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CHAPTER 6: COMMUNICABLE DISEASES — SORTED QUESTION LIST

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🔴 MALARIA (Long Essay Questions)

1. Strategies under National Vector Borne Diseases Control Programme (NVBDCP)
2. General guidelines for treatment of uncomplicated malaria as per National Drug Policy on March 2013
3. Write a brief note on integrated vector control
4. Reasons for persistence of malaria, ABER and API and importance of APP
5. Epidemiology of malaria and vector control strategies to prevent malaria in your PHC area
6. Clinical feature, mode of transmission and chemoprophylaxis of malaria
7. Instruction to health workers in the urban center for surveillance of fever cases
8. Long-term control measures for an outbreak of malignant malaria cases by the Block Medical Officer of Health
9. National Anti-Malaria Programme
10. Epidemiological aspects of kala-azar and strategies for control of disease (in a rural area)

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🔴 MALARIA (Short Notes)

1. Discuss surveillance of malaria
2. Malariometric measures
3. Slide positivity rate
4. Major epidemiological types of malaria
5. Aedes aegypti index
6. Radical treatment for vivax malaria
7. Factors responsible for resurgence of malaria
8. Approaches of malaria control
9. Difference between mosquito and sandfly
10. Enumerate the causes of resurgence of kala-azar
11. Enumerate mosquito-borne diseases
12. Integrated vector management
13. Man-made malaria
14. Comment on malaria week
15. Measures for control of urban malaria

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🔴 AIDS / HIV (Long Essay Questions)

1. Epidemiology of AIDS
2. National AIDS Control Program along with NACO
3. Various methods by which the disease can be prevented
4. Name of common STDs, measures for prevention and control with reference to HIV/AIDS
5. Syndromic approach in management of STDs
6. Role of (pre-test and post-test) counseling in controlling HIV/AIDS
7. As a BMOH, role of arranging health education programme in your area regarding HIV
8. One pregnant woman whose husband was found to be HIV positive, came to OPD on 2nd trimester, management of the case and advice for the couple

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🔴 AIDS / HIV (Short Notes)

1. What do you mean by HIV/AIDS?
2. Clinical manifestations / WHO criteria for diagnosis of AIDS and its control
3. What is ARC?
4. Mention modes of transmission of HIV/AIDS
5. List vertically transmitted diseases, prevention of parent to child transmission of HIV
6. Explain role of high-risk group and bridge population in HIV transmission / AIDS is no longer limited to high-risk population
7. HIV is a behavioral disease
8. Enumerate the various RTI/STI syndromes
9. Common complication of STDs
10. Describe risk factors of HIV/AIDS
11. ICTC should be supported by ART/link ART center
12. Opportunistic infections in AIDS
13. What is window period?
14. Contact tracing in STIs
15. Screening for diseases in blood bank
16. Universal precaution
17. Describe in brief the guidelines for PEP in HIV/AIDS (post-exposure prophylaxis) in health care settings
18. Treatment 2.0 of HIV and AIDS

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🔴 TUBERCULOSIS (Long Essay Questions)

1. Discuss the epidemiology of tuberculosis
2. Define goals and objectives of RNTCP. Describe various components of DOTS strategy
3. National Program on Control of Tuberculosis in India including strategies and components in RNTCP
4. The diagnostic process for initiation of treatment of TB under RNTCP
5. Category I and II and MDR, XDR TB
6. RNTCP in Bihar or any state of India
7. Cardinal symptoms for pulmonary TB, organogram of RNTCP in a primary health center area
8. Different levels of prevention and mode of interventions as applied to pulmonary tuberculosis

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🔴 TUBERCULOSIS (Short Notes)

1. RNTCP gives priority on detection of New Smear Positive cases
2. Sputum smear examination is the method of choice for case finding in TB
3. Passive surveillance in tuberculosis
4. Collection of sputum sample in tuberculosis
5. Describe in details DOTS plus

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🔴 REMAINING QUESTIONS (Other Topics — in original order)

