes of the meetings held
during the reporting period
7 Details trainings conducted on BMW

(i) Number of trainings conducted on BMW Management

(ii) Number of personnel trained
(iii) Number of personnel trained at the time of induction
(iv) Number of personnel not undergone any training so far
(v) Whether standard manual for training is available?
(vi) Any other information

8 Details of the accident occurred during the year

(i) Number of Accidents occurred
(ii) Number of the persons affected
(iii) Remedial Action taken (Please attach details if any)
(iv) Any Fatality occurred, details.

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 MANAGEMENT OF BIOMEDICAL WASTE

Appx ‘D’

Form - IV
(See rule 13)
ANNUAL REPORT (CONTD)

9. Standards of Air monitoring

Are you meeting the standards of air Pollution from the incinerator? How many times in last year could
not met the standards?

10. Liquid waste

(i) Generated
(ii) Treatment methods in place.
(iii) How many times you have not met the standards in a year?

11. Is the disinfection method or sterilization meeting the log 4 standards? How many times you have not
met the standards in a year?

12. Any other relevant information: (Air Pollution Control Devices attached with the Incinerator)
Certified that the above report is for the period from

Date : Name and Signature

of the Head
Place : of the Institution

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WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

Appx ‘E’

PROFORMA FOR INSPECTION OF HEALTH CARE EST FOR BMW DISPOSAL

1. Particulars
(i) Name of the Institution
(ii) Date of Inspection
2. Activities
(i) Amount of Waste generated (Category wise)

Quantity Method of
Category Type of Waste Generated or Treatment and Disposal
Collected, kg/day (Refer Schedule-I)
Yellow (a) Human Anatomical Waste :
(b) Animal Anatomical Waste :
(c) Soiled Waste :
(d) Expired or Discarded Medicines :
(e) Chemical Solid Waste :
(f) Chemical Liquid Waste :
(g) Discarded linen, mattresses, beddings
contaminated with blood or body fluid.
(h) Microbiology, Biotechnology and other
Red Contaminated Waste (Recyclable)
White Waste sharps including Metals :
(Translucent)
Blue Glassware :
Metalic Body Implants

(ii) Compliance

S.No. Activity Good/Satisfactory/Poor

1. Collection & Storage Availability of
Plastic Bags/buckets
2 Mode of Transportation
3 Knowledge Attitude & Practices among
BMW Handlers

436
 MANAGEMENT OF BIOMEDICAL WASTE

Appx ‘E’

PROFORMA FOR INSPECTION OF HEALTH CARE EST FOR BMW DISPOSAL (CONTD)

(iii) Final Disposal

S.No. Equipment Working/Not working Remarks

1 Incinerators
2 Plasma Pyrolysis
3 Autoclaves
4 Microwave
5 Hydroclave
6 Shredder
7 Needle tip cutter or destroyer
8 Sharps encapsulation or concrete pit
9 Deep burial pits
10 Chemical disinfection
11 Any other treatment equipment:

3. Declaration
I hereby declare that the statements made and information given above is true to the best of
my knowledge and belief and I have not concealed any information.

Dated : Signature of CO/Commandant

437
WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

Appx ‘F’

REPORT OF INSPECTION
1. Particulars
(i) Name of the Institution
(ii) Date of Inspection
2. Activities
(i) Amount of Waste generated (Category wise)

Quantity Method of
Category Type of Waste Generated or Treatment and Disposal
Collected, kg/day (Refer Schedule-I)
Yellow (a) Human Anatomical Waste :
(b) Animal Anatomical Waste :
(c) Soiled Waste :
(d) Expired or Discarded Medicines :
(e) Chemical Solid Waste :
(f) Chemical Liquid Waste :
(g) Discarded linen, mattresses, beddings
contaminated with blood or body fluid.
(h) Microbiology, Biotechnology and other
Red Contaminated Waste (Recyclable)
White Waste sharps including Metals :
(Translucent)
Blue Glassware :
Metalic Body Implants

(ii) Compliance

S.No. Activity Good/Satisfactory/Poor

1. Collection & Storage Availability of
Plastic Bags/buckets
2 Mode of Transportation
3 Knowledge Attitude & Practices among
BMW Handlers

438
 MANAGEMENT OF BIOMEDICAL WASTE

Appx ‘F’

REPORT OF INSPECTION

(iii) Final Disposal

S.No. Equipment Working/Not working Remarks

1 Incinerators
2 Plasma Pyrolysis
3 Autoclaves
4 Microwave
5 Hydroclave
6 Shredder
7 Needle tip cutter or destroyer
8 Sharps encapsulation or concrete pit
9 Deep burial pits
10 Chemical disinfection
11 Any other treatment equipment:

REMARKS OF INSPECTING/VISITING OFFICER

(Strike out whichever is not applicable)
Activities related to Biomedical waste management as illustrated in para 2 of proforma for
inspection of health care establishment for BMW disposal have been VERIFIED and CONCURRED.
OR
Following observations are made regarding Bio-medical waste management disposal
of
(Concerned Health Care Facility)

Dated : Signature and particulars of

Inspecting/visiting officer

439
 Appx ‘G’

BIO MEDICAL WASTE ANNUAL REPORT 2016

1. INFORMATION ON HCFS HAVING CAPTIVE TREATMENT FACILITIES (FOR THE YEAR :)

Total Bio Medical

Name Total installed treatment capacity
Quantity of Bio Medical Waste generation (in Kg/ day) Waste treated
& (in kg/day)
S. (in Kg/day)
address
No. Total Bio Medical
of the Deep Any
HCF Yellow Red Blue White Waste generated Incinerator Autoclave Incinerator
Burial Other
(in kg/day)
Autoclave
Deep Burial
Any Other
WASTE DISPOSAL IN ARMED FORCES ENVIRONMENT

Total

440
 2. INFORMATION ON COMMON BIO MEDICAL WASTE TREATMENT & DISPOSAL FACILITIES (FOR THE YEAR, FOR CBMWTF ONLY)

Total Method of
Name & Name of Total
Quantity Disposal of
address the Total No. Bio
of BMW treated
of the CBWTF Coverage cities/ of Total No. Capacity of treatment Medical
S. GPS collected wastes
with contact area in areas HCFs of beds equipments waste
No. Coordinates from (Incineration
person name Kms covered being covered installed by CBWTFS treated
member /Ash/Sharps
and telephone by covered in Kg/
HCFs (in /Plastics)
No. CBWTF day
kg/day)
Total
installed
Equipment Nos
capacity
(Kg/day)
Incinerator
Plasma
Pyrolysis
Autoclaves
Microwave

441
Hydroclave
Shredder
Sharps
encapsulation
or concrete
pit
Deep burial
pits
Any other
treatment
equipment
l No of vehicle used for collection of Biomedical Waste
l List of HCFs not having membership with the CBWTFs & neighter having captive treatment facilities
l No of training organized by the CBWTF
l No of accidents
(i) Reported
MANAGEMENT OF BIOMEDICAL WASTE

(ii) Remedial measures taken

 NUTRITION AND FOOD SAFETY

Chapter
XVIII
INTRODUCTION TO NUTRITION

18.1 Introduction.
The term “nutrition” is derived from the Latin word nutritic, meaning nourishment. Good nutrition is the foundation
for good health and freedom from disease. Simply defined, the word nutrition is used to refer to the processes
of the intake, digestion and assimilation of nutrients and the application of this knowledge to maintain health
and combat disease. The state of nutrition of troops determines their potential fitness, that is, their capacity to
overcome hardships and diseases. Ill-nourished troops may improve with physical training but would not attain as
high a standard of fitness as well-nourished troops would. If a high incidence of communicable diseases arises
among them, their wastage rate will be greater through an impaired power of recovery. Troops may be called
‘fighting fit’ when their nutrition is optimal, they have positive health, are adequately trained and when all possible
measures against disease have been taken. Unless nutrition is optimal, full benefit from training and minimal
wastage from diseases cannot be expected. Nutrition is also a basic factor in morale; only well-nourished troops
can show vitality and keenness at their highest.
With the modern knowledge of military nutritional science, the aim is not only to prevent starvation and deficiency
diseases but also, at maintaining the highest level of ‘fighting fitness’ as far as possible and this can be assured
by optimal nutrition. In actual practice, the benefits that diets of the best quality can produce are not always
immediately obvious. Nutritional shortcomings do not usually cause immediate apparent defects in health, but
slowly and surely impair reserves of stamina and vitality. This fact may be demonstrated in battle with considerable
embarrassment. With a recruit it is necessary that the greatest possible improvement in physique be made in the
shortest possible period. There is a difference between being ‘fit to fight’ and being ‘fighting fit’.
Under normal conditions, maintenance of adequate nutrition can be attained to a large extent automatically by
the provision of rations in accordance with well-designed ration scales and of suitable facilities for messing. In
war, however, conditions are often more or less abnormal in these aspects. Expansion of armies may require
enrolment of men with poor constitution necessitating special feeding to make them fit; shortage of food may
necessitate the modification of normal ration scales; limited logistics may result in failure to supply rations up to
the authorized scales; consideration of climate and distance may make impossible the use of certain valuable
but perishable foods; tactics may dictate the use of rations not exceeding a given weight and bulk; the unusual
physical stress or exposure to diseases may cause important changes in nutritional requirements. Unless these
difficulties are tackled effectively and, on a sound, nutritional basis, the fighting fitness of troops will be impaired,
possibly to a degree, which will jeopardize the success of operations.

18.2 Dietary Standards.

There are occasions when rations and food supplies are to be planned for general community and groups such as
soldiers, school or prison. For such planning, we must have a set of standard dietary allowances or intakes that are
universally acceptable and followed. The first such example (for cereals) can be traced back to ancient Rome. The
Romans gave their legionaries (soldiers) ration of one “librum” of wheat / day to meet their caloric requirement for a
day. The “librum” became the British pound (abbreviated to and still used as “lb”). One pound of cereal is now known
to be good enough to provide energy needed for an adult man for resting metabolism. In India, we have been using the
concept of Recommended Dietary Allowance (RDA) values nutrient vise as given by National Institute of Nutrition (NIN)
for planning food supplies for general community. However, in 2020 Expert Group of Indian Council of Medical Research
(ICMR), NIN gave Estimated Average Requirement (EAR) values for nutrients for Indians, which were revised in 2024.

18.3 Concept of Recommended Dietary Allowance (RDA) and Estimated Average Requirement (EAR).
The nutrient intake in a population follows a normal distribution curve. The median of this distribution is called EAR which
is the nutrient requirement used in public health nutrition, to evaluate the nutrient intakes of a population. Second, the

442
 INTRODUCTION TO NUTRITION

97.5th percentile of the distribution is called the RDA. Further RDA is an estimate that corresponds to mean intake of
the given nutrient + 2 Standard Deviation (SD) and, hence, it covers the requirement of 97.5% of the population. This
is the safe level of intake and the chance of this level being inadequate is not more than 2.5%.
EAR is the amount of a nutrient that is estimated to meet the requirement for a specific criterion of adequacy of half
of the healthy individuals of a specific age, sex and life-stage. EAR is not useful as an estimate of nutrient adequacy
in an individual, because it is a mean requirement for a group and the variation around this number is considerable.
RDA refers to the daily dietary nutrient intake level that is sufficient to meet the nutrient requirements of nearly all
(97-98%) healthy individuals in a particular life stage and gender group. This is derived from EAR as the mean plus two
SD of the distribution of requirements. The term is used to primarily evaluate individual diets. The RDA is inappropriate
for dietary assessment of groups as it is intake level that exceeds the requirements of a large proportion of individuals
within the group. RDA is sufficient for the maintenance of health in nearly all people. In other words, these are estimates
of nutrient intakes, which individuals in a population group need to consume to ensure that their physiological needs
are met. The RDA defines nutrient distribution and requirements for normal individuals of all age groups of Indian
population. A fundamental part of defining nutrient requirements is that the requirement is not the same in all people.
It can vary considerably in healthy individuals. In order to derive a single value for the requirement, two features of
this distribution of requirements are used. The RDA is for healthy individuals and may be prescribed to satisfy the
nutritional needs of specific nutrients in a specific life stage and gender group and ensures that there is a very small
risk of the nutrient intake being inadequate. With the RDA, there is also the risk of excess intake, since everyone may
not actually require that much. There is no need to consume higher doses on regular basis or for prolonged period
without supervision. As per ICMR, EAR should be used for evaluating population nutrient intake and the RDA for setting
the safe nutrient intake for an individual.RDA and EAR have been described in Fig 18.1:
EAR RDA
Proportion of people

Daily nutrient requirement

Fig 18.1 : Graph Explaining the Difference between RDA and EAR
The RDA and EAR for Indians as recommended by expert group ICMR, NIN 2024 are given in Table 18.1.

18.4 Proteins.
(a) General.
Proteins are macromolecules consisting of amino acid chains united by peptide linkages. In adults, approximately
16% of body weight is attributable to proteins. Next to water, proteins are the major component of body tissues.
They are indispensable constituents of living protoplasm as they participate in all vital processes. Twenty-two amino
acids are now known to be physiologically important for our body. Under proper conditions, the body is capable of
synthesizing some of these amino acids (non-essential amino acids). Others cannot be synthesized by our body and
must, therefore, be supplied in diet. These are the eight “essential amino acids,” namely, leucine, isoleucine, lysine,
valine, methionine, threonine, tryptophan and phenylalanine. To these may be added histidine, which appears to be
essential for infant growth. The cereal-legume-milk composition of the diet as per latest ICMR guidelines is 3:1:2.5.
The main sources of proteins are animal sources (eggs, milk, meat and fish) and vegetable sources (pulses, nuts,
cereals, beans and oilseed cakes). Sources of proteins are listed in Table 18.2.

443
 Table 18.1: Summary of RDA for Indians-ICMR-NIN, 2024
(Source: RDA and EAR, Report of Expert Group, NIN (ICMR) 2020, updated 2024)

Vit C
Vit A
Vit D

Work
Folate

Iodine
Vit B6

Niacin
(IU / d)

Protein
Dietary
Vit B12

(mg / d)
(mg / d)
(mg / d)
(mg / d)
(mg / d)
(mg / d)
(mg / d)
(mg / d)
(mg / d)
(mg / d)
(mg / d)

Calcium
Thiamine
Riboflavin

(g / kg / d)

Age Group
Category of
Magnesium
Iron (mg / d)

Body wt (kg)
Fiber* (g / d)
Zinc (mg  /  d)
Sed 30 1.4 2.0 14 1.9
NUTRITION AND FOOD SAFETY

Men Mod 65 0.83 40 1,000 440 19 17 140 1.8 2.5 18 2.4 300 2.2 80 1000 600
Heavy 50 2.3 3.2 23 3.1
Sed 25 1.4 1.9 11 1.9
Women Mod 55 0.83 30 1,000 370 29 13.2 140 1.7 2.4 14 1.9 220 2.2 65 840 600
Heavy 40 2.2 3.1 18 2.4
10.33
Pregnant 55+ (1st trimester)
- 1,000 440 27 14.5 220 2.0 2.7 13 2.3 570 2.45 80 900 600
women 10 22.83
(3rd trimester)
Lactation

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17.83
0-6 mths - 1,200 400 23 14.1 280 2.0 2.7 13 2.3 570 2.45 80 900 600
13.83
7-12 mths
Infants 0-6 mths* 5.8 1.40 - 300 30 - - 100 0.2 0.4 2 0.1 25 1.2 20 350 400

7-12 mths 8.5 1.23 - 300 75 3 2.5 130 0.4 0.6 5 0.6 85 1.2 30 350 400

Children 1-3 years 12.9 0.97 15 500 90 8 3.3 90 0.7 1.1 7 0.9 120 1.2 30 390 600

4-6 years 18.3 0.87 20 550 125 11 4.5 90 0.9 1.3 9 1.2 135 2.2 35 510 600
7-9 years 25.3 0.92 26 650 175 15 5.9 90 1.1 1.6 11 1.5 170 2.2 45 630 600
Boys 10-12 years 34.9 0.91 33 850 240 16 8.5 100 1.5 2.1 15 2.0 220 2.2 55 770 600
Girls 10-12 years 36.4 0.90 30 850 250 28 8.5 100 1.4 1.9 14 1.9 225 2.2 50 790 600
Boys 13-15 years 50.5 0.89 43 1,000 345 22 14.3 140 1.9 2.7 19 2.6 285 2.2 70 930 600
Girls 13-15 years 49.6 0.87 36 1,000 340 30 12.8 140 1.6 2.2 16 2.2 245 2.2 65 890 600
Boys 16-18 years 64.4 0.86 50 1,050 440 26 17.6 140 2.2 3.1 22 3.0 340 2.2 85 1000 600
Girls 16-18 years 55.7 0.83 38 1,050 380 32 14.2 140 1.7 2.3 17 2.3 270 2.2 70 860 600
 INTRODUCTION TO NUTRITION

Table 18.2 : Major Sources of Proteins and Their Protein Contents (g / 100 g)
Animal Sources Protein Content (g) Vegetable Sources Protein Content (g)
Eggs 13.3 Soya bean 43.2
Milk (cow) 3.2 Groundnuts 25.3
Meat (goat, lean) 21.4 Wheat flour 12.1
Fish (Hilsa) 21.8 Rice (Raw, milled) 6.8
Pulses (Red gram) 22.3
Almonds 21
(b) Digestion and Absorption.
After ingestion, dietary proteins are acted upon by proteolytic enzymes (pepsin, trypsin and chymotrypsin) in the
gastrointestinal tract (GI) and broken down into amino acids. These amino acids are absorbed from the lower
duodenum and jejunum and are used for tissue synthesis or formation of enzymes, certain hormones and other
proteins.
(c) Important Functions of Proteins.
(i) Body building, growth, repair and maintenance of body tissues.
(ii) Synthesis of plasma proteins, hemoglobin, enzymes, hormones and antibodies.
(iii) Synthesis of structural proteins such as collagen, actin and myosin to form skin and muscle.
(iv) Act as transport carriers for molecules such as iron, hemoglobin and lipids.
(v) Involvement in the acute phase of inflammation.
(vi) Action of albumin as a buffer in the maintenance of blood pH.
(d) Quality.
The nutritive value of a protein depends upon its amino acid composition. A biologically complete protein is one
that contains all the Essential Amino Acids (EAA) in adequate amounts to meet human requirements. Since animal
proteins contain all EAA, they are biologically superior to plant proteins. Plant proteins lack one or more amino
acid and are thus classified as biologically incomplete or inferior. The EAA that is in shortest supply in each food
item is known as the limiting amino acid; for example, the limiting amino acid in wheat is lysine and in pulses
is methionine. The quality of proteins in a vegetarian diet can be improved by providing a suitable combination
of plant proteins. Relative lack of a particular amino acid in one protein can be compensated by simultaneous
consumption of another protein, which contains that limiting amino acid. This is known as supplementary action.
Thus, a diet combining wheat products such as bread (Chapati) with pulses (Dal) will compensate for these
deficiencies (of lysine and methionine) and provide all the EAA. Other examples from Indian diet are Idli-Sambhar,
Dal-Wada and Pav, rice-dal and Khichri, etc.
(e) Quantifying Protein Quality.
The quality of a protein depends upon its amino acid composition. A protein containing all amino acids is
considered “ideal.” Egg protein is taken as the reference protein. There are various indices available for estimating
the quality of protein, namely, biological value, digestibility coefficient, net protein utilization and protein efficiency
ratio. The working formulae for each of these parameters are given below.
Nitrogen retained.
(i) Biological value (BV) = x 100
Nitrogen absorbed.
Nitrogen absorbed.
(ii) Digestibility coefficient = x 100
Nitrogen intake
Nitrogen retained.
(iii) Net protein utilization (NPU) = x 100
Nitrogen intake

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Weight gain in g
(iv) Protein efficiency ratio (PER) = x 100
Protein intake in g

(f) Net Protein Utilization (NPU).

The Net Protein Utilization (NPU) is the most used parameter. Protein with an NPU of more than 65 is of optimum
quality. Egg protein is considered to have an NPU of 100 and is considered ideal or reference protein against
which other proteins are compared. The Report of the expert Group of ICMR, NIN 2024 has used Digestible
Indispensable Amino Acid Score (DIAAS), which is based on true ileal digestibility of individual amino acids.
(g) RDA and EAR of Proteins.
It is generally accepted to be 0.83 g / kg / day for adults assuming NPU of 65 for most Indian foods. So, the RDA
for a reference adult male works out to 54 g / day and for a reference adult female it is 46 g / day. The EAR of
proteins for reference Indian male and female is 43 gm and 36 gm respectively. RDA and EAR for different age
groups is as given in Table 18.3.
Table 18.3 : RDA and EAR for Proteins
(Source: RDA and EAR, Report of Expert Group, NIN (ICMR) 2020, updated 2024)
Reference Body #EAR #RDA *EAR *RDA TULS
Groups
Weight (Kg) (g / d) (g / d) (g / kg / d) (g / kg / d) (PE Ratio)
Adult men Sedentary 65 43 54 0.66 0.83 < 40%
Moderate < 40%
Heavy work < 40%
Adult Sedentary 55 36 46 0.66 0.83 < 40%
women
Moderate < 40%
Heavy work < 40%
Pregnant 2nd Trimester 55 + GWG 44 55.5 0.66 (additional 0.83 (additional < 30%
women 7.6 g / day) 9.5 g / day)
3rd Trimester 54 68 0.66 (additional 0.83 (additional < 30%
17.6 gm / day) 22 g / day)
Lactating 0-6 months 55 50 63 0.66 (additional 0.83 (additional < 40%
women 13.6 g / day) 17 g / day)
6-12 months 47 59 0.66 (additional 0.83 (additional < 40%
10.6 g / day) 13 g / day)
Infants 0-6 months 5.8 7 8 1.16 1.4 < 15%
6-12 months 8.5 9 10.5 1.04 1.23 < 15%
Children 1-3 y 12.9 10 12.5 0.79 0.97 < 15%
4-6 y 18.3 13 16 0.70 0.87 < 15%
7-9 y 25.3 19 23 0.75 0.92 < 15%
Boys 10-12 y 34.9 26 32 0.75 0.91 < 15%
Girls 10-12 y 36.4 27 33 0.73 0.90 < 15%
Boys 13-15 y 50.5 36 45 0.72 0.89 < 15%
Girls 13-15 y 49.6 35 43 0.70 0.87 < 15%
Boys 16-18 y 64.4 45 55 0.70 0.86 < 15%
Girls 16-18 y 55.7 37 46 0.66 0.83 < 15%

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* For people consuming cereal-based diet with low quality protein, the protein requirements are 1 kg per day.
# Total protein required per day for 55 kg body weights are given in column 3. For specific body weight one can
calculate from EAR column* that provides protein requirement for per kg body weight.
$ Tolerable Upper Limits (TUL) indicates < 15-40% of total energy from proteins.
*EAR: Pregnant women (during 2nd & 3rd Trimester) and lactating women (during 0-6 & 6-12 months) should additionally
take 7.6 gm & 17.6 gm and 13.6 gm & 10.6 gm of protein per day respectively.
*RDA: Pregnant women (during 2nd & 3rd Trimester) and lactating women (during 0-6 & 6-12 months) should additionally
take 9.5 gm & 22 gm and 17 gm & 13 gm of protein per day respectively. Additional protein recommendation of protein
is for 10 kg gestational weight gain (GWG)
(h) Assessment of the protein nutrition status can be done by measuring arm circumference, creatinine height
index, serum albumin, serum transferrin, total body nitrogen, etc. Deficiency of proteins can occur when diet does
not provide enough protein vis-a-vis requirement, which may be high as in the case of young growing children.
If energy intake is insufficient, proteins will be diverted to produce energy causing a deficiency of proteins.
Childhood infections (especially measles) also play an important role in triggering and sustaining a long-term
protein deficiency.

18.5 Fats.
(a) General.
Fats are organic compounds, insoluble in polar solvents (water) but soluble in organic solvents such as ether,
chloroform and benzene. These are actual or potential esters of fatty acids. Fats are only distinguished from
oils by their different melting points; fats are solid and oils are liquid at room temperature. “Oils” are the ones
which the housewife buys and “lipid” (Greek, lipos meaning fat) is the term used by biochemists. However, the
general term fat is commonly used to refer to the whole group and is used interchangeably with lipids. Fats can
be classified into simple lipids (triglycerides), compound lipids (phospholipids) and derived lipids (cholesterol).
They are the most important single dietary component responsible for heart disease. Excess intake of fats has
been linked to an increase in the risk of Cardio Vascular Diseases (CVDs). The animal sources of fat include milk
and milk products (ghee, butter), lard, egg and fish oils. Animal fats, in general, are poor sources of Essential
Fatty Acids (EFA) except for certain marine fish oils, such as cod liver oil and sardine oil, but they are good
sources of retinol and cholecalciferol. The vegetable sources include various edible oils, such as groundnut,
gingelly, mustard, cottonseed, safflower, rapeseed, palm and coconut oils. Vegetable oils, except for coconut oil
and red palm oil, are rich in EFA, but they lack retinol and cholecalciferol (except red palm oil, which is rich in
carotenoids). Fat content in various food items is as given in Table 18.4.
Table 18.4 : Fat Content in Various Food Sources
Animal Sources Fat Content (g / 100 g) Vegetable Sources Fat Content (g / 100 g)
Egg (hen) 13.3 Groundnut 40.1
Milk (cow) 4.1 Mustard seeds 39.7
Meat (goat, lean) 3.6 Coconut, fresh 41.6
Fish (Hilsa) 19.4 Sunflower seeds 52.1
Ghee 100 Butter 81.0
(b) Visible and Invisible Fats.
Animal fats, for example, butter or ghee and plant (vegetable) oils such as groundnut, mustard, coconut, sunflower
or safflower seeds are generally considered visible fats. Hydrogenated oils and margarine are also visible oils.
These are the major sources of fats in our diet and are used for cooking and flavoring. Chemically, they are
triglycerides of fatty acids and could be saturated or unsaturated. Some amount of fat is present in all foods
such as cereals, pulses, oilseeds, nuts, milk, eggs and meat. This fat is not apparent and is thus known as
“invisible fat.” The “staple” cereals and pulses, which might be poor in absolute fat content, contribute significantly
toward invisible fat intake, as they are consumed in large quantities. Invisible fats account for 20–50% of all fat
consumed. They also contribute substantially to our EFA intake.

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(c) Fatty Acids.

Fats are esters of fatty acids. Fats can be either saturated or unsaturated. A fatty acid with hydrogen atoms on
every arm is said to be “saturated. “Unsaturated fatty acids contain double bonds where there is no hydrogen. If
there is only one double bond, it is termed monounsaturated acid and if more than one double bond is present,
it is termed polyunsaturated acid.
(i) Saturated Fatty Acids (SFAs).
SFAs have relatively high melting points and tend to be solid at room temperature. These are obtained from
animal fats, for example, meat fat, lard, milk, butter, cheese or cream. Plant fats tend to be unsaturated
(exceptions are coconut oil and palm oil). A high intake of SFAs is associated with increase in Low Density
Lipoproteins (LDL) and total cholesterol and thus increased risk of atherogenesis and CVD. Some examples
of SFAs are myristic, palmitic and stearic acids.
(ii) Monounsaturated Fatty Acids (MUFAs).
MUFAs contain only one double bond and are usually liquid (oil) at room temperature. Olive oil and rapeseed
oil are good dietary sources of MUFA. MUFAs are also present in meat fat and lard. Dietary MUFAs do not
raise plasma cholesterol. They lower LDL cholesterol without affecting high density lipoproteins. Oleic acid
is an example of MUFA.
(iii) Polyunsaturated Fatty Acids (PUFAs).
PUFAs contain two or more double bonds and are liquid at room temperature. They are involved in the
metabolism of cholesterol, are components of phospholipids in cell membranes and are precursors of
prostaglandins, interleukins and thromboxane. They have a vital role in immune response, blood clotting
and inflammation. PUFAs are divided into omega-3 (w3) or omega 6 (w6) groups. Omega-3 (w3) PUFAs
are found in fish and fish oils. The health benefits of these include reduction in the cardiovascular risk.
Research also indicates their beneficial role in cognitive function of brain. Some common omega-3 fatty
acids are alpha linolenic acid (linseed, soybean, rapeseed and leafy vegetables), eicosapentaenoic acid
(marine algae and fish oils) and docosahexaenoic acid (fish oils).
(iv) Trans-Fatty Acids (t-FAs).
When oil is heated over and over again, as happens during the process of frying, partial hydrogenation of
PUFA takes place, resulting in the formation of t-FAs. Consumption of t-FAs increases the risk of coronary
heart disease as these adversely affect the lipoprotein status by elevating LDL and depressing HDL. t-FAs
rarely occur in nature.
(v) Essential Fatty Acids (EFAs).
If fats are entirely excluded from diet, retarded growth, dermatitis, kidney lesions and an early death might
result. Studies have shown that feeding of certain unsaturated fatty acids, for example, linoleic and linolenic
acids, is effective in curing the condition. It is, therefore, evident that certain unsaturated fatty acids cannot
be synthesized in the body and must be acquired from diet. These are essential fatty acids. EFAs are
commonly found in plant and fish oils. Deficiency of linoleic acid has been demonstrated in children. The
EFA requirement is 3–6% of the total energy intake, depending on the age and physiological status of an
individual. The fatty acid content of different fats is given in Table 18.5.
Table 18.5 : Approximate Fatty Acid Contents of Common Oils (g / 100 g)
Mono
Predominant
Oil / Fat Saturated Unsaturated Linoleic Acid Linolenic Acid
Fatty Acid
Fatty Acid
Coconut 90 7 2 < 0.5 SFA
Palm kernel 82 15 2 < 0.5 SFA
Ghee 65 32 2 < 1.0 SFA
Vanaspati 24 19 3 < 0.5 SFA (t-FA)

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Mono
Predominant
Oil / Fat Saturated Unsaturated Linoleic Acid Linolenic Acid
Fatty Acid
Fatty Acid
Red palm oil 50 40 9 < 0.5 SFA + MUFA
Palm oil 45 44 10 < 0.5 SFA + MUFA
Olive 14 73 11 < 0.5 MUFA
Groundnut 19 41 32 < 0.5 MUFA
Rapeseed / mustard seed 8 70 12 10 MUFA
Sesame 15 42 42 1.0 MUFA + PUFA
Rice bran 22 41 35 1.5 MUFA + PUFA
Cottonseed 22 25 52 1.0 PUFA
Corn 12 32 55 1.0 PUFA
Sunflower 13 27 60 < 0.5 PUFA
Safflower 13 17 70 < 0.5 PUFA
Soybean 14 24 53 7 PUFA
(d) Functions of Fats.
(i) Fats are concentrated sources of energy, providing about 37.7 kJ / g or 9 kcal / g.
(ii) They serve as a vehicle for fat-soluble vitamins (A, D, E and K).
(iii) Fats are structural components of cell and cell membrane.
(iv) They improve palatability of diet, delay gastric emptying and raise caloric density.
(v) Some fats can be converted to steroid hormones, interleukins, thromboxane, prostaglandins and bile
acids (from cholesterol).
(e) Daily Intake.
An upper limit of visible fat intake for sedentary, moderate and heavy activity has been set at 25, 30 and
40 g / d for adult man and 20, 25 and 30 g / d for adult women for pregnant and lactating women, it is 30
grams. Growing children need 22–35 grams of visible fat / day in the diet. The energy provided by fats in the
diet should not exceed 30% (preferably not more than 20%) of total calories consumed. The dietary cholesterol
should be limited to 300 mg / day (preferably to 200 mg / day). Recommendations for dietary fat intake are
given in Table 18.6.
(f) Hazards of Excess Fat in Diet.
Excess fat could be hazardous on two counts either by consumption of fats in a quantity higher than what is
required and / or consumption of wrong quality fats.
(i) Quantity of Fat.
High fat intake leads to obesity and many other lifestyle diseases. A high level of fat in diet is notorious in
the causation of atherosclerosis, a major risk factor for Cardio Vascular Diseases (CVDs). Any amount that
contributes to more than 30% of the total calorie intake is considered high.
(ii) Quality of Fat.
High levels of SFAs are more dangerous. A proportionately higher content of PUFA is found to be protective
for CVD. Unfavorable levels of certain lipoproteins have adverse effects on health. High levels of LDL are
associated with higher atherosclerotic risk, so LDL is colloquially known as “bad cholesterol.” A high level
of HDL has a favorable effect on the cardiovascular system and is termed “good cholesterol.” To minimize
trans fats in diet all foods prepared in Partially Hydrogenated Vegetable Oil (PHVO) like processed, premix,

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ready to eat and fast foods should be avoided. To increase MUFA and PUFAs whole nuts may be consumed
keeping total energy and fat content within recommended limits. Examples of foods which can be consumed
to increase w-3 PUFA are flax seeds, walnuts, soyabean and mustard seeds. Individuals / populations who
do not consume fish should achieve higher intake of ALA. Marine microalgae are vegetarian sources of w-3
PUFA.
Table 18.6 : Recommendations of Dietary Fat Intake in Indians
(Source: RDA and EAR, Report of Expert Group, NIN (ICMR) 2020, updated 2024)
Minimum Level* of Added or
Gender / Age / Physical Activity Minimum Level fat (%E) from Foods Visible Fat
Physiological Groups Level of Total Fat (%E) (Excluding Fats / Oils
Used for Cooking) %E g/p/d

Sedentary 25
Adult men >18 years Moderate 20 15 15 30
Heavy 40
Sedentary 20
Adult women >18 years Moderate 20 15 15 25
Heavy 30
Pregnant women - 15 30
20 15
Lactating women 15 30
Infants -
40-60 Human Milk
0-6 months
6-24 months - 35 15 20 25
Children -
25
3-6 years
7-9 years - 30
Boys -
35
10-12 years
13-15 years - 25 15 15 45
16-18 years - 50
Girls -
35
10-12 years
13-15 years - 40
16-18 years - 35
*if diet provides higher than 10%E from fat, visible fat requirement proportionately reduces.

18.6 Carbohydrates.
Carbohydrates are the basic (first-line) fuel on which life runs. They are primarily obtained from plant sources. Plants
manufacture carbohydrates through the process of photosynthesis. However, a limited amount of carbohydrates is also
available in our food from animal sources, such as lactose present in milk as animals can convert proteins and fats
into carbohydrates and store it.
(a) Classification.
From the functional point of view, carbohydrates can be divided into two categories:

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(i) Available Carbohydrates.

These are carbohydrates, which can be digested in the upper GI tract, absorbed and utilized. These are further
subclassified into monosaccharides, disaccharides and polysaccharides (the word “saccharide” is derived from
the Latin word “Saccharum,” meaning “sugar”).
(aa) Monosaccharides include carbohydrates such as glucose, fructose and galactose.
(ab) Disaccharides include carbohydrates such as lactose, sucrose and maltose.
(ac) Polysaccharides include carbohydrates such as starch, dextrin and glycogen.
(ii) Dietary Fibre.
The second category comprises unavailable carbohydrates or dietary fiber, which are difficult to digest.
These are cellulose, hemicellulose, gums, pectin, etc.
(b) Sources.
The major source of dietary carbohydrates is starch from cereal grains, millets, legumes, roots and tubers (see Table
18.7). With increasing prosperity, sugar has replaced complex carbohydrates. The presence of monosaccharides is
limited to fruits and vegetables; otherwise, they are not abundant in natural foods. Fructose is found in honey, fruits
and vegetables. Sucrose and lactose are the commonest disaccharides. Sucrose is extracted from sugar cane. Table
sugar is 99% sucrose. Sucrose gets hydrolyzed into glucose and fructose. Lactose is found in milk. It is hydrolyzed to
glucose and galactose. Maltose is present in malted wheat and barley. Other sources are nuts and seeds.
Table 18.7 : Major Sources of Carbohydrates (Per 100 g)
Food Stuff Carbohydrates (g) Food Stuff Carbohydrates (g)
Cereals and Millets Pulses and Legumes
Wheat flour 69.4 Bengal gram 60.9
Rice polished 78.2 Soya bean 20.9
Bajra 67.5 Rajmah 60.6
Maize dry 66.2 Red gram 57.6
(Arhar)
Ragi 72.0 Pea dry 56.5
Fruits and Vegetables Miscellaneous
Banana 27.2 Groundnut 4.4
Apple 13.4 Milk 26.1
Mango 16.9 Cashew nut 22.3
Raisins 74.6 Coconut 13
Tapioca 38.1 Jaggery 95
Sweet potato 28.2 Sugar 99.4
Potato 22.6 Honey 79.5
(c) Digestion and Basic Metabolism.
Polysaccharides and disaccharides are hydrolyzed by the action of enzymes into monosaccharides and absorbed
from the small intestine to be transported to liver via portal circulation, where galactose is converted into glucose.
The absorbed glucose may be utilized directly for providing energy to tissues, temporarily stored in the form of
glycogen in liver and muscles or else, it may be converted into fat and stored.
(d) Functions.
Carbohydrates are the most significant and cheapest source of energy. One gram of carbohydrate provides

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4 kcal of energy. Carbohydrates provide 60–85% of energy in Indian diet. Various kinds of sugars (glucose,
fructose, sucrose, etc.), literally, impart sweet taste to life. Carbohydrates play an important role wherein glycogen
resources in the muscles and liver are in a state of dynamic exchange with the energy balance (of intake and
expenditure) through the liver. A constant supply of carbohydrates has a protein sparing action and proteins are
not required to be broken down for energy. Similarly, fats are also spared. The brain exclusively uses glucose
and is dependent on its constant supply for its functioning. Fiber is also a carbohydrate. It has the important
function of increasing faecal bulk, stimulating peristalsis and blocking cholesterol synthesis in liver.
(e) Requirement of Carbohydrates.
A minimum intake of 100-130 g of carbohydrates / day should be ensured for ages 1 year and above. This level
is the minimum required for brain glucose utilization.
(f) Problems due to Deficiency and Excess.
Whenever there is a deficiency of carbohydrates in diet, which is not compensated by other nutrients, energy
deficiency sets in. This is typically seen in children with protein calorie malnutrition. A similar situation results in
food-deprived people during starvation (famines and droughts). A very low carbohydrate diet results in utilization
of other macronutrients (lipids and proteins) for energy and may result in ketosis. Consumption of excess
carbohydrates and accumulation of excessive calories lead to obesity and contribute to lifestyle diseases (CVD,
Diabetes, etc.).
(g) Glycemic Index.
The glycemic index of a food is defined as the area under 2-hour blood glucose response curve following ingestion
of a fixed proportion of test carbohydrate (usually 50 g) as proportion (%) of the standard (either glucose or
white bread) as shown in figure 18.2 below. It is classified into low GI (55 or less—most fruit and vegetables,
except potatoes, watermelon, sweet corn), medium GI (56–69—sucrose, basmati rice, brown rice) or high (70 or
more—cornflakes, baked potato, white bread, syrupy foods). The application of GI is done in menu planning. This
is especially required while meal planning of patients with Type I Diabetes who are on insulin therapy. For those
with Type 2 Diabetes, meal planning with the GI involves choosing foods that have a low or medium GI. If one
is eating a food with a high GI, it should be combined with low GI foods to help balance the meal, for example,
rice and dal. Meat and fats do not have a GI because they do not contain carbohydrates. Fat and fibre in a diet
tend to lower the GI of a food. The drawback of GI is that it represents only the type of carbohydrate in a food
and not the amount of carbohydrate typically eaten. Hence, it is always important to tell the quantity of food
item to be consumed while counselling patients on diabetes or those planning to lose weight.

High GI (Rapidly digested or

absorbed carbohydrates)
Blood
glucose
levels

Low GI (Slowly digested or

absorbed)

1 2
Time (h)

Fig 18.2 : Blood Glucose Levels Based on Gi of Food Items

18.7 Dietary Fibers.

Dietary fibres are the remnants of plant cell, are resistant to hydrolysis by alimentary enzymes and do not provide
significant nourishment. They remain in the ileum but are partially hydrolysed by the colonic bacteria. It has been clearly

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shown that unrefined complex carbohydrates in the form of “dietary fibre” protect against ailments as colonic cancer,
diverticular disease, appendicitis, constipation, haemorrhoids, hiatus hernia, varicose veins, diabetes, heart disease,
gallstones and obesity.
(a) Classification.
Fibers can be classified based on their solubility into “soluble” and “insoluble” fibers.
(i) Insoluble Fibers.
They consist of cellulose, hemicellulose and lignin. Since they remain undigested in gut, they form bulk
and help in movement of food and peristalsis. After absorption of water, fibre swells up and facilitates the
gut movement, helping in elimination of waste products.
(ii) Soluble Fibers.
They are the natural gel-forming fibers such as pectin, gums and mucilages.
(b) Sources.
The important sources of fibre are summarized in Table 18.8.
Table 18.8 : Major Food Sources of Fiber
Insoluble Fibers Soluble Fibers
Vegetables: Peas, beans, amaranth leaves Citrus fruits: Orange, lime
Cereals: Rye, bran flakes, brown rice, corn, whole wheat Berries: Strawberry, raspberry
Whole meal cereals: Dalia, whole meal flour, ragi porridge Other fruits: Figs, grapes, guava,
pomegranate, sapota, custard apple
Breads: Granary bread, brown bread
Legumes: Bengal gram (whole), lentils, pulses, dals
Sprouts: Sprouted grains, legumes
Fruits: Fruits with edible seeds, such as guava and pomegranate
(c) Functions.
Dietary fibres stimulate chewing, improve flow of gastric juice, provide a sense of satiety and prevent constipation.
It is also well proven now that dietary fibres have an important role in prevention of the following diseases:
(i) CVD.
Fibers help in prevention of CVD. Soluble fibers bind with bile acids altering cholesterol metabolism favorably.
(ii) Obesity.
Fibers help in the maintenance of weight and prevention of obesity.
(iii) Diabetes.
Fibers blunt the response of blood glucose through prevention of direct glucose absorption in the gut. This
helps in the control of hyperglycaemia.
(iv) Colonic Carcinoma.
Fibers are known to prevent colonic cancer through many mechanisms. By reducing the transit time of
dietary carcinogens in bowel, their exposure to gut is reduced. Fiber dilutes carcinogens in colon and alters
the production of carcinogens in the stools. Diets rich in fibre also contain vitamins A and C, which are
strong antioxidants and are associated with lowering of cancer risk.
(v) Other GIT Disorders.
Fibers increase faecal bulk and relieve constipation. This reduces the incidence of diverticulitis and
appendicitis. Alteration in cholesterol production and further metabolism reduces the formation of gallstones.

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(d) Daily Requirement.

As per the expert group recommendations ICMR, NIN; 15 g / 1,000 kcal and 30 g / 2,000 kcal has been considered
as safe intake of dietary fiber. The fiber content of selected food stuffs is given in Table 18.9.
Table 18.9 : Dietary Fiber Content of Common Foods
Fiber Content Fiber Content
Food Stuff Food Stuff
(g / 100 g) (g / 100 g)
Cereals and Legumes Fruits
Rice, raw, milled 0.2 Guava 5.2
Wheat flour, whole 1.9 Mango, papaya 0.7
Bengal gram, whole 3.9 Pomegranate 5.1
Red gram (Arhar dal) 1.5 Peach, pears, apple 1.0–1.2
Peas dry, rajmah 4.5 Figs, sapota 2.2–2.6
Green Vegetables Nuts
Cabbage, cauliflower, fenugreek (methi) 1.0–1.2 Areca nut 11.2
Amaranth 1–6.1 Fresh coconut 3.6
Spinach, radish leaves 0.6 Groundnut 3.1

18.8 Vitamins.
Vitamins are organic compounds required in very small, but definite quantities for normal human growth and
maintenance. They are not synthesized in the body and must be supplied in diet (except for a few vitamins that can
be synthesized by microorganisms of bowel). Vitamins do not furnish energy and do not play a part in the constitution
of the structure of tissues but are essential for transformation of energy and regulation of tissue metabolism. Deficiency
of vitamins cause profound changes in structural and functional well-being, the picture of each deficiency being specific.
Vitamins can be classified into two groups water-soluble and fat-soluble vitamins. The water-soluble group comprises
vitamins B complex and C; the fat-soluble group includes vitamins A, D, E and K.
(a) Water-Soluble Vitamins.
(i) Thiamine (Vitamin B1).
Thiamine hydrochloride is a crystalline substance, which is readily soluble in water. It is present in the body
mostly as Thiamine Pyro Phosphate (TPP). The important stores of vitamin B1 are plant seeds. The germs of
cereals, nuts, pea, beans and other pulses and yeast are rich sources of vitamin B1. All green vegetables,
roots, fruits, nuts, flesh foods and dairy products contain significant amounts of vitamins. Pork has a higher
content of thiamine in comparison to beef or mutton. Highly processed foodstuffs such as white bread,
polished rice and refined sugar are deficient in thiamine. Milling of cereals below an extraction rate of 75%
greatly reduces thiamine content. As thiamine is readily soluble in water, considerable amounts may be
lost when foodstuffs are cooked in an excess of water, which is afterward discarded. It is relatively stable
to heat up to a boiling point, provided the medium is slightly acidic, as in baking with yeast. But if baking
powder or soda is added to the cooking of foods, almost all the vitamins may get destroyed. Thiamine is
an important coenzyme in many metabolic reactions, important ones being the oxidative decarboxylation of
pyruvic acid and transketolase reaction in Hexose Mono Phosphate (HMP) shunt. The vitamin is essential for
the health of the nerve tissue and for normal cardiac and gastrointestinal functions. It plays an important
role in carbohydrate metabolism. Its RDA is 1.4 mg for sedentary man and woman both and EAR is
1.2 mg and 1.1 mg for sedentary man and woman respectively. Thiamine deficiency causes beriberi and
Wernicke–Korsakoff psychosis. Deficiency of thiamine can be prevented by educating the community about
consumption of parboiled rice and undermilled rice. The word beriberi is derived from Singhalese and means
“I can’t, I can’t,” as the patient cannot walk or work, especially in a dry / neurotic form of beriberi due to
peripheral neuritis, pain in limbs and paralysis. Three forms of beriberi are as given below:
(aa) Wet beriberi is the acute form of presentation. It is characterized by high output cardiac failure,

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bounding pulse, warm extremities, peripheral edema and cardiac dilatation.

(ab) Dry beriberi is a chronic form of disease, characterized by progressive peripheral neuropathy.
Tendon jerks are sluggish and anesthesia of skin (especially over tibia) is common. The muscles
become progressively wasted and weak and walking becomes increasingly difficult. The thin, even
emaciated individual needs at first one stick, then two and may finally becomes bedridden.
(ac) Infantile beriberi occurs in the first few months of life, if the diet of mother is deficient in
thiamine. The infant remains constipated and appears plump due to water retention. The heart is
enlarged and the heart sounds muffled. The infant may die of heart failure if untreated.
(ad) Wernicke–Korsakoff psychosis is seen in chronic alcoholics with poor diet. It is characterized
by confusion, low levels of consciousness and poor coordination (encephalopathy). Memory loss often
follows encephalopathy.
(ii) Riboflavin (Vitamin B2).
The word riboflavin is derived from a Latin word “flavous” meaning yellow and a component, the sugar
named ribose. It is a yellow-green, fluorescent compound, soluble in water, but not in fats. Though stable in
acid solution, in alkaline solution it is readily destroyed by heat. It is also destroyed by ultraviolet rays. The
best sources of riboflavin are liver, milk, eggs and green vegetables. Cereals and yeast extracts also contain
vitamins. Riboflavin differs from other compounds of vitamin B complex in that it occurs in good amounts
in the dairy product. Cooking does not destroy the vitamin, but losses occur when the water in which green
vegetables have been boiled is discarded. If food, especially milk, is left exposed to sunshine, large losses
may occur. Important functions of riboflavin include promotion of normal growth, assisting synthesis of
steroids, RBC and glycogen, maintenance of mucous membranes, eyes and nervous system and aids iron
absorption. Its RDA is 2 mg for sedentary man and 1.9 mg for sedentary woman and EAR is 1.6 mg for
both sedentary man and woman. Riboflavin deficiency manifests as cheilosis, angular stomatitis, glossitis,
magenta tongue, nasolabial seborrhoea and genital (scrotal or vulval) dermatosis. Corneal vascularization
is seen but is not a specific sign. Severe deficiency is rare. Groups with an increased risk of deficiency are
children, adolescents, elderly, pregnancy and lactation, malabsorption (tropical sprue, celiac disease, chronic
diarrhea, irritable bowel syndrome), chronic dieters and anorexia nervosa, drugs impairing absorption (e.g.,
thyroid hormones, OC pills, phenothiazines, barbiturates) and alcoholism.
(iii) Niacin (Nicotinic Acid and Nicotinamide) (Vitamin B3)
Niacin is the generic term for a group of compounds that prevent pellagra. These are white crystalline
substances, readily soluble in water and are resistant to heat. Although related chemically to nicotine, niacin
possesses very different physiological properties. It occurs naturally in the body as an amide (nicotinamide).
Nicotinic acid is widely distributed in plant and animal foods. Meat (especially the organs), fish, chicken,
eggs, milk, whole meal cereals, groundnuts and pulses are good sources. In some cereals, especially maize,
the greater part of the vitamin may be in a bound unabsorbable form. The human body is not entirely
dependent on dietary sources of nicotinic acid as it may also be synthesized from tryptophan. On an
average, about 60 mg of tryptophan is needed to form 1 mg of niacin. Diets that are predominantly based
on maize may lead to deficiency of nicotinic acid, since maize is itself deficient in tryptophan. It has been
hypothesized that excessive consumption of jowar can lead to pellagra as excess of leucine in jowar inhibits
conversion of tryptophan to niacin. Nicotinamide is incorporated into the pyridine nucleotide coenzymes, NAD
and NADP. These coenzymes are involved in numerous oxidoreductase reactions, including glycolysis, fatty
acid metabolism, tissue respiration and detoxification. The RDA for niacin is 14 mg / day and 11 mg / day
for sedentary men and women respectively. The EAR is 12 mg / day and 9mg / day for sedentary man and
woman respectively. Pellagra (Latin pelle, skin; Greek agra, seizure) results from deficiency of niacin. It is
characterized by the three D’s:
(aa) Dermatitis (Pellagrous dermatosis).
The skin exposed to sunlight gets inflamed, pigmented, cracked and peeled. The neck is frequently
involved and the distinctive pigmentation leads to Casal’s collar.
(ab) Diarrhea.
This is often accompanied by inflamed scarlet tongue.

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(ac) Dementia.
It may present from mild confusion and disorientation to mania and psychosis.
Pellagra can be prevented by educating the community to consume a mixed diet and to avoid total
dependence on maize or sorghum.
(iv) Folic Acid (Folate or Pteroyl Glutamic Acid).
Folic acid is a yellow, crystalline substance that is sparingly soluble in water. When heated in a neutral or
alkaline medium, it undergoes rapid destruction. About three-quarter of folate in foods is in polyglutamyl
form. This is normally hydrolysed to free folate by a conjugate present in small intestinal epithelium. Free
folate is actively absorbed from the upper small intestine. It is mainly stored in the liver. A small amount is
excreted in urine and faeces. In liver, free folic acid is converted into tetrahydro folic acid (folinic acid), which
is its functionally active form. Folic acid is found in green leaves, pulses, cereals, liver, kidney, mushroom and
yeast. Canning, prolonged heating, reheating and discarding “cooking” water cause serious losses of folic
acid. Reducing agents in food tend to protect folic acid. Folinic acid plays an important role in the synthesis
of purines, pyrimidines, glycine and methionine. It is essential for the synthesis of DNA. The folate derivative
5-methyl tetrahydrofolate requires vitamin B12 to enable the use of methionine synthase in synthesis of
methionine and tetrahydrofolate. It is a potent antianemia factor in the treatment of megaloblastic anaemia
due to malnutrition, pregnancy and malabsorption. It is also effective in treatment of pernicious anaemia.
The RDA for folic acid is 300 mg for adult men and 220 mg for adult women. There is an additional
requirement of 300 mg / day during pregnancy i.e., 570 ug / day and 100 mg / day i.e 330 ug during
lactation. The EAR is 250 mg for adult men and 180 mg for adult women. There is an additional requirement
of 300 mg / day during pregnancy i.e. 480 ug / day and 100 mg / day i.e 280 ug during lactation. Dietary
folate deficiency is not uncommon. Deficiency results in megaloblastic anaemia. It may be accompanied
by depression, insomnia, forgetfulness, irritability and dementia. Low folate levels are also associated with
neural tube defects. To prevent neural tube defects such as anencephaly and spina bifida, all pregnant
females are advised 500 mg of folic acid tablets in the first trimester of pregnancy. Lack of folic acid is
known to cause accumulation of homocysteine (hyperhomocysteinemia), which is a potential risk factor for
coronary artery disease. High folate levels overcome hyperhomocysteinemia.
Low folate levels can also cause an altered methylation of DNA, increasing the risk of cancer. A high plasma
homocysteine level is a risk factor for heart disease and stroke. A strong inverse correlation between folate
intake and plasma homocysteine has been found. A significant dose–response relationship has also been
established. Folate supplementation is known to proportionately reduce the plasma homocysteine levels
and thus the risk of heart disease.
(v) Cyanocobalamin (Vitamin B12).
Cobalamin is a complex molecule containing cobalt, besides phosphorus and nitrogen. Cyanocobalamin is
the commercially available form. Vitamin B12 is the “extrinsic factor” originally postulated by WB Castle.
To be absorbed, it requires the “intrinsic factor” secreted by the parietal cells of the stomach. It is freely
soluble in water and resistant to boiling in neutral solution though unstable in the presence of alkalis.
Cobalamin is unique among vitamins in that it is not present in any vegetable foods. It is present in
animal products such as milk, milk products, meat and fish. It is also synthesized by the microorganisms
in the gut and assimilated in the food chain. The main functions of cobalamin include recycling of the
folate coenzyme, synthesis of DNA, maintenance of myelin in the nervous system, treatment of pernicious
anemia and conversion of homocysteine to methionine. The RDA for vitamin B12 is 2.2 ug / day and EAR
is 2 ug / day. Since vitamins are not available in vegetable foods, strict vegetarians are at a risk of its
deficiency. Malabsorption, gastric atrophy and reduced production of “intrinsic factor” are some other causes
of the deficiency resulting in Pernicious anaemia, which is a megaloblastic anemia due to deficiency of this
vitamin. Neurological symptoms characterized by loss of sensation and motor power in lower limbs (due to
degeneration of myelin leading to subacute combined degeneration of the spinal cord) may be seen.
(vi) Ascorbic Acid (Vitamin C).
Vitamin C is a water-soluble, crystalline, white substance. It is very sensitive to oxidation, which is accelerated
by heat, alkaline solutions, light and traces of metals, especially copper. The biologically active forms are
l-ascorbic acid and l-dehydroascorbic acid. It is rapidly absorbed from the intestine. It is present in all body

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tissues, but is in a higher concentration in adrenals, pituitary gland and intestinal wall. The rich sources
of ascorbic acid are citrus fruits (orange, lemon), guava, papaya, pineapple, mango, gooseberry (amla),
kiwi fruit and green vegetables. Sweet potato also contains vitamin C. It is also synthesized in germinating
seeds, pulses and grains. The vitamin C content of fruits and vegetables is reduced by storage and damage
to plant cells by rough handling, bruising or cutting, which results in release of the enzyme ascorbic acid
oxidase. Cooking of vegetables also destroys vitamin C. Pressure cooker steaming and rapid frying of green
vegetables destroy the enzyme, thereby causing a greater retention of vitamin C than that in boiling. Ascorbic
acid is a powerful reducing agent (antioxidant) and is essential for many oxidation–reduction reactions. It
is required for the formation of collagen and is, therefore, necessary for the formation and maintenance of
the normal structure of intercellular ground substance (connective tissue), bone, tendons, skin, teeth and
capillaries. It is important for hydroxylation of dopamine to noradrenaline and is also required to produce
carnitine. It enhances the absorption of iron, through the conversion of ferric (Fe3+) to ferrous ions (Fe2+).
Ascorbic acid has an antioxidant property similar to vitamins A and E, which plays an important role in
free radical scavenging and it also acts as an antiaging and anticancer factor. It influences the maturation
of RBC, synthesis of bile and metabolism of drugs and carcinogens (by liver). The RDA of Vitamin C is
80 mg / day for adult males and 65mg / day for adult females. For pregnant women, 80 mg / day and for
lactating women, 115 mg / day are recommended. The EAR of Vitamin C is 65 mg / day for adult males and
55 mg / day for adult females. For pregnant women, 65 mg / day and for lactating women, 95 mg / day are
recommended. Deficiency of vitamin C leads to defective formation of intercellular ground substance and
the characteristic lesions occur in gums, bones and capillaries. Wound healing is obstructed in vitamin C
deficiency due to lack of collagen formation. Deficiency leads to scurvy, manifesting as spongy and bleeding
gums, perifollicular haemorrhages in skin, subperiosteal hematomas and poor wound healing. Fatigue and
muscle weakness are also reported.
(b) Fat-Soluble Vitamins.
(i) Vitamin A (Retinol).
Vitamin A is a term used for the biologically active compound retinol (RE) and its provitamin (precursor)
carotenoids. Retinol is a fat- soluble, pale-yellow compound. It is stable to heat at ordinary cooking
temperatures, but liable to oxidation and destruction on rancidity of fat. Retinol consists of a hydrocarbon
chain with a β-ionone ring at one end and an alcohol group at the other.
Carotenoids cannot be wholly converted to retinol in the body and humans absorb and utilize these pigments
less efficiently. 6 mg of β-carotene has the biological activity of 1 mg RE. Other carotenoids have even lesser
vitamin A activity. Retinol is found in foods of animal origin. The important sources of retinol are meat, liver,
kidney, milk, fish and eggs. Retinol can also be formed in the intestinal mucosa from pigments known as
carotenoids, which are widely distributed in plants. Carotenoids are found in colored fruits and vegetables.
One of these, β-carotene, is by far the most important source of retinol (provitamin A) and is found in
abundance in yellow-orange vegetables and fruits (pumpkin, papaya, mango, apricots, peaches) and green
leafy vegetables. Retinol is destroyed by exposure to sunlight. Foods that are heated for a long period of
time lose an appreciable amount of vitamin A. Boiling, canning or freezing of foods does not cause loss, but
drying and dehydration cause considerable loss. Vitamin A activity of a diet is usually expressed in retinol
equivalents, as vitamin A is applied to both retinol (preformed vitamin A) and pro-vitamin A (β-carotene).
One mg of retinol is considered 1 retinol equivalent (1 RE). It is also known that the biological activity of
6 mg of β-carotene is equal to the activity of 1 mg of retinol. International Unit (IU) is an old unit.
One IU is equal to 0.3 mg of retinol.
1 RE = 1 mg of retinol / 1 mg retinol activity / 6 mg β-carotene / 3.33 IU.
1 mg β-carotene = 0.167 mg retinol
1 IU Vitamin A = 0.3 mg of retinol
After absorption, retinol is carried from the intestines as retinol palmitate in chylomicrons and is taken up
by liver and stored. Animals can store retinol sufficient to meet their needs for several months. Vitamin
A is released from liver as retinol and circulates in blood bound to a specific transport protein, Retinol-
Binding Protein (RBP). Retinol is vital for the formation of the retinal pigment rhodopsin in rods of retina.
Exposure to light results in a series of changes in its configuration, which leads to adaptation of vision in

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dark. Retinol deficiency leads to impairment of dark adaptation or night blindness. It is essential for the
integrity of cellular structure, especially of epithelial tissue—respiratory, gastrointestinal, genitourinary and
skin. Retinol plays a role in the immune defence mechanism of the body. Vitamin A has an antioxidant
property of free radical scavenging. Vitamin A (carotenoids) acts as an antioxidant, trapping singlet oxygen
generated during chemical reactions or lipid peroxidation of membranes. Many studies have indicated a
negative association between vitamin A intake and cancer incidence. The RDA of vitamin A is 1,000 ug / day
for adult males and 840 ug / day for adult females. It increases to 900 ug / day during pregnancy and
950 ug / day during lactation. The EAR is 460 ug / day for adult males and 390 ug / day for adult females.
It increases to 406 ug / day during pregnancy and 720 ug / day during lactation. Deficiency of vitamin A
manifests as ocular or extraocular symptoms. The ocular manifestations are more common and are grouped
as xerophthalmia (night blindness, dryness, itching, redness of conjunctiva, Bitot’s spots, corneal xerosis,
keratomalacia). Other signs and symptoms associated with vitamin A deficiency include dry rough, itchy
skin, rash, dry, brittle hair and nails, loss of acuity of senses like smell and taste, loss of appetite and poor
growth, anemia, fatigue, low immunity, increased vulnerability to infections and increased risk of certain
cancers. Deficiency is often seen to be associated with weaning, protein energy malnutrition and a diet
poor in vegetables, fruits and milk. Socioeconomic factors such as educational status, income, poverty; and
cultural beliefs such as misconceptions on breast feeding, faulty weaning practices, poor environmental
sanitation / hygienic practices and infections and infestations contribute to vitamin deficiency. Assessment
of Vitamin A deficiency can be done by both clinical and biochemical criteria. The criteria for prevalence
for different variables in population at risk (6 months to 6 years) are as under:
(aa) Night blindness (>1%)
(ab) Bitot’s spots (>0.5%)
(ac) Corneal xerosis (>0.01%)
(ad) Corneal scal (0.05%)
(ae) Serum retinol value < 10 mcg / dl (>5%)
The mainstay for prevention of vitamin A deficiency is to ensure regular intake of foods rich in vitamin A. The
same has been emphasized in infant and young child feeding practices for mothers during complimentary
feeding of children from 6 months to 2 years of age. Excess of Vitamin A in diet can lead to Hypervitaminosis
A. There are exotic stories of arctic explorers and fishermen who reported reddening and exfoliation of skin
after feasting on polar bear liver or halibut liver. Chronic hypervitaminosis may result from chronic misuse of
supplements of vitamin A. Persistent large doses of vitamin A (more than 100 times the required amount)
overwhelm the liver storage capacity and produce intoxication and liver disease.
Hypervitaminosis A is characterized by dry lips (cheilitis), dryness of nasal mucosa and eyes, erythema,
scaling, peeling of skin, hair loss and nail fragility. Headache, nausea and vomiting follow. Bone abnormalities
in the form of hip fractures are also reported. Toxicity to fetus manifests as craniofacial, CNS, CVS and
thymic malformations.
(ii) Vitamin D (Calciferol).
The term vitamin D refers to two molecules-ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3).
Cholecalciferol is the natural form of vitamin and is produced by conversion of 7-dehydrocholestrol through
ultraviolet irradiation (sunshine). Vitamin D is widely distributed in animal fats. Dietary ergocalciferol and
cholecalciferol are biologically inactive and are activated to 25-hydroxycholecalciferol in liver. Further
conversion in the kidney results in production of the more active form, 1,25-dihydroxy cholecalciferol
(calcitriol). Vitamin D is found in cod liver oil, other oily fish, milk, margarine, eggs and liver.
Vitamin D regulates absorption and excretion of calcium from the small intestine and also plays an essential
part in the mechanism for mineralizing bone. It is considered a hormone rather than a vitamin. Recently,
this vitamin has also been associated with diseases such as osteoporosis, diabetes, psoriasis, hypertension,
arthritis, multiple sclerosis and CVDs. The RDA of vitamin D is 600 IU / day for adult males and females.
It remains same during pregnancy and lactation. The EAR is 400 IU / day for adult males and females
and remains same during pregnancy and lactation. People who stay indoors and are fully covered (Purdah
system amongst women in some religious / ethnic groups) are at a higher risk of deficiency due to lack
of exposure to UV radiation from sunlight. Window panes, sunglasses and sunscreen creams block UV

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penetration, limiting vitamin D formation. Those permanently indoors (as in cold countries), using dark
clothing, face masks and Burqa might also be at a risk of deficiency. Malabsorption also increases the risk
of deficiency. Severe deficiency results in rickets in children, characterized by reduced calcification of bone
epiphysis. It leads to skeletal deformities, bone pain and muscle weakness. In adults, deficiency results in
osteomalacia. In the present world, severe forms of Vitamin D deficiency are not prevalent; however growing
urbanization, reduced physical activity and changing lifestyle have led to low exposure to sunlight. Even a
brief and casual exposure of the exposed parts of the body (face and arms) to sunlight is good enough
to provide about 5 mg equivalent of vitamin D. The ultraviolet (UV) penetration depends on the melanin
content of skin and is higher in light-skinned people.
(iii) Vitamin E (Tocopherol).
Eight naturally occurring forms of vitamin E are synthesized in plants. Alpha tocopherol, which is synthesized
commercially, has the highest biological activity and is used as standard against which the activity of other
forms is measured. The word tocopherol is derived from the Greek words tokos meaning childbirth and
pherin meaning to carry. This vitamin was so named after the work of early investigators indicated a strong
relationship to reproductive function in rats, which was, however, not found to be true in humans. Vitamin
E is widely distributed in foods and the richest sources are vegetable oils such as groundnut, sunflower,
safflower, cotton seed, corn, wheat germ, rape seed, palm and other oils. Nuts (such as almonds and
peanuts) are also good sources. Eggs, butter and whole meal cereals are moderately good sources. Meat,
fruits and vegetables contain small amounts. Foods rich in PUFA are also rich in vitamin E. Like vitamins
A and C, vitamin E has a strong antioxidant property and protects cell membranes and lipoproteins against
damage from free radicals. It also prevents non-nzymatic destruction of PUFA by oxygen. The “ACE” vitamins,
i.e., vitamins A, C and E, act as antioxidants, trapping singlet oxygen generated during chemical reactions
or lipid peroxidation of membranes. They are postulated to be helpful in prevention of certain cancers and
atherosclerosis. Vitamin E maintains the integrity of cell membrane and has role in DNA and prostaglandin
synthesis. The requirement of vitamin E is 7.5-10 mg per day.
Deficiency of vitamin E in animals interferes with normal reproduction and causes a form of muscular
dystrophy. However, the effects of Familial Isolated Vitamin E (FIVE) deficiency-is known. Patients develop
reduced tendon reflexes by the age of 3–4 years, loss of touch and pain sensation, unsteady gait, loss of
coordination and impaired eye movement in adolescence. Deficiencies have also been seen in people with
severe fat malabsorption.
(iv) Vitamin K.
It exists in nature in two forms: vitamin K1 and vitamin K2. Vitamin K1 (phylloquinine) is the only form
that occurs in plants. It is a yellow oil, soluble in fats whereas only slightly soluble in water. Vitamin K2
(menaquinone) is produced by bacteria in the lumen of the large intestine. Green leafy vegetables, vegetable
oils, especially soya bean oil, eggs, meat and dairy products are good sources of vitamin K. The functions of
vitamin K include promotion of synthesis of gamma-carboxyglutamic acid (Gla) in the liver, which is essential
for the formation of prothrombin (or factor II) and also factors VII, IX and X. It is well known that these
factors participate in the coagulation of blood. Some other proteins also contain Gla and require vitamin
K for their synthesis, for example, osteocalcin, a bone protein, made by osteoblasts. The requirement of
vitamin K is 55 mg for adults. Deficiency of vitamin K is characterized by poor blood clotting and results in
low prothrombin activity. Neonates are born with very low stores of vitamin K due to sterility of intestines
(and absence of bacteria producing vitamin K). So, neonates are given an injection of this vitamin at birth.
Adults rarely manifest the deficiency, but it can be seen in cases of obstructive jaundice as lack of bile leads
to poor absorption of vitamin K. Anticoagulants such as warfarin and dicoumarol can cause a deficiency.
The vitamin content of selected food items is given in Table 18.10.
A comparative summary of different vitamins with regard to their function, RDA, deficiency and sources is
given in Table 18.11.

18.9 Minerals.
Minerals are required in small quantities and constitute only a small portion of the body weight, but participate in the
metabolism to a much greater degree than their mere weight indicates. Twenty-five earth elements known as “minerals”
are known to be essential for human life, as they are responsible for various metabolic functions.

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Table 18.10 : Vitamin Content of Selected Food Items (per 100 gms)
Carotene Thiamine Riboflavin Niacin Folic Acid Vitamin C
Food Stuff
(mg) (mg) (mg) (mg) (mg) (mg)
Wheat flour 25 0.49 0.17 4.3 35.8 0
Rice polished 0 0.06 0.06 1.9 8 0
Bajra 132 0.33 0.25 2.3 45.5 0
Maize dry 90 0.42 0.1 1.8 20.0 0
Bengal gram 189 0.30 0.15 2.9 186 3
Soya bean 426 0.73 0.39 3.2 100 –
Beans 187 0.10 0.06 0.7 45.5 24
Spinach 5,580 0.03 0.26 0.5 123 28
Carrot 1,890 0.04 0.02 0.6 15 3
Groundnut 37 0.90 0.13 19.9 20 0
Guava 0 0.03 0.03 0.4 – 212
Amla 09 0.03 0.01 0.2 600
Egg 420 0.1 0.40 0.1 78.3 0
Liver sheep 6,690 0.36 1.7 17.6 188 20
Milk cow 53 0.05 0.19 0.1 8.5 2
Fish (Hilsa) – – – 2.8 – 24

Table 18.11 : Comparative Summary of Different Vitamins

Vitamin Function RDA EAR Deficiency Sources
Vitamin C Reductant in 80 mg for males 65 mg / day for Scurvy: Spongy, Citrus fruits,
(ascorbic acid) hydroxylation 65 mg for females males 55 mg / day bleeding guava,
in collagen for females gums, fatigue, amla,
80 mg during
and carnitine 65 mg / day in hemarthrosis tomatoes,
pregnancy 115 mg
synthesis. Drug pregnancy green
during lactation
metabolism vegetables,
95 mg / day during
strawberries
lactation
Vitamin B1 Normal growth, 1.4 mg 1.2 mg for males Beriberi— Meat, liver,
(thiamine) coenzyme for 1.1 mg for females cardiac (wet), legumes,
decarboxylation neuritic (dry) wheat germ
of 2-keto and infantile
acids and
transketolation
reactions
Vitamin B2 Normal growth, 2 mg for males 1.6 mg for both Ariboflavinosis: Milk, meat,
(riboflavin) coenzyme in 1.9 for females males and females Magenta green
redox reactions tongue, vegetables
of fatty acids cheilosis,
and tricarboxylic angular
acid cycle stomatitis,
corneal ulcer

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Vitamin Function RDA EAR Deficiency Sources

Niacin Coenzyme for 14 mg for males 12 mg for males Pellagra, Meat,
(nicotinic acid, dehydrogenases 11 mg for females 9 mg for females characterized groundnuts,
nicotinamide) by 3 Ds— legumes,
dermatitis, grains
diarrhea,
dementia
Vitamin B6 Coenzymes 1.9 mg; pregnancy, 1.6 mg; pregnancy, Anemia, Grains,
(pyridoxamine) in amino acid 2.3 mg 1.9 mg neuritis, seeds,
metabolism convulsions poultry,
meat
Folic acid Coenzymes in 300 mg for males, 250 mg for males Megaloblastic Liver, green
single carbon 220 ug for females; 180 mg for females anemia vegetables,
metabolism pregnancy 570 mg; pregnancy 480 ug yeast, fruits
lactation 330 mg lactation 280 ug
Vitamin B12 Coenzymes in 2.2 mg 2 ug Pernicious Liver, lean
(cobalamin) amino acid, pregnancy 2.45 mg; pregnancy 2.2 mg anemia meat, fish,
propionate and lactation 3.2 mg seafood,
lactation 2.8 mg
single carbon milk
fragment
metabolism
Vitamin A Vision, integrity 1,000 ug for males 460 ug for males Xerophthalmia, Retinol
(retinol, retinal, of epithelium, 840 ug for females; 390 ug / day for dry skin, (animal
carotenes, gene regulation, pregnancy 900 ug, females impaired foods):
cryptoxanthin) antioxidant lactation 950 ug immunity, Liver, egg,
pregnancy 406 ug
growth and meat, milk
during lactation 720
reproduction Provitamin
ug / day
A (plant
foods)
yellow,
green
vegetables
Vitamin D Calcium 600 IU 400 IU Rickets in Synthesized
(cholecalciferol, homeostasis, children, in skin with
D3; bone osteomalacia in exposure
ergocalciferol, metabolism adults to sunlight;
D2) fish oils,
milk
Vitamin E Cellular 7.5-10 mg -- RBC Vegetable
(tocopherols) membrane depending upon the breakdown, oils, green
antioxidant edible oil used anemia, nerve vegetables,
damage, cereal germ,
retinopathy nuts, seeds
Vitamin K Clotting of 55 mg Bleeding Synthesis
(phylloquinones, blood, calcium tendencies by intestinal
menaquinones) metabolism bacteria,
green
vegetables
soya oil,
liver, milk

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The main functions of minerals include providing rigidity and relative permanence to the bones and teeth; providing
essential elements for the formation and activities of muscular, glandular, neural and epithelial tissues; forming
components of enzyme systems; and providing dynamic characteristics to the intra- and extracellular fluids for regulation
of pH, osmotic pressure and electro-neutrality and of secretions and excretions.
Dietary minerals are classified into microminerals (those which constitute at least 0.01% of body weight (5 g in a 50 kg
person) and microminerals as minerals whose requirement is less than 100 mg / day. Various minerals are described
as under:
(a) Calcium (Ca).
Calcium is the most abundant mineral in the human body. Most of it is deposited as hydroxyapatite, in bones and
teeth. A constant level of calcium in the body / plasma is maintained under the influence of parathyroid hormone
and calcitonin. The factors promoting absorption of calcium are vitamin D, proteins and lactose. It is essential
for the building of bones and teeth. Rich sources of calcium are milk and milk products; ragi; fish (if eaten
whole); custard apple (sitaphal), dried fruits such as raisins, apricots and dates; and pulses and tofu. Calcium
in food is not uniformly available to the body; for example, calcium in vegetables and fruits is poorly absorbed
due to the presence of oxalic acid in certain foods (e.g., spinach), which forms insoluble calcium oxalate. Phytic
acid (in the pericarp of cereal grains) combines with calcium to form phytin, which is not absorbed. However,
many cereals such as rye and wheat contain an enzyme phytase, which splits phytic acid so that it can no
longer bind with calcium and thus makes calcium available for absorption. Excess of saturated fatty acids, in
the small intestine, may form insoluble soaps with calcium and may carry a significant amount of calcium into
faeces. Calcium in milk and dairy foods is more readily absorbed. The main functions include bone formation. It
provides structural rigidity to bones and teeth. Calcium is responsible for the maintenance of optimum excitability
of the nervous and muscular tissues. It has an important role in the coagulation of blood as factor IV. It also
acts as a cofactor for several enzymes, for example, lipase. The suggested level for calcium intake for adult men
is 1,000 mg / day. In case of pregnant it is same as 1,000 mg and lactating women; it is 1,200 mg / day. For
post-menopausal women it is 1,200 mg / day. The EAR of calcium is 800 mg / day for males, females and during
pregnancy. For lactating women, it is 1000 mg / day. Plasma calcium levels are strictly controlled and are not
usually affected by dietary insufficiency in healthy adults. Reduction in the level of circulating ionized calcium
produces tetany. This is characterized by twitching of muscles of face, hands and feet. Cardiac arrhythmias may
also result. A long-term calcium deficiency during the bone-formative age can cause stunted skeletal growth and
low bone density. Vitamin D deficiency leads to rickets in children due to poor calcium absorption. Osteoporosis
is abnormal thinning of bones. It is not due to a primary calcium deficiency, but results from conditions leading
to chronic calcium deficiency. These factors are inadequate calcium intake, poor absorption, abnormal hormone
levels, disrupting the calcium homeostasis and subnormal physical activity. Osteoporotic bones are more likely
to get fractured with trivial injuries (falls), as commonly seen in post-menopausal women and the elderly.
(b) Phosphorus (P).
The role of phosphorus in bone formation is almost as important as that of calcium and so it is a macromineral
of considerable value. It gets deposited in bones and teeth as calcium phosphate. An adult human body contains
about 400-700 g of phosphorus as phosphate, mostly in bones and teeth. Phosphorus is widely distributed in
foodstuffs and, therefore, its deficiency rarely occurs. Milk, milk products, cereals, meat, fish, nuts, fruits and
vegetables are good sources of phosphorus. A large part of phosphorus present in vegetable foods occurs
bound with phytin (fiber) and is available to the body only to an extent of 40-60%. Phosphorus is essential for
the formation of bones and teeth along with calcium, as hydroxyapatite. It also plays an important role in all
metabolisms for derivation of energy from the phosphate bonds in ATP. It acts as a buffer that prevents changes
in pH of body fluids. It is an important constituent of nucleic acids, phospholipids and membranes. It is suggested
that an elemental Calcium: Phosphorous ratio of 1:1 should be maintained in most age groups except in infancy
where the ratio is 1:1.5. Using this ratio the adequate intake of Phosphorous per day for adult men, women and
pregnant lady is 600 mg / day and for lactating and post menopausal women as 750 mg / day.
Phosphorus deficiency is unlikely to occur, as it is widely available. However, hypophosphatemia is seen in
pathological conditions, such as sepsis, liver disease, alcoholism, diabetic ketoacidosis, prolonged parenteral
nutrition, hypophosphatemic rickets and excessive use of aluminum-containing antacids.
(c) Iron (Fe).
Iron is one of the most important microminerals essential for life. The body of an adult human contains iron

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equal in weight to that of a large “nail” (about 4 g), of which more than two-third (about 2.4 g) is present in
hemoglobin. The sources of iron can be divided into two main groups as Heme and non-heme iron sources. The
heme sources are essentially the non-vegetarian sources of iron, for example, meat and fish. Milk is considered
a poor source of iron, but breast milk is an efficient source for infants, as iron is absorbed well from it. The
non-heme iron sources are the vegetarian sources, namely, cereals, dark-green leafy vegetables, pulses, nuts
and dry fruits. Non-heme iron is poorly absorbed (1-20%) and is influenced by dietary constituents. Certain
compounds such as phytic acid (in cereals, fiber), polyphenols (in plants), tannins (in tea) and phosphates (in milk,
eggs) present in foods of vegetable origin inhibit absorption of iron. Certain dietary factors increase non-heme
iron absorption,such as red meat, fish, chicken and liver. Ascorbic acid and low pH also enhance absorption of
non-heme iron. Heme iron is absorbed directly into mucosal cells, where iron is released by heme oxidase and
then bound to transferrin. The maximum absorption of iron takes place in duodenum and upper part of the
small intestine. The amount of iron absorbed also depends on the iron status of the individual. Iron absorption
increases during growth and pregnancy. When the body needs iron, it passes directly through the mucosal cells
and is transported by transferrin to bone marrow. If iron is not required, it is stored in the mucosal cells as
transferrin. It is lost in faeces through mucosal cell exfoliation. Excess iron is stored as ferritin or hemosiderin
in liver, spleen or bone marrow. It can be mobilized from these stores when the demand increases. Iron is
lost mainly during menstruation and from the gastrointestinal tract. Physiological losses from all other routes
(exfoliation from alimentary, urinary and respiratory tracts and by dermal and hair losses and losses in sweat)
also occur. Excretion of iron is very low (about 1 mg / day in men). Iron has many functions in human body. It is
a component of heme, hemoglobin and myoglobin. It is a constituent of enzymes such as cytochromes, catalase
and peroxidase. As a part of these hemocomplexes and metallo-enzymes, it serves in oxygen transport and
cellular respiration. Iron is also involved in cellular immune response for appropriate functioning of phagocytic
cells. It is known to play a part in optimum cognitive functioning of brain. The physiological daily requirement
of iron is quite small, 1-3 mg / day. It changes constantly depending on the age, sex and physiological status
of an individual, such as pregnancy, lactation and growth. But since the absorption of iron is rather poor, the
dietary intake of iron should be 10–25 times the “physiological” requirement. Hence, the RDA of iron is 19 mg
for males and 29 mg for females (27 mg for pregnant females). The EAR is 11 mg and 15 mg for males and
females respectively.
Iron deficiency leads to anemia (common nutritional deficiency). It is estimated that up to 50% of all women and
two-third of all pregnant women are anemic, especially in developing countries. The vulnerable groups for Iron
Deficiency include women with heavy menstruation, pregnancy, growing children and adolescents, chronic bleeds
(hemorrhoids, peptic ulcers, irritation from drugs / alcohol, acute gastritis), iron-poor diets, strict vegetarians,
heavy tea / coffee drinkers, persons with reduced gastric acid secretion as in atrophic gastritis, stomach surgery
and chronic antacid use, persons with reduced transport due to deficiencies of vitamin A, Vitamin B6 or copper.
Iron status can be evaluated by measuring hemoglobin concentration),serum iron concentration (levels less than
0.5 mg / L indicate deficiency), serum ferritin concentration (values less than 10 mcg / L indicate absence of
iron stores) and serum transferrin saturation (should be more than 116%). Low hemoglobin levels are a late
manifestation of iron deficiency. The cutoff levels for diagnosis of anemia as per National Health Mission are
given in Table 18.12.
Table 18.12 : Cutoff Llevels for Diagnosis of Anaemia
Category Hb Levels (g / dl)
Adult males 13
Adult females, non-pregnant 12
Adult females pregnant 11
Children 6 months to 6 years 11
Children 6–14 years 12
The major cause of iron overload is hereditary hemochromatosis; another cause could be transfusion overload as
seen in cases receiving frequent transfusions (sickle-cell anemia and thalassemia). Hemosiderosis is a condition
seen in individuals consuming an abnormally large amount of iron. Recent studies suggest that iron plays an
active role as a pro-oxidant (opposite to the “favorable” antioxidant activity of certain vitamins and minerals).

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(d) Iodine (I).

It is an essential trace element because it is an integral component of thyroid hormones thyroxine and
triiodothyronine Iodine deficiency is endemic in mountainous areas with poor soil content, such as the sub-
Himalayan regions. Its deficiency causes the widely prevalent and preventable iodine deficiency disorders.
The presence of iodine in food is a function of the iodine content of local soil. If the soil contains an adequate
amount of iodine, then all crops growing in that area are found to be rich in iodine. Among the natural foods,
the best sources of iodine are seafood and vegetables that are grown on iodine-rich soils. Dairy products, eggs,
cereal grains, legumes and green leaves (spinach) are also reasonable sources of iodine. Water contains traces
of iodine, which contributes to as much as 10% of our total iodine intake. Certain vegetables of Brassica group
(cabbage, cauliflower and radish) contain goitrogens, such as thiocyanates and cyanoglycosides. Consumption
of large quantities of these foods may lead to development of goiter by making the iodine present in food
unavailable to the body. Goitrogens are inactivated by heating.
Approximately 30% of absorbed iodine is used up by the thyroid gland for synthesis of the thyroxine hormone and
the remainder is excreted. Iodine is an integral component of thyroid hormones thyroxine (T4) and triiodothyronine
(T3). Thyroid hormones are required for normal metabolism, growth and development. In the fetus and neonate,
normal protein metabolism in the brain and CNS requires iodine. The daily requirement of iodine is 140 mg
for an adult. However, the requirements of iodine (RDA of iodine) differ with age (Infants: 100 mg, Adults:
140 mg, Pregnancy: 220 mg and Lactation: 280 mg). The EAR is 95 mg for males and females. It increases to
160 mg in pregnancy and 200 mg in lactation. Endemic goiter of varying degrees is found in a large proportion
of population in India, where the soil and consequently food materials are deficient in iodine. Iodine deficiency
of varying degrees is encountered in nearly all parts of the country. This deficiency results when the nutrient is
lacking in earth’s crust. The deficiency cannot be eliminated by changing the dietary habits of the population
or by eating specific kinds of foods. The deficiency of iodine leads to various deficiency disorders, commonly
termed as Iodine Deficiency Disorders (IDD), with a wide range of effects ranging from stillbirths to goiter in
adults. IDD in adults results in hypothyroidism and raised levels of Thyroid Stimulating Hormone (TSH), which
cause hyperplasia of thyroid resulting in goiter. Hypothyroidism is characterized by lethargy, poor cold tolerance,
bradycardia and myxedema. Infertility is also reported. In the fetus, IDD results in cretinism. It is manifested as
mental retardation, hearing / speech defects, squint, gait disorders and growth retardation in infant life. IDD is
linked to an increase in rates of stillbirth and miscarriage. Neonatal hypothyroidism is a sensitive indicator of the
incidence of IDD in a community. India has universal salt iodisation (fortification of salt with iodine to prevent
IDD) programme.
(e) Fluorine (F).
Fluorides are normally present in bones and teeth and are essential for the normal mineralization of bones and
formation of dental enamel. Fluorine is widely but unevenly distributed in nature. It is found in many foods, but
seafood, cheese and tea are particularly rich sources. However, the main source of fluorine for humans is drinking
water. The fluoride content of drinking water in India is about 0.5 mg / L, but in fluorosis-endemic areas, the
natural water has been found to contain as much as 3–12 mg of fluoride / L. A concentration of 0.5–0.8 mg / L
in water is considered a safe limit in India. In temperate climate where the intake of water is low, the optimum
level of fluorine in drinking water is accepted as 1 mg / L. Deficiency of fluoride in water below 0.5 mg / L is
usually associated with dental caries. Ingestion of large amounts of fluorine (>2–3 ppm in water) is associated
with dental and skeletal fluorosis. Skeletal fluorosis has been reported to be a health problem in rural districts
of Andhra Pradesh, Haryana, Karnataka, Kerala, Punjab, Rajasthan and Tamil Nadu and more recently from
areas of Jharkhand. Scientists working at the National Institute of Nutrition, Hyderabad, have found new form
of fluorosis, characterized by genu valgum and osteoporosis of lower limbs in some districts of Andhra Pradesh
and Tamil Nadu. In areas where the fluoride content of water is high, defluoridation techniques are adopted, to
bring down the fluorine content to < 1 mg / L. The defluoridation techniques can be broadly classified into four
categories:
(i) adsorption techniques
(ii) ion-exchange techniques
(iii) precipitation techniques
(iv) other techniques, which include electrochemical defluoridation and reverse osmosis.

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Nalgonda Technique.
It is a simple and economical technique evolved by National Environmental Engineering Research Institute (NEERI),
Nagpur, for removal of fluoride from water. The technique involves addition of aluminum salts, lime and bleaching
powder followed by rapid mixing, flocculation, sedimentation, filtration and disinfection. Aluminum salt may be
added as aluminum sulfate (alum) or aluminum chloride. Aluminum is responsible for removal of fluoride from
water. The dose of aluminum salt increases with increase in the fluoride and alkalinity levels of the raw water.
Lime facilitates forming dense flocks for rapid settling of insoluble fluoride salts. The dose of lime is 1 / 20th
of that of the dose of aluminum salt. Bleaching powder is added to the raw water at the rate of 3 mg / L for
disinfection. The technique is quite effective in various settings of our country, to achieve a fluorine content of
< 1 mg / L in the water, in various settings as:
(i) For large communities
(ii) Fill-and-draw technique for small communities
(iii) Fill-and-draw defluoridation plant for rural water supply
(iv) For domestic defluoridation.
(f) Zinc (Zn).
It is present in small amounts in all tissues of the body. The total zinc content of the body is over 2.0 grams.
It is widely distributed in food stuffs of both animal and vegetable origin. Good sources of zinc are meat, whole
grains and legumes. Its bioavailability in vegetable foods is poor due to presence of phytates, which impair its
absorption. The daily requirement of zinc is about 17 mg in men, 13.2 mg in women and 14.5 mg for pregnant
and 14.1 mg for lactating mothers. The EAR is 14.1 mg in males and 11 mg in females. It increases to
11.8 mg in lactation and 12 mg in pregnancy. Zinc is part of over 100 enzymes, including carbonic anhydrase,
alcohol dehydrogenase, alkaline phosphatase, super oxide dismutase, collagenase, leucine aminopeptidase,
aldolase, RNA polymerase and pancreatic carboxypeptidase. It is thus of importance in protein and carbohydrate
metabolism, bone metabolism and oxygen transport. It is important in the immune response and gene expression.
It is an important structural constituent of leucocytes and has a vital role to play in the synthesis of nucleic acids.
Zinc stabilizes the structure of DNA, RNA and ribosomes. Lymphoid tissue too contains substantial amounts of
zinc. It interacts with insulin in the pancreas and serves in its efficient storage. Zinc is also a powerful antioxidant.
A clinical syndrome characterized by small stature, hypogonadism, mild anemia and low plasma zinc occurs in
older children and adolescents. It is reported in poor peasant communities of Iran and elsewhere in Middle East,
where the staple diet is unleavened bread. The zinc intake is low and its absorption is impaired by phytate in
the unleavened bread. However, the common deficiency symptoms include growth retardation, failure to thrive
and delayed sexual maturation in children. Its deficiency impairs cellular immune mechanism while excess of
it may depress neutrophils. Zinc deficiency may present as a tetrad of symptoms comprising neuropsychiatric
changes, dermal lesions, diarrhea and alopecia (Acrodermatitis Enteropathica). Zinc supplementation is useful
in these conditions.
(g) Copper (Cu).
The adult body contains approximately about 80 mg Cu mainly stored in liver, followed by brain and muscle.
Sea foods, legume seeds and oilseeds like sesame, sunflower and nuts are some of its rich sources. Fruits and
vegetables are moderate sources. It is transported in the form of ceruloplasmin in blood / plasma. Zn is well
known to be antagonistic to copper bioavailability in terms of its competition with metallothionein binding and
thus enhancing the requirement of the mineral. Cytochrome C oxidase, Superoxide Dismutase (SOD), lysyl oxidase
and tyrosine oxidase are the major Copper containing metalloenzymes. Deficiency signs include anaemia, vascular
complications, osteoporosis and neurological manifestations. Lysyl oxidase is decreased in its deficiency leading
to diminished collagen and elastin crosslinking. The factorial computation of Copper requirements is not possible
due to lack of data on the obligatory copper losses in healthy people and estimates of additional requirements
due to growth (tissue and blood volume expansion), lactation and pregnancy needs. The acceptable intake is
1.7 mg / day.
(h) Manganese (Mn).
Plant foods like wheat, barley, rice bran are rich in Mn. Fruits and vegetables are moderate sources and animal
foods like eggs, beef and chicken contain low levels. About 10-20 mg of Mn is present in the body mainly in

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bone, liver, pancreas and kidney. Mn is the cofactor for the enzymes SOD, arginase and glycosyl transferase
which are involved in carbohydrate, lipid and amino acid metabolism. There are other enzymes like phosphoenol
pyruvate carboxy kinase and glutamine synthetase, which are activated by Mn ions. Growth failure, skeletal
abnormalities and impaired reproductive function have been reported to be caused by Mn deficiency. Abnormal
insulin metabolism and glucose tolerance are the important effects attributed to Mn deficiency. The acceptable
intake is 4 mg / day.
(j) Chromium (Cr).
It is found to be distributed in nature in a way similar to that of Cu. Trivalent chromium has been postulated
to be necessary for the efficacy of insulin in regulating pmetabolism of carbohydrates, lipids and protein. Sea
foods (oysters), meat and whole grain products are good sources, followed by egg, butter and tubers like potato.
Cheese is a concentrated source of Cr. Fruits and vegetables, in general, are not good sources of Cr. In chromium
deficiency too, impaired glucose tolerance and weight loss along with peripheral neuropathy can be seen. Cr
deficiency attributable to its lack in the body when an individual is on total parenteral nutrition. The acceptable
daily intake is 50 ug / day.
(k) Selenium (Se).
Importance of Selenium (Se) in biology has been intimately connected with that of the “trinity” of antioxidants,
the remaining two being cysteine and vitamin E. The discovery of selenium as an important nutrient by Schwarz
and Foltz can be traced to the prevention of nutritional liver necrosis in vitamin E deficient rats when Se in trace
amounts were supplemented to them. Selenium in food is present in at least two forms - as Selenomethionine
in plant foods and Selenocysteine in animal foods. The selenium content of food varies depending on the
selenium content of the soil where the animal was raised or the plant was grown. Organ meat and sea foods
are rich sources of selenium, their content in the diet being 0.10-1.3 mg / g. Bioavailability of Se from sea foods
may be low because of high concentration of heavy metals like Cadmium, Mercury etc. There are certain plant
foods like mustard and to a lesser extent garlic and broccoli, which accumulate Se from soil. Cereals and grains
are major dietary sources of Se (< 0.1 mg / g to 0.8 mg / g). Functions of Se include its presence in enzymes
Glutathione peroxidase and Deiodinase isoenzymes, apart from its antioxidant protection against free radicals,
Se was found to be functional in detoxification and immune potentiation. Its deficiency has been associated with
two childhood / adolescent endemic diseases, ‘Keshan’ (cardiomyopathy) and ‘Kashin Beck’ (osteoarthritis) in
China. These diseases are found to be prevalent in certain areas in China where the intake of Se is very low,
7-11 mg / d. A number of epidemiological studies suggest that poor intake of Se is associated with increased risk
of cancer or heart disease, both related to its antioxidant function. People undergoing long term hemodialysis
and people living with HIV are at risk groups of selenium inadequacy. Selenium toxicity (selenosis) is well known
in livestock in seleniferous areas leading to blind staggers. Selenium poisoning has been observed in humans
under occupational exposures or in seleniferous areas. Daily intakes above 700 mg / d or acute consumption
of 1-7 mg Se / kg / d result in toxicity in humans. Dermatitis, depression and brittle finger nails, excessive tooth
decay, numbness and hemiplegia are some of the non-specific symptoms of poisoning. An acceptable daily intake
of 40 ug / day is recommended.
Summary of Functions, RDA, EAR, Deficiency and Sources of various macrominerals and microminerals is given
in Table 18.13.

18.10 Energy.
We get energy from food in a chemical form, which is derived directly or indirectly from plants. This energy is bound
in molecules of carbohydrate, fat, protein and alcohol. Whilst converting chemical energy into mechanical energy, the
human body acts as an engine. Energy is required for maintaining the body temperature and vital activity of organs,
besides mechanical work and growth.
(a) Units of Energy.
Calorie is the basic unit of energy. Kilocalorie is defined as the heat required to raise the temperature of 1 kg of
water by 1°C from 14.5°C to 15.5°C. Joule (J) is now the accepted international unit of energy. It is the energy
expended when a mass of 1 kg is moved 1 meter by a force of 1 Newton. Since J is too small to describe the
energy value of diet, kilo joule (kJ) and mega joule (MJ) are of more practical use. One kJ is equal to 1,000 J
and one MJ is equal to 1,000 kJ. However, the old unit of energy, namely, kilocalorie (kcal) is still being used
in nutrition.

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Table 18.13 : Functions, RDA, EAR, Deficiency and Sources of Various Macrominerals
Mineral Function RDA EAR Deficiency Sources
Calcium Bone and teeth Adults 1000 mg Adults 800 mg Tetany, rickets, Dairy
formation, blood osteoporosis products,
Pregnancy 1000 mg Pregnancy 800 mg
clotting, muscle meat
contraction, nerve Lactation 1200 mg Lactation 1000 mg products,
transmission leafy
vegetables
Phosphorus Bone and teeth Adequate intake Not seen often, Dairy
formation, energy can cause bone products,
Adults 600 mg
metabolism, nucleic loss, anorexia meat
acid synthesis, acid Pregnancy 600 mg products,
base balance leafy
Lactation 750 mg
vegetables
Post menopausal women 750 mg
Sodium ECF component, 2000 mg / day which amounts to 5 gm of Cramps, Table salt
water balance, salt acid-base
acid base balance imbalance,
Desirable sodium: potassium ratio in mmol
nerve transmission, water
is 1:1.
muscle action imbalance
Potassium Major intracellular 3500 mg / day Muscle Fresh fruits,
fluid component, weakness, meats,
acid–base balance; arrhythmias whole grains,
nerve transmission, vegetables
muscle action
Magnesium Coenzyme in 440 mg for males 370 mg for males Tremors, spasm Meat, cheese,
metabolic reactions, and 370 mg for and 310mg for eggs, nuts,
nerve conduction females females legumes
Iron Hemoglobin male: 19 mg; male: 11 mg; Anemia, Meat
and myoglobin female: 29 mg; fatigability, products,
female: 15 mg;
formation, cellular pregnancy: 27 mg; impaired liver, green
oxidation reactions, pregnancy: 21 mg; immune leafy
lactation: 23 mg
antibody formation function vegetables
lactation: 16 mg
Iodine Thyroxine synthesis Adults 140 mg; Adults 95 mg; Goiter, Iodized salt,
pregnancy 220 mg cretinism, plant products
pregnancy 160 mg
hypothyroidism, grown in
lactation 280 ug
lactation 200 ug infertility, iodine-rich soil
stillbirths
Zinc Enzyme constituent, 17 mg males 14.1 mg males Retarded Dairy
protein metabolism, sexual and products,
13.2 mg females 11 mg females
immune function, physical activity; meat
insulin storage, 14.5 mg pregnancy 12 mg pregnancy impaired wound products,
sexual maturation 14.1 for lactation and 11.8 mg for healing eggs, whole
lactation grains
Selenium Antioxidant function, 40 mg Impaired Liver, meats,
forms glutathione immune whole grains,
peroxidase, spares function, seafood
vitamin E Keshan disease
Mineral Function RDA Deficiency Sources

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Mineral Function RDA EAR Deficiency Sources

Fluoride Bone and teeth < 1 mg - Dental caries Fluoridated
constituent water,
toothpaste
Copper Component of 1.7 mg -- Anemia, Seafood,
metalloenzyme vascular legumes,
like cytochrome C complications, sunflower
oxidase, superoxide osteoporosis, seeds, nuts
dismutase, lysyl neurological
oxidase and manifestations
tyrosine oxidase
Chromium Part of glucose 50 mg Impaired Seafood
tolerance factor glucose (oyster), meat,
tolerance, whole grain
weight loss products,
with peripheral cheese
neuropathy
Manganese Cofactor for 4 mg Growth failure, Wheat, barley,
enzymes superoxide skeletal rice bran
dismutase, arginase abnormalities
and glycosyl and impaired
transferase reproductive
function
The conversions of old and new units of energy are given below:
(i) 1 cal = 4.184 J
(ii) 1 kcal = 4.184 kJ
(iii) 1,000 kcal = 4.184 MJ
(iv) 1 kJ = 0.239 kcal
(v) 1 MJ = 239 kcal
(vi) 1 kJ = 1,000 J
(vii) 1 MJ = 1,000 kJ
(b) Basal Metabolic Rate (BMR).
Even when an individual is at complete rest and no physical work is being carried out, energy is needed for
the activities of internal organs and maintenance of body temperature. This energy is required for maintaining
the basal or resting metabolism. The BMR is determined experimentally when the subject is lying down at
complete physical and mental rest, wearing light clothing in a thermoneutral environment and at least
12 hours after taking the last meal. The daily energy expenditure of adults depends on their occupational
activity (sedentary / moderate / heavy activity), sleep and non-occupational activity, each typically for eight hours
in a day. FAO / WHO have adopted factorial method to estimate the energy requirements of adults. The BMR is
largely influenced by the body weight which can be used to predict basal metabolism of individuals. The expert
committee NIN, ICMR, 2020 proposes to lower the BMR by 10% and 9% for adult males and females respectively
from values obtained through the Schofield equations given in Table 18.14.
There are three important terms while defining energy expenditure using physical activity estimations. These
are – Physical Activity Ratio (PAR), Physical Activity Level (PAL) and Total Energy Expenditure (TEE). The Physical
Activity Ratio (PAR) is expressed as the ratio of the energy cost of an individual activity per minute to the cost
of the Basal Metabolic Rate (BMR) per minute. The PAR is unit-less and the distinct advantage of expressing
energy expenditure of an activity in terms of PAR values relates to its use for both genders, at all ages and at
all body sizes.

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Table 18.14 : Equations for Calculating BMR (kcal / 24hr)

Sex Age (Years) Prediction Equation Proposed by FAO / WHO / UNU Consultation (2004)
Males 18-30 15.1 x B.W. (kg) + 692.2
30-60 11.5 x B.W. (kg) + 873
>60 11.7 x B.W. (kg) + 587.7
Females 18-30 14.8 x B.W. (kg) + 486.6
30-60 8.1 x B.W. (kg) + 845.6
>60 9.1 x B.W. (kg) + 658.5
Energy cost of an activity per minute
(i) Physical Activity Ratio (PAR) =
Energy cost of basal metabolism per minute
(ii) Physical Activity Level (PAL) is the ratio of the energy expenditure for 24 hours and the BMR over 24
hours.
Total PAR – hours
Physical Activity Level (PAL) =
Total time – hours

For example, a person spending 8 hours in sleep (with a PAR of 1), 8 hours in domestic and leisure activity
(with an average PAR of 2) and 8 hours at work (with an average PAR of 3), would have a total PAR -hour
value = (8 x 1) + (8 x 2) + (8 x 3) = 48 PAR-hours.
Thus,
Total PAR – hours 48
PAL (for the entire day) = = =2
Total time – hours 24

(iii) Total Energy Expenditure (TEE).

A large proportion of the daily energy expenditure is accounted for by the Basal Metabolic Rate (BMR).
Therefore, TEE is calculated as a multiplication of BMR to PAL, since the PAL and PAR are indexed to the
basal metabolic rate:
TEE = PAL X BMR
The BMR is either measured directly or predicted from body weight, gender and age specific equations.
However, there are potential problems with this approach, given the body composition of Indians. The other
two methods to evaluate TEE are Individually calibrated Heart Rate Monitoring (HRM) method and Doubly
Labelled Water (DLW) technique.
Example of computation of energy expenditure of adult Indian population is given in Table 18.15 for different
levels of activities.
Table 18.15 : Computation of Energy Expenditure of an Adult Indian Population
Major Lifestyles, Energy Expenditure
Duration (PAR Values)
Main Daily Activities
(h) Moderate Heavy or
Sedentary
Active Vigourously Active
Sleep 8 1.0 1.0 1.0
Occupational activity 8 1.3 2.5 4.1
Non-occupational activity 8 1.9 1.9 1.9
Mean - 1.41 1.80 2.33

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Major Lifestyles, Energy Expenditure

Duration (PAR Values)
Main Daily Activities
(h) Moderate Heavy or
Sedentary
Active Vigourously Active
Non-occupational details
Personal care 1 1.6 1.6 1.6
Eating 1 1.2 1.2 1.2
Commuting to work by bus or by vehicle or by walk 1 2.0 2.0 2.0
General household or other activities 2 2.0 2.0 2.0
Walking at various speeds without load 1 3.4 3.4 3.4
Light leisure activity 2 1.4 1.4 1.4
Mean non-occupational activity 8 1.9 1.9 1.9
Men: body wt. (65 kg), BMR (1506 kcal) - 2123 2711 3509
Women: body wt. (55 kg), BMR (1184 kcal) - 1670 2131 2759
Different levels of activities are:
(aa) Sedentary activities like desk work, sitting, reading, standing for some time.
(ab) Moderate activities like standing, walking at various speed, cycling, carrying light weights.
(ac) Heavy activities include agricultural activities, carrying loads, pulling cart, mining.
PAL values as given by expert group, NIN, ICMR 2020 are 1.40, 1.80 and 2.30 for sedentary, moderate
and heavy work respectively.
Current estimated energy requirements of Indian men at different ages, body weights and activities to
maintain normal BMI are given in Table 18.16 (a):
Table 18.16 (a) : Energy Requirements of Indian Men, Women at Different Ages, Body Weights and Activities
(Source: RDA and EAR, Report of Expert Group, NIN (ICMR) 2020, updated 2024)
18-30 y 30-60 y > 60 y
Body Sedentary Moderate Sedentary Moderate Sedentary Moderate
Weight Activity Activity Activity Activity Activity Activity
(kg) TEE TEE TEE TEE TEE TEE
(Kcal / d)
50 1823 2344 1824 2346 1478 1900
51 1842 2369 1839 2364 1492 1919
52 1862 2393 1853 2383 1507 1938
53 1881 2418 1868 2402 1522 1957
54 1900 2442 1882 2420 1537 1976
55 1919 2467 1897 2439 1551 1995
56 1938 2491 1911 2458 1566 2013
57 1957 2516 1926 2476 1581 2032
58 1976 2540 1940 2495 1596 2051
59 1995 2565 1955 2413 1610 2070
60 2014 2589 1969 2532 1625 2089

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18-30 y 30-60 y > 60 y

Body Sedentary Moderate Sedentary Moderate Sedentary Moderate
Weight Activity Activity Activity Activity Activity Activity
(kg) TEE TEE TEE TEE TEE TEE
(Kcal / d)
61 2033 2614 1984 2551 1640 2108
62 2052 2638 1998 2569 1655 2127
63 2071 2662 2013 2588 1669 2146
64 2090 2687 2027 2607 1684 2165
65 2109 2711 2042 2625 1699 2184
66 2128 2736 2056 2644 1713 2203
67 2147 2760 2071 2662 1728 2222
68 2166 2785 2085 2681 1743 2241
69 2185 2809 2110 2700 1758 2260
70 2204 2834 2114 2718 1772 2279
71 2223 2858 2129 2737 1787 2298
72 2242 2883 2143 2756 1802 2317
73 2261 2907 2158 2774 1817 2336
74 2280 2907 2172 2793 1831 2355
75 2299 2932 2187 2812 1846 2374
76 2318 2956 2201 2830 1861 2393
77 2337 2980 2216 2849 1876 2412
78 2356 3005 2230 2867 1890 2430
79 2375 3029 2245 2886 1905 2449
80 2394 3054 2259 2905 1920 2468
81 2413 3078 2274 2923 1935 2487
PAL values: sedentary (1.40), moderate (1.80)
Table 18.16 (b) : Energy Requirements of Indian Women at Different Ages, Body Weights and
Activities to Maintain Normal BMI
(Source: RDA and EAR, Report of Expert Group, NIN (ICMR) 2020, updated 2024)
18-30 y 30-60 y > 60 y

Body Sedentary Moderate Sedentary Moderate Sedentary Moderate

Weight Activity Activity Activity Activity Activity Activity
(kg) TEE TEE TEE TEE TEE TEE
(Kcal / d)
45 1468 1888 1542 1982 1361 1749
46 1487 1912 1552 1995 1372 1764
47 1506 1936 1562 2009 1384 1779

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18-30 y 30-60 y > 60 y

Body Sedentary Moderate Sedentary Moderate Sedentary Moderate

Weight Activity Activity Activity Activity Activity Activity
(kg) TEE TEE TEE TEE TEE TEE
(Kcal / d)
48 1525 1961 1573 2022 1395 1794
49 1544 1985 1583 2035 1407 1809
50 1563 2009 1593 2048 1419 1824
51 1582 2033 1604 2062 1430 1839
52 1600 2058 1614 2075 1442 1854
53 1619 2082 1624 2088 1453 1869
54 1638 2106 1635 2102 1465 1884
55 1657 2130 1645 2115 1477 1898
56 1676 2155 1655 2128 1488 1913
57 1695 2179 1666 2141 1500 1928
58 1714 2203 1676 2155 1511 1943
59 1732 2227 1686 2168 1523 1958
60 1751 2252 1696 2181 1535 1973
61 1770 2276 1707 2194 1546 1988
62 1789 2300 1717 2208 1558 2003
63 1808 2324 1727 2221 1569 2018
64 1827 2349 1738 2234 1581 2033
65 1846 2373 1748 2247 1593 2048
66 1864 2397 1758 2261 1604 2062
67 1883 2421 1769 2274 1616 2077
68 1902 2446 1779 2287 1627 2092
69 1921 2470 1789 2301 1639 2107
70 1940 2494 1800 2314 1650 2122
71 1959 2518 1810 2327 1662 2137
72 1978 2543 1820 2340 1674 2152
73 1996 2567 1831 2354 1685 2167
(c) Reference Indian Adult Man.
A reference Indian adult man is between 19 and 39 years of age with a height of 1.73 m, weight of 65 kg and a
BMI of 21.7 kg / m2. He is free from disease and physically fit for work. On each working day, he is employed
for 8 hours in an occupation that usually involves moderate activity. While not at work, he spends 8 hours in
bed, 4–6 hours sitting and moving about and 2 hours in walking and active recreation or household duties.
(d) Reference Indian Adult Woman.
A reference Indian adult woman is between 19 and 39 years of age and healthy; non-pregnant, non-lactating,
weighs 55 kg with a height of 1.61 m and a BMI of 21.2 kg / m2. She may be engaged in general household
work, in light industry or in any other moderately active work for 8 hours. While not at work, she spends 8 hours
in bed, 4–6 hours sitting and moving about in light activity and 2 hours in walking or active household chores.
(e) Energy Requirements for Sedentary, Moderate and Hard Work.
The energy requirements of an individual vary over a wide range depending upon the sex, age, body size, BMR and
degree of physical activity. But it is the classification based on physical / occupational activity that is commonly

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used to determine the energy intake. A sedentary worker is one who is involved in a chair-borne occupation with
minimal physical activity, such as a clerk, shopkeeper, manager or a doctor, is classified as a sedentary worker.
Teachers will also fall in this category. A moderate worker will include occupations falling in between the two
extremes of sedentary and heavy worker are the moderate workers, such as the electrician, carpenter or a site
supervisor in a construction company. A heavy worker is one who is involved in stiff physical labor, such as a
farm / field laborer or an army soldier, would be classified as a heavy worker. The energy requirements for these
three categories are summarized in Table 18.17.
Table 18.17 : Energy Requirements of Reference Indian Man and Woman
(Source: RDA and EAR, Report of Expert Group, NIN (ICMR) 2020, updated 2024)
Category Physical Activity Level Body Weight (kg) Energy (Kcal / d)a
Men* Sedentary Work 65 2110
Moderate Work 2710
Heavy Work 3470
Women* Sedentary Work 55 1660
Moderate Work 2130
Heavy Work 2720
a - Rounded off to nearest 10 Kcal / day.
* Energy requirement is specefic for given body weight, gender, and physical activity.

18.5 Water.
Water is biologically important and has a major role in metabolism. Water is essential for various metabolic activities such
as transportation of nutrients and oxygen to cells, maintenance of blood volume, functioning of the cardiovascular and
digestive systems, regulation of body temperature, maintenance of acid-base balance, elimination of toxins, lubrication
of skin and tissues, maintenance of elasticity of tissues and muscles, cell shape and structural integrity, boosting energy
metabolism, reduction of arterial pressure, hydration of brain cells and thereby, maintaining better cognitive function.

18.6 Armed Forces.

Soldiers are deployed in different climatic conditions such as hot deserts, hot humid jungles, snow bound high-altitude
areas, underwater (submariners) etc. Fluid and electrolyte imbalances not only threaten the health of armed forces but
also significantly impair performance and reduce combat effectiveness. Fluid requirements of various types of troops
under different environmental conditions are calculated based on the energy expenditure estimated using indirect
calorimetry and doubly labelled water. An intake of 1.5 ml was considered per each calorie expended. The requirement
for sodium chloride is higher than the normal recommendations due to higher sweat loss. Approximately 15-16 g of
salt normally taken in diet is quite adequate for acclimatized soldiers. Acclimatization to the environmental conditions
for 3 days decreases the sodium losses through sweat. The fluid requirements are presented in Table 18.18.
Table 18.18 : Estimation Of Fluid Requirements for Indian Troops Based on Their Energy Expenditure
under Different Environments and Training
Average Fluid Average Fluid Average
Total Energy
Intake from Intake from Total Fluid
Type of Troops and Environment Expenditure
Foods Beverages Requirement
(kcal / day)
(ml / day) (ml / day) (ml / day)
Army
Sea level-Combat and support 3511 1600 3650 5250
Desert-Combat and support 3304 1500 3450 4950
Training centre - Infantry 4670 2100 4900 7000
Training centre - Support 3487 1600 3650 5250

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Average Fluid Average Fluid Average

Total Energy
Intake from Intake from Total Fluid
Type of Troops and Environment Expenditure
Foods Beverages Requirement
(kcal / day)
(ml / day) (ml / day) (ml / day)
Commando training 4498 2050 4700 6750
HA warfare training 4837 2200 5050 7250
HA (2,700-4,500 m) - Combat and support 3880 1750 4050 5800
HA (> 4,500 m) - Combat 4270 1900 4500 6400
Navy
Ground crew 2900 1300 3050 4350
Officers 3615 1600 3800 5400
Air Force
Ship crew 3313 1500 3450 4950
Submariners 3168 1450 3300 4750
MARCOs and divers 4055 1850 4250 6100
The above guidelines provided by Force Dot AaA (2003) and Luippold et al., (2018) can be adapted to recommend
water intake during work by armed forces. Fluid recommendations mentioned in Table 18.19 were given based on the
type of work involved, uniform configurations and work and rest cycles to maintain fluid and thermoregulation under five
designated flag conditions. Military work was divided into easy, moderate and hard work; easy work involves weapon
maintenance, walking on hard surface at 2.5 mph, < 30 pound (lb) load, manual of arms marksmanship training, drill
and ceremony; moderate work involves walking on loose sand at 2.5 mph, no load, walking hard surface at 3.5 mph,
< 40 lb load, calisthenics, patrolling, individual movement techniques, defensive position construction; heavy work
involves walking on hard surface at 3.5 mph, > or equal to 40 lb load and walking loose sand at 2.5 mph with load.
Table 18.19 : Fluid Replacement And Work / Rest Guidance for Warm Weather Training Conditions and
Refill Frequency for 3l Collapsible Drink System
WBGT Easy Work Moderate Wrok Hard Work
Heat
Index Work: Water Refilling Work: Water Refilling Work: Water Refilling
Category
(°F) Rest Intake Frequency Rest Intake Frequency Rest Intake Frequency
1 (White) 78-81.9 NL 475 4 NL 710 4 40:20 710 4
2 (Green) 82-84.9 NL 475 4 50:10 710 4 30:30 950 3
3 (Yellow) 85-87.9 NL 710 4 40:20 710 4 30:30 950 3
4 (Red) 88-89.9 NL 710 4 30:30 710 4 20:40 950 3
5 (Black) >90 50:10 950 3 20:40 950 3 10:50 950 3
NL- No limit for work; WBGT - Wet-Bulb Globe Temperature; Rest - Minimal physical activity like sitting or standing in
the shade.
Recommended Fluid Requirements and Work; Rest times will sustain performance and hydration for at least 4h of
work in the specified heat category. Fluid requirements can vary based on individual differences (± 240 ml / h) and
exposure to full sun or full shade (± 240 ml / h). If NBC (Nuclear, Biological, Chemical) clothing is worn (mission-oriented
protective posture (MOPP 4)), then 10°F should be added to WBGT index for easy work and 20°F should be added
to WBGT index for moderate and hard work. The guidelines are viable for use with modern uniform configurations in
primarily mild flag conditions.

18.11 Balanced Diet.

A balanced diet is defined as one that contains a variety of foods in such quantities and proportions that the need
for energy, amino acids, vitamins, minerals, fats, carbohydrate and other nutrients is adequately met for maintaining
health, vitality and makes a provision for extra nutrients to withstand short duration of leanness. However, the actual

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diet of a person depends upon his taste, liking for a particular food, culture, family background, age, gender, economic
capacity, religion, etc. A balanced diet can be easily achieved through a blend of four basic food groups as follows:
(a) Group 1: Cereals, millets and pulses
(b) Group 2: Vegetables and fruits
(c) Group 3: Milk and milk products, egg, meat and fish
(d) Group 4: Oils and fats and nuts and oil seeds
The nutrition guide containing all these food groups is called Food Guide Pyramid. The same is given in Fig 18.3 below:

Fig 18.3 : Food Guide Pyramid

A balanced diet should provide 45-65% of total calories from carbohydrates, preferably from complex carbohydrates,
about 5–15% from proteins and 15-35% from both visible and invisible fats. In addition, a balanced diet should provide
other non-nutrients such as dietary fiber, antioxidants and phytochemicals which bestow positive health benefits. The
percent total energy from different macronutrients, acceptable macronutrient distribution range (AMDR) as recommended
by expert committee 2024, ICMR NIN is given in Table 18.20.

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Table 18.20 : Percent Total Energy From Different Macronutrients

Acceptable Macronutrient Distribution Range (AMDR)
Age Group Pregnant and
Nutrients Energy (E)
1-2 years 3-18 years Adults Lactating Women

Protein, % E (PE ratio)* 5-15 5-15 7.5-20 7.5-20

Total Fat, %E 35-40 30-35 20-30 20-30
n-6 PUFA#, %E 4-10 4-10 4-10 4-10
n-3 PUFA, %E 0.5-1 0.5-1 0.5-1 0.5-1
## EPA+DHA, mg / day 100 250 300 300-500
Carbohydrate, %E 50-60 50-60 50-60 50-60
# n-6 to n-3 ratio should be 5-10: 1
## EPA and DHA (long chain n-3) cab be obtained from an intake of 250 g marine fish (fatty fish) per week or by
consuming n-3 rich plant foods with an optimal dietary n-6 to n-3 fat ratio of between 5-10:1
Note: For good health, adults should consumme a minimum of 100 to 130 g of carbohydrates and at least 20 g fats
(food sources).
*The PE ratio is for quality of protein
Balanced diet for sedentary and moderately active man and woman is given in Tables 18.21, 18,22, 18.23 & 18.24.
Table 18.21 : Balanced Diet for Sedentary Man
Food Cereals Pulses & Green Other Roots and Fruits Milk Fats Oil Seeds Spices
Composition and Beans /Fresh Leafy Vegetables Tubers and and Nuts
Millets* Foods** Vegetables (excluding Oils (Gingely
Potatoes) Seeds
and
Peanuts)
Amount 270 90 100 200 100 100 300 30 40 10
(g / day)
Nutrients from the above suggested balanced diet for a sedentary man
Nutrients Vegetarian Diet Non-vegetarian Diet EAR RDA
Energy (Kcal) 2103 2089 2110 -
Protein (g) 72.6 77.6 43 54
Visible Fat (g) 30 30 25 25
Calcium (mg) 1016 1125 800 1000
Iron (mg) 27.9 26.0 11.0 19.0
Zinc (mg) 9.7 9.2 14.1 17.0
Magnesium (mg) 956 623 370 440
Vitamin A (mg)# 569 784 460 1000
B-carotene (mg) 2159 2128 2760 6000
Thiamine (mg) 1.65 1.45 1.2 1.4
Riboflavin (mg) 0.9 0.9 1.6 2.0
Niacin (mg) 11.5 12.0 12 14

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 INTRODUCTION TO NUTRITION

Food Cereals Pulses & Green Other Roots and Fruits Milk Fats Oil Seeds Spices
Composition and Beans /Fresh Leafy Vegetables Tubers and and Nuts
Millets* Foods** Vegetables (excluding Oils (Gingely
Potatoes) Seeds
and
Peanuts)
Vitamin B6 (mg) 1.2 1.2 1.6 1.9
Vitamin C (mg) 147 149 65 80
Total Folates (mg) 345 357 250 300
Vitamin B12 (mg) 1.5 2.0 2.0 2.2

*30 % or more grains can come from millets. 50% of cereals should be consumed as whole grains.
**Portion of pulses can be replaced with animal foods (e.g., egg, meat, fish and chicken) for non-vegetarians. #Retinol
derived from β carotene from diet also added to total Vitamin A.
Table 18.22 : Balanced Diet for Moderately Active Man
Oil seeds
Roots and
Cereals Pulses & Fats and Nuts
Food Green Leafy Other Tubers
and Beans / Fresh Fruits Milk and (Gingely
Composition Vegetables Vegetables (excluding
Millets* Foods** Oils Seeds and
Potatoes)
Peanuts)
Amount 390 130 100 200 100 100 300 30 45
(g / day)
Nutrients from the above suggested balanced diet for a moderately active man
Nutrients Vegetarian Diet Non-vegetarian Diet EAR RDA
Energy (Kcal) 2640 2516 2710 -
Protein (g) 91.5 99.3 43 54
Visible Fat (g) 72.1 83.6 30 30
Calcium (mg) 1134.6 1819.0 800 1000
Iron (mg) 34.3 32.7 11 19.0
Zinc (mg) 13.2 11.0 14.1 17
Magnesium (mg) 728.4 580.5 370 440
Vitamin A (mg)# 559.4 697.7 460 1000
B-carotene (mg) 2108 2052 2760 6000
Thiamine (mg) 2.2 1.8 1.5 1.8
Riboflavin (mg) 1.2 1.0 2.1 2.5
Niacin (mg) 15.1 13.8 15 18
Vitamin B6 (mg) 1.5 1.3 2.1 2.4
Vitamin C (mg) 151.5 152.3 65 80
Total Folates (mg) 444.3 414.5 250 300
Vitamin B12 (mg) 1.5 2.4 2.0 2.2

*30 % or more grains can come from millets. 50% of cereals should be consumed as whole grains.

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 NUTRITION AND FOOD SAFETY

**Portion of pulses can be replaced with animal foods (e.g., egg, meat, fish and chicken) for non-vegetarians. #Retinol
derived from β carotene from diet also added to total Vitamin A.
Table 18.23 : Balanced Diet for Sedentary Woman
Oil seeds
Roots
and Nuts
Cereals Pulses & Green and Fats
Food Other (Gingely
and Beans /Fresh Leafy Tubers Fruits Milk and Spices
Composition Vegetables Seeds
Millets* Foods** Vegetables (excluding Oils
and
Potatoes)
Peanuts)
Amount
200 65 100 200 100 100 300 20 30 -
(g / day)
Nutrients from the above suggested balanced diet for a sedentary woman
Nutrients Vegetarian Diet Non-vegetarian Diet EAR RDA
Energy (Kcal) 1645 1640 1660 -
Protein (g) 58.5 61.3 36 46
Visible Fat (g) 20 20 20 20
Calcium (mg) 940 1006 800 1000
Iron (mg) 23.6 22.5 15 29.0
Zinc (mg) 7.4 7.2 11 13.2
Magnesium (mg) 542 500 310 370
Vitamin A (mg)# 565 695 390 840
B-carotene (mg) 2138 2120 - -
Thiamine (mg) 1.3 1.2 1.1 1.4
Riboflavin (mg) 0.8 0.75 1.6 1.9
Niacin (mg) 9.2 9.5 9 11
Vitamin B6 (mg) 1.0 1.0 1.6 1.9
Vitamin C (mg) 147 148 55 65
Total Folates (mg) 284 293 180 220
Vitamin B12 (mg) 1.5 2.0 2 2.2

*30 % or more grains can come from millets. 50% of cereals should be consumed as whole grains.
**Portion of pulses can be replaced with animal foods (e.g., egg, meat, fish and chicken) for non-vegetarians. #Retinol
derived from β carotene from diet also added to total Vitamin A.

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 INTRODUCTION TO NUTRITION

Table 18.24 : Balanced Diet for Moderately Active Woman

Pulses & Beans /Fresh

Cereals and Millets*

(excluding Potatoes)

(Gingely Seeds and

Oil seeds and Nuts
Food Composition

Roots and Tubers

Other Vegetables

Fats and Oils

Green Leafy
Vegetables

Peanuts)
Foods**

Spices
Fruits

Milk
Amount
280 95 100 200 100 100 300 25 40 -
(g / day)
Nutrients from the above suggested balanced diet for a moderately active woman
Non-vegetarian
Nutrients Vegetarian Diet EAR RDA
Diet
Energy (Kcal) 2085 2208 2130 -
Protein (g) 72.6 95.8 36.0 46.0
Visible Fat (g) 61.8 65.3 25 20
Calcium (mg) 1045 1603 800 1000
Iron (mg) 28.5 32.3 15.0 29.0
Zinc (mg) 10.1 10.6 11.0 13.2
Magnesium (mg) 570.6 574.9 310 370
Vitamin A (mg) #
554.7 657.8 390 840
B-carotene (mg) 2078 2078 - -
Thiamine (mg) 1.7 1.8 1.4 1.7
Riboflavin (mg) 1.0 1.0 2.0 2.4
Niacin (mg) 11.8 12.7 12 14
Vitamin B6 (mg) 1.2 1.3 1.6 1.9
Vitamin C (mg) 151 152 55 65
Total Folates (mg) 361 464 180 220
Vitamin B12 (mg) 1.5 2.0 2.0 2.2
*30 % or more grains can come from millets. 50% of cereals should be consumed as whole grains.
**Portion of pulses can be replaced with animal foods (e.g., egg, meat, fish and chicken) for non-vegetarians. #Retinol
derived from β carotene from diet also added to total Vitamin A.

18.12 Dietary Goals.

Dietary goals as given by the National Institute of Nutrition, Hyderabad, are as follows:
(a) Maintenance of a state of positive health and optimal performance in populations at large by maintaining
ideal body weight.
(b) Ensuring an adequate nutritional status for pregnant women and lactating mothers.
(c) Improvement of birth weights and promotion of growth of infants, children and adolescents to achieve their
full genetic potential.
(d) Achievement of adequacy in all nutrients and prevention of deficiency diseases.
(e) Prevention of chronic diet-related disorders.
(f) Maintenance of the health of the elderly and increasing the life expectancy

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18.13 Dietary Guidelines.

The dietary guidelines given by the National Institute of Nutrition, Hyderabad, are as follows:
(a) Eat variety of foods to ensure a balanced diet.
(b) Ensure provision of extra food and healthcare to pregnant and lactating women.
(c) Promote exclusive breastfeeding for 6 months and encourage breastfeeding till 2 years or as long as one
can.
(d) Feed home-based semisolid foods to the infant after 6 months.
(e) Ensure adequate and appropriate diets for children and adolescents, both in health and in sickness.
(f) Eat plenty of vegetables and fruits.
(g) Ensure moderate use of edible oils and animal foods and very less use of ghee / butter / vanaspati.
(h) Avoid overeating to prevent overweight and obesity.
(j) Exercise regularly and be physically active to maintain ideal body weight.
(k) Restrict salt intake to minimum.
(l) Ensure the use of safe and clean foods.
(m) Adopt right pre-cooking processes and appropriate cooking methods.
(n) Drink plenty of water and take beverages in moderation.
(o) Minimize the use of processed foods rich in salt, sugar and fats.
(p) Include micronutrient-rich foods in the diets of elderly people to enable them to be fit and active.

Suggested Reading.
1. National Institute of Nutrition, India [Internet]. www.nin.res.in. [cited 2024 Apr 27]. Available from: https://www.
nin.res.in/RDA_short_Report_2024.html
2. NUTRIENT REQUIREMENTS FOR INDIANS RECOMMENDED DIETARY ALLOWANCES AND ESTIMATED AVERAGE
REQUIREMENTS -2020 A Report of the Expert Group [Internet]. [cited 2024 Apr 27].
3. Rajvir Bhalwar. Textbook of Community Medicine. Wolters kluwer india Pvt Ltd; 2023.
4. Gopalan C, Rama V, Balasubramanian SC, Rao N, Deosthale YG, Pant KC. Nutritive Value of Indian Foods. 2021.
5. MANUAL OF DIETARY Guidelines for Indians 2011NIN [Internet].[cited 2024 Apr 27].
6. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity VMNIS | Vitamin and
Mineral Nutrition Information System Background Description of technical consultation 2 Recommendations 3 Summary
development Acknowledgements [Internet].
7. Eat Right Textbook. Available from: http://www.foodfuturefoundation.org/eat-right-textbook
8. Agila Elumalai, C. Cynthia Leslie, V. Anitha, Balachandran A, Shanmugam Muthukali. The eminence of nutrition
in periodontal health and therapy—a review. Nutrire. 2024 Jan 5;49(1).
9. Hayamizu K, Matsumoto K, Izumo N, Nakano M. Estimation of L-lysine Requirement by Indicator Amino Acid
Oxidation Method Using Random Effects Model. International Journal of Nutrition and Food Sciences. 2020;9(2):63.
10. Barve S, Gore M, Dnyanesh Datir, Patil R. A study about awareness and utilization of “Nikshay Poshan Yojana”
benefits in selected tuberculosis units in Pune district in India. Indian Journal of Tuberculosis. 2023 Dec 1
11. Malik D, Nandita Narayanasamy, Pratyusha VA, Thakur J, Sinha N. Textbook of Nutritional Biochemistry. 2023.
12. Eastwood M. Principles of Human Nutrition. Boston, MA: Springer US; 1997.
13. Radha Kushwaha, Neha Taslim Fatima, Singh M, Singh V, Kaur S, Puranik V, et al. Effect of cultivar and maturity
on functional properties, low molecular weight carbohydrate, and antioxidant activity of Jackfruit seed flour. Journal of
Food Processing and Preservation. 2020 Dec 20;45(2).

480
 INTRODUCTION TO NUTRITION

14. Geissler C, Powers HJ. Human Nutrition. 2023.

15. Lagua RT, Virginia Serraon Claudio. Nutrition and Diet Therapy Reference Dictionary. Springer eBooks. Springer
Nature; 1996.
16. Suter PM, Russell RM. Vitamin requirements of the elderly. The American Journal of Clinical Nutrition. 1987 Mar
1;45(3):501–12.
17. Smith JE, DeMoor LM, Handler CE, Green EL, Ritter SJ. The complex between retinol and retinol-binding protein
is formed in the rough microsomes of liver following repletion of vitamin A-depleted rats1Presented in part at the
70th Annual Meeting of the Federation of American Societies for Experimental Biology, April 1986, St. Louis, MO [L.M.
Crumbaugh, E.L. Green, J.E. Smith, The subcellular location for the formation of the retinol/retinol-binding protein
complex in rat liver, Federation Proc. 45 (1986) 710] and submitted in part as theses to The Biochimica et Biophysica
Acta (BBA) - General Subjects. 1998 Mar 1;1380(1):10–20.
McKenzie. RC. “Selenium, ultraviolet radiation and the skin”, Clinical and Experimental Dermatology, 11/2000.
19. Passmore R, Nicol BM, Rao MN, Beaton GH, Demayer EM. Handbook on human nutritional requirements.
Monograph Series World Health Organization [Internet]. 1974 [cited 2024 Mar 6] ;(61):1–66. Available from: https://
pubmed.ncbi.nlm.nih.gov/4213699
20. Halem. N van . 8 Spijsvertering [Internet]. mijn-bsl. [cited 2024 Mar 6]. Available from: https://mijn.bsl.nl/8-
spijsvertering/398092
21. Chan S, Gerson B, Subramaniam S. The Role of Copper, Molybdenum, Selenium, and Zinc in Nutrition and Health.
Clinics in Laboratory Medicine. 1998 Dec;18(4):673–85.
22. Swaminathan R. Handbook of Clinical Biochemistry. 2011.
23. Bulliyya G. Key role of dietary fats in coronary heart disease under progressive urbanization and nutritional
transition. Asia Pacific Journal of Clinical Nutrition. 2000 Dec 29;9(4):289–97.
24. Sanders T, Ensminger AH, Ensminger ME. Foods and nutrition encyclopedia, 2nd edn, Vols 1 and 2 A. H.
Ensminger, M. E. Ensminger, J. E. Konlande & J. R. K. Robson CRC Press, Boca Raton, Florida, 1994, 2415 pp ISBN
0–8493–8980-1 (set). Journal of the Science of Food and Agriculture [Internet]. 1995 Jan 1 [cited 2024 Mar 6]
25. Montain SJ, Latzka WA, Sawka MN. Fluid Replacement Recommendations for Training in Hot Weather. Military
Medicine. 1999 Jul 1;164(7):502–8.
26. Nutritional Needs in Cold and High-Altitude Environments Applications for Military Personnel in Field Operations.
Washington, D.C. National Academies Press; 1996.
27. Day D, Young A, Askew E. Chapter 6 Nutrition and Military Performance Introduction Historical Role Of The
Importance Of Food In Military Operations Environmental Stress And Nutrient Requirements;Cold Altitude Heat Stress
of Military Training, Oxidative Stress, and Immune Function Sports Nutrition and Military Nutrition: Similarities and
Differences SUMMARY [Internet]. [cited 2024 Apr 27].
28. Nadiger N, Anantharamu S, Cn P, Vidal-Puig A, Mukhopadhyay A. Unique attributes of obesity in India: A
narrative review. Obesity Medicine [Internet]. 2022 Oct 1 [cited 2022 Dec 3]; 35:100454. Available from: h ttps://
www.sciencedirect.com/science/article/abs/pii/S2451847622000665
29. Ayoob S, Gupta AK, Bhat VT. A Conceptual Overview on Sustainable Technologies for the Defluoridation of Drinking
Water. Critical Reviews in Environmental Science and Technology. 2008 Sep 15;38(6):401–70.
30. Alfin-Slater RB, Kritchevsky D. Nutrition and the Adult. Springer eBooks. Springer Nature; 1980.
31. SARDESAI VISHWANATHM. Introduction to Clinical Nutrition 2nd edition, Revised and Expanded [Internet]. silo.
pub. 2010 [cited 2024 Mar 6]. Available from: https://silo.pub/introduction-to-clinical-nutrition-2nd-edition-revised-and-
expanded.html
32. CPT Scott J. Mountain. Fluid Replacement Recommendations for Training in Hot Weather. Military Medicine,
164, 7:502.1999.
n

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Chapter
XIX
RATION SCALES IN ARMED FORCES & THEIR IMPORTANCE

19.1 History of Military Nutrition.

The Napoleonic dictum, ‘An army marches on its stomach’ only crystallized the fact that troops must be given
enough to eat and are more efficient when well fed. The old armies mainly focused on the efforts of foraging parties
for their rations and if the land was barren of food, they faced starvation. No account was taken of the nutritive
value of different foods per se. Navies, on the other hand, were familiar with the fact that on long voyages, crews
were decimated by scurvy. As early as the 16th century the cure for scurvy with oranges and lemon juice has been
described. Captain Cook kept his crew entirely free of scurvy-an unprecedented feat, during his second voyage to
the South Seas (1772-75) by using a variety of substances, including germinating seeds and lime juice. Beriberi
was the scourge of the Japanese Navy prior to 1882, when it was eliminated by Admiral Takaki who increased
the allowances of vegetables, fish, meat and barley, issued in addition to the staple food of polished rice.
ln the 1914-18 war, the first direct use of modern nutritional science in military was made. Both the quantity and
quality of rations were intensively studied In the year 1916, the food shortage increased and rations had to be
provided in adequate quantity to achieve military efficiency.
Cathcart and Orr determined the energy expenditure of soldiers performing different types of work, while Plimmer
analysed all foods likely to be used in rations, tabulating their protein, carbohydrate and fat content and their
caloric values. This made it possible to calculate whether any ration provided enough energy for full military activity.
By World War II, rations had taken modern organized forms. The U.S. military revised their World War I era ration
organization system into an alphabetized system: A-rations of fresh food, B-rations of packaged unprepared food,
C-rations of prepared canned food, D-rations of chocolate and K-rations of three-course meals. British soldiers
were issued 24-hour rations intended to sustain troops until composite rations and fresh food could be supplied
by field kitchens.
The U.S. military, initially issuing the canned meal, combat, individual (like the C-ration) from the late 1950s
through the Vietnam War. They further developed the Meal, Ready-to-Eat (MRE) in 1983, designed to provide
easy-to-prepare individual meals in retort pouches that could last for very long periods of time. Later the British
24-hour ration gradually advanced from tinned rations to freeze-dried and vacuum-sealed rations.

19.2 Military Rations.

Military rations, operational rations or military provisions are items which are authorized and issued to personnel to
sustain their needs. As their name suggests, military rations are subject to rationing, with everyone receiving specific
amounts from available supplies. Military rations are a key component of military nutrition. Significant research goes
into creating military rations, including the nutrition and energy of rations, food spoilage prevention, what meals should
be offered, the amount of food each ration should contain and the exact specifications of each meal and ingredient.
Before the war of 1914-18, Indian troops received a cash allowance from which each man purchased his own food,
with the result that no nutrition control whatsoever was possible. Experience in Mesopotamia in 1916 underlined the
danger of such a system and after the war it was modified so that certain foodstuffs were supplied in kind and a
cash allowance was made to units and not individuals) from which additional items were purchased. The issues made
in kind in peace scale were atta or rice 24 oz, dal 3 oz, potatoes and ghee 2 oz each, sugar 1½ oz and salt 1/2 oz.
The field service ration scale included the same items as issued at present except that the quantities of meat and
dal were less by an oz, vegetable by 2 oz and the milk issued was almost half of the present quantity in the field
service ration scale. The ghee was supposed to be pure animal ghee, a fact which is still remembered by some old
soldiers with nostalgia.  
During World War II, the army expansion and rise in the cost of living brought difficulties in their turn. In some
places food was not available in sufficient amounts to be purchased with the cash allowance at any reasonable

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price. In 1943, a modified field service scale was authorized in ‘peace’ areas, which was converted into a basic
ration scale for all Indian troops in 1944. However, in 1945, due to shortage of food, further changes were made
to overcome the food shortage in India. The present scale for Army in peace areas is the modified basic scale of
rations and is given in appendix ‘A’. Later during  / after operations in J and K, special scales of ration as given
in appendices B to D were introduced for troops on field service, for troops located at heights of 2,700 m and
above and for officers on field service respectively. The scales of rations for the Navy and Air Force are given in
appendices E and F respectively.
The medical officers should advice local commanders on all issues related to nutrition of troops. Hence, all medical
officers should be acquainted with the salient nutritional characteristics of food and rations scales; requirements of
different food constituents under conditions commonly encountered in war; the manifestations of malnutrition; the
organization of supply and inspection of rations and the scope of catering and cooking in maintaining satisfactory
nutritional status of troops.
A variety of rations have been formulated for different purposes and are published in ‘Scales of Rations and
Supplies’ (SRS) issue by the Army Supply Corps which are frequently amended to suit the supply position and
requirements. The fundamental regulations regarding ration scales, provisioning and supplies are contained in DSR
paras 884 to 901. In addition to the ordinary services ration scales, special rations are available for road and rail
journeys, hospitals and for special operational purposes. Policy matters regarding ration scales are dealt with on an
inter-services basis by the Armed Forces Health Sub Committee of the Medical Services Advisory Committee. The
fundamental consideration is to satisfy the quantitative and qualitative nutritional requirements of Armed Forces
personnel working under different conditions. The basis taken for consideration are the human requirements of
energy proportions of proximate principles of dietary, optimum quantities and proportions of vitamins, minerals and
trace substances. These requirements are drawn out of various tasks required to be performed by the troops. Various
administrative, tactical and operational contingencies are also considered. Other factors which are considered are
the supply position, durability (shelf life) of items, habits and tastes of personnel and acceptability of the items.
Substitutes for short supply items and to relieve monotony are recommended with appropriate restrictions against
continuous use. In drawing up ration scales the medical services, the supply, the purchase organizations and the
food inspectorate actively collaborate. Armed Force rations normally contain fourteen basic items - atta, rice, pulses,
potatoes, onions, meat, vegetables, milk, sugar, tea leaves, oil hydrogenated, salt, fruit and condiments; firewood for
cooking is also included in the ration scales. To provide variety and to meet the market fluctuations of availability
of items, substitutes like fish, pork, eggs, fowl, nuts and dry fruits are also included in the provisioning schedules.
Not less than 40% of the vegetables are required to be green leafy vegetables. Tinned, dried, dehydrated or AFD
(Accelerated Freeze Dried) items are provisioned for use under field conditions when the supply of standard fresh
items becomes logistically difficult or impossible.  
At times when there is prolonged absence of standard fresh items from rations the rations can be fortified by
authorizing the issue of synthetic vitamins by the orders of the GOC-in-C under the advice of the MG (Med). The
intention of controlling this is twofold; to restrict unnecessary use of the expensive item and to incidentally keep
the GOC-in-C informed of the fresh rations’ breakdown.
The energy value of the usual Armed Forces rations scales ranges from 3,700 (peace scale) to 5,000 Kcal (high
altitude scale). Values of rations for any special circumstances i.e. physical emergencies as in combat and training
may vary according to the needs. The usual peace scale ration for Army personnel contains about 120 gm of
protein of which 21 gm is of animal origin, Retinol 1,206 mg, Thiamine 4.9 mg, Riboflavin 2.8 mg, Nicotinic acid
32 mg, Ascorbic acid 130 mg and Iron 85 mg. Nutritive value of certain Armed Force scales of ration are given
in Appendix N. Carbohydrate is mainly from cereals, pulses, sugar and potatoes; animal proteins are drawn from
meat and milk; vegetable proteins are drawn from cereals, pulses and a few vegetables; fats are drawn from
hydrogenated vegetable oils and milk. 20 g of salt evaporated is supplied to satisfy the salt demand and 20 g of
salt can also be issued extra in summer. Field service rations contain more cereals, milk, meat and oil but less
vegetables. The high-altitude ration scale yields about 5,080 Kcal (21.2 MJ) and has a high carbohydrate and high
protein proportion. High protein contained in a high-altitude ration has been achieved by addition of extra meat,
egg, chana flour (besan) and milk powder, while higher carbohydrate energy is supplied by jam and extra sugar.
Air force and Navy rations are richer in animal protein than Army rations. In order to counterbalance the tissue,
wear and tear and to fortify against stress of hypoxia and cold at high altitudes, higher ascorbic acid as well as
higher protein intake is necessary; therefore, additional 100 mg of vitamin C has been added.
The composite packs contain multivitamin tablets, matchboxes, hexamine cooker, water sterilizing outfit and tin

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opener. The use and role of composite pack rations is given in the pamphlet ‘Operations Feeding – Use of Special
Rations Pack India’. These rations provide food of adequate variety and nutritive value of about 3,500 Kcal
(14.6 MJ) which does not require cooking and which is packed to facilitate easy handling. Their principal use is
in the operations, ‘between’ the initial assault and the establishment of a normal chain of supplies and cooking
facilities, in jungle operations or for air dropping. The type ‘A’ ration pack is meant for meat eaters and type B
contains cooked dal for vegetarians. These rations are not to be used when basic rations can be provided. The
use of composite rations will be restricted to a maximum period of two weeks at a stretch. The present container
has 5 men’s ration for one day. These packs are stocked in selected supply depots to be issued to troops when
necessary and as ordered by the authorities. The emergency rations are normally issued to the ‘teeth’ part of
the field force before going into operations, to be carried by everyone in person in the tin or cardboard container
provided for the purpose in the WET of the unit. It is consumed by the troops under specific orders only when
the other types of rations cannot be made available. It is intended to be substituted only for 24 hours. The pack
consists of 230 g service biscuits and 110 g raisins providing about 1,200 Kcal (5.09 MJ) without any special
regard to the nutritive value as a whole or its requirement for any special task.
The ration scales for personnel in the armed forces (Army, Navy and Air Force), as well as for cadets at the National
Defence Academy in Khadakvasla, Indian Military Academy in Dehradun, Officers Training Academy in Madras,
College of Military Engineering in Pune, Armed Forces Medical College in Pune, Military College of Telecommunication
Engineering in Secunderabad and Military College of Electronics and Mechanical Engineering in Secunderabad, and
hospital diet follow the guidelines provided in the SRS tables attached as annexures to the chapter.  
Foods have different nutritional profiles. Moreover, the availability of foods varies at different places and in different
seasons. People from diverse cultures, religions and states tend to consume different types of foodstuffs; however,
a common aspect for good health of humans is the necessity of a well-balanced diet. A brief description of the
main basic food items issued in armed forces rations are as given below:
(a) Cereals.
These form the staple food in nearly every human diet since they are cheap and have a high energy value. In
an agricultural country, rice, maize, wheat and millets form the bulk of the diet and a relatively small amount of
the protective foods rich in vitamins and minerals are consumed. Thus, the nutritive quality of the staple cereals
is of great importance in India. Cereals are rich sources of carbohydrates and moderate sources of proteins.
The quality of the protein varies, that of rice having a somewhat higher biological value than wheat protein. A
predominantly cereal diet should invariably contain supplementary sources of protein; for vegetarians, pulses
are very valuable in this respect. Cereals contain no vitamin C and little carotene. Whole (unrefined) cereals are
relatively good sources of the vitamin B complex, whereas refined cereals such as white flour (Maida) and highly
milled rice lose much of their vitamin content in processing. This is because the vitamins are concentrated in
the outer layer of the whole grains, which are removed by machine milling. Machine milling and refining cause a
considerable deterioration of nutritive value of staple human foods. For example, beriberi is endemic in countries
where polished rice is habitually eaten.  
Cereals are moderate sources of proteins (about 6–12 g  / 100 g). Cereal protein is of poor quality as it is deficient
in essential amino acids. Wheat proteins are deficient in lysine and threonine and maize in tryptophan. Pulse
proteins, on the other hand, are rich in these deficient amino acids, i.e. lysine and tryptophan (but are deficient in
methionine, which is the limiting amino acid for pulses). A predominantly cereal diet should, therefore, invariably
be supplemented with other sources of proteins such as pulses, especially for the vegetarians. This helps to
improve the quality of proteins in our diet. This is called the supplementary action of proteins, for example,
eating rice with pulses. Cereals provide quantitatively ample protein in an otherwise protein-deficient Indian diet.
As much as 50% of total proteins in Indian diet are contributed by cereals.
Rice is high in energy (about 350 kcal  / 100 g). The protein content is moderate, 6–9 gm%. It is richer in lysine
than other cereals. Rice is also rich in thiamine, riboflavin and niacin. It is a poor source of vitamins A, C and D.
It is poor in calcium and iron as well. Milling and polishing cause the greatest nutritional loss. During processing
the B-complex vitamins, fibre and proteins are lost to a great extent. Similarly, draining of the water in which rice
is cooked also causes loss of water-soluble nutrients. Rice supplied in Armed Forces rations is either undermilled
or parboiled.  
Brown Rice is a whole grain. It contains all parts of the grain the fibrous bran, the nutritious germ and the
carbohydrate rich endosperm. It has more fibre, vitamins and minerals as compared to white rice. Though white

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rice is the most consumed type, brown rice is widely recognized as a healthier option.
Poha is made by partly cooking paddy and then drying it out in the sun for hours until it turns a bit harder. They
are then pounded and flattened to give the form of ‘flat rice’ or Poha.
Wheat is used to make flour (Atta for Chapattis and Puris), Maida for bread, Dalia and Suji, to make various
savouries. Wheat contains gluten and certain individuals are allergic to this protein and suffer from a disease
called celiac disease. Such people should avoid eating gluten, a protein found in wheat, barley and rye. The
calorie content of wheat is almost the same as that of rice, i.e. about 350 kcal  / 100 g. The protein content is
higher, i.e. 9–16 gm%. The quality of protein is, however, poor as it is deficient in essential amino acids lysine
and threonine. Hard milling, extraction and discarding the bran cause loss of fibre, vitamins and proteins. It is
advisable to consume whole wheat Atta and Dalia. Products made of refined flour such as white bread, biscuits,
cakes, noodles and burgers should be discouraged.
Extraction Rate (ER) is the amount of white flour that is extracted from a given weight of clean and conditioned
wheat. It is expressed as a percentage of the wheat entering the first break rolls in a roller milling system. A
wheat kernel is composed of three parts, germ (embryo), endosperm and bran (pericarp). Using average values,
the germ constitutes 2.5%, the bran 14.5% and the endosperm 83% (starchy portion that contains gluten-forming
proteins) of the wheat kernel weight. Complete separation of the bran, endosperm and germ can never be
achieved by the dry milling process. Therefore, the theoretical yield of approximately 83% flour (or 100% pure
endosperm) is never achieved. In practice, extraction rate values of 72–76% are normally obtained in efficient
mills depending on the class of wheat used. Higher extraction rate values (>83%) will always mean a greater
proportion of bran particles in the resulting flour. Table shows composition of flours of various percentages of
extraction.
Table 19.1 : Constituents of Flour of Different Percentages of Extraction
(Values in Per 100 gms)
Flour Extraction (%) Protein (g) Fats (g) B1 (mg) B2 (mg) B6 (mg)
42-45% 11.8 0.9 0.03 0.05 0.6
80% 13.2 1.4 0.25 0.07 1.6
85% 13.6 1.7 0.36 0.08 2.0
92% 13.6 2.5 0.40 0.16 5.0
Atta produced for the Armed Forces is of 85% extraction and not more than 5% bran is permitted to be removed
during milling. Parboiled rice is the only cereal which does not suffer appreciably when machine milled. The
parboiling process consists of steaming the paddy after preliminary soaking so that the outer husk splits and
becomes easier to remove. This also causes the B group vitamins in the outer layers to diffuse into the interior
of the grain.
Maize is commonly eaten only as corn. It is also used to make cornflakes. Corn flour is used in confectionery
and to make custards. The calorie content of maize is about 342 kcal  / 100 g. The protein content is higher
than that of rice, i.e. 9–16 gm%. The quality of protein is poorer as it is deficient in lysine and tryptophan. It
also contains excess leucine, which interferes with conversion of tryptophan to niacin (60 mg of tryptophan is
required to produce 1 mg niacin). Thus, maize eaters may face deficiency of niacin and a higher risk of pellagra.
Maize is also rich in carotenoids.
Millets are coarse cereals and are consumed without milling. The commonly used millets are Jowar (sorghum),
Bajra (pearl millet) and Ragi. These are traditional foods in many parts of India. Millets hold great potential in
contributing substantially to food and nutritional security of our country and thus they are not only a powerhouse of
nutrients, but also climate-resilient crops and possess unique nutritional characteristics. They contain antidiabetic
properties and have low GI index and reduce the postprandial blood glucose level and glycosylated haemoglobin.
The Government of India has recently renamed jowar, bajra, ragi and other millets as “nutri cereals,” dispensing
with the nomenclature “coarse cereals.” This has been done to remove the wrong perception that these grains
are inferior to rice and wheat, as their health benefits are larger. Millets comprising Sorghum (Jowar), Pearl Millet
(Bajra), Finger Millet (Ragi  / Mandua), Minor Millets — Foxtail Millet (Kangani  / Kakun), Proso Millet (Cheena),
Kodo Millet (Kodo), Barnyard Millet (Sawa  / Sanwa  / Jhangora), Little Millet (Kutki) and two pseudo-millets — Buck
wheat (Kuttu) and Amaranthus (Chaulai) — have high nutritive value. According to the Indian Council of Medical

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Research, compared to rice, Foxtail millet has 81% more protein and little millet has even higher quantities of
fat, fibre and iron, as compared to rice. The calorie content of millets is about 350 kcal  / 100 g. The protein
content is 8-14 gm%. They are also rich in minerals. Ragi contains a high amount of calcium (344 mg  /
100 g). Jowar is important millet in western and central India (especially Maharashtra, Madhya Pradesh and
Andhra Pradesh) and is the staple food for many Indians. It is a nutritious millet with a high iron content of
4.1 mg  / 100 g. The protein content is in the range of 9–14%. Like other millets, protein is limited in amino
acids lysine and threonine. In some species, the leucine content is high, which interferes with conversion of
tryptophan to niacin; thus, Jowar taken as the sole food could be pellagrogenic. Bajra (Pearl millet) is grown in
arid regions of our country. It is relished in Rajasthan, Gujarat and parts of Maharashtra as porridge. It is also
used to make flour for preparing Chapatis. The protein content is in the range of 10–14%. The iron content of
Bajra is highest among all cereals and millets at 8 mg  / 100 g. It is also relatively rich in calcium, carotene,
riboflavin, niacin and folic acid.
Oats (Avena sativa) are cereal grass (family Poaceae) grown primarily for its edible starchy grains. Oats are widely
cultivated in the temperate regions of the world and are second only to rye in their ability to survive in poor
soils. Although oats are used chiefly as livestock feed, some are processed for human consumption, especially
as breakfast foods.
A pseudo cereal is one of any non-grasses that are used in much the same way as cereals (true cereals are
grasses). Their seed can be ground into flour and otherwise used as cereals. Examples of pseudocereals are
Amaranthus, quinoa, chia and buckwheat (kuttu ka atta).
(b) Meat.
Meat is a word commonly used for flesh of cattle (beef), goat and sheep (mutton), pig (pork) or chicken. It is
a good source of high-quality protein (15–20 g  / 100 g). Moreover, this protein is qualitatively as good as that
of fish, egg, milk, cheese and other dairy produce, since it contains all essential amino acids. It is also a good
source of most B vitamins including nicotinic acid. Meat is rich in phosphorus, but poor in calcium. Meat is
also rich in minerals, especially iron and zinc. The iron content of meat is of the heme variety, which has high
bioavailability. Meat has a high content of fat, including the saturated fatty acids, which may be a risk for good
health. Liver, a component of meat, is rich in vitamin A and B complex.
Fish is good for health, as it is rich in unsaturated fatty acids including omega-3 fatty acids and vitamins A and
D. Fish is rich in high quality easily digestible proteins (15–25 g  / 100 g). Sea fish is also rich in minerals such
as iodine. With the current emphasis on higher intake of polyunsaturated fatty acid (PUFA), including omega-3
fatty acids fish is of immense value in diet.
Meat extracts are of use in hospital dietetics on account of their mild stimulant action on the secretion of
gastric juice. Meat extracts are regarded as a reasonably good source of vitamins of the B complex. The forms
of preserved meat that may be issued in the Armed Forces rations are meat dried (mince and chunk) solid meat
pack, dehydrated meat and Accelerated Freeze Dried (AFD) meat. Generally, all these are good substitutes for
fresh meat as no extracts are removed from them. However, with the exception of AFD meat, they tend to cause
monotony in the diet when issued daily. AFD meat is an excellent substitute for fresh meat as it approximates
closely to the fresh article when it is reconstituted. It is estimated that 30 to 40% of Thiamine. and up to 10%
of Riboflavin and Nicotinic acid are lost in the process of ordinary dehydration and canning of meat. In case of
AFD products, however, the vitamin losses are negligible. The Army rations contain 100 to 110 g of meat and
Naval and Air Force rations contain up to 180 g of meat a day.
(c) Milk.
It is the sole food for growing young animals, it is as nearly complete a food as exists in nature. All the important
nutrients are well represented in milk except iron, nicotinic acid and ascorbic acid. On the average, one Liter
of cow’s and buffalo’s milk respectively yield 32 g and 43 g of protein, 41 g and 88 g of fat, 44 g and 50
g of lactose, 520 mg and 480 mg of retinol, 670 and 1,170 Kcal of energy and 1,200 mg and 2,100 mg of
calcium. Milk proteins are caseinogen (85%), lactalbumin (12%) and lactoglobulin (3%). These proteins are of
high biological value. Caseinogen is a phosphoprotein and is not coagulated by heat. Casein exists in solution
with calcium phosphate. Milk fat is an emulsion of extremely fine particles of the glycerides of butyric, palmitic
and oleic acid rendering it easily digestible and this is especially so in cow’s milk. Newly drawn milk contains
2 mg of vitamin C per 100 ml, but this readily disappears on storage, heating or processing in any other way.
When lactose in milk is broken down to lactic acid by bacterial (lactobacilli) action, the proteins are coagulated

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by the acid and the curd is formed. Curd and whole butter milk have the same nutritive values as that of the
original milk from which they are prepared and are easily digestible. Whole milk, curd and butter milk are all
very good sources of growth promoting animal protein, calcium, vitamin A and riboflavin and are most valuable
supplements to an ordinary Indian diet, especially the pure vegetarian diet. They are indispensable for the
feeding of children and adolescents up to young adult age, pregnant women, lactating mothers, patients and
convalescing persons. Skimmed milk and butter milk made from it have less fat content than the whole milk due
to extraction of butter. Cream, butter and ghee are gradations of fat extracted from milk. Cream has nutritive
value in between whole milk and butter. Good butter should not contain more than 16% of water and not less
than 80% of fat. 100 gm butter yields about 730 Kcal and 671microgram of retinol. 100 g of ghee yields
900 Kcal and 270 mg of retinol, which is however destroyed if ghee is used as a frying medium. The free ration
issued is either a mixture of buffalo’s and cow’s skimmed milk, designated as standard milk or a mixture of
buffalo’s whole milk and powder skimmed milk, designated as blended milk. The fat content of both these types
of milk should be 3.7%, solids not-fat 8.5% to 9.0% and total solids not less than 12.5%. Toned milk can be
manufactured by adding 1 part water and 1 / 8th part skimmed milk to 1 part milk. This blend is then stirred,
pasteurized and bottled. It becomes quite similar to cow’s milk.  
In peace areas, army ration scales contain 250 ml of milk fresh-standard or blended, the Naval rations
190 ml and Air force rations 150 ml. When fresh milk cannot be made available whole powdered or tinned milk
is supplied. Tinned milk may be condensed, evaporated or homogenized; condensed milk may be sweetened or
unsweetened. Condensed milk contains 50% cane sugar, which is a good preservative. Dried or powered milk is
reconstituted by adding 7 volumes of boiled water just before consumption. Tinned milk should be reconstituted
as per instructions given on each tin. Tinned or powered milk after reconstitution conforms to the specifications
laid down for fresh standard or blended milk except that it is deficient in vitamin C.
Milk Products.
Milk is used to prepare curd, yogurt, butter, ghee and buttermilk. These are used extensively for the preparation
of many traditional Indian sweets.
Curd is traditionally relished in Indian diet. It is produced by the action of lactobacilli on lactose (in milk), which
is broken down to lactic acid. The proteins are coagulated by the acid and curd is formed. Curd and whole butter
milk are easily digestible. They have the same nutritive value as that of the original milk from which they were
prepared, being Curd: very good sources of protein, calcium, vitamin A and riboflavin.  
Cream, butter and ghee are the Cream, Butter and Ghee. various types of fats extracted from milk. Cream can
be extracted by centrifugation of unboiled milk. Butter is the fat extracted from buttermilk. Ghee is the clear fat
extracted after boiling butter. Cream has nutritive value in between that of whole milk and butter. Good butter
should not contain more than 16% water and not less than 80% fat. 100 grams of butter yield about 729 kcal.
On the other hand, ghee is almost 100% fat, 100 grams of ghee yielding 900 kcal.
(d) Eggs.
In rations eggs are issued not by weight but by number. For average estimations, the minimum weight laid
down is not more than 25 eggs to the Kg and not less than 35g per egg. An egg provides about 70 kcal and
contains about 6 grams of protein. The proteins are of high biological value. The net protein utilization (NPU) of
egg protein is 100 and is taken as the standard protein with which other proteins are compared. An egg yolk
contains about 6 grams of fat. It is finely emulsified and, hence, easily assimilated. It also has a high cholesterol
content of 250 mg. The minerals and vitamins exist in the yolk, which is also a valuable source of calcium,
phosphorus, iron and vitamins A and D. The white of the egg is one of the best sources of riboflavin. Egg is,
however, deficient in vitamin C. The white of the egg is one of the best sources of riboflavin. Eggs are issued in
hospital dietary and high-altitude rations; in all other rations they are issued in lieu of meat. Egg powder may
be issued if fresh eggs are not obtainable.
(e) Vegetables.
Majority of the green leafy vegetables, are rich in carotene, ascorbic acid, calcium. iron and riboflavin. The
carotenoids and vit C possess antioxidant properties. The carotene of green vegetables like drumstick, amaranth
and methi is better utilized than of yellow vegetables. A progressive loss of vitamin C occurs when vegetables
are stored, bruised and cut. Cooking of green leafy vegetables in small quantity of oil (sauteing) increases the
retention rate of carotenes to between 41 to 100%. Due to their high moisture and fibre content, the calorie

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content of most of the green vegetables is in the range of 20–60 kcal  / 100 g.
Root and tuber vegetables are of variable nutritive value. Most of them contain moderate amounts of ascorbic
acid. The carrot is outstandingly rich in carotene. Gourd, so prolific during the summer when other types are
scarce, are generally of poor nutritive value; but the bitter gourd is relatively rich in ascorbic acid and the yellow
pumpkin is a fairly good source of carotene. Potatoes and sweet potatoes having a high carbohydrate content,
have a good fuel value and contain moderate quantities of ascorbic acid. The tomato has good carotene, ascorbic
acid and riboflavin contents. The onion has no outstanding nutritive properties but is virtually irreplaceable
because of its value as a flavouring agent and appetizer. Vegetables contain ample amounts of carotene, ascorbic
acid, folic acid, calcium, iron and riboflavin. The carotenoids, vitamin C and numerous other phytochemicals
possess antioxidant properties. Yellow vegetables such as pumpkin are rich in carotene. However, the carotene
of green vegetables such as drumstick, cabbage, amaranth and Methi is better utilized than that of yellow
vegetables. Gourds are generally of poor nutritive value, but the bitter gourd is relatively rich in ascorbic acid.
Tomato has good ascorbic acid, riboflavin and antioxidant lycopene contents.  
Vegetables are also a good source of minerals such as calcium, phosphorus, iron, zinc and trace elements. The
absorption and bioavailability of some minerals may not be very good. Iron from green leafy vegetables is not
very well absorbed, as it is present in ferric state, which is not conducive for absorption. In addition, calcium,
oxalates, phosphates and phytates present in vegetables further inhibit absorption of minerals.
Vegetables are rich in fibre, especially soluble fibre. Fiber is considered extremely important for normal bowel
motility, getting rid of toxins from the intestine and guarding against the rapid absorption of glucose and lipids,
thus preventing hyperglycaemia and hyperlipidaemia.
Canned vegetables have nutritive values equal to that of fresh, well-cooked vegetables of the same varieties
except that 50% vitamin C is destroyed during processing. Dehydrated vegetables lose some ascorbic acid and
vitamin A in processing and the remaining vitamin C is unstable. An accelerated freeze dying process, however,
retains most of the nutrients to a very high degree. In Army rations 80 gm of vegetables are issued; in Navy
and Air Force rations 160 g are issued. Not less than 40% of the vegetables should be green leafy vegetables.
Potatoes and onions (110 and 60 g respectively) are issued as separate items of rations.
(f) Pulses.
These comprise dried peas, beans, dals and grams. Dals are arhar, moong, urd massor or channa. They have
a high protein content, although with biological values inferior to foods of animal origin like meat, fish eggs
and milk. They are nevertheless, very suitable for supplementing the vegetarian diet. Pulses are cheap and a
valuable source of calcium, iron and Vitamin B. Bengal gram (channa dal) and to a lesser extent green gram
(moong dal) contain a small amount of ascorbic acid in the dry state. Soybean is a pulse, which has very high
protein (43.2 g  / 100 g) and fat content (19.5 g  / 100 g). It possesses high contents of iron as well. It is also
rich in carotene, niacin and folic acid. By virtue of its high fat contents, its oil is extracted and used as cooking
oil. This oil is one of the very few oils rich in alpha-linolenic acid (>5%), besides its high contents of linoleic acid
(53%). Soybean is truly the “queen” of pulses and legumes. The ascorbic acid content of all unsplit pulses can
be increased by germinating or sprouting. Whole unsplit dal or gram is first soaked in water for 12 to 24 h and
then spread on a damp blanket in a thin layer to allow access of air and covered with another blanket kept
damp by sprinkling water. In a few hours small sprouts appear when these are 10 to 20 cm long the process is
complete. The vitamin C content is maximal after about 30 h of germination. Boiling for 10 min causes a loss
of vitamin C from 15 to 30%. Germination causes an important increase in certain components of the vitamin
B complex also. Service rations contain 90 g of pulses. In addition, army ration scale for peace areas and ration
scale for high altitude areas contain channa dal flour (besan) 15 g and 30 g respectively.
(g) Fruits.
These are classified into citrus, non-citrus and dried varieties. They are inexpensive sources of antioxidants. Citrus
fruits are rich in vitamin C. Bottled lime juice supplied to hospitals and canteens is usually synthetic and completely
devoid of antiscorbutic properties. The loss of vitamin C in cooking of fruits and in the process of canning and bottling
is less than vegetables owing to the acids in fruit juices. Guavas are a very rich source of vitamin C. Papaya and
mango are rich in carotene and moderately rich in vitamin C. Banana and plantain have energy value but are not
particularly good source of vitamins. Tinned fruits are equal in nutritive value to well-cooked fresh fruits of the same
varieties but most varieties in common use are poor antiscorbutic. Dried fruits contain neither thiamine nor vitamin
C. Dried apricots, prunes and yellow peaches are a good source of carotene. Service rations provide fresh fruit citrus

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or non-citrus 50 g or 100 g respectively. A recommendation of a daily intake of at least 400 g of fruits and vegetables
for every adult has been made by the World Health Organization. It is wise to consume fresh, seasonal and locally
available fruits rather than buying costly or imported fruits.
(h) Nuts.
The common nuts in use are almond, cashew nut, groundnut, coconut, pistachio, walnut, etc. Nuts have high
fat and protein content and, hence, high energy value. They are a good source of fats, vitamins and proteins
as well. They contain minerals too in sufficient quantities. Pistachio is rich in iron, containing 7.7 mg  / 100 g.
Groundnuts are a good source of proteins, fats and vitamin B complex (niacin). These are also a rich source of
proteins. Almond and cashew nuts are also moderate sources of iron and proteins.  
Groundnuts are the cheapest and arguably the most nutritious of all nuts. Groundnut contains almost as much
oils and fats as an oilseed does (40%). Its Monounsaturated Fatty Acid (MUFA) content is one of the highest
among all Indian oilseeds, at 50% (exceeded only by mustard and rape seed). Its protein content is very high
(25.3%). Its niacin content is unmatched (about 20 mg / 100 g), i.e. 5–20 times higher than that of other nuts.
Owing to its low cost and high nutrition value, groundnut is used in “multipurpose food” (a mixture of 75%
groundnut flour and 25% roasted red gram). Its low cost, high nutritive value, immense variety of preparations
and delicious taste crowns the groundnuts as the “king of nuts.”
(j) Fats and Oils.
Fats and oils hold a vital place in our daily diet. They are an integral part of cooking as they not only impart good
taste but also contribute the texture, crispness and energy to our food. They also serve as a medium for cooking
as their boiling point is very high. Fats that are liquid at room temperature are termed oils. Fats and oils could
be of either plant or animal origin. Vegetable oils such as mustard, groundnut, gingelly, coconut and safflower
oils are widely used for cooking purposes. Vegetable oils (except red palm oil) are free of any vitamin A activity
and contain predominantly unsaturated fatty acids. However, coconut and palm oils are the only commonly used
plant oils that are rich in saturated fatty acids. Butter and ghee are fats of animal origin. These are also used as
a cooking medium. They are rich in vitamins A and D. All fats and oils provide 9 kcal of energy per gram. Excess
consumption of these is harmful as they are atherogenic. Excess consumption also contributes to Dyslipidaemia,
a risk factor for cardiovascular diseases. Groundnut, cotton seed and coconut oils are of importance as they
are used for hydrogenation to form vegetable ghee and margarine. Margarine and hydrogenated oils must be
fortified with synthetic retinol to the extent of 7.5 mg per g under statutory requirements. Armed Forces rations
contain 70 to 85 g of hydrogenated oil  / refined oil.
(k) Sugar.
It is pure sucrose and is used for its sweetening effect and energy value. Excessive consumption of such purified
food at the expense of energy provided in protective food lowers the vitamin, mineral and protein intake. On the
other hand, troops do benefit from a liberal sugar ration: hot sweet tea is a traditional reviving agent for fatigued
troops. Jaggery contains an appreciable amount of carotene and iron. Jams have the nutritive value of sugar
and increase the palatability of diets. Troops rations contain 70 to 90 g of sugar; high altitude rations contain
140 g of sugar and 14 g jam.
Jaggery is a sweet food popular in rural India. Besides being tasty, it contains an appreciable amount of carotene
and iron. There are occasions when sugar substitutes have to be used instead of sugar. They are quite popular
among diabetics and people desirous of losing weight. Sugar substitutes are classified into two groups as follows:
(i) Nutritive Sweeteners.
Sugar alcohols (sorbitol, mannitol, xylitol) are used as sugar substitutes in candies, chewing gum and
beverages. These provide 4 kcal  / g of energy. These are not absorbed as rapidly as sucrose and the risk
of dental caries with them is lower, as these alcohols cannot be used by oral bacteria.  
(ii) Non-nutritive Sweeteners.
These do not supply any calories. Common examples are aspartame, sucralose, alitame and saccharin.
They are several hundred times sweeter than sugar, so a small quantity is sufficient to sweeten the food.
(l) Spices, Condiments, Pickles and Chutney.
Most people use spices to flavour food and improve its palatability. They are essential to the culinary art and

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by stimulating the appetite improve health. They have little nutritional value as they are used in very small
quantities. Green or dry chillies have a high carotene and vitamin C content: certain other common spices also
have a high carotene content. Pickles and chutney are appetisers. Tamarind has preservative effect on vitamin C
if cooked along with vegetables. Turmeric, cloves and red chillies have been shown to have antioxidant properties
by inhibiting lipid peroxidation. Service ration scales permit allowance for 16 g of condiments.
(m) Beverages.  
(i) Non-alcoholic.
By themselves tea, coffee, cocoa or other non-alcoholic beverages may not provide energy or vitamins,
except for the sugar and milk added to them. Tea contains alkaloids such as caffeine, theophylline and
theobromine, which are cortical stimulants and help relieve fatigue. If used in excess, they may cause
insomnia, tachycardia and gastritis in some individuals. Recent studies show that tea contains substantial
amounts of antioxidants, which have distinct health benefits.
(ii) Alcoholic.
One gram of ethanol gives 7 kcal. The common alcoholic beverages consumed are beers (alcohol content
3–8% volume for volume (v  / v)), wines (alcohol content 10–20%, v  / v) and spirits such as rum, whisky,
brandy and gin (alcohol content 40–45%, v  / v). Usually, the level of distillation is “75% proof.” . Accordingly,
one small peg measuring 30 ml of spirits would have 10 grams of ethanol and would give 70 kcal of energy.
From a health point of view, alcohol usage is not recommended since alcohol consumption is linked to
various health hazards.
(n) Salt.
It contains the essential mineral sodium. Even though the daily sodium requirement is very low, an average daily
diet contains salt much in excess. The recommended daily salt intake is 5 grams. Excess of salt and a skewed
sodium: potassium ratio (>1) is known to be causative factors of hypertension. The average Indian consumes
nearly double the recommended amount of salt every day. It is the added salt that is harmful to the body rather
than moderate amounts put in food.
(o) Vitamin Concentrates.
These are normally available through ASC sources for supplementing dietary deficiency to prevent diseases and
preserve health; and through medical stores for therapeutic purposes to treat ailments. The multivitamin tablets
available through ASC contain vitamin A 5000 IU, vitamin D 500 IU, thiamine 2 mg, riboflavin 3 mg, nicotinic
acid 20 mg and ascorbic acid 75 mg and other vitamins of B group, zinc, selenium etc. They should not be
issued unless there are clear indications that the rations are deficient in vitamins. With special ration scales,
when the tablets form a component part of the rations these tablets are incorporated in the pack or scales
themselves and the issue is automatic. When an outbreak of vitamin deficiency disease is anticipated through
continued absence or severe shortage of supplies of fresh fruits and vegetables or of meat and milk and their
substitutes, authority to recommend to the Army Commander the issue of compound vitamin tablets to the
affected troops under his command with ordinary rations is vested in the MG (Medical) Command. The scale
of issue for prevention of disease is one tablet per man per day. There is no need for vitamin concentrates if
the diet contains adequate amounts of the vitamins. Excessive use of multivitamin tables has no benefits. The
medical officer should know that the multivitamin tablets issued through medical stores are much costlier and
less available than the ration compound tablets issued through ASC sources and contain therapeutic doses of
all vitamins and 8 important minerals. Therefore, the medicinal tablets obtained through medical stores should
not be issued in lieu of the ration multivitamin tablets issued by ASC.

19.3 Effects of Processing Foods.

Food processing aims to improve the colour, appearance, palatability, taste and texture, keeping quality and
marketability of food. It makes the food attractive and may increase its shelf life. Under special situations such
as space travel, high altitude expeditions, disaster aid situations and combat missions, only processed food is used.
Processing helps to remove toxins and it eases the marketing and distribution of foods. In addition, it increases
seasonal availability of many foods and enables transportation of delicate, perishable foods across long distances.
Food processing techniques are also used to add extra nutrients such as minerals and vitamins to the food
preparations. Some Common food processing techniques include Pureeing (vegetables and fruits), Liquefaction (fruit

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juice), Pickling (vegetables), Fermentation (soy, beer, cocoa), Baking (cakes, pastries, bread), Cooking (most foods),
Sprouting (cereals, pulses), Frying (French fries, Pakoras), Steaming (rice), Grilling (chicken), Boiling (vegetables),
Pasteurization (milk), Carbonation (beer, soft drinks), Spray drying (milk powder), Packaging (commercial foods),
Dehydration (fish, vegetables, soup powders), Canning (juices, fruits, fish), Freeze drying (meat). Variable quantities
of nutrients are lost during processing. Processed foods, however, do not normally form the actual constituents of
dietaries in the Armed Forces to any appreciable degree under normal conditions. Dried or tinned food stuffs must
be issued under adverse tactical or operational conditions or to tide over the temporary administrative / logistic
breakdown. Some common food processing techniques are discussed below:
(a) Cooking.
Effects of cooking vary greatly according to the method of preparation, cooking and serving. The losses are mainly
due to destruction by heat and / or extraction into washing or cooking water which is not consumed. The latter is
the most important of the two. The losses affect the vitamins and minerals. To minimize vitamin C destruction
in green vegetables they should be used when fresh, stored in cool damp places; crushing and bruising should
be avoided: the cooking time should be reduced to a minimum and cooking water be used up while cooking or
added to other items being cooked at the time. Food should be served as soon as possible after it is cooked. It
is better to allow it to cool and reheat, when necessary, rather than keep it hot; these conserves more vitamin
C. Rapid frying before boiling leads to conservation of vitamin C by hydrolyzing C vitminase.
(b) Tinning.
Tinned foods have the same nutritional values as cooked fresh foods and are good substitutes for fresh items. A
tinned diet is not necessarily lacking in nutrients compared to a fresh diet. On the other hand, a diet based on
fresh items offers a much greater variety than a tinned diet. For this and administrative and financial reasons,
a military ration composed of fresh foods is preferable to tinned rations.
(c) Dehydration, Drying and Freeze Drying.
Dehydrated and dried foods are those from which moisture has been extracted by evaporation. ‘Dehydration’ is
a term used when the evaporation has been carefully regulated as part of the factory process under controlled
temperature and moisture conditions, with the intention that the essential characteristics of the food should not be
altered and perfect reconstitution should take place when moisture is replaced. ‘Dried’ food is generally prepared
by exposure to sun. which results in a food with different characteristics to the original article and does not
reconstitute well. Freeze-drying is carried out by subjecting the cooked (or uncooked) foodstuffs to freezing and
extraction of moisture in a vacuum. The nutritive qualities of freeze-dried and precooked foods remain unaltered and
they reconstitute better than the dehydrated foods. These foods are used in composite pack rations or emergency
rations. Dried milk (milk powder) reconstitutes to an excellent substitute for fresh milk.

19.4 Fortification of Food.

Food fortification is the process by which nutrients are added to the commonly eaten foods at levels higher than
those found in the original or in comparable foods to improve their quality. WHO defines food fortification as “the
process whereby nutrients are added to foods in relatively small quantities to maintain or improve the quality of diet
of a group, a community or a population.” The food that carries the nutrient is referred to as the food vehicle; the
nutrient added is called the fortificant. While choosing an ideal food vehicle, the following aspects are considered:
(a) The food should be consumed by all population groups that are at risk of the nutritional deficiency.
(b) The food should be used regularly and in consistent amounts by the entire population at risk.                                                                                                                     
(c) Taste, appearance and smell of the food should not change after fortification.    
(d) The fortificant should remain stable under extreme conditions of cooking, food processing, delivery and
storage.                                                                                            
(e) The food should not be consumed in amounts that would present a risk of consumption at toxic levels of
the fortificant.      
(f) The fortificant should not increase the cost of food.
Fortification of food is a public health measure aimed at reinforcing the usual dietary intake of nutrients with
additional supplies to prevent  / control some nutritional disorders. A food fortification program is usually undertaken

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when there is a widespread and consistent nutritional deficit in the population’s diet. Food fortification has been
commonly used as a method to control micronutrient deficiencies. Some Initiatives on Fortification by the Government
of India are as given below:
(a) Wheat Flour (Atta).
In February 1970, the Government of India launched a program in Bombay for fortification of Atta with vitamins
and minerals and for increasing the protein content by admixture with edible groundnut flour.
(b) Edible Oils.
Fortification of Vanaspati (hydrogenated oil) with vitamin A has been made compulsory (2,500 IU of vitamin A
and 175 IU of vitamin D per 100 g of Vanaspati) by the Government or India.
(c) Common Salt.
Common salt must be fortified with iodine (commonly potassium iodate) in a dose of 30 ppm at the production
site. Double Fortified Salt (DFS) has been developed by National Institute of Nutrition (NIN) Hyderabad. This
formulation is intended to provide 100% of daily dietary iodine requirement and 30 to 60% of daily dietary iron
requirement. Iron in double fortified salt is 850-1,100 parts per million from ferrous sulphate or ferrous fumarate
sources.
The term food enrichment, on the other hand, is used for replacing nutrients lost in processing. It occurs with
grains, as some vitamins and minerals are lost in the milling process. Some examples of food fortification are
given in Table 19.2.
Table 19.2 : Examples of Food Fortification
Food Vehicle Fortificant
Rice  / Wheat flour (Atta) Iron, folic acid, Vitamin B12
Oil Vitamin A, Vitamin D
Salt Iodine, iron
Milk Vitamin A, Vitamin D
The benefits of food fortification effectively include prevention of major micronutrient deficiencies at a small cost without
any change in the dietary habits of the population. It can be implemented relatively quickly and can be sustained
over a long period of time and being a population based approach, it benefits all. It is a very cost effective approach.

19.5 Provisioning and Supply of Rations.

(a) Functions of Medical Services.
The role of medical services is to advice on the composition of ration scales and on any other matters relating
to rationing which have a bearing on the health of the troops. The Director Generals of Medical Services in
the Army, Navy and Air force are the advisers to their respective Chiefs of Staff. The DGsMS are assisted by
ADG (H and P), DirMS (H) and JDsMS (H) or equivalents in Navy and Airforce. Administrative Medical Officers at
lower levels have the same responsibilities towards local commanders, their technical advisers being the ADsH
at Corps and Area and DADsH at Division HQ levels. Officers of the equivalent appointments in Navy and Air
force administrative HQs are advisers to their commanders. However, any medical officer may be consulted by
Commanders on some aspect of food and nutrition. Medical Officers act in an advisory capacity: the discretion
of accepting or otherwise of medical advice rests with unit / formation commanders. The provision, supply and
handling of food are functions of the ASC organizations. Medical officers should ascertain the effect of their
advice and its implementation by checking the rations received, cooked and consumed. The methods of cooking
and facilities for cooking and serving should be checked as a routine. Hospital dietary is in a special category.
Since this is primarily a matter of treatment and not of prevention of disease the consultant and specialist
should advice regarding hospital rations.
(b) Functions of Supply Service (ASC).
The Quartermaster General (QMG) is responsible for provisioning and supplying rations. The Director General
of Supplies and Transport (DGST) assists him in his functioning. This organization has five main functions:

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provisioning, supply, inspection of food stuffs, training of cooks and catering. Provisioning and supply are based
on ration scale drawn up by the Service Headquarters in consultation with the Medical Services. Foodstuffs
are ordered centrally through the Food Ministry or purchased from local markets. Local purchase is eminently
suitable for perishable and fresh foodstuffs or for those with only localized distribution. Central provisioning is for
items which are non-perishable and not locally available or for foods of special importance. Before finalizing the
contracts for provisioning, representative samples of items are inspected by the Food Inspections Organization
of the S & T Directorate. If the samples conform to the specification laid down, the contracts are finalized.
Supplies are organized according to ration scales, strength of unit  / formation and availability of articles. When
the food has been passed as fit for acceptance it is held in supply depots for issue to troops in accordance with
unit indents. An elaborate system of book-keeping is essential so that demands can be foreseen and supplies
arranged accordingly. Supply officers are also responsible for maintaining and turnover of stocks in accordance
with their likelihood to deteriorate during storage. Following points are kept in mind at the time of provisioning
of rations:
(i) Where true nutritional equivalence is not possible, issues of substitutes should be limited so that the
total nutritional balance of the ration scale is not seriously impaired.
(ii) Variety should not be reduced by the injudicious use of the same substitute authorized against two
or more standard items.
(iii) Ration scales should, as far as possible, be composed of fresh foods.
(iv) Processed substitutes may be inevitable in war, but tinned and dehydrated foods should be resorted
towards the end and not as a perfectly satisfactory method of feeding troops.
(v) The importance of any given food in a ration is related not only to its absolute nutritive value but also
to the quantity in which it is or can be consumed. It is therefore quite justifiable to use a food of limited
nutritive value for the sake of variety or to check out short supplies, if issues are curtailed, so that the
value of the total ration is not seriously impaired.

19.6 Hospital Dietary.

Diet therapy is concerned with the use of food as an agent in effecting recovery from illness. In most instances the
patient’s diet supplements the medical or surgical treatment, that is the rate of recovery or failure to recover, may be
determined at least in part, by the patient’s acceptance or rejection of food. In military practice fevers, wounds and
disease of the alimentary tract are the conditions commonly met with. In fever there is an increased basal metabolic
rate, decreased glycogen storage, increased protein catabolism, increased loss of body fluids and decreased mobility
and reduced absorption of nutrients. It is therefore important that fever patients be given a high energy diet containing
liberal and good quality proteins (of high biological value) which are easily digestible. The protein requirements of
wounded and operated cases are also very high. Surgery or injury brings about a greatly increased need for nutrients
because of loss of blood, plasma or pus from the wound surface. Diarrhoea and dysentery can lead to conditional
deficiencies due to gastro-intestinal hurry resulting in poor absorption of nutritional principles of the diet. These cases
require a high-energy diet, containing adequate proteins, vitamins and salts. During convalescence it is important that
the diet should be liberal with high protein, of good quality and easily digestible, so that the soldier is returned to duty
as soon as possible and in perfect health. The special diet scales as authorized in the military hospitals are given in
AI 94  / 76 and amended vide AI/3/84.
There are 4 types of prevalent hospital diets.
(a) ‘O’ or ordinary diet
(b) ‘S’ or subsistence diet is drawn for patients admitted after 1200 hrs for the day of admission. Thereafter
patients will be placed on one of the standard diet or on ‘No Diet’.  
(c) ‘F’ or Fluid diet
(d) TB Diet
(e) ‘N’ or No diet Extras as per scale may be demanded for patients on ‘No diet’ or therapeutic diet
(f) ‘C” or Convalescence diet
(g) Probationer Nurses Diet

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Table 19.3 : For Children, the Following Scales are Adopted

Ages Distribution of Diet
0 to 4 years No diet
5 to 10 years Half adult scales
Above 10 years Full adult scale
The age groups indicate the beginning of the year of age to the completion of year of age. The daily scales of diets for
patients have been made as comprehensive as possible to suit the requirement of most patients likely to be treated
in military hospitals. These diets are as far as possible complete in themselves, so that the need for the prescription
of extras is reduced to a minimum. A scale of extras has been provided to meet the needs of special cases i.e. cases
the nature of whose illness require special dieting. Extras are not permitted for patients on ‘ordinary diet’ but are
permitted if the medical officer-in-charge considers it essential, for patients on the other prescribed classes of diet and
for those on ‘No diet’. If any authorized  / extras are not in stock, substitutes will be issued in lieu. In addition, Medical
Officers may demand any item  / proprietary supplementary food like Horlicks, Oveltin, Bournvita, Complan, Casian,
B-12 and so on for the patients in Service Hospitals even if the items demanded are not included either in Table 17
Section IV of SRS or in the ASC specifications as a part of treatment. When however, sago or Tapioca is demanded,
the supply officer concerned issues, whichever of these articles is cheaper and or more easily available. For special
cases when on ‘No Diet’, quantities more than those may be issued if considered necessary by the Medical Officer,
who may demand any article or substitute whether it is included in ASC specification or not. On active service or on
operations not entailing mobilization for hospitals at the base, for patients on the lines of communication, the scales
of diets and extras authorized will be followed as a guide as far as possible and any deviation found necessary on
account of the position, climate or the supplies obtainable will be sanctioned by the Force or Local Commander on the
advice of the administrative medical officer. If a special hospital for officers on active service is opened, the scale of
issue will be fixed from time to time by the force Commander and reported to Army Headquarters (Medical Directorate).
When the standard items of the Hospitals Diets and Extras are not available or when the medical officer wishes to
introduce variety into the dietary, substitutes as laid down in the Basic Scale or Ration for troops may be drawn in
lieu. The Hospital Diets and Extras are applicable to all dieted hospitals including Base Hospitals, General Hospitals,
Field Hospitals, Corps Field Hospitals and Staging Sections. Medical Battalions, Medical Companies (including Para
Medical Companies and Ambulance Trains). They will also draw Hospital diet and extras at the discretion of MG (Med)
or Brig Med Corps or Col Med Div /  Independent Brigade. Only ‘O’ Diet (ordinary diet) prescribed is issued to personnel
admitted into the Army Medical Rehabilitation Unit. All sick attendant mothers and nurses are issued with ‘O’ diet.

19.7 Feeding of Armed Forces Personnel.

Principles:
(a) During war or peace, the issue of rations in kind must be the mainstay.
(b) The standard ration scales must fulfil nutritional requirements under various circumstances.
(c) It must make every possible allowance for the habits and tastes of the consumers.
(d) Flexibility should be attained by authorizing substitutes through which fluctuations in supply and catering
can be met and variety can be achieved.

19.8 Operational Feeding.

Special pack rations are devised for operations when transport is limited, normal cooking and catering arrangement
are not available with limitations on weight and bulk; a compromise must be reached between what is nutritionally
desirable and what is practicable. Such special ration packs are not the normal method of feeding troops. As a varying
degree of risk is being accepted, the use of special packs should be kept to a minimum. There are three operational
ration scales and also the composite pack rations and the survival rations. The design of a special pack is influenced
by the following factors which vary in importance in different circumstances:
(a) Concentration.
The highest possible energy value must be put into a given weight packed into the smallest possible space. It
is extremely difficult to concentrate food beyond 418 kJ per 30 g of weight (including packing material) without

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serious loss of palatability; so, a normal ration should be expected to weigh less than about 1 kg. Energy value
can be increased for a given weight of food by utilizing the high fuel value of fat, excluding low energy foodstuffs
and dehydrating or freeze drying the precooked foods.
(b) Nutritive Value.
If such a concentrated ration is to be consumed for a continuously long time, nutritional requirements must be
met in full. Such a choice of high energy food is limited. To achieve concentration, vitamin enriched processed
foods are very useful or if the essential vitamins cannot be provided in food, vitamin concentrates must be used.
(c) Palatability.
Variety and attractiveness can be achieved beyond a certain point only at the expense of weight. Consideration
of customs and habits and the availability of facilities for cooking are also important.
(d) Keeping Quality.
The ration must retain its nutritive value as well as its keeping quality. The latter is largely a question of devising
a pack which will withstand the rough handling, humidity and heat.

Suggested Reading.
1. Army instructions 94/76, AI 13/84 Rations / Diets in hospital.
2. Special Ration Scales.
3. Davidson S, Passmore R. Brock JF, Truswell AS. Human Nutrition and Dietetics. 6th ed. Churchill Livingstone,
ELBS London. 1975.
4. Lingappa Y, Lingappa BT. Wholesome nutrition for mind, body and microflora. 3. Ling Ecobiology foundation.
Worchester, Massachusetts, 1992
5. Darby WJ, Ghaliongi PGrinvettill. Food, the gift of Osiris, London Academic Press. 1977.
6. Mc Collum EV. A history of Nutrition, Boston, Houghton Miffin Company, 1957.
7. Todhunter EN. Chronology of some events in the development and application of the science of Nutrition. Nutrition
Reviews, 1976, 34:354-375
8. Gabr M. IUNS in the 21st century on the shoulders of 20th century giants of nutrition. In : Aspects of , Present
and Future . Eds Elmadfa , Anklam EKonig JS. 2003. 56:13-18.
9. FSSAI. Food Safety and Standards Regulations [Internet]. www.fssai.gov.in. [Accessed 2024 Mar 7]. Available
from: https://www.fssai.gov.in/cms/food-safety-and-standards-regulations.php
10. World Health Organization. Food fortification [Internet]. www.who.int. 2022 [cited 2024 Mar 7]. Available from:
https://www.who.int/health-topics/food-fortification#tab=tab_1.
11. Dayakar B, Bhaskarachary R, Arlene G. Nutritional and Health Benefits of Millets [Internet]. ICAR – INDIAN
INSTITUTE OF MILLETS RESEARCH (IIMR). 2017 Jun [cited 2024 Mar 7]. Available from: https://millets.res.in/m_recipes/
Nutritional_health_benefits_millets.pdf.
12. Controller of Publications, Govt. of India. ASC Training Manual: Vol II (Supplies) Directorate General of Military
Training, Army Headquarters, New Delhi 1994.
13. C. J. K. HENRY, J. SEAMAN. “The Micronutrient Fortification of Refugee Rations to Prevent Nutritional Deficiencies
in Refugee Diets”, Journal of Refugee Studies, 1992

495
 NUTRITION AND FOOD SAFETY

Table 1 : Scale of Ration for Personnel Entitled to Free Rations

S. No. Items Scale Per Day (in gms)
1. Atta 620
or
Rice 620
or
Rice and Atta 620
2. Dal 90
3. Refined oil 80
4. Sugar 90
5. Tea 9
6. Salt Iodized 20
7. Condiments powder 16
8. Meat Fresh (with bone) 110
or MOH 275
9. Milk Fresh  / Blended / Standard  / TPM 250 ml
10. Vegetable Fresh 170
11. Potatoes Fresh 110
12. Fruit Fresh Citrus or 110
Fruit Fresh non-citrus 230
13. Onions fresh Or 60
Garlic (Lehsun) once Weekly (Only if demanded by troops) 20
14. Firewood or 900
Steam coal or 500
Soft Coke or 600
Firewood Kindling purpose or 200
Charcoal or 300
Kero (for kindling) or 5 ml
LPG
(a) cook house for str of 80 and above 125 gms per man
(b) cook house for str less than 80 135 gms per man
15. Matches Safety (i) For strength up to 45
members – 2 Match Boxes
per week
(ii) For strength above 45
members – One Match Box
per week for every twenty-five
members or part thereof.
16. Compound Vitamin Tabs Demand for compound
vitamin tablets must be
approved by the MG (Med)
Command concerned.
17. Rum & Cigarettes Cash allowance as
sanctioned by the
Government will be paid.

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 RATION SCALES IN ARMED FORCES & THEIR IMPORTANCE

Table 6 : Scale of Rations – National Defence Academy, Kharakvasla, Indian Military Academy, Dehradun, Officers
Training Academy, Technical Entry Scheme
Scale Per Day
S. No. Items
(in gms)
1. Atta/Rice/Bread/Flour 510
2. Dalia (crushed wheat) 30
Cornflakes (indigenous manufacture only). 28
Semolina (Suji) 30
Sago or Vermicelli 28
3. Cornflour 7
Custard powder 7
Jelly 7
Ice cream powder 7
4. Milk Standard/ fresh/blended 550 Millilitres
5. Butter Fresh 28
6. Eggs Nos 2½ /1½
Bacon (Fresh or tinned) 30
Ham (Fresh or tinned) 14
Liver/Kidney 60
For Vegetarians who do not prefer Eggs or its alternates
7. Milk standard/fresh/blended (for preparation of curd) 210 Millilitres
or Cheese processed.
or Cheese spread or Malted Food
8. Meat fresh 340
Fish Fresh 600
Chicken dressed/Fowl dressed 255
9. Milk standard/fresh/blended 660 ml
or oil hydrogenated 30
and vegetables fresh 340
or Eggs Nos. 8
10. Oil hydrogenated 85
11. Potatoes fresh 110
12. Onions fresh 60
13. Vegetables fresh 230
14. Fruits fresh citrus or 110
Non-citrus 230
15. Cheese tinned or cream or Cheese spread 14
16. Sugar 100
17. Tea 9
or Coffee soluble powder 4
Chocolate drinking /malted food 28
18. Salt 20
19. Condiments and spices or 20
Pickles/Chutneys/Vinegar 20

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NUTRITION AND FOOD SAFETY

Scale Per Day

S. No. Items
(in gms)
20. Jam/Marmalade or 14
Jam/Marmalade 14
and Golden syrup 14
and Fruits fresh 20
and sugar 10
21. Firewood split 500
Steam coal 700
Charcoal 200
22. * Coffee soluble powder 3
23. * Sugar 30
24. * Milk standard/fresh/blended 40 ml
25. * Compound Vitamin Tablets No 1
26. * Ice 450
27. * Salt Iodized 20
* To be issued on Medical recommendation only to meet special fatigue or bad weather conditions

498
 Table 16 : Hospital Diets and Extras
Convale- No
S. Fluid Sbsistence Ordinary
Description of Diet scent Diet Remarks
No. F S O
C N
(a) (b) (c) (d) (e) (f) (g) (h)
BREAD/CEREALS
(a) Atta or rice may be drawn in any proportion,
1. Atta / Rice (a) — 230 325 600 but normally patients should receive a proportion of
each.
(b) Whole or part may be drawn as atta or rice
2. Bread (b) — — 110 —
weight for weight.
(c) Pudding cereals to consist of sago, topioca,
3. Cereal for Pudding (c) — — 25 *
comflour, Suji or Flour (Maida).
4. Cereal for breakfast, — — 25 * * When the Standard items of the Hospital Diets
4A Cornflakes / oatmeal / sago / dhalia / semolina and Extras are not available or when the medical

To be substituted on extras
(b) Biscuits 30 officer wishes to introduce variety into the dietary
Substitutes as laid down in the Basic Scale or
DAIRY PRODUCE Ration fortroops may be drawn in lieu.

499
5. Milk fresh (d) 1,540 L 440 ML 1,000 ML 440 ML (d) Milk tinned or whole powder may be issued in
lieu of milk fresh. The rate of conversion being 110
gm of milk tinned or 40 gm of whole milk powder
equal to 280 ml of milk fresh. A maximum of 57
6. Butter — — 30 * grams liver/bacon/kedney/one egg may be drawn in
lieu of 110 ml, milk fresh for patients on C, O and TB
diets.
(e) (28 grams) bacon or (60 grams) fish fresh or
7. Eggs (e) (h) Nos. 2 — Nos 3 Nos 2 28 grams kedney or 35 grams jam or 30 grams
baked beans may be drawn in lieu of 1 egg for
8. Cream — — — — patients on C and O diets. Egg may be drawn for
MEAT / POULTRY / FISH OVO - Vegetarian also.
9. Meat fresh with bone (f) (h) — — 200 230 (f) Chicken dressed or fowl dressed (which ever is
economical) 340 grams once a week and fish fresh
(340 grams) / fish tinned (170 gms) once a week
may be drawn in lieu of 230 grams meat fresh with
bone. However, in the case of TB patients fish may
be drawn twice a week in lieu of meat fresh with
bone.
RATION SCALES IN ARMED FORCES & THEIR IMPORTANCE

(g) 280 grams dressed to be drawn once a

week.
 Convale- No
S. Fluid Sbsistence Ordinary
Description of Diet scent Diet Remarks
No. F S O
C N
Chicken dressed or fowl dressed (which even (h) For vegetarian patients, meat, fish and
10. — — 55 (g) —
is economical) (h) eggs may be substituted as follows on the
11. Fish Fresh (h) — — 50 (j) — recommendations of Medical Officers :
Or Meat fresh with bone - Milk fresh (110 ml)
Fish tinned 20 (j) — (60 grams) chicken - or skimmed milk
Or dressed (90 gm) / Fish - powder 21 gms
NUTRITION AND FOOD SAFETY

Liver (Twice a week) 50 gm fresh (90 gm) or egg - or milk tinned

number 1. - 45 gms or cheese tinned
- 21 gms or Pannier
- 48 g.
Chicken live at double the scale of chicken
dressed may be authorized at places where the
cost of chicken dressed does not exist.
Eggs 2 per patient per day may be drawn in lieu
of meat fresh (120 gm) /chicken dressed (180
gm) Fish fresh (180 gm) for OVO-Vegetarians. For
the remaining entitlement of Meat fresh / Chicken

500
dressed / Fish fresh-other substitutes as for
Vegetarians may be drawn.
(j) During a week two equivalent issues of fish
fresh / fish tinned may be drawn on any two days.
Fish td will only be issued when fish fresh is not
readily available.
VEGETABLES AND FRUITS
(k) Fresh preparing fruit drinks. If not available,
preserved undiluted citrus juice 113 gms may
12. Fruits Fresh citrus (k) 230 — — —
be given or ascorbic acid dissolved in time juice
cordia or organge squash.
(l) May be substitued by fruit tinned of
equivalent weight citrus fruits and other variety of
13. Fruits Fresh variety (I) — — 230 230
fruits may be drawn in the of ratio of 50:50 when
recommended by Medical authorities.
14. Vegetable fresh — — 170 170
15. Potatoes — — 110 110
16. Onion — — 100 60
 Convale- No
S. Fluid Sbsistence Ordinary
Description of Diet scent Diet Remarks
No. F S O
C N
(o) 50% of the entitlement of Dal Ration may be
17. Dal (0) — 30 60 60
issued in the form of Dal Meal (Baison)
SUGAR / PRESERVES
(m) 28 grams cheese tinned or 57 grams panir or
18. Sugar 90 40 90 90
chana in lieu twice a week.
(n) For 2.85 liters barley water 57 barely pearl
19. Jam / honey / marmala de / Golden Syrup (m) — — 20 *
and 60 grams sugar are allowed.
BEVERAGES
20. Tea 7 7 9 9 (p) To prepare 570 ml of lime juice drink, 60 gm
21. Barley water (n) OARB OARB — — — fresh lime and 30 gms sugar or 60 gm lime juice
cordial and 30 gm sugar allowed.
23. Fresh lime / lime juice cordial (p) OARB OARB OARB OARB
CONDIEMENTS
24. Condiments — 4 14 14
25. Achar — OARB OARB OARB

501
26. Sauce / Vinegar — OARB OARB OARB
MISCELLANEOUS
27. Salt evaporated 15 5 20 20
28. Ice
Oil Hydrogenated or — 30 60 60
29.
Oil Refined — — 60 —
30. Jelly — — —
Firewood (Split) 1.400 Kg 900 1.400 Kg 1.400
Or Kg
Soft Coke 900 600 900
900
31.
Firewood split and Kero Oil inferior for Firewood K/Oil
Kindling soft coke at the following scale : (Split) Inferior
(i) For cooking ranges for 45 men and above 90 gms 5 ml
(ii) For cooking for less than 45 men 140 gms 19 ml
Note. The scale at (i) above may be increased to that given at (ii) above at the discretion of the local Commander when owing to the nature of fire place
available or for any other reasons the increased scale is necessary. (OARB – On an as required basis).
RATION SCALES IN ARMED FORCES & THEIR IMPORTANCE
NUTRITION AND FOOD SAFETY

Table 9 : Scale of Rations for Officers in Peace / Field

S. No. Commodity Scale Per Officer Per Day in Grams
1. Atta or Rice (Undermilled or parboiled) 450
2. Atta 200
3. Dal 40
4. Oil Hydrogenated 80
5. Milk fresh/ standard/blended. 250
OR Milk tinned sweetened or unsweetened. 92
Whole milk powder 36
6. Sugar 90
Gur 110
7. Tea 09
Coffee soluble powder 03
8. Vegetables fresh 170
Vegetables tinned curried 90
9. Dal whole or germinating 90
Peas dried or beans dried 90
10. Potatoes fresh 110
Potatoes tinned 80
11. Onion fresh 60
Onion spring green 90
Onion dehydrated 07
12. Fresh fruits non citrus 230
Fresh fruits citrus 110
Fruit tinned. 90
Fruit dried 28
13. Salt evaporated 20
14. Condiments 20
15. Meat fresh (with bone) dressed. 260
Meat on hoof 640
16. For vegetarians(In lieu of meat)
Milk fresh / standard / blended OR 500 ml
Milk tinned OR 200
Whole milk powder 73
17. Baison 30
18. Eggs 03
19. Butter 20
20. Dhalia 20
21. Corn flour / Jelly Crystal 07
22. Jam 44
23. Firewood 1400
24. LPG 150

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 RATION SCALES IN ARMED FORCES & THEIR IMPORTANCE

S. No. Commodity Scale Per Officer Per Day in Grams

25. Dried coconut 04
26. Raisins 04
27. Pickle 15
28. On Medical Recommendation
(To meet special fatigue or bad weather conditions)
Coffee solution powder
Sugar
Milk fresh / blended / standardOR 03
Milk tinned OR 30
Rum 25 U.P. OR 40 ml
Rum London proof (100 percent proof) 16
Compound vitamin tablets 60 ml
(To be issued on medical recommendation) 40 ml
n

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NUTRITION AND FOOD SAFETY

Chapter
XX
FOOD SAFETY IN ARMED FORCES

20.1 Introduction.
Food safety is defined as steps undertaken for limiting the presence of those hazards, whether chronic or acute, that
may make food injurious to the health of the consumer. Food safety focusses on producing, handling, storing and
preparing food in such a way to prevent infection and contamination in the food production chain and to help ensure
that food quality and wholesomeness are maintained to promote good health. Food hygiene is defined as the conditions
and measures necessary to ensure the safety of food from production to consumption, i.e., from the point of harvesting
the crops (or slaughtering the animals), processing, storage, distribution, transportation and preparation. Its focus is
on preventing food becoming contaminated with microbes (or their toxins). Lack of adequate food hygiene can lead to
infective foodborne diseases and even death of the consumer. Food safety is thus the overall umbrella which covers
within it food hygiene as one of its important components. The other components of food safety include: (i) prevention of
food toxicants of non-microbial origin (as epidemic dropsy and pesticides), (ii) control of substandard food and (iii) various
legal measures to ensure safety of food for the community. Five Keys for Safe Food given by WHO are as under:
(a) Keep Clean.
(i) Wash your hands before handling food, after visiting toilet, before eating and often during
food preparation.
(ii) Wash and sanitize all surfaces and equipment used for food preparation.
(iii) Protect kitchen areas and food from insects, pests and other animals.
(b) Separate Raw and Cooked Foods.
(i) Separate raw meat, poultry and sea food from other foods.
(ii) Use separate equipment and utensils (as knives and cutting boards) for handling and
processing raw foods.
(iii) Store food in containers to avoid contact between raw and cooked food.
(c) Cook Thoroughly.
(i) Cook foods to at least 70º C (bring foods to a “rolling boil” and then continue to boil for at
least 1 minute).  
(ii) If storing cooked food (i.e., not eating freshly cooked food within 2 hours of preparation),
reheat such stored food to 70º C before eating, even if it has been stored in a refrigerator.
(d) Keep Food at Safe Temperatures.
(i) Do not leave cooked food at room temperature (eat within 2 hours).
(ii) If not eating within 2 hours of preparation, keep in a refrigerator at less than 5º C.
(iii) If cooked food was stored in a refrigerator, reheat such food to 70º C before eating.
(e) Use Safe Water and Raw Materials.
(i) Use safe water or treat it to make it safe.
(ii) Select fresh and wholesome raw food materials.
(iii) Choose foods processed for safety, as pasteurized milk.
(iv) Thoroughly wash fruits and vegetables, especially if they are to be eaten raw.

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 FOOD SAFETY IN ARMED FORCES

20.2 Food Inspection Organisation in Armed Forces.

Armed Forces of India provides dry and fresh rations for consumption of troops. These rations are procured keeping into
consideration operational requirement, terrain peculiarities, extreme climatic conditions and prolonged storage periods.
Therefore, it stands to logic the primary criteria must be to retain quality of rations under such conditions. These rations
thus must have specifications tailormade to suit these requirements. Further various processes are followed so as to
ensure that food safety is ensured from Farm to Fork.    
Armed Forces has a Food Inspection Organization manned by AMC, RVC, qualified ASC officers duly assisted by civilian
scientific staff mandated to formulate Defence Food Specifications (DFS) and ensure quality control and quality assurance
of all items of foodstuffs provisioned by Army. All procedures from registration of suppliers, technical and hygiene
inspection of factories, inspection of foodstuffs, sampling, analysis and monitoring of quality are highly elaborate and
exhaustive and are at par with the national standards given by Food Safety and Standards Authority of India (FSSAI).
DFS are formulated by Technical Standardization Committee (TSC) with ADGST as the Chairman and members from
Ministry of Defence, Ministry of Health & Family Welfare, Ministry of Rural Development, Ministry of Food & Civ Supplies,
Rep of FSSAI, Director, BIS and Director, Central Food Technological Research Institute (CFTRI), Mysore. Process of
formulation of DFS is given in Fig 20.1.

ASPIRATION OF
PROMULGATION OF DFS
THE TPS
(FEEDBACK) I
6
N MOD  /  
IN HOUSE P REVIEW BY
2 DGST 5
REVIEW AT TSC (FS)
DGST U MOD
T 3 (FINANCE)
1
GOVT S
PREP OF
STATUTES & TEMP  /  DRAFT
QMG 4
LAWS SEPC BY
DGST (ST 718)
  
Fig 20.1 : Formulation of DFS

20.3 Inspection of Food Stuffs.

The inspection of foodstuffs is necessary to ensure that they are of adequate nutritive value, will not cause food
borne diseases and conform to contract specifications. This is the responsibility of an ASC organization known as the
Food Inspection Organization. The Deputy Director of Food Inspection (DDGFI) / Brig (Med) FI is responsible to the
QMG for food inspection. He is a medical officer specialist in PSM appointed by the DGMS (Army) and has under him
several technically qualified ASC officers together with other technical personnel. Composite food laboratories (CFLs) are
established for special tests and food analysis. All medical officers should know the basic elements of food inspection as
they are frequently consulted on such matters by the commanders. Medical officers in units should inspect periodically
the rations at the ration stand, in food stores, cookhouses and dining halls. They are also required to inspect slaughter
houses, dairies and bakeries under military control. In addition, they may expect to receive occasional appeals from
units for a decision in respect of food thought to be unfit for consumption. In most cases, an opinion regarding fitness
for consumption by troops can be given after an intelligent use of the senses. Chemical analysis may be required. The
following notes on individual commodities have been complied with the objective of serving as a short guide to the
inspection of ration articles by medical officers.  
(a) Principles of Inspection.
Sampling of the product’s requiring inspection is the first important procedure if large consignments of food are
involved. Samples should be adequate in quantity and fully representative of the consignments. For example, if
tinned milk is being examined, it may be necessary to sort the consignment into different brands and thereafter
each brand into groups (rusted tins, ‘blown-up’ tins) and representative number of tins from each group examined

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NUTRITION AND FOOD SAFETY

in detail. Only by systematic sampling can the quality of large consignments be accurately assessed and suitable
instructions for disposal formulated. In the analysis of the sample obtained, the following factors should be
considered:
(i) The appearance, physical condition, taste and  /  or smell of the commodity in relation to its normal
characteristics and keeping qualities.
(ii) For the foodstuffs in cans, bottles, cartons, the external and internal condition of the container, date
of manufacture, date of expiry, warranty period and the manufacturer’s name or proprietary brand.
(b) Disposal of Food materials after Examination.
Food may be considered as fit for issue without conditions, fit for issue within a limited period or unfit for issue.
The procedure to be followed is laid down in para 899 DSR, 1987 (Revised Edition). If a unit takes rations on
charge, the ASC is absolved from further responsibility and the unit must adjust any loss and the medical officer
subsequently condemns the articles. Any queries regarding fitness for issue or consumption of rations should
therefore be raised before rations are accepted by units. If the supply officer agrees with the unit’s complaint,
he will immediately replace condemned articles. If he does not agree, the OC station will give a final decision,
usually after a formal board of enquiry has been convened to examine the disputed rations and to make
recommendations as per instructions issued from time to time.
Details of various food items are given as below:
(a) Atta and Flour.
The only difference between these two wheat products, from the point of view of inspection. is that atta contains
a larger proportion of the pericarp or bran and the germ of the wheat grain. It therefore has a greyish appearance
as compared with the dead whiteness of refined flour. Fresh flour or atta smells sweet, is of uniform consistency
and has a bland taste devoid of sharpness. Deterioration usually results from prolonged storage or from adverse
storage conditions. The main reasons for rejection are as follows:
(i) Poor Baking Quality.
The baking qualities of bread are due to gluten. If a small quantity of flour is made into dough and the starch
thoroughly washed out under running water, the sticky mass remaining is a gluten. With good quality flour
and atta this is golden yellow and is sufficiently elastic to be stretched for several inches without breaking.
Gluten from old flour is dull grey and is friable. The change is associated with an increase of rancidity in
the flour due to splitting of fats by enzymes in the wheat grain. The ultimate criterion on which a decision
to reject flour as unfit for baking purposes may be made, is the quality and palatability of a sample loaf,
baked by a competent baker.
(ii) Rancidity.
It is due to oxidative changes in the fat of atta or flour and gives rise to a distinctive flavour which is easily
detected by taste and smell. It is not a cause for condemnation unless the commodity is unpalatable.
(iii) Mustiness.
It is due to infestation with the flour-mite, a tiny 8-legged creature which is invisible to the naked eye. If
the surface of some infested atta / flour is smoothened with a knife, the mites will, in a few minutes, raise
small heaps on the smooth surface. A distinctive odour is present. A mild infestation with a slight musty
odour may be ignored, but in most cases, infestation develops rapidly and by the time it has become
obvious, the flour is usually unfit for human consumption.
(iv) Larval Infestation.
It is common, especially during the monsoon. The usual agent is the weevil, a small beetle that is easily
visible and lays eggs from which larvae hatch. Infestation with the larvae of certain moths may also occur
and this condition can be detected by the webs of silky material produced. Such flour or atta can be
cleaned by sieving through muslin provided infestation is not unduly heavy with infestation the excreta of
larvae render the flour objectionable.
(v) Mouldiness.
It may occur under moist conditions. The flour becomes lumpy owing to the network of mycelia produced.

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 FOOD SAFETY IN ARMED FORCES

If such lumps are carefully removed without breakage by sieving, it is usually possible to retain much of
the flour as fit for immediate consumption.
(b) Bread.
Ordinary bread is made from white flour and should be risen, evenly aerated, free from large cavities and has an

elastic crumb. The commonest defects in bread are sourness and heaviness, which may be due to bad baking
or poor storage. In the examination of bread, the chief guides are its general appearance, colour, smell, taste,
texture and the presence or absence of moulds and animal parasites. The loaf or loaves should be broken
open, a chunk should be taken from the middle of the loaf rolled into a tight ball and examined for resiliency
by dashing it against the wall or the floor. Good bread will rebound.
(c) Biscuits.
These are made of flour, sugar, hydrogenated oil, salt water, milk and bicarbonate of ammonia. On examination
of biscuits, note should be made of appearance, color, odour, crispness, hardness, palatability and the presence
or absence of insects. The commonest defects are rancidity, mustiness, softness and the presence of moulds.
(d) Rice.
The appearance of rice varies greatly according to the variety, the degree of milling and any other treatment to
which the rice may have been subjected, such as parboiling or polishing. The rice for consumption by troops
shall be lightly milled or parboiled. Ration rice, therefore, does not have the white appearance of highly milled
rice but may be of greyish colour. Parboiled rice has a characterstic translucent appearance. Under good storage
conditions, rice will not deteriorate or may even improve in quality up to about 2 years. The chief defects are
an undue degree of milling, infestation or mouldiness.
(i) Milling.
Normally all ration rice is inspected before being purchased, but there are occasions when apparently
highly milled rice may be issued to troops. Its thiamine levels can only be assessed by laboratory assay for
thiamine content (specified as not less than 2 mg / g) and for phosphorus pentoxide content (specified as
not less than 0.4 percent). Thiamine assay cannot be carried out as a routine but the phosphorous test
gives a safe indication of the degree of milling and hence of the thiamine content.
(ii) Infestation.
The condition is similar to that in atta and flour as given in para above.
(iii) Mouldiness.
Under damp storage-conditions or if rice is exposed to rain while in transit, the growth of mould is likely.
The mould may develop only in the layers of rice adjacent to the sack container especially if the dampness
has been caused by rain and in that case the rice in the centre of the sack may be perfectly good and
sound.
(e) Milk and Milk Products.
Fresh milk should be inspected both raw and pasteurized, described in paras below. Tinned milk may be either
sweetened or unsweetened and is condensed by means of evaporation to about half or one-third of its original
volume. The one used in military rations is whole milk. Sweetened tinned milk contains about 50 percent of
added cane sugar which is an important preservative. The inspection of tins and their contents should be carried
out as follows:  
(i) Tins.
One type of tin has ends soldered to the body without crimping, though the side seam is crimped and
soldered. This type is fragile and with rough handling is liable to develop leaks. The other type has crimped
and soldered seams and is less likely to develop leaks. Etching on the insides of tins is not a sufficient
cause for the rejection of contents. The contents of leaking tins are liable to rapid deterioration. Bulging,
badly dented and leaking tins should be rejected.
(ii) Unsweetened Tinned Milk.
The chief defect likely to be found, other than obvious deterioration within a leaky tin is an increase in

507
NUTRITION AND FOOD SAFETY

acidity. If this is high and an unpleasant sour taste is present, the milk is unfit for human consumption.
A milder degree of acidity is not harmful, but it is an indication for immediate use. In some tins the fat
may have separated, leading to an appearance like clotted cream. Sometimes a deposit of calcium lactate
takes place. Such milk is quite wholesome if sourness is not present.
(iii) Sweetened Tinned Milk.
It is not liable to deterioration due to bacterial action. But in hot climates caramelization tends to occur
resulting in a brownish discoloration or even separation of sugar crystals. This is harmless and is not a
cause for rejection.
(iv) Butter.
It should contain no more than 16 percent of water and not less than 80 percent of fat. Adulteration in
a small quantity is difficult to determine accurately even by chemical analysis. The smell, taste, color and
consistency must be considered on ordinary inspection. The common defects are rancidity, too much salt
and too much water. A decision whether to reject it must depend on the degree of fault in each case.
Butter on bacteriological examination may show large number of bacteria found in milk, if it has not been
prepared from pasteurized cream. Tinned butter will be melted during hot weather with the curds settled
at the bottom of the tin. It is perfectly wholesome in this state and can readily be reconstituted by stirring
thoroughly. The slight lumpiness in such reconditioned butter is not an adequate cause for rejection.
(v) Cheese.
The most important guide to its fitness for consumption are the smell, general appearance, taste and
presence of mould. Surface mould on cheese does not render the interior unfit for consumption.
(f) Hydrogenated Oil.
It is produced from vegetable oils such as cotton seed, groundnut, palm kernel or sesame oil. The product
should be clean and wholesome. When melted the product should be clear, bright and free from sediment,
unpleasant taste, smell and rancidity. The melting point should not be more than 39º C and not less than 35º C.
Hydrogenated oil rarely deteriorates.
(g) Eggs.
Fresh eggs should not be less than 35 g each and not more than 25 eggs per kg. In the candling test, an egg is
fitted into an opening cut in a shield (e.g., a piece of cardboard) behind which is placed a bright light. Viewed in
the dark, a fresh egg will appear uniformly pink and translucent, while a bad egg will show cloudy dark patches
or even opaque, owing to the presence of gases resulting from decomposition. In the floating test, an egg is
placed in a vessel containing 10 percent sodium chloride solution. A sound egg slowly sinks while a bad egg
floats.
(h) Fresh Vegetables and Fruits.
‘ASC Specifications’ lay down that fresh vegetables shall be freshly gathered, sound crisp and free from
discolouration. The vegetables shall be of good average size for their class and not coarse, stringy or old.
Potatoes must be of good quality, free from disease and of such a size that they average not more than 32
to a kg and must not be capable of passing through a 2.5 cm circular mesh. Fruits must be in good order,
sound, freshly plucked, free from mould and all unpleasant taste and smell, of good average size, ripe and in a
suitable condition for consumption and not over-ripe, bruised or otherwise damaged. Deterioration in fruit and
vegetables must be judged on the merits of each case, but all rotten products should be rejected. Freshness is
of nutritional importance, since old, limp or bruised fruits and vegetables have lost much ascorbic acid through
the action of oxidases.
(j) Tinned Fruits and Vegetables.
Tinned fruit and jam keep well because the sugar in them acts as a preservative. The can as well as its
contents should be inspected. The can may be ‘blown’ when the ends bulge and cannot readily be pressed in.
On puncturing, a hiss of escaping gas is heard. With tinned fruit and jam (and less commonly with other tinned
products), blown cans may be due to hydrogen formed by the action of the acid of the fruit on the tin coating,
which lays bare pinpoints of the underlying steel and may catch fire if the tin is punctured near a lighted match.
As long as the can remains intact, the contents remain perfectly sound and wholesome but at a late stage the

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acid erosion may produce small perforations and spoil the contents by bacterial action. If the gas in the blown
can is carbon dioxide due to fermentation of sugar, small bubbles will be seen throughout and an alcoholic
smell will be present. Advanced fermentation renders a product unfit for consumption.
(k) Dehydrated Vegetables.
If no advanced deterioration e.g., attack by mould is present, no judgement can be passed until the product
has been reconstituted, cooked and compared with the cooked fresh product as regards appearance, smell
and flavour. A good, dehydrated product should resemble the fresh product when cooked. Dehydrated potatoes
frequently have a somewhat dark yellow color which disappears almost entirely on reconstitution and cooking
and is no cause for rejection. The condition of the container is of utmost importance for the keeping quality of
all dehydrated foods. If tins are not hermetically sealed, the contents will deteriorate rapidly by becoming damp
and mouldy and in some cases, fermented. The freeze-drying process produces dried products of a much better
nutritive and keeping quality and the reconstituted freeze-dried products resemble more closely the cooked fresh
food than do the dehydrated products.
(l) Peas, Beans and Dals.
Pulses of all kinds are liable to attack by certain insects, the larvae of which develop within the seed and eat
away its substance until nothing but a hollow shell is left. One species of larva makes a neat circular hole in
the pulse, through which it escapes. This is preceded by the appearance of a circular mark. However, in the
absence of the mark or the hole, the pulse is not necessarily uninfected. The only sure method of estimating the
extent to which a consignment is infested is to take a sample and cut each individual seed into half. A grossly
infested consignment should be condemned. If pulses have been exposed to rain, germination may occur. In
the absence of fungus infection this is harmless. The decision regarding whether to accept or reject should be
based on the palatability of cooked samples.
(m) Sugar.
The commonest defects are dampness, dirt and the presence of animal parasites. On examining it, colour,
solubility and sweetening power must be considered. Sugar may be considered sound, if it is sweet and is readily
soluble in half its weight of water to form a clear bright syrup with no parasites.
(n) Condiments.
Mustard, pepper, turmeric and ginger under the category of condiments do not deteriorate. If, however, they
are not properly packed and become damp, they ultimately develop mould growths and are spoilt. Garlic and
to a lesser extent chillies, contain a higher percentage of water than other raw condiments and if not properly
dried before storage, may deteriorate rapidly. Garlic tends to germinate, rot and become black. Chillies become
mouldy. Parasite infestation is not uncommon in condiments.
(o) Tea.
Tea should be blend of medium quality with good colour and a fair size leaf producing good liquor. It should be
dry and free from impurities and adulteration.
(p) Salt.
Salt is of two types. ‘Edible common salt’ is pale pink, light gray or white in colour and may contain a small quantity of
insoluble matter. The sodium chloride content should not be less than 96 percent. Refined salt is a white crystalline
powder. It should dissolve freely in water with not more than a trace of insoluble matter. The ‘running quality ‘in table
salt is produced by blending it with bee’s wax. Iodized salt protects from Iodine deficiency disorders.  
(q) Fresh Fish.
The common signs of deterioration are as follows:­ 
(i) Smell.
It is probably the most important test of soundness. Fish with an unpleasant smell should be rejected,
even if all other tests are in its favour.
(ii) Appearance.
When freshly caught the gills are bright pink, but after death they rapidly become darker and in a matter

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of an hour or so assume a liver colour. The longer the fish is kept, the darker are the gills. This is not,
however, a completely reliable sign of deterioration.
(iii) Firmness.
The flesh should be firm to the touch, not rapidly separated from the bones and should not tear easily. In
early decomposition the flesh pits readily under pressure.
(iv) Colour.
It should be uniformly healthy. There should be no evidence of discoloured patches on the skin. These are
usually seen first along the line of the backbone.
(v) Eyes.
These should be prominent and not sunken, collapsed or dull.
(vi) Floatation Test.
If not eviscerated, a sound dead fish sinks in water while an unsound one floats, belly up.
(r) Poultry.
Fresh poultry have bright prominent eyes, the feet are limp and pliable, the flesh moderately firm and the skin
pale. Staleness is shown by stiff and dry feet, dull and collapsed eyes, soft and flabby flesh and probably a
greenish discolouration around the crop.
(s) Tinned Meat and Fish.
The interior of the tin and its contents are subjected to heat, though an absolute sterility is not· achieved, but
the growth of remaining live organisms and spores is so inhibited that hermetically sealed cans should normally
remain sound for several years. Under tropical conditions, the rate of deterioration is somewhat accelerated and
spoilage may result even in an intact tin. Sardines packed in oil have an exceptionally good keeping quality. Fish
packed in tomato sauce may deteriorate if the acidity of the sauce causes erosion of the tin and eventually
results in pinpoint leaks. Cans and contents should be systematically examined before giving a final opinion.
Cans should not be condemned as a result of external inspection only. It is essential to verify conclusions by
examination of the contents. Steps of inspection of tinned meat and fish are as under:   
(i) Inspection.
Note whether the tin is damaged, dented or rusted. Dents near a seam may indicate a leak. Both ends (and
the sides if the tin is flat) should be slightly concave due to negative internal pressure. If they are convex
in the absence of marked denting, the tin is ‘blown’ owing to the formation of gas from decomposition. The
pressure inside may be tested by putting a little water on the end of the tin (preferably near the edge, in
a hollow) and carefully puncturing through it. If the pressure is negative, the water is sucked into the hole;
if positive a stream of bubbles rises through the water.
(ii) Palpation.
A sound tin has a solid ‘dead’ feel. One in which for any reason the negative internal pressure has
been destroyed is sparingly under pressure and is known as a ‘springer’. Springers should be tested by
perforating through water and then opened for inspection of the contents. The latter may or may not be
fit for consumption.
(iii) Percussion.
A sound tin, when tapped by the fingers or by a piece of wood, gives a dull note, while one with gas is tympanic.
(iv) Contents.
All tins showing external defects should be opened and the interior of the tin and its contents examined. The
interior of the tin is normally somewhat blacked and this is not a cause for rejection of the contents. Tinned
meat which has been exposed to tropical conditions may show varying degrees of softening or liquefaction of
the fat. This indicates deterioration but is not a cause for rejection unless definite decomposition indicated
by tainted smell and taste, is present. Any tin, the contents of which are perceptibly tainted, should be
condemned.

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(v) Laboratory Tests.

The above routine indicates whether or not decomposition has occurred. The salmonella group of organisms,
which are responsible for the large majority of food poisoning outbreaks, do not cause any alteration in the
physical appearance of the food. The food which appears perfectly sound, may produce severe poisoning. When
considered necessary, the tins should be sent to a laboratory for bacteriological and chemical analysis and for
feeding tests on animals.
(t) Dehydrated Meat and Fish.
The same general principles as discussed in the preceding para apply. Dehydrated meat and fish tend to become
acidic after a short time. There may be a slight odour which disappears when the tin is opened or on cooking
and does not indicate unsuitability for consumption. At a later stage when marked rancidity or decomposition
occurs, the product should be condemned. Dehydrated meat and fish are liable to infestation by insects especially
Dermestids (the larder beetle). If it has been present for some time, adult beetles will be seen on opening the
tin, together with the discarded skins or larvae but in more recent infestations only the larvae will be found. In
heavily infested meat the muscle tissue is largely eaten away, leaving mainly fibrous tissue. Infested meat or
fish should be destroyed. The accelerated freeze-drying process, now employed, results in better quality of dried
products without loss of its nutrients and keeping quality.
(u) Refrigerated Meat.
(i) Chilled Meat.
It is preserved at a temperature of 14º C to 16º C. It can only be relied on to remain sound for a few
weeks after slaughter, extendable to six weeks if the air in the cold storage space contains 10 percent of
carbon dioxide. The carcass is cold to touch and stiff but is not frozen solid; and if carefully and slowly
thawed before jointing, it is difficult to distinguish from fresh meat. As a rule, however, the bark has lost
the characteristic shine of fresh meat and may be even dirty looking or torn in places. Mould may be
present but is harmless unless it has penetrated deeply. The cut muscles surface loses the marbled pink
appearance of fresh meat and assumes a uniform dark-red or even brick colour, due to extravasations
of pigment from muscle cells (ruptured by freezing) into the interfibrillar fat. If the carcass is thawed too
rapidly the surface ‘sweats’ and the meat becomes sodden and waterlogged.
(ii) Frozen Meat.
It is preserved at a temperature below 8º C. The carcass is frozen solid and can only be cut with a saw
and keeps indefinitely so long as it remains at this temperature. The exterior is white and the bark is often
torn and has completely lost its bright appearance. Ice crystals are apparent on the surface and after
sawing in the interior. Moulds are frequently present on the surface. On thawing, the appearance closely
resembles chilled meat, but the colour is usually somewhat darker, the more stained is fat and the meat
is more sodden and moister. Putrefactive and pathogenic bacteria are inhibited but not killed by freezing.
When frozen meat is thawed, decomposition sets in very rapidly.
(v) Fresh Meat.
Medical officers are sometimes asked to give an opinion whether meat kept for some time after slaughtering is
fit for human consumption or not. Smell is the most reliable indication of decomposition, but consistency and
general appearance are also important considerations. The outside of the carcass and the skewer thrust into the
substance should be smelt. Meat with an unpleasant smell is unfit for consumption. Decomposed meat loses
its firm elastic consistency and tends to become soft and slimy. The fat becomes pale and the muscle appears
dark brown to black. However, the decision should always be made on the smell.

20.4 Inspection of Animals and Carcasses.

In stations where a veterinary officer of the RVC is available the responsibility of ante and post­ mortem examination of
all meat issued, as rations to troops will devolve on the veterinary officer. Where a veterinary officer is not available, an
ASC officer trained in meat inspection carries out this duty. A medical officer may have to carry out the meat inspection,
if neither of them is available or after the rations have been received in the unit and there is doubt regarding fitness
of the meat for consumption. Every animal should be examined prior to slaughter and in this task the medical officers
must rely on its general appearance. If the animal looks well and has no obvious signs of disease, it can be passed
as fit for food in most cases. On the other hand, one should hesitate before passing a poor looking animal, even if

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presenting no obvious signs of illness. In general, the thin diseased body, rough and staring coat, hanging head, quick
laboured breathing, injected conjunctivae, dribbling saliva, diarrhoea, a raised temperature and a high pulse rate are
signs of disease. To prevent substitution, all animals examined ante-mortem and passed, as fit should be suitably
branded. The normal temperature of sheep is 40º C, of swine is 38.8º C and of cattle 38.6º C; and pulse rates of these
animals are 40, 75 and 75 respectively.
The carcass should be examined for its nutritional condition; evidence of bruising, haemorrhage or discolouration; local
or general oedema; the efficiency of bleeding; swelling or definitizes of bones or joints; or abnormalities in musculature.
The pleura and peritoneum should always be examined and their removal or tampering with, before examination,
is never permitted. After the carcass is split (those of bovine are always split and those of swine only if disease is
suspected), the sternum, ribs, vertebrae and spinal cord should be examined. The head including the tongue, the
palate, the retropharyngeal, sub maxillary and parotid glands should be examined and the cheek muscle incised by
a linear incision parallel to the lower jaws for evidence of actinomycosis, foot and mouth disease, cysticercosis and
glandular tuberculosis. All viscera should be examined as they are removed from the carcass or after ensuring that the
viscera are of a particular carcass. Every organ and its associated lymph glands should be examined visually and by
palpation. If any abnormal condition is observed, the nature and significance of which cannot be determined by such
examination, the organ and / or glands should be incised, care being taken to avoid soiling the rest of the carcass with
infective material. The examination of lymph of glands should be by multiple incisions into their substance. Very often
the slaughtering takes place in the middle of the night or in the early hours of the morning when a veterinary officer is
not available on the spot. To identify viscera of the particular animal with a view to enable the veterinary officer to carry
out a postmortem examination, the viscera of individual animals must be hung alongside the carcass. This will enable
the veterinary officer to trace the infected carcass in the event of tuberculosis etc. being later revealed in the viscera.
(a) Stomach, Intestine and Spleen.
The outer and, where necessary, the inner surfaces together with the omentum and glands should be examined.
The spleen is commonly the site of pyaemic and tubercular abscesses.
(b) Liver.
The liver and its associated glands should be examined. Lumps in its substances may be tubercular, pyaemia
or hydatid in origin. The bile duct should be examined for flukes.
(c) Kidney.
The renal and adrenal glands should first be examined and the kidney then inspected and if necessary, split
by an incision. The kidney should be smooth, uniform in consistency and of an even brown colour. Tubercular
abscesses are not uncommon.
(d) Uterus and Ovaries.
The inner and outer surface of the uterus and the substance of the ovaries should be seen for infection and
new growths.
(e) Lungs.
The lungs should be examined, together with the bronchial and mediastinal glands, by inspection, palpation
and unless obvious disease renders this unnecessary by incision. Tuberculosis, pneumonia and in the sheep,
strongyloides infection are common.
(f) Heart.
The pericardium should be opened and the heart examined. If necessary, it may be incised. The base of the
heart is a common site for tuberculosis and cysticercosis infection.
(g) Udder.
It should be examined by inspection, palpation and incision at the base of the teats. Incisions should also be
made into any indurated regions and into the supramammary gland.
(h) Scrotum.
The testicles, penis and superficial inguinal glands should be examined.

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(j) Lymph Glands.

These must be examined as a matter of routine. The important groups are the bronchial, mediastinal, hepatic,
mesenteric, retropharyngeal, submaxillary, popliteal and the prescapular glands.
Judgement regarding fitness for human consumption or otherwise depends upon the nature of the disease and
the extent to which the carcass is affected. Broadly speaking if animals show evidence of generalized pathological
conditions (including pathological emaciation) the whole carcass should be condemned. If a pathological condition
is localized and obviously not liable to cause a systemic infection (e.g., simple abscesses, benign tumours,
cirrhosis of the liver etc.) only the affected organ or portions of the carcass and portion contiguous there should
be condemned. In the absence of obvious pathological conditions, meat which is well cooked will not give rise to
disease; but since thorough cooking is not invariably carried out, a careful inspection of carcasses and raw meat
is necessary. Some degree of guidance may be obtained from the paragraphs which follow. In the conditions
described below the carcass is normally condemned, unless otherwise specifically stated under a particular
condition. If any doubt still exists and expert advice is not available, it is better condemned and be safe than
to take a risk.
(k) Important Conditions (Non-helminthic).
(i) Actinomycosis.
It occurs most commonly in cattle; it is not unusual in swine but is rare in sheep. Sites of lesions are
usually the tongue and jaw, hence the term “Wooden tongue” or ‘lumpy jaw’. It may be present in any
part of the carcass. The actinomycotic deposits may be nodular or diffuse and may vary in size from tiny
specks to areas 10 mm in diameter. They present a stellate appearance because the constituents of each
nodule are arranged in minute wedges with their apices in the centre. The ray fungi can be detected in
every nodule under a microscope.
(ii) Anthrax.
It is a disease rapidly fatal to animals and usually diagnosed only after death. Post-mortem appearances
include pale muscles with blackened areas due to haemorrhages; blood black and tarry; haemorrhages
into the substances of all organs; pulmonary congestion; spleen greatly enlarged, dark purple in colour
and intensely engorged with blood. In pigs there is usually oedema of the glottis, but enlargement of
the spleen is absent. Blood-tinged discharges from the nose and rectum are seen. When the animal is
suspected to have died of anthrax, it should be opened for post-mortem examination. The examination of
an animal suspected to have anthrax should be carried out after the greatest care has been taken to avoid
self-infection and contamination of the surroundings and inanimate objects. The usual plan is to take a
sample of blood from the ear of the dead beast and examine it microscopically. If an examination of the
direct smear leaves any doubt, a mouse is inoculated. The carcass should be destroyed by burning in a
meat destructor or by proper burial.
(iii) Blackleg.
It occurs chiefly in young cattle, but occasionally in goats and sheep. It is confined almost exclusively to
animals grazing in wet marshy pastures. The cause of the disease is a sporing anaerobic bacillus. The
disease is usually confined to one area of the body, generally to one quarter. The affected part is swollen,
black and edematous and ‘crackles’ owing to gas formation. On incision, a stale, sour smell is apparent
which is quite different to the taint of decomposition. Hemorrhages into serous cavities are common. It
is distinguished from anthrax by the presence of gas, absence of splenic enlargement, normality of blood
and by the localization of lesions. Malignant oedema or gas gangrene which is due to Cl. septique infection
resembles blackleg but causes a foul smell.
(iv) Dropsy.
It is a relatively rare condition. It affects sheep, young cattle and pigs, in that order of frequency. The blood
is pale and watery, the serous cavities contain effusion and the muscles are pale, watery, flabby and drip
with moisture.
(v) Erysipelas.
Erysipelas of swine is due to Erysipelothric rhusiopathiae and has no connection with the erysipelas of
man. In its severe form it is mostly fatal. It is characterized by fever, weakness and a dark red colouration

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of the skin, which begins first as a number of small red spots which later coalesce and spread over the
whole body. The spleen is enlarged. the internal organs and lymph glands are inflamed and haemorrhages
are found in the serous cavities. In its milder from it is known as ‘diamond’ or ‘hog urticaria’, the only
manifestation then being local diamond shaped red spots on the skin and perhaps slight general illness
for a day or two.
(vi) Foot and Mouth Disease.
It is most common in cattle and pigs but other animals may be affected. It is intensely infectious. The
disease begins with small clear vesicles on the toothless border of the upper jaw which then spread to
the nasal septum, the tongue, the skin above the hoof and the skin in the cleft of the hoof. The udder
and external genitals may be affected. Later, the vesicles enlarge, coalesce and burst, leaving pale watery
looking erosions or septic ulcers. At a late-stage septicemia may occur. It is also called epizootic eczema
or aphthous fever. When generalized, the whole carcass must be condemned. When strictly confined to the
mouth and feet only those parts need to be condemned.
(vii) Glanders.
It is primarily a disease of horses but occurs among goats, cattle and sheep. Pigs are practically immune. The
disease is characterized by small hard nodules (farcy buds) in and under the skin of the head and neck due
to an invasion of the lymph glands by the Malleomyces malllei. Ulcers occur on upper and lower extremities.
The larynx, pharynx. trachea and lungs may be affected. Rarely are other internal organs affected. Diagnosis
may be confirmed by making a section of an excised gland, staining it and finding the organism.
(viii) Immaturity.
Animals are regarded as being immature if they are less than 8-10 days old. The flesh is pale, soft and
flabby and usually moist and gelatinous in appearance. ‘Slink veal’ is applied to the flesh of the newly
born or still-born calf. Diagnosis may sometimes be confirmed by inspecting the lungs, which may not be
expanded by air.
(ix) Jaundice.
It shows in the carcass of an animal as a yellow colouration in the fat, intestines. fibrous tissues, muscles
and bones. If cattle, have fed on rich pastures, the fat may be yellow but not the other tissues.
(x) Lymphadenitis.
It usually occurs as part of a general infective process following invasion by different organisms e.g., simple
inflammatory lymphadenitis, glanders, actinomycosis, tuberculosis etc. A decision to condemn the whole
carcass or a part of it will depend upon the cause and extent of the condition.
(xi) Caseous Lymphadenitis (Pseudo-tuberculosis).
It is a disease of sheep which begins as an inflammation and goes on to caseation. The condition which
closely resembles tuberculosis attacks principally but not exclusively, the precrural and prescapular
glands. Caseous deposits are often in the bones, muscles, lungs and pleurae. At a late stage the caseous
matter becomes hard dry and finally calcified. It may be differentiated from tuberculosis by its histological
appearance and by the absence of Mycobacterium tuberculosis. The entire carcass will be rejected in case
of generalized caseous lymphadenitis. In case of localized caseous lymphadenitis, the entire part will be
condemned.
(xii) Malignant Catarrhal Fever.
It is an acute rapidly fatal disease of cattle characterized by fever, inflammation of the eye, catarrh of the
upper respiratory passage and sometimes of the mucosae of the intestinal and urinary tracts.
(xiii) Pyaemia and Septicaemia.
These occur in many diseases which, in addition to the signs of pyaemia and septicaemia, frequently also
exhibit special localized pathological conditions of an organ or region. Among the commoner members of
the group are mammitis, metritis, joint ill (a pyaemic infection of the joints of calves arising from infection
entering by way of the umbilicus), osteomyelitis, enteritis, pericarditis, pneumonia etc.

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(xiv) Rickets.
It is only found in young pigs. If the carcass is also malnourished it should be condemned.
(xv) Rinderpest (Cattle Plague).
It is an infectious viral fever found principally among cattle. It is common in India. The mucous membrane
of the lips, fauces and the first three stomachs may show coagulated areas. In the small intestine, there
is swelling and congestion of the mucous membrane, Peyer’s patches and associated glands. So called
‘zebra markings’ may appear in the rectum (redness of the mucous membrane covered by strips of grey
exudates). The kidneys may be congested, the liver is generally swollen and its surface is dull. The flesh
in the latter stage of the disease may be very dark in colour.
(xvi) Swine Fever (Hog Cholera, Pig Typhoid).
The chief indications are severe diarrhoea, high fever, marked prostration and death. The intestines, serous
cavities and lungs are acutely inflamed and may show haemorrhages into their tissues. Intestinal necrosis
and suppuration of mesenteric glands are not common. The cause is probably a filter passing organism.
(xvii) Swine Plague.
It is an acute pneumonia due to the same organism as is generally accompanied by inflammation of the
internal organs.
(xviii) Tuberculosis.
It occurs in cattle and pigs, sheep are almost immune and the remaining animals are only occasionally
attacked. The disease may be generalized or localized. In cattle, the lesions are found in most instances
in the head, lungs, pleurae and bronchial glands and are either acute or chronic. In the lungs the lesions
resemble those in man. The pleura and peritoneum become studded with pulpy inflammatory exudates which
later form masses of round, soft greyish connective tissue nodules, the so-called tuberculosis ‘bunches of
grapes’. These nodules may attain the size and appearance of a small cauliflower. Calcification may occur.
Stripping of the serous membranes may be practiced to conceal tuberculosis and a carcass from which
the serous membrane has been stripped before inspection should be condemned. The liver, kidney and
spleen may show nodules of caseating masses, cavities or calcified areas. The intestinal tract may be
affected throughout its length, but most commonly in the pharynx and ileum. Associated glands should be
inspected and incised. The udder is a common site and may show nodules, lumps and caseating tumors of
calcified areas. Infected lymph glands are accepted as evidence that the organ draining into those glands
is also diseased. At the outset, the glands are swollen; later caseating foci appear glandular tissue become
destroyed and finally the glands consist of large connective tissue sacks containing caseating material.
Calcified glands are common. Practically any part of the body may be affected and the ovaries, testicles,
uterus, brain, spinal cord and membranes, joints and bones (usually the vertebrae) are often tubercular.
(l) Helminthic Conditions.
(i) Trematodes.
Meat containing flukes will not cause disease in man, since animals harbour only the adult parasites. As
a rule, flukes will be found in the liver and bile ducts or in the intestine, but the lungs and other organs
should also be examined. General systemic effects may be apparent with a heavy infection. For example,
Fasciola hepatica infection may cause cirrhotic changes in the liver and thickening of the liver ducts. The
flesh may be pale and flabby. In the absence of systemic pathological changes only the part infected needs
to be condemned. Trematodes commonly encountered are Fasciola hepatica in sheep and other herbivores;
Clonorchis sinensis in fish; Fasciolopsis buski, Gastrodiscoides hominis and Heterophyes heterphyes in pigs.
The longest of them all is F. buski measuring 5 to 7 cm while the shortest is H. heterophyes which is just
visible, about 1-2 mm.
(ii) Cestodes.
Taenia infection may arise in man through the consumption of insufficiently cooked pork or beef containing
cyst cerci of Taenia solium and Taenia saginata respectively. Man is also a host of the adult worn.
Diphyllobothrium latum infection can occur by eating insufficiently cooked infected fish.

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(aa) Taenia Solium.

Man is the host of the adult worm. The larval or cysticercal stage usually occurs in tissues of the
pig and many other animals and occasionally those of man. Animals become infected chiefly by
eating grass or drinking water polluted by human faeces containing ova. Pigs are habituated to eat
human faeces. The ingested ova give rise to Cysticerci cellulosae (Pig bladder worms) in tissues and
organs most commonly in abdominal muscles, diaphragm, lumbar muscles, tongue, heart, muscles
of mastication, the intercostals, neck muscles and muscles around the sternum, but may also be
found in lymph glands, brain eye etc. Cysticerci are small oval bladder-like structures, 6 to 18 mm in
length and containing a clear fluid within a delicate capsule. Part of this wall which is surrounded by
a fibrous tissue capsule, is differentiated into a scolex. The naked-eye appearances in pork have been
described thus; ‘Small white seed pearls and barley grains.’ These are small dirty greyish-yellow cysts
of various sizes with a central or terminal white spot (the scolex); small yellow pimples or pustules;
showing up through the muscle fibers. If infection is light, cysts are easily overlooked. The muscles
as well as other organs, should be freely incised and the cut surfaces examined. Even a thorough
search, cannot guarantee the freedom from cysticerci. When a cyst is located it should be carefully
dissected out from the surrounding tissue and examined with a powerful hand lens or a low powered
microscope, when the scolex with its four suckers and double row of hooklets will be visible. Gentle
squeezing with the fingers usually causes the scolex to protrude and facilitates its examination.
After living in their host’s body from months to years, the cysts die, degenerate, caseate and finally
become calcified. C. cellulosae are highly resistant to storage and living cysts have been found in
pork slaughtered 42 days previously. Freezing and pickling do not reliably kill them and smoking has
no effect.
(ab) Taenia Saginata.
Man is the host of the adult worm whereas the larval or cysticercal stages are in the body of cattle.
Infection of the animal takes place through eating grass or drinking water contaminated with human
faeces. The cysts are known as Cysticerci bovis (beef bladder worm or beef measles). The tissues
most usually affected are the muscles of mastication, the heart, the tongue and the diaphragm. The
naked eye appearances are very similar to those of C. cellulosae, but the cysts are smaller 6 to 8
mm, are less delicate in structure so that the white spot representing the scolex is not so obvious
in the cyst wall and contain scolex armed with four suckers but no hooklets. In the examination of
meat, the same procedure should be followed as when searching for C. cellulosae in pork. C.bovis are
somewhat less resistant than C. cellulosae and storage of meat for three weeks kills them. Pickling
is not lethal and freezing is not reliable. Man, however, does not harbour the C. bovis, so that the
danger is less than from consuming C. cellulosae.
(ac) Echinococcus Granulosus.
This tiny tapeworm (3 to 6 mm long) exists in its adult form in all members of the dog and cat tribes,
while the larval or cystic form occurs in man, sheep and cattle. The unilocular hydatid cyst consists of
a single hollow bladder containing in its interior brood capsules, daughter cysts, hydatid and the cyst
fluid, the whole being surrounded by a fibrous capsule. Such cysts may attain the size of a child’s
head but in cattle and sheep are rarely larger than an orange. The multilocular variety consists of a
number of separate small cysts which are not enclosed within an encircling capsule and resemble a
bunch of grapes both in shape and size. Infected meat is not dangerous to man and it is sufficient
to condemn those portions which are visibly infected.
(ad) Diphyllobothrium Latum.
Infection with this tapeworm, of which man is the definitive host, arises from eating infected fish in
certain parts of the world. Human infection is common on the shores of the Baltic, in Central Europe,
Central Asia, Manchuria, Japan and on the shores of the Great Lakes on N. America. Very thorough
cooking renders infected fish safe to eat. Since it is doubtful if ordinary cooking is sufficient, it is wiser
to avoid all freshwater fish in localities where the disease is endemic. The eating of raw, smoked or
pickled fish in such areas is especially dangerous.

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(iii) Nematodes.
(aa) Trichinella Spiralis.
It is a small round worm (females 3-4 mm and males 1.5 mm long) of which man, pigs, dogs, cats
and rats are the hosts, both definitive and larval. Man becomes infected through eating pork in
which living larvae of T. spiralis are encysted. Fully developed larvae in muscle tissue appear as oval
bodies, about 0.5 to 1 mm long lying-in long axis of the muscle, each containing its curled-up larva.
The cyst wall is at first thin and delicate, later becomes thicker and after about 6 months begins to
show minute calcareous deposits. Usually within a year, but sometimes not for many years, the larva
dies and the cyst and its contents degenerate into a calcified nodule. The cysts can be seen by the
naked eye as small specks about the size of small pinhead scattered throughout the muscles. When
searching for cysts, several small pieces of muscle should be cut from the diaphragm, intercostals and
muscles of mastication. The fibers of each piece should be well teased out with needles on a slide
in a drop of water and then covered with a stout cover slip and well pressed down. The lowest power
available should be used for microscopic examination. The essential diagnostic sign is the fact that the
cysts lie within the muscle fibers, a sign which, even if the larva in the cyst cannot be distinguished,
enables a differentiation to be made between trichinella cysts and Rainey’s capsules. A temperature
of 55º C kills the cysts. Storage, freezing, smoking and pickling are not reliable destructive agencies.
Cooking renders pork safe to eat and in countries where pork is habitually well cooked, the disease
is rare.
(ab) Metastrongyloidae.
This family of worms contains a number of species which inhabit the lungs of mammals (lung worms).
The animal most commonly affected is the sheep, but cattle, goats, horses and rabbits may also
be parasitized showing yellowish-white or greenish-white nodules of firm consistency and of a size
varying from a pin-head to a large marble scattered throughout the lung substance, the larger nodules
being nearer the pleural surface. ln advanced cases the pleural surface is studded with tubercle-like
nodules and the lungs look solid. A section of the nodule shows positions of the adult worm containing
ova, numerous free ova and embryos, the whole being surrounded by an infiltration of small round
cells. Usually there is little in the way of constitutional signs and symptoms. but a fatal pneumonia
may result. The diagnosis in sheep is simplified by the fact that tuberculosis is almost unknown in
that animal. Although this condition does not affect man, the rule is to condemn the lungs of such
carcasses and, in a severe case with constitutional symptoms, the whole carcass.

20.5 Slaughterhouse Sanitation.

The sanitation of the slaughterhouse is important. The magnitude of the problem of maintaining a high standard of
hygiene and sanitation of the premises and surroundings of the slaughterhouse is proportionate to the magnitude of
work carried out. In very large commercial establishments mechanization of functions is necessary. A regular inspection
of slaughterhouses is essential to ensure cleanliness in the production of meat for human consumption and to ensure
that it does not become a center for the spread of infections. The most important points to note are:
(a) The method of disposal of offal, blood, animal excreta and discarded animal tissues.
(b) The fly proofing, rat proofing and dog proofing of the premises.
(c) The sanitation of the structural soundness of the building. The construction of the floor which should be
made of cement concrete and provided with rat proof drains.
(d) The spaciousness of the separate slaughtering, skinning and hanging rooms, their ventilation.
(e) Availability of water for maintaining the sanitation.
(f) The maintenance of equipment of slaughtering, skinning and handling and finally the personal hygiene of
the workers.  

20.6 Fresh Milk.

The main objectives of inspecting fresh milk supplies are to detect visible dirt deterioration and adulteration; assess
nutritive quality and keeping quality; and ascertain efficiency of pasteurization.

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(a) Visual Inspection.

Ropy milk or slimy milk may be due to a disease of the udder or contamination by lactis viscosum. Blue milk may
be due to skinning, watering or to the poor condition of the animal, (e.g., due to tuberculosis) or occasionally to
infection by Pscyanogena. Red milk may be due to a crushed udder; but milk for the first few days after calving
is highly coloured owing to the presence of colostrum. Dirty milk is due to manurial dust from the flanks and tail
of the cow or dirt in the container. The measurable amount of dirt on standing should be less than 100 ppm
and when this residue is diluted with water and centrifuged, the insoluble dirt should be less than 50 ppm of
the milk. Ropy milk or excessively dirty milk or red milk, other than that due to the presence of colostrum, should
be condemned at once. Blue milk should not be accepted as sound whole milk; but if it is due to skimming it
is not harmful to health.
(b) Taste.
Bad taste in milk may be due to the feeding of the cow (e.g., with turnips). Medicinal taste may occur if the cow
is being administered some drugs. Rejection is justified if the taste is unpalatable. Ordinary sourcing of milk,
though not harmful, is not acceptable. Souring of milk is not necessarily indicative of feacal contamination by
pathogenic organisms; they are lactose non fermenters and hence do not make milk sour. Therefore, non-sour
milk is not necessarily always safe either.
(c) Laboratory Tests.
The specific gravity of milk should be 1.029 to 1.033 but watered milk can be readily restored to its normal specific
gravity by adding sugar or cornflour. Tinned or powdered milk should be sent to Composite Food Laboratories.
Fresh milk, for detailed analysis chemical and bacteriological tests and to assess the efficiency of pasteurisation,
may be sent to the laboratory.
(i) Gerber’s Test.
In this test fat estimation is carried out by thoroughly mixing 10 ml of sulphuric acid. 1 ml of amyl alcohol
and 11 ml of milk in the special tube provided with the apparatus and centrifuging it for 5 to 7 min when
milk fat separates as a clear supernatant layer. This is read off from graduations on the tube, which shows
the percentage of fat in the sample.
(ii) Total Solids.
These are estimated by the evaporation of whole milk in a water bath and then weighing the dried residue
or by using Richmond’s formula viz. Total solids= 0.25 G + 1.2 F + 0.14 (G means specific gravity above
thousand i.e., 28 or 30 and F means percentage of fat). Solids not Fat (SNF) are estimated by deducting
the fat value from the total solids.
(iii) Methylene Blue Test.
It is carried out for testing the keeping quality and bacterial contamination in the milk. The basis of the
test is that the dye is reduced and decolourised by the bacterial enzymes. The rate of reduction is an index
of the extent of bacterial contamination. One drop of methylene blue solution of 1:3,00,000 strength is
added to 10 ml of milk sample in a test tube and then incubated at 37º C in a water bath or incubator.
The mixture should not decolourise within 5½ hours. If kept at room temperature above 37º C it should
not decolourise with 4½ hours.
(iv) Phosphatase Test.
This test is meant for ascertaining the efficiency of pasteurisation and depends on the fact that the enzyme
phosphatase is destroyed by the pasteurisation temperatures, but not destroyed at a lower temperature or
in a shorter period than that required for pasteurisation. Milk containing as little as 0.25 percent of raw
milk in the properly pasteurized milk still contains detectable quantities of enzyme. The test is performed
by addition of disodium phenyl-phosphate to pasteurised milk. The enzyme phosphatase if present splits
up the phenol by means of a phenol test reagent which gives different shades of blue colour depending
upon the amount of phosphatase enzyme present. The colour is matched against the standard colours in
a Lovibond colorimeter. Pasteurised milk must not contain more than 2.3 Lovibond units.  

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Table 20.1 : Diseases Conveyed Through Milk

Disease Organism Reservoir / Source
Tuberculosis Mycobacterium tuberculosis (bovine) Cattle
Brucellosis B. Abortus, Melitensis Cattle, Goat
Q Fever Coxiella burnetti Cattle
Septic sore throat S. pyogenes Cattle, Milk Handlers
Food poisoning, toxin type S. aureus Cattle, Milk Handlers
Cholera Vibrio cholera Cattle, Milk Handlers
Enteric Fever Salmonella, Paratyphi A Cattle, Milk Handlers
Viral Hepatitis, Poliomyelitis Hepatitis A, Polio viruses Cattle, Milk Handlers
(v) Bacteriological Tests.
These are rarely carried out as a routine but when indicated, are used for detection of M. tuberculosis or B.
abortus. Under such circumstances 100 ml of milk is centrifuged at 3000 rpm for half an hour. The deposit
is mixed with a little saline and injected into two guinea pigs. One of them is sacrificed after 4 weeks and
the other after 8 weeks. Lungs and other organs are examined for tubercular granulomas. Serum from
these guinea pigs can be used for agglutinating B. abortus culture or the spleen of the killed guinea pigs
can be cultured in a liver extract-agar medium containing gentian violet of concentration of 1 in 2,50,000
in the presence of 10 percent carbon dioxide. Deposits of centrifuged milk also can be cultured for other
organisms in appropriate media such as the Wilson Blair medium for the enteric group of organisms and
the tellurite medium for C. diphtheriae.
(d) Milk borne outbreaks of acute infection like food poisoning, typhoid or viral hepatitis may occur where
milk from various sources is pooled to provide to large community-feeding establishments like students’ hostels,
Armed Forces Personnel or large hotels and restaurants. The outbreaks are explosive, affecting persons in a
circumscribed area with a common milk supply from a common source. Such outbreaks in hotels, restaurants,
hostels, at formal dinners and in officers, JCOs or NCOs messes in Armed Forces, occur through consumption of
ice creams or puddings made of milk or cream. In order to assess the nutritive standard and initial purity the
raw milk should be subjected to various tests, described above. ln order to ensure its initial purity and prevent
outbreaks of milk borne diseases, extreme care as regards the milking cattle, their cleanliness and health: their
stabling and feeding conditions; personnel, their health and cleanliness; adequacy and condition of premises and
equipment; process of milking, pasteurisation, packing preparation of products and their delivery to consumers,
require attention. A periodical medical examination of personnel hygiene, inspection of premises and equipment,
veterinary inspection of cattle, scrutiny of all the process in the dairy, inspection of functional efficiency of the
farm, depot and plant and laboratory tests for purity and quality of pasteurisation are required to be carried out.
These measures should ensure the following:
(i) The live stock of milking cattle is healthy, free from infections and protected against any of the
illnesses; ill animals are isolated and contacts are segregated to prevent spread of infection; ill animals
are not milked.
(ii) Surroundings are maintained at high sanitary standards.
(iii) Milk handlers are healthy, free from and protected against infections and are prohibited from handling
milk if evidence of ailments is seen.
(iv) Water supply is pure and protected.
(v) Containers are clean, regularly washed, sterilized and protected from contamination.
(vi) Milk is protected against contamination by flies, dust or other extraneous matters from its production,
through processing and bottling / packing up to its delivery to the consumers.
(vii) Milk is treated to destroy pathogenic organisms and thereafter kept protected.
Note. As military farms have leased to exist, the measures described above can be ensured for civ vendors

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supplying milk and milk products.

20.7 Catering Services.

(a) Army.
At the Army HQ a catering cell with a specially trained catering officer and the Deputy Assistant Director (Catering)
as its head, functions under the Directorate of Supply and Transport. At the Command level the officer commanding
the Command School of Catering functions as the Adviser in Catering. In a Mountain Division, a catering JCO is
appointed in its ASC Battalion. At Bareilly, in the ASC School, there is catering wing for training of unit cooks.
The IMA and NDA are authorized catering officers / JCOs. At Command Hospitals there is an ASC catering JCO
while at other large hospitals an AMC JCO is trained to carry out the duties of a catering JCO. In each station
there is a Station Messing Committee with the Station commander as the Chairman; OsC of units, unit messing
officers, the manager of the dairy farm, Naval and Air Force representatives and the formation / station catering
officer / JCO as members and the supply officer as the Secretary. They assemble every month to discuss matters
concerning rations, the supply problems and catering related issues. In each unit there is a similar unit messing
committee with 2 IC as Chairman and Coy JCOs, MO, messing officer, QM, senior cook and Mess NCOs as
members. They also assemble once a month to discuss messing problems. A unit messing officer is appointed
to ensure proper catering in all the JCOs / OR messes. The catering officer / JCO from the formation HQ advises
units on all matters.
(b) Navy.
The Director of Supply and Victualling is responsible for laying down the policy at Naval Headquarters. Under his
direction the supply officers on the staff of the senior administrative authorities afloat and ashore take steps
to implement the various aspects concerning catering by giving proper guidance and direction to other senior
supply officers of ships / establishments under them. At large establishments and for the fleet, commissioned
store officers (catering) are responsible for carrying out the policy under the direction of senior supply officers.
(c) Air Force.
At Air Headquarters there is a staff officer in charge of catering. Under the AOC command there is a command
catering officer who is responsible for detailed supervision of the policy as laid down by Air Headquarters. At
stations the station administrative officer is responsible to the Commanding officer for general administration of
messing and supervision of rations. He has a station catering officer (when authorized) to advise him, otherwise
a messing officer is detailed to carry out these duties. The station catering officer is assisted by WO (catering
assistant) of catering. The minutes of the Station and Unit messing committees are recorded and circulated to
all concerned.

Functions of the Catering Establishments.

(a) Station Messing Committee.
(i) To acquaint units with the current supply policy matters regarding turnover of stocks and matters
connected with free and payment issues.
(ii) To discuss matters concerning popularity, quality and variety of ASC supplies.
(iii) To discuss suggestions from Unit Commanders on improving supplies.
(iv) To discuss and give out a monthly / fortnightly forecast issue programme prepared by the OC supply
depot.
(v) To hear and meet particular preference of units within the authorized scales of rations.
(b) Duties of Station Catering Advisers.
(i) To ensure that the men get the full benefit of authorized rations.
(ii) To advise unit commanders on all points in connection with the messing, cook houses and dining
halls.
(iii) To see that the ‘bill of fare’ is prepared intelligently to provide variety and a balanced diet.
(iv) Training and welfare of cooks.

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(v) Maintaining close liaison with medical, engineer and ordnance services on matters concerning
nutrition, hospital diets, designing of cooking equipment, cook houses and dining hall equipment.
(vi) Liaison with supply officers
(c) Unit Messing Committee.
(i) To ensure that men are properly fed on the rations available.
(ii) To acquaint members of the unit messing committee with the current supply position.
(iii) To hear and remedy genuine complaints and consider suggestions put forward by the members.
(iv) To draw up the ‘bill of fare’.
(v) To see that adequate facility exists in dining halls and there is no wastage of food.
(vi) To make suggestions for alternate dishes.
(d) Unit Responsibility.
It is the responsibility of the OC unit / ship to see that the meals of troops under his command are satisfactory
in every respect. The provision of good food is one of the most important factors for the promotion and
maintenance of positive health and welfare of a unit; failure raises frequent complaints. Unit should insist that
rations supplied to them conform to the quality and quantity laid down in the regulations. Medical Officers should
advise accordingly. If there is a legitimate cause for dissatisfaction, the matter must be taken up by the OC with
the local supply officer; the procedure is laid down in DSR­ Para 892, 1987 (Revised Edition).
The drawing, storage and cooking of the rations received have equal or even greater importance in ensuring that
troops nutrition is satisfactory. The commanding officer is assisted in efficient execution of these responsibilities
by the unit messing committee and the unit messing officer / JCO. All rations should be drawn in suitable clean
containers. Supplies should be properly stored in well-ventilated rat proof store rooms on proper dunnage. Fresh
rations should be drawn and stored on shelves in fly-proof baskets and crates in well-ventilated storerooms. Fresh
fruits and vegetables should under no circumstances be stored in gunny bags. Condiments, tea, oil hydrogenated
and salt should be kept away from each other.
(e) Messing Arrangements.
Rations are issued daily to the kitchen NCO according to the ‘bill of fare’. The MO should periodically scrutinize the
messing arrangements from the point of nutrition, wholesomeness of food and its freedom from contamination
during the process of cooking and serving. The quantity and quality of the rations and whether the troops are
receiving and consuming the rations to which they are entitled should always be ascertained. The unit catering
officer is responsible for the messing arrangements and should always consult the medical officer and accompany
him when on his inspection rounds.
Vegetables should always be obtained fresh and cooked in a minimum quantity of boiling water. Cooking must
be so timed that food is ready only a few minutes before the time of distribution. Such fruits and vegetables
which are eaten raw, should be first washed thoroughly in running water or in several changes of fresh water,
then immersed for not more than three or five minutes in clean WSP solution made by adding one scoop full
(2 gm) of WSP to 10 litres of clean water and again washed in clean running water. If the food is not cooked
and served well it causes wastage and adversely affects the nutrition of troops. An examination of the table
waste and swill bins should indicate which items of dietary or food are unpopular.

20.8 Sanitation of Cookhouses and Dining Halls.

A high standard of tidiness and cleanliness of all premises used for cooking and serving the food should be ensured:
(a) The entire cookhouse premises should be spacious, lighted, fly proof, rat proof, airy and spotlessly clean
always. The cookhouse should have a separate kitchen or cooking room, a storeroom for fresh provisions, a
preparation room, a scullery and a room for the cooks’ clothing. Sinks should be provided in preparation room,
kitchen and scullery and washing rooms. In peace stations and permanent camps and to some extent even
in the fields, fly proofing of cookhouses should be carried out using wire guaze fitted to windows and doors.
Under purely temporary conditions and awaiting permanent arrangements old mosquito nets fitted or camouflage
nets loosely hung serve as good improvised fly proofing. The floor, walls, ceiling, sinks tables, shelves, cooking

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appliances and utensils should be spotlessly clean.

(b) Kitchen.
The kitchen should be spacious sufficiently large, properly constructed cooking range which can economize
the consumption of fuel, keep the cookhouse clear of smoke and afford maximum comfort to the cooks. The
cooking room should be fly proof and yet be well ventilated. It should be meticulously clean and tidy. The floor
should be well cemented and free from cracks and crevices. Flit guns are authorized for each cook house and
dining hall for spraying a solution of pyrethrum extract just before the cooking starts. The cooking range should
be flanked with platforms for cooks to sit and for prepared food to be kept awaiting removal to a food serving
hatch, racks or hot-plates. Chapati baskets must be lined with clean cloth which is washed daily. All food should
be kept covered.
(c) Preparation Room.
Provision of fly proof and ventilated preparation room for the preliminaries of cooking such as peeling, cutting
and washing of food before they are cooked is necessary. The practice of preparation of vegetables on the floor
or gunny sacking must be prohibited. This should always be done on a zinc-toped table fitted with a chopping
board on it. The peeling and refuse should be deposited directly in a covered refuse bin specially kept for the
purpose. The provision of meat chopping block is essential. The block should be washed immediately after use
and covered with a layer of powedred salt and kept in the sun.
(d) Store Room.
A separate fly proof and airy storeroom for raw fresh food stuffs should be provided. Fresh rations should be kept
in baskets / crates ensuring free circulation of air and stacked on shelves. Fresh fruits and vegetables should
under no circumstances be kept in gunny bags. Meat, milk and curd should be kept in a fly proof meat and milk
safe or cupboard refrigerator. Dry rations should be kept in racks, away from the walls, either in neatly tied bags
or in tins, on dunnage, preferably in a separate well-ventilated storeroom. Condiments, tea, oil hydrogenated and
salt should be kept away from each other. Rations are issued daily to the kitchen NCO according to the ‘bill of
fare’ and proper accounts maintained. A room for equipment and utensils and for the cooks clothing and other
necessaries should be provided separately.
(e) Scullery.
The scullery should be dry, clean and tidy. Sinks should be adequate and draining boards should be sufficient and
clean. If a proper scullery cannot be provided, as on field service, a properly constructed washing platform with a
cement top draining into a properly constructed soak pit through a grease trap must be provided. Maintenance
of a grease trap and soak pit is extremely important to avoid fly, mosquito, cockroach and sand fly nuisance.
All utensils after use should be thoroughly cleaned, washed, dried and kept in clean places. Tables should be
scrubbed with washing soda and water twice a day using a hard brush.
(f) Dining Room.
The dining room should be clean, fly proof, well lit, ventilated, cozy in winter and cool in summer, near the
cookhouse and afford about one square meter of floor space per man, including passages, for 85 percent of the
strength in units and 90 percent in depots. In the field, camouflage netting can provide reasonable fly proofing
and a condemned mosquito net can be utilized for protection of cooked food. While serving food, care should
be taken to ensure that it is not exposed to flies or dust. It should be presented in a manner that will enhance
the acceptability or appeal and reduce wastage. An effort should be made to supply hot food at all mealtimes.
To achieve this aim, a hot plate should be incorporated in the serving hatch or platform. All necessary equipment
including water jugs and drinking vessels should be presentable and attractively laid out. Water should be taken
out by a ladle (which should always be kept dipped in the water) without dipping the hands. An occasional
visit at mealtime to see the arrangements for the protection, service and state of food is desirable. Provision
should be made for the collection of inedible portions of the meal i.e., bones, peelings, cores etc. Salt and
pepper containers should also be provided on each table. An examination of wastage is a valuable method of
ascertaining what items of dietary are unpopular; the reasons for excessive wastage must be sought for and
remedied. Dining tables must be scrubbed with hot water and washing soda after each meal.  
(g) Cooks Hygiene.
All men employed as cooks and in the handling of food should take a thorough bath before starting daily

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work, keep their hair and nails clipped short and invariably scrub and wash their hands with brush, soap and
water after every visit to the latrine or urinal and before handling food or raw rations. They should be regularly
medically examined, vaccinated against the enteric group of fevers and daily inspected for personal hygiene and
the condition of their fingernails. The list showing the names of the cooks, date of their employment, the date
and remarks of the medical officer at their last examination and dates of immunization should be displayed. If
civilian cooks are employed, each should have an identity card bearing his photograph to prevent impersonation.
(h) Cooks.
They should be provided with special clothing consisting of 4 aprons, 4 caps (or pugrees), 4 shirts, 2 shorts,
2 trousers to wear while on duty. Facilities for scrubbing hands with brush and washing with soap and running
water should always be available. Even in the field, improvised arrangements for provision of running water (tap
fixed to a drum) is preferable to a basin of water, which should always be always available in the cookhouse.
(j) Washing Arrangements.
Arrangements to clean and wash the mess tins or plates and hands should be made adjacent to the dining
hall. Covered swill bins should be provided and kept on impervious cement platforms. In the field service, mud
platforms properly rammed down after mixing crude oil and covered over with PBX sheeting should be constructed.
The lid of the swill drum should always be kept shut. A cement platform or sink should be provided for washing
hands. A platform with three open drums containing coarse ash and fine ash (or sand) and for putting used
ash should be provided. A third platform with three drums for washing and sterilizing mess tins or plates should
also be provided. Mess tins and plates should first be cleaned with coarse and then with fine ash and then
washed and rinsed in three drums placed over a kettle­ trench. The first ‘washing’ drum should contain hot water
and soap; the second, ‘rinsing drum’ should contain hot water and soda; the third, ‘sterilizing’ drum should
contain water kept constantly boiling during the period it is being used. The drums should be clearly marked
WASH / STERILISE. Utensils should be cleaned with sifted ash or sand before treating in the three containers
successively. They may be washed with clean water if the arrangements to boil water are not feasible.
(k) Rules of the cookhouse and dining hall hygiene as under should be incorporated in all unit standing orders
and displayed in a prominent position in all messes, cook houses and dining halls.

20.9 Unit Standing Orders for Cookhouse and Dining Room Hygiene.
(a) Anyone who may be a carrier of typhoid or para-typhoid or suffering from or under treatment for dysentery,
diarrhoea or any other communicable disease will not be employed in any capacity in the cookhouse or in
handling food. He must be examined and certified as fit by a medical officer before being so employed.
(b) An up-to-date nominal roll of all men employed in the cookhouse showing the immunization record and the
date of medical inspection will be maintained and displayed prominently in the cookhouse.
(c) Personnel employed in cooking of food will be provided with the authorized special clothing. Aprons will
always be worn at work, kept clean and changed and washed when dirty.
(d) Running clean water (hot during winter), soap, nail brush and clean towel will be provided in each cookhouse.
Cooks should keep their nails clipped short and invariably wash their hands before they handle the food and
after visits to latrine.
(e) No personal clothing, accessories or private property of men employed in the cook-house will be permitted
to be kept there; nor will they perform their toilet or washing or drying of their under-clothing in the cookhouse.
Personal clothing on the body will be removed and kept in the place provided for the purpose and overalls are
put on.
(f) Smoking in the cookhouse is prohibited.
(g) The NCO in-charge will be responsible to ensure that there is always a sufficient supply of clean jharons
available for drying washed dishes and cooking utensils. The jharons used for handling hot and sooty vessels
will be separate and distinct. After the last meal these cloths must be boiled in water containing washing soda
and hung up to dry.
(h) All pots and pans will be freed from grease, cleaned and dried after the last meal and placed on a shelf
on their sides with their interiors exposed to the air and to view.

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(j) The cookhouse sinks, tables, chopping blocks, cutting-up boards, pastry slabs, mincing machines, knives,
forks, spoons and all other utensils will be kept clean when in use and will be thoroughly cleaned after the
last meal. All utensils, when not in use, will be kept in the places allocated for them and will be available for
inspection at any time.
(k) Only food which is to be used during the current day will be kept in the cookhouse. When not in the process
of cooking or in preparation for cooking it will be protected from flies in fly proofed food safes.
(l) Food scraps, vegetable peelings and such like refuse will not be thrown on the floor but directly deposited
in covered refuse bins provided for the purpose.
(m) All cutting up of meat and pastry will be done on the cutting up blocks / boards and pastry slabs provided
for the purpose.
(n) The bill of fare for the week will be displayed in the cookhouse.
(o) Adequate arrangements will be made for the washing, rinsing and sterilizing of eating and drinking utensils.
(p) Any defect in the cooking apparatus or in the utensils will be reported at once by the NCO in­ charge to
the unit quartermaster, who will take the necessary steps to have the defect remedied.
(q) The floors of cookhouse will be scrubbed daily and excess water must be dried up by mopping.
(r) The cookhouse and dining hall should be sprayed daily with 0.1 percent pyrethrum solution, preferably
between 1000 to 1200 hours.

20.10 Ration Stores.

In permanent barracks these stores are usually solid, concrete, fly proof and rat proof buildings. Grains and flour
should be stacked on racks placed away from the wall. In field camps, grains should be stored in iron or tin containers.
Regular turnover of reserve rations should be ensured and their condition should always be examined by the medical
officer to ascertain whether they are infested with weevils and other food pests. Vegetables such as potatoes, onions
and tomatoes should be stored in ventilated shelves. Tinned foodstuffs should be periodically examined for damage
to tins and the expiry of the warranty period.
Various check lists issued by FSSAI for food safety inspections are enclosed as Appendices to the chapter.   
(a) Food Safety Inspection checklist for catering: Appx A
(b) Food Safety Inspection checklist for eating establishment / bakery / restaurant: Appx B
(c) Food Safety Inspection checklist for inhouse pantry and canteen: Appx C
(d) Food Safety Inspection checklist for storage and warehouse: Appx D
(e) Food Safety Inspection checklist for slaughterhouse: Appx E

Suggested Readings.
1. Army Order 10 / 2020 / DGMS: Prevention of Food and Water Borne Diseases
2. Jindal, A. K. (2019). Food safety and quality control: Best practices in the Indian Armed Forces. Medical Journal
Armed Forces India. doi:10.1016 / j.mjafi.2019.06.003
n

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Appx. ‘A’

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 HEALTHCARE IN ARMED FORCES

Chapter
XXI
HEALTH CARE & HEALTH ADMINISTRATION

21.1 Introduction.
Health has been defined by WHO in its preamble as, “a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity”. Later, an addition has been made of ability to lead a socially
and economically productive life. The WHO declaration of Health for All by 2000, Millennium Development Goals
(MDG) for 2015 and Sustainable Development Goals (SDG) of 2030 are steps taken to achieve highest level of
attainable health and well-being for all.
India, being a signatory to Alma Ata Declaration of 1978 for Primary Health Care, has introduced many government
programs and initiatives towards this goal. The recent addition is the Ayushman Bharat Program which deals with
the concept of health and wellness and availability of comprehensive health facilities at the primary level.
The Armed Forces of the country are a special group of people having specific health needs due to the nature
of their duties. The healthcare of the Armed Forces personnel and their families is of paramount importance to
ensure a fighting-fit defence force for keeping the nation safe. Healthcare services should be promotive, preventive,
curative and rehabilitative. The focus needs to shift from medical care to holistic health care and wellness. It
should be directed towards attainment of positive health and wellness rather than only treatment of illness.

21.2 Health Care of Armed Forces Personnel.

The administration of health care in the Armed Forces is necessarily comprehensive. Services have no control over
the individuals’ heredity & intra-uterine life, prenatal hazards and life up to the age of recruitment. At the recruitment,
however, a selection choice is available when persons with hereditary or acquired defects are eliminated. A medically
suitable sound bodied person, capable of being moulded into a fit serviceman, with adequate reserve against stress and
strain of service, can thus be selected. The further responsibility of building up his health is that of the Armed Forces.
In the process, the recruit has to surrender some of his individual characteristics nurtured by parents and community
from his very birth and assimilate certain unfamiliar new characteristics required for leading a close community life
under regimentation, various disciplinary restrictions and conditions that are quite often, physically very strenuous,
hazardous and emotionally stressful. In order to enable him to withstand the metamorphosis from a civilian individual
to a physically, mentally, emotionally and socially fit soldier and thereafter to maintain his qualities at a high standard
of fitness, the health care of serving individuals is well planned.

21.3 Factors Affecting Health of Troops.

In the Armed Forces “HEALTH’ embraces everything that prevents disease and promotes physical, mental and fighting
fitness amongst all ranks and ensures their welfare and high morale. The important means to achieve positive health are:
(a) Provision of adequate and healthy accommodation
(b) Balanced diet and clean dining arrangements.
(c) Clean water and milk supplies
(d) Good living and working conditions.
(e) Appropriate clothing
(f) Clean environment and sanitation
(g) Adequate personal care
(h) Health education of troops
(j) Regular health check-ups

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21.4 Responsibility of Providing Health Care Services.

Health and well-being of personnel is the responsibility of the commanders. Medical services advise the commanders at
all levels on all matters concerning health care and carry out treatment of ailments till their rehabilitation is complete.
In addition to these, various National Health Programmes are also adopted in the Armed Forces in close coordination
with the Central and State Health Services. The medical organization at the respective Service Headquarters coordinates
all the health-care requirements, which include:
(a) Health care of troops and their families
(b) Provisions of medical treatment and preventive measures
(c) Advising on accommodation, nutrition, food, milk and water supply in Armed Forces
(d) Health education of troops
(e) Environmental control
(f) Research on health and medical care, including matters affecting morale, fighting and functional efficiency
of Forces
(g) Health statistics
(h) Medical categorization
(j) Pathology services
(k) Scrutiny of fatal case documents
(l) Training of medical officers and paramedical personnel

21.5 Organization of Health Care.

(a) Director General Armed Forces Medical Services (DGAFMS).
The DGAFMS is the head of Armed Forces Medical Services and is responsible to the Ministry of Defence for
overall medical needs of the Armed Forces. The Director Generals of Medical Services (DGsMS) are the medical
advisers to the respective Chiefs of Staff of the Army, Navy and Air Force & are responsible for the day-to-day
administration and proper functioning of the medical services under their control. The DGAFMS is kept informed
of all general policies, decisions and directives issued by the three services HQ. He is kept informed by the
DGsMS regarding the planning of hospitals & research developments. A representative of DGAFMS attends all
meetings and discussions where matters of medical policies and planning are under consideration by the three
services. The DGAFMS is also the Chairman of Armed Forces Medical Research Committee (AFMRC). In this
connection collaboration is maintained with the following organizations:
(i) Indian Council of Medical Research (ICMR).
(aa) DGAFMS is a member of the governing body.
(ab) Asst Director General Medical Research and Senior Consultant (Medicine) are members of the
scientific advisory board.
(ac) Medical Officers of the three services are on various committees, as nominated.
(ii) Council of Scientific and Industrial Research (CSIR).
(aa) DGAFMS is a member of the executive council of Central Drugs Research Institute, Lucknow.
(ab) Chairman of Clinical Trials Subcommittee of the same institution.
(ac) Committee on ‘Problems of High Altitude’.
(iii) National Medical Council.
(iv) Directorate General Health Services.
(v) Niti Ayog.
(vi) Indian Standards Institute.

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(b) Medical Services Advisory Committee.

Medical Services Advisory Committee (MSAC) which consists of DGAFMS as the Chairman & the three DGsMS
as members is the highest policy-making body as far as medical services are concerned. It deals with and
decides all matters which have an inter-service bearing. The proceedings of the Committee are approved by the
three Chiefs of Staff. The DGAFMS has therefore a dual role. In inter-service matters the chairman, MSAC is
responsible to Chief of Defence Staff / Chiefs of Staff Committee. In other aspects of his duties, he is directly
responsible to the Ministry of Defence. Some of the important matters which are referred to MSAC for decision
are:
(i) Initial training of AMC officers at Army Medical Corps Centre & College.
(ii) Specialist training & specialist pool, selection of officers for courses in India and abroad, study leave,
grading / classification, appointment of advisors and consultants.
(iii) Policy regarding antedate of commission.
(iv) Policy regarding inter-service transfer / attachment of officers and their deputation to other medical
institutions.
(v) Recommendation for the appointment of honorary surgeons to the President and the grant of honorary
commissions to civilian medical practitioners.
(vi) Selection of officers to fill up appointments in the inter service organizations such as AFMSDs.
However, the administration of AFMC is the sole responsibility of DGAFMS.
(vii) Preparations and maintenance of regulations.
(viii) Any other matter having inter service bearing.
(c) Functions of DGAFMS.
The DGAFMS is directly under the Ministry of Defence for the following:
(i) The DGAFMS is the convenor as well as the chairman of the boards for recruitment of medical, dental
and nursing officers for three services of the Armed Forces.
(ii) Terms and conditions of service of all categories of officers (medical, dental and nursing).
(iii) Release, recall, invalidment, retirement, pension & gratuities of all categories.
(iv) Reserve of officers for the three services.
(v) Maintenance of personal documents of medical, dental and nursing officers. He records his remarks
on the technical and professional capability of all officers of the rank of Colonels and above (equivalent
rank in other services).
(vi) Provisioning, procurement, storing including reserve, issue of medical and dental equipment and
stores as required by the three services.
(vii) Standardization and development of medical, dental and non-medical equipment with a view to their
inclusion in equipment tables.
(viii) Arrange trials of stores and equipment in hospital and other units; convening equipment and scales
panel committee meetings, preparations of medical scales & equipment tables and publication of PVMS.
(ix) Control and Supervision of AFMSDs and ALC.
(x) Administration of AFMC and other research and training establishments attached to the institutions.
The Institute of Aviation Medicine will, however, be under direct control of the DGMS (Air).
(xi) Selection and appointments of instructional staff for the above institutions from the panel of suitable
names submitted by DGsMS.
(xii) Inter-service attachment or transfer of medical officers to meet the requirement of each service from
the panel of names given by the DGsMS.
(xiii) Coordination, planning, direction and development of research work carried out in the AFMC and the

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institutions under the control of three services headquarters. The DGAFMS is the Chairman of the Armed
Forces Medical Research Committee.
(xiv) Coordination of statistical works in the three services & compilation of annual reports including
Annual Health Report of the Armed Forces.
(xv) Recording recommendations on purely medical aspects of the cases for claims for disability pension
for service personnel.
(xvi) Issue of technical & medical instructions on matters concerning three services.
(xvii) Rendering technical & medical guidance to DGOF.
(xviii) Liaison with the Director General Health Services, the defence medical organizations of overseas
countries and the research institutions in India and abroad.
(xix) The DGAFMS is the Chairman for Selection Board for promotion of AMC, AD Corps and MNS to the
rank Colonel & equivalent rank in the Navy & Air Force. He is a member of the Chiefs of Staff Committee
for promotion to the rank of Brigadier & above (equivalent rank in other services), including the appointment
of DGsMS in three services.
(d) Medical Research.
Armed Forces Medical Research Committee (AFMRC) under the Defence Research and Development Council was
formed in November 1963 with the terms of reference as follows:
(i) The Armed Forces Research Committee is under the Defence R&D Council & functions under its
general authority & guidance.
(ii) All medical research problems, before being taken up for investigation, are submitted to the Armed
Forces Medical Research Committee, which makes recommendations regarding the choice of problems and
allotment thereof to institutions for progress of research. Decisions on such recommendations are taken
by or under the authority of the Defence Research and Development Council.
(iii) The Armed Forces Medical Research Committee is responsible for overseeing the progress of medical
research authorized by the Defence Council & such recommendations from time to time as may be necessary
for the consideration of the Defence Research and Development Council.
Composition of AFMRC
The AFMRC will be constituted as below:
(i) Chairman - DGAFMS
(ii) Ex-Officio members from Defence, eg. DGMS (Army), DGMS (Navy), DGMS (Air)
(iii) Scientific Adviser to Ministry of Defence.
(iv) DGHS (AF)
(v) Sr Consultant Surgery
(vi) Sr Consultant Medicine
(vii) Commandant AFMC
(viii) One member from the Indian Council of Medical Research. namely Director ICMR or his rep.
(ix) Six eminent workers in the field of medical research of whom at least three shall be from civil.
(x) Representative member of R&D Organisations (INMAS, DIPAS & DIPR)
(xi) Member Secretary- Addl DGAFMS (MR)
(e) Medical Training.
PG courses for Medical officers are held at AFMC and other Command Hospitals affiliated with various universities.
Technical training of paramedical staff such as health assistants, laboratory assistants, radiographers, etc
of the three services is conducted at AFMC. Regimental officers, JCOs and NCOs are trained to function as

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unit health staff under local arrangements in their stations / formations under the directions of DADsH / Field
Health Organization (FHO) / Station Health Organization (SHO) / Health section of Field Hospital.
(e) Nutrition of Troops.
(i) Good Nutrition is an important means of health promotion and maintenance. However, its provisioning
is not the direct responsibility of the Medical Services. Ration Scales are drawn up or amended by the
respective HQs in consultation with their Medical Directorates. Policy matters regarding ration scales are
dealt with on an inter-services basis by the Armed Forces Health Sub Committee (AFHSC) of the Medical
Services Advisory Committee.
(ii) Research in food and food technology is usually carried out by the Defence Science Organization
and routine inspection of food stuffs is carried out by Food Inspection Organization functioning under the
Director General Supplies and Transport (S&T Directorate, Army HQ). A senior medical officer of the Army
Medical Corps, a specialist in Preventive and Social Medicine is the head of the food inspectorate and is
designed as the Brigadier Food Inspection (Brig FI). He acts as the medical adviser in respect of assessment
of nutritional values of food and serves as the link between the supply and the Medical Organization at the
Army HQ. The DGsMS are consulted regarding nutritional aspect of the ration scales and foodstuffs included
in them. The respective technical staff officers viz. Col MS (H) Army, Gp Capt MS (H) Air Force & Surg Capt
MS (H) Navy, act as advisers to them on these matters. DGAFMS is consulted on any matter regarding
nutrition, ration or food problems common to all the three services. He may also order any research to be
carried out on these matters through ADGMR, R&D Organization and DGsMS.

21.6 Health Statistics.

All statistical work in the Army for recording compilation and interpretation of medical data is carried out by the
Management Information System Organization (MISO) from the returns received from medical units. In the Navy and Air
Force, this is done at their Medical Directorates. The Central Diseases Registry (CDR) is functioning in the Department
of Community Medicine of AFMC. It maintains records of all HIV / AIDS cases and cases of High-Altitude Pulmonary
Oedema. The Sexually Transmitted Disease (STD) registry is with Department of Dermatology of AFMC. More diseases
are likely to be brought under registry / surveillance.

21.7 Medical Boards and Fatal Documents.

(a) Medical categorization, invalidation and scrutiny of the fatal case documents are important activities of
the technical administration of health services. These functions are carried out by the medical staff of various
HQs in the chain of command of the three services. The medical categorization ensures that a person with a
disease or disability is kept under surveillance, continuity of remedial measures and sheltered conditions away
from possible hazards, which may aggravate the disease or disability. It also ensures that the task or work does
not suffer due to the handicap of the individual.
(b) Invalidation ensures primarily the fitness of the Armed Forces by eliminating the unfits or misfits and
secondarily avoids the exposure of the disabled to aggravating hazards.
(c) Scrutiny of the fatal case documents brings out the lacunae in the comprehensiveness of health care,
deficiencies in the treatment or even restorative care. In these activities, the specialists, advisers and consultants
play a vital role.

21.8 Pathology Services.

The Armed Forces Pathology Services carry out all the clinical pathological examinations including biopsy examinations
on tissues, special diagnostic skin tests, autopsies and histopathological examinations both for diagnostic and medico-
legal purposes, public health examinations such as examinations of water and milk supplies and wall scrapings or
samples for insecticides. Addl DG IS, H & PS at the Army HQ is an adviser to the DGMS. At the peripheral levels, there
are hospital laboratories. In addition to these, there are Departments of Pathology, Microbiology and Biochemistry at
AFMC.

