National Health Programs of India

The National Health Programs of India are a group of initiatives designed to reduce the burden of communicable and noncommunicable diseases, improve nutritional status, and strengthen the public health infrastructure across the country. These programs are primarily implemented through the National Health Mission (NHM), which includes the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM).

Communicable disease control programs focus on the surveillance, prevention, and treatment of infectious diseases that significantly impact morbidity and mortality.

Overview

• Centralized public health initiative managed by the National AIDS Control Organisation (NACO) under the Ministry of Health and Family Welfare
• Focuses on preventing HIV transmission, providing universal access to antiretroviral therapy (ART), and managing sexually transmitted infections through a multi-tiered administrative and clinical framework
• Organized through the NACO at the center and State AIDS Control Societies at the state level
• Monitoring is conducted via HIV Sentinel Surveillance, which aims to identify missing cases and track the burden of the epidemic

Targets and objectives

The current phase of the program emphasizes the 95-95-95 targets to be achieved by 2030:

• 95% of people living with HIV should know their status.
• 95% of those diagnosed should be receiving sustained ART.
• 95% of those receiving ART should have viral suppression.
• Universal ART: India follows a "test and treat" policy, where ART is initiated for all individuals diagnosed with HIV, regardless of their CD4 count or clinical stage.

Framework & structure ART Services

• 1. Subdistrict/Community Health Centre (CHC) level
  • Facility: link ART centers with link workers
  • Role: encourage HIV treatment uptake and ensure patient adherence to therapy
• 2. District level
  • Facility: ART centers (usually in district hospitals)
  • Role: provide first-line antiretroviral therapy (ART)
• 3. Tertiary level
  • Facility: ART plus centers (e.g., in tertiary care hospitals and medical colleges)
  • Role: provide second-line ART
• 4. Apex level
  • Facility: centers of excellence
  • Role: Develop treatment guidelines and carry out research activities

Diagnostics and screening

HIV testing in India is primarily conducted through Integrated Counselling & Testing Centres (ICTC).

Integrated counseling & testing center (ICTC)

• Main functions
  • Pre- and post-test counselling
  • Confidential HIV testing, free of cost
  • Referral for treatment, care, and/or support for HIV-positive individuals
  • Promotion of prevention measures
• Structure
  • Fixed
    • Facility-based ICTCs
    • Stand-alone ICTCs
  • Mobile ICTCs

Screening tests

• ELISA: most sensitive screening test
• Rapid test: utilizes immuno-concentration techniques
• Spot test: uses dried blood spots for field testing

Diagnostic and confirmatory tests

The investigation of choice for confirmation involves three screening tests; an individual is considered positive if all three samples are reactive.

• Western blot: highly specific confirmatory test
• qPCR HIV-1: used for assessing viral load and diagnosing infants
• RTPCR and viral isolation

Screening protocols

• Blood donations
  • Unlinked anonymous testing is performed
  • Unit is discarded if any one of three samples is positive
• Symptomatic individuals: referral for confirmation if two of three samples are positive
• Asymptomatic individuals: referral for confirmation only if all three samples are positive
• Antenatal care: "Opt-out" testing is the standard protocol for pregnant women.

Treatment regimens

Standardized ART regimens are based on the patient's age and weight. Viral load is the preferred marker to assess response to ART, followed by CD4 count.

• Individuals < 6 years and < 20 kg: abacavir + lamivudine + raltegravir (ALR)
• Individuals 6–10 years and 20–30 kg: abacavir + lamivudine + dolutegravir (ALD)
• Individuals > 10 years and > 30 kg: tenofovir + lamivudine + dolutegravir (TLD)

Prevention of transmission

Post-exposure prophylaxis (PEP)

• Indication: primarily for needle stick injuries
• Regimen: TLD (tenofovir 300 mg + lamivudine 300 mg + dolutegravir 50 mg) daily for 28 days.
• Timing: must be started within 72 hours of exposure (ideally < 2 hours)

Pre-exposure prophylaxis (PrEP)

• Indication: high-risk individuals (e.g., IV drug users, sexual behavior with high risk)
• Regimen: tenofovir (TDF) + emtricitabine.

Mother-to-child transmission

• Infant prophylaxis of babies exposed to HIV
  • Low risk (maternal viral load < 1,000 copies/mL and ART ≥ 4 weeks): nevirapine (NVP) for 6 weeks
  • High risk (maternal viral load > 1,000 copies/mL or ART < 4 weeks): NVP + zidovudine for 6 weeks or 12 weeks
• Breastfeeding
  • Exclusive breastfeeding for 6 months is encouraged.
  • If the child is HIV-positive, breastfeeding continues for 2 years; if HIV-negative, it continues for 1 year.
• Vaccination
  • Vaccines should all be given to the child according to schedule
  • Live vaccines should not be given if:
    • Individual is experiencing symptoms of HIV
    • Individual has stage 3 or 4 HIV
    • CD4 count is < 200/mm³
    • Relative CD4 count is < 15%

Managing complications

Tuberculosis coinfection

Tuberculosis (TB) is a common opportunistic infection in people living with HIV; the NTEP and NACP are highly integrated for management.