1. Diseases of public health importance in NVBDCP and its principles
2. Epidemiology of lymphatic filariasis and its control in India
3. Epidemiology, clinical presentations and classification of Dengue fever and its control
4. The arboviral diseases, epidemiology, clinical features, control of Japanese encephalitis
5. Clinical feature, diagnosis, treatment, control of Chikungunya fever
6. Problems, epidemiological factors and prevention of rabies
7. WHO categories of exposure in rabies
8. Prevention of human rabies
9. What is pre-exposure prophylaxis?
10. Measures for minimizing human rabies in the area
11. Epidemiology of leprosy
12. Classification, diagnosis and treatment (MDT as per WHO) of leprosy
13. Brief control methods with reference to NLEP
14. Different modes of intervention under levels of prevention in relation to leprosy
15. The steps for elimination of leprosy
16. Diagnosis of plague and its control measures
17. Epidemiology of poliomyelitis
18. Polio eradication in the light of epidemiological factors influencing poliomyelitis
19. AFP in brief, various strategies for eradication of poliomyelitis including the surveillance of AFP, environmental surveillance
20. Different levels of prevention and modes of intervention can be applied to poliomyelitis
21. The epidemiology, prevention and control of hepatitis B in India
22. Epidemiology, clinical features, diagnosis, management and prevention and control of swine flu (H1N1) / swine flu / diagnosis and prevention of swine flu
23. Integrated Disease Surveillance Programme (IDSP)
24. Mode of transmission of arthropod-borne diseases / What are the arthropod-borne diseases, control of vectors?
25. Environmental control - best approach to control of arthropods
26. Define blanket treatment with examples
27. Assessment of filarial control programme
28. Why filariasis never causes explosive epidemic?
29. What is night blood examination?
30. Suraksha clinic
31. The different presentation of leprosy to be encountered in out-patient department of hospitals
32. Leprosy eradication is very difficult to achieve
33. Indicators that are used by health workers to assess the disability of leprosy cases in field level
34. Lepromin test
35. Lepra reaction
36. Fixed virus
37. Essen regimen and rabies immunoglobulin for passive immunization in post-exposure
38. Hepatitis B infection should be considered more dangerous than HIV infection
39. Blocked flea / Partial blocked fleas are more dangerous
40. What is provocative poliomyelitis
41. Cyclops
42. What is Chandler's index?
43. Epidemiology and prevention of Ebola virus disease / Ebola virus disease
44. All influenza pandemics were caused by influenza virus A and not by B or C
45. What is antigenic shift and antigenic drift?
46. SAFE strategy for trachoma
47. Inappropriate and inadequate use of antibiotics leads to antimicrobial resistance
48. What is the criteria for successful parasitism?
49. Australia antigen
50. Serological marker of Hepatitis B
51. Measures to prevent entry of yellow fever into India
52. India is yellow fever receptive area

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• All AIDS/HIV questions are grouped together (Long Essay first, then Short Notes)
• All Malaria questions are grouped together (Long Essay first, then Short Notes)
• All TB questions are grouped together (Long Essay first, then Short Notes)
• No duplicates were found in the original list (all questions were unique)
• The remaining topics (Leprosy, Rabies, Polio, Hepatitis, Filariasis, etc.) follow in their original order

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CHAPTER 6: COMMUNICABLE DISEASES — FULLY SORTED

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🔴 MALARIA

1. Strategies under National Vector Borne Diseases Control Programme (NVBDCP)
2. Diseases of public health importance in NVBDCP and its principles
3. General guidelines for treatment of uncomplicated malaria as per National Drug Policy on March 2013
4. Write a brief note on integrated vector control
5. Reasons for persistence of malaria, ABER and API and importance of APP
6. Epidemiology of malaria and vector control strategies to prevent malaria in your PHC area
7. Clinical feature, mode of transmission and chemoprophylaxis of malaria
8. Instruction to health workers in the urban center for surveillance of fever cases
9. Long-term control measures for an outbreak of malignant malaria cases by the Block Medical Officer of Health
10. National Anti-Malaria Programme

