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Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 288
CHAPTER-6
GENERAL INFORMATION AND HEALTH RESUME
One of cardinal factors for achieving health for all by 2015
AD is the ability of the individual and the organization to recognize and
respond to change in advancing technology for health maintenance and
promotion, new pattern of disease, disability, etc., new social policies,
expectations and programmes for better health services. Towards this
era, the education of people concerning prevailing health problems and
methods of preventing and controlling them is the first requisite of
primary health care. This is more so in the case of public welfare
personnel and professionals through whom the knowledge and skills
should percolate to the grassroot level.
The availability of safe and adequate drinking water and
sanitary measures has a direct bearing on the working conditions of the
people and their capacity for optimum production. There are very few
investments which repay as much in health benefit as the provision of
safe water supply and sanitation. The provision of safe drinking water
and proper disposal of wastes is a pre-environmental control measure
against the transmission of most water borne diseases. This relationship
is the WHO statistics, which shows that 80 per cent of all the diseases in
developing countries are related to unsafe water supply and inadequate
sanitation. Water borne and water related diseases are responsible for
high infant mortality, low life expectancy and poor quality of life.
Examples serve to illustrate the causal relationship between unsafe and
inadequate water and diseases.
1. Gastroenteritis and diarrhoeal diseases are largely preventable
if safe water and adequate sanitation are made available.
2. Typhoid and paratyphoid fever, which are ramped throughout
the developing world, likewise can be traced from
contaminated public water supply and unsafe food.
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 289
3. Cholera, which results from contaminated water and poor
sanitation leads to fatality in 50 per cent of cases of without
medical attention.
4. Infectious hepatitis can be spread by contamination of
drinking water and food.
5. Amoebiasis, which can be eliminated by ensuring clean water
supply and proper excreta disposal, under certain conditions
effect more than 50 per cent of the population and if invasive,
can have mortality rates upto 20 per cent.
6. Schistosomiasis, which can be eliminated to affect more than
200 million people is caused by infection through skin as a
result of working, bathing, washing or playing in
contaminated water. The transmission cycle can be
interrupted and controlled through proper disposal of excreta.
7. Intestinal parasites come about through faecal pollution of the
soil.
8. Malarial filariasis, yellow fever, guinewarm and other vector
borne diseases share common condition water as the medium
in which their vectors breed (Nat, Hlth, Prg, Series 8).
The state of health of the people does not depend only on
the number of doctors and hospitals, but also on clear environment
because it is conductive to spread of diseases, the state of health of
people will be poor. A major part of Indian population resides in
villages and under developing townships and lacking the supply of
safe drinking water. The system has to be preventive as also curative
and both are important. Nearly 80 per cent of world’s diseases more
so in developing world, can be linked with water.
According to a report of WHO (1964) in Uttar Pradesh
after water works sanitation, the typhoid fever death rate decreased
by 63.3 per cent, cholera by 74.14 per cent, desentery by 23.1 per
cent and diarrhoeal death rate by 42.7 per cent. Increased pattern of
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 290
human population and unavailability of drinking water forced for
drilling of private dugwells, handpumps and tubewells while in other
handpumps problem of sewage disposal and accumulation of waste
in drainage system become the major source of contamination of
ground water reserves.
Water borne diseases constitute one of the major public
health hazards in developing countries. Worldwide, in 1995,
contaminated water and food caused more than 3 million deaths, of
which more than 80 per cent were among children under age five.
Besides the conventional pathogens, which are transmitted by water,
several emerging water borne pathogens have become increasingly
important during the last decade or so. These include Vibrio
cholerae, Cryptosporidium parvum, E. coli, etc.
Epidemiology and case definitions
1. Cholera
Epidemiology
Agent : Vibrio cholerae serogroups 01 and 0139, produces diarrhoea
by an enterotoxin. Biotype EI Tor is less pathogenic as compared to
the Classical biotype.
Host : Humans are the only host. Affects all ages and both sexes
equally. In endemic regions, children are more susceptible. Natural
infection confers effective immunity. Chronic carriers are rare.
Environment : Poor sanitary condition such as contaminated water
and food facilitate the growth and transmission of V. cholerae.
Environmental reservoirs exist in association with zooplankton in
brackish waters and estuaries.