• Screening: CBNAAT is the investigation of choice to rule out TB in all HIV cases.
• Prophylaxis
  • TB preventive therapy is provided to all HIV cases after ruling out active TB.
  • Rifabutin has replaced rifampicin.
• Timing of ART
  • Generally started 2 weeks after initiating anti-tuberculosis treatment to reduce the risk of immune reconstitution inflammatory syndrome
  • Exception: in case of TB meningitis, ART is delayed for 8 weeks

Pneumocystis jirovecii prophylaxis

• Risk of infection: CD4 count < 200/mm³
• Prophylaxis should be initiated if CD4 count is < 350/mm³ and can be halted if CD4 count is > 350/mm³ on 2 occasions that are more than 6 months apart and the patient does not have WHO clinical stage 3 or more
• Regimen: double-strength cotrimoxazole (sulphamethoxazole 800 mg + trimethoprim 160 mg)

HIV sentinel monitoring

Sentinel monitoring is aimed at finding missing HIV cases and is conducted at RTI/STI treatment centers, which are managed at Suraksha clinics using a presumptive, symptom-based approach with color-coded kits.

• Grey kit (1): cervicitis and/or cervical discharge
• Green kit (2): bacterial vaginosis
• White kit (3): genital ulcers
• Blue kit (4): genital ulcers in combination with penicillin allergy
• Red kit (5): viral genital ulcers
• Yellow kit (6): abdominal pain, pelvic inflammatory disease
• Black kit (7): inflamed inguinal lymph nodes
• Brown kit (8): anorectal discharge

HIV surveillance burden

• High-risk groups (e.g., prison inmates, sex workers, people sharing needles)
  • Have highest probability of acquiring or transmitting HIV
  • Represent where the infection might be concentrated
• Bridge population (e.g., transport workers, construction workers, clients of sex workers)
  • Interacts with high-risk groups and have partners in the general population, so they act as a bridge for transmission
  • Can help understand how the infection spreads outward
• General population (e.g., married couples, blood donors, women attending antenatel clinics)
  • Usually have no specific high-risk behavior
  • Represents the background prevalence in a society and how widespread the diease has become

Overview

• Formerly known as the RNTCP;
• India's strategic initiative to eliminate tuberculosis
• Primary goal: "TB Mukti Bharat" (TB-free India) by 2025, five years ahead of the global Sustainable Development Goals target
• Emphasizes early diagnosis via molecular testing, fixed-dose combination therapy, and financial incentives to improve patient adherence and nutritional status

Targets and objectives

The NTEP has established specific benchmarks for eliminating TB in India, measured against baseline data from 2010.

• WHO's goal: end TB by 2035
• UN's goal: Sustainable Development Goals by 2030
• India's goal: TB Mukti Bharat by 2025 (updated to 2027)

TB Mukti Bharat goals

• Mortality: > 90% reduction in the number of TB deaths
• Incidence: > 80% reduction in the TB incidence rate
• Economic impact: zero catastrophic costs due to TB for affected families

Administrative structure and surveillance

The NTEP utilizes a multi-tiered administrative structure and digital platforms for monitoring.

Administrative structure

1. Central level: MoHFW with the central TB division
2. State level: state TB cell
3. District level: district TB centre, which functions as the main administrative unit
4. Block level/CHC: TB unit, which covers a population of about 2–5 lakh and includes staff such as the Medical Officer, Senior Treatment Supervisor (STS), and Senior TB Laboratory Supervisor (STLS)
5. Peripheral level
   • TB testing center: usually one per 10,000 population; supervised STLS
   • TB treatment center: provide DOT; supervised by STS

Surveillance

• Notification: Nikshay software is used for mandatory reporting of all TB cases
• Compliance monitoring
  • 99DOTS: mobile phone-based system for tracking medication adherence
  • MERM: medication event reminder management system

Case definitions

Patients are categorized based on clinical presentation and drug sensitivity to determine the appropriate treatment course.

Presumptive TB case

Defined as an individual presenting with one or more of the following symptoms for > 14 days:

• Fever
• Cough
• Night sweats
• Unexplained weight loss

Drug-sensitive TB

• Patient is sensitive to first-line drugs: isoniazid (H), rifampicin (R), pyrazinamide (Z), ethambutol (E)

Drug-resistant TB (DRTB) categories

• H-mono/poly DRTB: resistant to H; sensitive to R
• Rifampicin-resistant TB (RR-TB): resistant to R
• Multidrug-resistant TB (MDR-TB): resistant to both H and R
• Pre-extensively drug-resistant (Pre-XDR TB): resistant to H, R, and a fluoroquinolone
• Extensively drug-resistant TB (XDR TB): resistant to H, R, a fluoroquinolone, and at least one Group A drug (bedaquiline, linezolid, moxifloxacin, levofloxacin)

Diagnostics

The NTEP prioritizes rapid molecular testing to ensure early detection and the identification of drug resistance.

