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INTRODUCTION-

Ischemia is a condition in which the blood flow (and thus oxygen) is restricted or reduced in a part of the body. Cardiac ischemia is the name for decreased blood flow and oxygen to the heart muscle.

Ischemic heart disease is a condition of recurring chest pain or discomfort that occurs when a part of the heart does not receive enough blood. This condition occurs most often during exertion or excitement, when the heart requires greater blood flow. Ischemic heart disease, also called coronary heart disease, is common in the United States and is a leading cause of death worldwide.

Ischemic heart disease develops when cholesterol particles in the blood begin to accumulate on the walls of the arteries that supply blood to the heart. Eventually, deposits called plaques may form. These deposits narrow the arteries and eventually block the flow of blood. This decrease in blood flow reduces the amount of oxygen supplied to the heart muscle.

The signs and symptoms of ischemic heart disease may develop slowly as arteries gradually become blocked, or they may occur quickly if an artery suddenly becomes blocked. Some people with ischemic heart disease have no symptoms at all, while others may have severe chest pain (angina) and shortness of breath that can pose a risk of heart attack.

Fortunately, ischemic heart disease can be treated successfully with lifestyle changes, medicines, and surgical procedures. Even better, you can reduce your risk of ischemic heart disease by following heart-healthy practices, such as eating a low-fat, low-sodium diet, being physically active, not smoking, and maintaining a healthy body weight.

Left untreated, ischemic heart disease may lead to severe heart damage. Heart damage can result in heart attack and shock and may be life threatening. Seek immediate medical care (call 911) for serious symptoms, such as difficulty breathing, which may be accompanied by pale or blue lips, rapid heart rate (tachycardia), and severe chest pain. Seek prompt medical care if you are being treated for angina but have mild symptoms that recur or are persistent.

ETIOLOGY-

Ischemic heart disease is caused by a decrease in blood flow through one or more of the blood vessels that carry oxygen to your heart (coronary arteries). When blood flow is reduced, the heart muscle does not receive the amount of oxygen it needs to function properly.

Ischemic heart disease may develop slowly, as plaque builds up over time, or it may occur quickly if an artery is suddenly blocked. For this reason, ischemic heart disease occurs most frequently in people who have atherosclerosis (buildup of plaque on the walls of the coronary arteries), blood clots, coronary artery spasm, or severe illnesses that increase the heart’s need for oxygen.

SYMPTOM –

If your coronary arteries narrow, they can’t supply enough oxygen-rich blood to your heart — especially when it’s beating hard, such as during exercise. At first, the decreased blood flow may not cause any symptoms. As plaque continues to build up in your coronary arteries, however, you may develop the following coronary artery disease signs and symptoms:

• Chest pain (angina). You may feel pressure or tightness in your chest, as if someone were standing on your chest. This pain, called angina, usually occurs on the middle or left side of the chest. Angina is generally triggered by physical or emotional stress. The pain usually goes away within minutes after stopping the stressful activity. In some people, especially women, the pain may be brief or sharp and felt in the neck, arm or back.
• Shortness of breath. If your heart can’t pump enough blood to meet your body’s needs, you may develop shortness of breath or extreme fatigue with activity.
• Heart attack. A completely blocked coronary artery will cause a heart attack. The classic signs and symptoms of a heart attack include crushing pressure in your chest and pain in your shoulder or arm, sometimes with shortness of breath and sweating. Women are somewhat more likely than men are to have less typical signs and symptoms of a heart attack, such as neck or jaw pain. And they may have other symptoms such as shortness of breath, fatigue and nausea. Sometimes a heart attack occurs without any apparent signs or symptoms.

Ischemic heart disease reduces the flow of blood to the coronary arteries, which carry oxygen to the heart. This reduction in blood flow may result in a number of symptoms, which can vary in intensity among individuals.

Common symptoms of ischemic heart disease

You may experience ischemic heart disease symptoms daily or just occasionally. Common symptoms include chest pain, chest pressure, or shortness of breath that:

• Is relieved by rest or medicine
• May feel as if pain starting in the chest spreads to the arms, back, or other areas
• May feel like gas or indigestion (more common in women)
• Occurs repeatedly; episodes tend to be alike
• Occurs when the heart must work harder, usually during physical exertion
• Usually lasts a short time (five minutes or less)

Serious symptoms that might indicate a life-threatening condition

In some cases, ischemic heart disease can be life threatening. Seek immediate medical care (call 911) if you, or someone you are with, have any of these life-threatening symptoms including:

• Chest pain, typically on the left side of the body (angina pectoris)
• Clammy skin
• Nausea with or without vomiting
• Pain in the neck or jaw
• Rapid breathing (tachypnea) or shortness of breath
• Shoulder or arm pain

When to see a doctor

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If you think you’re having a heart attack, immediately call 911 or your local emergency number. If you don’t have access to emergency medical services, have someone drive you to the nearest hospital. Drive yourself only as a last option.

If you have risk factors for coronary artery disease — such as high blood pressure, high cholesterol, tobacco use, diabetes, obesity a strong family history of heart disease — talk to your doctor. Your doctor may want to test you for coronary artery disease, especially if you have signs or symptoms of narrowed arteries.

RISK FACTOR-

Risk factors include:

• Age. Getting older increases your risk of damaged and narrowed arteries.
• Sex. Men are generally at greater risk of coronary artery disease. However, the risk for women increases after menopause.
• Family history. A family history of heart disease is associated with a higher risk of coronary artery disease, especially if a close relative developed heart disease at an early age. Your risk is highest if your father or a brother was diagnosed with heart disease before age 55 or if your mother or a sister developed it before age 65.
• Smoking. People who smoke have a significantly increased risk of heart disease. Breathing in secondhand smoke also increases a person’s risk of coronary artery disease.
• High blood pressure. Uncontrolled high blood pressure can result in hardening and thickening of your arteries, narrowing the channel through which blood can flow.
• High blood cholesterol levels. High levels of cholesterol in your blood can increase the risk of formation of plaque and atherosclerosis. High cholesterol can be caused by a high level of low-density lipoprotein (LDL) cholesterol, known as the “bad” cholesterol. A low level of high-density lipoprotein (HDL) cholesterol, known as the “good” cholesterol, can also contribute to the development of atherosclerosis.
• Diabetes. Diabetes is associated with an increased risk of coronary artery disease. Type 2 diabetes and coronary artery disease share similar risk factors, such as obesity and high blood pressure.
• Overweight or obesity. Excess weight typically worsens other risk factors.
• Physical inactivity. Lack of exercise also is associated with coronary artery disease and some of its risk factors, as well.
• High stress. Unrelieved stress in your life may damage your arteries as well as worsen other risk factors for coronary artery disease.
• Unhealthy diet. Eating too much food that has high amounts of saturated fat, trans fat, salt and sugar can increase your risk of coronary artery disease.

Risk factors often occur together and one may trigger another. For instance, obesity can lead to type 2 diabetes and high blood pressure. When grouped together, certain risk factors make you even more likely to develop coronary artery disease. For example, metabolic syndrome — a cluster of conditions that includes high blood pressure; high triglycerides; low HDL, or “good,” cholesterol; high insulin levels and excess body fat around the waist — increases the risk of coronary artery disease.

Sometimes coronary artery disease develops without any classic risk factors. Researchers are studying other possible risk factors, including:

• Sleep apnea. This disorder causes you to repeatedly stop and start breathing while you’re sleeping. Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system, possibly leading to coronary artery disease.
• High-sensitivity C-reactive protein (hs-CRP). This protein appears in higher-than-normal amounts when there’s inflammation somewhere in your body. High hs-CRP levels may be a risk factor for heart disease. It’s thought that as coronary arteries narrow, you’ll have more hs-CRP in your blood.
• High triglycerides. This is a type of fat (lipid) in your blood. High levels may raise the risk of coronary artery disease, especially for women.
• Homocysteine. Homocysteine is an amino acid your body uses to make protein and to build and maintain tissue. But high levels of homocysteine may increase your risk of coronary artery disease.
• Preeclampsia. This condition that can develop in women during pregnancy causes high blood pressure and a higher amount of protein in urine. It can lead to a higher risk of heart disease later in life.
• Alcohol use. Heavy alcohol use can lead to heart muscle damage. It can also worsen other risk factors of coronary artery disease.
• Autoimmune diseases. People who have conditions such as rheumatoid arthritis and lupus (and other inflammatory conditions) have an increased risk of atherosclerosis.

A number of factors increase the risk of developing ischemic heart disease. Not all people with risk factors will get ischemic heart disease. Risk factors for ischemic heart disease include:

• Diabetes
• Family history of heart disease
• High blood cholesterol
• High blood pressure
• High blood triglycerides
• Obesity
• Physical inactivity
• Smoking and other tobacco use

Reducing your risk of ischemic heart disease

You may be able to lower your risk of ischemic heart disease by:

• Carefully managing your diabetes, if applicable
• Getting regular physical activity
• Keeping your cholesterol at a healthy level
• Maintaining normal blood pressure
• Quitting smoking and other tobacco use
• Reducing the amount of cholesterol and fat in your diet

COMPLICATION-

Coronary artery disease can lead to:

• Chest pain (angina). When your coronary arteries narrow, your heart may not receive enough blood when demand is greatest — particularly during physical activity. This can cause chest pain (angina) or shortness of breath.
• Heart attack. If a cholesterol plaque ruptures and a blood clot forms, complete blockage of your heart artery may trigger a heart attack. The lack of blood flow to your heart may damage your heart muscle. The amount of damage depends in part on how quickly you receive treatment.
• Heart failure. If some areas of your heart are chronically deprived of oxygen and nutrients because of reduced blood flow, or if your heart has been damaged by a heart attack, your heart may become too weak to pump enough blood to meet your body’s needs. This condition is known as heart failure.
• Abnormal heart rhythm (arrhythmia). Inadequate blood supply to the heart or damage to heart tissue can interfere with your heart’s electrical impulses, causing abnormal heart rhythms.

EPIDEMIOLOGY

On the basis of data from the National Health and Nutrition Examination Survey (NHANES) for the period 2003 to 2006, an estimated 17.6 million Americans age 20 or older have CHD, with an overall prevalence of 7.9 percent (9.1 percent in men and 7 percent in women). The overall prevalence of MI is 3.6 percent (4.7 percent in men and 2.6 percent in women). The estimated annual incidence of MI is 935,000, which includes 610,000 new and 325,000 recurrent infarctions. The overall prevalence of angina pectoris is 4.6 percent, with age-adjusted prevalence higher in women than men. CHD accounts for more than half of all cardiovascular events in men and women under age 75. The lifetime risk of developing CHD after age 40 is 49 percent for men and 32 percent for women (Lloyd-Jones et al., 2010).

CHD is the leading cause of death in both men and women. It caused one of every six U.S. deaths in 2006; CHD mortality was 425,425, and MI mortality was 141,462. Approximately every 25 seconds, an American will experience a coronary event, and approximately every minute a death will be attributed to a coronary event. Approximately every 34 seconds, an American will have an MI and 15 percent will die of it (Lloyd-Jones et al., 2010).

In addition, in 2006, 1,115,000 inpatient diagnostic cardiac catheterizations were performed as well as 661,000 inpatient percutaneous coronary interventions (PCIs) and 253,000 coronary artery bypass surgery (CABG) procedures. The estimated direct and indirect cost of coronary heart disease for 2010 is $177.1 billion (Lloyd-Jones et al., 2010).

DIAGNOSIS AND METHOD –

Coronary heart disease (CHD) is usually diagnosed after a risk assessment and some further tests.

Risk assessment

If a GP thinks you may be at risk of CHD, they may do a risk assessment for cardiovascular disease, heart attack or stroke. 

The DOCTOR will:

• ask about your medical and family history
• check your blood pressure
• do a blood test to assess your cholesterol level

Before having the cholesterol test, you may be asked not to eat for 12 hours so there’s no food in your body that could affect the result.

The GP or practice nurse can carry out the blood test. A sample will be taken either using a needle and a syringe or by pricking your finger.

The GP will also ask about your lifestyle, how much exercise you do and whether you smoke. All these factors will be considered as part of the diagnosis.

Further tests

You may be referred for further tests to help confirm CHD. A number of different tests are used to diagnose heart-related problems, including:

• electrocardiogram (ECG)
• exercise stress tests
• X-rays
• echocardiogram
• blood tests
• coronary angiography
• radionuclide tests
• MRI scans
• CT scans

PREVENTION-

The same lifestyle habits used to help treat coronary artery disease can also help prevent it. A healthy lifestyle can help keep your arteries strong and clear of plaque. To improve your heart health, follow these tips:

• Quit smoking.
• Control conditions such as high blood pressure, high cholesterol and diabetes.
• Stay physically active.
• Eat a low-fat, low-salt diet that’s rich in fruits, vegetables and whole grains.
• Maintain a healthy weight.
• Reduce and manage stress.

TREATMENT –

Treatment for coronary heart disease (CHD) can help manage the symptoms and reduce the risk of further problems.

CHD can be managed effectively with a combination of lifestyle changes, medicine and, in some cases, surgery.

With the right treatment, the symptoms of CHD can be reduced and the functioning of the heart improved.

Things you can do to help with coronary heart disease (CHD)

If you’ve been diagnosed with CHD, making simple lifestyle changes can reduce your risk of having further episodes.

For example, stopping smoking after a heart attack quickly reduces your risk of having a heart attack in the future to near that of a non-smoker.

Other lifestyle changes, such as eating more healthily and doing regular exercise, will also reduce your future risk of heart disease.

Further information

• exercise and fitness
• healthy eating
• stop smoking

Medicines

Many different medicines are used to treat CHD. Usually they either aim to reduce blood pressure or widen your arteries.

Some heart medicines have side effects, so it may take a while to find one that works for you. A GP or specialist will discuss the various options with you.

Heart medicines should not be stopped suddenly without the advice of a doctor as there’s a risk this may make your symptoms worse.