Mode of transmission : From human to human through drinking or
eating contaminated water or food. Rarely through direct
transmission, i.e. faeco-oral route.
Incubation period : A few hours to 5 days, usually in the range from
2 to 3 days.
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 291
Period of infectivity : From onset of illness to about a week later.
Rarely chronic carriers may increase the period of infectivity.
Infectivity rate : Depends on the infective dose. About 1011
organisms are necessary to produce symptoms. A patient with
cholera excretes an average of 107 – 10
9 Vibrios per ml of stool.
Signs and symptoms : Abrupt onset of profuse, painless watery
diarrhoea with or without vomiting. The stool may have a rice water
appearance. Soon the patient becomes severely dehydrated which
may lead to death unless rapidly treated. At least 90 per cent cases
are mild and remain undiagnosed (Anonymous, 2007).
In India, more than 70 per cent of the epidemic
emergencies are either water-borne or are water related. Although a
sub-stanial amount of work has been carried out on common water-
borne pathogens in India. Unfortunately only a little information is
available on the emerging water-borne pathogens. A regular surveillance
or resource and drinking water are one of the major mainstays of
containing dreaded and often fatal water-borne diseases. It was in this
context that an assessment of microbial load of different types of water
and the prevalence of emerging water-borne pathogens, viz., Vibrio
cholerae, 0139 and Enterohaemorrhagic E.coli (EHEC, serotype
0157:H7) was undertaken in the national capital of Delhi (Sharma et al.,
2003).
The most common and widespread danger associated with
drinking water is contaminating either directly or indirectly by sewage,
by other wastes or by human or animal excrement. If such
contamination is recent and it among the contributers there are carriers
of communicable enteric diseases. Some of the living causal agents may
be present. The drinking water so contaminated on its use in the
preparation of certain foods may results in further cases of infection.
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 292
Water borne bacterial pathogens
Faecal pollution of drinking water may introduce a variety
of intestinal pathogen – bacteria, viral and parasitic, their presence being
related to microbial diseases and carriers, present at that moment in the
community. Intestinal bacterial pathogens are widely distributed
throughout the world. Those known to have occurred in contaminated
drinking water include strains of Salmonella, Shigella, Entero toxigenic
E.coli, Vibrio cholerae. These organisms may cause diseases that vary
in severity from mild gastroenteritis to severe and sometimes fatal
dysentery, cholera or typhoid.
Other organisms, naturally present in the environment and
not regarded as pathogens, may also cause occasional opportunist
disease. Such organisms in drinking water may cause infection
predominantly among people where local or general natural defence
mechanisms are impaired; this is most likely to be the case in the very
old, the very young and patients in hospitals, for example with burns or
on used by patients for drinking and bathing, if it contains excessive
number of organisms such as Pseudomonas, Flavobacterium,
Acinetobacter, Klebseilla and Serratia, may produce a variety of
infections involving the skin and mucus membranes of the eye, ear, nose
and throat.
The mode of transmission of bacterial pathogens include
ingestion of contaminated water and food contact with infected persons
or animals and exposure to aerosols. The significance of the water route
in the spread of intestinal bacterial infections varies considerably, both
with the disease and with local circumstances. Although, Shigella may
be water borne, water is not usually the main route for the spread of
Shigellosis but rather person to person contact in crowded living
conditions; in contrast, Cholera is usually water borne and Salmonellosis
is food borne.
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 293
Among the various water borne pathogens, there exists a
wide range of minimum infections dose levels necessary to cause a
human infection with Salmonella typhi ingestion of relatively few
organisms can cause disease; with Shigella flexneri, several hundred
cells may be needed, whereas many millions of cells of Salmonella
serotypes are usually required to cause gastroenteritis. Similarly, with
toxigenic organisms such as enteropathogenic E.coli and V. cholerae as
many as 108 organisms may be necessary to cause illness.