• Sputum microscopy for acid-fast bacilli
  • Screening test of choice with great sensitivity and good specificity
  • Uses Ziehl-Neelsen or fluorescent auramine-rhodamine staining
  • Requires a minimum of 5 mL of expectorated sputum and two samples (spot and morning)
• CBNAAT
  • Universal diagnostic test of choice
  • Provides results in 90 minutes and simultaneously detects rifampicin sensitivity
  • Can utilize urine, sputum, and body tissue as a sample, but not feces or blood
• Tru-NAAT: a cost-effective alternative to CBNAAT with similar sensitivity and specificity
• Culture
  • Gold standard for diagnosis
  • Liquid culture is preferred over solid culture for faster results
• Chest x-ray: used for screening but is not considered diagnostic on its own

Management

Drug-sensitive TB

Treatment is delivered using fixed-dose combinations based on patient weight bands.

• NTEP regimen
  • Intensive phase (2 months): 56 doses of HRZE
  • Continuation phase (4 months): 112 doses (16 weeks) of HRE
  • Adjuvant therapy: Pyridoxine (25–50 mg/day for adults; 10 mg/day for children) is administered with isoniazid to prevent peripheral neuropathy.
• CDC regimen: See "Antituberculosis therapy."

Drug-resistant TB

DRTB requires specialized, longer regimens and often involves the use of newer antitubercular agents.

• Shorter MDR regimen: 4–6 months of bedaquiline, levofloxacin, linezolid, clofazimine, pyrazinamide, ethambutol, and high-dose isoniazid, followed by 5 months of levofloxacin, clofazumine, pyrazinamide, and ethambutol
• Longer MDR regimen: 18–20 months of levofloxacin, bedaquiline, linezolid, clofazimine, and cycloserine
• BPaLM regimen: a 6-month trial regimen for MDR-TB using bedaquiline, pretomanid, linezolid, and moxifloxacin

Outcomes

• Treatment completed: patient has completed prescribed treatment regimen, but no sputum test is available at the end of the treatment
• Loss to follow up: treatment was started but was interrupted for 4 weeks or more
• Treatment failure
  • Patient who initially was sputum-negative later becomes sputum-positive again during treatment OR
  • Sputum remains positive at the fifth month of treatment or later
• Recurrent tuberculosis: patient had previously completed treatment successfully, but sputum became positive for tuberculosis again at any time later
• Cured: full course of anti-tubercular treatment has been completed, and sputum examination at the end of treatment is negative for TB

Prophylaxis

Tuberculosis preventive therapy is given to individuals at high risk of developing TB but do not have active disease, i.e., active TB must be ruled out.

Indications

• High-risk groups, including:
  • Healthcare workers with repeated occupational exposure to TB
  • Patients on dialysis
  • Patients undergoing or preparing for organ transplantation
  • Patients with silicosis
  • Individuals receiving immunosuppressive therapy
  • Homeless individuals
• People living with HIV (PLHIV)
• Household contacts of a patient with active tuberculosis

Standard regimen

• Isoniazid daily for 6 months
• Pyridoxine to reduce risk of peripheral neuropathy

Newer short-course regimens

• 3HP regimen: isoniazid + rifapentine once weekly for 3 months (total of 12 doses)
• 1HP regimen
  • Isoniazid + rifapentine daily for 1 month (total of 28 doses)
  • Recommended only for PLHIV and children living with HIV
  • Usually used in individuals > 13 years of age

Screening for latent tuberculosis infection

• For information on tuberculin skin testing and interpretation of its results, see "Purified protein derivative tuberculin skin test."

BCG vaccination

• For information about the BCG vaccination, see "Bacillus Calmette-Guérin vaccine."

Incentives and support

Financial support is provided to patients, informants, and providers to improve notification and treatment completion rates.

• Patient (Nikshay Poshan Yojana): ₹3,000 every 3 months (delivered in 2 installments)
• Informant : ₹500
• Treatment completion
  • DSTB: ₹1,000
  • DRTB: ₹5,000

Overview

• Launched in 2004
• Targets four primary mosquito genera, each with distinct biological characteristics and habitat preferences that dictate specific control strategies
• Umbrella program for the prevention and control of vector-borne diseases in India: malaria, dengue, Japanese encephalitis, chikungunya, kala-azar , and lymphatic filariasis
• Coordinates with the IDSP for rapid reporting and response to disease outbreaks (for more information about the IDSP, see "Integrated Disease Surveillance Program.")

