NPPCD

Deafness.

Anatomy of the Ear

The ear is divided into three main parts:

1. External Ear

• Pinna (Auricle): Captures sound waves and directs them into the ear canal.
• External Auditory Canal: Carries sound to the tympanic membrane.

2. Middle Ear

• Tympanic Membrane (Eardrum): Vibrates in response to sound waves.
• Ossicles (Tiny Bones):
• Malleus (hammer)
• Incus (anvil)
• Stapes (stirrup)
  These bones amplify and transmit vibrations from the eardrum to the inner ear.
• Eustachian Tube: Equalizes pressure between the middle ear and atmosphere.

3. Inner Ear

• Cochlea: Spiral-shaped organ responsible for converting sound vibrations into nerve impulses.
• Vestibular Apparatus (Semicircular Canals, Utricle, Saccule): Helps maintain balance.
• Auditory Nerve (Cochlear Nerve): Transmits signals from the cochlea to the brain.

Physiology of Hearing

1.     Sound waves enter the external ear.

2.     Tympanic membrane vibrates, moving the ossicles.

3.     Stapes taps on the oval window, creating fluid waves in the cochlea.

4.     Hair cells in the cochlea detect fluid movement and convert it into electrical signals.

5.     Auditory nerve carries these signals to the brain, where sound is interpreted.

Etiopathogenesis and Pharmacotherapy of Deafness – Summary

Etiopathogenesis of Deafness

Deafness is caused by damage or dysfunction in the auditory pathway and is broadly classified into:

1. Conductive Hearing Loss

Occurs due to obstruction or damage in the external or middle ear, preventing sound conduction.

• Causes:
• Impacted ear wax
• Otitis media (acute, chronic, secretory)
• Tympanic membrane perforation
• Otosclerosis
• Trauma or foreign body

2. Sensorineural Hearing Loss (SNHL)

Caused by damage to the cochlea, auditory nerve, or central auditory pathways.

• Causes:
• Congenital (genetic syndromes, birth injuries)
• Presbycusis (age-related)
• Noise-induced hearing loss
• Ototoxic drugs (e.g., aminoglycosides, cisplatin)
• Infections (e.g., rubella, meningitis)
• Head trauma

3. Mixed Hearing Loss

Involves both conductive and sensorineural components.

Pharmacotherapy of Deafness

Treatment depends on the underlying cause and type of deafness.

1. Conductive Hearing Loss

• Ear wax:
• Wax softeners: Carbamide peroxide, hydrogen peroxide, sodium bicarbonate drops
• Infections:
• Acute Otitis Media: Amoxicillin or amoxicillin-clavulanate
• Chronic Otitis Media: Topical antibiotics (e.g., ciprofloxacin drops)
• Otitis externa: Antibacterial or antifungal ear drops
• Inflammation:
• Steroid drops for allergic or inflammatory conditions

2. Sensorineural Hearing Loss

• Sudden SNHL:
• Systemic or intratympanic corticosteroids (e.g., prednisolone)
• Autoimmune causes:
• Immunosuppressive therapy (steroids, methotrexate)
• Infectious causes (e.g., syphilis):
• Specific antibiotics (e.g., penicillin)
• Ototoxicity:
• Discontinuation of offending drug
• Antioxidants under research (e.g., N-acetylcysteine)

3. Supportive Therapy

• Hearing Aids for irreversible hearing loss
• Cochlear Implants in profound SNHL
• Speech and language therapy
• Tinnitus management (e.g., ginkgo biloba, anti-anxiety meds)

National Programme for Prevention and Control of Deafness (NPPCD)
Objectives, Functioning, and Outcomes – Summary

Objectives:

1. Prevent avoidable hearing loss due to disease or injury.
2. Ensure early identification, diagnosis, and treatment of ear problems.
3. Provide medical rehabilitation for people of all age groups with hearing loss.
4. Strengthen inter-sectoral linkages for long-term rehabilitation.
5. Develop institutional capacity through training and equipment.
6. Reduce the overall burden of hearing impairment by 25% by the end of the 12th Five Year Plan.

Functioning:

• Training & Capacity Building:
  Training of ENT specialists to grassroot workers (e.g., ASHAs, AWWs, teachers). Strengthening PHCs, CHCs, and district hospitals with ENT kits and diagnostic tools.

