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Mamta Diwas (Health and Nutrition Day / Village Health and Nutrition Day)

1. Definition

• "Mamta" = mother's love/care in Hindi
• The concept evolved under the Reproductive and Child Health (RCH) Programme to strengthen outreach maternal and child health services
• In urban settings it is called "Mamta Day" or "Health and Nutrition Day" and is organized by Urban Health Centres (UHCs/UPHCs)

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2. Under Which Programme?

• National Health Mission (NHM) - specifically under Reproductive Maternal Newborn Child Health + Adolescent (RMNCH+A) strategy
• It is a key outreach activity under RCH-II / NHM
• Linked with ICDS (Integrated Child Development Services) through the Anganwadi centre

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3. Frequency and Site

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4. Beneficiaries

1. All pregnant women
2. Breastfeeding/lactating women
3. Under-5 children (especially infants and children up to 5 years)

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5. Services Provided

A. Maternal Health Services

• Antenatal registration and antenatal check-up (ANC)
• Weight measurement of pregnant women
• Blood pressure measurement
• Haemoglobin estimation (detection of anaemia)
• Tetanus Toxoid (TT) injection
• Iron and Folic Acid (IFA) tablet distribution
• Identification of high-risk pregnancies and referral
• Abdominal examination
• Promotion of institutional delivery
• Post-partum/postnatal care

B. Child Health Services

• Immunization (BCG, OPV, Hepatitis B, DPT/pentavalent, measles, etc.)
• Growth monitoring (weight, height/length recording)
• Growth chart plotting in the Mother and Child Protection (MCP) Card
• Detection and grading of malnutrition
• Vitamin A supplementation
• Management/referral of sick children

C. Family Planning Services

• Counselling and provision of contraceptives
• Promotion of spacing and limiting methods

D. Nutrition Services

• Supplementary nutrition (through AWW/ICDS)
• Nutrition counselling
• Promotion of breastfeeding and complementary feeding (IYCF)
• Health and nutrition education (IEC)

E. Other Services

• ORS distribution for diarrhoea management
• Completion and maintenance of the Mother and Child Protection (MCP) Card
• Health education to community
• ASHA incentive disbursement for beneficiaries brought to session

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6. Key Personnel Involved (Convergence)

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7. Mother and Child Protection (MCP) Card

• Family identification and registration number
• Identifying data of the mother and child
• Birth record
• Pregnancy and antenatal care records
• Immunization record of the child
• Growth chart (for monitoring child's growth)
• Details of services received at each session

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8. Monitoring & Supervision

• Coverage Monitoring Chart / Dropout Chart maintained at PHC
• AEFI (Adverse Events Following Immunization) to be reported
• Vaccine Preventable Disease (VPD) reporting
• District-level supervisory visits to Mamta Diwas sessions
• Meetings with PRI and ICDS functionaries about Mamta Diwas sessions
• Beneficiaries to wait at least 30 minutes post-vaccination to observe for AEFI

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9. Relation to RMNCH+A Strategy

• R - Reproductive health (family planning)
• M - Maternal health (ANC, PNC, safe delivery promotion)
• N - Newborn care (HBNC, newborn immunization)
• C - Child health (immunization, growth monitoring, nutrition)
• H - Health education
• +A - Adolescent health (life skills, ARSH services at VHND)

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10. Key Exam Points (Memory Pearls)

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• Park's Textbook of Preventive and Social Medicine - Village Health and Nutrition Day section (Block 7); NHM/RCH-II chapter (Block 6); Sub-centre services chapter (Block 12); Maternal and child health chapter (Block 8)
• National Journal of Community Medicine - Process Evaluation of Mamta Diwas, Kheda District, Gujarat (2013)

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Q26. Define Elimination Criteria for Leprosy. Types. Bacillary Leprosy. (10 marks)

Definition of Leprosy

1. Hypopigmented patches
2. Partial or total loss of cutaneous sensation in affected areas (earliest: loss of light touch)
3. Presence of thickened nerves
4. Presence of acid-fast bacilli in skin or nasal smears

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Elimination Criteria for Leprosy

• 1991: WHO member states resolved to eliminate leprosy globally by 2000
• India achieved national elimination in December 2005 (PR fell below 1/10,000)
• The fall in prevalence is attributed to: improved case management, very low relapse rates, high cure rates, absence of drug resistance, and shorter treatment duration with MDT

• Prevalence Rate (PR) - cases registered per 10,000 population (key elimination indicator)
• New Case Detection Rate (NCDR) - now considered more important than PR for programme monitoring
• Treatment Completion Rate - calculated annually by states
• Grade 2 Disability Rate among new cases - reflects delay in diagnosis
• Proportion of child cases among new cases - reflects ongoing transmission

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Classification / Types of Leprosy

A. Ridley-Jopling Classification (Immunological)

• Indeterminate (I): Earliest form - single hypopigmented patch, mildly impaired sensation, no nerve thickening; may heal spontaneously or progress

B. WHO / Field Classification (for MDT purposes)

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Bacillary Leprosy (Multibacillary / Lepromatous Leprosy)

• Represents the anergic end of the spectrum - deficient Cell Mediated Immunity (CMI)
• Widespread, symmetrical skin lesions - macules, papules, nodules, plaques
• Leonine facies - thickening and nodulation of facial skin
• Madarosis - loss of eyebrows (superciliary) and eyelashes (ciliary)
• Nasal stuffiness, epistaxis, nasal collapse (saddle nose)
• Glove-and-stocking anaesthesia (late finding)
• Bacillary index (BI) very high (5+ or 6+)
• NOT a localized disease - systemic involvement (testes causing gynaecomastia, orchitis)
• High infectivity

• Bacilli enter through respiratory route
• Migrate to neural tissue, enter Schwann cells and macrophages
• If CMI is deficient: uncontrolled spread → MB leprosy with multiple system involvement
• If CMI is strong: PB leprosy or spontaneous healing

• Duration: 12 months
• Each monthly blister pack = 1 supervised dose + 27 daily doses
• On completing 12 blister packs within 18 months = treatment completed

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Q27. Disability Limitation and Medical Rehabilitation in Leprosy (6 marks)

WHO Disability Grading in Leprosy

• The highest grade in any part = Disability Grade for that patient
• Eye + Hand + Feet score (0-12) recorded at each examination

Deformities Occurring in Leprosy

Prevention of Disability (POD)

• Care of dry, denervated skin of palms and soles
• Healing wounds, ulcers, skin cracks
• Preventing injuries to hands and feet by protective gloves and footwear
• Preventing joint stiffness in paralytic deformities
• Protecting eyes (lubricating drops, protective glasses)
• Periodic nerve function assessment (simple tests done in field)
• Improvement through prostheses, orthopaedic devices, corrective splints, corrective surgery

Medical Rehabilitation

Types of Rehabilitation:

1. Preventive rehabilitation - early diagnosis and adequate treatment to prevent deformities; cheapest and surest form
2. Medical rehabilitation - reconstructive surgery, physiotherapy, prostheses, splints
3. Social rehabilitation - reintegration into family and society, combating stigma
4. Vocational rehabilitation - training for alternative employment

Community-Based Rehabilitation (CBR):

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Q28. CASE - Syndromic Approach in Sexually Transmitted Diseases (10 marks)

Definition of Syndromic Approach

Rationale / Advantages

• Most STD patients present with symptoms that can be grouped into syndromes
• Lab facilities are often not available in peripheral areas
• Avoids delay in treatment
• Cost-effective
• Reduces transmission by immediate treatment
• Addresses the problem of co-infections (e.g., dual gonorrhoea + chlamydia)

Recognised STD Syndromes (NACO Guidelines)

1. Urethral discharge (in males)
2. Vaginal discharge (in females)
3. Genital ulcer disease
4. Inguinal bubo
5. Scrotal swelling
6. Lower abdominal pain (in females - Pelvic Inflammatory Disease/PID)
7. Neonatal conjunctivitis

