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Basic concept of Epidemiology – 1st chapter, MNSFT- 2011, Depuk Sir,1#Q. Definition of epidemiology? ===============================================Epidemiology has been defined by John M. Last in 1988 as “The study of the distribution and determinants of health related states or events in specified populations, and the application of this study to control of health problems.”Determinants: physical, biological, social, cultural, and behavioral factors that influence health.Health-related states or events: health status, diseases, death, other implications of disease such as disability, residual dysfunction, complication, recurrence, but also causes of death, behavior, provision and use of health services.2#Q. Aims / Objective of epidemiology?========================================

1. Describe the health status of a population 2. To assess the public health importance of diseases 3. To describe the natural history of disease, 4. Explain the etiology of disease 5. Predict the disease occurrence 6. To evaluate the prevention and control of disease7. Control the disease distribution

1. Epidemiology measurements tools?The basic tools of measurement in epidemiology are_____3 type, Rates, Ratios and Proportions #Q. Use of epidemiology?

i. TREND STUDY ii. COMMUNITY DIAGNOSIS iii. HEALTH SERVICES EVALUATION iv. TO KNOW THE INDIVIDUAL RISKS AND CHANCES v. SYNDROME IDENTIFICATION vi. COMPLETING THE CLINICAL PICTURE vii. SEARCHING FOR CAUSES / RISK FACTORS FOR ESTABLISHING CAUSAL RELATIONSHIP

Terminology and Definitionsa. Incidence The probability of a person being diagnosed with a disease during a specific period of time

(typically one year). The number of newly diagnosed cases of a disease during a specified time period

For example, a study of 1,000 bus drivers found 50 new cases of low back pain in one year The incidence is 50/1,000 = 0.05 or 5,000 per 100,000 Some workers may have had more than 1 episode of low back pain during the year, but only the first occurrence is usually counted PrevalenceThe proportion of persons in a given population that have a disease at a certain point in time The total number of cases of the disease in that population It does not matter when they were diagnosed with the condition Prevalence=Number of existing cases X 100,000.00 Population For example, a study of community with a population of 30,000 which found 1,000 persons with migraine headaches the prevalence is 1,000/30,000 = 0.033 or 3,300 per 100,000 persons It doesn’t matter that 200 of the cases were newly diagnosed and 800 already had migraine headaches when the study began

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2. Methods of epidemiology and Example?

b. Infection, event of infections: Infection is the entry and development or multiplication of an infectious agent in the body of man or animals. An infection does not always cause illness. There are several levels of infection (Gradients of infection): Colonization (S. aureus in skin and normal nasopharynx)

a. Subclinical or inapparent infection (polio)b. Latent infection (virus of herpes simplex)c. Manifest or clinical infection

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4#Q. Roll of confounder in epidemiological studyA confounder is a variable that is associated with the exposure and, independent of that exposure, is a risk factor for the disease.Confounding involves the possibility that an observed association is due, totally or in part, to the effects of differences between the study groups (other than the exposure under investigation) that could affect their risk of developing the outcome being studied. Depending on the nature of its relationship with the exposure and outcome, a confounder can even distort associations to such an extent that a positive association appears negative or no association appears as an association.For an incidental factor to be a confounder, it must satisfy the following conditions:

it must be associated with the exposure, it must be an independent risk factor for the outcome, it must not be an intermediate step in the causal chain between the exposure and outcome, and It must be present to a greater or lesser degree in the study group versus the comparison group.

Examples of confoundingA study found alcohol consumption to be associated with the risk of Coronary Heart Disease. However, smoking may have confounded the association between alcohol and CHD. For example smoking is independently associated with CHD (is a risk factor) and is also associated with alcohol consumption (smokers tend to drink more than non-smokers).

