Management of common diseases (EPI- related)

Table of Contents
Unit 4: 326
Management of Common Diseases (EPI-related) 326
Learning objectives: 327
Determinants of Health (Also please refer to Unit 1) 327
Introduction. 328
The determinants of Health: 328
Income and Social Status. 328
Social Support Networks. 328
Education and Literacy. 328
Employment and Working Conditions. 329
Social Environment 329
Physical environment 329
Personal Health Practices and Coping Skills. 329
Healthy Child Development 330
Genetics 330
Health Services. 330
Gender (Also please refer to Unit 1) 330
Culture 331
Determinants of Disease. 332
Health Promotion and its Primary Goal 332
Multilevel Health Promotion. 332
Health promotion objectives can focus on several societal levels: 332
Immunization. 333
Introduction. 333
Why immunization is essential?. 333
Activity. 333
How immunization works?. 333
Activity 334
Expanded Program on Immunization in Pakistan. 335
Activity 335
Activity 337
Diseases covered by the Expanded Program on Immunization. 337
Activity 337
Tuberculosis (TB) 337
Role of Dispensers in Prevention, Management and Treatment of TB: 337
Measles. 338
Diphtheria. 340
Poliomyelitis (Polio) 340
Pertussis. 341
Tetanus. 341
Hepatitis B. 342
Non-EPI covered disease. 343
Hepatitis C. 343
Childhood Diseases. 344
Integrated Management of Childhood Illness (IMCI) 344
Prevention and Treatment 344
Maternal and Peri-natal Conditions. 345
Integrated Management of Pregnancy and Childbirth (IMPAC) 345
Geriatrics. 345
Role of Dispensers. 346
Diabetes (Also please refer to Sub-unit 2.8) 347
Types of Diabetes. 347
Signs and Symptoms. 348
Diagnosis. 348
Treatment 348
Role of Dispensers in Prevention of Diabetes, Treatment and Prevention of Complications. 348
Hypertension (Also please refer to Sub-unit 2.1) 349
Types of Hypertension. 349
Role of Dispensers in Management of Hypertension: 350
Class room evaluation. 351

Unit 4:
Management of Common Diseases (EPI-related)
Learning objectives:
After completing unit 4 dispenser students will be able to:
a. describe determinants of health and disease
b. demonstrate skills and knowledge related to health promotion and preventive aspects of health
c. demonstrate how to properly advise, counsel and guide individuals, families and communities on how to access and utilize preventive and promotive health services
d. demonstrate knowledge and skills to provide limited and basic first line health care for various diseases
e. demonstrate knowledge and skills to effectively assess and refer to the appropriate healthcare provider or facility, cases of various diseases that merit further treatment and management.
f. define immune system, immunization, antigen and antibody
g. demonstrate an understanding of immunization and how vaccines work
h. demonstrate an understanding of the Expanded Program on Immunization
i. demonstrate an understanding of the immunization schedule followed in Pakistan
j. demonstrate an understanding of diseases covered by the Expanded Program on Immunization - tuberculosis, measles, diphtheria, poliomyelitis, pertussis, tetanus and hepatitis B
k. demonstrate an understanding of hepatitis C.
Determinants of Health (Also please refer to Unit 1)
Brainstorm
Ask students:
What is their understanding of health and disease?
How can people stay healthy? (also please refer to Unit 1)
What causes disease?
What is the role of the healthcare system in maintaining health of individuals, families and communities?
What is the role of BHUs, RHCs or hospitals in maintaining health of individuals, families and communities?
What could a community do to stay healthy?
What could a family do to stay healthy?