Flowcharts - Syndromic Management

1. Urethral Discharge (Males)

• Tab. Cefixime 400 mg orally, single dose PLUS
• Tab. Azithromycin 1 g orally, single dose (supervised)
• If symptoms persist/recur after 7 days: add Secnidazole 2 g (for Trichomonas)
• If allergy to Azithromycin: Erythromycin 500 mg QID x 7 days

2. Vaginal Discharge (Females)

• Cover gonorrhoea + chlamydia + BV + trichomoniasis simultaneously
• Tab. Cefixime + Azithromycin + Secnidazole + Fluconazole (depending on risk assessment)

3. Genital Ulcer Disease

• Benzathine Penicillin 2.4 MU IM (syphilis) PLUS
• Azithromycin 1 g single dose / Ciprofloxacin 500 mg BD x 3 days (chancroid) PLUS
• Acyclovir 400 mg TDS x 7 days (herpes)

4. Lower Abdominal Pain / PID

• Covers gonorrhoea, chlamydia, anaerobes
• Cefixime + Doxycycline + Metronidazole

Components of Each Syndromic Management Visit (5 Cs)

1. Compliance - ensure full treatment
2. Counselling - risk reduction, behaviour change
3. Condom promotion and provision
4. Contact tracing - partner notification and treatment
5. Check-up - follow-up visit

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Q29. Prevention of STDs (10 marks)

Primary Prevention

A. Health Education and Behaviour Change

• Education about modes of transmission and risk behaviours
• Promotion of safer sexual practices: abstinence, mutual fidelity (being faithful to one uninfected partner - "ABC": Abstain, Be faithful, use Condom)
• Delay of sexual debut in adolescents
• Reduction in number of sexual partners
• Avoidance of high-risk sexual behaviours

B. Condom Promotion

• Correct and consistent use of male condoms provides highly effective protection
• Female condom - also effective
• Social marketing of condoms
• Free distribution through health facilities, NGOs

C. Treatment of Existing STDs

• Treating STDs reduces HIV transmission (STIs increase HIV susceptibility 3-fold or more)
• Early and complete treatment of all STDs

D. Targeted Interventions for High-Risk Groups

• Sex workers, long-distance truck drivers, intravenous drug users (IDUs), MSM (men who have sex with men), migrants
• Peer-led outreach, frequent STD screening, condom promotion

E. Blood Safety

• Screening of all blood and blood products for HIV, HBV, HCV, syphilis
• Avoidance of unnecessary transfusions

F. Safe Injection Practices

• Use of sterile/disposable needles and syringes
• Needle exchange programmes for IDUs

G. Prevention of Mother-to-Child Transmission (PMTCT)

• Antenatal screening for syphilis, HIV, HBV
• Treatment of infected pregnant women
• Safe delivery practices

H. Male Circumcision

• Reduces risk of HIV acquisition in men by ~60%

I. Vaccines

• Hepatitis B vaccine - highly effective, included in UIP
• HPV vaccine - against HPV types 16, 18 (causes 70% of cervical cancers) and types 6, 11 (genital warts)

Secondary Prevention

• Early case detection through screening programmes
• Prompt and complete treatment
• Partner notification and treatment (contact tracing)
• Syndromic management at peripheral level

Tertiary Prevention

• Prevention of complications (PID, infertility, cervical cancer)
• Rehabilitation of patients with severe STD complications

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Q30. Prevention of HIV/AIDS (6 marks)

Prevention at Individual Level (Primary)

A. Behaviour Change (ABC Strategy)

• A - Abstinence from sex
• B - Be faithful to one uninfected partner
• C - Condom - correct and consistent use

B. Harm Reduction in IDUs

• Needle exchange / syringe exchange programmes
• Opioid substitution therapy (methadone, buprenorphine)
• Never share needles, syringes, drug paraphernalia

C. Pre-Exposure Prophylaxis (PrEP)

• Daily oral antiretroviral drugs (Tenofovir + Emtricitabine) in HIV-negative high-risk individuals
• Reduces HIV acquisition by >90%

D. Post-Exposure Prophylaxis (PEP) - see Q31

Prevention at Community/Programme Level

E. Blood Safety

• Mandatory screening of all blood/blood products for HIV
• Avoidance of unnecessary transfusions
• Promote voluntary blood donation

F. PMTCT (Prevention of Mother-to-Child Transmission)

• Universal HIV testing in ANC
• Option B+: All HIV+ pregnant women started on lifelong ART regardless of CD4 count
• Safe delivery (minimize obstetric trauma, avoid unnecessary episiotomy, avoid mixed feeding)
• Replacement feeding or exclusive breastfeeding (with ARV prophylaxis for the baby)
• ART for the infant (Nevirapine for 6 weeks)

G. Early Treatment = Prevention (Treatment as Prevention - TasP)

• ART reduces viral load to undetectable → Undetectable = Untransmittable (U=U)
• Universal Test and Treat (UTT) strategy

H. Targeted Interventions (TI)

• For high-risk groups: sex workers, truck drivers, IDUs, MSM
• Condom promotion, STI treatment, peer education

I. NACP (National AIDS Control Programme)

• Condom promotion and distribution
• Targeted interventions
• Blood safety programme
• ICTC (Integrated Counselling and Testing Centres)
• ART centres

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Q31. Post-Exposure Prophylaxis (PEP) of HIV (6 marks)

Definition

When to Give PEP

• Occupational exposure: needlestick injuries, cuts with sharp instruments, splashes to mucous membrane or broken skin with blood/body fluids of HIV+ or unknown status patient
• Non-occupational exposure: unprotected sexual intercourse (consensual or assault), sharing needles with HIV+ person

When NOT to give PEP

• Exposure more than 72 hours ago (ideally start within 2 hours; must start within 72 hours)
• Exposure to urine, saliva, tears, sweat (unless blood-stained)
• Source confirmed HIV-negative

Risk Assessment

PEP Regimen (Preferred)

Duration

• 28 days (4 weeks)

Management Steps After Exposure

1. Wound care - wash with soap and water; flush mucous membranes with water; do NOT squeeze wound
2. Assess risk - type of exposure, source status
3. Start PEP as soon as possible (within 2 hours, must be within 72 hours)
4. Baseline testing - HIV ELISA, CBC, LFT, RFT, HBsAg, HCV
5. Counselling - about PEP, side effects, adherence, safe sex during PEP
6. Follow-up testing - HIV at 6 weeks, 3 months, 6 months
7. Report exposure to infection control team

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Q32. Emerging and Re-emerging Infectious Diseases (10 marks)

Definitions

Examples

Emerging Infections

Re-emerging Infections

Factors Contributing to Emergence / Re-emergence

Control Measures

• Surveillance - robust global/national surveillance systems (IHR 2005 - International Health Regulations)
• Early detection and rapid response
• One Health approach - integrated human, animal, environmental health
• Vector control for vector-borne diseases
• Vaccine development - platform technologies (mRNA vaccines)
• Infection control in healthcare settings
• International cooperation - WHO, Global Health Security Agenda (GHSA)
• Risk communication and community engagement

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Q33. Nosocomial Infections / Hospital-Acquired Infections (6/10 marks)

Definition

• WHO definition: An infection acquired in hospital by a patient who was admitted for a reason other than that infection.
• Onset: usually after 48 hours of hospital admission (or after 30 days of a surgical procedure)

Magnitude

• Affects 5-15% of hospitalized patients globally
• One of the leading causes of morbidity and mortality in hospitals
• Common in ICUs, surgical wards, neonatal units

Types / Most Common Sites

Routes of Transmission

1. Contact transmission (most common) - direct or indirect contact with infected patient or contaminated surfaces/instruments
2. Droplet transmission - large droplets from coughing/sneezing
3. Airborne transmission - TB, measles, chickenpox, Aspergillus
4. Common vehicle - contaminated food, water, IV fluids, medications
5. Vector-borne - mosquitoes (rare in hospital setting)

Risk Factors

• Extremes of age (very young/old)
• Immunosuppression (HIV, steroids, chemotherapy)
• Underlying chronic diseases (diabetes, CKD)
• Malnutrition