Blood-thinning medicines

Blood thinners are a type of medicine that can help reduce the risk of a heart attack by thinning your blood and preventing it clotting.

Common blood-thinning medicines include:

• low-dose aspirin
• clopidogrel
• rivaroxaban
• ticagrelor
• prasugrel

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Statins

If you have high cholesterol, cholesterol-lowering medicine called statins may be prescribed.

Examples include:

• atorvastatin
• simvastatin
• rosuvastatin
• pravastatin

Statins work by blocking the formation of cholesterol and increasing the number of low-density lipoprotein (LDL) receptors in the liver.

This helps remove LDL cholesterol from your blood, which makes a heart attack less likely. 

Not all statins are suitable for everyone, so you may need to try several different types until you find one that’s suitable.

Beta blockers

Beta blockers, including atenolol, bisoprolol, metoprolol and nebivolol, are often used to prevent angina and treat high blood pressure.

They work by blocking the effects of a particular hormone in the body, which slows down your heartbeat and improves blood flow.

Nitrates

Nitrates are used to widen your blood vessels. Doctors sometimes refer to nitrates as vasodilators.

They’re available in a variety of forms, including tablets, sprays and skin patches such as glyceryl trinitrate and isosorbide mononitrate.

Nitrates work by relaxing your blood vessels, letting more blood pass through them. This lowers your blood pressure and relieves any heart pain you have.

Nitrates can have some mild side effects, including headaches, dizziness and flushed skin.

Angiotensin-converting enzyme (ACE) inhibitors

ACE inhibitors are commonly used to treat high blood pressure. Examples include ramipril and lisinopril.

They block the activity of a hormone called angiotensin-2, which causes the blood vessels to narrow.

As well as stopping the heart working so hard, ACE inhibitors improve the flow of blood around the body.

Your blood pressure will be monitored while you’re taking ACE inhibitors, and regular blood tests will be needed to check that your kidneys are working properly.

Less than 1 in 100 people have problems with the blood supply to their kidneys (renal stenosis) as a result of taking ACE inhibitors.

Side effects of ACE inhibitors can include a dry cough and dizziness.

Angiotensin-2 receptor blockers (ARBs)

Angiotensin-2 receptor blockers (ARBs) work in a similar way to ACE inhibitors.

They’re used to lower your blood pressure by blocking angiotensin-2.

Mild dizziness is usually the only side effect. They’re often prescribed as an alternative to ACE inhibitors, as they do not cause a dry cough.

Coronavirus advice

If you have coronavirus (COVID-19), or think you might have it, keep taking your blood pressure medicines as usual.

There is no clear evidence that taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin-2 receptor blockers (ARBs) will cause complications.

Calcium channel blockers

Calcium channel blockers also work to decrease blood pressure by relaxing the muscles that make up the walls of your arteries.

This causes the arteries to become wider, reducing your blood pressure.

Examples include amlodipine, verapamil and diltiazem.

Side effects include headaches and facial flushing, but these are mild and usually decrease over time.

Diuretics

Sometimes known as water pills, diuretics work by flushing excess water and salt from the body through urine.

Procedures and surgery

If your blood vessels are narrow as the result of a build-up of atheroma (fatty deposits) or if your symptoms cannot be controlled using medicines, interventional procedures or surgery may be needed to open up or bypass blocked arteries.

Here are some of the main procedures used to treat blocked arteries.

Coronary angioplasty

Coronary angioplasty is also known as percutaneous coronary intervention (PCI), percutaneous transluminal coronary angioplasty (PTCA) or balloon angioplasty.

Angioplasty may be a planned procedure for someone with angina, or an urgent treatment if the symptoms have become unstable.

Having a coronary angiogram (a type of X-ray used to check blood vessels) will determine if you’re suitable for treatment.

Coronary angioplasty is also performed as an emergency treatment during a heart attack.

During the procedure, a small balloon is inserted to push the fatty tissue in the narrowed artery outwards. This allows the blood to flow more easily.

A metal stent (a wire mesh tube) is usually placed in the artery to hold it open. Drug-eluting stents can also be used. These release medicines to stop the artery narrowing again.

Coronary artery bypass graft

Coronary artery bypass grafting (CABG) is also known as bypass surgery, a heart bypass, or coronary artery bypass surgery.

It’s carried out in people whose arteries are narrowed or blocked.

A coronary angiogram will determine if you’re suitable for treatment.

Off-pump coronary artery bypass (OPCAB) is a type of coronary artery bypass surgery. It’s performed while the heart continues to pump blood by itself without the need for a heart-lung machine.

A blood vessel is inserted (grafted) between the main artery leaving the heart (the aorta) and a part of the coronary artery beyond the narrowed or blocked area.

Sometimes, an artery that supplies blood to the chest wall is used and diverted to one of the heart arteries. This allows the blood to bypass (get around) the narrowed sections of coronary arteries.

Heart transplant

Occasionally, when the heart is severely damaged and medicine is not effective, or when the heart becomes unable to adequately pump blood around the body (heart failure), a heart transplant may be needed.

A heart transplant involves replacing a heart that’s damaged or is not working properly with a healthy donor heart.

Side Effects of Treatments

Nitroglycerin and nitrates can cause vasodilation-induced headache, a decrease in blood pressure, and, more rarely, severe hypotension with bradycardia. The vasodilation by nitroglycerin may be markedly exaggerated and prolonged in the presence of the phosphodiesterase inhibitors sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis), so these agents should not be used concurrently with nitrates.

Most of the adverse effects of beta-blockers occur as a consequence of the known properties of these drugs and include cardiac effects (e.g., severe sinus bradycardia, sinus arrest, reduced LV contractility), bronchoconstriction, fatigue, mental depression, nightmares, gastrointestinal upset, sexual dysfunction, intensification of insulin-induced hypoglycemia, and cutaneous reactions. Lethargy, weakness, and fatigue may be caused by reduced cardiac output or may arise from a direct effect on the central nervous system. Bronchoconstriction results from blockade of beta₂ receptors in the tracheobronchial tree. As a consequence, reversible obstructive lung disease (e.g., asthma) may be considered as relative contraindications to beta-blockers, even to beta₁-selective agents (Egred et al., 2005).

Calcium channel blockers are potent vasodilators, which may lead to dizziness, hypotension, and reflex tachycardia—particularly with some dihydropyridines. Peripheral edema can occur, usually with the dihydropyri dines. Both verapamil and diltiazem can cause bradycardia or conduction disturbances, particularly if coadministered with beta-blockers. Diltiazem and verapamil may exacerbate or precipitate heart failure in patients with reduced LV ejection fraction.

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Synonyms of Filariasis

• Bancroftian Filariasis
• Filarial Elephantiasis
• Filariasis Malayi
• Malayi Tropical Eosinphilia
• Wuchereriasis

INTRODUCTION-

Lymphatic filariasis is a disease associated with parasitic infection of one of three different nematodes: Wuchereria bancrofti, Brugia malayi, or Brugia timori. The microscopic worms enter the human body via mosquito transmission- in both children and adults- and can live up to 5-7 years in the lymphatic system. Although most people who are infected are asymptomatic, a small percentage of people will develop extreme lymphedema and multiple secondary infections as a result of years of exposure to the parasites.

Filariasis is an infectious tropical disease caused by any one of several thread-like parasitic round worms. The two species of worms most often associated with this disease are Wuchereria bancrofti and Brugia malayi. The larval form of the parasite transmits the disease to humans by the bite of a mosquito. In the early stages of the infection, the patient characteristically complains of fever, chills, headaches and skin lesions. Any one of several antiparasitic agents may be effective in eliminating the worm. However, if the disease is left untreated, obstruction of the lymph flow will cause particular areas of the body especially the legs and external genitals, to swell profoundly. Symptoms are primarily a response to adult worms that cause inflammation. Chronic inflammation may progress to hardening of the lymphatic vessels (fibrosis) and obstruction of the lymph flow.

ACCORDING TO WHO

Lymphatic filariasis, commonly known as elephantiasis, is a neglected tropical disease. Infection occurs when filarial parasites are transmitted to humans through mosquitoes. Infection is usually acquired in childhood causing hidden damage to the lymphatic system.

The painful and profoundly disfiguring visible manifestations of the disease, lymphoedema, elephantiasis and scrotal swelling occur later in life and can lead to permanent disability. These patients are not only physically disabled, but suffer mental, social and financial losses contributing to stigma and poverty.

In 2018, 893 million people in 49 countries were living in areas that require preventive chemotherapy to stop the spread of infection.

The global baseline estimate of people affected by lymphatic 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. Eliminating lymphatic filariasis can prevent unnecessary suffering and contribute to the reduction of poverty.

CAUSES-

Filariasis is a rare infectious tropical disorder caused by the round worm parasites (nematode) Wuchereria bancrofti or Brugia malayi. Symptoms result primarily from inflammatory reactions to the adult worms. Some people may also develop hypersensitivity reactions to the small larval parasites (microfilariae).

Lymphatic filariasis is caused by infection with parasites classified as nematodes (roundworms) of the family Filariodidea. There are 3 types of these thread-like filarial worms:

• Wuchereria bancrofti, which is responsible for 90% of the cases
• Brugia malayi, which causes most of the remainder of the cases
• Brugia timori, which also causes the disease.

Adult worms nest in the lymphatic vessels and disrupt the normal function of the lymphatic system. The worms can live for approximately 6–8 years and, during their life time, produce millions of microfilariae (immature larvae) that circulate in the blood.

Mosquitoes are infected with microfilariae by ingesting blood when biting an infected host. Microfilariae mature into infective larvae within the mosquito. When infected mosquitoes bite people, mature parasite larvae are deposited on the skin from where they can enter the body. The larvae then migrate to the lymphatic vessels where they develop into adult worms, thus continuing a cycle of transmission.

Lymphatic filariasis is transmitted by different types of mosquitoes for example by the Culex mosquito, widespread across urban and semi-urban areas, Anopheles, mainly found in rural areas, and Aedes, mainly in endemic islands in the Pacific.

Prevalence

It is estimated that more than 120 million people in 80 countries worldwide are currently infected with one of the three nematodes. Greater than 90% of those 120 million people are infected with the Wuchereria bancrofti filaria, and the majority of the remaining ~10% are infected with the Brugia malayi filaria. Reports also suggest that more than 40 million people are significantly dibilatated and disfigured by the disease. Worldwide distribution of Lymphatic Filariasis. Image credit: CDC

Lymphatic filariasis is endemic is the tropic and sub-tropics of Southeast Asia, Africa, the India Subcontinent, the Pacific islands, and parts of the Caribbean and Latin America.

Total Global Elimination treatments:

Region	# of Countries Treated	Total # of Treatments (millions)	Total Treatments to Children (millions)
Africa	17	51	12.8
Americas	4	2.7	0.8
Eastern Med	2	0.5	0.1
Mekong Plus	5	15.9	4.9
Pacific	14	0.3	0.09
Southeast Asia	9	0.4	44.6
Total	51	496.2	63.5

SIGN AND SYMPTOM-

Some people with filariasis have no symptoms. Other affected individuals may have episodes of acute inflammation of lymphatic vessels (lymphangitis) along with high temperatures, shaking chills, body aches, and swollen lymph nodes. Excessive amounts of fluid may accumulate (edema) in the affected areas (i.e., arms and/or legs), but the accumulation typically resolves after the other symptoms are gone. Attacks may also be accompanied by acute inflammation of the genitalia leading, in males, to inflammation, pain and swelling of the testes (orchitis), sperm track (funiculitis), and/or sperm ducts (epididymitis). The scrotum may become abnormally swollen and painful.

Bancroftian filariasis affects both the legs and the genitals. The Malayan variety affects the legs below the knees.

Some people with filariasis have abnormally high levels of certain white blood cells (eosinophilia) during acute episodes of symptoms. When the inflammation resolves, these levels return to normal.

Filariasis may cause chronic lymph node swelling (lymphadenopathy) even in the absence of other symptoms. Longstanding obstruction of the lymphatic vessels may lead to several other conditions. These include accumulation of fluid in the scrotum (hydrocele), the presence of lymphatic fluid in the urine (chyluria), and/or abnormally enlarged lymphatic vessels (varices). Other symptoms may include progressive edema (elephantiasis) of the female external genitalia (vulva), breasts, and/or arms and legs. Chronic edema may result in skin that is abnormally thick and has a “warty” appearance.

Characteristics/Clinical Presentation

The majority of people who become infected with filariasis do not show any overt clinical signs or symptoms, although they will experience irregularities in their lymphatic drainage. It is estimated that only one-third of those infected by any of the filarial nematodes show obvious clinical features of the condition. Experts have attributed the severity of symptoms as being positively correlated with extended time of exposure and accumulation of worms.

ACUTE Signs & Symptoms

• Adenolymphangitis
  
• Filarial fever
• Tropical pulmonary eosinophilia

Acute adenolymphangitis: Characteristics include painful lymphadenopathy and retrograde lymphangitis that most often affect the inguinal nodes, genitalia, and lower extremities leading to extreme edema, elephantiasis, and sometimes skin breakdown and secondary infections. Flare-ups can last 4-7 days and occur up to 4 times per year depending on the severity of the lymphedema.

Filarial fever: Often an acute fever that occurs independently of any other signs of lymphadenopathy. Filarial fever is sometimes misdiagnosed as a manifestation of malaria and other tropical diseases because of the lack of associated symptoms.

Tropical pulmonary eosinophilia: Most commonly seen in young males and is caused by microfilariae being trapped in the lungs. The immune system exhibits a respiratory “hyperresponsiveness” to the problem, causing excessive nocturnal wheezing.