Disease control objectives

• Annual parasite incidence: less than 1 per 1000 population
• Annual blood examination rate: greater than 10%
• Microfilaria rate: less than 1% in children
• Disease control: control Japanese encephalitis, Kala-azar, dengue, and chikungunya
• Integrated vector management: achieve effective vector control using biological, chemical, and environmental interventions (see below)

Strategy

The strategy focuses on reducing disease burden through integrated vector management, early case detection and complete treatment, and community-based prevention strategies.

Integrated vector management (IVM)

IVM is a strategy utilized by the NVBDCP to achieve effective control of vectors and includes:

• Anti-adult methods
  • Residual spray
    • Malathion: applied 3–4 times per year; most common
    • Dichloro-diphenyl-trichloroethane: applied biannually; now obsolete
  • Space spray (fogging)
    • Pyrethrum: more costly than alternatives
    • Synthetic pyrethroids (deltamethrin or cyfluthrin): most commonly used due to lower cost
• Anti-larval methods
  • Chemical: paris green (stomach poison), malathion and temephos (contact poisons)
  • Biological: Gambusia affinis, Poecilla reticulata, and Bacillus thuringiensis
  • Physical: larvicidal oils
• Source reduction: elimination of mosquito breeding sites (e.g., draining stagnant water, filling ditches, deweeding)
• Personal protection
  • Long-lasting insecticidal nets: distribution of bed nets treated with long-acting insecticides, particularly in high-transmission areas
  • Repellents and protective clothing: promotion of mosquito repellents (e.g., DEET) and wearing light-colored, skin-covering clothing during peak biting times.

Malaria

• See "Malaria" for information on diagnosis, different Plasmodium species, and treatment.
• Malaria monitoring relies on metrics that assess both the intensity of transmission and the quality of surveillance.

Pathogens

• Main parasites
  • Plasmodium vivax
  • Plasmodium falciparum
• Occasionally found
  • Plasmodium knowlesi
  • Plasmodium malariae
  • Plasmodium ovale

Malarial indicators

• Annual Parasite Incidence (API)
  • Number of confirmed malaria cases per 1,000 population per year
  • Serves as the main measure of overall malaria burden and the effectiveness of malaria control programmes
• Slide Positivity Rate
  • Percentage of examined blood slides (or rapid diagnostic tests) that test positive for malaria parasites
  • Considered the most sensitive indicator for identifying outbreaks
• Annual Blood Examination Rate
  • Percentage of the population screened for malaria (by microscopy or rapid diagnostic test) in a year
  • Provides insight into the level of surveillance activity and underlying fever prevalence

Treatment

Overview

• Definitive therapy includes
  • Chloroquine (CQ)
  • Artemisinin-based combination therapy (ACT)
• Primaquine (PQ)
  • Helps prevent relapse
  • Contraindications: pregnancy, G6PD deficiency, and infants

Treatment based on infecting Plasmodium species

• Plasmodium vivax
  • CQ 25 mg/kg over 3 days (day 1: 10 mg/kg; day 2: 10 mg/kg; day 3: 5 mg/kg)
  • PQ 0.25 mg/kg
  • Regimen: 3-day CQ + 14-day PQ course
• Plasmodium falciparum
  • PQ 0.75 mg/kg single dose on day 2
    • ACT regimen:
      • Northeastern states: artemether + lumefantrine (ACT-AL)
      • Other states: artesunate + sulfadoxine + pyrimethamine (ACT-SP)
  • Regimen: PQ (Day 2) + ACT (3 days)
• Mixed infection (vivax + falciparum)
  • PQ 0.25 mg/kg
  • ACT regimen:
    • Northeastern states: ACT-AL
    • Other states: ACT-SP
  • Regimen: PQ × 14 days + ACT × 3 days
• Uncomplicated falciparum malaria in pregnancy
  • PQ contraindicated
  • First trimester: oral quinine salts for 3 days
  • Second and third trimesters: ACT for 3 days:
    • Northeastern states: ACT-AL
    • Other states: ACT-SP
• Vivax malaria in pregnancy
  • PQ contraindicated
  • Regimen: CQ × 3 days

Prophylaxis

• Short-term travel (< 6 weeks)
  • Doxycycline daily
  • Start: 1–2 days before travel; continue throughout travel
  • After return: continued for 4 weeks
• Long-term travel (> 6 weeks):
  • Mefloquine weekly
  • Start: 1–2 weeks before travel, continue throughout travel
  • After return: continued for 4 weeks

Lymphatic Filariasis

• See "Lymphatic filariasis" in "Helminth infections" for information on pathogens, mode of transmission, and clinical features.

