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Rural health program

Mortality
- Prevention of diseases by
Objectives Achieved by establishing maternal & child
health serises, school health
Morbidity
services.
- Curative services
By clinics, labs, 1st aid
services

Occupational Health

Occupational Health: is the science & art that aim at achieving optimum state of physical,
mental & social wellbeing of workers.
Types of occupational diseases:
- Occupational diseases: during doing the occupational work.
- Work related diseases: by occupational stresses as  HTN, CHD.
Prevention of diseases
Occupational health services achieved by Early detection of diseases
Promotion of health
Occupational health team: Physician, Nurse, Hygienist

Occupational health Team Duties:

1. Preplacement Examination: must be place in a suitable place

2. Prevention of accidents
3. Protective clothing
4. Rehabilitation: following injury, need physiotherapy.
5. Records: concerned diseases, accidents … Noise
6. Supervision of the work environment: by measuring level of Heat
7. Therapeutic services Radiation
8. Health education
9. Nutrition of workers Prevent diseases
10. Periodic medical Examination: every 6 months to detect early stages of diseases

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Occupational Health Diseases

A) Diseases caused by physical agents

1. Exposure to extremes of temperature Heat disorders

In building
Mining
Causes: Ovens
Improper ventilated areas
Clinical Picture

A) Heat Exhaustion exposure to heat VD of BV  Blood loss from vessels to tissues 

Blood goes to brain  loss of consciosness.
Treatment: removing the patient to cool place.
Water
B) Heat Cramps excessive sweating  loss of NaCl
Treatment: Water & NaCl

C) Heat Pyrexia Exposure to extreme heat damage to the heat regulatory center
Treatment: immersion of the patient into ice cold water.

D) Miliary Rubra (Sweat rash) Blocking of orifices of sweat gland accumulation of

sweat red popular eruptions.

Prevention of Heat disorders

Insulation of hot machines
Prevention of steam leakage
A) Environmental measures
Proper ventilation
Protective clothing

Pre-employment examination
B) Medical Measurements
Periodic medical examination
Salts & fluids intake

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B) Diseases caused by Noise

A) Air conduction deafness exposure to noise > 150 decibels  rupture of drum e.g. in
military explosions.

B) Nerve conduction deafness Prolonged exposure to noise level > 90 d.b.

Prevention: echo
1. Environmental control: Proper maintenance of machines.
2. Medical control: Periodic examination
Use of ear plugs

Occupational Health Diseases caused by abnormalities in pressure

Decompression thickness can affect  diving, building under water …

Problems that the workers suffer from:

1. During Descent: (Harmless process), it harms only if bleeding from close cavities
2. During Stay: N2 & O2 dissolving in tissues  toxicity

Slow compression (gradual compression)  no hazards

3. During Ascent
Rapid compression (Sudden compression)  Pain around
joints, dyspnea & chock.

Dyspnia: decompression illness occurring in aeroplanes during rapid ascent to upper

atmosphere
Prevention of decompression illness

Gradual decompression
A) Environmental measures
Inhalation of helium to avoid level of dissolved N2

Pre-employment examination
B) Medical Measurements
Periodic medical examination

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Diseases caused by exposure to ionizing
radiation
Occupational Exposure
- Mining - Use of radium, uranium - Accidental leakage of radiation.
- Exposure in medical field.
Effects of exposure to ionizing radiation
Acute effects
Affect the rapidly divided cells as bone marrow & intestine
Treatment supportive
Delayed effects lung cancer, Cataract, Premature aging, skin cancer, leukemia
Prevention
environmental measures:
- Isolation - use of radiation proof containers - protective clothing
Medical measures: - pre-employment examination
- Periodic medical examination
- Health education

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Occupational respiratory diseases caused by dust
(pneumoconiosis)
Silica, Asbestos, talc, coal

Silicosis
A fibrotic lung disease produced by inhalation of dust containing Silicon dioxide.
Etiology It is present in sand, sand stone & granite.
In these occupations: Mines, Porcelain manufacture & Glass industry.
Predisposing factors:
1. Duration of exposure (long period 5 — 10 years).
2. Size: Smaller dust particles are more injurious.
3. Concentration: the higher the conc. of dust  the more injurious.
4. The presence of free silica in the dust.
5. Personal susceptibility.
Pathogenesis Silica particles are ingested by alveolar macrophages  carry them to lung
tissue  macrophages disintegrate  stimulate fibroblast function & collagen formation,
- Damaged macrophages attract others that ingest released silica particles
Pathology Silicosis  nodular fibrosis, layers of collagen (ONION RING APPEARANCE)
Clinical picture DYSNEA
Complications: Tuberculosis.
Corpulmonale as a result of pulmonary hypertension, chronic bronchitis & emphysema
Diagnosis:
1. History of exposure
2. Radiological examination: Nodular shadow
3. Pulmonary function testing FVC, FEV1 below normal levels.
Prevention:
A) Environmental measures to reduce dust below TLV (Threshold Limit Value).
1. Substitution 2. Segregation. 3. Enclose of machines releasing dust.
4. Ventilation 5. Wetting Water is sprayed to precipitate dust.
6. Cleanliness 7. Protective clothes
B) Medical measures:
1. Pre-emp1oyment examination
2. Periodic medical examination 3. Health education.

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Asbestosis
Asbestos is a fibrous material obtained from mines; it has an insulating & fire protecting
characters & can resist chemicals.
Hazards:
Cement Asbestos industry (used in roofs, buildings & pipes manufacture)
During manufacture, fixation, or removal of car breaks.
Pathology Asbestos fibers can be found in the terminal bronchiols or penetrate lung tissue
 irritation & injury of lung tissues
- When coated with iron rich protieneanous material  Asbestos Bodies (found in sputum)
Predisposing Factors:
1. Duration of exposure  after 5-10 years.
2. Dose response relationship.
3. Smoking has synergistic effect in production of lung cancer & mesothelioma.
Clinical picture
Dysnea, cough & expectoration (Chest pain is an indication of involvement of pleura)
On examination Cyanosis, clubbing of fingers
Diagnosis:
1) History
2) X-RAY of the chest
Early stages  Frosted glass of cob web appearance.
Late stages  opacities appear in lower lobes, pleural fibrosis & calcifications, pleural
effusion (in mesothelioma)
3) Sputum examination: ASBESTOS BODIES, Malignant cells may also be seen.
4) Pulmonary function tests: FVC & FEV1 are reduced
5) Bronchoscopy, Lung & Pleural biopsy: to diagnose lung cancer & mesothelioma of pleura.
Complications:
1. Bronchogenic carcinoma.
2. Mesothelioma of pleura or peritoneum.
3. cor-pulmonale.