Controlling for the potential confounding effect of smoking may in fact show no association between alcohol consumption and CHD.Effects of confounding: Confounding factors, if not controlled for, cause bias in the estimate of the impact of the exposure being studied.The effects of confounding can result in:* An observed difference between study populations when no real difference exists.* No observed difference between study populations when a true association does exist.* An underestimate of an effect.* An overestimate of an effect.5#Q. What is Test sensitivity and specificity of epidemiology? SensitivitySensitivity is the probability that a human or animal will have a positive test result if indeed the human or animal does have a disease.  Sensitivity identifies the proportion of individuals who truly DO have the disease AND are given a positive test resultI find it helpful to remember: sensitivity = sensitive to the Truth (i.e. do have disease + do have positive result)We want to know what proportions of individuals who have the disease (a+c) were given a positive test result (a), therefore…

Sensitivity = a / (a+c)Specificity:

Specificity identifies the proportion of individuals who truly DO NOT have the disease AND were given the correct negative test result

I find it helpful to remember: specificity = specifies the False (i.e. do not have disease and do not have positive test resultThis time we want to know what proportion of people who do not have the disease (b+d) were given the correct negative test result (d), therefore…

Specificity = d /(b + d)

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6#Q. The Four Most Common Types of Epidemiological Studies Cohort Study Case Control Study Occupational Epidemiological Study Cross-Sectional Study

Cohort studies Cohort studies allow an investigator to estimate the disease incidence rate because the study measures the time that participants don’t have the disease. As compared to cross-sectional studies, cohort studies are better able to assess causality because the temporal relationship of exposure preceding outcome is not subject to question. This design is implemented through three steps. First, exposed and unexposed individuals who are free of the outcome of interest are identified and become the cohort. Next, each cohort is observed for a minimum period of time to determine if the outcome of interest develops. The risk of developing the outcome is calculated separately for the exposed group and for the unexposed group. Finally, the risk for the exposed and unexposed study subjects is compared, often by estimating the relative risk. Essentially, the incidence of disease over time is measured in exposed and unexposed individuals to determine the risk of disease in relation to exposure to a factor of interest. These studies can be performed retrospectively, where a post-hoc study is executed on previously collected data, or prospectively, where study subjects who do not have the outcome of interest are followed forward through time. Examples of cohort studies in honey bees include Genersch et al. (2010), Gisder et al. (2010) and van Engelsdorp et al. (2013).Cross-sectional studies Cross-sectional studies are a point-in-time study, such as a one-time disease surveillance survey, and are typically used to estimate disease prevalence or the simultaneous association between a risk factor and a disease. In this design, the exposure and outcome for each subject in the study are ascertained simultaneously. This simultaneity often leads to difficulty in conclusively establishing the temporal relationship between the exposure and the outcome. It is also important to note that chronic conditions are more likely to be identified in a survey because they are more likely to persist in a population and are more common. Therefore this study design is less useful for studies of rare exposures and rare outcomes. However, cross-sectional studies can be inexpensive, relatively quick to conduct, and are used to identify potential associations between exposures and outcomes that warrant further research with more rigorous population-based study designs. An example of a cross-sectional study is when a bee inspector examines hives in an apiary for characteristics, such as size, strength, activity, and disease and then uses these data to generate estimates of the prevalence of hives with a particular disease (e.g., Chalkbrood) in a region.Case-control studies In contrast to cohort studies where participants are identified by exposure status, participants in case-control studies are identified by their disease or outcome status. Cases are participants who have developed the outcome of interest. Controls are subjects who do not have the outcome of interest and provide an estimate of the frequency of exposure in the population at risk. In this retrospective study design, cases and controls are first identified. Subsequently, the exposure to the factor of interest is ascertained, for each case and control. Lastly, an odds ratio for the outcome of interest (in relation to exposure status) is calculated. Case-control studies are retrospective because they seek to determine previous exposure after the outcome has been established. Thus, they are subject to recall or information bias. Case-control studies are also subject to sampling bias because it is difficult to select controls which are (ideally) perfectly similar to cases, with the exception of outcome status. However, techniques such as matching controls to cases and stratified analysis can improve the precision of estimates from case-control studies.Case-control studies are useful when attempting to isolate a cause or causes for an emerging disease condition. Most recently this approach was used in attempts to determine the factors contributing to Colony Collapse Disorder (CCD) (vanEngelsdorpet al., 2009b, 2010; Dainat et al., 2012)