CHRONIC Signs & Symptoms:

• Lymphedema
• Renal Pathology
• Secondary infections

Lymphedema: Commonly involves vessels in the inguinal and axillary lymph nodes, affecting all four extremities.  Early stage lymphedema is usually characterized by pitting edema, but more chronic stages exhibit non-pitting edema with hardening of the surrounding tissues, eventually leading to hyperpigmentation and hyperkeratosis. Chronic manifestations can also involve the breasts and male genitalia. Hydroceles (swelling of the scrotum) can be greater than 30cm in diameter, but are usually painless unless bacterial infection is present. 

Renal Pathology: When renal system lymphatic are obstructed, lymph fluid can be passed into the renal pelvis. Chyluria, or lymph fluid in the urine, causes a milky appearance in the excreted urine. Hematuria and proteinuria may also be present and can eventually cause  nutritional deficiencies and anemia.

Secondary infections: Bacterial and fungal infections become problematic in lymphatic filariasis due to edema-causing skin folds and skin tears.

DIAGNOSIS-

Nonspecific test abnormalities:

• Eosinophilia (>3000/microliter)
• Microscopic hematuria
• Microscopic proteinuria

Blood smears:

• Samples are drawn ideally between 10pm and 2am due to peak biting time of mosquito vectors
• 20 microliters of blood can detect microfilariae, but a 1 mL blood sample may be required to make a diagnosis
• >10,000 microfilariae per 1 mL of blood can be found in endemic regions
• Samples are stained and centrifuged
• Microfilariae species can be differentiated by morphological characteristics

Antibody tests:

• Serologic testing for filarial antibodies can detect elevated levels of IgG and IgE
• Poor specificity
• Cannot distinguish between filarial types
• Cannot differentiate between past and present infections
• Newer tests are being developed that look at specific anti-filarial IgG4 antibodies for showing active infections

Antigen tests:

• Detect the presence of adult worms
• Circulating Filarial Antigen (CFA) tests are considered the gold standard for diagnosing Wuchereria bancrofti infections
• No antigen testing currently available for Brugian malayi filariasis

Radiology:

• Ultrasound can be used to detect adult worms and vessel destruction
• Ultrasound can localize worms in epididymal and breast lymphatics
• “Filarial dance”, or the constant movement of live worms, can be picked up with ultrasound imaging and is sometimes used to monitor effectiveness of certain treatments
• Lymphoscintigraphy is used for assessment of the extent of lymphatic destruction.

Differential Diagnoses-

Most highly suspected causes of Lymphadenopathy:

1. Mononucleosis
2. Epstein-Barr Virus
3. Toxoplasmosis
4. Cytomegalovirus
5. HIV
6. Cat-scratch disease
7. Pharyngitis
8. Tuberculosis
9. Secondary syphilis
10. Hepatitis B
11. Lymphogranuloma venereum
12. Chancroid
13. SLE
14. Rheumatoid Arthritis
15. Lymphoma
16. Leukemia
17. Serum sickness
18. Sarcoidosis
19. Kawasaki disease

Travel-related causes of Lymphadenopathy:

1. Coccidioidomycosis
2. Bubonic Plague
3. Histoplasmosis
4. Scrub typhus
5. African trypanosomiasis
6. American trypanosomiasis
7. Kala-azar
8. Typhoid fever

Systemic Involvement

1. Lymphatic: Adult filariae can live in the lymphatic system for up to 7 years while continuing to reproduce, leading to obstruction of drainage and destruction of vessels.

2.  Renal: Intestinal lymph fluid can be deposited into the renal pelvis and eventually make its way to the urine to be excreted by the body (chyluria). This can lead to hypoproteinemia, hematuria, and anemia as large amounts of fat and protein are lost through the urine and lymph fluid. 

3. Dermatological: Pitting edema, hyperpigmentation, and hyperkeratosis are present as a result of the associated lymphedema. In severe cases, affected individuals develop elephantiasis. Lymphatic filariasis.

4. Reproductive: In females, involvement of the breast tissue and ovaries (along with upper or lower limb edema) is not uncommon. In males, the genitalia can be severely affected. Unilateral or bilateral hydroceles in the scrotum (especially in the spermatic cord) can lead to disfigurement and loss of sexual function.

5. Immune: Other bacterial or fungal infections often develop as a secondary result of lymphatic filariasis, primarily due to excessive skin folds and skin tears.

Related Disorders

Symptoms of the following disorders can be similar to those of Filariasis. Comparisons may be useful for a differential diagnosis:

Acanthocheilonemiasis is a tropical infectious disease caused by a multicellular parasite (filarial worm [nematode]), called Acanthocheilonema perstans. This parasite is found most commonly in Africa. Initially people with Acanthocheilonemiasis may have no symptoms. Symptoms may include itchy skin (pruritis), abdominal pain, chest pain, muscle pain (myalgias), and/or areas of swelling under the skin. Other symptoms may include an abnormally enlarged liver and spleen (hepatosplenomegaly), and inflammation in the affected organs. (For more information on this disorder, choose “Acanthocheilo” as your search term in the Rare Disease Database.)

Filarial Disease, or the general term “filariasis,” may also refer to a group of parasitic diseases caused by various species of filarial worms (nematodes). These include mumu, loiasis (Calabar swellings), dirofilariasis (human infection by dog heartworm), and onchocerciasis (river blindness). All these except dirofilariasis can be acquired only in the tropics, where they are common, but are extremely rare in temperate climates such as North America. Taken together, filarial diseases of all types affect approximately 100 million people worldwide.

MEDICAL MANAGEMENT –

• Prescription Drug Therapy

1. Prevention
2. Post-infection treatment

• Clinical Care

1. Lymphedema management
2. Wash and dry affected area twice daily
3. Elevate lower extremities at night
4. Exercise and move affected limb regularly
5. Antibiotics/Topical medications for small wounds
6. Comfortable shoes

• Surgery

1. Hydroceles

• Patient Education
• Patient Counseling

Prevention for travelers:

Chronic conditions of LF is generally not a concern for those people who wish to visit endemic regions of the world because they do not stay long enough to accumulate a harmful amount of microfilariae, although the following mild, allergic-like symptoms have been reported: lymphangitis/lymphadenitis, urticaria (hives), rash, and peripheral eosinophilia. Recommendations for travelers are as follows: wear long sleeves and long pants, sleep under a mosquito net or in air conditioning, use bug repellent, and stay indoors or away from mosquito breeding grounds between dusk and dawn (they’re preferred biting time).

Physical Therapy Management

Clinical manifestations of filariasis such as lymphedema and elephantiasis are caused by prolonged exposure to filariae and the mosquitos that transmit them in endemic regions. These affected individuals are usually not actively infected; rather, they are suffering from the effects of years of exposure to one of the three nematodes. Medical management is not appropriate for these individuals.

Physical therapy management of the disease primarily consists of treatment from a lymphedema therapist, along with education of proper skin care and hygiene. Appropriate exercise prescription and wound care management are also indicated. There is no physical therapy intervention indicated for hydrocele; those infected usually do not respond well to DEC, and surgery is required in some cases.

WHO response

World Health Assembly resolution WHA50.29 encourages Member States to eliminate lymphatic filariasis as a public health problem. In response, WHO launched its Global Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000. In 2012, the WHO neglected tropical diseases roadmap reconfirmed the target date for achieving elimination by 2020.

WHO’s strategy is based on 2 key components:

• stopping the spread of infection through large-scale annual treatment of all eligible people in an area or region where infection is present; and
• alleviating the suffering caused by lymphatic filariasis through provision of the recommended basic package of care.

Large-scale treatment (preventive chemotherapy)

Elimination of lymphatic filariasis is possible by stopping the spread of the infection through preventive chemotherapy. The WHO recommended preventive chemotherapy strategy for lymphatic filariasis elimination is mass drug administration (MDA).  MDA involves administering an annual dose of medicines to the entire at-risk population. The medicines used have a limited effect on adult parasites but effectively reduce the density of microfilariae in the bloodstream and prevent the spread of parasites to mosquitoes.

The MDA regimen recommended depends on the co-endemicity of lymphatic filariasis with other filarial diseases. WHO recommends the following MDA regimens:

• albendazole (400 mg) alone twice per year for areas co-endemic with loiasis
• ivermectin (200 mcg/kg) with albendazole (400 mg) in countries with onchocerciasis
• diethylcarbamazine citrate (DEC) (6 mg/kg) and albendazole (400 mg) in countries without onchocerciasis

Recent evidence indicates that the combination of all three medicines can safely clear almost all microfilariae from the blood of infected people within a few weeks, as opposed to years using the routine two-medicine combination.

WHO now recommends the following MDA regimen in countries without onchocerciasis:

• ivermectin (200 mcg/kg) together with diethylcarbamazine citrate (DEC) (6 mg/kg) and albendazole (400 mg) in certain settings

The impact of MDA depends on the efficacy of the regimen and the coverage (proportion of total population ingesting the medicines). MDA with the two-medicine regimens have interrupted the transmission cycle when conducted annually for 4–6 years with effective coverage of the total population at risk. Salt fortified with DEC has also been used in a few unique settings to interrupt the transmission cycle.

At the start of GPELF, 81 countries were considered endemic for lymphatic filariasis. Further epidemiological data reviewed since, indicate that preventive chemotherapy was not required in 10 countries. From 2000 to 2018, 7.7 billion treatments were delivered to more than 910 million people at least once in 68 countries, considerably reducing transmission in many places. The population requiring MDA has declined by 42% (597 million) where infection prevalence has been reduced below elimination thresholds.  The overall economic benefit of the programme during 2000-2007 is conservatively estimated at US$ 24 billion. Treatments until 2015 are estimated to have averted at least US$ 100.5 billion of economic loss expected to have occurred over the lifetime of cohorts who have benefited from treatment.

Sixteen countries and territory (Cambodia, The Cook Islands, Egypt, Kiribati, Maldives, Marshall Islands, Niue, Palau, Sri Lanka, Thailand, Togo, Tonga, Vanuatu, Viet Nam, Wallis and Futuna, and Yemen) are now acknowledged as achieving elimination of lymphatic filariasis as a public health problem. Seven additional countries have successfully implemented recommended strategies, stopped large-scale treatment and are under surveillance to demonstrate that elimination has been achieved. Preventive chemotherapy is still required in 49 countries and within 15 of these countries MDA has not yet been delivered to all endemic areas as of the end of 2018.  

Morbidity management

Morbidity management and disability prevention are vital for improving public health and are essential services that should be provided by the health care system to ensure sustainability. Surgery can alleviate most cases of hydrocele. Clinical severity and progression of the disease, including acute inflammatory episodes, can be reduced and prevented with simple measures of hygiene, skin care, exercises, and elevation of affected limbs. People with lymphoedema must have access to continuing care throughout their lives, both to manage the disease and to prevent progression to more advanced stages.

The GPELF aims to provide access to a minimum package of care for every person with associated chronic manifestations of lymphatic filariasis in all areas where the disease is present, thus alleviating suffering and promoting improvement in their quality of life.

Success in 2020 will be achieved if patients have access to the following minimum package of care:

• treatment for episodes of adenolymphangitis (ADL);
• guidance in applying simple measures to manage lymphoedema to prevent progression of disease and debilitating, inflammatory episodes of ADL;
• surgery for hydrocele;
• treatment of infected people with antifilarial medicines

Vector control

Mosquito control is a supplemental strategy supported by WHO. It is used to reduce transmission of lymphatic filariasis and other mosquito-borne infections. Depending on the parasite-vector species, measures such as insecticide-treated nets, indoor residual spraying or personal protection measures may help protect people from infection. The use of insecticide-treated nets in areas where Anopheles is the primary vector for filariasis enhances the impact on transmission during and after MDA. Historically, vector control has in select settings contributed to the elimination of lymphatic filariasis in the absence of large-scale preventive chemotherapy.

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INTRODUCTION-

Malaria is a life-threatening mosquito-borne blood disease. The Anopheles mosquito transmits it to humans

Malaria is a disease caused by a parasite. The parasite is transmitted to humans through the bites of infected mosquitoes. People who have malaria usually feel very sick, with a high fever and shaking chills. Each year, approximately 210 million people are infected with malaria, and about 440,000 people die from the disease. Most of the people who die from the disease are young children in Africa.

While the disease is uncommon in temperate climates, malaria is still common in tropical and subtropical countries. World health officials are trying to reduce the incidence of malaria by distributing bed nets to help protect people from mosquito bites as they sleep. Scientists around the world are working to develop a vaccine to prevent malaria.

If you’re traveling to locations where malaria is common, take steps to prevent mosquito bites by wearing protective clothing, using insect repellants and sleeping under treated mosquito nets. Depending on the area you are visiting and your individual risk factors for infection, you may also want to take preventive medicine before, during and after your trip. Many malaria parasites are now resistant to the most common drugs used to treat the disease.

Malaria is a life-threatening disease. It’s typically transmitted through the bite of an infected Anopheles mosquito. Infected mosquitoes carry the Plasmodium parasite. When this mosquito bites you, the parasite is released into your bloodstream.

Once the parasites are inside your body, they travel to the liver, where they mature. After several days, the mature parasites enter the bloodstream and begin to infect red blood cells.

Within 48 to 72 hours, the parasites inside the red blood cells multiply, causing the infected cells to burst open.

The parasites continue to infect red blood cells, resulting in symptoms that occur in cycles that last two to three days at a time.

Malaria is typically found in tropical and subtropical climates where the parasites can live. The World Health Organization (WHO)Trusted Source states that, in 2016, there were an estimated 216 million cases of malaria in 91 countries.

In the United States, the Centers for Disease Control and Prevention (CDC) report 1,700 casesTrusted Source of malaria annually. Most cases of malaria develop in people who travel to countries where malaria is more common.

The parasites in mosquitos that spread malaria belong to the Plasmodium genus. Over 100 types of Plasmodium parasite can infect a variety of species. Different types replicate at different rates, changing how quickly the symptoms escalate, and the severity of the disease.

Five types of Plasmodium parasite can infect humans. These occur in different parts of the world. Some cause a more severe type of malaria than others.

Once an infected mosquito bites a human, the parasites multiply in the host’s liver before infecting and destroying red blood cells.