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Occupational Diseases caused by exposure to Cotton
Dust
A) Mill
Fever
Workers in cotton mills for the 1st time suffer the first week fever, muscle aches and
malaise. (Diagnosed as common cold or influenza)
Cause is unknown; may be Endotoxins of E-coli.
B)
Byssinosis
Tightness of the chest on the day following a holiday, (called MONDAY FEVER)
Exposure hazards of byssinosis
1) Ginning of cotton 2) Bale opening & bale breaking  large amounts of
dust
3) Carding 4) Spinning 5) Weaving
Predisposing Factors
1) Duration of exposure  5-10 years 2) Intensity of exposure
3) Personal susceptibility.
Pathogenesis
A) The allergic theory: On exposure to cotton dust antigen antibody reaction develops.
B) The chemical theory: assumes presence of histamine releasing substance in cotton dust
 BRONCHOSPASM
Pathology:
NON SPECIFIC
Mucous metaplasia in small airways, Mucious hyperplasia in larger bronchi
Clinical Picture:
STAGE 1/2: Tightness of chest occurring OCCASIONALLY in the day following holiday
STAGE 1: Tightness of chest occurring on EACH DAY following holiday
STAGE 2: Tightness of chest occurring on each day following holiday & EXTENDING FOR
FEW DAYS AFTER.
DIAGNOSIS
1. History of exposure 2. Clinical picture
3. Pulmonary function testing: FVC & FEV1 are reduced
Prevention
Environmental measures

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Medical measures:
1) Pre-employment examination.
2) Periodic medical examination

Epidemiology of cardiovascular diseases

Congenital heart
diseases
An abnormality in cardio-circulatory structure or function that is present at birth, even if it
is discovered much later.
Risk
factors:
1. Host factors (Genetic factors)
Offsprings of parents with CHD have malformation rates ranging from 1.4% to 16.1%.
2. Environmental factors:
1. Maternal viral infections: Rubella accounts for 2% to 4% of all CHDs.
2. Maternal X-ray exposure: especially of pelvis  ↑ incidence of Down’s syndrome.
3. Teratogenic drugs as:
- Thalidomide & folic acid antagonist - Lithium chloride. - Anti-convulsion drugs.
- Alcohol - Progesterone / estrogen: acting in the 1st trimester.
4. Acute hypoxia
5. Cigarette smoking  uterine vascular changes
6. Maternal metabolic defects: diabetes mellitus.
7. Obstetric problems association of advanced maternal age with Down’s syndrome
8. Dietary deficiencies during pregnancy  congenital malformation.
Preventio
n
1. Genetic counseling of parents & families with CHD.
2. Rubella immunization programs through premarital care.
3. Avoidance of exposure to viral diseases during pregnancy
4. Physician should avoid Teratogenic drugs & radiological influence on the fetal & newborn
heart during prenatal care.
5. Family planning services
6. Health education of mothers: to avoid cigarette smoking, alcohol consumption or any
drugs without prescription.

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Hypertension
The elevation of arterial blood pressure over 140 / 90 in adults
Risk
factors

a) Host factors
1. Genetic
- Heredity interacting with the environmental role  not all hypertensive patients have
diseased offspring.
- So children of hypertensive parents should be screened & advised to avoid environmental
factors that aggravate hypertension (e.g. smoking, physical inactivity, and excess sodium)
2. Low birth weight
Low birth weight due to fetal under- nutrition followed by  ↑ B.P. later in life
3. The role of sodium salt in essential hypertension
- ↑ sodium intake in diet  ↑ B.P…
4. Obesity: HTN is common among obese individuals  ↑ risk of ischemic heart disease
5. Physical inactivity: Physical fitness  prevent HTN
6. Alcohol intake
7. Smoke: Cigarette smoking  ↑ B.P., through nicotine  release of nor-epinephrin.
8. Hyperuricemia: Present in 25 - 50 % of individuals with untreated 1ry HTN.
9. Ethnic group: Adult blacks have HTN  to higher rises of morbidity and mortality.
10. Sex: Before menopause, HTN is less common in women than in men, but after that HTN
is equally common & dangerous in elderly males & females.
11. Age: At old age  more HTN cases & age related atherosclerosis.
12. Diabetes mellitus:
HTN & diabetes coexist commonly

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Diabetics are susceptible to adverse effects of HTN therapy, because diuretics & β-
blockers  ↑ insulin resistance.

Environmental factors
Tension, anxiety & continuous exposure to external stress factors  ↑ blood pressure in
normo-tensives but high ↑ in hypertensives.

Prevention of
Hypertension
1. Life style modification:
A) Weight reduction: - ↑ exercise - Use ↓ caloric supplement
B) Avoidance of tobacco
C) Dietary Na restriction
B) K supplementation: Patients should ↓ K depletion & ↑ dietary K intake
E) Mg & Ca supplementation: ↓ B.P.
F) Prevent alcohol consumption
G) Physical exercise
H) Relaxation exercises: ↓ stress & anxiety.
2. Anti-hypertensive drug therapy:
Drugs are used if: - life style modification is not followed or ineffective with the patient
- ↑ HTN at the onset
3. Management of etiology of 2ry hypertension.

Bronchial asthma
Asthma cannot be cured, but could be controlled.
CAUSES
1. Indoor allergens (e.g. domestic mites, carpets & furniture, cats)
2. Family history of asthma or allergy. 3. Tobacco smoke.
4. Exposure to chemicals in the workplace.
5. Drugs: aspirin & NSAIDs. 6. Low birth weight & respiratory infection.

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7. Weather (cold air)
8. Extreme emotional expression & physical exercise.
9. Urbanization.
Preventio
n
1. Increase public awareness
2. Organize global epidemiological surveillance to monitor asthma
3. Develop & implement a strategy for its prevention
4. Stimulate research into the causes of asthma to develop new control strategies &
treatment techniques.