The microbiological quality of potable water shows its
potential for transmitting water-borne diseases. These diseases may be
caused by viruses, bacteria, protozoa or higher organisms. A
microbiological test will reveal the quality of the raw water sources and
aid in determining any treatment required. The test is necessary to
maintain the quality of the water. The testing for microorganisms in
water is extremely difficult. The number of these organisms is usually
very low, even in a badly polluted water supply and the test used to find
them is difficult. For these reasons, indicator organisms are used to
detect the presence of contamination. The bacterial used as an indicator
of possible contamination are total coliforms. These organisms occur in
large quantities in the intestines of warm-blooded animals. The
presence of any coliform organism in treated potable water is an
indication of water contamination. Thus, detection of surrogate
organism like E.coli indicates contamination of water (APHA, 1998).
Organisms indicative of faecal pollution
The use of normal intestinal organisms as indicators of
faecal pollution rather than the pathogens themselves is a universally
accepted principle for monitoring and assessing the microbial safety of
water supplies. Ideally, the finding of such indicator bacteria should
denote the possible presence of all relevant pathogens. Indicator
organisms should be abundant in excrement but absent or present only in
small numbers in other sources, they should be easily isolated, identified
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 294
and enumerated and should be unable to grow in water. Escherichia coli
as the essential indicator of pollution by faecal material of human or
animal origin (WHO, 1971).
Orally transmitted infections of high priority
The human pathogens that can be transmitted orally by
drinking water are E.coli, Salmonella, Shigella, Vibrio cholerae,
Pseudomonas aeruginosa, together with a summary of their health
significance and main properties. Those that present a serious risk of
disease whenever present in drinking water include Salmonella species,
Shigella species, pathogenic E.coli, Vibrio cholerae. Most of these
pathogens are distributed worldwide.
Epidemic potential : It may cause rapidly progressive epidemics or
worldwide pandemics. In endemic cases, sporadic cases and small
outbreaks may occur.
Lab confirmation : Isolation of V. cholerae 01 or 0139 is the gold
standard specimens may be transported from the field using transport
media like Cary-Blair media.
2. Typhoid / para-typhoid fever
Epidemiology
Agent : Salmonella enteric serotype Typhi, serotype paratyphoid A, B
and C.
Host : In endemic areas typhoid fever is most common in school and
pre-school aged children i.e. 2 to 19 years.
Mode of transmission : By contaminated food and water with faeces
and urine of patients and carriers. Important vehicles include raw fruits,
vegetables fertilized by night soil and eaten raw, contaminated milk and
milk products usually by hands of carriers and missed. Flies may infect
food in which the organisms then multiply to achieve an infective dose.
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 295
Incubation period
The incubation period depends upon the size of the
infecting dose from 3 days to 3 months with a usual range of 1-3 weeks.
For paratyphoid fever it is as low as 1-10 days.
Period of communicability
As long as bacilli appears in excreta, usually from the first
week throughout convalenscence; variable thereafter (commonly 1-2
weeks for paratyphoid). About 10 per cent of untreated typhoid fever
patients will discharge bacilli for 3 months after onset of symptoms, and
2 per cent to 5 per cent become permanent carriers.
Diagnosis
The etiologic organisms can be isolated from the blood
early in the disease and from urine and feces after the first week. A
fourfold rise in somatic (O) agglutination titers in paired sera appears
during the second week in less than 70 per cent of cases of typhoid
fever; when it occurs, it supports the diagnosis, provided vaccine had
been given recently.
Clinical manifestations
Disease is characterized by insidious onset of sustained
fever, severe headache, malaise, anorexia, a relative bradycardia, and
splenomegaly. Constipation more commonly than diarrhoea in adults.
In typhoid fever, ulceration of Peyer’s patches in the ileum can produce
intestinal hemorrhage or perforation (about 1 per cent of cases),
especially late in untreated cases. Severe forms have been described
with cerebral dysfunction. Paratyphoid fever presents a similar clinical
picture, but tends to be milder, and case-fatality rate is much lower.
Relapses may occur in approximately 3 per cent – 4 per cent of cases.
Case fatality ratio
The usual case fatality rate of 10 per cent can be reduced
to < 1 per cent with prompt antibiotic therapy. It is much lower in
paratyphoid fevers.
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 296
Complications
Intestinal perforation, typhoid encephalopathy and chronic
carrier states are some of the complications. Relapses occur in 5 per
cent to 10 per cent of untreated cases and may be more common (15 per
cent – 20 per cent) following therapy with appropriate antibiotics.