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🔴 AIDS / HIV & STIs

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🔴 TUBERCULOSIS

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🔴 LEPROSY

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🔴 POLIOMYELITIS

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🔴 RABIES

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🔴 HEPATITIS

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🔴 FILARIASIS

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🔴 VECTOR-BORNE & ARTHROPOD-BORNE DISEASES (General)

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🔴 INFLUENZA & VIRAL RESPIRATORY DISEASES

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🔴 PLAGUE

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🔴 TRACHOMA & ANTIMICROBIAL RESISTANCE

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🔴 PARASITOLOGY / GENERAL MICROBIOLOGY

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🔴 SURVEILLANCE & PUBLIC HEALTH PROGRAMMES

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🔴 MALARIA — Long Essay Questions

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Q1. Strategies under National Vector Borne Diseases Control Programme (NVBDCP)

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• Active and passive surveillance of fever cases
• Peripheral fever treatment depots (FTDs) at village level
• Rapid Diagnostic Tests (RDTs) for quick diagnosis
• Complete treatment with ACT (Artemisinin Combination Therapy) for P. falciparum
• Radical treatment with Primaquine for P. vivax (14 days)

• Indoor Residual Spraying (IRS) with DDT / Malathion / Synthetic pyrethroids
• Larval source management - anti-larval measures (Paris green, Temephos)
• Biological control - Gambusia fish, Bacillus thuringiensis israelensis (Bti)
• Personal protection - insecticide-treated bed nets (ITNs), Long-Lasting Insecticidal Nets (LLINs)
• Environmental management - drainage, filling of breeding sites

• Sentinel surveillance sites
• Stockpiling of drugs, insecticides, diagnostics
• Rapid response teams at district level

• Behaviour Change Communication (BCC)
• Inter-sectoral convergence (with water, sanitation, agriculture departments)
• Capacity building of health workers (ASHAs, ANMs, MPWs)
• Public-private partnership

• Focus on tribal, forest, hard-to-reach areas
• Annual Blood Examination Rate (ABER) target: minimum 10% of population
• Slide Positivity Rate (SPR) and Annual Parasite Incidence (API) monitoring

• API < 1 per 1000 population = elimination target
• District-wise mapping of malaria burden
• HMIS reporting

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🔴 MALARIA — Q2

Q2. Diseases of Public Health Importance in NVBDCP and its Principles

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1. MALARIA

• Caused by Plasmodium species (P. vivax, P. falciparum, P. malariae, P. ovale)
• Vector: Female Anopheles mosquito
• Public health importance: Leading cause of fever-related morbidity in India; P. falciparum causes cerebral malaria and death
• High burden states: Odisha, Jharkhand, Chhattisgarh, MP, NE states

2. DENGUE

• Caused by Dengue virus (4 serotypes - DEN 1, 2, 3, 4)
• Vector: Aedes aegypti (day-biting mosquito)
• Public health importance: Urban epidemic potential; Dengue Hemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS) are life-threatening
• No specific treatment; only supportive care

3. CHIKUNGUNYA

• Caused by Chikungunya virus (Alphavirus)
• Vector: Aedes aegypti and Aedes albopictus
• Public health importance: Causes debilitating joint pain; large urban outbreaks possible

4. JAPANESE ENCEPHALITIS (JE)

• Caused by JE virus (Flavivirus)
• Vector: Culex tritaeniorhynchus mosquito
• Public health importance: High case fatality rate (20-30%); neurological sequelae in survivors
• Endemic in UP, Bihar, Assam, West Bengal

5. KALA-AZAR (Visceral Leishmaniasis)

• Caused by Leishmania donovani
• Vector: Female sandfly (Phlebotomus argentipes)
• Public health importance: 100% fatal if untreated; target for elimination (< 1 case per 10,000 population at block level by 2023)
• Endemic in Bihar, Jharkhand, UP, West Bengal

6. LYMPHATIC FILARIASIS

• Caused by Wuchereria bancrofti
• Vector: Culex quinquefasciatus
• Public health importance: Causes lymphoedema, hydrocele, elephantiasis - permanent disability; huge social stigma
• Target: Elimination as public health problem