Cancer
Descriptive
epidemiology
Cancers arise from undifferentiated stem that are capable of mitotic division &
differentiation.
1. Age: most cancers develop in the 6th, 7th, 8th decades of life.
2. Sex: cancers of non-sexual sites occur in men than women, except in gallbladder & bile
ducts.
3. Race & Geography: Cancers varies among racial groups in the same country.
This variation is due to: - genetic difference among the races
- Cultural patterns - social behavior - economic status.
4. Time Trends:
- The high ↑ in rates of lung cancer is largely due to cigarette smoking.
- Decline in rates of stomach cancer is unknown but may be related to dietary habits,
(consumption of less preserved & more fresher foods)
- Decline in mortality from uterine cancer is probably due to combination of 3 factors:
1. ↓ number of women who still have a uterus
2. ↑ cytological screening 3. Decline in the incidence of new cases
Etiology & 1ry
prevention
Initiators
- Agents cause the genetic damage to the stem or intermediate cells.
- Ionizing radiation, chemicals & certain viruses

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Initiators  rearrangements in DNA  ↑ expression of normal genes (ONCOGENES)
Promotors  ↑ rate of growth & number of stem & intermediate cells (targets for initiators)
 to enhance growth of tumor cells
Estrogens  ↑ proliferation of endometrium  endometrial cancer
Risk factors
1. Tobacco
- Compared to non-smokers, risk in the average cigarette smoker is
- ↑ 10 fold  lung cancer, - ↑ 8 folds  laryngeal cancer
- ↑ 4 folds  mouth & pharynx - ↑ 3 folds  esophageal cancer
- ↑ 2 folds  bladder, renal pelvis, ureter & pancreas
- Risk is increased by about 30% in non-smoking members with a resident smoker.
2. Alcohol
- Risk of neoplasms is associated with alcohol consumption.
- Hepatocellular carcinomas develop at ↑ rate in alcoholics with macro-nodular cirrhosis.
- ↑ Risk for carcinomas of mouth (buccal cavity & pharynx) & esophagus

3. Industrial exposures

Specific exposure Site or tumor type

Arsenic & arsenic Lung, skin

compounds

Asbestos Lung, mesothelioma

Benzene Leukemia

4. Drugs not an important cause of cancer (account for less than 1% of neoplasms)
5. Ionizing radiation
- Among the atomic bomb survivors in Japan there were
- High ↑ in rates of carcinomas of thyroid & mammary glands & of leukemias
- Lesser ↑ in rates of lymphomas & carcinomas of stomach, esophagus, & bladder
- Risk of leukemia ↑ in early radiologists who took few precautions against radiation

6. Non-ionizing radiation

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Sunlight cause squamous & basal cell carcinomas of skin (occur on exposed parts of body)
7. Exogenous hormones
- ↑ endometrial cancer in women receiving estrogens for menopausal conditions

8. Infectious agents:
EBV  nasopharvnea1 carcinomas
HBV  Hepatocellular carcinoma (Hepatoma)
HBV viral DNA  cervical cancers
Human immunodeficiency virus (HIV)  AIDS
An RNA virus  Kaposi sarcoma & non Hodgkin’s lymphomas

9. Nutrition
Aflatoxins produced by fungi  liver cancers it some parts of the world.
Food additives May be carcinogenic, the evidence is weak
- ↑ artificial sweeteners  ↑ risk of bladder cancer
- ↑ fat diet  cancers of colon, breast & prostate
Over-nutrition  obesity  associated with endometrial & postmenopausal breast cancers

N.B. - Fibers in diet ↑ bulk of bowel contents & ↓ intraluminal carcinogens by ↓

contact of colonic mucosa with carcinogens.
- ↑ Fresh fruits Diets & raw vegetables  ↓ carcinomas risks in GIT & RT.
10. Reproductive factors
Single women (specifically nulliparous)  at ↑ risk of ovary, endometrium & breast cancers.

11. Genetic factors

Some individuals exposed to a carcinogen  develop cancer & others with identical exposure
do not, Due to differences in genetic susceptibility to carcinogens
- Carcinomas of breast & prostate.
- Malignant melanomas occur in light skinned individuals with blond or red hair & blue eyes.
- Stomach cancers occur more in persons with blood gp A.
Hazards of blood
transfusion
1. Infection 2. Blood incompatibility. 3. Sensitization of Rh
4. Fever due to pyrogens.
Preventio

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n
1. Precautions with blood donors:
1. Must be healthy & not addicts.
2. Must be free of infection: no history of recent disease, especially viral hepatitis &
testing blood for any existing infection.
3. Blood grouping: ABO & Rh to be registered in the identity cards.
2. Precautions with blood recipients:
1. Blood grouping: ABO & Rh, if not already registered in identify card.
But if not available, & no facilities or time for pre-transfusion grouping, group 0 (RH -ve for
females) blood is used.
2. Supervision of the case during & after the process of transfusion, for any reaction
Family Planning Service

It is a basic need of reproductive health, safe motherhood & child health & survival
Aim of family planning services
1. Avoid pregnancy outside the safe childbearing period (20 —34 years).
2. Allow for having the suitable no. of children & avoid unwanted pregnancy
3. For proper pregnancy spacing.
4. For mothers having chronic disease.
Methods for family planning
1. Natural methods: Safe period, lactation, isolation
2. Mechanical: Condom, vaginal diaphragm, cervical cap, IUD
3. Chemicals: Vaginal foam, tablets & vaginal creams
4. Hormonal: Contraceptive pills
Benefits of Proper inter-pregnancy spacing
For the sake of mother:
1. Protection of mothers from risk of multiple pregnancies & labour
2. ↓ maternal mortality ratio.
3. Malnutrition including teeth decay & osteomalacia.
4. ↓ health hazards of pregnancy & labour: e.g. toxemia & puerperal sepsis.
5. ↓ hazards related to urogenital system e.g. fistulae, uterine prolapse.
6. ↓ hazards of illegal abortion to get rid of unwanted child.
For the sake of foetus
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↓ Infant mortality rate & ↓ congenital Abnormalities & pregnancy wastage, lethal sublethal.
- Mother give better care nutritional, psychological, education & medical care for smaller
number of children.
For the sake of husband
1) Better psychological & emotional states.
2) Better working for the non loaded father.
For the community
1. Better educational level. 2. Better housing.
3. Increased percapita share. 4. Improvement of health services.
5. The public resources is allotted to industrial & national promotion program.

Care of the Newborn

- Neonatal care contributes to maternal health, reproductive health & safe motherhood.
- Neonatal care aims at: health promotion of newborn, prevention of morbidity & mortality.