3. Acute Viral Hepatitis
Acute illness typically including following
Acute jaundice (Yellow sclera / skin)
Dark urine
Anorexia, malaise
Extreme fatigue
Right upper quadrant tenderness
Biological signs include:
Increased urine urobilonogen
>2.5 times the upper limit of serum alanine aminotransferase.
Laboratory criteria for diagnosis
Hepatitis A IgM anti HAV positive
Hepatitis B Positive for HbsAg or IgM anti-HBc
Hepatitis C Positive for anti-HCV
Hepatitis D Positive for HbsAg or IgM anti-HBc plus anti-
HDV
Hepatitis E Positive for anti-HEV (Footnotes)
Case classification
Suspect case As per clinical case definition
Probable case Not applicable
Confirmed case A suspect case that is laboratory confirmed. For
Hepatitis A, a case compatible with the clinical
description and with epidemiological link with a
lab confirmed case of Hepatitis A.
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 297
4. Malaria
Epidemiology
Agent: There are four species of human malaria parasites, among them
first three found in India.
a. Plasmodium vivax
b. Plasmodium falciparum
c. Plasmodium malariae
d. Plasmodium ovale
a. Plasmodium vivax
The name vivax is given to the species because it shows
marked amoebiodicity. It produces a disease in man known as benign
tertian type. The hot and cold stages are more commonly seen. It is
called benign as it is rarely fatal and tertian because the temperature
comes after every 48 hours. The parasite shows a greater tendency to
invade younger red cells.
b. Plasmodium flaciparum
This is the species that is responsible for virtually all the
mortality associated with malaria and for substantial portion of its
morbidity.
c. Plasmodium malariae
It produces quartan malaria in man since the attacks of
fever occur every 72 hours.
Vector: Anopheles Mosquito-breeds in fresh water containers in and
around the residential areas, water coolers, flowerpots etc.
Signs and symptoms: The presentation of uncomplicated PF. Malaria is
very variable and can mimic many other diseases. Fever - Very
common. Initially persistent and may or may not be accompanied by
rigors. Jaundice and Anemia – May be present with
Hepatosplenomegaly. The early diagnosis and prompt treatment is
extremely essential to avoid fatal complications (Anonymous, 2007).
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 298
QUESTIONNAIRE
A detailed questionnaire was prepared (refer Annexure) to
assess the impact of contaminated water on resides of study area, prime
importance was given to those, which suppose to be major sources of
ground water pollution i.e. sewage disposal system, sanitation facilities,
situation of septic tanks, stagnation of waste water and leakage in
drainage system etc.
A total of 259 families (comprising of 1417 persons) were
surveyed in and around Beed town. These families were randomly
selected and visited their homes with giving questionnaire. It was filled
by family head. These families were categorized according to their
annual income (in Rs.) grouped as < 50000, < 100000 and > 100000.
Total members in annual income group Rs. < 50000 comprised 640 and
children below 14 years age was 187. The total members in income
group ≤ 100000 having 477 and children below 14 years age were 95
and total members in income group > 100000 were 300 and children
below 14 years were 74 (Table 86 and Fig. 27 and 28). The study
revealed that more than 1/4th
of the population (86.79 per cent) uses
open sewage disposal system in family of income group <50000 and
remaining either close or absent. In house daefication facility was
found 29.25, 90.32 and 96.67 per cent respectively and remaining either
open field or lavatory used (Table 87). During survey, it was also
focused on the type of drinking water used. Major population used tap
water (41.51, 55.91 and 68.33 per cent respectively). Later, ground
water (55.66, 33.33 and 26.67 per cent respectively). Regarding
condition of water used, more than 1/4 population (income group <
50000) consumed water without filtration and less than 0.1 per cent
population in the said income group were using disinfectants in drinking
water. Awareness was noted in families having higher income group
related to use of filtration and disinfectants in drinking water. About
less than ½ (46.23 per cent), more than ¼ (26.28 per cent) and less than
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 299
¼ (23.33 per cent) population replaced drinking water after a day in said
annual income group, respectively. The overall percentage of persons
complaining are using open fields as their toilets. Community toilets
are very limited facility availed by only less than 1 per cent persons.