21.9 Pathology Services in Armed Forces Medical College.

There are three independent departments of Pathology, Microbiology and Biochemistry providing pathology cover to
local medical units and also acting as a reference laboratory to all other service laboratories. All these departments are

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staffed with specialists experienced and qualified in respective branches of Pathology, Microbiology and Biochemistry.
The functions of these departments are:
(a) To establish standard methods of laboratory and clinical side room techniques for all medical units in Armed
Forces.
(b) To conduct training of undergraduates, postgraduates, B.Sc. Nursing students, Lab Technicians and Lab
Assistants.
(c) To conduct courses for training of all medical officers coming for different courses.
(d) To prepare, standardize and issue chemical and biological reagents to all other service laboratories.
(e) To carry out research work in different branches of Pathology, Microbiology and Biochemistry.
(f) The Dept of Lab sciences has the following advanced facilities available like DNA analysis by Cytogenetics
workstation, Morphometric analysis, FISH, Next Generation sequencing (NGS) and Pyrosequencing etc.
(g) The Dept of Microbiology has established Viral Research Dignostic Laboratory (VRDL) under the ageis of Indian
Council of Medical Research (ICMR)

21.10 Health Services.

(a) Army.
DGMS (Army) is responsible for all matters regarding health of the troops and their families to the Chief of Army
Staff. The health services in the Army function with the Addl DGMS (IS, H & PS) at the Army Headquarters.
He is the head of the professional and technical section of Medical Directorate & is responsible for advising
the DGMS on the health of the troops, the promotion and maintenance of positive health and prevention of
illness being the main objectives. Addl DGMS (IS, H & PS) has two specialists, Col MS (PS) and Col MS (H)
on his staff to assist him. The advisers in various specialties are available to him for consultation on matters
pertaining to their respective specialties. All matters regarding health of troops, accommodation, clothing,
nutrition, comprehensive medical care, control of communicable and non-communicable diseases, pathology
services, scrutiny of fatal case documents, medical examination and boards, entitlements of military and
civilian personnel to medical care from Army sources and research. At the Command and Corps level, the Col
Health / ADsH and at the Area and Divisional level the ADsH / DADsH are responsible to their administrative
medical heads for all the duties of this section.
(b) Navy.
Surg Capt MS (H) at the Naval HQ is responsible to the DGMS (Navy) on all matters concerning the Health of
Naval personnel. DGMS (Navy) is responsible to Chief of Naval Staff (CNS). The Senior Medical Officer (SMO)
of the ship establishment is the adviser to the Commanding Officer on all matters pertaining to health, hygiene
and sanitation. He maintains a sanitary diary from which extracts are submitted to the Medical Directorate,
Naval HQ when required. Naval shore establishments have Station Health Organization similar in organization
and function, to those in the Army.
(c) Air Force.
Gp Capt MS (H) at Air HQ, is the adviser to the DGMS (Air) on all matters affecting the health of IAF Personnel.
DGMS (Air) in turn is responsible for the same to the Chief of Air Staff (CAS). Principal Medical Officers (PMOs)
of all the Operation, Training and Maintenance Commands are similarly responsible to their own Air Officer
Commanding in Chief (AOC­in-C) and also to DGMS (Air). They are assisted by DPMOs who are specialists in
Preventive Medicine and Aviation Medicine. Operational Commands have both these specialists while other
commands have either of them. There is a Station Health Organization at all permanent IAF Stations, which are
classified as large, medium or small. These organizations work directly under the supervision of the SMO or
MO of the Stations. In large stations a specialist in Community Medicine is in charge of this unit. The medium
and small stations are under the control of NCOs, who are trained in health and sanitation, under the overall
command of SMO / MO of the station.
(d) Field Areas.
In the operational areas, Brig Med Corps and Col Med Division (and equivalent appointments in Navy and Air
Force) are responsible to their respective commanders for the medical administration and to the MG Med of

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the higher formation for all medical, technical and administrative matters. Commanding Officer Field Hospitals
work under the overall supervision, guidance and administrative command of the Col Med. “Conventionally
each Division has 2 Field Hospitals (Fd Hosps). Each of these Fd Hosps are to provide medical and health
cover, including establishment of Advanced Dressing Stations (ADSs) and Forward Surgical Centres (FSCs) to
earmarked Bdes / Div Tp units within the Division. The CO of the Fd Hosp affiliated to the respective Bde / Div
Tp unit is also designated as the SMO of that particular Bde / Div Tp unit. In addition there are Fd Hosps
affiliated to independent Bdes also.
(e) Peace Areas.
In each garrison station there is a hospital (Army, Navy or Air Force). Generally, CO of the service hospital
is the Senior Executive Medical Officer (SEMO). However, the Brig Med / Col Med is empowered to nominate
any medical officer to perform the duties of SEMO of a part or the whole of the military station. The SEMO
is responsible for advising the local station Commander on all matters regarding health and sickness among
troops and their families in the garrison or station and is the head of all the local medical establishments. He
is also the Health Officer of the Cantonment and adviser to the Cantonment Board on all health matters. OC
Station Health Organization, a specialist in Preventive and Social Medicine, assists in the comprehensive health
care of troops and their families in the military station and in the Cantonment area. SEMO is responsible for all
the local medical administrative and technical matters to the MG Med of the area (and equivalent appointments
in Navy and Air Force) and for administration of the hospital to the local Commander. AO 165 / 79 may be
referred for detailed account of duties and responsibilities of various administrative and health authorities in
relation to health of troops and their families.

21.11 Station Health Organization.

The stations and garrisons are classified as large, medium and small depending on the strength of tps and families in
the station. Station Health Organizations (SHOs) are authorized to large garrisons. This is a unit, besides the service
hospital, which organizes the health care of troops, in a garrison or station. It is responsible for the maintenance of
healthy conditions of environmental sanitation, anti-malaria measures and disease prevention and control in the station.
The OC of this unit is a classified or graded specialist in Community Medicine who also functions as the Assistant
Health Officer (AHO) of the Cantonment, when so appointed by the Command HQ. He is responsible to the Health Officer
for the health of civilians and sanitation within the cantonment and to the SEMO for the health and sanitation within
the Armed Forces lodger units and establishments in the garrison. The OC SHO works in close collaboration with the
Cantonment Board Authorities. In smaller stations, the erstwhile medium / small / unclassified, SHOs have been merged
with the local service hospital. They now function as the Health Section of the hospital.
Functions of the OC SHO.
(a) OC SHO has four-fold functions to perform and his time is proportionately divided into the duties required
of him to fulfill these. For all these four-fold functions he is responsible to the SEMO in station, who is generally
the CO Hospital. In order to carry out these functions properly, the OC SHO is required to keep a close liaison
with local civil health authorities and is also required to participate in all the National / local health programs
that are carried out under their auspices.
(b) On appointment as AHO of the Cantonment by Command HQ, his duties are concerned with maintenance
of health of civilian population with the main objective of keeping in check all the influences which might
jeopardize the health of troops garrisoned in and around the cantonment and embrace the environmental
sanitation; quality control of food, milk, water supply, disposal of sewage, sullage, refuse and industrial
waste; control of communicable diseases; supervision of health of workers employed under the cantonment
board; execution of health programs as directed from time to time: licensing of catering establishments and
market including hawkers; enforcement of cantonment regulations regarding abatement of public nuisance
and environmental sanitation in commercial, industrial, residential and trade areas. On all these matters he
is expected to render a monthly report for deliberation of the Cantonment Board of which the Health Officer
(SEMO) is an important member.
(c) As SEMO’s adviser on all matters regarding health of the troops, it is his responsibility to have first hand
knowledge of influences that might adversely affect the health of troops in the station so that the SEMO is
in a position to appropriately advise the Station Cdr, who is also the President of the Cantonment Board. For
fulfilment of this function, his duties include:

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(i) Regular inspection of the garrison and unit lines

(ii) Control and prevention of communicable diseases among troops
(iii) To ensure proper execution of anti-mosquito, anti-rodent and anti-fly measures
(iv) To ensure safe water and milk supply; disposal of sewage and waste matters
(v) Inspection of licensed catering establishments for permitting them to be put ‘In bounds’ for troops
and also periodical inspection to keep them on the approved list
(vi) To maintain, interpret and report the vital and health statistics in respect to troops in the garrison
(vii) He is the permanent secretary of the Station Health Committee
(viii) He also inspects the schools established for children of the serving personnel
(ix) The OC SHO should carry out surveys on diseases found to be locally prevalent among troops,
families or civilians in the cantonment and garrison or neighbouring areas and submit report through
the SEMO to higher medical authorities
(d) As OC of the unit, he is responsible for its administration and supervision of the work of the staff.
(e) As the permanent Secretary of Station Health Committee he is required to correlate all the information
available to him from the four-fold functions described above. The information is then presented comprehensively
to the Station Health Committee, the inferences relevant to the health and well-being of the troops are drawn
and action to safeguard them against untoward influences are recommended. The committee consists of the
Station Commander as the Chairman and OC units in the station as members. The Garrison Engineer or his
representative, the Supply Officer or his representative and the Cantonment Executive Officer are the co-opted
members of this committee. The representatives of local civil health authorities are also invited to attend the
meeting. The Committee meets once a quarter or more often to discuss relevant health matters. The OC units
are then required to carry out the decisions taken at the committee meeting. The records are maintained and
action pursued by the OC Station Health Organization in his capacity as the secretary of the Committee.

21.12 Health Organization in Field Formation.

Brig Med Corps has an ADH as his adviser and assistant in all matters of health of troops in the formation. A Corps
Field Hospital (Fd Hosp) is allotted to each Corps. There are 04 Field Health Organisation (FHO) auth to a total of four
Corps, presently their disbandment is under process. The role of FHO and health section of Fd Hosp is to reinforce the
existing health resources in the field formations or its part deployed under such conditions, which threaten outbreaks
of communicable diseases. The decision to deploy these units or their part in various locations or formations is left
to the Brig Med Corps as advised by his ADH. He coordinates the matters on health of troops in the whole formation
and its component formations.
In a Division, the DADH advises and assists the Col Med at the Divisional HQ. The health section of Fd Hosp in a
Division provides the technical element. Normally, their requirements at particular places, sub-formations or units
are assessed by the DADH and decided upon by the Col Med. The Fd Hosp is instructed to locate these personnel
according to requirements.
(a) Functions of Health Section of Fd Hosp.
These are mainly supervisory, inspectorial, instructional and executive under the technical guidance of the
DADH of a Division. Col Med Div HQ deploys the detachments of Health Section in consultation with the DADH.
The executive duties are carried out on a smaller scale with the present authorized limited establishment and
equipment. The functions of Health Section include:
(i) Supervisory and Inspectorial.
(aa) Environmental sanitation measures in and around the units / sub-units, such as disposal
of waste matter and pest control measures particularly against mosquitoes, house flies, bedbugs,
mites, ticks and rats.
(ab) Purification, chlorination, storage and distribution of water supply.
(ac) Ration supplies, fresh, dry and tinned for their wholesomeness.

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(ad) Sanitary vigilance in civil areas around camps in collaboration with the local health
authorities.
(ae) Control measures against communicable diseases.
(ii) Instructional.
Assist DADH / SMO in conducting health courses for Regimental Officers, JCOs, NCOs and ORs.
(iii) Executive.
(aa) Technical assistance to rectify sanitary defects in the unit lines.
(ab) Carry out disinfection and disinfestation whenever required.
(ac) Periodic collection and dispatch of water, milk and food samples as and when required to
laboratories for examination. This should also be done while establishing new water points.
(ad) Assist DADH in the collection of statistical data on health of troops by maintaining records
and preparing periodic reports and returns.
(ae) Help units in investigating and carrying out control measures in case of outbreak of
communicable diseases and high incidence of other preventable diseases.
(af) Assist unit in implementation of national health programs in the formation.
(ag) Help DADH in carrying out investigations / health surveys whenever required.
(b) Unit Health Establishment.
The responsibility of the unit sanitation and hygiene and health of troops rests with CO and his regimental
officers with expert advice and assistance of the RMO. The principal means of preventing diseases are the
maintenance of effective sanitation and personal care and hygiene. Therefore, knowledge of elementary hygiene,
sanitation and the best means of preserving them are incumbent on all ranks. The unit health establishment
enabling the CO to carry out his responsibilities for maintaining the effective fighting strength consists of the
RMO, the unit hygiene officer, the unit sanitary, anti-malaria and water duty personnel and the medical platoon
consisting of stretcher bearers and MI Rooms / RAP nursing assistants. There are two AMC Nursing assistants
authorized for each unit having RME on their establishment. The unit catering and welfare officers are also
concerned in unit health organization. In a regimental centre depending on its strength, there may be two
or more RMOs & one of them can be graded / classified specialist in Community Medicine. The RMO is the
adviser to the CO in all matters pertaining to the health of troops.
(c) Duties of Regimental Medical Officer (RMO).
He is the first medical officer in the chain of medical echelons at which a patient is first examined at the time
of contracting illness or sustaining injury. In order to perform his duties effectively, the RMO will have to be
always abreast in his professional knowledge, rules, regulations, orders and instructions regarding all health
matters and possess power of decision. As a practitioner of preventive and social medicine, he is required to
perform the duties as laid down in RMSAF-2010 (revised ver) para 105 to 117 and AO 165 / 79. The unit MI
Room functions as a miniature health center for the unit. All medical officers nominated by the CO hospital
to be in medical charge of units without RMOs, will also perform all these duties. These are briefly as under:
(i) He will be in medical charge of all personnel of the unit and the families entitled for medical
attendance. He will advise the CO unit on all sanitary and medical matters pertaining to the health of
the troops.
(ii) He will conduct morning sick parade at the MI Room / RAP at an hour fixed in consultation with
CO unit and SEMO. Usually, the sick parade is held at the time of the first duty parade of the day viz.
physical training. He should treat minor ailments in the MI Room and refer other cases to hospital for
admission / investigation / consultation by specialists. He enters on AFMSF-44 prepared in duplicate by
the unit, the diagnosis of each case reporting sick and the disposal of the case in the column of remarks
in the following terms:
(aa) Medicine and duty’ (M&D) meaning treatment and return to duty.
(ab) Attend ‘A’ meaning attend for treatment as ordered and to perform ordinary regimental

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duties.
(ac) Attend ‘B’ meaning attend for treatment as ordered and to perform Light duties only.
(ad) Attend ‘C’ meaning attend for treatment and to be excused all duties.
(ae) ‘Hospital’ meaning admitted to hospital.
(af) Duty’ meaning reported sick unnecessarily without enough cause.
(iii) He will carry out a detailed annual medical examination of all JCOs and OR and keep a record
thereof in accordance with AO 03 / 2001 and officers as per AO 9 / 2011 if he is the AMA as per age
for the given year of med examination.
(iv) He will carry out quarterly medical examination of all low medical category personnel and monthly
medical inspection of all food handlers and keep a record of such examinations.
(v) He will examine all men going out on Posting / Course and all men returning to the unit from
temporary duty course, leave and hospital.
(vi) He will visit unit-run schools and carry out examinations of school children and hygiene inspection
of school premises.
(vii) He will impart health education to the troops regularly and repeatedly throughout the year. Unit
cinemas whenever available should display health education slides. Notice boards in unit lines should
display salient features about major diseases and their preventive measures.
(viii) He will arrange with CO, training of requisite number of men in first aid, hygiene sanitation, water
and anti-mosquito duties.
(ix) He will be responsible for carrying out all preventive inoculations and vaccinations of alI ranks,
civilian employees and families under his charge.
(x) He will inspect every portion of the unit line including family quarters, cook houses, JCOs Mess,
Officers Mess, clubs, institutes and civilian quarters within unit lines and report in writing of the defects
to CO with remedial measures and suggestions. These will be recorded in a sanitary diary once a month.
The report will be written in two parts. Part I will include the complete current observations. Part II will
only include the defects remaining un-remedied for more than two months. The report of RMO will be
objective one giving constructive suggestions, alternative means and methods to remedy the defects.
The sanitary diary will be put up to the OC unit and after his remarks and action taken to remedy these
defects, will be sent to SEMO for his perusal by 20th of the following month.
(xi) He should examine all families on their arrival in the station and ensure their immunization is
completed and any disease / defect is attended to.
(xii) He should execute all the National, Regional, Armed Forces health programmes or his formation
health, surveys and studies as directed by the medical authorities and render report thereupon as
required.
(xiii) He should ensure that medical stores and equipment for RAP authorized vide RME scale AMC-08,
are in perfect working order and should be checked once a month for any shortages, discrepancies or
defects. He should ensure that replacement is demanded promptly from the medical units on which the
unit is dependent.
(xiv) Ordnance stores authorized as per WET, medical comforts for patients and stationery articles from
the unit should be obtained regularly.
(xv) He should maintain an emergency cupboard for prompt attention of the emergencies. He should
maintain the following registers in the unit:
(aa) Sanitary diary
(ab) Barrack treatment, admission and discharge register
(ac) Infectious Disease Notification Register
(ad) Malaria & Hepatitis Register

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(ae) Register of water tested for free chlorine

(af) Low medical category personnel & Obese personnel register
(ag) Record of health education lectures
(ah) Record of eligible couples
(xvi) He will advise the unit to maintain following records / registers according to existing orders:
(aa) STD Register
(ab) Inoculation and Vaccination Register
(ac) Yearly Medical Inspection Register
(ad) Insecticide Spray Records
(ae) Sanitary Diary
(af) Blood Donors Panel Register
(ag) Register showing nominal roll of all ranks trained in hygiene and sanitation and water duties
& BFNAs
(xvii) He will maintain health records and charts, graphs or histograms of daily sickness, hospital
admissions and incidence of infectious diseases.
(xviii) He will submit report and returns to SEMO on health of the troops as required. Any case of
infectious disease or unusual sickness is to be reported to SEMO without delay.
(xix) With the concurrence of the CO unit he may be called upon to:
(aa) Work in local military hospitals as and when required by the SEMO / Col Med to enable him
to remain in touch with clinical procedures and hospital practice.
(ab) Visit the patients sent in for admission by him to follow up their diagnosis, treatment,
progress and disposal.
(ac) Attend clinical meetings / discussions and other professional training arranged by the SEMO.
(d) Duties of Unit Sanitary Establishment.
A regimental officer is detailed by name to act as Hygiene and Sanitation Officer of the unit. The unit hygiene
officer is mainly required to carry out the duties concerning maintenance of environmental sanitation, personal
hygiene of all ranks and hygiene of cookhouses, dining halls and messes in the unit. He should be properly
trained for these duties under local arrangements by the SEMO / SMO. He is also responsible to ensure that all
the unit health documents, other than those that are to be maintained by RMO are up to date. A unit Hygiene
and Sanitation squad will be maintained to carry out the sanitary duties in a unit. This consists of 4xNCOs and
6xOR for Major units and 2xNCOs and 3xOR for minor units with 100% reserve. They will work under the unit
QM / Reglt officer and will be trained by the RMO / under arrangements of SEMO / SMO. The duties of the sanitary
squad and water duty personnel are as under:
(i) Supervision of the sanitation of cookhouses, wet canteens, aerated water factory including proper
disposal of waste products.
(ii) Spraying of insecticides within unit lines.
(iii) All anti-mosquito, anti-fly and anti-rat measures
(iv) Supervision of personal protective measures for prevention of vector borne diseases.
(v) Acting as sanitary police to ensure general cleanliness and disinfection.
(vi) The daily supervision of the water supply and its purification for drinking purposes.
(vii) The care of all apparatus and stores connected with water supply of the unit.
(viii) Chlorination or super chlorination and testing for chlorine contents.

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21.13 Personal Care.

(a) Introduction.
Armed Forces personnel are a selected group of individuals who undergo health and fitness test before
induction into the Armed Forces. They are provided an environment reasonably free from contracting diseases,
nutritious diet and wholesome water supply during their service. It must be emphasized that personal habits
contribute to the achievement of positive health, morale and wellbeing and also reduce vulnerability to disease,
both communicable and non-communicable. When men live a close community life they need to be more
particular in practicing healthy habits to protect themselves and the community in which they live. Though the
facilities to live healthy are offered, personal action and care demands active cooperation and compliance by
the individuals themselves. This depends upon their will, efforts, awareness and education.
Health Education.
(i) Health education is defined as ‘the active process and the end result of providing a learning
experience to the people in order to influence their knowledge, beliefs, attitude and practices so as
to enable them to achieve and maintain positive health and prevent illness through their own efforts.
Health education is necessary to enable the personnel to observe their own health care, get over wrong
beliefs and replace them with rational ones, acquire correct and adequate knowledge regarding health
and means of its promotion and maintenance, prevent ailments and take early care and convert illness
consciousness into health consciousness for making ‘health’ their valued asset.
(ii) The conventional regimental method of enforcement of orders and instruction proves temporarily
successful but does not yield lasting results. Health education sows’ healthy habits more permanently
among the personnel and their families. Order and instructions regarding health are useful to a limited
extent only because the code of conduct laid down through them is without the consent, knowledge or
conviction of the personnel. They do bring about some modification but do not necessarily produce a
permanent change in the habits of personnel. As soon as laxity in enforcement of regulations occurs,
the disease rates rise. If personnel are induced by health education to incorporate these habits as a
permanent component of their behaviour pattern, this laxity may not occur.
(iii) The serviceman’s education also benefits his children in improving their health and inculcating
healthy habits from the very childhood. It also benefits the community when the serviceman goes back
to his permanent place of residence and shows people an example of healthy living, thus, becoming a
means to spread the message of healthy living.
(iv) Knowledge is very important, but merely imparting knowledge is not fruitful unless the attitude is
favourable. That also may not make persons adopt healthy habits and surrender to wrong beliefs unless
he is motivated and group acceptance is ensured.
(v) After motivation has been created, the newly acquired beliefs and practices should become
permanent habits. Further, the ‘felt needs’ created have to be first fulfilled and these habits made part
of his way of life, which is the primary aim and desired end result of health education.
(vi) Beliefs and cultural practices acquired by people through past generations cannot be readily and
easily removed by implementing new ones unless they are willing to accept them and make these a
part and parcel of their culture pattern. The benefits of the new habits over the older ones must be
experienced by the people so as to take root.
(vii) The task of health education, whether carried out by the RMO, regimental officers and JCOs or
paramedical personnel, demands patience, perseverance and hard work. It needs pre-planning, use of
audiovisual aids like charts, graphs, flash cards, film charts, pictures, posters and so on. Cinema films and
filmstrips are very good adjuncts. They should be simple, culturally appropriate and easily understandable.
(viii) Group discussions help in convincing the personnel and families of the advantages and rationality
of the new practices and beliefs and habits. The set hours for such education should be included in the
formal training programme.
(ix) A high standard in the provision of healthy work environment, sanitary facilities, hygienic catering
arrangements, potable water supply and good living accommodation provide an apt setting of good health
care.

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(c) Personal Hygiene.

(i) Regular bowel habits are important for maintaining good health. It is cultivated by regularity in its
act. It is necessary on the part of unit administration to provide enough sanitary facilities in the form
of clean, well-constructed, sanitary latrines with adequate privacy to encourage personnel to use only
the authorized latrines every time. Irregularity of bowel habits is often due to inadequacy or unsuitability
or lack of privacy and cleanliness of latrines. Moreover, such conditions also lead the personnel to
foul the grounds near the camp causing insanitary conditions, fly breeding and spread of intestinal
diseases. Personnel should also be educated and habituated to make use of latrines and not indulge
in indiscriminate defecation. Similarly, adequate urinals of proper standard design should be provided
by the unit and made use of by the personnel.
(ii) A daily bath is the chief means to maintain a healthy skin and prevent communicable skin diseases.
Excessive use of soap is not always good. After bath the body should be dried by rubbing with a
moderately rough towel, such as the one provided as issue in the Armed forces. Adequate provision
for washing and bathing should be made. Daily bath is beneficial not only for the cleanliness of the
skin but brisk rubbing of the skin activates the surface circulation. This stimulates the cutaneous nerve
endings making them more responsive and clears the sweat and sebaceous pores. An elastic, clean
healthy skin surface is an efficient safeguard against adverse effects of extremes of heat and also cold.
The invigorating effect of a bath is due to stimulation of steroid secretions brought about by the mild
stimulus produced by sudden contact of skin with water, cold in summer and hot in winter. Cold and
hot water baths respectively cool down the body in summer and warm it in winter.
(iii) Hair should be washed regularly, if not daily and properly groomed; they should always be kept
cut short to avoid dirt accumulating in them and also for aesthetic reasons. Nails accumulate dirt and
pathogenic organisms and introduce them to one’s food if hands are not washed properly and in the
skin if one happens to scratch it. They should be kept cut short.
(iv) Teeth should be brushed preferably after every meal, but at least after the last meal of the day.
A proper brush should be used for cleaning the teeth. The habit of using a toothpick is not good as it
harms the teeth and gums.
(v) Eyes should not be rubbed too often or wiped with dirty hands. A clean handkerchief should be
used for wiping the eyes and another one for clearing the nose and while sneezing or coughing. Spitting
indiscriminately or coughing or sneezing without use of a handkerchief are bad habits, which help to
spread the respiratory infection. Such habits must be discouraged. Fingers should not be used to clean
the nose and ears. It is bad habit and may damage the eardrum or nasal mucosa. The nose should not
be blown too violently as it results in driving the mucous or serous discharge up the eustachian tube
and may even rupture the ear drum. All ranks must shave daily with their own individual safety razor.
Community shaving by a barber using same shaving blades and uncleaned blade holder may cause
transmission of sycosis, HIV, Hepatitis B or taenia infection.
(vi) Clothes must be washed and dried regularly; facilities must be provided to enable them to do so.
They should not use each other’s clothing, socks, shoes or boots or bed linen and blankets.
(vii) Clean bowels, a good shave, brisk physical exercise, a good bath, brisk rubbing of the skin with
a rough towel, a good nutritious breakfast and clean teeth and mouth in the morning before starting
daily routine enhance efficiency in work.
(d) Food Habits.
This indicates the habit of eating adequate nutritionally balanced food at fixed times, from healthy sources
where it is well and hygienically cooked, preserved, protected and served. It should be eaten in sanitary
surroundings without the fly or dust nuisance or bad odours. It should be served by hygienic food handlers in a
hygienic manner. Starvation does not harm a man as much as eating indiscriminately from unhygienic sources.
Eating over and above the usual requirements even after starvation, also causes harm. Overeating harms
persons more than undereating, especially among those above 35. Personal hygiene before and after eating
is extremely important. Hands and mouth should be washed before and also after eating. Over-consumption
of oils, vanaspati or pure ghee is not beneficial as is usually believed. Service rations are well balanced and
the various scales provide adequate quantities for the particular area, types of activities and functions they

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are intended for. It is important that unit catering should be wholesome and sumptuous so that eating outside
the unit is not felt necessary by personnel.
(e) Water Discipline.
Water should be consumed in adequate quantity and from an authorized or a known safe source. Slackness
in adhering to this habit may cause outbreak of gastrointestinal diseases. All ranks going out on patrol, convoy
duties, route marches, on exercises, manoeuvres, reconnaissance, movement by transport or railway journeys
should be habituated to carry full water bottles, individual water sterilizing outfits and strictly adhere to the
rules of water hygiene and discipline. Arrangements should be made to facilitate these habits and personnel
should be trained to make use of the equipment given to them for water purification. It is quite impossible to
train personnel to go without water and any attempt to do so inevitably inflicts injury on the individual. The
belief that soldiers can be hardened by forcing them to go short of water when undergoing training is irrational
and dangerous. For troops undertaking hard work in hot weather, an ample supply of pure cool drinking water
is essential to maintain fitness and to prevent effects of heat. True water discipline is enduring thirst and
drinking when necessary from authorized sources and when there is acute shortage of safe water, drinking
only when ordered; it does not mean unnecessary water deprivation.
(f) Regular Exercise.
(i) Human body requires regular exercise. Physical inertia leads to obesity, low Catabolism, muscular
laxity, low threshold for exercise, low vital capacity, low cardiac tolerance and low threshold for physical
and emotional stress.
(ii) Physical activity is a stimulus to the growth of children and adolescents and promotes mental
relaxation in adults. It produces and enhances resistance against coronary disease, frostbite, trench
foot, respiratory infection, obesity, mental disorders and physical fatigue. Exertion should, however, not
be so excessive as to cause extreme fatigue as, like all stimuli it becomes a stress-producing factor if it
is excessive. It should be enough to produce pleasant fatigue demanding relaxation. Stage of recovery
should follow exertion-causing fatigue.
(g) Relaxation and Sleep.
Relaxation and sleep are necessary for recovery of the body from fatigue by eliminating biochemical products
and physical and mental exertion. Sleep should be sound without any artificial aids. A sound sleep is ensured
by freedom from ill health; good feeding and enough physical and mental exercise: comfortable thermal
environments; freedom from pests like bedbugs, mosquitoes, sandflies, rats and so on; comfortable garments
must therefore be provided to ensure sound sleep-in barracks. Men should get used to sleeping with open
windows and uncovered faces. In winter, reliance must be to put on adequate clothing and blankets for warmth
while sleeping than on closed doors and windows and artificial heat from fireplaces  / heaters etc. Enough
rest and sleep are very necessary for efficiency in work, avoiding accidents, including traffic accidents and
greater output of work. If the drivers are offered a cinema show after long driving during the day, which keeps
them awake beyond midnight and cuts down sleeping time, the accident rate on convoy driving increases on
subsequent days. Some recruits like to huddle together under common blankets in winter. This habit spreads
respiratory diseases. Provision of charpoy for each person, mosquito net, sufficient warm clothes and adequate
blankets is to be made.
(h) Leisure.
(i) Recreation by inducing personnel to get interested in healthy outdoor or indoor games, recreational
outings, visits to places of historical, cultural and religious interests, hobbies like painting, music,
photography or handicraft and other recreative pastime engagements for using leisure in healthy pursuits
produces a healthy attitude to life, inhibits temptation to indulge in unhealthy activities, aimless loitering,
promiscuous tendencies, quarrelsome behaviour and provides relaxation without lethargy. All facilities
should be provided and men should be urged to take full advantage of them.
(ii) Religious, ethical and moral teachings keep the mind of people geared to healthy thought and
action, provide a strong inhibiting factor in unhealthy pursuits like promiscuity and alcoholism or heavy
smoking habits.
(iii) General education, a high degree of professional efficiency achieved by constant professional

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training and basic military training, a high standard of self-discipline achieved without fear of punishment
and a high physical standard achieved by regular exercise, produce high resistance against unhealthy
pursuits, habits and tendencies. All officers and JCOs should be educated to understand and practice
these principles.
(j) Alcohol Consumption.
(i) The value of alcohol from the physiological and psychological point of view is not subject to a
difference of opinion. It has some food value in the sense that yields energy. In any form it is definitely
not essential for nutrition. It has an energy value of 6-7 kcal per ml. The improvement in the health of
the troops is a direct result of a balanced diet with adequate energy and care of their well-being and
not due to the addition or absence of alcohol.
(ii) The psychological stimulant effect of the alcohol in moderate doses as is issued to our troops
at present, has been accepted over the ages. Alcohol produces a sense of wellbeing and ‘will do more’
in our troops employed under adverse conditions. It is at present issued for this purpose in ration to
troops at high altitude and during cold and inclement weather on field service, more as a psychological
booster than for any other reason.
(iii) If alcohol is consumed in excess it may produce deleterious effects on the tissues particularly
the liver, heart and central nervous system such as cirrhosis, peptic ulcers, delirium, tremor, psychosis,
lowering of rational thinking, delayed reaction time, increased irritability, lack of concentration and so on.
These effects are mainly due to resultant avitaminosis from lack of proper diet of confirmed alcoholics or
improper absorption as a result of chronic alcoholic gastritis. The troops should, therefore, be educated
in these aspects of alcohol consumption. The example set by regimental officers and JCOs in moderation,
temperance or abstinence goes a long way to educate them or make them habituated to moderations.
(k) Smoking.
(i) Smoking is another harmful habit. Like drinking, this habit also often starts as a social
accompaniment for relaxation under tense conditions, for masking shyness or diffidence, as an escape
from realities of life or from false beliefs in their beneficial values. The temporary relief is followed by
irritation or lack of concentration and craving for further smoking. Just like tobacco chewing or alcohol
drinking, this leads to compulsive smoking and then to addiction. Excessive smoking, especially if started
in early life, causes an increased incidence of lung cancer. It leads to a higher incidence of ischemic
heart disease, peptic ulcers, gastric carcinomatosis, tobacco amblyopia and tremors. Nicotine causes
powerful vasospasms, thrombotic tendencies and reduced cardiac dynamics. Chronic bronchitis and
pharyngitis are its constant accompaniments and dental staining is often seen. These points should be
brought out to discourage troops from indulging in smoking.
(ii) It is said that the personality makeup of people who take to heavy smoking and drinking is basically
vulnerable to stress-producing factors and hence smoking and drinking aggravate the fundamental effect
of stress on such persons. Smoking causes increased vulnerability to frostbite due to vasospasm induced
by it and once it has set in, smoking should be prohibited. Withdrawal symptoms or denial of smoking
to a person used to it are similar to the withdrawal of any other substance of addiction i.e. restlessness,
irritability, lack of concentration, delayed reaction time and delayed cerebration.
(iii) The policy adopted in respect of alcohol consumption in Armed Forces is one of moderation and
of discouraging habitual or heavy indulgence. Neither of them has got any nutritional or health-producing
values and heavy indulgence has definite unhealthy effects. However, in order to give psychological
satisfaction, a token-free issue is allowed while in field service to those who are accustomed to it. To
others and also to discourage these habits, other items of nutritional value like sweets, coffee and cocoa
are given in lieu. The token small amounts issued at present are not expected to produce addiction or
lead to regular or heavy indulgence and are considered to be tolerable when issued under supervision
within those limits. Medical officers should, however, always emphasize the uselessness and bad effects
of immoderation in their use. The younger officers should be made a special target of such education as
they are vulnerable to get addicted, need more nutrition which is likely to fall short of requirement due
to heavy alcohol drinking; have to work harder to be alert and provide a good example to their troops.
They are on their lowest rungs of their career and hence need guarding against bad habits. Medical
officers themselves should provide good examples in this respect.

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(l) Obesity.
Obesity means an excess deposition of fat in the body with an increase in body weight of more than 10 percent
above normal or average for the age, sex, height and stock or clan. The averages for each of these variables differ.
An extraordinarily well-developed muscular individual may have weight above the average for his age, sex, height
and stock but he is not obese. Fat in the body is deposited in the fat depots ie. over the abdominal wall, buttocks,
thighs and over the shoulders and the back. This is accompanied by deposition of extra fat in interstitial tissues in
the body, bone marrow, around the heart, liver, spleen and kidneys and also higher lipoids circulating in the blood.
In all the western countries (and in India also) it is estimated to be around 20 percent. Apart from an ungainly
and unseemly appearance, obesity is associated with serious disease processes. A premature death rate is more
amongst obese persons. It is one of the major risk factors for ischaemic heart disease.
Besides some organic pathological causes like the basophilic anterior pituitary tumour causing Cushing’s
syndrome, Dercum’s disease (adiposis dolorosa) due to menopausal hormonal imbalance and deficiency,
Frohlich’s syndrome due to posterior pituitary deficiency and some anxiety states or genetic pituitary adiposity,
the most important and the most universal cause of obesity among otherwise normal people is overeating and
lack of exercise. A person of normal weight eats more if he is more active and less if he is less active. Activity
catabolizes all carbohydrates and most of the fat. Obesity develops if activity becomes very low and one is
not able to reduce the food intake. Reduced exercise tolerance in environmental heat and cold, malnutrition,
illnesses and injuries are a consequence of obesity. All personnel, particularly officers and JCOs, who are more
prone to develop it, should be warned against overweight and obesity. The only two ways of preventing and
controlling it are regular exercises and a restricted diet, especially the fatty items such as items deep fried in
ghee, oil and processed food items to include cakes, pastries, burgers, samosas and other fast-food items.
The Medical officer should always be on the look-out for such tendencies in personnel and educate them
accordingly. Amongst the method to reduce obesity, one effective method is restricting diet. The standard
method is to reduce total calories in the diet. If a sedentary worker requires 2,000 calories per day and has
a calorie deficit ranging from 200-500 calorie per day he will lose weight. Such diets can be worked out to
suit individual requirements and to include a modicum of almost any food the patient has been accustomed
to eating. Diet therapy requires as much enthusiasm and perseverance from the subject as from a doctor. In
practice it means persuading the subject to continue to go short of food. The most important single item of
food the avoidance of which can be expected to contribute to weight loss is sugar in any form including sweet
dishes.
Table 21.1 : The Relevant Army / Navy / Air Force Orders Give the Desirable
Weights for Various Ages and Heights for Men & Women
Armed Forces Army Order
Army AO 09 / 2011 (Offrs)
AO 03 / 2001 (JCOs & ORs)
Navy Naval Order 14 / 2014 for both officers and JCOs / OR
Air Force IAP 4303 (6th Edition July 2024 for both officers and JCOs / OR)
(m) Personal Protective Measures Against Diseases.
Active preventive measures against diseases may be non-specific, which are directed to build highly resistant
positive health against ill-health in general as described above and also specific, like the use of mosquito
net or DMP against arthropod borne diseases such as malaria & dengue, use of DBP on clothing against
high scrub typhus risk, protection of eyes by dark glasses against snow blindness, use of proper clothing or
adoption of other protective measures against frostbite and so on. Immunisation is the single most important
measure against some specific diseases. These procedures have been described in Chapter XXIII. Troops must
be provided with appropriate means, knowledge and practical training for the adoption of and activate the
motivation to practice all the personal protective measures. Orders and instructions are effective to a limited
degree in the absence of the willing cooperation of the personnel. Moreover, enforcement of orders and
instructions in the absence of their willing cooperation and clear understanding entails avoidable wastage of
time and energy on the part of officers and JCOs incurred at the expense of other more important operational
tasks. Troops, therefore, should be educated to understand and give active cooperation by adopting personal

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protective measures of their own accord. Observance of personal protective measures must become a part of
their behaviour pattern or a ‘second nature’ without being required to be preoccupied with them. Similar to the
specific or non-specific measures to prevent the diseases, there are direct or indirect measures which protect
against physical injuries, mental breakdown and other apparently non-preventable diseases. For example,
maintenance of vehicles, good training, precautions to avoid imminent or likely accidents, physical and mental
fitness are some of the non-specific measures. In workshops, considerable personal safety can be ensured
by simple rules of man-management and housekeeping. Specific preventive measures such as wearing of
protective clothing, taking care of specific rules of work methods, such as laid down in chemicals and atomic
industry are important. One of the most important specific personal protective measure against head injuries,
likely to be sustained by a motor cycle dispatch rider, is to wear the crash-helmet and wear it correctly.
90 percent of head injuries can be avoided by this simple devise and faithful observance of it. All ranks should
be conversant with first aid methods to render quick efficient aid on the spot of an accident and methods of
artificial respiration and cardiac massage.
(n) Modifications in Mode of life.
Modification becomes necessary under certain conditions. Desert life and life in extremely hot surroundings
require high water and an adequate salt intake. Life at high altitude needs adequate caloric intake to combat
effects of cold and hypoxia. Acclimatization to hypoxia is essential before going higher than 3,000 meters for a
prolonged stay. Adequate protection by proper use of extra-issue clothing is necessary in cold at high altitude.
Use of dark glasses is necessary to avoid snow-blindness at high altitude. Protective clothing must be used to
ward off insect vectors, leeches and snake bites. These protective measures are the personal responsibility of
the men but they have to be educated and trained to adopt them as a habit. Similarly living in difficult and
different terrains requires training to form habits of living in unison with the surroundings.

21.14 Family Welfare.

(a) Care of wife and children is the personal responsibility of each person; and a serviceman is not an
exception to this. The welfare and health of the family affects the health, efficiency, wellbeing and morale
of the troops directly and indirectly. Unit administration has a moral and ethical responsibility to ensure the
welfare of all families in station. Medical Officers should educate and guide them and unit Commanders
should arrange for proper facilities. Habits of the parents are likely to be picked up by the progeny, hence
the personnel and their wives should practice correct health habits. Immunization schedule as mentioned in
Chapter XXIII should be followed in case of children of all service personnel. Antenatal, maternity, postnatal,
child welfare and family planning facilities should be provided under station and or unit arrangements. School
health care should be provided to all children attending Armed Forces Station or Regimental Schools. Families
therefore, require health education
(b) Family Welfare Programme in Armed Forces.
(i) Family Welfare programme was initiated in the Armed Forces as a welfare activity long before the
official programme was introduced in the country in 1956. It started in 1951, when Family Welfares
Centres were established in military units supported and financed out of unit funds. When the Union
Ministry of Health and Family Welfare launched the Family Welfare programme, Armed Forces started
full participation in this national programme on high priority.
(ii) Organisation.
The organization is as under;
(aa) At Dte level
Program Welfare Centre in the office of DGAFMS.
(ab) At Command Level.
Regional Family Welfare Medical Officers (RFW) along with one Statistical Assistant and one clerk
each.
(ac) At station Level.
Family welfare centres. In all, there are 137 (44 Class I and 193 Class II) Family Welfare centres
established. These FWCs give cover to the Armed Forces Personnel, their families as well as civilian

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population residing in Cantonments / Military Stations. They work under supervision of respective
Senior Executive Medical Officers (SEMOs)
(iii) Staffing Pattern of FWCs.
Table 21.2 : FWCs - Classification, Staffing Pattern and Services Offered
Type of FWC Class I Class II
Staffing Pattern LMO full time – 1 Part time LMO – 1
Part time LMO – 1 FWEE – 1
Nurse - 1 LHV – 1
FWEE – 1 SKT – 1
LHV - 2 Ayah – 1
SKT – 1
Ayah – 2
Part time sweeper – 1
Services ANC ANC
PNC PNC
Normal Delivery Under 5 Clinic
IUCD insertion Child Immunization
Under 5 Clinic Contraceptive advise and distribution
Child Immunization IEC activities
Contraceptive advise and Health Camps
distribution
IEC activities
Health Camps
(iv) Function of Staff of FWCs.
(aa) Lady Medical Officer.
O To plan and organise family welfare programme in FWCs and the units / areas covered
by the centres.
O To guide and supervise the staff of the centre on all family welfare activities.
O To provide clinical consultation services to families
O To carry out IUD insertions and regular follow up of such cases to prevent
complications.
O To motivate families to adopt family planning measures.
(ab) Family Welfare Extension Educator (FWEE).
O To plan and organise extension education work to meet the needs of civil / military
population of the station.
O To visit the units and organise health education campaign according to the felt needs
of the clientele.
O To help Lady Medical Officer in organising special events and arrange for film shows,
lectures, exhibitions etc.

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(ac) Lady Health Visitor (LHV).

O To assist the Lady Medical Officer in organising and planning family welfare activities
in the station
O To health educate mothers in the station and distribute the educational material and
motivate them to accept contraceptives and IUD insertions
O To establish contact with local ladies, social organisations and hold group discussions
to popularise the small family norm
O To visit homes to collect data and to persuade women to accept appropriate methods
of family welfare and advise them on child health care and other health matters
(c) Family Planning.
Family limitation is the greatest need at present from the national, community, family and individual point of
view. For Armed forces personnel, family planning and limitation of progeny is of vital importance because of
the peculiar nature of their service requirements, conditions and commitments. At least for half of their career,
with the exception of extremely few categories, they have to remain away from their families and entrust their
wives with all the burden of bringing up, education and looking after the illness and other problems of children.
This entails an extraordinary strain on wives besides the maintenance of a double establishment. If the serving
person has to give his best to the service, he should remain free from the worries of his family while away from
them (or living with them). It is therefore necessary that the size of the family should be small and manageable
and within his means. All ranks should, therefore be educated in rational beliefs and practices of planning and
limitation of families. It is the responsibility of the RMO as well as the regimental officers to help the personnel
acquire the knowledge and means to practice limitation and planning of the family.

21.15 Health Care During Moves.

Care of personnel during a move is much more taxing than when they are static under well­controlled environmental living
and working conditions. Movement in Armed forces is undertaken for administrative, logistic, strategic or operational
purposes. It is accomplished by marching, by mechanical transport, by railway journey, by sea or air. The special
taxing conditions during moves, depending on the mode of progression, are concerned with extra energy requirements,
change in atmospheric, biological, physiological, physical and psychological environments, loss of sleep, change in
body metabolism consequent upon the change in environs and mode of life, depletion of nutrition due to difficulties
in food supply and water supply, difficulty in maintaining personal hygiene and environmental sanitation and so on. All
the modes of movements require pre-planning and utmost care to ensure that personnel do not suffer from ill effects
due to these conditions and arrive at their destination in a fit state to undertake further administrative or operational
tasks without much delay or lack of efficiency. Tracking back to the base during withdrawal operations adds to all other
stress producing factors. The various requirements and management of a move by marching, road transport, railway
and sea are briefly described in the subsequent paragraphs.
(a) Marching.
This is a normal activity of troops undertaken for administrative logistic, tactical, strategic, operational and
training purposes. Marching comprises orderly walking, wearing certain clothes in a definite fashion, carrying
a certain load disposed on the body in a particular manner and moving together as a body of men at a
regulated pace. It is interrupted by ‘halts’, the number and duration of which are directed by strategy. Further,
this exertion may be prolonged for hours and days after physical and mental strain e.g. withdrawal operation
in retreat. In short marching is a community form of exertion. Training in the practice and habits of walking
is, however, a prerequisite in every case.
(b) Training for Marching.
Training for prolonged marching must be gradual and must be on full rations. Any attempt to force men in
this preliminary training or train them to endure on inadequate rations will only result in a breakdown. Officers
are responsible for instructing their men in march discipline, care of their feet, personal cleanliness, water
discipline and in march sanitation. The medical officer should give them technical advice on the physiology
and hygiene of the march. He should also ensure that water duty personnel and the sanitary squads are
thoroughly familiar with their duties, which will be required of them on the line of march.

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(c) Preliminary Preparations.

A rapid survey of men should be made by the medical officer before the marching starts to eliminate those
who are likely to be unfit to carry out the march. Only men who are in sound health should be allowed to start.
Inspection of their feet, socks and boots is the duty of the platoon / sub unit commanders in collaboration
with the medical officer. Water trucks and receptacles for carrying water and all water bottles and cooking
arrangements for the march should also be included within the inspection by the medical officer. Each person
should know the route proposed to be followed and arrangements to keep in contact with and recovery of
stragglers should be made. Alternative or escape routes, own camp positions and modes of communication
when segregated must be known. Emergency and survival rations must be given to each individual and
composite pack rations kept in reserve.
(d) Start.
The best time to start a day’s march is the time at which the soldier would normally start his day’s work
in that season and climate. Marching in the very early mornings should be avoided as far as the military
situation permits, as they involves much loss of sleep and greatly increases energy expenditure. The tactical
situation may make it necessary to undertake a series of night marches. However, they cause considerable
strain and result in loss of manpower and efficiency. In extremely hot weather the march should be finished
before the worst heat of the day, by starting earlier in the morning, if necessary. Apart from this, the time to
start should be late enough to allow men a reasonable night’s sleep. This should always be impressed upon
the force commander by the medical officer. Military necessity must of course govern the situation and each
case must be considered on its merit. Before the march starts, a light breakfast and hot sweet tea should
always be issued.
(e) March.
The most economic rate with minimum energy wastage for the fully laden, trained infantry man on a fair,
flat road is 90 m in a minute with a pace of 75 cm. At this rate and including the usual allowance of a ten
minutes halt for an hour marching, 5 km an hour for a smaller formation than a brigade and 4 km an hour
for a division may be taken as very good marching on fair roads. In hilly or broken country the rate will be
less. At altitudes above 3,000 m the rate will be progressively reduced due to hypoxia. A faster rate either
by increasing the number of paces per minute or the length of pace, become rapidly and progressively less
economic and throws a strain on the troops and reduces their operational efficiency.
(f) Halts.
A halt of 10 min should be made at the end of the first 2 km for adjustment of equipment and thereafter a 10 min
halt every hour should be allowed. This is physiologically necessity. Long halts for an hour or more should always
be allowed when the day’s march exceeds 25 km. At this halt the troops should be given a substantial meal. At
every halt, short or long, every man should take off his equipment, lie down and raise his feet.
(g) Distances.
The distance covered is determined by the load, the climate conditions, the terrain or condition of the route
and the training and health of troops. For seasoned troops marching on six successive days, a speed of
24 km a day is good and 32 km a day very good. ‘Forced marching’ at faster speed than this is only possible
with a small number of specially picked tough and trained troops. One day’s rest a week is essential. It is
physiologically and psychologically much healthier to march 140 km in six days, with one day’s rest than to
cover that distance by continuously marching for seven days without rest. Forced marching leads to a great
wastage from exhaustion and sickness and the tactical or strategic advantage contingent upon it may not,
outweigh the loss. But if the military situation demands a forced march, medical authorities should advise
the force Commander on all possible steps to minimize the anticipated man power loss. The most important
of these measures are the provision of full scale rations, an ample water supply, minimum load carriage and
ensuring of all possible restful nights.
(h) Load.
(i) Bones and ligaments take the main brunt of load during the static load carriage, but the main strain
of energy expenditure during dynamic load carriage falls on the muscular system. The more the energy
expended on carrying excessive loads the less there will remain to be expended on the distance marched

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and in fighting. Therefore, all possible means should be adopted to economize in muscular energy.
(ii) For comfortable carriage, the body and the load carried on it should form one unit. In order to
achieve even distribution and optimum stability and support, the load should be close to the body and
over its centre; if loosely disposed, this causes friction and instability. If the load is further away from
the body, the support has to be broad-based which causes more expenditure of muscular energy.
(iii) A single load evenly distributed between the two shoulders and suspended by strappings to the
shoulders can be advantageously carried on the back, but large and irregular size loads are difficult to
carry by this method. The load must be compact, preferably in an oblong cube-shaped package.
(iv) The weights of loads carried by infantry have varied considerably at different periods. Rationally
the weight of load should have an optimum ratio with the body weight. A load of about 30 percent
of the body weight can be carried with most economical energy expenditure by an infantry soldier i.e.
approximately 21 kg for a man weighing 70 Kg, the effective maximum should be about 45 percent
viz. 32 kg for the same man. With loads of over 45 percent of the body weight, the amount of energy
expended increases to three times of the increased load.
(j) Physiological Consideration.
(i) The optimum body temperature for the efficient performance of muscular exercise is 38°C, above
which muscular efficiency becomes impaired: and if it continues to rise, heatstroke may result. The total
body heat produced by a trained, physically fit, infantry soldier marching with full equipment on a level
ground is 360 Kcal (1506 KJ) per hour. Allowing for the heat of metabolism approximately 1,000 Kcal
(4184 KJ) of heat is required to be dissipated from his body during a straightforward march of 25 km
over level ground at the atmospheric temperature of 21°C. As evaporation of approximately 2 ml of sweat
dissipates one Kcal (4.184 KJ) of heat, the evaporation of about 2 litres of sweat is necessary to dissipate
the excess heat. Heat produced will increase above 1,500 Kcal (6276 KJ) in an untrained, unsuitably
clad, tired person with sore feet, marching on a rough and hilly terrain with more than 18 kg of load
and the speed above 90m a minute. In addition, as the atmospheric temperature rises above 21°C, the
evaporation of progressively increasing amounts of sweat from the skin is necessary to prevent a rise in
body temperature.
(ii) The total loss of water from the body will be at least 5 litres when the atmospheric temperature is
32°C and 12 litres when it is above 40°C. Although the total water content of the average man’s body
is about 40 litres, a considerable portion of it cannot be drawn upon for the dissipation of heat without
damage to the tissue structure. When he loses three litres, physical inefficiency becomes marked and the
loss of more than four litres brings him near to dehydration. Therefore, in marching at an atmospheric
temperature of over 38°C without water replacement, there is a risk of precipitation of effects of heat.
During 25 km march with the atmospheric temperature at 32°C, water should be consumed at the
midday halt and when the atmospheric temperature is over 40°C it should be consumed at every halt.
(iii) Physically fit, suitably clad, seasoned soldiers when adequately fed and supplied with water suffer little
ill effects from marching even in the hottest weather, if the march is not unduly long and the relative humidity
not usually high. The amount of sweat produced does not necessarily indicate the amount evaporated.
(iv) When the temperature and relative humidity are 32°C and 90 percent respectively, an individual
whose body is bathed in sweat is evaporating much less sweat from his skin than one with the dry body
when the temperature is 45°C and the relative humidity 20 percent. The critical factors therefore are
the high relative humidity with high dry bulb temperature.
(v) When the dry bulb temperature is above 38°C with the relative humidity above 85 percent, there
is a very real danger of a number of cases of heat exhaustion and heat stroke occurring among even
the fittest marching soldiers.
(vi) Under all the above conditions marches should be short, halts frequent, equipment and clothing
light, drinking water liberally supplied and the worst heat of the day avoided.
(vii) Evaporation of sweat is less in a humid and still atmosphere; therefore, a hot and airless day is
less suitable for marching.
(viii) Effects of the heat are much more likely to occur among those who are over fatigued, debilitated

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and in poor physical condition.

(ix) Profuse sweating also causes depletion of salt. While undertaking a 25 km march under an
atmospheric temperature of 40°C maximum, a man loses about 15 to 20 g of salt. When undertaking
hard work or longer marches in hot humid weather more salt may be needed.
(x) Also refer to humidity temperature chart in Chapt VI to determine heat risk of exercising / marching
during hot weather.
(k) Mountain Terrain At High Altitude.
The tactical and operational marches undertaken for long range patrol or tracking have two different
physiological considerations.
(i) The troops may be required to ascend a height above 3,000 m and upto 6,000 m Above Sea
Level. Troops not fully acclimatized to high altitude are liable to suffer from altitude sickness and even
pulmonary oedema. The danger lies in the possibility of its being mistaken for ordinary exhaustion and
the real condition thus unknowingly progressing into irreversible physical breakdown and death. The
progress of walking and its rate progressively diminishes at successive higher altitude. The danger is
more for apparently stout or sturdy people who try to overdo the task of climbing with heavier loads.
(ii) The other danger is that of exposure to severe cold with blizzard, especially when swollen feet
due to prolonged walking induce personnel to remove the boots and socks. Loss of water is caused by
exhaling moisture saturated air at body temperature while inhaling cold air without much moisture. These
conditions must be guarded against and personnel trained to recognize their importance and likelihood
of danger. For long range patrols, tracking and manoeuvres, oxygen cylinders may have to be carried.
(iii) Other side effects of marching in mountains terrain are foot injuries due to twisting, running or
jumping and several injuries due to falls or landslides. Leeches in foothills at lower altitudes may cause
minor nuisance and snow or rain may retard the progress.
(iv) First aid equipment is always necessary while marching in mountainous terrain.
(l) Sanitary Arrangements.
Normally all people should have defaecated before the march beings. At short halts all that can be done to
ensure that those who must defaecate excavate, a shallow hole in the ground in which they deposit their
faeces, afterwards covering them with earth, At a long halt, shallow trench latrines are dug by the battalion
sanitary personnel who should always proceed with the advance party and leave detachment behind to cover
the trenches and mark them properly for the succeeding trackers to be aware of the latrine area. Disposal of
other waste matters should be carried out by burning or burying in shallow trenches.
(m) Personal Hygiene.
Men should get facilities each day for washing and changing. If it is not possible to wash the socks worn
during the day’s march, they should be turned inside out and hung up to dry in the sun. In hot weather, a
campsite which allows washing arrangements should be chosen. At the same time the dangers of bathing in
rivers or lakes which are polluted with sewage should be remembered. The danger of scrub typhus should be
borne in mind when selecting resting sites, campsites and washing places.
(n) Procedures on Arriving at Camp.
On arrival at camp the men should get hot sweat tea. After tea, the necessary camp work should be performed
and the men should attend to their personal hygiene. Finally, the main meal of the day, which should be hot
and substantial, should be served, but the issue of this should not be delayed too long, otherwise men who
are overtired are apt to go to rest without food. In order to avoid a muscle-bound condition, men should not
rest immediately but carry out light tasks or walk about for some time before lying down for complete rest.
After the march is over for the day, the platoon commanders should carry out an inspection of boots, socks,
feet and general condition of persons. The Medical Officer should assist in it and thoroughly examine the cases
requiring his attention.
(o) Duties of Medical Officer on March.
The normal position of the unit Medical Officer is at the rear of the column so that he can attend to men who

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fall out. He should, however, once in each hour to go to the head of his battalion and allow it to march past
him. By watching the appearance of the men as they file past him and speaking to each Company Commander,
he can gauge the effect of the march on the men and supply his battalion commander with vital information.
At halts he should attend to any minor ailments. At the long halt he should help the unit hygiene officer to
select a site for the shallow trench latrines and ensure the refilling and purification of water in the water
vehicles and containers. Immediately after the last short halt of the march, he should proceed forward to the
site of the camp or billets and satisfy himself that sufficient latrines and urinals are ready for the immediate
needs of his unit. He should also satisfy himself as to the suitability of the proposed sources of water supply.
(p) Care of Feet.
(i) Hardening of Feet.
All men should wash their feet at least once a day, preferably in tepid water. After this they should be
steeped in cold water for ten minutes. Soaking them in a solution of salt and alum, 100 g of each to
10 litres of water, is useful to harden very soft feet.
(ii) Prevention of Sore Feet.
It is useful to wear a pair of thin nylon or cotton socks under the regulation socks if the boots are large
enough to allow this. If any particular part of the foot feels sore a search should be made inside the
boot for any roughness and projection of a nail: corns are due to nails pricking the sole of the foot.
Changing into chappals at the end of the day’s work is of great value. Those with a tendency to sore
feet should dust their feet liberally each day with ‘foot powder’ (zinc oxide 10%, boric acid 10% and
kieselguhr 80%). It is an advantage to have the medical assistants trained in the elements of chiropody.
At all halts on the march and at the end of the march, he should attend to all those who are known to
have tender feet. The feet must be kept scrupulously clean.
(iii) Hyperhidrosis.
Men who suffer from excessively sweaty feet develop inflamed and blistered feet. The best treatment for
these conditions is to bathe the feet in 0.5% solution of formaldehyde and dry them thoroughly, followed
by dusting with ‘foot powder’.
(iv) Blisters.
If the sore or irritation in the boot or socks is removed and the foot rested, the blister fluid will be
gradually absorbed in four to five days. This can be hastened by draining the blister through a stout,
sterilized long hypodermic needle, inserted into the blister through the surrounding sound skin painted
with tincture of iodine. When the blister is empty, the skin over it should be carefully flattened down, but
not cut away and painted with iodine. Over this a piece of lint secured in position by adhesive plaster
should be placed.
(q) Care of Footwear.
(i) Boots.
These should always be kept pliant and soft. The foot spreads about 1 cm in length and 1.25 cm in
breadth under the weight of the full marching load. Therefore, they should be fitted over regulation socks
while the soldier is carrying his load and standing.
(ii) Socks.
A clean pair of socks should always be carried on the march for putting on after feet have been washed
at the end of the march. Woolen socks shrink after being washed. New socks should therefore, be
2.5 cm long and worn by the soldier while on duty in barracks. Two washes make them the right size
for marching. Darning must be carefully done as holes in socks or badly darned socks cause blisters.
Socks should be carefully washed and be kept clean at all times.
(r) Move by Rail.
In addition to all the usual measures to ensure the health, comfort, well-being and efficiency of the personnel
required to be taken during a move, the following precautions to safeguard against health hazards should be
taken when moving by rail:

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(i) All electric fans in military coaches should be checked for their working. Overcrowding should be
avoided in the coaches. These should be washed and sprayed with insecticides prior to occupation.
(ii) A compartment, in addition to that for hospital accommodation, should be reserved and equipped
for the treatment of men suffering from effects of heat.
(iii) Entrainment should not take place overnight when the train is due to leave in the early morning; a
long period cooped up in a stationary train in the hot weather is most uncomfortable and even dangerous.
(iv) Ice containers are authorized and should be supplied at the scale of 5 per military coach and
1 per hospital compartment, Officers compartment and kitchen cars.
(v) Ice is authorized at the scale of 35 kg per container or per 8 men at the beginning of the journey
and a further 35 kg for replenishment later in the day.
(vi) Adequate cold drinking water should be supplied to troops,
(vii) Taking food, drinks or water from unauthorized sources at halts enroute should be prohibited. Halts
for meals should be scheduled prior to starting and meals prepared by own cooks should be given.
(s) Move by Mechanical Transport.
Precautions during moves in Mechanical Transport (M.T.) by road to be taken in addition to those mentioned
above are as under:
(i) Movement should, as far as possible, be in the cooler hours of the day.
(ii) Distance covered daily should not, as a rule exceed 160 km and there should be one day’s rest
after every 4 days driving.
(iii) Every effort should be made to take the maximum benefit of available shade for halts even if it
means going some km further than scheduled.
(iv) Canvas water bags (chaguls) filled with water should be carried, slung on the outside of each
vehicle for ensuring cool drinking water.
(t) Disembarkation from a Ship.
Men freshly disembarked possibly suffering from the aftereffects of sea sickness and certainly soft from being
on board ship, are susceptible to the effects of heat. They should on no account be subjected to a long march,
moving heavy baggage, fatiguing works etc; until they have been fed and rested. Water points, shelters from
the sun and heat stroke centers should be provided at the docks.

21.16 Maternal and Child Health Care.

Government of India adopted the Reproductive, Maternal, New-born, Child and Adolescent Health (RMNCH+A) framework
in 2013. It essentially aims to address the major causes of mortality and morbidity among women and children. This
framework also helps to understand the delays in accessing and utilizing health care services
Based on the framework, comprehensive care is provided to women and children through five pillars or thematic areas
of reproductive, maternal, neonatal, child and adolescent health. The programmes and strategies developed by various
divisions are guided by central tenets of equity, universal care, entitlement and accountability to provide ‘continuum of
care’ ensuring equal focus on various life stages.
In the Armed Forces, Family Welfare Centers are organized on a station basis in all large, medium and small stations.
In large stations the establishment is more elaborate than other stations. In addition to these centers some stations
also run the Health Centers. Antenatal, postnatal, under five clinics and family planning clinics are held on specific
week-days at those centers. Although a standard plan for staff and equipment is recommended for Health Centers
(Table 21.2), its implementation depends mainly on local resources, needs and enthusiasm.
In the Navy, “Family Clinics” funded from non-public funds but under control of medical administrative authorities
provide for comprehensive health care of families of naval personnel and are located at convenient places close to
concentrations of family quarters.
The OC Station Health Organization provides technical assistance and guidance on behalf of and under the general
direction of the SEMO. The lady medical officer-in-charge is, however, the actual working head. The unit family welfare

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or health centers are also organized by some large units under their own resources. The RMO is then responsible for
the supervision of work in such centers. To enable the Medical Officers at various levels to carry out their duties in
respect of the families of Armed forces personnel, a brief resume of maternal and child health care is given here under:
(a) Women in the reproductive age group and infants constitute about 25% of the population and are
considered a vulnerable group with high risk to life and health. Women carry a special risk to life and health
during pregnancy, parturition and puerperium; the child bearing age shows higher death rates and morbidity
rate in the female population. Infants are highly susceptible to infections, malnutrition, dehydration and
environmental changes. The risk to life decreases as children grow up but they are still vulnerable to many
adversities and infections. These are the pre-school and the school going children from one to ten years of
age and form 20% of the community; if adolescents upto 15 years of age are added to this, the total is about
40 percent of the community.
(b) Maternal Mortality and Morbidity.
Maternal mortality means the death of a woman while pregnant or within 42 days of termination of pregnancy,
irrespective of the duration and site of pregnancy, from any cause related to or aggravated by pregnancy or its
management but not from accidental or incidental causes. Maternal mortality ratio is expressed as maternal
deaths per lakh live births. As per SRS 2020, it is 52 per lakh live births. However, as compared with developed
western countries 12 per lakh live births, this is still very high. Maternal morbidity is about 20 times the
mortality. The major medical causes of maternal mortality are hemorrhage, sepsis, abortions, hypertensive
disorders, obstructed labour and anemia. In addition, the pathological processes of some preexisting diseases,
such as chronic heart diseases, hypertension, kidney diseases and pulmonary tuberculosis are aggravated
by pregnancy and childbirth. A majority, of all the conditions causing maternal mortality and morbidity are
preventable: by ensuring efficient antenatal, intra-natal and postnatal care.
(c) Child Mortality and Morbidity.
(i) Pre-school age child mortality means the deaths of children aged 1-4 years, ‘infant mortality’
means death of children upto 1 year of age, ‘neonatal mortality’ means death upto 28 days after birth,
early neonatal deaths are the ones that occur upto 7 days after birth. Deaths including stillbirths, from
the 28th week of pregnancy upto 7 days after the birth are included in ‘perinatal deaths’.
(ii) The crude death rate in India which was 40 to 45 per 1,000 of population at the beginning of last
century has now fallen to 7.2 per 1,000 on account of general improvement in environmental conditions,
specific control of endemic communicable diseases, improved general nutrition and medical care and
health (or rather illness) consciousness of the people. Approximately half of the total mortality occurs
among children below 5 years. half of the under-five child mortality occurs below one year and half of
these die before they become one-month old.
(iii) Infant mortality in India was above 230 per 1,000 live births at the beginning of last century,
in 1947-48 about 150 per 1,000 live births and in 2023, 28 (SRS-2020) & 32 (NFHS-5) per 1,000 of
live births. In developed western countries the infant mortality rates are uniformly below 10 per 1,000
live births. At least 50 to 60 percent of the child mortality & morbidity can be prevented by efficient
antenatal, intra-natal and postnatal care.
(d) The better the health of the mother during pregnancy and after delivery, the lesser will be the risk to her
own life and health and that of the infant, because the care of the mother before, during and after parturition
contributes to the health of the foetus and infant as well. Maternal and childcare as a combined service is
thus an important constituent of the comprehensive health care of the community. Continuity of supervision
is essential and the prenatal services cannot be separated from the intra-natal midwifery services and the
infant and child welfare services. The aim of the combined services are:
(i) To further reduce the maternal mortality and morbidity during pregnancy, labour, puerperium and
thereafter
(ii) To ensure normal progress of pregnancy
(iii) To further reduce the perinatal, neonatal and infant mortality and morbidity
(iv) To ensure normal growth of children up to the time their health care is taken over by the school
health service. The maternal and child health care programme includes antenatal care, maternity services

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and postnatal care, mother craft, under five clinics and family planning services. Various clinics may
be held on different days of the week at the same premises and also the services may be extended to
homes of the families.
(e) Antenatal Care.
The antenatal service may be offered in the clinic or extended to the home through a lady health visitor or Auxiliary
Nurse Midwives (ANM). The objectives of antenatal care are to decrease maternal morbidity and mortality before,
during and after childbirth and to ensure the safe and healthy progress of pregnancy. Most of the causes of maternal
morbidity and mortality can be rectified or avoided if detected early during pregnancy, if the nutrition of the mother
is kept at its best during pregnancy and if diseases like syphilis, anaemia, hypertension. Diabetes, infections and
toxaemias are treated early and kept controlled. Normally each expectant mother should be seen at least once
a month in obstetric OPD or by lady health visitor. To study environmental conditions and give practicable advice
and demonstration, a proportion of the visits should be at the homes. Ensure that every pregnant woman makes
at least 4 visits for ANC, including the first visit / registration and any home visits by the ANM / lady health visitor
(LHV). The first visit is recommended as soon as the pregnancy is suspected. Ideally, the first visit or registration
of a pregnant woman for ANC should take place in the first trimester, before or at the 12th week of pregnancy. The
second visit should be scheduled between the 4-6 months (around 26 weeks). The third one should be planned
in the 8th month (around 32 weeks) and the fourth one in the 9th month (36-40 weeks). Antenatal card for every
woman registered should be made at the time of first contact with health authorities. Instruct her to bring the card
with her for all subsequent check-ups / visits. A general review of the health of the mother and her mode of life
accompanies each medical examination.
(f) The pregnant woman is usually first brought under antenatal observation about the 3rd month of
pregnancy when she is thoroughly examined for any defects or diseases, approximate period of pregnancy is
determined and in primipara the pelvic measurements are taken and recorded. The weight is recorded; blood
for VDRL / WR / Kahn / , HIV, Hepatitis B, HBsAg, Malaria, Rhesus factor, ABO grouping, Blood Glucose and
complete haemogram is taken. Urine is examined for sugar, albumin and casts. Blood pressure is taken and
recorded. Appropriate treatment for any defects or diseases is started. Immunization against tetanus should
be given. Iron and Folic acid supplementation (100 mg elemental iron and 500 mcg folic acid) is started from
second trimester onwards and continued for 180 days after delivery. Advice on personal hygiene & nutrition
in pregnancy and the instructions to return again after a fortnight / month or earlier if she feels is unwell, are
given. By 32nd and 34th week the position, lie and presentation of the foetus should be ascertained and any
remedial external measures, if considered necessary, can be carried out for correcting it. After the 36th week
the visit should be weekly and presentation checked. The head is generally fixed in the pelvic brim by the
38th or 39th week and prediction as to the absolute normality of labour can be made and case referred to
the specialist if considered necessary.
(g) Maternity Service.
In the Armed forces, the delivery should be institutional. It is needed to ensure safe and aseptic delivery practices
as well as for prenatal and postnatal complications, for abnormal labour, for normal labour in primiparas and
to provide safe and hygienic confinement to the mother and the baby. An institutional midwifery service run in
conjunction with a welfare centre is practiced in the Armed Forces. The personnel should be advised to ensure
that their wives are admitted to military hospital for delivery and discourage domiciliary delivery in their villages.
(h) Postnatal Care.
The postnatal practice is also conducted either at the clinic on fixed days of the week or extended through
health visitors to homes. The postnatal rehabilitation of mothers, their mother craft training and inspection
of babies for normality can be carried out simultaneously. The mother is educated regarding her own health
and the health of the baby and given advice regarding personal hygiene. Family planning clinic is attended
by the mother about a month after the first child birth. IUD is usually inserted 6 weeks after childbirth. After
the second child, the couple should be advised to adopt permanent methods of family planning. In under
five Clinic, immunization schedule as given in Chapter XXIII should be carried out and the child examined for
normality of growth, nutrition, function of all organs and ‘milestones’.
(j) Home Visits.
The lady health visitor at Family Welfare Centre should visit each expected mother and every infant once a

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month and each child between 1 to 5 years once every three months. More frequent visits are desirable
between the 36th and 40th week of pregnancy and the first month of the infant’s life, which are the periods
of maximum danger. Apart from 8 to 10 visits to each expectant mother and visits to every pre-school child,
each infant should be visited 12 times in the first year of life for teaching the mother to observe the normal
developments and signs of danger, therefrom to manage feeding successfully, to supplements her own diet and
to wean the child, deal with vaccination, clothing, bathing, teething habit training and prevention and treatment
of minor ailments, educate against wrong customs and habits to instil into her the elements of home and
environmental hygiene, family budgeting, storage of food and to help her to ameliorate social maladjustments.
She has to demonstrate to the mother the preparation of suitable foods for the baby and to supervise the
mother while she gains skill in carrying out treatment of minor ailments of the eye, ear or skin. Early visiting
also enables the health visitor to directly or indirectly supervise the work of the dai or midwife and to influence
her methods and practices.
(k) School Health Care.
Schools play a critical role in helping students establish lifelong healthy behaviours. Recognizing the importance
of this, school-based health promotion activities have been incorporated by Govt of India as a part of the
Health and Wellness component of the Ayushman Bharat Programme. School Health & Wellness Programme
(launched in Feb 2020) is being implemented in government and government aided schools in districts
(including aspirational districts). Two teachers, preferably one male and one female, in every school, designated
as “Health and Wellness Ambassadors” shall be trained to transact with school children & conduct health
promotion and disease prevention activities for one hour every week. These health promotion messages will
also have bearing on improving health practices in the country as students will act as Health and Wellness
Messengers in the society. Every Tuesday may be dedicated as Health and Wellness Day in the schools.
Schools for children of Armed forces personnel are organised and maintained under the auspices of and
financed from the Defense Ministry, services HQs, local formation / Station HQs or regimental authorities. The
RMOs and / or any MO detailed by the SEMO should regularly inspect the school premises and children and
submit the report to the administrative authorities to enable them to arrange the remedial action for rectifying
the defects and improve the health of children.
Schools provided for children of service personnel should be inspected at least once a month in accordance
with RMSAF para 112. The important points to note are the heating, lighting, ventilation, floor space per child,
suitability of desks, condition of water closets and urinals, presence or absence of cloak rooms and play shelters
and general appearance of the children. In respect of the inspection of school children a distinction should
be made from the thorough annual examination as described below. At the inspection of the school buildings,
which should be carried out at least once a month, a general survey should be made of the children in the
classrooms. The points to note are the general appearance and demeanour of each child and their cleanliness.
Speaking generally, a clean happy looking child is healthy. The teacher in charge of each class should be
invited to give his / her opinion on the general welfare of the children. Any child considered by him / her to
be suffering from any defect should be carefully examined afterwards. Particular attention should be paid to
defects of vision, hearing and posture. The condition of the teeth, tonsils and adenoids and the intelligence
and personal cleanliness of the child should also be looked into. It is not suggested of each child, but merely
that all children detected in the general survey of the whole class as having some defect or reported by the
mistress or teacher as having some defect, should be thus examined. In addition to this monthly survey, a
complete examination should be made of all children before on joining the school, at the third and sixth year
of school life and leaving the school or annually if possible as described below. The school register should be
signed by the inspecting medical officer as a record of his visit. A detailed report covering all points described
in the section should be submitted to the school organising authority i.e. Station, Sub Area or other formation
as the case may be, through the SEMO or preferably under SEMO’s signature.
Objectives of School Health Programme.
(i) To provide age-appropriate information about health and nutrition to the children in schools
(ii) To promote healthy behaviours among the children that they will inculcate for life
(iii) To detect and treat diseases early in children and adolescents including identification of
malnourished and anemic children with appropriate referrals to PHCs and hospitals

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(iv) To promote use of safe drinking water in schools

(v) To promote safe menstrual hygiene practices by girls
(vi) To promote yoga and meditation through Health & Wellness Ambassadors
(vii) To encourage research on health, wellness and nutrition for children
The Main Objectives of the School Health Care are as follows:
(i) Help children in this critical period of their physical and mental growth towards normal healthy
adulthood
(ii) Maintaining working efficiency at a high level and improving mental assimilating power by:
(aa) Ensuring congenial working conditions
(ab) Keeping them physically and mentally fit at all times
(ac) Improving the general nutrition of the children
(ad) Reducing absenteeism and thus increasing average study hours / days.
(iii) Prevent spread of infections, reduce and detect minor ailments before they develop into major
ones or permanent disabilities
(iv) Imparting health education and physical training to children
(v) Providing special arrangement for the education of handicapped children
(l) Healthful School Environment-Aspects & Points to be Considere.
(i) General environs around the school building should be made healthy and sanitary by ensuring
the following:
(aa) The school should be located in areas free from crowded surroundings, away from bazars,
butcheries, factories, disposal grounds for waste matters, public sanitary areas or enclaves and
such other places which may create a public health nuisance.
(ab) There should be sufficient open space around the buildings.
(ac) Enough playgrounds should be provided. Free muscular activity reduces mental boredom
and strain and provides a stimulus for growth.
(ad) There should not be any mosquito or fly breeding places around the school area.
(ae) Traffic around the area should be restricted to the minimum so as to avoid noise, smoke
and dust nuisance and mainly accidents.
(af) Accidents should be prevented not only on roads around school but also on the playgrounds
and in class rooms. First aid should be taught to all teachers and senior pupils.
(ag) Transport facilities should be provided for conveying school children from home to school
and back. This, incidentally, will reduce the likelihood of road accidents.
(ii) Working conditions in the room should be ideal and conform to the minimum requirements. The
school building, site and equipment are part of the environment in which the child grows and develops. A
healthful school environment therefore is necessary for the best emotional, social and personal health of
the pupils. Schools should also serve as demonstration centres of good sanitation to the community. The
following minimum standards for sanitation of the school and its environs have been suggested in India:
(aa) Location.
The school should normally be centrally situated with proper approach roads and at a fair distance
from busy places and roads, cinema houses, factories, railway tracks and marketplaces. The school
premises should be properly fenced and kept free from all hazards.
(ab) Site.
The site should be on suitable high land and not subject to inundation or dampness and can be

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properly drained. The School Health Committee (1961) had recommended that 10 acres of land
be provided for higher elementary schools and 5 acres for primary schools with an additional one
acre of land per 100 students. In congested areas, the nearest public park or playground should
be made available to the students.
(ac) Structure.
Nursery and secondary schools, as far as possible, be single storied. Exterior walls should have
a minimum thickness of 10 inches and should be heat resistant. Floor should damp-free and
impervious materials and in good repair at all times.
(ad) Classroom.
Verandas’ should be attached to classrooms. No classroom should accommodate more than 40
students. Per capita space for students in a classroom should not be less than 10 sq. ft. Preferably
rooms should be fitted with fans. The rooms should be acoustically non-resonant and perpetration
of noises around should be reduced to the minimum.
(ae) Furniture.
Furniture should suit the age group of students. It is desirable to provide single desks and chairs.
Desks should be of “minus” type. Chairs should be provided with proper back-rests, with facilities
for desk-work.
(af) Doors and Windows.
The windows should be broad with the bottom sill, at a height of 2’-6” from the floor level; combined
door and window area should be at least 25% of the floor space; windows should be placed on
different walls for cross-ventilation; the ventilators should not be less than 2% of the floor area.
(ag) Colour.
Inside colour of the classroom should be white and should be periodically white-washed.
(ah) Lighting.
Classrooms should have sufficient natural light, preferably from the left and should not be from
the front.
(iii) Seating Arrangement.
These should be such as to allow adequate space, permitting freedom of movement for children on the
bench so as to enable them to work without strain. The vertical and horizontal distance between seat
and desk should be such as to permit children to write without raising their shoulders or stooping down
on the desk. The distance of the seat from the floor should be such that the child is not required to
either hang the legs down or raise the knees too high. Feet should rest on the ground while sitting on
the seats without the popliteal space touching the seat i.e. the height of the seat should be an inch
shorter than the leg from knee to the sole. An inclined footrest under the desk is the best device to
achieve this. There should not be any obstructions to knee protruding under the desk. Normally the desk
should be at elbow level when the child is seated. Its horizontal distance from the seat should not be
more than 5 to 7 cm and vertical elevation such, that he is not required to lean forward while writing.
The backrest should be adapted to the normal spinal curvatures. The black board should be at such a
distance that the last student should be able to see the letters distinctly. Provision for keeping books
and stationery should be made in the desk.
(iv) Drinking Water.
It should be procured from an authorized clean source, centrally stored and chlorinated. Water coolers
should be provided with closed lids and water should be sent for bacteriological examination at regular
intervals. Children should fill their water bottles from these water coolers and sharing of water bottles
should be discouraged as it has the inherent danger of spreading upper respiratory tract infections.
(v) Toilets and Urinals.
Enough sanitary urinals should be provided at a central place but as near the classrooms as possible. Normally

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privies and urinals should be provided, one urinal for 60 students and one latrine for 100 students. These
should be kept clean at all times. Habitual use of clean sanitary urinals and latrines serves as a good medium
for inculcating healthy habits in children. Toilet facilities should be separate for boys and girls.
(vi) Midday Meals.
These should be provided for supplementing the food available at home. These should provide about
one third of the total daily requirements of calories, proteins, vitamins ‘A’ and ‘B’ complex and calcium.
They should provide about 20-30 g of fat, 20 g of protein of which one-third should be of animal
origin. Inclusion of milk in the meals will ensure this requirement. The school meals not only aim at
supplementing the nutritional requirement but also at inculcating healthy food and eating habits. In
order to derive the greatest benefit the teacher must be trained in to elements of health and nutrition.
However, in the Armed forces, the school children bring lunch boxes / tiffins comprising of home cooked
food and are provided a clean and hygienic environment to partake this food during tiffin break. Hand-
washing facility with soap and running water should be available to the students. Vendors other than
those approved by the school authorities should not be allowed inside school premises; there should be
a separate room provided for mid-day meals.
(vii) Immunization
Children should be immunized against vaccine preventable diseases as per the National Immunization
Schedule. (Ref chapter XXIII)
(viii) Medical Examination.
All children should be thoroughly examined once a year. Results should be recorded in the health card and
parents should be advised regarding remedial action. There should be a permanent register and health
cards with column for remarks against examination of each system. The card is meant to be transferred to
the institution the child may go after leaving one institution. A monthly, quarterly and annual report must be
sent to the coordinating authority and medical authorities. The special points to look for are given below:
(aa) Eyes for trachoma and vision. Tests for acuity of vision and refraction should be arranged
for children showing defective vision.
(ab) Ears for perforated drums, otitis and power of hearing.
(ac) Teeth for caries, non-alignment and defects like mottling, gingivitis and so on.
(ad) Nose and throat for adenoids and enlarged or infected tonsils.
(ae) Neck for enlarged glands.
(af) Chest for lung involvement or congenital cardiac defects.
(ag) Abdomen for enlarged spleen, liver and any palpable lymph nodes.
(ah) Genitalia for phimosis, undescended testicles or patent inguinal canal or hernia.
(aj) Lower limbs for varicosity, knock-knee, bowlegs, flat feet or other skeletal and muscular
defects or deformities.
(ak) Skin for ring worm, scabies and any depigmented patches.
(al) Weight and height for normality.
(am) General examination for abnormal curvatures / postures, infections, nutrition and so on.
(ix) Minor Ailment Clinics.
These should be provided and children should be encouraged to visit them whenever they feel unwell.
It not only helps to reduce minor ailments from developing into major ailments or disabilities but also
helps to detect any other major ailments or disabilities undetected in the incipient or early stages.
(x) Referral Facilities.
Facilities for reference of children to a specialist for investigation of ailments and their treatment or
hospitalization should be ensured.

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(xi) Physical Training.

It is a major item of a school curriculum and should be insisted upon. A few teachers should be trained
in physical training or special instructors should be appointed.
(xii) Health Education.
This should be part of the curriculum. It can be imparted either as an integrated subject or a non-
integrated subject. Health education is also incidentally acquired by children through the experiences
and observation of healthy school life as described above.
(xiii) School health Committee.
It should consist of the Headmaster as the Chairman and class teacher, health educator, school nurse,
physical training instructor and the school medical officer as members. They should meet once a month
or a quarter. A few parents should also be invited to attend these health committee meetings.
(xiv) Parents Committee.
Setting up of a parents committee is more helpful to improve the health of children as this will facilitate
active participation of parents in the school health programme.

Suggested Reading.
1. AO 165/79 - Station Health Officer (SHO) duties and different level health responsibilities.
2. AO 9/2020 - Immunization.
3. Regulation for Medical Services of the Armed Forces - 2010.
n

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Chapter
XXII
MEDICAL EXAMINATION AND BOARDS: RELEVANT
ORDERS AND POLICIES
22.1 Introduction.
Medical examination and boards are an integral part of the health care system of the Armed Forces. The objective
of medical examination is to detect disease at an early stage when it may be latent (without producing any ill
effect) and institute timely preventive and curative measures promoting positive health. The examination is to
be carried out by the Authorised Medical Attendant (AMA) at the dependent service hospital / med echelon. The
various types of examinations and boards to which an individual is subjected to are as given below:
(a) Initial Medical Examination
(b) Annual Medical Examination (AME)
(c) Periodic Medical Examination (PME)
(d) Classification / Re-classification Medical Board
(e) Release Medical Examination (RME) / Release Medical Board (RMB)
(f) Invalidment Medical Board (IMB, if applicable)
(g) Re-assessment Medical Board (RAMB) (if applicable)
(h) Appeal Medical Boards- First and Second (if applicable)
(j) Review Board (if applicable)
Medical examination and boards in the Armed Forces for serving personnel is guided by the following Orders:
(a) Army: AO 9 / 2011 for officers and AO 3 / 2001 for JCOs / OR
(b) Navy: Naval Order 7 / 2014 and 14 / 2014 for both officers and JCOs / OR
(c) Air Force: IAP 4303 (6th edition) for both officers and JCOs / OR
The conduct of IMB in Army is guided by AO 513 / 71. RME / RMB / RAMB is conducted as per the provisions
contained in Guide to Medical Officers (GMO 1955, 1980, 2002, Ch VI and VII amendment in 2008 and 2023)
and as amended from time to time, Entitlement Rules 2008 and AO 3 / 89, both as amended in 2023.

22.2 Initial Medical Examination.

Initial medical examination is conducted by specialists in Med, Surg, ENT, Eye, Gynae (for women entry) and Dental on
AFMSF-2 and is approved by a Board of Officers. This examination is conducted for the following:
(a) Various entries (commissioning / enrolment) into the Armed Forces Institutes (AFMC, schools for probationer
Nurses, recruits), Training Academies (NDA, IMA, OTA) and Military Schools including Women candidates and
Territorial Army. Candidates are examined against the reference medical standards requirements of Army, Navy
or Air Force. The general criteria of selection of individuals in the Armed Forces is that the individual should be
able to withstand rigorous physical and mental stress of service in all types of terrains, climatic and geographical
conditions.
(b) Officers seeking extension of re-employment at the age of 56 years.
(c) Short Service Commisioned (SSC) officers applying for permanent commission.

22.3 Annual Medical Examination (AME).

(a) During AME, complete clinical examination and investigations are carried out by the Authorised Medical

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Attendant (AMA). The details and findings of examination including medical advice, if any, are entered in the
Health Record Card (HRC) (two copies-original and duplicate) for officers below 35 years of age, while for those
above 35 years, AFMSF - 3B (ver 2002) is filled up. In addition to HRC, for JCOs / OR, AME findings are entered
in original and duplicate HRC copies only. In Navy and Air Force AME findings are filled in AFMSF-3B only.
(b) Four copies of AFMSF-3B are prepared for officers in Army. The distribution of AFMSF-3B for officers
depending on their arm / service includes- one copy to Military Secretary’s Branch / Personnel branch / DGMS-
1B / DG DS / DGMS-4 / GS Branch / ADG TA; one copy to AG’s Branch / MP-5 & 6 / MPRS (O) / GS Branch / ADG
TA; one copy to the officer concerned and one copy to the officer’s unit / Formation. The unit copy is transferred
to next unit on posting out of officer.
(c) In case during the AME, the AMA finds that the individual requires specialized investigations / treatment, a
referral is made to the nearest hospital where such medical facilities are available. The AMA will suitably advise
the individual, if a minor disability is noted during medical examination and record it on AFMSF-3B / HRC.
(d) Medical classification recorded in AME immediately preceding the ACR remains valid unless, due to disease
or injury during the interim period, it has been changed by an appropriate Medical Categorisation Board.
(e) The venue and investigations to be conducted during AME of serving personnel in Army is tabulated in
Table 22.1:
Table 22.1 : Venue, Investigations and Schedule of AME in Army
Officers JCOs  /   OR*
AME by AMA: Upto 25 years (completed), 26+, 27+, AME for JCOs: yearly two months before the initiation of
28+, 29+, 31+, 32+, 33+, 34+, 36+, 38+, 39+, ACR and in the months of Mar to Jun for those individuals
41+, 43+, 44+, 46+, 48+ for whom there is no ACR
Lab inv:  Hb, TLC, DLC, Urine RE & specific gravity AME for ORs*: 26th, 31st, then every 5 years
AME at nearest MH: 25+, 30+, 37+, 42+, 47+, 49+, 51+, Lab inv: Urine sugar & proteins
52+, 54+, 55+, 56+, 58+, 59+, 60+, 61+
Lab inv: Hb, TLC, DLC, Urine RE & specific gravity, Blood * For ORs: only AME is applicable
sugar F & PP, Resting ECG

AME Schedule for Officers

(a) AME upto 45 yrs age (completed): 01 Jan–30 Jun (a) AME before 54 years: carried out by MO deputed
(Last date of completion: 30 Jun) by CO, hospital
(b) AME 45 yrs and one day and beyond: 01 Jul–31 (b) AME for 54 years and beyond: carried out by
Dec (Last date of completion: 31 Dec) Medical Spl deputed by CO, hospital
(f) In Navy, the age-wise schedule of AME for Officers and Sailors is as mentioned in Table 22.2:
Table 22.2 : Age-wise Schedule of AME for Officers and Sailors
Age Conducted by  /   at Investigations
AME upto 29 yrs, 30, 31, 32, 33, AME by AMA Hb, TLC, DLC, Urine RE  /  ME
34, 36, 37, 38, 39, 41, 42, 43,
AMA for Flag officers: Medical Spl Addl tests: Blood sugar F & PP, resting
44, 46, 47, 48, 49, 51, 52, 53,
designated by CO of nearest service ECG are carried out during AME at 30,
54, 56, 57, 59 yrs completed
hospital 51, 52, 54, 56, 57, 59 yrs
Addl tests: Blood sugar F &PP, resting
ECG, Urea, Creatinine, Cholesterol  /  Lipid
profile (if cholesterol > 200 mg  /  dl), Chest
X Ray PA view are carried out during AME
at 53 yrs
Note. Timing for AME / PME for officers mentioned vide IHQ MoD (Navy) letter MH / 1301 / Policy dt 25 Jun 18 and for
sailors vide No. 14 / 2014 is given below:

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 MEDICAL EXAMINATION AND BOARDS: RELEVANT ORDERS AND POLICIES

S. No. Rank Dates of AME / PME

(a) Flag Officers 01 Apr–30 Apr
(b) Cmde and Capt 01 Oct–30 Nov
(c) Capt(TS) 01 Oct–30 Nov
(d) Cdr(> 15years of service) 01 Jan–28 Feb
(e) Cdr(< 15years of service) 01 Jan–28 Feb
(f) Lt Cdr 01 May–30 Jun
(g) Lt and Sub Lt 01 Jul–31 Aug
(h) SD list officers & Reemployed officers 01 Jul–31 Aug

S. No. Rank Dates of AME / PME

(j) Hon SLt / Lt / MCPOs 01 Jan to 28 Feb
(k) CPOs 01 Apr to 30 Apr
(l) POs 01 Jun to 31 Jul
(m) Leadings 01 Aug to 30 Sep
(n) Sea I & II / Equivalent and below 01 Sep to 31 Oct
This amended schedule is effective from 01st Jan 2019.
(g) In Air Force, only AME is held. No PME is carried out. The schedule and investigations carried out during
AME are as mentioned in Table 22.3:
Table 22.3 : Timing of AME
Branch Schedule Validity of AME
OFFICERS
Medical / Dental branch
Wg Cdr and above 01 Nov–31 Dec Till 31 Dec next year
Sqn Ldr and below 01 Apr–31 May Till 31 May next year
Other branches
Fg Offr / Flt Lt 01 Oct–30 Nov Till 30 Nov next year
Sqn Ldr 01 Feb–31 Mar Till 31 Mar next year
Wg Cdr / Gp Capt (TS) 01 May–30 Jun Till 30 Jun next year
Gp Capt (S) / Air Cmde 01 Aug–30 Sep Till 30 Sep next year
AVM / Air Mshl 01 Oct–30 Nov Till 30 Nov next year
WARRANT RANKS, SNCOS, PERSONNEL > 40 YRS AGE
Warrant ranks 01 Aug–31 Oct Till 31 Oct next year
SNCOs JWO (AUP) 01 May–31 Jul Till 31 Jul next year
Cpl and below 01 Jan–30 Apr Till 30 Apr next year
NCs(E) 01 Oct–30 Nov Till 30 Nov next year

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(h) Investigations During AME.

(aa) At SMC Level.
Complete blood count, Urine RE / ME, ECG, Chest X Ray, Additional tests as indicated / considered appropriate
by Medical Officer
(ab) At Boarding Centre.
Hb, TLC, DLC, Urine RE / ME, ECG, Chest X Ray, Blood sugar level-F / PP, HbA1c, Lipid profile, Serum creatinine,
Serum Urea, Pure Tone Audiometry (Only for aircrew, for ground duties only if indicated), Intraocular Pressure
in all individuals, USG abdomen, LFT with liver enzymes, Additional tests as indicated / considered appropriate
by Medical Officer

22.4 Periodic Medical Examination (PME) / Periodic Medical Board (PMB).

(a) The aim of carrying out PME is to ensure an individual is periodically examined in detail by all relevant
specialists for early detection and cure of any disease. The individuals are required to be examined by all the
specialists - Medical Specialist, Surgical specialist including Dental surgeon, Eye specialist and ENT specialist.
The women officers are additionally examined by the Gynaecologist.
(b) The conduct of PME is governed by the same orders as AME in Army and Navy. No PME is carried out in
Air Force.
(c) The PMB as well as all medical examination / boards are required to be held at the duty station of the
individual, if a service hospital with requisite facilities is located at the station. Otherwise, it will be carried out
at the nearest station where such facilities exist.
(d) Age-wise schedule of PME in Army and Navy is as tabulated below:
Table 22.4 : Age-wise Schedule of PME in Army and Navy
Services Age Venue Investigations
Officers: 36th, 41st, 46th, Dependent AFMS hospital Hb, TLC, DLC, Urine RE & specific gravity,
51st, 54th, 58th years Blood sugar level-F / PPP, Lipid profile,
Serum creatinine, Serum Uric acid, resting
ECG and Chest X Ray PA view.

Army
JCOs: 41st year age (on -do- Lady officers are examined by
completion of 40 years of Gynaecologist and additional test- USG
age) or within 1 year of Abdomen & Pelvis is carried out.
promotion to Nb Sub rank, The investigations in JCOs are same as
whichever is earlier officers except that Blood Urea is carried
out in place of Serum Uric acid.
35, 40, 45, 50, 55, 58, Nearest Service Hospital Hb, TLC, DLC, Urine RE / ME, Blood sugar
60, 61, 62 yrs completed F & PP, resting ECG, Urea, Creatinine,
Cholesterol / Lipid profile (if cholesterol>
200 mg / dl), Chest X Ray PA view
President Medical Board Lady officers are examined by
Navy for PME of Flag Officers: Gynaecologist. Addl tests: USG abdomen
CO nearest service hospital & Pelvis, PAP smear
Submarine and
diving / aircrew officers:
Marine medicine / Aviation
Medicine specialists are
members of PME
Air Force No PME is carried out

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(e) The PME findings are recorded in AFMSF-3A and the individual is brought before a medical board. Four
copies of AFMSF-3A are prepared for officers and three copies for JCOs.
(i) The distribution of AFMSF-3A for officers depending on the arms and service include- one copy to
Military Secretary’s Branch / Personnel branch / DGMS-1B / DG DS / DGMS-4 / GS Branch / ADG TA; one copy
to AG’s Branch / MP-5 & 6 / MPRS (O) / GS Branch / ADG TA; one copy to the officer concerned and one
copy to the officer’s unit / Formation. The unit copy is transferred to next unit on posting out of officer.
(ii) The distribution of AFMSF-3A for JCOs include- Record Office, unit concerned and Field service
documents.
(f) The approving and perusing authorities for PME of Army officers and JCOs is as tabulated in Table 22.5:
Table 22.5 : Approving and Perusing Authorities for PME of Army Officers and JCOs
PME documents Approving authority Perusing authority
Officers outside Army HQ
Officers upto the rank of Brig CO / Comdt Hosp Next higher HQ (Med)

Maj Gen and above (less those at Comd MG Med, Comd ADGMS (IS, H & PS)
HQ)
Maj Gen and above posted at Comd HQ ADGMS (IS, H & PS) DGMS (Army)
Officers posted to AHQ / AHQ units / Inter Service Organisations  / MoD / NDC or on deputation with Civil
Offices / PSU in Delhi and other places
Officers upto the rank of Brig Comdt AFC ADGMS (IS, H & PS)
Officers in the rank of Maj Gen and above ADGMS (IS, H & PS) DGMS (Army)
PME of CO / Comdt hospital Col Med, Div / Brig Med Brig Med Corps / MG Med
Corps / MG Med Area / Comd Area / Comd
PME of Comdt, CH and AH (R & R) MG Med Comd ADGMS (IS, H & PS)
PME of Army personnel held at Naval Brig Med Corps / MG Med Area MG Med Comd
and Air Force Hospital
PME of JCOs Col Med Div / Brig Med –
Corps / Area / Dy Comdt
(g) Officers who are abroad during the schedule of PMB, will undergo the same within three months of arrival
in India and no sanction will be required for the same.
(h) It is the responsibility of the individual as well as the CO of the unit to which he / she is posted to ensure
that the PMB is held on time when due. However, if for any reason the individual fails to undergo PME during
scheduled time, he / she will take up a case for delayed PME. Sanction for delayed PME is provided based on
the merits of the case and any deliberate omissions are administratively dealt with.
(j) In Navy approving authority is CMO Command and perusing authority is Office of DGMS (Navy).

22.5 Medical Boards.

There are various types of medical boards.
(a) Classification / Re-classification Medical Boards for all ranks of the Armed Forces, who are to be placed in
lower medical category.
(b) Discharge prior to completion of terms of engagement: Invaliding Medical Boards (IMB) for all ranks of the
Armed Forces considered unfit for further service or claiming a disability pension or gratuity.
(c) Superannuation / release / retirement / discharge on completion of terms of engagement:
(i) Release Medical Examination (RME) for release of individuals in medical classification SHAPE-1

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(ii) Release Medical Board (RMB) for all ranks of the Armed Forces permanently placed in a low medical
category who are proposed to be discharged, because no suitable employment compatible with their low
medical category can be found for them.
(d) Sick leave medical board for officers / cadets of the Armed Forces recommended sick leave and on return
there-from.
(e) Re-assessment Medical Board (RAMB) for all pensioners and ex-service personnel for assessment
/ reassessment of the percentage of their disability in case Release Medical Board assessment has not been
done for life. Re-survey Medical Board (RSMB) has been discontinued and RAMB is being held in place of RSMB.
(f) First and Second appeal medical board, Review Board are held after release of individual from service in
certain circumstances only.

22.6 Medical Classification.

The aim of medical classification is:
(a) To apprise Commanders about health status of its troops at any point of time.
(b) To assist Commanders to utilise precious trained manpower under them adequately by suitably employing
the troops as per advice of the medical authorities based on the disease / disability of the individuals.
(c) To ensure that the individual is also provided with adequate sheltered appointment so that his / her
disease / disability does not worsen.
(d) Medical classification system in armed forces is as given below in Table 22.6 to 22.11.
Table 22.6 : Medical Classification System in Armed Forces
Service Medical Classification System
SHAPE: Organ system based
Army
COPE: Employability restrictions for officers
‘S’ : Fitness for sailing
Navy
‘A’ : Physical fitness for duties ashore
‘A’ : Fitness for flying
Air Force
‘G’ : Physical fitness for ground duties
Table 22.7 : Equivalence of Medical Categorisation system in Armed Forces
Army Air Force Navy
SHAPE-1A G1 S1A1
SHAPE-1B G1 / G2 S2A2
SHAPE-2 G2 / G3 S2A2
SHAPE-3 G4 S3A2
SHAPE-4 Gt S4A4
SHAPE-5 Gp S5A5
Table 22.9 : Medical Classification System: Navy (Auth: Para 22 of NO 7 / 2014)
S. No. Classification Definitions
1. S1 A1 Fit for sea and ashore service without any restrictions.
2. S2 A2 Fit for sea and ashore service with restrictions.
3. S3 A3 Unfit for sea service but fit for ashore service with restrictions.
4. S4 A4 Sick leave / hospital
5. S5 A5 Unfit for service

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Table 22.8 : Medical Classification System: Air Force (Auth: IAP 4303 6th Ed)
S. Medical
Functional Capacity Employability
No. Category
Air Categories

1. A1 Physically fit and capable of enduring physical Fit for full flying duties in any type of
and mental stress of military flying in any part aircraft commensurate with anthropometric
of the world. measurements.

2. A2 Physically fit and capable of enduring physical (i) Fit for flying duties with minor
and mental stress of military flying. May have impairment well compensated by flying
minor impairment in hearing, visual acuity or experience. May use prescription spectacles
functional capacity not interfering with flying. for correction of vision.
(ii) Requires periodic medical follow up as
advised.

3. A3 Functional defect / disability controlled and (i) Fit for flying duties with restrictions
adequately compensated for restricted flying which may be type of mission (including
duties only. Possesses hearing and visual instructional duties), type of AC, altitude
acuity commensurate with restricted flying. restrictions, levels of G stress or any other
Must be psychologically stable. May have restriction as specified by the medical board.
suffered from disease / injuries or recovered Unfit to fly as Captain of the aircraft, fit to
from operative procedures, which are now fly only as copilot of multicrew aircraft with
well stabilized to a degree which will not other Qualified Experienced Pilot.
interfere with safe operation of the aircraft.

4. A4 Aircrew with functional capacity impaired to Unfit to fly as an aircrew. Fit to fly as a
the extent that it interferes with flying duties passenger only.
as an aircrew. Ground duty personnel who
have not been assessed for fitness as aircrew
with functional capacity not interfering with
flying as a passenger.

5. At Functional capacity not compatible with any Temporarily unfit for flying duties.
form of military flying duties.

6. Ap Has gross limitation in physical / mental Permanently unfit for flying duties.
capacity without possibility of improvement in
reasonable time.

Ground Categories

7. G1 Physically fit and capable of enduring Fit for all trade / branch duties and general
physical and mental stress related to military duties at all times of the day and
service / operational requirements for night in any part of the world.
prolonged periods.

8. G2 Physically fit and possesses adequate Fit for all trade / branch duties and general
functional capacity, capable of enduring military duties at all times of the day and
physical and mental stress related to night in any part of the world. Requires
service / operational requirements. May have periodic medical follow up as advised.
disease process which is well stabilized
without any functional damage to organs.
Treatment if any is well tolerated and
without any side effects. Requires periodic
monitoring / follow up.

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S. Medical
Functional Capacity Employability
No. Category

9. G3 Possesses reasonable degree of physical (i) Fit for all trade / branch duties at all
fitness, visual acuity, hearing and times of the day and night.
psychological stability as to withstand stress
related to service / operational requirements. Restricted from certain general military
Has disease process which is stable / duties by the medical board as per the
improving without any ongoing functional clinical condition.
damage to organs. Gradually recovering
from any surgical procedure without ongoing
complications.

10. G4 Has significant /  major disablement with (i) Needs assistance / supervision to
limited / restricted physical capacity and perform trade / branch duties.
stamina. Capable of undergoing limited
physical exertion. Suffered from disease /  Exempted from general military duties
injury which is not fully stabilized. Recovery by the medical board as per the clinical
from surgical procedure, if any, is incomplete. condition.

11. Gt Temporary incapacitated for any form of Temporarily unfit for any form of service
military duty due to sickness /  injury. duties.

12. Gp Has gross limitations in physical / mental Permanently unfit for any form of service
capacity without possibility of improvement in duties.
reasonable time.

Medical Classification System: Army : For Officers (Auth: AO 9 / 2011)

The medical classification system in Army is based on functional capacity of individual to perform military duties with a
view to enable better cadre management especially of LMC individuals as regard their treatment, employment, promotion
and financial emoluments. The SHAPE classification is based on fitness includes following five factors:
(a) ‘S’ Factors (Psychological).
This factor denotes psychological aspect and covers personality, mental acuity, emotional stability and psychiatric
disease.
(b) ‘H’ Factor (Hearing).
This factor covers auditory ability to hear spoken voice or audible signals often against considerable background
noise and its important in certain trades and military situations.
(c) ‘A’ Factor (Appendages).
This covers the functional efficiency of upper and lower limbs (including amputees, loss of fingers and toes),
shoulder girdle, pelvic girdle and associated joints and muscles.
(d) ‘P’ Factor (Physical Capacity).
This covers general physical capacity or stamina as may be affected by medical / surgical conditions not covered
by other factors.
(e) ‘E’ Factor (Eyesight).
This covers visual acuity and good eye sight.
Medical classification is further divided into 5 grades based on the functional capability of the individual. The grades
are as under:

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Table 22.10 : Grades Based on the Functional Capability

Grade Functional capacity
1A Fit for all duties anywhere
1B Fit for all duties anywhere, under medical observation and has no employability restrictions.
2 Fit for all duties but may have limitations as to type of duties and areas of employability.
Except ‘S’ factors, fit for routine or sedentary duties but may have limitations of employability as spelt out
3
in the Employment Management Index
4 Temporarily unfit for Military duties on account of hospitalization / sick leave
5 Permanently unfit for Military duties

Table 22.11 : SHAPE Classification System for Medical Categories for Officers
Grade Functional Capacity
S: Psychological
Can withstand severe mental stress. May have fully recovered from a psychological condition with no
S1
likelihood of further breakdown
Can withstand moderate stress. Had suffered from psychoneurosis. Now fully stabilised. Likelihood of
S2
breakdown under severe mental stress cannot be ruled out
Has limited tolerance to stress. Has recently recovered from psychoneurosis or toxic confusional states or
S3 acute psychotic reaction of temporary nature as a result of external causes unrelated to alcohol or drug
addiction. LMC S3 cannot be awarded on permanent basis and can be awarded only on temporary basis
S4 On sick leave / in hospital
S5 Mentally unstable on account of psychological / psychiatric disorder / psychopathic personality
H: Hearing
Has excellent hearing in both ears. With back to the examiner, can hear Forced Whisper (FW) at a
distance of 6 m with each ear separately. Pure Tone Average (PTA) for each ear not more than 25 dB
H1
with no individual level greater than 30 dB at the speech frequencies. Not over 45 dB at 4000 Hz.
Diseases which do not affect hearing e.g. sinusitis, tonsillitis are classified under ‘P’ factor
Has normal hearing in one ear with impaired acuity in other ear or partial impairment in both ears i.e.
with back to the examiner, can hear FW at 6 m with one ear and Conversational Voice (CV) at 1.2 m or
less with other ear or can hear CV at 3 m with both ears. In unilateral hearing loss, PTA for better ear
H2 less than 25 dB with no individual level greater than 30 dB at the speech frequencies. Not over 45 dB
at 4000 Hz in better ear. Affected ear may be completely deaf. In bilateral hearing loss, PTA for each ear
not more than 30 dB with no individual level greater than 35 dB in the speech frequencies and level not
more than 55 dB at 4000 Hz
Has hearing loss in both ears with hearing below H2 standard i.e. with back to the examiner, can only
H3 hear CV at less than 3 m with both ears. Bilateral hearing loss with PTA in both ears 35 dB hearing loss
or worse measured without hearing aid
H4 On sick leave / in hospital
Hearing acuity below H3 standard. Patient unable to hear CV at 100 cm and / or speech discrimination
H5 score < 50% with hearing aid / implantable otological device. Patient should be evaluated by Senior
Advisor ENT before placement in H5

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Grade Functional Capacity

A: Appendages
Has full functional capacity though may be having minor impairments like the following:

A1 (i) Loss or disability of terminal phalanx of any one of 5th, 4th and 3rd fingers
(ii) Loss of terminal phalanges of 3rd and 4th fingers of left hand in a right-handed officer provided
he / she has good grip in the left hand also
Has moderate defects of function of upper limbs like:
A2
(i) Loss / disability / disease of index finger of dominant hand
(U)
(ii) Loss of terminal 2 phalanges of 3rd and 4th finger of right hand in left-handed officer
(iii) Disease / disability in left hand in right-handed officer
Defect / disease or disability of moderate nature in lower limbs, is capable of marching upto 8 Km and
A2 (L)
standing for 2 hrs
A3 Has major disability or disease in one arm, like complete loss of hand including fingers or amputation
(U) through wrist or metacarpal or disease / disability of shoulder on one side
Has disease or disability of lower limb including pelvic girdle. Should be able to walk upto 5 Km at his
A3 (L)
own pace
A4 On sick leave / in hospital
A5 Severe derangement of functional efficiency
P: Physical capacity
P1 Has fully functional capacity and physical stamina but may have minor impairments
Has moderate physical capacity and stamina. Suffered from constitutional / metabolic / infective
P2
disease / operative procedures but now well stabilized
P3 Has minor disablement with limited physical capacity and stamina
P4 On sick leave / in hospital
P5 Gross limitations in physical capacity and stamina
E: Eye
Corrected vision with conventional spectacles Better eye Worse eye
(Myopia or manifest Hypermetropia not to exceed
7 diopters) Diseases of eye which do not affect (i) 6/6 6 / 36
vision should be classified under ‘P’ factor or
E1
(ii) 6/9 6 / 24
or
(iii) 6 / 12 6 / 12

Moderate eyesight corrected vision with

(ii) 6/9 6 / 60
E2 conventional spectacles (Myopia or manifest
Hypermetropia not to exceed 3.5 diopters) (or less if other eye is aphakic or absent)

Adequate eyesight for ordinary purpose. Corrected (i) 6 / 24 6 / 36

E3 vision with conventional spectacles or contact or
lenses (ii) 6 / 18 other eye completely blind or absent

E4 On sick leave / in hospital

E5 Visual acuity below E3 grade

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22.7 Endorsement of Low Medical Category (LMC): Functional Capacity and Disability Profile.
LMC is mentioned in two parts:
(a) Functional Capacity.
(i) Includes acronym SHAPE
(ii) Numeral denoting lowest functional capacity recommended in any of SHAPE factors
(iii) Suffix letter
x – Suffix used if officer is placed in LMC for a single disease
y – Suffix used if officer is placed in LMC for two separate disease entities. Complications classified
separately in International Classification of Diseases (ICD) are mentioned as separate disability
z – Suffix used if officer is placed in LMC for three or more disease entities
(b) Disability Profile.
(i) List of disabilities
(ii) Factors under which LMC is awarded is mentioned in front of every disability
In case one or more factors of the medical classification is required to be lowered temporarily on account of
disablement, the overall grade assessed should be the lowest one from which no further deterioration is expected.
Under disability profile, period of permanent classification will not be mentioned and will be presumed to be for
2 years unless specific remark is made by medical board for an early review to consider upgradation. However,
endorsement of temporary grading of factor (s) in profile will be made against the numeral, to which it refers and
will consist of capital letter ‘T’ together with the figure to indicate week for which temporary grading has been
recommended / has been in operation such as ‘E2 (T-24): in the case of first grading.’ For denoting a permanent
grading, only requisite numeral will be written against the factor like S2, H2 etc. Certain examples of LMC and
disability profile are given as under:
Table 22.12 : Examples of LMC and Disability Profile
Examples Medical Classification Disability Profile
Normal healthy officer SHAPE-1 Nil
Type 2 Diabetes Mellitus on oral SHAPE-2x P2 (T-24)
hypoglycemic agents
Hypertension without target organ damage SHAPE-3y P2 for Hypertension
and Acute Myocardial Infarction
P3 (T-24) for Acute
Myocardial Infarction
Hypertension without target organ damage SHAPE-3z P2 for Hypertension
with Fracture Femur old operated, Bronchial
A2 for Fracture Femur old operated
Asthma and Viral Hepatitis
P2 for Bronchial Asthma
P3 (T-24) for Viral Hepatitis
Multiple Sclerosis with Bowel Incontinence SHAPE-3z P2 for Multiple Sclerosis
and Foot Drop
P3 for Bowel Incontinence
A3 for Foot Drop

22.8 Employability of Low Medical Classification Officers.

Posting / job assignment of Low Medical Classification officers is guided by a matrix based on COPE coding as given
by medical board, specifying employability restrictions. The COPE coding matrix is as follows:

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Table 22.13 : COPE Coding Matrix

COPE Coding Limitations
Climate C0 Fit for all climate and terrains
& terrain
C1 Fit for all climates and terrains, less altitudes above 15,000 feet
restrictions (C)
C2 Unfit for a specific climate or terrain:
(a) High altitude (9,000 feet to 15,000 feet)
(b) Extremes of cold or hot climate (Board to specify including period) e.g. places with
subzero temperature for more than three months in a year
(c) Others (Board to specify)
Degree of O0 No medical observation required
medical
Observation O1 To be under surveillance by nearest MO (to be posted to a station where MO is available)
required (O) O2 (a) To be under periodic surveillance by basic specialists at MH / civil hospital where such
facility is available
(b) To be under periodic surveillance by a particular superspecialist at nearest MH / civil
hospital (Board to specify and justify)
Physical P0 Fit for all activity
capability
P1 Fit for all activities, less those involving prolonged extreme exertion
limitations (P)
P2 Unfit for extreme exertion and competitive sports. Fit only for sedentary or desk job due
to:
(a) General or systemic disease
(b) Limb dysfunction (Board to specify)
Exclusive E0 No exclusive limitations
limitations as
E1 Medical advise the nature of which does not interfere with fitness to serve in any area or
per disease
perform any duty the officer has been performing or is expected to undertake (Board to
(E)
specify from the examples listed below)
E2 Medical advise specific to a disease which will interfere with fitness to serve in any area
or perform any duty the officer has been performing or is expected to undertake (Board to
specify from the examples listed below)
Examples of Medical Advice.
(a) Unfit to drive a vehicle (Visual defects or Epilepsy)
(b) Unfit to work near running machinery (Epilepsy)
(c) Unfit to command independent body of troops (Psychotic diseases)
(d) Unfit for handling of fire arms, handle cash / independent charge, or posting to isolated location (Psychiatric
diseases)
(e) Dietary restrictions for specific disease (Hypercholesterolemia / Obesity / Gout)
(f) Advised not to wear shoes or shave beard (skin diseases)
(g) Advised to wear braces / collar / plaster as advised by Orthopaedics surgeon / other / specialist
(h) Not to be utilized in duties involving good binaural hearing (due to impairment of localization and
detection of friend or foe sounds, scouting and other combat duties, forward listening post duties, and use of
radio / telephone etc for unilateral hearing loss)
(j) Not to be exposed to loud noise or weapon firing without use of properly fitted hearing protection (For
unilateral hearing loss)
(k) Any other (specify)

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Provision for composite COPE coding exists whereby higher COPE coding of the two disabilities is enfaced on the medical
board proceedings even if the medical board for different disabilities is held separately. Guidelines to be implemented
while recommending employability restrictions are as under:
(a) Specialist and medical board will not recommend any restrictions on posting to Field or CI Ops areas.
(b) All officers in LMC need not be attended to by specialists / superspecialists on a monthly basis. Frequency
of review may be specified by the medical board, keeping in view individual requirement of each case and term
‘to be reviewed periodically’ should not be used. This should be substituted by monthly / quarterly / six monthly
review as medically indicated.
(c) ‘Unfit for extreme exertion’ would translate to unfit for BPET / PPT.
(d) Exclusive restrictions to be imposed for disability in factor ‘E’ (i.e. exclusive restrictions) in a disease specific
manner rather than a broad based manner.

22.9 SHAPE Classification System and Employability Restrictions: Jcos / OR (Army).

The SHAPE classification system and employability restrictions for JCOs / OR is given as under: (Auth: AO 3 / 2001)
Table 22.14 : SHAPE Classification System and Employability Restrictions for JCOs / OR
Functional Capacity Employability Restrictions
Category 1. An individual who is fit in all respects for general service in any area / theatre of war, will be placed in
medical category ‘1’, even though he may have some minor (remediable) disability
(a) Psychological (S1). Can withstand severe mental stress, may have recovered Nil restrictions
from a psychological condition with no likelihood of further break down
(b) Hearing (H1). Has excellent hearing in both ears with back to the examiner
can hear FW at the distance of 6m with each ear separately
(c) Appendages (A1). Has full functional capacity, though may be having minor
impairments like the following:
(i) Loss of terminal phalanx of anyone of 5th, 4th and 3rd fingers
(ii) Loss of terminal phalanges of 3rd and 4th fingers of left hand in a right
handed person, provided he has a good grip in the left hand also
(d) Physical (P1). Has full functional capacity and physical stamina but may
have minor impairments
(e) Eye sight (E1): Good eye sight. May have corrected vision with conventional
spectacles (Myopia or Manifest Hypermetropia not to exceed 7 diopters)
Better eye Worse eye
(i) 6/6 or 6 / 36
(ii) 6/9 or 6 / 24
(iii) 6 / 12 or 6 / 12

Category 2. An individual will be placed in medical category ‘2’, who has only a moderate degree of disability,
which does not interfere with the performance of normal work
(a) Psychological (S2). Can withstand moderate stress. Has mild psychological (a) Fit for normal duties
disturbances of temporary nature. Likelihood of break down under severe mental anywhere, including overseas
stress cannot be ruled out except for actual / close combat.
May have restrictions for the
following:
Duties involving independent
posts at isolated location

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Functional Capacity Employability Restrictions

(b) Not fit for duties at altitude
above 2,500 m and extreme
cold areas
(c) Not fit for duties at hilly
terrain, altitude above 2,500 m
and extreme cold areas
(d) Hearing (H2). With his back to the examiner, can hear CV at a distance of Not fit for patrol / sentry duties
6 m with one ear and 3 m with the other. (The ear not being tested should be which demand keen hearing
closed by an assistant) acuity of both ears
(e) Appendages(A2) Not fit for duties at altitude
(i) Upper limb (A2U). Has slight defects of upper limbs but these in no above 2,500 m and extreme
way incapacitate him from making normal movements of daily work cold areas

(ii) Lower limb (A2L). Has slight defects of locomotion but these do not Not fit for duties at hilly terrain,
incapacitate him from normal movements of daily work altitude above 2,500 m and
extreme cold areas
(f) Physical capacity (P2). Has only mild degree of disability which does not Not fit for duties at altitude
interfere with the performance of normal work. Suffered from constitutional above 2,500 m, extreme cold
/ metabolic / infective diseases / operative procedures, but now well stabilized. areas and hilly terrain
Can undergo exertion not involving severe strain
(g) Eye sight (E2). Can see for ordinary purposes in the fighting area No restriction
(sub shooting standard) but may be called upon to fight under exceptional
circumstances.
Visual standards are as given below:
(i) Left eye 6 / 36 and right eye 6 / 12
or
(ii) 6 / 18 each eye
These visual standards are applicable to right-handed persons and should be
reversed in left-handed person.
One eyed person. Those with normal vision in right eye without correction
Aphakia. Unilateral - with correction 6 / 12 or better, other eye 6 / 9 or better
with correction - medical category ‘2’
Category 3. Individuals whose defects / disabilities are of a higher degree than those acceptable for category ‘2’,
but who are considered fit for duties in Unit / Formations located in Line of Control areas and Unit / Formation HQs
in operational areas (provided such duties do not involve severe stress and strain) will be placed in category ‘3’
(a) Psychological (S3). Has limited tolerance to stress. Has recently recovered Fit for routine duties (except
from acute psychoneurosis and toxic confusional states and acute psychotic sentry duties) under supervision
reaction of temporary nature as a result of external causes unrelated to alcohol in areas where hospital facilities
or drug addiction JCOs / OR can be placed in category S ‘3’ on temporary basis exist nearby Not fit for duties at
for a maximum period of one year only. He cannot be placed in category S altitude above 2,500 m
‘3’ (Permanent). If at the end of one year of S ‘3’ temporary, an individual’s Not fit for duties involving
medical category cannot be upgraded, he will be downgraded to medical independent responsible task
category S ‘5’ and invalided out (e.g. i / c kote, drawing money
from bank and independent
command)
(b) Hearing (H3). Is partially deaf in both the ears Fit for routine duties anywhere
viz with his back to examiner, can hear a CV at a not requiring good hearing
distance of 3 m with both ears standards.
Not fit for guard / sentry duties

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Functional Capacity Employability Restrictions

(c) Appendages (A3). Not fit for combat duties but
(i) Upper limb (A3U). Has major disability or disease in one area like fit for routine duties anywhere
complete loss of one hand including fingers or amputation through wrist or except in
through metacarpal or a disease / disability of shoulder on one side extreme cold climates. Fit for
sedentary duties only. Not fit for
(ii) Lower limb (A3L). Has disease or disability above knee on one side,
duties at hilly terrain
including pelvic girdle. Should be able to walk upto 5 km at his own pace.
(d) Physical Capacity (P3). Has moderate disablement with limited physical Fit for sedentary duties in areas
capacity and stamina, can undergo exertion not involving severe strain where hospitals with appropriate
specialist facilities is available
nearby. May have restrictions in
employability in hilly terrain and
in extreme cold climates
(e) Eyesight (E3). Can see for ordinary purposes. Fit for garrison duties in India.
Corrected vision with conventional spectacles or contact lenses Fit for duties not requiring good
visual acuity
Left eye Right eye
or
(i) 6 / 12 6 / 36
(ii) 6 / 24 each eye
One eyed personnel
(i) Those with normal vision in left eye without correction
(ii) Those with corrected vision in right or left eye upto 6 / 12 or better
Category 4. An individual who is under medical care in hospital or on sick leave, ending his final categorisation
and disposal (i.e. a person who is temporarily unfit for service)
Category 5. Person who are considered permanently unfit for further military service under any of the SHAPE
factor
S5: Mentally unable on account of psychological / psychiatric Permanently unfit for further
disorders / psychopathic personality military service
H5: Hearing acuity below E3 standards
A5: Severe derangement of functional efficiency
P5: Gross limitations in physical capacity and stamina
E5: Visual acuity below E-3 grade, bilateral aphakia

Terminologies
Hilly Terrain Denotes such areas where a person has to climb up and down the heights, which is likely
to aggravate or put to difficulty persons with cardiac, respiratory, arthritic or such disabilities
Extreme Cold Climate Where temperature remains below 7° Celsius for 6 months or more in a year
Cold Climate Climate like that prevailing in Punjab or other areas in Western Command, where an
individual in category ‘2’ or ‘3’ should normally be able to work

22.10 Classification / Re-Classification Medical Board.

(a) If AMA is of the view that the existing medical classification of an individual needs to be changed,
he / she will refer the individual to the appropriate specialist in that discipline. After clinical examination and
investigations, the concerned specialist will write his / her opinion and recommendations about the medical
classification of the individual on AFMSF-15 and request CO of the hospital for holding Medical Board. The
individual will be communicated about the disability and medical classification awarded. It will be explained to

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him / her that it is subject to approval from higher medical authorities. The medical classification awarded to
the officer will be communicated to the officers’ unit by the approving / perusing authority at the earliest but
not later than thirty days from the date of holding the board.
(b) While placing an individual in a classification below SHAPE-1, Medical Board must clearly state in the
Board proceedings whether or not the disease / disability of the officer is attributable to service and will also
bring out aggravation, if any. In formulating opinion about attributability or non–attributability, all medical
officers comprising the Medical Boards and the approving authorities must follow the guidelines given in the
publication ‘Guide To Medical Officers (Military Pensions) 2002 (amended 2008)’, as amended in 2023.
(c) In case one or more factors of the medical classification is required to be lowered temporarily on
account of disablement, the grade assessed should be that from which no further deterioration is expected.
Temporary classification in any grade factor will be permissible for a maximum period of 24 weeks. Then the
officer will be upgraded / downgraded / placed in permanent LMC in the same grade factor depending on the
clinical response. Opinions given by Specialist officers for classification / reclassification purposes will be valid
for a period of three months. If an officer requires observation beyond the permissible period, he / she will be
placed in permanent LMC, except in ‘S’ factor.
(d) All personnel in ‘S3’ factor can be observed on a temporary basis for a maximum period of 48 weeks.
He / she will not be placed in S3 permanent. In case, after 48 weeks, the officer cannot be upgraded to S2
temporary, he / she will be downgraded to S5.
(e) Composition of Medical Board.
(i) President Medical Board will ordinarily be of the rank of Major or above. For invaliding officers,
President must be the CO of hospital of the rank of Lt Col or above.
(ii) MO in charge of a patient or who gives a specialist opinion on the case will not, as far as possible
be a member of the board which considers it and in no instance may act as President of the board.
(f) The approving and perusing authority for Classification / Re-classification medical board of officers (except
S factor*) is as follows:
Table 22.15 : Approving and Perusing Authority for Classification / Re-Classification Medical Board of Officers
Officers Approving Authority Perusing Authority
Officers outside Army HQ
Officers upto the rank of Brig CO / Commandant Hospital Next higher HQ (Med)
where PMB held
Maj Gen and above MG Med, Comd ADGMS (IS, H & PS)
(less those at Comd HQ)
Maj Gen and above posted at Comd HQ ADGMS (IS, H & PS) DGMS (Army)
Officers posted to AHQ / AHQ units / ISO / MoD / NDC or on Deputation with Civil Offices / PSU in Delhi and other
places
Officers upto the rank of Brig Commandant AFC ADGMS (IS, H & PS)
Officers in the rank of Maj Gen and above ADGMS (IS, H & PS) DGMS (Army)
CO / Comdt Hospital Col Med, Div / Brig Med Brig Med Corps / MG Med
Corps / MG Med Area / Comd Area / Comd
Comdt, CH and AH (R&R) MG Med Command ADGMS (IS, H & PS)
Naval and Air Force Hospitals Brig Med Corps / MG Med Area MG Med Command
*Perusing authority for cat / recat medical boards of patients with psychiatric illnesses will be as under-

Offrs - DGMS (Army) As per Letter no. 76086 / Policy / DGMS-5A dt 28th Feb 2024
JCOs / OR - MGs Med (Area / Comd) applicable from 01st Mar 24

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(g) Classification / Re-classification medical boards of JCOs / OR does not require approval (RMSAF 2010
(revised ver) para 425 (a) (v)). One level of scrutiny of duly constituted medical board is required to be carried
out by using the appropriate column in AFMSF-15. The board proceedings will be considered complete only
after perusal.

22.11 Follow Up of LMC Personnel.

All LMC individuals are required to be followed up and may require specialist care and change of treatment from time
to time. The follow-up system for LMC individuals is as mentioned below:
(a) AMA will maintain a register for all LMC officers on posted strength of the unit. Necessary information
will be obtained from the unit HQ. OC unit, who has no RMO, will forward names of LMC officers to the Staff
Surgeon / MO-I / C, Central MI Room to enable AMA to maintain the requisite register.
(b) AMA will call such officers for examination and enter their personal particulars, nature of disability,
medical classification and date of the next review in a register. The register will have separate page for each
officer. In case of new arrivals (LMC officers) in the unit, the information will be forwarded by the unit to AMA
within a week of arrival for entry in the register.
(c) The register will be perused by AMA / RMO in the first week of every month to complete all formalities
and ensure that Re-classification Medical Board is held on due date. In the remarks column, AMA will enter
the due date of review recommended by the concerned specialist and also any investigation, treatment or
any follow up action required to be taken. Where no periodic review has been recommended by the specialist,
AMA will fix the same after taking into account the nature of the disease and the officer’s condition. All LMC
officers are to be seen by AMA at least once a month and cases may be referred to the concerned specialist,
if required.
(d) AMA will also raise a case sheet for each officer placed in LMC. He / she will review the officer placed
in LMC every month and note any change in physical condition / findings, response to treatment, changes in
treatment where indicated, results of investigation as well as the opinion of the specialist concerned. This
case sheet will be sent to the concerned Specialist whenever the officer is referred to him.
(e) Necessary investigations will be carried out well in advance of the date of the next Medical Board and
specialist opinion obtained in time.
(f) Medical examination and management of all ranks must be carried out by their AMA only and through
their authorized medical channels with medical boards being held only at the dependent Armed Forces Medical
Services hospital, irrespective of being Indian Air Force / Indian Navy hospital.
(i) The prerogative of designation of AMA and authorized medical channels for medical management
rests with the MGs (Med) Comd and as delegated further by them in their areas of responsibility.
(ii) When an individual is on course, study leave or long temporary duty, medical examination and
medical boards may be held at hospitals where the individual is temporarily located. However, such
medical examination / medical board can be carried out only after obtaining prior sanction of Col Med,
Brig Med or MG (Med) Div / Corps / Area / Comd.
(g) When an officer in LMC is posted out from a unit, all medical documents will be forwarded by the Officer
Commanding Unit to the next unit with a request that these documents be handed over to the RMO / AMA of
the new unit.
(h) When an individual is placed in a classification lower than SHAPE-1, whether temporary or permanent,
it is obligatory for him / her to appear before Re-classification Medical Board on due date.
(j) Whenever an officer is in permanent LMC for two or more disabilities the officer will be assessed for
both the disabilities simultaneously along with the review of the classification for the disability which falls
earlier, irrespective of the time when the second disability was due for review and awarded the necessary
classification. Where an officer, already in LMC for one disability, develops another disease requiring permanent
LMC, he / she may be reviewed for the first disability while conduct of medical board for the second disability,
provided more than six months have passed since the review of first disability. If a period of less than six
months has elapsed, then the second disability review be recommended at the time when the review for first
disability was due. This will allow the officer to be reviewed simultaneously for both the disabilities during next

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review. Same rule would also apply for re-classification of temporary LMC for two or more disabilities. Timing
of their review should be similarly synchronized so that reclassification for both can be done at same time.
However, review of classification for temporary and permanent disability reviews will not be clubbed.

22.12 Sick Leave: Officers.

(a) Sick leave concession is admissible to officers only for a period of 30 days or less. In case the period
of hospitalization exceeds 30 days, the entire period of sickness will be treated as sick leave.
(b) Sick leave will be admissible for a period upto 6 weeks in the first instance and will be adjusted against
the annual leave. In case the sick leave overlaps in the next calendar year (e.g. commencing from 15th Dec
2021 to 20th Jan 2022, the absence of sick leave period from 15th Dec 2021 to 31st Dec 2021, will be
adjusted from the annual leave of the year 2021 and sick leave from 01st Jan 2022 to 20th Jan 2022, will
be adjusted against the annual leave of the year 2022).
(c) Officers undergoing treatment in MHs can be granted leave to a maximum of 10 days to attend to their
domestic emergencies provided the grant of such leave does not interfere with their treatment. This leave
will be treated as part of sick leave admissible under leave rules and will be granted at the discretion of the
commanding officer of the hospital.
(d) The competent authority to grant sick leave to officers is given as under:
Table 22.16 : Competent Authority to Grant Sick Leave to Officers of Army
S. No. Spell of Sick Leave Approving Authority for Grant of Sick Leave

(i) First spell of sick leave: upto 6 weeks Comdt / CO / OC hospital and no approval is required

(ii) Second spell of sick leave: more than 06 weeks for MG (Med) Comd under whom service hospital is
officers upto the rank of Col located / Comdt AH (R & R) if medical board is held
at AH (R & R)

(iii) Second spell of sick leave for Brigs and above DGMS (Army)

(iv) Ex post facto approval for 2nd spell of sick leave DGMS (Army)

(e) Aim of approval of second spell of sick leave is to regularise continuous absence from duty on medical
grounds. Request for approval of second spell of sick leave should be accompanied with the following documents:
(i) Opinion by specialist recommending sick leave
(ii) Copy of AFMSF-15 (First spell of sick leave), specialist opinion, Appx ‘F’
(iii) Recommendations of Comdt / CO / OC of service hospital
(f) Grant of sick leave for Air Force ( IAP 4303 6th Ed).
(i) Airmen / NCs.
Medical officers are authorized to recommend a period of sick leave based on the recommendations of
concerned hospital where individual was treated. Sick leave may be recommended on own authority if
treated at Station Medicare Centre.
(ii) Officers.
(aa) Officers are to be granted sick leave only from the hospital where they were admitted and
will return to that or another designated hospital on expiry of sick leave.
(ab) Medical board will be held on being granted sick leave wherein the officer will be placed
in category At Gt for the period of sick leave.
(iii) Second spell of sick leave: All service personnel are to be hospitalized when a second spell of
sick leave is considered necessary on expiry of first spell of sick leave. Such cases are to be referred
to Air HQ for prior approval of DGMS (Air) (para 426 of RMSAF 2010 refers).

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(g) Grant of Sick Leave for Navy.

(i) Officers and Cadets.
Sick leave for convalescence of officers and cadets is to be given only on the recommendations of a
Medical Board. AFMSF-79 is to be completed in all cases. A second period of convalescent sick leave,
when considered essential may be recommended to Integrated HQ of Min of Def (Navy) for approval.
(ii) Sailors and Recruits.
Sick leave will be recommended where necessary in accordance with the provisions of Regulation 35 of
the Navy Leave Regulations 1970. Refer NO 7 / 2014 Para 29-30 for detailed information.

22.13 Early Review of Low Medical Classification (ARMY).

(a) Army
(i) Officers.
Army officers placed in temporary and permanent LMC may request for an early review of LMC status
after a period of 12 weeks from date of last medical categorization board but not more than once for
disability, if AMA certifies that officer’s medical and physical condition has improved materially. The
requisite application will be recommended by CO of the individual certifying the performance of the officer
and will be forwarded through the immediate superior Formation Commander to MG (Med) Area / Comd.
The competent authority to grant such a review will be MG (Med) Area / Comd.
(ii) JCOs / OR.
Policy on grant of early review to JCOs / OR will entail the following:
(aa) JCOs / OR placed in temporary and permanent LMC may request for an early review of the
LMC status after a period of 12 weeks from the date of last medical categorization board but
not more than once for a disability, if the AMA certifies that the medical and physical condition
of the JCO / OR has improved.
(ab) The requisite application by the individual will be recommended by the CO of the individual
certifying his / her performance and will be forwarded through the immediate superior Formation
Commander to Brig (Med), Corps / MG (Med), Area / Comd. The competent authority to grant such
a review will be MG (Med), Area / Comd.
(ac) JCOs / OR in temporary / permanent LMC and reporting for RMB / RME consequent to issue
of orders by records for discharge / release from service will not be granted early review. CO of
the individual should be advised not to process such applications. In such cases, the medical
board will ensure that the individual is examined for release purpose only and his existing medical
category is not changed.
(b) Air Force.
Individual in permanent medical category can exercise the option to apply for early review provided the following
conditions are met:
(i) The grounds are reasonable and the clinical condition of the individual has improved to an extent
which necessitates an early upgradation.
(ii) At least half the observation period has elapsed i.e. six months from the last medical board.
(iii) The process for early review is as follows:
(aa) The individual will submit a personal application which will be forwarded for sanction through
proper administrative and medical channels to the PMO Command in case of airmen and to Dte
Gen Med Services Air HQ (Med-7) (through PMO Command) in case of officers / cadets.
(ab) The medical authorities recommending the early review have to provide detailed
justification / cogent reasoning with specific details of the disease entity which merit the
consideration for such an early review. (IAP 4303 6th ed)

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(c) Navy.
Personnel in permanent medical classification can apply for an early review any time after a minimum of half
the observation period has elapsed if the AMA certifies that the individual’s condition has improved materially.
The requisite application will be recommended by the Commanding Officer of the unit duly certifying the
improvement of performance of the individual and will be forwarded to the Command Medical Officer. The
competent authority to grant an early review will be the Command Medical Officer for sailors and Integrated
HQ of Min of Def (Navy) / DGMS in case of officers (Para 10 of NO 7 / 2014).

22.14 Condonation of Delay (ARMY).

(a) Officers.
(i) The competent authority for providing sanction for delayed AME for officers is as follows:
Table 22.17 : Competent Authority for Providing Sanction for Delayed AME for Officers
Type of Sanction Authority for Sanction
Officers posted to various units / Fmns
Delayed AME GOC Div / Area / COS Corps / MG-IC-Adm Comd HQ for Officers
under their jurisdiction
Dispensation of AME upto 1 year GOC Div / Area / COS Corps / MG-IC-Adm Comd HQ for Officers
under their jurisdiction
Dispensation of AME for >1 year COS Comd
Officers posted at AHQ / AHQ units / ISO / MoD / NDC or on deputation with Civil Offices / PSU in Delhi
Delayed AME ADG of the concerned Dte
Dispensation of AME upto 1 year DDG MP (P & P)
Dispensation of AME for >1 year ADG MP (P & P)
Officers on deputation to ISO / Civil Officers, PSU outside Delhi
Delayed AME DDG / Comd (Brig) Equivalent
Dispensation of AME upto 1 year ADG / IG (Maj Gen Equivalent)
Dispensation of AME >1 year ADG MP (P & P)
(ii) The competent authority for providing sanction for delayed PME for officers is as follows:
Table 22.18 : Competent Authority for Providing Sanction for Delayed PME for Officers
Officers Posted to Various Units / Fmns
Type of Sanction Authority for Sanction
Delayed upto 6 months GOC Div / Area / COS Corps / MG-IC-Adm Comd HQ for Officers under their jurisdiction
Delayed upto 1 year GOC Corps for Officers under their Corps / MG-IC-Adm Comd HQ
Delayed beyond 1 year COS Comd
Officers posted at AHQ / AHQ units / Inter Service Organisation / MoD / NDC or on Deputation with Civil Offices / PSU
in Delhi
Delayed upto 6 months ADG of the concerned Dte
Delayed upto 1 year DDG MP (P & P)
Delayed upto 2 years ADG MP (P & P)
Delayed beyond 2 years DG (MP & PS)
Officers on deputation to ISO / Civil Officers and PSU outside Delhi
Delayed upto 6 months DDG / Comd (Brig) Equivalent
Delayed upto 1 year ADG / IG (Maj Gen Equivalent)
Delayed beyond 1 year DG (MP & PS)

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(iii) Re-Classification Medical Boards.

In case an officer fails to undergo re-classification medical board on due date, condonation of delay
will be required. The competent authority to sanction the delay of duration > 15 days but < 60 days
is Reviewing Officer and of more than 60 days duration is Senior Reviewing Officer. In case there is an
anticipated delay upto 15 days, it will be intimated by CO / OC unit of the officer to AMA. CO / OC unit will
forward Statement of Case (SoC) whenever delay in holding re-classification medical board is anticipated
by more than two weeks from the due date.
(b) JCOs / OR.
In case JCOs / OR is not able to undergo AME / PME / Re-classification medical board in time, the competent
authority to provide sanction will be as given below:
Table 22.19 : Competent Authority for Sanctioning Delayed AME / PME /
Re-Classification Medical Board for JCOS / OR
Type of Medical Examination / Board Authority
AME of JCOs / OR Bde / Sub Area Cdr / Deputy
GOC Div / Area and
(a) Delayed AME (AME was not conducted during the scheduled period but is
equivalent
required to be held during the same calendar year)
(b) Dispensation of AME (AME for the year was not held and requires dispensation)
PME of JCOs
(a) Delay for period less than 6 months -do-
(b) Delay for period more than 6 months -do
(a) Re-classification medical board of JCOs / OR Bde / Sub Area Cdr / Dy
All except those posted in Army HQ / Army HQ units or on deputation: GOC
(i) Delay for period less than 6 months Div / Area and equivalent

(ii) Delay for period more than 6 months GOC Div / Area and
equivalent
(b) JCOs / OR posted at Army HQ, Army HQ units and on deputation to DDG and equivalent officer
units / organisation located in Delhi / New Delhi: in respective Line Dtes
(i) Delay for period less than 6 months
(ii) Delay for period more than 6 months ADG and equivalent officer
in respective Line Dtes
(c) JCOs / OR on deputation and located outside Delhi: By an officer of Brig rank
or
equivalent
(i) Delay for period more than 6 months By an officer of Maj Gen
rank or equivalent

(c) Condonation of Delay in Conduct of AME / Medical Board (Air Force) – in case there is a delay in reporting
by an officer for AME / Medical board (for Officers with low medical category) or conduct of AME thereafter the
delay may be condoned by an appropriate condoning authority (as listed in the table below) based on the period
of delay. For such a condonation, the concerned officer is to put up an application with reasons for delay and
stating the number of occasions such as labs has occurred earlier. The application is to be forwarded to the
appropriate condoning authority through defined channel for condonation of delay and issue of warning where
applicable. Record of condonation and warning letter is to be retained in the officers personal documents at
the unit. Thereafter, a letter of sanction alongwith a copy of application (and warning letter where applicable)
is to be forwarded to SMO for conduct of medical examination / medical board. Refer Para 12-13 of HRP Part
1 / PO / MISC / 07 / 2022 dt 22nd Dec 2022)

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S. No. Period of Delay Condoning Authority

(i) Up to 3 months IO (as per ACR channel)
(ii) Up to 6 months RO (as per ACR channel)
(iii) 6 months to 1 year SRO (as per ACR channel)
(iv) Beyond 1 year Branch Head at Comd HQ / PSO at Air HQ (for offrs posted at Air
HQ or units directly under Air HQ)

(d) Condonation of Delay in Conduct of AME / Medical Board (Navy) - Any delay has to be condoned by
IO / RO / SRO / COP on submission of Statement of Case (SOC) by the Officer as per format. The request for
condonation along with recommended SOC has to be forwarded through proper administrative channel (not
medical). This should be an exception rather than routine. A copy of individual’s request and sanction of
appropriate authority are to be enclosed while forwarding copy of the AME / PME to Medical Record Section
of IHQ of MoD (N) / DGMS (N). A serious view is to be taken on defaulting officers and punitive actions as
deemed fit may be initiated by the Administrative Authorities. The delayed AME / PME are not to be initiated
by MOs unless accompanied by sanction by appropriate authorities. The authority for condonation of delay in
medicals is vested with the following :
(i) Commanders and below:
S. No. Period of Delay Condoning Authority
(i) Up to 3 months IO (as per ACR channel)
(ii) Up to 6 months RO (as per ACR channel)

(iii) 6 months to 1 year SRO (as per ACR channel)

(iv) Beyond 1 year COP

(ii) Commanders and above:

S. No. Period of Delay Condoning Authority
(i) Up to 3 months IO (as per ACR channel)
(ii) Up to 6 months RO (as per ACR channel)

(iii) Beyond 6 months COP

(iii) Sailors.
The condonation of delay for AME / PME up to 3 months may be accorded by Departmental Officer, up to
6 months by Executive Officer and beyond 6 months by Commanding Officer on Captain’s Request. The
delayed AME / PME are not be initiated by MOs unless accompanied by sanction letter by appropriate
authorities. A copy of individual’s request and sanction of appropriate authority are to be enclosed while
forwarding copy of the AME / PME to Medical Record Section of Commodore Bureau of Sailors

22.15 Disease Specific Policies In Army.

(a) DIABETES MELLITUS: LMC for individuals with Diabetes Mellitus is given as under:

SHAPE factor Illness

P2 All cases of Diabetes on oral hypoglycaemic drugs
P3 All cases of Diabetes on Insulin or with an evidence of target organ damage

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Table 22.20 : COPE Coding for Diabetes Mellitus

COPE Coding Guidelines for COPE Coding
Climate & terrain C0 Impaired Fasting Glucose / Impaired Glucose Tolerance / single non hypoglycaemic
(C) drug (Metformin / Sitagliptin / Alpha Glucosidase Inhibitor)
C1 For all diabetics on more than one oral hypoglycaemic drugs
C2 For all diabetics on Insulin / any other injectable therapy / Target Organ Damage (TOD)
Degree of O1 For all diabetics on oral hypoglycaemic drugs (Monthly review by AMA)
medical
O2 (a) For all diabetics on basal Insulin with or without oral hypoglycaemic drugs (Monthly
Observation (O)
review by medical specialist)
O2 (b) For all diabetics on multiple subcutaneous Insulin injections with or without target
organ damage (Monthly review by endocrinologist)
Physical capacity P0 For all diabetics on oral hypoglycaemic drugs
limitations (P)
P1 For all diabetics on single Insulin with or without oral hypoglycaemic drugs
P2 For all diabetics with target organ damage / multiple subcutaneous Insulin injections
Exclusive E1e Dietary restrictions for Diabetes Mellitus
restrictions (E)

(b) Primary / Secondary / Subclinical Hypothyroidism.

LMC for officers with Hypothyroidism is given as under:
SHAPE Factor Illness
P2 All cases of Hypothyroidism on drugs without any systemic complications
P3 All cases of Hypothyroidism on drugs with documented evidence of systemic complications

Table 22.21 : COPE Coding for officers with Hypothyroidism

COPE Coding Guidelines for COPE Coding
Climate & terrain (C) C0 Subclinical Hypothyroidism
C1 For all Primary / Secondary / Subclinical Hypothyroidism on treatment
C2 For Hypothyroidism with documented systemic complications
Degree of medical O1 Monthly review by AMA
Observation (O)
Physical capacity P0 No restrictions
limitations (P)
Exclusive restrictions (E) E0 No restrictions

(c) Hypertension.
Table 22.22 : COPE Coding for Officers with Hypertension
COPE Coding Guidelines for COPE Coding
Climate & C0 Only when in SHAPE-1 (i.e. no employment restrictions)
terrain (C)
C1 Not applicable
C2 All cases of Hypertension

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COPE Coding Guidelines for COPE Coding

Degree of O0 Normotensive i.e. documented normal blood pressure and being observed in LMC
medical without medication and only on lifestyle modification.
Observation (O)
O1 All cases of Hypertension on medication (Without Target Organ Damage (TOD)
O2 (a) All cases of Hypertension on medication (With TOD)
Physical P0 Only when in SHAPE-1 (i.e. No employment restrictions)
capacity
P1 All cases of Hypertension without TOD
limitations (P)
P2 All cases of Hypertension with TOD
Exclusive E0 Not applicable
restrictions (E)
E1 Dietary advice (Salt restricted diet, Dietary Approaches to Stop Hypertension-DASH
diet); Lifestyle advice (Avoidance of alcohol, cessation of tobacco use, weight loss)
All cases of Hypertension on no drugs and only on lifestyle modifications or on
medication without target organ damage
E2 All cases of Hypertension with TOD
QUICK REFERENCE

Hypertension without TOD C2O1P1E1

Hypertension with TOD C2O2P2E2
Target Organ Damage. TOD includes the following:
(i) Heart: Left Ventricular Hypertrophy, prior coronary revascularization, Angina / prior Myocardial
Infarction, Heart Failure
(ii) Brain: Stroke or Transient Ischaemic Attack, Dementia
(iii) Chronic Kidney Disease: Peripheral Arterial Disease, Retinopathy Grade 3 or 4
(d) Backache, Prolapsed Intervertebral Disc (PIVD), Spondylosis, Ailments of Musculoskeletal System of
Axial Skeleton.
Table 22.23 : LMC and COPE Coding for Officers with Backache, PIVD, Spondylosis, Ailments of
Musculoskeletal System of Axial Skeleton
Medical Category Illness
P2 Case involving axial skeleton system without neurological deficit
P3A2 Case involving axial skeleton system with neurological deficit

COPE Coding Clinical remarks

C2 All cases placed in LMC for any illness of axial musculoskeletal system
O/P/E Awarded by medical board based on clinical condition of the individual
(e) Obesity.
(i) Individuals with body weight >10% of Ideal Body Weight (IBW) are placed in LMC P2 (T-12). At the
end of 12 weeks, if the weight remains >10% IBW, the individual is again placed in LMC P2 (T-12). If
again after the end of 12 weeks, weight remains >10% IBW, the individual is placed in P2 (P). However,
if at the end of 12 weeks, weight is <10% IBW, an individual is placed in P1.
(ii) Individuals with body weight >20% of IBW, are placed in LMC P2 (T-24). At the end of 24 weeks,
if the body weight remains > 10% of IBW, an individual is placed in LMC P2 (P). However, if the body
weight is reduced to < 10% of IBW, he / she is upgraded to P1.

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(iii) Individual will be placed in P3 (P) if:

(aa) Upgraded to P1 and subsequently gains weight >10% IBW.
(ab) Continues to be overweight / obese (i.e. >10% IBW) after 2 years in P2 (P) [excluding initial
P2 (T-24)] at the time of review.
(ac) Develops any other features of Metabolic Syndrome.
(f) Alcohol Dependence Syndrome and / or Drug Abuse.
(i) Patients diagnosed to have alcohol dependence / drug abuse, will be observed under surveillance
over a period of 96 weeks i.e. twice in S3 (T-24) and twice in S2 (T-24). After this, the individual will be
upgraded to medical classification S1. For upgradation to S1 classification, the individual should have
been drug free for a minimum period of 24 weeks. The disposal however will be decided only by the
clinical condition of the patient.
(ii) No patient of alcohol dependence / drug abuse will be placed in permanent LMC during surveillance
(iii) In exceptional circumstances if patient shows strong motivation to improve and abstains from
alcohol / drug after initial treatment he may be considered for upgradation to S2 (T-24) even after one
spell of S3 (T-24) and / or to S1 even after one spell of S2 (T24). The individual should be drug free for
at least 24 weeks. However, CO’s remarks on AFMSF-10 particularly about patient’s habits and socio-
occupational impairment will be given due importance.
(iv) A patient of Alcohol Dependence / drug abuse will be given once a maximum of 96 weeks period
for total recovery and the individual must become S1 (medical classification) within or at the end of 96
weeks period of observation in LMC and sheltered appointment. Any individual, who fails to become S1
due to any reason / circumstances, will be invalided out of service. If there is relapse after the patient
has been upgraded to SHAPE 1, he / she will be invalided out of service.
(g) Seizures / Epilepsy.

Suspected case of seizures Suspected case of Epilepsy

Evaluation by Medical Spl Evaluation and medical

categorization by Neurologist

Diagnosis of seizures confirmed AED - Anti Epileptic Drugs

P3 on AED* for 3-5 years

Medical categorization by Medical Spl in P3 (T-24) No recurrence

Review by Neurologist after 24 weeks for Recat P3 for one year without AED
and final etiological and semiological diagnosis
P1

Acute Symptomatic seizures with inflammatory granuloma Solitary seizures Remote

symptomatic P3 (T-24) ± P3 (T-24) Lesion persists P3 (T-24) + P3 (T-24) Symptomatic
seizures : To Seizures P3 (T-24)
be upgraded Recurrence No
Lesion disappears and
P3 on AED
to P1 after seizures controlled Yes P1 P3 for 2-3 years
maximum P3 for 2-3 years on AED on AEDs
category of P3 without AED for 1 year Recurrence
P3 (T-24) No recurrence P3 for one year
without AED
No recurrence of seizures P3 for one year without AED
P1
P1 P1

Fig 22.1 : LMC for Individuals with Seizures / Epilepsy

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For individuals with Seizures / Epilepsy, medical boards done after review by Neurologist should specify
entitlement (Attributability, Aggravation / NANA). The upgradation of Seizures / Epilepsy cases to P1 or
invalidment should be done by Neurologist countersigned by Sr Adv / Consultant (Med).
(h) Thalassemia Trait.
COPE coding for Thalassemia trait cases is as mentioned below:
(i) All patients of ‘Thalassemia trait’ are unfit for extreme high altitude more than 15,000 feet (C1).
(ii) Patients of Thalassemia trait with haemoglobin <12g / dL and / or splenomegaly on ultrasound
abdomen and / or evidence of hemolysis (Serum bilirubin 1.5 times of laboratory upper limit of normal
and / or increased reticulocyte count) are unfit for high altitude more than 9,000 feet (C2).
(iii) These employability restrictions will be awarded by the medical board each time the patient is
placed in LMC for the condition ‘Thalassemia Trait’.
(j) Cerebral Venous Thrombosis (CVT).
LMC and COPE coding of individuals with CVT will be as follows:
(i) All patients of CVT will remain unfit for high altitude area in their lifetime. They will be awarded
C2 of COPE grading implying that they cannot be upgraded to SHAPE-1 and hence will be required to
be followed up in LMC P2 (Permanent) / P3 (Permanent).
(ii) Patients who have had good clinical recovery and are off drugs and do not have any neurological
deficit should be observed in medical category P2 (Permanent) to prevent recurrence of the disease due
to exposure to the precipitating factors.
(iii) Patients who have mild neurological deficit and are on drugs or off drugs should be observed in
medical category P2 (Permanent).
(iv) Patients who have significant, residual neurological deficit and are on drugs or off drugs should
be observed in medical category P3 (Permanent).
(k) Coronary Artery Disease (CAD).
All cases of CAD such as Acute Myocardial Infarction (AMI), Acute Coronary Syndrome (ACS), cases of
Percutaneous Coronary Intervention (PCI) and Post Coronary Artery Bypass Grafting (CABG) will be awarded
COPE-2 and it follows that they will not qualify for award of medical category SHAPE-1B. LMC and COPE coding
for CAD cases is as given in Table 22.24:
Table 22.24 : LMC and COPE Coding for CAD
COPE Coding Guidelines for COPE Coding
Climate & C0 Only when in SHAPE-1
Terrain (C) C1 Not applicable to cases of CAD
C2 Applicable to all cases of CAD
Degree of O0 Only when in SHAPE-1
medical O1 Not applicable to cases of CAD
Observation
O2 (a) All cases of CAD in medical category P2 (Temporary / Permanent)
(O)
O2 (b) All cases of CAD in medical category P3 (Temporary / Permanent)
Physical P0 Only when in SHAPE-1
capacity P1 LVEF > 55%
limitations
(P) P2 LVEF< 55%
Exclusive E0 Only when in SHAPE-1
restrictions E1 Not applicable to cases of CAD
(E) E2 (e) All cases of CAD in medical category P2 / P3 (Temporary / Permanent) low saturated fat diet
for all cases of CAD; To undertake regular physical activity to enhance recovery and improve
functional capacity

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(l) Sensorineural Hearing Loss.

There is normally no justification to award a grade other than zero under C, O and P factors of COPE (C0
O0 P0) in cases of SNHL. The exclusive restrictions may only be awarded specific to hearing loss (E of COPE
factor) by the medical board after careful consideration of hearing status of the individual in cases of SNHL.
(m) Sarcoidosis.
The disability ‘Sarcoidosis’ has no causal connection with service nor is it proven to be aggravated by any service
factors. Medical boards should therefore endorse it as Neither Attributable to Nor Aggravated (NANA) by service.

22.16 Medical Examination of Army Aviators.

The medical classification of Army Aviators will be indicated as follows:
(a) SHAPE – 1 FLYING FIT
(b) SHAPE – 1 AND FLYING UNFIT
(c) SHAPE– 1 AND FLYING RESTRICTED. “Flying restricted” status will not be acceptable for initial entry into
Army Aviation.
AME in respect of Army Aviators will be carried out on the scheduled time as per AO 9 / 2011 / DGMS by medical
officers trained in Aviation Medicine. In case aviation-trained medical officers is not present in the station, the Army
Aviator may be directed to SMO of the nearest Air Force Wing (Flying station).
(a) If any Army Aviator is declared as ‘Flying unfit’ at the time of AME it will be recorded on AFMSF 15 and
his category will be downgraded to ensure that the officer is not allowed to resume flying duties.
(b) AME which is scheduled to be held at MH on the specified age will be carried out as in vogue, which
is in addition, to that conducted by a specialist in aviation medicine.
(c) ECG during AME will be carried out on alternate years upto 30 years of age and thereafter it will be
carried out each year. TMT (Max) will be carried out on all air crew provided no medical contraindication exists
at the age of 40 and every five years thereafter.
Army Aviators will acclimatize for high altitude area for a minimum period of 36 hours before undertaking flying in
high altitude area. After 36 hours of acclimatization, Army Aviators will be cleared for flying by MO of the Aviation unit.
A record of such medical examination and clearance for flying will be maintained by the concerned medical authority
as well as Aviation unit. Similarly, a post-flight check will be conducted on return from high altitude area and a record
will be maintained.

22.17 Medical Examination of Individuals Proceeding Abroad.

Serving personnel proceeding abroad at Government expense on duty / deputation / study leave or any other form of
official duty will in all cases be examined by AMA and obtain a certificate of medical fitness. When a body of men
are moving overseas, findings of the medical examination will be recorded on a nominal roll in case of officers and
JCOs / OR. Within a week of return from overseas, similar medical examination will be carried out of all service personnel.

22.18 Invaliding Medical Boards (IMB) (ARMY).

(a) Individuals who are unlikely to become fit for military duties as a result of grading 5 in any of the SHAPE
factors, will be brought before an Invaliding Medical Board in accordance with the existing instructions as per
AO 513 / 71.
Processing of IMB.
(i) Seven copies of IMB should be prepared on AFMSF-16 and completed as per AO 513 / 71.
(ii) Show cause notice is mandatorily issued on the day of holding IMB and not before signing of IMB
by the President Medical Board. The issue of show cause notice should be complied with notwithstanding
the fact that an officer / cadet is willing to be released or has given a certificate that he has no intention
of exercising the right of appeal.
(iii) Reply to show cause notice must be received within 15 days of issue of show cause notice. If

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no reply is received within 15 days, then comments to this effect should be mentioned on a separate
sheet duly authenticated by the President Medical Board and IMB should be processed expeditiously.
(iv) In case the individual undergoing IMB, does not appeal against the board proceedings, the case is
treated as a Non-Appeal case. However, in case the individual undergoing IMB, appeals against the board
proceedings, the case is treated as an Appeal case. Appeals, if any received within 15 days of the issue of
the show cause notice are also sent along with the remarks of the Presiding Officer of the invaliding medical
board. All seven copies with connected documents, show cause notice, appeal in original and comments on
appeal will be forwarded to DGMS-5A. Comments of the treating physician, Comdt / CO hospital and heads
of the medical branches of intermediary Formation HQs should be attached with the appeal.
(v) IMB proceedings of cadets should be processed on top priority and all efforts must be taken to
avoid any inordinate delay in processing of these documents.
(vi) Non Service Liability (NSL) of Probationary Nursing (PN) students and AFMC cadets is carried out
on AFMSF-2 (Modified) and processed to O / o DGAFMS for acceptance. For PN students, a certificate
along with the medical board proceedings for AGIF should be endorsed. The ibid certificate duly filled will
be forwarded along with medical board proceedings for obtaining AGIF benefits under ‘Student Nurses
Group Insurance Scheme-2012.’
Venue For RMB / IMBs in Respect of General / Flag / Air Officers of Armed Forces
Table 22.25 : The Venue for RMB / IMBs in Respect of General / Flag / Air Officers of Armed Forces
Rank / Members as Approving Confirming
Service Venue Presiding Officer
Designation Detailed By Authority Authority
Army Lt General Armed Forces Commandant Commandant ADGMS (IS, H DGMS (Army)
Clinic (AFC), AFC, New Delhi AFC & PS)
New Delhi
Navy Vice Admiral Base Hospital As detailed by Commandant DGMS (Navy)
Delhi Cantt Base Hospital Base Hospital
Delhi Cantt
Air Air Marshal AFCME / IAM Commandant Commandant DGMS (Air)
AFCME / IAM AFCME / IAM
In addition,
RMB is vetted
by collegiate
comprising
of Air Officer
Administration
(AOA), DGMS
(Air), JAG (Air)
and DMS (MB)
Channel for Approval / Confirmation and Acceptance of IMB.
Table 22.26 : Channel for Approval / Confirmation and Acceptance of IMB
Accepting
Place of Holding IMB Approving Authority Confirming Authority
Authority
Officers / Cadets
Hospitals under Col (Med) Div / Brig (Med) Area or MG (Med) Comd DGMS (Army)
Div / Area / Corps Corps / MG Med (Area)
Hospitals directly Brig (Med) / Col (Health) Comd HQ MG (Med) Comd DGMS (Army)
under Comd HQ
Army Hospital (R&R) Brig (Med) / Col (Health) HQ West Comd MG (Med), HQ West Comd DGMS (Army)

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JCOs / OR
Hospitals under Brig (Med) Corps / MG (Med) Area MG (Med) Comd -
Div / Area / Corps
Hospitals directly Brig (Med) / Col (Health) Comd MG (Med) Comd -
under Comd HQ
Army Hospital (R&R) Brig (Med) / Col (Health), HQ West Comd MG (Med), HQ West Comd -
Channel of Processing of IMB Documents
Non Appeal Cases

IMB initiated from hospital on AFMSF-16

Concerned Corps/Area HQ: Approving authority

Concerned Command HQ: Confirming authority

DGMS-5A

Approval by AG

Final acceptance by DGMS (Army)

Dispatch to concerned cadre controlling auhority - MS branch for non AMC Officers and DGAFMS for AMC/ADC/
MNS Officers for final release

Fig 22.2 : Channel of Processing of IMB Documents in Non Appeal Cases

Appeal Cases

IMB initiated from hospital on AFMSF-16

Concerned Corps/Area HQ: Approving authority

Concerned Command HQ: Confirming authority

DGMS-5A

AG

DGMS (Army)

DGAFMS / DG-3A

MoD/D (Med): Approval/Rejection

Final acceptance by DGMS-5A and dispatched to concerned cadre controlling authority- MS branch for non AMC Officers
and DGAFMS for AMC/ADC/MNS Officers for final release

Fig 22.3 : Channel of Processing of IMB Documents in Appeal Cases

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(b) Invaliding Medical Boards (IMB) Air Force.

The conduct of Invaliding Medical Boards (IMB), of regular officers / Personnel in respect of venue, IMB of
SSC Officers, disposal, processing, forwarding and approval, special waiver of DGMS (Air) will be governed by
the guidelines enumerated in IAP 4303 6th Ed.
(c) Invaliding Medical Boards (IMB) Navy.
The conduct of Invaliding Medical Boards (IMB) in respect of Officers / Cadets, post appeal, sailors in S5A5,
accused or Offender will be governed by the guidelines enumerated in the paragraphs 30 to 44 mentioned in
NO 7 / 2014.

22.19 Release Medical Examination (RME) / Release Medical Board (RMB) Army.
Medical examination prior to release / retirement / discharge on completion of tenure or service limit will be governed
as per AO 3 / 89.
(a) Individuals in SHAPE-1 will be required to undergo only RME. Such medical examination will be conducted
by AMA (MO / Staff surgeon) and report will be recorded on form AFMSF-18 in quadruplicate. RME documents
are not required to be approved by Col Med and will be disposed of directly by the OC unit of individual.
(b) Individuals in LMC or in case any disability is found at the time of release, he / she will be brought before
a medical board well in time so that the RMB proceedings are completed prior to his release from service.
The RMB proceedings will be recorded on form AFMSF-16. The medical board will also render a certificate in
the prescribed proforma to be attached with the AFMSF-16 (for those released in LMC), making an annotation
about the individual’s longevity, which will be accepted by competent authority for the purpose of commutation
of pension.
(i) RMB proceedings will be approved by Col Med / Brig Med Area / Div / Corps / Command, who will
in turn forward the medical board proceedings to MG (Med) Command for confirmation and disposal.
(ii) In case where the confirming authority does not concur with opinion of RMB, precise reason for the
same should be conveyed to the concerned hospital, with a direction to make necessary amendments.
RMB proceedings should be confirmed only when the opinion offered therein is in consonance with the
opinion of confirming authority. However, if consensus cannot be arrived at despite all efforts and if
conflicts between RMB and confirming authority still remains unresolved, then the decision of confirming
authority will be deemed as final. Such cases will be forwarded for perusal of respective DGsMS. The
same would also be applicable for IMBs.
(iii) Attributability / Aggravation.
Before an award can be made for a disability or death claimed to be related to service, a causal connection
between disability or death and military service has to be established by evidence. Disablement or death
shall be accepted as attributable due to military service, if it is certified by appropriate medical authority
that the disablement / death is due to wound, injury or disease that is attributable to military service.
Cases in which it is established that conditions of military service did not determine or contribute to
the onset of the disease but influenced the subsequent course of the disease, will fall for acceptance
on the basis of aggravation. In case where it is established that the conditions of military service did
not contribute to the onset or adversely affect the course of disease, the disease will not be deemed
to have arisen during service and entitlement for causal pensionary award will not be conceded, even
if the disease has arisen during service.
(iv) Diseases due to infection arising in service, will merit an entitlement of attributability. Aggravation
is conceded for diseases affected by environment factors related to service conditions such as diseases
affected by exposure to weather. Diseases which run their course independently of external circumstances
like cancer, sexually transmitted diseases etc are not accepted as attributable to / aggravated by service.
(v) In respect of accidents or injuries the following rules shall be observed:
(aa) Injuries sustained when the individual is “on duty” is defined as deemed to have resulted
from military service, but in cases of injuries due to serious negligence / misconduct the question
of reducing the disability pension will be considered.

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(ab) In cases of self-inflicted injuries whilst on duty, attributability shall not be conceded.
(ac) In all injury cases, Board should ask for injury report (IAFY - 2006) and Court of Inquiry
proceedings. While deciding attributability, Board should rely on directions of Fmn Cdr given on
Injury Report and findings of Court of Inquiry.
(ad) In cases where there is no record in official documents or other verification, date, place,
circumstances etc should be carefully recorded in the individual’s statement and board should
say whether the disability claimed resulted from the injury. The board should leave the question
of entitlement open for decision by the Pension Sanctioning Authority (PSA).
(vi) RME / RMBs should be held 8 months prior to the date of SOS. RMB proceedings done after the
date of SOS will not be approved without sanction of appropriate authority which is ADG PS for JCOs / OR
and ADG MP for officers.
Sanction for delayed RME / RMB: Officers / JCOs / OR
In case an individual is not able to undergo RME / RMB prior to release / discharge from service, then the
competent authority to grant sanction is as mentioned below:
Table 22.27 : Sanction for Delayed RME / RMB: Officers / JCOs / OR
Type of Cases for which RME / RMB
Type of Medical
has not been Held before Sanctioning Authority
Examination / Board
Release / Discharge of Individual
Officers in SHAPE-1 RME DGMS (Army)
Officers in LMC RMB ADG MP
JCOs / OR in SHAPE-1 RME Officer-in-charge Record Office
JCOs / OR in LMC RMB ADG PS
Process of Initial Adjudication of RMB / IMB Documents.
The process of initial adjudication of RMB / IMB documents is as given below:

RMB – (After Confirmation) and IMB – (After Acceptance)

Sanction letter MP7 Rejection letter

(From MP5/6/MPRS(O)

Injury cases: Decision regarding Disease cases: Decision

attributability/aggravation in regarding attributability/
respect of injury cases in aggravation in respect
Invalidment/retirement or Analysis and scrutiny of disease cases shall
discharge would be taken by the be taken by the service
service HQs in case of officers HQs in case of officers
and OIC Records in case of JCOS/ and OIC Records in case
OR, for the purpose of casualty Brig AFMC (Pension) of JCOS/OR on the basis
pensionary awards (Only doubtful cases) of the findings of the
RMB/IMB as approved by
the next higher medical
authority which would be
Principal IFA (Q&M) treated as final for life
For financial
concurrence
Origin of disability due to Origin of disability due to
injury Disease in accordance
Para 9 of ER 2023 Approval of CFA With GMO

Fig 22.4 : The Process of Initial Adjudication of RMB / IMB Documents

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Right to Appeal.
Where entitlement is denied by the Pension Sanctioning Authority (PSA) on initial consideration of the claim,
the claimant has a right of appeal against decision on entitlement and assessment. Assessment of degree of
disablement is entirely a matter of medical judgement and is responsibility of medical authorities. However,
for decision on entitlement, all concerned authorities have to give opinion.
(c) Release Medical Boards (RMB) Air Force.
The conduct of Release Medical Boards (RMB) in respect of documentation, commutation certificate, timelines,
change in medical status after RMB, RMB after release / retirement / discharge will be governed by the
guidelines enumerated in IAP 4303 6th Ed.
(d) Release Medical Boards (RMB) Navy
The conduct of Release Medical Boards (RMB) in respect of personnel in S1A1 and LMC, Re-employment
officers will be governed by the guidelines enumerated in the paragraphs 15 to 19 of NO 7 / 2014.

22.20 Medical Examination On Re-Employment.

Retiring officers seeking re-employment will undergo fresh medical board on AFMSF-2 while undergoing RMB if in LMC
or RME if in medical classification SHAPE-1, at the time of release / discharge from service.
(a) Officers in medical classification lower than S-1 will not be eligible for re-employment. officers invalided
out of service on medical grounds will not be eligible for re-employment.
(b) Medical classification as endorsed in RMB will be endorsed in AFMSF-2 to avoid variation in medical
classification. AFMSF-2 will be prepared in quadruplicate- one copy each for MS-3, respective MS, Records
and officer concerned.
(c) AME / PME / Re-classification medical board is not held during the period of re-employment. Medical
category established by RMB will be final and for life. There is no provision of change of medical category
established by RMB.
(d) For grant / extension of re-employment, fresh medial board on AFMSF-2 is carried out. It is signed by
board of officers and approved by Comdt / CO MH. Re-employed officers acquiring a fresh disability other than
in which they were released from service will be subjected to classification medical board during the period
of re-employment.
(e) A re-employed officer will undergo RME / RMB while proceeding on release from re-employed service as
per AO 3 / 89 without having any pensionary benefit other than already in receipt unless he is being invalided
out.
(f) Serving officers reporting to AFMS hospitals for medical examination for the purpose of re-employment
when found to be overweight will be referred by President Medical Board to medical specialist for being placed
in LMC.
(g) AFMSF-2 will be completed only after officer is placed in LMC and needful endorsement to the effect is
done. In case of retired officers reporting to hospital for medical examination for re-employment, medical board
should specifically mention status of weight (overweight or obese) in final observation section of AFMSF-2.
Officers who are overweight / obese are not fit for re-employment.

22.21 Re-Assessment Medical Boards (RAMBs).

RAMBs are held to do a one-time assessment of disability / disabilities of an individual after an individual has already
proceeded on release / discharge. RAMBs are held on revised AFMSF-17 (version 2020) as applicable with effect from
01st Dec 2020. Medical boards should mandatorily state admissibility of the award of disability pension in intervening
period in all cases in column notes below serial number 7 of AFMSF-17 at page number 3. RAMBs are held in following
situations:
(a) After completion of duration as awarded by RMB / IMB.
(b) RAMB on court order.
(c) In cases where the individual has applied for RAMB after a long period to continue reassessment with

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the disability pension which was stopped by PCDA in absence of percentage disablement after expiry of earlier
RMB / IMB.
(d) Sanction of DGMS-5A and respective DGsMS for Navy and Air Force is required for cases qualifying
under para (b) and (c) above. No sanction is required to conduct this board for cases under para (a) above.
Hospitals should conduct RAMB for routine cases reporting on time without any prior sanction.

22.22 First Appeal, Second Appeal and Review Medical Board.

(a) First Appeal.
If a person is aggrieved by the denial of entitlement, he may, if he so desires, submit an appeal before the
Record Office / Service HQs within six months, which would be considered by the Appellate Committee for first
appeal. The Appellate committee’s decision for upholding or rejecting the appeal will be by consensus. The
composition of the Appellate Committee for First Appeal (ACFA) i.e. First Appeal Medical Board is:
Presiding officer: Brig AFMS (Pens)
Members: Sr Adv concerned specialist, Col AFMS / AAG AFMS, MA (Pens)
(b) Second Appeal.
Any person, aggrieved by the decision in the first appeal, may file a second appeal within six months of the
decision of the Appellate Committee for first appeal, to the Defence Minister’s Appellate Committee on pension
(DMACP). The composition of the Second Appeal Medical Board / PDC / Review Medical Board is:
Presiding Officer: DGHS (AF)
Members: Senior Consultant (Med), Senior Consultant (Surg)
In attendance: Brig AFMs (Pens), Sr Adv (Concerned spl)
(c) Review Medical Board.
(i) Assessment.
The assessment with regard to percentage of disability in both injury and disease cases as recommended
by the Invaliding / Release Medical Board as approved by the next higher medical authority shall be
treated as final and for life unless the individual himself requests for a review, except in the cases of
disability / ies which are not of a permanent nature.
Where disablement is due to more than one disability, a composite assessment of the degree of
disablement shall be made by reference to the combined effect of all such disabilities in addition to
separate assessment for each disability. In case of overlapping disabilities, the composite assessment
may not be the sum of individual disabilities.
(ii) Re-assessment of Disability.
There shall be no periodical review by Re-assessment Medical Board (RAMB) for re-assessing disabilities
except for disabilities which are not of a permanent nature, for which there shall be only one re-assessment
of the percentage by RAMB. The percentage of disability assessed / recommended by RAMB shall be
final and for life unless the individual himself asks for a review.
Post Discharge Claim (PDC). Cases in which a disease was not present at the time of the member’s
retirement / discharge from service but arose within 7 years thereafter, may be recognised as Attributable to
service if it can be established by the competent medical authority that the disability is a delayed manifestation
of the pathological process set in motion by service conditions obtaining prior to discharge.

22.23 Medical Documents.

(a) Fatal Case Documents (FCD).
The responsibility of preparing and processing the fatal case documents is of the hospital where the death occurs
irrespective of the fact whether the patient was originally admitted there or received as a sick transfer from
another hospital. If, however, a patient died enroute during sick transfer, he will be taken to the nearest service
hospital, who will accept him as a Found Dead case and, after carrying out Postmortem / histopathological

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examination, (if required), he will complete fatal case documents and process them in accordance with the
instructions contained in this lesson. Fatal case documents will be prepared in duplicate as follows :
(i) Original set will comprise of hand written medical case sheets. Investigation forms and other
relevant documents.
(ii) Duplicate set will comprise of typed copies of all the documents of the original set.
(iii) Only original fatal case documents will be prepared in case of :
(aa) NCC Officers and cadets
(ab) Police Battalions, Assam Rifles, Indo - Tibetan Border Police and BSF
(ac) Coast Guard Personnel
(iv) The composition of original and duplicate set FCDs in respect of serving personnel is as under:
Table 22.28 : Composition of Original and Duplicate Set FCDs
Original Set of Documents Duplicate Set of Documents
Death certificate (AFMSF-93 Part I) Death certificate (AFMSF-93 Part I)
Temperature chart (AFMSF-44) Certificate of Attributability (AFMSF-93 Part II) - 3 copies
Medical case sheets (AFMSF-7A) Report on the case where death is due to causes other than
injuries (AFMSF-81 Revised)
Laboratory investigation reports (AFMSF-9) Typed copies of case sheets (AFMSF-7A)
Flimsy card (AFMSF-8B) Postmortem / histopathological / chemical examination reports
Miscellaneous documents, fluid charts Injury report (IAFY-2006), if applicable
(AFMSF-7)
Report on the case, where death is due to Copy of Court of Inquiry, if applicable
causes other than injuries (AFMSF-81)
Clinical documents from previous hospital Any other relevant documents
Postmortem / histopathological / chemical
examination reports
Any other relevant documents
X-ray films and reports
Details of the deceased (on top of documents)
(v) Documents will be submitted to Office of DGMS direct by the OC hospital in respect of Foreign
Nationals who die while undergoing treatment in a Military Hospital, for perusal and onward transmission
to Govt of the Country concerned, through the Min of Def / D (Med) and Min of External Affairs.
(vi) Medical case sheets and connected medical documents of pensioners, will be perused and
disposed of by the MG (Med) Command concerned to the respective Records holding Offices.
(vii) In case of unnatural deaths, i.e. deaths due to suicide, violence, accident, under suspicious
circumstances and so on, OC hospital will ensure that civil police is informed in writing about the
incident and their clearance obtained, in writing, before handing over the dead body to the relatives of
the deceased. Confirmation that this requirement has been complied with will be incorporated in clear
terms in the remarks endorsed by the OC hospital on the fatal case documents.
(viii) In cases of unnatural and unattended deaths, the main interest of the civil authorities in performing
the postmortem examination is to find out whether death was due to foul play or not and, as such,
they carry out few, if any, histopathological examinations on the tissues. In case a pathological death
is suspected liaison will be maintained with civil authorities so that pathologist / MO of hospital attends
the postmortem.

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(ix) Fatal case documents in respect of service personnel who are transferred to civil hospitals and
die there while under treatment. The following action will be taken:
(aa) OC hospital who transfers the case to civil should liaise with the civil medical authorities
regarding progress of the case and treatment given to the individual.
(ab) On the basis of the above information, he will complete the case sheets and other
hospitalization documents and initiate fatal documents.
(x) The responsibility of preparing and processing of FCDs is tabulated as under:
Table 22.29 : Responsibility of Preparing and Processing of FCDs
Case Scenario Remarks
Death in hospital Hospital where death occurs irrespective of the fact that whether patient
was originally admitted or received as sick transfer from another hospital
Death of patient enroute during Deceased will be taken to nearest service hospital, which will
sick transfer accept him / her as a Found Dead case and after carrying
postmortem / histopathological examination (if required) will complete FCDs
and process documents
Patient under treatment of Documents will not be routed through Advisors, but only through Col Med
Professor at AFMC Pune Div, Brig Med Corps and MG Med Comd
Brought-in-dead cases Documents will be routed only though Advisor in Pathology
(xi) The current procedure for obtaining remarks of Senior Advisor Pathology while processing of
original set of FCDs has been ceased. FCDs shall be forwarded directly to the Advisors in the specialty
concerned without routing them through Senior Advisor Pathology.
(xii) The channel of submission of FCDs of Army personnel is given as under:
Table 22.30 : Channel of Submission of FCDs
Death in Army Hospital Death in Naval Hospital Death in Air Force Hospital

ORIGINAL SET

OC hospital OC hospital OC hospital

Advisor in specialty Advisors Advisors

Col Med Div / Brig Med Corps CMO / PMO PMO (AF)

MG (Med) Comd MG (Med) Comd (for Army Pers) MG (Med) Comd (for Army Pers)

DGMS (Army) DGMS (Navy) DGMS (Air)

DGMS (Army) (for Army Pers) DGMS (for Army Pers)

DUPLICATE SET. Dispatched by OC hospital under Op Immediate letter for countersignature by MG (Med) Comd

For Further dispatch to:

Category Authority to Whom Documents are Forwarded

Officers other than AMC, AD Corps AG / Org 3(b)

and MNS

AMC, AD Corps and MNS officers MPRS(O)

Cadets MT-6

JCOs / OR Individual’s unit Cdr in local cases and Record Office in other cases

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(b) Non-fatal Cases.

The non-fatal cases include medical case sheets and connected hospitalization documents. The Consumer
Protection Act (CPA) 1986 amended from time to time provides for the legal right of the patient to be informed
about the quality, quantity, potency, purity and standard of services provided to the consumer. Further the
Right to Information Act also provides for right to medical information. The policy to be followed by all medical
establishments in the Armed Forces is as under:
(i) Medical documents can be produced in a court of law under the instructions of competent legal
authorities.
(ii) Patients / NOKs will be informed verbally about the medical status and management of a case on
a daily basis, particularly when a request is made. A medical summary of the case along with results of
investigations undertaken and treatment provided will be handed over to the patients / NOKs in addition
to the info being endorsed on the discharge slip, as and when requested by the patients / NOKs. This
is aimed at satisfying the needs of the patients / NOKs as well as facilitate subsequent management at
a different medical facility. The fact that a summary has been handed over to the patient / NOK will be
prominently endorsed on the case sheet.
(iii) On transfer of a patient from one hospital to another, the medical case sheets and connected
medical documents pertaining to the case will be handed over to the patient or an attendant, if detailed,
to accompany the patient, in a sealed envelope, for delivering them to the receiving hospital. Before
sending the documents, OC of the forwarding hospital will satisfy himself that the documents are up -
to - date and the word ‘Transferred’ is inserted in the columns provided for in the medical case sheets,
admission card, Field Medical card and clinical chart.
(iv) The disposal of non-fatal cases is as given under:
Table 22.31 : Disposal of Non-fatal Cases
Category Authority to Whom Documents are Forwarded

Officers other than AMC, AD Corps and AG / Org-9

MNS discharged to duty

AMC, AD Corps and MNS officers MPRS (O)

Cadets declared fit to continue training Comdt of the training institution

JCOs / OR Record Office concerned under intimation to individual’s unit

Families of Armed Forces May be destroyed at discretion of OC hospital soon after

personnel / civilians paid from Defence discharge of patient from hospital, if no follow up action is to be
Services Estimates taken

(c) FCDs in Air Force and Navy.

(i) Processing of FCDs in Air Force is guided by Para 5.2.20 of IAP 4307.
(ii) Processing of FCDs in Navy is guided by Navy letter 76077 / Fatal / DGMS- 5A dt 04 Aug 20.

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Suggested Readings.
1. AO 09 / 2011- Heath care system in the Army: Instr for medical examination and classification of serving officers
2. AO 03 / 2001- Heath care system in the Army: Instr for medical examination and categorization of serving
JCOs / OR
3. AO 3 / 89- Release Medical Board
4. Ministry of Defence letter No. 16(3) / 2023 / D(Pen / Pol)Vol-II dated 21.09.2023.
5. Entitlement Rules for Casualty Pension and Disability Compensation awards to Armed Forces Personnel, 2023.
6. Guide to Medical Officers (Military Pensions) - 2023.
7. IHQ of MoD (Army) letter No 76086 / Policy / DGMS-5A dated 22 Feb 2023.
8. IAP 4303 6th Ed (2024)- Manual Of Medical Examination And Medical Boards, IAP 4307- Manual of Administration
for Medical Officers
9. NO 07 / 2014- Medical Boards Classification Serving Officers / Cadets / Sailors / Recruits
10. NO 14 / 2014- Navy Order On Annual Medical Examination And Periodic Medical Examination Of Officers And
Sailors.
n

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Chapter
XXIII
IMMUNIZATION

23.1 History of Immunization.

The history of immunization spans millennia, with its origins tracing back to ancient civilizations like China and
India, where variolation—a primitive form of inoculation—was practiced. However, the modern era of immunization
began in the late 18th century when Edward Jenner developed the first successful vaccine against smallpox. In
1774 Benjamin Jesty tested his hypothesis that infection with cowpox – a bovine virus which can spread to humans
– could protect a person from smallpox and subsequently English physician Edward Jenner inoculated 8-year-old
James Phipps with matter collected from a cowpox sore on the hand of a milkmaid. Phipps remained in perfect
health and became the first human to be vaccinated against smallpox. The term ‘vaccine’ is later coined, taken
from the Latin word for cow, vacca. It paved the way for further vaccines like the anti rabies vaccine by Louis
Pasteur in 1885. Nine-year-old Joseph Meister, who had been mauled by a rabid dog, was the first human to
receive this vaccine and after 12 doses he had been saved. Since then there has been rapid advancement till
date for vaccine preventable diseases. From experiments and taking chances to a global vaccine roll-out during
an unprecedented pandemic, immunization has a long history (Table 23.1).

Table 23.1 : Vaccines – Milestones

19TH CENTURY
1880 – First vaccine for cholera by Louis Pasteur
1885 – First vaccine for rabies by Louis Pasteur and Émile Roux
1890 – First vaccine for tetanus (serum antitoxin) by Emil von Behring
1896 – First vaccine for typhoid fever by Almroth Edward Wright, Richard Pfeiffer and Wilhelm Kolle
1897 – First vaccine for bubonic plague by Waldemar Haffkine

20TH CENTURY
1921 –Tuberculosis by Albert Calmette 1967 – Mumps
1923 – Diphtheria by Gaston Ramon, Emil von Behring and Kitasato 1970 – Rubella
Shibasaburo
1924 – Tetanus (TT) by Gaston Ramon, C. Zoeller and P. Descombey 1977 – Pneumonia (Streptococcus pneumoniae)
1926 –Pertussis (whooping cough) by Leila Denmark 1978 – Meningitis (Neisseria meningitidis)
1932 – Yellow fever by Max Theiler and Jean Laigret 1981 – Hepatitis B
1937 – Typhus by Rudolf Weigl, Ludwik Fleck and Hans Zinsser 1984 – Chicken Pox
1937 – Influenza 1985 – Haemophilus influenzae type b (HiB)
1940 – Japanese Encephalitis 1989 – Q fever
1941 – Tick-borne encephalitis 1990 – Hantavirus Hemorrhagic Fever With
Renal Syndrome
1952 – Polio (Salk vaccine) 1991 – Hepatitis A
1954 – Anthrax 1998 – Lyme disease
1962 – Polio vaccine (Sabin vaccine) 1998 – Rotavirus
1963 – Measles

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21ST CENTURY
2000 – First pneumococcal conjugate vaccine approved 2015 – Malaria
2003 – First nasal influenza vaccine 2015 – Dengue Fever
2006 – Human Papillomavirus 2019 – Ebola
2006 – Herpes Zoster Vaccine for shingles 2020 – COVID-19
2012 – Hepatitis E 2023 – Respiratory Syncytial Virus Vaccine
2012 – Quadrivalent (4-strain) influenza vaccine 2023 – Chikungunya
2013 – Enterovirus 71, one cause of hand, foot and
mouth disease

23.2 Introduction.
Burnet and Medawar, Nobel Prize winners in 1960, put forth the concept that ‘Man had learned to tolerate his tissues
(self) and was intolerant to foreign tissues (i.e. not self).’ The concept of ‘self’ and ‘not self,’ therefore, means that
under normal conditions, the body tolerates its tissues (immunological tolerance) and recognizes and destroys foreign
tissues. In the modern sense, immunity has been defined as the body’s ability to recognize, destroy and eliminate
antigenic material foreign to itself.

23.3 Antigens.
An antigen is defined as a substance that, when introduced into the tissues, stimulates the production of specific
antibodies and combines specifically with the antibody so produced. By far, the best antigens are proteins (e.g. diphtheria
toxin, tetanus toxin); others include polysaccharides (e.g. blood group antigens), lipids and nucleic acids. There are also
incomplete antigens called ‘haptens,’ which by themselves, are not antigenic but can provoke an immune response
by combining with one of the body’s proteins in such a way that the protein becomes ‘foreign’ to the body. Penicillin
is an example of a ‘hapten.’
On contact with an antigen, the host can respond in three different ways:
(a) A circulating antibody is formed.
(b) A delayed-type cell-mediated hypersensitivity reaction may result in the second contact with the antigen.
(c) Tolerance, which means that on the second contact with the same antigen, no response will be provoked.
The type of response in a particular case will depend largely on the antigen itself, the dosage, the route of application
and possibly on other lesser-known factors.

23.4 Antibodies.
An antibody is a protein substance that appears in the body as a result of the invasion of an antigen. It is capable of
reacting specifically with the same antigen, which provokes its production. The sites of maximum antibody formation
are the lymph nodes and spleen. Smaller collections of antibody-producing cells are widely scattered in various tissues
throughout the body. Plasma cells also produce antibodies. Antibodies may be antitoxic, such as those for diphtheria
and tetanus, antibacterial, like those for typhoid or antiviral, such as those for polio.

23.5 Antisera.
Antisera are of three types: ­
(a) Antibacterial Sera.
When a bacterial cell body itself is used to produce an antiserum, the antibodies in it have the power to
agglutinate, opsonize, kill or lyse the bacterial cell; such antiserum is known as antibacterial serum, e.g. anti-
streptococcal, anti-meningococcal and anti-plague sera.
(b) Antitoxic Sera.
If the filtered toxin of a bacterium is used, the protective substance present in antisera only neutralizes the

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toxins of the organism without affecting the organism itself; such a serum is known as antitoxic serum, e.g.
anti-diphtheritic, anti-tetanus and anti-snake venom sera.
(c) Convalescent Sera.
The serum of recovered cases of viral diseases like measles and poliomyelitis contains specific antibodies against
the virus; such serum is known as ‘convalescent’ or antiviral serum. It contains no foreign protein and therefore,
is not likely to produce serum reactions or sensitization.
‘Hyperimmune’ sera are concentrated immune sera, e.g. given to severe cases of rabid dog bites. Gamma
globulins are the active antibodies extracted from immune sera.

23.6 Immunoglobulins.
These comprise families of closely related globulin molecules, which are synthesized by cells of the reticuloendothelial
system. The human immunoglobulin system is divided into five major classes: IgG, IgA, IgM, IgD and IgE. The molecule
of each immunoglobulin is understood to consist of K (Kappa) and L (Lambda) polypeptide chains. It is still an open
question whether all immunoglobulins are antibodies that have arisen because of antigenic stimulation.
(a) lgG.
Repeated exposure to antigen leads to its accumulation in the serum, comprising about 80% of serum antibodies in
an adult. Antibodies to gram-positive pyogenic bacteria and antiviral and antitoxic antibodies are found exclusively
among IgG globulins. This immunoglobulin is transported across the placenta. Maternally derived IgG is slowly
replaced by actively synthesized IgG, which appears at 1-3 months of age and then rapidly rises; adult levels
are reached by the age of 1-2 years. The normal adult serum level of IgG is 600-1,800 mg / 100 ml.
(b) lgA.
This fraction has been found to contain isohaemagglutinins, anti-brucella, anti-diphtheria antibodies and comprises
about 10% of the serum antibodies. Saliva, colostrum and tears are relatively rich in this fraction. Nasal and
bronchial secretions, bile, intestinal juices, and prostatic fluid also contain IgA. It seems to play a decisive role
in local immunity. IgA synthesis begins two weeks after birth. The normal adult serum level is 70-380 mg / 100
ml.
(c) lgM.
This specific fraction of antibodies has been observed to hold a significant ability to agglutinate and fix complement.
Wasserman antibodies and bactericidal antibodies against Gram-negative organisms, specifically endotoxins, are
predominantly detected in Immunoglobulin M (IgM). This type of antibody accounts for a mere 5 to 10% of the
serum’s antibodies and is unable to cross the placenta. The standard range of the IgM serum level in adults is
between 20 to 130 mg per 100 ml.
(d) lgD.
The present antibody is categorized as a monomeric isotype and is generally found to be associated with immature
B-lymphocyte membranes. Although its precise function within the human immune system is yet to be comprehensively
elucidated, normal levels of this antibody in adult serum typically range between 4-40 mg / 100 ml.
(e) lgE.
The antibodies in this fraction can fix themselves firmly to tissues and remain so fixed. They are likely to play
an important role in allergic reactions.

23.7 Interferon.
Interferon is an antiviral substance produced early in virus infections. Originally only viruses were thought to be capable
of inducing the production of interferon, but now it is known that various other agents like bacteria, Protozoa, rickettsia,
microbial extracts and synthetic polymers are also capable of eliciting interferon response. Human interferon is a specific
protein having a molecular weight of 18,000 to 30,000. The most important characteristic of interferon is its ‘species
specificity’. It does not prevent virus attachment to the cell, penetration into the cell or release from the cell. Instead, it
blocks the synthesis of new viruses within the cell. Interferon does not act directly on viruses. Interferons exert cellular
activities by binding to specific membrane receptors on the cell surface, initiating a complex sequence of intracellular
events, which are not clearly understood. However, studies show that it inhibits viral replication, enhances phagocytic

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activity of macrophages and augmentation of the specific cytotoxicity of lymphocytes for target cells. Interferons (a-2b)
also suppress cell proliferation which is therapeutically used in the treatment of multiple myeloma, malignant melanoma
and Kaposi’s sarcoma. It is now conceded that interferon is an important humoral factor in the defence mechanism of
the body, coming into operation before the appearance of specific antibodies. Interferon, in some cases, can appear
as early as 1 to 2 hours after infection and increases in amount until by the 2nd or 4th day when the levels are high
enough to inhibit the multiplication of many viruses.

23.8 Immune Mechanism.

The immune system of the body may be considered under 2 divisions: Humoral Immunity and Cellular immunity. These
two divisions are illustrated in Fig 23.1. There are two types of lymphocytes: one derived from the thymus (T cells)
and the other derived from bone marrow (B cell). T cells circulate in the body and are responsible for the recognition
of antigens, but they do not secrete antibodies. T cells are of two types - ‘Helper T cells’ and ‘Suppressor T cells’.
‘Helper T cells’ are required for the optimal production of antibodies to most antigens. ‘Suppressor T cells’ inhibit
immunoglobulin synthesis. These cells are implicated in immunodeficiency and autoimmunity. The B­ cells and the cells
derived from them (plasma cells) contribute to immunity by their unique capacity to synthesize and secrete antibodies.
It is now becoming increasingly recognized that vaccines eliciting mainly or exclusively antibody production may be
ineffective and that effective prophylactic immunization may require immunization procedures also aimed at eliciting
the cell-mediated immunity. Broadly, humoral immunity is elicited by B-cell response whereas the cell-mediated type is
driven by mature T-cells, macrophages and the release of cytokines towards the antigen.

Fig 23.1 : Immune System of the Body

23.9 Types of Immune Response.

(a) Primary Response.
The first encounter with an antigen is known as the primary response.
(b) Secondary (Booster) Response.
Re-encounter with the same antigen causes a secondary response and is rapid and more powerful.
The immune response generally depends on the following factors.
(i) Nature and dose of antigen
(ii) Route of administration
(iii) Type of adjuvants used
(iv) Nutritional status of the patient

23.10 Classification.
The modern word “immunity” derives from the latin immunis meaning exemption from military service, tax payments or

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other public services and is defined as “Ability of an organism to recognize and defend itself against specific pathogens
or antigens”.
Immunity can be classified as innate (natural) or adaptive (acquired) which can be active or passive immunisation.
(Table 23.2)
(a) Innate Immunity.
Innate or inherent immunity is that which the individual possesses by virtue of his constitutional and genetic
makeup. For example, man is resistant to the virus that causes rinderpest in cattle. Similarly, S. typhi, which
produces serious invasive disease in man, is non-pathogenic under normal conditions in mice. This is called
‘species immunity.’ There are also interspecies differences in the resistance to infection. The best example of this
is the resistance of Algerian sheep to anthrax compared with European sheep. This is called ‘racial immunity.’
(b) Acquired Immunity.
Acquired immunity is also called adaptive immunity and develops only after exposure to inducing agents such
as microbes, toxins or other foreign substances.
Table 23.2 : Types of Immunity
IMMUNITY
INNATE ACQUIRED
Active Passive
Natural. Natural.
O Natural attack by disease From mother via
O Sub-clinical infection O Placenta
O Milk
Acquired. Artificial.
O Live vaccine O Antitoxin
O Killed vaccine O Gamma-globulins
O Toxoid
Differentiating features between innate and acquired / adaptive immunity is enumerated in Table 23.3.
Table 23.3 : Difference Between Innate Immunity and Acquired Immunity
Innate immunity Acquired Immunity
Its response is antigen independent. Its response is antigen dependent.
There is an immediate response. There is a lag time between exposure and maximal
response.
It is not antigen specific. It is antigen specific.
Exposure does not result in the induction of memory Exposure results in the induction of memory cells.
cells.
Some of its cellular components or their products may Some of its products may aid specific immunity.
aid specific immunity.
(i) Active Immunity.
Active immunity is the immunity that the individual develops as a result of natural infection with an agent,
either recognized or in-apparent. It may also be produced by:
(aa) Immunization with an antigen that may be inactivated (killed vaccine) or a living attenuated
strain of some organism (live vaccine).
(ab) Injection of an altered toxin (toxoid).

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(ii) Passive Immunity.

When protection against disease is given through the introduction of antibodies antitoxin or other substances,
which have been actively produced in other human beings or animals, it is known as passive immunity.
Passive immunity may be acquired naturally from the mother via the placenta or through the mother’s milk.
It can also be acquired through artificial means by antisera prepared against specific diseases such as
tetanus, diphtheria, gas gangrene and rabies; human gammaglobulin which contains 15 to 20 times more
antibodies than an equivalent amount of serum; and transfer of lymphocytes to induce passive cellular
immunity. Cellular immunity may protect against viruses, intracellular bacteria, fungi and some protozoa.
Active versus Passive Immunity
Some differentiating points between active and passive immunity are given in Table 23.4.
Table 23.4 : Comparison Between Active and Passive Immunity
Active Immunity Passive Immunity
Usually produced in response to bacteria, viruses, Produced by serum containing already prepared
toxins or toxoids. antibodies.
Body cells take an active part in the production of Cells of the body do not take part in the production of
immunity. antibodies.
It takes some time to develop the antibody in the No time is lapsed to get the antibodies circulating in the
system. system.
Immunity lasts long. Immunity lasts for a short period, usually 10-14 days.
Used for pre pathogenic prophylaxis and treatment Used for treatment of acute infection and for tiding over
of subacute or chronic infections in order to the crisis or incubation period.
increase resistance of the body.

23.11 Local Immunity.

The cells of the tissue attacked are as much concerned with offering resistance to the infecting agent as the antibodies
or phagocytes; this is the local immunity. Local immunity is believed to be produced by the fixation of various specific
humoral antibodies in tissues and cells; or it may be the nonspecific response of local tissues, induced by a local
application of antigen, against a subsequent infection-threatening systemic disease. This principle is now employed for
producing immunity against poliomyelitis by giving Sabin’s oral poliomyelitis vaccine.

23.12 Herd Immunity, Herd Effect, Herd Protection and Contact Immunity.
“Herd immunity” refers to “the proportion of subjects with immunity in a given population” or in other words, it reflects
the “immunity of a population or a community” reflecting the literal meaning of the word. It should not be confused with
the “herd effect” which is defined as “the reduction of infection or disease in the unimmunized segment as a result of
immunizing a proportion of the population”. Herd effect is due to reduced carriage of the causative microorganism by
the vaccinated cohort and thus is seen only with vaccines against those diseases where humans are the only source.
An effective vaccine is a prerequisite for good herd effect; tetanus and BCG vaccines have no herd effect. Conjugated
pneumococcal and Hib vaccines have good herd effect.
Conventionally, “herd immunity” theory suggests that, in contagious diseases that are transmitted from individual
to individual, chains of infection are likely to be disrupted when a large number of populations are immune or less
susceptible to the disease. For example, in Finland when coverage with 3 doses Inactivated Polio Vaccine (IPV) reached
51%, the poliomyelitis disappeared from the country. The greater the proportion of individuals who are resistant, the
smaller the probability that a susceptible individual will come into contact with an infectious individual. However, it
does not apply to diseases such as tetanus (which is infectious but is not contagious), where the vaccine protects only
the vaccinated person from disease.
“Herd immunity” should not be confused with “contact immunity”, a related concept wherein a vaccinated individual
can “pass on” the vaccine to another individual through contact. Not all vaccines possess this virtue which is mainly
the quality of certain live attenuated vaccines that shed very efficiently either through gut or nasal mucosa though still
producing “herd effect” and contributing in the generation of “herd immunity”. OPV has this unique quality and provides

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efficient “contact immunization”. Another live oral vaccine like the rotavirus vaccine may theoretically also exhibit this
phenomenon; however, the evidence is lacking. On the other hand, IPV despite providing “herd immunity” and “herd
effect”, does not provide “contact immunity”. The greater the transmissibility, the higher the contact immunization.
“Herd protection” is another term often used to describe a group of unimmunized individuals that remain protected in
a herd by virtue of protection rendered by immunized individuals in a herd or population. However, when this group
of individuals moves out of that group / population, they again become susceptible. In this situation, the unvaccinated
individuals are indirectly protected by vaccinated individuals, as the latter will not contract and transmit the disease
between infected and susceptible individuals.
Herd immunity results from immunization or infection which is transmitted from human to human or otherwise. Herd
effect results from immunization or other health intervention / program in the community as such program(s) reduce
the probability of transmission of infection in the community.

23.13 Epidemiologic Shift.

This refers to an upward shift in the age of infection / disease in communities with partial immunization coverage. Owing
to vaccination, the natural circulation of the pathogen decreases and the age of acquisition of infection advances. This
is especially important for diseases like rubella, varicella and hepatitis A, wherein the severity of the disease worsens
with advancing age.

23.14 Immunization.
WHO defines Immunization as a process whereby a person is made resistant to a disease, typically by the administration
of a vaccine. Types of vaccines are given in Table 23.5.
Table 23.5 : Types of Vaccine
BCG Cholera
Bacterial
Typhoid (Oral)
Yellow fever Varicella
Live attenuated vaccines Oral polio (Sabin) Rotavirus
Viral Measles Influenza-nasal
Rubella Dengue
Mumps
Typhoid Pertussis
Bacteria
Cholera Plague
Hepatitis A Japanese encephalitis
Inactivated or killed vaccines
Rabies KFD
Virus
IPV COVID-19
Influenza
Subunit (purified antigen) Virus Hepatitis B
Diphtheria Tetanus
Toxoid Bacteria
Acellular pertussis Anthrax
Hepatitis A Rubella
Human normal
Human Immunoglobulins Measles Tetanus
Immunoglobin
Mumps Rabies
Diphtheria Botulism
Bacterial
Non-human (Antisera) Tetanus Gas gangrene
Virus Rabies

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(a) Live Vaccines.

Are prepared from live attenuated organisms. They are very potent immunizing agents because:
(i) Live organisms multiply in the host.
(ii) All major and minor antigenic components are present.
(iii) Target organs may be colonized.
(iv) May replace wild strains in the community.
However, live vaccines also suffer from some drawbacks. Safety is an issue because mutation may take place
resulting in disease. Live vaccines cannot be used for immune deficient patients and they cannot be used during
pregnancy. Two important precautions must be observed while using live vaccines. Two live vaccines are usually
not used together. They are to be given at different sites or three weeks apart. The other important aspect that
must be kept in mind is that live vaccines have exacting storage requirements.
(b) Inactivated (Killed) Vaccines.
These are prepared from organisms killed by heat or chemicals. Killed vaccines are very safe but less efficacious
than live vaccines. They require multiple doses which may be administered as a series of primary doses followed
by regular booster doses. The only absolute contraindication is hypersensitivity.
(c) Toxoids.
These are produced from detoxicated toxins. The body produces antibodies against the toxin in response to
toxoids. They offer no protection against infection. Toxoids are very safe and highly effective.

23.15 Other Components in Vaccines (Excipients).

(a) Adjuvant.
Sometimes a substance is added to a vaccine to enhance the immune response by degree and / or duration,
making it possible to reduce the amount of immunogen per dose or the total number of doses needed
to achieve immunity. The commonly used adjuvant are aluminium salts (aluminium hydroxide, aluminium
phosphate or potassium aluminium sulfate) which primarily enhance the immune response to proteins. They
have been shown to be safe over several decades of use. Rarely, they may cause injection site reactions,
including subcutaneous nodules, sterile abscess, granulomatous inflammation or contact hypersensitivity. Table
23.6 shows the approved human vaccine adjuvants in use, their class, components and the vaccines in which
they are used.
Table 23.6 : Human Vaccine Adjuvants
Name Class Components Vaccine
Alum Mineral salts Aluminium phosphate, aluminium Diphtheria, tetanus,
hydroxide pneumococcus, HAV,
HBV, anthrax, tick-borne
encephalitis, MenC, HPV
MF59 Oil-in-water emulsion Squalene, Tween 80, Span 85 Seasonal and pandemic
influenza
AS03 Oil-in-water emulsion Squalene, Tween 80, α-tocopherol Pandemic influenza
AF03 Oil-in-water emulsion Squalene, Montane 80, Eumulgin B1PH Pandemic influenza
Virosomes Liposomes Phospholipids, cholesterol, ÍÀ Seasonal influenza, HAV
AS04 Alum-adsorbed TLR4 agonist Aluminium hydroxide, MPL HBV, HPV
RC-529 Alum-adsorbed TLR4 agonist Aluminium hydroxide, synthetic MPL HBV
HAV - Hepatitis A Virus; HBV - Hepatitis B Virus; HPV - Human Papilloma Virus; Men - Meningococcus,
MPL - Monophosphoryl Lipid A; TLR - Toll Like Receptor

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(b) Antibiotics.
Antibiotics are used during the manufacturing phase to prevent bacterial contamination of the tissue culture
cells in which the viruses are grown. For example, MMR vaccine and IPV each contains less than 25 micrograms
of neomycin per dose (less than 0.000025 g). Persons who are known to be allergic to neomycin should be
closely observed after vaccination so that any allergic reaction can be treated at once.
(c) Preservatives.
These are chemicals (e.g. thiomersal, formaldehyde) added to killed or subunit vaccines in order to inactivate
viruses, detoxify bacterial toxins and to prevent serious secondary infections as a result of bacterial or fungal
contamination.
(d) Stabilizers.
To confirm product quality or stability, compounds may be added to vaccines for a variety of manufacture related
issues: controlling acidity (pH); stabilizing antigens through necessary steps in the manufacturing process, such
as freeze drying; and preventing antigens from adhering to the sides of glass vials with a resultant loss in
immunogenicity. Examples of such additives include potassium or sodium salts, lactose, human serum albumin
and a variety of animal proteins, such as gelatine and bovine serum albumin.

23.16 Adverse Events Following Immunization (AEFI).

An Adverse Event Following Immunization (AEFI) is defined as any untoward medical occurrence that follows immunization
and does not necessarily have a causal relationship with the usage of the vaccine. The adverse event may be any
unfavourable or unintended sign, abnormal laboratory finding, symptom or disease. The majority of adverse events are
coincidental, i.e., unrelated to the vaccine or vaccination process but have to be reported as the symptoms or signs
have occurred after vaccination.
(a) Types of AEFIs.
In 2024, a revised classification relevant to the cause-specific categorization of AEFIs was introduced and the
same is enumerated in Table 23.7.
Table 23.7 : Cause-specific Categorization of AEFIs
Cause-specific type of AEFI Definition
Vaccine product-related reaction An AEFI that is caused or precipitated by a vaccine
due to one or more of the inherent properties of the
vaccine product
Vaccine quality defect-related reaction (Both 1 & 2 An AEFI that is caused or precipitated by a vaccine that
were earlier categorised in Vaccine Reaction) is due to one or more quality defects of the vaccine
product, including its administration device as provided
by the manufacturer
Immunization error-related An AEFI that is caused by inappropriate vaccine
handling, prescribing or administration and thus by its
reaction (formerly “programme error”)
nature is preventable
Immunization triggered An AEFI arising from anxiety about immunization
stress response (earlier
Immunization anxiety related reaction)
Coincidental event An AEFI that is caused by something other than the
vaccine product, immunization error or immunization
anxiety
(b) Types of Adverse Events Following Immunizations Based on Severity.
(i) Serious AEFI. An AEFI is considered serious if it:
(aa) Results in death, hospitalization or persistent or significant disability / incapacity.

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(ab) Occurs in clusters.

(ac) Causes parental / community concern.
(ad) Or results in a congenital anomaly / birth defect.
(ii) Severe AEFI.
Severe AEFIs are minor AEFIs with increased intensity / severity, e.g. high-grade fever following pentavalent
vaccination or post-DPT swelling extending beyond the nearest joint. The patient may not be hospitalized
and will not have sequelae.
(iii) Minor AEFI.
Minor AEFIs can be local reactions (pain, swelling and redness) or systemic reactions (fever > 38°C,
irritability, malaise, etc.), which can be managed with antipyretics and anti-inflammatory medications and
resolve within 2–3 days.

23.17 Common Reactions.

Immunization is not completely free from hazards. However, with due precautions, they can be prevented and controlled.
Their incidence is very low. Active immunization may cause local or systemic reactions. The local reaction consists of
soreness at the site of injection. This is more often present after the injection of a bacterial vaccine, particularly the
Typhoid vaccine than after the toxoid. If the toxoid contains alum, a fibrous nodule and occasionally a sterile abscess
cyst may form; therefore, such materials should not be injected too superficially. Systemic reactions like fever, headache,
malaise and nausea are more common after bacterial vaccines like Typhoid and may last for one to two days. Very
rarely, a condition of protein shock with rigour and high temperature may manifest within half to one hour after injection
if some of the material has accidentally entered a vein.
Administration of antisera may cause either a sudden allergic or anaphylactic shock or a delayed serum sickness.
Allergic shock is most likely to occur in persons who have some inborn or acquired predisposition to allergic disorders
like asthma, eczema or urticaria. Before giving an antiserum the personal and family history of such allergic conditions
should be inquired into. If in doubt, an intradermal injection of 0.1 ml of 1:100 diluted serum should be given. This will
produce a local wheal and erythema in a sensitized person who may then be particularly and temporarily desensitized
by repeated small injections of the antiserum.
Injection of any foreign protein may cause, within a short time, an acute anaphylactic reaction with dyspnoea, pain in
the chest and oedema of the glottis and face. In the presence of a definite history of a previous injection of serum or
of allergy to a foreign protein, especially horse serum, a test dose of 0.2 ml of undiluted serum should be given; if there
is no general reaction in 30 min the balance of the full dose can be given. Safer practice is to give the test dose 1:10
dilution of antitoxin and 30 min later 0.2 ml of undiluted antitoxin if there is no general reaction. The full dose may
then be given after 30 min if there is again no reaction. If there is a reaction, the dose of 0.2 ml of undiluted antitoxin
should be repeated after the blood pressure has become normal and rashes have subsided, usually in 6 to 12 hours. If
no general reaction occurs after 30 min the dose can be given. Every time serum is given a syringe filled with 2 ml of
1:1000 adrenaline (1 ml ampoule comes with 1 mg in 1 ml i.e. 1:1000 dilution), 200 mg of hydrocortisone hemisuccinate
and oxygen must be handy to counteract such condition and the patient should be kept under observation for half an
hour. General measures to combat shock and occasionally, steroid therapy may be required.
The objective of the trial dose is to determine any predisposition to the general reaction and not the local reaction. As
an alternative for those rare cases in which antitoxin is needed and the horse serum is contraindicated, human gamma
globulin might be used. Convalescent human serum, especially those prepared from pooled blood may cause serum
jaundice two to three months after the injection. This risk can be prevented by sterilizing the serum with ultraviolet
radiation. This is particularly non-existent with concentrated gamma globulin.

23.18 Mass Immunization.

The case for a mass immunization programme as a public health measure depends on the prevalence and socio-
economic importance of the particular disease; the relative value of immunization compared with other control measures;
the safety, efficacy and practicability of the particular immunization and its procedure; the availability, producibility and
cost of the immunization agent; and the non-endemicity of infections that may be introduced from another country,
such as yellow fever. Infectious diseases against which immunizing agents are available may be divided, from the point
of view of epidemiological control, into three groups:

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(a) Those in which there is no other satisfactory method of control such as diphtheria, tetanus, whooping
cough, poliomyelitis, influenza and sylvatic yellow fever.
(b) Those in which prophylactic vaccination would be useful along with other control measures such as
typhoid, cholera, tuberculosis, rabies and yellow fever.
(c) Those in which the value of vaccination is limited in view of the availability of other better control
measures such as plague, brucellosis, leptospirosis and certain forms of encephalitis.
Each country has its priority list according to its known needs. Smallpox, which had very high priority in Eastern and
Mid-Eastern countries, has now been successfully eradicated from the world. Diphtheria, tetanus, whooping cough
and measles are still highly prevalent in many of these countries. Immunization against yellow fever and influenza
is of more restricted application. Typhoid also occupies a place of priority in most developing countries where it
is very prevalent, although its long-term control, without doubt, depends on good standards of environmental
sanitation and household hygiene. Mass vaccination plays a useful part as a short-term prophylactic measure,
particularly in close communities like the Armed Forces. Vaccination against most zoonosis, e.g. brucellosis,
tularaemia, anthrax and insect-borne encephalitis, will be of less importance except in areas of high prevalence,
as these diseases are more intimately linked with the control of disease in animals.

23.19 Catch-Up Immunization.

Vaccination catch-up regimens are generally individualized. Any number of vaccines live or inactivated may be given on
the same day either singly or as combination vaccines maintaining a gap of 5 cm between different vaccines. Inactivated
vaccines can be given at any time in relation to any other live or inactivated vaccines. If not given on the same day,
a gap of 4 weeks should be maintained between two live injectable vaccines, especially MMR and varicella and also
yellow fever and LAIV (Live Attenuated Influenza Vaccine). However, OPV, rotavirus and oral typhoid vaccines may be
given at any time in relation to any live or inactivated vaccine. For catch-up immunization, doses should preferably be
given at the minimum possible interval to entail early protection.

23.20 The Cold Chain.

Cold chain is a system of storing and transporting vaccines at recommended temperatures from the point of manufacture
to the point of use. The cold chain system is necessary because vaccine failure may occur due to failure to store and
transport under strict temperature controls. The cold chain system is depicted in Fig 23.2.
The key elements of the cold chain are:
(a) Personnel: To manage vaccine storage and distribution (vaccine and cold chain handler at each cold
chain point).
(b) Equipment: To store and transport vaccine and monitor temperature.
(c) Procedures: To ensure correct utilization of equipment and ensure vaccines are stored and transported
safely.

Fig 23.2 : Cold Chain System

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23.21 Temperature Requirement for Vaccines

Vaccines are sensitive biological products. Some vaccines are sensitive to freezing, some to heat and others to light
(Table 23.8). Vaccine potency, meaning its ability to adequately protect the vaccinated patient, can diminish when the
vaccine is exposed to inappropriate temperatures. Once lost vaccine, potency cannot be regained. To maintain quality,
the vaccine must be protected from temperature extremes. Vaccine quality is maintained using a cold chain that meets
specific temperature requirements. All those who handle vaccines and diluents must know the temperature sensitivities
and the recommended storage temperature for all the vaccines.
Table 23.8 : Sensitivity of Vaccines to Heat, Light and Freezing
Vaccine Exposure to Heat/Light Exposure to Cold
Heat and Light Sensitive Vaccines
OPV Sensitive to light Not damaged by freezing
Freezes at –0.5º C
BCG RVV and JE Relatively heat stable
(Should not be frozen)
Freezes at –3º C
IPV, DPT and TT Relatively heat stable
(Should not be frozen)
At the PHC level, all vaccines are kept in the ILR for a period of one month at temperature of +2º C to +8º C
Vaccines Sensitive to Heat Vaccines Sensitive to Freezing
Most Sensitive Most Sensitive
■ BCG (after reconstitution)
■ OPV, Rota
■ HepB
■ IPV
■ PCV
■ MR
■ Penta
■ Rotavirus
■ IPV
■ JE
■ DPT
■ DPT
■ TT
■ BCG(before reconstitution)
■ TT
■ Penta, HepB, PCV
Least Sensitive Least Sensitive

Do not keep any vials that are expired, frozen or with VVM beyond the end point in
the cold chain, as they may be confused with those containing potent vaccines.

23.22 Equipment and Procedures.

Cold chain equipment, both electrical and non-electrical, is used for storing vaccines and / or transporting them at
appropriate temperatures. Fig 23.3 summarizes the cold chain equipment supplied under the UIP. The NCCMIS (National
Cold Chain Management Information System) website is the platform where all information on the cold chain equipment
and management is being collated.

23.23 Holdover Time.

In the event of power failure, “holdover time” for any functional healthy cold chain equipment is defined as “the
time taken by the equipment to raise the inside cabinet temperature from its cut-off temperature to the maximum
temperature limit of its recommended range”, e.g. in the case of ILR, if the temperature is 4°C, then the time taken
to reach 8°C from 4°C will be the holdover time for that ILR.
(a) Holdover time of ILR depends on the following factors:
(i) Ambient temperature – more the ambient temperature, less will be the holdover time
(ii) Frequency of opening of lid and use of basket

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COLD CHAIN EQUIPMENT

ASSOCIATED TEMPERATURE
STORAGE TRANSPORTATION
EQUIPMENT MONITORING
DEVICES

NON- REFRIGERATED STABILIZER

O THERMOMETER
ELECTRICAL SOLAR O O
ELECTRICAL VAN
O GENERATOR
O ELECTRIC DATA
O INSULATED LOGGER
VAN O INVERTOR
O FREEZE
WIC COLD BOX O COLD BOX INDICATOR
SOLAR
O O

WIF VACCINE O VACCINE

O REFRIGE- O O REALTIME
CARRIER CARRIER
O ILR RATOR TEMP
O ICE-PACKS MONITORING
O DF
DEVICE

WIC - Walk In Cooler; WIF - Walk In Freezer; ILR - Ice Lined Refrigerator; DF - Deep Freezer

Fig 23.3 : Cold Chain Equipment

Table 23.9 : Technical Specifications of Cold Chain Equipment

Equipment Temperature Storage Capacity Holdover time
Electrical
Deep Freezer -15º C to -25º C Ice packs or OPV stock for 3 months At 43º C for 2 hrs
(Large) (275 to 300 Litres) 30 mins (minimum)
ILR +2º C to +8º C BCG, OPV, IPV, RVV, DPT, TT, Measles/ MR, At 43º C for 20 hrs
(Large) Hep-B, Penta, IPV, Vaccine stock for 3 months (minimum)
(135 to 160 litres)
Deep Freezer -15º C to -25º C Ice packs (105 to 125 litres) At 43º C for 2 hrs
(Small) 30 mins (minimum)
ILR +2º C to +8º C BCG, OPV, IPV,RVV, DPT, TT, Measles/ MR, At 43º C for 20 hrs
(Small) Hep-B vaccine stocks for one month (90-105 (minimum)
litres)
Non-electrical
Cold Box +2º C to +8º C All vaccines stored for transport or in case of At 43º C for 96 hrs
(Large) power failure (20 to 25 litres) (minimum)
Cold Box +2º C to +8º C All vaccines stored for transport or in case of At 43º C for 48 hrs
(Small) power failure. (5 to 8 litres) (minimum)
Vaccine carrier +2º C to +8º C All vaccines carried for 12 hours (4 conditioned At 43º C for 36 Hrs
(1.7 litres) Ice packs & 16-20 vials) (minimum)

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(iii) Quantity of vaccines kept inside with adequate space between the containers (equipment
empty / loaded)
(iv) Condition of the ice pack lining (frozen / partially frozen / melted) inside electrical / nonelectrical
cold chain equipment.
Note. Deep freezer does not have a holdover time like ILR as it does not have an ice lining inside its wall. It
is dependent on the number of frozen ice packs kept inside it.
(b) ILR point or Cold Chain Point.
An ILR point or Cold Chain Point (CCP) is located at a health centre (usually PHC / UHC / CHC / SHOs / Mil Hosp)
with an Ice Lined Refrigerator for storage of vaccines and a Deep Freezer for preparation of frozen ice packs.
The cold chain point must have a generator as power back up. The function of the CCP is to receive, store
and further distribute vaccines, diluents and other logistics to another ILR point or directly to the session sites.
(c) Cold Chain Room.
Keep all electrical
cold chain equipment
in a separate room
(Fig 23.4) with
restricted entry to
keep the vaccines
and cold chain
equipment safe and
secure. During visits
to the cold chain
room and the weekly
meetings, review
the cold chain and
vaccine distribution
system of your centre.
Ensure proper display
of all the cold chain
related job aids and
use them to refresh
knowledge and skills. Fig 23.4 : Cold Chain Room
23.24 Ice-lined Refrigerator (ILR).

NEVER keep any vials that are expired,

frozen or with VVMs beyond the end
point in the cold chain, as they may be
confused with those containing potent
vaccines. Keep them in the red bag for
disinfection and disposal.
IDENTIFY A DRY SPACE FOR STORING
EXPIRED / UNUSABLE VACCINES BEFORE
FINAL DISPOSAL

Fig 23.5 : Storing Vaccines in ILR

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A diagrammatic representation of an ILR is given in (Fig 23.5). An ILR maintains a cabinet temperature between +2°C
and +8°C. It is used to store UIP vaccines at the PHC and district levels. An ILR with a top opening lid prevents loss
of cold air during door opening and can keep vaccines safe with as little as 8 hours electricity supply in a 24-hour
period. ILRs are available in two sizes – large (for districts) and small (for PHCs). In case baskets are not available, two
layers of empty ice packs can be laid flat on the bottom of the ILR to avoid contact with the inside floor of the cabinet.
Vaccines should never be kept on the floor of the ILR. Other Do’s and Don’ts for ILR use are given in (Table 23.10).
Table 23.10 : Do’s and Don’ts for ILR Use
Do’s Don’ts
Keep all vaccines including those returned under open Do not store any other drugs / non UIP vaccines in the
vial policy in the basket supplied along with the ILR. ILR.
Store diluents at +2°C to +8°C at least 24 hours Do not open the ILR frequently.
before use.
Leave a space in between vaccine boxes Do not keep food or drinking water in the ILR.
Place a thermometer in the basket in between the Do not keep vaccines which have expired and have
vaccines. crossed the discard point of VVM.
Keep freeze sensitive vaccines at the top of the basket. Do not disturb the thermostat setting frequently.
Keep heat sensitive vaccines at the bottom of the Do not place heavy weight on the ILR.
basket.
Arrange vaccines as per the expiry dates (Early expiry Do not store excess stock of vaccines, i.e more than
should be kept above the late expiry ones). the maximum stock.

23.25 Deep Freezer.

Fig 23.6 : Freezing Ice Packs in the Deep Freezer

Freezing ice packs in the deep freezer maintains the cabinet temperature between -15°C and -25°C. Unlike the ILR,
the deep freezer has little or limited holdover time, which is dependent on the number of frozen ice packs in it (See
Fig 23.6 and 23.7 for correct placement of ice packs in the deep freezer) and the frequency of opening (See Table
23.11 for Do’s and don`ts on use of deep Freezers).
(a) At the PHC level, deep freezer is used only for preparation of ice packs.

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(b) At the district headquarters / zonal hospital in armed forces, Deep Freezers have been supplied for the
storage of recommended vaccines such as OPV and the preparation of ice packs.
Table 23.11 : Do’s and Don’ts for Deep Freezer Use
Do’s Don’ts
Use deep freezer for preparation of ice packs at the Do not keep any vaccine in the deep freezer at the sub
sub district level cold chain points (PHC / CHC / SC) district level
Use deep freezer to store OPV at the district level Never keep diluents in the deep freezer
Keep frozen ice packs in the vaccine storing deep At district level do not use the same deep freezer
freezer to increase the holdover time for simultaneously storing vaccines and preparing ice
packs

Fig 23.7 : Brick Layered Ice Packs in Deep Freezer

23.26 ILR / Deep Freezer Control Panel.

A control panel monitors the temperature / supply voltage and operates the cold chain equipment. It is placed at the
front right bottom side of the ILR and Deep Freezer. The control panel may differ as per the make / model of the cold
chain equipment. The functions of various components of the control panel are as follows:
(a) Green Light.
This is an indicator lamp, which shows that electric power is available up to the equipment from the stabilizer.
(b) Red Light (In Deep Freezer Control Panel Only).
It indicates that the temperature inside the equipment is not in safe range.
(c) Yellow switch (In ILR Control Panel Only).
It is a thermostat bypass switch used when the ambient temperature is more than 45°C or when it requires
lowering down inside temperature quickly.
(d) Thermometer.
Shows the inside temperature of the equipment.
(e) Thermostat.
A thermostat is a component which senses the temperature of inside the cabinet of the cold chain equipment
so that the system’s temperature is maintained near a desired set point. The thermostat does this by switching
the compressor on or off to maintain the correct temperature.

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23.27 Domestic Refrigerators.

Domestic refrigerators also maintain a cabinet temperature between +2°C and +8°C with a holdover time of only 4 hours.
Therefore, they are not recommended for common use in the UIP. However, they are used in urban dispensaries and by
private practitioners in urban areas due to more assured power supply and non-availability of ILRs and deep freezers.
(a) The refrigerator if used must be:
(i) Used exclusively for vaccines.
(ii) No vaccine should be kept in the compartments of the freezer, chiller, door or basket of the
refrigerator.
(iii) Follow the guidelines to store vaccines on the shelves of the refrigerator in the same order as
used for ILR.

Fig 23.8 : Storage of Vaccines in Domestic Refrigerators

23.28 Vaccine Van.

A cold box is an insulated box used for transportation and emergency storage of vaccines and ice packs. It is available
in two sizes, large and small. It is used to:
(a) Collect and transport large quantities of vaccines.
(a) Store vaccines for transfer up to 5 days, if necessary for outreach sessions or when there is a power
cut.
(b) Store vaccines in case of breakdown of ILR, as a contingency measure.
(c) Also used for storing frozen ice packs, e.g. during emergencies and before campaigns.
Packing a Cold Box (Fig 23.9)
(a) Place conditioned ice packs at the bottom and sides
of the cold box.
(b) Load the vaccines in cardboard cartons or polythene
bags.
(c) Never place freeze sensitive vaccines in direct contact
with the ice packs. Surround them with OPV / BCG / JE
vaccines.
(d) Keep a thermometer in the cold box. Fig 23.9 : Packing a Cold Box

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(e) Place a plastic sheet to cover the ice packs kept on top to ensure
full holdover time.
(f) Securely close the lid of the cold box.

23.29 Ice Packs. (Fig 23.10)

Ice packs are plastic containers filled with water. These are hard frozen in the
Deep Freezer. They are placed inside a vaccine carrier and cold box to improve
and maintain the holdover time. They are also used in ILRs as inside lining to
improve and maintain holdover time during electricity failure. Do’s and Don’ts for
use of ice packs is given in Table 23.11. About 20–25 ice packs (8–10 kg of ice)
and 35–40 ice packs (12–14 kg of ice) can be frozen in one day in small and
large Deep Freezers respectively. Standard ice packs used in UIP for cold box and
vaccine carrier are of 0.4 litre capacity.
Note. The personnel involved in preparing the vaccine carriers and “conditioned”
ice packs may include other staff of the health centre. It is essential to train these
staff as well on the importance and method of conditioning ice packs.

Fig 23.10 : Ice Packs

Table 23.12 : Do’s and Don’ts in Using Ice Packs

Do’s
Fill water only up to the level mark on the side to leave 10 mm room for expansion as water freezes.
While filling, keep the ice packs vertically upwards under the tap so that it will overflow after reaching the desired
level
Fit the stopper and screw on the cap tight
Check and ensure the ice pack doesn’t leak
Clean the Outer surface of the ice packs with dry cloths before putting into the deep freezer
Keep ice packs horizontally (not flat) in a criss cross manner in the deep freezer (see Fig 23.7) For brick layered
pattern
Keep a gap / breathing space between ice packs for freezing to be faster and uniform
Ensure use of conditioned ice packs when storing / transporting RI vaccines

Don’ts
Do not use ice packs that are cracked and / or are without cap / cork
Do not use ice packs with leakage; discard them
Never add salt to the water as it lowers the temp to sub Zero level, which is not recommended
Do not refill an ice pack every time before use; the same water can be used repeatedly

23.30 Conditioning of Ice Packs.

Ice packs come out of the freezer at a temperature of about -20°C. They need to be kept at room temperature for
a period of time to allow the ice at the core of the ice pack to rise to 0°C. This takes up to one hour at +20°C and
rather less at higher temperatures. This process is called “conditioning” (Fig 23.11).
(a) Conditioning of ice packs prevents freezing of vaccines (freeze-sensitive vaccines such as Hep B and T
series) during transportation.
(b) Freeze-sensitive vaccines can be damaged if they come in direct contact with the frozen ice packs.

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(c) At the start of session day, take all the frozen ice packs that you need from the freezer and close the
door. Lay these out on a table leaving a 5 cm space all round each ice pack.

Fig 23.11 : Conditioning of Ice Packs

23.31 Vaccine Sensitivities.

Vaccines lose their potency due to exposure to heat (temperatures above +8°C), cold (temperatures below + 2°C) and
light. Reconstituted BCG, measles / MR and JE vaccines are the most heat and light sensitive. Since these live vaccines
do not contain preservatives, there is risk of contamination with Staphylococcus aureus leading to toxic shock syndrome
and, therefore, they should be used within 4 hours of reconstitution. These light-sensitive vaccines are supplied in
amber coloured vials. Under the Open Vial Policy (OVP), any open vaccine vial returned from the field has to be used
within 4 weeks (28 days) from the date of opening, provided the Vaccine Vial Monitor (VVM) is in usable condition,
vaccine has not been frozen and is within expiry date. The vaccines that come under this policy are Hep B, OPV, DPT,
pentavalent, TT and IPV. Only those diluents that are provided with the vaccine by the manufacturer should be used.
Keep diluents in an ILR at between +2°C and +8°C at least 24 hours before use to ensure that the vaccine and diluent
are at the same temperature when being reconstituted. Keep diluents with the vaccines in a plastic zipper bag inside
the vaccine carrier during transportation. Sensitivity of various vaccines
to heat, light and freezing is given in Table 23.5.

23.32 How to Check Vaccines for Correct Maintenance of Cold

Chain.
Vaccines need to be checked both for damage from excessive heat as
well as from freezing. However, the physical appearance of a vaccine
may remain unchanged even after it is damaged.

23.33 Checking Vaccines for Heat Damage.

VVM is a label containing a heat-sensitive material to record cumulative
heat exposure over time. The combined effect of time and temperature
causes the inner square of the VVM to darken gradually and irreversibly. Fig 23.12 : Different Stages of Vaccine
Before opening a vial, check the status of the VVM (Fig 23.12). If the Vial Monitor

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VVM shows change in colour to the end point, then discard the vaccines.

23.34 Checking Vaccines for Cold Damage (Freezing).

DPT, TT, IPV, HepB and penta vaccines lose their potency if frozen. Moreover, the risk of Adverse Events Following
Immunization (AEFIs) such as sterile abscesses may increase. Freezing can occur at any level in the cold chain. Discard
the vial if it is frozen or it contains floccules after shaking. Conduct the shake test, if you suspect that a large number
of vials at the cold chain point could have been frozen. Information on vaccine sensitivities is given in Table 23.8, Do’s
and Don’ts in cold chain are given in Table 23.13. (Shake test NOT applicable for IPV)
Table 23.13 : Do’s and Don’ts in Cold Chain and Vaccine Sensitivities
Do’s Don’ts
Keep all vaccines in ILR at +2°C to +8°C at PHC Do not keep expired vials, frozen
vials or vials with VVM beyond
the end point in the cold chain.
Use diluent provided by the manufacturer with the vaccine. Do not use Rotavirus vaccines
Keep diluents in ILR at +2°C to +8°C at least 24 hours before use or reconstituted BCG, JE and
Measles / MR vaccines after 4
Use Rota virus vaccine, reconstituted BCG, JE and measles / MR within 4 hours hours
Discard all damaged vials for disinfection and disposal
(a) Shake test - Test Vial.
Take a vaccine vial you suspect that may have been frozen – This is “TEST” vial.
(b) Shake test - Control Vial.
Take a vaccine vial of the same antigen, same manufacturer and same batch number as the suspect vaccine
vial you want to test.
(i) Freeze solid this vial at -20°C overnight in the DEEP FREEZER and this is the ‘CONTROL’ vial and
label accordingly to avoid its usage.
(ii) Let it thaw. Do NOT heat it.
(iii) Hold the Control and the Test vials together between thumb and forefinger and vigorously shake
the vials for 10-15 seconds.
(iv) Place both vials to rest on a flat surface, side-by-side and observe them for 30 minutes.
(v) Compare for rate of sedimentation.
(vi) If the sedimentation rate in the “Test vial” is slower than in the “Frozen vial”, the vaccine has not
been damaged, it has passed the shake test. Use the vaccine batch – it is not damaged {Fig 23.13 (a)}.
(vii) If the sedimentation rate is similar in both vials or if sedimentation is faster in the “Test” vial than
in the “Frozen” vial, the vaccine is damaged, it failed in shake test. Do NOT use {Fig 23.13 (b)}. Notify
your supervisor.

(a) Shake Test Passes Vaccine Usable (b) Shake Test Failed– Don’t Use Vaccine
Fig 23.13

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Information Types of VVM

VVMs are unique to each vaccine.
There are four types of VVM: VVM 30, VVM 14, VVM 7 and VVM 2. The number corresponds to the number of days the
vaccine remains potent with exposure at +37°C. In combined vaccines the VVM corresponds to the most heat sensitive
component of the vaccines, e.g. in DPT vaccine the VVM corresponds to the Pertussis component of the vaccine.

23.35 Preventing Freezing of Vaccines in Extreme Cold Climates.

(a) Keep cold chain equipment in heated rooms.
(b) Do not leave cold boxes outdoors or in unheated rooms.
(c) Use room temperature water packs for vaccine transport. Fill ice packs with ordinary tap water; do not
freeze or chill them. In extremely cold conditions, use ice packs filled with warm water at 20°C.
(d) Use freeze indicators in all refrigerators and cold boxes, if possible.
(e) Use a heated vehicle. Never leave cold boxes in an unheated vehicle, especially overnight.

23.36 Storage and Use of Diluents.

Only use the diluents supplied / packaged by the manufacturer with the vaccine, since the diluents are specifically
designed for the needs of that vaccine, with respect to volume, pH level and chemical properties. The diluents should
be stored in the ILR at the last cold chain point. If the ILR has space constraints, then the diluents may be stored
outside the cold chain. However, diluents must be kept in ILR at least 24 hours before use or issuing to sessions to
ensure that vaccines and diluents are at same temperature (i.e. +2°C to +8°C) during reconstitution. Otherwise, it can
lead to thermal shock that is, the death of some or all the essential live organisms in the vaccine. Store the diluents
and droppers with the vaccines in the vaccine carrier during transportation.

23.37 Vaccine Carrier.

It is an insulated box used for carrying vaccines (16–20 vials) and diluents from the PHC / cold chain point to session
sites and to bring back the open vials (under the open vial policy) from the session sites to the cold chain point on
the same day after the session for storage and subsequent use. The vaccine carrier (with 4 conditioned ice packs)
maintains the inside temperature between +2°C and +8°C for 12 hours, if not opened frequently. Do’s and Don’ts of
vaccine carrier are given in Table 23.14.
Table 23.14 : Do’s and Don’ts in Using a Vaccine Carrier
Do’s Dont’s
Place vaccines and diluents in cartoons or polythene Never use day carriers, which contain 2 ice packs or
bags to ensure labels are protected thermos flasks for routine immunization
Use only conditioned ice packs in the vaccine carrier Never use a screwdriver or any other sharp shaft to
open the lid of vaccine carrier
Ensure that some ice is present in the ice packs while Do not drop, knock or sit on the vaccine carrier
conducting immunization session
Ensure collection of vaccines in the vaccine carrier on Do not leave the vaccine carrier in the sun light
the session day itself
Close the lid tightly and securely Do not leave the lid open once packed
Keep the interior of the vaccine carrier clean and dry
after every use

23.38 Packing a Vaccine Carrier.

(a) Confirm that there are no cracks in the walls of the vaccine carrier.

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(b) Take out the required number of ice packs from the Deep Freezer and wipe them dry.
(c) Keep them outside for conditioning before placing into the carrier.
(d) Place four conditioned ice packs into the vaccine carrier along the sides.
(e) Wrap vaccine vials and ampoules in thick paper, e.g. plain white paper before putting in a polythene
bag to prevent them from touching the ice packs. Place some packing material between “T” series vaccine
and the ice packs to prevent them from touching the ice packs.
(f) Place the plastic bag in the centre, away from the ice packs. This will prevent labels from peeling off
from the vials.
(g) Place foam pad on top of the ice packs.
(h) If more than one vaccine carrier is being carried, keep the whole range of vaccines required for the
day’s use in each carrier so that only one carrier is opened at a time.

Fig 23.14 : Correct Packing of a Vaccine Carrier

Fig 23.15 : Placement of Vaccines when at RI Session Site

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23.39 Immunization in Armed Forces.

Immunization of troops against the enteric group of fevers and tetanus has proved efficacious in reducing the incidence
of this disease and preventing outbreaks in units, though stationed amidst epidemic or endemic localities. All ranks
and their families and civilian employees, including private servants, are therefore immunized. Those who refuse or
neglect to be immunized run a personal risk and endanger the health of the community as a whole. The immunization
against quarantinable disease under the International Health Regulations, 2005 viz, yellow fever, is carried out in the
designated centres. Immunizations specially offered for infants and children are DTaP, DT, Polio, Measles and BCG.
Commanders are responsible for always maintaining the immunization state of units under their command at 100%
level against the diseases notified, providing facilities for carrying out immunization recommended, maintaining a unit
vaccination register ensuring that personnel proceeding on leave or temporary duty or permanent transfer to another
unit are fully protected before their departure and will not fall due for immunization during transit or soon after arrival at
their destination and ensure that all the families in the unit / station are fully protected. All personnel whose families are
residing in places where there are no military establishments should be advised to protect themselves from civil health
authorities. Medical Officers are responsible for maintaining facilities for carrying out immunization and administering the
same to all individuals who present themselves. They are also required to keep necessary records in the health record card
of the individuals immunized and render such returns as may be called for by higher authorities after checking the unit
immunization state. Medical officers should periodically check the protection state of the units under their medical care
and always ensure 100% protection level. Ref letter no 41187 / DGAFMS / DG-3A dated 08 Jan 2024 policy letter for Armed
Forces Immunization schedule for infants and children and DGAFMS / DG-3A note no. 41187 / DGAFMS / DG-3A dated 03
Mar 2020 for recruits, cadets and serving solders. Schedule is given in Table 23.16 and 23.17.

23.40 Immunization Records.

A register in which the details of immunizations are recorded for all ranks of the units is maintained by every unit / sub-
unit commander as shown in Table 23.15. The date of administration of Typhoid and Td should be recorded immediately
in ink. The column which shows the ‘date next due’ should always be filled in pencil. Three or four lines should be
allotted to each individual in these registers. A similar register should be maintained for families of all ranks living in
the station. The unit administrative officer should ensure that the registers are maintained up to date, checked on the
first day of every month and a list of individuals who are due for immunization sent to the MI Room / RAP. Personnel
should then be sent in batches once a week, usually on a Saturday before the actual date on which due with a nominal
roll and their Health Record Card. Entries in respect of officers and JCOs should be made in the Health Record Card
and unit copy of the medical history AFMSF-1. The medical officer should ensure that all immunizations carried out
are at the same time entered in the Health Record Card, dated and signed and the MO’s name is entered in block
capitals below his signature. From this nominal roll, the unit immunization register is brought up to date.
Table 23.15 : Register of Vaccination and Inoculation
Personal Rank / Special immunisation
Name Typhoid Inoculation Anti-tetanus (Td)
No Rate if any
Date Date next due Date Date next due Date Date next due
done (in pencil) done (in pencil) done (in pencil)

The immunization schedule recommended for families and children of the Armed Forces personnel is as under:
Table 23.16 : Armed Forces Immunization Schedule for Serving Personnel
Vaccine When to give Schedule & Dose
Tetanus and adult On entry for all cadets and recruits, then (a) Primary Immunisation
diphtheria booster every 05 years throughout service Individuals without previous immunisation
3 doses (0.5 ml IM)
1st Dose: 0 Day
2nd Dose: 4 Weeks
3rd Dose: 1 year
Previously Immunised individuals
Single Dose (0.5 ml IM)
(b) Booster Dose (0.5 ml IM)
Every 5 years or as recommended by AMA

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Vaccine When to give Schedule & Dose

Typhoid vaccine On entry for all cadets and recruits, then Initial dose
(Vi polysaccharide) every 03 years throughout the service Single 0.5 ml IM
Booster 0.5 ml IM every three year
Hepatitis-B (a) On entry for all recruits and cadets Three doses (1.0 ml IM)
(recombinant DNA (b) All healthcare workers including all 1st Dose: 0 day
vaccine) AFMS personnel 2nd Dose: At one month
3rd Dose: At six months
Varicella vaccine On entry for all cadets and recruits Two Doses: Four weeks apart
(Live attenuated 0.5 ml Subcutaneous injection (outer upper
vaccine against aspect Deltoid)
Chicken Pox)
Meningococcal On entry for all cadets and recruits Single Dose 0.5 ml Subcutaneous injection
vaccine* (outer upper aspect Deltoid)
(Polysaccharide
vaccine, tetravalent
A,C,Y,W-35 strains)
* Immunisation policy for all cadets and recruits with the Meningococcal Meningitis vaccine is presently on hold.
Instructions on the same will be passed subsequently.

Table 23.17 : Comparison of Armed Forces Immunization Schedule with UIP for Infants, Children and
Pregnant Women
Vaccine When to give Dose Route Site UIP Schedule
For Infants
BCG At birth or as 0.05 ml Intra-dermal Left upper arm Similar schedule
early as possible (0.1 ml for ages
till one year of beyond 01 to 12
age months)
Hepatitis B-Birth At birth or as 0.5 ml Intra-muscular Anterolateral Similar schedule
dose early as possible side of mid-thigh
within 24 hrs
OPV Zero Dose At birth or as 02 drops Oral Oral Similar schedule
early as possible
within the first
15 days
OPV-1,2,3 At 6 weeks, 10 02 drops Oral Oral Similar schedule
weeks & and NOTE:
14 weeks (OPV OPV-Booster at
can be given 16-24 months
till 5 years of
age during
each round
of pulse polio
immunization)
Fractional IPV At 06 weeks, 0.1 ml Intradermal Right upper arm: Similar schedule
14 weeks and 9 (fIPV 1 and 2)
months Left upper arm:
fIPV 3

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Vaccine When to give Dose Route Site UIP Schedule

Rotavirus At 6 weeks, 10 05 drops Oral Oral Similar schedule
weeks and 14
weeks 5 drops
(liquid vaccine)
or 2.5 ml
Pentavalent- At 6 weeks,10 0.5 ml Intra muscular Anterolateral Similar schedule
1,2,3 (DPT, HiB weeks & 14 side of mid-thigh
& Hepatitis B) weeks (Can be (left)
given till 1 year
of age)
Pneumococcal At 06 weeks, 14 0.5 ml Intra-muscular Anterolateral Two primary
conjugate weeks and 09 side of mid-thigh doses at 6
vaccine (PCV) months (right) and 14 weeks
10/13 followed by a
Booster dose at
9-12 months.
PCV which
was optional
before is now
mandatory since
Jan 2023
Typhoid At 09 months 0.5 ml Intramuscular Anterolateral Not included
conjugate aspect of mid-
vaccine thigh (left)
MMR 1 09 months 0.5 ml Subcutaneous Right upper arm MR 9 completed
months-12
months. (can be
given till 5 years
of age)
Japanese At 9 completed 0.5 ml Subcutaneous Left Upper arm Similar schedule
Encephalitis (JE)- months-12 only in selected
1st dose* months endemic regions
Vitamin A (1st At 9 completed 1 ml (1 Lakh IU) Oral Oral At 9 completed
dose) months with months with
MMR measles Rubella
For Children
Hepatitis A 12-15 months 0.5 ml Intramuscular Anterolateral Not included
vaccine (live and 18-24 aspect of mid-
attenuated) months thigh (right)
Varicella 12-15 months 0.5 ml Subcutaneous Left upper arm Not included
and 18-24
months (2 doses
3-6 months
apart)
OPV- Booster 16 months to 24 02 drops Oral Oral Similar schedule
months

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Vaccine When to give Dose Route Site UIP Schedule

TDaP- 1st 18 months to 24 0.5 ml Intra-muscular Antero lateral DPT booster-1
Booster months aspect of mid- at 16-24
thigh (left) months 0.5 ml
intramuscular
at anterolateral
aspect of mid-
thigh
MMR- 2nd dose 18 months 0.5 ml Subcutaneous Right upper arm Similar schedule

JE*- 2nd dose 16 months to 24 0.5 ml Subcutaneous Left upper arm Similar schedule
months only in selected
endemic regions
Vit- A (2nd to 9th 16 months to 24 2 ml (02 lakh Oral Oral 16-18 months.
dose) ** months. Then IU) Then one dose
one dose at 6 every 6 months
monthly intervals up to the age of
till the age of 5 5 years.
years.
MMR booster 05 years 2 drops Oral Oral Not included
DTaP 2 nd
booster 05 years to 06 0.5 ml Intra-muscular Left upper arm DPT 2nd booster
years
HPV vaccine 02 doses 0.5 ml Intra-muscular Upper arm Not included
at 6-month
intervals
between 09-14
years (for both
boys and girls
quadrivalent
vaccine to be
used).
Td (tetanus & 10 years and 16 0.5 ml Intra-muscular Upper arm TT with a similar
adult diphtheria years schedule
vaccine)
For Pregnant Women
Td-1 Early in 0.5 ml Intra-muscular Upper arm TT with a similar
pregnancy schedule
Td-2 *** 04 weeks after 0.5 ml Intra-muscular Upper arm TT with a similar
Td-1 schedule
Td- booster *** If received 2 0.5 ml Intra-muscular Upper arm TT with a similar
Td doses in a schedule
pregnancy within
the last 3 yrs*
* JE vaccine is introduced in selected endemic districts after the campaign & should be given as per state / district
guidelines.
** The second to ninth dose of Vit A can be administered to children 1-5 years old during bi annual rounds, in
collaboration with ICDS (Integrated Child Development Service).
*** Give Td-2 or booster doses before 36 weeks of pregnancy. However, give these even if more than 36 weeks
have passed. Give Td to a woman in labour, if she has not received Td.

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Note. Under Armed Forces Immunisation: Immunization is generally done at SHO / Hospital by health staff, monthly
ident is prepared for vaccines by SHO / Hospital. Vaccines are collected monthly by SHO / Hospital staff under liason
with DIO from the district.
General Instructions for Immunisation
The key recommendations on practical aspects of immunisation are enumerated in the box given subsequently:

– Vaccination at birth means as early as possible within 24–72 hours after birth as or at least not later than
1 week after birth.
– Whenever multiple vaccinations are to be given simultaneously, they should be given within 24 hours if
simultaneous administration is not feasible due to some reasons.
– The recommended age in weeks / months / years means completed weeks / months / years.
– Any dose not administered at the recommended age should be administered at a subsequent visit, when
indicated and feasible.
– The use of a combination vaccine generally is preferred over separate injections of its equivalent component
vaccines.
– When two or more live parenteral / intranasal vaccines are not administered on the same day, they should be
given at least 28 days (4 weeks) apart; this rule does not apply to live oral vaccines.
– If given <4 weeks apart, the vaccine given second should be repeated. The minimum interval between 2 doses
of inactivated vaccines is usually 4 weeks (except rabies)
– Vaccine doses administered up to 4 days before the minimum interval or age can be counted as valid (except
rabies). If the vaccine is administered > 5 days before the minimum period, it is counted as an invalid dose.
– Any number of antigens can be given on the same day.
– Changing needles between drawing the vaccine into the syringe and injecting it into the child is not necessary.
– Different vaccines should not be mixed in the same syringe unless specifically licensed and labelled for such use.
– Patients should be observed for an allergic reaction (anaphylaxis) for 15–20 minutes after receiving
immunization(s).
– When necessary, two vaccines can be given in the same limb (1–2 inches apart) at a single visit.
– The anterolateral aspect of the thigh is the preferred site for two simultaneous intramuscular (IM) injections
because of its greater muscle mass.
– The distance separating the two injections is arbitrary but should be at least 1 inch so that local reactions
are unlikely to overlap.
– Although most experts recommend “aspiration” by gently pulling back on the syringe before the injection is
given, there is no data to document the necessity for this procedure. If blood appears after negative pressure, the
needle should be withdrawn and another site should be selected using a new needle.
– A previous immunization with a dose that was less than the standard dose or one administered by a nonstandard
route should not be counted and the person should be re-immunized as appropriate for age.

23.41 Medico-Legal Aspects

The vaccine administrator must explain in detail the characteristics and anticipated side effects of the vaccine in
reasonable detail to the caregivers before immunization. A verbal consent is usually adequate. In any case, the recipient
must be observed for any allergic effects for at least 15 minutes after vaccination and all resuscitative equipment must
be kept on standby for possible anaphylaxis. The caregivers should also be counselled about possible side effects,
their management and danger signs before the vaccine is sent home.

23.42 U-WIN & eVIN.

(a) GoI launched a platform U-Win in Jan 2023 to digitize India’s Universal Immunization Program (UIP).
The U-WIN platform is a replica of the CO-WIN platform. It is used to register every pregnant woman, record
the delivery outcome, register every newborn baby, administer the birth dose and conduct all subsequent
vaccinations up to 5 years of age.
(b) eVIN (Electronic Vaccine Intelligence Network) is an indigenous technology system in India that digitizes

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vaccine stocks and monitors cold chain temperature using a smartphone application. It empowers cold chain
handlers and strengthens health systems by ensuring timely and equitable access to vaccines for all children.
Following are the key features of eVIN
(i) Real-time information on vaccine stocks and temperatures
(ii) Systemized stock tracking
(iii) Capacity building for cold chain handlers
(iv) Data-driven decision-making
(v) Reduced stock-outs and replenishment time

23.43 Brief on Important Individual Vaccines.

The following section gives a series of brief notes on individual vaccines included in the schedules as mentioned above.
(a) Immunization Against Typhoid.
A typhoid vaccine is used for pre exposure active immunization. The vaccine used in India is a Vi polysaccharide
vaccine (Vi capsular polysaccharide from Ty2 S) and Ty21a vaccine (lyophilized vaccine available as enteric-
coated capsules), however, Vi polysaccharide vaccine is used in the Armed Forces. Routine immunization of
all categories of entrants to the Armed Forces is to be carried out as soon as they join their training centres
by giving vaccines as mentioned in Table 23.18. The dose will be reduced for the elderly and physically weak
persons.
Reactions due to this vaccination vary in intensity from individual to individual but an overwhelming majority
do not suffer for more than 48 hours, most of them showing only malaise after 24 hours. The most commonly
occurring manifestations of the reaction are local pain, swelling and redness, fever up to 39°C, headache
and body aches. Very few persons may exhibit severe reactions like anaphylaxis, particularly those who have
a previous hypersensitivity reaction to vaccine components. Immunization does not abort the disease if the
person is already incubating the infection, but it will do him no harm and reduce the severity and cut short
the course of clinical illness.
(b) Immunization Against Tetanus.
This is an obligatory immunization in the Armed Forces. Pre exposure active immunization is carried out by
tetanus toxoid (TT / Td). For post-exposure passive immunization, anti-tetanus serum may be administered.
(i) Active Immunization.
Tetanus Toxoid (Td) is used in the Armed Forces for pre exposure immunization against Tetanus and
Diphtheria. It confers long-lasting, active immunity. All ranks are immunized as soon as they enter the
Armed forces and subsequently re-immunized with the procedure described below. The RMO should
scrutinize the records of all newly posted personnel for this requirement and always ensure that the
Immunization State of the personnel under his medical care is at 100% level. On recruitment, Armed
Forces personnel should be immunized as per Table 23.16. A high degree of immunity is conferred only
when the third dose of toxoid is administered. Therefore, it should be considered as part of the basic
course of immunization. A ‘booster’ dose of 0.5 ml given every five years maintains the immunity at a
high level. The booster dose should be repeated annually when a greater liability to injuries is expected
e.g. when a greater risk of contamination of wounds is expected e.g. while working in proximity with
animals in AT Coy or dairy farms. In the event of a wound or injury with a high risk of tetanus in a
person who is adequately immunized, a booster dose of 0.5 ml of Td should be given provided the last
dose was given more than a year back. Injections are given deep intramuscularly. Individuals with a
history of asthma or hay fever may develop an allergic reaction, otherwise, in normal individuals there
is no particular reaction. Children who have received the full course of triple antigen should get 5 yearly
booster doses of Td.
The tetanus & adult diphtheria vaccine (Td) is a combination of tetanus and diphtheria with a lower
concentration of diphtheria antigen (d) and is recommended for older children and adults. It has replaced
TT in all age groups including pregnant mothers being a safe vaccine.

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Table 23.18 : Dosage of Tetanus and Diphtheria Vaccine

Category Primary Vaccination Re-vaccination
Adult male / female First dose (ml) Second dose after Third dose after Half-yearly (ml)
& children above 4-6 weeks (ml) 6-12 months (ml)
10 years.
0.5 0.5 0.5 0.5
(ii) Passive Immunization.
Passive cum active immunization is recommended for persons who sustain potentially infected wounds
with a high risk of tetanus and who have not been actively immunized against tetanus or whose immune
status is in doubt. The person is given 1500 IU of Anti Tetanus Serum (ATS) in one arm followed by
administration of 0.5 ml Td into the other arm or gluteal region. This procedure induces an active
response with minimum interference while passive immunity wanes.
The administration of anti-tetanus serum of equine origin is encountered with dangers. In all cases, its
administration carries the risk of sensitizing the individual who will not be able to have the benefit of
any serum therapy at a later date or in the case of snakebite. In those persons who are sensitive to
horse serum, its administration will give rise to severe reactions which may sometimes lead to death.
Therefore, the best and the most practicable way of achieving protection against tetanus is by active pre
exposure immunization. After a basic course of immunization with three doses of the Td, the individuals
develop immunity, which is maintained by booster doses given every five years. When such a person
suffers a tetanus-prone injury a booster dose of toxoid is sufficient to prevent the development of the
disease. A homologous (human) antitoxin is an adjunct to surgery and antibiotics. The dose for all ages
is 250-500 TU given intramuscularly. It provides passive immunity for up to 30 days or so.
(c) Immunization Against Diphtheria.
Similar to the immunization against tetanus, there are two types of immunization available against diphtheria:
the pre exposure active immunization with a toxoid and the post-exposure passive immunization with an
antitoxin. In India, sufficient cases rarely occur to warrant routine or mass active immunization of troops or
the civilian population. It is, however, now a common practice to immunize children during the first year of
life, followed by booster doses at the 2nd and 5th years of age.
(i) Active Immunization.
The most commonly used antigen is the Purified Toxoid Aluminium Phosphate (or Hydroxide) precipitated
(PTAP or PTAH). For initial childhood immunization, it is combined with TTPA and anti-pertussis vaccine
in the form of a Triple Vaccine. If this has not been given in infancy, 2 doses of 0.5 ml of DT should be
given at an interval of 4 to 6 weeks.
(ii) Passive Immunization.
Passive immunity may be conferred upon a susceptible individual known to have recently been exposed
to a massive dose of infection, e.g. the children in a family in which a case of diphtheria has occurred.
This is done by injecting 20,000 to 1,00,000 units of anti-diphtheria serum depending upon the severity
after the sensitivity test. This should be followed by active immunization. As a therapeutic agent, this is
given in doses of 20,000 units IM in conjunction with antibiotic therapy (penicillin or erythromycin). All
precautions to avoid and treat allergic or anaphylactic reactions as described earlier should be ensured.
(d) Immunization Against Whooping Cough (Pertussis).
Anti-pertussis immunization of children is essential as the case mortality in infants is high and prolonged
morbidity and intermittent illness among older children, especially of early school going age leaves them weaker
for a long time. The use of triple antigen obviates the need for separate immunizations.
(i) Combined Antigen DPT.
‘Triple antigen’ contains alum-adsorbed, purified diphtheria and tetanus toxoids i.e., PTAP and TTPA
respectively and the anti-pertussis vaccine made from killed B pertussis (DPT vaccine). Infants possess
natural immunity against certain infections including whooping cough and diphtheria for the first few
months but gradually become susceptible as they get older. They are not so congenitally immune to

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tetanus and become more vulnerable due to the increased risk of bodily injuries when they start toddling
about. The liability to contract diphtheria and pertussis infection also increases as the toddlers’ sphere of
contact increases when they start walking and more so when they go to school. Therefore, immunization
by triple antigen should begin by six weeks of life and be completed before the ninth month at the latest,
although it can be given at any period before 5 years of age. Initially, three doses at monthly intervals
are injected intramuscularly. Booster doses are given during the second year and just before the child
starts going to school. The reaction is slight and rare. Children who have not been so preimmunized up
to their fifth year need immunization against diphtheria and tetanus only, for which a combined diphtheria
tetanus vaccine can be used. Two injections of purified adsorbed combined diphtheria-tetanus vaccine
should be given at an interval of 4 to 6 weeks.
Triple vaccine or monovalent pertussis vaccine should be administered only to healthy children. Children
who are suffering from fever, coryza or any other infection and those who have very recently recovered
from any febrile or infectious disease should NOT be immunized with triple vaccine. It should NOT be
administered to infants and children who have a history of fits, attacks of urticaria, eczema or other
allergic disorders.
(ii) Diphtheria Tetanus (DT) Vaccine.
A booster dose of 0.5 ml DT vaccine is administered to pre immunized children at five years of age as
immunization against whooping cough is not considered necessary at this age.
(e) Immunization Against Tuberculosis.
BCG vaccination confers an elevated level of specific immunity, especially against TB meningitis and miliary
tuberculosis. BCG vaccine is a freeze-dried, non-virulent, bovine strain of tubercle bacilli, attenuated by repeated
culturing in the presence of bile and designated as Bacillus Calmette Guerin. The first prospective control
trial of BCG showed 80% effectiveness over an observation period of 20 years. However, other studies have
shown protection offered by BCG varied from 0 to 80% in different parts of the world. There is a large body of
evidence that BCG gives an appreciable degree of protection against childhood tuberculosis. WHO recommends
that the use of the BCG vaccine should be continued as an anti-tubercular measure.
Method.
Vaccination is conducted by injecting 0.1 ml (0.1 mg) of BCG vaccine intradermally and as superficially as
possible, on the upper portion of the arm over the insertion of deltoid. The dose for newborns aged below 4
weeks is 0.05 ml. Two to three weeks after receiving an intradermal injection, a papule develops at the site,
followed by ulceration by around 4 to 6 weeks. Healing takes place by 6 to 12 weeks leaving a tiny scar.
(f) Immunization Against Cholera.
The vaccine produced and used in India contains 6,000 million each of classical Inaba and Ogawa serotypes
of V. cholera 01 per ml. Universal mass immunization in the civil population is not practised. United Nations
vide its new guidelines Medical Support Manual for UN Fd Msns. 3rd edition (2015) has made mandatory that
the troops being deployed in UN Msn are to be administered with Cholera vaccine and the Armed Forces have
implemented the same in its guidelines in Dec 2016.
Table 23.19 : Dosage of Cholera Vaccine
Name of Vaccine Type of Vaccine Route Adult doses Booster
Dukoral Monovalent Formalin/heat- Oral Two doses 7 days apart 2 years
killed whole cell (WC) of V
Cholera 01 + Recombinant
Cholera toxin B Subunit
Shanchol Bivalent (sero group 01 & Oral Two doses 14 days apart 2 years
MORCVAX 0139
Mass vaccination is never justified in anticipation of an outbreak of cholera or even on the occurrence of a
case near a military camp or an epidemic some distance away. As per WHO OCV should be used in areas
with endemic cholera, in humanitarian crises with high risk of cholera and during cholera outbreaks, always
in conjunction with other cholera prevention and control strategies.

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Two types of Oral Cholera Vaccines (OCVs) are currently available at: (i) WC-rBS, killed whole cell monovalent
(O1) vaccines with a recombinant B subunit of cholera toxin (Dukoral®)37 and (ii) WC, killed modified whole
cell bivalent (O1 and O139) vaccines without the B subunit (ShancholTM, Euvichol® and MORCVAX™).
(i) Killed Whole-cell Monovalent (O1) Vaccine with Cholera Toxin B Subunit (WC-BS and WC-rBS).
The vaccine is provided in 3 ml single-dose vials together with the bicarbonate buffer (effervescent
granules in sachets). Vaccine and buffer are mixed in 150 ml of potable water for persons > 6 years of
age and 75 ml for children aged 2–6 years. The vaccine has a shelf-life of 3 years at 2–8°C and remains
stable for 1 month at 37°C. The vaccine is not licensed for use in infants < 2 years of age. According
to the manufacturer, for children aged 2–5 years primary immunization consists of 3 oral doses given
at least 7 days (but less than 6 weeks) apart. For adults and children aged ≥ 6 years only 2 oral doses
given at least 7 days (but < 6 weeks) apart are required.
Intake of food and drinks should be avoided for one hour before and after vaccination. If the second
dose is delayed for >6 weeks after the first, primary immunization should be restarted. For those with
continuing risk of V. cholerae infection, the manufacturer recommends re-vaccination.
(ii) Modified Killed Whole-cell Only Vaccines (WC).
Shanchol™ and Euvichol® are provided in single dose vials, MORCVAX™ in single and 5-dose vials. A
fill-seal plastic presentation of Euvichol® is available. According to the manufacturers, Shanchol™ and
Euvichol® should be administered orally in 2 liquid doses 14 days apart in individuals aged ≥ 1 years.
In a study conducted to compare the immunogenicity of 2 dosage regimens of Shanchol™, 2 doses
given 14 days apart versus 2 doses given 28 days apart, comparable immune responses were observed.
Maintenance of cold chain (2–8°C) is currently required for these vaccines. The vaccines have a shelf
life of 2 years.
(g) Immunization Against Plague.
(i) Vaccine.
The plague vaccine used in India is that of Haffkine as modified by Sokhey. It is a formalin-killed
preparation containing 2,000 million organisms per ml.
(ii) Indications.
Immunization against the plague has been stopped because of the adverse effects of the vaccine and
vaccine trials with newer vaccines are underway as published by WHO.
(h) Immunization Against Smallpox (Obituary).
The eradication achievement will find a place when the history of the 20th century will be written. Smallpox
was once a major killer throughout the world. Mass vaccination was conducted in India till India was declared
Smallpox free by an international commission for assessment of Smallpox eradication. The smallpox vaccine
was a live vaccine and was supplied in freeze dried form. It used to be given by Bifurcate<.l needle (F 9551)
at 3 months of age on the upper arm on the outer aspect over the deltoid muscle. The needle first used to
be introduced in the vaccine ampule, a very small quantity of vaccine used to get adhered to the needle. The
bifurcate needle used to be held at a 90° angle to the skin and 15 up and down rapid strokes of the needle
were made through which the droplets were deposited on the skin in an area of 3.5 mm diameter.
(j) Immunization Against Poliomyelitis.
In poliomyelitis, the virus enters, multiplies and colonizes in the intestinal tract before the brief viraemic phase
which precedes nerve involvement. The attenuated live trivalent Sabin’s vaccine, which is administered orally,
becomes established in the intestine, multiplies and brings about a ‘local intestinal immunity’, which interferes
with the colonization of virulent wild virus strains.
(i) Inactivated Polio Vaccine.
Inactivated Polio Vaccine (IPV), first developed and licensed in 1955, is given by injection and is available
only in trivalent form containing the three virus serotypes PV1, PV2 and PV3. Inactivated polio vaccine is
made from selected WPV strains— Mahoney or Brunhilde (type 1), MEF-1 (type 2) and Saukett (type 3)—or
from Sabin strains and are now grown in Vero cell culture or in human diploid cells. IPV manufacturing

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relies on inactivation of cell culture-derived polioviruses with formaldehyde, in a final formulation containing
sufficient antigen units for each serotype. IPV may contain formaldehyde, as well as traces of streptomycin,
neomycin or polymyxin B. Some formulations of IPV contain 2-phenoxyethanol (0.5%) as a preservative for
multi-dose vials. IPV formulations do not contain thiomersal, which is incompatible with IPV antigenicity. The
vaccine should be refrigerated to preserve potency but not frozen as this could diminish potency. Available
as 10 dose and 5 dose IPV vials can be used up to 28 days after opening. The inactivated polio vaccine
is very safe, whether given alone or in combination with other vaccines. There may be transient minor
local erythema (0.5–1%), induration (3–11%) and tenderness (14–29%). Two fractional doses are given at
6 and 14 weeks of age and the third dose is given at 9 months of age.
(ii) Attenuated Live (Sabin’s) Vaccine.
The vaccine has evolved on the basis that the local immunity conferred by the oral use of the vaccine is
more potent and long lasting as compared to the humoral immunity conferred by the parenteral use of
the inactivated vaccine. Sabin’s vaccine is prepared from a genetically stable avirulent strain of all three
important types of viruses and does not become virulent by passage through the human system. When
given by mouth, ‘the immunogenic infection’ gets established and the rapid multiplication of the virus
starts within 24 hours in the intestinal tract rendering it resistant to colonization by virulent virus strains
and their transmission through the mucosa. The rapid local immunity thus produced is independent of the
antibodies in the blood. This process also reduces the dissemination of infective viruses through excreta.
Some unvaccinated persons become immune through contact with young, vaccinated children. This leads to
a break in the chain of transmission of infection and rapid elimination of the disease from the community.
Ideally, Sabin’s oral vaccine should be administered in a monovalent form in the order of type 1, 3
and 2 or type 2, 1 and 3. In India, however, it is more convenient to administer it in trivalent form. For
institutional deliveries, one dose (2 drops) of oral polio vaccine is given before the baby leaves for home.
In 25th Apr 2016 India has switched from Trivalent to bivalent Oral Polio Vaccine (bOPV) vaccine (OPV1
& OPV3). This dose, however, is not counted and is known as zero dose. 3 doses of the vaccine are
then given from 6 weeks to 9 months of age at an interval of 4 to 6 weeks between doses. A booster
dose is then given at 16 months-24 months of age. It is convenient to drop the vaccine with the help
of a dropper into the mouth of an infant as it cries.
(k) Immunization Against Rubella.
The main purpose of giving the rubella vaccine is to prevent congenital defects due to rubella infection in
mothers during pregnancy. The commonly used rubella vaccine is RA 27 / 3. This is given in a single dose of
0.5 ml by intra-muscular Injection. Pregnancy is an absolute contraindication. Side effects such as mild fever,
lymphadenopathy, sore throat, arthralgia and occasionally rubelliform rash may occur. Pregnancy should be
avoided for 3 months following vaccination.
(i) Measles-Rubella vaccine (MR vaccine).
The Measles-Rubella (MR) vaccine is prepared from the live, attenuated strains of Edmonston-Zagreb
measles virus and Wistar RA 27 / 3 rubella virus. Both measles and rubella viruses are propagated on
Human Diploid Cells (HDCs). The vaccine is lyophilized and is provided with diluent. The diluent (sterile
water for injections) supplied is specially designed for use with the vaccine. Only this diluent must be used
to reconstitute the vaccine. Do not use diluents from other types of vaccine or for MR vaccine from other
manufacturers. Water for injections must not be used for this purpose. It is a freeze-dried vaccine, available
as single dose and multi dose vials and is to be administered subcutaneously. Each single-human dose
when reconstituted in a volume of 0.5 ml contains not less than 1,000 median Cell Culture Infective Doses
(CCID50) of live measles virus particles and 1,000 CCID50 of rubella virus. The dose is 0.5 ml subcutaneously
or intramuscularly, preferably over the upper arm / anterolateral thigh. If pregnancy is planned, then an
interval of one month should be observed after MR vaccination. The vaccine is contraindicated in the
severely immunocompromised, in those with a history of severe allergic reactions to the constituents and in
pregnancy. MR vaccine should not be administered to pregnant women. The vaccine should be administered
to those with HIV infection unless severely immunocompromised as here the benefits outweigh the risks.
(ii) Measles, Mumps and Rubella (MMR) Vaccine.
Formulations from different manufacturers have different strains of the vaccine virus. Mumps vaccine

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virus strains include Leningrad-Zagreb, Leningrad-3, Jeryl Lynn, RIT 4385 or Urabe AM9 strains and are
grown in chick embryo / HDC cultures. MMR vaccines are supplied in lyophilized form and should be
frozen for long-term storage. The dose is 0.5 ml subcutaneously. Adverse effects include mild fever, rash,
lymphadenopathy and arthralgia.
Other Vaccines
(l) HAV Vaccine.
(i) Inactivated Vaccines.
Most of the currently available vaccines are derived from HM 175 / GBM strains and grown on MRC-5
human diploid cell lines. The virus is formalin inactivated and adjuvant with aluminium hydroxide. The
vaccine is stored at 2–8°C. The serologic correlate of protection is 20 mIU / ml. All hepatitis A vaccines
are licensed for use in children aged 1 year or older. A liposomal adjuvant hepatitis A vaccine derived
from the RG-SB strain, harvested from disrupted MRC-5 cells and inactivated by formalin is now available.
Indian Academy of Paediatrics (IAP) Advisory Committee on Vaccines and Immunization Practices (ACVIP)
recommends two doses of inactivated hepatitis A vaccine given intramuscularly. Administer the second
dose 6–18 months after the first. The minimum age for giving hepatitis A vaccine is 12 months. The dose
for children below 14 years is 0.5 ml and for adults is 1 ml. Side effect includes pain at the injection
site, induration, headache and fever.
(ii) Live Attenuated Vaccine.
This vaccine is derived from the H2 strain of the virus attenuated after serial passage in the Human
Diploid Cell (KMB 17 cell line). It has been in use in China since the 1990s in mass vaccination
programs. The vaccine meets WHO requirements and is now licensed and available in India. Controlled
trials conducted among large numbers of children 1–15 years of age have shown up to 100% efficacy
for pre exposure prophylaxis and 95% efficacy for post exposure prophylaxis. However, live attenuated
hepatitis A vaccine does not provide post exposure protection against HAV infection during the outbreak.
The live attenuated vaccine is administered as a single subcutaneous dose. The IAP ACVIP committee
has already recommended a single dose of this vaccine at 12 months of age. IAP ACVIP (2018–19)
also recommends a single dose of live Hepatitis A vaccine. A second dose of live attenuated hepatitis
A vaccine is not recommended. It is to be remembered that an inactivated vaccine is preferred during
an outbreak situation.
(m) Varicella (Chicken Pox) Vaccine.
Varicella vaccines, in use today, are all derived from the original Oka strain which was first isolated by Takhashi
from the vesicles of an otherwise healthy 3 year old boy named Oka. However, the virus contents may vary from
one manufacturer to another. They differ in passage number in human diploid cells, the virus dose, antibiotics
used, stabilizers and other minor components incorporated. Vaccination induces both humoral and cellular
immunity. The dosage of the vaccine for children 1-13 years of age, not vaccinated previously and lacking
a reliable history of varicella infection is 0.5 ml subcutaneous, given in a single dose. In children above 13
years, 2 doses are given 6-8 weeks apart.
Monovalent varicella vaccines available in India currently are as under:
(i) Variped (MSD)
(ii) Varilrix (GSK)
(iii) Biovac-V (Mf. China, Mkt-Wockhardt)
(iv) Varivax (Mf. China, Mkt-VHB Life Sciences)
(v) Nexipox (Mf. China, Mkt-NovoMedi Sciences)
(vi) Zuvicella (Mkt Zuventus healthcare).
All vaccines are approved by the Central Drugs Standard Control Organization (CDSCO) after phase II and III
immunogenicity and safety studies. All varicella vaccines are freeze dried and lyophilized. They are licensed
for use in persons aged > 12 months. All of them employ live attenuated varicella zoster virus (Oka strain).
Adverse effects of the vaccine include fever, rash and pain at the injection site. It is stored between 2 to 8°C.

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(n) Oral Typhoid Vaccine Ty21a.

It is a live oral vaccine prepared from attenuated non-pathogenic strains of S.typhi Ty21a, a mutant strain of
S. typhi developed by Gennanier & Feurer in 1975.
(i) Composition.
Enteric coated capsule of lyophilized vaccine containing not less than 109 viable bacilli of ‘Ty21a’ strain.
They are marketed as Typhoral by Hoechst.
(ii) Dose.
1 capsule each on days 1, 3 & 5; 1 hr before meals with cold / lukewarm water or milk (Bacillus is acid
labile). A booster dose is given after 3 years. 3 capsules on days 1, 3 and 5 are also to be given during
booster dose.
(iii) Contraindications.
(aa) Acute febrile illness (as with other vaccines)
(ab) Immunocompromised states.
(ac) Intestinal infections.
(ad) Pregnancy.
After oral administration of the vaccine, the lymphocytes in the Peyer’s patches & other gut associated
lymphoid tissue are activated. These lymphocytes then migrate to the lymph nodes to mature. After
maturation, they return to the lamina propria of the intestine as well as to the other organs of the mucosal
immune system such as salivary glands, respiratory tract & genito-urinary tract. These IgA producing cells
are only detectable a few days after immunization. CMI is also potent after oral vaccine.
(o) Hepatitis B Vaccine.
The currently available vaccine containing the surface antigen of hepatitis B has been produced by recombinant
technology in yeast adjuvant with aluminium salts and preserved with thimerosal (thimerosal-free vaccines
are also available) since 1986. Hepatitis B vaccine is available as single and multidose vials and should be
stored at 2–8°C. The vaccine should not be frozen; frozen vaccines should be discarded. There are different
recombinant preparations available in the market. A well-known brand is ‘Engerix B’ (SKB). It is made from
recombinant yeast producing the surface Ag of HBV. It contains HBs Ag absorbed to alum as an adjuvant, the
preservative is thiomersol 0.005%. Three doses are given over 6 months at 0, 1 and 6 months. It should be
given to all neonates as early as possible. Adverse reactions include injection site erythema, pain, soreness,
fatigue, headache and fever.
(p) Immunization Against Influenza.
Influenza infection is a public health problem, as it is known to assume pandemic proportions in addition
to occurring sporadically. Mortality and morbidity are higher amongst infants, old age (> 50 years) and
persons with chronic respiratory diseases, bronchial asthma, cardiovascular disorder, diabetes mellitus, CRF,
haemoglobinopathy etc. This gives rise to the need for an Influenza vaccine. Currently both Formalin inactivated
parenteral as well as live intranasal vaccines are available however, split vaccine is preferred for children
as it has fewer adverse effects. The adverse effects are pain, erythema, tenderness, indurations, myalgia,
headache, malaise and fever. Intranasal vaccine has milder reactions, which range from nasal stuffiness,
rhinorrhoea, pharyngitis, cough and fever. Immunity develops in 60-90% of those vaccinated and peaks between
2-4 months. It starts to wane thereafter and in approximately 12 months antibody titre reaches baseline
level. Intranasal vaccine overcomes the need for an annual shot. It provides both local as well as systemic
immunity. Influenza immunisation is indicated in high-risk groups already enumerated besides health care
providers, caretakers of old age homes and other such institutes: this group is not only exposed to influenza
themselves but also puts their persons at risk. The dose schedule for immunization is shown in Table 23.20.
Influenza virus is characterized by the presence of the phenomenon of antigenic shift and antigenic drift. WHO
constantly monitors the prevalence of wild strains. By September, of each year it recommends the strains to
be used in the vaccine for the next year. Routinely a trivalent split vaccine having H1N1 and H3N2 strains
and the prevalent strain of Influenza Virus A are used for vaccination.

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Table 23.20 : Dose Schedule of Influenza Vaccine

Age Quantity Route Dose
6-35 Months 0.25 ml IM 2 Doses 4 Weeks Apart

3-8 Years 0.5 ml IM 2 Doses 4 Weeks Apart

8-12 Years 0.5 ml IM 1 Dose
> 12 Years 0.5 ml IM 1 Dose
(q) Immunisation Against Meningococcal Meningitis.
Vaccines are available against four serogroups of meningococci A, C, W-135 and Y. No effective serogroup B
vaccine is presently available. The vaccines are either monovalent i.e., A. C, etc. or polyvalent i.e., A-C, A-C-Y,
A-C-Y-W135, etc. The efficacy rate of a single dose of serogroup A or serogroup C vaccine is 90% in adults
and children over 2 years of age. The four polysaccharide antigens (A, C, Y and WI 35) have been combined
into a tetravalent vaccine. It is available in single dose and multi dose vials distributed as a lyophilized powder
that contains 50 micrograms of each component per dose. The vaccine should be stored at -20°C.
(i) Dosage and Route of Administration.
For both adults and children, the vaccine when reconstituted is administered subcutaneously as a 0.5
ml dose. It can be administered subcutaneously with other vaccines at different sites. Protective levels
of antibodies can be expected after 7-10 days.
(ii) Indications.
(aa) Routine immunisation of recruits may be considered. This practice has eliminated nearly
all diseases among military personnel in the United States.
(ab) In household contacts, vaccination is recommended as an adjunct to chemoprophylaxis.
(ac) Routine immunisation with quadrivalent vaccine is recommended for asplenic people and
those with previously described immunodeficiencies.
(ad) Vaccination is recommended for outbreak control for disease caused by any of the serotypes
carried by the vaccine.
(ae) Travellers to hyperendemic or endemic areas such as Nepal, Saudi Arabia & Kenya and the
meningitis belt of sub Saharan Africa.
(iii) Precautions and Contra-indications.
Adverse reactions are mild and consist of pain and tenderness at the site of injection for 1-2 days. Mild
to moderate local reactions range from infrequent to more than 40%, among vaccine recipients. Fever
is rare. No adverse effects have been documented among women vaccinated during pregnancy or their
newborns. There are no known contraindications. The vaccine is not recommended for use in children
under 2 years of age.
(iv) Revaccination.
Revaccination may be recommended for people at high risk of infection e.g. people remaining in areas
where the disease is epidemic, particularly for children who were first vaccinated when they were younger
than 4 years; such children should be reconsidered for vaccination after 2 to 3 years if they remain at
high risk. Although the need for revaccination of older children and adults has not been determined,
antibody levels decline rapidly over 2 to 3 years and if indications still exist for immunisation, revaccination
may be considered within 3 to 5 years.
(v) Availability of Vaccine in India.
Although all types of meningococcal vaccines are available through import, only monovalent or polyvalent
(A-C, A-C-Y, etc.) vaccines are being manufactured in the country. The quadrivalent polysaccharide vaccine
is currently not manufactured in India.

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(r) Rabies Vaccine.

Vaccines are the mainstay for the prevention of development of rabies. The nerve tissue vaccines, used earlier,
are no longer available due to poor efficacy and life-threatening adverse effects of neuro paralytic reactions.
(i) Post Exposure Prophylaxis.
(aa) Indications.
All animal bite victims of category II and III exposures irrespective of age and body weight require
the same number of injections and dose per injection. All category III exposures and category
II exposures in immuno-compromised individuals, in addition, require administration of RIG.
Individuals in category II but previously vaccinated will be given only 2 doses of rabies vaccine
on day 0 and 3.
(ab) Storage.
The vaccines are available in lyophilized form with sterile water as a diluent, are stable for 3 years
at 2–8°C and should be used within 6 hours of reconstitution.
(ac) Adverse Effects Following Administration of CCVs (Cell Culture Vaccine).
The CCVs are widely accepted as the least reactogenic rabies vaccines available today. However,
few studies have now shown that adverse effects can be either general in nature or allergic in
origin. Mild systemic Adverse Events Following Immunization (AEFI) include headache, malaise,
nausea and fever. Symptomatic treatment may be needed.
(ad) Vaccines Approved for Intradermal Use in the Country.
Currently, the following vaccines have been approved by DCGI for use by intradermal route.
PCECV (Purified Chick Embryo Cell Vaccine)
O Rabipur, Chiron Behring, Vaccines Pvt. Ltd
O Vaxirab N, ZydusCadila
O PVRV (Purified Vero Cell Rabies Vaccine)
O Verorab, Aventis Pasteur (Sanofi Pasteur) India Pvt. Ltd
O Pasteur Institute of India, Coonoor
O Abhayrab, Human Biologicals Institute
O Indirab, Bharat BiotechInternational Ltd.
(ae) Intradermal Regimen (Post-exposure regimen Updated Thai Red Cross Schedule (2-2-2-0-2)).
This involves the injection of 0.1 ml of reconstituted vaccine per ID site and on two sites per visit
(one on each deltoid area, an inch above the insertion of deltoid muscle) on days 0, 3, 7 and
28. Day 0 is the date of the first dose administration of the anti rabies vaccine and may not be
the date of rabies exposure / animal bite.
(af) Intra-Muscular Regimen. [Essen Regimen (1-1-1-1-1)].
Five-dose intramuscular schedule - The course for post-exposure prophylaxis consists of
intramuscular administration of five injections, one dose each given on days 0, 3, 7, 14 and
28. Day 0 indicates the date of administration of the first dose of the vaccine. Site of injection:
The deltoid region is ideal for the administration of these vaccines. The gluteal region is not
recommended because the fat present in this region retards the absorption of antigen and hence
impairs the generation of the optimal immune response. In the case of infants and young children,
the anterolateral part of the thigh is the preferred site.
Vaccine approved for Intra-muscular (IM) use: The currently available vaccines in India for IM
administration are described in Table 23.21.

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Table 23.21 : Cell Culture Vaccines

Human Diploid Cell Vaccine (HDCV), Liquid (Adsorbed), 1 ml: Produced locally in the private sector.
Cell Purified Chick Embryo Cell Vaccine (PCECV), 1 ml: Produced locally in the private sector
Culture
Purified Vero Cell Rabies Vaccine (PVRV), 0.5 ml and 1 ml: Imported and also produced locally in
Vaccines
public & private sectors
Purified Duck Embryo Vaccine (PDEV), 1 ml: Produced locally in the private sector and is currently
being exported
(ii) Pre Exposure Prophylaxis.
Pre exposure vaccination may be offered to high risk groups like laboratory staff handling the virus and
infected material, clinicians and persons attending to human rabies cases, veterinarians, animal handlers
and catchers, wildlife wardens, quarantine officers and travellers from rabies free areas to rabies endemic
areas.
Schedule of Vaccination.
Pre exposure vaccination is administered as one full dose of vaccine intramuscularly or 0.1 ml intradermal
on days 0, 7 and either day 21 or 28. Laboratory staff and others at high continuing risk of exposure
should have their neutralizing antibody titres checked every 6 months during the initial two-year period
after the primary vaccination. If it is less than 0.5 IU / ml a booster dose of vaccine should be given.
Subsequently, sero-monitoring is recommended every two years. Because vaccine induced immunological
memory persists in most cases for years, a booster would be recommended only if rabies virus neutralizing
antibody titres have dropped to less than 0.5 IU / ml. Such individuals getting exposed to rabies virus
after successful pre exposure immunization require only two booster injections of vaccine given on days
0 and 3 and no RIG.
(s) COVID-19 Vaccine.
The vaccines namely Covishield (Astra Zeneca’s vaccine manufactured by Serum Institute of India), Covaxin
(manufactured by Bharat Biotech Limited), Sputnik V (Manufactured by Gamaleya Research Institute, Russia and
imported by Dr Reddy’s Lab), CorBEvax (manufactured by M / s Biological E) and Covovax (manufactured by M / s
Serum Institute of India) are being used in the country. As of August 2022, Covishield and Covaxin have received
market authorization with certain conditions; whereas other vaccines are permitted for restricted use in emergency
situation in the country by the Central Drugs Standard Control Organization (CDSCO), the National Regulator.
Compositions of the above Vaccines.
(i) Composition of Covishield.
It includes inactivated adenovirus with segments of coronavirus, Aluminium Hydroxide Gel, L-histidine,
L-Histidine hydrochloride monohydrate, Magnesium chloride hexahydrate, Polysorbate 80, Ethanol,
Sucrose, Sodium chloride and Disodium edetate dihydrate.
(ii) Composition of Covaxin.
It includes inactivated Corona Virus, Aluminium Hydroxide Gel, TLR 7 / 8 agonist, 2-phenoxyethanol and
Phosphate Buffered Saline.
(iii) Composition of Sputnik V.
Component I Active substance: replication-incompetent recombinant adenovirus serotype 26 particles
containing the SARS-CoV-2 protein S gene.
Component II Active substance: replication-incompetent recombinant adenovirus serotype 5 particles
containing SARS-CoV-2 protein S gene. Excipients: Tris (hydroxymethyl) aminomethane, sodium chloride,
sucrose, magnesium chloride hexahydrate, EDTA disodium salt dihydrate, polysorbate-80, ethanol 95%
and water for injection.
(iv) Composition of CorBEvax.
Ingredients: Aluminium hydroxide gel as Al+++, CpG 1018 and Buffer (Tris and NaCl in WFI).

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(v) Composition of Covovax.

The COVOVAX vaccine includes the following ingredients: SARS-CoV-2 rS Protein, DS Adjuvant Matrix-M1
Disodium hydrogen phosphate heptahydrate, Sodium dihydrogen phosphate monohydrate, Sodium
chloride Polysorbate 80.
(vi) Schedule of the Vaccines under the National COVID-19 Vaccination Program (for age 12 and above)
(aa) Covishield: two doses, an interval of 12-16 weeks (84-112 days)
(ab) Covaxin: two doses at an interval of 4-6 weeks (28-42 days)
(ac) CorBEvax: two doses at an interval of 4 weeks (28 days)
(ad) Covovax: two doses at an interval of 3 weeks (21 Days)
(ae) Sputnik V: two doses at an interval of 3 weeks (21 days)
(af) ZyCoV-D: two doses at an interval of 4 weeks (28 days)
(ag) Precaution dose (with the same vaccine or with CorBEvax following primary vaccination of
Covishield & Covaxin), at an interval of 6 months (26 weeks) from the date of administration of
2nd dose.
International Vaccination Requirement
(t) Immunization Against Yellow Fever.
Vaccination against yellow fever is the most effective method for the prevention of the spread of the disease
by international travel. Two types of vaccines are available.
(i) 17 D Vaccine.
The 17D live YF vaccine has been widely acknowledged as one of the most effective and safe vaccines
in use and is the only commercially available YF vaccine. This is the approved vaccine for international
travel. It is a live, attenuated chick embryo grown l7D-strain freeze-dried vaccine. For storage at WHO-
approved centres, the vaccine can be kept for 3 months at +4°C. If the storage is for a longer duration, a
temperature of -25°C is to be maintained. After reconstitution, it should be used within half an hour.
Procedure.
17D vaccine is given subcutaneously at the insertion of the deltoid in a single dose of 0.5 ml. The
immunity begins to appear on the 07th day and lasts for life. Yellow fever vaccination is available at
designated centres certified by the Government of India. Armed Forces Clinic New Delhi, Base Hospital
Delhi Cantt & SHO Navy (Mumbai) is one of such centres.
An international certificate of vaccination is required only for one disease i.e. Yellow fever. The period of
validity of the certificate is shown in Table 23.22.
Table 23.22 : Validity of International Certificate of Vaccination
Type of vaccination Certificate
Yellow fever-vaccination Valid for Valid from
Lifetime 10 days after vaccination

Protection is recommended against certain other diseases for international travellers although an
international certificate is not required. These diseases are as under:
(ii) Cholera.
Cholera vaccine may be taken by all travellers proceeding to endemic areas. It provides partial protection
against the disease.
(iii) Enteric Infections.
Vaccination and revaccination against typhoid are strongly advised for all travellers proceeding to endemic
areas.

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(iv) Hepatitis A.
Active immunisation with HAVRIX is available in our country. It is approved for use in persons 12 months
of age and older. Primary immunisation should be administered at least two weeks before travel. The
efficacy after single dose lasts for 6 months to a year.
(v) Tetanus.
A booster dose of Tetanus toxoid should be taken if 5 years or more have elapsed since the last injection
of a complete course or booster.
International Certificate of Vaccination
These are individual certificates and should not be used collectively. Certificates are printed in English and
French; an additional language may be used. The dates should be recorded in the following sequence:
day, month, year, the month to be written in letters e.g. 20th March 1999. A certificate issued to a child
who is unable to write should be signed by the parent or guardian. The signature of an illiterate person
should be indicated by his left thumb mark certified by another person. The certificate requires the
personal signature of a medical practitioner; his official stamp is not accepted as a substitute nor is the
signature of the clinic nurse. The correct procedure for the doctor is to do the vaccination himself and sign
the certificate as the vaccinator. On all international vaccination certificates name of the manufacturer
of vaccine as well as the batch number must be given.
Suggested Reading.
1. O/o DGAFMS/DG-1C letter no. 43645 / Est / DGAFMS / DG-1C dt 09 Jan 2024
2. O/o DGAFMS/DG-3A note no. 41187/DGAFMS/DG-3 dt 03 March 2020.
3. AO-9 / 2020 for immunization
4. Patrikar S, Bhatti VK, Suryam V, Kotwal A, Basannar DR, Khera A, et al. Health technology assessment of varicella
vaccine in the Armed Forces. Med J Armed Forces India. 2022 Apr;78(2):213–20.
5. Immunization_Handbook_for_Health_Workers-English.pDeep Freezer [Internet]. [accessed 2024 Feb 22]. Available
from: https://www.nhm.gov.in / New_Updates_2018 / NHM_Components / Immunization / Guildelines_for_immunization/
Immunization_Handbook_for_Health_Workers-English.pDeep Freezer
6. Balasubramanian S, Shah A, Pemde HK, Chatterjee P, Shivananda S, Guduru VK, et al. Indian Academy of
Pediatrics (IAP) Advisory Committee on Vaccines and Immunization Practices (ACVIP) Recommended Immunization
Schedule (2018-19) and Update on Immunization for Children Aged 0 Through 18 Years. Indian Pediatr. 2018 Dec
15;55(12):1066–74.
7. Vaccines and immunization [Internet]. [accessed 2024 Feb 22]. Available from: https://www.who.int / health-
topics / vaccines-and-immunization
8. World Health Organization. International travel and health: situation as on 1 January 2012 [Internet]. Geneva:
World Health Organization; 2012 [accessed 2024 Feb 22]. Available from: https://iris.who.int / handle / 10665 / 75329
9. Think Travel Vaccine Guide | Travelers’ Health | CDC [Internet]. [accessed 2024 Feb 22]. Available from: https://
wwwnc.cdc.gov / travel / page / vaccine-guide
10. CDC. Centers for Disease Control and Prevention. 2023 [accessed 2024 Feb 22]. Stay Up-to-Date on Recommended
Vaccines. Available from: https://www.cdc.gov / vaccines / schedules / index.html
11. Vaccines [Internet]. [accessed 2024 Feb 22]. Available from: https://www.who.int / travel-advice / vaccines
12. Goldman AS, Prabhakar BS. Immunology Overview. In: Baron S, editor. Medical Microbiology [Internet]. 4th ed.
Galveston (TX): University of Texas Medical Branch at Galveston; 1996 [accessed 2024 Feb 22]. Available from: http://
www.ncbi.nlm.nih.gov / books / NBK7795 /
n

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Chapter
XXIV
HEALTH GUIDELINES FOR UN MISSIONS

24.1 Introduction.
Large contingents of Armed Forces personnel are being detailed as a part of peacekeeping forces of United
Nation Organisation (UNO) and are deployed in different countries. The troops are likely to encounter different
communicable and non-communicable diseases in alien settings where continued civil strife may lead to adverse
living and sanitary conditions.
Housing may be primitive and many would have been damaged, destroyed or abandoned during the civil war.
Lack of other basic amenities such as piped potable water supply, food sanitation, proper drainage and waste
disposal coupled with depleted or non existent public health services can lead to foci of endemic communicable
diseases in the local population jeopardizing the health of the deployed troops. Even after hostilities cease these
countries require many years to rebuild with large-scale external assistance.
The current country / continent specific epidemiological intelligence and counter measures are available through
Armed Forces Central Epidemiological Surveillance Center (AFCESC), Dept of Community Medicine, AFMC, Pune
and through latest publications of UN / WHO which can be obtained by Service HQs directly.