• Urinary catheterization (CAUTI)
• Intravenous lines/central catheters (CLABSI)
• Mechanical ventilation (VAP)
• Surgical procedures
• Organ transplantation

• Overcrowding
• Poor hand hygiene compliance
• Inadequate sterilization/disinfection
• Inappropriate antibiotic use → MRSA, VRE, carbapenem-resistant organisms

Prevention and Control (Bundle Approaches)

Standard Precautions (for all patients at all times):

1. Hand hygiene - WHO 5 moments: before patient contact, before aseptic task, after body fluid exposure, after patient contact, after contact with patient surroundings
2. PPE - gloves, gowns, mask, eye protection as required
3. Safe handling of sharps (no recapping, puncture-resistant containers)
4. Respiratory hygiene / cough etiquette
5. Environmental cleaning and disinfection
6. Proper waste management
7. Safe injection practices
8. Sterilization of patient-care equipment

Transmission-Based Precautions:

• Contact precautions - MRSA, VRE, C. difficile
• Droplet precautions - influenza, meningococcal disease
• Airborne precautions - TB (negative pressure rooms), measles

Specific Bundles:

Antimicrobial Stewardship:

• Rational antibiotic use to prevent emergence of MDR organisms
• De-escalation of antibiotics based on culture sensitivity

Surveillance:

• Regular monitoring of HAI rates (NNIS system)
• Infection Control Committee (ICC) in every hospital
• Infection Control Nurse (ICN) / Infection Control Officer (ICO)

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Post-Exposure Prophylaxis (PEP) of HIV

(From Park's Textbook of Preventive and Social Medicine)

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1. Definition

• First aid care
• Counselling and risk assessment
• HIV testing and counselling
• Short-term provision of antiretroviral drugs (28 days)
• Support and follow-up

"PEP for HIV consists of a comprehensive set of services to prevent infection developing in an exposed person." - Park's

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2. Types of PEP

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3. Principle / Rationale

• HIV does not immediately enter the bloodstream and seed systemic infection
• After exposure, virus replicates locally at the site of exposure and in regional lymph nodes before systemic dissemination
• This "window of opportunity" (estimated 24-72 hours) allows ARV drugs to prevent or abort infection if given promptly
• Therefore, PEP must be started as early as possible, ideally within 2 hours, and must be started within 72 hours

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4. Risk of HIV Transmission per Exposure

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5. Eligibility Criteria for PEP

1. All individuals with exposure that has potential for HIV transmission, initiated as early as possible, ideally within 72 hours
2. Assessment based on HIV status of source whenever possible (also considers background prevalence and local epidemiology)
3. Exposures warranting PEP include:
   • Parenteral or mucous membrane exposure - sexual exposure, splashes to the eye, nose, oral cavity
   • Body fluids posing HIV risk: blood, blood-stained saliva, breast milk, genital secretions, CSF, amniotic fluid, rectal/peritoneal/synovial/pericardial/pleural fluids

Important: Assessment of the HIV status of the exposed individual should NOT be a barrier to initiating PEP. If HIV testing is not immediately available but risk is high - start PEP first, test later.

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6. Time Window

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7. Immediate First Aid After Exposure

For needlestick / sharps injury:

• Wash the wound immediately with soap and running water
• Allow wound to bleed freely (do NOT squeeze/press wound to force bleeding)
• Apply antiseptic (povidone-iodine)
• Do NOT suck the wound

For splash to mucous membrane / eye:

• Flush with copious water or normal saline immediately
• For eye: flush with clean water or eye wash

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8. PEP Regimen (As per Park's / WHO 2016 Guidelines)

Preferred 3-Drug Regimen (Adults and Adolescents):

Raltegravir (RAL) 400 mg PO twice daily + Tenofovir DF (TDF) 300 mg / Emtricitabine (FTC) 200 mg (Truvada) PO once daily

Dolutegravir (DTG) 50 mg once daily + Tenofovir DF (TDF) 300 mg / Emtricitabine (FTC) 200 mg once daily

• Duration: 28 days (4 weeks)
• Three-drug regimens are now recommended for all exposures regardless of severity
• 2-drug regimens: only when recommended ARVs unavailable or concern about adherence/toxicity (require expert consultation)

For Children < 10 years:

• LPV/r (Lopinavir/ritonavir) is the preferred third drug
• Age-appropriate alternatives: ATV/r, RAL, DRV, EFV, NVP

Special Consideration - Women of Childbearing Age:

• Pregnancy test before starting PEP
• If prescribed DTG: counsel to use effective contraception during PEP course
• Pregnant women on DTG: monitor for neural tube defects (especially if exposure in first trimester)

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9. Complete PEP Protocol - Step by Step

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10. Counselling Points During PEP

• Importance of completing the full 28-day course (adherence)
• Common side effects of ARVs (nausea, fatigue, headache, diarrhoea)
• PEP is not 100% effective - still requires condom use during follow-up period
• Avoid blood donation, pregnancy, unprotected sex during PEP and until confirmed HIV negative
• Importance of follow-up HIV testing even if PEP completed
• Psychological support for the exposed person

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11. Follow-Up HIV Testing Schedule

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12. Effectiveness of PEP

• When taken correctly and promptly, PEP reduces the risk of HIV infection by approximately 80% after exposure
• Efficacy depends on: time to initiation, adherence, duration of full 28-day course
• Not 100% effective - hence counselling on safe behaviour during follow-up is essential

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13. PEP vs PrEP - Quick Comparison (Exam Favourite)

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14. Key Exam Memory Points

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Revised Drug Policy of Malaria Treatment (India - 2013)

From Park's Textbook of Preventive and Social Medicine

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Key Principle of the Revised Drug Policy 2013

"According to the revised drug policy 2013, there is NO scope of presumptive treatment in malaria control."

• All fever cases must be confirmed by either microscopy or Rapid Diagnostic Test (RDT) before starting anti-malarial treatment
• This replaced the old policy of giving chloroquine empirically to all fever cases
• ACT (Artemisinin Combination Therapy) replaced chloroquine as first-line for P. falciparum

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Diagnostic Flowchart (Fig. 2 from Park's)

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I. Treatment of Uncomplicated P. vivax Malaria

Drugs:

• Day 1: 10 mg/kg
• Day 2: 10 mg/kg
• Day 3: 5 mg/kg

• Relapse rate in vivax malaria in India: ~30%
• 14-day regimen must be given under supervision

Primaquine Contraindications:

• Infants (children < 1 year)
• Pregnant women
• G6PD deficient individuals

Caution: In areas with high G6PD deficiency prevalence, screen before giving PQ. Warn patients to stop immediately if dark urine, yellow conjunctiva, bluish lips, abdominal pain, nausea/vomiting appear.

Dosage Chart - P. vivax Treatment:

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II. Treatment of Uncomplicated P. falciparum Malaria

A. Other States (All states except North-East):

1. Artesunate (AS): 4 mg/kg body weight/day for 3 days
2. Sulfadoxine-Pyrimethamine (SP): Sulfadoxine 25 mg/kg + Pyrimethamine 1.25 mg/kg on Day 1 only
3. Primaquine (PQ): 0.75 mg/kg body weight as single dose on Day 2 (gametocytocidal)

All tablets for the day to be taken together, swallowed with water.

Dosage Chart - P. falciparum (ACT-SP):

B. North-Eastern States (NE States):

• Plus Primaquine 0.75 mg/kg single dose on Day 2

ACT-AL is NOT recommended:

• During 1st trimester of pregnancy
• Children weighing < 5 kg

IMPORTANT: Production and sale of Artemisinin monotherapy has been BANNED in India as it can lead to development of parasite resistance.

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III. Treatment of P. falciparum in Pregnancy

Primaquine is CONTRAINDICATED in ALL trimesters of pregnancy.