Commonly toilets were seen excreting their filth directly into the sewage
channel. During the survey it was noted that more than 58.49 per cent
population in the annual income group < 50000 used drinking water
other than tap water and more than 40.86 per cent and more than 33.34
per cent population in the income group < 10000 and > 100000 used
drinking water other than tap water, respectively (Table 88 and Fig. 30).
Besides sanitary conditions and people access to safe
drinking water, survey was also made for incidence of water-borne
diseases. Total 1417 persons were surveyed in and around Beed town.
The survey realized that total population was using the water without
chlorination and a major person among income group < 50000 was
using open fields as their toilets. During survey, it was pointed out that
major population was found to be infected for one of the other water
borne diseases. The most dominant diseases of Beed town were
gastroenteritis, enteric fever, dysentery, bacterial diarrhoea, amoebiasis
and to lesser extent infective hepatitis. In children, below 14 years of
age were infected with round worms infestation which was more than
44, 41 and 31 per cent respectively, according to income group.
Gastroenteritis victims were 17.34, 14.47 and 8.67 per cent respectively
according to income group, whereas enteric fever (typhoid and
paratyphoid) case were found more than 21.93, 7.34 and 3.00 per cent
respectively during survey of the population. Another prevalent
diseases were dysentery (7.5, 6.92 and 4.67 per cent, respectively),
bacterial diarrhoea (coliform and fecal coliforms : 3.75, 2.94, 3.67per
cent respectively) and protozoal (Amoebiasis : 2.66, 2.94, 1.67 %,
respectively). Disease like infective hepatitis (1.56, 1.05 and 1.00 per
cent, respectively) was also reported in the present study. Major
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 300
population in the study area did not use any vaccination for juandice and
typhoid. Only few persons used vaccination. Awareness was found
about vaccination only in higher income group > 100000 (3.33 per cent
for juindice and 1.00 % for typhoid) (Table 89 and Fig. 31).
Data of incidence of water borne and diarrhoeal diseases
were collected from Civil Hospital, Beed for a period of three years :
2005, 2006 and 2007 (Table 90 to 92). It suggested that water borne
diseases : gastroenteritis, infective hepatitis and enteric fever were
predominant. Further, present study is also in accordance with the data
of Civil Hospital, Beed.
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 301
Table 86: Categories of family according to income group in study
area.
Annual income group
(in Rs.)
Number of families randomly
selected
Percentage
< 50000 106 40.93
< 100000 93 35.91
> 100000 60 23.16
Total 259 100.00
Table 87: Details of hygiene and sanitation in the population
Sr.
No. Total families
Annual income group of families
(in Rs.)
<50000 < 100000 >100000
1 Total members 640 477 300
2 Children below 14 years 187 95 74
3 Open sewage disposal
system in family
92 26 11
4 Percentage 86.79 27.96 18.33
5 Close sewage disposal in
family
14 67 49
6 Percentage 13.21 72.04 81.67
7 Inhouse defecation in
family
31 84 58
8 Percentage 29.25 90.32 96.67
9 Open field defecation 75 09 02
10 Percentage 70.75 9.68 3.33
Say
ed R
izw
an,
Ph
.D. T
hes
is,
Dr.
BA
MU
, A
ura
ngab
ad
Pa
ge
30
2
Tab
le 8
8:
Det
ail
s a
bo
ut
dri
nk
ing
wa
ter
use
d b
y f
am
ily
mem
ber
s in
stu
dy
are
a
Sr.
No
.
Fa
mil
ies
ha
vin
g
inco
me
gro
up
in
Rs.