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• ABER (Annual Blood Examination Rate) - target ≥ 10%
• API (Annual Parasite Incidence) - target < 1 for elimination
• SPR (Slide Positivity Rate)
• ABER for Filariasis - Microfilaria rate

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🔴 MALARIA — Q3

Q3. General Guidelines for Treatment of Uncomplicated Malaria as per National Drug Policy on March 2013

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TREATMENT OF P. vivax (Uncomplicated)

• Primaquine is given to eliminate hypnozoites (dormant liver stage)
• Contraindicated in G6PD deficiency, pregnancy, infants < 6 months
• G6PD testing before Primaquine in endemic areas

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TREATMENT OF P. falciparum (Uncomplicated)

In NE States (where resistance is high):

In Rest of India:

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TREATMENT OF MIXED INFECTION (P. vivax + P. falciparum)

• Treat as P. falciparum with ACT (3 days)
• Add Primaquine 0.25 mg/kg/day for 14 days (for vivax radical cure)

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TREATMENT OF P. falciparum IN PREGNANCY

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SEVERE / COMPLICATED MALARIA

• Artesunate IV/IM is drug of choice (replaced Quinine)
• Artesunate 2.4 mg/kg IV at 0, 12, 24 hours, then daily
• Shift to oral ACT once patient can tolerate oral medication
• Manage complications: cerebral malaria, hypoglycemia, severe anemia, renal failure

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KEY POINTS OF 2013 POLICY:

1. ACT replaced Chloroquine as first-line for P. falciparum across India
2. Artesunate IV replaced Quinine for severe malaria
3. Primaquine single dose (0.75 mg/kg) added for P. falciparum to kill gametocytes and reduce transmission
4. 14-day Primaquine mandatory for P. vivax radical cure
5. Chloroquine monotherapy no longer recommended for P. falciparum
6. RDT (Rapid Diagnostic Test) to be used where microscopy not available before starting treatment
7. Do not start treatment without parasitological confirmation (microscopy or RDT)

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• Chloroquine alone for P. falciparum
• Artemisinin monotherapy (to prevent resistance)
• SP (Sulfadoxine-Pyrimethamine) as first-line

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🔴 MALARIA — Q4

Q4. Write a Brief Note on Integrated Vector Control (IVC) / Integrated Vector Management (IVM)

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• Defined by WHO (2004)
• It is the cornerstone of NVBDCP vector control strategy

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• Single method of vector control is insufficient
• Insecticide resistance developing in vectors
• Environmental concerns with chemical use
• Cost-effectiveness demands combination approach
• Multiple diseases share same vector (e.g., Aedes for Dengue + Chikungunya)

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COMPONENTS OF INTEGRATED VECTOR MANAGEMENT:

1. CHEMICAL METHODS

• Spraying of insecticides on indoor walls and surfaces
• Kills mosquitoes when they rest on walls after blood meal
• Insecticides used: DDT, Malathion, Synthetic Pyrethroids (Deltamethrin, Cyfluthrin)
• Done twice a year in high-transmission areas

• Thermal fogging or cold fogging
• Used during outbreaks of Dengue / Chikungunya
• Kills adult mosquitoes in the air
• Pyrethrum extract used

• Application of chemicals to breeding sites
• Temephos (Abate) - organophosphate larvicide
• Used in water bodies where biological control not feasible

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2. BIOLOGICAL METHODS

• Gambusia affinis and Poecilia reticulata (Guppy fish)
• Introduced into wells, ponds, rice fields
• Eats mosquito larvae
• Most widely used biological control in India

• Bacillus thuringiensis israelensis (Bti) - kills Anopheles and Aedes larvae
• Bacillus sphaericus - kills Culex larvae
• Eco-friendly, no harm to non-target organisms

• Cyclops (copepod crustacean) - predator of Aedes larvae
• Used in water storage containers