Introduction
Many factors combine together to affect health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment. To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact.
The determinants of Health:
The context and environment of people’s lives determine their health, and so blaming individuals for having poor health or crediting them for good health is inappropriate. Individuals are unlikely to be able to directly control many of the determinants of health. These determinants—or things that make people healthy or not—include the following:
Income and Social Status
Higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health. Health status improves at each step up the income and social hierarchy. High income determines living conditions such as safe housing and ability to buy sufficient good food. The healthiest populations are those in societies which are prosperous and have an equitable distribution of wealth.
Social Support Networks
Support from families, friends and communities is called social support. It is associated with better health. Social support networks could be very important in helping people solve problems and deal with adversity, as well as in maintaining a sense of control over life circumstances. The caring and respect that occurs in social relationships, and the resulting sense of satisfaction and well-being, seem to act as a buffer against health problems.
Education and Literacy
Low education levels are linked with poor health, more stress and lower self-confidence. Education is closely linked to socioeconomic status, and effective education for children and lifelong learning for adults are key contributors to health and prosperity for individuals, and for the country. Education contributes to health and prosperity by equipping people with knowledge and skills for problem solving, and helps provide a sense of control and mastery over life circumstances. It increases opportunities for job and income security, and job satisfaction. And it improves people's ability to access and understand information to help keep them healthy.
Employment and Working Conditions
Unemployment, underemployment, stressful or unsafe work are associated with poorer health. People who have more control over their work circumstances and fewer stress related demands of the job are healthier and often live longer than those in more stressful or riskier work and activities.
Social Environment
The importance of social support also extends to the broader community. Civic vitality refers to the strength of social networks within a community, village, district, province or country. It is reflected in the institutions, organizations and informal giving practices that people create to share resources and build attachments with others. The values and norms of a society influence in many ways the health and well being of individuals and populations. In addition, social stability, recognition of diversity, safety, good working relationships, and cohesive communities provide a supportive society that reduces or avoids many potential risks to good health.
Physical environment
The physical environment is an important determinant of health. At certain levels of exposure, contaminants in our air, water, food and soil can cause a variety of adverse health effects, including cancer, birth defects, respiratory illness and gastrointestinal ailments. In the built environment, factors related to housing, clean water, clean air, roads, and the design of communities and transportation systems can significantly influence our physical and psychological well-being.
Personal Health Practices and Coping Skills
These are actions by which individuals can prevent diseases and promote self-care, cope with challenges, and develop self-reliance, solve problems and make choices that enhance health.
Our lifestyle includes not only our choices, but also the influence of social, economic, and environmental factors on the decisions we make about their health. There is a growing recognition that our personal life "choices" are greatly influenced by the socioeconomic environments in which we live, learn, work and play. These influences impact our lifestyle choice through at least five areas: personal life skills, stress, culture, social relationships and belonging, and a sense of control. Interventions that support the creation of supportive environments will enhance our capacity to make healthy lifestyle choices in a world where many choices are possible.
Healthy Child Development
Evidence on the effects of early experiences on brain development, school readiness and health in later life suggest that early child development is a powerful determinant of health. All other determinants of health affect the physical, social, mental, emotional and spiritual development of children and youth. For example, a young person's development is greatly affected by his or her housing and neighborhood, family income and level of parents' education, access to nutritious foods and physical recreation, genetic makeup and access to dental and medical care.
Genetics
Inheritance plays a part in determining lifespan, healthiness and the likelihood of developing certain illnesses. The basic biology and organic make-up of the human body are a fundamental determinant of health. Genetic make-up provides an inherited tendency to a wide range of individual responses that affect health status. Although socio-economic and environmental factors are important determinants of overall health, in some circumstances genetic make-up appears to predispose certain individuals to particular diseases or health problems.
Health Services
Health services, particularly those designed to maintain and promote health, to prevent disease, and to restore health and function contribute to population health. The health services continuum of care includes treatment and secondary prevention
Gender (Also please refer to Unit 1)
Gender refers to the range of society-determined roles, personality traits, attitudes, behaviors, values, relative power and influence that society ascribes to the two sexes on a differential basis. "Gendered" norms influence the health system's practices and priorities. Many health issues are a function of gender-based social status or roles.
Culture
Some persons or groups may face additional health risks due to a socio-economic environment, which is largely determined by dominant cultural values that contribute to the perpetuation of conditions such as marginalization, stigmatization, loss or devaluation of language and culture and lack of access to culturally appropriate health care and services.
Also customs and traditions, and the beliefs of individuals, families and communities affect health status.
The above factors have been found to have the most significant influence on health of individuals and groups. They are known as the determinants of health. The important thing to understand is that while health and social services make a contribution to health, most of the key determinants of health lie outside the direct influence of health and social care, for example, education, employment, housing, and environment. Figure 1 below presents the determinants of health in terms of layers of influence, starting with the individual and moving to wider society.
Figure 1
Source: Dahlgren G and Whitehead M (1991) Policies and strategies to promote social equity in health. Stockholm, Institute for Futures Studies
Determinants of Disease
Factors that directly or indirectly influence the frequency of occurrence and/or the distribution of a disease are called determinants of disease. They include specific disease agents such as micro-organisms, host characteristics such as a weak or a susceptible individuals or habits such as smoking and environmental factors such as unhealthy housing facilities. A combination of determinants of disease leads to the propagation of illness.
Health Promotion and its Primary Goal
The primary goal of health promotion is to offer specific processes that will support individuals in practicing healthy behaviors. While people may understand the need to improve their health habits, many times they lack necessary resources in terms of motivation, discipline, or the specific knowledge which would enhance their efforts. Health promotion can provide resources to assist people in making lifestyle behavior changes.
We should understand that causes of health problems and diseases are multi-factorial and interrelated.
For example, a young boy or a girl with asthma may have:
· A genetic predisposition to asthma
· Parents who smoke in the home-environmental issue
· Refusal to use an inhaler-personal behavior, compliance issue
· Inadequate treatment-health services deficiency
Solutions to these problems using the processes of health promotion would target both the individual related to using an inhaler and the family related to second hand smoking consequence. In addition, it would target people who set policy at schools and those who can help to improve health services for this family. Health promotion is considered “multi-tiered” because it involves various levels of society to help address a health problem.
Multilevel Health Promotion
Targets of health promotion are not just the individual with the health problem but also those who can set policy or health and education professionals because they can foster the adoption of healthful changes in the environment, improve health services, and encourage healthful personal behavior change.
Health promotion objectives can focus on several societal levels:
· Individual
· Organization
· Community
· Government