Diagnosis

• Peripheral blood examination
  • Microfilariae are best detected in night blood samples due to nocturnal periodicity
  • Optimal collection time: 10 PM–2 AM
• Concentration techniques
  • Membrane filtration (highest sensitivity)
  • Knott concentration method
• DEC provocation test
  • Utilized when routine microscopy is inconclusive
  • Procedure: Diethylcarbamazine (DEC) 100 mg is given orally, then a blood examination is performed after approximately 1 hour

Prevention and Control

• Mass drug administration
  • Typically conducted twice yearly using a combination therapy:
    • DEC: 6 mg/kg/day in divided doses
    • Albendazole: 400 mg (for individuals > 2 years)
    • Ivermectin: 150–200 µg/kg (generally for individuals ≥ 5 years)
• Additional public health measures
  • Deworming campaigns: Albendazole administered during national deworming days (e.g., February and August)
  • Fortification strategy: Use of DEC-medicated salt (approximately 1–4 g DEC per kg of salt) in endemic areas

Elimination strategies

• Based on an integrated vector management approach, combining vector control with preventive chemotherapy
• Goal: elimination of lymphatic filariasis as a public health problem by 2027

Kala-azar (Leishmaniasis)

• See "Leishmaniasis" for information on pathogens, mode of transmission, and treatment.

Diagnosis

• Screening: rK39 serological test
• Confirmatory test: demonstration of parasites on microscopy from splenic aspirate (gold standard test)

Dengue

• See "Dengue" for information on pathogens, mode of transmission, clinical features, and treatment.

Indicators

• Breteau index
  • Number of containers with Aedes larvae per 100 houses inspected
  • Indicates the risk of dengue transmission and outbreaks
• Aedes aegypti index (AAI)
  • Percentage of houses infested with Aedes aegypti mosquitoes.
  • EYE strategy: for yellow fever prevention, the target is an Aedes aegypti index below 1 within 400 m of international airports and seaports

Diagnosis

• Days 0-5: NS1 antigen test and/or RT-PCR
• Day 5: IgM ELISA preferred over NS1 antigen test
• From day 5 onward: IgM ELISA

Japanese encephalitis

• See "Japanese encephalitis" for information on pathogens, mode of transmission, and clinical features.

Affected regions

• Predominantly seen in rural and agricultural regions of northern, northeastern, and southern India
• Especially in states such as Karnataka, Tamil Nadu, West Bengal, Assam, Bihar, and Uttar Pradesh

Prevention

• JENVAC vaccine
  • Inactivated vaccine; Kolar strain
  • Vaccine is freeze-sensitive, does not require reconstitution, and is equipped with a vaccine vial monitor.
  • Protection against all known strains of Japanese encephalitis
  • Injection: 0.5 mL IM into the deltoid (adults) or thigh (young children)
  • Vials can be reused according to the open vial policy
  • Schedule: 2 doses administered at 9 months and 16–24 months

Overview

• Centralized health initiative focused on the elimination of leprosy as a public health problem in India
• Emphasizes early case detection, standardized multidrug therapy (MDT), and the prevention of disability
• Vision of the program: a Leprosy Mukt Bharat (leprosy-free India) by 2027

Targets and goals

The NLEP uses specific indicators to monitor progress toward elimination, with India having achieved initial elimination status in 2015.

• Prevalence rate: < 1 per 10,000 population.
• Annual new case detection rate: < 10 per lakh population.
• Grade 2 disability rate: < 1 per million population (considered the best indicator for general population monitoring).
• Cure rate: > 85%
• Disability target: zero disability among new child leprosy cases and no stigma or discrimination against persons affected by leprosy.

Case definition and diagnosis

A case of leprosy is identified by the presence of at least one of the three cardinal features:

• Skin lesions: hypopigmented or reddish skin lesions with definite hypoanesthesia
• Nerve involvement: involvement of peripheral nerves with definite thickening and loss of sensation or muscle weakness
• Microscopy: demonstration of M. leprae in slit-skin smears (SSS)

Classification and MDT

Patients are classified into two categories based on clinical and diagnostic criteria to determine the duration of MDT.

Standard MDT regimen

• Rifampicin: 600 mg once a month (supervised)
• Dapsone: 100 mg daily (unsupervised)
• Clofazimine: 300 mg once a month (supervised) and 50 mg daily (unsupervised)

Prevention and contact prophylaxis

To prevent the transmission of leprosy, a single dose of rifampicin is administered as prophylaxis to eligible contacts of a confirmed leprosy patient.

• Household contacts: individuals living in the same house for > 6 months in the last year
• Social contacts: individuals sharing the same closed space for > 20 hours per week
• Neighborhood contacts: individuals living in the three houses on each side of the patient’s residence

Surveillance and support initiatives

• Nikusth 2.0: A unified digital platform for leprosy reporting, tracking, and case management.
• ABSULS (ASHA-Based Surveillance for Leprosy Suspects): A community-level screening approach that engages ASHA workers to identify suspected leprosy cases.
• Welfare allowance: Patients who undergo reconstructive surgery receive a financial assistance amount of ₹12,000.
• Mascots: The initiative features Sapna (national mascot) and Meena for awareness and outreach campaigns.