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3. ENVIRONMENTAL MANAGEMENT

• Elimination / modification of breeding sites
• Draining stagnant water, filling low-lying areas
• Proper solid waste disposal
• Covering water storage containers

• Permanent changes - land filling, drainage construction
• Irrigation management - intermittent irrigation in rice fields

• Temporary changes - flushing canals, changing water salinity

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4. PERSONAL PROTECTION MEASURES

• Insecticide Treated Nets (ITNs) - impregnated with Permethrin/Deltamethrin
• Long Lasting Insecticidal Nets (LLINs) - effective for 3-5 years without re-treatment
• Repellents - DEET (Diethyl toluamide), Neem oil
• Protective clothing - full sleeves, light colors
• Wire mesh on windows and doors
• Mosquito coils, mats, vaporizers

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5. LEGISLATIVE / REGULATORY MEASURES

• Anti-larval bylaws by municipal corporations
• Penalty for allowing mosquito breeding in premises
• House-to-house inspection during outbreaks
• Container index surveys

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6. COMMUNITY PARTICIPATION

• Jan Andolan (public movement)
• Dry Day - every Friday (emptying water containers)
• School health education
• Self-help groups involvement
• ASHAs and AWWs as frontline workers

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PRINCIPLES OF IVM (WHO):

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• Delays insecticide resistance
• More cost-effective
• Environmentally safe
• Sustainable long-term impact
• Covers multiple vector-borne diseases simultaneously

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🔴 MALARIA — ALL REMAINING QUESTIONS (Q5 to Q21)

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Q5. Reasons for Persistence of Malaria, ABER, API and Importance of APP

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• Drug resistance - Chloroquine resistance in P. falciparum
• Multiple Plasmodium species (P. vivax relapses from hypnozoites)
• Artemisinin partial resistance emerging in NE India

• Insecticide resistance in Anopheles mosquitoes (to DDT, HCH)
• Multiple vector species (An. culicifacies, An. stephensi, An. fluviatilis, An. minimus)
• Behavioral changes in vectors (outdoor resting, early biting)
• Adaptability to new breeding sites

• Deforestation, mining, construction activities creating new breeding sites
• Irrigation projects, dams, waterlogged areas
• Urbanization - An. stephensi thriving in urban water storage
• Climate change - extending transmission season and geography

• Poverty - poor housing, no bed nets
• Migration of labor (tribal workers, construction workers) from high endemic to low endemic areas
• Forest dwellers, tribal populations - difficult to reach
• Low health-seeking behavior

• Inadequate surveillance (low ABER)
• Irregular / incomplete treatment
• Shortage of drugs, RDTs, insecticides
• Weak health infrastructure in tribal/remote areas
• Poor inter-sectoral coordination

• Irregular IRS coverage
• Resistance to insecticides not monitored regularly
• Inadequate BCC activities

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ABER - Annual Blood Examination Rate

• Definition: Number of blood smears examined per 100 population per year
• Formula: ABER = (Blood smears examined in a year / Total population) × 100
• Target: Minimum 10% of the population (i.e., ABER ≥ 10)
• Significance:
  • Measures intensity of surveillance
  • Low ABER = poor surveillance = underreporting
  • High-risk areas need higher ABER

API - Annual Parasite Incidence

• Definition: Number of confirmed malaria cases per 1000 population per year
• Formula: API = (Confirmed malaria cases in a year / Total population) × 1000
• Classification by API:

• Significance:
  • Best single indicator of malaria burden
  • Used for resource allocation
  • Monitors programme progress
  • India's target: API < 1 (elimination)

SPR - Slide Positivity Rate

• Formula: SPR = (Positive slides / Total slides examined) × 100
• If SPR > 5% = high transmission area

APP - Annual Falciparum Incidence / Annual P. falciparum Proportion

• Definition: Proportion of P. falciparum cases among total malaria cases
• Formula: APP = (P. falciparum cases / Total malaria cases) × 100
• Importance of APP:
  • P. falciparum causes severe and fatal malaria
  • High APP = high risk of cerebral malaria, death
  • Guides choice of drug (ACT needed for P. falciparum)
  • Identifies areas needing intensive intervention
  • Districts with high APP get priority for ACT supply and LLINs
  • Monitors shift from P. vivax to P. falciparum dominance