Immunization
Brainstorm
Ask students:
What is their understanding about immune system and vaccination?
Do they know if they or their family members have been vaccinated?
If yes, what have they been vaccinated against?
Introduction
An immune system is a collection of mechanisms within us that protects against disease by identifying and killing pathogens (germs) and tumor cells.
Immunization (vaccination) is a way to trigger body’s immune system and prevent serious, life-threatening diseases.
Why immunization is essential?
Immunization is a way of protecting children against serious disease. Once children have been immunized their bodies can fight those diseases if they come into contact with them. If a child is not immunized they will be at risk from catching the disease. If lots of people choose not to immunize their children, then the number of children at risk of catching a disease will increase and outbreaks of the disease will occur. The only time to stop immunizing children is when a disease has been eradicated worldwide. For example when every country had eliminated smallpox in 1979, immunization against the disease was stopped. It is hoped that polio will soon be eradicated (already eliminated from the Americas) and measles may follow.
Activity
Students act out the role of a dispenser and a father with a small baby. The father is afraid of injections. He is arguing with the dispenser that there is no reason why he should have his baby immunized. Dispenser should explain to the father why immunization is essential.
How immunization works?
Our bodies are designed to protect us from diseases. When a person is exposed to an illness, the immune system actually learns from the experience. The next time the person is exposed to the same illness, the immune system often recognizes the germs that had caused the illness and sets out to destroy it.
Immunization exposes us to a very small, very safe amount of the most important diseases one is likely to encounter at some point in our life. This mild exposure helps the immune system recognize and attack the disease efficiently. If the immunized person is exposed to the full-blown disease later in life, he/she will either not become infected or have a much less serious infection. This is a natural way to deal with infectious diseases.
The following steps explain how vaccines work:
i. Vaccines contain antigens. An antigen is a substance that can cause an immune response in the body. Antigens used in vaccines are viruses, bacteria, and fungi that cause disease and infection but have been made weak or are already dead so that they cannot cause disease. When introduced into the body, the antigens stimulate the immune system to produce antibodies. The antibodies are produced by the body to fight against the weakened or dead antigens in the vaccine.
ii. The antibodies fight or "practice" on the weakened antigens, preparing the immune system to destroy real and stronger antigens in the future.
iii. When new and “real” antigens enter the body sometimes later in the life, one type of white blood (see Unit 1, Sub-unit 1, Cardiovascular System) cells eat the antigens, process the information contained in the antigens, and make the same kind of antibodies as in ‘A’ above.
Figure 2: Antigen-containing vaccine and antibody production within the body

Activity
In small groups students to discuss:
The definition of antigen and antibody.
What is happening in Figure 2?
Apart from vaccines, what else are the routes for the entry of antigens into the body?
Expanded Program on Immunization in Pakistan
Activity
What do the students know about the Expanded Program on Immunization?
What are the diseases covered by the Expanded Program on Immunization?
Are the students aware of any national and local campaigns in favor of eradicating the vaccine-preventable diseases covered by the Expanded Program on Immunization?
Are the students aware of any campaigns against vaccination?

Large number of deaths in children under-five years of age is due to infectious diseases which are vaccine preventable. The Expanded Program on Immunization (EPI) is a world-wide program launched by the World Health Organization (WHO) in 1974. The EPI is a disease prevention activity aiming at reducing mortality and morbidity from childhood diseases preventable by immunization. The vaccine-preventable diseases targeted in the EPI in Pakistan are referred to as the seven EPI target diseases. The seven diseases are measles, diphtheria, pertussis, tetanus, polio, tuberculosis and the recently introduced hepatitis B. All vaccines are provided for free through government run EPI.
There is a recommended schedule for childhood immunizations which differs from country to country. It gives children the best chance of developing immunity against these diseases in a safe and effective way and minimizes their risk of catching the diseases. Following is the current EPI schedule followed in Pakistan.
Table 1: Immunization schedule for children