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IV. Treatment of Mixed Infections (P. falciparum + P. vivax)

• Mixed infections with P. falciparum should be treated as P. vivax malaria:
  • NE states: ACT-AL for 3 days + Primaquine 0.25 mg/kg/day for 14 days
  • Other states: ACT-SP for 3 days + Primaquine 0.25 mg/kg/day for 14 days

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V. Treatment Failure / Drug Resistance

• Resistance suspected if: despite full treatment (no vomiting/diarrhoea), patient does not respond within 72 hours clinically and parasitologically
• Cases not responding to ACT: treat with Quinine + Tetracycline/Doxycycline (oral)
• Such cases must be reported to District Malaria Officer / State Malaria Officer / ROHFW for initiation of therapeutic efficacy studies

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VI. Treatment of Severe / Complicated Malaria

Features of Severe Malaria (any one):

1. Impaired consciousness / coma (Cerebral malaria)
2. Repeated generalized convulsions
3. Renal failure (Serum Creatinine > 3 mg/dl)
4. Jaundice (Serum Bilirubin > 3 mg/dl)
5. Severe anaemia (Hb < 5 g/dl)
6. Pulmonary oedema / ARDS
7. Hypoglycaemia (Plasma glucose < 40 mg/dl)
8. Metabolic acidosis
9. Circulatory collapse / shock (SBP < 80 mmHg; < 50 mmHg in children)
10. Abnormal bleeding / DIC
11. Haemoglobinuria
12. Hyperthermia (> 106°F / 42°C)
13. Hyperparasitaemia (> 5% parasitized RBCs in low endemic; > 10% in hyperendemic areas)

Treatment of Severe Malaria:

Parenteral treatment must be given for minimum 24 hours once started, irrespective of patient's ability to take oral medicine.

• After parenteral Quinine: Oral Quinine 10 mg/kg TDS + Doxycycline 100 mg OD (or Clindamycin in pregnant women/children < 8 yrs) to complete 7 days total
• After parenteral Artemisinin derivative: Full oral course of area-specific ACT for 3 days

Special Note - Severe Malaria in Pregnancy:

• Pregnant women with severe malaria in any trimester can be treated with artemisinin derivatives (unlike uncomplicated malaria in 1st trimester)
• Artemisinin, unlike quinine, does not aggravate hypoglycaemia

"Don'ts" in Severe Malaria:

• Do NOT use corticosteroids
• Do NOT give IV mannitol
• Do NOT use heparin as anticoagulant
• Do NOT administer adrenaline
• Do NOT overhydrate
• Do NOT use mefloquine in cerebral malaria (risk of neuropsychiatric complications)

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VII. Summary Table - Revised Drug Policy 2013 at a Glance

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VIII. Key Exam Points to Remember

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Kangaroo Mother Care (KMC)

From Park's Textbook of Preventive and Social Medicine + WHO Guidelines

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1. Introduction / Historical Background

• KMC was introduced in Bogota, Colombia in 1979 by Drs. Hector Martinez and Edgar Rey
• It was developed as a response to:
  • High infection and mortality rates in neonates
  • Overcrowding in hospitals
  • Shortage of incubators
• Has since been adopted across the developing world and has become an essential element in the continuum of neonatal care

"Kangaroo mother care for low birth-weight babies was introduced in Colombia in 1979 by Drs. Hector Martinez and Edzar Rey as a response to, inter alia, high infection and mortality rates due to overcrowding in hospitals." - Park's

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2. Definition

• Early and continuous skin-to-skin contact between the newborn and mother (or father/caregiver)
• Exclusive breastfeeding/breast milk feeding support
• Ambulatory / early discharge from hospital
• Supportive care to the mother and family

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3. Target Beneficiaries

• All low birth-weight (LBW) babies - birth weight < 2500 g
• Preterm babies - gestational age < 37 weeks
• Especially effective for very low birth weight babies (birth weight 1000-1799 g)
• Can be practiced even at home - thus improving chances of newborn survival

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4. Four Components of KMC (PARK'S)

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5. How to Practice KMC - Position

• Baby is placed upright (vertical position) against the mother's chest
• Baby is between mother's breasts, with head turned to one side
• Baby's neck is slightly extended (to keep airway open)
• Hips are flexed (frog-leg position) and abdomen at mother's epigastric level
• Baby is secured using a wrap/cloth/binder
• Mother can move around with baby attached
• Duration: As long and as continuous as possible (ideally 24 hours/day, with breaks for hygiene and feeding)

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6. When to Start KMC

• Can start as soon as the newborn is clinically stable
• Immediate KMC (started immediately after birth) is now recommended by WHO 2022 for stable preterm/LBW newborns even before full stabilization
• In India under NACP/NHM: KMC is recommended at the health facility level as an Essential (E) intervention

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7. Benefits of KMC

A. Benefits to the Baby

B. Benefits to the Mother

• Promotes mother-newborn bonding and attachment
• Reduces maternal anxiety and depression
• Promotes and prolongs breastfeeding
• Boosts mother's confidence in caring for her newborn
• Empowers mother as primary caregiver
• May reduce postpartum haemorrhage

C. Benefits to Health Facility / System

• Reduces dependence on incubators (especially in resource-poor settings)
• Shorter hospital stay - earlier discharge
• Cost-effective - significant cost savings
• Less need for additional nursing staff
• Reduces overcrowding in NICUs

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8. KMC vs Conventional (Incubator) Care

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9. KMC under India's National Programmes

Under NHM / RMNCH+A:

• KMC is listed as an Essential (E) intervention at the health facility level for care of small and sick newborns
• Part of India Newborn Action Plan (INAP)

Facility-based care continuum (from Park's block 7):

1. Thermal care and feeding support (community)
2. IMNCI and oral antibiotics (sub-centre)
3. Injectable Gentamicin by ANMs (pre-referral)
4. KMC at facility (Health Facility) - Essential
5. Full supportive care at block (NBSU) and district level (SNCU)
6. NICU services at regional level

Under NHM interventions to reduce neonatal mortality (Park's):

• "Newer interventions to reduce newborn mortality: vitamin K injection at birth, antenatal corticosteroids for preterm labour, kangaroo mother care and injection gentamicin to young infants in cases of suspected sepsis."

Under Sub-centre / CHC services (Park's):

• Essential newborn care includes: "provision of warmth / Kangaroo Mother Care (KMC), maintain the airway and breathing, initiate breastfeeding within one hour, infection protection, cord care and identification of sick newborn and prompt referral."

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10. WHO 2022 Updated Recommendations

• WHO updated KMC recommendations in 2022
• Immediate KMC (initiated immediately or very soon after birth, even before stabilization) is now recommended for all preterm (<37 weeks) or LBW (<2500g) newborns requiring specialized care
• KMC should be provided as soon as possible and continued for as long as possible
• Can be practiced by father or other family members (not just mother) - also called "Kangaroo Father Care"

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11. Intensive Care for LBW Babies (Park's - alongside KMC)

• Adjustment of temperature, humidity, oxygen supply
• Continuous monitoring of oxygen levels in blood (to prevent hypoxia → cerebral palsy)
• Excess oxygen may lead to retrolental fibroplasia (ROP)

• Breastfeeding promoted; breast milk used if available
• Feeding may be by nasal catheter if baby cannot suck

• Infection is the greatest hazard in LBW babies
• Death may occur within hours following respiratory infection

Leading Causes of Death in LBW Babies (Park's):

1. Atelectasis
2. Malformation
3. Pulmonary haemorrhage
4. Intracranial bleeding (secondary to anoxia or birth trauma)
5. Pneumonia and other infections

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12. Key Exam Points to Remember

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Kangaroo Mother Care (KMC)

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Definition

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Origin

• Introduced in Bogota, Colombia, 1979
• By Drs. Hector Martinez & Edgar Rey
• Developed due to high neonatal mortality and shortage of incubators

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Four Components (Park's)

1. Skin-to-skin positioning - baby upright on mother's bare chest
2. Breastfeeding / breast milk - exclusive, as early as possible
3. Ambulatory / early discharge - mother carries baby at home
4. Support for mother and family - education and counselling