In some places, early diagnosis can help treat and control malaria. However, some countries lack the resources to carry out effective screening.

Currently, no vaccine is available for use in the United States, although one vaccine has a license in Europe.

In the early 1950s, advances in treatment eliminated malaria from the U.S. However, between 1,500 and 2,000 cases still occur each year, mostly in those who have recently traveled to malaria-endemic areas.

CAUSES-

Malaria can occur if a mosquito infected with the Plasmodium parasite bites you. There are four kinds of malaria parasites that can infect humans: Plasmodium vivax, P. ovale, P. malariae, and P. falciparum.

P. falciparum causes a more severe form of the disease and those who contract this form of malaria have a higher risk of death. An infected mother can also pass the disease to her baby at birth. This is known as congenital malaria.

• Uninfected mosquito. A mosquito becomes infected by feeding on a person who has malaria.
• Transmission of parasite. If this mosquito bites you in the future, it can transmit malaria parasites to you.
• In the liver. Once the parasites enter your body, they travel to your liver — where some types can lie dormant for as long as a year.
• Into the bloodstream. When the parasites mature, they leave the liver and infect your red blood cells. This is when people typically develop malaria symptoms.
• On to the next person. If an uninfected mosquito bites you at this point in the cycle, it will become infected with your malaria parasites and can spread them to the other people it bites.

Other modes of transmission

Because the parasites that cause malaria affect red blood cells, people can also catch malaria from exposure to infected blood, including:

• From mother to unborn child
• Through blood transfusions
• By sharing needles used to inject drugs

Malaria is transmitted by blood, so it can also be transmitted through:

• an organ transplant
• a transfusion
• use of shared needles or syringes

SYMPTOM-

A doctor would give this diagnosis when symptoms are present, but no symptoms occur that suggest severe infection or dysfunction of the vital organs.

This form can become severe malaria without treatment, or if the host has poor or no immunity.

Symptoms of uncomplicated malaria typically last 6 to 10 hours and recur every second day.

Some strains of the parasite can have a longer cycle or cause mixed symptoms.

As symptoms resemble those of flu, they may remain undiagnosed or misdiagnosed in areas where malaria is less common.

In uncomplicated malaria, symptoms progress as follows, through cold, hot, and sweating stages:

• a sensation of cold with shivering
• fever, headaches, and vomiting
• seizures sometimes occur in younger people with the disease
• sweats, followed by a return to normal temperature, with tiredness

In areas where malaria is common, many people recognize the symptoms as malaria and treat themselves without visiting a doctor.

Severe malaria

In severe malaria, clinical or laboratory evidence shows signs of vital organ dysfunction.

Symptoms of severe malaria include:

• fever and chills
• impaired consciousness
• prostration, or adopting a prone position
• multiple convulsions
• deep breathing and respiratory distress
• abnormal bleeding and signs of anemia
• clinical jaundice and evidence of vital organ dysfunction

Severe malaria can be fatal without treatment.

Some people who have malaria experience cycles of malaria “attacks.” An attack usually starts with shivering and chills, followed by a high fever, followed by sweating and a return to normal temperature. Malaria signs and symptoms typically begin within a few weeks after being bitten by an infected mosquito. However, some types of malaria parasites can lie dormant in your body for up to a year.

ACCORDING TO WHO

Malaria is an acute febrile illness. In a non-immune individual, symptoms usually appear 10–15 days after the infective mosquito bite. The first symptoms – fever, headache, and chills – may be mild and difficult to recognize as malaria. If not treated within 24 hours, P. falciparum malaria can progress to severe illness, often leading to death.

Children with severe malaria frequently develop one or more of the following symptoms: severe anaemia, respiratory distress in relation to metabolic acidosis, or cerebral malaria. In adults, multi-organ failure is also frequent. In malaria endemic areas, people may develop partial immunity, allowing asymptomatic infections to occur.

When to see a doctor

Talk to your doctor if you experience a fever while living in or after traveling to a high-risk malaria region. The parasites that cause malaria can lie dormant in your body for up to a year. If you have severe symptoms, seek emergency medical attention.

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RISK FACTOR-

The biggest risk factor for developing malaria is to live in or to visit areas where the disease is common. There are many different varieties of malaria parasites. The variety that causes the most serious complications is most commonly found in:

• African countries south of the Sahara Desert
• The Asian subcontinent
• New Guinea, the Dominican Republic and Haiti

ACCORDING TO WHO

In 2018, nearly half of the world’s population was at risk of malaria. Most malaria cases and deaths occur in sub-Saharan Africa. However, the WHO regions of South-East Asia, Eastern Mediterranean, Western Pacific, and the Americas are also at risk.

Some population groups are at considerably higher risk of contracting malaria, and developing severe disease, than others. These include infants, children under 5 years of age, pregnant women and patients with HIV/AIDS, as well as non-immune migrants, mobile populations and travellers. National malaria control programmes need to take special measures to protect these population groups from malaria infection, taking into consideration their specific circumstances

Risks of more-severe disease

People at increased risk of serious disease include:

• Young children and infants
• Older adults
• Travelers coming from areas with no malaria
• Pregnant women and their unborn children

Poverty, lack of knowledge, and little or no access to health care also contribute to malaria deaths worldwide.

Immunity can wane

Residents of a malaria region may be exposed to the disease so frequently that they acquire a partial immunity, which can lessen the severity of malaria symptoms. However, this partial immunity can disappear if you move to a country where you’re no longer frequently exposed to the parasite.

COMPLICATION-

Malaria can be fatal, particularly malaria caused by the variety of parasite that’s common in tropical parts of Africa. The Centers for Disease Control and Prevention estimates that 91 percent of all malaria deaths occur in Africa — most commonly in children under the age of 5.

In most cases, malaria deaths are related to one or more serious complications, including:

• Cerebral malaria. If parasite-filled blood cells block small blood vessels to your brain (cerebral malaria), swelling of your brain or brain damage may occur. Cerebral malaria may cause seizures and coma.
• Breathing problems. Accumulated fluid in your lungs (pulmonary edema) can make it difficult to breathe.
• Organ failure. Malaria can cause your kidneys or liver to fail, or your spleen to rupture. Any of these conditions can be life-threatening.
• Anemia. Malaria damages red blood cells, which can result in anemia.
• Low blood sugar. Severe forms of malaria itself can cause low blood sugar (hypoglycemia), as can quinine — one of the most common medications used to combat malaria. Very low blood sugar can result in coma or death.

Malaria may recur

Some varieties of the malaria parasite, which typically cause milder forms of the disease, can persist for years and cause relapses.

TRANSMISSION-

In most cases, malaria is transmitted through the bites of female Anopheles mosquitoes. There are more than 400 different species of Anopheles mosquito; around 30 are malaria vectors of major importance. All of the important vector species bite between dusk and dawn. The intensity of transmission depends on factors related to the parasite, the vector, the human host, and the environment.

Anopheles mosquitoes lay their eggs in water, which hatch into larvae, eventually emerging as adult mosquitoes. The female mosquitoes seek a blood meal to nurture their eggs. Each species of Anopheles mosquito has its own preferred aquatic habitat; for example, some prefer small, shallow collections of fresh water, such as puddles and hoof prints, which are abundant during the rainy season in tropical countries.

Transmission is more intense in places where the mosquito lifespan is longer (so that the parasite has time to complete its development inside the mosquito) and where it prefers to bite humans rather than other animals. The long lifespan and strong human-biting habit of the African vector species is the main reason why approximately 90% of the world’s malaria cases are in Africa.

Transmission also depends on climatic conditions that may affect the number and survival of mosquitoes, such as rainfall patterns, temperature and humidity. In many places, transmission is seasonal, with the peak during and just after the rainy season. Malaria epidemics can occur when climate and other conditions suddenly favour transmission in areas where people have little or no immunity to malaria. They can also occur when people with low immunity move into areas with intense malaria transmission, for instance to find work, or as refugees.

Human immunity is another important factor, especially among adults in areas of moderate or intense transmission conditions. Partial immunity is developed over years of exposure, and while it never provides complete protection, it does reduce the risk that malaria infection will cause severe disease. For this reason, most malaria deaths in Africa occur in young children, whereas in areas with less transmission and low immunity, all age groups are at risk.

Lifecycle

The natural history of malaria involves cyclical infection of humans and female Anopheles mosquitoes. In humans, the parasites grow and multiply first in the liver cells and then in the red cells of the blood. In the blood, successive broods of parasites grow inside the red cells and destroy them, releasing daughter parasites (“merozoites”) that continue the cycle by invading other red cells.

The blood stage parasites are those that cause the symptoms of malaria. When certain forms of blood stage parasites (gametocytes, which occur in male and female forms) are ingested during blood feeding by a female Anopheles mosquito, they mate in the gut of the mosquito and begin a cycle of growth and multiplication in the mosquito. After 10-18 days, a form of the parasite called a sporozoite migrates to the mosquito’s salivary glands. When the Anopheles mosquito takes a blood meal on another human, anticoagulant saliva is injected together with the sporozoites, which migrate to the liver, thereby beginning a new cycle.

Thus the infected mosquito carries the disease from one human to another (acting as a “vector”), while infected humans transmit the parasite to the mosquito, In contrast to the human host, the mosquito vector does not suffer from the presence of the parasites.

The malaria parasite life cycle involves two hosts. During a blood meal, a malaria-infected female Anopheles mosquito inoculates sporozoites into the human host

. Sporozoites infect liver cellsand mature into schizonts, which rupture and release merozoites. (Of note, in P. vivax and P. ovale a dormant stage [hypnozoites] can persist in the liver (if untreated) and cause relapses by invading the bloodstream weeks, or even years later.) After this initial replication in the liver (exo-erythrocytic schizogony), the parasites undergo asexual multiplication in the erythrocytes (erythrocytic schizogony). Merozoites infect red blood cells. The ring stage trophozoites mature into schizonts, which rupture releasing merozoites. Some parasites differentiate into sexual erythrocytic stages (gametocytes). Blood stage parasites are responsible for the clinical manifestations of the disease. The gametocytes, male (microgametocytes) and female (macrogametocytes), are ingested by an Anopheles mosquito during a blood meal. The parasites’ multiplication in the mosquito is known as the sporogonic cycle. While in the mosquito’s stomach, the microgametes penetrate the macrogametes generating zygotes. The zygotes in turn become motile and elongated (ookinetes)which invade the midgut wall of the mosquito where they develop into oocysts. The oocysts grow, rupture, and release sporozoites, which make their way to the mosquito’s salivary glands. Inoculation of the sporozoitesinto a new human host perpetuates the malaria life cycle.

DIAGNOSIS-

Your doctor will be able to diagnose malaria. During your appointment, your doctor will review your health history, including any recent travel to tropical climates. A physical exam will also be performed.

Your doctor will be able to determine if you have an enlarged spleen or liver. If you have symptoms of malaria, your doctor may order additional blood tests to confirm your diagnosis.

These tests will show:

• whether you have malaria
• what type of malaria you have
• if your infection is caused by a parasite that’s resistant to certain types of drugs
• if the disease has caused anemia
• if the disease has affected your vital organs

PREVENTION-

Vector control is the main way to prevent and reduce malaria transmission. If coverage of vector control interventions within a specific area is high enough, then a measure of protection will be conferred across the community.

WHO recommends protection for all people at risk of malaria with effective malaria vector control. Two forms of vector control – insecticide-treated mosquito nets and indoor residual spraying – are effective in a wide range of circumstances.

Insecticide-treated mosquito nets

Sleeping under an insecticide-treated net (ITN) can reduce contact between mosquitoes and humans by providing both a physical barrier and an insecticidal effect. Population-wide protection can result from the killing of mosquitoes on a large scale where there is high access and usage of such nets within a community.

In 2018, about half of all people at risk of malaria in Africa were protected by an insecticide-treated net, compared to 29% in 2010. However, ITN coverage has been at a standstill since 2016.

Indoor spraying with residual insecticides

Indoor residual spraying (IRS) with insecticides is another powerful way to rapidly reduce malaria transmission. It involves spraying the inside of housing structures with an insecticide, typically once or twice per year. To confer significant community protection, IRS should be implemented at a high level of coverage.

Globally, IRS protection declined from a peak of 5% in 2010 to  2% in 2018, with decreases seen across all WHO regions, apart from the WHO Eastern Mediterranean Region. The declines in IRS coverage are occurring as countries switch from pyrethroid insecticides to more expensive alternatives to mitigate mosquito resistance to pyrethroids. 

Antimalarial drugs

Antimalarial medicines can also be used to prevent malaria. For travellers, malaria can be prevented through chemoprophylaxis, which suppresses the blood stage of malaria infections, thereby preventing malaria disease. For pregnant women living in moderate-to-high transmission areas, WHO recommends intermittent preventive treatment with sulfadoxine-pyrimethamine, at each scheduled antenatal visit after the first trimester. Similarly, for infants living in high-transmission areas of Africa, 3 doses of intermittent preventive treatment with sulfadoxine-pyrimethamine are recommended, delivered alongside routine vaccinations.

Since 2012, WHO has recommended seasonal malaria chemoprevention as an additional malaria prevention strategy for areas of the Sahel sub-region of Africa. The strategy involves the administration of monthly courses of amodiaquine plus sulfadoxine-pyrimethamine to all children under 5 years of age during the high transmission season.

Insecticide resistance

Since 2000, progress in malaria control has resulted primarily from expanded access to vector control interventions, particularly in sub-Saharan Africa. However, these gains are threatened by emerging resistance to insecticides among Anopheles mosquitoes.  According to the latest World malaria report, 73 countries reported mosquito resistance to at least 1 of the 4 commonly-used insecticide classes in the period 2010-2018. In 27 countries, mosquito resistance was reported to all of the main insecticide classes.

Despite the emergence and spread of mosquito resistance to pyrethroids, insecticide-treated nets continue to provide a substantial level of protection in most settings. This was evidenced in a large 5-country study coordinated by WHO between 2011 and 2016.