Vaccine
Description
Schedule
BCG
Bacille Calmette-Guérin
birth
DTwP
Diphtheria and tetanus toxoid with whole cell pertussis vaccine
6, 10, 14 weeks
DTwPHep
Diphtheria and tetanus toxoid with whole cell pertussis and Hepatitis B vaccine
6, 10, 14 weeks
HepB
Hepatitis B vaccine
6, 10, 14 weeks
Measles
Measles vaccine
9 months
OPV
Oral polio vaccine
birth;
6, 10, 14 weeks
TT
Tetanus toxoid
at 1st contact with child bearing aged women (CBAW);
+1, +6 months;
+1, +1 year
Newborn babies have some immunity to disease passed on to them from their mothers. In the last three months of pregnancy, some antibodies pass through the placenta (the connection between mother and her unborn baby) from the mother to the unborn baby. The amount and types of antibodies depend on the mother’s immunity. The protection given to the baby by these antibodies varies. For example, a mother's antibodies to measles usually protect her baby against the disease for 6-12 months, but those against other diseases, such as whooping cough, only last a few weeks. Following is the schedule for child-bearing aged females followed in Pakistan.
Table 2: Immunization schedule for child-bearing aged females
Schedule
Vaccine
At 1st contact with child bearing aged women or as early as possible during pregnancy (during the 1st trimester)
TT1
At least 4 weeks after TTI
TT2
At least 6 months after TT2 (in 2nd pregnancy)
TT3
At least 1 year after TT3 (in 3rd pregnancy)
TT4
At least 1 year after TT4 (in 4th pregnancy)
TT5
Activity
There is a six month old and a 24 month old baby who are both not immunized against measles. Their 10 year old brother gets measles. Discuss with the class whether the six month old and the 24 month old babies will develop measles or not. Give reasons.
Discuss why child-bearing aged females are given vaccination.
Discuss why oral polio vaccine is given at birth whereas measles vaccine is given at the age of 9 months.
Diseases covered by the Expanded Program on Immunization
Activity
Ask students if they have ever seen patients with any of the seven diseases covered by the EPI?
Can they describe their signs and symptoms?
Tuberculosis (TB)
Please see Sub-unit 2.3 on the Pulmonary System for details on tuberculosis.
(See Table 1 for the BCG vaccine schedule)
TB is highly prevalent in Pakistan. Every year around 250,000 new individuals are infected with TB in Pakistan. It ranks 6th among the 22 countries with high burden of TB. Government of Pakistan has therefore given high priority to TB control. It has declared TB as national emergency in 2001, and have expanded the WHO recommended TB control strategy (or DOTS) throughout the health services. In MDGs (see Unit 1), goal number 6 refers to control of TB and other diseases.
Population of the 2005 earthquake affected areas is very vulnerable due to poverty and unhygienic living conditions that unfortunately favorable the spread of TB.
Role of Dispensers in Prevention, Management and Treatment of TB:
o Dispensers have a strong role in motivating people to ensure that their children are vaccinated against TB. Explaining complications of TB, especially pulmonary TB, while working at the Central Registration Point (CRP), indoors, pharmacy, laboratory or at any other place in BHUs, RHCs, THQH, DHQH and tertiary hospitals.
o It is the duty of the dispenser to give health education and health promotion messages to the families of patients with pulmonary TB. These are:
o TB is a curable disease, if it is diagnosed properly and treated according to TB DOTS (Directly Observed Treatment, Short Course) guidelines for 8 months.
o All individuals with cough lasting more than 3 weeks should consult their nearest health facility for sputum checking. Suspect TB if:
o Cough more than 3 weeks
o Cough less than 3 weeks but with following symptoms such as blood stains in Sputum or fever at night or weight loss or previous history of TB in the patient or his family or his relatives
o Interruption of TB care and treatment without the advice of a doctor could result in an incurable form of multi-drug resistant TB.
o Pulmonary TB is dangerous because patients sometimes throw microorganism or bacillus or bacteria of TB which can infect others. Such patients are called AFB (Acid Fast Bacillus) positive patients. Therefore, it is essential that sputum of such patients is regularly checked to see if they have become negative or stopped coughing out TB bacteria.
o AFB positive patients are a risk to their families and their communities as they can infect others. However, with TB DOTS treatment and simple precautions they can save themselves and others. These precautions include, covering their mouth while coughing, living and sleeping in well-ventilated places, regular treatment. When patients become AFB negative they cannot spread disease to others but still have to complete the treatment course.
o TB DOTS treatment is available free of cost from government health facilities all over the country.
o Dispensers have also an important responsibility to ensure patient’s compliance to the treatment. They have to explain dosage and side effects of anti- tuberculosis drugs to the patients and his or her family.
o Health education to the general population explaining role of balanced diet, good living and working conditions, proper ventilation and healthy environment associated with TB is another important task of dispensers.
Measles
Measles is an infectious disease caused by a virus. It is highly contagious; it spreads from person to person via the respiratory system through contact with fluids from an infected person's nose and mouth.
Symptoms of measles include a fever for at least three days, cough, runny nose, and red eyes. The fever may rise to 40° Celsius (104° Fahrenheit).
The characteristic measles rash is generalized and comprises raised and flat small, red, lesions. It starts on the head before spreading to cover most of the body, often causing itching. The rash changes color from red to dark brown, before disappearing.
Complications with measles are relatively common, ranging from diarrhea, to pneumonia and brain inflammation. In developing countries like Pakistan with high rates of malnutrition and poor healthcare, 10 % of people with measles may die.
If children do not receive vaccination and vaccination rates fall, the number of non-immune persons in the community rises, and the risk of an outbreak of measles rises. (See Table 1 for the measles vaccine schedule)
Figure 3: Measles rash