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Who Benefits

• All LBW babies (< 2500 g)
• Preterm babies (< 37 weeks)
• Can be practiced at home also

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Benefits

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Under India's Programmes

• Essential (E) intervention at health facility level under NHM / RMNCH+A
• Part of India Newborn Action Plan (INAP)
• Listed alongside Vitamin K, antenatal corticosteroids, Gentamicin as key interventions to reduce neonatal mortality

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Key Exam Facts

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Environment & Health - All 12 Questions

From Park's Textbook of Preventive and Social Medicine

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Q1. Chlorination of Water (6/10 marks)

Definition

Action of Chlorine

• Cl₂ + H₂O → HCl + HOCl (hypochlorous acid)
• HOCl → H⁺ + OCl⁻
• Hypochlorous acid is the active germicidal agent - 70-80 times more effective than hypochlorite ion
• Best action at pH 7; unreliable above pH 8.5

What Chlorine Kills/Does NOT Kill

Secondary Properties of Chlorine

• Oxidizes iron, manganese, hydrogen sulphide
• Destroys taste and odour-producing substances
• Controls algae and slime
• Aids coagulation

Principles of Chlorination

1. Water must be clear and free from turbidity (turbidity impedes chlorination)
2. Chlorine demand of water must be satisfied first
3. Free residual chlorine of 0.5 mg/litre must remain after 1 hour contact
4. Sufficient contact time must be allowed

Methods of Chlorination

1. Chlorine gas - first choice; cheap, quick, efficient; applied using "chlorinating equipment" (Paterson's Chloronome)
2. Chloramine - slower action; persistent residual; less taste; not widely used
3. Perchloron (HTH) - 60-70% available chlorine

• Bleaching powder, chlorine tablets, HTH solutions

Break-Point Chlorination

• Adding chlorine to water with ammonia produces chloramines (less efficient)
• As more chlorine is added, residual falls (chloramines destroyed)
• Then rises again - the point where residual reappears = "break point"
• Breakpoint chlorination = controlled superchlorination; all combined chlorine destroyed; only free chlorine remains

Superchlorination

• Addition of large doses of chlorine, followed by dechlorination
• Used for heavily polluted, variable-quality water

OT (Orthotolidine) Test

• Used to measure free and combined residual chlorine
• Turns yellow in presence of chlorine; intensity varies with concentration

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Q2. Purification of Water at Small Scale (10 marks)

(a) BOILING

• Water brought to rolling boil for 10-20 minutes
• Kills all bacteria, spores, cysts, ova → yields sterile water
• Removes temporary hardness (precipitates CaCO₃)
• Disadvantage: No residual protection against re-contamination; taste altered
• Store in the same container in which it was boiled

(b) CHEMICAL DISINFECTION

• White powder, pungent smell
• Contains ~33% available chlorine (freshly made)
• Unstable - loses chlorine on exposure to air, light, moisture
• Store in dark, cool, dry, closed, corrosion-resistant container
• Ensure free residual chlorine of 0.5 mg/L after 1 hour

• Prepared from bleaching powder: 4 kg BP (25% Cl) + 20L water = 5% chlorine solution
• Store away from light

• 60-70% available chlorine
• More stable than bleaching powder

• Good for small quantities; costly
• NEERI tablet: 1 tablet (0.5 g) disinfects 20 litres

• 2 drops of 2% iodine solution per litre of clear water
• Contact time: 20-30 minutes
• Used for emergency disinfection

(c) FILTRATION AT HOUSEHOLD LEVEL

• Sand/candle filters (Berkefeld, Chamberland filters)
• Removes turbidity and some bacteria
• Does NOT sterilize - still needs chemical disinfection

(d) SOLAR DISINFECTION (SODIS)

• PET bottles filled with clear water, placed in sunlight 6-8 hours
• UV rays and heat kill pathogens

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Q3. Safe and Wholesome Water (6/10 marks)

Definition (Park's)

• (a) Free from pathogenic agents
• (b) Free from harmful chemical substances
• (c) Pleasant to taste - free from colour and odour
• (d) Usable for domestic purposes

Water Requirements

• Basic physiological minimum: 2 litres/person/day
• Urban domestic standard: 150-200 litres/capita/day
• India's rural target: 40 litres/capita/day

WHO/BIS Standards for Drinking Water

Water-Related Diseases

1. Waterborne - cholera, typhoid, hepatitis A, dysentery (water vehicle)
2. Water-washed - trachoma, scabies (inadequate water for hygiene)
3. Water-based - guinea worm, schistosomiasis (aquatic host)
4. Water-related vector - malaria, dengue, filaria (vectors breed in water)

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Q4. Surveillance of Drinking Water Quality (10 marks)

Definition

Objectives

1. Ensure drinking water meets quality standards at all times
2. Early detection of deterioration in quality
3. Identify sources of contamination
4. Evaluate effectiveness of treatment processes
5. Provide data for action

Components of Surveillance

• Quality of raw water (river, lake, groundwater) before treatment

• Adequacy of each treatment step (coagulation, filtration, disinfection)
• Check residual chlorine after disinfection

• Quality at various points in distribution network
• Check for cross-connections, leakages, back-siphonage
• Residual chlorine must be ≥ 0.2 mg/L at consumer's tap

• Tap water testing at households

Water Quality Parameters Tested

• Physical: turbidity, colour, taste, odour, temperature
• Chemical: pH, dissolved oxygen, nitrates, fluoride, heavy metals, pesticides
• Bacteriological: total coliform, faecal coliform (E. coli), faecal streptococci

Bacteriological Tests

• MPN (Most Probable Number) - estimates coliform count per 100 mL
• Membrane filtration technique - most widely used
• Presence/absence test (P-A test) - for field use

Standard

• Zero coliforms per 100 mL of treated piped water
• E. coli: nil/100 mL

WHO Guidelines

• National surveillance should be independent of water supply authorities
• WHO recommends Water Safety Plans (WSPs) - risk assessment and risk management approach

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Q5. Water Conservation (6 marks)

Definition

Why Needed?

• Freshwater constitutes only 2.5% of total water on earth
• Increasing demand due to population growth, urbanization, industrialization
• Climate change causing water scarcity

Methods of Water Conservation

• Collection and storage of rainwater from rooftops, roads, open areas
• Recharges groundwater; reduces runoff

• Conservation of soil and water in a catchment area
• Contour farming, check dams, afforestation

• Repair of leaky pipes and taps in distribution systems
• About 30-40% of urban water is lost through leakages (non-revenue water)

• Treated sewage reused for irrigation, industrial cooling
• Greywater recycling for flushing

• Drip irrigation, sprinkler systems (reduce 30-60% water use vs flood irrigation)

• Water Pollution Prevention Acts
• Regulation of groundwater extraction

• Awareness campaigns on water conservation practices

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Q6. Air Pollution (10 marks)

Definition (Park's)

Types of Air Pollutants

• Primary pollutants: Emitted directly from source (automobiles, industry) - CO, SO₂, NO₂, particulate matter
• Secondary pollutants: Formed within atmosphere by chemical reactions - Ozone, photochemical smog
• Gaseous: CO, SO₂, H₂S, NOx, ozone, hydrocarbons
• Particulate: Dust, smoke, soot, fly ash, aerosols

Sources of Air Pollution

1. Automobiles - CO, hydrocarbons, lead, NOx, particulates
2. Industries - SO₂, NOx, CO, fly ash, fluorides
3. Domestic - coal, wood, oil burning → smoke, SO₂ (London disaster, 1952)
4. Tobacco smoke - most direct source affecting individual health ("passive smoking")
5. Miscellaneous - burning refuse, pesticide spraying, natural sources

Meteorological Factors

• Temperature inversion - cold air trapped below warm air; pollutants cannot disperse; leads to SMOG (common in winter)
• Wind, topography, humidity affect pollution levels