Outcome of Pregnancy:
1. Favorable: delivery of a healthy live born.
2. Unfavorable i.e. dead baby (called pregnancy wastage),
It is of two types:
• Lethal i.e. abortion, miscarriage, stillbirth, neonatal death & postneonatal deaths
• Sublethal: e.g. congenital anomalies, mental retardation, cerebral palsy, Also prematurity.

Factors affecting the outcome of pregnancy

1. Age of mother, risk is below [6 and above 40 years
2. Parity risk is lowest with parity 1-4
3. Pregnancy spacing, most suitable 2-3 years
4. State of maternal health including:
- Body built (height) - Nutritional status
- Syphilis and malaria - Smoking
- Drugs & radiations - Outcome of previous pregnancy.
5. Factors related to labour:
Analgesic or anesthetic drugs given during labour  Prolonged labour, malposition

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6. Infection acquired by the foetus during labour
7. Social factor: Poor living conditions and lack of medical care

Maternal mortality
Maternal mortality: a biostatistical index which monitors the safety of the reproductive
process through which mothers in the reproductive age might pass through.

The interaction between the maternal fitness & environmental factors would determine
the process of maternity and its outcome part of which is the maternal survival
- Maternal mortality is death of women during performing their maternity function at
pregnancy, delivery or puerperium.
Maternal Mortality is one of the main indicators of the health status & welfare of a
community.
Ecology of maternal mortality
Agent
- Failure of adaptation to pregnancy, delivery or puerperium.
- Occurs when the stress of the maternity process exceeds the vital reserve of the mother.
Host
- Mothers who are intolerant to maternity stress might be due to:
1. Limited vital reserve due to constitutional factors
2. Incomplete recovery of their vital reserve due to previous maternity or other stressing
factor (recovery needs 2 years at least).
3. Morbid condition whether limiting her vital reserve to the maternity process.
• Endocrine Balance: Pregnancy & delivery are the stresses to which mothers are exposed.

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• Nutrition: Proper nutrition makes mother more tolerant to stress of maternity process.
• Age: Excess of deaths among older women & excess among women younger than 20.
- Risk of maternal death was higher in mothers aged more than 40 years
• Parity: Maternal mortality is high among primipara then it drops & reincreases again among
those who had five or more children.
Time of maternal death
The 2000 NMMS found that most maternal deaths took place during delivery or postpartum:
Maternal deaths in 2000 were more likely to occur during delivery (49% compared to 39% in
1992-93) and less likely to occur during the postpartum period (27% compared to 35% in
1992-93).

Causes of maternal mortality”

- There are three groups of causes which lead to maternal mortality”
1. Direct causes
These are the causes due to complications of pregnancy, delivery & puerperium & trials to
manage the case during this maternity process including abortion.
The three leading causes of maternal mortality in Egypt: haemorrhage, toxemia & sepsis.
- Hemorrhage before & after delivery (43%of maternal death), with most hemorrhage
deaths due to postpartum hemorrhage.
- Other direct causes: hypertensive disease of pregnancy (22%), sepsis (8%), ruptured
uterus (8%), cesarean section (7%) & obstructed labor (5%).
2. Indirect causes
- These are causes due to aggravation of pre-existing conditions as rheumatic heart during
pregnancy, delivery & purperium.
- Cardiac disease: the indirect cause of maternal deaths (13%)
- Anemia was the second most important indirect cause of maternal death (11 %).
3. Causes not related to the mortality process: as traffic accidents

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Interventions to reduce maternal mortality

1. Setting up maternal mortality committees on national, regional & local levels & keeping
them operative.
2. Improving the system for the registration & capture of information of all heath
actions relating to pregnancy, delivery & family planning.
3. Ensuring the existence of a national system for the epidemiologic surveillance of
mortality of women of reproductive age that provides data of sufficient quantity & quality
to determine the real scope of the problem, the structure of its causes & the social
determinants of maternal mortality.
4. Incorporate the investigation of maternal mortality within the routine work of
personnel working in MCH Units.
5. Formulate maternal mortality panel at district level so as to be able to thoroughly revise
the causes of conditions of every maternal health.
6. Training Obs/Gynophysician at hospitals on accurate diagnosis of direct & underlying
causes of maternal deaths.
7. Establishment of system for accurate diagnosis of maternal deaths in death
certificate in the health office.
8. Set monthly audits to discuss any case of death due to pregnancy & labor to
determine the cause of death
9. Community education and mobilization is essential so that women & their families learn
about the need for special care during pregnancy & childbirth.

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10. Community education must address traditional beliefs about pregnancy-related
complications that are often blamed on a woman’s behavior, fate, evil influences & other
factors beyond the reach of the health system.
11. Dialogue among communities, policy-makers, and health system staff is essential to
identify ways of overcoming barriers to women seeking maternal care.

Child Health Care

- MCH centers are responsible for care of under 5 years children (from birth to school age),
& include infants & preschool children.
Objectives of the child health care program
1. Monitoring of growth & development of children.
2. Implementation of the program of compulsory (obligatory) vaccination to prevent diseases.
3. Treatment of common diseases & early detection of critical cases to be referred to
specialized clinics.
4. Control of infectious diseases.
5. Minimization of under 5 years mortality.
6. Prevention of diarrhoeal diseases as well as respiratory tract infection.
7. Health education.
8. Rehabilitation.
Health problems among
children
(1) Morbidity (2) Mortality

(1) Morbidity problems

I. Infectious diseases. III. Malnutrition. V. Social disorders.
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II. Parasitic infections IV. Accidents. VI. Handicapping (disability).

I. Infectious
diseases
- Infection is a health problem in developing countries.
- It may be congenital or acquired.
(a) Congenital infection
It is in utero infection (vertical infection)
- Transmitted from the mother to her
- embryo (during the 1st trimester) before formation of placenta
- fetus (trans-placental infection)
N.B. Congenital infection lead to unfavorable outcome of pregnancy which is lethal
(abortion, still birth) or sublethal (congenital anomalies or congenital diseases e.g. Syphilis,
Rubella syndrome, , AIDS)
Forms of congenital infection: Syphilis, rubella, cytomegallo inclusi5n virus, hepatitis B virus
infection, AIDS, Toxoplasma gondii.