Diphtheria
Diphtheria is an upper respiratory tract illness caused by a bacterium. It is a contagious disease that spreads by direct physical contact or breathing the secretions of infected persons. It is characterized by sore throat, low fever, and a membrane on the tonsils, pharynx, and/or nasal cavity. There may be swelling in the neck causing difficulty in breathing and swallowing which may require intubation or a tracheotomy. Antibiotics are used in patients or carriers to eradicate the bacteria and prevent its transmission to others.
(See Table 1 for the diphtheria vaccine schedule)
Figure 4: Diphtheria patient showing swollen neck


Poliomyelitis (Polio)
Poliomyelitis is an acute viral infectious disease which spreads from person to person, via the fecal-oral route by ingesting food or water contaminated with the polio virus. Around 90% of polio infections have no symptoms at all. In less than 1% of cases the virus enters the central nervous system, and infects and destroys motor neurons, leading to muscle weakness and sudden onset of muscle paralysis (most commonly of legs).
Enhanced vaccination efforts led by the WHO and other organizations could one day result in eradication of the disease from the world as smallpox has been eradicated. Today, polio remains endemic in only four countries: Nigeria, India, Pakistan, and Afghanistan (See Table ? for the OPV schedule)
"Update on vaccine-derived polioviruses". 2006. MMWR Morb Mortal Wkly Rep 55 (40): 1093–7. PMID 17035927
Pertussis
Pertussis, also known as whooping cough, a highly contagious disease caused by a bacterium. Pertussis is spread by contact with airborne discharges from the infected people. In infants and young children it is characterized initially by mild respiratory infection symptoms such as cough, sneezing, and runny nose. After one to two weeks, the cough changes character, with an increase of coughing followed by a "whooping" sound during inspiration. Symptoms may be less severe if treatment with an effective antibiotic is started early in the disease.
It is one of the leading causes of vaccine-preventable deaths world-wide. Most deaths occur in young infants who are either unvaccinated or incompletely vaccinated; three doses of the vaccine are necessary for complete protection against pertussis (See Table ? for the pertussis schedule). Ninety percent of all cases occur in the developing world like Pakistan. Children tend to catch it more than adults but infection of adolescents and adults is also common. (See Table ? for the pertussis vaccine schedule)
Tetanus
Tetanus is a potentially deadly nervous system disease due to a bacterium called Clostridium tetani. Tetanus occurs almost exclusively in persons who are unvaccinated or inadequately immunized.
Infection begins when the bacterial spores enter the body through an injury or wound. The spores release active bacteria that spread through the body and make a poison. The poison blocks nerve signals from the spinal cord to the skeletal muscles, causing severe muscle spasm. Spasms can be so powerful that they tear the muscles or cause fractures of the vertebrae. Tetanus often begins with mild spasms and tightening of the jaw muscles ("lockjaw"), and neck, face, abdominal and back muscles.
Tetanus can be prevented by thorough cleaning of all injuries and wounds and the removal of dead or severely injured tissue. All tetanus patients should be vaccinated against the disease or offered a booster shot. Tetanus is completely preventable by active tetanus immunization.
Immunization is thought to provide protection for 10 years; adults should receive a booster vaccine every ten years, and booster should be given to any patient with a wound who is uncertain of when he or she was last vaccinated, or if the patient has had fewer than 3 lifetime doses of the vaccine. (See Table ? for the tetanus vaccine schedule)
Many people believe injuries caused by rusty nails are the most dangerous. This is true only if the nail is dirty as well as rusty, as is usually the case. It is the dirt, not the rust that carries the risk for tetanus.
Figure 5: Lock-jaw in a patient suffering from tetanus