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7#Q. Measures of Disease OccurrenceMost measures of disease occurrence involve rates, and sometimes ratios:RATES.   A rate is a measure of the frequency with which an event occurs in a defined population in a defined time (e.g., number of deaths per hundred thousand Canadians in one year).  It has a time dimension, whereas a proportion (e.g., number of Canadians with cancer divided by the total population) does not. RATIOS. The value obtained by dividing one quantity by another: the male to female ratio in your class.  A ratio often compares two rates, for example comparing death rates for women and men at a given age.  The important difference between a rate and a ratio is that for a rate, the numerator is included in the population defined by the denominator (e.g., number of new cases of a disease divided by the total population). This is not necessarily so for a ratio. In a ratio, the numerator and denominator are usually separate and distinct quantities, neither being included in the other (e.g., number of males in the class compared to the number of females).INCIDENCE . Incidence = Number of new cases in a fixed time period / Number of people at risk.  Usually the period of study is chosen to be one year, in which case we speak of the annual incidence.  This gives a proportion, ranging from 0 to 1, that is useful in communicating the idea of risk: what is the probability that my patient will get this disease within the time-frame?  Note that you may also see the term CUMULATIVE INCIDENCE to represent the incidence proportionPREVALENCE. "How many people actually have the disease at any point in time?"  Prevalence = Number of people with the disease at a given time / Number of people at risk.  It is thus a proportion, rather than a rate, although you may sometimes see it called a "rate." Prevalence is influenced by the incidence and by the duration of the condition, and provides a good way to indicate the burden of disease in a population.CASE FATALITY RATE. The proportion of people with a specified condition who die within a specified time.  The time frame is typically the period during which the patient is sick from the disease.  This works for an infectious disease but can be problematic for a chronic disease like a cancer that may remit for a period and then prove fatal after a recurrence.  In such instances we tend to speak of mortality or survival rates rather than case fatality.ATTACK RATE The attack rate, or case rate, refers to the cumulative incidence of infection over a period of time. This is typically used during an epidemic.  The time period may not be indicated, but would typically refer to the period of the outbreak: "During the influenza outbreak the attack rate was 12%".COMPARING RATES.  A common reason for recording these various types of rates is to identify factors that are associated with a disease.  To measure the association between a factor and a disease, it is common to compare rates of the disease among people exposed to the factor and other people not exposed.  This can be done either as a relative statistic (e.g., relative risk), or in an absolute manner (e.g., rate difference)RELATIVE RISK The ratio of the risk of disease (or death) among people who are exposed to the risk factor, to the risk among people who are unexposed.  This is synonymous with risk ratio.  Alternatively, relative risk is defined as the ratio of the cumulative incidence rate among those exposed, to the rate among those not exposed.  To estimate a relative risk, you need a cohort study, from which incidence can be calculated. An RR of 1.0 means that the two incidence rates are equal so the factor has no effect. An RR of 2 would indicate that the exposed people were twice as likely to get the disease; an RR of 0.5 means they were half as likely, so the factor protected them from the disease.ODDS RATIO. The term "odds" is defined differently according to the situation under discussion, but it is the ratio of the probability of occurrence of an event to that of non-occurrence.  If 60 smokers develop a cough and 40 do not, the odds of developing the cough are 60:40 (or 1.5).   [Note that the probability of developing a cough is 60/100, or 0.6].The odds ratio expresses the association between a risk factor and a disease by comparing the likelihood of disease under two circumstances, such as the risk of a cough among smokers compared to non-smokers.  The ratio of the two odds is closely related to the concept of relative risk, but the very useful feature is that the odds ratio can be calculated from a case-control study, and does not require knowing incidence rates.