Overview

• Specialized initiative launched in 1995 to oversee the eradication of poliomyelitis in India
• Successfully achieved polio-free status for India, which was officially certified by the WHO on March 27, 2014, through intensive immunization campaigns and a rigorous surveillance network
• Organized at a district level

Eradication milestones

The program monitors the eradication of specific wild poliovirus strains. The last recorded cases for each strain in India were:

• WPV2 (Type 2): October 24, 1999 (Uttar Pradesh)
• WPV3 (Type 3): October 22, 2010 (Jharkhand)
• WPV1 (Type 1): January 13, 2011 (West Bengal)

Vaccination strategy and endgame plan

The program has transitioned its vaccination strategy to minimize the risk of vaccine-derived polio and ensure long-term immunity.

• National Switch Day (April 25, 2016): switch from the trivalent oral polio vaccine to the bivalent oral polio vaccine to reduce the risk of type 2 vaccine-derived poliovirus
• Inactivated Polio Vaccine (IPV)
  • Introduced to provide safe, systemic immunity
  • Current schedule utilizes the fractional inactivated polio vaccine (fIPV) administered intradermally at 6 weeks, 14 weeks, and 9 months
  • 3rd dose was introduced on January 1, 2023

Course of the disease

• 90–95% of cases are asymptomatic.
• 4–8% of cases are self-limiting.
• 1% of cases are complicated by non-paralytic aseptic meningitis.
• < 1% of cases results in paralytic polio.

Acute Flaccid Paralysis (AFP) surveillance

• It is the primary indicator of a country's ability to detect polio
• Involves the clinical identification and laboratory investigation of any child < 15 years of age presenting with sudden-onset flaccid paralysis

Investigation protocol

• Reporting: AFP must be reported within 48 hours of identification.
• Stool collection: Two "adequate" stool samples (each > 8 grams) must be collected 24 hours apart and within 14 days of the onset of paralysis.
• Reverse cold chain: Samples must be maintained at 2–8°C and reach the laboratory within 72 hours.
• Follow-up: A check for residual paralysis is conducted after 60 days.

AFP surveillance indicators

The effectiveness of the surveillance system is evaluated using specific performance targets.

• Sensitivity: > 1 AFP case per lakh population < 15 years per year
• Efficacy of operation: Samples reach the laboratory within 72 hours of collection.
• Completeness of case investigation: adequate collection of stool samples in > 80% of reported cases
• Comprehensiveness of follow-up: > 80% of cases checked for residual paralysis after 60 days

Differential diagnosis of AFP

• Poliomyelitis
• Guillain-Barré syndrome
• Botulism
• Traumatic neuritis
• Spinal cord compression
• Transverse myelitis
• Enterovirus A71 infection

Polio vaccine comparison

The program utilizes two types of vaccines with distinct immunological properties.

NCD and disability programs focus on chronic conditions that require long-term management and secondary prevention.

Overview

• Population-based screening and management initiative in India
• Focuses on lifestyle modifications and early screening via NCD clinics.
• Program has been expanded to include a wider range of chronic conditions and is integrated with primary healthcare services, including AYUSH
• Coordinates with other national programs, such as the NTEP

Program scope and integration

The program focuses on the early detection and management of the most prevalent chronic diseases in India.

• Core diseases: Cancer (breast, cervical, oral), diabetes mellitus, cardiovascular diseases, and stroke.
• Expanded scope: Includes chronic obstructive pulmonary disease (COPD), rheumatic fever, chronic kidney disease (CKD), and non-alcoholic fatty liver disease (NAFLD).
• Integration: Services are integrated with the Ayushman Bharat Health and Wellness Centres (HWCs) to provide comprehensive primary care.

National targets for NCD reduction

In alignment with the WHO Global Action Plan (extended to 2027), India has established specific targets for the reduction of NCD risk factors and outcomes.

• 30% reduction: salt consumption, smoking prevalence
• 25% reduction: premature deaths from NCDs, hypertension
• 10% reduction: alcohol consumption, physical inactivity

Obesity and anthropometric indicators

Obesity is a major risk factor for NCDs and is monitored using specific clinical measurements.

• Body mass index (BMI)
  • Also known as the Quetelet index
  • Normal range for South Asians is 18.5–22.9 kg/m².
• Broca’s index
  • Calculated as Height (cm) - 100
  • Used to estimate ideal body weight.
• Corpulence index: calculated as actual weight / desirable weight.

Criteria for obesity

Obesity is defined by specific cut-off points for waist circumference and skin-fold thickness (measured using Harpenden calipers at the triceps, biceps, subscapular, and suprailiac regions).