Figure 6: A baby suffering from tetanus showing extreme muscle stiffness

Hepatitis B
Hepatitis B is a liver inflammation caused by a virus called Hepatitis B virus (HBV) which is transmitted by blood or other body fluids through unprotected sexual contact, blood transfusions, re-use of contaminated needles and syringes. An infected woman can give hepatitis B to her baby at birth. Hepatitis B is the most infectious blood borne pathogen known.
The infection may either be acute or chronic. Acute infection may have no symptoms and may go unrecognized or it begins with flu-like symptoms - general ill-health, loss of appetite, nausea, vomiting, body aches, mild fever, dark urine, and then progresses to development of jaundice. A few patients may have more severe liver disease and may die as a result of it.
HBV usually gets better on its own after a few months. If it does not get better, it is called chronic HBV, which lasts a lifetime. Chronic HBV can lead to scarring of the liver, liver failure or liver cancer.
Hepatitis B is preventable by a vaccine which requires three shots. All babies should get the vaccine, but older children and adults can get it too. (See Table 1 for the HBV vaccine schedule)
Non-EPI covered disease
Hepatitis C
Hepatitis C is a liver inflammation caused by a virus called Hepatitis C virus (HCV) that is also transmitted by blood-to-blood contact with an infected person's blood. It can also cross the placenta. The infection can cause liver inflammation that can remain asymptomatic for 10-20 years, but later on chronic hepatitis can result in liver scarring and liver cancer.
No vaccine against hepatitis C is available. The symptoms of infection can be medically managed, and a proportion of patients can be cleared of the virus by a long course of anti-viral medicines.

Childhood Diseases
In developing countries, about half of all childhood deaths -- 4.9 million -- are caused by no more than four conditions: pneumonia, diarrheal diseases, malaria and measles. Every day, almost 13500 children die from them. Malnutrition is associated with many of these deaths and is the underlying cause of half of all child deaths in developing countries.
Integrated Management of Childhood Illness (IMCI)
This low-cost strategy has been developed to improve child health through ensuring the prompt recognition and treatment of the five most common causes of childhood deaths: pneumonia, diarrheal diseases, malaria, measles, and malnutrition. IMCI treatment guidelines have been developed to help health workers recognize the signs of illness and take prompt action -- even if the child is suffering from more than one condition at the same time. Working through health services and communities, IMCI builds on the experience of best practice and provides a holistic approach to the major childhood diseases.
The IMCI strategy involves
· prompt recognition of all co-existing conditions
· rapid and effective treatment through standard case management
· prevention of illness through improved immunization and improved nutrition (including breastfeeding)
· promotion of family practices to protect child health, including improved feeding practices, use of insecticide-treated bed nets, and appropriate care seeking for illness.
Prevention and Treatment
WHO and UNICEF have drawn up a list of essential drugs to treat the most common diseases of childhood. The average cost for a full course of treatment with one of these drugs is about Rs 50. They include: oral antibiotics, an anti-malarial drug, oral rehydration salts, vitamin A, treatment for intestinal worms, and treatments for eye and skin infections and mouth ulcers. In addition, immunization with measles vaccine --costing Rs 75 for both the vaccine and injection equipment-- could prevent most of the almost one million deaths from measles every year.
Many more lives could be saved through ensuring that mothers can recognize the onset of childhood diseases and that they have access to rapid treatment --ideally in the home. Meanwhile improved training of health workers would help ensure rapid diagnosis of life-threatening diseases-- especially where children are suffering from more than one condition.

Maternal and Peri-natal Conditions
Every year, about half a million women worldwide die from complications of pregnancy and childbirth -- mainly severe bleeding, infections, unsafe abortions, hypertension, and obstructed labor. More than 90% of these deaths occur in Asia and sub-Saharan Africa. And most of them could be prevented at low cost.
In addition, over 50 million women suffer from acute pregnancy-related conditions -- over a third of them with long-term, painful, and often distressing conditions that will affect them for the rest of their lives. They include permanent incontinence, chronic pain, nerve and muscle damage, and infertility.
Meanwhile, perinatal conditions are the major cause of death among children under five -- accounting for more than one in five deaths. Of these, over 3 million die during the first week of life. Most deaths are the result of poor maternal health and nutrition, inadequate care during pregnancy and delivery, lack of essential care for the newborn baby, infections, birth injury, asphyxia, and problems relating to premature births.
Integrated Management of Pregnancy and Childbirth (IMPAC)
This low-cost strategy, based on WHO's Mother-Baby Package, which costs no more than Rs 250 per year per person in low-income countries, is designed to prevent maternal and infant deaths and the often lifelong disability due to complications of pregnancy and childbirth.
The strategy involves ensuring access to:
· antenatal care
· normal delivery care assisted by a skilled birth attendant
· treatment for complications of pregnancy (including hemorrhage, obstructed labor, eclampsia, sepsis, abortion complications)
· neonatal care
· family planning advice
· management of sexually transmitted infections.