Major Pollutants and Effects

Health Effects of Air Pollution

• Immediate: acute bronchitis, suffocation (London fog 1952: thousands died)
• Delayed/Chronic: chronic bronchitis, lung cancer, bronchial asthma, emphysema, respiratory allergies
• Most vulnerable: elderly, children, smokers, chronic respiratory disease patients

Control of Air Pollution

1. Substitution - replace coal with cleaner fuels (gas, electricity)
2. Process changes - switch from leaded to unleaded petrol
3. Treatment of waste gases - catalytic converters in vehicles, scrubbers in industries
4. Dilution - tall chimneys, green belts between industrial and residential areas
5. Legislation - The Air (Prevention and Control of Pollution) Act, 1981 (India); Clean Air Acts
6. International action - WHO global air quality monitoring network
7. Disinfection of air - mechanical ventilation, UV radiation (OT/wards), chemical mists (triethylene glycol)

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Q7. Noise Pollution (10 marks)

Definition

Sources of Noise

1. Transportation - road traffic, aircraft, railways (major urban source)
2. Industrial - factories, construction sites, drilling
3. Domestic - TV, music systems, household appliances
4. Social - loudspeakers, firecrackers, public gatherings
5. Occupational - textile mills, metal workshops, airports

Measurement

• Decibel (dB) - unit of sound intensity
• dB(A) - A-weighted decibel scale (matches human ear response)

WHO Permissible Noise Levels

Health Effects of Noise

• Noise-Induced Hearing Loss (NIHL) - most important; irreversible
• Temporary Threshold Shift (TTS) - temporary hearing loss after acute exposure; recovers with rest
• Permanent Threshold Shift (PTS) - irreversible after prolonged exposure
• Acoustic trauma - sudden intense noise (explosion)

• Cardiovascular: hypertension, increased heart rate, vasoconstriction
• Psychological: stress, irritability, anxiety, sleep disturbance, reduced concentration
• Performance: reduced work efficiency, decreased productivity
• Endocrine: increased cortisol, catecholamines
• Interference with communication

Control of Noise Pollution

1. At source - use of silencers, mufflers, vibration dampers; engine redesign
2. During transmission - sound-insulating materials (double glazed windows), noise barriers/walls along highways, green belts
3. At receiver - ear muffs, ear plugs (most common occupational protection); limit exposure time
4. Land use planning - industries, airports away from residential areas
5. Legislation - Noise Pollution (Regulation and Control) Rules, 2000 (India)
6. Education - awareness about harmful effects of noise

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Q8. Radiation Hazards and Prevention (6/10 marks)

Types of Radiation

• Alpha particles - low penetration; dangerous if inhaled/ingested
• Beta particles - moderate penetration; skin burns
• Gamma rays - high penetration; most dangerous externally
• X-rays - similar to gamma rays
• Neutrons - highly penetrating

• Ultraviolet (UV) rays - from arc welding, sun
• Infrared rays - from molten metal, glass blowing, welding
• Microwaves, radiofrequency - mobile phones, radar

Sources of Occupational Exposure (Park's)

• Painting luminous dials (radium)
• Mining radioactive ores (uranium, monazite sand)
• X-ray use in medicine and industry
• Arc/electric welding (UV rays)
• Glass blowing, foundry work, welding (Infrared)
• Nuclear energy programmes

Health Effects

Units of Radiation

• Roentgen (R) - exposure dose of X/gamma rays
• Rad - absorbed dose (100 ergs/g tissue)
• Rem - dose equivalent (biological effect)
• Gray (Gy) = 100 rad; Sievert (Sv) = 100 rem (SI units)
• Maximum Permissible Dose (MPD): 5 rem/year for radiation workers

Prevention (Park's - 7 Measures)

1. Avoid inhalation, swallowing, or direct skin contact
2. Shielding - lead aprons, lead glass for X-rays; adequate material thickness
3. Monitoring - film badge or pocket electrometer every 6 months max for workers
4. Protective clothing against contact with harmful materials
5. Adequate ventilation to prevent inhalation of gases/dusts
6. Periodic examination of workers every 2 months; if effects found → transfer to non-radiation work
7. Pregnant women should NOT be allowed to work in areas of continuous radiation exposure

3 Principles of Radiation Protection (ALARA)

1. Justification - benefit must outweigh risk
2. Optimization / ALARA - As Low As Reasonably Achievable
3. Dose limitation - not exceed MPD

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Q9. Overcrowding (6 marks)

Definition

Criteria / Measurement

• Persons per room - most practical measure
• Room density standard: > 1.5 persons per room = overcrowding
• Air space standard: minimum 14 m³/person (Indian standard: 28-40 m³/person for adults)
• Floor area: minimum 4.5 m²/person

Causes

• Rapid urbanization, rural-urban migration
• Poverty and unaffordable housing
• Population explosion
• Slum development

Health Effects

1. Airborne diseases - TB, measles, influenza, meningitis, COVID-19; more efficient droplet/airborne spread
2. Contact diseases - scabies, ringworm, impetigo, conjunctivitis
3. Gastrointestinal diseases - due to shared toilets/water, poor hygiene
4. Mental health - stress, anxiety, violence, domestic abuse
5. Accidents - fire hazards, falls
6. Impaired sleep and reduced productivity
7. Promotes vector breeding (mosquitoes, rodents)

Control

• Urban planning and housing development
• Slum improvement programmes
• Regulation of minimum floor space per person (building codes)
• National Urban Housing Policy
• Rajiv Awas Yojana / Pradhan Mantri Awas Yojana (PMAY)

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Q10. Sanitation Barrier (6 marks)

Concept (Park's)

Definition of Sanitation Barrier

"In simple terms, this barrier can be provided by a sanitary latrine and a disposal pit. The more elaborate schemes envisage installation of a sewerage system and sewage treatment plants." - Park's

The Five "Fs" Blocked by Sanitation Barrier

• Faeces → stopped at source by latrine
• Fingers → hand washing (personal hygiene)
• Flies → proper disposal removes breeding ground
• Food → protection of food from contamination
• Fluids (Water) → proper water supply and treatment

Methods of Excreta Disposal

1. Service type latrines (bucket/pail type) - least preferred
2. Non-service (sanitary) latrines:
   • Bore hole latrine
   • Pit latrine
   • Water-seal latrines - PRAI type, RCA type, Sulabh Shauchalaya (most popular in India)
   • Septic tank
   • Aqua privy

• Water-carriage system with sewage treatment (primary, secondary, tertiary)

Swachh Bharat Mission

• India's national programme to achieve Open Defecation Free (ODF) status
• Constructing individual household latrines in rural and urban areas
• The sanitation barrier at national scale

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Q11. Breeding Places of Mosquitoes + Reasons + Control (10 marks)

Types of Mosquitoes and Their Breeding Places

Reasons Why These Are Breeding Places

• Mosquitoes require still or slow-moving water for egg-laying (oviposition)
• Larvae are aquatic and require water to complete development (egg → larva → pupa → adult)
• Anopheles needs clean water; Culex thrives in polluted water; Aedes uses stored clean water in small containers
• Temperature optimum: 25-30°C; favoured by tropical climate

Life Cycle

• Larval stage: 5-14 days in water
• Female mosquito requires blood meal for egg development

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Q12. Mosquito Control Measures (10 marks)

A. Anti-Larval Measures (Source Reduction)

• Drainage - filling, levelling, draining of stagnant water bodies
• Intermittent irrigation - dry rice fields every 7-10 days (breaks larval cycle)
• Removal of water from containers, old tyres, flower pots weekly
• Cleaning and covering water storage containers
• Anti-larval fish - Gambusia affinis (Larvivorous fish) - eats larvae; most eco-friendly method; used for Anopheles control
• Oreochromis mossambicus (Tilapia) also used

• Temephos (Abate) - organophosphate; 1 mg/L; safe for drinking water containers; used for Aedes
• Paris green (copper acetoarsenite) - only for Anopheles in rice fields; applied at 4-5 kg/acre
• Pyrethrum oil - applied to water surface; kills larvae
• Mineral oils / petroleum products - surface film suffocates larvae; 28 litres/acre