• Service Provision:
  Audiometric assistants and speech instructors posted at district hospitals. Services include screening, treatment (medical/surgical), rehabilitation, and referral.

• Awareness Generation (IEC/BCC):
  Public campaigns to promote early detection and reduce stigma around deafness.

• Screening Camps & School Screening:
  Regular camps and annual screening of primary school children for ear conditions.

• Hearing Aids Distribution:
  Free hearing aids provided to children under 15, with one-year service support.

Outcomes:

• Expansion to 228 districts across 27 States/UTs.
• Over 6,380 hearing aids distributed.
• More than 335 screening camps conducted.
• Improved public awareness, early intervention, and infrastructure for ear and hearing care.

National Leprosy Control Program1955

Leprosy 

• Leprosy (Hansen’s disease): Chronic infectious disease caused by Mycobacterium leprae.
• Mainly affects: Skin, peripheral nerves, eyes, and upper respiratory tract.
• Symptoms: Pale/red skin patches, numbness, muscle weakness in hands/feet.

Classification:

• Paucibacillary (PB): Up to 5 pale/red skin lesions.
• Multibacillary (MB): More than 5 lesions, nodules, plaques, or thickened skin.

Mode of Spread:

• Through droplets from nose/mouth of untreated person.
• Enters healthy body via respiratory system.
• Migrates to nerves and skin, causing potential permanent disability.

WHO Grades for Leprosy:

Grade 0:

• Eyes: Normal
• Hands: Normal
• Feet: Normal

Grade 1:

• Eyes: Corneal reflex weak
• Hands: Loss of feeling in the palm of the hand
• Feet: Loss of feeling in the sole of the foot

Grade 2:

• Eyes: Reduced weakness, lagophthalmos
• Hands: Visible damage to the hands such as claw hands or loss of tissue
• Feet: Visible damage to the foot, such as wounds, loss of tissue, or foot drop

Introduction to National Leprosy Eradication Programme (NLEP)

The NLEP is a centrally sponsored health scheme under the Ministry of Health and Family Welfare, Govt. of India. It originated from efforts by the Gandhi Memorial Leprosy Foundation in 1952. The National Leprosy Control Programme (NLCP) began in 1955, and NLEP started under the 12th Five Year Plan (2012–2017) to achieve zero leprosy cases.

Milestones in the Programme:

• 1955: NLCP launched
• 1983: NLEP launched; MDT introduced
• 2005: National-level elimination of leprosy achieved
• 2006: DPMR services introduced
• 2012: Special action plan for 209 high endemic districts
• 2016: Goal to reduce Grade 2 disability to <1 case/million population
• 2017: Targeted 35% reduction in disability rate in new cases (vs 2010 baseline)
• 2020: Target to reduce visible disabilities to <1 per 10,000 population

Objectives of NLEP:

1.     Early detection through trained health workers.

2.     Regular treatment via Multi-Drug Therapy (MDT) at fixed centers.

3.     Health education & awareness to reduce social stigma.

4.     Disability Prevention and Medical Rehabilitation (DPMR).

5.     Provide medical rehab and ulcer care services.

6.     Goal: Eliminate leprosy at state/district level to <1 case/10,000 population.

7.     Goal: Reduce Grade-II deformity rate to <1 per 10 lakh population.

Components of the Programme:

A. Case Detection and Management

B. Disability Prevention and Medical Rehabilitation (DPMR):

• Provide dressing materials, medicines, ulcer kits, and footwear.
• Support Reconstructive Surgery (RCS) through NGOs/medical colleges.
• ₹5000 support for RCS to leprosy-affected persons from BPL families.
• ₹5000 incentive to institutions per RCS performed.
• Activities include: treating reactions, ulcers, physiotherapy, footwear distribution.
• DPMR services are integrated with NRHM.
• Target: Reduce visible disabilities to <1 per 10 lakh population by 2020.

DPMR Activities

Primary Level Care (First Level):

• Rural Areas: Village or community level to Community Health Center (CHC) level.
• Urban Areas: Sub-Divisional Hospitals and Urban Leprosy Centers/dispensaries.

Secondary Level Care (Second Level):

• District hospitals and district nucleus team.
• In some areas, secondary level care is also provided by NGO-supported leprosy units.