Geriatrics
Geriatrics is the branch of medicine that focuses on health care of the elderly. Medical doctors especially trained for the disease prevention, management and rehabilitation in older people are called Geriatricians. Geriatrics aims to promote health, prevent and treat diseases and disabilities in older adults. There is no set age at which the patient may be under the care of a geriatrician but most people above the age of 65 needs to see a geriatrician.
Geriatrics focuses on certain problems that come with advancing age namely, instability, immobility, incontinence and impaired intellect/memory. Impaired vision and hearing, delirium and use of multiple medications are also important health problems of older people.
A Geriatric team in addition to a geriatrician may include all or some of the following:
· Dispenser
· Nurse
· LHW
· Social Worker
· Psychiatrist
· Nutritionist
· Physical therapist
· Occupational therapist
· Consultant pharmacist
The team looks at many aspects of patient’s life and evaluates social support for the patient. These include usually a spouse, children and friends and his or her living and community conditions. The team also assesses the patient’s ability to perform activities for daily living (ADLs) such as bathing, dressing and eating.
Specialized geriatric services include ortho-geriatrics (focus on osteoporosis and rehabilitation) and psycho-geriatrics (focus on dementias, depression and other common conditions in elderly)
Role of Dispensers
· A dispenser being an important member of the geriatric team should provide health education to older patients, their families and communities about the disease prevention, appropriate medication, management of complications and rehabilitation at OPD as well as in the in-patient department.
· A dispenser may refer geriatrics patients to the most appropriate specialist according to the type and magnitude of the problem. In addition to geriatricians there is a dire need to orient/sensitize healthcare providers about this important issue in Pakistan, as a number of deaths and disabilities could be prevented in the elderly by integrated efforts of health care providers and the community.
· Dispensers should guide geriatrics patients about the correct dosage of medicines and advice them on possible drug interactions according to the guidelines of doctors or geriatricians.
· Dispenser should seek social support for elderly patients by disseminating information to families, friends and general population about rehabilitative measure to improve the quality of life.
Diabetes (Also please refer to Sub-unit 2.8)
Diabetes is a lifelong disease marked by high level of sugar in the blood. It can be caused by too little insulin, resistance to insulin or both. Insulin is a hormone produced by pancreas to control blood sugar.
To understand diabetes, it is essential to understand the food metabolism. Several things happen when food is digested or metabolized.
After metabolism of food, a sugar called glucose enters the blood stream which acts as a fuel for the body. Pancreas makes a hormone called insulin which mobilizes the sugar from bloodstream to muscles, fats and liver cells where it is used as a fuel. A person’s blood sugar is raised when pancreas makes very little insulin or inability of muscle, fat and liver cells to respond insulin or both.
Various studies have proved that obesity is the most important risk factor for diabetes and in Pakistan almost 12 % of under 25 years of age are suffering from diabetes.
Eye, kidney, brain and nerve damage are the most common complications of uncontrolled diabetes.
Types of Diabetes
There are three types of diabetes.
· Type-I Diabetes
It mostly occurs in childhood where body produces very little or no insulin and child has to be given insulin daily to sustain life.
· Type-II Diabetes
It is more common and occurs in adulthood mostly. It is because pancreas produces very little insulin or body does not respond to the insulin resulting in a high blood glucose level
· Gestational Diabetes
A woman develops diabetes (high blood glucose level) during pregnancy when she is pregnant but she has no diabetes before pregnancy. Mostly she returns to normal blood sugar levels after pregnancy.
Signs and Symptoms
Increased thirst, urination and appetite and fatigue, nausea, vomiting and blurred vision are common symptoms of diabetes
Diagnosis
· Urine test
Urine analysis to look for glucose and ketones from the breakdown of fat but alone urine analysis is not sufficient to diagnose diabetes.
· Fasting Blood Sugar
Diabetes diagnose if glucose e level is found higher than 126 mg/dl on two occasions. Levels between 100 to 126 mg/dl are labeled as impaired fasting glucose or pre diabetes.
· Random (non fasting) Blood Glucose Level
Diabetes is diagnosed if blood glucose is higher than 200 mg/dl and accompanies by associated symptoms of increased thirst, urination and fatigue.
Treatment
There is no cure for diabetes. Medicines, diet and exercise have a strong role in the prevention of complications.
Role of Dispensers in Prevention of Diabetes, Treatment and Prevention of Complications
· Dispensers should impart specific health education and awareness messages to the clients, patients and the community for prevention of disease, management and prevention of complications if disease is established. A dispenser could affect the individual and community behavior by creating awareness about the diabetes.
· Precautionary measures to be told to all those who have a family history of diabetes and obesity as research has proved that obese people are more prone to diabetes.
· S/he should tell them to take diet which is low in calories, fat and having no un-natural sugar (sweets, chocolates and beverages). S/he should provide all diabetic patients with a diet chart explaining which diet is most appropriate for the diabetic patients.
· Dispensers should highlight the importance of daily walk and exercise in managing and controlling diabetes because dispensers could have an important role in influencing the behavior and attitude of population thus changing the lifestyle by regularly disseminating the health education messages to them.
· Dispensers should guide patients about the importance of taking medicines as there is no cure of diabetes. Correct dosage of medicines to be explained to the patients according to the prescription of a doctor/specialist.
· As a preventive measure, dispenser should guide diabetic patients for regular medical checkup for the timely diagnosis of any complication and in case of any complications (eye, kidney or nerve damage), dispenser should be able to promptly identify the complications due to diabetes and refer timely to the most appropriate health care facility.
· Dispensers should highlight the importance of wearing loose and comfortable shoes. Foot care in diabetic patients is important as many patients develop gangrene in toes due to bad foot care.
Hypertension (Also please refer to Sub-unit 2.1)
Hypertension is the medical term used for high blood pressure. It means high blood pressure in the arteries. Arteries are blood vessels that carry blood from heart to all tissues and organs of the body. The top number, the systolic blood pressure represents the pressure of blood in the arteries when heart contracts and bottom number, the diastolic blood pressure is the pressure of blood in the arteries when heart relaxes after the contraction.
Normal blood pressure is below 120/90 while a blood pressure between 120/80 and 139/89 is called pre hypertension and a blood pressure of 140/90 or above it is considered as high blood pressure.
Hypertension is also known as silent killer and can lead to heart attack, kidney damage and other serious health problems.
Types of Hypertension
· Primary/Essential Hypertension
It is more common and accounts for almost 95% of hypertension. Although basic causes are not always known but it is mostly associated with advancing age, excessive salt intake (exceeding 5.8 grams daily), Alcohol, smoking, caffeine, genetic factors, obesity and lack of regular exercise
· Secondary Hypertension
It accounts for almost 5% of the total hypertension and high blood pressure is secondary to some of the problems of some organs or systems of the body for example kidneys, adrenal glands and aortic artery.
1.1. Signs and Symptoms of Hypertension:
Uncomplicated hypertension presents no typical symptoms and disease can progress silently to develop several fatal complications like heart attacks and strokes. Some people with uncomplicated hypertension may present symptoms like headache, dizziness, shortness of breath and blurred vision.
Role of Dispensers in Management of Hypertension:
· Dispensers have an important role in prevention of disease by imparting health education and awareness about lifestyle of people. Lifestyle modification could also play an important role in prevention of further complications when disease is established. A dispenser should advise about hazards of smoking, caffeine, high salt intake and obesity to patients and general population while working at BHUs, RHCs, and THQ, DHQ and tertiary care hospitals.
· Health education/awareness about dietary restriction (diet low in fats, low in calories and also restricted salt intake) and role of regular physical exercise in preventing fatal complications of this silent killer is also the responsibility of a dispenser. A dispenser could have an effective role in management of disease by disseminating information about the fatal complications such as heart attack and strokes (paralysis).
· Dispensers should guide patients about the accurate dosage according to the prescription and refer them to appropriate specialist if side effects or drug interaction occur. The most important thing to highlight to the patient is regular check up and regular medication, as leaving medication without the advice of a doctor could lead to fatal results.