24.2 General Preventive Counter-measures.

General preventive medicine measures as outlined below should be adopted by all contingents going abroad. This is
intended to supplement the country-specific summaries. However, not all the information included here is applicable
to every country, season or mission. The following points should be considered:
(a) Medical Screening
(b) Immunization
(c) Sexually Transmitted Diseases & HIV
(d) Personal Hygiene
(e) Malaria Chemoprophylaxis
(f) Insect / Arthropod-borne Diseases
(g) Acute Diarrhoeal Diseases
(h) Acute Respiratory Diseases
(j) Injuries
(k) Occupational Hazard
(l) Environmental Injury
(m) Animals
(n) Bites and Stings
(o) Diseases that spread by contact with soil
(p) Diseases that spread by contact with water
(q) Oral Health
(r) Stress
(s) Jet Lag

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(t) Health Education

24.3 Medical Screening.

(a) Medical Category.
All personnel before deployment to foreign missions should undergo medical examination and should be in
SHAPE-I or equivalent medical category. Women candidates should not be pregnant at the time of departure.
(b) Lab Investigations.
Following investigations are suggested:
(i) For All Ranks.
O Urine RE
O Hb, TLC, DLC
O Blood urea
O Blood sugar-F, PP
O Serum cholesterol
O X Ray chest
O ECG
(c) HIV Screening.
HIV screening will be done before departure to and after return from foreign assignments as per guidelines
mentioned in DGAFMS letter No 5496 / HIV policy / DGAFMS / DG - 3A dated 08th Mar 19.

24.4 Immunizations.
Immunization against typhoid and tetanus as currently enforced, will be given as due both before and during the tenure
abroad, as applicable. In addition, vaccines shall be administered depending on the anticipated disease risk in the region
of deployment based on the epidemiological intelligence collected from UN / WHO / AFCESC / other sources by DGsMS well
in advance of the move of the contingent. The vaccines should be procured through the Office of DGAFMS / DG-2 along with
the requirements of various other prophylactics and other drugs. Information about some of the vaccines, which may be
required, is summarised below. However, the latest available literature will be consulted for details of the vaccines.
(a) Yellow Fever Vaccine.
One dose 0.5 ml SC at least 10 days before the deployment. A valid international certificate of immunization
against Yellow Fever is required by many countries for entry of persons coming from or going to recognized yellow
fever zones of Africa and South America; otherwise quarantine measures are applicable for up to 6 days. The
International Certificate of Vaccination against Yellow Fever is valid for lifetime. In India, there are currently 52
vaccination centres for Yellow Fever, three of which are in Armed Forces medical establishments are as follows:
(i) Armed Forces Clinic, New Delhi.
(ii) Base Hospital, Delhi Cantt.
(iii) Station Health Organisation (Navy), Mumbai.
(b) Hepatitis B Vaccine.
All medical personnel and those at high risk for contact with blood and body fluids should have received a 3-dose
series, 1 ml, IM (deltoid) at months 0, 1, 6; prior to deployment, if possible; otherwise, remaining doses can be
given in the deployed country.
(c) Meningococcal Vaccine.
Quadrivalent (A, C, Y, W-135) 0.5 ml SC single dose should be given prior to deployment. Protective level of
antibodies are expected within 7-10 days after vaccination.

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(d) Japanese Encephalitis Vaccine.

Immunization should be considered for persons travelling to JE endemic areas for both short(< 4 weeks) and
long duration. Jenvac is given in 1 dose, 0.5 ml intra muscularly in deltoid region. For routine immunization it is
recommended to administer 2 doses 28 days apart. If primary series is more then 1 year then a booster dose
can be given on potential re-exposure.
(e) Influenza / COVID-19 Vaccine.
Current annual vaccine or WHO recommended vaccine depending on prevalent pandemic or destination country’s
endemic situation should be considered.
(f) Hepatitis A Vaccine.
1 ml IM (deltoid); two dose series, with second dose given between 6-12 months following the first dose. The
first dose should be given at least 14 days prior to departure. If this is not possible and there is a high hepatitis
risk immediately after vaccination, consider giving Immune Globulin (IG) at an alternate site in addition to the
vaccine.
[Alternate: Immune globulin (IG, ISG, GG). 2 ml IM will protect against Hepatitis A for three months; 5 ml IM will
protect for five months].
(g) Cholera Vaccine.
United Nations vide its new guidelines Medical Support Manual for UN Fd Msns. 3rd edition (2015) has made
mandatory that the troops being deployed in UN Msn are to be administered with Cholera vaccine. Two dose, 14
days apart, Oral Cholera vaccine Shanchol MORCVAX [Bivalent (sero group O1 & O139)] need to be administered
before deployment. Intake of food and drinks should be avoided for one hour before and after vaccination.
(h) Polio Vaccine.
All troops travelling to polio infected countries on UN msn (Afghanistan, Democratic Republic of Congo and Syria)
who have received 3 doses of OPV / IPV in the past will be administered a single dose of one time lifetime
booster dose of 0.5 ml Injectable Polio Vaccine (IPV) by IM route. However, travellers to polio infected countries
who have not received any polio vaccine previously should complete a primary schedule of polio vaccination
before departure.

24.5 Sexually Transmitted Diseases including HIV / AIDS.

Military personnel have a high risk of exposure to sexually transmitted diseases including HIV. The risk can be even
greater in times of conflict. Studies in the USA, the UK and France show that soldiers from these countries have a
much higher risk of HIV infection than equivalent age / sex groups in the civilian population.
Although military personnel are highly susceptible to STD and HIV infections as a group, military service is also a
unique opportunity in which HIV / AIDS prevention and education can be provided to a large audience in a disciplined,
highly organized setting.
Abstinence is the only way to ensure prevention. However, condoms should be made available for all who choose to be
sexually active. Proper use includes placement prior to any sexual activity, use of non-petroleum lubricant to decrease
breakage and to be used for each sexual contact. Encourage personnel to promptly seek evaluation for symptoms of
any sexually transmitted disease.

24.6 Personal Hygiene.

Good hygiene includes frequent hand washing, proper dental care, maintenance of clean, dry clothing (especially socks,
underwear and boots) and bathing with water from an approved source. If a shower is not available, wash sites of
perspiration and clean with a wash cloth daily. Change socks as frequently as practical. Foot powder application will
help in preventing fungal infections.

24.7 Malaria.
This is one of the most important disease that troops may encounter. The picture of malaria, particularly in the African
continent, which is one of the most affected area with malaria in the world, is at total variance with the pattern prevalent
in India and where upto 80-90% malaria cases have been due to P. falciparum strains.

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(a) Prevention.
An SOP should be formulated which should include all directions on prevention of malaria, including on procurement
of drugs, spraying equipment training, supervision and command support. This should be incorporated in the
administrative instructions issued by Commander of the Contingent. Adequate stocks of second and third line
antimalarial drugs should be ensured. Also provision for synthetic pyrethroids such as Deltamethrin / Permethrin
for impregnating mosquito nets / uniforms should be catered for and impregnation of mosquito nets / uniforms
implemented preferably before deployment and monitored.
(b) Chemoprophylaxis Regimens.
Drugs for chemoprophylaxis will be given under strict unit supervision and records of issues to each individual
will be maintained including the modified radical treatment issued on termination of chemoprophylaxis.
(i) Long term stay (Duration > 6 weeks).
Mefloquine 250 mg / wk begin 2 weeks before entering risk area; continue weekly while in risk area and
for 4 weeks after departure. Mefloquine is contraindicated for personnel with neuropsychiatric illnesses.
Neurological side effects such as dizziness and sleep disturbance should be evaluated by a physician.
(ii) Short term stay (Duration < 6 weeks).
Doxycycline 100 mg / day is the drug of choice. Begin 2 days before entering risk area; continue daily while
in country and for 04 weeks after departure. Take with food to avoid GI upset.

24.8 Insect / Arthropod-borne Diseases.

The key to preventing vector-borne diseases is to avoid being bitten by disease carrying insects and other arthropods.
For some diseases, it is the only means of protection. Arthropod vectors of disease can pose a threat at any time, day
or night. A comprehensive vector-borne disease prevention program will include:
(a) Emphasizing prevention of disease by ensuring appropriate supplies, educating personnel about diseases
and preventive measures and command support at all levels.
(b) Proper camp site selection.
(c) Ensuring command emphasis on compliance with malaria chemoprophylaxis.
(d) Issuing adequate DEET / DEPA insect / arthropod repellent lotion or spray per person. Personnel should be
instructed in its proper use. While at risk (during periods of vector biting activity), all personnel should apply the
repellant to all exposed skin surfaces.
(e) Requiring all personnel to sleep under mosquito nets both during day and night. The mosquito nets should
be treated with synthetic pyrethroids to increase their efficacy.
(f) Applying insecticides (camp area treatments) by properly trained personnel after coordination with medical
authority.
(g) Avoiding use of untested local commercial products as repellents because these products generally may
not provide adequate protection against disease carrying arthropods.
(h) Consulting medical authority if rodent control measures are needed. (Fleas must be eradicated before
rodents are killed to prevent transmission of flea-borne diseases, such as plague).

24.9 Acute Diarrhoeal Diseases.

This constitutes one of the greatest infectious disease threats to deployed troops, though initial bout of gastro-intestinal
upsets is expected as the food available may be different from the traditional Indian food. Fluid loss from diarrhoea
worsens the effects of heat. Prophylactic antibiotics against diarrhoea causing organisms are generally not indicated.
Infection by bacteria, viruses and parasites that cause diarrhoea can be prevented by command emphasis on basic
principles of food and water precautions, field sanitation and hygiene.
(a) Water Precautions.
Most gastrointestinal diseases are transmitted by drinking contaminated, inadequately treated water. Educate all
personnel on the following basic water and ice precautions.

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(i) Consume water and ice from approved sources only. Do not use local water for drinking or cooking
purposes, including ice made from local water. Locally bottled water and carbonated beverages must be
approved by the command medical authority. However, for personnel who have no access to approved
sources because of mission requirements, carbonated (bottled or canned) beverages are usually safe as
long as ice is not added to these.
(ii) Ensure bulk water containers remain properly sanitized. Maintain adequate chlorine residual level
(minimum of 2.0 ppm) in all bulk water.
(iii) If local water must be used, proper chlorination or even super chlorination depending on the risk
should be carried out after calculating the chlorine demand by Horrock’s test. If reagents for Horrock’s
test are not readily available, ‘fixed dose’ chlorination may be resorted to by adding 4 scoopfuls of WSP
to 500 L of water and confirming adequate chlorination after 30 minutes contact period by OT reagent,
before water is certified fit for consumption.
(iv) When detachments are separated from the main bodies, availability of treated water may not be
possible. All personnel on such detachments should carry individual water sterilising outfits.
(v) Wherever contingents are equipped with portable water purification / Reverse Osmosis plants, their
proper functioning and maintenance must be ensured at all times.
(b) Food Precautions.
Educate all personnel on the following:
(i) Consume food from medically approved sources only. Obtain medical clearance before obtaining food
provisions from local establishments. (Unit orders placing local civil eating establishments ‘out or bounds’
is recommended).
(ii) Wash hands with soap and water before eating, handling food or kitchen utensils and after using latrines.
(iii) Ensure that food handlers comply with guidelines emphasizing the following:
(aa) Maintain personal hygiene.
(ab) Keep hot foods at 140°F (60°C) or above (food temperature).
(ac) Keep cold foods at 40°F (5°C) or below (food temperature).
(ad) Properly dispose off kitchen waste.
(ae) Locate latrines at least 100 yards downwind and downstream of mess facilities.
(af) Ensure that vehicles used to carry trash or petroleum products are not used for food transport
before being properly sanitized.
(iv) If personnel have no access to approved food sources because of mission requirements, make sure
food is thoroughly cooked and served steaming hot. Avoid dairy products, seafood and raw foods of any
kind. Fruits that are peeled before consumption are OK, if peeled by the person consuming them.
(v) The health authorities should inspect all tinned food. All the non vegetarian food supplied is frozen
(at -20°C) or tinned. Potential hazards of such food must be known.

24.10 Acute Respiratory Diseases.

Acute respiratory diseases such as COVID-19, influenza, cold, sore throat and meningococcal disease can be highly
contagious, particularly in crowded conditions. Additionally, tuberculosis infections are increasing rapidly in many areas
of the world and can be a significant threat to personnel in close contact with indigenous populations. Preventive
measures include providing living areas with adequate space and ventilation, head to foot sleeping arrangements, to
reduce droplet and aerosol spread of these diseases.

24.11 Injuries.
(a) Motor Vehicles.
The most common cause of Non Battle Casualty (NBC) resulting in high morbidity and mortality. Special training

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on left hand drive vehicles must be conducted before leaving for mission. Vehicle crashes in areas not well
served medically are more likely to be fatal. The safety of local blood supplies cannot be guaranteed.
(b) Sports and Recreation.
Even morale building sport events can cause significant injuries. Attention to recreational programs can reduce
needless injuries. Participants in hazardous sports should wear protective equipments.

24.12 Occupational Hazards.

Heavy machinery and equipment, loaded weapons, nighttime air traffic and motor vehicles are all opportunities for disaster,
if safety is not emphasized. Commanders must enforce use of proper personal equipment and safe operating practices.

24.13 Environmental Injuries.

(a) Heat.
An illness due to effects of heat is a significant risk to military personnel deployed in warm climates.
Acclimatization, which may take 10-14 days, proper work-rest cycles, adequate balance and hydration, are
important parts of a heat injury prevention program.
(i) Commanders should insist that personnel drink adequate water to prevent dehydration upto two
quarts per hour under severe heat / work conditions).
(ii) Schedule work during the coolest hours of the day. Establish appropriate work-rest cycles.
(iii) Conditions that increase vulnerability to heat injuries include diarrhea, skin trauma (e.g. heat rash,
sunburn), drinking alcohol, fever, obesity, older age, poor physical condition and the use of drugs (e.g.
atropine, antihistamines or ‘cold’ medications).
(b) Cold.
At times, troops may be deployed in colder climates while on missions abroad. Risk of cold injuries is increased
for persons who are in poor physical condition, dehydrated or wet. Counter-measures include:
(i) Clothing and Cover.
Exposed skin is more likely to develop frostbite. Ensure full provision of ECC clothing. Clothing should
be clean, loose, multi-layered and dry. Remove layers of clothing, as needed to avoid sweating. Change
socks 2-3 times per day, if wet, cover the head to conserve heat.
(ii) Hydration and Nutrition.
Provide warm food and beverages, especially at night. Increase water intake to 3-6 L per day. Avoid
alcohol.
(iii) Physical Activity.
Plan for shortened periods of sentry / guard duty. Shivering is a warning sign of impending cold injury;
increase activity, add clothing or seek warm shelter. Use the buddy system; observe all personnel for
early warning signs / symptoms.
(c) Sun / Wind.
Use sunglasses to diminish glare and wind / dust irritation to the eyes.
(d) High Terrestrial Altitude.
Adverse health effects will most likely occur at elevations of about 2,900 meters and higher. Acute mountain
sickness, high altitude pulmonary edema and high altitude cerebral edema are the most serious types of
altitude illness. Symptoms may be delayed for several days after ascent. Pulmonary edema and cerebral edema
are life-threatening emergencies that require immediate descent to lower elevation. Risk of cold injury, heat
injury and solar UV radiation are all increased at high elevations. Counter-measures include:
(i) Acclimatization schedule as per AO 110 / 80.
(ii) Avoid alcohol and barbiturates.

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(iii) Remain well hydrated; individual water requirements are greater at high altitude.
(iv) Protect skin (sunscreen), lips (lip balm) and eyes (sunglasses) from UV radiation.

24.14 Animals.
Animals can spread disease through close contact (e.g. anthrax, Q fever) or bites and scratches (e.g. rabies). Animals
with these diseases, including rabies, may not exhibit any obvious signs of illness. Educate all personnel to:
(a) Avoid all unnecessary contact with local animals. Commanders must insist that stray or wild local animals
will not be fed or kept as pets or mascots.
(b) Conduct proper food storage and waste disposal inspections to prevent attracting stray animals. Water
containers should be protected or raised high enough from the ground to prevent animals from contaminating
the water.
(c) If bitten or scratched, immediately wash the wound with soap and water and seek medical evaluation.

24.15 Bites and Stings.

Educate all personnel to take adequate precautions to adopt measures to protect themselves from being bitten by
snakes, centipedes, scorpions and spiders. Personnel should not go bare foot, sleep directly on the ground and put
their hands or feet in crevices or holes. Boots, clothing and bedding should be checked and shaken out before use. In
the event of stings or bites, should report immediately to the nearest medical post. First-aid measures may be taken
as appropriate while evacuating / moving to the medical post.

24.16 Diseases Spread By Contact with Soil.

Hookworm, strongyloides and various diseases can be contracted by contact of skin with contaminated soil. Minimize
direct skin contact with soil (such as walking barefoot and sleeping on bare ground). Wash hands frequently.

24.17 Diseases Spread By Contact with Water.

Diseases like schistosomiasis, leptospirosis etc, are spread by direct contact with fresh water lakes, ponds and streams.
Counter-measures include:
(a) Avoid / minimize swimming, wading or bathing in fresh water that may be contaminated. All recreational
swimming areas must be inspected and cleared by the medical authority.
(b) Keep feet and footwear as dry and clean as possible. Change socks often.
(c) Leptospirosis Prophylaxis.
Prophylaxis should be considered when personnel are in a high-risk area and they have prolonged contact
with mud or standing water. Doxycycline, 200 mg once a week, can provide protection. Take Doxycycline with
food to avoid GI upset.

24.18 Oral Health.

Neglecting routine oral hygiene practices during deployment can result in periodontal disease and increases the risk
of problems such as trench mouth and tooth decay. All personnel should undergo periodic dental inspection.

24.19 Stress.
The confusion, uncertainty and anxiety that naturally occur during deployment affects individual’s ability to sleep and
perform their mission. Counter-measures include physical exercise, adequate rest and keeping informed.
(a) Before deployment, Commanders should ensure that all personnel have secured a current will, made
arrangements for childcare, arranged for bills to be paid in absentia and provided in advance for possible
family separation.
(b) Commanders should remain especially alert for personnel having serious problems adjusting to
deployment; they may be at risk for suicide. These persons may have suffered recent personal loss (end of
relationship, death etc.) and may exhibit withdrawal or other personality changes. Recognition and early referral

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of personnel at risk is an important aspect of preventing suicides.

24.20 Jet Lag.

Rapidly crossing several time zones may result in fatigue, irritability, reduced efficiency and early morning wakefulness
within the first 24 hours, lasting up to five days after landing. Prevention includes scheduling sleep before deployment
to coincide with the destination time zone, avoiding alcohol and caffeinated beverages, maintaining adequate hydration
and refraining from overeating.

24.21 Health Education.

Before the troops leave their native country for overseas deployment, it is essential that they have foreknowledge of
the anticipated health risks in the country of deployment. Mission / country specific health directions can be obtained
from the UN or DGAFMS through Army HQ (SD-3). Not only the troops but also the accompanying medical teams should
be well acquainted with the disease hazards, their preventive measures and latest treatment schedules particularly
in diseases like malaria where there are frequent changes in the distribution and parasite resistance necessitating
frequent revision of prophylaxis and treatment schedules. Moreover, no expert health advice may be forthcoming in the
deployed territory because of depleted or non-existent health infrastructure. Talks will be given and preventive measures
demonstrated and drilled to ensure that troops understand the rationale and methods for prevention of diseases.
Before departure on foreign mission, the accompanying medical authorities should endeavor to collect the relevant
health intelligence and based on this, impart relevant health education to the troops which should continue during the
period of deployment at regular intervals.

24.22 Epidemiological Surveillance.

SMO / Medical Officers in the Contingent will develop and employ a plan for epidemiological surveillance for the entire
period of deployment, including during the moves, on all aspects relating to the agent, environment and host for
early detection of any case(s) which may adversely affect the health of the troops and take appropriate containment
measures, both medical and administrative, to control any outbreak.

24.23 Other Health Hazards.

Other specific hazards, as ascertained through epidemiological intelligence should also be addressed through appropriate
formulation and implementation of SOPs / drills.

24.24 In Charge.
The overall responsibility for maintaining the health of the troops vests with the Commanders. SMO and other Medical
Officers at different echelons act as advisers to Commanders.
(a) SMO In Charge Contingent.
He will formulate SOPs on health and medical care of troops as per existing policies and epidemiological
intelligence compiled from various sources and in consultation with the specialist in Preventive and Social
Medicine, if accompanying the Contingent. The SOPs will be issued through the Commander of the contingent
as administrative instructions.
(b) Medical Officers (MOs).
All Medical Officers of the Contingent will be responsible for educating troops about the health hazards,
monitoring the implementation of the preventive measures and advising Commanders through the SMO, or,
directly, as per policy, for removal of any lacunae in implementation of preventive measures.

24.25 Notification and Report.

The SMO will submit notification of cases with specific diseases and periodic and final Health & Med Reports on
completion of mission as per policy prescribed. One copy each of the final Health & Med Report, in addition to other
addressees, will be forwarded to O / o DGAFMS / DG-3A, and, to OIC AFCESC, Dept of Community Medicine, AFMC, Pune
for analysis, record publication and dissemination of fresh instructions based on the lessons learnt during mission.
The following actions should be taken once the body of troops is earmarked for deployment on foreign missions.

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(a) D - 60 to 30 days.
(i) Medical examination of all personnel.
(ii) Immunization (including special immunization schedule if indicated)
(iii) Intimation should be sent to AFCESC asking for detailed health information of the country of
deployment.
(b) D - 30 to 15 day.
(i) Evaluate baseline knowledge on health topics before planning a health education program
(ii) Implement health education program for the troops. The topics to be covered will depend on
the particular health hazards of the place of deployment and also based on information received from
AFCESC.
(iii) Evaluate knowledge after the health education program to assess change in knowledge and attitudes.
(iv) Show films / issue necessary health information literature if same could be procured.

24.26 Geographical Distribution (Landscape Epidemiology) of various Health Hazards.

Geographical distribution of various health hazards (Landscape Epidemiology) is given as appendix to these guidelines.

24.27 Outline of Health Care System in UN Missions.

The UN Peace Keeping Operations follow an echelon based medical care system. The Armed Forces hospitals of various
countries deployed to these missions form the backbone of this system. Salient aspects of the health and medical
care in UN missions in field are described below
(a) Hospitals.
The contingents deployed in peripheral areas have one or more (depending on the role and str of tps) Level
1 hospitals, manned by Armed Forces doctors and paramedical staff. These provide basic OPD, initial casualty
management, laboratory and advisory services to respective contingents (usually, one Bn str). There are also
Level 1 hospitals manned by civilian doctors employed by the UN and located at designated sites by the local
Force HQ. Level 2 hospitals are available as referral services and located strategically along the cas evac routes.
They have medical, surgical, anaesthesia & critical care and other specialist facilities (such as ophthalmology,
orthopaedics etc, depending on the requirement of the mission). Level 3 hospitals are located centrally and
provide all the requisite advanced specialist care and support to the mission. Cases which require super
specialist care can be transferred to contracted civil multispecialty hospitals in the same or nearby country
where the mission is active. The Level 1, 2 and 3 hospitals manned by Armed Forces Medical Services of the
designated countries cater mainly to the routine and combat medical support to the deployed contingents,
irrespective of their nationalities. Civilians working with the UN in these field missions, though covered by
medical insurance, can be provided OPD and IPD care at contingent hospitals as and when referred by the
UN authorities.
(b) Medical Hierarchy and Administration.
All the medical and health care policies, guidelines and supervision is undertaken by the DHMOSH (Division of
Health Management and Occupational Safety and Health) at UNHQ in New York. At mission level, the CMO –
Chief Medical Officer (civilian) and the FMO – Force Medical Officer (military) oversee the execution of medical
services from mission HQ. Level 1, 2 and 3 hospitals work in close coordination with the offices of CMO and
FMO for their day to day functioning and cas evac matters.
(c) Equipment.
The armed forces hospitals deployed by a country in the peace keeping missions are made responsible for
provisioning of requisite expendable and non-expendable medical stores appropriate for the level of care
provided by them. These Contingent Owned Equipment (COE) are inspected by the UN authorities at regular
intervals for their quality and quantity as per the MOU of the hospital with the UN.

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(d) Bio-Medical Waste.

The UN has its own Bio Medical Waste (BMW) disposal policy. The same are prepared and approved by the
respective mission medical cells depending on the local pollution control guidelines and available resources.
Medical officers deployed in missions abroad must be encouraged to refer and follow these policies for their
hospitals.

24.28 Health Guidelines for Armed Forces Personnel proceeding as Part of UN Peace Keeping Forces.
The Armed Forces Central Epidemiological Surveillance Centre (AFCESC), Dept of Community Medicine, AFMC Pune-
411040, has built up global health intelligence and country / continent specific preventive medicine countermeasures
from various sources, such as WHO publications / websites, CD-ROM developed by the Armed Forces Medical Intelligence
Center of the American Armed Forces, etc. All contingents that are deployed / return from UN / foreign assignments
should send health intelligence feedback to AFCESC so that the information can be used to update these guidelines.
Moreover, AFCESC should be intimated in advance of any such deployment to enable it to forward any country specific
information, for specific preventive countermeasures.
AFCESC has information on the following aspects of some countries:
(i) Environmental Health Risk Assessment
(ii) Infectious Disease Risk Assessment
(iii) Preventive Medicine Recommendations
(iv) Disease Vector Profiles
(a) Geographical distribution (Landscape Epidemiology) of potential health hazards to troops in various
regions of the World.
This section is intended to give a broad indication of the health risks to which our troops may be exposed in
various areas of the world and may not encounter in their usual place of residence.
In practice, to identify areas accurately and define the degree of risk likely in each of them is extremely
difficult, if not impossible. For example, viral hepatitis A is ubiquitous but the risk of infection varies not only
according to area but also according to eating habits; hence, there may be more risk from communal eating
in an area of low incidence than from eating in a private home in an area of high incidence. Generalizations
may therefore be misleading.
(i) Australia, New Zealand and the Antarctic.
(aa) In Australia, the mainland has tropical monsoon forests in the north and east, dry tropical
forests, Savannah and deserts in the centre and Mediterranean scrub and subtropical forests in
the south. New Zealand has a temperate climate with the North Island characterized by subtropical
forests and the South Island by steppe vegetation and hardwood forests.
(ab) International travelers to Australia and New Zealand will, in general, not be subjected to
the hazards of communicable diseases to an extent greater than that found in their own country.
(ac) Arthropod-borne diseases-Mosquito-borne epidemic polyarthritis (Ross river virus) and viral
encephalitis (JE) may occur in some rural areas of Australia. Occasional outbreaks of dengue have
occurred in northern Australia in recent years.
(ad) Other hazards: Coelenterates (corals, jellyfish) may prove a hazard to the sea-bather and
heat is a hazard in the northern and central parts of Australia. Insectivorous and fruit-eating bats in
Australia have been found to harbour a virus (Australian bat lyssavirus- ABLV) related to rabies virus
and should be avoided. Snakes and poisonous spiders are a hazard in most part of the country.
(ii) Caribbean Middle America.
(aa) Antigua and Barbuda, Aruba. Bahamas, Barbados, British Virgin Islands, Cayman
Islands, Cuba, Dominica, Dominican Republic, Grenada, Guadeloupe, Haiti. Jamaica. Martinique,
Montserrat, Netherlands Antilles, Puerto Rico, Saint Kitts and Nevis, Saint Lucia, Saint Vincent
and the Grenadines, Trinidad and Tobago, Turks and Caicos Islands and the Virgin Islands (USA)
comprise of Carribean Middle America. The islands, a number of them are mountainous with peaks

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1,000-2,500 m high, have an equable tropical climate with heavy rain storms and high winds at
certain times of the year.
(ab) Of the arthropod-borne diseases, malaria occurs in endemic form only in Haiti and in parts
of the Dominican Republic. Leishmaniasis was recently discovered in the Dominican Republic,
Guadeloupe and Martinique. Bancroftian filariasis occurs in Haiti and some other islands and
other filariases may occasionally be found. Human fascioliasis due to Fasciola hepatica is endemic
in Cuba. Outbreaks of dengue fever occur in the area and dengue haemorrhagic fever has also
occurred. Tularemia has been reported from Haiti.
(ac) Of the foodborne and waterborne diseases, bacillary and amoebic dysentery are common
and Hepatitis A is reported particularly in the northern islands. Active cholera transmission is
present in a few islands but rare in travelers.
(ad) Other diseases: Schistosomiasis (bilharziasis) is endemic in the Dominican Republic,
Guadeloupe, Martinique, Puerto Rico and Saint Lucia, in each of which control operations are
in progress and it may also· occur sporadically in other islands. Animal rabies particularly in the
mongoose, is reported from several islands.
(ae) Other hazards: Spiny sea urchins and coelenterates (corals and jellyfish) and snakes may
be a hazard in some areas.
(iii) East Asia.
(aa) China (including Hong Kong and Macao Special Administrative Regions), The Democratic
People’s Republic of Korea, Hong Kong, Japan, Mongolia and the Republic of Korea. The area
includes the high mountain complexes, the desert and the steppes of the west and the various
forest zones of the east, down to the subtropical forests of the southeast.
(ab) Among the arthropod-borne diseases, malaria occurs in China and the Korean peninsula.
Although reduced in distribution and prevalence, bancroftian and brugian filariasis are still reported
in southern China. A resurgence of visceral leishmaniasis is occurring in China. Cutaneous
leishmaniasis has been recently reported from Xinjiang, Uygur Autonomous Region. Plague may
be found in China and Mongolia. Haemorrhagic fever with renal syndrome - rodent-borne, Korean
haemorrhagic fever - is endemic except in Mongolia and epidemics of dengue fever and Japanese
encephalitis may occur in some countries. Mite borne or scrub typhus may be found in scrub areas
in southern China, certain river valleys in Japan and in the Republic of Korea.
(ac) Foodborne and waterborne diseases such as the diarrhoeal diseases and hepatitis A are
common in most countries. Hepatitis E is prevalent in western China. Clonorchiasis (oriental liver
fluke) and paragonimiasis (oriental lung fluke) are reported in China, including Macao Special
Administrative Region and the Republic of Korea,. Brucellosis occurs in China. Cholera may occur
in some countries in this area.
(ad) Other diseases: Hepatitis B is highly endemic.
(ae) The present endemic area of schistosomiasis (bilharziasis) is in the central Chang Jiang
(Yangtze) river basin in China. Active foci no longer exist in Japan. Trachoma and leptospirosis occur
in China. Rabies is endemic in some countries. Outbreaks of meningococcal meningitis occur in
Mongolia. Incidence of newer strains of influenza are found to occur in regions of China.
(iv) Eastern South Asia.
(aa) Brunei Darussalam, Cambodia, Indonesia, Lao People’s Democratic Republic. Malaysia,
Myanmar, the Philippines, Singapore, Thailand and Vietnam. From the tropical rain and monsoon
forests of the northwest, the area extends through the savanna and the dry tropical forests of the
Indochina peninsula, returning to the tropical rain and monsoon forests of the islands bordering
the South China Sea.
(ab) The arthropod-borne diseases are an important cause of morbidity and mortality throughout
the area. Malaria and filariasis are endemic in many parts of the rural areas of all the countries
or areas except for malaria in Brunei Darussalam and Singapore, where normally only imported
cases occur. Natural foci of plague have been reported in Indochina, Myanmar and in Vietnam.

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Japanese encephalitis, dengue and dengue haemorrhagic fever can occur in epidemics in both
urban and rural areas. Chikungunya and Zika have been known to occur in a few countries. Mite-
borne typhus has been reported in deforested areas in most countries.
(ac) Foodborne and waterborne diseases are common. Cholera and other watery diarrhoeas,
amoebic and bacillary dysentery, typhoid fever, leptospirosis and hepatitis A and E may occur in
all countries in the area.
(ad) Other Diseases. Hepatitis B is highly endemic. Schistosomiasis (bilharziasis) is endemic
in the southern Philippines and in central Sulawesi (Indonesia) and occurs in small foci in the
Mekong delta in Vietnam. Trachoma exists in Indonesia, Myanmar, Thailand and Vietnam. Rabies
has been reported. Many viral respiratory illnesses such as COVID-19 and H1N1 have been known
to originate in East Asia.
(ae) Other hazards include snakes and leeches. A natural focus of plague is a strictly delimited
area where ecological conditions ensure the persistence of plague in wild rodents (and occasionally
others animals) for long periods of time and where epizootics and periods of quiescence may
alternate.
(v) Mainland Middle America.
(aa) Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua and Panama. It
ranges from the deserts of the north to the tropical rain forests of the southeast.
(ab) Of the arthropod-borne diseases, malaria and cutaneous and mucocutaneous leishmaniasis
occur in all eight countries. Visceral leishmaniasis occurs in El Salvador, Guatemala, Honduras,
Mexico and Nicaragua. American trypanosomiasis (Chagas disease) has been reported to occur in
localized foci in rural areas in all eight countries. Dengue fever and Venezuelan equine encephalitis
may occur in all countries.
(ac) The foodborne and waterborne diseases, including amoebic and bacillary dysentery and
other diarrhoeal diseases and the typhoid fever are very common throughout the area. Cholera is
known to occur sporadically in past. Hepatitis A occurs throughout the area and hepatitis E has
been reported in Mexico. Helminthic infections are common. Paragonimiasis (oriental lung fluke)
has been reported in Costa Rica, Honduras and Panama. Brucellosis occurs in the northern part of
the area. Many Salmonella typhi infections from Mexico and Shigella dysenteriae type 1 infections
from mainland Middle America as a whole have been caused by drug-resistant Enterobacteria.
(ad) Other Diseases: Rabies in animals (usually dogs and bats) is widespread throughout the
area.
(ae) Other Hazards: Snakes may be a hazard in some areas.
(vi) Middle South Asia.
(aa) Afghanistan, Armenia, Azerbaijan, Bangladesh, Bhutan, Georgia, Islamic Republic of
Iran, Kazakstan, Kyrgyzstan, Maldives, Nepal, Pakistan, Sri Lanka, Tajikistan, Turkmenistan and
Uzbekistan. Bordered from the most part by high mountain ranges in the north, the area extends
from steppes and desert in the west to monsoon and tropical rain forests in the east and south.
(ab) Arthropod-borne diseases are endemic in all of these countries except for malaria in
Kazakhstan, Kyrgyzstan, the Maldives and Uzbekistan. In some of the other countries malaria
occurs in urban as well as rural areas. Filariasis is common in Bangladesh and the south-western
coastal belt of Sri Lanka. Cutaneous leishmaniasis occurs in Afghanistan, the Islamic Republic of
Iran and Pakistan. There are very small foci of cutaneous and visceral leishmaniasis in Azerbaijan
and Tajikistan. There is evidence that natural foci of plague exist in India and Kazakstan (a natural
focus of plague is a strictly delimited area where ecological conditions ensure the persistence
of plague in wild rodents (and occasionally others animals) for long periods of time and where
epizootics and periods of quiescence may alternate). Tick borne relapsing fever is reported from
Afghanistan and the Islamic Republic of Iran and typhus occurs in Afghanistan and India. Outbreaks
of dengue fever may occur in Bangladesh, Pakistan and Sri Lanka and the haemorrhagic form has
been reported from Sri Lanka. Japanese encephalitis has been reported from the eastern part

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of the area and Crimean-Congo Haemorrhagic Fever (CCHF) from the western part. Another tick
borne haemorrhagic fever has been reported in a rural area of Rawalpindi district in Pakistan.
(ac) Foodborne and waterborne diseases are common throughout the area, in particular cholera
and other watery diarrhoeas, the dysenteries, typhoid fever, hepatitis A and E and helminthic
infections. Large epidemics of hepatitis E can occur. Giardiasis is common in the area. Brucellosis
and echinococcosis (hydatid disease) are found in many countries in the area.
(ad) Other diseases. Hepatitis B is endemic. A very limited focus of urinary schistosomiasis
(bilharziasis) persists in the south-west of the Islamic Republic of Iran. Outbreaks of meningococcal
meningitis have been reported in Nepal. Poliomyelitis with wild poliovirus circulation still remains
a problem in Pakistan and Afghanistan. Trachoma is common in Afghanistan, the Islamic Republic
of Iran, Nepal and Pakistan. Rabies is present in animals.
(ae) Other hazards. Snakes are a hazard in most of the countries in the area
(vii) North America.
(aa) Bermuda, Canada, Greenland, Saint Pierre and Miquelon and the United States of America
(with Hawaii) extends from the Arctic to the subtropical cays of the southern USA.
(ab) The incidence of communicable diseases is such that they are unlikely to prove a hazard for
the international traveller greater than that found in his or her own country. There are, of course,
health risks, but in general the precautions required are minimal. Certain diseases occasionally
occur, such as plague, rabies in wildlife including bats, Rocky Mountain spotted fever, tularemia and
arthropod-borne encephalitis. Recently, rodent-borne Hantavirus has been identified, predominantly
in the western states of the USA and the southwestern provinces of Canada. Lyme disease is
endemic in the north-eastern, mid-Atlantic and the upper mid-western USA Occasional cases have
been reported from the Pacific Northwest. During recent years, the incidence of certain foodborne
diseases, e.g. salmonellosis, has increased in some regions. Other hazards include poisonous
snakes, poison ivy and poison oak. In the north, a serious hazard is the very low temperature in
the winter.
(viii) Northern Africa.
(aa) Algeria, Egypt, Libyan Arab Jamahiriya, Morocco and Tunisia is characterized by a generally
fertile coastal area and a desert hinterland with oases that are often foci of infections.
(ab) The arthropod borne diseases are unlikely to be a major problem to the traveller, although
filariasis (focally in the Nile delta), leishmaniasis, malaria, relapsing fever, Rift Valley fever. Sandfly
fever, typhus and West Nile fever occur in some areas.
(ac) Foodborne and waterborne diseases are endemic, the dysenteries and other diarrhoeal
diseases being particularly common. Hepatitis A occurs throughout the area and hepatitis E is
endemic in some regions. The typhoid fevers are common in some areas. Alimentary helminthic
infections, Brucellosis and Giardiasis are common. Echinococcosis (hydatid disease) and sporadic
cases of cholera may occur.
(ad) Other diseases. Trachoma and rabies are found in certain areas. Schistosomiasis (bilharziasis)
is prevalent both in the Nile delta area and in the Nile valley; it occurs focally elsewhere in the
area.
(ad) Other hazards. Snakes and scorpions are a hazard in certain areas.
(ix) Northern Europe.
(aa) Belarus, Belgium, Czech Republic, Denmark (with the Faro Islands), Estonia, Finland,
Germany, Iceland, Ireland, Latvia, Lithuania, Luxembourg, Netherlands, Norway, Poland, Republic
of Moldavia, Russian Federation, Slovakia, Sweden, Ukraine and the United Kingdom (with the
Channel Islands and the Isle of Man). The area encompassed by these countries extends from
the broadleaf forests and the plains of the west to the boreal and mixed forest to be found as
far east as the Pacific Ocean.
(ab) The incidence of communicable diseases in most parts of the area is such that they are unlikely

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to prove a hazard to the international traveller greater than that found in his or her own country. There
are, of course, health risks, but in most of the area very few precautions are required.
(ac) Of the arthropod borne diseases, there are very small foci of tick borne typhus in east and central
Siberia. Tick borne encephalitis, for which a vaccine exists and Lyme disease may occur throughout
forested areas where vector ticks are found. Rodent borne haemorrhagic fever with renal syndrome is
now recognized as occurring at low endemic levels in this area.
(ad) The food borne and water borne diseases reported other than the ubiquitous diarrhoeal diseases
are taeniasis (tapeworm) and trichinellosis in parts of northern Europe and diphyllobothriasis (fish
tapewonn) from the freshwater fish around the Baltic Sea area. Fasciola hepatica infection can occur.
Hepatitis A occurs in the eastern European countries. The incidence of certain foodborne diseases, e.g.
salmonellosis and campylobacteriosis, is increasing significantly in some countries.
(ae) Other diseases. Rabies is endemic in wild animals (particularly foxes) in rural areas of northern
Europe. In recent years, Belarus, the Russian Federation and Ukraine have experienced extensive
epidemics of diphtheria. Diphtheria cases, mostly imported from these three countries, have also been
reported from neighbouring countries: Estonia, Finland, Latvia, Lithuania, Poland and the Republic of
Moldavia.
(af) Other hazards. The extreme cold in winter is a climatic hazard in parts of northern Europe.
(x) Southern Africa.
(aa) (Botswana, Lesotho, Namibia, Saint Helena, South Africa and Swaziland) varies physically
from the Namibia and Kalahari deserts to fertile plateaus and plains and to the more temperate
climate of the southern coast.
(ab) Arthropod-borne diseases such as Crimean-Congo haemorrhagic fever, malaria, plague,
relapsing fever, Rift Valley fever, tick-bite fever and typhus-mainly tick-borne-have been reported
from most of this area except Saint Helena, but, apart from malaria in certain areas, they are
unlikely to be a major health problem for the traveller. Natural foci of plague have been reported
in Namibia and South Africa. Trypanosomiasis (sleeping sickness) may occur in Botswana and
Namibia.
(ac) Foodborne and waterborne diseases are common in some areas, particularly amoebiasis
and the typhoid fevers. Hepatitis A occurs in this area.
(ad) Other diseases: Hepatitis B is hyperendemic. Schistosomiasis (bilharziasis) is endemic in
Botswana, Namibia, South Africa and Swaziland.
(ae) Other hazards: Snakes may be a hazard in some areas.
(af) A natural focus of plague in a strictly delimited area where ecological conditions ensure the
persistence of plague in wild rodents (and occasionally others animals) for long periods of time
and where epizootics and periods of quiescence may alternate.
(xi) Southern Europe.
(aa) Albania, Andorra, Austria, Bosnia and Herzegovina, Bulgaria, Croatia, France, Gibraltar,
Greece, Hungary, Italy, Liechtenstein, Malta, Monaco, Portugal (with the Azores and Madeira),
Romania, San Marino, Slovenia, Spain (with the Canary Islands), Switzerland, the former Yugoslav
Republic of Macedonia and Federal Republic of Yugoslavia (Serbia and Montenegro). The area
extends from the broadleaf forests in the northwest and the mountains of the Alps to the prairie
and, in the south and southeast, the scrub vegetation of the Mediterranean.
(ab) Among the arthropod borne diseases, sporadic cases of murine and tick borne typhus and
mosquito borne West Nile fever occur in some countries bordering the Mediterranean littoral.
Both cutaneous and visceral leishmaniasis and Sandfly fever are also reported from this area.
Leishmania / HIV co-infections have been notified from France, Greece, Italy, Portugal and Spain.
Tick borne encephalitis, for which a vaccine exists, Lyme disease and rodent-borne hemorrhagic
fever with renal syndrome may occur in the eastern and southern parts of the area.
(ac) The food borne and water borne diseases like Bacillary dysentery and other diarrhoea and

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typhoid fever are more common in the summer and autumn months, with a high incidence in the
south-eastern and south-western parts of the area. Brucellosis can occur in the extreme southwest
and southeast and echinococcosis (hydatid disease) in the south-east. Fasciola hepatica infection
has been reported from different countries in this area. Hepatitis A occurs in eastern European
countries. The incidence of certain food borne diseases, e.g. salmonellosis and campylobacteriosis
is increasing significantly in some countries.
(ad) Other diseases: Hepatitis B is endemic in the southern part of eastern Europe (Albania,
Bulgaria and Romania). Rabies in animals exists in most countries of southern Europe.
(xii) Sub-Saharan Africa.
(aa) (Angola, Benin, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic,
Chad, Comoros, Congo, Cote d’Ivoire, Democratic Republic of the Congo, Djibouti, Equatorial Guinea,
Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea Bissau, Kenya, Liberia, Madagascar,
Malawi, Mali, Mauritania, Mauritius, Mozambique, Niger, Nigeria, Reunion, Rwanda, Sao Tome
and Principe, Senegal, Seychelles, Sierra, Leone, Somalia, Sudan, Togo, Uganda, United Republic
of Tanzania, Zambia and Zimbabwe) In this area, entirely within the tropics, the vegetation varies
from the tropical rain forests of the west and center to the wooded steppes of the east and from
the desert of the north through the Sahel and Sudan savannas to the moist orchard savanna and
woodlands north and south of the equator.
(ab) Many of the diseases listed below occur in localized foci and are confined to rural areas.
They are mentioned so that the international traveler and the medical practitioner concerned may
be aware of the diseases that may occur.
(ac) Arthropod borne diseases are a major cause of morbidity. Malaria occurs throughout the
area, except at over 2,600 meters altitude and in the islands of Reunion and the Seychelles.
Various forms of filariasis are widespread; endemic foci of Onchocerciasis (river blindness) exist
in all the countries listed except in the greater part of Kenya and in Djibouti, Gambia, Mauritania,
Mozambique, Somalia, Zambia, Zimbabwe and the island countries of the Atlantic and Indian
Oceans. Both cutaneous and visceral leishmaniasis may be found, particularly in the drier areas.
Visceral leishmaniasis is epidemic in eastern and southern Sudan. Human trypanosomiasis
(sleeping sickness), in discrete foci, is reported from all countries except Djibouti, Eritrea,
Gambia, Mauritania, Niger, Somalia and the island countries of the Atlantic and Indian Oceans.
The transmission rate of human trypanosomiasis is high in north western Uganda and very high
in northern Angola, the Democratic Republic of the Congo (mostly Equateur and Bandundu) and
southern Sudan and there is a significant risk of infection for travelers visiting or working in rural
areas. Relapsing fever and louse, flea and tick borne typhus occur. Natural foci of plague have
been reported in Angola, the Democratic Republic of the Congo, Kenya, Madagascar, Mozambique,
Uganda, the United Republic of Tanzania, Zambia and Zimbabwe. Many viral diseases, some
presenting as severe haemorrhagic fevers, are transmitted by mosquitoes, ticks, sandflies etc.
which are found throughout this region. Large outbreaks of yellow fever occur periodically in the
unvaccinated population.
(ad) Food borne and water borne diseases are highly endemic. Alimentary helminthic infections,
dysenteries and diarrhoeal diseases, including Giardiasis, typhoid fever and hepatitis A and E are
widespread. Cholera is actively transmitted in many countries in this area. Dracunculiasis occurs in
isolated foci. Paragonimiasis (oriental lung fluke) has been reported in Cameroon, Gabon, Liberia
and Equatorial Guinea. Echinococcosis (hydatid disease) is widespread in animal-breeding areas.
(ae) Other Diseases: Hepatitis B is hyperendemic. Schistosomiasis (bilharziasis) is present
throughout the area except in Cape Verde, Comoros, Djibouti, Reunion and Seychelles. Trachoma
is widespread. Among other diseases, certain, frequently fatal, Arenavirus haemorrhagic fever
have attained notoriety. Lassa fever has a major reservoir in a commonly found multimammate
rat. Studies have shown that an appreciable reservoir exists in some rural areas of West Africa
and people visiting these areas should take particular care to avoid rat contaminated food or
food containers, but the extent of the disease should not be exaggerated. Ebola and Marburg
haemorrhagic fevers are present but reported only infrequently. Ebola Virus Disease (EVD) has

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become a major public health threat in recent years. Epidemics of meningococcal meningitis may
occur throughout tropical Africa, particularly in the savanna areas during the dry season.
(af) Other hazards include rabies and snakes. A natural focus of plague in a strictly delimited
area where ecological conditions ensure the existence of plague in wild rodents (and occasionally
other animals) for long periods of time and where epizootics and periods of quiescence may
alternate.
(xiii) Temperate South America.
(aa) Argentina, Chile, Falkland Islands (Malvinas) and Uruguay. The mainland ranges from the
Mediterranean climatic area of the western coastal strip over the Andes divide on to the steppes
and desert of Patagonia in the south and to the prairies of the northeast.
(ab) The arthropod borne diseases are relatively unimportant except for the occurrence of
American trypanosomiasis (Chagas disease). Outbreaks of malaria occur in northwestern Argentina
and cutaneous leishmaniasis is also reported from the northeastern part of the country.
(ac) Of the food borne and water borne diseases, gastroenteritis (mainly salmonellosis) is
relatively common in Argentina, especially in suburban areas and among children below the age
of 5 years. Typhoid fever is not very common in Argentina but hepatitis A and intestinal parasitosis
are widespread, the latter especially in the coastal region. Taeniasis (tapeworm), typhoid fever,
viral hepatitis and echinococcosis (hydatid disease) are reported from the other countries.
(ad) Other diseases. Meningococcal meningitis occurs in the form of epidemic outbreaks in
Chile. Rodent borne Hantavirus pulmonary syndrome has been identified in the north-central and
south-western regions of Argentina and in Chile.
(xiv) Tropical South America.
(aa) Bolivia, Brazil, Colombia, Ecuador, French Guinea, Guyana, Paraguay, Peru, Suriname and
Venezuela. It covers the narrow coastal strip on the Pacific Ocean, the high Andean range with
numerous peaks 5,000-7,000 m high and the tropical rain forests of the Amazon basin, bordered
to the north and south by savanna zones and dry tropical forests or scrub.
(ab) Arthropod borne diseases are an important cause of ill health in rural areas. Malaria occurs
in all ten countries or areas, as do American trypanosomiasis (Chagas disease) and cutaneous and
mucocutaneous leishmaniasis. There has been an increase in the latter in Brazil and Paraguay.
Visceral leishmaniasis is endemic in northeast Brazil, with foci in other parts of Brazil, less
frequent in Colombia and Venezuela, rare in Bolivia and Paraguay and unknown in Peru. Endemic
Onchocerciasis occurs in isolated foci in rural areas in Ecuador, Venezuela and northern Brazil. The
bites of blackflies may cause unpleasant reactions. Bancroftian filariasis is endemic in parts of
Brazil, Guyana and Suriname. Plague has been reported in natural foci (a natural focus of plague
is a strictly delimited area where ecological conditions ensure the persistence of plague in wild
rodents (and occasionally other animals) for long periods of time and where epizootics and periods
of quiescence may alternate) in Bolivia, Brazil, Ecuador and Peru. Among the arthropod-borne viral
diseases, jungle yellow fever may be found in forest areas in all countries except Paraguay and
areas east of the Andes; in Brazil it is confined to the northern and western states. Epidemics of
viral encephalitis and dengue fever occur in some countries of this area. Bartonellosis or Oroya
fever, a Sandfly borne disease, occurs in arid river valleys on the western slopes of the Andes up
to 3,000 m. Louse-borne typhus is often found in mountain areas of Colombia and Peru.
(ac) Food borne and water borne diseases are common and include amoebiasis, diarrhoeal
diseases, helminthic infections and hepatitis A. Paragonimiasis (oriental lung fluke) has been
reported from Ecuador, Peru and Venezuela. Brucellosis is common and echinococcosis (hydatid
disease) occurs particularly in Peru. Bolivia, Brazil, Colombia, Ecuador, Peru and Venezuela all
reported autochthonous cases of cholera in 1996.
(ad) Other diseases include rodent borne arenavirus haemorrhagic fever in Bolivia and Venezuela
and rodent borne pulmonary syndrome in Brazil and Paraguay. Hepatitis B and D (delta hepatitis)
is highly endemic in the Amazon basin. The intestinal form of schistosomiasis (bilharziasis) is found

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in Brazil, Suriname and north-central Venezuela.

(ae) Rabies has been reported from many of the countries in this area. Meningococcal meningitis
occurs in the form of epidemic outbreaks in Brazil.
(af) Other Hazards. Snakes and leeches may be a hazard in some areas.
(xv) Western South Asia.
(aa) Bahrain, Cyprus, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syrian
Arab Republic, Turkey, the United Arab Emirates and Yemen. The area ranges from the mountains
and steppes of the northwest to the large deserts and dry tropical scrub of the south.
(ab) The arthropod borne diseases, except for malaria in certain areas, these are major hazard
for the traveller. Malaria does not exist in Kuwait and no longer occurs in Bahrain, Cyprus, Israel,
Jordan, Lebanon or Qatar. Its incidence in Oman, the Syrian Arab Republic and United Arab
Emirates is low, but elsewhere it is endemic in certain rural areas. Murine and tick borne typhus
can occur in certain countries. Tick borne relapsing fever may occur. Crimean-Congo hemorrhagic
fever has been reported from Iraq. Limited foci of Onchocerciasis are reported from Yemen.
(ac) The food borne and water borne diseases are, however, a major hazard in most countries
in the area. Typhoid fever and hepatitis A exist in all countries. Dracunculiasis occurs in isolated
foci in Yemen. Taeniasis (tapeworm) is reported from many countries in the area. Brucellosis is
reported from most countries and there are foci of echinococcosis (hydatid disease).
(ad) Other Diseases. Hepatitis B is endemic. Schistosomiasis (bilharziasis) occurs in Iraq, Saudi
Arabia, the Syrian Arab Republic and Yemen. Trachoma and animal rabies are found in many of
the countries.
(ae) Other Hazards. The greatest hazards to pilgrims to Mecca and Medina are heat and water
depletion if the period of the Haj coincides with the the hot season.

24.29 Medical Conditions Precluding Participation in Peacekeeping Operations.

Immunisation. Skin Problems.

O Failure to provide proof of having received all O An active skin disease such as eczema or widespread
United Nations-mandated immunisations psoriasis

Chest. Any Known Heart Disease.

O Asthma, strong asthma-like symptoms or O Hypertension not controlled with medication
treatment for related illnesses within the last four O Recent episodes necessitating emergency room visits or
years closely monitored follow-up care
O Chronic lung diseases such as emphysema, O Pacemakers
bronchiectasis or cystic fibrosis O Conditions requiring anticoagulants
O Active tuberculosis O Coronary heart diseases
Back Problems. History of Cancer.
O Spinal surgery (including internal fixation or Soldiers with a history of cancer who have been on
fusion) palliative treatment, but have a requirement for periodic
O Recurrent lower back pain monitoring every six months or less, should not deploy.

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Bone and Joint Problems. Other Conditions.

O Meniscectomy (knee cartilage operation) within O Loss of spleen (splenectomy)
the last year O Having received transplanted organs
O Lower limb fractures with internal fixation O Severe allergic reactions or anaphylaxis
(metalwork) still in place O Severe nut allergy
O Loss of a limb O Circulation problems such as Raynaud’s phenomenon
O Complete loss of a thumb or big toe O Insulin dependent diabetes
O Clubfoot (including past surgery) O Diseases requiring long-term medication, continuous
O Chronic joint diseases such as ankylosing monitoring or replacement therapy such as endocrine diseases
spondylitis, psoriatic arthritis, rheumatoid arthritis or O Known allergy to or intolerance of anti-malarial medication;
gout
O Any immunocompromised condition, including AIDS
O Reiter’s disease within the last five years
O History of being hepatitis B or C carrier
O Osteochondritis dissecans
O Cholera

Eye Disorders. Chronic Medical Conditions.

O Chronic eye diseases such as glaucoma, Any chronic illness requiring:
keratoconus and retinitis pigmentosa O Regular medication(s) and where maintenance
O Surgery for a squint within the last six months medication is of such toxicity as to require frequent clinical
O Corneal problems such as a corneal graft or and laboratory follow up; or
recurrent corneal ulcers Where the chronic medical condition requires frequent
O Loss or dislocation of an eye lens follow up that cannot be delayed for the duration of the
tour, e.g. malignant tumours.
O Cataract or cataract surgery
O Detached retina
Ear Disorders. Kidney Diseases.
O Current perforation of ear drum O Chronic nephritis and urolithiasis
O Chronic ear diseases such as cholesteatoma O Polycystic kidney disease or kidney stones
O Presence of eardrum ‘grommets’ O Donation of a kidney within the last two years
O Kidney disease within the last two years
Abdominal Disorders. Pregnancy.
Chronic abdominal diseases such as Crohn’s O Pregnant peacekeepers will be repatriated at the end
Disease or ulcerative colitis the fifth month of gestation, to ensure that the health and
wellbeing of the peacekeeper and her child is not put at risk.
Neurological Disorders. Psychiatric Conditions.
O Epilepsy or more than one seizure or fit after O Schizophrenia
the age of five O Obsessive-compulsive disorder
O Any seizure or fit within the last 10 years O Alcohol or drug dependence
O Multiple sclerosis O Post-traumatic stress disorder
Blood Diseases.
O Sickle cell anaemia
O Congenital spherocytosis
O Thalassemia
O AIDS
O Being a carrier of hepatitis B or C
O Past history of leukaemia or malignant lymphoma.
Must be disease, treatment and review free for five
years.

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24.30 MS2 or Entry Medical Examination Form.

FAO IAEA ILO ITC ITU UN UNDP UNESCO UNICEF UNIDO WHO WIPO WMO WTO

CONFIDENTIAL ENTRY MEDICAL EXAMINATION UNITED NATIONS AND SPECILIZED AGENCIES

I hereby authorize any of the doctors, hospitals or clinics mentioned in this form to provide the United Nations Medical
Service with copies of all my medical records so that the Organization can take action upon my application for employment.

I certify that the statements made by me in answer to the questions below are, to the best of my knowledge, true, complete
and correct. I realize that any incorrect statement or material omission in the medical form or in any other document required
by the Organization renders a staff member liable to termination of dismissal.

Date: (dd/mm/yy) d Signature:

Pages 1 and 2 are to be completed by the candidate

FAMILY NAME (IN BLOCK CAPITALS) MAIDEN NAME (FOR WOMEN ONLY) SEX
M F
ADDRESS (STREET, TOWN, DISTRICT OR PROVINCE, COUNTRY ) DATE OF BIRTH

NATIONALITY

POSITION APPLIED FOR (DESCRIBE NATURE OF WORK) TELEPHONE BIRTHPLACE

PRESENT MARITAL STATUS

Single
DUTY STATION
Married DATE: (d/m/y) Divorced DATE: (d/m/y)

Separated DATE: (d/m/y) Separated DATE: (d/m/y)

Have you ever undergone a medical examination for the United Nations or one of its agencies?
Have you ever been employed by the United Nations or one of its agencies?
If so, please state when, where and for which Organization:

FAMILY HISTORY
Age State of Health Age Have members of your
Relative (if still (If still alive, present state; At family had the following Yes No Who?
alive) if deceased, cause of death) death illness or disorders?
Father High Blood Pressure
Mother Heart Disease
Brothers Diabetes
Sisters Tuberculosis
Spouse Asthma
Children Cancer
Epilepsy
Mental Disorders
Paralysis

TO BE COMPLETED BY THE OFFICIAL REQUESTING TO BE COMPLETED BY THE DIRECTOR

THE MEDICAL EXAMINATION OF THE MEDICAL SERVICE
Medical Classification: 1a 1b 2a 2b
Name of Official:

Comments:

Department of Unit:
Date: DATE: (d/m/y) Signature:

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 HEALTHCARE IN ARMED FORCES

VERY IMPORTANT : Please indicate the recruiting Agency or Organisation:

Each question requires a specific answer (yes, no, dat, etc.); to leave a blank or draw a line is not sufficient. If the questionnaire is not fully completed
and equiries are therefore needed, time may be lost.
1. Have you suffered from any of the following diseases or disorders? Check yes or no. If yes, state the year.
YES YES YES NO YES
Date NO Date NO Date Date NO
Frequent sore throats Heart and blood vessel disease Urinary disorder Fainting spells
Hay fever Pains in the heart region Kidney trouble Epilepsy
Asthma Vericose veins Kidney stones Diabetes
Tuberculosis Frequent indigestion Back pain Gonorrhoea
Pneumonia Ulcer of stomach or duodenum Joint problems Any other sexually
transmitted disease
Pleurisy Jaundice Skin desease Tropical diseases
Repeatd bronchitis Gall stones Sleeplessness Amoebic dysentry
Rheumatic fever Hernia Any nervous or Malaria
mental disorder
HIgh blood pressure Haemorrhoids Frequent
headaches
2. Are you being treated for any condition now? Describe:
3. Have you ever coughed up blood?
4. Have you ever noticed blood in your stools? In your urine? Give details:
5. Have you ever been hospitalized (hospital, clinic, etc.)?
Why, where and when?
6. Have you ever been absent from work for longer than one month through illness? If so, when?
And for what illness?
7. Have you had any accidents as a result of which you are parially disabled? If so, what and when?
Do you have any other disability?
8. Have you ever consulted a neurologist, a psychiatrist or a psychoanalyst?
If so, please give his/her name and address:
For what reason? Date of consultation:(d/m/y)
9. Are you taking any medicine regularly? If so, which?
10. Have you gained or lost weight during the last three years? If so, how much?
11. Have you ever been refused life insurance? If so, state reason:
12. Have you ever been refused employment on health grounds? If so, state reason:
13. Have you ever received or applied for a pension or compensation for any permanent disability? Degree?
Please give details:
14. Have you ever stayed in a tropical country? If so, for how long?
15. Have you in the past suffered from any condition which prevented travel by air?
16. Do you consider yourself to be in good health? Do you have full work capacity?
17. Do you smoke regularly? Yes No If so, what do you smoke? Cigarettes Pipe Cigars
For how many years have you smoked? How much per day?
18. Daily consumption of alcoholic beverages:
19. Has any doctor or dentist advised you to undergo medical or surgical treatment in the foreseeable future?
Give details:
20. Give any other significant information concerning your health:

21. What is your occupation? Indicate at least three posts you have occupied:
22. List any occupational or other hazards to which you have been exposed:

23. Have you been rejected for millitary service for medical reasons?
24. FOR WOMEN Are your periods regular? Yes No | Do you take contraceptive pills? Yes No If so, for
Are they painful? Yes No | how many years have you been doing so? Have you ever
Do you have to stay in bed when they come? Yes No | been treated for a gyanaecological complaint? Yes No
If so, for how long? Date of your last period: If so, which?

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 HEALTH GUIDELINES FOR UN MISSIONS

TO BE COMPLETED BY THE EXAMINING PHYSICIAN

GENERAL APPEARANCE Height: Weight:

Skin: Scalp:

SIGHT, MEASURED VISUAL ACUITY

Gross vision Left Pupils: Equal? Regular?
Vision with spectacles Left Fundi (if necessary):
Near vision Left Colour vision:
With correction Left

HEARING | Right Sufficient: Insufficient:

(test by | Left Sufficient: Insufficient:
whispering) | Ear drum Left:

NOSE-MOUTH-NECK Nose Pharynx Teeth

Tongue Tonsils Thyroid
CARDIOVASCULAR SYSTEM Peripheral Arteries
Pulse rate: Auscultation: -carotid:
Rhythm: Blood pressure: -posterior tibial:
Apex beat: Varicose veins: -dorsalis pedes:
Electrocardiogram Please attach tracing
RESPIRATORY SYSTEM | Breasts
Thorax: |

DIGESTIVE SYSTEM Spleen:

Abdomen Hernia:
Liver Rectal examination:

NERVOUS SYSTEM Plantar reflexes:

Papillary reflexes:
Patellar reflexes: {
- To light:
- On accommodation
Motor functions
Secondary functions
Achilles reflexes: Muscular tonus
Romberg’s sign

MENTAL STATE
Appearance: Behaviour:
GENITO-URINARY SYSTEM
Kidneys: Genitals:

SKELETAL SYSTEM
Skull: Upper extremities:
Spine: Lower extremities:
LYMPHATIC SYSTEM

CHEEST X-RAY (Please send only the radiologist’s report based on a “full-size” X-ray film).

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 HEALTHCARE IN ARMED FORCES

LABORATORY
The results of all the following investigations must be included except where marked “if indicated”.
Except by prior agreement, only the investigations mentioned are done at the Organization’s expense.
Urine: Sugar: Microscopic
Blood: % Grams/1 Leucocytes:
% Differential count (if indicated):
Blood sedimentation rate:
Blood chemistry:
Urea or creatinine:
Uric acid
Serological test Please attach laboratory report.
Stool examination (if

COMMENTS (Please comment on all the positive answers given by the candidate and summarize the abnormal findings)

CONCLUSIONS (Please state your opinion on the physical and mental health of the candidate and fitness for the proposed post)

The examining doctor is requested before sending this report to verify that the questionnaire, pages 1 and 2 of this form, has been fully completed
by the candidate and that all the results of the investigations required are given on the report. Incomplete reports are a major source of delay in
recruitment.
Name of the examining physician (in block capitals):

Address: Signature:
DATE:
(d/m/y)

Suggested Readings.
1. DG Memorandum No 169 - Medical guidelines for troops proceeding on mission abroad.
2. DG Memorandum No 187 - Malaria prophylaxis and treatment.
3. IHQ of MoD (Army) letter No B / 75750 / Gen / DGMS-3E / UN Msn dt 27th Dec 21
4. O / o DGAFMS / DG-3A note No 5496 / MSAC / DGAFMS / DG-3A dt 14th Jul 11
5. Medical Support Manual For United Nations Field Missions
n

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 COMBAT MEDICAL CARE

Chapter
XXV
COMBAT MEDICAL CARE

25.1 Introduction.
The principal aim of the Army Medical Corps is to provide combat medical support to Indian troops in times of
war and counter-insurgency operations. The military doctors shall provide expert medical care in the battle zone
amidst hostile fire and minimize casualties of troops in an offensive or defensive combat situation.
Combat Medical Care needs to be identified as a separate entity. There are shared principles of Advanced Trauma
Life Support (ATLS) with Combat Trauma Medical Support management protocols but for a combat trauma patient
they can be very different from a civilian trauma for which the ATLS has been actually designed.
Military trauma is a separate entity which needs to be dealt within a tailored fashion to minimize fatal outcomes.
The mechanism of injuries, mode of injuries, age group, environmental factors, limitations of resources, evacuation
challenges and availability of nearest trauma centers makes it a separate entity which cannot be dealt with as
given in ATLS. Hence, it is pertinent to design the Combat trauma life support customized to the need of Indian
Armed Forces keeping the principles of ATLS in background. With the expansion of battle space and weapons of
mass destruction it is pertinent to learn the nuances of trauma life support in combat zone.
US Army is adhering to the norms of Tactical Combat Casualty Care with basic tenets such as:
(a) Care under fire
(b) Tactical Field care
(c) Tactical Medevac of casualties
The armed forces of other countries are also following the similar tenets and the Indian Armed forces are not
different in conforming to these basic tenets.

25.2 Military Combat Trauma.

Military Trauma is an ever-evolving disease process. Just as any novel virus that would mutate and would inflict morbidity
and mortality by affecting different organ systems, the research and innovation which drives the modernization of
warfare keeps upgrading the challenges that are associated with management of the trauma that it inflicts.
The recent assessment of military trauma from the last century has revealed a shift in the composition of fatalities
from Gun Shot wounds (GSW) and Explosive Mechanism.
The differences between Military Trauma and Civilian Trauma can be grouped into the following headings:
(a) Mechanism of Injury
(b) Age group
(c) Gender
(d) Environmental Factors
(e) Evacuation Challenges
(f) Availability and Feasibility of Resources
(a) Mechanism of Injury.
Missile and Blast injuries together comprises majority of military combat trauma. As mentioned above there has
been a noted shift toward blast injuries as compared to GSW after WW-I. So, in conventional warfare following
mechanisms of injury play a role in inducing morbidity and mortality.

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 HEALTHCARE IN ARMED FORCES

(i) Penetrating Missile Wound Injuries

(ii) Blast Injuries
(i) Penetrating Missile Wound Injuries.
This can include both the gunshot wounds and the splinters which are propelled following blast injuries.
The study of the projectile motion of object like bullet through the weapon, the medium like air / water and
finally through the target is called Ballistics. The damage caused by the projectile is following the transfer
of energy to the tissue they traverse through. The kinetic energy transferred is calculated by the formula:

KE = ½ M (V12 – V22) KE - Kinetic Energy M - mass of projectile

V1 - velocity at wound entry V2 - velocity at wound exit
and is affected by the distance from where the bullet is fired, the flight characteristic of the bullet (yaw,
precession and nutation), whether the bullet has exited the wound or remained inside the body and whether
the bullet fragmented inside the wound. Based on the quantum energy transfer (Table 25.1), wounds can
be categorized into
(aa) Low Energy Transfer Wound
(ab) High Energy Transfer Wound
Table 25.1 : Type of Wounds Based on Quantum of Energy Transfer
Small projectiles with low velocity Large projectiles with high velocity
Muzzle velocity <  1200 fps (<  400 m / s) Muzzle velocity >  2500 fps (>  800 m / s)
Energy transfer 50-100 Joules Energy transfer 2000-3000 Joules
Tissue damage confined to the track of projectile Tissue damage extends beyond the track of projectile
Minimal Cavitation and collateral damage Large cavitation and collateral damage.
A high velocity missile when passing through the tissues, dissipates its kinetic energy along its track. The
tissues are accelerated forward and laterally away from the track and a cavity is formed. This collapses
and re-cavitates multiple times with diminishing amplitude, thus generating a shock wave which results in
stretching, compressions and shearing of tissues and causes damage extending several centimeters lateral
to the missile track (Fig 25.1). The damage to tissues also depends on the consistency of tissues involved.
Solid organs are severely injured while elastic tissues like lung sustain relatively minor injuries. Bones
may get splintered and generate secondary missiles while nerves and blood vessels may be sheared or
undergo complete disruption. Missile wounds to the skull lead to the widespread disruption of the neurons,
hemorrhage and damage to vital centers at the base of the brain which are often fatal.

Fig 25.1 : Effect of High Velocity Missile on Tissue

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 COMBAT MEDICAL CARE

(ii) Blast Injuries.

These are complex injuries following explosion leading to a sequential set of traumatic events causing myriad
injuries involving multiple organ systems in varying severity. They have the potential to upset a well-trained
trauma team and overwhelm a well-equipped trauma hospital.
Blast injuries in combat can occur in both conventional warfare and during counter-terrorist activities. Their
ability to cause multiple casualties with fatal injuries and severe morbidities make them a preferred mode
of assault. Improvised Explosive Devices (IED) made using locally available chemical and hardware, have
seen preferential utilization by terrorist groups and the various injuries caused by IED and gunshot are
shown in Fig 25.2, 25.3 and 25.4.
The blast injuries are primarily caused by pressure differentials caused by release of overpressure supersonic
waves, propulsion of projectiles leading to multiple penetrating injuries, violent displacement, infrastructure
collapse and thermal injuries. These mechanisms of injuries are characteristic of energy waves that are
created following explosions (Table 25.2).
Table 25.2 : Types of Shock Waves
Nomenclature Mechanism Injuries
Primary Alternating overpressure and under pressure Tympanic membrane rupture, “Blast Lung”,
on tissue of heterogenous densities (“Air Hollow viscous injury
Filled”)
Secondary Fragmentation or airborne debris accelerated Multiple penetrating injuries, Extensive tissue
upon victim devastations, Traumatic amputations
Tertiary Structural collapse, Violent displacement, Multiple blunt injuries, Traumatic
Entrapment asphyxiation, Crush syndromes
Quaternary Thermal, other Burns (thermal, chemical), Inhalation injury,
Other
The air filled organs are particularly affected by these alternating over-pressure and under-pressure currents.
The ear is particularly sensitive to these shock waves and can undergo rupture at pressure differential as
low as 5 psi. Lungs come next in order and sustain damage at 56-76 psi. There is structural damage to lung
architecture which predisposes to air embolism, pneumothorax, haemothorax, lung contusion, pulmonary
haemorrhage, subcutaneous emphysema and mediastinal air. Once alveoli are flooded with cellular debris
and fluids it leads to impaired oxygenation following ventilation-perfusion mismatch, classically described
as ‘blast lung’.
Blast overpressure waves can lead to bowel injuries which are not very common and can present in a
delayed fashion too. Shock waves affect the brain causing mild Traumatic Brain Injury (mTBI). These can
be debilitating with persistent headaches. They are attributed to oxidative stress following release of free
radicals and neuronal cell death following impact from overpressure waves. The effect of these waves is
compounded in closed spaces and underwater whereas in open spaces their effects are mellowed.
Secondary Blast Injuries are caused by propulsion of a variety of debris by explosive energy leading to
penetrating missile trauma. It has been recorded that the major contribution to injuries following blast is
caused by Secondary Injuries (14% vs 48% as per a Marine Corps Surgical unit study done in Iraq). Data
also suggests that most of the immediately fatal injuries are also caused by the Secondary injuries. At close
proximities these injuries can often lead to traumatic decapitation and amputation. Involvement of extremities
are prominently seen in the survivors. Large burden of projectiles leads to extensive musculoskeletal trauma
and soft tissue injuries. The passage of these projectiles can lead to cavitation up to 20-25 times the size
of the projectile and pressure differential up to 100 psi. They have been implicated for tissue damage away
from the site of impact.
Tertiary injuries are following the structural collapse, violent displacements and entrapments. The effects
are magnified if the blast is triggered in closed spaces. They have the potential to inflict large number of
casualties however the fatalities are proportionally lower.
Quaternary Blast injuries comprise of trauma following burns both thermal and chemical. Augmentation by

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HEALTHCARE IN ARMED FORCES

chemical, biological and radiological agents are also considered under this category.

Fig 25.2 Fig 25.3 Fig 25.4

Blast Injury Hand Gun Shot Wound Injury Groin Anti-personnel IED Explosion Injury Foot

(b) Age Group.

The maximum casualties are to young soldiers in age group 21-30 years. A study done by Cross JD et al recorded
the average age for a soldier being unfit for military duties following war wounds was 26 years as per the data
collected from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).
(c) Gender.
Males are primarily affected in Combat Injuries in our scenario as the inclusion of female combatants is still in
early phases in Indian Army and data on female casualties is not available yet.
(d) Environmental Factors.
The peculiar topography of Indian subcontinent offers a wide spectrum of climatic challenges and hostile terrains.
Indian borders comprise of 15200 km of land frontiers and coastline of 7516 km. The average Indian troops
serve in temperature ranging from 50°C in deserts to -50°C in glaciers of India. From regions ranging from arid
to excessively hot and humid, from vast desert to unforgiving glaciers, from marshes and wetlands to mountains
and valleys, from scenic grassland to dense jungles, our troops are deployed and engaged in all possibilities
of nature. This brings us to the peculiar challenges of providing tactical medical care in these scenarios and
coordinating timely evacuation of casualties. This further emphasizes building our robust channels and protocols
for rapid and tactical evacuation of casualties. There is a need to re-visit our requirements in different terrains
and tailor our response and infrastructure as per the challenges of that scenario rather than pan approach to
all our problems. Technology and innovations have a big role to play in designing and manufacturing medical
equipment’s which are ergonomic and combat worthy. Similar zeal and enthusiasm need to be directed towards
combat medical research and innovation to solve problems pertaining to us as recently seen in other defence
innovations.
(e) Evacuation Challenges.
Evacuating casualties from a combat scenario is always a challenging task where the safety of the patient as
well as the medical personnel both are paramount. This aspect of military trauma has a massive bearing and
distinguishes it from civilian trauma. There are usually multiple levels of threat in terms of incoming hostile fire,
artillery shelling, air-raids and minefields that must be catered for while evacuating a casualty from a combat zone.
The highly unpredictable nature of casualty evacuation makes it even more challenging for medical personnel to
perform field medical care and to sustain lives till green channels are established for possible evacuation. Non-
motorable areas in mountain warfare’s, dense jungles, marshlands and glaciated regions adversely affect the
evacuation efforts. Air evacuations are utilized when feasible and form an important aspect of combat casualty
evacuation channel. Depending on the level of engagements in conventional warfare and channels of evacuation,
the battle scenarios can be divided into following zones.
(i) Red Zone.
This is the area of engagement between the two forces and is usually in the direct range of small arms of

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 COMBAT MEDICAL CARE

Infantry, fire power of Armour and Field and Medium range Artilleries. This zone usually varies between 5
to 30 km, depending upon the terrain and type of engagement.
(ii) Yellow Zone.
This is the zone which will usually cater for first- and second-line reserves in terms of manpower, ammunitions
and logistics. This may range from 10 to 50 kms. They fall in the range of Medium to Long range weapon systems.
(iii) Green Zone.
These are usually beyond the range of artillery and comprise of the logistic channels for reinforcements.
They are usually targeted by air raids or medium to long range missiles. They are typically beyond 30 to
50 km from the Red Zone. These ranges are not sacrosanct and will depend on the terrain, intensity of
engagements and weapons deployed. However, with a broad understanding, this can allow us to establish
our channels of evacuation, establishment of medical care posts and commitment of medical resources.
Also depending on the zones of engagement the level of medical care and intervention will vary and thus
help in planning and training of resources and manpower. This will be dealt with in detail subsequently.
(f) Availability and Feasibility of Resources.
This is an important aspect that differentiates military and civilian trauma. In ordinary situation following a
civilian trauma, unless the scale is massive which has affected the trauma response channel and facilities,
quick evacuation and early treatment measures can be deployed in most scenarios without difficulty, however in
military trauma the initial resuscitation and evacuation is often done under hostile fire. The combat medical care
provider must deal with the challenge of safeguarding his own life and simultaneously provide resuscitation and
evacuation to his fellow soldier. The following echelons are usually makeshift temporary treatment and staging
areas where triage, secondary surveys and certain lifesaving interventions can be carried out. Forward Surgical
Centers (FSC) are the forwardmost medical posts where damage control surgeries, life and limb saving procedures
can be carried out. Strategically locating these medical sub-echelons can affect the outcome in terms of mortality
and morbidity and thus allocation of resources and manpower to these sub-echelons and their location in the
channel of evacuation plays a critical role in military trauma management.

25.3 Combat Injuries.

A detailed analysis of Combat casualties from multiple theatres have re-emphasised the fact that a majority of casualties
happen on the field, before reaching a hospital set-up. Analysing various military data reveals that the fatalities to total
injured ratio usually swings between 20%-30%. A study done on Indian troops over a period of 08 years (Jan 1999-
Dec 2006) revealed an average ratio of 21%. Data suggests that out of the total casualties 89.5% casualties were
Killed in Action (KIA) and only 10.5% succumbed to their injuries after reaching the hospital. In conventional wars for
every casualty who dies in a medical treatment facility, as many as nine are reported to have died in the battlefield.
Studying the trends of war casualties, a shift has been noted from Gun Shot Wounds (GSW) to Explosion Injuries as
the cause of death. Data from Kargil War suggests that 36.7% deaths resulted from GSW compared to 62.1% from
splinter injuries. Also, there has been an upsurge in utilisation of IEDs as a means of offence in insurgency zones.
This has changed the wounding pattern and mechanism of injury as the trauma from explosions and splinters affects
a more generalised area with multi-system involvement. This fact is corroborated from analysis of Kargil War casualties
where it was found that the most affected body part was multiple body parts (40.5%), followed by head (26.6%), lungs
(11.7%), face / neck (6.8%), abdomen (6.4%), limbs (5.3%) and heart (2.7%).
American experience in Iraq reveals pelvic fractures in nearly 30% of soldiers who were killed in action, with most
wounds presenting because of IEDs. A study done on American troops suggest that combat-related pelvic trauma was
associated with low survival (10%); citing major haemorrhage or the combination of shock and associated head injuries
as the leading cause of mortality.
Another study on American troops examining the incidence of combat-related spinal injury in a brigade combat team,
documented a rate of 7%.
In combat casualties, there is a very high burden of musculo-skeletal injuries. Uncontrolled bleeding from traumatized
extremity was the cause of death for > 2500 fatalities in Vietnam War and continues to be the leading cause of
preventable deaths on the battlefield today. Combat casualty data derived during OIF (Operation Iraqi Freedom) and
OEF (Operation Endurance Freedom) has revealed 54% casualties with musculoskeletal injuries involving extremities.
The incidence of associated extremity skeletal trauma was 54% of total extremity injury cases as per Indian data which

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is higher compared to the figure from US engagements in Iraq and Afghanistan which stands at 40%.
Indian data on the subject, as per a study done by Arora et al which studied the mortal remains of Indian troops
from Counter-terrorist operations and the Kargil War, from a period extending from Jan 1999 to Dec 2006 provides
significant insight into casualty patterns from conventional war and those from low intensity conflicts and operations.
There was a significant difference noted in the mode of injury that led to fatal casualties. It was observed that GSW lead
to 78.2% of fatalities in terrorist actions however it was splintering injuries in Kargil war that lead to 62% of fatalities.
The increasing use of IEDs was also found to inflict 16.9% of the casualties from terrorist action.
Table 25.3 : Casualty Burden from Various Modalities in Combat
Injuring agent Terrorist induced Enemy induced Kargil war
GSW 78.2% 43.5% 36.7%
Splinters 4.6% 55.1% 62.1%
IED 16.9% 1.2%
Burns 0.1% 1.4%
Drowning 0.1
Total 100% 100% 100%
It was also observed that compared to GSW which targeted vital organs of head, neck and chest leading to fatal
injury in 70% of the cases, such involvement was only seen in 33% of cases in Splinter / IED induced mortality. This
highlights the random nature and wide area of affliction in blast mechanism as compared to more targeted injuries
in GSWs. (Fig 25.5)
Points to Remember.
O Approximate fatal casualty rate in conventional war ranges between 20% to 30% of the total injuries.
O Killed in action (KIA) to Dying of wounds (after hospital admission) ratio is 9:1.
O Increasing trend towards explosive mechanism of offence compared to GSW.
O Body region affected in casualties suggests multiple system involvement as the topmost cause.
O Pelvic trauma and Spinal cord trauma have remained undermentioned cause of death and are likely to have
an iceberg phenomenon.
O GSW induced mortalities are caused by fatal injuries to head, neck and chest in 70% of the cases, which
are primarily seen during terrorist and counter-terrorist operations.
O In conventional wars blast mechanism induced injuries cause more fatalities than GSW and multiple organ
affliction is the cause of death in approximately 60% of deaths.

ORGAN AFFECTED
GSW% Splinter / IED%

57.6

25.4
22.5
17.5 16.3
9.6 12.3
6.5 8.1 5.8 5.8
3.5 5.5 3.6

HEAD FACE & LUNG HEART ABDOMEN LIMBS MULTIPLE

NECK

Fig 25.5 : Distribution of Organs Affected in Military Trauma

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 COMBAT MEDICAL CARE

As almost 90% of the fatalities happen before reaching the hospital; the aim of combat medicine is to reduce the fatal
counts in field by enhancing the capability to manage polytrauma cases and promote quick evacuations.
Death has a tri-modal pattern of distribution following trauma. According to this concept first explained by Trunkey in
his paper published in 1983; there are three peaks in which death usually happens following a major trauma. The
three peaks are described below: (Fig 25.6, Table 25.4)

Lacerations
Brain
Brainstem
Aorta
Cord
Heart
Deaths

Epidural
Subdural
Hemopneumothorax
Pelivc fractures Sepsis
Long bone fractures Multiple organ
Abdominal injuries failure

0 1 hour 3 hours 2 weeks 4 weeks

Time

Fig 25.6 : Trimodal Distribution of Death

The aim of Combat Medical Care is to attempt medical care and resuscitation of the first peak cases, reduce the
second peak mortality amidst various challenges of combat environment and definitely prevent third peak by providing
the standard of care in and near the battlefield.
Table 25.4 : Trimodal Distribution of Death
Peaks 1st Peak 2nd Peak 3rd Peak

Time Frame Minutes Minutes to few hours Days to Weeks

Cause of Death Head injuries, Head injuries, Spinal cord Multiple Organ
High Spinal cord Dysfunction
Injuries, haemo-pneumothorax,
injuries, Injury to Syndrome (MODS),
airway obstructions and
heart / aorta / other Sepsis
injuries, abdominal injuries
major blood vessel
(liver / spleen / kidneys), injuries
causing major blood loss

25.4 Approach to Combat Injuries.

The role of combat medic in our scenarios is usually performed by Battlefield Nursing Assistants (BFNA). They are
non-AMC (Army Medical Corps) soldiers who should be trained in Care Under Fire situations as described in Tactical
Combat Casualty Care manual version-5. They are the ones who will provide emergency medical aid and will perform
tactical evacuation of casualties from the zones of engagements. Once they have performed tactical evacuation, the first
proper tactical care is performed by the battalion Regimental Medical Officer (RMO) and his Nursing Assistants (NAs).
This resuscitative care is performed at Regimental Aid Post (RAP) followed by quick evacuation to either an Advanced
Dressing Station (ADS) or a Forward Surgical Centre (FSC) which are deployed depending on the expected quantum of
casualties, terrain, distance, hostile fire, channels of reinforcements and replenishments.
The sequential deployments of tactical medical echelons in corroboration to zones of engagement is depicted in Fig 25.7.

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 HEALTHCARE IN ARMED FORCES

RED ZONE YELLOW ZONE GREEN ZONE

ENEMY BFNA RAP MA ADS FSC MH/ZH C

FIRE

Fig 25.7 : Zones of Engagements

The roles of combat care providers in red and yellow zones has been discussed subsequently in this chapter. We can
divide the combat care roles in red zone in three phases. These terminologies are proposed for the first time via this
chapter.

AID UNDER COMBAT EARLY TACTICAL

ATTACK CASUALTY CARE EVACUATION
(AUA) (CCC) (ETE)

(a) Phase I: Aid Under Attack (AUA).

This is the first phase of combat medical care and is usually performed under hostile fire. In usual scenario this
part will be performed by the BFNAs and thus massive effort needs to be directed in the training and upgradation
of BFNAs in terms of their skills, education and equipment. Aid Under Attack (AUA) can be comprehensively
explained by the COMBAT principles, proposed through this chapter Fig 25.8, 25.9.

c • COVER

O • OFFENSIVE FIRE & COVER FIRE

M • MOBILISE

B • BLEEDING CONTROL

• AIRWAY MANAGEMENT
A

T • TACTICAL TREADING

Fig 25.8 : COMBAT Acronym

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 COMBAT MEDICAL CARE

TACTICAL TREADING
This may require the BFNA to
Enemy Fire evacuate casualty by active
return of fire as he treads
rearward. This should be assisted
COVER by the casualty by returning fire if
Prevent further damage by feasible and aid in safe evac.
tactical positioning and taking
cover.

AIRWAY MANAGEMENT
If airway is compromised chin lift
OFFENSIVE FIRE and jaw thrust maneuver can
Respond to incoming fire and provide patency and application of
attempt to gain tactical oropharyngeal or nasopharyngeal
superiority airway can allow temporizing
Ask/provide cover fire. options.

MOBILISE BLEEDING CONTROL

Reach/Drag/ Direct the casualty Efforts to be directed in
towards a area where some form controlling bleed by applying
of medical aid can be provided pressure, medical dressings,
under fire without jeopardizing and bandaging. Failure to
safety and mission control bleed should prompt for
quick application of torniquet.

Fig 25.9 : COMBAT Flow Chart

(i) Cover, Offensive Fire and Mobilise components of “COMBAT” principle are a part of tactical training
which the BFNAs receive as a part of their combat training and beyond the purview of this book. Here we
will focus on bleeding control, airway and tactical treading.
(ii) Bleeding control, as a part of AUA, the following measures must be undertaken to control bleed.
(aa) Minimal Exposure.
Do not attempt to expose the casualty. Minimal exposure to identify the exact location of bleeding
site can be attempted. No wound wash / irrigation to be carried out at this point.
(ab) Pressure.
Manual pressure aids in natural haemostasis and clot formation. A constant pressure of up to 3-5
minutes is recommended.
(ac) Packing.
Pack the wound cavity with medical gauzes and dressing material.
(ad) Clotting Adjuncts.
Haemostatic agents and dressings are available can be used to aid in difficult bleeds. e.g. Chitosan
and Quick clot dressings.
(ae) If the haemorrhage cannot be controlled and the body part is amenable to torniquet application,
junctional or otherwise, should be applied.
(af) If the haemorrhage is still not controlled, tightening the first torniquet or applying the second
torniquet should be considered.

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HEALTHCARE IN ARMED FORCES

(ag) It is essential to endorse the time of application on all torniquets and an early attempt for
conversion of torniquets to haemostatic dressing should be given.
(ah) Torniquets can be converted in field setting if the duration of application is < 2 hours. However,
conversion should not be attempted if > 6 hours have elapsed in the absence of critical care and lab
facilities. The criteria for torniquet conversion is given in Table 25.5.
Table 25.5 : Criteria for Torniquet Conversion in Field
CRITERIA FOR CONVERSION IN FIELD

O Duration of Torniquet application <  2 hours

O Casualty is not in Shock.
O It is possible to monitor the wound closely for any bleed.
O Torniquet is not applied on an amputated limb.

(iii) Airway Management.

Airway management as a part of AUA should have the components as described in Fig 25.10.
(iv) Tactical Treading.
The flowchart of tactical evacuation of causalities is illustrated in Fig 25.11.
YES
Can speak
normally? No immediate
intervention

NO

Stridor, noisy breathing,

adventitious sounds, NO
maxillofacial trauma/
neck trauma/ unconscious

YES

Perform Chin Lift and

Jaw Thrust maneuver.

Remove foreign
bodies if any.
To lie down in
Recovery position.

NO
Can maintain airway? Insert NPA/OPA/ SGA

YES

Plan and execute

Tactical Evacuation.

Fig 25.10 : Airway Management Flow Chart in AUA

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 COMBAT MEDICAL CARE

Casualty

Conscious Unconscious

1. Dragging
Mobile Non-mobile 2. Sledging
3. Fireman lift

Support and evacuate Casualty will also provide

with appropriate cover retaliatory fire while
and retaliatory fire being evacuated

1. Dragging
2. Sledging
3. Fireman lift
4. Piggy back

Fig 25.11 : Flowchart on Tactical Evacuation of Casualty under Fire

Fig 25.12 : Dragging Fig 25.13 : Sledging

Fig 25.14 : Fireman’s Lift Fig 25.15 : Mobile Casualty Evacuation

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(b) Phase II: Combat Casualty Care.

In actual conflict situation, after the AUA phase, which was executed by the BFNA and other combat members of
the team and the patient has been mobilized from active conflict zone using Tactical Treading. The next phase of
treatment will be executed at RAP (Regimental Aid Post) by trained Medical Officers and Nursing Assistants. Here
the management of combat casualty will be in line with the ATLS protocol and this will be the first time that Primary
Survey and adjuncts of evaluation and management will be implemented as per availability of time and resources.
The algorithm designated as REACT NOW, for the step wise evaluation and management of a combat casualty
in field setting should be followed (Fig 25.16).

R •RESPONSE

E •EARLY REASONABLE EXPOSURE (ERE)

A •AIRWAY & VENTILATION

C •CIRCULATION

T •THORACIC TRAUMA

N •NEUROLOGICAL EVALUATION (HEAD & SPINE)

O •OPTIMAL MEDICATIONS

W •WATCH & WHISK

Fig 25.16 : REACT NOW Acronym

(i) Response.
As soon as the casualty has been received at RAP, the first step is to check whether the patient responds
to verbal communication or not. There can be 3 possible scenarios at this level as shown in Fig 25.17.

Check for
verbal response

Does not respond

Responds normally Responds with distress (Check GCS,
if less than 8
obtain definitive airway)

Move to E (Expose) Sequentially perform

Skip A (Airway) Sequentially perform next steps of
Check for C (Circulation) next steps of REACT NOW
and further as per REACT NOW (* apply cervical collar)
REACT NOW

Fig 25.17 : Evaluation of ‘Response’ Flow Chart

Any casualty who is able to maintain normal verbal communication is indicative that he or she has a patent
airway with adequate respiratory pressures required to generate phonation. This can allow us to quickly
move to pending areas of concern like ventilation, circulation, thorax and neurological evaluation.

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If the casualty expresses difficulty in verbal communication with gurgling, noisy breathing, gasping,
tachypnoea, these are suggestive of impaired airway and immediate intervention are required which will
be covered in Airway.
If the casualty is not responding to verbal communication, he or she should be subjected to immediate
step wise evaluation as per REACT NOW.
(ii) Early Reasonable Exposure (ERE).
After a quick evaluation on RESPONSE to verbal communication and classifying the patient as per response,
the next step should be to expose the patient as this will be the first time that you will get an opportunity
to expose and examine the patient properly. Now, contrary to many guidelines where exposure has been
brought very late into examination, we recommend this step to be executed early in the management of
the patient. The steps are given in Table 25.6.
(aa) Soldiers are typically clad in protective gear which will obstruct the proper evaluation of Airway
and Breathing which form the first two steps in ATLS protocol.
(ab) Without adequate exposure it will be difficult to assess and manage injuries of chest and neck
which are essential for Airway and Breathing management in trauma.
(ac) Without reasonable exposure the combat medical officer / RMO will be unable to execute
emergency life-saving procedures including application of a rigid cervical collar, needle chest
decompression, gaining Intra-osseous access etc.
(ad) Without adequate exposure it is likely that a major exsanguinating external bleed is being missed
which required a preferential management against Airway and Breathing.
(ae) Objective signs of intra-abdominal bleed and pelvic trauma are also likely to be missed if one
fails to achieve early reasonable exposure.
(af) Early reasonable exposure also aids in quick stepwise evaluation in an unconscious patient.
Table 25.6 : Components of Early Reasonable Exposure
Early Reasonable Exposure (ERE) consists of:

O Remove helmet.
O Open Bullet Proof Jacket (BPJ) to gain access to thorax and abdomen
O Open / cut shirt in order to expose thorax and abdomen.
O Open belt and pull-down trousers / cut open till knees without mobilizing
the casualty much.
O Quickly cover the patient with a blanket to prevent Hypothermia

This step can however be avoided in a well responding, walking wounded casualty but should be
done in all the patients who display features of respiratory distress, shock or are not responding.
(iii) Airway.
As the patient is assessed for verbal response, casualties with respiratory distress or unconsciousness
are identified, the combat medical officer / RMO will quickly evaluate airway and ventilation as the NA will
execute ERE.
A compromised airway can lead to inadequate delivery of oxygen to lungs leading to hypoxia and tissue death.
However, inadequate ventilation can result from airway obstruction, impaired ventilatory mechanism or CNS
injuries. Noisy breathing indicates partial airway obstruction that can suddenly become complete, whereas
the absence of breath sounds suggests complete obstruction. When the patient’s level of consciousness
is depressed, detection of significant airway obstruction is more subtle and laboured breathing may be the
only clue to airway obstruction or tracheobronchial injury. The objective signs of airway obstruction and
inadequate ventilation are described in Table 25.7 and 25.8.
In combat trauma airway obstruction will typically result from maxillofacial injuries and neck injuries leading

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to vascular / laryngeal / tracheal injuries.

Table 25.7 : Objective Signs of Airway Obstruction
Objective Signs of Airway Obstruction

O Agitated / Abusive – suggest hypoxia

O Obtunded – hypercarbia
O Cyanosis – late finding of hypoxia
O Noisy breathing / stridor / snoring / gurgling
O Accessory muscles of respiration

Table 25.8 : Objective Signs of Inadequate Ventilation

Objective Signs of Inadequate Ventilation
O Asymmetrical Chest Movements
O Laboured breathing
O Tachypnoea
O Decrease breath sounds
O Agitated / Abusive – suggest hypoxia
O Obtunded- hypercarbia
O Cyanosis- late finding of hypoxia
O Poor Peripheral Oxygen Saturation (SpO2)

The airway maintenance technique requires cervical spine extension however in combat trauma scenarios it
is prudent that due restriction of cervical spine is followed unless absence of any cervical injury is proven.
The various techniques and devices that can be utilized are described in subsequent paragraphs. Fig 25.18
describes sequential airway management in combat trauma.

AIRWAY
MANAGEMENT

AIRWAY AIRWAY
DEFINITIVE
MAINTENANCE MAINTENANCE
AIRWAY
MANEUVRES DEVICES

JAW TUBO- EXTRAGLOTIC

CHIN LIFT ENDOTRACHEAL SURGICAL
THRUST PHARYNGEAL SUPRAGLOTIC
INTUBATION AIRWAY
DEVICES DEVICES

NASO ORO- TRACHEO-

LIMA/ILMA LTA/ILTA NEEDLE CRICO-
PHARYNGEAL PHARYNGEAL STOMMY
CRIOD THYRO-
AIRWAY AIRWAY
THYROIDOTOMY IDOTOMY

Fig 25.18 : Sequential Flowchart for Airway Management in Combat Trauma

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(aa) Chin Lift Manoeuvre.

The chin-lift manoeuvre is performed by placing the fingers of one hand under the mandible and
then gently lifting it upward to bring the chin anterior. With the thumb of the same hand, slightly
depress the lower lip to open the mouth. The thumb also may be placed behind the lower incisors
while simultaneously lifting the chin gently. Do not hyperextend the neck while employing the chin-lift
manoeuvre. Fig 25.19.

Fig 25.19 : Chin-lift Manoeuvre Fig 25.20 : Jaw Thrust Manoeuvre

(ab) Jaw Thrust Manoeuvre.

It is performed by holding the angle of jaws by your hands on both side and then displace the
mandible forward (Fig 25.20). When used with the facemask or a bag-mask device, this manoeuvre
can result in a good seal and adequate ventilation. As in the chin-lift manoeuvre, be careful not to
extend the patient’s neck.
(ac) Nasopharyngeal Airway (NPA).
Nasopharyngeal airways are inserted in one nostril and passed gently into the posterior oropharynx.
They should be well lubricated and inserted into the nostril that appears to be unobstructed. If
obstruction is encountered during introduction of the airway, stop and try the other nostril. Do not
attempt this procedure in patients with suspected or potential cribriform plate fracture. The correct
size can be measured by placing the NP tube from Tip of nose to Tragus of ear (T to T) Fig 25.21
and 25.22.

Fig 25.21 : Nasopharyngeal Airway Fig 25.22 : NPA Selecting Correct Size

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(ad) Oropharyngeal Airway.

Oral airways are inserted into the mouth behind the tongue. The preferred technique is to insert the
oral airway upside down, with its curved part directed upward, until it touches the soft palate. At
that point, rotate the device 180 degrees, so the curve faces downward and slip it into place over
the tongue Fig 25.23.

Fig 25.23 : Oropharyngeal Airway

(ae) Laryngeal Mask Airway.
The Laryngeal Mask Airway (LMA) and Intubating Laryngeal Mask Airway (ILMA) have been shown to
be effective in the treatment of patients with difficult airways, particularly if attempts at endotracheal
intubation or bag-mask ventilation have failed. Fig 25.24.

Fig 25.24 : Inserting a Laryngeal Mask Airway

(af) Endo-Tracheal Intubation.
A definitive airway requires a tube placed in the trachea with the cuff inflated below the vocal cords,
the tube connected to oxygen-enriched assisted ventilation and the airway secured in place with an
appropriate stabilizing method. Endo tracheal tube can be inserted via oral route or nasal route.
However, the oral route is preferred in view of its comparative ease. Facial, frontal sinus, basilar and
cribriform plate fractures are relative contra-indication for naso-tracheal intubation. Difficult intubation

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when encountered can be managed with manoeuvres like cricoid pressure, BURP i.e. backward-
upward-rightward pressure on the thyroid cartilage and use of GEB i.e. Gum Elastic Bougie. The need
for definitive airway management and steps in endotracheal intubation are given in Table 25.9 and
Fig 25.25 respectively.
In cases where intact gag reflex is present and patient requires intubation; Drug Assisted Intubation is
performed using induction agent like etomidate (0.3 mg / kg) and muscle relaxants like succinylcholine
(1-2 mg / kg). However, these drugs are not available and administered at RAP level, where adequate
monitoring and back-up / bail-out surgical technique for establishing airway might not be present. This
technique of RSI (Rapid Sequence Intubation) should ideally be performed under specialist supervisions.

Fig 25.25 : Steps of Endotracheal Intubation

Table 25.9 : Need for Definitive Airway Management
NEED FOR AIRWAY PROTECTION NEED FOR VENTILATION OR OXYGENATION
Severe Maxillofacial Fractures Inadequate Respiratory Efforts
Risk for aspiration from bleeding and / or vomiting Tachypnea Hypoxia Hypercarbia
Cyanosis Combativeness
Neck Injury
Neck Laryngeal or Voice change Progressive Accessory Respiratory
hematoma tracheal injury change muscle use muscle paralysis
Stridor Inhalation injury from burns and facial burns Abdominal breating
Head Injury
Unconscious Acute neurological deterioration or herniation
Combative Apnea from loss of consciousness or
neuromuscular paralysis
(ag) Need for Definitive Airway.
Failure to establish an airway by any of the above method in a patient who requires a definitive airway
is an indication for a surgical airway. This can be performed by surgical techniques.
Surgical Airway-Needle Cricothyroidotomy. It is a temporary technique to tide over a difficult airway

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situation where 12 to 14-gauge needle for adults is placed through the cricothyroid membrane into
the trachea below the level of the obstruction. The cannula is then connected to oxygen at 15 L / min
(50 to 60 psi) with a Y-connector or a side hole cut in the tubing between the oxygen source and the
plastic cannula. Intermittent insufflation, 1 second on and 4 seconds off, can then be achieved by
placing the thumb over the open end of the Y-connector or the side hole. A patient can be ventilated
for a duration of 30-45 mins using this technique following which conversion to definitive airway is
required.
Surgical Cricothyroidotomy. Performing a surgical cricothyroidotomy is preferrable to emergency
tracheostomy as it easier to perform, associated with lesser bleeding and can be performed in
short duration as compared to emergency tracheostomy. Surgical cricothyroidotomy is performed by
making a skin incision that extends through the cricothyroid membrane. Insert a curved haemostat
or scalpel handle to dilate the opening and then insert a small endotracheal or (preferably 5 to
7 ID) or tracheostomy tube (preferably 5 to 7 mm OD) Fig 25.26 and 25.27.

Fig 25.26 : Anatomy of Crico-thyroid Membrane

Fig 25.27 : Steps of Surgical Cricothyroidotomy

(iv) Ventilation.
The important aspect which is leading to hypoxia once airway has been secured / injury has been ruled out is
inadequate ventilatory mechanism. In combat situation immediately life threatening ventilatory compromise
can happen in following conditions

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(aa) Tension Pneumothorax.

It is a condition when one-way valve mechanism is created with air accumulation in the pleural space
following leak from the lung or the chest wall. The most common cause of tension pneumothorax is
mechanical positive-pressure ventilation in patients with visceral pleural injury. Tension pneumothorax
also can complicate a simple pneumothorax following penetrating or blunt chest trauma in which a
parenchymal lung injury fails to seal. Clinical picture is summarized in the Table 25.10.
Table 25.10 : Signs and Symptoms of Tension Pneumothorax
Symptoms Signs
Chest pain Tachypnoea Tachycardia Hypotension
Air hunger Tracheal deviation Unilateral absent breath sound
Respiratory distress Distended neck veins Cyanosis
Hyper-resonant chest on percussion
Elevated hemithorax with absent respiratory movement
This is an emergency condition and requires no radiological confirmation for decompression. As temporary
method a needle decompression can be done which needs to be converted into a tube thoracostomy.
Needle Decompression. Necessary equipment: Large-bore needle with catheter (10 to 14 gauge, at
least 3.25 inches in length) and tape.
Locate (the second intercostal space (between the second and third ribs) at the midclavicular line
(approximately in line with the nipple) on the affected side of the casualty’s chest (see Fig 25.28).
(An acceptable alternative site is located at the fourth or fifth rib space at the anterior axillary line
or as per 10th Edition ATLS guidelines. Needle decompression to be done at 5th or 4th ICS anterior
to mid axillary line in adults. However, in paediatric population in 2nd ICS Mid clavicular line. Insert a
large-bore (10 to 14-gauge) needle / catheter unit. Place the needle tip on the insertion site (between
the second and third intercostal space, midclavicular line). Lower the proximal end of the needle to
permit the tip to enter the skin just above the third rib margin. Firmly insert the needle into the skin
over the third rib at a 90-degree angle to the chest wall until the pleura has been penetrated, as
evidenced by feeling a “pop” as the needle enters the pleural space and a hiss of air escapes from
the chest. Secure the catheter to the chest with tape and monitor the casualty for possible return of
symptoms.
Monitor the patient for signs and symptoms of a recurring tension pneumothorax. If a tension
pneumothorax returns, reassess all interventions (chest seals and needle chest decompressions).
If a chest seal becomes dislodged, replace it. If a needle chest decompression catheter (NCD) has
become occluded, insert a second catheter in accordance with steps given in previous paragraph,
directly laterally of the first catheter on the mid-clavicular line (primary site) or directly superior of
the first catheter on the anterior axillary line (alternate site) (Fig 25.29).

Fig 25.28 : Anatomical Location for NCD Fig 25.29 : Performing a NCD in Tension Pneumothorax

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Tube Thoracostomy.
Place the casualty in the supine position. Raise the arm on the affected side above the casualty’s
head. Select the insertion site at the anterior axillary line over the fourth or fifth intercostal space
within the triangle of safety (Fig 25.30). Clean and drape and under aseptic precautions liberally
infiltrate the area with the 1 or 2 percent lidocaine solution.
Make a 2 to 3 cm transverse incision over the selected site and extend it down to the intercostal
muscles. Incision should be deepened and blunt dissection should be performed using artery forceps
and or finger. Once pleura is reached puncture the parietal pleura with the tip of Robert’s forceps
and slightly enlarge the hole by opening the clamp 1.5 to 2 cm immediately insert a gloved finger
in the incision to clear any adhesions, clots, etc. Grasp the tip of the chest tube with forceps. Insert
the tip of the tube into the incision as you withdraw your finger. Advance the tube until the last side
hole is 2.5 to 5 cm inside the chest wall. (Fig 25.31)
Connect the end of the tube to a one-way underwater seal. Secure the tube using the suture materials.
Apply an occlusive dressing over the incision site. Radiograph the chest to confirm placement, if
available. Reassess the casualty. Check for bilateral breath sounds and movement of the air column
(Fig 25.31).

Fig 25.30 : Anatomical Boundaries of Triangle of Safety

Fig 25.31 : Steps of Performing Tube Thoracostomy

(ab) Open Pneumothorax.
In case of large wound to chest that tend to remain open with preferential entry of air through the
open wound leads to suckling effect and development of open Pneumothorax where immediate
equilibration occurs between intra-thoracic and atmospheric pressure. Clinical signs and symptoms

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include pain, difficulty in breathing, decreased breath sound on the affected side and noisy movement
of air through the open wound. This condition usually does not pose emergency but if gets converted
to Tension pneumothorax following positive pressure ventilation can be life threatening. For initial
management of an open pneumothorax, promptly close the defect with a sterile dressing large enough
to overlap the wound’s edges. Any occlusive dressing (e.g. plastic wrap or petrolatum gauze) may be
used as temporary measure to enable rapid assessment to continue. Tape it securely on only three
sides to provide a flutter-valve effect. As the patient breathes in, the dressing occludes the wound,
preventing air from entering. (Fig 25.32) During exhalation, the open end of the dressing allows air
to escape from the pleural space. Taping all four edges of the dressing can cause air to accumulate
in the thoracic cavity, resulting in a tension pneumothorax unless a chest tube is in place. Place a
chest tube remote from the wound as soon as possible. Subsequent definitive surgical closure of the
wound is frequently required.

Fig 25.32 : Vented-Triple Seal

(ac) Massive Haemothorax.
It is defined as rapid accumulation of more than 1500 ml of blood or accumulation of more than 1 / 3rd
of patient’s blood volume in the thoracic cavity or haemorrhagic output in chest drain of more than
200 ml / hr for 2 to 4 hours. However, we can classify this as massive only after putting a chest drain,
but the important aspect is to clinically recognize and act urgently. This is usually following penetrating
trauma due to injury to hilar or systemic vessel. Clinically patient will complain of pain, breathing
difficulty and air hunger. Patient will have features of shock associated with absent breath sound on
the affected side and dull note on percussion. Neck veins are usually collapsed due to hypovolemia
unless associated with Tension Pneumothorax. The differences between Tension pneumothorax and
Massive pneumothorax are given in Table 25.11 adapted from ATLS, Student Course Manual (10th
Edition) published by American College of Surgeons. Management principles are Volume Replacement
and Chest Decompression.
Volume replacement is done using intravenous crystalloids and early transfusion of blood and blood
products, in line with the management of haemorrhagic shock. Chest decompression is done by
inserting a thoracostomy tube of 28-32 Fr as described above. Close monitoring and early evacuation
is the key as any patient who qualifies for massive haemothorax is likely to undergo thoracotomy for
surgical control of the haemorrhage.

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Table 25.11 : Difference between Tension Pneumothorax and Massive Haemothora

PHYSICAL SIGNS
BREATH TRACHEAL CHEST
CONDITION PERCUSSION NECK VEINS
SOUNDS POSITION MOVEMENT
Tension Decreased or Hyperresonant Deviated away Distended Expanded
pneumothorax absent immobile
Massive Decreased Dull MidLine Collapsed Mobile
hemothorax
(v) Circulation.
In combat trauma exsanguinating haemorrhage is a primary area of concern with a significant burden of
mortality share in the second peak of Trunkey’s trimodal distribution. Once airway and ventilation are taken
care, an urgent focus should be directed towards management of haemorrhagic shock which might be an
external bleed or an internal bleed. The first and the most important area of management of shock is the
recognition of shock. The various signs and symptoms that are likely to be observed depending upon the
volume of blood loss is described in the Table 25.12. The second most important point for the management
of haemorrhagic shock is to identify the source of bleed with ongoing resuscitation using intravenous
fluids and blood and blood products. Final point in the management is control of the ongoing bleed either
compression or definitive surgical control. We must look for ongoing haemorrhage in our primary survey
and identify the area of concern. Internal bleed unlike external bleed can be difficult to identify especially
in an unconscious patient.
With the parameters given in Table 25.12 we can identify shock. and with the systematic examination following
ERE, we can identify source of bleed. The following stepwise process should be adopted to identify the source
of bleed as outlined in Fig 25.33 and Table 25.13. FAST- which stands for Focused Abdominal Sonography
in Trauma forms the part of primary survey and adjuncts, forms an inseparable part of primary evaluation if
possible. It looks for fluid in the abdomen by focusing on Morrison’s pouch, spleno-renal pouch, pericardial fluid
and pelvic fluid. Positive detection of fluid in a combat scenario suggests intra-abdominal bleed.
Table 25.12 : Patho-Physiological Classification of Haemorrhagic Shock
PARAMETER CLASS I CLASS II (MILD) CLASS (MODERATE) CLASS IV (SEVERE)
Approximate blood loss <15% 15-30% 31-40% >40%
Heart rate ↔ ↔/↑ ↑ ↑ / ↑↑
Blood pressure ↔ ↔ ↔/↓ ↓
Pulse pressure ↔ ↓ ↓ ↓
Respiratory rate ↔ ↔ ↔/↑ ↑
Urine output ↔ ↔ ↓ ↓↓
Glasgow Coma Scale score ↔ ↔ ↓ ↓
Base deficit 0 to -2 mEq/L -2 to -6 mEq/L -6 to -10 mEq/L -10 mEq/L or less
Monitor Possible Yes Massive Transfusion
Need for blood products
Protocol
Base excess is the quantity of base [HCO, in mEq/L) that is above or bellow the normal range in the body. A
negative number is called a base deficit and indicates metabotic acidosis.
Data from: Mutschler A, Nienaber U, Brockamp T, et al. A critical reappraisal of the ATLS classification of
hypovolaemic shock: does it really reflect clinical reality? Resuscitation 203.84-309-313.

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POST TRAUMATIC SHOCK

EXTERNAL INTERNAL NON HAEMORRHAGIC

Massive bleed in Major cavities Injuries to specific

1. Long bones 1. Thoracic cavity trauma eg. 1. Obstructive Shock

fractures Hemothorax, cardiac injury, : eg Tension
vascular injury pneumo-thorax,
2. Pelvic fractures
cardiac
2. Abdominal blunt trauma
3. Penetrating injuries tamponade
causing major vascular
4. Visceral injuries and/or visceral injuries eg. 2. Cardiogenic :
Liver, Spleen penetrating injury
5. Major vascular
to heart
injuries 3. Retro-peritoneal bleed
3. Distributive : High
4. Blunt trauma to pelvis
Spinal cord Injury
Injuries to specific

Fig 25.33 : Stepwise Evaluation for Site of Haemorrhage

Table 25.13 : Evaluation of Signs of Internal Bleed in a Patient with Shock

Signs Of Internal Bleed in Blunt Trauma Patient With Shock
1. Thoracic trauma 1. Visible signs of trauma 5. Splinting of chest
2. Asymmetrical chest movement 6. Tenderness
3. Paradoxical chest movement 7. Shallow breathing
4. Dull note on percussion 8. Surgical Emphysema
2. Abdominal Trauma 1. Visible signs of trauma 5. Cullen’s sign
2. Distension 6. Absent / Sluggish bowel sounds
3. Tenderness 7. Positive DPL / e FAST
4. Grey Turner’s sign 8. DRE-blood stained
3. Pelvic Trauma 1. Visible signs of injuries 4. Altered attitude of lower limb
2. Tenderness 5. Unstable pelvis on compression test
3. Limb-length discrepancy 6. Haematuria
4. Long Bone 1. Deformity 4. Swollen limb
Fractures 2. Loss of function 5. Discoloration
3. Weak / absent pulse 6. Compartment syndrome
Initial Management of Shock: This depends on two primary principles given in subsequent paragraphs.
(aa) Volume Replacement
(ab) Haemostasis

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Needless to stay in a setting of combat trauma at the level of RAP / ADS both the process happens
simultaneously.
(aa) Volume Replacement.
This can be subdivided into following components for better understanding.
Access for Volume Replacement.
It is imperative for any patient being evaluated for shock to achieve intravenous access. It is done
using two large bore peripheral iv cannulas preferably size 16 or 18 Fr. The flow rate is directly
proportional to the radius of the cannula and inversely proportional to the length of the cannula.
Hence, short wide bore cannulas are preferred for rapid infusion of fluid therapy. In circumstances
where iv access could not be achieved or feasible, intra-osseous access is achieved using specially
designed intra-osseous cannulas. The preferred site for such intra-osseous access are tibia, humerus
and manubrium.
Fluid Management.
Absolute volumes of resuscitation fluid should be based on patient response to fluid administration,
keeping in mind that this initial fluid amount includes any fluid given in the prehospital setting. Assess
the patient’s response to fluid resuscitation and identify evidence of adequate end-organ perfusion
and tissue oxygenation. Observe the patient’s response during this initial fluid administration and base
further therapeutic and diagnostic decisions on this response. Persistent infusion of large volumes
of fluid and blood to achieve a normal blood pressure is not a substitute for definitive control of
bleeding.
The present recommendations of ATLS suggest administering 1 Liter of crystalloids preferably lactated
ringer solution as bolus in patient identified in shock. Based on the response the patient can be
classified as Responder, Transient Responder or a Non- Responder as given in Table 25.14.
Table 25.14 : Classification of Patients on the Basis of Fluid Challenge
Rapid Response Transient Response Minimal Or No Response
Vital signs Return to normal Transient improvement Remain abnormal
recurrence of decreased
blood pressure and
increased heart rate
Estimated blood loss Minimal (<15%) Moderate and ongoing Severe (> 40%)
(15% - 40%)
Need for blood Low Moderate to high Immediate
Blood prepareation Type and crossmatch Type-specific Emergency blood release
Need for operative Possibly Likely Highly likely
intervention
Early presence surgeon Yes Yes Yes
* Isotonic crystalloid solution, up to 1000 ml in adults; 20 ml/kg in children
Aggressive fluid resuscitation is to be avoided to achieve normal blood pressure as it may lead to re-
bleeding, volume overload and hypothermia. Thus, the present emphasis is on permissive hypotension
where a Mean Arterial Pressure (MAP) of 60 mm Hg is acceptable for organ perfusion and avoidance
of enthusiastic fluid resuscitation.
Such a resuscitation strategy may be a bridge to but is not a substitute for, definitive surgical control
of bleeding. Early resuscitation with blood and blood products must be considered in patients with
evidence of class III and IV haemorrhage. Early administration of blood products at a low ratio of
packed red blood cells to plasma and platelets can prevent the development of coagulopathy and
thrombocytopenia.

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Blood and Blood Products.

Transient and Non-Responder are candidates of early blood transfusion, as the goal is to maintain
tissue perfusion and prevent lethal triad of acidosis, coagulopathy and hypothermia. Blood transfusion
is an effective bridging process of functional volume replacement till surgical control of ongoing
haemorrhage is achieved. It is the whole blood which is given in forward zone. Blood can be
transported in blood transportation boxes or can be collected by bleeding at Forward Surgical Centres.
Fully crossmatched pRBCs are preferable for this purpose, but the complete crossmatching process
requires approximately 1 hour in most blood banks. For patients who stabilize rapidly, crossmatched
pRBCs should be obtained and made available for transfusion when indicated. If crossmatched blood
is unavailable, type O pRBCs are indicated for patients with exsanguinating haemorrhage. AB plasma
is given when uncross matched plasma is needed. Massive Transfusion Protocols are initiated when
more than 10 units of PRBCS are required for a patient within 24 hours of admission or more than
4 units of PRBC in 1 hour.
Monitoring of Fluid Resuscitation.
Fluids are an important lifesaving tool in Gun Shot wounds and blast injuries due to severe
haemorrhage. This would lead to the need of urgent fluid replenishment with volume expanders in
large quantities. It is the colloids and crystalloids that needs to be planned for battle fluid therapy. The
same signs and symptoms of inadequate perfusion that are used to diagnose shock help determine
the patient’s response to therapy. The return of normal blood pressure, pulse pressure and pulse rate
are signs that perfusion is returning to normal. However, these observations do not provide information
regarding organ perfusion and tissue oxygenation. Improvement in the intravascular volume status is
important evidence of enhanced perfusion, but it is difficult to quantitate. The volume of urinary output
is a reasonably sensitive indicator of renal perfusion; normal urine volumes generally imply adequate
renal blood flow and thus implies good organ perfusion. A urine output more than 0.5 ml / kg / hr
is considered adequate in an adult. Thus, it is also essential to place an indwelling urinary catheter
early in the management of a casualty in shock.
Blood gas analysis also helps us monitoring response and understanding shock pathophysiology.
Persistent acidosis is usually caused by inadequate resuscitation or ongoing blood loss. In patients
in shock, treat metabolic acidosis with fluids, blood and interventions to control haemorrhage. Base
deficit and / or lactate values can be useful in determining the presence and severity of shock and
then serial measurement of these parameters can be used to monitor the response to therapy. Do
not use sodium bicarbonate to treat metabolic acidosis from hypovolemic shock.
(ab) Haemostasis.
Exsanguinating haemorrhage in a combat casualty can be managed using the proposed management
options. Most of the extremity haemorrhaging wound can be managed with good compression,
haemostatic agent application, bandaging and limb elevation. However, those wound which cannot
be managed with the above approach need torniquet application. The torniquet is then tightened using
the windlass till haemorrhage is controlled and time of application of the torniquet is meticulously
mentioned. Conversion of torniquet can be attempted in a field setting if done within 2 hours,
however it is not recommended beyond 6 hours. The torniquet needs to be applied proximal to the
haemorrhaging wound on a bony prominence if possible. All patients in haemorrhagic shock should
be given Inj Tranexamic Acid 1 gm (20 mg / kg) stat in 100 ml of Normal Saline infusion. All patients
should be protected against Hypothermia by using warm blankets, body warmers, warm fluids, blood
and blood products, as hypothermia induces coagulopathy and thus predisposes to further bleeding.
The key features of management of combat casualty in hemorrhagic shock is given in Table 25.15.
(vi) Thoracic Trauma.
After the immediate life-threatening conditions have been managed as a part of initial Airway & Ventilation,
evaluation and management described earlier, we need to understand and train to be able to detect and
timely manage possible lethal conditions in combat casualty with thoracic trauma. These conditions are:
O Simple pneumothorax
O Haemothorax

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O Cardiac tamponade
O Flail chest
O Pulmonary contusion
O Traumatic aortic disruption
O Traumatic diaphragmatic injury
O Blunt oesophageal rupture
Table 25.15 : Management of Combat Casualty in Haemorrhaging Shock
MANAGEMENT OPTIONS OF HAEMORRHAGING COMBAT CASUALTY
1 Extremity Trauma Apply torniquet
Amputation (above wrist and ankle)
Not-Amputated Compression
Bandaging
Approved Haemostatic agents
Limb elevation
Splinting
Torniquet application
2 Abdominal/ Retroperitoneal Trauma Application of approved haemostatic agent
Penetrating injury Wound dressing
Do NOT attempt to remove any foreign body
Blunt trauma (intra-peritoneal bleed)
Volume replacement
Close monitoring
Early evacuation for surgical control of haemorrhage
3 Thoracic Injury Sealing of wound using leak-proof dressings
Penetrating injury Tube thoracostomy
Pain management
Oxygen supplementation
Blunt Trauma Tube thoracostomy (if haemo/pneumo thorax suspected)
Pain management
Oxygen supplementation
Positive pressure ventilation
4 Pelvic Injury Pelvic binder
Volume replacement
Close monitoring
Early evacuation
Simple pneumothorax and haemothorax have already been discussed in detail earlier in Ventilation.
(aa) Cardiac Tamponade.
Accumulation of blood in pericardial sac affecting the dilatation of cardiac chambers and thus
preventing the filling of the chambers and in turn leading to reduced cardiac output is defined as
Cardiac Tamponade. Usually occurs because of penetrating injury but can also result from blunt
injury. The classic clinical triad of muffled heart sounds, hypotension and distended veins is not
uniformly present with cardiac tamponade. The features of cardiac tamponade are shown in Fig
25.35. Muffled heart tones are difficult to assess in the noisy resuscitation room and distended
neck veins may be absent due to hypovolemia. Kussmaul’s sign (i.e., a rise in venous pressure with
inspiration when breathing spontaneously) is a true paradoxical venous pressure abnormality that is
associated with tamponade. FAST is an accurate way of detecting cardiac tamponade, however it’s
availability at a forwardmost echelon is presently not ascertained. Management constitutes urgent
Surgical intervention in the form of sternotomy or thoracotomy, however if not feasible USG guided
pericardiocentesis should be performed. Blind procedures are associated with complications and thus
not recommended in a field setting.

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Fig 25.34 : Cardiac Tamponade and Its Clinical Signs and ECG Changes
(ab) Flail Chest.
A flail chest occurs when a segment of the chest wall does not have bony continuity with the rest of
the thoracic cage. This condition usually results from trauma associated with multiple rib fractures
(i.e., two or more adjacent ribs fractured in two or more places), although it can also occur when
there is a costochondral separation of a single rib from the thorax. Clinically patients will have pain,
tenderness, breathing difficulty and paradoxical breathing movement. (Fig 25.35) Pulmonary contusion
is usually associated with such injuries. Restricted chest wall movement associated with pain and
underlying lung contusion can lead to respiratory failure. Initial treatment of flail chest and pulmonary
contusion includes administration of humidified oxygen, adequate ventilation and pain management
and cautious fluid resuscitation. In the absence of systemic hypotension, the administration of
crystalloid intravenous solutions should be carefully controlled to prevent volume overload, which
can further compromise the patient’s respiratory status. Patients with significant hypoxia (i.e., PaO,
< 60 mm Hg [8.6 kPa] or SaO, < 90%) on room air may require intubation and ventilation within the
first hour after injury.

Fig 25.35 : Paradoxical Respiratory Movements in Flail Chest

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(ac) Pulmonary Contusion.

A pulmonary contusion is a bruise of the lung, caused by thoracic trauma. Blood and other fluids
accumulate in the lung tissue, interfering with ventilation and potentially leading to hypoxia. Pulmonary
contusion can occur without rib fractures or flail chest, particularly in young patients without completely
ossified ribs. The initial line of treatment remains same as that discussed in flail chest.
(ad) Traumatic Aortic Disruption.
If complete tear has happened it usually results in immediate death, however in cases of partial tear
with controlled haematoma, early transfer to facility equipped with surgical expertise can save the
patient. Specific signs and symptoms are usually absent however with a high index of suspicion and
specific findings on Xray (Fig 25.36) a controlled / stable / incomplete aortic injury can be identified.
Management includes adequate analgesia, control tachycardia and hypotensive resuscitation. Pain
should be managed. If no contraindications exist, heart rate control with a short-acting beta blocker
to a goal heart rate of less than 80 beats per minute (BPM) and blood pressure control with a goal
mean arterial pressure of 60 to 70 mm Hg is recommended.

Fig 25.36 : Xray Findings in Aortic Disruption

(ae) Traumatic Diaphragmatic Injury.
It is more common on the left than right. Identified on Xray usually with an elevated diaphragm and
presence of abdominal viscera in thoracic cavity. They are often misdiagnosed as gastric dilatation,
haemo-pneumo thorax, sub pulmonic haematoma. Also, they are often detected during abdominal
exploration for some other injury. Management is surgical repair.
(af) Traumatic Oesophageal Injury.
It is usually associated with penetrating but rarely associated with blunt trauma. Clinical setting is
usually associated with thoracic trauma with haemo / pneumo-thorax, with or without rib fractures;
pain and shock which is out of proportion to the apparent injury. Particulate matter may be noticed
in the chest drain.

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(vii) Neurological Evaluation.

Approximately 15-25% of the war casualties happen following head injuries. Most of them lead to deaths
that contribute to first peak of deaths. Thus, it is essential to identify, classify and initiate management for
the head injuries. Evaluation of spinal injuries also forms part of this sub section. The step wise evaluation
of head and spine in a combat casualty has been described in Fig 25.37 and Glasgow coma scale in Table
25.16.

COMBAT CASLIALTY

CONSCIOUS UNCONSCIOUS

Complaints of
• Cervical spine
pain/tenderness NO
• Midline tenderness at black
• Motor/Sensory deficit of
upper
• No further
management. • Manage patient as a case of
YES suspected spinal injury
• Move to next
step as per • Apply hard cervical collar after
• Apply Hard cervical Collar examining the cervical spine.
• Perform log rolling to evaluate spinal REACT NOW
• All maneuvers of Airway evaluation
deformity/ tenderness/injuries. and management have to be done
• Ascertain motor and sensory deficits using in-line restriction of cervical
wether complete/incomplete, spine.
Paraplegia/ quadriplegia, Level and • Perform tog rolling to evaluate
extent of injury. spinal deformity/tenderness/
• Document findings injuries.

Fig 25.37 : Evaluation and Management Scheme for Head Injury in Field Etting
Tableand
• Plan transter ta facility with Xray, CT scan 25.16 : Glassgow Coma Scale
a Neurosurgeon.
• Transfer the patient using Orthoscoop stretcher /hard spinal board.
Original restriction
• Prevent prolonged Scale Revised
on a Hard spinal board as it can lead Scale Score
to serious decubitus ulcers formation.
Eye Opening (E) Eye Opening (E)
Spontaneous Spontaneous 4
To speech To sound 3
To pain To pressure 2
None None 1
Non-testable NT
Verbal Response (V) Verbal Response (V)
Oriented Oriented 5
Confused conversation Confused 4
Inappropriate words Words 3
Incomprehensible sounds Sounds 2
None None 1
Non-testable NT

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Original Scale Revised Scale Score

Best Motor Response (M) Best Motor Response (M)
Obeys command Obeys commands 6
Localizes pain Localizing 5
Flexion withdrawal to pain Normal flexion 4
Abnoraml flexion (decorticate) Abnormal flexion 3
Extension (decerebrate) Extension 2
None (flaccid) None 1
Non-testable NT
GCS Score = (E [4] + V [5] + M [6]) = Best possible score 15; worst possible score 3.
* If an area cannot be assessed, no numerical score is given for that region, and it is considered “non-testable.”
Source : www.glasgowcomascale.org
Approximately 5% of patients with brain injury have an associated spinal injury, whereas 25% of patients
with spinal injury have at least a mild brain injury. Approximately 55% of spinal injuries occur in the cervical
region, 15% in the thoracic region, 15% at the thoracolumbar junction and 15% in the lumbosacral area. Up
to 10% of patients with a cervical spine fracture have a second, non-contiguous vertebral column fracture.
It is imperative to know that inadequate handling of such casualties can cause deterioration of the spinal
injuries and thus it is essential to identify and document such injuries. Although one musty note that at a
forward field setup only precautionary steps can be taken to prevent deterioration of a clinically established
or suspected injury can be done. Definitive diagnosis and management will happen only at centre equipped
with facilities of CT scan and a neurosurgeon.
A schematic guide to evaluation and management for spinal injuries at a forward field centre / RAP is
presented below in Fig 25.38.

COMBAT CASLIALTY

CONSCIOUS UNCONSCIOUS

Complaints of
• Cervical spine
pain/tenderness NO
• Midline tenderness at black
• Motor/Sensory deficit of
upper
• No further
management. • Manage patient as a case of
YES suspected spinal injury
• Move to next
step as per • Apply hard cervical collar after
• Apply Hard cervical Collar examining the cervical spine.
• Perform log rolling to evaluate spinal REACT NOW
• All maneuvers of Airway evaluation
deformity/ tenderness/injuries. and management have to be done
• Ascertain motor and sensory deficits using in-line restriction of cervical
wether complete/incomplete, spine.
Paraplegia/ quadriplegia, Level and • Perform tog rolling to evaluate
extent of injury. spinal deformity/tenderness/
• Document findings injuries.

• Plan transter ta facility with Xray, CT scan and a Neurosurgeon.

• Transfer the patient using Orthoscoop stretcher /hard spinal board.
• Prevent prolonged restriction on a Hard spinal board as it can lead to serious decubitus ulcers formation.

Fig 25.38 : Evaluation and Management Scheme for Spinal Injuries in Field Setting

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(viii) Optimal Medication.

As we provide Combat Medical Care in a forward field scenario, we need to understand that availability
of only essential drugs which can be safely given and do not require very intensive monitoring should be
given. To be able to administer important drugs without fail following acronym AMRAT (Fig 25.39), should
be followed on the lines of Pain management Antibiotics Wounds Splinting (PAWS) guidelines from Tactical
Combat Causality Care (TCCC).

A •ANALGESTA

M •MANNITOL

R •RINGER LACTATE

A •ANTIBIOTICS

T •TRANEXAMICACID & TT

Fig 25.39 : AMRAT Acronym for Drugs to be Administered in Field Setting

(aa) Analgesia.
For mild to moderate pain in a patient with no oral restriction NSAIDS as given below can be used.
O Acetaminophen 625 mg 1 tab TDS
O Tab Combiflam (Paracetamol + Ibuprofen) 1 tab TDS.
O Tab Diclofenac SR 150 mg OD.
O Tab Meloxicam 15 mg OD.
For moderate to severe pain recommended analgesics are
O Inj Diclofenac 75 mg im / iv 8 hrly.
O Inj Paracetamol 1gm infusion in 100 ml NS 6-8 hrly.
O Inj Tramadol 100 mg iv 6-8 hrly in 100 ml infusion.
O Inj Morphine 0.1 mg / kg iv repeated at 15 mins interval. (* Monitor for respiratory
depression).
(ab) Mannitol.
It is an osmotic diuretic to be utilized in patients with features of raised ICT. This drug should not be
given in patients with hypovolemia as it will aggravate hypovolemic shock. It should ideally be given
following surgical / neurosurgical consultation. Consider giving Mannitol i / v 1 gm / kg over 5 minutes
followed by 100ml of 20% solution 8 hourly.
(ac) Ringer Lactate.
It is the fluid of choice in trauma management. Initial 1 Litre of crystalloids have to be given by
rapid infusion which will guide us to classify patient on the basis of their response. Further fluid
management is as per the response. Over-enthusiastic resuscitation with fluids must avoided and
permissive hypotension can be practiced. Also, earlier utilization of blood and blood products needs to
be considered in transient and non-responders. Details have been discussed in Circulation subhead.

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(ad) Antibiotic.
If orally not restricted then Tab Augmentin (Amoxicillin + Clavulanic Acid) 1 gm BD is recommended. If
orally restricted, then Inj Augmentin 1.2 gm BD or any third generation Cephalosporin is recommended.
(ae) Tranexamic Acid (TXA) & TT.
Tranexamic acid (TXA), 1 gm IV piggyback with 100 ml normal saline, lactated ringer. Indications are
excessive haemorrhage and should be given within three hours of injury. TXA is an antifibrinolytic
agent. It can be repeated 8 hourly. Also, it is important to give all trauma patients a shot of Tetanus
Toxoid due to the nature of the wounds and irrespective of their last immunization status, which
might be difficult and unreasonable to ascertain.
(ix) Watch And Whisk.
This is the step by when we have completed a detailed primary survey of our patient and administered the
necessary intervention. However, Combat trauma like any other trauma is an evolving condition and thus
comes the role of serial monitoring, secondary survey and plan for safe evacuation. However, it must be
noted that secondary survey should not be performed at the cost of delay in transfer of a critical patient.
Secondary survey starts by taking a detailed history (Acronym AMPLE can be used).
A - ALLERGIES
M - MEDICATIONS
P - PAST HISTORY
L - LAST MEAL
E - ENVIRONMENT AND EXPOSURE
Following the AMPLE history, detailed and deliberate head to toe examination as per the ATLS guidelines
should be conducted. The same should be conducted as per ATLS guidelines given in Table 25.17.
Table 25.17 : Secondary Survey in Trauma Patients
Item to Assess Establishes/Identifies Assess Finding Confirm By
Level of • Severity of head • GCS Score • ≤ 8, Severe head injury • CT
Consciousness injury • 9~12, Moderate head
• 13~15, Mild head injury
Pupils • Type of head injury • Size • Mass effect • CT
• Presence of eye • Shape • Diffuse brain injury
injury • Reactivity • Ophthalmic injury
Head • Scalp injury • Inspect for laceration • Scalp laceration • CT
• Skull injury and skull fractures • Depressed skull fracture
• Palpable defects • Basilar skull fracture
Maxillofacial • Soft-tissue injury • Visual deformity • Facial fracture • Facial bone X-ray
• Bone injury • Malocclusion • Soft-tissue injury • Facial bone CT
• Nerve injury • Palpation fo crepitus
• Teeth/mouth injury
Neck • Laryngeal injury • Visual inspection • Laryngeal deformity • C-spine X-ray
• C-spine injury • Palpation • Subcutaneous • Angiography/
• Vascular injury • Auscultation • Hematoma Duplex exam
• Esophageal injury • Bruit • Esophagoscopy
• Neurologic deficit • Platysmal penetration • Laryngoscopy
• Pain, tenderness of
C-spine

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Item to Assess Establishes/Identifies Assess Finding Confirm By

Thorax • Thoracic wall injury • Visual inspection • Bruising, Deformity, • Chest X-ray
• Subcutaneous • Palpation paradoxical motion • CT
emphysema • Auscultation • Chest wall tenderness, • Tube
• Bronchial injury crepitus thoracostomy
• Pulmonary contusion • Diminished breath • Pericardiocentesis
sounds
• Thoracic aortic • Bronchoscopy
disruption • Muffled heart tones
• Angiography
• Mediastinal crepitus
• TE ultrasound
• Severe back pain
Abdomen/ • Abdominal wall injury • Visual inspection • Abdominal wall pain/ • DPL/Ultrasound
Flank • Intraperitoneal injury • Palpation tenderness • CT
• Retroperitoneal injury • Auscultation • Peritoneal irritation • Celiotomy
• Determine path of • Visceral injury • Contrast Gl x-ray
penetration • Retroperioneal organ • Angiography
injury
Item to assess Establishes/Identifies Assess Finding Confirm by
Pelvis • GU tract injuries • Palpate symphysis • GU tract injury • Pelvic X-ray
• Pelvic fracture pubis for widening (hematuria) • GU contrast
• Palpate bony pelvis • Pelvic fracture studies
for tenderness • Rectal, vaginal, and/or • Urethrogram
• Determine pelvic perineal injury • Cystogram
stability only once
• IVP
• Inspect perineum
• Contrast-
• Rectal/Vaginal exam enhanced CT
Spinal Cord • Cranial injury • Motor response • Unilateral cranial mass • Plain spine x-rays
• Cord injury • Pain response effect • MRI
• Peripheral nerve • Quadriplegia
injury • Paraplegia
• Nerve root injury
Vertebral • Column injury • Verbal response to • Fracture vs dislocation • Plain x-rays
column • Vertebral instability pain, lateralizing signs • CT
• Nerve injury • Palpate for
tenderness
• Deformity
Extremities • Soft-tissue injury • Visual inspection • Swelling, bruising, pallor • Specific x-rays
• Bony deformities • Palpation • Malalignment • Doppler
• Joint abnormalities • Pain, tenderness, examination
• Neurovascular crepitus • Compartment
defects • Absent/diminished pressures
pulses • Angiography
• Tense muscular
compartments
• Neurologic deficits
Once the secondary survey has been done casualty needs to be accorded a triage priority for planned and
systemic evacuation (Table 25.18).

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Table 25.18 : Priority Scheme for Transfer to Higher Echelon

Priority Group
Color Description
Number Name
Patients who have life-threatening injuries that
are treatable with a minimum amount of time,
P1 Emergency/Immediate Red
personnel, and supplies. These patients also
have a good chance of recovery.
Indicates that treatment may be delayed for
a limited period of time without significant
P2 Urgent Yellow mortality or in the ICU setting patients for
whom life support may or may not change their
outcome given the severity of their illness.
Patients with minor injuries whose treatment
may be delayed until the patients in the other
P3 Delayed Green categories have been dealt with or patients who
do not require ICU admission for the provision of
life support.
Patients who have injuries requiring extensive
treatment that exceeds the medical resources
P4 Expectant Blue
available in the situation or for whom life
support is considered futile.
Patients who are in cardiac arrest and for
-- Dead Black which resuscitation efforts are not going to be
provided.
(c) Early Tactical Evacuation (ETE).
It is mandatory that once the patient has been stabilized and triage priority accorded, relevant information
has to be communicated to the next echelon about the patient. The systematic communication is done
using ABC-SPAR template from ATLS recommendations is given in Table 25.19. Armed Forces utilize
AFMSF-20 and 21 for such communication.
Table 25.19 : Template for Communication to Higher Echelon
ACRONYM Meaning Information To Provide
A Airway
All airway, breathing, and circulation problems identified and
B Breathing
interventions performed
C Circulation
S Situation Patient Name
Age
Referring Facility
Referring physician name
Reporting nurse name
Indication for transfer
IV access site
IV fluid and rate
Other interventions completed

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ACRONYM Meaning Information To Provide

B Background Event history
AMPLE assessment
Blood products
Medications given (date and time)
Imaging performed
Splinting
A Assessment Vital signs
Pertinent physical exam findings
Patient response to treatment
R Recommendation Transport mode
Level of transport care
Medication intervention during transport
Needed assessments and interventions

25.4 Evacuation of Causalities in Armed Forces.

The responsibility for evacuation of casualties from the Regimental Aid Post is that of the Advance Dressing Station / Field
Hospital. Certain difficulty is experienced in sectors where the Regimental Aid Post is not located at the road-head due
to non-availability of adequate stretcher bearers in the Field Hospital. Consequently, other modes of casualty evacuation
by means of Stretcher Bearer Squads from some central resources, such as civilian porters or air evacuation have to
be arranged. All Terrain Vehicles (ATV) or Ambulance Cars from the Advance Dressing Station may be attached to each
Regimental Aid Post before the battle commences. The following posts may be established between the Regimental
Aid Post and the Advance Dressing Station to facilitate evacuation:
(a) Walking Wounded Collection Post (WWCP).
When many casualties are expected, it is better to establish a Walking Wounded Collection Post, in order to
avoid congestion in the Advance Dressing Station. Less serious walking cases are directed to Walking Wounded
Collection Post from the Regimental Aid Posts or Advance Dressing Station. The site should be easily accessible
from the front line and close to a road leading to medical echelons in the rear.
(b) Bearer Relay Post (BRP).
Established when mechanical transport can’t be used and the carriage is more than 1.5 km. At these relay posts,
a fresh set of Stretcher Bearers takes over the casualties for evacuation to the next medical echelon / relay post.
(c) Car Post (CP).
This is established when Mechanical Transport cannot reach the Regimental Aid Post. This should be established
as near to the Regimental Aid Post as possible, at the road head. One or more ambulance cars normally wait
here to evacuate casualties. The chain of evacuation followed in Army has been illustrated in Table 25.20.
The Early Tactical Evacuation in field situation is aided by following modes of transportation.
(i) Ambulances: The following types of ambulances are available with field medical units:
(aa) Based on the light vehicles like Tata Sumo or Mahindra.
(ab) Based on small truck like 2.5-ton truck.
The carrying capacity of these ambulances’ car is as follows:
(aa) Light Ambulance. Four sitting or two sitting and two lying or only two lying.
(ab) 2.5 Ton Ambulance. Eight sitting or four sitting and two lying or four lying.

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 Table 25.20 : Chain of Evacuation
Area Chain of Evacuation Mode of Transportation Responsibility Action taken
UNIT FDL FDL FDL FDL Regimental Stretcher bearers, CO Unit FDL
Light Ambulance (Infantry 1. First Field Dressing Applied.
Battalion).
2. First Aid.
RAP RAP RAP Armoured Personnel Carrier 3. Ammunition and automatic
Ambulance (Armoured weapons removed.
UNIT regiment/ Mechanised
4. Temporary splints applied.
Infantry Battalion) Modified
HEALTHCARE IN ARMED FORCES

stretcher fitted jeep

WALKING BEARER CAR
BRIGADE WOUNDED RELAY POST Stretcher bearer (Central Senior Medical ADS
COLLECTION POST
POST resources -Porters/pioneers) Officer Brigade 1. Triage.
Senior Medical Officer 2. Dressing adjusted.
Mules GS with Hamilton 3. Drugs and Injections.
BRIGADE B CAR POST
ECHELON saddle, Ambulance cars from 4. Resuscitation.
ADS, Returning ASC second 5. Medical Comfort provided.
line transport,
6. Documentation.
Helicopter (selected cases
ADVANCE DRESSING STATION direct to FSC/hospital). 7. Evacuate to FSC/Hospital.

720
DIVISION Ambulance car from Field CO Field FSC
FORWARD Ambulance, Ambulance /
SURGICAL BORDER STATIC 1. Triage.
HOSPITAL/MILITARY ADMS Division
CENTRE Returning ASC second line 2. Resuscitation/Life and Limb
HOSPITAL
transport, saving surgery.
Helicopter (selected cases).
3. Personal weapon removed.
4. Personal effects checked. 5.
Minor cases may be retained.
6. Documentation.
7. Remaining cas evacuated to
GH/Hospitals in the rear.
 COMBAT MEDICAL CARE

To ensure that more serious casualties are loaded last and unloaded first, following pattern of loading and
unloading is followed for ambulance car carrying four lying casualties:
(aa) Loading.
O Left upper
O Right upper
O Left lower
O Right lower
(ab) Unloading.
O Right lower
O Left lower
O Right upper
O Left upper
In Light Ambulance lower casualty is loaded last and unloaded first.
Each ambulance should be equipped with at least basic lifesaving and support equipment for rendering
first aid and immediate care on the site and enroute to hospital. The following is the suggested list
of essential equipment.
O Oxygen therapy set and oxygen masks
O Oral and nasopharyngeal airways of all sizes
O Endotracheal tubes
O BP apparatus
O Stethoscope
O Portable suction units
O Suction catheters of all sizes
O Boards / bags, rigid cervical collars, pneumatic apparatus for spinal and neck immobilisation
O Splints
O Syringes– all sizes
O Blood sample tube / vacutainers
O Assorted bandages, splints, PPE such as gloves, goggles, face shields
O Folding stretchers with safety belts
O Intravenous fluids and injectables
O Breathing Resuscitation Equipment’s. A set of instruments for emergency intubations,
tracheostomy and mouth to mouth resuscitation
(iii) Stretcher fitted Jeep and 5 / 7.5 Ton GS.
In stretcher fitted light vehicles, only one stretcher can be loaded. Accordingly, these vehicles can transfer
only one lying casualty. Two sitting casualties can be evacuated along with one lying casualty.
(aa) 5 / 7.5-ton GS vehicle can be modified for carriage of casualties by fitting two (front and rear)
bars across the body for carriage of casualties on stretchers. Such vehicle can carry six lying casualties
and additional 8 sitting casualties. When modification is not done by fixing these bars, about 18-21
sitting casualties can be carried in the body of the vehicle.
The loading pattern of the lying casualties is as follows:
O Left upper

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HEALTHCARE IN ARMED FORCES

O Right upper
O Left lower
O Right lower
O Centre upper
O Centre lower
(iv) Armoured Personnel Carrier (APC) based Ambulance.
Ambulances based on APC are used in mechanised warfare. The body of APC has been modified so that
stretchers can be fitted in it. An APC ambulance can carry four lying or eight sitting or four sitting and two
lying casualties. The loading pattern is like the loading pattern of 2.5-ton ambulances.
(v) Onboard Ships.
Casualties may be required to be carried onboard ship during amphibious operations. Indian Naval Ships
are authorised following types of stretchers:
(aa) Neil Robertson Stretcher
(ab) Airborne Stretcher Mark-II
Using Neil Robertson Stretcher, it is possible to transport and evacuate casualties through narrow spaces,
even vertically where the hatches or ladders are too small to use other stretchers. On board ships, a casualty
is required to be transferred to Neil Robertson stretcher even if it has been brought on a different stretcher.
(vi) Air Evacuation of Casualties.
Using the aircrafts for evacuation it is possible to overcome the barrier on transportation imposed by natural
obstacles. It is also a speedy method of evacuation. It helps in early institution of definitive treatment and
saving of skilled manpower. However, during operations, required air effort may not be available due to
constraints such as-
(aa) Non availability of air superiority,
(ab) Non availability of helipads / airfields,
(ac) Restrictions imposed by weather or operations.
(vii) Priorities for Evacuation by Air.
For evacuation of casualties by air following priorities are followed. The priority given indicates the degree
of urgency to be applied in the management of aero medical evacuation of individual patients.
(aa) Priority I.
Patients whose transfer by the quickest possible means is necessary as a life saving measure or to
avoid serious permanent disability.
(ab) Priority II.
Patients whose condition is likely to be adversely affected unless they are speedily evacuated or who
need early specialised treatment not available locally.
(ac) Priority III.
Patients whose immediate treatment requirements are within the powers of local medical units, but
whose progress would be faster if moved by air rather than by surface transport.
(ad) Priority IV.
Patients for whom move by air is a matter of convenience rather than a med requirement.
(viii) Classification of Patients for Air Evacuation.
Classification of patients is done based on the requirement of restraints in flight. Patients are classified as
follows:

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(aa) CLASS I - Neuropsychiatry (mental) Patients.

O Class IA.
Patients who are frankly disturbed & inaccessible and require the use of restraint in
sedation & close supervision.
O Class IB.
Patients who do not require use of restraint and are not at the moment mentally disturbed
but may react badly to air travel or commit acts likely to endanger themselves or the
safety of the aircraft & its occupants.
O Class IC.
Patient who are co-operative & have proved reliable under observation.
(ab) CLASS 2 - Stretcher Patient (other than psychiatric).
O Class 2A.
Patients who are unable to move about of their own in any circumstances.
O Class 2B.
Patient who in an emergency will be able to move themselves.
O Class 2C.
Walking patients (other than psychiatric patients) who need only minor attention.
O Class 2D.
Patient who do not need any medical treatment enroute and are physically able to travel
unattended.
(ix) Carrying Capacity of Aircrafts.
The carrying capacity of casualties by various aircrafts is as shown in Table 25.21. Use of Light Aircraft.
They are useful for evacuation of casualties from the battle frontline units. The average flying range is 100
to 150 miles. They can be operated from a small air strip. Due to the limited space available in these types
of aircraft, only serious cases can be evacuated.
Use of Medium or Heavy Aircraft. These types of aircrafts require proper and larger airfields. They are used for
taking men and material forward and casualties back. Various length of runway is required for different aircrafts.
Table 25.21 : Casualty Carrying Capacity of Various Aircrafts
Type of Aircraft Sitting Cases Lying Cases Med Assts
HELICOPTERS
Cheetah 3 or - -
Chetak 4 or 2 1
MI-8/MI-17 24 or 12 1
MI-26 82 or 60 4
ALH 10 or 4 -
AIRCRAFTS
Avro HS 74B 40 or 21 -
AN-32 50 or 24 3
Dornier 16 or 2 1
IL-76 Version-I 225 or 42 & 72 3
IL-76 Version-II 225 or 07 & 80 3
IL-76 Version-III 225 or 12 & 32 3

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Suggested Reading.
1. American College of Surgeons. (2018). Advanced Trauma Life Support (ATLS) Student Course Manual (10th ed.).
Chicago, IL: American College of Surgeons.)
2. Organisation and Employment of Medical Services- (MOBC) Officers Training College, AMC Centre & College,
Lucknow.
3. American Red Cross. American Red Cross first aid/CPR/AED participant’s manual. Yardley, Pa: Staywell; 2011
4. Christos Giannou. War Surgery. 2009.
5. Nayduch D. Nurse to nurse trauma care. New York Mcgraw Hill Professional; 2011.
6. Champion HR, Bellamy RF, Roberts CP, Leppaniemi A. A profile of combat injury. J Trauma. 2003 May;54(5
Suppl):S13-9. doi: 10.1097/01.TA.0000057151.02906.27. PMID: 12768096.
7. Khorram-Manesh A, Goniewicz K, Burkle FM, Robinson Y. Review of Military Casualties in Modern Conflicts—The
Re-emergence of Casualties From Armored Warfare. Military Medicine. 2021 Mar 20;187(3-4).
8. Casualty burden from various modalities in combat trauma (Arora MM, Bhatia JK, Rana KVS. Pattern of Fatal
Injuries in Counter Terrorist Operations: An Innovative Analysis through Embalming Services. MJAFI 2009; 65: 103-107.)
9. Trunkey, Donald D. “Trauma. Accidental and intentional injuries account for more years of life lost in the U.S.
than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and
further research.” Scientific American 249 2 (1983): 28-35
10. Reanimación y vía aérea [Internet]. Reanimación y vía aérea. Reanimación y vía aérea; 2019 [cited 2024 Apr
18]. Available from: https://viaaerearcp.wordpress.com/
11. US Army Combined Arms Center [Internet]. usacac.army.mil. Available from: https://usacac.army.mil/
12. The Official Home Page of the Indian Army [Internet]. www.indianarmy.nic.in. Available from: https://indianarmy.
nic.in/
n

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Chapter
XXVI
EPIDEMIOLOGY AND STATISTICAL METHODS

26.1 Epidemiology.
(a) Introduction.
Epidemiology is the study of occurrence and distribution of health- related events, states and processes in specified
populations, including the study of determinants influencing such processes and the application of this knowledge
to control relevant health problems. “Study” includes surveillance, observation, hypotheses testing, analytic research
and experiments. “Distribution” refers to analysis by time, place and classes of persons affected. “Determinants”
are all physical, biological, social, cultural and behavioural factors that influence health. “Health-related states and
events” include diseases, causes of death, behaviour such as use of tobacco, reactions to preventive regimens
and provision and use of health services. “Specified populations” are those who can be grouped together by
geography or other features. “Application to control” makes explicit the aim of epidemiology - to prevent disease
and promote, protect and restore health. There have been many definitions of epidemiology. In the past 70 years
or so the definition has broadened from concern with communicable disease epidemics to occurrence of Non
communicable diseases and all phenomena related to health in populations.
Historically, epidemiology was developed to investigate epidemics of infectious disease. An epidemic is occurrence
of cases of illness, specific health related behaviour or other health related events clearly more than normal
expectancy in a community or region. The term outbreak is often used synonymously with epidemic which refers
to an epidemic confined to localized area. Endemic refers to ongoing usual or constant presence of a disease in
a community or among a group of people while Pandemic is an epidemic affecting the population of an extensive
region, country or continent.
Epidemiology is an eclectic discipline. It draws skills and techniques from many disciplines such as sociology,
anthropology, biostatistics, in addition to the various disciplines within sciences pertaining to environment in
general and medical sciences in particular. Practice of epidemiology is the combined application of the clinical
skills of medical sciences, laboratory methods, social sciences, biostatistics, ethics and logic.
The changing pattern of disease both in the developed and developing world has brought epidemiology right to
the forefront of health care and the planning of health services. Alongside this change in disease pattern comes
the fact that health services almost everywhere are faced with increasing financial constraints and must decide
rationally how limited resources should be deployed and good health care planned.
There are four general questions in health, which currently confront almost all societies:
(i) What are the appropriate strategies for prevention and control of diseases?
(ii) Should preventive, curative or care services be provided for particular population groups and how
can these services be coordinated?
(iii) What health hazards exist in the environment and how can these be removed or ameliorated?
(iv) What are the priorities between different population groups and parts of the health service and how
are these priorities to be decided?
There are no easy and straight answers, but epidemiology can make a significant contribution in providing a
base of scientific information for use in health planning and decision making. Epidemiology is the core research
method that underpins medical research and public health practice from the design and analysis of clinical
trials, to conducting large scale cohort studies, community trials, to understand emerging health problems, to
the containment of outbreaks. The activities which an epidemiologist may be required to undertake are following:
(i) Identifying risk factors for disease, injuries and death

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(ii) Describing the natural history of disease

(iii) Identifying individuals and populations at greater risk for disease
(iv) Identifying where the public health problem is greatest
(v) Monitoring disease and other health related events over time
(vi) Evaluating the efficacy and effectiveness of prevention and treatment programme
(vii) Providing information that is useful in health planning and decision making for establishing health
programmes
(viii) Communicating public health information
Traditional epidemiological studies include quantitative and qualitative study designs. Qualitative studies employ non-
numeric methods to obtain “richer” information on how people perceive or experience situations. They are ideal for
answering “why” questions, either by themselves or in combination with quantitative data. Quantitative methods are
more commonly used for epidemiological studies and ideal for answering questions like “how many” “how much” or
“how often”.
Epidemiologic methods for quantitative studies fall under different classifications. Based on whether the suspected
causal factor is under control of the investigator they may be classified as observational methods and experimental
methods. While doing research, the choice of design depends on a variety of considerations, including the clinical
topic (e.g. whether the disease or condition is rare or common) and the cost and availability of data. Depending on
the purpose for which a study is carried out i.e. whether to generate a hypothesis or test a hypothesis observational
studies are classified as descriptive studies and analytic studies. Depending on how information is collected over
time on the suspected cause-effect relationship or occurrence of disease or other outcomes, they are classified as
retrospective and prospective studies.
Division into longitudinal studies or cross-sectional studies is again based on how information is collected over time
whether at one point in time or repeatedly over a period. In an experimental study design the investigator has more control
over the assignment of participants, often placing them in treatment and control groups (e.g. by using a randomization
method before the start of any treatment). Each type of research design has advantages and disadvantages, the same
is summarized in Table below. However, there cannot be any dogma in categorizing a study into a particular class.
There is lot of overlap and hybrid study designs do exist.
Table 26.1 : Different Types of Study Designs
Approach Designs Advantages Disadvantages
Qualitative Research
Methods - Grounded theory - Generates hypotheses and initial - Cannot test study hypotheses
- Ethnographic exploration of issues in participants’ - Can explore only what is presented
- Document
Studies own language. or stated
study
- Observations - Phenomenological - Has potential for bias
studies
- In-depth
interviews - Narrative research
- Focus group - Historical studies
discussions - Case studies
Quantitative Research
Cross-sectional - Are fairly quick and easy to - Do not offer evidence of a
surveys perform temporal relationship between risk
Observational factors and disease
- Are useful for hypothesis
Studies
generation - Are subject to late-look bias
- Are not good for hypothesis testing

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 EPIDEMIOLOGY AND STATISTICAL METHODS

Approach Designs Advantages Disadvantages

Case-control - Are quick and easy to perform - Are subject to recall bias
studies - Can study many risk factors at - Selection of controls at times
same time may be a challenge
- Are good for studying rare - Temporal relationships may be
diseases unclear hence causation cannot be
proven
- Can study only one disease
outcome at a time
- Can obtain only Odds ratio as a
measure of strength of association
Cohort studies - Can be performed retrospectively, - Are time-consuming and costly
Observational prospectively or amphi-directional (especially prospective and amphi-
Studies - Can be used to obtain a true directional studies)
(absolute) measure of risk - Can study only the exposure
- Can study many outcomes at measured at the beginning
same time - Can be used only for common
- Are good for studying rare risk diseases
factors -May have loss to follow-up
Ecological studies - Are quick and easy to perform - Do not allow for causal
- Are useful for hypothesis conclusions to be drawn because
generation the data are not associated with
individual persons
- Are subject to ecological fallacy
- Are not good for hypothesis testing
Non-Randomized - Alternative when randomized study - More prone to systematic and
Trials (Quasi- is not feasible confounding biases than are
experimental - The extensive planning and control randomized trails
studies) that are needed for randomized - Limited ability to guarantee the
studies are not required comparability of the intervention
and control groups
Interventional  /   Randomized - Are gold-standard for evaluating - Are time-consuming and usually
Experimental controlled trials treatment interventions (clinical costly
trials) or preventive interventions - Can study only interventions or
Studies
(field trials) exposures that are controlled by
- Allow investigator to have extensive investigator
control over research process - May have problems related to
therapy changes and dropouts
- May be limited in generalizability
- Ethical issues
Systematic - Decrease subjective element of - Mixing poor quality studies
methods and literature review together in a review or meta-
statistical tools - Increase statistical power analysis does not improve the
Systematic
are used to obtain underlying quality of studies.
reviews and - Allow exploration of subgroups
answers to a
meta-analysis - Provide quantitative estimates of
specific question
from available effect
empirical research

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 EPIDEMIOLOGY & BIOSTATISTICS

26.2 Descriptive Studies.

When an epidemiological study is not structured formally as an analytic or experimental study, i.e. when it is not aimed
specifically to test an etiological hypothesis, it is called a descriptive study and belongs to the observational category
of studies. The wealth of material obtained in most descriptive studies allows the generation of hypotheses, which can
then be tested by analytical or experimental designs.
(a) Conduct of Descriptive Studies.
Descriptive studies entail the collection, analysis and interpretation of data. Both qualitative and quantitative
techniques may be used, including questionnaires, interviews, observation of participants, service statistics and
documents describing communities, groups, situations, programmes and other individual or ecological units.
The distinguishing feature of this approach is that its primary concern is with description rather than with the
testing of hypotheses or establishing cause-effect relationship. The descriptive approach may, nevertheless, be
integrated with or supplement methods that address these issues and may add considerably to the information
base.
(b) Kinds of Descriptive Studies.
(i) Case Series.
This kind of study is based on reports of a series of cases of a specific condition or a series of treated
cases, with no specifically allocated control group. They represent the numerator of disease occurrence
and should not be used to estimate risks.
(ii) Community Diagnosis or Needs Assessment.
This kind of study entails collection of data on existing health problems, programmes, achievements,
constraints, social stratification, leadership patterns, focal points of resistance or high prevalence or groups
at highest risk. Their purpose is to identify existing needs and to provide base-line data for the design of
further studies or action.
(iii) Epidemiological Description of Disease Occurrence.
This common use of the descriptive approach entails the collection of data on the occurrence and
distribution of disease in populations according to specific characteristics of individuals (age, sex, education,
smoking habits, religion, occupation, social class, marital status, health status, personality, etc.), place
(rural / urban, local, subnational, national, international) and time (epidemic, seasonal, cyclic, secular). To
show the time course of a disease outbreak or epidemic, epidemiologists use a graph called an epidemic
curve. In an epidemic curve y-axis shows the number of cases, while the x-axis shows time as either date
of symptom onset or date of diagnosis. Conventionally, the data are displayed as a histogram. The shape
and other features of an epidemic curve can suggest hypotheses about the time and source of exposure,
the mode of transmission and the causative agent (Fig 26.1). A description may also be given by familial
characteristics, such as birth order, parity, family size, maternal age, birth interval or family type. The detailed
epidemic / outbreak investigation has been mentioned in section 30 on excremental diseases.
(iv) Descriptive Cross-sectional Studies or Community (population) Surveys.
Cross-sectional studies entail the collection of data on, as the term implies, a cross-section of the population,
which may comprise the whole population or a proportion (a sample). Many cross-sectional studies do not
aim at testing a hypothesis about an association and are thus descriptive. They provide a prevalence rate
at a point in time. The study population at risk is the denominator for these prevalence rates. Included in
this type of descriptive studies are surveys, in which the distribution of a disease, disability, pathological
condition, immunological condition, nutritional status, fitness, intelligence, etc. are assessed. This design
may also be used in health systems research to describe “prevalence” by certain characteristics - the pattern
of health service utilization and compliance or in opinion surveys. A common study is the KAPB (knowledge,
attitude, practice and behaviour) earlier used in family planning and now in other areas especially HIV / AIDS.
(v) Ecological Descriptive Studies.
When the unit of observation is an aggregate (e.g. a family, clan or school) or an ecological unit (a village,
town, district, state or country), the study becomes a descriptive ecological study.

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 EPIDEMIOLOGY AND STATISTICAL METHODS

Fig 26.1 : Different Types of Epidemic Curves

26.3 Analytical Studies.

Analytic strategies are observational methods used in epidemiological investigations to test specific etiological hypothesis.
The term “analytic” implies that the study is designed to establish the cause of a disease by looking for associations
between exposure to a risk factor and disease occurrence or a predictor and outcome variable of interest. The basic
approach in analytic studies is to develop a specific hypothesis and to design the study to control for extraneous
variables that could potentially confound the observed relationship between the studied factor and the disease. The
approach varies according to the specific strategy used.
(a) Case - Control Studies.
With this type of study, one investigates an association by contrasting the exposure of a series of cases of the
specified disease with the exposure pattern of carefully selected controls free from that disease (Fig 26.2). The
design is relatively simple, except that it is backward looking, “retrospective”, based on the exposure histories of
cases and controls. The risk factor is something that happened in the past, presumably before disease onset,
e.g. smoking or a previous infection or medication. The data are analysed to determine whether exposure was

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EPIDEMIOLOGY & BIOSTATISTICS

different for cases and for controls.

Exposure +
Disease +
Exposure −
Study Compare
Population Results
Exposure +
Disease −
Exposure −

Outcome Exposure

Fig 26.2 : Design of Case-Control Study

(b) Prospective Cohort Studies (Forward Looking or Incidence Studies).
A cohort is a group of subjects who have undergone a similar exposure  /  experience. The common strategy of
cohort studies is to start with a reference population (or a representative sample thereof), some of whom have
certain characteristics or attributes or have undergone exposure relevant to the study (exposed group) and others
who do not have those characteristics  /  exposure (unexposed group). Both groups need to be, at the outset of
the study free of the disease or outcome of interest (Fig 26.3). Both groups are then observed over a period to
find out occurrence of the disease / outcome.

Disease +
Exposure +
Disease −
Study Compare
Population Results
Disease +
Exposure −
Disease −

Exposure Outcome

Fig 26.3 : Design of a Cohort Study

(c) Retrospective Cohort Studies.
In a retrospective cohort study, all the relevant events (causes and effects) have already occurred when the study
is initiated. This type of study is possible if records are available, which allow reconstruction of the exposure of
cohorts to a suspected risk factor and follow up of their mortality / morbidity over a period.
(d) Prognostic Cohort Studies.
The cohort consists of cases diagnosed at a fixed time or cases treated at a fixed time by a medical or surgical
treatment, rehabilitation procedure, psychological adjustment or vocational adjustment. By definition such cases
are not free of a specified disease, as in the conventional cohort study. The outcome of interest is cure, survival,
improvement, disability, vocational functioning or psychological adjustment.
(e) Analytical Cross-sectional Studies.
In an analytical cross-sectional study, the investigator measures exposures and disease simultaneously in a
representative sample of the population (Fig 26.4). By taking a representative sample, it is possible to generalize
the results obtained in the sample to the population. Cross-sectional studies measure the association between the
exposure variable and existing disease (prevalence), unlike cohort studies, which measure the rate of developing
disease (incidence). Rare diseases, conditions of short duration or diseases with high mortality are often not

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 EPIDEMIOLOGY AND STATISTICAL METHODS

detected by the one-time “snapshot” of the cross-sectional study. Therefore, cross-sectional studies are more
appropriate for measuring the relationship between permanent characteristics in individuals and chronic diseases
or stable conditions.

Disease + / −
Snapshot of
Study Population Compare Results
Sample
Exposure + / −

Fig 26.4 : Design of a Cross Sectional Study

26.4 Interventional  /  Experimental Studies.

In testing hypothesis, the investigator may be able to assign the independent or exposure variable to a number of
subjects in the study and withhold it from others (controls), while controlling for other extraneous or confounding
variables. This strategy constitutes an experiment and covers hypothesis testing through intervention. Although an
experiment is an important step in establishing causality, it is often neither feasible nor ethical to subject human beings
to risk factors in etiological studies. However, there is one area in which experimental strategies are used extensively.
This is the area of clinical and field trials [Randomized Controlled Trials (RCT)] for testing new drugs or intervention
programmes (Fig 26.5). Randomization of subjects to experimental and control groups makes it more likely that the
distribution of some extraneous variable will be equalized between the two groups, although it is still necessary in the
analysis to compare the distribution of these variables to ensure the validity of inferences drawn from the study. The
basic steps in conducting a randomized controlled trial include the following:
Step I - Drawing up a protocol (aims and objectives, questions to be answered, criteria for selection of study and control
groups, treatments to be applied, standardization of work procedures, measurements)
Step II - Selecting reference and experimental populations (reference or target population is the population to which the
findings of the trial are expected to be applicable - the study or experimental population is derived from the reference
population; it is the actual population that participates in the experimental study; it should be randomly chosen from
the reference population)
Step III - Randomization (this is a statistical procedure by which the participants are allocated into groups called “study”
and “control” groups, to receive or not to receive an experimental, preventive or therapeutic procedure)

Treatment Treatment
Follow-up
Study Group Group Compare
Randomization
Population Results
Control Control
Follow-up
Group Group

Fig 26.5 : Design of Experimental Study (RCT)

Step IV - Intervention: the actual administration of the drug, vaccine or other intervention and depending on the protocol
may involve use of a placebo in control groups.
Step V - Follow up (examination of the experimental and control group subjects at defined intervals of time, in a standard
manner, with equal intensity, under the same given circumstances, in the same time frame till final assessment of
outcome)
Step VI - Assessment of outcome (the incidence of positive / negative results is rigorously compared in both the groups
and the difference if any, are tested for statistical significance)
Step VII - Control of bias at all stages of design, conduct, ascertainment of effects and analysis is essential by following
procedures such as randomization, stratification, blinding, etc.
Bias may occur in a variety of ways in the conduct of RCT. Selection bias may result if volunteers are taken into a
study or subjects are included according to the choice of the investigator. Randomization solves this problem. Bias may
also arise from varied administration of intervention to different groups in the study or arise from errors of differential

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 EPIDEMIOLOGY & BIOSTATISTICS

assessment of the outcome due to human element or other factors. These may be from various sources: There may
be bias on the part of the participants, who may subjectively feel better if they know they were receiving a new form
of treatment; on part of investigator who may not administer the intervention with equal vigour to study and control
groups if he is aware of their identities and on part of observer (observer bias) i.e. the investigator measuring the
outcome may be influenced if he knows whether the patient has been subjected to the intervention or otherwise - this
is known as “observer bias”. There may be bias in evaluation i.e. the investigator may subconsciously give a favourable
report of the outcome of the trial. Randomization cannot guard against these sorts of bias, nor the size of the sample.
To reduce these problems, a technique known as “blinding” is adopted. Blinding can be done in three ways:
Single blind.
The trial is so planned that the participant is not aware whether he belongs to the study group or control group.
Double blind.
Neither the investigator nor the participant is aware of the group allocation and the intervention given.
Triple blind.
The participant, the investigator and the person analysing the data are all “blinded”. The more subjective the outcome
more the need for blinding.
Fig 26.6 shows the level of evidence pyramid in which the bottom of the pyramid represents lower level of evidence
and top of the pyramid represents highest level of evidence.

Meta
analysis
Sytematic
Reviews
Randomized
Control Trials

Cohort Studies

Case Control Studies

Case series & Case Reports

Expert opinion

Animal Studies / Laboratories studies

Fig 26.6 : Levels of Evidence Pyramid

26.5 Ecological Studies.

These studies consist of an aggregate analysis of the correlation between a study factor and disease (or mortality from
a specific cause) in the geographical locale. They do not offer information on the exposure status of the individuals
afflicted with or dead from the specific cause. Instead, the level of exposure in the geographical unit or country is
taken as surrogate measure for all individuals in that unit or country. Examples include:
(a) Ecological correlation of per-capita consumption of cigarettes and level of mortality from lung cancer.
(b) Ecological correlation between water hardness and mortality from cardiovascular disease.
(c) Maps of cancer frequency in different regions of a country which vary by some suspected risk factors and
their interpretation by national cancer research authorities.
(d) Ecological correlation of birth rate with gainful employment of women outside home.

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26.6 Epidemiological Triad.

It is well known that not everyone exposed to tuberculosis develops tuberculosis. The same exposure, however, in an
under-nourished or otherwise susceptible person may result in clinical disease. Similarly, not everyone exposed to easy
access to alcohol becomes an alcoholic. There are many factors relating to the host and environment besides the
agent of disease which are equally important to determine whether or not disease will occur in the exposed host. This
demands a broader concept of disease causation that synthesizes the basic factors of agent, host and environment.
The causes of a disease are often considered in terms of a triad of factors: the host, the agent and the environment.
According to this, the disease is the product of an interaction of the human host, an infectious or other type of agent
and the environment that promotes the exposure. The time accounts for incubation period, life expectancy of the host
or agent and duration of course of illness or condition (Fig 26.7). For many diseases, it is also useful to add a fourth
factor, the vector.
Agent

Environment Host
Fig 26.7 : Epidemiological Triad
The above model - agent, host and environment - has been in use for many years. It helped epidemiologists to focus
on different classes of factors, especially regarding infectious diseases. A disease may have a single agent, several
independent alternative agents or a complex of two or more factors whose combined presence is essential for the
development of the disease. Agents may be biological, physical, chemical, mechanical, nutritional deficiencies or even
social such as drugs, alcohol or poverty. Host factors may be demographic (age, sex, ethnicity etc.) socioeconomic
status, lifestyle or biochemical (serum cholesterol, immunity etc.). Environmental factors may be physical, biological or
psychosocial. For humans, the environment is not limited to a set of climatic factors. For man social and economic
conditions are more important than the mean annual temperature.

26.7 Public Health Surveillance.

Public health surveillance is the ongoing systematic collection, analysis and interpretation of outcome-specific data for
use in the planning, implementation and evaluation of public health practice. By observing trends in time, place and
person, changes can be observed or anticipated and appropriate action, including investigative or control measures,
can be taken. Sources of data may relate directly to disease or to factors influencing disease. Thus, they may include:
(a) Mortality and morbidity reports based on death certificates, hospital records, general practice sentinels or
notifications.
(b) Laboratory reports.
(c) Outbreak reports.
(d) Vaccine utilization records - uptake and side effects.
(e) Sickness absence records.
(f) Study / survey reports of disease determinants such as biological changes in agents, vectors or reservoirs.
(g) Study / survey reports of susceptibility to disease, as by skin testing or serological surveillance (e.g. serum
banks).

26.8 Uses of surveillance.

(a) To provide a scientific database for rational prevention and control of disease. Surveillance activities are
essential for planning, implementation and evaluation of control measures for both communicable and non-
communicable diseases. It also facilitates the recognition and evaluation of the disease problem. Surveillance
methods may bring forward facts related to the success or failure of any control programme. For example, failure
of a vaccination programme may be due to inadequate implementation of the programme, inadequate quality of
vaccine or deterioration of vaccine during transport, storage or handling, defective composition of the vaccine,
defective techniques used, a particular ecological pattern (live polio vaccine in the tropics) or a combination of

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 EPIDEMIOLOGY & BIOSTATISTICS

any of the above factors.

(b) To help in periodic evaluation of control measures.
(c) To assess the control measures from the point of view of their cost-effectiveness.
(d) To recognize and understand the recent trends in the spread of disease, that may necessitate adjustment
of control measures.
(e) To determine strategies, establish priorities and suggest areas for further research in health planning and
management.
(f) To facilitate epidemiological forecasts of disease incidence, trend and outbreak.

Field Investigations, Surveys

& Case Investigations
Identificton of
Sources of Data Laboratory Data

Morbidity & Mortality Data

Collection of Data

Compilaton of
Data

Data Analysis and

Evaluation

Recommandations
Local Level

State Level
Dissemination of
data
National Level

International Level

Fig 26.8: Organization of An Epidemiological Surveillance System

The organization of an epidemiological surveillance system is depicted in Fig 26.8. In any sort of surveillance system,
an assessment and evaluation process should be inherent to the system to measure its reliability and efficacy. The
surveillance team must decide on two major issues:
(a) Which are the most important diseases existing in the community for which surveillance system should be
established on priority basis?
(b) What are the recommendations to be made for their control?

26.9 Creating a Surveillance System.

The development of a surveillance system requires clear objectives regarding the diseases or conditions to be covered
(e.g. infectious diseases, side effects of vaccines, elevated lead levels, pneumonia-related deaths in patients with
influenza). Also, the objectives for each surveillance item should be clear, including surveillance of an infectious disease

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 EPIDEMIOLOGY AND STATISTICAL METHODS

to determine whether a vaccine program is effective, the search for possible side effects of new vaccines or vaccine
programs and the determination of progress toward meeting health objectives for a particular disease. The criteria
for defining a case of a reportable disease or condition must be known to develop standardized reporting procedures
and reporting forms. As discussed later, the case definition usually is based on clinical findings, laboratory results; and
epidemiological data (time, place and characteristics of affected persons). The intensity of the planned surveillance
(active vs passive) and duration of the surveillance (ongoing vs time limited) must be known in advance. The types of
analysis needed (e.g. incidence, prevalence, case fatality ratio, years of potential life lost, quality-adjusted life years,
costs) should be stated in advance. In addition, plans should be made for disseminating the findings.

26.10 Methods and Functions of Disease Surveillance.

Surveillance may be either passive or active. Most surveillance conducted on a routine basis is passive surveillance.
In passive surveillance, physicians, clinics, laboratories and hospitals that are required to report disease are given the
appropriate forms and instructions, with the expectation that they will record all cases of reportable disease that come
to their attention. Active surveillance, on the other hand, requires periodic (usually weekly) telephone calls, electronic
contact or personal visits to the reporting individuals and institutions to obtain the required data. Active surveillance
is more labour intensive and costly, so it is seldom done on a routine basis.

26.11 Surveillance System Specified in IHR 2005

International Health Regulations (IHR) are binding to all WHO member countries and it requires that all countries have
the ability to detect, assess, report and respond to public health events. In terms of health-related events that occur
in a country’s territory, a state party must notify WHO of “all events which may constitute a Public Health Emergency
of International Concern (PHEIC)”.
Under IHR (2005), a PHEIC is declared by the World Health Organization if the situation meets 2 of 4 criteria:
(a) Is the public health impact of the event serious?
(b) Is the event unusual or unexpected?
(c) Is there a significant risk of international spread?
(d) Is there a significant risk of international travel or trade restrictions?
Notifiable diseases or conditions under international health regulations:
(a) Smallpox
(b) Poliomyelitis due to wild-type poliovirus
(c) Human influenza caused by a new subtype
(d) Severe Acute Respiratory Syndrome (SARS)
(e) Other Potentially Notifiable Events: May include Cholera, Pneumonic Plague, Yellow Fever, Viral Hemorrhagic
Fever and West Nile fever, as well as any others that meet the criteria laid out by the IHR.
(f) Other biological, radiological or chemical events that meet IHR criteria.

26.12 Field Investigation.

Surveillance provides information for action. One of the first actions that results from a surveillance case report or
report of a cluster is investigation by the public health department. Investigations often lead to the identification
of additional unreported or unrecognized ill persons who might otherwise continue to spread infection to others.
For some diseases, investigations may identify a source or vehicle of infection that can be controlled or eliminated.
Occasionally, the objective of an investigation may simply be to learn more about the natural history, clinical spectrum,
descriptive epidemiology and risk factors of the disease before determining what disease intervention methods might be
appropriate. Early investigations of the epidemic of COVID-19 were needed to establish a case definition based on the
clinical presentation and to characterize the populations at risk by time, place and person. As more was learned about
the epidemiology of the disease and communicability of the virus, appropriate recommendations regarding isolation
and quarantine were issued. Field investigations are sometimes referred to as “shoe leather epidemiology” as much
of the work is carried out on foot in the community.

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26.13 Spot Maps.

Map (even a rough sketch will do) of an area / station with details of all important features such as living accommodation,
pipelines, sewage lines, etc should be maintained by all unit MOs / RMOs / SHOs  /  SEMOs. A spot map is produced by
placing a dot or other symbol on the map where the disease or health condition occurred or exists. Different symbols
can be used for multiple events at a single location. Clustering of cases may indicate a common source of infection.
Analysis of geographical distribution may provide evidence of the source of disease and its mode of spread. A careful
maintenance of such maps in conjunction with graphs and charts has been useful to arrive at incubation periods,
periods of infectivity, modes and routes of transmission and the efficiency of transmission of diseases.

26.14 Dynamics.
When a disease takes root in a community and perpetuates in a community or in an area for a prolonged period at
a relatively low level, it is said to be ‘endemic’ in the community or area. In such a community the manifest disease
may be absent or may occur in mild form as a certain amount of herd immunity exists in the community. There may
be seasonal exacerbations due to lowering of this immunity or epidemic outbreaks due to arrival of immigrants. The
endemicity of a disease in combination with environmental conditions in an area is termed ‘Landscape Epidemiology’.
This aspect, therefore, should from a part of the MO’s inspection of the site before its selection for camping. The scrub
typhus area provides a good example of landscape epidemiology. An upsurge may occur in an endemic area seasonally
or when extrinsic and intrinsic factors change. Conventionally such outbreaks are also called ‘epidemics’ although the
term ‘epidemic’ classically means the occurrence of a group of diseases of similar nature in each geographical area
clearly more than its normal expectancy without any importation from outside. When disease occurs discretely, without
apparent interrelation, it is called ‘sporadic’. Sporadic incidence may occur when the disease is endemic but due to high
herd immunity or partial control measures, the clinical cases are minimum. However, the endemic potential remains
dormant and epidemics may break out among the immigrants.

26.15 Use of Epidemiological Methods.

Epidemiology and epidemiological methods measure or assess community health and ill health, determine vital events
such as births and deaths and human indices such as heights, weights and so on. The following are its main uses:
(a) To study historically the rise and fall of disease in the population
(b) Community diagnosis
(c) Planning and evaluation
(d) Evaluation of individual’s risks and chances
(e) Syndrome identification
(f) Completing the natural history of disease
(g) Searching for causes and risk factors
The use of epidemiological methods has been increasing over the past decades, finding application in all branches
of public health and medicine. The most fundamental aspect of epidemiology is the scientific rigor it demands in
measurement of various biologic, clinical, environmental, behavioural and other characteristics / phenomena. Therefore,
standardization of definitions and measurement methods is of paramount importance. No measurement process can
be perfect. Therefore, efforts to minimize the various types of bias that may occur in the conduct of epidemiological
studies should be given due consideration. This is essential to draw valid conclusions from the observations and to
apply the results of epidemiological studies confidently and safely to real life situations to prevent disease and promote
health and control health problems.

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Statistical Methods
26.16 Introduction.
Statistics is a science, which deals with collection, compilation, presentation, summarization and analysis and
interpretation of numerical data of a group of events, phenomena or characteristics including the design issues
as well. Further, it enables us to compare such phenomena, events or characteristics of one group with those of
another and draw conclusions as to their comparability and contrasts thereof. The statistical approach is part of our
everyday rational thinking which enables us to describe or characterize persons, animals, events, objects, situations
and phenomena with some reliability; to make assessments and comparisons in an objective manner: to make
wiser decisions by sifting the true from the untrue, the relevant from the irrelevant; and to take measures in such
a way that risks and losses involved are kept at a minimum. Statistics is, therefore, an aid to solving problems.

26.17 Biostatistics.
When statistics is applied to biological problems, including public health, medicine, ecological and environmental
sciences it is termed as Biostatistics. Biostatistics is a numerical expression and a mathematical analysis of countable
or measurable biological events, which occur ‘en masse’. Medical statistics is a branch of biostatistics applied to the
science and practice of medicine. The modem practice of comprehensive medical care requires exact information and
reliable evidence of the prevalence of a disease, defect, disability, derangement or condition and its extent, intensity
and epidemiological behaviour. When a new prophylactic or therapeutic measure is introduced or when such material
changes are made in an established method as to make it equivalent to a new method, adequate proof of its significant
efficiency is required to be established at the earliest opportunity before its universal introduction is undertaken. The
difference in the protected and the unprotected groups or in those under the new and the conventional remedies
maybe so large as to need no exact measurement to establish the value of the method under trial; but it is when the
difference is not so large that the real difficulties arise. While an inexperienced worker on apparent success of the
method may accept it as valuable, the experienced and critical worker who studies the same results and submits them
to simple statistical technique may arrive at different conclusions and reject the evidence as not sufficient to establish
the value of the procedure under test. To avoid such conflicting opinions, it is necessary to have working knowledge of
statistical methods so as to enable the worker to arrive at conclusions supported by facts and not to have to rely on
opinions which are often no better than pure conjectures. A correct interpretation depends upon a methodical collection
of data and their analysis by the application of correct statistical methods.
In statistical terms data is nothing but information or facts regarding the parameter under study. There are two types of
data that a researcher can collect namely quantitative and qualitative data. Data that can be numerically measured like
age, blood pressure, serum cholesterol level, height, weight etc is called quantitative data whereas data that cannot be
measured but can only be observed like colour of eye, blood group, sex of a person etc is called qualitative data. Along
with the type of data the scale used to record the data should also be known. The various scales of measurement for
quantitative data are continuous scale and discrete scale. Continuous scale allows a decimal point whereas discrete
scale takes only whole numbers or integers (no decimal point allowed). Qualitative data is categorized into nominal,
ordinal and dichotomous scale. Nominal scale is just putting the data into different groups or categories where all the
groups have equal importance (e.g. Blood Group). Ordinal scale has an inherent order to the scale (e.g. Socioeconomic
status as High, Medium and Low or Severity of Pain as Mild, Moderate and Severe). Dichotomous scale segregates out
into two outcomes. Di meaning two and chotomous meaning outcome (e.g. Presence or absence of disease, Yes / No,
M / F etc.).

26.18 Planning of an Experiment, Trial, Survey or Study.

No statistical method can compensate for a badly planned survey or study. Much thought must be given to develop
a good plan and the statistical aspect should be borne in mind from the start. Statistical technique is not merely
something which is to be applied for drawing conclusions from an experiment which has been completed, but it
should be considered as a part of the experiment itself and an essential factor in its planning. General planning of
an experiment, survey or study should start with the definition and writing of the problems and should define aims
of study or survey give terms of reference and its limits, formulate a working hypothesis, describe the actual plan of
collecting data, detailing what to collect, how much to collect and how to record it, what degree of accuracy to aim at
and finally the analysis and interpretation. It should be so planned that the chances of collection of data for and against
the hypothesis are about the same. All uncontrollable variable and disturbing factors which have no direct bearing on

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the subject or which may confuse the issue should be eliminated or reduced to the minimum. This may be difficult
and unforeseen as major disturbing factors may arise during the trial. It is fundamental for the critical evaluation of
results that the ‘control’ and ‘trial’ groups taken, should be similar in all relevant respects except in relation to the
factor under study. Unless this is done at the outset, the results achieved will be a mixture of established facts, half
knowledge, hopeful guessing, bewilderment and often a waste of time and efforts.
The problems encountered in planning of an investigation or an experiment varies with the type of material and nature
of information that is required. Laboratory investigation or hospital experiments are carried out under much better
and more controlled conditions than the trials or surveys in the field. Generally, the data collected from laboratory
investigations and hospital experiments are less voluminous than those from field trials are. In a laboratory, the
conditions favourable for collection of desirable data can be created which may not be possible in the field. In clinical
experiments planned to assess the comparative merits of two therapeutic regimes, it is necessary to ensure beforehand
that the ‘control’ groups under the conventional regime closely resembles the ‘experimental’ group under the new
regime in all factors that may influence the outcome of the trial. In planning such an experiment, one should therefore
deliberate on all the conceivable factors and then create the conditions and select the groups in such a way that they
balance each other in all respects. It is always better to seek the advice of a medical statistician in the planning of
such type of experiments. He  /  She can also indicate the optimum number of persons that should be included in the
two groups or in each group.
The collection and compilation of data suitable to the objective of one’s study is the first step towards any statistical
study. These maybe collected directly from deliberately planned surveys, trials, experiments or investigation or maybe
obtained from surveys in communities or wards during normal happening and activities or collected from the secondary
sources like routine official reports, returns, documents, publications and records. Collection of ‘data’ however, may
not be such a simple task and may be beset with a swarm of difficulties. A haphazard and slip-shod collection gives
rise to illusory conclusions. The reliability of data must be examined before any attempt is made to arrive at any
conclusions. It is a waste of time to apply refined theoretical methods of statistics to data which are suspicious and
unreliable from the beginning.
Field investigations and surveys are sine qua non of epidemiological studies. The questions requiring consideration
in planning of the field investigation are broadly, the specification of the purpose of the investigation or survey; the
decision on the category of material to be covered by the investigation: the decision on the nature of information to be
collected, consideration of time, cost and availability of resources, framing of a questionnaire and the decision on the
method of collection of data. After carefully defining the purpose at the outset, the decision is to be made as to the
category of population to be covered and material to be sought and regarding the geographical and temporal coverage.
In relevance to the material to be covered by the investigation, a decision should be made regarding the nature of
information required and how it can be best collected. The emphasis should be on selecting the most relevant items of
information with a bearing on the matters and problems under investigation. All the items of information relevant to the
matter under investigation should be arranged in a systematic fashion in the form of a questionnaire. Each term used
in the questionnaire should have a distinct meaning without any ambiguity so that there is one and only one answer
to each question. It is always advisable to prepare a proforma and carry out a pilot study to pretest the questionnaire
on a small sample and then suitably modify the original proforma, if considered necessary. The methods of collection
of data are mostly conditioned by the material under investigation and the type of information required. Instead of an
investigation in the entire population, collection of data is made generally from a representative sample. In order to
have a representative sample, the definite technique of Random Sampling is employed.
The basic facts required and collected for any statistical investigation are called the ‘Observations’. The observation,
which varies from one individual to another, is called ‘variable’. For example, in a study of the stature of recruits in the
Army, the investigator obtains, among other observations, the height of each recruit. The height of a specified recruit is
a single observation and it varies from one recruit to another, therefore, it is a ‘variable’. The variable represented by
observation may be quantitative or qualitative. Whenever the observations refer to a measurable magnitude, they are
called ‘quantitative’. Thus height, age, temperature and so on, which are expressed in units of measurement, are of
quantitative character. Such quantitative variables may be either discrete or continuous. The discrete variables adopt
values of only whole positive numbers while continuous variables take any intermediate numerical value. In biostatistics
they are mostly within a certain range. Thus, the number of daily outpatients in a hospital or number of births / deaths
per year in a area is a discrete variable, but the body temperature of the patient or height or weight of an individual
is a continuous variable. When each observation gives only a particular quality or attribute such as ‘vaccinated’ or ‘not
vaccinated’, ‘healthy’ or ‘unhealthy’, such observations are called qualitative and are amenable to statistical treatment
by counting the number of observations in which a given quality is present and the number in which it is absent. In some

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inquiries such as an attitude survey or nutrition enquiry, qualitative observations are ranked or graded. For example.
the attitude to family planning may be graded or ranked as ‘very favourable’, ‘favourable’ ‘neutral’, ‘unfavourable’ and
‘very unfavourable’ and a nutritional status as ‘satisfactory’, ‘average’ or ‘poor’. Sometimes scores are attributed to
each of the ranks according to the degree of variability to facilitate statistical treatment thereupon.

26.19 Sampling.
When many individuals, items or units must be studied, it is easier and more economical to study a sample rather than
the whole population or universe. Sampling is carried out in such a manner that each member of the population has
the same chance of being represented in the sample. Exact size of samples is calculated by using different formulae,
for which reference may be made to advanced textbooks on statistical methods or a medical statistician.
(a) Criteria.
A representative sample should satisfy the following criteria:
(i) It should be selected by a sampling technique from the population it represents.
(ii) It should differ from the population in its composition solely by chance.
(iii) All members of the population should have an equal chance of being included in the sample.
(iv) All bias has been ruled out and it will give estimate of the attribute under study almost equal to
the population value called ‘true value’.
(v) Sample size should be sufficiently large to represent the population from which it is drawn.
(b) Methods.
The following are some of the common sampling methods:
(i) Simple Random Sampling.
This can be done by throwing lots or using ‘random numbers’ or other suitable procedures mentioned
in standard textbooks.
(ii) Systematic Sampling.
This is done by picking every ‘nth’ number at regular intervals, the number being picked up from a table
of random numbers.
(iii) Stratified Sampling.
In this method, the population is divided into different strata such that the variation within the strata is
as small as possible, then a simple random sample is taken from each strata.
(iv) Multiphase Sampling.
In this method, part of the information is collected from the whole sample, apart from the sub-sample
and so on. For example, in a tuberculosis survey, Mantoux test may be done in all cases of the sample
and sputum examination for the Mantoux positive cases. Such a sampling procedure is less costly, easier,
time saving and yet more purposeful.
(v) Cluster Sampling.
This involves choosing groups of units or clusters at random. All the units in each group or samples of
them, are then used in the study. For example, all the inhabitants of entire blocks might be selected
for study rather than individuals scattered throughout the city. In a large study, this method is simpler
administratively and is less expensive than simple random sampling.
(vi) Multistage Sampling.
It is sub sampling within groups chosen as cluster samples. The first stage is to select the groups or
clusters. Then subsamples are taken in as many subsequent stages as necessary to obtain the desired
sample size. For example:
1st stage: choice of states within country.

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2nd stage: choice of towns within each state.

3rd stage: choice of neighbourhoods within each town.

26.20 Collection of Statistical Data in the Armed Forces.

Vital, Morbidity and Health Statistics.
‘Vital statistics’ are conventionally the numerical records of births, deaths and marriages etc. by which the reduction and
growth of a community may be studied. Morbidity statistics show only the sickness in the community. ‘Health statistics’
is a more comprehensive term than ‘Vital statistics’ and includes data required for the day-to-day administration of
health services, planning of health programmes, diagnosis of community health problems and measurement of the
health status of the community. It also indicates the data arising in medical and public health research. Some important
definitions are given below:
(a) Live Birth.
It is the complete expulsion or extraction from its mother of the product of conception, irrespective of the
duration of pregnancy, which, after separation, breathes or shows any other evidence of life such as beating
of the heart or definite movements of voluntary muscles and pulsation of the umbilical cord whether or not
the umbilical cord has been cut or the placenta is attached. Each product of such a birth is considered ‘live
born’. The annual birth rate per 1,000 of the population is calculated by dividing the number of births reported
during the year by the estimated population on 1st July of the same year and then multiplying it by 1,000.
(b) Death.
It is the permanent disappearance of all evidence of life at any time after live birth has taken place. In other
words, it is a post-natal cessation of vital functions with no capability of resuscitation. This definition, therefore,
excludes foetal deaths. The annual crude death rate per 1,000 of population is calculated by dividing the
number of deaths at all ages occurring during the year by the estimated population on 1st July of that year
and then multiplying by 1,000. Age specific mortality is calculated similarly by dividing the number of deaths at
or within particular age groups by the population at that age or within those age groups and then multiplying
by 1,000.
(c) Foetal Death.
It is death prior to the complete expulsion or extraction from its mother of the product of conception irrespective
of the duration of pregnancy. The death is indicated by the fact that after such separation the foetus does
not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord
or a definite movement of voluntary muscles If such a product of conception has attained at least 28 weeks
of gestation it will be a ‘still birth’. These rates are found by dividing the number of such deaths during the
year by live births (or total births) during the year and then multiplying by 1,000. These are expressed as rates
per 1,000 of live or total births.
(d) Maternal Mortality.
A maternal death is the death of a woman while pregnant or within 42 days of termination or pregnancy,
irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the
pregnancy or it’s management, but not from accidental or incidental causes (ICD 10). The maternal mortality
rate is also calculated in the same manner as the ‘still birth rate’ by dividing the number of death under ICD
to given above by the total number of live (or total) births and then multiplying by 1,000 and is expressed as
the rate per 1,000 of live (or total) births.
(e) Child Mortality Rate.
It is the age specific mortality rate as described in sub para (b) above for the age group that is desired to be
taken for statistical analysis. This is calculated by dividing the deaths of children up to the age by the mid-year
population of children within that age and then multiplying by 1,000.
(f) Infant Mortality.
It is the death of children under one year of age and the rate is calculated by dividing the number of deaths
of children under one year of age reported during a given year by the number of live births reported during
the same year and then multiplying by 1,000. It is expressed as the rate per 1,000 of live births.

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(g) Neonatal Mortality.

It is the death of infants; under 28 days from birth and this rate is found by dividing the number of deaths of
children under 28 days of age reported during a given year by the number of live births reported during the
year and then multiplying it by 1,000. It is expressed as the rate per 1,000 of live births.
(h) Perinatal Mortality.
It is the neonatal mortality within one week plus the ‘stillbirths’. It is expressed as the rate per 1,000 of live
and stillbirths in a year.
(j) Case Fatality Rate.
It is the percentage of deaths among persons affected by a particular disease (admitted to hospital or treated
in dispensaries). This, as well as morbidity data, can be age / sex / race specific.
(k) Prevalence Rate.
The prevalence rate of a disease is the number of old and new cases of that disease in each population of
a geographical area at a specified point in time or period. The purpose of studying the prevalence is to know
the magnitude of the disease problem in the population and thereby its needs for health care. The prevalence
rate per 1,000 is calculated by dividing the number of persons with the disease at a specified time by the
number of persons in the population at risk and multiplying by 1,000.
(l) Incidence Rate.
It is the number of new cases in each period in specified population. To calculate incidence rates the numerator
is the number of new cases and the denominator is population at risk of experiencing that disease. For example,
the annual incidence rate per 1,000 of a disease would be the number of new cases of that disease in that
year divided by the total population under surveillance multiplied by 1,000.

26.21 Vital Statistics.

A vital event refers to the live birth, death, foetal death, marriage, divorce, adoption, legitimization, recognition of
parenthood, annulment of marriage or legal separation.
Vital Statistics.
Denote facts systematically collected and compiled in numerical form, relating to or derived from records of
vital events namely births, deaths, marriages, adoptions, as well as relevant characteristics of the events
themselves. Traditionally, vital statistics were lists of births and deaths, which were then used to determine
whether the population was growing or shrinking. It is conceivable to consider John Graunt of London to be
the Father of Demography, as he was the first to make the estimate of the population size.
Sources of Vital Statistics.
The following are the sources of vital statistics.
(a) Census
(b) Vital Events Registers
(c) Hospital Records
(d) Surveys
(e) Sample Registration System
(f) Analytical Methods

(a) Census.
Population census may be described as the total process of collecting, compiling, analysing or otherwise
disseminating demographic, economic and social data pertaining, at a specific time, of all persons in a country
or a well-defined part of a country (https://censusmp.gov.in/censusmp/english/home.html). The first systematic
attempt to count the whole population of India was made in India during the British Rule between 1867 and 1782.

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A second census was conducted in 1881 by W.C. Plowden, Census Commissioner of India and has since then been
conducted every ten years baring last census-2021 which is delayed due to COVID-19 pandemic. At the time of
census enumeration data on vital events along with socio-economic and cultural are collected. Only aggregates
for the census year are provided; no up-to-date vital statistics for the time between censuses are provided.
(b) Vital Events Registers.
It is a continuous and permanent method of collection of data on vital events. It includes legal registration,
statistical recording, reporting and compiling, processing, analysing, evaluating, presenting and disseminating
this information in statistical form pertaining to vital events. In India, the first voluntary registration of births,
stillbirths and deaths was undertaken under Civil Registration System (CRS) in 1873, due to voluntary
registration and multiple registration agencies the data collected by this system lacks coverage, reliability and
completeness. Indian Government passed the unified legislation in the country entitled Registration of Births
and Deaths (RBD) Act, 1969 and the Act provided the compulsory registration of births and deaths Because of
a lack of awareness, necessity and importance among mases, which have a high level of illiteracy and those
involved in the registration system, the data collected by this system is either do not exist or are deficient in
respect of coverage, reliability and completeness, even though it is a mandatory registration system and a fine
could be imposed in case of default.
(c) Hospital Records.
Every hospital is required to keep records on every patient, including information on their age, sex, sickness
type and prognosis (including births and deaths).
(d) Surveys.
In countries with defective registration system, occasionally surveys are conducted to collect data on vital events.
(e) Sample Registration System (SRS).
Data on vital events collected by vital events registration system under the Registration of Birth and Death Act
1969 (RBD Act 1969) is incomplete and not reliable because of ignorance, lack of concern and motivation
and high illiteracy level in India. Hence government of India initiated SRS in mid 1960s to get more reliable
data on vital events. Presently SRS is the main source of data on vital events for calculation of fertility rates,
mortality rates and growth rates, etc. In SRS, a random sample of rural units and urban blocks is selected
from each State. In selected rural units / urban blocks events of births and deaths are continuously registered
by a resident part time enumerator. The enumerator visits each house in his / her area once a quarter in
the rural units while once a month in the urban blocks. Once in six month a survey is carried by a full-time
supervisor. The data obtained by the resident part time enumerator and the supervisor is compared and
matched, discrepancies are rectified if any.
(f) Analytical Methods.
This method is mathematical one, based on returns of two consecutive population censuses. The data from
census of population used to derive approximate number of births and deaths, which have occurred in this
population over the inter-censual period. It provides aggregates only. It does not provide current vital statistics.

26.22 Measures of Mortality.

(a) Crude Death Rate (CDR).
D
CDR =
P
Where ‘D’ is the number of deaths, which occurred among the population of a given geographical area during
a given year & ‘P’ is the mid-year population of the same geographical area during the same year.
CDR, it a crude measure of the overall healthiness of a community. It indicates the decrease in the population
due to death. Mortality fluctuates with age-sex composition and health status of the population; as a result, CDR
shouldn’t be used to compare populations over time, either within the same population or across populations.
To eliminate decimal fractions and facilitate interpretation, CDR is often expressed per K population, where K
may be 1,000 or 10,000 or 1,00,000, etc. Example: If CDR = 0.0012 then we can say CDR is 12 per 10,000
population (K = 10,000).

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(b) Age Specific Death Rate (ASDR).

To neutralize the effect of age and sex, age specific death rate for each sex can be calculated. Age specific
death rate provides better basis for comparing the mortality experience of different populations. It is defined
as,
Dx
ASDR =
Px
Where Dx is the number of deaths which occurred among the population of age group ‘x’ of a given geographical
area during a given year and Px is the mid-year population of specified age group x.
Total Number of deaths = D = ∑
x
Dx

Total population = P = ∑x Px

ASDR can be calculated separately for male and female. ASDR takes account of age-sex structure of the
population hence provides better measure of mortality and can be used for international comparisons.
(c)
Maternal Mortality Rate (MMR).
a
MMR =
b
Where ‘a’ is the number of maternal deaths which occurred among the population of a given geographical
area during a given year & ‘b’ is the number of live births, which occurred among the population of the same
geographical area during the same year.
Note. maternal death is defined as female deaths from any cause related to or aggravated by pregnancy or
its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days
of termination of pregnancy, irrespective of the duration and site of the pregnancy (WHO).
Limitations.
(i) The denominator should have been the number of mothers who delivered live born babies plus
the number of mothers who delivered dead foetuses.
(ii) There could be a maternal death without producing live birth, this results in inflated rates.
(iii) A maternal death can be counted once although twins or larger births may have occurred, this
results in smaller rate.
(iv) Live births are poorly registered whereas maternal deaths are more completely registered, this
results in an inflated rate.
(v) Maternal death may occur in a year later than the year in which birth occurred.
(vi) If above mentioned limitations are minimum, then MMR represents chance of death associated
with birth. It serves as an index of success or failure of many public health programs.
(vii) It is also known as Maternal Mortality Ratio since actually numerator is not a part of denominator.
(d)
Infant Mortality Rate (IMR).
a
IMR =
b
Where ‘a’ is the number of deaths under 1 year of age, which occurred among the population of a given
geographical area during a given year and ‘b’ is the number of live births, which occurred among the population
of the same geographical area during the same year.

Limitations.
(i) Live births are poorly registered whereas infant deaths are more completely registered, this results
in an inflated rate.
(ii) Many infants who die in a given calendar year were born during the previous year. Similarly, many
children born in a given calendar year will die during the following year.

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(iii) All the live births included in the denominator do not expose to the risk of death during the infancy
because many live births included in the denominator do not complete one year during the given year.
(iv) It is the most sensitive of all measures of mortality because mortality is higher under 1 year of age
than at any other age except at very old age. If above mentioned limitations are minimum, it represents
the chance of death under 1 year of age. It is a measure of the overall health status of a community.
It serves as an index of success or failure of many public health programs.
(e)
Neonatal Mortality Rate (NMR).
a
NMR =
b
Where a is the number of deaths under 28 days of age, which occurred among the population of a given
geographical area during a given year & b is the number of live births, which occurred among the population
of the same geographical area during the same year.
Limitations.
The limitations are same as in IMR.
(f)
Post Neonatal Mortality Rate (PNMR).
a
PNMR =
b
Where ‘a’ is the number of deaths under 1 year of age but more than 28 days of age, which occurred among
the population of a given geographical area during a given year & ‘b’ is the number of live births, which
occurred among the population of the same geographical area during the same year.
Limitations.
The limitations are same as in IMR.
(g)
Perinatal Mortality Rate (PMR).
a
PMR =
b
Where ‘a’ is the number of foetal deaths of 28 or more completed weeks gestation plus number of neonatal
deaths below the age of 7 days, which occurred among the population of a given geographical area during a
given year & ‘b’ is the number of foetal deaths of 28 or more completed weeks gestation plus number of live
births, which occurred among the population of the same geographical area during the same year. It measures
the total wastage of pregnancy both before and after delivery.
(h)
Proportional Mortality Rate (PMR).
a
PMR =
b
Where ‘a’ is the number of deaths from the specified cause, which occurred among the population of a given
geographical area during a given year & ‘b’ is the total number of deaths, which occurred among the population
of the same geographical area during the same year.
It is used for describing the relative importance of different fatal diseases in a population. It can be calculated
for specific age groups and used for determining the order of importance of cause of death in different age
groups.

26.24 Measures of Fertility.

(a)
Crude Birth Rate (CBR).
a
CBR =
b
Where ‘a’ is the number of live births, which occurred among the population of a given geographical area
during a given year & ‘b’ is the mid-year population of the same geographical area during the same year.
Mid-year population is the population on 1st July of the given year.

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This rate is an index to the relative speed at which additions are being made to a population through childbirth.
This rate should not be used to compare the fertility levels in two different population because it does not
take account of age-sex structure of the population.
This rate is known as General Fertility Rate, if denominator is replaced by mid-year female population of age
group 15 to 45 or 49 years of the same geographical area during the same year.
General Fertility Rate is known as General Marital Fertility Rate, if denominator is replaced by mid-year married
female population of age group 15 to 45 or 49 years of the same geographical area during the same year.
(b)
Age specific Fertility Rate (ASFR).
a
ASFR =
b
Where ‘a’ is the number of live births, which occurred to mothers of specific age group of population of a
given geographical area during a given year & ‘b’ is the mid-year female population of the specified age group
of the same geographical area during the same year.
This rate takes account of the age-sex structure of the population therefore it provides the best basis for
international comparisons.

26.25 Measures of Population Growth.

(a) Natural Increase Rate (NIR).
NIR = CBR − CDR
This rate is simplest measure of population growth. It measures the overall gain or loss in the population
through the addition of births and subtraction of deaths.
(b) Total Fertility Rate (TFR)
45
∑
TFR = ASFR (i)
b (i) = 15

Where ASFR (i) is the age specific fertility rate for the ith age group.
The cumulated value of the age specific fertility rates at the end of the reproductive period gives a measure
of fertility known as Total Fertility Rate. This rate indicates the average number of children expected to be
born per woman of a cohort of women who are beginning life together during the entire span of reproductive
period, if current age specific fertility rates continue to be the same and there is no mortality.
(c) Gross Reproduction Rate (GRR).
45
∑
GFR = FASFR (i)
b (i) = 15

Where FASFR (i) is the female age specific fertility rate for the ith age group.
The cumulated value of the female age specific fertility rates at the end of the reproductive period gives a
measure of fertility known as Gross Fertility Rate. This rate indicates the average number of female children
expected to born per woman of a cohort of women who are beginning life together during the entire span
of reproductive period, if current female age specific fertility rates continue to be the same and there is no
mortality.
(d) Net Reproduction Rate (NRR).
45
∑
NRR = FASFR (i) × P (i)
b
(i) = 15
Where FASFR (i) is the female age specific fertility rate for the ith age group.

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 EPIDEMIOLOGY & BIOSTATISTICS

p(i) is the chance of survival of female from the birth to the age “i”.
TFR and GRR take account of current fertility only but ignores current mortality. NRR considers the fact that
some women will die before completing their childbearing years. NRR indicates the average number of female
children expected to be born per woman of a group of women beginning life together if they were subject to
the observed rates of mortality and fertility throughout their lifetimes.
If NRR = 1, then it may be said that the current levels of fertility and mortality are such that a group of newly
born females will easily replace itself in the next generation. In such case the population may be said to tend
to remain constant in size.
If NRR > or < 1, then a group of newly born females is expected to be replaced by a larger or smaller number
of females in the next generation subject to current levels of fertility and mortality respectively.

26.26 Measures of Central Tendency.

It is often referred as “Averages”, it is measure which is used to summarize the central tendency of a given set of
data and refereed as a descriptive statistic. It is the measure that describes the location of the centre of a distribution
of the set of data. There are five measures of central tendency namely mean, median, mode, geometric mean and
harmonic mean.
(a) Mean.
If x1, x2, …………xn are ‘n’ observations then mean is defined as:
n
∑ xi
(i = 1)
Mean =
n
Example: 82, 79, 60, 76, 63, 81, 68, 74, 60 and 75 are the pulse rate per minute of 10 healthy individuals.
The mean for this data is:
82 + 79 + 60 + ...... + 75 718
Mean = = = 71.8 per min
n 10
It is unique for the given set of data and it is based on all the observations. In the presence of extreme
observations, particularly if ‘n’ is small, it is not representative of the data. It should be used only for quantitative
type.
(b) Median.
Median depends on number of observations (‘n’). If given observations (data) are ordered in ascending or
descending order of magnitude, then it is the value of the middle observation or the average of the middle
two observations.
Example: 82, 79, 60, 76, 63, 81, 68, 74, 60 and 75 are the pulse rate per minute of 10 healthy individuals.
First arrange the given data in ascending order of magnitude as below
60, 60, 63, 68, 74, 75, 76, 79, 81, 82
If ‘n’ is even, then median is mean of middle two observations = (74 + 75)  /  2 = 74.5
Example: 184, 170, 168, 188, 162, 164, 174, 172, 178, 166 and 188 are the BP(S) of 11 hypertensive
patients of aged 50yrs.
First arrange the given data in ascending order of magnitude as below:
162, 164, 166, 168, 170, 172, 174, 178, 184, 188, 188.
If ‘n’ is odd, then median is value of middle observation = 172
The median is a better indicator of central tendency than the mean when the lowest and highest observations
are far apart and it is also advised when the distribution is skewed. It is unique for the given set of data
and not affected by presence of extreme observations. It can be used for qualitative data, which cannot be
measured quantitatively but can be arranged in ascending or descending order of magnitude.

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(c) Mode.
It is most frequently occurring observation in a given data set. If all the observations are different, then there
is no mode. There may be more than one mode for given a set of data.
The manufacturer of ready-made garments, shoes, etc. use mode to find ideal size.
Example: 184, 170, 168, 188, 162, 164, 174, 172, 178, 166 and are BP(S) of 11 hypertensive patients of
aged 50yrs, the observation 188 has occurred twice and mode is 188.
(d) Geometric Mean (G.M.).
1/
If x1, x2, …………xn are ‘n’ observations then G.M. is defined as G.M. = (X1 ∙ X2 ∙ X3.... Xn) n
It is based on all the observations and unique for the given set of data.
Example: Consider the following data: 5, 7, 6, 9, 7, 8, 10, 40.
1/ 1
G.M. = (5 × 7 × 6 × 9 × 7 × 8 × 10 × 40) 8 = (42336000) /8 = 8.98

Note. It cannot be used if any observation is either negative or zero.

(e) Harmonic Mean (H.M.).
If observations under study are fluctuating too much then harmonic mean can be used. For example, heart
rate and pulse of a patient rate very too much during surgery, in such cases one can use harmonic mean to
represent the patient’s central tendency of heart rate and pulse during the surgery. It is when if x1, x2, ……xn
are ‘n’ observations then H.M. is defined as:
1
H.M. = n
1
∑ x
(i = 1) i

Note. It cannot be used if any observation is zero.

26.27 Measures of Variability.

Variability, dispersion, scatter and spread of observations in a particular data set are synonyms in statistics. It is a
descriptive or summary measure that demonstrates the degree of dispersion in a given data set, that is, it is concerned
with the data set’s width of distribution. Understanding variability is incredibly vital, necessary and crucial whenever
working with data. When combined with measurements of central tendency, it provides a deeper understanding of the
data set.
The commonly used measures of dispersion are range, standard deviation and coefficient of variation.
(a) Range.
Range is the difference between two extreme observations. It is the simplest and crude measure of dispersion,
which is based on two extreme observations that are also prone to chance variation. Range is not a reliable
measure of dispersion; it gives only rough idea about the spread of the data.
(b) Standard Deviation (SD).
If x1, x2, x3 …….xn are ‘n’ observations then it is defined as square root of average of squared deviations
measured from mean and mathematically it is expressed as.
n 2
∑ ( xi − x̄ )
(i = 1)
S.D. = , where x̄ is mean of given set of data.
n
Note. If ‘n’ is less than 30 then replace ‘n’ in the denominator by (n – 1).
It is a very efficient and powerful measure of spread of data about mean. SD increases as spread about mean
increases. If SD is 0, then it indicates that all the observations are identical there is no variation about mean.

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It is based on all the observations and it is a better measure of dispersion than Range. It is independent of
change of origin.
Applications of SD
(i) To determine spread of the distribution about mean.
(ii) To determine the precision / consistency / reliability of the instrument.
(iii) To determine, how well any process is performing.
(iv) SD provides basis for the most of the statistical inference procedures.
(v) According to P.L. Chebyshev’s theorem, irrespective of nature of distribution data under study,
(aa) At least 75% of all observation falls within the range of Mean ± 2 SD.
(ab) At least 89% of all observation falls within the range of Mean ± 3 SD.
(ac) The range (Mean ± 3 SD) can be used to determine normal limits of any biological variables.
(c) Coefficient of Variance (C.V.).
Whenever you want to compare the variability in two or more series of data, which differ in their averages or
measured in different units of measurement C.V. is used. It measures the variation / spread in the data relative
to the size of the mean. It is independent of unit of measurement.
S.D.
C.V. = x 100
Mean

Applications of C.V.:
(i) It can be used to compare the variability in the same characteristic / attribute between two or
more series of data sets.
(ii) It can be used to compare the variability between two or more characteristic / attribute within the
series of data set.
(iii) It can be used to study reliability of an instrument.

26.28 Statistical Inference Procedure.

The following few definitions are very essential to understand the concept about statistical inference procedure.
(a) Population.
The large collection of items / objects / individuals / kinds is called a population. In health research population
can be defined as a group of individuals who are having something in common with respect to place and
time. This is also known as total population or reference population or Universe. In addition to defining the
population, it is very important that investigators define inclusion and exclusion criteria with proper justification
for study participants while designing research protocols.
(b) Study Population.
The need for a study population definition result from the fact that it is frequently not viable or feasible to
study the entire population. Study population is a subset of the universe i.e. it is the collection of individuals
from the universe who are feasible to contact or study.
(c) Sample.
The research question is always about the characteristic or relationships in the defined population which is
generally large and therefore it is never easy or economical or particularly because of time factor to study
entire population, thus there is need to define sample. Sample is a subset of the population.
(d) Sampling.
The sampling is the process of selecting a sample of study units from the defined population or universe.
Choosing research participants is an important decision in any clinical study. There are essentially two

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methods: probability sampling and nonprobability. In contrast to nonprobability sampling, which is considered
unscientific, probability sampling is a scientific method. Probability sampling methods used in health research
include simple random sampling, systematic random sampling, stratified random sampling, cluster sampling,
multistage sampling and multiphase sampling. The non-probability sampling techniques include voluntary
sampling, convenience sampling, quota sampling and snowball sampling. The snowball sampling is used for
conducting qualitative research, with a population that is hard to locate.
(e) Parameter.
It is a descriptive measure that is calculated from the population data, it represents the population’s unchanging
reality which is constant.
(f) Statistic.
It is a descriptive measure that is calculated from the sample data. It is used to estimate unknown population
parameter; hence a sample statistic is known as an estimator. The estimator is not constant; it fluctuates from
sample to sample, depending on the population’s variation, sample size and sampling technique. Therefore,
it is important to understand how these sample estimates fluctuate from sample to sample and name given
to this variation is Standard Error (SE) of Estimate.
(g) Sampling Distribution of Statistic.
Suppose that we draw all possible samples of size ‘n’ from a given population and compute a statistic (e.g.
mean, proportion, standard deviation) for each sample. The set of all possible sample statistics is called a
sampling distribution of the statistic.
(h) Standard Error (S.E.) of Estimates.
It is a measure of dispersion of sampling distribution of statistic. It is a standard deviation of sampling
distribution of statistic which is depending on the population’s variation, sample size and sampling technique
used. It is used to measure the precision of the estimate. It is used in statistical inference procedure.

26.29 Statistical inference Procedure.

It is the scientific procedure whereby inference about population parameter(s) is (are) made with specified degree
of confidence or level of significance on the basis of results obtained from the probability sample drawn from that
population. Using statistical inference procedure one can generalize the sample results to the population with defined
level of confidence or level of significance. There are two statistical inference procedures: Confidence Interval (CI) and
hypothesis testing.
(a) Confidence Interval (CI).
It is calculated using sample data for decided level of confidence. It is an interval estimation population
parameter (ø), it is the range of possible values of ø with desired level of confidence (1- α)100% (0 ≤ α ≤ 1)
and for statistical meaningful confidence level the value of α should be less than or equal to 0.05. There
are two types of CI, a) Two Tailed CI (L, U), ‘L’, ‘U’ are real numbers and indicates lower and upper limits of CI
b) One Tailed CI which includes Lower One-Sided Confidence Interval (-∞ a) and Upper One-Sided Confidence
Interval (a, ∞), ‘a’ is real number. Wider the range of CI lower the reliability of CI. It is used to generalize
sample results to the population for decided level of confidence.
Interpretation of 100 (1 - α)% Two Tailed CI for ø.
Consider a simple case of single population with one parameter, if sample of size ‘n’ is selected from the
population then there are many possible samples of size ‘n’ and let ‘K’ denote the number of possible samples.
Theoretically, if you calculate CI for each of these possible samples then out of these ‘K’ confidence intervals
(L, U) calculated, 100 (1 - α)% will include ø. For example, if α = 5% = 0.05 then 100 (1 − α) % = 95%, out
of these ‘K’ confidence intervals 95% of CI will include ø. In reality we would be drawing only one of these ‘K’
possible samples and ours would be one of these ‘K’ confidence interval; therefore, all practical purpose it could
be concluded based on our sample that we would be 95% confident that CI would include ø. That is, researcher
would be only 5% times unlucky, thus out of ‘K’ possible CI’s only 5% of these CI’s will not include ø.
(b) Hypothesis Testing.
Hypothesis Testing is carried out in 9 steps:

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(i) Formulate hypothesis.

(ii) Collect sample data.
(iii) Specify assumption(s) required to perform certain hypothesis testing procedure.
(iv) Specify chance of committing Type-I error {Level of Significance (α)}
(v) Calculate Test Statistic using sample data and assuming that H0 is true.
(vi) Determine Distribution of Test Statistic under the null hypothesis and find out table value from
standard statistical table for decided Level of Significance (α ) and type of hypothesis.
(vii) Statistical Decision is taken by comparing the value of Test statistic with table value.
(viii) Conclusion
(ix) Clinical significance

26.30 Hypothesis.
It is a statement of belief about population parameter. It is a declarative mathematical statement about population
parameter or some form association, which may be either true or false at a given point of time. To prevent bias,
hypotheses are always formulated prior to the gathering of data. Researcher should spend some time on formulating
it because arbitrary formulation could get you into problems and occasionally lead to a dead end. It may be developed
with the aid of a published paper, with your experience, intuition or guesses or alternatively by conducting pilot research.
Hypothesis has two parts; Null and Alternative Hypothesis and which are compliment of each other. Your study hypothesis
or alternative hypothesis, explains what you planned to conclude after conducting statistical analysis.
Null Hypothesis (Ho).
It is denoted by Ho. It is a statement claiming that there is no difference between the hypothesized value and true
value of population parameter.
Alternative Hypothesis (H1).
It is denoted by H1. It is a statement that disagrees with null hypothesis.
Type of Hypothesis.
Hypothesis may be one tailed or two tailed or equivalence which is decided based on H1. Let us consider simple case
with two populations and µ1 and µ2 are means of population-1 and population-2 respectively.
Two tailed hypotheses: Ho: µ1 - µ2 = 0 against H1: µ1 - µ2 ≠ 0
One tailed hypothesis: Ho: µ1 - µ2 ≥ 0 against H1: µ1 - µ2 < 0, it can also be stated as, Ho: µ1 - µ2 = 0 against
H1: µ1 - µ2 < 0
One tailed hypothesis: Ho: µ1 - µ2 ≤ 0 against H1: µ1 - µ2 > 0, it can also be stated as, Ho: µ1 - µ2 = 0 against
H1: µ1 - µ2 > 0
Equivalence hypothesis: Ho: |µ1 - µ2| = δ against H1: |µ1 - µ2| ≠ δ, where δ is an acceptable difference between µ1
and µ2. |µ1 - µ2| = δ implies - δ ≤ µ1 - µ2 ≤ δ thus it is converted into pair of one tailed hypothesis as follows.
Ho: µ1 - µ2 ≥ δ against H1: µ1 - µ2 < δ
Ho: µ1 - µ2 ≤ -δ against H1: µ1 - µ2 > - δ
It is crucial to remember that choosing the test direction whether to employ a one-tailed or two-tailed test must be
done before data collection.

26.31 Possible Errors in Hypothesis Testing Procedure.

Consider a simple case of single population with one parameter. Using statistical inference procedure is carried out
under the assumption that null hypothesis is true. At the end of statistical analysis null hypothesis may or may not
be rejected based single sample data. But we cannot claim that whatever decision taken based on the sample data
is 100% correct, because there are many possible samples of size ‘n’, whatever decision you take using statistical
inference procedure, always there is some chance of error in decision you make. There are mainly two types of errors

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namely type I error and type II error as shown below.

Types of Error.
Statistical Decision Ho true Ho false
Reject- Ho Type - I error Correct Decision
Do not reject- Ho Correct Decision Type - II error

The hypothesis is formulated based some available information and we do not know whether statement (Ho) is true
or false. Thus, there are two possible outcomes: either the null hypothesis is true or false, in any case Ho may or may
not be rejected at the end of analysis.
Case 1) Suppose null hypothesis is true. Statistical inference procedure may or may not reject the null hypothesis
based on sample data.
(a) Reject- Ho.
Null hypothesis is true and you reject the null hypothesis using statistical inference procedure based on sample
data, then your decision is wrong and error occurs. This error is known as Type-I error. Type-I error is measured
by α and it is a chance of incorrectly rejecting true null hypothesis. It is also known as Level of Significance.
Commonly used values of level of significance (α) are 1%, 5% and 10%. Smaller the value of α higher is the
statistical significance, i.e. smaller the value of α lower is the chance of committing type-I error.
(b) Do not reject- Ho.
Null hypothesis is true and you do not reject the null hypothesis using statistical inference procedure-based
sample data, then your decision is correct.
Case 2) Null hypothesis is false. Statistical inference procedure based on sample data may or may not reject null
hypothesis.
(a) Reject- Ho.
Null hypothesis is false and statistical inference procedure based on sample data rejects the null hypothesis,
then your decision is correct.
(b) Do not reject- Ho.
Null hypothesis is false and fail to reject the null hypothesis using statistical inference procedure-based sample
data, then your decision is wrong and error occurs. This error is known as Type-II error. Type -II error is measured
by β, it is a chance of incorrectly not rejecting false null hypothesis. One of the reasons for Type-II possibly
could be inadequate sample size for proposed research hypothesis. The Type -II error can be controlled at
the time of determining sample size required for conducting a study or it can be determined after analysis by
assuming value of population parameter under H1.
Statistical decision is decided based on the predefined value of α. Researcher would be happy whenever Ho is
rejected because it meant that H1 is concluded, that is, the research hypothesis and chance (α) of incorrectly
rejecting true Ho is known. Whenever Ho is not rejected, there is always a risk that a Type II error happened,
which would make the researcher unhappy because the study hypothesis could not be verified. One of the two
possibilities is that Ho is true or that the sample size is not large to detect a statistically significant difference.
Consider a case, Ho: µ1 - µ2 = 0 against H1: µ1 - µ2 ≠ 0, if Ho is not rejected then there is a chance that Type
error-II might have occurred and it cannot be concluded that there is no difference in means of population-1
and population-2 because just Ho is not rejected. Thus, not rejecting Ho does not mean that Ho can be
concluded.

26.32 p-value.
It indicates exact value of chance of committing Type-I error when Ho is true. For decided value of type-I error (α), null
hypothesis may or may not be rejected whereas p-value, it is exact value of chance of committing type-I error at which
null hypothesis is always rejected. Smaller the value of p-value higher is the statistical significance. p-value less than or
equal to 0.05 considered statistically significant. As sample size increases the p-value decreases, that is, the statistical
significance increases. The following table shows statistical decision for different values of α for p-value of 0.02.

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α p-value Statistical Decision

.05 .02 Rejected
.04 .02 Rejected
.03 .02 Rejected
.02 .02 Rejected
.01 .02 Not Rejected

26.33 Choice of Statistical Inference Procedure.

Various statistical inference procedures are available, which statistical inference procedure to be applied to collected
data to answer the research question mainly depends upon the following points:
(a) Number of variables studied including their scales of measurement and their role and relationship among
themselves.
(b) Number of study groups, study design and research question or hypothesis.
(c) The study groups are independent or related.
(d) Descriptive measure(s) used.
(e) Sample size (s).
(f) Sampling method.
(g) The assumption (s) required for conducting certain statistical inference procedure are met or not.

26.34 Statistical Inference Procedure Applied in Various Situations.

(a) If there is a single population and a single variable of interest that is a quantitative type of data, the
statistical procedures listed below can be used:
100 (1 - α)% Confidence Interval for µ:
Sample mean ± Z1 - α / 2(σ / n ), if sample size (n) ≥ 30
Sample mean ± t1 - α / 2, n - 1 (S / n ), if n < 30 and sample is selected from the population that follows Normal
distribution.
Where Z1 - α / 2 and t1 - α / 2, n - 1 are two tailed Table values corresponding to area (1 - α) from Standard Normal
Distribution and Student’s ‘t’ distribution with (n - 1) degrees of freedom respectively. σ and S indicate population
and sample SD respectively.
Hypothesis testing about mean (µ): Ho : µ = µ0 against H1 : µ ≠ µ0
If n ≥ 30, then apply Z test based on Normal Distribution else apply Student’s ‘t’ test provided parent population
follows Normal distribution.
(Sample mean − µ0)
Test Statistic =
S.D.
n
Reject the null hypothesis at α% of level of significance if absolute value of Test Statistic is greater than or
equal to two tailed Table value (Standard Normal Distribution or Student’s ‘t’ distribution with (n - 1) degrees
of freedom for given α).
Apply Median Test (Non-parametric test), either n < 30 and parent population is not Normal distributed or data
type is Ordinal data.
(b) If there are two independent populations and a single variable of interest that is a quantitative type
of data, the statistical procedures listed below can be used:

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100 (1 - α)% Confidence Interval for µ1 - µ2 :

σ12 σ22
( x̄ − ȳ ) ± Z1 − α/2 × + , if n1 and n2 ≥ 30
n1 n2
If either n1 or n2 or both < 30 and parent populations follows Normal distribution and population variances
are equal.
2 2
S12 S22 2 (n1 - 1) - S1 + (n2 - 1) S2
( x̄ − ȳ ) ± t1 − α/2 × + , where SP = and k = n1 + n2 − 2
n1 n2 (n1 - 1) (n2 - 1)

If either n1 or n2 or both < 30 and parent populations follows Normal distribution and population variances
are not equal.
S12 S2
+ 2
S12 S22 n1 n2
( x̄ − ȳ ) ± t1 − α/2 × + where k =
n1 n2 S12 S22
n1 n2
+
(n1 − 1) (n2 − 1)

Where Z1 - α / 2 and t1 - α / 2, k are two tailed Table values corresponding to area (1 − α) from Standard Normal
Distribution and Student’s ‘t’ distribution with ‘k’ degrees of freedom respectively. σ1 and σ2 are population
standard deviations of populations 1 and 2 respectively. S1 and S2 are sample standard deviations of samples
from populations 1 and 2 respectively. x̄ and ȳ are means of samples from populations 1 and 2 respectively.
n1 and n2 are sample sizes of samples from populations 1 and 2 respectively.
Hypothesis testing about difference between means (µ1 − µ2):
Ho: µ1 − µ2 = 0 against H1: µ1 − µ2 ≠ 0

( x̄ − ȳ ) − (µ1 − µ0)
Test Statistic =
S.E.
If both n1 and n2 ≥ 30 then apply Z test based on Normal Distribution.

σ12 σ22
S.E. = +
n1 n2
Apply Student’s ‘t’ test, if either n1 or n2 or both < 30 and parent populations follows Normal distribution and
population variances are equal.
2 2
S12 S22 (n1 - 1) - S1 + (n2 - 1) S2
S.E. = +
2
where SP =
n1 n2 (n1 - 1) (n2 - 1)

Degrees of freedom = k = n1 + n2 − 2
Apply Student’s ‘t’ test, if either n1 or n2 or both < 30 and parent populations follows Normal distribution and
population variances are not equal.
S12 S22
S.E. = +
n1 n2
S12 S2
+ 2
n1 n2
Degrees of freedom = k =
S12 S22
n1 n2
+
(n1 − 1) (n2 − 1)

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Reject the null hypothesis at α% of level of significance, if absolute value of Test Statistic is greater than or
equal to two tailed Table value (Standard Normal Distribution or Student’s ‘t’ distribution with ‘k’ degrees of
freedom for given α).
Apply Mann-Whitney Test (Nonparametric test), if either n1 or n2 or both < 30 and parent populations do not
follow Normal distribution or data type is ordinal data.
(c) If either there are two related observations in the same Population or two related Populations and
single variable of interest which is quantitative data, the statistical procedures listed below can be used:
Paired ‘t’ test is used:
There are two possibilities, as will be detailed below, if two populations are related:
Two related observations in the same Population. When the same variable in the same Population is observed
at two different occasions, that is, observations are related or dependent.
Two related Populations. When subjects in two populations are one to one matched; for example, two treatment
populations in which subjects are one to one matched between populations, matched case control study, study
unit is a couple, etc.
In each of above explained possibilities the purpose is to determine whether or not a difference exists between
a related pair of observations or measurements. Paired ‘t’ test based on Student’s ‘t’ distribution is applied
only if difference between related pair of observations follows Normal distribution.
Confidence Interval.
S
d̄ ± t1 − α / 2 ×
n
Where d̄, S and n are mean & SD of difference between related pair of observations and samples size
respectively.
k = degrees of freedom = n − 1
t1 − α / 2, k are two tailed Table values corresponding to area (1 − α) from Student’s ‘t’ distribution with (k)
degrees of freedom.
Hypothesis. H0: µd = 0 against H1: µd ≠ 0
Where µd is the mean of difference between related pair of observation in the defined study population.
( d̄ − µd )
Test Statistic =
S
n
Where d̄, S and n are mean & SD of difference between related pair of observations and samples size
respectively.
k = degrees of freedom = n − 1
Reject the null hypothesis at α% of level of significance, if absolute value of Test Statistic is greater than or
equal to two tailed Student’s ‘t’ distribution Table value corresponding to area (1-α) with ‘k’ degrees of freedom.
Wilcoxon Matched Pairs Signed Ranks Test is applied either difference between related pair of observations
do not follow Normal distribution or data type is ordinal data.
(d) If there are more than two populations which are independent and a single variable of interest that is
a quantitative type of data, the statistical procedures listed below can be used:
Analysis of Variance (ANOVA) is applied when:
No of populations is K (K > 2).
K populations are normally distributed with equal variances.
Hypothesis for ANOVA is H0: µ1 = µ2 = µ3 ………. = µk against H1: At least one population mean is different from

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the rest
Where µ1, µ2, µ3 …………………., µk are K population means.
Kruskal-Wallis Test is applied either above mention assumptions for ANOVA not satisfied or data type is Ordinal
data.
(e) If there is a single population and a single variable of interest that is a qualitative type of data, the
statistical procedures listed below can be used:
100 (1 − α)% Confidence Interval for π:

π × (1 − π)
Sample proportion (p) Z1− α / 2 ×
n
Where π is population proportion, Z1− α / 2 is two tailed Table values corresponding to area (1-α) from Standard
Normal Distribution and ‘n’ is sample size.
Hypothesis testing about π: Ho: π = π0 against H1: π ≠ π0
(P - π0)
Text Statistic = π0 × (1 − π0)
n
Where π0 hypothesized value population proportion under Ho.
Reject the null hypothesis at α% of level of significance, if absolute value of Test Statistic is greater than or
equal to two tailed Table values corresponding to area (1 − α) from Standard Normal Distribution.
Note.
Sample sizes n should be sufficiently large.
Variable of interest is not rare, that is p should not be close to 0.
(f) If there are two independent populations and a single variable of interest that is a qualitative type of
data, the statistical procedures listed below can be used:
100 (1 − α)% Confidence Interval for π1 − π2:

π1× (1 − π1) π2× (1 − π2)

(p1 − p2) ± Z1− α / 2 × + ,
n1 n2

Where Z1− α / 2 is two tailed Table values corresponding to area (1 − α) from Standard Normal Distribution, π1,
π2 are population proportions, p1 and p2 are sample proportions and n1 and n2 are sample sizes.
Hypothesis testing about π1 − π2 : Ho: π1 − π2 = 0 against H1 : π1 − π2 ≠ 0

(P1 - P2) − (π1 − π2)

Text Statistic = π × (1 − π) π × (1 − π)
+
n1 n2
(n1 × P1 + n2 × P2 )
Where π =
(n1 + n2 )

Reject the null hypothesis at α% of level of significance, if absolute value of Test Statistic is greater than or
equal to two tailed Table values corresponding to area (1 − α) from Standard Normal Distribution.
Note.
Sample sizes n1 and n2 should be sufficiently large
Apply Fisher’s exact test if n1 π1 < 5 or n1 π1 (1 − π1) < 5 or n2 π2 < 5 or n2 π2 (1 - π2) < 5.

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26.35 Applications of Chi-square Distribution.

Chi-square distribution is a continuous probability distribution and derived from the normal distribution. It is a family
of distribution, in which one member is distinguished from one member from based on degrees of freedom.
Note. Degrees of freedom is the number of logically independent observations in a data set. Suppose we want to select
sample of size of 5 using simple random sampling without replacement from the set {a, b, c, d, e} such that one of
the members must be ‘c’. The first four members can be chosen at random, but the fifth observation must be selected
such that sample contains ‘c’, as a result, the degree of freedom for this data set is 4, since the first four observations
can be chosen at random and the fifth observation depends on the choices made for the first four members in the
sample. There are numerous uses of Chi-square distribution, but we’ll focus on the following three here.
To test the null hypothesis that whether two criteria of classification when applied to the same set of data are
independent?
H0: two criterion of classification, when applied to the same set of data are independent.
H1: two criterion of classification, when applied to the same set of data are not independent.
Data. The data on two criterion of classification (variable-1 and variable-2) collected from ‘n’ subjects in the sample
then the data cross classified as shown in the Table-A. In Table-A, there are ‘r’ rows and ‘c’ columns, it is called r by c
contingency table. ‘r’ indicates number of levels of first criterion of classification (variable-1) and ‘c’ indicates number
of levels of second criterion of classification (variable-2).
To test the null hypothesis that whether two or more populations are homogeneous with respect to characteristic of
interest.
H0: k study populations are homogeneous with respect to characteristic of interest.
H1: k study populations are not homogeneous with respect to characteristic of interest.
Data: The data on categorical variable of interest which has ‘r’ levels is collected from ‘k’ samples of sizes n1, n2,
……., nk drawn from the ‘k’ defined populations then the data is cross classified as shown in the Table-A. In Table-A,
there are ‘r’ rows and c = k.
To test the null hypothesis of equality of two or more independent population proportions.
H0: π1 = π2 = ……… = πk (k population proportions are equal)
H1: k population proportions are not equal.
Data. The data on dichotomous variable of interest which has ‘r’ levels (r = 2) is collected from ‘k’ samples of sizes
n1, n2, ……., nk drawn from the ‘k’ defined populations then the data is cross classified as shown in the Table-A. In
Table-A, r = 2 and c = k.
Note. It is a particular case of test of homogeneity.
In order to apply statistical inferences based on Chi-square distribution, we require two criteria of classification, that
is, two variables of interest which are categorical, as shown in Table 26.3.
Data. The data is cross classified with respect to two criterion of classification as shown in the Table 26.2.
Table 26.2 : r by c Contingency Table
Second Criterion of Classification
First criterion of Levels 1 2 . . c Total
classification
1 O11 O12 . . O1c R1
2 O21 O22 . . O2c R2
.
.
r Or1 Or2 . . Orc Rr
Total C1 C2 . . Cc n

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Where Oij indicates observed frequency of the (i, j)th cell (i indicates the level of First criterion of classification and j
indicates the level of Second criterion of classification).
Riis the is the sum of observed frequency of ith row. Cj is the is the sum of observed frequency of jth column. r is the
number of levels of First criterion of classification (rows) and c is the number levels of Second criterion of classification
(columns).
The Test Statistic is calculated using following formula assuming H0 is true.
r c (Oij − Eij) Oij2
Text Statistic = ∑∑ Eij
= ∑∑ Eij
−n
i= 1 j= 1

Ri × Cj
Where Eij = is the expected frequency of (i , j)th cell, calculated under H0.
n
Degrees of freedom = df = (r - 1) (c - 1)
Reject the null hypothesis at α% of level of significance, if value of Test Statistic is greater than or equal to Table value
from Chi-square distribution with degrees freedom (df) for given α.
Note.
Only 20% of cells can have expected frequency less than 5.
If more than 20% cells have expected frequency less than 5, then rearrange the table by clubbing adjacent
rows / columns, which contains cells with expected frequency less than 5 then recalculate expected frequency and
repeat step 2 till condition 1 is satisfied.
Table 26.3 : Criteria of Classification for Chi Square Distribution
Example Variable-1 Variable-2 Test
1 Smoking category Grades of lung cancer Test of independence
Smoking Mild
Not smoking Moderate
Severe
2 Personality type Physical activity category Test of homogeneity
Type-B No
Type-A Mild
Moderate
Severe
3 Cigarettes smoked / day Hypertension status Test of comparison of proportions
0 Yes
1-5 No
6-10
>10
4 Food habit type Dental problem Test of independence
Vegetarian Yes
Non-vegetarian No

26.36 Correlation and Regression Analysis.

(a) Correlation Analysis.
Many times, clinician come across a situation where they are interested to assess the relationship between

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two variables; say ‘x’ and ’y’; various forms of hypothetical relationships between ‘x’ and ’y’ are shown in the
following figures using scatter diagram.

Fig 26.7

Fig 26. 8

Fig 26.9

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Fig 26.10

Fig 26.11

Fig 26.12

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Fig 26.13
Correlation analysis is used for studying the strength of linear between two variables of interest which are
quantitative type of data. The data depicted in Fig 26.7 to Fig 26.10 can be analyzed by Correlation analysis
whereas data depicted in Fig 26.11, Fig 26.12 and Fig 26.13 cannot be analyzed by Correlation analysis
because the relationship doesn’t appear to be linear.
Any one of the variable is labelled as ‘x’ while other variables is labelled as ‘y’. The series of values on two
variables ‘x’ and ‘y’ are represented by x1, x2, x3, ……………., xn and y1, y2, y3, ……………., yn respectively.
It measures the strength of linear relationship between ‘x’ and ‘y’, it is known as Karl Pearson Product Moment
Correlation Coefficient.
Measurements on two variables of interest, say, ‘x’ and ‘y’ on ‘n’ subjects in the sample are denoted by (x1,
y1), (x2, y2), (x3, y3), ……………., (xn, yn), for each subject there is a pair of observations and for ith subject
measurement on two variables ‘x’ and ‘y’ is represented by (xi, yi). Karl Pearson Product Moment Correlation
Coefficient ‘r’ is defined as,
n
1
∑
n i= 1 i
(x − x̄ ) (yi - ȳ )
r=
SD (x) × SD (y)

Where x̄ and SD (x) are mean and SD of 'n' values x series and and ȳ SD (y) are mean and SD of 'n' values
y series.
Note.
If ‘n’ is less than 30 then ‘n’ in the above formula is replaced by (n-1).
Correlation Analysis is carried out under the following assumptions.
‘x’ and ‘y’ are random variables and follows a bivariate normal distribution.
For each value of ‘x’, there is a subpopulation of ‘y’ values which follows normal distribution and similarly
for each value of ‘y’, there is a subpopulation of ‘x’ values which follows normal distribution. Suppose age in
years is labelled as ‘x’ while SBP is labeled as ‘y’, for x = 30 then there are many people with age 30 but
with different values of y (SBP) i.e. there are many possible values of y (SBP) for fixed value of ‘x’, it is known
as subpopulation of ‘y’ values for x = 30.
Variances of all subpopulations of ‘y’ values are equal.
Variances of all subpopulations of ‘x’ values are equal.
‘r’ lies in the range – 1 to 1 (−1 ≤ r ≤ 1), sample correlation coefficient ‘r’ is an estimate of population
correlation coefficient ρ. If r is 0, then there is no linear relationship between ‘x’ and ‘y’ (Fig 26.11). If r = 1,
then there is perfect positive linear relationship between ‘x’ and ‘y’ (Fig 26.7). If r = -1, then there is perfect

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negative linear relationship between ‘x’ and ‘y’ (Fig 26.8). If 0 < r <1, then there is positive linear relationship
between ‘x’ and ‘y’ (Fig 26.9). If -1 <r < 0, then there is negative linear relationship between ‘x’ and ‘y’ (Fig
26.10).
Before interpreting correlation coefficient take the note of following points:
Correlation may be coincidental.
Correlation may be due to the action of third variable.
Even if two variables have a respectable correlation (|r| ≤ 1), that does not necessarily mean that there is
a cause-and-effect link between them, because without background knowledge, it might be challenging to
determine whether “x” influences “y” or “y” effects x and it may be possible that both variables are influenced
by the action of some other variable or variables. However, causation always implies good correlation and hence
correlation analysis based on experimental studies may help to ascertain cause- effect relationship between
the variables.
Regression Analysis.
Let us consider a simple case with two variables only which are quantitative, one of the variables is labelled
as dependent variable(y) and another variable is labelled as independent variable(x), it is also known as
‘predictor’, ‘covariate’, ‘explanatory’ variable. The variable (y) is referred to as a dependent variable since it
depends in some way on the independent variable (x); in this case, the linear relationship is of special interest.
Simple Linear regression: it is used to examine the linear relationship between the dependent variable and
the independent variable, predict the dependent variable using the knowledge of the independent variable and
determine how much the independent variable affects the dependent variable. Regression analysis with two
variables which are quantitative is called a simple linear regression while regression analysis with more two
variables is called a multiple regression. In multiple regression, one of the variables is labelled as dependent
variable (y) which is quantitative while remaining variables are labelled as independent variables which could
be quantitative or categorical or combination of both. Regression Analysis is used for prediction purpose and
explaining system.
In Simple Linear regression, first values of independent variable (x) are pre-selected then for each value of ‘x’
measurement on corresponding dependent variable (y) is recorded, hence x is a non-random variable whereas
y is a random variable. It is recommended to have as large as possible the spread of x values (range).
Most important step in regression analysis is plotting scatter diagram as shown in the Fig 26.7 to 26.13. If
scatter plot looks like Fig 26.11, Fig 26.12 or nonlinear like Fig 26.13, simple linear regression model is not
recommended even though there is a relationship between ‘x’ and ‘y’ (Fig 26.13) but which is “Not Linear”.
Regression Analysis is carried out under the following assumptions:
‘x’ is a non-random variable and y is a random variable.
For each value of ‘x’, there is subpopulation of ‘y’ values which is normal with mean µy‌|x and standard
deviation σy‌|x.
Variances of all subpopulations of ‘y’ values are equal.
The means of all subpopulation’s ‘y’ values lie on the same straight line and it can be mathematically expressed
as µy‌|x = A + Bx, this assumption is known as condition of linearity i.e. the means of subpopulations of
dependent variable increases (or decreases) linearly as independent variable increases (or decreases).
Since for each value of ‘x’, there is the subpopulation of ‘y’ values thus regression analysis using sample data
can predict the mean of subpopulation of ‘y’ values (Y) for given value of independent variable (x) which is an
estimate of population mean µy‌|x.
Regression Model, is nothing but the mathematical relationship between ‘x’ and ‘y’ expressed as:
y = A + Bx +ε,
Where ‘x’ and ’y’ are observed value of independent and dependent variable respectively and ‘A’ and ‘B’ are
known as regression coefficients. ‘A’ and ‘B’ are population parameters (in most of the books ‘A’ is denoted by
α and ‘B’ is denoted by β but same symbols we have used for denoting type I and type II errors just to avoid
confusion, here ‘A’ and ‘B’ are used). ‘A’ is known as a Y-intercept; this is a point on Y–axis through which

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regression line passes. ‘B’ is known as regression coefficient which indicates the slope of the regression line,
it also indicates on an average the amount of increase (if B > 0) or decrease (if B < 0) in dependent variable
for each unit increase in independent variable and ε is known as an error term (y - µy‌|x), which indicates the
amount of deviation of observed value y from the mean (µy‌|x ) of the subpopulation of y values for a given
value of x, that is, it is the difference between observed and predicted value of y by the regression model.
Under the assumption (d), µy‌|x = A + Bx. Let Y = µy‌|x, it is also known as the predicted or estimated value
of ‘y’ for a given value of ’x’, it is the mean of subpopulation of ‘y’ values for given value of independent
variable (x).
Regression coefficients A, B and error term ε are estimated using sample data from the defined population.
Consider sample data on n members; if (x1, y1), (x2, y2), (x3, y3), ……………., (xn, yn) are n pair observations,
where x1, x2, x3, ………….. xn are pre-selected values of independent variable(x) and corresponding values of
dependent variable(y) are y1, y2, y3, ………….. yn respectively. Using sample data, a Regression Line ‘y’ on ‘x’
is fitted or obtained using principal of Least Square Method it determines ‘a’ and ‘b’ which are estimates of
‘A’ and ‘B’ respectively. The Regression equation is ŷ = a + bx, where is ŷ an estimated or predicted value of
y for given value of x.
Consider the following few hypothetical examples:
Regression Line ‘SBP’ on ‘age’ is:
SBP = 100 + 0.5*Age
On an average SBP is increased by 0.5 mm Hg (b = 0.5) for each unit increase in age.
Regression Line ‘SBP’ on ‘Physical Activity’ is:
SBP = 110 - 0.2*Physical Activity
On an average SBP is decreased by 0.2 mm Hg (b = 0.5) for each unit increase in Physical Activity.
Regression Line ‘SBP’ on ‘age’ and ‘Physical Activity’ is:
SBP = 102 + 0.4*Age - 0.1*Physical Activity
On an average SBP is increased by 0.4 mm Hg (b1 = 0.4) for each unit increase in age while Physical Activity
is held constant and on an average SBP is decreased by 0.1 mm Hg (b2 = 0.1) for each unit increase in
Physical Activity.
Multiple regression allows to examine the average amount of influence each independent variable has on the
dependent variable (y) when the other independent variables in the model are held constant.
Goodness of Fit. Before interpreting regression analysis one must check for goodness of fit which indicates
how well the sample data fits the proposed regression model. It compares the observed values of ‘y’ with its
predicted values (ŷ) using the fitted regression model to the observed data (sample data).
Before assessing goodness of fit, check scatter plot for linear relationship otherwise sometimes measure of
goodness of fit may be misleading particularly if the relationship is not linear. In addition to this, must check
for residual plot that is the scatter plot of independent variable (x) vs residuals ( ^ε ), regression model provides
a good fit to the given data, if the values of residuals ( ^ε ) are not related to the values of ‘x’. The residual plot
can be used to check the assumptions mentioned above required for regression analysis and can be used to
identify outliers or extreme observations.
In a simple linear regression model goodness of fit is determined by R2 is nothing but square of correlation
coefficient (r) as per formula of r, it is also called as Coefficient of Determination; it measures the percentage
of total variation present in the dependent variable ‘y’ that is explained by (simple linear regression model)
linear relationship between the observed values of ‘x’ and ‘y’ and R2 lies in the range 0 to 1. For example,
if R2 = 0.81 or 81%, it can be said that 81% of the total variation existing in the dependent variable y has
been explained by the regression line. Larger the value of R2, better the regression model fits the observed
data. The hypothesis test regarding goodness of fit for simple linear regression model can be tested using
Chi-square goodness of fit test.

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Suggested Reading.
1. Bhalwar R, Vaidya R, Gupta R, Tilak R, Kunte R. Textbook of Public Health and Community Medicine, Pune.
Publisher: Department of Community Medicine, Armed Forces Medical College, Pune in collaboration with WHO India
Office; 2009.
2. Punch KF. Introduction to Social Research: Quantitative & Qualitative Approaches. London, England: SAGE
Publications; 1998.
3. Office of Registrar General and Commissioner, India. Ministry of Home Affairs, Goverment of India. Census of
India [Internet]. 2011 [cited 2024 Jan 3]. Available from: https: //censusindia.gov.in /census.website /
4. Inclusion and exclusion criteria in research studies: definitions and why they matter. Cecilia Maria Patino, Juliana
Carvalho Ferreira. J Bras Pneumol. 2018;44(2):84-84.
n

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Chapter
XXVII
GENERAL PRINCIPLES OF PREVENTION & CONTROL OF
COMMUNICABLE DISEASES (INCLUDING NOTIFICATION,
DISINFECTION METHODS & PRACTICES)
27.1 General Prevention and Control Measures against Diseases.
The fields of preventive medicine and public health share the goals of promoting general health, preventing specific
diseases, preserving health, restoring health when it is impaired, minimizing suffering and distress and applying the
concepts and techniques of epidemiology to attain these goals. Disease results from a complex interaction between
man, an agent (or cause of disease) and the environment. The objective of preventive medicine is to intercept the
cause and thereby the disease process, thus not only helping individuals to improve their health but also the health
of the population.

27.2 Classification of Diseases.

Diseases can be broadly classified into two broad groups.
(a) Communicable Diseases.
These are illnesses due to invasion by specific microorganisms or their toxic products, arising through transmission
of the agents or their products from reservoirs to susceptible hosts either directly or indirectly.
Communicable diseases can be classified according to the etiological agent. They can also be classified as per
the mode of transmission (how an infectious agent / pathogen, can be transferred from one person, object or
animal to another) as they have definite chain of transmission. Communicable diseases spread from the source
or reservoir through a route up to the susceptible host or recipient. They can also be classified as per the route
of entry and exit of the infecting organism (Table 27.1).
Table 27.1 : Modes of Transmission of Diseases
Modes of Transmission Routes of Transmission
Contact transmission Direct and indirect
Vehicle transmission Water, food, milk, etc.
Vector transmission Arthropods
Air-borne transmission Droplet, droplet nuclei and infected dust
Animal-borne transmission Zoonoses
Transplacental transmission
(b) Non-Communicable Diseases.
These are diseases, which are not caused by specific microorganisms and are not spread from one person to the
other. These diseases may be constitutional, metabolic, allergic, degenerative, neoplastic, psychological or traumatic.

27.3 Principles of Prevention and Control.

The aim of epidemiological investigation and intelligence is to prevent and control the entry / onset and spread of
diseases at a community level. Knowledge of disease epidemiology in terms of causes / sources (aetiology), agent and
host characteristics, contact patterns, routes and modes of transmission, natural history (course of the disease) and
incubation period helps to decide the preventive measures, which are best suited to disrupt the chain of transmission
within the given economy of effort. It is not necessary to know everything about the natural history of a disease to
initiate preventive measures. Removal / elimination of a single known essential cause may be sufficient to prevent a

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disease. However, the better the knowledge of these factors, the greater is the amenability of the disease to prevention
and control.
The principles of prevention and control are applicable to Non-Communicable Diseases as well as Communicable
Diseases. In this chapter general preventive and control measures against Communicable Diseases will be discussed.

27.4 Natural History of Disease.

The term ‘natural history of disease’ is applied to the disease course in humans, which may vary within a given range
among different hosts. The disease process too is dynamic and evolves in a human. Therefore, the natural history
of a disease is divided into three phases for ease of understanding, i.e. the pre-pathogenic, the pathogenic and the
post-pathogenic phase.
(a) Pre-Pathogenic Phase.
This phase refers to the period before the onset of the disease in human host. The disease agent has not yet
entered the human but the factors which favour its interaction with the human host are already existing in the
environment. Humans are constantly in the midst of disease-causing agents but only when the balance between
the agent, host and environmental factors, i.e. the three components of the epidemiological triad is disturbed
that the disease process gets initiated.
(b) Pathogenic Phase.
This phase begins with the entry of disease agent in the susceptible human host.
(i) Sub-Clinical Phase.
The initial stage when the agent enters the human host pathologic changes occur, but without overt signs
and symptoms of the disease, due to factors such as good host resistance; the disease remains below the
clinical horizon.
(ii) Clinical Phase.
Once the agent becomes established and multiplies, it induces tissue and physiologic changes in the host.
At this stage, disease process crosses the clinical horizon and becomes clinically apparent. The end result
of the disease process may be either complete recovery or it may take a chronic course, with complications
or residual disability or may even lead to death.
(c) Post-Pathogenic Phase.
A disease process may eventually culminate in either complete recovery or residual disability or death. Disabilities
are caused by sequelae or complications of a disease. This phase is marked by the end of the disease process,
i.e. after the disease agent is cleared from the body.

27.5 Levels of Prevention and Modes of Intervention.

The modern concept of health as ‘the state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity’ warrants the application of preventive and control measures in the pre-pathogenic,
pathogenic and post-pathogenic phases in the natural history of disease. The various levels of prevention in relation
to the periods in the natural history of disease are shown in Table 27.2. Intervention can be defined as an attempt
to intervene or interrupt the usual sequence in the development of disease in human. This may be by provision of
treatment, education, help or social support.
(a) Primordial Prevention.
The prevention of the emergence or development of risk factors in countries or population groups in which they
have not yet appeared. It is the earliest prevention modality and consists of strategies which reduce the risk
from social and environmental determinants of diseases that promote disease onset. It is targeted towards an
entire population, hence, is generally implemented through legislature and national / state policies. This stage
of prevention targets the underlying stage of disease in the natural history. The main intervention in primordial
prevention is through individual and mass education.
(b) Primary Prevention - Pre-Pathogenic Phase.
The objective of primary prevention is to prevent a disease from ever occurring by preventing the entry of

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the disease agent in the body during the pre-pathogenic phase. Primary prevention measures are aimed at a
susceptible population or healthy individuals. The various intervention at this stage to prevent the occurrence
of disease in humans are by health promotion and specific protection.
(i) Health Promotion.
Health promotion is the process of enabling people to increase control over and to improve health. This can
be achieved by broad measures to improve the standard of living like socio-economic improvement, healthy
housing conditions, adequate nutrition, clothing, healthy living and working environments and behavioural
changes.
(ii) Specific Protection.
Primary prevention can also be achieved through specific interventions against particular disease-causing
agents like immunization, environmental sanitation, use of specific nutrients, protection against occupational
hazards, accidents, protection from specific carcinogens or allergens and so on.
(c) Secondary Prevention - Pathogenic Phase.
Secondary prevention measures are applied in the pathogenic phase when the disease agent has entered
the body. It can be defined as “actions which halt the progress of a disease at its incipient stage and prevent
complications” Its primary target are healthy appearing individuals with subclinical forms of the disease. The
specific interventions are early detection like screenings e.g. Papanicolaou (Pap) smear for Cancer Cervix and
adequate treatment.
(i) Early Detection and Treatment.
It aims to prevent dissemination of the infection in the community, thus reducing the possible contact of
healthy individuals with infected people. This measure limits occurrence of secondary cases and further
propagation of the disease.
(ii) Early Case Detection.
The methods employed are as follows:
(aa) Individual or Mass Contact Tracing.
(ab) Screening surveys.
(ac) Selective examination of High-Risk Groups.
(ad) Routine Surveillance.
(d) Tertiary Prevention - Post-Pathogenic Phase.
Tertiary prevention measures are applied in the post-pathogenic phase, when the disease agent has caused
permanent damage to the body. It is implemented in symptomatic patients and aims to reduce the severity of
the disease as well as of any associated sequelae. The interventions at this stage are disability limitation and
rehabilitation.
(i) Disability Limitation.
The objective is to halt the further progress of the disease process by instituting adequate therapy to
limit the disability, prevent further complications through physiotherapy and other techniques of physical
medicine. It aids in early rehabilitation of the patients, thus, preventing the individual from lapsing back
into ill health, both physical and mental and protects the community from social disruption and diseases.
(ii) Rehabilitation.
It aims at restoring and retraining a patient to live and work within the limits of his disability but to the
maximum of his residual capacity.

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Table 27.2 : Levels of Prevention

Phase of Natural History of Disease Levels of Prevention Modes of Intervention
Pre-pathogenesis Primary Prevention Health Promotion
Specific Protection
Pathogenesis Secondary Prevention Early Diagnosis and Treatment
Post-pathogenesis Tertiary Prevention Disability Limitation
Rehabilitation

27.6 Prevention vs Control of Disease.

(a) Prevention.
It entails measures to prevent the onset or initial entry of the disease agent or toxins into hosts / humans or a
community. Preventive measures are anticipatory actions to remove the possibility that a disease will ever occur.
(b) Control.
It means arresting the further progress and propagation of the disease-causing agent, after its entry in the
community such that it ceases to be a public health issue. Control entails actions to prevent disease-in healthy
individuals in the affected community.
(c) Elimination of Disease.
Reduction of the incidence of a specified disease in a defined geographical area to zero as a result of deliberate
efforts and continued intervention measures. Example: Neonatal Tetanus.
(d) Elimination of Infection.
Reduction of the incidence of infection caused by a specific agent in a defined geographical area to zero because
of deliberate efforts and continued measures to prevent re-establishment of transmission. Example: Measles,
Poliomyelitis.
(e) Eradication.
Permanent reduction to zero of the worldwide incidence of an infection caused by a specific agent as a result
of deliberate efforts and intervention measures are no longer needed. Example: Smallpox.

27.7 Control Measures.

Disease control measures mean the management of persons, animals, goods and facilities that are infected with,
suspected to be infected with, exposed to or suspected to be exposed to an infectious agent in a manner to prevent
transmission of the infectious agent to humans. These measures aim at removal of the causative agent from the
source or reservoir, i.e. from the site of production or multiplication / transformation, respectively. It may also aim to
destroy the agent soon after it’s exit from the source / reservoir or by interrupting the route of transmission. Action at
these levels requires knowledge of the source or reservoir, various links in the chain of transmission and different host
related factors which make it susceptible. Control measures broadly fall under three main heads.
(a) Control of Source and / or Reservoir of Infection.
A reservoir may be a person, an animal, an arthropod, plant, soil or substance in which an infectious agent
lives and multiplies. It is the natural habitat of the infectious agent. The first link in the chain of communicable
disease transmission is the existence of an infected person, case (clinical or subclinical) or carrier, who continues
to shed the infective agent and is identified as the primary source of infection. The general measures of control
at this stage are as follows:
(i) Early Detection of Cases.
The objective of case detection is to identify individual with the disease. Case detection can be active like
during Outbreak Investigation or passive like in Routine Surveillance. Case definition is used to detect cases,
which is a statement of features both necessary and sufficient to classify a sick individual as having the

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infection or disease.
(ii) Notification.
A notifiable disease is any disease that is required by law to be reported to government authorities. The
collation of information allows the authorities to monitor the disease and provide early warning of possible
outbreaks.
(iii) Isolation.
It is the separation of the infected individual from the healthy population by use of infection prevention and
control precautions. It may range from source isolation like confinement of infected person as in air-borne
infection and barrier nursing like in Dengue Fever to Protective isolation or reverse barrier nursing where
the patient being immune-compromised requires protection.
(iv) Treatment.
It is the action or way of treating a patient or a condition medically or surgically and care to prevent, cure,
ameliorate or slow progression of a medical condition. It aims at eliminating the disease-causing agent
from the body to make the person non-infective.
(v) Quarantine.
Quarantine is the separation and restriction of movement or activities of persons who are not ill but who
are believed to have been exposed to infection for a period not longer than the longest incubation period of
the disease, for the purpose of preventing transmission of the disease. It is a restriction on the movement
of people, animals and goods which is intended to prevent the spread of disease or pests.
(vi) Surveillance.
It is the ongoing and systematic collection, analysis and interpretation of health data in the process of
describing and monitoring a health event. This information is used for planning, implementing and evaluating
public health interventions and programs.
(vii) Sterilization.
It is a process of complete elimination or destruction of all forms of microbial life (both vegetative and
spore forms), which is carried out by various physical and chemical methods.
(viii) Disinfection.
It is a process that eliminates vegetative forms of all pathogenic micro-organisms from a surface or an
area, but may not kill bacterial spores.
(b) Block the Channels of Transmission.
This may be achieved by general environmental control, specific control measures such as safe water supply,
sanitary disposal of sewage and other waste products, high standard of food hygiene, vector control, personal
hygiene, proper ventilation, prevention of overcrowding and dust control.
(c) Protection of Susceptible Population.
This is carried out by immunization, chemoprophylaxis, instituting behavioural changes, access to nutrition, health
education, etc. Susceptible persons are more likely than others in the general population to experience the
disease.

27.8 Control Measures on the Occurrence of an Infectious Disease.

In public health practice, the actions to control the communicable diseases have to be crystallized into the form of a
‘drill’ which should involve no elaborate thought or preparation. The usual sequence of actions to control the spread
of an infectious disease is as follows:
(a) Early Detection of Case.
(b) Isolation of the case for the entire period of infectivity.
(c) Prompt and effective treatment of cases.

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(d) Disinfection of discharges and fomites

(e) Notification.
(f) Surveillance of contacts.
(g) Mass immunization of the vulnerable community.
(h) Investigation of the current outbreak.
(j) Survey to assess endemicity.

27.9 Legislative Control.

Statutory legislation has been made at the central, state and district levels or bye laws at municipal or cantonment
or peripheral rural levels for imposing legal obligations on people to facilitate control actions. ln the Armed Forces,
notification to higher authorities and other actions in connection with communicable diseases are to be carried out
in accordance with Regulations for the Medical Services for the Armed Forces (RMSAF), 2010, Chapter XIII and under
the provisions of the Cantonment Act 2006, in so far as it pertains to the civil population in the cantonments. Similar
action has been evolved and enforced by statutes to prevent and control occupational diseases like effects of ionizing
radiations. More and more disease-causing agents are being included in national and international surveillance
procedures with a view to prevent and control them. The list of notifiable communicable diseases in the Armed forces
is given here under. The list of notifiable industrial diseases is given in Chapter XV. The notification form, Armed Forces
Medical Services Form-73 (AFMSF-73), is used for reporting the infectious case.

27.10 Notifiable Diseases.

Diseases which are notifiable in the Armed Forces are arranged in groups according to the procedures to be adopted.
These are shown in Table 27.3.
Table 27.3 : Notifiable Diseases in the Armed Forces
Groups Diseases Measures
‘ A’ Cholera, By Signal reported to Col Med (Div), Brig Med Corps / MG Med (Area Command)
and DGMS Army (and equivalent in IN and IAF) and Director of Health Services
Yellow Fever
of the state.
In addition, the notification form AFMSF-73 will be forwarded to MO in charge unit
and Col Med (Div), with a copy to Brig Med Corps / MG Med (Area Command)
and equivalent in IN and IAF.
The following information is given in the Signal:
(a) Disease
(b) Date of occurrence
(c) Rank and unit of patient.
(d) Probable source of infection
(e) Preventable precautions taken.
(f) Number of deaths since last report
(g) Whether the disease is prevalent in local civil population, town or district.

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‘B’ Acute poliomyelitis, On the AFMSF-73 notification form in Quintuplicate.

Anthrax,
Cerebrospinal Distribution:
fever, Diphtheria,
(a) 01 x copy for MO in charge unit.
Encephalitis,
(b) 01 x copy for Col Med (Div)
Enteric group of
(c) 01 x copy each for Brig Med Corps / MG Med (Area Command)
fevers,
(d) 01 x copy for DGMS Army (and equivalent in IN / IAF)
Epidemic influenza,
(e) 01 x copy to be retained in the hospital.
Epidemic pneumonia,
Food poisoning
outbreak,
Plague,
Relapsing fever,
Typhus and other
rickettsial diseases
‘C’ Chickenpox, On the AFMSF-73 notification form in Quadriplicate.
Dysentery,
Hepatitis B, Distribution:
Malaria, (a) 01 x copy for MO in charge unit.
Measles, (b) 01 x copy for Col Med (Div)
(c) 01 x copy for Brig Med Corps / MG Med (Area / Command) (and
Mumps,
equivalent in IN / IAF)
Pulmonary (d) 01 x copy to be retained in the hospital.
Tuberculosis,
Scarlet fever,
Whooping cough

27.11 Notification Procedure.

Copies of the notification form (AFMSF-73) are prepared in respect of all ranks including families and civilians by the
medical officer in charge of the case in collaboration with the medical officer in charge of the unit and submitted to
the Commanding Officer (CO) hospital who then distributes them as above and retains one copy for record. When a
case has been received as a transfer from another station, a note is made in the general remarks’ column stating the
station from which the case was transferred.
Only information of interest or practical value regarding the source of infection, preventive measures, etc. is entered
on the form. Medical officer in charge of the unit should be informed as soon as possible by telephone about the
notifiable disease.
In the event of an outbreak attaining epidemic proportions, it will suffice if the number of cases by units or sub-units is
submitted, whereas names of individuals may be omitted. A detailed special report of the outbreak should be submitted
by the Col Med (Div) to the Maj Gen Med (Area / Command) and equivalent in Indian Navy (IN) and Indian Air Force
(IAF) for onward transmission to the concerned DGMS.
The occurrence of the diseases amongst personnel of the Armed Forces as per the notification requirement of Integrated
Disease Surveillance Programme (IDSP) should be notified by the Commanding Officer (CO) / Commandant service
hospital to the local civil health authority. Details of rank, name, number (and any other sensitive data) required in
notification form, need not be given in the reports.

27.12 Alteration in Diagnosis.

In the event of an alteration of diagnosis becoming necessary, all those originally notified should be informed accordingly.

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A new notification form should be rendered if the new diagnosis is that of a notifiable disease.

27.13 Other Infectious Diseases.

Infectious diseases other than those in Group ‘A’ to ‘C’ should, if occurring in epidemic form, be reported in manuscript
to the Col Med (Div) and Brig Med Corps / MG Med (Area / Command) and equivalent in IN and IAF. They should be
informed of the progress of such epidemics. In the event of occurrence of any infectious diseases as mentioned in
Table 27.3 or other infectious diseases occurring in epidemic form among the civil population in localities adjacent to
those occupied by the troops and likely to spread to the troops, manuscript reports should be made to the Col Med
(Div) (equivalent in IN and IAF) and Brig Med Corps / MG Med (Area / Command) (equivalent in IN and IAF).

27.14 Disinfection – General Principles: Definitions.

(a) Disinfection.
Disinfection is defined as a procedure, the result of which is transient and that eliminates or kills microorganisms
and / or deactivates undesirable viruses that are carried by inert contaminated environments.
(b) Antiseptics.
Antiseptics are defined as antimicrobial substances that are nondamaging to living tissue / skin while reducing
the possibility of infection, sepsis or putrefaction.
(c) Dis-infestation.
This means destruction of undesirable animal forms, especially arthropod ectoparasites present upon the
persons or on domestic animals. The term also includes destruction or avoidance of endoparasites like helminths
and rodent destruction. However, in practice this term mainly refers to the destruction of ectoparasites like
lice, sarcoptes, bugs and fleas and their ova and eggs. Dis-infestants are the agents used for disinfestation.
Dis-infestants which are specially used against arthropods are called ‘insecticides’ and ‘acaricides’ depending
on their special values in practice. A number of disinfectants are dis-infestants if used in adequate strength,
but all dis-infestants or insecticides are not disinfectants.
(d) Detergents.
These are surface cleansers and degreasers. They dissolve grease and oily matter and thereby help removal
of dirt etc. from any material when rinsed or washed with water consequently removing the micro-organisms
sheltered by grease and dirt.
(e) Deodorants.
These are substances, which mask the unpleasant odours without having disinfecting or antiseptic powers.
Many disinfectants and antiseptics mask putrefactive odours also.

27.15 Objective.
These processes aim to break the chain of the spread of communicable diseases. They are used as supplementary
measures to environmental sanitation. The main objective can be achieved with minimum effort and maximum success
if the aetiology and mode of transmission of each disease is clearly understood, ecology and bionomics of their agents
are known, procedures are rational and specifically directed against the paths of its spread and not employed merely
as placebos to appease the community.
Much time, energy and money are wasted on disinfection of places which only require ventilation and cleansing. Some
situations may need only disinfection and other may need only disinfestation while a few may need both. Agents and
procedures adopted will, therefore, depend upon the situation as well as nature of the problem. Disinfestation and its
procedures are discussed in Chapter XXXIV under the appropriate heads.

27.16 Disinfection Procedures.

Although the virulence of the pathogenic organisms is at its height just when they leave the host, some organisms
retain it at a high level for a long time after their exit from the host, under favourable conditions. Thus, all spores and
some bacteria, like tuberculosis, survive and retain their virulence for a long time outside the host; some intestinal
pathogens have a long saprophytic life and some viruses are markedly tenacious extracorporeally.

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(a) Concurrent Disinfection.

“Concurrent disinfection” indicates the application of disinfectant immediately after the discharge of infectious
material from the body of an infected person or after the soiling of articles with such infectious discharges, all
personal contact with such discharges or articles being prevented prior to disinfection. Concurrent disinfection
destroys maximum number of pathogenic organisms when their virulence and infectivity are maximum.
(b) Terminal Disinfection.
Terminal disinfection has the objective of preparing complete rooms or areas for subsequent patients or
residents for them to be treated or cared for without the risk of acquiring an infection. This includes the
vehicle or ambulance, the wheelchairs and stretcher used by the patient. Terminal disinfection exterminates
the residual infection likely to have been left behind by the patient. This is either local or complete.
(i) Local.
It is the disinfection of the bedding and the bedsheet occupied by the patient, the walls, floor, furniture
including the kit box, shelf, lockers and their contents and all other surfaces or articles within 2 meters
all around the bed.
(ii) Complete.
It is the disinfection of the whole room and all its contents.
(c) Prophylactic Disinfection.
It means chemical treatment or boiling of water, pasteurization of milk, washing of hands and so on.
While greater reduction in dissemination of infection is achieved by immediate or concurrent disinfection,
terminal disinfection is definitely complementary. However, as the infective propensity for non-sporing bacteria
rapidly diminishes in their extra-corporeal existence, properly carried out concurrent disinfection minimizes the
requirement of terminal disinfection.

27.17 Classification of Disinfecting Agents.

(a) Natural Agents.
(i) Fresh air
(ii) Sunlight
(b) Physical Agents.
(i) Dry Heat.
(aa) Burning
(ab) Hot dry air
(ac) Contact heat-ironing
(ii) Moist Heat.
(aa) Boiling (with or without chemical agent)
(ab) Steaming-current steam and steam under pressure
(iii) Radiation.
(aa) Ionizing radiation
(ab) Ultraviolet rays
(c) Chemical Agents.
(i) Solids
(ii) Liquids
(iii) Gases

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(iv) Aerosols
It will not, however, be correct to suppose that the action of any agent is circumscribed in or confined to its
particular group only. Many disinfectants act both by physical action and chemical action, for example soap acts
by physically removing the grease and dirt which shelter the organisms as well as by its chemical action. Often,
in practice, disinfection by chemical agents can be complemented or supplemented by physical agents. Thus,
clothing can first be soaked in a chemical agent, then steamed and finally washed, dried in the sun and ironed.
Similarly, disinfection by boiling can be accelerated or aided by the addition of a chemical or soap.

27.18 Natural Agents.

Fresh air dilutes the bacterial content in enclosed places and desiccates micro-organisms by dehumidification. Sunlight
disinfects due to the desiccating effect of its heat rays and the action of its ultraviolet rays. Indeed, this disinfecting
power of the sun has made life possible in insanitary tropical and subtropical environments. Although these agents
are slow in action and frequently unreliable owing to the resistance of certain organisms, they are valuable adjuncts
to artificial methods. In their absence the saprophytic life of all germs is prolonged. Thus, during epidemics, cinema
theatres act as foci for the dissemination of infection since they usually admit no direct sunlight and little fresh air.
whilst respiratory moisture delays desiccation.

27.19 Physical Agents.

Heat kills ectoparasites and micro-organisms by coagulating their protoplasm. It may be employed in a dry or moist form.
To ensure perfect sterility, the former demands a higher temperature and / or longer exposure than the latter. Heat,
especially in the moist form, is the only physical agent that is reliably used for artificial disinfection and disinfestation
in preventive medical practice.
(a) Dry Heat.
Burning is a certain and rapid method of disinfecting but has only a limited scope. It may, however, be the only
available method on active service. For example, clothing contaminated by excreta of cholera patients may be
burnt or the ground which has been contaminated by an anthrax carcass may be disinfected by burning straw
or oil on the top of it. Contact heat applied by pressing irons over clothing may be used to disinfest louse and
mites. Hot air ovens are used to disinfect glass ware such as petri dishes, sharp instruments, swabs, dressing,
chalk, Vaseline etc. The temperature of the air in the oven should be maintained at 60°C for at least one
hour.
(b) Moist Heat.
Boiling is quite effective in killing all non-sporing organisms, Spores being very resistant require boiling for an
hour and a half. Boiling is largely used for sterilizing instruments and is useful for disinfecting bed clothing,
underwear and similar articles. Blood stains become fixed by boiling owing to the coagulation of protein; these
should, therefore, be first removed by soaking in cold soapy water. Another disadvantage of boiling is that it
is unsuitable for thick bedding of woollens. The effect of boiling can be enhanced by adding soap or washing
soda to water. Steaming is the most efficient procedure of disinfection and dis-infestation. The usual method
is to expose the infected articles to ‘saturated steam’ in ‘current steam’ or ‘under pressure’.
(c) Radiation.
(i) Ionizing Radiation.
Ionizing radiation is a form of energy that acts by removing electrons from atoms and molecules of
materials that include air, water and living tissue. Ionizing radiation can travel unseen and pass through
these materials. Gamma radiation or electron beams have the advantage of combining great penetrative
power with little or no effect on the object to be sterilized. Bandages, catgut, dressing and surgical
instruments may be sterilized by ionizing radiation. These methods are used commercially. The isotope
used is Cobalt 60.
(ii) Ultraviolet Rays.
Ultraviolet rays delivered from an apparatus hung in the ceiling at the entrance of special purpose rooms
like the one in which premature infants are kept or in operation theatres, temporarily disinfect the objects
and air entering inside. Some halogen, fluorescent and incandescent lights emit ultraviolet rays.

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(d) Steam Disinfection.

Steam in contact with boiling water from which it is generated has the temperature of 100°C and is called as
‘saturated steam’. When it comes in contact with colder objects it immediately condenses and every gram of
it transfers a latent heat of 537 calories to that object and it contracts to about 0.0015th of its volume and
creates a partial vacuum. To fill the empty space more steam immediately rushes, condenses releases the
latent heat and again creates a partial vacuum. Continued repetition of this process achieves penetration of
steam throughout the mass of the fabric. Heat is thus transferred to the exposed articles until its temperature
is raised to 100°C. Intimate contact with saturated steam is instantly fatal to all non-sporing organisms.
Steam, however, gets mixed with the air contained in the clothing. Air absorbs heat, impedes intimate contact
of steam with the fabric and being a bad conductor of heat, insulates clothing and reduces penetration and
thus disinfects much less efficiently than pure steam. This difficulty can be overcome by extracting air from
the disinfection chamber before introducing steam into it or by a downward displacement of air by steam
introduced at the top of the chamber.
Steam being lighter than air when introduced from below into a chamber, it naturally ascends taking the line
of least resistance between the layers of the clothing instead of through their texture, without displacing the
air contained in it. If admitted at the top of the container it forms a supernatant layer and if it cannot escape
from above descends gradually layer by layer through the fabric. If steam continues to enter from the top, all
the air is pressed out of the fabric and the container through an escape hole at the bottom of the chamber.
Finally, the steam completely penetrating throughout the mass of textiles rapidly raises the temperature of
everything in the container to 100°C. The ‘Serbian barrel’ shown in Fig 27.1 demonstrates this ‘downward
displacement of air’ principle with clarity and simplicity.

Fig 27.1 : Serbian Barrel

Steam introduced at atmospheric pressure is known as ‘current’ or ‘unconfined’ steam; and at pressure in
excess of that is called ‘pressure’ or ‘confined steam’. The penetration of the pressure steam is no better than
the current steam unless the chamber is vacuumized. By increasing pressure after creating vacuum much
higher temperatures can be attained than the 100°C obtained with current steam. This renders ‘pressure
steam’ disinfection more effective. This temperature of steam with a 0.33 kg / cm2 rise of pressure above the
atmosphere is 109°C, at 0.66 kg it is 115°C, at 1 kg 121°C, at 1.33 kg 126°C and at 2.66 kg per square
cm it goes up to 141°C and so on.
(e) Pressure Steam Disinfectors.
A typical pressure steam disinfector consists of a double-jacketed wrought-iron cylinder, loaded at one end and
unloaded at the other, each end having a hinged iron door. The clothing is placed in a cradle which is run
on rails in the cylinder and the doors are clamped. Steam is first admitted in the outer jacket for heating the
cylinder. The cylinder is then vacuumized and steam is introduced in it at 133 kg / cm2 pressure for 10 min.

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After this, it is vacuumized and recharged with steam at the same pressure for further ten minutes, followed
by aspiration of hot air through the clothing. Finally, the clothing is taken out in a dry state from the other
end. The whole operation takes about 35 minutes. Pressure-steam disinfectors of various types but operated
on the same principle are seen in large military hospitals.
(f) Current Steam Disinfector.
Pressure steam requires apparatus with considerable extra strength and weight. Therefore, its use is practical
only in garrison stations and large hospitals. The current-steam apparatus, operated on the ‘principle’ of
downward displacement of air’ being lighter and portable, is ideal for use on active service and in temporary
camps. The current-steam disinfectors at present in use are the TOT Disinfector (Fig 27.2) and disinfector
portable field No.3 (Fig 27.3).

Fig 27.2 : TOT Disinfector

(g) ‘TOT’ Disinfector.
This is a portable ‘downward-air-displacement’ current-steam disinfector named after its designer T.O. Thompson.
It is a rectangular metal box, the bottom of which has the fire chamber (F) with a built in 20 L capacity boiler
(B) over it and the upper part is a double jacketed steam chamber (S). The lid (L) is well fitting, airtight and
asbestos / hemp or felt lined. Heating is done by a burner, firewood or coal, for which a simple trench-fireplace
(T) is required. Clothing is placed in the steam chamber and the lid is clamped to fit firmly. Steam generated
in the boiler travels up between the two jackets of the steam chamber and, being stopped by the clamped
lid, is forced down into it. It cannot escape until all air is displaced downwards and forced out of the spaces
between the interstices of the fabrics. It finally reaches the escape pipe through the hole (H) in the bottom
of the container. This entire process takes about 10 min when steam will be seen spurting from the steam
escape pipe (P) with a whistling noise.
A definite continuous spout and not the intermittent wisps of steam, indicates that the chamber is filled with
steam without any air left in it. Steam is allowed to spout for 5 min and then the lid is opened, clothing is
taken out and aired for drying. At each loading about 9 to 10 blankets or one man’s full kit can be treated,
provided the blankets are not brand new and are neatly folded and pressed well down into the chamber,

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corners upmost to allow easy removal. About 5 L of water should be added at each reloading.
(h) Disinfector Portable Field No. 3.
The disinfector is also of the ‘downward air displacement’
type. It has two halves of identical construction bolted
together (Fig 27.3). The front burner half carries a
detachable 180 L capacity water reservoir with a water
level gauge. The back flue-box half carries the detachable
flue box and a pipe which is immersed in boiler water
and is open to atmosphere and therefore serves as
low water alarm and also as a pressure limiting device.
Through the detachable boiler section at the bottom,
runs the fire tube with 5 cm space around it. The boiler
holds 80 L of water. The top chamber section carries the
disinfecting chamber. Between this and the outer sheet
is a 3 cm steam space surrounding the chamber. The
front and back halves are interconnected by a loose fire Fig. 27.3 : Disinfector Portable Field
tube connector, a water-pipe assembly which equalizes
the water level and drains the water space and steam pipe assembly which collects the steam generated in both
halves and passes it to either of the disinfecting chambers separately or to both simultaneously.
The water and steam pipe assemblies are joined to the disinfector body by unions with ground faces. When
union nuts are taken off, the entire assembly comes away. The procedure of its working is briefly as follows:
(i) The boiler is filled via the water reservoir till the gauge shows 1.5 cm and then the water reservoir
itself is filled. There will then be about 260 L of water in the boiler and the reservoir, enough for two
hours steaming. The burner is started and pushed into the opening of the fire tube with the burner plate
abutting against its porch way. The flame should be kept steady.
(ii) Articles for disinfection are collected on a ground sheet on the ‘dirty side’. These may be tied in
blankets to make bundles of the size of the chamber or loaded directly in layers. Blankets are folded
to make neat bundles on the slings supplied. Steam from the boiler rises up in the steam space from
where it is drawn off by tubes and admitted at the top of the disinfection chambers, at a pressure slightly
above the atmosphere. Steam continuously entering from the top displaces all the air in the chamber
and fabrics downwards and finally, completely filling the chamber, escapes through the bottom exhaust
pipe in a continuous ‘full bore’ steam of vapor.
(iii) To start with, the first chamber is loaded while the steam is diverted by the three-way valve to the
other chamber. After loading, the lid is clamped down and the three-way valve is turned over to admit
all steam into it. The second chamber is then loaded and the three-way valve is turned midway to admit
steam to both chambers simultaneously. After 12 min, steam will issue forth ‘full bore’ from the exhaust
pipe of the first chamber. After 5 min of the ‘full bore’ exhaust, disinfection of that chamber is complete
and the three-way valve is set to pass all steam to the second chamber, while the first is emptied and
reloaded. By this time the second chamber may have completed its 5 min of ‘full bore’ exhaust and all
steam is passed to the new load in the first chamber while the second is recharged. These cycles are
repeated till all clothes are disinfected. The water level is always maintained showing 1.5 cm up in the
gauge glass by replenishing at shot intervals.
(iv) Operating and working party as follows will be needed. 3 men to hand over the dirty clothing: 3
men to take over the disinfected clothing; and 3 men to operate the disinfector, No. 1 to attend to the
boiler and burner, No. 2 to load the disinfector on the dirty side and No. 3 on the clean side to operate
the three-way valve, unload the disinfector and pass the disinfected clothing to men who air them and
hand them over to the loading party. There should be no passage of persons between dirty and clean
sides and the only passage of articles should be via the disinfection chambers. The output is about 200
blankets per hour. After the work is over the water should be drained out of the disinfector.
(v) The ‘Disinfection centre’ should have two apartments, the ‘infected’ or ‘dirty’ apartment and the
‘disinfected’ or ‘clean’ apartment. The disinfector should be built in between the two rooms. without
communication between the two sides except through the disinfector, so that the receiving end opens

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into the ‘infected’ side and the other into the ‘disinfected’ side. After the work is over the water should
be drained out of the disinfector.

27.20 Chemical Agents.

Chemical disinfectants may be solid, liquids, gases or aerosols. Solids act as disinfectants only in solution. A few
disinfectants as powders, act better when dissolved. Gases like Sulphur dioxide and formaldehyde also act as better
disinfectants in the presence of adequate moisture. The disinfecting power of a chemical depends upon its basic
toxicity, concentration, penetrating power, the medium in which it is to act, the resistance of organism required to be
killed, the extent to which the organism is protected by organic matter like pus or faeces and the period of contact
allowed. The ideal chemical disinfectant should be capable of destroying all micro-organisms in all probable media
within half an hour; it should be harmless to man and higher animals; it should not spoil metals, clothing and other
household goods in the concentration usually employed; for convenience of transportation, it should be obtainable in a
highly concentrated form; it should be capable of forming a solution or stable emulsion in water (even in hard water);
and finally, it should be cheap. The main problem with any disinfectant, however, is the ability of its particles to gain
contact with bacteria. Capsulated organisms resist penetration to a marked degree; the organisms locked up even in
microscopic masses of pus, mucus, faeces etc. are protected against most disinfectants unless the time of contact is
long and the concentration high. Disinfection by chemicals is thus a complex process and the estimation of the true
disinfecting power of any chemical agent is difficult.

27.21 Estimation of Germicidal Power.

The best-known test for assessing germicidal power is the ‘Rideal-Walker phenol coefficient test’ (RW). In this test
the bactericidal power of any chemical is compared with that of phenol under identical conditions. This is done by
observing the comparative sterilizing effects of a series of dilutions of the particular chemical and those of phenol
against a standard dose of a standard culture of the Lister strain of B. typhosum, in a standard time, at a standard
temperature. The RW coefficient is obtained by dividing the highest sterilizing dilution of the agent under test by the
highest dilution of phenol sterilizing in the same time. For example, if cresol diluted 1 :1200 and phenol diluted 1 :100
both produce sterility, say, in 15 min, the RW coefficient of cresol would be 12 i.e. cresol has 12 times the disinfecting
power of phenol. The test, however, does not indicate the disinfecting powers of disinfectants under natural conditions.
For example, the mercurial salts show a high RW coefficient, but their disinfecting action is arrested by albuminous
materials. Chlorine and potassium permanganate lose a great deal of potency in the presence of organic matter, while
others like cresol are only slightly handicapped. Various modified tests, like Chick-Martins test, take into account the
effects of extraneous material. However, the unmodified Rideal-Walker test is useful for comparing the germicidal power
of different batches of the same disinfectant.

27.22 Solids.
(a) Quicklime.
It is used in the burial of animals dead of anthrax; for disinfecting byres and stables after the occurrence of a
case of anthrax; and as 25 percent lime wash for walls, ceiling and floors of barns, sheds, stables, kitchen, stores
and so on. Slaked lime is used as a deodorant in and around urinals, soakage pits, grease traps; to promote
bacterial growth by retarding acidity in deep trench latrines; and as a final spread over shallow trenches.
(b) Chlorine Compounds.
Bleaching powder, water sterilizing powder. sodium hypochlorite and many other kindred substances containing
chlorine are used to sterilise water and vegetables. Bleaching powder in combination with boric acid has been
used as eusol in surgery. The practice of sprinkling bleaching powder in drains, gutters, latrine pails etc. is
wasteful and useless.

27.23 Liquids.
(a) Coal Tar Derivatives.
These are obtained by its fractional distillation and are most widely used of all the liquid disinfectants. This
group includes the aniline dyes, the phenols and the cresols.

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(i) Cresol.
It is a dark brown, oily, readily emulsifiable liquid. Liquor cresoli fortis, known in the Armed Forces
as ‘disinfecting fluid black’ or simply as cresol, is the most convenient and the most useful general
disinfectant. It turns white on dilution with water and is extremely stable. Liquor cresoli fortis has a RW
coefficient of 12, but cresol commercially supplied may have 10 RW. All containers are marked with the
RW of the contained cresol so that, by increasing or decreasing the amount of dilution with water a final
disinfectant liquid of known strength can be made. For general use, like scrubbing bedsteads, the dilution
of 1 percent of RW 10 cresol is enough. In this dilution it is not dangerously toxic if swallowed, is only
mildly irritating to the skin and possesses high germicidal power. For disinfecting bedpans, sputum or
excreta a dilution of 2.5% of RW 10 cresol is needed. Even in this dilution cresol does not destroy fabrics.
Although it is rapidly fatal to micro-organisms when it comes in contact with them, its penetration into a
mass of sputum or faeces is not good. Therefore, as a measure of greater safety a 5 percent emulsion
is used for disinfecting sputum of tuberculosis cases and faeces of some excremental disease cases.
Cresol is of great value in the disinfection of the receptacle after the contained infective material has
been disposed off.
(ii) Izal.
This is saponified cresol, officially known as ‘disinfecting fluid white (Izal)’. This correct nomenclature
should always be used. It is used in 3 percent strength for disinfecting mouthpieces of telephones
and microphones, of Radio-Telephone (RT) sets and Public-Address (PA) sets and the face pieces of
respirators. It should not be used for any other purpose.
(b) Dettol.
This is chloroxylenol. It is non-irritating but inactivated by organic matter. It is active against streptococci but
has no effect on some gram-negative bacteria.
(c) Commercial Formalin.
This is a 40 percent aqueous solution of formaldehyde. It is a powerful disinfectant but since it is very irritating
to the hands, eyes and respiratory passages, it is not used as a general disinfectant. It can be used in a
5 percent dilution for disinfecting rooms, tents. huts or vehicles and for spraying fur-coats, leather, rubber,
metal and similar articles which are destroyed by steam. It is used for disinfecting valuables like jewellery, gold
ornaments and watches. It is used for preserving tissues required to be sent to the laboratory for examination.