• Bacillus thuringiensis israelensis (Bti) - bacterial larvicide; highly specific; safe
• Bacillus sphaericus - for Culex
• Larvivorous fish (Gambusia, Tilapia)

B. Anti-Adult Measures

• Spraying insecticide on indoor walls/ceilings
• Resting mosquitoes killed when they sit on treated surfaces
• Insecticides: DDT, Malathion, Deltamethrin, Bifenthrin
• Done twice a year before and during malaria season

• Fogging (ULV) / Misting - insecticide dispersed as fine mist outdoors
• Kills adult mosquitoes in flight
• Used for dengue/chikungunya outbreaks

• Mosquito nets (bed nets, preferably ITNs - Insecticide-Treated Nets)
• LLINs (Long-Lasting Insecticide-treated Nets) - treated with permethrin, last 3-5 years
• Repellents: DEET (diethyl toluamide), Citronella oil, Picaridin
• Protective clothing (full sleeves, socks)
• Window and door screens

• Pyrethroid-based products for indoor use

C. Integrated Vector Management (IVM)

• Environmental management (source reduction)
• Biological control
• Chemical control (judicious use)
• Personal protection
• Community participation

D. Legal Measures

• Prevention of Food Adulteration Act / Public Health Acts empower authorities to eliminate mosquito breeding sites
• Community notification to remove stagnant water around premises

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The Employees' State Insurance (ESI) Act, 1948

From Park's Textbook of Preventive and Social Medicine

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1. Introduction

• Sickness
• Maternity
• Employment injury

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2. Historical Background

• Adarkar's Report on Health Insurance for Industrial Workers (1945)
• Report of the Health Survey and Development Committee (1946)
• Thomas Bedford's Report on Health of Industrial Workers (1946)
• Jones's Report on Health of Workers in Plantation (1947)

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3. Scope / Coverage

Original Coverage (1948):

• All power-using factories (excluding mines, railways, defence) employing 10 or more persons
• Excluded seasonal factories

Extended by Amendment Act 1975 to:

Wage Ceiling:

• Effective 1.5.2010: employees earning up to Rs. 15,000/month covered
• Revised to Rs. 21,000/month w.e.f. 6.9.2016
• Employees earning daily wages below Rs. 176 are exempted from contribution

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4. Administration

Infrastructure (as on 31.3.2020):

• Beneficiaries: ~13.24 crore
• Coverage: ~341 lakh family units in 7.83 lakh factories/establishments
• 1526 ESI dispensaries
• 1753 panel clinics
• 307 diagnostic centres
• 159 ESI hospitals + 42 hospital annexes
• > 22,600 beds
• 559 branch offices, 185 cash offices, 406 inspection offices

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5. Finance (Contributions)

Employees earning daily wages < Rs. 176 are exempted from contributions but still eligible for all benefits.

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6. Benefits to Employees (7 Benefits)

(1) Medical Benefit - Most Important

1. Out-patient care
2. Supply of drugs and dressings
3. Specialist services (all branches of medicine)
4. Pathological and radiological investigations
5. Domiciliary services
6. Antenatal, natal and postnatal services
7. Immunization services
8. Family planning services
9. Emergency services
10. Ambulance services
11. Health education
12. In-patient treatment

• Also: dentures, spectacles, hearing aids free for employment injury
• Artificial limbs free for those who lose limbs due to employment injury

• Direct pattern: ESI dispensaries (full-time for ≥1000 employee family units; part-time for <750; mobile dispensaries for scattered areas)
• Indirect pattern (Panel system): Registered Medical Practitioners appointed as Insurance Medical Practitioners (IMPs)

• "Restricted medical care" = outpatient care only for families
• "Expanded medical care" = full care except hospitalization for families

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(2) Sickness Benefit

• Cash payment certified by Insurance Medical Officer/Practitioner
• Payable for maximum 91 days in any continuous period of 365 days
• Daily rate: approximately 70% of average daily wages

• For 34 specified long-term diseases (must be in continuous employment for 2 years)
• Payable for maximum 2 years
• Selected diseases include:
  • TB, Leprosy, AIDS (Infectious)
  • Malignant diseases (Cancer)
  • Diabetes with complications
  • Neurological disorders (hemiplegia, paraplegia)
  • Cardiac diseases (MI, CHF, Cardiomyopathy)
  • Renal failure / Transplant

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(3) Maternity Benefit

• For confinement (delivery)
• Payable for 26 weeks (12 weeks before + 6 weeks after expected date of delivery)
• For miscarriage/MTP: 6 weeks
• At rate of full wages (double the sickness benefit rate)

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(4) Disablement Benefit

• For temporary disablement due to employment injury
• Payable as long as disablement lasts at full wages (100% of daily wages)
• For permanent disablement: pension for life based on loss of earning capacity
• Permanent total disablement: same rate as temporary disablement (100% of wages)

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(5) Dependant's Benefit

• Pension to dependants of insured worker who dies due to employment injury
• Widow receives pension for life (or until remarriage)
• Children until age 18 (or 25 if unmarried female)
• Aggregate not to exceed the full rate paid for total permanent disablement

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(6) Funeral Expenses

• Lump sum payment to person performing last rites of deceased insured person
• Amount: Rs. 15,000 (revised)

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(7) Rehabilitation Allowance

• For insured persons who suffer permanent disablement and undergo vocational rehabilitation at a recognised institution
• Paid during rehabilitation period

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(8) Unemployment Allowance (Rajiv Gandhi Shramik Kalyan Yojana)

• For insured persons losing employment involuntarily (factory closure, retrenchment, permanent invalidity from non-employment injury)
• Must have contributed for 5 or more years
• Allowance for maximum 6 months (in one or multiple spells of ≥1 month)
• Medical care also continues during unemployment allowance period

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7. Summary Table - Key Facts

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8. Exam Memory Trick - Benefits (S M D D F R U)

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IUD (Intrauterine Contraceptive Device) and Hormonal Contraceptives

From Park's Textbook of Preventive and Social Medicine

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PART A: INTRAUTERINE CONTRACEPTIVE DEVICE (IUCD)

1. Definition

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2. Types / Generations of IUDs

First Generation - Inert / Non-Medicated Devices

• Made of polyethylene or other polymers
• Shapes: loops, spirals, coils, rings, bows
• Best known: Lippes Loop

• Double-S shaped device made of polyethylene (non-toxic, non-tissue reactive)
• Contains barium sulphate (for X-ray visibility)
• Has a nylon tail/thread projecting into vagina - confirms position, aids removal
• Available in 4 sizes: A, B, C, D (D = largest)
• Larger sizes (C, D) suitable for multiparous women
• Larger size = greater anti-fertility + lower expulsion, but higher removal rate (more side effects)

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Second Generation - Copper-Bearing Devices

• Metallic copper added to IUD in 1970s - strong anti-fertility effect
• Smaller; easier to fit even in nulliparous women

• The number indicates copper surface area in mm² - effectiveness proportional to copper area
• Cu-T-380A (IUCD 380A): Effective for 10 years; pregnancy rate only 0.5-0.8%/year - used under India's National Family Planning Programme
• IUCD 375: Effective for 5 years

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Third Generation - Hormone-Releasing Devices

• Release progesterone or levonorgestrel locally

• Levonorgestrel IUD: lowest pregnancy rate - 0.2%/year

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3. Mechanism of Action (Park's)

"The most widely accepted view is that the IUD causes a foreign-body reaction in the uterus causing cellular and biochemical changes in the endometrium and uterine fluids, impairing viability of the gamete and reducing chances of fertilization."

• Copper enhances cellular response in endometrium
• Alters biochemical composition of cervical mucus
• Affects sperm motility, capacitation and survival

• Increases viscosity of cervical mucus → prevents sperm entry
• Maintains high progesterone in endometrium → unfavourable for implantation
• Inhibits ovulation (with LNG-IUS)

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4. Effectiveness

Overall pregnancy rate: 3-5 per 100 typical users in first year. "Theoretical effectiveness" of IUD is less than oral/injectable pills, but due to higher continuation rates, overall effectiveness is about the same in family planning programmes.