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Q6. Epidemiology of Malaria and Vector Control Strategies to Prevent Malaria in Your PHC Area

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• Plasmodium vivax - most common in India (~50%)
• Plasmodium falciparum - most dangerous (~45-47%)
• P. malariae, P. ovale - rare
• P. knowlesi - zoonotic, emerging in NE India

• Universal susceptibility
• Partial immunity develops after repeated infections
• High-risk groups: children < 5 years, pregnant women, non-immune migrants, tribal populations
• Sickle cell trait provides some protection against P. falciparum

• Female Anopheles mosquito (20 species in India, 6 are major vectors)
• Major vectors:
  • An. culicifacies - rural plains
  • An. stephensi - urban, breeds in overhead tanks
  • An. fluviatilis - hilly, forest areas
  • An. minimus - NE India
  • An. sundaicus - coastal areas
  • An. dirus - forest areas

• High temperature (20-30°C), high humidity
• Rainy season (July-November) - peak transmission
• Stagnant water bodies for breeding
• Forest and tribal areas - high burden

• Bite of infected female Anopheles (mainly between dusk and dawn)
• Blood transfusion, needle sharing, congenital (rare)

• P. vivax / P. ovale: 12-17 days (can be up to 6-12 months with hypnozoites)
• P. falciparum: 9-14 days
• P. malariae: 18-40 days

• 90% of cases from 8 states: Odisha, Chhattisgarh, Jharkhand, MP, Maharashtra, Gujarat, Rajasthan, NE states
• Odisha alone contributes ~25-30% of national malaria burden
• Urban malaria rising (An. stephensi)

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• Weekly anti-larval operations in all known breeding sites
• Application of Temephos (Abate) to water bodies
• Releasing Gambusia fish in ponds, wells, irrigation channels
• Filling and draining of small water collections
• Oiling of water surfaces

• Indoor Residual Spraying (IRS) twice a year before transmission season
• Space spraying / fogging during outbreaks
• Use of Pyrethrum space spray

• Distribution of LLINs (Long Lasting Insecticidal Nets) to high-risk families
• Promotion of repellents, mosquito coils
• Health education on protective clothing

• Maintaining ABER ≥ 10%
• Active fever case detection by MPW/ASHA every 2 weeks
• Passive surveillance through OPD
• Malaria clinic in high-burden PHCs

• Blood smear / RDT for all fever cases
• Immediate treatment: ACT for P. falciparum, Chloroquine + Primaquine for P. vivax
• Follow-up to ensure complete treatment

• Friday "Dry Day" - emptying water containers
• Involving Panchayati Raj institutions
• ASHA home visits for fever surveillance

• Weekly reporting of cases to district
• Immediate reporting of outbreaks / deaths

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Q7. Clinical Feature, Mode of Transmission and Chemoprophylaxis of Malaria

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• P. vivax / P. ovale: Every 48 hours (tertian / benign tertian fever)
• P. falciparum: Every 48 hours (malignant tertian - irregular initially)
• P. malariae: Every 72 hours (quartan fever)

• Anemia (due to RBC destruction)
• Splenomegaly (repeated infections)
• Hepatomegaly
• Jaundice
• Thrombocytopenia

• Cerebral malaria - altered consciousness, seizures, coma
• Blackwater fever - massive hemolysis, hemoglobinuria (black urine)
• Algid malaria - circulatory collapse, shock
• Severe anemia (Hb < 5 g/dL)
• Acute Renal Failure (ARF) - "big spleen disease"
• Hypoglycemia
• Pulmonary edema / ARDS
• Abnormal bleeding

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• Mosquito injects sporozoites during blood meal
• Bites mainly between dusk and dawn

• Blood transfusion with infected blood
• Needle/syringe sharing (IV drug users)
• Congenital malaria (mother to child transplacentally)
• Organ transplant