Cancer surveillance and registry

The program utilizes the National Cancer Registry Program to monitor cancer trends across the country.

• Most common cancers in India (incidence):
  • Males: lip/oral cavity > lung > stomach/esophagus
  • Females: breast > cervical > ovarian
  • Overall: breast > lip/oral cavity > cervical
• Mortality: Breast cancer accounts for the highest mortality rate (25%) among cancers in India.

Overview

• Specialized initiative focused on the prevention and control of iodine deficiency disorders (IDD).
• Evolved from the national goiter control program, which was launched in 1962, and was renamed NIDDCP in 1992 to reflect the broader spectrum of disorders caused by iodine deficiency

Targets and goals

• Primary objective: reduce the prevalence of iodine deficiency disorders to a level where they are no longer a public health problem.
• Target: Achieve a total goiter rate (TGR) of < 5% in the population.

Strategy: universal salt iodization

The core strategy of the program is the mandatory iodization of all edible salt for human consumption.

• Production level: Salt must contain > 30 ppm of iodine at the manufacturing stage.
• Consumer level: Salt must contain > 15 ppm of iodine at the household/retail level to account for losses during distribution and storage.

Monitoring and indicators

The program utilizes four specific indicators to monitor progress and assess the impact of interventions.

Assessment of goiter severity

Goiter is assessed through physical examination (palpation and inspection) and categorized into three grades.

• Grade 0: no palpable or visible goiter
• Grade 1: A mass in the neck that is palpable but not visible when the neck is in the normal position; it moves upward with deglutition.
• Grade 2: A swelling in the neck that is visible when the neck is in a normal position and is consistent with an enlarged thyroid gland on palpation.

Classification of IDD severity

The severity of iodine deficiency in a region is determined by the TGR and the median urinary iodine excretion (UIE).

Overview

• Specialized health initiative aimed at reducing the prevalence of blindness through cataract surgeries, refractive error correction, and eye donation awareness.
• Focuses on cataract surgery, the distribution of free spectacles, and the prevention of nutritional and infectious causes of blindness

Targets and goals

The NPCBVI has established specific benchmarks to improve the accessibility and quality of eye health services across the country.

• Blindness rate: Target < 0.25% (current prevalence: 0.36%)
• Cataract surgery rate (CSR): Target > 3,000 per million per year
• Bitot spots rate: Target < 0.5% (as a proxy for Vitamin A deficiency control)

Organization

The program follows a decentralized administrative structure to ensure service delivery at the primary care level.

• Central level: policy and planning
• State level: coordination and resource allocation
• District level: implementation through the District Blindness Control Society (DBCS)
• PHC level: screening and referral by the medical officer

Netra Jyoti Abhiyan (2025)

This recent campaign focuses on intensifying eye care services to ensure "Eye health for all."

• Spectacles: provision of free spectacles for refractive errors
• Cataract surgery: intensified efforts to provide free cataract surgery, particularly for individuals aged > 50 years
• Eye donation: organizing the Intensified Eye Donation Fortnight (August 25 – September 8) to increase corneal transplants.
• CSR target: Emphasizing the achievement of a CSR > 3,000 per million per year.

Organisation of eye care centers

Eye care centers in India, listed from most to least numerous, with increasing levels of specialization:

• Vision centers with optometrists that do basic eye care and refractive error correction
• Service centers with ophthalmologists that do minor eye surgery and basic specialist eye care
• Training centers with ophthalmologists that do major eye surgeries (e.g., corneal transplants) and specialized eye care
• Centers of excellence with senior ophthalmologists that are involved in conferences, continuous medical education, as well as research, drawing up guidelines, and program management

Classification of visual impairment

Visual impairment is categorized based on the presenting visual acuity in the better eye with the best possible correction.

WHO Classification

• Normal (category 0): ≥ 6/18
• Visual impairment (category 1): < 6/18–6/60
• Severe visual impairment (category 2): < 6/60–3/60
• Blind (categories 3–5): < 3/60 to no light perception

Common causes of visual impairment and blindness

The primary causes of eye health issues vary significantly depending on the age of the individual.

School health and nutrition programs in India focus on improving the physical health, nutritional status, and educational outcomes of children through environment-based standards, screening services, and specialized feeding programs.

School health services

Launched in 1909, school health services are integrated into the primary health care system to ensure regular screening and a healthy learning environment. The medical officer of the local primary health centre is in charge of overseeing school health services.

• Land area standards
  • Primary school: minimum ≥ 1 acre
  • Higher secondary school: minimum ≥ 1.5 acres
• Classroom standards
  • Capacity: maximum of 40 students per classroom
  • Environment
    • Walls should be white
    • Light should enter from the left side
  • Furniture: Desks should be of the "minus type."
• Sanitation standards
  • Urinals: 1 for every 60 students
  • Latrines: 1 for every 100 students

POSHAN Abhiyaan (National Nutrition Mission)

The POSHAN Abhiyaan (Prime Minister's Overarching Scheme for Holistic Nourishment) is a multi-ministerial initiative aimed at improving the nutritional status of children, adolescent girls, and pregnant/lactating women. It is jointly managed by the Ministry of Health and Family Welfare (MoHFW) and the Ministry of Women and Child Development (MoWCD).