(b) Acquired infections (classification acc. to the age of the child)

1. Neonatal infections: Infections acquired during the 1st 4 weeks after birth.
- These infections are acquired during the process of delivery from the birth canal of the
mother or faulty practices after birth, environment has very little contribution to
acquired neonatal infection.
Important forms of neonatal Infections: Opthalmia neonatoruan, conjunctivitis, Otitis
media, Pneumonia, Herpes simplex, Tetanus neontorum, diarrhoeal diseases of new born,
AIDES, cytomegallo inclusion virus.
2. Prenatal infection: infections occur in the prenatal period (from the 28th week of
intrauterine life till the 1St week neonatal period).
3. Infections occurring in infants: (Children during the 1st year of life)
They are exposed to:
a. Diarrhoeal diseases it was the 1st killer for infants accounting for half of deaths of
infants.which before the introduction of ORT,
b. Acute respiratory tract infections (Upper & lower).
c. Infective conjunctivitis & infective skin diseases.
4- Infections of childhood

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- Many infectious diseases are endemic in the developing countries.
- Susceptibility begins from the 6th month of infancy due to the fade out of maternally
acquired immunity except for pertussis & T.B. in which there is no maternally acquired
immunity.
- Pertussis: Big molecule of immunoglobulin “M”, that can not pass through the placenta.
- Tuberculosis: cell-mediated immunity.
The risk of infection is aggravated by faulty breast feeding practices, malnutrition & faulty
weaning practices.
Infectious diseases occur in sporadic cases, epidemics or outbreaks.
Forms of infectious diseases:
1. Poliomyelitis: sporadic cases in endemic areas like Egypt (no epidemics).
2. Diarrhoea
3. Acute respiratory tract infections (ARI).
4. Measles.
5. infective conjunctivitis & skin diseases.
6. Tuberculosis: (milk borne) intestinal TB.
Prevention of infectious diseases in childhood
1. Maternal measures
a) Health education of mothers & girls
b) Premarital care: active immunization & treatment of any infection.
c) Prenatal care: Health appraisal, active immunization by tetanus toxoid (no live vaccines
during pregnancy).
d) Intra-natal care: Asepsis is the rule
2. Child care measures:
a) Neonatal care:
1. Aseptic cutting of the cord & slump dressing.
2. Antibiotic eye drops immediately after birth
3. Early initiation of breast feeding within half an hour after birth & establish good breast
feeding practices.
b) Health appraisal  for diagnosis & management of morbidity that may predispose to
infection.
c) Proper nutrition.
d) Prevention of infection in low birth weight units, incubators & paediatric units

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II- Parasitic
diseases
Some parasitic diseases are endemic in developing countries particularly in rural areas
e.g. Entrobius vermicularis (most prevalent), Schistosoma (infrequent in preschool children),
Ascaris lumbercoids, giardia lamblia, Hymenolepis nane, Entamoeba histolytica, Ancylostorna,
Malaria
Impact of parasitic diseases on child health:
a) Impairment in physical & mental development.
b) Predispose to malnutrition.
III-
Malnutrition
About 50% -60% of under 5 years mortality is at attributed to or associated with
malnutrition.
Important forms of malnutrition: Iron deficiency anaemia, Protein-energy malnutrition
Rickets, Vit A deficiency, Riboflavin deficiency, I2 deficiency (endemic goiter).
The government compat vit A deficiency by its adminstration to pregnant females (600.000
iu) & to infants at the 9th month l00000 iu) also, iodinization of table salt to combat iodine
deficiency

IV-
Accidents
Below-five-year children are exposed to Varity of injuries starting from birth injuries, home
& road injuries.
V- Social
disorders
Contributing factors
1) Big family size & low percapita income.
2) Poor housing & high crowdness index
3) Low socioeconomic standards
4) Separation of parents (loss of love & security)
5) Mother’s Employment (lack of close with mother)
VI- Handicapping
(Disability)
Definition: Any physical, mental, social or psychological morbidity that interferes with
leading normal life & activities.

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- It is classified according to its etiology into:
a) Congenital b) Acquired
a) Congenital handicapping
Examples: Mental retardation — Microcephaly — Hydrocephalus — cleft lip or palate.
Causes:
1. Genetic factor: Gene mutation & chronomosomal abrasion e.g down’s syndrome.
2. Inutero Exposure to adverse condition:
a. Maternal infection acquired during pregnancy e.g. toxoplasma gondii, hepatitis B
infection, syphilis, measles, mumps, rubella.
b. Live vaccines administered to pregnant mothers during or shortly before (less than 3
months) pregnancy.
c. Teratogenic agents (drugs, heavy metals, radiation).
d. Smoking: risk factor for low birth weight & prematurely.
e. Air pollution & Malnutrition of the mother may play a role:
Examples
i. Iodine deficiency predispose to congenital cretinism.
ii. Severe protein deficiency may predispose to LBW

Prevention:
Congenital disability could be prevented through premarital, preconceptional & pre- natal
care.
1. Premarital care
a. Premarital counseling & examination for diagnosis & treatment of sexually transmitted
diseases, genetic counseling to avoid hereditary diseases.
b. Vaccination in non immune couples; females are vaccinated at least 3 months before
pregnancy.
c. Health education for healthy life & avoid any harmful practices that may affect
pregnancy.
2. Prenatal care: to ensure healthy safe intrauterine growth & development & to avoid
adverse intrauterine.
3. Health education: It is a continuous process to preparation of girls to be the future
mothers. It is continued till child birth.

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Control
- Case finding: It is better to be carried out at birth.
- Management of case: Once diagnosed start medical, social & educational care &
rehabilitation of the case physically, mentally, psychological & socially to lead independent
life.
b) Acquired handicapping
- It is disability acquired at any age of childhood, adolescence or geriatric age group.
- Acquired disability during child hood is due to either or as complications for some
infectious diseases.
1) Accidents:
a. The 1st accident that might occur is birth injury that may lead to neurological damage.
b. Home accidents e.g fall, swallowing of caustic materials that lead to permanent
oesophageal fibrosis.
c. Road accidents: traffic accidents.

2) Complications of infectious diseases:

a) Streptococcal pharyngitis: improperly treated case may be complicated with:
a. Impaired hearing & conductive deafness.
b. Rheumatic heart disease. c. Glomerulonephritis.
d. Conjunctivitis (purulent) is the most common cause of blindness in Egypt (corneal opacity
as a result of corneal ulceration).
- Corneal opacity has no treatment except corneal transplantation.
e. Poliomyelitis: paralytic form lead to paralysis.
f. Meningococcal meningitis: it is complicated by paralysis of cranial nerves subnormal
mentality.
h. Diphtheria. i. Leprosy.
j. Tuberculosis k. Syphilis,
Forms of handicapping
- Impaired hearing, vision, blindness, paralysis, rheumatic heart disease, skeletal deformity &
mental retardation.
Prevention
1- Primary prevention
- Prevention of infections diseases by general or specific measures e.g. vaccination &
chemoprophylaxis.