27.24 Gases.
(a) Sulphur Dioxide.
This gas has been used for fumigation against rats in ships and warehouses by the Clayton apparatus in
which a forced draft from a blower ensures complete combustion of Sulphur. By means of pipes led from the
generator, a concentration of 15 percent Sulphur dioxide is attained in the air in enclosed places. Sulphur
dioxide is not dangerous to human life but tarnishes metals, discolours paints, destroys pictures, spoils grains
and entails a risk of fire.
(b) Formaldehyde.
The gas is generated popularly by pouring liquid formalin over crystals of potassium permanganate placed in
a deep pan. About 300 ml of formalin and 150 gm of potassium permanganate are required for 1,000 ft of
space. The room is to be kept closed for 6 to 12 hours to allow disinfection.
(c) Aerosols.
Aerosols are mists released into the air by a special atomizer to disinfect the air in enclosed places. Their action
is believed to be either due to collision with and absorption by organisms or condensation of vapor on bacteria-
carrying particles, quickly destroying their bacterial content. The ideal aerosol should be non-irritating to the
mucosa, non-toxic even after prolonged exposure, invisible, inodorous. non-corrosive, non-inflammable. highly
bactericidal in low concentrations and capable of penetrating organisms in dried secretions such as saliva. The
most effective and initiating particles have a diameter of less than 1 micron and act at dilution ranging 1 in
100 million to 500 million volumes of air. Aerosol has an advantage over ultraviolet rays in the disinfection of
air in enclosed places due to their penetration to the remote corners of rooms. Aerosols used for killing bacteria

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suspended in the air, fall into three groups viz. hypochlorites, resorcinols and glycols. Insecticide aerosols are
effective against insects only. They contain Freon gas and pyrethrum and dichlorodiphenyltrichloroethane (DDT)
in solutions.

27.25 Practice in the Armed Forces.

On the occurrence of a case of communicable disease in the Armed Forces barracks and married quarters or treatment
of a case in hospital, both concurrent and terminal disinfection are required to be carried out vide Regulations for the
Medical Services of the Armed Forces (RMSAF), 2010, paras 705 to 712. Concurrent disinfection of the patient himself,
of his infective body discharges immediately on voidance, of all articles used by him, nursing appliances immediately
changed after use and clothing and linen when soiled or changed is carried out during the course of an infectious illness.
Terminal disinfection is carried out after the patient is dead or discharged or transferred. While only the ‘local’ terminal
disinfection is necessary in all cases of infections, ‘complete’ disinfection is carried out for cholera, pulmonary tuberculosis,
puerperal sepsis and pneumonic plague after the diagnosis. Chemical disinfectants like cresol and formalin are usually
used for treating walls, floors, bedstead, furniture, fixtures, nursing appliances and articles of personal use. Blankets used
by all patients and complete clothing used by infectious patient are disinfected by steam and then washed, dried in the
sun and ironed. If a steam disinfector is not available, they are soaked in 2.5 percent cresol for half an hour.
To summarize, disinfection of the following must always be considered in all cases of infectious illness:
(a) The patient’s excreta and discharges, linen, utensils and other articles used by the patient.
(b) The quarters occupied by the patient before removal to hospital and their contents.
(c) The vehicle in which the patient is conveyed to hospital.
(d) On recovery of the patient, the ward / room in which the patient was treated and its contents.
(e) In the case of carriers or contacts disinfection should be carried out at the discretion of the medical
officer in charge.
In the Armed Forces, as practically all cases of infectious diseases are treated in hospitals, the disinfection is always
carried out by trained persons. Occasionally, when an infectious case is treated in quarters, full instructions in writing
should be given. Disinfection and dis-infestation should be carried out under the direction of medical authorities. Working
parties are to be provided by the CO of units. ln Army, the scales of authorized disinfectants are given in scales of
hygene chemicals; in the Navy and Air Force these are to be drawn as per scales authorized from time to time through
administrative orders / instructions.

27.26 Details of Procedures to be Followed.

(a) Concurrent Disinfection.
It should always be considered as extremely important. Concurrent disinfection of various infective materials
in appropriate cases should be carried out as follows:
(i) Sputum should be received directly into sputum cups containing 2.5% cresol and afterwards burnt.
(ii) Nasal, aural and eye discharges should be received directly into small pieces of linen, cotton or
cotton wool and immediately burnt. Vaginal or urethral discharges and those from open sores should also
be similarly received on pads left in situ under dressings and burnt after removal at frequent intervals.
Handkerchiefs should be soaked in 2.5% cresol solution before washing with soap and ironing.
(iii) Contents of bed pans and urine bottles used by patients suffering from gastro-intestinal diseases
as well as their vomits should be thoroughly mixed with an equal quantity of 2.5% cresol and allowed to
stand for 2 hours before throwing down the sluice or water closet or incinerated. Bedpans and bottles
should subsequently be steeped in 2.5% cresol for 15 min to half an hour and then washed.
(iv) Bed linen, blankets etc. which have been soiled with infectious discharges. exudates or excreta
should be steeped in 2.5% cresol for half an hour before removal from the ward. Special bedding and
clothing marked with ‘I’ are reserved for use of patients suffering from infectious diseases.
(b) Terminal Disinfection.
It is complementary to the concurrent disinfection. All clothing, mattresses, bedding, linen, personal wear and

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similar articles within the specified areas for local or complete disinfection as indicated are packed in sacks
or sheets soaked in 2.5 percent cresol and removed to the disinfection centre for steam disinfection. After
disinfecting, the articles of clothing and linen are washed with soap, dried in the sun and ironed. The floor,
the walls, the tent-walls and wall-skirting, bedsteads, shelves, kit boxes and any other metal or wooden article,
other than those which are removed for steam disinfection, are disinfected in situ by scrubbing or spraying
with 2.5 percent cresol. After a suitable period of contact with the disinfectant, these may be washed.
(c) Some Special Disinfections.
(i) Vehicle or Aircraft
Spray or swab with 5% formalin or 2.5% cresol followed by washing in hot water with soda.
(ii) Crockery and Cutlery
Steep for half an hour in 2.5% cresol followed by washing in hot water with soda.
(iii) Toys, Books and Papers
If of small value, they may be burnt. If valuable, spray or swab with 5% formalin followed by exposure
to the air for two to three days.
(iv) Shaving Brushes
Thoroughly wash in 5% soap solution containing one percent soda ash at 50°C. Allow to stand in one
percent soda ash at 50°C for half an hour. Soak for half an hour in 10 percent formalin solution at
50°C. Allow to dry in the shade, bristles downwards.
(v) Latrine Seats
Scrub with 2.5% cresol, which should then be allowed to dry on the seat.

27.27 Routine Disinfection of Personal Clothing.

Disinfection / dis-infestation of personal clothing in units obviates the possibility of any inadvertent transmission of
contagious infection or louse infestation or bedbugs from person to person. Formerly routine steam disinfection of
winter clothing used to be carried out after the clothing was withdrawn at the termination of the winter season, before
stowing away for the summer. The present practice is to wash such clothing with soap and hot water at 60°C and
afterwards expose them to the sun for 24 hours. After drying and ironing, it is stowed away in rat proof boxes or racks,
after interposing naphthalene mothballs in between layers. Coloured clothing is fumigated with carbon tetrachloride by
laundry units. Cotton clothing is boiled in soap solution, dried and ironed. The common disinfectants in use and their
dosage are shown in Table 27.4 and 27.5.

27.28 Sodium Hypochlorite.

Sodium hypochlorite, commonly kown as bleach, is most frequently used as a disinfecting agent. It is a broad-spectrum
disinfect that is effective for the disinfection of viruses, bacteria, fungi and mycobacterium. During the COVID-19
pandemic, the most recommended disinfectants were 70% ethanol and chlorinated disinfectants such as sodium
hypochlorite and calcium hypochlorite.
Concentration & Contact Time.
The appropriate concentration of sodium hypochlorite for disinfecting general liquid biological waste is 5,000 ppm,
approximately 0.5%. Household bleach is 5-6% sodium hypochlorite; therefore a 1:10 (v / v) dilution of bleach to liquid
biological waste is appropriate. For biological waste containing a high organic load (e.g. blood, proteins or lipids) the
appropriate concentration of sodium hypochlorite is 10,000 ppm, approximately 1%, therefore a 1:5 (v / v) dilution of
bleach to liquid biological waste is appropriate. Minimum Contact time for surface disinfection is 1 min and for liquid
waste disinfection is 20 min. Sodium hypochlorite is known to be corrosive to metals, therefore, it important to wipe
down metal surfaces with water or ethanol after treating them with a bleach solution.

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Table 27.4 : Recommended Dilution of Chlorine Releasing Compounds

Clean condition Dirty Condition
Chlorine Compounds
(Required Chlorine 0.1% (Required Chlorine 0.5%
(Available chlorine)
or 1 gm / litre) or 5 gm / litre)
Sodium hypochlorite solution (5% available chlorine) 20 ml / litre 100 ml / litre
Calcium hypochlorite (70% available chlorine) 1.4 gm / litre 7.0 gm / litre
Sodium dichloroisocyanurate (NaDCC Powder) 1.7 gm / litre 8.5 gm / litre
Sodium dichloroisocyanurate (NaDCC Tablets) 1 tablet / litre 4 tablets / litre
Chloramine (25% available chlorine) 20 gm / litre 20 gm / litre
Table 27.5 : Non-Chlorine Releasing Compounds
(Used for Disinfection of Items which are Adversely Affected upon by Chlorine)
Required Contact
Name of Disinfectant Used for Disinfection of
concentration period
Ethanol 70% 3-5 min Smooth metal surfaces, tabletops, incubators,
thermometers
Alkaline Glutaraldehyde 2% 30 min Ambu bags, suction tubes / bottles. laryngoscopes,
endotracheal tubes, catheters, etc.
Formaldehyde / Formalin 3-4% 30 min Furniture, rooms, walls, blankets. beds, books etc.
Savlon 1% 30 min Cheatle forceps
Dettol (chloroxylenol) 5% 15 min Instruments & plastic equipment
Cresol 2.5 - 5% 30 min All-purpose disinfectant

Suggested Readings.
1. Col Z, Singh, Col L, Bhalwar R. An Introduction to Essentials of Bio-Medical Waste Management [Internet]. Available
from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4925840/pdf/main.pdf
2. Missouri Department of Health and Senior Services B of CDC and P. Prevention and Control of Communicable
Diseases [Internet]. Internet Archive. 2011 [cited 2024 Feb 22]. Available from: https://archive.org/details/2011comm
unicablediseases/page/n5/mode/2up
n

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Chapter
XXVIII
ANIMAL BORNE DISEASES (ZOONOSES)

28.1 Introduction.
Zoonoses is the state in which the infections chiefly or initially affecting animals are transmissible to human
beings; the process may be reversed and more infections may pass from man to animals. Many vertebrates
experimentally show susceptibility to infections primarily affecting man and may also get occasionally infected in
nature under unusual circumstances, but such infections do not constitute zoonoses. The Food and Agriculture
Organization (FAO) / WHO definition of zoonoses refers to ‘those diseases and infections (the agents of) which are
naturally transmitted between (other) vertebrate animals and man.’ Plague, rabies, anthrax, rickettsial infections,
leishmaniasis, relapsing fevers, yellow fever, trypanosomiasis and several parasitic diseases are typical examples
of such infections originally affecting animals and transmitted to human beings.

28.2 Genesis.
Achievement of success in parasitism and symbiosis is the genesis of zoonoses. ‘Parasitism’ aims at self- preservation
and species propagation by obtaining sustenance from the host. For this purpose six degrees of host-parasite relationship
have evolved; they are: the host-sensitivity, the host-resistance, combination of sensitivity and resistance in varying
proportions, tolerance, commensalism and symbiosis. Absolute host-resistance is the complete defeat of parasitism.
Absolute host-sensitivity causes ecological failure of parasitism. Because, unless the parasite can live a partial
saprophytic or saprogenic life, as is the case with B. anthracis and Cl. tetanus, cessation of the host entails cessation of
the parasite also. Therefore, a variable combination of host-sensitivity and resistance strikes a balance. Host-tolerance,
which does not make any demands on the parasite for its own sustenance, leads to perfect parasitism. The further
perfection of parasitism is commensalism, which does not require the lodger organism to be totally ‘parasitic’. For
example, the B. coli in the human intestinal canal derives its nutrient saprophytically and not directly from the body
of the host. Symbiosis makes mutual host-parasite interdependence obligatory; hence it is not parasitism in its strict
sense. However, it makes lodger organism biologically successful.

28.3 Reservoir.
Most zoonoses start with the host sensitivity and through the stages described above, attain tolerance, commensalism
and symbiosis so as to make zoonoses progressively more successful. However. more often the host is partially sensitive.
When some vertebrate animal hosts are sensitive to a parasite, some other animal in the background is likely to be
tolerant or symbiotic host, as to permit perpetuation of the parasite in nature. For example, while dogs are intensely
sensitive to rabies virus, the wild canidae like wolf, jackal or fox, which transmit this infection to dogs also suffers
from rabies. The search for more tolerant hosts which can permit perpetuation of virus in nature, without themselves
succumbing to the infection, has led to the discovery that vampire bats, Mustelidae, Viperidae and some rodent species
act as such hosts for rabies virus. Similarly, the urban rodents, who acquire plague infection from sylvatic rodents,
themselves die of the disease. Symbiotic host has been hypothesized in certain wild rodents of Arvicanthis and Olomys
spp. In this case the sylvatic rodents are presumed to be less sensitive than the urban rodents. Tolerant or symbiotic
animal hosts are the ‘permanent reservoir’ of zoonoses; the ones either sensitive or only partially resistant are the
‘semi-permanent’ reservoir; and the ones who are more sensitive are the ‘temporary reservoir’ of zoonoses.

28.4 Epizootic Epidemic Cycle.

The permanent reservoir allows parasite perpetuation; the semi-permanent reservoir allows propagation at low virulence;
the temporary reservoir permits its rapid propagation and spread by endowing it with extraordinary invasiveness and
virulence. When an infection explosively breaks out among animals it is called an ‘epizootic’ and when it perpetually

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remains among them it is called ‘enzootic’. These terms are equivalent to ‘epidemic’ and ‘endemic’ in the human
population. When the sensitive host-animal population increases, their contact with the permanent host-animals also
increases. This causes the parasite to be rapidly transmitted from the permanent to the temporary reservoir producing
an epizootic. Following the epizootic, the epidemic in the human population starts. In course of time the epizootic is
reduced due to the diminution in the population of sensitive animal-hosts. Thus, the epizootics arise cyclically followed
by cyclic epidemics. Infections such as bovine tuberculosis, brucellosis or Q fever, which are enzootic, are transmitted
endemically to man.

28.5 Importance of Knowledge.

When an infection is known to be zoonotic and its permanent or temporary carrier is known, its control in human
population becomes easy by either veterinarian controlling it among animals, by destruction of animals themselves
or by interrupting its transmission to human population. The negative information is also important as it enables us
to exclude certain vertebrates from the possibility of being natural reservoirs. The knowledge of zoonoses enables us
to study the parasite, its behaviour and reaction caused by it in the animal host during the pathogenic process. It,
thereafter, lends us to form a picture of the natural history, epidemiology and remedy of the disease. It also helps in
finally diagnosing the otherwise intractable infection. Sometimes the similarity of the zoonotic infection with the strain
or species of parasite causing a human disease permits us to draw inferences and conclusions from parallel studies.
The evolution and devolution of an infection through the historical and pre-historical periods can also be traced by
the knowledge of zoonoses. For epidemiological purposes, the search for zoonoses can be extended infinitely through
enzootic survey in zoological fauna in nature and through experimental transmission in the laboratory for determining
the ‘host range’.

28.6 Socio-economic Aspects.

Zoonoses with reservoirs of infection in domestic animals impose a particularly serious burden of ill health on vast
number of people who live in rural areas and earn their livelihood through animal farming and other forms of agriculture.
In some countries this high-risk group comprises up to 90 percent of the total population. Parasitic zoonoses, which
are particularly prevalent in such populations, especially among the children, cause exacerbation of the vicious circle
of protein-energy malnutrition and infection. Keeping of pets and companion animals, which is becoming more and
more popular not only in the developing countries but also in the developed parts of the world, has further enlarged
the risk of zoonoses.

28.7 Occupational Hazards.

Some zoonoses have significantly higher attack rates for workers in the course of their occupation than for the rest
of the population. Well known examples are the occurrence of hydatidosis in shepherds, cutaneous leishmaniasis
and schistosomiasis in agricultural and irrigation canal workers, dracunculiasis in water carriers and tick and mite
infestations in animal handlers. Cooks and housewives are at risk of contracting diseases due to handling and testing
of uncooked food (e.g; taeniasis, trichinellosis and toxoplasmosis). Laboratory workers constitute another group, which
faces such occupational hazards.

28.8 Mode of Transmission.

Transmission of zoonoses to human being occurs through the bite of an infected animal e.g. rabies and rat bite fever;
through consumption of its milk e.g. brucellosis and bovine tuberculosis: through its flesh consumed by human being as
in taeniasis and trichinellosis; through direct contact or through media of air such as psittacosis and Q fever; through
contact with its excreta containing organisms like leptospirosis and echinococcosis and through contamination of food
meant for human consumption as in salmonellosis and melioidosis. Arthropod vectors play an important part in the
transmission of zoonoses and account for about half the human morbidity due to zoonoses. Seasonal migrations of
birds and animals, their migrations due to clearance of jungles or due to food shortages or expansion of animal fauna
in natural habitats, cause shifting of zoonoses from place to place. For example - migration of jungle yellow fever to
urban area is caused by migration of monkeys and infected mosquitoes and rabies is taken from one area to another
by migrating infected wild Canidae, Mustelids and Viverids and possibly some wild infected rodents.
Transmission of zoonoses from the permanent reservoirs to human population may involve several chains through
different species of animals. Two good examples of this chain transmission are Y. pestis from the hypothetical permanent
reservoir in Arvicanthis and Olomys Spp. through sylvatic rodents, urbanized rodents and finally to house rat; and the
transmission of rabies virus from Musrelidae and Viviridae; permanent reservoir through wild Canidae to domestic

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Canidae. Cattle, horses, dogs, cats, pigs are the animals which come in intimate human contact. Out of these a vast
majority of transmission can be attributed to proximity of dogs and rodents. In some infections the animal acts as an
initial reservoir but once the infection is acquired by the human host, the infection propagates through human source.
For example - leishmaniasis in the Mediterranean region is initially acquired from dogs but is later transmitted from
man to man through the bite of infected female phlebotomine sandfly.

28.9 Natural Foci.

Zoonoses often occur within definite geographical areas. The terrain of such areas is characterized by well-defined
ecological systems and peculiarities determined by vegetation and topographical, geophysical, climatic and other
environmental factors. In such natural settings the pathogenic organisms, vectors, vertebrate hosts and vegetation
form collective symbiotic groups. This is termed ‘biocenose’ ‘biome’ or ‘ecosystem’. The entire naturally correlated
assemblage of zoological species within a biocenose is termed the ‘species network’, which may be composed of
many local groups and combinations. Within this ‘species network’ the infection circulates and perpetuates in nature
independent of human being if they do not come in contact with them. Even today, numerous natural foci of zoonoses
exist in their primary form in vast areas of all the continents but, under the influence of man’s economic activities,
in many places the ecosystems are changing as a result of agricultural development into fields, meadows, gardens,
pastures and plantations of various trees and crops. Other human activities such as water resource development in
the form of dam construction or irrigation scheme and spread of towns and cities into previously uninhabited areas
containing natural foci of disease and leading to increased human contact with these foci. These may create or worsen
existing conditions favourable to the spread of zoonoses. A good example of such a natural focus of infection is the
one, which harbours the assemblage of rodents, trombiculid mites and R. tsutsugamushi causing scrub typhus in man.
The rickettsia, the mite vector, the rodent reservoir all coexists in the sanctuary of typical vegetation and geophysical
environment, ecologically sustaining all of them. Other similar biocenoses or natural foci of infection are the Kyassanur
Forest Disease focus in Karnataka and that of plague in adjoining districts of Kolar (Karnataka), Chittoor (Andhra
Pradesh) and Salem (Tamil Nādu). Recognition of existence of and prevention and control of human epidemics, the
knowledge of the biocenoses and the geographical background and terrain causing them is termed by Pavlowsky as
‘landscape epidemiology’.
If the conditions in such foci alter so as to endanger the parasitism, the pre-existing infection flares up into an
epidemic proportion. Such unstable areas are found at the marginal areas around biocenose with ‘fringe habitats` of
the members of the biocenose. From here the infections spread out and cause epidemic in the surrounding areas. The
local human population, however, usually acquires partial immunity against the zoonoses due to repeated exposure
to low grade infections; but the immigrants suffer from an outbreak of infection. Some parasites use both man and
animals as alternative host; some use man as a definitive and animal as an intermediary host; some others use man
as intermediate and animals as definitive host. In some cases, the host requirement is obligatory while in other cases
it is not so. Some zoonoses produce severe diseases in animals but milder ones in human host.

28.10 Multidisciplinary Approach.

Study of zoonoses takes us far wide a field into medical, veterinary, zoological, botanical, ecological and biometeorological
areas. The final objective for medical practitioner is, however, restricted only to study and control of the transmission
of disease to human beings. This may make it necessary to study the epizootic patterns and cyclic tendencies; search
for the permanent or semi-permanent reservoirs: and find the method of perpetuation and spread of infection in the
nature and transmission through various chains to man. These studies, therefore, require a close coordination between
various branches of science to provide a rational basis for the control of human infections. The data collected by such
studies are integrated to give the knowledge of ‘landscape epidemiology’ or natural focal distribution of communicable
diseases.

28.11 Prevention and Control.

The narrower the natural range of zoonoses, the earlier and easier it is to indicate the disease in human population.
For example, the bovine strain of tuberculosis was discovered to be the cause of human non-pulmonary tuberculosis
infection and the search proved that the natural host range of infection is extremely narrow and almost confined to
cows. As extensive drive in the U.K. for raising non-tuberculosis herds has been so successful that at present there is
no infection among the milching cows and hardly any bovine infection among human beings in that country. Similarly,
rabies and hydrophobia in many western countries have been almost eradicated by efficient cuniculture. The larger the
host range, the wider is the spread of infection and more difficult its eradication. On the other hand, if it is confirmed

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that no zoonoses exists in respect of a particular human disease, it leaves us free to concentrate all attention on the
measures to control or eradicate human reservoir, as happened in the case of smallpox.
The general scheme of prevention and control of zoonoses may necessitate emphasis on one or more of the following
measures; control of the arthropod vector; protection of domestic animals from sylvatic disease; protection of man
from contact with the vertebrate reservoir, domestic source or the relevant articles of use from getting contaminated;
destruction of sylvatic or domestic sources; eradication of the enzootic in the domestic reservoir; search for the
permanent reservoir in nature and its destruction; and control the migration of such susceptible animals. Each of these
methods has special application in particular zoonosis. International surveillance is also needed to control international
transmission of zoonoses.

28.12 Common Zoonoses.

WHO has enumerated more than 200 diseases constituting zoonoses, many of them involve dogs, cats and rodents of
various types. The important examples of Zoonoses commonly met with are rodent borne infections such as plague,
relapsing fever, rickettsial diseases, salmonellosis, helminthic infections (like trichinellosis), meleioidosis, leptospirosis,
listeriosis, toxoplasmosis, tularaemia and so on; the primate borne infections like yellow fever, malaria and possibly
viral hepatitis; non-pulmonary tuberculosis due to drinking of milk of an infected cow, brucellosis, Q fever and taeniasis;
canine infections like rabies, leishmaniasis, echinococcosis. Swine are presumed to be permanent reservoirs of influenza
viruses in nature. Trypanosomiasis in Africa is also a Zoonoses. Toxoplasmosis is very widespread in nature and is
symbiotic with many animal hosts. Exact transmission to man of this infection is not yet certain but domestic animal
such as cats which is closely associated with man is incriminated. Ornithosis is originally a disease of a group of
birds, especially the parrots, hawks, kites and so on. Psittacosis is the ornithosis of parrots transmitted to man. The
virus of lymphocytic choriomeningitis is widespread among mice but is transmitted to man through dog or cat due to
his proximity of these animals. Anthrax is common among farm animals and cattle: its spread to man may be due
to the use of wool, hide or meat of infected animals. Some of the zoonoses which are transmitted by arthropods are
described in chapter XXXIV as control of the vector is a more important means of controlling the transmission of those
diseases. Some important zoonoses transmitted directly by the reservoir animals or after some latency e.g., tetanus
and anthrax are briefly described in this chapter. For detail information the standard textbooks should be consulted.

28.13 Rabies (A82.9).

(a) Introduction.
Rabies is an acute, invariably fatal, infectious disease of animals, chiefly the canidae tribe, from which man is
secondarily infected. After incubation period of about a fortnight, the infected dogs manifest symptoms in one
of the two forms, the furious form and dumb or paralytic form. These are in fact the successive stages of the
same disease. Furious canine rabies causes most cases of the disease in man. To start with, the animal may
be unusually depressed or unusually affectionate. After a day or two it develops an irresistible desire to roam
aimlessly and to bite anything or anyone on its way; but rarely does it wilfully attack anyone not directly in its
immediate path. It tries to eat sticks, stones and rags and its bark shows a change. It may look ill or may not
look abnormal enough to attract attention. The foaming at the jaw results from difficulty in swallowing coupled
with constant movement of the jaws. In the dumb rabies the dog presents no signs of frenzy or irritation, but
it can convey the virus by licking on broken skin surface. The animal seeks out a secluded corner, develops
paralysis of the lower jaw followed by paralysis of the rest of the body and death occurs in one to three days.
A rabid cat usually hides in a corner or under a piece of furniture and attacks anyone who comes near. The
animal mews hoarsely and finally the voice is lost. This is followed by paralysis and death in a few days.
In man the disease is characterized by rapid onset with a sense of apprehension, headache, malaise and
nervous system symptoms of excitation or depression, progressing to paresis or paralysis with spasm of the
muscles of deglutition on attempt to drink, followed by delirium and convulsions and resulting in death from
respiratory paralysis within two days to a week. ‘Hydrophobia’ meaning ‘fear of water’ is the name given to the
disease occurring in human being from the patient’s difficulty to drink water. This symptom is characteristic
feature of the disease in man and does not occur in dogs or other animals.
(b) Geographical Distribution.
Rabies has a worldwide distribution. In countries like Australia, New Zealand, Cyprus, Hawaii and other South
Pacific Island where the disease has been initially absent and in Scandinavia & United Kingdom where strict

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COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

anti-rabies vigilance is maintained, the disease is rare. As per WHO in Africa and Asia, the disease is very
common and takes a considerable toll from the civil population. India is endemic for rabies and accounts for
36% of the world’s rabies deaths. True burden of rabies in India is not fully known; although as per available
information, it causes 18,000-20,000 deaths every year. Approximately, 29 million people receive post exposure
prophylaxis each year. ln the Armed Forces the incidence of the disease earlier in 1970s was at 0.01 per
1,000 strength and has declined over the years to negligible cases now.
(c) Agent.
The causal organism (lyssavirus type 1) is a specific neurotropic filterable virus classified as Rhabdovirus. It
has bullet shaped neurotropic Ribonucleic Acid (RNA) containing virus with spikes projecting from its surface.
The strain recovered from the stray rabid dogs has been designated ‘the street virus’. Microscopically, the
oxyphilic inclusion body called the ‘Negri body’ is found in the cytoplasm of the neurons of the rabid animal
and that of man dying of hydrophobia. It is found most abundantly in the hippocampus of the dog’s brain.
Virus is present in the saliva one week before symptoms appear. Street virus loses its virulence but retains
the antigenic properties when ‘passaged’ a hundred times through the rabbit. This is used for preparation of
anti-rabies vaccine and is termed the ‘virus fixed’.
(d) Reservoir.
Rabies exists in 3 forms: urban rabies, sylvatic (wildlife) rabies and bat rabies:
(i) Urban Rabies.
The transfer of infection from wildlife to domestic dogs results in the creation of the urban cycle which
is maintained by the dog and is responsible for 99% of human cases in India.
(ii) Sylvatic Rabies.
This form of rabies is perpetuated by the jackal, fox, hyena and other wildlife carriers which are the
main reservoir and transmitters of rabies. In South Africa the disease is enzootic in the mongoose who
transmit the infection to dogs and domestic animals.
(iii) Bat Rabies.
In certain Latin American countries (e.g., Mexico, Venezuela, Brazil, Trinidad, Tobago) the vampire bat is
an important host and vector of rabies to animals and humans and is responsible for killing thousands
of cattle annually. Humans are affected when they sleep outdoors. Vampire bats have not been reported
in India.
(e) Source of Infection.
The canines suffer and die of the disease within 10 days after the symptoms appear. For man the immediate
source of infection is essentially the rabid domestic, street or pet dogs or cats. In rural areas wild dogs,
foxes, jackals, wolves or mongooses may also attack human beings in a frenzy, besides causing the epizootics
amongst domestic dogs and cats.
(f) Mode of Transmission.
The commonest mode of transmission in man is through animal bites drawing blood or licks on the abraded
skin surface or mucous membrane by the rabid dogs. The virus deposited at the site of the bite finally
reaches the Central Nervous System (CNS). The route of its travel up to CNS is believed to be essentially by
neural transmission. Air borne transmission in man has been conclusively shown to occur in nature in caves
harbouring rabies infected bats. Oral infection has been demonstrated in experimental animals. Man to man
transmission, although rare, is possible. A case of a child biting its parents has been reported. There are also
reports of transmission of rabies by corneal and organ transplants.
(g) Host.
All warm-blooded animals in general and mammals are susceptible. Animal susceptibility to rabies infection is
highest amongst foxes, jackals, wolves, high amongst domestic cats, mongooses, rabbits, guinea pigs, cattle,
bats, moderate in dogs, sheep, goats, horses, non-human primates and low amongst opossums. Man possesses
no natural immunity against infection. Rabies in man is a dead-end infection. The immunity conferred by a
course of anti-rabies vaccine, though initially high, is short lived; probably only six months.

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(h) Incubation Period.

The incubation period in man is highly variable and may vary from 3 to 8 weeks following exposure commonly
but it may be as low as 4 days and may be extended to many years. The incubation period depends on the
site of bite, severity of bite, number of wounds, amount of virus injected, species of biting animal, protection
provided by the clothing and treatment taken, if any. In general incubation period is shorter in severe exposures
and bites on face, head, neck and upper extremities and bites by wild animals.
(j) Communicability Period.
Saliva of a rabid dog is infective for a week to ten days, before the symptoms appear and continues to be
infective until the death of the dog. However, the transmission, which depends on the irresistible proclivity for
biting, usually occurs only a short time before the established symptoms of rabies appear.
(k) Clinical Diagnosis.
Rabies can be diagnosed from:
(i) Clinical Presentation.
(aa) Prodromal Phase.
This phase is marked by nonspecific symptoms such as fever, headache and malaise. There may
also be discomfort or tingling at the site of the bite wound.
(ab) Acute Neurological Phase.
This phase is characterized by more specific symptoms such as anxiety, agitation, hallucinations,
hydrophobia (fear of water), excessive salivation and paralysis.
(ii) History of Animal Exposure.
Rabies is usually transmitted through the saliva of an infected animal via a bite or scratch. A history of
exposure to a potentially rabid animal is crucial for diagnosis.
(iii) Time Course.
The progression of symptoms is rapid once they appear. The disease can advance to a stage where
neurological symptoms become severe within a few days.
(l) Laboratory Diagnosis.
(i) Fluorescent Antibody Test.
This is the most reliable laboratory test for diagnosis of rabies. The result is available within a few hours.
If the nervous tissue of the animal is negative for the antibody, it can be presumed that the saliva too,
is negative and the person bitten need not be vaccinated.
(ii) Detection of Negri Bodies.
This is positive in approximately 90 percent of the naturally infected dogs.
(iii) Animal Inoculation.
The test is carried out by injecting an emulsion of suspected brain tissue intracerebrally into mice.
(iv) Corneal Test.
The test involves demonstration of antigen in corneal cells even before the onset of clinical signs, but
this test has been proved unreliable.
(v) Virus Isolation.
Virus can be isolated from saliva and other secretions.
(m) Prevention of Human Rabies.
(i) Local Treatment.
All bites from dogs and other animals, particularly if unprovoked, should be regarded as dangerous. The

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combined administration of anti-rabies serum and vaccine, together with the local treatment, provides the
best possible prophylaxis of rabies in an exposed person. However, the most valuable procedure in post-
exposure treatment is the local treatment of wounds. It is of maximal value when applied immediately
after exposure (within minutes if possible), but it should not be neglected even if several hours or days
have elapsed.
(aa) The wound should be immediately flushed and washed thoroughly with soap and water,
detergent or water alone.
(ab) Application of either 40-70 percent alcohol or aqueous solution of tincture of iodine should
be carried out with a fine swab to reach the depths and pockets of the wound. Twenty percent
soap solution can be used for this purpose in an emergency.
(ac) Local application of 5 ml of anti-rabies serum by careful instillation in the depth of the
wound is an added help. Sensitivity to serum should be determined prior to its use.
(ad) Wound debridement and antibiotic therapy may be needed to treat badly lacerated wounds
and subsequent infection. Sutures should not be applied for at least three days.
(ae) Tetanus toxoid 0.5 ml should be given to all pre-immunized persons. If the patient is not
immunized against tetanus, administration of Anti Tetanus Serum (ATS) and active immunization
with tetanus toxoid may be carried out.
(ii) Specific Treatment.
In a rabies endemic country like India, where there is sustained dog-to-dog transmission every animal
bite is potentially suspected as a rabid animal bite, the treatment should be started immediately
after exposure. To bring out uniformity globally, the National guidelines for Rabies prophylaxis include
classification of animal bite exposure broadly based on WHO recommendations which should be followed.
Although unvaccinated animals are more likely to transmit rabies, vaccinated animals can also do so if
the vaccination of the biting animal was ineffective for any reason. The risk of dog being infected with
rabies is greatly reduced when it appears healthy and there is confirmed history of vaccination with
minimum of two immunisations with potent rabies vaccine in last two years. The treatment should be
started immediately after the bite. (Table 28.1)
Table 28.1 : Type of Contact, Exposure and Recommended Post-Exposure Prophylaxis (PEP)
Category of
Type of Exposure Recommended Post-Exposure Prophylaxis
Exposure
− Touching or feeding of animals − None, if reliable case history is available.
− Licks on intact skin − Wash Exposed area with Soap and running
Category I
− Contact of intact skin with secretions / water for 15 minutes and then apply Antiseptic
excretions of rabid animal / human case
− Nibbling of uncovered skin − Wound management. Wash Exposed area
− Minor scratches or abrasions without with Soap and running water for 15 minutes
Category II and then apply Antiseptic.
bleeding
− Rabies vaccine
− Single or multiple transdermal bites or − Wound management
scratches − Rabies Immunoglobulin
Category III − Licks on broken skin − Rabies vaccine
− Contamination of mucous membrane with
saliva (i.e, licks)
Note. Bites by wild animals and all bites in forest areas should be considered as Category III exposure and treated
accordingly.
The treatment may be modified if the suspected dog or cat involved in the incident is healthy after a 10-day observation
and PEP can be converted to Pre-Exposure Prophylaxis (PrEP) by skipping the vaccine dose on day 14 and administering
it on day 28 while using IM regimen (ESSEN Schedule). While using ID route of administration complete course of

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vaccination should be given irrespective of the status of the animal. The observation period is valid for dogs and cats
only. Bite by all wild animals should be treated as category III exposure. It should be noted that bites by rats, mice,
squirrel, hare and rabbits seldom require treatment. Bat rabies has not been conclusively proved in India and hence
exposure does not warrant treatment. But there is a serological evidence of lyssavirus infection among bats in Nagaland,
India and Gannoruwa bat lyssavirus has been isolated from the brains of Indian flying foxes in Sri Lanka. The animal
bite victims are generally managed at primary health centres with limited resources for primary wound management
and rabies prophylaxis. As there is no remedy available for the rabies after appearance of clinical signs, rabies may
result in death of almost all patients unless there is timely and appropriate case management. Palliative care of
rabies patients is an integral part of rabies control and management guidelines. Palliative care by trained healthcare
workers should be accessible to all patients with confirmed rabies. World Health Organization’s guide for palliative care
can be referred for further reading. In exceptional cases, aggressive management may be considered. The aggressive
management of rabies cases should only be done at reference centres with well-trained teams of experts who have
experience in managing rabies patients using ethically pre-accepted protocols.

28.14 National Guidelines for Recommended Post-exposure Treatment against Rabies based on Categories
of Exposure.
It is re-emphasised that the treatment should be started immediately after the exposure, but it should not be denied to
person reporting late for treatment. There are three components of prevention of rabies in man. All three components
carry equal importance and one should not be given undue importance or utter neglect, at the cost of other two
components. Physician must attempt to provide the animal bite victim the benefit of all three of these as per category
of bite. The three components are.
(a) Management of animal bite wound(s)
(b) Passive immunization with Rabies Immunoglobulin (RIG)
(c) Active immunization with Anti-rabies Vaccine (RABIES VACCINE)
(a) Management of Animal Bite Wound (s).
Wound toilet: Since the rabies virus enters the human body through a bite or scratch, it is imperative to
remove as much saliva and thereby the virus, from the wound as is possible by an efficient wound toilet
that should not involve additional trauma. Since the rabies virus can persist and even multiply at the site
of bite for a long time, wound toilet must be performed even if the patient reports late. The recommended
first-aid procedures include immediate, thorough flushing and washing of all wounds with soap and water and
application of Povidone Iodine or Antiseptic having virucidal activity. Tetanus prophylaxis should be given as
per national guidelines. To prevent sepsis in the wound, a suitable course of an antibiotic may be prescribed.
Suturing of wound should be avoided as far as possible. If unavoidable, minimum loose sutures should be
applied after adequate local treatment along with proper instillation of Equine Rabies Immunoglobulin ERIG
or Human Rabies Immunoglobulins (HRIG) in the wound. (Table 28.2)
Table 28.2 : Wound (s) Management
Do’s Act Effect
Physical − Wash all wounds with running water − Mechanical removal of virus from wound
Chemical − Wash all wounds with soap and water, apply − Inactivation of the virus
antiseptic
Biological − Infiltrate immunoglobulin into the depth and − Neutralization of the virus
around the wound(s) in Category III exposures
Don’ts
− Don’t touch the wound (s) with bare hands.
− Don’t apply irritants like soil, chillies, oil, lime, herbs, chalk, betel leaves, etc.
(b) Passive Immunization.
(i) Equine Rabies Immunoglobulin (ERIG).
The anti-rabies serum provides passive immunity. in the form of ready-made anti rabies antibody to tide

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 COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

over the initial phase of the infection. Anti-rabies serum or RIG has the property of binding with the
rabies virus, thereby resulting in the loss of infectivity of the virus.
(ii) Human Rabies Immunoglobulins (HRIG).
They are free from the side effects encountered in a serum of heterologous origin and because of their
longer half-life, are given in half the dose of equine anti-rabies serum. The anti-rabies sera should always
be brought to room temperature (20–25°C) before use. Dose of Rabies Immunoglobulins (RIG): The dose
of equine anti-rabies serum is 40 IU per kg body weight of patient and is given after testing of sensitivity,
up to a maximum of 3,000 IU. The Anti Rabies Serum (ARS) produced in India contains 300 IU per ml.
The dose of the human rabies immunoglobulins (HRIG) is 20 IU per kg body weight (maximum 1,500 IU).
HRIG does not require any prior sensitivity testing. HRIG preparation is available at a concentration of
150 IU per ml.
(c) Active Immunization.
Active immunization is achieved by administration of safe and potent Cell Culture Vaccines (CCVs). The
vaccination schedule as per the National Guidelines for Rabies Prophylaxis, 2019 (by National Rabies Control
Program, National Centre for Disease Control, Delhi) is provided in following Table 28.3.
Table 28.3 : Immunization Schedule for Rabies Prophylaxis
Number of Total
Type of Route of Site of
Dose of Vaccine Day of Dose Injections Number
Prophylaxis Administration Injection
Per Visit of Visits
Post-Exposure Intradermal 0.1 ml per dose Day 0, 3, 7 2 4
and 28
Prophylaxis
Intramuscular 1 entire vaccine vial Day 0, 3, 7, 1 5
14 and 28
Adults:
Pre-Exposure Intradermal 0.1 ml per dose Day 0, 7 and 1 3 Deltoid
21 or 28 Muscle
Prophylaxis
Intramuscular 1 entire vaccine vial Day 0, 7 and 1 3
21 or 28
Re-exposure Intradermal 0.1 ml per dose Day 0 & 3 1 2 Infants
(No vaccination and Small
needed if full Children:
PEP has been Anterolateral
received in the Thigh
last 3 months)
Intramuscular 1 entire Day 0 & 3 1 2
vaccine vial
Protocol for rabies post exposure prophylaxis after animal bite. (Fig 28.1)

28.15 Management and Control of Rabies.

(a) Management of Re-exposure in Previously Vaccinated Individuals.
If re-exposed, persons who have previously received full pre-exposure or post-exposure treatment (either by
IM or ID route) vaccine should be given for only two booster doses, intramuscularly / intradermally (0.1 ml at
two sites) on days 0 and 3, but no rabies immunoglobulin. Only adequate wound washing would be required
in case of re-exposure where animal bite victim has documented proof of complete PEP or PrEP within last
three months. People who have previously received full post- exposure treatment with Neural Tissue Vaccine
(NTV) or vaccine of unproven potency or cannot document complete previous PEP or PrEP treatment should
be treated as fresh case or given full PEP.

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 ANIMAL BORNE DISEASES (ZOONOSES)

Protocol for Rabies Post Exposure Prophylaxis after Animal Bite : Decision to Treat

CATEGORY - I CATEGORY - II CATEGORY - III

O Touching or feeding of O Nibbling of uncovered skin O Single or multiple transdermal
animals O Minor scratches or bites or scratches
O Licks on intact skin abrasions without O Licks on broken skin
bleeding O Contamination of mucous
membrane with saliva

No prophylaxis needed Previously immunised

Previously not Previously
(if reliable contact (if in doubt, treat as not
immunised not immunised
history is available) immunised)

O Wash exposed area with running water and O Wash exposed area with running water and Soap up
Soap up to 15 minutes and apply Antiseptic to 15 minutes and apply Antiseptic
Q Vaccinate Q Vaccinate
Immune-competent person* : Immune-competent person* :
O Give 04 Doses ID (0.1 ml, 2 sites) on Day O Give 02 Doses ID (0.1 ml, 1 sites) on Day 0 & 3
0, 3, 7 and 28 or
or O Give 02 Doses IM (1 Vial, 1 site) on Day 0 & 3
O Give 05 Doses IM (1 Vial, 1 site) on Day 0, RIG is not indicated
3, 7, 14 and 28 Immune-compromised person :
RIG is not indicated
Give 02 Doses IM (1 vial, 1 site) on Day 0 & 3 RIG is
Immune-compromised person : not indicated.
O Give 05 Doses IM (1 vial, 1 site) on Day 0,
3, 7, 14 and 28
O Infiltrate wound(s) with RIG as soon as
O Wash exposed area with running water and Soap up to
possible.
15 minutes and apply Antiseptic
Q Vaccinate and infiltrate RIG
If further exposures in the Immune-competent person :
future, treat as previously O Give 04 Doses ID (0.1 ml, 2 sites) on Day 0, 3, 7 and
immunised and follow 28
algorithm as above or
O Give 05 Doses IM (1 Vial, 1 site) on Day 0, 3, 7, 14

Rabies Immunoglobulin (RIG) Dosage : and 28

The maximum dose of HRIG is 20 IU/kg of O Infiltrate wound(s) with RIG as soon as possible.
th
body weight, while that of ERIG is 40 IU/kg O Do not give RIG beyond the 7 day after the 1st
of body weight. vaccine dose on day 0.
Immune-compromised person :
(The entire immunoglobulin dose, or as much
as anatomically possible but avoiding possible Give 05 Doses IM (1 Vial, 1 site) on Day 0, 3, 7, 14
O

compartment syndrome, should be infiltrated and 28

carefully into or as close as possible to the O Infiltrate wound(s) with RIG as soon as possible.
th
wound(s) or exposure sites.) O Do not give RIG beyond the 7 day after the
st
1 vaccine dose on day 0.
Fig 28.1 : Protocol for Deciding the Course of Rabies Post-Exposure Prophylaxis in Case of an Animal Bite Victim

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COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

(b) Pre-exposure Prophylaxis.

Pre-exposure prophylaxis may be offered to high-risk group like laboratory staff handling the virus and infected
material, clinicians and para-medicals attending to hydrophobia cases, veterinarians, animal handlers and
catchers, wildlife wardens, quarantine officers and travellers from rabies free areas to rabies endemic areas.
Total three doses are recommended for pre-exposure prophylaxis.
(i) In case of IM route 1 full vial to be given on days 0, 7 and day 21 or 28.
(ii) In case of ID route, 0.1 ml on one site to be given on days 0, 7 and on either day 21 or 28.
Note: High-risk groups should have their neutralizing antibody titres checked every 6 months during the initial
two years period after the primary vaccination. If it is less than 0.5 IU / ml, a booster dose of vaccine should
be given. Subsequently, sero-monitoring is recommended every two years. Vaccine-induced immunological
memory persists in most cases for years. A booster would be recommended only if rabies virus neutralizing
antibody titres have dropped to less than 0.5 IU / ml. Vaccinated Individuals on being exposed to Rabies virus
(RABV) after successful pre-exposure immunization would require only two booster injections of vaccine given
on day 0 and day 3. There is no need for RIG.
(c) Prevention and Control.
Control and preventive measures against rabies and rabid dog-bite consists of controlling the stray dog
population; protection of pet dogs and cats; prevention of importation of disease from outside (if the country
is already disease free); and personal protection against dog bite.
(i) In compliance with Animal Birth Control Rules, 2023, stray dogs may not be killed, only sterilized
and hence can control the stray dog population. Registration of all pet dogs and the use of a metal
badge on the collar, to distinguish them from the stray and ownerless dogs should be done. In order to
promote registration, the local authorities should offer free treatment for other canine ailments.
(ii) Ingress of wild Canidae inhabitation and their mixing with domestic dogs can be controlled by
making the slaughterhouses, rubbish disposal yards, poultry farms and such other places attracting dogs,
animal proof and by disposal of all offal by burning.
(iii) Publicity campaigns must be carried out to promote registration of pet dogs and their protection,
education regarding the dangers of rabies, rabid dog bites and efficacy of early vaccination and treatment
of animal bites.
(iv) Pre-exposure immunization of pet dogs and cats can be used to supplement, but not to replace these
measures. Restrain the movement of all dogs and muzzle them for at least 3 months during an epizootic.
(v) Dogs that have been bitten by a known rabid dog should be dealt as per law of the land. Dogs
in contact with but not known to have been bitten by a rabid dog, if desired to be kept should have
anti-rabies treatment and be quarantined for six months.
(vi) Self-protection from dog bites is an individual responsibility. As the bites through clothes are less
likely to transmit infection, trousers and shirtsleeves rolled down are more protective than any other type
of usual Indian clothing.
(vii) Disinfect all places where a rabid animal has been confined. The carcass of a rabid animal must
be cremated.
(viii) Health laws of some countries do not permit any dog to be imported from any country. Some
countries permit them to be imported after quarantining for 6 months; some with and others without
compulsory immunization.
(ix) Particulars of all animal bites and cases of hydrophobia mainly to warn all concerned regarding
the presence of epizootic or enzootic in the area, should be given to higher medical authorities and units
in the locality. Precautions as described above should be tightened in unit / station area when such an
information has been received.

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(d) As per Training Module on Rabies for Medical Officers (2024)

(i) Dog Census.
Efforts shall be made by the district authorities in the Animal Husbandry department to estimate the
number of free roaming / stray dogs and pet dogs. This would help in designing and evaluating the canine
mass vaccination programme.
(aa) Pet / owned dogs
(ab) Community / semi-owned dogs and
(ac) Feral / stray dogs
(ii) Responsible Pet Ownership.
The strategy of promoting ‘Responsible Pet Ownership’ can prevent the spread of rabies. The public is
advised to get pet dog licensing from the local authorities, 1st dose of anti-rabies vaccination when the
puppy is about 2 / 3 months of age and yearly thereafter, provide proper nutrition and shelter to their
pet dogs and not allow their pet dogs to loiter to prevent contact with infected animals.
(iii) Mass Dog Vaccination.
Dog vaccination is the most cost-effective single measure to protect humans from rabies and the mainstay
of dog-mediated rabies control. In addition, vaccinating a dog is much cheaper than providing care to
the victim of its bite.
Completion of a mass dog vaccination drive, covering at least 70% of the dog population, within the
shortest period possible should be attempted to stop transmission between dogs and from dog to human.
Campaigns must be conducted recurrently (usually annually) to maintain the level of herd immunity in
the susceptible population despite dog population turnover (births, deaths, animal movements) in the
period between campaigns.
The Department of Animal Husbandry and Veterinary Services at the State and District level, local
government such as Municipal councils, corporations, should take the lead in mass dog vaccination
campaigns every year to cover at least 70% of dogs.
(iv) Dog Population Management.
This shall include stray dog population management by effective implementation of the ‘Animal Birth
Control and Anti rabies (ABC-AR) programme’ throughout the country. ABC is undertaken by the Veterinary
Department of Municipal councils, corporations in urban / rural areas and this authority could be contacted
for ABC. The objective of dog population management in the context of dog-mediated rabies control is
to improve and maintain vaccination coverage by reducing population turnover and risky dog behaviour.
Mass culling of dogs has been proven ineffective and may even be counterproductive.
(v) Animal Rabies.
Stray or unwanted dogs, cats or any other domestic animal involved in an exposure that could potentially
transmit rabies should be confined and observed. If this is not possible, the animal should be humanely
euthanized in a way that does as little damage to the brain as possible and the head / brain sample
submitted for laboratory examination and rabies testing.
(vi) Risk of Rabies Transmission in Other Animals.
A history of abnormal or aggressive behaviour in any domestic animal or potential exposure of a domestic
animal to other animals that could transmit rabies (including other domestic animals of unknown rabies
vaccination status or wild animals) would also have the likelihood of rabies exposure.
(vii) Environmental Influences on Rabies.
It is important to understand the influence that environmental factors can have on dog populations and
behaviour. Achieving and maintaining a high dog vaccination coverage can be hampered by high dog
population turnover rates, when unvaccinated dogs quickly replace vaccinated dogs. Transmissions cycles
can further include wildlife which can be infected by dogs as well. Open garbage disposal sites or solid
waste accumulation in urban settlements can attract a high number of dogs and increase the transfer

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of infectious diseases. Dogs competing for food at these sites can increase overall aggression further
leading to an increased risk of dog bites.
Efficient waste management is therefore contributing to dog population management and needs
engagement beyond the veterinary and human health sectors.

28.16 Immunization of Dogs and Animals.

(a) Pre-exposure vaccination of dogs can be carried out by veterinary avianised live virus anti rabies vaccine.
It is a single dose vaccine. Each freeze-dried ampoule or vial when reconstituted with 3 ml of sterile chilled
distilled water constitutes one full dose for a dog. If this is not available, veterinary Beta-Propio Lactone (BPL)
anti-rabies vaccine, either single dose of 5 ml daily for 7 days for dogs weighing 15 kg or more and 2 ml
daily for 7 days for dogs weighing < 15 kg, affords tolerable protection. Revaccination with the first one is
recommended every three years. Central Research Institute Kasauli recommends the first revaccination with
BPL single dose vaccine after six months and thereafter once a year.
(b) All other valuable animals should be protected in enzootic areas by veterinary BPL anti rabies vaccine.
The single dose schedule consists of 10 ml for animals weighing 100 kg or below and 20 ml injected on same
day in divided doses at two different sites in animals weighing more than 100 kg. The multiple dose schedule
is same as described above.
(c) Post-exposure treatment of dogs with vaccine is not reliable and therefore, the safest course would be
to destroy the dog bitten by a rabid animal, especially if not preimmunized against rabies. In animals receiving
regular pre-exposure vaccination, post-exposure treatment is more effective. Therefore. if the dog has been
preimmunized, it may be treated with veterinary BPL anti-rabies vaccine (multiple dose). The dosage schedule
for dogs weighing 15 kg or more is 5 ml daily for 14 days and for those weighing less than 15 kg it is
2 ml daily for 14 days. Dogs exposed to rabies within a month of primary immunization with any of the three
types of vaccines mentioned above should be considered as unprotected and treated accordingly. Even after
treatment, the pre-immunized dog should, however, be quarantined for one month and unprotected dog for
6 months.

28.17 Rabies in Man.

The mortality in Hydrophobia is almost cent per cent and no curative treatment is yet available. The following action
should, however be taken:
(a) The WHO recommends that the patient should be isolated in an intensive medical care unit. However,
he may be kept in a quiet room with a subdued light; every form of disturbance being avoided. Symptomatic
treatment with sedatives, antispasmodics, diuretics, including management of respiratory function, should be
carried out.
(b) Attendant should wear gown, rubber gloves, mask and goggles. If he becomes exposed to risk of infection
by the bite of the patient or by contact with his saliva on broken skin or on intact conjunctiva or mucous
membrane, he should receive the appropriate course of treatment.
(c) Clothing, bedding, carpets used by the patient or soiled by rabid dogs, need not be destroyed; they
should be soaked in 5 percent cresol or exposed to formalin fumes overnight. then washed and dried in sun
for 24 hours.

28.18 Rodents.
(a) Introduction.
Rodents are part of man’s environment. Some of them live close to him. They are the reservoir and source of
at least 20 percent of Zoonoses known up till now. They form more than one third of all the living species of
mammals and exceed any other mammalian order in the number of individuals. All rodents are without canine
teeth, but they have strongly developed incisors, which grow throughout the life of the animal, the front incisors
covered with enamel are sharp and chisel like. Family Muridae is the most extensive family of rodents. This
is divided into several sub-families. Sub-family Murine, which includes the Genus Mus (mice) and the Genus
Rattus (rats); is the most important in human ecology and medicine. Mice can be distinguished from rats by
their smaller size and the presence of a notch on the inner side of the upper incisors. There are many species

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of rats and mice. The different species of rats are identified by their colour. length of ears, body, tail and hind
feet; shape of the head; texture of pelage; number of mammae; and by the skull and teeth.
(b) Distribution.
Most of them remain indigenous and local Mus musculus, the common house mouse, Rattus rattus, the roof
rat and Rattus norvegius, the sewer rat follow man to all parts of the world. The genus Rattus has more than
250 species and several hundred sub-species, the principal populations of which are in Asia. R. norvegicus has
spread throughout Europe and to practically every country and island in the world with human traffic, but M.
musculus and R. rattus are generally limited to tropical and sub-tropical regions. There are approximately 110
species of rodents in India. These are broadly classified into two groups. The first group comprises domestic
rodents which include Rattus rattus (the black rat), Rattus norvegicus (Norway rat) and Mus musculus or the
common house mouse. The second group consists of wild rodents like Tatera indica, Bandicota bengalensis,
Bandicota indica and Tatera meltada. The commonest species in India are Rattus rattus, Rattus norvegicus
and Mus musculus.
(c) Morphology.
Brief description of commonest species is given below. For further studies standard works should be consulted.
(i) Rattus Norvegicus.
It is a brown rat of large size, with a blunt nose and small opaque ears which barely cover the eyes
when laid forward. The tail is shorter than the length of the head and body together. The female has 12
mammae. It is essentially an outdoor rat, frequenting sewers and the fields. When it enters houses, it
usually invades only the ground floors. It feeds on sewer and house rubbish, garbage and other decaying
material. It gnaws even the rusty iron sheets or bars.
(ii) Rattus Rattus.
It is a more delicately built rat with slender body and pointed head. It is often black in colour, but
reddish-brown varieties are abundant in many parts of India. The ears are translucent and large and
reach beyond the middle of the eye when laid forward. The tail is more delicate and much longer than
the length of the head and body. The female has 8 or 10 mammae. It is essentially a dweller in human
habitations and being a good climber, it nests in roofs. It feeds mainly on man’s food, garbage or swill.
It gnaws fabrics, wiring, leather, woodwork and so on.
(d) Importance of Rodents to Human Health and Ecology.
(i) Rodents and Disease.
Rodents act as hosts to several ectoparasites and endoparasites causing human and animal diseases.
The flea is the most important ectoparasite from medical point of view. Rodents also serve as hosts
in the life cycle of ticks and mites. Rat louse helps migration of some endoparasite from rodent to
rodent. Yersinia pestis causing bubonic plague is the most important, if not the commonest, of all the
pathogenic organisms; P. tularensis and certain salmonella species are the other bacterial infections
associated with rodents. The three species of Rickettsia, viz. R. tsutsugamushi, R. typhi and R. rickettsia
causing scrub, endemic and tick typhus respectively; the three species of spirochaetes, viz. Leptospira
icterohaemorrhagica, Spirillum minus and Borrelia recurrentis and duttoni, causing Weil’s disease, rat bite
fever and relapsing fever respectively; the viruses of lymphocytic choriomeningitis, haemorrhagic fever,
encephalitis and certain parasites causing leishmaniasis, chagas disease, histoplasmosis and melioidosis
are other important infections. Rat is an intermediary host of Trichinella spiralis, while Hymenolepis
diminuta and amoebiasis can also be caused by it. Majority of these infections are transmitted through
the ectoparasites. A dead rat is as dangerous as a living rat because the ectoparasites leave the cooling
body and attack other animals and man causing disease. Spirillum minus causing rat-bite fever is
transmitted through rat bite. Tularaemia and melioidosis occur by ingesting food contaminated by rats.
Salmonellosis is transmitted mechanically through dropping by contamination of food. Similarly, many
diseases of cattle and other animals of importance to human ecology are due to rats and their parasites.
(ii) Rodents and Human Ecology.
Rats are voracious consumers and great destroyers of food grains and standing crops: they spoil and
render food grains unfit many times more than they consume. They are a menace to eggs and poultry,

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which they eat and destroy more than all the other wild animals. They burrow and cause damage to
buildings, dams, embankments and other structures. They gnaw articles of clothing, furniture, leather,
electric wire and even rusty iron pipes. The destruction of food, crops, household articles, property,
masonry, buildings and merchandise caused by rodents is so great that this alone would justify active
measures to exterminate them at any cost, even if rodent related human and animal diseases were to be
controlled by alternative methods such as the control of ectoparasites and immunization. On the ships,
they act not only as a harassing menace, consumers and destroyers of food, damagers of structures
and fitting of ships and personal belongings and as health hazard to the ship’s crew and passengers,
but also constitute international conveyers of epidemic disease like plague. The great plague epidemics
of the past were due to migration of infected rats on ships from China to India, Middle East and Europe
and South America.
(e) Bionomics.
(i) Growth Potential.
Reproduction occurs all the year round, but in some places, there may be maximum births in spring
and late autumn. The percentage of females at a time varies between 18 to 40. The pregnancy rate
per annum per female and the birth rate per pregnancy varies between four to eight. The weanling rate
is about nine per females. The annual death rate among weanlings is about three per annual brood.
Changes in rat population mainly depends upon death rates than upon the birth rates. The death rate is
determined by competition among rats for food and harbourage available. Fierce fighting permits a few
rats to dominate the others. These aggressive rats feed and reproduce inhibiting growth and reproduction
of the inferior ones. Destruction by poisons, traps, cats and so on are rarely sufficiently intense and
sustained to keep the population perpetually down. Actually, these procedures as generally practiced,
make room for other rats to grow up and reproduce. Even very intensive poisoning campaigns reduce
the rat population only temporarily. They will rapidly increase to the level up to the capacity of the area
to support them and then remain at that level.
(ii) Nesting Habits.
When present along with R. norvegicus, which is a larger, more vicious and aggressive rat, the R. rattus
usually nests in the upper parts of the building and in burrows, in dark and moist places over the false
roof, in and behind cupboards, under wooden doors and behind wall panelling. In tropical climates they
also nest in trees. Although R. norvegicus prefer underground places, their nests may frequently be found
inside the buildings, even in the upper parts where there is abundant harbourage. In temperate climates
all the rodent species, including the mouse, infest the fields at considerable distance from buildings.
(iii) Locomotion.
Norwegian rats are not as agile as the other species and are less expert climbers. In the open, rats
have defective vision; by daylight they move slowly and uncertainly. In contact with the wall, they run in
great speed. This fact suggests that the vibrissae (whiskers) serve as feelers and that they are extremely
sensitive.
(iv) Rat Runs.
Rats prefer narrow places and overhead pipes and beams as highways and habitually follow the same
course. These highways or ‘runs’ are useful in tracing their nesting and hiding places, in discovering
defects that allow passage to such places and are also available guides for placing traps and poisoned
baits.
(v) Feeding Habits.
Rats are omnivorous but, as a group, grains are their food of choice. Roof rats prefer fruits and vegetables.
Rats learn to eat the foods of the locality in which they live and will often ignore food selected by rats
in other places. On the other hand, those of the same species and locality may show great divergence
in their choice of foods. Most rats will take fresh meat and dried meat which when mixed with grain is
the best bait; dried coconut and pakoras also form good baits. Rats cannot vomit and hence poisons
which have an emetic effect on all other mammals, e.g. red squill, can be used against them. They are
however, very suspicious and any strange thing is shunned by them; even a strange smell deters them.

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(vi) Migration.
Rats, like other mammals, normally tend to remain within a limited area of home ‘range’ for long periods
of time, provided enough food supply is constantly available and an undisturbed harbourage is ensured.
They stay within 10 to 20 m, while house mice live within an area of only 4 to 5 m diameter for many
months, unless there are radical conditions, denying nesting, feeding and breeding. In urban residential
areas the diameter of the home range may be about 20 to 40 m. Overland mass migration of rats has
been reported from country to country especially when food supplies are depleted. Ships and trains
have been the commonest vehicles for migration. Movements of rats from houses and barns to the
fields take place in the spring with the harvesting of crops and there is a return during rains and winter
months. Similar migrations occur from urban areas to rural areas. Rats liberated in a strange place
may travel long distances in search of a new home, but after finding a suitable place they also remain
within a circumscribed area for many months or until there is a change in the environment. Rats may
enter vessels when they berth at docks and many of them are carried abroad in cargo. Now-a-days rat
proofing is included as a standard requirement in the building of new ships and vessels.
(f) Rodent control.
(i) Permanent Measures.
Rodent control is best achieved by denying them ingress; denying them nesting, breeding and hiding
places; denying them food; and destroying them. Practical methods to achieve these measures are anti-
rodent engineering; anti-rodent hygiene; anti-rodent housekeeping; and health education. Scientific and
healthy town planning is essential to keep rats out of the blocks of human habitations. Good planning,
designing and construction of buildings keep them out of dwelling, factories, shops, godowns and places
like slaughterhouses, granaries and stores. Environmental tidiness, sanitation, high standard of living
and good housekeeping are essential adjuncts to anti-rodent engineering. Education and civic sense are
essential so that people take all these steps with understanding. Permanent rodent control in urban areas
can be achieved only by these methods, because rat destruction alone rarely reduces their population
to an appreciably low level and it rapidly builds up to the original level. Furthermore. This still does not
improve the living and sanitary conditions.
(ii) Anti-rodent Engineering.
Rats enter through drainpipes left open; through doors and windows, especially from alleys; through
basement windows and outside fittings; through the lower parts of the doors, ventilators, sky lights.
unused chimney flues, down the electric wire casings and so on. The doors and windows should be tight
fitting and reinforced with metal sheets to keep the rats from gnawing through the basement and upper
windows; the other places of ingress such as ventilator, skylights, unused chimney flues and opening
around water, sewer, gas and steam pipes and electric wires must be suitably protected. Screens to
prevent rats wandering from one place to another in large groups of buildings should be provided.
Foundation walls laid without a break around the entire building, flush with the under surface on the
floor above and extending not less than 45 cm beneath the surface of the surrounding ground, prevents
rats burrowing through. Floor joists should be embedded in the wall or the spaces between the joists
filled in and completely closed to the floor level. Floor should be concreted with a layer of at least 7 to
8 cm of thickness and finished with a soling surface of cement about 1 to 15 cm thick or tiles. All water
and drainpipes should be surrounded by concrete where they pierce the walls. If the lower portion of all
the walls is made of glazed tiles or tinned with galvanized non-corrugated iron sheets, rats do not enter
buildings.
(iii) The chief sanctuaries for rats in cities are the provision houses, markets, warehouses,
slaughterhouses, dairy farms, restaurants, bakeries, shops, candy factories and human dwellings. In the
rural areas corn godowns or warehouses, barns, granaries, cattle sheds, fodder rooms, piggeries, horse
stables are the chief places which afford nesting, breeding and feeding sanctuaries for rats. The field
rats in rural areas cannot be controlled by rat proofing as there is continual abundance of exterior food.
Raising the flooring on piers 15 cm or more above the ground surface reduces rat harbourage under
them. Rat burrows can be closed with a mixture of cement, sand and broken glass. Provision stores
should be built in such a way that the height of each step is more than 25 cm. The tiles covering the
steps should be jutting out. In urban and rural areas alike, the access of rats to places where they can

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secure nesting facilities, food or water should be barred.

(iv) Anti-rodent Hygiene
All solid waste must be disposed of hygienically. Slaughterhouse waste should be incinerated. Very high
standard of environmental sanitation, general neatness and tidiness in and about the houses, godowns,
factories, provision stores, market places, slaughter houses deprive rats of places for nesting, breeding
and resting.
(v) Temporary Control.
Temporary measures are not as effective as the permanent control measures. These only bring down
the rat population for a short period which soon builds up to the original level unless the permanent
measures are also simultaneously adopted.
(vi) Trapping.
It can reduce the population of domestic rats quickly, only if the traps are properly set and baited. Sewer
rats or large population of house rats do not respond well to trapping. The proper method to attack is to
use many traps at the same time in an infested area; and when maximum results have been achieved, to
shift the traps to a new area. The traps should be placed either near the burrows or along the rat runs.
The break back traps can kill only one rat at a time, but the catching trap can trap several of them at
the same time, without killing. Another method of trapping is the use of lithographic varnish, ‘rat sticker’.
The varnish is spread on a board with a piece of cheese or other material as a bait in the centre. On
encountering varnish, the rat becomes hopelessly entangled and its squeal attracts other rodents to the
rescue so that they in turn become trapped. The most efficient bait for any locality is determined by
trials. Dried meat, fish heads, coarse flour or ground grain, fresh vegetables, fruits, tomatoes, coconuts,
pakoras are generally good baits.
(g) Rodenticides.
These are of two types i.e. acute or single dose and cumulative or multiple dose poisons. Doses are lethal
to the rats after a single feeding in the former, while repeated feedings are required in the latter. The WHO
Expert Committee grouped the rodenticides as follows:
(i) Acute Rodenticides.
(aa) Those requiring ordinary care such as Red squill, norbormide and zinc phosphide.
(ab) Those requiring maximal precautions-such as sodium fluoroacetate (1080), fluoroacetamide
(1081) and strychnine.
(ac) Too dangerous for use such as arsenic-trioxide, phosphors, thallium sulphate, Alpha-Naphthyl
Thio Urea (ANTU) and gophacide.
(ad) Calciferol: leaches calcium from bone into the blood.
(ii) Multiple Dose Rodenticides.
(aa) Warfarin. Its dose varies from 250-500 ppm.
(ab) Diphacinone. Its dose varies from 50-250 ppm.
(ac) Coumafuryl
(ad) Pindone
(ae) Coumatetralyl
(iii) Bromadiolone.
The latest acute anticoagulant which can be used in domestic areas.
(h) Choice of Rodenticide.
Among the many available rat poisons, red squill is favourite because its emetic action protects animals that
can vomit; strychnine and thallium are used at times but are somewhat dangerous: zinc phosphide is seldom
used because of erratic results and danger to human population; barium carbonate is used in Armed Forces,

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mainly due to its comparative safety, simplicity of use and availability. ANTU is specific for Norway rats but
kills dogs and cats; does not kill roof rats. Sodium fluoroacetate is a powerful poison but its use has been
prohibited in many places because of human deaths. Warfarin is an anticoagulant that has a large safety
margin because of the very low dosage (0.1 per cent) that is required to be given for four days to kill a rat.
It keeps the rate population in area constantly low over a long period, provided it is used continuously. It is
dangerous to household pets and is chiefly used on board the ships.
(j) Baiting Procedures.
The poisoning campaign should be carried out in three stages as follows:
(i) ‘Trial baiting’.
It is the first step in the poisoning programme. Rats are usually accustomed to eat the ‘bait base’ of
plain food such as bread crumbs or coarse atta. This should be placed along runway and at their visiting
places for a day or two. Any other food commonly eaten by the local people may also be tried.
(ii) ‘Pre-baiting’.
This should be carried out with the most acceptable materials without mixing the poison. The pre-baits
are kept under supervision and replenished daily for 5 to 7 days.
(ii) ‘Poison baits’.
These are prepared by adding poison to the bait base and are laid in the same manner and at the same
places for the next one week or more.
(k) Preparation of Baits.
(i) Barium Carbonate.
It is mixed with three times the quantity of floor or bread mash, made from the grain which have been
found to be readily consumed by the rats. Sufficient water is added to the mixture to make a fairly firm
paste and rolled into pills weighing one gram each.
(ii) Zinc Phosphide.
It is usually not made into pills but mixed as a dry meal baited with 1 / 5th to 1 / 8th the quantity of the
poison and left at the baiting stations in bait-boxes which are not approachable by children and pet
animals. This is used on docks, warfs, godowns, granaries and such other places.
(iii) Warfarin.
It is similarly used in dry meal of breadcrumbs, roasted grains or crushed chapatti in the proportion of
1:19 and left in bait trays or boxes. This is used mainly on board the ships and also in granaries where
constant anti-rodent measures are very essential.
(iv) ANTU (Alpha Naphthylthiourea).
It is sprinkled in and around rat holes, rat runways and burrows. The rats lick their feet after running
through it and can swallow enough poison to kill them. Poison may be sprinkled on and around the baits
such as ground grain, sliced apples or melons, chopped meat, chicken or turkey heads and left in the
evening in thin layers in each rat-infested area.
(v) Coumatetralyl.
The compound is available as Racumin tracking powder (0.75%). The powder should be scattered into
the rodent burrows and on rodent runways. Racumin ready-made bait and wax blocks (0.0375%), are
also available. For field rodents, Racumin oil concentrate (2.0%) is mixed with whole grains in 1:50 ratio.
Any other food material can be mixed with racumin (1:19) for domestic use.
(vi) Fumigants.
Fumigation may kill rats with certainty in any enclosed places, like ships, godowns, granaries and rodent
burrows on embankments. Sulphur dioxide, carbon disulphide, calcium cyanide (cynogas or cymag) carbon
monoxide and methyl bromide are usually used. All enclosed spaces are opened to allow penetration of
the gases and exits are closed. The gases are then pumped in or mechanically released. Cyanogas has

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been extensively used in India for the fumigation of rats’ burrows. Aluminum phosphide tablets (3 gm /
rodent burrow) provide effective rodent control in peri domestic area and agricultural fields. The rodent
burrows should be closed after bait placement with wet soil.
(l) Precautions.
Clean hands and dishes are necessary to avoid imparting extraneous taste and odour to the bats as rats are
very suspicious. The baits should be made fresh each day and unconsumed baits should be laid systematically
and with great care to be beyond the reach of children or domestic animals. For initial baiting, 15-20 baits for
a room of size of an I.P. tent (about 15 feet х 15 feet) are required and for subsequent baiting 5-10 baits may
be enough. At the time of baiting all sources of food and water supply should be closed and baits should be
placed near the places where food is normally stored, cooked, eaten or discarded and near washing places. Pre-
baiting and baiting should be done during periods of clear and calm weather, as unsettled weather conditions
interfere with the normal movement of rodents. Left over baits should be counted or measured and removed
the next morning to prevent pets and livestock from eating it and replaced in the evening. Prepared baits and
water must be stored in places out of reach of human pets and domestic animals. Hands should be washed
thoroughly with soap and water after handling powder or prepared bait.
(m) Biological Control.
The natural enemies of the rats are the cats, larger hawks, eagles, vultures, owls, snakes, coyotes, weasels,
mongoose, minks, dogs and ferrets. However, although some of these may be helping to keep down the rat
population to some extent in nature, none of them is of practicable value in the rat control programme. They
are also carriers of biological agents like Salmonella typhimurium and enteriditis. These are either impracticable
or unsafe in the rat control programmes.

28.19 Leptospirosis (A27.9).

(a) Introduction.
The disease due to leptospirosis is commonly known as Weil’s disease. It is also known as icterus gravis and
caused by Leptospirosis icterohaemorrhagica. This is an acute febrile zoonotic infection characterized in human
beings by fever, icterus, albuminuria, haemorrhages, excruciating headache and pains in body, prostration, skin
rashes, hepatomegaly and excretion of bile in urine and faeces. The ‘febrile stage’ starts suddenly with rigor,
vomiting, headache, diarrhoea and abdominal pains and continues with irregular fever through the ‘icteric
stage’ which starts on the 4th day and lasts for a week or 10 days after which fever comes down with lysis.
By the 14th day the ‘convalescence’ starts. Sometimes there is a short febrile recrudescence during the third
stage in third week.
(b) Geographical Distribution.
This disease was formerly thought to be especially prevalent in Japan, but it has now been recorded from
countries in Europe. It is especially endemic in Holland, coastal Germany, Congo, Equatorial Africa, Sudan,
Andamans, Indonesia and Malaysia. The disease is especially virulent in warm countries.
(c) Agent.
Leptospira icterohaemorrhagiae is the causal organism. It is a slender, closely wound, very actively motile
spirochaete varying in length from 6 µ to 20 µ. It is found in the blood, urine & cerebrospinal fluid of the
patient. It can be demonstrated by dark ground illumination by 10th day in urine. The diagnosis of leptospiral
infection by direct microscopic examination of tissue preparations and body fluids has had limited application.
The introduction of fluorescent antibody techniques offers a promising method for its diagnosis. It can be
cultured in Johnson and Rogers medium by using 5 fluorouracil. The microscopic agglutination test is the
standard reference procedure for the serological classification of Leptospira. There are more than 130 strains
of Leptospira at present with varying invasive potentialities.
(d) Reservoir and Source.
Recent Studies indicate that certain groups of wild mammals such as insectivores, carnivores and ruminants
may act as animal hosts of leptospirosis. However, rats (R. ratus, R. norvegicus) and certain field mice (M.
montebello) have been found to be the most important reservoirs. These rodents are tolerant to the spirochaetes
and do not suffer from the disease. The organism is excreted in their urine and faeces. The disease also

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occurs in dogs but the immediate source of infection to man is through contact with the soil contaminated
with infective excreta, especially urine.
(e) Mode of Transmission.
The entry in man is through microscopic abrasions sustained during work in soil, drain, sewers or cellars.
Bathing in contaminated water also has given rise to outbreaks. Trench digging and trench habitation during
defensive battles may cause epidemics. The outbreaks may, therefore, occur among rice field workers, cane
cutters, butchers, sewer workers, miners, fishmongers and other occupationally exposed persons including
soldiers and sailors.
(f) Host.
Man possesses no natural immunity. Acquired immunity is not solid or long lasting. The disease runs severe
or mild course depending on the type of infecting organism.
(g) Incubation Period.
The usual incubation period is one week, a range of six to eight days rarely extending up to 13 days.
(h) Communicability Period.
Patient’s urine can be infective from the end of first febrile week onwards, usually from the 10 to 25th day
but may extend up to 60 days in rare cases. Rats are infective throughout their life.
(j) Treatment.
Treatment of Leptospirosis involves the prompt initiation of antibiotic therapy, ideally before the fifth day of
illness, with most clinicians opting for antibiotics regardless of the onset date. Waiting for laboratory test results
is discouraged due to delayed serological positivity and culture results.
(i) Antibiotics.
Severe cases warrant high-dose intravenous penicillin, while less severe cases can be treated with oral
antibiotics such as amoxicillin, ampicillin, doxycycline or erythromycin. Third generation cephalosporins
(e.g., ceftriaxone, cefotaxime) and quinolone antibiotics have shown effectiveness.
(ii) Supportive Treatment.
(aa) Hospital admission is necessary for severe cases.
(ab) Aggressive supportive care is crucial, focusing on fluid and electrolyte balance.
(ac) Peritoneal or haemodialysis is indicated in cases of renal failure.
(ad) Recent advancements in supportive care and dialysis have contributed to a reduction in
mortality associated with leptospirosis.
(k) Prevention and Control.
(i) General Measures.
Improvement of sanitation in vulnerable areas, such as coastal areas, sewers, coal mines and old
trenches can go a long way in controlling the rat population.
(ii) Protective Clothing.
Workers especially those employed in vulnerable trades such as sewer workers, salmon waders, divers
and miners should wear protective clothing. Soldiers in infected areas should wear shirts with sleeves
rolled down and anklets over the lower ends of trousers. Attendants in hospital should wear protective
clothing.
(iii) Swimming.
Troops should avoid swimming in infected pools.
(iv) Vaccine.
Vaccine against human leptospirosis is used in many countries with good results. These give protection

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against clinical illness but do not confer total protection. Specific gamma globulin can also prevent clinical
illness.
(v) Disinfection.
Both concurrent as well as terminal disinfection should be ensured.
(vi) Surveillance.
A systematic surveillance programme to monitor the ecological and epizootiological situations in selected
areas can assist in the development of measures for preventing outbreaks in man.

28.20 Brucellosis (A23.9).

(a) Introduction.
Brucellosis is a zoonosis causing abortions in animals and recurrent febrile infectious disease called the
‘undulant fever’ or ‘abortus fever’ and Malta fever in human beings. The disease generally runs a chronic
course but can take an acute character. It starts with body aches, headache, malaise and joint pains
followed by an insidious stepladder type of rise of fever, sometimes ushered in with a rigor showing diurnal
undulations, decreasing daily with profuse sweating. The fever reaches its height within a week or so
and continues for a few weeks with toxaemia and then comes down by lysis. The exacerbation of similar
type of fever occurs at an interval of few days or weeks. Several such relapses presenting an undulating
temperature chart occur. The spleen and liver enlarge, increasing with every febrile attack. Each attack is
accompanied with increased headache, body ache, joint pain with arthritis, malaise, abdominal pain and
intestinal disturbances. There are two main varieties; the Malta fever due to B. melitensis and abortus
fever due to B. abortus; a third type of variety due to B. suis also occurs. Case fatality is low but morbidly
due to microcytic, hypochromic anaemia and chronic debility with depression is very high. Leukopenia with
relative granulocytopenia and monocytosis is common. Diagnosis is made by culturing blood or urine and
complement fixation or agglutination test.
The disease runs a longer and more severe course in Malta fever than in abortus fever. Abortions are common
in cattle due to B. abortus infection but do not occur in human illness. Chronic arthritis, neuritis, meningitis,
orchitis, encephalitis, nephritis, bronchopneumonia, myocarditis, endocarditis, pleurisy, osteomyelitis, may
complicate the illness which may last for 6 months to a year or longer. A small number of cases may go into
a chronic course of illness lasting months and years. Such patients are in a state of ill health manifested by
weakness, fatigue, mental depression, vague aches and pains.
(b) Geographical Distribution.
Malta fever is endemic in Mediterranean region (Malta, Gibraltar, Spain, South France, North and NW Africa,
Mexico, South and Central American, Sudan and Kenya). Abortus fever occurs sporadically in all parts of the
world including India. No epidemics have been reported from any part of the world: but upsurge of the sporadic
cases occurs in various parts from time to time. In India cattle in Maharashtra, Karnataka, Madhya Pradesh,
Tamil Nadu and Orissa have been found infected; in Punjab the infection is in goats.
(c) Incidence.
Studies by the joint FAO / WHO Expert Committee on brucellosis have shown that brucellosis in goats, sheep
and cattle are one of the most important zoonoses in human illness and economic loss in many areas of the
world including Asia. Many endemic areas are known. In India very few surveys have been made. A few surveys
in dairy farms show low incidence. Among workers of the dairy farms at Pune 2% were found serologically
positive for brucellosis; only 0.6% were skin test positive and 0.3% showed apparent symptoms of the disease.
125 blood donors examined serologically for brucellosis were negative to the test. 500 samples of milk from
the buffaloes and cows were examined at Dairy Farm; 2.6% were positive. All 13 animals positive for milk ring
test were also positive serologically.
(d) Agent.
Brucella is a Gram negative, non-motile coccobacillus. It can be cultured from the blood during the febrile
period or from urine after the second week. B. abortus causes bovine infection, B. melitensis causes caprine
infection while B. suis is a porcine infection. Similar organisms have been found in other animals like horse,
mules, dogs and so on. B. abortus needs presence of CO2 for its growth in culture while B. melitensis and

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suis are aerobic. The culture takes a long period to develop, even up to a month or more.
(e) Reservoir and Source.
Goats serve as a reservoir for B. melitensis with inapparent infection in endemic areas around Mediterranean
littoral. B. abortus occurs in cattle causing a febrile illness and abortions; the bovine ‘carrier ship’ is extremely
common. B. suis infection occurs in pigs and can be transmitted to other animals including cattle and goats.
Infection is acquired by these animals through grazing on pastures contaminated with excreta of infected
animals. Cows or goats serve as the source for human infection. Human cases though excrete organisms, do
not normally serve as a source of infection to others.
(f) Mode of Infection.
The entry of the infection is via the oral route. Consuming milk and milk products, from the infected cow and
goat act as the main route and mode of infection. Handling of placenta and uterine discharges or foetus by
dairy farmers and veterinarian and meat by butchers and excreta by personnel engaged in dairy farming or
animal husbandry is known to cause infection. There is some evidence that the disease may be airborne.
Spread through dermal contact in B. abortus infection is also suspected. Thus, brucellosis is primarily an
occupational disease of rural areas, involving farmers, veterinarians, butchers and dairy farmers. Eating of
undercooked meat, pork or beef also acts as a source of infection.
(g) Host.
Man possesses no natural immunity. Repeated sub clinical infection and clinical attack produces immunity for
variable period but less than in typhoid infection.
(h) Incubation Period.
It is variable between a week to a month. Average incubation period is three weeks.
(j) Communicability Period.
Animals are infective throughout the period of their apparent or inapparent infection. Man is infective during
the entire period of illness and for variable length after the apparent clinical remission, just as in enteric fever.
The period of communicability, therefore, is unpredictable, unless the stools and urine do not show growth.
(k) Laboratory Diagnosis.
(i) Sensitization Test.
The antigen ‘brucellin’ 0.1 ml is given intradermally. A raised reddened oedematous area 2-6 cm in
diameter, 4 to 38 hours later constitutes a positive reaction. The reaction is a group specific and not a
species-specific reaction.
(ii) Milk Ring Test (MRT).
The milk sample is thoroughly mixed and poured 2.5 cm high into a small test tube. One drop of the
stained antigen is added and contents mixed thoroughly. Frothing is avoided. It is then incubated at
37°C in water bath for 50 minutes. In positive cases the bacteria are agglutinated and rise with cream
forming a blue cream line. In negative cases, there is a white cream line and the rest of the milk is
stained blue (stained antigen is used).
(iii) Serological Test.
This is carried out on the human and animal sera. A titre of 1:100 confirms infection and a rising titre
up to 1:1000 confirms the active disease. Component fixation and anti-human immunoglobulin tests are
useful in chronic infections.
(l) Treatment.
Treatment options include doxycycline 100 mg twice a day for 45 days, plus streptomycin 1 g daily for
15 days. The main alternative therapy is doxycycline at 100 mg, twice a day for 45 days, plus rifampicin at
15 mg / kg / day (600-900 mg) for 45 days. The optimal treatment for pregnant women, neonates and children
under 8 is not yet determined; for children, options include trimethoprim / sulfamethoxazole (co-trimoxazole)
combined with an aminoglycoside (streptomycin, gentamycin) or rifampicin.

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(m) Prevention and Control.

(i) Pasteurization.
Proper pasteurization or boiling of milk is the most important measure to protect the human population.
(ii) Personal Protection.
Protection of persons exposed to occupational risk by immunization is neither practical nor safe at
present. Use of gloves while handling the meat, placenta and excreta and personal cleanliness, especially
washing hands after work and before food intake are the important precautions.
(iii) Immunization of Animals.
Protection of herds by immunizing with attenuated vaccine is carried out to protect the young animals,
especially the female calves of 5 to 8 months age. This confers a protection throughout their fertile period.
(iv) Elimination of Source.
The elimination of infection from domestic animals especially cows and goats is the surest measures of
eradication of disease but is not a practical proposition as the reinfection is rapidly acquired and the
infection is widespread.

28.21 Anthrax (A22.9).

(a) Introduction.
It is an acute infectious disease of animals particularly affecting cattle, sheep, goats, pigs and horses. In
animals the disease is usually an acute septicaemia and on account of great splenomegaly, is known as
‘splenic fever’. In man it occurs in three forms: cutaneous, gastro-intestinal and pulmonary.
The 2001 anthrax attacks in the US exposed the chilling efficiency of this biological weapon. Five letters
containing anthrax spores were sent to media outlets and politicians, resulting in 5 deaths and 22 cases of
the disease. This incident serves as a stark reminder of the need for constant vigilance and preparedness in
the face of such threats.
(b) Geographical Distribution.
Anthrax is enzootic in both wild and domesticated animals. Heavy contamination of the soil exists in many areas
of the world, particularly in Asia, Southern Europe and Africa. The problem is not as serious in the Western
Hemisphere as it is in other parts of the world. The disease is now essentially an occupational hazard for
agricultural and industrial workers. It may be encountered among muleteers in the army.
(c) Incidence.
The disease often causes serious economic losses in livestock. Human infections in the world have been estimated
to number between 20,000 to 1,00,000 annually. In India, the incidence in the civil population is mostly focal.
(d) Agent.
Causal organism is B. anthracis which is a spore forming, Gram positive, aerobic and facultative anaerobic
large bacillus, commonly seen in chains.
(e) Reservoir.
The spores of B. anthracis are highly resistant to chemical and environmental influence and have a very long
extracorporeal existence. These can survive for years in pastures contaminated by the discharges and blood of
the deceased animals as well as in animal products such as hides, hair and wool. When the livestock becomes
infected by grazing in a contaminated pasture, an enzootic focus of infection is created in that locality. The
anthrax bacillus can also spread from carcasses to healthy animals by flesh-eating birds, animals and insects.
Non-infected material becomes contaminated during transport of vehicles or ships that have recently conveyed
infected bones, hides, hoofs, tusks, horns or hair. Anthrax may be introduced into some countries by feeds
and fertilizers prepared from bones and other parts of animals that die of anthrax.
(f) Source of Infection.
The source for man is the domestic animals, their wool, hide, flesh and excreta.

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(g) Mode of Transmission.

(i) Direct Contact.
This form of infection which is caused by contact with contaminated carcasses or animal by products,
such as wool, hair, hides, skins, blood pigments, bone meals, is by far the most frequent form of anthrax
encountered in agricultural and industrial workers.
(ii) By Ingestion.
The ingestion of insufficiently cooked meat derived from infected animals is another source of infection.
Severe outbreaks in man have been traced in Africa to wildlife, notably hippopotamus, elephants and
other animals whose flesh may be eaten. Similarly in certain areas inhabited by aboriginal tribes in India,
who consume flesh of dead animals, this mode of spread is well known.
(iii) By Inhalation.
The inhalation form of anthrax amongst wool sorters or shearers, called ‘wool sorters’ disease, is now
rarely encountered. However, health authorities should be on the alert for local epidemic of this type.
(h) Human Host.
Man possesses no immunity against B. anthracis and is highly susceptible to infection. With very strict controls
in force, danger of this infection is remote except among those who habitually come in close contact with
animals. Such persons are shepherds, butchers, grooms, cowherds, veterinary personnel, workers in wool, hair,
hides and skins and occasionally the pathologists.
(j) Incubation Period.
The average incubation period is 1 to 3 days.
(k) Communicability Period.
Animals are infective from the time the clinical manifestations occur, throughout the disease and even after
the death for a long time. In fact, most of the human infections occur after the death of the animal.
(l) Treatment.
Hospitalization is required for all human cases identified. Individuals exposed may receive prophylactic
treatment. Antibiotics, particularly penicillin, are effective against this disease. Prompt treatment can reduce
case-fatality rate to <1%. Vaccines are also available for livestock and humans in limited supply. Human
vaccines are limited to those with possible occupational exposure.
(m) Prevention and Control (In Man).
(i) Isolation.
The patient is admitted to hospital and is isolated in infectious disease ward. There is no case of infection
from human source on record in the Armed Forces.
(ii) Disinfection.
All discharges should be burnt concurrently and all bed linen and all other articles contaminated by him
disinfected terminally. Disinfection of the lines as described in chapter XXVII should be carefully carried
out.
(iii) Protective Clothing.
Attendants should wear gowns, gauze masks and rubber gloves.
(iv) Notification.
Routine notification including to the civil health authority should be carried out.
(v) Epidemiological Investigation.
Every effort should be made to trace the probable sources of infection, which will almost certainly be
an animal. In this, close liaison with the veterinary authorities should be maintained.

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(vi) Immunization.
Both an attenuated live vaccine and a killed vaccine have been developed. However. the only human
vaccine in current use in United States is the killed vaccine derived from a component of the exotoxin
and is very effective. The vaccine is given parentally with three doses given at 2-week intervals followed
by three booster inoculations at 6 monthly intervals and the annual booster inoculations.
(n) Prevention and Control (ln Animals).
This problem is essentially that of veterinary authorities both military and civil. However, in the absence of such
authorities, medical officers may have to act. The carcass of an animal died of anthrax or suspected anthrax
must not be cut open and must be disposed as per standard guidelines.
(o) Prevention in Industry.
The following measures must be taken for anthrax prevention in all industries where contaminated materials
are likely to be handled:
(i) Suspected anthrax materials should be handled separately in a place where there are adequate
exhaust facilities.
(ii) Protective clothing should be supplied to all employees working with potentially contaminated
materials.
(iii) Proper health education to the workers, regarding the cause, nature and control of anthrax and
adequate medical attention should be given to all cuts, scratches and pimples.
(iv) All dust and dirt from the floors, walls and vehicles should be burnt after cleaning by wet sweeping
or by suction method.
(v) All animals are passed through an arsenate bath before sheering. All wool, hides, skins and other
suspected materials which are likely to have been contaminated by anthrax, should be properly disinfected
by the ‘Duckering’ disinfection process. This consists of the following steps: -
(aa) Render the spores susceptible to disinfectant by agitating the material by rakes in alkaline
soap water at 40°C for half an hour.
(ab) Expose it to 2.5 percent formalin solution under agitation for half an hour.
(ac) Dry in hot air current at 71°C and cool it down.
(ad) Warehouse it for a few days before use.
(ae) Recover the grease from the effluent by trapping before it is finally disposed off. The grease
must be properly burnt as it may contain viable spores.

28.22 Tetanus (A35).

(a) Introduction.
Tetanus is a disease characterized by series of tonic spasms which may be local or may involve the whole of
the somatic muscular system, leading to ultimate exhaustion and death about a week later due to respiratory
failure. The frequency with which the masseter muscles are involved has given rise to the popular term ‘lockjaw’.
In protected individuals the disease is milder, often localized and without the development of reflex spasms,
if they occur at all. The case fatality rate varies from 40 to 80 percent.
(b) Geographical Distribution.
The disease is worldwide in distribution. It is most prevalent in the tropical countries. From 1990 to 2019,
the incident cases of tetanus decreased by 88%. However, the disease still causes around 50,000 deaths
worldwide annually and especially affects regions where sanitation is lacking and vaccination rates are low.
Even though South Asia still sees more cases of tetanus than any other region, in just three decades the
number of new infections has fallen massively, from close to 4,00,000 infections in 1990 to around 30,000
in 2019. Several countries, such as India, Pakistan, Chad and Somalia, had tetanus infection rates higher
than 20 per 1,00,000 people. But by 2019, infection rates had declined in many countries and only a few
countries worldwide had infection rates of tetanus greater than 5 per 1,00,000 people per year.

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Neonatal tetanus accounts for about half of tetanus deaths in developing nations. India has completed validation
of maternal and neonatal tetanus elimination in all of its 36 states and union territories in April 2015. The
incidence of tetanus in the Armed Forces is not known. In civil population it is much higher due to lack of
specific protection, late and faulty treatment of injuries, wrong beliefs and unclean habits.
(c) Agent.
The causal organism is Clostridium tetani. It is an anaerobic spore bearing organism. On gaining entrance into
the tissues, spores revive under anaerobic conditions produced by local oligemia, due to tissue damage and
necrosis and pyococcal infection. Assuming slender, 5 micron long, gram-positive, rhabdite forms with rounded
ends, looking like drumsticks, they multiply. The exotoxin, which is produced by them, while themselves remaining
topically stationary without circulating in the system, has a strychnine like action on the central nervous system.
(d) Reservoir.
The organism is a commensal of equine and also bovine and human intestines. Soil, contaminated by the
excreta of these animals, especially the well manured alluvial soil, harbours anaerobic spores of Cl. tetani.
The immediate source of tetanus infection is, therefore, the soil; the cultivated soil being the most dangerous
source of infection. Objects contaminated with spore-bearing dirt are also dangerous.
(e) Host.
Man possesses no natural immunity against Cl. tetani or its exotoxin. The ecology of the organism in the
tissues, however, depends upon several factors. which, therefore, determine the development and severity of
the disease. Deep penetrating or badly lacerated wounds allow spores to develop better due to comparatively
severe oxygen depletion and necrosis further favoured by the presence of pyococcal organisms and foreign
bodies. Tetanus may also develop in unclean superficial wounds with scab formation or even after their healing
or from infection of body cavities. Lack of personal hygiene and / or inefficient first aid are the most important
predisposing causes of developing tetanus.
All ages and both sexes are susceptible. However, children are more prone to infection due to their higher
chances of getting injured added with neglect of the wound. For the same reasons male population in rural areas
are more prone to get the disease. In rural areas proximity to animals also increases the risk. Armed Forces
personnel are a specially vulnerable group due to their higher liability to sustain injuries, their contamination
with polluted spore bearing soil, in field service, frost bite, trench foot and delayed expert attention, especially
in combat and while on patrol. Personnel in Animal Transport (AT) Units, paratroopers, aircrew and to a lesser
extent the Mechanical Transport (MT) drivers and Motor Cycle (MC) dispatch riders are exposed to greater risk.
Although the infection is ubiquitous and the chances of its contraction are omnipresent, the prevalence of
disease depends on various environmental and host factors, the state of health consciousness and education
of the people, facilities for medical treatment and the state of artificial immunity. Widespread poverty. religious
prejudices and traditional unhygienic customs and habits, lack of mother and child health services and health
education are important social factors responsible for high prevalence of the disease in all developing countries.
(f) Mode of Infection.
Tetanus spores gain entrance in tissues through a cut or a puncture, laceration or other wounds contaminated
with spore bearing soil or any other substances contaminated with it. Unusual routes of infection are the use
of infected surgical gut or following an intramuscular injection of a substance which causes local necrosis
or extraction of a tooth in presence of oral sepsis and lack of oral hygiene. Frost bitten toes, burns, chronic
suppurative otitis media, umbilical cord sepsis, diabetic gangrene may also facilitate revival of pre-existing
spores or get freshly infected. Autoinfection of an injured person by his own faecal material is also possible.
Topical application of contaminated drugs, dressing, plaster of paris and talcum may also introduce infection.
(g) Incubation Period.
In unprotected individuals it varies from 3 to 21 days, the average being about 7 days. It may be as short as
one day. In mild infection or in partially protected individuals. it is lengthened to 50 days or more.
(h) Treatment.
Tetanus is a medical emergency requiring:
(i) Care in the hospital.

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(ii) Immediate treatment with medicine called Human Tetanus Immunoglobulin (TIG)
(iii) Aggressive wound care
(iv) Drugs to control muscle spasms.
(v) Antibiotics
(vi) Tetanus vaccination.
(vii) People who recover from tetanus do not have natural immunity and can be infected again and
therefore need to be immunized.
(j) Prevention and Control.
(i) Primary Prevention.
Active pre-exposure immunization is the most important primary preventive measure (for details refer to
chapter XXIII).
Tetanus toxoids are inactivated exotoxins of C. tetani and it induces protective antibody to tetanus
exotoxin. There are two types of toxoids-absorbed and fluid; absorbed toxoid is preferable because of its
ability to produce higher and long-lasting immune response in comparison to plain or fluid toxoid. It is
the most extensively used antigen with a high degree of efficacy and safety.
Two preparations of Tetanus Toxoid Containing Vaccine (TTCV) available for active immunization are as follow:
(aa) Combined vaccine-DPT
(ab) Monovalent vaccines
O Plain or fluid (formal) toxoid
O Tetanus vaccine, adsorbed (PTAP, APT)
(aa) Combined Vaccine.
Trivalent vaccine: Diphtheria, pertussis and tetanus (DPT)
Bivalent vaccine: Diphtheria and tetanus (DT and Td) toxoid combination: DT vaccine is used in
children (under 7 years). Td vaccine contains an equivalent amount of tetanus toxoid and reduced
amount of diphtheria toxoid in comparison to DPT or DT.
WHO recommends the use of Td vaccine in place of monovalent TT to boost up diphtheria immunity
in the community.
Pentavalent: DPT with hepatitis B and Haemophilus influenzae (Hib)
Tetanus vaccine is offered routinely to infants (Expanded Immunization Programme) in combination
with diphtheria vaccine and killed B. pertussis organisms as DPT vaccine. According to NIS, primary
course consists of 3 doses of DPT / Pentavalent vaccine starting at 6 weeks of age at intervals
of 4-8 weeks, followed by booster at 18 months of age, second booster at 5-6 years of age and
a third booster of Td after 10 years of age.
(ab) Monovalent Vaccine.
Purified tetanus toxoid (adsorbed) has largely supplanted plain toxoid because it stimulates a higher
and longer-lasting immune response than plain toxoid. However, the latter may be employed for
purpose of booster injection when rapid protection is indicated.
A primary course of immunization consists of two doses of tetanus toxoid adsorbed (each dose
0.5 ml, injected into the arm) given at intervals of 1-2 months. The longer the intervals between
the two doses, the better is the immune response (for details refer to chapter XXIII).
(ii) Secondary Prevention.
(aa) First Aid.
Efficient first aid in all injuries, frostbites and burns is an important prophylactic measure.

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(ab) Surgical Toilet.

Early surgical treatment by debridement and repair of wounds without primary suturing, antibiotic
therapy and further efficient follow up of the wounds are the secondary preventive measures of
paramount importance.
(ac) Isolation.
On occurrence of tetanus the patient should be isolated in a secluded room in hospital.
(ad) Treatment.
Treatment with antibiotics, anti-tetanic serum and sedatives or hypnotics and corticosteroids should
be pursued. Iron lung may become necessary.
(ae) Disinfection.
All discharge from the wound should be burnt and soiled clothes disinfected.

Suggested Reading.
1. National Rabies Control Programme [Internet]. National Center for Disease Control (NCDC). [accessed 2024 Feb 26].
Available from: https://ncdc.mohfw.gov.in/national-rabies-control-programme/
2. Tejpratap S.P. Tiwari, MD; Pedro L. Moro, MD, MPH; and Anna M. Acosta, MD. Pinkbook [Internet]. CDC. 2020.
Available from: https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html
3. World Health Organization. Tetanus [Internet]. Who.int. World Health Organization: WHO; 2023. Available from: https://
www.who.int/news-room/fact-sheets/detail/tetanus
4. The Rudolf-Rudi doctrine of Spiritualism [Internet]. The Rudolf-Rudi doctrine of Spiritualism. 2024 [accessed 2024
Feb 26]. Available from: https://bhavanajagat.com/
5. Arambulo PV, Thakur AK. Impact of Zoonoses in Tropical America. Annals of the New York Academy of Sciences.
1992 Jun 1;653(1 Tropical Vete):6–18.
6. Bacterial Infections of Humans. Springer eBooks. 1991.
7. Shaw MM, Leggat PA, Williams ML. Intradermal pre-exposure rabies immunisation in New Zealand. Travel Medicine
and Infectious Disease. 2006 Jan;4(1):29–33.
8. Bacterial Infections of Humans. 1998.
n

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Chapter
XXIX
HELMINTHIASIS

29.1 Introduction.
Helminth means worm. Helminths are multicellular, bilaterally symmetrical parasites belonging to class Nematodea,
Phylum Nemathelminthes. The diseases caused by them are grouped under the heading “helminthiasis”.

29.2 Prevalence.
(a) Global Scenario.
The World Health Organization (WHO) estimates that 1.5 billion persons (24% of world’s population) are infected
with Soil Transmitted Helminth (STH) infection worldwide. These infections affect the poorest and most deprived
communities with poor access to clean water, sanitation and hygiene in tropical and subtropical areas, with the
highest prevalence reported from sub-Saharan Africa, China, South America and Asia. They are transmitted by
eggs present in human faeces, which in turn contaminate soil in areas where sanitation is poor.
(b) Indian Scenario.
Prevalence of STH among children was reported as high as 50% in a systematic review published in 2017.
Community-based study conducted during 2017–2018 in southern part of India reported an age-adjusted
prevalence of 21% across all age groups. There is heterogeneity in the prevalence and burden of STH, likely due
to diverse climactic and geographic conditions, socio-demographic status, and behavioural and cultural practices
of the population.
(c) Armed Forces.
The prevalence in the Armed Forces follows that in the civil population. Recruits hailing from high endemic
areas may have high prevalence while those from areas of low endemicity show a lower rate of infestation. As
the prevalence is higher in rural than urban areas, it probably accounts for higher incidence in the Army as
compared to Air force & Navy. As a result of treatment and comparative freedom from reinfection, these rates
naturally fall very considerably after enrolment. Some personnel are however reinfested when they spend their
leave in their homes in rural areas.

29.3 Classification.
Helminths can be classified into Phylum Nemathelminthes, Class Nematoda or round worms and Platyhelminthes, Class
Cestoda or tape worms and Class Trematoda or flukes. They can be grouped according to their mode of transmission
such as soil, food and animal borne (Table 29.1). In this chapter only those helminths which are of importance in the
Armed Forces in India are described. Arthropod borne helminthiasis i.e. filariasis is described in chapter XXXIV.
Table 29.1 : Classification of Helminths
Mode of Transmission Nematodes Cestodes Trematodes
Soil transmitted. − Ascaris lumbricoides
− Ancylostoma duodenale
− Necator americanus
- -
− Trichuris trichiura
− Strongyloides stercoralis
Contagious (Faecal − Enterobius vermicularis − Taenia
borne) − Echinococcus -
− Hymenolepis nana

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Mode of Transmission Nematodes Cestodes Trematodes

Arthropod transmitted − Wuchereria bancrofti
− Brugia malayi - -
− Onchocerca volvulus
Snail & Cyclops − Dracunculusis medinensis − Schistosoma
transmitted (Guinea-worm) haematobium
− Schistosoma
japonicum
- − Schistosoma
mansoni
− Fasciola hepatica
− Fasciolopsis buski
− Paragonimus
westermani
− Clonorchis sinensis
Food & animal − Trichinella spiralis − Taenia solium
transmitted − Taenia saginata -
− Diphyllobothrium
latum

29.4 Soil Transmitted Helminths.

These helminths pass their ova into soil wherein they proceed to develop into infective forms. Without soil life they
cannot become infective. Man acquires infestation from soil either through the oral route or by penetration of the skin.
The important helminths of this group are Ascaris lumbricoides, Ancylostoma duodenale, and Necator americanus; all
are nemathelminthes.

29.5 Ascaris Lumbricoides.

The common name is ‘round worm’. The infestation is termed ‘Ascariasis’. Distribution is worldwide. Infestation is most
common in moist, hot tropical countries, where hygienic disposal of faeces is inadequate, and the soil is of clay type.
The high atmospheric and terrestrial moisture and temperature favour development of the infective stage of the eggs.
Children are more frequently and more heavily infected than adults. This is more likely to occur in those localities
where defecation and faecal contamination occur indiscriminately near the dwellings. The infestation is very heavy in
rural India and in insanitary urbanized areas. Permanent habitat of the adult worm is the small intestine of man. No
natural or induced immunity exists.
(a) Morphology.
The female adult can reach up to 20 cm to 30 cm in length, and adult males up to 15 cm to 20 cm. The
nematodes are pink / yellow  /  white roundworms. The female worms are thicker and have a straight rear end.
The male worm is slenderer with a ventrally incurvated rear end with two retractile copulating spicules. The
average life of the adult parasite is one year, after which it dies.
(b) Eggs.
Fertilized egg is round or oval, mamillated, bile stained and brownish in colour, 60-75 microns in length by
40-50 microns in breadth. It contains a large conspicuous unsegmented ovum and floats in a saturated solution
of common salt. The female is capable of liberating eggs even if not fertilized. Unfertilized egg is narrower and
more elliptical in shape with thinner shell containing a small, atrophied ovum and does not float in salt solution.
Fertilization takes place in small intestine.
(c) Diagnosis.
Stool examination for evidence of eggs is the commonest laboratory method. The presence of worms can be
demonstrated by radiography with a barium meal, which on being ingested by the worm within 4-6 hours, casts

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an opaque shadow. The confirmation of diagnosis is by finding the adult worm in stool or vomit with or without
an anti-helminthic administration.
(d) Reservoir and Source of Infection.
Reservoir is an infested person discharging eggs in and about houses where facilities for proper faecal disposal
are lacking. The adhesive nature of the egg probably results in gradual contamination of most of the objects in
houses and public places as well as food, particularly vegetables grown in soil where faeces is used as manure.
(e) Life Cycle.
Fertilized eggs passed in the faeces are not infective immediately. In the soil a rhabditiform larva develops within
the eggshell in 10-40 days. The embryonated eggs may be swallowed through contaminated water or vegetable or
through soil or contaminated fingers. The eggshells are digested by the digestive juices and the larvae penetrate
the intestinal wall; carried to the liver via the portal circulation and enter the pulmonary circulation through the
right heart. Here they grow, moult twice and enter the lung alveoli. Subsequently, they crawl up the bronchi and
trachea, are propelled into the larynx and pharynx and then swallowed down the oesophagus to the stomach
and finally localize in the small intestine. Sexual maturity takes place, and the gravid female begins to discharge
eggs in about 2 months from the time of infestation. Embryonated eggs remain viable in soil for months and
even years under favourable conditions. The life cycle is shown in Fig 29.1.

Fig 29.1 : Life Cycle of Ascaris lumbricoides

(f) Pathogenicity and Clinical Features.
(i) Larval Phase (Larval Ascariasis).
Clinical manifestations may first appear in relation to pulmonary migration of the larvae. They range from
a mild dry cough to severe dyspnoea, cyanosis, whooping type of cough and haemoptysis. There may be
urticarial rashes, eosinophilia, asthmatic attacks, and mottled lung infiltration noticed in chest radiograph.

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This syndrome is called Loeffler’s syndrome which may turn out to be fatal. The nature and severity of
symptoms depend upon the number of invading organisms and on the degree of the sensitivity of the
host. Children with ascariasis suffer from hepatomegaly more commonly than children free of infection.
Eosinophilia is quite a common feature at this stage and later.
(ii) Adult Stage (Intestinal Ascariasis).
Presence of many worms in the intestine increases the abdominal contour producing a protuberant abdomen
and lumbar lordosis. They rob the host of his nutrition and give rise to colicky pain. They may produce
appendicular, biliary, and intestinal obstruction. They may migrate into the peritoneal cavity through a
perforated intestinal ulcer.
(g) Prevention and Control.
(i) Primary Prevention.
Methods based on primary prevention are the most effective in interrupting transmission. Health education
on these aspects, taking into consideration the life cycle of the parasite and the peculiar ecological, social,
and cultural circumstances that prevail in a community are the ultimate keys to the control of ascariasis.
These are as follows:
(aa) Sanitary disposal of human excreta to prevent or reduce faecal contamination of the soil.
Mothers should be educated regarding the dangers of indiscriminate defecation by children. Open
air defecation in general, should be prohibited. On the other hand, effective and acceptable sanitary
facilities should be provided.
(ab) Safe drinking water from a safe source, after proper treatment including filtration should be
provided. Water hygiene discipline in homes should be strictly followed where again, education of
mothers is important.
(ac) Food hygiene by way of thorough washing of vegetables, fruits or items consumed raw should
be insisted upon.
(ad) Personal hygiene in form of proper washing of hands before taking any meal and after ablution
should be practiced, biting of nails or sucking of thumb / fingers should not be practiced.
(ii) Secondary Prevention.
Ascariasis is treated with albendazole, mebendazole or ivermectin. Dosage is the same for children above
2 years of age as for adults. Albendazole should be taken with food. Ivermectin should be taken on an
empty stomach with water. Early diagnosis and treatment are important tools in prevention and control
of transmission of the disease in low endemic areas. Even in hyperendemic areas they form a part of
mass treatment and thereby a useful and important option. However, mass treatment will not interrupt
transmission of the disease but merely reduce the worm load. Medical therapy will target adult worms,
which is the reason why treatment should be repeated after one to three months, to give time to larvae
to mature to adulthood and be susceptible to therapy. To eliminate the morbidity of STH in preschool and
school children by 2030, breaking the chain of transmission is essential. This could be attained by improving
sanitation and hygiene practices with preventive strategies. Hence, WHO implemented biannual deworming
with 400 mg of albendazole to all high-risk groups including pregnant women.
In 2015 the Government of India launched the fixed-day Anganwadi and school-based National Deworming Day
to deworm all children aged 1-19 years. The National Deworming Day is conducted in all states / UTs in 2 rounds
– 1st round on 10th February followed by 2nd round on 10th August every year.

29.6 Ancylostoma Duodenale (Ancylostomiasis).

(a) Introduction.
Common name is the old world ‘hook worm’. The very closely allied species is Necator americanus, the new
world hook worm. The intestinal infestation is commonly termed ‘ancylostomiasis’ and the clinical syndrome of
anaemia is usually called the ‘hook worm disease’.

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(b) Geographical Distribution.

Of the estimated more than 1.5 billion people worldwide at risk for infection with Ancylostoma and other STH, half
of the infections occur in Asia and the Pacific where tropical climate, overcrowded population, poor hygiene, and
poor sanitation are present. Ancylostoma, along with the other hookworms, cause more disability than mortality.
Hookworm-associated malnutrition and anaemia account for the loss of up to 4.1 million disability-adjusted
life-years (DALY) annually. The highest at-risk population to contract Ancylostoma infections are the pre-school
and school-aged children and travellers who return from tropical countries. Additionally, people in close contact
with dogs and cats are at risk to acquire zoonotic Ancylostomiases infection. The incidence of Ancylostomiases
infection is tied to seasonal distribution where during the summer-autumn period, the incidence is more prevalent.
Endemicity Index- Morbidity & mortality due to this worm depends much on the worm load. Chandler’s Index is
still used in epidemiological studies to assess worm load and the effect of mass treatment in different populations
(Table 29.2).
Table 29.2 : Assessment of Worm Load (Chandler’s Index)
Average number of eggs per gram of stools Significance
Below 200 Hookworm infection is not of much significance
200-250 May be regarded as potential danger
250-300 Minor public health problem
Above 300 Important Public health problem
(c) Morphology.
The adult worm is cylindrical, greyish white and about one cm long. The anterior end of the worm is bent slightly
to form a hook. In A. duodenale the buccal capsule is provided with six cutting teeth; four hook like triangular
plates on the ventral surface and two knob like on the dorsal surface. Necator americanus has got four chitinous
plates instead of six cutting teeth, two on the ventral surface and two on the dorsal surface; hence they are
less invasive and less effective blood suckers. Sexes are separate. The male is smaller, and its posterior end is
expanded in an umbrella fashioned copulatory bursa, whereas in the female it is tapering.
(d) Egg.
It is colourless (not bile stained) with a thin eggshell containing segmented ovum usually with four blastomeres
and a clear space between the eggshell and the ovum. Eggs float in saturated solution of common salt. The
eggs are oval or elliptical in shape, measuring 65 microns in length by 45 microns in breadth.
(e) Diagnosis.
Diagnosis of ancylostomiasis is made by stool examination for ova or adult forms. The ‘hook worm disease’
is assessed by taking a complete hemogram, intradermal test using antigen prepared from adult worms may
sometimes be used for epidemiological surveys. In the laboratory the faeces are examined for the ova by the
following methods: -
(i) Direct Method.
After making a saline suspension on a glass slide and covering the suspension with a cover slip.
(ii) Concentration Method.
A moderately dense suspension of faeces is made in a small bottle with a wide mouth, such as an empty
penicillin vial, using saturated solution of common salt. The bottle is then filled to the brim with a salt
solution. A microscope slide is put carefully on the top of the bottle, so that the fluid is in contact with the
slide. It is left undisturbed for 20 min. Then the slide is removed vertically up and turned upside down, so
that adherent fluid is upper most. A cover slip is put and examined.
(f) Reservoir and Source of Infection.
Reservoir is an infected person discharging eggs in the faeces. The usual immediate source of infection is soil
contaminated with infective larvae.

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(g) Life History and Mode of Transmission.

The eggs with fertilized ovum are passed in the faeces of the human host into the soil. From each egg a
rhabditiform larva (250 microns) hatches out in the soil. It moults twice and develops into filariform larva
(500 microns-600 microns) which is the infective stage of the parasite. The time taken for development from egg
to filariform larva is on an average 8-10 days. The optimum temperature required for development is between
28°C to 32°C for N.americans and 5°C to 8°C lower than that for the A. duodenale. Direct desiccation kills
larva quickly; hence moisture, is essential for its survival. This is usually supplied to the soil by frequent light
showers of rain. Sandy or loamy soil is most suitable for hookworm larvae but not clay. Under favourable condition
these larvae can remain infective for two months. Gaining entrance into a new human host through the bare
skin, the infective filariform larvae cast off their sheaths and penetrate the skin deeper. Fanning practices in
which raw manure infested with larvae is used and when hands must be used for harrowing the earth as in
potato farming, carry the risk. The custom of walking barefoot in the polluted fields and in deep mining, where
defecation is indiscriminate also carries risk of infection. Ancylostoma may at times, utilize the oral source of
entry. On reaching the subcutaneous tissue, the larvae enter the venous circulation and then via the right heart
into the pulmonary capillaries, breaking through the capillary wall and entering the alveolar spaces. They then
migrate upto the bronchi, trachea, larynx, and crawl over the epiglottis to the pharynx and they are ultimately
swallowed. During migration a third moulting takes place, and a buccal capsule is formed. It takes about 10
days for migration from skin to the small intestine. The growing larvae settle down in the small intestine, undergo
a fourth moulting and develop into adolescent worms. In 3-4 weeks’ time they are sexually matured, and the
fertilized females begin to lay eggs. The adult worm anchors to the mucosa of the small intestine particularly
the jejunum, less often of the duodenum, and sucks blood. Eggs are passed in the faeces. The cycle is then
repeated. The interval between the time of skin penetration and the first appearance of eggs in the faeces
is about six weeks. Symptoms may take a few weeks, months or even years to appear, depending upon the
intensity of infection, state of nutrition and general condition of the host or may not appear at all. However,
they remain potential source of infection as long as they are infected and continue to pollute the soil. The life
cycle is shown in Fig 29.2.
(h) Pathogenicity and Clinical Features.
Both genders are equally susceptible to infection. Animal experiments have shown that partial immunity develops
with repeated and continuous infection. The clinical effects produced vary from individual to individual.
(i) Larval Form.
Dermatitis called the ‘ground itch’ occurs at the site of entry. It is more commonly seen on the outer margin
of the sole and under the toes and generally disappears in one to two weeks. Ground itch may be marked
by epidermophytosis. Bronchitis, bronchopneumonia and asthmatic spasms may occur at the time of larval
migration through the lungs. However, pulmonary reactions are apparently milder as compared with those
of ascaris, particularly in Necator infection. A marked eosinophilia occurs at this stage.
(ii) Adult Worm.
Anaemia of microcytic hypochromic type is the prominent feature of the hookworm disease. A direct
relationship exists between anaemia and hookworm infection. This may be accompanied with epigastric
discomfort, oedema and cardiac manifestation. The factors generally held responsible for its causation are
loss or failure of absorption of iron, protein or other essential constituents of red blood cells; erythropoietic
dysfunction due to toxins, intestinal malfunction or malabsorption and liver damage. The degree of anaemia
varies with the intensity and duration of infection, the age, sex, physical condition, and nutritional status of
the host. Protein deficiency in diet aggravates the condition while animal protein in diet increases resistance
to anaemia although it has no effect on infection itself.

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Fig 29.2 : Life Cycle of Ancylostoma Duodenale / Necator Americanus

(j) Prevention and control.
The sheet anchor is to prevent contamination of soil. To prevent development of the infective stage of the parasite
or exposure to it, the following measures should be adopted.
(i) Sanitary Measures.
Provision of proper latrines, proper disposal of faeces and prohibition of indiscriminate defaecation are the
trio of first importance. Shallow trench latrines are dangerous; deep trench latrines and bore hole latrines
are better: trenching of stool is inferior to composting; septic tank or sewage disposal plants are the best
disposal systems.
(ii) Health Education.
It is very important as only the provision of sanitary latrine does not ensure its’ use. All should be educated
not to walk bare foot and to wear footwear in the neighbourhood of latrines and not to use human manure
before two months of its maturation.
(iii) Mass Deworming.
The WHO recommends mass deworming for STH depending on the prevalence of worm infection. Deworming,
using single dose albendazole (400 mg) or mebendazole (500 mg), is recommended as a public health
intervention to reduce the worm burden of hookworm. Further treatment of anaemia is important in individual
cases of hookworm disease.

29.7 Food and Animal Transmitted Helminths.

In these helminths the infective stage develops in animals whose flesh is an important item of food for man. They are

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the cestodes- Taenia saginata (beef tape worm), Taenia solium (pork tapeworm), Diphyllobothrium latum (fish tapeworm);
and a nematode - Trichinella spiralis.

29.8 Taenia saginata and Taenia solium (Taeniasis).

(a) Introduction.
T. solium is the pork tape worm, the ‘armed ‘ tape worm of man and T. saginata is the beef tape worm, the
‘unarmed’ tape worm of man. Adults of both tapeworms infest the small intestines of man, and this infestation
is commonly termed “Taeniasis”. The larval stages infect the porcine and bovine muscles; the larva of T. solium
(Cysticercus cellulosae) may infect man also.
(b) Geographical Distribution.
The infection is common in countries where sanitation is poor and where animals are allowed to graze in the
neighbourhood of human habitation. T. Saginata infestation is prevalent among the beef eating population and
T. Solium is common among pork eaters. Neurocysticercosis is the most frequent preventable cause of epilepsy
worldwide and is estimated to cause 20-30% of all epilepsy cases in countries where the parasite is endemic.
The WHO Foodborne Disease Burden Epidemiology Reference Group identified T. solium as a leading cause of
deaths from food-borne diseases, resulting in a considerable total of 2.8 million disability-adjusted life-years
(DALYs). The total number of people suffering from Neurocysticercosis, including symptomatic and asymptomatic
cases, is estimated to be between 2.5–8 million.
(c) Morphology.
Adult tape worms are white, semitransparent, 5-10 m in length and consists of head(scolex) neck and segments
(proglottides). Scolex in T. saginata measures 1-2 mm in diameter, quadrate in outline and has four lateral
circular suckers but no rostellum and hooklets. The neck is thin and tapering behind the scolex. Scolex in T.
solium is 2-3 mm long and has a short rostellum and is provided with a double row of 20 to 50 hooklets. The
number of segments varies from 1,000-2,000 in T. saginata and 800-900 in T.solium. The segments near the
scolex are immature, in the middle portion they are mature showing both the sex organs and at the tail-end
are seen gravid segments. The uterus in the gravid segment consists of a central longitudinal stem with lateral
dichotomous branches which are 5 to 10 in T. solium and 15 to 30 in T. saginata.
(d) Eggs.
Eggs are liberated by the rupture of gravid proglottides. The eggs are spherical and brown due to bile stain, 30-
40 microns in diameter with thick radially striated wall containing hexacanth (3 pairs of hooklets) embryo. They
do not float in saturated salt solution. They may remain viable for 8 weeks. Eggs of T. saginata are infective to
cattle and those of T. solium are infective to pigs and man.
(e) Diagnosis.
Presence of gravid segments on naked eye examination of stools is an evidence of tape worm infestation. These
should be collected for further microscopic examination for determining the type of worm and demonstration of
eggs. The sample of faeces after anti-helminthic treatment should be screened and examined for the presence
of scolex to confirm cure. Cysticercus cellulosae can be diagnosed by biopsy examination and radiological
examination revealing calcified cysts.
(f) Life Cycle.
Man is the sole definitive host; the adult tapeworm inhabits man’s intestinal canal. The gravid segments of the
worm containing eggs are passed in faeces. The cow / pig acquires infection by eating grass or drinking water
which has been contaminated by human faeces. After reaching the stomach of the cow or pig the eggs release
the contained larvae which pierce the gut wall and are carried via the blood stream to the muscles and other
organs where they encyst. This stage is known as Cysticercus bovis (measly beef in cattle) and Cysticercus
cellulosae in pigs (measly pork). The cysts resemble small mistletoe berries. For their further development the
encysted larvae must be consumed by man while they are in a viable stage, and this occurs when man eats
undercooked beef or pork. Encysted larvae are released in man’s stomach, pass into the intestine, and then
develop into adult tapeworms. The important difference in infestation by these two tape worms is that while
for T. saginata man never acts as an intermediary host, he may do so for T. solium when he swallows eggs
through contaminated water or food or by regurgitation of a gravid segment from his intestine to his stomach.

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The cysticerci developing in the muscles or brain give rise to various syndromes. Man may thus harbour both
adult T. solium and its larval form. After the larvae are ingested, it takes 8 to 10 weeks for the worm to develop,
become sexually mature and produce eggs. Their life cycle is shown in Fig 29.3 & 29.4.
(g) Reservoir.
Reservoir is an infected person discharging eggs in faeces. Immediate source of infection is the flesh of the
infested animal. Person harbouring T. solium can, however become a source of infection to another person or
to himself. Man remains a source of infection for 10 years or even 30 to 40 years. Susceptibility is universal
and there is no acquired immunity.
(h) Pathogenicity and Clinical Features.
Adult worm living in the intestine usually does not give rise to any symptoms. It may sometimes give rise to
vague abdominal discomfort, chronic indigestion, diarrhoea alternating with constipation, anaemia, anorexia,
loss of weight, nervousness, and insomnia. Cysticercus cellulosae may give rise to symptoms referable to the
particular organ affected; thus, it may produce epilepsy if the brain is the seat.
(j) Prevention and Control.
(i) Proper animal husbandry and hygienic feeding of cattle and pigs and avoidance of eating underdone
beef or pork are the most important measures for prevention and control. Adequate meat inspection and
health education of the consumer supplement these measures.
(ii) Proper sewage disposal, prohibition of indiscriminate defecation, health education of the people are
the long-term control measures.
(iii) The treatment can be done on an individual basis or as preventive chemotherapy depending on the
local circumstances and the control approaches being implemented. Taeniasis can be treated with single
doses of praziquantel (10 mg / kg) or niclosamide (adults and children over 6 years: 2 g, children aged
2–6 years: 1 g). Albendazole at 400 mg for 3 consecutive days has also been used. Personal hygiene and
hygiene of all the food handlers is important to prevent likelihood of ingestion of eggs of T. solium through
auto infection and infection from others.
(iv) In neurocysticercosis, since the destruction of cysts may lead to an inflammatory response, specialised
treatment is required and may include long courses with high doses of praziquantel and / or albendazole,
as well as supporting therapy with corticosteroids and / or anti-epileptic drugs, and possibly surgery. The
dosage and the duration of treatment can vary greatly and depend mainly on the number, size, location
and developmental stage of the cysts, their surrounding inflammatory oedema, acuteness and severity of
clinical symptoms or signs.
(v) Those harbouring the adult worms infect the cows and pigs and hence should be treated until
the scolex is excreted. The patient of T. solium infestation should be isolated and treated with the same
precautions as a case of enteric fever. He should be warned of the danger of auto- infestation and hence
must practice scrupulous personal hygiene. Stools should preferably be destroyed by burning.

29.9 Echinococcus Granulosus (Echinococcosis).

(a) Introduction.
This is an infestation of the small intestine of a dog with a tape worm, Echinococcus granulosus. It constitutes a
zoonosis as the larval form of the worm produces the hydatid disease in human beings as well as in sheep and cattle.
(b) Distribution.
Although the hydatid disease is worldwide in distribution, it is mostly found in those countries where sheep and
cattle raising is an important industry resulting in close association between man, sheep, and dog. The disease
is more prevalent in the subtropics and in temperate climate than in the tropics.
(c) Morphology.
Adult worm is 3 to 6 mm long. It has a scolex, neck and strobila consisting of 3 to 4 segments. The first segment
is immature, the second one is mature and the next are gravid. The head bears four suckers and a rostellum
with two circular rows of hooks. The neck is short and thick. Eggs resemble those of other taenia.

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Fig 29.3 : Life Cycle of Taenia saginata

Fig 29.4 : Life Cycle of Taenia solium

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(d) Reservoir, Source and Mode of Infestation.

The reservoirs are the carnivorous animals like dogs, wolves, jackals, and foxes who are the definitive hosts
harbouring the adult worm. Out of these animals, dog is the most important animal as far as the hydatid disease
in man is concerned. The sheep is the most suitable intermediate host, but cattle can also act as such. The
eggs discharged in the faeces of the definitive hosts are swallowed by the intermediate hosts, while grazing in
the field. Man gets the infestation by handling and fondling of the dogs.
(e) Life Cycle.
In the duodenum the hexacanth embryos hatch out and they bore their way through the intestinal wall and are
carried though radicals of the portal vein to the liver which acts as a first filter. Some of the embryos may pass
through the hepatic capillaries, enter the pulmonary circulation, and filter out in the lungs. A few of the embryos
may pass the pulmonary capillaries, enter the general blood stream, and invade ·any other organ. However, they
are most found in the liver and lungs. Wherever the embryo settles, it forms the hydatid cyst. From the inner
layer of the cyst, ‘brood capsule’ with several scolices develops. A fully developed scolex is the sign of complete
biological development of the hydatid cyst. When ingested by the definitive host, the scolices can develop into
adult worms in about 6 to 7 weeks’ time. Thus, the cycle is repeated usually between dog and sheep. As the
dogs have no access to the hydatid cysts developed in the viscera of man, the human infestation is a blind alley.
Life span of the adult worm is a few months in contrast to the life span of the larval from which may continue
to develop for many years. Its life cycle is shown in Fig 29.5.

Fig 29.5 : Life Cycle of Echinococcus granulosus & E. multilocularis

(f) Hydatid Cyst.
The larval form causes hydatid cyst in man. The cyst walls consist of the ectocyst which is the outer chitinous

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laminated hyaline membrane about 1 mm thick and the endocyst which is the inner germinal layer. This is a
cellular vital layer of the cyst giving rise to brood capsule with scolices and the hydatid fluid. The host reacts
by forming a fibrous layer known as pericyst around the growing embryo. The parasite derives its nourishment
through it. When an old cyst becomes sclerosed or calcified, the parasite within it dies due to lack of nutrition.
Hydatid fluid is antigenic and highly toxic. If it is allowed to stand, the granular deposit which settles at the
bottom consists of liberated brood capsule, free scolices and loose hooklets.
(g) Diagnosis.
Diagnosis is made by precipitin, complement fixation and haemagglutination test and intradermal Casoni’s test.
Microscopic examination for hooklets, scolices and cyst membrane in sputum, vomitus, urine or faeces after
rupture of cysts or in discharge from a sinus also aids in diagnosis. Confirmation is by examination of tissues
obtained surgically or at autopsy. Eosinophilia is present. Radiological examination for hydatid is often helpful.
(h) Prevention and Control.
(i) Prevention of infection in dogs by rigid control of slaughterhouses so that dogs do not have access
to them.
(ii) Deworming of infested dogs with specific anthelminthics.
(iii) Health education of people for understanding the nature of the disease, precautions to be taken,
need for personal prophylaxis (cleaning of hands before eating) and controlled slaughtering of animals,
should be emphasized. General household hygiene must be improved.
(iv) Both cystic echinococcosis and alveolar echinococcosis are often expensive and complicated to treat,
sometimes requiring extensive surgery and / or prolonged drug therapy. There are 4 options for the treatment
of cystic echinococcosis-percutaneous treatment of the hydatid cysts with the PAIR (Puncture, Aspiration,
Injection, Re-aspiration) technique; surgery; anti-infective drug treatment and “watch and wait”. The choice
must primarily be based on the ultrasound images of the cyst, following a stage-specific approach, and on
the medical infrastructure and human resources available.

Cyclops and Snail Transmitted Helminths.

29.10 Dracunculus medinensis.
(a) Introduction.
D. medinensis is a nematode infesting the tissue of man. Its common name is Guinea worm. The infestation is
termed as the ‘Dracontiasis’ or the Guinea worm disease which is an infestation of the tissues of man in which
the female worm delivers its embryos through the aperture made by tissue lysis in the skin of the host. The
adult female is found in the subcutaneous tissue, especially of the legs, forearms and back.
(b) Distribution.
In last two decades, the disease showed a spectacular decrease. Over the past eight years, human cases have
stayed at double digits (54 in 2019 and 27 human cases in 2020). These human cases were reported from
following countries: Angola (1), Chad (12), Ethiopia (11), Mali (1), South Sudan (1) and Cameroon (1). The last
case reported in India was in Jul 1996. On completion of three years of zero incidence, India has been declared
free from Guinea worm disease. This was the second disease eradicated from India after smallpox.
(c) Morphology.
The adult female is a slender long worm about one meter in length, milky white in colour, resembling a piece
of thread; the male is about 12-30 mm in length. The life span of the female is about one year and that of the
male not more than six months. The embryos are coiled bodies measuring 650 to 750 microns in length. They
are set free at the time of parturition when the affected part meets water.
(d) Reservoir and Source of Infection.
Reservoir is an infected person. Source of infestation is by consumption of water from wells and ponds harbouring
infested Cyclops.

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(e) Life Cycle.

Man harbours the adult worms in the subcutaneous tissue. The female is fertilized by the male in lymphoid
or areolar tissue. The gravid female after a journey of about a year through the body of the infested person
eventually comes to the surface under the skin. When the part meets the water, the gravid female under the skin
protrudes a blister which ruptures and through the opening thus made, her uterus protrudes through the vulva
located just behind her head and discharge up to 3 million embryos. For further development, these embryos
must reach water in which the Cyclops (water fleas) are present. The cyclops is a minute lozenge shaped, semi-
transparent and shrimp like crustacean measuring about 1 mm in length. It can be seen swimming in water
with jerky movement in a glass jar held against window. The embryos are taken up by the Cyclops and in 2 to 4
weeks they are ready to parasitize man. Man acquires infestation by drinking water containing infested cyclops.
The cyclops are killed in the gastric juice and the contained larvae are liberated and becomes adults. The period
from ingestion of the infested cyclops to the onset of symptoms is about 8 to 14 weeks. Larvae may survive in
the water up to 6 weeks. Its life cycle is shown in Fig 29.6.

Fig 29.6 : Life Cycle of Dracunculus medinensis

(f) Pathogenicity and Clinical Features.
Symptoms are manifested when the gravid female prepares to discharge larvae. It liberates a toxic substance
causing allergic symptoms and formation of blister which ultimately rupture. Through the opening thus made,
a milky fluid containing larvae is discharged. Careless attempt to extract the worm before the uterus is empty
may result in violent tissue reaction and secondary bacterial infection.

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(g) Diagnosis.
Diagnosis is made when the adult female comes to the surface of the skin, by detection of embryos in the milky
white fluid discharged by the female under the microscope. X-ray examination helps when the worm is calcified.
Blood examination may show eosinophilia. No serologic test is available.
(h) Treatment.
No drug cures the infection but metronidazole and mebendazole are sometimes used to limit inflammation and
facilitate worm removal. Wet compress may relieve discomfort. Occlusive dressing improves hygiene and limit
shedding of infectious larvae. Worms are removed by sequentially rolling them out over a small stick.
(j) Prevention and Control.
Converting stepwells into sanitary wells and enhancing safe water supply of the locality by providing tube-wells
are the most important control measures. Destruction of Cyclops by filtration and super chlorination of water may
help but it is a laborious task in rural areas. Boiling of water also kills cyclops. Health education of people in
endemic areas about the mode of spread of disease, particularly regarding the danger that exists in contaminating
wells or water supplies, is an extremely important measure to get their active cooperation.

29.11 Schistosoma haematobium.

(a) Introduction.
Schistosomiasis is an infestation of the blood vessels of the portal and urinary systems by adult trematodes
of the genus Schistosoma, of which three species infest man viz. Schistosoma haematobium causing urinary
schistosomiasis, S. mansoni causing intestinal schistosomiasis and S. japonicum causing intestinal and hepatic
schistosomiasis.
(b) Distribution.
S. haematobium and S. mansoni are in general endemic in the countries of Africa and Middle East while S.
japonicum is endemic in Far Eastern Countries. In India the disease has so far been detected in the Ratnagiri
District of Maharashtra, Rajasthan, Orissa and Uttar Pradesh. In the Armed Forces a few cases have so far been
detected amongst those who have served abroad.
(c) Morphology.
Schistosomes are uni-sexual worms. The male is 12 mm long and is stouter than the female, which is about
25 mm long. The lateral margins of the body of the male are curved to form a groove, the gynaecophoric canal,
in which the female lodges.
(d) Reservoir and Source of Infestation.
Man is the definitive host of the adult parasite and is the reservoir of infestation but in S. japonicum, animals
also act as reservoir. Certain species of snails are the intermediate hosts of schistosomiasis.
(e) Life History.
The adults live in the portal system and its tributaries. The female leaves its partner to lay eggs in the walls of the
bladder or the large intestine. The eggs eventually penetrate the walls of the rectum and bladder and escape in
the faeces and urine. Having reached water, the egg splits open and the first larval stage, the miracidium (‘little
boy’) emerges. The miracidium can live for a few hours only and for further development it must enter the right
species of a snail. In the snail considerable asexual multiplication takes place and in about three weeks, the bifid
tailed cercariae, the infective stage for man, escape from the snail. The cercariae swim in water but can only live
for about 48 hours unless they gain access to man. The life cycle of S haematobium is shown in Fig 29.7.
(f) Pathogenicity.
The passage of the spined eggs causes trauma and leads to the characteristic symptoms of the disease. Urinary
schistosomiasis is characterised by haematuria and cystitis with varying local and general symptoms; intestinal
schistosomiasis is characterised by dysenteric and abdominal symptoms. Symptoms usually appear a month to
three months after infestation, but they may also be so mild as not to attract attention for a long time.

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Fig 29.7 : Life Cycle of Schistosoma spp

(g) Route and Mode of Transmission.
This is through water. The cercariae, after emerging from their snail host, swim about in water. They can readily
penetrate the unbroken skin or mucous membrane of man and develop into adults. Ordinary clothing, putties and
stockings present no barrier to their penetration; but they are unable to pierce leather, waterproofed material or
even the thinnest rubber gloves. They are unable to pass through the bacterial filters. The ordinary sand filter,
even if used with a coagulant, presents no barrier.
(h) Prevention and Control.
Proper disposal of faeces and urine and destruction of snail hosts are the main stay of schistosomiasis control.
(i) Snail Control.
Removal of all vegetation from the canals and periodic drying followed by sunbaking of the beds; filtration
of snails by mechanical means, such as filters of metal gauze screen; chemical destruction using one part
of copper sulphate per million parts of water and residual insecticides like Abate, are some of the measures
so far used for controlling snails in large canals.
(ii) Health Education.
Prevention of indiscriminate voidance of excreta (defecating and urinating) through health education is
necessary. Prevention of cercariae gaining access to the human host is achieved by educating people against
the use of untreated water for bathing, wading, washing in or drinking. Workers in potentially infested water,
for example during bridge building operations, should be motivated to wear gum boots and rubber gloves.

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(iii) Safe Water Supply.

Chlorination of water destroys the cercariae and boiled water is safe. Water not required for drinking
purposes i.e. water for bathing or washing can be rendered immediately safe by the addition of cresol 1
part to 10000 of water. Storage for 48 hours may render water safe.
(iv) The strategy for schistosomiasis control focuses on reducing disease through periodic, targeted
treatment with praziquantel through the large-scale treatment (preventive chemotherapy) of affected
populations. In endemic areas, where the infestation is heavy it would require a well organized mass
treatment of the whole population with strict control to prevent further infestation. This at present is not
possible due to absence of safe and inexpensive drugs. Despite being cheap, safe, and effective against
all schistosome species, praziquantel is ineffective against immature worms, which may lead to reinfections
and treatment failure in endemic areas; a situation that necessitates repeated administration besides other
limitations. Therefore, novel drugs are urgently needed to overcome this situation.

29.12 Fasciolopisbuski.
Infestation with trematode Fasciolopsis buski, a gut fluke of man, occurs in China, Malaysia, Indonesia and other
places in the Far East. In India, it is found mainly in Assam and Bengal, with isolated foci in Bihar. The worm also
infests pigs, which serve as a reservoir of infection. Man acquires infestation by eating certain water plants in which
infective larval stage (cercariae) are encysted. In China infestation is mainly due to the eating of the red caltrop (Trapa
natans) cultivated extensively in ponds and eaten raw. These plants are peeled with the teeth during which process
the encysted larvae gain access to the mouth and are swallowed. Another plant which conveys infection is the water
chestnut (Fliocharis tuberosa) often grows in flooded fields and of which the bulbs are eaten raw. In Bengal the water
nut Trapa bicornis (‘jol singara’) also eaten raw after peeling with the teeth, conveys infection. Its life cycle is shown
in Fig 29.8. Light infestations are often asymptomatic, but when heavy, give rise to gastrointestinal symptoms and
progressive exhaustion. Prevention consists of the prohibition of eating raw water plants in endemic areas.

Fig 29.8 : Life Cycle of Fasciolopsis buski

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Suggested Reading.
1. World Health Organization: WHO. Soil-transmitted helminth infections [Internet]. Who.int. World Health Organization:
WHO; 2023. Available from: https: /  / www.who.int / news-room / fact-sheets / detail / soil-transmitted-helminth-infections
2. Mehlhorn H. Soil-Transmitted Helminth Infections (STH). Springer eBooks. 2015 Jan 1;2
3. Ajjampur, Sitara SR, et al. “Epidemiology of Soil Transmitted Helminths and Risk Analysis of Hookworm Infections
in the Community: Results from the DeWorm3 Trial in Southern India.” PLOS Neglected Tropical Diseases, vol. 15, no.
4, 30 Apr. 2021, p. e0009338, https: /  / doi.org / 10.1371 / journal.pntd.0009338.
4. Salam, Nasir, and Saud Azam. “Prevalence and Distribution of Soil-Transmitted Helminth Infections in India.”
BMC Public Health, vol. 17, no. 1, 16 Feb. 2017, https: /  / doi.org / 10.1186 / s12889-017-4113-2
5. World Health Organization: WHO. “Soil-Transmitted Helminth Infections.” Who.int, World Health Organization: WHO,
18 Jan. 2023, www.who.int / news-room / fact-sheets / detail / soil-transmitted-helminth-infections.
n

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 EXCREMENTAL DISEASES

Chapter
XXX
EXCREMENTAL DISEASES

30.1 Introduction.
Excremental diseases are caused by infectious agents which enter by the mouth and either make the gastrointestinal
tract seat of pathogenesis or the portal of entry for subsequent effects on other tissues or organs of the body,
as in poliomyelitis and viral hepatitis A. In the former case the syndrome caused is fundamentally due to local
mucosal involvement, as in dysentery and in the latter case it is mainly due to invasion by the organisms, as in
enteric fever. The organisms causing excremental diseases are viruses, bacteria, protozoa and helminths.
All organisms causing excremental diseases exit from the body of the infected person in excreta. The fundamental
route of transmission of these infections is faecal-oral route. In a few infections like salmonellosis and the
tapeworms, animals are the fundamental reservoir for human infection but in all others the reservoir is the human
being. The organism is conveyed to the mouth of the recipient by food, water, milk, fruit or meat contaminated
with the infective excreta by flies, hands of the infected person or his attendant or contact, the fomites of the
sufferer or by direct pollution through the soil.
The important excremental diseases are diarrhoeas, dysenteries (amoebic and bacillary), food poisoning, cholera,
enteric group of fevers, poliomyelitis, viral hepatitis A and so on. The effective control of these diseases is by
treating the reservoir of infection i.e. patients including carriers and contacts and breaking channels of transmission
by controlling water, milk and food and safe disposal of excreta. Attention to personal hygiene, protection of food
against flies and rodents and use of available immunization procedures helps in reducing excremental diseases.

30.2 Diarrhoea and Dysentery (R00-R99).

(a) Introduction.
It is convenient to consider diarrhoea, amoebic dysentery and bacillary dysentery together. In all these there is
intestinal flux and all are of great importance to Armies both in peace and field. No hard and fast differentiation
exits between diarrhoea, characterized by the passage of loose unformed stools and dysentery characterized by
frequent loose stools with blood and mucus. The epidemiology, route and mode of transmission and preventive
and control measures are the same for diarrhoea and dysentery. In an outbreak of bacillary dysentery, a good
proportion of cases show only diarrhoea which is frequently the precursor of dysentery; many mild attacks
of dysentery are wrongly called diarrhoea and a majority of undiagnosed diarrhoeas may be labelled as mild
dysenteries.
(b) Prevalence & Incidence.
(i) Global Burden.
Diarrhoea is a leading killer of children, accounting for approximately 9% of all deaths among children under
age 5 worldwide in 2021. This translates to over 1,200 young children dying each day or about 4,44,000
children a year, despite the availability of a simple treatment solution. It is the third leading cause of death
in children 1-59 months of age.
(ii) Indian Scenario.
Total diarrhoeal deaths in India in year 2020, among children aged 0-6 years was estimated to 1,58,209
and proportionate mortality due to diarrhoea in this age-group was 9.1%. Average estimated incidence of
diarrhoea in children aged 0-6 years was 1.71 and 1.09 episodes/person/year in rural and urban areas
respectively. The National Family Health Survey-5 showed that the prevalence of childhood diarrhoea has
increased from 9% to 9.2% from 2016 to 2020 in India.
(iii) The disease flourishes where the standard of hygiene is low. Two thirds of the cases and most of

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the deaths, are in children under 10 years of age in case of bacillary dysentery. Outbreaks are common
under conditions of overcrowding and where sanitation is poor particularly in times of war, mass migration
of population and big religious fairs. Entamoeba histolytica infection is widely prevalent in all communities.
The prevalence of infection varies widely from place to place. The proportion of infected persons who
have proven disease may be low. Diarrhoea and dysentery are always associated with campaigns of war.
In camping anywhere, the least carelessness in camp sanitation will result in epidemics of diarrhoea and
dysenteries.
(c) Agent.
(i) Bacillary dysentery is caused by Shigella group of gram negative non-motile organisms. They are
divided into 4 groups as given in Table 30.1:
Table 30.1 : Types of Shigella
Group A Shigella dysenteriae
Group B Shigella flexneri
Group C Shigella boydii
Group D Shigella sonnei
(ii) Amoebiasis means harbouring a protozoal parasite, Entamoeba histolytica with or without clinical
manifestations. Intestinal amoebiasis includes amoebic dysentery, colitis, ameboma, amoebic appendicitis
and various complications. Giardiasis is also a recognised cause of diarrhoea.
(iii) Acute diarrhoeal disease and ubiquitous clinical syndrome of diverse and frequently unidentifiable
aetiology presents with loose stools. While it may include specific infectious diseases such as cholera,
bacillary dysentery, salmonellosis, amoebiasis, enteropathogenic Escherichia coli infections, acute viral
gastroenteritis, helminths or protozoa; abnormally frequent and watery stools often result from chemical,
nutritional, metabolic or psychogenic stimuli. Identification of the causative infectious agent in the stool
should be attempted wherever possible. In the past, it was only possible in 25% of the cases but now with
newer techniques it is possible in 75% of the cases.
(iv) Rotaviruses and campylobacters have been discovered as causes of acute diarrhoea (15-25% &
10-15% respectively of all cases of diarrhoea in children in developing countries).
(d) Reservoir.
Man is the reservoir of these infections. Mild cases which clinically recover in a few days without going to hospital,
constitute one of the chief means by which the reservoir is maintained. Patients with acute amoebic dysentery
pose only limited danger to others because of the fragility of trophozoites. Asymptomatic or mild cases excreting
cystic forms of E. histolytica on the other hand are important reservoir of infection.
(e) Mode of Transmission.
Infection by all organisms of this group of diseases is invariably by ingestion of food or drink i.e., faeco-oral route.
(i) Individuals primarily responsible for transmission are those with poor personal hygiene and who fail
to cleanse contaminated hands and carry organisms under their fingernails after defecation.
(ii) The organisms of bacillary dysentery do not thrive in water and chlorination readily kills those which
may be present. However, contaminated water is believed to play a major role in the transmission of
amoebiasis. The cysts are not killed by chlorine in amounts normally added for water disinfection. Water
can be rendered free from cyst only by sand filtration.
(iii) Milk and food are contaminated by infected water or by the hands of a carrier or case or more likely
by flies & cockroaches which act as vehicles.
(iv) Contamination of crockery, cutlery, kitchen utensils by food handlers or by dust containing cysts in
case of Entamoeba histolytica is a possibility.
(v) Vegetable from fields irrigated with polluted water specially those cultivated with raw sewage as
practiced in improper sewage fanning are liable to carry infection.

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(f) Susceptibility.
Man has no natural immunity against the organisms of diarrhoea and dysentery. Both sexes are equally
susceptible. Children and the aged suffer more. Transient immunity develops against the specific strain of
Shigella. Although susceptibility to infection of E. histolytica is general, many persons harbouring the organism do
not develop the disease. Host differences such as race and age have been described as affecting susceptibility
of individuals to infection. Immunity to reinfection has not been clearly demonstrated.
(g) Incubation Period.
(i) Bacillary dysentery usually 1 to 2 days, sometimes about a week.
(ii) Amoebic dysentery variable, few days to several months, usually 2 to 4 weeks.
(h) Period of Communicability.
Diarrhoea and bacillary dysentery cases are most infective during the course of clinical illness and a short period
thereafter. A case of amoebic dysentery is infective mostly during the non-clinical period between the remissions
of clinical attack, because it is the cystic stage of amoeba which is infective and not the vegetative form.
(j) Prevention and Control.
A constant maintenance of a high standard of waste disposal and environmental sanitation; personal hygiene
including food hygiene and habits; wholesome water and milk supply; and extermination of flies are the measures
to be relied upon for preventing the infection in a unit. The following measures should be taken for controlling
an outbreak:
(i) Isolation.
All serious cases should be admitted to hospital and isolated during acute illness with rigid personal
precautions by attendants. Fluid and electrolyte replacement is important along with specific drugs. This
will break the chain of transmission.
(ii) Oral Rehydration Therapy (ORT).
The introduction of oral fluid is a positive advance in the treatment of diarrhoeas / cholera. It is based
on the observation that glucose given orally enhances the intestinal absorption of salt and water and is
capable of correcting the electrolyte and water deficit in mild to moderate cases. The composition of oral
fluid, as suggested by World Health Organization (WHO), is as given in Table 30.2.
Table 30.2 : Composition of Reduced Osmolarity Oral Rehydration Solution (ORS)
New ORS Grams / lit New ORS Mmol / lit
Sodium chloride 2.6 Sodium 75
Glucose, anhydrous 13.5 Chloride 65
Potassium chloride 1.5 Glucose, anhydrous 75
Trisodium citrate, dihydrate 2.9 Potassium 20
Citrate 10
Total 20.5 Total osmolarity 245
Packets of oral rehydration mixture are freely available. The contents of the packet are dissolved in 1 lit
of drinking water. The prepared solution should be used within 24 h. It should not be boiled or sterilized
otherwise. It alone can correct mild to moderate dehydration. The inclusion of tri-sodium citrate in place of
sodium bicarbonate has made the product more stable. Moreover, the use of ORS-Citrate results in less stool
output especially in high output diarrhoea (e.g. cholera), probably because of a direct effect of trisodium
citrate in increasing intestinal absorption of sodium and water. The WHO & United Nations International
Children’s Emergency Fund (UNICEF) now recommend that countries use ORS Citrate wherever feasible.
If these mixtures of salts are not available, a simple mixture consisting of table salt 5 gm and sugar
20 gm dissolved in 1 litre of drinking water may safely be used until then. The general rule is that patients
should be given as much ORS solution as they want and that signs of dehydration should be checked until

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they subside. If the child’s weight is known, the amount of ORS solutions required for rehydration during
the first four hours may be calculated by setting the deficit at approx 75 ml/kg body weight. Intravenous
infusion is usually required only for the initial rehydration of severely dehydrated patients who are in shock
or unable to drink. Such patients are best transferred to the nearest hospital.
(iii) Notification.
It should be carried out as per existing orders.
(iv) Concurrent Disinfection.
All underclothing, soiled linen, bedding, crockery, cutlery and particularly the excreta should be treated by
concurrent disinfection.
(v) Personal Hygiene.
Thorough hand washing before handling food must be stressed.
(vi) Outbreak Investigation.
Epidemiological Investigation for the source of infection and modes of transmission should be carried out
and appropriate control measures instituted.
(vii) Control of Flies.
Control and destruction of flies is the most important method of controlling an outbreak of dysentery.
Patient’s efforts and persistent attention to exterminate breeding places by proper disposal of faeces and
manure as described in chapter on environmental sanitation, ensuring good general sanitation, prohibiting
indiscriminate defecation and grazing of cattle and the use of insecticides to control the flies. Health
education of all personnel is of paramount important. Water supplies should be scrutinized and super
chlorinated. Food hygiene should be made stricter, milk should be boiled and the food habits of personnel
should be improved.

30.3 Cholera. (A00.9)

(a) Introduction.
A serious acute intestinal disease caused by Vibrio cholera O1 (Classical or El Tor) and characterized by sudden
onset, profuse, effortless watery stools, vomiting, rapid dehydration, muscular cramps, acidosis and circulatory
collapse. Fatality rates in untreated cases may exceed 30-40 percent; inapparent and wholly asymptomatic
infections are many times more frequent than clinically recognized cases, especially Vibrio cholerae biotype El
Tor.
(b) Incidence and Prevalence.
Explosive epidemics through common vehicles are not common now a day. This is possibly due to prompt
containment measures. A protracted pattern with only a few cases per day or week, may be due to contact
spread, is often seen.
(i) Global Scenario.
The global burden of cholera is largely unknown because most cases are not reported, however, WHO
estimates 1.3 to 4.0 million cases and 21,000 to 1,43,000 deaths worldwide every year.
(ii) Indian Scenario.
Data of 2017 from population-based diarrhoea surveillance in an endemic area of Kolkata, India, revealed a
cholera incidence of 2.2 cases per 1,000 person-years. Cholera is said to be an under-recognized problem
in India.
(c) Agent.
The causative agent, Vibrio cholerae is a gram negative, comma shaped, actively motile organism. It grows easily
in peptone water and on the usual laboratory media at 37°C and at a pH between 7.4 to 9.6. The purpose of
classification of vibrios is to distinguish between the various pathogenic and non-pathogenic species of genus
vibrio including other closely related genera. Vibrios were classified by Heiberg into 6 groups on the basis of

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fermentation (acid only) of mannose, sucrose and arabinose. The cholera vibrios usually but not invariably are
Heiberg Group 1, fermenting mannose and sucrose but not arabinose.
The antigenic classification of vibrios depends on the specific somatic (O) antigens. The flagellar antigen (H) is
nonspecific and common to all. The group A vibrios which include both cholera and cholera like vibrios have
been divided into six subgroups (I to VI) based on the antigenically different ‘O’ antigens. V. cholerae belong to
serological O sub­ group I of Gardner and Venkataraman and other serological Sub-group (II to VI) are NAG vibrios
(non-agglutinable to O group I antisera). The O subgroup I Vibrios comprises of classical V. Cholera and V. El
Tor biotype and they cannot be differentiated by serological or biochemical tests; but they can be differentiated
by haemolytic property, sensitivity to lysis by Mukherjee’s Group IV cholera phage, polymyxin B sensitivity and
chicken red cell agglutination. Based on the O antigenic components, both classical V cholerae and biotype El
tor have been divided into 3 serotypes Ogawa, Inaba and Hikojima. The former two are common. Classical Vibrio
cholerae can be distinguished from El Tor by the following tests as given in Table 30.3 below:
Table 30.3 : Difference between Classical and El Tor Vibrio Cholerae
Reaction
Property
Classical El Tor
Voges-Proskauer (modified with 1% NaCl) Negative Positive
Zone around polymyxin B (50 U) Positive Negative
Agglutination of chicken erythrocytes Negative Positive
Lysis by bacteriophage:
Classical IV Positive Negative
El Tor V. Negative Positive
(d) Reservoir.
The only reservoir of infection is man, either a case or a carrier. The ratio of severe cases to mild or inapparent
infections has been shown to be about 1:5 for classical cholera and 1:25 to 1:100 for El Tor cholera. There
have been isolations of El Tor vibrios from the faeces of some domestic animals, but these may be accidental
infections and have not been shown to play any definite role in transmission of disease to man. Carriers in
cholera are mainly of two types viz. convalescent and contact carriers. Duration of carrier period is short, about
4 or 5 days. Chronic carriers who harbour the vibrio for more than 3 months are not many.
(e) Source of Infection.
The immediate source of infection is the faeces & vomitus of infected man, case or carrier.
(f) Mode of Transmission.
Infection by V. cholerae is invariably by ingestion. Most important mode of transmission is through contaminated
water. Disease may spread through food contaminated by food handlers and flies. Fruits and vegetables washed
with contaminated water may transmit the infection. Person to person contact particularly in overcrowded dwellings
without sanitary facilities is very important due to careless handling of human excreta under such conditions.
(g) Host Factors.
Cholera usually affects persons belonging to the low socio-economic strata because of poor environmental
sanitation. Their standard of personal hygiene is low. When cholera epidemic occurs in non-endemic areas, male
adults are more affected. In contrast, in endemic areas, attack rate is equal in both the sexes and it is distinctly
higher for children than for adults. This phenomenon is due to development of naturally acquired immunity with
increasing age in the endemic areas.
(h) Incubation Period.
It varies from a few hours up to 5 days, but commonly 1 to 2 days. Infectivity of cholera is high, but the disease
rate is low; as a rule, although many members of family may be infected, usually one of them falls ill.

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(j) Period of Infectivity.

A case or carrier is infective for variable periods. The period of infectivity is usually 7-10 days in a clinical case
of cholera.
(k) Pathogenesis.
The main symptom of cholera is diarrhoea. Diarrhoea in cholera was attributed in the past to such factors as
increased permeability of the intestinal epithelial cells, increased peristalsis, mucosal damage, an increase in
mesenteric blood flow and failure of the “sodium pump”, i.e., interference with the passage of sodium from the
lumen to the plasma. None of these theories stood the test of time. According to current concepts, the cholera
vibrio gets through the mucus which overlies the intestinal epithelium. It probably secretes mucinase, which
helps it move rapidly through the mucus. Then it gets attached or adhered to the intestinal epithelial cells and
this it probably does by an adherence factor on its surface. When the vibrio becomes adherent to the mucosa,
it produces its enterotoxin which consists of 2 parts - the light or L toxin and the heavy or H toxin. The L toxin
combines with substances in the epithelial cell membrane called gangliosides and this binds the vibrio to the
cell wall. Binding is irreversible.
The mode of action of H toxin is not fully clear. H toxin activates “adenyl cyclase” present in the intestinal
epithelial cells. The activated adenyl cyclase causes a rise in cyclic adenosine monophosphate or cAMP. cAMP
provides energy which drives fluid and ions into the lumen of the intestine. This fluid is isotonic and is secreted
by all segments of small intestine. The increase in fluid is the cause of diarrhoea and not increased peristalsis.
There is no evidence that V. cholerae invades any tissue, nor the enterotoxin to have any direct effect on any
organ other than the small intestine.
(l) Clinical Features.
The severity of cholera is dependent on the rapidity and duration of fluid loss. Epidemiological studies have
shown that more than 90 percent of El Tor cholera cases are mild and clinically indistinguishable from other
acute diarrhoeas. However, a typical case of cholera shows 3 stages:
(i) Stage of Evacuation.
The onset is abrupt with profuse, painless, watery diarrhoea followed by vomiting. The patient may pass
as many as 40 stools in a day. The stools may have a “rice water” appearance.
(ii) Stage of Collapse.
The patient soon passes into a stage of collapse because of dehydration. The classical signs are sunken
eyes, hollow cheeks, scaphoid abdomen, sub-normal temperature, washerman’s hands and feet, absent
pulse, unrecordable blood pressure, loss of skin elasticity, shallow and quick respiration. The urinary output
decreases and may ultimately cease. The patient becomes restless and complains of intense thirst and
cramps in legs and abdomen. Death may occur at this stage, due to dehydration and acidosis resulting
from diarrhoea.
(iii) Stage of Recovery.
If death does not occur, the patient begins to show signs of clinical improvement. The blood pressure
begins to rise, the temperature returns to normal and urine output is reestablished. If anuria persists, the
patient may die of renal failure. The classical form of severe cholera occurs in only 5-10 percent of cases.
In the rest, the disease tends to be mild characterised by diarrhoea with or without vomiting or marked
dehydration. As a rule, mild cases recover in 1-3 days. Epidemiologically, cholera due to El Tor biotype
differs from classical cholera in the following respects:
(aa) A higher incidence of mild and asymptomatic infection. This implies that the characteristic
picture of rice-water stools and other signs of classical cholera described above may not be seen
often.
(ab) Fewer secondary cases in the affected families.
(ac) Occurrence of chronic carriers.
(ad) Since El Tor Vibrios are more resistant than classical cholera vibrios, they survive longer in the
extra intestinal environment.

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(m) Laboratory Diagnosis of Cholera.

The diagnosis of cholera can never be made with certainty on clinical grounds. Cholera can be diagnosed by
a stool test or a rapid immunochromatographic dipstick test, although the dipstick test is less accurate. This
involves placing a dipstick strip into a stool sample and reading the lines it then displays. Cholera is confirmed
if two red lines appear on the dipstick, whereas it is ruled out if only one line appears. It takes between 2 and
15 minutes for the test to make a diagnosis. The culture method is the gold standard or most recommended
test for diagnosis of cholera. The process details for stool collection, microscopy and culture are as under:
(i) Collection of Stools.
A fresh specimen of stool should be collected for laboratory examination. Sample should be collected before
the person is treated with antibiotics. Collection may be made generally in one of the following ways:
(aa) Rubber Catheter.
Collection by the catheter (26-28 size) is the best method but is complicated under field conditions.
Soft rubber catheter sterilized by boiling should be used. The catheter is introduced (after lubrication
with liquid paraffin) for at least 4-5 cm into the rectum. The specimen voided may be collected directly
into a transport (holding) media. e.g., Venkatraman-Ramakrishnan (VR) medium and alkaline peptone
water.
(ab) Rectal Swab.
Swabs consisting of 15-20 cm long wooden sticks with one end wrapped with absorbent cotton,
sterilized by autoclaving have been found to be satisfactory. Rectal swabs should be dipped into the
holding medium before being introduced into the rectum.
(ac) If no transport medium is available, a cotton-tipped rectal swab should be soaked in the liquid
stool, placed in a sterile plastic bag, tightly sealed and sent to the testing laboratory.
(ii) Vomitus.
This is practically never used as the chances of isolating vibrios are much less and there is no advantage.
(iii) Water.
Samples containing 1-3 litres of suspect water should be collected in sterile bottles (for the filter method)
or 9 volumes of the sample water added to 1 volume of 10 percent peptone water and despatched to the
laboratory by the quickest method of transport.
(iv) Food Samples.
Samples of food suspected to be contaminated with V. cholerae (or other enteric bacteria) amounting to
1-3 g are collected in transport media and sent to the laboratory.
(v) Transportation.
(aa) The stools should be transported in sterilized McCartney bottles, 30 ml capacity containing
alkaline peptone water or VR medium can be used if larger stool specimens can be collected. The
specimen should be transported in alkaline peptone water or Cary-Blair medium if it is collected by
a rectal swab. One gram or one ml of faeces in 10 ml of the holding medium will suffice. Rectal
swabs should have their tops broken off so that caps of the containers can be replaced.
(ab) If suitable plating media are available (e.g. bile salt agar) at the bedside, the stools should be
streaked on to the media and forwarded to the laboratory with the transport media.
(vi) Direct Examination.
If a microscope with a dark field illumination is available, it may be possible to diagnose about 80 percent
of the cases within a few minutes and more cases after 5-6 hours of incubation in alkaline peptone water.
In the dark field, the vibrios evoke the image of many shooting stars in a dark sky.
If motility ceases on mixing with polyvalent anti-cholera diagnostic serum, the organisms are presumed to
be V. cholerae. A presumptive diagnosis of cholera can thus be established.

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(vii) Culture Methods.

On arrival at the laboratory, the specimen in holding fluid is shaken well and about 0.5 to 1.0 ml of material
is inoculated into Peptone Water Tellurite (PWT) medium for enrichment. After 4 to 6 hours incubation at
37°C. a loopful of the culture from the surface is sub-cultured on Bile Salt Agar medium (BSA, pH 8.6).
After overnight incubation, the plates are screened under oblique light illumination for vibrio colonies.
(viii) Characterisation.
V. cholerae usually appear on Bile Salt Agar (BSA) as translucent, moist, raised, smooth and easily
emulsifiable colonies about 1 mm in diameter. The typical colonies are picked up and tested as follows:
(aa) Gram Stain and Motility.
Gram negative and curved rods with characteristic scintillating type of movement in hanging drop
preparations are very characteristic of V. cholerae.
(ab) Serological Test.
Slide agglutination test is done by picking up suspected colonies and making a homogeneous
suspension in 0.85 percent sterile saline and adding one drop of polyvalent anti-cholera diagnostic
serum. If agglutination is positive, the test is repeated with Inaba and Ogawa antisera, to determine
the subtype.
(n) Biochemical Test.
Serologically positive colonies should be sub cultured in one tube each of the sugar broths (mannose, sucrose,
arabinose) and a tube of peptone water pH 7.2 for the cholera red reaction. Production of acid in sucrose and
mannose, but not arabinose is characteristic of V. cholerae.
(o) Further Characterisation.
For further characterisation of biotypes of V. cholerae, the following tests are carried out.
(i) The direct haemagglutination test with chicken or sheep red blood cells.
(ii) Polymyxin B sensitivity test using 50 mcg discs.
(iii) Sensitivity to cholera phage IV.
(iv) V-P reaction.
(v) Haemolysis test.
Suspicious colonies that do not agglutinate with anticholera sera are tested further by the oxidase and
string tests.
(p) Prevention & Control.
Control of cholera depends on the improvement of environmental sanitation. Main aspects of environmental
sanitation are adequately chlorinated and protected water supply, proper disposal of night soil/sewage and safe
food supply. Food may be contaminated at the source, at different stages of processing, storing, serving and
due to exposure to flies. Health education is important for improvement of personal hygiene.
(q) Immunization.
Two types of oral cholera vaccines are available:
(i) Dukoral (WC-rBS) is a monovalent vaccine based on formalin and heat killed whole cells of V. Cholera
O1 plus recombinant cholera toxin B subunit. The vaccine is provided in 3ml single dose vials together
with bicarbonate buffer. Vaccine and buffer are mixed in 150 ml of water for person > 6 years and in 75
ml of water for children aged 2-6 years. 2 oral doses are given ≥ 7 days apart (but <6 week apart).
The duration of protection has been assessed to be 2 years in adults, but only 6 months in children aged
2–5 years. 3 oral doses should be given to children aged 2–5 years and 2 doses to children aged ≥ 6 years
and adults, with an interval of 1–6 weeks between doses in both groups. The cumulative efficacy of the
2 vaccine doses over 3 years was 51% (95% CI: 40–60%) against El Tor and classical cholera combined.

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 EXCREMENTAL DISEASES

(ii) Shanchol and mORCVAX.

These bivalent oral cholera vaccines are based on serogroups O1 and O139. They do not contain bacterial
toxin B subunit and does not require buffer. Vaccine is administered in two doses 14 days apart for
individuals aged ≥ 1 year. Where there is continued risk of V. cholerae infection then re-vaccination is
recommended after 2 years. Cumulative protective efficacy of Shanchol at 5 years was 65% (95% CI:
52–74%; P < 0·0001). The overall effectiveness for mORCVAX 3–5 years after vaccination was 50% (95%
CI: 9–63%) in individuals aged ≥2 years.
Given the current availability of killed whole cell OCVs (Oral cholera Vaccine) and data on their safety,
efficacy, field effectiveness, feasibility, impact and acceptability in cholera affected populations, these
vaccines should be used in areas with endemic cholera, in humanitarian crises with high risk of cholera and
during cholera outbreaks. The vaccines should always be used in conjunction with other cholera prevention
and control strategies. Vaccination for cholera is not routinely administered in Armed Forces. At best they
can be used as an adjunct to other preventive measures such as drug prophylaxis, proper sanitation and
health education. Immunization against cholera is not regarded as an effective means of preventing the
spread of cholera internationally. Cholera vaccination is not mandatory for international travel. However,
certain countries still insist on vaccination certificate against cholera. Before undertaking any travel, one
should consult the booklet issued by WHO every year.
“Vaccination Certificate Requirements for International Travel”. For troops travelling abroad on UN mission,
the vaccination schedule, dosage etc. has been described in Chapter XXIV.
(r) Action on Occurrence of the Disease.
(i) Isolation.
Even on the slightest of suspicion, the patient must be admitted immediately to the hospital where he must
be strictly isolated in a special fly-proofed ward and diagnosis should be confirmed by identifying V cholerae
O1 in the stool. Generally, several cases occur at the same time; therefore, adequate arrangements for
hospitalization of all cases are essential. In a large outbreak a separate hospital in the vicinity of the main
hospital may have to be opened.
(ii) Disinfection.
Soiled bedding and clothing, which cannot be sterilized, must be burnt. The floors of wards, huts and
barracks must be thoroughly scrubbed with 5 percent cresol (cresol liquid). The place in which bed pans,
urinals and soiled linen are stored should be fly-proofed or carefully covered with a sheet soaked in and
kept moist with 5 percent cresol. The stool and vomit should be poured into a receptacle containing an
equal quantity of 5 percent solution of cresol and left covered for 4 hours before its final disposal. Fresh
Water-Soluble Powder (WSP) thoroughly mixed in the proportion of 1.5 g to l lit of faeces/vomitus may also
be used as a disinfectant.
(iii) Notification.
On occurrence of a case of cholera notification must be carried out by signal/telephone to all concerned
in accordance with current instructions. Routine notification on a prescribed form must also be rendered
in the usual way. The Director of Health Services of the state should also be informed. Close liaison with
the local civil health authorities is essential.
(iv) Attendants.
They should be specially detailed and be isolated from the nursing staff of the main hospital. They should
dip their hands in antiseptic solution after washing, after every contact with the patient, his bedding, objects
or utensils. They should all be vaccinated against cholera beforehand. The consumption of any food or
drink by these attendants while in the cholera ward should be strictly prohibited. Gowns should always be
worn while on duty.
(v) Contacts.
They need not be isolated. All persons who are suspected of having partaken of the same infected food or
drink as the patient, however remotely, should be kept under daily morning and evening surveillance for 5
days.

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(vi) Food and Drinks.

Control of food and drinks is the most important method of control of an outbreak. The following rules
should be followed in the presence of an outbreak in the civilian community nearby:
(aa) Drinking water should be super chlorinated. Washing and bathing water should be chlorinated.
All rivers, ponds, wells etc. in the neighbourhood should be put strictly ‘out of bounds’ to all troops
other than authorized water duty personnel. Soda water and other drinks should be used only after
the most careful investigation of their source of supply. Ice should not be used unless from an
authorized source.
(ab) Milk must be boiled. Cream and butter should be obtained only from reliable sources.
Consumption of ice cream, unless its origin is absolutely beyond suspicion, should be strictly prohibited.
(ac) Uncooked vegetables and fruits which are customarily eaten unpeeled should be avoided during
epidemics. Otherwise, should always be washed and then soaked in a solution made by adding 3
scoopfuls or 6 g WSP to a bucketful of water, before peeling. Cut fruits exposed for sale should not
be eaten.
(ad) All food must be protected against flies. Strict supervision of cookhouses and cooks are
necessary to ensure that food is prepared, cooked stored and served under clean conditions.
(ae) A search for mild cases should be carried out by examination of the stools of all those who are
suffering from diarrhoea. All diarrhoea cases, however, should be treated with suspicion until proved
otherwise. Civilian labourers must be kept under strict supervision and given protective inoculation
if considered necessary.
(af) All villages and bazaars in the town in which a case of cholera has occurred must be placed ‘out
of bounds’ to all troops until declared free from cholera. During an outbreak all eating and drinking
places which are not absolutely above suspicion should also be placed ‘out of bounds’.

30.4 Food poisoning. (A05)

(a) Introduction.
Food poisoning is an acute gastro-enteritis caused by ingestion of food or drink contaminated with either living
bacteria or their toxins or inorganic chemical substances and poisons derived from plants and animals. Food
poisoning outbreaks are usually recognized by the sudden occurrences of group of illness within a short period
of time among individuals who have consumed one or more foods in common. The food poisoning is of two
types Non-bacterial and bacterial:
(i) Non-bacterial.
It is caused by chemical such as arsenic, certain plants and sea foods. Substances containing specific
poisons like Amanita phyllodes instead of edible mushroom or eating sprouting potatoes which contains
excess of alkaloid solanine. Food contaminated by poisons due to agricultural or industrial activities,
fertilizers and pesticides in food.
(ii) Bacterial.
Foods infected with organisms may be of the following types-Salmonellosis, Clostridium, Staphylococcus,
Botulism, Bacillus cereus, E. Coli diarrhoea, Shigellosis, non-cholera vibrio illness, V. parahaemolyticus
infection.
(b) Outbreaks.
The commonest epidemiological pattern of this disease is sharp and short explosive outbreaks, mostly in close
community catering organizations like student hostels, old people’s homes and Armed Forces Messes, but
sometimes even in hotels and restaurants, especially when contaminated meat is used or milk preparations
are made from pooled milk in bulk. Rarely, do such outbreaks occur in household cooking and are mostly on
festival occasions when large gatherings partake the meal. Outbreaks are common when the environmental
temperature is high. A number of outbreaks are reported every year in the Armed Forces involving a varying
number of personnel.

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(c) Global Scenario.

Each year worldwide, unsafe food causes 600 million cases of foodborne diseases and 4,20,000 deaths. In
WHO south-east Asia region 150 million fall ill and 1,75,000 die due to food poisoning.
(d) India Scenario.
If food safety standards in India remain at current state, over 100 million annual cases of food-borne diseases
are estimated, which would increase to 150–177 million cases by 2030.
(e) Agent.
The common causative organism of bacterial type includes salmonella and the species most commonly
incriminated in human outbreaks is Salmonella typhimurium. Others include S. enteritidis, S. cholera-suis, Sh.
sonnei, enterotoxin of certain strains of coagulase positive Staphylococcus aureus. These toxins can be formed
at optimum temperature of 35-37°C. These toxins are relatively heat stable and resist boiling for 30 minutes
or more. Botulism is produced by exotoxin of Clostridium botulinum. The foods most commonly responsible for
botulism are home preserved foods such as home canned vegetable, smoked or pickled fish and similar low acid
foods. Clostridium perfringens poisoning associated with ingestion of meat, meat dishes and poultry. The spores
can survive cooking and if cooked meat or poultry are not cooled enough, they will germinate and organism
produce toxin (alpha toxin, theta toxin). In B. cereus food poisoning, the spores survive cooking and subsequently
germinate and then multiply rapidly when food is held at favourable temperature. Tabulated summary of common
bacterial food poisoning is given in Table 30.4.
Table 30.4 : Summary of Food Poisoning
Infection Type Toxin type Botulism
Items
(Bacterial growth) (Toxin Produced by pyococci) (Toxin Produced by Botulinum)
Causal Sal. typhimurium (aertrycke) − Staphylococcus aureus − Clostridium botulinum.
Organisms Salmonella Enteritidis and others; Streptococci, Intoxication and not infection.
(Gaertner) and 225 other rarely Proteus, etc. The most potent bacterial
named species of Salmonella; − Heat stable toxin is the poison known; withstands
rarely infection by S. sonnei or actual pathogenic agent. acids and heat; destroyed by
Bact. paratyphosum C. alcohol.
Habit of − Natural infection in − Environment, human − Present in soil. Accidental
organisms rodents, pigs, cows, poultry, infections like nasopharyngitis, entry in food during
duck eggs. septic flesh (or eggs) of preparation
− Flesh (or eggs) of infected animals, septic fingers,
animals insufficiently cooked. wounds and boils etc.
− Healthy food contaminated − Accidental entry in food
by excreta of infected rodents. during preparation.
− Human carriers (rare)
Food − Meat, fish, eggs (ducks) − Tinned meat or fish, − Tinned foods, sausages,
concerned milk 'made up' dishes and inadequately processed, ham, tin 'blown' or flat food
stored food. Food may appear pickled meats, creams, milk. reopened or natural.
normal. Uneven distribution in − Dangerous even to taste
food. suspected food.
Incubation 6 to 24 h, rarely longer 1/2 to 4 h Within 24 h (may be 72 h)
period
Clinical − Vomiting and diarrhoea, − Vomiting marked slight − Vomiting, Temperature
symptoms temperature raised. pyrexia. normal or low
− Recovery in a week or − Recovery in 24 h − Paralysis of ocular
cholera like death. nerves. Slow recovery in 6 to
8 months.
Mortality 0.2 percent Rarely fatal 60 to 70 percent

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(f) Reservoir.
Salmonella organisms are natural commensals of rodents, pigs, cattle, poultry, ducks, eggs and some healthy
human carriers. Staphylococcus is ubiquitous. Clostridium botulinum is a natural commensal of the intestines
of goats, pigs, cattle etc. Clostridium botulinum is widely distributed in soil, dust and intestinal tract of animals
and enters food as spores. B cereus is ubiquitous in soil and in raw, dried and processed foods.
(g) Source.
Commonly the initial source of infection is the man handling the food from its production to the consumer. Rat
dropping and fowl faeces (or eggs) may also act as source of infection.
(h) Mode of Transmission.
Route of transmission is generally the tinned and preserved food stuffs, commonly of animal origin or milk or
fruits. Infective organisms are derived from animals slaughtered or milked or are transferred from the handlers
of milk, meat or fruit from its sources, through processing to the consumer. A milkman may transfer it from his
infected finger, ear, nasopharynx, skin-boil or contaminated hands. Contamination may occur during processing.
Flies may also transfer infection.
(j) Host.
Man possesses no natural immunity against salmonellosis, toxins of staphylococci, Cl botulinum or B. cereus.
An attack does not confer long lasting immunity. Children suffer more from symptoms and case fatality is also
higher among children than adults.
(k) Incubation Period.
In bacterial type it is 6 to 24 h, preformed toxin type 1/2 to 4 h and botulism 24 to 72 h.
(l) Communicability Period.
All those who have been infected do not necessarily suffer from the classical syndrome. Excretion of organisms
of the salmonella group is quite common among chronic cases of diarrhoea. Carrier state may exist. A case is
infectious during the course of the attack and for some time thereafter. Any person harbouring salmonella and
staphylococci may possess an indefinite infectivity for variable periods.
(m) Investigation of an Outbreak.
An outbreak of food poisoning must be investigated very expeditiously by a team of clinicians, pathologist and
an epidemiologist. Delay may result in the destruction of valuable evidence due to deterioration of specimens
and through carelessness of the kitchen staff or deliberate attempt to remove the evidence. The aim of an
investigation is to implicate the exact item of food and ascertain circumstances leading to its contamination.
The objective is to prevent recurrence of the outbreak.
An investigation has three sequential stages or parts: the epidemiological, the circumstantial and laboratory
investigation.
(i) Epidemiological Investigation.
It is carried out by obtaining a complete history of the outbreak. A complete list of persons, whether affected
or unaffected, who consumed the incriminated meal is obtained, together with a list of the various items
of food served at the said meal. Each person is then interviewed and all cases are examined or clinical
reports are obtained. A complete food history is taken with a view to identify the items of food consumed
by them. A history of the outbreak is written down giving the identity of persons affected by the illness, the
sequence of events leading to an outbreak, the time interval between the consumption of food and the
onset of the illness and signs and symptoms and the duration of the illness. A tentative diagnosis of the
poisoning can be made from these data. Some important points of differentiation between food poisoning
and cholera are tabulated in Table 30.5. If the number of persons who ate the meal be very large or not
definitely known or the taking of food histories and illness histories from all the persons (affected and
unaffected) be not feasible, a representative sample of the population (in this case the consumers of the
incriminated meal) may be investigated. A list of articles consumed during the meal under suspicion is
obtained. A table as illustrated in Table 30.6 is then constructed testing all the items of food served at the
said meal, the number of persons who ate or did not eat each item of food and the number among them

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who were affected or unaffected by the illness. The attack rates among those who ate or did not eat each
specific item of food are then calculated and the difference between attack rates is calculated to identify
the food most probably responsible for the outbreak.
If only the attack rates among those who consumed individual items of food are examined it is difficult to
identify the food (Raita or curd) which is most probably was responsible for the outbreak, because the attack
rates in respect of some of the other items of food were not very different, except those for “Chatni” and
‘Papad’. At the most, therefore only a negative conclusion can be drawn from these attack rates, namely,
that ‘chatni’ and ‘papad’ were not the probable foods responsible for the outbreak. However, when the
attack rates among those who ate the specific items of food are contrasted with those who did not eat
them, it becomes easier to identify ‘raita’ as being the most likely food that caused the outbreak. In theory,
all those who ate the particular item of food (in this case ‘Raita’) which caused the outbreak, should be
affected by the illness, but in practice the association between illness and the food is seldom so perfect.
There can be many reasons for this such as:
(aa) Some persons who ate the food were resistant to the infectious agent and therefore remained
unaffected.
(ab) One item of food may be contaminated by traces of another during preparation, storage, handling
or serving.
(ac) The history of the consumption of individual items of food may be incorrect, due to lapses of
memory, misunderstanding of the question put and a subconscious bias in the mind of the investigator
or the person being questioned in favour or against a particular item of food as being the one
responsible for the outbreak or a conscious bias in the mind of an individual motivated by a desire
to claim or disclaim the illness.
Table 30.5 : Difference between Food Poisoning and Cholera
Cholera Food Poisoning
Epidemiology Occurs often in epidemic form associated Often single group of persons who shared
with other cases in the neighborhood. common meal are affected. No secondary
Secondary cases occur. cases.

Incubation period From few hours to 5 days 1 to 24 hours

Onset With purging With vomiting
Nausea and retching None Present
Vomiting Projectile, effortless, watery & continuous Often single severe vomit mucus & blood
streaked
Stools Copious, rice watery & Frequent may contain mucus & blood,
offensive
inoffensive
Tenesmus None Yes
Abdominal tenderness None Yes
Dehydration Very marked Distinct
Muscular cramps Constant and severe Less constant
Headache None Often

Fever Surface temperature below normal 100-102°F

Urine Complete suppression Seldom suppressed

Blood Leukocytosis Normal

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Table 30.6 : Calculation of Food Specific Attack Rates

Difference between
Persons who ate the Specific Persons who did not eat the
Food Attack Rates
Item of Food Specific Item of Food
(Absolute Number)
Attack No. who Attack
No. who
No. ill rate did not No. ill rate
ate
% eat %
Mutton curry 109 80 73 21 14 66 -7
Dal 88 70 79 32 24 75 -4
Pulao (Rice) 95 76 80 25 18 72 -8
Raita (Curd) 98 84 85 22 2 9 -76
Potato-Pea curry 78 60 77 42 20 48 -29
Chatni (Pickle) 65 13 20 55 27 48 -28
Papad 60 6 10 60 24 40 -30
Sweet (Kheer) 110 77 75 10 6 60 -15
(ii) Laboratory Investigations.
These are carried out by bacteriological and chemical examination of the remnants of the specific article
or articles of food to which suspicion has been directed; specimens of faeces, urine, vomitus and blood,
for culture and agglutination, from the patient; viscera, especially spleen, liver, stomach and intestine
(both ends tied) and also clotted blood from fatal cases. All these should be sent expeditiously to the
laboratory for appropriate examination. The laboratory should be informed by telephone or telegram so as
to enable them to keep themselves in readiness for starting the examination immediately on arrival of the
specimens. The material should be carefully packed in ice and sent by the quickest route, preferably by a
special messenger, together with a full report of the outbreak including its brief history, number of persons
attacked, time and prominent symptoms and the present condition of patients. The samples of food should
be the remnants of the actual food consumed and not samples of food of similar origin. Liquids should be
sent in sterile stoppered bottles and solids should be sent in clean tins, any original container from which
the consumed food was taken may also be sent. Blood for culture should be sent in a suitable media
bottle. Agglutinins develop slowly and an interpretation of the results is difficult in personnel who have
received Typhoid Vaccination. Therefore, a pathologist’s advice should be obtained before this investigation
is requested for.
(iii) Circumstantial Enquiry.
As a part of epidemiological investigation, it should then be carried out to ascertain the circumstances under
which the contamination of the suspected item and the outbreak occurred. The various samples having been
despatched to the laboratory, attention should be directed towards the source of infection or contamination.
This involves a study of the history of the implicated food. The source of the article suspected should be
ascertained. The place of preparation should be inspected for general cleanliness. The amount of handling
the food received before, during and after cooking should be ascertained. The source of supply, method
of storage and transport of the food item should be examined, paying particular attention to any chance
of contamination and for the presence of rodents. The health of all workers, who handled the food at any
stage, should be investigated. The results of the examination of the food, excreta, urine, vomit or blood
samples and viscera of the dead individuals should be compiled. The complete information regarding the
outbreak is paramount for taking further remedial action against recurrence. This information pertains to:
(aa) The aetiological agent.
(ab) The source of contamination.
(ac) The article of food responsible.

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(ad) The circumstances leading to contamination.

(ae) The incidence, severity and mortality rate.
(af) Remedial measures recommended.
(n) Prevention and Control.
(i) Meat and Meat products.
Animals should be slaughtered in a hygienic, rat proof, vermin free butchery. Strict supervision should be
kept on the whole cycle of meat processing.
(ii) Milk and Milk Products.
Milk should be pasteurized or boiled and every care should be taken against subsequent contamination.
(iii) Protection of Foods.
Adequate precautions should be taken against contamination of food during storage or during processing.
The food items should not be left overnight in warm pantries and those not eaten immediately should be
kept in cold storage to prevent bacterial multiplication and toxin production.
(iv) Food Handlers.
They should be periodically examined and those suffering from boils, ulcers throat or eye infections and with
history of having suffered from enteric fever or diarrhoea in recent past should not be employed as food
handlers. A high standard of personal hygiene among food handlers must be maintained. Food handlers
should be educated in matters of clean habits and personal hygiene.

30.5 Enteric Group of Fevers (A01-02).

(a) Introduction.
This is a group of clinically close allied, but immunologically distinct fevers, characterized by typical continuous
fever for 3-4 weeks, relative bradycardia, with involvement of lymphoid tissues and considerable constitutional
symptoms. The disease varies in severity and many mild cases occur. The term ‘enteric fever’ includes both the
typhoid and paratyphoid fevers.
(b) Incidence and Prevalence.
(i) Global scenario.
Typhoid occurs predominantly in association with poor sanitation and lack of clean drinking water, in both
urban and rural settings. However, urbanization, with associated overcrowded populations and inadequate
water and sanitation systems, as well as climate change have the potential to further increase the global
burden of typhoid. As of 2019 an estimated 9 million people had typhoid fever and 1,10,000 people died
from it worldwide every year.
(ii) Indian scenario.
Enteric fever is endemic in India. Reported data for the year 2020 shows 1.069 million cases and 126
deaths. However, these diseases are major public health problems as survivors may take several months
to recover and resume work.
(iii) Armed Forces scenario.
In Armed Forces due to better hygiene and sanitation, safe water supply and systematic immunization the
incidence is low. In the Armed forces morbidity due to enteric group of fevers contribute to 0.51/1,000 in 2020.
(c) Agent.
Salmonella typhi causes typhoid fever and the causal organisms for paratyphoid fevers are Salmonella paratyphi
A, B and C. They are readily killed by heat at 60°C.
(d) Reservoir.
Man is the only reservoir of infection; either a case (mild, moderate or severe) or carrier (convalescent or chronic).

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Chronic carriers are those who excrete the bacilli for more than one year after clinical attack. A chronic carrier may
excrete the bacilli for several years, either continuously or intermittently. S. typhi once lodged in human carrier may
persist for 20-50 years. Faecal carriers are commoner than urinary carriers. The carrier state is commoner in middle
aged persons; females predominating over males. The famous case of “Typhoid Mary” who gave rise to more than
1,300 cases is a good example of a chronic carrier. Urinary carriers, though less common, are more dangerous to the
community than faecal carriers because of greater chances of contamination of hands during micturition. Detection
of carriers is by isolation of organisms from faeces or urine of suspects, agglutination tests are much less reliable.
(e) Source of Infection.
The sole source of infection is the faeces or urine of cases and carriers. The bacilli are excreted for varying
periods in faeces and urine.
(f) Mode of Transmission.
Enteric fever is spread chiefly through the medium of contaminated water, food, milk and vegetables. Flies
constitute an important subsidiary vehicle for sporadic incidence. A small proportion of cases may occur due
to direct transmission of infection from an actual case / carrier through contamination of hands, while handling
patients or their excreta. The mode of transmission for explosive outbreaks of any considerable size, is, however
water, milk or milk products adulterated by contaminated water or handling by carriers.
(g) Host.
Enteric fever can occur at any age. Highest incidence of this disease occurs in the 5-19 years of age group.
An attack of the disease gives lasting immunity; second attacks however are not uncommon. More cases are
reported among males probably as a result of increased exposure to infection, but carrier rates are more common
in females. The Armed Forces personnel, due to routine inoculation, constitute a relatively immune population.
(h) Environmental and Social Factors.
Enteric fevers are observed all through the year. The peak incidence is reported during July-September. This
period coincides with the rainy season and an increase in fly population. Outside the human body, the bacilli
are found in water, ice, food, milk and soil for varying periods of time. Typhoid bacilli do not multiply in water;
many of them perish within 48 hours, but some may survive for about 7 days. They may survive for over a
month in ice and ice-cream and up to 70 days in soil irrigated with sewage under moist winter conditions. Food
being a bad conductor of heat, provides shelter to the bacilli in which they may multiply and survive for some
time. Typhoid bacilli grow rapidly in milk without altering its taste or appearance in anyway. Vegetables grown
in sewage farms or washed in contaminated water are a positive health hazard. These factors are compounded
by such social factors as pollution of drinking water supplies, open air defecation and urination, low standards
of food and personal hygiene and health ignorance. Typhoid fever may therefore be regarded as an index of
general sanitation in any country.
(j) Incubation Period and Period of Communicability.
It is usually 10-14 days but, in many cases, it may well be outside the range. When the disease is water-borne,
the incubation period tends to be longer. The incubation period for paratyphoid is 4 to 5 days. The case is
infectious during the later part of incubation period and for a variable period thereafter.
(k) Clinical Features.
Onset is usually insidious with chills and fever. During the prodromal stage there may be malaise, headache,
cough and sore throat often with abdominal pain and constipation. The fever ascends in a step-ladder fashion and
reaches a plateau after 7-10 days. The patient looks toxic and may have marked constipation or pea soup diarrhoea
Later splenomegaly, abdominal distension and tenderness, relative bradycardia, dicrotic pulse and occasionally
meningismus appear. The rash commonly appear during second week of the disease. Serious complications occur
in up to 10 percent of typhoid fever patients especially in those who have been ill longer than 2 weeks.
(l) Prevention.
The fundamental preventive measures are:
(i) Ensure food is properly cooked and still hot when served.
(ii) Avoid raw milk and products from raw milk. Drink only pasteurized or boiled milk.

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(iii) Avoid ice unless it is made from safe water.

(iv) When the safety of drinking water is questionable, boil it or if this is not possible, disinfect it with a
reliable, slow-release disinfectant agent such as Chlorine.
(v) Wash hands thoroughly and frequently using soap, in particular after contact with pets or farm animals
or after having been to the toilet.
(vi) Wash fruits and vegetables carefully, particularly if they are eaten raw. If possible, vegetables and
fruits should be peeled.
(vii) Proper sanitary disposal of night soil
(viii) Strict anti-fly measures
(ix) High standard of food handlers’ hygiene
(x) Personal hygiene and food habits
(xi) Protective inoculation
(m) Immunization.
Currently 3 types of typhoid vaccines are licensed for use:
(i) Unconjugated Vi polysaccharide (ViPS).
The Vi polysaccharide vaccine is composed of a purified Vi capsular polysaccharide from the Ty2 S. typhi
strain. ViPS is licensed for use in individuals aged 2 years and older, to be administered subcutaneously
or intramuscularly as a single dose of 0.5 ml. A single dose of ViPS vaccine elicits high levels of serum
IgG anti-Vi antibodies. In persons aged 18–55 years living in non-endemic areas and vaccinated with the
non-conjugated Vi, the titres of serum anti-Vi antibody decline rapidly after the second year but may still
offer protection. The ViPS vaccine confers protection from 7 days after vaccination. To maintain protection,
revaccination is recommended every 3 years. The ViPS vaccine has also proved to be well tolerated and
safe when co-administered with routine childhood vaccines. Currently this vaccine is approved for use in
the Armed Forces serving personnel.
(ii) Typhoid Conjugate Vaccine (TCV).
Typbar-TCV was first licensed in India in 2013 for intramuscular administration of a single dose
(0.5 ml) in children aged 6 months and older and in adults up to 45 years of age. Available evidence from
immunogenicity studies on Typbar-TCV suggests that protection may persist for up to 5 years after primary
immunization. Recommended storage temperature for the vaccine is 2–8°C.
(iii) Live Oral Vaccine.
The Ty21a vaccine is available as enteric-coated capsules for oral administration on alternate days in a
3-dose regimen. It is approved for use in individuals older than 6 years. Ty21a is well tolerated and is
associated with low rates of adverse events. Ty21a vaccine requires storage at 2–8°C and retains potency
for approximately 14 days at 25°C. The Ty21a vaccine stimulates serum and mucosal antibodies to O, H
and other surface antigens and elicits long-lived cell-mediated immune responses. Vaccine efficacy of Ty21a
was 87-96% in various trials. It is indicated for immunisation of adults and children more than 6 years
of age. One capsule is administered on days 1, 3 and 5 irrespective of age, one hour before a meal with
cold or lukewarm milk or water. Protection commences 7 days after taking the last capsule and lasts for
3 years. Therefore, it is recommended to repeat the 3 doses once every 3 years.
On the occurrence of an outbreak or increasing incidence, all these measures must be tightened. A search
for carriers and missed cases, by stool and urine culture, blood culture and serological methods may be
made within the unit, particularly among the cooks, mess waiters and other food handlers. Restaurants,
cafes and other such places should be placed “out of bound’ to all ranks. If only few cases have occurred,
the chances of tracing the source are good. Immunization is the most important measure in arresting the
progress of an outbreak. The occurrence of a case in the unit warrants scrutiny of the inoculation state of
the unit followed by immediate protection of those who are due within the next quarter and of all doubtful
cases. Inoculation may not prevent the disease in those who are incubating the infection, but it will do
them no harm and definitely arrests the outbreak.

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(n) Action on Occurrence of a Case.

(i) Hospitalization.
The patient should be admitted immediately to hospital and treated in a flyproof ward. The food handlers
should be discharged from hospital when their stool and urine culture show negative result.
(ii) Disinfection.
Concurrent and terminal disinfection as described in chapter XXVII should be done. Faeces and urine can
be disposed of directly into sewer without preliminary disinfection where adequate sewage disposal systems
are available.
(iii) Notification.
It should be carried out as per existing order. Ref chapter XXVII.
(iv) Personal Hygiene/Protection.
Attendants should be immunized first and should wear gowns and wash hands scrupulously whenever they
handle the patients.
(v) Close Contacts.
They should be kept under daily medical surveillance for 21 days.

30.6 Viral Hepatitis (B15-19).

(a) Introduction.
Viral hepatitis is a widespread infectious disease normally caused by the hepatitis viruses A, B, C, D and E, but
only hepatitis A and E are faeco-orally transmitted. The condition can be self-limiting or can progress to liver
fibrosis (scarring), cirrhosis or liver cancer. It is known 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, varicella
and adenoviruses can also cause severe hepatitis in immunocompromised individuals but are rare.
(b) Definition.
An acute or sub-acute febrile infectious disease characterized by sudden onset, nausea, anorexia & abdominal
discomfort followed by dark coloured urine, light coloured stools and appearance of jaundice in sclera or skin.
(c) Incidence and Prevalence.
Viral Hepatitis caused 1.34 million deaths in 2015, a number comparable to deaths, caused by tuberculosis
and higher than those caused by HIV. It is estimated that worldwide, Hepatitis A Virus (HAV) infections caused
approximately 7100 deaths in 2016 (accounting for 0.5% of the mortality from viral hepatitis).
(i) Global Scenario.
In total over 350 million people in the world are living with viral hepatitis. Each year over a million people
lose their lives because of conditions related to acute hepatitis and chronic infection that cause liver cancer
and cirrhosis. Chronic hepatitis B and C infections are the leading cause of liver cancer.
As per WHO estimates of 2019, 296 million people worldwide are living with hepatitis B, 58 million people
worldwide are living with hepatitis C, 1.5 million people were newly infected with chronic hepatitis B &
1.5 million people were newly infected with chronic hepatitis C. Both hepatitis B and hepatitis C can lead
to lifelong infection.
Hepatitis A and hepatitis E infections do not result in chronic infection but can be severe and cause liver
damage and death. Outbreaks of these infections occur worldwide, particularly in parts of the world with
poor sanitation.
In 2016, WHO’s World Health Assembly (WHA) called for global elimination of viral hepatitis by 2030 and
set global targets of achieving 90% reduction in new cases of hepatitis B and hepatitis C, a 65% reduction
in deaths from hepatitis B and hepatitis C and treatment of 80% of people living with these infections.
Individual countries are now in different stages of developing their own viral hepatitis elimination plans. At the
2021 WHA, WHO released the Interim Guidance for Country Validation of Viral Hepatitis Elimination providing

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a global framework for the process and standards for validation of elimination, including absolute impact
and programmatic targets.
(ii) Indian Scenario.
Viral hepatitis is increasingly being recognized as a public health problem in India. It places a huge disease,
social and economic burden on the affected individual, family, as well as the health system.
Due to paucity of data, the exact burden of disease for the country is not established. However, available
literature indicates a wide range and suggests that HAV is responsible for 10-30% of acute hepatitis and
5-15% of acute liver failure cases in India. It is further reported that HEV causes 10-40% of acute hepatitis
and 15-45% of acute liver failure. Acute HEV has inordinately high mortality rate of 15 to 25 percent in
women in the third trimester.
Based on the prevalence of Hepatitis B surface antigen, different areas of the world are classified as high
(≥8%), intermediate (2-7%) or low HBV endemicity. India falls under the category of intermediate endemicity
zone (average of 4%). It has been estimated that India has around 40 million HBV carriers. About 15-
25% of HBsAg carriers are likely to suffer from cirrhosis and liver cancer and may die prematurely. As per
National Action Plan Combating Viral Hepatitis in India, Anti-Hepatitis C virus (HCV) antibody prevalence
in the general population is estimated to be between 0.09-15%. Based on some regional level studies, it
is estimated that there are 6-12 million people with Hepatitis C in India. Chronic HBV infection accounts
for 40-50% of Hepatocellular carcinoma (HCC) and 20-30% cases of cirrhosis and chronic HCV infection
accounts for 12-32% of HCC and 12-20% of cirrhosis in the country.
In peace time, the incidence of the HAV & HEV disease, which have a faeco-oral route of transmission,
is low, but in war time and field service with the movement of troops into endemic areas and lowering
of standards of sanitation, there is often a local high incidence. Hep B, C & D which have a parenteral
route of spread have a high incidence in a set up where proper sterilization is not maintained in surgical
procedures or in injection rooms or in blood transfusion banks.
(d) Agent.
Hepatitis A virus has been identified and detected in faeces and serum of humans in acute stage of illness.
The virus is fairly resistant to low pH, heat and chemicals, it has been shown to survive more than 10 weeks in
well water. It withstands heating to 60 deg C for one hour and is not affected by usual chlorine dose in water.
Hepatitis B virus is present in human blood of patients and carriers. Antigenically, it is very complex. It has at
least 3 separate antigen- surface antigen (HbsAg), core antigen (HbcAg) and secretory antigen (HbeAg). The virus
has not yet been grown in the organ culture system. It is killed by heat at 60°C for 10 hours in plasma. The
assay that detects the presence of either antigens or antibodies, typically in serum or plasma but also in capillary
blood and oral fluid includes Rapid Diagnostic Tests (RDTs) and laboratory-based immunoassay e.g., Enzyme
Immunoassay (EIAs), Chemiluminescence Immunoassay (CLIAs) and electrochemiluminescence immunoassay
(ECLs). HCV is an RNA agent similar to Flavivirus. HDV also called the ‘Delta Agent’  / ‘Defective Virus’/’Dane
Particle’, has a lipoprotein envelope containing HbsAg and a core with a circular RNA genome and delta antigen.
HEV is a 27-34 nm long non-enveloped RNA virus.
(e) Reservoir of Infection.
Man is the reservoir for all the viruses. However, non-human primates may also serve as reservoir of hepatitis
A virus (chimpanzees and marmoset monkeys).
(f) Mode of Transmission.
(i) Hepatitis A & E.
Person to person spread by faeco-oral route is the most common mode of transmission. Common vehicle
explosive outbreaks have been related to contaminated water and food including milk. The infecting agent
is present in circulating blood prior to the onset of jaundice and for a few days later. Spread by ingestion
or by parenteral inoculation of infected blood or blood products is also possible.
(ii) Hepatitis B, C & D.
(aa) Parenteral Route.
Hepatitis B is essentially a blood-borne infection. It is transmitted by infected blood and blood products

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through transfusions, dialysis, contaminated syringes and needles, pricks of skin, handling of infected
blood, accidental inoculation of minute quantities of blood which may occur during surgical and
dental procedures, immunization, traditional tattooing, ear piercing, nose piercing, ritual circumcision,
acupuncture, etc. Accidental percutaneous inoculations by shared razors and toothbrushes have been
implicated as occasional causes of hepatitis B.
(ab) Perinatal Transmission.
Spread of infection from HBV carrier mothers to their babies appears to be an important factor for the
high prevalence of HBV infection in some regions, particularly China and SE Asia. The risk of infection
varies from country to country and may reach 40 percent. The mechanism of perinatal infection is
uncertain. Although HBV can infect the foetus in utero, this rarely happens and most infections appear
to occur at birth, as a result of a leak of maternal blood into the baby’s circulation or ingestion or
accidental inoculation of blood. Infection of the baby is usually anicteric and is recognised by the
appearance of surface antigen between 60-120 days after birth.
(ac) Sexual Transmission.
There is ample evidence for the spread of infection by intimate contact or by sexual route. The sexually
promiscuous, particularly male homosexuals, are at very high risk of infection with hepatitis B.
(ad) Other Routes.
Transmission from child-to-child, often called horizontal transmission, is responsible for a majority of
HBV infections and carriers in parts of the world other than Asia. The researchers believe that the
spread occurs through physical contact between children with skin conditions such as impetigo and
scabies or with cuts or grazes. Often transmission occurs when children play together or share the
same bed. In short, transmission occurs in a wide variety of epidemiological settings. It can spread
either from carriers or from people with no apparent infection or during the incubation period, illness
or early convalescence. Hepatitis C & D have similar modes of transmission.
(g) Host.
Susceptibility is general. Usually, the disease is commoner and milder in children and young adults. Degree and
duration of homologous immunity after attack are unknown but presumed to be long lasting. Certain occupational
categories have been identified as associated with an excess risk of hepatitis B, C & D infection. The categories
include dentists, nurses, laboratory technicians and the work areas include hemodialysis units, blood banks,
surgical intensive care units. Higher mortality rate has been reported in hepatitis A during pregnancy and hepatitis
B developing after blood transfusion.
(h) Incubation Period.
The average incubation period for Hepatitis B is 75 days (range 30-180 days). The IP for Hepatitis A is
10-50 day (usually 14-28 days), for hepatitis C it is 2 weeks to 6 months and for Hepatitis E it is 3-8 weeks with a
mean of 40 days.
(j) Communicability Period.
Maximum infectivity for hepatitis A & E is during the latter half of incubation period continuing through early
acute phase of infection during the first 1-2 weeks or longer. In hepatitis B, C & D blood remains infective for
many weeks before the onset of symptoms, through the acute clinical course and during the chronic carrier
state. Many persons may be carriers without having experienced a clinically recognized attack.
(k) Epidemiological Patterns.
The tendency of viral hepatitis A & E to occur among children in endemic areas with poor environmental sanitation
but amongst adults with better sanitation standards and of a socio-economically higher class has been observed.
Sporadic cases occur from person to person through intimate contact evenly spread all round the year with
seasonal upsurge in the fly breeding season. Explosive outbreaks may occur due to massive pollution of water
supplies with sewage or of milk through milk handlers or water used for adulteration. Hepatitis B, C & D cases
have been traced to clinics among patients who have received parenteral inoculations from contaminated and
inadequately sterilized syringes and needles.

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(l) Treatment.
There is no specific treatment for Acute Hepatitis B. Care is aimed at maintaining comfort and adequate nutritional
and fluid balance. In Chronic Hepatitis B antiviral treatment is only indicated if there is evidence of compensated or
decompensated cirrhosis or are aged more than 30 years (in particular) and have persistently abnormal ALT levels.
The antivirals used are Tenofovir Disoproxil Fumarate (TDF), Entecavir and Tenofovir Alafenamide Fumarate (TAF)
with dose to be adjusted for adult and children. All persons with cirrhosis based on clinical evidence require lifelong
treatment. The availability of highly effective Directly Acting Antivirals (DAAs) (Sofosbuvir, Daclatasvir, Sofosbuvir +
Velpatasvir & Ribavirin) has however changed the HCV treatment paradigm, any individual diagnosed to have infection
with hepatitis C virus (viremia+) needs treatment. The duration of treatment will depend on the several situations such
as, cirrhosis versus non-cirrhosis, presence of decompensation (ascites, variceal bleeding, hepatic encephalopathy
or infection(s). There is no role for antiviral drugs in therapy for self-limiting HAV infection or HEV infection.
(m) Prevention and Control.
(i) The patient should be admitted to hospital based on condition of the patient.
(ii) Concurrent and terminal disinfection as for any other excremental diseases should be ensured.
(iii) Notification of the disease is essential.
(iv) Attendants should take precautions based on the type of virus causing the disease.
(v) Immunisation
(aa) Passive Immunisation.
Hepatitis B Immunoglobulin (HBIG) is used for those acutely exposed to HBsAg positive blood e.g.,
surgeons, nurses or laboratory workers, newborn infants of carrier mother, sexual contacts of acute
hepatitis B patients and patients who need protection against HBV infection after liver transplantation.
It should be given as soon as possible after an accidental inoculation (ideally 6 h and not later than
48h). The recommended dose is 0.05 to 0.07 ml/kg of body weight.
(ab) Active Immunization.
O HAV - Hepatitis A Vaccine.
This Inactivated vaccine is licensed for use in person ≥  12 months of age. The complete
schedule consists of 2 doses separated by 6-12 months and is administered intramuscularly.
The live attenuated vaccine is administered as a single subcutaneous dose.
O HBV - Hepatitis B Vaccine.
The recombinant vaccine is available as monovalent or in fixed combination with other vaccine
(Pentavalent). The dose for adult is 1 ml (10-20 mcg) initially and then at 1 and 6 months.
(vi) Water supply should be safeguarded against faecal contamination. Even super chlorination may not
kill the virus, unless water is very efficiently chlorinated and a half an hour contact period is ensured. Water
should be preferably boiled during an outbreak.
(vii) Sanitation should be kept at a very high level. Methods of proper disposal of human wastes and
strict anti-fly measures should be reinforced.
(viii) Personal hygiene must be maintained at an extremely high level. All ranks must be persuaded to
wash their hands with soap and water after defecation and before handling or consuming food, particularly
so in case of cooks and food handlers.
(ix) Needles and syringes used for routine immunization must be autoclaved for twenty minutes under
15 lb/sq inch pressure or boiled for 30 min.
(x) It is mandatory that all blood donors and blood products be screened for HBV and HCV infection and
those found positive should be rejected. Voluntary blood donation should be encouraged because purchased
blood has shown a higher risk of post-transfusion hepatitis.
(xi) Carriers should be told not to share razors or toothbrushes and use barrier methods of contraception;
they should not donate blood.

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30.7 Poliomyelitis (A80).

(a) Introduction.
Poliomyelitis (polio) is a highly infectious viral disease that largely affects children under 5 years of age. It is an
acute viral infection characterized clinically by an initial short febrile illness with sore throat, headache, vomiting,
stiffness of the neck and back and sometimes causing affection of the central nervous system.
(b) Incidence and Prevalence.
(i) Global Scenario.
In the pre-vaccination era, poliomyelitis was found in all countries of the world. The extensive use of
polio vaccines since 1954 has virtually eliminated the disease from the world and is now on the verge of
eradication. In 1998, World Health Assembly adopted a resolution for the global eradication of poliomyelitis.
wild poliovirus has decreased by over 99% since 1988, from an estimated 3,50,000 cases in more than
125 endemic countries, to just two endemic countries (as of October 2023).
The 3 strains of wild poliovirus (type 1, type 2 and type 3), wild poliovirus type 2 was eradicated in 1999
and wild poliovirus type 3 was eradicated in 2020. As at 2022, endemic wild poliovirus type 1 remains in
two countries: Pakistan and Afghanistan. As long as a single child remains infected, children in all countries
are at risk of contracting polio. Failure to eradicate polio from these last remaining strongholds could result
in a global resurgence of the disease. In most countries, the global effort has expanded capacities to tackle
other infectious diseases by building effective surveillance and immunization systems.
(ii) Indian Scenario.
India rolled out the Pulse Polio Immunization Programme on 2nd Oct 1994, when the country accounted
for around 60% of the global polio cases. Within two decades, India received ‘Polio-free certification’ from
WHO on the 27th Mar 2014, with the last polio case being reported in Howrah in West Bengal on 13th Jan
2011. India holds one NID (National Immunization Day) and two Sub-National Immunization Days for polio
every year to maintain population immunity against wild poliovirus and to sustain its polio free status.
(c) Types and Clinical Features.
Among cases, affection of the central nervous system is more a rarity than a rule, but such cases are more obvious than
the non-paralytic cases and also cause socio-economic hardships later. This makes the disease more recognizable
by its nervous involvement. The anterior horns in the spinal cord and motor neurons of cranial nerves are affected
in such cases, resulting in a lower motor neuron type of flaccid muscular paralysis mainly in the limbs and specially
the lower limbs. The case fatality rate in paralytic cases is 2 to 3% and in the bulbar type it is 5 to 6%. The paralysis
starts with varying degrees, initially more extensive but gradually reducing down to a lesser residual paralysis.
Patients with paralysis represent a small minority of clinical cases. Febrile attack and neck rigidity, not going on to
the paralytic stage, are the only manifestations in the majority of cases followed by complete recovery. Many do not
show any disturbance whatsoever. Such inapparent infections exceed clinical cases a hundred-fold. However, the
virus is present in the faeces of all such cases. Provocative factors like surgical procedures, such as tonsillectomy and
dental extractions, administration of triple antigen, pregnancy and severe physical exertion increase the incidence
of clinical cases and the risk of nerve involvement during epidemics.
(d) Agent.
The causal organism is a filterable neurotropic virus with three immunological types­ Polio virus types 1, 2 and
3. All types can cause paralysis but type 1 has been most commonly involved. Polio viruses are resistant to
freezing and drying. They are easily killed by heat at 55°C for 30 min, potassium permanganate, ultraviolet rays
and chlorine. In a cold environment, it can live in water for 4 months and in faeces for 6 months. It is therefore
well adapted for the faeco-oral route of transmission.
(e) Reservoir.
Man is the only reservoir. Persons with inapparent infection, especially children constitute the main reservoir. It
is estimated that for every clinical case there may be 1,000 subclinical cases in children and 75 in adults.
(f) Source of Infection.
Man is the only reservoir. Persons with inapparent infection, in early clinical period; generally, prior to paralysis,

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mostly from non-paralytic sub clinical or inapparent cases. Such cases also serve to keep infection going in a
community through their faeces or pharyngeal secretions. However, the silver lining is that there are no chronic
carriers.
(g) Mode of Transmission.
This is similar to excremental intestinal infections with a faeco-oral mode of transmission, such as the enteric
group of fevers and viral hepatitis type A; the vehicles are water, milk, flies or direct contact. Mouth to mouth
spread by droplets can also occur.
(h) Host.
Susceptibility to infection is general but few infected persons develop paralysis. In India, poliomyelitis is essentially
a disease of childhood and infancy, most vulnerable age being between 6 months to 3 years. In western countries
25 percent of cases are over the age of 15 years. Males are more prone to clinical attack, the ratio being
3:1 in favour of males. An increased susceptibility to paralytic poliomyelitis is associated with pregnancy.
(j) Incubation Period.
The incubation period is generally 7 to 14 days with a range of 3 to 35 days.
(k) Communicability Period.
(i) Cases are most infectious from 7 to 14 days before onset of symptoms and a similar period thereafter,
but sometimes as long as 3 to 4 months.
(ii) The infection being mainly faeco-oral in its mode of transmission. The rate of contraction of disease
depends upon efficiency with which sewage is disposed of and its opportunity to pollute water, milk and
food, cooked or raw, consumed by people and the personal hygiene and eating habits of people.
(l) Epidemiological Patterns.
The infection is ubiquitous but its contraction by human beings depends upon the standard of environmental
sanitation and personal hygiene. The rate of contraction is directly related while the rate of paralytic sequelae
is inversely proportionate to the environmental sanitation and personal hygiene. This is due to the fact that the
population with a lower socio-economic status acquire partial or considerable immunity due to repeated sub-
clinical infections or antigenic stimuli since their childhood.
Endemicity is naturally high in places with a low standard of environmental sanitation. Just like viral hepatitis,
the epidemiological pattern of the disease is of a sporadic nature evenly spread over the year with a seasonal
upsurge during the fly breeding season. Short outbreaks among newcomers and the child population with a
preponderance among the high socio-economic class are experienced at intervals. The periodical upsurge in
tropical and subtropical countries represents the ‘epidemic flare up of an endemic infection’ due to an increase
in the non-immune population and their opportunities of contraction of infection in the ward and insanitary
season. In advanced countries the common feature is for school children to be attacked by the paralytic form
rather than the preschool children as is found in countries with poor environmental conditions due to immunity
difference among children.
(m) Seasonal Variation.
There are striking seasonal variation in the incidence of paralytic poliomyelitis. In tropical countries most cases
are recorded during June to September and in temperate zone more cases are seen in late summer and early
autumn.
(n) Prevention.
(i) A high standard of hygiene and sanitation should be maintained with arrangements for proper disposal
of faeces, safe water supply and proper food hygiene.
(ii) Active immunization is the most effective means of preventing poliomyelitis. In the National
Immunization Schedule (NIS) the bivalent Oral Polio Vaccine (bOPV) is given at birth as zero dose, then at
6, 10 and 14 weeks, while bOPV booster is given at 16-24 months and 5 yrs of age. In addition, inactivated
polio vaccine is given as two fractional dose (fIPV) at 6 and 14 weeks of age and third dose at 9-12 months
with Measles-Rubella (MR) vaccine.

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(o) Steps to Maintain Polio Free Status in India.

Immunity against Poliomyelitis in community is maintained through high quality National and Sub National polio
rounds each year. In Armed Forces stations, the same is implemented through Station Health Organization and
SMO/SEMO. An extremely high level of vigilance through surveillance across the country for any importation
or circulation of poliovirus and VDPV is being maintained. Environmental surveillance (sewage sampling) has
been established to detect poliovirus transmission and as a surrogate indicator of the progress as well for
any programmatic interventions strategically in Mumbai, Delhi, Patna, Kolkata Punjab and Gujarat. All States
and Union Territories in the country have developed a Rapid Response Team (RRT) to respond to any polio
outbreak in the country. Emergency Preparedness and Response Plans (EPRP) has also been developed by all
States indicating steps to be undertaken in case of detection of a polio case. To reduce risk of importation
from neighbouring countries, international border vaccination is being provided through Continuous Vaccination
Teams (CVT) to all eligible children round the clock. These are provided through special booths set up at the
international borders that India shares with Pakistan, Bangladesh, Bhutan Nepal and Myanmar. Government of
India has issued guidelines effective since March 2014, for mandatory requirement of polio vaccination to all
international travellers for travel to India and other affected countries namely Afghanistan, Nigeria, Pakistan,
Ethiopia, Kenya, Somalia Syria and Cameroon. A rolling emergency stock of OPV is being maintained to respond
to detection/importation of wild poliovirus (WPV) or emergence of circulating vaccine derived poliovirus (cVDPV).
(p) National Polio Surveillance Project (NPSP).
The National Polio Surveillance Project (NPSP) -India was launched in 1997 to work closely with the Union and
State governments to support polio eradication activities in India. Following elimination of polio from India in
2011 and certification of WHO SEAR as polio-free in March 2014, NPSP continues to support the government in
implementation of the Polio Eradication and End Game Strategic Plan (2019-23). Further, NPSP has transitioned
to the National Public Health Surveillance Project by broadening its scope of work and is providing support for
the intensification of routine immunization and vaccine preventable disease surveillance as a part of the overall
health system strengthening, supporting the goal of measles and rubella elimination, introducing new vaccines
and addressing other public health priorities in consultation with the Government of India.

Suggested Reading.
1. Cholera vaccines: WHO Position Paper – August 2017 [Internet]. www.who.int. Available from: https://www.who.
int/publications/i/item/who-wer9234-477-500
2. Kushwaha A, Aggarwal S, Sharma L, Singh M, Nimonkar R. Accidental Outbreak of Non-Bacterial Food Poisoning.
Medical Journal Armed Forces India. 2008 Oct;64(4):346–9.
3. Bisht A, Kamble MP, Choudhary P, Chaturvedi K, Kohli G, Juneja VK, et al. A surveillance of food borne disease
outbreaks in India: 2009–2018. Food Control. 2020 Sep;121(107630):107630.
4. Awofeso N, Aldabk K. Cholera, Migration and Global Health – A Critical Review. International Journal of Travel
Medicine and Global Health. 2018 Sep 25;6(3):92–9.
5. Chandra Sekhar K, Ravideep Y. Laboratory Abnormalities in Acute Diarrhoea in Children. Journal of evolution of
medical and dental sciences. 2017 Nov 27;6(91):6515–20.
6. Peeling RW, Boeras DI, Marinucci F, Easterbrook P. The Future of Viral Hepatitis testing: Innovations in Testing
Technologies and Approaches. BMC Infectious Diseases. 2017 Nov;17(S1).
7. Jadhav S, Sinha A, Banerjee A, Chawla P. An Outbreak of Food Poisoning in a Military Establishment. Medical
Journal Armed Forces India. 2007 Apr;63(2):130–3.
8. Heggers JP. Food-Borne Diseases: A Food Service Supervisor’s Dilemma. Military Medicine. 1978 May
1;143(5):330–2.
9. Division of Viral Hepatitis Home Page | Division of Viral Hepatitis | CDC [Internet]. www.cdc.gov. 2020. Available
from: https://www.cdc.gov/hepatitis/
10. laboratory-methods-for-the-diagnosis-of-vibrio-cholerae-chapter-6.pdf [Internet]. [accessed 2024 Mar 20]. Available
from: https://www.cdc.gov/cholera/pdf/laboratory-methods-for-the-diagnosis-of-vibrio-cholerae-chapter-6.pdf
n

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Chapter
XXXI
AIRBORNE DISEASES

31.1 Introduction.
Airborne and droplet infections are those which enter the body through the respiratory passage of the recipient.
The exit for the pathogenic organism is throat or nose of the host who is either a case or carrier of the organism.
The pathogenic organisms are released into the environment through sneezing, coughing, spitting, laughing,
shouting, talking etc. by the infected person. The spray of nasopharyngeal secretions during coughing, sneezing
etc. containing pathogenic organism projects up to 1-1.5 meter and persons within the range are liable to inhale
such organisms. Some of the finer particles may become airborne and travel further (especially in case of viruses)
enhancing the infective range of such pathogens. Heavier & larger particles which are not able to travel settle
down and are transmitted directly like becoming airborne during activities like sweeping or directly from articles or
fomites contaminated with such pathogens. Airborne and droplet infections may make the respiratory tract itself
as their seat of action and also a portal of entry for infecting some other organs or tissues e.g. CSF, mumps etc.
Respiratory tract harbors many organisms as commensals for long time and these become virulent when either
their quantum increases suddenly or the host defences are affected due to some other disease or debility.
Respiratory infections are among the top causes of morbidity in Armed forces. Man-days are lost to great extent
due to respiratory infections ranging from common cold to Tuberculosis (TB), pneumonia etc. Overcrowding, poor
ventilation, improper hygienic conditions, inadequate protection from cold climate / weather changes etc. contribute
to increased risk of airborne infections in Armed forces.

31.2 Tuberculosis.
(ICD 10 Code: A15-A19)
(a) Introduction.
Tuberculosis (TB) is one of the oldest diseases known to mankind. Its causative organism Mycobacterium
tuberculosis was one of the first bacterial pathogens to be identified. Though vaccine against tuberculosis and
effective treatment regimens for cure of the disease has been available since close to a century, yet the fight
against TB is ongoing. An overwhelming majority of cases and practically all deaths due to tuberculosis take
place in developing countries. The fight against TB globally has remained a priority of World Health Organization
(WHO) and countries including India since 1993 (declaration of TB as global public health emergency by WHO)
and has made encouraging progress in recent decade. However, the COVID-19 pandemic has put these gains at
risk. Tuberculosis is considered as an indicator of social development and thus the struggle to end TB includes
measures towards the disease as well as against social and development issues of inequity, unsafe environments,
stigma, discrimination, lack of or limited access to social protection and universal health coverage.
(b) History.
Tuberculosis has been known by several names through history. The ancient Greeks called it phthisis (to waste).
The swollen glands of the neck due to tuberculosis were called scrofula. TB of the skin was known Lupus vulgaris.
TB of the bone is known as Pott’s disease with characteristic vertebral fusion and deformity of the spine. The
most familiar term for TB was consumption, which means to consume or wear away. Among all these names,
perhaps the most fitting is ‘Captain of the Men of Death’. Mycobacterium tuberculosis has been present in the
human population since antiquity. There is evidence of the disease in fragments of the spinal column from
Egyptian mummies from 2400 B.C. which show definite pathological signs of tubercular decay. Around 460 BC,
Hippocrates identified phthisis as the most widespread disease of the times and noted that it was almost always
fatal. Sylvius was the first to identify actual tubercles in the lungs and other areas of consumptive patients in

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1679. He also described their progression to abscesses and cavities. In 1882, Robert Koch discovered a staining
technique that enabled him to see Mycobacterium tuberculosis.
(c) Epidemiology.
(i) World.
Tuberculosis is present in all countries and age groups with skewed global distribution and contributes to
high economic burden in Asian and African regions. Though the absolute numbers of cases and deaths
are the largest in Asia, the rates of disease and deaths are the highest in Africa. As per Global TB report
2023, eight countries accounted for more than two-thirds of the global total namely, India, Indonesia, China,
the Philippines, Pakistan, Nigeria, Bangladesh and the Democratic Republic of the Congo.
According to WHO, 1.3 million people died from TB in 2022 (including 1,67,000 people with HIV). Worldwide,
TB is the second leading cause of mortality by infectious diseases preceded by COVID-19 (above HIV
and AIDS). It is estimated 10.6 million people fell ill with TB worldwide, of which 5.8 million were men,
3.5 million women and 1.3 million were children. Further, in 2020, 1.1 million children and adolescents under
15 years fell ill with TB globally. Around 2,26,000 children and adolescents lost their lives because of TB
and 21,000 (or 9%) of these young adolescents were living with HIV.
Eighty-six percent of new TB cases were reported from 30 high TB burden countries. Multidrug-resistant TB
(MDR-TB) remains a public health crisis and a health security threat. Only about one in three people with
drug resistant TB accessed treatment in 2020.
The 2023 Global Tuberculosis Report highlights that COVID-19 pandemic has adversely impacted the access
to TB diagnosis and treatment and has resulted in slowing or even reversing the progress made in the
years up to 2019.
(ii) India.
In India, the integration of TB and COVID-19 bi-directional screening strategy, laboratory services, diagnostic
and treatment capacity upgrades and procedures for co-located testing for TB (among COVID-19 patient
as well as Influenza-like Illness (ILI) / Severe Acute Respiratory Infections (SARI) patients) and testing for
COVID-19 (among notified TB patients) laid foundations for capturing TB burden during the pandemic.
According to India TB Report 2023, a total of 24.2 lakh cases were notified in the year 2022 i.e., a case
notification rate of approximately 172 cases per lakh population, 13% more as compared to year 2021. A
quarter of these were detected through active TB case-finding. The private sector also contributed to highest
notifications of 7.3 lakh patients (31% of total notifications), 3% more than in 2019. Age distribution of TB
shows predominance in young adults between 15 to 30 years.
(iii) Armed Forces.
In the Armed Forces, prevalence of TB has been much lower owing to the initial selective recruitment
including investigations like chest X ray and much better living standards and general nutrition & comparative
seclusion from the general population. As per AHR 2020 hospital admission rate due to TB in all three
services was 0.33 / 1,000 which was lower than the decadal average of 0.64 / 1,000.
(d) Natural History of Tuberculosis.
(i) Agent Factors.
Human tuberculosis is caused by Mycobacterium tuberculosis which belongs to the genus Mycobacterium,
family Mycobacteriaceae and order Actinomycetes. Mycobacterium tuberculosis is Gram positive, non-motile,
non-sporing, pleomorphic rod. The bacilli are obligate aerobes growing most successfully in tissues having
the highest partial pressure of oxygen, such as lung apices. They are facultative intracellular pathogens,
slow-growing with a generation time of 12 to 18 hours. Hence, lesions typically evolve in a sub-acute to
chronic course. They are classified as Acid Fast Bacilli (AFB) because they retain the carbol fuchsin red
dye after washing with acid, alcohol or both.
Mycobacterium bovis is the etiologic agent of TB in cows and rarely in humans. Both cows and humans
can serve as reservoirs. Humans can also be infected by the consumption of unpasteurized milk.
Mycobacteriun africanum can be a rare cause of tuberculosis. Other human pathogens belonging to the
genus Mycobacterium include Mycobacterium avium which causes a TB – like disease especially prevalent

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in AIDS patients and Mycobacterium leprae, the causative agent of leprosy.

(ii) Host Factors.
Tuberculosis can occur at any age. In India disease prevalence is more in the older age groups. It is now
known that both delayed hypersensitivity and acquired resistance to TB are cell mediated immune responses.
Persons who are undernourished and suffering from Silicosis, Diabetes, Myxoedema, HIV infection or under
immuno-suppressive drugs are more susceptible. Tuberculosis has often been described as a barometer
of social welfare. It strikes poor people and those who do not have access to health care. The highest
burden of TB is in the most impoverished countries. Poor housing conditions and overcrowding are closely
associated with transmission of infection.
(iii) Mode of Transmission.
The source of infection is an open case (sputum positive) of pulmonary TB. Mycobacterium tuberculosis is
spread by airborne particles, known as droplet nuclei, that can be generated when persons with pulmonary
or laryngeal TB sneeze, cough, speak or sing. It has been estimated that a cough can generate 3,000 droplet
nuclei. The same number is generated by a person talking for five minutes. Persons who share the same
airspace with persons with infectious TB disease are at greatest risk for infection. Infection occurs when a
susceptible person inhales droplet nuclei containing tubercle bacilli and these bacilli become established
in the alveoli of the lungs and spread throughout the body. Living conditions of military barracks, hostels,
dormitories can lead to an increased risk of infection. Prolonged household contact with an open case
may lead to infection. Fomites do not play any role in transmission of the disease. There can be bovine
source of TB infection, through ingestion of infected unpasteurized milk or dairy products. However, there
is no definite evidence that bovine TB is of concern in India, because of practice of boiling milk before
consumption. Direct inoculation through the skin can also lead to infection. However, both these modes of
transmission probably cause a very small number of cases.
(iv) Pathogenesis of TB.
Primary infection occurs on first exposure to tubercle bacilli. Inhaled droplet nuclei are so small that they
avoid the mucociliary defenses of the bronchi and lodge in the terminal alveoli of the lungs. Infection begins
with multiplication of tubercle bacilli in the lungs which forms the Ghon’s focus. Lymphatics drain the bacilli
to the hilar lymph nodes. The Ghon’s focus and related hilar lymphadenopathy form the Ghon’s complex.
Bacilli may spread in the blood from the primary complex throughout the body. The immune response
(delayed hypersensitivity and cellular immunity) develops about 4-6 weeks after the primary infection.
The size of the infecting dose of bacilli and the strength of the immune response determines the course
following primary infection. In most cases, the immune response stops the multiplication of bacilli. However,
a few dormant bacilli may persist. A positive tuberculin skin test would be the only evidence of infection.
The immune response in a few cases is not strong enough to prevent multiplication of bacilli and disease
occurs within a few months. Post-primary TB occurs after a latent period of months or years after primary
infection. It may occur either by reactivation or by reinfection. Reactivation means that dormant bacilli
persisting in tissues for months or years after primary infection start to multiply. This may be in response to
a trigger, such as weakening of the immune system by HIV infection. Reinfection means a repeat infection
in a person who has already previously had a primary infection. Post-primary TB usually affects the lungs
but can involve any part of the body. The characteristic features of post-primary Pulmonary TB (PTB) are
extensive lung destruction with cavitation, positive sputum smear, upper lobe involvement with usually no
intra-thoracic lymphadenopathy. Extra-pulmonary TB can affect the lymph nodes, pleura, bones and joints,
the genito-urinary tract, the nervous system (meningitis), intestines etc. If untreated, TB leads to death
within 2-3 years in at least half the patients.
(v) Management.
Diagnosis and treatment of cases of tuberculosis is carried out in accordance with the guidelines issued
by the NTEP. The diagnostic algorithm for Pulmonary TB, Extrapulmonary TB and Paediatric Pulmonary TB
according to Training Module for Programme Managers & Medical Officers 2020, NTEP are given in Fig
31.1, Fig 31.2 and Fig 31.3 respectively.

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Fig 31.1 : Diagnostic Algorithm for Pulmonary Tuberculosis

Fig 31.2 : Diagnostic Algorithm for Extra Pulmonary Tuberculosis

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To achieve universal access to early accurate diagnosis of TB and enhancing case finding efficiency,
identification of presumptive TB cases at the first point of care and linking them to the best available
diagnostic tests is of paramount importance. Most patients with TB visit health facilities promptly after
symptoms occur. Hence, every adult patient with respiratory symptoms attending the health facility must be
asked about symptoms suggestive of TB. The most common symptom of pulmonary TB is a persistent cough
for 2 weeks, fever > 2 weeks, significant weight loss, haemoptysis, any abnormality in chest radiograph.
Presence of organ specific symptoms and signs like swelling of lymph node, pain and swelling in joints,
neck stiffness, disorientation, etc and / or constitutional symptoms like significant weight loss, persistent
fever for > 2 weeks and night sweats are common symptoms in extra-pulmonary TB.

O Persistent Fever > 2 wk, without a known cause and / or

O Unremitting Cough for > 2 wk and / or
O Wt loss of 5% in 3 m or no wt gain in past 3 months h / o contact

Chest X-ray

CXR CXR NS shadows / NA CXR Normal CXR Normal

highly suggestive Skin test +ve / NA Skin test +ve Skin test –ve

Expectorated sputum / Give course of

Microbiological Evaluate for EPTB
GA / IS for CBNAAT Antibiotics
confirmed TB Case Refer to expert

CBNAAT CBNAAT –ve CBNAAT –ve Persistent shadow Look for

+ve Skin test +ve Skin test –ve and symptoms alternate cause

Look for Expectorated sputum /

alternate cause GA / IS for CBNAAT

No other likely alternative diagnosis CBNAAT –ve &

Clinically Diagnosed TB case Refer to
Skin test +ve expert for
work up of
CBNAAT CBNAAT –ve &
persistent
+ve Skin test –ve
pneumonia

Fig 31.3 : Diagnostic algorithm for Paediatric Pulmonary Tuberculosis

(e) Case Finding Tools.
The acceptable methods for microbiological diagnosis of TB are Sputum Smear Microscopy (for AFB) by Zeihl-
Neelson staining or Fluorescence staining, Culture using Solid (Lowenstein Jensen) media, Automated Liquid
culture systems e.g. BACTEC MGIT 960, Bacti Alert or Versatrek, Drug Sensitivity Testing using Modified
Proportionate Sensitivity Testing (PST) for MGIT 960 system, Economic variant of Proportion sensitivity testing
(1%) using LJ medium and Rapid molecular diagnostic testing which includes Line Probe Assay for MTB complex
and detection of RIF & INH resistance and FQ and SLI resistance, Nucleic Acid Amplification Test (NAAT) and
Xpert MTB / Rif testing using the GeneXpert system. Smear microscopy being the most commonly used method
for microbiological diagnosis of TB for the last several decades, has had enormous value in TB diagnosis but
with limited sensitivity, more so in children and people living with HIV (PLHIV). Culture though highly sensitive
and specific method for TB diagnosis, requires 2-8 weeks to yield results and hence alone does not help in
early diagnosis. However, culture is used for follow up of patients on Drug Resistant TB treatment to detect early
recurrence as part of using the indicator of relapse free cure. Nucleic Acid Amplification Test (NAAT) provides
accurate and rapid diagnosis of TB by detecting Mycobacterium tuberculosis and Rifampicin (Rif) resistance

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conferring mutations, in sputum specimen as well as specimen from extra-pulmonary sites. Other diagnostic
tools include radiography, tuberculin skin testing, interferon gamma release assay and serological tests.
(f) Diagnosis by Sputum Microscopy.
Microscopic examination of sputum is, as a rule, the only way by which the diagnosis of pulmonary TB can be
confirmed. Whenever TB is suspected, at least 2 specimens of sputum should be collected over 2 consecutive
days and examined by microscopy. Only one laboratory form needs to be filled for one patient. The smears are
fixed by drying or heating and stained with the Ziehl - Neelsen (ZN) stain & examined under the oil immersion
lens of a microscope. The interpretation of the slides is as given in Table 31.1.
Table 31.1 : Reporting of Smears
Examination Finding Result Recorded Grading No. of Fields Examined
> 10 AFB per oil immersion field Positive 3+ 20
1 - 10 AFB per oil immersion field Positive 2+ 50
10 - 99 AFB per 100 oil immersion fields Positive 1+ 100
1 - 9 AFB per 100 oil immersion fields Positive Scanty 100
No AFB in 100 oil immersion fields Negative Negative 100
(g) Definitions and Reporting Framework for Tuberculosis.
The treatment of tuberculosis is standardized into different categories. It is important to classify a patient into the
correct category so that correct combination of drugs and duration of treatment be provided. The definitions of
cases have been revised by WHO in 2020 to include biomarker-based techniques. These definitions are revised
to incorporate new diagnostic modalities and treatment regimens from time to time.
(i) Presumptive Pulmonary TB refers to a patient who presents with symptoms or signs suggestive of
TB (previously known as a TB suspect), including cough for 2 weeks or more, fever for 2 weeks or more,
significant weight loss, haemoptysis, any abnormality in chest radiograph. Sputum should also be examined
for cases of suspected extra - pulmonary TB if pulmonary symptoms are present.
(ii) A Bacteriologically Confirmed TB case is one from whom a biological specimen is positive by smear
microscopy, culture or WHO Recommended Rapid Diagnostic Test (WRD) (such as Xpert MTB / RIF). All such
cases should be notified, regardless of whether TB treatment has started.
(iii) A Clinically Diagnosed TB case is one who does not fulfil the criteria for bacteriological confirmation
but has been diagnosed with active TB by a clinician or other medical practitioner who has decided to give
the patient a full course of TB treatment. This definition includes cases diagnosed on the basis of X-ray
abnormalities or suggestive histology and extrapulmonary cases without laboratory confirmation. Clinically
diagnosed cases subsequently found to be bacteriologically positive (before or after starting treatment)
should be reclassified as bacteriologically confirmed.
(iv) Bacteriologically confirmed or clinically diagnosed cases of TB are also classified according to the
anatomical site of disease; history of previous treatment; drug resistance; and HIV status.
(aa) Pulmonary Tuberculosis (PTB) refers to any bacteriologically confirmed or clinically diagnosed
case of TB involving the lung parenchyma or the tracheobronchial tree. Miliary TB is classified as
PTB because there are lesions in the lungs. Tuberculous intra-thoracic lymphadenopathy (mediastinal
and / or hilar) or tuberculous pleural effusion, without radiographic abnormalities in the lungs,
constitutes a case of extrapulmonary TB. A patient with both pulmonary and extrapulmonary TB
should be classified as a case of PTB.
(ab) Extrapulmonary Tuberculosis (EPTB) refers to any bacteriologically confirmed or clinically
diagnosed case of TB involving organs other than the lungs, e.g. pleura, lymph nodes, abdomen,
genitourinary tract, skin, joints and bones, meninges.
(v) New patients are defined as those patients who have never been treated for TB or have taken anti-TB
drugs for less than 1 month. Previously treated patients are who have received 1 month or more of anti-TB
drugs in the past. They are further classified by the outcome of their most recent course of treatment.

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(vi) Relapse patients have previously been treated for TB, were declared cured or treatment completed
at the end of their most recent course of treatment. Relapse patients can be either a true relapse or
reinfection. Treatment after failure patients are those who have previously been treated for TB and whose
treatment failed at the end of their most recent course of treatment.
(vii) Treatment after loss to follow-up patients have previously been treated for TB and were declared
lost to follow-up at the end of their most recent course of treatment. Other previously treated patients
are those who have previously been treated for TB but whose outcome after their most recent course of
treatment is unknown or undocumented. Patients with unknown previous TB treatment history do not fit
into any of the categories. New and relapse cases of TB are incident TB cases. HIV-positive TB patient
refers to any bacteriologically confirmed or clinically diagnosed case of TB who has a positive result from
HIV testing conducted at the time of TB diagnosis or other documented evidence of enrolment in HIV care.
(viii) HIV-negative TB patient refers to any bacteriologically confirmed or clinically diagnosed case of TB who
has a negative result from HIV testing conducted at the time of TB diagnosis. Any HIV-negative TB patient
subsequently found to be HIV-positive should be reclassified accordingly. HIV status unknown TB patient
refers to any bacteriologically confirmed or clinically diagnosed case of TB who has no result of HIV testing
and no other documented evidence of enrolment in HIV care. If the patient’s HIV status is subsequently
determined, he or she should be reclassified accordingly.
(ix) Monoresistance is defined as resistance to one first-line anti-TB drug only. Polydrug resistance is
defined as resistance to more than one first-line anti-TB drugs (other than both Isoniazid and Rifampicin).
(x) Multidrug resistance is defined as resistance to at least both isoniazid and rifampicin.
(xi) Extensive drug resistance is defined as resistance to any fluoroquinolone and to at least one of three
second-line injectable drugs (Capreomycin, Kanamycin and Amikacin), in addition to multidrug resistance.
(xii) Rifampicin resistance is defined as resistance to Rifampicin detected using phenotypic or genotypic
methods, with or without resistance to other anti-TB drugs. It includes any resistance to rifampicin, whether
monoresistance, multidrug resistance or extensive drug resistance. It is important to understand that these
categories are not all mutually exclusive.
(xiii) The new treatment outcome definitions make a clear distinction between two types of patients
viz patients treated for drug-susceptible TB and patients treated for drug-resistant TB using second-line
treatment (mutually exclusive categories). All bacteriologically confirmed and clinically diagnosed TB cases
should be assigned an outcome except those with RR-TB or MDR-TB, who are placed on a second-line drug
regimen, as:
(aa) Cured.
When bacteriologically confirmed pulmonary TB patient at the beginning of treatment who was smear
or culture negative in the last month of treatment and on at least one previous occasion.
(ab) Treatment completed.
TB patient when completed treatment without evidence of failure but with no record to show that
sputum smear or culture results in the last month of treatment and on at least one previous occasion
were negative, either because tests were not done or because results are unavailable.
(ac) Treatment failed TB patient when sputum smear or culture is positive at month 5 or later during
treatment.
(ad) Died TB patient when dies for any reason before starting or during the course of treatment;
(ae) Lost to follow-up when patient did not start treatment or whose treatment was interrupted for
2 consecutive months or more.
(af) Treatment success includes the sum of cured and treatment completed patients.
(ag) Similarly, those with RR-TB or MDR-TB, who are placed on a second-line drug regimen are
classified as:
O Cured when Treatment completed without evidence of failure and three or more consecutive
cultures taken at least 30 days apart are negative after the intensive phase.

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O Treatment completed when treatment is completed without evidence of failure but no

record that three or more consecutive cultures taken at least 30 days apart are negative after
the intensive phase.
O Treatment failed when treatment terminated or need for permanent regimen change of
at least two anti-TB drugs.
(h) Treatment Regimens.
The goals of TB treatment are to decrease case fatality and morbidity by ensuring relapse free cure, to minimize
and prevent development of drug resistance, to render patient non-infectious, break the chain of transmission
and to decrease the pool of infection.
(i) Drug Sensitive TB.
Revised National Tuberculosis Programme (RNTCP) had adopted alternate day drug regimen for treatment
of drug sensitive TB. National Tuberculosis Elimination Programme (NTEP) has introduced daily regimen for
treatment of drug sensitive tuberculosis among all patients, Persons Living with HIV (PLHIV) and paediatric
TB patients in the entire country. The regimen for drug sensitive TB is given as under (Table 31.2):
Table 31.2 : Regimen for Drug Sensitive TB
Treatment Regimen Treatment Regimen
Type of TB Case in Intensive Phase in Continuation Phase
(IP) (CP)
New and previously treated cases (H and R sensitive / Unknown) (2) HRZE (4) HRE
H - Isoniazid, R - Rifampicin, Z - Pyrazinamide, E - Ethambutol
(ii) Drug Resistant TB.
The regimen and for drug resistant TB is given in Table 31.3–31.6.
Table 31.3 : Grouping of Medicines Recommended for Use in Longer MDR-TB Regimens
Groups & Steps Medicine
Group A: Levofloxacin OR Lfx
Include all three medicines Moxifloxacin Mfx
Bedaquiline Bdq
Linezolid Lzd
Group B: Clofazimine Cfz
Add one or both medicine Cycloserine OR Cs
Terizidone Trd
Group C: Ethambutol E
Add to complete the regimen and when medicines Delamanid Dlm
from Group A and B cannot be used
Pyrazinamide Z
Imipenem- cilastatin Ipm-Cln
OR Meropenem Mpm
Amikacin Am
(OR Streptomycin) (S)
Ethionamide OR Eto
Prothionamide Pto
p-aminosalicylic acid PAS

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Table 31.4 : Oral Bedaquiline-Containing MDR / RR-TB Regimen

Treatment Regimen in Intensive Phase Treatment Regimen in
Type of Regimen
(IP) Continuation Phase (CP)
Shorter Oral MDR / RR- TB regimen (4-6 months) Bdq, Lfx, Cfx, Z, E, H, Eto (5 months) Lfx, Cfx, Z, E
Longer Oral M / XDR TB treatment regimen (18-20 m) Bdq(6m), Lfx, Lzd, Cfz, Cs
Bdq - Bedaquiline, Lfx - Levofloxacin, Cfz - Clofazimine, Z - Pyrazinamide, E - Ethambutol, Eto - Ethionamide, H - Isoniazid,
Lzd - Linezolid, Cs - Cycloserine
Table 31.5 : Shorter Injectables Containing Regimen
Treatment Regimen in Intensive Phase (IP) Treatment Regimen in Continuation Phase (CP)
(4-6 m) Mfx, Km / Am, Eto, Cfz, Z, H, E (5 m) Mfx, Cfz, Z, E
Mfx - Moxifloxacin, Km - Kanamycin, Am - Amikacin, Eto - Ethionamide, Cfz - Clofazimine, Z - Pyrazinamide, E - Ethambutol
Table 31.6 : H Mono / Poly DR-TB Regimen
(6 m) Lfx, R, E, Z
Lfx - Levofloxacin, R - Rifampicin, Z - Pyrazinamide, E - Ethambutol
(j) TB in Pregnancy and Lactating Women.
A collaborative framework has been developed by NTEP and Maternal health (MH) division for management of TB
in pregnant women to reduce mortality and morbidity in both mother and the newborn. Before initiating treatment
for tuberculosis, women should be asked about current or planned pregnancy and counselled appropriately. With
exception of streptomycin, the first line anti-TB drugs are safe for use in pregnancy. Management of MDR TB
patients with pregnancy is summarized in Fig 31.4. MDR / RR TB Regimen is (4-6 m) Bdq (6 m) Lfx, Cfz, Eto,
Hh, Z, E / 5 Lfx, Cfz, Z, E and Bedaquiline-containing M / XDR-TB regimen is (18-20 m) Lfx, Bdq (6 m or longer)
Lzd, Cfz, Cs.

Fig 31.4 : Management of MDR-TB Patients during Pregnancy

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(k) Bedaquiline Conditional Access Programme: Introduction of New Anti TB Drug.

Bedaquiline (BDQ): BDQ is a new class of drug, diarylquinoline that specifically targets mycobacterial ATP synthase,
an enzyme essential for the supply of energy to Mycobacterium tuberculosis and most other mycobacteria.
Strong bactericidal and sterilizing activities against M. tuberculosis have been shown in pre-clinical, laboratory
and animal experiments. The drug has a high volume of distribution, with extensive tissue distribution, highly
bound to plasma proteins and hepatically metabolized. The drug has an extended half-life, which means that it
is still present in the plasma up to 5.5 months post stopping BDQ. BDQ demonstrates no cross-resistance with
existing first- and second-line anti-TB drugs and has shown significant benefits in improving the time to culture
conversion in MDR-TB patients. In June 2013, WHO published interim policy guidance for the use of BDQ in
conjunction with the WHO-recommended MDR-TB treatments. RNTCP is introducing BDQ through conditional
access programme at 6 sites in the country initially.
(l) Criteria for Patients to Receive Bedaquiline.
(i) Basic criteria.
The criteria for patients to receive BDQ as approved by the Apex Committee is adult suffering from pulmonary
MDR-TB having age 18 years and above.
(ii) Additional requirements
(aa) Females should not be pregnant or should be using effective non-hormone-based birth control
methods. They should be willing to continue practicing birth control methods throughout the treatment
period or have been post-menopausal for the past 2 years.
(ab) Patients with controlled stable arrhythmia can be considered after obtaining cardiac consultation.
(m) Dosage of Anti TB drugs is summarized in Table 31.7. Drug dosage for adults and paediatric age group
are given in Table 31.8 & 31.9.
Table 31.7 : Drug Dosages for First Line Anti TB Drugs
Drugs Adults Children Maximum in Children
Isoniazid 10 mg / kg daily 5 mg / kg daily 300 mg
(7 to 15 mg / kg) (4 to 6 mg / kg)
Rifampicin 15 mg / kg daily (10 to 20 mg / kg) 10 mg / kg daily 600 mg
(8 to 12 mg / kg)
Pyrazinamide 35 mg / kg daily (30 to 40 mg / kg) 25 mg / kg daily (20 to 30 mg / kg) 2,000 mg
Ethambutol** 20 mg / kg daily (15 to 25 mg / kg) 15 mg / kg daily (12 to 15 mg / kg) 1,500 mg
Streptomycin* 20 mg / kg daily (15 to 20 mg / kg) 15 mg / kg daily (15 to 20 mg / kg) 1,000 mg
* Streptomycin is administered only in certain situations, like TB meningitis or if any first line drug needs to be replaced
due to Adverse Drug Reaction (ADR) as per weight of the patient
** Ethambutol is given separately for children to monitor ophthalmic ADR
Table 31.8 : Daily Dose Schedule for Adults as per Weight Bands
Number of Tablets (Fixed Dose Combinations - FDCs)
Weight Category Intensive Phase HRZE Continuation Phase HRE
75 / 150 / 400 / 275 75 / 150 / 275
25-34 kg 2 2
35-49 kg 3 3
50-64 kg 4 4
65-75 kg 5 5
More than or equal to 75 kg 6 6

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Table 31.9 : Drug Dosage for Paediatric TB

Number of Tablets (Dispersible FDCs)
Intensive Phase (IP) Continuation Phase (CP) - HRE
Weight Category
HRZ E HR E
50 / 75 / 150 100 50 / 75 100
4-7 kgs 1 1 1 1
8-11 kg 2 2 2 2
12-15 kg 3 3 3 3
16-24 kg 4 4 4 4
25-29 kg 3 + 1A* 3 3 + 1A* 3
30-39 kg 2 + 2A* 2 2 + 2A* 2
* A= adult FDC (HRZE= 75 / 150 / 400 / 275; HRE= 75 / 150 / 275). It is added in higher weight band categories i.e.,
> 25 kg as these children may be able to swallow tablets
(n) Follow Up of the Treatment.
(i) Clinical Follow-up.
It should be done at monthly intervals. Improvement in chest symptoms, increase in weight etc. may indicate
a good prognosis.
(ii) Laboratory Investigations.
Sputum smear microscopy should be done at the end of intensive phase and at the end of treatment.
A negative sputum smear at the end of IP indicates good prognosis. However, in the presence of clinical
deterioration, the medical officer may consider repeating sputum smear microscopy even during the
continuation phase. This will provide the patient an early opportunity to undergo drug susceptibility testing.
At completion of the treatment, a sputum smear and / or culture should be done for every patient, as culture
is more specific and sensitive compared to smear microscopy to detect the presence of M. tuberculosis in
biological specimens. Long term follow-up at the end of 6, 12, 18 and 24 months should be done. In the
presence of any clinical symptoms and / or cough, sputum microscopy and / or culture should be considered.
(o) Isoniazid Preventive Therapy.
The dose of INH for chemoprophylaxis is 10 mg / kg administered daily for 6 months.
TB preventive therapy should be provided to:
(i) All asymptomatic contacts (under 6 years of age) of a smear positive case, after ruling out active
disease and irrespective of their BCG or nutritional status.
(ii) All HIV infected children who either had a known exposure to an infectious TB case or Tuberculin
Skin Test (TST) positive (> 5 mm induration) but have no active TB disease.
(iii) All TST positive children who are receiving immunosuppressive therapy (children with nephrotic
syndrome, acute leukemia etc.)
(iv) A child born to mother, who was diagnosed to have TB in pregnancy should receive chemoprophylaxis
of 6 months, provided congenital TB has been ruled out followed by BCG vaccination.
(p) Adverse Drug Reactions.
Most individuals undergoing TB treatment successfully finish their regimen without experiencing notable adverse
effects from the medication. However, some patients may experience significant reactions, emphasizing the
importance of close clinical monitoring of all individuals (Table 31.10). A patient who experiences one of the
following reactions, should never receive that drug again.

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Table 31.10 : Adverse Drug Reaction of Anti TB Drugs

Reaction Drug Responsible
Severe rash, agranulocytosis Thioacetazone
Hearing loss or disturbed balance Streptomycin
Visual disturbances (poor vision and colour perception) Ethambutol
Renal failure, shock or thrombocytopenia Rifampicin
Hepatitis Pyrazinamide
(q) Prevention and Management of Adverse Drug Reactions.
During the initial counselling session, the healthcare provider should explain the reasons behind Tuberculosis
Preventive Therapy (TPT), with special emphasis on the significance of completing the entire course and reiterate
the risks associated with TB. The individuals undergoing TPT should be informed about potential adverse events
mentioned in the Table 31.11.
Table 31.11 : Possible Adverse Events Associated with TPT Drugs
Drug Known Adverse Events Rare Adverse Events
Isoniazid (a) Asymptomatic elevation of serum liver (a) Convulsions
enzyme concentrations (b) Pellagra
(b) Hepatitis (c) Arthralgia
(c) Peripheral neuropathy (paraesthesia, (d) Anaemia
numbness and limb pain)
(e) Lupoid reactions
(d) Skin rash
(e) Sleepiness and lethargy
Rifampicin (a) Gastrointestinal reactions (a) Osteomalacia
(abdominal pain, nausea, vomiting) (b) Pseudomembranous colitis
(b) Hepatitis (c) Pseudoadrenal crisis
(c) Generalized cutaneous reactions. (d) Acute renal failure
(d) Thrombocytopenic purpura (e) Shock
(e) Discoloration of body fluids (f) Hemolytic anemia
(g) Flu-like syndrome
Rifapentine (a) Gastrointestinal reactions (abdominal (a) Hypotension / syncope
pain, nausea, vomiting) (b) Decrease in white blood cell and red
(b) Hypersensitivity reactions (flu-like blood cell count.
symptoms) (c) Decreased appetite.
(c) Hepatitis (d) Hyperbilirubinemia.
(d) Discoloration of body fluids
The management of the various adverse drug reactions is as follows:
(i) Drug-induced Hepatitis.
Features like transient, asymptomatic increase in serum liver transaminases (> 3 times than upper limits
of normal (ULN)) that occur during the early weeks of treatment are the indications to stop the treatment.
There is no need to interrupt or change treatment unless there is anorexia, malaise, vomiting or clinically
evident jaundice.
(ii) Clinical features of concern include protracted vomiting, mental changes and signs of bleeding. All
of this suggest impending acute liver failure and medications should be stopped immediately and patient
to be referred to a health facility for further management.

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(iii) Management of Jaundice and Other Severe Features.

If jaundice or any of the clinical features like yellowish discoloration of skin and eyes, pale stools, dark
urine suggestive of acute liver failure develop or elevation of serum transaminases (e.g. ALT / AST > 5 times
ULN or > 3 times ULN with symptoms), all drugs must be stopped until jaundice or hepatic symptoms
have resolved and liver enzymes have returned to baseline levels. If liver enzymes cannot be measured,
it is advisable to wait for two weeks after the jaundice has disappeared before starting treatment. Other
causes of hepatitis must be explored. Reintroduction of the same drug is considered, either gradually or
all at once (“re-challenge”) only after resolution of hepatitis.
(iv) Skin Reactions.
Itching with no rash or with a mild rash are common skin reactions. Symptomatic treatment with
antihistamines may be tried and treatment continued.
Itching with Moderate / Severe Rash. If the rash is severe or there is evidence of mucosal involvement,
hypotension or severe illness, treatment with oral prednisolone (40–60 mg) should be given daily until there
is a response and the dose should then be reduced gradually in the following days according to the clinical
response. Treatment should be withheld until the reaction has completely subsided. If a severe reaction
occurs, the suspected medicine should not be given again and an alternative regimen may be considered.
(v) Isoniazid-associated Pellagra.
Discontinue Isoniazid. Start nicotinamide (vitamin B3), 300 mg daily for three to four weeks. The
recommended treatment for pellagra is 300 mg of nicotinamide daily for three to four weeks.
(vi) Peripheral Neuropathy.
To prevent peripheral neuropathy, daily dose of vitamin B6 (pyridoxine) or multi-vitamins / B complex to
people at risk at a dose of 10 mg / day in children and 25 mg / day in adults should be given. Dose would
be 50 mg / day for adult PLHIV. In known cases of peripheral neuropathy, pyridoxine should be given at a
larger dose of 100–200 mg daily.
(vii) Gastrointestinal reactions occur with rifampicin (abdominal pain, nausea, vomiting). Mild symptoms
are usually self-limiting and reassurance may suffice. In case of severe GI intolerance, suspend rifampicin
for three or four doses and symptomatic treatment is given (Metoclopramide can be given for vomiting).
(viii) Reassurance to the person for symptoms like lethargy and red or orange discolouration of body
secretions (urine, tears, semen and sweat) is the mainstay of management.
(r) Action on Occurrence of a Case (Armed Forces).
All suspected cases suffering from pulmonary tuberculosis are to be transferred to respiratory centres with TB beds
for establishing diagnosis and Attributability Medical Board (AMB). After detailed evaluation, the diagnosis must
be confirmed and Attributability Medical Board (AMB) should be held within 60 days of the transfer to respiratory
centre with TB beds. Officers, JCOs / OR should be transferred to AICTS, Pune or other respiratory centres as laid
down in policy letters / relevant AO / AFO / NO issued from time to time (DG Memorandum No 178).
(s) Duration of Hospitalization.
The intensive phase of treatment should be under supervision of chest physician in a respiratory center with TB
beds and the patient should remain hospitalized till sputum becomes negative. If DST reveals sensitivity to first line
ATT and there is satisfactory clinico-radiological response, subsequently they should be transferred to the nearest
military hospital under the care of medical specialists for the remaining period till declared cured or treatment
completed. If the patient, during continuation phase does not show satisfactory clinical / radiological / bacteriological
response or develops complication he / she should be transferred back to the respiratory center where he / she
had completed his / her intensive phase.
(t) Discharge from the Hospital and Disposal.
(i) Drug Susceptible Tuberculosis.
If the patient of pulmonary tuberculosis has been declared cured or treatment completed, he should be
placed in LMC P3 (T-24) and discharged to unit. The patient should remain in medical category P3 until
he has been declared cured or treatment completed or maximum of one year.

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(ii) Subsequent Categorization.

In case treatment is completed and cure achieved before one year and there is no relapse of disease,
no residual significant structural or functional deficit, he can be considered for upgradation to P2 (T-24)
category and subsequently to P1.
(iii) If the individual cannot be upgraded to category P2 after remaining in category P3 for one year he
will be transferred to nearest respiratory center for detailed evaluation. If he is found unfit for upgradation
to category P2, he may be considered for invalidment.
(u) Drug Resistant Cases.
(i) All cases of pulmonary tuberculosis suspected to be suffering from drug resistant pulmonary
tuberculosis should be transferred to nearest respiratory center with TB beds for management by a
pulmonologist / respiratory physician.
(ii) All cases of drug resistant tuberculosis (mono, poly, MDR, XDR) who show poor response to ATT in
the form of persistence of sputum smear and culture positivity for AFB should be invalidated out of service.
(v) Assessment of Pulmonary Tuberculosis as per Guide to Medical Officers (GMO) 2023.
Pulmonary tuberculosis will be assessed as per following:
(i) Restrictive sequel after treatment: Assessment as per restrictive lung disease.
(ii) Obstructive sequel after treatment: Assessment as per obstructive lung disease.
(iii) Degree of disablement will be regarded as 100% for two years if the patient is regarded as incapable
of improvement and is invalidated out of service.
(iv) Active Pulmonary Tuberculosis on regular discharge from service while on treatment and is capable
of improvement will be assessed at 60% for two years.
(v) Active Pulmonary Tuberculosis on regular discharge and is doubtful of improvement (drug resistant
cases) will be assessed at 100% for two years. If on the other hand, Reassessment Medical Board finds that
there has been an improvement subsequently they will classify the impairment as capable of improvement
and the degree of disablement will be assessed as in (iv) above.
(w) Treatment and Disposal of Recruits / Cadets.
Cadets, Recruits, Boys, Apprentices, Direct Entry Sailors, Airmen (Under Training) and probationer nurses: (Para
442 of RMSAF-2010 (revised version)).
If any of these personnel are suffering from TB (pulmonary / intrathoracic), they will be transferred at government
expense to a designated military hospital and will be afforded free treatment for maximum period of 6 months.
Such patients who do not recover fully or require more than 6 months of anti-tubercular treatment will be
invalidated out of service.
Cases having no residual disability with normal functional capacity may be considered for continuing training in
case such continuation is acceptable to the Commandants of respective training establishments. Their suitability
for retention has to be assessed after 4 months of institutional treatment and acceptability of these trainees
must be obtained before completion of 5 months of institutional therapy.
Those who are being retained in service will be placed in low medical category P2 / equivalent in Air Force and
Navy for 24 weeks on completion of 6 months of institutional treatment. Observation in LMC for minimum 6
months after completion of treatment is required because the cadets / recruits may not be fit enough to resume
the training immediately after completion of anti-tuberculosis treatment. The cadet / recruit would lose 2 terms and
will have to be relegated by one year before he / she will be permitted to resume training. The cadet / recruit who
have residual disease and / or functional incapacitation as determined by the exercise tolerance and spirometry
will be invalidated out of service.
Cases of extra pulmonary TB will be disposed of by the respective senior advisors depending upon the outcome
of treatment / residual disease / sequelae / complication and likelihood of his / her becoming fit for military duty
after 6 months of anti-tubercular treatment.

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31.3 Diphtheria.
(ICD-10-CM Code: A36.9)
(a) Introduction.
This is an acute, specific, infectious disease characterized by the formation of a false membrane at the site
of the infection and spreading around it and by the toxemia due to absorption of the exotoxin produced by
C. diphtheria at the site of infection and affecting the cardiac, vasomotor and nervous systems. The infection
is typically that of the upper respiratory tract; the sites most commonly affected are the fauces, nasal mucosa,
pharynx and the larynx; but it may occur in almost any tissue. The second important though less common site
is the skin.
Diphtheria was a leading cause of child mortality in the pre-vaccine era. Introduction of Diphtheria–Tetanus–
Pertussis (DTP) vaccine after World War II decreased the disease incidence rapidly. Global incidence started
decreasing after the launch of the World Health Organization (WHO) Expanded Programme on Immunization in
1974.
(b) Epidemiological Distribution.
(i) Global Scenario.
Diphtheria occurs in all parts of the world, but it is mainly a disease of temperate climate. It occurs more in
cities than in the rural areas and more in dry areas than wet. The incidence is higher during late monsoon,
autumn and winter months than in spring and summer. Cold weather favours its spread. Although adults
may be affected, it is pre­dominantly a disease of children and the attack rate shows a sharp decline after
puberty. Majority of the cases have been reported from South East Asian Region since 2000. India, Nepal
and Bangladesh collectively have contributed about 96% of cases in SEAR.
(ii) Indian Scenario.
The incidence of diphtheria cases declined significantly from 1,00,000 cases in 1980 to 2,500 in 2015,
globally. India contributed to half of the diphtheria cases reported globally from 2001 to 2015. In 2018,
India reported 8788 cases with a case fatality rate 5-10% among which higher fatality (20%) being reported
among children below 5 years and adults above 40 years. The disease has higher case mortality and
morbidity rate due to various geographic-specific factors. In India the disease occurs sporadically and
occasionally in focal outbreaks. Diphtheria is not an important cause of sick wastage in the Armed Forces
and the incidence is low.
(iii) Armed Forces Scenario.
Annual Health Report of previous three years have not shown any cases of Diphtheria among troops.
(c) Epidemiological Factors.
(i) Agent.
The causative organism, Corynebacterium diphtheria, is a gram positive, non-motile organism. Three types of
diphtheria bacilli are differentiated-gravis, mitis and intermedius. There are both virulent & avirulent strains
of diphtheria bacilli. The avirulent strains do not produce exotoxin. The toxin, which is a protein, has been
isolated in crystalline form. The virulence of C. diphtheria is conditioned by the presence of one or more
bacteriophages. The diphtheria bacilli are sensitive to penicillin and are readily killed by heat and common
disinfectants.
(ii) Reservoir.
Man is the only reservoir of infection.
(iii) Carrier State.
Diphtheria carriers are the usual cause of clinical cases. They may be temporary or chronic carriers, nasal
or throat carriers. The nasal carriers are particularly dangerous as source of infection since they shed more
organisms into the environment than do throat carriers. The temporary carrier state may last for about a
month, but the chronic carrier state may persist for a year or so. The fear that immunization might abolish
clinical diphtheria but lead to a high rate of carriers has proved groundless.

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(iv) Source of Infection.

A case of clinical diphtheria is highly infectious but being usually isolated in hospital (or at home) becomes
a less important means of spreading the disease. Sub-clinical cases which are frequently missed, are an
important source of infection. The healthy ‘carrier’ is, however, a particularly important cause of outbreaks
in close communities such as the Armed Forces units, schools and other residential institutions. In schools
a ‘carrier epidemic’ often precedes the clinical epidemic.
(v) Communicability Period.
The period of communicability is variable. It is usually two weeks or less but seldom more than 4 weeks;
carriers may remain infective much longer.
(d) Host Factors.
Diphtheria is primarily a disease of children. Infants born of immune mothers derive maternal antibodies which
protect them during the first few months of life against diphtheria. Recovery from clinical attack is not always
followed by lasting immunity. Immunity is often acquired through an inapparent infection. Schick test surveys in
India have revealed that 70 percent of children over the age of 3 years and 99 percent over the age of 5 years
are already immune to diphtheria. When there is a decline in incidence due to increasing vaccination coverage
in children, it is observed that the age distribution shifts and the majority of cases occur in adolescents and
adults. After the introduction of a primary series of childhood diphtheria vaccination in a population where
diphtheria is endemic, 2 epidemiologic stages have been described. In the first stage, disease incidence shifts
from predominantly pre-school pattern to a greater proportion of cases in school-age children. In the second
stage, cases are seen primarily in adolescents and young adults aged >15 years.
(e) Mode of Transmission.
The mode of transmission may be droplets, direct contact or indirect contact. The droplet route is the most
important mode of spread of diphtheria in the Armed Forces. The greater the overcrowding in barracks the
higher is the probability for infection of a susceptible individual. Among children direct contact as in kissing or
close fondling is an important route of transmission of infection from adult carriers. Commonly, older children
bring the infection home from their schools and transmit it to younger ones. Indirect transmission, especially by
putting in their mouths, toys or pencils which may have been sucked by a ‘carrier’ child, also plays an important
part. Outbreaks have also been recorded from milk infected by a ‘carrier’ or a mild case.
(f) Incubation Period.
The incubation period is usually 2 to 6 days, occasionally may be longer.
(g) Clinical Features.
Diphtheria can involve almost any mucous membrane. Depending upon the site of infection and type of
manifestation the disease can be classified:
(i) Respiratory diphtheria
(ii) Nasal diphtheria
(iii) Pharyngeal and tonsillar diphtheria
(iv) Laryngeal diphtheria
(v) Cutaneous diphtheria

(i) Respiratory Diphtheria.

It has a gradual onset and is characterized by symptoms like mild fever, sore throat, difficulty in swallowing,
malaise, loss of appetite, hoarseness (if the larynx is involved). Respiratory diphtheria presents with hallmark
sign as a pseudo-membrane that appears within 2–3 days of illness. The membrane appears over the
mucous lining of the tonsils, pharynx, larynx or nares and rarely into the trachea. If the pseudo-membrane
extends into the larynx or trachea or if a piece of it dislodges and goes into trachea, fatal airway obstruction
may occur.

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(ii) Cutaneous Diphtheria.

It is comparatively a less toxigenic form with few systemic complications. It may present as a scaling rash
or ulcers with clearly demarcated edges and membrane and can harbour in any chronic skin lesion along
with other organisms.
(iii) Complications.
Most complications of respiratory diphtheria including death, are attributable to effects of the toxin. The
most frequent complications of respiratory diphtheria are myocarditis and neuritis. Other complications
include otitis media and respiratory insufficiency due to airway obstruction, especially in infants.
(h) Diagnosis.
Laboratory diagnosis of suspected cases of diphtheria is essential for confirmation of cases. The specificity of
culture for diphtheria is considered to be 100%. In the antibiotic era the sensitivity of culture method is low.
Molecular tests (PCR) have shown considerable sensitivity and faster reporting of results. Though molecular test
can detect genes from dead bacteria, it is however, is less specific than culture method. Diagnosis of diphtheria
is confirmed by isolating C. diphtheriae and testing the isolate for toxin production by the Elek test, an in vitro
immunoprecipitation (immunodiffusion) assay. Other tests, such as Polymerase Chain Reaction (PCR) and matrix
assisted laser desorption / ionization-time of flight mass spectrometry (MALDI-TOF), may identify C. diphtheriae.
However, when used alone, these tests do not confirm toxin production and are considered supplemental.
Specimens for culture should be obtained from the nares and oropharynx or any mucosal or cutaneous lesion.
If possible, material should be obtained from beneath the membrane (if present) or a portion of the membrane
itself. Specimens are more likely to be culture-positive if obtained before the patient receives antibiotic treatment.
(j) Treatment.
Intravenous or intramuscular administration of equine Derived Antitoxin (DAT) (polyclonal IgG antibody) is highly
effective and is the gold standard for diphtheria treatment. Diphtheria toxin that has already entered the host
cells is unaffected by DAT. Therefore, to reduce complications and mortality DAT should be administered as soon
as possible after disease onset, preferably intravenously in serious cases. The entire therapeutic dose should be
administered at one time. The amount of antitoxin recommended varies between 20,000 and 1,00,000 units,
with larger amounts recommended for persons with extensive local lesions and with longer interval since onset.
The dose is the same for children and adults.
(k) Prevention and Control.
The control of diphtheria is based on primary prevention of disease by ensuring high population immunity
through vaccination and secondary prevention of spread by the rapid investigation of close contacts to ensure
prompt treatment of those infected. Improvement in housing, environmental sanitation and personal hygiene
combined with childhood immunization are the important primary preventive measures against diphtheria among
the population. The general preventive measures are the same as per other airborne infections. Avoidance of
overcrowding, spacing of beds, adequate ventilation in all barracks, rooms, huts and tents and protection from
cold should be ensured. DPT vaccine is given as a part of pentavalent vaccine that includes protection against
Diphtheria, Pertussis, Tetanus, Hib, Hepatitis B.
Several vaccines help protect against diphtheria, all of which provide protection against other diseases too:
(i) DTaP helps protect against diphtheria, tetanus and pertussis (whooping cough).
(ii) DT helps protect against diphtheria and tetanus.
(iii) Tdap helps protect against tetanus, diphtheria and pertussis.
(iv) Td helps protect against tetanus and diphtheria.
(v) Other single vaccines like Formal Toxoid (FT), Alum-Precipitated Toxoid (APT), Purified Toxoid Aluminium
Phosphate (PTAP), Purified Toxoid Aluminium Hydroxide (PTAH) and Toxoid-Antitoxin Flocculus (TAF) protect
against diphtheria.
Catch-up schedule in children aged ≥ 1 year, adolescents and adults. Opportunities should be taken to provide or
complete the 3-dose diphtheria toxoid-containing vaccine series for those who were not vaccinated or incompletely
vaccinated, during infancy. For previously unimmunized children aged 1–7 years, the recommended primary

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schedule is 3 doses with a minimum interval of 4 weeks between the first and the second dose and an
interval of at least 6 months between the second and third dose, using DTP-containing vaccine. Using Td or
Tdap combination vaccine, the recommended schedule for primary immunization of older children (>7 years),
adolescents and adults is 3 doses with a minimum interval of 4 weeks between the first and the second dose
and an interval of at least 6 months between the second and a third dose. Two subsequent booster doses
using Td or Tdap combination vaccines are needed with an interval of at least 1 year between doses. To further
promote immunity against diphtheria, the use of Td rather than TT is recommended during pregnancy to protect
against maternal and neonatal tetanus in the context of prenatal care and when tetanus prophylaxis is needed
following injuries.
A routine adult immunization is not considered necessary in the Armed Forces. The most important single primary
prophylactic measure in children of Armed Forces personnel is their routine immunization by administration of
pentavalent (DPT, Hib, Hep B) in infancy, besides health education of families to ensure ventilation and adequate
spacing in bedrooms.
(l) Control Actions on Occurrence of a Case.
(i) Isolation.
It should be continued until 2 cultures, taken not less than 24 hours apart (after cessation of antimicrobial
therapy) from throat and nose, fail to show diphtheria bacilli; where culture is impractical, isolation may be
ended after 14 days with fair degree of safety.
(ii) Concurrent Disinfection.
It should be carried out for naso-pharyngeal discharges, linen and cutlery used by patients and local terminal
disinfection.
(iii) Notification.
It should be carried out immediately including information to the local health authorities.
(iv) Attendants.
They should be Schick test negative otherwise active immunization should be carried out.
(m) Surveillance of Contacts.
(i) All intimate contacts should be segregated until nose or throat cultures are negative.
(ii) All carriers should be treated with antibiotics.
(iii) Post-exposure Prophylaxis.
For susceptible exposed individuals, active immunization with diphtheria toxoid-containing vaccine is strongly
recommended. Swabs should be taken from contacts and the samples cultured for C. diphtheriae and a
course of penicillin or erythromycin should be administered for 7 days. Diphtheria Anti Toxin (DAT) is not
recommended for post-exposure prophylaxis, as evidence regarding its benefit is limited. During outbreaks,
vaccination records of all contacts of each case should be reviewed. Unvaccinated contacts should receive
a full course of diphtheria toxoid-containing vaccine and under-vaccinated contacts should receive the doses
needed to complete their vaccination series.
(n) Epidemic Control Measures.
Immediate action should be taken to immunize the population group involved with emphasis on protection of
infants and pre-school children. If cases continue to occur in the unit, Schick test and examination of throat
swab should be carried out. The results of the throat swab and Schick test should be analysed and action as
under should be taken.
When incidence among children in a locality is high, all children below the age of 10 years should be immunized
without any preliminary Schick test, children up to 5 years of age with triple vaccine and children over 5 years of
age, with the combined diphtheria-tetanus vaccine. However, PTAP or PTAH alone can also be used if immunization
against tetanus is not required. A preliminary Schick test should be carried out when dealing with children above
the age of 10 years and adults. TAF is a safer agent than PTAP or PTAH among adults.
In case of contacts among school children, especially in residential schools, the following procedures are adopted:

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(i) Throat swabs of all contacts are taken and all are given 5,000 units of antitoxin in one arm after
sensitivity test has been carried out: the first dose of PTAP is given in the other arm.
(ii) Those showing positive swabs are segregated until virulence test shows them non-virulent. Then they
are returned to the hostel / school and given the rest of the active immunization.
(iii) Those with virulent bacilli are treated with topical and systemic antibiotics. They are returned to the
hostel / school when three consecutive swabs with intervals of 3 days between each show negative result
or after 14 days of the 2nd dose of antigen is given to the rest of the community, whichever is earlier.
(o) Schick Test.
The ‘Schick test’ shows the susceptibility to diphtheria. It helps in separating the immune and susceptible groups
for epidemiological survey and for determining the necessity of mass immunization. It is performed by injecting
intradermally 0.2 ml of the Schick diphtheria test-toxin into the left forearm and 0.2 ml of the control solution of
foreign protein (supplied with the test-toxin) into the right forearm. In positive reaction the left test-arm manifests
a definite local erythema between 24 and 48 hours, becoming well marked by the fourth day, gradually fading
and presenting a brownish appearance with some slight desquamation by seventh day or it may persist for 2
weeks. The ‘control’ arm shows nothing or slight erythema which vanishes by the fourth day. The negative reaction
shows no sign on either forearm or some erythema may appear in 24 hours but disappears completely by the
fourth day leaving no desquamation or discoloration. Schick reaction is, therefore, commonly read on the fourth
day and again on seventh day. The positive reaction indicates that the person is immune to the infection. This
test is required to be carried out during outbreaks. Ordinarily it is not necessary to immunize Schick negative
individuals against diphtheria as they have acquired varying grades of natural immunity and can be expected
to resist the disease except when they come in direct and intimate contact with a virulent case of diphtheria. It
has also been observed that pseudo-reactors, i.e., those who show a positive reaction to both Schick test toxin
and control fluid are generally immune and do not require immunization. However, the immunity of all Schick
negative persons is not absolute. There will be varying grades of immunity among such people and may be
overwhelmed by heavy infections especially with the gravis type. Therefore, Schick negative individuals who are
constantly at a high risk like doctors, medical students, nurses and other hospital staff should be protected.

31.4 Chickenpox.
(ICD-10-CM Code B01.9)
(a) Introduction.
Varicella (chickenpox) is an acute, highly infectious disease caused by the Varicella Zoster (VZ) virus (human
herpesvirus type 3), which is transmitted by airborne route. It is known for high secondary attack rate and
therefore it occurs in cluster of cases in family or as an outbreak in school, nurseries and Armed Forces units.
In Armed Forces it is commonly seen in training centres with large number of recruits living in barracks. It often
remains a challenge to control these outbreaks. In most cases the disease is self-limiting, however it extracts
a high price in terms of absenteeism from schools or training establishments. Like other Herpes viruses the
Varicella zoster virus is capable of remaining latent in the neural ganglia. Reactivation of the latent virus causes
Herpes Zoster (HZ). Thus, the same virus causes both varicella (chickenpox), usually during childhood and herpes
zoster (shingles), usually much later in adult life.
(b) Epidemiology.
(i) Global Scenario.
It is worldwide in distribution and occurs both in epidemic and endemic forms. As the virus is highly
contagious, disease rates are higher among the children living in temperate countries as compared to
tropical countries whereas adult infection rates are higher. Chickenpox occurs in both endemic and epidemic
forms in India. There has been a significant decline in the incidence and mortality due to chickenpox in
countries with widespread paediatric immunization.
(ii) Indian Scenario.
Most cases of Chicken pox go unreported in India due to benign nature of the disease. However, some
outbreaks are reported. In India, during the year 2020, about 29,481 cases of chickenpox were reported
with 15 deaths. The case fatality rate was about 0.05 percent. Kerala reported the highest number of

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cases (17,086) and West Bengal reported the maximum number of deaths (08) due to chickenpox.
(iii) Armed Forces Scenario.
Chickenpox is one of the important causes of hospitalization / loss of training in Armed Forces. In 2019 and
2020, the hospitalization rates were 2.0 and 0.57 per thousand soldiers of Indian Army, which accounted
for 2.2% and 0.81% of all admissions. The average length of stay in the hospital in year 2020 was
12.29 days. In Armed Forces, outbreaks tend to occur when there is overcrowding especially in training
centres with large number of recruits living in barracks. Control of Chickenpox outbreaks is also a challenge
onboard warship, due to space constraints and difficulties in isolation of cases.
(c) Epidemiological Factors.
(i) Agent.
VZV is a DNA virus also known as Human Herpes Virus-3 (HHV-3), one of the eight herpes viruses known
to affect humans and is member of the herpes virus group. Humans are the only known host. The source
of infection is usually a case of chickenpox. The virus occurs in the oropharyngeal secretions and lesions
of skin and mucosa. The virus can be readily isolated from the vesicular fluid during the first three days
of illness.
(ii) Host Factors.
Chicken pox is primarily a disease of childhood particularly in temperate countries where 90% of cases
occur before 13 years of age. In tropical countries, it is more a disease of young adults. There is no gender
or ethnic group variation in the disease. Natural infection usually confers lifelong immunity and a second
attack of chicken pox is rare. However, the virus can remain latent in sensory root ganglia. Any reduction
in cell mediated immunity can result in reactivation of the virus which causes Herpes zoster. The disease
occurs with greater severity among adults, newborns, infants, immunocompromised children and pregnant
women. Mortality rates in normal young children are estimated to be less than 2 per 1,00,000 but is higher
among adults.
Infection during pregnancy poses a risk of congenital varicella syndrome in the developing foetus in-utero. It
occurs in 0.4-2.0% of infants born to mothers who had Chicken pox during the first 20 weeks of gestation.
In addition, infants, whose mothers had chickenpox during pregnancy, have a higher risk of developing
herpes zoster in the first years of life. Maternal infection just prior to delivery may result in neonatal varicella
which carries high mortality.
(iii) Environment.
The disease epidemiology varies with ambient temperatures with higher incidence in temperate climate.
In temperate countries the disease exhibits distinct seasonal variation with peak incidence in winter and
spring.
(iv) Transmission.
The source of infection is almost always a case of chickenpox as subclinical cases are rare (less than 5%).
Transmission is mainly through droplets and air borne spread of droplet nuclei. The virus can also spread
through direct contact or indirectly by touching freshly soiled contaminated items. The portal of entry for
the virus is the upper respiratory tract. Patients are infective from one to two days before onset of rash
to five days after first appearance of rash. After crusting of lesions dry scabs become non-infectious. The
contagiousness of the disease is one of the highest among all infectious diseases with secondary attack
rate among household contacts of 90 percent. The virus is extremely contagious and can cross the placental
barrier.
(d) Clinical Features.
The incubation period ranges from one to three weeks, usually 13 to 17 days. The clinical spectrum of chickenpox
varies from a mild illness with only a few lesions to a severe febrile illness with widespread rash. Subclinical
infection is rare and estimated to be less than 5 percent of susceptible children. In the majority of cases, the
disease tends to be mild and typical. The clinical course of chickenpox extends into two stages i.e., pre-eruptive
stage and eruptive stage. The pre-eruptive stage of the disease is characterized by mild to moderate fever, malaise
and shivering. This stage usually lasts a day or two but may be longer in adults. The rash which is the hallmark

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of the disease is distributed centripetally, the highest concentration of lesions is on the trunk. The rashes are
symmetrical. It first appears on the trunk and then comes on the face, arms and legs where it is less abundant.
Mucosal surfaces (e.g. buccal, pharyngeal) are generally involved. Axilla may be affected, but palms and soles
are not usually affected. The rash consisting of macules, papules, vesicles and scabs shows rapid evolution and
pleomorphism. A thin-walled, clear vesicle (dew drop) develops on top of the area of redness. This “dew drop
on a rose petal” lesion is very characteristic for chickenpox. Early in the disease all stages of the rash can be
seen. The rash appears in crops with each exacerbation of fever resulting in a fresh crop of rash. Healing starts
within 4-5 days and the crusts fall of completely within one to two weeks. Immunocompromised children have
a greater number of lesions which take longer to heal.
(e) Complications.
Chickenpox is usually a mild self-limiting disease. However, complications can occur even in otherwise normal
children. Secondary bacterial infection of the lesions is the commonest complication with Staphylococci
and Streptococci being the most common pathogens. Rare complications include neurologic complications
(Meningoencephalitis) and Reye’s syndrome which occurs almost exclusively among children who have been
given aspirin during the acute phase. In adults, primary varicella pneumonia or haemorrhagic complications may
occur.
Maternal infection during the first trimester of pregnancy could result in the congenital varicella syndrome which
is characterized by cicatricial skin scarring, hypoplasia of an extremity, mental retardation and low birth weight.
Neonatal varicella occurs as a consequence of maternal infection in late pregnancy. The risk is highest in case
of maternal disease 5 days prior to two days after delivery. These children may remain asymptomatic or they
may develop Herpes zoster at a young age without previous history of primary chickenpox infection.
(f) Diagnosis.
The diagnosis of chickenpox is usually based on history of exposure and clinical features such as the characteristic
rash. Laboratory confirmation of diagnosis is usually not required except in cases of atypical disease presentation.
A Tzanck smear of vesicular fluid, demonstrates multinucleated giant cells and epithelial cells with eosinophilic
intranuclear inclusion bodies. Detection of VZV-specific serum IgM antibody is considerably less sensitive than
PCR and is not the method of choice for confirming varicella. Other viral isolation techniques for confirming
varicella are Direct Fluorescent Antibody Assay (DFA) and viral culture. However, these techniques are generally
not recommended because they are less sensitive than PCR and, in the case of viral culture, will take longer
to generate results. IgM serologic testing is considerably less sensitive than PCR testing of skin lesions. IgM
serology can provide evidence for a recent active VZV infection but cannot discriminate between a primary
infection and reinfection or reactivation from latency since specific IgM antibodies are transiently produced on
each exposure to VZV. IgM tests are also inherently prone to poor specificity. Serologic screening of serum for
IgG antibodies is used to assess immunity or susceptibility to varicella in unvaccinated persons, e.g. in health-
care workers / susceptible population.
(g) Herpes Zoster.
After the primary infection of chicken pox, the virus remains dormant within the dorsal root ganglia for many
years. Reactivation of Varicella-Zoster Virus (VZV) later can cause herpes zoster (shingles). Between 10% and
20% of cases of chicken pox develop Herpes zoster later in life. The disease is characterized by vesicular
eruptions which are typically unilateral and follow a specific dermatomal distribution. The most commonly involved
dermatomes are thoracic and lumbar. Most cases of Herpes zoster occur after the age of 50 years or among
immunocompromised persons.
It is a relatively common complication in HIV positive persons, occurring in 8-11% of patients. The disease may
rarely result in permanent neurological damage in the form of cranial nerve palsies or visual impairment following
Herpes zoster ophthalmia. Nearly 15% of zoster patients have pain or paraesthesia in the affected dermatome
for several weeks and sometimes permanently (postherpetic neuralgia).
Disseminated herpes zoster may occur in patients suffering from malignancies, AIDS or other immunocompromised
states. Transmission of Varicella zoster from Herpes zoster patients may cause chickenpox in non-immune contacts.
(h) Treatment.
No antiviral therapy is recommended for routine use in uncomplicated varicella. In adults, acyclovir is effective

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in reducing the duration and severity of illness, if the drug is administered within 24 hours of onset of rash.
Antiviral therapy is indicated among the immunocompromised. These patients should be administered oral and
intravenous acyclovir within 24 hrs of onset of rash. Famciclovir and valacyclovir have better bioavailability. For
patients of Herpes zoster, acyclovir and famciclovir, have been approved by FDA for treating. Treatment reduces
the severity of pain and hastens the healing of cutaneous lesions.
(j) Vaccination.
(i) Active Immunization.
Vaccines against both varicella and HZ are based on live attenuated VZV (Oka strain); they differ in the number
of plaque-forming viral units per vaccine dose and volume of the inoculum. A live attenuated varicella virus
vaccine (oka strain) is safe and currently available. Varicella vaccine may be used either at an individual
level to protect susceptible adolescents and adults or at a population level, to cover all children as part of a
national immunization programme. For children between 12-18 months of age who have not had chickenpox,
single dose of 0.5 ml SC is recommended. The vaccine is contraindicated in pregnancy and symptomatic
HIV patients apart from those who are allergic to vaccine or its ingredients. Vaccination of adolescents and
adults will protect at-risk individuals but will not have a significant impact on the epidemiology of the disease
on a population basis. The recommended schedule for individuals aged 13 years and above is two doses of
0.5 ml SC four to eight weeks apart. On the other hand, extensive use as a routine vaccine in children will
have a significant impact on the epidemiology of the disease. If sustained high coverage can be achieved, the
disease may virtually disappear. If only partial coverage can be obtained, the epidemiology may shift, leading
to an increase in the number of cases in older children and adults.
(k) The Recommendations by WHO for varicella vaccine are:
(i) There is strong scientific evidence that varicella vaccine is safe and effective in preventing varicella
related morbidity and mortality in immunocompetent individuals. WHO recommended that routine childhood
immunization against varicella could be considered in countries where the disease has an important public
health impact. Resources should be sufficient to support sustained vaccine coverage > 80%.
(ii) Countries deciding to introduce routine childhood varicella immunization, should administer vaccination
at 12-18 months of age. The number of doses administered is dependent on the goal of the vaccination
program. One dose is sufficient to reduce mortality and severe morbidity from varicella. Two doses induce
higher effectiveness and should therefore be recommended in countries where the programmatic goal is, in
addition to decreasing mortality and severe morbidity, to further reduce the number of cases and outbreaks.
(iii) Due to the increase in severity of varicella in immunocompromised, certain groups of immunocompromised
should be considered for VZV vaccination.
(l) Armed Forces Vaccination Schedule.
(i) Serving personnel.
Recruits and cadets, on entry, will be vaccinated against chicken pox along with hepatitis B. Two doses of
0.5 ml Subcutaneous Injection (Outer upper deltoid) of Varicella Vaccine (Live Attenuated vaccine) are given
four weeks apart as laid down in O / o DGAFMS letter dated 03rd March 2020 and AO 09 / 2020 / DGMS.
(ii) Children.
Children of the serving personnel are protected against varicella by administration of two doses live
attenuated varicella vaccine, given 0.5 ml subcutaneous at 12-15 months & 18-24 months of age in
accordance with O / o DGAFMS letter dated 08th Jan 2024.
(iii) MMRV Vaccine.
MMRV vaccine is indicated for vaccination against measles, mumps, rubella and varicella in children
12 months to 12 yrs of age. Persons 13 yrs of age and older should not receive MMRV. MMRV may be
used for both the first and second doses of MMR and varicella in children younger than 13 years. The
minimum interval between doses of MMRV is 3 months.
(iv) Herpes Zoster Vaccine.
Herpes zoster vaccine is safe and demonstrated clinical protection against herpes zoster, postherpetic

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neuralgia and other serious herpes zoster complications. However, no data are available on long term
protection induced by the vaccine. Due to limited data and the unknown burden of disease in most countries,
initial evidence of waning of protection over time and uncertainty of the optimal age for vaccination SAGE
has not made any recommendation about routine herpes zoster vaccination.
(v) Post Exposure Prophylaxis.
It is recommended to use varicella vaccine for susceptible persons following exposure to varicella and
for outbreak control. Single-dose varicella vaccine administered within 3–5 days of exposure has proved
to be highly effective for prevention of moderate or severe disease (79%–100%) but estimates varied for
prevention of varicella disease of any severity (9%–93%).
(m) Varicella Zoster Immune Globulin.
Passive immunization against the Varicella zoster virus is available in the form of Varicella Zoster Immune Globulin
(VZIG). It is recommended for use in high-risk groups including immunocompromised individuals, susceptible
pregnant women and newborn infants. VZIG is most effective in preventing varicella infection when given within
72 hours of varicella exposure.
(n) Investigation and Control of Chickenpox Outbreaks.
Chicken pox is known to cause explosive outbreaks specially in training centres where large number of recruits
staying in barracks get affected, posing a serious challenge to administrative and health authorities. Outlined
below are the steps of investigation and control of the outbreak:
(i) Confirm outbreak, investigate all persons exposed in the outbreak and determine varicella susceptibility.
(ii) Define cases
(iii) Screen outbreak cohort for susceptibility to varicella (vaccination coverage, previous history etc.).
(iv) Investigate cases to characterize illness including onset, severity, duration, pre-existing medical
conditions and medications and complications.
(v) Initiate outbreak control
(vi) Isolate infective cases in hospital or separate barrack.
(vii) Protect non-vaccinated persons without history of disease.
(viii) Recommend treatment of active cases with antiviral therapy (adolescents and adults only).
(ix) Offer vaccine to susceptible persons.
(x) Offer VZIG to exposed, susceptible persons at high risk of severe disease.
(xi) Establish Surveillance for:
(aa) Obvious varicella cases.
(ab) Fever cases.
(ac) Watch out for geographical spread.
(xii) Evaluate Environmental Factors.
(aa) Living conditions to rule out overcrowding.
(ab) Ventilation
(ac) Arrangements of disinfection
(xiii) Analyse Collected Data.
(aa) Describe cases and transmission (date of rash onset, age, sex, severity, etc.).
(ab) Identify risk factors.
(xiv) Implement and concurrently evaluate outbreak control measures.

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31.5 Cerebrospinal Fever (Meningococcal Meningitis).