Dri
nk
ing
wa
ter
Co
nd
itio
n o
f w
ate
r
Rep
lace
men
t o
f w
ate
r in
da
ys
Oth
er
sou
rce
Ta
p
Gro
un
d
wa
ter
Du
gw
ells
F
ilte
red
U
n
filt
ered
Use
of
dis
infe
cta
nts
1
2
3
4
5
6
7
1
<5
00
00
44
59
3
25
80
1
4
9
31
8
1
4
3
0
1
--
Per
cen
tag
e 4
1.5
1
55
.66
2
.83
2
3.5
8
75.4
7
0.9
4
46
.23
29
.25
7.5
5
13
.21
2
.83
--
0
.94
--
2
< 1
00
00
0
52
31
7
68
25
1
3
25
35
1
9
14
--
--
--
Per
cen
tag
e 5
5.9
1
33
.33
7
.53
7
3.1
2
26
.88
1
3.9
8
26
.88
37
.63
20
.43
1
5.0
6
--
--
--
3.2
3
3
> 1
00
00
0
41
16
4
40
19
8
1
4
26
1
4
6
--
--
--
1
Per
cen
tag
e 6
8.3
3
26
.67
6
.67
6
6.6
7
31
.67
1
3.3
3
23
.33
43
.33
23
.33
1
0
--
--
--
1.6
7
Say
ed R
izw
an,
Ph
.D. T
hes
is,
Dr.
BA
MU
, A
ura
ngab
ad
Pa
ge
30
3
Tab
le 8
9:
Inci
den
ce o
f w
ate
r b
orn
e d
isease
s a
mon
g t
he
fam
ily
mem
ber
s in
stu
dy
are
a
Sr.
No
.
Fa
mil
ies
ha
vin
g
inco
me
gro
up
in
Rs.
Wa
ter b
orn
e d
isea
ses
Ty
pe
of
va
ccin
ati
on
use
d
Dy
sen
tery
P
roto
zoa
l
(Am
oeb
iasi
s)
Ba
cter
ial
dia
rrh
oea
Ga
stro
-
ente
riti
s
Infe
ctiv
e
hep
ati
tis
(En
teri
c
fev
er)
Ty
ph
oid
an
d
pa
raty
ph
oid
Ro
un
d
wo
rm
infe
sta
tio
n
(bel
ow
14
yrs
ch
ild
)
Ja
un
dic
e
Ty
ph
oid
1
< 5
00
00
48
17
24
11
1
10
41
84
1
2
Per
centa
ge
7.5
2
.66
3.7
5
17
.34
1.5
6
21
.93
44
.92
0.1
6
0.3
1
2
< 1
00
00
0
33
14
14
69
5
35
39
18
--
Per
centa
ge
6.9
2
2.9
4
2.9
4
14
.47
1.0
5
7.3
4
41
.05
3.7
7
--
3
> 1
00
00
0
14
5
11
26
3
9
25
10
3
Per
centa
ge
4.6
7
1.6
7
3.6
7
8.6
7
1.0
0
3.0
0
33
.78
3.3
3
1.0
0
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 304
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 305
Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 306
Say
ed R
izw
an,
Ph
.D. T
hes
is,
Dr.
BA
MU
, A
ura
ngab
ad
Pa
ge
30
7
Ta
ble
90:
Inci
den
ce o
f w
ate
r b
orn
e a
nd
oth
er i
nfe
ctio
us
dis
ease
s re
gis
tere
d d
uri
ng
20
05
in
Civ
il H
osp
ita
l, B
eed
.
S
r. N
o.
Na
me
of
wa
ter b
orn
e a
nd
oth
er i
nfe
ctio
us
dis
ease
s
Ja
n.
Feb
. M
ar.
A
pri
l M
ay
Ju
ne
Ju
ly
Au
g.
Sep
t.
Oct
. N
ov
. D
ec.
1
Cho
lera
*+
--
--
--
--
--
2
--
--
--
--
--
--
2
Gas
tro
ente
riti
s*+
4
6
44
74
42
90
10
9
14
9
16
7
99
42
85
52
3
Infe
ctiv
e hep
atit
is*
1
0
6
5
6
2
16
10
6
15
14
17
15
4
Ente
ric
fever
*
6
7
8
4
7
2
9
18
31
8
13
4
5
Dia
rrho
ea*+
3
1
4
2
2
4
4
2
5
--
2
--
6
Dyse
nte
ry*+
--
--
--
--
--
1
1
--
--
--
--
--
7
Men
ingit
is
--
--
--
--
--
--
--
--
--
--
--
--
8
Mea
sles
--
--
--
2
--
1
--
--
1
--
1
1
9
Po
lio
*
--
--
--
--
--
--
--
--
--
--
--
--
10
Tet
anus
--
--
--
--
--
--
--
--
--
--
--
--
11
Vo
up
hin
g c
oug
h
--
--
--
--
--
--
--
--
--
--
--
--
*W
ater
born
e d
isea
ses,
+ d
iarr
ho
eal
dis
ease
s.
