Epidemiology of Tetanus,

Leprosy, HIV and other STD

Biju George
 Tetanus
• Neonatal tetanus and adult tetanus
• Endemic in India.
• Occasional cases in Kerala in un-
immunized children
• Clostridium tetani
• Spores resistant to autoclaving
• Germinate in anaerobic conditions
• Exotoxin- tetano spasmin
 Tetanus
• Organism in soil and dust
• Bacilli in intestine of many herbivorous
animals like cattle, hoarse, goats, sheep.
• excreted in feces.
• In adults
• Puerperal tetanus
• Neonatal tetanus
• More common in agricultural workers
 Tetanus
• More in rural area.
• No herd immunity
• Surroundings play a role
• So cannot be eradicated
• But can be disease can be controlled and
eliminated practically.
• Contamination of wounds by spores
• Toxin bind to receptors in nerve.
 Tetanus
• Incubation period – 6-10 days
• Tetanus neonatorum - 8th day disease

• Neonatal tetanus (NT) elimination

• High risk
– NT cases>1/1000 live births
– Or TT2 coverage <70%
– Or Attended deliveries- <50%
• Control
– NT cases<1/1000 live births
– And TT2 coverage >70%
– And Attended deliveries- >50%
• Elimination
– NT cases<1/10000 live births
– And TT2 coverage >90%
– And Attended deliveries- >75%
 Tetanus
• Active immunization-DPT/ DT / TT vaccine
• Passive immunization TIG / ATS
• Antibiotics -long acting penicillin/
erythromycin
• Prevention of Neonatal tetanus
– 5 cleans- hand, surface, blade, cord tie, cord
– TT2 dozes in pregnancy
– Attended Delivery / dhai training
• Prevention of tetanus after injury
 Prevention of tetanus after injury
• A- Complete course and booster with in last 5 yrs
• B-Complete course and booster between 5 - 10 yrs
• C-Complete course and booster more than 10 yrs
• No complete immunity / immunization unknown

wound <6 hrs, clean, small other wounds

• A- nothing more • A- nothing more
• B- TT 1 doze • B- TT 1 doze
• C- TT 1 doze • C- TT 1 doze + Hu Ig
• D- TT complete course • D- TT complete
course + Hu Ig
 Leprosy
• Characterized by cardinal features
• Hypo-pigmented patches
• Partial or total loss of cutaneous
sensations (light touch)
• Presence of thickened nerves
• Presence of AFB in skin or nasal smears
 Leprosy
• Advanced stage
• Nodes or lumps in skin of face / ears
• Plantar ulcers
• Loss of fingers / toes
• Nasal depression
• Foot drop
• Claw toes and other deformities
 Leprosy
• M. leprae
• Intracellular and extra cellular
• Affinity for schwann cells and cells of RES
• Max bacterial load in lepromatous cases
• Multi-bacillary cases are the important sources
• Nose is the major port of exit
• Ulcerated sin, broken skin
• 4-12% attack rate in house hold in 5 yrs
 Leprosy
• In endemic areas- infection in childhood
itself.
• 10-20 yrs
• CMI plays an important role
• High cell mediated immunity- Tuberculoid
spectrum
• Low CMI- lepromatous spectrum
• Factors favoring close contact
 Leprosy
• Droplet transmission / contact
• 3-5 yrs incubation period
• Clinical classification
• Indian classification
– Indeterminate / tuberculoid / boderline / lepromatous /
pure neuritic
• Madrid classification
– Indeterminate / tuberculoid / boderline / lepromatous
• Ridley Jopling classification
– TT / BT / BB / BL / LL
 Leprosy
• Initially diagnosis as Paucibacillary / multi
bacillary bases on Bacteriological index
• Bactriological Index > 2 – multibacillary