(ICD-10-CM Code: A39.0)
(a) Introduction.
It is an acute infectious disease, occurring sporadically and in epidemics, usually manifesting itself as acute, highly
infectious, nasopharyngitis with a tendency to invade the meningeal coverings of the brain and that of the whole
cerebrospinal axis. Invasion of blood and meninges occurs only as a less common complication in those who are
weak, immunocompromised and are exposed to privations, cold or physical exertions or have been debilitated
due to some illnesses and rendered highly susceptible to infection during an outbreak of cerebrospinal fever.
Mortality was high in the nineteenth century when explosive, widespread epidemics occurred and also in the
first 3 decades of 20th century due to focal prevalence but has drastically reduced with advent of antibiotics
like penicillin and cephalosporins.
(b) Epidemiology.
(i) Global Scenario.
Meningococcal meningitis is endemic in temperate countries. N. meningitidis was estimated to cause
around 1.2 million infections annually, leading to approximately 1,35,000 deaths globally. Infants and
adolescents face a higher risk of developing meningococcal disease due to increased rates of colonization
in the nasopharynx and waning maternal antibodies and carries a risk of epidemics; many cases could be
prevented by vaccination. Geographic distribution and epidemic potential differ according to serogroup. The
largest burden of meningococcal meningitis occurs in the meningitis belt, an area of sub-Saharan Africa,
which stretches from Senegal in the west to Ethiopia in the east.
(ii) Indian Scenario.
The disease remains endemic in India, with major outbreaks reported in Delhi (2005-08), Meghalaya (2008-
09) and Tripura (2009) over the last 25 years.
(iii) Armed Forces Scenario.
Armed Forces personnel are at risk for developing meningococcal meningitis due to the community living
conditions. The sporadic cases have been reported amongst Armed Forces personnel.
(c) Epidemiological Factors.
(i) Agent.
Neisseria meningitidis is a gram-negative diplococcus closely resembling N. gonorrhoea. There are 13
serogroups (A, B, C, D, 29E, H, I, K, L, W135, X, Y and Z) of Neisseria meningitidis. These serogroups are
characterized by differences in the structure of their capsular polysaccharides and they are important for
epidemiological and vaccine-related considerations. Among these serogroups, some are more commonly
associated with meningococcal disease, while others are less prevalent. The most common serogroups that
can cause meningococcal meningitis epidemics include A, B, C, W, X and Y. It used to be held that group A
meningococci caused epidemic disease, while group B caused inter-epidemic sporadic infections. However, other
serogroups, such as D, 29E, W135 and Z, can also be responsible for meningococcal infections, although they
may be less common. So, it is clear that the pattern of infection in any one population is constantly changing.
(ii) Reservoir.
Man is the only reservoir of infection. N. meningitides is one of the commensals of nasopharynx of many
persons in a community. Many recent investigations have shown that the earlier rate bears no direct
relationship to the incidence of clinical disease; the rate can move up or down in one community without
effect on the presence or absence of clinical cases.
(iii) Source.
The source of infection may be either a case or a carrier. Carriers are more common source of infection
and carrier state can prolong up to one year.
(iv) Incubation Period.
The incubation period varies between 2 to 10 days and is usually 3 to 4 days.

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(iv) Host Factors.

Very few individuals possess natural immunity against invasion of the nasopharynx by the N. meningitidis
but the great majority are able to resist its extension to the blood and meninges. The lowering of the
general body resistance or the resistance of the nasopharynx by physical exertion, privations, poor nutrition,
debilitating conditions, inadequate protection against cold, damp weather and the existence of other upper
respiratory diseases all predispose to its extension to the blood and meninges. Clinical cases showing signs
of meningeal involvement occur. Thus, on acquiring an infection either of the three courses may occur; the
person may suffer from a mild clinical nasopharyngitis and may remain infectious for a week or so or the
susceptible may develop the clinical disease with or without the meningeal involvement or may not show
any of these two courses but become a carrier for 6 to 8 weeks.
(v) Environment.
The disease epidemiology varies with ambient temperatures with higher incidence in temperate climate. In
temperate countries the disease exhibits distinct seasonal variation with peak incidence in winter and spring.
(vi) Transmission.
The mode of transmission is by direct contact, including droplets and discharges from the nose and throat
of infected persons. This occurs more often from carriers than cases. The infection usually causes an
acute nasopharyngitis or a sub clinical mucosal infection; invasion sufficient to cause systemic disease is
comparatively rare. The connection between infection and clinical disease is neither clear cut nor can it
be determined with anything approaching mathematical accuracy. Overcrowding and poor ventilation in the
dormitory, barracks, hostels etc. leads to increased probability of each susceptible individual to get infected
by a carrier.
(vii) Period of Communicability.
The clinical case is infectious throughout the period of the fever and for a short period prior to onset of
fever. However, the actual infections occur more during the late incubation period and early clinical period
while the meningococci are harbouring in the upper respiratory tract. During the invasion of meninges, the
infectivity is less. Carriers are, however, responsible for more spread than the clinical case and can be
infective even up to 6 weeks.
(d) Clinical Features.
The clinical features associated with disease manifest suddenly and escalate rapidly. Patients experience a
sudden onset of high fever, accompanied by severe headache. Characteristic symptoms of meningitis are
neck stiffness, projectile vomiting, nausea, photophobia, altered mental sensorium (confusion, irritability and
drowsiness). Seizure can also occur in some cases. In infants, poor feeding, irritability and fontanelle bulging are
the common symptoms. On physical examination Brudzinski’s and Kernig’s signs can be positive. Meningitis is a
medical emergency and immediate attention from healthcare professionals is imperative, as timely intervention
can save life.
(e) Prevention and Control.
Prevention of overcrowding, adequate ventilation, protection from cold by providing adequate clothing and a charpoy
when feasible and actions to reduce the carrier rate and liability of exposure of the susceptibles to carriers in
the community are the chief measures. The following actions should be taken when cases start occurring:
(i) Isolation.
The patients should be admitted immediately to hospital and isolated in a special room or ward.
(ii) Attendant.
They should use barrier precautions.
(iii) Notification.
It should be carried out as for group B diseases.
(iv) Disinfection.
Concurrent disinfection of sputum, personal clothing like towels, nursing appliances, cutlery and crockery

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and terminal local disinfection should be carried out as described in Chapter XXVII. All nasopharyngeal and
throat discharges should be received in a spittoon with 2.5 percent cresol solution in it.
(v) Contacts.
Close contacts should be kept under daily medical surveillance for ten days: anyone developing suspicious
signs of the disease should be immediately admitted to hospital for treatment. Close contacts are to be
given Chemoprophylaxis as shown in Table 31.12. Close contacts include:
(aa) Household members
(ab) Childcare centre contacts and
(ac) Anyone else directly exposed to an infected patient’s oral / nasopharyngeal secretions (e.g., via
kissing, mouth-to-mouth resuscitation, endotracheal intubation or endotracheal tube management) in
the 7 days before symptom onset.
Table 31.12 : Chemoprophylaxis for Close Contacts of Meningococcal Meningitis Cases
As Per CDC Guidelines
Drug Age Dose Duration Efficacy Caution
Rifampicin <1 month 5 mg / kg, orally, 2 days - Discussion with an expert for
every 12 hours infants < 1 month
>1 month 10 mg / kg 2 days Can interfere with efficacy of oral
(max 600 mg), contraceptives and some seizure
orally, prevention and anticoagulant
every 12 hours 90-95% medications; may stain soft contact
lenses.
Not recommended for pregnant
women
Ceftriaxone ≤15 years 125 mg IM Single dose 90-95% To decrease pain at injection site,
dilute with 1% lidocaine.
≥15 years 250 mg IM Single dose 90-95%
Ciprofloxacin ≥ 1 month 20 mg / kg Single dose 90-95% Not recommended for pregnant
(max 500 mg), women
orally
Azithromycin - 10 mg / kg Single dose 90% Not recommended routinely.
(max 500 mg)
(vi) Carriers.
The search for carriers has now tightly fallen into disrepute. Routine swabbing for the detection of carriers
serves no useful purpose in controlling the incidence of the disease and should not be carried out.
(vii) Mass Chemoprophylaxis.
In centres & barracks where cases occur mass chemoprophylaxis is recommended as mentioned in paras
above. This causes an immediate drop in the incidence rate & in the proportion of carriers.
(viii) Immunization.
Effective vaccines prepared from Group A, C, Y and / or W135 polysaccharides are available which may be
monovalent (A or C) or polyvalent. CDC recommends routine Men ACWY vaccination for all preteens and
teens at 11 to 12 years old with a booster dose at 16 years old and for children and adults at increased
risk for meningococcal disease. CDC recommends routine MenB vaccination for people 10 years or older
at increased risk for meningococcal disease.
In July 2023, the World Health Organization (WHO) pre-qualified a novel meningococcal conjugate vaccine,
a collaborative effort between the Serum Institute of India and the global health non-profit PATH. This
vaccine is designed to protect against meningitis and was developed in research sites spanning Africa,

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India and the USA. It is anticipated that this vaccine will be more affordable and accessible to countries
located in the meningitis belt, in contrast to current multivalent meningococcal vaccines, which are often
prohibitively expensive for these nations to include in their routine vaccination programs. SAGE then advised
all countries in the meningitis belt to introduce the new vaccine, which it described as Men5CV, into their
routine immunization programmes: a single dose scheduled at 9 to 18 months of age.
In Armed Forces, Immunisation of the troops proceeding on foreign mission or international travel should
be conducted as per DGAFMS Medical Memorandum 169 and relevant policy letters, AO / AFO / NO (AO
09 / 2020 / DGMS). The immunization of personnel or families travelling abroad or proceeding on foreign
missions will be as per the mandate of the specific country. Troops and families proceeding to or visiting
Saudi Arabia, like in case of Haj pilgrimage need to be immunised against meningococcal meningitis with
a tetravalent vaccine.
(ix) Overcrowding.
It needs to be emphasized that the single most important measure is to reduce overcrowding. Individuals
should be spread in the barracks & verandas for maintaining adequate distance between beds & head to
toe position should be applied between adjacent beds in conditions of space constraints.

31.6 Coronavirus Disease 2019 (COVID-19)

(ICD-10-CM Code: U07.1)
(a) Introduction.
Coronavirus disease 2019 (COVID-19) is a highly contagious disease caused by severe acute respiratory syndrome
related coronavirus 2 (SARS-CoV-2). The first known case was identified in Wuhan, China in December 2019.
The disease quickly spread worldwide, resulting in the COVID-19 pandemic. World Health Organization declared
the outbreak of Public Health Emergency of International Concern on 30th January 2020 and a pandemic on
11th March 2020.
(b) Epidemiological Factors.
(i) Agent.
Coronavirus 2, also called as SARS-CoV-2, is a novel coronavirus responsible for the COVID-19 pandemic.
It is a member of the Coronaviridae family, a group of viruses that can infect humans and other animals.
This virus possesses an enveloped structure and carries a single-stranded RNA genome with a positive
sense enveloped within a helical nucleocapsid, it showcases distinctive club-shaped spikes that protrude
from its surface, creating an image in electron micrographs that bears a striking resemblance to a solar
corona. It is from this solar-like appearance that the virus derives its name.
SARS-CoV-2, the virus responsible for COVID-19, naturally evolves over time due to mutations, leading to
the emergence of new variants. While most of these mutations have little impact on the virus’s behaviour,
some can affect how easily it spreads, the severity of the disease it causes and its interaction with vaccines,
treatments and public health measures. Certain variants, like the Omicron variant, spread more quickly,
potentially resulting in more COVID-19 cases. Even if a variant causes milder disease, a surge in cases
can strain healthcare resources and lead to more hospitalizations and deaths.
(ii) Some Important Terminologies.
(aa) Variant of Interest (VOI).
As per WHO, VOI is a term used to describe a SARS-CoV-2 variant with changes that are known to
affect how the virus behaves or its potential impact on human health. This can include its ability to
spread, its ability to cause serious disease or how easily it may be detected or treated.
A variant may be identified as VOI, because of its higher capacity for transmission compared to other
prevalent variants, indicating a potential emerging threat to global public health.
Examples: XBB.1.5, XBB.1.16, EG.5, BA.2.86 JN.1
(ab) Variant of Concern (VOC).
A Variant of Concern (VOC) is a term that describes a SARS-CoV-2 variant that meets the definition

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of a VOI, but also meets at least one of the following criteria when compared with other variants:
O It can cause a detrimental change in disease severity.
O It can have a substantial impact on the ability of health systems to provide care to patients
with COVID-19 or other illnesses and therefore require major public health interventions.
O There is a significant decrease in the effectiveness of available vaccines in protecting
against severe disease.
O Currently, no SARS-CoV-2 variants are designated as VOC. Classifications may change
over time, based on the information available. Examples of variants labelled earlier as VOC
are given in Table 31.13.
Table 31.13 : WHO Variants of Concern (VOC)
WHO Label Pango Lineage GISAID Clade Next Strain Clade
Alpha B.1.1.7 GRY 20I (V1)
Beta B.1.351 GH / 501Y.V2 20H (V2)
Gamma P.1 GR / 501Y.V3 20J (V3)
Delta B.1.617.2 G / 478K.V1 21A, 21I, 21J
Omicron parent lineage B.1.1.529 GR / 484A 21K

(ac) Variant Under Monitoring (VUM).

A Variant Under Monitoring (VUM) is a term used to signal to public health authorities that a SARS-
CoV-2 variant may require prioritized attention and monitoring. The main objective of this category is
to investigate if this variant (and others closely related to it) may pose an additional threat to global
public health as compared to other circulating variants. A VUM is de-escalated if its prevalence is
<1% at the global level and in all WHO regions for 8 consecutive weeks.
Examples: XXB, XBB.1.9.1, XBB.2.3
(ad) Variants Being Monitored (VBM).
These are variants that have shown potential impacts on medical countermeasures or have been
linked to more severe disease or increased transmission. However, they are either no longer detected
or exist at very low levels and do not currently pose a threat to public health. Table 31.14 shows
various SARS-CoV-2 variants being monitored.
Table 31.14 : Various SARS-CoV-2 Variants Being Monitored (VBM)
Variants Being Monitored (VBM)
WHO Label Pango Lineage
Alpha B.l.1.7 and Q lineages
Beta B.1.351 and descendent lineages
Gamma P.l and descendent lineages
Delta B.1.617.2 and AY lineages
Epsilon B.1.427 B.1.429
Eta B.1.525
Iota B.1.526
Kappa B.1.617.1
N / A Zeta B.1.617
B.1.617.3
P.2

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(iii) Host Factors.

COVID-19 demonstrates varying degrees of severity based on age groups. Elderly adults, typically those aged
65 and older, are at the highest risk of experiencing severe illness, hospitalization and death due to the virus.
Their severity increases with age, often aggravated by underlying health conditions. Middle-aged adults, in the
45 to 64 age range, have risk of severe outcomes as well, though not as severe as in the elderly. In contrast,
younger adults, aged 18 to 44, generally experience a lower risk of severe illness and hospitalization. However,
severe cases can still occur, particularly if individuals have underlying health conditions like diabetes mellitus,
hypertension, heart disease, obesity, other immunocompromised conditions. Children and adolescents, under
the age of 18, tend to have milder disease and a lower risk of severe outcomes.
(iv) Reservoir.
Man is the reservoir of human infections, although mammalian reservoirs such as swine and horses and
avian species are suspected as sources of new human strains.
(v) Source.
The source of infection to man is a case or subclinical case which plays an important role in the spread
of infection.
(vi) Transmission.
COVID-19 spreads through respiratory droplets released when an infected person talks, coughs, sneezes or
even breathes. These droplets can carry the virus and infect individuals in close proximity. Close contact
with an infected person, typically within about 6 feet, poses a significant risk of transmission, especially
during prolonged interactions, in enclosed spaces with poor ventilation. The virus can spread through
contact with contaminated surfaces, which highlights the importance of proper hand hygiene. The virus
can be transmitted in any climatic condition, hot, humid or cold and evidence so far has shown that it can
survive and has the potential to infect in both hot and cold climatic conditions.
(c) Clinical Features.
COVID-19 is highly contagious, with fever, cough, breathlessness and high-grade fever being the most commonly
reported symptoms. Some less frequent symptoms that may affect are aches and pains, nasal congestion, headache,
conjunctivitis, sore throat, diarrhoea, loss of taste or smell and skin rashes or discoloration of fingers and toes.
Typically, symptoms are mild and develop gradually. Many infected individuals experience only mild symptoms, with
approximately 80% recovering without the need for hospitalization. However, around 20% of people who contract
COVID-19 become seriously ill and may experience difficulty in breathing. Older individuals and those with underlying
medical conditions like high blood pressure, heart and lung issues, diabetes or cancer face a higher risk of severe
illness. Pneumonia is a common complication, sometimes requiring ventilator support. Other potential complications
include acute respiratory failure, coma, acute respiratory distress syndrome, disseminated and septic shock.
(d) Diagnosis.
Diagnostic tests are important. They help identify cases and control the spread of diseases. Among these tests,
RT-PCR is a key tool for diagnosing COVID-19. RT-PCR is considered the gold standard for diagnosing COVID-19.
Additionally, indigenous technologies like TrueNat, originally designed for Mycobacterium tuberculosis, had been
used for both COVID-19 screening and confirmation. Rapid Antigen Testing (RAT) for diagnosing COVID-19 is also
used. This involves a rapid point-of-care test using a nasopharyngeal swab to directly detect the presence or
absence of the coronavirus antigen, generating results within 30 minutes.
(e) Treatment.
(i) Isolation and Quarantine.
Infected individuals are isolated to prevent the spread of the virus to others. Those who have been in close
contact with a confirmed case but are not showing symptoms are quarantined to monitor for signs of infection.
(ii) Medical Evaluation.
Patients with COVID-19 may need medical evaluation to determine the severity of their condition. This can
include physical examinations, vital sign monitoring and laboratory tests.

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(iii) Symptom Management.

Many COVID-19 cases involve mild symptoms that can be managed at home. Common over-the-counter
medications may be used to relieve fever, cough and other symptoms. Adequate hydration and rest are also
essential.
(iv) Hospitalization.
Severe cases of COVID-19 may require hospitalization. Hospitalized patients receive medical care such as
oxygen therapy, mechanical ventilation and intravenous fluids as needed.
(v) Medications.
The mainstay of treatment is supplementary oxygen and other supportive therapy. No specific antivirals
have been proven effective. However, some drugs like budesonide, methylprednisolone, low molecular weight
heparin, corticosteroids, ivermectin, were recommended to manage symptoms or complications.
(vi) Vaccination.
Types of vaccines as given in Table 31.15.
Table 31.15 : Types of Vaccines
Type Vaccine
mRNA Pfizer-BioNTech and Moderna
Viral Vector Covishield, SputnikV, Astra Zeneca, Johnson & Johnson
Inactivated or Protein Subunit Covaxin, Sinovac, Sinopharm
Protein Subunit Novavax
DNA ZyCoV-D
(vii) Vaccines available in India.
(aa) Covishield (AstraZeneca-Oxford).
This is a viral vector vaccine that uses a harmless adenovirus to deliver the genetic material of the
spike protein. Dosage: Administered as two doses intramuscular over deltoid region. Schedule: The
two doses are usually given 12-16 weeks apart; second dose can be given at 4-8 weeks in special
circumstances. Age Group: Recommended for adults over 18 years of age.
(ab) Covaxin (Bharat Biotech).
This is an inactivated virus vaccine containing pieces of the SARS-CoV-2 virus. Dosage and schedule:
Administered in two doses (0.5ml each), intramuscularly in deltoid muscle 28 days apart. Age Group:
Recommended for adults over 18 years of age. Recently approved for 15-18 years age group.
(ac) Sputnik V (Gamaleya Research Institute, Russia).
It is viral vector vaccine, similar to AstraZeneca, using different adenovirus vectors for each of the
two doses. Dosage and Schedule: Given as two doses, 0.5 ml each Intramuscularly. Recommended
interval between doses is 3 weeks. Age Group: For adults over 18 years of age.
(ad) ZyCoV-D (Zydus Cadila).
It is a DNA-based vaccine that uses a small piece of the SARS-CoV-2 virus’s genetic material. Dosage
and Schedule: Administered as a three-dose vaccine, given at an interval of 28 days each (day 0,
day 28, day 56). Each dose consists of 2 shots (0.1 ml each) given via intradermal route at two
separate sites (preferably deltoid region of both the arms). In April 2022 the dosage schedule given
was 02 doses for those above 12 years of age. Age Group: Recommended for adults and adolescents
aged 12 and above.
(ae) iNCOVACC, BBV154 (Bharat Biotech).
A novel adenovirus vectored, intranasal vaccine for Covid-19. Dosage and schedule: iNCOVACC is

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given via the nose in two doses taken within an interval of 4 weeks from the first dose. A total of
8 drops (0.5 ml per dose) are administered, 4 drops into each nostril. Age Group: Recommended for
adults above 18 years of age. It can be taken as a booster dose by adults who have taken 2 shots
of either Covaxin or Covishield.
(f) Contact Tracing.
Identifying and notifying individuals who have been in close contact with confirmed cases is crucial to prevent
further transmission. Contact tracing helps individuals take necessary precautions and get tested.
(g) Public Health Measures.
Promoting measures like wearing masks, practicing physical distancing and maintaining good hand hygiene is
essential to control the spread of the virus within the community.
(h) Monitoring and Recovery.
Recovered individuals are monitored for a period to ensure they are no longer contagious and have fully recovered.
(j) Mental Health Support.
The psychological and emotional impact of COVID-19 should not be underestimated. Providing mental health
support to patients and healthcare workers is important.
(k) Dead Body Management.
The management of dead bodies in cases of COVID-19 is a critical aspect of public health and safety. Proper handling
and disposal are essential to prevent the transmission of the virus to healthcare workers and the community.
(i) Guidelines for COVID-19 Dead Body Management
(aa) Removal of the Body from the Isolation Room or Area.
O The health worker attending to the dead body should perform hand hygiene, ensure proper
use of PPE (water resistant apron, goggles, N95 mask, gloves etc).
O All tubes, drains and catheters on the dead body should be removed.
O All the natural orifices like oral, nasal orifices of the dead body should be plugged to
prevent leakage of body fluids.
O The dead body should be kept in leak-proof plastic body bag. The exterior of the body bag
can be decontaminated with 1% hypochlorite. The body bag can be wrapped with a mortuary
sheet or sheet provided by the family members.
O All used / soiled linen should be handled with standard precautions, put in biohazard bag
and the outer surface of the bag disinfected with hypochlorite solution.
O Used equipment should be autoclaved or decontaminated with disinfectant.
O All medical waste must be handled and disposed of in accordance with Bio medical waste
management rules.
(ab) Environmental Cleaning and Disinfection.
Environmental sanitation of the floors, bed, railings, side tables and IV stand, should be carried out
with a 1% Sodium Hypochlorite solution, allowing contact period of 30 minute and then air dried.
(ac) Handling of Dead Body in Mortuary.
O Mortuary staff handling COVID dead body should observe standard precautions.
O Dead bodies should be stored in cold chambers maintained at approximately 4°C.
O Environmental surfaces, instruments and transport trolleys should be properly disinfected
with 1% Hypochlorite solution.
O After removing the body, the chamber door, handles and floor should be cleaned with
sodium hypochlorite 1% solution.

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31.7 Influenza.
(ICD-10-CM Code: J9-J11)
(a) Introduction.
Influenza is an acute respiratory tract infection. Sudden onset of chills, fever, malaise, muscular pains / aches
and cough are the characteristic symptoms of the disease.
(i) Global Scenario.
Influenza is a disease with global presence and affects millions across all countries on yearly basis. Influenza
occurs in pandemics, epidemics and sporadic forms. The well-known pandemics occurred in 1918 (Spanish
Influenza), 1957 (Asian Influenza), 1968 (Hong Kong Influenza) and 2009 (Pandemic Influenza H1N1).
Epidemics occur every 2-3 years of Influenza A and every 3-6 years of Influenza B. The epidemics are
preceded by few cases with sudden spurt of cases leading to hospitalizations and sickness absenteeism.
Worldwide, annually 3-5 million cases with 2,90,000 to 6,50,000 deaths are estimated.
(ii) Indian Scenario.
In 2009, a strain of influenza A (H1N1) virus pdm2009, caused pandemic that emerged in Mexico and
spread all over the world. In India, it caused 27,236 cases and 981 deaths in 2009 and 20,604 cases
and 1763 deaths during 2010. As per IDSP, last major outbreak, post pandemic occurred in 2015 causing
42,592 reported cases and 2,990 deaths. In 2017, a total of 38,811 laboratory confirmed cases and 2266
deaths were reported. Most influenza activity in northern India was seen during the summer months, but in
southern and western India, cases occurred mostly during winter months. In March 2023, a total of 3,038
laboratory confirmed cases of various subtypes of Influenza including H3N2 were reported.
(iii) Armed Forces Scenario.
Being a closed community, armed forces personnel are at a higher risk of contracting acute respiratory
infections. As per Annual Health Report 2020, the rate of hospital admission due to acute respiratory
infections including pneumonias and influenza was highest in Airforce with 6.76 / 1,000 population followed
by Navy, 3.64 / 1000 and Army 2.51 / 1,000 population. Cadets were most affected, with highest rates
across all three services.
(b) Epidemiological Factors.
(i) Agent.
Influenza viruses belong to Orthomyxoviridae family and are classified into four types; designated as A,
B C & D. Types A and B have long been associated with epidemics, type C so far has appeared only in
sporadic cases and in minor localised outbreaks. They have an internal antigen, the ribonucleo-protein
(RNP) which determines the virus type A, B, C & D. There is no cross immunity between them. There are
two surface antigens-the haemagglutinin (H) and the neuraminidase (N). Antibodies to each are associated
with immunity. Antibody to H prevents initiation of virus infection; antibody to N prevents virus release and
spread. Both the surface antigens (H and N) are antigenically variable for influenza types A and B. Influenza
D virus primarily infects animals such as cattle. Human case of influenza D are not reported till date.
When the antigenic change is gradual over a period of time it is referred to as a ‘drift’, while a sudden
and complete or major change in either or both surface antigens is referred to as a ‘shift’. The later form
of variation has occurred only with influenza type ‘A’. Since the isolation of the first human influenza type
A virus in 1933, antigenic shifts have occurred twice, once in 1957 (H2N2) and again in 1968 (H3N3).
The strains that emerged between 1946 and 1957 are referred to as H1N1 strains. In 1968, there was a
shift in which only the H antigen was involved.
(ii) Reservoir.
Man is the reservoir of human infections, although mammalian reservoirs such as swine and horses and
avian species are suspected as sources of new human strains.
(iii) Source.
The source of infection to man is a case or subclinical case which plays an important role in the spread
of infection.

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(iv) Host Factors.

Influenza affects all ages. Infection produces immunity to the specific infecting virus. Infections with related
viruses broaden the base of immunity. Age specific attack rates during an epidemic reflect existing immunity
from past experience with strains related to the epidemic subtype. Severe disease and deaths normally
occur among the elderly and those debilitated by chronic cardiac, pulmonary, renal or metabolic diseases.
(c) Environment Factors.
(i) Season.
The seasonal incidence is striking, epidemics usually occurring in winter months in the Northern Hemisphere
and in the winter or rainy season in the Southern Hemisphere. In tropical countries, influenza virus circulates
throughout the year with one or two peaks during the rainy season.
(ii) Overcrowding.
It enhances transmission and the attack rates are high in close population groups, e.g., schools, institutions,
ships, etc.
(d) Incubation Period.
The incubation period lasts approximately 2 days but can vary, ranging from 1 to 4 days.
(e) Communicability Period.
Period of communicability is from 1 day before to 7 days after onset of symptoms. However, this may be more
among those who have prolonged illness and among children who may remain communicable for longer.
(f) Transmission.
Influenza is spread by direct contact, through droplet infection or by articles freshly in contact with discharges
of the nose and throat of infected persons. Airborne transmission is possible among crowded populations in
closed spaces such as barracks, ships or school buses.
(g) Clinical Features.
The virus infiltrates the respiratory tract, leading to inflammation and necrosis of the upper respiratory epithelium
and bronchial mucosa, subsequently allowing for secondary bacterial invasion. Symptoms of the influenza are
fever, chills, aches and pains, coughing and generalised weakness. Fever lasts for an average of 3 days in adults
(1 to 5 days). There might be GI symptoms like diarrhoea and vomiting. Frequent complications are like recurring
bronchitis, acute sinusitis, otitis media, pneumonia. Amongst all, pneumonia is the most dreaded complication
and high degree of suspicion should be kept if the fever persists for more than 4 or 5 days or recurs abruptly
after convalescence.
(h) Case definitions for Pandemic Influenza A (H1N1) 2009 (SWINE FLU) as per MoHFW. Various case definitions
are:
(i) Suspected Case.
A suspected case of influenza A (H1N1) 2009 is defined as a person with acute febrile respiratory illness
(fever > or equal to 38°C) with onset (aa) within 7 days of close contact with a person who is a confirmed
case of influenza A (H1N1) 2009 virus infection or; (ab) within 7 days of travel to areas where there are
one or more confirmed cases or (ac) resides in a community where there are one or more confirmed cases
influenza A (H1N1) 2009 cases.
(ii) Probable Cases.
A probable case of influenza A (H1N1) 2009 virus infection is defined as a person with an acute febrile
respiratory illness who:
(aa) Is positive for influenza A, but unsub-typable for H1 and H3 by influenza RT-PCR or reagents
used to detect seasonal influenza virus infection, or;
(ab) Is positive for influenza A by an influenza rapid test or an influenza immunofluorescence assay
(IFA) and meets criteria for a suspected case or;

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(ac) Individual with a clinically compatible illness who died of an unexplained acute respiratory illness
who is considered to be epidemiologically linked to a probable or confirmed case.
(iii) Confirmed Cases.
A confirmed case of pandemic influenza A (H1N1) 2009 virus infection is defined as a person with an
acute febrile respiratory illness with laboratory confirmed influenza A (H1N1) 2009 virus infection at WHO
approved laboratory by one or more of the following tests:
(aa) Real Time PCR
(ab) Viral Culture
(ac) Four-fold rise in influenza A (H1N1) virus specific neutralizing antibodies.
(j) Diagnostic Methods.
Laboratory diagnosis of pandemic influenza A (H1N1) 2009 is crucial is terms of public health implications such
as infection control procedures, consideration of antiviral treatment options and avoiding the inappropriate use
of antibiotics. Being the gold standard, Reverse Transcriptase Polymerase Chain Reaction (RTPCR) provides the
most timely and sensitive detection of the infection.
Clinical specimens: Respiratory samples such as nasal and or nasopharyngeal samples, throat swab are advised
for the laboratory diagnosis. In patients with lower respiratory tract infection samples like tracheal and bronchial
aspirates provide higher yield as compared to upper respiratory tract samples.
When the viruses are known to be circulating in the community, diagnosis of uncomplicated influenza can be
made on clinical and epidemiological grounds and should be followed up in case they develop any signs or
symptoms of progressive disease or do not improve within 72 hours of the onset of symptoms.
(k) Prevention and Control.
Prevention of overcrowding, efficient ventilation and protection from cold and chill are the chief preventive
measures. Certain antiviral medications, such as oseltamivir and zanamivir, have the ability to decrease the
duration of viral replication, thereby enhancing the chances of survival.
(i) Oseltamivir.
Indicated for prevention and treatment of influenza. For adults the recommended oral dose is 75 mg
Oseltamivir twice daily for 5 days. For children below 1 year the dose is given in Table 31.16. For children
more than 1 year to 12 years of age the dose is given in Table 31.17.
Table 31.16 : Dose of Oseltamivir for Infants <1 Year of Age
< 3 months* 12 mg twice daily for 5 days
3–5 months 20 mg twice daily for 5 days
6–11 months 25 mg twice daily for 5 days
* In pre-term infants the dose may be modified from 1-3 mg / kg / dose twice daily. Oseltamivir is also
available as syrup (6-12 mg per ml). If needed dose and duration can be modified as per clinical
condition.
Table 31.17 : Dose of Oseltamivir for Infants > 1 to 12 Year Age
less than 15 30 mg twice daily for 5 days
15–23 kg 45 mg / kg twice daily for 5 days
24–40 kg 60 mg per kg twice daily for 5 days
>40 kg 75 mg per kg twice daily for 5 days
(ii) Zanamivir.
Zanamivir is indicated for treatment of influenza in adults and children above 5 years of age. The
recommended dose for treatment of adult and children over the age of 5 year is 2 inhalations (2 x 5 mg)

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twice daily for 5 days.

(iii) Chemoprophylaxis.
Oseltamivir is the drug of choice for chemoprophylaxis to healthcare personnel and close contacts of
suspected probable or confirmed cases of pandemic influenza A (H1N1) 2009. It should be given till
10 days after the last exposure. Dose by body weight is given in Table 31.18.
Table 31.18 : Chemoprophylaxis Dose for Pandemic Influenza A (H1N1) 2009
Weight (in Kgs) Dose
Adults
weight less than 15 kg 30 mg OD
15 to 23 kg 45 mg OD
24 to 40 kg 60 mg OD
> 40 kg 75 mg OD
Infants
< 3 months Not recommended unless situation is critical
3 to 5 months 20 mg OD
6 to 11 months 25 mg OD

(l) Active immunization is effective when vaccine is potent and contains antigens which closely match the
prevailing strain of virus. Because of the uncertainty that epidemic influenza will occur in any given year &
frequent mutation of virus, vaccines may not be effective. Immunization programmes should be directed at
people. with greatest risk of serious complications or death. The following vaccines are available:
(i) Live Attenuated Influenza Vaccines (LAIV).
All nasal spray influenza (flu) vaccines for the 2023-2024 season are quadrivalent, meaning they are
designed to protect against four flu viruses: an influenza A (H1N1) virus, an influenza A (H3N2) virus and
two influenza B viruses
(ii) Activated Influenza Vaccines (IIV).
IIV is a flu shot that contains viruses rendered non-infectious, providing a safe and effective way to stimulate
the immune system. It safeguards against multiple influenza strains, including influenza A and B. IIV is
available in various formulations, such as standard-dose, high-dose (for older adults) and adjuvanted
versions.
To ensure optimal Vaccine Effectiveness (VE) against prevailing strains in both the northern and southern
hemispheres, the antigenic composition of influenza vaccines is revised twice a year and adjusted to
the antigenic characteristics of circulating influenza viruses, as obtained by the WHO Global Influenza
Surveillance and Response System (GISRS).
(iii) WHO recommends compositions of influenza virus vaccines twice a year during the months of February
and September for Northern and Southern hemisphere, respectively.
(aa) Northern Hemisphere (February 2022 & 2023)
O an A / Victoria / 2570 / 2019 (H1N1) pdm09-like virus (2022)
O an A / Victoria / 4897 / 2022 (H1N1) pdm09-like virus (2023)
(ab) Remaining Viruses are same in both NH 2022 & 2023 and are below:
O an A / Darwin / 9 / 2021 (H3N2)-like virus.
O a Austria / 1359417 / 2021 (B / Victoria lineage)-like virus; and
O a B / Phuket / 3073 / 2013 (B / Yamagata lineage)-like virus

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(ac) Southern Hemisphere (September 2022)

O an A / Sydney / 5 / 2021 (H1N1) pdm09-like virus.
O an A / Darwin / 9 / 2021 (H3N2)-like virus.
O a B / Austria / 1359417 / 2021 (B / Victoria lineage)-like virus; and
O a B / Phuket / 3073 / 2013 (B / Yamagata lineage)-like virus.
There is an updation in the base strain of influenza A (H1N1) pdm09 virus in the recent
recommendations of Northern Hemisphere.
In India, the influenza surveillance is conducted through structured influenza surveillance network
of DHR-ICMR VRDLs and its National Influenza Centre (WHO-NIC) situated at ICMR-NIV Pune (also a
WHO CC for GISRS) since July 2021.

31.8 Avian Influenza.

(ICD-10 Code: U69.21)
(a) Introduction.
A large group of viruses affecting primarily birds different from influenza viruses constitute avian influenza group.
Only on rare occasions other species are affected like pigs and humans. Avian influenza viruses lead to an acute
infectious disease of the respiratory tract characterized by abrupt onset of fever, chills, headache, myalgia and
sometimes prostration.
(b) Epidemiological Factors.
(i) Agent.
The avian H5N1 strain is of particular concern due to its pandemic potential. This strain has the capability to
undergo adaptation, potentially transforming into a virus capable of efficient human-to-human transmission,
thus transitioning from being solely a bird virus to becoming a human influenza virus.
(ii) Reservoir.
Wild birds, especially waterfowl like ducks and geese, serve as the primary natural reservoir for avian
influenza viruses. These birds can harbour different strains of avian influenza without displaying any
symptoms of the disease, making them a key host and virus source.
(iii) Source.
The source of infection for avian influenza in humans is typically direct or indirect contact with infected
birds, whether alive or dead. This contact can occur through handling infected poultry or coming into contact
with contaminated environments, such as live bird markets.
(iv) Incubation period.
2-5 days
(v) Communicability Period.
Period of communicability is from 1 day before to 7 days after onset of symptoms. However, this may be
more among those who have prolonged illness and among children who may remain communicable for
longer.
(vi) Transmission.
Although infrequent, sporadic cases of human infections with avian influenza viruses have been reported.
These infections are mainly contracted through direct interaction with live or deceased poultry birds
that are infected or through exposure to environments contaminated with the virus, such as live bird
markets.
(c) Diagnosis.
The diagnosis is established through RT-PCR testing, which provides definitive confirmation. It is important to

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recognize that Rapid Influenza Diagnostic Tests (RDTs) are an alternative, but they exhibit lower sensitivity in
contrast to RT-PCR.
(d) Prevention and Control.
Public health management means taking care of your health and the health of others. This involves personal
protective measures like hand washing and proper drying, covering your mouth and nose when you cough or
sneeze (respiratory hygiene), staying away from others if you feel sick, avoiding close contact with people who
are sick and not touching your eyes, mouth or nose with contaminated or dirty hands.
In the year 2007, a vaccine for bird flu was licensed, this vaccine is for people 18 years through 64 years of
age. It is an inactivated influenza vaccine given in two doses, 28 days apart. The recipient can have pain and
tenderness at the injection site, headache, muscle pain and general ill feeling.
Some antiviral drugs, notably oseltamivir and zanamivir can reduce the duration of viral replication and improve
prospects of survival.

31.9 Pertussis (Whooping Cough)

(ICD 10 Code: A37.0.)
(a) Introduction.
Pertussis, literally meaning “a violent cough,” also known as whooping cough or “the cough of 100 days,” was
first described in the Paris epidemic of 1578. Pertussis, is a highly contagious respiratory tract infection, usually
occurring in children. It is caused by the bacterium Bordetella pertussis. It primarily affects the respiratory tract,
leading to persistent bouts of cough and distinctive “whooping” sounds during inhalation.
(i) Global Scenario.
In 2022, there were 63,023 cases of pertussis reported globally with incidence rate of 9.2 per 10,00,000
total population. Maximum reported cases, 38,978, were from western pacific region followed by Southeast
Asia that reported 9,614 cases. About 84% of infants worldwide received 3 doses of diphtheria-tetanus-
pertussis (DTP3) vaccine.
(ii) Indian Scenario.
In India, in 2022, the reported cases of pertussis saw a rise, reaching a total of 4,362 cases. Contrastingly,
the year 2020 documented a higher count with 12566 cases, followed by a significant reduction to
593 cases in 2021.
(iii) Armed Forces Scenario.
No cases of pertussis were reported in the previous three years in the Armed Forces. As per the immunisation
policy, based on national immunisation schedule all dependent children are given DPT / Pentavalent vaccine
as per the schedule.
(b) Epidemiological Determinants.
(i) Agent Factors.
The causative agent in majority of cases is B. pertussis. In a small percentage of cases (less than 5%)
B. parapertussis is probably responsible. Viruses like adenoviruses, parainfluenza virus are also responsible
for the whooping cough syndrome and may cause coincidental infection. Bordetella is a gram-negative
coccobacillus that adheres to ciliated respiratory epithelial cells. It causes local inflammatory changes in the
mucosal lining of the respiratory tract. It releases endotoxin and exotoxins (pertussis toxin, dermonecrotic
toxin, adenylate cyclase toxin and tracheal cytotoxin) that act locally and systemically. It carries 3 major
agglutinogens 1, 2 and 3 and several minor ones. The bacterium can survive outside the human body for
a short period of time.
(ii) Source of Infection.
B. pertussis infects only man. The source of infection is a case of pertussis which is more often mild, missed
or unrecognised. No evidence of chronic carrier state and subclinical infection has been established. The
bacteria occur abundantly in the nasopharyngeal and bronchial secretions. The objects which are freshly

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contaminated by such discharge are also infective.

A case of pertussis is most infectious during the catarrhal stage that may extend from a week after exposure
to about 3 weeks after the onset of paroxysmal stage. Although communicability of the disease diminishes
rapidly after the catararhal stage. It shows a secondary attack rate of 90% in unimmunised household
contacts.
(iii) Host Factors.
(aa) Age.
It is primarily a disease of infants and pre-school children. Highest incidence is found below 5 years
of age. Median age of infection is between 20 to 30 months in developing countries and 50 months
in developed countries. Infants below 6 months of age show high rates of mortality. In older children,
adolescents and adults, pertussis is often unrecognised because of its atypical course. However, they
act as an important source of infection for the susceptible infants.
(ab) Sex.
Incidence of fatality is observed to be more among female child than male child.
(ac) Immunity.
Recovered cases of whooping cough or adequate immunisation confers the person immune. Infants
are susceptible to infection from birth because maternal antibody does not appear to give them
protection. Also, there is no cross immunity with B. parapertussis.
(iv) Environmental Factor.
Pertussis occurs throughout the year, but the disease shows seasonal trend. More cases occur during winter
and spring months. Overcrowding is also one of the major factors for occurrence of pertussis cases.
Socio economic conditions also play greater role in lower social economic classes and people living in
crowded conditions as compared to people of the higher social economic status.
(v) Mode of Transmission.
Whooping cough is mainly a droplet infection and other mode of transmission include direct contact. Each
time the patient sneezes, coughs, talks, the bacilli are sprayed in the air. Most of the children get the
infection from their playmates who are in the early stages of the disease. The disease may also spread
through the fomites that are freshly contaminated with these discharges.
(vi) Incubation Period : Usually, 7 to 14 days but not more than 3 weeks.
(vii) Clinical Features.
B. pertussis infection occurs in 3 stages as described below:
(i) Catarrhal Stage.
It lasts for about 10 days and is characterised by insidious onset of symptoms that include lacrimation,
sneezing, coryza, anorexia, malaise and hacking night cough that becomes diurnal.
(ii) Paroxysmal Stage.
Lasting for about 2 to 4 weeks, it is characterised by burst of rapid consecutive coughs followed by
a deep high-pitched inspiration, also known as whoop. It is usually followed by vomiting.
(iii) Convalescent Stage.
Last for 1 to 2 weeks. The illness generally lasts for 6 to 8 weeks.
Complications occur in 5 to 6% of cases, most frequently in infant aged less than 6 months. The
chief complication of pertussis are bronchitis, bronchopneumonia and bronchiectasis. The violence
of paroxysm may precipitate subconjunctival haemorrhage, epistaxis, haemoptysis and punctate
cerebral haemorrhages which may cause convulsions and coma. The most prominent problem is
bronchopneumonia which occurs in about 5% of the cases and has relatively high mortality.

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(c) Prevention and Control of Whooping Cough.

Cases and Contacts:
(i) Cases.
Early diagnosis, isolation and treatment of cases and disinfection of discharge 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 nasopharyngeal swabs. The chances
of isolating the organism are less than 60% if the material is obtained within 10 to 14 days from the onset
of illness. Rapid diagnosis of pertussis can be obtained by fluorescent antibody technique. The patient
should be isolated till the time he / she becomes non-infectious. Erythromycin 30-50 mg per kg of body
weight in 4 divided doses for 10 days is recommended. Other drugs that can be used are Azithromycin or
Clarithromycin. When given during incubation period or in early catarrhal stage, antibiotics may prevent or
moderate clinical pertussis. However, when given during paroxysmal stage, antimicrobial drugs do not alter
the clinical course but may eliminate the bacterium from the nasopharynx, thus reducing the transmission
of the disease and also control the secondary bacterial infections.
(ii) Contacts.
Infants and young children should be kept away from the cases. Those known to have been in contact with
a case of whooping cough may be given prophylactic antibiotic. Erythromycin or Azithromycin treatment for
10 days is given to prevent the infection.
(iii) Active Immunization.
The vaccines such as DPT, DTWP or Pentavalent are a part of national childhood immunization programme.
In India, the national policy is to immunise against diphtheria, whooping cough, tetanus, haemophilus
influenza B and Hepatis B simultaneously by administering 3 doses (each dose about 0.5 ml) of Pentavalent
vaccine intramuscularly given at 6, 10 and 14 weeks of age followed by a booster dose at 18 to 24 months.
Children who have missed on their vaccination dose should resume the dose schedule without repeating
previous doses. In older children and adults, only acellular pertussis vaccines are used for vaccination.
In the comprehensive clinical trials both whole cell and acellular pertussis vaccine have demonstrated that
the most efficacious vaccines of their category will protect 85% of the recipients from clinical disease. The
duration of protection in a fully immunised child as per the national immunisation schedule is believed to
be on an average 6 to 12 years for both whole cell and acellular pertussis vaccine. All infants including
HIV positive individuals should be immunised against pertussis.
Commercially available vaccines containing acellular pertussis include combination of some or all of the
following components: diphtheria toxoid, tetanus toxoid, Hep B and IPV.
(d) Untoward Reaction.
Pertussis vaccine may give rise to local reaction at the site of infection, mild fever and irritability. Rarely the
vaccine may cause persistent (more than 3 hours) inconsolable screaming, seizures, hypotonic hypo responsive
episodes, anaphylactic reactions and rarely encephalopathy.
(e) Contraindications
Anaphylactic reaction, encephalopathy, previous history or strong family history of epilepsy convulsions or CNS
disorders, any febrile illness until fully recovered or a reaction to one of the previous given triple or pentavalent
vaccine injections.
(f) Passive Immunization
The advantages of hyper immune globulin in pertussis prophylaxis is not yet established. As of now there is
no evidence of its efficacy in well controlled trials. The control of pertussis by immunization is still a challenge.
Even if the level of immunization reaches 100% it is possible that the disease would not be entirely eliminated
because whooping cough vaccines have never been claimed to be more than 90% effective.

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31.10 Measles.
(ICD-10 Code: B05)
(a) Introduction.
Measles, originating from rinderpest in cattle, likely started infecting humans between the 4th century BC
and 500 AD. The first systematic description came from the Persian physician al-Razi in the 9th-10th century.
By 1100-1200 AD, the measles virus fully diverged from rinderpest, becoming distinct. Maurice Hilleman’s
measles vaccine, estimated to prevent a million deaths annually, has been crucial. Measles is an endemic
disease, historically causing devastating outbreaks in populations with no prior exposure. Between 1855 and
2005, it is estimated to have killed around 200 million people worldwide. Outbreaks, like the one in the Faroe
Islands in 1846, highlighted the severity when a population lacked immunity. In the 19th century, measles killed
over 40,000 Fijians and more than half of the Great Andamanese population. Before the vaccine, 7-8 million
children died from measles annually. In 1954, the virus was isolated and Maurice Hilleman developed the first
successful vaccine, licensed in 1963. The US eliminated endemic measles in 2000 but faces reintroductions.
In 2019, over 1,200 cases occurred in the US, mostly in New York, emphasizing the ongoing challenge of
measles control.
(i) Global Scenario.
Measles is a highly infectious airborne disease. Measles vaccination averted 56 million deaths between
2000 and 2021. Despite the availability of a safe and cost-effective vaccine, in 2021, there were
approximately 1,28,000 measles deaths globally, mostly affecting unvaccinated or under vaccinated
children under the age of 5 years.
Approximately 83% of children worldwide, in 2022, received a single dose of the measles vaccine by the
time they reach their first birthday through regular healthcare services, marking the lowest percentage
since 2008.
(ii) Indian Scenario.
In the year 2022, many parts of the country witnessed the measles outbreaks that primarily involved
children aged 9 months to 15 years, constituting 93% of the cases, with the highest incidence observed
in the 1–4 years age group, accounting for 40% of cases. India had maximum cases in the recent
global measles outbreak. From October 2021 to September 2022, there were 172 confirmed measles
outbreaks, resulting in a total of 12,589 cases.
(iii) Armed Forces Scenario.
Measles is a disease with high infectivity. However, since 1995 to 2020, there has been a single measles
outbreak reported in the Armed Forces, in which 235 individuals were affected.
(b) Epidemiology.
(i) Agent.
(aa) The aetiology of measles, referring to the cause of the disease, is the measles virus.
It belongs to the genus Morbillivirus within the family Paramyxoviridae. It is a single-stranded,
enveloped RNA virus with only one known serotype. The virus cannot survive outside the human
body for any length of time but remains infective if stored at subzero temperatures.
(ab) Source of Infection.
A case of measles is the source. Carriers are not known to occur. Evidence suggests that subclinical
measles occurs more often than previously thought.
(ac) Infective Material.
Secretions of the nose, throat and respiratory tract of a case of measles during the prodromal
stage and the early stages of the rash.
(ad) Communicability.
Measles is highly infectious during the prodromal phase and at the time of eruption. Communicability
declines rapidly after the appearance of rash, the period of communicability is approximately 4

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days before and 4 days after the presence of your rash.

(ae) Second Attacks.
Only one antigenic type of measles virus infection confers lifelong immunity.
(ii) Host Factors.
(aa) Age.
Affects everyone in infancy & childhood between 6 months and 3 years of age in developing
countries where environmental conditions are generally poor and older children usually over 5
years in developed countries.
(ab) Incidences are equal among both sexes.
(ac) Immunity.
No age is immune if there was no previous immunity. One attack of measles generally confers life
community. Second attacks are rare. Infants are protected by maternal antibodies till 6 months
of age and in some cases beyond 9 months. Immunity after vaccination is long lasting.
(ad) Nutrition.
Measles tends to be very severe in malnourished child carrying a mortality up to 400 times
higher than in well-nourished children having measles. This may possibly be related to poor cell
mediated immunity response secondary to malnutrition. Additionally, it has been found that severe
malnourished children excrete measles virus for longer periods than better nourished children,
indicating prolonged risk to themselves and of intensity of spread to others.
(iii) Environmental Factors.
In Tropical zones most cases of measles occur during dry season. In temperate climate, measles is a
winter disease probably because people crowd together indoors. Epidemics of measles are common in
India during winter and early spring (January to April).
(iv) Incubation Period.
10 days from exposure to onset of fever and 14 days from exposure to appearance of rash.
(v) Mode of Transmission.
It is highly contagious and spreads through respiratory droplets and aerosol transmission when an
infected person coughs, sneezes or talks. The virus attaches to and infects cells in the respiratory tract,
where it replicates and spreads throughout the body. The R0 (basic reproduction number) of measles
is 12-18 i.e. each infected person can transmit the virus to 12-18 other people in a population with no
immunity. This makes measles one of the most contagious diseases.
(c) Clinical Features.
(i) Stages of Measles.
(aa) Prodromal Phase (3-5 days).
Early symptoms include high grade fever, often exceeding 104°F (40°C), dry hacking cough that
may worsen over time, coryza, conjunctivitis which is characterised by inflammation of the eyes,
causing redness, irritation and photophobia (sensitivity to light).
Koplik spots: Tiny white spots with blue-white centres appear on the buccal mucosa opposite the
first and second lower molars, 1-2 days before the rash (highly characteristic of measles).
(ab) Eruptive Phase (3-5 days).
The characteristic maculopapular rash that starts behind the ears and hairline, spreading downward
to the face, neck, trunk, arms, legs and feet. These are flat red spots that gradually become raised
bumps (papules) that may merge into confluent patches. It usually spreads over 2-3 days, reaching
complete eruption by the third day. Fever peaks during the rash outbreak.

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(ac) Post Measles Stage (7-10 days).

Fever gradually declines and returns to normal within a few days and the rash fades and disappears
without leaving scars. Cough may persist for several weeks.
(ii) Variations.
(aa) Atypical Measles.
Individuals with partial immunity (e.g., from receiving one dose of vaccine) may experience milder
symptoms without Koplik spots or a full-blown rash.
(ab) Congenital Measles.
Infants born to infected mothers may have low birth weight, pneumonia and other complications.
(iii) Complications.
(aa) Ear Infections (otitis media).
Common, especially in young children.
(ab) Pneumonia.
Bacterial or viral, potentially life-threatening.
(ac) Encephalitis (brain inflammation).
Rare but severe, causing seizures, coma and long-term neurological damage.
(ad) Subacute Sclerosing Panencephalitis (SSPE).
A very rare, fatal degenerative brain disease months or years after infection.
(ae) Vitamin A deficiency.
Measles can increase the risk of deficiency, leading to blindness, particularly in children with
existing malnutrition.
(af) Prompt diagnosis and isolation of infected individuals are crucial to prevent spread.
(ag) Vaccination with the MMR vaccine is the most effective way to prevent measles and its
complications.
(d) Prevention.
(i) The most effective way to prevent measles is through community wide vaccination. The measles
vaccine is safe, effective and inexpensive, with children needing two doses for immunity.
(ii) The first dose is typically given at 9 months in high-risk areas and 12-15 months in elsewhere,
followed by a second dose at 15–18 months. The vaccine may also include protection against mumps,
rubella, and / or varicella. Children of serving personnel are protected by providing vaccine as per O / o
DGAFMS letter No 76910 / IMM / DGMS-5 (B) dt 12 Jan 2024.
(iii) The vaccine is presented as a freeze-dried product. Before use, the lyophilized vaccine is reconstituted
with sterile diluent. Each dose of 0.5 ml contains > 1000 viral infective units of the vaccine strain.
(iv) Reconstituted vaccine loses about 50% potency after 1 hr at 20°C; it loses almost all potency
after 1 hr at 37°C.
(v) After reconstitution vaccine must be stored in the dark at 2-8°C and used within 4 hrs.
(vi) Measles vaccine is available in monovalent (measles only) form and in combination: Measles
-Rubella (MR), Measles-Mumps-Rubella (MMR) vaccine, Measles-Mumps-Rubella-Varicella (MMRV).
(vii) Routine vaccination, alongside mass campaigns in high-risk countries, is crucial for reducing global
measles deaths.
(e) Outbreak Control Measures.
(i) Isolation for 7days after onset of rash.

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(ii) Immunization of contacts within 2 days of exposure (if vaccine is contraindicated, immunoglobulin
should be given within 3-4 days of exposure)
(iii) Prompt immunization at the beginning of an epidemic is essential to limit the spread.
(f) Global Measles and Rubella Strategic Framework 2021-2030 (MRSF)
WHO Response.
The Immunization Agenda 2021–2030, endorsed by WHO and global stakeholders in 2020, focuses on
achieving regional targets and uses measles as a tracer for a health system’s ability to deliver essential
childhood vaccines. The Measles and Rubella Strategic Framework, published in 2020, outlines seven strategic
priorities to eliminate measles and rubella. From 2000 to 2021, measles vaccination, supported by initiatives
like the Measles and Rubella Partnership and GAVI, prevented an estimated 56 million deaths, primarily in the
WHO African Region and GAVI supported countries. However, recent trends in measles vaccination coverage
and incidence threaten elimination, prompting concerns from the WHO Strategic Advisory Group of Experts
on Immunization. Without sustained attention, gains may be lost, leading to outbreaks where children are
unvaccinated.
The WHO is actively strengthening the Global Measles and Rubella Laboratory Network to ensure timely
diagnosis, track virus spread and coordinate targeted vaccination activities to reduce deaths from this
preventable disease.
Immunization Agenda 2030 Measles & Rubella Partnership.
Immunization Agenda 2030 Measles & Rubella Partnership (M&RP) is a partnership led by the American
Red Cross, United Nations Foundation, Centres for Disease Control and Prevention (CDC), GAVI, the Vaccines
Alliance, the Bill and Melinda French Gates Foundation, UNICEF and WHO, to achieve the IA2030 measles and
rubella specific targets. Launched in 2001, as the Measles and Rubella Initiative, the revitalized Partnership is
committed to ensuring no child dies from measles or is born with congenital rubella syndrome. The Partnership
helps countries plan, fund and measure efforts to permanently stop measles and rubella.
Refer to chapter XXIII for details of measles vaccination.

31.11 Rubella.
(ICD-10 Code: B06)
(a) History.
The name rubella is derived from Latin, meaning “little red.” Rubella was initially considered to be a variant
of measles or scarlet fever. In 1814, George Maton, first recognized that a mild illness characterized by rash,
adenopathy and little or no fever was a discrete entity in the German medical literature, hence the common
name “German measles.” Henry Veale, in 1866, named the disease rubella. The illness attracted little attention
until 1942, when Norman Gregg, an Australian ophthalmologist, reported in 1941 the occurrence of congenital
cataracts among infants born following maternal rubella.
(b) Epidemiology.
Rubella is generally a mild disease but also has public health importance because of the teratogenic potential
of infection acquired during pregnancy. Rubella virus is generally recognized as the most common infectious
cause of birth defects, accounting for an estimated 1,00,000 infants born with congenital rubella syndrome
(CRS) each year worldwide. In the pre-vaccination era, rubella usually occurred in a seasonal pattern, with
epidemics every 5–9 years.
(i) Global Scenario.
Rubella virus is a leading cause of vaccine-preventable birth defects and can cause epidemics. Progress
towards rubella elimination is reflected by increase in the number of countries introducing Rubella
Containing Vaccine (RCV) into national childhood immunization schedules and the coverage achieved.
From 2012 to 2020, the number of countries that have introduced RCV increased from 132 to 173 and
global coverage increased from 40% to 70%. By 2020, 173 (89%) of 194 countries had introduced RCVs
and 93 (48%) had been verified as having eliminated rubella transmission.

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(ii) Indian Scenario.

India has vaccinated over 348 million children between 2017 and 2023 through nationwide measles-
rubella vaccination campaign. Measles cases dropped by 62% between 2017 and 2021, from 10.4 to
4 cases per million population, while rubella cases decreased by 48%, from 2.3 to 1.2 cases per million
population. Starting November 2022 to May 2023, 7,00,000 children between nine months and five
years received the MR vaccine during outbreaks, including in Mumbai, as part of Outbreak Response
Immunization (ORI). Additionally, 6,00,000 children in the same age groups were vaccinated during
special immunization sessions in outbreak-adjoining areas across India.
(iii) Armed Forces Scenario.
The extent and periodicity of rubella epidemics are highly variable in both industrialized and developing
countries. As per Annual Health Report (AHR) 2020, Armed Forces has seen one Rubella outbreak in
last 25 years affecting 212 individuals.
(iv) Agent.
(aa) Rubella virus is an enveloped virus with a single-stranded RNA of positive polarity and has
a single antigenic type. It belongs to genus Rubivirus of the Matonaviridae (earlier classified in
Togaviridae) family. It has been recovered from the nasopharynx, throat, blood, Cerebro Spinal
Fluid (CSF) and urine. It can be propagated in cell culture. The virus replicates in the nasopharynx
and regional lymph nodes.
(ab) Source of Infection.
Clinical or subclinical cases of rubella. A large number of rubella infections are, in fact, subclinical.
This represents one of the major differences between measles and rubella. There is no known
carrier state for postnatally acquired rubella. Infants born with congenital rubella may shed the
virus for many months. The vaccine virus is not communicable.
(ac) Period of Communicability.
Rubella is most contagious when the rash first appears, but virus may be shed from 7 days
before to 7 days after rash onset. It is much less communicable than measles, probably because
of the absence of coughing in rubella. Infants with CRS shed large quantities of virus from body
secretions for up to 1 year and can therefore transmit rubella to persons caring for them who are
susceptible to the disease. Infectivity is greatest in 1-5 days after the appearance of rash.
(v) Host Factors.
(aa) Age.
Rubella is a usually a mild, self-limited illness occurring during childhood, 3 to 10 years of age.
Joint symptoms (arthritis, arthralgia), usually of short duration, may occur in up to 70% of adult
women with rubella but are less common in men and children. Persons older than 15 years now
account for over 70 percent cases in developed countries, similar to the changing epidemiological
pattern with measles, following widespread immunization campaigns against the disease.
(ab) Immunity.
One attack result in life-long immunity; second attacks are rare. Infants of immune mothers are
protected for 4 to 6 months. It is estimated that 10 to 40 percent of the population could reach
adulthood without experiencing rubella infection in the absence of immunization.
(v) Environmental Factors.
Disease usually occurs in a seasonal pattern i.e. in temperate zones during the late winter and spring. Humans
are the only known host, with seasonal epidemics occurring every 5-9 years over a worldwide distribution.
(vi) Incubation Period.
The average incubation period of rubella is 18 days, with a range of 12 to 23 days.

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(vii) Mode of Transmission.

Rubella is spread from person-to-person via direct contact or droplets shed from the respiratory secretions
of infected persons. Humans are the only known host. The virus can cross placenta (vertical transmission)
and infect foetus in-utero.
The R0, basic reproduction number of rubella, is estimated to be between 6 and 7, i.e., on average, each
person infected with rubella is likely to infect 6 to 7 other people in a population that has no immunity
to the virus. However, this value can vary depending on factors such as population density, vaccination
rates and social behaviours.
(c) Clinical Features.
A large percentage of infections (20-50%) are asymptomatic. Following are clinical features of a typical case:
(i) Prodromal Phase.
The prodromal symptoms (coryza, sore throat, low-grade fever) herald the onset of viraemia. They are
generally mild and insignificant and less frequent in children.
(ii) Lymphadenopathy.
In susceptible individuals, the enlargement of the postauricular, occipital and posterior cervical lymph nodes
appear as early as 5-10 days before the appearance of the rash. This, however, is not pathognomonic
since cases of clinical rubella without enlargement of lymph nodes have been documented. The glands
may be found enlarged for 10 to 14 days after the rash.
(iii) Rash.
A maculopapular, erythematous and often pruritic rash occurs in 50–80% of rubella-infected people
and is often the first indication of the disease in children. It appears first on the face, usually within
24 hours of the onset of prodromal symptoms. Conjunctivitis may occur more commonly in adults. The
rash spreads rapidly to the trunk and extremities, by which time it is often no longer apparent on the
face. The rash spreads much faster and clears more rapidly than the rash of measles. It disappears
altogether by the third day. The rash is an inconstant feature of the disease; it is absent in subclinical
cases. The serological studies have shown that the incidence of sub-clinical rubella or infection without
rash can be between 20-50%.
(iv) Complications.
Joint symptoms (arthritis, arthralgia), usually of short duration, may occur in up to 70% of adult women
with rubella but are less common in men and children. Post-infectious encephalitis, although rare, occurs
in approximately 1 / 6,000 rubella cases, but incidences as high as 1 / 500 and 1 / 1,600 have been
reported. Thrombocytopenic purpura has also been observed as a complication.
(d) Lab Diagnosis.
(i) Serological testing with Enzyme Immuno Assays (EIA) is the preferred method for routine laboratory
diagnosis of rubella. The presence of rubella IgM or demonstration of a significant rise in rubella IgG between
paired acute and convalescent serum samples provides evidence of ongoing or recent rubella infection. In
areas with a low or zero incidence, the positive predictive value of the IgM EIA (Mostly Indirect) is low and
these tests may give rise to false-positive results. Therefore, to confirm initial laboratory findings, additional
serological testing with an antibody capture assay, the IgG avidity assay, should be conducted.
(ii) Reverse transcriptase–polymerase chain reaction (RT-PCR) is highly sensitive and specific for
diagnosis but has other limitations. As viraemia is short-lived and viral shedding occurs at low titres,
virus RNA is detectable in clinical specimens for only up to about 1 week from the onset of symptoms.
Therefore, a negative RT-PCR result cannot be used to rule out a diagnosis.
(iii) Virus isolation is labour-intensive and costly, although a definitive way for diagnosis, is not used
in routine.
(e) Prevention.
(i) The most effective way to prevent rubella is through community-wide vaccination. The rubella

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vaccine is safe, effective and inexpensive, with children needing only one dose for lifelong immunity.
(aa) The currently used rubella vaccines are based on the live attenuated RA 27 / 3 strain. Most
rubella vaccines are available in combination with other vaccine antigens such as measles, mumps
and varicella (MR, MMR, MMRV, respectively) and also in a monovalent formulation. Each dose
of a Rubella containing vaccine (RCV) contains a minimum number of infectious units (> 1,000
plaque-forming units or 50% cell culture infectious dose). When stored at 4°C, most RCVs have
a shelf -life of 2-3 years. Monovalent rubella, MR and MMR vaccines should be stored at 2-8°C,
protected from light.
(ab) Diluent vials may be stored at ambient temperatures but must never be frozen.
(ac) Dose.
The standard volume of a single dose of RCV is 0.5 ml and the vaccine is usually injected
subcutaneously.
(ad) Site & Route.
The preferred site of injection is the anterolateral thigh or outer aspect of upper arm, depending
on the age of the individual by subcutaneous route.
(ae) Since rubella is not as highly infectious as measles and because the effectiveness of 1
dose of an RCV is > 95%, even at 9 months of age, only 1 dose of rubella vaccine is required to
achieve rubella elimination if high coverage is achieved. However, when combined with measles
vaccination, it may be easier to implement a second dose of RCV using the same combined MR
vaccine or MMR vaccine for both doses.
(af) RCV can be administered concurrently with inactivated vaccines. Generally, live vaccines
should be given either simultaneously with RCV or at least 4 weeks apart. An exception to this
is oral polio vaccine, which can be given at any time before or after RCV without interfering in
the response to either vaccine. Interference may occur between MMR and yellow fever vaccines
if they are simultaneously administered to children < 2 years of age.
(ag) The vaccine induced immunity persists for lifetime. To provide direct protection against
rubella, all nonpregnant women of reproductive age who are not already vaccinated or who are
sero-negative for rubella should receive one dose of RCV.
(ah) Precautions & Contraindication.
RCV should not be given to anyone who has experienced a severe allergic reaction after a previous
vaccine dose or vaccine component. It is recommended not to provide the vaccine to those
with active Tuberculosis (TB) or severe immunodeficiency (including individuals with symptomatic
Human Immunodeficiency Virus (HIV) infection, Acquired Immunodeficiency Syndrome (AIDS),
congenital immune disorders, malignancies or aggressive immunosuppressive therapy). Rubella
vaccination should be avoided in pregnancy because of a theoretical (but never demonstrated)
risk of teratogenic outcomes. Women planning a pregnancy are advised to avoid pregnancy for
1 month after rubella vaccination. Inadvertent vaccination with RCV during pregnancy is not an
indication for terminating the pregnancy. People who receive blood products wait at least 3 months
before vaccination with RCV, and, if possible, avoid administration of blood products for 2 weeks
after vaccination.
(f) Outbreak Control Measures.
(i) Isolation for 7 days after onset of rash.
(ii) Immunization of contacts within 3 days of exposure (if vaccine is contraindicated, immunoglobulin
should be given within 3-4 days of exposure)
(iii) Prompt immunization at the beginning of an epidemic is essential to limit the spread.
(g) Global Measles and Rubella Strategic Framework 2021-2030 (MRSF)
Refer paragraph (f) in Measles

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31.12 Mumps.
(ICD 10 Code: B26)
(a) History.
Mumps has derived its name from British name “to mump” which means grimace or grin. It is an acute
viral illness with a historical record dating back to Hippocrates in the 5th century BCE, who described
its characteristic symptoms of parotitis and orchitis. It wasn’t until 1934 that Claud Johnson and Ernest
Goodpasture demonstrated its transmissibility from infected individuals to rhesus monkeys, establishing that
mumps was caused by a filterable agent found in saliva. Subsequently, in 1935, this agent was confirmed to
be a virus. Prior to the introduction of a vaccine in 1967, mumps posed a significant health threat, being one
of the leading causes of aseptic meningitis and sensorineural hearing loss in children in the United States. The
licensing of the mumps vaccine as part of the combined measles, mumps and rubella (MMR) vaccine in 1971
marked a significant milestone in disease prevention. Further progress occurred in 2005 with the licensing of
a combination measles, mumps, rubella and varicella (MMRV) vaccine.
(b) Epidemiology.
(i) Global Scenario.
Mumps is a global occurrence, with an average of 5,00,000 reported cases annually. In countries without
routine mumps vaccination, the burden of the disease remains high, ranging from 100 to 1,000 cases
per 1,00,000 population, with epidemic peaks occurring every 2-5 years. Recently, there has been a
resurgence of mumps even in countries that have incorporated the mumps vaccine into their national
immunization programs (NIPs). The World Health Organization (WHO) Global health Observatory reported
832 cases of mumps in the Southeast Asia Region (SEAR) in 2021.
(ii) Indian Scenario.
There are recent sporadic outbreaks throughout India but due to a lack of data, it is not considered an
important public health problem in India. As per Integrated Disease Surveillance Programme (IDSP), 63
districts reported mumps outbreak between 2017-2021. India reported 758 cases in 2021.
(iii) Armed Forces Scenario.
As per AHR 2020, 20 cases of mumps were reported among individuals and their dependants in Armed
Forces in the year 2020.
(iv) Agent Factors.
Mumps is a highly infectious disease with SAR estimated to be 86%. Causative agent is Myxovirus parotiditis
which is an RNA virus of Myxovirus family with one serotype only. Clinical and subclinical cases are source
of infection with transmission chain maintained by subclinical cases. Virus is commonly found in saliva or
Stenson’s duct. It can also be found in other body fluids. Communicability period of the disease starts 4-6
days before onset of symptoms and lasts for one week with maximum infectivity being just before the onset
of parotitis and occurrence of parotitis. The infectivity ceases with subsiding of swelling of parotid gland.
(v) Host and Environmental Factors.
It is a frequent cause of parotitis in the age group 5-9 years. However, with lack of previous immunity,
every age group is susceptible and severity increases with age. With one antigenic variety, single episode
of clinical or subclinical infection gives absolute lifelong immunity. Maternal antibody is protective till 6
months of age. Overcrowding favours epidemic as droplet and direct contact with the infected person
being the modes of transmission. It shows perennial incidence of cases with peak in winter and spring.
(vi) Incubation Period.
The average incubation period is from 2 to 4 weeks.
(c) Clinical Features.
30-40% of cases are clinically non-apparent. Unilateral or bilateral involvement of parotid gland is characterized
by pain and swelling. Earache and stiffness in opening of mouth may precede the onset of swelling. Some cases
also show involvement of submandibular and sublingual glands. Swelling subsides in 1-2 weeks. There may

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be presence of constitutional symptoms like fever, headache etc. It affects other organs like testes, pancreas,
CNS, ovaries, prostate etc. Complications like orchitis, pancreatitis, thyroiditis, neuritis, hepatitis, myocarditis
etc. are frequent though not serious. Unilateral orchitis with symptoms like testicular swelling, tenderness and
high-grade fever is the most common extra salivary manifestation among adults. Evidence regarding mumps
orchitis leading to sterility is scarce. Mumps is the leading cause of pancreatitis among children with symptoms
like upper abdominal pain, nausea and vomiting. Lower abdominal pain and ovarian enlargement suggests
oophoritis which is generally unilateral. Mumps is one of the leading causes of Sensory-Neural Hearing Loss
(SNHL). Rare complications include encephalitis, cerebral ataxia, facial palsy, transverse myelitis etc. About one
fourth of the pregnancy ends with spontaneous abortion if mumps infection occurs in first trimester though
there is no report regarding the occurrence of congenital malformation.
(d) Lab Diagnosis.
Molecular assays like real-time reverse transcription PCR (rRT-PCR) are used for detecting mumps viral RNA,
a method for viral detection. While IgM testing can be helpful for diagnosis, it is not definitive. Tests are
available to detect IgM, aiding in diagnosing acute mumps infections, as well as to measure IgG antibodies,
indicating prior exposure to mumps. Upon suspicion of mumps disease, prompt collection of a buccal swab
specimen is crucial for accurate laboratory confirmation, especially for vaccinated individuals. If symptoms have
persisted for less than 3 days, only a buccal swab for viral RNA detection by rRT-PCR is necessary. Beyond
3 days of symptoms, both a buccal swab for rRT-PCR and a serum specimen for IgM detection should be
collected. Additionally, patients presenting with complications such as orchitis, mastitis, pancreatitis, hearing
loss, meningitis or encephalitis should undergo both buccal swab for rRT-PCR and serum specimen for IgM
detection, irrespective of symptom duration.
(e) Prevention & Control.
(i) Vaccination.
Single dose 0.5 ml live attenuated vaccine at more than 1 year of age given by IM route produces
detectable antibodies in 95% of the recipients. A 2nd dose is recommended at the age of 4-6 years.
Jeryl Lynn strain is used to produce mumps vaccine. Jeryl Lynn strain is associated least with AEFIs &
post vaccine aseptic meningitis. Vaccine does not offer lifelong immunity. It can be given alone or in
combination like MMR or MMRV vaccine. Though MMR vaccine is not on NIS schedule, Armed forces
has recently recommended a 3-dose immunization schedule at 09 months, 18 months and booster dose
at 5 years (0.5 ml sc) for infants and children.
(ii) Control.
Control of spread of mumps is difficult because of longer incubation period, maximum cases being
subclinical and modality of transmission incudes direct contact and droplet. However, cases should be
isolated till clinical symptoms subside. Contacts should be kept under surveillance. Used articles of the
patient should be disinfected.
(iii) Mumps Surveillance.
Various case definitions are as follows:
(aa) Clinical Mumps.
It is defined as acute onset of unilateral or bilateral, tender and self-limited swelling of the parotid
or other salivary gland, lasting 2 or more days and without other apparent cause.
(ab) Lab Confirmed Case.
A patient with clinical mumps and laboratory confirmation by positive IgM antibody or seroconversion
of > 4-fold titre or isolation of mumps virus from saliva, urine or CSF.
(ac) Epidemiologically Confirmed Cases.
A clinically confirmed case linked epidemiologically to a laboratory confirmed case.

Suggested Reading.
1. Centers for Disease Control and Prevention. COVID-19 [Internet]. Centers for Disease Control and Prevention.

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2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/index.html.

2. India. Home: Central TB Division [Internet]. Tbcindia.gov.in. 2017. Available from: https://tbcindia.gov.in/
3. India. Home: National Centre for Disease Control (NCDC) [Internet]. Mohfw.gov.in. 2023. Available from: https://
ncdc.mohfw.gov.in/
4. Training Module for Programme Managers & Medical Officers 2020, NTEP, MOHFW.
5. National Tuberculosis Control Programme – An Official Website of National Tuberculosis Control Program of
Bangladesh [Internet]. Available from: https://www.ntp.gov.bd/
6. ICMR | Government of India [Internet]. main.icmr.nic.in. Available from: https://main.icmr.nic.in/
7. Ghia CJ, Rambhad GS. Meningococcal Disease Burden in India: A Systematic Review and Meta-Analysis.
Microbiology Insights. 2021 Jan;14:117863612110533.
8. Alspach JG. Measles: Eliminated but Not Eradicated. Critical Care Nurse. 2015 May 31;35(3):10–4.
9. Pomilio AB, Vitale AA, Lazarowski AJ. COVID-19 and Alzheimer’s Disease: Neuroinflammation, Oxidative Stress,
Ferroptosis and Mechanisms Involved. Current Medicinal Chemistry. 2022 Oct 3;29.
10. Delineating Health and Health System: Mechanistic Insights into Covid 19 Complications. Springer eBooks.
Springer Nature; 2021.
11. Giovanni Battista Migliori, Raviglione MC. Essential Tuberculosis. Springer; 2021.
12. Dias VM de CH, Oliveira AF, Marinho AKBB, Santos Ferreira CE dos, Domingues CEF, Fortaleza CMCB, et al.
COVID-19 and isolation: Risks and implications in the scenario of new variants. The Brazilian Journal of Infectious
Diseases [Internet]. 2022 Sep 6 [cited 2022 Sep 13];102703. Available from: https://www.sciencedirect.com/science/
article/pii/S1413867022003956
13. Emerging Epidemics: Management and Control | Wiley [Internet]. Wiley.com. [cited 2024 Feb 28]. Available from:
https://www.wiley.com/en-in/Emerging+Epidemics%3A+Management+and+Control-p-9781118393253
14. Gaur M, Singh A, Sharma V, Tandon G, Bothra A, Vasudeva A, et al. Diagnostic performance of non-invasive,
stool-based molecular assays in patients with paucibacillary tuberculosis. Scientific Reports. 2020 Apr 28;10(1).
15. Siedler K, Skopnik H. Oseltamivir for Treatment of Influenza in Infants Less Than One Year. Pediatric Infectious
Disease Journal. 2010 Jun;29(6):495–8.
16. XDR-TB: An outcome of programmatic management of TB in India [Internet]. Indian Journal of Medical Ethics. [cited
2024 Feb 28]. Available from: https://ijme.in/articles/xdr-tb-an-outcome-of-programmatic-management-of-tb-in-india/
17. Tandale BV, Pawar SD, Gurav YK, Chadha MS, Koratkar SS, Shelke VN, et al. Seroepidemiology of pandemic
influenza A (H1N1) 2009 virus infections in Pune, India. BMC Infectious Diseases. 2010 Aug 25;10(1).
18. Lachiewicz AM, Srinivas ML. Varicella-zoster virus post-exposure management and prophylaxis: A review. Preventive
Medicine Reports. 2019 Dec;16:101016.
19. Bellamkonda N, Lambe UP, Sawant S, Nandi SS, Chakraborty C, Shukla D. Immune Response to SARS-CoV-2
Vaccines. Biomedicines. 2022 Jun 21;10(7):1464.
20. Bader MS, Brooks AA, Srigley JA. Postexposure management of healthcare personnel to infectious diseases.
Hospital Practice. 2015 Mar;43(2):107–27.
21. Hviid A, Rubin S, Mühlemann K. Mumps. The Lancet. 2008 Mar;371(9616):932–44.
22. Musteikienė G, Miliauskas S, Zaveckienė J, Žemaitis M, Vitkauskienė A. Factors associated with sputum culture
conversion in patients with pulmonary tuberculosis. Medicina. 2017;53(6):386–93.
23. Gillim-Ross L, Subbarao K. Emerging Respiratory Viruses: Challenges and Vaccine Strategies. Clinical Microbiology
Reviews. 2006 Oct 1;19(4):614–36.
24. Yang H, Lu S. COVID-19 and tuberculosis. Journal of Translational Internal Medicine. 2020 Jun 25;8(2):59–65.
25. Menser MA, Hudson JR. Population studies of diphtheria immunity using antitoxin radioimmunoassay. The journal
of hygiene. 1984 Feb 1;92(1):1–7.
n

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Chapter
XXXII
CONTACT DISEASES (INCLUDING STIs)

32.1 Definition.
Diseases transmitted from person to person through direct or indirect contact are usually called ‘contagious’
diseases, although strictly speaking only the infections transmitted by direct contact with a sick person should be
so designated. This term is also often used in lieu of the word ‘infectious’. Thus, a number of infections which
are actually air or droplet borne, such as diphtheria, cerebrospinal fever or exanthematous fevers are sometimes
termed as ‘contagious’. Sometimes even the diseases transmitted via the faeco­oral route, such as typhoid and
viral hepatitis A, are also termed ‘contagious’ diseases. Though, it is true that transmission of infections through
both these routes is better facilitated by closer contact with an infectious person, it will not be justifiable to object
to this common usage. However, by an unopposed convention, the use of the word ‘contagious’ and contact­
transmission is reserved in medical literature for those diseases which are transmitted only through direct or
indirect personal contact and not through the other routes of transmission. Such infections cause mainly the skin
and Sexually Transmitted Diseases (STDs) and also diseases like trachoma, conjunctivitis and so on. Direct contact
is necessary for transmitting skin infections like scabies and STDs. Indirect contact can transmit infections like
fungal or pyogenic infections, trachoma and so on. Indirect infections can take place mainly through clothing and
the use of common soaps, towels, combs, razors, cosmetics like surma and so on. Some common infective and
non-infective skin diseases, STDs and trachoma are briefly discussed in this chapter. Standard textbooks should
be referred to for a detailed study.

32.2 Skin Diseases. Importance in the Armed Forces.

Although the fatalities from skin diseases are negligible but DALYs occurring are vast and varying with types of skin
problems. The following statistics are noteworthy with respect to skin diseases in Armed Forces.
(a) They result in a considerable loss of effective manpower as 10 percent of all admissions to hospitals are
due to skin diseases.
(b) In spite of a great reduction in total morbidity and especially the incidence of communicable diseases, the
proportion of admissions to hospital for skin diseases has remained constant over the last 4 to 5 decades.
(c) Diseases in this group have always shown a rapid increase under conditions of military expansion and
actual warfare, possibly due to space and resource constraints and difficulties in maintaining personal hygiene
around the clock.
(d) A large number of ambulatory cases occur in cutaneous diseases than in diseases of other organs. Therefore,
the number of persons who report to the medical officer is far less than the actual incidence.
Morbidity and manpower wastage due to skin diseases are preventable by advising the unit commander and subunit-
commanders regarding preventive and control measures, by educating all ranks on personal hygiene, by early detection
of cases and by dealing with them more effectively.

32.3 Structure and Functions of Skin.

The skin is the outermost protective structure of the body which intervenes between the internal structure of an
organism and its environment. The main functions of the skin are:
(a) Protection of the organism from noxious environmental physical, chemical and biological agents
(b) Perception of sensory stimuli through cutaneous nerve endings
(c) Bringing about thermal regulation through vasomotor and sweat mechanisms finally ensures the maintenance
of milieu interior at the normal physiological level.

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Anatomically, the skin is eminently adapted to effectively fulfil these vital functions. The skin also shows topical
peculiarities, which facilitate functions like friction, weight bearing and locomotion, which are very important from
the point of view of the soldier. Being the outermost structure, which comes in direct contact with environment, it is
naturally exposed to various noxious agents. But for the clothing which provides partial protection, the bare skin cannot
avoid traumas caused by friction, pressure, bruising, open cuts, solar radiation, many chemicals, extreme temperatures
and the frequently occurring variations in atmospheric conditions to which it is continually and inevitably exposed. It is
liable to be attacked and infected by many kinds of bacteria, moulds, fungi and parasites. Even intact undamaged skin
can act as a route of entry of many chemical and biological agents causing damage to the inner tissues and systemic
diseases. It can also reveal manifestations or complications of many systemic diseases. A large number of internal
disorders produce skin manifestations, but the primary skin disorders may not cause internal manifestations, unless
the disease process is affecting multiple systems. The disorders of the skin are often reflected in its appendages, viz.
nails and hair. Psychosomatic disorders may cause purely skin manifestations and the skin conditions may produce
psychological disturbances.

32.4 Healthy Skin.

A healthy skin is an efficient barrier against all the environmental rigors and noxious agents and can withstand
adversities within limits, in spite of all the handicaps. However, when these stresses continue over long periods or in
excess of the critical resisting power, the skin reacts in a variety of ways causing skin diseases. The health of the skin
depends upon the environment, general health of the body and the care given to it. The norms vary according to the
age-related changes. The healthy skin of the adult is elastic. Its thickness varies with the site. It is neither dry nor oily
and is only slightly moist. It has a natural colour, glow and bloom which is uniform and consistent with the race and
areas of exposure to sunlight. It bears hair on sites determined by sex and the quantity is determined by race and
heredity of the individual.
It readily conducts all the protective stimuli of touch, pain and temperature. An intact healthy skin has properties which
prevent colonization of transient pathogenic organisms and any pathogenic organism, placed on the surface of the
skin is naturally eliminated in a short time. The chief factors responsible for this property are desiccation and acid pH
of the skin surface due to decomposition products of fatty acid secretions. In addition, daily bathing will reduce the
quantity of residual flora and to a certain extent chance habitation of transient pathogens. But it is never absolutely
sterile and supports a number of commensal bacterial and fungal organisms. However, a large number of pathogenic
fauna are present in the intertriginous areas, body folds and hairy regions which are markedly increased by unhygienic
habits and circumstances leading to excessive perspiration.

32.5 Some Peculiarities of Skin.

Persons with extremely dry skins do not withstand extremes of climates. They do not stand the action of detergents
and solvents well. Hairy individuals and persons with oily skin are prone to follicular infections and acneiform lesions.
Excessive sweating promotes fungal growth. Persons with disorders of sweating are prone to ill effects of heat. Pre-
existing dermatoses and non-elastic skin, especially due to scarring around the joints, are likely to interfere with military
duty. Any abnormal discoloration over an area of the body, either loss of pigment or increased pigments, is objectionable
from the aesthetic point of view. These points should be borne in mind during pre-recruitment examinations.

32.6 Care of the Skin.

(a) The skin and its appendages should be kept clean by regular washing with soap and clean water. The frequency
is dependent upon the climatic conditions, type of skin, nature of duty and adequacy of facilities. Adequate bathing
facilities should be provided in units and sub-units and it should be ensured that personnel take full advantage
of the facilities. Too frequent and harsh methods of cleaning by use of strong detergents is to be avoided. In
temperate climate one bath daily with warm water and soft toilet soap is adequate. If the work involves excessive
sweating, either due to environmental or working conditions or after games, a second bath may be necessary.
Besides cleaning the body, a bath gives an exhilarating feeling and deodorizes the body, making a person socially
acceptable. The temperature of the water used depends upon environmental temperature and personal habits.
(b) During bathing, particular attention is paid to one’s body folds viz. webs of the fingers and toes, antecubital
areas, armpits, groins, gluteal folds, perineum and popliteal areas. These should be cleaned with soap, washed
with enough water, thoroughly dried and dusted with dusting powder specially in the hot humid weather and by
persons who habitually perspire more.

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(c) The scalp must be washed with any toilet soap for removing dirt, debris or any excess of oil. The frequency
of washing depends upon the atmospheric cleanliness and oiliness or dryness of the hair and scalp. Hair should
always be kept short.
(d) Dry shaving damages the skin and may produce infective conditions of the face. Unclean razors should
never be used. Self-shaving should be encouraged in preference to the communal shaving by a barber. Blades
should be clean and sharp.
(e) It is a common practice with men to massage the body with oil before or after the bath. Massaging vigorously
or with unclean hands causes inapparent injury and infection of the hair roots. Scented oils are especially
injurious and therefore, should not be used for massaging. However, a very thin layer of oil applied on the skin
immediately after bathing keeps it elastic.
(f) Clothes should always be clean, especially the undergarments. They should be changed and washed daily.
(g) Abrasions, cuts and bruises should be promptly treated to avoid development into skin infections.
(h) Early recognition and treatment of skin diseases reduces the manpower wastage. Therefore, troops should
be inspected regularly for cleanliness and the condition of skin and encouraged to report to the RMO who should
be able to treat them promptly and recognize those conditions which are beyond his power or local resources.

32.7 Care of the Feet.

Disorders of the skin of the feet, cause significant morbidity in young recruits. This is due to the increased use of an
enclosed boot and socks over the skin which has been unaccustomed to their use, giving rise to friction, sweating and
vascular changes, coupled with inadequate care of the feet. The general measures to keep the skin of the feet healthy are:
(a) Soap should be removed from the skin. Feet should be dusted with a bland, smooth talc. Addition of
antifungal agents like salicylic acid helps. Shoes should be well fitting, neither loose nor too tight, smooth, pliable,
comfortable and of a permeable material.
(b) The material should be consistent with the climatic conditions. Rubber and canvas shoes in hot humid
environments cause sweat retention and sodden skin; hard leather causes callosities; projections like nails inside
the shoes predispose to corns.
(c) Every person must use only his own pair of shoes.
(d) Socks should be changed and washed daily. While darning, care should be taken to ensure that no rough
patches are left. Colouring material of the socks is a frequent cause of eczema of the feet.
(e) Feet should be washed with soap and water taking special care of webs of toe to prevent infections like
Tenia pedis.

32.8 Care of the Hands.

Adequate facilities should be provided to wash hands after work involving soiling and untidy processes. Frequency of
washing the hands is dependent upon the nature of work. However, the capacity of the hands to tolerate frequent
washing varies. Certain occupations require constant contact of hands with water. These conditions predispose hands
to irritant and inflammatory reactions. Besides these the hands come directly in contact with sensitizing compounds
and virulent infective agents. Hands should, therefore, be well protected during work by means of well-fitting, permeable
work gloves especially in hazardous occupations and in persons particularly predisposed. Harsh scrubbing with strong
chemicals and detergents, too frequent washing of the hands with soap and water and prolonged immersion of hands
in water should be avoided. While working attention should be given to areas around the nails, webs of the fingers,
around the ring if worn and the wrists.

32.9 Clothing.
It must be clean, suitable to the weather and working conditions, not too tightly fitting, non-irritating and non-occlusive.

32.10 Skin Inspection.

The skin forms an important portal of entry of a number of disease processes, many of them unseen. Many internal
diseases manifest as skin lesions; periodic skin inspections of troops will reveal forerunners of many ailments. Early

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diagnosis and therefore the early institution of treatment results in economy of drugs, manhours and man days. To
be effective this periodical examination must be carried out regularly and according to a definite plan. Skin inspection
should form an important part of the annual medical inspection and should be carried out in a good light with the
individual standing stripped and with his arms above the head.

32.11 Bacterial Infections.

The normal skin of a healthy person is resistant to invasion by most of the bacteria. Infection develops when the right
combination of agent, host and environmental factors exists. The usual bacteria involved are pyococci, fusiform bacilli,
diphtheria or diphtheroid bacilli, spirochetes and M. leprae.

32.12 Pyoderma.
(a) Acute Pyoderma Infections.
Pyodermas are the skin infections caused by Staphylococci and streptococci. The chief organisms which are
responsible to initiate the infection are coagulase positive staphylococcus aureus, the haemolytic streptococci
usually being secondary invaders.
(b) Reservoir and Source of Infection.
The reservoir of infection are the human carriers with the nasal, oropharyngeal and gastro-intestinal commensal
organisms. The foci of overt infection in these sites, infected sores or wounds, discharging sinuses, draining
furuncles in the ears and so on, also act as sources of infection to self or others.
(c) Mode of Transmission.
The organisms are transferred to the site by autoinfection or from one person to another by contact. However,
the infectivity of the lesions of pyoderma is not very high except for the vulnerable individual under adverse
conditions and in children. Contaminated clothing and dressings are also a means of transfer of organisms
from one person to another.
(d) Predisposing Conditions.
Children are more susceptible to these conditions. Scaly, dry and hairy skins are more vulnerable. Maceration,
increased sweating, friction between surfaces or from clothing are the most important factors increasing
vulnerability. Cuts, wounds, abrasions, burns, skin conditions like eczema, fungal infections, viral exanthemata
or itchy dermatoses like insect bites, urticaria, mite and louse infestation (which on scratching cause
excoriation), obesity, diabetes mellitus, malnutrition, blood dyscrasias, hypogammaglobulinemia, unhygienic
habits, infrequent baths and overcrowding, all increase the liability to develop pyodermas.
(e) Clinical Entities.
The clinical classification of common pyodermas is mainly based on the site of skin affected and severity of
the disease. The following common conditions are recognized:
(i) Furunculosis.
A boil is an inflammation of a pilosebaceous follicle or a ceruminous gland commonly caused by
Staphylococcus aureus. Often the boils are multiple and cause considerable disability. Aggregations
of boils (carbuncles) occur in conditions like diabetes mellitus. The common sites for furunculosis are
hairy, sweaty parts liable to friction and maceration such as the buttocks, neck, face, axillae and the
area underlying the belt. Bad personal hygiene is an important factor causing recurring furunculosis. The
infection is quite common in athletes. A temporary cessation of athletic activity may be necessary to control
recurrent furunculosis. Although boils may occur in otherwise healthy individuals, they are commonly
seen in persons suffering from some pre-existing disease. The important conditions predisposing to
furunculosis are prickly heat, acne, pediculosis, scabies, septic foci in the tonsils, throat, discharging
ear and antra, diabetes, nephritis, malaria and other debilitating diseases or obesity. Many individuals
suffering from recurrent boils are carriers of staphylococci in their anterior nares or the perineum.
However, furunculosis may occur in the absence of any apparent predisposing cause.
(ii) Impetigo.
A contagious inflammatory disease generally caused by staphylococcus affecting the superficial layers

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of epidermis. The lesions consist of fragile vesicles which quickly rupture and the serum which exudes
forms typical honey-coloured crusts on the skin. As a primary condition it affects the face, particularly
the chin and beard area, but may complicate other skin conditions like scabies, pediculosis, prickly heat
and so on. The condition is very infectious, spreading rapidly within 48 hours of direct contact or contact
with contaminated toilet articles or through insanitary barbers.
(iii) Ecthyma.
This is essentially a deep type of impetigo caused by haemolytic streptococci. It ordinarily begins with
a blister which erodes through the epidermis to produce a shallow ulcer. Oozing occurs with formation
of a hard, adherent, thick crust which may conceal the underlying ulcer completely. The most common
sites are on the legs. Lesions may occur repeatedly after minor trauma. Poor hygiene and neglect of a
primary skin condition are predisposing factors. The lesions may follow insect bites, minor scratches,
chickenpox, vaccinia and herpes zoster.
(iv) Folliculitis (Follicular Impetigo).
This is also a form of impetigo characterized by small dome shaped pustules at the mouth of the follicles,
generally on the legs and thighs, caused by coagulase positive staphylococci. The process is superficial;
therefore, there is no scarring. This type of infection is quite common among the troops and causes
considerable disability. Massaging the extremities with dirty hands causes trauma and infection of the hair
follicles is one of the predisposing factors. It occurs commonly in persons with a tendency to seborrheic
dermatitis. It may develop as a complication of shaving. It may become extremely chronic and persist in
the absence of any bacterial infection. Cutting oils and tar products are occupational causative agents
of folliculitis.
(v) Sycosis Barbae (Barber’s Rash).
It is a staphylococcal pustular folliculitis affecting male beard area and upper lip. The disease may be
contracted from infected razors, shaving brushes or towels; often it is preceded by chronic blepharitis.
Seborrheic men are somewhat more prone to sycosis barbae. In many cases there is gross sepsis in the
gums, nasal sinuses or antra. The disease usually commences in a localized area and spreads rapidly.
The primary lesion is papulopustular and from each lesion a hair protrudes which ultimately rupture and
crusts are formed. Adjacent follicles are infected and as resistance of the skin weakens, the lesions
become nodular. Suppuration occurs in the nodules and the hair may come off even by a gentle pull.
(f) Prevention and Control.
Prophylaxis against these pyococcal conditions is achieved by a high standard of personal cleanliness, a daily
bath and avoidance of using each other’s toilet articles such as shaving kit and towels. The barber should
not shave or cut the hair of those suffering from skin infections until the MO authorizes him to do so. The
barber’s shop should be regularly inspected to ensure that brushes, combs, implements and linen are kept
scrupulously clean and disinfected. Self-shaving is the rule today, communal shaving by the barber may only
be resorted to during specific situations like illness. Certain common personal hygiene measures like washing
of hands after ablution, avoiding nose picking or thumb sucking, keeping the nails short, avoiding the massage
of hairy areas especially legs and forearm with irritant oils like mustard oil, need emphasis. Early treatment
curbs transmission by destroying the source of organisms. Individual carders are dealt with according to the
site viz. nasal, oro-pharyngeal and gastro-intestinal carriers. Strict aseptic measures in self-handling infected
lesions, soiled clothing and dressings prevent spread of the disease among other personnel.
(g) Treatment.
Squeezing or early incising is harmful. Hot compresses, allowing the infection to follow its normal course, without
much interference is enough for solitary boils. When the lesion ‘points’, it may be gently nicked aseptically, drainage
established and an aseptic dressing applied. The pus should be wiped, collected on dressings and removed as
soon as it forms without allowing it to drain over the surrounding skin. The cleanliness of the surrounding area
of skin is of paramount importance, otherwise satellite furuncles occur. Other pyococcal conditions should be
thoroughly cleaned with soap and water once or twice daily and as much cutaneous debris as possible should
be removed. Adherent crusts can be removed by intermittent hot compresses with normal saline. Thereafter anti-
bacterial creams like 1% silver sulfadiazine should be applied and penicillin or sulphonamide creams should be
avoided. Warm magnesium sulphate-glycerine dressing done daily for a few days causes pointing of the furuncles.

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Ordinary impetigo should show distinct evidence of clearing within 48 hours and will be healed within a week.
Systemic antibiotics may become necessary if the disease becomes widespread and or severe. In such cases-or
if the condition becomes resistant or recurrent, hospitalization and or treatment by a dermatologist is necessary.

32.13 Chronic Infectious Sores.

Any trauma causing break in the continuity of the skin surface can get infected by specific organisms such as B.
anthracis, M. tuberculosis or common pyococci and cause ulceration and formation of chronic, intractable sores covered
with slough or crust and discharging pus or sero-sanguinous discharge when the crust is disturbed. The lymph nodes
draining the area get inflamed and systemic symptoms may occur. Some sores manifest a specific natural course and
appearance. Tropical ulcers and desert sores are typical examples of such specific sores.
(a) Tropical Ulcers. (Ulcer Tropicum).
These are confined to the hot and moist foothill areas of the northeastern regions of India and commonly
occur amongst road labourers and others who, from the nature of their work, are liable to receive minute
injuries. The ulcers are often named after the region in which they are especially prevalent e.g. Naga sore,
Annam ulcer. The starting point is a cut, abrasion, insect bite or other minor injury specially on the leg, often
trivial in nature and hence neglected. A small, tender, papule or bleb develops on the infected abrasion. This
soon breaks down and after a short period of inflammatory reaction the ulcer becomes sub-acute or chronic,
indolent and spreading. It rapidly deepens and becomes covered with a greyish, yellow, thick, purulent, foul-
smelling slough. The margins are indurated and raised edges are undermined and the depth is often difficult
to determine on account of the presence of the tenacious slough. These sores are extremely painful, but in
the absence of secondary infection there is little constitutional disturbance and generally there is no fever.
Healing is very slow and leaves a whitish scar.
(b) Desert Sore.
It occurs in deserts and arid areas usually in men associated with horses, camels and mules. The sores occur at
the site of abrasion or insect bite on the exposed parts of arms and legs, covered by hair such as dorsum of the
hands and forearm, elbows and knee joints. The lesion starts with a painful vesicle full of straw-coloured fluid.
When the vesicle bursts a shallow, tender ulcer covered with a thin grey slough is left. The chronic ulcer has a
characteristic circular punched out appearance with undermined edges, thickened margins and the base covered
with grey coloured thin debris beneath which an adherent membrane is present. There is little or no discharge.
The aetiology of these ulcers is obscure but often spirochaetes (S.schaudini) and fusiform bacilli are found in
the serosanguinous discharge of ‘tropical ulcer’ and C. diphtheria may be found in examination of discharge
beneath the membrane of the ‘desert ulcer’. Diphtheritic paresis or paralysis, blurring of vision, tingling,
numbness and coldness of the extremities have also been observed in the latter case.
(c) Prevention and Control.
Prophylactic measures are as follows:
(i) Protection from injuries, abrasions, insect bites and brushing against bush and vegetation or scrub
by use of long trousers and shirt sleeves rolled down.
(ii) A high standard of personal hygiene is very important.
(iii) Early efficient treatment of even the trivial injuries.
(iv) In an endemic area of tropical ulcers i.e. North-Eastern India, all men, who are prone to receive
minor injuries should immerse their legs in a solution of bleaching powder (one teaspoon to 5 litre) at
the end of the day’s work.
(v) Usual antiseptic dressing and a course of penicillin and sulphamezathine prevents chronicity. Cases
not responding to this regime early should be referred to the dermatologist. 2,000 units of antidiphtheritic
serum injected locally clears the desert ulcers which show C. diphtheriae.

32.14 Dermatophytosis (ringworm).

(a) Definition.
Dermatophytosis is an infection of the skin, nails and hair by a group of fungi called dermatophytes. Out of

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large number of fungi present in nature only a few are pathogenic to human beings. As the parasitic fungi
need keratin as a substratum, the keratinous structures of the body viz. skin, hair and nails are affected by
them without giving rise to the disease of the internal organs.
(b) Agent.
The pathogenic fungi belong to the three principal genera. Microspora infect hair and skin; Trichophyton infects
hair, skin or nails and Epidermophyton infects skin or nails. The different species can only be distinguished
by a study of the morphological characteristics of their conidia (spores) and other accessory structures after
culturing them. Microspora may be identified by a direct microscopic examination of infected hair. However,
the cutaneous lesions are in most cases indistinguishable.
(c) Reservoir and Source.
The reservoir and source of infection in the community is a person suffering from an infection. Another
important source of infection is the animal reservoir. This causes highly inflammatory and resistant lesions.
(d) Mode of Transmission.
Direct contact is an important mode of transmission. The part played by toilet seats, bath boards, neck rests,
towels etc., in transmission of fungal infection from one person to another is rather doubtful. Undergarments
may play some part but this has not been authentically proved. However, in cases of T. pedis the shoes of the
affected individual will perpetuate the lesions in him. In cases of T. capitis, the combs and barber’s scissors
and clippers are a factor in transmission. Besides, the innocuous trauma of combing aids in supplanting spores
on the scalp. Combing in case of T. capitis, occlusive footwear in case of T. pedis, local skin peculiarities
in intertriginous areas which are subject to friction, maceration and increased temperature predispose to
development of the disease after acquiring the infection. In fact, the liability of developing skin manifestations
of a fungal infection is dependent mainly upon these factors rather than the contraction of infection alone.
(e) Predisposing Conditions.
Fungal infections are extremely common in hot-damp areas and few persons escape completely. There is
always an improvement in the dry season when less cases are seen and they are less severe. Persons who
habitually perspire more, suffer more. Mild cases easily become severe by friction and sweating, rendering the
sufferer unfit for duty. The commonest sites are therefore the sweaty areas of the body liable to be exposed
to friction like the armpits, groins and feet, especially in between the toes. The superimposing secondary
pyococcal infections increase the disability.
(f) Clinical Varieties.
The commonest manifestation of this fungal infection of the skin is a ring (annular) lesion; hence, the lay term
‘ringworm’ (Tinea and dermatophytosis are other names). The manifestations vary with the anatomical site involved
and the species of fungus affecting. Therefore, the clinical types are classified according to the site involved viz.,
T. capitis, T. corporis, T. cruris, T. barbae and T. unguium. The commonest clinical types are the T. pedis and T.
cruris, T. barbae comes next, followed by T. corporis. Infection of the armpits, scalp and nails are less important
among troops. In children any part of the body may be affected but they are more susceptible to T. capitis
which subsides as they grow. In women T. pedis is uncommon but skin under the breast and around the waist
is commonly affected. In adult men, the feet are usually the first to be infected to produce what is commonly
known as ‘Athlete’s foot’. Intertriginous, vesiculo-bullous or dry squamous lesions may occur.
(i) Intertriginous Ringworm “Athletes Foot”.
It is the commonest type affecting the skin between and underneath the toes and producing maceration,
sogginess, peeling and fissuring, accompanied by foul odour and pruritis. The initial lesion is a group of
small vesicles occurring most commonly in the 4th and 5th interspaces; but extension to all interdigital
spaces occur in severe cases and subsequent extension to the under surface of the toes and adjacent
part of the soles is frequent.
(ii) Vesiculo-Bullous Ringworm.
It most commonly affects the insteps of the soles and balls of the foot. In severe cases, the whole sole
may be involved. Deep-seated vesicles of variable size and number develop and often fuse to form bullae
or multilocular blisters which contain yellowish gelatinous fluid. Pruritus is severe.

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(iii) Squamous Ringworm.

It is characterised by scaling, relative lack of inflammation and extreme chronicity and usually affects the
entire plantar surface extending over the sides of the foot These may be associated with intertriginous
involvement of the toes.
(iv) Tinea Cruris.
It is another common type occurring in males. It is essentially an intertriginous type of infection starting
in the crura or perineal folds with extension posteriorly, anteriorly and on to the upper-inner surfaces of
the thigh. The disease is not seriously disabling by itself, but it frequently becomes so by inappropriate
and irritating treatment. In patients who are fat and sweat easily, the affected areas may become severely
macerated and ooze; secondary infection with pyogenic organisms then readily occurs and increases
suffering and disability.
(g) Prevention.
Prophylaxis is achieved by the following general measures:
(i) Maintenance of strict personal hygiene with special care in drying and keeping dry. Areas between
the toes and armpits and in crotches should be more carefully dried after a bath, among athletes or in
excessive sweating due to any cause.
(ii) Applications of foot powder or dusting powder before wearing socks and boots / shoes and
undergarments for the day, aids in maintaining the skin dry in these places.
(iii) Education of all ranks concerning the nature of the infection and its mode of spread is necessary.
(iv) The towel which is used for drying the vulnerable parts of the body should be washed every day
and dried.
(v) Men should not exchange each other’s towels, footwear and items of underclothing.
(vi) Clothing should be loose and non-irritating.
(vii) Whether infection spreads through fomites or not is doubtful but general cleanliness in the ablution
rooms and swimming baths have proved helpful. Floors and duckboards should be scrubbed and washed
with cresol or bleaching powder solution. Shallow footbath containing a solution of bleach (1 scoop to
10 L of water) may be provided at the swimming baths and showers, for use of all persons entering the
bath. Coconut coir matting should not be used as it always remains wet.
(h) Control Measures.
The control of spread of ringworm infection in a unit is intimately related to early detection and effective
treatment of all cases suffering from ringworm. A routine foot inspection should be conducted by RMOs and
those infected should be given prompt active treatment by the RMO or specialist in the hospital according to
the degree of infection. However, the number of personnel with infection is generally so large that hospitalization
is impossible, except of really severe cases. Therefore, a general knowledge of such regime as can be applied
in units without the necessity of hospitalization, after obtaining the dermatologist’s advice, if necessary, is of
great importance to the RMO. The basic considerations in control are:
(i) Dryness of skin is the most important single factor in successful treatment. Meticulous drying of
the toes after bathing or removing the shoes should be carried out. All dead skin should be removed
by a washcloth once a day.
(ii) Mechanical irritation produced by closely fitting garments should be minimized by making the
patient wear loose clothing.
(iii) Aeration of the feet by wearing chappals is helpful.
(iv) Drying and protection from mechanical rubbing may be aided by inserting absorbent cotton wool
into the interspaces.
(v) Dusting of the toes with foot-powder should be done once or twice a day but not in acute stage.
(vi) Socks should be changed, thoroughly washed and dried every day.

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(vii) Rest is essential in severe intertriginous ringworm. As the acute manifestations subside, gradual
increase in activity is allowed within reasonable limits.
(viii) Therapeutic measures as given in subsequent paragraphs should be carried out in the MI Room
under the dermatologist’s advice. Severe and extensive cases may require hospitalization.
(aa) The administration of griseofulvin is the specific treatment of all fungal infections. This
should be administered by the RMO in the unit as prescribed by the dermatologist. Average adult
dose is 0.5 g a day for 3 to 4 weeks.
(ab) Regular use of 5 to 10 percent salicylic acid ointment for several months is an alternative
treatment in the absence of the facilities or pending specialist advice and in mild cases. Moderate
Tinea Cruris can be relieved with the application of Whitfield’s ointment every night and Castellani’s
paint during the day.
(ac) Acute flare-ups can be relieved with soaks of 1:8,000 potassium permanganate lotion (colour
should be light pink) for 20 min twice a day and dressed with calamine lotion. The vesicles and
bullae should be pricked with a sterile needle and the contents evacuated. The entire top of the
bullae should be removed. Castellani’s paint should be used topically. However, it is always better
to seek advice from a dermatologist in such cases.

32.15 Scabies.
(a) Definition.
Scabies or ‘the itch’ is a specific contagious
disease caused by the presence of
Sarcoptes scabiei var hominis in the
stratum corneum of the human skin.
It is characterized by the formation of
burrows and intense itching which is most
troublesome when the infested person is
in bed or in a warm room. Prolonged loss
of sleep or the disturbed sleep produced
by almost intolerable itching adversely
affects the efficiency of the person.
Besides itching, suffering in a case of
scabies is mainly due to a secondary EGG LARVA ADULT FEMALE
pyogenic infection of the scabies lesions,
such as follicular pustules, boils, impetigo
and even abscesses. The proportion of
such complicated cases depends on the
attention given to early diagnosis and
efficient treatment.
(b) Agent.
Sarcoptes scabiei is a very small mite just
visible to a person with good eyesight.
The female measures 0.4 mm. It is oval
in shape and dirty white in colour; the
male, which is rarely found, is about 2 / 3
the size of the female (Fig 32.1)
(c) Life Cycle. VENTRAL DORSAL
The female of the species is responsible Fig 32.1 : Sarcoptes Scabiei
for the symptoms. She burrows in between
the folds of horny layer and lays 2 to 3
eggs a day for 2 months. The eggs hatch out in 3 to 4 days. The larvae leave the burrow and take a temporary
residence in the neighbouring hair follicles. Here they moult into nymphs and then into immature adults in

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4 to 6 days. The somewhat complex life cycle from egg to adult takes a minimum of 8 days. The life cycle is
passed solely in the skin. Successive generations cause further infestation.
(d) Reservoir and Source.
The itching is due to sensitization of the skin produced by absorbed products of the acarus metabolism and
occurs after a month after infestation. Therefore, a person infested with scabies is unlikely to report sick and
get treated up to a month. Thus, he has ample opportunity and time to infect other individuals in the house,
barrack or community, before the symptoms start. In an untreated case, after intense irritation for 3 to 4
months the mite population falls and a spontaneous cure may occur; on the other hand, the infestation may
persist indefinitely, the person gets used to itching and forms a reservoir of infection.
(e) Mode of Transmission.
Scabies spreads rapidly from one person to another through intimate contact, especially at night when the
family sleeps huddled together in a one-room tenement. It is primarily a family disease. The older child brings
it home from school or from the neighbourhood and gives it to the younger ones and to the parents. This is
also one of the important infestations of residential schools. The infestation is brought in by children returning
from home after vacation. In Armed Forces barracks, it spreads from one person to another when there is
overcrowding and poor personal hygiene. Under war conditions the chances of transmission are increased due
to inevitable overcrowding in depots and training centres when men must sleep huddled together and personal
hygiene suffers. The infestation is generally brought in by new recruits and personnel returning from leave.
The communal use of sports shirts and shorts and perhaps also towels used immediately after removal from
an infested person may, although very rarely, cause transmission. It is not transmitted through blankets or if
clothes are left aside for some time after removal by the infested person.
(f) Diagnosis
The diagnosis is made by finding a mite in the burrow. The typical burrow is 5 to 10 mm long. In a fair skinned
individual, it may appear grey to black, due to dirt and the faeces of the mite within it and is therefore easily
mapped out. To extract the mite, a burrow should be selected in which it can be seen as a wax- like speck near
the blind end of the burrow. A sterile needle is driven in the horny layer below the mite keeping it almost parallel
with the skin surface. The tip of the needle is then raised so that the burrow is opened out. The mite will be
found clinging to the needle tip or on the under surface of the skin flap. In dark skins it is difficult to see the
burrow and reliance must be put mainly on the distribution of the lesion and the history of itching. (Fig 32.2)

Fig 32.2 : Diagrammatic Representation of Itch Mite in a Burrow made in the Skin
The sites of predilection for the burrow are; the sides and webs of the fingers, the front of the wrist, the points

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of the elbows, the anterior folds of the axillae, but not their hollows, the umbilical region, the prepuce, glans
penis, scrotum and lower gluteal regions, in fact all areas of the skin which are soft and folded. There is
almost always a large number of red, scratched patches on the sites of predilection, becoming scantier as the
distance from these centres increases. In troops, burrows may be rare on the fingers and when short sleeves
are worn, not so common on the wrists. When secondary infection occurs burrows often become obscure.
If the diagnosis is not immediately apparent the man should be stripped and examined in good light when
lesions in the other covered sites may be seen. In the lax tissues of the penis and scrotum a small papule is
often seen, across the top of which, unless it has been scratched or ulcerated, a typical burrow can often be
detected. These lesions at times are mistaken for and are occasionally complicated by, venereal sores. Similar
but distinctly elongated papules are often found around the umbilicus and in axillary folds. The lesions on
the gluteal folds and the elbows are often accompanied by secondary impetigo and such a condition should
arouse suspicion of underlying scabies. On the typical presentation of rash, but without any typical burrows,
one should not hesitate to diagnose scabies, particularly if there is a history of itching.
(g) Prevention and Control Measures.
All ranks should be educated regarding the nature, mode of spread and preventive precautions, especially,
before going home on leave. Infestation rapidly spreads in overcrowded barracks unless relieved by proper
spacing of beds, use of verandahs and tents for influx of recruits. Interchange of clothing and sleeping huddled
together should be forbidden. Personal hygiene among men in barracks should be maintained at a very high
level. Bathing and laundering facilities in barracks should be adequate. It is necessary that the infested persons
are detected very early. Men usually report sick only when they suffer from intolerable itching, which usually
takes place in a later stage after the infestation. Therefore, regular inspections must be carried out at short
intervals for early detection of infestation. Early detection followed by prompt and thorough treatment of the
infested area is the most important control measures. All men returning from leave also should be inspected
from this point of view.
(h) Radical Treatment.
The radical treatment of every case is one of the most important control measures. Mass treatment may
be necessary in the case of widespread infestation especially in training and recruiting centres / depots and
other large units. The treatment of scabies is carried out by benzyl benzoate application. The whole success
of the treatment depends on the thoroughness with which it is carried out. Failure to cure is commonly due to
slipshod treatment with faulty supervision. The whole family or community should be treated at the same time
as a ‘drill’. The patient takes a fairly prolonged soap and warm bath, scrubbing the whole body from the neck
to the toes with a brush or a washcloth. An emulsion containing 25 percent benzyl benzoate is applied with a
brush by an attendant to the entire body, except the head and face. If thoroughly carried out, one application
is usually adequate; 2nd application after an interval of 10 days may sometimes be needed. Applications on
two consecutive days without washing may be occasionally required for individual cases of severe infestation.
A bath is given after 24th of the treatment. No disinfestation of clothing is necessary; ordinary laundering is
sufficient. Cases showing complications of secondary bacterial infection and secondary eczematous changes
should be admitted to hospital.

32.16 Physical Agents.

(a) Prickly Heat (Miliaria).
This is an erythematous eruption resulting from blocking of the sweat pores by horny plugs of the excoriated
cutaneous debris and a dried decomposition product of sweat, leading to a rupture of the occluded sweat ducts
with subsequent extravasation of sweat into the epidermis or less commonly into the dermis. This occurs by
excessive sweating in a hot humid climate aided by the removal of the natural cutaneous lipoid covering by
frequent washing with soap and a maceration of the epidermis due to friction by rough clothing. Men from the
hills are especially liable. Acclimatized individuals progressively suffer less and less but some others continue
to suffer whenever the hot season sets in. Prickly heat is not a grave matter but is sufficiently distressing so
as to interfere with efficient occupational pursuits because of the incessant burning itch. On the other hand,
it may be so extensive as to lead to a relative anhidrosis and precipitate heat stroke.
(b) Clinical Features.
Clinically prickly heat appears as erythematous papular vesicles mostly on the sides of the trunk, abdomen,

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antecubital and popliteal fossae and sites such as the belt line and the areas where clothing rubs. The face,
palms and soles escape. The lesions are usually bilateral. The eruption waxes and wanes in close correlation
with the heat load. Vigorous exercise may also cause the rash. Secondary infection may give rise to furunculosis
and bullous impetigo.
(c) Prophylaxis.
It is achieved by rapid evaporation of sweat and avoidance of friction by clothing. Any unnecessary exercise or
work which promotes sweating should be avoided. Too much starch on clothing promotes sweating and friction
and should be avoided. A bare body suffers less from prickly heat. Ointments are occlusive and should be
avoided. Excessive bathing with use of harsh, irritant agents, too much soap and friction by a rough towel are
all contributory factors which should be avoided. However, after activity leading to increased sweating, bathing
without use of soap is helpful. The treatment in the MI Room focuses on measures which inhibit sweating. At
present the prickly heat powder containing 1 part each of sulphur precipitatum, camphor and boric acid, 2
parts of zinc oxide and 3 parts of starch powder is useful. A light application of vegetable oils, without rubbing
is also useful. Severe and chronic cases are likely to develop effects of heat or secondary infection.

32.17 Contact Dermatoses.

(a) A serviceman may come in contact with potentially dangerous substances or he may be particularly
sensitive to some substances which are used in the modern weaponry and equipment. The contact dermatoses
are recognized by the following points:
(i) Eruption is localized to the point of contact.
(ii) Remission on removal from the source and exacerbation occurs on re-exposure.
(iii) Distribution and correlation exist with the nature of duties.
(iv) Similarity of results of patch testing with a suspected agent is diagnostic (this should not be
attempted when the dermatoses is in an acute stage).
(b) The following general principles will help in understanding the causation of dermatosis for adopting
suitable preventive measures.
(c) Predisposing Factors.
These render the skin surface susceptible to biological, physical and chemical agents. Some important factors
are as under:
(i) Light coloured skins are liable to be affected by contact sensitizations and solar radiation.
(ii) Hairy skins are liable to be afflicted by follicular infections.
(iii) Certain sites which are liable to friction, heat retention, soddening and maceration increase liability
to dermatosis. This may be aided by conditions like cramping shoes, tight clothing, forced marches etc.
Hyperhidrosis, ichthyosis and seborrhoea also increase the skin susceptibility.
(iv) Infrequent or too frequent bathing or washing using harsh detergents and inadequate removal of
detergents increase likelihood of sensitization to chemicals.
(d) Precipitating Material Factors.
Some materials in their natural state or in the form of dust, fume, gas or radiation are particularly handful
owing to the following properties:
(i) Physical properties, causing friction as by abrasives, foreign body reaction by piercing body parts
such as nose and ears and local effects of the silver or other particles and local effects by heat, cold,
moisture or radiation.
(ii) Chemical properties cause contact dermatitis by a primary irritant or by sensitization. The primary
irritant reaction is due to interaction between the acidic or alkaline substances and skin proteins causing
desiccation, keratolysis, protein precipitation or oxidation. Sensitization of skin gives rise to allergic
reactions causing dermatosis.
(iii) Biological agents like anthrax, fungus and lice may be associated with the occupation of servicemen

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and cause dermatosis; plants may cause dermatosis when camping in a jungle.
(e) Preventive and Control Measures.
The following general measures should be adopted to prevent and control dermatoses in service personnel:
(i) Before any product which will be handled by the personnel, is introduced in the service, its
potentiality for causing a sensitization reaction should be ascertained from its composition, patch testing
and controlled field trials. Harmful agents should be substituted by innocuous ones.
(ii) Pre-recruitment skin inspection and routine skin inspection while in service and eliminating contact
with harmful substances.
(iii) The working rooms should be clean and ventilated. Issue of adequate protective clothing and
barrier creams, adequate washing, bathing and laundry facilities, health education to induce personnel
to take prophylactic care and the other specific measures described in this chapter should be taken.

32.18 Psycho-Cutaneous Disorders.

(a) Mechanism.
The mechanisms by which psycho-cutaneous disorders brought about are:
(i) Increased physiological vasomotor responses.
(ii) Hyperhidrosis and increased sebaceous activity changing the metabolism of the skin.
(iii) Certain skin disorders termed as ‘reaction-pattern disorders’ are precipitated while certain disorders
are aggravated by psychic stresses. Anxiety produces conflicts with the conscience due to self-imposed
inhibitions in susceptible individuals. Conflicts build up tensions which find ‘conscious’ outlets in the
form of psychosomatic disorders. These also form avenues for the expression of ‘deep seated beliefs’
in the form of obsessions and phobias. Self-infliction and malingering to obtain physical well-being and
monetary gains may also be contributory factors.
(b) Common Psycho-Cutaneous Disorders.
(i) Increased Physiological Responses or Psychogenic Factors.
(aa) Hyperhidrosis of palms and soles.
(ab) Neurotic excoriations
(ac) Factitial dermatitis
(ad) Trichotillomania
(ii) With Strong Probable Psychic Aetiology.
(aa) Alopecia
(ab) Vitiligo
(ac) Neurodermatitis or lichen simplex, atopic dermatitis, etc.
(ad) Herpes simplex
(ae) Warts
(iii) Reaction Pattern.
(aa) Pruritis
(ab) Urticaria
(ac) Dyshidrosis
(ad) Nail dystrophies
(iv) Aggravated by Psychic Factors.
(aa) Lichen planus

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(ab) Psoriasis
(ac) Seborrhoeic dermatitis
(ad) Acne vulgaris
(c) Diagnosis.
Although a skin disorder may be a manifestation of anxiety, the patient may be completely unaware of the tensions
unless deeply probed. A casual question, “Do you have any worries?” will be answered in the negative and any
amateurish attempt to unravel anxieties will be unsuccessful and harmful. Psycho-cutaneous disorders present
a clinical picture showing a bizarre pattern, the diagnosis of which is not obvious. A disturbing experience before
the onset, multiplicity of complaints, personal and family history of mental abnormality and a history of childhood
experiences will aid in the diagnosis. Factors aimed at physical and material gain should also be kept in mind.
(d) Prevention.
It is by elimination of emotionally unstable individuals or those with a familial background of psychic disorders
at the time of recruitment. The life in the Armed Forces presents far too many occasions for stressful situations
with its resulting psychosomatic disorders. Man management which reduces strains and stresses, mental
anxiety, oppressed emotions, boredom and monotony and promotes relaxation, is necessary to minimize such
conditions.

32.19 Leprosy.
(a) Importance of Leprosy.
The seriousness of endemic leprosy in relation to other diseases cannot be evaluated solely by the number
of patients or by the prevalence rates. The duration of the disease, the disabilities it causes and the human
and social consequences to the leprosy patients and their families must also be taken into account. It is
not only the long duration of the disease for lepromatous cases that is discouraging, but also the present
uncertainty of ultimate freedom from infection even after long periods of treatment. The prejudices of past
have led unnecessarily either to costly institutions or to pressure on patients to segregate in socially­isolated
communities. These measures have resulted in serious problems affecting the upbringing of children and
causing them to be socially deprived or disadvantaged on entering adult life. In general, it can be said that
no other disease arouses such adverse reactions in the families as leprosy. The anxiety and self-stigmatization
may follow leprosy patients and their relatives throughout their lives and cast a permanent shadow over their
families and their professional and social activities.
(b) Definition.
Leprosy is a chronic granulomatous disease caused by M. leprae. It primarily affects the peripheral nerves, skin
and mucous membrane. It also affects eye, certain internal organs such as the kidney, liver, adrenal glands and
in the male, testicle. The disease is clinically characterized by hypopigmented patches or partial / total loss of
sensation in the affected area or presence of thickened nerves or presence of acid-fast bacilli in the skin smears.
(c) Geographical Distribution.
In 2022, 182 countries, areas and territories shared information on leprosy, accounting for a registered
prevalence of 165 459 cases and 1,74,087 new cases, of which 67,657 (39%) were among females. Globally,
9554 new cases with Grade 2 Disability were detected and 278 (3%) of them were among children. Most of
the countries with high rates of detection of new cases are in WHO African and South-East Asia Regions.
(d) Leprosy Problem in India.
Leprosy has been associated with mankind since time immemorial. Reference to leprosy can be traced back
to earliest medical texts i.e. the Sushruta Samhita and the Charaka Samhita (dating from 600 BC and 300 BC
respectively). India being an endemic country for leprosy, is committed to its eradication. The National Leprosy
Control Programme (NLCP) was launched in 1955. Multi Drug Therapy (MDT) for leprosy was introduced and
the NLCP was renamed as National Leprosy Eradication Programme (NLEP) in 1983 and implemented as
a Centrally Sponsored Scheme which significantly accelerated the elimination of leprosy as a public health
problem. In 1983 the prevalence rate of leprosy was 57.8 per 10,000 population and by 1992 it was reduced
to 24 per 10,000 population. As India stepped into the new millennium, the prevalence rate of leprosy was

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3.7 per 10,000 in March 2001. The country adopted the strategy of decentralization of the leprosy programme
to States and Union Territories and integration of leprosy into the general health care services. With this,
treatment of leprosy became more accessible and leprosy patients received treatment from health facilities
of the general health care system. The peripheral staff was involved in delivering of MDT to the patients. The
MDT comprises of the antibiotics, Rifampicin, Clofazimine and Dapsone.
In 2005, India achieved the goal set by the National Health Policy, 2002 of elimination of leprosy as a public
health problem, defined as less than 1 case per 10,000 population at the national level. However, prevalence
rate remained above 1 per 10,000 population in several districts and blocks and new cases continued to
occur. In March 2020, 114,451 annual new cases were reported and 610 out of 717 districts had achieved
prevalence rate of less than 1 per 10,000 population. Among the new cases detected, 2.41 % had reported
with visible deformities. Total of 23 States / UTs have sustained the elimination status (PR< 1 per 10,000
population) at state level since 2009-10 until 2021-22. These States are Andhra Pradesh, Arunachal Pradesh,
Assam, Gujarat, Haryana, Himachal Pradesh, Jammu & Kashmir, Karnataka, Kerala, Madhya Pradesh, Manipur,
Meghalaya, Mizoram, Nagaland, Punjab, Rajasthan, Sikkim, Tamil Nadu, Tripura, Uttar Pradesh, Uttarakhand,
A&N Islands and Puducherry. In addition to above, Telangana and Ladakh (UT) are sustaining the status of
leprosy elimination since 2014-15 and 2019-20 respectively.
In 2021-22, a total of 75,394 new cases were detected in India. A total of 1,863 grade 2 disabilities detected
amongst the new leprosy cases during 2021-22, indicating the Grade 2 Disability rate of 1.36 per million
population and 2.47% Grade 2 Disability among new cases.
(e) Agent.
Leprosy is caused by Mycobacterium leprae. The bacilli are acid fast and resemble the tubercle bacilli
morphologically. The occurrence of the bacilli in clumps or bundles (called Globi) can be seen in lepromatous
cases. Other than man, it has multiplied in the footpads of mice, in tissues of immunosuppressed rodents
and in the nine-banded armadillo.
(f) Reservoir.
Man is the only known reservoir. Epidemiologically, the “Open” cases who are shedding the organisms are the
chief source of infection. Nasal discharges from lepromatous patients present an important source of infection.
(g) Mode of Transmission.
The mode of transmission is not clearly established. The bacilli from nasal discharges of infectious patients
gain entrance through the skin or respiratory tract. Household contact is important.
(h) Host.
Infection can take place at any age depending upon the opportunities for exposure in endemic areas. The
disease is acquired commonly during infancy and childhood. A high incidence of infection among children
means the disease is active and spreading. In general, leprosy is more commonly seen in men than women.
Lepromatous leprosy is low in Africans and very high in Caucasians. This variation is attributed to skin
pigmentation. Only a few people exposed to infection develop clinical signs of leprosy, although immunological
conversion takes place in large proportions of contacts. It is now recognized that the effective immune response
in leprosy is a cell-mediated one. In lepromatous leprosy there is a complete breakdown in the cell mediated
immune response.
(j) Incubation Period.
Most probably the average incubation period is 3 to 5 years, although many years may lapse before recognition.
(k) Communicability.
A patient is infective, if morphologically solid-staining (viable) bacilli are demonstrable.
(l) Classification.
(i) Indian Classification.
Leprosy is a disease bedeviled by classifications. This is probably a reflection of great variation in individual
host resistance to the disease. The classification is as follows:

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(aa) Indeterminate Type.

Early cases with one or two vague hypopigmented macules and with or without sensory impairment.
Lesions are bacteriologically negative.
(ab) Tuberculoid Type.
Cases with one or two well defined lesions which may be flat or raised, hypopigmented or
erythematous or are anaesthetic.
(ac) Borderline Type.
Cases with four or more lesions which may be flat or raised, well or ill defined, hypopigmented or
erythematous and shows sensory impairment or loss. Bacteriological positivity is variable. Without
treatment it can progress to lepromatous type.
(ad) Lepromatous Type.
Cases with diffuse infiltration or numerous flat or raised lesions, symmetrical without any sensory
loss. Lesions are bacteriologically positive.
(ae) Pure Neuritic Type.
Cases show nerve involvement but do not have any lesion in skin. Cases are bacteriologically
negative.
(ii) WHO Classification.
Based on the above, the cases are classified into two types for treatment purposes: Paucibacillary (PB)
case and Multibacillary (MB) case
(aa) PB Case.
A case of leprosy with 1 to 5 skin lesions, without demonstrated presence of bacilli in a skin
smear.
(ab) MB case.
A case of leprosy with more than five skin lesions; or with nerve Involvement (pure neuritis or any
number of skin lesions and neuritis); or with the demonstrated presence of bacilli in a slit-skin
smear, irrespective of the number of skin lesions.
(m) Diagnosis.
If there is one diagnosis that should not be established unless there is absolute certainty, it is that of leprosy. If
there is the slightest doubt in the diagnosis the patient should be put under observation until further evidence
confirms the disease. The following features assist in the diagnosis of the disease:
(i) Skin Lesions.
Infiltration, macules, papules, tubercles and nodules usually appear gradually but in some cases can
appear suddenly on the limbs / face / trunk. They do not itch and generally become anaesthetic sometime
after their appearance.
(ii) Paraesthesia.
There is usually history of numbness and hot and cold sensations in the extremities especially in the
areas of the ulnar, lateral popliteal, median and posterior tibial nerves.
(iii) Loss of Sensation.
Loss of cutaneous sensibility to temperature, pain and light touch can be detected in skin lesions.
(iv) Thickening of Nerve Trunks.
Because of neuritis nerve trunks often increase in volume.
(v) Anhidrosis.
It is observed in skin lesions and / or in the extremities.

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(vi) Histamine Test.

0.1 ml of 1 / 1,000 solution of histamine chlorhydrate or phosphate is injected intradermally into the
skin. In normal persons it gives rise to wheal surrounded by an erythematous flare within a few minutes.
In cases of leprosy where nerve supply is destroyed this response is lost.
(vii) Bacteriological Examination.
Whenever possible, a smear of the nasal mucosa should be examined. A negative result, usually seen
in indeterminate and tuberculoid cases; does not eliminate the diagnosis of leprosy. In certain cases
histopathological examination may be necessary.
(n) Lepromin Test.
The lepromin test, also called Mitsuda reaction, was first described by the Japanese worker, K Mitsuda in
1916. It is an intradermal test employed to classify the type of disease and to find out the prognosis in any
given case. Lepromin is a suspension of triturated lepromatous tissue rich in M. leprae in an isotonic solution
of sodium chlorides sterilized by heating. The test is performed by injecting intradermally 0.1 ml of lepromin or
lepra antigen in the forearm of a patient and the reaction is examined at the end of 48 hours and 21 days.
The test results in 2 types of reaction.
(i) Early Reaction (Fernandez Reaction).
If there is erythema and induration measuring more than 10 mm in diameter at the end of 48 hours
at the site of injection it is considered positive.
(ii) Delayed Reaction.
At the end of 21 days, if there is a nodule more than 5 mm in diameter at the site of inoculation, it is
said to be positive. This delayed reaction is also known as the classical or Mitsuda reaction. In strongly
positive individuals there may be ulceration.
The early reaction has the same significance as the late reaction. The test is often positive in healthy
persons and in those suffering from non-lepromatous form of leprosy. The test is generally negative in
patients suffering from lepromatous form of disease. The lepromin test is not a diagnostic test, its value
lies in estimating prognosis, positive test indicating good prognosis. At present, the test suffers from the
drawback that it is unstandardized in both its nature and its interpretation.
(o) Prevention and Control.
(i) Case Finding.
In all areas where leprosy is endemic the disease should be detected by active methods of case
finding. Contact tracing is a good method. Contact surveillance of households with a lepromatous
case is recommended for a minimum period of 10 years after a lepromatous case is bacteriologically
negative and for 5 years in households with a non-lepromatous case from the time of diagnosis of
the index case. Mass surveys are expensive but repeated annual examinations of school children yield
better results at relatively low cost. The medical officers and para medical workers should participate
in detecting cases early. MOs should be alert to detect cases early during their periodical medical
examination of troops.
(ii) Chemotherapy.
Due to dependance on Dapsone Monotherapy for many years, drug resistant leprosy bacilli have emerged.
In order to cope up with this problem. WHO study group has recommended multi-drug therapy for both
multi-bacillary and pauci bacillary leprosy.
Objectives.
To interrupt transmission of infection in the community by sterilizing infectious patients as rapidly as
possible with bactericidal drugs.
To ensure early detection and treatment of cases.
To prevent deformities and to prevent drug resistance curtailing the duration of treatment.

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(aa) Multibacillary Leprosy.

As per the recent recommendations, following groups of patients are to be given MDT:
O All smear positive cases
O Skin lesions more than five in number
O More than one nerve trunk thickening
O All cases of relapse / reactivation
O All cases who have been treated with Dapsone monotherapy earlier.
Rifampicin - 600 mg once monthly supervised
Dapsone - 100 mg daily self-administered
Clofazimine - 300 mg once monthly supervised and 50 mg daily self-administered.
Where Clofazimine is totally unaccepted, its replacement by 250–375 mg self-administered daily
dose of Ethionamide or Protionamide has been suggested. Since Dapsone is hemolytic drug, its
dose should be based on body weight of the patient.
(ab) Paucibacillary Leprosy.
Rifampicin- 600 mg once monthly supervised
Dapsone- 100 mg daily self-administered
Clofazimine- 300 mg once monthly supervised and 50 mg daily self-administered.
(iii) Duration of Treatment.
The currently recommended treatment regimen consists of three drugs: Dapsone, Rifampicin and
Clofazimine. The combination is referred to as Multi-Drug Therapy (MDT). The duration of treatment is
six months for PB and 12 months for MB cases. MDT kills the pathogen and cures the patient. Early
diagnosis and prompt treatment can help to prevent disabilities.
(iv) Follow-up of Cases.
As the treatment is long term, large proportion of patients take drugs irregularly. Health education and
motivation of the patients are essential so that they take regular treatment. Infectious cases should be
taught to avoid contact at home with susceptible persons particularly children.
(v) Chemoprophylaxis.
The WHO expert committee on leprosy recommend the use of Single Dose Rifampicin (SDR) as
preventive treatment for contacts of leprosy patients (adults and children 2 years of age and above),
after excluding leprosy and TB disease and in the absence of other contraindications. This intervention
shall be implemented by programmes that can ensure: (aa) adequate management of contacts and
(ab) consent of the index case to disclose his / her disease. The age and weight wise dosage is as below:
Table 32.1 : Dosage of Single Dose Rifampicin in Preventive Treatment
Age / Weight Rifampicin Single Dose
15 years and above 600 mg

10–14 years 450 mg

Children 6–9 years (weight ≥ 20 kg) 300 mg

Children < 20 kg (> 2 years) 10-15 mg / kg

(vi) BCG Vaccination.

Various vaccines are in trial since 1939 when BCG vaccine was first used against Leprosy. In 2018, WHO officially
recognized BCG vaccine for prevention of Tuberculosis and Leprosy. A misconception is that there is no leprosy
vaccine. Studies show that the BCG vaccine used to prevent tuberculosis caused by M. tuberculosis, a bacterium

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closely related to M. leprae, offers more protection against leprosy than against tuberculosis. Other leprosy
vaccine candidates besides the M. bovis BCG and rBCGs include the non-pathogenic M. leprae mycobacterium
species to induce cross-reactivity such as the ICRC (Indian Cancer Research Centre bacilli), M. welchii (M. w)
or M. indicus pranii (MIP) and M. habana and recombinant protein subunits, such as the LEP-F1 + GLA-SE
(LepVax), to induce target-specific immune responses. LepVax is the latest defined subunit vaccine candidate
moving in the clinical trial pipeline.
(vii) Rehabilitation.
It is an important aspect of leprosy control. It means the physical and mental restoration as far as
possible of treated patients to normal activity so that they resume their place in the home, in society
and industry. Early treatment helps in disability limitation.
(viii) Health Education.
It is an important component of leprosy control. The education should be directed towards general public
and to patients. They should be told that leprosy is like any other disease and not result of a divine
curse.
(p) In the Armed Forces, though AO 36 / 87, GMO 2023 (VI & VII)) and various guidelines issued from
time to time by DGAFMS (DG-3A) in lines with National Program as well as specific scenarios pertaining to
Armed Forces are being followed. Present treatment schedule is in line with National Leprosy Eradication
Program (NLEP) rather than WHO schedule.
(q) As per AO 36 / 87.
While on Institutional treatment (Hospital treatment for 12 months), individual can be invalidated out of
service and discharged from the hospital any time during their stay if,
(i) Unwillingness to continue treatment.
(ii) Attaining the date of superannuation.
(r) If any time during the period of (twelve months) the disease is arrested / inactive (described in Table 32.2
below) and is considered non-infectious (bacteriologically negative for three consecutive months), individual
will be brought before a duly constituted medical board to determine his fitness for retention in service with
fresh assessment of classification. If found fit for retention, then placed in appropriate low medical category.
Table 32.2 : Differences Between Disease Arrest & Inactivity in Cases of Leprosy
ARREST INACTIVITY
No new lesion or increase in the size of existing lesions Complete resolution of lesions and recovery of sensory
for a minimum period of 03 months loss (except residual minor sequelae) for a period of
preceding 06 months
No new nerve involvement, nerve tenderness or Absence of neuritic pains and tenderness for a period
reactional episodes for a minimum period of 03 months of preceding 06 months
Attainment of bacterial negativity in bacteriologically Continues bacteriological negativity
positive cases
Satisfactory clinical resolution in existing lesions Histological evidence of complete resolution of the
lesions
(s) Pre-requisites for Upgradation to Medical Category P1 and Its Equivalent in Navy and Air Force.
(i) No evidence of clinical activity of the disease i.e. the disease has become inactive.
(ii) No histological evidence of granuloma or active infiltration in biopsy indicating complete resolution.
(iii) Continued bacterial negativity for two years in multibacillary cases.
(iv) No functional disability or deformity. Patients who cannot be upgraded to SHAPE-1 or equivalent
due to physical disability / deformity should be placed in permanent low medical category appropriate to
his / her physical condition.

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(t) Assessment of Disability Percentage Based on Guide to Medical Officers 2023 (Chapter VI & VII).
The residual disabilities in cases of Leprosy are assessed as per assessment of functional impairment to be based
upon guidelines contained in Rights of Persons with Disabilities (RPwD) Act of 2016 for Locomotor impairment.
Extra points are awarded in cases of amputation on account of leprosy as given in table below:
Table 32.3 : Assessment of Disablement for Amputation of Fingers
Amputation through Proximal phalanx or Disarticulation through MP joint Percentage Assessment
Index Finger 15
Middle Finger 5
Ring Finger 3
Little Finger 2
Amputation through Proximal phalanx or Disarticulation through PIP joint
Index Finger 10
Middle Finger 4
Ring Finger 2
Little Finger 1
Amputation through Proximal phalanx or Disarticulation through DIP joint
Index Finger 5
Middle Finger 2
Ring Finger 1
Little Finger 1
The other manifestations of Leprosy are assessed as per guidelines in RPwD Act 2016 or Guide to Medical
Officers-2023.
Table 32.3 : Assessment of other Manifestations of Leprosy
Trophic Ulceration.
Recurrent trophic ulceration of hands and / feet Assessment will be as per the functional impairment of
locomotor component as RPwD Act of 2016 as para 35 (viii).

Face Involvement.
Face involvement with deformity of nose / ear Assessment as per Para 41 of Guide to Medical Officers-2023
for superficial burns

32.20 Mpox (Monkeypox).

ICD 11 Code: 1E71
(a) Introduction.
Mpox (formerly known as monkeypox) first discovered in 1958 among colonies of monkeys kept for research
in Denmark. The first human case of Monkeypox was reported from Democratic Republic of Congo in 1970.
It is a rare disease caused by infection with the mpox virus. Monkeypox virus is part of the same family of
viruses as variola virus, the virus that causes smallpox. Mpox symptoms are similar to smallpox symptoms,
but milder and mpox is rarely fatal. Mpox is not related to chickenpox.
(b) Epidemiology.
About 100 countries have reported cases of monkeypox since May 2022, with over 62,000 confirmed cases.

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Confirmed cases were mostly male (>99%), with a median age of 35–38 years (range: 18–67). In an outbreak
in non-endemic countries, the occurrence of almost all cases (>90%) was identified primarily among men
describing themselves as men who have sex with men. In the outbreak, most of the human monkeypox cases
had presented with mild to moderate symptoms. The viruses were isolated from semen and vaginal fluids to
confirm the possibility of their sexual transmission.
(c) Global Scenario.
In 2022–2023 a global outbreak of mpox was caused by a strain known as clade IIb. Before the 2022 outbreak,
mpox had been reported in people in several central and western African countries. Previously, almost all mpox
cases in people outside of Africa were linked to international travel to countries where the disease commonly
occurs or through imported animals. These cases occurred on multiple continents.
(d) Indian Scenario.
All the retrieved mpox sequences from India covering 90% to 99% of the genome belong to the A.2 lineage
of clade II b. Three sub-clusters of monkeypox cases detected in India- first cluster of Kerala (5 cases) and
two clusters of Delhi (2 cases and 3 cases each). However, monkeypox is not endemic in India.
(e) Epidemiological Factors.
(i) Agent.
Monkeypox virus is an enveloped double-stranded DNA virus that belongs to the Orthopoxvirus genus
of the Poxviridae family. There are two distinct genetic clades of the monkeypox virus – the Central
African (Congo Basin) clade and the West African clade. The Congo Basin clade has historically caused
more severe disease and was thought to be more transmissible. The two genetic clades of the virus
are also denoted as clades I and II. Following eradication of smallpox in 1980 and the end of smallpox
vaccination worldwide, mpox steadily emerged in central, east and west Africa. A global outbreak occurred
in 2022–2023. The natural reservoir of the virus is unknown, various small mammals such as squirrels
and monkeys are susceptible.
(ii) Host Factors.
Reservoir is yet unknown. However, certain rodents (including rope squirrels, tree squirrels, Gambian
pouched rats, dormice) and non-human primates are known to be naturally susceptible to monkeypox
virus.
(iii) Incubation Period.
The incubation period is 3-17 days. During this time, a person does not have symptoms. A person is not
contagious during this period.
(iv) Period of Communicability.
1-2 days before the rash to until all the scabs fall off / gets subsided.
(v) Transmission.
Human-to-human transmission is known to occur primarily through large respiratory droplets generally
requiring a prolonged close contact. It can also be transmitted through direct contact with body fluids
or lesion material and indirect contact with lesion material, such as through contaminated clothing or
linens of an infected person. Mpox can spread to other members of the household and to sex partners.
People with multiple sexual partners are at higher risk. Animal-to-human transmission may occur by bite
or scratch of infected animals like small mammals including rodents (rats, squirrels) and non-human
primates (monkeys, apes) or through bush meat preparation.
(f) Clinical Features.
Monkeypox is usually a self-limited disease with the symptoms lasting from 2 to 4 weeks. Severe cases occur
more commonly among children and are related to the extent of virus exposure, patient health status and
nature of complications. The extent to which asymptomatic infection occurs is unknown. The case fatality ratio
of monkeypox has historically ranged from 0 to 11% in the general population and has been higher among
young children. In recent times, the case fatality ratio has been around 3-6%.

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(i) Prodrome (0-5 days).

The infected person may develop an early set of symptoms (prodrome). These symptoms include fever,
malaise, headache, sore throat or cough and (in many cases) swollen lymph nodes. Lymphadenopathy
is a characteristic feature of mpox and lymph nodes may swell in the neck (submandibular & cervical),
armpits (axillary) or groin (inguinal) and can occur on both sides of the body or just one. A person may
be contagious during this period. Here, patients are advised to isolate if they develop symptoms.
(ii) Rash.
People with mpox infection develop lesions that typically progress from papules, macules, vesicles,
pustules and then scabs. A person is contagious until after all the scabs on the skin have fallen off
and a fresh layer of intact skin has formed underneath.
Table 32.4 : Stages of Rash in Monkey Pox
Stage Duration Characteristics
Enanthem - Sometimes, lesions first form on the tongue and in the mouth.
Macules 1−2 days Macular lesions appear.
Papules 1−2 days Lesions typically progress from macular (flat) to papular (raised).
Vesicles 1−2 days Lesions then typically become vesicular (raised and filled with clear fluid).
Pustules Lesions then typically become pustular (filled with opaque fluid) – sharply raised,
usually round and firm to the touch (deep seated).
5−7 days
Finally, lesions typically develop a depression in the center (umbilication).
The pustules will remain for approximately 5 to 7 days before beginning to crust.
Scabs By the end of the second week, pustules have crusted and scabbed over.
7−14 days
Scabs will remain for about a week before beginning to fall off.
*This is a typical timeline, but timeline can vary.
Rash resolved: Pitted scars and / or areas of lighter or darker skin may remain after scabs have fallen
off. Once all scabs have fallen off and a fresh layer of skin has formed, a person is no longer contagious.
(g) Complications.
Complications involve secondary infections, Pneumonia, sepsis, encephalitis, corneal involvement which may
lead to loss of vision.
(h) Diagnosis.
Identifying mpox can be difficult as other infections and conditions can look similar. It is important to distinguish
mpox from chickenpox, measles, bacterial skin infections, scabies, herpes, syphilis, other sexually transmissible
infections and medication-associated allergies. Detection of viral DNA by polymerase chain reaction (PCR) is the
preferred laboratory test for mpox. The best diagnostic specimens are taken directly from the rash – skin, fluid or
crusts – collected by vigorous swabbing. In the absence of skin lesions, testing can be done on oropharyngeal,
anal or rectal swabs. Testing blood is not recommended. The following are the testing modalities:
(i) PCR for Orthopoxvirus genus [Cowpox, Buffalopox, Camelpox, Monkeypox] will be done.
(ii) If specimen will show positivity for the Orthopoxvirus, it would be further confirmed by Monkeypox
specific conventional PCR or real time PCR for Monkeypox DNA.
(iii) Additionally, virus isolation and the Next Generation Sequencing of clinical samples (Miniseq and
Nextseq) will be used for characterization of the positive clinical specimens.
(j) Treatment.
Principles of Management include Patient isolation, Protection of compromised skin and mucous membranes,
Rehydration therapy and Nutritional support, Symptom alleviation and Monitoring and treatment of complications.

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(k) Patient Isolation.

(i) Isolation of the patient in an isolation room of the hospital / at home in a separate room with
separate ventilation.
(ii) Patient to wear a triple layer mask.
(iii) Skin lesions should be covered to the best extent possible (e.g., long sleeves, long pants) to
minimize risk of contact with others.
(iv) Isolation to be continued until all lesions have resolved and scabs have completely fallen off.
(l) Monitoring and Treatment of Complications.
(i) The patient should closely monitor for the appearance of any of the following symptoms during
the period of isolation:
(ii) Pain in eye or blurring of vision.
(iii) Shortness of breath, chest pain, difficulty in breathing
(iv) Altered consciousness, seizure.
(v) Decrease in urine output.
(vi) Poor oral intake
(vii) Lethargy in case any of the above symptoms appear, the patient should immediately contact
nearby healthcare facility / specialist.
(m) Contact Tracing.
A contact is defined as a person who has been exposed to an infected person during the infectious period i.e.
in the period beginning with the onset of the source case’s first symptoms and ending when all scabs have
fallen off, has had one or more of the following exposures with a probable or confirmed case of monkey pox:
(i) Face-to-face exposure (including health care workers without appropriate PPE).
(ii) Direct physical contact, including sexual contact.
(iii) Contact with contaminated materials such as clothing or bedding.
(n) Contact Identification.
Cases can be prompted to identify contacts across household, workplace, school / nursery, sexual contacts,
healthcare, houses of worship, transportation, sports, social gatherings and any other recalled interactions.
(o) Contact Monitoring.
Contacts should be monitored at least daily for the onset of signs / symptoms for a period of 21 days (as per
case definition above) from the last contact with a patient or their contaminated materials during the infectious
period. In case of occurrence of fever clinical / lab evaluation is warranted.
(i) Asymptomatic contacts should not donate blood, cells, tissue, organs or semen while they are
under surveillance.
(ii) Pre-school children may be excluded from day care, nursery or other group settings.
(iii) Health workers who have unprotected exposures to patients with monkeypox or possibly
contaminated materials do not need to be excluded from work duty if asymptomatic but should undergo
active surveillance for symptoms for 21 days.
(p) Self-care and Prevention.
Most people with mpox will recover within 2-4 weeks. Things to do to help the symptoms and prevent infecting
others.
(i) Do.
(aa) Stay home and in your own room if possible.

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(ab) Wash hands often with soap and water or hand sanitizer, especially before or after touching
sores.
(ac) Wear a mask and cover lesions when around other people until your rash heals.
(ad) Keep skin dry and uncovered (unless in a room with someone else)
(ae) Avoid touching items in shared spaces and disinfect shared spaces frequently.
(af) Use saltwater rinses for sores in the mouth.
(ag) Take sitz baths or warm baths with baking soda or epsom salts for body sores.
(ah) Take over-the-counter medications for pain like paracetamol (acetaminophen) or ibuprofen.
(ii) Do not.
(aa) Pop blisters or scratch sores, which can slow healing, spread the rash to other parts of the
body and cause sores to become infected.
(ab) Shave areas with sores until scabs have healed and you have new skin underneath (this
can spread the rash to other parts of the body).
(ac) To prevent spread of mpox to others, persons with mpox should be isolated at home or
in hospital if needed, for the duration of the infectious period (from onset of symptoms until
lesions have healed and scabs fall off). Covering lesions and wearing a medical mask when in
the presence of others may help prevent spread. Using condoms during sex will help reduce the
risk getting mpox but will not prevent spread from skin-to-skin or mouth-to-skin contact.
Monkeypox is not typically considered to be very contagious because it requires close physical contact
with someone who is infectious (e.g., skin to skin) to widely spread between people. The risk of large-
scale outbreaks is therefore low. However, travellers to endemic countries should avoid contact with sick
animals that could harbour monkeypox virus such as rodents, marsupials, primates and should refrain
from eating or handling wild animals. When outbreaks are reported in other countries, all international
travellers entering India from the affected countries, any illness during travel or upon return from an
endemic area should be reported to a healthcare professional (Authorised Medical Attendant), including
information about all recent travel, immunization history and contact with any known cases.

32.21 Sexually Transmitted Infections (STIs).

(a) Introduction.
STIs are a group of contagious diseases transmitted predominantly by sexual contact and caused by wide range
of bacterial / viral, protozoal, fungal and ectoparasites. During the past two decades, STDs have undergone a
dramatic transformation like.
(i) Greatly reduced rates of the STIs due to effective public health programs and changing sexual
behaviour.
(ii) Changing patterns of STI rates due to HIV / AIDS calling for intensified AIDS-STI control efforts.
(iii) The growing evidence that certain STIs function as risk factor for transmission of HIV infection.
(iv) Attention is now given not only to specific diseases but also to clinical syndromes associated with
STIs. Most of the recently recognised STIs are now referred to as second generation STIs.
(b) Epidemiological Pattern of STD.
There are more than 30 pathogens that can be transmitted sexually and individuals may have multiple infections
at the same time. True incidence of STIs is not known because of stigma involved but the trend in gonorrhoea
and primary syphilis is on the increase. The matter of concern is emergence of antimicrobial resistant agents
of STI. Second generation STIs are tending to replace the classical bacterial diseases (syphilis, gonorrhoea,
chancroid). The World Health Organization produces global and regional estimates of the prevalence and
incidence of four of the most common curable STIs in adults 15 to 49 years of age: Chlamydia (etiological
agent: Chlamydia trachomatis), Gonorrhoea (Neisseria gonorrhoeae), Trichomoniasis (Trichomonas vaginalis)
and Syphilis (Treponema pallidum) every 4 years. As per WHO global incidence of the diseases in 2020 was:

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Table 32.5 : WHO Global Incidence of the Diseases

Disease Male (Incidence in 1,000) Female (Incidence in 1,000)
Syphilis 3,591 [890 - 6,048] 3,461 [1,456 - 5,467]
Gonorrhoea 46,448 [20,004 - 86,291] 35,902 [20,657 – 55,548]
Chlamydia 58,612 [33,762 - 90,354] 69,859 [44,219 – 97,832]
Trichomoniasis 82,575 [37,163 - 1,48,274] 74,345 [50,038 – 1,08,685]
In 2020, WHO estimated 374 million new infections with 1 of 4 STIs: Chlamydia (129 million), Gonorrhoea (82
million), Syphilis (7.1 million) and Trichomoniasis (156 million).
(c) India.
In India, it is estimated that 6% of the adult population is infected with one or more STIs at any one time. However,
it is assumed that STI prevalence is much higher among subpopulations practicing high-risk behaviour. Like Men
who have Sex with Men (MSM), Transgender (TG), Injecting Drug Users (IDU) and Female Sex Workers (FSW).
(i) Syphilis.
Prevalence of 1.4–2.4% in serological surveys.
(ii) Gonorrhoea.
More widely prevalent than syphilis, 80% of the infected women are asymptomatic carrier.
(iii) Chancroid.
Widely prevalent in India.
(iv) LGV.
Its more prevalent in southern states of Tamil Nadu, AP, Maharashtra and Karnataka than in northern
states. Greater prevalence in coastal areas is found. Information on other STI’s are not available because
of poor reporting system.
(d) Importance of STDs in the Armed Forces.
The incidence of STDs in the Indian Army has always been low and has now dropped so low that it cannot be
considered as of any real medical significance. However, the underlying factors which cause increased incidence
in a unit, points directly or indirectly to bad discipline, low moral and lack of man-management. These factors
also have considerable importance in determining the efficiency of unit administration and fighting reliability. The
rates increased progressively during war years and remained high till 1948. From 1949 onwards the incidence
of STDs declined and from 1962 to 1972 when the Armed Forces expanded and were actively deployed during
the national emergency the rates marginally increased. Thereafter it has shown decline and is stabilized. Even
the WHO has felt that members of Armed Forces form a high risk group for STDs.
(e) Classification of STDs Agents.
Table 32.6 : Classification of STDs Agents
Bacterial Agents
Neisseria gonorrhoea Mycoplasma hominis Shigella
Chlamydia trachomatis Ureaplasma urealyticum Campylobacter
Treponema pallidum Calymmatobacterium Group B Streptococcus
Haemophilus ducreyi Granulomatis Bacterial vaginosis related Organism
Viral Agents
Human (alpha) herpes virus 1 and 2 Hepatitis B virus Molluscum contagiosum
Human (beta) herpes virus 5 Human Papilloma Virus HIV
Other Agents
Fungal Agents Ectoparasites Protozoal
Candida albicans Sarcoptes scabiei Entamoeba histolytica
Pthirus pubis Giardia lamblia
Trichomonas

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(f) Syndromic Management of STI / RTI.

Many STIs / RTIs can be identified and treated on the basis of characteristic symptoms and signs. Symptoms
and signs can be grouped together into Syndromes, upper respiratory infection, gastroenteritis and vaginal
discharge are examples of common syndromes. It is often difficult to know exactly what organism is causing
the syndrome and treatment may need to cover several possible infections. Syndromic management refers to
the approach of treating STI / RTI symptoms and signs based on the organisms most commonly responsible
for each syndrome. Laboratory tests require resources, add to the cost of treatment, may require clients to
make extra visits to the clinic and almost always result in delays in treatment. For these reasons, syndromic
management guidelines are widely used for syndromes such as lower abdominal pain, urethral discharge and
genital ulcer, even in developed countries with advanced laboratory facilities.
Table 32.7 : Syndromic Approach
Syndrome Symptoms Signs Most Common Causes
Genital Ulcer Genital sore Genital ulcers Chancroid
Disease (GUD) Genital herpes
Syphilis
Urethral discharge Dysuria (pain during Urethral discharge (if Chlamydia
urination) necessary, ask the patient Gonorrhoea
Frequent urination to milk the urethra)
Urethral discharge
Vaginal discharge Dyspareunia (pain during Abnormal vaginal Candidiasis
sexual intercourse) discharge Chlamydia
Dysuria (pain during Gonorrhoea
urination)
Trichomoniasis
Unusual vaginal discharge
Vaginal itching
(g) Control of STDs in the General Population.
Male promiscuity is due to immature sexual interest, the result of internal emotional disharmony with situation
in life and maladjustment with intrinsic or extrinsic conflicts. Professional, commercialized and to some extent,
amateur female prostitution provides this opportunity for male promiscuity. Various chains and combinations of
complex social, economic behavioural, environmental and other intrinsic and extrinsic factors are at the root of
this social evil. Economic distress, lack of security in childhood and adolescence, disharmony in married life,
social persecution of or an apathy for abandoned, abducted, waylaid, ‘fallen’ or forlorn women and failure to
rescue and rehabilitate them are some of the important causes which lead women to take refuge in prostitution.
Adolescent delinquency is the next important cause.
(h) Treatment of Partners.
Breaking the cycle of infection is a critical part of STI prevention and so the client should be encouraged to
refer his or her partner(s) for treatment, even when no clinical signs of infection are evident. Providers should
advise clients to notify their partners (including those without symptoms) of their exposure and encourage
them to seek treatment.

32.22 Syphilis.
(a) Agent.
The causal organism is Treponema pallidum. In vivo replication time, relative to most bacteria is about 30 hrs.
The organism is 6 to 15 microns in length to 0.15 micron wide.
(b) Mode of Transmission.
Syphilis is usually acquired by sexual contact. Infants acquire congenital infection by transplacental transmission
of Treponema pallidum.

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Table 32.8 : STIs Treatment Guidelines

Colour
Kit Indication Drug Dose Frequency Partner Treatment Code
of Kit
1 Urethral discharge T. Azithromycin 1 gm Stat All recent Grey
Painful Scrotal swelling T. Cefixime 400 mg Stat All recent
Cervical Discharge Only when
symptomatic
2 Vaginal discharge T. Secnidazole 2 gm Stat Only when Green
symptomatic
C. Fluconazole 150 mg Stat
3 Genital ulcer- non-herpetic Inj. Benzathine 2.4 MU Stat All partners for past White
penicillin 3 months
1 gm Stat
T. Azithromycin
4 Genital ulcer non-herpetic C. Doxycycline (if 100 mg BD 14 days All partners for past Blue
penicillin allergy) 3 months
5 Genital ulcer Herpetic T. Acyclovir 400 mg 7 days No partner Red
TDS treatment

6 Lower Abdominal Pain T. Cefixime 400 mg Stat Treat male partners Yellow
with kit 1
T. Metronidazole 400 mg 14 days
C. Doxycycline 100 mg BD 14 days
7 Inguinal Bubo T. Azithromycin 1 gm Stat All partners Black
for past 3 weeks
C. Doxycycline 100 mg BD 21 days
(c) Stages of Syphilis.
Both congenital and acquired syphilis are divided into early and late stages. Early acquired syphilis is further
subdivided into an incubation period, primary, secondary and early latent stages. The following types and
stages are recognized:-
(i) Acquired Syphilis.
(aa) Early Syphilis (diagnosed in first two years of infection).
O Primary stage
O Secondary stage
O Recurrent stage
O Early latent stage
(ab) Late Syphilis (diagnosed after the second year of infection).
O Late latent stage
O Late Benign stage (gumma)
O Cardiovascular Syphilis
O Central Nervous System Syphilis
(ii) Congenital Syphilis.
(Since T. pallidum is introduced directly into the foetal circulation, there is no primary stage as seen in
acquired syphilis)

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 CONTACT DISEASES (INCLUDING STIs)

(aa) Early Phase (within the first two years of life) Analogous to the secondary stage of acquired
syphilis.
(ab) Late Phase (after two years of age) Analogous to the tertiary stage of acquired syphilis.
(ac) Stigmata-scars and deformities resulting from early or late lesions which have healed.
(d) Pathogenesis.
T. pallidum enters the body through a break in squamous or columnar epithelium during sexual contact. The
incubation period has a mean of 21 days with extremes of 10 to 90 days. Variation in expression of disease
reflect differences in the immune status of the hosts.
(e) Clinical Features.
(i) Primary Syphilis.
The first clinical manifestation is usually a local lesion at the site of entry. The lesion starts as dull red
macule, which rapidly becomes papular and then ulcerate. A small, clean, painless, hard ulcer (Hunterian
chancre) appears on the site. The early chancre has a clear red base, but later covers with a gray slough.
Untreated, a chancre will persist for 3 to 6 wks and then heal. Regional lymphadenopathy develops within
a week and the nodes are painless, nontender, small to moderate in size, rubbery and nonsuppurative.
(ii) Secondary Syphilis.
T. pallidum disseminate widely throughout the body. After 3-6 weeks, the disease is seen to be systemic.
The more common symptoms include sore throat, malaise, headache, weight loss, fever, musculoskeletal
pains. A rash of early secondary stage appears on the back, chest, abdomen, arms and thighs and also
on the mucous patches in the mouth. Rash characteristically includes the palms and the soles. Rashes
can be of follicular, annular or papular type. Papular rashes may become large and raised and may
resemble viral warts, but they are characteristically broad and flat so called Condylomata lata. Generalised
lympadenopathy is common with moderately enlarged nodes rubbery, discrete and nontender. Even the
rash may subside with a little treatment but infective relapses occur with varying intervals of latent
periods.
(iii) Tertiary Syphilis.
Involvement of other systems occurs in 10 percent of cases or less. After 3 to 4 years, the benign
manifestations as gumma in bones, deeper parts of the skin, muscles or liver make their appearance.
After about 5-10 years or upto even 20 years, the vital organs like the brain, heart, nerves and big arteries
are affected and the severe signs of cardiovascular and neuro-syphilis may appear. The predominant
features of cardiac syphilis are aortic regurgitation, aortic aneurysm, arrhythmias and angina. The
neurosyphilis can present in a variety of ways; meningovascular syphilis, tabes dorsalis and general
paresis.
(iv) The Classification of Neurosyphilis is -
(aa) Asyptomatic neurosyphilis
(ab) Meningeal neurosyphilis
(ac) Meningovascular neurosyphilis
(ad) Parenchymatous neurosyphilis
(ae) Gummatous neurosyphilis.
(f) HIV infection and Neurosyphilis.
Conventional syphilis treatment often fails in HIV infected patients. Moreover HIV patients demonstrate
accelerated progression to early neurosyphilis. As a result of AIDS epidemic, neurosyphilis is becoming more
common in young adults. Spontaneous cure may occur at any time after the late secondary manifestations
subside or this latent phase may prolong throughout life. The disease is almost completely curable in the early
stages but becomes progressively resistant as it advances. Infected man infects other women perhaps including
his own wife during infective relapses. The disease is transmitted by the infected mother to the foetus after
the 4th intrauterine month. Some of them are still born; others die soon after birth. Those who survive may

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 COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

become crippled, blind, deaf and mentally subnormal called congenital syphilis.
(g) Diagnosis.
A presumptive diagnosis of syphilis requires use of two laboratory serologic tests: a nontreponemal test (i.e.,
Venereal Disease Research Laboratory [VDRL] or rapid plasma reagin [RPR] test) and a treponemal test (i.e.,
the T. pallidum passive particle agglutination [TP-PA] assay, various EIAs, chemiluminescence immunoassays
[CIAs] and immunoblots or rapid treponemal assays).
(h) Treatment.
Table 32.9 : Treatment Options for STIs
For Pregnant and
Disease First-line Options Effective Substitutes Breastfeeding Women and
People Younger Than 16 Years
Syphilis (early) Benzathine penicillin 2.4 Doxycycline 100 mg, orally, Benzathine penicillin 2.4
(treatment million units, intramuscularly twice a day for 14 days million units, intramuscularly in
for primary, in a single dose or a single dose
secondary and or
Erythromycin 500 mg, 4
early latent
times a day for 14 days Erythromycin 500 mg, orally, 4
[less than two
times a day for 14 days.
years since
infection]
syphilis)
Syphilis (late) Benzathine penicillin 2.4 Procaine penicillin 1.2 million Benzathine penicillin 2.4
(treatment million units by intramuscular units by intramuscular million units, intramuscularly in
for late latent injection, once weekly for 3 injection, once daily for a single dose
and tertiary consecutive weeks 20 consecutive days or or
syphilis). Doxycycline 100 mg, orally,
Erythromycin 500 mg, orally, 4
twice daily for 30 days
times a day for 14 days.
N. gonorrhoeae Ceftriaxone 250 mg, Cefixime 400 mg, orally, Ceftriaxone 250 mg,
intramuscularly, single dose single dose intramuscularly, single dose
Plus plus plus Azithromycin 1 gram,
orally, single dose
Azithromycin 1 gram, orally, Azithromycin 1 gram, orally,
single dose single dose or
Cefixime 400 mg, orally, two
doses plus Azithromycin 1
gram, orally, single dose
C. trachomatis Azithromycin 1 gram, orally, Erythromycin 500 mg, four Azithromycin 1 gram, orally,
single dose times daily for 7 days single dose
or (to be given only if or
Doxycycline 100 mg, orally, gonorrhoea therapy did not Erythromycin 500 mg, orally, 4
twice daily for 7 days include azithromycin) times a day for 7 days

32.23 Gonorrhoea.
(a) Epidemiology.
This is the commonest cause of urethritis in India. Gonorrhoea is caused by Neisseria gonorrhoeae, Gram
negative intracellular diplococcus, a bacteria that grows and multiplies quickly in moist, warm areas of the
body such as the cervix, urethra, mouth or rectum. In women, the cervix is the most common site of infection.
However, the disease can also spread to the uterus (womb) and fallopian tubes, causing pelvic inflammatory
disease leading to infertility.

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(b) Mode of Transmission.

Gonorrhoea is most commonly spread during genital contact, but can also be passed from the genitals of one
partner to the throat of the other during oral sex. Gonorrhoea of the rectum can occur in people who practice
anal intercourse. In pregnant women, gonorrhoea can be passed from an infected woman to her newborn
infant during delivery if left untreated.
Although transmission from males to females is easier, in females the infection is often mild and many women
who are infected have no visible symptoms of the disease. Most patients are males only. If symptoms of
gonorrhoea develop, they usually appear within 2 to 10 days after sexual contact with an infected partner,
although a small percentage of patients may be infected for several months without showing symptoms.
(c) Symptoms.
Table 32.10 : Symptoms for Gonorrhoea
Symptoms in Men Symptoms in Women
Burning sensation during urination Painful, burning sensation when urinating
Yellowish-white discharge from the penis that usually Yellowish or bloody discharge from the vagina
stains the undergarments. Bleeding between periods
(d) Diagnosis.
A diagnosis is made through detection of bacteria in samples taken from the urethra, cervix, throat or rectum.
The condition is treated with antibiotics and treatment should also be given to the patient’s partner. As with
Chlamydia, further testing is recommended once treatment has ended to check whether the infection has
cleared. The complications of Gonorrhoea are posterior urethritis, urethral stricture, cystitis, prostatitis, seminal
vesiculitis, epididymo-orchitis and urethral fistulae (watercan Perineum). It is generally more cost effective to
treat presumptive chlamydial infection also in all persons with gonorrhoea.

32.24 Chlamydia.
(a) Chlamydia is the most common and fastest spreading sexually transmitted disease. It stems from a
bacterium, Chlamydia trachomatis. One of the three species within the genus Chlamydia, is an important cause
of blindness and STD in humans.
(b) Women diagnosed with Chlamydia can also infect their newborn infant during delivery. Symptoms usually
appear approximately 7 to 21 days after infection and differ for men, women and children.
(c) Symptoms.
Table 32.11 : Symptoms for Chlamydia
Symptoms in Men Symptoms in Women Symptoms in Infants
Inflammation of the urethra (the Stinging feeling when passing water. Inflammation of the eye
bladder duct within the penis) Unusual vaginal discharge (conjunctivitis) at birth
Stinging feeling when passing water. Pain caused by pelvic inflammation Breathing Problems
Clear discharge from penis and (PID) Premature birth
possible itchiness around the Pain during intercourse In rare instances, pneumonia
opening
In some cases, bleeding between
Pain or tenderness in the testicles. periods

32.25 Herpes Genitalis (Genital Herpes).

(a) Agent.
Genital herpes is a highly contagious viral condition caused by the Herpes Simplex Virus (HSV).
(b) Mode of Transmission.
It principally infects the skin and mucous membranes of the genitals and rectum but can also appear in areas
such as the mouth. It is transmitted primarily through physical and sexual contact. During birth, the presence

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of herpes simplex virus on the genitalia or in the birth canal is a threat to the infant. Infection in the newborn
infant can lead to herpetic meningitis, herpetic viremia (herpes virus particles present in the blood) and chronic
skin infection.
(c) Symptoms.
The symptoms of herpes simplex virus usually occur a week after infection, but sometimes take longer to
appear. Initially, the skin becomes reddened and multiple small blisters filled with a clear, straw-coloured fluid
appear. Prior to the presence of blisters, the infected individual may also experience increased skin sensitivity,
tingling, burning or pain at the site where blisters will appear. Later, the blisters burst leaving shallow, painful
ulcers which eventually scab and heal over a period of 7 to 14 days.
(d) Treatment.
There is no cure for the herpes simplex virus; once infected, patients will remain a carrier for the rest of their
lives. Some remedies, however, can reduce the duration of the eruption. In addition, by being more aware
of the initial symptoms of recurrence (skin sensitivity and tingling), timely treatment with medication such as
Acyclovir will often abort the outbreak of blisters.
(e) Although the symptoms of genital herpes may not be present, it is important for those infected to inform
their partner that they have the disease. This will encourage both parties to use barrier protection (condoms)
to prevent the spread of the illness. Using condoms and not sharing towels are good ways of reducing the
chance of infection in the first place.

32.26 Genital Warts.

Warts or condylomata acuminata, are caused by the Human Papilloma Virus (HPV). Up to nine months can pass from
the time of infection to the actual development of warts. In women, Human Papilloma Virus can lead to changes in the
cervix and to the development of cervical cancer. Therefore, it is important that this condition is diagnosed and treated.
The common symptoms are raised, rough, wart-like growths that may occur singly or in clusters. In men, they are
usually found around the head of the penis. In women, they appear most often around the vaginal opening and may
spread to the rectal area. It is also possible for the virus to appear on or near the cervix as whitish, flat-like lesions,
usually only detectable through close visual examination of the cervix (colposcopy). In both men and women, lesions
may also be present in the mouth and throat. In general, symptoms can intensify if the immune system is weakened
or during pregnancy or if the person has diabetes. The warts are very contagious, so safe sex is advisable. A diagnosis
is made when a characteristic lesion is visible. By swabbing the skin with 5 per cent acetic acid, ‘invisible’ warts will
emerge as white-coloured patches.

32.27 Chancroid.
Chancroid is a sexually transmitted ulcerative disease often associated with an inguinal bubo. The causal organism
of chancroid is Haemophilus ducreyi. The incubation period ranges between 3 to 10 days. Men usually present with
ulcerative lesion or inguinal tenderness. The chancre begins with tender papule surrounded by erythema and within
2 to 3 days after the infection sloughing ulcer appears on the penis and goes on increasing until it affects a large
portion of the penis. Women often present with less obvious symptoms including pain in voiding, pain on defecation,
rectal bleeding, dyspareunia or vaginal discharge. Most lesions in males are on either the external or internal surface
of the prepuce, on the frenulum or in the coronal sulcus. In females, most lesions are at the entrance to the vagina
and include lesions on the fourchette, labia, vestibule and clitoris. Diagnosis of chancroid depends on the isolation
of H.ducreyi from a genital ulcer or bubo. Direct examination by a gram stain reveals gram negative organisms in a
‘school of fish’ pattern. It is best to confirm the diagnosis by culture. The patients of chancroid who are HIV positive are
more likely to have treatment failure. If both pathogens are present, they act synergistically with increased infectivity,
susceptibility and failure to respond to treatment. Chancroid is one of the major reason for the rapid heterosexual
spread of HIV -1 in eastern and southern Africa.

32.28 Policy regarding STDs in the Armed Forces.

Detailed methods of prevention and control of STDs in Armed Forces are given in recent instructions (AO 7 / 2020)
and Medical Officers are advised to refer to them. The responsibility of Cdrs / COs and AMA / RMO are:

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(a) Responsibilities of Cdrs / COs.

(i) The COs of units in consultation with RMO / AMA will be responsible for ensuring that various
preventive measures for STIs are being followed by all personnel.
(ii) To ensure maintenance and regular updation of the unit STI register.
(iii) To maintain a high level of discipline amongst unit personnel to ensure ‘Out of Bounds’ areas are
not frequented by tps.
(iv) To identify areas near cantonments with suspected commercial sexual activities / Red light Areas
and declare such areas as “Out of Bounds.
(v) To org regular interactive sessions and lectures through RT JCOs / Counsellors to educate and
dissuade indls from immoral activities.
(vi) To provide adequate recreational facilities for all personnel.
(b) Responsibilities of RMO / AMA. The RMO / AMA of the unit is also responsible for the following:
(i) Perusal, dating and signing the Unit STI Register and advising the OC unit, where necessary.
(ii) Taking custody of all AFMSF-6 on behalf of OC Unit and maintaining records on them.
(iii) Ensuring that all individuals attending Sexually Transmitted Infections Treatment Centre (STITC)
during review take their AFMSF-6 with them.
(iv) Informing the STITC responsible for surveillance when a patient has been struck off the strength
of the unit. Details of new location of the individual will also be communicated to the NEW STITC who
will take responsibility for individual’s further treatment / surveillance.
(v) Ensure action taken as per para 23 of AO 7 / 2020 when soldier whose name is on the unit STI
Register is released / discharged from the service before completion of surveillance.
(c) Preventive Measures.
This includes the primary preventive measures, the secondary preventive (or control) measures and the
administrative measures which support them. Prevention is achieved by inhibiting promiscuous tendencies
amongst Armed Forces personnel. The extent of promiscuity depends upon the following factors:
(i) The availability to brothels / prostitutes in the locality.
(ii) Manner in which the energies of Armed Forces personnel are used during their leisure period.
(iii) The higher the education the greater the possibility of diverting energies to creative healthy
pursuits; education also disuades them from promiscuity or persuades them to use prophylactics.
(d) Primary Prevention.
(i) Provide alternative healthy diversions, incentives and facilities for education and betterment in
careers and providing a healthy psychological atmosphere for a tranquil regimental life. Excellent facilities
should be provided for indoor and outdoor recreation, organized games, educational and recreational
outings, amateur dramas and concerts.
(ii) Man-management should be of a high standard. Grant of full entitled leave should be ensured
and regular letters are some remedies.
(iii) Develop good Officer-men relationship in the units.
(iv) The officers and JCOs should themselves set an example by always maintaining a high moral and
ethical standard. The education officer, the welfare officer and the religious teacher should keep the
social, religious, ethical and the moral virtues before the service personnel.
(v) Health education should be carried out through lectures, multimedia, flip charts, group or individual
discussions and articles in the periodicals read by service personnel. These lectures should follow the
general patterns as under.
(aa) Lectures should bring out all the scientifically accurate facts clearly, briefly, with simplicity

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and without ambiguity.

(ab) Salient features and the possible after effects on self, wife and children on the transmission
of infection to them in respect of these important diseases should first be brought out in simple
language without exaggeration.
(ac) The necessity for self control from promiscuous habits should be emphasized.
(ad) Use of prophylactic means to avoid STD if an exposure does occur should be explained.
(ae) Treatment from the Armed Forces Medical Services and faithful observance of surveillance
should be emphasized.
(e) Secondary Prevention.
As a practical consideration, main objectives should be to reduce opportunities for promiscuity by administrative
measures and acquaint them with hazards of STD and methods of avoiding contraction by use of prophylactics.
Use of condoms during coitus is the simplest prophylactic method. It should be made easily available in MI
Room / RAP.
(f) Administrative Measures.
Following administrative measures must be adopted to augment the measures described above:
(i) All known and suspected areas in the cantonment habited by prostitutes should be placed ‘out
of bounds’ to all ranks and watched by the military police.
(ii) Personnel should be warned on roll calls and through unit part I order repeatedly against
promiscuity, concealment of STD and about the places and areas placed ‘out of bounds’. Contravention
of these orders then becomes a military offence in accordance with paras 351 and 352 of the DSR.
(iii) A epidemiological investigation of cases enables location of infective foci in the towns or locality.
(iv) Regular six monthly medical examinations and special inspection before proceeding on and after
reporting from leave, temporary duty and courses of instructions and for permanent duty should be
carried out. Regular periodical anti-STD lectures and supply of condoms should be arranged.
(v) One who has contracted STD should be immediately admitted to hospital.
(g) Surveillance and Disposal.
(i) Non-Syphilis STIs.
Service personnel detected to have non syphilis STIs will be kept under surveillance for 12 weeks.
After 12 weeks, the individual will be followed up with examination and relevant investigations including
VDRL with titres and HIV-ELISA. He will be placed in surveillance for a period of another 12 weeks. A
minimum of 24 weeks surveillance will be ensured for all cases. Those who continue to have persistent
lesion / sign / symptoms and lab investigations suggestive of STI, even after 24 weeks of surveillance, will
be further continued under 24 weekly surveillance till cure. The review during surveillance will be carried
out at the nearest STITC with latest blood VDRL and blood ELISA for HIV reports and other relevant
investigations. Surveillance will be stopped only once the individual is found cured with no signs and
symptoms of STI and normal lab investigation reports.
(ii) Syphilis.
All patients detected to be VDRL positive (with significant titres) confirmed by positive TPHA will be
placed in P 2 (T-24) followed by P 2 (Perm) with advice to report for review every six months (clinical
and investigations) or earlier in case of recurrence of lesions / symptoms. VDRL test with titres along
with HIV-ELISA and other relevant investigations will be done in every review. The indl will be followed
up in P 2 (Perm) till complete cure and will be upgraded to SHAPE-1 only if asymptomatic, without any
complications and a significant fall in titres. Any case developing complications / not showing cure will
be considered for invalidation from service.
(iii) Documents.
Post hospital surveillance must be carried out to ensure radical cure. All units should maintain a STD

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register compiled from the particulars given in AFMSF-(iv) The unit should ensure that the person reports
on due dates to RMO who should carry out the treatment or send him to hospital whichever is indicated.
The examination and treatment of his wife and if necessary, of the children should also be arranged.

32.29 Acquired Immunodeficiency Syndrome (AIDS).

(a) Introduction.
Acquired Immunodeficiency Syndrome (AIDS) is a potentially lethal sexually transmitted disease and is caused
by the HIV virus. AIDS is a severe life threatening clinical condition first recognized as a clinical syndrome in
1981. This syndrome represents the late clinical stage of infection with the human immunodeficiency virus
(HIV), which most often results in progressive damage to the immune and other organ systems, including the
CNS. This means that a person who carries the HIV virus is prone to many different illnesses and may die
from diseases that are harmless to healthy people.
AIDS is still most widespread in sub Saharan Africa, Asia and the Caribbean islands and is more common
among homosexual and bisexual men. However, in more developed countries the disease is becoming more
frequent among heterosexuals, especially young people. In the UK, new cases of HIV are now more prevalent
among heterosexuals. Intravenous drug users and people with many different partners are particularly at risk
from HIV.
(b) Global Occurrence.
Promising developments have been made in prevention and control of HIV / AIDS in recent years. Global efforts
to address the AIDS epidemic, including increased access to effective treatment and prevention programmes
have been commendable. Since the beginning of the epidemic, 85.6 million [65.0–113.0 million] people have
been infected with the HIV virus and about 40.4 million [32.9–51.3 million] people have died of HIV.
(i) Number of People with HIV.
Globally, 39.0 million [33.1–45.7 million] people were living with HIV at the end of 2022. An estimated
0.7% [0.6-0.8%] of adults aged 15–49 years worldwide are living with HIV, although the burden of the
epidemic continues to vary considerably between countries and regions. Out of 39 million, 37.5 million
were adults and 1.5 million were children (<15 years old). In addition, 53% were women and girls.
The WHO African Region remains most severely affected, with nearly 1 in every 25 adults (3.2%) living
with HIV and accounting for more than two-thirds of the people living with HIV worldwide.
(ii) New HIV Infections.
An estimated 1.3 million individuals worldwide acquired HIV in 2022, marking a 38% decline in new HIV
infections since 2010 and 59% since the peak in 1995. New HIV infections or “HIV incidence,” refers
to the estimated number of people who newly acquired HIV during a given period such as a year, which
is different from the number of people diagnosed with HIV during a year. (Some people may have HIV
but not know it.) Women and girls accounted for 46% of all new HIV infections in 2022.
(c) National Occurrence.
As per Sankalak booklet 2023, India is estimated to have around 24.67 lakh (20.84-29.52 lakh) people living
with HIV (PLHIV) in 2022 out of which 23.99 lakh (20.29-28.70) are 15+ and 10.86 lakh (9.19-12.94) women
(15+ years). With an adult (15-49 years) prevalence of 0.20% (0.17-0.25%) out of which 0.22% (0.18-0.27)
among men and 0.19% (0.16-0.23) among women, India has Annual new HIV infections of 66.41 thousand
(41.51-106.94) cases. India has the second largest HIV epidemic in the world, accounting for around 6.3% of all
PLHIV worldwide, with an estimated 3.9 crores HIV cases worldwide and 65 lakh cases in Asia and the Pacific
(UNAIDS 2023 Estimates). In terms of adult HIV prevalence, the global HIV prevalence (0.70%, 0.60-0.80%) is 3.5
times that of national prevalence in India. After attaining a peak in year 2000, the HIV epidemic size started to
decline. The decline in the size of the epidemic continued till 2015-18 and has been almost stable since then.
(d) Epidemiology.
(i) Infectious Agent.
(aa) HIV is a Retrovirus belongs to a class of viruses called retroviruses. Two types have been
identified type 1 (HIV-1) and type 2 (HIV2). Retroviruses are RNA (ribonucleic acid) viruses and in

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order to replicate (duplicate) they must make a DNA (deoxyribonucleic acid) copy of their RNA. It
is the DNA genes that allow the virus to replicate. Like all viruses, HIV can replicate only inside
cells, commandeering the cell’s machinery to reproduce. Only HIV and other retroviruses, however,
once inside a cell, use an enzyme called reverse transcriptase to convert their RNA into DNA,
which can be incorporated into the host cell’s genes.
(ab) Slow Viruses.
HIV belongs to a subgroup of retroviruses known as lentivirus or “slow” viruses. The course of
infection with these viruses is characterized by a long interval between initial infection and the
onset of serious symptoms.
(ii) Structure of HIV.
(aa) The Viral Envelope.
HIV has a diameter of 1 / 10,000
of a millimeter and is spherical
in shape. The outer coat of
the virus, known as the viral
envelope, is composed of two
layers of fatty molecules called
lipids, taken from the membrane
of a human cell when a newly
formed virus particle buds from
the cell. Embedded in the viral
envelope are proteins from the
host cell, as well as 72 copies (on
average) of a complex HIV protein
(frequently called “spikes”) that
protrudes through the surface
of the virus particle (virion). This Fig 32.3 : Organization of HIV-1 Virion
protein, known as Env, consists
of a cap made of three molecules called glycoprotein (gp) 120 and a stem consisting of three
gp41 molecules that anchor the structure in the viral envelope.
(ab) The Viral Core.
Within the envelope of a mature HIV particle is a bulletshaped core or capsid, made of 2,000
copies of another viral protein, p24. The capsid surrounds two single strands of HIV RNA, each
of which has a copy of the virus’s nine genes. Three of these genes, gag, pol and env, contain
information needed to make structural proteins for new virus particles. Six regulatory genes, tat,
rev, nef, vif, vpr and vpu, contain information necessary to produce proteins that control the ability
of HIV to infect a cell, produce new copies of virus or cause disease.
In the cytoplasm of the cell, HIV reverse transcriptase converts viral RNA into DNA, the nucleic
acid form in which the cell carries its genes. The newly made HIV DNA moves to the cell’s nucleus,
where it is spliced into the host’s DNA with the help of HIV integrase. HIV DNA that enters the
DNA of the cell is called a provirus. For a provirus to produce new viruses, RNA copies must be
made that can be read by the host cell’s protein. Three enzymes carry out steps in the virus’s
life cycle: reverse transcriptase, integrase and protease.
(iii) Replication Cycle of HIV.
(aa) Entry of HIV into Cells.
O Infection typically begins when an HIV particle, which contains two copies of the HIV
RNA, encounters a cell with a surface molecule called Cluster Designation 4 (CD4). Cells
carrying this molecule are known as CD4+ cells. One or more of the virus’s molecules
binds tightly to CD4 molecule(s) and co-receptor molecules on cell surface which lead to
entry of the virus into the cell.

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O The gp41 of the envelope is critical to the fusion process. Although CD4+ T cells
appear to be the main targets of HIV, other immune system cells with and without CD4
molecules on their surfaces are infected as well.
O Among these are long-lived cells called monocytes and macrophages, which
apparently can harbour large quantities of the virus without being killed, thus acting as
reservoirs of HIV.
(ab) Reverse Transcription.
In the cytoplasm of the cell, HIV reverse transcriptase converts viral RNA into DNA, the nucleic
acid form in which the cell carries its genes.
(ac) Integration.
The newly made HIV DNA moves to the cell’s nucleus, where it is spliced into the host’s DNA with
the help of HIV integrase. HIV DNA that enters the DNA of the cell is called a provirus.
(ad) Transcription.
For a provirus to produce new viruses, RNA copies must be made that can be read by the host
cell’s protein-making machinery. These copies are called messenger RNA (mRNA) and production
of mRNA is called transcription, a process that involves the host cell’s own enzymes.
(ae) Translation.
After HIV mRNA is processed in the cell’s nucleus, it is transported to the cytoplasm. In the
cytoplasm, the virus co-opts the cell’s protein-making machinery-including structures called
ribosomes-to make long chains of viral proteins and enzymes, using HIV mRNA as a template.
This process is called translation.
(af) Assembly and Budding.
Newly made HIV core proteins, enzymes and genomic RNA gather inside the cell and an immature
viral particle forms and buds off from the cell, acquiring an envelope that includes both cellular
and HIV proteins from the cell membrane. During this part of the viral life cycle, the core of the
virus is immature and the virus is not yet infectious. The long chains of proteins and enzymes
that make up the immature viral core are now cut into smaller pieces by a viral enzyme called
protease.
(iv) Reservoir.
Humans

(v) Transmission.
(aa) How HIV is and is not Transmitted.
HIV is a fragile virus. It cannot live for very long outside the body. As a result, the virus is not
transmitted through day to-day activities such as shaking hands, hugging or a casual kiss. You
cannot become infected from a toilet seat, drinking fountain, doorknob, dishes, drinking glasses,
food or pets. You also cannot get HIV from mosquitoes.
(ab) Mode of Transmission.
HIV can be transmitted from person to person through:
O Sexual contact
O Sharing of HIV contaminated needles and syringe
O Transfusion of infected blood or its components.
O Vertical transmission (i.e. from infected mother to foetus)
(From 15% to 30% infants born to HIV-infected mothers are infected before, during or shortly after
birth; treatment of pregnant women results in marked reduction in infant infections).

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Fig 32.4 : HIV Replication Cycle

(ac) Transmission of HIV.
Among adults, HIV is spread most commonly during sexual intercourse with an infected partner.
During intercourse, the virus can enter the body through the mucosal linings of the vagina, vulva,
penis or rectum or rarely via the mouth and possibly the upper gastrointestinal tract after oral sex.
The likelihood of transmission is increased by factors that may damage these linings, especially
other sexually transmitted infections that cause ulcers or inflammation. Research suggests that
immune system cells of the dendritic cell type, which live in the mucosa, may begin the infection
process after sexual exposure by binding to and carrying the virus from the site of infection to
the lymph nodes where other immune system cells become infected. A molecule on the surface
of dendritic cells, DC-SIGN, may be critical for this transmission process.

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(ad) Factors Increasing the Risk of Acquisition of HIV.

Table 32.12 : Factors Increasing the Risk of Acquisition of HIV
Common to All Transmission Categories IV Drug Use
High Viral Load Sharing equipment
Lower CD4 cell count Intravenous use
AIDS Frequency of use
Seroconversion Cocaine use
Linked Commercial sex
Vertical Transmission Incarceration
Lower income
Older gestational age
Vaginal vs elective caesarean
Occupational Transmission
Prolonged rupture of membranes
No peripartum prophylaxis Deep injury
Chorioamnionitis Previous arterial or venous siting
First born twin Visible blood on device
Lower birth weight

Breast Feeding
Longer duration feeding
Younger age
Lower parity
Mastitis

Sexual transmission
STI’s especially genital ulcers
Male to male vs heterosexual sex
Cervical ectopy
Non circumcised
Receptive vs insertive anal sex
Increased no of partners
Rectal or vaginal trauma
Menstruation
(vi) Theories of Immune System Cell Loss in HIV Infection.
How HIV destroys or disables CD4+ T cells and that a number of mechanisms may occur simultaneously in
an HIV-infected person. Data suggest that billions of CD4+ T cells may be destroyed every day, eventually
overwhelming the immune system’s capacity to regenerate.
(aa) Direct Cell Killing.
Infected CD4+ T cells may be killed directly when large amounts of virus are produced and bud
out from the cell surface, disrupting the cell membrane or when viral proteins and nucleic acids
collect inside the cell, interfering with cellular machinery.
(ab) Apoptosis.
Infected CD4+ T cells may be killed when the regulation of cell function is distorted by HIV proteins,
probably leading to cell suicide by a process known as programmed cell death or apoptosis.

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 COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

(ac) Innocent Bystanders.

Uninfected cells may die in an innocent bystander scenario: HIV particles may bind to the cell
surface, giving them the appearance of an infected cell and marking them for destruction by killer
T cells after antibody attaches to the viral particle on the cell. This process is called antibody-
dependent cellular cytotoxicity.
(ad) Anergy.
Researchers have shown in cell cultures that CD4+ T cells can be turned off by activation signals
from HIV that leaves them unable to respond to further immune stimulation. This inactivated state
is known as anergy.
(ae) Damage to Precursor Cells.
Studies suggest that HIV also destroys precursor cells that mature to have special immune
functions as well as the microenvironment of the bone marrow and the thymus. Studies suggest
that HIV also destroys precursor cells that mature to have special immune functions as well as
the microenvironment of the bone marrow and the thymus.
(vii) Incubation Period.
It is widely variable although the time from infection to the development of detectable antibodies is
generally 1-3 months, the time from HIV infection to diagnosis of AIDS has an observed range of less
than 1 year to 10 years or more.
(e) Course of HIV Infection.
Among people enrolled in large epidemiologic studies in Western countries, the median time from infection with
HIV to the development of AIDS-related symptoms has been approximately 10 to 12 years in the absence of
antiretroviral therapy. However, there is a wide variation in disease progression. Approximately 10 percent of
HIV infected people in these studies have progressed to AIDS within the first 2 to 3 years following infection,
while up to 5 percent of individuals in the studies have stable CD4+ T cell counts and no symptoms even
after 12 or more years.
(i) Clinical Features.
For the purpose of AIDS surveillance an adult or adolescent (>12 years of age) is considered to have
AIDS if at least 2 of the following major signs are present in combination with at least 1 of the minor
signs listed below and if these signs are not known to be due to a condition unrelated to HIV infection.
Table 32.13 : Major and Minor Symptoms of HIV
Major Signs Minor Signs
Weight loss > or = 10% of body weight Persistent cough for more than 1 month
Chronic diarrhoea for more than 1 month Generalized pruritic dermatitis
Prolonged fever for more than 1 month History of herpes zoster
(intermittent or constant) Oropharyngeal candidiasis
Chronic progressive or disseminated Herpes simplex infection
Generalized lymphadenopathy
(ii) Cohort studies of HIV infected adults indicate that about 15%-20% develop AIDS within 5 years,
about 50% within 7-10 years and close to 70% within 15 years. The case fatality of AIDS is very high
and most patients (80-90%) die within 3-5 years after the diagnosis of AIDS is made.
(iii) WHO Clinical Stages. WHO has defined HIV / AIDS into 4 Clinical stages.

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Table 32.14 : WHO Classification of Clinical Stages for HIV / AIDS

Stage 1 Stage 2 Stage 3 Stage 4
Asymptomatic Mild Disease Moderate Disease Severe Disease (AIDS)
No symptoms Wt. loss 5-10% Wt. loss >10% HIV wasting syndrome
Sore or cracks around the lip Oral thrush Esophageal thrush
Or only persistent Seborrhea Oral hairy More than 1 month : Herpes
simplex ulceration
generalized Prurigo Leukoplakia
Lymphoma
lymphadenopathy Herpes zoster More than 1 month
Kaposi sarcoma
Recurrent URTI O Diarrhea
Invasive cervicalcancer
Recurrent mouth ulcer O Unexplained fever
Pneumocystic pneumonia
O Severe bacterial infection
Extrapulmonary TB
O Pneumonia
Cryptococcal meningitis
O Muscle infection
Toxoplasma brain abscess
Pulmonary TB
Visceral leishmaniasis
TB lymphadenopathy
HIV encephalopathy
Acute necrotizing ulcerative
gingivitis
HIV : Human Immunodeficiency Virus, AIDS : Acquired Immunodeficiency Syndrome
(f) Events in HIV Infection.
(i) Once it enters the body, HIV infects a large number of CD4+ cells and replicates rapidly. During
this acute or primary phase of infection, the blood contains many viral particles that spread throughout
the body, seeding various organs, particularly the lymphoid organs.
(ii) Two to four weeks after exposure to the virus, up to 70 percent of HIV-infected people suffer flu-
like symptoms related to the acute infection. Their immune system fights back with killer T cells (CD8+
T cells) and B-cell-produced antibodies, which dramatically reduce HIV levels. A person’s CD4+ T cell
count may rebound somewhat and even approach its original level. A person may then remain free of
HIV-related symptoms for years despite continuous replication of HIV in the lymphoid organs that had
been seeded during the acute phase of infection.
(iii) One reason that HIV is unique is the fact that despite the body’s aggressive immune responses,
which are sufficient to clear most viral infections, some HIV invariably escapes. This is due in large part
to the high rate of mutations that occur during the process of HIV replication. Finally, the virus may hide
within the chromosomes of an infected cell and be shielded from surveillance by the immune system.
Such cells can be considered as a latent reservoir of the virus. Because the antiviral agents currently
in our therapeutic arsenal attack actively replicating virus, they are not effective against hidden, inactive
viral DNA (so-called provirus).
(g) Period of Communicability.
Presumed to begin early after onset of HIV infection and extend throughout life. Infectiousness increases with
increasing immune deficiency, clinical symptoms and other STDs. Recent studies indicate that it may be high
during initial period after HIV infection. However, patients on ART are less likely to transmit HIV infection to others.
(h) Testing.
Currently, the diagnosis and monitoring of HIV infection is performed on blood specimens. Generally, for
serological tests (antigen and antibody detection) serum / plasma / whole blood is used, whereas for CD4
enumeration tests only whole blood collected in K2 / K3 ethylene diamine tetra acetic acid (EDTA) evacuated
tubes is used. For DNA / RNA PCR, Dried Blood Spots (DBS) or whole blood collected in K2 / K3 EDTA is used.

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 COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

Laboratory diagnosis
in Adults and
children >18 months

Detection of antibodies to Detection of virus or

HIV-1 and or 2 viral products

P24 antigen
Rapid tests
detection

DNA PCR
ELISA for viral
nucleic acid

Western Blot

Fig 32.5 : Tests Used for HIV Diagnosis in Individuals above 18 Months of Age
(i) Screening Tests.
Serological tests for the detection of HIV are classified as first to fourth generation tests based on the
type of antigens used and principle of the assay.
(aa) Generation of Anti-HIV Antibody Tests.
Table 32.15 : Generation of Anti-HIV Antibody Tests
Generation Antigens / Antibodies Comment / Characteristic
First Antigens from HIV lysates Lack of sensitivity and specificity
Second Recombinant proteins and / or synthetic peptides Improved sensitivity
Third Recombinant proteins and / or synthetic peptides in Very high sensitivity and able to detect
an antigen sandwich configuration IgM antibody in addition to IgG antibody;
reduces the window period considerably.
Detects HIV-1 and HIV-2 simultaneously.
Fourth Detection of both HIV antigen (p24) and both Further reducing the window period
antibodies, IgG and IgM

(ab) Commonly Used Screening Tests.

Enzyme Linked Immunosorbent Assay (ELISA)
Rapid tests-
O Immunoconcentration / Dot Blot assay (vertical flow)
O Agglutination assay
O Immunochromatographic assay (lateral flow)
O Dipstick and comb assay based on Enzyme Immune Assay (EIA)

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 CONTACT DISEASES (INCLUDING STIs)

(ii) HIV Testing Strategies.

The various strategies, so designated, involve the use of categories of tests in various permutations and
combinations based on:
(aa) ELISA / Rapid tests (E / R) used in strategy I, II, & Ill
(ab) Confirmatory tests with high specificity, like WBs and line immunoassays, are used in
problem cases, e.g., in cases of indeterminate / discordant result of E / R.
(iii) Strategy 1 (For Blood Transfusion / Transplant Safety).

(For transfusion / transplant safety)

One test required
A1

A1+ A1–
Consider Positive Consider Positive

Fig 32.6 : Strategy 1 for Blood Transfusion / Transplant Safety

(iv) Strategy 2 A (Used in Sentinel Surveillance)

(For surveillance)
2 tests required
1
A1

A1+ A1-
Report negative

A21

A1+ A2+ A1+ A2-

Report positive Report negative

Fig 32.7 : Strategy 2A for Sentinel Surveillance

1. Assays A1, A2, A3 represent 3 different assays based on different principles or different antigenic compositions.
Assay A1 should be of high sensitivity and A2 and A3 should be of high specificity. A2 & A3 should also be able to
differentiate between HIV 1 & 2 infection. Such a result is not adequate for diagnostic purposes: use strategies 2B
or 3.
2. Whatever the final diagnosis, donations, which were initially reactive should not be used for transfusions or
transplants. Refer to ICTC after informed consent for confirmation of HIV status.
3. Testing should be repeated on a second specimen taken after 14-28 days. In case the serological results
continue to be indeterminate, then the specimen is to be subjected to a WB / PCR if facilities are available or refer
to the NRL for further testing.

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COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

(v) Strategy 2 B (Used For Diagnosis in Symptomatic Patients)

(Diagnosis of an individual with AIDS indicator disease symptoms)

1
A1

A1+ A1-
Report negative

A21

A1+ A2+ A1+ A2+

Report positive
with post test counseling
A31

A1+ A2-A3+ A1+ A2-A3-

Indeterminate Report negative

Fig 32.8 : Strategy 2B for Symptomatic Patients

(vi) Strategy 3 (Used For Diagnosis in Asymptomatic Patients)

(To detect HIV infection in asymptomatic individuals (ICTC’s, PPTCTC’s)

3 tests required
1
A1

A1+ A1–
Report negative

A21

A1+ A2+ A1+ A2+

A31 A31

A1+ A2+ A3+ A1+ A2+ A3+ A1+ A2– A3+ A1+ A2– A3–
Report positive Indeterminate Indeterminate
with post-test
High risk Low risk
counseling consider consider
indeterminate Negative

Fig 32.9 : Strategy 3 for Asymptomatic Patients

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 CONTACT DISEASES (INCLUDING STIs)

(j) Monitoring.
The laboratory tests currently available for monitoring the stage and progression of HIV infection can be
classified into:
(i) Immunologic tests - CD4 T cell enumeration
(ii) Virological assays –
(aa) HIV RNA load assays
(ab) Other Assays - Measurement of HIV p24, Reverse Transcriptase (RT) activity assay
(k) Counselling - Any HIV testing should be accompanied by proper pre and post-test counselling.
Table 32.16 : Pre-Test and Post-Test Counselling
Pre-test counselling Post test counselling.
Provide information on HIV and AIDS. Test Result Negative
Explain the benefits of HIV testing. An explanation of the test result.
Assure the individual that the test Risk education counselling, condom demonstration and provision of
result and any information shared will condoms.
be kept confidential.
Emphasis on the importance of knowing the status of sexual partner(s)
Explain that the individual has the and information about the availability of partner and couples testing and
right to opt out of HIV testing and counselling services.
this will not affect their access to any
Information about the window period and retesting (Retesting is needed
other health-related services.
only for HIV-non-reactive individuals who report recent or on-going risk of
Obtain informed consent and exposure).
document it in the relevant register.
An opportunity for additional counselling of the individual, clarification on
Carry out a risk assessment of the myths and misconceptions.
individual.
Information on genital, menstrual and sexual hygiene.
Provide information on genital,
Linkages to tuberculosis (TB), sexually transmitted infection (STI),
menstrual and sexual hygiene.
antenatal care (ANC), TI, etc
Demonstrate the use of a condom
using a model.
Test Result Positive
Provide information on spouse/sexual
partner testing. This is only a screening test for HIV.
Conduct symptomatic screening for With this result, it is not possible to confirm the HIV status.
STI/RTI. Explain the need for confirmation of HIV diagnosis at an SA-ICTC.
Conduct verbal screening (4 Symptom Explain the process followed at the SA-ICTC for test confirmation.
Screening) for tuberculosis (TB), use
Fill the linkage form and provide directions for reaching the nearest
10-point Counselling Tool for TB.
SA-ICTC.
Extend the opportunity to the
Provide risk education, counselling, condom demonstration and provision
individual to ask and clarify doubts.
of condoms.
The information may be delivered in
Provide information on genital, menstrual and sexual hygiene.
a local language and tailored to the
specific audience. Emphasize the importance of knowing the status of the sexual partner(s)
and provide information about the availability of partner and couples
testing and counselling services.
Provide an opportunity to the individual for additional counselling,
clarification of myths and misconceptions.
Provide linkages to facility providing TB, STI, ANC services etc. as applicable.
(l) Treatment.
ARV drugs used in first-line ART regimens for adults and adolescents in the national ART programme in India
are Zidovudine (AZT), Tenofovir (TDF), Abacavir (ABC), Lamivudine (3TC), Efavirenz (EFV) and Nevirapine (NVP).
The preferred first line ART regimen for all PLHIV with age >10 years and weight >30Kg is TLD therapy which

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consists of Tenofovir 300 mg, Lamivudine 300 mg, Dolutegravir 50 mg, Fixed-Dose Combination in a single pill
once daily (at a fixed time every day as per patient’s convenience). These drugs are associated with toxicities,
which may be class specific and / or drug specific.
Table 32.17 : First Line ARV Drugs Toxicities

First-line ARV drugs toxicities

NsRTI
Integrase inhibitor NNRTIs
Zidovudine, NtRTI
Dolutegravir, Efavirenz.
Stavudine, Tenofovir
Raltegravir Nevirapine
Lamivudine

Mitochondrial toxicities Weight gain Skin rash Hepatitis

• Lactic acidosis Nephrotoxicity Hepatotoxicity Central nervous system
• Pancreatitis Allergic reaction (CNS) manifestations
• Lipodystrophy
• Hepatic steatosis
• Peripheral neuropathy
• Anaemia
• Myopathy

(m) Prevention and Control.

Medical officers may note that the various details regarding epidemiology, transmission, prevention, control
and various policy / medical administrative matters are given in the compilation Handbook on HIV / AIDS for
Medical, Dental and Nursing Officers. These handbooks have been distributed by Armed Forces AIDS Control
Organisation (ACO) to all the IEC nodes. The various strategies of HIV / AIDS prevention include:
(i) Information, Education and Communication (IEC).
(aa) IEC should promote:
O Delay in first sexual encounter (targeting adolescents and young adults).
O Reduction in number of sexual partners (ideally mutually monogamous relationship).
O Increase in use of condoms.
(ab) In the Armed Forces, research, training, planning and development of IEC materials are
carried out at the AIDS Control Organization (ACO) located at the Dept of Community Medicine,
AFMC Pune-40. IEC materials are produced in bulk by ACO for dissemination to the IEC nodes
(located at Station Health Organizations) in the form of:
O Books
O Posters
O CD-ROMs
O Video cassettes
O Flip charts
(ii) Station Health Organizations (SHO’s) with additional inputs from ACO are carrying out IEC activities
in their respective stations. The activities include:

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(aa) Advocacy at level of Commanders,

(ab) Health education of all ranks / families,
(ac) Peer group training to influence safe peer behaviour, etc.
Monitoring and evaluation of these activities are carried out by periodic review of relevant indicators
besides repeated behavioural surveys particularly on three core areas i.e. age of first sexual encounter,
number of sexual partners and prevalence of condom use.
(n) Prevention of Blood-borne HIV Transmission.
All blood should be screened for HIV before transfusion. Strict sterilization practices should be ensured in
hospitals and clinics. Autoclaved syringes and needles and other instruments should be used. Sharing of
needles among drug addicts should be eliminated by health education.
(o) Antiretroviral Treatment and Specific Prophylaxis.
The prohibitive cost precludes the use of antiretroviral drugs on a mass scale in management of HIV infection
in developing countries. Its use at present is limited to prevent perinatal transmission and for post exposure
prophylaxis in cases of occupational exposure of Health Care Worker (HCW). Primary prophylaxis against P.
carinii pneumonia is indicated when CD4 count falls below 200 cells per cu mm. The regimens available are
Trimethoprim Sulphamethoxazole, Aerosolized Pentamidine and Dapsone.
(p) Blood Safety, Licensing of Blood Banks and Exemption from Licensing under Certain Conditions.
All blood banks in Armed Forces will transfuse blood only after it has been tested and found negative for HIV
1 & 2, HBsAG, Malaria, Syphilis and other tests as specified in the current edition of Indian Pharmacopeia
as well as consistent with the National Blood Policy. All blood banks of Armed forces should therefore obtain
the necessary license. An exemption has been given by Govt of India in respect of centres of Armed Forces
Medical Service in border areas, small mid zonal hospitals including peripheral hospitals, Field Hospitals, Mobile
Medical Units and other field medical units including blood supply units in border / sensitive / field areas. The
exemption from license in respect of above establishments is, however, subject to the condition that these
centres shall collect, process and transfuse blood only in life saving emergency situations; they will be under
the supervision of a qualified Medical Officer as per specifications and that they will undertake all the tests
(HIV-1 and 2 / HBsAg / Malaria / Syphilis / others as specified). Concerned Medical Officers are advised to
acquaint themselves with the provisions of aforementioned Govt of India Gazette.

32.30 Policy And Procedures on Testing, Notification and Surveillance of HIV Infection in The Armed Forces
The policy and procedures are contained in Office of the DGAFMS letters No 76896 / HIV Policy / DGAFMS / DG-3A dt
08 Mar 2019 and 5496 / HIV Policy / DGAFMS / DG-3A dt 04 May 2022.
(a) Immunosurveillance: Coordination and Control.
The AIDS Control Programme (ACP) under the overall guidance of ACO will be implemented in a three-tier
system to facilitate optimal patient care and utilization of available resources. This will ensure comprehensive
management, documentation, surveillance and referral for AIDS cases. The three-tier system will comprise the
following:
(i) Apex Immunodeficiency Centres (AIDC).
These will function as referral, research and training centres with a view to provide upgraded diagnostic
modalities and therapeutic interventions. The AIDCs will be located at following locations:
(aa) AFMC / CH (SC) Pune.
(ab) Base Hospital Delhi Cantt.
(ii) Immunodeficiency Centres (IDC).
The following IDCs will continue to function as hitherto fore and be responsible for confirmation of diagnosis,
counselling, therapeutic intervention, follow up, disposal, documentation and returns. The IDCs will be
located at:
(aa) CH (EC) Kolkata

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(ab) CH (NC) Udhampur

(ac) CH (WC) Chandimandir
(ad) CH (CC) Lucknow
(ae) INHS Ashwini Mumbai
(af) CHAF Bengaluru
(ag) INHS Kalyani Vishakapatnam
(ah) 151 BH Guwahati
All IDCs will transfer treatment failure cases to AIDCs for further evaluation and change of regimen.
(iii) First Line Immunodeficiency Centres (FIDC).
In addition to the above IDCs, the beds of Dermatology / STD wards of zonal service hospitals will be
re-designated as Dermatology / STD / Immunodeficiency beds. This will facilitate the creation of First Line
Immunodeficiency Centres (FIDC) so as to provide the basic diagnostic, monitoring and follow up treatment
facilities at the zonal level for patient and organizational convenience. Medical specialist / Dermatologist
will be responsible for starting ART, monitoring and periodic review. In case of any complications, drug
resistance or ART failure, patients will be transferred to IDC. It would also allow follow up of cases close
to their duty station and curtail prolonged absence from duty.
(b) Testing Policy.
(i) AFMS HIV testing policy will be kept in synchrony with the National AIDS Control Programme
(NACP). The procurement of HIV testing kits (ELISA and Rapid) will be based on those kits which have
been approved by the NACP National Referral Lab(s) for HIV testing.
(ii) HIV testing will be carried out only on a voluntary basis with appropriate pre-test and post-
test counselling. The counselling records will be maintained for use during further counselling of
individual / disclosure of HIV status to NOK / settling disputes subsequently. All individuals / patients
advised to undergo testing for HIV will report in person to the hospital blood collection centres for
collection of their blood samples. Blood samples of inpatients will be collected in the respective wards.
(iii) Persons to be Screened for HIV.
The following groups of persons will be screened for HIV:
(aa) All blood donors
(ab) All STD cases
(ac) All cases giving history of sexual promiscuity
(ad) All antenatal cases and the husbands / children of the HIV positive cases
(ae) Spouses and dependent children of HIV infected persons
(af) All Intravenous drug users
(ag) All recipients of blood and blood products
(ah) Patients on dialysis
(aj) Suspected ARC / AIDS cases
(ak) Personnel proceeding to and returning from tenures abroad.
(al) All cases of pulmonary & extra-pulmonary tuberculosis.
(am) Other high risk cases e g. those who test positive for HbsAg / HCV / VDRL
(an) Any other case which the treating physician deems necessary including cases undergoing
invasive procedures / investigations where risk of transmission is high.
(ao) Voluntary self-testing for individuals

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(c) Action on E / R Test Being Positive.

(i) Serving personnel who are found positive on E / R test at any of the testing centres, will be admitted
and transferred to the nearest service hospital with an AIDC / IDC, with the diagnosis of Immune surveillance
(Inv). Their diagnosis will be confirmed at this centre, which will be based on three E / R tests using HIV
kits.
(ii) An Accession number  / Index Number of individuals found to be HIV positive will be generated
by the testing centre, which will be used in further documentation of that individual.
(iii) Indeterminate / Discrepant HIV Test. In all indeterminate / discrepant HIV test results on E / R, the
appropriate sample will be routed through AIDC / IDC labs and then to the nearest NACP-designated national
reference lab, if required, for the confirmatory HIV testing. The individuals with indeterminate results will
be kept under observation for follow-up for repeat testing at 3, 6, 12 and up to 18 months, as required.
(iv) In case of families of HIV positive serving personnel, the CO / OC will facilitate the counselling
of the spouse by the health care provider. Counselling should be done in consonance with HIV AIDS
Act 2017. The counselling will be carried out by a trained counsellor / AMA in consultation with the
SEMO / specialist concerned, to motivate them to get themselves investigated at the nearest service / civil
HIV testing centre for E / R / S test. In case of spouses, the following two scenarios are envisaged.
(aa) If Spouse is Co-located in Station.
The CO in consultation with the AMA is to ensure that the spouse and children report to AMA for
further HIV testing and follow up, after due counselling.
(ab) If Spouse is not Co-located in Station.
The individual will be sent on casual Leave / part of annual leave / sick leave in consultation with
his unit with advice to inform his / her status to the spouse and get her / his HIV status tested
as well as that of their children.
(d) Surveillance Reports.
The service laboratory at AIDC / IDC carrying out E / R- test and / or confirmatory test will forward a report within
48 hrs of confirmation of the result to the following:
(i) ACO, Dept of Community Medicine, AFMC, Pune
(ii) Fmn HQ (Med) of the unit of the individual
(iii) MISO (M&H), GS Br, West Block III, RK Puram, New Delhi 110066 (for Army pers)
(iv) DMS (H), Office of DGMS (Navy) A Wing, Sena Bhawan, New Delhi 11 (for Navy pers)
(v) DMS (H), Office of DGMS (Air), Air HQ, West Block VI, RK Puram, New Delhi 66 (for Air Force pers)
(vi) One copy of ACO-1 will be attached with case sheet for record
(vii) Record office of individual
(viii) IDC nearest to the individual’s unit.
They will also inform the Commanding officer of the individual by a confidential DO letter.
(e) Initiation of Therapy.
(i) The HIV trained Physician at one of the AIDC / IDC will initiate Antiretroviral therapy (ART). The
personnel put on ART will be adequately monitored as indoor patients during the initial phase of ART.
(ii) Patient’s Preparedness for ART.
Prior to initiating ART, the patients should be counselled appropriately by the treating HIV physician for
better adherence to the therapy. This should include a detailed discussion about the willingness and
readiness of patients to initiate ART, the Antiretroviral (ARV) drug regimen, dosage, scheduling, likely
benefits, possible adverse effects and the required follow-up and monitoring visits. The ART counsellor
is a valuable resource for the initial counselling prior to initiation of therapy.

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COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

(iii) When to Start Therapy?

(aa) All patients should be started on HIV therapy irrespective of their CD4 count. However, if
the patient is not well prepared, he is likely to have poor compliance, leading to drug resistance.
Hence ART to be initiated only after physician is satisfied about patient being well prepared towards
good adherence.
(ab) Efforts should be made to reduce the time between HIV diagnosis and ART initiation based
on an assessment of a person’s readiness.
(iv) Role of Plasma HIV Viral Load and HIV Drug-resistance Testing at Baseline.
(aa) Plasma HIV viral load and HIV drug resistance testing is recommended for persons with
HIV at entry into care to guide selection of the initial Antiretroviral therapy (ART) regimen.
(ab) Antiretroviral Therapy Naive Patients. Genotypic testing is recommended as the preferred
resistance testing to guide therapy in antiretroviral (ARV) - naive patients.
(ac) In special circumstances (e.g., in persons with acute or recent (early) HIV infection and in
pregnant women with HIV), ART initiation should not be delayed while awaiting resistance testing
results, the regimen can be modified once results are reported.
(ad) Standard genotypic drug-resistance testing in ARV-naive persons involves testing for
mutations in the reverse transcriptase (RT) and protease (PR) genes. If transmitted Integrase
Strand Transfer Inhibitor (INSTI) resistance is a concern, providers should ensure that genotypic
resistance testing also includes INSTI genotype testing.
(v) Antiretroviral Therapy.
(aa) The preferred regimen in adults would include Tenofovir, Lamivudine / Emtricitabine,
Dolutegravir. (TLD regimen)
(ab) The alternate regimens can be as under
O Zidovudine as alternative to Tenofovir
O Dolutegravir / Raltegravir as alternative to Efavirenz
(ac) Second line ART will ideally be started only in AIDCs / IDCs. Second line regimen will include
at least two new drugs to which the patient has not been exposed.
(ad) The regimen of TLD is safe and effective in Hepatitis B co-infection, TB co- Infection and
in second and third trimester of pregnancy. Adult women and adolescent girls of reproductive
age / potential who wish to become pregnant and who are not using effective contraception have
to be explained the minimal risk of neural tube defects (0.19%) by Dolutegravir (at conception
and until the end of the first trimester of pregnancy), so that they can make an informed consent.
Dolutegravir should be avoided in pregnancy.
(f) Follow up, Monitoring and Availability of Drugs.
(i) HIV positive cases will undergo a monthly evaluation by their AMA. If required, they will be referred
to the Medical Specialist at the nearest service hospital. They would be required to report every 6 months
(or earlier if required) at the AIDC / IDC for evaluation.
(ii) CD4 cell count testing will be done six monthly.
(iii) Viral load is recommended as the preferred monitoring approach to diagnose and confirm treatment
failure.
(aa) Routine viral load testing should be conducted at 6 and 12 months after ART initiation and
every 12 months thereafter.
(ab) Viral load testing gives clients a measure of understanding, control and motivation to adhere
to treatment and understand their HIV infection. Adherence counselling needs to address the
implications of a detectable or undetectable viral load.
(iv) All patients on ART should be preferably posted in a station with an AIDC / IDC to ensure proper

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monitoring and treatment compliance.

(g) Medical Classification. Patients will be classified as follows:
(i) Patients on ART Therapy.
(aa) Serving personnel on ART will be placed in low medical classification S1H1A1P3 (Temp)
E1 for a period of 24+24 weeks. The diagnosis of “Immune surveillance on ART with appropriate
employability restrictions:
O Not to be posted to High Altitude Area / Cl ops / Field area
O Not to be put on flying / para-jumping / submarine / diving duties
O Not to be detailed on foreign assignment
(ab) They will be subsequently placed in S1H1A1 P2 (Perm) if they have following:
O Good functional status
O CD4 >500
O Plasma Viral load < 1000 copies
(ii) Patients not on ART Therapy.
Asymptomatic / symptomatic HIV positive individuals advised ART but unwilling to take antiretroviral drugs
will be placed in S1H1A1P3E1 (Perm)
(h) Invalidment.
The guiding factor will be the functional ability of the Individual. However, disabling manifestations of disease
corresponding to WHO Stage IV with unsatisfactory response to the therapy will be considered for invalidment.
These conditions include:
(i) HIV wasting syndrome.
(ii) Disabling neurological / psychiatric illness or AIDS Dementia Complex.
(iii) Disseminated tuberculosis.
(iv) HIV-related malignancies.
(v) Any other AIDS defining criteria / disabling illness including decline of CD4 count by more than 30%
or more than 100 cells / µl in one year or CC count below 200 cells / ul despite having been exhibited
adequate trial of ART and Poor suppression of PVL(>1,000 copies / cmm) due to poor adherence in 1 year.
(j) Post Exposure Prophylaxis.
On exposure to a needle stick injury, blood and body fluids from a known HIV positive case, the individual will
report to MO i / c MI Room / Duty Medical Officer who will send him / her for HIV testing and administer ART.
(i) The preferred regimen for PEP in adults should be Tenofovir + Lamivudine + Dolutegravir for 28
days.
(ii) Alternatively, the third drug along with Tenofovir and Lamivudine could be a boosted protease
inhibitor (Lopinavir / Ritonavir) or. Efavirenz.
(k) Health Care Workers (HCWs).
(i) The HCWs are a special category of people who come in contact with patients (or their products)
suffering from HIV / AIDS frequently and may contract infection in spite of all possible precautions. This
becomes an occupational hazard for the HCWs.
(ii) Definition of HCW.
“Those persons whose activities involve contact with patients or patients’ blood and / or other body
fluids / tissues”. This includes Medical / Dental / Nursing / Paramedical / Paradental staff and any other
person (medical or Non-medical) directly involved in the activities mentioned above.

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 COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

(iii) Guidelines as per Guide to Medical Officers (Military Pensions) 2023 or as amended from time
to time will be taken into consideration while deciding attributability in HCWs.
(iv) Occupational Exposure in HCWs
(aa) Necessary action of PEP.
(ab) “Report of Occupational Exposure to HIV” will be initiated. The report of occupational
exposure, duly countersigned by the Commandant / CO of the hospital will be distributed as in
sextuplicate and distribute the same as under-
O To the individual who sustained occupational exposure to HIV
O To the ACO, C / o Dept of Community Medicine, AFMC, Pune
O To the Commanding Officer of the HCW
O Office copy to be retained along with the PEP register
O Office of the DGAFMS / DG-3A
O MPRSO / Org 9, MP 5 & 6 / Equivalent in Air Force and Navy in case of Officer / Nursing
officer and to Records in case of JCO / OR equivalents in Air Force and Navy.
(l) Attributability / Aggravation.
(i) In HIV / AIDS cases, attributability / aggravation will be guided by the policy guidelines prevailing
as per Guide to Medical Officers (Military Pensions) 2023 or as amended from time to time.
(ii) Longevity and assessment of disablement. Will be decided as per guidelines in Guide to Medical
Officers (Military Pensions) 2023 or as amended from time to time.

32.31 Autopsies on HIV-positive Cadavers.

An autopsy on confirmed HIV-positive cadavers is not mandatory. The details of procedure are as per Appx ‘O’ and
DGAFMS Memorandum 170 on the subject. No embalming will normally be undertaken in confirmed HIV cases.

Suggested Reading.
1. Jensen JM, Proksch E. The skin’s barrier. G Ital Dermatol Venereol. 2009 Dec;144(6):689-700. PMID: 19907407
2. Larson E. Hygiene of the Skin: When Is Clean Too Clean? Emerging Infectious Diseases. 2001 Apr;7(2):225–30.
3. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing Transmission of
Infectious Agents in Health Care Settings. American Journal of Infection Control [Internet]. 2007 Dec;35(10): S65–164.
[Accessed on 2024 Mar 10] Available from: https:// www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.
pdf
4. American Academy of Dermatology Association. Acne-like breakouts could be folliculitis [Internet]. www.aad.org.
[Accessed on 2024 Mar 10]. Available from: https:// www.aad.org/public/diseases/a-z/folliculitis.
5. Jafferany M. Psychodermatology: a guide to understanding common psychocutaneous disorders. Prim Care Companion
J Clin Psychiatry. 2007;9(3):203-13. doi: 10.4088/pcc. v09n0306. PMID: 17632653; PMCID: PMC1911167.
6. Heat rash (Miliaria): Images, Causes and Treatment - DermNet NZ [Internet]. dermnetnz.org. [Accessed on 2024 Mar
10]. Available from: https:// dermnetnz.org/topics/miliaria
7. CDC. Frequently Asked Questions (FAQ) About Extreme Heat | Natural Disasters and Severe Weather | CDC [Internet].
www.cdc.gov. 2020 [Accessed on 2024 Mar 10]. Available from: https:// www.cdc.gov/disasters/extremeheat/faq.
html#:~:text=Heat%20rash%20is%20a%20skin
8. American Academy of Dermatology Association. Impetigo: Overview [Internet]. www.aad.org. [Accessed on 2024 Mar
10]. Available from: https:// www.aad.org/public/diseases/a-z/impetigo-overview.
9. American Academy of Dermatology Association. Acne-like breakouts could be folliculitis [Internet]. www.aad.org.
[Accessed on 2024 Mar 10]. Available from: https:// www.aad.org/public/diseases/a-z/folliculitis
10. American Academy of Dermatology Association. Eczema types: Contact dermatitis overview [Internet]. www.aad.org.

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 CONTACT DISEASES (INCLUDING STIs)

[Accessed on 2024 Mar 10]. Available from: https:// www.aad.org/public/diseases/eczema/types/contact-dermatitis

11. CDC. Information for Healthcare Professionals | Ringworm | Types of Diseases | Fungal Diseases | CDC [Internet].
www.cdc.gov. 2022 [Accessed on 2024 Mar 10]. Available from: https:// www.cdc.gov/fungal/diseases/ringworm/health-
professionals.html#:~:text=Tinea%20corporis%2Fcruris%3A%20Tinea%20corporis
12. Pyoderma - an overview | ScienceDirect Topics [Internet]. www.sciencedirect.com. [Accessed on 2024
Mar 10]. Available from: https:// www.sciencedirect.com/topics/veterinary-science-and-veterinary-medicine/
pyoderma#:~:text=Pyoderma%20is%20a%20cutaneous%20infection
13. Tropical Ulcer - an overview | ScienceDirect Topics [Internet]. www.sciencedirect.com. [Accessed on 2024 Mar
10]. Available from: https:// www.sciencedirect.com/topics/medicine-and-dentistry/tropical-ulcer#:~:text=Tropical%20
ulcers%20are%20an%20acute
14. American Academy of Dermatology Association. Scabies: Overview [Internet]. www.aad.org. [Accessed on 2024 Mar
10]. Available from: https:// www.aad.org/public/diseases/a-z/scabies-overview.
15. WHO. Guidelines for the Diagnosis, Treatment and Prevention of Leprosy [Internet]. [Accessed on 2024 Mar 10].
Available from: https:// iris.who.int/bitstream/handle/10665/274127/9789290226383-eng.pdf?sequence=58.
16. CDC. What is Hansen’s Disease? [Internet]. Centers for disease control and prevention. 2019 [Accessed on 2024
Mar 10]. Available from: https:// www.cdc.gov/leprosy/about/about.html.
17. MoHFW,GoI, Central Leprosy Division directorate of general health services, ,Guidelines for certification and award at
the district level for achieving potential leprosy elimination/leprosy elimination status under national leprosy eradication
programme [Internet]. 2021 [Accessed on 2024 Mar 10]. Available from: https:// dghs.gov.in/WriteReadData/userfiles/
file/Leprosy/District%20award%20guidelines%2010%20aug%2021.pdf
18. MoHFW. National Leprosy Eradication Programme, Active case detection and regular surveillance for leprosy
[Internet]. 2020 Jul [Accessed on 2024 Mar 10]. Available from: https:// dghs.gov.in/WriteReadData/userfiles/file/
Leprosy/2020%20Operational%20Guidelines%20for%20ACD%20and%20RS%20NLEP%20final.pdf
19. Sehgal VN, Srivastava G. Indeterminate leprosy. A passing phase in the evolution of leprosy. Lepr Rev. 1987
Sep;58(3):291-9. doi: 10.5935/0305-7518.19870032. PMID: 3312898.
20. CDC. Mpox in the U.S. [Internet]. Centers for Disease Control and Prevention. 2023. Available from: https:// www.
cdc.gov/poxvirus/mpox/index.html
21. American Academy of Dermatology Association. Dermatologist explains what the monkeypox rash looks like [Internet].
www.aad.org. [Accessed on 2024 Mar 10]. Available from: https:// www.aad.org/public/diseases/a-z/monkeypox-rash.
22. MoHFW. Guidelines for management of monkeypox disease Ministry of Health and Family Welfare GOVERNMENT
OF INDIA 2 [Internet]. 2024 Mar. [Accessed on 2024 Mar 10]. Available from: https:// main.mohfw.gov.in/sites/default/
files/Guidelines%20for%20Management%20of%20Monkeypox%20Disease.pdf.
23. National STI/RTI Control and Prevention Programme NACP, Phase-III, India [Internet]. 2024 Mar [Accessed on 2024
Mar 21]. Available from: https:// naco.gov.in/sites/default/files/STI-Report_7.pdf
24. Walensky R. Morbidity and Mortality Weekly Report Sexually Transmitted Infections Treatment Guidelines, 2021
Centers for Disease Control and Prevention MMWR Editorial and Production Staff (Serials) MMWR Editorial Board
[Internet]. 2021 [Accessed on 2024 Mar 21]. Available from: https:// www.cdc.gov/std/treatment-guidelines/STI-
Guidelines-2021.pdf
25. WHO, Guidelines for the management of symptomatic sexually transmitted infections guidelines [Internet]. 2021
[Accessed on 2024 Mar 21]. Available from: https:// iris.who.int/bitstream/handle/10665/342523/9789240024168-
eng.pdf?sequence=1
26. WHO, Sexually transmitted infections (STIs) [Internet]. www.who.int. 2022 [Accessed on 2024 Mar 21]. Available
from: https:// www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis)#:~:text=Key%20facts
27. National Guidelines for HIV Testing National Guidelines for HIV Testing National AIDS Control Organisaiton Ministry
of Health & Family Welfare, Government of India [Internet]. 2015 Jul [Accessed on on 2024 Mar 21]. Available from:
https:// www.naco.gov.in/sites/default/files/National_Guidelines_for_HIV_Testing_21Apr2016.pdf
28. National Guidelines for HIV Testing, National AIDS Control Organization Ministry of Health & Family Welfare,

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 COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

Government of India [Internet]. 2016 Apr [Accessed on 2024 Mar 21]. Available from: https:// www.naco.gov.in/sites/
default/files/National_Guidelines_for_HIV_Testing_21Apr2016.pdf
29. NACO, Sankalak booklet [Internet]. 2023 Dec [Accessed on 2024 Mar 21]. Available from: https:// naco.gov.in/
sites/default/files/Sankalak%20Booklet.pdf
30. HIV.gov. The global HIV/AIDS epidemic [Internet]. HIV.gov. 2022 [Accessed on 2024 Mar 21]. Available from:
https:// www.hiv.gov/hiv-basics/overview/data-and-trends/global-statistics
31. WHO. HIV Country Profiles [Internet]. cfs.hivci.org. 2022 [Accessed on 2024 Mar 21]. Available from: https:// cfs.
hivci.org/
32. National Guidelines for HIV Care and Treatment, National AIDS Control Organization Ministry of Health & Family
Welfare, Government of India [Internet]. 2021 [Accessed on 2024 Mar 21]. Available from: https:// naco.gov.in/sites/
default/files/National_Guidelines_for_HIV_Care_and_Treatment_2021.pdf
33. DGAFMS letters No 76896/HIV Policy/DGAFMS/DG-3A dt 08 Mar 2019
34. DGAFMS letter No 5496/HIV Policy/DGAFMS/DG-3A dt 04 May 2022
n

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Chapter
XXXIII
COLLECTION OF SPECIMENS FOR LAB INVESTIGATIONS

33.1 Introduction.
Outbreaks of communicable and infectious disease cause significant morbidity and mortality, consume scarce
national health resources and have the potential for national and international spread. Rapid identification of the
causative agent and the likely source or mode of transmission is essential to minimise their impact. Successful
laboratory confirmation of a disease depends upon:
(a) Prior planning
(b) Collection of appropriate and adequate specimens
(c) Appropriate packaging and rapid transport to an appropriate laboratory
(d) Choice of laboratory to accurately perform the diagnostic tests.
Proper biosafety and decontamination procedures reduce the risk of further spread. The ultimate goals of outbreak
investigations are the implementation of successful control measures in the immediate term and preventive
measures across the longer term, but these can only be correctly formulated in the light of accurate epidemiological
and laboratory data. All medical officers should be familiar with new methods that may be introduced, or
modifications made in the established methods of sample collection. In the subsequent paragraphs, basic methods
for collection and dispatch are outlined. These must be supplemented and modified in accordance with instructions
issued from time to time and by liaison with the laboratory undertaking the work.

33.2 Outbreak Syndromes.

Outbreaks develop over a short duration of time, presenting with a myriad of symptoms. These present generally as
syndromes having one or more signs or symptoms which are generally correlated. The syndromes are defined according
to clinical criteria:
(a) Acute Diarrhoea Syndrome
(b) Acute Haemorrhagic Fever Syndrome
(c) Acute Jaundice Syndrome
(d) Acute Neurological Syndrome
(e) Acute Respiratory Syndrome
(f) Acute Dermatological Syndrome
(g) Acute Ophthalmological Syndrome
(h) Acute “Systemic” Syndrome
These syndromes warrant collection of various suitable laboratory specimens for confirmation of diagnosis. The kinds
of specimen that are commonly collected in field trials include:
(a) Specimens from humans, including blood, stool, urine, sputum, CSF, urine, faeces, other sterile pathological
fluids, postmortem tissue and gross specimens, skin snips, other tissue biopsies, and swabs or smears collected
from skin or mucosal surfaces.
(b) Entomological specimens for studies of vectors, and animal or malacological specimens for studies of
intermediate hosts.

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(c) Food, water, and environmental samples.

33.3 Syndrome Wise Collection of Samples.

(a) Acute Diarrhoea Syndrome.
(i) Disease Syndrome.
Acute onset of diarrhoea and severe illness and absence of known predisposing factors.
(ii) Possible Diseases / Pathogens.
Watery-Viral-gastroenteritis, Cholera, Enterotoxigenic E. coli, Giardiasis, Cryptosporidium, Salmonellosis,
Campylobacteriosis, Amoebic dysentery, Enterohaemorrhagic E. coli, Clostridium difficile, Ebola and other
haemorrhagic fevers, poisoning.
(iii) Specimen Required.
blood, faeces, food, water, pathological fluids, specimen of viscera.
(b) Acute Haemorrhagic Fever.
(i) Disease Syndrome.
Acute onset of fever of less than 3 weeks duration and any two of the following:
(aa) Haemorrhagic or purpuric rash
(ab) Epistaxis
(ac) Haemoptysis
(ad) Blood in stool
(ae) Other haemorrhagic symptom and absence of known predisposing factors.
(ii) Possible Diseases / Pathogens.
Dengue haemorrhagic fever and shock syndrome, other arboviral fevers.
(iii) Specimen Required.
Blood, Blood smear, Serum, Post-mortem tissue specimens (e.g. skin biopsy and / or liver biopsy).
(c) Acute Jaundice Syndrome.
(i) Disease Syndrome.
Acute onset of jaundice and severe illness and absence of known predisposing factors.
(ii) Possible Diseases / Pathogen.
Hepatitis A-E, Leptospirosis, and other spirochaetal diseases.
(iii) Specimen Required.
Blood, serum, blood culture, urine, faeces, postmortem liver biopsy.
(d) Acute Neurological Syndrome.
(i) Disease Syndrome.
Acute neurological dysfunction with one or more of the following:
(aa) Deterioration of mental function
(ab) Acute paralysis
(ac) Convulsions
(ad) Signs of meningeal irritation
(ae) Involuntary movements

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(af) Other neurological symptoms and severe illness and absence of predisposing factors.
(ii) Possible Diseases / Pathogens.
Poliomyelitis, Rabies, Guillain Barré syndrome, Viral, bacterial, fungal, or parasitic meningoencephalitis.
(iii) Specimen Required.
Faeces, CSF, Blood culture, smears, serum, Throat swab, postmortem specimens.
(e) Acute Respiratory Syndrome.
(i) Disease Syndrome.
Acute onset of cough or respiratory distress and severe illness and absence of known predisposing factors.
(ii) Possible Diseases / Pathogens.
Bacterial / viral pneumoniae, streptococcal pharyngitis, influenza, RSV, diphtheria, pertussis, pneumonic
plague.
(iii) Specimen Required.
Throat swab, sputum, nasopharyngeal swab, blood culture, serum.
(f) Acute Dermatological Syndrome.
(i) Disease Syndrome.
Acute febrile illness with rash or other skin manifestations and absence of known predisposing factors.
(ii) Possible Diseases / Pathogens.
Chicken pox, monkey pox, measles, rubella, typhus, cutaneous anthrax, leprosy.
(iii) Specimen Required.
Vesicular fluid crust, serum, lesion swab (vesicular exudate) for microscopy, culture, skin biopsy, skin, and
nasal scraping.
(g) Acute Ophthalmological Syndrome.
(i) Disease Syndrome.
Acute onset of conjunctivitis with or without sub-conjunctival haemorrhages and absence of known
predisposing factors.
(ii) Possible Diseases / Pathogens.
Trachoma, bacterial, viral conjunctivitis, haemorrhagic conjunctivitis.
(iii) Specimen required.
Conjunctival swab and smear, serum.
(h) Acute “Systemic” Syndrome.
(i) Disease Syndrome.
Acute febrile illness characterized by symptoms from several body systems, with three or more of the
following:
(aa) Appetite and weight loss
(ab) Nausea and vomiting
(ac) Diarrhoea
(ad) Abdominal discomfort
(ae) Sweats and chills
(af) Headache

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(ag) Arthralgia, myalgia, and back pain

(ah) Rash and absence of known predisposing factors.
(ii) Possible Diseases.
Pathogen. Viral fevers, typhus, typhoid, malaria.
(iii) Specimen Required.
Blood, serum, blood culture, blood smears, food sample, water sample.

33.4 Checklist for Specimen Collection and Transport.

(a) Documentation.
(i) Specimen label
(ii) Case investigation forms
(iii) Patient register book
(iv) Marker pen
(v) Writing pens and pencils
(vi) Outbreak investigation guidelines.
(b) Personal Protective Equipment.
(i) Gowns / coveralls
(ii) Plastic apron
(iii) Masks
(iv) Cups
(v) Disinfectants- Sodium hypochlorite, soap, 70% alcohol, Povidone iodine 10%
(vi) Biohazard bags
(vii) Goggles
(viii) Caps
(ix) Scrub suits.
(x) Gloves – (surgical and disposable)
(c) Specimen Collection, Packaging Transportation and Referral.
(i) Racks
(ii) Needles (gauge; 21, 23)
(iii) Tourniquet
(iv) Cotton wool
(v) Alcohol swabs
(vi) CSF collection kit
(vii) Leak proof screw capped container.
(viii) Vacutainers
(ix) Vacutainer sleeves
(x) Adhesive tape
(xi) Lancets
(xii) Stool containers.

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(xiii) Water sampling kits

(xiv) Gauze large pack
(xv) Filter Paper
(xvi) Slides
(xvii) Cover slips.
(xviii) Skin snip kits
(xix) Formalin + Coplin jar
(xx) Cryotubes
(xxi) Plastic Pasteur pipettes
(xxii) Absorbent materials
(xxiii) Parafilm (small rolls)
(xxiv) Thermometers
(xxv) Tongue depressors
(xxvi) Kit boxes
(xxvii) Slide boxes.
(xxviii) Staining racks
(xxix) Microscopes (light binoculars)
(xxx) Immersion oil
(xxxi) Lens tissue.
(xxxii) Water testing kits
(xxxiii) Transport media.
(xxxiv) Triple packing systems
(xxxv) Cold boxes
(xxxvi) Cold packs / Ice packs
(xxxvii) Sterile cotton tipped applicator (e.g. for rectal swab)
(xxxviii) Blood culture bottles
(xxxix) Sputum containers
(xl) Safe box / bio safety bags
(xli) Normal saline

33.5 Planning for Specimen Collection.

(a) Zero in on a differential diagnosis of the outbreak.
(b) Decide which clinical specimens are required to confirm the cause of the outbreak.
(c) Select the laboratory, suitable and adequate for specimen testing.
(d) Delegate who will collect, process, and transport the specimens.
(e) Define the procedures necessary for specimen management from collection till receiving at the laboratory.

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33.6 Sample Collection Techniques.

(a) Blood.
Blood and serum are the most common specimens taken to investigate outbreaks of communicable diseases.
Venous blood can be used for isolation and identification of the pathogen by culture and inoculation or separated
into serum for the detection of genetic material (e.g. using the polymerase chain reaction), specific antibodies,
antigens, or toxins (e.g. by ELISA). For the processing of most specimens for diagnosis of viral pathogens, serum is
preferable over unseparated blood except where otherwise directed. When specific antibodies are being assayed,
it is often helpful to collect paired sera, i.e. an acute sample at the onset of illness and a convalescent sample
one to four weeks later.
For collection of blood, equipment Required Include:
(i) Skin disinfectant: 70% alcohol (isopropyl alcohol, ethanol) or 10% povidone
(ii) Iodine, swabs, gauze pads, band aid
(iii) Disposable latex gloves
(iv) Tourniquet, Vacutainer, or similar vacuum blood collection devices, or 5 ml or 10 ml syringe fitted
with a wide bore needle (19-20 SWG)
(v) Vacutainer or sterile screw-cap tubes (or cryotubes if indicated), blood culture bottles (50 ml for
adults, 25 ml for children) with appropriate media.
(vi) Labels and indelible marker pen.
Procedure of Withdrawing Blood.
(i) Place a tourniquet above the venepuncture site.
(ii) Palpate and locate the vein. It is critical to disinfect the venepuncture site meticulously with 10%
povidone iodine or 70% isopropyl alcohol by swabbing the skin concentrically from the centre of the
venepuncture site outwards. Let the disinfectant evaporate. Do not repalpate the vein again.
(iii) Perform venepuncture.
(iv) If withdrawing with conventional disposable syringes, withdraw 5-10 ml of whole blood from adults,
2-5 ml from children and 0.5-2 ml for infants.
(v) If withdrawing with vacuum systems, withdraw the desired amount of blood directly into each transport
tube and culture bottle.
(vi) Remove the tourniquet. Apply pressure to site until bleeding stops and apply sticking plaster (if
desired).
(vii) Using aseptic technique, transfer the specimen to relevant cap transport tubes and culture bottles.
Secure caps tightly. Be sure to follow manufacturer’s instructions on the correct amount and method for
inoculation of blood culture bottles.
(vii) Label the tube, including the unique patient identification number, using indelible marker pen.
(ix) Do not recap used sharps. Discard directly into the sharp’s disposal container.
(x) Complete the case investigation and the laboratory request forms using the same identification number.
(b) Separation of Serum.
Additional materials required –
(i) Sterile Pasteur pipettes and bulb, or soft, disposable transfer pipettes. The latter are easier to handle
and dispose of in the field laboratory.
(ii) Sterile screw-cap tubes - 2 per sample.
(c) Method of Separation.
(i) Using the materials and methods described above, draw 10 ml of venous blood and transfer to a screw

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cap tube without anti-coagulant. Alternatively, blood may be collected directly into a proprietary collection
and transport tube (e.g., Vacutainer, Monovette, etc.).
(ii) Let the blood specimen clot for 30 minutes at ambient temperature, then place in a cool box to
retract at 4 to 8°C for a minimum of 1 to 2 hours (it may be stored at this temperature for 48-72 hours).
(iii) The specimen should be centrifuged at the laboratory at low speed (300 RPM for 10 minutes)
to remove residual blood cells. When serum separation is performed in a field laboratory proper safety
precaution should be taken.
(iv) Ensure that the centrifuge is in good condition and the tubes are properly closed and balanced to
avoid breakage and spilling.
(v) If a viral haemorrhagic fever is strongly suspected, samples should only be processed in properly
equipped, specialized laboratories. Discuss with the laboratory whether a separation gel blood tube would
be acceptable in this case.
(vi) Separate the serum aseptically from the clot using a sterile Pasteur pipette and bulb or soft, disposable
transfer pipette. Transfer equally to 2 plastic screw cap tubes. Secure the caps tightly.
(vii) If a centrifuge is not available and there will be a delay before samples can be transported to a
laboratory, serum may still be separated carefully from the retracted clot using a disposable transfer pipette.
(viii) Allow 4-6 hours to elapse after taking the blood sample to ensure adequate clot retraction.
(ix) Using the transfer pipette, remove the clear yellow serum whilst taking care to keep the tip as far as
possible from the clot, and avoid agitating the blood tube during the removal process. (This may be easier if
a separation gel collection tube has been used.) Transfer to plastic screwcap tubes and secure caps tightly.
(x) Label the tubes with the same patient details that appear on the blood sample tube.
(d) Handling and Transport.
(i) If serum will be required for testing, separation from blood should take place as soon as possible,
preferably within 24 hours at ambient temperature.
(ii) If the specimen will not reach a laboratory for processing within 24 hours, serum should, if possible,
be separated from blood prior to transportation.
(iii) Sera may be stored at 4-8°C for up to 10 days. If testing is delayed for a long period, serum samples
may be frozen.
(e) Blood Slides.
(i) Thin Blood Films.
The sides of the finger are pressed so as to raise the pulp of the finger. Ideally, commercially available
pricking lancet is used. Otherwise, a bayonet pointed disposable needle serves well for the purpose of
pricking. Pins, injection needles, and sewing needles should be avoided. The prick should be bold and
about 3 mm deep. Light pressure on the sides of this finger in an outward direction helps the flow of
blood by opening the wound. Squeezing is to be discouraged as it leads to dilution of capillary blood with
tissue fluid and thus to erroneous results. The first drop of blood from a skin puncture is wiped dry with
cotton wool and subsequent drops of blood are utilised for tests. A drop of blood is placed ½ inch from
the edge of the slide. Take two or three polished slides and select one with a smooth and even end as
a spreader. Place the slide with drop of blood on a table so that the end with the blood drop is towards
the right, while holding the other end by the edges with the forefinger and thumb of left hand, place the
spreader somewhere about the middle of the slide at an angle of about 45º and draw it to the right till it
touches the drop of blood which then runs and spreads along the edge of the spreader. Before the blood
has reached the margins, push spreader with the blood following it along the slide with a firm steady
motion but without unnecessary pressure, to obtain a tongue - shaped smear. An ideal film should be about
1½ long and ¾ wide. It should be slightly thick at its beginning but reasonably thin near its tail, where
red cells when seen under a microscope should be seen, just touching one another but not overlapping.
When held against light, the thin portion of the films should show a play of colours. Films which are too
long or too wide, which show bands due to irregular thickness, vacuoles due to grease, or streakness due

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to an irregular edge to the “spreader” should be rejected.

(ii) Thick Blood Films.
These smears are better suited for the detailed examination of blood parasites: thick films are preferable
when a large number of examinations have to be made. As a large volume of blood is examined, the thick
film method increases the number of positive findings. Three to five drops of blood, each of the size of
a drop for the thin film, are collected on a clean and polished slide, pooled together and spread with a
needle into an even thick film about 10 mm square. The thickness of the film should be such as to allow
a newsprint to be read through it. The slide is then placed on a flat surface to dry in the air, but not in
the sun, and covered with a saucer or petri dish to prevent flies spoiling the film. When dry, the slide is
wrapped in a piece of paper on which the patient’s name and the date are written. When examination for
filaria is needed, the slide is fixed in methanol for a few minutes before wrapping it up in paper.
(f) Handling and Transport.
Air dried and / or fixed films are transported at ambient temperature preferably within 24 hours of specimen
collection. They must not be refrigerated. Thick and thin films are usually kept in separate slide boxes.
(g) Blood Culture.
(i) Blood cultures should be collected as soon as possible after the onset of clinical symptoms; ideally,
prior to the administration of antimicrobial therapy.
(ii) For an adult, the recommended volume of blood to be obtained per culture is 20 to 30 ml. Since
each set includes an aerobic and an anaerobic bottle, each bottle should be inoculated with approximately
10 ml of blood. It is also generally recommended that two or three bottle sets (two bottles per set) are
used per septic episode, meaning, for adults, 40 to 60 ml of blood collected from the patient for the 4 to
6 bottles, with 10 ml per bottle.
(iii) Guidelines recommend that the first two / three sets (2 bottles / set) of blood culture be obtained
either at one time or over a brief time period (e.g., within 1 hour) from multiple venipuncture sites.
(iv) For paediatric age group, the recommended volume of blood collected should be based on the weight
of the patient and an aerobic bottle should be used, unless an anaerobic infection is suspected.
Table 33.1 : Paediatric Age Group - Recommendation for Volume of Blood Collected for Culture
Weight (kg) Culture 1 (ml) Culture 2 (ml) Total Volume (ml)
<1 2 2
1.1-2 2 2 4
2.1-12.7 4 2 6
12.8-36.3 10 10 20
> 36.3 20-30 20-30 40-60
(v) When rare organisms such as Brucella, Campylobacter or Bartonella are suspected, an Infectius
Desease (ID) physician shall be consulted.
(vi) The Microbiology laboratory shall be consulted to advise which type of specimen is most likely to
support the suspected organism.
(vii) Blood Parasites.
Malaria, Babesiosis, Trypanosomiasis, and Filariasis
(aa) Draw 3 ml of blood in a lavender top (EDTA) vacutainer tube using the standard venipuncture
procedure.
(ab) Deliver the tube to the Microbiology lab immediately or within 2 hours of collection.
(ac) Indicate patient’s travel history (if available) and suspected pathogen (i.e., rule-out Loa loa
filariasis).

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 COLLECTION OF SPECIMENS FOR LAB INVESTIGATIONS

(h) CSF.
CSF is used to in the diagnosis of viral, bacterial, parasitic, and fungal meningitis.
(i) Constituents of Lumbar Puncture Tray.
(aa) Sterile materials: gloves, cotton wool, towels or drapes.
(ab) Local anaesthetic, needle, syringe.
(ac) Skin disinfectant: 10% povidone iodine or 70% alcohol.
(ad) Two lumbar puncture needles, small bore with stylet
(ae) Six small sterile screw-cap tubes and tube rack
(af) Microscope slides and slide boxes.
(ii) Method of Collection.
(aa) As only experienced personnel should be involved in the collection of CSF samples, the method
is not described in this document. CSF is collected directly into the separate screw-cap tubes.
(ab) Collected in 3 tubes (1 ml each) 1st for Biochemistry and serology, 2nd for microbiology and 3rd
for Cytology, immunology, additional tests.
(ac) If the samples will not be promptly transported, they should be collected in separate tubes for
bacterial and viral processing.
(iii) Handling and Transport.
(aa) In general, specimens should be delivered to the laboratory and processed as soon as possible.
(ab) CSF specimens for bacteriology are transported at ambient temperature, generally without
transport media. They must never be refrigerated as many of the relevant pathogens do not survive
well at low temperatures.
(ac) CSF specimens for virology do not need transport medium. They may be transported at 4-8°C
for up to 48 hours, or at -70°C for longer periods.
(j) Exudates and Pathological Fluids [Body Fluids, Sterile (except urine and cerebrospinal fluid)].
(aa) Prepare the skin as mentioned earlier paragraphs.
(ab) Collect the fluid using a sterile needle and syringe and place in transport container based on
test being requested:
O For aerobic organisms submit 10 ml in a sterile container (30 mL for pleural fluid).
O For aerobic and anaerobic organisms, submit 10 ml in anaerobe transport (30 mL for
pleural fluid).
O If mycobacterial or fungal infections are suspected, collect a minimum of 5 ml of fluid
into a sterile container.
O If testing for multiple labs, add up the volume needed, based on the above volumes,
collect in a sterile container, and deliver to the lab within 1 hour.
(ac) Transport immediately.
Note. *Do not send Sterile Body Fluids on swabs.
(k) Faeces.
Stool specimens are most useful for microbiological diagnosis if collected soon after onset of diarrhoea (for viruses
< 48 hours and for bacteria < 4 days), and preferably before the initiation of antibiotic therapy. If required, two
or three specimens may be collected on separate days. Stool is the preferred specimen for culture of bacterial,
viral, and parasitic diarrhoeal pathogens. Rectal swabs showing faeces may also be used from infants. In general,
rectal swabs are not recommended for the diagnosis of viruses.

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(i) Materials for Collection.

(aa) Clean, dry, leak-proof screw cap container and tape
(ab) Appropriate bacterial transport media for transport of rectal swabs from infants
(ac) Parasitology transport pack: 10% formalin in water or Polyvinyl Isopropyl Alcohol (PVA).
(ii) Method of Collecting a Stool Specimen.
(aa) Collect freshly passed stool, 5 ml liquid or 5 g solid (pea-size), in a container.
(ab) Label the container.
(iii) Method of Collecting a Rectal Swab from Infants.
(aa) Moisten a swab in sterile saline.
(ab) Insert the swab tip just past the anal sphincter and rotate gently.
(ac) Withdraw the swab and examine to ensure that the cotton tip is stained with faeces.
(ad) Place the swab in sterile tube / container containing the appropriate bacterial or viral transport
medium.
(ae) Break off the top part of the stick without touching the tube and tighten the screw cap firmly.
(af) Label the specimen tube.
(iv) Handling and Transport.
(aa) Stool specimens should be transported at 4-8ºC. Bacterial yields may fall significantly if
specimens are not processed within 1-2 days of collection.
(ab) Shigella are particularly sensitive to elevated temperatures.
(ac) Specimens to be examined for parasites should be mixed with 10% formalin or PVA, 3 parts
stools to 1 part preservative. Transport at ambient temperature in containers sealed in plastic bags.
(l) Food and Beverages.
Samples of fresh milk, water and aerated waters for chemical and bacteriological examination are sent to the
nearest laboratory. Samples of tinned food, grains and beverages are sent to the composite food laboratories
(ASC) located at Delhi, Mumbai, and Jammu. These laboratories deal with examination of such samples for their
storage life and fitness for human consumption. Samples must be taken under the supervision of an officer who
should ensure that the following directions are carried out:
(i) A fair average sample should be taken e.g. both the crust and core of bread and cheese should be
included; the milk should be well mixed by stirring before taking the sample and so on. The use of paper or
other packing inside the receptacle, in which any of the samples except grains is forwarded, is prohibited,
unless the sample is contained in its original wrapper.
(ii) Canned articles should be sent in unopened containers. If this is unfeasible, at least send the original
container with the sample.
(iii) Articles not packed in original containers should be packed in clean glass stoppered bottles of such
a size that the sample completely fills the bottles; solids should be packed in clean tins; and semisolids
should be packed either in bottles or tins, whichever is more suitable, or in clean glazed earthenware jars
fitted with clean bungs.
(iv) Samples for bacteriological examination should be packed with aseptic precautions in sterile glass
stoppered bottles. The material should be dispatched to reach the laboratory within three hours of collection,
otherwise bacterial multiplication may alter initial picture. If delay is inevitable the material should be
preserved in a refrigerator or ice and then forwarded.
Minimum Quantities. The minimum quantities which should be sent for examination are as follows:

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Table 33.2 : Minimum Quantities of Food Items Required for Examination

Food Product Quantity
Milk 180 ml
Condensed milk 1 tin
Dried milk, milk food etc 60 g
Butter, margarine, ghee etc 120 g
Cheese 120 g
Bread 1 complete loaf
Biscuits 240 g
Flour 120 g
Oatmeal. 60 g
Atta 120 g
Rice. 120 g
Tea. 60 g
Coffee 120 g
Cocoa 60 g
Tinned meat, fish etc. 1 tin
Sausages 1 full tin
Dried or smoked meat or fish 240 g
Lard or its manufacture substitutes 120 g
Tinned or bottled fruits, vegetables etc. 1 tin or bottle
Sugar 120 g
Jams / syrups 1 tin / jar
Confectionery, sweets etc. 120 g
Pepper, mustard, spices etc. 60 g
Vinegar, sauces etc. 150 g
Lime juice and other similar preparations 150 g
Beer or stout. 1 bottle
Spirits (whisky, gin, brandy, rum) 1 bottle
Aerated water. 1 bottle
Dispatching Particulars of Samples.
Each sample must be securely packed, labelled, and sealed by the medical officer taking the sample and forwarded
to reach the laboratory expeditiously. The request should be signed by the officer taking the samples and may be
countersigned by the officer at whose request the sample was taken. Full details of each sample sent should be
dispatched separately by registered post on laboratory request. This information should include the nature and quantity
of the sample, the source of the sample and the date of procuring it, the exact nature of the examination required, and
the reasons for examination. In suspected poisoning, a clinical summary of the case must be sent. This summary should
state the length of the time which elapsed between the consumption of the article and the onset of the symptoms
observed in the order of their occurrence, the present condition of the patient or patients and the condition of other
persons who have partaken of the articles or of similar articles from the same consignment as the sample. Reports
of analysis carried out at the military food laboratory are sent to the unit sending the sample.

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(m) Skin and Nasal Scrapings.

Thickened areas of skin are selected. The site is cleaned with alcohol and ether, pinched up between thumb and
index finger and a linear cut is made up to the dermis at the apex of the fold by means of a sharp scalpel point,
the base and the sides of the incision are thoroughly scraped, and the material collected is smeared on the slide
and fixed with heat. For nasal scraping the nose is cleaned with moist swabs and a cut is made in the mucus
membrane of the septum if no obviously ulcerated areas are present and scraped to obtain the material for smears.
(n) Skin Biopsy.
(i) It iss taken from a lesion situated in a richly enervated area e.g. forearm. The biopsy should be
reasonably large and taken from the progressive edge of the lesion including normal skin. It should be
wedge shaped reaching deep into the subcutaneous tissue. The base of the wedge in the subcutaneous
tissue should be broader than the skin surface. The longitudinal axis of the wedge should be parallel to
the general course of the subcutaneous nerve bundle in the area chosen. The biopsy material obtained is
immediately fixed in 10 percent normal saline and forwarded for histological examination.
(ii) In the lepromatous type of leprosy, material is collected for demonstration of Mycobacterium. In the
neural type, clinical examination suffices for diagnosis and bacteriological methods are of little use.
(o) Specimens (In case of suspected poisoning).
(i) Procedure.
Poisoning is sometimes obvious from the start but when it is uncertain or obscure or being considered
because of lack of positive findings the alimentary tract and the organs of elimination deserve prime
consideration. However, it must be remembered that except in corrosive poisons, the pathological findings
are rarely conclusive, and appropriate viscera will have to be submitted for chemical analysis. It is therefore
vital to collect and preserve the right material in the right way, quickly enough to avert failure and preferably
in cold storage. The selection of viscera and materials to be preserved for chemical analysis is based on the
course the poison takes in the body and its distribution in various organs and tissues. There is a common
misconception that it is necessary to preserve only gastric contents in order to establish if poisoning has
occurred in a given case. It should be pointed out that the gastrointestinal tract is not the only route of
entry of poison into the body. Furthermore, if any significant period (4 to 6 hours) elapses from the time
of ingestion until death or treatment, the poison will have passed out of the stomach. Poison could also
have been introduced in the stomach after death to mask a homicidal act. The detection and distribution
of a toxic agent in different body fluids and tissues is therefore of vital importance.
(ii) Specimens.
In non-fatal cases vomitus, faeces, urine, blood, remnants of food consumed, and any other article suspected
to be the source of the poison should be sent. In fatal cases, kidney, liver, stomach contents, intestines and
bladder should be sent in addition. At the time of postmortem, care must be taken that the contents of the
hollow organs do not contaminate the solid organs. Details of material to be sent for chemical examination
are given in Table 33.3.
Table 33.3 : Details of Viscera to be Sent for Chemical Examination in Fatal Cases
Material Quantity
Stomach Whole
Stomach contents 300 ml. If less available, whole quantity
Small intestine 90 cm in adults, 180 cm in children and whole in infants
Small intestine contents 100 ml. If less available, whole quantity
Liver, preferably the portion containing gall bladder 500 gm of liver in adults and whole in children
along with its contents*
Spleen + Kidneys Half in adults and whole in children Half from each kidney
Urine 100-200 ml. If less available, whole quantity

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The gall bladder and bile should be routinely preserved because examination of bile or, if the gall bladder was empty
at postmortem, the gall bladder itself will show the presence of a large number of drugs including morphine (free and
conjugated), cocaine, methadone and its metabolites, glutathione, many anti-biotics and major tranquilizers or their
metabolites. If septicaemia is suspected and the cause of it is not obvious, spleen tissue should be cultured. It may
reveal an unsuspected terminal infection.

33.7 Packing.
Specimens must be packed separately. Clean bottles or jars made of good quality glass with well fitting, clean and sound
corks, or glass stoppers, and large enough to contain one and a half times the volume of the specimen should be used.
In case of suspected poisoning by substances other than alcohol, all perishable material should be sent immersed in
good quality rectified spirit or saturated solution of sodium chloride sufficient in quality to cover the material in whatever
position the vessel containing it may be held; a sample of spirit / preservative used should be sent for ready reference.
In case of suspected alcohol poisoning the contents of the stomach and its washings in water are placed in a bottle
with a sufficient quantity of salt to saturate the solution and leave a little salt undissolved. The stomach itself and
other materials are placed in rectified spirit as above. The stopper should be carefully tied down with a piece of cloth
or leather and carefully sealed. A ring of beeswax or candle wax should be placed round the lip of the bottle to cover
the shoulder of the bottle and sealed with the office seal of the officer in charge of the case. Each packing should
be labelled giving name of the case, nature of the contents, preservative used and date of packing. The containers
should be placed in a wooden or tin box, large enough to allow a layer of raw cotton (at least 2 cm thick) between
the vessels as well as between the vessels and the box. The box itself is encased in cloth, which should be securely
stitched and sealed. The seal should be at intervals not exceeding 7.5 cm along each line of sewing.

33.8 Dispatch.
The specimens are sent with minimum possible delay to the nearest Government Chemical Examiner by registered
post or courier with all details, which will give him a clue. The forwarding letter should enumerate the specimens sent
giving the exact date and means of dispatch. A specimen of the seal should also be enclosed.

33.9 Respiratory Tract Specimen Collection.

Specimens are collected from the upper or lower respiratory tract, depending on the site of infection. Upper respiratory
tract pathogens (viral and bacterial) are found in throat and nasopharyngeal specimens. Lower respiratory tract
pathogens are found in sputum specimens.
(a) Materials for Collection.
(i) Transport media – bacterial and viral.
(ii) Dacron and cotton swabs
(iii) Tongue depressor
(iv) Flexible wire calcium alginate tipped swab (for suspected pertussis)
(v) Nasal speculum (for suspected pertussis – not essential)
(vi) Suction apparatus or 20-50 ml syringe.
(vii) Sterile screw-cap tubes, and wide-mouthed clean sterile jars (minimum volume 25 ml).
(b) Upper Respiratory Tract Specimens.
(i) Method of Collecting a Throat Swab.
(aa) Hold the tongue down with the depressor. Use a strong light source to locate areas of inflammation
and exudate in the posterior pharynx and the tonsillar region of the throat behind the uvula.
(ab) Rub the area back and forth with a Dacron or calcium alginate swab.
(ac) Withdraw the swab without touching cheeks, teeth or gums and insert into a screw-cap tube
containing transport medium.
(ad) Break off the top part of the stick without touching the tube and tighten the screw cap firmly.

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 COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

(ae) Label the specimen containers.

(af) Complete the laboratory request form.
(ii) Pertussis.
(aa) Seat the patient comfortably, tilt the head back and insert the nasal speculum.
(ab) Insert a flexible calcium alginate / Dacron swab through the speculum parallel to the floor of
nose without pointing upwards. Alternately, bend the wire and insert it into the throat and move the
swab upwards into the nasopharyngeal space.
(ac) Rotate the swab on the nasopharyngeal membrane a few times, remove it carefully and insert
it into a screw-cap tube containing transport medium.
(ad) Break off the top part of the stick without touching the tube and tighten the screw cap firmly.
(ae) Label the specimen tube.
(c) Lower Respiratory Tract Specimens.
(i) Method of Collecting Sputum.
(aa) Instruct patient to take a deep breath and cough up sputum directly into a wide-mouth sterile
container. Avoid saliva or postnasal discharge. Minimum volume should be about 1 ml.
(ab) Label the specimen containers.
(ac) Complete the laboratory request form.
(ii) Handling and Transport.
(aa) All respiratory specimens except sputum are transported in appropriate bacterial / viral media.
(ab) Transport as quickly as possible to the laboratory to reduce overgrowth by commensal oral flora.
(ac) For transit periods up to 24 hours, transport bacterial specimens at ambient temperature and
viruses at 4-8ºC in appropriate media.

33.10 Tissue For Histopathology.

Strict precautions, including respiratory protection from aerosolized particles, must be taken when carrying out post-
mortem specimen collection in communicable disease outbreaks. Collect the specimens as soon as possible, since viral
titres decline while bacteria multiply rapidly after death. Instructions for taking a skin biopsy from highly contagious
cadavers (e.g. during suspected Ebola outbreaks). Thorough post-mortem examinations may only be accomplished
by experienced medical personnel. Prior experience and training is also advised even for the minimal collection of
specimens from cadavers.
(a) Materials for Collection.
(i) Barrier precautions: double gloves, sterile gown, eye goggles, mask
(ii) For collecting blood and other fluids, refer to corresponding sections in the chapter for materials.
(iii) Aseptic surgical and biopsy instruments for collecting tissue specimens.
(iv) Fixatives: saline formalin for histology
(v) Sterile saline, appropriate viral and bacterial transport media
(vi) Sterile containers, sterile screw cap tubes or vials, glass slides and slide box
(vii) Disinfectant such as household bleach 1:10.
(b) Method of Collection.
(i) Use a separate sterile instrument for each tissue specimen from affected sites (several fragments
with 1-2 grams of each is sufficient). Smaller, but adequate, specimens are taken with a biopsy needle.
(ii) Place different tissues in separate sterile containers containing the relevant medium: fixatives

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for histopathology; sterile saline for preparation of tissues for immunofluorescence microscopy; and
microbiological transport media for the isolation of bacterial and viral pathogens.
(iii) Label all containers and tighten the screw caps firmly.
(iv) Other specimens are collected as per relevant section of this chapter.
(v) Blood may be taken from the heart cavities.
(vi) If cerebral malaria is suspected, make several smears from the cerebral cortex on glass slides to
detect Plasmodium falciparum. Label the slides and transport in a slide box.
(c) Handling and Transport.
(i) Fixed specimens can be stored and transported at ambient temperature.
(ii) Tissue specimens for isolation of bacterial pathogens can be transported at ambient temperature
in transport media for up to 24 hours.
(iii) Transport tissue specimens for isolation of viral pathogens in viral transport medium or sterile
saline at 4-8°C for 24-48 hours. For longer periods, freeze and store at -70°C.
(iv) If rabies is suspected and brain samples are collected, freeze unfixed specimens immediately after
collection. Formalin-fixed samples are also useful and may be transported at ambient temperature.

33.11 Urine.
(a) Materials for Collection.
(i) Sterile plastic cup with lid (50 ml or more)
(ii) Clean, screw-top specimen transport containers (“universal” containers are often used)
(iii) Gauze pads
(iv) Soap and clean water (or normal saline) if possible.
(b) Method of Collection.
(i) Give the patient clear instructions to pass urine for a few seconds, and then to hold the cup in
the urine stream for a few seconds to catch a midstream urine sample. This should decrease the risk
of contamination from organisms living in the urethra.
(ii) To decrease the risk of contamination from skin organisms, the patient should be directed to
avoid touching the inside or rim of the plastic cup with the skin of the hands, legs, or external genitalia.
Tighten the cap firmly when finished.
(iii) For every patient it is necessary to wash the external genitalia with soapy water to reduce the risk
of contamination. If soap and clean water are not available, the area may be rinsed with normal saline.
Dry the area thoroughly with gauze pads before collecting the urine.
(iv) In case of infants, urine sample can be taken by suprapubic aspiration. A non-invasive method
of stimulating urine flow in a baby is by tapping just above pubis with two fingers at 1 h. after feed:
1 tap / sec for 1 min, an interval of 1 min is allowed and tapping resumed in this cycle.
(v) Label the specimen containers.
(c) Handling and Transport.
(i) Transport to the laboratory within 2–3 hours of collection. If this is not possible, do not freeze
but keep the specimen refrigerated at 4-8°C.
(ii) Keeping the specimen refrigerated will decrease the risk of overgrowth of contaminating organisms.
(iii) Ensure that transport containers are leak-proof and tightly sealed.

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33.12 Water.
(a) Collection of Samples.
(i) These should be collected under the supervision of the MO. A fair average sample of the supply
should be collected and submitted. Samples from any individual source should be taken at the same
point and at the same time for chemical and bacteriological examination.
(ii) Samples for chemical examination should measure at least 5 lit and should be forwarded in
Winchester bottles. Samples should be taken without disturbing any sediment and while the bottles are
fully submerged.
(iii) For bacteriological examination 180 ml is required. If circumstances allow the media should be
inoculated with water on the spot; a delay of 24 h in inoculation, however, does not affect the results.
Samples must be collected and forwarded in sterile bottles obtained from the laboratory. If chlorinated
water is being tested a crystal of sodium thiosulphate should be added to the sterile bottle, so that the
bacteriological picture at the time of sampling is obtained; otherwise, sterilization will continue during transit.
(iv) In piped supplies samples should be taken directly from the mains and from delivery taps to the
houses. Before a sample is taken, water should be allowed to run freely so that the impurities in the
pipe’s lumen may be washed out. Flame the tap for a minute before taking the sample, ensuring against
leakage from the washer at the top of the tap into the samples.
(v) Before reopening the sterilized bottle, flame its neck and stopper for half a minute by means of
split lamp. Remove the stopper and hold it with a sterilized pair of forceps. The stopper is flamed again
before it is replaced in the bottle, which in the meanwhile has been completely filled in, so that no
bubble of air is retained.
(vi) In the case of streams, rivers and lakes, collect water from the middle as well as from near the
banks. The bottle is filled by dipping the bottle (with a stopper in position attached to the neck with a
piece of string) below the surface and then removing the stopper under water with a forceps. This avoids
the collection of surface water with scum.
(vii) Samples from a well are obtained with bottles weighted with lead or stone having two cords
attached, one to the neck and the other to the stopper. The bottle is lowered to the required depth and
is filled by jerking out the stopper by means of the attached cord. The bottle should be quickly raised
after it is filled and then recapped.
(b) Transportation.
Each sample should be labelled giving full particulars of its source, date of collection and examination requested.
Samples should be forwarded by the most expeditious route. Those for bacteriological examination should reach
the laboratory within three hours of collection. Where a delay of more than three hours is unavoidable the
bottle must be kept on ice; and where the specimen must be transported some distance, it must be packed
with saw dust and ice and dispatched by courier escort.

33.13 Arthropods / Larvae.

(a) Arthropod specimens (ticks, lice, nits, bed bugs, etc.) should be collected using tweezers to remove or
extract from the skin if attached. Immerse parasite in 5-10 mL of 70-80 percent ethanol (or other alcohol) in
a clean container and secure the lid well to prevent leaking. Make sure to keep the arthropod as intact as
possible, identification is performed by visual analysis.
(b) If scabies is suspected, scrape the skin from the leading edge of the lesion. Place in 2-3 mL of
70-80 percent ethanol (or other alcohol) in a clean container.
(c) Identification is performed at a reference laboratory.
(d) Larvae.
Mosquito larval sampling should be done by standard larval ladles. The method is as follows-
(i) Dip the ladle sideways- a minimum of five dips may be taken for calculation of larval density.
(ii) Transfer the larvae into an enamel bowl- count the total number of larvae and calculate larval density.

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(iii) Other larval sampling procedures like larval nets (when water body has vegetation) or well nets (when
mosquito breeding is noticed in wells) may be used in specific situations.

33.14 Pus / Vesicular / Scab Collection.

For most dermatological conditions, diagnosis may be established on the basis of physical examination and clinical
history without the collection of diagnostic specimens. Important characteristics to be noted on physical examination
include the nature of the skin lesions (erythematous, macular, papular, maculopapular, vesicular, bullous, petechial,
purpuric, etc.) and the anatomic distribution of spread (central, peripheral, diffuse, etc.). In cases of indeterminate
diagnoses, unusual presentations, and some rare conditions, collection of specimens from rashes and / or skin lesions
may be necessary. In the case of vesicular rashes, specimens for microscopy and culture are taken directly from vesicles.
In other exanthemata (macular and / or papular), the diagnosis may be more readily established from alternative
specimens (e.g. blood cultures, serology). In suspected cutaneous anthrax or bubonic plague, specimens from the skin
lesions (eschars and buboes, respectively) and blood cultures may be taken.
(a) Materials for Collection.
(i) Sterile saline
(ii) Sterile swabs and appropriate transport media
(iii) Sterile screw-cap vials
(iv) Sterile lancets or needles (for piercing of vesicles)
(v) Syringe with wide-bore needle (for aspiration of abscesses / buboes)
(vi) Wide-mouth screw-cap containers (for biopsy specimens)
(vii) Glass slides and slide boxes.
(b) Method of Collection.
(i) Vesicular or Vesiculo-pustular Rash (for diagnosis of viral infections).
(aa) Pierce roof of fluid-containing vesicle with sterile lancet.
(ab) Swab fluid with sterile swab. Try to get a good amount of fluid onto the swab.
(ac) Take a clean labelled microscope slide and make a smear with the swab in the central
area of the slide. Make 2 slides if possible. The slides should be left to dry in air.
(ad) Place swab directly into virus transport medium.
(ae) Label the bottles or tubes containing swabs in transport media.
(af) When glass slides have dried, place carefully into a plastic slide box. Do not refrigerate or
freeze the slides during storage or transport. Keep in the closed container at room temperature.
(ii) Crusting Stage.
(aa) Gently ease off crust with a lancet or scalpel and a pair of disposable forceps.
(ab) Take 5-10 crusts; place them in a plastic screw-cap vial. Make sure the lid is tightly closed.
(ac) Label the specimen containers.
(ad) Discard forceps, lancets, and scalpels into sharps disposal container. Do not re-use forceps
on specimens from another patient.
(ae) If cutaneous anthrax is suspected, the vesicular fluid under the eschar is a better diagnostic
specimen than a piece of the eschar.
(iii) Aspiration of Abscesses.
(aa) Aspiration of abscesses should only be performed by experienced personnel.
(ab) Disinfect the skin overlying the abscess / bubo with 70% isopropyl alcohol.
(ac) Aspirate the fluid from the abscess with a sterile needle and syringe. Only enough fluid to

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COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

perform the diagnostic tests is required.

(ad) Transfer the aspirate aseptically into a sterile tube with transport medium.
(c) Labelling and Identification of Specimens.
Each specimen should be labelled. The information on the label should correspond with the patient information
in the register book and on the case investigation form. Adequate labelling ensures that the laboratory results
can be linked to the correct patient. The label may be a piece of paper attached to the specimen container.
Alternatively, the information may be written directly on the specimen container. The label should be permanently
affixed to the specimen container. It should contain the following:
(i) Patient name
(ii) Unique identification number
(iii) Specimen type and date and place of collection
(iv) Name or initials of specimen collector.
Glass slides for microscopy must be labelled individually, and this should not interfere with the staining process.
Each slide should bear the patient’s name, unique identifier, and date of collection. The laboratory may require
other information to select and interpret the necessary tests; this may include:
(i) Patient information.
Age (or date of birth), sex, complete address
(ii) Clinical information.
Date of onset of symptoms, clinical and immunization history, risk factors or contact history where
relevant, antimicrobial drugs taken prior to specimen collection.
(iii) Laboratory information.
Acute or convalescent specimen, other specimens from the same patient.
(d) Storage, Packing and Transport of Specimen.
To preserve bacterial viability or viral integrity in specimens for microbiological culture or inoculation, they
should be placed in appropriate media and stored at recommended temperatures. These conditions must be
preserved throughout transport to the laboratory and will vary according to transportation time. They will differ
for specimens and pathogens, depending on their sensitivity to desiccation, temperature, nutrient, and pH.
In any outbreak investigation, it should be considered essential to consult the receiving laboratory about the
handling of the most likely specimen types before setting out into the field.
Many specimens taken for viral isolation are acceptable for culture after two days if maintained in type specific
media at 4-8°C. For longer periods, freeze these specimens as directed by expert advice, as infectivity may
be altered. For prolonged storage periods, preservation at –70°C may be indicated.
Specimens for bacterial culture should be kept in appropriate transport media at the recommended temperature.
This ensures bacterial viability while minimizing overgrowth of other microorganisms. With the exceptions of
urine and sputum, most specimens may be kept at ambient temperature if the specimen will be processed
within 24 hours. For longer periods, storage on at 4-8°C would be advisable with the exception of particularly
cold-sensitive organisms, such as shigella, meningococcus, and pneumococcus. Longer delays are not advisable
as the yield of bacteria may fall significantly.
Specimens for antigen or antibody detection may be stored at 4-8°C for 24-48 hours, or at –20°C for longer periods.
Some specimens may require special handling, for example freezing, so specific instructions should always be
sought prior to collection. Sera for antibody detection may be stored at 4-8°C for up to 10 days. It is important to
avoid unnecessary freeze-thaw cycles, so do not freeze sera unless the facilities are available to keep them frozen
until delivery. Although not ideal, sera stored at room temperature may still be useful for antibody testing even after
prolonged periods (weeks) if the sample is collected in a sterile container and is not contaminated. Therefore, do
not discard sera which have been collected simply because there are no refrigeration facilities available. Valuable
information can sometimes be obtained from samples which have not been handled optimally because of resource
or logistic limitations, but for the correct laboratory handling and interpretation of results the samples must be

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labelled and accompanied by a history of the storage and transport conditions.

(i) Packing.
Standardized packaging methods and materials ensure safety of personnel and specimen integrity, even
if the package is damaged during transport. Laboratory request forms must accompany the labelled
specimens. Specimens must be packaged, labelled, and transported in compliance with specific national
and international regulations for infectious materials. Address labels on outer packages should display
the sender and laboratory name with complete addresses and telephone numbers for both the sender
and receiver. Documentation should also contain specimen details (number, type, date of collection),
appropriate biohazard labels, and the storage temperature requirements.
(ii) Triple Packaging System and Maintenance of Transit Temperature. (Fig 33.1)
The specimen is in the labelled primary container which must be watertight, airtight, and wrapped in
absorbent material (e.g. cotton wool) in case of leakage. If necessary, tape the label to the container to
prevent it loosening in transit. Place the primary containers in a single durable, watertight, and leakproof
secondary container or a sealed plastic bag if this is not available. Use additional absorbent material to
cushion multiple primary receptacles. A biohazard label and the laboratory request form sealed in a plastic
bag should be taped to the outside of this secondary container. The outer package protects the contents
from physical damage and water while in transit. It should have a resistant, high density external cover
(e.g. metal, wood, or fibreboard), shock-absorbent padding on the inside, and a tight-fitting lid. The outer
package must be leak-proof and well insulated, and can contain ice, cold packs or dry ice when required.
The rigid outer package is placed within an outer carton of double-ply corrugated cardboard or plastic, and
a biohazard label is applied. The specimen carriers and ice packs can be reused after disinfection.

Fig. 33.1 : Triple Packaging System

(iii) Maintenance of Transit Temperature.
(aa) 4-8ºC.
The transport box should be fitted with a minimum of 4 ice packs, or more if room is available,
around the secondary container. This will maintain refrigeration for 2-3 days. If available, a cold
chain monitor should be inserted.
(ab) -20ºC.
Use 2 kg of dry ice within the insulated outer package, which must permit the release of carbon
dioxide gas to prevent explosions. This will keep the specimens frozen for 1-2 days.

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Annexure L4: Specimen Referral Form

CASE ID NUMBER:

SPECIMEN REFERRAL FORM

SPECIMEN INFORMATION:

Specimen source / type: Collection date: D D M M Y Y Y Y

Fresh stool Stool Swab Rectal Swab Other (please list) Time colleced : H H M N

INFORMATION ABOUT PERSON / FACILITY REQUESTING TEST:

Name of Person sending the specimen:

Designation:

Phone Number:

Email:

Type of Facility from where the specimen was sent:

District Hospital CHC / Block PHC PHC Other (List) N / A, specimen sent directly from field

Facility Name:

PATIENT DEMOGRAPHICS:

Name: Age: Years Months

Sex: Male Female S / O, D / O, W / O

Address

(Street Address) (Village) (Block) (District) (State)

Patient Phone Number:

PATIENT CLINCIAL HISTORY:

Date of Onset of Illness:  /   / (DD MM YYYY)

Time of Onset of Illness: AM PM Clinical Signs / Symptoms (TICK ALL THAT APPLY):

Diarrhea Vomiting Nausea Fever

Presence of Mucous / Blood in Stool Other (please specify)

Antimicrobial Treatment Received Prior to Specimen Collection: Yes No Unknown

If Yes, Specify which antibiotic: Hospitalized for this illness: Yes No Unknown

Primary Diagnosis:

Laboratory Examination Requested:

Facility to which specimen is being sent:

Type of Examination Requested (Tick all that apply):

Stool Microscopy and Bacterial Culture Microscopic Examination for Parasites
Antimicrobial Susceptibility Testing Other

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Suggested Reading.
1. IDSP. training manual for state & district surveillance officers, Case definitions of diseases & syndromes under
surveillance, Module 5 [Internet]. [Accessed 2024 Feb 28]. Available from: https://idsp.mohfw.gov.in/WriteReadData/
OldSite/2WkDSOSept08/Resources_files/DistrictSurvMan/Module5.pdf
2. DSP, Training manual for state & district surveillance officers, Laboratory methods for confirmation of diagnosis,
collection, storage, transportation of specimen, Module 6 [Internet]. [Accessed 2024 Feb 28]. Available from: https://
idsp.mohfw.gov.in/WriteReadData/OldSite/2WkDSOSept08/Resources_files/DistrictSurvMan/Module6.pdf
3. Centre for Disease Control and Prevention. Outbreak Case Definitions [Internet]. 2008 [Accessed 2024 Feb 28].
Available from: https://www.cdc.gov/urdo/downloads/CaseDefinitions.pdf
4. Integrated Disease Surveillance Programme (IDSP), Data Management: [Internet]. idsp.mohfw.gov.in. [Accessed
2024 Feb 28]. Available from: https://idsp.mohfw.gov.in/index4.php?lang=1&level=0&linkid=412&lid=3695#:~:text=
5. National Centre for Disease Control (NCDC), Training Manual for Medical Officers For Hospital Based Disease
Surveillance 2 Training manual for Medical Officers [Internet]. [Accessed 2024 Feb 28]. Available from: https://idsp.
nic.in/WriteReadData/OldSite/MedOff.pdf
6. CDC. Guidelines for Specimen Collection | Foodborne Outbreaks | Food Safety | CDC [Internet]. www.cdc.
gov. 2018. [Accessed 2024 Feb 28] Available from: https://www.cdc.gov/foodsafety/outbreaks/investigating-outbreaks/
specimen-collection.html
7. CDC. Influenza Specimen Collection Nasopharyngeal Swab [Internet]. [Accessed 2024 Feb 28]. Available from:
https://www.cdc.gov/flu/pdf/freeresources/healthcare/flu-specimen-collection-guide.pdf
8. IDSP. Action points for laboratory investigation of suspected foodborne/ADD outbreak and routine laboratory-
based surveillance [Internet]. [Accessed 2024 Feb 28]. Available from: https://idsp.mohfw.gov.in/WriteReadData/
l892s/71326225631477052556.pdf
9. WHO New sample collection kit 2022 technical note scope of sample collection kit 2022 [Internet]. [Accessed
2024 Feb 28]. Available from: https://cdn.who.int/media/docs/default-source/documents/emergencies/supplies/
sck2022-content 31august2022.pdf?sfvrsn=6a8509cb_5&download=true
10. WHO. Laboratory Quality Management System The laboratory’ s responsibilities Test requisition Sample collection
requirements 5-3: Collection and preservation [Internet]. [Accessed 2024 Feb 28]. Available from: https://extranet.who.
int/lqsi/sites/default/files/attachedfiles/LQMS%205-3%205-6%20Sample%20collection%20transport.pdf
11. WHO. BASIC LABORATORY PROCEDURES [Internet]. [Accessed 2024 Feb 28]. Available from: file://C:/Users/
Admin/Downloads/9241545453.pdf
12. National Centre for Disease Control (NCDC) UNDER IDSP MANUAL FOR HEALTH WORKERS INDEX [Internet]. 2015
Jun [Accessed 2024 Feb 28]. Available from: https://idsp.mohfw.gov.in/WriteReadData/OldSite/HWM.pdf
13. UNC SCHOOL OF PUBLIC HEALTH. Collecting Specimens in Outbreak Investigations [Internet]. 2009 [Accessed
2024 Feb 28]. Available from: https://nciph.sph.unc.edu/focus/vol4/issue2/4-2Specimen_issue.pdf
n

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Chapter
XXXIV
ARTHROPOD BORNE DISEASES
MEDICAL ENTOMOLOGY
34.1 Definition.
The word ‘Entomology’ is derived from the Greek words ‘ENTOMON’ meaning an insect and ‘LOGOS’ meaning a science.
Medical entomology is that branch of entomology which deals with the ecology of insects, arachnids and other arthropods
in relation to the causation of pathological conditions or transmission of pathogenic organisms to man. It is thus an inter-
disciplinary branch of biological science. Various creatures differ in details with regard to their morphology, life cycle and
habits, but possess certain common features, which group them together under a ‘Phylum’. Phylum Arthropoda is the
largest group in the animal kingdom. They are segmented invertebrates with bilateral symmetry, hard exoskeleton and
paired jointed appendages; the last character gives this phylum the name ‘Arthropoda’. They have a single body cavity
containing the haemolymph, in which the various internal organs float. The life cycle may be simple with only ovular,
larval and adult stages or may be with complicated metamorphosis through pupal stage and intermediary sub stages.

34.2 Classification of Arthropods.

Diversity of structures amongst arthropods necessitates the sub division of the phylum Arthropoda into a number of
classes, orders, families, genera and species. The following classes include species of medical importance.
(a) Class Insecta.
It comprises about 70 percent of all the known species in the animal kingdom. The body is divided into head,
thorax and abdomen. The head bears the mouthparts and a pair of antennae. The thorax is subdivided into
three segments with a pair of legs in each. The class is further subdivided into 29 orders of which only 4 contain
species of medical importance.
(i) Order Diptera.
It possesses one pair of wings (Greek: Di-two, ptera-wings) and a pair of ‘halters’, which are vestigial wings.
This is the largest order comprising about one and half lakh described species with worldwide distribution.
It contains such insects of medical importance as mosquitoes, sandflies, simulium flies and houseflies.
(ii) Order Anoplura.
It comprises of true or sucking lice, which are parasitic on mammals and the chewing lice, which infest
birds as well as mammals. Lice of medical importance to man are the human lice.
(iii) Order Siphonaptera.
It contains many species of fleas including the rat flea, the vector of plague and endemic typhus.
(iv) Order Hemiptera.
It contains the bedbugs and some other species like kissing or ‘assassin’ bugs, which act as vectors of
Chagas disease.
(b) Class Arachnida.
It includes arthropods like ticks, mites, spiders and scorpions. The body consists of cephalothorax, in which the
head and thorax are fused together and the abdomen. The cephalothorax bears six pairs of appendages, the
first two pairs function as mouthparts and last four pairs as walking legs. They have no feelers, antennae or
wings.
(c) Class Crustacea.
It includes lobsters, crabs, water fleas and cyclops; some species of these are intermediate hosts of certain
human helminths, e.g. Cyclops as intermediate host of guinea worm infestation.

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 ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY

(d) Class Myriapoda.

It includes centipedes and millipedes.

34.3 Mode of Transmission.

Many species of arthropods have been closely associated with the transmission of pathogens in domesticated animals
over millions of years. Since many problems of the two fields overlap, relationship of medical entomology to veterinary
entomology is very close. Many of the free-living arthropods have in course of time become parasitic. Some burrow
into the skin, others invade the alimentary tract causing myiasis and still others have become blood suckers e.g., bugs,
sucking lice, sand flies and mosquitoes. Some of these insects, by virtue of their blood sucking habit, have become
vectors of pathogenic organisms. When the pathogen is transmitted on the outside or inside of the bodies of arthropods
without undergoing any development, propagation or any changes in the pathogenicity, it is called the ‘mechanical’
mode of transmission. When the arthropod serves as obligatory host for the pathogen to undergo further development
or propagation in the course of transmission from one vertebrate host to the other, it is called the ‘cyclic’ or ‘biological’
mode of transmission. In this mode of transmission when the parasite undergoes numerical multiplication in the
arthropod hosts without any morphological change, it is called the ‘propagative’ development; this occurs in the case
of viruses, rickettsia, spirochaetes and some bacteria. When the parasite changes its morphology without numerical
multiplication, it is called the ‘cyclo-developmental’ change; this occurs in the case of filariasis. When both multiplication
and morphological changes occur, as seen in the case of malarial parasite, it is called ‘cyclo-propagative’ development.
The definite period essential for completing the cyclic development in the arthropod host before it becomes infective
is called the ‘extrinsic incubation period’. The vertebrate hosts may be man or any particular species of animals. The
intermediary arthropod host acts as obligatory vector in between human hosts causing epidemics or in between animal
hosts causing epizootics or in between animals and human hosts causing zoonoses. In certain infections, transovarian
transmission occurs in arthropods when the infective organisms pass through the eggs to the next generation. Under
such circumstances the arthropod serves as a vector and also as a reservoir of the infection, besides the vertebrate
reservoir.

34.4 Chain of Transmission.

Arthropod borne human diseases progress in a chain of events. The chain consists of several links. The first link is
the development of infection in human body. The second link concerns the morphology, bionomics and ecology of the
arthropod vector and the third is the development of the pathogen within the vector. The fourth link is the mode and
mechanism of transmission of infection to human host. An extra link in the infection chain of zoonoses is similar to
the first link but in the body of an animal host.