While the findings of this study are encouraging, WHO continues to highlight the urgent need for new and improved tools in the global response to malaria. To prevent an erosion of the impact of core vector control tools, WHO also underscores the critical need for all countries with ongoing malaria transmission to develop and apply effective insecticide resistance management strategies.

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Advice for travelers

While malaria is not endemic to the U.S., travel to many countries around the world entails a risk.

The Centers for Disease Control advise travelers to take the following precautions:

• find out what the risk of malaria is in the country and city or region they are visiting
• ask their doctor what medications they should use to prevent infection in that region
• obtain antimalarial drugs before leaving home, to avoid the risk of buying counterfeit drugs while abroad
• consider the risk for individual travelers, including children, older people, pregnant women, and the existing medical conditions of any travelers

TREATMENT –

Treatment aims to eliminate the Plasmodium parasite from the bloodstream.

Those without symptoms may be treated for infection to reduce the risk of disease transmission in the surrounding population.

The World Health Organization (WHO) recommends artemisinin-based combination therapy (ACT) to treat uncomplicated malaria.

Artemisinin is derived from the plant Artemisia annua, better known as sweet wormwood. It rapidly reduces the concentration of Plasmodium parasites in the bloodstream.

Practitioners often combine ACT with a partner drug. ACT aims to reduce the number of parasites within the first 3 days of infection, while the partner drugs eliminate the rest.

Expanding access to ACT treatment worldwide has helped reduce the impact of malaria, but the disease is becoming increasingly resistant to the effects of ACT.

In places where malaria is resistant to ACT, treatment must contain an effective partner drug.

The WHO has warned that no alternatives to artemisinin are likely to become available for several years.

ACCORDING TO WHO

Early diagnosis and treatment of malaria reduces disease and prevents deaths. It also contributes to reducing malaria transmission. The best available treatment, particularly for P. falciparum malaria, is artemisinin-based combination therapy (ACT).

WHO recommends that all cases of suspected malaria be confirmed using parasite-based diagnostic testing (either microscopy or rapid diagnostic test) before administering treatment. Results of parasitological confirmation can be available in 30 minutes or less. Treatment, solely on the basis of symptoms should only be considered when a parasitological diagnosis is not possible. More detailed recommendations are available in the third edition of the “WHOGuidelines for the treatment of malaria”, published in April 2015.

Antimalarial drug resistance

Resistance to antimalarial medicines is a recurring problem. Resistance of P. falciparum malaria parasites to previous generations of medicines, such as chloroquine and sulfadoxine-pyrimethamine (SP), became widespread in the 1950s and 1960s, undermining malaria control efforts and reversing gains in child survival.

Protecting the efficacy of antimalarial medicines is critical to malaria control and elimination. Regular monitoring of drug efficacy is needed to inform treatment policies in malaria-endemic countries, and to ensure early detection of, and response to, drug resistance.

In 2013, WHO launched the Emergency response to artemisinin resistance (ERAR) in the Greater Mekong subregion (GMS), a high-level plan of attack to contain the spread of drug-resistant parasites and to provide life-saving tools for all populations at risk of malaria. But even as this work was under way, additional pockets of resistance emerged independently in new geographic areas of the subregion. In parallel, there were reports of increased resistance to ACT partner drugs in some settings. A new approach was needed to keep pace with the changing malaria landscape.

At the World Health Assembly in May 2015, WHO launched the Strategy for malaria elimination in the Greater Mekong subregion (2015–2030), which was endorsed by all the countries in the subregion. Urging immediate action, the strategy calls for the elimination of all species of human malaria across the region by 2030, with priority action targeted to areas where multidrug resistant malaria has taken root.With technical guidance from WHO, all countries in the region have developed national malaria elimination plans. Together with partners, WHO is providing ongoing support for country elimination efforts through the Mekong Malaria Elimination programme, an initiative that evolved from the ERAR

Surveillance

Surveillance entails tracking of the disease and programmatic responses, and taking action based on the data received. Currently, many countries with a high burden of malaria have weak surveillance systems and are not in a position to assess disease distribution and trends, making it difficult to optimize responses and respond to outbreaks.

Effective surveillance is required at all points on the path to malaria elimination. Stronger malaria surveillance systems are urgently needed to enable a timely and effective malaria response in endemic regions, to prevent outbreaks and resurgences, to track progress, and to hold governments and the global malaria community accountable.

In March 2018, WHO released a reference manual on malaria surveillance, monitoring and evaluation. The manual provides information on global surveillance standards and guides countries in their efforts to strengthen surveillance systems.

Elimination

Malaria elimination is defined as the interruption of local transmission of a specified malaria parasite species in a defined geographical area as a result of deliberate activities. Continued measures are required to prevent re-establishment of transmission. Malaria eradication is defined as the permanent reduction to zero of the worldwide incidence of malaria infection caused by human malaria parasites as a result of deliberate activities. Interventions are no longer required once eradication has been achieved.

Globally, the elimination net is widening, with more countries moving towards the goal of zero malaria. In 2018, 27 countries reported fewer than 100 indigenous cases of the disease, up from 17 countries in 2010.  

Countries that have achieved at least 3 consecutive years of 0 indigenous cases of malaria are eligible to apply for the WHO certification of malaria elimination. Over the last decade,  10 countries have been certified by the WHO Director-General as malaria-free: Morocco (2010), Turkmenistan (2010), Armenia (2011), Maldives (2015), Sri Lanka (2016), Kyrgyzstan (2016), Paraguay (2018), Uzbekistan (2018), Algeria (2019) and Argentina (2018). The WHO Framework for Malaria Elimination (2017) provides a detailed set of tools and strategies for achieving and maintaining elimination.

Vaccines against malaria

RTS,S/AS01 (RTS,S) is the first and, to date, the only vaccine to show that it can significantly reduce malaria, and life-threatening severe malaria, in young African children. It acts against P. falciparum, the most deadly malaria parasite globally and the most prevalent in Africa. Among children who received 4 doses in large-scale clinical trials, the vaccine prevented approximately 4 in 10 cases of malaria over a 4-year period.

In view of its public health potential, WHO’s top advisory bodies for malaria and immunization have jointly recommended phased introduction of the vaccine in selected areas of sub-Saharan Africa. Three countries – Ghana, Kenya and Malawi – began introducing the vaccine in selected areas of moderate and high malaria transmission in 2019. Vaccinations are being provided through each country’s routine immunization programme.

The pilot programme will address several outstanding questions related to the public health use of the vaccine. It will be critical for understanding how best to deliver the recommended 4 doses of RTS,S; the vaccine’s potential role in reducing childhood deaths; and its safety in the context of routine use.

This WHO-coordinated programme is a collaborative effort with Ministries of Health in Ghana, Kenya and Malawi and a range of in-country and international partners, including PATH, a non-profit organization, and GSK, the vaccine developer and manufacturer.Financing for the vaccine programme has been mobilized through a collaboration between 3 major global health funding bodies: Gavi, the Vaccine Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and Unitaid.

WHO response

WHO Global technical strategy for malaria 2016-2030 

The WHO Global technical strategy for malaria 2016-2030 – adopted by the World Health Assembly in May 2015 – provides a technical framework for all malaria-endemic countries. It is intended to guide and support regional and country programmes as they work towards malaria control and elimination.

The Strategy sets ambitious but achievable global targets, including:

• reducing malaria case incidence by at least 90% by 2030;
• reducing malaria mortality rates by at least 90% by 2030;
• eliminating malaria in at least 35 countries by 2030;
• preventing a resurgence of malaria in all countries that are malaria-free.

This Strategy was the result of an extensive consultative process that spanned 2 years and involved the participation of more than 400 technical experts from 70 Member States.

The Global Malaria Programme

The WHO Global Malaria Programme coordinates WHO’s global efforts to control and eliminate malaria by:

• setting, communicating and promoting the adoption of evidence-based norms, standards, policies, technical strategies, and guidelines;
• keeping independent score of global progress;
• developing approaches for capacity building, systems strengthening, and surveillance; and
• identifying threats to malaria control and elimination as well as new areas for action.

The Programme is supported and advised by the Malaria Policy Advisory Committee (MPAC), a group of global malaria experts appointed following an open nomination process. The mandate of MPAC is to provide strategic advice and technical input, and extends to all aspects of malaria control and elimination, as part of a transparent, responsive and credible policy-setting process. 

“High burden high impact approach”

At the World Health Assembly in May 2018, the WHO Director-General, Dr Tedros Adhanom Ghebreyesus, called for an aggressive new approach to jump-start progress against malaria. A new country-driven response – “ High burden to high impact” – was launched in Mozambique in November 2018. 

The approach is currently being driven by the 11 countries that carry a high burden of the disease (Burkina Faso, Cameroon, Democratic Republic of the Congo, Ghana, India, Mali, Mozambique, Niger, Nigeria, Uganda and United Republic of Tanzania). Key elements include: 

1. political will to reduce the toll of malaria; 
2. strategic information to drive impact; 
3. better guidance, policies and strategies; and 
4. a coordinated national malaria response. 

Catalysed by WHO and the RBM Partnership to End Malaria, “High burden to high impact” builds on the principle that no one should die from a disease that can be prevented and diagnosed, and that is entirely curable with available treatments.

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Basic Principles of Health Education

Basic Principles of Health Education

In this module, you will learn about the definition of health, health education, and health promotion. This will help you to understand then important components of health.

•  Physical
•  Psychological
•  Social

 Personal Views on Health

Think about your responses to the following questions:

• What does health mean to you?
• How important is health to you?
• What do you do (if anything) to stay healthy?

Health promotion and disease prevention programs focus on keeping people healthy. Health promotion programs aim to engage and empower individuals and communities to choose healthy behaviors, and make changes that reduce the risk of developing chronic diseases and other morbidities. Defined by the World Health Organization, health promotion:

Disease prevention differs from health promotion because it focuses on specific efforts aimed at reducing the development and severity of chronic diseases and other morbidities.

Wellness is related to health promotion and disease prevention. Wellness is described as the attitudes and active decisions made by an individual that contribute to positive health behaviors and outcomes.

Health promotion and disease prevention programs often address social determinants of health, which influence modifiable risk behaviors. Social determinants of health are the economic, social, cultural, and political conditions in which people are born, grow, and live that affect health status. Modifiable risk behaviors include, for example, tobacco use, poor eating habits, and lack of physical activity, which contribute to the development of chronic disease.

Typical activities for health promotion, disease prevention, and wellness programs include:

• Communication: Raising awareness about healthy behaviors for the general public. Examples of communication strategies include public service announcements, health fairs, mass media campaigns, and newsletters.
• Education: Empowering behavior change and actions through increased knowledge. Examples of health education strategies include courses, trainings, and support groups.
• Policy, Systems, and Environment: Making systematic changes – through improved laws, rules, and regulations (policy), functional organizational components (systems), and economic, social, or physical environment – to encourage, make available, and enable healthy choices.

Clearly health is not quite as simple as the definition implies.
The concept of health is wide, and the way we define health also depends on individual perception, religious beliefs, cultural values, norms, and social class. Generally, there are two different perspectives concerning people’s own definitions of health: a narrow perspective and a broader perspective.

1. Narrow Perspectives of Health

People with a narrow perspective consider health as the absence of disease, disability, or biological dysfunction. According to this view, to call someone unhealthy or sick means there should be evidence of a particular illness. Social, emotional, and psychological factors are not believed to cause unhealthy conditions. This view is narrow and limits the definition of health to the physical and physiological capabilities that are necessary to perform routine tasks.

According to this definition, the individual is healthy if all the body parts, cells, tissues, and organ systems are functioning well, and there is no apparent dysfunction of the body. Using this view, people view the human body in the same say as a computer or mechanical device. When something is wrong, the object is taken to experts who will maintain it. Hence, physicians often focus on treatment and clinical interventions with medication rather than health education to bring about behavior change.

Serena’s Story

• About two months ago Serena lost her six month old twins. She is grief stricken. She has always been slender, but now she looks very thin. She cannot sleep; she cannot eat, and she doesn’t want to talk to anyone.
• Do you think the view of health you have just read about applies to Serena?

This view of health ignores many of the social and psychological causes of ill health. Serena’s grief is not an illness, but it is certainly affecting her health.

2. Broader Perspectives of Health

In the previous section you read about a narrow definition of health. Now this section will help you understand the concept of health in a broader and more holistic way.

The most widely used broader definition of health is that within the constitution of the World Health Organization (1948), which defines health as: “Health is not only the absence of infirmity and disease but also a state of physical mental and social well-being.” This classic definition is important, as it identifies the vital components of health. To more fully understand the meaning of health, it is important to understand each of its individual components.

• Think back to Serena.
• Describe her state of health.
• Serena is mentally distressed. She does not by any means have mental and social well-being.

Physical Health

Physical health, which is one of the components of the definition of health, could be defined as the absence of diseases or disability of the body parts. Physical health could be defined as the ability to perform routine tasks without any physical restriction

To understand physical health, one needs to know what is considered to be physically unhealthy.

The following examples can help to understand someone who is physically unhealthy:

• A person who has been harmed due to a car accident
• A farmer infected by malaria and unable to do their farming duties
• A person infected by tuberculosis and unable to perform his or her tasks.

According to the WHO definition, do you see any of the above unhealthy examples as healthy? Also think about someone in your community who you would consider to be physically disabled.

While both of these people may be restricted in their movement and ability to do routine tasks, they may still be in a state of physical and mental well-being.

Psychological Health

Health is not limited to the biological integrity and the physiological functioning of the human body. Psychological health is also an important aspect of a health definition.

• Think about people in the community who are showing behavior that may indicate they are going through a period of mental distress in their lives.
• Or think about Serena again.
• Do you think that everyone in distress shows the same sorts of symptoms?