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5. Timing of Insertion

• Any time during menstrual cycle if not pregnant
• Preferably during or just after menstruation
• Post-partum: After 6 weeks (not between 48 hours and 6 weeks - higher perforation risk)
• Post-abortion: Immediately after (first trimester)
• Post-coital (emergency): Within 5 days of unprotected sex

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6. Contraindications

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7. Complications / Side Effects

(1) Menstrual Problems - Most Common

• Increased menstrual blood loss (esp. inert/copper devices) → anaemia
• Intermenstrual bleeding and spotting
• Dysmenorrhoea (painful periods)
• Hormone-releasing devices REDUCE blood loss - benefit

(2) Pain

• Cramp-like lower abdominal pain especially after insertion
• Usually subsides with analgesics

(3) Pelvic Inflammatory Disease (PID) - Important

• IUD users are 2-8 times more likely to develop PID
• Risk highest in first few months after insertion
• Organisms: Gardnerella, Anaerobic streptococci, Bacteroides, Coliforms, Actinomyces
• Bacteria ascend via IUD tail from lower genital tract
• Even 1-2 episodes of PID can cause permanent infertility (blocked tubes)
• Management: broad-spectrum antibiotics; remove IUD if no response in 24-48 hours

(4) Uterine Perforation

• Incidence: 1:150 to 1:9000 insertions
• With trained physicians: not higher than 0.3%
• Device may migrate into peritoneal cavity → intestinal obstruction
• Copper devices cause intense tissue reaction → peritoneal adhesions
• Diagnosed by pelvic X-ray
• Higher risk: insertion between 48 hours and 6 weeks postpartum

(5) Expulsion

• More common in: young women, nulliparous women, postpartum insertion
• Usually in first few weeks or during menstruation
• 20% of expulsions go undetected → may lead to pregnancy
• Expulsion rates: copper < inert devices

(6) Pregnancy

• Actual use failure rate: ~3% in first year
• If pregnancy occurs with IUD in situ → increased risk of ectopic pregnancy and spontaneous abortion
• If intrauterine pregnancy: IUD should be removed if thread visible

(7) Ectopic Pregnancy

• IUD protects against intrauterine pregnancy but does NOT protect equally against ectopic pregnancy
• If pregnancy occurs despite IUD → increased risk of ectopic

(8) Fertility After Removal

• Fertility NOT impaired if no episode of PID
• >70% conceive within 1 year of IUD removal

(9) Cancer/Teratogenesis

• NO evidence that IUD use increases cancer risk
• No evidence of congenital malformations in offspring

(10) Mortality

• Extremely rare: 1 death per 100,000 woman-years
• IUD is safer than oral contraceptives in mortality - especially in older/high-risk patients

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8. Advantages of IUD

• Highly effective long-term reversible contraception
• Independent of coitus (no need to remember daily)
• Does not interfere with lactation
• No systemic metabolic effects (inert/copper devices)
• Cost-effective (long life)
• High continuation rates
• Suitable for women who cannot take hormonal pills

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PART B: HORMONAL CONTRACEPTIVES

1. Classification of Hormonal Contraceptives

Hormonal Contraceptives
├── Oral (Pills)
│   ├── Combined (Estrogen + Progestogen)
│   │   ├── Monophasic
│   │   ├── Biphasic
│   │   └── Triphasic
│   ├── Progestogen-only (Mini-pill)
│   └── Emergency contraceptive pill
├── Injectable
│   ├── Progestogen-only (DMPA, NET-EN)
│   └── Combined (monthly injection)
├── Implants (Subdermal)
├── Vaginal rings
└── Hormonal IUS (LNG-IUS/Mirena)

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2. Combined Oral Contraceptive Pills (COC)

Composition

• Estrogen component: Ethinyl estradiol (EE) - 20, 30, 35 or 50 mcg
• Progestogen component: Levonorgestrel, Norgestrel, Norethisterone, Desogestrel, Drospirenone

Types in India (National Programme)

How to Take the Pill

• Start on 5th day of menstrual period (strictly)
• Take daily at fixed time (preferably at night)
• 21 pills taken, then 7-day break → withdrawal bleeding occurs
• Not true menstruation; loss is about half of normal
• If a pill is missed: take it as soon as remembered + take next pill at usual time

Mode of Action (Park's)

1. Inhibits ovulation - blocks pituitary secretion of gonadotropins (FSH, LH)
2. Thickens cervical mucus → inhibits sperm penetration (progestogen)
3. Alters endometrium → unfavourable for implantation
4. Inhibits tubal motility → delays sperm and ovum transport

Effectiveness

• Almost 100% effective when taken correctly (theoretical)
• Actual use: pregnancy rate < 1%/year in developed countries
• Reduced effectiveness with: Rifampicin, Phenobarbitone, Ampicillin (enzyme inducers)

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3. Progestogen-Only Pill (Mini-pill)

• Contains only progestogen (Norethisterone, Levonorgestrel)
• Mechanism: thickens cervical mucus, inhibits tubal motility; does NOT reliably inhibit ovulation
• Disadvantages: poor cycle control, higher pregnancy rate than combined pill
• Indications: women for whom combined pill is contraindicated (cardiovascular risk, older women >35 years, lactating women)

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4. Injectable Contraceptives

a. DMPA (Depot Medroxyprogesterone Acetate) - "Antara Programme" in India

b. NET-EN (Norethisterone Enantate)

• Dose: 200 mg IM every 2 months (60 days)
• Slightly higher failure rate (0.4%) than DMPA
• Available since 1966

c. DMPA-SC (Subcutaneous)

• Dose: 104 mg subcutaneously (lower than IM)
• Given every 3 months

Combined Monthly Injectable

• Medroxyprogesterone 25 mg + Estradiol cypionate 5 mg
• One IM injection every 28-30 days
• Trade names: Cyclofem, Lunelle

Mode of Action of Injectables

• Inhibit ovulation (primary)
• Progestogenic effects on cervical mucus → sperm cannot penetrate
• Alter endometrium

Side Effects of Injectables

• Menstrual irregularities (most common) - spotting, amenorrhoea
• Weight gain
• Delayed return of fertility (average 10-12 months after last injection)
• No protection against STIs

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5. Adverse Effects of Combined Oral Pills

a. Cardiovascular Effects

• Deep vein thrombosis (DVT) and pulmonary embolism - due to estrogen component
• Myocardial infarction - risk increased, especially in smokers over 35
• Hypertension - small but real increase in BP
• Current low-dose pills (30-35 mcg EE) have much reduced risk compared to earlier high-dose pills

b. Neoplastic Effects

• Cervical cancer: Slightly increased risk with long-term use
• Breast cancer: Very small/no overall increase in risk
• Liver tumours: Rare benign hepatic adenoma associated with use
• PROTECTIVE against: endometrial cancer, ovarian cancer, benign breast disease, ovarian cysts

c. Other Adverse Effects

• Nausea, vomiting (especially initial weeks)
• Headache, breast tenderness
• Mood changes, depression
• Breakthrough bleeding (spotting)
• Chloasma (skin pigmentation)
• Weight gain

d. Effects on Fertility After Stopping

• Post-pill amenorrhoea - delay in return of menstruation
• Fertility does return; most women conceive within 1-2 years

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6. Benefits of Combined Oral Pills

1. Nearly 100% effective when used correctly
2. Reduces menstrual blood loss and dysmenorrhoea
3. Protection against endometrial and ovarian cancer
4. Reduces benign breast disease and ovarian cysts
5. Reduces PID (thickened cervical mucus)
6. Treats endometriosis and PCOS
7. Regularizes menstrual cycle
8. Reversible - fertility returns after stopping

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7. Contraindications to OCP

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8. Emergency Contraception (Post-coital)

• Failure rate: < 1%
• Emergency only - NOT for regular use

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9. Summary Comparison Table

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