Say
ed R
izw
an,
Ph
.D. T
hes
is,
Dr.
BA
MU
, A
ura
ngab
ad
Pa
ge
30
8
Ta
ble
91
: In
cid
en
ce o
f w
ate
r b
orn
e a
nd
oth
er i
nfe
ctio
us
dis
ease
s re
gis
tere
d d
uri
ng
20
06
in
Civ
il H
osp
ital,
Beed
.
S
r. N
o.
Na
me
of
wa
ter b
orn
e a
nd
oth
er i
nfe
ctio
us
dis
ease
s
Ja
n.
Feb
. M
ar.
A
pri
l M
ay
Ju
ne
Ju
ly
Au
g.
Sep
t.
Oct
. N
ov
. D
ec.
1
Cho
lera
*+
--
--
--
--
--
--
--
--
--
--
--
--
2
Gas
tro
ente
riti
s*+
7
2
96
11
4#
61
82
82
70
41
28
44
23
47
3
Infe
ctiv
e hep
atit
is*
1
1
2
12
3
11
10
10
13
6
11
9
3
4
Ente
ric
fever
*
9
7
1
10
15
*
66
5
6
18
05
*
17
73
*
79
6*
40
9*
54
*
14
5
Dia
rrho
ea*+
4
2
1
--
3
3
2
3
1
--
2
2
6
Dyse
nte
ry*+
--
--
5
--
--
--
--
--
--
--
1
--
7
Men
ingit
is
--
--
--
--
--
--
--
--
--
--
--
--
8
Mea
sles
--
--
4
--
--
--
--
--
--
--
--
--
9
Po
lio
*
--
--
--
--
--
--
--
--
--
--
--
--
10
Tet
anus
--
--
--
--
--
--
--
--
--
--
--
--
11
Vo
up
hin
g c
oug
h
--
--
--
--
--
--
--
--
--
--
--
--
*W
ater
born
e d
isea
ses,
+ d
iarr
ho
eal
dis
ease
s,
# P
erio
d s
tart
s fo
r ch
ick
eng
uin
ea
Say
ed R
izw
an,
Ph
.D. T
hes
is,
Dr.
BA
MU
, A
ura
ngab
ad
Pa
ge
30
9
Tab
le 9
2:
Inci
den
ce o
f w
ate
r b
orn
e an
d o
ther
in
fect
iou
s d
isea
ses
reg
iste
red
du
rin
g 2
00
7 i
n C
ivil
Hosp
ital,
Beed
.
S
r. N
o.
Na
me
of
wa
ter b
orn
e a
nd
oth
er i
nfe
ctio
us
dis
ease
s
Ja
n.
Feb
. M
ar.
A
pri
l M
ay
Ju
ne
Ju
ly
Au
g.
Sep
t.
Oct
. N
ov
. D
ec.
1
Cho
lera
*+
--
--
--
--
--
--
--
--
1
--
--
--
2
Gas
tro
ente
riti
s*+
3
5
40
97
10
2
87
13
3
16
1
12
5
66
65
53
12
7
3
Infe
ctiv
e hep
atit
is*
5
6
5
8
6
1
1
5
11
8
7
10
22
4
Ente
ric
fever
*
5
13
13
11
3
8
10
17
14
11
5
12
5
Dia
rrho
ea*+
2
4
3
9
2
6
1
4
3
1
--
--
6
Dyse
nte
ry*+
--
--
1
2
--
1
--
5
--
--
--
--
7
Men
ingit
is
--
--
--
--
--
--
--
--
--
--
--
--
8
Mea
sles
--
--
--
1
--
1
--
1
--
--
--
--
9
Po
lio
*
--
--
--
--
--
--
--
--
--
--
--
--
10
Tet
anus
--
--
--
--
--
--
--
--
--
--
--
--
11
Vo
up
hin
g c
oug
h
--
--
--
--
--
--
--
--
--
--
--
--
*W
ater
born
e dis
ease
s, +
dia
rrhoea
l dis
ease
s.