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8#Q. Communicable diseases: A communicable disease is an illness due to a specific infectious (biological) agent or its toxic products capable of being directly or indirectly transmitted from man to man, from animal to man, from animal to animal, or from the environment (through air, water, food, etc..) to man.9#Q. Risk Factors of Non-communication diseases:Risk factors such as a person's background, lifestyle and environment are known to increase the likelihood of certain non-communicable diseases. They include: age, sex, genetics, exposure to air pollution, and behaviors such as smoking, unhealthy diet and physical inactivity which can lead to hypertension and obesity, in turn leading to increased risk of many NCDs.Are they preventable? Most NCDs are considered preventable because they are caused by modifiable risk factors. What does “modifiable” mean?Five Important Risk Factors The WHO's World Health Report 2002 identified five important risk factors for non-communicable disease in the top ten leading risks to health. These are raised blood pressure, raised cholesterol, tobacco use, alcohol consumption, and overweight.10#Q. Diabetes Mellitus Type 2

Formerly non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes – is a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency

Diabetes is often initially managed by increasing exercise and dietary modification. If the condition progresses, medications may be needed.

Long-term complications from high blood sugar can include increased risk of heart attacks, strokes, amputation, and kidney failure.

For extreme cases, circulation of limbs is affected, potentially requiring amputation. Loss of hearing, eyesight, and cognitive ability has also been linked to this condition.11#Q. What is Cancer? Cancer is the general name for a group of more than 100 diseases in which cells in a part of the body begin to grow out of control. Although there are many kinds of cancer, they all start because abnormal cells grow out of control. Untreated cancers can cause serious illness and even death. How Cancer Starts

Cancer starts when cells in a part of the body start to grow out of control. There are many kinds of cancer, but they all start because of out-of-control growth of abnormal cells.

Cancer cell growth is different from normal cell growth. Instead of dying, cancer cells continue to grow and form new, abnormal cells. Cancer cells can also invade (grow into) other tissues, something that normal cells cannot do. Growing out of control and invading other tissues are what makes a cell a cancer cell.

12 #Q. Measure of Disease Frequency 1. Cumulative Incidence (Incidence, Risk, I, R)= Number of new case over a time period Population at risk at the outset Indicates the risk for the disease to occur in population at risk over a time period. Value from 0 to 1. 2. Incidence Density (Incidence Rate, ID, IR)= Number of new case over a time period Person time at risk Indicates the velocity (speed) of the disease to occur in population over a time period. Value from 0 to

infinity 3. Prevalence (Point Prevalence): Number of new and old cases at a point of time Population Indicates burden of disease. Value from 0 to 1.

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13#Q. Definition of non-communicable chronic diseases? Characteristics of NCD?

NCDs are diseases of long duration and generally slow progression. They include: heart disease, stroke, cancer, asthma, diabetes, chronic kidney disease, osteoporosis, Alzheimer's disease, cataracts, and more. An impairment of bodily structure or function that necessitates a modification of patient’s normal life and has persisted over an extended period of time. Diseases comprising all impairments or deviations from normal, which have one or more of the followingCharacteristics: Are permanent, Leave residual disability, Are caused by non reversible pathological alterations Require special training of the patient for rehabilitation, May be expected to require a long period of supervision, observation or careCausesRise in life expectancy and increasing number of senior citizensChanging lifestyles: faulty diet, alcohol intake, sedentary life, obesity, stress, Tobacco, Exposure to environmental risk factors- air pollution, increasing populationsRisk FactorsRisk factors such as a person's background, lifestyle and environment are known to increase the likelihood of certain non-communicable diseases. They include: age, sex, genetics, exposure to air pollution, and behaviors such as smoking, unhealthy diet and physical inactivity which can lead to hypertension and obesity, in turn leading to increased risk of many NCDs. Five Important Risk Factors: The WHO's World Health Report 2002 identified five important risk factors for non-communicable disease in the top ten leading risks to health. These are raised blood pressure, raised cholesterol, tobacco use, alcohol consumption, and overweight.14#Q. Prevention of NCDLevels of prevention