Class room evaluation


Student: _________________________ ID: __________________________

Teacher: _________________________ Unit 4

Date: ________________________


Define immune system and immunization
________________________________________________________________________________________________________________________________________________________________________________________________________________________


What is the difference between antigen and antibody?
________________________________________________________________________________________________________________________________________________


What is the Expanded Program on Immunization?
________________________________________________________________________________________________________________________________________________________________________________________________________________________

The seven vaccine-preventable diseases included in the EPI in Pakistan are:
______________________
______________________
______________________
______________________
______________________
______________________
______________________

BCG vaccine is given at ___________.


What are the characteristic features of diphtheria?
________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe the condition of poliomyelitis.
________________________________________________________________________________________________________________________________________________________________________________________________________________________

How does whooping cough spread?



Which organ of the body is affected by Hepatitis B and C?
________________________________________________________________________


Diphtheria and tetanus toxoid with whole cell pertussis and Hepatitis B vaccine are given at the following weeks (circle the correct answer)
a. 6, 12, 16 weeks
b. 6, 10, 14 weeks
c. 4, 10, 14 weeks


Oral polio vaccine is given at birth only.
True False


Measles spreads from person to person via the respiratory system through contact with fluids from an infected person's nose and mouth.
True False


The characteristic measles rash is localized to the head region
True False


Tetanus is completely preventable by active tetanus immunization.
True False


Annex to Unit 4 (pages 1 – 17)
WHO Guidelines for Management of Common Diseases in Young Children in Emergencies



Notes