• Casual contact, respiratory route, fecal-oral route

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• Travelers to endemic areas
• Military personnel in jungle/forest operations
• Non-immune migrants
• Pregnant women in high endemic areas

• Chloroquine weekly is safe throughout pregnancy
• Doxycycline and Primaquine are CONTRAINDICATED in pregnancy

• Chemoprophylaxis NOT recommended as a routine public health measure in India
• Used only for specific high-risk groups (military, travelers, epidemic situations)

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Q8. Instruction to Health Workers in the Urban Centre for Surveillance of Fever Cases

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• Visit every household at least once a fortnight
• Record all fever cases in the past 2 weeks
• Examine all fever cases: take blood smear / use RDT
• Maintain house register (name, age, sex, fever history)
• Any fever > 2 days = suspect malaria = take blood smear immediately

• Ensure all fever patients visiting PHC/dispensary are screened for malaria
• Maintain OPD fever register
• Refer severe cases to hospital immediately

• Collect thick and thin blood smear from ALL fever cases
• Label slides properly (name, age, date, village)
• Send slides to laboratory same day
• Do NOT wait for results - give presumptive treatment if RDT not available

• Give RDT result-based treatment immediately:
  • P. vivax positive: Chloroquine + Primaquine
  • P. falciparum positive: ACT + single dose Primaquine
• Ensure complete treatment - directly observed for at least 3 days
• Refer complicated/severe cases to hospital

• Identify and map all breeding sites in the area
• Weekly source reduction activities (drain stagnant water, fill pits)
• Anti-larval operations: apply Temephos to overhead tanks, construction sites, coolers
• Advise household members to cover water containers, use bed nets, repellents
• Coordinate with municipal corporation for IRS

• Collect mosquito larvae from breeding sites (monthly)
• Note Anopheles species
• Report to PHC / District Malaria Officer

• Maintain:
  • Fever register
  • Blood smear register
  • Treatment register
  • Breeding site register
• Weekly report to MO-PHC
• Immediately report any cluster of cases (≥ 3 linked cases) = suspected outbreak

• Intensify house-to-house visits (daily)
• Emergency fogging / IRS
• Mass fever survey
• Inform District Rapid Response Team

• Educate community about:
  • Malaria symptoms
  • Early treatment-seeking
  • Mosquito prevention (dry day every Friday)
  • Proper use of bed nets
  • No self-medication

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Q9. Long-Term Control Measures for an Outbreak of Malignant Malaria Cases by the Block Medical Officer of Health

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• Most dangerous form - causes cerebral malaria, death
• Outbreak = unusual increase in cases beyond expected level

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• Confirm outbreak - verify case reports, examine slides
• Inform District CMO / State surveillance unit
• Form Rapid Response Team (RRT)
• Mobilize emergency drug supplies (ACT, Artesunate injectables), RDTs

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• Increase ABER to > 10% of population
• Daily house-to-house fever surveys during outbreak
• Set up temporary fever treatment posts in affected areas
• Sentinel surveillance at PHC and sub-centres

• Ensure all P. falciparum cases get complete ACT (3 days)
• Directly Observed Treatment for first 3 days
• Hospitalize all severe/complicated cases
• Ensure adequate stock of Artesunate IV/IM for severe cases
• Follow up all cases after treatment

• IRS: Two rounds per year (pre-transmission season)
  • 1st round: Before monsoon (May-June)
  • 2nd round: Post-monsoon (October-November)
• Larviciding: Regular weekly anti-larval operations
• Biological control: Release of Gambusia fish in permanent water bodies
• Environmental management: Permanent drainage of waterlogged areas, filling of pits
• LLINs: Distribute Long Lasting Insecticidal Nets to all households in high-risk areas (100% coverage)
• Insecticide resistance monitoring: Test vectors for resistance, rotate insecticides if needed

• Train all health workers (MPW, ASHA, ANM) in malaria case detection and treatment
• Ensure uninterrupted supply of drugs, RDTs, slides at all levels
• 24-hour fever clinic at PHC level
• Referral linkage for severe cases (PHC → CHC → District Hospital)