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2- Secondary prevention
- Early case finding & management of infectious diseases through health appraisal.
- 1st aid, emergency services for early management of infection & accidents.
3- Tertiary prevention:
- Rehabilitation of cases suffering from any disability.
- It is comprise of physical, mental social rehabilitation.

Quality of health care

Quality It defined as “Fitness for purpose”. Or as “conformance to specification” Or as

"a degree or standard of achievement”.
- The British standards Institute defines quality as the totality of feature &
characteristics of a product or service that bear on its ability to satisfy stated needs.

- Quality of technical care consists of: application of medical science & technology in a
manner that maximizes its benefits to health without increasing its risks.

- Degree of quality is, the extent to which the care provided is expected to achieve the
most favorable balance of risks & benefits.
- Quality of health care is a process of change or fully meeting requirements of lowest cost
or more specifically full meeting the needs of consumers
Quality:-
- Doing the right thing  Appropriate.
- Doing the right thing right  Effective.
- Doing the right thing for 1st time & every time  Efficient.

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How Can we improve?
- We must change: Change  Improvement  Quality

How change?
1. Cooperation 2. Involvement 3. Education 4. Management 5.
Resources
- The costumer: Expectation & rights & satisfaction,
• Measuring Quality?
- Structure
- Process
- Outcome
Total Quality Management (TQM)
Definitions: • Definitely customer focused.
• Philosophy, concepts, tools & techniques focused.
• Emphasis in employee involvement.
• Continuous improvement and TQM a never ending journey.
• Organization wide-all departments function and level.
• Everyone responsible for quality.
• Involves process and culture change.

The quality control proces

1. Evaluate actual operating performance.
2. Compare actual performance to goals.
3. Act on the difference.

TQM
• Total Quality management is about improvement.
• Improvement requires change
• The change process requires consensus between all concerned.
• Education & training may assist the process of change but it is not sufficient by itself
changes in the organization’s policies, structures & technical systems are also likely to be
necessary.
Practical approach of TOM

Total Quality Management

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Quality Improvement in Health Care
• Quality council • Team work • Information system
• Reducing deficiency in the services • Adding new services
• Better care under limited budgets
• Attract new customer • Lower the cost of services
• Customer satisfaction
— Internal (health team provider).
— External (population & patients)
Total quality management
— Quality planning: adding new services
— Quality improvement: removed deficiencies
— Quality control: establish standard for structure and process, measure actual
performance & corn pare to standard & regulate the process.

Family Medicine
Principles of Family Medicine
1. Continuity of care 2. Comprehensive care
3. Coordinated care 4. Care of patient in the family context
5. Health care in the community context.
1. Continuity of care
Family practice is defined as the medical specialty that provides continuity and
comprehensive health care for the individual & the family.
2. Comprehensive care
Family practitioners can provide independent care for 85 90% of problems
encountered in daily practice.
- Comprehensive care may be synonymous with personal medicine.
- Personal medicine is a process of providing broad-based health care which both physician &
patient recognize that the relationship extends beyond that of provider and client.
- When providing personal medicine, the physician may act as advisor, advocate, confidant or
healer.

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- The specialty of family physician including adolescent health care, sports medicine,
addiction medicine and geriatrics.
3. Coordinated care
- Family physician have traditionally served as the patient’s first contact and point of entry
into the health care system.
- Hence, care is provided for all problems.
- This physician serves as the patient’s or family’s advocate in all health-related matters,
including the appropriate use of consultants and community resources.
- His training and experience qualify him to practice in the several fields of medicine &
surgery.
4. Health care of the patient in the family environment
Family is part of family physician and family practice is integral to their definitions.
5. Family practice
- is a people —oriented specialty physicians today choose family practice because they wish
to be people doctors not doctors for organs, machines or age groups.

General guidelines for family medicine

1. Provide personal care for individual & family
2. Manage acute & chronic medical problems in the community.
3. Provide anticipatory (predicted) health care using education, risk reduction, & health
enhancement strategies.
4. Provide continuous health care, not limited by a specific disease
5. Provide comprehensive care of complex and sever problems.
6. Establish physician-patient relationships by using interpersonal communication skills to
provide quality health care.

Five Star Doctor

- The concept of the “five-star doctor” is an ideal profile of a doctor possessing a mix of
aptitudes to carry out the range of services that health settings must deliver to meet the
requirements, quality, cost-effectiveness & equity in health.
- The five sets of attributes of the “five-star doctor” are summarized as follows:

- Care provider - Decision-maker - Communicator

- Community leader - Manager
1. Care-provider
- Besides giving individual treatment “five- star Doctors” must take into account the total
(physical, mental & social) needs of the patient.
- They must ensure that a full range of treatment — curative, preventive will be dispensed in
ways that are complementary, integrated & continuous.
- And they must ensure that the treatment is of the highest quality.
2. Decision-maker
“Five-star doctors” have to take justified & efficient decisions.
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- In treating a given health condition, the one that seems most appropriate in the given
situation must be chosen.
3. Communicator
- The doctors of tomorrow must be excellent communicators in order to persuade individuals,
families & the communities in their charge to adopt healthy lifestyles & become partner in
the health effort.
4. Community leader
The needs and problems of the whole community- in a suburb or a district — must not be
forgotten.
By understanding the determinants of health inherent in the physical and social environment
“five-star doctors” will not simply be treating individuals who seek help but will also take a
positive interest in community health activities which will benefit large numbers of people.
5. Manager
- To carry out all these functions, it will be essential for “five-star doctors” to acquire
managerial skills.
- This will enable them to initiate exchanges of information in order to make better
decisions.

Vaccination Schedule

Vaccine or Toxoid Dose

First 3 0.1 ml intradermally in deltoid

• BCG for tuberculosis,
months region (without tuberculin test).

• Sabin (poliomyelitis).
- 3 drops on tongue
• Hepatitis B vaccine.
2nd month - 0.5 ml IM
• Quadruple vaccine
- 0.5 ml IM or deep subcutaneous.
(OPT + polio salk)

• Sabin (poliomyelitis). - 3 drops on tongue.

4th month • Hepatitis B vaccine. - 0.5 ml IM.
• OPT. - 0.5 ml IM or deep subcutaneous.

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• Sabin (polio). - 3 drops on tongue.