Tertiary Level Care Institutions (Third Level):

• Centers of excellence including medical colleges and Reconstructive Surgery (RCS) centers recognized by the Government of India

Program Strategies:

C. IEC (Information, Education, Communication):

• Behavior change communication.
• Campaign title: "Towards Leprosy-Free India".
• Focus on:
• Reducing stigma.
• Promoting early diagnosis and treatment.

D. Human Resource & Capacity Building

E. Program Management:

F. Current strategies and activities

I. Use ASHAs to identify and follow up on suspected cases.

J. Revised indicators for programme monitoring

1. Sparsh  Leprosy Awareness Campaign (2018):

• Conducted from 30th January to 13th February as an annual activity.
• Aimed to raise awareness about leprosy.

2. Sparsh Leprosy Elimination Campaign (SLEC):

• Launched on Mahatma Gandhi’s 150th birth anniversary.
• Focused on community awareness, stigma reduction, and case detection.
• Aimed to reduce leprosy burden and visible deformities to <1 per 10 lakh.

Rolled out in 36 states, including house-to-house visits

Key Messages of Leprosy Programme:

1.     Leprosy is curable with Multi-Drug Therapy (MDT).

2.     Regular MDT use cures leprosy, prevents deformities, and stops transmission.

3.     Early diagnosis and treatment prevent disability.

4.     Leprosy is not hereditary.

5.     No spread by casual contact (e.g., shaking hands or playing).

6.     Caused by Mycobacterium leprae, not sins or immoral behavior.

7.     Leprosy patients have a right to dignity and livelihood.

Strategies for Leprosy Elimination in India:

• Decentralized integration of leprosy services with general health care.
• Early detection and treatment of new and child cases.
• Household contact surveys for identifying hidden cases.
• Prompt MDT administration.
• ASHAs involved in detection and treatment.
• Strengthen DPMR services (Disability Prevention & Medical Rehab).
• IEC activities to improve awareness and reduce stigma.
• Regular monitoring at PHCs and CHCs.
• Establishment of:
• Leprosy Control Units (LCU)
• Survey, Education and Treatment (SET) Centres
• Urban Leprosy Centres
• Mobile Leprosy Treatment Units (MLTU)

Outcome Highlights:

• Leprosy elimination at the national level was officially achieved in 2005.
• However, India still accounts for ~57% of the world’s leprosy cases.
• By March 2017, 554 out of 682 districts (81.23%) had achieved leprosy elimination.
• As per the 2015 report, national prevalence rate was 0.67 per 10,000 population.
• Deformity rates:
• Grade I: 5.18%
• Grade II: 4.61%
• In 2013–14, 1.27 lakh new cases were detected.
• Annual New Case Detection Rate (ANCDR): 9.98 per 100,000 (a 7.4% decrease from 2012–13).
• As of April 1, 2014, 0.86 lakh cases were on record.
• Prevalence rate: 0.68/10,000 (a 12.8% drop from 2012–13).
• 33 States/UTs had achieved elimination (PR < 1 per 10,000).
• 111 institutions (60 Govt + 51 NGO) are recognized for Reconstructive Surgery (RCS) to correct leprosy-related disabilities.

Reference 

Malviya K, Sahoo S, Dasadiya D, Acharya V. Social and Preventive Pharmacy. 1st ed. Pee Vee (Regd.); 2021

National Mental Health Program 1982

National Mental Health Program (NMHP)

Mental health is a crucial part of overall health. According to the WHO, it is a state of well-being where individuals can cope with life’s stresses, work productively, and contribute to their communities. Mental disorders include anxiety, depression, bipolar disorder, eating and personality disorders, PTSD, and schizophrenia.

In India, the lifetime prevalence is 12.3% for common and 1.95% for severe mental disorders, highlighting the urgent need for accessible mental health services.

To address this, the Government of India launched NMHP in 1982, aiming to reduce the burden of mental illness and overcome the lack of mental healthcare infrastructure.

World Mental Health Day is observed on 10th October annually to raise global awareness and promote mental health efforts.