1. Primordial For healthy 2. Primary3. Secondary people4. Tertiary For unhealthy people

Primordial prevention; Prevention of the emergence or development of risk factors in countries or population groups in which they have not yet appeared. Efforts are directed towards discouraging children from adopting harmful life styles.Primary prevention - Action taken prior to the onset of disease which removes the possibility that the disease will ever occur. Can be divided into population & high risk strategyHealth promotionSpecific protection Primary preventionAdequate nutritionSafe water and sanitationSecondary prevention- Action which halts the progress of the disease at its incipient stage and prevents complications. Mostly curative Disadvantage - patient has already suffered mental & physical anguish & community to loss of production. Often more expensive & less effective. Intervention – EARLY DIAGNOSIS AND TREATMENTTertiary prevention- defined as all measures available to reduce impairments & disabilities, minimize suffering due to departure from good health & promote patient’s adjustment to irremediable conditions. Intervention – DISABILITY LIMITATION AND REHABILITATION

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15#Q.Communicable diseases1. Chickenpo x

Agent: Varicella-zoster virus, a member of the herpes virus family.Factor: - By touching the blister fluid or secretions from the nose or mouth. - By coughing or sneezing.Symptoms: Your child will have a rash that begins as red bumps and may have a fever.If your child is infected, it may take 10-21 days for symptoms to begin.Control /Prevention:

a. In Missouri, all children 12 months and older attending childcare or school must be Vaccinated with varicella vaccine, have a history of disease, or have an exemption.

b. Cover nose and mouth when sneezing or coughing. Use a tissue or your sleeve. Dispose of used tissues.c. Wash hands after touching anything that could be contaminated with secretions from the nose and mouth.

Your child may need help with hand washing.d. Clean and disinfect any objects or surfaces that come in contact with secretions from the nose or mouth.

Use a product that kills viruses.2. Smallpox (Variola )

Clinical Description An illness with acute onset of fever ≥101°F (≥38.3°C) followed by a rash characterized by firm, deep seated vesicles or pustules in the same stage of development without other apparent cause. Clinically consistent cases are those presentations of smallpox that do not meet this classical clinical case definition: a) hemorrhagic type, b) flat type, and c) variola sine eruptionThere is no proven treatment for smallpox. Scientists are currently researching new treatments. Patients with smallpox may be helped by intravenous fluids, medicine to control fever or pain, and antibiotics for any secondary bacterial infections that may occur. Certain antiviral drugs might potentially have benefit. One of the best ways to prevent smallpox is through vaccination. Smallpox vaccination provides high level immunity for 3 to 5 years and decreasing immunity thereafter. If a person is vaccinated again later, immunity lasts even longer. Historically, the vaccine has been effective in preventing smallpox infection in 95% of those vaccinated. Vaccination within 3 days after exposure will prevent or greatly lessen the severity of smallpox in most people. Vaccination 4 to 7 days after exposure likely offers some protection from disease or may decrease the severity of disease. Vaccination will not protect smallpox patients who already have a rash.3. Type 1 Diabetes Type 1 Diabetes OverviewNormally, the body's immune system fights off foreign invaders like viruses or bacteria. But for unknown reasons, in people with type 1 diabetes, the immune system attacks various cells in the body.Type 1 Diabetes SymptomsSymptoms of type 1 diabetes usually develop quickly, over a few days to weeks, and are caused by blood sugar levels rising above the normal range (hyperglycemia).Type 1 Diabetes CausesYou can inherit a tendency to develop type 1 diabetes, but most people who have the disease have no family history of it.Type 1 Diabetes Treatment OverviewType 1 diabetes requires lifelong treatment to keep blood sugar levels within a target range.The Basics of a Healthy Diabetes DietContrary to what you may have heard, there is no single "diabetes diet.Types of Insulin for Diabetes TreatmentThere are many forms of insulin to treat diabetes. They are classified by how fast they start to work and how long their effects last. Type 1 Diabetes PreventionCurrently there is no way to prevent type 1 diabetes, but ongoing studies are exploring ways to prevent diabetes in those who are most likely to develop it.

