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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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