Evolution of the National Mental Health Program (NMHP)

• 1982: NMHP launched to reduce the burden of mental illness and improve care.
• 1996: District Mental Health Program (DMHP) added under the IX Five-Year Plan (based on the Bellary Model).
• 2003: NMHP restructured with two schemes:
• Modernization of State Mental Hospitals
• Upgradation of Psychiatric Wings in Medical/General Hospitals
• 2009: Manpower Development Schemes (A & B) included.

Aim of NMHP

• Prevent and treat mental and neurological disorders.
• Use mental health technology to enhance general health services.
• Apply mental health principles to national development.

Objectives of NMHP

• Ensure accessible mental health care, especially for the vulnerable.
• Integrate mental health knowledge into general and social health care.
• Promote community participation and self-help in mental health.

District Mental Health Program (DMHP)

• Provides basic, community-based mental health services.
• Focuses on early detection, treatment, and rehabilitation.
• Reduces stigma through public awareness.

Components of NMHP

1.     Treatment of mentally ill

2.     Rehabilitation

3.     Prevention & Promotion of positive mental health

Key Activities under NMHP

I. District & Sub-district Level (under NHM):

• Basic mental health services at community level
• 10-bedded inpatient mental health facilities
• 4 satellite clinics/month at CHCs/PHCs
• Targeted interventions include:
• Life skills & counseling in schools/colleges
• Workplace stress management
• Suicide prevention
• Awareness campaigns involving local stakeholders
• Community participation via SHGs, caregivers, NGOs
• 241 districts covered; expansion ongoing

II. Public-Private Partnership (PPP):

• Up to ₹5 lakhs per NGO for mental health activities

III. Primary Health Centers & Hospitals:

• OPD & emergency psychiatry services
• Counseling services
• Up to ₹15 lakhs/year support to medical institutions

IV. Mental Health Helpline:

• 24/7 national helpline for crisis support, info, and legal aid
• NMHP is linked with district hospitals, medical colleges, mental hospitals, private facilities, NGOs, and all mental health providers across states.

V. Research & Surveys

• Conduct mental health research to identify regional needs.
• Guides future planning and strategies.
• Budget: ₹18 crore (₹6 crore/year).

VI. Central IEC (Information, Education, Communication)

• Dedicated website for mental health resources and programs.
• Mass media campaigns in local languages via TV, radio, and other media.
• Online data monitoring and communication system.

VII. Training & Workshops

• Master trainers trained at central hubs.
• Standardized manuals used for consistent state-level training.

3.5.5 Manpower Development Schemes

Scheme A: Centers of Excellence

• Upgrade 10 institutes/medical colleges to offer psychiatry and allied mental health courses.
• Financial support: up to ₹33.70 crore per center.
• 15 centers funded so far for development.

Scheme B. PG Training Departments of Mental Health facilities

. Government Medical Colleges/ Government Mental Hospitals will be supported for starting/increasing intake of PG courses in Mental Health.

Financial support of up to Rs.0.86 to 0.99 cr per dept. would be provided. The support includes physical work for establishing /improving department in specialties of mental health, equipment's, tools and basic infrastructure & for engaging required faculty for starting/enhancing the PG courses.

39 PG Departments in 15 Medical Colleges/ Mental Hospitals in mental health specialties viz. Psychiatry, Clinical Psychology, Psychiatric Nursing and Psychiatric Social Work have been provided support for their establishment/strengthening.

3.5.6 OUTCOME OF PROGRAMME

The number of districts currently covered by the DMHP out of the aimed 500, the figure is 241(2014-2015). After 18 years of existence the program has achieved less than 50% of goals and objectives.

Reference 

Malviya K, Sahoo S, Dasadiya D, Acharya V. Social and Preventive Pharmacy. 1st ed. Pee Vee (Regd.); 2021

Revised National TB Control Program

Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium tuberculosis. It primarily affects the lungs (pulmonary TB) but can also affect other parts of the body (extrapulmonary TB). TB spreads through the air when an infected person coughs, sneezes, or speaks.

Etiology & Pathogenesis:

• Caused by Mycobacterium tuberculosis.
• Spread mainly through airborne droplets.
• Affects lungs (pulmonary TB) and other organs (extrapulmonary TB).
• Risk factors: HIV, malnutrition, diabetes, smoking, poor living conditions.