34.5 Arthropod Borne Diseases.

Arthropods are responsible for transmission of innumerable diseases. Some of the important diseases showing the
vector responsible for transmission, the causative organisms and their reservoir host are given in Table 34.1.
Table 34.1 : Arthropod Borne Diseases
Disease Vector Causal organism Reservoir
(a) Mosquito Borne Diseases
Malaria Anopheles species Plasmodium species Man
Filariasis Culex quinquefasciatus Wuchereria bancrofti Man
(nocturnal, periodic)
Aedes niveus group Wuchereria bancrofti Man
(diurnal, sub-periodic)
Mansonoides species Brugia malayi Man, Primate
Chikungunya Aedes aegypti & Arbovirus group A Man
Aedes albopictus
Dengue fever Aedes aegypti & Aedes Arbovirus group B Man
albopictus

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Disease Vector Causal organism Reservoir

Dengue haemorrhagic fever Aedes aegypti & Aedes Arbovirus group B Man
albopictus
Yellow fever Aedes aegypti & Aedes Arbovirus group B Man / Monkeys
albopictus
Zika Aedes aegypti & Aedes Arbovirus group B Man / Monkeys
albopictus
Japanese Encephalitis Culex vishnui group Arbovirus group B Mammals / Birds
West Nile Fever Culex species Arbovirus group B Birds
(b) Sandfly Borne Diseases
(i) Leishmaniasis
(a) Visceral (Kala azar) Phlebotomus argentipes Leishmania donovani Man
(b) Cutaneous (Oriental sore) Phlebotomus papatasi Leishmania tropica Man
(c) Espundia Phlebotomus sergenti Virus Man
(ii) Sandfly fever Phlebotomus sergenti Virus Man
Phlebotomus papatasi
(c) Fly Borne Disease
Bacillary dysentery Musca domestica Shigella Man
Amoebic dysentery Musca domestica Entamoeba histolytica Man
Gastroenteritis Musca domestica Specific / Non specific Man / animals
organisms
Food poisoning Musca domestica Salmonella spp Man / Rodents
Typhoid Fever Musca domestica Salmonella typhi Man
Paratyphoid Fever Musca domestica Salmonella paratyphi Man
A&B
Cholera Musca domestica Vibrio cholera Man
Poliomyelitis Musca domestica Polio virus Man

Viral hepatitis (Type A) Musca domestica Hepatitis A virus Man

Conjunctivitis & Trachoma Musca domestica Chlamydia trachomatis Man

Anthrax Musca domestica Bacillus anthracis Man
Yaws Musca domestica Treponema pertenue Man
(d) Flea Borne Diseases
Plague (Bubonic) Xenopsylla cheopis Yersinia pestis Rodents

Endemic / Murine Typhus Xenopsylla cheopis Rickettsia typhi Rodents / Domestic

animal
Chiggerosis (Jigger) Tunga penetrans (chigoe) - -
Dipylidium caninum Ctenocephalides Dipylidium caninum Dogs, cats, wild
felis / canis carnivores

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Disease Vector Causal organism Reservoir

Hymenolepiasis X cheopis / Hymenolepsis diminuta Dogs, cats, wild
carnivores
Nosopsyllus fasciatus
X cheopis / C canis / Rats, mice
Pullex irritans Hymenolepis nana
(e) Louse Borne Diseases
Epidemic typhus Pediculus humanus Rickettsia prowazeki Man

Epidemic relapsing fever Pediculus humanus Borrelia recurrentis Man

Trench fever Pediculus Borrelia quintana Man / animals
humanus / capitis
Dermatitis - Secondary organisms Man
(f) Tick Borne Diseases
(i) Hard tick species

Kyasanur Forest Disease (KFD) Haemophysalis spinigera Flavivirus Ticks

Indian Tick typhus Rhiphicephalus Rickettsia conori Dogs / Rodents
sanguineus
Crimean Congo Heamorrhagic Hyalomma anatolicum Nairovirus Ticks
Fever (CCHF)
Lyme Disease Ixodes scapularis Borrelia burgdorferi Ticks

Rocky Mountain Spotted Fever Dermacentor Rickettsia rickettsii Ticks

(RMSF)
variabilis
Tularaemia Dermacentor Francisella tularensis Rabbits / Rodents / Cattle
variabilis
(ii) Soft tick
Relapsing fever Ornithdorus moubata Borrelia duttoni Rats

(g) Mite Borne Diseases

Scrub typhus Leptotrombidium Orientia tsutsugamushi Trombiculid mite
deliense
Rickettsial pox Schoengastiella ligula Rickettsia akari Rodents
Liponyssoides
sanguineus
Scabies Sarcoptes scabei - Man
(h) Cyclops Transmitted Diseases

Dracunculiasis Cyclops species Dracunculus Dogs

medinensis
(Guinea worm disease)
Fish tape worm Cyclops species Diphyllobothrium latum Fish

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Disease Vector Causal organism Reservoir

(j) Reduviid Bugs Transmitted Disease
Chagas disease Reduviid / Cone-nosed Trypanosoma cruzi Domestic animals / man
bugs
(k) Glossina Species (Tsetse flies) Transmitted Disease
Trypanosomiasis Glossina species Trypanosoma Wild
gambiense animals / cattle / man
T. rhodesiense

34.6 Mosquitoes.
(a) Classification.
The mosquitoes belong to phylum Arthropoda, class Insecta, order Diptera and family Culicidae. Among the
numerous species of blood sucking arthropods that annoy man and other warm-blooded animals, mosquitoes
stand out most prominently. The family Culicidae is divided into sub-families; the Culicinae, the Chaoborinae
and the Dixinae. Of these only the sub-family Culicinae, which comprises all the true mosquitoes, is of medical
importance.
(b) Distribution.
Mosquitoes have a worldwide distribution, being found in the tropics, temperate zones and also in the arctic
circles. They have even been found breeding in underground tunnels, deep mines and at altitudes as high as
4,000 m above sea level. There are about more than 3,000 described species of mosquitoes in the world,
grouped in 41 genera out of which only ten contain species of medical importance. Only the Anopheles, Culex,
Aedes and Mansonia are of importance in India.
(c) Morphology.
Mosquitoes are small, slender bodied and not more than a centimetre long. The division of the body into the
head, thorax and abdomen is sharply defined. The head bears two large compound eyes, long antennae and
elongated mouthparts. Each antenna has 14 to 15 segments. In the male, it is densely covered with long hairs
and looks like a test tube brush; in the female, it is very sparsely haired. The mouthparts drawn out to form
the elongated proboscis, consist of a gutter-shaped labium, a pair of maxillary palps and a biting fascicle. The
fascicle is composed of the labrum, the hypopharynx, a pair of maxillae and a pair of mandibles. The common
salivary duct runs through the middle of hypopharynx. The mouth parts of the two sexes resemble each other
superficially but the mandibles and maxillae of only the female are developed for cutting the human skin.
Therefore, only the female mosquitoes can suck the blood and transmit diseases. The thorax of the mosquito
is stoutly built and slightly bumped. It consists of three segments viz. the pro, meso and meta thorax, each of
which bears a pair of long and slender legs terminating into claws. The mesothorax also bears the wings. The
abdomen consists of 10 to 11 segments of which 7 or 8 are clearly marked out and the terminal ones form
the male and female external genitalia.
(d) Life History.
All mosquitoes breed in water. While developing, they undergo complete metamorphosis through the stages of
egg, larva, pupa and adult. The number of eggs laid at each oviposition varies between 50 and 150. The eggs
of Aedes species can withstand desiccation up to 8 months. The total number of eggs laid during the lifetime
depends on the species, longevity of the mosquito, the blood supply and the environmental temperature and
humidity. The eggs hatch into larvae in one to two days, but in cold weather the hatching may be delayed.
Mosquito larvae feed voraciously on microorganisms, water algae or other organic matter and breathe through
spiracles. They move actively with wriggling motion, hence are known as “wrigglers”. Larvae pass through four
stages or instars in five days depending on the species, the temperature of the water and availability of food
supply. At the end of the fourth instar the fully grown larva casts its skin and becomes a pupa. During this stage
it undergoes transformation to the adult usually within three days. The adult mosquito wriggles out of the pupal
skin through a ‘T’ shaped slit and balances itself on the water surface or some nearby floating object until its
wings are dry and then flies off. The total duration of the life cycle varies between seven days to one month.

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The life span of adult mosquitoes is upto a maximum of 6 months in the temperate zones, but in the tropics,
they seldom survive for more than a month.
(e) Bionomics.
The females of all the medically important mosquitoes are normally bloodsuckers, as they require a blood meal
for maturation of eggs. Females are fertilized during swarming (nuptial dance) at dusk. The source of the blood
meal varies with the species. Those feeding on human blood are called anthropophilic and those feeding on
animals are called zoophilic. Estimation of human biting habit by different species is measured using Human
Blood Index (HBI), which can be used as a proxy measure of malaria transmission. Majority of species are
nocturnal in their feeding habits. some are diurnal while others feed indiscriminately by day or night. Some are
outdoor biters (exophagous) and some are indoor biters (endophagous). After the blood meal the female goes
in search of a quiet place indoors (endophilic) or outdoors (exophilic) to rest for a variable period, usually 2 to
4 days and matures her eggs. When the eggs are fully matured, she goes in search of a water collection to lay
them. The resting and oviposition places differ according to the species of the mosquito. Male mosquitoes feed
on flower-nectar and plant-juices and do not survive long after fertilizing the female mosquito.
(f) Vector Potential.
Certain species of Anopheline mosquitoes are vectors of Plasmodia causing human malaria. Some species of
Culicine and Mansonoides mosquitoes cause human filariasis. Aedes mosquitoes cause yellow fever, dengue,
dengue haemorrhagic fever, zika and chikungunya.
Many species of mosquitoes belonging to the genera
Culex and Aedes are the vectors of a number of
viral encephalitis. Vector potential is possessed only
by certain species of a particular genus and for
specific infection only. All species are not efficient
in spreading the particular infection. The potential
generally depends upon the feeding, breeding and
resting habits and the biological capability of serving
as a host to an aetiological agent. A short description
of the important genera is given below.
(g) Genus Anopheles. (Fig 34.1)
Members of this genus have 63 species in India.
There are 6 primary and 3 secondary / local species
of Anopheline mosquitoes which are the vectors of
human Plasmodia in India. In certain parts of the
world some species of Anopheline mosquitoes are
the vectors of W. bancrofti and B. malayi infections as
well. Anophelines mostly breed in fresh, unpolluted
and oxygenated water. The larvae of a few species
like Anopheles subpictus may be found in polluted
water. The major malaria vector species prevalent in Fig 34.1 : Anopheles Mosquito
different ecosystems in India are given in Table 34.2.
Table 34.2 : Major Malaria Vector Species Prevalent in Different Ecosystems in India
S. Major Vector Species and
Ecosystem Regions / States
No. Sibling Species Observed in Ecosystems
(a) Rural plains, undulating An. culicifacies A, B, C, D, E (sibling Entire country
plains species with variable prevalence exhibit
specific sympatric associations)
(b) Plain and undulating An. culicifacies B, C, D Central and eastern regions:
forests (deep valleys, hills An. fluviatilis S, T Madhya Pradesh, Chhattisgarh,
and hillocks with thick Jharkhand
forests)

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S. Major Vector Species and

Ecosystem Regions / States
No. Sibling Species Observed in Ecosystems
(c) Hilly-forested terrains An. fluviatilis S, T Eastern region: Odisha,
An. culicifacies B, C, E Chhattisgarh and Andhra Pradesh.

An. minimus Eastern region: parts of Odisha

An. fluviatilis S, T
(d) Forest and forest-fringe An. baimaii All northeastern states
areas of northeast
An. baimaii Northeastern states: Arunachal
An. minimus Pradesh, Assam, Manipur,
Meghalaya, Mizoram, Nagaland
and Tripura
(e) Foothill regions An. minimus Northeastern states

(f) Deforested areas where An. minimus Northeastern states: Assam,

rice cultivation is prevalent An. culicifacies s. l. Manipur, Meghalaya, Sikkim
(g) Peri-urban areas An. stephensi Delhi, Goa, Tamil Nadu, etc.
An. culicifacies s. l.
(h) Urban and semi-urban An. Stephensi-3 ecological forms-type Andhra Pradesh, Delhi, Goa
areas form, intermediate form, var. mysorensis Maharashtra, Kerala, Telangana,
Tamil Nadu, West Bengal
(j) Arid zone An. Stephensi-type form and Rajasthan, Gujarat
var. mysorensis
(k) Island ecosystem areas An. sundaicus species D (cytotype D) Andaman and Nicobar Islands
with brackish water and
freshwater breeding places
Adult mosquitoes of the various species differ from each other in their feeding habits, resting habits, range of flight
and dispersion. However, it is difficult to assign any single habit as an essential requirement for malaria transmission.
All-important vector species are preferentially anthropophilic. Flight and dispersion show variations amongst various
species. The time of feeding is also variable; some species prefer the dusk for their blood meals, others late night
while still others select the early morning. A knowledge of their habits is
useful in designing control measures. An identification kit for common
Anophelines of India is attached as Appx ‘A’.
(h) Genus Culex. (Fig 34.2)
Members of this genus are found in temperate and tropical
zones throughout the world. There are 240 Indian species in this
Genus. Adult mosquitoes of this genus are generally dull in colour
and inconspicuous due to unspotted wings. Their breeding sites
vary from clear water, such as wells and springs, to collections
of muddy, brackish or polluted water; but unlike Anopheline
mosquitoes these mosquitoes generally prefer stagnant and
muddy pools. Culex quinquefasciatus is prevalent universally. It
is a night biting mosquito and is the most important vector of
W. bancrofti.
(j) Genus Aedes.
Some members of the Aedes have almost worldwide distribution
while others have restricted habitats. The chief species in India Fig 34.2 : Culex Mosquito

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are Aedes aegypti, Aedes albopictus and Aedes vittatus. They are black or dense brown and medium sized
mosquitoes with silvery white scales forming patterns on the thorax, bands on the legs and rings around each
abdominal segment. These are container breeders. The cigar shaped eggs are laid singly on damp surfaces
on stagnant water. These mosquitoes are mostly anthropophilic and are adapted to domestic or semi-domestic
environments. During the pre-monsoon period the breeding is restricted to water collections meant for domestic
use. Communities or sections of the cities with water scarcity, which leads to water storage practices, are mostly
harassed by Ae. aegypti. In the shore areas, barges and country crafts provide ample places for Aedes breeding
and constitute a permanent source of Aedes infiltration in the shore establishments and cities. They are well
adapted for breeding in small collections
of water in a wide variety of natural and
artificial containers such as masonary
tanks, earthenware pots, small and
large tins, barrel drums, coconut shells,
stored or discarded motor car tyres,
junk and hardware, flower pots, fire
buckets, depressions in tree trunks,
axils of leaves and so on. Most common
household breeding places are water
collection tray of refrigerator, desert
water coolers, flower pots, discarded
plastic waste, overhead water tanks etc.
They may breed in tree holes. The eggs
after maturing may remain viable for Aedes albopictus Aedes aegypti
considerable periods even after drying- Fig 34.3 : Morphological Difference between
up of the breeding sites and hatch out Ae. albopictus and Ae. aegypti
during rains. Such surviving eggs rapidly
build up the adult mosquito population
when rains come. Their capacity to complete life cycle indoors enables them to breed in urban areas throughout
the year, irrespective of the prevailing external climate. They are generally diurnal feeders but may feed at night
also. They may feed indoors or outdoors and rest near the breeding places in dark, shady corners and such
places as behind cupboards, hanging clothes, inside shoes, umbrellas, below the furniture and in containers
providing breeding sites. Aedes mosquitoes are the vectors of urban and rural yellow fever, dengue, dengue
haemorrhagic fever, zika and chikungunya. Ae. niveus has been reported as vector of W. bancrofti (diurnally sub
periodic) infection in Nicobar islands. Aedes aegypti and Aedes albopictus, the two important vector species can
be easily distinguished by their thoracic pattern. Ae. aegypti has sickle or lyre shaped pattern on the thorax,
whereas Ae. albopictus has a single central mark present on the thorax (Fig 34.3).
(k) Genus Mansonia. (Fig 34.4)
This has wide distribution in tropical countries. In India, Mansonia annulifera, Mansonia uniformis and Mansonia
indiana are the prevalent species in Kerala. The adult mosquitoes are robust and yellowish brown. The wings
are covered with flat, broad scales, which give the wings a speckled appearance as if dusted with mixed salt
and pepper. The female lays eggs in cluster anchored to the under surface of the leaves of aquatic plants such
as Pistia, Lemna, Eichornia, Salvinia and
so on. On hatching out, the larvae obtain
oxygen from the plant cells through their
modified siphon tubes by attaching
themselves to the rootlets of these
plants. The pupae are similarly attached
to the plant stems by the modified
breathing trumpets. When matures, they
detach themselves and come to the
water surface. The adults then emerge
and fly away. They are persistent biters,
particularly during darkness. Mansonia
mosquitoes are the vectors of B. malayi Fig 34.4 : Mansonia Adult with Wing Depicting Typical Salt &
infection of filariasis in several pockets in Pepper Appearance

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rural areas of Kerala, Tamil Nadu, Andhra Pradesh, Madhya Pradesh, Assam and West Bengal.
Some of the important differences between Anopheline and Culicine mosquitoes are shown in Table 34.3.
Table 34.3 : Important Differences between Anopheline and Culicine Mosquitoes
Sr.
Stage Anopheline Culicine
No.
(i) Egg O Boat shaped O Elongated
O Laid singly O Aggregation occurs into rafts of hundreds
of eggs in Culex.
O Possess two lateral floats.
O Aedes eggs are laid singly.
O Mansonia eggs are laid on under surface of
leaves of aquatic plants in star shaped clusters.
(ii) Larva O No siphon tube but only apertures on 8th O Single siphon tube on 8th abdominal
abdominal segment. segment.
O Larvae rest parallel to the surface of water. O In Culex, siphon tube is long and narrow
whereas, in Aedes, it is short and broad.
O Swim with swift wriggling movements. Mansonia larvae are attached to roots of
O Palmate hairs for floatation arranged in aquatic plants.
pairs on all abdominal segments. O Culicine larvae rest at an angle to surface.
O Swim with slow snail or worm like
movements.
O No palmate hairs for floatation.
(iii) Pupa O Pupa is comma shaped. O Pupa is comma shaped.
O In Anophelines, spiracle is short stumpy O In Culicines, spiracles are longer, slender
and funnel shaped. and trumpet shaped.
O Breathing trumpets are broad and short. O Breathing trumpets are long and narrow.
(iv) Adult O Wings usually spotted. O Wings usually not spotted.
O Rests at an angle to surface, with the O Rests parallel to the surface.
exception of An. culicifacies. O Thorax is humped.
O In the male, palpi are long and club shaped O In the male palpi long and tapering and
at the termination; in the female, they are as
deflected out; in the female palpi are much
long as proboscis and are straight.
shorter than proboscis and budlike.
O Accumulation of scales at anterior border O No dappling
of wings giving a dappling appearance.
O Last abdominal segment is narrow and
O Last abdominal segment is broad and
pointed.
rounded at tip.
(v) Breeding O Prefer fresh water such as running water, O Culex spp. oviposit in dirty, contaminated
rain water, water used for irrigation purposes, water such as those in the drains, cess pit,
streams, lakes etc. ditches etc., Aedes spp. usually prefers water
held in containers, such as tanks, water stored
in buckets, rain water in the tree holes, tyres,
tins, pots etc.
(l) Mosquito Control.
Anti-adult measures and anti-larval measures are the two most important mosquito control measures. Personal
protection against their bites aids these measures in control of disease.

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(i) Anti-adult Measures.

(aa) Residual Insecticides.
The residual insecticide spray has been conclusively established as a major method for use against
adult mosquitoes for controlling mosquito borne diseases, though not of mosquitoes themselves. This
is a more practicable and simpler method of interruption of transmission of disease than species
eradication. For the limited objective of disease control, it is not necessary to carry out the work
throughout the year or in the entire territory but only in houses and shelters in endemic zones during
the transmission season. However, there are certain conditions under which the absolute efficacy of
this procedure may be doubted, for instance, where people sleep outdoors without mosquito nets or
the vector mosquito bites habitually out of doors or though biting indoors it does not rest indoors
or where the surfaces sprayed are subject to frequent mud plastering or white washing. Even when
local conditions do not appear to be absolutely favourable, the application of residual insecticide gives
relative success in disease control. DDT, Malathion and the members of synthetic pyrethroids like
Cyfluthrin, Deltamethrin etc. are the residual insecticides of choice depending upon the susceptibility
of the vectors.
(ab) Space Sprays.
Space spraying of insecticides can be used against adult mosquitoes. Pyrethrum in the strength of
0.1 percent is an excellent space spray. It is used mainly when an uncontrolled, unknown or infected
area has to be occupied at a short notice or when an unforeseen epidemic breaks out. Space spraying
carried out more often results in better mosquito control. Aerosols are also used as space insecticides
under emergency conditions in small enclosed places. In some areas spraying of organophosphorus
compounds such as Malathion by ground generated fogs and aerial Ultra Low Volume (ULV) application
has been tried with varying results.
(ac) Genetic Control.
A recent trend in the control of adult mosquitoes is by means of ‘Sterile Male Release’ (SMR) technique
and other genetic methods such as cytoplasmic incompatibility, chromosomal translocations, sex
distortion and gene replacement. All these methods have still to prove their worth and utility in the
field. The scope of recombinant DNA technology is immense and research is being carried out to use
this tool for vector control.
(ii) Anti-larval Measures.
Larval control is the only effective method of radical mosquito control. In urban areas, like cantonments,
garrison stations and base areas, this method complements the adult mosquito control. Anti­larval work
is carried out by preventing breeding and destruction of larvae and pupae. For long term and permanent
mosquito control, greater emphasis should be placed on the prevention of breeding during non­transmission
season than on larvicidal measures during breeding season.
(aa) Vector Engineering.
Avoidance of man-made mosquito-genic conditions is of primary importance. A positive aspect of
mosquito breeding prevention should be kept in view and deliberately incorporated in the planning
and execution of all engineering constructions and town planning schemes. River valley projects, dams
and barrage constructions, road and railway constructions, irrigation systems and drainage water
supply projects may lead to mosquitogenic conditions. Besides these, indiscriminate digging, disposal
of discarded tins, containers and water collections, overhead storage tanks and septic tanks without
covers are potential mosquito breeding places in urban areas. Clean edging and water weeding,
channeling, filling or draining, exposing to sunlight, shading or covering are the usual methods
adopted. Underground drainage constitutes the best method of bio-engineering method for control
of mosquito breeding.
(ab) Dry Day.
Intermittent drying once a week is an effective method of prevention of breeding. This principle
is applied for the control of breeding in irrigated areas and also in domestic breeding places by
observance of a weekly ‘dry day’. It should fall on the day when the antimosquito staff is due to

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visit that area for antilarval work. All firefighting tanks, ornamental ponds or water storage tanks, fire
buckets and all domestic water containers should be emptied and allowed to remain dry for a few
hours on the weekly ‘dry day’.
(ac) Larvicidal Measures.
Destruction of larvae is achieved by application of larvicidal oils, paris green, organochlorine or
organophosphorus insecticides and use of larvivorous fish.
(ad) Larvicidal Oils.
Oiling of the breeding places with larvicidal mineral oils like ‘malariol’ is the mainstay of the antilarval
measures in all sorts of mosquito breeding places, except those which are used for drinking,
agricultural, horticultural and piscicultural purposes or in the ornamental, firefighting and overhead
water storage tanks. Oils act primarily by suffocating and poisoning the larvae and denying them the
surface tension required for floatation. 70 to 100 ltr of oil are required to cover one acre of water
surface or 5 ltr to treat 250 linear metres. Oil is applied once a week with a knapsack sprayer or
a broom or a mop tied at the end of a long handle. It does not penetrate thick and long weeds
efficiently; but burns the light scrub along the banks of ponds or water course. The only drawback
of this method is that the oil film may be broken by wind or raindrops. It is also not very effective in
the presence of excessive weeds and other vegetation.
(ae) Paris Green (Copper aceto-arsenite).
Paris green used as a dust in varying proportions is mainly effective against larvae of Anopheline
mosquitoes because of the latter being surface feeders. Used in granular form it also kills Culicine
larvae. This method is not used anywhere for mosquito control, as better and more effective
methods / chemicals are available.
(af) Insecticides.
Use of organochlorine insecticides as contact and oral poisons to mosquito larvae has been stopped
due to emergence of a genotype of resistance. Organophosphorus compounds like Temephos (Abate),
Fenthion (available as Baytex liquid and Baytex granules), Pirimiphos methyl and Dursban are being
used as larvicides in some countries.
(ag) Biological Control.
Various predators, parasites and pathogens have been trial evaluated for mosquito control. Larvivorous
fishes like Gambusia affinis, Poecelia reticulata and Aplocheilus lineatus have been found effective
and are being used for larval control in India. The other promising & effective agents are the biocides,
Bacillus thuringiensis var israelensis and Bacillus sphaericus, which are currently being evaluated in
our country. These biocides are spore producing bacteria and when ingested they kill the mosquito
larvae by causing internal lysis of gut due to the action of delta endotoxin. Various other fungal agents
e.g. Lagenidium, Coelomomyces, Culicinomyces alongwith nematodes Romanomermis culicivorax and
R. iyengari are also under evaluation for future use. Protozoans like Nosema thelohania and viruses
like Cytoplasmic polyhedrosis virus and Iridovirus also hold promise.
(iii) Personal Protection.
Individual personal protection against mosquito bites is achieved by use of mosquito nets, repellents and
protective clothing. Screening the houses and hospital wards has been practiced on a restricted scale.
(aa) Mosquito Nets.
The use of mosquito net is the most effective personal protective measure. Net should be put up
before dusk and tucked all round under the bedding. They should always be maintained in a good state
of repairs by patching holes and tears and not by stitching or knotting. Mosquito net inspection should
be held regularly as a drill. Definite arrangements should be made to fix the nets in barracks, huts
and tents. For making the mosquito nets more effective, the nets are now being treated / medicated
with synthetic pyrethroids like Deltamethrin, Cyfluthrin etc. This Insecticide Treated Bed Nets (ITBN)
provide an irritant and excitorepellent effect besides the contact action. An additional collateral benefit
is also provided against pests like bed bugs, houseflies etc. These ITBN’s can be used even if torn

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 ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY

slightly. These nets can be used by pregnant women, infants and small children. These nets are also
effective against sand flies.
O Long Lasting Insecticide Nets (LLINs).
The advancement in the insecticide treated net technology has seen the development of
pretreated or Long-Lasting Insecticide Nets (LLIN’s). These nets may also be treated manually
or may be pretreated with insecticide Permethrin or Deltamethrin. The shelf life of these nets
is 5 years.
(ab) Repellents.
Diethyl Toluamide (DEET) is ·another repellent, which is reputed to be even better than DMP. A new
repellent DEPA (Diethyl phenyl acetamide), indigenously manufactured by DRDE, Gwalior, has been
found to be at par with DEET in efficacy and spectrum, in the trials conducted at AFMC. DEET & DEPA
have been found to be very effective when applied on uniform against all hematophagous arthropods
as well as leeches.
(ac) Protective Clothing.
The wearing of long trousers and shirts with rolled down sleeves after dusk should be enforced in
all epidemic areas and when personnel move by rail or road. Added protection is given by wearing
web anklets.
(ad) Screening of Houses and Barracks.
This measure is effective only when all doors, windows and ventilators in the building are screened
by wire mesh of proper gauge and size (1.2 to 1.5 mm).

34.7 Malaria.
(a) Definition.
Malaria is a communicable disease caused by protozoan parasites of the genus Plasmodium and transmitted to
man by certain species of infected, female Anopheline mosquitoes. The disease is characterized by intermittent
or remittent febrile paroxysms occurring on alternate days (tertian) or daily (quotidian) or rarely after two days
(quartan) and often irregularly recurring twice within 36 or 48 hours (subtertian). A typical paroxysm has an
initial short ‘cold’ stage of shivering when patient gets himself covered with blankets and quilts, followed by the
long ‘hot’ stage when rapidly increasing temperature shooting upto 39° to 40°C makes the patient throw them
off and finally the ‘wet’ stage when profuse sweating brings down the temperature. The periodicity, duration
and severity of paroxysms depend upon the species of Plasmodium. The two important clinical types of malaria
are the benign tertian and the malignant tertian or subtertian: quotidian fever is more common with the mixed
infection. Series of paroxysms occurring over long periods and relapses produce enlargement of spleen and
secondary anaemia. Relapses usually are the common feature of benign tertian malaria and are not common in
malignant tertian malaria: the other forms show variable tendency to relapses. Persons who are partially immune
or who have been taking prophylactic drugs may show an atypical clinical picture.
(b) Geographical Distribution.
Malaria occurs primarily in tropical and subtropical countries. The vast majority of malaria cases and deaths
are found in the WHO African Region, with nearly all cases caused by the Plasmodium falciparum parasite.
This parasite is also dominant in other malaria hotspots, including the WHO regions of South-East Asia, Eastern
Mediterranean and Western Pacific. In the WHO Region of the Americas, the Plasmodium vivax parasite is
predominant, causing 75% of malaria cases. The threat of malaria is highest in Sub-Saharan Africa and 4
countries in that region accounted for nearly half of all malaria deaths worldwide in 2021: Nigeria (26.6%), the
Democratic Republic of the Congo (12.3%), Uganda (5.1%) and Mozambique (4.1%).
(c) Incidence.
The decadal trend in hospital admissions due to malaria in the Indian Armed Forces is shown in Table 34.4. It
is seen that the incidence in Army and Air force continued to decline, whereas a rising trend has been observed
in Navy for last two years.

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(d) Agent.
The disease is caused by the haemoparasites of genus Plasmodium. There are four species: P. vivax, P. falciparurn,
P. malariae and P. ovale. The first two are the commonest; the third is of focal distribution and the fourth is
rare. The cyclopropagative life cycle of the plasmodium occurs in two stages (Fig 34.5). The sexual stage starts
with the gametogony in the human host and progresses through ‘sporogony’ in the mosquito. The asexual stage
starts with ‘injection of sporozoites’ by the infective mosquito into the human host and progresses through three
phases ‘schizogony’. The broad outline of events occurring during the two stages is as follows:
(i) Sexual Cycle in Mosquito (Sporogony)
The vector, female Anopheline mosquito ingests male and female gametocytes from a malarial subject. In
the mosquito’s stomach the male gametocyte becomes rounded, its chromatin splits into 5 to 8 particles,
which get arranged along its edge. Cytoplasm around each chromatin particle elongates into a ‘flagellum’
and together with chromatin separates from the main mass as a ‘microgamete’. Female gametocyte
extrudes polar bodies and becomes a ‘macrogamete’ ready to be fertilized. Syngamy of microgamete and
macro gamete forms ‘zygote’. This becomes an elongated, motile ‘ookinete’ penetrating the stomach wall,
this comes to lie under its external basement membrane, becomes rounded and develops into ‘oocyst’
measuring 6 to 12 mm. As the oocyst matures, it increases in diameter from 6 to 60 mm and rapidly
undergoes division and subdivision to form a large number of haploid sporozoites (varying from few
hundreds to thousands). Finally, the oocysts rupture, releasing sporozoites into the body cavity, majority
of which find their way into the salivary gland. Sporozoites injected in human host through the mosquito
bite start schizogony.
Table 34.4 : Decadal Incidence of Malaria by Category of Personnel 2010 To 2020 (Rate Per 1000)
Year Army Navy Airforce Armed Forces
2010 3.62 6.39 2.51 3.61
2011 4.10 5.81 3.49 3.99
2012 3.65 3.85 2.99 3.55
2013 2.43 3.58 1.65 2.37
2014 1.42 2.56 0.98 1.30
2015 1.37 2.69 0.88 1.38
2016 1.25 3.05 0.69 1.28
2017 1.05 2.56 0.86 1.10
2018 0.74 2.29 0.75 0.82
2019 0.54 3.30 0.42 0.67
Average for 10 years 2.02 3.60 1.52 2.00
2020 0.33 3.66 0.30 0.50
(ii) Asexual Cycle.
(aa) Pre-erythrocytic Phase.
Sporozoites injected by infective mosquitos into human body circulate for approximately 30 mins and
thereafter leave the peripheral blood. Fully matured pigmentless schizonts containing cryptozoites
are seen in the parenchymal liver cells. The cycle last approximately 8 days in P. vivax, 6 days in P.
falciparum and 9 days in P. ovale. On full maturity of the pre erythrocytic schizonts the liver cells
rupture and cryptozoites enter the erythrocytes.
(ab) Erythrocytic Phase.
The earliest intracapsular form of parasite is the ‘trophozoite’ which has a fine ring of cytoplasm

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with a small chromatin dot. It grows in the parasitised RBC that becomes pale and in some
species, enlarged or distorted. The hemoglobin changes into hemozoin pigment and is seen in the
cytoplasm of the parasite as black or brown granule. Fully developed trophozoite fills the RBC and
undergoes segmentation. The chromatin divides into a number of particles which migrate towards
the periphery. The cytoplasm around each particle separates off forming merozoites; the pigment
concentrates in the centre of the RBC. This is called ‘rosette’ or ‘schizont’. The parasitized RBC
eventually ruptures releasing merozoites which enter other RBCs repeating the asexual cycle. Each
asexual cycle is completed in 48 hours in P. falciparum, P. vivax and P. ovale and in 72 hours in
P. malariae.
After a few cycles of erythrocytic schizogony, male and female gametocytes appear in the blood. The
female macrogametocyte has a dense and deeply staining cytoplasm and a small compact nucleus,
while the male microgametocyte has a less dense and faintly staining cytoplasm and a relatively
large and diffuse nucleus. The gametocyte of P. vivax is large and round filling, the enlarged RBC, the
gametocyte of P. falciparum is sausage or crescent shaped. Gametocytes remain within the corpuscles
until taken up by the mosquito or their final disintegration.
(ac) Persistent Tissue Phase (Exoerythrocytic phase).
After the establishment of blood infection, the initial tissue phase (pre-erythrocytic phase) disappears
completely in P. falciparum, whereas in P. vivax, P. ovale and P. malariae it continues in the form of
a persistent tissue phase in the liver. These exoerythrocytic forms never arise from the merozoites of
erythrocytic schizogamy and are now considered responsible for relapses of vivax, ovale and quartan
malaria.
(e) Reservoir and Source.
For human plasmodia the only reservoir is a malaria case. In some parts of Africa, chimpanzees may act as
reservoir of P. malariae. The source of infection is a malaria case with adequate number of mature viable
gametocytes circulating in the blood. It has been estimated that in order to infect a mosquito, the blood of a
human carrier must contain at least 12 gametocytes per mm3 and the number of female gametocytes must be
more than the male gametocytes.
(f) Communicability Period.
The human case of malaria becomes infective to mosquito when mature, viable gametocytes develop in the
blood of the patient in sufficient density. Gametocytes of P. vivax appear in peripheral blood 3 to 5 days after
the initial appearance of the asexual forms of parasites where as in falciparum infections they do not appear
until 10-14 days after the first appearance of asexual parasites.
(g) Host Factors.
(i) Age.
All ages are equally affected. Children are usually effective carriers of gametocytes.
(ii) Sex.
It makes no difference except by way of clothing and the occupation which have a bearing on the man-
mosquito contact.

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Fig 34.5 : Life Cycle of The Malaria Parasite

(iii) Race.
Racial immunity against one or more species of malaria parasite has been observed in certain parts of
the world. Black people with sickle cell trait have been found to be relatively immune to P. falciparum
infection. Recent studies indicate that HbE or Beta thalassemia traits do not confer any selective advantage
or disadvantage in malaria. Persons with G6PD deficiency suffer more from P. vivax infection. They are not
protected from P. falciparurn infection.
(iv) Economic Status.
It is inversely related mainly because of poor housing. Ill ventilated and poorly lighted houses provide ideal
resting places for mosquitoes.
(v) Movements.
Migration of populations due to natural calamities, aggregations of labourers and movements of nomads
may lead to reintroduction of malaria into areas where the disease has already been eradicated or effectively
controlled.
(vi) Habits.
Habits of sleeping outdoors without mosquito nets, ignorance and apathy, social and religious beliefs, all
these factors may either create malariogenic conditions or lead to perpetuation of malaria transmission in
a locality.

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(vii) Immunity.
Man possesses no natural immunity. Repeated attacks in an endemic area may confer partial immunity
which is type specific. Maternal antibodies provide immunity during the first 3 to 5 months of infancy. Efforts
to produce human vaccines against malaria parasites, by using sexual forms of the erythrocytic cycle, are
still in the research stage.
(h) Environmental Factors.
Environmental factors influence the bionomics of the vector species of Anopheline mosquito and the habits of
human host. In most parts of the India, the meteorological and physiographical conditions are favourable to the
occurrence of malaria.
(i) Climate.
The topography, weather, flora and fauna modify the life cycle of the mosquito. There are seasonal variations
in their density, resting, feeding and biting habits, longevity and flight capabilities. Malaria is, therefore,
seasonal in most parts of the country. In most of the states the maximum transmission is during the period
July to November.
(ii) Temperature.
An optimum temperature of 20° to 30°C is necessary for completion of the sporogonic cycle of malaria
parasite. P. vivax is, however, adapted to lower temperatures and may complete its developmental cycle at
15°C. Although these temperatures may suggest limits for survival of the parasites, the temperature and
humidity in the actual surroundings of vectors, particularly their day time resting places, are more important.
This microclimate plays a vital role on longevity and biting habits of mosquito, sporogonic development of
malaria parasite and consequently on the transmission of malaria.
(iii) Humidity.
Humidity plays a vital influence on the life of a mosquito by determining the speed of its development, its
daytime resting habits, its biting activity and also on the development of parasites in its gut. A Relative
Humidity (RH) of 60 percent is considered optimum for transmission of malaria.
(iv) Rainfall.
It has influence on the breeding of vectors and hence on the incidence of malaria. However, the correlation
is not always obvious. While heavy rains in certain areas may discourage stream breeders, intermittent
moderate rain with intervals of sunshine may be conducive to Anopheline breeding. Similarly, droughts may
either precede or eliminate vectors in other areas. The influence of rainfall should, therefore, be assessed
only in relation to the local pattern of vector breeding. Rainfall also increases the atmospheric humidity,
which has already been discussed above.
(v) Wind.
While it favours the dispersal of adult mosquitoes, it has an adverse effect on oviposition. The wind being
minimum as a rule at dawn and dusk, it favours man mosquito contact at these hours.
(vi) Topography.
Altitude, configuration and character of water collections determine the transmission of malaria to a great
extent. Transmission decreases with increasing altitude and as a rule, it stops above the heights of 2,000 m.
(vii) Man-made Malaria.
Construction of roads, railways, irrigation works, dams and barrages, deforestation and other engineering
projects have resulted in creation of mosquito breeding places in many new areas. All these ecological
changes have led to an increase in the incidence of malaria.
(j) Vectors of Malaria.
There are 63 species of anopheline mosquitoes in India but only 6 are regarded as primary vectors and another
3 or 4 as secondary or local vectors. The following characteristics of vector mosquitoes play an important role
in the epidemiology of malaria.

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(i) Breeding Habits.

The breeding habits of mosquitoes show a lot of variation. Hence, vector mosquitoes tend to be confined
to certain geographical areas only. A few examples are as follows:
Table 34.5 : Breeding Habits of Anopheline Mosquitoes
S. No. Type of Breeding Places Species
(a) Slow moving water, seepages, terraced rice fields, Brackish waters An. fluviatilis
An. sundaicus
(b) Wells, cisterns and overhead tanks An. stephensi

(c) Tanks, pools, burrow pits and ditches forest pools, streams and slit trenches An. philippinensis,
An. annularis
An. baimaii
(ii) Vectorial Capacity.
Why only certain species and not others act as vectors is not exactly known. A complexity of factors
determines the vectorial status of a mosquito. Certain new species are emerging as secondary vectors in
different parts of the country.
(iii) Density.
For effective transmission of malaria in a locality, the mosquito vector must attain and maintain a certain
density. This is called critical density and it varies from one mosquito to another and also under different
environmental conditions. An. culicifacies needs a very high density for transmission of malaria.
(iv) Longevity.
A mosquito, after an infective blood meal, must live for at least 10 days to complete the development of
malaria parasites.
(v) Tropism.
Some mosquitoes like An. fluviatilis prefer human blood and are called anthropophilic. Others like An.
culicifacies preferably feed on animal blood and are called zoophilic. This preferential feeding habit is called
tropism. It has obvious bearing on the transmission of malaria.
(vi) Biting Behaviour.
Some vector mosquitoes bite at or soon after dusk, others either during late night or early hours of the
morning. However, some species may be active at two different periods during the same night.
(vii) Resting Habits.
A female mosquito after a blood meal rests either indoors (endophilic) or outdoors (exophilic) for maturation
of its eggs. A knowledge of these habits is necessary for organizing anti-adult measures. The common
resting places are either human dwellings, cattle sheds or mixed dwellings.
(viii) Flight Range.
The range of flight and dispersion varies from one vector to another. Knowledge of this is important for
planning control measures. Some have a short flight range e.g. An. baimaii is 0.5 km, An. minimus and
An. fluviatilis upto 1 km distance; An. culicifacies and An. stephensi upto 2 km: and An. sundaicus which
may fly even upto 8 or 10 km.
(ix) Resistance to Insecticides.
When a vector mosquito in a locality becomes resistant to a particular insecticide one has to use an alternative
insecticide. A close liaison with local NVBDCP unit is necessary for knowing the susceptibility / resistance
status of the vectors to various insecticides.
As per the global classification, India is covered by 3 out of the 12 epidemiological zones. The present

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distribution of malaria vectors in these zones is given below:

Table 34.6 : Species Distribution of Anopheles in India
Northen and Penisular India
Main vectors An. culicifacies, An. stephensi
Local Vetors An. fluvitalis, An. sundaicus, An. annularis and An.
varuna
Eastern India
Main vectors An. dirus, An. maculatus, An. sundicus,
An. philippinensis and An minimus
Andaman and Nicobar Islands
Main Vectors An. sundicus,
New Vectors An. maculatus and An. tesselatus
(k) Mode of Transmission.
Malaria is transmitted through the bite of an infective female Anopheline mosquito 10 to 14 days after its
feeding on a gametocyte carrier. For successful transmission of malaria in a locality there must be a reservoir
of infection, sufficient density of vector Anophelines and favorable environmental conditions.
(l) Incubation period.
The intrinsic incubation period in human host in the case of P. vivax, P. ovale and P. falciparum is 10 to
14 days; whereas in P. malariae it may vary from 18 days to 6 months. However, with some strains of P. vivax
and P. malariae this duration may be exceeded. The incubation period is also prolonged when prophylactic doses
of antimalarial drugs are administered.
(m) Malaria Survey.
Survey is carried out for assessing extent and intensity of malaria in an area, distribution and period of transmission
and establishing the identity and bionomics of mosquito vectors. Detailed surveys are carried out by examination
of the population, especially children, for the spleen and parasite rate, collection of mortality and morbidity data,
enquiries into past surveys, hospital admission records and dispensary attendance, scrutiny of meteorological
conditions in relation to mosquito genesis and bionomics, collection and identification of larvae and adult mosquitoes,
dissection of adult mosquitoes, studying their bionomics and determine the feeding habits and host preference
of mosquitoes. Study of topography is important. Rapid diagnostic kits namely immuno-chromatographic test and
dipstick antigen captive assay are sensitive kits for rapid diagnosis of P. falciparium malaria in field.
(i) Measures of Prevalence.
(aa) Malariometry.
During an emergency when it is not feasible to carry out a detailed malaria survey, it is possible to
assess the prevalence of malaria in an area in a short time by the collection of following data:
(ab) Spleen Rate
It is expressed as the percentage of children between two and ten years of age showing enlargement of
spleen. Child spleen rate above 10 is considered high, warranting implementation of control measures
in the Armed forces.
(ac) Parasite Rate
It is expressed as the percentage of children between two and ten years having malaria parasites in
their blood films. The child parasite rate is a true index of local prevalence of malaria because the
children do not possess premonition and are less likely to have contracted the infection outside the
area.

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(ad) Infant Parasite Rate

It is defined as the percentage of infants below the age of one year showing malaria parasites in
their blood films. It is regarded as the most sensitive index of recent transmission of malaria in a
community.
(ae) Proportional Case Rate
It is expressed as the number of cases diagnosed as clinical malaria for every 100 patients attending
the outpatient departments of hospitals and dispensaries.
(ii) Measures of Incidence.
The indices described above indicate the prevalence of malaria in a locality as judged from a sample of the
population. A new tool of evaluation has been introduced under the National Programme, which measures
not prevalence but the incidence of malaria. This method is called case detection or surveillance and is
expressed as Annual Parasite Incidence (API).
(aa) Annual Parasite Index (API).
It is calculated as under:
Confirmed cases of malaria during one year
API = x 1000
Population under surveillance
(ab) Annual Blood Examination Rate (ABER).
It is linked with adequacy of coverage of the population under surveillance in respect of blood
examination. This is indicated by ABER. It is recommended that the monthly number of blood smears
examined should be at least 1 percent of the population.
Number of blood smears examined
ABER = x 1000
Total population under surveillance
(n) Prevention and Control Measures.
There are three broad groups of malaria control measures aimed at breaking the ‘man-mosquito­man’ cycle of
transmission: the anti-mosquito measures, personal protection against mosquito bites, the chemoprophylaxis and
chemotherapy. A survey enables us to plan and organize antimalarial measures and decide as to whether they
should include permanent or temporary anti-mosquito measures or both: mainly aim at the protection against
the mosquito bites or chemoprophylaxis and therapy. In practice the majority of schemes will include all these
measures in various grades. The degree of emphasis on particular measures and the methods of implementing
them differ in details, not because of any difference technically wanted but due to the requirements of situation
and urgency of circumstances.
(o) Mosquito Control Measures.
Anti-mosquito measures described in para 34.6.(l) and thereafter yield permanent results and radically control
the mosquito population in that area. Therefore, these anti-mosquito measures are definitely indicated in urban
areas and at engineering or river valley projects to obviate the possibility of devastating malaria, which has been
so commonly experienced at such projects in the past. However, these methods require elaborate organization,
longer time and liberal finances. The mosquito eradication as a means of malaria control can therefore be
categorically stated as well-nigh impossible in the rural areas in a vast country like India. Species control and
vector control are the two modifications circumscribing the wider concept of the mosquito control. However, these
methods also are time consuming and relatively expensive and can be employed only to a limited extent.
(i) Residual Insecticides.
The principle of malaria control, by intercepting its transmission, by shortening the life span of the vector
species to a period shorter than the extrinsic incubation period of the parasite, has become established.
This principle has been successfully employed by the application of residual insecticides to the resting
places of mosquitoes viz. the inside of all the walls of habitations. It is a cost-effective control measure
for Malaria. However, as very few cases of Malaria are getting reported, its use should be synchronized
with case detection and not empirical. IRS plan should be developed well in advance in Malaria endemic

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areas so that there is no last-minute rush during implementation. It should be carried out only in high-risk
areas i.e. with API more than 2. In areas where vector has shown DDT resistance alternatives Malathion
and synthetic pyrethroid should be used. The first round of spray in an area should be done coinciding
with time of build-up of vector population which precedes the malaria season. At least 85% of the dwelling
units should be covered for effective control. Residual spray is of limited value where the vector species
are exophilic.
(ii) Space Spray.
Space spraying by 0.1 percent pyrethrum extract is carried out once a week or often at the scale of one
ml of 0.1% solution per m3 space. This is indicated in a highly malarious area required to be occupied for
purposes of industrial, defence or engineering projects at a short notice; to quickly control an explosive
epidemic: to tide over the period before residual spray takes effect or as a remedial measure in the locality
where local transmission is detected. A recent concept in space spraying is the Ultra Low Volume (ULV)
fogging using organophosphorus compounds like Malathion and Cyphenothrin. The other group of ULV
compatible insecticides are the synthetic pyrethroids.
(iii) Personal Protection.
Individual protection against mosquito bites is achieved by the use of the mosquito net, application of
repellents to exposed skin surfaces when not under the net and protection by proper use of clothing from
dusk to dawn.
(p) Chemoprophylaxis.
Chemoprophylaxis is a valuable supplementary measure under high-risk situations, but not a substitute for other
control measures. It reduces clinical attacks by suppressing the schizogony. Extent of suppression depends
upon the virulence of the local strain, the state of herd premunition, the density of infected mosquitoes and
the sporozoites introduced per infected mosquito bite. These are high at the height of the malaria transmission
season. Chemoprophylaxis is indicated only when there is a high degree of malaria risk in an area.
(i) Short-term Chemoprophylaxis (less than 6 weeks).
Doxycycline 100 mg daily in adults. The drug should be started 2 days before travel and continued for
4 weeks after leaving the malaria endemic area. Doxycycline is contraindicated in pregnant and lactating
women and children less than 8 years
(ii) Long-term Chemoprophylaxis (more than 6 weeks).
Mefloquine 5 mg / kg body weight (up to 250 mg) weekly and should be administered two weeks before,
during and four weeks after leaving the area. Mefloquine is contraindicated in cases with history of
convulsions, neuropsychiatric problems and cardiac conditions.
(q) Chemotherapy.
For details of chemotherapy refer to National treatment policy for Malaria in India given in Chapter no. XXXIII.
(r) Malaria Control in the Armed Forces-Basic Principles.
Malaria control measures in civilian or military life, in peace or war, in garrison stations or operational areas are
based on the same scientific principles. Circumstances, however, may require emphasis on a particular control
measure to be employed and its implementation, which should be suitable to the specific requirement of the
particular area occupied.
In garrison peace stations and cantonments, long term mosquito control should be carried out by prevention of
breeding through permanent engineering anti-mosquito methods and by application of other antilarval measures;
use of residual insecticides should be the second line of defence. Personal protection by the use of a mosquito
net or repellents may be needed for greater safety. In the endemic areas, in base camps, at comn zones and in
static formations, greater emphasis and reliance should be placed on anti-adult measures by residual insecticide
spraying, antilarval measures and personal protection against mosquito bites. In order to achieve perfect safety,
the surrounding villages should also be included in the insecticidal spraying programme. Close collaboration and
in certain cases, integration of anti-malaria scheme with the local civil anti malaria organization is essential.
Their representative should be co-opted on the ‘Station Health and Antimalaria Committee’.

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In operational areas personal protection by the use of mosquito nets gives maximum protection, provided its use
is not hampered by intolerable heat, rain, night air attacks and other unfavourable conditions. Repellents are
useful under high-risk situations. Residual insecticidal spraying carried out with good organization and efforts
keeps malaria incidence very low even in the operational areas.
The chemoprophylaxis will be instituted under the orders of the GOC-in-C Command on the advice of his MG
Med. Some of the situations under which chemoprophylaxis may be recommended are as follows:
(i) When troops are about to enter an operational area in which malaria risk at the time of entry is high.
(ii) When troops in occupation of an area liable to high seasonal malaria incidence have to remain in
that area during the whole or part of the malaria season.
(iii) When personnel in malarious areas, already on suppressive treatment, are proceeding on temporary
duty / annual leave to stations in non-malarious areas.
(iv) When personnel from non-malarious area are proceeding on temporary duty to stations in malarious
areas where suppressive treatment is already in force.
(v) Personnel or body of troops, not on suppressive treatment, when moving out on exercise / training in
uncontrolled area where risk of contracting malaria.
(vi) At the termination of malaria season or on withdrawal of troops from a malarious area to a non-
endemic area, suppressive treatment will be stopped.
A camp site which affords little chance to mosquitoes for breeding and biting should be selected for occupation
in operational and training areas. If tactical reasons demand siting of camps in malarious areas, the least
dangerous site should be selected. The camp or its sectors should be at least one and a half km away from
habitation and from any collections of water likely to breed vector species. The camp should preferably be on
high ground and the direction of the prevailing wind should not be from the village or breeding places. Troop
movements towards villages from dusk to dawn should be forbidden. For deciding on a suitable camp site,
antimalaria measures and for subsequently assessing the success of such measures, an investigation into the
local malaria risk is necessary.
Finally, the success of all measures depends upon the discipline and cooperation of all ranks and a well-organized
execution of all measures. Discipline depends mainly on training. Well trained and disciplined troops have a lower
incidence of malaria than ill trained and indiscipline personnel. Training in the prevention and control of malaria
should be an essential part of all ‘training for war’. All ranks must receive frequent practical demonstrations
in the correct method of using a mosquito net, protective use of clothing and application of insect repellent.
Unit spraying squads must be drilled in the proper method of spraying in barracks, tents, bashas, bunkers and
bivouacs. Spraying equipment must be used properly and always maintained in working condition; the squad must
be adequately trained to do this. Commanders should be constantly advised in the principles of camp selection
and siting, anti-malaria measures and discipline. Full cooperation of all ranks will not be obtained unless officers
and men realize the seriousness of the malaria menace to war efforts, if it breaks out among troops and the
importance and the necessity of prevention of its occurrence under the present unbalanced state of malaria
eradication in our country.
(s) Anti-malaria Organization in the Armed Forces.
In cantonments and garrisons, the Station Commander, under the advice of the SEMO, is responsible for
the initiation and execution of all control measures, broadly based upon the current formation orders and
instructions in collaboration with the Station Health Committee. This committee scrutinizes the proposed anti-
malaria measures, notes the progress of the campaign and remedies any observed defects, in the months prior
to the beginning of the malaria season and in the month preceding the one in which malaria incidence is usually
at its maximum. It reviews the results of the anti-malaria measures and formulates a tentative scheme for the
following year in the month after the termination of the malaria season.
Officers commanding the units are responsible for all anti-malaria measures within their units and in the adjoining
area placed under their charge.
Every unit has an anti-malaria squad under the supervision of the trained regimental anti­ malaria officer.
In operational areas the Formation Commander may call similar meetings of Unit Commanders and representatives

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of the medical and engineering services to discuss similar subjects whenever necessary.
Technical medical staff officers (DADH / ADH) and the officers Commanding Station and Field Health Organization
assist the Commanders in planning control measures, advise Unit Commanders, maintain scrutiny regarding
anti-malaria measures within their respective zones and co-ordinate control in different sectors of the station or
area into a closely integrated scheme.
The station, camp, base or comn zone and its periphery for 1 km in depth is divided into a number of circles
depending upon the size of the station or area and the degree of prevailing malaria. Each is further sub-divided
into five zones, each of which is capable of being treated on one working day by the available labour gang or
unit squad.
Records to be maintained by units / formations:
(i) A chronological diary showing the principal events in the malaria season, the programme and progress
of anti-malaria work, meetings held, state of equipment, initiation and termination of anti-larval measures
and of spraying campaign, initial determination and periodical check of spleen and parasite rates in villages.
(ii) Weekly meteorological records containing the number of adult Anophelines (by species) caught per
collection in any catching stations ear marked, incidence of malaria cases by units and sub units.
(iii) The records regarding the dates, dosage and number of rooms, houses, huts and tents treated with
insecticide.
(iv) A large-scale map of the area showing temporary or permanent (potential and actual) breeding places
and a unit spot map showing each case by barracks and quarters for indicating the effectiveness of control
measures.
(v) Malaria case register showing the personal, clinical and epidemiological particulars of each case with
columns showing number rank, unit / sub unit, date of onset of fever, date of admission to hospital, date of
positive microscopic diagnosis; the species of Plasmodium, relapse or fresh; if relapse the previous dates
of fever or hospital admission for malaria, movements during the previous three months to determine the
probable place of infection and whether the transmission is local or the case is imported from another
locality, indication of the personal precautions taken especially as regards chemoprophylaxis and finally the
date of discharge from hospital.

34.8 Filariasis.
(a) Definition.
Filariasis is the name given to group of arthropod-borne infections caused by certain nematode worms belonging to
the super family Filarioidea and family Acanthocheilonematidae. These worms invade the lymphatic, subcutaneous
and deep tissues producing acute and chronic reactions. The adult female worm discharges microfilariae into
the blood or subcutaneous tissues where they live for weeks or months till taken up by the haematophagous
arthropods. The term lymphatic filariasis is used to describe the disease produced by Wuchereria bancrofti and
Brugia malayi. Loa loa causes transient subcutaneous swellings (calabar swellings) and Onchocerca volvulus
produces blindness and skin rashes. The human filarial infections are shown in Table 34.7.
(b) Geographical Distribution.
Wuchereria bancrofti infection is endemic between latitudes 41°N and 30°S involving primarily Africa, South
Eastern Asia from Korea to India, Pacific islands, West Indies, Central America and South America. The distribution
of B. malayi is restricted to India, Bunna, Thailand. Vietnam, China, South Korea, Japan, Malaysia, Indonesia, New
Guinea and Philippines. Bancroftian filariasis is one of the major public health problems in India. The disease
is prevalent is almost all the states except those in the western part of the country. The endemic areas are
Uttar Pradesh, Bihar, Orissa, Tamil Nadu, Andhra Pradesh and Kerala. The largest single endemic focus of B.
malayi infection is along the coast of Kerala. The largest single endemic focus of diurnal subpetiodic form of W.
bancrofti has been discovered in Nicobar Islands.
(c) Incidence.
As per recent estimates in 2021, 882.5 million people in 44 countries were living in areas that require preventive
chemotherapy to stop the spread of infection. The global baseline estimates of people affected by lymphatic

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filariasis was 25 million men with hydrocele and over 15 million people with lymphoedema. At least 36 million
people remain with these chronic disease manifestations. In Indian Armed Forces, person found infected during
routine filaria surveys have reduced over a period of time. During 2019, the infection rate was 0.02 percent only.
Table 34.7 : Human Filarial Infections
Mf Habitat
Species Major vector
Sheath Mf Adult
Wuchereria bancrofti + Blood Lymphatic system Culex quinquefasciatus
Brugia malayi + Circulation -do- Mansonoides
Loa loa + -do- Connective tissue Chrysops sp.
Mansonella perstans - -do- -do- Cullicoides sp.
Mansonella ozzardi - -do- Mesentery -do-
Mansonella streptocerca - Skin Connective tissue -do-

Onchocercha volvulus - Skin and sub-cutaneous tissue. -do- Simulid sp.

(d) Agent.
The adult W. bancrofti is 5 to 8 cm long; females are broader and longer than the male. Male and female live
together coiled or knotted in lymphatic glands, cystic dilations and varices of lymphatic ducts and connective
tissue. The life span of the adult worm is not known but it may live for long periods even up to 12 years. The
embryo or microfilaria is about 280 µm and lives for a fortnight if not picked up by the mosquito vector. They
have a regular nocturnal periodicity and appear in the peripheral blood round about midnight.
(e) Life History.
Two hosts are essential for the completion of the whole life cycle of the parasite; mosquito the intermediate
host and man the definitive host. The embryos are produced in the human host: they morphologically develop
in the mosquito to become infective.
(i) Intermediate Host.
The cyclo-developmental metamorphosis in the vector species of mosquito produces an infective larva from
the non-infective embryo ingested during blood meal from man. ln the gut of the mosquito, the microfilaria
wriggles out of its sheath quickly, penetrates the gut wall within an hour or two and migrates to the thoracic
muscles. This unsheathed larva is thin, 250 to 300 µm in length, very active and motile. During the
next 2 days, it becomes thick, sausage-shaped, with a short spiky tail-like process and measures 125 to
250 µm in length. It possesses a rudimentary digestive tract. This is called the first stage larva. In 3 to
7 days it develops into the 2nd stage larva, moults once or twice and measures 225 to 330 µm length and
15 to 30 µm in breadth. In about 10 days, the 3rd stage infective larva develops. The tail atrophies to a
stump; the digestive system, body cavity and genital organs are fully developed. It now enters the proboscis
of the mosquito. The 3rd stage larva is thin, actively motile and measures 1,500 to 2,000 µm in length
and 18.2 µm in breadth. The time taken for the complete development of the microfilaria in the mosquito
vector (extrinsic incubation period) is 10 to 20 days depending on the atmospheric temperature, humidity
and species of the mosquito. One microfilaria gives rise only to one infective larva. There may be several
larvae in the mosquito proboscis awaiting an opportunity to infect man during the nocturnal blood meal.
(ii) Definitive Host.
When the infected mosquito bites a human host, the 3rd stage larvae are deposited on the skin near the
site of puncture. Later, the larvae either enter through the puncture wound or penetrate through the skin on
their own. The infective larvae, having penetrated the skin, reach the lymphatic channels and settle down
in the inguinal, axillary, scrotal or abdominal lymphatic glands. They grow into adult worms and in about 5
to 18 months become sexually mature. The male fertilizes the female and then dies. The gravid females
produce the embryos or microfilariae, which pass either through the thoracic duct or the right lymphatic
duct to the venous system and pulmonary capillaries and thence to the peripheral circulation.

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(iii) W. bancrofti and B. malayi occurring in India are truly nocturnal and circulate in the peripheral blood
normally at night and are rare or absent during the day. Diurnal overflow of the microfilariae of W. bancrofti
may occur with altered sleeping habits. If not taken up by the females of the vector mosquito within a
fortnight or so they die. The important points of differentiation between microfilariae of the two species
are given in Table 34.8.
Table 34.8 : Difference Between Microfilariae of W. bancrofti and B. malayi
W. bancrofti B. malayi
Appearance Gracefully sweeping curves Stiff with secondary kinks.
Length 244 to 296 mm 177 to 230 mm
Cephalic space As long as broad Length 1.5 to 2 times the breadth.
Body nuclei Discrete and well defined Ill-defined giving smudged appearance.
Caudal end Tapering to delicate point; no terminal Kinked with two terminal nuclei.
nuclei.

(aa) Reservoir and Source.

The reservoir and source of W. bancrofti infection is the infected person with circulating microfilariae. The
person may be infective while remaining below the threshold for microscopic detection of microfilariae.
No animal reservoir of W. bancrofti infection has yet been found. A number of filarial infections have
been reported in lizards, birds, dogs, cattle and monkeys. However, in India man is the only reservoir.
The immediate source of infection to man is the vector mosquito containing infective larvae.
(f) Host Factors.
(i) Age.
No age is immune. The B. malayi infection appears at an earlier age than W. bancrofli. Hence, elephantiasis
appears in B. malayi in an earlier age group than in W. bancrofti. The infection rate rises rapidly with age
in the earlier years up to 30 years but no consistent rise is seen in the later age groups. The disease
remains considerably below the infection rate up to 30 years of age; above that age, the disease rates
exceed the infection rate in an endemic area.
(ii) Sex.
Both sexes are equally susceptible. Minor differences, however, are shown by various groups. The disease
appears less in females, probably due to the relative absence of genital lesions.
(iii) Occupation.
The occupations which expose the person more to mosquito bites show a higher incidence.
(iv) Migration.
The movement of people for pleasure or pilgrimage as well as in search of jobs has resulted in establishment
of new foci of infection in the erstwhile non-endemic areas like Haryana, Delhi, other Western states and
even Port Blair and Andamans.
(v) Social Aspects.
Rapid urbanization and industrialization, coupled with mass migrations of people and sleeping habits of
people have helped in the increased endemicity of filariasis. The chronic genital and non-genital lesions
are responsible not only for much physical and mental suffering but are also a cause of social stigma.
(vi) Immune Response.
The immune response of the human host to W. bancrofti is both humoral and cellular. This is effective only
against the microfilariae. A high level of serum antibodies prevents microfilariae in reaching the peripheral
blood. The humoral antibodies consist of Complement-Fixing (CF), Haemagglutinating (HA) and fluorescent.
The CF test is carried out by using the antigen of Dirofilaria immitis. Cross reactions are noticed with other
helminthic infections like ascariasis. A high level of serum IgM may be observed in infections due to W.

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bancrofti.
(vii) Communicability Period.
Man is infective to the mosquito vector for at least a fortnight after the release of embryos in the peripheral
circulation and the mosquito is infective to man for about a fortnight after the larvae become infective.
(viii) Environmental Factors.
Climate affects the mosquito vector and vertebrate host and the parasite in either of them and consequently,
the endemicity. The optimum conditions for the breeding of the vectors and the development of parasites
in them are: relative humidity above 60 percent and the temperature above 15.6 degrees C. The density of
C. quinquefasciatus is at its minimum during the monsoon, but due to favourable atmospheric conditions,
somehow the maximum infectivity rate in the mosquitoes occurs during this period. Filarial endemicity of
places with a dry hot summer and a dry-cold winter is, therefore, much less than of places nearer the
sea coast and also around the equator or with a tropical climate. Transmission of infection is seasonal in
the former and perennial in the latter. India, on account of its extent and variable climates from region to
region, presents areas of widely variable endemicity. There are areas of low endemicity with a prevalence
rate below 15 percent where favourable climatic conditions exist for 4 months or less duration: moderate
endemicity with a prevalence rate upto 20 percent where favourable climatic conditions continue for 4 to
6 months; high endemicity and prevalence rate upto 30 percent in places with favourable conditions are
present all-round the year. Suitable climatic conditions, insanitary surroundings, high vector density and
presence of sufficient number of carriers of W. bancrofti renders a terrain filarious.
(ix) Vector of Filariasis.
(aa) Culex quinquefasciatus.
This species is the main vector of bancroftian filariasis in India. It preferentially breeds in dirty water
collections such as in drains, cesspools, soakwells and septic tanks. When denied such opportunities,
it can also breed in clear water.
(bb) Mansonoides.
Mansonoides species are the vectors of B. malayi infection in India. ln Kerala, M. annulifera and M.
uniformis are the major vector species. These mosquitoes are associated with aquatic plants like
Pistia stratiotes, Eichornia speciosa and Salvinia auriculata.
(cc) Aedes niveus.
This species has been incriminated as a vector of diurnally subperiodic form of Bancroftian filariasis
in Nicobar group of islands.
(dd) Other Species.
Experimentally many Anopheline species have been infected with filarial larvae. An. philippinensis has
been found infected with W. bancrofti in nature. However, in India, Anopheline mosquitoes have not
been found to play any significant role in the transmission of any type of filarial infection.
(g) Mode of Transmission.
The vector mosquito, with infective larvae in its proboscis, bites man and introduces the larvae. The larvae do
not always directly enter the blood circulation, but after the bite lie at or near about the puncture made by the
mosquito. They then get activated by the body warmth and enter the circulation. Afterwards they migrate to their
selective location in the lymphatic system and tissues for further development.
(h) Incubation Period.
The intrinsic incubation period in man from the introduction of infective larvae to the development of clinical
manifestations is 8 to 16 months or even longer. The extrinsic incubation period in the mosquito is 10 to 14 days.
(j) Filaria Survey.
The object of filaria survey is to find out the extent of filaria infection and filarial disease prevalent in a locality,
factors responsible thereof and to recommend suitable control measures. Three main purposes of the survey
are as under-

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(i) To obtain baseline data on the prevalence and distribution of filariasis.

(ii) To define the public health importance of filariasis in an area.
(iii) To monitor and evaluate changes in endemicity including those due to control programmes.
(k) Method of Survey.
A filaria survey comprises of the following elements and procedures:
(i) General.
This should include meteorological data, local morbidity, statistics, socio-economic aspects of local population
such as occupation, income, literacy, social habits and attitudes, records of previous survey if any and any
existing control measures. A close liaison must be established with local populations before starting the
actual survey. A map should also be prepared.
(ii) Technique.
It should be a random representative sample of the area. All persons in a house hold should be examined.
Following four types of surveys can be conducted:
(aa) Blood (Parasitological) survey.
The blood smears should be collected between 9.30 p.m. to midnight. Approximately 20 mm3 of blood
(3 drops) from each person should be taken on a clean glass slide and made into a thick smear.
After drying, a serial number is given as in the proforma. The slides are dehaemoglobinised, fixed and
stained next day, preferably with JSB-1 stain. The slides are then washed, dried and examined for
microfilariae. The other methods employed in parasitological surveys are counting chamber technique
and membrane filter concentration method.
(ab) Clinical Survey.
It is better if this is carried out separately during day time when all members of the family are present
and detailed history of each case can also be taken. Each person’s length of stay, history of fever,
lymphangitis, chyluria and clinical signs of filarial disease are recorded.
(ac) Skin Tests.
Recent studies have revealed that the intradermal tests are of considerable importance in detecting
early cases of filariasis. Lack of standardized antigens and their specificity is the main drawback.
(ad) Diethylcarbmnazine Provocative Test.
This test is based on the principle that administration of hetrazan stimulates the appearance of
microfilarae (mf) in the blood circulation. After administration of 100 mg of hetrazan, mf begin to
reach their peak in 15 min and decrease 2 hours later. The test consists of taking a blood smear
one hour after administration of the drug and examining the same for presence of mf.
(ae) Entomological Survey.
This should include types of vector breeding places, collection of larvae, adult collections and
dissections, precipitin tests and bionomics of local vectors such as their density, resting habits and
their biting / feeding behaviour.
(af) Zoonotic Infection.
To rule out the prevalence of any zoonotic focus of filariasis, the study may include a blood survey
on the local animals and birds.
(iii) Filarial Indices.
The extent of filariasis problem in a given area before and after the institution of control measures can be
assessed by certain indices which are defined as under:
(aa) Microfilaria Rate.
It is the number of persons showing microfilariae in a unit (20 mm3) of blood expressed as a

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percentage of population examined.

(ab) Filarial Disease Rate.
It is the number of persons showing clinical manifestations of filariasis expressed as percentage of
population examined.
(ac) Filarial Endemicity Rate.
It is the number of persons showing microfilariae in blood or filarial disease or both per 100 persons
examined during a survey.
(ad) Microfilaria Density.
It is the number of microfilariae present in a unit volume of blood (20 mm3) from individual persons.
(ae) Average infestation Rate.
It is the average number of microfilariae per positive person in a sample.
(af) Filaria Mosquito Infection Rate.
It is the number of mosquitoes found positive for all stages of developing larvae expressed as
percentage of the total female mosquitoes dissected.
(ag) Mosquito Infectivity Rate.
It is the number of mosquitoes positive for infective stage of larvae expressed as percentage of the
total female mosquitoes dissected.
(l) Prevention and Control.
The three important measures for prevention and control of infection in the community are the same as for
malaria control, viz. mosquito control at all stages of their life cycle, chemotherapy and personal protection from
mosquito bites
(i) Vector Control.
The best and permanent method of vector control is to prevent breeding of vector mosquitoes by underground
drainage schemes. Because of financial constraints in a developing country like India, this may not be
feasible in the near future. The temporary measures are as follows.
(aa) Antilarval Measures.
O Organophosphorus Compounds.
Fenthion applied at the rate of 1 ppm has been reported to be an excellent larvicide. Temephos
is another larvicide which is very effective and can also be used in potable water.
O Oiling.
Regular oiling programme has been the sheet anchor for mosquito larval control in the
cantonment and garrison stations.
O Herbicides.
Use of certain herbicides and weedicides for removal of aquatic plants will help in preventing
breeding of mansonoides mosquitoes.
O Filarial Engineering.
Filling up of ditches, channelling, desilting and deweeding of drains, proper maintenance of
septic tanks and soak wells / pit all contribute to the control of mosquito breeding.
O Biolarvicides.
Biocide Bacillus sphaericus has proved to be very effective against culex mosquitoes @ 0.5 to
1.0 ppm depending on the type of water collection (i.e levels of water pollution)

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O Expanded Polystyrene beads.

These beads can be spread on water to form a floating layer & cover the surface completely. The
mosquitoes die, as they cannot reach the surface to breathe. Long term efficacy, non-toxicity to
non-target organisms & safe for use in potable water, make it an ideal choice for water bodies
confined between surrounding walls.
(ii) Anti-adult Measures.
The vectors of filariasis have become resistant to insecticides like DDT, HCH and Dieldrin. Use of Malathion,
especially by ground generated fogs and aerial sprays by ULV technique, has helped in controlling the adult
mosquitoes in some countries. Use of pyrethrum as a space spray, especially by power operated sprayers
can help in the abatement of mosquitoes as a temporary measure. Genetic control measure employing a
sterile male release technique has been tried in Burma with promising results. Synthetic pyrethroids as used
under the NVBDCP, will also provide the desired impact against Culex quinquefasciatus, where resistance
to the known insecticides has been reported.
(iii) Chemotherapy.
Admission in the hospital is not mandatory unless otherwise warranted. Diethylcarbamazine (Hetrazan) is
an effective and relatively safe drug against all filarial infections. The dose for Bancrofrion filariasis is 6
mg  / kg body weight per day for 12 days, given perferably in divided doses after meals. This amounts to a
total of 72 mg or of DEC per kg body weight as a full treatment. For Brugian filariasis, dose ranges from
3-6 mg per kg body weight per day. The full dose must be reached slowly, starting with 50 mg (one tablet)
daily to avoid side effects. This course may be repeated twice at intervals of 4-6 weeks. Antihistamines or
corticosteroids may be required to control allergic phenomenon. Common salt medicated with 1-4 gm of
DEC / kg for 6-9 months has been shown to be safe, cheap and effective in preventing filariasis. Ivermectin
(a semi synthetic macrolide antibiotic) in a single oral dose of 150-200 µg / kg of body weight has also been
found effective in completely cleaning blood microfilaria within weeks. As per WHO weekly epidemiological
record No 20,2001;76, two drug regimens as follows have been prescribed: 400 mg albendazole + 6 mg / kg
DEC; or 400 mg albendazole +150 mg / kg ivermectin once a year for a period of 4-6 years. Subsequent
follow up by examining blood smears once a month should be carried out for one year. For details on
epidemiology, prevention and control of filariasis please refer to DGAFMS Medical Memorandum on the
subject.
(iv) Personal Protection.
Persons residing in filaria endemic areas must sleep under mosquito nets. Impregnated mosquito nets
provide additional benefits. They should get their blood periodically examined and if found positive take
a course of hetrazan. Health education and active participation of the community is very essential in
eliminating mosquitogenic conditions in the locality, arranging nocturnal blood examination, carrying out
treatment of positive cases and finally surveillance of the known cases and carriers.

34.9 Sand Flies.

(a) Classification.
The family Psychodidae consists of several hundred species occurring in many parts of the world and includes
the insects Phlebotomus which comprises the sand flies. The species P. argentipes, P. papatasii and P. sergenti
are medically important in India.
(b) Morphology.
The adult sandfly is a small greyish yellow to brown insect 1.5 to 4.0 mm long. The head, thorax and abdomen
are very densely hairy. The head covered with long hairs hangs downward from the thorax and bears large
conspicuous dark eyes. The antennae are long filamentous and give a beaded appearance. The mouth parts are
very short and are adapted for biting and piercing in the females. The thorax is markedly humped and bears a pair
of wings which are like lancets or spears and held erect from body at about 60° angle. The wings are densely
hairy and carry parallel veins; of which the second vein branches twice, the first branching in the centre of the
wing and second at the margin. Scales are entirely absent. There are 3 pairs of legs, which are long, slender,
hairy and permit the insect to hop. The abdomen is clothed with hairs and consists of 10 segments, the last

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two are modified for sexual functions. The abdomen of a

female is rounded posteriorly; in the males it is modified
into claspers (Fig 34.6).
(c) Life History.
The eggs are laid in small batches. They are longer when
compared to the size of the insect itself and are torpedo
shaped. The eggs hatch out in one or two weeks under
optimum favourable conditions. The minute whitish larvae
feed on organic excrement of lizards and mammals and
other decaying material. The larva undergoes three
moults (There are four larval instars). Its life span
is from 2 to 6 weeks, depending on the temperature
and humidity. The larva bears two anal spines but the
most striking feature of the larvae is the presence of
conspicuous thick bristles with feathered stems, which
in many species have slightly enlarged tip, on the head
and all body segments. These are called as matchstick
hairs and identify the larvae as those of Phlebotomine
sandflies. The pupa is naked and requires about 10 days
for development, after which the adult emerges. The total
period required from egg to the adult stage is about 4
weeks under favourable conditions. The female usually
lays eggs in 5 to 7 days under microclimatic conditions Fig 34.6 : Sand Fly - Morphology and Life Cycle
of virtually 100 percent relative humidity. The period of
interval from egg to next generation egg may vary from 5 to 10 weeks. In the tropics the breeding goes on all
the year round. In north India, they appear about the middle of March and persist until November, with their
maximum density in March and April.
(d) Bionomics.
The female has piercing mouth parts and is a blood sucker. Some species feed on cold blooded animals such
as lizards and snakes, others feed on warm blooded animals including man. The males live entirely on plant
juices or similar fluids from other available sources. The sand flies are weak on their wings and have a very
short flight range. Thus, they remain confined to their breeding places and close to ground level. After fertilization
and a blood meal the female lays eggs in shady, damp and warm places with sufficient supply of organic matter
such as insect remnants and faeces and excrements of tiny animals which form the future larval food. Such
conditions are found under stones, in stables and poultry houses, around soakage pits, grease traps and water
sinks, in hollowed trees and rodent burrows, bases of walls and embankments.
(e) Vector Potential.
Sandflies are responsible for the transmission of various species of Leishmania causing Kala-azar or visceral
leishmaniasis, oriental sore or cutaneous leishmaniasis and espundia or mucocutaneous leishmniasis (naso-
oral). Sandflies also transmit the virus of sandfly fever, also known as papatasi and phlebotomus fever and the
re-emerging viral disease – Chandipura disease. It also transmits Bartonella bacilliformis or Oraya fever also
known as Bartonellosis, Canion’s disease and verruga peruana. In addition, the sandflies are a biting nuisance
causing skin reactions (Herara) in sensitized persons.
(f) Phlebotomus Control.
(i) Prevention of breeding.
This is primarily achieved by extremely good environmental tidiness. Places providing humidity, darkness and
organic matter should be dealt with by removing all collections of rubble and heaps of rubbish; obliterating
all cracks and fissures in the floors of buildings and indoor constructions, sides of culverts, gutters, nullahs,
cattle sheds and poultry houses which are common breeding places for sandflies. Cracks and holes in the
walls up to a metre from the ground should be sealed by plastering; the earthen floor of cattle sheds should
be rammed down and made hard to make it difficult for the larvae to burrow. Empty buildings should be

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kept in good repairs; soakpits and grease traps should be well maintained.
(ii) Anti-larval Measures.
Anti larval measures are generally difficult to undertake as identification of larval breeding sites is difficult.
Even if insecticidal control is planned, it has been found to be of little importance in the control of sand-
flies.
(iii) Anti-adult Measures.
Sandflies are sensitive to organochlorine and organo-phosphorus insecticides. They make short flights with
relatively long pauses on entering or leaving any place or shelter. Therefore, any surface treated with
residual insecticide on which the flies rest will form a lethal barrier. Because of development of resistance
to DDT, synthetic pyrethroid has been used for IRS since 2015; this strategy has proved to have a dramatic
impact on the density of sand-flies in the area. If outdoor resting sites have been identified, they can also
be sprayed with residual insecticides. Outdoor fogging may provide additional benefit in reduction of sand-
fly density, but temporarily.
(iv) Personal Protection.
This includes wearing shirts with sleeves rolled down and buttoned at the cuffs and long trousers with
socks tops drawn over the trouser cuffs and / or anklets worn over them. Use of repellents viz. DEET is one
of the most efficient methods of preventing bites from sand-flies; the repellents may be applied topically
or sprayed on clothes. Other repellants that can be used are piperidene-based ones and neem oil. The
ordinary mosquito net does not give adequate protection because of the minute size of the sandflies. A
sandfly net is useful; but it reduces air movements and causes great discomfort and therefore the mosquito
net impregnated with synthetic pyrethroids can be successfully used.
(v) Other Measures.
These include encouragement of gardening (cultivation of ground) and planning of embankments with native
aromatic plants. Free cross ventilation and ingress of sunlight keeps the sandfly out of barracks, bashas
and bunkers. Electric fans are useful as the air current drives them away. Electric light shades, smeared
with Vaseline, trap a large number of sandflies. Siting of human habitation away from the cattle sheds is
a very effective measure in reducing man-vector contact.
(vi) Treatment of animals.
Earlier practice of culling of dogs or killing of rodents is no more undertaken. Dogs are treated by dipping
in insecticide solution (Deltamethrin 50 ppm) or applying insecticide solution (1-2 ml of 65% Permethrin
or Imidacloprid 10%). Even insecticide treated dog collars and treatment of non-reservoir animals reduces
transmission of Leishmaniasis. Novel control measures, like vaccination, have been found to provide lasting
protection against Leishmaniasis in dogs, thus reducing the reservoir of infection.

34.10 Leishmaniasis.
(a) Definition.
Under the common head of ‘Leishmaniasis’ are included at least three diseases, caused by what morphologically
and ecologically appears to be the same protozoa, but with quite distinctive clinical and epidemiological
characters. The diseases are kala-azar, oriental sore and espundia.
(i) Kala-azar (Visceral Leishmaniasis).
It is a chronic visceral leishmaniasis occurring in India and characterized by irregular fever of long
duration, enlargement of the spleen and liver, anaemia and leucopenia, progressive emaciation and
development of a strange, earthy-greasy, dusky pigmentation of skin giving the disease its name. About
10 percent of cases may finally recover without treatment but the majority succumb to some complicating
intercurrent disease. Visceral leishmaniasis of other varieties is common in the Mediterranean littoral,
China and Middle East.
(ii) Oriental Sore (Cutaneous Leishmaniasis).
It is a specific granuloma of the skin which usually breaks down to form an indolent ulcer. The lesions

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are usually multiple but may be single and are invariably on the exposed parts of the body, especially
where the epidermis is thin and delicate like the face, ears, feet and hands. The scalp and palms are
never affected. After healing, a depressed scar is left.
(iii) Espundia (American Mucosal Leishmaniasis).
It is similar to oriental sore with the difference that while the granuloma of oriental sore affects the
skin surface, that of espundia affects the mucous surface of mucocutaneous junction. The occurrence
of a primary tropical sore on the arms has been recorded in some cases. They may thus cause scars
or blockage in the respiratory tract causing obstruction. Lymphoid tissue is secondarily involved.
(b) Geographical Distribution.
Leishmaniasis in its three main forms is endemic in various region of the world.
(i) Visceral Leishmaniasis.
More than 1 billion people live in areas endemic for leishmaniasis and are at risk of infection. Visceral
leishmaniasis (VL), also known as kala-azar (KA), is endemic in 75 countries across Asia, Africa and
the Americas. Most cases occur in Brazil, East Africa and India. An estimated 50,000 to 90,000 new
cases of VL occur worldwide annually, with only 25–45% reported to WHO. It has outbreak and mortality
potential. Globally, an estimated 30,000 new cases of Visceral leishmaniasis and more than 1 million
new cases of cutaneous leishmaniasis occur annually.
(ii) Oriental Sore.
It is endemic in all the Middle East and Mediterranean countries, but more inland than areas showing
visceral leishmaniasis endemicity, extending eastwards towards Tashkent and Bokhara. In India, it is
common in the western drier portions of the Indo-Gangetic plains extending eastwards upto Varanasi and
westwards continuing into Pakistan and getting more endemic. The density and distribution of infection
corresponds with the distribution and density of the vector species of sandflies: P. papatasii and P.
sergenti vectors for L. tropica breed in drier areas than P. argentipes and other vectors of L. donovani.
(iii) Espundia.
It is endemic in South and Central America.
(c) Incidence.
India accounts for 18% of the global burden of kala-azar in 2020. Kala-azar remains a substantial public
health problem in the country as it is present in 54 districts across four states — Bihar (33 out of 38 districts),
Jharkhand (4 out of 24 districts), Uttar Pradesh (6 out of 75 districts) and West Bengal (11 out of 23 districts).
Micro-stratification surveys reveal that there are 633 blocks in these four states that are endemic. Sporadic
cases are also reported in other states including Assam, Gujarat, Himachal Pradesh, Jammu & Kashmir, Kerala,
Madhya Pradesh, Haryana, Puducherry, Sikkim, Tamil Nadu and Uttaranchal. Much progress has occurred in the
country in the past decades. Kala-azar cases have decreased by 98% (1,275 cases in 2021) since the start
of intensified activities in 1992 (77,102 cases). To get to the 2030 Sustainable Development Goals and WHO
targets for kala-azar elimination as a public health problem, block level incidence of cases should be reduced
to less than 1 case per 10,000 population. This target is aligned with the new NTDs roadmap 2021-2030. By
the end of 2021, 98% of blocks have achieved the WHO elimination threshold and only seven blocks which
are yet to reach the targets.
(d) Agent.
The causal organisms in all types of leishmaniasis belong to the genus Leishmania, morphologically
indistinguishable from Leptomonas. The parasite causing Kala-azar or visceral leishmaniasis is L. donovani, that
causing oriental sore is L. tropica and the one causing espundia is L. braziliensis. They are all morphologically
and culturally similar but serologically distinct. Two forms are recognized.
(i) Intra-cellular (Amastigote).
It requires the arthropod host and the vertebrate host for development. In the human host it grows
intracellularly in the spleen, lymph nodes, bone marrow and in case of oriental sore and espundia, in
the subcutaneous and submucous reticulo-endothelial system giving rise to the granulomas. This form is

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a small, ovoid or nearly spherical, non-flagellate organism. In the arthropod host viz. Sandfly, the whole
midgut becomes the nursery for cyclo-propagative development of the parasites. This is a leptomonad
flagellate, which is the true morphological form of leishmania. From the midgut they spread to the pharynx
and buccal cavity and the sandfly becomes infective two weeks after feeding on a case.
(ii) Extra-Cellular (Promastigote).
Grown on a culture (N. N. N.) medium at temperature of 20°C to 22°C, the agent multiplies rapidly and
assumes an undulating membrane. This form is analogous to the leptomonad found in the arthropod
vector. They can be transmitted by injection to dogs, hamsters, monkeys, jackals, rats and mice but do
not cause disease in man for whom the intermediary arthropod­host cycle is obligatory.
(e) Host.
The reservoir of infection is considered as being primarily in animals. In East Russia and in Turkestan, L.
donovani has been discovered in jackals; in the Mediterranean littoral it is found in dogs. In China, the striped
hamster, in Morocco, the squirrel and in Kenya, the gerbils and squirrels are considered to be permanent
hosts. In India, however, no animal reservoir has yet been discovered and man is supposed to be the only
reservoir.
(f) Source.
A person or an animal suffering from infection is the source of infection. In India, the human carrier of parasites
forms the source. The immediate source of the disease is an infective sandfly that has fed upon the reservoir.
(g) Immunity.
Man has no natural immunity. All ages are equally susceptible. Although childhood leishmaniasis is particularly
common in the Mediterranean littoral, it is not common in India. Both sexes have equal susceptibility. The
local population develops premunity enabling them to tolerate fever and heavy infection without much direct
mortality or heavy morbidity. The immigrants to the areas pronouncedly suffer. Repeated infection by L. tropica
causing oriental sore produces considerable and finally even solid immunity against a successive occurrence
of granulomas.
(h) Incubation Period.
For visceral leishmaniasis, although the incubation period varies widely from 2 weeks to 2 years, in a majority
of cases it is 3 to 6 months. In case of dermal and mucosal leishmaniasis, the incubation period is more fixed
within the limits of 2 to 4 months.
(j) Extrinsic Incubation Period.
The extrinsic incubation period in the vector sand flies vary from 4-25 days which is the time required for the
vector to become infective after an infective blood meal.
(k) Communicability Period.
Human cases are infective throughout their clinical course. The sandfly remains infective for about a month.
(l) Mode of Transmission.
The vector sandfly becomes infective about two weeks after feeding on a case and transmits the parasite
through its bite to the human host.
(m) Prevention and Control.
(i) Anti-sandfly measures as described earlier, use of impregnated mosquito nets with permethrin
and repellents are the important measures.
(ii) No vaccine for the prevention of leishmaniasis is available at present, although trials have been
carried out in Israel and Russia using alternate strains of L. tropica.
(iii) The first-line treatment for kala-azar in India is injectable liposomal amphotericin B 10 mg / kg
body weight and for PKDL, it is 12 weeks oral miltefosine adjusting the dosage according to age and
weight of the patient.

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34.11 Housefly.
(a) Classification and Distribution.
The housefly belongs to the Order Diptera, Family Muscidae and Genus
Musca. There are 70 species of flies in genus Musca, of which M. vicina,
M. nebulo and M. sorbens are found in tropical and subtropical countries.
M. domestica has a worldwide distribution.
(b) Morphology.
It measures 6-7 mm in length and varies in colour from mouse grey to
dark-gray, with 2 to 4 distinct longitudinal black stripes on the thorax. The
body is divided into head, thorax and abdomen: the neck is mobile. The
head bears a pair of compound eyes which are close together in males
but are widely separated in females. The mouth parts, collectively known Fig 34.7 : Musca domestica
as the proboscis, are capable of considerable extension and retraction.
The thorax bears a pair of clear transparent wings which are directed
more posteriorly so as to give the fly at rest a triangular appearance when viewed from above. There are three
pairs of legs and each terminates in five segments of tarsus. The last segment bears a pair of claws and pair
of pad-like pulvilli provided with a large number of glandular hairs. These secrete a substance which keeps
the pads wet and sticky for clinging to vertical and smooth surfaces; small particles of matter readily adhere
to them. The abdomen is short, broadly oval with five visible segments and is studded with ochre- coloured
bands or patches (Fig 34.7).
(c) Life History. (Fig 34.8)
The life history of housefly is marked by four Pupae
different stages i.e. egg, larva (maggot),
pupa and adult. After copulation, a female
fly takes 2 to 4 days or more before it
begins to lay eggs. The eggs are pearly
white, oval in shape and measure about
1 mm in length. They are laid close to
each other in crevices and cracks in moist Adult
manure heaps or any decaying animal Larvae
or vegetable matter. Human and animal
excreta offer particularly suitable breeding
places. A female fly may lay 300 to 900 or
more eggs in 3 to 10 batches during her
life time. In summer, the eggs hatch after
8-12 h whereas in winter it may take 2 to 3 Eggs
days. There are three larval stages or instars Fig 34.8 : Life Cycle of House Fly
in the life of a fly. The first stage larva is
2 mm in length, white in colour and has no
eyes or legs. It is very active; it burrows into the medium and feeds voraciously. After 20 h to 4 days, depending on
temperature and availability of food, the larva moults into the second stage which is twice the original size. After 24 h
to a few days it undergoes the second moulting and develops into the third stage larva which is creamy white and
12 mm or more in length. It moves from deep moist burrows to the neighboring dry soil and contracts to form
a cylindrical dark brown pupa about 6 mm in length. The pupa neither feeds nor grows. Within 3 to 9 days, the
adult fly emerges out of the pupal case. Under favorable conditions of temperature and food supply, the whole
life cycle from egg to adult may be completed in 5 days. During winter it may take as many as 20 to 22 days.
(d) Bionomics.
The housefly has a remarkable capacity to reproduce. It is estimated that at an average of 10 days’
developmental cycle for each generation, one female housefly, laying about 120 eggs, could produce a progeny
of 5,59,87,20,00,000 adult flies by the end of 5 months in summer. However, nature does not allow this, as
a number of eggs, larvae and pupae are lost due to desiccation, starvation, predators and adverse climatic
conditions. A high percentage of flies remain near the breeding places. Depending on the prevailing wind

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and availability of food, some of them may migrate up to 20 km from breeding places. The flies are torpid
at 10°C and most active between 26°C to 32°C. A temperature of 43°C is usually fatal. High temperature
is also lethal to larvae and the heat generated in a tightly packed manure heap quickly kills them. The adult
houseflies are attracted to light. The housefly is omnivorous and a voracious feeder. It is particularly partial to
faecal matter, sputum, discharges from wounds and open sores. It is also easily attracted to sugars, milk and
other articles of food meant for human consumption. The solid or semi-solid foods are softened by extrusion
of a vomit drop and then sucked up. Well-fed fly defecates every 5 min, particularly while feeding and vomits
every 2-3 minutes. Adult flies generally avoid direct sunlight and prefer to take shelter in buildings inhabited
by humans or animals. In darkness, it mostly remains inactive or slowly crawling and it is an important aspect
in control of houseflies while at rest.
(e) Vector Potential.
Immediately after visiting a dirty place, the fly may rest on any foodstuff or drink meant for human consumption
or an exposed part of body e.g. mouth, eyes or a wound and deposit the disease producing organisms. The
housefly is thus a mechanical carrier of the causative organisms of diarrhoeas, dysenteries, gastroenteritis,
cholera, enteric group of fevers, intestinal worms, poliomyelitis, viral hepatitis A, other enteroviruses, trachoma,
conjunctivitis, anthrax, yaws and tuberculosis. At times the housefly may cause conditions known as internal
and external myiasis in which the flies breed in sloughing wound, intestinal contents and suppurating cavities.
(f) Fly Control.
(i) Environmental Control.
The best control of houseflies is to eliminate their breeding places and to maintain a high standard of
environmental sanitation, especially by proper disposal of human and animal excreta, swill, garbage, all
other decaying organic rubbish, offal and carcasses. Access of flies to faeces should be prevented by fly
proofing the latrines and latrine pans and prompt removal of faeces. Their access to food is prevented
by fly-proofing cookhouses and messing blocks and by use of fly-proof cupboards and containers. The
doors of all entrances and windows should open outwards. Constant vigilance is necessary to destroy
all flies that gain entrance otherwise the fly-proofed rooms become large fly-traps. In pantries and mess
rooms fly-proof cupboards for food storage and wire gauze, weighted with leads, afford protection to food
in jugs or bowls, but their repair and cleanliness require constant supervision. When the table is being
laid, cups should be inverted in saucers and bowls should be kept either upside down or under cover
when not in use.
(ii) Insecticidal Control.
(aa) Residual Spray.
The housefly has developed resistance to conventional organochlorine compounds as well as to
several organophosphorus and carbamate group of insecticides. Residual sprays are ideally not
recommended for fly control.
(ab) Space Spray.
For immediate destruction of flies and specially for suppression of fly borne epidemics, pyrethrum
(0.1%) spray is useful, mainly in cook houses and dining rooms before meal times and in canteens.
Certain combinations of space sprays containing pyrethrum or synthetic pyrethroids and / or
organophosphorus / carbamate compounds are available commercially.
(ac) Poison Baits.
Propoxur baits have been in use since long for fly control. Recent introduction in this concept is
Imidacloprid baits containing Imidacloprid as the toxicant with Pheromone – Muscalure, which helps
in attracting the flies to the bait. This bait (Quickbayt ®) has been found to be effective for use in
areas with low to moderate fly infestation. However, while using these baits in cookhouses / dining
areas, care should be taken that they are not placed close to cooking or serving place.
(ad) Cord and Ribbons.
Cotton or nylon cords and strips impregnated with insecticides hung from ceilings in kitchens,
dining halls, store rooms, dairy farms and poultry houses also provide effective control during the

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fly season. The period of effectiveness ranges from 1 to 6 months. Bed nets, curtains impregnated
with synthetic pyrethroids will be of additional benefit.
(ae) Larvicides.
Insecticides such as Diazinon 0.5%, DDVP 2%, Fenthion (4%) have been used as larvicides in the
past to control fly breeding but the use of larvicides may favour the development of resistance,
the choice should therefore be made carefully.
(af) Paints.
The concept of using insecticidal paint for housefly is catching up. Imidacloprid baits wetted with
water may be used as paint on housefly resting places.
(iii) Mechanical Control.
(aa) Fly Traps.
Various types of flytraps such as the cage trap and the kerosene tin trap were used in the past
with fairly good results. These are no longer in use because of the availability of more potent and
convenient methods mentioned above.
(ab) Swatting.
The fly population of a cookhouse or dining room cannot be greatly reduced by persistent swatting.
A good swat is the one, which is resistant enough to effect a rapid hit. The flaps should be
perforated and washable.
(ac) Fly Paper (Tangle Foot).
Sticky fly papers can be prepared by mixing 8 parts of powdered resin and 5 parts by weight of
crude castor oil and heating the same in a water bath while stirring constantly. The paste mixture
is spread on glazed paper. The latter can be prepared by coating an ordinary paper with a hot
solution of 1 g of glue in 3ml of water and allowing to dry. The fly papers do not give lasting
results and hence are not much in use.
(iv) Physical Control.
Use of light traps (electrocutors) are very useful in the dining area & other public eating places. The
traps should be placed away from dining tables & food. Electric fly swats are also useful in controlling
houseflies in low density areas.

34.12 Fleas.
(a) Classification and Distribution.
Fleas belong to the order Siphonaptera comprising about 2,500 species and sub-species of fleas in about 220
genera, distributed all over the world. Fleas can be classified into two main groups, ‘combless’ fleas and the
‘combed’ fleas. The combless fleas contain the important genus Xenopsylla which has about sixty species and
sub-species including the well-known vectors of plague viz, X. cheopis, X. astia and X. braziliensis. X. cheopis,
the oriental rat flea, is widely distributed in the tropics and is the principal plague flea in India. X. astia is also
found in India, Burma, Sri Lanka, Hong Kong and Iran. X. braziliensis is found in Africa, especially in Nigeria,
Congo, Kenya and in South America but in India its distribution is very restricted. The combed fleas are the
cat-fleas Ctenocephalides felis, the dog flea C. canis and the rat fleas of temperate zones, Nosopsyllus fasciatus.
These fleas serve as intermediate host of certain veterinary cestodes (dog­ tapeworm) but are more of a biting
nuisance to man. The other important combless flea is the Pulex irritans, which occurs only in the hills of the
tropical countries of the Eastern Hemisphere. It breeds in and around dwellings and principally attacks man
besides animals and rats. Tunga penetrans, a sand flea is found in tropical and sub-tropical regions of North
and South Americas and Africa and occasionally in Western India.
(a) Morphology.
Adult fleas are small, laterally compressed, highly chitinised, wingless, 6-legged, blood sucking ectoparasites
of many warm-blooded vertebrates (Fig 34.9). The size varies from 1.5 to 6 mm in length and the colour
from light amber to dark brown. They have a compact appearance without a sharp division between the head,

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thorax and abdomen. The head is roughly triangular and

bears a pair of three segmented antennae, the mouth
parts and in a number of species, a row of powerful
teeth like spines collectively known as the genal comb,
arranged on the lower border of the head. The mouth
parts are adapted for biting, piercing and sucking blood,
which forms the only food for both sexes. The thorax of
the flea is compact and consists of the pro, meso and
meta-thorax without any wings. The legs are long and
powerful and are adapted for the purpose of hopping
and jumping. The abdomen consists of 10 segments,
the 9th and 10th being modified for sexual functions. The
7th segment in both sexes bears a pair of setae known Fig 34.9 : Adult Rat Flea
as the antepygidial bristles, so named because the 9th
segment bears the pygidium which is a pin-cushion like structure with a sensory function. In the female, the
abdomen has a rounded terminal outline whereas in the male it has a rather cocked up appearance. The body
and the legs are provided with stiff setae, which give the insect a bristly appearance. The tapering pharynx
continues into the esophagus leading into the conical proventriculus. This is lined with closely set, backwardly
directed rods converging towards the center. These rods are pressed together during the act of sucking blood
to prevent regurgitation of the stomach contents. This is an important structure involved in the transmission
of the plague bacilli.
(b) Life History.
The flea undergoes a complete metamorphosis
through the successive stages of egg, larva, pupa
and adult (Fig 34.10). When the female is ready to
lay eggs, it leaves the body of the vertebrate host
and lays eggs in dark place in the host’s nest, lair,
rubbish, debris, accumulation of dust, in cracks or
crevices in the floor of granaries etc. or under carpets
in dwelling houses. During her lifetime of 6 months
or a year, the female lays 300 to 500 eggs in small
batches of about a dozen at a time. A temperature
between 18°C and 27°C and humidity about
70 percent favour egg laying. However, most of them
complete their life cycle in one to two months. The
eggs are just visible to the naked eye. They hatch in
2-10 days depending on temperature and humidity.
The larvae are very active, slender, 13 segmented and
yellowish white with a number of bristles. They feed Fig 34.10 : Flea Life Cycle
on the excreta of rodents and on partially digested
blood discharged from the faeces of adult fleas. Larvae complete their development in a week or two and
enter quiescent stage, spin cocoons which are whitish, translucent and so loosely spun that the pupae can
be seen within them. Hence the pupa closely resembles the adult which usually emerges within a week. The
whole metamorphosis takes two to four weeks, but may need several months under less favorable conditions.
(c) Bionomics.
The fleas are temporarily parasitic on their host as their immature forms are free living and even the adults
frequently leave it between blood feeds which, however, are obligatory for both sexes. After the death of the
host, its body becomes cold and then the flea seeks a new host. This behavior is of profound epidemiological
importance in plague transmission. Fleas feed frequently and much more than their actual requirements, as
a result of which much of the ingested blood is passed out in a semi digested state. Fleas are not strictly
host specific and may attack unusual hosts when hungry or with rise of ambient temperature, when they feed
more frequently. They are very sensitive to light and air currents. They always hide under dark objects and
when blown up they at once get agitated. They are able to jump up to 16 cm and hop 30 cm.

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(d) Vector Potential.

The flea transmits mainly the zoonoses to man, chiefly from rodents and also from the dog and cat. The most
important microorganism that is conveyed to man from rat is the Yersinia pestis causing bubonic plague. The
most important vector species i.e. X. cheopis, X. astia and X. braziliensis are also effective vectors. Rickettsia
typhi is also transmitted from its rodent reservoir to man by the same rat fleas. Cat and dog tapeworms use
fleas as their intermediate hosts for their development of cysticercoid stages. Cats and dogs become infested
by the ingestion of infested fleas. Children also get the infection similarly due to accidental ingestion of the
infested fleas. The South American and African flea Tunga penetrans burrows under the soft skin in between
toes and under the nail bed and causes a disease called ‘chigger’, ‘jigger’ or ‘chigoe’ in endemic areas.
(e) Flea Control.
(i) Vector Control.
DDT and HCH have become non-effective against fleas in many parts of the world. Malathion resistance
has appeared in certain parts of India. Prior susceptibility tests should be carried out to find out the most
effective insecticide. Indoor residual spraying at the lower one metre of the wall surface and adjacent
floor area is effective. Patch dusting also brings about marked reduction in flea density. For this, dusts
of Diazinon (2%), Malathion (5%), Bendiocarb (1%) or Carbaryl (2%) may be applied at a dosage of 2 to
3 g per m² of surface area under grain bins, on rat runs, furniture, upholstery, rugs and bedding. The
dust of Deltamethrin may also be used for dusting in rodent infested area.
(ii) Disinfestation.
Disinfestation of pet animals like dogs and cats along with good environmental sanitation of the household
and public places helps in flea control. Pet animals may be treated with dusts, sprays or dips of Malathion,
Propoxur, Permethrin or Pyriproxyfen. It is important to consider that most of the fleas are found away from
the host and not on the host. Hence it is equally important to apply control measures to surroundings of
pet animals. Animal premises may be sprayed with insecticides (Malathion, Deltamethrin, Pyrethrum etc) at
4–8 lit/ 100 m2. Insecticidal treatment of animals and their premises should be carried out simultaneously.
(iii) Rodent control.
It is an indirect method of flea control. Though a radically effective method during non- epidemic period,
it is dangerous during epidemics because the fleas leave dead rats quickly and start attacking human
beings. However, a constantly sustained campaign keeps the rodent population down and aids significantly
in keeping the flea index constantly low.
(iv) Personal Protection.
This is achieved by the use of protective clothing such as wearing long trousers, socks and shoes. Use
of a high charpoy with the net and application of repellent viz DEET are necessary precautions while
in endemic or epidemic areas of flea borne disease. Using flea collars for pets are effective means of
keeping them free from infestation.

34.13 Plague.
(a) Definition.
Plague is primarily a zoonotic infection. It is transmitted among the natural animal reservoirs, which are
predominantly urban and sylvatic rodents, by flea bites or by ingestion of contaminated animal tissues. Humans
become accidental host in the natural cycle of plague when bitten by infected rodent fleas. In man it can
occur in bubonic, pneumonic or septicemic form. The bubonic plague is characterized by sudden high fever,
headache, backache, flushed face and delirium. A bubo develops generally in the groin or armpit. Profound
toxemia develops heralding the fatal end. In pneumonic attack, blood-stained sputum is coughed out; the
cough is hacking and painful. Toxemia is more profound and death is quick.
(b) Geographical Distribution.
As an animal disease, plague is found in all continents, except Oceania. There is a risk of human plague
wherever the presence of plague natural foci (the bacteria, an animal reservoir and a vector) and human
population co-exist. Plague epidemics have occurred in Africa, Asia and South America; but since the 1990s,

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most human cases have occurred in Africa. The three most endemic countries are the Democratic Republic
of Congo, Madagascar and Peru. Worldwide, between 1,000 and 2,000 cases each year are reported to the
World Health Organization.
(c) Incidence.
In the early years of this century, plague constituted a serious problem in India. The annual mortality was over
5,00,000 deaths between 1898 and 1908. With the introduction of DDT in malaria control and eradication,
the incidence of plague began to decline. During the last few decades, at least three geographical areas
experienced outbreaks of plague after silent period of 28 years. Human plague was reported in Mulbagal
area of Karnataka in 1966-67 only to re-emerge in the country in 1994 in Beed district (Maharashtra) and
subsequently in Surat (Gujarat) resulting in huge economic loss. Later Plague outbreak has been reported in
the year 2002 with index case from Village Hatkoi, Shimla District in Himachal Pradesh. The last outbreak
reported from India was in 2004 from Village Dangaud, Uttarkashi District in Uttarakhand.
(d) Agent.
The causal organism is Yersinia pestis, which lives and multiplies in the tissues and blood of the infected
animal or man. It is a gram-negative bipolar staining and non-motile bacillus.
(e) Reservoir and Source.
The disease is one of the classical examples of zoonoses. The rat is the known reservoir and always acts as
a source for human infection of bubonic plague. Rats suffer from and succumb to the disease in both acute
and chronic forms; the latter keeps the infection smouldering. Rats most concerned in the spread of plague to
human population are R. rattus & R. norvegicus. In India, Tatera indica has been found to be the permanent
reservoir. Cases of pneumonic plague can infect people by the ‘droplet’ mode of transmission. Their blood is
also infectious. The immediate source of infection to man is always the infective vector flea which has fed on
an infective rodent host.
(f) Mode of Transmission.
The epidemics are almost always preceded by an epizootic in urban or rural house-rats and that is usually
preceded by sylvatic epizootic in jungle rodents. The transmission cycle in the epizootic is rat-flea­ rat. The rat
fleas become infected after taking a blood meal from their infected rodent host. They leave the dying host
and infest another rat. This cycle is repeated. Initial infection in the sylvatic reservoir is thus transmitted to
rural and urban rats. R. norvegicus, which generally are out-door rodents in India, act as intermediary between
sylvatic rodents and house rat, R. rattus. The epizootic in house rats reduces their number and the fleas start
attacking human beings. Many species of rat fleas have been incriminated but Xenopsylla cheopis is the most
important plague vector flea in India.
(g) Blocked Flea.
The developing and multiplying plague bacilli partially block the slanting rods in the wall of proventriculus
causing the loss of valve action and permitting regurgitation of the stomach contents loaded with the developed
plague bacilli into the puncture made by the feeding flea. A completely blocked flea cannot draw blood in
the stomach but the oscillating column of blood in contact with the proventriculus loosens clumps of bacilli
which gain access to the wound. As blood is the only food for adults of both sexes, the disease is transmitted
by males and females alike. The potentiality of infected rodents to cause epidemics depends upon the ‘flea
index’ and ‘specific flea index’. The ‘flea index’ is the number of fleas per rat. The ‘specific flea index’ means
the number of particular species of fleas per rat. X. cheopis index of even three per rat is considered enough
to start an epizootic of plague. Experience has shown that a specific index of over 1 for X. cheopis must be
regarded as indicative of a dangerous situation, especially in plague pockets. During epidemics, there is a
significant rise of the cheopis index.
(h) Host.
Man possesses no natural immunity. Both sexes, any age and all races are susceptible. The disease shows
marked difference in degree or severity ranging from the mild ambulatory to the almost inevitably fatal
pneumonic variety in untreated cases.

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(j) Incubation Period.

The incubation period of bubonic plague varies from 2 to 8 days. It is usually 2 to 3 days. In case of pneumonic
plague, it is 1 to 4 days.
(k) Clinical Features.
People infected with plague usually develop influenza-like symptoms after an incubation period of 3–7 days.
Symptoms include fever, chills, aches, weakness, vomiting and nausea. There are 3 main forms of plague.
Bubonic plague is the most common and is caused by the bite of an infected flea. Septicaemic plague occurs
when infection spreads through the bloodstream. Pneumonic plague – or lung-based plague – is the most
virulent. Typically, it is caused by spread to the lungs from advanced bubonic plague.
(l) Diagnosing Plague.
Confirmation of plague requires lab testing. The best practice is to identify Y. pestis from a sample of pus
from a bubo, blood or sputum. The various lab techniques used to diagnose plague includes microscopy of
material from bubo, blood, sputum showing gram negative coccobacilli in Grams staining and bipolar after
Wayson or Giemsa staining, F1 antigen detection in bubo aspirate, blood or sputum, anti F1 serology, direct
PCR on clinical specimen.
(m) Treatment.
Antibiotics such as Streptomycin, Gentamicin, Doxycycline or Ciprofloxacin are used to treat plague. Oxygen,
intravenous fluids and respiratory support are usually also needed. People with pneumonic plague must be
kept away from other patients and isolation procedures should be followed in the hospital.
(n) Prevention and Control.
Anti-rat engineering, anti-rat hygiene and rat destruction persistently enforced are the only long-term effective
measures to prevent the epizootics in order to maintain low endemic potential. Strict anti-rat measures at the
ports, railway yards, granaries, flour mills, stores, godowns, slaughter houses and in crowded localities must
be enforced. Following action should be taken on occurrence of a case:
(i) Isolation.
The patient should be admitted to hospital and isolated in a special ward. With pneumonic plague, the
isolation of the patient must be more rigorous and the patient should wear a mask.
(ii) Disinfection.
Disinfection of personal clothing, ward linen and beddings should be carried out. Sputum should be
received in 5 percent cresol liquid and all naso-pharyngeal discharges should be similarly treated in
case of pneumonic plague or even on suspicion of it.
(iii) Notification.
The occurrence of each case must be reported in the normal manner as for group B diseases. The Director
of Health Services of the state must also be notified. Liaison with the civil authorities is essential.
(iv) Attendants.
Persons on plague duties i.e. working in the plague ward or infected houses or disinfecting material
suspected to contain plague bacilli, should be inoculated against plague and must wear protective clothing
made of smooth strong linen. A suitable outfit consists of a white, one-piece overall with a cowl to fit
over the head, buttoned upto the neck. The trouser part of this should end over the feet like salmon-
waders, while the sleeves should terminate in tight fitting wrist bands. Rubber gloves should be worn
overlapping the wrist bands. Gum-boots reaching upto the knee are also desirable. These garments must
be impregnated with an insecticide or treated on leaving infected premises or disinfected daily. A fresh
mask should be used at each visit of the ward when nursing a case of pneumonic plague.
(v) Contacts.
Close contacts living in the same premises should be immunized with plague vaccine and put under
medical surveillance for 10 days as they also may have been bitten by infected fleas. Contacts of
pneumonic plague must be segregated and inspected daily for 10 days and close contacts should receive

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a prophylactic regimen of Tetracycline (1 g per day) or Sulfonamides (2 to 3 g daily) for 5 to 7 days.

(o) Action During Suspected  Outbreak of Plague.
(i) Insecticide Spray.
Insecticidal method for control of fleas is rapidly effective and is definitely safer, cheaper and easier
method of Plague containment.
(aa) Epidemic Area.
The area should be immediately sprayed with ULV spraying either with Malathion or synthetic
pyrethroids like Deltamethrin. The premises should be treated with insecticidal dusts (Malathion,
Deltamethrin or any other synthetic pyrethroid) and spraying of insecticides should be undertaken
to thoroughly cover the entire area. On reduction in flea population antirodent activities can be
undertaken. Individuals should be advised to use protective clothing, repellent and sleep on
charpoys with a mosquito net during night for additional safety.
(ab) Plague Potential Area.
Plague surveillance should be undertaken in all areas positive for Yersinia pestis activity. Rodents
should be trapped for eliciting the flea index specifically X. cheopis index.
Flea index <1 - Insecticide dusting
Flea index >1 - Spraying + dusting in rodent burrows
Every area must be examined at least once a year, preferably before month of August.
(ac) Non Plague Potential Area.
(No evidence of Y. pestis activity)
Flea index 5-7 - Dusting in Rodent burrows
Flea index >7 - Spraying+ dusting in rodent burrows
(ii) Rodent Destruction.
The rodents should not be killed during a plague epidemic prior to reduction in flea population. The
rodents trapped should be destroyed by incinerating, burrowing or drowning. The rodents in field may be
killed by using fumigants.
(iii) Examination of Dead Rats.
Examination of a dead rat for evidence of plague infection needs adequate precaution as the fleas leaving
its body may be present around it. Rubber gloves should be worn. The area around the rat should be
drenched with 5 percent cresol thrown from a distance. The rat should then be picked up with tongs
or a pitch fork, placed in another bucket of disinfectant and pressed down below the surface to drown
all fleas. After sometime it can be removed and examined. A plague rat has flushed pink feet. The
typical postmortem signs are enlarged and engorged, dark, friable spleen; red serous membranes with
petechial or diffuse haemorrhages; blood-stained fluid in the serous cavities; sometimes white miliary
foci of necrosis in the spleen and liver and enlargement of the lymph glands especially of the cervical
region. Smears for microscopic examination should be taken from the spleen, blood or from enlarged
glands. Cultures for the isolation of bacilli are taken in the same way. When plague is found in more
than 5 percent of trapped rats there is a strong reason to expect an outbreak in the human population
in that area.

34.14 Sucking lice.

(a) Classification.
The order Anoplura contains the sucking lice which are parasitic on mammals and the chewing lice which infest
birds and mammals. Only the sucking lice transmit human diseases. The important species of human lice are
Pediculus humanus varieties corporis and capitis, the body and the head louse respectively and Phthirus pubis:
the crab louse. The head louse infests the hair on the head and may be found in the neck region and behind

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the ears. The body louse infests the hairs of chest and axilla, seams of clothing in contact with the body and
sometimes linen. The crab louse infests the hair of the pubic region and occasionally invades eyelashes and
eyebrows.
(b) Morphology.
Lice are small, dorsoventrally flattened, wingless insects with simple metamorphosis. They are permanent
obligatory ectoparasites living entirely on mammals. Both males and females derive their nourishment by
sucking blood. Hence both are equally concerned in the transmission of the diseases. They are highly host
specific. The mouthparts are of a sucking and piercing type. They have two eyes. The legs are short, stout
and thick with claws for grasping hairs and fibres. The abdomen is oval or somewhat circular in shape. In the
female the last abdominal segment is bilobed and in the male it is pointed from which the aedeagus (penis)
projects. Phthirus resembles Pediculus in its general morphology, but its body is almost circular, all the three
pairs of legs of Pediculus are equal whereas in Phthirus the first pair is less developed; P. capitis has a smaller
and deeply pigmented body, while that of P. corporis is larger and non-pigmented. Abdominal segments of P.
corporis are rounded with shallower intersegmental indentations while those of P. capitis are clearly marked
and deeper. Antennae and legs of P. corporis are longer and thinner than those of P. capitis (Fig 34.11 &
34.12).

Fig 34.11 : Body Louse Fig 34.12 : Head Louse

(c) Life History.

The life histories of all the three varieties are similar. After fertilization, the female lays eggs (or nits) either
on the hairs or under clothing chiefly along the seams of the vests, pants and shirts etc. Freshly laid eggs
are white and proportionally large for the size of the insect. They are firmly cemented to the hair or seams
of the clothing, singly or in groups. As the embryos develop, they become yellowish. The number of eggs laid
depends upon the food supply and the temperature. Under optimum favorable conditions the louse lays 4 to
9 eggs in each batch. The immature stages, called nymphs, begin sucking blood at once and throughout their
development feed frequently during the day and night, mostly when the host is quiet. There are three nymphal
stages and the young ones resemble the adults except in size. It takes about 18 days between hatching of
the eggs and appearance of the adults.
(d) Bionomics.
Lice like warm and moist environments; 38°C is the optimum temperature. Higher temperature and death
of the host are detrimental and make lice leave the body of the host. The average life of a louse is 30 to
50 days. Females live longer than the males.
Once the lice are acquired by a human host, their multiplication depends on the neglect of personal hygiene.
Following factors are responsible for the dissemination of lice.
(i) Close contact with lousy persons; sharing the same bed and clothing in the household, barracks,
underground shelters etc. In fact, any prolonged crowding of human beings in insanitary surroundings will
spread lousiness. Hence lice and louse borne diseases are closely associated with wars and disasters
among prisoners and refugees.

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(ii) Indirect contact as, for example, exchange of beddings, clothing, blankets, towels, hats, combs
and brushes.
(iii) Hair bearing nits from lousy persons scattered in public conveyance are picked up from the seats
and cushions of railways carriages and buses etc.
(iv) Head lice easily pass from one child to another in school by communal use of caps and combs.
(v) The pubic or crab lice spreads through sexual contact and sometimes from toilet seats, beds and
by close personal contact. Small children may become infested with crab lice on their eyebrows and
eyelashes from their mothers or wet nurses.
(e) Vector Potential.
Body lice is responsible for the transmission of Rickettsia prowazeki, causing the Epidemic typhus, Bartonella
quintana causing Trench fever and Borrelia recurrentis causing Relapsing fever. The presence of lice on any
part of the body is termed ‘pediculosis’ which causes irritation with loss of sleep and scratching may lead to
secondary infections. The skin of a heavily louse infested person becomes hardened and deeply pigmented
and a condition known as ‘Vagabonds’ disease or melanoderma develops.
(f) Prevention and Control.
Louse infestation should never occur among troops under static conditions where ample facilities for bathing
and washing are provided and their regular use ensured. In mobile operations, however, when it may be
difficult to provide these facilities adequately, the danger of louse infestation becomes imminent, particularly
when contact with local civilians, refugees and P.O.W. is unavoidable. In order to prevent lousiness amongst
troops, their contacts with refugees and local civilians should be reduced to the minimum. Regular hot baths
and washing of clothes should be ensured. For this purpose, field bath and laundry units may be required.
If stray louse infestation occurs under static conditions, steam disinfection of clothing may be carried out
simultaneously with the hair clipping and bath of infested persons. In the past, anti-louse powder, containing
10 percent DDT, was used for reduction of infestation in a controlled community by dusting the lousy individuals
and garments. But lice have developed resistance to DDT in most parts of the world. Currently, the insecticides
of choice are Permethrin dust (0.5%), Propoxur dust (1.0%) for body louse and shampoo formulations like
Phenothrin (0.2-0.4%) and Permethrin (1%) for head lice infestation. For mass treatments against body louse,
dusts should be applied through neck openings, up sleeves and from all sides of the loosened waist of trousers.
Socks, head coverings, the inner surfaces of extra garments and bedding should also be treated.
For application on hair, the hair of the infested persons should be wetted thoroughly before application. The
insecticidal shampoo is thoroughly massaged on the head and left for minimum 10 min. Thereafter, the shampoo
is rinsed off from the hair, hair is towel dried and combed with lice comb to remove dead / stunned lice.
Impregnation of clothing with a pyrethroid insecticide may provide long-lasting protection against louse
infestations and such treated clothing may remain effective after several washings. Probably the best pyrethroid
for this is permethrin. Trials have shown that orally administered Ivermectin kills body lice and also head lice,
but it is not yet universally approved for control of human lice.

34.15 Ticks and mites.

(a) Order Acarina.
It includes ticks and mites which belong to the class Arachnida. Their body is not clearly demarcated into head,
thorax and abdomen but only two distinct parts, the cephalothorax and the abdomen are seen. Antennae are
absent and eyes may or may not be present. There are two pairs of mouth appendages, the chelicerae and
the pedipalps. The palps are sensory organs and the chelicerae are the actual cutting organs. Hypostome is
situated ventrally, projecting forward from the base of the capitulum. By the apposition of the chelicerae above
and the hypostome below, the sucking tube is formed. Metamorphosis is incomplete and the adult resembles
the younger stages, except that the adult and nymph has four pairs of legs while the larva has only three
pairs and the nymph has no genital aperture while in the adult the sexes are distinct.
(b) Ticks.
Ticks belong to the super-family Ixodoidea having more than 500 species of worldwide distribution.

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(i) Morphology.
They are distinguished from other acarines by their relatively large size and absence of prominent hairs
on the body. They are oval in shape and of varying colours, dorsoventrally compressed and slow in their
movements. Females are larger than males and are capable of great distention. Both sexes thrive on
blood alone and lead an intermittent parasitic life during a major part of their life cycle. The wide host
range includes the cold blooded as well as the warm blooded animals. They are free living on the ground
in between various moults during development. There are two families; Family Ixodidae which is the hard
tick and Family Argasidae which is the soft tick. The hard tick is the jungle tick while the soft tick is a
domestic or household tick like a bedbug.
(aa) Ixodidae or Hard
Ticks.
The dorsum of the adult male
is covered by a dark shield,
like that of the tortoise,
called the scutum. This may
be ornate with grey or white
‘patterns’. In females and
immature males, it covers
only the anterior part behind
‘the capitulum’ which is the Fig 34.13 : Hard Tick-Dorsal and Ventral Aspect
false head actually formed
by the mouthparts anteriorly
and, therefore, visible from
above (Fig 34.13)
(ab) Argasidae or Soft
Ticks.
These are oval with leathery
cuticle, devoid of scutum.
Their mouth parts are not
visible from above and
possess no festoons (Fig
34.14).
Fig 34.14 : Soft Tick-Dorsal and Ventral Aspect
(ii) Life History.
Both the Ixodidae and Argasidae have hemimetabolous life cycle, i.e. there is incomplete metamorphosis,
passing through four stages during their development viz., egg, larva, nymph and adult. The total period
required for full development of a tick is from six weeks to 2 years. Fully engorged fertilized female
drops off to the ground and lays eggs in cracks and crevices in the soil under stones or among roots
of shrubs and grass and such other sheltered spots. Number of eggs laid varies from a few hundred in
some species to several thousand in others. Hard ticks deposit all their eggs in a single act of oviposition
after which they die. Eggs take a few weeks to several months to hatch. Larvae are six legged and do
not feed for about a week after emergence. Thereafter, they become hungry and active and get attached
to their animal hosts. They feed for some days and drop off when engorged and remain quiescent for
digestion of blood. After the first moulting the nymphs emerge with their fourth pair of legs and seek a
new host, feed and again drop off. They again moult and become sexually mature. Hard ticks have only
one nymphal stage but soft ticks may have as many as five. Copulation takes place after the last moult:
the male dies after fertilizing the female. The female engorges and then deposits eggs.
(iii) Bionomics.
A few species of hard ticks, mostly members of the genus Boophilus, spend the whole of their life cycle
on the same host and are known as ‘one host ticks’. Ticks of the Genera Hyalomma and Rhiphicephalus
remain on the same host during the larval and nymphal stages but the adult form seeks a new host
and are known as ‘two-host ticks’. Ticks which feed on different animal hosts in the larval, nymphal

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and adult stages are known as ‘three host ticks’. Medically important hard ticks of the genera Ixodes,
Haemaphysalis and Dermacentor are all three-host ticks. In soft ticks of the genus Ornithodorus, each
stage of the five moults is completed on a different host: and adults may also feed intermittently on
different hosts. Such ticks are known as ‘multiple-host ticks’. Hard ticks are open jungle dwellers and
thrive on animal hosts, hence they do not attach themselves to human beings voluntarily, except when
a person comes across them accidentally. The larvae, nymph and adult, especially of Ixodid, exhibit a
peculiar host-seeking behaviour called as Questing, during which it climbs up the vegetation and waits
for the passing host. When suitable host comes in contact, it extends its front legs in the air and gets
attached to hairs or feathers of the passing host. Argasidae although preferentially parasitic on animals
and birds, attack man voluntarily. These are found in human dwellings and cattle sheds and attack man
and animals during their sleep. They however, live away from their hosts, like bedbugs, in cracks and
crevices and only emerge at night to feed on the host. They all can survive starvation for long time even
for 2 or 3 years in case of Argasidae.
(iv) Vector Potential.
Ticks produce diseases in man by transmitting the viruses, rickettsiae, spirochaetes and bacilli of
infectious diseases and through toxin present in their saliva. Some of the factors which account for
high vector potential are that-they feed entirely on blood and are persistent blood suckers; while feeding
they attach firmly and cannot be easily removed. They are resistant to varying environmental conditions
as nymphs and adults are sclerotinized and thus relatively protected from natural enemies. A wide host
range always ensures certainty of enough supply of blood; high production potential and long life. The
trans-stadial and trans-ovarian transmission of infection helps in maintaining infection for several years.
Ticks have the power to regenerate lost parts such as amputated legs and also the ability to repair
mutilated mouth parts, which conserves them for long.
(aa) Soft Ticks.
Soft ticks of the genus Ornithodorus transmit various types of spirochaetae causing relapsing
fevers in certain parts of the world. O.moubata is the vector of Borrelia duttoni in Africa; O. hermsi
and O. turicata are the vectors in America. O. tholozani has a very wide distribution over a large
area from Iran to Central Asia. O. lahorensis has a very wide distribution in Central Asia and North
West India. In India they are found in Kashmir and are known as O. crossi.
(ab) Hard Ticks.
These are much more ubiquitous and produce larger varieties of human diseases. The most
important of all are the various rickettsial infections transmitted by the hard ticks of the genera
Ixodes, Dermacentor, Amblyomma, Haemaphysalis, Rhipicephalus, Hylomma and Boophilus.
Viruses causing Kyasanur Forest Disease, Colorado tick fever and other haemorrhagic fevers
and encephalitides are transmitted. These also transmit P. tularensis, the causative organism of
Tularaemia. Tick paralysis is an acute ascending flaccid paralysis due to an unknown toxin the
ticks’ saliva introduces through the bite of certain species of ticks of the genera Dermacentor.
Ixodes and Amblyomma. It affects mostly children and young domestic animals in Australia, South
Africa, North America, Southern USA and North Western Pacific. Even a single tick bite may cause
fatal paralysis. In certain cases, reaction from improper or partial removal of ticks or due to the
bite itself may cause itching, swelling and ulceration at the site of the bite.
(c) Mites.
Mites belong to the order Acarina and family Trombiculidae which comprises many hundreds of species of
worldwide distribution. They are found in great abundance in areas with hot, humid climate, thick vegetation
and presence of small vertebrates like rodents. The foothills in subtropical and temperate regions offer them
ideal conditions. In the tropics, they are found even at heights in mountain valleys. These have also been found
in the Alpine-subarctic terrain in the Himalayas as well as at the level of coniferous forest-glacial valleys in
Pakistan. They are known by various names such as chiggers, harvest mites, Kedany or scrub mite. Important
species of the genus Leptotrombidium are Leptotrombidium akamushi which is distributed widely in Japan,
Formosa, South East China, Korea, Malaysia and Philippines and Leptotrombidium deliense which is vastly
distributed in the tropical regions of Southeast Asia, Indian sub-continent, Ceylon and Maldive Islands. In India,
it is present in the whole of the Shivalik range from Kashmir to Assam, the Eastern half of the plains adjoining

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the foothill ranges, the Eastern and Western ghats and the Vindhyachal range
in Central India. Its presence has also been reported from southern parts of
India.
(i) Morphology. (Fig 34.15)
Adult mite is around 3-4 mm in size, has a figure of eight body shape
with eight legs & is densely covered with hair. The mouth parts consist
of a pair of chelicerae and a pair of palps, together giving the mite an
appearance of having a false head. The adult resembles the nymph
except that it is larger and more densely covered with hairs: ‘Kedany’
meaning hair in Japanese language. A cluster of 5 to 6 larvae is as big
as a pin-head. When the cluster detaches, a scab is formed showing
evidence of recent infestation. The larva is ochre-yellow to orange-red
in colour with a circular body bearing three pairs of legs which have six
or seven segments and branched hairs on the body and on the legs.
On the dorsal surface, the mouth parts are placed well anteriorly, there Fig 34.15 :
is a roughly triangular dorsal scutum which bears 5 setae; the rest of Adult Trombiculid Mite
the dorsal surface bears more than 30 setae arranged in definite rows.
They are found in nature in the interior of ear cusps or on rumps of rats, mice, shrews, bandicoots and
other small mammals, reptiles and birds in orange-coloured clusters of as many as 50 to 200 larvae.
(ii) Life History.
The stages in the life history of a mite are egg, larva, nymph and adult. The eggs are laid singly on the
surface of the soil. After about a week the egg-shell splits and the larva, although exposed, remains
quiescent in the egg-shell for about a week or more (deutovum stage). After this the larva leaves the
egg­shell and becomes very active. Moving quickly over the surface of the soil and low-lying vegetation,
it seeks a suitable host such as rat, mouse, bandicoot, shrew and so on. Only the larval stages are
parasitic. While feeding it buries the whole length of its chelicerae in the host’s skin and injects an
irritant secretion which causes tissue lysis. The larva feeds on the lymph and the tissue juice but not
on blood. Therefore, the orange red colour of the larva is not due to ingested blood. The larvae feed
for 2 to 3 days and then drop off to the ground concealing themselves in loose soil. They then enter
the next quiescent stage known as ‘nymphochrysalis’ which lasts for another 7 days. The 8-legged
nymph develops within the larval integument. The nymphal stage lasts 14 days. During this period, it is
active on the soil and then enters another quiescent stage, known as the ‘imagochrysalis’. After about
a week or ten days the adult with sex differentiation emerges. Generally, it takes 6 to 12 weeks for its
development from egg to adult. The nymphs and adults are never parasitic. They exist free in the soil
near the surface and feed on other small soil inhabiting arthropods and their eggs.
(d) Bionomics.
The whole life cycle is influenced by temperature, humidity and availability of food to the free-living adults
and nymphs and for the parasitic larvae. The environment, microclimate, vegetation and fauna of a place
determine their abundance. The patches of ground known as ‘Mite Islands’ are characterized by thick vegetation
cover, mainly the scrub jungles or other tall grasses, offering protection from direct sunrays and desiccation,
100 percent humidity at ground level and ambient temperature between 27 ± 5°C. Such conditions also provide
sanctuaries for small vertebrate life such as rats, mice, bandicoots and shrews which are hosts for larval mites.
These animals are also the reservoirs of rickettsiae for which the trombiculid mites are vectors. Hence these
mite islands may also become typhus endemic foci. Mites are most active during the whole rainy season and
their prevalence in such mite islands in India is related to the intensity and length of the monsoons. In dry
season, the adults migrate deeper into the soil, the egg laying ceases and the mite islands shrink; during
monsoon, there is prolific activity and the mite islands expand. Patchy distribution of mite islands and their
selective choice of locality explains the patchy nature of typhus endemic foci. The typical terrains favorable
for the mite to thrive and propagate are as under:
(i) Man-made rural and urban wastelands like overgrown clearings produced by shifting cultivations.
(ii) Domestic sub-urban waste lands produced around neglected patches in and around villages and
even big towns, such as neglected gardens and plantations or overgrown clearings therein. Deserted

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villages are heavily infested.

(iii) Around the edges of moist depressions, water meadows, grassy but not swampy river banks and
moist sites such as seepages along over ground canal areas.
(iv) The hedgerow types of features ranging from a simple bushy hedgerow to belts of forests following
water courses and ravines which are commonly left in deforested areas in and below the foothills.
(v) The scrub at the outskirts of the forests and low lying patches overgrown with elephant grass in
sunny clearings inside thick forest.
(e) Vector Potential.
Larval mites belonging to several genera attack man but only the Genus Leptotrombidium contains species of
medical importance. In India, Leptotrombidium deliense is the vector; in Japan the closely related variety L.
akamushi (kedanimite) transmits Orientia tsutsugamushi. Rickettsiae taken up by larvae are carried through its
nymph, adult and then its eggs. The larvae hatching out of these infected eggs are capable of transmitting the
rickettsiae to the next host. The infection is thus transovarially transmitted for some generations and hence the
mite also acts as a reservoir of infection. Larvae feed only once during the lifetime. Therefore, transmission of
infection occurs in second or subsequent generations. When a larva lying on the ground comes in contact with
a human being (instead of a rodent as would happen in the normal course), it attaches on to the human and
feeds on his lymph. In the process, the ricketssiae contained in the mouth parts are injected into the lymph
of the human, causing scrub typhus.
(f) Control of Ticks and Mites.
Insecticidal Control.
(i) Area Treatment.
This is the only reliable acarine control method. Before the application of an insecticide to the areas
infested with hard ticks and mites, clearing of bushes either by cutting or by burning is advantageous. If
possible, a bulldozer should be employed and the grass burnt. When the top soil is bare and dry, an area
becomes considerably safe and more suitable for insecticidal action. Initial coverage of the area should
be thorough. It may require repetition after 8 weeks and occasionally a third time during the hot-humid
season. If men have to go to some nearby stream for bathing or washing their clothes, the selected area
should be similarly treated, as the stream edges covered with vegetation are favorite sites for acarines.
Ticks in gardens, yards and nearby fields can be killed by spraying these areas with Carbaryl, Propoxur,
Deltamethrin or Cyhalothrin. “Malathion 50% EC” (converted into 5% solution) should be sprayed in a dosage
of 4 kilograms of active ingredient (ai) per hectare of ground surface area or else “Cyfluthrin EC” applied
in dosage of 0.1 Kg (100 grams) of active ingredient per hectare. (4 Kg of active ingredient of Malathion
will be present in 8 litres of 50% EC commercial supply; these 8 litres will be mixed with 72 litres of water
to get 80 litres of 5% solution which should then be sprayed over one hectare of ground surface area).
(ii) On Vegetation.
Control of ticks on vegetation can be achieved by insecticide dusting or spraying from the ground or air
at the dosage varying from 0.5 to 2 kg / hectare. In woody and bushy areas, the dosage is increased
proportionately. Malathion, Fenthion, Propoxur and Permethrin are suitable.
(iii) Premises.
Against soft ticks, six applications of insecticides suspension to floors and wall surfaces of infested
premises on alternate days, after initial scraping and scorching, are necessary. Treatment for 2 weeks
before occupation gives good control. During this period, sweeping of floors should be discontinued.
Such a series of applications repeated 6 weeks afterwards gives adequate protection to troops billeted
in such huts. The insecticides should also be applied to floors, cracks, crevices, beds, mattresses,
rugs and furniture. In known tick infested areas, particularly where there is a history of relapsing fever,
infested caves, huts and houses should be avoided as far as possible. Organophosphorus compounds
like Malathion and Fenitrothion or Carbamate compounds like propoxur can be used either as 0.5 to
1.0 percent spray or as 5 to 10 percent dust.

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(iv) Domestic Animals.

Dogs and other domestic animals can be freed of ticks by a wash or spray containing, 2% Malathion,
1% Propoxur, Deltamethrin (0.025%) etc. Only half these concentrations should be used if the animal is
to be dipped and the entire animal should be immersed except the head. Dusts containing 5 percent
of Malathion, Propoxur (1%), Cyfluthrin (0.1%), Deltamethrin (0.05%), Temephos (2%), Fenthion (2%) etc.
may also be used. The premises which animal visits or is tied in, should also be treated.
Personal Protection.
(i) The repellant materials used for personal protection against ticks and mites are Dibutyl-Pthalate
(DBP) and Diethyltoluamide (DEET). These are more effective when applied to the clothing than to the
skin. The effect may last for nearly six washings or weeks whichever is earlier. However, if it is ironed, the
concentration falls below effective limits. DEET may be used for application on the exposed parts of the
body to reinforce the use of protective clothing treated with DEET / DBP, when working in an uncontrolled
area or under acute emergency when application of DBP on the clothing prior to entry in an unknown or
uncontrolled area is absolutely impossible. Another indigenously produced repellent DEPA (Diethylphenyl
Acetamide) has also been approved for use in the Armed Forces as a repellent against ticks & mites.
It can be applied on the uniform as well as on the exposed parts of the body. The persistence of DEPA
on ironing of clothes is superior to DEET, which otherwise has been found to be equally effective.
(ii) Wearing shirts with rolled down sleeves tightly buttoned at the cuffs, the lower ends of trousers
tucked in socks and wearing of anklets considerably reduce the risk against ticks and mites, especially
when treated with repellent.
(iii) Clothes for drying should be hung on ropes especially fixed for the purpose and not on the
vegetation. Bush and grass on the periphery of a camp becomes infested by larval mites and ticks
brought in by the rats migrating into the camp. Therefore, purposeless wandering in such areas should
be discouraged.
(iv) More mites and ticks are picked up by standing or sitting than by walking over the infested ground.
Therefore, while on patrols and marches it is unsafe to lie down on a grassy ground. The immediate
vicinity of a tree base should be avoided for resting, so also the green edges of a stream or an irrigation
channel. Open grassy grounds should be avoided in tick infested areas.
(v) Before retiring at night or after leaving a tick infested area one should take a bath and carefully
search one’s body and clothing for presence of ticks. If a tick is found attached to the body it should
be removed immediately, because every added moment of its attachment increases the danger of
transmission of infection. Pulling of a tick has the danger of breaking off its parts, therefore, it should
be removed by making the surrounding skin taut, slipping the point of a flat needle or a scalpel under
the mouth parts and then removing the mouth parts by raising the point of the needle with a minimum
of tissue damage. Iodine or any other antiseptic should then be applied to the site.
(vi) Use of mosquito net gives some protection against soft ticks.
Anti-Rodent Measures
Persistent anti-rat hygiene is of great value in reducing the risk of diseases conveyed to man through
ticks and mites. The main objective should be to reduce ingress of rodents by proper disposal of camp
and kitchen refuse and removal of overgrown vegetation and rubble which afford them shelter. Rat
destruction requires forethought; because if the feeding of larval ticks and mites is interrupted by the
death of rodent hosts, a number of released acarines may reattach themselves to another host, which
may be man. Active rat destruction may be adopted when the first infestation is at its peak i.e. a month
or so after the rain starts. It is better to trap and then destroy them so that their parasites do not
escape. When dead rats are collected from any endemic foci the soil under and immediately around
them should be treated with insecticide. Soft tick control is further achieved by rat-and-tick-proofing of
dwellings. All cracks and crevices, fissures and other points of ingress should be closed and all doors
should be made tight fitting to keep away rodents.
Camp Siting.
Before any area in the known endemic tract is selected for camping or before the insecticide treatment

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is undertaken, the degree of risk should be assessed by determining the prevalence of adult and larval
acari.
(i) Mite Survey.
Superficial layers of earth are scraped from moist areas around the roots of shrubs and mixed with water
in a bowl. Adult mites resembling a figure of 8 will float in a few minutes. Pieces of dark cardboard
are placed edge wise forming tent fashion structures on the ground at intervals. Larvae will crawl up
the cardboard and congregate at its top edge within a few minutes. Rats caught from the area should
be examined for the clusters of larvae or scabs in ear-cusps and shrews for clusters on their rumps. If
the ears or rump is infested, they should be carefully cut with fine scissors and placed in 70% alcohol
vials. Rodent trapping is done in field (Camps, fringe areas) by specialized traps called Sherman traps,
whereas in peri-domestic areas Wonder traps may also be used. The trapping procedure is described in
a subsequent chapter on rodents. Once the traps are brought to the laboratory, the rats are transferred
in to large polythene bags, anaesthetized and thereafter ectoparasite screening is undertaken. While
carrying out the survey, one must protect oneself adequately with protective clothing and repellents.
(ii) Tick-survey.
Ticks are collected by sweeping flags made of white flannel across the vegetation. The larvae, nymphs
and adults get attached to them and are easily detected against the white background of the flag.
Parasite ticks on various animals can be collected by catching rodents, shrews and other animals and
then identifying them.
As a rough guide it can be said that the scrub typhus risk in any area during the monsoon is considered
low if only up to 10 percent of the rats have been found infested on two consecutive surveys unless cases
have occurred already; if 20-40 percent of rats have been found infested, the contraction of infection
is very probable and if 50 percent or more rats have been found infested, the risk is high and the site
should be considered as dangerous. Similarly, even if a single rat is found infested with more than 100
larval mites the area should be avoided, being a very high-risk area.

34.16 Rickettsioses.
(a) Introduction.
Rickettsioses are zoonoses that, except for Q fever, are usually transmitted to humans by arthropods (tick,
mite, flea, louse or chigger). Infections by rickettsiae cause a group of closely related diseases characterized by
high fever, prostration, mental confusion or delirium and often a rash. These infections are collectively termed
‘rickettsioses’. Rickettsiae, so named after Ricketts who died while experimenting with them in Texas, are
organisms in between viruses and bacteriae in size, with qualities more like viruses than bacteria. Rickettsiae
are small, Gram-negative bacilli that have evolved in such close association with arthropod hosts that they
are adapted to survive within the host cells. Wild rodents are, in general their natural reservoir host. The two
exceptions are R. prowazeki and R. Quintana.
(b) Classification.
The rickettsia infections are divided into four biotype groups. Table 34.9 shows further sub-classification of
these four groups.
Table 34.9 : Classification of Rickettsial Infections
Broad Group Species Disease Weil Felix
R. prowazekii Epidemic Typhus OX 19 ++++ & OX 2 + / -
Brill Zinsser Disease Negative or weakly positive
Typhus Group
Orientia tsutsugamushi Scrub typhus OX 19 & OX 2 negative / OX +
R. typhi Endemic Typhus OX 19 ++++ & OX 2 + / -

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Broad Group Species Disease Weil Felix

R. rickettsii Rocky Mountain OX 19 ++ & OX 2++
Spotted Fever (RMSF)
Spotted Fever Group R.conori Indian Tick Typhus (ITT) OX 19 ++ & OX 2++
R.africae African Tick bite fever OX 19 ++ & OX 2++
R.akari Rickettsial Pox All negative
Trench fever Rochalimoea quintana Trench fever None
Q fever Coxiella burnetii Q fever None

33.17 Louse Borne Epidemic Typhus.

(a) Definition.
Epidemic typhus is the classical form of rickettsial disease. It is characterized by sub-acute onset, with fever
interposed by rigors, accompanied by headache, nausea, giddiness, vomiting and flushed dry skin. On the
third day, the temperature rapidly rises up to 40°C, face and eyes become suffused, headache and bodyache
become severe and the peculiar stuporose, drunken, confused and delirious state, similar to that found in
enteric fever is seen. The patient has a foul and heavily coated tongue. The spleen is enlarged and haematuria
and albuminuria occur. Blood pressure falls. Temperature remains high for 12-14 days. Rash occurs on 5th
or 6th day. The case fatality varies widely and is influenced by the nutritional state and age of patient. In
healthy, well fed young adults the case fatality is less than 5 percent. Diagnosis is confirmed by the Weil-Felix,
Microscopic Agglutination (MA), Complement Fixation (CF) and Fluorescent Antibody (FA) tests.
(b) Geographical Distribution.
It occurs primarily in the colder, mountainous regions of central and east Africa, as well as Central and South
America. Between the 1950s and 1980s, large epidemics of louse-borne typhus became less frequent and its
geographical distribution has declined due to improvements in living standards. It is considered a rare disease
that occurs mainly in populations that suffer unhygienic extreme overcrowding. In India, there is a small focus
of infection in the mountainous regions of Jammu and Kashmir.
(c) Incidence.
About 30 million cases including 3 million deaths occurred in the Soviet Union & Eastern Europe during 1918-
1922. During World War II, typhus struck heavily in concentration camps in Eastern Europe and North America.
No case has been reported in the Indian Armed Forces since 1970.
(d) Agent.
Rickettsia prowazekii is the casual organism, which is an obligate intracellular bacterium.
(e) Reservoir and Source.
Man is the sole reservoir. In endemic areas, the disease has evolved a partial tolerance in man. Relapses
after several years are known. Whenever the louse multiplication occurs, such cases act as reservoirs. During
an epidemic, human cases and infected lice act as source of infection.
(f) Mode of Transmission.
Human body louse. P. humanus corporis transmits R. prowazekii. Rickettsiae multiply enormously intra cellularly
in the midgut of the louse. Within 10 days, they rupture, releasing a large number of rickettsiae in the body fluid
and in the insect’s faeces. The infection is transmitted by the entry of the infectious faeces, the gut contents
or the body fluid of the crushed louse through abrasion on the skin caused by simultaneous scratching. The
rickettsiae present in the insect dried excreta may also enter through the conjunctivae or even through inhalation.
The infected lice remain infective throughout their remaining life. Usually, they die in a week to 12 days.
(g) Host.
Man has no natural immunity; one clinical attack confers high immunity but not lifelong and a second attack

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may occur. All ages and sexes are susceptible. The immunity is type specific; therefore, an attack does not
confer immunity against other rickettsial diseases.
(h) Incubation Period.
Average incubation period is 12 days with a range between 6 to 15 days.
(j) Communicability Period.
The case is infectious to the louse during the last two or three days of the incubation period and throughout
the febrile period i.e., for a total of about 12 to 13 days. ·
(k) Prevention and Control.
A high standard of personal hygiene to prevent louse infestation, avoidance of contact with those likely to be
infected with the disease and infested with louse and preventive immunization are the important preventive
measures.
(i) Personal Hygiene.
In order to reduce the likelihood of troops getting infested, a very high standard of personal hygiene
should always be ensured. Louse infested areas should be put out of bounds to troops.
(ii) Delousing.
Treatment of louse infested individuals can be carried out by application of phenothrin dust 0.3-0.4%,
other lotion or shampoo formulations can also be applied for better results e.g. Permethrin lotion (1.0%),
Deltamethrin lotion (0.03%) etc.
(iii) Immunization.
A formalin inactivated epidemic typhus vaccine prepared from rickettsia grown in embryonated eggs was
used to protect troops during World War II. It is given in 2 subcutaneous injections of 1 ml each at an
interval of 10 to 14 days. Booster doses are recommended every 6 months. Unfortunately, up to 14%
of vaccinees developed mild to moderate illness 9–14 days after immunization. It is not yet available
for general use.
(l) Treatment.
Doxycycline is the drug of choice for treatment of epidemic typhus. Duration of therapy will depend on the
severity of the illness and is typically about 1 week. In an outbreak setting, a single dose of 200 mg doxycycline
is often sufficient. The response to therapy is usually rapid. In an outbreak setting, delousing is also necessary.
(m) Brill-Zinsser Disease.
It is a recrudescent episode of epidemic typhus which occurs years after the initial attack, in persons who
have recovered from the epidemic disease acquired while residing in the endemic country. The recurrence is
presumed to be precipitated by stress or a waning immune system. The illness is similar to louse borne typhus
but is usually milder. Weil-Felix reaction may be negative in very low titre.
(n) Murine Typhus (Endemic Typhus).
It is an acute febrile illness caused by Rickettsia typhi and transmitted to humans by the rat flea­ Xenopsylla
cheopis. The mode of transmission is by contamination of the broken skin by rickettsia-laden faeces and dried
flea faeces gaining entry through conjunctivae or the upper respiratory tract by aerosol. Complement fixing
antibodies against murine typhus have been detected in paired sera from local cases of PUO by workers of
NIV, Pune. Similar studies elsewhere indicate that murine typhus is endemic in practically every town of India
especially where rats are abundant. Control measures should be directed against rodents and rat fleas. There
is no specific vaccine. Epidemic typhus vaccine does not protect against murine typhus. However, following
attack by one disease, there is some cross-protection against the other disease.
(o) Indian Tick Typhus.
This disease belongs to the group of Tick-borne rickettsioses with a clinical picture resembling that of
Boutenneuse fever of the Mediterranean region. It is generally milder than epidemic typhus. The disease
is caused by R. conorii and is transmitted to man through the bite of hard ticks such as Rhiphicephalus

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sanguineus in Kashmir, lxodes ricinus in Almora and Haemaphysalis leachi var indica in Manipur. The ticks are
acquired by man from domestic animals such as cattle, horses and dogs. The disease is sporadic in all parts
of India, particularly in hilly terrain. It can be prevented by proper camp siting, keeping it free from animals and
dogs, insecticidal spray of the area before occupying the same, anti- rodent measures and personal protective
measures like wearing of proper clothing and use of repellents.
(p) Rickettsial Pox.
It is a mild febrile illness caused by Rickettsia akari and transmitted to man by a small colourless mite
Allodermanyssus sanguinus which infests small mice and rodents. The disease may be confused with
chickenpox. Weil-Felix reaction is negative but specific complement fixation, microscopic agglutination and
immunofluorescent antibody reactions help in confirming the diagnosis. The disease has been reported from
USA and USSR. Control measures are directed against house mice and the vector mite.

34.18 Mite Borne Scrub Typhus.

(a) Definition.
It is a rickettsial infection with a broad clinical spectrum. There may be many inapparent or mild infections. A
severe attack of the disease is characterized by fever, headache, conjunctivitis, lymphadenopathy and a local
vesicular lesion at the site of mite attachment which turns into an ulcer or eschar. A macular rash may appear
on the body on 5th to 7th day and last for a few hours to a few days. Complications such as pneumonitis,
myocarditis, encephalitis and peripheral circulatory failure may occur. With modern therapeutic agents, the
case fatality and period of convalescence have been markedly reduced. The diagnosis can be confirmed by
Weil-Felix (WF), Fluorescent Antibody (FA), Complement Fixation (CF) or Microscopic Agglutination (MA) test.
(b) Geographical Distribution.
The disease is limited to Southeastern and Eastern Asia, Northern Australia, India, Pakistan. Ceylon and other
islands in the region. In India, it is present in whole of the Shivalak range from Kashmir to Assam, Eastern
and Western Ghats and the Vindhyachal and Satpura ranges in the central part of lndia. The distribution of
the disease corresponds with the distribution of Leptotrombidium deliense and L. akamushi. The vector mite
is now known to be present in diverse ecological niches such as equatorial rain forests, semi-deserts and
Alpine subarctic terrains in the Himalayan regions. Endemic foci are usually associated with specific habitats
such as abandoned plantations, gardens or rice fields, overgrown forest clearings, shrubby fringes of fields and
forests, river banks and grassy fields. These ecological patches which attract the natural host of mite vectors
are called “mite islands”. Within the mite islands there may be a limited area of intensive transmission of
rickettsiae called “Typhus island”.
(c) Incidence.
This disease is known to occur in various parts of India with many cases being reported from Tamil Nadu,
Andhra Pradesh, Karnataka and Kerala in the South, Himachal Pradesh, Uttaranchal, Jammu and Kashmir
in the North, Meghalaya, Assam and Nagaland in the North-East, West Bengal and Bihar in the East and
Maharashtra and Rajasthan in the West. During the last 10 years, there were 18,781 confirmed scrub typhus
cases published in medical literatures from 138 hospital-based studies and 2 community-based studies. Among
the patients with Acute Undifferentiated Febrile Illness (AUFI), an estimated proportion of 25.3% lab-confirmed
scrub typhus had been observed. Community-based studies had estimated seroprevalences of 40.3% and
31.8%, respectively, with an average of 34.2% among healthy individuals.
(d) Agent.
O. tsutsugamushi is the agent of scrub typhus in India. It differs from other rickettsiae in its antigenic structure.
At least eight serotypes are recognized. Infection with one strain does not produce immunity against infection
by others.
(e) Reservoir and Source.
Permanent reservoir of infection are many species of wild rodents, other mammals and birds. The infection is
transmitted through the larval mites or “chiggers” belonging to the family Trombiculidae, genus and subgenus
Leptotrombidium. More than 150 species have been described but only a few are known to be of importance
to man. These are L. deliense, L. akamushi, L. scutellare, L. pallidum and so on. The rodents and acarine

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hosts do not succumb to the disease. Transovarian transmission of rickettsiae occurs in mites for at least 12
generations. Thus the field rodents and the vector mites act as a reservoir and between the two the infection
perpetuates in nature. The migration of infested or infected rodents leads to establishment of new foci of
disease. The immediate source of infection for man are the infected larval mites.
(f) Mode of Ttransmission.
The infection is transmitted to man through the bite of an infective mite larvae which feed on lymph and tissue
fluid rather than blood. Human infection takes place when man accidentally picks up an infective larval mite
while walking, sitting or lying on the infested ground.
(g) Immunity.
Man has no natural immunity. All ages and both sexes are equally susceptible. Infection with one strain does
not produce immunity against that by other strains.
(h) Incubation Period.
The range of incubation period is 6 to 21 days: average is 12 days.
(j) Communicability Period.
No person to person spread occurs.
(k) Prevention and Control.
Camp site selection, it’s clearing and disinfestation with Malathion or Cyfluthrin and treatment of clothing with
repellents like DEET & DEPA are the most important preventive measures against scrub typhus. Anti -rodent
measures maintain low level of mite infestation in an area. Before occupation the camp site should be first
examined for typhus risk by assessing mite infestation of rats and soil and scrutinizing records of previous
units for typhus incidence. As far as possible the infested areas should be avoided. If it must be occupied. it
should be cleared and treated with insecticide before occupation. This may be repeated if necessary at intervals
specified by local medical authorities, depending on the density of infestation and extent of typhus risk. All mite
infested areas may not be typhus areas. The method of area treatment is described elsewhere in this chapter.
Manual application of repellents to all the clothes normally used when working outdoors has always caused a
reduction in the infection rate. The process is tedious and very seldom carried out thoroughly. Barrier treatment
is less laborious and easily implemented in an emergency. Impregnation of clothing by mixing DBP in soap
water while washing or by mechanical means has been thought of from time to time. But this has presented
several difficulties including that of a heavy financial burden. Until such time as a more convenient method
is not available, a systematic manual application, in a parade is the only sure way to reduce the incidence of
scrub typhus, especially when area treatment is not possible when engaged in active operations. Anti-typhus
precautions should be observed by personnel during the periods and in localities as per instructions issued
from time to time.
(l) Occurrence of Cases.
On occurrence of the disease, the patient should be admitted to hospital. lsolation and disinfection are
unnecessary as the patient is not infectious. Attendants and contacts do not require any special precautions.
Notification of the clinical diagnosis as Gp B disease should be immediately communicated to the unit,
ADMS, DDMS and DGMS and equivalent appointments in Navy and Air Force without waiting for serological
confirmation. Units require early notification for taking necessary remedial and control measures. Technical
staff officers should keep a spot map of case incidence as they require a general picture of endemicity of
the areas successively occupied by troops keeping in view the patchy distribution of the disease. The general
measures in order of importance under the operational conditions are:
(i) Camp Siting.
Mite avoidance by proper site selection and personal precautions.
(ii) Housekeeping.
Persistent anti-rodent hygiene by denying shelter and food to rodents by proper storage of food, hygienic
disposal of refuse and keeping the area and lines cleared of all junk, rubble, vegetation and by good
housekeeping.

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(iii) Rodent Control.

Active anti-rat measures to reduce the rodent population wherever feasible. This should be carried out
during the dry season.
(iv) Vector Control.
Use of malathion or cyfluthrin on the ground after thorough clearing, before occupying the area in an
endemic zone. This has to be carried out every year before the monsoon starts and repeated as required
until risk exists.
(v) Repellents.
Application of repellants to all clothing is the most important single preventive measure while preparing
for combat in or occupation of uncontrolled area.
(m) Trench Fever.
It is a febrile illness transmitted from man to man by the body louse Pediculus humanus corporis. The causative
organisms Bartonella quintana grow extracellularly in the louse gut. Human are infected by the inoculation of the
contaminated faeces into the abraded skin or conjunctiva. The disease is characterized by a variety of clinical
manifestations, ranging from a mild afebrile to protracted debilitating disease. The treatment is symptomatic.
The methods employed to control epidemic typhus are equally efficacious in controlling trench fever.

34.19 Q Fever (Query Fever).

(a) Definition.
It is an acute infectious disease caused by Coxiella burneti and characterized by fever, malaise, myalgia,
headache, weakness, anorexia, loss of weight and interstitial pneumonitis. Case fatality is low but convalescence
is prolonged. Complications such as hepatitis, endocarditis, thrombosis, hemorrhages and meningitis may
follow. The diagnosis is confirmed by CF tests. Phase II antibodies develop by the 4th week. Phase 1 antibodies
indicate past infection, presence of chronic infection or immunity due to immunization. Radiological findings
resemble those of primary atypical pneumonia.
(b) Geographical Distribution.
Coxiella burnetii, the causative agent of Q fever (QF) is reported across the world, with the exception of New
Zealand and Antartica. The most commonly identified sources of human infection are farm animals, especially
cattle, goats and sheep.
(c) Incidence.
The actual prevalence of Q fever is underestimated in many countries worldwide including India. The infection is
acquired by humans through domestic livestock by inhalation of infective aerosols released into the environment
from aborted animals and in a few cases by consumption of unpasteurized milk.
(d) Agent.
The causative organism of Q fever was described by Derrick in Brisbane, Australia in 1930s and named as
Rickettsia burneti. It was later renamed Coxiella burneti. It is resistant to heat, drying, chemical agents and
UV light. The antigen of C. burneti isolated from ticks, animals or man and maintained in laboratory animals is
called phase I. It does not react with convalescent sera from Q fever cases. After adaptation to egg embryos,
the antigen is changed into phase II, which is used for serological tests.
(e) Reservoir and Source.
Small mammals and possibly some birds are the permanent reservoirs of infection with some Ixodid and Argasid
ticks acting as vectors. From the wild animals, the infection spreads to cattle, sheep and goats. The immediate
source of infection to man is the dust contaminated by products of domestic animals particularly placental tissues
& fluids and raw milk. Other sources are animal carcasses, contaminated straw, wool and so on.
(f) Mode of Transmission.
The mode of transmission for humans is by inhalation of infected dust, by handling infected materials and
possibly by drinking contaminated raw milk.

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(g) Human Host.

Focal outbreaks or sporadic cases may occur amongst people who have close contact with infected cattle, sheep
and goats. Thus, it is an occupational hazard for dairy workers, farmers, veterinarians and laboratory workers.
(h) Incubation Period.
It ranges from 15 to 26 days; the average incubation period is approximately 19 days.
(j) Communicability Period.
The disease is not transmitted from man to man.
(k) Prevention and Control.
The disease can be prevented by avoiding exposure to infected aerosols. Milk from infected cattle must be
boiled or pasteurized. The Q fever vaccine (Q-VAX®, a whole-cell, inactivated vaccine) for people working in “at
risk” occupations has been licensed for use in Australia since 1989 and has shown to be highly effective in
preventing Q fever. However, the potential for hypersensitivity reactions following vaccination has likely precluded
licensing of Q-Vax® beyond Australia. In human cases of Q fever, treatment with 2 weeks of doxycycline
antibiotic is recommended.

34.20 Arthropod Borne (Arbo) Viruses.

(a) Definition.
Arboviruses are a heterogeneous group of viruses which are maintained in nature principally or to a certain
extent, through biological transmission between susceptible vertebrate hosts by hematophagous arthropods;
they multiply and produce viremia in the vertebrates, multiply in the tissues of arthropods and are passed on
to new vertebrates by the bites of arthropods after an extrinsic incubation period.
(b) Classification.
The arboviruses constitute a group of taxonomically diverse viruses which are transmitted between vertebrate
hosts through the agency of hematophagous arthropod vectors. As many as 389 viruses are registered in the
International Catalogue of Viruses. However, only about 100 are known to produce disease in man. The number
of viruses which are of public health importance is even smaller. The arboviruses are grouped into families on
the basis of their morphological and physiochemical characteristics. Each family is further divided into groups
on the basis of serological similarities. A number of arboviruses still remain ungrouped. The arboviruses of
greatest public health importance are grouped into 5 families as follows: Togaviridae, Bunyaviridae, Reoviridae,
Rhabdoviridae and Arenaviridae. The family Togaviridae contains two very important genera i.e. the Alphaviruses
and Flaviviruses, previously known as group A and group B arboviruses respectively. Based on the predominant
clinical features and severity of illness, three broad clinical syndromes have been described. Table 34.10 shows
some of the selected arboviral infections which are of epidemiological importance.

34.21 Japanese Encephalitis.

(a) Definition.
Japanese encephalitis (JE) is an acute viral infection transmitted to man by infected female mosquitoes
belonging to Culex vishnui complex. The disease is characterized by high fever, severe headache, vomiting,
neck rigidity, cloudiness of mind, convulsions, coma and paralysis. During an epidemic, there may be as many
as 500 to 1,000 inapparent infections for every recognized case. The disease was first noticed in Japan in
1871; it was distinguished from Von Economo’s disease designated as type A encephalitis in 1924 and hence
was called Japanese B encephalitis.
(b) Geographical Distribution.
Japanese Encephalitis (JE) is an ongoing public health issue in Asia. As per the literature, approximately
67,900 cases are reported every year. The case fatality rate is around 25% and approximately 50% of the
cases reportedly suffer from permanent neuropsychiatric dysfunction. Several countries, such as Japan, Korea
and Taiwan, Thailand, Sri Lanka and Nepal have achieved near elimination of JE incidence with a successful
vaccination programme.

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(c) Incidence.
Japanese encephalitis is considered endemic in several states of India, especially in the northeastern and
northern parts of the country. Outbreaks have been reported from different parts of the country. It is endemic
in 327 districts of 24 states. Approximately 5,97,542,000 people in India live in JE-endemic regions and 1,500
to 4,000 cases are reported every year. JE cases in India often follow a seasonal pattern, with increased
transmission during the monsoon and post-monsoon periods when mosquito populations are higher.
Table 34.10 : Some Selected Arboviral Infections
Predominant
Virus Family / Group
syndrome
CNS Infection Eastern Equine Encephalitis (EEE) Togaviridae (alphavirus)
(Encephalitis)
Western Equine Encephalitis (WEE) -do-
Venezuelan Equine Encephalitis (VEE) -do-
St. Louis Encephalitis (SLE) Togaviridae (flavivirus)
Murray Valley Encephalitis (MVE) -do-
California Encephalitis (L Crosse) -do-
Japanese Encephalitis (JE) -do-
Bunyaviridae (California)
Tick Borne encephalitis (TBE) (European & Far Eastern)
Togaviridae (flavivirus)
Louping illness -do-
Febrile illness Dengue Togaviridae (flavivirus)
(with or
without rash) West Nile (WN) Fever -do-
Chikungunya Togaviridae (alphavirus)
O’ Nyong nyong -do-
Sindbis -do-
Mayaro -do-
Ross River fever -do-
Rift valley fever -do-
Vesicular stomatitis Bunyaviridae
Colarado Tick Fever (CTF) Rhabdoviridae
Phlebotomus fever Reoviridae (orbi virus)
Haemorrhagic Yellow fever Toga viridae (flavivirus)
Fever (HF)
Dengue -do-
Kyasanur Forest Disease (KFD) -do-
Omsk HF (OHF) -do-
Crimean HF (CHF) Bunyaviridae

(d) Agent.
The JE virus belongs to group flaviviruses of the family Togaviridae.
(e) Reservoir and Source.
There are several extra human hosts such as pigs, buffaloes, cattles and birds. The basic cycle in India is

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pig-mosquito-pig, the pigs being the amplifiers of the virus.

(f) Host.
Man is the accidental host in the transmission cycle. A higher incidence of cases has been reported in children
under 9 years and in old people.
(g) Incubation Period.
It varies from 4 to 14 days.
(h) Vectors.
JE is transmitted by Culex vishnui complex which consists of C. vishnui, C. pseudovishnui and C. tritaeniorhynchus.
These mosquitoes breed preferentially in paddy fields.
(j) Control Measures.
(i) Vector Control.
The vector mosquitoes are not easily susceptible to insecticidal control. Intensive anti-adult as well as
anti-larval measures are needed to control an outbreak. Spraying of animal houses such as pig stys and
cattle sheds as well as use of larvicides in paddy fields and cesspools should need special attention.
(ii) Personal Protection.
During an outbreak, the safest method of prevention is the use of mosquito nets. A live-attenuated SA
14-14-2 JE vaccine (LAJEV) has been licensed and used in Asian countries, including India. This vaccine
is used in the national immunization schedule of the Government of India and is given in two doses at
9-12 months and 16-24 months respectively. An indigenous inactivated Japanese Encephalitis (JE) vaccine
(JENVAC) jointly developed by Bharat Biotech and NIV, Pune and a purified inactivated vaccine (JEEV)
manufactured by Biological E limited are also available. NTAGI has recommended that for campaigns in
children (1-15 years of age) as well as in adults (above 15 years), one dose of any of the three vaccines
(for JEEV, 6-µg dose) may be used.
(iii) Reservoir Control.
In areas which are vulnerable or have had an epidemic of JE, the reservoir control is important. The pigs
should not be allowed to be reared near human habitation and if wild pigs are present, they should be
appropriately dealt with.

34.22 Dengue.
(a) Definition.
Dengue is an acute febrile illness, characterized by severe muscle and joint pains and a rash, remission of
fever and a terminal rise of temperature. This saddle-back temperature curve is considered typical but may
not always be encountered. The febrile illness usually lasts 5 to 6 days and terminates abruptly. The patient
may complain of fatigue for a few weeks after the infection. Mild atypical attacks are frequent.
(b) Geographical Distribution.
The disease is now endemic in more than 100 countries in the WHO Regions of Africa, the Americas, the
Eastern Mediterranean, South-East Asia and the Western Pacific. The Americas, South-East Asia and Western
Pacific regions are the most seriously affected, with Asia representing around 70% of the global disease burden.
(c) Incidence.
Though Dengue is a self-limiting acute mosquito-transmitted disease, it is important as it may incapacitate
large numbers of men when occurring in epidemic form. The incidence of dengue has grown dramatically
around the world in recent decades, with cases reported to WHO increased from 5,05,430 cases in 2000 to
5.2 million in 2019. In India, recurring outbreaks of DF / DHF have been reported from various States / UTs
namely Andhra Pradesh, Delhi, Goa, Haryana, Gujarat, Karnataka, Kerala, Maharashtra, Rajasthan, Uttar
Pradesh, Pondicherry, Punjab, Tamil Nadu, West Bengal and Chandigarh. Every year during the period of July-
Nov there is an upsurge in the cases of Dengue / DHF. Over the years dengue has become one of the leading
causes of hospital admissions in the Armed Forces. The rate of hospital admission due to Dengue / Chikungunya

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in the Armed Forces was 0.65 per 1,000 in 2019.

(d) Agent.
The causal agent is an arbovirus belonging to Flavi-virus group and called Dengue virus. It has four sero types i.e.
Dengue 1, 2, 3 & 4. All can cause either dengue fever or its severe form i.e. Dengue Haemorrhagic Fever (DHF).
(e) Reservoir and Source.
Man is the sole reservoir of infection. There are no true healthy carriers, but in an endemic area, the infection is
maintained by mild sub-clinical cases. Serological evidence suggests that dengue virus has an animal reservoir.
However, the essential source of infection during an outbreak is the case of dengue itself. The Aedes mosquito
which has acquired the infection from a case is the immediate source of infection.
(f) Vector.
The most important vector species in India is Aedes aegypti, which is a day biter. The fact that dengue has
in recent years assumed in South East Asia a severe form known as dengue haemorrhagic fever has made
it a serious responsibility for the Community Health Workers to study Aedes aegypti and its bionomics very
thoroughly in order to have a better understanding of the epidemiology of this disease.
(g) Mode of Transmission.
The virus multiplies by ‘propagative’ development in the stomach of the female mosquito of the genus Aedes.
Its transmission to man occurs through its bite about 10 days after taking a blood meal from a case of dengue
during its infective period.
(h) Immunity.
Man possesses no natural immunity. Primary or first infection in non-immune persons usually causes Dengue
fever. Recovery from infection by one dengue virus provides lifelong immunity against that particular virus
serotype. However, this immunity confers only partial and transient protection against subsequent infection by
the other three serotypes of the virus. Subsequent dengue infection by different serotype causes more severe
illness like DHF / DSS
(j) Communicability Period.
A case is infective to mosquitoes during the first three days of the illness. The mosquito remains infective for
the whole of its life span of 3 to 4 weeks after it becomes infective.
(k) Incubation Period.
It varies from to 3-15 days, the average being 4 to 7 days.
(l) Surveillance, Prevention and Control.
(i) Surveillance.
The purpose of vector surveys for surveillance is to obtain information. which can be used to control the
Aedes vector.
(aa) Larval survey.
Three indices are commonly used to record Ae. aegypti and Ae. albopictus density levels.
O HOUSE INDEX (HI).
Percentage of houses or premises positive for Aedes larvae. The HI is calculated as follows:
No. of houses positive for Aedes larvae
HI = x 100
No. of houses inspected
O CONTAINER INDEX (CI).
Percentage of water-holding containers positive for Aedes larvae. CI is calculated as follows:
No. of positive containers
CI = x 100
No. of containers inspected

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O BRETEAU INDEX (BI).

Number of positive containers per 100 houses in a specific location. BI is calculated as follows:
No. of positive containers
BI= x 100
No. of houses inspected
A HI> 5% & / or a BI> 20 for any locality is an indication that the locality is dengue sensitive
and therefore adequate preventive measures should be taken.
(ab) Adult surveys.
Human bare-leg catches (landing catches) of Aedes adults (both males and females) or indoor
resting collections of adults are normally used to assess adult Aedes populations. The data
collected are calculated to reflect the number of female Aedes mosquitoes landing / biting on a
single human bait per hour (e.g. number per man hour). The collectors should move from house
to house and not collect in one place for more than 15 or 20 minutes. In a similar manner, indoor
resting collections can be made and the data expressed as numbers collected per man-hour or
per house.
(ac) Oviposition traps.
“Ovitraps” provide a sensitive and economical method for detecting the presence of Ae. aegypti
and Ae. albopictus in situations where the Aedes density is low and general larval surveys produce
unsatisfactory results (e.g. when the Breteau Index is< 5). The standard ovitrap is a wide-mouthed
glass jar of approximately 250 ml capacity which is painted black on the outside to attract the
Aedes females to oviposit. A piece of hardboard or a wooden paddle is placed diagonally inside the
glass as an oviposition substrate. In addition, the jar is partially filled with clean water to provide
the right ovipositing medium for the female mosquito. Such jars in the absence of ovipaddles can
have white toweling strips placed inside attached by paper clips.
(ii) Vector Control.
The only effective method of preventing dengue is the control of the vector mosquito Aedes aegypti. The
organophosphorus compound abate is very effective as a larvicide especially when used in the form of
impregnated sand granules. For anti-adult measures, a technique consisting of aerosol spray of malathion
or sumithion by Ultra Low Volume (ULV) technique has been found to be highly successful in interrupting
transmission and stopping the epidemic. Insect growth regulators are increasingly being used against
Aedes for prevention of Dengue.
(iii) Personal Protection.
Use of personal protective measures like barrier clothing and applying mosquito repellents are helpful
during outbreaks. The patient should be provided with a mosquito net for use during day as well as
night.
(iv) Immunisation.
Chimeric Yellow fever virus-DENV Tetravalent Dengue Vaccine (CYD-TDV) is the first licensed dengue
vaccine. It is a live recombinant tetravalent dengue vaccine developed by Sanofi Pasteur for use in
individuals 9-45 years of age living in endemic areas and is now licensed in 20 countries but yet not
licensed in India. CYD-TDV given as a 3-dose series on a 0 / 6 / 12 month schedule. Vaccine efficacy
against symptomatic virologically confirmed dengue was estimated to be 56.5-60.8%.

34.23 Chikungunya.
It is an arbovirus belonging to the group alphaviruses of the family Togaviridae. It is responsible for a dengue like illness
in South East Asia, India and Africa. It also causes a mild form of haemorrhagic fever in Asian children. Outbreaks are
associated with high attack rates of as much as 80 percent. During 1963-65 it caused widespread outbreaks of an
illness in India when 5 to 6 million people in the Eastern, South Eastern and Central parts of the country were affected.
The disease was named Chikungunya (“that which bends up”) when it appeared first time in Tanzania because of its
characteristic symptom of pain in large joints soon after the onset of illness. Like dengue virus, it is also transmitted
by Aedes aegypti. A non­human reservoir is suggested in Thailand. In Africa antibodies were found in Chimpanzees.

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34.24 West Nile Virus.

It is an arbovirus belonging to group flaviviruses of the family Togaviridae. It is distributed from South Africa to South
Eastern India. Outbreaks of disease involving several hundred cases occurred in Israel during the period 1950 to
1952. The disease is highly endemic in UAE but goes largely unrecognized. The transmission cycle is believed to be
bird-mosquito-bird with C. univittatus as the principal vector. In IsraeI, C. molestus and C. univittatus are the vectors.
Accurate diagnosis rests on virus isolation during the illness or by demonstration of a rising specific antibody titre. The
virus has been isolated in several southern and eastern parts of India from various mosquito species as well as from
human sera without evidence of any clinical disease. Presumably most of the adult population is immune because of
having suffered from an undifferentiated mild febrile illness during childhood.

34.25 Phlebotomus Fever (Sandfly, Papatasi or 3-day Fever).

It is an acute, relatively mild febrile illness caused by at least 2 out of 27 immunologically related arboviruses belonging
to the family Bunyaviridae and transmitted to man by the bite of sandflies belonging to the family Psychodidae. The
major vector in India is P. papatasi. The disease is prevalent throughout the Mediterranean, near and Middle East,
Eastern Africa, Central Asia, Pakistan, India and South China. In endemic areas the local population acquires the
infection at an early age and develops high levels of immunity. The disease is seasonal being related to the presence
of sandflies which are most active during hot and dry season.

34.26 Haemorrhagic Fevers.

The terms Viral haemorrhagic fever syndrome is applied to a group of diverse illnesses resulting from several viruses and
perhaps immunologic responses to them. The common clinical features include high fever, headache, backache, myalgia,
prostration followed after a couple of days by haemorrhagic diasthesis with petechae or purpura and bleeding from nose,
gastrointestinal and genitourinary tract with thrombocytopaenia, leucopaenia and marked toxicity often leading to shock
and death usually in second week of illness. Depending on the vectors the syndrome can be characterized as under:
(a) Tick Borne.
e.g Omsk Haemorrhagic Fever (Russia), Kysanur Forest Disease (India)
(b) Mosquito Borne.
Dengue and DHF, Chikungunya Haemorrhagic Fever, Yellow Fever (Africa and Central America)
(c) Zoonotic.
(i) Rodent- e.g., Hantaan Virus Infection (Argentina), Lassa Haemorrhagic Fever (West Africa)
(ii) Monkeys- e.g., Marburg Haemorrhagic Fever (Africa), Ebola Haemorrhagic Fever (Africa)
(d) Dengue Haemorrhagic Fever (DHF).
During the last two decades, Southeast Asia and Western Pacific regions of WHO have reported several
epidemics of a variant dengue fever, known as DHF. This syndrome exists almost exclusively as disease of
children under 14 years of age. The disease manifestations start with a mild febrile illness and non-specific
symptoms and progresses to moderate or severe degrees of haemorrhages and fatal shock. The severity of
illness is thought to be due to double infection with dengue viruses. Specific virological diagnosis by serological
means is difficult. Virus isolation may be the only means of confirming the diagnosis. The WHO’s clinical
classification of DHF is given in Table 34.11.
Table 34.11 : WHO Clinical Classification of DHF
Grade Clinical Features Laboratory Findings
I Fever, constitutional symptoms, positive tourniquet test Hemoconcentration,
Thrombocytopenia

II Grade I plus spontaneous bleeding (e.g. skin, gums, gastrointestinal tract.) -do-
III Grade II plus circulatory failure, agitation. -do-
IV Grade II plus profound shock (blood pressure = 0 mm Hg) -do-

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34.27 Kyasanur Forest Disease (KFD).

(a) Definition.
The disease was first recognized in South India in 1957 as discrete clinical entity due to an arbovirus. The
disease is characterized by sudden onset of fever, headache, severe myalgia and marked prostration. The
earlier accounts gave the description of a disease resembling Omsk haemorrhagic fever with gastro­intestinal
disturbances and haemorrhages in severe case being the most characteristic feature. Later accounts described
the presence of bronchiolar involvement with the illness having a diaphasic course with mild meningoencephalitis
in the second phase, a picture more resembling Central European Tickborne Encephalitis. Case fatality is
about 3-5 percent. Serological tests using ELISA and neutralizing antigens and isolation of virus confirms the
diagnosis.
(b) Geographical Distribution.
Since its discovery in 1957, KFD was seen primarily in and around the Sagar and Sorab taluks in the Shimoga
district of Karnataka. However, KFD has now spread to as far as Sindhudurg district in Maharashtra to the
north and Palakkad district in Kerala to the south, with recent news indicating that the virus has spread to
new villages in Sindhudurg. Antibodies against the virus have also been detected in humans in areas of Gujrat
state, parts of West Bengal and in Andaman and Nicobar island.
(c) Incidence.
From 1957 to 2017, there were an estimated 9,594 cases of KFD within 16 districts in India. The most
significant human outbreaks of the disease were in the years 1957–1958 (681 cases), 1983–1984 (2,589
cases), 2002–2003 (1,562 cases) and 2016–2017 (809 cases).
(d) Agent.
The agent is an arbovirus belonging to group flaviviruses of the family Togaviridae.
(e) Reservoir and Source.
Small mammals like rodents and shrews, birds and reptiles are the natural hosts. Cattle also act as multipliers
of the vector population. The two common species of monkeys in the forest, Presbytus entellus and Macaca
radiata are affected by the virus and die of the disease. The source of infection for man, monkey and small
mammals is the infected nymphal stage of vector Haemaphysalis ticks.
(f) Mode of Transmission.
The proven vectors of KFD in nature are ticks of the genus Haemaphysalis. Out of the 14 prevalent species,
H. spinigera and H. turturis are the two major vectors. Only the nymphal stages are known to attack man.
Man acquires the infection from bites of infected hard ticks during the nymphal stage.
(g) Human Host.
The disease occurs mostly in the males of age group 20 to 40 years. It is an occupational hazard for cultivators,
wood cutters, hunters and cattle grazers. The disease in man occurs between January and May with the peak in
February or March. This coincides with the period of maximum activity of the nymphal stages of the vector ticks.
(h) Incubation Period.
The incubation period of KFD in humans is around 2–4 days.
(j) Prevention and Control
Preventive measures consist of insecticidal treatment of the affected areas and the animals, restriction of
cattle movement, personal protective measures such as adequate clothing and use of tick repellents. Currently,
there is no treatment available for KFDV but a formalin-inactivated, whole virus vaccine that requires multiple
booster immunizations with limited efficacy is used in India.

34.28 Yellow Fever.

(a) Definition.
It is an acute febrile illness of varying severity from almost a symptomless form to severe and rapidly fatal

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infection. In its classical form, it is associated with jaundice, haemorrhages and albuminuria. Many abortive
types resembling mild influenza and sub-clinical types without jaundice occur. The average case fatality is
about 10 percent. From the type of locality of occurrence, the disease is designated as urban, rural or jungle
Yellow Fever (YF).
(b) Geographical Distribution.
Yellow fever is now confined almost entirely to South and Central America and Africa.
(c) Incidence.
There has so far never been a case of yellow fever in the Armed Forces or even in civilian population in India.
(d) Agent.
The causal organism is a flavivirus belonging to the family Togaviridae.
(e) Reservoir.
The reservoir of urban yellow fever is sub-clinical human cases. For rural yellow fever certain animals also
serve as reservoirs; the most important animal reservoir is the monkey; in the endemic areas some 30 percent
monkeys are infected. Monkey is the only reservoir for jungle yellow fever.
(f) Source.
An infective human case or monkey is the source of spread of infection in an endemic area. The immediate
source of infection for an individual is the infective vector mosquito which has fed on an infective human case
or monkey.
(g) Mode of Transmission.
The natural route of transmission is through the bite of an infected vector mosquito. Aedes aegypti, Ae.
africanus, Ae. albopictus and Culex fatigans are all capable of transmitting infection. Aedes aegypti, being
domestic in its habit, is the principal vector for rural and urban yellow fever. It bites by day as well as by
night. Haemagogus mosquito is the vector for spreading jungle yellow fever, mostly among monkeys in South
America and Ae. africanus in Africa. Ae. simpsoni carries it to rural areas from infective monkeys which raid
the outskirts of plantations; further spread in the community is carried on by Ae. aegypti. Ae. aegypti should
not be more than 1% in towns and seaports in endemic areas to ensure freedom from Yellow fever.
(h) Host.
Man possesses no natural immunity against yellow fever. An attack of the disease confers complete lifelong
immunity. In endemic areas, adults are immune having had the disease, often inapparent, in their childhood.
This immunity can be ascertained by demonstration of neutralizing antibodies in their blood. Persons in non-
endemic areas do not possess these immune antibodies.
(j) Incubation Period.
The intrinsic incubation period in human beings is between 2 and 6 days. The extrinsic incubation period in
a mosquito is 8 to 15 days (average 12 days), varying with the temperature and humidity. Once the mosquito
becomes infective, it remains so for the rest of its life.
(k) Communicability Period.
The case is infective to the vector mosquito during the later part of the incubation period and first three
clinical days. An infected individual, therefore, can spread infection for about 4 to 6 days. starting 2 to 3 days
after exposure to the infection. It is to prevent the entry of such individuals in India that rigorous rules and
regulations are enforced.
(l) Prevention of Entry of Disease in India.
In India, Aedes aegypti is wide spread and the people possess no immunity against yellow fever. Yellow fever has
not so far entered India due to the stringent regulations and their rigid enforcement. lt is, however, interesting
to note that yellow fever never entered India even before these regulations were introduced. May be, this was
due to the slow mode of voyage from the African coast to India. Due to faster means of travel the danger of
its entry has increased. Therefore, the following measures have to be enforced rigidly:

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(i) All persons proceeding to or through yellow fever area are to be immunized against yellow fever
and possess a valid certificate to that effect. Yellow fever vaccination certificate becomes valid only
after 10 days of vaccination. A single dose provides lifelong protection for most people. YF vaccination
certificate if taken in India is valid only if taken from YF centre designated by GOI The yellow fever vaccine
is available with Armed Forces Clinic, Delhi, SHO Mumbai and Base Hospital, Delhi.
(ii) Country Requirements at Entry Points in India.
Anyone (except infants up to the age of 9 months) arriving by air or sea without a yellow fever vaccination
certificate is detained in isolation for up to 6 days if that person arrives within 6 days of departure from
an area with risk of yellow fever transmission or
has been in such an area in transit (except those passengers and members of the crew who, while in
transit through an airport situated in an area with risk of yellow fever transmission, remained within the
airport premises during the period of their entire stay and the Health Officer agrees to such exemption)
or
arrives on a ship that started from or touched at any port in an area with risk of yellow fever transmission
up to 30 days before its arrival in India, unless such a ship has been disinfected in accordance with the
procedure laid down by WHO or
arrives on an aircraft that has been in an area with risk of yellow fever transmission and has not been
disinsected in accordance with the Indian Aircraft Public Health Rules, 1954 or as recommended by
WHO.
(iii) Entry of animals from endemic areas is prohibited.
(iv) Anti-mosquito measures in an around the ports and aerodromes are strictly carried out.

34.29 Some Annoying Pests.

(a) Simulium Flies.
The family Simulidae contains over 2,000 species in 25 genera and includes insects known as buffalo gnats,
turkey gnats, black flies and midges in different parts of the world. In Arunachal Pradesh, these are called
Dim dam flies. There are more than 30 described species in India.
(i) Distribution.
Family Simulidae has worldwide distribution. The members of this family are found from sea level to a
height of 2,000 m. In India, these have been reported from Kumaon Hills, Himachal Pradesh, Kashmir,
Assam, Arunachal Pradesh, Manipur, Nagaland, Bengal, Bihar, Maharashtra, Tamil Nadu and Nilgiri Hills.
(ii) Morphology.
The adults are small stout bodied and blood sucking flies varying in length from 1 to 5 mm (Fig 34.16).
The colour varies from dark amber to bright yellow to orange. The name “black fly” is therefore a
misnomer.
(iii) Life History.
Simulium flies breed in fast flowing turbulent
mountain streams and torrents because they
require well aerated water. A female lives for 2
to 3 months and lays several batches of eggs
under the rocks, stones, vegetation or debris
submerged just below the water surface. Eggs
hatch in one to two days; in temperate zones the
hatching period may be one week. The larvae are
attached to submerged objects with their heads
downstream. They feed on microscopic animals
and plants and do not swim. The larva undergoes
six moults in about 10 to 14 days in the tropics
and 3 to 4 weeks in temperate regions. The silken Fig 34.16 : Black Fly

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pupa also is firmly anchored to the substratum. The pupal stage may extend from 4 to 5 days to 2 to 3
weeks. The imago emerges from the submerged pupal case and comes on to the water surface where
it rests for a while and after sometime starts flying. In the tropics and subtropics breeding is continuous
throughout the year. The life span of the adult is about three months.
(iv) Bionomics.
Simulids are strong fliers. Their normal flight range is about 4 to 5 km. Flights up to 20 to 40 km with
favorable wind are not unusual. Occasionally they fly in huge swarms. Male simulids feed on plant
juices, nectar and pollens of flowers; the females require blood meal for development of eggs and are
voracious and persistent biters. They may enter through any opening in the clothing such as the sleeves
or through the trousers lower opening for biting. They bite only by day in the open and are especially
active on bright sunny days and retire at night to the neighboring vegetation where the females mature
their eggs.
(v) Vector Potential.
Several species of simulids are known vectors of onchocerciasis, a filarial disease due to Onchocerca
volvulus occurring in tropical Africa, Central America and Venezuela, where S. damnosum, S. mettallicum
and S. neavei are the vectors. In India, simulids however are not vectors of any known human disease.
But the very annoying and persistent attacks in large numbers make working in the open virtually
impossible. The immediate trauma caused by its bite produces a red haemorhagic spot leading to
papule formation. In certain cases, it may lead to secondary infections and ulcers like ‘ulcus tropicum’.
In sensitized person’s allergic reactions like lymphangitis, lymphadenitis, rhinitis and fever may occur.
Their bites are responsible for loss of livestock.
(vi) Control Measures.
Control of the biting flies has been achieved by the use of larvicides and aerosol treatment. In the
Onchocerciasis control programme in Africa, temephos 200 g / L emulsion has been used as a larvicide
with good results. BTI has also been evaluated with great success. Aerosols and fogs produced by fogging
machines are useful in killing adult flies. Clearing of vegetation around the perimeter also reduces the
dimdam fly nuisance. Other OP and carbamate compounds like Fenthion, Dursban, Fenitrothion, Carbaryl
and Abate have also been evaluated. Use of protective clothing will prevent the flies from ascending
up the sleeves and trousers or entering into the shirt front. Socks should be pulled over the bottom of
trousers. Additional protection may be obtained by treating the clothing and the exposed parts of the
body with any of the repellents such as DBP, Diethyl Toluamide (DEET), ethylhexanediol or DEPA.
(b) Bugs.
Members of the Order Hemiptera popularly known as bugs, have a worldwide distribution. Of the many families
only two are important; these are Cimicidae and Reduviidae. Family Cimicidae includes the ‘bed bugs’, Cimex
lectularius of temperate regions and C. rotundatus or C. hemipterus of the tropics. Family Reduviidae includes
the cone nose Triatomine bugs, also known as ‘kissing’ or assasin bugs.
(i) Morphology.
Bed bugs are small, 5 to 6 mm long dorsoventrally flattened wingless, dark brown insects with a mahogany
tint. They have a very short and broad head attached to the prothorax. The head bears the antennae and
a pair of well-developed eyes. The short and fine proboscis lies in a deep groove on the ventral surface
of the head and encloses the true biting and sucking organs. The thorax consists of three segments of
which the first is distinctly larger. On either side of the thorax the stink-glands are situated which give off
the nasty, pungent and offensive odour associated with this group. There are no wings, although their
rudiments (known as hemelytra) may be recognized. Legs are slender and moderately long. The abdomen
is oval with eight visible segments. The tip of the abdomen is broad in females and narrow in males.
(ii) Life History.
A bed bug passes through the stages of egg and 4 nymphal stages. Metamorphosis is incomplete. The
fertilized females lay flask shaped, operculated eggs singly, in hidden sites such as cracks and crevices
in the walls and floorings, spaces in the wood work of furniture, behind pictures, mattresses, pillows etc.
A female lays 2 to 10 eggs a day, a total upto 200 to 300 in her lifetime of 6 to 8 months. The eggs

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usually take 5 to 10 days to hatch. The nymph starts feeding within an hour or two after emergence
and continues to feed intermittently in all the further stages of development. There are four nymphal
stages, each lasting 6 to 7 days; at the end of each a skin is cast off. It takes 4 to 6 weeks for the
development from egg to adult. The method of mating in bedbugs is unique among insects. The penis
penetrates the integument and enters the mesospermalege situated on the ventral surface of the female
abdomen. Sperm introduced into this ‘copulatory pouch’ (= sinus) pass into the haemocoel and then
ascend the oviducts to fertlize the eggs.
(iii) Bionomics.
Adults can subsist without food for months under favourable conditions. Bugs are disseminated through
travelling bags, laundry, furniture, bedding, old charpoys, soiled clothing, infested household goods, public
conveyance and public gathering places. Bed bugs, like lice have been companions of man for centuries.
Hiding in cracks and crevices during the day, they become active during the night and come out of their
hiding places to feed on hosts and engorge completely in 3-6 min. They may travel long distances for
sucking blood. They are gregarious, occurring in great assemblages. All stages are parasitic and thrive on
human blood, but occasionally establish a foothold in laboratory animals such as white rats, guinea pigs
and rabbits.
(iv) Medical Importance.
Bedbugs have all along been suspected for the transmission of various diseases but so far they have
not been incriminated for any human disease. They are of public health importance primarily for their
biting nuisance and demoralizing effect on the troops as their infestation may cause insomnia, pruritus,
dermatitis, allergy and anemia.
(v) Prevention and Control.
The first and foremost principle for the prevention of bedbug infestation is to maintain a very high
standard of hygiene. All furniture and belongings of new occupants should be thoroughly checked for
the presence of bed bugs and immediate measures taken to prevent their multiplication by one of the
appropriate insecticides. Residual insecticides applied directly into the hiding places control the bedbugs.
The bed bugs are reported to have developed resistance to organochlorine insecticides like DDT, HCH
and Dieldrin. Their use should, therefore not be relied upon except in places where bed bugs are
known to be susceptible. Organophosphorus compound malathion is reported to be losing its effect at
a number of places. In some places development of actual resistance has also been confirmed. In its
place Fenitrothion (sumithion) or DDVP (nuvan) in a concentration of 0.5 to 1.0 percent and propoxur may
be used effectively. An application of 0.2 percent Pyrethrum, in combination with 2.0 percent Piperonyl-
butoxide, also gives very satisfactory control. It, however lacks residual action. A range of pyrethroids
including Cypermethrin and also Insect Growth Regulators (IGRs) such as Methoprene can be utilized.
Disinfestation of blankets, beddings, mattresses and mosquito nets may be carried out by subjecting
them to heat at or above 70° C. Synthetic pyrethroids like Permethrin (0.5%), Cyfluthrin (0.01%) and
Deltarmethrin (0.005%) can also be used to achieve optimum results. Alternatively, clothes can be placed
in sealed plastic bags and placed in a freezer (–18°C) for 24 hours to kill the bedbugs. Commercially
available small insecticidal smoke bombs containing insecticides, such as Permethrin, which burn for
up to 15 minutes, can be used to fumigate infested premises.
(vi) Debugging.
In the Armed Forces barracks, all furniture, charpoys, beddings, walls, floor and ceiling should be
thoroughly inspected every week for the presence of bed bugs. The charpoy should be lifted to a height
of about 1 meter by two persons holding it at opposite ends and gently dropped on the floor. This
process repeated 2 to 3 times will result in the bugs falling on the floor from their hideouts. Whenever
charpoys, chairs and other items of furniture are found infested, these should be thoroughly sprayed with
a residual insecticide. The charpoy need not be inclined against the wall nor the coir netting or niwar
loosened. The cots should be thoroughly treated from all sides with the spray. All cracks and crevices
should be fully flooded. The kit boxes, chairs, tables and other items of furniture may be similarly treated.
The insecticide formulation may also be directly applied to the hiding places such as joints, cracks and
crevices in the cots / chairs / tables and folds or creases in the mattresses and other items of beddings.

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The studies carried out at the Armed Forces Medical College, Pune have shown that the slow drip
technique involving the use of the common paintbrush for treatment of the infested cots and other
items of furniture, is far superior as compared to the routine method of spraying with the compression
sprayer. In this technique, the ready to use solution of insecticide in water is taken in a plastic mug of
one litre capacity, a paint brush is dipped in the solution and the solution so lifted is slowly drained into
the cracks and crevices as well as the joint spaces from different directions. The process is repeated by
turning the cot upside down so that all such hiding places are thoroughly flooded with the insecticide.

34.30 Cockroaches.
(a) Introduction.
Cockroaches are very annoying pests. The common domestic species which infest buildings are Blatella
germanica, the German roach; Periplaneta americana, the American roach and Blatta orientalis, the oriental
roach. The German cockroach, although a native of Europe, is the most widely distributed species.
(b) Morphology.
Cockroaches are dorso-ventrally flattened creatures with colour varying from dark brown to black. The head
is flexed backward. The antennae are filiform. Most of the species have two pairs of wings. In some of them
the wings are vestigial. In the oriental cockroach the wings are short in the females but much developed in
the males which possess the power of flight.
(c) Life History.
They have simple metamorphosis and lay 16 to 48 capsulated eggs. The eggs hatch out in 2-6 months in most
of the species, depending on temperature and humidity. The young ones are almost white and wingless. They
moult a number of times and the total developmental period may be 6 months to 1 year. They may produce
three generations in a year and usually have a long-life span.
(d) Bionomics.
They breed in warm moist places in the humid microclimate of the kitchen and pantry laying eggs in cracks,
crevices and sinks. They can run swiftly by means of long well-developed legs. They are highly gregarious and
primarily nocturnal in habit, but may be seen during the day as well. The mouth parts are adapted for biting
and chewing and they are omnivorous, feeding on any material meant for human consumption like meat, milk,
grains and sugar.
(e) Disease potential.
They are filthy, annoying pests imparting a nauseating ‘cockroach’ odour to the food articles and utensils they
come in contact with and the places they infest. They destroy food, damage fabrics, books and other household
articles. They may enter houses and other buildings from outdoors through infested containers or from adjoining
rooms and apartments or through drains. On account of their indiscriminate roaming and feeding habits, they
may spread diseases like cholera, typhoid, dysentery, protozoal cysts, intestinal worms etc. by polluting food
with filth carried on their legs and bodies.
(f) Control Measures.
(i) Prevention.
Good housekeeping is the key to cockroach control, whether in the home, restaurant, hotel or grocery stores.
(aa) All cracks and crevices should be properly filled up.
(ab) All areas should be kept thoroughly clean so that no food particles, debris, dust and rubbish
remain to support and nourish cockroaches.
(ii) Surveillance.
(aa) Use of sticky traps for surveillance.
(ab) Use of visual assessment method, whereby light is switched on late in night and the
cockroaches counted for a stipulated time period, say five minutes. This method also indicates
the hiding places in a room of the cockroaches besides indicating the level of infestation.

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(iii) Control.
Cockroach infestation can be controlled with insecticide sprays, dusts or baits. Cockroaches have been
found resistant to organochlorines, organophosphates, carbamates and pyrethroids. Blattella germanica
has been found resistant to all these groups. However, in the absence of resistance, sprays or dusts
of the carbamate insecticide Bendiocarb and organophosphates such as Malathion and Diazinon can
be used to control cockroaches. The insecticide should be applied thoroughly to runways, cracks,
crevices, undersides of tables and even under the table spreads, rear of sinks, meat safes and other
harborage areas. Use of 2-5 percent dust or 1-3 percent solution or emulsion of organophosphorus
compounds like Malathion or Carbamate insecticide such as Propoxur gives excellent results. To obtain
a quick effect in heavy infestations or to drive them out from the hiding places a direct spray containing
0.3 percent pyrethrum or 0.5 to 1.0 percent DDVP or Fenitrothion may be used. Small pills of flour
containing boric powder left on dining table, food safes, pantry boards or under table cloth also kill
cockroaches. Ivermectin and synthetic pyrethroids are currently being used for control. A new group of
insecticide Fipronil and Imidacloprid has been found to be very effective in controlling the cockroaches.
Plant insecticide like Neem is currently being used with success. Sprays or aerosols of insect growth
regulators (IGRs) such as Hydroprene, Fenoxycarb or Pyriproxfen, can be helpful in giving good control.
Commercial lacquers and varnishes containing residual insecticides such as Diazinon, Permethrin or
Cypermethrin are effective in killing cockroaches for several months when painted on walls or other
surfaces.

34.31 Scorpions.
Scorpions are also members of the class Arachnida like ticks and mites, having the last segment of their bodies
modified to form a flexible tail, with a vesicle holding poison glands and a sharp spine. They vary in size from about 2 to
20 cm and are cryptozoic and nocturnal, spending the day concealed under stones or fallen tree branches or in burrows,
venturing out after sunset in search of food. The common Indian species belongs to the genera Buthus (Mesobuthus)
and Palamnoeus; the former are more poisonous.
Scorpion sting as a rule is not more dangerous than bee or wasp sting, as the chemical nature of the poison is similar
to formic acid. It is, however, much more painful and if sufficient poison has been injected, may cause distressing
symptoms which may take twenty-four hours to pass off. Cardiovascular effects like hypertension, arrhythmia, cardiac
failure and pulmonary oedema may be encountered following stings of Mesobuthus tamulus. The effects are more
marked in children. It is, however, very rare that a fatal dose of the venom is injected. Application of a strong solution
of ammonia relieves pain in a majority of cases; a series of injections of 1 percent novocaine and adrenaline at the
spot and along the nerve may be necessary in others. Barbiturates in large doses are useful in reducing restlessness.
Prazosin is recommended for the treatment of scorpion envenoming, especially in India. This drug is easy to use and
has no major contraindications. Prazosin is more effective than nifepidine which blocks calcium ion influx of smooth
muscle cells in the arterioles and inhibits their contraction. Patients developing priapism, dilated pupils, sweating and
bradycardia may require early energetic treatment with vasodilators. Preventive measures include alertness in avoiding
contact with scorpions in infested areas, putting on clothes and shoes after shaking them well and proper housekeeping.
Chemical pesticides containing Cyfluthrin, Bfenthrin, Permethrin and Tralomethrin are a few of the commercially available
products that can kill scorpions. Apply of the desired insecticide to the exterior walls of the house foundation. Spray the
exterior walls thoroughly with the insecticide starting from the ground and moving up the wall so the bottom 1 foot of the
wall is covered with the pesticide. Furthermore, apply the insecticide around windows, doors and other points of entry.

34.32 Ants.
Ants are common annoying insects. They have also been experimentally incriminated in the mechanical transmission
of excremental infections. They should therefore, be kept away from foodstuffs by placing the legs of food safes,
tables etc. in anti-formicas viz. bowls or tins containing water or waste crude oil. Insecticidal sprays like Pyrethrum or
Malathion are effective. Ordinarily the ant-bite causes only a sharp stinging; the bites of some of the larger ants may be
very painful involving faintness and shivering. Dilute ammonia or any other alkaline solution applied relieves the pain.

34.33 Bee, Wasp and Hornet.

The stings of these insects are often painful with local wheeling and redness. In sensitized individuals there may
be alarming symptoms. The sting along with poison gland may be frequently left in the puncture, particularly by the

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honeybee. It should be removed gently by pulling it out, care being taken not to squeeze the venom in the wound. Local
application of an alkaline solution of sodium bicarbonate or ammonia or soap and applying pressure with a moistened
piece of lint are useful in relieving pain. Papain diluted roughly 1:5 with tap water is said to produce immediate relief of
pain. Disturbing the honeycomb may bring the whole swarm on the person responsible or anyone who happens to be in
the vicinity and their stings may cause serious allergic symptoms requiring adrenaline and / or morphia administration.

34.34 Centipede.
Centipedes (Class Chilopoda) possess a pair of legs to each apparent segment of the body; the first pair is modified
to form poison claws. The bites of small centipedes give rise to mild local inflammation but the larger centipede
Scolopendra gigantia, may cause a severe painful bite with marked local and general reaction. Solution of ammonia
is useful for local application and in bites of the larger centipedes, local anesthesia with lidocaine at the bite site
should provide significant relief.

34.35 Fish Bites.

There are many species of fish especially in tropical waters which possess poison glands in their mouths like a snake
or have poison spines or barbs. Their bites or stings may lead to severe consequences or even death. Certain jellyfish
stings produce marked local reaction. In sensitized individuals more alarming symptoms may develop. Vinegar swabbed
well over the whole area or applied by compress gives relief. Tetanus toxoid should also may be given. Sedatives to
relieve the pain and measures to prevent secondary infection may be indicated.

34.36 Leech Bites.

Leeches (Hirudinea) are a class of Annelid worms. They are particularly troublesome near streams and rivers, in leafy
forests and marshy jungles. The two important species are:
(a) Haemadipsa zelanica.
It is the small land leech, about 2.5 cm long with great power of penetration into the interstices of clothing, putties
or laced boots. They often drop from tree leaves onto man or animals passing by and suck blood. Leech bites are
painless but the bleeding may be prolonged due to a powerful anti-coagulant, hirudin, present in its saliva.
(b) Limnatis nilotica.
It is the large aquatic leech which on being ingested, fastens itself to the mucus lining of the mouth, pharynx, larynx or
nasal cavities of man or animal producing prolonged bleeding unless removed. Gum boots or jungle boots protect one
from leech bite. A frequent search of the body for the presence of leeches should be made. The leech should not be
dragged or pulled off the skin because of the risk of breaking and leaving behind its suction apparatus which is liable
to cause inflammation and suppuration. Salt, vinegar or a tobacco infusion application or a touch of the lighted end
of a cigarette induces the leech to relinquish its hold. Subsequently, tincture of iodine should be applied to the bitten
spot and a piece of adhesive plaster may be applied to the bitten spot. Dibutyl-phthalate (DBP) and dimethylphthalate
(DMP) rubbed on the skin, openings of clothing, into socks and boots keep leeches away. Repellents DEET & DEPA can
also be used to provide better protection and can be applied on the clothing as well as topical application. At night
a properly adjusted mosquito net; similarly treated, affords protection. Aquatic leeches can be removed from drinking
water by filtering through a sieve or a piece of muslin.

34.37 Lizards.
The only poisonous lizard is the Gila monster (Heloderma) found in the desert of Mexico. Non­poisonous lizards
sometimes bite man and may produce severe local sepsis of bacterial origin. All such bites should be cleaned thoroughly
and dressed with an antiseptic. Treatment should consist of cleaning of the bitten area and measures to prevent
secondary infection including tetanus and other supportive measures.

34.38 Spiders.
The true spiders (Arachnida) have poison glands and inject venom into their prey. The common species of spiders as
a rule do note bite man. If by chance it happens to bite, the bite amounts to no more than a pin prick. Some spiders,
especially those belonging to the genus Latrodectus produce severe effects in man. Important species are L. hasselti,
the ‘red-backed’ spider and L. mactans the black widow and the allied species. The acute symptoms generally subside
after a few days but pain may persist for some time. In latrodectus bites, the death rate may amount to 6 percent

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or higher. The ‘tarantulas’ of the tropics are loathsome spider like creatures, but contain no poison glands and are
not dangerous, though they are severe biters. In case of a spider bite an immediate washing should be carried out.
For local urticarial reactions, antihistamines will control the symptoms. Morphia may be necessary for relieving pain.
A hot tub bath affords prompt but temporary relief. Intravenous calcium gluconate or magnesium sulphate also gives
dramatic relief to cramps.

34.39 Control of Arthropods.

(a) Introduction.
Control of arthropods is one of the key strategies in the management of vector borne diseases. A strategist
should have sound knowledge of the bionomics, distribution, seasonal prevalence, vectorial capacity, insecticide
susceptibility status and role of arthropods in diseases transmission coupled with the knowledge of identification
features of the vectors incriminated for formulating effective control strategies. Once armed with this knowledge,
the choice of effective vector management tools may be exercised. The range and sophistication of control
methods is impressive. The various control options available are as follows:
(i) Environmental Control
(ii) Chemical Control
(iii) Biological Control
(iv) Genetic control
(v) Personal Protective measures
(vi) Physical control
(vii) Mechanical control
(viii) Legislative control
(b) Environmental Control.
Although the use of chemical insecticides has been man’s foremost weapon for control of vectors, the increased
incidence of resistance to insecticides by most vector species, along with the associated environmental
contamination have warranted significant reduction in the application or overall ban of some chemical
insecticides. Therefore, there has been an increasing need to adopt alternatives that would be devoid of the
hazards of chemical insecticides. Hence, the environmental control of vectors has seen renewed interest for
the control of vectors, as it has been proven to be effective and efficient in this regard.
The important environmental control measures which are increasingly being used in the developed countries
are described below:
(i) Environmental Management.
This has been defined as “The planning, organization, carrying out and monitoring of activities for the
modification and / or manipulation of environmental factors or their interaction with man with a view
to preventing or minimizing vector propagation and reducing man-vector­pathogen contact.” This is a
naturalistic approach which attempts to extend and intensify natural factors which limit vector breeding,
survival and contact with man.
(ii) Environmental Modification.
It is defined as “A form of environmental management consisting of any physical transformation that is
permanent or long-lasting of land, water and vegetation, aimed at preventing, eliminating or reducing the
habitats of vectors without causing undue adverse effects on the quality of the human environment”.
Environmental modification includes drainage, filling, velocity alteration, land levelling and transformation
of impoundment margins.
(iii) Environmental Manipulation.
It is defined as “A form of environmental management consisting of any planned recurrent activity aimed
at producing temporary conditions unfavourable to the breeding of vectors in their habitats”. Examples
of environmental manipulation activities are water salinity changes, stream flushing, regulation of the

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water level in reservoirs, vegetation removal, shading and exposure to sunlight.

(iv) Modification or Manipulation of Human Habitation or Behaviour.
This means- “A form of environmental management that reduces man-vector-pathogen contact”. Examples
of this approach are siting of settlements away from vector sources, mosquito / rodent proofing, personal
protection and hygienic measures against vectors and provision of mechanical barriers, providing facilities
for water supply, disposal of waste water and excreta, laundry, bathing and recreation to prevent or
discourage human contact with infested water.
For example, an environmental approach to control Aedes mosquitoes, the vectors of Dengue, Chikungunya,
Yellow fever, Zika etc. can include the following measures:
O Improved Water Supply.
Whenever piped water supply is inadequate and available only at restricted hours or at low pressure,
the storage of water in varied types of containers is encouraged, thus leading to increased Aedes
breeding. The majority of such containers are large and heavy (e.g. storage jars) and can neither be
easily disposed of nor cleaned. It is essential that potable water supplies be delivered in sufficient
quantity, quality and consistency to reduce the necessity and use of water storage containers that
serve as the most productive larval habitats.
O Mosquito-proofing of Overhead Tanks / Cisterns or Underground Reservoirs.
Where Aedes aegypti larval habitats include overhead tanks / cisterns and masonry chambers
of piped waterlines, these structures should be mosquito-proofed. Similarly, mosquito-proofing of
domestic wells and underground water storage tanks should be undertaken.
O Flower Pots / Vases and Ant Traps.
Flower pots, flower vases and ant traps are common sources of Aedes aegypti breeding. Live
flowers can be placed in a mixture of sand and water. Flowers should also be removed and
discarded weekly and vases scrubbed and cleaned before reuse. Brass flower pots, which make
poor larval habitats, can be used in cemeteries in place of traditional glass containers. Ant traps
to protect food storage cabinets can be treated with common salt or oil or disinfectant.
O Desert (evaporation) water coolers, condensation collection pans under refrigerators and
air conditioners should be regularly inspected, drained and cleaned.
O Mandatory Water Storage for Firefighting.
Fire prevention regulations may require mandatory water storage. Such storage tanks need to be
kept mosquito-proofed. Also, metal drums used for water storage at construction sites should be
mosquito proofed. Weekly dry day is an efficient method for preventing breeding of the vector.
O Solid Waste Disposal.
Solid wastes, namely tins, bottles, buckets or any other waste material scattered around houses,
should be removed and buried in landfills. Scrap material in factories and warehouses should be
stored appropriately until disposal. Household and garden utensils (buckets, bowls and watering
devices) should be turned upside down to prevent the accumulation of rain water. Similarly, canoes
and small boats should be emptied and turned upside down when not in use. Plant waste (coconut
shells, cocoa husks) should be disposed of properly and without delay.
O Tyre Management.
Used automobile tyres are of major importance as breeding sites for urban Aedes and are therefore
a significant public health problem. Imported used tyres are believed to be responsible for the
introduction of Aedes albopictus into the United States, Europe and Africa. Tyre depots should
always be kept under cover to prevent the collection of rain water. Old or used tyres, if stored,
should be punctured to produce a drain hole.
Common sites of breeding for Anopheles mosquitoes include rainwater pools and puddles, burrow
pits, river bed pools, irrigation channels, seepages, rice fields, wells, pond margins, sluggish
streams with sandy margins, hoof prints, tyre tracks etc. Water stagnation due to construction of

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dams, reforestation, shrimp farming, fish ponds etc., have also been identified as possible sites
of Anopheles breeding. Anopheles stephensi is a well-adapted urban vector, being a container
breeder, making use of man-made sites such as building-construction sites, wells, garden ponds,
cisterns, overhead tanks, cemented terrace, ground level cement tanks etc. Anopheles breeding
sites increase with rainfall and resultant water stagnation. The environmental approach for control
of Anopheles is by avoiding or eliminating the clean water collections. It may include following,
but not limited to, measures:
O All tanks should be kept tightly closed. A black plastic sheet can be used for the
purpose. Also, all tanks should be emptied, cleaned and allowed to dry for at least half an
hour, once every week.
O At construction sites, all the care should be taken to avoid collection of water at
one place for more than a week. The layer of water on the surface of the concrete, used
for concrete curing, should be cleared at least once a week and allowed to dry for half an
hour. All other puddles should be cleared regularly.
O Terraces and roofs should ideally have a slope, particularly in places where monsoon
tends to be heavy. All such roofs / terraces should have adequate drainage for water.
O All unused wells and tanks should be closed or destroyed.
Similar environmental approach may be adopted for control of Culex mosquito by avoiding or
eliminating dirty water collections.
(c) Chemical control.
(i) History.
The new era of control of vector borne disease began with the discovery of the insecticidal value
of Dichloro-diphenyl-trichloro ethane (DDT). DDT was first synthesized by Othmar Zeidler in 1874 at
Strasbourg, Germany. In 1939, Paul Muller of the Geigy Company in Basle, Switzerland, discovered its
remarkably long residual insecticidal property, earning him the Noble Prize in Medicine. The availability
of several effective, safe and low cost pesticides, coupled with improvements in the techniques of their
application, made it possible for many governments in the developed as well as developing countries to
embark upon extensive countrywide programmes for the control or eradication of vector borne diseases.
However, development of resistance amongst vectors to insecticides has necessitated reassessment of
the place of pesticides in vector control programmes. As per a study in 2017, the susceptibility data of
Anopheles culicifacies, (the rural and major vector of Malaria in India), reported from 105 districts of 16
states, found resistant to at least one insecticide in 101 districts of India. Single insecticide resistance to
DDT was reported from 32 districts, Malathion from 4 and Deltamethrin resistance in 2 districts. Double
insecticide resistance to DDT and Malathion was reported in 22 districts, DDT and Deltamethrin in 5
districts and to Malathion and Deltamethrin it was reported from 5 districts. Triple insecticide resistance,
i.e. to DDT, Malathion and Deltamethrin was reported from 31 districts. Also besides the technical and
financial difficulties, there is a growing concern about the environmental contamination resulting from
the use of persistent insecticides.
(ii) Classification of Insecticides.
Pesticides may be classified in many ways based on mode of entry, target stage, chemical composition
and mode of action. However, the most common classification used is based on chemical composition.
According to this classification the insecticides are classified in the following categories as presented in
Fig 34.17.
Natural Insecticides.
(aa) Plant Based.
Pyrethrum.
Pyrethrum extract is obtained from the dried heads of the flower Chrysanthemum cinerariafolium
and contains the active ingredients pyrethrins I and II, constituting 1 to 2 percent of the total
weight of the raw Pyrethrum. Pyrethrum is a contact poison, characterized by rapid knockdown

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action on arthropods even when used in very low dilution. It is very unstable in light and air
and has practically no residual effect. This makes repeated applications necessary. Pyrethrum is
available as 2 percent extract, which needs 20 times dilution respectively to make it 0.1 percent
solution, which is actually used for spraying. Using a 0.4 mm or lower calibre nozzle, 50 to
100 ml of Pyrethrum solution in kerosene oil is sprayed per 100 m3 of space. Addition of an
organophosphorus insecticide to Pyrethrum formulation is a common commercial practice for
obtaining a better effect. It is one of the main insecticidal constituents in aerosol dispensers and
also an insecticide of choice for ULV sprays. Pyrethrum is perhaps the most acceptable insecticide
for use in cook houses, dining halls and other food preparation areas.

INSECTICIDES

NATURAL SYNTHETIC

PLANT BASED MINERAL OILS ORGANIC

• Pyrethrum
• Azadirachtin

ORGANOCHLORINES ORGANOPHOSPHATES CARBAMATES SYNTHETIC

• DDT • Malathion • Propoxur PYRETHROIDS
• Temephos • Bendiocarb • Deltamethrin
• Fenitrothion • Carbaryl • Cyfluthrin
• Pirimiphos methyl • Bifenthrin
• Lambda-
Cyhalothrin
• Permethrin

Fig 34.17 : Classification of Insecticides As Per Chemical Composition

(ab) Mineral Oils.
Kerosene oil, diesel oil, petrol and crude engine oil have been successfully used as mosquito
larvicides. The oil film cuts off the air supply, enters and blocks the trachea, may act as a stomach
poison and also lowers surface tension which prevents larvae from floating. Malariol is the best and
easiest larvicidal oil to use for Anopheline and Culicine larvae. Malariol is used as it is @ 10 litres
per 500 linear mts.
Synthetic insecticides.
These can be organic or inorganic. The only inorganic compound used in vector control (mosquito
larvicide) was Paris green (Copper-aceto-arsenite). It acted as stomach poison when ingested by
mosquito larvae. However, it is not used any more for mosquito control. The organic insecticides
fall into four major groups’ viz. Organochlorines, Organophosphates, Carbamates and Synthetic
pyrethroids.

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(aa) Organochlorine Compounds.

These compounds are contact poisons and act on the nervous system. These or their degradation
products are more or less stored in body fat and may be demonstrated in milk, urine or sweat.
They all have variable residual action for variable periods and are toxic to man and animals. The
most important and the only member of this group used in public health programmes is DDT.
O Dichloro Diphenyl Trichloroethane (DDT).
Currently DDT is being used for indoor residual spray in North Eastern states. DDT has an
intrinsic chemical nature of excito-repellency that makes the mosquitoes to exit from the
sprayed houses immediately after contact apart from its ability to kill mosquitoes. IRS is at
present carried out in high-risk areas (API ≥ 2) with coverage of about 80 million populations.
DDT is the insecticide of choice; in areas where the vector has shown resistance to DDT, the
alternatives are Malathion and synthetic pyrethroids. Two rounds of spraying are done for DDT
and synthetic pyrethroids to provide protection during the entire transmission season. About
60% of the high-risk areas targeted under IRS are under coverage with DDT. A deposit of
1 g of DDT / m2 of surface area of walls and ceilings upto a height of 3.5 m in all dwellings
applied at 10-12 weeks’ interval, effectively controls majority of the mosquitoes and also
other arthropods resting on the treated wall (Refer to Chapter on Mosquitoes for further
details on use).
Stockholm Convention on Persistent Organic Pollutants is an international environmental
treaty, signed on 22nd May 2001 in Stockholm and effective from 17th May 2004, that
aims to eliminate or restrict the production and use of Persistent Organic Pollutants (POPs)
and India, which uses DDT, is a signatory to the Stockholm Convention. Exposure to POPs
causes serious health effects. The Convention requires Parties to take measures to eliminate
or reduce the release of POPs into the environment. In terms of this convention, the use
of DDT for agricultural purposes is not allowed. The convention has given an exemption
for the production and public health use of DDT for indoor application to vector borne
diseases, such as Malaria and Kala-azar, mainly because of the absence of equally effective
alternatives. The use of DDT for public health programme is also restricted upto 10,000
MT per year except in case of major outbreak or epidemics. World Health Organization
(WHO) also allowed the use of DDT for public heath interventions for disease vector control.
WHO recommends the use of DDT only for Indoor Residual Spraying (IRS) provided that
the guidelines and recommendations of WHO and the Stockholm Convention are met. DDT
may be used until locally appropriate and cost-effective alternatives are available for a
sustainable transition from DDT.
(ab) Organophosphorus Compounds.
These insecticides are derivatives of phosphoric acid and act by inhibiting the activity of cholinesterase.
Many of the insects, which have become resistant to Organochlorines are still susceptible to the
members of this group. However, due to their extensive use in agricultural as well as public health
field, more and more insects are developing resistance to Organophosphorus compounds. Some of
the common compounds are Malathion, Temephos, Fenthion, Dichlorovos (DDVP) and Fenitrothion.
O Malathion.
It is one of the least toxic Organophosphorus compounds. Malathion is a broad-spectrum
insecticide, with efficacy against a large number of pests ranging from mosquitoes, houseflies,
cockroaches, bedbugs, lice etc. It is available as Malathion Technical (95%) for use as space
spray, 50 percent Water Dispersible Powder (WDP) and Emulsifiable Concentrate (EC) for
residual control and 90% dust for use against fleas and lice. Malathion under the National Vector
Borne Diseases Control Programme is being used as Indoor Residual Spray against mosquitoes
in areas where the vectors have become resistant to DDT. The dosage of its application is
2 g / m2 (Refer to Chapter on Mosquitoes for details). As ULV spray it has been very widely
used during outbreaks of Dengue and JE as an anti-adult mosquito measure. However,
development of resistance has been reported in a large number of vectors to Malathion.

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O Temephos (Abate).
It is available as 50% EC. It is the only insecticide approved for use in potable water.
The product acts as a contact poison and has a prolonged residual effect. If used in
the recommended doses, it is not toxic to fish and other aquatic life. Because of its low
toxicity, it has been successfully used for the control of An. stephensi breeding in wells and
domestic containers at a dosage of 1 ppm (Refer to Chapter on Mosquitoes for details). Sand
impregnated with Temephos in 1 percent concentration has been used in some countries
against Ae. aegypti which breeds in containers of clean and potable water and even in
desert air coolers for control of Dengue. It has proved to be very successful in Guinea worm
eradication programme in India.
O Pirimiphos methyl.
This insecticide is being considered as an alternative insecticide for indoor residual spray. It
is available as 25% WP; 2 kg is mixed in 10 litres of water and sprayed @ 10 litres / 250 m2
area to give a deposit of 2 g / m2. Three rounds of spray are recommended as is followed
in case of Malathion. Recent study showed that, it was even possible to achieve year-round
protection with a single round of IRS due to long residual effect of pirimiphos.
O Fenitrothion (Sumithion).
It is available as Fenitrothion 40% Water Dispersible Powder (WDP). The insecticide has
shown promise as an effective insecticide for control of bedbugs; however, toxicity constraints
have limited its widespread use.
(ac) Carbamates.
These compounds are derivatives of carbamic acid and resemble organophosphorus compounds
in their mode of action. Some of the preparations produce a rapid knockdown effect like that
of Pyrethrum. The inhibition of Acetylcholine esterase is reversible with Carbamates and hence
these compounds are less toxic. Some of the compounds in common use are Propoxur (baygon),
Carbaryl (sevin) and Bendiocarb.
O Propoxur (Baygon / Blattenex).
It is formulated as WDP as well as EC. It is considered as the least toxic Carbamate
compound for man and domestic animals. It has a flushing out effect and therefore is
commonly used for cockroach and bedbug control. It is also used in bait formulations
against houseflies and cockroaches.
O Bendiocarb.
Bendiocarb is an alternative insecticide for indoor residual spraying. It is available as 80%
WP. For indoor residual spraying, it is recommended @ 200 mg / m2. Two rounds of spray
are recommended for effective control against Malaria.
(ad) Synthetic Pyrethroids.
These are synthetic derivatives or analogues of natural Pyrethrum. These are broad spectrum, highly
potent with quick knock down action and long residual life. Synthetic pyrethroids are many times
more effective than the previously available insecticides. Their relative safety to man and higher
animals, their efficient biodegradability together with their higher target specific toxicity makes
them very attractive materials for integrated vector control. The commonly available products are
Permethrin, Allethrin, Phenothrin, Cypermethrin, Lambdacyhalothrin, Cyfluthrin, Deltamethrin and
Bifenthrin. The synthetic pyrethroids are formulated as WDP, EC, SC, Flow, EW and ULV formulations.
Being broad spectrum, these insecticides are being used for pest or vector control as residual
spray, space spray and topical application as well as for treatment of clothing.
O Deltamethrin.
It is one of the most widely used synthetic pyrethroid molecule in the field of vector control.
It is available in many formulations for various vector control strategies viz. SC 2.5% (Flow)
formulation for treatment of bed-nets and routine household pest control activity; 2.5% WP

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formulation for indoor residual spray in Malathion resistant areas and 1.25 ULV for space
spraying. The target dose is generally 20 mg of a.i. (active ingredient) per m2 of surface area.
Deltamethrin is also used for treatment of Long-Lasting Insecticidal Nets (LLIN).
O Cyfluthrin.
Besides Deltamethrin, this is the next most widely used molecule. It is available as 0.5 EW
formulation for treatment of bed-nets; 5% EC for household use and 10% WP for use as
indoor residual spray in Malathion resistant areas.
O Permethrin.
Widely used for control of lice, scabies and for treatment of clothing and bed-nets. The
product is formulated as shampoo formulation for use as anti-lice treatment and 5% cream
for use in scabies treatment. Bed nets treated with Permethrin at the manufacturing stage
itself are available as Pre-treated or Long-Lasting Nets (LLN’s).
O Other Synthetic Pyrethroids Used in Public Health.
There is a large range of molecules used in the field of Public health besides the ones listed
above. These molecules are Allethrin, Resmethrin, Phenothrin, Cypermethrin, Imiprothrim,
Bifenthrin, Cyhalothrin, Cyphenothrin etc. These are all available as WP, EC or Aerosol
formulations for use against pests like cockroaches, houseflies to mosquito control.
(ae) Newer group of Insecticides.
O Phenyl Pyrazoles.
Fipronil is the only member of this class of insecticide. Fipronil acts by antagonizing the
effect of GABA. It is available as 0.3% gel for use against cockroach as a crack and crevice
treatment. It is a systemic material with contact and stomach activity. It has a unique action
called ‘cascade effect’ which is possible due to necrophagy seen in cockroaches. When
cockroaches consume the insecticide bait, they are killed, these dead cockroaches when
are consumed by other cockroaches, it results in their death and this goes on for about
two months or so, thus obviating the need to retreat the area at lesser intervals.
O Neo Nicotinoids.
Imidacloprid is the sole member from this class. It acts by causing irreversible blockage
of postsynaptic acetylcholine receptors. Imidacloprid is a systemic insecticide, having
notable contact and stomach action. Imidacloprid is available as 2.15% gel for use against
cockroaches and as bait for use against houseflies, where it is formulated with housefly
pheromone – Muscalure.
O Biorational Insecticides.
‘Biorational’ means any substance of natural origin that has a detrimental or lethal effect on
specific target pest, e.g. insects. These insecticides are non-toxic to man, plants and animals
and have little or no adverse effects on the environment. At present, they are mainly in the
research or else early stages of introduction into public health practice; however, it is felt
that with passage of time they may be increasingly used in public health. Novaluron is a
recent addition to the list, which has been found effective against the mosquitoes. Novaluron
is a contact larvicide and is available as 10% EC; it is used @ 20 mg a.i. / and the efficacy
lasts up to 3 months. Diflubenzuron is available as 25% EC, WP & 0.5% granules and is
used @ 1.0 g / acre of surface water as mosquito larvicide. An overview of the biorational
insecticides is presented in Fig 34.18.
- Biocides.
The development of insecticide resistance amongst the major pests and vectors coupled
with the non-target toxicity necessitated development of safer alternatives to insecticides.
This led to the screening, promotion and use of a large number of biorational products of
which biocides are one of the most important control options. The two biocides used in
the field of vector control are Bacillus thuringiensis var israelensis and Bacillus sphaericus.

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Both these products are widely used as larvicides in mosquito control programmes and act
as stomach poison.

BIORATIONAL
INSECTICIDES

INSECT GROWTH PHEROMONES BIOCIDES

REGULATORS • Musculure • Bacillus
• Oviposition attractant thuringiensis var
israelensis
• Bacillus
CHITIN SYNTHESIS JUVENILE sphaericus
INHIBITORS HORMONE MIMICS
• Diflubenzuron • Pyriproxyfen
• Lufenuron • Fenoxycarb
• Novaluron • Triflumuron

Fig 34.18 : Biorational Insecticides Used in Vector Control

Bacillus Thuringiensis Var Israelensis (Bti).
It was discovered in 1976 and has been found to be effective as mosquito larvicide. It is a
gram positive spore forming bacteria. Bti acts through the action of delta-endotoxin. When
the mosquito larva ingests the active ingredient (protoxin), it is activated inside its midgut
causing holes in the gut lining which leads to gut paralysis and eventually larval death
(Fig 34.19). The product is available as WP, Granules, AS & Briquette. Bti 12 AS is used @
20 ml / m2 and has been found to be effective up to 15 days (for details refer chapter on
mosquito). Bti however, suffers from the disadvantage that it cannot be used in polluted
waters or where particulate matter is more; it also cannot recycle in nature. It is used in
non-potable water bodies.
Bacillus Sphaericus.
A naturally occurring bacterium used against mosquito larvae. It is more effective in polluted
water and can recycle in nature. It is available in various formulations like Bti viz. pellets,
briquettes, granules & WP. It is used @ 20 ml / m2 and has been found to be effective up
to three weeks.

Fig 34.19 : Diagrammatic Representation of Mode of Action of BTI

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 ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY

(iii) Application Technique.

Control of arthropods in different habitats necessitates the use of different types of spraying equipment
as well as a variety of formulations such as liquids, granules and dusts. For example, control may involve
treatment of small domestic or peri-domestic water collections which are ideal breeding places for Aedes
mosquitoes; applications to stagnant waters in cesspools, ditches and drains where Culex mosquitoes
breed, large bodies of standing water where certain Anopheles mosquito species may be breeding; or
aerosol spraying of extensive areas to halt epidemics. To meet with diverse situations, significant progress
has been made in improving the spraying equipment. The Ultra-Low Volume (ULV) equipment for ground
and aerial spray to control mosquitoes and other haematophagous arthropods has resulted in not only
the elimination of several impediments like frequent mixing and reloading but helped in increasing the
speed of application and reducing the dosages and costs. It is specially recommended for control of
an outbreak of vector borne disease. The various insecticides with their formulations and dosages are
listed in Table 34.12 (Insecticides for Indoor Residual Spray), Table 34.13 (Insecticides for Indoor Space
Spray), Table 34.14 ( Insecticides for Outdoor Space Spray) and Table 34.15 (Larvicide Formulations and
Dosages) at the end of this chapter.
(aa) Formulations.
Manufacturers combine pesticides with other materials to make usable concentrations called
formulations. These formulations are designed to kill insects readily without causing undue hazards to
non-target organisms when diluted and applied correctly. Factors influencing application and efficacy
of an insecticide are its toxicity, size and shape of its particles, concentration in formulation; type of
solvent used, type of surface to be sprayed, atmospheric temperature and humidity, type of sprayer
and its nozzle, training of the spraying personnel, the bionomics, morphology and physiology of the
particular arthropod. No single preparation can meet the requirement of vector control in all spheres
of human ecology. Solutions, emulsions, suspensions, water dispersible powders, dusts and granules
to suit different conditions and problems are, therefore, prepared and used.
Technical Grade Pesticide. This is the basic toxic agent in its purest commercial form. Some
technical grade pesticides are liquids; others occur in solid form. Technical grade Malathion is
used in ultra-low volume space applications.
Types of Formulations. Formulations essentially are of three types: Solid or dry, liquid and gaseous
formulations.
O Solid or Dry Formulations.
- Dusts.
Dusts are normally ready-to-use formulations with a low percentage of active ingredient
(usually 1-10%) plus a very fine inert carrier such as talc, chalk, diatomaceous earth,
clay or volcanic ash. These materials are usually low in cost, easy to apply, non-staining
and nontoxic to vegetation. Dusts are always used dry and can easily drift into non-
target areas if they are not applied carefully. For this reason, outdoor applications
should be made only when the wind is calm. A common use for dusts is in crack
and crevice or spot treatments indoors in out-of-sight areas (behind equipment, in
wall voids and so on) which remain dry. The residual pesticidal activity of dust is
normally fairly long, provided the dust stays dry, but quickly loses its toxicity in the
presence of moisture. They don’t adhere well to vertical surfaces.
Dusts are used on people during mass delousing operations to control outbreaks
of lice borne diseases. Dusts are also used for flea control during Plague outbreak.
Dusts aren’t generally absorbed through the skin, but may be dangerous if inhaled
into the respiratory tract.
- Granules.
These are basically the same as dust formulation, except the carrier particles are
larger and thus don’t stick to leaves allowing penetration in dense foliage. This is a
real advantage when the pesticide must reach the water surface for mosquito control

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COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

in vegetated swamps or if it must get to the ground surface through trees and shrubs
for chigger control. Granules are also available in timed-release formulations that
release a dosage of the pesticide over an extended period of time. Other advantages
of using granules are that they provide longer lasting effects and their use results
in less drift than generally occurs with liquids or dusts.
The percentage of insecticide in granules and pellets varies from 1 to 5%. These can be
used in irrigation channels, irrigated or flooded lands, paddy fields and particularly where
there is vegetation on the water surface. After sinking, these formulations disintegrate
slowly releasing small particles of insecticides. These can also be effectively used in
small water collections such as ornamental tanks and earthen pots, tree holes and
other domestic or peridomestic breeding places of Aedes mosquitoes.
- Wettable Powder.
This formulation consists of the technical grade pesticide, an inert carrier and a
wetting agent (usually a synthetic detergent) that helps it mix with water. These
usually contain 50 to 75% of the toxicant. Most of these can be put directly into
water and require only slight agitation to make suspension; others may require mixing
with a small amount of water to form a paste or slurry. The required volume of water
is then added to paste or slurry followed by thorough agitation of the mixture.
When water is added to a wettable powder it makes a suspension; this enables the
pesticide to stay on porous surfaces like concrete, plaster or unpainted wood. Water
penetrates these surfaces, leaving the carrier and the maximum amount of the pesticide
on the surface available to kill pests. Suspensions have other advantages, too. They
have no solvent odour and they don’t tend to irritate or penetrate skin. However, they
generally need agitation to keep pesticidal particles from settling out. Also, they tend
to clog sprayer nozzles and strainers, especially when the wettable powder is stored
for long periods in humid areas or when a high concentration is used.
O Liquid formulations.
- Emulsifiable Concentrates.
Emulsifiable concentrates consist of the technical grade pesticide (typically 45% to
75%), a solvent and an emulsifying agent, usually a synthetic detergent. This agent
is used to allow the concentrate to be diluted in water, resulting in an emulsion.
Emulsifiable concentrates are usually clear but emulsions look similar to milk. Finished
sprays are emulsions or solutions diluted to field strength. Unlike solutions, most
emulsions need a little periodic agitation to keep the concentrate from separating out
of the water. Emulsions are used for residual treatments. Pests that contact these
surfaces are killed by the pesticidal residue. Emulsions may damage aluminum,
varnish and painted surfaces, due to the action of solvents such as Xylene. Emulsions
may also be corrosive to metal sprayers and their fittings and hence sprayers made
of stainless steel, aluminum or other non-corrosive materials should be used.
- Oil Solutions.
These formulations consist of a technical grade pesticide dissolved in a solvent
such as kerosene or diesel oil. Solutions are available as ready-to-use formulations
(for example ordinary household fly and mosquito sprays with a low percentage of
pesticide) and as solution concentrates. These concentrates contain a high percentage
of insecticide and must ordinarily be diluted in oil or another suitable solvent. Some
concentrates are used without dilution in Ultra Low Volume (ULV) applications. Oil
solutions applied as finished sprays often kill insects on contact, since the oil helps
the pesticide penetrate the insect’s waxy body wall.
- Ultra-Low Volume (ULV).
While most items of ULV pesticide dispersal equipment use the readily available

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 ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY

solutions or technical grade formulations, there are special ULV formulations available.
- Aerosols.
Aerosols are pressurized cans containing a small amount of pesticide driven through a
small nozzle. They’re commonly used as space sprays for flying insect’s viz. mosquitoes
and houseflies and as residual sprays (mites / ticks) depending on the formulation.
Care should be taken since they can explode if punctured or overheated, even after the
pesticide has been dispensed. Common insecticides used are Pyrethroids, Malathion,
DDVP and repellents like DEET and DEPA. These are used for disinsecting aircrafts,
tents, rooms, other small enclosures, uniforms and for topical application. An emission
of nearly 15 seconds is enough for a 100 m3 space.
O Fumigants / Gaseous formulations.
Gases are primarily used in fumigation operations. They may be prepared as liquefied
gases and packaged in pressure containers or in a material form that reacts with the
moisture in the air to form a gas. The gas molecules can penetrate cracks, crevices
and tightly packed material. Gases are the most dangerous pesticides used and
hence special safety equipment and training are necessary when using gases and
must never be attempted except by trained pest management personnel operating
in pairs. One of the common gaseous formulations viz. Cyanogas (Calcium cyanide
powder) and Phosphine (Aluminium phosphide tablet) are used for rodent control.
- Pesticide bombs.
Total release foggers, also known as “bug bombs,” are pesticide products containing
aerosol propellants that release their contents at once to fumigate an area. These
products are often used around the home to kill cockroaches, fleas and other pests.
Because the aerosol propellants in these foggers typically are flammable, improper
use may cause a fire or explosion. In addition to this hazard, failure to vacate premises
during fogging or re-entering without airing out may result in illness.
O Special Formulations.
- Resin Strips.
Pesticide-impregnated resin strips release a vapor as they are heated or exposed to
normal room temperatures. The use of resin strips in rooms occupied by the young,
the elderly or in food preparation and food serving areas is strictly prohibited.
- Baits.
Baits are commonly used to manage scavenging pests such as rodents, ants, flies
and cockroaches, which are particularly difficult to manage with standard techniques.
Baits consist of the toxicant mixed with a food attractive to the target pest or with
water. For this reason, baits made with local foods are normally more effective than
premixed formulations. The use of pheromone Muscalure with Imidacloprid as bait
for houseflies is now common in practice.
- Gel.
One of special formulations developed for use against cockroaches is gel formulation.
Gels comprise some food attractant mixed with the toxicant and some stabilizing
agents. Examples are Fipronil and Imidacloprid gels marketed against cockroaches.
- Shampoo.
This formulation has been specially developed for use against head lice infestation.
Permethrin is available as shampoo formulation under the trade name “Mediker”.
- Beads / Pellets / Briquettes.
Small floating beads, pellets or briquettes incorporating biocides Bti and B. sphaericus
have been developed against Anopheline larvae. These formulations can be made

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controlled release formulations as well.

- Paints and Lacquers.
These can be used for incorporation of insecticides especially for control of pests
on ships. These preparations remain effective for long periods. The new insecticide,
Imidacloprid is also available as a paint formulation against houseflies.
- Mats / Coils.
These are special formulations which have been developed as controlled release
formulation for indoor use against mosquitoes. These have synthetic pyrethroids as
Allethrin, as the toxicant which knocks down the mosquitoes when used indoors.
(ab) Equipment.
Equipment used for vector control can be broadly classified as ground equipment and equipment
used for aerial applications.
Ground Equipment.
O Sprayers for production of fine or coarse spray which may be either manually operated
or power operated. Sprayers for the production of mist which may be either with gaseous
energy nozzles (manual operated or power operated) or with centrifugal nozzles.
O Devices for the production of aerosols which may be mechanical, thermal or gaseous
energy aerosol generators.
O Dusting equipment which may be manually operated or power operated.
O Applicators for granules and pellets may be manually or power operated.
Aerial Equipment.
Equipment for aerial sprays is essentially the same but with certain modifications. The equipment
in common use is the boom and nozzle system.
Sprayers.
The equipment commonly used for spraying various insecticidal formulations are the hand operated
sprayers, power operated sprayers, aerosol dispensers, fog generators and dusters.
O Hand Operated.
These are hand sprayers, knapsack sprayer and compression sprayer.
- Hand Sprayer.
The hand sprayer is used for space spraying of small apartments. It is provided with a
small can for holding ½ to 1½ L of spray fluid and a cylindrical plunger type air pump. The
nozzle size is less than 0.4 mm, in order to produce a fine spray. The simplest form is the
familiar ‘flit gun’ producing intermittent spray. A number of other light hand sprayers have
been designed which can be pressurized in the manner of compression sprayers and are
used to produce a mist or fine droplet spray.
- Knapsack Sprayer.
This is designed to fit on to the back of the operator and usually has a capacity of 15 to
20 ltr. It incorporates a light but powerful diaphragm pump actuated by a lever carried
forward to the operator’s hand where it is worked by an up-and-down movement. These
sprayers are used both for larviciding and residual spraying. The nozzle size used for residual
spraying varies between 0.78 to 1.0 mm so as to produce a coarse spray.
- Compression Pneumatic Sprayer.
This is the commonest type of equipment used in NVBDCP for the application of insecticides.
It has a hand operated pump incorporated to build up adequate pressure. When the pressure
is released by a trigger on the lance, the liquid is forced out from the tank to the nozzle

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 ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY

by the compressed air and a continuous spray of the insecticide formulation is produced.
It is slung over the shoulder with one strap or may be carried on the back with two straps.
It is operated by one person.
O Power Operated Sprayers.
These are useful for application of insecticides over large areas. These are hydraulic sprayers
in which the spray liquid is expelled to the nozzle by positive displacement by the plunger
pump. Insecticide tanks built into a truck or mounted over a hand trolley are connected
directly to a power operated compressor. By means of a long hose the spraying fluid is
conveyed under pressure through the lance to the nozzle.
O Insecticidal Fog Generators.
Several types of these are now available for the production of insecticidal fogs in the open
on a large scale. In these fogging machines the oily solution of the insecticide is finely
atomized by the powerful blast of hot exhaust gases from a petrol engine.
O Aerosol Dispensers.
These are used for disinsection of aircrafts, tents, rooms and similar small enclosures. It
contains insecticide and a propellant. Common aerosols contain synthetic pyrethroids or
their combination, which are routinely used for mosquito and fly control.
O Dust Gun.
Insecticidal dusts are applied against lice, fleas in rat burrows or on water surfaces as dry
powders diluted with inert dusts. Small light weight guns are used for mass delousing of
infested people.
(ac) Residual Spraying.
This is the application of insecticides to surfaces so that the insecticide particles remain on the
surface in the form, size and quantity suitable for insects to pick up on contact and sufficient to
exert a lethal effect over a long period. Organochlorine, Organophosphorus, Synthetic Pyrethroids
and Carbamate compounds can thus be applied on the inside walls of houses and also on thick
bushes in forests. The type of surface to which an insecticide is applied influences its toxicity
against insects and its persistence. Solutions and emulsions quickly get soaked in the absorbent
surfaces of soft bricks and mud walls which take in a large portion of insecticidal material deposited
on them; but when suspended in water it remains over the surface after the water evaporates or
gets absorbed. The nozzles of sprayers used for residual spraying must conform to the need of
having a droplet size which is neither too large nor too small. Similarly, safety precautions should
be observed, as follows, while spraying:
A. Broad rim hat (protects O Do not eat, drink or smoke while working.
head, face and neck from O Wash your hands and face with soap and water
spray droplets)
after spraying and before eating, smoking or drinking.
B. Goggles or face shield
(protects face and eyes O Shower or bathe at the end of every day’s work
against spray fall-out.) and change into clean clothes.
C. Face mask (protects nose O Wash your overalls and other protective clothing
and mouth from airborne
particles of the spray fall-
at the end of each working day in soap and water and
out.) keep them separate from the rest of the family’s clothes.
D. Long sleeved overalls. O If the insecticide gets on your skin, wash off
(Keep overalls outside of immediately with soap and water.
boots.)
O Change your clothes immediately if they become
E. Rubber gloves.
contaminated with insecticides.
F. Boots.
O Inform your supervisor immediately, if you do not
feel well. Wear protective clothing as shown in Fig 34.20.
Fig 34.20 : Protective Clothing

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The Household.
Inform the householder of the spraying schedule and the purpose of spraying, giving them time to
prepare and vacate the house. Occupants MUST leave houses before spraying. Rooms occupied by
sick people who cannot be moved must NOT be sprayed. Remove all household items, including
water, food, cooking utensils and toys from the house. Move and cover or take out the furniture
to allow easy access for spraying walls. Items that can not be removed should be well covered.
Equipment.
Indoor residual spraying of insecticides is normally done using hand-operated compression sprayers.
Before starting a spray operation, the equipment must be checked. Faulty sprayers may result in
poor control or over-treatment. Examine the sprayer visually to ensure that all parts are present,
assembled correctly and are in good condition (Fig 34.21).

A. Sprayer tank
B. Shoulder strap
C. Lid
D. Pump (handle)
E. Pressure gauge
F. Lance
G. Strainer
H. Hose
I. Nozzle – check correct type of nozzle is fitted and is not damaged
or worn (flat fan nozzle with 55 to 60º swath and 0.75 L / min flow
rate at 700 g / sq cm).
J. Trigger on / off valve. Is the strainer inside valve handle clean
K. Foot Rest

Fig 34.21 : Hand-operated Compression Sprayer

Before using an insecticide use clean water to ensure that the equipment operates properly and
does not leak. Wear protective clothing. To check, follow the steps below:
O Pour clean water into the tank
(never fill tank more than 3 / 4 full) (Fig
34.22).

O Fit the lid. Turn the handle to lock

the lid in position (Fig 34.23).

Fig 34.22 Fig 34.24 O Operate the pump using both

hands and with foot on the footrest.
Pump to the working pressure 55 psi
(Fig 34.24).

O Check tank is holding pressure.

Listen for hissing sound of escaping air
(Fig 34.25).

Fig 34.23 Fig 34.25

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 ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY

O Check to make sure there are no leaks along lance and hose, especially
where hose joins tank and trigger on / off valve (Fig 34.26).
O Operate trigger on / off valve to make sure that spray is emitted from
the nozzle (Fig 34.27).
O Check the spray pattern from the nozzle by spraying a dry wall surface.
Look to see that the pattern is even and without streaks. Ensure nozzle does
not drip when trigger on-off valve is released (Fig 34.28).

O Calibrate the nozzle with water in the tank. Pump to 55 psi

Fig 34.26
(700 g / sq cm). Open the trigger on-off valve for one minute, collect the
discharge and measure the amount in a measuring jug. Empty the jug.
Discharge for a further one minute and measure the amount. Repeat for a
3rd discharge. Calculate the average of the three, one-minute measurements.
O With the above procedure, the average discharge of an 8002 nozzle
is about 750 ml per minute. If the discharge is incorrect, check the nozzle
and the screen filters to ensure they are not clogged. If necessary, replace
nozzle. Repeat the calibration.
If the Nozzle is Clogged.
The opening in a nozzle is very small and must not be damaged. Clogged
nozzles should be put in a container with water for several hours before
the blockage is removed by a very soft toothbrush. NEVER clean nozzle
Fig 34.27 with a hard pin or piece of wire and NEVER put a nozzle to your mouth to
blow through it.
Mixing, Handling and Spray Techniques.
Prepare the insecticide spray according to the manufacturer’s instructions.
The insecticide may be mixed separately in a bucket and poured into the
sprayer. Water soluble sachets, tablets and insecticides granules are added
directly to the water filled tank. These formulations mix readily with water
and reduce the hazards associated with handling and mixing in a separate
container. When the sprayer has been filled with water to the maximum level
indicated on the tank, the lid of the tank is fitted and the sprayer pumped
to a pressure of 55 psi by pumping 55 times (700 g / sq cm). The contents
of the tank should be thoroughly mixed by shaking the tank before starting
to spray (Fig 34.29).
Spraying in a room should commence from the backside of a door clockwise
completing the plain surfaces of walls. Then the crevices on the walls and
Fig 34.28
inside portion of windows etc. should be sprayed. Thereafter the pillars,
under surfaces of furniture and lastly the ceilings should be taken for spray.
Spray is done from roof to floor, using downward motion, to complete one
swath; then stepping sideways and spraying upwards from floor to roof.
Spray is applied in vertical swaths 52-56 cm wide. Swaths should overlap
by 5 cm and spraying should be undertaken as shown in Fig 34.28. Normal
swath coverage will take 2.7 sec and hence in one minute 22-23 swaths
will be required to cover a wall of 10-11 metres length and 3 metres height
i.e 30-33 sq.m. It takes about 5 minutes to spray a house with an average
surface area of 150 sq. metres.
To ensure the correct swath width, keep the spray tip about 45 cm from
the wall. Lean forwards as you spray from top of the wall and move back
as you bring the nozzle downwards (Fig 34.30).
Fig 34.29 The flow of liquid from the nozzle tip at 700 g / sq cm pressure is

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COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

750 ml / minute. Hence 30 sq m surface will be covered with 750 ml of

the insecticide solution.
Time your spray speed to cover one meter every 2.2 seconds, i.e.,
4.5 seconds for a 2 m high wall. Timing may be aided by mentally counting
“one thousand and one – one thousand and two – one thousand and three
-….” Adjust the mental counting procedure according to the local language
(Fig 34.31).
If spray stops due to a blockage in nozzle, unscrew the nozzle cap, remove
blocked nozzle and replace with a new one. The blocked nozzle should be
cleaned as explained above. Do not let spray drip on the floor. Re-pressurize
the tank when the pressure falls.
Procedures after Spraying.
Fig 34.30 O Advise the occupants to stay outside until the spray is dry.
O Instruct the householder to sweep or mop the floor before
children or pets are allowed to re-enter.
O Instruct the householder not to clean the sprayed surfaces
Disposal of Remains of Insecticides and Empty Packaging.
At the end of the day’s work, put the washings from the sprayer into pit
latrines, if available or into pits dug especially for this purpose and away
from sources of drinking water. Dilute any insecticide with more water before
putting into pits. It is advisable to prepare only sufficient insecticide to avoid
disposal of remaining. Never pour the remaining insecticide into rivers, pools
or drinking water sources. All empty packaging should be returned to the
supervisor for SAFE disposal. Never re-use empty insecticide containers.
Fig 34.31 Empty insecticide containers should NOT be burned or buried.
Maintenance of Equipment.
After completing the day’s work, de-
pressurize the tank and empty any
remaining insecticide, following the
instructions given in the previous section.
Clean the tank as explained below:
O De-pressurize the tank.
O Fill the tank half-full with clean
water.
O Replace the lid.

Fig 34.32 Fig 34.34 O Shake the tank so all inside

surfaces are washed (Fig 34.32).
O Pump up to 700 g / sq cm pressure.
O Spray water through nozzle (Fig
34.33)
O De-pressurize the tank and pour
out any remaining water into pit latrines
or into a pit away from sources of water.
O Unscrew trigger on / off valve
handle and check and clean the strainer.
O Reassemble the trigger on / off
Fig 34.33 Fig 34.35
valve (Fig 34.34).

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 ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY

}
O Remove the nozzle tip and wash
O Refit the nozzle (Fig 34.36)
O Clean outside of tank.

Fig 34.36
O With lid open, turn tank upside down, open the on / off valve and let all the
water drain out of the hose and lance.
O Ensure the lance is parked to protect nozzle when not in use.
O When storing the sprayer for a long period, hang it upside down with lid open
to allow air circulation. Allow lance to hang from D-ring on the tank with the trigger
valve kept open (Fig 34.37).
(ad) Space Spraying.
It is an ideal method for bringing about rapid control of vectors in emergency or epidemic
situations and may also be used for seasonal control of flying insect pests or vectors. An
additional objective may be to reduce or interrupt the transmission cycle of insect-borne
diseases. However, it may not be ideal for all vectors or situations and as such may
not be an economical method of control. Among the disease vectors affecting public
health, the most important and widespread are mosquitoes, houseflies, sandflies and
other biting flies; some of these may be targeted for space treatment.
Immediate killing of actively flying insects requires a cloud of insecticide droplets that
they will encounter in flight. To be cost-effective and obtain good biological efficacy,
space spraying requires:
Fig 34.37 O Knowledge of the behaviour and biology of the target species to understand
where and when space treatments will be effective;
O Knowledge of insecticides and formulations most suitable for space spraying;
O Knowledge of pesticide application technology to know which equipment is needed
and how to use it; and
O Monitoring and surveillance of the target species and vector-borne disease problem
to evaluate the efficacy of the programme.
A space spray – technically a fog (sometimes referred to as an aerosol) – is a liquid insecticide
dispersed into the air in the form of hundreds of millions of tiny droplets less than 50 µm in
diameter with a view to cause by contact, immediate knock down of the flying or resting insects
in confined spaces. Space sprays, even when they settle on surfaces do not have much residual
action. It is only effective while the droplets remain airborne. Therefore, they have to be repeated
at frequent intervals. Space sprays are applied mainly as thermal fogs or cold fogs.
Thermal Fog.
Thermal fog is produced by special devices known as thermal foggers that use heat to break up
the chemical into very small droplets (usually in 5-30 micron diameter range) which then disperse
in the air. When the chemical (usually diluted with oil-based carrier) is heated, it is vaporized in

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COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

a combustion chamber and then expelled via an outlet tube to form a dense fog cloud when it
condenses on contact with cool ambient air.
The insecticide used in thermal fogs is diluted in a carrier liquid, which is usually oil-based. Hot
gas is used to heat the pesticide spray, decreasing the viscosity of the oil carrier and vaporizing
it. When it leaves the nozzle the vapour hits colder air and condenses to form a dense white
cloud of fog. Most of the droplets are smaller than 20 µm. The droplet size is affected by the
interaction between the formulation, the flow rate and the temperature at the nozzle (usually
> 500°C). The volume of spray mixture applied in vector control is usually 5–10 litres per hectare,
with an absolute maximum of 50 litres per hectare. The hot emission gas is obtained from engine
exhaust, friction plate / engine exhaust or from a pulse jet engine.
Advantages.
O Easily visible fog so dispersal and penetration can be readily observed and monitored;
O Good public relations in some circumstances as people can see something being
done about the problem; and
O Low concentration of active ingredient in the spray mixture and reduced operator
exposure.
Disadvantages.
O Large volumes of organic solvents are used as diluents, which may have bad odour
and result in staining;
O High cost of diluent and spray application;
O Householders may object and obstruct penetration of fog into houses by closing
windows and doors;
O Fire risk from machinery operating at very high temperatures with flammable solvents;
O Can cause traffic hazards in urban areas.
Cold fog.
The cold fog is produced by a special device (cold fogger) that breaks up the chemical into
microscopic droplets by mechanical means, basically with a high-pressure pump and an extremely
fine nozzle. The spray droplets are generated without any external heat. With cold fogs the volume
of spray is kept to a minimum. Ultra-low-volume insecticide formulations are commonly used for
such applications. The cold fogger may dispense formulations in a very concentrated form and
generate the droplets (usually in the 5-30 micron diameter range) in a precise manner. However,
its ability to penetrate dense foliage or obstacles is not as good as that of thermal fogging. Cold
fogging is sometimes called Ultra Low Volume (ULV) treatment as it allows the utilization of only
a very small amount of chemical for coverage of a large area.
Like thermal fogging, cold fogging also does not have lasting residual effects. It is, therefore,
essential to carry out fogging at the time when the vectors are most active to hit them directly.
Advantages.
O The amount of diluent is kept to a minimum, resulting in lower application cost and
increased acceptability. Some formulations are ready to use, thereby reducing operator exposure.
O Mostly use water-based and water-diluted formulations, which pose a low fire hazard
and are more environmentally friendly.
O Because a lower volume of liquid is applied, application is more efficient.
O No traffic hazard as the spray cloud is nearly invisible.
Disadvantages.
O Dispersal of the spray cloud is difficult to observe.

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O Higher technical skills and regular calibration are required for efficient operation of
equipment.
Space Spray Equipment.
Selection of appropriate equipment for space spraying depends on the size and accessibility of
the target area as well as the human resources and operational capacity of the programme.
Sometimes smaller machines may be needed in conjunction with vehicle-mounted equipment to
treat narrow pathways and other areas inaccessible to vehicles or sheltered from prevailing air
movements. Cold fog equipment is recommended where thermal fogs may cause a traffic hazard.
Aerial application of space sprays may be justified where access with ground equipment is difficult
and / or extensive areas need to be treated very quickly.
Equipment for Thermal Fogging.
O Hand-Carried Thermal Foggers.
These are used for treating houses and certain
outdoor areas of limited size or accessibility, e.g.
markets, hotel grounds and parks. There are two types
of hand-carried thermal foggers; pulse jet and friction
plate (Fig 34.38).
O Vehicle-Mounted Thermal Foggers.
Large thermal fog generators use an air-cooled motor
to run an air blower, fuel pump and insecticide pump.
Air from the “roots type air blower” is delivered into the
combustion chamber. There it is mixed with gasoline
vapour and ignited, so that temperatures reach 426–
648°C. The diluted insecticide liquid is pumped via a
Fig 34.38 : Hand Held Thermal Fogger simple flow delivery valve and injected into a cup in
the fog head or directly into the nozzle. The insecticide
liquid is vaporized by the blast of hot gases. Despite this high temperature, insecticides
show very little degradation of active ingredient. This is because the time spent at that
temperature is only a fraction of a second, which is not long enough to cause serious
degradation. The hot gases then pass out of the machine. As the hot oil vapour is discharged
through a relatively large nozzle into the cooler outside air, it condenses to form very small
droplets of thick white fog. Delivery rates of up to 10 litres per minute can be achieved
with larger machines.
O Aircraft Application of Thermal Fogs.
For aircraft application of thermal fogs, the diluted
insecticide formulation is fed into the aircraft exhaust. The
exhaust is adapted with vanes to swirl the fog droplets
as they are formed. The application of thermal fogs by
aircraft has been very limited.
Equipment for cold fog application.
O Hand-Carried Cold Foggers.
Most of these machines have gasoline engine or are
electric operated which drives a blower unit to discharge
air through the nozzle. Air may also slightly pressurize
the insecticide formulation tank so that the liquid is fed
via a restrictor to the nozzle. However, negative pressure
generated by the air flow passing through the nozzle allows
liquid to flow from the tank. In addition to hand-carried
units, knapsack cold fogging units are also available (Fig
Fig 34.39 : Hand Carried Cold Fogging Equipment 34.39), as are several electrically driven models.

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O Vehicle Mounted Cold Foggers.

A high volume air blower, forces air at a rate of approximately 6 m3 per minute at low
pressure to nozzle. The pesticide container may be pressurized to force the formulation to
the nozzle or positive-displacement pumps may be used.
Alternatively a high-pressure, low-volume air source is used with an air compressor, rather
than a blower. On these machines, nozzles ranging from the standard industry “paint gun
nozzle” to proprietary nozzles that atomize well up to a flow rate of 0.5 litre per minute
are available. Another design uses a rotary nozzle coupled with an electric motor which
operates at a very high speed.
O Aircraft Application of Cold Fogs.
Both fixed-wing aircraft and helicopters have been used to apply cold fogs. Conventional
low-volume nozzles (e.g. flat fan) have been used on fixed wing aircraft to create fine
sprays, using moderate or high pressures. However, the droplet spectrum is generally poor
so preference is given to the use of rotary atomizers or very-high-pressure systems.
Insecticide Products For Space Spraying.
Space-spraying formulations are generally oil-based. The oil carrier inhibits evaporation of
small fog droplets. Only insecticide products with high flash points are used for thermal
fogging. Diesel is used as a carrier for thermal fogging, but creates a thick smoke and
oily deposits, which may lead to public rejection. For environmental reasons, water-based
formulations have been made available in recent years. These formulations may also contain
substances that prevent rapid evaporation. These insecticides may also be used against
other insect pests and vectors, but different dosages may be required.
Space Spray Treatments – General Considerations.
Optimum Droplet Size.
Space treatments are only effective while the droplets remain airborne. Droplets fall by gravity
and some are deposited on horizontal surfaces while the majority is lost to the atmosphere
especially in outdoor spraying. Droplets bigger than 30 µm in diameter are less effective as
they do not remain airborne for sufficient time. Droplets smaller than 5 µm in diameter do
not readily come in contact with flying insects, as the movement of the smallest droplets
is affected by the air turbulence created by the insect’s flight. It is generally accepted that
droplets should be generated at 10–30 µm so that, even with some evaporation and after
some time, they remain in the correct range for optimal airborne suspension and insect
impact. The optimum droplet size for space spraying against mosquitoes is 10-20 µm.
Spray Concentration.
For a flying insect to be killed, it must acquire a lethal dose of insecticide in the droplets
that impact on it. The lower the concentration of active ingredient, the larger the number of
droplets of a given size required to achieve a lethal dose. Ultra-low-volume spraying aims,
largely for operational reasons, to minimize the total volume of diluted insecticide applied
(usually < 2 litres per hectare).
Wind Speed.
Wind speed has a profound effect on droplet distribution and impingement on insects.
Spraying should not take place when wind speed exceeds 15 km / hour. The type of terrain
and vegetation affects air movement and hence the distribution of the droplets. In open
terrain with relatively sparse vegetation, wider effective swaths can be obtained than in
urban areas where the obstruction of buildings alters the flow of air.
Wind Direction.
With vehicle-mounted and aerial spraying the spray route must take account of the wind
direction to maximize the distribution of the spray throughout the target area. Figure 34.40
illustrates the spray application route relative to wind direction.

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Fig 34.40 : Spray Application Route Relative to Wind Direction

Temperature Effects.
In direct sunlight the ground is heated. This causes air to rise. In the middle of the day,
outdoor space spraying will largely be wasted as the spray droplets will tend to rise upwards
rather than drift horizontally. Ideally an inversion is needed, i.e. colder air closer to the
ground. This generally occurs early in the morning after the ground temperature has fallen
during the night, but can also occur in the evening when the sun has set and ground
temperatures begin to fall.
Time of Treatment.
Knowledge of the time of peak flight activity of the target species is crucial to ensure that
space treatments are planned to coincide, as far as possible, with these times. Fortunately,
peak flight activity of many vectors is around dusk and / or dawn, when weather conditions
are often favourable for space treatment. Aedes aegypti and Aedes albopictus, mosquito
vectors of Dengue fever and Chikungunya are active during daytime with peak flight activity
in the morning and afternoon. With these species a compromise is usually made outdoors
by spraying in the early morning or late afternoon. The timing is less important if indoor
spraying is conducted.
Indoor Fogging.
Personnel conducting this work require training on the safety measures to be followed.
Several rules apply:
O Protect all water containers and foodstuffs.
O Remove fish or cover fish tanks.
O Ensure all occupants and animals remain outside the house during spraying and
stay outside for 30 minutes after spraying. Ensure that the building is ventilated before
reoccupation.
O Close all doors and windows before spraying and keep them closed for 30 minutes
after spraying to ensure maximum efficacy.

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O Spray operators should work backwards and away from the fog to minimize exposure.
O For small single-storey houses, the spray can be delivered from the front door or
through an open window without having to enter every room of the house, provided that
adequate dispersal of the insecticide droplets can be achieved.
O For large single-storey buildings, it may be necessary to apply the spray room by
room, beginning at the back of the building and working towards the front.
O For multi-storey buildings, spraying is carried out from top floor to the ground floor
and from the back of the building to the front. This ensures that the operator has good
visibility at all times.
Outdoor Ground Fogging.
O Advanced route planning should precede outdoor ground fogging operations and may
require a combination of vehicle-mounted and hand carried or knapsack equipment in areas
with difficult or limited vehicle access. Consideration must also be given to the following:
O Spraying should not be undertaken when it is raining, when winds exceed 15 km / hour
or in the heat of the day.
O Doors and windows of houses and other buildings should be open to allow penetration
of the spray cloud for improved efficacy.
O For vehicle-mounted equipment, in areas where the roads are narrow and the houses
are close to the roadside, the spray should be directed backwards from the vehicle. In
areas where the roads are wide, with buildings far from the roadside, the vehicle should
be driven close to the roadside and the spray should be directed at an angle (downwind)
to the road rather than directly behind the vehicle.
O The nozzle of vehicle-mounted cold fog machines may be directed upwards at an
angle when there are barriers that impede airflow, e.g. boundary walls and fences; for
vehicle-mounted thermal foggers, the nozzle should be directed horizontally.
O A track spacing of 50 metres is generally recommended, with the vehicle moving
upwind so that the fog drifts downwind away from it and the operators.
Aerial Application Of Fogs.
Suppression of vector populations over large areas can be carried out using space sprays released
from aircraft, especially over areas where access with ground equipment is difficult and extensive
areas need to be treated very rapidly.
Evaluation.
Evaluation of the efficacy of spray operations is carried out using techniques that are largely
specific to the target insect. Space sprays are transient and only insects flying at the time of the
application are affected.
(ae) Area Spraying.
This is carried out for treatment of land against mites and ticks and also as an anti-larval measure
over vast water surfaces. Against mites and ticks, suspensions are used on land and vegetation;
WDP is used for antilarval treatment of lakes and swamps. Aerial spraying is resorted to for
agricultural purposes and sometimes for veterinary and rarely medical purposes. Dusts are applied
to manure yards and dry refuse yards to control flies and other pests. For all such uses power
driven sprayers and dust guns are used. The larvicidal oils are applied by spraying it on the surface
of water by means of a knap-sack sprayer or hand pumps or by a mop stick.
(iv) Resistance of Vectors to Insecticides.
(aa) History.
Ever since the introduction of the potent synthetic insecticides into public health programmes at
the close of the Second World War, the main problem has been the development of resistance to

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them by the arthropods they formerly controlled. In 1947, DDT resistance was discovered in the
housefly and Culex molestus in Italy. In 1951, DDT resistance was noticed in body louse in Korea
and in Anopheles sacharovi in Greece. In 1955, Dieldrin resistance was discovered in Anopheles
gambiae in Northern Nigeria. In 1959, in Western India, the oriental rat flea was found to have
developed resistance to DDT. The number of arthropods showing resistance is on the increase.
(ab) Definition.
Resistance is defined as “The development of an ability in a strain of insects to tolerate doses
of toxicants which would prove lethal to the majority of individuals in a normal population of the
same species “. The word tolerance is normally used when the increase in LC50 is less than the
indicated minimum for the tests, but is nevertheless statistically significant. Vigour tolerance is
a term, which has been applied to enhanced insecticidal tolerance resulting from extra vigour of
the strain rather than from any specific defence mechanism.
(ac) Types.
Resistance is of two types i.e. physiological and behaviouristic. Physiological resistance is the one
described above. Behaviouristic resistance means the development of ability to avoid a lethal dose.
This term is applied most often to mosquitoes in relation to DDT.
(ad) Nature and Cause.
Genetic.
Resistance develops in arthropods after a long period of insecticidal pressure. It is brought about
by the accumulation of the contributing genes through successive selection with a number of
insecticides, each of which confers some cross-resistance. This is called polygenic or multiplicate
resistance. In contrast, the resistance may be due to a single gene and bear no similarity to
the complexities involved in the multiplicate resistance. Monogenic resistant strains are more
vulnerable to counter measures such as addition of synergists; hence the importance of distinction
between the two types.
Biochemical.
Many causes of resistance have been defined although several defy explanation in biochemical
terms. Resistance to DDT and dieldrin due to the gene Kdr does not involve detoxification and
is thought to be due to an altered site of action. On the other hand, an altered site of action
as a cause of resistance has been definitely established with cholinesterase inhibitors. In these
cases, a mutant cholinesterase is produced that is inhibited more slowly than the normal enzyme
in susceptible strains. This produces resistance against a large number of compounds and the
resultant extensive cross-resistance makes it a serious type of resistance.
Increased Detoxification.
Detoxification enzymes in resistant strains are generally more efficient and are not necessarily
produced in higher amounts; oxidases are particularly important as they affect a wide variety of
insecticides. The following enzymes or classes of enzymes are known to be of importance:
O DDT dehydrochlorinase or DDT ase which affects DDT and several analogues.
O Hydrolases which affects phosphate esters or carboxylic ester groups in OP compounds
and in some pyrethroids.
O Glutathion S transferase affects OP compounds.
O Oxidases affect carbamates, OP compounds, DDT and its analogues, as well as
pyrethroids
(ae) Dynamics.
If the genetic potentiality to development of resistance to a given insecticide is present, the rate
of development of resistance will depend upon factors such as the frequency of resistant genes
and their dominance, the selection pressure, previous history of exposure to insecticides, isolation,
inbreeding and reproductive potential of the arthropod population.

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The rate of development of resistance in previously unselected populations is normally very low at
first. During the period when the frequency of major genes for resistance is gradually increased
and the genetic background is progressively organized towards greater fitness in the contaminated
environment, the rate of development of resistance accelerates rapidly, often leading to failure of
control measures.
(d) Biological Control.
Intentional manipulation of populations of living beneficial organisms, called natural enemies, in order to reduce
the numbers of pests or amount of damage is called Biological Control.
Natural control strategies that employ biological agents for pest suppression are classified as biological control
tactics. In conventional usage, this term usually refers to the practice of rearing and releasing natural enemies:
parasites, predators or pathogens. Biological control is a particularly appealing pest control alternative because,
unlike most other tactics, it does not always have to be reapplied each time a pest outbreak occurs. However,
Biological control is not a “quick fix” for most pest problems. Natural enemies usually take longer to suppress
a pest population than other forms of pest control and therefore often regarded as a disadvantage or limitation
of biological control. It also may be difficult to “integrate” natural enemies when pesticides are still in use.
Beneficial insects are often highly sensitive to pesticides and their resurgence (recovery to pre-spray densities)
is usually much slower than that of pest populations. Rapid pest resurgence often leads to a vicious cycle of
continued chemical usage that prevents natural enemies from ever becoming reestablished.
Classification Of Biological Agents : Predators, Parasites And Pathogens.
(i) Predators.
Predators are insects or other insectivorous animals, each of which consumes much insect prey during
its lifetime. Predators are often large, active, and / or conspicuous in their behaviour and are therefore
more readily recognized than are parasites and pathogens. Most commonly used predators are the
larvivorous fishes for the control of mosquitoes.
Larvivorous Fish.
There are areas and habitats where larvivorous fish, such as Gambusia affinis (Fig 34.39) and Poecilia
reticulata (Fig 34.40), can make considerable contribution to vector control.

Fig 34.41 : Gambusia affinis Fig 34.42 : Poecilia reticulata

The larvivorous efficiency of Gambusia is due to the fact that a single full grown fish eats about 100 to 300
mosquito larvae per day, is a surface feeder, hence it is suitable for feeding on both Anophelines and Culicines,
is small and inedible and can tolerate salinity. Poecilia’s larvivorous efficiency is due to its capability to negotiate
margins of ponds more easily, tolerate handling and transportation very well, survives and reproduces when
introduced into new water bodies, survives in new places (water bodies) and multiplies easily and can survive
in good numbers for years and does not require constant care.
Release of fishes is done at the rate of 5–10 fish per linear meter. If the larval density is high up to 20 fishes
can be released. Fishes should be released in the morning hours or in the evening.
Criteria for selecting a water body for a fish hatchery are
O It should be a permanent water body.

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O Depth of water should be at least 1.5 metre or more.

O Water should be confined and without big natural outlet.
O The minimum size of water body should be at least 5 m X 4 m. The water body of 10 m X 5 m
can support 50,000 fish.
O It should be free from other carnivorous fish.
O Water should not be contaminated by chemical or other harmful substances.
O Easily accessible for daily or periodic inspection and for collection of fish.
O De-weeding in ponds and shallow water bodies and cleaning of margins should be carried out
periodically.
(ii) Parasites.
Parasites are those organisms which depend on their host for shelter or food. Many parasites are very
specific to the type of host insect they can attack and they are not harmful to humans. Although insect
parasites are very common, they are not well known because of their small size. Some of the categories
of Parasites are as follows:
(aa) Nematodes.
Nematode Romanomermis culicivorax and R. iyengari have been evaluated and have been found
to give variable control of mosquitoes. The mode of action of the nematodes is presented in
Fig 34.43.

Eggs Preparasitic nematodes invade

Laid in mud mosq larvae
7 days

Drops to bottom Kills larvae Exits through

cuticle

Moults, mates &

females start laying eggs.

Fig 34.43 : Mode of Action of Romanomermis Against Mosquito Larvae

(ab) Fungi.
Fungal agents Laegenidium and Culicinomyces have shown immense potential as mosquito larval
control agents and can be exploited for use against mosquitoes.
(iii) Pathogens.
The pathogens which have been found promising are the Bacterial agents, Bacillus thuringiensis var
israelensis and Bacillus sphaericus in mosquito larval control. However, these have been classified as
Biocides or Microbial insecticides and have been discussed earlier. Viruses like Nuclear Polyhedrosis
virus and Irido virus have also shown promise against mosquito larvae. Another promising biocontrol
agent is Androctonus australis anti-insect toxin (AaIT), which targets the neurological system of the insect
vectors. Thus, exploitation of certain characteristics of the naturally occurring organisms in nature may
potentially lead to the development of useful biocontrol agents against vector populations.

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(iv) Nontoxic Heat Treatments.

New methods of pest control are based on low-toxic solutions that can be more sustainable and effective
than harsh chemicals; one such method is to use heat to eliminate insects. Rentokil’s Entotherm is a
new solution that eradicates bedbugs and cockroaches. Rather than using sprays, which often do not
penetrate the hard outer shell, the heat delivered by the Entotherm system kills insects from the inside
through dehydration and damage to essential physiological processes. Another benefit is that the heat
effectively kills all the life stages of insects—egg, larva, pupa and adult, without needing to go over
56–60°C, which is high enough to kill the pests rapidly.
(e) Genetic Control.
This is defined as “the use of any condition or treatment that can reduce the reproductive potential of noxious
forms by altering or replacing the hereditary material”. The various methods of genetic control fall into two
general groups: those leading to population control, reduction or elimination through the release of partially or
completely sterile insects in sufficient numbers to overcome the reproductive capability of the natural population
and those leading to population control or population replacement through the release of partially sterile or
fully fertile genetically altered insects.
New genetic control methods, such as those involving sex distortion mechanisms or the selection and release of
strains refractory to pathogens, sensitive to selected ecological factors or susceptible to insecticides, are being
tested under field conditions. However, unless some new and revolutionary ideas emerge, the genetic control
measures so far known are capable of achieving only “management” or “manipulation” of insect population
rather than complete suppression or reduction in densities.
CRISPR gene editing tool is a method to alter key genes that regulate the fertility and sex determination of
insects. CRISPR technology has allowed researchers to invent a new effective control technology which can be
safe, self-limiting and scalable genetic population for a specific species. It has the potential to be developed
and utilized for a plethora of insect pests and disease vectors. This technology can be safely used in the field
to suppress and even destroy target species.
(f) Personal Protective Measures.
The role of personal protective measures in arthropod-borne disease control is to prevent the arthropod vector
from biting and feeding on its host, whether susceptible or already infected, thereby blocking the chain of
transmission of disease from one host to another. Biting can be prevented either by protective clothing or
chemically by using appropriate repellents.
(i) Protective Clothing.
Individual personal protection against bites of arthropods can be achieved by use of mosquito nets,
wearing of long trousers, rolled down sleeves of shirts, socks, shoes and anklets, particularly when going
out on patrols and exercises in areas heavily infested with arthropods. These measures will vary according
to the nature of problem faced in a particular locality. Personal protective measures have already been
described as part of control measures against different arthropods elsewhere in this chapter.
(ii) Repellents.
Insect repellents are chemicals which repel insects when applied to body surfaces or clothing. The
suitability of substances for use as repellents is dependent primarily on their inherent repellency and
duration of effectiveness. The important factors are the ease of application on the skin; odour, appearance
or feel on the skin e.g. oily or greasy; the likelihood of being rubbed off or absorbed by the skin; irritant
effect or toxicity if absorbed; and its stability under high humidity, high temperature, rain and perspiration.
The efficacy may also be influenced by the amount of sweating, rubbing and the avidity of the insect
itself. Moreover, as is the case with insecticides, repellents exhibit specificity of action so that some
species of insects are more sensitive to one and some to other repellents.
Common Repellents.
The following compounds are among the most effective when used alone as repellents against one or
more groups of arthropods: benzyl benzoate, DEET (N, N-diethyl-m-tolumide), dibutyl phthalate, DEPA
(di ethyl phenyl acetamide) and Neem oil. Repellents are formulated as liquids, gels, creams and in
pressurized containers. Some of the common compounds are discussed below:

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(aa) N, N-diethyl m-toluamide (DEET).

DEET has been reported to be an outstanding all-purpose repellent. It provides 6-8 h of protection
against mosquitoes, 2-3 hour against Chrysops, 9 hour against Culicoids. It feels less oily on the
skin than the other repellents. DEET can also be used very effectively for impregnation of clothing.
In experiments conducted at AFMC it has been shown to provide repellence up to two launderings
of the clothing. As a skin application DEET may be used for protection against mosquitoes, sand
flies, fleas and other biting Diptera. It is a good repellent against all haematophagous arthropods
and also against leeches.
(ab) Dibutyl Phthalate (DBP).
It is more persistent but somewhat less rapid repellent. When smeared on clothing, its effect
lasts up to 2-4 washes, ironing destroys it. It is specifically useful against ticks and mites as it is
acaricidal as well as a repellent. DBP is a good repellent against leeches and Dimdam flies.
(ac) Benzyl Benzoate.
The oily liquid has a faintly pleasant aromatic odour and sharp bitter taste. It has been applied
in 5 percent emulsion to skin as repellent for many arthropods. Clothing impregnated with benzyl
benzoate show repellence to fleas, chiggers and other arthropods. A mixture of equal parts of
diethyltoluamide and benzyl benzoate with the addition of an emulisifier acts as a good impregnant
for clothing against trombiculid mites.
(ad) Diethyl Phenyl Acetamide (DEPA).
It is available as cream and sprays. It is a broad spectrum repellent and can be used for topical
application against mosquitoes, ticks & mites or any other haematophagous arthropod and leeches.
It can also be applied on clothing / uniform as repellent. It can withstand 2-3 launderings and
ironing. It matches DEET in its spectrum and efficacy.
(iii) Application Procedures.
(aa) Skin Application.
Repellents like DEET and DEPA are applied to the skin as cream formulation. These are generally
effective against such pests as midges, mosquitoes, sandflies and so on. A good repellent applied
in this way gives protection from insect bites for about five to seven hours.
(ab) Impregnation of Clothing.
Application to clothing is carried out when longer protection against insects is required. Application
of DBP, DEET or DEPA to clothing to protect oneself from mites and ticks is much more persistent
than skin treatment and remains effective for a period up to a month.
O Hand Application (Repellent Drill).
Hand Application of repellent is the simplest way to treat the clothing. The fingers of one
hand are dipped into the chemical in an open container or a few drops of the chemical are
poured into one hand, both the hands are rubbed together and then they are wiped lightly on
the inside and also on the outside of all the openings of all garments to produce a thin layer
of the chemical on them. The chemical should be applied more particularly to the opening
such as inside the neckband of shirts and the fly and turn ups of trousers and tops of socks
turned inside out. 60 ml per man per fortnight of DBP is enough to impregnate two shirts,
two pairs of trousers, 2 pairs of socks, anklets and two sets of underclothing. The application
should be started a fortnight before the mite borne disease (like scrub typhus) season in any
area begins and repeated every fortnight thereafter until the season lasts. This should be
done on a parade as a drill supervised by a person who has had training and experience of
the procedure. The repellents DEET, DEPA require lesser quantities for impregnation.
O Spraying / impregnation.
The chemical can be applied to the entire clothing by spraying or the clothing can be
impregnated with a solution or emulsion of the repellent when large quantities of clothing

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are required to be treated. Clothing should be soaked in the solution, then wrung out lightly
and dried. DEPA is available as spray formulation for treatment of clothing.
O Barrier Application.
Considerable protection may also be obtained by treating only the openings of the clothes
inside the neckband and cuffs of shirts, inside the waistband, fly and turn ups of trousers
and on the socks above and inside the shoes and below its tongue. These methods, called
the barrier application, are particularly useful when people go for amateur camping or
trekking or when sufficient supplies of repellents are not available.
(ac) Mosquito Nets.
Mosquito nets are very effective means of protection against the bites of haematophagous
arthropods. Untreated or insecticide treated nets may be used as per the availability. Insecticide
treated bednets may be manually treated with Synthetic pyrethroids like Deltamethrin 2.5% SC or
Cyfluthrin 5% EW. These nets have to be treated every six months.
(ad) Long Lasting Insecticide Nets (LLINs).
The advancement in the insecticide treated net technology has seen the development of pretreated
or Long Lasting Insecticide Nets (LLIN’s). These nets may also be treated manually or may be
pretreated with insecticide Permethrin or Deltamethrin. The shelf life of these nets is 5 years.

Steps For Treatment of Bednets

(a) Measure the total area of the net in m2.
(2 x length x height + 2 breadth x height + length x breadth) in metres.
Average area of a single net is 10 Sq m
(b) Measure the absorption capacity
(i) Measure 1 litre of water and take in a tub.
(ii) Immerse the dry net, when completely wet, take it out by gently wringing the net to prevent dripping of
water.
(iii) Measure the remaining water in the tub. 1 litre – the remaining water gives us the absorption capacity
of the net.
(c) Wash the net to be treated and dry it.
(d) Calculate the dosage of the insecticide required
(i) Deltamethrin 2.5% SC – dosage required 25 mg a.i. per Sq m
1 ml of the 2.5% insecticide contains 25 mg; therefore the dosage will be 1ml per Sq m to give the dosage
of 25 mg a.i. / Sq m. So if the net is of 10 Sq m and the absorption capacity is say 500 ml then we need
to add 10 ml of insecticide in 500 ml of water to give the reqd. dosage.
(ii) Cyfluthrin 05% EW- dosages required 50 mg a.i. / sq m
1 ml of the 05% insecticide contains 50 mg; therefore the dosage will be 1ml per sq m to give the dosage
of 50 mg a.i. / Sq m. So if the net is of 10 Sq m and the absorption capacity is say 500 ml then we need
to add 10 ml of insecticide in 500 ml of water to give the reqd. dosage.
(e) Put the net in the insecticide solution prepared as per the procedure given above and knead it well to ensure
the net is completely soaked in soln.
(f) Take out the net and spread it in shade, once semi dry it can be hung for drying.

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Long Lasting Insecticide Nets (LLIN’s)

O A Long lasting insecticide net is a treated net which can withstand insecticidal efficacy up to at least 20 washes
with more than 80% mortality after 24 hrs (95% KD after 60 min)
O The treatment is done by either incorporating Insecticide
Q In the yarn itself which is made into textile and then used for making nets
P Polyethylene net treated with Permethrin (1000 mg / m2 net)
P Washing cleans the surface and hence it is recommended to be heated up (i.e. sun
dried) after washing for the active ingredient to “migrate” to the surface
P Biological activity lasts for 4 to 5 years
Or
Q By coating around fibres,
P Polyester net treated with 55 mg / m2 Deltamethrin or Alphacypermethrin (200mg / m2)
P Resists multiple washes
P Biological activity lasts for 3 to 4 years)
O Manually treated LLIN
Q Any untreated net can be treated with long lasting formulation of Deltamethrin using K-O Tab.
Q Low cost as compared to pretreated nets.
(g) Newer Vector Control Tools.
Many new tools, have capability to reduce vector populations and / or viral multiplication to minimal
levels and thereby preventing transmission. Although various tools have shown promising evidence of
entomological effect, full scale programmatic implementation is currently not recommended, in the
absence of strong data on its epidemiological impact. The tools under development are as below,
(i) Use of Wolbachia.
It is a bacterium (family Rickettsiaceae), which infests arthropod species, including a high proportion
of insects. Vectors of Dengue & Malaria are not naturally infected by Wolbachia. Laboratory studies
showed that Wolbachia infection (symbiotic) affects the longevity of the infected mosquitoes and
when introduced in Aedes aegypti populations, reduce mosquitos’ ability to transmit arboviruses in
humans. Lab results have indicated that Wolbachia infection reduces viral replication of Dengue,
Chikungunya and Zika viruses within Aedes mosquitoes and eliminates or substantially delays
appearance of virus in mosquito saliva, reducing its competence for transmitting Dengue viruses.
The strategy involves establishing and sustaining Wolbachia in Aedes mosquito populations,
thereby providing ongoing protection from virus transmission. Two methodologies are being used
to study the efficacy of Wolbachia on Aedes mosquitoes – Population alteration (using wMel strain
Wolbachia in Aedes aegypti) and Population reduction (Ae. aegypti & Ae. albopictus infected with
Wolbachia species using sterile male technique).
(ii) Sterile Insect Technique (SIT).
It involves mass production, sex-separation and sterilization of male mosquitoes. Males, sterilized
by low dose radiation exposure, are released in the field to mate with wild female mosquitoes.
It results in production of unviable eggs leading to decline in wild mosquito populations. When
sterile males outnumber fertile males in the natural environment, the target mosquito population
is reduced. SIT technology has been successfully used for agricultural and veterinary pests.
(iii) Release of Insects Carrying a Dominant Lethal (RIDL).
It is a development of the sterile insect technique that involves the release of genetically engineered
(‘GE’) insects homozygous for a dominant lethal genetic construct instead of being irradiated. These

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COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

insects compete for mates with wild type insects and pass the construct onto their offspring,
causing them to die before they fully mature. The timing of death during insect development can
be engineered in order to maximise population suppression. For example, early acting lethality
is preferable for some agricultural pests such as Medfly where the larval stages cause the most
damage. Late acting lethality on the other hand is used for insects, such as mosquitoes, that
have a density dependent mortality phase during their development; if the lethality acts after this
phase, population suppression is maximised.
(iv) Vector Traps.
This technology may reduce mosquito population by attracting and killing egg-laying female
mosquitoes and also has potential for improved vector surveillance. The entomological efficacy of
these traps has been demonstrated in limited field trials, but public health impact needs to be
established before operational consideration.
(v) Attract-And-Kill Baits / Attractive Toxic Sugar Bait (ATSB).
It is a novel application method involving use of insecticide classes that act as stomach poison for
mosquitoes. This technology is based on an “attract and kill” principle, where mosquito attractants
are combined with oral toxins that kill the target insects. ATSB is being used for sandfly control
as well.
(vi) Second-Generation Green Products.
Since last few years, the major focus surrounding green products has been from a public health
perspective. The demand of green products is increasing and shifting to eco-protection. Nowadays,
second-generation green products are emerging. These second-generation green products will
have better ingredients, greater efficacy and less disadvantages. For example, a first-generation
insecticide containing plant essential oils may have an unpleasant smell. In contrast to this,
the second-generation insecticide contains different amounts of the original ingredients or other
materials, which reduces the smell, while it is still being effective.
(h) Integrated Vector Management.
Development of resistance, effects on non-target organisms and damage to the environment can all be
minimized with selective and judicious use of multi-faceted control tactics. This approach, commonly
known as integrated control, requires an understanding of ecological principles as well as a thorough
knowledge of the pest’s life history and population dynamics. Today, integrated pest control forms the
foundation of Integrated Vector Management programs (IVM) that take a comprehensive and multi-
disciplinary approach to solving pest problems. These programs emphasize management rather than
eradication. They take a broad ecological approach to pest problems, focusing on all members of a
pest complex in an effort to identify the optimum combination of control tactics that will reduce vector
populations below economic thresholds and maintain these levels with the least possible impact on the
rest of the environment.
IVM is a dynamic approach which requires a broad knowledge of vector biology, ecology and behaviour
on the one hand and that of system analysis approach on the other so that a variety of control
measures, such as environmental, chemical, biological, genetic and personal protective measures can
be integrated with a view to achieve the ultimate aim of combating human disease. Whereas, chemical
and biological methods may provide temporary control of vectors, environmental control measures may
lead to permanent control. In this approach initial costs may be high and programmes may require years
for implementation, but commanders at all levels should be advised to include environmental changes
and improvements relating to vector control in all long term planning. However, these methods require
elaborate organization, longer time and liberal finances. Species control and vector control are the two
modifications circumscribing the wider concept of vector control.
(j) Future Policy.
The aim of future vector control by use of insecticides should be to reduce the intensity of chemical
selection by reducing the frequency and coverage of insecticide sprays in public health programmes,
minimizing the agricultural use of persistent chemicals as far as possible and by supplementing the

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 ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY

chemical control methods by other methods whenever feasible. There is a need to strengthen existing
surveillance methods and incorporating the benefits of the newer methods like Remote sensing,
Geographical Information System, Global Positioning System, etc whenever and wherever feasible. There
is a continued effort to evolve safer alternatives for vector control coupled with intensive research using
molecular biology tools for production of Genetically Modified Vectors (GMV) to address the problems of
vector control.
(k) Vector Control in Armed Forces.
The vector control policy in Armed Forces follows the National policy on the same. Apart from the National
policy, various additional measures are taken in Armed Forces for control of vector and thereby prevention
of vector borne diseases. These measures include:
(i) IRS in all residential as well as official spaces in the station
(ii) Availability of spot map of the station depicting various places of water accumulation during and
after monsoon period as well as regular update of the same
(iii) Regular Survey of potential mosquito breeding sites in the station
(iv) Weekly spraying of larvicides in the station in preidentified areas of water accumulation
(v) Observation of weekly dry day for prevention of Dengue vector breeding
(vi) Implementation of policy of ‘Sun down sleeves down’
(vii) Use of mosquito topical repellant creams by personnel on guard posts round the clock
(viii) Use of repellent treated uniforms by the troops
(ix) Use of mosquito nets (issued to them) by the personnel in their residential areas
(x) Regular Health Education through sainik sammelans, Army Wifes’ Welfare Association health
activities to personnel and families on ‘Prevention and Control of Vector Borne Diseases’.
Table 34.12 : Insecticides for Indoor Residual Spray
Amount of
Area (in m2)
Insecticide Dosage Per Residual
S. to be Covered
Name of Insecticide Class of Insecticide to Prepare m2 of Active Effect in
No. by 10 Lit of
10 Litres of Ingredient Weeks
Suspension
Suspension
1 DDT 50% WP Organochlorine 1.000 Kg 1 gm 10-12 500
2 Malathion 25% WP Organophosphate 2.000 Kg 2 gm 6-8 500
3 Deltamethrin 2.5% WP Synthetic Pyrethroid 0.400 Kg 20 mg 10-12 500
4 Cyfluthrin 10% WP Synthetic Pyrethroid 0.125 Kg 25 mg 10-12 500
5 Lambdacyhalothrin Synthetic Pyrethroid 0.125 Kg 25 mg 10-12 500
10% WP
6 Alphacypermethrin 5% Synthetic Pyrethroid 0.250 Kg 25 mg 10-12 500
WP
7 Bifenthrin 10% WP Synthetic Pyrethroid 0.125 Kg 25 mg 10-12 500

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 COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

Table 34.13 : Insecticides for Indoor Space Spray

S. Name of Class of Commercial Equipment
Preparation of Formulation Remarks
No. Insecticide Insecticide Formulation Required

1 Pyrethrum Plant 2.0% 1:19 i.e. 1 part of 2% Pressurised Used for

Extract Extract Extract Pyrethrum Extract in 19 parts Spray machine Indoor
of Kerosene (50 ml in 1 litre or fogging Space
K.Oil) machine Spray
2 Cyphenothrin Synthetic 5% EC 0.5 mg a.i per sq.mt. (5 ml in
Pyrethroid 200 ml kerosene oil for 500
sq. mts. (Flow rate @ 20 ml
per minute)

Table 34.14 : Insecticides for Outdoor Fogging

S. Name of Class of Commercial Preparation of Equipment
Remarks
No. Insecticide Insecticide Formulation Formulation Required
1 Malathion Organophosphate Technical 1:19 i.e.1 part of Shoulder mounted Used for
Malathion Malathion Tech in 19 fogging machine Outdoor
parts of Diesel (50 ml or Vehicle Thermal
in 1 litre Diesel) mounted thermal Fogging
fogging machine
2 Cyphenothrin Synthetic 5% EC 3.5 g a.i per hactare
Pyrethroid (70 ml in 500 ml Diesel
for 1 hectare)
(Flow rate @ 30 ml per
minute)

Table 34.15 : Larvicide Formulations and Dosages

Preparation Dosage of suspension per
S. Frequency
Name of Class of Commercial of Ready- One 50 of Remarks
No. Larvicide Insecticide Formulation to-spray sq. Linear Hectare Application
Formulation mtr. meter
1 MLO 100% As it is 20 1 Litre 200 Weekly To be
petroleum c.c. Litres applied
product along the
shore of
water
body
2 Temephos (EC) Organophosphate 50% EC 2.5 cc in 20 1 Litre 200 Weekly Can be
10 litres of c.c. Litres applied
potable water in clean
water
3 Bacillus Bio-larvicide 5% Wettable 5 Kg in 200 20 1 Litre 200 Fortnightly For both
thuringiensis Powder litres of water c.c. litres clean
var israelensis and non-
(250 gms in
5% WP potable
10 litres of
Strain - 164, polluted
water)
Serotype H-14 water

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 ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY

Preparation Dosage of suspension per

S. Frequency
Name of Class of Commercial of Ready- One 50 of Remarks
No. Larvicide Insecticide Formulation to-spray sq. Linear Hectare Application
Formulation mtr. meter
4 Bacillus Bio-larvicide 5% Wettable 7.5 Kg in 20 1 Litre 200 Weekly Clean
thuringiensis Powder 200 litres c.c. litres Water
var israelensis of water
5% WP (375 gms in
Strain - ABIL, 10 litres of
Serotype H-14 water )
Accession No.
10 Kg in 200 20 1 Litre 200 Polluted
01318
litres of water c.c. litres Water
(500 gms in
10 litres of
water )
5 Bacillus Bio-larvicide Aqueous 1 litre in 200 20 1 Litre 200 Weekly Clean
thuringiensis Suspension litres of water c.c. litres Water
var israelensis
(50 cc in 10
12 Aqueous
litre)
Suspension
(12AS) 2 litre in 20 1 Litre 200 Polluted
200 Litres of c.c. litres Water
water
(100 cc in
10 litre)
6 Diflubenzuron Insect growth 25% 100 gms (25 - - 100 Weekly Clean
25% WP regulator Wettable gm a.i) in litre Water
Powder 100 litres of
water
(10 g in 10
litre)
200 gms (50 100 Polluted
gm a.i) in litre Water
100 litres of
water (20 g
in 10 litre)
7 Pyriproxyfen Insect growth 0.5% Ready -to- - - 2 kg 3 Weekly Clean
GR regulator Granular use Water
4 kg Polluted
Water

Suggested Reading.
1. Bhalwar R, Vaidya R, Tilak R, Gupta R, Kunte R, editors. Textbook of Public Health and Community Medicine. First
Edition. Department of Community Medicine, AFMC, Pune in collaboration with WHO, India Office, New Delhi; 2009.
2. Subbarao SK, Nanda N, Rahi M, Raghavendra K. Biology and bionomics of malaria vectors in India: existing
information and what more needs to be known for strategizing elimination of malaria. Malaria Journal. 2019 Dec;18(1).
3. Arun Chopdar. Malaria in Western Orissa. Indian Journal of Pediatrics (Print). 1979 Dec 1;46(12):441–4.
4. Tyagi BK. Desert Malaria. Springer Nature; 2023.