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Type 2 DiabetesType 2 Diabetes OverviewType 2 diabetes, once called non-insulin dependent diabetes, is the most common form of diabetes, affecting 90% to 95% of the 26 million Americans with diabetes.Symptoms of Type 2 DiabetesType 2 diabetes can cause serious health complications. That's why is very important to know how to spot type 2 diabetes symptoms.Causes of Type 2 DiabetesDiabetes is a number of diseases that involve problems with the hormone insulin. While not everyone with type 2 diabetes is overweight, obesity and lack of physical activity are two of the most common causes of this form of diabetes.Type 2 Diabetes ScreeningType 2 diabetes is a common and serious disease in the United States and worldwide. However, it’s thought that one-third of those with type 2 diabetes are unaware that they have this serious illness.Diabetes TestingIf you experience symptoms of severe increased thirst, frequent urination, unexplained weight loss, increased hunger, tingling of your hands or feet -- your doctor may run a test for diabetes. Oral Glucose Tolerance TestThough not routinely used anymore, the oral glucose tolerance test (OGTT) is the gold standard for making the diagnosis of type 2 diabetes.The Hemoglobin A1c (HbA1c) Test for DiabetesThe hemoglobin A1c test -- also called HbA1c, glycated hemoglobin test, or glycohemoglobin -- is an important blood test used to determine how well your diabetes is being controlled.TreatmentsWeight Loss Surgery and Type 2 DiabetesIncreasingly, weight loss surgery is being used as a tool to manage type 2 diabetes. That's because controlling diabetes and managing the related health risks is directly related to losing weight.Natural Remedies for Type 2 DiabetesDiabetes treatment can include many elements, including traditional medications, alternative medicine, and natural remedies.Non-Insulin Diabetes InjectablesToday, metformin is the first drug doctors usually recommend for people with type 2 diabetes who need to take medication.Oral Diabetes MedicationsOral diabetes medications -- diabetes pills -- help control blood sugar levels in people whose bodies still produce some insulin (the majority of people with type 2 diabetes).Your Diabetes Care TeamIf you have diabetes, you likely have a care team that includes a primary care doctor, dietitian, diabetes educator, eye doctor, foot doctor, dentist, and possibly an exercise trainer.InsulinDiabetes Treatment With InsulinWhen used as a medication, it is derived from either pork (porcine), beef (no longer available in the U.S.), or is genetically made to be identical to human insulin.Inhaled InsulinInhaled insulin is another option that’s been considered. Although it’s possible to make inhaled insulin, there are no inhaled insulin drugs on the market.Giving Yourself an Insulin Shot for DiabetesFor those with diabetes, an insulin shot delivers medicine into your subcutaneous tissue -- the tissue between your skin and muscle.Diabetic Shock and Insulin ReactionsThe symptoms of diabetic shock may seem mild at first. But they should not be ignored.

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4. MEASLES CAUSE/Agent: Measles virus.SYMPTOMS: The first symptoms seem like the beginning of a cold with a high fever, watery eyes, runny nose, and cough. A red blotchy rash appears 3 to 5 days after the start of symptoms, usually beginning on the face (hairline), spreading down the trunk and down the arms and legs. The fever may still be present after the rash starts. The rash usually lasts 4 to 7 days. Measles is sometimes complicated by diarrhea, ear infection, or pneumonia.SPREAD When a person with measles coughs, sneezes, or breathes out tiny droplets with measles virus into the air and another person breathes them in. The virus can sometimes float in the air and infect others for approximately two hours after a person with measles leaves a room. Also by handling or touching contaminated objects and then touching your eyes, nose, and/or mouth.PREVENTION/CONTROL

a. Measles vaccine is usually combined with mumps and rubella vaccine (MMR) and given at 12 to 15 months of age.

b. Unvaccinated people who have been exposed to measles should call their healthcare provider or local public health clinic as soon as possible to be vaccinated. Vaccination is contraindicated during pregnancy.

c. If measles vaccine is given within 72 hours of exposure, it may provide some protection. Encourage parents/guardians to notify the childcare provider or school when their child is vaccinated so their records can be updated.

d. Recommend staff stay home if they develop symptoms of measles. Encourage parents/guardians keep their child home if they develop symptoms of measles.

e. Teach children and staff not to touch their eyes, nose, or mouth.f. Cover your nose and mouth with a tissue when coughing or sneezing, or cough/sneeze into your sleeve.