2. Signs & Symptoms:

• Persistent cough (>2 weeks)
• Weight loss
• Fever, night sweats
• Chest pain, blood in sputum

3. Diagnosis:

• Sputum microscopy, CBNAAT (GeneXpert)
• Chest X-ray
• Tuberculin Skin Test (TST)
• Drug-resistance testing (especially Rifampicin)

4. Prevention:

• BCG vaccination at birth
• Infection control (cough etiquette, ventilation)
• Contact tracing and preventive therapy
• Addressing social factors (poverty, overcrowding)

5. Treatment:

·        New TB Cases:

• IP: 8 weeks - HRZE (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol)
• CP: 16 weeks - HRE (Isoniazid, Rifampicin, Ethambutol)

·        Previously Treated TB Cases:

• IP: 12 weeks - HRZE + Streptomycin (8 weeks), then HRZE (4 weeks)
• CP: 20 weeks - HR daily

·        Special Cases:

• Extension of treatment by 12-24 weeks for complicated TB.

6. Drug-Resistant TB:

• MDR-TB: Resistant to INH and Rifampicin.
• Treatment includes Bedaquiline under special programs.

7. Supportive Schemes:

• Nikshay Poshan Yojana:
• Rs. 500/month for nutritional support to TB patients.
• Nikshay App:
• Digital tracking of TB patients and their treatment.

8. Key Programs:

• National Strategic Plan 2017-2025: Goal to eliminate TB by 2025.
• DTPB Strategy: Detect, Treat, Prevent, Build.

Quick Memory Tip:

• Think "4 D's" — Detect early, Diagnose properly, Drug treatment directly observed, Defeat TB by 2025!

Evolution of TB Control Program in India:

• 1962: National TB Programme (NTP) started with BCG vaccination and TB treatment.
• 1992: Programme review showed poor success — only 30% of diagnosed patients were treated successfully.
• 1993: Revised National TB Control Programme (RNTCP) pilot began.
• 1997: RNTCP officially launched with DOTS (Directly Observed Treatment, Short-course) strategy.
• 2001: 450 million people covered under RNTCP.
• 2004: 90% of the country was covered (Phase I of RNTCP completed).
• 2006: Entire country covered (Phase II of RNTCP).
• 2012: National Strategic Plan for TB Control was documented to achieve universal access to TB care.

National Strategic Plan (NSP) for Tuberculosis Elimination 2017–2025

Goal:

• Eliminate TB in India by 2025.

Strategy (DTPB):

• Detect: Find all TB cases (including drug-resistant) early, especially among high-risk groups.
• Treat: Start and maintain patients on proper anti-TB treatment with good support.
• Prevent: Stop TB spread among vulnerable people.
• Build: Strengthen policies, institutions, and human resources.

Key Services of the Program:

• Free TB diagnosis and treatment.
• Rapid diagnostic testing.
• Testing TB patients for drug resistance and HIV.
• Management of other associated diseases.
• Support to help patients stick to treatment.
• Nutrition support (like Nikshay Poshan Yojana).
• Preventive actions to avoid TB spread.
• Special focus on private sector patients:
• Incentives for private doctors to report TB cases.
• Free medicines even through private healthcare.
• Use of modern MIS (management information system) systems for tracking cases.
• SMS reminders to patients for better treatment compliance.

TB Vulnerability and Control Activities:

• Special focus on high-risk groups:
• HIV patients
• Smokers, alcoholics, and drug addicts
• Poor, malnourished, marginalized groups
• Remote and hilly areas
• Sexual minorities and pregnant women
• Children (pediatric TB)
• Prison inmates
• Patients with extra-pulmonary TB

Airborne Infection Control Measures:

• Early diagnosis and proper management of TB cases.
• Cough hygiene: Cover mouth with tissue/elbow while sneezing/coughing.
• Good ventilation in houses and hospitals.
• Use airborne infection control practices in health centers.
• Evaluate contacts of TB patients (even during treatment).
• Reverse contact tracing for pediatric TB cases.

Isoniazid Preventive Therapy (IPT):

• For children under 6 years old who are close contacts of TB patients.
• TB active disease must be ruled out before starting IPT.
• Also given to HIV-infected children exposed to TB but without active disease.

Treatment of TB:

• Daily Fixed Dose Combinations (FDCs) are given for all TB cases, supervised through Directly Observed Treatment (DOT).
• Rifampicin resistance screening (and other drugs if needed) is done before starting treatment.