Sometimes it can be really difficult to tell if people are struggling with mental health issues, but at other times they may show symptoms that suggest a lack of self-awareness or personal identity, or an inability of rational and logical decision-making. At other times it might be apparent that they are not looking after themselves and are without a proper purpose in their lives. They may be drinking alcohol and have a non-logical response to any request. It may also be noticed that they have an inability to maintain their personal autonomy and are unable to maintain good relationships with people around them.

Social Health

The social component of health is considered to be the ability to make and maintain “acceptable” and “proper” interactions and to communicate with other people within the social environment. This component also includes being able to maintain satisfying interpersonal relationships and being able to fulfill a social role. Having a social role is the ability that people have to maintain their own identity while sharing, cooperating, communicating, and enjoying the company of others. This is really important when participating in friendships and taking a full part in family and community life.

Which of the following examples could be considered to contribute to social health? Explain and discuss your answers.

1. Mourning when a close family member dies
2. Going to a football game or involvement in a community meeting
3. Celebrating traditional cultural events within a community
4. Shopping in the market
5. Creating and maintaining friendships

In reality, all these events could have a social component and help towards building people’s social view of health. They all involve interacting with others and gaining support, friendship, and in many instances joy from being with other people.

The World Health Organization said that health promotion is defined as the process of enabling people to increase control over, and to improve, their health. The aim of health promotion is to reduce the underlying causes of ill-health so that there is a long-term reduction in many diseases.

Clearly health is not quite as simple as the definition implies.
The concept of health is wide, and the way we define health also depends on individual perception, religious beliefs, cultural values, norms, and social class. Generally, there are two different perspectives concerning people’s own definitions of health: a narrow perspective and a broader perspective.

1. Narrow Perspectives of Health

People with a narrow perspective consider health as the absence of disease, disability, or biological dysfunction. According to this view, to call someone unhealthy or sick means there should be evidence of a particular illness. Social, emotional, and psychological factors are not believed to cause unhealthy conditions. This view is narrow and limits the definition of health to the physical and physiological capabilities that are necessary to perform routine tasks.

According to this definition, the individual is healthy if all the body parts, cells, tissues, and organ systems are functioning well, and there is no apparent dysfunction of the body. Using this view, people view the human body in the same say as a computer or mechanical device. When something is wrong, the object is taken to experts who will maintain it. Hence, physicians often focus on treatment and clinical interventions with medication rather than health education to bring about behavior change.

Serena’s Story

• About two months ago Serena lost her six month old twins. She is grief stricken. She has always been slender, but now she looks very thin. She cannot sleep; she cannot eat, and she doesn’t want to talk to anyone.
• Do you think the view of health you have just read about applies to Serena?

This view of health ignores many of the social and psychological causes of ill health. Serena’s grief is not an illness, but it is certainly affecting her health.

2. Broader Perspectives of Health

In the previous section you read about a narrow definition of health. Now this section will help you understand the concept of health in a broader and more holistic way.

The most widely used broader definition of health is that within the constitution of the World Health Organization (1948), which defines health as: “Health is not only the absence of infirmity and disease but also a state of physical mental and social well-being.” This classic definition is important, as it identifies the vital components of health. To more fully understand the meaning of health, it is important to understand each of its individual components.

• Think back to Serena.
• Describe her state of health.
• Serena is mentally distressed. She does not by any means have mental and social well-being.

Physical Health

Physical health, which is one of the components of the definition of health, could be defined as the absence of diseases or disability of the body parts. Physical health could be defined as the ability to perform routine tasks without any physical restriction

REQUEST AN APPOINTMENT OR BOOK A CONSULANT – Sargam.dange.18@gmail.com

To understand physical health, one needs to know what is considered to be physically unhealthy.

The following examples can help to understand someone who is physically unhealthy:

• A person who has been harmed due to a car accident
• A farmer infected by malaria and unable to do their farming duties
• A person infected by tuberculosis and unable to perform his or her tasks.

According to the WHO definition, do you see any of the above unhealthy examples as healthy? Also think about someone in your community who you would consider to be physically disabled.

While both of these people may be restricted in their movement and ability to do routine tasks, they may still be in a state of physical and mental well-being.

Psychological Health

Health is not limited to the biological integrity and the physiological functioning of the human body. Psychological health is also an important aspect of a health definition.

• Think about people in the community who are showing behavior that may indicate they are going through a period of mental distress in their lives.
• Or think about Serena again.
• Do you think that everyone in distress shows the same sorts of symptoms?

Sometimes it can be really difficult to tell if people are struggling with mental health issues, but at other times they may show symptoms that suggest a lack of self-awareness or personal identity, or an inability of rational and logical decision-making. At other times it might be apparent that they are not looking after themselves and are without a proper purpose in their lives. They may be drinking alcohol and have a non-logical response to any request. It may also be noticed that they have an inability to maintain their personal autonomy and are unable to maintain good relationships with people around them.

Social Health

The social component of health is considered to be the ability to make and maintain “acceptable” and “proper” interactions and to communicate with other people within the social environment. This component also includes being able to maintain satisfying interpersonal relationships and being able to fulfill a social role. Having a social role is the ability that people have to maintain their own identity while sharing, cooperating, communicating, and enjoying the company of others. This is really important when participating in friendships and taking a full part in family and community life.

Which of the following examples could be considered to contribute to social health? Explain and discuss your answers.

1. Mourning when a close family member dies
2. Going to a football game or involvement in a community meeting
3. Celebrating traditional cultural events within a community
4. Shopping in the market
5. Creating and maintaining friendships

In reality, all these events could have a social component and help towards building people’s social view of health. They all involve interacting with others and gaining support, friendship, and in many instances joy from being with other people.

The World Health Organization said that health promotion is defined as the process of enabling people to increase control over, and to improve, their health. The aim of health promotion is to reduce the underlying causes of ill-health so that there is a long-term reduction in many diseases.

The World Health Organization said that health promotion is defined as the process of enabling people to increase control over, and to improve, their health. The aim of health promotion is to reduce the underlying causes of ill-health so that there is a long-term reduction in many diseases.

REQUEST AN APPOINTMENT OR BOOK A CONSULANT – Sargam.dange.18@gmail.com

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Physiotherapy in mental health care and psychiatry is a recognized specialty within physiotherapy. It offers a rich variety of observational and evaluation tools as well as a range of interventions that are related to the patient’s physical and mental health problems based on evidence‐based literature and a 50‐year history. Physiotherapy in mental health care addresses human movement, function, physical activity and exercise in individual and group therapeutic settings. Additionally, it connects the physical and mental health needs of humans. This chapter offers general reflections on mental health, the scope of physiotherapy in mental health care and physiotherapy research. Physiotherapy in mental health care and psychiatry can offer added and beneficial value to the treatment of people with mental health problems.

Mental health is a topic of growing interest in society. Various mental health organizations are engaged in the prevention, treatment and rehabilitation of persons with mental health problems and disorders. Unfortunately, physiotherapy is not always considered to be a significant profession within mental health because the role and the added value it offers can remain unclear among patients and other health care providers. However, physiotherapy is a recognized conventional profession within health care and can offer an extensive range of physical approaches (physical activity, exercise, movement, relaxation techniques and body and movement awareness). These approaches are aimed at symptom relief, the enhancement of self‐confidence and the improvement of quality of life. Additionally, they are relevant to rehabilitation programmes in mental health care.

The goal of this chapter is to present an overview of why physiotherapy in mental health is necessary and what it can offer to fulfil requests for help and to increase the quality of life of persons with mental health problems. It describes physiotherapy methods and their applications in the fields of mental health and psychiatry.

Epidemiology

About half of the mental disorders begin before the age of 14. Similar types of disorders are being reported across cultures. Neuropsychiatric disorders are among the leading causes of worldwide disability in young people. About 23% of all years lost because of disability is caused by mental and substance use disorders. War and disasters have a large impact on mental health and psychosocial well-being. Rates of mental disorder tend to double after emergencies. Mental disorders increase the risk of getting ill from other diseases such as HIV, cardiovascular disease, diabetes, and vice-versa.

• 1 in 4 people will experience a mental health issue of some sort during their lifetime
• 1 in 6 people are likely to have had mental health issues in the past seven days
• people with mental health issues are more at risk of having poor physical health
• 70% of premature deaths in people with mental health issues are due to poor physical health
• mental health issues are one of the main causes of the overall disease burden worldwide.

The Relation of Physical Activity and Exercise to Mental Health

Mental disorders are of major public health significance. It has been claimed that vigorous physical activity has positive effects on mental health in both clinical and non-clinical populations.Mental health problems are the leading predictor of years lived with disability worldwide. Furthermore, without intensified prevention and management, the burden is estimated to increase to a greater extent. The consequences of mental health problems are devastating for the person and society as a whole and are compounded by physical health comorbidities with which most people with mental health problems are confronted. Physical health comorbidities are a major cause of the reduced life expectancy of 15–20 years in this population. The relationship between mental health and physical activity is supported by a growing number of articles. There is rigorous evidence now that physiotherapy improves mental and physical health in this vulnerable population.

Unfortunately, these efforts are becoming integrated into clinical practice at a slow pace. Physical activity is not always considered to be a worthwhile strategy. The benefits of physical activity are twofold, as people with mental health problems are also at an increased risk of a range of physical health problems, including cardiovascular diseases, endocrine disorders and obesity. Physical activity influences cognition and cardiorespiratory fitness and reduces dropout due to a wide range of mental health problems. The relationship between physical activity and mental health has been widely investigated.

The health benefits of regular exercise are:

• Improved cardiovascular fitness
• Improved sleep
• Better endurance
• A positive influence on metabolic syndrome and diabetes
• Stress relief
• Improved mood
• Increased energy and reduced tiredness.
• Exercise reduces anxiety, depression, negative mood and social isolation and improves self‐esteem, cognitive functions and quality of life.

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The Role of Physiotherapy in Improving Mental Health

Not all physiotherapists realize that mental health is all the business of physiotherapy. However, it is well illustrated in this quotation: ‘no health without mental health’. Physiotherapists are seen as experts in aspects of physical health care and can offer:

• Non-pharmacological management of pain
• Expertise in prescribing individualised exercise programs, which can improve mood, promote wellbeing and address co-morbidities associated with mental health diagnoses.
• Interventions to address physical issues of people with mental health diagnoses which hinder social participation and recovery, eg. minimising or counteracting the side-effects some of psychotropic medications
• Expertise in motivating, where appropriate, patients and promoting self-management in the context of mental and physical health issues.
• Management of falls and mobility issues for older people and developmental issues for children and young people.
• Expert advice and intervention to address impaired body awareness and reduce dissociation (disconnection from ‘thoughts, feelings, memories or sense of identity) associated with poor mental health.
• Development and delivery of individually-tailored lifestyle and weight management advice and programs.

Good mental health is fundamental to the well-being of individuals, families and communities. Poor mental health is identified as one of the biggest causes of disability, poor quality of life and reduced productivity. There is also a strong association between mental health conditions and people reporting multiple pain sites. It has been documented that physical activity can improve quality of life for people with serious mental illness. Improved physical health can alleviate psychiatric and social disability. A notable number of longitudinal and cross-sectional studies have proven the usefulness of physical activity as a preventative strategy and as adjunct treatment for mental illness. Several physiotherapy interventions are potentially effective in improving physical and mental health and health- related quality of life. The most commonly used forms of exercise are aerobic- and strength exercises. Aerobic exercises, such as walking, jogging, cycling, swimming, have been proven to reduce anxiety and depression

The burden of depression, anxiety and other mental disorders call for concerted, intersectoral response. Not only to raise public awareness but also to provide treatment and prevention strategies that can reduce this large and growing health problem, including the economic losses attributable to them. The correlations between poor mental health and an increased prevalence of musculoskeletal conditions, multiple areas of pain, chronic and preventable diseases, emphasizes the need for an effective and holistic multidisciplinary approach to the management of these conditions.

Physiotherapists have also a key role in the treatment of patients with schizophrenia and their interventions may have a broad spectrum of benefits for patients. In particular, physiotherapists are physical health experts providing an important bridge between physical and mental health in patients with schizophrenia. Promoting and encouraging physical activity is central to the physiotherapist’s role in treating individuals with schizophrenia.

Definition of Physiotherapy in Mental Health

Physiotherapists who were working in mental health and psychiatry applied in 2011 for recognition as a subgroup within the World Confederation of Physical Therapy. The main goal of this subgroup is to bring the different physiotherapy interventions in mental health and psychiatry together to clarify the role of physiotherapy in this field.

For that reason, the International Organization of Physical Therapy in Mental Health (IOPTMH) developed a definition that generally describes the field of physiotherapy in mental health that is recognizable among most colleagues across the world. Physiotherapy in mental health is a specialty within physiotherapy. It is implemented in different health and mental health settings: psychiatry and psychosomatic medicine. It is person-centered and provided for children, adolescents, adults and older people with common (mild, moderate) and severe, acute and chronic mental health problems, in primary and community care, inpatients and outpatients. Physiotherapists in mental health provide health promotion, preventive health care, treatment and rehabilitation for individuals, groups and in‐group therapeutic settings. They create a therapeutic relationship to provide assessment and services specifically related to the complexity of mental health within a supportive environment applying a model including biological and psychosocial aspects. Physiotherapy in mental health aims to optimize wellbeing and empower the individual by promoting functional movement, movement awareness, physical activity and exercises, bringing together physical and mental aspects. It is based on the available scientific and best clinical evidence. Physiotherapists in mental health contribute to the multidisciplinary team and interprofessional care.

Mental health and physiotherapy

The importance of the implementation of physiotherapy in both common and severe mental health disorders and psychiatry is underestimated, even if there is a tradition of more than 50 years in some countries (Belgium, Scandinavia, etc.), even if the attention to ‘the moving body’ increases in society and even if the moving body is an important issue that is integral to psychopathology. To overcome this problem, physiotherapists who were working in mental health and psychiatry applied in 2011 for recognition as a subgroup within the World Confederation of Physical Therapy. The main goal of this subgroup is to bring the different physiotherapy interventions in mental health and psychiatry together to clarify the role of physiotherapy in this field. For that reason, the International Organization of Physical Therapy in Mental Health (IOPTMH) adapted the recommendations of the WHO concerning mental health care using physiotherapy language.