Dispose of used tissues.g. Clean and sanitize mouthed objects and surfaces at least daily and when soiled.5. MUMPS

CAUSE Mumps virus.SYMPTOMS Most commonly, swollen glands in front of and below the ear, headache, low-grade fever, and earache. Up to 30% of all people infected with the mumps virus have no symptoms. Orchitis (swelling of the testicles) is a common symptom in males after puberty. Rarely, swelling of the spinal cord and brain (encephalitis), inflammation of the ovaries (oophoritis) or breasts (mastitis), and deafness may occur. Seriousproblems from mumps are more common among adults than among children.DIAGNOSIS Swollen glands can be found with other illnesses. A blood test specific for mumps antibody should be done as soon as possible after symptoms begin. Sometimes, healthcare providers will obtain a second blood test 2 to 3 weeks later.TREATMENT None. PREVENTION/CONTROL

a. Unvaccinated people who have been exposed to mumps should call their healthcare provider or local public health clinic as soon as possible to be vaccinated

b. Encourage parents/guardians to notify their childcare provider or school when their child is vaccinated so their records can be updated

c. Recommend staff stay home if they develop symptoms of mumps. Encourage parents/guardians to keep their child home if they develop symptoms of mumps.

d. Cover your nose and mouth with a tissue when coughing or sneezing, or cough/sneeze into your sleeve. Dispose of used tissues.

e. DO NOT allow sharing of beverage containers, eating utensils, smoking materials (cigarettes, cigars, snuff, pipes, etc.), toothbrushes, lip gloss, lip balm, and lipstick.

f. Regular and thorough hand washing is the best way to prevent the spread of communicable diseases. Wash hands thoroughly with soap and warm running water after contact with secretions from the nose or mouth.

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6. Cholera : What is Cholera Disease?

Cholera disease causes a lot of watery diarrhea and vomiting. Cholera diarrhea can look like cloudy rice water. Cholera can cause death from dehydration (the loss of water and salts from the body) within hours if not

treated.Cholera CausesVibrio cholerae, the bacterium that causes cholera, is usually found in food or water contaminated by feces from a person with the infection. Common sources include:

Municipal water supplies Ice made from municipal water Foods and drinks sold by street vendors Vegetables grown with water containing human wastes Raw or undercooked fish and seafood caught in waters polluted with sewage

When a person consumes the contaminated food or water, the bacteria release a toxin in the intestines that produces severe diarrhea.Illness & SymptomsApproximately 5-10% of persons will have severe cholera which in the early stages includes:

profuse watery diarrhea, sometimes described as “rice-water stools,” vomiting rapid heart rate loss of skin elasticity dry mucous membranes low blood pressure thirst muscle cramps restlessness or irritability

Cholera is an acute intestinal infection causing profuse watery diarrhea, vomiting, circulatory collapse and shock. Many infections are milder diarrhea or are asymptomatic. If left untreated, 25-50% of typical cholera cases are fatal.Prevention and Control of Cholera

Prompt diagnosis and management Establish treatment centers with barrier nursing. Fecal material and vomit properly disinfected and disposed. Health Education on hygiene, safe water, safe food and hand washing. Funerals to be held quickly and near the place of death. Meticulous hand washing for those who handle the

body. Promote washing hands with soap and water when food is being handled.

Protect yourself and your family from Cholera and other diarrheal diseases: • Drink and use safe water. Safe water is water that is bottled with an unbroken seal, has been boiled, or has been treated with a chlorine product.• Wash hands often with soap and safe water. If no soap is available, scrub hands often with ash or sand and rinse with safe water.• Use latrines or bury your feces (poop), do not defecate in any body of water. • Cook food well (especially seafood), eat it hot, keep it covered, and peel fruits and vegetables.• Clean up safely—in the kitchen and in places where your family bathes and washes clothes.