Treatment Regimens:

·        New TB cases:

• Intensive Phase (IP): 8 weeks with 4 drugs — Isoniazid (INH), Rifampicin, Pyrazinamide, Ethambutol (HRZE).
• Continuation Phase: 16 weeks with 3 drugs — INH, Rifampicin, Ethambutol (HRE).

·        Previously treated cases:

• IP: 12 weeks with streptomycin + HRZE.
• Continue for 4 more weeks with HRZE.
• Continuation Phase: 20 weeks with HR drugs (daily doses).

·        Extended treatment (by 12–24 weeks) may be needed for complicated TB cases like skeletal or disseminated TB.

Special Notes:

• Bedaquiline introduced for MDR-TB under special programs from 2016 onward.
• Nikshay Poshan Yojana:
• Financial support of Rs. 500/month to each TB patient for nutritional needs during treatment.

ICT-based Treatment Adherence Support Mechanisms:

• Mobile-based "Pill-in-Hand" tool.
• Interactive Voice Response (IVR) and SMS reminders.
• Special electronic pill boxes with GSM connection.
• Mobile apps for patients to report treatment compliance.
• Automated pill loading systems.
• ICT-enabled smart cards and SMS gateway.

Outcomes of the TB Elimination Programme (NSP 2017-2025):

• Over 22 lakh (94.4%) of drug-sensitive TB patients started on treatment.
• Core populations screened across 23 states leading to 62,958 TB cases identified.
• 1180 CBNAAT centers set up; 35.31 lakh tests performed (47% rise).
• 66,359 MDR/RR-TB cases notified, 85% started on treatment.
• New injection-free oral regimens introduced for MDR TB patients.
• 94% of People Living with HIV (PLHIV) screened for TB symptoms.
• 2.4 lakh PLHIV got rapid NAAT testing; 3 lakh+ PLHIV started on TB preventive therapy.
• Blood sugar testing done for over 60% of notified TB patients in the public

Tuberculosis (TB) – One-Page Revision
National Strategic Plan (NSP) 2017–2025 Goals:
• Eliminate TB in India by 2025.
• Strategy: Detect – Treat – Prevent – Build (DTPB).

Key Services:
• Free diagnosis and treatment.
• Rapid diagnostics and HIV testing.
• Management of drug resistance and associated diseases.
• Nutrition support (e.g., Nikshay Poshan Yojana - ₹500/month).
• Digital monitoring (MIS systems, ICT tools).

Treatment Regimen:
• New TB Cases:
◦ Intensive Phase (8 weeks): 4 drugs (HRZE) daily.
◦ Continuation Phase (16 weeks): 3 drugs (HRE) daily.
• Previously Treated Cases:
◦ Intensive Phase (12 weeks): 4 drugs + Streptomycin.
◦ Continuation Phase (20 weeks): HRZE continuation.
• MDR/RR-TB:
◦ Special oral regimens and Bedaquiline treatment started under conditional access.

ICT-Based Adherence Support:
• SMS Reminders, Mobile Apps (compliance reporting).
• Smart Cards, Electronic Pillboxes with GSM.
• Automated pill loading systems.

Achievements (Outcomes):
• Over 22 lakh TB cases treated in a year.
• 62,985 TB cases identified from vulnerable groups.
• 66,359 MDR/RR-TB cases notified; 85% started on treatment.
• 94% PLHIV screened for TB symptoms; over 3 lakh started preventive therapy.
• Blood sugar screening integrated for TB-diabetes.

Important Initiatives:
• Nikshay App: Case tracking and nutrition support.
• Nikshay Poshan Yojana: Nutritional financial support.
• Integrated Disease Surveillance Program (IDSP): Early disease outbreak detection.

Quick Abbreviations:
• DS-TB: Drug Sensitive TB
• DR-TB: Drug Resistant TB
• MDR-TB: Multi-Drug Resistant TB
• HRZE: Isoniazid, Rifampicin, Pyrazinamide, Ethambutol
• PLHIV: People Living with HIV
• CBNAAT/NAAT: Rapid molecular TB diagnosis methods

Reference 

Malviya K, Sahoo S, Dasadiya D, Acharya V. Social and Preventive Pharmacy. 1st ed. Pee Vee (Regd.); 2021