15 Chapter 6 - Shodhgangashodhganga.inflibnet.ac.in/bitstream/10603/78817/15/15...Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 288 CHAPTER-6 GENERAL INFORMATION AND HEALTH

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.


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


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.


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.


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.


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


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.


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.


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.


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).


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


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


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.


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

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anus

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up

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h

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born

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, A

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ge

30

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ble

91

: In

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orn

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nd

oth

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nfe

ctio

us

dis

ease

s re

gis

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d d

uri

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20

06

in

Civ

il H

osp

ital,

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.

S

r. N

o.

Na

me

of

wa

ter b

orn

e a

nd

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nfe

ctio

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dis

ease

s

Ja

n.

Feb

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ar.

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pri

l M

ay

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ne

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ly

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10

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--

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lio

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anus

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--

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--

--

--

--

--

--

--

--

11

Vo

up

hin

g c

oug

h

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--

--

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--

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--

--

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--

--

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born

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ses,

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Tab

le 9

2:

Inci

den

ce o

f w

ate

r b

orn

e an

d o

ther

in

fect

iou

s d

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ses

reg

iste

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rin

g 2

00

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n C

ivil

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ital,

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.

S

r. N

o.

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me

of

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ter b

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nd

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nfe

ctio

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ease

s

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n.

Feb

. M

ar.

A

pri

l M

ay

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ne

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ly

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g.

Sep

t.

Oct

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ov

. D

ec.

1

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lera

*+

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tro

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7

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5

6

5

8

6

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1

5

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8

7

10

22

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ric

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13

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12

5

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--

--

--

--

--

--

--

8

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sles

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--

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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.

Documents

15 Chapter 6 - Shodhgangashodhganga.inflibnet.ac.in/bitstream/10603/78817/15/15...Sayed Rizwan, Ph.D. Thesis, Dr. BAMU, Aurangabad Page 288 CHAPTER-6 GENERAL INFORMATION AND HEALTH