1073
 COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

5. Beata Gabrys, John L. Capinera, Jesusa C. Legaspi, Benjamin C. Legaspi et al. “Chapter 446 Caddisflies
(Trichoptera)”, Springer Science and Business Media LLC, 2008.
6. Kumar A, Rai KS. Molecular organization and evolution of mosquito genomes. Comparative Biochemistry and
Physiology Part B: Comparative Biochemistry. 1993 Nov;106(3):495–504.
7. India. Home :: National Center for Vector Borne Diseases Control (NCVBDC) [Internet]. Mohfw.gov.in. 2022.
Available from: https://ncvbdc.mohfw.gov.in/
8. Powell RD. The chemotherapy of malaria. Clinical Pharmacology & Therapeutics. 1966 Jan;7(1):48–76.
9. T C Goel, Surgeon, Apul Goel. Lymphatic filariasis. Singapore: Springer; 2016.
10. Kumar P, Singh V. Oral myiasis: case report and review of literature. Oral and Maxillofacial Surgery. 2012 Nov
20;18(1):25–9.
11. Singhai M, Dhar Shah Y, Gupta N, Bala M, Kulsange S, Kataria J, et al. Chronicle down memory lane: India’s
sixty years of plague experience. Indian Journal of Medical Microbiology. 2021 Jul;39(3):279–85.
12. Leishmaniasis [Internet]. www.who.int. Available from: https://www.who.int/news-room/fact-sheets/detail/leishm
aniasis#:~:text=Leishmaniasis%20is%20caused%20by%20a
13. Service MW. A Guide to Medical Entomology. 1980.
14. Singh S, Madhukar M, Manas Ranjan Dikhit, Vidya Nand Ravidas, Pandey K, Sen A. Transcriptome analysis
of dermal fibroblasts derived from VL and PKDL patients reveal disease specific gene expression and pathological
regulation. 2023 Feb 23;
15. Masson E. Plague [Internet]. EM-Consulte. [cited 2024 Apr 9]. Available from: https://www.em-consulte.com/
article/495429/figures/plague
16. 64th Annual Conference of Indian Society of Hematology & Blood Transfusion (ISHBT) November 2023.
Indian journal of hematology and blood transfusion/Indian Journal of Hematology and Blood Transfusion. 2023 Oct
19;39(S1):1–199.
17. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention [Internet]. Centers for
Disease Control and Prevention. U.S. Department of Health & Human Services; 2022. Available from: https://www.cdc.
gov/
18. Kaur R, Kumar R, Chaudhary V, Devi V, Dhir D, Kumari S, et al. Prevalence of HIV infection among visceral
leishmaniasis patients in India: A systematic review and meta-analysis. Clinical epidemiology and global health (Online).
2024 Jan 1;101504–4.
19. Cairns JE. Cutaneous leishmaniasis (Oriental sore). A case with corneal involvement. British Journal of
Ophthalmology [Internet]. 1968 Jun 1 [cited 2021 Jan 17];52(6):481–3. Available from: https://bjo.bmj.com/content/
bjophthalmol/52/6/481.full.pdf
20. John. The Hazard from Dangerous Exotic Diseases. Palgrave Macmillan UK eBooks. Palgrave Macmillan; 1980.
21. Alvar J, Beca-Martínez MT, Argaw D, Jain S, Aagaard-Hansen J. Social determinants of visceral leishmaniasis
elimination in Eastern Africa. BMJ Global Health [Internet]. 2023 Jun 1 [cited 2023 Oct 5];8(6):e012638. Available
from: https://gh.bmj.com/content/8/6/e012638
22. Kala-azar in India – progress and challenges towards its elimination as a public health problem [Internet]. www.
who.int. [cited 2022 Oct 26]. Available from: https://www.who.int/publications/i/item/who-wer9626-267-279
23. Devasagayam E, Dayanand D, Kundu D, Kamath MS, Kirubakaran R, Varghese GM. The burden of scrub typhus
in India: A systematic review. Campbell SJ, editor. PLOS Neglected Tropical Diseases. 2021 Jul 27;15(7):e0009619.
24. Service MW. Medical Entomology for Students. 5th ed. Cambridge: Cambridge University Press; 2012.
25. Sharma SN, Singh R, Balakrishnan N, Kumawat R, Singh SK. Vectors of Crimean-Congo Hemorrhagic Fever (CCHF):
Prevention and its Control. J Commun Dis 2020; 52(3): 22-26.
26. Casals, Jordi. “Arboviruses: Incorporation in a General System of Virus Classification.” Comparative
Virology,1971,pp.307–333, https://doi.org/10.1016/B978-0-12-470260-8.50014-2.

1074
 ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY

27. Rajaiah, Paramasivan, and Ashwani Kumar. “Japanese Encephalitis Virus in India: An Update on Virus Genotypes.”
The Indian Journal of Medical Research, vol. 156, no. 4-5, 2022, pp. 588–597, https://doi.org/10.4103/ijmr.
IJMR_2606_19.
28. World Health Organization. Dengue and Severe Dengue [Fact Sheet]. 2023. Retrieved from https://www.who.int/
news-room/fact-sheets/detail/dengue-and-severe-dengue
29. World Health Organization. International Travel and Health. 18 Nov. 2022.
30. Thomas, Emy Aby, et al. “Cutaneous Manifestations of Dengue Viral Infection in Punjab (North India).” International
Journal of Dermatology, vol. 46, no. 7, July 2007, pp. 715–719, https://doi.org/10.1111/j.1365-4632.2007.03298.x.
31. Matthews GA (2000). Pesticide application methods. 3rd ed. Blackwell Science.
32. Reiter P, Nathan MB (2001). Guidelines for assessing the efficacy of insecticidal space spray for control of the
Dengue vector Aedes aegypti. Geneva, World Health Organization (document WHO/CDS/CPE/PVC/2001.1).
33. Najera J, Zaim M (2002). Malaria vector control: decision making criteria and procedures for judicious use of
insecticides. Geneva, World Health Organization (document WHO/CDS/WHOPES/2002.5).WHO (1990). Equipment for
vector control, 3rd ed. Geneva, World Health Organization
34. Journal of Vector Borne Diseases [Internet]. journals.lww.com. [cited 2024 Apr 9]. Available from: https://journals.
lww.com/jvbd/pages/default.aspx
35. Abong’o B, Gimnig JE, Torr SJ, Longman B, Omoke D, Muchoki M, et al. Impact of indoor residual spraying with
pirimiphos-methyl (Actellic 300CS) on entomological indicators of transmission and malaria case burden in Migori
County, western Kenya. Scientific Reports [Internet]. 2020 Mar 11 [cited 2022 Jan 9];10(1):4518. Available from:
https://www.nature.com/articles/s41598-020-61350-2#Sec21
36. Becker N, Petrić D, Zgomba M, Boase C, Madon MB, Dahl C, et al. Mosquitoes. Fascinating Life Sciences. Cham:
Springer International Publishing; 2020.
37. Georghiou GP. The Evolution of Resistance to Pesticides. Annual Review of Ecology and Systematics. 1972
Nov;3(1):133–68.
38. National Vector Borne Disease Control Programme. Ministry of Health & Family Welfare, Govt of India. Guidelines
on Insecticides – Formulations and dosage. 2020. Retrieved from https://ncvbdc.mohfw.gov.in/Doc/tech-specification/
Insecticides Formulations_Dosage(IRS%20and%20Larvicide).pdf
39. National Vector Borne Disease Control Programme. Ministry of Health & Family Welfare, Govt of India. Guidelines
on Mosquito and Other Vector Control Response. 2020. Retrieved from https://ncvbdc.mohfw.gov.in/Doc/Guidelines-
Mosquito-and-other-vector-control-response-2020.pdf
n

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Appendix ‘A’
Anopheles mosquitoes identification : Group - I

Costa uniformly dark i.e., not interrupted by any pale spot.

Also no white spot on the wing field

Anterior forked cell much larger Anterior forked cell of nearly

than the posterior A. aitkeni the same size as posterior

Distinct white banding at the distal

end of hind femur, frontal white scale Banding absent. Scale tuft
tuft present A. barianesis absent A. culiciformis

Group III to VI have at least 4 dark spots

Involving the costa, sub Costa and vein 1.

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 Anopheles mosquitoes identification: Group - II
Less than four dark
spots, involving the costa,
subcostal and vein 1

Palpi with
distinct pale Palpi
banding Unbanded

A prominent tuft of scales Hind femur with Hind femur

black above & white below, No such tuft of a conspicuous without
about femoro-tibial joint of scales present white band A. lindesay any band
hind legs A. annandalei

i. Inner quarter of costa with i. Inner quarter of costo dark Palpi shaggi fringe Palpi thinner. Fringe
marked pale interruptions, ii. Tip of wing golden. spot at V5.2 present. spot at V5.2 absent.
ii. Wing fringe between V5.2 A dark mosquito, Presence of both Only dark scales on
and 6 white. A brightly A. hyracanus varnigerrimus dark and white scales the wing field.
colored mosquito, A. gigas on wing veins. A rare species
A common species : in India A. umbrósus

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A barbirostris
ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY
 Anopheles mosquitoes’ identification: Group III
Darkfooted series (of hind legs only).
Femorae & tibiae not speckled

Tips of palpi pale

Tips of palpi dark

V-3 mostly dark V-3 mostly pale

Wings veins except All wing veins
on costa and V1 contain both dark
contain only dark & white scales
Only 2 fringe
scales; A. dthali spots V-4 and V- 5.1 The two apical pale The two pale
present (palpi of bands are of equal or apical band are
2 indefinite dark nearly equal length and definitely unequal
normal length).
spot on V-6 the the intervening dark
A. culicifacies
distal one being area is small
very long, A. turkhudi
The intervening The intervening dark
Fringe spots at all dark area on the
veins except V-6. area is either of
palp is much the same size as
3 definite dark (palpi very long) larger than the apical pale band
spots on V-6 A. A. sergenti No fringe spots at V-6
either of them or very much smaller.
multicolor

1078
Broad white bands at
the tarsal joints of
Basal area of the
inner third of costa Inner third of the front legs.
costa dark
uninterruptedly dark costa interrupted
without any pale
COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

interruption.
A. varuna The dark area is of
Tarsal joints of leg the same size as
2 dark spots on 1 banded. Fringe the apical area
V 6. Tibiotarsal spot at V-6. A. subpictus
Basal area of joints dark.
the costa with A. jeyporiensis
A. fluvitalis
one pale interruption. The dark area is
A. minimus very much smaller.
A. vagus
3 dark spots on Tarsal banding of
V- 6 tibiotarsal joints leg 1 absent. No
of front legs narrowly fringe spot at V-6.
banded. A. superpictus
A. moghulensis
 ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY

Anopheles mosquitoes’ identification: Group IV

Dark footed series (Hind legs only).

Femorae & tibiae speckled

3 pale bands on the palp 4 pale bands on the palp

The apical and the sub apical bands Broad tibio tarsal bands on
are equally broad. A. stephensi the hind leg. A. leucosphyrus

The apical and the sub apical are The three distal bands are much
unequal the former being broader broader then the proximal band
than the latter. A. sundaicus which is narrow. A. tessellatus

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 White footed series •ANOPHELES MOSQUITOES’ IDENTIFICATION: GROUP V
(Hind legs only)

Only tarsus 5 and 1/3 of At least tarsal segments 3,

tarsus 4 of hind legs 4 and 5 of hind legs
completely white completely white

3 pale bands on
the palp. A. majidi
Vein 4 mainly dark with a Veins 5 extensively pale Conspicuous white scales
dark spot at its bifurcation. and no dark spot at its on the dorsum of
A. annularis bifurcation the abdomen & thorax.
4 pale bands on A. pulcherrimus
the palp. A. karwari

1080
Distal end of tarsus 1 of
hind legs conspicuously
marked white.
COMMUNICABLE DISEASES IN ARMED FORCES: EPIDEMIOLOGY AND PREVENTION

A. philippinensis

Distal end of the tarsus 1 of

hind legs dark. A. pallidus
 White footed series ANOPHELES MOSQUITOES’
(Hind legs only). IDENTIFICATION: GROUP VI
Femorae & tibiae
speckled

Half of tarsus 5 of Whole of Whole of At least tarsi 3, 4 and 5 of

hind legs white. tarsus 5 and tarsus 5 and 4 hind legs completely white.
Prominent scale 1/3 of 4 of of hind legs
tufts on the ventral hind legs white.
surface of each white with A. theobaldi
abdominal segment. dark band on Two equally broad
The two pale
A. kochi tarsus 4. pale apical bands,
A. maculatus apical bands
palpi speckled.
are unequal
A. splendidus

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At least the last Dark scales Conspicuous white scales on
two segments on the the dorsum of the thorax
of the dorsum abdomen and abdomen (Femorae and
of the abdomen A. ramsayi tibiae may be speckled or not
covered with speckled). A. pulcherrimus
golden scales
A. jamesi
ARTHROPOD BORNE DISEASES MEDICAL ENTOMOLOGY
 NON-COMMUNICABLE DISEASES

Chapter
XXXV
NON-COMMUNICABLE DISEASES (NCDs)

35.1 Introduction.
It has been brought out earlier that the general fall in the morbidity in the Armed Forces as well as in the country
has been because of a decline in communicable diseases. However, non-communicable diseases and injuries have
shown an increased incidence. Similar to the communicable diseases, the non-communicable diseases also follow
a rationally understandable epidemiological pattern and trend. Therefore, the epidemiological concept and the
three levels of prevention are applicable to non-communicable diseases including accidental injuries, as much as
to the communicable disease group. The application of this multifaceted preventive concept is the concern of the
members of all specialties and disciplines of the medical profession and also involves statisticians, sociologists,
social workers, anthropologists, meteorologists and others belonging to the various scientific disciplines.
Non-Communicable Diseases (NCDs) are gradually emerging as an important group in the list of diseases in
the Armed Forces as in the general population. NCDs were predominantly associated with higher socioeconomic
status (SES) communities, recent epidemiological trends reveal a significant shift. While the incidence of NCDs
continues to rise in richer, well-to-do communities, there has been a noteworthy increase in their occurrence among
middle and lower SES populations. This trend extends beyond urban centers to include tier-2 cities, towns and
even rural villages. This evolving facet emphasizes the need for comprehensive interventions addressing NCDs
across all socioeconomic strata. The group broadly includes some types of psychiatric disorders including alcohol
dependence, drug abuse & other psychosomatic syndromes, hypertension, Diabetes Mellitus, IHDs, metabolic
disorders including obesity, injuries including traffic injuries, accidents, non-endemic and non-infective peptic and
intestinal ulcerations. The impact of the COVID-19 pandemic has further complicated this scenario by altering
the metabolic profiles of both infected individuals and those vaccinated but unaffected. This highlights the urgent
need for comprehensive interventions targeting NCDs across diverse socioeconomic strata. NCDs kill 41 million
people each year, equivalent to 74% of all deaths globally. Each year, more than 15 million people die from NCD
between the ages of 30 and 69 years; 85% of these “premature” deaths occur in low- and middle-income countries.
Cardiovascular diseases account for most NCD deaths or 17.9 million people annually, followed by cancers (9.3
million), respiratory diseases (4.1 million) and diabetes (1.5 million). These four groups of diseases account for
over 80% of all premature NCD deaths.
Every year 7,03,000 people take their own life and many more people attempt suicide. Suicide occurs throughout
the lifespan and was the fourth leading cause of death among 15–29-year-olds globally in 2019. Suicide does not
just occur in high-income countries but is a global phenomenon in all regions of the world. Over 77% of global
suicides occurred in low- and middle-income countries.

35.2 Stress.
(a) Nature.
The words ‘stress’ and ‘strain’ are usually used as synonyms or conjointly used for greater emphasis, which is
not scientifically correct. The biological concept of ‘stress’ is a stimulus-response-complex produced in an invaded
organism, prior to the development of the organised resistance. The stress producing alien factors may be termed
as ‘strain’, specially the physical or psychological. The final resistance produced may be physical, psychological
or biological or a combination of all, depending upon the nature of the invasive factor. In this sense ‘stress’ is
an intrinsic line in the chain of reactions, which constitute the process of development of final resistance to
extrinsic strains. Resistance produced may be general or specific. In the biological consideration of ‘stress’, these
reactions produce the ‘general adaptation syndrome’. These ‘syndromes’ are in reality the normal mechanisms
of the development of resistance and not the symptom complex. The use of the word ‘syndrome’ in this context
is therefore an antithesis because the symptoms do not manifest themselves if the process of production of
resistance proceeds smoothly. John Boyd, a United States Air Force fighter pilot and a Pentagon consultant on

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military strategies, has pointed out that ‘stress precedes and promotes all the resistance phenomena, it is in
itself fundamentally and initially a beneficial stimulus like any other stimuli, when produced in tolerable quantum
and spread over a tolerable period’.
The general adaptation mechanism is produced when the general defensive processes of the body are stimulated.
Production of specific antibodies by an invasion of a specific biological antigen is an example of ‘specific adaptation’.
Final resistance produced by any biological, physical and psychological stress-producing factor determines the
somatic, psychic and social success, survival or defeat / death of an organism under the strain. The biological
stress is caused by a pathogenic organism; physical stress is caused by physical factors like heat, cold, burn, injury
or privations; the psychological stress is produced by an adverse situation, proximity of a particularly aggressive
or overwhelming personality or an intellectual, emotional or social challenge. Presently, it is in the last sense that
‘stress’ is almost specifically referred to as disease producing factor. The group of diseases at present considered
to be produced and / or influenced by such ‘stress’ and strain of life are nicknamed the ‘stress diseases’.
(b) Biological Genesis.
The part played by adrenals in the body’s adaptation to ‘stress’ was first recognized in Cannons ‘emergency’
theory. This theory hypothesized that epinephrine was produced as a protective phenomenon in time of fury,
fight and flight, trauma, sudden exposure to cold or infection and other biological emergencies.
As further hypothesized by Style in the ‘general adaptation’ mechanism, the endocrine system particularly the
pituitary-adrenal axis plays an important part, with the hypothalamus as an essential link. It helps to raise
resistance against stress irrespective of the nature of the stimulus i.e. infection, trauma, cold, burns, heat,
muscular fatigue, nervous (emotional and intellectual) strain and even cosmic radiation. Stress initially produces
an ‘alarm’ or ‘call to alarms’ reaction after sudden exposure to ‘stress’ stimulus. This acts on the adrenal medulla
through the parasympathetic channel and produce epinephrine. The hypothalamic centres produce stimuli while
the organism continues to be under stress and through the pituitary excitation, stimulate the adrenal cortex; the
latter relationship is reciprocal. Additional sustenance of stress results in further ACTH stimulation of the adrenal
cortex. This progresses to the general (non-specific) resistance against prolonged stimuli and produces the stage
of resistance; but if the stress stimuli become more aggressive or are sustained over a very long period, the
general adaptation mechanism may fail and a ‘stage of exhaustion’ may follow with the defeat of the organism.
(c) Role Played.
Ailments have multiple etiological factors and stress acts as a precipitating element or only one factor in the chain
of these multifarious factors under unfavourable conditions. The basic vulnerable personality predisposes one to
the effect of stress. The basic vulnerable part played by the stress varies in different individuals according to their
basic personalities and environmental influences, in different communities according to varied background of culture
patterns and life habits and in different parts of the world according to the degree and stage of modernization.
Psychophysical biological response brought about by exposure to adverse conditions forms the initial link in the
chain of reaction culminating in the production of biological resistance against adverse conditions and is, therefore,
a physiological need. Pre-existent resistance against stress reduces the requirement of immediate psychophysical
response or ‘alarm reaction’ i.e. the ‘stress’ is reduced by pre-existing resistance. The defect, imperfect production
of resistance or premature arrest of the process of its production gives rise to disease.

35.3 Ischaemic Heart Disease (IHD).

(a) Definition.
Ischemic or coronary heart disease occurs due to a deprivation of blood supply to the cardiac muscle by increased
cardiac demand or decreased coronary supply. Usually, both these elements are complementary in precipitating
the actual attack. Complete blockage of the coronary artery results in myocardial infarction if the individual
survives the attack of occlusion. The probability of occurrence and the extent of the myocardial infarction is mostly
determined by the extent and speed of ischemia and partly by the extent and rapidity of the establishment of
the collateral circulation.
(b) Extent of Problem.
Ischemic (Coronary) heart disease is the most common type of heart disease and the single most important
cause of premature death across globe. An estimated 17.9 million people died from CVDs in 2019, representing
32% of all global deaths. Of these deaths, 85% were due to heart attack and stroke. Over three quarter of CVD

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deaths take place in low and middle-income countries. Out of the 17 million premature deaths (under the age
of 70) due to noncommunicable diseases in 2019, 38% were caused by CVDs. WHO has drawn attention to the
fact that the CHD is our “modern epidemic” and may manifest itself in any one of the many presentations.
(i) Angina pectoris of effort
(ii) Myocardial Infarction
(iii) Irregularities of the heart
(iv) Cardiac failure
(v) Sudden death
(c) Trend of IHD in Armed Forces.
The decadal trend of IHD in the three services of the Armed Forces is shown in Table 35.1. Morbidity due to
IHD in the Armed Forces was lower than the decadal average. A decline in rates was observed in Army and Navy
while Airforce had an increasing trend.
Table 35.1 : Decadal Trend of Hospital Admissions for IHD (Rate Per 1000)
Service
Year
Army Navy Air Force Armed Forces
2010 0.79 0.70 0.49 0.74
2011 0.68 1.2 0.36 0.67
2012 0.56 0.63 0.36 0.54
2013 0.55 1.22 0.44 0.58
2014 0.55 0.74 0.69 0.59
2015 0.95 1 0.35 0.89
2016 0.64 0.51 0.53 0.62
2017 0.59 0.28 0.6 0.58
2018 0.62 0.25 0.94 0.63
2019 0.57 0.5 0.97 0.6
Avg of 10 years 0.65 0.71 0.57 0.64
2020 0.46 0.1 0.81 0.48

(d) Pathophysiology.
Disease of the coronary arteries is almost always due to atheroma and its complications, particularly thrombosis.
ATHEROMA or atherosclerosis is a patchy focal disease of the arterial wall. Fatty streaks develop as circulating
monocytes migrate into the intima, take up oxidized Low-Density Lipoprotein (LDL) from the plasma and become
lipid-laden foam cells. As these foam cells die and release their contents, extracellular lipid pools appear. Local
and systemic factors will determine whether a fatty streak resolves or progresses into an atheromatous lesion.
In early atheroma, smooth muscle cells migrate into and proliferate within the plaque. Such plaques may rupture
or fissure, allowing blood to enter and disrupt the arterial wall; this may compromise the lumen of the vessel
and often precipitate thrombosis and local vasospasm. Plaque rupture may lead to rapid growth of the lesion
or occlusion of the vessel and is thought to be the cause of most acute coronary syndromes.
(e) Clinical Syndromes.
Syndromes Identified under the Groups of Ischemic or Coronary Heart Diseases
(i) Coronary Thrombosis.
It is a clinico-pathological diagnosis of the syndrome caused by occlusion of the coronary artery by

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thrombosis with or without atheroma. The clinical syndromes due to any other process of blockage are
similar and the basic cause is diagnosed either from antecedent history or postmortem appearance. In
brief, a person of advancing years while at rest is suddenly seized with substernal pain, extending in some
cases to epigastrium, sustained over a prolonged period, not relieved by rest or amyl nitrite, accompanied
with restlessness, signs of profound shock and ashen grey pallor, cold clammy perspiration, vomiting,
breathlessness and loss of consciousness is generally diagnosed or strongly suspected of having a ‘coronary
thrombosis’ or occlusion.
(ii) Myocardial Infarction.
It is a pathological diagnosis following the clinical syndrome of coronary thrombosis and showing
manifestations of the myocardial damage like fever, leukocytosis, altered cardiac rhythm and sounds,
electrocardiographic changes and further signs of myocardial failure. Occasionally silent infarcts may occur.
A silent heart attack as a myocardial infarction (heart attack) that occurs without the usual symptoms such
as chest pain or discomfort. It may be detected only through diagnostic tests like electrocardiography (ECG)
or blood tests for cardiac enzymes. Despite the absence of symptoms, silent heart attacks can still cause
damage to the heart muscle and increase the risk of future cardiovascular events.
(iii) Angina Pectoris.
It is a clinical syndrome without manifestations or pathological processes of either coronary occlusion or
myocardial damage. Briefly, it is characterized by sudden intense retrosternal pain coming on during an
activity, migrating up the neck and down to the left arm and the fingers, steadfastness of victims’ decubitus
doing the attack instead of restlessness, parchment pallor of the face and not the ashen grey colour,
holding of breath instead of breathlessness and absence of signs of shock. The retrosternal pain passes
away soon with rest and sooner by use of amyl nitrite. Hypertension is common in these cases. Many such
episodes may be followed by coronary occlusion and / or sudden death.
(iv) Myocardial Insufficiency.
It is a diagnosis of syndrome showing symptoms of coronary occlusion and angina pectoris, without complete
conformity with the pathological process of the former or the clinical picture of the latter and yet showing
some of the features of both. This is due to a relative deficiency in blood supply because of increased
cardiac demand or diminished supply due to partial occlusion.
(f) Epidemiological Features.
Death rates due to ischemic disease of the heart have increased over the last 40 to 50 years almost everywhere
in the world, especially in the highly modernized and industrially and commercially developed Western countries.
The incidence is closely related with the national income and industrial production and activity, international
commercial transactions and tempo of life. The increased incidence is revealed by the mortality figures
confirmed by autopsy studies, medical practitioners and hospital statistics of national insurance and social
security organizations, commercial insurance organizations and by various surveys in the general population. The
increased incidence may be partly explained by improved diagnostic knowledge and acumen, better diagnostic
and general medical facilities, improved knowledge of the disease, increased sickness consciousness among
the people and an increased proportion of the vulnerable age group in the population.
Epidemiological Factors Affecting Incidence of IHD
(i) Age.
The disease is commonest in people 40-60 years of age, although more and more younger people are
being affected these days.
(ii) Sex.
The incidence is more in men than in women; under 50 years of age the ratio is 8 men to 1 female and
above 70 years it is one man to one woman, showing that the sex hormones may have to play some part
in its genesis.
(iii) Socio-Economic Status.
It is more common amongst members of the high socioeconomic group of the population. Primitive people
suffer less than the agricultural communities who suffer less than the handicraft workers do and they in

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turn suffer less than the modernized, industrialized or commercially advanced communities.
(iv) Profession.
It is more common amongst highly efficient, conscientious professional men in medical, legal, priestly
professions and senior executives of large corporate industrial and business establishments. More people
getting attacks are at the height of their professional and / or social careers and status and are in the
process or more often in the intense expectation of attaining further quick and surpassing achievements
in life. It occurs less commonly among farmers, miners, unskilled manual workers and so on.
(v) Mode of Life.
It is more common among people with sedentary professions and habits. More cases occur among urban
than rural population. Long sustained intellectual or emotional stress has been shown to be correlated
with the incidence. Sudden severe emotional strain precedes and precipitates more attacks among such
individuals. Smokers suffer more than the non-smokers.
(vi) Obesity.
It predisposes a person more than the thin built, although the thin built ones are not immune to an attack.
It is 2.5 times more amongst those who weigh 20 percent or more over their ideal weight for age.
(vii) Association with other Disease.
It is associated with Hypertension, Pneumococcal Pneumonia, Rheumatic Carditis, Viral Myocarditis, Diabetes
Mellitus or Dyslipidemia.
(viii) Heredity.
The incidence is more among siblings of those who have had attacks.
(g) Risk Factors for Coronary Artery Disease (CAD).
Important risk factors for coronary heart disease may be classified as non-modifiable or modifiable.
(a) Non-modifiable.
(aa) Age
(ab) Sex
(ac) Family History
(ad) Race
(b) Modifiable.
(aa) Hypertension
(ab) Lipid disorders
(ac) Diabetes
(ad) Tobacco use
(ae) Sedentary lifestyle
(af) Obesity
(ag) Dietary deficiencies of antioxidant vitamins and polyunsaturated fatty acids
(ah) Unregulated / excess intake of Coffee / Tea
The Non-Modifiable Factors, as the name suggests, cannot be “changed”; only thing is that if a person has
any of them, he / she needs to be even more careful as compared to modifiable factors.
(i) Age.
> 45 years for males and > 55 years for females increases the risk.

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(ii) Sex.
Male sex is at a higher risk. However, after menopause, the risk for females increases and equalizes
that of males by the age of 50 to 55 years.
(iii) Family History.
History of definite MI or sudden death in father or 1st degree male relative before 45 years age or
in mother or 1st degree female relative before 55 years age indicates high risk.
(iv) Race.
Some races may be more predisposed. For example, South Asian populations are said to be at higher
risk, possibly because of “thrifty gene”.
The modifiable risk factors are summarized in Table 35.2. Major risk factors are as follows.
(I) Tobacco Use.
In a large number of prospective studies, the risk of coronary artery disease in relation to tobacco use has
been estimated. Statistical evidence supports a mean increase of about 70 percent death rate and a 3-to-5-fold
increase in the risk of IHD in smokers as compared to non-smokers. In general, the increase in death rate is
proportional to the amount smoked. Those who stop tobacco consumption show a prompt decline in risk and
may reach the risk level of non-users as early as one year after abstinence.
(ii) Hypertension.
High Systolic blood pressure (SBP) is an important risk factor for IHD. Risk increases progressively with
increasing SBP. As per systematic review by Razo et al., Relative Risk of IHD with BP exceeding 160 mm
Hg is more than five times than that of SBP 100 mm Hg. Hypertensive men and women are both affected.
Systolic hypertension is no more considered a benign event and is a risk factor for IHD.
(iii) Elevated Serum Lipids.
Individuals with familial hyperlipidemia have a high incidence of premature coronary disease and many
epidemiological studies have demonstrated a positive correlation between population plasma cholesterol
concentration and morbidity and death from coronary disease. The excess risk is closely related to the
plasma concentration of LDL cholesterol and is inversely related to the plasma High-density lipoprotein
(HDL) cholesterol concentration. There is also a correlation between plasma triglyceride concentration and
the incidence of coronary artery disease.
(iv) Hyperglycemia / Abnormal Glucose Tolerance.
Patients with diabetes mellitus have been found in retrospective studies to have a greater prevalence of
coronary atherosclerosis and IHD at an earlier age than in non-diabetic patients. It is difficult to isolate
diabetes mellitus as a single factor, since it is well recognized that obesity, hypertension and hyperlipidemia
are frequent in patients with impaired glucose tolerance. There is some evidence that high levels of circulating
insulin may have a role in the development of atherosclerosis. Exposure of arterial tissue to insulin results
in proliferation of smooth muscle cells, inhibition of glycolysis and synthesis of cholesterol, phospholipids
& triglycerides.
(v) Sedentary Lifestyle.
Modern lifestyle and affluence have reduced the average level of exercise in daily activities. This may have
contributed to causing obesity. Physical activity can be done in two forms. The first is a structured exercise
regimen (like in gymnasium) and the other is done as part of daily routine (like climbing stairs). So, thirty
minutes exercise in a relaxed environment in the form of walking at a fast pace, cycling, jogging, playing
tennis, swimming or any physical training can be enjoyable and can provide a good level of physical work.
(vi) Diet.
A habitual dietary pattern with a high intake of total calories, total fats, saturated fats, cholesterol, refined
carbohydrates and salt are coronary risk factors. Saturated fats as a whole have been shown to raise LDL
cholesterol levels. However not all saturated fatty acids are equally hypercholesterolaemic. Excessive intake
of fats especially saturated fats contributes significantly to the development of four important coronary risk

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Table 35.2 : Modifiable Coronary Risk Factors

Well Established Emerging / Being Researched
Lipid Non Lipid Lipid Non Lipid
Raised Total Cholesterol Tobacco Use (Even small amount Raised TC: HDL-C ratio Inflammatory markers
(Desirable: <200 mg / dL, can increase risk) (>4.5)
(a) Raised Total WBC
Borderline High: 200-239
Count
mg / dL, High: > / = 240
mg / dL) (b) Raised C-Reactive
Protein
Raised LDL – C (Optimal: Raised Blood Pressure “Lipid Triad” Prothrombotic Factors
<100 mg / dL, Near (Concomitant presence
(a) Platelet
Optimal: 100-129 mg / dL, of raised Triglycerides,
Hyperaggregability
Borderline High: 130-159 small dense LDL
mg / dL, High: > / =160 particles and low HDL) (b) Raised Fibrinogen
mg / dL)   (c) Raised
Plasminogen Activator
Inhibitor (PAI-1)
(d) Tissue
Plasminogen Activator
(tPa)
Raised Triglycerides Diabetes mellitus-Type 2 or Lipoprotein A Others
(Normal: <150 mg / dL, Impaired Glucose Tolerance
(a) Raised serum
Borderline High: 150-199
homocysteine
mg / dL, High: > / =200
mg / dL) (b) Microalbuminaria
(c) Raised resting
pulse rate
Low HDL-C (<40 mg / dL Obesity (Central or Generalized) Raised Lipoprotein B
in men or <50 mg / dL in
women)
Metabolic Syndrome Physical Inactivity Low Apoliporotein A-1
(Syndrome X) – a
clustering of low HDL,
raised Triglycerides,
Hypertension, Impaired
Glucose Tolerance and
Obesity)
Atherogenic diet (High in Small, dense LDL
total calories, Total fat, particles
saturated fats, cholesterol, salt
and refined sugar; low in whole
grains, cereals, legumes,
fruits, vegetables,
antioxidant vitamins, folic
acid, fibre, and Omega-3 fatty
acids)
Mental Stress (Depression, low Raised Non-HDL
job control, suppressed hostility) Cholesterol (This is
and personality (Type A) VLDL+LDL and is
routinely calculated as
TC-HDL)

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factors viz. hypercholesterolemia, hypertension, diabetes mellitus and obesity and the disturbance of lipid
metabolism cause atherosclerosis and thrombosis. A high intake of fat (more than 30% of total calories)
generally increases intake of saturated fat and is associated with consumption of excess calories and weight
gain. On the other hand, low intake of fats and oils (less than 20% of total calories) increases the risk of
inadequate intakes of vitamin E and essential fatty acids and may contribute to unfavourable changes in
HDL and triglycerides. Current guidelines recommend a diet that provides less than 30% of calories from
dietary fat, less than 10% of calories from saturated fats, up to 10% from polyunsaturated fats and about
15% from monounsaturated fats. Recommended intake of salt is 5 gm / day and sugar is 30 gm / day (for
a moderately active individual).
(vii) Coffee or Tea Intake.
Excessive intake of caffeine (in coffee) or theophylline (in tea) may play a part in association with other
risk factors in increasing the risk of coronary artery disease.
(viii) Stress.
Prolonged high intense intellectual and more so the emotional stress producing experience can precipitate
a clinical coronary ischemic episode in persons with advanced coronary atherosclerosis. A personality
behaviour pattern (Type A) has been shown as a significant coronary risk factor for premature coronary
disease among middle aged men with high drive, ambition and intense intellectual or emotional activity.
(ix) Oral Contraceptives.
In susceptible women oral contraceptives may precipitate thrombotic complication and increase the risk of
atherosclerotic heart disease.
(x) Alcohol.
The relationship between alcohol intake and association with IHD has always remained controversial and
reports published show variable results.
(xi) Multiple Risk Factors.
The presence of more than one risk factor has a multiplicative effect on IHD, rather than a simple additive
effect.
(h) Preventive Measures.
The preventive strategies that can be adopted are enumerated in Table 35.3. Two complementary strategies can
be used to prevent coronary disease in apparently healthy but at-risk individuals. These are
(i) The population strategy
(ii) The targeted strategy
The population strategy aims to modify the risk factors of the whole population through diet and lifestyle advice
on the basis that even a small reduction in smoking, average cholesterol etc. will produce substantial benefits.
In contrast the targeted strategy aims to identify and treat high-risk individuals, who usually have a combination
of risk factors and can be identified by using composite scoring system.
Table 35.3 : Preventive Strategies for IHD
O Primordial Prevention
O Primary Prevention  
P Population Strategy
Q Mass Approach
Q Targeted Group Approach
P Targeted High Risk Individual Strategy
O Secondary Prevention
O Tertiary Prevention

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The preventive strategies are described briefly as under

(i) IHD prevention needs to be addressed by not just medical functionaries but also by administrators.
(ii) Diet control is essential to prevent obesity and to balance anabolism and catabolism. Caloric
requirement is lowered progressively as age advances after 40 years. Continuance of the diet at the same
level as consumed during young age increases depot-fat, tissue fat and also imbalances the metabolism,
increasing the blood lipids. Therefore, fat consumption should be drastically reduced, especially animal fats.
All vegetable (non-hydrogenated) oils except coconut oil have a high proportion of unsaturated essential
fatty acids.
(iii) Serum cholesterol and triglyceride concentration are controlled by diets moderate in total calories,
with moderate carbohydrates and total fat yielding less than 20 percent of total calories and low saturated
fat contents viz. less than 5% of total calories.
(iv) Regular exercise is an insurance against obesity, dyslipidemia and hypercholesterolemia,
hypertriglyceridemia, thrombotic tendencies, atherosclerosis and finally the ischemic episodes. It keeps
the myocardium in training to meet the additional demands in times of strain. According to one theory, it
increases the coronary collateral circulatory potential. Individuals who are sedentary workers should adopt
habits of regular exercise.
(v) Weight regulation by avoiding obesity through diet regulation and regular exercise should be
practiced. The individual may inherit tendencies for obesity together with that for hypercholesterolemia and
hyperglycaemia which is emerging as a significant risk factor on its own; such persons have to be more
careful and vigilant.
(vi) Total abstinence from smoking and when it comes to alcohol consumption, there is no safe amount
that does not affect health.
(vii) Hypertension, both systolic and diastolic and of mild grade should be treated to keep the blood
pressure within normal level. Diabetes should also be treated appropriately and blood sugar should be
kept under control.
(viii) Spells of relaxations for appropriate intermittent periods after a sustained period of intense intellectual
and emotional activity, especially for all vulnerable groups, is a valuable prophylactic measure against
sustained strain of high intensity work. Govt of India has launched an initiative of easy-to-do activities like
“Y break Yoga at workplace’ at workplace with an aim to de-stress, refresh & re-focus.
(ix) Regular medical check-up to ensure that the cardiovascular and urinary systems are functioning
normally goes a long way in forecasting an episode. Annual & periodic medical examination followed in
Armed Forces help in early detection and timely treatment. Out of the multiple intrinsic and extrinsic factors,
some are more amenable to control than others, while some may not be controllable at all or even detectable
viz., anatomical, congenital, coronary peculiarities or the genetic hypercholesterolemia tendency. Similarly,
control of thrombotic tendencies is difficult because there are no measures for detection of persons with
such tendencies in the population and there are no therapeutic measures to check thrombosis en masse.
Anticoagulants produce only marginal benefits in the management of frank and massive arterial thrombosis.
They cannot be used for prevention of ischemic heart diseases.
Research in all aspects starting from pre-ischemic conditions to post-mortem examination and histopathological
examination of autopsy material is an important pre requisite to the formulation of authentic preventive
measures. However, it can be summarized that keeping the metabolism balanced, avoiding obesity by diet
control and regular exercise, relaxation and maintenance of tranquillity of mind and avoiding excessive
intellectual and emotional stress producing activity and control of smoking and alcohol consumption should
be relied upon. Moreover, early diagnosis and treatment of all the antecedent and sequential conditions is
extremely essential to enhance the knowledge, to give us epidemiological data, to check further deterioration
from hypercholesterolemia to atherosis, from atherosis to thrombosis, from thrombosis to infarction, from
infarction to aneurysm or rupture and death or a long period of invalidity.

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35.4 Hypertension.
(a) Definition.
The term arterial hypertension indicates a chronically elevated systolic and / or diastolic arterial blood pressure.
The higher the arterial pressure, systolic or diastolic, the greater the cardiovascular morbidity and mortality. WHO
Guidelines for the pharmacological treatment of Hypertension in adults has defined hypertension in adults as
“Those with BP of ≥ 140 / ≥ 90 mmHg or those with CVD having SBP ≥ 130–139 mmHg”.
(b) Classification.
Arterial hypertension may be classified in three separate ways: by blood pressure levels, by extent of damage to
organs and by etiology. For clinical classification, Hypertension is diagnosed when it is measured on two different
days, the systolic blood pressure readings on both days is ≥ 140 mmHg and / or the diastolic blood pressure
readings on both days is ≥ 90 mmHg.
(c) Classification by Etiology.
(i) Essential, Primary or Idiopathic Hypertension.
This is defined as high blood pressure without evident organic cause.
(ii) Secondary Hypertension.
It is defined as hypertension with specific identifiable cause.
The possible causes are:
(aa) Hypertension due to administration of drugs such as hormonal contraceptives, liquorice,
carbenoxolone, ACTH and corticosteroids.
(ab) Hypertensive disease of pregnancy.
(ac) Organic disease like coarctation of aorta, collagen disorders, renal artery stenosis, acute
and chronic glomerulonephritis, pyelonephritis, radiation nephritis, renal tuberculosis, renal cysts,
hydronephrosis, renal tumors including renin secreting tumors, renal failure, primary aldosteronism,
Cushing’s syndrome, pheochromocytoma, acromegaly and myxoedema.
(d) Classification According to Extent of Organ Damage (Stages of Hypertension)
(i) Stage I.
No objective signs of organic changes are evident.
(ii) Stage II.
At least one of the following signs of organ involvement is present:
(aa) Left ventricular hypertrophy on physical examination, chest X-ray, electrocardiography and
echocardiography.
(ab) Generalized and focal narrowing of the retinal arteries.
(ac) Proteinemia and / or slight elevation of plasma creatinine concentration.
(iii) Stage III.
Both symptoms and signs have appeared as a result of damage to various organs from hypertensive disease.
These include
(aa) Left ventricular failure
(ab) Cerebral, cerebellar or brain stem haemorrhage, hypertensive encephalopathy
(ac) Retinal haemorrhage and exudates with or without papilledema. These features are
pathognomonic of the malignant (accelerated) phase.
(ad) Other conditions frequently present in stage III but less clearly a direct consequence of
hypertension include angina pectoris, myocardial infarction, intracranial artery thrombosis, dissecting
aneurysm and occlusive arterial disease and renal failure

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Hypertension-Mediated Organ Damage (HMOD).

Hypertension-mediated organ damage (HMOD) is defined as the structural or functional alteration of the arterial
vasculature and / or the organs it supplies that is caused by elevated BP. End organs include the brain, the
heart, the kidneys, central and peripheral arteries and the eyes. While assessment of overall cardiovascular
risk is important for the management of hypertension, additional detection of HMOD is unlikely to change the
management of those patients already identified as high risk (ie, those with established CVD, stroke, diabetes,
CKD or familial hypercholesterolemia). However, it can provide important therapeutic guidance on (1) management
for hypertensive patients with low or moderate overall risk through reclassification due to presence of HMOD
and (2) preferential selection of drug treatment based on the specific impact on HMOD.
(e) Magnitude of the Problem.
(i) Prevalence Worldwide.
As per WHO, an estimated 1.28 billion adults aged 30–79 years worldwide have hypertension, most (two-
thirds) living in low and middle-income countries. An estimated 46% of adults with hypertension are unaware
that they have the condition. Less than half of adults (42%) with hypertension are diagnosed and treated.
Hypertension is a major cause of premature death worldwide.
(ii) Prevalence in India.
It is estimated that at least one in four adults in India has hypertension, but, only about 12% of them have
their blood pressure under control, of the estimated 220 million people in India living with hypertension,
only 12% have their blood pressure under control.
(iii) Prevalence in Armed Forces.
The trend in hospital admission for hypertensive diseases shows no major changes in trend over the last
decade as depicted in Table 35.4.
Table 35.4 : Decadal Trend in Hospital Admission for Hypertensive Diseases (Rate Per 1000)
Service
Year
Army Navy Air Force Armed Forces
2010 2.76 2.76 3.09 2.81  
2011 2.73 3.24 2.91 2.79
2012 3.07 2.86 3.22 3.08
2013 3.24 3.19 3.7 3.3
2014 2.74 2.36 4.78 2.94
2015 2.61 3.06 3.44 2.72
2016 2.91 2.01 3.67 2.94
2017 2.75 1.86 1.57 2.6
2018 2.57 2.26 1.64 2.47
2019 2.7 1.52 3.3 2.7
Avg of 10 years   2.77 2.67 3.13 2.82
2020 1.84 0.35 2.94 1.87

(f) Epidemiology of Hypertension.

(i) Age and Sex.
Virtually all surveys, including those from Africa, Latin America and India have shown a rise in BP with age
in both men and women, this phenomenon being more marked in women after the age of 50 years. The
increase in systolic pressure appears to continue throughout life, whereas there is a tendency for diastolic

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pressure to level off around the age of 55-60 years.

(ii) Genetic Factors.
Precise mode of inheritance is not known but it appears to be polygenic. The evidence supporting this
contention is as follows
(aa) Familial aggregation of blood pressure is significantly correlated amongst first degree relatives
(parents, siblings and children) at all ages.
(ab) The similarity between both systolic and diastolic pressures in monozygotic twins is significantly
closer than in dizygotic twins.
(iii) Dietary Influences.
(aa) Body Weight.
There is a close relationship between blood pressure and body weight and this holds good for
childhood as well as adulthood. Those who gain more weight show more increase in blood pressure.
Weight reduction has been seen to be accompanied by a fall in arterial pressure.
(ab) Sodium Chloride Intake.
Several communities whose daily intake of sodium chloride is 3 g or less have low average blood
pressure and show little tendency for pressures to rise with age. When the daily salt intake increases
to 7-8 g, blood pressure increases proportionately.
(ac) Protein Intake.
A high protein intake may be useful in attenuating the adverse effects of high salt intake on blood
pressure. These observations are based on both animal experiments and limited human studies in
Japan.
(ad) Alcohol.
High alcohol intake is associated with an increased risk of high blood pressure. It appears that alcohol
consumption raises systolic pressure more than diastolic.
(ae) Saturated Fat.
Evidence suggests that saturated fat raises blood pressure as well as serum cholesterol.
(af) Psychological Factors.
Their role is of considerable debate. In general, there is no evidence of any harm resulting from short-
term blood pressure elevations in response to acute psychological stimuli. Long-term exposure to an
adverse psychological environment might be important and might lead to permanent hypertension.
(g) Factors Influencing Prognosis.
The following factors are usually / generally known to adversely affect the prognosis of essential hypertension.
(i) African American
(ii) Young age
(iii) Male sex
(iv) Persistent diastolic pressure equal to or above 115 mm Hg
(v) Smoking
(vi) Diabetes Mellitus
(vii) Hypercholesterolemia
(viii) Obesity
(ix) Evidence of end-organ damage like cardiac enlargement. ECG changes of ischemia or LV strain,
myocardial infarction, congestive heart failure, retinal haemorrhage and exudates, papilledema, impaired

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renal function and cerebrovascular accident.

(h) Management.
The objective of treating systemic arterial hypertension is to reduce the risk of complications and improve survival.
The benefits of treatment must be weighed against side effects and inconvenience, so it is important to treat
the whole patient, not just the blood pressure. In view of these considerations, it is not particularly helpful to
set up arbitrary levels of blood pressure at which treatment should be commenced. However, in most patients,
the aim of treatment is to reduce BP to less than 140 / 90 mm Hg. The management of hypertension can be
divided into two categories.
(i) General Measures.
(aa) Diet.
This includes reducing alcohol consumption, low salt in food and correcting obesity.
(ab) Risk Factor Modification.
This includes cessation of smoking and reducing hyperlipidemia.
(ac) Exercise and relaxation.
AntiHypertensive Drug Therapy.
Many patients can be satisfactorily treated with a single antihypertensive drug, the choice of which will be
determined by safety and freedom from side effects. The remainder will require a combination of two, three or
more antihypertensive drugs.
(aa) Principal Agents used in a Single Drug Treatment of Hypertension are:
O Thiazide diuretics
O β-adrenoceptor antagonists
O ACE inhibitors.
O Calcium antagonists.
O Vasodilators.
(ab) Combinations depend upon their Complementary Actions and Optimum requirement of the
patient. Some of the combinations in use are as follows.
O Diuretic plus β-adrenoceptor antagonist ACE inhibitors.
O β-adrenoceptor antagonist plus diuretic calcium antagonist I alpha blockers.
O ACE Inhibitors plus diuretic calcium antagonist.
The guidelines issued by WHO / International Society of hypertension for treatment makes eight recommendations
(R)
Drug Therapy Initiation.
R1: BP threshold for starting drug treatment:
Those with diagnosis of HTN and BP of ≥ 140 / ≥ 90 mmHg
Those with CVD and SBP ≥ 130–139 mmHg.
R2 & 3: Screening and assessment are needed before treatment is started.
Obtain tests to screen for comorbidities and conduct CV risk assessment but only if it doesn’t delay treatment.
R4: Which drug(s) to prescribe
Any of these drug classes: Diuretics / ACEi, ARB / CCBs.
R5: Combination therapy
To improve adherence and persistence combination therapy recommended preferably in a single pill

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Targets and Follow-up

R6: BP target for control of HTN:
140 / 90 mm Hg in those without comorbidities
SBP 130 mm Hg in those with CVD
SBP < 130 mm Hg in those with high CVD risk, diabetes and CKD.
R7: Follow-up intervals:
Monthly follow up until patient reaches target BP or 3–6 month follow up once target BP is reached.
R8: Use of nonphysician HCWs in further management of HTN:
Treatment can be provided by nonphysician professionals as long as they are given training, prescribing authority,
management protocols and physician oversight.
(j) Prevention of Essential Hypertension.
Since the cause or causes of essential hypertension remain unknown, any specific recommendations for
prevention are purely conjectural. A number of factors may influence the development of hypertension and
therefore preventive steps also could be multifactorial in each case
(i) Weight Control.
In both adults and children, body weight is directly related to the blood pressure level. Reduction in weight
achieves proportionate lessening of arterial pressure. Therefore, long-term weight control or mid-term weight
control may be an important preventive measure.
(ii) Control of Salt Intake.
Increasing emphasis is now being placed on the desirability of salt intake being kept below 3-5 g per day.
Encouraging a more prudent use of low salt direct and indirect (papad, pickle etc.) diet in groups at high
risk is recommended.
(iii) Physical Activity.
Physical exercise may have an indirect effect on blood pressure by reducing body weight. A few studies have
also shown a significant reduction of blood pressure with physical training. However, the effect of exercise
on stabilized hypertension is unknown and it is also not known what effect regular physical activity may
have in the prevention of hypertension.
(iv) Behavioural Approaches.
There is no definite evidence that behavioural procedures such as biofeedback, relaxation, psychotherapy,
yoga and transcendental meditation can lead to sustained lowering of blood pressure. Such measures
deserve further study.
(v) Psychological and Social Influences.
Prolonged adverse psychological and social factors have not been proved to contribute to blood pressure
elevation, although, both could well be relevant. This is a large and potentially profitable area for further
research.
(vi) Prevention of Secondary Hypertension.
A small, but important, contribution to the prevention of hypertension will be achieved by the more effective
identification, surveillance and management of subjects with these conditions. Analgesic drugs (especially
phenacetin) are an important risk factor for Secondary hypertension. Therefore, measure against abusing
of this are already in place in several countries. The rise in blood pressure with hormonal contraceptive
therapy is not widely recognized. It is recommended that women intending to take estrogen-progesterone
pills should do so only after a blood pressure measurement. Moreover, the blood pressure should be
checked every three to six months. It is not appropriate for anyone with established hypertension to receive
estrogen-progesterone oral contraceptives.

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35.5 Diabetes Mellitus.

(a) Introduction.
Diabetes mellitus is a universal health problem and is an important cause of morbidity and mortality. Compared
to a non-diabetic, a diabetic is 20 times more prone to gangrene, 17 times more affected with kidney disease,
10 times more susceptible to develop blindness and twice as prone to have coronary artery disease. The life
expectancy of a diabetic person is about one-third less than that of his / her non-diabetic companion. During the
last few years there has been a considerable change in concept regarding the etiopathogenesis, classification and
diagnostic criteria that are used. The newer criteria and classification suggested by WHO have been incorporated
in the following account.
(b) Definition.
In clinical terms, diabetes is the name given to a syndrome that has, as its most prominent feature, an elevation
of blood glucose with consequent glycosuria. Diabetes is a chronic disease that occurs either when the pancreas
does not produce enough insulin or when the body cannot effectively use the insulin it produces.
(c) Classification.
As per classification adopted by American Diabetes Association (WHO), Diabetes Mellitus is classified as:
(i) Type 1 diabetes (due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency,
including latent autoimmune diabetes of adulthood)
(ii) Type 2 diabetes (due to a progressive loss of adequate β-cell insulin secretion frequently on the
background of insulin resistance)
(iii) Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal
diabetes and maturity-onset diabetes of the young), diseases of the exocrine pancreas (such as cystic
fibrosis and pancreatitis) and drug- or chemical-induced diabetes (such as with glucocorticoid use, in the
treatment of HIV / AIDS or after organ transplantation)
(iv) Gestational diabetes mellitus (diabetes diagnosed in the second or third trimester of pregnancy that
was not clearly overt diabetes prior to gestation)
(d) Magnitude of the Problem.
(i) Prevalence Worldwide.
The number of people with diabetes rose from 108 million in 1980 to 422 million in 2014. Prevalence
has been rising more rapidly in low- and middle-income countries than in high-income countries. Diabetes
is a major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation. Between
2000 and 2019, there was a 3% increase in diabetes mortality rates by age. In 2019, diabetes and kidney
disease due to diabetes caused an estimated 2 million deaths. In 2017 there were 9 million people with
Type 1 diabetes; the majority of them live in high-income countries. Between 2000 and 2019, there was
a 3% increase in age-standardized mortality rates from diabetes. In lower-middle-income countries, the
mortality rate due to diabetes increased by 13%.
(ii) Prevalence in India.
According to WHO reports, in India there are estimated 77 million people above the age of 18 years who
are suffering from diabetes (Type 2) and nearly 25 million are prediabetics (at a higher risk of developing
diabetes in near future). More than 50% of people are unaware of their diabetic status, which leads to
health complications if not detected and treated early.
(iii) Trend in Armed Forces.
The trend in hospital admissions due to Diabetes mellitus over last decade reveals a marginal increasing
trend as depicted in Table 35.5.
(e) Etiopathogenesis.
The etiopathogenesis of secondary diabetes (referred to as “other types” in the WHO classification) is easy to
comprehend. It is either due to an absolute deficiency of insulin due to a pancreatic disease or due to insulin
antagonism by other hormones as an endocrine disease (Acromegaly, Cushing’s disease, Conn’s syndromes,

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etc.) or by drugs like oral contraceptives and steroids. The exact etiopathogenesis of primary diabetes however
is still not clear. The various theories are
(i) Inherent defect in the B cell / insulin secretion.
(ii) Excess of anti-insulin hormones like glucagons.
(iii) Insulin antibodies.
(iv) Defect in the insulin receptors or the various cells.
Table 35.5 : Decadal Trend in Hospital Admissions for Diabetes Mellitus (Rate Per 1000)
Year Service
Army Navy Air Force Armed Forces
2010   0.68   0.55   0.70   0.67
2011    0.80 0.94 0.96 0.83
2012   0.77 0.60 1.17 0.82
2013   0.77 0.75 1.06 0.81
2014   0.70 0.55 1.41 0.79
2015    0.95 0.66 0.91 0.93
2016    0.75 0.89 0.95 0.78
2017   0.73 0.85 0.62 0.73
2018     0.68 0.57 0.76 0.68
2019   0.70 0.45 1.05 0.72
Avg of 10 years 0.75 0.68 0.95 0.76
2020   0.53 0.25 1.08 0.57

(f) Etiological Factors.

The factors involved are different in the two main types of diabetes. In Type-Il, the following factors are incriminated
(i) Age.
There is an increase in the incidence with advancing age and about 75 percent of the diabetics are over
50 years.
(ii) Heredity.
There is little doubt that there is a strong familial incidence and as many as 50 to 60 percent of the
diabetics have a close relative suffering from it. The exact mode of inheritance, however, is uncertain and
it is presumed to be polygenic, i.e. multiple genes are involved.
(iii) Obesity.
This is an important predisposing factor and is probably due to resistance of the fat cells to the action of
insulin. Attainment of ideal body weight itself enables many diabetics to become euglycemic.
(iv) Parity.
There is some evidence to suggest that the chances of developing diabetes in a genetically predisposed
person increase with the number of pregnancies.
(v) Stress.
Surgery, trauma, infection, pregnancy and steroid therapy are all known to precipitate diabetes in a person
predisposed to it.

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Three etiological factors are involved in the causation of Type I insulin dependent diabetes. These factors are
HLA linked susceptibility, autoimmunity and viral infections. The postulated mechanism incorporating these three
factors is as follows.
HLA linked genetic susceptibility

Viral Infection

  
Autoimmune reaction

Production of islet cell antibodies

Islet cell destruction

Insulinopenia

Type-1 Diabetes Mellitus

Fig 35.1 : Mechanism Type-1 Diabetes mellitus

(g) Diagnosis.
As per WHO diagnostic guidelines and International Diabetes Federation following diagnostic criteria to be
followed.
(i) Fasting venous or capillary plasma glucose ≥ 7.0 mmol / L (126 mg / dL)
(ii) 2-hour post-load venous plasma glucose ≥ 11.1 mmol / L (200 mg / dL)
(iii) 2-hour post-load capillary plasma glucose ≥ 12.2 mmol / L (220 mg / dL
(iv) Random plasma glucose ≥ 11.1 mmol / L (200 mg / dL)
Impaired Glucose Tolerance (IGT) & Impaired Fasting Glucose (IFG)
(i) IFG when fasting plasma glucose ≥ 110 mg% but ≤125 mg%
(ii) IGT when 2-hour post glucose values of plasma glucose ≥ l40 mg% but ≤199 mg%.
Diagnostic criteria are shown as Table 35.6.
Table 35.6 : Diagnostic Criteria for IGT And IFG
Plasma Sample Capillary Sample
(mg / dL) (mg / dL)
Normal Adults
Fasting <110 <101
2-hour post glucose <140 <129
Diabetes Mellitus ≥ 126 ≥ 115

Fasting 2-hour post glucose or random

≥ 200 ≥ 184
IFG 110-125 101-114
IGT 140-199 129-183

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(h) Complications.
The various complications which are likely to occur are as follows:
(i) Acute.
(aa) Diabetic ketoacidosis.
(ab) Hyperosmolar non ketotic coma.
(ac) Lactic acidosis.
(ad) Acute infections.
(ii) Chronic.
(aa) Cardiovascular.
Coronary artery disease, cerebrovascular disease and peripheral vascular disease.
(ab) Neurological.
Acute neuritis, peripheral neuropathy and autonomic neuropathy.
(ac) Ocular.
Cataract and diabetic retinopathy.
(ad) Renal.
Diabetic nephropathy.
(ae) Skin.
Furuncles, boils, diabetic gangrene and perforating ulcers.
(af) Infection.
Pulmonary tuberculosis and urinary tract infection.
(j) Treatment.
(i) Diet forms the mainstay in the treatment of Type -II diabetics. If obese, energy intake reduction should
be imposed in addition to omission of refined carbohydrates (sugar, sweet, cakes, pastries, creams, jam,
sweetened drinks and sweet fruits). Oral drugs should be introduced only after a fair trial with diet.
(ii) If the diabetic state is not controlled on diet alone, sulphonylureas are the drugs of choice for thin
or normal weight diabetics whereas biguanides are preferred for obese diabetics.
(iii) Type-I diabetics generally need insulin therapy. They are usually under-weight and their diet should
not only be liberal but distributed throughout the day.
(iv) Frequent supervision of therapy is essential.
(v) Exercise forms part of therapy as it improves metabolism by utilization of glucose by muscles.
(vi) Education and Self Care. These include the following:
(aa) A basic knowledge of diabetes and its complications.
(ab) Recognition of symptoms and signs of hypoglycemia and measures to correct it.
(ac) A few skills such as capillary blood testing for sugar and injection techniques, if patient is
receiving insulin.
(ad) Recognition of importance of diet.
(vii) Care of feet, fingers and toenails.
(k) Prevention.
(i) Primary.
(aa) Since type-II diabetes has a strong genetic basis, diabetics should be advised not to marry

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another diabetic as the incidence of diabetes in such offsprings would be invariably high
(ab) In view of the strong association between diabetes and obesity, people should be advised to
maintain normal weight and to avoid overeating.
(ac) Genetically predisposed individuals should also be asked to avoid diabetogenic drugs like oral
contraceptives, steroids and excessive use of thiazide diuretics.
(ad) People with a strong family history should be advised to have regular checkups especially after
the age of 50 years. They should also have their blood glucose checked during stressful periods like
infection, surgery, trauma and pregnancy.
(ae) Since incidence of diabetes increases with parity, female with a strong family history should
be advised to have a minimum number of pregnancies. Regular exercise and avoidance of excessive
refined carbohydrates in the diet probably helps in delaying the onset of diabetes.
(ii) Secondary.
(aa) Case detection.
(ab) Full assessment of a diagnosed case in regard to the type, the severity and the presence or
absence of complications.
(ac) Institution of the correct mode of therapy.
(ad) Regular follow up and early mode of therapy.
(ae) Education in diabetes.
(af) Establishment of diabetic clinics with provision of clinical and laboratory facilities as well as
dieticians. These clinics should not only undertake regular therapy but also impart education as well
as carry out periodic surveys.
(ag) Screening for Diabetes
The methods commonly employed for screening of whole population are
O Urine test for glucose - 2 hours after a meal
O Estimation of blood glucose levels, fasting, post-prandial or random.
However, screening of ‘high risk groups’ is considered more appropriate. These groups are
O Age group 40 and above
O Those with family history of diabetes
O Obese individuals
O Women who have had a baby weighing > 3.5 kg at birth
O Women who show excess weight gain during pregnancy
O Patients with premature atherosclerosis.

35.6 Obesity.
Obesity is a medical and public health problem and is much more common amongst affluent societies. Apart from the
increased risk of developing diabetes mellitus, hypertension, cardiovascular disease and osteoarthrosis, obesity has
important social, psychological and economic impacts.
(a) Definition.
Obesity is a condition in which there is an excessive accumulation of adipose tissue in the body. In obesity of
early onset there is an increase in the number as well as the size of the fat cells hyperplasia of the adipose
tissues. In late onset obesity there is predominantly increased packing of fat cells with triglycerides (hypertrophy).
(b) Prevalence of Obesity.
As per WHO fact sheet in 2016, more than 1.9 billion adults, 18 years and older, were overweight. Of these

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over 650 million were obese. 39% of adults aged 18 years and over were overweight in 2016 and 13% were
obese. Most of the world’s population live in countries where overweight and obesity kills more people than
underweight.
The important points to note are as follows:
(i) More females than males are obese at any given age.
(ii) Prevalence rises progressively with increasing age, reaching a peak between 40-60 yrs.
(iii) Family history of obesity is important. A child has 10% chance of being obese when his parents are
normal weight but the incidence rises to 50% when one parent is obese and to as much as 80% when
both parents are obese.
(iv) The earlier the onset of obesity, the poorer the outlook.
(v) Major consequence of childhood obesity is its persistence into adult life.
(c) Diagnosis.
The term ‘excessive’ used in the above definition is somewhat arbitrary and there is no clear cut-off point between
lean and obese individuals. Also, it is important to remember that obesity and overweight are not synonymous.
Various methods, some simple and other extremely complicated have been described for estimation of body
fat and quantifying obesity. Simpler methods, such as anthropometric measurements and determination of skin
fold thickness, though provide only indirect information have been found suitable for clinical and epidemiological
purposes. They are as follows
(i) Body Weight.
(aa) Body Weight Corrected for Height and Sex.
The average or “ideal” weight is given in standard tables of Armed Forces and deviation of more than
10% from the ideal is considered indicative of obesity. This is simple method of assessment but does
not take into account the variation in body build, bone size and muscularity.
Obesity in Armed Forces is guided by following:
O Army: AO 9 / 2011 for officers and AO 3 / 2001 for JCOs / OR
O Navy: Naval Order 14 / 2014 for both officers and JCOs / OR
O Air Force: IAP 4303 (6th edition) for both officers and JCOs / OR
(ab) Body Mass Index (BMI).
This is one of the useful and popular indices of obesity. It is arrived at by dividing the weight (without
clothes) in Kg by the square of height (without shoes) in metres (Wt (kg) / Ht (m)2. Normal value for
males is 20-25 and for females 19-24. If the value is more than 30 it is considered as indicative of
significant obesity (also known as Quetelet’s index). WHO weight classification as per BMI is given in
Table 35.7 and 35.8.
(ac) Ponderal lndex.
Height (cm) / Cube root of body weight (kg)
Table 35.7 : Asian Classification of BMI
BMI (Kg / m2) Classification
<18.5 Underweight
18.5 – 22.9 Normal
23.0 – 24.9 Overweight (at risk)
25.0 – 29.9 Obese I
≥ 30.0 Obesity II

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Table 35.8 : WHO Classification of Weight As Per BMI

BMI (Kg / m2) Classification
<18.5 Underweight
18.5 – 24.9 Normal range
25.0 – 29.9 Overweight  
≥ 30 Obese
30.0 – 34.9 Obese class I
35.0 – 39.9 Obese class II
≥ 40 Obese class III

(ad) Brocca Index.

Height (cm) minus 100
For example, if a person’s height is 160 cm, his ideal weight is (160 -100) = 60 Kg
(ae) Lorentz’s Formula.
Ht (cm) -100 – (Ht -150) / 2 (women) or 4 (men)
(af) Corpulence Index.
Actual weight / Desirable weight
Thus, should not exceed 1.2.
(ii) Skin Fold Thickness.
Measurement of skin fold thickness is relatively simple and perhaps more direct means of assessing body
fat. A single measurement of triceps skin fold posteriorly at the mid humeral level has been used as a
standard. A skin fold thickness of greater than 15 mm in the male and 25 mm in the female is taken to
indicate excess of adipose tissue. Considerable experience in measurements is required before consistent
results can be obtained.
(iii) Waist Hip Ratio.
According to the World Health Organization’s data gathering protocol,[3] the waist circumference should be
measured at the midpoint between the lower margin of the last palpable ribs and the top of the iliac crest,
using a stretch-resistant tape that provides constant 100 g (3.53 oz) tension. Hip circumference should be
measured around the widest portion of the buttocks, with the tape parallel to the floor. Abdominal obesity
is defined as a waist–hip ratio above 0.90 for males and above 0.85 for females.
(d) Etiology of Obesity.
Weight gain is due to an imbalance between energy intake and energy expenditure. To carry out this excess weight,
the body requires increased muscle mass and the metabolism associated with this. If intake rises progressively
or expenditure is reduced by decreasing exercise, then weight rise continues. An extra 10 kg indicates an extra
70,000 kcal. This storage potential explains why it takes so long to lose weight, for an energy reduction of
600 kcal per day from the usual intake will require over 100 days of compliance to lose 10 kg.
Behavioural Changes.
(i) High-fat diet.
(ii) Snacking and loss of formalized meal patterns.
(iii) Alcohol consumption.
(iv) Decreased physical activity.
(v) Giving up smoking.

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(e) Complications.
(i) Type 2 Diabetes Mellitus
(ii) Hypertension
(iii) Stroke
(iv) Hyperlipidaemias
(v) CHD
(vi) Cancers - Postmenopausal breast, endometrium, ovarian, gall bladder and colonic cancers.
(vii) Gallstones
(viii) Arthritis of hip, knee and foot
(ix) Varicose veins
(x) Breathlessness, sleep apnoea
(xi) Hirsutism
(xii) Pregnancy complications like neural tube defects, perinatal mortality, pre- eclampsia, gestational
diabetes, pre-term labour, deep vein thrombosis etc.
(xiii) Stress incontinence; abdominal hernia
(xiv) Psychological: depression
(xv) Social: disability or low income, reduced employment prospects.
(f) Treatment.
In theory, treatment of obesity should be simple but in practice it is demanding and at times frustrating both for
the physician and the patient. The long-term results are unfortunately poor. The successful treatment of obesity
is dependent on the interest and enthusiasm on the part of the physician and the cooperation and motivation
on the part of the patient. The principles of management are as follows
(i) Diet.
Its restriction is the cornerstone of the treatment. Drastic reduction or total starvation are extreme measures
unlikely to succeed. Patience and moderation are essential and one should neither expect nor demand
miraculous results. A deficit of 7,500 kcal will produce a weight loss of approximately 1 kg. Therefore,
eating 100 kcal / day less for a year should cause a 5 kg weight loss and a deficit of 1,000 kcal / day
should cause a loss of ~1 kg per week.
(ii) Exercise.
It is a valuable component of the management of obesity. Physical activity should be increased to a minimum
of 150 min of moderate intensity per week.
(iii) Drugs.
Pharmacotherapy may be added to a lifestyle program for patients with a BMI ≥ 30 kg / m2 with concomitant
obesity-related diseases. Medications for obesity have traditionally fallen into two major categories: Appetite
suppressants (anorexiants) and gastrointestinal fat blockers.
Four anti-obesity medications were approved by the U.S. Food and Drug Administration (FDA) since
2012: Lorcaserin, Phentermine / Topiramate (PHEN / TPM) extended release, Naltrexone sustained release
(SR) / Bupropion SR and Liraglutide. Gastrointestinal fat blockers (Orlistat) reduce the absorption of selective
macronutrients, such as fat, from the gastrointestinal tract. Response to medications should be assessed
after 3 months.
(iv) Surgery.
Surgical procedures like jejuno-ileal shunt, laparoscopic adjustable silicone gastric banding and gastric
bypass restrictive-malabsorptive, such as Roux-en-Y gastric bypass are effective in morbidly obese patients

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but should be reserved only for very severe cases resistant to other types of therapy.
(g) Prevention.
The idiom that ‘prevention is better than cure’ applies equally well to obesity. The public should be educated about
the inherent dangers of this condition and the simple measures like promotion of healthy activity, regular physical
activity, prevention of childhood obesity, community-based intervention etc. can be involved for prevention. If
already obese, he should be motivated to reduce weight by bringing home the vast advantages of reducing
weight.

35.7 Allergic Disorders.

(a) Allergy.
Allergy has been defined by Farr and Spector as “untoward physiological events mediated by a variety of different
immunological reactions”. The following three criteria are necessary for the definite diagnosis of an allergic state:
(i) Identification of the antigen
(ii) Establishment of a causal relationship between exposure to the antigen and occurrence of the lesion
(iii) Identification of the immunological mechanism involved in the illness
(b) Atopy.
It implies familial tendency or allergy to manifest alone or in combination with such conditions like asthma,
rhinitis, urticaria and the eczematous or atopic dermatitis; the passive transfer factor is now recognized to be
the Immunoglobulin E (IgE).
(c) Immune Reactions.
There are four main types of immune reactions that give rise to numerous types of diseases. Depending upon
the type of immune reaction a number of allergic disorders can develop in the human, although in all instances
it is not possible to identify the offending antigen and the possible mechanism involved.
(i) Type I Anaphylactic Reaction (Reagin-dependent IgE).
In type I reaction the disease process can be attributed to release of and / or activation of histamine,
SRS (slow reaction substance - A), serotonin and the plasma kinin, bradykinin and kallikrein and others.
Diseases like asthma, hay fever, atopic dermatitis, systemic anaphylaxis (usually with drugs and foreign
proteins or insect stings) and urticaria may develop. But in all cases of urticaria a specific antigen may
not be found, as it may occur due to physical agents such as trauma or cold. In these circumstances, the
pharmacological agents that cause urticaria can be released in the system.
(ii) Type II Reaction (Cytotoxic Humoral Antibody).
The commonest example of the disease due to this type of reaction is autoimmune hemolytic anemia. Both
IgG and IgM antibodies have been implicated. Another example of IgG antibodies being directly pathogenic
is antibody to glomerular basement membrane in animals. This is a rare type of glomerulonephritis in man
associated with hemoptysis (Goodpasteur’s syndrome).
(iii) Type III Reaction (Immune Complex Arthus Type).
In this reaction, there is deposition of antigen-antibody complexes in the tissue, causing an inflammatory
reaction via mediators such as complement. Activation of complement results in a polymorphonuclear
response and also damage to the cell membrane of the adjacent tissues. Hydrolytic enzymes released
from granules of leucocytes contribute to irreversible vascular damage. Such immune complex reactions in
man are red and edematous reaching maximum intensity between 4-12 hours after intradermal injections.
The example of diseases in man are chronic serum sickness, glomerulonephritis associated with SLE,
polyarteritis, viral hepatitis, the renal manifestations of infective endocarditis and nephrotic syndrome in
children with P. malariae infections.
(iv) Type IV Reactions (Cell Mediated Delayed Hypersensitivity Type).
These are mediated by T-lymphocytes and are induced by infectious agents like virus of measles, smallpox,
herpes and some bacterial infections such as tuberculosis, brucellosis, pertussis and syphilis. The example

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of this reaction is a tuberculin response in which a sensitized individual produces an inflammatory indurated
area consisting of mainly mononuclear cells which appears after 18 to 48 hours. Type IV reactions can
occur with skin contact to a variety of substances ranging from nickel in the brassier straps to drugs like
penicillin. These substances themselves are not antigenic but become antigenic by covalently binding
to protein in the skin. The hypersensitivity of the skin is generalized and may be detected by skin-patch
test. These are also responsible for autoimmune diseases like Hashimoto’s thyroiditis, atrophic gastritis of
pernicious anaemia and idiopathic renal failure.
The above-mentioned immune reactions play an important role in the genesis of allergic reactions. The allergens
are usually foreign proteins, chemicals, drugs, fungi, animal danders, house dust, grasses, pollens, weeds, excreta
of birds, stings of insects and cockroaches. Allergens can be identified in the vast majority of cases. Careful and
diligent efforts should be made to elucidate the offending allergen. This can be achieved by the following.
(i) A careful history of previous allergic reactions to drugs or any particular food or contact with a foreign
substance
(ii) Confirmation by skin tests or a patch test or by local application of small quantity of a dilute solution
to the mucous membrane
(iii) Estimation of levels of Immunoglobulin E in the blood. These levels are about six times higher in
individuals with atopic asthma compared to normal person
(d) Prevention and Control.
A person having history of allergic diathesis should be careful and avoid contact with possible known allergens.
Any history of adverse drug reaction should be made note of and the individual advised not to take such drugs
in future, such as sulpha and penicillin. For allergic rhinitis, hay fever and bronchial asthma of extrinsic type,
prophylactic use of sodium cromoglycate in the form of aerosol powder before the anticipated season and its
continuation for a period of 3-6 months is useful. Desensitization with extracts of antigenic substances helps in
some individuals. Whenever there is evidence of acute bacterial infection which may produce sensitization like
streptococcal or E. coli infection, it should be tackled with suitable antibiotics. Any stress phenomenon, which
is known to aggravate or precipitate an allergic reaction, should be tackled with reassurance of the individual
and preferably by avoiding such a situation. Administration of antisera and drugs like penicillin should be done
with proper care after doing a skin sensitivity test before giving the full dose.

35.8 Peptic Ulcer.

(a) Definition.
Peptic ulcer is a sharply circumscribed loss of tissue lining of those parts of the digestive tract exposed to gastric
juice containing acid and pepsin. These parts consist of lower esophagus, stomach, upper intestine (usually first
part of duodenum), small intestine adjacent to surgically produced connections with stomach and those Meckel’s
diverticula which contain functioning gastric glands. Ulcer in the first part of the duodenum is called duodenal
ulcer and is the commonest. Ulceration of gastric mucosa is called gastric ulcer and it is less common. Rarely
peptic ulcers are in the distal duodenum and jejunum due to Zollinger-Ellison syndromes (gastrinoma).
(b) Magnitude of the Problem.
(i) Prevalence Worldwide.
Peptic Ulcer Disease (PUD) affects four million people worldwide annually and has an estimated lifetime
prevalence of 5−10% in the general population. The male to female ratio for duodenal ulcer varies from
5:1 or less whilst that for gastric ulcer is 2:1 or less.
(ii) Prevalence in India.
The prevalence is highest in South India although exact prevalence is not known, but duodenal ulcers are
much more common than gastric ulcers.
(iii) Prevalence in Armed Forces.
Table 35.9 shows the decadal trend in hospital admission due to Peptic Ulcer. It reveals that the trend is
showing a decline in its incidence over last ten years. However, cases are more among officers of Indian
Army and Cadets of Navy as compared to JCOs / OR, sailors and airmen.

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Table 35.9 : Decadal Trend in Hospital Admission Due to Peptic Ulcer (Rate Per 1000)
Year Service
Army Navy Air Force Armed Forces
2010 1.95 1.38 5.52 2.43
2011 1.64 1.27 4.99 2.11
2012 1.75 1.04 4.28 2.07
2013 1.70 1.09 4.89 2.14
2014 1.52 0.99 5.18 2.04
2015 1.71 1.35 4.40 1.97
2016 1.48 1.18 3.01 1.61
2017 1.34 0.31 1.73 1.33
2018 1.45 0.43 2.03 1.45
2019 1.53 0.64 1.93 1.52
Avg of 10 years 1 0.96 3.79 1.86
2020 1.03 0.57 1.34 1.04

(c) Etiology.
Acid and pepsin are secreted in all individuals in varying amounts but peptic ulcer occurs in only a few. What
makes a person prone to peptic ulcer is not known. Various theories have been put forward to explain its etiology
& pathogenesis. These are
(i) Increased acid secretion due to an increased parietal cell mass in stomach.
(ii) Decreased mucosal resistance which may be the result of derangement of mucosal blood flow, defects
in mucous production or abnormality in the rate of cell renewal or preexisting inflammatory disease of the
gastric or duodenal mucosa.
(iii) Rapid gastric emptying time contributing to the development of duodenal ulcer by rapid delivery of
acid into duodenum.
(iv) Non-Steroidal Anti-Inflammatory Drugs (NSAIDS). These damage the gastric mucosal barrier and are
an important etiological factor in up to 30% of gastric ulcers. They also increase the risk of bleeding or
perforation from pre-existing gastric and duodenal ulcers.
(d) Epidemiology.
In seeking the etiological causes of peptic ulcer, epidemiology analysis has shown the following associations
(i) Age.
The vulnerable period of life for peptic ulcer is from 20-50 years. Highest incidence is at the age of 30
years.
(ii) Sex.
This distribution is almost the same up to puberty and then rises in men. At the highest vulnerable age,
duodenal ulcers are 10-20 times more common in men. The classic duodenal ulcer is almost exclusively
the disease of men. Sex ratio of Male: Female varies from 1.76:1 in general surveys, whereas from hospital
records the ratio has varied from 15.6:1 to 35:1.
(iii) Socio Economic Status.
From surveys carried out in South India, it is revealed that peptic ulcer is more common in lower
socioeconomic status due to faulty dietary habits and H. pylori infection.

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(iv) Profession Distribution.

Professional work which involves stress and anxiety are more prone to develop peptic ulcer; also, people
who are anxious and tense, run more risk.
(v) Diet.
Diet having high fibre contents is thought to be protective for peptic ulcer High condiments like chillies
play some part in predisposition to peptic ulcer. Diets poor in vitamins / proteins have also been known
to cause ulcers. Irregular dietary habits have been found to be a significant factor in causing peptic ulcer.
Long intervals between the meals have been found to be the cause in 61.4% cases.
(vi) Smoking.
Smokers were found to be four times more at risk than controls. Cigarette smokers have more peptic ulcers
than hukka or bidi smokers. It has been suggested that there may be some psychological factors which
might predispose to the development of ulcer.
(vii) Alcohol.
There are controversial reports regarding alcohol as a predisposing factor for peptic ulcer. Wherever,
association of alcohol has been found in cases of peptic ulcer it is explained that alcohol may be acting
as irritant and causing chronic gastritis and rendering mucosa more prone for ulcer formation.
(viii) Heredity.
The diathesis or actual occurrence often runs in the family. Duodenal ulcers are approximately three times
as common in first degree relatives of duodenal ulcer patients when compared with the population at large.
(ix) Association with Diseases and Conditions.
A possible association between duodenal ulcer and hookworm disease in India and other tropical countries
has been found.
(x) Drugs / Beverages.
Certain drugs like aspirin, butazolidine and steroids increase susceptibility of stomach to develop the ulcer,
particularly in subjects with diathesis. Coffee / Tea taken in excess also causes increased gastric secretion
and motility and makes individuals more vulnerable to ulcer.
(xi) Stress.
Acute diffuse lesions caused by stress have also been observed. Prominent examples are sepsis, advanced
carcinomatosis, shock, severe trauma and burns (Curling’s ulcer). Brain injuries, surgical as well as traumatic
can also cause peptic ulceration (called Cushing’s ulcer).
(xii) Helicobacter pylori.
It is a ubiquitous organism which can be found in normal gastric mucosa. There is a high degree of
correlation between Helicobacter Pylori and the presence of gastritis. However, its association with peptic
ulcers is much less clear.
(xiii) Prostaglandins.
Recent advances suggest that prostaglandins may play an important role in ulcers. Mainly PGE2 inhibits
ulcer development and promotes healing by exerting an antisecretory effect on parietal cells, inhibits gastric
acid secretion and possibly increases the resistance of gastro-duodenal mucosa.
(e) Clinical Features.
The most common presentation is that of recurrent abdominal pain which has three notable characteristics
(i) Localization to epigastrium.
(ii) Patient identifies it as ‘hunger pain’ and obtains relief by eating.
(iii) Episodic occurrence
(iv) Waterbrash (a sudden flow of saliva associated with indigestion)

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(v) Heart burn

(vi) Loss of appetite
(vii) Vomiting
(f) Management.
(i) Among the General Measures.
Cigarette smoking, alcohol, aspirin / disprin and NSAIDs should be avoided.
(ii) Specific measures include treatment with the following group of drugs
(aa) Antacids
(ab) Histamine H2 receptor antagonist drug
(ac) H+ / K+ ATPase inhibitors
(ad) Colloidal bismuth compounds
(ae) Sucralfate
(af) Synthetic prostaglandin analogues (Misoprostol)
(g) Complications.
These include the following.
(i) Perforation of ulcer
(ii) Gastric outlet obstruction
(iii) Bleeding from ulcer
(iv) Carcinoma
(v) Non-ulcer dyspepsia
(h) Prevention.
It is certain to a fair degree that duodenal ulcer occurs in certain types of personalities and in persons where
some predisposing factors are playing a great role. Preventive measures should be applied at the earliest to
check the occurrence of disease. These are as follows.
(i) Avoidance of anxiety, worry and stressful situation as far as possible
(ii) Regulation of food habits, taking a diet with high protein and high roughage content and avoiding
long intervals between meals. Drinking lots of water on an hourly basis to complete daily requirement of
minimum 3 liters / day.
(iii) Avoidance of alcohol and smoking
(iv) Avoidance of taking drugs without medical prescription especially analgesic group of drugs

35.9 Goitre.
The term goitre is used to describe enlargement of the thyroid gland. Precise definition of Goitre is not possible since the
thyroid size in the general population is variable in different parts of the world and the degree of thyroid enlargement
considered abnormal varies between different observers. WHO (1960) has suggested the following classification of
Goitre depending upon the size of the thyroid:
According to WHO grading system
(a) Grade 0 – No palpable / visible goitre
(b) Grade 1 – Palpable goitre / visible on neck extension
(c) Grade 2 – Goitre visible in normal neck position
(d) Grade 3 – Very large goitre

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(a) Endemic Goitre.

The term “endemic goitre” is used to describe enlargement of thyroid gland occurring in significant number of
people living in any circumscribed locality. Public health intervention is recommended if the prevalence among
girls aged 12-14 yrs is 5% or more.
(b) Etiology.
(i) It is generally accepted that the major factor is dietary iodine deficiency. The condition remains
common in isolated mountainous areas far from the sea where the soil, water or food iodine content is
low.
(ii) Other Factors.
The involvement of other factors in the pathogenesis of endemic goitre has been more difficult to
substantiate. Genetic factors, fluorides, hardness of water and contamination of water have all been
incriminated. The role of dietary goitrogens especially thiocyanates in certain food stuffs like cabbage has
been amply proved. In certain areas of Japan, endemic goitre results from iodide excess delivered from a
high intake of certain varieties of seaweeds.
(c) Geographical Distribution.
Goitre is more prevalent in the young. The global prevalence is high in the mountainous areas of the Alps, Andes
and the Himalayas. The Himalayan endemic zone extends from the western tip of the Hindukush range to the
eastern districts of Assam and Meghalaya. Besides this, the endemic map of India includes the following areas.
(i) Sub-Himalayan districts of Ambala, Dehradun, Pilibhit, Bareilly, Gonda, Gorakhpur and Ranchi
(ii) Aravalli range and Ajmer
(iii) Vindhyachal range and Jabalpur
(iv) Sambalpur in Odisha
(v) Certain areas like Bijapur, Arcot and Coimbatore in South India
(d) Clinical Features.
In young people, the thyroid enlargement is diffuse but this gradually evolves to nodule formation and occasionally
to hypothyroidism, depending on the severity of the iodine deficiency. If the deficiency is severe during intrauterine
or neonatal life cretinism may be an unfortunate outcome, which may assume epidemic proportions in iodine
deficient areas.
(e) Prophylaxis and Treatment.
Ideally prophylaxis of endemic goitre can be achieved by making more iodine available to the population in the
form of iodized salt and bread. Unfortunately, these methods are only successful in developed communities
and in isolated areas most success has been achieved by the use of injections of iodized oil. Iodized poppy
seed oil is given in doses of 0.5-1.0 ml (1 ml contains 475 mg of iodine) and a single injection is effective for
3-5 years; goitre size decreases and hypothyroidism resolves. Endemic cretinism can be prevented by adequate
iodine prophylaxis.

35.10 Cancer.
(a) Definition.
Cancer is regarded as a group of diseases characterized by an abnormal growth of cells and their ability to invade
adjacent tissues and distant organs leading to eventual death of the affected patient if the tumor has progressed
beyond that stage when it cannot be successfully removed. The synonym of malignant tumor is cancer which is
characterized by an increase in abnormal mass of tissue, the growth of which exceeds and is more than that
of the normal tissues and persists in the same excessive manner after cessation of stimuli which evoked the
change. Tumors could be benign or malignant. Benign tumors grow so slowly and remain so localized that patient
usually experiences little difficulty. They lack invasive and metastatic properties and their histological appearance
does not show aberrant mitosis and invasive erosion of the surrounding tissues. Malignant tumors proliferate so
rapidly and abnormally and spread through the body so relentlessly that unless treated they eventually cause

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death. They are of more clinical importance because of the inherent extensive mortality and morbidity.
(b) Categories.
The major categories of cancer are as follows:
(i) Carcinomas - which arise from epithelial cells lining the internal surfaces of various organs e.g.
mouth, oesophagus, intestines, uterus, etc.
(ii) Sarcomas - which arise from mesodermal cells constituting the various connective tissues e.g.
fibrous tissue, fat and bone.
(iii) Lymphomas, myelomas and leukemias - arising from the cells of bone marrow and immune system.
(c) Metastasis.
The most common route for the metastatic spread of cancer is through the lymphatic vessels. In general,
carcinomas tend to metastasize this way; while sarcomas favour the venous route but frequently carcinomas
such as that of lung, breast, kidney, prostate and thyroid gland are particularly likely to disseminate by blood
borne metastases. Metastases developing through the trans-coelomic route in the peritoneum tend to gravitate
to the pelvis, into the rectovaginal or rectovesical pouches. Other possible routes of metastatic spread such
as through the spinal fluid, ureters and bronchi are infrequent.
(d) Clinical Staging.
It is a useful method of describing consistently the extent of spread of an individual tumor as an indication
of prognosis and guide to determine, the type and modality of treatment which is required. The TNM system
of staging uses the symbol T for size of the primary tumor, N for extent of the local lymph node involvement
and M for distant metastases according to a defined plan for each site.
(e) General Effects.
The local and systemic effects of malignant tumors are valid. Malignant tumors have a great tendency to
necrosis, infarction, ulceration and hemorrhage. Symptoms of anaemia produced by hemorrhage or by the
presence of tumor products, symptoms of obstruction due to involvement of hollow viscera and symptoms of
pressure due to both compression and destruction of tissue, all of which are common findings in cancer. Most
patients with cancer eventually become so weakened from widespread disseminated disease that they become
prone to infection especially bronchopneumonia, which is the most common terminal event in cancer patients.
Many patients with widely disseminated disease show an extreme wasting or malnutrition called cachexia. It
is the result of a few causes including ulceration, hemorrhage, infection, necrosis of tissues with release of
toxins and insomnia with anxiety that many terminal cancer patients experience.
(f) Geographic Distribution.
Cancer occurs in all parts of the world. There are differences in the frequency and mortality of cancer in
different countries. This may be due to variation in modes of life and environmental factors from country to
country. Hepatic cancer is more frequent in the African, South East Asian and Far Eastern countries. It is also
common in India. Mortality from stomach cancer is high in Japan, Chile, Finland and Central Europe, whereas
it is low in USA and UK. Incidence of lung cancer is high in developed countries and low in India. Cancer cervix
is very common among women in India, China, South America but it is low in western countries. Breast cancer
is common in USA, UK and India. In India it occurs one decade earlier than women in western countries. Colo-
rectal cancers occur commonly in USA, Denmark, Scotland and other European countries.
(g) Magnitude of the Problem.
(i) Worldwide.
Cancer is a leading cause of death worldwide, accounting for nearly 10 million deaths in 2020 or nearly
one in six deaths. The most common cancers are breast, lung, colon and rectum and prostate cancers.
In the developed countries, it is the second leading cause of death, next only to cardiovascular diseases,
accounting for 21% of all mortality, whereas in the developing countries, it ranks third as a cause of
death and accounts for 9.5% of all deaths.

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(ii) India.
Estimated number of people with cancer: around 2.7 million (2020). Every year, new cancer patients
registered: 13.9 lakhs. Cancer-related deaths: 8.5 lakhs. Risk of developing cancer before the age of
75 years for Indians, overall (both sexes included): 1 in 9. The projected 5 most common cancers in 2020
for males (lung, mouth, prostate, tongue and stomach) constitute 36% of all cancers and for females
(breast, cervix uteri, ovary, corpus uteri and lung) constitute 53% of all cancers. Nearly 15 lakh patients
require facilities for diagnosis, treatment and follow-up at any given time.
(iii) Armed Forces.
Hospital admissions due to neoplasms showed a decrease trend amongst all three services of Armed Forces
over the last 10 years. The prevalence of cancer in Armed Forces is 0.7 / 1,000 as shown in Table 35.10.
The leading three categories of cancers in Armed Forces
(i) Genitourinary organs - 25-26%
(ii) Lip, oral cavity and pharynx - 17-18%
(iii) Bone, connective tissue, skin and breast - 15-16%
Table 35.10 : Decadal Trend in Hospital Admissions for Malignant Neoplasms (Rate Per 1000)
Service
Year
Army Navy Air Force Armed Forces
2010 0.98 0.38 0.47 0.86
2011 0.72 0.80 0.42 0.68
2012 0.71 1.11 0.45 0.70
2013 0.66 0.77 0.43 0.63
2014 0.77 0.66 0.52 0.73
2015 1.04 0.78 0.24 0.94
2016 0.67 1.31 0.30 0.67
2017 0.81 1.02 0.15 0.76
2018 0.90 0.27 0.75 0.86
2019 0.81 0.36 0.90 0.80
Avg of 10 years 0.81 0.76 0.41 0.78
2020 0.75 0.08 0.59 0.70
(h) Epidemiological Factors.
The prevention of cancer depends upon the complete understanding of the primary etiology and pathogenesis
of the disease. The exact etiology of malignant disease is not yet known. However, considerable data regarding
the epidemiological, extrinsic, intrinsic and genetic carcinogenic factors have become available during the recent
years and the primary prevention mainly rests on the application of our knowledge of these factors.
Climate change plays a significant role in the increasing incidence of cancers, particularly those affecting
the respiratory tract. Prolonged exposure to pollutants in air has been linked to various respiratory cancers,
including lung cancer and cancers of the throat and larynx. Additionally, climate change contributes to the
spread of allergens and infectious agents, further compounding the risk of respiratory illnesses and potentially
leading to the development of cancerous conditions.
(i) Agent Factors.
There are variety of agents which have been shown or suspected to be associated with cancer. They are
as follows:

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(aa) Physical.
Agents like ultraviolet rays, ionizing radiations, cosmic rays and heat can initiate cancer. Radiologists
are 10 times more prone to leukemia than other physicians. Rodent ulcers in whites of Australia
are suspected to be due to their more sensitive depigmented skin and predominance of shorter
wavelength rays in the Australian atmosphere. Oral cancer due to reverse smoking in South India
and Kangri cancer in Kashmir are because of heat.
(ab) Chemical.
Tars, dyes, aromatic amines, uranium, radium, nickel, arsenic, chromium, beryllium, asbestos,
azo dyes and a host of other agents have carcinogenic properties. A definite association between
exogenous estrogen taken as a drug and development of specific forms of cancers has been
demonstrated. The synthetic estrogens given prenatally are transmitted through placenta and
cause squamous cell carcinoma of vagina and adeno-carcinoma of vagina in offspring when they
are between 7 and 29 years of age. Conjugated estrogens increase the risk of endometrial cancer
about 4 to 8 times when administered for the treatment of menopausal symptoms.
(ac) Nutritional.
Deficiency of vitamins, proteins, iodine, addition of dangerous food contaminants and consumption
of alcohol are known to have deleterious effects.
(ad) Biological.
Schistosoma haematobium has been associated with cancer bladder. Burkitt’s lymphoma and
Hodgkin’s disease are associated with viruses.
(ae) Mechanical.
Chronic friction, irritation and repeated injuries have carcinogenic effect. Classical example is that
of ‘Dhoti Cancer’. Chronic inflammation in peptic ulcer, ulcerative colitis and cervicitis can also
lead to cancers.
(ii) Host Factors.
(aa) Age.
Cancer prevalence increases as the age increases; some occur earlier in old age and some late.
Thus on the whole, bronchial cancer occurs before 60 years while that of prostate occurs after 65
years; breast cancers are more common after middle ages; first rising very sharply, the prevalence
continues to rise gradually in later ages; cancer of the brain shows a higher prevalence in younger
age group and leukemia occurs in childhood.
(ab) Sex.
On a global basis, the first ranking cancer sites in males and females is shown in Table 35.11.
Table 35.11 : Ranking Order by Site of 8 Selected Cancers
Rank Males Females
1 Lip, Oral cavity Breast
2 Lung Cervix uteri
3 Stomach Ovary
4 Colorectal Lip, Oral cavity
5 Oesophagus Colorectal
(ac) Marital Status.
Breast cancer is more common in nulliparous women as compared to parus women. Cancer cervix
is more common in multipara and in women with early marriage.

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(ad) Race.
White and persons with fair skin are more prone to skin cancers. Cancer of cervix and uterus
occur more commonly among Negro women than among white women.
(ae) Genetic.
The genetic influence has been suspected because cancer cases aggregate in families.
Retinoblastoma, neurofibromatosis, Von Recklinghausen’s disease, osteosarcoma, polyposis
colon and thyroid neoplasms are some of the conditions showing genetic influence. Philadelphia
chromosome is associated with chronic granulocytic leukemia. Rising incidence of cancer is
associated with Downs syndrome and Klinefelter’s syndrome.
(af) Occupation
There are many cancers which are related to the individual exposure to a carcinogenic agent in his
occupation. Classical example is that of carbon soot associated with cancer scrotum in chimney sweepers.
(ag) Economic Status.
Cancer of stomach, oesophagus and penis are more common among persons of the low-income
group. Breast cancer is more common in women of higher socio-economic status.
(ah) Customs and Habits.
Many customs and habits are associated with various cancers.
O Tobacco Chewing.
Tobacco, beetel and lime chewing increase incidence of cancers of mouth and throat
O Smoking.
Cigarette, beedi, hukka and pipe smoking has been related to cancers of lung, pharynx,
oesophagus, tongue, mouth, tonsils and so on. Incidence is directly proportional to the
severity and length of smoking.
O Areca.
Habitual chewing of areca may cause oral cancer due to repeated trauma and friction
O Alcohol.
Excessive drinking has been shown to have relation with cancers of oesophagus and liver
O Dietary Factors.
Smoked fish is related to stomach cancer, low dietary fibre to intestinal cancer, beef
consumption to bowel cancer and a high fat diet to breast cancer. Food additives and
contaminants also fall under suspicion as causative agents.
O Breast Feeding.
Mothers who breast-feed their infants have a lesser risk of cancer breast
O Circumcision.
This reduces the risk of cancer penis as well as cancer cervix in the sexual partner
O Contraceptives.
No clear-cut association between oral contraceptives and cancer cervix though suspected
is yet to be established.
O Early Marriage.
This has an association with cervical cancer probably due to prolonged exposure to trauma
(ai) Stress and Anxiety.
Stress and anxiety play a significant role in cancer epidemiology, impacting physiological processes

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and behaviours linked to cancer development. Chronic stress may dysregulate immune function
and DNA repair mechanisms, contributing to increased cancer risk.
(iii) Environmental Factors.
(aa) Climate.
Prolonged exposure to sunlight, cosmic rays, ultraviolet rays act as carcinogenic agents for cancer
skin.
(ab) Air Pollution.
With industrialization and urbanization occurrence of cancer lung is seen to be more among city
dwellers as against rural inhabitants. This can be reasonably explained by the extra exposure
to the carcinogenic air pollutants in urban areas, especially 3, 4 benzopyrene which is a known
carcinogenic substance in polluted air.
(ac) Viruses.
Common viruses related to cancer are Human Papilloma virus (skin and cervical cancer), Epstein
Barr virus (lymphoma, cancer of nasopharynx), Hepatitis B and C virus (Hepatocellular Carcinoma),
HTLV-I, II (Leukemias) and HIV 1 and 2 (Kaposi sarcoma, lymphomas).
(ad) Parasites.
Schistosomiasis in Middle East is a known high-risk factor in carcinoma of the bladder.
(ae) Radiation.
Leukemias are associated with exposure to radioactive materials among X-Ray workers & radium
watch dial painters.
(j) Early Warning Signs of Cancer.
(aa) A lump or hard area in the breast
(ab) A change in a wart or mole
(ac) A persistent change in digestive and bowel habits
(ad) A persistent cough or hoarseness
(ae) Excessive loss of blood at the monthly period or loss of blood outside the usual dates
(af) Blood loss from any natural orifice
(ag) A swelling or sore that does not get better
(ah) Unexplained loss of weight
(k) Prevention and Control.
(i) Primary Prevention.
It is the method where the exposure to the known carcinogen can be avoided so that the onset of cancer
is prevented.
(aa) Tobacco Consumption.
Individuals should be convinced to give up smoking or persuaded not to start it. Legislative
measures to give effect to this action will be useful.
(ab) Alcohol Consumption.
Alcohol is associated with cancers of various sites especially oral, oropharyngeal region and
oesophagus. The effect is multiplied, if combined with tobacco smoking.
(ac) Dietary Modifications and lifestyle measures such as
O Avoid being underweight / overweight.

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O Reduction in fat intake.

O Increase consumption of vegetable / fruits (especially citrus fruits).
O Adjust exercise and food intake to maintain healthy body weight.
O Limit use of salt and consumption of salt preserved food.
O Restrict the intake of red meat and preserved meat.
(ad) Occupational Exposure.
In professions related to use of chemicals and radiations, proper protection is required to prevent
cancers.
(ae) Infection.
Vaccination against Hepatitis B will prevent liver cancer.
(af) Personal Hygiene.
Improvement in personal hygiene may lead to decline in the incidence of certain types of cancers
e.g. cancer cervix.
(ag) Control of Air Pollution.
(ah) Treatment.
Treatment of precancerous conditions such as cervical tears, intestinal polyposis, warts, chronic
gastritis, chronic cervicitis etc.
(aj) Cancer Education.
The aim is to motivate people to seek early diagnosis and early treatment. It should be directed
at high-risk people.
(ii) Secondary Prevention.
(aa) Cancer Registration.
It provides a base for assessing the magnitude of the problem and for planning the necessary
services. Cancer registries are of two types- hospital based and population based.
(ab) Early Detection of Cases.
Cancer screening is the most acceptable method for detection of cancer at pre-invasive or in-
situ stage. Efficacy of screening programs can be increased by focusing on high-risk groups. The
methods adopted for cancer screening could be as follows.
O Mass screening by comprehensive cancer detection examination.
O Mass screening at single sites e.g. uterine cervix, breast cancer, lung cancer, etc.
(ac) Selective Screening.
This refers to those who are at special risk e.g. parous women of lower socioeconomic strata
upwards of 35 years of age for detection of cancer cervix, chronic smokers for lung cancers etc.
Screening techniques adopted for some of the common cancers are as follows:
(aa) Cancer Cervix.
Pap smear: As per ACOG guidelines, all women between 21-29 years of age are recommended to
be screened by Pap smear. Current guidelines recommend Visual Inspection with Acetic acid (VIA)
followed by HPV DNA testing from 30 years of age and then every 5 years (Operational Framework
Management of Common Cancers, MoHFW, Govt of India)
(ab) Cancer Breast.
Breast self-examination
O Palpation by a physician.

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O Thermography.
O Mammography.
(ac) Cancer Lung.
Chest radiograph
O Sputum cytology for malignant cells
(l) Treatment.
Certain forms of cancer are amenable to surgical removal while some other respond favourably to radiation or
chemotherapy or both. Multi-modality approach to cancer control has become a standard practice in cancer
centres all over the world.
(m) Chemoprevention of Cancers.
(i) Some of the common agents supposed to be helpful in chemoprevention are as follows:

Micronutrients Vit A, C, B, Calcium, Zinc

Food additives Antioxidants
Food molecules Carotenoids, alkaloids, indoles, retinoids
Pharmaceutical agents NSAIDs, anti-prostaglandins
(ii) For prevention of Cervical Cancer, at least 2 doses of HPV vaccine are recommended for girls,
starting at the age of 9 years.

35.11 Non-Enemy Action Injuries.

Non-Enemy Action injuries constitute the leading cause of sickness in the Armed Forces. These injuries vary to a great
extent in degree of severity and may be trivial requiring only outpatient treatment or may be serious necessitating
prolonged hospitalization. The latter group may remove the individual from work for considerable time before his injury
reaches surgical finalization. Proper rehabilitation of such a long-term injury also poses a great problem.
(a) Types.
(i) Minor Injuries.
Examples are abrasions, contusions, sprains and superficial incised and lacerated wounds.
(ii) Major Injuries.
Their examples are simple and compound fractures, head injuries, perforated abdominal and chest
injuries and deep lacerated wounds of soft parts and burns.
(b) Trends in Armed Forces.
The decadal trend in hospital admissions for injuries NEA (All forms) has been shown in Table 35.12. The
incidence of Injuries (NEA) in the Armed Forces is 8.58 / 1,000 and was significantly lower when compared
with the decadal trend as well as the previous year. The highest morbidity for Injuries (NEA) was amongst
cadets of Army.
(c) Epidemiology.
Injuries in non-enemy action, result from the interaction of various agent, host and environmental factors. The
relative importance of these factors varies in different types of accidents.
(i) Agent Factors.
The important agent factors are as follows.
(aa) Goods and Equipment.
The troops handle complex arms and equipment and this may expose them to injury e.g. operating
or lifting heavy equipment, use of tools such as hammer, chisel and cutting instruments may

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expose some individuals to injuries.

Table 35.12 : Decadal Trend in Hospital Admissions for Injuries NEA (All Forms) (Rate Per 1000)
Service
Year
Army Navy Air Force Armed Forces
2010 19.50 12.03 19.34 17.85
2011 18.23 4.99 18.26 17.31
2012 17.90 6.57 16.06 16.84
2013 17.00 6.16 18.60 16.91
2014 17.11 5.39 17.82 16.86
2015 19.07 4.51 16.24 18.04
2016 17.77 4.61 9.95 16.38
2017 17.67 1.66 3.64 15.62
2018 17.65 0.87 7.35 15.87
2019 15.88 0.97 10.12 14.55
Avg of 10 years 17.78 4.77 13.73 16.62
2020 8.58 0.50 4.99 7.80
(ab) Vehicles.
A poorly maintained vehicle may be the cause of accident e.g. improper working of brakes and
lights.
(ac) Machinery without guards or with inadequate guards
(ad) Poor maintenance of machinery and equipment
(ae) Uneven and poorly maintained playgrounds, tracks, paths and so on
(af) Faulty design and poor maintenance of buildings
(ag) Faulty electric connections and fittings and poorly maintained electric gadgets
(ii) Host Factors.
The host factors, directly or indirectly, play an important role in the causation of injuries. The important
host factors are as follows.
(aa) Training.
A properly trained worker is expected to exercise better care in the performance of his routine
duties and is, therefore, less liable to injuries. During the times of national emergency there is
sudden expansion of Armed Forces and heavy recruitment. This puts heavy load of work on the
regimental training centers and the training afforded to recruits cannot conform to peacetime
standards. These soldiers are more liable to sustain injuries. Lack of proper training in the use
of oil cookers, oil stoves and pressure cookers may expose the cooks to risk of injuries
(ab) Lack of interest in training / work.
(ac) Physical disabilities such as vision, poor agility, etc. predispose the individual to injuries
(ad) Carelessness and willful negligence while working
(ae) Faulty work methods
(af) Use of loose fitting and unsafe clothing
(ag) Mishandling of goods, tools and equipments

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(ah) Consumption of alcohol while driving or working

(ai) Tiredness due to long working hours
(aj) Psychological Factors
These include the following
O Improper selection of the individual for a particular job e.g. non-adaptation of person
to the job concerned.
O An unhappy and dissatisfied person shows higher incidence of injuries. This may be
caused by financial, domestic or work stress.
O Low morale caused by long hours of work, improper management, poor leadership
and inadequate recreational facilities.
O Boredom and lack of essential amenities like postal, messing arrangements, bathing
facilities etc.
(ak) Injury Proneness.
Some individuals may be naturally injury prone and in spite of all efforts they will show a higher
incidence of injuries than others under the similar circumstances. It has been estimated by
epidemiological surveys in certain industries that between 10-25 percent of the workers are accident-
prone. This accident proneness is attributed to defective neuro-muscular control in these persons.
(iii) Environmental Factors.
(aa) Terrain.
When troops are deployed in difficult terrain like high mountains, jungles, on high seas, at frontier
airbases and marshy areas, they are more likely to sustain injuries while engaged in exercises
and training.
(ab) Climatic Conditions.
Adverse climatic conditions like rain, fog and glare increase the risk of sustaining injury.
(ac) Roads.
Poorly maintained roads, roads with sharp bends and narrow roads greatly increase the risk of
mechanical transport accidents
(ad) Working Environment.
Unhealthy working environment such as inadequate lighting and thermal comfort, excessive noise
and poor house-keeping increase the risk of injuries at work places
(ae) Overcrowding.
Overcrowding of machinery and men at workplaces enhances the risk of injuries
(d) Prevention.
Most of non-enemy action injuries are preventable if attention is paid to the following measures
(i) Health Promotion.
All ranks must be well informed on the various causes of injuries and their prevention. Physical fitness of
personnel must be ensured by a balanced diet, good living conditions and proper medical and health care
including periodical health check-ups. In addition, high standard of morale by good man-management,
by good leadership and by provision of adequate recreational facilities will go a long way in reducing the
incidence of injuries.
(ii) Specific Protection.
It is ensured by
(aa) Training of all ranks in the handling of stores and equipment in general

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(ab) Training in specialized trades like MT driving, arms and ammunition, special vehicles / machines
and industrial processes
(ac) Providing healthy work environment
(ad) Proper maintenance of vehicles, amns and equipment, electrical fittings, etc
(ae) Antifire precautions
(af) Eliminating all types of stresses both at work and at home as far as possible
(ag) Guarding of dangerous machines
(ah) Enforcement of personal protective measures in workshops and other work places wherever
indicated
(ai) Supervision of workers
(aj) Investigation of all injuries with a view to take necessary preventive measures
(ak) Good house-keeping
(al) Proper maintenance and lighting of buildings
(am) Securing electrical fittings and eliminating live wires
(an) Ensuring adequate precaution, by education regarding handling of stoves. gases, pressure
cookers and electrical appliances.

35.12 Burns.
(a) Introduction.
An estimated 1,80,000 deaths every year are caused by burns – the vast majority occur in low and middle-
income countries. Non-fatal burn injuries are a leading cause of morbidity. A trend of increased incidence of
burns is observed in South Asia during the festive season of Diwali, celebrated each year in the months of
October or November. The situation in India is particularly worrying. The estimated annual burn incidence in
India is approximately 6-7 million per year, more than 23,000 fire-related deaths were estimated in India, which
is about 20% of the global mortality burden. Thermal burns constitute the majority of burns cases in India,
although, with rapid electrification higher voltage electric burns and domestic-electric burns are becoming more
and more common. Although most of the burn cases are accidental, yet suicidal and homicidal burns are not
unknown.
(b) Definition.
Burns may be defined as injury to the tissues of the body arising from exposure to heat, electric conduction
or radiation. These are amongst the commonest surgical emergencies both during peace and war.
(c) Epidemiology.
In the study of burn injuries: the burnt patient is the host, the source of injury is the agent; and home and
workplace constitute the environment. It is the interaction between these factors which results in a burn injury.
(d) Agent Factors.
The agent factors are multiple and varied. Each has its own distinctive features.
(i) Scalds.
Commonest cause is spillage of boiling water, hot water or steam. Even a cup of hot tea or coffee can
cause sufficient scalding. Commonly seen among children.
(ii) Fat Burns.
Due to spillage of cooking oil which has a much higher boiling temperature (180°C) than boiling water.
It can cause deep burns.
(iii) Flame Burns.

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The causes could be house fires, clothing fires, butane gas fires and spills of petrol on skin. Generally,
results in deep burns.
(iv) Electric Burns.
Due to high tension wires or even at home, from low voltage power supplies. It is due to poorly maintained
electrical connections or gadgets. The passage of electric current through the tissues causes heating
that results in cellular damage.
(v) Cold Injuries.
These include injuries due to accidental spills of liquid nitrogen injuries, freezing injuries like frostbite,
etc.
(vi) Friction Burns.
The tissue damage is due to a combination of heat and abrasions.
(vii) Ionising Radiation.
X-Ray irradiation may lead to tissue necrosis; of other significance is the long term cumulative effect in
causing skin cancers.
(viii) Chemical Burns.
Occurs in industrial and domestic situations. The agents are various acids and alkalis. These cause local
coagulation of proteins & tissue necrosis.
(e) Host Factors.
(i) Age.
It has an important relationship with burn injuries and their causation. The studies carried out in India
have shown that adults and adolescents constitute the majority of cases of burns.
(ii) Sex.
The studies carried out by most of the workers have shown that the incidence of burn injuries is higher
among females as compared with males. In fact, some recent studies, higher proportions of burn due
to dry heat (flame or hot surface contact) and electricity were seen in the male group.
(iii) Associated Diseases.
Burns are associated with diseases like epileptic fits, cardiovascular accidents, giddiness, parkinsonism,
paralysis and debility.
(iv) Clothing.
(aa) Loose fitting and flowing design clothing such as ends of saree / dupatta have been found
to be responsible for the causation of burns in many cases.
(ab) Material.
The chemical, thermal and physical properties of the garment contribute significantly to the
flammability characteristics of a given article of clothing. Synthetic garments such as nylon fabrics
tend to catch fire much easily as compared to cotton clothing.
(f) Environmental Factors.
Environment plays an important role in burn injuries by bringing about the contact between agent and the
host. It comprises of both human & physical shortcomings in the area in which the agent host relationship
functions. It may be domestic or workplace environment. The domestic environment consists of the type of
home, number of rooms and overcrowding. The workplace environment consists of the nature of fire-guards
and the degree of safety precautions. Males suffer more burns injuries at workplace & female suffer more
from domestic burns. The domestic burn injuries are more common as compared to those in workplace. Some
of the important environmental factors are as follows.
(i) Overcrowding

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(ii) Poor housing

(iii) Open fire cooking
(iv) Practice of cooking at the guard level
(v) Faulty electric connection and fittings
(g) Assessment of Severity.
(i) Extent.
An approximate clinical rule in wide use is the ‘rule of nines’ which acts as a rough guide of percentage
of body surface area involved due to burns. The assessment criterion is as follows.
Table 35.13 : ‘Rule of Nines’
Body Parts % given
Head, face & neck 9%
Chest (front & back) 2 x 9%
Upper limbs 2 x 9%
Abdomen and back 2 x 9%
Thighs (front & back) 2 x 9%
Legs (front & back) 2 x 9%
Genital area 1%

Fig 35.2 : ‘Rule of Nines’

As a general rule, an adult with more than 20% and a child with more than 10% body surface involved
will require intravenous fluid replacements. A rough guide is that if the age and percentage of burns
add together to a score of 100, then the burn is likely to be fatal.
(ii) Depth.

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Deeper the burn, poorer is the prognosis. According to the depth, burns are classified as follows.
(aa) Superficial.
Epidermis only is involved.
(ab) Partial Thickness.
Epidermis and part of dermis are involved.
(ac) Deep or Full Thickness.
Epidermis and dermis are involved. It may also involve subcutaneous tissues or even muscles.
(iii) Site.
The sites which bear poor prognosis are face, neck, perineum and chest.
(iv) Age.
Extremes of age always bear a poor prognosis.
(h) Pathophysiology.
The lesion in burns is summarized as cellular destruction or damage of varying depths associated with an
acute vascular reaction leading to rapid loss of circulatory fluid into and from the tissues. Pathophysiology
following burns can be described as local and systemic.
Local
(i) Tissue Damage.
(aa) Cell rupture or cell necrosis.
(ab) Denaturing of collagen.
(ac) Thrombosis of capillaries in severe burns.
(ad) Increased permeability of capillaries if damage to tissues is less.
(ii) Inflammation.
In the areas least damaged by burning, there is ‘erythema’. More severely damaged tissues may develop
a more prolonged inflammatory response in the form of macrophages producing inflammatory mediators
or cytokines. Neutrophils and later lymphocytes provide protection against infection and de-sloughing is
generally completed in 3 weeks.
(iii) Infection.
The damaged tissue represents a nidus for infection. Burn wounds will almost inevitably be colonized by
microorganisms within 24-48 hours and this may remain as a local or regional infection. There may be
in addition, a bacteremia or septicemia; which are the common causes of fatality in severe burns. Beta
haemolytic streptococci and pseudomonas produce protease enzymes that prevent skin graft adhesions.
Systemic.
(i) Shock.
It is a common accompaniment of burns, which may be neurogenic or hypovolemic.
(aa) Neurogenic Shock.
It is produced by intense pain caused by irritation of nerve endings and is further accentuated by
apprehension and fright.
(ab) Hypovolaemic Shock.
Abnormal capillary permeability is accompanied by arteriolar dilatation, which increases the rate
of local blood flow and accelerates the outpouring of protein containing fluid through capillary
endothelium. This fluid may escape superficially to form blisters and within the tissue space as
oedema. The fluid lost has the same electrolyte composition as plasma but the protein content is

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about 50% of that plasma. The rate of loss of fluid reaches its peak during immediate post burn
period and then slowly diminishes and stops by 48 hours. The volume of fluid lost is proportionate
to surface area burnt. The fall of blood volume activates the compensatory reactions in the body
as in hypovolemic shock due to other reasons. After about 48 hours, the capillaries recover normal
tone and oedema fluid starts getting shifted to vascular compartment.
(ii) Renal Function.
Extensive burns can cause acute renal failure. This happens because blood flow to the kidneys reduces,
leading to reduced glomerular filtration. Oligemia, a condition with low blood flow, makes things worse.
It’s worsened by hypertension and renal vasoconstriction from oligemia and haemoglobinemia. High
output renal failure can occur too. A common finding is diffuse distal tubular necrosis.
(iii) Anaemia.
Although initial haemoconcentration is the prevalent picture, yet in extensive burns, anaemia invariably
complicates the final outcome. Factors responsible for anaemia are
(aa) Immediate destruction of RBC by heat. This, however, does not amount to more than 5-10%
of circulatory RBC volume.
(ab) Increased RBC-fragility as they undergo morphological changes and become ‘microcytes’.
(ac) Depression of haemoglobin synthesis by bone marrow.
(iv) Negative Nitrogen-Balance.
A continuous loss of protein is invariable in major burns. Loss of plasma protein into the burn-wounds
takes place through damaged capillaries. Loss of albumin is more than that of globulin. A further steady
loss of protein continues from the surface through granulating period until skin coverage is complete.
Increased excretion of urinary nitrogen represents the protein catabolism. As much as 200-250 gm of
protein may be lost daily in extensively burnt patients.
(v) Infection.
A burn wound may show all types of organisms. The ones which cause concern are Staph pyogenes,
Pseudomonas pyocyaneous, Pseudomonas mirabilis, Streptococcus haemolyticus which used to cause
concern in early days have lost their importance due to routine use of antibiotics. In recent years, interest
has been generated on the role of fungal infection and infection by bacteroids in extensive burn wounds.
(vi) Curling’s Ulcer.
Acute ulceration of stomach and duodenum is the most formidable gastrointestinal complication. The exact
pathogenesis of Curling’s ulceration is not known. Various hypotheses have been put forward as follows:
(aa) Sharp decrease of mucus secretion of stomach and increase in acid / mucus ratio
(ab) Sludging of blood vessels supplying the gut-wall
(ac) Manifestation of toxemia and septicemia
(vii) Toxemia.
This ill-understood condition is responsible for death in majority of burn cases. It supervenes on a patient who
has a large granulating wound at about 2-6 weeks of post burn period. Deterioration of sensorium is followed
by acute peripheral circulatory failure. Although most of the modern workers believe that septicemia is the
cause, isolation of organisms has not been possible in certain cases. It is believed that, although infection
is the principal factor leading to mortality, ‘some other factors’ may also play a contributory role.
(j) Management.
(i) First Aid.
(aa) Stop the burning process by extinguishing the flames by wrapping the patient in a blanket or any
other readily available garment such as the bystanders own clothing. With electric burns, it is important
to switch off any live current and with chemical burns, the contact with the chemical should be avoided.

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(ab) Cool the burn surface. Immediate cooling of the part is beneficial and should continue for 20 mins.
Irrigation with cold water under a tap is best, especially in scalds and chemical injuries. Hypothermia
must be avoided. Do not use ice or iced water. The burn should then be wrapped in clean linen and
patient transported immediately to hospital.
(ii) Emergency Examination and Treatment.
The order of priorities in the management of a major burn injury is
A - Airway maintenance D - Disability-neurological status
B - Breathing and ventilation E - Exposure and environment control
C - Circulation F - Fluid resuscitation
(iii) Fluid Resuscitation.
It is important at an early stage to secure large bore intravenous lines. Having estimated the percentage
burnt surface area and measured the body weight, initial fluid resuscitation can be planned. The simplest
formula for adults is: 3-4 ml / kg body weight / % burn in first 24 hours. Half of this volume is given in
first 8 hours and the rest in next 16 hours. Hartmann’s solution is preferred but other isotonic fluids may
be used. A urinary catheter is essential. Urine output is the best guide to adequate tissue perfusion. In
an adult one should aim for 30-50 ml / hour.
(iv) Dressing.
Epidermal burns with erythema and no blisters do not need dressings. Analgesia and moisturizing creams
are used. Burns of the face are generally treated by exposure because of difficulty of dressing. Antibiotic
ointments and petroleum jelly, particularly around the eyes and frequent toilet of eyes and orifices may
be needed. Burns of the trunk and limbs are usually dressed.
(v) Infections.
There is controversy about the use of routine antibiotic administration. Beta haemolytic streptococci are
likely to delay healing and should be treated. Staph aureus and Pseudomonas are treated by local antiseptic
preparations. Whenever there is evidence of cellulitis, systemic antibiotics should be administered.
(vi) Surgical Treatment.
Partial thickness burns should heal without surgical intervention but full thickness burns require surgical
management. One can await spontaneous desloughing and apply split skin grafts at 3 weeks.
(vii) Mobilization and Rehabilitation.
Early mobilization of the patient succeeds in reducing the incidence of complications such as infection
and deep vein thrombosis. Physiotherapy is very important to prevent joint contractures.

Suggested Reading.
1. Dietary Guidelines for Indians – A Manual by National Institute of Nutrition, Indian Council of Medical Research,
Hyderabad
2. Total fat intake for the prevention of unhealthy weight gain in adults and children: WHO guideline 2023
3. Budreviciute A, Damiati S, Sabir DK, Onder K, Schuller-Goetzburg P, Plakys G, Katileviciute A, Khoja S and Kodzius
R (2020) Management and Prevention Strategies for Non-communicable Diseases (NCDs) and Their Risk Factors. Front.
Public Health 8:574111. doi: 10.3389 / fpubh.2020.574111
4. Operational Framework Management of Common Cancers, MoHFW, Govt of India
5. Annual Health Report of The Armed Forces, O / o DGAFMS, Ministry of Defence, New Delhi
6. Army Order 9 / 2011 & 3 / 2001, Naval Order 14 / 2014.
9. IAP 4303 (6th Edition)
n 

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Chapter
XXXVI
MENTAL HEALTH

36.1 General Considerations.

Mental health is a crucial aspect of overall well-being, encompassing both the physical and mental components of an
individual. Every physical ailment has a corresponding mental component and conversely, every mental illness has a
physical dimension. The social health of a community is heavily reliant on the positive mental health of its members,
as challenges in this area can lead to the development of antisocial behaviours.
Traditionally, mental health care focused on diagnosing and treating established psychiatric cases. However, the
contemporary approach to mental health care extends beyond treating disorders to proactively strengthen social
cohesion. The goal is to influence individual and group behaviour so that psychosocial situations are managed rationally
and logically, ensuring solutions are reached without disrupting the physical, mental or social well-being of the community.
The World Health Organization (WHO) expert committee defines mental health as ‘an individual’s capacity to form
harmonious relationships and actively contribute to positive social change’. Achieving this requires the various
components of an individual’s personality to work in harmony, enabling them to navigate life’s challenges in a rational,
successful and happy manner. The comprehensive concept of mental health involves understanding and treating
mental disorders, identifying early signs of potential breakdowns, preventing or minimizing occurrences of disorders
and enhancing the overall mental health of the community.
Mental health encompasses both intellectual and emotional well-being. Intellectual breakdowns, marked by a loss of
logical thinking, can lead to faulty decisions that impact an individual’s and even a community’s well-being. While rare,
an intellectual breakdown without an accompanying emotional breakdown is less harmful. Emotional imbalances, on the
other hand, affect relationships, the ability to cope with life stresses, adherence to social norms and may compromise
intellectual capacities. When emotional imbalance is severe, it can lead individuals to become unsocial, unsociable or
even antisocial, hindering their ability to navigate life situations effectively.

36.2 Individual’s Personality.

The autonomic process of ‘personality integration’ plays a crucial role in building resistance against mental and particularly
emotional breakdowns. This process is a natural aspect of personality development within a group environment. In the
transition from the secure intrauterine environment to the unpredictable external world, infants are exposed to unfamiliar
physical and biological surroundings. Human contact becomes a significant element in these biological surroundings,
influencing newborns not only through infectious processes but also through psychological and cultural factors.
As an individual grows within their group, the sphere of influences expand with the child’s physical, neural, somatic
and functional development. Beginning within the family, these influences gradually extend to include neighbours,
schools, community, vocational settings and social connections. Similar to how biological factors create resistance
against infections, psycho-social interactions contribute to the ‘integration of personality’, fostering resilience against
challenging situations and aggressive personalities. This integration equips individuals to respond healthily when faced
with unfavourable life circumstances.
Internal stress arising from external psychological pressures in life situations triggers reactions that lead to psychological
resilience against adversities and a determination to navigate challenges successfully. The stress acts as stimuli and
if too intense or prolonged, it may result in a breakdown and deterioration. The extent of this breakdown depends on
the pre-existing resistance against such challenging situations.

36.3 Personalities and Stress.

Personalities can be categorized into five types based on their capacity to withstand strain and stress without experiencing
a physical or mental breakdown while effectively managing challenging situations. The response to psychogenic stimuli
varies among individuals, with each person reacting differently depending on their classification within the described

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groups below:
(a) Group I.
Individuals in this category exhibit high resistance. They possess either innate superior resistance or the ability
to swiftly develop it when faced with challenges. These individuals successfully navigate through stress, emerging
triumphant over adverse conditions and assert mastery. They can execute tasks even in the face of significant
stress without succumbing to personal distress. Such individuals showcase well-integrated personalities
characterized by dominant willpower and enduring strength.
(b) Group II.
The possession of preexisting resistance allows these individuals to partially overcome stress. While they don’t
exhibit overt stress syndromes, they may experience concealed syndromes in their efforts to master a successful
situation and achieve success. The task at hand remains unaffected. Individuals in this category are prone
to developing internal conditions like hypertension, coronary occlusion, peptic ulcers and similar issues when
additional causative factors are also present.
(c) Group III.
Individuals with minimal preexisting resistance may, over time, develop resistance to a stressful situation, but
ultimately, they may “resign” to the circumstances and display evident overt syndromes. This process is akin to
an allergic or anaphylactic reaction to foreign animate or inanimate proteins. While the task at hand may not
always be negatively impacted, many of these manifestations are classified as psychosomatic syndromes.
(d) Group IV.
Individuals lacking preexisting resistance and having a limited capacity to generate immediate resistance tend
to abandon the task. Consequently, they may extricate themselves from the stressful situation, leading to the
task being adversely affected. In such cases, individuals might either escape the situation entirely or exhibit
unpredictable symptoms without a discernible pattern.
(e) Group V.
Individuals categorized as non-resistant lack preexisting resistance and are incapable of responding positively to
stress-inducing situations. They succumb to the pressure, becoming psychiatric casualties and ultimately disintegrate
as an organized organism. In severe cases, they may struggle to maintain even their basic biological existence.
Individuals with low preformed resistance against stress should be recognised in their childhood and their innate
resistance boosted up by providing proper environment. However, having no means of finding out the innate
degree of resistance, it is necessary to ensure a congenial environment universally to all children to give them
a better chance to develop integrated personalities.
Psychotic or psychopathic traits as well as intellectual and emotional peculiarities which may have a definite
genetic origin, are also further influenced by physical, social and psychological environs. Climate, housing, nutrition,
environmental conditions, health of the individual himself and of those in his constant contact, the psychological
atmosphere in his home, vocational and social environs, security afforded to him since infancy, security of vocational
tenure and socio-economic status, medical care afforded to him and his family, group and community; all aid to
create healthful, unhealthy or indifferent environments for the individual within his/her group.

36.4 Classification of Psychiatric Disorders.

The classification of psychiatric disorders based on ICD-10 is as under:
(a) Organic.
(i) Acute e.g. delirium
(ii) Chronic e.g. dementia
(b) Substance Misuse.
(c) Schizophrenia and delusional disorders.
(d) Affective (Mood) Disorders.
(i) Depression

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(ii) Mania
(iii) Recurrent affective disorders
(iv) Bipolar affective disorder
(e) Neurotic, Stress Related and Somatoform Disorders.
(i) Anxiety disorders
(aa) Generalised anxiety    
(ab) Phobic anxiety
(ac) Panic disorder   
(ii) Obsessive compulsive disorder
(iii) Reaction to severe stress
(aa) Acute stress disorder
(ab) Post-traumatic stress disorder  
(ac) Adjustment disorder
(iv) Dissociative disorder
(v) Somatoform disorder
(vi) Neurasthenia
(f) Behavioural Disturbances.
(i) Eating disorders
(ii) Sleeping disorders
(iii) Sexual function
(g) Puerperal mental disorders.
(h) Personality disorders e.g. thumb sucking, bed wetting, juvenile delinquencies  
(j) Mental Retardation.
(i) Mild
(ii) Moderate
(iii) Severe
(iv) Profound
(k) Disorders of Psychological Development of speech, language & motor function
(l) Behavioural and emotional disorders with onset during childhood or adolescence

36.5 Magnitude of the Problem.

(a) Global Scope.
In 2019, an estimated 970 million people globally were living with a mental disorder, according to the World
Health Organization (WHO). This represents about 1 in every 8 people. Due to the COVID-19 pandemic, the
number of people with anxiety and depressive disorders rose significantly. Estimates show a 26% and 28%
increase respectively for anxiety and major depressive disorders in just one year (WHO, 2022).
Specific Disorders:
(i) Anxiety Disorders.
374 million people are estimated to have an anxiety disorder (WHO, 2022), a 25% increase compared to
pre-pandemic figures.

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(ii) Depressive Disorders.

246 million people are estimated to have a depressive disorder (WHO, 2022), a 28% increase from pre-
pandemic levels.
(iii) Mood Disorders.
Statistics for general “mood disorders” are less readily available, but the increase in depressive disorders
suggests a likely overall rise in this category as well.
(iv) Mental Retardation.
The term “mental retardation” is considered outdated and replaced by “intellectual disability”. The estimated
global prevalence is around 1%.
(v) Schizophrenia.
20 million people are estimated to be suffering from schizophrenia, though specific data updates are not
available.
(b) India.
Global Burden of Disease Study (GBD) 2017 estimated that 197.3 million (14. 6%) Indians were affected by mental
disorders. According to a study conducted by NIMHANS, Bangalore in year 2019-2020; 15% of adult Indians
(roughly 223 million) were estimated to have a diagnosable mental illness. WHO Mental Health Day 2023 report
mentions 60-70 million people in India suffer from common and severe mental disorders. It’s important to note
that different studies have used varying methodologies and definitions, leading to discrepancies in figures. The
true number of individuals is difficult to be estimated due to underdiagnosis and underreporting. Over 90% of
individuals with mental disorders in India remain untreated due to stigma, lack of awareness and inadequate
mental health resources. India also has the highest suicide rate among South Asian countries (11.6/1,00, 000
in 2022), further highlighting the mental health crisis.   
(c) Armed Forces.
As per the Annual Health Report of Armed Forces-2020; the average rate of hospital admissions for psychiatric
illnesses in year 2020 is lower than the average of last 10 years. The decadal trend in hospital admissions for
psychiatric disorders in Armed Forces is shown in table 36.1.
Table 36.1 : Decadal Trend Of Hospital Admission For Psychiatric Disorders
Incl Psychosis, Neurosis (Rate Per 1,000)
Year Army Navy Air Force Armed Forces
2010 1. 83 2. 01 1. 21 1. 75
2011 1. 65 3. 16 0. 96 1. 65
2012 1. 62 4. 13 0. 97 1. 70
2013 1. 42 4. 16 1. 15 1. 57
2014 1. 23 2. 49 2. 50 1. 50
2015 1. 36 2. 19 1. 93 1. 46
2016 1. 09 2. 12 1. 53 1. 18
2017 1. 10 1. 78 1. 30 1. 15
2018 1. 04 1. 25 1. 88 1. 13
2019 0. 99 1. 93 2. 82 1. 21
Avg of 10 years 1. 33 2. 63 1. 63 1. 49
2020 0. 87 0. 89 2. 48 1. 03

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36.6 Mental Health in Relation to Armed Forces.

Psychiatric disorders naturally increase during war and are fewer during peace time. The obvious reasons for increase
during wartime are the stressors like fear of impending death or injuries, death or injuries of colleagues, fear of being
held as prisoner of war etc. Increased liability of sudden overwhelming stress of combat or due to prolonged periods
of sustained and monotonous duties cause breakdown of the vulnerable personnel. Separation from main unit bodies,
family members etc. causes severance of social support. Preoccupation of unit authorities with duties of operational
and administrative tasks can lead to inadequate attention to the young service persons, causing a feeling of insecurity
in them.

36.7 Importance of Mental Health Care.

It is of importance in the Armed Forces not only from the point of view of reducing the incidence of psychiatric casualties
and prevention of mental breakdown of the individuals but also to promote functional efficiency of the individual
and the unit. The group efficiency and strength which is of paramount importance for carrying out the specific task
entrusted to the Armed Forces is solely dependent on the extremely high standard of physical and mental integrity of
the individual and the group.

36.8 Peculiarities of Military Life.

For most individuals it is radically different from their civilian life and the difficulty in making the necessary adjustments
is often the forerunner of a breakdown. An ideal soldier’s mind must fit as well in his body. He must get on well with
his colleagues, must not be abnormally attached to any person or place and must not be hypersensitive. He should
be reasonably intelligent, healthy, active, alert and should not resent taking orders. He must identify himself with the
group and must have faith and confidence in his leaders.
The life of a person in the Armed Forces can be divided into three arbitrary periods; the ‘breaking-in’ period lasting
about one, two or three years; the ‘career planning’ period for 7 to 12 years and an ‘established’ period thereafter.
In the first, ‘breaking in’ period he may commit lapses of various severity, may physically or mentally breakdown, may
desert or get discharged. If he survives this period, he is motivated to do the best in his career in the Armed Forces.
When he reaches the conventional high rank and the environments get gradually familiar to him, he wants to ‘establish’
himself as a veteran. His reaction pattern to various situations confronting him during his early career is moulded by
the attitude of his mind, motivation and severity and length of stimuli experienced in his career. The reactions are
generally favourable, but rarely a psychological breakdown occurs manifesting itself in emotional derangements ranging
from the anxiety state to a severe psychotic breakdown or showing internal or external psychosomatic stress syndromes.
The aim in the formative stage should be to recognize such individuals who are likely to be vulnerable to succumb to
the stress of military life. Early detection of emotional peculiarities saves many persons recruited to the Armed Forces
from the later difficult, resistant and severe psychotic, neurotic, psychosomatic, stress or physical syndromes.

36.9 Situations Causing Breakdown During Combat.

Psychiatric casualties in combat often result from either ‘fear’ or ‘conflict’. Fear, a natural response to danger, becomes
abnormal when it occurs without just cause, is disproportionate to the current environment or persists unduly after the
threat has passed. In small doses, fear can help in sharpening judgment and stimulating attention. However, excessive
fear, when dominating the mind, can lead to physical or mental discomfort and psychoneurosis. Many individuals can
successfully suppress the emotion of fear.
Pure ‘conflict neurosis’ arises when an individual has a strong inclination to flee for self-preservation, but qualities
like pride and a sense of duty act as restraining forces. The strength of these barriers varies based on upbringing,
self-pride and sense of duty and it can fluctuate in the same individual at different times. Fatigue, pain and other
stresses can lower resistance. Battle stresses, accompanied by fear, may manifest in bodily symptoms like muscular
tension, trembling, sweating, polyuria, tachycardia, irritability, insomnia, loss of appetite and euphoria. However, these
manifestations do not necessarily indicate an individual’s absolute incapacity for combat duty.
Morale, a key component of personality, plays a vital role in troop’s adjustment to battle environments. Soldiers perform
challenging tasks driven by a sense of duty, honour, self-esteem and self-respect, even in the face of terror. Self-esteem
is a powerful force in human behaviour and feelings of guilt may arise, particularly among troops raised with the notion
that killing is wrong. Post-battle, remorse may lead to reactive or endogenous depression, while guilt over letting down
comrades can contribute to breakdown.

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Abnormal behaviour seldom occurs abruptly; it is often a gradual process shaped by heredity, past experiences and
culture. Approximately half of psychiatric casualties exhibit a history of instability or predisposition to it. Those with a
psychopathic constitution or a family history of it are more prone to breakdown under adverse circumstances.
Soldiers maintain strong attachments to their families and disruptions to leaves, especially during significant family
events, can cause considerable anxiety. The emotional link with home is crucial, with regular receipt of letters serving
as a vital connection. Group dynamics play a significant role; soldiers fighting together develop close emotional ties,
encouraging them to perform heroic deeds for their comrades. The group provides protection against external fear and
poor integration within the unit can lead to emotional collapse.
Leadership quality is a crucial factor affecting morale, with indifferent leadership lowering morale and fighting efficiency.
Inadequate training under wartime conditions can also contribute to insecurity, as troops may find themselves ill-
prepared for battle. Technical mastery of weapons alone is insufficient; confidence in using weapons under battle
conditions is essential for maintaining morale.

36.10 Types of Mental Breakdown Syndromes.

Clinical Picture.
It is crucial to differentiate between normal and pathological reactions to stress. In the face of an imminent threat
to life, every individual will naturally experience fear as part of the instinct for self-preservation. This normal reaction
triggers involuntary responses in psychosomatic defences to confront the threat. The autonomic nervous system is
activated, leading to tachycardia, increased blood pressure, respiratory changes and sweating. Mental tension heightens,
alertness intensifies and relaxation becomes challenging, often accompanied by feelings of uneasiness and discomfort.
Some individuals may exhibit these symptoms and seek medical attention. A simple check-up, reassurance and an
explanation that these reactions are normal and will diminish over time without treatment are usually sufficient. Such
individuals should promptly return to full duty.
In contrast, pathological reactions involve decompensation to stress. The severity and duration of environmental stress,
coupled with individual personality traits, contribute to the problem of decompensation. Various clinical manifestations
of pathological reactions are detailed in the following paragraphs.
(a) Battle Exhaustion.
Common symptoms of battle exhaustion include weariness, dejection, irritability, tremors and sleep disturbances.
The triad of irritability, weariness and sleep disturbances represents the initial stages of exhaustion, which
can persist for days, weeks or even months. However, this marginal state of unstable equilibrium is eventually
disrupted by an incident, leading the soldier to become a casualty. It is crucial to detect and manage this incipient
stage to prevent further breakdown, ultimately saving manpower and avoiding unnecessary evacuations. If
the exhaustion state goes unnoticed and untreated, decompensation intensifies. Weariness progresses to
lassitude and apathy, with the individual inclined to lie down and sleep. Disregard for personal hygiene and
an inability to attend to basic needs for food, drink and personal safety follow. Muscle tension may lead to
aches and pains and obvious tremors can interfere with speech and movement. Emotional instability may
manifest as uncontrolled outbursts of weeping or temper. The individual experiences a loss of self-confidence
and demoralization. Despite possessing good personalities and enduring anxiety for an extended period, these
individuals eventually succumb to physical and emotional stress. The onset is typically not dramatic unless
the incipient stages have been ignored or unrecognized. With proper rest and treatment, most of these cases
recover promptly and can be returned to duty.
(b) Anxiety Reactions.
These are common clinical syndromes and consist of heightened sense of fear associated with disabling signs
and symptoms. Some may start acutely during stressful episode of battle or bombing and are known as ‘panic
reactions’. In the others, the signs of anxiety are more insidious in onset and may become chronic.
(c) Panic Reactions.
The onset is sudden and usually occurs in the young, inexperienced soldier in his first battle although, if the
battle stress or bombing is overwhelming, even hardened soldiers may be affected. The symptoms are those of
acute terror. The individual may shout and scream, weep and run aimlessly disregarding orders. He is seeking
safety through flight. The condition is contagious and may spread rapidly among the men, unless it is dealt
with promptly and firmly in the front line.

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(d) Anxiety State.

This is insidious and represents a decompensation to fear. The symptoms may be mild, such as increased
sweating, tremors, tachycardia, anxious and fearful expression and anticipation of being wounded or killed.
In more severe cases, there is also loss of emotional control, crying or fits of anger and irritability. Coarse
tremors of the limbs may interfere with his actions. There may be headaches, pre-cordial pain, dyspnoea and
giddiness. There may be nausea, vomiting, diarrhoea or polyuria.
These conditions may be confused with other physical illnesses or may be masking a head injury, acute
infection, fever and dehydration. Hence a proper physical examination is essential. A rise of systolic blood
pressure and tachycardia are common physical findings. These subside with rest and sedation. They do not
need evacuation.
(e) Somatoform Reactions.
These reactions were formerly referred to as hysterical reactions, marking a further progression in the
decompensation mechanism. At this stage, anxiety or fear is subconsciously transformed into specific physical
conditions that incapacitate the individual, preventing further exposure to stress. The physical symptoms vary
and impact the motor and/or sensory systems. Examples include paralysis in different body parts, aphonia
and sensory disturbances such as sudden blindness, deafness and anaesthesia. Non-epileptic convulsions,
vomiting, severe pain in the back and other body parts, as well as unusual complaints like loss of memory,
sleepwalking or a sensation of being possessed by “spirits” may also manifest. While there might be a history
of a minor injury, the clinical presentation is disproportionate to the injury. A thorough physical examination
reveals contradictory signs and confirms the absence of an organic basis for the symptoms. It is crucial to
recognize that the individual is not intentionally feigning illness; rather, the condition serves as a subconscious
defence mechanism against the decompensation caused by stress.
(f) Depressed Reaction.
This represents a further descent from a sense of helplessness to a sense of hopelessness, characterized by
overwhelming feelings of sadness and despair, a loss of the will to fight and even a loss of the will to live.
Individuals experiencing this state appear dull, listless and apathetic; they may be in a dazed, confused or
semi-stupor state. Speech becomes slow and monosyllabic, with prolonged reaction times. Loss of appetite
and constipation are common, along with a decline in self-confidence, initiative and drive. In contrast to
battle exhaustion, individuals facing depression struggle with sleep and if they do manage to sleep, they
wake up without feeling refreshed. Older soldiers seem more prone to this type of reaction than their younger
counterparts. This syndrome is often linked to grief over the death of comrades, guilt feelings associated with
taking another person’s life or an unwarranted sense of shame for letting down fellow soldiers. Such thoughts
can lead to suicidal tendencies. In some cases, the depression may be mixed, resulting in restlessness and
agitation. Occasionally, physical symptoms or a wound may mask the depression, but the key to diagnosis lies
in identifying the pervasive sense of sadness and despair.
(g) Hyperactive Reaction.
Initially appearing as normal and purposeful, these reactions can, in fact, be indicative of decompensation
resulting from an unrealistic overconfidence in one’s abilities. Such individuals may become liabilities, forming a
nucleus of opposition to orders and plans that are objectively better than their own. Gaining their attention and
cooperation becomes challenging, as they tend to be aggressive, hostile and quick to place blame on others.
In extreme cases, they may even disobey orders or commit crimes. Handling these individuals requires a firm
and tactful approach, emphasizing the importance of coordinated action within the team. If persuasion fails,
adequate sedation and evacuation with escorts may be necessary. Reasoning with them is often ineffective
in these situations.
(h) Psychotic Reaction.
The psychotic reaction represents the ultimate decompensation. The individual’s contact with the real-life
situation is broken and his personality is shattered. The clinical picture and severity will depend on the
personality and the stress. Where the personality is strong, the psychosis may be transient (e.g. ‘three-day
psychosis’). But where the personality is weak or predisposed by heredity, the psychotic illness will be severe
and will be similar to that occurring in civilian life (e.g. Schizophrenia, mania, depression etc.). Psychosis is to
be diagnosed when there are disturbances of thinking with hallucinations and delusions and impairment or

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loss of insight and judgement. There may be disorientation and confusion. Psychomotor activity is unpredictable
and may range from stupor to violent excitement.
(j) Delayed Reaction.
Some individuals may exhibit excellent behaviour during an actual battle, but after a certain period, they begin
to manifest symptoms that can be highly disabling. This is often attributed to a subconscious fear of reliving
the intense experience. Insomnia, terrifying dreams and nighttime screaming may develop, accompanied by a
decrease in efficiency. Physical symptoms like tachycardia and sweating may also emerge. Masserman likened
this phenomenon to Pavlov’s conditioned reflex, where the instinct of self-preservation is triggered to avoid
further danger. A straightforward explanation, reassurance and mild tranquilizers may be sufficient to restore
the individual to full duty within a few days. However, if neglected or misdiagnosed, the condition may become
‘fixed’ and more challenging to treat. In such cases, evacuation for specialist treatment becomes a necessity.
(k) Post Traumatic Stress Disorder (PTSD).
These conditions emerge from the violence and combat a soldier faces like seeing their fellow soldiers lose
their lives, killing “enemy” soldiers, the near-constant threat of death, natural disasters, accidents, military
excesses that may undermine their beliefs etc. Combat exposure remains one of the key causes of PTSD.
Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about
the event. Majority of the persons who go through traumatic events may have temporary difficulty adjusting
and coping, but with time and good self-care, they usually get better. The symptoms may last for months or
even years and interfere with day-to-day functioning.
(l) Mental Symptoms in Physical Disease.
In every case with mental symptoms, the possibility of physical factors being responsible or of coexisting
physical disease, should always be considered. A thorough physical examination is essential to avoid pitfalls in
diagnosis. Heat exhaustion, cerebral malaria, acute infections, liver and renal failure etc are not infrequently
associated with psychiatric symptoms, which may vary from mild irritability to complete confusional states.
(m) Malingering.
Malingerers intentionally feign physical or mental illness to evade field service, demonstrating a fully conscious
and deliberate effort that warrants a firm disciplinary response. The symptoms they present may vary as they
seek attention and when they believe they are unobserved, they may revert to normal behaviour. Discomfort,
such as going without food for a day or two, can prompt them to abandon the pretence. A comprehensive
physical examination is essential to rule out serious organic diseases. Malingering is not a medical issue but
rather an administrative one. Once malingering is definitively diagnosed, the individual should be returned to
their unit for disciplinary measures.   

36.11 Prevention of Psychiatric Breakdown.  

As with all other diseases, prevention is the first line of defence against psychiatric illnesses. The preventive measures
are as follows:
(a) Careful Recruitment.
This stage is of utmost importance, involving not only a physical examination of the recruit but also an evaluation
of their mental capacity and personality strength. Individuals displaying somatic symptoms of anxiety, such as
tachycardia, hyperhidrosis and tremors should be deemed unsuitable. The motive behind recruitment must be
determined and those with poor or negative motivations should be rejected. Indications for rejection include
a history of previous mental illness and personal instability. While a comprehensive psychological assessment
may not always be feasible, every effort should be made to exclude individuals with low intelligence, emotional
instability, weak personalities and a history of significant maladjustment in civilian life.
(b) Screening at the Training Centres.
It is possible to detect susceptible individuals during the training periods at the centres where the recruits are
under constant observation of their instructors. Apart from homesickness, which usually passes off within 2-3
months, a recruit who does not show satisfactory adjustment at the end of 3 months should be evaluated by
psychiatrist.

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(c) Training and Selection for Specialist Trades.

Many breakdowns are precipitated by unhappiness and discontentment with their trades. Every effort should
be made to select men according to their individual aptitudes and capabilities. This is very important regarding
the highly skilled specialist trades like radar operators, signalmen, engineers and so on who may breakdown
at critical moments and for whom replacements may not be readily available.
(d) Maintenance of High Morale.
This is essential for a fighting unit and is more important than even superior equipment. The basic ingredients
are leadership and good man-management. In addition to these, adequate training and battle indoctrination
before action are essential to keep the men mentally fit, confident and eager to fight.
(e) Elimination of Precipitating Factors.
The stress of service in forward areas and of actual battle cannot be eliminated. But there are several
factors which aggravate this stress and precipitate breakdowns. These may be domestic problems like marital
disharmony, financial difficulties, illness of the wife and children and other social & cultural difficulties. A man
can fight and work better if his mind is free from these problems. Frequent interactions with unit and family
members, regular remittances of authorized emoluments, leave as needed (within authorization), promotion
in due course and well-organized welfare services reduce these stresses and hence minimize the chances
of breakdown. Proper living conditions, adequate food water and sleep are also important factors. Human
nature is such that a man will put up with physical hardships if he knows that these are inevitable. But if he
suspects that these are due to the leader’s carelessness, his morale is quickly lowered and this constitutes
a dangerous precipitating factor. No one is prepared to suffer and die because of bad leadership.

36.12 Early Recognition of Psychiatric Disorders.

It is not difficult to diagnose a frank psychiatric illness. Early diagnosis of these conditions is more important, as
some of these illnesses become chronic and lead to invalidity. Moreover, some of them especially panic reactions and
hysteria, tend to be contagious and may cause a serious loss of manpower and efficiency in a unit and to a lowering
of morale. With few exceptions, most patients present prodromal symptoms. The RMO and the unit officers should be
able to recognize them. The common early signs and symptoms of incipient breakdown are:
(a) Deviation from normal habits of eating, sleeping, working and speaking. These are noticed first by his
comrades.
(b) Sleep disturbances.
(c) Excessive smoking and drinking.
(d) Irritability, tension and emotional instability.
(e) Progressive tiredness, weakness and loss of weight.

36.13 Stress.  
The term ‘Stress’ is used as an umbrella term to cover all aspects associated with the phenomena. However, what
really concerns us is the “Stress Response”. It is the body’s reaction, both physiological and psychological, in response
to a ‘stressor’ i.e., an event occurring outside the body in an external environment. It is this stress response which
leads to various “Stress Symptoms” or “Stress Response”. So, it is not really the “Stressor” that leads to stress but our
perception of that event, the meaning we attach to it and the way we react or respond to it that leads to symptoms
diseases of stress.
Each of us respond differently to stress stimulus. In other words, each of us has a different threshold. It is determined
by genetic make-up, to our health, cultivated habits, training received, personality and environmental factors. Nature
has built the stress response into our bodies for a protective and desirable reason, viz, to gear up the entire body to
deal with acute physical emergencies. But the same stress response which was so useful and protective during the
evolutionary stages of human race, now seems to have become a major hazard to our health.   
In modern day, we seldom face physical dangers however to negotiate modern day stressors or challenges like having
a difficult senior, staying separate from family, various competitive exams, difficulties in career, etc our body’s stress
response remains perpetual or massive. The increase in blood pressure and heart rate, increase in blood sugar,

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increase in blood clotting mechanisms, taut muscles, lowering the immune defence of the body and reduction in the
digestive process for long periods lead to major diseases like hypertension, diabetes, peptic ulcer, asthma, infections
due to reduced immunity, various muscle & joint pains, etc. Hence, it is essential for us to learn ways to calm down
our reactions to tackle day to day stressors and to develop adequate “coping mechanisms”.

36.14 Preventing Stress and Developing “Coping Resources”

Interestingly most of the measures which can help us are not medical measures but are general managerial techniques
as discussed below:
(a) Learning and Practicing Decision Making Techniques.
It involves defining the problem at hand, identifying the various alternative options at hand to tackle the
problem, deciding on the best option and finally committing oneself to the selected course of action.
(b) Develop Personal Financial Management Skills.
Improperly managed finances are one of the most important stressors of modern life. So, it’s important to
take stock of our existing /projected income and should avoid falling into the category of excessive desires for
materialistic things, impulsive spending and rather should be striving towards essential/ desirable for decent
life to avoid adding further stressors in our lives.
(c) Develop Time Management Skills. 
Managing available time in the most gainful and productive manner is a skill which must be learnt, practiced
and sharpened over the years. Improper time management is an important cause of stress in today’s life.
(d) Make Conscious and Deliberate Efforts to Maintain Good Health.
One should make conscious efforts to maintain good health for self and for family members as the amount
of stress due to ill health of self and anyone in the family would be tremendous.
(e) Undertake Regular and Brisk Exercise.
It has been well established that brisk and regular exercise leads to release of beta endorphins which bring
about a feeling of well-being, confidence, alertness and decrease in pain sensations. It plays an important role
in subsiding the adverse effects of stressors and overall wellbeing.
(f) Spend “Quality Time” with Your Family.
From psychological point of view, one of the major stressors is feeling of being “isolated” or “disconnected”.
By spending quality time with your family members, you feel connected which helps preventing stress.
(g) Train the family members for difficult situations.
An important reason for stress among the head of the family, when he stays away from family, stems from the
constant worries that occur about the family. It is therefore logical that one should visualise that occasions
may come when family must stay separated and should think of the problems family members would face
at such times. Accordingly, family members be made aware of such anticipated problems and train them to
handle those situations, be it routine or difficult. This will reduce the stress for both the head of the family
and family members during the period of separation.
(h) Develop Social Support Systems.
It would be wise to put in some efforts to develop some close friends towards whom we can look up for
support during stressful situations.
(j) Avoid Ego Struggles.
Often the stressful encounters with others are, in fact, unnecessary ego struggles, where the only prize is
protection of self-image however the price is exposure to substantial stress not only in the imminent future
but also in the long run. It is best to avoid the tendency to get into such ego struggles for your own health
and well-being.
(k) Adopt Traditional Cultures.
Yoga has been advocated as means of attaining physical and psychological health 5,000 years ago. Our

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traditional cultural values like need based living, sharing, acceptance of good with the bad, renunciation, if
combined with modern living can improve the quality of life manyfold.
(l) Practice Methods to Get Good Sleep.
Good sleep is essential for de-stressing as well as in assisting in repair of the physical and mental breakdown
that occurs during whole day. Some important aspects for getting good sleep are:
(i) Avoid caffeine containing drinks or tobacco before retiring  
(ii) Don’t use alcohol to get sleep as it interferes with the rhythm of normal sleep and causes rebound
arousal of brain.
(iii) Do not sleep in afternoons if you have difficulty falling asleep at night.
(iv) Schedule brisk exercises in the morning and light exercises in the evening.
(v) Keep a regular sleep schedule.
(vi) Associate bed with sleep only and don’t eat, read or watch TV on bed.
(vii) Try some light reading and relaxing before retiring to bed.     
(m) Practice “Assertiveness” Skills.
Assertiveness does not mean being aggressive. Assertiveness is the honest expression of what you feel and
want from others, without trying to force them to give it. It is particularly useful while dealing with “difficult”
people and the consequent stress.   
(n) Practice “Relaxation Techniques”.
There are various proven techniques, which, if practiced for 15 to 20 minutes a day will help control stress
related tension. It could include abdominal breathing, deep muscular relaxation, etc.
(o) Spiritual Practice and Meditation.
Engagement in spiritual practice in various forms has been shown to have a strong role in both, preventing the
stress response as well as for coping up with stressful situations. The soothing physiological & psychological
benefits of meditation are well known.
(p) Yoga.
There is enough evidence to indicate that Yoga is effective to cope up with stressful situations. In general, try
to practice Yoga daily or at least 4 to 5 days in a week.
(q) Emotion Focussed Coping and Accepting the Inevitable.
There are certain inevitable situations in everyone’s life where we must learn to live with them, like loss of
some family member, developing some chronic illness, growing old, not getting promotion, etc. Once we accept
that this situation is going to stay and we can’t do anything about it then it is best to accept that and move
on in life.
(r) Suppress the Distressing Thoughts.
If you have done what can be done then further mental processing will only make the situation worse. The
body’s physiology and hormonal system does not distinguish between fact and fantasy. Hence, it is better to
suppress our thoughts to control the resultant emotional responses.
(s) Reframing.
Reframing is the strategy in which we start looking differently at a situation. We accept the problem and start
looking for positive elements to make the situation less stressful.
(t) Discharging Painful/negative Emotions.
It’s not uncommon to become unhappy or even sick due to bottled up emotions. Disclosing our feelings to a
near one or to a doctor or just writing it in personal diary (therapeutic writing) often provides much relief.

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36.15 Early Signs of Stress.   

It is important to recognise stress at an early stage and hence the need to be alert to the signals of stress emanating
from our body and mind. Few signs of stress are as under:  
(a) Headache, pain in neck, backache, aches in muscles and joints, fatigue & exhaustion, vague symptoms
of indigestion, sleep problems (either difficulty in falling asleep or getting up in between or not feeling fresh
after getting up in the morning, etc).
(b) Feeling of being distressed/ harassed, decreased interest in life and decline in cheerfulness.
(c) Deterioration of interpersonal relationships, whether at home, workplace or in social circles, frequent
bouts of irritability and social withdrawal.
(d) Deterioration of performance, difficulty in concentration, forgetfulness, increased errors, reduced efficiency
and decreased motivation.
(e) Initiation or increase of substance abuse (alcohol, tobacco, etc)
(f) Excessive and frequent eating of food/snacks or avoidance of food; gain or loss of body weight in a
short span of time.

36.16 Stress Prevention in Armed Forces.  

Armed Forces have peculiar types of stresses, like being faced with life & death situations, uncertainties about future
and compounded by staying alone. Certain aspects which armed forces doctors can educate the military commanders
to help prevent stress in their subordinates are as under:  
(a) Educate their subordinates on various preventive/pre-emptive as well as coping methods as explained
earlier in this chapter.
(b) Stay “connected” with their subordinates either by playing games with them or other informal interactions.
(c) Talk to your subordinates and encourage them to talk about themselves, their families, their problems,
etc.
(d) Allow, rather promote humour and laughter. Make sure people speak out their painful experiences.
(e) As a leader develop the art of “listening” effectively to your subordinates.
(f) Encourage regular and brisk physical exercise in the form of organised physical training or sports activities.
(g) Keep everybody informed about your plans and job expectations. One of the causes of stress at workplace
is “lack of control on circumstances”. By letting everyone know about the tasks to be performed and the
reasons for same, it will give the subordinates feeling that they are “in control” of the situation.
(h) Promote spirituality, yoga and meditation.
(j) Be fair and impartial to your subordinates.
(k) Leave is a very important aspect in Armed forces as people stay away from family for long durations.
Leave should be provided regularly to the extent possible as it breaks the vicious circle of isolation and stress.
(l) Keep optimism alive in yourself and your subordinates.
(m) Establish a “buddy” system wherein each member of pair is responsible for taking care of his buddy
and keep vigil for early signs of stress.   

Suggested Readings.
1. Guide to Medical Officers (Military Pensions)- 2023.
2. DG Memorandum No 171.


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Chapter
XXXVII

DENTAL AND ORAL HEALTH

37.1 Introduction.
During the past few decades, oral health authorities in the fields of epidemiology, education, services, health
education and disease prevention have given special attention to the highly prevalent problems of dental caries
and periodontal diseases. With these approaches, dramatic improvement in scientific knowledge and technology
has taken place in the field of oral health.

37.2 Structure of the Tooth.

The teeth are hard-calcified structures set firmly in bone sockets in the maxilla and mandible by means of a root or
roots. The part visible in the oral cavity is the crown, which is separated from the roots by a narrow portion called
the neck or cervical portion of the tooth. The crown is covered with hard shiny enamel. The tissue covering the root
is the cementum. The ivory-like structure that forms the bulk of the tooth is the dentin. Enamel lacks the capacity for
self-repair since it contains no cells. It resists wear only through its extreme degree of hardness. Dentin is capable
of repair, but it is less hard and resistant than enamel. Investing between the roots of teeth and socket wall formed
by alveolar bone is the thin periodontal ligament, the fiber-bundles of which help to suspend and anchor the teeth
in place. Its cushioning effect also helps in protecting periapical tissues from likely compression during mastication.
The dental pulp occupies hollow pulp chambers and pulp canals in the crown and roots of teeth. It contains a plexus
formed by connective tissue fibers, nerve endings, blood vessels, tissue cells and lymphatics which communicate with
their major source of supply through apical foramina in the root ends.

Fig 37.1 : Healthy Tooth

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The gingival, periodontal ligament, alveolar bone and cementum which support the teeth are collectively termed
as periodontium (Fig 37.1)

37.3 Dentition.
The first detention brings forth the deciduous or Primary teeth or “Milk teeth”. There are twenty teeth in this set:
ten in each jaw. The tooth buds begin to form about the sixth week of prenatal life and calcification starts about the
sixteenth week of prenatal life. The position of the first permanent molar helps to determine the shape of the lower
part of the face. Their position and health, to a great extent also determine the position of the other teeth. Therefore,
early examination and care will help to ensure their retention throughout life. These teeth are shed about the 6th to
7th year when the permanent teeth follow. There are 32 teeth in the permanent set: 16 in each jaw. Calcification of
permanent teeth begins in the jaws about the time of birth. The last four teeth to erupt are the third permanent molars
or “wisdom teeth”. They do not erupt until about the age of 18 years or later and may even never erupt. Sometimes
they become “impacted” below the gum surface necessitating extraction to preserve the heath of the adjacent teeth.
Dentition schedule is shown in Table 37.1
Table 37.1 : Dentition Schedule
Maxillary Mandibular

DECIDUOUS Formation Formation

Eruption Shedding Eruption Shedding
Begins Begins
TEETH
Intrauterine Postnatal
(Years) (Months) (Months) (Years)
(months) (months)
Centralincisors 4 7 7 40 6 7
Lateral incisors 4½ 9 8 40 7 7-8
Canines
5 18 11-12 5 16 10-12
First molar
5 14 9-10 5 12 8-9
Second molar
6 24 11-12 6 20 10-11
PERMANENT Postnatal (Years) (Years)
(months)
TEETH
Central incisors 8-12 7-8 No definite 3-4years 6-7 No definite
schedule schedule
Lateralincisors 10-12 8-9 3-4 years 7-8
Canine 4-5 11-12 4-5 years 10
First molar 13-19 10-11 1-2 years 10-12
Second molar 2-3 10-12 23-31 months 11-12
First molar At birth 6-7 At birth 6-7
Second molar 2-3yrs 12-13 20 mths-3 years 11-13
Third molar 7-9 yrs 17-21 8-10 mths 17-21

37.4 Tooth Numbering.

The system in current use in service is as per Federation Dentaire International System (Modified Palmer System). In
this two-digit system, the first digit indicates the quadrant and the second digit a particular tooth in that quadrant.
Quadrants are allotted the digit 1 to 4 for the permanent and 5 to 8 for the deciduous teeth in a clockwise sequence,
starting at the upper right side; permanent teeth within the same quadrant are allotted the digits 1 to 8 whereas
deciduous teeth (1 to 5) from the mid-line backwards. The digits should be pronounced separately: thus, the permanent
canines are teeth one-three, two-three, three-three and four-three. Numbering system is as follows:

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Permanent teeth:
(Upper right) (Upper left)
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
(Lower right) (Lower left)
Deciduous teeth:
(Upper right) (Upper left)
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
(Lower right) (Lower left)

37.5 Functions of Teeth.

Besides mastication, the teeth help in phonetics and contribute towards aesthetics. The process of mastication involves
incision and grinding of food. The incisors serve to incise the food and the premolars and molars do the grinding. The
food is broken into smaller portions and is thoroughly mixed with saliva before it is swallowed. For efficient performance
of their function the teeth must be correctly aligned in arches and meet in normal occlusion. Occlusion means a
contact relationship of the teeth when the jaws are closed. Normally mastication is done on one side only at a time.
Chewing ability depends upon the soundness of teeth, firmness of their embedment, hardness of enamel, uniformity
of occlusion and strength of the jaws. Chewing fibrous foods such as meat, radish, celery, carrots, apples and so on
develops the jaws and at the same time keeps the gums in proper tone by stimulating blood circulation through them.
Children should be taught to chew their food thoroughly, but not to crack nuts or very hard items, less it may damage
the enamel, so that the teeth and the supporting structures develop properly as a well-functioning organ. Teeth that
are properly aligned and occlude normally, help in proper pronunciation of words. Facial appearance, beauty and
symmetry depend upon well-developed jaws and a full complement of teeth developed in proper alignment. If the teeth
are mal-aligned or have spaces between them or a few teeth are missing, the speech becomes faulty and lacks clarity.
The unpleasing expression due to irregular or missing teeth may cause self -consciousness, which leads to inferiority
complex that may ultimately result in social maladjustment. Teeth and their supporting structures thus considerably
influence and affect the personality.
It has always been commonly believed that with the advancing age the loss of teeth should be considered a natural and
inevitable occurrence. However, it is now recognized to be a direct result of pathological process. It was earlier inferred,
although rather incorrectly, that below the age of 35, the tooth loss was the result of dental caries, whereas beyond
the age of 35 it results from ‘pyorrhea’. However, from epidemiological studies world over, it has been established that
diseases of four different supporting structures of the teeth (termed collectively as ‘periodontium’) can have their onset
even amongst the school going children. Such global surveys therefore indicate, that although drastic and damaging
results might be discernable in most of the population, beyond the age of 35 or more, the damaging influences on
the periodontal tissues can be traced to have commenced even as early as 12-15 years of age. The universal axiom
that ‘prevention is better than cure’ still holds true and to be more effective, this too must therefore commence during
the school-going age.

37.6 Dental Plaque.

Dental plaque is thin, tenacious, firmly adherent and well-organized biofilm adhering to the tooth surface, restorations
and dentures. It is different from other deposits on the tooth surface such as materia alba and calculus. Materia alba
refers to soft accumulations of bacteria and tissue cells that lack organized structure of dental plaque and are easily
displaced with water spray. Calculus is a hard deposit that forms by mineralization of dental plaque and is always
covered by a layer of unmineralized plaque. Dental plaque is composed primarily of more than 325 different bacterial
species and one gram of plaque contains approximately 2 x 1011 bacteria. The dental plaque may be cariogenic, causing
dental caries or calculogenic, causing periodontal diseases.

37.7 Dental Caries.

It is an irreversible progressive disease of the calcified dental tissue characterised by loss of tooth structure resulting
from the dissolution of the tooth mineral and the destruction of its organic matrix. Streptococcus mutans, lactobacilli

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and other strains from calculogenic plaque act upon refined carbohydrates like sucrose, lactose etc. and produce organic
acids which cause demineralization of tooth enamel / cementum. The parts of teeth most vulnerable to cations attack
are the pits, fissures and proximal surfaces of teeth. Regardless of where caries starts, if unchecked, it proceeds and
spreads from the enamel into the dentine and then reaches the dental pulp. Once the pulp is infected, acute pulpitis
may occur which is in an acute inflammatory response in the pulpal tissue and most often becomes chronic leading
to inflammatory response in periapical tissues.

37.8 Diagnosis.
Although bacteria on the teeth are the direct cause of dental caries, many microbiological, environmental and host
factors interact to determine whether or not an individual will be affected and if affected, how and to what extent.
Dental caries is therefore a multifactorial disease.
In the past, diagnosis of dental caries involved the use of a mouth mirror, an explorer and perhaps bite wing radiographs.
“Tug back” or a feeling of resistance when the explorer was moved on the tooth surface led to an almost confirmed
diagnosis of caries. Treatment of dental caries as per Black’s “Extension for prevention” necessitated considerable
loss of tooth substance beyond the actual carious lesion. The modern approach to diagnosis and treatment based
on a series of important advances differs from Black’s rules in almost all respects. The diagnostic process does not
focus only on the presence of lesions but is expanded to include identification of factors that lead to the formation of
lesions. This approach therefore makes a distinction between the caries lesion and the caries disease and comprises
several important stages:
(a) Clinical and radiological examination to detect early lesions.
(b) Evaluation of factors causing formation of cavities.
(c) Diagnosis of caries disease.
(d) Control of identified etiological factors.
(e) Treatment of caries lesions.
(f) Formation of maintenance programme.
Future diagnosis of caries may be improved using subtraction radiography or lasers. Practical tests like levels of
Streptococci mutans and lactobacilli, secretion rate and buffering capacity of saliva are among the factors that can
now be evaluated reliably.

37.9 Prevention.
The multifactorial nature of caries allows scope for several different approaches for prevention of this disease. It should
also be recognized that certain etiological factors have vastly different consequences, depending on the total mix of
factors. For example, the consequence of a diet rich in sucrose is quite different for a person who is frequently exposed
to fluorides than for one who has very little exposure.
(a) Diet.
The contribution of sucrose to implantation, colonization and metabolic activities of cariogenic bacteria has
been clearly established and has led to search of sucrose substitutes. Non-sucrose sugars like high fructose
corn syrup, invert sugar, glucose, fructose are found to be less carcinogenic than sucrose. Caloric sweetener
like palatinose, non-caloric sweeteners like aspartame, cyclamate and saccharin and sugar alcohols like sorbitol,
xylitol and maltitol can be substituted for sucrose in food products, medicines and toothpaste.
(b) Fluoride.
The safety and efficacy of fluoride in preventing dental caries is known. The United States has set a limit of
4 mg / liter as the maximum allowable level in drinking water and recommends a level of 0.7 to 1.2 mg / liter.
During decrease in the pH of the dental plaque free fluoride is available and helps in remineralization process.
Moreover, fluoride used on a regular basis becomes concentrated in dental plaque and appears to interfere with
enzymes used by the bacteria in metabolizing sugars. Fluoridated toothpaste, rinses, gels and tablets are the
most important delivery system. Water, salt and milk are highly cost-effective vehicles and should be implemented
wherever technically and politically feasible.

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(c) Sealant.
The use of dental sealant is an effective way to prevent pit and fissure caries. One of the greatest barriers to
increased use, however is the fact that successful placement and retention of sealant are highly dependent on
technique and the availability of appropriate equipment including air and water spray and adequate suction.
(d) Antimicrobials.
Infants acquire the bacteria that colonize the oral cavity and digestive tract usually through normal handling by
their mothers or other care givers. Investigators have found that it is possible to interfere with the process of
transmission of mutans Streptococci by treating mothers and other close family members with antimicrobials
like chlorhexidine gluconate 0.2 or 0.12%.

37.10 Immunization.
An improved understanding of genetics of oral bacteria is also leading to new approaches to development of safe and
effective oral vaccines. The possibility of creating a polyvalent vaccine effective against caries, as well as measles,
poliomyelitis and other serious infections is under consideration. With successful programme to reduce the effects
of etiological agents & increase host resistance, a new approach to treatment of the caries lesion can therefore be
outlined as follows:
(a) Incipient Lesion.
(i) Remineralization using topical fluoride therapy.
(ii) Counselling on dietary and other risk factors.
(b) Initial Cavitation.
(i) Application of a sealant
(ii) Restoration with preventive materials after minimal excavation and preparation with hand or
rotating instruments if necessary.
(c) Moderately Sized Lesion.
Restoration conserving maximum amount of tooth substance.
(d) Deep Lesion.
(i) Restoration, conserving maximum amount of tooth substance.
(ii) Endodontic therapy, if necessary.
This new approach can also be applied to retreatment using the same steps and repairing physical defects only if
symptoms are evident in the teeth or supporting tissues.
Periodontal Diseases.

37.11 Gingivitis.
While caries has been linked strongly with only a few organisms, the development of gingivitis appears to be caused by
nonspecific bacterial plaque flora, which changes over time from predominantly gram positive to more gram negative. In
gingivitis the gums become spongy, red, swollen, bleed when brushed or touched, stand away from teeth, often causing
little pain and discomfort. Gingivitis therefore is often neglected until it has reached an advanced stage. Gingivitis does
not necessarily develop into periodontitis. However, periodontitis is always preceded by gingivitis. The disease can spread
to involve deeper supporting tissues viz. periodontal ligament, cementum and alveolar bone. Due to apical migration
of junctional epithelium, there is formation of a gap between teeth and gums known as the periodontal pocket. Such
pockets harbor dental plaque and calculus which, if untreated, ultimately leads to alveolar bone resorption, mobility
of teeth and exfoliation.
(a) Diagnosis.
Traditional approaches to periodontal diagnosis include assessment of gingival health and measure of pocket
depth, alveolar bone height and loss of periodontal attachment. In addition, the presence or absence of dental
plaque and supra and sub gingival calculus is recorded. Assessment of gingival health continues to rely on

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visual evaluation of the tissues and the extent to which gingival gentle probing can provoke bleeding. The
height of alveolar bone is assessed from radiographs. A complete assessment of the periodontal situation
should include quantification of the loss of attachment around the teeth (pocket depth and gingival recession
as measured from the cemento - enamel junction or some fixed points). It is important to note that pocket
depth, bone height and periodontal attachment, represents only the cumulative results of past pathological
events and do not reflect the rate of progression of lesions unless measurements of radiographic assessments
are made at short time intervals. Many diagnostic tests aimed at detecting early events in the disease process
such as bacterial cultures, DNA probes, immunofluorescent assays, specific antibody determinations and the
measurements of hydrolytic enzymes, break down products and cytokines are currently being studied. Markers
of host defense mechanisms, such as chemotactic responses and phagocytic capability of polymorphonuclear
leucocytes have also been investigated.
There is no single organism that is pathognomonic of a change from gingivitis to adult periodontitis. Several
species like Porphyromonas gingivalis, Prevotella interrnedia, Eikenella corrodens, Wolinella recta, Treponema
denticola and Capnocytophaga are present in various combinations in patients with adult periodontitis. The
association between a gram-negative anaerobic microflora and periodontitis has been extensively demonstrated
and elimination/control of this flora will reduce risk of periodontitis.
(b) Treatment.
Epidemiological studies from many countries show that severe periodontal destruction is less prevalent than it
was thought to be 10 to 15 years ago. Improvements in oral hygiene are believed to be the primary factor in
this change. Due to increased life expectancy, periodontal care will also be needed by many elderly people who
are medically compromised, have physical and mental handicaps, live in nursing homes or take medications
with potentially harmful side effects.
At present, the prevention of periodontitis is based on mechanical removal of plaque, plus antimicrobial and
antiseptic mouthwashes, if necessary. Where oral hygiene levels are generally high, fewer than 10% of adult
population develop advanced periodontal destruction. However, treatment of gingival inflammation (gingivitis)
and maintenance of gingival health depend on adequate plaque control through self-care. Instruction in good
oral hygiene and constant practice early in life may lead to good habits, which will help to prevent the formation
of calculus. Regular examinations and frequent removal of calculus are also beneficial.
Moderate or advanced periodontitis can be treated by elimination of bacterial infection and establishment of
effective plaque control. It has been conclusively demonstrated that most periodontal problems can be treated
using non-surgical, conservative approaches. With a better understanding of the biology of connective tissue
and of the regenerative potential of periodontal tissues, guided tissue regenerative procedures have been
shown to enhance formation of new alveolar bone. This approach has great potential value for individual teeth
but cannot be applied as a public health measure.
A rare condition, Juvenile periodontitis, seems to be familial and is characterized clinically by inflammation
and rapid progression of periodontal lesion. The presence of Actinobacillus actinomycetecomitans may be an
early marker of this disease.
Necrotizing ulcerative gingivitis and its most severe form, Noma (now included in list of Neglected Tropical
Diseases) appears to be associated with malnutrition in children in some parts of the world. Necrotizing
ulcerative gingivitis and stomatitis are also sometimes associated with HIV infection.

37.12 Oral Manifestations of HIV Infections and AIDS.

In most of the countries, HIV has spread with an alarming speed. In many cases, oral lesions are the first signs of HIV
infection and members of the oral health profession should therefore be well trained in recognizing these lesions. The
following oral conditions have been reported to occur in HIV infected patients.
(a) Candidiasis.
(b) Erythematous, hyperplastic, pseudomembranous hairy leukoplakia.
(c) HIV gingivitis.
(d) HIV Necrotizing gingivitis
(e) HIV Periodontitis

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(f) Kaposi’s sarcoma

(g) Non-Hodgkin’s Lymphomas
In patients with AIDS, treatment of oral Candidiasis should follow general recommended guidelines; use
of a triazol drug or Fluconazole may be required. Necrotizing gingivitis and Stomatitis are also frequently
encountered. Good oral hygiene is essential, supplemented with antibiotic treatment if necessary. The drug
of choice is often Metronidazole. For Kaposi’s sarcoma various treatments are used including radiotherapy,
surgery and intralesional cytotoxic drugs such as Vinblastine, Vincristine and Bleomycin. Like Candidiasis,
hairy leukoplakia is a strong predictor of AIDS. However, it is not a precancerous lesion, hence no treatment
is indicated. The commonly used drugs in HIV infected adults are AZT (Zidovudine), 3 TC & Abacavir.
Lesions of oral mucosa related to secondary immunodeficiency are like the oral manifestations of HIV infection.
These lesions are often encountered following organ transplantation, radiation or chemotherapy etc.

37.13 Oral Cancer.

Worldwide, oral squamous cell carcinoma is one of the most common cancers. Epidemiological and cancer surveillance
studies have shown that its prevalence varies from country to country but about 30% of all cancerous lesions of oral
cavity occur in our country. Genetic factors, malnutrition, smoking and alcohol abuse are the main predisposing factors
while some of the oral white and red lesions show variable transformation rates to cancer. At present histopathological
investigation of the lesions remains the method of choice for diagnosis, but blood antigens, cell surface carbohydrate
fractions, DNA cytology, oncogene expression and flow cytometry have an important part to play in future.
Treatment of oral carcinoma remains largely surgical and radio therapeutic but the 5-year survival rate is unchanged.
Patient’s quality of life has undoubtedly been enhanced by improved diagnostic and surgical techniques and rehabilitation
but only the very earliest detection of disease can improve survival, as patient’s behavior is unlikely to change radically
in the short term.

37.14 Malocclusion.
Orthodontic treatment is aimed primarily at malocclusion that lies within the normal range of variation, though even
severe malocclusion can be managed with combined orthodontic and surgical treatment. Most cases of malocclusion
are not pathological in origin and so the potential for prevention or biomedical treatment is very limited. The main
emphasis in this field is assessment of the effect of various forms of treatment and on improvements in appliance
design. Examples of advances in these areas include:
(a) Improved design of brackets, arch wires and headgear.
(b) Improved aesthetics through bonding agents and ceramic brackets.
(c) Standardized indices and reliable measures of malocclusion treatment needs and outcomes.
(d) Increased understanding of the mechanics and long-term effects of treatment.
(e) Computerized programmes to aid in diagnosis customized appliance fabrication and analysis of treatment.

37.15 Missing Teeth.

Over the years, tooth loss has decreased significantly due to improvements in scientific knowledge and technology.
Increased life expectancy and lifelong sequelae of dental caries and restorative treatment still means that edentulousness
and replacement of teeth will remain issues of concern. Most people want to retain their teeth and when this is not
possible, they seek tooth replacement. The concept of loss of all teeth at older age is no longer valid. The aim of at
least 20 functioning teeth, not requiring prosthesis mentioned by the WHO is not an absolute goal but rather a step
towards the retention of all natural teeth by future generations. Prostheses that either endanger the remaining dentition
or supporting tissues are to be discouraged. The development of bonded replacement is a major achievement in this
field.

37.16 Dental Implants.

In the recent past, dental implants have been successfully used for replacing missing teeth without unnecessarily
damaging adjacent tissues or compromising function. The principle of osseo-integration of dental implants using high
biocompatible materials and appropriate prosthetic concepts has provided the oral health profession with opportunities

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that transcend the original concept of tissue restitution. During the past decade, implementation of this principle in
the treatment of total and partial edentulousness has contributed to a rapid increase in replacing removable dental
prosthesis with fixed restorations.

37.17 Oro Facial Lesions

Through continuous research over the years, it is well established that a number of systematic diseases have oral
manifestations. Oro-facial lesions include primarily viral, bacterial and fungal infections, ulceration, pre-cancerous
lesions, oral cancers and oral manifestations of systemic diseases. Prevention is still impossible in many cases and
treatment remains largely symptomatic rather than curative. However, comprehensive evaluation of the patient, including
assessment of lifestyle and risk profile is essential in all treatment of oro-facial lesions. This evaluation includes a
search for systemic disease as a possible causative factor and assessment of any other predisposing factors.
(a) Infection of the Oral Mucosa.
(i) The oral mucosa can be affected by any infective agent, but fungal, viral and bacterial infections
are the predominant sources of problems. In the herpes viral infection Acyclovir, an antiviral agent has
been found to be effective and has shown to reduce the duration of initial disease.
(ii) For diagnosis of fungal infections, a variety of new laboratory methods are available to supplement
traditional techniques of direct microscopy, biopsy, staining of smears and culture. The role of saliva
in the host defense against such infections is of considerable interest. The triazole group of drugs are
remarkably effective against oral candidiasis.
(iii) Bacterial infections of the oral mucosa are commonly seen in the form of pericoronitis in otherwise
apparently healthy patients. Intraoral manifestations of bacterial infection are increasingly encountered
in immunocompromised patients and in those with sexually transmitted diseases. Research continues
towards the development of newer and safer drugs for the treatment of these disorders and prevention
is a continuing long-term objective.
(b) Aphthous Stomatitis.
This most common oral condition has been usually associated with stress, nutritional deficiencies and
malabsorption syndrome. Various symptomatic treatment options have been proposed but improvements seen
are considered to be due to placebo effect.
(c) Lichen Planus.
It is a common oral mucosal disease of unknown etiology, which often occurs without simultaneous skin lesions.
In the ulcerated form, the disease often presents significant therapeutic problems. Occasionally, patients may
present with lesions called lichenoid reactions, which are sometimes related to drugs and / or graft versus
host reactions.
37.18 Armed Forces Perspective.
The Armed Forces personnel are often subjected to various kinds of conflict situations may be arising due to conventional
or unconventional warfare in field scenario, injuries in conflicts or due to Road Traffic Accidents (RTA) or less frequently
during unit organized games. Due to these eventualities, the personnel may sustain various forms of maxillofacial injuries
alone or associated with other injuries termed as polytrauma. The injuries could only involve the dental component alone
or along with involvement of the underlying hard tissues i.e the maxilla or mandible. The basic principle of management
of maxillofacial trauma remains the same which is to restore the preinjury form and function. The maxillofacial region
is in close proximity to the airway and numerous vital structures like the eye, ear, nose, cranial nerves, pneumatic
air sinuses and blood vessels which are essential for routine functions such as sight, smell, speech and swallowing.
The treatment usually involves a multidisciplinary team approach consisting of a Maxillofacial Surgeon, ENT surgeon,
neurosurgeon and an ophthalmologist. The extent of intervention will depend upon the nature of the injury and will
involve either a conservative approach or surgical intervention in the form of open reduction and internal fixation.
‘Occlusion’ is the key factor in restoring the anatomy of the jaw especially whenever the dental components are involved.

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Suggested Reading.
1. Bhalwar R, Vaidya R, Tilak R, Gupta R, Kunte R, editors. Textbook of Public Health and Community Medicine. First
Edition. Department of Community Medicine, AFMC, Pune in collaboration with WHO, India Office, New Delhi; 2009.
2. Walker WB. The Oral Cavity and Associated Structures. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods:
The History, Physical and Laboratory Examinations. 3rd ed. Boston: Butterworths; 1990. Chapter 129.
3. Hajime Iwama, Kaku M, Lay Thant, Masaru Mizukoshi, Arai M, Ono Y, et al. Acellular Extrinsic Fiber Cementum
Is Invariably Present in the Superficial Layer of Apical Cementum in Mouse Molar. Journal of Histochemistry and
Cytochemistry. 2024 Jan 30;
4. Le Révérend BJD, Edelson LR, Loret C. Anatomical, functional, physiological and behavioural aspects of the
development of mastication in early childhood. British Journal of Nutrition [Internet]. 2013 Sep 24;111(3):403–14.
Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3927374/
n

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Chapter
XXXVIII
NATIONAL HEALTH PROGRAMMES

38.1 Introduction.
India was one of the pioneers in health service, with focus on primary health care. In 1946, the Health Survey
and Development Committee, headed by Sir Joseph Bhore recommended establishment of a well-structured and
comprehensive health service with sound primary health care infrastructure. This report not only provided a
historical landmark in the development of public health system but also laid down the blueprint for subsequent
health planning and development in independent India. India’s National Health Programmes place a strong
emphasis on preventive healthcare and health promotion, encouraging communities to adopt healthy behaviour
and preventive practices. These initiatives focus on creating awareness, educating citizens and empowering them
to actively participate in their healthcare decision making process.
National Health Programmes in India play a vital role in addressing the country’s diverse health challenges and
ensuring that all citizens have access to essential healthcare services. These initiatives represent a significant
commitment by the government towards building a healthier nation and fostering better quality of life for its
people. As India’s healthcare landscape continues to evolve, the success of these programmes will depend on
sustained efforts, collaborative partnerships and an unwavering dedication to the health and well-being of every
individual in the country.
Improvement in the health status of the population has been one of the major thrust areas for the social
development of the country. This was to be achieved through improving the access to health, family welfare
and nutrition services with special focus on underserved and underprivileged segments of the population. Main
responsibility of infrastructure and manpower building rests with the state government supplemented by funds
from the Central Government and external assistance. Major disease control programmes and family welfare
programmes are funded by the centre (some with assistance from external agencies) and are implemented
through the state infrastructure. One of the most significant milestones in India’s public health journey was the
launch of National Health Mission (NHM) in 2013, which integrated the earlier National Rural Health Mission and
National Urban Health Mission. The NHM aimed to strengthen healthcare infrastructure, enhance the availability
and accessibility of essential healthcare services and promote health equity across urban and rural areas.

38.2 Relevance of National Health Programmes for Armed Forces.

Armed Forces Medical Services provide comprehensive health services (promotive, preventive and curative) to its
clientele. By and large these services are self-sufficient and insulated from the civilian health services. National Health
Programmes are planned to deal with specific health problems among most affected population subgroups, allocating
large sums of money. These health problems are very much relevant to the serving personnel and their families. All
efforts should be made to take full advantage of the resources available through these programmes, by maintaining
good liaison with civil health authorities at all levels. The following examples of collaboration between the civilian health
authorities and military medical services bring out the importance of the national health programmes in the service
setting.
(a) Liaison with Civil Health Authorities in Public Health Work.
Communicable diseases do not respect any boundaries, natural or man-made. Most cantonments / military
stations exist in proximity with civilian settlements. Any public health menace in the civil population is likely
to spill over among the troops and families. Health intelligence on the prevailing disease patterns in the local
population must be obtained by liaising with the civil health authorities. At times, combined efforts by the military
and civilian health authorities may be required.
(b) Supply of Vaccines.
Under the Universal Immunization Programme, all vaccines for childhood immunization are obtained from local

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civilian health authorities, to facilitate the cold chain. Reports and returns on vaccine utilization and surveillance
on vaccine preventable diseases must be periodically submitted to the local civilian health authorities.
(c) Family Welfare Programmes.
There is very close collaboration / similarity in family welfare programme between the civilian and military health
services. Service hospitals are actively participating in the National Family Welfare Programmes.
(d) Treatment of Families and Dependents of Service Personnel for Certain Diseases.
Families and dependents may not be entitled for indoor treatment of certain chronic diseases like Hansen’s,
malignancies, tuberculosis, etc. in a particular station or else the family may be staying in a place (e.g., native
village) where no service medical facility is available. Awareness of the benefits available to the common citizen
under the various health programmes will enable the service medical officers to appropriately counsel the clientele
on the sources from where appropriate treatment and care can be available from the civil health sources.
(e) Adoption of Disease Control Strategies in Service Setting.
At times the disease control strategies being followed in some of the National Health Programmes can be adopted
in the service setting with advantage. On the other hand, we may also learn lessons from some of the failures
in our National Health Programmes and similar mistakes can be avoided in our public health practice.
(f) Reports and Returns.
Reports and returns for various diseases and health problems sent periodically from all Armed Forces establishments,
compiled at the highest level should contribute to the statistics of our programmes at the national level.
A brief account of the National Health Programmes, which are currently in operation, is given in succeeding
paragraphs.

NATIONAL VECTOR BORNE DISEASES CONTROL PROGRAMME

(NVBDCP)

38.3 Introduction.
This programme was launched in 2003-04 as an umbrella programme for prevention and control of vector borne
diseases (VBDs) by convergence of three ongoing programmes on Malaria, Filaria and Kala-azar with inclusion of
Japanese Encephalitis, Dengue / Dengue Hemorrhagic Fever and Chikungunya fever. Since 2005, NVBDCP has been a
part of National Health Mission (NHM). Out of the six diseases under this programme, five diseases are transmitted by
mosquitoes and Kala-azar by sandflies. Three diseases have been targeted for elimination, namely Kala-azar by 2017,
Lymphatic Filariasis by 2020 and Malaria by 2030.
(a) Strategies under NVBDCP.
(i) Disease management includes early case detection with active, passive and sentinel surveillance,
complete effective treatment, strengthening of referral services, epidemic preparedness, rapid response
(ii) Integrated vector management including Indoor Residual Spray in high-risk areas, long lasting
insecticidal nets, use of larvivorous fish, anti-larval measure in urban areas including biolarvicides and
minor environmental engineering including source reduction
(iii) Supportive interventions that include, behavior change communication (BCC), intersectoral convergence,
human resource development, public-private partnership (PPP), operational research, monitoring and
surveillance
(iv) Vaccination.
Against Japanese encephalitis

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(v) Annual mass drug administration against Lymphatic Filariasis

38.4 Malaria.
Malaria has been a major public health problem in India. Intermittent fever, with high incidence during the rainy season,
coinciding with agriculture, sowing and harvesting, was first recognized by Romans and Greeks who associated it with
swampy areas. They postulated that intermittent fevers were due to the ‘bad odour’ coming from the marshy areas
and thus gave the name ‘malaria’ (‘mal’ = ‘bad’ + ‘air’) to intermittent fevers.
Magnitude of the Problem.
Malaria is a public health problem in several parts of the country. About 95% population in the country resides
in malaria endemic areas and 80% of malaria reported in the country is confined to areas consisting 20% of
population residing in tribal, hilly, difficult and inaccessible areas.
Road Map for Malaria Elimination.
(a) Government of India envisages eliminating malaria by 2030 in a phased manner.
(b) Launch of National Framework for Malaria Elimination (NFME) 2016-2030 in February 2016 by Hon’ble
Health Minister.
(c) Dissemination of NFME 2016-2030 to all States and UTs with instructions to initiate key actions.
(d) Launch of Operational Manual for Malaria Elimination - April 2016: The National Strategic Plan (NSP) 2017-
2022 for Malaria Elimination was launched in July 2017 by Hon’ble Health Minister.
(e) Award to the Districts / States for achieving ‘Zero indigenous case status’ and maintaining it for 3 consecutive
years on attaining sub-national malaria elimination, instituted for Year 1 and Year 3.
The broad strategies under National Framework for Malaria Elimination (2016-2030) are
(a) Early diagnosis and complete treatment
(b) Case-based surveillance and rapid response: Integrated Vector Management (IVM), Indoor Residual Spray
(IRS), Long-Lasting Insecticidal Nets (LLINs) / Insecticide Treated Bed Nets (ITNs), Larval Source Management
(LSM), Epidemic preparedness and early response.
(c) Monitoring and evaluation, programme planning and management.
(d) Advocacy, coordination and partnerships, Behaviour Change Communication and community mobilization.
Global Fund Supported Malaria Elimination Project.
Goal.
To reduce malaria morbidity by at least 50% and mortality by at least 75% in project areas by 2023 compared
to baseline 2018.
Objectives.
(a) Achieve near universal coverage of population at risk of malaria with an appropriate vector control
intervention (LLIN).
(b) Achieve universal coverage of case detection and treatment services (in project areas) to ensure 100%
parasitological diagnosis of suspected malaria cases and complete treatment of all confirmed cases.
(c) Strengthen the surveillance to detect, notify, investigate, classify and respond to all cases and foci in all
districts (in project areas) to move towards malaria elimination.
(d) Achieve near universal coverage in project areas by appropriate BCC activities to improve knowledge,
awareness and responsive behavior regarding effective preventive and curative interventions.
(e) Ensure effective programme management and coordination to deliver a combination of interventions for
malaria elimination.
Project Period.
The Global Fund to fight AIDS, Tuberculosis & Malaria (GFATM) is supporting malaria control in India since 2005.

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GF supported Intensified Malaria Control Projects (IMCP) I to III were implemented from July 2005 – December
2017. From January 2018 - March 2021, Intensified Malaria Elimination Project (IMEP) was implemented in 7
North-Eastern States and Madhya Pradesh. From April 2021 onwards Intensified Malaria Elimination Project-2 has
been implemented in 10 states {i.e. 7 North-Eastern States (Arunachal Pradesh, Assam, Meghalaya, Mizoram,
Nagaland, Manipur & Tripura), Odisha, Jharkhand and Chhattisgarh} covering 166 million population in 155
districts.
Surveillance in Malaria.
Surveillance in malaria is aimed at case detection through laboratory services and providing facilities for proper
treatment. Surveillance in malaria is of two types, active and passive.
(a) Active Surveillance.
This is carried out by the multipurpose workers (MPWs). Each MPW is allotted for a population of 10,000 or
approximately 2,000 houses and for every 4 MPW, there is a surveillance inspector (Health Assistant). For difficult
terrain areas, there is one multipurpose worker (MPW) for a population of 8,000 and one surveillance inspector for
32,000 population. The surveillance worker (MPW) will visit each house in his area once a fortnight and enquire
(i) Whether there is a case of fever in the house, including guests or visitors in the house.
(ii) Whether there was a fever case in the house between his previous visit and the present visit. If the
answer to either of these two questions is “yes”, the surveillance worker / MPW collects a blood film (thick
and thin on the same slide) and administers a single dose (600 mg for adults and proportionate doses
for children) of chloroquine according to the prescribed NMEP schedule. This is known as “presumptive
treatment”. If the blood film is reported positive for malaria parasite, the MPW returns to the patient and
administers a course of radical treatment for malaria, as prescribed.
(b) Passive Surveillance.
The search for malaria cases by the local health agencies such as the primary health centres, sub-centres,
hospitals, dispensaries and local medical practitioners amongst people reporting to the facilities is known as
“passive surveillance”. The passive agencies collect blood smears from all fever cases and from those with
history of recent fever. After the collection of blood smear, a single dose treatment for malaria is administered
as is done under the active surveillance programme. The blood slides are collected by the MPW and sent to the
unit laboratory for examination. The results of the blood examination are communicated to the local surveillance
worker / MPW for institution of radical treatment.
Parameters of Malaria Surveillance.
Surveillance also implies the continuing scrutiny of all aspects of occurrence and spread of a disease, that are
pertinent to effective control. Included in these are the systemic collection and evaluation of field investigations
etc. The following parameters are widely used in the epidemiological surveillance of malaria:
(a) Annual Parasite Incidence (API).
(b) Annual Blood Examination Rate (ABER).
(c) Annual Falciparum Incidence (AFI).
(d) Slide Positivity Rate (SPR).
(e) Slide Falciparum Rate (SFR).
Classification of States / UTs based on API as Primary Criteria (Table 38.1)
(a) Category 0 (Prevention of Re-establishment Phase).
The probability of malaria becoming re-established in a malaria free area varies with the level of receptivity and
vulnerability of the area. If either of these factors is zero, the probability of malaria becoming re-established is
zero even if the other factor has a high value. When importation of malaria due to the arrival of migrants from a
malaria area coincides with increase in receptivity because of halted vector control measures or socioeconomic
development of an area for example, re-establishment of malaria transmission is possible. In the absence of
appropriate action, the area is likely to become malarious again and the duration is determined by the level of
receptivity and vulnerability.

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Table 38.1 : Classification of States / UTs based on API as Primary Criteria

Categories of States / UTs Definition Actions to be Taken
Category 0: Prevention of re- States / UTs with zero −
establishment phase indigenous cases of
malaria
Category 1: Elimination phase States / UTs (15) including (a) Surveillance using active case detection,
their districts reporting an passive case detection and sentinel
API of less than 1 case surveillance.
per 1,000 population at (b) Screening of migrants in these areas.
risk
(c) Integrated vector management by
involvement of Village Health and
Sanitation Committees, other Panchayati
Raj Institutions and MNREGA schemes. IEC
and BCC activities for the community
Category 2: Pre-elimination phase States / UTs (11) with an (a) Epidemiological surveillance and disease
API of less than 1 case management (3 Ts: Test Treat and Track).
per 1,000 population at (b) Screening of migrants in these areas,
risk, but some of their IVM by source reduction through minor
districts are reporting an engineering, environmental and focal spray.
API of 1 case per 1,000
(c) IEC activities with involvement of
population at risk or
private health care providers, NGOs and
above
communities.
Category 3: Intensified control States / UTs (10) with an (a) Epidemiological surveillance and disease
phase API of 1 case per 1,000 management by early diagnosis and
population at risk or complete treatment (EDCT).
above. (b) Management of severe malaria cases by
strengthening of district and sub district
hospitals and quality referral services.
(c) IVM by IRS and ITNs / LLINs so as to
saturate the entire high-risk population
(d) Additional supportive interventions for areas
with perennial transmission > 5 months in a
year: 2 rounds of IRS with DDT / Synthetic
Pyrethroids (SP) or 3 rounds with Malathion
depending on vector susceptibility and
priority distribution of LLINs as per the
guidelines
(e) For areas with seasonal transmission <5
months per year: One round of IRS with
DDT or Malathion or Synthetic Pyrethroids
such as Deltamethrin, Cyfluthrin before
start of transmission. Focal spray whenever
and wherever needed and priority
distribution of LLINs
When any area, whether a state / UT or a district within a state / UT, has achieved malaria elimination, the specific
objectives will be as follows
(i) detect any re-introduced case of malaria
(ii) notify immediately all detected cases of malaria
(iii) determine the underlying causes of resumed local transmission

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(iv) apply rapid curative and preventive measures

(v) prevent re-introduction and possible re-establishment of malaria transmission
(vi) maintain malaria-free status in these areas
(b) Category 1 (Elimination Phase).
The specific objectives and key interventions recommended for the Category 1 (Elimination phase) states / UTs
are detailed in Table 38.2.
Table 38.2 : Specific Objectives and Key Interventions in Elimination Phase (Category 1)
Specific Objectives Key Interventions
(a) Interrupt (a) In elimination areas, where transmission is focal and incidence / risk has become
transmission of extremely low, all efforts will be directed at interrupting local transmission in all
malaria active foci of malaria.
(b) Immediately notify (b) Mandatory notification of each case of malaria from the private sector, other
each detected case organized government sectors or any other health facility.
(c) Detect any possible (c) Adequate case-based surveillance and complete case management established and
continuation fully functional across the entire country to handle each case of malaria.
of malaria (d) Investigation and classification of all foci of malaria.
transmission
(e) A strict total coverage of all active foci by effective vector control measures.
(d) Determine the
(f) Early detection and treatment of all cases of malaria by means of active and / or
underlying causes
passive case detection to prevent onward transmission.
of residual
transmission (g) State and national level malaria elimination database established and operational.
(e) Forecast and (h) Implementation of interventions for effective screening, management and
prevent any prevention of malaria among mobile and migrant populations.
unusual situations (j) Establishment of an effective epidemic forecasting and response system.
related to malaria, (k) Ensuring rigorous quality assurance of all medicines and diagnostics.
ensure epidemic
(l) Setting up a national-level reference laboratory which will serve the following two
preparedness
functions —
and respond in a
timely and efficient (i) All positive and a fixed percentage of negative slides will be referred to this
manner to outbreak laboratory for confirmation of diagnosis and cross-checking.
situations (ii) After elimination has been achieved in each State / UT, 100% of cases will be
(f) Prevent re- notified to this laboratory for confirmation of diagnosis. The laboratory will be
establishment of notified immediately on all positive cases of malaria by each state / UT through
local transmission either SMS, e-mail or telephone with information on name, gender, address
of malaria (village and district), date and type of testing and type of parasite for each
positive case of malaria so that a national level database can be maintained.
(g) Ascertain
elimination of (iii) Training of master trainers and accreditation / certification of microscopists as
malaria per Indian Public Health Standards shall also be undertaken at this laboratory.
During investigation of foci, all suspected cases of malaria are to be screened
for malaria. These could include household members, neighbours, schoolchildren,
workplace colleagues and relatives.
(m) Surveillance of special groups, migrant populations or populations residing in the
vicinity of industrial areas are also to be covered under surveillance operations.

(c) Category 2 (Pre-elimination Phase).

The states / UTs in pre-elimination phase are those close to entering the elimination phase. Therefore, malaria
elimination interventions will be introduced with particular focus on setting up an elimination surveillance system
and initiating elimination phase activities in those districts where the API has been reduced to less than 1 case
per 1,000 population at risk per year. The planning of elimination measures will be based on epidemiological
investigation and classification of each malaria case and focus.

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(d) Category 3 (Intensified Control Phase).

The specific objectives and key interventions recommended for Category 3 (intensified control phase) states / UTs
are detailed in Table 38.3.
Table 38.3 : Specific Objectives and Key Interventions in Intensified Control Phase (Category 3)
Specific Objectives Key Interventions
(a) Achieve universal (a) Massive scaling up of existing disease management and preventive approaches
coverage with malaria and tools, aimed at a significant reduction in the prevalence and incidence of
preventive and malaria as well as associated deaths.
curative services. (b) Screening of all fever cases suspected of malaria.
(b) Reduce malaria (c) Classification of areas as per local malaria epidemiology and grading of areas
specific morbidity and as per risk of malaria transmission followed by implementation of tailored
mortality. interventions.
(c) Establish an efficient (d) Strengthening of intersectoral collaboration.
system to reduce
(e) Special interventions for high-risk groups such as tribal populations and
ongoing transmission
populations residing in conflict affected or hard-to-reach areas.
of malaria.
(f) One-stop centres or mobile clinics on fixed days in tribal or conflict affected areas
(d) Contain and prevent
to provide malaria diagnosis and treatment and increasing community awareness
possible outbreaks of
with the involvement of other agencies and service providers as required.
malaria, particularly
among non-immune (g) Timely referral and treatment of severe malaria cases to reduce malaria-related
high-risk mobile and mortality.
migrant population (h) Strengthening all district and sub district hospitals in malaria endemic areas
groups. as per Indian Public Health Standards with facilities for management of severe
(e) Emphasize reducing malaria cases.
malaria morbidity (j) Establishment of a robust supply chain management system.
and mortality in high (k) Maintenance of an optimum level of surveillance using appropriate diagnostic
transmission pockets measures.
such as tribal, hilly,
(l) Equipping all health institutions (primary health care level and above),
forested and conflict
especially in high-risk areas, with microscopy facilities and RDTs for emergency
affected areas.
use and injectable artemisinin derivatives for treatment of severe malaria.

38.5 Filaria.
Magnitude of Disease.
Filariasis has been a major public health problem in India next only to malaria. The disease was recorded in India
as early as 6th century B.C. by the famous Indian physician, Sushruta in his book Sushruta Samhita. In 1709,
Clarke called elephantoid legs in Cochin as Malabar legs. The discovery of Microfilariae (Mf) in the peripheral
blood was made first by Lewis in 1872 in Kolkata.
Filariasis is the common term for a group of diseases caused by parasitic nematodes belonging to super family
Filarioidea. The adult worms of these parasites live in the lymphatic system of the human body. The three
nematode parasites causing LF in human are Wuchereria bancrofti, Brugia malayi and Brugia timori. Among
these, only Wuchereria bancrofti and Brugia malayi are found in India and Wuchereria bancrofti, transmitted
by the ubiquitous vector, Culex quinquefasciatus, has been the predominant infection contributing to 99.4% of
the problem in the country. The infection is prevalent in both urban and rural areas. The vector species breeds
preferably in dirty and polluted water.
Lymphatic Filariasis (LF), commonly known as elephantiasis is a disfiguring, disabling disease, usually acquired
in childhood but generally there are no symptoms. Infact a vast majority of individuals may remain asymptomatic
though all of them would have subclinical lymphatic damage. Disease manifestation appears in a small proportion
of infected individuals, commonly over 10 years of age. Lymphoedema or elephantiasis and hydrocele are the
main clinical symptoms of chronic filariasis that disrupt the normal daily activities to a large extent among the
infected persons.

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Disease Burden.
Till 2020, the disease was known to be endemic for LF endemic across 20 States / UTs, (16 States & 4 UTs)
covering 272 districts. In 2021, after the reconciliation exercise, the total LF endemic districts number now
stands at 328. The overall estimated population at risk from the filaria infection currently is estimated to be
around 740 million.
Indigenous cases have been reported from about 257 districts in 21 States / Union Territories. The North-Western
States / UTs namely Jammu and Kashmir, Himachal Pradesh, Punjab, Haryana, Chandigarh, Rajasthan, Delhi
and Uttarakhand and North-Eastern States namely Sikkim, Arunachal Pradesh, Nagaland, Meghalaya, Mizoram,
Manipur and Tripura are known to be free from indigenously acquired filarial infection. Cases of filariasis have
been recorded from Andhra Pradesh, Assam, Bihar, Chhattisgarh, Goa, Jharkhand, Karnataka, Gujarat, Kerala,
Madhya Pradesh, Maharashtra, Odisha, Tamil Nadu, Uttar Pradesh, West Bengal, Pondicherry, Andaman and
Nicobar Islands, Daman and Diu, Dadra and Nagar Haveli and Lakshadweep.
Strategy for Elimination of Lymphatic Filariasis.
India adopted the twin pillar strategy for elimination of LF as per recommendation of WHO. This strategy includes:
Transmission control interruption of transmission through annual Mass Drug Administration (MDA): To prevent
the occurrence of new infection and disease, annual single dose (Mass Drug Administration - MDA) of anti-filarial
drugs i.e., DEC + Albendazole (DA) / Ivermectin + DEC + Albendazole (IDA), is administered to the entire eligible
population of the endemic districts.
Disability Prevention and Management: For those individuals who already have the disease: Home based
management for lymphoedema and surgical correction for hydrocele in hospital / camps are being provided.
Enhanced Strategies for Elimination of Lymphatic Filariasis.
Under this strategy, a renewed five-pronged strategy for elimination of LF has been adopted. The five strategies
are as follows.
(a) Multi-drug administration (MDA) campaign twice a year synchronized with National Deworming Day
(10th Feb and 10th Aug).
(b) Early diagnosis and treatment: engagement of Medical Colleges for strengthening Morbidity
Management and Disability (MMDP) services. MMDP targets 100% coverage for hydrocele surgery and
home-based morbidity management services for lymphoedema cases.
(c) Integrated Vector Control with multi sectoral coordinated efforts.
(d) For inter sectoral convergence with allied departments and ministries.
(e) Leveraging existing digital platforms for LF and exploring alternate diagnostics.

38.6 Dengue.
Dengue is a fast-spreading outbreak prone arboviral disease. Dengue Fever is transmitted by Aedes mosquito which is
a day biting mosquito and prefers to rest in hard-to-find dark areas inside the houses. Aedes aegypti is the principal
vector; however, at present Aedes albopictus, has also been reported to play a role in Southern and NE States. There
is no drug available to cure dengue infection.
Every year during the period of July-November, there is an upsurge in the cases of Dengue in northern parts of the
country. However, in the Southern and Western parts of the country, the disease has become perennial.
In 2022, a total of 1,10,473 cases and 81 deaths were reported from 28 States and 8 UTs. Maximum cases were
reported from Telangana (13,345) followed by Karnataka (7,317), Maharashtra (6,330), Rajasthan (8,427), Odisha
(5,786), Punjab (5,139), Andhra Pradesh (4796), Tamil Nadu (4,784), Gujarat (4536) and Kerala (3,353). Deaths are
reported from Kerala (21), Haryana (12), J & K (10), Bihar (7), Rajasthan (6), Maharashtra (5), Punjab (5), Karnataka
(4), Tamil Nadu (4), West Bengal (3), Manipur (2), one each from Uttar Pradesh and Puducherry (1). Case Fatality Rate
(CFR, deaths per 100 cases) which was 3.3% in 1996 has come down to 0.1% in 2019 & 2020 and 0.2% in 2021
because of better management of Dengue cases.

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38.7 Chikungunya.
Chikungunya is a debilitating viral illness caused by Chikungunya virus. The disease re-emerged in the country after
a gap of almost three decades. This disease is also transmitted by Aedes mosquito, both Aedes aegypti and Aedes
albopictus can transmit the disease. Symptoms of Chikungunya fever are most often clinically indistinguishable from
those observed in dengue fever. It is characterized by fever with severe joint pain (arthralgia) and rash. Joint pains
sometimes persist for a long time even after the disease is cured. There is neither any vaccine nor drugs available to
cure the Chikungunya and the cases are managed symptomatically.
Disease Burden.
After re-emergence of Chikungunya in 2006, the cases of Clinically Suspected Chikungunya cases reported every
year but gradually declined till 2014. However, due to the report of increased numbers of cases by few States, the
disease shows an upward trend in 2015 (Karnataka) and 2016 (Delhi and nearby States). Currently, Chikungunya
is endemic in 26 States and 6 UTs. During 2021 a total of 1,19,070 suspected Chikungunya cases were reported
from 25 States / UTs, whereas in 2022 (till 31st October), 1,07,968 clinically suspected Chikungunya cases were
reported from 23 States / UTs.

38.8 Kala Azar.

Introduction.
According to the World Health Organization (WHO), Kala-azar is the second deadliest parasitic disease in the
world. Most cases occur in Brazil, east Africa and India. An estimated 50,000 to 90,000 new cases of Visceral
Leishmaniasis (VL) occur worldwide annually, with only 25–45% reported to WHO. It has outbreak and mortality
potential. India contributes about 11.5% of total cases of Kala-azar reported globally.
A centrally sponsored programme was launched in 1990-91. The prevalence of cases reduced from 77,102 in
1992 to 2,502 cases in 2020. The only block that remains endemic is Littipara in the Pakur district of Jharkhand
(1.23 cases per 10,000).
Strategies.
(a) Enhanced case detection and complete treatment including introduction of rK39 rapid diagnostic kits and
oral drug Miltefosine.
(b) Interruption of transmission through vector control.
(c) Replacing DDT with Synthetic Pyrethroids.
(d) Behavioural Change Communication and Intersectoral Convergence.
(e) Capacity building.
(f) Monitoring, evaluation and supervision.
(g) Quarterly case search during “Kala azar fortnight”: Door to door search and referral of cases conforming
to the case definition of Kala azar and Post Kala azar Dermal Leishmaniasis (PKDL).
(h) Introduction of Rapid Diagnostic Kit developed by ICMR and single dose treatment with Liposomal
Amphotericin B (10 mg / kg IV).
(j) Incentives as a Strategy to Disease Control.
Beneficiary Incentive (₹)
ASHA on case identification of each case 300
ASHA on ensuring one round of insecticide spray 100
ASHA on ensuring 2 rounds of insecticide spray 200
Compensation of daily wage to patient for one day spent at hospital (Kala azar) 500
Compensation of daily wage to patient for one day spent at hospital (PKDL) 2,000

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38.9 Japanese Encephalitis

Introduction.
Prevention and control of Japanese Encephalitis include strengthening of the surveillance activities through
sentinel sites in tertiary healthcare institutions, early diagnosis and proper case management, integrated vector
control, particularly personal protection and use of larvivorous fishes, capacity building and behaviour change
communication. Indoor Residual Spray is not effective as JE vectors are outdoor resters. The Government of India
provides need-based assistance to the states, including support for training programmes and social mobilization.
Strategies.
Early case detection is the most important key to control as there is no specific cure to this disease. Other
important multi-pronged strategies are
(a) Strengthening and expanding JE vaccination
(b) Health education through different media and interpersonal communication for the community
(c) Emphasis on keeping pigs away from human dwellings
(d) Clothing to fully cover the body
(e) Use of bed nets
(f) Use of malathion for outdoor fogging

NATIONAL LEPROSY ERADICATION PROGRAMME (NLEP)

The emblem symbolizes beauty and purity in lotus: Leprosy can be cured, and a
leprosy patient can be a useful member of the society in the form of a partially
affected thumb; a normal fore-finger and the shape of house; the symbol of
hope and optimism in a rising sun. The emblem captures the spirit of hope
positive action in the eradication of Leprosy.

Introduction.
India has achieved the elimination of leprosy as a public health problem i.e., defined as less than 1 case per 10,000
population, at the National level in December 2005. Thereafter, the trend is gradually declining. Prevalence Rate (PR) at
National level was 0.84 per 10,000 population in 2005-06 which has been reduced to 0.66 per 10,000 population in
2015-16 which further reduced to 0.57 per 10,000 population in 2019-20. Due to COVID-19 pandemic, case detection
was compromised, which led to sudden downward trend of Prevalence Rate (PR) to 0.40 and 0.45 per 10,000 population
in 2020-21 and 2021-22 respectively.

38.10 National Leprosy Eradication Programme (NLEP).

Vision.
Leprosy-Free India
Mission.
To provide quality leprosy services free of cost to all sections of the population, with easy accessibility, through the
integrated healthcare system, including care for disability after cure of the disease
Objectives.
(a) To reduce the prevalence rate to less than 1 / 10,000 population at sub national and district level.
(b) To reduce Grade II disability % to <1 among new cases at National level.
(c) To reduce Grade II disability cases to <1 case per million population at National level.
(d) Zero disabilities among new Child cases.
(e) Zero stigma and discrimination against persons affected by leprosy.

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Strategies.
(a) Decentralized integrated leprosy services through General Health Care system.
(b) Early detection and complete treatment of all new leprosy cases.
(c) Carrying out household contact survey for early detection of cases.
(d) Capacity building of all general health services functionaries.
(e) Involvement of ASHAs in the detection and completion of treatment of leprosy cases on time.
(f) Strengthening of Disability Prevention and Medical Rehabilitation (DPMR) services.
(g) IEC activities in the community to improve self-reporting to PHC and reduction of stigma.
(h) Intensive monitoring and supervision at Health and Wellness centres and at PHC / CHC.
Recent Strategies in NLEP.
(a) Three-pronged strategy- LCDC, FLC, Hard to reach areas.
(b) ASHA based Surveillance for Leprosy Suspects (ABSULS).
(c) Sparsh Leprosy Awareness Campaign (SLAC).
(d) Post Exposure Prophylaxis - Single Dose Rifampicin (PEP-SDR).
(e) Immunoprophylaxis - Mycobacterium indicus Pranii (MIP) vaccine.
(f) Implementation of online reporting system (‘Nikushth’) for improved monitoring and supervision.
(g) Detailed investigation Grade II disability cases.
(h) Drug resistance surveillance.
(j) Modelling studies in leprosy.
(k) Active Case Detection and Regular Surveillance (ACD & RS).
(l) District Award Scheme for achievements in NLEP.

National Strategic Plan (NSP) and Roadmap for Leprosy 2023-2027.

Vision.
Leprosy free India with zero infection and disease, zero disability, zero stigma and discrimination.
Goal.
Accelerate towards achieving interruption of leprosy transmission in India
Specific Objectives.
(a) Strengthen leadership, commitment and partnerships.
(b) Acceleration of case detection.
(c) Provision of quality services.
(d) Enhanced measures for prevention of disease, disabilities, stigma, discrimination and violation of human
rights.
(e) Digitalization of surveillance systems.
Five Strategic Pillars of NSP.
(a) Strengthen leaderships, commitment, partnership
(b) Accelerate case detection
(c) Quality services
(d) Prevention of disease, disabilities, stigma, discrimination and violation of human rights

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(e) Digitalization: Nikushth 2.0 digital reporting and drug management.

NATIONAL TUBERCULOSIS CONTROL PROGRAMME

New logo launched in 2020. Logo is circular with yellow and red colour. Caption
of the programme “TB Harega Desh Jeetega”. There is red colour joyful person
surrounded by National Flag with image of lung in the logo.

The visual icon, when deciphered, presents a graphic of human anatomy divided
in two parts – half red and half orange. While the orange part symbolizes the
diseased state, the red represents healthy metabolism. On the other level, the
icon suggests a transition from the state of tuberculosis to a healthy life, which
is the very promise of DOTS.

38.11 National TB Elimination Programme (NTEP).

In 2020, Revised National Tuberculosis Control Programme (RNTCP) was renamed as ‘National Tuberculosis Elimination
Programme’. NTEP or TB Free India campaign calls for a social movement focused on patient-centric and holistic care
driven by integrated actions for TB Free India. India has committed to end TB by 2025, 5 years ahead of the global
Sustainable Development Goals (SDG) target.
Vision.
A world free of TB. Zero TB deaths, Zero TB disease and Zero TB suffering
Goal.
End the Global TB epidemic (<10 cases per 1,00,000 population)
Table 38.9 : Indicators of NTEP
Indicator Targets SDG 2030
Reduction in number of TB deaths compared with 2015 (%) 90%
Reduction in TB incidence (new case) rate compared with 2015 (%) 80%
TB-affected families facing catastrophic expenditures due to TB (%) Zero
TB Laboratory services.
3-tier System include
(a) The peripheral laboratories.
(b) State level.
Intermediate Reference Laboratory (IRL).
(c) Central level.
Key Activities for NTEP.
(a) Active TB case finding.
Active case finding (ACF), means going out and identifying TB in individuals who don’t come themselves for
health care using community volunteers. active case finding is to be done among high-risk groups (HRGs) which
have been identified as PLHIV (people living with HIV), all contacts of bacteriologically confirmed pulmonary TB
patient, other risk groups (silicosis, immuno-compromised, organ transplant, hemodialysis, anti TNF-therapy,
etc), migrants and people living in urban slums / construction sites / hard-to-reach areas. It is planned to
conduct 3 rounds of ACF / year. TB patients detected during ACF are referred for diagnosis and TB treatment.

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TB patients are also screened for Diabetes. Screening of diabetes patients for TB is done using 4 symptoms
complex in every visit and if diabetic patient is found to have TB, linkage with TB management centre is done.
(b) Newer and Shorter Regimen.
For drug sensitive TB cases, Directly Observed Treatment Short course (DOTS) chemotherapy is followed. For
details refer to chapter on airborne diseases.
(c) Private Sector Engagement.
Guidelines have been made available for treatment and follow-up of TB patients. TB notification is mandatory.
NIKSHAY- a web enabled application facilitates monitoring of universal access to TB patients’ data by all
concerned and sero-diagnostics have been banned.
(d) Financial / Nutritional Support to TB Patients.
(i) Nikshay Poshan Yojana (NPY).
Direct Benefit Transfer (DBT) i.e. money credited directly to the beneficiary’s account at notification and
then during treatment. ₹ 500 each month of treatment and up to ₹ 1,000 as advance are given.
(ii) Mitigating Catastrophic Expenditure.
Catastrophic expenditure includes expenses for tests, medicines, travel, loss of wages etc. Free diagnostic
and treatment are provided by private sector also. Financial support is also provided to patients and care
providers through DBT: Nutritional support (₹ 500 / -month); travel support to tribal patients (₹ 750 / -);
private practitioners incentives (₹ 500 / - for notification and ₹ 500 / - for reporting of treatment outcome)
and treatment supporters honorarium (₹ 1,000 / - to ₹ 5,000 / -).
(iii) Nutritional Support to TB Patients.
In terms of assessment of malnutrition and counselling based on their nutritional status.
(e) IT Enabled Surveillance, Preventive and Awareness Measures.
TB patients are educated on prevention of airborne infection at home and at workplace e.g., cough hygiene.
Airborne infection control measures like increased ventilation, reduced crowding, faster processing of patients and
samples (fast tracking), wet mopping, cough etiquette, provision of spittoon, disinfectant and, reusable masks
and education to patients on their use are implemented in health facilities, community and at household level.

38.12 National Strategic Plan 2017-25 (NSP).

This has been introduced for Tuberculosis elimination by 2025. This plan sets out how the government proposed to
eliminate TB in India describing the activities and interventions that would bring about major and effective changes
in the incidence, prevalence and mortality from tuberculosis. This is in addition to what was already practiced. The
goals under NSP 2017–2025 are
(a) Improving and expanding early detection in TB and testing drug resistance in TB.
(b) To correctly treat TB to prevent any emergence of drug resistance and thus cut the chain of transmission.
(c) Building capacity for continuous surveillance.
(d) Preventing the emergence of TB and Latent tuberculosis infection (LTBI).
(e) Ending TB infection in India.
The major organizational change included creation of a sub-district administrative level i.e. at the Block / PHC
level; ‘Tuberculosis Unit’ (TU) with MO-TC having the overall responsibility of management of TB Control
Programme at the TU. The team of STS and STLS are under the administrative supervision of MO-TC and
DTO. PHI is a health facility, having at least 1 Medical Officer. Dispensaries, PHCs, CHCs, referral hospitals,
major hospitals, specialty clinics or hospitals, TB hospitals, ART Centres and Medical colleges in the district
and even the private NGO participating in NTEP are considered as Peripheral Health Institutions (PHIs). Some
of these PHIs also function as DMCs. PHI has the main responsibility of case finding and management. If > 1
MO is posted in a PHI, one is to be identified for the responsibilities of the NTEP. Referral for screening for
Diabetes Mellitus is the responsibility of the PHI where TB treatment is initiated and all Diabetic TB patients

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should be linked for diabetic care.

NSP has 4 pillars of strategies −
(a) Detect.
All drug sensitive cases (DS-TB) and drug resistant TB cases (DR-TB) especially from private providers and
undiagnosed TB cases in high-risk groups (prisoners, migrant workers, PLHIV / AIDS, contacts etc.) and report
these
(b) Treat.
Provision of free TB drugs in the form of daily fixed dose combinations (FDCs) for all TB cases is advised with
the support of directly observed treatment (DOT) and screening of all patients for rifampicin resistance
(c) Prevent.
Air-borne infection control measures at health care facilities. Treatment for latent TB infection in contacts of
bacteriologically confirmed cases; Tuberculosis Preventive Treatment (TPT); BCG; address social determinants
of TB through intersectoral approach
(d) Build.
Health system strengthening for TB control, enabling policies, empowering institutions and human resources
By 2020 it was clear that the NSP 2017–25 will not be able to meet these objectives, so a new NSP India
2025 was launched in 2020.

38.13 National Strategic Plan India 2020-2025.

NSP India 2020–2025 identifies a number of goals which still need to be carried out for the elimination of TB from
India. This plan intends to accelerate the national response to TB. The recommended actions include
(a) To mount a TB elimination campaign inspired by lessons gained from the eradication of Polio.
(b) Provide top priority reinforcements to the existing workforce.
(c) Scale up private provider engagement.
(d) Changes in approach from passive community involvement to full community participation and ownership.
(e) Investment in TB surveillance staff and systems for accurate, complete and timely information.
(f) Deployment of new precision diagnostic tools.
(g) Support patients comprehensively throughout treatment.
(h) Redesign and pursue targeted active case finding.
(j) Deploy and evaluate ambitious plans to implement TB preventive treatment in household and other close
contacts, children, People living with HIV (PLHIV) and other locally defined “high risk” groups, using new and
short regimens.

38.14 Tuberculosis (TB) Mukt Bharat Abhiyaan.

MoHFW along with various development partners of the Health Ministry launched the Tuberculosis (TB) Mukt Bharat
Abhiyaan in 2021 under the NSP India 2020–25 for TB Elimination in a major mission activity for ending the epidemic
of TB by 2025. It is a multi-dimensional approach which aims to detect all TB patients and emphasizes on reaching
for patients who are seeking TB care from private practitioners and undiagnosed TB in high-risk populations.
Objectives of the Initiative.
(a) Provide additional patient support to improve treatment outcomes of TB patients.
(b) Augment community involvement in meeting India’s commitment to end TB by 2025.
(c) Leverage Corporate Social Responsibility (CSR) activities.

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NATIONAL AIDS CONTROL PROGRAMME (NACP)

Introduction.
India’s response to the HIV / AIDS epidemic was initiated in the form of sero-surveillance in 1985. While initial
responses (1985-1991) focused on search of HIV in different population groups and locations, screening of blood
before transfusion and targeted awareness generation; the launch of National AIDS and STD Control Programme (NACP)
in 1992 institutionalized beginning of a comprehensive response to the HIV / AIDS epidemic in India. The first phase
of NACP (1992-1999) focussed on awareness generation and blood safety. The second phase witnessed launch of
direct interventions across the prevention-detection-treatment continuum with capacity building of States on programme
management. The third phase (2007-2012) was story of scale-up with programme management decentralised up to
the district level. The fourth phase (2012-2017) was a period of consolidation and enhanced Government funding.
The NACP Phase-IV (Extension) was first approved for the period of 2017-2020 and then further extended for one more
year i.e., 2020-21. Several game changer initiative were taken during NACP Phase-IV (Extension). The Phase started with
the passing of the HIV and AIDS (Prevention and Control) Bill, 2017 and the launch of the ‘Test and Treat’ policy for
HIV patients in April 2017. The Bill ensured equal rights for the people infected with HIV and AIDS in getting treatment
and prevent discrimination of any kind. The Act came into force in September 2018. As the ‘Test and Treat’ policy
was being scaled-up, the Programme implemented “Mission Sampark” in 2017 to bring back People Living with HIV
(PLHIV) who have left treatment after starting ART. ‘Test and Treat’ was complemented by the launch of universal viral
load testing for on-ART PLHIV in February 2018. The year 2020-21 witnessed the onset of the COVID-19 pandemic.
The national AIDS response was challenged in the initial months like any other aspect of life. However, the programme
soon took many initiatives turning challenges into opportunities. IT systems were leveraged to enhance programme
review and capacity building. This resulted in improved inter and intra-State coordination. Initiatives like multi-month
dispensation and community-based ART refill ensured continuity in service provisions. NACP Phase-V (2021-26) aims to
reduce annual new HIV infections and AIDS-related mortalities by 80% by 2025-26 from the baseline value of 2010.
The NACP Phase-V also aims to attain dual elimination of vertical transmission, elimination of HIV / AIDS related stigma
while promoting universal access to quality STI / RTI services to at-risk and vulnerable populations.
Table 38.10 : Evolution of the National HIV / AIDS Response
Initial NACP NACP NACP NACP NACP Phase-IV NACP
Response Phase-I Phase-II Phase-III Phase-IV (Extension) Phase-V
1985-1991 1992-1999 1999-2007 2007-2012 2012-2017 2017-2021 2021-2026

Disease burden.
India.
National Summary of the HIV / AIDS Epidemic 2021: Nationally, as per ‘India HIV Estimation 2021’ report there were
an estimated 24.01 lakh (19.92 lakh - 29.07 lakh) PLHIV, with an adult (15-49 years) HIV prevalence of 0.21%
(0.17%–0.25%) in 2021.

38.15 NACP Phase-V.

Goals.
(a) Reduce annual new HIV Infection by 80%.
(b) Reduce AIDS related mortalities by 80%.
(c) Eliminate vertical transmission of HIV and syphilis.
(d) Promote universal access to quality STI / RTI Services.
(e) Eliminate HIV / AIDS related stigma and discrimination.
Guiding Principles.
(a) Beneficiary and community in centre.
(b) Break the silos, build synergies.
(c) Strategic information driven.

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(d) Leverage technology and innovation.

(e) High impact programme management and review.
(f) Integrate gender sensitive response.
(g) Enhance and harness partnership.
(h) Continue fostering technical arrangements and institutions.
Specific Objectives.
(a) HIV / AIDS Prevention and Control.
(i) 95% of people who are most at risk of acquiring HIV infection use comprehensive prevention.
(ii) 95% of HIV positive know their status, 95% of those who know their status are on treatment and
95% of those who are on treatment have suppressed viral load.
(iii) 95% of pregnant and breastfeeding women living with HIV have suppressed viral load towards
attainment of elimination of vertical transmission of HIV.
(iv) Less than 10% of people living with HIV and key populations experience stigma and discrimination.
(b) STI / RTI Prevention and Control.
(i) Universal access to quality STI / RTI services to at-risk and vulnerable populations.
(ii) Attainment of elimination of vertical transmission of syphilis.
Current Achievements, Impact and Challenges.
(a) Achievements.
Evidence-driven AIDS response of India, following a three-pronged strategy of prevention-detection-treatment
while keeping the community and gender in the center, has been a global success story. As of March 2021,
there were 1,472 targeted interventions, 232 opioid substitution therapy (OST) centers, 33862 ICTC, 619 ART
centers, 478 CD4 testing sites and 64 Viral load laboratories offering prevention, HIV counselling and testing,
ART treatment, CD4 testing and viral load monitoring services. Rural areas in 138 districts were directly
being covered through the link worker scheme (LWS) while 868 employer-led models (ELM) interventions were
covering its worker in formal and informal sectors. The programme covered 1059 prisons reaching out to 40%
of the total admitted inmates in 2020-21. The service uptake at these facilities has increased significantly
during NACP Phase-IV and Extension with more than 6 crore population being directly reached under the
programme through these service delivery structures.
(b) Impact.
The impact of the national AIDS response has been significant. The annual new HIV infections in India have
declined by 48% against the global average of 31% (the baseline year of 2010). The annual AIDS-related
mortalities have declined by 0.22%.
(c) Challenges.
Despite the significant achievements and impact, there is no place for complacency given the country’s
commitment to ending the AIDS epidemic as a public health threat by 2030. HIV remains a national public
health priority with new HIV infections happening at a rate higher than the desired level. The annual number
of new infections among adults has declined by 48% since 2010, but still has a long way to go to achieve a
90% decline by 2030. The progress 82% against the global average of 47% (the baseline year of 2010). The
HIV prevalence in India continues to be low with an adult HIV prevalence of 0.22%. on targets of 90-90-90
to be achieved by 2020 has gauged the country’s progress on ending the epidemic. The full realization of
90-90-90 by 2020 would have meant that at least 73% of PLHIV have suppressed viral loads in 2020 cutting
down the transmission significantly. At the end of 2020, 78% of PLHIV knew their HIV status, 83% of PLHIV
who knew their HIV status were on ART and 85% of PLHIV on ART were virally suppressed.
The country aimed to achieve the dual elimination of vertical transmission of HIV and syphilis by 2020. One
of the key process targets for dual elimination was to test 95% of pregnant women for HIV and syphilis.
There has been significant progress in testing pregnant women for HIV and syphilis. The testing coverage of

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pregnant women for HIV increased from 69% in 2017-18 to 82% in 2019-20. However, the strong momentum
was adversely impacted by the COVID-19 pandemic as the testing coverage among pregnant women declined
to 76% in 2020-21. The progress in syphilis testing among pregnant women, although improving, is far from
the envisioned target. In 2020-21, around 37% of the pregnant women were tested for syphilis, almost twice
the level in 2017 but still missing the target of 95% coverage by a huge margin.
In the spirit of the provisions of the HIV and AIDS (Prevention and Control) Act, 2017 and recognizing the
HIV / AIDS-related stigma and discrimination as a significant barrier to uptake of HIV / AIDS-related services, the
national AIDS response is committed to eliminate HIV / AIDS related stigma. In 2005-06, 60-63% of women
and men were willing to buy fresh vegetables from a shopkeeper who has HIV / AIDS. In comparison, 69-73%
of women and men in 2015-16 were willing to buy fresh vegetables from a shopkeeper who has HIV / AIDS.
Despite the progress, the levels are still of concern and far from elimination targets.

38.16 The HIV and AIDS (Prevention and Control) Act, 2017.
The HIV and AIDS (Prevention and Control) Act, 2017 is a landmark legislation to provide for the prevention and control
of the spread of HIV and AIDS and for the protection of human rights of persons affected by HIV / AIDS. The Act aims
to address stigma and discrimination so that people infected with and affected by HIV and AIDS are not discriminated
against in household settings, establishment settings and healthcare settings.
Salient Features of the HIV and AIDS (Prevention and Control) Act, 2017.
This includes denial, termination, discontinuation or unfair treatment to PLHIV with regard to
(i) Employment.
(ii) Educational establishments.
(iii) Health care services.
(iv) Residing or renting property.
(v) Standing for public or private office.
(vi) Provision of insurance.

38.17 HIV Surveillance.

In the year 1985 ICMR started screening of blood from high-risk groups at National Institute of Virology at Pune and
Christian Medical College at Vellore to determine if HIV was present in India. The first case of HIV was diagnosed in 1986
at Chennai. The surveillance activity was extended by establishing 62 sero-surveillance centres and 9 HIV Reference
Centres in the country for identification of geographic spread of HIV and determination of major modes of transmission.
The objectives were to identify trends in seropositivity in specific high-risk groups as well as in the general population.
Different types of surveillance activities are being carried out in the country to detect the spread of the disease and
to make appropriate strategy for prevention and control viz., area specific targeted intervention and best practice
approach. The types of surveillance are
(a) HIV sentinel surveillance.
(b) HIV sero-surveillance.
(c) AIDS case surveillance.
(d) STD surveillance.
(e) Behavioral surveillance.
(f) Integration with surveillance of other diseases like tuberculosis.

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NATIONAL PROGRAMME FOR CONTROL OF BLINDNESS AND

VISUAL IMPAIRMENT (NPCB & VI)

38.18 Introduction.
National Programme for Control of Blindness was launched in the year 1976 as a centrally sponsored scheme (now
60:40 in all States and 90:10 in NE States and other hilly States) with the goal of reducing the prevalence of blindness
0.25% by the year 2025. The National Blindness & Visual Impairment Survey (2015-19) conducted under the programme
showed reduction in the prevalence of blindness from 1% (2007) to 0.36% (2019).
The National Blindness Survey (2015-19) has shown a reduction in the prevalence of blindness from 1% (2007) to 0.36%
(2019). In the beginning, it was a 100% centrally sponsored scheme. From 12th FYP it is 60:40 in all States / UTs and
90:10 in hilly states and all NE States. The nomenclature of the programme was also changed from National Programme
for Control of Blindness to National Programme for Control of Blindness and Visual Impairment (NPCBVI) in 2017.
Goal.
Under the National Health Policy (NHP), the target is to reduce the prevalence of blindness to 0.25% by 2025.
Objectives of NPCBVI in the XII Plan.
(a) To reduce the backlog of blindness through identification and treatment of blind at primary, secondary
and tertiary levels based on assessment of the overall burden of visual impairment in the country.
(b) Develop and strengthen the strategy of NPCBVI for “Eye Health” and prevention of visual impairment,
through provision of comprehensive Eye Care services and quality service delivery.
(c) Strengthening and upgradation of Regional Institutes of Ophthalmology to become centre of excellence
in various sub-specialities of ophthalmology.
(d) Strengthening the existing and developing additional human resources and infrastructure facilities for
providing high quality comprehensive Eye Care in all districts of the country.
(e) To enhance community awareness on eye care and lay stress on preventive measures.
(f) Increase and expand research for prevention of blindness and visual impairment.
(g) To secure participation of voluntary organizations / private practitioners in eye care.
Table 38.11 : Causes of blindness in India: 2015-19 National Survey on Blindness
Cataract untreated 66.2%
Non trachomatous corneal opacity 7.4%
Cataract surgical complications 7.2%
Other Posterior segment disorders excluding Diabetic Retinopathy and Age-related Macular Degeneration 5.9%
(ARMD)
Glaucoma 5.5%
Phthisis 2.8%
Aphakia uncorrected 1.7%
Diabetic Retinopathy 1.2%
Trachomatous corneal opacity 0.8%
ARMD 0.7%
All other globe / CNS abnormalities 0.5%
Refractive error 0.1%

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Newer Initiatives / Focus Areas Under the Programme.

(a) Revision of NPCBVI guidelines to provide comprehensive eye health care through AB- Health and Wellness
Centers.
(b) “Standards of eye banking in India 2020” have been launched for improvement in eye donation, collection,
processing and maintenance of quality standards, equitable distribution of scarce corneal tissue, strengthening
of institutional capacity for corneal transplantation, community awareness and training of health personnel
(c) Development of a network of eye banks and eye donation centres and linked with medical colleges and
RIOs to promote collection and timely utilization of donated eyes in a transparent manner
(d) Focus on other causes of Visual impairment, besides Cataract, treatment / management of other eye
diseases like Diabetic retinopathy (DR), Retinopathy of prematurity (ROP). Corneal Blindness and glaucoma
have increased. DR screening and glaucoma clinics have been made an integral part at district and sub-district
hospitals.
(e) In order to achieve elimination of trachoma by the year 2020 as per WHO global action plan, surveillance,
case detection and treatment of Trachoma trichiasis (TT) is being executed which will be followed by TT only
survey in all previously trachoma endemic districts
(f) Issuing COVID-19 guidelines to all stakeholders for safe ophthalmology practices to minimize and avoid
the spread of COVID-19 in eye care facilities
(g) Setting up of super-specialty clinics for all major eye diseases including diabetic retinopathy, glaucoma,
retinopathy of prematurity etc. in state level hospitals and medical colleges all over the country
(h) Linkage of tele-ophthalmology centers at PHC / Vision centers with super-specialty eye hospitals to ensure
delivery of best possible diagnosis and treatment for eye diseases, especially in hilly terrains and difficult areas

38.19 VISION 2020 – The Global Initiative for the Elimination of Avoidable Blindness.
Towards a global effort, VISION 2020: The Right to Sight – the Global Initiative for the Elimination of Avoidable Blindness
by the year 2020 was formally launched from WHO Headquarters, Geneva in 1999 with the goal of eliminating avoidable
blindness by the year 2020. VISION 2020’s mission statement emphasizes, “Our mission is to eliminate the main causes
of blindness in order to give all people in the world, particularly the millions of needlessly blind, the right to sight”.

O Professional leadership
Tertiary Level Centres O Strategy development and CME
of Excellence: O Laying standards, quality assurance, research
20

O Tertiary eye care

Tertiary Level Training Centres: 200 O Training and CME

Secondary Level
O Cataract Surgery
Service Centres: 2000 O Facilities for refraction
O Referral Services

Primary Level O Refraction and glass prescription

Primary Level Vision Centres: 20000 O Primary Eye Care
O School eye screening and referral

Fig 38.1 : Proposed Structure of VISION 2020: The Right to Sight

India was among the 183 countries in the world signatories to the VISION 2020: The Right to Sight Global Initiative. In
India, VISION 2020: The Right to Sight – India was launched in 2004. This was in coordination with all NGOs working
in the area of blindness in India, the government, centres of excellence in eye care in India and premier eye institute,
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS.

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38.20 Rashtriya Netra Jyoti Abhiyaan.

This campaign has been launched under the NPCB&VI with the aim to cover the backlog of cataract surgeries causing
blindness and severe visual impairment (SVI) among the people aged 50 years and above by conducting primary
screening of people for cataract through household surveys and through conducting NCD screening along with blindness
and visual impairment screening in health and wellness centers / hospitals.

38.21 External Assistance.

Apart from the external assistance provided by DANIDA and WHO, a World Bank assisted blindness control project is
being implemented since 1994-1995, with the project period of 7 years. The voluntary organizations such as Lions
International and its branches, Rotary International and its branches, etc. are encouraged to organize eye camps in
remote rural and urban areas.

IODINE DEFICIENCY DISORDERS (IDD) PROGRAMME

38.22 Introduction.
Realizing the magnitude of the problem, the Government of India launched a 100 percent centrally assisted National
Goiter Control Programme (NGCP) in 1962. In August 1992 the National Goiter Control Programme (NGCP) was renamed
as National Iodine Deficiency Disorders Control Programme (NIDDCP) with a view of wide spectrum of Iodine Deficiency
Disorders.
Goal.
(a) To bring the prevalence of IDD to below 5% in the country.
(b) To ensure 100% consumption of adequately iodised salt (15 ppm) at the household level.
Objectives.
(a) Surveys to assess the magnitude of Iodine Deficiency Disorders in the districts.
(b) Supply of iodised salt in place of common salt.
(c) Resurveys to assess iodine deficiency disorders and the impact of iodised salt after every 5 years in the
districts.
(d) Laboratory monitoring of iodised salt and urinary iodine excretion.
(e) Health Education and Publicity.

UNIVERSAL IMMUNIZATION PROGRAMME

Mission Indradhanush: Special drive to vaccinate all unvaccinated and partially

vaccinated children under Universal Immunisation Programme (UIP)

38.23 Introduction.
Experience with smallpox eradication programme showed the world that immunization was the most powerful and
cost-effective weapon against vaccine preventable diseases. In 1974, WHO launched the “Expanded Programme on
Immunization” (EPI) against 6 diseases which were common during childhood, viz. diphtheria, pertussis, tetanus,
polio, tuberculosis and measles. “Expanded” in the WHO definition meant adding more disease controlling antigens
of vaccinations to the schedules, extending coverage to all corners of a country and spreading services to reach the
less privileged sectors of society.
The immunization services are being provided through the existing health care delivery system (i.e., MCH centres,
Primary Health Centres and sub centres, hospitals, dispensaries and ICDS units). Under UIP, immunization is being
provided free of cost against 12 vaccine preventable diseases: Nationally against 11 diseases- Diphtheria, Pertussis,
Tetanus, Polio, Measles, Rubella, severe form of Childhood Tuberculosis, Rotavirus diarrhoea, Hepatitis B, Meningitis

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and Pneumonia caused by Hemophilus Influenza Type B and Pneumococcal Pneumonia and sub-nationally against
Japanese Encephalitis (JE vaccine is provided only in endemic districts).
Objectives of UIP.
(a) To rapidly increase immunization coverage.
(b) To improve the quality of services.
(c) To establish a reliable cold chain system to the health facility level.
(d) Monitoring of performance.
(e) To achieve self-sufficiency in vaccine production.

38.24 New Initiatives under UIP: Introduction of New Vaccines.

(a) Rotavirus Vaccine (RVV).
Rotavirus is one of the leading causes of severe diarrhoea and death among young children. RVV has been
introduced in India in March 2016 to reduce mortality and morbidity caused by Rotavirus diarrhea.
(b) Measles-Rubella (MR) Vaccine.
Measles Rubella (MR) vaccine was introduced through campaign in 2017 targeting around 41 crore children
in the age group of 9 months to 15 years (covering one third of the total population of the country) followed
by 2 doses in routine immunization at 9-12 months and 16-24 months.
(c) Pneumococcal Conjugate Vaccine (PCV).
PCV was launched in a phased manner in UIP in May 2017 for reducing infant mortality and morbidity caused
by pneumococcal pneumonia.
(d) Tetanus and Adult Diphtheria (Td) Vaccine.
Increase in immunization coverage in children led to shift in age-group of diphtheria cases to school going
children and adults. As per recommendation of National Technical Advisory Group on Immunization (NTAGI) in
2016, Td vaccine has replaced TT vaccine and given to pregnant woman and children of 10 and 16 years of
age from February 2019 as per National Immunization Schedule.
(e) Inactivated Polio Vaccine (IPV).
Introduced in UIP as part of Global Polio end-game strategy, to mitigate the risk associated with tOPV to bOPV
switch. IPV was introduced in November 2015 initially in 6 states, which was expanded across the country by
April 2016. From 1st Jan 2023 onwards, 3 doses of fIPV, at 6 week and 14-week: 0.1 ml Intradermal injection
at RIGHT Upper Arm. At 9 months: 0.1 ml Intradermal injection at LEFT Upper Arm (since MR vaccine is already
being given at Right Upper Arm).
(f) The National Technical Advisory Group on Immunization (NTAGI) has recommended the introduction of
HPV vaccine into the UIP, proposing a one-time catch up program for adolescent girls aged 9-14 years, followed
by routine introduction at 09 years of age.
Details of Immunization Schedule have been described in Chapter XXIII.

PULSE POLIO PROGRAMME

38.25 Introduction.
With the global initiative of eradication of polio in 1988 following World Health Assembly resolution in 1988, India was
committed to resolution passed by World Health Assembly for global polio eradication. National Immunization Day (NID)
commonly known as Pulse Polio Immunization programme was launched in India in 1995 and till 2017, it was being
conducted twice in early part of each year. As recommended by India Expert Advisory Group (IEAG) for Polio, since 2018
it is being conducted once in early part of each year. Additionally, multiple rounds of Sub National Immunization Day
(SNID) have been conducted over the years in high-risk states / areas. Since 2017, country is conducting two rounds
of SNID during June-Nov months of the year in the high-risk states / areas of the country. In these campaigns, children
in the age group of 0-5 years are administered oral polio drops. Over 160 million children are immunized during each

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NID and 70 million in SNID.

The last polio case in the country was reported from Howrah district of West Bengal with date of onset 13th January
2011. Thereafter no polio case has been reported in the country and India continues to maintain the polio-free status
for > 11 years. WHO on 24th February 2012 removed India from the list of countries with active endemic wild polio
virus transmission. South-East Asia Region of WHO including India was certified polio free by World Health Organization
on 27th March 2014. Surveillance for detection of poliovirus transmission is being done through acute flaccid paralysis
(AFP) Surveillance with laboratory network.
Objective.
The Pulse Polio Initiative was started with an objective of achieving hundred percent coverage under Oral Polio Vaccine.
It aimed to immunize children through improved social mobilization, plan mop-up operations in areas where poliovirus
has almost disappeared and maintain high level of morale among the public.

38.26 Steps Taken by GoI to Maintain Polio Free Status.

This is required as risk persist on account of ongoing transmission in other countries which may lead to importation
of polio virus. Following steps are undertaken by GoI
(a) Maintaining community immunity through high quality National and Sub National polio rounds each year.
(b) Polio surveillance across the country for importation or circulation of poliovirus and Vaccine Derived Polio
Virus (VDPV). Polio surveillance in country is considered to be of international standards.
(c) Environmental surveillance (sewage sampling) has been established to detect poliovirus transmission and
as a surrogate indicator of the progress as well for any programmatic interventions. There are 60 environmental
surveillance sites in the country located strategically in 13 states.
(d) Country has eight WHO accredited laboratories located at Kasauli, Delhi, Lucknow, Kolkata, Ahmedabad,
Mumbai, Bengaluru and Chennai.
(e) All States and Union Territories in the country have developed a Rapid Response Team (RRT) to respond
to any polio outbreak in the country. Emergency Preparedness and Response Plans (EPRP) has also been
developed by the country indicating steps to be undertaken in case of detection of a polio case.
(f) To reduce risk of importation from neighbouring countries, international border vaccination is being
provided through continuous vaccination teams (CVT) to all eligible children round the clock.
(g) Guidelines for mandatory requirement of polio vaccination to all international travelers for travel to India
and other affected countries.
(h) Rolling emergency stock of OPV is being maintained to respond to detection / importation of wild poliovirus
(WPV) or emergence of circulating vaccine derived poliovirus (cVDPV).
(j) Introduction of injectable Inactivated Poliovirus Vaccine (IPV) as an additional dose along with 3rd dose
of pentavalent vaccine as a part of polio endgame strategy and tOPV-bOPV switch.
(k) On 25th April 2016, country successfully switched from tOPV vaccine to bOPV vaccine. This was done
in view of the WHO declaration of eradication of type 2 WPV and to minimize the risk of VDPV due to type 2
component of OPV.
(l) In 2017, India introduced the fractional dose of Inactivated Poliovirus Vaccine (IPV) into routine
immunization. Two doses of fIPV were introduced along with first and third dose of oral polio vaccine (OPV) at
6 weeks and 14 weeks of age of the child.
(m) Introduction of third dose of fIPV in the UIP wef 1st January 2023. Three doses to be given at – 6 weeks,
14 weeks and 9 months of age.

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NATIONAL MENTAL HEALTH PROGRAMME

The Flannel flower, an Australian native, has been chosen as the national symbol
to promote mental health for its inherent beauty, strength and adaptability needed
to survive.

38.27 Introduction.
The National Mental Health Programme (NMHP) was launched in 1982 with a view to ensure availability of mental
health care services for all, especially for community at risk and under privileged section of the population, to encourage
application of mental health knowledge in general health care and social development.
Aim of NMHP.
(a) Prevention and treatment of mental and neurological disorders and their associated disabilities.
(b) Use of mental health technology to improve general health services.
(c) Application of mental health principles in total national development to improve quality of life.
Objectives.
(a) To ensure availability and accessibility of minimum mental health care for all in the foreseeable future
especially to the most vulnerable and underprivileged section of population.
(b) To encourage application of mental health knowledge in general health care and social development.
(c) To promote community participation in mental health services development and to stimulate efforts
towards self-help in the community.
Strategies.
(a) Integration of mental health and primary health care.
(b) Provision of tertiary care institutions for treatment of mental disorders.
(c) Eradicating stigmatization of mentally ill patients and protecting their rights through regulatory institutions
like The Central Mental Health authority and The State Mental Health authority.

38.28 District Mental Health Programme (DMHP).

During the eighth five-year plan, NIMHANS Bangalore developed a district mental health care model in Bellary district
with the following components
(a) Training programme of all workers in mental health team at the identified nodal institute in the state.
(b) Public education in mental health to increase awareness and reduce stigma.
(c) Early Detection, Treatment.
OPD and indoor services are provided.
(d) Providing valuable data and experience at level of community to the state and Centre for future planning,
improvement in services and research.
Preventive and promotive activities in DMHP.
(a) School Mental Health Services.
Life skills education, counselling services.
(b) College counselling services through trained teachers / counsellors.
(c) Workplace stress management in formal and informal sectors including farmers, women etc.
(d) Suicide Prevention Services.

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Counselling center at district level, sensitization workshops, IEC, helpline.

38.29 Thrust areas of NMHP.

(a) DMHP in enlarged and more effective form covering entire population.
(b) Streamlining modernization of mental hospitals to modify their custodian role.
(c) Upgrading the Department of Psychiatry in medical colleges and enhancing psychiatric content of medical
curriculum at undergraduate and postgraduate level.
(d) Strengthening central and state mental health authorities with a permanent Secretariat.
(e) Appointment of Medical Officer at state HQs for monitoring purposes.
(f) Research and training in community mental health, substance abuse and child adolescent psychiatric
clinics.

38.30 National Mental Health Act, 2017.

Individuals with mental illnesses are vulnerable and are subject to social discrimination. The Mental Health Care Bill
2013 was introduced in the Parliament and it received assent of the Hon’ble President of India on 07th April 2017.
Salient Features of National Mental Health Act.
(a) To protect and promote the rights of persons with mental illness.
(b) Ensure health care, treatment and their rehabilitation.
(c) Regulate public and private mental health sectors.
(d) Promote principles of equity, efficiency.
(e) Promote active participation of all stakeholders.
(f) Suicide has been decriminalized under the Act.

NATIONAL PROGRAMME FOR PREVENTION AND

CONTROL OF NON-COMMUNICABLE DISEASES (NP-NCD)
38.31 Introduction.
Non-Communicable Diseases (NCDs) are chronic diseases that are not transmissible from one person to another. NCDs
include wide spectrum of medical disorders both acute and chronic like Cancers, Diabetes, Hypertension, Cardiovascular
Diseases and Stroke, Chronic Kidney Diseases (CKDs), Chronic Obstructive Pulmonary Diseases (COPDs) and Asthma,
Non-Alcoholic Fatty Liver Disease (NAFLD) and a gamut of other diseases. As per WHO, the NCDs are collectively
responsible for more than 74 percent of all deaths worldwide including heart disease, stroke, cancer, chronic respiratory
diseases and diabetes. NCDs cause significant morbidity and mortality, both in urban and rural population and across
all socio-economic strata, with considerable loss in potentially productive years of life. NCDs are also responsible for
the maximum out-of-pocket expenditure on health.
Objectives.
(a) Health promotion through behaviour change with involvement of community, civil society, community-
based organizations, media and development partners.
(b) Screening, early diagnosis, management, referral and follow-up at each level of healthcare delivery to
ensure continuum of care.
(c) Build capacity of health care providers at various levels for prevention, early diagnosis, treatment, follow-
up, rehabilitation, IEC / BCC, monitoring and evaluation and research.
(d) Strengthen supply chain management for drugs, equipment and logistics for diagnosis and management
at all health care levels.
(e) Monitoring, supervision and evaluation of programme through proper implementation of uniform ICT

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application across India.

(f) To coordinate and collaborate with other programmes, departments / ministries, civil societies
Table 38.13 : Package of Services
Level of Care Package of Services
Community level (a) Active enumeration of the eligible population and registration of the families, risk
assessment of NCDs using Community Based Assessment Checklist (CBAC)
(b) Mobilization of community for screening of NCDs at nearest AB-HWC
(c) Health promotion, lifestyle modification, follow up for treatment compliance and
lifestyle modification
Sub-centre / SHC-HWC (a) Health education for awareness generation and behaviour change, organising
wellness activities
(b) Screening of Diabetes, Hypertension, three common cancers (oral, breast,
cervical)
(c) Referral of suspected cases to PHC / PHC-HWC or nearby health facility for
diagnosis confirmation and management. SHC- HWC team to also facilitate the
referrals and follow up on referred suspected patients
(d) Dispensing of prescribed medicines and follow up of patient for treatment
compliance and lifestyle modification
(e) Teleconsultation services from SHC-HWC to HWC- PHC / UPHC
(f) Maintaining Electronic Health Records (EHR) and generation of ABHA IDs
PHC / PHC (a) Health promotion activities including wellness activities for behaviour change
HWC / UPHC (b) Screening of Diabetes, Hypertension, three common cancers (oral, breast and
HWC cervical), COPD and Asthma, CKD, NAFLD among OPD attendees
(c) Confirmation of diagnosis, treatment initiation and management of common NCDs
as per standard management protocol and guidelines
(d) Referral of complicated NCD cases to higher facilities
(e) Bi-directional referral linkages to be established and follow up to be ensured
(f) Teleconsultation and EHR services
CHC / SDH In addition to services provided at PHC, following services are provided:
(a) Management of cases of common NCDs and regular follow-up
(b) Referral of complicated cases to District Hospital / higher healthcare facility
District Hospital (a) Opportunistic screening of Diabetes, Hypertension, three common cancers (oral,
breast and cervical)
(b) Screening of COPD and Asthma, CKD, NAFLD, STEMI among suspected cases
(c) Diagnosis and management of cases of common NCDs: outpatient and inpatient
care, including emergency care particularly for cardiac and stroke cases
(d) Management of complicated cases of common NCDs or referral to higher
healthcare facility
(e) Follow-up cancer chemotherapy and palliative care services for cancer cases
physiotherapy services for NCDs including Stroke patients, Dialysis facilities for
CKD patients, etc.
(f) Health promotion for behaviour change and counselling for NCD cases
(g) IEC activities on important Health Days
(h) Bidirectional referral linkages, teleconsultation and EHR services

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Medical College / Tertiary (a) Diagnosis and management of complicated cases of common NCDs acts as
Cancer Centres tertiary referral facility
(b) Comprehensive cancer care including prevention, early detection, diagnosis,
treatment, palliative care and rehabilitation at Tertiary Cancer Centres
(c) Support programme in capacity building of health staff
(d) Support programme in preparing standard guidelines and protocols
(e) Support in supervision, monitoring, evaluation and operational research
(f) Bidirectional referral, teleconsultation and EHR services
Other Services under NP-NCD.
(a) Critical Care Units.
Under it, the support is provided for 50 / 75 / 100 bedded Critical Care Units (Cardiac Care Unit (CCU) / Cardiac
and Stroke Care Unit (CSCU)) in 602 districts across all States / UTs
(b) Day Care Centre for Cancer Chemotherapy.
Day Care Centres are established for provision of continuation of simple chemotherapy regimens to cancer patients
at the District Hospitals to support those already undergoing treatment at Tertiary Care Cancer Centres (TCCC)
(c) Strengthening of Tertiary Cancer Care Centres Facilities Scheme.
Under the scheme, support is provided to States / UTs for setting up of State Cancer Institutes (SCIs) and
Tertiary Care Cancer Centres (TCCCs) in different parts of the country
(d) India Hypertension Control Initiative (IHCI).
IHCI was launched in November 2017. The initiative includes scanning of QR code of health ID Card for
beneficiary identification and observing the progress rate of the programme through number of patients on
treatment and control rate.

INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)

The ICDS logo symbolises India’s commitment to its children and mothers

38.32 Introduction.
ICDS is a centrally sponsored scheme initiated by the Ministry of Women and Child Development in 1975, in pursuance of
the National Policy for children. This scheme is a unique early childhood development programme, aimed at addressing
malnutrition, health and also development needs of young children, pregnant and nursing mothers through providing
supplementary nutrition, immunization and pre-school education to the children. ICDS is presently anchored by Ministry
of Women and Child Development (MoWCD), GoI. The scheme is universal covering all districts of the country. Anganwadi
Services are now offered as part of the Saksham Anganwadi and Poshan 2.0 (Poshan 2.0) - an Integrated Nutrition
Support Programme.
Beneficiaries under ICDS.
(a) Children below 6 years.
(b) Pregnant and lactating women.
(c) Women in the age group of 15-45 years.
(d) Adolescent girls in selected block.
Objectives.
(a) To improve nutritional and health status of children in age-group 0-6 years.

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(b) To lay foundation for proper psychological, physical and social development of the child.
(c) To reduce incidence of mortality, morbidity, malnutrition and school dropout.
(d) To achieve effective co-ordination of policy and implementation amongst various departments to promote
child development.
(e) To enhance capability of mother to look after the normal health and nutritional needs of child through
proper nutrition and health education.
Table 38.14 : Services Provided under ICDS Scheme
Services Target Group Service Provided by
Supplementary nutrition Children below 6 years, Anganwadi Worker (AWW) and Anganwadi Helper
pregnant and lactating
mothers
Immunization Children below 6 years, Auxiliary Nurse Midwife (ANM) / Medical Officer (MO)
pregnant and lactating
mothers
Health services Children below 6 years, ANM / MO / AWW
pregnant and lactating
mothers
Referral services Children below 6 years, AWW / ANM / MO
pregnant and lactating
mothers
Pre-school education Children 3-6 years AWW
Nutrition and health education Women (15-45 years) AWW / ANM / MO

Umbrella ICDS Scheme.

Currently, ICDS is termed as Umbrella ICDS scheme and comprises of several sub schemes
(a) Anganwadi Services.
(b) POSHAN Abhiyaan.
(c) Scheme for Adolescent Girls (SAG).
(d) Pradhan Mantri Matru Vandana Yojana (PMMVY).
(e) Child Protection Services.
(f) National Creche scheme.
(a) Anganwadi services.
These services aim at holistic development of children below 6 years of age and pregnant women and lactating
mothers, by providing a package of six services comprising of
(i) Supplementary nutrition.
(ii) Pre-school non-formal education.
(iii) Nutrition and health education.
(iv) Immunization.
(v) Health check-up.
(vi) Referral services through Anganwadi Centres at grassroots level.
3 of the 6 services viz., immunization, health check-up and referral services are related to health and are provided
by Ministry of Health and Family Welfare through NRHM and public health infrastructure. As Anganwadi Services is a
Centrally Sponsored Scheme, the overall management and monitoring regarding implementation of the ICDS Scheme

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are being done by the concerned State Government / UT Administration.

Table 38.15 : Population Norm for Setting Up of AWCs and Mini AWCs
Population Number of AWC
For AWC in rural / urban projects 400-800 1 AWC
800-1600 2 AWCs
1600-2400 3 AWCs
Thereafter in multiple of 800: 1 AWC
For mini AWC 150-400 1 mini AWC
For tribal / riverine / desert, hilly and 300-800 1 AWC for mini AWC
other difficult areas and project
150-300 1 mini AWC
Anganwadi on demand (AOD) Where settlement has at least 40 children under 6 years, but no AWC
Other Schemes Implemented Through ICDs.
(a) POSHAN Abhiyaan.
POSHAN Abhiyaan was launched in March 2018, to comprehensively address the problem of malnutrition in
the country. The goals of POSHAN Abhiyaan are to achieve improvement in nutritional status of Children from
0-6 years, Adolescent Girls, Pregnant Women and Lactating Mothers in a time bound manner and reduction
in stunting, wasting in children (0-6 years) as well as reduction of anaemia in women and children.
Mission Poshan 2.0 will contribute to human capital development of the country; address malnutrition
challenges; promote nutrition awareness and good eating habits for sustainable health and well-being and
address nutrition related deficiencies through key strategies.
Poshan 2.0 focusses on Maternal Nutrition, Infant and Young Child Feeding Norms, Treatment of MAM / SAM
and Wellness through AYUSH. It will rest on the pillars of Convergence, Governance and Capacity-building.
Poshan Abhiyan will be the key pillar for Outreach and will cover innovations related to nutritional support, ICT
interventions, Media Advocacy and Research, Community Outreach and Jan Andolan in the form of Poshan
Maah and Poshan Pakhwada.
(b) Role of Panchayats.
Panchayats shall play the continuing role in creation and management of Anganwadi Infrastructure. Active
participation of Village Health Sanitation and Nutrition Committees (VHSNC), Mothers Groups etc., for regular
monitoring and social audit and local community ownership of the programme under Poshan 2.0.
(c) Pradhan Mantri Matru Vandana Yojana.
The Ministry of Women and Child Development implements Pradhan Mantri Matru Vandana Yojana (PMMVY),
a Centrally Sponsored Conditional Cash Transfer Scheme.
(d) Scheme for Adolescent Girls.
The focus of the scheme is to mainstream out of school adolescent girls into formal education system. Under
this scheme, out of school adolescent girls in the age group of 11-14 years are provided supplementary
nutrition under ICDS containing 600 calories, 18-20 grams of protein and micronutrients for 300 days in a
year. Under the non-nutrition component, the scheme aims at motivating out of schoolgirls in the age group
of 11-14 years to return to formal schooling or skill training and several services like IFA supplementation,
health check-up and referral services are provided to the beneficiaries.
(e) The Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (RGSEAG) Sabla.
It is a centrally sponsored program of the Government of India initiated on 1st April 2011. The scheme would
cover adolescent girls in the age group of 11-18 years under all ICDS projects.

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Objectives.
(i) To enable adolescent girls’ self-development and empowerment.
(ii) Improve their nutrition and health status.
(iii) Promote awareness about health, hygiene, nutrition, adolescent reproductive and sexual health
(ARSH) and family and childcare.
(iv) Upgrade home-based skills, life skills and integrate with the National Skill Development Program
(NSDP) for vocational skills.
(v) Mainstream out of school adolescent girls into formal / non-formal education.
(vi) Provide information / guidance about existing public services such as PHC, CHC, post office, bank,
police station, etc.
Services.
(i) Nutrition provision: Iron and Folic Acid (IFA) supplementation.
(ii) Health check-up and Referral services.
(iii) Nutrition and Health Education (NHE).
(iv) Counseling / Guidance on family welfare, ARSH, childcare practices and home management.
(v) Life Skill Education and accessing public services.
(vi) Vocational training for girls aged 16 and above under National Skill Development Program (NSDP).
(f) The Palna or National Creche Scheme. This scheme is functional since 1st Jan 2017 to provide day care
facilities to children (age group of 6 months- 6 years) of working mothers. The scheme provides an integrated
package of the following services
(i) Daycare facilities including sleeping facilities.
(ii) Early Stimulation for children below 3 years and Pre-school Education for 3 to 6 years old children.
(iii) Supplementary nutrition (to be locally sourced).
(iv) Growth monitoring.
(v) Health check-up and Immunization.
(vi) Safe and secure place for the children of working mothers in the age group of 6 months to 6
years for 7½ hours a day.
(vii) Financial support for pregnant and lactating mothers is to improve the health and nutrition for
mother and child as well as for partial compensation of wage loss, if any.

NATIONAL PROGRAMME FOR HEALTHCARE OF THE ELDERLY (NPHCE)

38.33 Background.
The unprecedented increase in human longevity in 20th century has resulted in the phenomenon of population ageing
all over the world. The population over the age of 60 years has more than tripled in last 50 years in India.
The National Programme for the Health Care for the Elderly (NPHCE) is an articulation of the International and national
commitments of the Government as envisaged under the UN Convention on the Rights of Persons with Disabilities
(UNCRPD), National Policy on Older Persons (NPOP) adopted by the Government of India in 1999 and Section 20 of
“The Maintenance and Welfare of Parents and Senior Citizens Act, 2007” dealing with provisions for medical care of
Senior Citizen.
Objectives.
(a) To provide accessible, affordable and high-quality long-term, comprehensive and dedicated care services
to an Ageing population.

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(b) Creating a new “architecture” for Ageing.

(c) To build a framework to create an enabling environment for “a Society for all Ages”.
(d) To promote the concept of Active and Healthy Ageing.
Specific Objectives.
(a) To provide an easy access to promotional, preventive, curative and rehabilitative services to the elderly
through community based primary health care approach.
(b) To identify health problems in the elderly and provide appropriate health interventions in the community
with a strong referral backup support.
(c) To build capacity of the medical and paramedical professionals as well as the caretakers within the
family for providing health care to the elderly.
(d) To provide referral services to the elderly patients through district hospitals, regional medical institutions.
(e) Convergence with National Rural Health Mission, AYUSH and other line departments like Ministry of
Social Justice and Empowerment.

AYUSHMAN BHARAT PROGRAMME

Icon of a human being sitting in an upright position and is preceded by petals of
a flower, which symbolizes sound health and wellbeing. This spot also mentions
Ayushman Bharat in Devanagari script, which indicates longevity or long life of
human beings.

38.34 Introduction.
Ayushman Bharat, a flagship scheme of Government of India, was launched as recommended by the National Health
Policy 2017 to achieve the vision of Universal Health Coverage (UHC). This initiative has been designed to meet
Sustainable Development Goals (SDGs) and its underlining commitment, which is to “leave no one behind.”
Initiatives under Ayushman Bharat.
In Feb 2018, the Govt. of India announced two major initiatives in health sector, with aim to cover preventive and
health promotive interventions at primary, secondary and tertiary care system.
Health and Wellness Centre.
Under this 1.5 lakh existing sub centres will bring health care system closer to the homes of people in the form of
Health and wellness centres. These centres will provide comprehensive health care, including for non-communicable
diseases and maternal and child health services.
List of services to be provided at Health and Wellness Centre.
(a) Pregnancy care and maternal health services.
(b) Neonatal and infant health services.
(c) Child health.
(d) Chronic communicable diseases.
(e) Non-communicable diseases.
(f) Management of mental illness.
(g) Dental care.
(h) Eye care.
(j) Geriatric care Emergency medicine.

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38.35 Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY).

Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is the world’s largest health insurance scheme that
intends to minimise the out-of-pocket expenditure of the target beneficiaries arising due to catastrophic expenditure
on healthcare. The scheme provides health cover of ₹ 5 lakhs per family per year for secondary and tertiary care
hospitalization to over 10.74 crores poor and vulnerable families (approximately 50 crore beneficiaries) that form the
bottom 40% of the Indian population. The households included in the scheme are based on the deprivation and
occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) and other State schemes that consider similar
deprivation criterion as of AB-PMJAY.
The scheme was launched subsuming the erstwhile Rashtriya Swasthya Bima Yojana (RSBY) on 23rd September 2018 with
an aim to improve affordability, accessibility and quality of healthcare for the poor and vulnerable section of the population.
Salient features of AB-PMJAY.
(a) Around 10.74 crore poor and vulnerable families (approximately 50 crore individuals) are entitled under
ABPMJAY for cashless and paperless healthcare services of upto ₹ 5 lakhs annually which can be accessed at
any of the AB-PMJAY empanelled hospitals. Many of the 33 States / UTs have further expanded the beneficiary
base to 15.5 crores.
(b) The beneficiaries can avail healthcare services across 27 specialities covering 1949 procedures. This
health coverage includes 3 days of pre-hospitalisation and 15 days of post-hospitalisation expenses.
(c) There is no cap on family size, age or gender to ensure that all members of the beneficiary families are
covered.
(d) The benefits under the scheme are portable across the country.
(e) The scheme is also implemented in convergence with the State schemes where the State governments
have identified other beneficiaries based on similar parameter as of AB-PMJAY.

NATIONAL HEALTH MISSION (NHM)

Logo of NHM depicts a family of one man and woman, along with a child

38.36 Introduction.
The Ministry of Health and family welfare is implementing various schemes and programmes and initiatives to provide
universal access to quality healthcare. The approach is to increase access to decentralised health system by establishing
new infrastructure in deficient areas and by upgrading the infrastructure in existing institutions. As part of the plan
process, many different programmes have been brought together under the overarching umbrella of National Health
Mission (NHM) with National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM) as its two
Sub-Missions. National Health Mission was approved in May 2013. The main programmatic component includes
health system strengthening in rural and urban areas; Reproductive- Maternal- Newborn- Child and Adolescent health
(RMNCH+A) and control of communicable and non-communicable diseases. An important achievement of NHM has
been considerable reduction in out-of-pocket expenditure from 72% to 60%.
Goals of NHM.
(a) Reduce Maternal Mortality Rate to 1 / 1,000 live births.
(b) Reduce Infant Mortality Ratio to 25 / 1,000 live births.
(c) Reduce Total Fertility Rate (TFR) to 2.1.
(d) Prevention and reduction of anaemia in women aged 15-49 years.
(e) Prevent and reduce mortality and morbidity from communicable, non-communicable; injuries and
emerging diseases.

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(f) Reduce household out-of-pocket expenditure on total health care expenditure

(g) Reduce annual incidence and mortality from Tuberculosis by half.
(h) Reduce prevalence of Leprosy to <1 / 10,000 population and incidence to zero in all districts.
(j) Reduce annual Malaria incidence to <1 / 1,000.
(k) Less than 1 percent microfilaria prevalence in all districts.
(l) Kala-azar elimination by 2015, <1 case per 10,000 population in all blocks.
Interventions.
(a) Promotion of institutional deliveries through Janani Suraksha Yojana (JSY).
(b) Capacity building of health care providers by basic and comprehensive obstetric care.
(c) Operationalization of sub centres, primary health centres, community health centres and district hospitals
for providing 24 into seven basic and comprehensive obstetric care services.
(d) Name based web enabled tracking of pregnant women to ensure anti natal, intra natal and postnatal
care
(e) Mother and child protection card in collaboration to monitor service delivery for mother and children.
(f) Antenatal, intra-natal and postnatal care including iron and folic acid supplementation to pregnant and
lactating women for prevention and treatment of anaemia.
(g) Village health and nutrition days in rural areas as an outreach activity for provision of maternal and child
health services.
(h) Health and nutrition education to promote dietary diversification.
(j) Janani Shishu Suraksha Karyakram (JSSK) entitles all pregnant women delivering in public health
institutions to absolutely free and no expense delivery including caesarean section.
(k) Reproductive Maternal Newborn Child Health Adolescent (RMNCH+ A) interventions: To sharpen the
focus on the low performing districts, 184 high priority districts have been prioritised for achieving improved
maternal and child health outcomes.
(l) Emphasis on facility based newborn care at different levels to reduce child morbidity and mortality: Setting
up of facilities for care of sick newborn, such as special newborn care unit (SNCUs), Newborn stabilisation
unit (NBSUs) and Newborn Care Corners (NBCCs) at different levels.
(m) Capacity building of health care providers by training doctors, nurses and ANM for essential newborn
care early diagnosis and case management of common elements of children.
(n) India Newborn Action Plan (INAP): launched with the aim to reduce neonatal mortality and stillbirth.

NATIONAL URBAN HEALTH MISSION (NUHM)

38.37 Introduction.
NUHM aims to address the health concerns of the urban population especially the poor and disadvantaged by facilitating
equitable access to health services which are rationalized, revamped and strengthened. NUHM as a sub-mission of
NHM has been approved by the Cabinet on 1st May 2013.
Goals.
(a) Need based city specific urban health care system to meet the diverse health care needs of the urban
poor and other vulnerable sections.
(b) Institutional mechanism and management systems to meet the health-related challenges of a rapidly
growing urban population.
(c) Partnership with community and local bodies for a more proactive involvement in planning, implementation
and monitoring of health activities.

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(d) Availability of resources for providing essential primary health care to urban poor.
(e) Partnerships with NGOs, for profit and not for profit health service providers and other stakeholders.
Focus of NUHM.
(a) Urban poor population living in listed and unlisted slums.
(b) All other vulnerable population such as homeless, rag-pickers, street children, rickshaw pullers,
construction and brick and lime kiln workers, sex-workers and other temporary migrants.
(c) Public health thrust on sanitation, clean drinking water, vector control, etc.
(d) Strengthening public health capacity of urban local bodies.
Urban Health Infrastructure.
The health care infrastructure in urban areas consists of the Community Health Centres and Primary Health Centres.
The population norms for urban health infrastructure are as mentioned below −
Table 38.16 : Urban Health Infrastructure
Community Health Centres 2,50,000 population (5 lakh for metros)
Primary Health Centres 50,000 population
(a) Urban Primary Health Centre (U-PHC).
In order to provide comprehensive primary healthcare services, NUHM aims to establish UPHC, not as
a stand-alone health facility, but as a hub of preventive, promotive and basic curative healthcare for its
catchment population. Within its catchment area, UPHC is responsible for providing the primary health care
and public health needs of the population. UPHC is located preferably closer to slum or similar habitations. It
is recommended that the UPHC operates preferably from 12 noon to 8 pm or in dual shifts (i.e. 8 am to 12
pm and 4 pm to 8 pm); dual shift timing of UPHC could be flexible with the ability to be modified according
to the catchment communities.
The package of services envisaged at UPHC inclusive of preventive, promotive, curative, rehabilitative and
palliative care.
(b) Urban Community Health Centres (U-CHCs).
U-CHC is set up as a referral facility for every 4-5 U-PHCs. The U-CHC caters to a population of 2,50,000 to 5
lakhs. For the metro cities, UCHCs may be established for every 5 lakh population with 100 beds. In addition
to primary health care facilities, it provides inpatient services, medical care, surgical facilities and institutional
delivery facilities. It is a 30-50 bedded facility.
(c) Urban Health and Wellness Centres.
To ensure delivery of Comprehensive Primary Health Care (CPHC) services, existing U-PHCs would be converted
to Health and Wellness Centres (HWC). Services could also be provided / complemented through outreach
services, Mobile Medical Units, health camps, home visits and community-based interaction.
(d) Referral linkages.
Existing hospitals including Urban Local Bodies (ULB) maternity homes, state government hospitals and medical
colleges, apart from private hospitals will be empanelled and accredited to act as a referral point for different
types of healthcare services.

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NATIONAL RURAL HEALTH MISSION (NRHM)

38.38 Introduction.
National Rural Health Mission was launched on 12th April 2005, to provide accessible, affordable and quality health
care to the rural population, especially the vulnerable groups.
Goals.
(a) To establish a fully functional, community owned, decentralized health delivery system with inter-sectoral
convergence at all levels.
(b) To ensure simultaneous action on a wide range of determinants of health such as water, sanitation,
education, nutrition, social and gender equality.
Focus of NRHM
(a) NRHM focuses on Reproductive, Maternal, Newborn, Child Health and Adolescent (RMNCH+A) Services.
The emphasis here is on strategies for improving maternal and child health through a continuum of care and
the life cycle approach. It recognises the inextricable linkages between adolescent health, family planning,
maternal health and child survival.
(b) Linking of community and facility-based care and strengthening referrals between various levels of health
care system to create a continuous care pathway.
Major initiatives under NRHM.
(a) Selection of ASHA.
ASHA must be the resident of the village- a woman (married / widow / divorced) preferably in the age group
of 25-45 years with formal education up to 8th class having communication skills and leadership qualities.
General norm of selection is one ASHA for every 1,000 population.
(b) Rogi Kalyan Samiti (Patient Welfare Committee / Hospital Management Society).
This committee is a registered society whose members act as trustee to manage the affairs of the hospital
and is responsible for the upkeep of the hospital facilities and ensure better health facilities to the patient in
the hospital.
(c) Untied Grants to Sub-centres (SCs).
The SCs are far better equipped now with blood pressure measuring equipment, Haemoglobin measuring
equipment, stethoscope, weighing machine etc. which has facilitated provision of quality antenatal care and
other healthcare services.
(d) Village Health Sanitation and Nutrition Committee (VHSNC).
It is an important tool of community empowerment and participation at the grass root level. It reflects the
aspirations of the local community.
(e) Janani Suraksha Yojana (JSY).
Aims to reduce maternal mortality among pregnant women by encouraging them to deliver in government
health facilities.
(f) Janani Shishu Suraksha Karyakram (JSSK).
Launched on 1st Jun 2011, JSSK entitles all pregnant women delivering in public health institutions to absolutely
free and no expense delivery, including caesarean section.
(g) National Mobile Medical Units (NMMUs).
To increase visibility, awareness and accountability, all Mobile Medical Units have been repositioned as “National

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Mobile Medical Unit Service” with universal colour and design.

(h) National Ambulance Services.
NRHM has supported free ambulance service to provide patient transport in every part of the country connected
with a toll-free number. Currently 35 states / UTs have the facility where people can dial 108 / 102 telephone
number for calling an ambulance.
(j) Dial 108 is predominantly an emergency response system, primarily designed to attend a patient of
critical care, trauma and accident victims.
(k) Dial 102 essentially consist of basic patient transport aimed to cater the need of pregnant women and
children.
(l) Web enabled Mother and Child Tracking System (MCTS).
The name-based tracking of pregnant women and children have been initiated under NRHM with an intention
to track every pregnant woman, infant and child up to the age of 3 years by name, for ensuring delivery of
services like timely antenatal care, institutional delivery and post-natal care for the mothers and immunization
and other related services for the child.
Newer Initiatives.
The following are the major decisions of Mission Steering Group taken since 2011 −
(a) Home delivery of contraceptives by ASHA.
(b) Conducting district level household surveys (DLHS).
(c) Modification in the scheme for promotion of menstrual hygiene covering 152 districts and nearly 1.5
crores of adolescent girls in 20 states.
(d) Differential financial approach for comprehensive health care by which allocation of untied Funds and
Rogi Kalyan Samiti grants will be made based on the case load and services provided by the health facility.
(e) Involving ASHA in Home Based Newborn Care.
(f) Expansion of the Village Health and Sanitation Committee to include nutrition in its mandate and renaming
it as “Village Health Sanitation and Nutrition Committee (VHSNC)”.
(g) Rashtriya Bal Swasthya Karyakram (RBSK).
This initiative was launched in Feb 2013 and provides for child health screening and early intervention services
through early detection and management of 4 Ds i.e., Defects at Birth, Diseases, Deficiencies, Developmental
Delays including disability.
(h) Rashtriya Kishor Swasthya Karyakram (RKSK).
This initiative was launched in Jan 2014 to reach out to 253 million adolescents in the country in their own
spaces and introduce peer led interventions at the community level, supported by augmentation of facility-
based services.
(j) Mother and Child Health Wings (MCH Wings).
100 / 50 / 30 bedded Maternal and Child Health (MCH) Wings have been sanctioned in public health facilities
with high bed occupancy to cater to the increased demand for the services.
(k) Free drugs and free diagnostic services.
(l) National Iron + Initiative was launched in 2013 to prevent and control Iron deficiency anaemia. Weekly
Iron and Folic acid Supplementation (WIFS) for adolescents is an important strategy under this initiative.
(m) Reproductive, Maternal, Newborn, Child and Adolescent Health Services (RMNCH+A): This brings focus on
adolescents as a critical life stage and linkages between child survival, maternal health and family planning efforts.
(n) Universal Health Coverage (UHC).
Moving towards UHC is a key goal of the 12th Five Year plan. The National Health Mission is the primary vehicle
to move towards this goal.

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(o) Comprehensive Primary Healthcare.

9 areas for action to make primary healthcare comprehensive and universal are proposed as follow −
(i) Strengthen institutional structures and organization of primary healthcare services.
(ii) Improve access to technologies, drugs and diagnostics for comprehensive primary healthcare.
(iii) Increase utilization of Information, communication and Technologies (ICT)
(iv) Promote continuity of care.
(v) Enhance quality of care.
(vi) Focus on social determinants of health.
(vii) Emphasize community participation and address equity concerns in health.
(viii) Develop a human resource policy to support primary healthcare.
(ix) Strengthen governance including financing, partnership and accountability.
(x) States are also offered support through PIPs of the NHM to strengthen existing sub-centres.
(p) Kilkari.
Kilkari is an interactive voice response (IVR) based mobile service that delivers time sensitive audio messages
(voice call) about pregnancy and child health directly to the mobile phones of pregnant women, mothers of
young children and their families.
(q) ANMOL.
ANMOL (Auxiliary Nurse Midwife On Line) is a tablet- based application which helps ANMs in carrying out their
day to say work effectively and efficiently by entering and updating service records of beneficiaries on real
time basis.

NATIONAL TOBACCO CONTROL PROGRAMME (NTCP)

38.39 Introduction.
Government of India launched the National Tobacco Control Programme (NTCP) in the year 2007-08 during the 11th
Five-Year-Plan. It was up-scaled in the 12th Five Year Plan with a goal to reduce the prevalence of tobacco use by 5%
by the end of the 12th FYP. As per the second round of Global Adult Tobacco Survey (GATS), the number of tobacco
users has reduced by about 81 lakh (8.1 million).
Goals of NTCP.
(a) Create awareness about the harmful effects of tobacco consumption.
(b) Reduce the production and supply of tobacco products.
(c) Ensure effective implementation of the provisions under “The Cigarettes and Other Tobacco Products
(Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act,
2003” (COTPA).
(d) Help the people quit tobacco use.
(e) Facilitate implementation of strategies for prevention and control of tobacco advocated by WHO Framework
Convention of Tobacco Control.
Thrust areas for NTCP.
(a) Training of health and social workers, NGOs, school teachers and enforcement officers.
(b) Information, education and communication (IEC) activities.
(c) School programmes.
(d) Monitoring of tobacco control laws.

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(e) Coordination with Panchayati Raj Institutions for village level activities.
(f) Setting-up and strengthening of cessation facilities including provision of pharmacological treatment
facilities at district level.
Important provisions of COTPA.
(a) Prohibition of smoking in public places.
(b) Prohibition of direct and indirect advertisement of cigarette and other products.
(c) Prohibition of sale of cigarette and other tobacco products to a person below 18 years of age.
(d) Prohibition of sale of tobacco products near educational institutions.
(e) Mandatory depiction of statutory warnings (including pictorial warnings) on tobacco packs.
(f) Mandatory depiction of tar and nicotine contents along with maximum permissible limits on tobacco packs.
The rules related to provisions of smoking came into force on 2nd October 2008 under which any violation
amounts to a minimum fine of ₹ 200.

NATIONAL WATER SUPPLY AND SANITATION PROGRAMME

38.40 Introduction.
The National Water supply and sanitation programme was initiated in 1954 with the object of providing safe water
supply and adequate drainage facilities for the entire urban and rural population of the country.
Targets.
(a) 100% urban and rural water supply.
(b) 50% urban sanitation.
(c) 25% rural sanitation.
ARWSP (ACCELERATED RURAL WATER SUPPLY PROGRAMME).
O In 1972, a special programme known as “ARWSP” was started as supplement to the national water
supply and sanitation programme.
O The central government supports the efforts of the states in identifying problem villages through
assistance under ARWSP.
(a) ARWSP (ACCELERATED RURAL WATER SUPPLY PROGRAMME).
In 1972, a special programme known as “ARWSP” was started as supplement to the national water supply
and sanitation programme. The central government supports the efforts of the states in identifying problem
villages through assistance under ARWSP.
A ‘Problem village’ has been defined as one where no source of safe water is available within a distance of
1.6 km / 15 m deep or where source has excess salinity iron, fluorides and other toxic elements or where
water is exposed to the risk of cholera.
(b) International Drinking Water Supply and Sanitation Programme.
This programme was launched in 1981 by the Government of India. Targets of 100% coverage for water, both
urban and rural, 80% for urban sanitation and 25% for rural sanitation were set up. The stipulated norm of
water supply is 40 litres of safe drinking water per capita per day. At least one hand pump / spot source for
every 250 persons. Adopt proper environmental practices including disposal of garbage, refuse and wastewater.
(c) Swajaldhara.
Swajaldhara was launched in 25th Dec 2002. Swajaldhara is a community led participatory programme, which
aims at providing safe drinking water in rural areas with full ownership of the community, building awareness
among the village community on the management of drinking water project including better hygiene practices
and encouraging water conservation practices along with rainwater harvesting.