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7. What are the Symptoms of High Blood Pressure? There's a common misconception that people with high blood pressure, also called hypertension, will experience symptoms such as nervousness, sweating, difficulty sleeping or facial flushing. The truth is that HBP is largely a symptomless condition. If you ignore your blood pressure because you think symptoms will alert you to the problem, you are taking a dangerous chance with your life. Everybody needs to know their blood pressure numbers, and everyone needs to prevent high blood pressure from developing.

There are eight main ways you can   control your blood pressure. They are:

Eat a better diet, which may include reducing salt Enjoy regular physical activity Maintain a healthy weight Manage stress Avoid tobacco smoke Comply with medication prescriptions If you drink, limit alcohol Understand hot tub safety

Adopting a healthy lifestyle is critical for the prevention of HBP and an indispensable part of managing it. Think of these changes as a "lifestyle prescription" and make every effort to comply with them.Whether you have been diagnosed with high blood pressure, also called hypertension, or are concerned because you have some of the risk factors for the disease, understand this: while there is no cure, high blood pressure is manageable.

8. Influenza:Agent: Influenza virus. The two main types of influenza viruses are type A and type B.SYMPTOMS: Influenza starts quickly with fever, chills, body aches, headache, cough, runny or stuffy nose, and sore throat. Illness usually lasts 3 to 7 days. Children may develop ear infections, pneumonia, or croup as a result of influenza infection.Factor: Influenza is spread mainly person to person through droplets created with coughing and sneezing by persons infected with the virus. Infection occurs when a person has contact with droplets in the air or touches contaminated surfaces then touches their mouth or nose.PREVENTION/CONTROL Annual influenza vaccinations are recommended for:

1) All children 6 months to 18 years of age.2) All adults 50 years and older.3) Anyone 6 months of age and older with chronic health conditions. 4) Cover nose and mouth with a tissue when coughing or sneezing, or cough/sneeze into your sleeve.

Dispose of used tissues.5) Try to avoid close contact with sick people.6) While sick, limit contact with others as much as possible to keep from infecting them.7) Take flu antiviral drugs if your doctor recommends them.8) Stay home if you are ill.

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9. RUBELLA (GERMAN MEASLES) CAUSE Rubella virus.SYMPTOMS Low-grade fever, swollen glands in the area behind the ears and in the neck, and rash. Rash usually appears first on the face and moves from head to foot. The rash usually lasts 3 days. Adults, especially women, may have sore or swollen joints.This joint pain usually lasts for less than one month. Up to half of all persons have no symptoms. Rarely, encephalitis (inflammation of the brain) may occur.DIAGNOSIS A blood test for rubella should be done 3 to 5 days after the symptoms begin. Other laboratory specimens may be collected.TREATMENT Recommend parents/guardians call their healthcare provider.PREVENTION/CONTROL

a. Unvaccinated people who have been exposed to rubella should call their healthcare provider or local public health clinic as soon as possible to be vaccinated.

b. Encourage parents/guardians to notify the childcare provider or school when their child is vaccinated so their records can be updated. All children by the age of 15 months must be vaccinated against rubella or have an exemption for childcare enrollment. An additional dose of rubella is highly recommended for kindergarten or two doses by eighth grade enrollment.

c. When a rubella outbreak is identified, susceptible individuals should be excluded or vaccinated. Exclusion should continue until 3 weeks after the onset of rash of the last reported case-patient in the outbreak setting.

d. Parents should keep infants away from individuals suspected of having rubella.e. People who have close contact with infants should be up-to-date on their immunizations.f. Cover nose and mouth when coughing and sneezing. Use a tissue or your sleeve. Dispose of used tissues.g. Wash hands after touching anything that could be contaminated with secretions from the nose or mouth.

Your child may need help with handwashing.h. Clean and disinfect anything that comes in contact with secretions from the nose or mouth. Use a product

that kills viruses.i. DO NOT share anything that you put in your mouth, for example, beverage containers, eating utensils,

cigarettes, toothbrushes, and lip balm