Recommendation for mental health care of the World Health Organisation adapted by the IOPTMH.

1. To improve [physiotherapy] mental health care
2. To organize specific [physiotherapy] care for different ages including children, adolescents and elderly and risk‐related groups as persons with eating disorders, psychotic disorders, etc.
3. To ensure access to primary [physiotherapy] care for people with mental health problems
4. To provide treatment in ‘community‐based [physiotherapy] services for persons with severe mental health problems.

Mental health in physiotherapy

Not all physiotherapists realize that mental health is all the business of physiotherapy. However, it is well illustrated in the following quotation: ‘no health without mental health’.

As health care providers, physiotherapists are also involved in the prevention and promotion of health, including mental health. It is their responsibility to inform individuals adequately about mental health, eliminate misconceptions about mental illness and refer them when necessary to specialized professionals in mental health and psychiatry.

Consciously or unconsciously, colleagues will be confronted in their practice with individuals with frail mental health, chronic musculoskeletal disorders, chronic pain and psychosomatic disorders. In their stories, components of mental health are interwoven, and the patients deserve an appropriate physiotherapy intervention. In addition to these conditions, more severe physical diseases such as cardiovascular diseases, Parkinson’s disease, rheumatoid arthritis, hypertension, Diabetes mellitus, metabolic syndrome, asthma, asthma/chronic obstructive pulmonary disorder (COPD), cerebrovascular diseases (stroke), obesity, epilepsy, cancer and other diseases are frequently accompanied with a ‘rollercoaster’ of emotions, feelings of anxiety and pain. After all, individuals with mental disorders have numerous physical health complaints (cardiovascular diseases, metabolic syndrome, obesity, osteoporosis, etc.) due to medication, sedentary behaviour or inactivity and consult primary health services.

The scope of physiotherapy in mental health

Depending upon the problem, the story of the patient, and the results of the observation/evaluation, the patient’s treatment goals will be established, and the physiotherapist can choose a more health-related approach or psychotherapeutic physiotherapy. The physical health‐related approach aims to improve the global physical health of patients with psychiatric disorders. Physical activity can help to reduce cardiovascular disease and premature mortality in people with psychological problems. The psychosocial‐related approach emphasizes the acquisition of mental and physical proficiencies related to the body in motion and support of personal development to enhance people’s ability to function independently in society. The psychotherapeutic‐related approach uses the body in movement as a gateway to ameliorate the social affective functioning of an individual. When using this approach, the physiotherapist creates a setting that favours the initiation and development of a process in the patient by employing specific working methods that aim to help patients to access their inner workings.

In physiotherapy in mental health, a rationale for applying psychological models (e.g. cognitive behavioural therapy, acceptance and commitment therapy, etc.) is offered as a tool to strengthen physiotherapy interventions in the treatment of a wide variety of disorders in children, adolescents, adults and the elderly. The cognitive behavioural physiotherapy treatment approach consists of the identification of current and specific problems related to the moving human being. The physiotherapy goals are based on the SMART principles (Specific, measurable, acceptable/attainable, realistic/relevant and time bound). The treatment is I think it is patient-centered and the ultimate physiotherapy goal is to change unhealthy habits and promoting an active lifestyle and healthy posture. The focus lays on self‐management and relapse prevention. Different modalities such as cognitive techniques (cognitive restructuring, problem solving and cognitive functional training), behavioural (relaxation, pacing and graded exercise therapy and behavioural activation), supportive, educational and other techniques such as (bio‐) feedback, movement and body awareness and relapse prevention for children and adults are integrated into this treatment . The acceptance and commitment physiotherapy approach is supporting the patient to clarify his/her values and helping them to take the necessary steps towards living a meaningful life despite the discomfort .

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Immunization Programs

The Expanded Programme on Immunization (EPI), with recommended guidelines established by the World Health Organization, is a major international effort to increase the proportion of children covered by basic immunizations against childhood diseases. Because of Africa’s unusually high rates of child mortality from measles, the prevalence of tuberculosis, and in many places, substantial mortality due to neonatal tetanus, EPI plays a central role in the health strategy for Africa. In addition, the low levels of funding for health programs in Africa have forced many countries to focus their scarce resources on what are perceived as the most cost-effective interventions, which include EPI (Walsh and Warren, 1979).

Universal Immunisation Programme

Immunization Programme in India was introduced in 1978 as ‘Expanded Programme of Immunization’ (EPI) by the Ministry of Health and Family Welfare, Government of India. In 1985, the programme was modified as ‘Universal Immunization Programme’ (UIP) to be implemented in phased manner to cover all districts in the country by 1989-90 with the one of largest health programme in the world.

Ministry of Health and Family Welfare, Government of India provides several vaccines to infants, children and pregnant women through the Universal Immunisation Programme.

About immunization

Immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine. Vaccines are substances that stimulate the body’s own immune system to protect the person against subsequent infection or disease.

Vaccines provided under UIP:

BCG

• About-BCG stands for Bacillus Calmette-Guerin vaccine. It is given to infants to protect them from tubercular meningitis and disseminated TB.
• When to give – BCG vaccine is given at birth or as early as possible till 1year of
• Route and site- BCG is given as intradermal injection in left upper arm.

OPV

• About-OPV stands for Oral Polio Vaccine. It protects children from poliomylitis.
• When to give- OPV is given at birth called zero dose and three doses are given at 6, 10 and 14 weeks. A booster dose is given at 16-24 months of age.
• Route and site – OPV is given orally in the form of two drops.

Hepatitis B vaccine

• About – Hepatitis B vaccine protects from Hepatitis B virus infection.
• When to give- Hepatitis B vaccine is given at birth or as early as possible within 24 hours. Subsequently 3 dose are given at 6, 10 and 14 weeks in combination with DPT and Hib in the form of pentavalent vaccine.
• Route and site- Intramuscular injection is given at anterolateral side of mid thigh

Pentavalent Vaccine

• About-Pentavalent vaccine is a combined vaccine to protect children from five diseases Diptheria, Tetanus, Pertusis, Haemophilis influenza type b infection and Hepatitis B.
• When to give – Three doses are given at 6, 10 and 14 weeks of age (can be given till one year of age).
• Route and site-Pentavalent vaccine is given intramuscularly on anterolateral side of mid thigh

Rotavirus Vaccine

• About -RVV stands for Rotavirus vaccine. It gives protection to infants and children against rotavirus diarrhoea. It is given in select states.
• When to give – Three doses of vaccine are given at 6, 10, 14 weeks of age.
• Route and site-5 drops of vaccine are given orally.

PCV

• About- PCV stands for Pneumococcal Conjugate Vaccine. It protects infants and young children against disease caused by the bacterium Streptococcus pneumoniae. It is given in select states.
• When to give – The vaccine is given as two primary doses at 6 & 14 weeks of age followed by a booster dose at 9 months of age
• Route and site-  PCV is given as intramuscular (IM) injection in outer right upper thigh. It should be noted that pentavalent vaccine and PCV are given as two separate injections into opposite thighs.

fIPV

• About– fIPV stands for Fractional Inactivated Poliomylitis Vaccine. It is used to boost the protection against poliomylitis.
• When to give- Two fractional doses of IVP are given intradermally at 6 and 14 weeks of age.
• Route and site- It is given as intradermal injection at right upper arm.

Measles/ MR vaccine

• About-Measles vaccine is used to protect children from measles. In few states Measles and Rubella a combined vaccine is given to protect from Measles and Rubella infection.
• When to given- First dose of Measles or MR vaccine is given at 9 completed months to12 months (vaccine can be given up to 5 years if not given at 9-12 months age) and second dose is given at 16-24 months.
• Route and site – Measles Vaccine is given as subcutaneous injection in right upper arm.

JE vaccine

• About- JE stands for Japanese encephalitis vaccine. It gives protection against Japanese Encephalitis disease. JE vaccine is given in select districts endemic for JE.
• When to given- JE vaccine is given in two doses first dose is given at 9 completed months-12 months of age and second dose at 16-24 months of age.
• Route and site- It is given as subcutaneous injection.

DPT booster

• About-DPT is a combined vaccine; it protects children from Diphtheria, Tetanus and Pertussis.
• When to give -DPT vaccine is given at 16-24 months of age is called as DPT first booster and DPT 2^nd booster is given at 5-6 years of age.
• Route and site- DPT first booster is given as intramuscular injection in antero-lateral side of mid thigh in left leg. DPT second booster is given as intramuscular injection in left upper arm.

 TT

• About- Tetanus toxoid vaccine is used to provide protection against tetanus. 
• When to give– Tetanus toxoid vaccine is given at 10 years and 15 years of age when previous injections of pentavalent vaccine and DPT vaccine are given at scheduled age.
• Pregnant women-TT-1 is given early in pregnancy;  and TT-2 is given 4 weeks after TT-1.TT booster is given when two doses of TT are given in a pregnancy in last three years.
• Route and site– TT is given as Intramuscular injection in upper arm.

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INTRODUCTION-

Immunization saves 2 to 3 million lives each year. By protecting children against serious diseases, vaccines play a central role in ending preventable child deaths. UNICEF’s immunization programme helps identify children who have been left behind by health systems, and brings them life-saving care.

Vaccines now protect more children than ever before, but in 2019, approximately 14 million infants did not receive any vaccines. Low immunization levels among poor and marginalized children compromise gains made in all other areas of maternal and child health. Over 1.5 million people die annually from diseases that can be prevented by vaccination.

Vaccination is one of the great public health achievements of human history. Vaccines used in national immunization programmes (NIPs) are considered safe and effective when used correctly. Vaccines are, however, not risk-free and adverse events will occasionally occur following vaccination. Public trust in vaccine safety is key to the success of vaccination programmes.

Goal

This course aims to establish a shared understanding among professionals whose work is linked to vaccine safety issues. This may include nurses/midwives/community health workers, as well as pharmacists medical doctors and programme or technical officers.

Rationale

Professionals involved in vaccine safety come from different backgrounds. As their jobs are all interrelated and co-dependent, they need a ‘common language’ in order to ensure smooth collaboration.

The E-learning Course on Vaccine Safety Basics meets different starting points, learning needs and country contexts. It offers the learner options to work at the speed and depth he prefers, recognizing his prior knowledge. Accommodating the different mechanisms between regions and nations is a challenge to any global course. For this reason we ask you from time to time to shift your focus to your own local context and look how vaccine safety is ensured in your country.

WHO RESPONSE

MODULE 1

This module serves as an introduction to the whole course. You will learn about the importance of immunization programmes and how vaccines work. You will understand the relationship between vaccine coverage, adverse events and disease spread. You will also learn about the importance of vaccine regulations in ensuring the effectiveness of vaccine initiatives.

Module outcomes

By the end of this module you should be able to:

• 1Explain the importance of vaccinationVaccinationInoculation with a vaccine for the purpose of inducing immunity. in the control of infectious diseases,
• 2Describe the basic principles of vaccination,
• 3Explain how the public are less tolerant of the risksRiskThe probability that an individual will experience a certain event during a defined period of time. associated with vaccinesVaccineA material containing live attenuated or inactivated (killed) microorganisms, or constituents of microorganisms, capable of eliciting protection against infection. (although very low) than they are of those associated with drugsDrug (or medicine)Any substance in a pharmaceutical product that is used to modify or exploit physiological systems or pathological states for the benefit of the recipient. The term drug/medicinal product is used in a wider sense to include the whole formulated and registered product, including the presentation and packaging, and the accompanying information. Vaccines are drugs/medicines. used to treat disease,
• 4List the main types of vaccine and illustrate them with examples,
• 5Describe the importance of post marketing vaccine safety surveillance,
• 6Identify some vaccines that have been associated with adverse vaccine reactions.

MODULE 2

There are many types of vaccines. Different types or formulations affect how they are used, how they are stored, and how they are administered. If they are to be safe and effective, it is vital to be familiar with the different types and to know how to handle them.

Different vaccines can cause different adverse reactions, and it is important to recognize what these may be. Can you identify the contraindications for vaccination and know which present an additional risk? What special considerations should you make when immunizing pregnant women or immunocompromised clients?

This module will explain the different types of vaccine and the main routes of administration. You will learn about the main vaccine reactions and the importance of understanding contraindications – as ignoring these could lead to vaccine reactions. Finally, you will look at public concern over vaccines and consider some rumours about vaccine safety that have been disproved by research.

Module outcomes

By the end of this module you should be able to:

• 1Explain the modes of action of live attenuated vaccines, conjugate vaccines, subunit vaccines, and toxoid vaccines,
• 2List types of vaccine components, including adjuvants and preservatives, and explain their functions,
• 3Explain the difference between live attenuated and inactivated vaccines,
• 4Identify the contraindications for vaccination that may present an additional risk.

MODULE 3

Under recommended conditions, all vaccines used in national immunization programmes are safe and effective if used correctly. In practice, however, no vaccine is completely risk-free and adverse events can occasionally result after an immunization.

Adverse events can range from minor side-effects to more severe reactions. They can be a cause of public concerns about vaccine safety. To understand a specific event and to be able to respond appropriately, there are several questions that you need to answer:

• What caused the reaction?
• Was it related to the vaccine or the way it was administered, or was it unrelated?
• Are the reactions minor or severe?

This module will help you to answer these questions. You will look at the main types of adverse events and the situations in which they may occur. You will also be introduced to the challenges and opportunities of mass vaccination campaigns. Because of the nature of these campaigns, adverse events may be more noticeable.