6th month • Hepatitis B vaccine. - 0.5 ml IM.
• OPT. - 0.5 ml IM or deep subcutaneous.

9tb month • Measles. - 0.5 ml subcutaneous.

• DPT.
18 to 24th • MMR (measles, mumps, - 0.5 ml IM. 0.5 ml subcutaneous.
month Rubella) - 3 drops on tongue.
• Sabin (polio).

Ten steps to successful breast feeding

1. Have a written breast feeding policy communicated to all health care staff
2. Train all health care staff necessary to implement the policy.
3. Inform all pregnant women about the benefits and management of breast feeding.
4. Help mothers initiate beast feeding within a half-hour of birth.
5. Show mothers how to breast feed
6. Give new born babies no food or drink other than breast milk unless medically indicated.
7. Practice rooming in-allow mothers and babies to remain together-24 hrs a day.
8. Encourage breast feeding on demand.
9. Give no artificial teats.
10. Establishment of breast feeding support groups.
What is Optimal for Breastfeedinr Practice?
1. Initiation of breastfeeding within about one hour of birth.
newborn should be offered the breast as soon after delivery as possible, preferably within
one hour of birth. Nothing, nothing all except breast milk, should be given to a young infant.
Early initiation stimulates breast milk production.

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- It fosters mothers—child bonding and serves the baby’s first immunization with antibodies
present in colostrums (the 1st milk).
Early initiation of breastfeeding is beneficial
For the mother
• Early suckling promotes the release of a hormone that reducing the risk of mother’s
haemorrhage after labor.
- It helps the uterus to shrink back to normal size.
- The suckling action can help expel the placenta & reduce postpartum hemorrhage.
• Establishment of emotional bond between mother and child.
For the child
• It is important to receive the colostrums which contains antibodies that protect infant
against illnesses & enhances the baby’s immune system.
- Early & frequent feeding may bring in mother’s milk more quickly.
- The infant will immediately benefit from the protective effect of the concentrated
amounts of antibodies present in colostrum. The colostrums is like a first immunization.
2. Frequent, on-demand feeding (including night feeds)
Why young infants should suckle frequently?
An infant should suckle frequentlr, both day and night.
Frequent feeds are needed because:
• An infant’s stomach is small and can only take in a limited quantity of breast mild at any one
time. The small stomach needs to be refilled often.
• Breast milk is perfectly adapted to the baby.
- This means Ms more easily and quickly digested than other foods, and the infant will need
to feed often.
• Since the supply of breast milk is dependent on demand, frequent feeds are needed to keep
up a mother ‘s milk supply.
• Frequent suckling maximizes the contraceptive benefit to mothers and helps delay the
return of menses.
N.B. An infant should be put to the breast 8-12 times per 24 hours, for about 10-20 minutes
on each breast.
- Infant should sleep with the mother so that it can feed “on demand”.

Reproductive health

A state of complete physical, mental, & social wellbeing & not merely the absence of disease
or infirmity (‫)عجز‬, in all matters related to the reproductive system & to its function &
processes.
Components of Reproductive Health
I. Health promotion of females, from birth, childhood, adolescence & childbearing period.
II. Safe motherhood.
III. Family planning service.
IV. Prevention & management of:
• Complicated abortion.

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• Infections of reproductive system, including STDs.
• Noninfectious hazards of reproductive system.
• Infertility.
• Management of menopause.
V. Elimination of harmful practices for girls & women.
VI. Care of the Newborn
Basic Requirements for Safe Motherhood
1. Preconceptional Care:
1- Health promotion
• Proper nutrition • Prevention of infectious diseases • Health education
2- Premarital guidance Education includes:
• Family life • Family planning • Child bearing
3- Premarital immunization
• Mumps for males and females not affected before
• German measles for females not affected before.
4- Premarital examination Includes:
• Complete family and medical history • Systematic medical examination
• Investigations X-ray of chest, RH factor & Wasserman reaction
2. Obstetric Care
A. Prenatal care for safe childbirth
a) Early, regular, & good antenatal care including:
1. Nutrition 2. Screening for high risk
3. 1ry & 2ry prevention of certain conditions as anemia.
4. Health education: to make women understand nature of maternity process, how to care
for themselves, the service resources available around & how to benefit of it.
5. Treatment of mild diseases if occur
6. Immunization: against tetanus to prevent tetanus of child & post partum tetanus of
mother.
b. Recognition of & early care seeking for danger signs.
c. Birth preparedness d. Plan for emergencies
e. Immunization against Tetanus With Tetanus Toxoid.
Immunization of Pregnant Women Against Tetanus With Tetanus Toxoid (TT)
- Tetanus Toxoid protects all women of child-bearing age, including pregnant women during &
after labour. Child must be vaccinated with the 1st dose of DPT at 2 months of age.
The reasons underlying the female malpractice:
1. Psychosexual reason reduction or elimination of the sensitive tissue of the outer
genitalia, particularly the clitoris, in order to attenuate sexual desire in the female.
2. Sociological reason identification with the culture heritage, initiation of girls into
womanhood.
3. Hygiene reason the external female genitalia are considered dirty & unsightly and should
be removed to promote hygiene.
4. Religious reason there is no substantive evidence that it is a religious requirement.
5. Myths (‫)خرافة‬enhancement of fertility & promotion of child survival.

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Levels & Trend of the Problem in Egypt
- Maternal Mortality is measured through the maternal mortality ratio = =
no. of mothers who died due to pregnancy, delivery and puerperium
1000 live Births at the Same Period & Locality
- There is a definite drop of maternal mortality rate.
“National Maternal Mortality in Egypt during 1992-93”, determined the mortality to be
174/100.000 live births).
- In the 2000, National Maternal Mortality Study of maternal death carried out in Egypt,
maternal mortality decreases to 84/100,000 live births.
- This direct reduction of more than 50% is a remarkable achievement Egypt’s efforts to
improve the quality of obstetric care, ↑ access to family planning, & educate women about
see medical care.

Non-human resources (to decrease maternal mortality)

1. Transportation & communication 2. Drugs
3. Blood & plasma expanders 4. Hospital & maternity homers
5. Reproduction regulators 6. Training facilities & resources
7. Research facilities & funds 8. Health education resources
Main Avoidable Factors contributing to maternal Death
1. Health Provider Factors
General practitioners contributed disproportionately to maternal deaths, due to delays in
referral of woman with obstetric complications & misuse of drugs used to speed up labor.
2. Woman & Family Factors
Failure by the woman or her family to recognize danger signs and consequently delay in
seeking care, was the second most
3. Health Facility Factors
Shortage of blood was the most frequent health facility factors, contributing to 16% of
maternal deaths.
4. Main Medical Care of Maternal Death
Medical causes of death were classified in direct causes and indirect causes.