• Programmatically it is done on the basis of

number of lesions
• 1-5 skin lesion- pauci bacillary and / only one
nerve lesions
• More than 5 skin lesions- multibacillary and /
have more than 2 nerve involvement
 Leprosy
• Lepromin test – 0.1 ml lepromin ID forearm
• Early reaction- Fernandez reaction-read at 48
hrs red area >10 mm
• Late reaction- Mitsuda reaction read at 21 day-
nodule more than 5 mm- CMI
• Not diagnostic
• Used for evaluating CMI in leprosy pts
• Alternatively -Lymphocyte transformation test
(LTT) and Leukocyte migration inhibition test
(LMIT)
 Leprosy - control
• Medical measures
– Estimation of problem – prevalence, ACDR
– Early case detection – skin lesion
– Multidrug therapy
– Surveillance of cases – 2 yrs / 5 yrs
– Immunoprophylaxis- BCG
– Chemoprophylaxis
– Deformity reduction Grade 0 / Grade I / grade II
– Rehabilitation
• Social support
• Program management
• Program evaluation
 Leprosy
• Multidrug Rx
• Multibacillry leprosy – 12 months
– Rifampacin 600 mg once monthly supervised
– Dapsone 100 mg daily self administered
– Clofazimine- 300 mg once monthly
supervised and 50 mg daily self administered
• Paucibacillary leprosy – 6 months
– Rifampacin 600 mg once monthly supervised
– Dapsone 100 mg daily self administered
 STD
• Bacterial
– Neisseria gonorrhea
– Chlamydia trachomatis
– Treponema pallidum
– Mycoplasma Hominis
• Viral
– HSV (HHV-1 or 2)
– HHV-5- CMV
– Hepatitis B
– Human Papilloma virus
– Molluscum contagiosum virus
– HIV
 STD
• Protozoal
– Entamoeba histolytica
– Giardia lamblia
– Trichomonas Vaginalis
• Fungal agents
– Candida Albicans
• Ectoparasite
– Phthirus pubis
– Sarcoptis scabie
 STD
• Classical Venereal disease
– Syphilis
– Gonorrhea
– Chancroid
– Lymphogranuloma venereum
– Donovanosis
• Second generation STD- HIV
 STD
• N. Gonorrhoeae • Gonorrhea
• T. Pallidum • Syphilis
• H. Ducreyi • Chancroid
• Chlamatobactrrium • Donovanosis (Granuloma
granulomatis inguinale)
• H. simplex • Genetal Herpes
• HPV • Genital and anal warts
• HIV • AIDS
• Candida albicans • Vaginitis
• Trichomonas Vaginalis • Vaginitis
 STD
• 20-24 age group then 25-29 yrs then 15-19 yrs
• More men than females
• Social factors
– Prostitution
– Broken homes
– Sexual disharmony
– Easy money
– Emotional immaturity
– Urbanization and industrialization
– Social disruption
– International travel
– Changing behavioral pattern
– Social stigma
– Alcoholism
 STD
• Gonococcal infection- Urethritis, vaginiyis,
cervicitis
• Syphilis- Ulceration of urogenital tract late
stage complication
• Chlamydial infection- Urethritis, vaginiyis,
cervicitis
• Trichomoniasis- vaginitis
• Chancroid- genital ulcer + bubo
• LGV- inguinal LN swelling
 STD
• Donovaniosis- granulomatous lesion
• Syndromic approach
– Male urthritis
– Vaginitis / Cervicitis / Urethritis
– Gentital ulceration
– Proctitis / colitis
– PID
 Control of STD
• Interventions
– Case detection
– Case holding and Treatment
– Epidemiological Rx- contact Rx
– Personal prophylaxis
– Health education
• Support service
– STD clinics
– Lab services
– Primary health care
– Information services
– Legislation
– Social welfare measures
 HIV / AIDS
• world
– ~40 million people with HIV
– Every year ~4.5 million people get infected
– ~3 million deaths every year
• India
– ~1lak people with AIDS
– ~5 million with HIV
– ~0.36% prevalence
 HIV / AIDS

• Risk
– Unprotected heterosexual route
– MSM
– Inj drug users
– Unsafe blood transfusion
– Unsafe injection
• Lag time from infection to symptoms 9-11
yrs
 HIV / AIDS
• Mostly adults 20-50 yrs
• More mortality in females
• RNA virus
• Destroy the T4 helper cells
• Easily killed by heat and chemicals
• Cases are the reservoir /// carriers
• Source of infection – Blood, semen, CSF and
other body fluids
• Produce immune system disorder
 HIV / AIDS
• Person to person transmission
– Sexual transmission
• Presence of STD 8-10 times
• Sex and age of uninfected partner
• Virulence of HIV stain
– Blood contact BT-95% risk
– parent to child transmission
• 15-30% with our Rx
• With Rx less than 5%
• Incubation period-10 yrs or more
 HIV / AIDS
• Clinical features
– Initial infection
• Window period- Ab after 2-12 wks
– Asymptomatic carrier state
– AIDS related complex
• Diarrhoea
• Fever
• Loss of wt
– AIDS
• TB/ Kaposil sarcoma / candidiasis / CMV retinitis
• Penumocystis carini infection / Toxoplasmosis
 HIV control
• Prevention
– Education
– Prevention of blood born HIV transmission

• Antiretroviral treatment
– Rx of patients
– Post exposure prophylaxis
– PPCT
• Specific prophylaxis against opportunistic
infection
• Primary health care
• NACP
Testing strategy- symptomatic-2
Testing strategy- asymptomatic-3