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(d) New initiatives in 12th 5 year plan.

(i) Rural Water Supply and Sanitation Project:
To raise coverage of piped water supply, toilet coverage and strengthening of institutions and systems
in rural drinking water and sanitation sectors in low-income states.
(ii) Enhancement of service levels for rural water supply from 40 lpcd to 55 lpcd.
Targets.
(aa) 50% coverage of rural population should have access to water within their household
premises or within 100-meter radius.
(ab) 30% should have individual household connections as against the present 13%.
(e) Swachh Bharat Mission (SBM).
Swachh Bharat Mission was launched on 2nd October 2014. The mission covers all rural and urban areas.
The urban component of the mission is implemented by the Ministry of Urban Development and the rural
component by the Ministry of Drinking Water and Sanitation.

NATIONAL PROGRAMME FOR PREVENTION AND MANAGEMENT OF TRAUMA AND

BURN INJURIES (NPPMTBI)
38.41 Introduction.
This programme was started on pilot mode under the 9th and 10th FYP as “Pilot Project for strengthening emergency
facilities along the highways”. Now, the scheme has been extended beyond the 12th FYP, till March 2020 as “National
Programme for Prevention and Management of Trauma and Burn Injuries”.
COMPONENT 1: TRAUMA CARE
Objectives.
(a) To establish a network of trauma care facilities to reduce the incidence of preventable deaths due to
traffic accidents by observing golden hour principle.
(b) To develop proper referral and communication network between ambulances and trauma centres and
within the trauma centres.
(c) To develop National Injury Surveillance, Trauma Registry and Capacity Building Centre for collection,
compilation, analysis and dissemination of information for policy formulation and preventive interventions.
(d) To develop trauma registry centres for ensuring delivery of quality services.
(e) To develop a National Trauma System Plan.
(f) To improve awareness through IEC activities.
COMPONENT 2: BURN INJURIES.
Objectives.
(a) To establish a network of burn units with adequate infrastructural facility for burn management and
rehabilitation in all identified Government Medical Colleges and District Hospitals.
(b) To improve the awareness among the general masses and vulnerable groups especially the women,
children, industrial and hazardous occupational workers.
(c) To establish burn data registry under NPPMBI with integration with National Injury Surveillance Centre
for collection, compilation and analysis of burn injury data to bring down the incidence of burn injury cases.
(d) To carry out Research for assessing behavioral, social and other determinants of Burn Injuries in the
country to facilitate effective need-based program planning, monitoring and evaluation.
(e) To organize Burn Injury Training Programmes for doctors, nurses and paramedical staff associated in

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management of burn injuries from the identified District Hospitals and Government Medical Colleges.
Components.
(a) Information Education and Communication.
(b) Treatment.
(c) Rehabilitation.
(d) Training.
(e) Monitoring and Evaluation.
(f) Research.

NATIONAL PROGRAMME FOR CONTROL AND TREATMENT OF OCCUPATIONAL DISEASES

38.42 Introduction.
Occupational health was one of the components of the National Health Policy 1983 and now also included in National
Health Policy 2002 but very little attention has been paid to mitigate the effect of occupational disease through proper
programme. Ministry of Health and Family Welfare, Government of India has launched a scheme entitled “National
Programme for Control and Treatment of Occupational Diseases” in 1998-99. The National Institute of Occupational
Health, Ahmedabad (ICMR) has been identified as the nodal agency for the same.
Strategies.
The global strategy for achieving occupational health for all (WHO-SEARO 1999) includes the following ten major areas
for action −
(a) Strengthening of International and national policies for health at work and development of policy tools.
(b) Developing healthy work environments.
(c) Developing healthy work practices and promoting health at work.
(d) Strengthening occupational health services.
(e) Establishing support services for occupational health.
(f) Developing occupational health standards based on scientific risk assessment.
(g) Developing human resources for occupational health.
(h) Establishing registration and data system including development of information services for experts,
effective transmission of data and raising public awareness through strengthened public information system.
(j) Strengthening research.
(k) Developing collaboration in occupational health services and organisations.

REPRODUCTIVE AND CHILD HEALTH (RCH) PROGRAMME

38.43 Introduction.
Reproductive and child health (RCH) programme was launched on 15th Oct 1997. The Government of India has introduced
a series of programme over the past two decades to address maternal and new-born health.
RCH I
Key Interventions.
(a) Essential obstetric care.
(b) Emergency obstetric care.
(c) 24-hour delivery services at PHC / CHC.
(d) Medical termination of pregnancy.

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(e) Control of Reproductive Tract Infections (RTI) and Sexually Transmitted Diseases.
(f) Immunization through Universal Immunization Programme.
(g) Essential newborn care.
(h) Diarrhoeal diseases and Acute Respiratory diseases control.
(j) Prevention and control of Vitamin A deficiency, Anaemia in children.
(k) Training of dais for conduct of safe delivery.
RCH II.
Introduction.
RCH phase II was launched on 1st April 2005 with the aim to reduce maternal and child morbidity and mortality with
emphasis on rural healthcare

MATERNAL HEALTH COMPONENT UNDER RCH II.

Strategies under RCH II.
(a) Essential Obstetric Care.
(i) Institutional delivery.
(ii) Skilled attendance at delivery.
(b) Emergency Obstetric Care
(i) Operationalizing first referral units (FRUs).
(ii) Operationalizing PHCs and CHCs for round the clock delivery services.
(c) Strengthening referral system.
Initiatives under RCH II.
(a) Quality Ante Natal Care.
Quality and comprehensive ANC incorporates minimum of at least four ANCs including early registration and
first ANC with first trimester.
(b) Essential Obstetric Care during Delivery.
Provision of essential obstetric care services, 24 X 7 PHCs services and providing training to SNs / LHVs / ANMs
under skilled attendance at birth.
(c) Post-Natal Care for Mother and Newborn.
Ensuring post-natal care within first 24 hours of delivery and subsequent home visits on 3rd, 7th, 14th and
42nd day of the post-natal period.
(d) Provision of Emergency Obstetric and Neonatal Care at FRUs.
Provision of Emergency Obstetric and Neonatal Care at FRUs. The thrust is on critical components such as
manpower, blood storage units and referral linkages etc.
(e) Augmentation of Skilled Human Resources for Maternal Health.
To overcome the shortage of skilled manpower particularly anesthetists and gynecologists, through skill-
based training programs
(f) Referral Services at Both Community and Institutional Level.
Basic patient care transportation through ambulances.
Strategies and Interventions.
(a) Janani Suraksha Yojana (JSY).
Janani Suraksha Yojana, a demand promotion and conditional cash transfer scheme was launched in April

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2005 with the objective of reducing maternal and infant mortality by promoting institutional delivery among
pregnant women. It is being implemented with the objective of reducing maternal and neonatal mortality by
promoting institutional delivery among poor pregnant women.
Table 38.17 : Scale of Assistance under JSY
Rural Area Urban Area

Category Mother’s ASHA’s Mother’s ASHA’s

Total (₹) Total (₹)
Package Package Package Package

Low Performing States (LPS) 1,400 600 2000 1,000 400 1,400

High Performing States (HPS) 700 600 1300 600 400 1,000

Cash Assistance for Home Delivery.

BPL pregnant women, who prefer to deliver at home, are entitled to a cash assistance of ₹ 500 per delivery
regardless of the age of pregnant women and number of children.
(b) Janani Shishu Suraksha Karyakram (JSSK).
Launched by Government of India on 1st June 2011, which entitles all pregnant women delivering in public
health institutions to absolutely free and no expense delivery including Caesarean section. The initiative
stipulates free drugs, diagnostics, blood and diet, besides free transport from home to institution, between
facilities in case of a referral and drop back home. Similar entitlements have been put in place for all sick
new-born accessing public health institutions for treatment till 30 days after birth. In 2013, this has been
expanded to sick infants and antenatal and postnatal complications.
(c) Vandematram scheme.
This is a voluntary scheme wherein any obstetrics and gynaecology specialist, maternity home, nursing home,
lady doctor can volunteer themselves for providing safe motherhood services like IFA tablets, oral pills, Td
injection. The enrolled doctors will display ‘Vandematram logo’ at their clinic.
(d) Safe abortion services.
(i) Medical method of abortion with two drugs-Mifepristone (RU 486) followed by Misoprostol and
blood transfusion.
(ii) Manual Vacuum Aspiration (MVA).
It is a safe and simple technique for termination of early pregnancy, makes it feasible to be used in
primary health centers or comparable facilities.
(e) Village Health and Nutrition Day.
Organizing Village Health and Nutrition Day once a month at Anganwadi centre to provide ANC / PNC care to
pregnant women, promote institutional delivery, health education, immunization, family planning and nutrition
services.
(f) Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA).
Carrying forward the vision of our Hon’ble Prime Minister, the Pradhan Mantri Surakshit Matritva Abhiyan was
launched in 2016 to ensure quality antenatal care and high-risk pregnancy detection in pregnant women on
9th of every month.
(g) Anemia Mukt Bharat (AMB) Programme.
This programme was launched in 2018 to achieve the envisaged target of 3% reduction in anemia prevalence
every year through life cycle approach. The strategy recommends 6 x 6 x 6 strategy that focusses on six target
beneficiary groups, through six interventions and six institutional mechanisms to achieve the envisaged target
of anemia reduction under the POSHAN Abhiyaan.

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Table 38.18 : 6 x 6 x 6 Strategy under AMB

Six Institutional
Six Beneficiaries Six Interventions
Mechanisms
Children 6 months to 59 Prophylactic Iron and Folic Acid supplementation Inter-ministerial
months coordination
Children 5-9 years of age Periodic deworming National Anemia Mukt
Bharat Unit
Adolescent girls and boys Intensified year-round Behaviour Change Communication National Centre of
(10-19 years) Campaign (Solid Body, Smart Mind) focusing on four key Excellence and Advance
behaviours: Research on Anemia
Control
(a) Improving compliance to Iron Folic Acid
supplementation and deworming
(b) Appropriate infant and young child feeding practices
(c) Increase in intake of iron-rich food through diet
diversity / quantity / frequency and / or fortified foods
with focus on harnessing locally available resources
(d) Ensuring delayed after delivery (by 3 minutes) in
health facilities
Pregnant women Testing and treatment of anaemia, using digital methods Convergence with other
and point of care treatment, with special focus on ministries
pregnant women and school-going adolescents

Lactating women Mandatory provision of Iron and Folic Acid fortified foods Strengthening supply
in government-funded public health programmes chain and logistics

Women in reproductive Intensifying awareness, screening and treatment of non- Anemia Mukt Bharat
age group (15-49 years) nutritional causes of anemia in endemic pockets, with Dashboard and Digital
special focus on malaria, haemoglobinopathies portal- One stop shop for
anemia
(h) LaQshya.
In order to further accelerate decline in MMR in the coming years, MoHFW has recently launched ‘LaQshya -
Labour room Quality Improvement Initiative. LaQshya program is a focused and targeted approach to strengthen
key processes related to the labour rooms and maternity operation theatres which aims at improving quality
of care around birth and ensuring Respectful Maternity Care.
(j) Mother’s Absolute Affection (MAA) Programme.
This programme focuses on promotion of optimum Infant and Young Child Feeding (IYCF) practices including
early initiation of breast feeding within one hour, exclusive breast feeding up to six months, age appropriate
and adequate complementary feeding after six months and continuation of breastfeeding for two years and
beyond through capacity building of frontline health care workers and comprehensive IEC campaigns.
(k) Comprehensive Abortion Care.
Comprehensive abortion care is an important element in the reproductive health component of the RMNCH+A
strategy as 8% (2001-03 SRS) of maternal deaths in India are attributed to unsafe abortions, thereby this is
indeed a very important component of RNMCH+A program. This program is implemented as per the mandates
of the Medical Termination of Pregnancy Act.

38.44 Medical Termination of Pregnancy (Amendment) Act and Rules, 2021.

The MTP Act, 1971 recognized the importance of providing safe, affordable, accessible and legal abortion services to
women who need to terminate a pregnancy due to certain therapeutic, eugenic, humanitarian or social grounds. The

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Act was amended for expanding the base of beneficiaries to provide safe abortion services. The Rules were formulated
and notified for commencement on 12th October 2021.
Provisions of the Medical Termination of Pregnancy (Amendment) Act, 2021.
(a) Requirement of opinion of one registered medical practitioner for termination of pregnancy up to twenty
weeks of gestation.
(b) Requirement of opinion of two registered medical practitioners for termination of pregnancy of twenty to
twenty-four weeks of gestation.
(c) Enhancing the upper gestation limit from twenty to twenty-four weeks for vulnerable groups of women.
(d) Non-applicability of the provisions relating to the length of pregnancy in cases where the termination
of pregnancy is necessitated by the diagnosis of any of the substantial foetal abnormalities diagnosed by a
Medical Board.
(e) Strengthening the protection of privacy of a woman whose pregnancy has been terminated.
(f) Failure of contraceptive clause extended to the woman and her partner.
Details of The Medical Termination of Pregnancy (Amendment) Act, 2021 have been described in Chapter XXXIX.

38.45 Child Health Components under RCH II.

(a) Nutritional Rehabilitation Centre (NRCs).
These are the facility-based units providing medical and nutritional care to Severe Acute Malnutrition (SAM)
children under five years of age who have medical complications. The services provided are
(i) 24-hour care and monitoring of child.
(ii) Treatment of the medical complications.
(iii) Therapeutic feeding.
(iv) Sensory stimulation and emotional care.
(v) Counselling on appropriate feed, care and hygiene.
(vi) Demonstration and practice by doing on the preparation of energy dense food using locally
available, culturally acceptable and affordable food items.
(vii) Social assessment of the family to identify and address contributory factors.
(viii) Follow up of the children discharged from the facility.
(b) Integrated Management of Neonatal and Childhood Illness (IMNCI).
IMNCI strategy is one of the main interventions under the RCH II / NRHM. The strategy encompasses a range
of interventions to prevent and manage the commonest major childhood diseases. It focuses on preventive,
promotive and curative aspects of the programme.
Objective.
To implement IMNCI package at the level of household and through ANM at Sub Centre level through medical
officers, nurses and LHVs at PHCs level. The major highlights of the strategy are:
(i) Inclusion of 0-7 day age group in the program.
(ii) Incorporating national guidelines on malaria, anemia, vitamin A supplementation and immunization
schedule.
(iii) Training of the health personnel begins with sick young infant upto 2 months.
(iv) Proportion of training time devoted to sick young infant and sick child is almost equal and skill
based.

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Interventions under IMNCI Package.

(aa) Care of Newborns and Young Infants (infants under 2 months).
O Keeping the child warm.
O Initiation of breastfeeding immediately after birth and counseling for exclusive breastfeeding
and non-use of pre lacteal feeds.
O Cord, skin and eye care.
O Recognition of illness in newborn and management and / or referral.
O Immunization.
O Home visits in the postnatal period: 3 home visits are to be provided to every newborn
starting with first visit on the day of birth (day 1) followed by visits on day 3 and day 7 and
for low birth weight babies, 3 more visits (total of 6 visits) are to be undertaken before the
baby is one month of age by health workers (ANMs, AWWs, ASHAs and link volunteers) to help
mothers and families to understand and provide essential newborn care at home and detect
and manage newborns with special needs due to low birth weight or sickness.
(ab) Care of Infants (2 months to 5 years).
O Management of diarrhea, acute respiratory infections (pneumonia) malaria, measles,
acute ear infection.
O Malnutrition and anemia.
O Recognition of illness and at-risk conditions and management / referral.
O Prevention and management of Iron and Vitamin A deficiency.
O Counseling on feeding for all children below 2 years.
O Counseling on feeding for malnourished children between 2 to 5 years.
O Immunization.

38.46 Navjat Shishu Suraksha Karyakram (NSSKU).

This programme aims to train healthcare personnel in basic newborn care and resuscitation. It has been launched to
address care at birth issue i.e. prevention of hypothermia, prevention of infection, early initiation of breast feeding and
basic newborn resuscitation. The objective of the new initiative is to have a trained health person in basic newborn
care and resuscitation unit at every delivery point.

38.47 Rashtriya Bal Swasthya Karyakram (RBSK).

RBSK is a new initiative aiming at early identification and early intervention for children from birth to 18 years. It is
important to note that the 0-6 years’ age group will be specifically managed at District Early Intervention Centre (DEIC)
level while for 6-18 years’ age group, management of conditions will be done through existing public health facilities.
DEIC will act as referral linkages for both the age groups.
Mechanisms for Screening at Community and Facility Level.
Child screening under RBSK is at two levels community level and facility level. While facility based newborn screening
at public health facilities like PHCs / CHCs / DH, will be by existing health manpower like Medical Officers, Staff Nurses
and ANMs, the community level screening will be conducted by the Mobile health teams at Anganwadi Centres and
Government and Government aided schools.
(a) Screening at Anganwadi Centre.
All pre-school children below 6 years of age would be screened by Mobile Block Health teams for deficiencies,
diseases, developmental delays including disability at the Anganwadi centre at least twice a year. Screening
tools for 0-6 years age group are supported by pictorial activities and job aids specifically for developmental
delays. Children suspected with developmental delays would be referred to DEIC for further management.

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(b) Screening at Schools - Government and Government Aided.

School children in age group 6 to 18 years would be screened by Mobile Health teams for deficiencies,
diseases, developmental delays including disability, adolescent health screening at the local schools at least
once a year. The tool used is a questionnaire (preferably translated to local or regional language) and clinical
examination.
Table 38.19 : Selected Health Conditions for Child Health Screening and Early Intervention Services
Developmental Delays
Defects at Birth Deficiencies Diseases of Childhood
and Disabilities
(a) Neural tube defect (a) Anaemia especially (a) Skin conditions (a) Vision Impairment
(b) Down’s Syndrome severe anaemia (Scabies, fungal (b) Hearing Impairment
(b) Vitamin A deficiency infection and Eczema)
(c) Cleft Lip and (c) Neuro-motor
Palate / Cleft palate (Bitot spot) (b) Otitis Media Impairment
alone (c) Vitamin D Deficiency (c) Rheumatic heart (d) Motor delay
(d) Talipes (club foot) (Rickets) disease
(e) Cognitive delay
(e) Developmental (d) Severe Acute (d) Reactive airway
(f) Language delay
dysplasia of the hip Malnutrition disease
(g) Behaviour disorder
(f) Congenital cataract (e) Goitre (e) Dental conditions
(Autism)
(g) Congenital deafness (f) Convulsive disorders
(h) Learning disorder
(h) Congenital heart (j) Attention deficit
diseases hyperactivity disorder
(j) Retinopathy of (k) Congenital
Prematurity Hypothyroidism, Sickle
cell anaemia, Beta
thalassemia (optional)

38.48 Reproductive, Maternal, Newborn, Child Plus Adolescent Health (RMNCH+A) Programme.
Introduction.
SDG Goal 3 includes the focus on reducing maternal, newborn and child mortality. The RMNCH+A strategy is built
upon the continuum of care concept and is holistic in design, encompassing all interventions aimed at reproductive,
maternal, newborn, child and adolescent health under a broad umbrella and focusing on the strategic lifecycle approach.
Key features of RMNCH+A strategy.
(a) Including adolescence for the first time as a distinct life stage.
(b) Linking maternal and child health to reproductive health, family planning, adolescent health, HIV, gender,
preconception and prenatal diagnostic techniques.
(c) Linking home and community-based services to facility-based care.
(d) Ensuring linkages, referrals and counter-referrals between and among health facilities at primary (PHC),
secondary (CHC) and tertiary levels (district hospital).
Interventions.
5 x 5 matrix for high impact RMNCH+A interventions.
(a) Reproductive Health.
(i) Focus on spacing methods, particularly Post Partum Intra Uterine contraceptive Devices (PPIUCD)
at high case load facilities.
(ii) Focus on interval IUCD at all facilities including sub centres on fixed days.
(iii) Home delivery of contraceptives (HDC) and Ensuring Spacing at Birth (ESB) through ASHAs.
(iv) Ensuring access to Pregnancy Testing Kits (PTK) “Nishchay Kits” and strengthening comprehensive

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abortive care services.

(v) Maintaining quality sterilisation services.
(b) Maternal Health.
(i) Use Mother and Child Tracking System (MCTS) to ensure early registration of pregnancy and full ANC.
(ii) Detect high risk pregnancies and line list including severely anaemic mothers and ensure
appropriate management.
(iii) Equip delivery points with highly trained HR and ensure equitable access to Emergency Obstetric
Care (EmOC) services through FRUs, add MHC wings as per need.
(iv) Review maternal, infant and child deaths for corrective actions.
(v) Identify villages with high numbers of home deliveries and distribute misoprostol to select women in
8th month of pregnancy for consumption during 3rd stage of labour incentivize ANMs for home deliveries.
(c) Newborn Health.
(i) Early initiation and exclusive breastfeeding.
(ii) Home based newborn care through ASHA.
(iii) Essential newborn care and resuscitation services at all delivery points.
(iv) Special newborn care units with highly trained human resource and other infrastructures.
(v) Community level use of Gentamycin by ANM.
(d) Child Health.
(i) Complementary feeding, IFA supplementation and focus on nutrition.
(ii) Diarrhea management at community level using ORS and zinc.
(iii) Management of pneumonia.
(iv) Full immunization coverage.
(v) Rashtriya Bal Swasthya Karyakram (RBSK); screening of children for 4 D’s (birth defects,
developmental delays, deficiencies and disease) and its management.
(e) Adolescent Health.
(i) Address teenage pregnancy and increase contraceptive prevalence in adolescents.
(ii) Introduce community-based services through peer educators.
(iii) Strengthen ARSH clinics.
(iv) Roll out National Iron Plus Initiative including weekly IFA supplementation.
(v) Promote menstrual hygiene.
Health System Strengthening.
(a) Case load based deployment of human resources at all levels.
(b) Ambulances, drugs, diagnostics, reproductive health commodities.
(c) Health education, demand promotion and behavior change communication.
(d) Supportive supervision and use of data for monitoring and review including scorecard based on
HMIS.
(e) Public grievances redressal mechanism client satisfaction and patient safety through all round
quality assurance.
Cross Cutting Interventions.
(a) Bring down out of pocket expenses by ensuring JSSK, RBSK and other free entitlements.

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(b) ANMs nurses to provide specialized and quality care to pregnant and women and children.
(c) Address social determinants of health through convergence.
(d) Focus on unserved and underserved villages, urban slums and blocks.
(e) Introduce difficult areas and performance-based incentives.

38.49 Adolescent Health Programme.

Taking cognizance of the diverse nature of adolescent health needs, a comprehensive adolescent health strategy has
been developed. The priority interventions under this program are as follows
(a) Adolescent nutrition; iron and folic acid supplementation.
(b) Facility based Adolescent Reproductive and Sexual Health Services (ARSH) (Adolescent Health Clinics).
(c) Information and counselling on adolescent sexual reproductive health and other health issues.
(d) Menstrual hygiene.
(e) Preventive health check ups.
Adolescent Reproductive and Sexual Health Programme (ARSH).
ARSH focuses on recognising the existing public health system in order to meet service needs of adolescent. Steps are
being taken to ensure improved service delivery for adolescents during routine sub-centre clinics and also to ensure
service availability on fixed days and timings at Primary Health Centres, Community Health Centres and District Hospital
level. Core package of services include promotive, preventive, curative and counselling services being made available
to all adolescents- married and unmarried, girls and boys through adolescent friendly health clinics.
Weekly Iron and Folic Acid Supplementation (WIFS).
The key intervention under this programme are as follows:
(a) Administration of supervised weekly Iron Folic Acid supplements of 100 mg elemental iron and 500
microgram Folic Acid using a fixed day approach.
(b) Screening of target groups for moderate / severe anaemia and referring these cases to an appropriate
health facility.
(c) Biannual de-worming (Albendazole 400 mg), six months apart for control of helminths infestation.
(d) Information and counselling for improving dietary intake and for taking actions for prevention of intestinal
worm infestation.
Menstrual Hygiene Scheme.
This scheme was launched for promotion of menstrual hygiene among adolescent girls in the age group of 10 to 19
years in rural areas. The program aims at ensuring that girls have adequate knowledge and information about menstrual
hygiene and have access to high quality sanitary napkins along with safe disposal mechanism.
Reproductive, Maternal, Newborn, Child, Adolescent Health “Plus” Nutrition Strategy (RMNCAH + N).
Due to the importance of nutrition across all life stages, the strategy now includes nutrition as one of its important
pillars. RMNCAH +N strategy thus covers reproductive, maternal, newborn, child and adolescent health and the “plus”
within it focuses on nutrition as well as important linkages between these services and with other components like
family planning, adolescent health, HIV, gender and preconception and prenatal diagnostic techniques.
India Newborn Action Plan (INAP).
Indian newborn action plan (INAP) was developed in response to the Global Every Newborn Action Plan (ENAP) and was
launched in June 2014.The plan outlines the targeted strategy for accelerating the reduction of preventable newborn
deaths and stillbirths in the country. INAP defines the latest evidence on effective intervention which will not only help
in reducing the burden of still births and neonatal mortality but also maternal deaths. The goal is to attain “Single
Digit Neonatal Mortality Rate By 2030” and “Single Digit Stillbirth Rate By 2030”.
INAP is based on six pillars of intervention packages impacting still birth and newborn health which includes

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(a) Pre-conception and antenatal care.

(b) Care during labour and childbirth.
(c) Immediate newborn care.
(d) Care of the healthy newborn.
(e) Care of the small and sick newborn.
(f) Care beyond newborn survival.

38.50 MINIMUM NEEDS PROGRAMME.

Introduction.
The minimum needs programme was introduced in the first year of the fifth plan (1974-78). The objective of the
programme is to provide certain basic minimum needs and thereby improve the living standards of the people. It is
the expression of the commitment of the government for the “social and economic development of the community
particularly the underprivileged and underserved population”. The programme includes the following components
(a) Rural Health.
(b) Rural Water Supply.
(c) Rural Electrification.
(d) Elementary Education.
(e) Adult Education.
(f) Nutrition.
(g) Environmental improvement of urban slums.
(h) Houses for landless labourers.

NATIONAL GUINEAWORM ERADICATION PROGRAMME

38.51 Introduction.
India launched its National Guineaworm Eradication Programme in 1984 with technical assistance from WHO. From
the very beginning the programme was integrated into the national health system at village level. With well-defined
strategies, an efficient information and evaluation system, intersectoral coordination at all levels and close collaboration
with WHO and UNICEF, India was able to significantly reduce the disease in affected areas. The country has reported
zero cases since August 1996. In February 2000, the International Commission for the Certification of Dracunculiasis
Eradication recommended that India be certified free of dracunculiasis transmission.

YAWS ERADICATION PROGRAMME (YEP)

38.52 Introduction.
India has achieved breakthrough public health milestones in the past by eradication of smallpox and guinea
worm disease.  There has been a concerted effort to target other diseases in the country which are amenable to
eradication / elimination.
Objectives.
(a) Cessation of transmission of yaws in the country (defined as nil reporting of new yaws cases).
(b) Eradication of yaws defined as absence of new cases for a continuous period of three years, supported
by absence of evidence of transmission through sero-survey among under-five children (i.e. no sero-reactivity
to RPR / VDRL in < 5-year children).
Factors in Favour for Eradication of Yaws:
(a) Man is the only reservoir of infection.

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(b) Patients with early lesions are the main sources of infection.
(c) Direct contact with secretions of skin lesions is the main mode of transmission; no vector is involved
(d) “Magic bullet” is available for intervention i.e., a single injection of long-acting Benzathine benzyl penicillin,
which is easily available at low cost, has no toxicity, is stable preparation and is operationally feasible.
(e) Yaws infection was localized to small pockets within the country.

Suggested Reading.
1. National Framework for Malaria Elimination in India 2016-2030, Directorate Directorate Of National Vector Borne
Disease Control Programme (NVBDCP), Directorate General Of Health Services (DGHS), Ministry Of Health & Family
Welfare, Government Of India.
2. Training Manual for Medical Officers 2019, National Leprosy Eradication Programme, Central Leprosy Division,
New Delhi and Central Leprosy Teaching & Research Institute, Directorate General of Health Services, Ministry of Health
and Family Welfare Government of India.
3. Khanna A, Saha R, Ahmad N. National TB elimination programme – What has changed. Indian J Med Microbiol.
2023;42:103-7 https://www.naco.gov.in/documents/operational-guidelines.
4. Operational Guidelines National Programme for Prevention and Control of Non-Communicable Diseases (2023-
2030), Ministry of Health & Family Welfare, Government of India.
5. Ayushman Bharat: Comprehensive Primary Health Care through Health and Wellness Centers, Operational
Guidelines, National Health Systems Resource Centre, Government of India.
n

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Chapter
XXXIX
PUBLIC HEALTH LEGISLATIONS RELATED TO HEALTH
(INCLUDING RELEVANT ARMED FORCES POLICIES)
39.1 Introduction.
Right to health is one of the fundamental human rights which is often compromised by outcomes of human
behaviour either individually or as a social group, which are faced by the entire population in everyday life. This
can be managed by changing the health behaviour through one of the basic approaches like- regulatory approach,
service approach and health education approach. Though health education is the ideal approach, but many times
regulatory approach is also necessary considering the seriousness of the issue. The holistic vision of Indian
medicine focusing on philosophy, technical and scientific aspects, has grabbed attention of many historians over
the years and has evolved traversing a long path with constant changes adopted through trial-and-error method.
Not only the form of medical care, but also the code of conduct has gained focus lately. Continuous efforts were
done to make this science a legal, ethical and morally focused one. To strengthen the health care system, a
focused legislatory approach is a pre-requisite.
Universal Health Care forms the platform over which the health care system of India takes its strength. It is a
concerted effort made by the central governments and states  /  Union territories. The constitution charges every
state for the improvement of public health among its primary duties. Laws are an obligation on the part of society
imposed by the competent authority which have been instrumental in controlling such public health issues and
hence referred to as public health legislations.
Public health legislation concerns the legal power and duties of the state to improve the health of the general
population (e.g. to identify, prevent and ameliorate risks to health in the population) and the limitations on the
power of the state to constrain the autonomy, privacy, liberty, proprietary or other legally protected interests of
individuals for the protection or promotion of community health. The scope of public health law is not limited; it
is as broad as public health itself and both have expanded a lot to meet the needs of the society.
The objectives of public health legislations are to:
(a) Protect and promote the health of their population.
(b) Sustain the health policies and programmes.
(c) Prevent ill health resulting from unsafe products and unsafe living conditions.
(d) Fight new and re-emerging communicable diseases.
(e) Support the development of health systems.
(f) Combat continuing poverty, inequities in health and discrimination.
The Constitution of India has sufficient provision for the protection, promotion and growth of every individual,
worker, groups and vulnerable population in relation to health and nutrition. To achieve these goals, various acts
are adopted.

39.2 Terminologies Commonly Used.

(a) Law.
The principles and regulations established in a community by some authority and applicable to its people, whether
in the form of legal powers or of customs and policies recognized and enforced by judicial decision.
(b) Legislation.
Process or act of making law by the legislative body or governing body in a country.
(c) Bill.

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Draft statute which becomes law after it is passed by both the Houses of Parliament and assented to by the
President.
(d) Act.
A law adopted (enacted) by a national or state legislative or other governing body.
(e) Rules.
Are explicit statements that tell an employee what he or she ought or ought not to do.

39.3 THE FACTORIES ACT, 1948.

(a) Overview.
The Factories Act, 1948, is a comprehensive legislation enacted by the Indian government to regulate the working
conditions in factories and safeguard the health, safety and welfare of factory workers. It aims to prevent industrial
accidents, occupational diseases and ensure better working conditions for workers in factories.
(b) Applicability.
The Act applies to any premises where ten or more workers are employed or if manufacturing processes are
carried out using power or twenty or more workers are employed without the use of power. It also covers factories
engaged in specific hazardous processes, irrespective of the number of workers.
(c) Working Hours and Overtime.
The Act stipulates the maximum number of working hours per day (not exceeding 9 hours) and per week (not
exceeding 48 hours) for adult workers. It also provides for 30 min rest interval and mandatory weekly off. Overtime
work (not exceeding 60 hours per week) is permitted under certain conditions and must be compensated at a
double wages rate than regular working hours. Working hours for children have been stipulated as 4.5 hrs a
day and for adolescent is that of an adult.
(d) Health and Safety Provisions.
The Act mandates various safety measures in factories, including adequate ventilation, sufficient lighting, proper
sanitation facilities, overcrowding, latrines, urinals, spittons and safe drinking water. It sets standards for the
handling of hazardous substances, machinery safety and protection against dangerous fumes, dust and noise.
It requires the appointment of qualified personnel for supervising health and safety aspects in the factory.
(e) Welfare Provisions.
The Factories Act emphasizes the provision of welfare facilities for workers, such as canteens, first aid rooms
with ambulance, creches for working mothers and restrooms. Cleanliness, disposal of waste and general upkeep
of the factory premises are also addressed to ensure the well-being of workers.
(f) Employment of Young Persons and Women.
The Act lays down specific regulations concerning the employment of young persons (adolescents) and women
in factories, including restrictions on night work and heavy machinery operation. It includes provisions for the
health and welfare of young persons and nursing mothers.
(g) Inspections and Enforcement.
The Act provides for regular inspection of factories by government-appointed inspectors to ensure compliance
with the prescribed standards. Non-compliance with the Act’s provisions can lead to penalties and legal action
against the factory owners.
(h) Facilities in case of large factories.
(i) Factories with 1,000 or more workers require Safety Officer
(ii) Factories with more than 500 workers must have an ambulance and Full time Welfare Officer
(iii) Factories with more than 250 workers must have a Canteen
(iv) Factories with more than 150 workers must provide rest room  /  shelters with Drinking Water

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(v) Creches must be provided if 30 or more women workers are employed.

(j) Leave Entitlement.
(i) Leave accrual: 1 leave per 20 days of working
(ii) Maternity leaves: 6 months under Maternity Act
(iii) Leave Accumulation of up to 30 days
(iv) Holidays cannot be counted as part of the leave duration
(v) Leave Encashment components should include DA and Basic Pay
(k) General Penalty for Offences.
Table 39.1 : General Penalty for Offences
Section Offence Punishment
General penalty for offences Any kind of violation with the laws Imprisonment up to 2 years and fine
(Sec 92) of the Act, Occupier and Manager up to ₹ 1 lakh. If they continue the
of the factory will be equally breach, they will be punishable with
responsible for the breaking of the ₹ 1,000 each day of the continuing
law breach

Enhanced penalty for offences Any kind of violation pertaining Fine shall not less than ₹ 25,000
to safety or dangerous operation, incase of death
(Chap 4, Sec 87)
resulting in an accident-causing If serious bodily injury fine upto
death or body injury ₹ 5,000
Enhanced penalty Any kind of violation with the laws Imprisonment upto 3 years and fine
(subsequent contravention) of the Act previous offence (Sec not less than ₹ 10,000 which may
92) extend ₹ 2 lakh
Under Chap 4, Sec 87 Fine shall not be less than ₹ 35,000
For Serious bodily injury in case of death
Fine upto ₹ 10,000 incase of bodily
injury
Sec 95 Penalty for obstructing inspector Imprisonment of 6 months or fine
with ₹ 10,000 or with both
Imprisonment of 6 months or fine
with ₹ 10,000 or with both
Sec 97 Offences by workers Fine with ₹ 500
Sec 98 Penalty for permitting double Fine with ₹ 1,000
employment of child
(l) Relevance  /  Applicability in Armed Forces.
The civilian industrial workers employed in armed forces establishments are governed by provisions of the Act
with regard to working hours, leave entitlement etc.

39.4 EMPLOYEES’ STATE INSURANCE ACT (ESI), 1948.

(a) Overview.
The Employee’s State Insurance Act, 1948, is a significant social security legislation in India that provides medical
and cash benefits to employees and their dependents in times of sickness, maternity, disability or death arising
out of employment-related incidents. The Act was enacted to protect workers in the organized sector and ensure
their access to quality healthcare and financial support during periods of need.

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(b) Coverage and Applicability.

The Act applies to employees working in factories, establishments or businesses with 10 or more employees (in
some states, it is applicable to establishments with 20 or more employees). Employees earning up to a specific
wage threshold are eligible for coverage under the Employees State Insurance Scheme.
(c) Benefits Provided.
(i) Medical Benefits.
These benefits are provided as a direct pattern in area with more than 1000 employees through permanent
medical and paramedical staff, indirect pattern through panel system. The covered employees and
their dependents are entitled to free and comprehensive medical care, including outpatient treatment,
hospitalization, specialist consultations, diagnostic tests and medicines. This benefit is accessible through
the network of ESI dispensaries, hospitals and clinics.
(ii) Sickness Benefit is of 3 types as described below:
(aa) Sickness Benefit
in the form of cash compensation @70% of wages which is payable to insured persons during the
period of certified sickness for a maximum of 91 days in a year.
(ab) Extended Sickness Benefit
upto 2 years in the case of 34 malignant and long term disease at enhanced rate of 80% of wages.
(ac) Enhanced Sickness Benefit
is equal to full wages to insured persons undergoing sterilization for family planning upto 7 days in
vasectomy and 14 days in tubectomy cases.
(iii) Maternity Benefit.
For confinement duration of benefit is 26 weeks and for miscarriage 6 weeks. The benefit is allowed at full
wages. For sickness arising out of confinement etc the period is 30 days. The expenses per confinement
is ₹ 7,500.
(iv) Disablement Benefit.
Compensation for employment-related disablement: In case an employee suffers from a temporary or
permanent disablement due to an employment-related injury or occupational disease, they are eligible for
disablement benefit. For temp disablement payment is done at the rate of 90% of wages so long disability
continues & for permanent disablement the amount of compensation is determined based on the extent
of loss of earning capacity as certifies by medical board.
(v) Dependent Benefit.
This is paid for death due to employment injury and is applicable from day one of insurable employment.
The duration is for entire life to the widow or until her remarriage and to the dependent son till the age of
25yrs, till marriage of daughter and to dependent parents. The rate is 90% of average daily wages shared
in fixed proportion amongst all dependents.
(vi) Funeral Expenses.
Reimbursement of funeral expenses: The ESI Act also covers the reimbursement of funeral expenses upto
amount of ₹ 15,000 incurred upon the death of a covered employee. This benefit helps ease the financial
burden on the bereaved family during a difficult time.
(vii) Rehabilitation Services.
Vocational rehabilitation: The Act provides for vocational rehabilitation services to employees who have
been injured or disabled due to work-related incidents. These services aim to help them reintegrate into
the workforce or acquire new skills for alternative employment.
(viii) Other Benefits.
Unemployment Allowance. Employees who become unemployed due to closure of the factory or establishment

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may be eligible for an unemployment allowance for a specific period.

(d) Funding and Administration.
The Employees State Insurance Corporation (ESIC) manages the scheme and it is funded through contributions
from employers and employees and grants from central and state govt. For all employees earning ₹ 21,000  /  - or
less, employer contributes 3.25% and employees contribute 0.75%, total share being 4 %. The state govt as per
provisions of act contributes 1  /  8th of the expenditure of medical benefits with a per capita ceiling of ₹ 1,500
per insured person per annum The ESIC oversees the implementation, administration and delivery of benefits
through regional offices and ESI dispensaries and hospitals across the country.
(e) Impact and Social Security.
The Employees State Insurance Act has played a vital role in providing social security to millions of workers in
the organized sector, ensuring access to medical care and financial support during challenging times. It has
contributed significantly to reducing the financial burden on families during sickness, maternity and disability,
leading to improved overall welfare of workers.
(f) Relevance  /  Applicability in Armed Forces.
(i) Medical Benefits.
Free treatment at Armed Forces healthcare establishments is available to serving personnel, ex-servicemen
and their dependents. Treatment modalities or facilities not available at armed forces healthcare
establishments can be re-imbursed to members of armed forces and their dependents; ex-servicemen
and their dependents avail such facilities through Ex-servicemen Contributory Health Scheme.
(ii) Sickness Benefits.
Sick leave  /  sick list concession is granted to Armed Forces personnel as laid down in leave rules for armed
forces. In the first instance upto 6 months of sick leave can be granted with inclusion of annual leave
of that year. Extended sick leave  /  hospitalization upto 24 months can be granted by competent medical
board. The grant of sick leave is subject to conditions laid down in leave rules and Regulations of Medical
Services of the Armed Forces-2010 (revised version) and policies of Armed Forces on the subject.
(iii) Maternity Benefit.
Maternity leave upto 6 months is applicable to women officers  / women serving in armed forces for childbirth
(for two children). Leave upto 30 days can be granted for abortion or miscarriage.
(iv) Child Care Leave.
PC women officers of the Defence Forces to be granted 360 days Child Care Leave (CCL) and SSC women
officers 180 days of CCL vide GoI, MoD letter dtd 14th Aug 2019. As per revised provision, women officers
can now avail CCL of not less than 05 days and not more than 30 days in each spell for rearing or looking
after of their children till 18 years of age.
(v) Benefits for Sterilization  /  Contraception Procedure.
Male officers  /  personnel whose wives undergo tubectomy can be granted leave upto 7 days. Women officers
undergoing tubectomy can be granted leave upto 14 days. For IUCD insertion or re-insertion1 day leave
can be granted. One day leave can be granted to women officers whose husband’s undergo vasectomy.
The hospitalization period for any complications arising out of sterilization procedures are covered under
sick list concession. Leave upto 21 days can be granted for re-canalization procedures.
(vi) Disablement Benefit.
Impairment relief or disability pension as governed by Entitlement Rules 2023 are applicable for members
of armed forces for disabilities considered attributable or aggravated by military service subject to certain
conditions laid in Entitelement Rules 2023 and Guide to Medical Officers 2023.

39.5 WORKMEN’S COMPENSATION ACT, 1923.

(a) Overview.
The Workmen’s Compensation Act also known as the Employees Compensation Act, is a social security legislation

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that provides compensation to workers in case of employment-related injuries, accidents or occupational diseases.
The Act ensures financial protection for workers and their dependents in the event of work-related accidents or
illnesses. The workman must have been employed for atleast 6 months.
(b) Scope and Applicability.
The Act applies to all employed in any capacities specified in schedule II of the act which includes factories, mines,
plantations, mechanically propelled vehicles, construction works, hazardous occupations & specifies categories
in railways
(c) Exclusion from Compensation.
(i) Injury or accident
(ii) Due to certain perils or wars
(iii) When ignored  / refused to follow the safety guidelines & mechanisms
(iv) Under the influence of intoxicants
(v) Injury resulting in partial or total disablement for less than 3 days.
(d) Coverage and Compensation.
The Act provides compensation to employees who suffer injuries or death resulting from accidents arising out
of and during the course of employment. It also covers occupational diseases arising due to the nature of the
job or working conditions. Compensation is payable to the worker or the worker’s dependents in case of death,
partial or permanent disablement or temporary disablement due to the injury or disease.
(e) Compensation Amount.
(i) Death of the Worker.
50% of the worker’s monthly wage multiplied with relevant factors  /  ₹1,20,000, whichever is more.
(ii) Permanent Total Disability.
60% of the monthly wages, multiplied by relevant factor  /  ₹1,40,000, whichever is more.
(iii) Permanent Partial Disability.
the amount payable is a percentage of the loss of earning capacity due to injury.
(iv) Temporary Disability.
25% of the employee’s monthly wages
(v) Funeral Expenses.
₹ 5,000
(f) Employer’s Liability and Insurance.
The Act places the primary responsibility for paying compensation on the employer. Employers are required to
provide compensation to injured employees or their dependents promptly. Employers can meet their liability by
taking out an insurance policy with an insurer approved by the government to cover the compensation amount.
This is known as the Workmen’s Compensation Insurance Policy.
(g) Statutory Limits and Amendment.
The Act has statutory limits for the maximum compensation amount payable in different cases, which are
revised periodically. Over the years, the Act has been amended to expand its scope, enhance compensation and
streamline the process for easier access to benefits by workers and their dependents.
(h) Importance and Impact.
The Workmen’s Compensation Act plays a crucial role in providing financial security to workers and their families
in case of work-related accidents or illnesses. It encourages employers to maintain safe working conditions and
reduce the risk of accidents by imposing a liability on them to compensate for any mishaps that may occur
during employment.

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(j) Relevance  /  Applicability in Armed Forces.

Insurance cover for members of armed forces is available through group insurance schemes of Army, Navy and Air
Force. In cases of invalidment from service, a lumpsum payment is made to the members of armed forces based
on rules of group insurance scheme to compensate for the loss of employment. Pension (special or liberalized or
ordinary family) is paid to next of kin on demise of armed forces personnel, subject to circumstances of death.

39.6 THE CONSUMER PROTECTION ACT (COPRA), 1986 Amended 2019.

(a) Overview.
The Consumer Protection Act (COPRA), 1986 (revised in 2019), is a crucial legislation in India that aims to protect
the rights and interests of consumers The Act provides a legal framework for addressing consumer grievances
and ensuring fair trade practices.
(b) Key Objectives.
The Act seeks to protect consumers from unfair trade practices, sale of defective goods & services, unsafe and
hazardous sale of goods and overcharging on goods & services. It aims to establish Consumer Dispute Redressal
Forums at different levels for the speedy resolution of consumer complaints.
(c) Consumer Rights.
COPRA enshrines six consumer rights: right to safety, right to be informed, right to choose, right to be heard, right
to seek redressal and right to consumer education. These rights empower consumers and encourage businesses
to adhere to ethical practices.
(d) Redressal Mechanism.
The Act establishes Consumer Dispute Redressal Commissions at the district, state and national levels to
adjudicate consumer complaints. Consumers can seek compensation, replacement or refund for defective
products or deficient services through these forums.
(e) E-Commerce and Digital Consumer Protection.
The amended Act includes provisions to address consumer issues related to e-commerce and online transactions.
It enhances consumer protection in the digital space and provides a mechanism to deal with digital frauds and
grievances.
(f) Product Liability.
The 2019 amendment introduces the concept of product liability, holding manufacturers, sellers and service
providers accountable for defective products or services causing harm to consumers Consumers can claim
compensation for any injury or damage caused by such products or services.
(g) Mediation and Simplified Resolution.
COPRA encourages mediation as an alternative dispute resolution mechanism to expedite consumer complaint
resolution. The 2019 amendment provides for the setting up of the Central Consumer Protection Authority (CCPA)
and Consumer Disputes Redressal Commission (CDRC) to protect, promote and enforce consumer rights. The
pecuniary jurisdiction for filing of complaints is based on the value of the goods or services paid.
(h) Strengthening Consumer Rights.
The amended Act aims to enhance consumer protection, ensure timely and effective resolution of complaints and
promote a transparent and competitive marketplace. It introduces provisions to prevent misleading advertisements
and imposes stricter penalties for violations.
(j) Penalty.
(i) Up to ₹ 10 lakhs or imprisonment up to 2 years: manufacturer  /  endorser
(ii) Subsequent offence may extend to ₹ 50 lakhs or imprisonment up to 5 years
(iii) Prohibits the endorser from practicing misleading advertising:
(a) Up to a period of 1 year and

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(b) For the subsequent offence, it may extend to 3 years.

(k) Relevance  /  Applicability in Armed Forces.
Armed Forces Healthcare establishments are covered under this act and are liable for penalty to be levied by
consumer redressal commission for deficiency(s) in service. The penalty can be monetary compensation to
suspension  /  removal of name of erring medical officer from Medical Council Register.

39.7 THE REGISTRATION OF BIRTH AND DEATHS ACT, 1969.

(a) Overview.
The Registration of Births and Deaths Act, 1969, is a vital piece of legislation in India that aims to regulate the
registration of births and deaths and establish a comprehensive civil registration system across the country.
The Act facilitates the collection and maintenance of accurate data on births and deaths which is essential for
public health planning, demographic analysis and social welfare programs.
(b) Birth Registration.
The Act makes it mandatory to register every birth that occurs in India. It is the responsibility of the parents or
legal guardians to register the birth within 21 days from the date of occurrence at the concerned Registrar’s
office. Births can also be registered after the stipulated period with a late fee but the registration process should
be completed as soon as possible.
(c) Death Registration.
The Act requires the registration of every death that occurs within India. The responsibility for registration lies
with the head of the family or any person who was present at the time of death or the person responsible for
carrying out the funeral. Similar to birth registration, deaths must be registered within 21 days from the date of
occurrence at the concerned Registrar’s office.
(d) Registration Authorities.
The Act designates Registrars and Chief Registrars at the local, district and state levels to oversee the registration
process. The local Registrar is responsible for registering births and deaths within their jurisdiction, while the
Chief Registrar coordinates and supervises the registration activities at the district or state level.
(e) Issuance of Certificates.
Upon successful registration of births and deaths, the concerned Registrar issues Birth and Death Certificates,
respectively, to the parties involved. These certificates serve as official documents for various purposes such as
obtaining identity documents, availing government benefits or legal purposes.
(f) Importance of Birth and Death Registration.
Birth and death registration is crucial for accurate demographic data collection, population planning and the
implementation of various social welfare programs and public health initiatives. It helps in monitoring health
trends assessing maternal and child health indicators and understanding population dynamics.
(g) Penalties and Amendments.
The Act imposes penalties for non-compliance with the registration requirements. It has been amended over the
years to simplify the registration process, encourage prompt registration and enhance data accuracy.
(h) Relevance  /  Applicability in Armed Forces.
Healthcare establishments of armed forces are duty bound for informing the births and deaths occurring in the
healthcare establishments to the concerned district or cantonment authorities.

39.8 THE FOOD SAFETY AND STANDARDS AUTHORITY OF INDIA (FSSAI)

(a) Overview.
The Food Safety and Standards Authority of India (FSSAI) is an autonomous body established under the Ministry
of Health and Family Welfare, Government of India. It was formed under the Food Safety and Standards Act,
2006, to regulate and ensure food safety and hygiene across the country.

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(b) Objective.
FSSAI’s primary objective is to lay down scientific standards for food products and regulate their manufacture,
storage, distribution, sale and import to ensure the availability of safe and wholesome food for consumers.
(c) Functions and Responsibilities.
(i) Setting Food Standards.
FSSAI sets standards for food products based on scientific principles, ensuring the safety, quality and
nutritional value of food items.
(ii) Licensing and Registration.
FSSAI is responsible for licensing and registration of food businesses, including manufacturers, processors,
distributors and sellers, to ensure compliance with food safety regulations.
(iii) Surveillance and Monitoring.
FSSAI conducts regular inspections and surveillance of food businesses to ensure adherence to food safety
standards.
(iv) Food Labelling and Packaging.
FSSAI mandates proper labelling and packaging requirements for food products including information on
nutritional content, allergens and expiry dates, to provide consumers with transparent information.
(v) Consumer Awareness and Education.
FSSAI conducts awareness campaigns and educational programs to promote food safety awareness among
consumers and food businesses.
(vi) Import Clearance.
FSSAI regulates the import of food products into India and ensures that imported goods meet the required
safety standards.
(d) Applicability for FSSAI Registration or License.
Registration. for turnover less than ₹ 12 lakh  / annum
State license. for turnover between ₹ 12 lakh to ₹ 20 crores  / annum
Central license. for turnover above ₹ 20 crores  / annum
(e) Food Safety and Standards Act, 2006.
The Food Safety and Standards Act, 2006, provides the legal framework for FSSAI’s functioning. It consolidates
various food-related laws and brings them under a single umbrella for effective regulation.
(f) Harmonization with International Standards.
FSSAI aligns its food safety standards with international organizations like the Codex Alimentarius Commission
to ensure consistency and facilitate international trade.
(g) Food Fortification and Nutrition.
FSSAI also works towards promoting food fortification and nutrition initiatives to address malnutrition and improve
the nutritional content of commonly consumed food items.
(h) Impact and Consumer Confidence.
FSSAI’s efforts in ensuring food safety and quality have instilled greater consumer confidence in the food products
available in the market. It has helped in reducing foodborne illnesses and maintaining high food safety standards
across the food industry.
(j) Checking for Adulteration.
This act gives the Food Safety Officer (FSO) the power to inspect any place where any adulterated food item is
found to be manufactured. He  /  she can collect samples suspected to be adulterated and send them for analysis.

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(k) Penalty and Procedures under FSSAI, 2006.

Table 39.2 : Penalty and Procedures under FSSAI, 2006
Substandard food ₹ 5 lakhs
Misbranded food ₹ 3 lakhs
Misleading advertisement ₹ 10 lakhs
Food with extraneous matter ₹ 1 lakh
Failure to comply with food safety officer/false & 3 months imprisonment/ ₹ 2 lakhs
misleading info
Unhygienic food processing ₹ 1 lakh
Unsafe food
6 months imprisonment & ₹ 1 lakh
Doesn’t result in injury
1 year imprisonment & ₹ 3 lakhs
Non grievous injury
6 years imprisonment & ₹ 5 lakh
Grievous injury
7 years life imprisonment & ₹ 10 lakh
Death
Unhygienic or unsanitary conditions ₹ 1 lakh
Not having valid license 6 months imprisonment & ₹ 5 lakh
Compensation to consumer
₹ 5 lakhs
Death
₹ 3 lakhs
Grievous injury
₹ 1 lakh
Injury
(l) Relevance  /  Applicability in Armed Forces.
The catering establishments, vendors of food & food products etc. in cantonments should be registered or
licensed by FSSAI in consonance with turnover per annum. All ration suppliers should also be checked for
registration or licence during hygiene inspection of factories. The food vendors in units, regimental and station
institutes should be checked for registration or licence during sanitary inspections.

39.9 THE EPIDEMIC DISEASES ACT, 1897.

(a) Overview.
The Epidemic Diseases Act, 1897, was enacted by the British government in India to empower authorities to take
preventive measures during outbreaks of epidemic diseases. The Act grants special powers to the government
to control and manage such health emergencies.
(b) Objectives.
The primary objective of the Epidemic Diseases Act is to provide a legal framework for controlling the spread of
dangerous epidemic diseases and protect public health during outbreaks.
(c) Special Powers of Government.
Under the Act, state governments and local authorities are empowered to take necessary measures to prevent
the outbreak and spread of epidemic diseases. The Act allows authorities to implement quarantines, isolation
and surveillance measures to contain the disease and protect public health.
Under Section 2.
(i) 2A.
Powers of Central Government- the Central Government may take such measures, as it deems fit and

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prescribe regulations for the inspection of any bus or train or goods vehicle or ship or vessel or aircraft
leaving or arriving at any land port or aerodrome, as the case may be in the territories to which this Act
extends and for such detention thereof or of any person intending to travel therein or arriving thereby, as
may be necessary
(ii) 2B.
Prohibition of violence against healthcare service personnel and damage to property. No person shall
indulge in any act of violence against a healthcare service personnel or cause any damage or loss to any
property during an epidemic
(d) Declaration of Epidemic Diseases.
The Act authorizes the government to declare any disease as an epidemic disease in the affected areas to
enable the implementation of necessary containment measures.
(e) Enabling Provisions.
The Act provides for the appointment of health officers and grants them the authority to take appropriate actions
for the prevention and control of the disease. It empowers authorities to take possession of buildings and areas
for establishing quarantine facilities or isolation centres.
(f) Public Cooperation.
The Act emphasizes the importance of public cooperation in implementing preventive measures during epidemics.
It obligates individuals to comply with health officer’s order and cooperate in the containment efforts to safeguard
public health.
(g) Implementation during COVID-19 Pandemic.
The Epidemic Diseases Act played a crucial role in the management of the COVID-19 pandemic in India. It allowed
the government to enforce lockdowns, impose travel restrictions and implement other measures to control the
spread of the virus.
(h) Epidemic Act Amendment (2020).
The provisions for prohibition under violence against healthcare service personnel and damage to property have
now been declared as a grave offence. A jail term of up to 7 years and fine up to 5 lakh can be imposed. The
guilty to pay twice the market value of damaged property. All such cases are to be investigated within 30 days
and verdict to be given within a year.
(j) Penalty.
Offence punishable under section 188 of the IPC
(i) Commits or abets Act of violence or abets or cause damage or loss to any property.
(aa) Imprisonment 3 months to 5 years
(ab) Fine of ₹ 50,000 to ₹ 2 lakhs
(ii) Acts of Violence Against Health Care Service Personnel Causing Grievous Hurt.
(aa) Imprisonment up to 6 months to 7 years
(ab) Fine of ₹ 1 lakh to 5 lakhs
(k) Relevance  /  Applicability in Armed Forces.
Provisions of the act can be utilised for controlling spread of diseases in armed forces and measures like isolation,
quarantine, vaccination etc are implemented.

39.10 MEDICAL TERMINATION OF PREGNANCY (MTP) AMENDMENT ACT, 2021.

(a) Overview.
The Medical Termination of Pregnancy (MTP) Amendment Act, 2021, is a significant legislative change in India
that aims to enhance women’s reproductive rights and access to safe abortion services. The amendment seeks

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to address certain shortcomings in the existing MTP Act, 1971 (Table 39.3, 39.5 and 39.6) and improve access
to safe and legal abortion services for women in the country. The implementation of provisions of the act for
conduct of MTP are summarized in the Table 39.4.
Table 39.3 : Provisions under the Act of 1971
Grounds under which MTP can be
Who can conduct MTP Where MTP can be conducted
conducted
Therapeutic For up to 12 weeks period of Government hospital
gestation (POG)
Eugenic Medical officer who has assisted Nursing homes private/public
25 MTPs with 5 MTPs done (Government recognised )
Humanitarian independently in an approved
establishment
Social Category A - MTP up to 12 weeks
For 20 weeks POG POG
Mentally not sound Medical officer having 3 years
experience in Obstetrics & Category B - MTP up to 20 weeks
Gynaecology POG

Post Graduate or Diploma in

Obstetrics & Gynaecology

6 months house residency in

Obstetrics & Gynaecology

1 year experience at a hospital with

Obstetrics & Gynaecology

(b) Increase in Gestational Limit.

One of the key provisions of the MTP Amendment Act, 2021, is the increase in the upper gestational limit for
abortion from 20 weeks to 24 weeks. This extension allows women to avail safe abortion services in cases
of foetal abnormalities or when the womens’ physical or mental health is at risk, even at a later stage of
pregnancy.
Table 39.4 : MTP Act 1971 Vs MTP Amendment Act 2021
Indication MTP Act 1971 MTP Act 2021
Contraceptive failure Only applies to married women Unmarried women are also covered
Gestational Age limit 20 weeks POG for all indications 24 weeks for rape survivors
Beyond 24 weeks for substantial
fetal abnormalities
Medical practitioner’s opinion One RMP till 12 weeks POG One RMP till 20 weeks
required before termination Two RMPs till 20 weeks POG Two RMPs 20-24 weeks
Medical Board approval after 24
weeks
Breach of the woman’s Fine up to ₹ 1,000 Fine and/or imprisonment upto 1
confidentiality year

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Table 39.5 : Important Rules under MTP Act 1971

Rule 3 Rule 6 Rule 7 Rule 8
District level committee Certificate of approval Certificate of approval The owner can apply for
for 2 years tenure displayed at prominent can be cancelled or review of the order to
consists of 01 place in hospital/clinic suspended after a the government within a
Gynaecologist/surgeon/ detailed inspection report period of 60 days.
anesthetist, is submitted
Inspection by CMO of
a person from local
district
medical professional body,
NGOs, Panchayati Raj
institution One of them
May seize any article,
shall be women
medicine, ampoule,
admission register
or other document
maintained
Table 39.6 : Important Rules under MTP Act 1971
Regulation 3 Regulation 4 Penalty
Certify opinion and the termination Monthly report in Form II Medical practitioner not registered
within 3 hours in Form I - 2 to 7 years of rigorous
Maintain a register in Form III serial
imprisonment
year wise entry
Informed consent
Place or hospital not registered
Document to be kept secretly
- 2 to 7 years of rigorous
Record of termination to be kept in imprisonment
a sealed envelope “SECRET” and
Reproduced during inspections or
sent to the Head of the Hospital
MTP certification
(c) Approval for Certain Categories of Women.
The amendment permits the termination of pregnancies beyond 24 weeks in cases where severe foetal
anomalies are detected. This provision is significant in providing options to women facing distressing medical
situations during late-term pregnancies.
(d) Emphasis on Women’s Autonomy.
The MTP Amendment Act, 2021, aims to empower women and strengthen their autonomy in making decisions
about their reproductive health. It seeks to reduce delays in accessing abortion services and ensures that
women have greater control over their reproductive choices.
(e) Expanding Access to Safe Abortion Services.
The amendment proposes the establishment of a wider network of medical facilities to provide safe abortion
services, especially in rural and remote areas. It aims to improve access to trained healthcare providers and
promote the availability of safe abortion methods.
(f) Qualified Auxiliary Nurse-Midwives (ANMs) Authorization.
The amendment authorizes trained ANMs to conduct medical termination of pregnancies up to 20 weeks of
gestation, ensuring increased availability of safe abortion services at the primary healthcare level.
(g) Strengthening Confidentiality and Privacy.
The MTP Amendment Act prioritizes confidentiality and privacy in accessing abortion services. It aims to
reduce the stigma associated with abortion and promote an enabling environment for women to seek medical
termination of pregnancy without fear of judgment or discrimination.

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(h) Impact on Reproductive Healthcare.

The MTP Amendment Act, 2021, has the potential to significantly improve women’s access to safe and legal
abortion services, reduce maternal mortality due to unsafe abortions and uphold women reproductive rights.
(j) Relevance  /  Applicability in Armed Forces.
The provisions of MTP Act are applicable to armed forces hospitals and healthcare establishments. CO  /  Comdt
of armed forces hospital should ensure implementation of rules and regulations of MTP act in the hospital.

39.11 THE PRE-CONCEPTION AND PRE-NATAL DIAGNOSTIC TECHNIQUES (PROHIBITION OF SEX SELECTION)
ACT, 1994
(a) Overview.
The Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition of Sex Selection) Act, 1994, commonly
known as the PCPNDT Act, is an important legislation in India that aims to prevent the misuse of prenatal
diagnostic techniques for sex determination and selective abortion of female foetuses.
(b) Objective.
PCPNDT act combats the practice of sex-selective abortions and the declining sex ratio in the country. It seeks
to protect the girl child’s right to life and ensure gender equality. Provisions of this act is given in Table 39.7
Table 39.7 : Provisions of PCPNDT Act
Conditions when Prenatal Diagnostic
No Person shall Conduct the
Prenatal Diagnostic Techniques Techniques may be done where
Prenatal Diagnostic Procedures
done under These Conditions Qualified Persons are Satisfied with
unless
Reasons Recorded in Writing
(i) Chromosomal abnormalities (i) Age of the pregnant women (i) Explain all known side and
(ii) Genetic metabolic diseases >35 years after-effects of such procedures
(iii) Hemoglobinopathies (ii) History of two or more (ii) Obtained written consent
spontaneous abortions or foetal (iii) A copy of the written consent
(iv) Sex-linked genetic diseases
loss given to the pregnant women
(v) Congenital anomalies
(iii) Exposure to potentially
(vi) Any other abnormalities or teratogenic agents
diseases as may be specified
(iv) Family history of mental
by the Central Supervisory
retardation or physical
Board
deformities
(v) Any other condition that may
be specified by the board
(c) Prohibition of Sex Selection.
The Act strictly prohibits sex determination during pregnancy through pre-natal diagnostic techniques. It makes
it illegal for anyone to conduct tests to ascertain the sex of the foetus for non-medical reasons.
(d) Regulating Pre-Natal Diagnostic Techniques.
The PCPNDT Act regulates the use of pre-natal diagnostic techniques like ultrasound and other tests to ensure
that they are used solely for medical purposes and not for sex determination.
(e) Prohibition of Advertisements.
The Act also prohibits the advertisement of facilities or services related to pre-natal determination of the sex
of the foetus. It aims to prevent the promotion of such illegal practices.
(f) Empowerment of Appropriate Authorities.
The Act empowers the appropriate authorities at the district, state and national levels to implement and enforce
its provisions effectively. These authorities conduct inspections, take necessary actions against violators and
ensure compliance with the Act. Offence and Punishments under PCPNDT act is summarized in the Table 39.8

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Table 39.8 : Offence and Punishments under PCPNDT Act

Offence Punishment (cognizable, non-bailable, non-compoundable)
(i) Breach of any provision of the Act by (i) 3 years imprisonment and/or fine of ₹ 10,000
any service providers (ii) 5 years imprisonment and/or fine of ₹ 50,000
(ii) For subsequent offence
(i) Medical professionals (i) Suspension of the registration
(ii) Removal of name from register for 2 years on first conviction
and permanently in case of subsequent offences
(i) Persons seeking to know the sex of (i) Imprisonment up to 3 years and/or fine of ₹ 50,000
the foetus. (ii) Imprisonment up to 5 years and/or fine of ₹ 1 Lakh
(ii) For subsequent offence
(i) Persons connected with (i) Imprisonment up to 3 years and/ or fine of ₹ 10,000 with
advertisement of sex selection/sex additional of continuing contravention at the rate of ₹ 500/ day
determination services
(j) Amendments and Strengthening.
Over the years, the PCPNDT Act has been amended to enhance its effectiveness and address emerging
challenges in curbing sex-selective practices. Amendments have been made to strengthen enforcement,
increase penalties and extend the Act’s coverage to emerging technologies.
(k) Relevance  /  Applicability in Armed Forces.
The implementation of the act in Armed Forces is governed vide DGAFMS letter No.20028  /  PNDT  / DGAFMS  /  DG-
3A dt 27th Jan 2003. ‘Form A’ pertains to Application for registration and renewal of registration of a genetic
counselling centre  /  genetic laboratory  /  genetic clinic, ‘Form B’ pertains to list of doctors using the equipment.
The list  /  names of doctors authorized to use  /  operate the equipment is published in routine   part I order of the
healthcare establishment  /  hospital. In armed forces, MG (Med) is the appropriate authority for registration and
renewal of pre-natal diagnostic techniques and genetic counselling centre  /  genetic laboratory  /  genetic clinic.

39.12 TRANSPLANTATION OF HUMAN ORGANS ACT (THOA), 1994.

(a) Overview.
The Transplantation of Human Organs Act (THOA), 1994, is a significant legislation in India that regulates the
transplantation of human organs and tissues to prevent commercial trading and organ trafficking while promoting
ethical practices in organ donation and transplantation. The act has been amended in the year 2011.
(b) Objective.
The primary objective of the THOA is to facilitate the lawful and ethical transplantation of human organs and
tissues for therapeutic purposes, ensuring transparency, fairness and patient safety.
(c) Regulating Organ Transplants.
The Act establishes a legal framework for the removal, storage and transplantation of human organs and tissues. It
sets guidelines for the authorization, procedures and conditions under which organ transplants can be performed.
(d) Definition of Authorized Transplantation.
The THOA defines organ transplantation conditions which can be legally authorized, such as the relationship
between the donor and recipient, the need for approval from appropriate authorities and informed consent.
(e) Prohibition of Commercial Transactions.
The Act strictly prohibits the commercial trading of human organs and tissues. It aims to prevent organ
trafficking and exploitation of vulnerable individuals for organ transplantation.
(f) Authorization Committees.
The THOA establishes Authorization Committees at the state and central levels to grant approval for organ

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transplantation cases. These committees verify the legitimacy of the transplant, ensure the welfare of both
donors and recipients and safeguard against commercial transactions.
(g) Donor and Recipient Eligibility.
The Act prescribes eligibility criteria for both organ donors and recipients. It ensures that donors are mentally
competent, legally competent and have given informed consent voluntarily. The Act also ensures that recipients
are genuine patients in need of transplantation for medical reasons.
(h) Cadaver Transplantation.
A deceased donor transplant (cadaveric) is a transplant where the donated organ comes from a person who
has died or certified as brain dead where brain death is defined as below:
Brain death is defined as the irreversible loss of all functions of the brain, including the brainstem, the three
essential findings in brain death are coma, the absence of brain stem reflexes and apnea. The individuals
who certify brain stem death are as under:
(i) Medical administrator in charge of the hospital.
(ii) Authorised Specialist.
(iii) Neurologist  /  Neurosurgeon.
(iv) Medical officer treating the patient.
(j) Offences and Penalties: see Table 39.9
Table 39.9 : Offences and Penalties under THOA
Offence Punishment
Any person who renders his services to or at any 10 years imprisonment and fine upto ₹ 20 lakh
hospital without authority
For Doctors involved Suspension of registration for 3 years on first conviction
Permanent suspension of registration in case of
subsequent offences
Any illegal supply or giving commitment or publishing/ Up to 5 to 10 years imprisonment and fine ₹ 20 lakhs
advertisement to supply human organs or giving to ₹ 1 crore
human organs on payment by an individual or society
or organization or agent
(k) Amendments and Strengthening.
The Act has been amended over the years to address emerging issues in organ transplantation and strengthen
the regulatory mechanisms to ensure better compliance and transparency. The important amndments are as
below:
(i) Near relatives in TOHA 1994 included mother, father, son, daughter, brother, sister, spouse and
was amended to include grandchildren and grandparents in 2011.
(ii) Tissues have been included along with organs in 2011 amendement in the act.
(iii) Guidelines for Retrieval centers and Tissue banks have been included in amendements carried
out in 2011.
(iv) Swap donation has been allowed in 2011.
(v) Provision of mandatory ‘Transplant Coordinator’ at all registered hospitals has been implemented
through the amendement.
(vi) National Human Organs and Tissue Removal and Storage Network and National Registry of
donors and recipients has been implemented through 2011 amendment.
(vii) Enucleation has been permitted to be done by trained technician from a cadaveric donor.

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(j) Applicability  /  Relevance in Armed Forces.

Armed Forces is a deemed state under the provisions of the act. Director General Armed Forces Medical
Services (DGAFMS) is vested with the powers of transferring  /  sharing donated organs between armed forces
hospitals. Armed Forces Organ Retrieval and Transplantation Authority (AORTA) functions from premises of Army
Hospital (Research & Referral), New Delhi. AORTA not only creates awareness about organ donation but also
trains and equips Armed Forces medical and paramedical workers on coordination for transplant of organs,
retrieval and transport of organs.

39.13 THE HUMAN IMMUNODEFICIENCY VIRUS AND ACQUIRED IMMUNE DEFICIENCY SYNDROME
(PREVENTION AND CONTROL) ACT, 2017.
(a) Overview.
The Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (Prevention and Control) Act,
2017, is a landmark legislation in India aimed at preventing and controlling the spread of HIV  /  AIDS and
protecting the rights and dignity of people living with HIV (PLHIV).
(b) Objectives.
The primary objectives of the Act are to prevent the spread of HIV, provide access to healthcare and support
services for PLHIV and eliminate discrimination and stigmatization associated with HIV  /  AIDS.
(c) Non-Discrimination and Equal Rights.
The Act prohibits discrimination against PLHIV in various settings, including healthcare, education, employment
and public facilities. It ensures equal rights, opportunities and treatment for PLHIV, safeguarding their dignity
and social integration.
(d) Confidentiality and Informed Consent.
The Act emphasizes the confidentiality of HIV-related information and prohibits the disclosure of a person’s HIV
status without their informed consent. Healthcare providers are required to obtain informed consent before
conducting HIV testing or disclosing test results.
(e) Prevention, Testing and Treatment.
The Act promotes HIV prevention strategies, including awareness campaigns, condom distribution and harm
reduction programs. It mandates HIV testing and counselling services and treatment access for all PLHIV,
irrespective of their economic or social status.
(f) Safe working environment.
The act promotes the safe working environment by providing training in universal precautions and implementing
the same to all to healthcare providers. Further, it also mentions guidelines on post exposure prophylaxis for
accidental exposure.
(g) Measures to Control Spread.
The Act empowers the government to take necessary measures to control the spread of HIV, including
surveillance, monitoring and interventions in high-risk populations. It encourages public-private partnerships
to enhance the effectiveness of prevention and control efforts.
(h) Role of the National and State AIDS Control Organizations.
The Act outlines the roles and responsibilities of the National AIDS Control Organization (NACO) and State AIDS
Control Organizations (SACOs) in implementing HIV prevention and control programs.
(j) Grievance Redressal Mechanism.
The Act establishes a grievance redressal mechanism for PLHIV to seek remedies in case of discrimination,
denial of services or violation of their rights. It ensures access to justice and protection of rights for PLHIV.
(k) Offences and Penalty – see Table 39.10

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Table 39.10 : Offences and Penalty under Human Immunodeficiency Virus And Acquired Immune
Deficiency Syndrome (Prevention And Control) Act, 2017
Offence Penalty
Penalty for contravention Imprisonment of not less than 3 months may extend
upto 2 years or fine up to ₹ 1 lakh or both
Failure to comply with any order given by an Ombudsman Fine up to ₹ 10,000 and in case the failure continues
additional fine up to ₹ 5,000/day till the failure continues
Breach of confidentiality in legal proceedings Fine which may extend to ₹ 1 lakh rupees unless such
disclosure is pursuant to any order or direction of a court
(l) Amendments and Strengthening.
It was introduced as a comprehensive legislation to address the evolving challenges of HIV  /  AIDS prevention and
control in India. It builds upon the previous legal framework and aims to strengthen the country’s response to
HIV  /  AIDS.
(m) Relevance  /  Applicability in Armed Forces.
Guidelines for management and prevention of HIV  /  AIDS infection in the Armed Forces are governed vide
DGAFMS letter No 5496  /  HIV Policy  /  DGAFMS  /  DG-3A date 08th Mar 2019.

39.14 THE CLINICAL ESTABLISHMENTS (REGISTRATION AND REGULATION) ACT, 2010.

(a) Overview.
This act is a significant legislation in India that aims to standardize and regulate the functioning of clinical
establishments to ensure quality healthcare services and patient safety. It is adopted by 13 states and 6 UTs.
3 states (Gujarat, Kerala and Goa) have neither adopted CEA and nor have their own.
(b) Objective.
The primary objective of the Act is to establish a uniform framework for the registration and regulation of
all clinical establishments including hospitals, clinics, diagnostic centres and laboratories to maintain a high
standard of medical care.
(c) Mandatory Registration.
The Act makes it mandatory for all clinical establishments to register with the appropriate authority designated
by the state government. Registration is essential for any clinical establishment to legally operate and provide
medical services. This does not include establishment owned, controlled or managed by Armed Forces.
(d) Classification and Standards.
The Act classifies clinical establishments into different categories based on their size, services provided and
infrastructure facilities. It sets specific standards for each category to ensure patient safety, medical ethics and
quality of care.
(e) Patient Rights and Responsibilities.
The Act emphasizes patient rights, including the right to access medical records, informed consent and
confidentiality of medical information. It also outlines patients’ responsibilities, such as following treatment
protocols and complying with prescribed medical advice.
(f) Fees and Charges.
The Act aims to regulate the fees and charges levied by clinical establishments to prevent exorbitant pricing
and ensure affordability of healthcare services for patients.
(g) Clinical Standards and Quality Assurance.
The Act mandates adherence to clinical protocols and guidelines to maintain quality and safety in medical
practice. It promotes regular audits and inspections to monitor compliance with the prescribed standards.

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 PUBLIC HEALTH LEGISLATIONS RELATED TO HEALTH (INCLUDING RELEVANT ARMED FORCES POLICIES)

(h) Grievance Redressal Mechanism.

The Act establishes a grievance redressal mechanism for patients to file complaints against clinical
establishments for any negligence, malpractice or violation of patient rights. It aims to provide timely resolution
and justice to affected patients and their families.
(j) Role of State Governments.
State Governments set up State Councils and State Registration Authorities for it’s effective implementation. They
are responsible for the registration, regulation and supervision of clinical establishments within their jurisdiction.
In provisional registration no enquiry is required, given within 10 days and valid till last day of that year. Permanent
registration is considered after notification of minimum standards and is renewed after 5 years.
(k) National Council and Central Government’s Role.
The Act establishes a National Council to oversee and coordinate the implementation of the Act across the
country. The Central Government plays a supervisory role in supporting the states and ensuring uniformity in
the registration and regulation of clinical establishments.
(l) Offences & Penalty.
Under the Act for running clinical establishment without registration, a fine could range from ₹ 50,000 to ₹ 5 lakh.
(m) Relevance  /  Applicability in Armed Forces.
The clinical establishments owned, governed or managed by Armed Forces are not covered under this act.
However, Armed Forces have been way ahead in regulating and fulfilling various standards laid down by national
and international agencies in establishing and running Armed Forces healthcare establishments. Various
inspections (technical, administrative, quality assurance etc.) are in vogue. Grievance redressal mechanisms
for patients and their attendants exist in the Armed Forces.

39.15 Conclusion.
Public health legislations aim to safeguard health of the citizens of the country. Various laws enacted by Govt of India
are applicable or relevant to Armed Forces health care establishments and its’ clientele. Bio-Medical Waste Management
Rules (under Environmental Protection Act) and other relevant laws are discussed in the relevant chapters.

Suggested Reading.
1. World Health Organization. Human rights and health [Internet]. World Health Organisation. 2022.
2. Kaaviya C, Lavanya SM, Krishnakumare B. Consumers’ Opinion towards Food Product Recall. European Journal
of Nutrition & Food Safety. 2019 Oct 21;(1):208–15.
3. Dudeja P, Singh A. Chapter 18 - Role of government authorities in food safety [Internet]. Gupta RK, Dudeja, Singh
Minhas, editors. ScienceDirect. San Diego: Academic Press; 2017. p. 243–56.
4. Dhanwate A. Brainstem death: A comprehensive review in Indian perspective. Indian Journal of Critical Care
Medicine. 2014;18(9):596–605.
5. Rakesh P. Implementing the Epidemic Diseases Act to combat Covid-19 in India: An ethical analysis. Indian
Journal of Medical Ethics. 2021 Feb 16;06(01):13–7.
6. Nair SS, Kalarivayil R. Has India’s Surrogacy Bill Failed Women Who Become Surrogates? ANTYAJAA: Indian
Journal of Women and Social Change. 2018 Jun;3(1):1–11.
7. Rahaman M, Roy A, Das KC, Rana MJ. Revisiting the predisposing, enabling and need factors of unsafe abortion in
India using the Heckman Probit model. Journal of biosocial science [Internet]. 2023 Nov 20 [cited 2024 Jan 18];2:1–21.
8. Seth AK, Nambiar P, Joshi A, Ramprasad R, Choubey R, Puri P, et al. First prospective study on brain stem death
and attitudes toward organ donation in India. Liver Transplantation. 2009 Oct 28;15(11):1443–7.
9. Rahman TA, Siddiqui AT. Discrepancies in the laws on identifying foetal sex and terminating a pregnancy in India.
Indian Journal of Medical Ethics. 2007 Jul 1;(3).
10. Kosare S, Gala A. Brain Death and Organ Donation. Res Inno in Anesth 2019;4(2):45–49
n

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Chapter
XXXX
IMPORTANT MEDICOSOCIAL PROBLEMS AND
POPULATION CONTROL
40.1 Introduction.
Concepts of disease, illness and health are ever evolving and entail not only physical, but mental, emotional,
economic and social aspects of human life. History of study of social determinants of disease and health can be
traced back to humanity itself as the first man tried to “Do Something” about suffering arising out of ailments and
injuries. The organized study of Medical Sociology came into existence in 1950s when doctor-patient relationship
was studied for the first time. Since then, medical sociology has evolved into a complex science and art with
engagement of multiple stakeholders ranging from doctors, paramedical staff, sociologist and even politicians
and civil societies.  
Newer advances in every field have given rise to newer medico social problems like “social media addiction’
and “health infodemic” while the older issues of caste and poverty, population, gender discrimination, illiteracy,
migration, social isolation of elderly, inequity in healthcare coverage, human trafficking, alcoholism and substance
abuse continue to pose threat of diseases that directly affect human health and health care determinants.  

40.2 Important Medico-Social Problems.

(a) Medico-Social Problems of General Population.
(i) Poverty.
Poverty is a major cause of ill health and a barrier to accessing health care when needed. This relationship
is financial; the poor cannot afford to purchase those things that are needed for good health, including
sufficient quantities of quality food and health care. But the relationship is also related to other factors
related to poverty, such as lack of information on appropriate health-promoting practices or lack of voice
needed to make social services work for them. Ill health, in turn, is a major cause of poverty. This is partly
due to the costs of seeking health care, which include not only out-of-pocket spending on care (such as
consultations, tests and medicine), but also transportation costs and any informal payments to providers.
It is also due to the considerable loss of income associated with illness in developing countries, both
breadwinners, but also of family members who may be obliged to stop working or attending school to take
care of an ill relative. In addition, poor families coping with illness might be forced to sell assets to cover
medical expenses, borrow at high interest rates or become indebted to the community. The World Bank’s
initiatives in area of health equity and financial protection outline the strategies to be adopted by countries
in ensuring Universal Health Coverage (UHC).   
(ii) Food Insecurity.
Today, nearly one in three persons globally suffers from at least one form of malnutrition: wasting, stunting,
vitamin and mineral deficiency, overweight or obesity and diet related NCDs. Combating malnutrition in all
its forms is one of the greatest global health challenges. Nutrition is critical to both health and economic
development Focus and investment for integrated solutions will tackle malnutrition in all its forms. The double
burden of malnutrition confers a serious and negative economic impact on individuals and populations.
Through its effects on health, malnutrition increases healthcare costs, reduces productivity and slows
economic growth, which in turn can perpetuate a cycle of poverty and ill-health. The direct and indirect,
macro and micro-economic costs incurred by individuals and populations are often unsustainable and
contribute a significant barrier to economic and social development.
(iii) Inequitable Access to Health Care.
UHC provides an avenue for uniting global health, fighting against poverty, reducing social inequity and is
a hallmark of a government’s commitment to improving the well-being of all its citizens. The relationship

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between catastrophic health expenses and extreme poverty has led to an increased focus on UHC not only
to improve healthcare utilization but also to eliminate extreme poverty by protecting individuals and families
from catastrophic health expenditures. A few challenges identified in providing universal health coverage
are inadequate human resource, challenges related to finances, challenges related to stewardship, political
commitment and unregulated and fragmented healthcare system.  
(iv) Health Literacy (HL).
As defined in Health Promotion Glossary, 1998, “Health literacy implies the achievement of a level of
knowledge, personal skills and confidence to take action to improve personal and community health by
changing personal lifestyles and living conditions. Thus, health literacy means more than being able to read
pamphlets and make appointments. By improving people’s access to health information and their capacity
to use it effectively, health literacy is critical to empowerment.”  
The ability to understand the complexities of the healthcare system and engage in health-related behaviours
are both influenced by a person’s level of health literacy. In India, at least nine out of ten individuals lack
health literacy. Additionally, India has a high rate of general illiteracy and extreme poverty, both of which
have a negative impact on health literacy. Frequent hospital visits are a result of an unhealthy lifestyle.  
Limited health literacy is negatively associated with the use of preventive services (e.g., mammograms or
flu shots), management of chronic conditions (e.g., diabetes, high blood pressure, asthma and HIV / AIDS)
and self-reported health. Researchers also found an association between limited health literacy and an
increase in preventable hospital visits and admissions. Additional studies have linked limited health literacy
to misunderstanding instructions about prescription medication, medication errors, poor comprehension of
nutrition labels and mortality.
Barriers to Health Literacy (HL).
Language, literacy level of patient, beliefs, customs and practices, cultural norms, level of education and
comprehension of patient, their felt needs, communication skills of health care provider, standardization of
procedures and health literacy resource material are some challenges in delivering health literacy. Adults
over the age of 65 years, recent refugees and immigrants, people with less than a high school degree or
low general educational development, people with incomes at or below the poverty level are most likely to
experience limited health literacy.
The interventions that aim to increase people’s knowledge, self-efficacy, behavioural intent, health skills
and behaviour capacity to obtain, process and comprehend basic health information and services required
to make wise decisions are known as HL interventions. Community-based health literacy interventions
emphasize the development of sustainable actions at the individual and community level. They bring people
together, offer the opportunity to share knowledge and experiences and create common understandings.
Such approaches aim to empower participants and their communities through their roles as active agents
throughout the whole process.
Evidence-based strategies to address health literacy are emerging from the fields of communication, health
care, public health and adult education. Much of the evidence on interventions comes from simplifying and
improving written materials, using video or other targeted approaches to patient education and improving
patient–provider communication. Strong evidence supports involving members of the target audience in
the design and testing of communication products. Many health professionals advocate using a universal
precautions approach to health communication, assuming that most patients will have difficulty understanding
health information. Targeted approaches to communication can improve self-management and related health
outcomes among patients with limited health literacy. Targeted approaches are adapted to meet the needs of
specific groups of people, such as patients with limited literacy skills. Tailored programs and communication,
on the other hand, are individually crafted based on the unique characteristics of each person.  
(v) Health Infodemic.
An infodemic is too much information including false or misleading information in digital and physical
environments during a disease outbreak. It causes confusion and risk-taking behaviours that can harm
health. It also leads to mistrust in health authorities and undermines the public health response. An
infodemic can intensify or lengthen outbreaks when people are unsure about what they need to do to
protect their health and the health of people around them. With growing digitalisation, expansion of social

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media and internet use the information can spread more rapidly. This can help to fill information voids
more quickly but can also amplify harmful messages.  
Infodemic management is the systematic use of risk and evidence based analysis and approaches to
manage the infodemic and reduce its impact on health behaviours during health emergencies.
Infodemic management aims to enable good health practices through 4 types of activities: Listening to
community concerns and questions, promoting understanding of risk and health expert advice, building
resilience to misinformation, engaging and empowering communities to take positive action.
(b) Medico-Social Problems of Women.
(i) Gender Discrimination.
Gender norms, socialization, roles, differentials in power relations and in access to and control over resources
contribute to differences in vulnerabilities and susceptibilities to illness, how illness is experienced, health
behaviours (including health-seeking), access to and uptake of health services, treatment responses and
health outcomes. The Gender Inequality Index (GII) provides insights into gender disparities in health,
empowerment and the labour market. The GII is a composite measure, reflecting inequality in achievements
between women and men in three dimensions: reproductive health, empowerment and the labour market.
The health dimension is measured by the maternal mortality ratio and the adolescent fertility rate. The
empowerment dimension is measured by the share of parliamentary seats held by each gender and
by secondary and higher education attainment levels. The labour dimension is measured by women’s
participation in the workforce.
The GII varies between 0 (when women and men fare equally) and 1 (when men or women fare poorly
compared to the other in all dimensions). It is designed to reveal the extent to which national human
development achievements are eroded by gender inequality and to provide empirical foundations for policy
analysis and advocacy efforts.
Low status restricts women’s opportunities and freedom, giving them less interaction with others and fewer
opportunities for independent behaviour, restricting the transmission of new knowledge and damaging
their self-esteem and self-expression. It is a particularly important determinant of two resources for care:
mothers physical and mental health and their autonomy and control over household resources. Low status
restricts women’s capacity to act in their own and their children’s best interests. There is a demonstrated
association between women’s status and malnutrition in children.
(ii) Gender Based Violence.
The United Nations defines violence against women as “any act of gender-based violence that results in or
is likely to result in physical, sexual or mental harm or suffering to women, including threats of such acts,
coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.”
The term includes but is not restricted to intimate partner violence which refers to behaviour by an intimate
partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression,
sexual coercion, psychological abuse and controlling behaviours.
(iii) Sexual Assault and Abuse.
Sexual violence is a broad term that encompasses all sexual acts, committed or attempted, without
consent or that occur when the person is unable to consent. Sexual violence is a major public health and
human rights issue affecting more than 40% of women during their lifetimes. Although men and women
experience sexual assault, women are at greatest risk. Health consequences of sexual assault include
sexually transmitted infections, risk of unintended pregnancy, high rates of mental health conditions (e.g.,
post-traumatic stress disorder) and development of chronic medical conditions (e.g., chronic pelvic pain).  
Analysis of prevalence data from 2000-2018 across 161 countries and areas, conducted by WHO on
violence against women, found that worldwide nearly 1 in 3 or 30% of women have been subjected to
physical and / or sexual violence by an intimate partner or non-partner or both.
(iv) Risk factors for Both Intimate Partner and Sexual Violence.
(aa) Lower levels of education.  

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(ab) A history of exposure to child maltreatment.

(ac) Witnessing family violence.
(ad) Anti-social personality disorder.
(ae) Harmful use of alcohol or drugs.  
(af) Harmful masculine behaviours, including having multiple partners or attitudes that condone
violence.
(ag) Community norms that privilege or ascribe higher status to men and lower status to women.  
(ah) Low levels of women’s access to paid employment.
(aj) Low level of gender equality (discriminatory laws etc.).
To prevent Gender Based Violence UN and WHO have adopted RESPECT women framework. Each letter of
RESPECT stands for one of seven strategies: Relationship skills strengthening; Empowerment of women;
Services ensured; Poverty reduced; Enabling environments (schools, workplaces, public spaces) created;
Child and adolescent abuse prevented; and Transformed attitudes, beliefs and norms.  
(c) Medico-Social Problems of Children.
Child Maltreatment.
Child maltreatment is the abuse and neglect that occurs to children under 18 years of age. It includes
all types of physical and / or emotional ill-treatment, sexual abuse, neglect, negligence and commercial or
other exploitation, which results in actual or potential harm to the child’s health, survival, development
or dignity in the context of a relationship of responsibility, trust or power. International studies reveal that
nearly 3 in 4 children aged 2-4 years regularly suffer physical punishment and / or psychological violence
at the hands of parents and caregivers.
Child maltreatment has often severe short and long term physical, sexual and mental health consequences.
These include injuries, including head injuries and severe disability in young children, post-traumatic stress,
anxiety, depression and sexually transmitted infections (STIs) including HIV. Adolescent girls may face additional
health issues including gynaecological disorders and unwanted pregnancy. Child maltreatment can affect
cognitive and academic performance and is strongly associated with alcohol and drug abuse and smoking.
Maltreatment causes stress that is associated with disruption in early brain development. Extreme stress
can impair the development of the nervous and immune systems.  
Several risk factors for child maltreatment have been identified. Not all risk factors are present in all social
and cultural contexts and the list given below provides an overview when attempting to understand the
causes of child maltreatment.
(i) Child Characteristics.
It is important to emphasize that children are the victims and are never to blame for maltreatment.
Characteristics of an individual child that may increase the likelihood of being maltreated include
being either under four years old or an adolescent, being unwanted or failing to fulfil the expectations
of parents, having special needs, crying persistently or having abnormal physical features, having an
intellectual disability or neurological disorder, identifying as or being identified as lesbian, gay, bisexual
or transgender.
(ii) Parent or Caregiver Characteristics.
Characteristics of a parent or caregiver that may increase the risk of child maltreatment include:
difficulty bonding with a newborn, not nurturing the child, having been maltreated themselves as a
child, lacking awareness of child development or having unrealistic expectations, misusing alcohol or
drugs, including during pregnancy, having low self-esteem, suffering from poor impulse control, having
a mental or neurological disorder, being involved in criminal activity, experiencing financial difficulties.
(iii) Relationship.
Characteristics of the relationships within families or among intimate partners, friends and peers that

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may increase the risk of child maltreatment include family breakdown or violence between other family
members, being isolated in the community or lacking a support network, a breakdown of support in
child rearing from the extended family.
(iv) Community and Societal Factors.
Characteristics of communities and societies that may increase the risk of child maltreatment include:
gender and social inequality, lack of adequate housing or services to support families and institutions,
high levels of unemployment or poverty, the easy availability of alcohol and drugs, inadequate policies
and programmes to prevent child maltreatment, child pornography, child prostitution and child labour,
social and cultural norms that promote or glorify violence towards others, support the use of corporal
punishment, demand rigid gender roles or diminish the status of the child in parent-child relationships,
social, economic, health and education policies that lead to poor living standards or socioeconomic
inequality or instability.  
(d) Medico-Social Problems of Elderly.
Between 2015 and 2050, the proportion of the world’s population over 60 years will nearly double from
12% to 22%. By 2030, 1 in 6 people in the world will be aged 60 years or more. In the last few years,
medical science has identified a new group within the senior citizen category, namely that of super-agers.
The term refers to people in their 70s and 80s who have the mental or physical capability of their decade
younger counterparts. Increase in longevity and decline of joint family and breakdown in social fabric pushes
seniors into loneliness and neglect.   
Abuse of Older People.
The abuse of older people, also known as elder abuse, is a single or repeated act or lack of appropriate
action, occurring within any relationship where there is an expectation of trust, which causes harm or
distress to an older person. Abuse of elderly can happen in either community setting or institutional setting.  
Individual level characteristics which increase the risk of becoming a victim of abuse include functional
dependence / disability, poor physical health, cognitive impairment, poor mental health and low income.
Individual level characteristics which increase the risk of becoming a perpetrator of abuse include mental
illness, substance abuse and dependency often financial of the abuser on the victim. At the relationship
level, the type of relationship (e.g., spouse / partner or child / parent) and marital status may be associated
with an elevated risk of abuse, but these factors vary by country and region. Community and societal level
factors linked to elder abuse may include ageism against older people and certain cultural norms (e.g.,
normalization of violence). Social support and living alone reduce the likelihood of elder abuse.
Many strategies have been tried to prevent and respond to abuse of older people, but evidence for the
effectiveness of most of these interventions is limited at present. Strategies considered most promising
include caregiver interventions, which provide services to relieve the burden of caregiving; money
management programmes for older adults vulnerable to financial exploitation; helplines and emergency
shelters; and multi-disciplinary teams, as the responses required often cut across many systems, including
criminal justice, health care, mental health care, adult’s protective services and long-term care.  
Government of India’s National Policy on Older Persons 1999, Maintenance and Welfare of Parents and
Senior Citizens Act, 2007 and National Policy for Senior Citizens 2011, provide the legal framework for
supporting the needs of seniors. The National Programme for Health Care of Elderly and Health and Wellness
Centres under the Ayushman Bharat programme provide dedicated healthcare to elderly at primary health
care settings.
(e) Addictive Disorders.  
(i) Alcoholism.
WHO estimates 3 million deaths worldwide every year result from harmful use of alcohol. This
represents 5.3% of all deaths. Beyond health consequences, the harmful use of alcohol brings
significant social and economic losses to individuals and society at large. The individuals consuming
alcohol are at risk of committing crime, violence, marital discord and loss of productivity. India is
also witnessing a considerable increase in alcohol consumption and alcohol-related problems. The
use of alcohol among adolescents and young women is also on the rise. The population groups at

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great risk are those undergoing rapid socio economic and cultural changes and they view alcohol as
a symbol of social status. The prevalence of alcohol use in India is described in Table 40.1 with use
of other drugs. Cases of Alcohol intoxication and Alcohol Dependence Syndrome are reported among
Armed forces personnel. The ill-effects of alcohol can be described as follows:
(aa) Gastrointestinal System.
O Pain Right upper quadrant of abdomen, Bloating, Nausea and vomiting
O Gastric ulcers
O Liver diseases like hepatitis and cirrhosis
(ab) Cardiovascular System.
O Hypertension  
O Stroke
O Heart failure
O Alcoholic cardiomyopathies, Cardiac arrythmias
(ac) Haematological System.
O Bone marrow hypofunction
O Persistent leukopenia  
O Thrombocytopenia
(ad) Gynaecological Effects.
O Amenorrhoea
O Dysfunctional Uterine Bleeding, Dysmenorrhoea
O Infertility, Spontaneous Abortions, Stillbirths
O Premature onset of labour
(ae) Metabolic Disorders.
O Metabolic acidosis
O Respiratory alkalosis (from withdrawal), hypokalaemia, hyponatremia etc.
O Malnutrition
(af) CNS Symptoms / Effects.
O Confusion, stupor, depression, nystagmus, dysarthria and ataxia.
O Physical dependence.
O Wernicke’s encephalopathy caused by Vit B1 deficiency, polyneuropathies.
(ag) Drug Interactions.
Alcohol interacts with hypno-sedative phenothiazines and opiates to cause respiratory depression.
(ah) Signs of Chronic Alcoholism / Alcohol Dependence.  
Some of the physical findings among heavy alcohol users include spider angiomata, palmar erythema,
gynaecomastia, parotid enlargement, hepatosplenomegaly, tachycardia, hypertension, jaundice,
periorbital oedema and melena.
(aj) Preventive Strategies in Armed Forces.
Alcohol abuse / intoxication especially while on military duty is a cognisable offence under Section 48
of Army Act, 1950. The expected role of mil society in tackling alcohol abuse needs better perception
at the level of PRIMARY PREVENTION by not allowing an occasional social drinker from growing into
chronic alcoholic. The following measures are useful to tackle the growing menace of alcoholism in

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the service.
O Health education by MOs / RMOs / Cdrs in the form of lectures, talks or group discussions.
O Discourage hoarding of liquor by individuals in their barracks through frequent surprise
checks by Cdrs.
O Avoid use of liquor as remuneration or token of appreciation to ORs for good work. This
is especially relevant in trades such as bandmen, washermen. mess waiters, cooks, sahayaks
and drivers.
O Teetotalers can be regularly rewarded or appreciated during monthly Sainik Sammelan to
encourage sobriety among soldiers.
O Never let go an alcohol-related offence unpunished even if it was his first offence.
O Psychiatric referrals should never be used as a substitute for institution of discipline.
O Close monitoring and psychotherapy for chronic alcoholic dependence syndrome especially
when they are on withdrawal.
(ak) Preventive Strategies at National Level.
O Legislation.
The efforts of legislation to promote positive health are relevant to the prevention of alcohol
related problems. As a part of these efforts to reduce supply and demand, The Narcotic Drugs
and Psychotropic Substance Act, 1985 was enacted by the Govt of India. This Act also provides
provisions for treatment and social integration of dependents and addicts.
O Regulating Sale.
The other policy issue involves sale and use of alcohol at public places. Putting heavy excise
duty on alcohol also helps, to some extent, restricting its consumption.
O Education.
Principal means of preventing alcohol abuse is appropriate information and knowledge regarding
ill effects at school level and college level and has a good effect.
O Information.
Extensive IEC activities involving different types of media including print and electronic media
have been found to be effective.
O Training Programme.
Behaviour change theory has important implications for developing training programmes for
prevention strategies at the level of the individual. Abstinence or awareness of the problem is
the first step in this change process. The practicing physicians and other health professionals
should understand their role in the prevention of alcohol abuse problems through patient
education, risk identification and prescription practices.
O Role of Family and Community.
Families can have powerful influence on shaping the attitudes, values and behaviour. Social
recreational activities, congenial home atmosphere, religious involvement and meditation with
family members can help in getting rid of alcohol abuse problems. Influence of peer groups
can be even stronger in bringing about the change in behaviour.
O Self-help Groups.
These groups are normally organized by lay citizens and NGOs. They are effective in reducing
the chronicity (e.g. Alcoholics Anonymous), educating the community about the nature of alcohol
related disorders and playing an advocacy role.

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O Culture and Religious influence.

These are among the principal determinants of human behaviour. Knowledge of these can be
utilized by health workers in their efforts to reduce health damaging modes of life.
(ii) Drug Abuse.
(aa) Introduction.
The rise in OTC (Over the Counter) availability of drugs like tranquilizers and designer drugs in
the urban population have given rise to the phenomenon of Polydrug Abuse.  
(ab) Definitions.
The word ‘Drug’ is defined as ‘any substance that, when taken into the living organism, may
modify one or more of its functions.’
‘Drug Abuse’ is defined as self-administration of a drug for non-medical reasons, in quantities
and frequencies which may impair an individual’s ability to function effectively and which may
result in social, emotional or physical harm’.
‘Drug Dependence’ is described as a psychic and sometimes also physical state, resulting
from an interaction between a living organism and a drug, characterized by behavioural and
other responses that always include a compulsion to take the drug on a continuous or periodic
basis in order to experience the psychic effects and sometimes to avoid the discomfort of its’
absence.
(c) Drug User Profile in India.
As per the National Survey on Extent and Pattern of Substance Use in India conducted by the
Ministry through NDDTC, AIIMS during 2018, prevalence (%) and estimated number of adults
and children who are currently users of various psychoactive substances is mentioned in table
40.1.
Table 40.1 : Prevalence and Estimated Numbers of Alcohol and Drug Users in India
Children and Adolescents Adults
(10-17 years) (18-75 years)
Substance
Prevalence Estimated No. of Prevalence Estimated No. of
(%) Users (%) Users
Alcohol 1.30 30,00,000 17.10 15,10,00,000
Cannabis 0.90 20,00,000 3.30 2,90,00,000
Opioids 1.80 40,00,000 2.10 1,90,00,000
Sedatives 0.58 20,00,000 1.21 1,10,00,000
Inhalants 1.17 30,00,000 0.58 60,00,000
Cocaine 0.06 2,00,000 0.11 10,00,000
Amphetamine Type
0.18 4,00,000 0.18 20,00,000
Stimulants (ATS)
Hallucinogens 0.07 2,00,000 0.13 20,00,000
Injectable drug use is associated with increased risk of HIV and other parenterally transmitted
infections. The demographic profile of drug and alcohol users and high-risk behaviour are an
emerging public health challenge in India.
(ad) Symptoms of Drug Addiction.
O Loss of interest in daily routine.
O Loss of appetite and body weight.

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O Unsteady gait, tremors.

O Redness and puffiness of eyes.
O Unclear vision.
O Slurring of speech.
O Fresh, numerous injection marks on body and blood stains on clothes.
O Nausea, vomiting and body pain.
O Drowsiness or sleeplessness, lethargy and passivity.
O Acute anxiety, depression, profuse sweating.
O Changing moods and temper tantrums.
O De-personalisation and emotional detachment.
O Impaired memory and concentration.
(ae) Management in Armed Forces.
The management of armed forces personnel suffering from alcohol or substance abuse is
described in chapter XXII.  
(af) Preventive Actions.
O Stringent enforcement of Anti-Narcotic Laws for reduction in drug supplies.
O Treatment and rehabilitation of addicts.
O Involvement of community, youth and society in fight against drug abuse.
O The activities comprise of: Community based action for identification, motivation,
counselling, treatment and after care; Generation of awareness about the consequences
of drug abuse; Training of service providers; Involvement of NGOs in implementation of
the programme.
(ag) National Action Plan for Drug Demand Reduction (NAPDDR).
The Ministry of Social Justice and Empowerment is implementing National Action Plan for Drug
Demand Reduction (NAPDDR). Under the NAPDDR, Nasha Mukt Bharat Abhiyaan (NMBA) was
launched on 15.08.2020 in 272 vulnerable districts identified based on the findings of the first
Comprehensive National Survey and inputs from the Narcotics Control Bureau (NCB). The aim
of NMBA is to create awareness about ill effects of substance abuse among the youth, with
special focus on higher education institutes, university campuses, schools and reaching out into
the community and garnering community involvement and ownership of the Abhiyaan. During
the month of August 2022, 100 districts have been added under NMBA. Now, the NMBA is
being implemented in 372 districts.
The interventions under NMBA are:
O As part of the Abhiyaan, special emphasis is laid on the participation of stakeholders
such as women, children, educational institutions, civil society organizations etc. who may be
directly or indirectly affected by substance use.
O More than 8,000 Master Volunteers have been selected and trained to lead the Abhiyaan
activities in the 372 identified districts.  
O Active participation of youth is being encouraged in the activities of the Abhiyaan and
spreading the message against substance use.  
O Role of women has been identified as vital in reaching out to a larger community through
the Anganwadi and ASHA Workers, ANMs, Mahila Mandals and Women SHGs.
O Effective use of social media to spread the message of the Abhiyaan online by creating
handles on Facebook, Twitter and Instagram and sharing daily updates on them.

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 IMPORTANT MEDICOSOCIAL PROBLEMS AND POPULATION CONTROL

O An Android based mobile Application has been developed to capture the data of activities
happening on ground on a real-time basis by the districts and master volunteers. This App has
been placed on the Google Play Store.
O NMBA website has been launched which provides real-time information about field
activities through dashboards and various resources to understand the issue of substance use.

40.3 Population and Population Control.

Population change is an important source of other changes in society. The study of population is so significant that it
occupies a special subfield within sociology called demography. Demography experts continue to be concerned about
overpopulation, as they feel it is directly responsible for the hunger and malnutrition that plague hundreds of millions
of people in poor nations. The available resources must be shared among larger number of people. Population growth
strains the healthcare delivery services thereby affecting quality of care.
India was the first country in the world to have launched a National Programme for Family Planning in 1952. Over the
decades, the programme has undergone transformation in terms of policy and actual programme implementation and
currently being repositioned to not only achieve population stabilization goals but also promote reproductive health
and reduce maternal, infant and child mortality and morbidity.
Factors influencing population growth can be grouped into following 3 categories−
(A) Unmet Need of Family Planning.
This includes the currently married women, who wish to stop childbearing or wait for next two or more years for
the next childbirth, but not using any contraceptive method. Total unmet need of Family Planning is 9.4 (NFHS-V)
in our country.
(B) Age at Marriage and First Childbirth.
In India 23.3% (as per NFHS-V) of the girls get married below the age of 18 years and out of the total deliveries
6.8% are among teenagers i.e. 15-19 years. The situation regarding age of girls at marriage is more alarming
in few states like, Bihar (40.8%), Rajasthan (25.4.%), Jharkhand (32.2%), UP (15.8%) and MP (23.1%). Delaying
the age at marriage and first childbirth could reduce the impact of Population Momentum on population growth.
(C) Spacing between Births.
Healthy spacing of 3 years improves the chances of survival of infants and also helps in reducing the impact of
population momentum on population growth. SRS 2019 data shows that in India, spacing between two childbirths
is less than the recommended period of 3 years in 49.1% of births.
(D) Total Fertility Rate (TFR).
Total Fertility Rate (TFR) in the country has recorded a steady decline to the current levels of 2.0 (SRS 2020)
from 2.9 in 2005. Various strategies under family planning programme in India, contraceptive services at various  
levels of public health facilities are given in table 40.2 and 40.3.
Table 40.2 : Strategies Under Family Planning Programme in India
Policy Level Service Level
Target free approach More emphasis on spacing methods
Voluntary adoption of Family Planning Methods Assuring Quality of services
Based on felt need of the community Expanding Contraceptive choices
Children by choice and not chance Expanding Contraceptive choices

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Table 40.3 : Contraceptive Services Provided at Various Levels of Public Health Sector Facilities
Family Planning Method Service Provider Service Location
SPACING METHODS
IUCD 380 A, IUCD 375 Trained and certified ANMs, LHVs, Sub centre and higher levels
SNs and doctors
Injectable Contraceptive MPA Trained ANMs, SNs and doctors Sub centre and higher levels
(Antara Programme)
Oral Contraceptive Pills (OCPs) Trained ASHAs, ANMs, LHVs, SNs Village level Sub centre and higher
and doctors levels
Condoms (Nirodh) Trained ASHAs, ANMs, LHVs, SNs Village level Sub centre and higher
and doctors levels

EMERGENCY CONTRACEPTION
Emergency Contraceptive Pills Trained ASHAs, ANMs, LHVs, SNs Village level Sub centre and higher
(ECPs) and doctors levels
LIMITING METHODS
Minilap Trained and certified MBBS doctors PHC and higher levels
and Specialist Doctors
Laparoscopic Sterilization Trained and certified MBBS doctors Usually CHC and higher levels
and Specialist Doctors
NSV: No Scalpel Vasectomy Trained and certified MBBS doctors PHC and higher levels
and Specialist Doctors

40.4 Mission Parivar Vikas.

It was initially for 146 high priority districts in the 7 high focus states (Bihar, Uttar Pradesh, Assam, Chhattisgarh,
Madhya Pradesh, Rajasthan and Jharkhand) and later scaled up in all districts of the seven high focus states as
well as six north-eastern states of the country with an aim to ensure availability of contraceptive products to the
clients at all the levels of health systems. It provides more choices through newly introduced contraceptives: Injectable
Contraceptive MPA (Antara Programme) and Centchroman. Emphasis is on spacing methods like IUCD, revitalizing
Postpartum Family Planning including Post Partum IUCD Insertion (PPIUCD) to capitalise on the opportunity provided
by increased institutional deliveries. Appointment of counsellors at high institutional delivery facilities is a key activity.
Strengthening of community based distribution of contraceptives by involving ASHAs and focussed IEC / BCC efforts for
enhancing demand and creating awareness on family planning is one of the strategy. Under the programme availability
of Fixed Day Static Services at all facilities is to be ensured. Emphasis is on minilap tubectomy services because of
its logistical simplicity and requirement of only MBBS doctors. A rational human resource development plan for IUCD,
Minilap and Non Scalpel Vasectomy (NSV) be chalked up to empower the facilities (District Hospital, Community Health
Centre, Primary Health Centre, Sub Health Centre) with at least one provider each for every service and Sub Centres
with ANMs trained in IUD insertion.
Ensuring quality care in family planning services by establishing Quality Assurance Committees at state and district
levels plan for accreditation of more private / NGO facilities to increase the provider base for family planning services
under Public Private Partnerships (PPP).
Increasing male participation and promoting NSV demand generation activities in the form of display of posters,
billboards and other audio and video materials in the various facilities be planned and budgeted. Strong political will
and advocacy at the highest level, especially in states with high fertility rates.

40.5 Population Control and Family Planning in Armed Forces.

Family limitation is the greatest need at present from the national, community, family and individual point of view.

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 IMPORTANT MEDICOSOCIAL PROBLEMS AND POPULATION CONTROL

For Armed forces personnel family planning and limitation of progeny is of vital importance because of the peculiar
nature of their service requirements, condition and commitments. At least for half of their career, with the exception
of extremely few categories, they have to remain away from their families and entrust their wives with all the burden
of bringing up, education and looking after the illness and other problems of children. This entails an extraordinary
strain on wives besides the maintenance of a double establishment. If the serving person has to give his best to the
service, he should remain free from the worries of his family while away from them (or living with them). It is therefore
necessary that the size of the family should be small and manageable and within his means. All ranks should, therefore,
be educated in rational beliefs and practices of planning and limitation of families. It is the responsibility of the RMO
as well as the regimental officers to help the personnel in acquiring the knowledge and means to practice limitation
and planning of the family. In the Armed Forces, Family Planning services are provided through “Family Welfare Centres”
which are organized on a station basis in all large, medium and small stations.  

40.6 Medico-Social Problems in Armed Forces.

What took mankind centuries to experience is experienced by a soldier in a single lifetime, either in combat or preparing
for combat. Due to the nature of their deployment, soldiers have exposure to both physical as well as psychological
stress and strain. Medico social issues like mental health issues, alcohol dependence, drug abuse, are not uncommon.
Suicide and fratricides are not unheard of. These may result from prolonged duration of stay away from family, stress
and strain of military service and exposure to extremes of weather, terrain, violence associated with combat, social
deprivation and low quality of amenities and recreational facilities.  
Some of the measures adopted to mitigate the effects of non-modifiable factors responsible for medico-social issues
in armed forces are as follows:   
(A) Welfare measures.
The welfare measures include annual leaves, rotation of peace and field postings, buddy system, facilities of
psychological counsellor, station welfare parades, “Sainik Samellans” and “Darbars”, provisions of health care
facilities to families residing in hometowns. Family / wives welfare associations are available in all the three
services to look after the welfare of families residing away from the soldier.
(B) Coercive measures.
Rationing of liquor, prohibition of tobacco and drugs, screening for use of narcotics and if found positive for
such abuse are put under psychiatric treatment and follow up. Soldiers with mental health disorders, alcohol or
other substance abuse disorders are put on psychiatric treatment and observed in low medical category. If the
condition does not improve in 96 weeks, they can be medically boarded out.   

Suggested Reading.
1. Violence against Women [Internet]. World Health Organization. 2021 [accessed 2024 Feb 25]. Available from:
https://www.who.int/news-room/fact-sheets/detail/violence-against-women
2. NHSRC. Training Manual on Family Planning and Reproductive Health Care Services for Community Health Officer
at Ayushman Bharat -Health and Wellness Centres [Internet]. 2021 [accessed 2024 Feb 25]. Available from: https://
nhsrcindia.org/sites/default/files/2021-12/Family%20Planning%20and%20Reproductive%20Health%20Care%20
Services%20Training%20Manual%20for%20CHO%20at%20AB-HWC.pdf
3. GoI. Population Control [Internet]. pib.gov.in. 2019 [accessed 2024 Feb 25]. Available from: https://pib.gov.in/
PressReleasePage.aspx?PRID=1593004
4. National Health Mission, Analytical Paper Series - Impact of the Mission Parivar Vikas Programme: Evidence from
National Family Health Surveys [Internet]. UNFPA India. 2016 [accessed 2024 Feb 25]. Available from: https://india.
unfpa.org/en/publications/analytical-paper-series-impact-mission-parivar-vikas-programme-evidence-national-family
5. Ministry of social justice and empowerment government of India. Department of Social Justice and Empowerment;
Government of India [Internet]. socialjustice.gov.in. 1999 [accessed 2024 25]. Available from:https://socialjustice.gov.
in/writereaddata/UploadFile/National%20Policy%20for%20Older%20Persons%20Year%201999.pdf
6. National Health mission, mohfw.gov.in. 2016[accessed 2024 Feb 25]. Available from: https://main.mohfw.
gov.in/sites/default/files/Detailed%20Breif%20of%20NPHCE.pdf?utm_medium=emailandutm_source=transaction#:~
:text=National%20Programme%20for%20Health%20Care%20of%20the%20Elderly%20(NPHCE)%3Aandtext=The%20

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 MISCELLANEOUS ASPECTS OF HEALTH & PREVENTIVE MEDICINE

programme%20is%20State%20oriented
7. World Bank. Poverty Overview [Internet]. World Bank. 2023 [accessed 2024 Feb 25]. Available from: https://
www.worldbank.org/en/topic/poverty/overview#:~:text=The%20World%20Bank%20Group%20is
8. Health Promotion Glossary W. Health Promotion [Internet]. 1998 Jun [accessed 2024 Feb 25]. Available from:
https://iris.who.int/bitstream/handle/10665/64546/WHO_HPR_HEP_98.1.pdf?sequence=1
9. M of W and CD, GoI, Executive summary – report on the status of women in India [Internet]. wcd.nic.in. 2015
[accessed 2024 Feb 25]. Available from: https://wcd.nic.in/sites/default/files/Executive%20Summary_HLC_0.pdf
10. Grief SN, Miller JP. Infectious Disease Issues in Underserved Populations. Primary Care: Clinics in Office Practice.
2017 Mar;44(1):67–85.
11. Bhatt S. Social care of children in India. www.academiaedu [Internet]. [accessed 2024 Feb 25]; Available from:
https://www.academia.edu/4401599/Social_care_of_children_in_India
12. M of W and CD, GoI, National Policy for Women 2016 Articulating a Vision for Empowerment of Women [Internet].
wcd.nic.in. 2016 [accessed 2024 Feb 25]. Available from: https://wcd.nic.in/sites/default/files/draft%20national%20
policy%20for%20women%202016_0.pdf
13. NMBA Composition | Nasha Mukt Bharat Abhiyaan (dosje.gov.in). www.india.gov.in/spotlight/nasha-mukt-bharat-
abhiyaan
n

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 DISASTER MANAGEMENT

Chapter
XXXXI
DISASTER MANAGEMENT

41.1 Introduction.
Disasters have existed ever since the beginning of the mankind and no community is immune to the adversities
caused by natural and manmade disasters. Worldwide natural disasters are a major concern in terms of mortality,
number of people affected and economic loss. There is no evidence to suggest that frequency of natural disasters
will reduce significantly in the immediate future. Natural disasters have tended to be more destructive in the last
few decades due to larger concentration of population, increased urbanization and settlements in disaster prone
areas.
The number of disaster occurrences indicate the Asian continent as the most disaster-prone, as 60% of the major
natural disasters reported globally were from this region. India is amongst the most disaster-prone countries in
the world due to its high vulnerability to natural disasters like floods, earthquakes, cyclones and droughts. In India
due to floods, 75 lakh hectares of land is affected annually, 1,600 lives are lost and the damage caused to crops,
houses and public utilities is ₹ 1,805 crores. As per the current seismic zone map of the country, over 59 per
cent of India’s land area is under threat of moderate to severe seismic hazard. In fact, the entire Himalayan belt
is considered prone to great earthquakes of magnitude exceeding 8.0. India is one of the worst cyclone affected
regions in the world. Close to 5,700 km, out of the 7,516 km long coastline is prone to cyclones and tsunamis.
Besides natural disasters, humans are also vulnerable to manmade disasters.
The Third UN World Conference in Sendai, Japan, adopted a disaster management framework on 18 March 2015
called Sendai Framework for Disaster Risk Reduction: 2015-2030. It is the successor instrument to the Hyogo
Framework for Action (HFA) 2005-2015: Building the Resilience of Nations and Communities to Disasters.
Based on these UN disaster risk frameworks, India formulated its own Disaster Management Act, 2005 with a
National Disaster Management Authority (NDMA) headed by the Prime Minister. This National Disaster Management
Plan (NDMP) provides a framework and direction to the government agencies for all phases of the disaster
management cycle.

41.2 Definition of Disaster.

The concept and definition of disasters have undergone suitable alterations over time in accordance with changing
concepts concerning their cause and effect. The definition of disasters has reflected this change, with increasing
attention being given to the social aspects of disaster situations and the collective ability to meet the requirements
arising out of these situations. Disasters have been defined in various ways based on the degree of the physical impact
of the event, magnitude, disruption of public safety, disproportion of resources and in terms of special efforts required
and controllability of events.
As per the Disaster Management Act 2005, Disaster is defined as “A catastrophe, mishap, calamity or grave occurrence
in any area, arising from natural or manmade causes or by accident or negligence which results in substantial loss of
life or human suffering or damage to and destruction of, property or damage to or degradation of, environment and is
of such a nature or magnitude as to be beyond the coping capacity of the community of the affected area.”
The United Nations Office for Disaster Risk Reduction (2009) defines disaster as:
“A serious disruption of the functioning of a community or a society involving widespread human, material, economic
or environmental losses and impacts, which exceeds the ability of the affected community or society to cope using
its own resources”.
Pan American Health Organization (PAHO) describes disaster as an ‘overwhelming ecological disruption occurring on a
scale sufficient to require outside assistance’.

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41.3 Classification of Disaster.

Disasters have been classified in various ways, but the most convenient method used is the division of disasters into
two distinct categories according to the nature of their causes, i.e., natural and manmade.
(a) Natural Disasters.
(i) Meteorological Disasters such as storms, cyclones, hailstorms, hurricanes, tornadoes, typhoons,
snowstorms, cold spells, heat waves and droughts.
(ii) Topological Disasters like earthquakes, avalanches, landslides and floods.
(iii) Biological Disasters such as epidemics of communicable diseases and insect swarms (e.g. locust
swarms)
(b) Manmade Disasters.
(i) Accidents.
Transportation accidents (land, air and sea), collapse of buildings, dams and other structures, mine disasters
and technological failures such as mishap at a nuclear power station or leaks at a chemical plant cause
atmospheric pollution.
(ii) Civil disturbances like riots and demonstrations.
(iii) Warfare.
Conventional warfare (Bombardment, blockage or siege), non-conventional warfare (Nuclear, Biological and
Chemical warfare, guerrilla warfare, including terrorism).
(iv) Refugees.
Forced movement of a large number of people, usually across frontiers.

41.4 Hospital Disaster.

Internal Disaster and External Disaster
(a) Internal Disaster.
The incidents that occur within the health care facility or system. Employees, physical plant, workflow and
operations of the clinic, hospital or system can be disrupted.
(b) External Disaster.
These are the incidents that occur outside of the health care facility or system.

41.5 Disaster Management in India.

In India the Central Government and State Government share the responsibility for disaster management. The primary
responsibility for disaster planning, preparedness, rescue and relief is of the State Government. The States are supported
by Central Government by providing informational, financial, technical, material and training support. In the State
Government plans, the district, which represents the basic administrative unit, is the focal point of disaster management.
The Armed Forces are the key resource and response organization for relief and rescue. The Armed forces Medical
Services are a critical element in the emergency response. In order to be effective and efficient during disasters, event
pre-planning and coordination with various government organizations and health care institutions in the region would be
necessary. Therefore, during the preparedness phase, the role, responsibilities and coordination of health care become
very essential at all levels from formation HQs to the Medical Establishments and up to the RMO level.

41.6 The Disaster Management Act of 2005 (DMA 2005).

This an act passed by the Government of India for the efficient management of disasters and other matters connected
to it on 23rd Dec 2005. It came into effect on 07th Aug 2007; contains 11 chapters and 79 sections.
(a) Objectives.
(i) To establish an efficient disaster management system for the country in the event of both natural

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and man-made calamities.

(ii) A legislation empowers the central government to declare all or a portion of the nation as being
impacted by a disaster and to develop preparations for mitigating the disaster’s “risks, consequences and
effects”.
(iii) This Act also gives the federal government and state governments the authority to create various
authorities at respective levels to seek out such management in the event of a disaster in order to achieve
this goal.
(iv) It covers other things like capacity-building, relief measures and mitigation methods.
(b) National Disaster Management Authority (NDMA).
The National Disaster Management Authority is headed by the Prime Minister of India as the Chairperson and
has not more than nine members including a Vice-Chairperson. All the members have tenure of five years. The
main responsibility of the NDMA is to lay down the policies, plans and guidelines for disaster management to
ensure an effective response in the event of any disaster. In India, NDMA is the apex statutory body for disaster
management. It was formally constituted on 27th September 2006, in accordance with the Disaster Management
Act, 2005 with the Prime Minister as its Chairperson. Indian Defence Forces, under the aegis of Headquarters
Integrated Defence Staff (HQ IDS), have been carrying out Humanitarian Assistance and Disaster Relief (HADR)
operations within the country as well as outside the country. The defence forces can deliver during various HADR
contingencies because of their expertise in damage assessment, evacuation, setting up of relief infrastructure,
restoring communication and providing medical facilities, distributing ration supplies, clothing etc.
(c) National Executive Committee.
The DMA empowers the Central Government to create a National Executive Committee (NEC) to assist the National
Disaster Management Authority. The NEC consists of secretary level officers of the government in the home,
health, power, defence, finance and agricultural ministries. NEC is responsible for the preparation of the National
Disaster Management Plan for the whole country and to ensure that it is “reviewed and updated annually”.
(d) State Disaster Management Authority.
The State Disaster Management Authority (SDMA) is responsible for drawing the disaster plan and policies for
state. It consists of the Chief Minister who is the chairperson and 8 members appointed by the Chief Minister.
The SDMA is mandated under section 28 to ensure that all the departments of the state prepare the disaster
management plans as prescribed by the national and state authorities.
(e) National Disaster Response Force (NDRF).
The National Disaster Response Force is tasked with responding to a threatening disaster or a situation similar
to it. It is led by a Director-General appointed by the Central Government. NDRF has played a major role in
rescuing people from many disaster-related events in the past, such as the Kashmir floods of 2014 and the
Kerala floods of 2018.

41.7 Role of Armed Forces in Disaster Management.

As per the National Disaster Management Policy 2009, Armed Forces form an important part of the Government’s
response capacity and are immediate responders in all serious disaster situations. On account of its vast potential
to meet any adverse challenge, speed of operational response and the resources and capabilities at their disposal,
the Armed Forces have historically played a major role in emergency support functions. These include communication,
search and rescue operations, health and medical facilities and transportation, especially in the immediate aftermath
of a disaster. Airlift, heli-lift and movement of assistance to neighbouring countries primarily fall within the expertise
and domain of the Armed Forces. The Armed Forces will participate in imparting training to trainers and DM managers,
especially in CBRN aspects, heli-insertion, high-altitude rescue, watermanship and training of paramedics. At the National
level, the Chief of the Integrated Defence Staff to the Chairman Chiefs of Staff Committee has already been included
in the NEC. Similarly, at the State and District levels, the local representatives of the Armed Forces may be included
in their executive committees to ensure closer coordination and cohesion.

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MISCELLANEOUS ASPECTS OF HEALTH & PREVENTIVE MEDICINE

Fig 41.1 : Disaster Management Framework in India

Overall Coordination
Ministry of Home Affairs
Designated
Nodal Ministries
(Disaster-Specific)
Top Level Decision Making National Disaster
Management
Authority (NDMA)
National
Cabinet Crisis
Committee Management
on Committee
Security (NCMC)
(CCS) National
Executive
Committee
(NEC)

Armed Forces National National

& Institure Disaster
State Central Armed of Disaster Response
Government Police Forces Management Force
UTs (CAPF) (NIDM) (NDRF)

Fig 41.2 : National Disaster Management Institutional Mechanism

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 DISASTER MANAGEMENT

41.8 Concept of Risk and Vulnerability.

‘Vulnerability + Hazard = Disaster’
(a) Outcome and Impact of Disaster Depends upon
(i) Nature of the hazard.
(ii) Vulnerability.
“The extent to which a community, structure, services or geographic area is likely to be damaged or disrupted
by the impact of particular hazard, on account of their nature, construction and proximity to hazardous
terrains or a disaster-prone area.”
(iii) Capacity.
“Resources, means and strengths which exist in households and communities and which enable them to
cope with, withstand, prepare for, prevent, mitigate or quickly recover from a disaster”.
(iv) Risk is a “measure of the expected losses due to a hazard event occurring in a given area over a
specific time period”.
(b) Vulnerability Factors Include.
(i) Limited physical capacity.
(ii) Limited mobility.
(iii) Reliance on important medication and / or home care.
(iv) Reliance on regular care at health facility.
(v) Weak social networks.
(vi) Poor awareness.
(vii) Lack of resources.
(viii) Lack of access to information and warnings.
(ix) Staying in places at high risk.
(c) Vulnerable Groups include
(i) Children.
(ii) Pregnant women.
(iii) People with chronic illnesses.
(iv) People who rely on home care.
(v) Elderly people.
(vi) People with physical, sensory and cognitive impairments.
(vii) Tourists
(viii) Homeless people
(ix) People from minority populations
(x) Socially isolated people

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Vulnerability Disaster Hazard

• Earthquake
Underlying causes Dynamicpressure • Floods
• Limited access to • Lack of resources Unsafe conditions • Tsunami
resources
• Population explosion • Dangerous locations • Droughts
• Illness
• Uncontrolled • Dangerous buildings • Cyclone
• Disability urbanisation
• Land slides
• Age • Environmental
degradation • WAR
• Sex
• Accidents

Fig 41.3 : Disaster Risk and Vulnerability

41.9 Disaster Process / Stages of Disaster.

Disaster situation has been conceptualized as a process with differing phases. In each phase, the information needed,
the action required, the problems encountered and the needs of survivors can be quite different. A better understanding
of the disaster process and inter relationship of these different phases are important for effective response.

Inter Disaster
Stage

Rehabilitation Pre-impact
Stage Stage

Disaster Stage

Fig 41.4 : Stages of Disaster

(a) Inter-Disaster Stage.
The inter-disaster stage is the period between two consecutive disasters during which there is a lull period. This
is the time when the community must undertake detailed planning, training and preparations to react when (and
if) disaster strikes. This is also the period when all community measures which can prevent disasters (such as
building dikes to prevent floods, building earthquake-proof houses, ensuring better safety measures in industries,
etc.) are undertaken and enforced.
(b) Pre-Impact Stage.
Pre-impact is the stage that may last for a few hours or days before the actual disaster strikes the community,

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such as initial tremors before a major earthquake or heavy rains and rising water levels in rivers before major
floods. The occurrence of a disaster, by and large, is inevitable and cannot be completely prevented at this stage
since the disaster process has already commenced. During this stage, there is great importance of establishing
efficient “warning systems,” which can detect the impending disaster and issue warnings to the susceptible
population to be prepared for the oncoming disaster.
(c) Stage of Disaster.
It is the stage when disaster strikes. This stage has the following sub-stages:
(i) Stage of Isolation.
This is the stage immediately after the has disaster struck. The affected community gets isolated from the
rest of the world, since the roads / rail / air / water routes are totally cut off, the telephonic communications
are completely paralyzed and electricity supply is totally disrupted. During the stage of isolation, no help
from outside the community can reach the people in the affected areas. After the initial impact, the affected
community members generally recover to some extent and themselves help each other within the isolated
community. The effectiveness of these measures depends on the disaster preparedness of that community
undertaken during inter-disaster and / or pre-disaster stage.
(ii) Stage of Rescue and Relief.
Gradually, help from outside the immediate affected community starts coming in; road / air communications
are opened to a limited extent, basic telecommunication services are established and most urgent assistance
(such as food, drinking water, medical care and shelters, etc.) starts coming in. The people of the affected
population are rescued and evacuated from the site of disaster to safer places by rescue and medical
teams. The major health problems at this stage generally pertain to multiple injuries / polytrauma, sudden
emotional trauma and disposal of dead bodies.
(iii) Stage of Temporary Shelters.
As road and air communications are restored, the affected population is rescued and evacuated to safer
places which often results in large scale displacement of people from their original place of residence;
temporary accommodation for the displaced population has to be provided in the form of shelters. The
health problems faced at this stage are initially (during first and second weeks) those of communicable
diseases due to contaminated water or contaminated food and those of acute respiratory infections (ARIs),
besides complications among cases of injuries suffered during the actual impact stage. In addition, psycho
emotional problems also need to be tackled among a substantial proportion of the displaced population.
Law and order issues (such as rioting, looting, mob attacks, etc. in makeshift relief camps) may also be
faced during later part of this stage.
(d) Rehabilitation.
Rehabilitation is the longest and most expensive phase of disaster management and should be accessible to
all disaster survivors. Rehabilitation includes the provision of temporary public utilities and housing as interim
measures to assist long-term recovery.

41.10 Special Characteristics of Disasters.

(a) Disasters are considered phenomena in themselves and have profiles with some special characteristics.
Understanding these basic characteristics is essential for its management.
(b) The geographic divisions of areas concerned with disaster were conceived to classify the arising problems
and to help manage them. Three major divisions are in vogue, impact area, filter area, community aid area.
(i) The Impact Area is where disaster has struck causing damage.
(ii) Filter Area is the undamaged zone surrounding the impact area from where immediate aid by
community is provided.
(iii) The Community Aid area is immediately outside the filter area from where the organized rescue and
relief flows.
(c) Analysis of various disaster situations of differing magnitude and its consequences confirm that there are

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many common patterns of human and organizational behaviour.

(i) In emergency, the psychology of disaster involves some distinct facets like victim before, during and
after disaster, of the volunteer helper, trained professionals and onlookers. Behaviour patterns and disaster
psychology must be understood in order to cope with the problem.
(ii) Convergence is observed to be a common problem in most disaster events and it has an important
bearing on disaster management. Convergence characterized by the spontaneous movement of a large
number of people, large amounts of material towards the zone of impact and communication convergence
are the common problems. Convergence cannot be completely blocked but it can be channelled.

41.11 Disaster Management.

Disaster management means a planned and systematic approach towards understanding and solving problems in the
wake of disasters. Disaster planning cannot prevent disasters, but its effects could be minimised by appropriate plans
and preparedness. Some of the general principles of disaster planning are universal and can be applied in all situations.
The foremost requirement is that it should be a continuous process, it should reduce the unknown in a problematic
situation and it should be based on valid knowledge. Other important facts are that it should evoke appropriate action,
focus on general principles and it must be tested.
The disaster plans and preparedness are necessary for every community and particularly the health care system with
its critical component, the hospitals which are to be prepared consistently to mobilize all their facilities for maximum
use. The key issues in disaster management are communication, coordination and control. Important issues in pre-
disaster management are prediction, prevention, planning and preparedness. The critical issue when a disaster event
occurs is the immediate response, rescue, relief and rehabilitation.
Disaster management requires well-coordinated public policy for disaster prevention, mitigation, preparedness,
emergency response and reconstruction. The provision of quality comprehensive health care in a disaster is one of
the critical elements.

41.12 Disaster Management Cycle.

The spectrum of disaster management involves the following:

Response Disaster

Predisaster Postdisaster

Preparedness Recovery

Mitigation,
Prevention and
risk reduction

Fig 41.5 : Disaster Management Cycle

(a) Disaster Prevention.
It includes measures aimed at preventing the occurrence of a disaster event and / or preventing such an occurrence
from having harmful effects on the communities. It is concerned with the formulations and implementation of
long-term policies and programs. Long-term laws pertaining to water harvesting, afforestation, enacting laws to
promote earthquake-proof houses, laws to ensure good safety measures for hazardous industries, legislations

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to ban hazardous industries from heavily populated areas, etc. are examples of such measures.
(b) Disaster Mitigation.
It includes measures aimed at reducing the impact of a natural or man-made disaster on a nation or community,
for example, construction of earthquake-resistant buildings and laying down of sturdy and well-protected public
water supply systems.
(c) Disaster Preparedness.
It includes measures that enable governments, organizations, communities and individuals to respond rapidly
and effectively to disasters. Preparedness measures include formulation of viable disaster plans, maintenance
of resources and regular training of personnel. Organizing, planning, coordinating, resources planning / allocation
and training are its major concerns.
(d) Disaster Response.
Response measures are those which are taken immediately prior to and following disasters. Such measures are
directed toward saving life, protecting property and dealing with the immediate damage caused by the disaster.
Their success depends heavily on good preparedness
e) Disaster Recovery.
Recovery is the process by which communities and nations are assisted in returning to their normal (pre-disaster)
level of functioning following a disaster. Disaster situation has been conceptualized as a process with differing
phases. In each different phase, the information needed, the action required, the problem encountered and
people involved may be quite different.

41.13 Health Problems Related to Disasters.

Though all disasters are unique in that, they affect areas with different social, medical and economic backgrounds,
there are still similarities between disasters, which, if recognized, can optimize the management of health relief and
the use of resources. There is a relationship between the type of disaster and its effects on health. Some effects are
potential rather than an inevitable threat e.g., population movements and other environmental changes may lead to
increased risk of disease transmission. The actual and potential health risks after a disaster do not all occur at the
same time. Instead, they tend to arise at different times and varies in importance e.g. casualties are highest when
there is overcrowding and standards of sanitation have declined. People generally recover quickly from their immediate
shock and spontaneously engage in search and rescue, transport of the injured and other relief activities.
Table 41.1 : Short-Term Effects of Disasters
High Winds Tidal Waves
Effect Earthquakes Floods
(Without Flooding) (Flash Floods)
Death Many Few Many Few
Severe injuries
requiring Overwhelming Moderate Few Few
extensive care
Increased Potential risk following all major disasters.
communicable
diseases load (Probably rising with over crowding and declining sanitary conditions)

Food scarcity Rare Rare Common Common

Population
displacements Rare Rare Common Common
and movements

41.14 Health Problems Common to All Disasters.

(a) Social Reactions.
These could be grouped as follows:

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(i) Spontaneous behavioural reaction e.g., generalized panic or stunned waiting.

(ii) Widespread looting.
(iii) Rumour regarding the spread of an epidemic.
(iv) Population displacements leading to excessive burden on relatives and friends, parks, city squares,
vacant lots and government buildings and urban areas where public services can’t cope resulting in
increased morbidity and mortality.
(b) Climatic Exposure.
The need to provide emergency shelter varies greatly with local conditions.
(i) Food and Nutrition.
Food shortages in the immediate aftermath may arise in two ways. Food stock destruction within the disaster
area may reduce the absolute amount of food available or disruption of distribution systems may curtail
access to food even if there is no absolute shortage.
(ii) Communicable Disease.
The transmission of communicable diseases after natural disasters may be influenced by the following
factors:
(aa) Pre-Existing Disease in the Population.
The risk of an epidemic after a disaster is related to the endemic levels of disease in the population.
These include diarrhoea and dysentery, cholera, measles, whooping cough, meningococcal meningitis,
tuberculosis, malaria, intestinal parasites, scabies and other skin diseases, louse borne typhus, etc.
(ab) Ecological Changes Resulting from Natural Disasters.
Natural disasters may alter the potential for disease transmission by altering the ecological conditions.
In this context, the most important diseases are those transmitted by mosquito vectors and by water.
The breakdown in living conditions following disasters may increase the hazard of transmission of
plague, louse borne typhus and relapsing fever. The incidence of dog bite and risk of rabies may
increase as neglected strays come in close contact with persons living in temporary shelters.
(ac) Population Movements.
Population movements may influence the transmission of diseases by increasing population density
causing burden on the water supply and other services in the receiving areas and / or introducing
susceptible population to a new disease or disease vector. The important diseases to occur in
temporary settlements are diarrheal disease and dysentery, viral hepatitis, measles, whooping cough,
malaria, tuberculosis, scabies and other skin infections.
(ad) Damage to Public Utilities.
Damage to water supplies and sewage disposal systems may increase water borne and excremental
diseases.
(ae) Interruption in Public Health Services.
The important services interrupted in this context are vector control programs, which might lead
to resurgence of malaria and other vector borne diseases, routine immunization programs against
measles, whooping cough, poliomyelitis, tuberculosis and diphtheria.
(af) Altered Individual Resistance to Diseases.
Protein Energy Malnutrition, which affects children in poorer population of most of the developing
countries, increases susceptibility to many communicable diseases including malaria and tuberculosis.

41.15 Prevention and Control of Communicable Diseases.

The prevention and control measures of communicable diseases should be on the following broad principles:

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(a) Setting Up a Surveillance System.

It is established to collect, collate and interpret the data. It will need the services of an epidemiologist / public
health specialist, paramedical and health personal and clerical staff.
(b) Disease Surveillance.
The objective of disease surveillance after disaster is to identify disease outbreaks, to investigate them and to
initiate appropriate disease control measures. The diseases considered for surveillance include those known to
be endemic to the area, those which represent a serious health hazard and those which are amenable to control.
A more focused, system-based surveillance system should be instituted. These symptom complexes, which might
be important, include fever, fever and diarrhoea, fever and cough, trauma, burns, measles etc. These data should
be analysed, interpreted and presented to the higher authorities.
(c) Laboratory Services.
Laboratory for basic diagnostic tests of stool and blood may be established by field reporting units but for specific
bacteriological and virological tests, the referral labs in nearby cities or areas will have to be marked.
(d) Mass Vaccination.
Mass vaccination campaigns against the following diseases will be helpful like tetanus and measles, however
mass vaccination campaign against typhoid and cholera should be avoided because they:
(i) Offer low and little individual protection.
(ii) Complete coverage of the population is probably impossible.
(iii) Require many workers who could be better employed elsewhere.
(iv) Could lead to reuse of inadequately sterilized needles that may transmit Hepatitis-B / HIV.
(v) May lead to a false sense of security about the risk of disease and to neglect effective control measures.

41.16 Public Health Aspects.

In the case of natural disasters like floods, tsunami and cyclones it is important to plan the public health activities so
that one is prepared for proper management of the disaster. The important aspects include provisioning of appropriate
shelter for displaced population, potable water supply, food and nutrition and sanitation.
(a) Shelter.
In natural disasters, the displaced population must be sheltered in temporary settlements or camps. The selection
of sites must be well planned to avoid risk factors for communicable disease transmission, such as overcrowding,
poor hygiene, inadequate water supply, insanitary disposal of excreta vector breeding sites and lack of adequate
shelter. Such conditions favour the transmission of diseases such as measles, meningitis and cholera. Critical
factors to consider when planning a site are water availability, means of transport, access to fuel and access
to fertile soil. Site planning norms is in the Table 41.2.
Table 41.2 : Site Planning Norm
Shelter space per person 3.5 m2
Distance between shelters 2 m minimum
Number of people per water point 200-250
20–50 (a ratio of 1:50 can be adopted in the beginning and should
Number of people per toilet
preferably be brought up to 1 for 20 as soon as possible.)
Distance of latrine from shelter 30 m
Distance from water supplies < 500 m
(b) Establishment of Water Point.
(i) Location of Water Distribution Point.
Water distribution points must be set up in suitable places around the camp. A good location is an elevated

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spot in the centre of a living area. If the water points are from ground sources, no sanitation facilities
should be within 50 metres and not closer than 30 meters. If the water point is too far away, people will
not collect enough water. Average use of water is at least 3 litres per person per day for drinking and 15
litres for toilet and bathing.
(ii) Designs.
Water points must be included in any risk assessment and preparedness plan. To ensure access to potable
water after the disaster and emergencies, consider these accessibility measures to ensure their safe use
by everyone:
(aa) The platform around water points should preferably use concrete base for safer mobility of
wheelchair users or older persons, avoid slippery surface and ensure good drainage. Avoid gravel,
bricks or other uneven surfaces.
(ab) Level Platforms with the Surrounding Ground.
Alternatively, construction of a ramp at least 90 cm wide and with a gradient of at least 1:10. The
nearer users can get to the water source, the easier it is to use.
(ac) Build a seat in front of the tap, at a height of 50 cm for sitting while collecting water (wood, concrete
or metal can be used for this purpose). Install a small handrail beside the seat at a height of 90 cm.
(ad) Install easy to use hand pumps for tube wells, with long handles and low resistance when
pumping. In case a tap is installed on a water tank, the tap height should be 90cm. In case of lifting
devices, using a ratchet and pawl will allow a winding and locking mechanism for the rope.
(ae) Build water points close to people’s homes / settlements for easier access.
(af) Involve community members, including women and men of different ages, with different types
of disabilities in the planning and design of the location, specifications and resources for installation
water points.
(iii) Number.
One tap per 200-250 people is the ratio recommended by the United Nations High Commissioner for Refugees
(UNHCR). The more people per tap, the more is wear and tear. Nobody should have to wait longer than a few minutes;
if collection takes a long time, people will return to old, contaminated but quicker sources. The mass distribution of
water sterilizing tablet, bleaching powder or liquid disinfectants should be adapted as per Table 41.3.
Table 41.3 : Dosage of Water Sterilizing Tablet, Bleaching Powder or Liquid Disinfectant
Protected Water known
Unprotected Wells
Clear and Tube Wells, to have Faecal
Type of Water and Source and Cloudy Water :
Piped Water Ring Wells, Contamination : Filter
Filter before Purifying
Clear Water before Purifying
Tablet Size Chlorine volume of water
in mg Per Tablet Treated in it
8.5 mg 5 5 2.5 1 .5
17 10 10 5 2 1
67 39.41 39.41 19.7 7.88 3.94
340 200 200 100 40 20
500 294 294 147 58.8 29.4
Free chlorine available chlorine
1 mg  /  litre 2 mg  /  litre 5 mg  /  litre 10 mg  /  litre
content after treatment mg / litre)
Note. The individuals in limited and controlled groups may be given such disinfectants to purify small amounts of
drinking water for one or two weeks.

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(c) Nutrition.
(i) Milk and other dairy products shall be provided for the children and lactating mothers. Every effort
shall be taken in the given circumstances to ensure sufficient quantity of food is made available to the
affected people (especially for aged people and children) staying in the relief shelters  /  camps.
(ii) Sufficient steps shall be taken to ensure hygiene at community and camp kitchens. Date of
manufacturing and date of expiry on the packaged food items shall be kept in view before distribution.
(iii) It shall be ensured that men and women are supplied food with minimum calorie of 2,400 Kcal per
day. In respect of children  /  infants, the food to be supplied would be 1,700 Kcal per day.
(iv) Sufficient quantity of water shall be provided in the relief camps for personal cleanliness and hand
wash.
(v) It may be ensured that the minimum supply of 3 liters per person, per day of drinking water is made
available in the relief camps. Further, the State  /  UT  /  District authorities shall adjust the minimum quantity
of water etc as per the geographic, demographic and social practices of the region. If other means for
providing safe drinking water is not possible at-least double chlorination of water needs to be ensured.
(vi) In order to ensure adequate water supply, the location of the source of water supply shall preferably
be within the premises of relief shelter / camp. However, the maximum distance from the relief camp to
the nearest water point shall not be more than 500 mtrs. if tapped water supply is available.
(d) Basic Sanitation.
These include the following:
(i) Making emergency latrines.
(ii) Development of solid waste collection and disposal facilities. Burying or burning solid waste is
recommended.
(iii) Health education.
(e) Vector Control.
Essential vector control measures in disaster are as follows:
(i) Elimination of breeding places by water management and not allowing stagnant pools i.e., by draining,
filling and overturning receptacles. Anti-larval insecticides may be used.
(ii) Enforcement of personal protective measures by people.
(iii) Indoors spraying with Pyrethrum Extract 2% (Mix 1 litre with 19 litres of Kerosene Oil and spray 400
households, each household with 100 Cubic / m. Indoor space).
(iv) In case of increased density of mosquitoes Outdoors fogging can be done in consultation with public
health authorities using Malathion Technical 95%, (Mix 5 L with 95 L of Diesel or Kerosene Oil). To be used
for quick knock down of vectors. windows and doors should be kept open during the fogging operation.
(vi) Control of houseflies by spray of Cyphenothrin 5% Emulsifiable Concentrate (2 ml in 10 L water to be
sprayed over 500 m2) or Propoxur 20% (Emulsifiable Concentrate 100 ml in 1 L of water and spray over
100 sq m area), should be used on dumping sites and around cooking places.
(v) Prevention against rodents by improving environmental sanitation and storing. Keeping food in closed
areas, early and safe disposal of solid wastes and use of rodenticides like zinc phosphide.
(f) Personal Hygiene.
Ensure adequate provision of washing, cleaning and bathing facilities, avoidance of overcrowding in sleeping
quarters and regular health IEC sessions to be conducted.
(g) Burial / Disposal of the Dead Bodies.
Dead Bodies are unlikely to cause outbreaks of diseases such as typhoid fever, cholera or plague, if death
resulted from trauma. However, they may transmit gastroenteritis or food poisoning syndrome to survivors if they
contaminate water sources. Despite the negligible risk, dead bodies represent a delicate social problem. The

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normal local method of burial or cremation should be used although mass cremation requires large amounts
of fuel. Before disposal, bodies must be identified and the identifications recorded. The following points should
be taken care while handling dead bodies:
(i) Removal of the dead from the disaster scene.
(ii) Shifting to the mortuary.
(iii) Identification.
(iv) Reception of bereaved relatives.
(v) The workers who handle dead bodies regularly should follow these steps:
(aa) Wear gloves and dispose of them properly after use.
(ab) Wash hands with soap after handling bodies.
(ac) Use body bags if available.
(ad) Disinfect vehicles and equipment.
(ae) Do not disinfect bodies before disposal, unless they have cholera, shigellosis or haemorrhagic
fever.
(af) Make sure the bottom of any grave is at least 1.5 meters above the water table and has a
0.7 meter unsaturated zone.

41.17 Organization of Medical Care for Disaster.

Medical care in disaster situations has two distinct facets, pre-hospital care and hospital care. The pre-hospital care
involves dispatch of the medical team, care at site and evacuation of victims to definitive care facilities. The hospital care
involves triage, emergency care and continuation of treatment, intensive care, diagnosis, treatment and rehabilitation.
The principles of mass casualty management are universal and can be applied in any mass casualty situation natural
or manmade. The importance of triage, first aid, life-saving measures, transport and evacuation for definitive care
to hospitals has been recognized world over. The mass casualty management demands standard simple therapeutic
procedures and standardised drugs & medical supplies. On site care demands the establishment of a command post
triage team, first aid team, mobile hospital (if required), evacuation team, transport and communication.
Hospitals play a crucial role in medical care of the disaster victims. All hospitals must be prepared to meet the
challenge of disasters by having an appropriate disaster organisation, pragmatic disaster plan, clearly defined roles and
responsibilities of various staffs, laid down plans for each department, accident and emergency department, critical
services like OT, ICU, Laboratory, diagnostic, blood bank and other supportive services.
41.18 Critical Elements of Preparedness and Response.
(a) Preparation and Response Depend upon Various Critical Elements.
The information of the disaster plans from State Level to District Level, roles and responsibilities of various
resource organizations, mechanism for coordination, control and practice are some of the critical issues. The
preparedness will depend upon appropriate disaster plans for regional  /  local areas based on risk, hazards and
vulnerability analysis and the resources available.
(b) The coordination at various levels of government by the appropriate Formation Headquarters and at local
level by the Medical Establishment based on the anticipated role and responsibility is critical for rational response
during disasters.
(c) Disaster preparedness and response are dependent on the State Government policies, legislation,
organisation, resource organisation, role and responsibilities of various agencies, logistic plans, coordination,
evacuation and shelter plans, training, public awareness and drills. The State Government plans become the
baseline for the matching formation Headquarters plans to provide the support expected in disasters.
(d) The Formation Headquarters plans at various levels will include all the elements of resource organisation
to meet the demand anticipated in disaster event. The role and responsibilities allotted for health care will be
used for preparedness and developing health care plans. Each medical establishment then prepares its plans

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based on the overall objectives, roles and responsibilities and resources available.
Stakeholders in the medical aspects of disaster response are as follow:
(i) Hospital Users
(ii) Hospital Management
(iii) Architects
(iv) Engineers
(v) Local Govt
(vi) National Govt
(vii) International Agencies
(viii) NGO / Volunteers

41.19 Disasters Response.

The response is the actions taken before, during or after a disaster to help the people affected. The response can
include warning people, saving people, giving people food, water, shelter, medicine, checking and reporting on health
problems, working with other groups and supporting people’s feelings and thoughts. The response can also prevent or
reduce more harm from disasters. The greatest need for emergency care occurs in the first few hours. Management
of mass casualties can be further divided into further steps:
(a) Search, Rescue and First Aid; most immediate help comes from the uninjured survivors.
(b) Field Care / Services near disaster affected area.
(i) Bed availability and surgical services should be maximised.
(ii) Provisions should be made for food and shelter.
(iii) Centre to be established to respond to inquiries from patients’ relatives and friends.
(iv) Priority should be given to victim identification.
(v) Adequate mortuary space to be provided.
(c) Triage.
(i) It consists of rapidly classifying the injured on the basis of the severity of their injuries and the
likelihood of their survival with prompt medical intervention.
(ii) Higher priority is granted to victims whose immediate or long-term prognosis can be dramatically
affected by simple intensive care.
(iii) Moribund patients who require a great deal of attention, with questionable benefit, have the lowest
priority.
(iv) It is the only approach that can provide maximum benefit to the greatest number of injured in a
major disaster situation.
(d) Tagging.
(i) All patients should be identified with tags stating their name, age, place of origin, triage category,
diagnosis and initial treatment.
(ii) Transportation for definitive care at designated hospitals.
(iii) Hospital Care in terms of immediate lifesaving and definitive care.
(iv) Long term rehabilitation

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site of Disaster / MCl

Suggested
Flow of
Patients in a On Site Triage
network Nearest Hospital small Facility / CHC
Triage

STABLE UNSTABLE

FIRST AID RESUSITATE AND STABILIZE

DISCHARGED Facilities not present Facilities available

Refer to OPD of
Networked
Hospital where
specialists are Refer for treatment DEFINITIVE
present in networked hospital TREATMENT

Fig 41.6 : Triage at Disaster Site

41.20 Training of Medical Personnel for Disasters.

Training is an essential aspect of the preparedness and it will determine the outcome of the response as well. Training
needs attention at all levels of Formation HQs, Medical units and up to the RMO level. The factors to be considered are:
(a) Creating awareness of the risk, vulnerability and hazards.
(b) Dissemination of disaster management plans.
(c) Awareness of roles and responsibilities of various functionaries.
(d) Arrangements for mobilization and its practice.
(e) Training of hospital staff in operationalizing the hospital disaster plans.

41.21 Medical Aspects of Disaster Preparedness.

(a) Preparedness is the next crucial stage where the following aspects are to be given attention by the Formation
HQs and Medical units.
(i) Development of disaster plans, which is realistic and adaptable and is harmonized at all levels. It
must be clearly written and periodically tested.
(ii) Resource plans for healthcare.
(iii) Roles and responsibility of resource organization.
(iv) Logistics, equipment and supplies required.
(v) Arrangement for communication, transportation and evacuation.
(vi) Coordination and control.
(vii) Disaster drills.
(b) Arrangements for On-site Medical Help include the following:
(i) Alerting and dispatch of a mobile help team.

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(ii) Staff, equipment, transport and communication arrangements for onsite coordination for rescue and
relief.
(iii) Triage, First Aid and Evacuation Team.
(c) Hospital Disaster Plans.
No plan can be made to fit every emergency, but a general schedule of enunciated activities will prove to be
extremely useful if executed in a coordinated and disciplined fashion. Disaster preparedness includes the following
aspects:
(i) Alert, recall, deployment system.
(i) Triage, First aid and Emergency Care arrangements.
(ii) Critical area response like OT, ICU etc.
(iii) Support services like blood bank, radio diagnosis, pharmacy, CSSD etc.
(iv) Expansion and creation of facilities for disaster victims.
(v) Sustaining the plan and matching resource allocation.
(vi) Mock Disaster drills.

41.22 Organisation and Operations.

The disaster management services of the hospital should have elements of quick medical response, effective pre-
hospital care and efficient definite hospital care. The plan must be comprehensive and holistic. It should incorporate
Standing Operating Procedures (SOPs) for the management of internal and external disasters. It should include pre-
hospital and hospital components. It should incorporate the following:
(a) Hospital Emergency Incident Command System (HEICS).
The composition of HEICS should as given in Fig 41.7. The tools for HEICS are:
(i) Organisation charts.
(ii) Job Action sheets.
(iii) Hazard Vulnerability Analysis (HVA) for the hospital / health facility.
(iv) Hospital Incident Response System
(v) Individual Roles and Responsibilities
(vi) Hospital Capacity and Capability Analysis
(vii) Hospital-Community Coordination
(viii) Hospital Command Centre

Incident Commander

Safety Officer Security Officer

Public Information Liaison Officer

Officer

Logistics Chief Planning Chief Finance Chief Operations Chief

Fig 41.7 : Hospital Emergency Incident Command System (Organogram)

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MISCELLANEOUS ASPECTS OF HEALTH & PREVENTIVE MEDICINE

(b) Disaster Management Committee.

(i) Components of Disaster Management Committee is as given in Fig 41.8.

Fig 41.8 : Components of Disaster Management Committee

(ii) Functions.
(aa) Alert Actuation.
Intimation regarding the disaster may be received by the MO I / C MI Room / DMO / Brig IC Adm &
OC Tps / Sr Registrar & OC Tps / Adm Officer / Commandant / Commanding Officer or anyone else. The
information should immediately be conveyed to the Commandant / Commanding Officer. Depending
on time availability Commandant / Commanding Officer may instruct the Brig IC Adm & OC Tps / Sr
Registrar & OC Tps / Adm Officer to activate the Plan or he / she may hold an emergency meeting
with the Disaster Management Committee.
(ab) Pre-Hospital Care.
It should have the characteristics of effectiveness and efficiency and it can be represented by the
acronym “TRAUMA”, which stands for the following:
T - Tailored to the requirement
R - Response coordinated
A - Active including medical management of casualties
U - Urgent reactions
M - Methodical approach
A - Authority, roles and responsibilities well defined
The essential details which can be sought may be represented by the acronym “METHANE” are as
follows:
M - My call sign
E - Exact location (grid reference)
T - Type of incident
H - Hazards both present and potential
A - Access and egress routes at disaster site
N - Number and severity of casualties
E - Emergency services present or not
(ac) Control Centre.
A control centre must be established to coordinate and monitor the various activities. Brig IC Adm &
OC Tps / Sr Registrar & OC Tps / Adm Officer should be operationally functional from this centre.

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(ad) Reception Centre.

This centre receives casualties. Traffic, vehicular as well as human access, to the centre must be
effectively directed and controlled. The centre should be managed by DMO / MO I / C MI Room.
Stretcher squads, stretchers and trolleys should be readily available.
(ae) Disposal of Dead Bodies.
Brought in dead and those who die while on medical management should be sent to morgue. Details
of dead bodies with correct identification mark, sex, physical characteristics and preferable with
photographs should be maintained. Dead bodies should be handed over to the NOK after completion
of medico-legal formalities.
(af) Collection of Valuables.
All belongings of the patients including valuables should be collected and deposited with the Assistant
Registrar / Chief Ward Master. A proper accounting of the same should be done. Arms and ammunition
should be deposited in Kote and proper records maintained.
(ag) Additional Bed Space.
Disaster casualties may require additional beds. The crisis expansion beds should be utilized. If
required the convalescing patients, elective surgery patients and patients who can have domiciliary
care / daycare / OPD management should be discharged.
(ah) Emergency Blood Bank.
Blood of all groups should be stocked to meet emergency requirements. A list of potential blood donors
should be available and they should be requested to report to the hospital as and when required.
(aj) Staff.
O Medical Staff.
In addition to members of clinical staff, para and preclinical disciplines should render assistance
in managing the casualties. The duty roster for standby staff should be available in the DMO
room.
O Nursing Staff.
A list of nursing staff who may be made available at short notice to render nursing assistance
should be available in the DMO Room, the Principal Matron (PM) should regularly update this
list.
O Other Staff.
Duty roster including those on standby duty of other hospital services like radiology, laboratory,
housekeeping / sanitation service should be available with the DMO.
(ak) Hospital Security.
Security of admitted patients, their belongings, hospital staff and equipment are essential. It should
receive attention during planning execution of the disaster plan.
(al) Dietary Services.
The dietary services should be capable of handling additional loads during a disaster situation.
Acquisition of raw materials and supply of appropriate meals for staff patients should be planned.
(am) Transport Services.
Intramural and extramural transport services should be predetermined and coordinated for disaster
situations.
(an) Information Services.
An officer should be designated to issue details of casualties to the media etc. He / She should obtain
prior clearance from competent authorities before issuing information.

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(ao) Engineering and Maintenance Services.

These services should ensure an uninterrupted supply of water and electricity during the management
of disasters. Standby generators should be inspected and maintained in operationally serviceable
condition.
41.23 Action By MOs / RMOs.
In general, the RMOs  /  MOs should ensure that they have an adequate amount of the following items to deal with
such situations. Medical Administrative Officers at higher level should ensure adequate replenishment of these items,
as well as the evacuation of casualties, specialized treatment and coordination of resources within the same and
neighbouring formations deployed for relief operations:
(a) Arrest of bleeding and management of wounds, including dressing material, antiseptics, suturing material
and so on.
(b) Intravenous fluids.
(c) Resuscitation equipment, including equipment for maintenance of the airway.
(d) Splints
(e) Spraying equipment and insecticides for mosquito and fly control.
(f) Water purification and testing equipment and chemicals, i.e. Horrocks apparatus ,Chloroscope, bleaching
powder. Disinfectants like sodium hypochlorite, cresol etc.
(g) Vaccines and sera, especially TT / Td, Typhoid and other specialized vaccines / sera as the situation demands.
(h) Drugs for first aid, management / chemoprophylaxis of common illnesses, injuries, diarrhoeal diseases,
malaria, URTI, skin diseases, meningococcal diseases, adjustment problems and so on.
(j) Ambulance vehicle.
(k) Forms for referrals, requests for air evacuation and so on.
(l) Methods for establishing communication with other functionaries.

41.24 Hospital Emergency Plan.

The disaster management plan of Armed Forces Medical Services (AFMS) Hospitals is divided into three main phases,
namely Pre-disaster, Disaster & Post-Disaster phase.
(a) Pre-Disaster Phase (Phase of Planning).
(i) Hospital Disaster Management Committee.
The following officers of the Hospital will form the ‘Disaster Management Committee’ under the Chairperson.
It would comprise of the following members (depending upon posted strength) as given is Table 41.4.
(ii) The Committee can co-opt any other functionary of the hospital depending upon the situation and the
type of disaster. It would also form sub-committee / s to assist it as and when necessary. The Committee
will meet at least once in 3 months to review the working of contingency plan, problem faced in recent
disaster and amendment / modification to be adopted in future. The Committee will be responsible for
overall management of the disaster situation, take administrative decisions as and when required, review
the disaster plan and to inform the adm auth on the situation.
(iii) Job Cards.
Action sheets or job cards as mentioned at Appendix ‘A’ are basis of a successful disaster / emergency
management plan. The job cards should be detailed, stored safely, colour coded and laminated. Delineation
of jobs according to job cards placed will be done.
(iv) Control Room.
The office of the Brig IC Adm & Cdr Tps  /  Sr Registrar OC & Tps will act as the control room. It will be
ensured that the control room has all the contact numbers of the hospital staff which is mentioned in the
incident command. The control room will also have contact numbers of District Medical Authorities, District

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Administration, Police, Fire Services, nearby hospitals, Private Physicians, Blood Banks, NGOs etc. which
can be contacted if external help is needed.
Table 41.4 : Composition of Disaster Management Committee
S. No. Designation Responsibility
1. Chairman Commandant
2. Coordinator Brig IC Adm & Cdr Tps /Sr Registrar OC & Tps
OIC Disaster Plan : In Surgical Disaster - Surgery Dept
3.
In Medical Disaster – Int Medicine Dept
4. OIC Operating Dept Anaesthesia Dept
5. OIC Radiological services Radiodiagnosis Dept
6. OIC Nursing Services Principal Matron
OIC Lab &Mortuary Pathology Dept
7.
Services
8. Other Members OIC Stats
Sr Adv (Hosp Adm)
MOIC Accident & Emergency Dept
OIC Medical Store
QM
Coy Cdr
IT Offr
MTO
Asst Registrar
OIC Civ Est
GE(I)(P)/GE(Maintenance)
(v) Organization of Patient Treatment Areas.
Surgery Dept will be actively involved in deciding about the organization of patient treatment areas as
she / he will be the one responsible for all medical care in time of disaster. The following areas in the
hospital are designated for patient care activities:
(aa) Casualty Reception Area (CRA).
The patient will be triaged here and located nearby the Accident & Emergency (A&E), which is manned
by 01 Med Spl, 01 x Surgeon / Orthopaedician / ENT / OBGY / Eye Spl, 02x MOs, 03 x NA, 01 x MNS.
These personnel to be detailed in an incremental manner depending upon the number & type of
casualties by the senior most medical officer.
(ab) Patient Resuscitation Area.
Located at Accident & Emergency department, manned by 01 x Anaesthesiologist, 01 x MO, 02 x
ORA / NA, 01 x MNS
(ac) Patient Observation / Detention Area.
Near the Accident &Emergency manned by 01 x MO, 01 x MNS, 01 x NA / NT.
(ad) Minor Treatment Area.
Minor OT in A&E dept manned by 01 x ORA.

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(ae) Operation Theatre.

OIC OT complex and NOIC OT complex to ensure all elective surgeries should be suspended and OTs
should get ready for emergency victims.
(af) Organization of Wards.
Principal Matron (PM) along with respective wards’ MOIC & NOIC to ensure demarcation of Disaster
Beds and creation of new beds by discharging old recuperating patients, discharging patients for
elective surgery.
(ag) Organization of the Mortuary.
OIC Mortuary services will organise the existing mortuary to take the load of Mass Casualty Incident
(MCI) and make completion report to Brig IC Adm & Cdr Tps / Sr Registrar OC & Tps.
(vi) Medical Support Services.
Brig IC Adm & Cdr Tps  /  Sr Registrar Oc &Tps will ensure that the necessary support services like Radiology,
Laboratory etc. are not delayed. She / He will be assisted by the respective depts.
(vii) Quick Reaction Medical Team (QRMT).
QRMT to respond to acute medical and surgical emergencies during disaster will be constituted by Brig IC
Adm & Cdr Tps  /  Sr Registrar OC &Tps and Coy Cdr Weekly QRMT will be published in Unit Part-I orders.
QRMT constituting of 01 x JCO / NT, 01 x NA / NT, 01 x ORA and 02 x AA, will be made available at short
notice and stay within the hospital premises during their duty period. ADMO of the day will be the part of
the QRMT as OIC.
(viii) Nursing Services.
PM will directly report to the Chairperson and provide adequate nursing staff wherever needed.
(ix) Logistics Services.
QM has an important role to play once the disaster is declared. He will be in-charge of all ancillary services
of the hospital like:
(aa) Communication.
Assistant Registrar / Coy Cdr under guidance of QM will be responsible for ensuring proper communication
system (both intramural & extramural) throughout the hospital and will make completion report to
QM.
(ab) Transport.
MTO to ensure availability of adequate number of transport vehicles like ambulances, critical care
vans, hearse vans, cars and other vehicles as and when required during the disaster.
(ac) Dietary Supply.
QM / OIC Kitchen services (Patient & Pers) to ensure stocking and uninterrupted issuance of adequate
quantities of ration stores to dependent sections of the hospital, by establishing effective liaison with
the other agencies.
(ad) Sanitation.
JCO IC Hygiene & Sanitation will ensure availability of adequate quantity of items and manpower
required for ensuring proper hygiene and sanitation of the entire hospital with special emphasis to
the disaster management areas.
(ae) Water & Electricity.
Uninterrupted water and electric supply to be ensured during disaster by establishing liaison with
MES and Civil authorities. Prompt action from QM dept will be done to ensure the same.
(x) Medical Supplies.
Officer In-charge Medical Stores will ensure availability of stores as specified by respective depts and will

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also ensure early procurement of stores, if required. Disaster bricks to be kept ready at all times, so as to
cater for the contingency. Contents of Disaster Bricks, First Aid Bags, Doctor’s Bag, Pioneer Box and other
required medical equipment are being placed by med stores.
(xi) Public Relations Officer (PRO).
President Medical Board (PMB) will be the PRO of the hospital during disaster. He / She will be responsible
to establish liaison with the relatives of the victims to keep them informed on their clinical status. For such
purpose, information desk will be established at the central registration to provide the requisite information.
They will display a list of the casualties along with their status at a prominent site, in both English and
local language, which would be updated regularly. Arrangements for drinking water, tent etc. to be made
for attendants outside casualty. The PRO or an officer authorized by him / her will brief the media.
(xii) Documentation.
Documentation will be done at the MI Room by OIC Stats. All the MLCs will be recorded properly. However,
the treatment of the patients will get priority over the paperwork. The Duty Medical Officer will prepare the
list of casualties including nature of injury sustained and give it to OIC stats. For heavy load of causalities,
Officer In-charge Stat Section will post an additional clerks / NA to cater to the additional load of work.
One senior Nursing Officer will be posted to check the documentation and identification of patients. Rapid
Health Assessment form as per format placed at Appendix ‘B’ to be forwarded by medical record section,
after perusal of Chairperson.
(xiii) Mortuary.
Those brought dead or died in hospital will be kept in the mortuary to its fullest capacity. Required formalities
as laid down for Medico-Legal Cases will be followed and ensured by OIC Mortuary. Whenever the space
falls short, he / she will liaise with nearby medical facilities / Govt / Pvt hospitals for the augmentation of
additional mortuary facilities. Necessary identification and handing over of the bodies to the relatives after
medicolegal clearance will be done in this area. The officer In-charge photography section shall arrange to
take photographs of dead bodies, if required.
(xiv) Security & Crowd Management.
Coy Cdr will ensure the heightened security of the premises, foreseeing the increased crowd including
visitors, attendants and media. Vulnerable areas be identified and adequate manpower to manage
them be ensured. Vehicular movement within the premises be restricted accordingly and prioritised for
disaster-related movements. On receiving the information of disaster, Coy Cdr will immediately mobilize
security staff available within the hospital campus to augment the security in the Accident & Emergency
Departments / Casualty Reception Area to manage the crowd. The local police station may also be informed
to provide assistance in managing the crowd.
(b) Disaster Phase.
(i) Increasing the Bed Capacity in Emergencies.
The newly arriving patients would require admission for definitive treatment. This can be achieved by the
following actions:
(aa) Discharge elective cases.
(ab) Discharge stable recovering patients.
(ac) Stop admitting non-emergency patients.
(ad) As per requirement convert existing wards into disaster wards.
(ii) The actions to be coordinated by Brig Adm IC & Cdr Troops / Sr Registrar OC & Tps for cas reaching
the MH are:
(aa) Stretcher trolleys and wheelchairs will be shifted to the desired place(s).
(ab) Assistance of local units in the vicinity of site of occurrence for patient collection and blood
donation, Provost unit – for traffic control.
(ac) However, in exceptional situation only the QRMT team will be activated for casualty collection.

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O Means of Evacuation.
By any available Transport / Ambulances.
O Air Evac.
Nearest ground may be used for evac of casualty by heptor if there is no helipad at MH.
(iii) Bed Distribution Plan.
To cater for additional load, the surge capacity will be augmented depending on the class of disaster based
on categorization. Disaster management committee will promptly declare the class of disaster happened.
(aa) Class A Disaster.
No alterations required, hospital will function as hitherto and cater for this class of disaster.
(ab) Class B Disaster.
Crisis Expansion Beds (CEB) will be from within the existing hospital resources, to cater for class B
disaster. These beds will be permanently laid and utilised as and when disaster is announced.
(ac) Class C Disaster.
CEBs will be planned for this class of disaster, which includes CEBs mentioned above.
Note: Wards to be vacated by discharging and relocating balance patients in other wards.
(iv) Notification and Activation of Plan.
(aa) On receipt of the information of any disaster, the hospital will be activated as per the following
drill in Table 41.5.
Table 41.5 : Activation Plan
Time Action Taken
H Receipt of Information.
(a) The MO I/C MI Room/ DMO/Brig IC Adm & Cdr Tps/Sr Registrar OC & Tps are the persons
likely to receive the first information.
(b) The pers receiving the information should immediately inform :
(i) Comdt
(ii) Dy Comdt/ Brig Adm & Cdr Tps / Sr Registrar OC& Tps
(iii) PM
(iv) QM
(v) OI/C Status Sr Adv (Hosp Adm)
(vi) Asst Registrar
(vii) Coy Cdr/Security Officer for info to central control room and all JCOs/ORs
(viii) Logistic Offr/MTO
(ix) Duty Clk
(c) Asst Registrar to utilize Duty Clk/PA to Brig I/C Adm& Cdr Tps/ Sr Registrar & OC Tps and
ensure that information is disseminated to:
(i) All depts
(ii) Stn HQ/Area HQ/CMP
(iii) Local Police Stn
(iv) Govt hosp /Pvt hospital
Note. List of all the categories of staff with addresses, telephone numbers are to be made
available in the Control Room and DMO Room. The officers staying in KLP accommodation will
be informed first. All officers to report to Central place. All HsoD to contact all dept offrs to
ensure that they reach respective depts as soon as possible.

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(d) Further Action on Receipt of Information.

(i) Principal Matron will ensure that all Members of Nursing Services are detailed
for disaster management and to report for duty by H+15 min. She will also ensure
that all off duty Members of Nursing Services to report to their place of duty (Triage
area/resuscitation ward/ disaster wards/OT) and are available to help in disaster
management.
(ii) Coy Cdr to call Duty JCO/Adm JCO/Duty NCO & RP NCO. Coy Cdr to ensure
complete manpower from lines and all JCO/ORs residing in hospital complex to fall-in in
predefined designated location by the hospital.
(iii) Trimodal approach to indicate a disaster situation will be used involving
announcement on the code blue system, telephonic information, and hooter alarm.
(iv) Brig Adm & Cdr Tps/Sr Registrar & OC Tps to inform higher HQs
O MG (Med)
O MG (Adm)
H+5 Actions by MO I/C MI Room/DMO (Only in exceptional situation the QRMT team will be
min activated for casualty collection)
(a) Mov ADMO and Med /Surg spl on duty to the site of the accident in Amb along with
Disaster management kit kept in casualty. (Vehs to be detailed by QM)
(b) 2x Nursing Assts and 4x Amb Assts with a mobile phone to also move in an ambulance
(Nur Asst to be detailed by Chief Ward Master and Amb Asst by Coy Cdr/Adm JCO).
(c) Move of all vehicles to the area of disaster shall be done only on orders from Brig I/C Adm
& Cdr Tps/ Sr Registrar OC&Tps.
(d) Transform A&E waiting hall into Cas Reception Area & Triage Area by removing all waiting
chairs from their and shifting them to the central registration area (PRO). MOIC MI Room/DMO&
Coy Cdr to ensure the same.
H + 10 (a) Collection of expendable and non-expendable medical stores by OIC Resuscitationcentre.
min Stores to be kept earmarked in medical stores.
(b) Evacuation of earmarked beds in the disaster wards by respective MO I/C of the wards. To
be coordinated by surgical Division.
H + 15 (a) Opening of Reception Centre near entrance of A&E dept by Coy Cdr and QM.
min (b) Opening of PR Cell and information centre in predefined designated location by the hospital.
Existing Admission counter will be augmented by OIC Computer cell, OIC Stats and Asst Registrar.
H + 20 (a) Augmentation of Resuscitation room at existing Accident & Emergency dept. QM to provide
min therequired extra beds with mattresses for the detention room.
(b) Opening of relatives waiting area at in the appropriateplace by Coy Cdr and QM.
H + 30 Activation of earmarked Disaster Wards, Operation theatre, Blood bank and radiology dept
min
Reorganising wards for receiving casualties as mentioned above.
(ab) Med Offrs working in casualty will immediately conduct a triage i.e. sorting out case into
4 categories by putting coloured triage bands on patient’s left / right upper arm and take steps
accordingly.
O Priority I Red.
Requires immediate resuscitation; in the red area i.e. Main Casualty receiving area (existing MI
Room waiting hall).
O Priority II Yellow.
Requires urgent medical attention and possible surgery after 4 to 6 hrs in the yellow area i.e.
disaster room.

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O Priority III Green.

Walking wounded (non-urgent ambulatory) needing first aid and delayed treatment in the green
area, i.e. observation room.
O Priority IV Black.
Dead; to be shifted to mortuary.
(ac) Colour bands will be available in the MOIC MI Room cupboard.
(ad) Blood shall be indented immediately and patient taken to OT directly when so required.
(ae) All the MLCs will be recorded properly and in details in MLC register.
(af) OIC OT to ensure more number of OT tables shall be made available to handle the increased
load of surgery.
(ag) A comprehensive list of all patients coming to casualty shall be prepared and prominently
displayed in English & Hindi outside A&E Dept.
(ah) Dedicated telephone lines shall be activated with the help of Comd Signal Regt, as disaster
helplines, by IT Offr.
(aj) As far as possible, all the cases shall be disposed of in the shortest possible time.
(ak) Extra resuscitation beds should always be available in A&E, whenever required.
(al) Wherever necessary, emergency drugs, which are not available, shall be procured at the earliest.
(am) If necessary, extra dressing, suture trays and other equipment shall be indented from CSSD
which is working round the clock.
(an) Creation of extra beds will take priority.
(ao) All the dead bodies shall be properly packed; identification tags put on them and then sent to
mortuary.
(ap) Arrangements for tent, drinking water etc. shall be made for attendants / staff through kitchen,
canteen, at parking area opposite auditorium.
(v) Staffing Pattern of Disaster Plan.
The staffing pattern of disaster plan will be as mentioned in Table 41.6.
Table 41.6 : Staffing Pattern for Disaster Plan in Hospital
S. No. Area Staffing Pattern
1. Reception centre (a) Overall OIC: QM
(b) Asst OIC: Coy Cdr
(c) SKT/Clerks
(d) Amb Asst
(e) Photographer
2. Triage team (a) MOIC
(b) Surgeon & Physician on call
(c) Surgery dept
(d) Anaesthesia dept
(e) Nursing officers
3. Resuscitation team (a) I/C OT
(b) Anaesthesiologist
(c) Surgeon
(d) Physician

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S. No. Area Staffing Pattern

(e) Radiologist
(f) Nursing Officers
(g) Nursing Assistants
(h) Ambulance Assistants
(j) Radiographer
(k) ORA
(l) Lab technician
(m) Safaiwala
4. Disaster ward All these wards are being manned 24 x 7 x 365 days by dedicated staff of all
categories
(a) MOs I/C of respective wards
(b) Anaesthetist
(c) Surgeon
(d) Physician
(e) Nursing officers
(f) Nursing assistants
(g) Ambulance assistants
(h) ORA
(i) Safaiwala (Male+ Female)
(vi) Area demarcation for various activities in the event of disaster: Various areas to be modified during
the disaster are as given in Table 41.7.
Table 41.7 : Area Demarcation for Various Activities in the Event of Disaster
Designated Area &
S. No. Areas Action Taken
Responsibility
1. Reception Designated Area : (a) Trolleys to be placed in the lobby at the receipt of
A&E entrance disaster information under arng of CWM.
Overall responsibility : (b) To organise manpower, collect tentage from QM
Coy Cdr / Adm JCO Stores. To establish a covered area for reception
&organise chairs for relatives.
(c) A dedicated person will be detailed for identification
and photography of all causalities received for hospital
records.
(d) Exchange to be contacted to set up a phone line in
the reception area, PR booth and information centre to be
established.
(e) To arrange for hot tea and snacks from the cook
house and setting up a stall by wet canteen.
2. Triage Designated Area : (a) Patients to be received on trolleys and triage done.
A&E waiting room (b) Priority I & II cases to be shifted to resuscitation
Overall responsibility : centre/ICU/OTas per need. Priority III cases to be shifted
MOIC MI Room/Coy to disaster wards.
Cdr (c) In case of overflow of cas, the adjoining suitable
place to be used for the Triage purpose.
(d) At completion of triage the team should move to the
resuscitation area.

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Designated Area &

S. No. Areas Action Taken
Responsibility
3. Resuscitation Designated Area : (a) Max number of beds to be made ready at short
centre & Existing Resuscitation notice by Nur Offrs I/C A&E.Addl bedswith mattresses to
Observation room and Detention be provided by QM.
room room at Accident (b) Ventilators to be moved to the resuscitation centre
& Emergency dept from ICU.
respectively
(c) Portable X-ray machine and USG Machine to be made
operational from Radiology dept to A & E.
Overall responsibility :
Sr Adv Anaesthesiology (d) Patient belongings will be collected by one JCO Clk
designated by HoD detailed by the Head clerk, along with two SKTs in A&E.
Anaesthesia (e) OIC Med store to move disaster store/ kits to reach
the resuscitation room (A & E).
Additional (f) Adequate transfusion fluids will be kept in A&E at all
responsibility: times. (Responsibility - MOIC MI Room).
Radiology dept to
(g) Activation of CSR station with a Lab Asst in the
detail one radiologist
Resuscitation Centre.
for FAST
Pathology dept to
detail CSR team
4. Admission Designated Area : (a) Set up a LAN connection for two computers (with
centre existing centre with printers) for data entry, storage and transfer of data to
augmentation designated places.
(b) To set up a tele in co-ordination with exchange.
(c) To be staffed by data entry trained Amb Asst and
Overall responsibility :
NCO I/C Computer cell.
IT Officer
(d) Adequate sets of documentation papers will be kept
OIC Stats Sec & Chief ready in a box earmarked for the same. The box will
Ward Master be kept with disaster kits in A&E dept and moved to
admission centre at short notice.
(e) Numbered documentation sets containing case
sheets, admission flimsy (x2), investigation forms and new
medico-legal register, stocked with disaster kits in A & E
by chief ward master.
(f) To tie up with mortuary for documentation of non-
survivors.
5. Public Designated Area : (a) Patient’s belongings will be collected by one JCO Clk
Information Predefined designated detailed by Head clerk along with two SKTs.
Centre location by the (b) Information centre will return the patients belongings
hospital after due receipt taken for the same.
(c) Information centre will maintain records of all
discharged patients and will hand over discharge slip to
Overall responsibility:
the patient.
PMB
6. Disaster wards Designated wards/ (a) To mobilise a combined bed as when required.
areas : (b) Walking patients to be discharged and beds prepared
to receive cas.
(c) All Priority I & II cases to be shifted to desired wards.
(d) All Priority III cases to be shifted disaster ward.

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Designated Area &

S. No. Areas Action Taken
Responsibility
7. Operation Designated wards / (a) Suspension of all elective surgeries.
theatre areas : (b) Adequate theatres to be activated to receive cas at a
Responsibility : short notice
Anaesthesiology dept
8. Mortuary Designated wards / (a) Mortuary I/C to be available to receive bodies.
areas :
Hospital mortuary
Responsibility :
HoD Pathology
(vii) Flow of Casualties: The flow of cas will be as follows:
Reception
(Documentation responsibility-OIC Stats)

Triage Mortuary

Priority I Priority II Priority III

Resuscitation Disaster Ward

Priority I Priority II

OT / ICU
Fig 41.9 : Flow of Causalities
(viii) Deactivation of Plan.
It is a very important phase of the emergency plan. The timing of the deactivation has a bearing on the
successful outcome of the plan. An early deactivation might lead to a situation where casualties continue
to come after Emergency Plan has been deactivated and a late deactivation would put undue pressure in
the hospital resources and also delay in resumption of normal activity.
(c) Post Disaster Phase.
(i) Under the chairmanship of the Commandant / Commanding Officer, a debrief will be carried out post
disaster (within 24-72 h) by Brig IC Adm & Cdr Tps / Sr Registrar OC & Tps as and when required, to assist
with coping and recovery, providing access to mental health resources and improve wok performance.
(ii) Brig IC Adm & Cdr Tps / Sr Registrar OC & Tps will be the Disaster Recovery Officer, who will be
assisted by Sr Adv (Hosp Adm) for overseeing the hospital recovery operations. They will determine essential
criteria and processes for incident demobilization and system recovery.
(iii) In case of damage to the hospital building, a comprehensive structural integrity and safety assessment
will be performed. In case if evacuation of building is required for repairs and replacement before the
hospital can be reopened, time and resources needed to complete the same be determined.
(iv) Post-Action Hospital Inventory Assessment.
A team comprising of OIC Med Stores, QM, Deputy PM and reps from respective wards / OPDs will be formed
for assessing the status of sophisticated equipment that may need to be repaired or replaced. They will
diligently analyse every equipment being proposed by the user depts, for their functionality and conditioning.
(v) Post-Action Report.
A detailed post-action report including summary, a response assessment and expenses report be formulated

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in consultation with Sr Adv (Hosp Adm), OIC Medical Stores, Accounts Officer and QM will be submitted
through Brig IC Adm to the Chairperson.
(vi) A post-disaster employee recovery assistance programme according to staff needs, including
counselling and family support services be established. Assistance of AWWA ladies may be sought for this.
(vii) Additionally, appropriate programme in recognition of the services being provided by the staff,
volunteers, external personnel and donors be organised during disaster response & recovery phase.

41.25 Hospital Evacuation Plan.

(a) Purpose.
Evacuation i.e. the removal of patients, staff and / or visitors in response to a situation which renders any medical
facility unsafe for occupancy or prevents the delivery of necessary patient care.
(b) Policy Statement.
(i) Partial Evacuation.
Patients are transferred within the hospital. There are two levels of a partial response:
(aa) Horizontal; first response patient movement occurs horizontally to one side of a set of fire barrier
doors.
(ab) Vertical; movement of patients to a safe area on another floor or outside the building.
This type of evacuation is more difficult due to stairways which will require carrying of non-ambulatory
patients; elevators cannot be used.
(ii) Full Evacuation.
Patients are transferred from hospital to an outside area, other hospitals or other alternatives areas. Patients
will be transferred to nearby MH / Private & Civil hospitals.
(aa) Paramedic escorted patients will be diverted from the emergency department due to internal
disruption.
(ab) The building should be evacuated from the top down as evacuation at lower levels can be easily
accelerated if the danger increases rapidly.
(c) Evacuation plan and roles / responsibilities.
This evacuation plan is based on the premise that an event has occurred, causing the hospital to be in an
internal disaster mode. Depending upon the extent of involvement of hospital compartments, the evacuation will
happen. Procedure for evacuation is as follows:
(i) General Instructions.
(aa) Evacuate most hazardous areas first (those closest to danger or farthest from exit).
(ab) Use nearest or safest appropriate exit. Sequence of evacuation should be:
O Patients in immediate danger.
O Ambulatory patients.
O Semi-ambulatory patients.
O Non-ambulatory patients.
(ac) If time permits, close all doors, shut off oxygen, water, light and gas, if able to do so.
(ad) Elevators may be used, except during a fire or after an earthquake.
(ii) All available information shall be evaluated and evacuation schedule established in coordination with
the respective stakeholders. This information shall include:
(aa) Structural, non-structural and utility evaluation from Engineering / Damage Assessment & Control
Officer.

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(ab) Patient status reports from OIC Stats.

(ac) Evaluate manpower levels and authorize activation of staff call-in plans, as needed.
(iii) Disaster evacuation will be planned by Brig IC Adm & Cdr Tps / Sr Registrar OC & Tps will ensure all
directions are followed & supervised accordingly:
(aa) Liaison Offr as nominated by chairperson.
(ab) Logistics; QM
(ac) Safety and Security Offr; Coy Cdr
(iv) Liaison Officer.
(aa) OIC Stats / Offr nominated by the Commandant / Commanding Officer will be the liaison offr.
(ab) Maintain contact with respective HQs, HQ (Med Br & A Br), public safety officials, civil health
dept and ambulance agencies.
(ac) Complete “Hospital Evacuation Worksheet”
(v) QM & MTO.
(aa) Assign MTO to assemble evacuation teams from the coy.
(ab) Notify planning section chief of plans.
(ac) Ensure coordination of off-campus patient transportation.
(ad) Confirm implementation of Transportation Action Plan.
(vi) Coy Cdr.
(aa) Assemble evacuation teams from the Coy.
(ab) If possible, assign appropriate people to each floor per block for evacuation manpower.
(ac) Brief team members on evacuation techniques.
(ad) Arrange transportation devices (wheelchairs, gurneys, etc. to be delivered to assist in evacuation).
(ae) Report to floor being evacuated and supervise evacuation.
(af) Liaise with PM for order of patients being evacuated and method of evacuation.
(vii) Principal Matron (PM).
(aa) Designate holding areas for critical, semi-critical and ambulatory evacuated patients.
(ab) Organize efforts to meet medical care needs and staffing of Evacuation Holding areas.
(ac) Distribute evacuation schedule to Nursing Offrs.
(ad) Verify Nursing Offr-in-Charge have initiated evacuation procedure.
(ae) Request Medical Staff Officer to notify physicians of need for transfer orders.
(af) Assign holding area coordinators and adequate number of nurses to holding areas.
(ag) Contact pre-established lists of hospitals, extended care facilities, school, etc. to determine
places to relocate patients. Forward responses to Brig IC Adm & Cdr Tps / Sr Registrar OC & Tps
(viii) OIC Stats.
(aa) Notify physicians of need for patient transfer orders.
(ab) Stat clerks can assist ward masters of respective wards, as needed.
(ix) Duty Nursing Offrs / In-Charge Nurses.
(aa) Determine patient status. Patients will be evacuated according to status.
(ab) Communicate status with large sticker on patient’s chart according to the following criteria:

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O Non-critical / ambulatory
O Non-critical / non-ambulatory
O Critical / requires ventilation or special equipment
(ac) Report patient status to PM.
(ad) Assign specific nurses to maintain patient care.
(ae) Assign two nurses to prepare patients for evacuation.
O Place personal belongings in a bag labelled “BELONGINGS” with personal number and
name with medications, prosthetics and special patient need items inside the bag.
O Place addressograph in Patient’s chart secured with tape, which is to remain with the
patient.
(af) Designate a safe exit after determining location of patients to be evacuated.
(ag) Assign a person to record evacuation activity, including:
O Time of evacuation
O Method of evacuation
O Name of patient
O Evacuation status A B C
O Evacuated from __(area) to ___ (area)
(ah) Forward documentation of evacuation and patient disposition to Patient Tracking Coordinator
or Patient Information Manager.
(x) Patient Information Manager.
(aa) OIC Civ Est will be the Patient information Manager.
(ab) He will compile patient info on Inquiry Sheets, so as to ensure proper record of patients’
movement.
(xi) Critical Care Manager.
(aa) Anaesthetists as nominated by HoD Anaesthesia.
(ab) Assign staff members to perform ventilation on required patients.
(ac) Assess number of positive pressure breathing devices / bag-valve-masks available.
(xii) Safety And Security Officer.
(aa) Coy Cdr will assign a security person to each area being evacuated for traffic control / safety.
(ab) Turn off oxygen, lights, etc. as situation demands.
(ac) Check the complete evacuation has taken place and that no patients / staff remain.
(ad) Place “Evacuated at (date / time)” sign up at main area exit / entrance of evacuated area after
evacuation is complete.

41.26 Medical and Surgical Bricks for Disaster Relief.

Disasters strike with minimal warning and with catastrophic consequences leading to unprecedented morbidity and
mortality of human life and damage to health infrastructure and ecosystem. Saving lives with minimal loss of time is
the first and foremost step to mitigate some of the consequences. Assistance of Armed Forces is invariably requisitioned
by the civil authorities during any such eventuality. As per the O / o DGAFMS, the Medical and Surgical Disaster Bricks,
medical stores and equipment are being maintained by AFMSDs / AMSDs / FMSDs as per laid down scales.

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Appendix ‘A’

JOB CARDS
1. Job cards will be made available in all areas concerned with the emergency management plan. Each card will
contain a checklist of instructions for the key individuals in the respective areas to enable them to carry out their
duties effectively.
2. These cards will also have all the information required for the individual to carry out his instructions, e.g., phone
numbers, mobile numbers and addresses (updated periodically).
3. These cards will be colour coded for different categories of staff for easy identification, e.g., consultants,
specialists, Nursing Offrs, JCO, ORs etc.
4. The cards will be kept in an easily accessible area in clearly labelled slots. In addition, colour coded cards, as
per international guidelines will be kept in the casualty for triaging and further management.

JOB CARDS – Surgery & Allied Speciality

Surgical & Allied Specialist (ENT/Obs & Gynae/Ophthalmology) Admitting Dept

Reporting Area - Casualty (A&E Dept)

Reporting Officer - HoD of the admitting Dept
(a)0 Assess whether an emergency exists.
(b)0 Arrange for the entire surgery unit on call to report to the casualty.
(c)0 Distribute treatment protocols to offr.
(d)0 Supervise treatment for patients who have been triaged.
(e)0 Assign residents to these patients.
(f) Prioritize patients for surgery in order of urgency.
(g)0 Communicate with relatives of surgical patients as and when required.

Surgical Specialist
Reporting Area - Casualty (A&E Dept)
Reporting Officer - HoDSurgery Dept
(a)0 Triage the patients in the casualty (A&E Dept) as per triage guidelines laid down for a disaster situation.
(b)0 Inform Surgery Dept (Phone/ Residence/ Intercom/ Mobile/ Other)
(c)0 Designate one faculty to the designated ward if the casualty is full.
(d)0 Alert the next day’s duty team about looking after the operation theatres.
(e)0 Alert the previous days duty team to report to the casualty to help.

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JOB CARDS – Casualty (A&E Dept)

MOIC MI Room
Reporting Area - Casualty (A&E Dept)
Reporting Officer - Brig IC Adm & Cdr Tps/Sr Registrar OC & Tps
(a) Clear and organise the incoming patient and triage area.
(b) Allot another consultant to the triage area.
(c) Contact the heads of units of the other service and support departments.
(d) Shift patients requiring acute resuscitation to the resuscitation rooms.
(e) Shift the walking wounded patients to the designated area for them.
(f) Shift those patients categorized as ‘delayed’ or beyond salvage’ to the designated area for them and
allot a nurse to man this area.
(g) Shift those received dead to the mortuary after identification and other medico legal procedures.
(h) Supervise the medico legal formalities.
(j) Reorganize the shifts for the next day.

Senior MO Casualty (A&E Dept)

Reporting Area - Casualty (A&E Dept)
Reporting Officer - MOIC MI Room
(a) Clear the emergency department of any patients, either admit or discharge them.
(b) Inform the MOIC MI Room.
(c) Inform the NOIC MI Room to organize additional trolleys and drugs and disposables.
(d) Allot emergency residents and physicians to the different receiving areas of the department.
(e) As the patients come in inform the heads of units of the involved departments.
(f) Send an intern to contact medical officers who are not on duty depending on the number of patients
that have arrived.

Surgical Consultant OT
Reporting Area - Operation Theatre
Reporting Officer - HoD Surgery Dept
(a) Receive cases for surgery from the Casualty (A&E Dept) or the other designated wards and assign them
to different OTs.
(b) Make scrub teams for each table who will operate on cases assigned by you.
(c) Depute NA for obtaining blood and communicate with other teams.
(d) If you have to scrub for any case, ensure availability of another consultant to receive patients and to
co-ordinate surgery.
(e) Supervise surgical teams in the OT.
(f) Ensure monitoring of patients while transferring back to ward/ Intensive care areas.

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Orthopaedic Specialist
Reporting Area - Casualty (A&E Dept)
Reporting Officer - HoD Orthopaedics Dept
(a) Receive cases for surgery from the Casualty (A&E Dept) or the other designated wards and assign them
to different OTs.
(b) Make scrub teams for each table who will operate on cases assigned by you.
(c) Depute NA for obtaining blood and communicate with other teams.
(d) If you have to scrub for any case, ensure availability of another consultant to receive patients and to
co-ordinate surgery.
(e) Supervise surgical teams in the OT.
(f) Ensure monitoring of patients while transferring back to ward/ Intensive care areas.

Orthopaedic Specialist OT
Reporting Area - Operation Theatre
Reporting Officer - HoD Orthopaedics Dept
(a) Receive cases for surgery from the Casualty (A&E Dept) or the other designated ward and assign them
to different OTs.
(b) Make scrub teams for each table who will operate on cases assigned by you.
(c) Depute resident/intern for obtaining blood/communicating with other teams.
(d) If you have to scrub for any case, ensure availability of another consultant to receive patients and co-
ordinate surgery.
(e) Supervise orthopaedic teams in the OT.
(f) Ensure monitoring of patients while transferring back to ward/Intensive care areas.
(g) Prioritize patients for surgery in order of urgency.
(h) Communicate with relatives of patients as and when required.

JOB CARDS – Department of Anaesthesiology

Anaesthesiologist on Duty
Reporting Area - Operation Theatre
Reporting Officer - HoD Anaesthesia Dept.
(a) Inform the NOIC OTabout the Emergency.
(b) Oversee the functioning of the Operation Theatres.
(c) Send one offr to the Casualty to do a pre-anaesthetic check-up for patients requiring surgery.
(d) Inform the Anaesthesiology Dept about the emergency.
(e) Recruit additional residents and consultants depending on the number of surgical cases posted.
(f) Inform the concerned wards about the cancellation of the elective surgery list.

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JOB CARDS – Department of Medicine

Medicine Specialist on Call

Reporting Area - Casualty (A&E Dept)

Reporting Officer - HoD Medicine Dept
(a) Alert all consults of his/her unit.
(b) Take over the medical management of cases in the Casualty (A&E Dept)

JOB CARDS – Department of Paediatrics and Paediatric Surgery

Paediatrician / Paediatric Surg on Call

Reporting Area - Casualty (A&E Dept)

Reporting Officer - HoD of Respective Dept
(a) Alert residents and consultants of his unit.
(b) Take over the management of cases in the Casualty.

JOB CARDS – Principal Matron

Principal Matron
Reporting Area - Control Room
Reporting Officer - Brig IC Adm & Cdr Tps/Sr Registrar OC & Tps
(a) Mobilizes adequate nurses to the casualty and other designated areas.
(b) Organizes shift duties so that the nurses can be replaced after 8 hours by a fresh batch of nurses to
ensure efficient patient care.

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JOB CARDS – Nursing Officer in-charge of alternate ward to receive emergencies

Nursing Officer in-charge

Reporting Area - Respective Alternate Wards
Reporting Officer - Principal Matron
(a) Arranges to shift patients from that ward to other hospital beds after getting a list of vacant bedsfrom
the reception.
(b) Arranges for an adequate number of mattresses for the emergency patients.
(c) Contacts the Principal Matron to depute necessary additional staff to her ward.
(d) The drugs, supplies and equipment required for the emergency as per the list has to be brought from
the medical stores.
(e) Allot nurses to receive, resuscitate and stabilize the urgent cases, triaged in from the Casualty.
(f) Shift these cases to the OT, ICU, dialysis unit or other areas as specified by the respective consultants
managing the cases.
(g) Receive post-operative cases in a separate receiving area.

JOB CARDS – OIC Medical Stores

OIC Medical Stores

Reporting Area - Casualty (A&E Dept)
Reporting Officer - Brig IC Adm & Cdr Tps/Sr Registrar OC & Tps

Arranges to shift medical supplies and equipment as previously designated in the disaster plan to the casualty
and other designated areas.

JOB CARDS –NOIC OT

NOIC OT
Reporting Area - Operation Theatre
Reporting Officer - OIC OT Complex
(a) Mobilizes adequate personnel and gets the theatres ready.
(b) Quickly gets the pre-medication and recovery rooms ready.
(c) Organizes shift duties and sees that reserve operation theatre staff is available 24 hours a day.
(d) Ensures that additional supplies of clothing and sterile surgical instruments are readily available.
(e) Allots staff to receive and transfer out the operated cases.
(f) Allots staff to transfer postoperative cases back to the designated ward.

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JOB CARDS – JCO IC OT

JCO IC OT
Reporting Area - Operation Theatre
Reporting Officer - OIC OT Complex
(a) Assist OT Matron in mobilizing adequate personnel and gets the theatres ready.
(b) Organizes shift duties and sees that reserve operation theatre staff is available 24 hours a day.
(c) Ensures that additional supplies of clothing and sterile surgical instruments are readily available.
(d) Aid OT Matron in allotting staff to receive and transfer in-out the operated cases.

JOB CARDS – Clinical Pathology and Microbiology Laboratories

Clinical Pathology and Microbiology Laboratories

Reporting Area - Dept of Laboratory Sciences
Reporting Officer - HoD Dept of Laboratory Sciences
(a) Arranges additional residents, consultants, and laboratory technicians.
(b) Deputes staff to the casualty to collect the specimens.
(c) Deputes a senior laboratory technician to keep all the required material for processing the specimens,
like the stains, media and reagents for various biochemical tests ready.
(d) Makes necessary arrangements for grouping and issue of blood or blood components.
(e) Assigns one of the consultants to mobilize voluntary donors as per the existing list.
(f) Liaisons with blood banks to procure blood.
(g) Handles autopsies in liaison with Govt Hospital.

JOB CARDS – Radiology Dept

Radiologist on Call
Reporting Area - Radiology Department
Reporting Officer - HoD Radiology Dept
(a) Ensures the presence of adequate medical and technical staff in the department to handle requestsfor
various radiological investigations including X-rays, Ultrasonography, CT-Scan, etc.
(b) Ensures that the necessary quantities of film and developer are available.
(c) Collaborates with the Anaesthesiology Dept to ensure that facilities for the resuscitation of patients are
available in the department.
(d) Allots a separate portable X-ray machine for the Casualty and the other designated wards so that unstable
patients do not have to be shifted to the radiology department.

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JOB CARDS – OIC Dispensary

OIC Dispensary
Reporting Area - Service Dispensary
Reporting Officer - Brig IC Adm & Cdr Tps/Sr Registrar OC & Tps
Ensures the availability of drugs and supplies from the emergency reserves and keeps a record of items distributed
and needs that may arise.

JOB CARD – OIC Stats

OIC Stats
Reporting Area - Medical Records Department
Reporting Officer - Brig IC Adm & Cdr Tps/Sr Registrar OC & Tps
(a) Mobilizes staff to the Casualty and the registration area to register victims in the emergency.
(b) Designates one Stat clerk/NA to keep up to date records of the hospital bed position and send the list
of vacant beds to the MOIC MI Room.

JOB CARDS – JCO IC House Keeping Department

JCO IC Housekeeping Department

Reporting Area - House-keeping department
Reporting Officer - Coy cdr
(a) Mobilizes additional aides and helpers to the Casualty and other designated areas.
(b) Mobilizes extra staff to move patients to and from the theatre and radiology department, to bring linen,
medicine, IV fluids, blood etc., to take specimens to the laboratories for analysis etc.

JOB CARDS – JCO / NCO IC Maintenance & Works

JCO/NCO IC Maintenance & Works

Reporting Area - Maintenance Department
Reporting Officer - Quarter master
Deputes additional people to look after the electricity, water supply, sanitation, oxygen and suction units
required during the emergency, and liaise with respective MES authorities

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JOB CARDS – JCO / NCO IC Laundry

JCO/NCO IC Laundry
Reporting Area - Laundry
Reporting Officer - Quarter master

Ensures fresh supply of linen to the casualty, other designated areas and the operation theatres.

JOB CARDS – OIC CSSD (Central Sterile Supply Dept)

OIC CSSD (Central Sterile Supply Dept)

Reporting Area - CSSD
Reporting Officer - OIC OT Complex

Supplies sterile equipment and linen to the casualty, other designated areas and the operation theatres.

JOB CARDS – JCO IC Dietary Services

JCO IC Dietary Services

Reporting Area - Central Dietary Services
Reporting Officer - Quarter master

Makes the necessary arrangement to provide coffee and snacks to the casualty, other designated areas and
the operation theatre.

JOB CARDS – Public Relations Officer

Public Relations Officer

Reporting Area - Public Relations Office
Reporting Officer - Brig IC Adm & Cdr Tps / Sr Registrar OC & Tps
(a) Is responsible for giving information to the press and public, after consultation with Brig IC Adm &
Commandant.
(b) Issues periodic bulletins that provide information of general interest.

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JOB CARDS – Coy Cdr

Coy Cdr
Reporting Area - Control room
Reporting Officer - Brig Brig IC Adm & Cdr Tps / Sr Registrar OC & Tps
(a) As Chief of Security Services, he is responsible for maintaining order and safety within and outside the
hospital.
(b) Allots personnel to direct traffic so that ambulances are guaranteed free access to the incoming patient
area.
(c) Allots personnel to protect the key installations of the hospital.
(d) If the hospital’s security personnel are not sufficient to handle the situation, he requests help from the
Station resources.
(e) Deputes additional security staff to the Casualty and other designated wards.
(f) Designates a separate waiting area in the hospital for relatives of the injured.
(g) Makes sure that on no account will be relatives be permitted into the Casualty or designated wards
during the emergency.
(h) Deputes JCO to be in charge of ensuring the comfort and needs to the relatives. He will be responsible
for obtaining information about individual patients to pass on to the relatives.

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Appendix ‘B’

RAPID HEALTH ASSESSMENT FOR MASS CASUALTY INCIDENT

(To be submitted within 24 hrs)

A. Description of the Event.

Nature of the Event:
Time of the Event:
Date of the Event:
Place of the Event:

B. Number of persons affected.

Death:
Injured:
Treated on site:
Referred to Hospital:
OPD:
Admitted:
Missing:
Total:

C. Action Taken.

D. Problems Encountered.

E. Recommendations.

Prepared by:
Position:
Office:
Date:

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Suggested Reading.
1. https://ndma.gov.in/sites/default/files/PDF/Guidelines/guideline-on-minimum-standard-of-relief.pdf
2. https://ndma.gov.in/index.php
3. O/o DGAFMS letter No 43645/DGAFMS/DG-1C dt 20 Aug 2015 Policy on Medical and Surgical bricks for Disaster
relief.
4. Disaster impact and response - Convergence. convergence.nl/pandemic-disaster-preparedness-center/disaster-
impact-and-response.
5. Sendai Framework for Disaster Risk Reduction 2015 - 2030 as promulgated by UN International Strategy for
Disaster Reduction (UNISDR) adopted at the Third UN World Conference in Sendai, Japan, on March 18, 2015.
6. https://www.preventionweb.net/understanding-disaster-risk
7. www.nidm.gov.in/pdf/guidelines/new/TemporarySheltersDisasterAffectedfamilies.pdf
8. Hans Günter Brauch, Springerlink (Online Service, Al E. Facing global environmental change: environmental,
human, energy, food, health and water security concepts. Berlin: Springer; 2009.
9. https://spherestandards.org/wp-content/uploads/Sphere-Handbook-2018-EN.pdf
10. Wang Y, Kyriakidis M, Dang VN. Incorporating human factors in emergency evacuation – An overview of behavioral
factors and models. International Journal of Disaster Risk Reduction [Internet]. 2021 Jun 15; 60:102254.
11. Kouadio IK, Kamigai T, Hitoshi O. (P1-83) Infectious Diseases Following Natural Disasters: Prevention and Control
Measures. Prehospital and Disaster Medicine. 2011 May;26(S1): s125–6.
12. Cefalu CA. Disaster Preparedness for Seniors A Comprehensive Guide for Healthcare Professionals. New York,
Ny Springer; 2014.
13. Emmanouil Pikoulis. Emergency Medicine, Trauma and Disaster Management. Springer
14. https://www.unhcr.org/
15. Pal I, Shaw R. Disaster Risk Governance in India and Cross Cutting Issues. Springer; 2017.
16. Jürgen Scheffran, Brzoska M, Hans Günter Brauch, Peter Michael Link, Janpeter Schilling. Climate Change, Human
Security and Violent Conflict Challenges for Societal Stability. Berlin, Heidelberg Springer Berlin Heidelberg; 2012.
17. Sajjad H, Siddiqui L, Rahman A, Tahir M, Masood Ahsan Siddiqui. Challenges of Disasters in Asia. 2022.
18. Amaratunga D, Haigh R, Dias N. Multi-hazard early warning and disaster risks. Cham, Switzerland: Springer;
2021.
n

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Chapter
XXXXII
PANDEMIC MANAGEMENT

42.1 Introduction.
How diseases impact the populations and the various determinants for the disease frequency includes a complex
interaction of epidemiological factors including but not limited to the agent, host and environment. Occurrence
of a disease within an expected frequency at a given time and place, is considered to be normal for the given
population. However, if there is an unusual increase in the frequency, change in type of host population, clinical
manifestations or involvement of newer geographical locations, then depending upon the extent of involvement,
it can be called an outbreak, epidemic or pandemic.
In 1666, the term "pandemic" was first used to describe a continuously spreading disease in a country. The
words epidemic and pandemic were used broadly and often alternatively in many social and medical contexts
during the 17th and 18th centuries. However, as the terminology has developed throughout time, new concepts
have emerged. The terms endemic, outbreak, epidemic and pandemic express how frequent and geographically
extensive a disease is now compared to previously.
There are numerous factors which interact within the agent, host and environment framework over a specified
period of time determining the extent of spread of the disease. However, some of the factors which are leading to
the increased spread of diseases include globalization, urbanization, increased travel, deforestation, anthropologic
environmental changes and exploitation of the natural habitats due to ever increasing demands for human
resources.
The disease transmission pathways depending upon the agent, host susceptibilities and human-human or human-
agent contact patterns are other critical factors which lead to enhanced spread of endemic diseases, emerging
and re-emerging diseases and pandemics due to novel viruses and microbiological agents.

42.2 Definitions.  
(a) Expected Level of Disease.
The disease frequency which is usually present in a population over a specified time period is known as the
expected or baseline or endemic level of the disease. The expected level of a disease is the observed level and
may or may not be a desired level. It may be zero for a given population or be present in a specified proportion
of the population.
(b) Sporadic, Endemic and Hyperendemic Levels.
Sporadic refers to a disease that occurs infrequently and irregularly. Endemic refers to the constant presence
and/or usual prevalence of a disease or infectious agent in a population within a geographic area. Hyperendemic
refers to persistent, high levels of disease occurrence.
(c) Epidemic, Outbreak and Disease Clusters.
Epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally
expected in that population in that area. Outbreak carries the same definition of epidemic but is often used for
a more limited geographic area. Cluster refers to an aggregation of cases grouped in place and time that are
suspected to be greater than the expected level of the disease.
(d) Pandemic.
Term pandemic is derived from a Greek word (pan, ="all" and demos, ="people"). It refers to an epidemic occurring
over a very wide area, crossing international boundaries and usually affecting many people. Some important
pandemics outlined in the history are mentioned in Fig 42.1.

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Antonine Plague HIV/ AID SARS

(165 AD) S (1981) (2002-03)

Plague of Hong Kong Swine Flu

Justinian Flue (2009-10)
(541-542 AD) (1968)

The Black Death Seventh Cholera Ebola

(1343-1353 AD) Pandemic (2014-2016)
(1961-1975)

Third Cholera Flu Pandemic COVID-19

Pandemic (1918) (2019-till date)
(1852-1860 AD)

Flu Sixth Cholera

Pandemic Pandemic
(1889-1890 AD) (1899-1923)
  
Fig 42.1 : History of Pandemics

42.3 Phases of Pandemic.

Based on learnings from pandemics resulting from respiratory viruses, WHO established global influenza surveillance
and monitoring systems for active surveillance of the virus strains. The phases of pandemics depend upon various
dynamics and varies with disease. Influenza pandemic phases as defined by WHO are given in Table 42.1:
Table 42.1 : Phases of Influenza Pandemic
Phases of Pandemic Description
Phase 1 No animal influenza virus circulating among animals have been reported to cause
infection in humans.
Phase 2 An animal influenza virus circulating in domesticated or wild animals is known to have
caused infection in humans and is therefore, considered a specific potential pandemic
threat.
Phase 3 An animal or human-animal influenza reassortant virus has caused sporadic cases
or small clusters of disease in people but has not resulted in human to human
transmission sufficient to sustain community level outbreaks.
Phase 4 Human to human transmission of an animal or human-animal influenza reassortant
virus able to sustain community level outbreaks has been verified.
Phase 5 The same identified virus has caused sustained community level outbreaks in two or
more countries in one WHO region.
Phase 6 In addition to the criteria defined in Phase 5, the same virus has caused sustained
community level outbreaks in at least one other country in another WHO region.
Post peak period Levels of pandemic influenza in most countries with adequate surveillance have
dropped below peak levels.
Post pandemic period Levels of influenza activity have returned to the levels seen for seasonal influenza in
most countries with adequate surveillance.

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(a) Early Identification and Control of New Infections.

Pandemic management is a multidimensional and multidisciplinary public health action which is guided by the
principles of public health leadership. It includes outbreak investigation, measures for its containment (both
pharmacological and non-pharmacological), infection control practices in the health care settings and in the
community and active involvement of administrators and the community.  
Alexander Fleming’s serendipitous discovery of Penicillin gave an illusion of human victory over microbes. However,
emerging and re-emerging diseases leading to disease spread, epidemics and pandemics calls for high priority
to health intelligence strategies in health care systems. Further, early identification of zoonotic diseases which
contributes to substantial ever-increasing burden of these emerging and re-emerging diseases requires one-health
approach.
Station Health Organizations and health sections in hospitals play a fundamental role in early identification and
public health control of new infections in the station. The health intelligence by SHOs / health sections needs
to incorporate daily surveillance of not only notifiable diseases but needs to be vigilant on unusual disease
occurrences in the hospitals and community, both in the cantonment areas / stations and the civil hospitals.
Rumour reporting and reports of the Media Scanning and Verification Cell of Integrated Disease Surveillance
Programme (IDSP), National Centre for Disease Control (NCDC) for the respective stations should be included
in the health intelligence for updates. Also, additional mechanisms, such as newspapers, media reports, social
media trends, etc needs to be incorporated into the surveillance strategies. For one health surveillance system
establishments and monitoring, a close association with veterinary hospitals and Remount Veterinary Corps (RVC)
regarding unusual disease occurrences for zoonotic diseases is recommended.
Diagnostics are vital component of a successful surveillance, early identification, outbreak containment and
control strategies. Each microorganism and pathogen have specific diagnostic challenges. Re-emerging diseases
though have validated diagnostic protocols, an early suspicion for the same is required. On the other hand, novel
diseases either lack availability of diagnostic tests or if available, needs validation and performance characteristics
before recommendations.
(b) Outbreak Investigation and Surveillance.
The outbreak investigation is aimed to find out answers to what, where, when, who, why and how the disease is
distributed in the population and factors associated which may suggest control measures to contain the outbreak.
For details of the outbreak investigation, kindly refer to the chapter on epidemiology and excremental diseases.  
Public health surveillance is defined as ongoing systematic collection, collation, analysis and interpretation of
data and dissemination of information to those who need to know to take the appropriate actions. Key elements
of surveillance system include detection and notification of health event, its investigation and confirmation
(epidemiological, clinical, laboratory), collection, analysis and interpretation of data, feedback and dissemination
of results to public health programmes and response for prevention and control. The surveillance in pandemics is
classified as syndromic (Diagnosis based on symptoms / clinical pattern by paramedical personnel and members
of the community), Presumptive (Diagnosis made on typical history and clinical examination by Medical Officer)
and Confirmed (Clinical diagnosis confirmed by laboratory test). The data collection methods may be based on
either or combination of routine reporting (passive surveillance), sentinel surveillance, active surveillance and
laboratory surveillance.
(c) Infection Prevention and Control.
Infection prevention and control during an outbreak, epidemic or a pandemic requires public health actions in
the community settings, at the quarantine and isolation facilities and at health facility level. The detailed plan for
all the public health actions should be based on the natural history of the health condition and its transmission
dynamics.  
In the community settings, the environmental cleaning/decontamination of common public places should be carried
out. For practical purposes, the development of guidelines for decontamination may be issued for indoor areas,
outdoor areas and public toilets. The choice of disinfectant to be used should be based on the susceptibility of
the microorganism (e.g., phenolic disinfectant such as 1% sodium hypochlorite for COVID-19) and the risk benefit
analysis based on the interaction of the disinfectant with the object being disinfected (for example, corrosive agents
should be avoided over machinery). The emerging evidence during a pandemic should be taken into consideration
and guidelines / SOPs should be revised accordingly. In other words, during an emerging epidemic / pandemic, the

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documents need to be real time and dynamic rather than one time effort. Similarly, in quarantine and isolation
facilities, infection prevention and control strategies should be made as per the risk assessment for a given area
of the facility such as reception, lodging area, patient examination area, toilets, etc.
The core components of infection prevention and control programmes at health facility level includes evidence
based guidelines / SOPs, education and training of all healthcare and paramedical staff, ongoing surveillance
for Hospital Acquired Infections, monitoring and audit of the activities being carried out for infection prevention
and control, well defined roles and responsibilities with overarching control to build environment, materials and
equipment related to infection prevention and control. The procedures and practices for infection prevention and
control, in addition to standard precautions, include the following:
(i) Hand hygiene
(ii) Appropriate use of personal protective equipment  
(iii) Safe handling of patient care equipment
(iv) Respiratory hygiene
(v) Cough etiquettes
(vi) Preventive measures from sharp injuries
(vii) Principles of asepsis
(viii) Environmental infection control
(ix) Transmission-based precautions such as airborne precautions, droplet precautions and contact
precautions.  
Control of environment includes control of ventilation, cleanliness, safe water and food and biomedical waste
management. Health facilities with special units such as ICUs, OTs, Maternal and Neonatal Units, Dialysis units,
etc require additional measures for infection prevention and control. It is important to understand that the health
facilities need to be prepared for effective infection prevention and control measures during epidemic / pandemic
situations because of the overwhelming demand, altered priorities of the health facility during the surge and
limited time to strengthen the links / partnerships. To prepare the health facility to handle an epidemic / pandemic
situation, the role of the health facility during such a situation needs to be well defined beforehand and designated
hospitals needs to be earmarked for such contingencies. The health facility should have a Hospital Emergency
Response Plan and all the hospital staff should be trained regularly through drills / simulations.  

42.4 Non-pharmacological Public Health Interventions.

To prevent and control unusual disease frequency during an epidemic / pandemic, non-pharmacological interventions
enable public health managers and administrators in multiple domains. A few of the benefits from such interventions
include identification of the likely route of transmission in the community and the population at risk of contracting
and developing the disease, implementation of preventive and control measures to break the chain of transmission,
early diagnosis, delaying and flattening the peak of epidemic to strengthen the health care infrastructure, etc.
Nonpharmacological public health interventions should be based on scientific knowledge about the disease dynamics
and usually encompasses the following measures:
(a) Enhanced awareness drives.
(b) Contact tracing.
(c) Quarantine of healthy contacts.
(d) Isolation of mild cases.
(e) Self-monitoring by contacts.
(f) Implementation of regulatory approaches (such as physical distancing, use of masks and lockdowns).
(g) Implementation of service approaches (such as free vaccination drives), etc.  
Traditional drug development and discovery have not kept speed with warnings from emerging and re‑emerging diseases
such as Zika, Nipah, Ebola virus, MERS‑CoV and more newly the pandemic of COVID‑19. The new drug discovery has a

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 MISCELLANEOUS ASPECTS OF HEALTH & PREVENTIVE MEDICINE

limitation of high attrition rates, substantial costs and longer duration for discovery, so repurposing old drugs to treat the
diseases becomes a popular and feasible proposition. In contrast, repurposed drugs may be beneficial for patients in
a time of pandemics when the natural history of the disease remains unclear. The use of repurposed drugs in primary
care saves money as well as time, particularly important in pandemic times, which can be a cost‑effective measure in
the public health aspect. The use of repurposed drugs is beneficial, particularly in pandemic and rare diseases, but
their use should be taken with due caution and thorough evaluation. Important public health aspect in primary care
includes avoidance of unnecessary hoarding of such drugs.  
To break the chain of transmission in the early phase of a pandemic / epidemic, when community transmission is not
established, early detection of the effective contacts of a positive case is required. An effective contact of a positive
case is a person who is exposed to a known case and likely to contract the disease from the case. Contact tracing
identifies the population at risk of developing the disease and allows for containment measures (e.g. Quarantine) and
early diagnosis (e.g. Self-monitoring). For an effective contact tracing activity, a dedicated team for contact tracing and
follow-up should be established and trained. The team members may consist of non-healthcare personnel considering
the enhanced health care load of the cases on the health professionals. The list of the probable contacts should be
developed based on the understanding of contact rates for a given individual. For example, for a household, the probable
contacts shall include family members, visiting relatives, domestic help and caretakers, if any. However, whenever a
doubt exists, it is prudent to consider the exposed person as a contact (effective contact). The role of administrators
is pivotal to ensure effective contact tracing and institution of further preventive measures.

42.5 Vaccination Strategies including Vaccine Development and Implementation.

If available, an effective vaccine can develop immunity in population and thus break the chain of transmission. However,
vaccine development and its implementation strategies in pandemics due to novel microbial agents are faced with
challenge of lengthy, expensive process on one hand and need for a speedy availability for a mass vaccination on the
other. The cost and high failure rates of multiple candidate vaccines restricted vaccine developers to typically follow a
linear sequence of steps, with multiple pauses for data analysis or manufacturing process checks.  
Learnings from vaccine industry over the past decade deliberates for a new paradigm for vaccine development which
was followed for SARS-CoV-2 vaccine development. H1N1 pandemic witnessed rapid development of the influenza vaccine
as the sanctions for egg and cell-based vaccines from the regulating agencies could be obtained quickly under the rules
used for change of strains. However, for vaccines against SARS and Zika epidemics, vaccine development could not
be completed and huge financial losses and setback for other vaccine development programs was witnessed. In case
of Ebola, though the vaccine could not be developed for the 2013–2016 Ebola outbreak, the development program
continued and was thus available for use during Ebola outbreaks in the Democratic Republic of Congo later.  
Expansion in basic scientific understanding and newer domains such as structural biology and genomics supported a
new era in vaccine development against SARS-CoV-2. The new paradigm for SARS-CoV-2 vaccine development included
a fast start and execution of multiple steps in parallel before confirming a successful outcome of another step, rather
than the linear process being followed earlier. For example, for vaccine platforms earlier used in humans, phase 1
clinical trials were conducted parallel to animal model testing.
Another important aspect to be considered for vaccine roll out and implementation is the strategy to be followed
for maximum benefit. Since mass vaccinations are to be conducted, ideally, the entire eligible population should be
vaccinated in one go. However, considering the resource constraints, risk stratification of the population based on
scientific evidence is cortical to ensure early protection of the most vulnerable.  

42.6 Hospital Preparedness and Response.

Hospital preparedness is an ongoing dynamic activity which depends heavily on well thought and planned Standard
Operating Procedures which have been practiced regularly by all hospital staff. Each health care facility should conduct
its surge capacity calculations and have implementable expansion plans ready. During any pandemic, infected persons
can be divided into three categories. asymptomatic persons, mildly symptomatic and advanced disease. The patients
who come to the hospital are mostly symptomatic. Some of them may be serious enough to be hospitalized and
some may need intensive care. They are usually graded as mild, moderate and severe, based on clinical finding and
prognosis. The institutional approach to a person reaching the health system includes proper triaging with the purpose
of recognizing and restricting the potential for transmission of infection to others, recognizing bad prognostic signs and
early institution of care depending on the presentation. All health care workers at the triage point should be aware of the
specific information that needs to be elicited (e.g., travel history) and the bad prognostic indicators (symptoms and signs).

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In many illnesses, contact / airborne precautions must be initiated in the triage area itself and unnecessary movement
of patients and close associates must be restricted too. The clinical management of patients during pandemics must be
based on evidence based specific protocols / guidelines. Extreme care should be taken to document all history and other
epidemiologic evidence, however subtle they may be. All activities should be properly documented and communicated
to higher authorities as required. The treatment can be divided into non-pharmacologic interventions (like isolation,
nutritional support), supportive care, specific management (if any), recognition and management of complications.

42.7 Increased Biomedical and Plastic Waste Generation.

Pandemic and the resultant fear of contracting infection impact human behaviour in such a way that it leads to a
stupendous increase in usage of Personal Protective Equipment (PPE). In addition, there is likely to be a surge in demand
of plastic packaged food and use of disposable utensils. All these things will amplify the already existing inadequacies
in our waste management system. The incorrect disposal of PPE especially along with general household waste will
pose an added hazard of infection transmission to those handling this waste. Adequate training of the waste handlers
and provision resources as guidelines for safe disposal of infectious should be ensured at all stages of pandemic.  

42.8 Role of Non-medical Units and Personnel in Pandemic Management.  

The planning and roll out of policies for management of pandemic in the organization is carried out at multiple
echelons from the directorates to local formation headquarters from being general to specific in order. Response to
pandemic being multisectoral, including measures beyond the health care set-up requires community participation and
intersectoral coordination. Existing station health committees can become a nodal agency for pandemic management
at station level. Establishment of Crisis Management Centres comprising of administrative channel can support medical
services for communication, transport, management of fatal cases, reporting, screening of personnel reporting from
leave / temporary duties, establishment of quarantine centres, etc. The focus of medical personnel should be placed
on health care and active support from other branches should be ensured.  

42.9 Preservation of Routine Healthcare Services.

Diversion of healthcare resources towards handling of pandemic would result in disruption of routine healthcare as well
as preventive activities for communicable as well as Non-Communicable Diseases (NCDs). Routine health care activities
are likely to be affected resulting in delay in diagnosis and initiation of treatment as well as disruption of ongoing
treatment for chronic diseases like HIV, TB, Cancers, Hypertension, Diabetes etc. either due to closure of treatment
centres or due to inability of the patients to reach these centres due to restrictions on movement. All efforts should
be made to ensure unhampered continuation of routine preventive and curative services.  

42.10 Infodemic Management.

An infodemic is defined as an overabundance of information including mis / disinformation that occurs during an
epidemic/pandemic. The term was first used in 2003, combining the words “information” and “epidemic”. An infodemic
spreads between humans in a similar manner to an epidemic, via digital and physical information systems. It makes it
hard for people to find trustworthy sources and reliable guidance when they need it. It is propagated by the fundamentally
interconnected ways in which information is disseminated and consumed, through social media platforms, online and
through other channels.
During epidemics, more so than in normal times, people need accurate information so that they can adapt their
behaviour and protect themselves, their families and their communities against infection.  
In the epidemic curve of an infodemic response, analogous to an epidemic response, there are five major workstreams
which form the core domains of the competency framework viz. measure and monitor, detect and understand, respond
and deploy interventions and strengthen resilience. The activities during each workstream are as under: -
(a) Measure and monitor the impact of infodemics during health emergencies. The application of standardized
metrics and tools are needed to track the evolution of infodemics among individuals, communities, societies and
health systems, in both the digital and the physical information environments.  
(b) Detect and understand the spread and impact of infodemics. A common approach is needed to understand
how information and mis/disinformation is spread and how it affects online and offline behaviour in different
populations.
(c) Respond and deploy interventions that mitigate and protect against the infodemic and its harmful effects.

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 MISCELLANEOUS ASPECTS OF HEALTH & PREVENTIVE MEDICINE

An evidence base is needed to identify interventions that are effective in different contexts and for different
types of acute health event.
(d) Evaluate infodemic interventions and strengthen the resilience of individuals and communities to infodemics.
Common evaluation frames are needed to improve the development of interventions and programmatic responses
to infodemics.
(e) Enable, i.e., promote the development, adaptation and application of tools for the management of infodemics.
There is a need to enhance the transferability of lessons and evidence-based interventions between countries
and continents.

42.11 One Health and Pandemics.

Against a constant background of recognized infections, epidemics of new and old infectious diseases periodically
emerge, greatly magnifying the global burden of emerging and re‑emerging diseases. The emergence/re‑emergence of
these diseases is related to multifaceted factors, such as viral recombination and mutation, leading to more infectious
and adaptive strains, industrialization and urbanization and human activities such as deforestation creating a more
permissive environment for vector‑host interaction. A better knowledge of the causes and consequences of certain
human activities, lifestyles and behaviours in ecosystems is crucial for a rigorous interpretation of disease dynamics and
to drive public health policies. Health‑care professionals can prevent and control antimicrobial resistance by prescribing
and dispensing antibiotics as per the laid down guidelines and indications. Sentinel surveillance at the point of entry
should be strengthened. Successful One Health approaches require intersectoral coordination, with a team approach
despite functioning in different sectors or domains. The government and policy‑makers should take scientific decisions
about the creation of epidemiological surveillance centres at the district level on the concept of One Health. It should
have facilities and infrastructure for ecosystem surveillance, namely air, water, soil, flora and fauna, monitoring as well
as investigation of the outbreak. Equally important is to empower the community and family members about the One
Health concept and the concerned matters.

42.12 Conclusion.
World stands at an important turning point. The capability to prevent and manage such global pandemics needs to
be incorporated in its policies. A pandemic offers multitude of challenges to national and global communities. The
countries with better public health care infrastructure are likely to fare better as compared to others. For countries with
insufficient health infrastructure, health and economic impact of the COVID-19 pandemic has offered an opportunity
to rethink their approach to public health. A much-needed public investment in health, a well-equipped workforce to
respond to future pandemics and system capacity for surveillance, contact tracing, research and disease modelling
amongst others will be most crucial for the future generations.  

Suggested Reading.
1. Reynolds MM, Theodore L. A Guide to Virology for Engineers and Applied Scientists. 2023.
2. Abdullahi IN, Emeribe AU, Adekola HA, Abubakar SD, Dangana A, Shuwa HA, et al. Leveraging on the genomics
and immunopathology of SARS-CoV-2 for vaccines development: prospects and challenges. Human Vaccines &
Immunotherapeutics. 2020 Sep 16;1–18.
3. Basu S, Basu D, Niharendu Ghara. Blood Product Support in HSCT. Organ and tissue transplantation. 2021 Jan
1;561–76.
4. WHO Public Health Research Agenda for Managing Infodemics [Internet]. www.who.int. [accessed 2024 Jan 30].
Available from: https://www.who.int/publications/i/item/9789240019508
5. Pandemic Influenza Preparedness and Response: A WHO Guidance Document.
6. Sampath S, Khedr A, Qamar S, et al. (September 20, 2021) Pandemics Throughout the History. Cureus 13(9):
e18136. DOI 10.7759/cureus.18136
n

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 SOP FOR EMBALMING & TRANSPORTATION OF DEAD BODIES

Chapter
XXXXIII
EMBALMING & TRANSPORTATION OF DEAD BODIES

43.1 SOP for Embalming of Bodies for Transportation.

(a) Definition.
Embalming is a procedure used for preserving a cadaver in a life like manner as much as possible and prevent
any decomposition and putrefaction. It is essentially used for transporting cadavers from one place to another,
but it can also be used for preservation of dead bodies for future dissection, public display, etc.
(b) Aim.
The aim of this SOP is to formulate general guidelines for embalming of cadavers in Armed Forces.
(c) Pre-conditions for Embalming.
(i) The body should be explicitly intact.
(ii) There should be no decomposition of the body.
(iii) The cause of death should be known.
(iv) There should be no history of any serious transmissible infection in the deceased.
(d) Pre-Requisites for Embalming.
(i) Identification of body.
(ii) Death certificate indicating the cause of death.
(iii) Short case summary of deceased.
(iv) Application from NOK / OC Unit / Fmn Cdr as per the proforma attached as Appx ‘A’.
(v) In case of battle causality, certificate from OC Unit.
(vi) In the case of medicolegal cases, police clearance certificate.
(vii) Certificate of autopsy completion, if done.
(e) Responsibility of Embalming.
At present there is no law regulating the practice of embalming and there is no special training given for this
procedure in India. The departments of Anatomy or Pathology or Forensic Medicine of medical institutions have
taken the responsibility to embalm cadavers as and when required. However, any medical officer, preferably a
pathologist can perform the embalming as per the procedure laid down in subsequent paras.  
(f) Most Suitable Time for Embalming.
Best results can be achieved when the body is embalmed immediately after the death. Depending upon the
climatic conditions, results are good if the body is embalmed within 6 to 12 hours after death in summer and
24 to 48 hours in winter since the process of decomposition and putrefaction begins after this which is not
desirable for embalming.  
(g) Principle of Embalming.
Infuse a cadaver with an embalming fluid through a large accessible artery or by multiple injections throughout
the body depending upon whether the vasculature is intact or not.

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43.2 Staff and Equipment.

(a) Staff Requirement (Minimum) for the Embalming.
(i) Medical officer One
(ii) Lab Asst One
(iii) House Keeper One
(iv) One trained Ambulance Assistant for packing the embalmed body for transportation is also required.
(b) Equipment.
(i) Mechanical injectors along with tubing and a ‘Y’ canula.
(ii) Drip sets with wide bore long steel/plastic canula.
(iii) Disposable type overalls, which includes - plastic apron, double rubber gloves, head cover, shoe cover,
face mask and goggles for each man of embalming team.
(iv) Steel top table with central hole to drain fluid and a plastic bucket for collection of spilled fluid.
(v) Two enamel buckets lined with plastic disposable bags.
(vi) Instruments trolley on wheel.
(vii) Separate autoclave machine for this purpose only.
(viii) Instruments: Toothed forceps, scalpel with disposable blades, aneurysms needle, artery forceps,
scissors, twine thread, disposable syringes and needles.
Note. All instruments should be sterilized by hypochlorite solution and cleaned with soap and water and then
autoclaved.

43.3 Embalming Set-up.

In an ideal setting for establishing this facility following other equipment/furniture is recommended:
(a) Embalming Room.
(i) Post-Mortem table with inbuilt washing facility and tilting arrangement.
(ii) Shadowless ceiling light.
(iii) Instrument trolley.
(iv) Post-mortem Box.
(v) Iron stand 12’ high stainless-steel container (12-15 lit capacity) for gravity method or embalming
infusion pump system (cost approx 35,000/-)
(vi) Plastic bags for wrapping the bodies.
(vii) Coffins
(b) Preparation Room.
(i) Steel table with washing facility.
(ii) Cupboard to store chemicals.
(iii) Buckets.
(c) Changing Room
(i) Lockers to keep operative clothing.
(ii) Chairs and table.
(iii) Bin to collect spoiled aprons.
(iv) Plastic bags to collect disposable articles.

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(d) Hand washing facility.

(e) Mourner’s Room.
(f) Furniture for seating 6-8 persons.

43.4 Embalming Fluids.

(a) Ideal Fluid.
(i) Methylated spirit 2 lit
(ii) Formalin 1 lit
(iii) Liquid phenol 2 lit
(iv) Glycerin 3 lit
(v) Propylene glycol 5 lit
(b) Less Expensive Alternative Fluid.
(i) Formalin 2-3 lit
(ii) Glycerin ½-1 lit
(iii) Salt (NaCl) 250 gm
(iv) Sodium acetate 25 gm
(v) Potassium acetate 250 gm
(vi) Red lead 100 gm
(vii) Carbolic acid 100 gm
(viii) Water to make 7-10 lit of solution

43.5  Procedure of Embalming.  
(a) Methods.
The methods used will depend on whether the cadaver has undergone the dissection or not. Broadly, three
methods are being used for embalming:
(i) Gravity method
(ii) Electric infusion pump method  
(iii) Multiple injection method
(b) Embalming of Bodies (Intact Vasculature).
Embalming of intact bodies can be carried out by infusion using a Gravity method or an Electric infusion pump
method. In Gravity method, a large reservoir having a capacity of approx. 10 lit is kept at a height of 4 to 5 feet
above the level of table. It is modified by fixing an outlet with a tap system connected with a rubber tubing at
one end and a canula at the other end. Meanwhile in an electric pump method, embalming fluid is infused by
using an electrical pump which exerts a positive pressure.  
Steps:
(i) Step-I.
To embalm, dissect out one femoral triangle and expose the femoral artery for 3 to 4 inch length.
(ii) Step-II.
Place two thick sutures under the artery one at the most proximal exposed part and other at the distal
exposed part (like in case of veins section).

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(iii) Step-III.
Make a nick in the wall and extend it up and down. (Be careful, not to puncture the artery through and
through). Now place one thick bore canula from injector pointing upwards to common iliac and other
downwards to foot. Tie the sutures properly so that the fluid does not leak.
(iv) Step-IV.
Switch on the mechanical injector, about 6-7 litres of embalming mixture is required. This takes about
45-60 minutes to complete the process.
(v) Step-V.
Check completion by feeling hardening of body and development of patches over the skin, all over. This
indicates completion of embalming procedure.
(vi) Step-VI.
Switch off the pump and remove canula one by one tying the femoral artery so that no leakage is possible.
Stich the wound and apply sticking plaster.
(vii) Step-VII.
Put the body in plastic bag and then in a container as per the norms ensuring no leakage of fluid is
possible during transit.
(viii) Step-VIII.
Complete the embalming certificates and sign it. Check all other documents to be accompanied with the body.
(c) Embalming of Bodies (Disrupted Vasculature).
These bodies are embalmed by using injection method. The body cavities are packed with cotton soaked in
appropriate embalming fluid mixture and close it with proper sutures. Embalming fluids should be injected through
iliac vessels into the lower limbs by using two canulae of injectors. Abdomen is sutured. Now take 100 ml or
50 ml plastic syringes with wide bore long needles and inject the fluid in the upper limbs, abdominal mass and
back. Feel for hardness. Pack the body in the plastic bag and then in container, check documents, including
embalming certificate to accompany the deceased body.
(d) Post Embalming.
(i) The body should be thoroughly cleaned and washed after completion of embalming and made
presentable.
(ii) A certificate of embalming should be issued to NOK by the embalming authority as this is required
for transportation of the body for performing last rites.

43.6 Summary.
Embalming is a scientific treatment of the body of the deceased to ensure that it is free from possible infection to the
living. Depending upon the climatic condition, the embalming should be done immediately after death (6-12 hrs after
death in summer and 12-24 hrs after death in winter). The contact of dead body with moisture hastens the process
of decomposition. Hence ice block should not be in direct contact with the dead body. All universal precautions should
be observed for embalming to avoid infection. Embalming is not to be done in medico legal cases before post-mortem
examination. As a precaution police clearance should be obtained in all MLCs. Check all documents before embalming.
Ensure proper sealing of body and container before being dispatched.

Suggested Reading.  
1. Embalming of Cadavers, DG Laboratory Manual of Armed Forces (Vol-I) - 2016.
2. AG’s Branch, Army HQ letter No B/01802/98/AG Secretariat dt 09 Sep 98, Directorate General of Medical
Services (Army) letter No 76776/DGMS-SB dt 20 Aug 98.
3. Bergmann K. Letters to the Editor. Journal of Clinical Pharmacy and Therapeutics. 2003 Apr;28(2):151–3.
n

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Appendix ‘A’
Form of Application For Embalming Human Cadavers
1. Name of deceased: .....................................................................................................................................................................
2. Son / Daughter / wife of: ..........................................................................................................................................................
3. Profession of the deceased: ......................................................................................................................................................
4. Permanent address of the deceased: .....................................................................................................................................
5. Passport No.: ................................................................................................................................................................................
6. Time and Date of death: .................................................. A.M. / P.M. :...................................................................
7. Age: .................................................................................. yrs Sex :....................................................... .Male / Female
8. Place of death: .............................................................................................................................................................................
9. Cause of death: ............................................................................ (died of ..............................................................................)
Medical certificate enclosed / accidental death....................................................................................................................
10. The dead body is to be (transported) to..................................................................................................................................
By Air / Flt No.: .................................................................. Air Lines: ........................................................................
Road / other: ...................................................................... In India:...........................................................................
Place:..................................................................................... District: ...........................................................................
Province / Abroad city: ...............................................................................................................................................................
Country:...........................................................................................................................................................................................
11. The applicant is released to the deceased as friend / colleague / relation................................................................./
any other.........................................................................................................................................................................................
12. Name and address of the applicant.........................................................................................................................................
13. Police clearing for the embalming of the body is enclosed :..........................................................Yes / No: ................
14. Deceased being a foreign national clearance for embalming of his dead body has been obtained from the
Embassy / High commission / Mission of ............................................................................................................................
15. The requisite embalming fee deposited vide receipt No. ................................................. with the cashier / deposited
with the Department of Anatomy.
16. Enclousures with the application:
(i) ....................................................................................... (ii) ..................................................................................
(iii) ....................................................................................... (iv) ..................................................................................
17. Any specific disease, the deceased from, known to the person filling the form:
Tuberculosis Malaria Cancer Hepatitis AIDS etc.
By Air / Flt No. :.................................................................. Air Lines: ........................................................................
Signature of the witness: ................................................. Signature of the applicant: ........................................
Name: ................................................................................... Name: .............................................................................
Address: ............................................................................... Address: .........................................................................
................................................................................................ ..........................................................................................
Tel. No.: ................................................................................ Tel. No.:............................................................................
Certified that:
1. The body has been identified.
2. This is a natural death andno foul play is suspected in this case.
3. Certified that the information given here is correct and no relevant fact has been concealed.
4. Embalming may please be done at our risk and responsibility. The embalmed body will be removed from this
Department within 24 hours.
* Delete whichever is not applicable.

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 ADDITIONAL INFORMATION

ADDITIONAL INFORMATION

List of Hygiene Chemicals Used in Armed Forces

S. Preparation of Ratio of
Items Uses Scale for Use Remarks
No. Solution Solution
ADULTICIDES
1. Malathion Residual 2 gm per sqm 100 ml in 1 ltr of Item: water 02 coats are
premium grade spray against water and spray 1:10 required to
50% mosquitoes. Over 25 sqm be done
Effect lasts upto
2 months
2. Deltamethrin Residual 20 mg per sqm 40 gm in 1 ltr of Item: water Can be used
2.5% WP spray can be water and spray 1:25 against other
used against over 50 sqm vectors and
mosquitoes. pests
Effect lasts upto
3 months
3. Cyfluthrin 10% WP Residual 25 mg per sqm 12.5 gm in 1 ltr Item: water Can be used
spray can be of water and spray 1:80 against other
used against over 50 sqm vectors and
mosquitoes. pests
Effect lasts upto
3 months
4. Lambdacyhalothrin -do-
10% WP
5. Bifenthrin 10% WP -do -
IMPREGNATION OF BED NETS
6. Deltamethrin Impregnation of 11 ml per net Ad 11 ml in 01 ltr Item: water Retreatment
2.5% SC bed nets against of water and dip 1:90 required
mosquitoes mosquito net in it every 6
months
7. Cyfluthrin 5% EW For impregnation 50 mg sqm 1 ml per sqm area — Retreatment
of bed nets in the required qty required
against of water every 6
mosquitoes months

SPACE SPRAY
8. Pyrethrum 2 % For indoor space 100 ml per 40 Mix 100 ml in Item: Used for
spray households 1.9 ltr of kerosene kerosene quick knock
SIP 2 %
oil or diesel oil or diesel down of
1:19 vectors
FOGGING
9. Malathion For outdoor — Mix 5 ltr in Item: To be done
technical grade fogging 95 ltr of diesel kerosene during dawn
95% oil or diesel and dusk
1:19

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 ADDITIONAL INFORMATION

S. Preparation of Ratio of
Items Uses Scale for Use Remarks
No. Solution Solution
10. Deltamethrin For outdoor 0.5 gm per Mix 1 ltr in Item: Window and
1.25% ULV fogging hectare 199 ltr of diesel or kerosene doors to be
k oil oil or diesel kept open
1:199
LARVICIDES
11. Fenthion 82.5% As mosquito 5 /25 ml in Mix 5/25 ml in Item: water Not to be
(Baytex 1000) larvicide 500 sqm when 10 ltrs of water as 1:400/2000 used in
water depth is per depth of water drinking or
up to 10/50 cm portable
water
collection
12. Temephos 50% Mosquito larvae 25 ml for 500 Mix 2.5 ml in Item: water Reapply every
(Abate C) control in linear mtrs 10 ltrs of water 1:400 week
portable water
13. Fenthion 2% Mosquito larval 5 /25 kgs per Throw with hand — —
(Baytex G) control in hectare in water in stagnated or
portable water upto 10/50 cms polluted water
depth
14. Bacillus Kills mosquito 25 gm per 50 Mix 250 gms in Item :water Should not
thuringiensis var larva stage on linear mtrs 10 ltrs of water 1:40 be used in
israelensis (Bti) ingestion portable
12 AS water
RODENTICIDES
15. Bromadialone Available as Single dose of Single dose — —
0.005% ready to use bait 50 milligram per consumption by
kg bait kills rat rodents result in
and mice death
COCKROACHES
16. Baygon C For cockroaches 100 ml /100 Mix 100 ml in 1 ltr Item: water Also used for
(Propoxur 20%) sqm area of water 1:10 debugging in
Armed Forces
ANTI FLY
17. DDVP 76% EC Used as housefly 10 ml /50 sqm Mix 10 ml in 1 ltr Item: water Highly toxic
(Nuvan) larvicide area of water 1:100 insecticide

18. Diflubenzuron Used as housefly 10 gms /10 Mix10 gm in 5 ltr Item: water Can also
25% WP larvicide sqm area of water 1:500 be used as
mosquito
larvicide
n

1283
ADDITIONAL INFORMATION

ARMY ORDERS (ADJUTANT GENERAL’S BRANCH)

S. No. ARMY ORDER (AO) Title

1. 513/71 Invaliding Medical Board – Officers, Nursing Officers and Cadets

Medical Examination of Army Personnel and Families Proceeding Abroad at

2. 299/72
Government Expense on Duty/Deputation/Study Leave

3. 57/73 Prevention of Heat Stroke and Heat Exhaustion

4. 150/75 TB LEPROSY Treatment

5. 165/79 SHO Duties and Different Level Health Responsibilities

6. 7/80 Battle Physical Efficiency Test

7. 14/80 Right to Appeal Against the Findings of a Medical Board

8. 110/80 Effects of High Altitude and Their Prevention

9. 36/87 Leprosy Disposal

Medical Examination of All Ranks Prior to Release, Retirement, Discharge

10. 3/89
Completion of Tenure or Service Limit

Instruction for Holding Disability Compensation Medical Boards (While in

11. 17/89
Service)

12. 15/2000 Re Survey Medical Board

Health Care System in the Army – Instructions for Medical Examination and
13. 3/2001
Categorisation of Serving Jcos/Ors

Health care system in the Army – Instructions for Medical Examination and
14. 9/2007
Categorisation of Serving JCOs/ORs (Amendment No.1)

15. 9/2009 Management of ADS Cases

Health Care System in the Army – Instructions for Medical Examination of

16. 9/2011
serving Officers

17. 5/2020 Instructions for Management of Physical and Battle Casualties

18. 7/2020 Sexually Transmitted Diseases

19. 8/2020 Prevention and Control of Scrub Typhus

20. 9/2020 Immunization

21. 10/2020 Prevention of Food and Water Borne Diseases

22. 11/2020 Prevention of Malaria, Dengue and other Mosquito Borne Diseases

1284
 ADDITIONAL INFORMATION

AIR FORCE ORDERS

S. No. AIR FORCE ORDER (AFO) Title

1. 147/70 Arsene Poisoning

2. 239/70 Air Craft Noise and Preservation of Hearing

3. 460/70 CO Poisoning

4. 473/70 Relapsing Fever

5. 162/75 Responsibilities of AF Health

6. 163/76 Prevention of Epidemic Typhus (Louse Borne)

7. 277/76 Prevention of Scrub Typhus

8. 326/76 Air Craft Noise and Preservation of Hearing

9. 414/76 Prevention of Disease Conveyed by Infected Food and Drinks

10. 461/76 International Certificate of Vaccination and Inoculation

11. 462/76 Effect of Cold and High Altitude and Their Prevention

12. 1091/76 Malaria Eradication

13. 113/80 Prevention of Viral Hepatitis

NAVY ORDERS
S. No. NAVY ORDER (NO) Title

1. 31/79 Medical Check-up of Ex-servicemen Boarded out due to T.B

2. 40/79 Medical Attendance in Ships and Establishment

3. 3(S)/85 Medical Standard (Officers/Sailors)

4. 36/86 Mosquito Borne Diseases

5. 5/87 Sick List Concession Officers

6. 16/87 Annual Health Return

7. 4/90 Alcohol and Drug Abuse

8. 1/91 Control of Meningococcal Meningitis

9. 4/94 Hospital Stoppage Sick Attendant

10. 12/94 Medical Treatment in Quarters: Service Officers

11. 27/94 Medical Treatment of Dependant Parents

12. 31/94 Posting of Personnel in Low Med cat to Remote Areas

13. 34/94 Immunization

14. 38/94 Naval Medical Research Advisory Panel

1285
ADDITIONAL INFORMATION

S. No. NAVY ORDER (NO) Title

15. 45/94 Procedure for Disposal of Naval Personnel on Discharge from Hospitals

Refusal to Undergo Medical Examination, Treatment, Operation, Immunization

16. 51/94
and to Appear Before Medical Board

17. 54/94 Protection of Ears from High Intensity Noise

18. 59/94 Mouth to Mouth Breathing

Entitlement of Medical Treatment in Civil/Private Hospital and Procedure for Re-

19. 6/95
Imbursement

20. 11/95 Medical Board – Assessment of Dental Disability of Officers and Sailors

Medical Examination of Naval Personnel before Release, Retirement and

21. 15/95
Discharge

22. 21/95 Naval Health Committee in Shore Command/ Establishments

23. 22 & 23/95 Dental Returns

24. 24/95 Medical and Dental Treatment of Ex-service Personnel and Families

25. 25/95 Notification of Communicable Diseases

26. 31/95 Pest Control on Ships and Aircrafts

27. 32/95 Dental Inspections

28. 34/95 Sanitary Rules of Food handlers

29. 35/95 Hospital and Blood Bank

30. 36/95 Provision of Beds for Crisis Expansion – Naval Hospitals

31. 38/95 Food Poisoning

32. 2/96 Annual Medical Examination Officers

Psychiatric Examination, Treatment and Disposal of Naval Personnel and

33. 3/96
Families

OPD Treatment of Naval Personnel and Families from Govt Civil Hospitals where
34. 21/96
Service Facilities are not Available

35. Spl 3/99 Reporting of Casualties

36. 3/99 Preventive Measures Against Effects of Heat

37. 6/99 Morbidity and Mortality Return

38. 26/99 Control of Rabies

39. 1/2000 Maintenance of STD Register

n

1286
 ADDITIONAL INFORMATION

DGAFMS Medical Memorandum List

S. No. Memo No. Title
1. 145 AIDS general information and control strategy
2. 146 Allergic Manifestation following drug and serum therapy
3. 147 Penicillin Reaction
4. 148 Pleural Effusion – Diagnosis, management and disposal
5. 149 Cardiac Arrest
6. 152 Medical Aspects of Nuclear Warfare (Vol-I)
7. 152 Medical Aspect of Biological and chemical warfare (Vol-II)
8. 153 Medical certification of cause of death
9. 154 Treatment of poisonous Snake Bite
10. 155 Acute Renal Failure
11. 156 The care, use, storage supply of transfusion fluids and equipments
12. 157 Early detection of cancer
13. 159 Accounting of drugs and stores in ward and in department
14. 161 Inguinal hernia and their disposal
15. 162 Guidelines for the management of acute heart failure and cardiogenic shock
16. 163 Rheumatic valvular heart disease
17. 164 Care in mixing drugs with intravenous infusion
18. 165 Artificial limbs
19. 166 Chronic Renal Failure
20. 168 Routine maintenance and handling of x-ray & electro- medical eqpt by the users vol 1
21. 168 Routine maintenance and handling of x-ray & electro- medical eqpt by the users vol 2
22. 169 Medical guidelines for troops proceeding on mission abroad
23. 170 Autopsies of Cadavers Infected with the human immunodeficiency virus
Reference for psychiatric examination diagnosis treatment and disposal of service
24. 171
personnel and their family suffering from_psychiatric disorders
25. 172 Health Problems Due to Effects of High Environmental Heat and Desert Conditions
26. 173 Typhus Fevers
27. 174 Cardiac murmers
28. 175 Cardiomyopathies
29. 176 Medico Legal Issues- Guide to MO
30. 177 Pan Management for combatants
31. 178 Tuberculosis
32. 179 Diabetes Mellitus
33. 180 Bronchial asthma
34. 181 Spondyloarthritis

1287
ADDITIONAL INFORMATION

S. No. Memo No. Title

35. 182 Hypertension
36. 183 Rabies Control and Treatment
37. 184 Ca re of the wounded in the forward area
38. 185 Ischaemic Heart Disease (Coronary Artery Disease)
39. 186 Retention & Storage of pathology Records & Specimen
40. 187 Malaria Prophylaxis ant treatment
41. 188 Guidelines for management and disposal of cases with Seizures/Epilepsy in the Armed Forces
42. 189 Problems of High Altitude
43. 190 Chronic Kidney Disease
n

1288
 INDEX

INDEX

A Acute flaccid paralysis surveillance – 1167

Abate – 1046 Acute mountain sickness – 152

Abattoir – 46 Acute pulmonary oedema – 152

Abortion – 1205-1207 Acute respiratory disease control – 667, 1185

Abstinence – 665 Acute respiratory infections – 852

Acceleration – 214 Adaptation – 108, 148

Accident prevention – 361 Addictive disorders – 1218

Accidents – 158, 191, 266 Adolescent health programme – 1192

Acclimatization – 137, 154, 281 Adverse events following immunization – 632

Accommodation – 43, 161 Aedes aegypti – 975, 980

Acid Aedes aegypti index – 1030

Ascorbic – 456 Aerated lagoon – 389
Amino – 443, 445 Aerated water – 46, 362
Essential amino – 443 Aerosols – 778
Essential fatty – 448
AFMRC – 559
Fatty – 448
Folic – 456 Age at marriage – 1123
Linoleic – 448 Age specific death rate – 743
Nicotinic – 455 Age specific marital fertility rate – 745
Act Agent – 764, 765
Central Births and Deaths Registration – 1202
Agent factors – 887, 897, 1111
Central Maternity benefit – 1198
AIDS – 665, 1160
Child Labour (Prohibition Regulation) – 1218
ART schedule – 398
Children – 1221, 1223
Clinical staging – 933
Commission for the protection of Child Rights Act
Aims of Epidemiology – 725
Consumer Protection – 1201
Employee State Insurance – 1197 Air
Epidemic diseases – 1204 Conditioning – 1042
Factories Act – 337 Discomfort – 131
Indian Factories – 1196 Disinfection – 193
Medical Termination of Pregnancy – 1187 Pollutions – 366
National Tobacco Control Programme – 1181 Temperature – 33, 115
Prevention of Food Adulteration – 1203 Velocity – 115, 125
Water (Prevention and Control of Pollution) – 59 Air borne transmission – 786
Workmen’s Compensation – 1199 Air-borne infections – 851
Activated sludge process – 385 Air Force Orders – 571
Active immunity – 628 Alcohol – 1089
Active immunization – 651 Alcoholism – 1218
Alcohol abuse – 1219
Acute diarrhoeal diseases – 666

1289
 INDEX

Alcoholic beverages – 490 Anti-malaria organization – 994

Alkalis – 1120 Antioxidants – 488, 1116
Allergic disorders – 633 Antirabies treatment – 659
Allergy – 1104 Antiseptics – 1246
Alma- Ata Declarations – 556 Antisera – 625
Alpha particles – 303
Antitoxins – 633, 652
Altitudes – 141, 293
Ants – 1093
Alzheimer’s disease – 61
Aphthous stomatitis – 1144
Amino acids – 443
Aqua privy – 374
Amoebiasis – 678, 795, 828
Arboviral diseases – 975
Anaemia
Area spraying – 1062
Iron deficiency – 463
Arms circumference – 447
Megaloblastic – 456
Pernicious – 456 Army Orders – 49, 1124
Sickle cell – 463 ARSH – 1192
Anaemia mukt bharat programme – 1186 Artesian wells – 51
Analytical Epidemiology – 728 Arthropod borne diseases – 974
Ancyclostomiasis – 813 Arthropods – 974
Anemometer – 120 Asbestosis – 16
Anganwadi worker – 1172 ASC – 335
Animal foods – 477 ASC specifications – 494, 508
Animal house – 409 Ascariasis – 811
Animal lines – 46 ASHA – 1154, 1179, 1224
Animal reservoir – 906 Association – 730
Animal studies – 732 At risk groups – 466
ANMOL – 1181 Atmosphere – 105, 370
Annual blood examination rate – 992 Atmospheric pressure – 106, 107
Annual parasite incidence – 992 Atopy – 1104
Annual parasitic incidence – 992 ATS – 807
Anopheles – 1043 Attack rate – 839
Antenatal care – 581 Attitudes – 1217
Anthrax – 513 Attributable – 617
Anthropology – 725 Audiovisual aids – 567
Anthropometry – 253 Autoclave – 418, 423
Anthropozoonoses – 782 Auxiliary workers – 581, 1172
Anti-adult measures – 982 Averages – 746
Antibodies – 997, 1104 Avian influenza – 886
Antigen – 625 Ayushman Bharat Programme – 1175
Anti-larval measures – 982, 983

1290
 INDEX

B Bird flu – 887

Bacillus sphaericus – 984, 1048 Birth

And Death Registration Act – 1202
Bacillus thuringiensis – 1047, 1048
Defects – 893
Bacterial infections – 77, 889 Rates – 744, 1192
Bacteriological test for milk – 519 Weight – 1189
Bag sleeping – 37 Bitot’s spot – 458
Baiting – 799 Blackflies – 678
Balanced diet – 474 Bleaching powder – 777, 1238
Ballistic resistant clothing – 41 Blinding – 732
Barber shop – 43 Blindness – 1163
Barotrauma – 179, 184 Blocked flea – 1011
Barrier methods – 847 Blood culture – 955, 958
Basic needs – 79, 1130 Blood groups – 625
Baygon – 169, 1046 Blood pressure – 708
Baytex – 984 Blood slides preparation – 959
BCG vaccine – 653 BMR – 468
Bedaquiline – 858, 859 BOD – 384
Bee – 164 Body composition – 469
Behaviour – 1095, 1102 Body mass index – 1101
Benzene – 349 Body weight – 1101
Benzyl benzoate – 1067 Boiling of water – 71
Beriberi – 454 Bonding – 1217
Beta particles – 303 Bore hole latrine – 816
Bias – 732 Botulism – 836
Bill of fare – 44 Bread – 497
Biochemical Oxygen Demand – 384 Breakdown during combat – 1129
Biohazard symbol – 426 Breakpoint chlorination – 66, 390
Biological Breast feeding – 937, 1113
Environment – 105 Breeding habits – 990
Transmission – 318, 357 Breteau’s index – 1031
Variation – 914 Brill-Zinsser disease – 1021
Biological agents – 800, 901
Brucellosis – 10, 802
Biological control – 984
Bugs – 968, 978
Biological hazards – 16, 335
Bunkers – 17
Biological value – 445
Burns – 246, 257
Biological warfare – 332
Byssinosis – 345
Biomedical waste – 416
Bionomics – 796

1291
 INDEX

C Container index – 1030

Calcium – 462 Copper – 44, 465

Cancer – 308, 357, 1109-116 Cresol – 778

Cantonment water supply – 97 Cross-sectional study – 726, 729, 731

Carbamate – 1007, 1019, 1036, 1039, 1044, 1046, CSIR – 557

1053, 1063 Culex – 980
Carbohydrate – 450-454 Current steam disinfector – 775
Carbon monoxide – 162, 352
Case fatality rate – 11, 741, 806, 848, 865, 869, 1027, D
1153
DBP – 571, 1025, 1067
Centipede – 167
DDT – 82, 1010, 1045
Cereal – 484-486
DDVP – 1045, 1051
Cerebrospinal fever – 770, 874, 900
Death rate – 740, 742
CET – 125, 126
Debugging – 1037
CFC – 154, 155, 414
Decompression sickness – 180
Chancroid – 923
Decontamination – 323, 329
Chemical hazard – 334, 361
Deep wells – 55
Chemical warfare – 36, 323, 324, 1228
DEET – 1067
Chickenpox – 869-873
Dengue – 1029
Chikungunya – 1031, 1154
Dengue haemorrhagic fever – 1032
Child mortality rate – 740
Dental caries – 1139
Chi-square test – 756-757
Dental health – 1137
Chlorination – 66-70
Dental implants – 1143
Chlorine demand – 69-71
Deodorants – 771
Chlorine gas – 67, 68, 176, 196, 317
DEPA – 1067
Cholera – 834-835
Dermatophytosis – 905
Chromium – 73, 84, 348, 466, 468, 1112
Dermatoses – 911
Chronic pulmonary hypertension – 152, 153
Desert – 905
Cisterns – 52, 98, 99, 101, 990, 1042, 1043
Desert sore – 282
Climate – 105-156
Detergents – 771
Clothing – 28-41
Dettol – 778
Cobalt – 312, 333, 353, 456, 773
Diabetes mellitus – 608, 1096
Cockroach – 1038-1039
Diarrhoea – 666, 827, 954
Cohort studies – 725, 727, 730, 731, 732, 738
Diazinon – 1008, 1010
Comfort zone – 109, 110, 128, 172
Dieldrin – 1037, 1063
Comprehensive health care – 562, 580, 581, 1175,
1180, 1234 Dietary fibre – 452

Concurrent disinfection – 772, 779, 830, 868, 875 Digestibility coefficient – 445

Contact diseases – 900-950 Diphtheria – 652, 865

1292
 INDEX

Disability prevention – 1153 Emotions – 913, 1135

Disaster management – 266, 1227 Endemic typhus – 1021, 1023, 974
Disaster management India – 1128 Energy requirements – 468, 470, 471, 472, 473, 574
Disaster planning – 1234 Enteric fever – 6, 7, 8, 80, 519, 803, 818, 827, 841,
842, 974, 1022, 1281
Disaster preparedness – 1233, 1240
Entomology – 974, 975, 977, 979
Disinfectants – 771, 1238
Environment – 574, 580, 581, 583, 584, 585, 617, 634,
Disinfection – 66, 193, 425, 771
663, 668, 670, 672, 685, 688, 691, 716, 725, 733
Disinfection water – 66
Environmental sanitation – 4, 42, 334, 369, 370, 766,
Disinfection wells – 78 771, 798, 829, 830, 834, 846, 849, 867, 881, 1007,
1010, 1239
Disinfestation – 771, 1010
Epidemic Curve – 728
Disposal of dead animals – 410
Propagated Epidemic – 655, 894, 1275
Double blind – 732
Epidemic dropsy – 504
DPT – 652
Epidemic investigation – 838-840
Dracunculiasis – 977, 1193
Epidemiologic methods – 726
Driven wells – 57
Epidemiological methods – 736
Drowning – 191
Epidemiological triad – 765
Drug abuse – 611, 1221
Epidemiology – uses – 782
Dry day – 983
Epidemiology – 725-736
Dust control – 356
Epizootic – 9, 514, 675, 676, 678, 726, 783, 786, 792,
Dust gun – 1053 975, 1011, 1012
Dysentery – 827 Epizootic epidemic cycle – 782
Eradication – 10, 93, 654, 767, 784, 785, 804, 848,
E 850, 913, 918, 920, 951, 983, 992, 994, 1011, 1043,
1048, 1070, 1155, 1159, 1165, 1167, 1193, 1194
Earthquakes – 1, 277, 1227, 1228, 1235
Ergonomics – 174, 280, 335, 341, 367, 368
Ebola viral disease – 625, 678, 954, 966, 1032, 1271,
1273, 1274 Erythema – 129, 145458, 633, 655, 657, 869, 895,
910, 916, 930, 1122, 1124, 1219, 129
Echinococcus granulosus – 516, 818, 820
Erythrocytic phase – 986, 987
Echinococcus multilocularis – 820
ESI Act – 1197, 1198, 1199
Ecthyma – 904
Essentia fatty acids – 448, 1089,
Effective temperature – 125, 126, 128, 172
Essential amino acids – 443, 445, 484, 485, 486,
Egg – 447-448
Essential obstetric care – 1184, 1185
Eligible couples – 566
Excremental diseases – 282, 728, 827, 829, 847, 1236,
Embalming – 1277 1272
Emergency contraception – 724, 1278, 1279, 1280, Excreta disposal – 47, 92, 93, 372, 378, 379, 383, 395,
1281
Exotic – 58, 458, 1074
Emergency obstetric care – 1184, 1185, 1191
Expanded polysterene beads – 1001
Emerging and re-emerging infectious diseases – 11, 67,
298, 725, 824, 877, 899, 950, 990, 1002, 1070, 1082, Experimental studies – 727, 731, 761
1088, 1090, 1126, 1176, 1209, 1210, 1215, 1221,
1270, 1272, 1273, 1276

1293
 INDEX

F G
Factories Act – 337, 340, 345, 364, 1196 Gametogony – 986
Faeces disposal – 376 Garrison water plants – 97
Family planning – 572, 574, 579, 581, 582, 729, 739, Genetic control – 983, 1001, 1041, 1066
1179, 1180, 1186, 1190, 1192, 1223, 1224, 1225
Ghee tin urinal – 381
Family welfare programme – 572, 573, 1147
Gingivitis – 586, 939, 1141, 1142, 1143
Family welfare programme, Armed Forces – 572
Global warming – 154, 155
Fasciolopis buski – 825
Glossitis – 455
Fats – 447, 475, 489, 1088, 1090
Gobar gas plant – 395, 396
Fenitrothion – 1019, 1036, 1037, 1039, 1044, 1046
Goiter – 59, 464, 467, 1108, 1109, 1165, 1190
Fernandez reaction – 916
Filarial indices – 999
H
Filarial survey – 999
Haemorrhagic fever – 954, 1028
Filariasis – 975, 995, 1147, 1148, 1152, 1153
HAPO – 290-295
Filter mechanical – 65
Hardness – 75-76
Filter membrane – 74
Haworth system – 387
Filter rapid sand – 64, 65
HCH – 1010, 1037
Filter slow sand – 62, 65
Head gear – 359
Filtration – 53, 60, 61, 64, 75, 91, 97, 393
Health promotion – 766
Fish – 191, 197, 445, 486, 497, 499, 500, 509, 510,
Health related Illness – 130-140
977, 1064
Helmet – 37
Fish bite – 1040
Helminths – 810-825
Fleas – 666, 1008, 1009
Herd immunity – 627
Flight range – 990
High altitude related illness – 286-302
Fluorine – 464
HIV – 933-952
Foetal death – 740, 741, 744
Homeostasis – 108
Folic acid – 351, 456, 460, 461, 488, 492, 581, 1187,
1192, 1088, 1174, 1177, 1180 Horrock’s test – 69-70
Folliculitis – 904, 950 Hospital dietary – 493-494
Food and beverages examination – 962 House fly – 1006-1008
Food poisoning – 7, 158, 337, 519, 770, 827, 836, Housing and health – 15-27
837, 839, 976
Humidity – 112-122
Formaldehyde – 16, 578, 632, 655, 778, 777, 781
Hydatid cyst – 516, 820
Frost bite – 141, 142, 143, 147, 208, 245, 273, 569,
Hydroclave – 426
570, 571, 807, 808
Hydrogen cyanide – 352
Fruits – 451, 453, 475, 488, 498, 502, 508, 1115
Hydrogenated oil – 508
Funnel urinal – 159, 380, 381
Hygiene – 568
Furunculosis – 137, 903, 911
Hygiene of cookhouse – 43,160, 521-524
Hypertension – 1091-1095

1294
 INDEX

I L
IHD – 1083 Laparoscopy sterilization – 1224
Immune reaction – 1104 LAQSHYA program – 1187
Immunity – 627 Larvicidal measures – 983-984
Immunization – 628, 630 Larvivores fish – 984
Immunoglobulins – 626 Latent period – 308
Impetigo – 903 Latent TB – 1159
Incidence rate – 741 Latrines – 375-378
Indian tick typhus – 977, 1023 Lead exposure – 15
Infant mortality rate – 581, 743 Leech bites – 1040
Influenza – 882 Legislative control – 769, 1040
Injuries, NEA – 1116 Leishmaniasis – 1003-1005
Insect growth regulators – 1031, 1037 Lepra reaction – 916
Insecticides – 893, 984 Lepromin test – 916
Inspection, diaries – 43, 44 Leprosy – 913-919
Integrated vector management – 1070 Leptospirosis – 800-801
International health regulations – 192 Levels of health care – 1170
Iodine – 444, 464 Levels of prevention – 765-767
Ionization – 304 Lice – 977, 1013-1015
Iron – 462 Life style – 609, 1087, 1089, 1115
Lighting – 43, 273, 249, 338-339
J Lipids – 447-450, 1088
Japanese encephalitis – 1027-1029 Lipoproteins – 448-449
JSSK – 1177, 1179, 1186, 1191 Literacy (Health) – 1215
JSY – 1177, 1179, 1185, 1186 Live birth – 740
Live vaccines – 631
K Lizards – 1002
Kala-azar – 1002, 1147, 1154, 1177 Longitudinal studies – 726
Kata thermometer – 120, 125 Louse-borne epidemic typhus – 977
Keratomalacia – 458 Low birth weight – 871, 1189
Kessenger process – 387 Lung cancer – 366, 570, 1110
KFD – 630, 977, 1028, 1033 Lux – 249
Kilkari – 1181 Lymphatic Filariasis control – 1000-1001
Killed vaccines – 630, 631
Knapsack sprayer – 984, 1028, 1052, 1059, 1062 M
Koplik spot – 891, 892 Magnesium – 476-479
Maize – 451, 455, 456, 460, 484, 485
Malaria – 985–995, 1073-1075, 1187-1189

1295
 INDEX

Chemoprophylaxis – 663, 666, 1147-1152 Mercury – 84, 86, 88, 115-117, 120, 345, 348, 423
Control program – 1147-52 Messing arrangement – 521
Malaria elimination in India (2016-2030) - 1194
Metabolic heat – 31, 34, 123
Malathion – 1043 -1049
Metal fume fever – 349
Malnutrition – 1171–73, 1188–90
Meteorological environment – 107, 113-117, 121, 125,
Malocclusion – 716, 1143 285, 1229
Manmade disaster – 1228 Microwave – 426
Mansonoides – 975, 979, 996, 998, 1000 Mid day meal program – 585
Mantoux test – 739 Miliaria – 910
Manual vacuum aspiration – 1186 Military nutrition – 442, 482
Marching – 32, 39, 132, 574-78, 596 Milk – 486, 487
Mass screening – 358, 1115 Milk borne diseases – 519
Mass treatment – 813, 814, 825, 910, 1015 Milk hygiene – 517-20
Matching – 709, 1240, 1243 Milk ring test – 803
Maternal and Child Health – 579-81, 1175, 1177, 1179, Millet – 485-486
1180, 1190, 1202
Mineral – 349, 459-474
Maternal and Child Health wing – 1180
Mineral oils – 349, 984, 1044
Maternal mortality rate – 580, 581, 740, 743, 1176,
Minimum needs programme – 1193
1179, 1208, 1216
Mission Indradhanush – 1165
MCH – 1165, 1180, 1187
Mission parivar vikas – 1224
MDG – 556
Mite borne scrub typhus – 1024-1027
Mean – 29, 32, 33, 102, 111-117, 121-24, 154, 155,
213, 216, 469, 470, 746-62 Mites – 977, 1015, 1017-1021
Measles – 890-96 Mode – 747
Measles and rubella elimination strategic plan – 893, Modes of intervention – 765-767
896
Modes of transmission – 764
Measurement of maternal mortality – 580
Molybdenum – 481
Measurement of morbidity – 741-742
Monitoring – 314, 315
Measurement of mortality – 742-745
Morbidity pattern – 1, 4
Meat – 455-68, 486-91
Mosquito borne diseases – 111, 975, 983
Median – 746
Mosquito control measures – 982, 992
Medical care – 685-724
Mosquitoes – 978-985
Medical entomology – 974-1081
Mother and child protection cards – 1177
Medical records – 250, 358, 365
Motivation – 109, 161, 216, 299, 363, 567, 572, 611,
Medical sociology – 1214 742, 917, 948, 1103, 1129, 1132, 1136, 1222
Meningococcal meningitis – 647, 658, 665, 678, 874-877 MPW – 1149
Mental Health – 16, 143, 310, 881, 1125-1136, 1168- MSAC – 558, 684
1169, 1125
MTP -1187, 1205-08
Mental health act – 1169
MUFA – 448-450
Mental retardation – 309, 1127, 1128
Mumps – 896 – 899

1296
 INDEX

Murine typhus – 976, 1023 Neonatal tetanus – 807, 868

Mutation – 72, 298, 304, 307, 309, 310, 616, 618, Net protein utilisation – 446
631, 856, 877, 885, 939, 941, 948, 1276
Net reproduction rate – 745
Neutral red test – 71
N Niacin – 455
NACO – 421, 1211
Night blindness – 458
National Health Programmes
Nikshay – 1158
NACP – 946, 1160
Nitro-glycerine – 351
Chikungunya fever – 1154
Family welfare programme – 572, 1147 Nitrous fumes – 353
Filaria control programme – 1152 Noise – 173, 177, 263, 355
Guinea worm eradication programme – 1193 Non carbonate hardness – 75
IDSP – 770, 973, 1272
Non communicable diseases – 1082
Iodine deficiency disorders control programme – 1165
Japanese Encephalitis control – 1147, 1155 Non enemy action – 6, 12, 1116
Kala-azar control programme – 1154 Non randomized trials – 727
Leprosy eradication programme – 1155 Nosocomial infection – 335
Malaria programme – 1148 Notifiable disease – 345, 735, 768-770
Mental Health programme – 1168
Notification – 768
Minimum needs programme – 1193
NHM – 1176 NSSK – 1189
NP-NCD – 1169 Nuclear accidents – 319
NRHM – 1179 Null hypothesis – 750
NTEP – 857, 1157 Nutrients – 442
NUHM – 1177
Nutritional rehabilitation centre – 1188
Nutritional anaemia prophylaxis programme – 1186
Nuts and Oil Seeds – 475
NVBDCP – 1147
Programme for control and treatment of occupational
diseases – 1184 O
Programme for control of blindness and visual
Obesity – 571
impairment – 1163
Programme for health care of elderly – 1218 Observer bias – 732
RCH – 1184 Occupational cancer – 357
RMNCH+A – 1190
Occupational dermatitis – 350
STD control programme – 1160
Occupational disease – 338, 1184
UIP – 1165
Water supply and sanitation programme – 1182 Occupational hazards – 335, 346, 668, 783
Yaws eradication programme – 1193 Occupational psychology – 364
National strategic plan for TB elimination – 1158 Oral cancer – 1143
Natural history of disease – 765 Oral health – 1137
Navy Orders – 1285 Oral manifestations of HIV/AIDS – 1142
Neonatal care – 1185 Oral rehydration – 829
Neonatal hypothyroidism – 464 Order, Anoplura – 974
Neonatal mortality rate – 744, 1192 Order, Diptera – 974

1297
 INDEX

Order, Hemiplura – 974 Phenol – 777, 1279

Order, Siphonoplura – 974 Phlebotomus – 976
Organochlorine compounds – 1045 Phosphorus – 1003, 344, 345, 348, 462
Orofacial lesion – 1144 Physical environment – 369, 105, 341
Orthotolidine Test – 70 Physical hazards – 334, 353
Oviposition traps – 1031 Plague – 515, 654, 770, 976, 1008
Oxford index – 128 Planning and evaluation – 736
Oxidation pond – 388 Plasma torch technique – 426
Ozone – 71, 154 Plasmodium falciparum – 985
Pneumoconiosis – 283, 345, 366
P Poisoning – 519, 770, 836
P value – 751-752 Policy on HIV testing – 946
Paediatric TB – 858, 861 Poliomyelitis – 770, 848, 850
Pakhal – 101 Ponds – 51, 52
Panchayati Raj – 1150, 1182, 1207 Population at risk – 741, 1150
Pandemic – 1270 Portal of entry – 827, 851, 870, 902
Pandemic Influenza A (H1N1) – 882 Poshan abhiyan – 1173
Parasite rate – 991 Positive health – 1220, 556
Paris green – 984, 1044 Post neonatal mortality – 744
Passive immunity – 629, 652 Postnatal care – 582, 1177
Passive immunization – 789, 873, 889, 652 Potassium – 72, 270, 777, 1279
Pasteurization of milk – 772 Poverty – 1214
PDK no. 1 & 2 – 323 Predictive value – 895
PEL – 340 Pregnancy detection – 1186
Pellagra – 455, 461, 485 Pregnancy rate – 796
Peptic ulcer – 1105 Preplacement medical examination – 316, 358, 364
Perinatal Mortality – 741, 744 Presentation of data – 31
Perinatal mortality rate – 744 Pressure steam disinfectors – 774
Period prevalence – 741 Presumptive coliform test – 90
Periodic Medical Examination – 587, 590 Prevalence rate – 729, 741
Periodontal disease – 669 Prevalence studies – 729
Personal care – 556, 567 Preventive medicine – 764 , 1, 14, 663, 672
Personal hygiene – 663, 665, 162, 568 Prickly heat – 132, 137, 169, 910
Personal protection – 804, 982, 343 Primary Health Centre – 1224
Personality – 594, 1125 Primary Prevention – 146, 342, 765
Personality development – 342, 1125 Probability – 749, 272
Personality traits – 1130, 341 Proportion – 452, 469, 749
Pertussis – 624, 652, 887 Proportional case rate – 992

1298
 INDEX

Proportional mortality rate – 744 Red cross – 659

Propoxur – 1007 Reference body weight – 446
Prospective cohort studies – 730 Reference population – 730, 731, 748
Protection against radiation – 311 Refuse – 46, 47, 48, 159, 172, 199, 260, 261, 371,
372, 393, 397, 399, 400, 402, 405, 522, 524, 562,
Protective clothing – 312, 313, 315, 350, 801
646, 682, 1200
Protein energy malnutrition – 458, 783
Registration of Births and Deaths – 1202
Protein quality – 445
Regression – 758, 761, 762, 763
Protein requirements – 447, 493
Rehabilitation – 12, 14, 325, 326, 342, 359, 374, 494,
Proteins – 443, 1107, 136, 273, 350 557, 582, 731, 766, 767, 918, 1116, 1124, 1143,
1156, 1169, 1171, 1183, 1184, 1188, 1198, 1222,
Psychiatric disorders – 1126, 1133
1232, 1233, 1234, 1240, 1241
Psychology – 364
Relative risk – 1087
Psychosocial environment – 334
Repellents – 4, 8, 9, 169, 666, 984, 985, 993, 994,
Psychrometer – 117 1003, 1105, 1121, 1124, 1125, 1126, 1031, 1033,
PUFA – 448, 449, 476 1136, 1140, 1151, 1166, 1167, 1168

Pulse Polio immunization – 647, 848, 1166 Reservoir of infection – 10, 767, 825, 827, 828, 831,
841, 845, 865, 874, 903, 909, 991, 1003, 1005, 1019,
Pulses – 445, 451 1024, 1030, 1193
Pyrethrum – 983, 993, 1037, 1043 Residual insecticides – 9, 824, 983, 992, 993, 1003,
Pyridoxine – 863 1037, 1039
Residual spraying – 1010, 1045, 1046, 1052, 1053,
1054, 1075
Q
Respirators – 315, 344, 347, 348, 352, 353, 360, 361,
Q fever – 519, 669, 1022, 1026 362, 778
Quality of life – 1168, 1135, 1143 Retrospective cohort studies – 730
Quarantine – 1205, 1272, 1275, 193, 330, 768 Reverse osmosis purification – 72
Quartering – 17 Rheumatic heart disease – 1190
Quicklime – 68, 777 Riboflavin – 444, 455, 460, 477, 478, 479, 483, 484,
486, 487, 488, 490

R Rice – 459, 484-485

Rabies – 785-794 Rickets – 459, 461, 462, 467, 515, 1019, 1190

Radiation – 304-321 Rickettsial disease – 770, 785, 1022, 1023

Radiation effects – 129, 306, 307, 336 Rickettsial pox – 977, 1022, 1024

Radiation hazards – 306, 311, 312, 315, 316 Rickettsioses – 1021, 1023

Radioisotopes – 303, 306, 312, 314, 315 Ringworm – 905, 906, 907, 951

Random numbers – 739 Risk Factors – 289, 291, 292, 293, 295, 571, 725, 726,
727, 731, 733, 736, 765, 873, 970, 1086, 1087, 1088,
Randomization – 726, 731, 732 1089, 1124, 1141, 1216, 1217, 1237
Rapid sand filters – 61, 62, 64, 65, 97 Risk Groups – 291, 466, 657, 660, 766, 792, 813, 873,
Rashtriya bal swasthya karyakram – 1180, 1189, 1191 1100, 1115, 1152, 1157, 1159, 1162

Rate – 741 Rivers & streams – 53

RCT – 727, 731 RMNCH+A – 579, 1176, 1179, 1180, 1187, 1190

1299
 INDEX

RNTCP – 858, 860, 1157 Sickle cell anaemia – 680

Road traffic accidents – 158, 1144 Sickness absenteeism – 882
Rodents – 794-800 Sickness benefits – 1199
Rodent control – 198, 199, 666, 797, 800, 1010, 1026, Silicosis – 354, 853
1051
Skin disease – 900-919
Rodenticide – 798, 1239
Slaughterhouse – 409, 517, 554-555
Rubella – 844, 849, 850, 872, 892-897
Slow sand filter 62
Rural development – 93, 505
Sludge treatment – 392-393
Small family norm 573
S Smallpox – 10, 654
Sabin Vaccine – 624
Smallpox – 10, 317, 624, 735
Safe abortion services – 1186, 1206
Snake bites – 282, 572
Salk vaccine – 624
Snakes – 169, 191
Sample registration system – 741, 742
Social agents
Sampling – 505, 739, 748, 957 Agencies – 17, 92, 266, 412
Sand flea – 282, 1008 Communication – 7, 157, 213, 414, 696
Sandflies – 569, 677, 974, 1002 Control mechanism – 28
Defence – 31, 86, 197, 230
Sandfly fever – 675, 976
Indicators – 103, 234
Sanitary latrine – 375, 568
Institutions – 394, 559, 866
Sanitary well – 55, 823 Medicine – 14, 171, 210
SARS – 660, 735, 877, 1274 Mobility – 35, 165
Scatter diagram – 758 Obstetrics – 1186, 1206
Organization – 7, 86, 159, 482, 561, 1127
Sciences – 725
Paediatrics – 656, 1262
Screening test – 940, 943
Pathology – 16, 180, 254
Scrub typhus – 2, 9, 18, 158, 977, 1024 Sodium – 467, 490 (Ration scales), 829 (ORS/ORT)
Secondary attack rate – 869, 888 Solar dermatitis – 129
Security – 359, 1085, 1197 Solar radiation – 113-114 (Solar radiation thermometer),
Selective screening – 1115 128, 129, 283
Selenium – 84, 244, 466 Sources of water – 51-57
Self Care – 1099 Specific protection – 766-767
Sensitivity – 143, 306, 635, 940 Spiders – 1040-1041
Sentinel surveillance – 941, 1147, 1162, 1276 Springs – 57
Septic tank – 47, 374, 383, 816, 1000 Standard error (SE) – 749
Serum cholesterol – 664, 733, 1090 STDs syndromic approach – 925
Sewage – 47, 85, 197, 369 STDs – 923-952
Sewage purification – 384 Step wells – 57
Sex ratio – 1106 Stevenson screen – 115-116
Shake test – 642 Stress – 11,669-670 (UN mission), 1082-1083

1300
 INDEX

Structure of tooth – 1137-1138 Trachoma – 924

Submarines – 174-177 Trans fatty acids – 448
Surface water – 51-54 Transmission dynamics – 736
Surveillance in AFP – 850 Trench fever – 1026
Surveillance in HIV – 1162 Treponematosis – 925
Surveillance in malaria – 1149-1152 Triage – 718
Survival at sea – 200-209 Triangle of Epidemiology – 733
Swimming pool – 77-78 Trichomoniasis – 924
Syphilis – 925-928, 932 Trickling Filter – 386
Triglycerides – 1088
T Triple blind trials – 732
Taenia saginata – 515 Tsetse flies – 978
Taenia solium – 516 Tube wells – 51
Taeniasis – 678 Tuberculin test – 853
Tallow melting – 409 Tuberculosis – 851
Targeted interventions – 1161 Type A personality – 1125
Temperature requirement of vaccines – 635 Typhoid fever – 841
Temporal association – 727 Typhoid vaccine – 843
Temporary carrier – 865 Typhus – 168
Terminal disinfection – 772
Termination of pregnancy – 1205 U
Tertiary prevention – 342 Ulcer tropicum – 905, 1036
Test of significance – 749 Ultraviolet radiation – 66, 72, 105, 129, 154, 155, 210,
212, 287, 303, 318, 334, 354, 458, 633, 772, 1112,
Tetanus – 806
1114
Tetanus neonatorum – 807
UN mission health guidelines – 664-684
Thalassemia – 612
UN mission immunisation – 3, 7, 8, 11, 663
The water (Prevention & Control Act) – 59
UN mission injuries – 12, 14, 663, 718, 1116
Thiamine – 454
UN mission malaria prevention – 2, 4, 7, 8, 160, 167,
Ticks – 1015 564, 666, 673, 675, 677, 679, 785, 993
Tinea cruris – 907 UN mission notification and reports – 670, 770, 1272
TNT – 351 UNDP – 92, 93, 357, 681
Tobacco control legislation – 1181 UNICEF – 681, 829, 893, 1193
Tooth numbering – 1138 Unit inspection – 7, 42, 43, 45, 47-49, 97, 261, 334,
371, 420, 424, 521, 523- 524, 562- 567, 574, 907,
Total dissolved solids (TDS) – 81
910, 932
Total fertility rate – 1223
Unmet needs of family planning – 1223
Total marital fertility rate – 745
Urbanization – 5, 17, 154, 408, 459, 481, 841, 997,
Toxoids – 631 114, 1227, 1270, 1276
Trace elements – 462 Urine disposal – 371, 376, 379, 399, 416, 824, 844

1301
 INDEX

V Subunit – 880 (Covid-19), 630 (Hep B), 654 &

834 (Cholera)
Vaccination
Toxoid – 631
In Armed Forces – 646-650
Chickenpox – 656, 872 Validity – 661 (Yellow fever vaccination certificate), 589
(AME)
Cholera – 653, 834-835
COVID-19 – 660, 880 Varicella – 869-873
Diptheria – 652, 867 Vasectomy – 1198 (ESI sickness benefit), 1224
Dogs and animals – 794 (Contraceptive service & Mission Parivar Vikas)
Hepatitis A – 656, 662 Vector-borne transmission – 764, 975-978
Hepatitis B – 657 Vegetables – 451 (Carbohydrates source), 453-454
Influenza – 657 (Fiber source), 454-459 (Vitamin source), 459-466, 467
Measles – 655, 892 (Mineral source), 474-479 (Balanced diet), 487 (Military
rations), 496-497, 502 (Scales of rations), 500 (Hospital
Meningitis – 658, 876 diet), 508-509 (Inspection in Armed forces), 522, 524
Mumps (MMR) – 655, 898 (Storage in armed forces)
Pertussis – 652, 889 Vehicle-borne Transmission – 764
Plague – 654
Ventilation – 20 (ventilation standards), 172 (Ship), 174
Pneumococcal Disease – 648, 1166 (Submarine), 339 (at workplace)
Polio – 654, 849
Viral hepatitis – 7, 53, 58, 80, 282, 337, 519, 597,
Rabies – 659 672, 678, 785, 827, 844, 845, 846, 849, 850, 900,
Rota Virus – 648 976, 1007, 1104, 1236
Rubella – 655, 895-896 Viral hepatitis – 844-850
Tetanus – 651
Vision
Tuberculosis – 653
Underwater – 178
Typhoid – 651, 657, 843
Effect of ‘G’ – 216
UN missions – 664
Effect of hypoxia – 230
Universal Immunization Programme – 1165-1166
School health – 585
Yellow Fever – 661
SHAPE – 596
Vaccine Derived Polio Virus – 850, 1167
VISION 2020 – 1164
Vaccine Reactions Vision 2020: Right to Sight – 1164
Common – 633 Visual impairment – 1163-1164 (National Programme
AEFI – 632 for Control of Blindness & Visual Impairment), 1165
(Rashtriya Netra Jyoti Abhiyaan)
Vaccine Vial Monitor – 642-644
Vital statistics – 740 (Armed Forces), 741-742
Vaccines
Vitamins – 454-459
Acellular Fractions – 630 & 889 (Pertussis)
Conjugated – 843 (typhoid conjugate vaccine),
648 (Pneumococcal vaccine) W
Killed – 631 Water
Live – 631 Acceptability aspect – 80
Borne diseases – 58, 158, 49
Pentavalent – 648, 808
Chlorination – 95, 100
Polysaccharide based – 647, 651 (typhoid),
Coliform Organisms – 90, 91
658 (Meningococcal)
Disinfection – 74
Recombinant – 647 (Hep B), 654 & 834 (Cholera)
Distribution – 196, 1237
Stabilizers – 632

1302
 INDEX

Fluoridation – 77 West nile fever – 675, 676, 735, 976

Hardness – 75 Wheat – 442, 445, 451, 460, 485, 492
Harvesting – 92
White phosphorus – 348
Inorganic Constituents – 81
Whooping cough – 624, 634, 652, 770, 887, 1236
Microbiological aspect – 80, 83
Organic constituents – 82 Work environment – 338
Pollution – 57 World bank – 50, 92
Purification – 60
Quality standards – 80
X
Radiological aspect – 80, 83
XDR – TB 859, 864
Reverse osmosis purification – 72, 195
Safe and wholesome – 51 Xenopsylla – 976, 1008-1010
Standard of Quality – 80 Xeropthalmia – 497-498
Water carriage system – 372 Xerosis – 458
Water closet – 47, 337, 373, 375
Water points – 97, 98, 99 Y
Water repellent clothing – 40 Yaws – 58, 976, 1193
Water seal latrine – 375 Yellow fever – 1033-1035
Weaning – 458
Weather forecasting – 113 Z
Weekly iron & folic Acid supplementation – 1180, 1187 Zika virus disease – 976, 1069
Weight for Age – 1086 Zinc – 465, 1190, 1239
Welding hazards – 354 Zinc phosphide – 199, 798
Wells – 51, 54, 55, 56, 57, 78, 1238 Zoonoses – 975-976
n

1303