• Key metrics
  • Low birth weight (LBW): reduce prevalence by 2% per year
  • Anemia: reduce prevalence by 3% per year
• Integration: The program is integrated with the Anemia Mukt Bharat strategy, national nutritional meals, and the Anganwadi (ICDS) system.

Pradhan Mantri Poshan Shakti Nirman (PM POSHAN)

Formerly known as the Mid-Day Meal Scheme, PM POSHAN (POshan SHAKti Nirman) provides hot cooked meals to students to improve nutritional levels and increase school enrollment. It is managed by the Ministry of Education.

• Beneficiaries: children in Balvatika (pre-school) and classes I–VIII.
• Nutritional norms per day
  • Primary classes (I–V): 450 kCal and 12 g of protein
  • Upper primary classes (VI–VIII): 700 kCal and 20 g of protein

Specialized school health interventions

• Weekly iron-folic acid supplementation: provided to adolescents (10–19 years) to prevent anemia
• National deworming day: biannual administration of albendazole in schools and Anganwadi centers to control soil-transmitted helminthic infections
• RBSK screening: See "Rashtriya Bal Swasthya Karyakram" for more information.

Overview

• Decentralized system aimed at detecting early warning signals of outbreaks through syndromic, presumptive, and laboratory-confirmed surveillance
• Operates under the Ministry of Health and Family Welfare
• Recently transitioned into a more advanced digital format known as the Integrated Health Intelligence Platform (IHIP)

Objectives and Reporting

• Primary goal: provide early warning signals for impending outbreaks and to facilitate a rapid response
• Reporting frequency: Data is collected and reported through 52 weekly reports per year.
• IHIP: The digitized version of IDSP, managed under the National Centre for Disease Control, which allows for timely reporting and analysis.

Types of Surveillance

The program utilizes a tiered approach to surveillance, depending on the personnel involved and the tools available for diagnosis.

• Laboratory surveillance: performed by laboratories and reported through lab results and diagnostic tests
• Presumptive surveillance: done by clinicians at health centers and hospitals in the form of clinical history and physical examination
• Syndromic surveillance: carried out by health workers (e.g., ASHA, ANM) who identify clinical syndromes during field surveys

Monitored syndromes

The IDSP monitors specific clinical syndromes that act as indicators for potentially infectious outbreaks.

• Fever: monitored as a general indicator for several infectious diseases (e.g., malaria, dengue)
• Cough: specifically, cough of < 2 weeks duration
• Jaundice: an indicator for viral hepatitis outbreaks
• Acute diarrhea: defined as the passage of ≥ 3 loose stools per day
• Acute flaccid paralysis: monitored in children < 15 years of age to track potential polio transmission
• Unusual events: any unexplained clusters of disease or events causing sudden death or hospitalization in the community

Primary Prevention (1° level)

• Measures taken to prevent the occurrence of disease
• In certain contexts, screening healthy populations to prevent transmission is considered primary prevention for the community.
• Examples include:
  • Prospective/predictive screening: Identifying at-risk individuals before disease onset or entry into a population
  • Pre-employment medical checks: Ensuring health standards for specific roles, such as screening chefs and food handlers for typhoid to prevent community outbreaks
  • Airport/port health screening: Implementing COVID-19 screening or yellow fever checks at international points of entry to prevent the importation of pathogens
  • Immigrant screening protocols: Presumptive or systematic screening for communicable diseases (e.g., TB, Malaria, parasites) in individuals arriving from endemic regions
  • HIV screening: Routine testing in high-risk groups or mothers in antenatal care to manage infection and prevent mother-to-child transmission

Secondary Prevention (2° level):

• Measures aimed at early detection and prompt treatment of disease to halt progression and prevent complications
• Focuses on identifying disease in its asymptomatic or early clinical stage through screening
• Examples include:
  • Prescriptive screening: Systematic testing of individuals (often asymptomatic) to detect disease early and enable timely intervention
  • Fecal occult blood test: Screening for colorectal cancer by detecting occult gastrointestinal bleeding
  • Pap smear / visual inspection with acetic acid: Screening for cervical cancer by detecting premalignant or malignant changes
  • Mammography: Early detection of breast cancer in asymptomatic women
  • Urinary δ-aminolevulinic acid: Screening for lead poisoning (plumbism), especially in at-risk populations
  • Fasting blood glucose / HbA1c: Screening for diabetes mellitus
  • VDRL test: Screening for syphilis, particularly in antenatal care and high-risk groups