Module outcomes

By the end of this module you should be able to:

• 1Define the main types of adverse events following immunization (AEFIs),

• 2Differentiate between a reaction related to the vaccine itself, to the vaccination procedure (immunization error), or to coincidental events that are not linked to the vaccine,

• 3Differentiate between minor and severe vaccine reactions,

• 4Describe potential underlying causes for each type of AEFI, and understand the link between the AEFI and its cause,

• 5Summarize the expected incidence of the different types of AEFI.

MODULE 4

Pharmacovigilance is the practice of detecting, assessing, understanding, responding and preventing adverse drug reactions, including reactions to vaccines. It is now an integral part of the regulation of drug and vaccine safety. Surveillance systems exist at national and international levels to ensure effective monitoring and prompt actions in response to AEFIs.

Pharmacovigilance requires that incidents of adverse events are followed up in the correct way. Some adverse events need to be reported and/or investigated, and you will need to know which to report, how and to whom. Causality assessment procedures also need to be carried out effectively.

This module introduces you to the concept of pharmacovigilance and describes national and international surveillance systems. It helps you to assess how to report an AEFI in the correct way and explains the procedure of causality assessment. Finally, you will look at the subject of risk/benefit assessment, including the factors that influence the balance between risks and benefits of vaccines, risk evaluation and options analysis.

Module outcomes

By the end of this module you should be able to:

• 1Describe the basic principles of pharmacovigilancePharmacovigilanceThe science and activities relating to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problem. and the special considerations that apply to vaccination programmes,
• 2Use AEFI case definitions to evaluate which AEFIs should be detected and reported to the National regulatory authority (NRA)National regulatory authority (NRA)The regulatory body that approves procedures to ensure that medicines, including vaccines, are of adequate safety and potency. The vaccine manufacturer is responsible for demonstrating that the vaccine batch produced meets the requirements, based on the test specifications given by the NRA. The NRA is also responsible both for the official vaccine lot release process, based on the data and information provided by the manufacturer and, eventually, for confirmatory testing. or its equivalent,
• 3Describe the principles of risk-benefit analysisRisk-benefit analysisEvaluation and assessment of the relative risks and benefits of an intervention, e.g. the potential benefit of protection from measles and its complications due to vaccination, relative to the potential risk of adverse reactions to the vaccine. relative to the protective effect of immunization and the importance of causality assessmentsCausality assessment (or causality association)The systematic review of data about an AEFI case to determine the likelihood of a causal association between the event and the vaccine(s) received. to evaluate possible links between AEFIs and a vaccine or vaccine lot,
• 4Explain how investigation of AEFI reports and vaccine testing can contribute to surveillanceSurveillanceThe systematic collection, analysis, interpretation, and dissemination of health data on an ongoing basis, to gain knowledge of the pattern of disease occurrence and potential in a community, in order to control and prevent disease in the community. that ensures vaccine safety.

MODULE 5

The general principles for the surveillance of adverse events following immunization (AEFIs) are similar in all countries. However, approaches may differ due to factors such as how immunization services are organized and the level of resources available.

The first half of the Module describes the central role of the national regulatory authority (NRA) and the national immunization programme (NIP) along with the role of the AEFI review committee; other participants are also briefly introduced.

In the second half of the Module you will look into the international services available to support vaccine safety in countries. You will understand how national and international agencies work together and how information flows between them and countries.

Module outcomes

By the end of this module you should be able to:

• 1List the main functions or services for vaccine safety, including national and international bodies, as well as manufacturers,
• 2Describe the relevant areas of responsibility and (if applicable) the areas of collaboration between the National regulatory authority and immunization programmes within your own country,
• 3Identify the mechanisms by which an AEFI seen in a clinic can be reported to the national regulatory authority,
• 4Summarize information flows between institutions at national level (immunization clinics, NRAs, etc.) and international bodies.

MODULE 6

Every year, billions of doses of vaccine are given in immunization programmes around the world. Vaccines are designed to provoke an immune response in the body, and it is inevitable that this reaction carries a small attributable risk to the health of a tiny minority of recipients. This risk is hugely outweighed by the very significant benefits of immunization in terms of protection from vaccine-preventable diseases and their wide-ranging consequences.

Explaining risks and benefits of vaccines clearly to parents, guardians and vaccine recipients requires effective communication and interpersonal skills from trained health professionals in immunization programmes and educators such as school teachers.

This module will help you to understand public fear and concerns, and how you can improve your communication skills on the subject of vaccine safety.

Module outcomes

By the end of this module you should be able to:

• 1Understand the need for improved communication on vaccine safety,
• 2Critically evaluate and assess new information about vaccines before communicating to the target audience,
• 3Gather information about the various target audiences, who they are, how they perceive vaccine risk and their knowledge about vaccines and safety,
• 4Outline the fears and concerns of different groups associated with, or likely to be affected by, an immunization programme,
• 5Design simple, clear and tailor-made messages to communicate information about vaccine safety to your target audience (e.g. parent, vaccinee, clinic staff, media, health professional, drug regulatory authority, health minister, etc.),
• 6Identify the most suitable means and channels of communication to convey information to different target groups,
• 7Understand the media as being an important ally in vaccine safety.

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UNICEF

UNICEF works with partners in governments, NGOs, other UN agencies and the private sector to provide immunization to the children who need it the most.

Vaccinating children in every community: Wherever children are not immunized, their lives and communities are at risk. UNICEF tailors new approaches to vaccinate every child in every community – no matter how remote or challenging.

The cold chain: UNICEF and partners harness solar power, mobile technology and telemetrics to make sure vaccines reach all children without losing their effectiveness from exposure to extreme heat or cold weather conditions.

Vaccine supply: With UNICEF efforts, the price of many essential childhood vaccines has reached all-time lows. This has facilitated the introduction of new vaccines to children living in the poorest countries.

Innovation: Working with private and public partners, UNICEF steers investment towards new vaccines, and diagnostic and health technologies.  

Disease eradication and elimination programmes: Thanks to steady progress on expanding vaccination, the world has never been in a better position to eradicate polio. Immunization against measles, rubella and tetanus are bringing the world closer to eliminating these devastating diseases.

Background note on Immunization :-

• Expanded Programme on Immunization was launched in 1978. It was renamed as Universal Immunization Programme in 1985 when its reach was expanded beyond urban areas. In 1992, it became part of Child Survival and Safe Motherhood Programme and in 1997 it was included in the ambit of National Reproductive and Child Health Programme. Since the launch of National Rural Health Mission in 2005, Universal Immunization Programme has always been an integral part of it.
• Universal Immunization Programme (UIP) is one of the largest public health programmes targeting close of 2.67 crore newborns and 2.9 crore pregnant women annually.
• It is one of the most cost-effective public health interventions and largely responsible for reduction of vaccine preventable under-5 mortality rate.
• Under UIP, immunization is providing free of cost against 12 vaccine preventable diseases:
• Nationally against 9 diseases – Diphtheria, Pertussis, Tetanus, Polio, Measles, Rubella, severe form of Childhood Tuberculosis, Hepatitis B and Meningitis & Pneumonia caused by Hemophilus Influenza type B
• Sub-nationally against 3 diseases – Rotavirus diarrhoea, Pneumococcal Pneumonia and Japanese Encephalitis; of which Rotavirus vaccine and Pneumococcal Conjugate vaccine are in process of expansion while JE vaccine is provided only in endemic districts.
• A child is said to be fully immunized if child receives all due vaccine as per national immunization schedule within 1st year age of child.
• The two major milestones of UIP have been the elimination of polio in 2014 and maternal and neonatal tetanus elimination in 2015.

New vaccines

• Inactivated Polio Vaccine (IPV): IPV has been 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.
• Rotavirus vaccine (RVV): RVV has been introduced to reduce mortality and morbidity caused by Rotavirus diarrhoea in March 2016. It has been introduced in 11 states (Andhra Pradesh, Haryana, Himachal Pradesh, Jharkhand, Odisha, Assam, Tripura, Rajasthan, Tamil Nadu, Madhya Pradesh and Uttar Pradesh). The vaccine will be expanded across the country in 2019-20.
• Measles Rubella (MR) vaccine: India is committed to the goal of measles elimination and rubella control and to achieve the goal MR vaccine was introduced in the country through a campaign mode in a phased manner in 2017. MR campaign target around 41 crore children in the age group of 9 months to 15 years (covering ⅓ of the total population of the country) followed by 2 doses in routine immunization at 9-12 months and 16-24 months. Rubella component is now under routine immunization as MR vaccine.
• Pneumococcal Conjugate Vaccine (PCV): PCV has been launched in May 2017 for reducing Infant mortality and morbidity caused by pneumococcal pneumonia. It has been introduced in Bihar, Himachal Pradesh, Madhya Pradesh, 19 districts of Uttar Pradesh and 18 districts of Rajasthan.
• Tetanus and adult diphtheria (Td) vaccine: TT vaccine has been replaced with Td vaccine in UIP to limit the waning immunity against diphtheria in older age groups. Td vaccine to be administered to adolescents at 10 and 16 years of age and to pregnant women.

Mission Indradhanush

• Mission Indradhanush (MI) was launched in December 2014 and aims at increasing the full immunization coverage to children to 90%.
• Under this drive focus is given on pockets of low immunization coverage and hard to reach areas where the proportion of unvaccinated and partially vaccinated children is highest.
• A total of six phases of Mission Indradhanush have been completed covering 554 districts across the country.
• It was also identified as one of the flagship schemes under Gram Swaraj Abhiyan (16,850 villages across 541 districts) and Extended Gram Swaraj Abhiyan (48,929 villages across 117 aspirational districts).
• While the first two phases of Mission Indradhanush resulted in 6.7% increase in full immunization coverage in a year, a recent survey carried out in 190 districts covered in Intensified Mission Indradhanush (5th phase of Mission Indradhanush) shows 18.5% points increase in full immunization coverage as compared to NFHS-4 survey carried out in 2015-16.

New Initiatives in Vaccine Logistics & Cold Chain Management

1. Capacity building

• National Cold Chain Training Centre (NCCTE), Pune and National Cold Chain  & Vaccine Management Resource Centre (NCCVMRC) -NIHFW, New Delhi have been established to provide technical training to cold chain technicians in repair & maintenance of cold chain equipment

1. System strengthening

• Electronic Vaccine Intelligence Network (eVIN) rollout:
• The Government of India has rolled out an Electronic Vaccine Intelligence Network (eVIN)system that digitizes the entire vaccine stock management, their logistics and temperature tracking at all levels of vaccine storage – from national to the sub-district.
• This enables program managers to have real time view of the vaccine stock position and their storage temperature across all the cold chain points providing a detailed overview of the vaccine cold chain logistics system across the entire country.
• eVIN system has been completed in 12 states in the first phase – Assam, Bihar, Chhattisgarh, Himachal Pradesh Gujarat, Jharkhand, Madhya Pradesh, Manipur, Nagaland, Odisha, Rajasthan, and Uttar Pradesh.
• Second phase is ongoing in 9 states – Andhra Pradesh, Daman & Diu, Dadra & Nagar Haveli, Goa, Karnataka, Maharashtra, Telangana, Tripura and Uttarakhand.
• eVIN is to be scaled up to entire country.
• National Cold Chain Management Information System (NCCMIS)to track the cold chain equipment inventory, availability and functionality.

History of vaccine development

Although inoculationInoculationThe practice of intentionally exposing someone to matter from smallpox pustules in order to initiate a mild, protective response to the disease. against smallpox was practiced over 2000 years ago in China and India, a British physician, Edward Jenner, is generally credited with ushering in the modern concept of vaccination. In 1796 he used matter from cowpox pustules to inoculate patients successfully against smallpox, which is caused by a related virusVirusAn ultramicroscopic infectious agent that consists of genetic material surrounded by a protein coat. A virus can replicate themselves only within cells of living hosts..

By 1900, there were two human virus vaccines, against smallpox and rabiesRabiesA potentially fatal viral infection spread through the bite of certain warm-blooded animals. It attacks the central nervous system and, if left untreated, is highly fatal in animals., and three bacterial vaccines against typhoidTyphoid (typhoid fever)A serious disease caused by a bacteria called Salmonella Typhi. Typhoid causes a high fever, weakness, stomach pains, headache, loss of appetite, and sometimes a rash. If it is not treated, it can kill up to 30% of people who get it. There are different vaccines to prevent typhoid: inactivated vaccines that require injection, and live attenuated vaccines that are taken orally (by mouth)., choleraCholeraAn acute infectious disease of the small intestine, caused by the bacterium Vibrio cholerae and characterized by profuse watery diarrhea, vomiting, muscle cramps, severe dehydration, and depletion of electrolytes., and plaguePlagueA serious, potentially life-threatening infectious disease that is usually transmitted to humans by the bites of rodent fleas. It was one of the scourges of early human history..

A worldwide case detection and vaccination programme against smallpox gathered pace and, in 1979, the World Health Assembly officially declared smallpox eradicated — a feat that remains one of history’s greatest public health triumphs.

During the 20th century, other vaccines that protect against once commonly fatal infections such as pertussisPertussis (also known as whooping cough)An infectious bacterial disease caused by Bordetella pertussis that produces violent, spasmodic coughing; also called whooping cough., diphtheriaDiphtheriaA disease caused by toxigenic strains of Corynebacterium diphtheriae. Often marked by the formation of a false membrane in the throat, diphtheria is a serious vaccine-preventable disease that can cause death in unvaccinated children., tetanusTetanusA disease caused primarily by toxigenic C. tetani. The rare but often fatal disease affects the central nervous system by causing painful muscular contractions., polio, measlesMeaslesA contagious viral disease marked by fever, the eruption of red circular spots on the skin that can be deadly to young and weakened individuals., rubellaRubella (German measles)A viral infection that is usually milder than measles but can cause serious damage or death to a fetus when a pregnant woman is infected., and several other communicable diseases were developed. As these vaccines became available, high-income industrial nations began recommending routine vaccination of their children. There are now over 20 vaccine-preventable diseases.

REFERANCE-https://vaccine-safety-training.org/home.html

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