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- Direct causes were responsible for 77% of maternal deaths
- Indirect causes for 20% of maternal deaths. For 3% it

Health record
It is a file initiated at birth of any child & follows him (her) to school & through the whole
life, for registration of all concerning health & morbidity.
Contents of health record
1. Birth data (date, weight, length, head circumference and any detected abnormality.
2. Results of health appraisal at the periodic visits to the MCH center as.
a- General health status & body built.
b- Growth monitoring by anthropometric measurements plotted on growth chart for early
detection of any deviation from normal to be managed.
c- Criteria of developmental milestones according to age.
3. Vaccinations given, by date & age.
4. Curative services provided on morbidity & referral if any value of health record.
Value of health record
1. Follow-up and growth monitoring.
2. a data for statistical analysis for comparison between countries, current & past states.

Health hazards of smoking

Health hazards
1. Malignancy: Cancer lung & other parts of the body (mouth, larynx, Pharynx, esophagus)
2. Cardiovascular disease:
- CHD & Cerebrovascular disease. - stroke. * Peripheral vascular disease.
3. Respiratory hazards other than cancer: - Bronchitis, emphysema, Asthma.
5. Unfavorable outcome of pregnancy: risk of abortion, & Congenital Hazards.
4. Peptic ulcer. 6. Others, e.g. gingivitis, heart burn, and indigestion.
Particular hazards to which females smokers are exposed
1. Unfavorable outcome of pregnancy.
2. Cardiovascular hazards in contraceptive pill users.
3. Increased incidence of CHD and lung cancer.
Control of smoking
1. Extensive education program.
2. Management of smokers, and helping them to give up.
2. Restriction of manufacture, sale and advertising of Cigarettes
Vital & Morbidity Statistics
Functions & Purpose of Vital and Health Statistics
1. Research: (diagnosis & treatment) in medicine, surgery and public health researches.
2. Organization: in prevention and control of diseases.
3. Planning health program
4. Evaluation of Health program
5. For comparison between one country & another and with one country over the years.
Mortality Statistics
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Death: It is the postnatal cessation of vital function without capability of resuscitation.
Crude Death rate C.D.R. =

Specific Death Rates: rates calculated by taking in consideration one or more of

characteristics of
population like age, sex,
occupation, religion
Specific Death Rate =

Sex Specific Mortality rate =

Case fatality rate =

Infant mortality rate IMR: The infant is the baby in his first year

Causes of infant deaths

A) Biological: • Congenital malformation • Prematurity
• Rh factor • Birth injuries and birth complication.
B) Environmental
• Respiratory infection • Gastroenteritis • Malnutrition • Accidents
C) General Factors: • Ignorance • Low income • Big family

Leading causes of infant mortality in Egypt

Bronchitis, pneumonia and bronchopneurnonia, gastroenteritis, prematurely constitutes
(90%) of death. Other causes constitutes (10%) of deaths.
Causes of death (other cause 10%) of infant in the first year of life are.
Tetanus, Pertussis, Measles, Diphtheria, T.B., Poliomyelitis, Meningitis, PEM and accidents
Neonatal Mortality Rate =

Post-neonatal mortality rate =

Morbidity Statistics
Incidence Rate =

Prevalence Rate =

Measures of fertility

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1- Crude birth rate C.B.R. =

2- General fertility rate (G F R)=

3- Age specific fertility rate

(ASFR) =
Basic Hospital Medical Records
a. Diagnostic summary index: listing of admissions with dates, diagnosis and operations.
b. Admission and discharge records. c. History and physical examination.
d. Progress notes. e. Discharge summary.
f. Physician’s orders. h. Nurses note.
i. Vital signs record Temp, pulse, respiration, blood pressure, state of consciousness.
Uses of Medical Records
1. Document the course of the patient’s illness and medical treatmentt inpatient or an out-
patient.
2. Serves as a basis for planning individual patient care.
3. Provide continuity of patient care on subsequent admission of the patient.
4. Review, study and evaluate patient care by hospital or medical staff committees.
5. Provide data for fluid parties concerned with the patient e.g. governmental agencies.
6. Communicates between the physician and other professionals contributing to patient care.

FEV1: Forced Expiratory Volume in the first second. The volume of air that can be forced
out in one second after taking a deep breath, an important measure of pulmonary function.
Fibroblasts cells of connective tissue play a critical role in wound healing.

They are the most common cells of connective tissue in animals.

Emphysema is a type of cshronic obstructive lung disease.
It is often caused by exposure to toxic chemicals or long-term exposure to tobacco smoke.
Emphysema is caused by loss of elasticity (increased compliance) of the lung tissue, from
destruction of structures supporting the alveoli, and destruction of capillaries feeding the alveoli.
Lungs overworking your heart
Cor pulmonale is failure of the right side of the heart caused by prolonged high blood pressure in
the pulmonary artery and right ventricle of the heart.

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Forced vital capacity (FVC) measures lung volume which will be reduced if the lungs are stiffened
by scar.
Mesothelioma is a rare form of cancer (malignancy) that most frequently arises from the cells lining
the sacs of the chest (the pleura) or the abdomen (the peritoneum).
Appraisal: ‫تقييم‬
Asepsis: ‫خلو من الجراثيم‬
infrequent ‫نادر‬
Prevalent: ‫منتشر‬

Percapita: each person

Microcephaly: the condition of having a small head or having reduced space for the brain in the
skull, often associated with learning difficulties

Hydrocephalus: an increase of cerebrospinal fluid around the brain, resulting in an enlargement of

the head in infants, because the bones of the skull are still unfused. The fluid is blocked by a
congenital condition or a disease, and can be drained into the abdominal cavity.

Mumps: an acute contagious disease, usually affecting children, that causes a fever with swelling of
the salivary glands and sometimes also affects the pancreas and ovaries or testes. It is caused by a
virus and can be prevented through vaccination. It may cause sterility if contracted by a man.
Rubella: a highly contagious viral disease, especially affecting children, that causes swelling of the
lymph glands and a reddish pink rash on the skin. It can be harmful to the unborn baby of a
pregnant woman who contracts it.

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