• Coordinate with PWD for drainage improvement
• Coordinate with irrigation department for intermittent irrigation
• Coordinate with municipalities for waste disposal, construction site monitoring
• Involve Panchayati Raj Institutions

• Mass awareness campaigns - radio, TV, loudspeaker
• Involve village health committees, SHGs
• Friday "Dry Day" - compulsory in all households
• Promote bed net use - especially for children and pregnant women

• Weekly review of cases - is the outbreak declining?
• Monitor API, SPR, ABER regularly
• Entomological surveillance - adult density, larval indices
• Monthly review meeting at block level
• Adjust strategies based on data

• Pregnant women: Weekly Chloroquine prophylaxis + LLINs
• Children < 5 years: Priority for LLINs, early treatment
• Migrant workers: Screen on arrival, treat immediately

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Q10. National Anti-Malaria Programme (NAMP)

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• 1953: National Malaria Control Programme (NMCP) launched
• 1958: National Malaria Eradication Programme (NMEP) - target was eradication
• Cases reduced from 75 million (1953) to 100,000 (1965)
• 1970s: Resurgence due to DDT resistance, drug resistance, administrative failures
• 1977: Modified Plan of Operation - realistic goals
• 1995: Enhanced Malaria Control Project (World Bank funded)
• 1997: Merged into NVBDCP
• 2007: National Vector Borne Disease Control Programme

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1. Reduce malaria morbidity and mortality
2. Prevent deaths due to P. falciparum
3. Achieve API < 1 (elimination)
4. Prevent re-introduction of malaria after elimination

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• ABER ≥ 10% in all districts
• RDT at village level by ASHAs
• ACT for P. falciparum, CQ + Primaquine for P. vivax

• IRS in high-risk areas only (API > 2)
• LLINs for tribal/forest/hard-to-reach populations
• Anti-larval measures
• IVM approach

• Mass media campaigns
• Malaria week (last week of April)
• School health education

• Training of all health workers
• Malaria Technical Supervisor (MTS) at block level

• Prepositioning of drugs/RDTs at district level
• Rapid Response Teams

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• Cases reduced from 2 million/year (2000) to <5 lakh (recent years)
• Malaria deaths reduced significantly
• India removed from WHO "high burden" list in 2022

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🔴 MALARIA — SHORT NOTES (Q11 to Q25)

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Q11. Discuss Surveillance of Malaria

• Health worker visits households fortnightly
• Examines all fever cases
• Takes blood smear / RDT
• ABER ≥ 10% ensures adequate active surveillance

• Patient self-reports to health facility
• OPD-based detection
• Cheaper but misses many cases

• Selected sites (hospitals, PHCs) provide detailed data
• Quality-assured data for trend analysis

• ABER (target ≥ 10%)
• API (target < 1)
• SPR (Slide Positivity Rate)
• SFR (Slide Falciparum Rate)

• MPW maintains fever register, blood smear register
• Weekly report to PHC → CHC → District → State → Centre
• Immediate notification of outbreaks

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Q12. Malariometric Measures

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Q13. Slide Positivity Rate (SPR)

• Definition: Percentage of blood slides examined that are found positive for malaria parasites
• Formula: SPR = (Number of positive slides / Total slides examined) × 100
• Significance:
  • Measures intensity of malaria transmission
  • SPR > 5% = high transmission
  • SPR < 2% = low transmission / near elimination
  • Used alongside ABER - high ABER + low SPR = good control
  • If ABER is low, SPR may be artificially high (only sick patients tested)
• Slide Falciparum Rate (SFR): Proportion of slides positive for P. falciparum specifically

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Q14. Major Epidemiological Types of Malaria

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Q15. Aedes aegypti Index

• Aedes aegypti is the vector for Dengue, Chikungunya, Zika, Yellow fever
• NOT a malaria vector (included here as it appears in the short notes list under vector-borne diseases chapter)

• HI > 1% = risk of Dengue epidemic
• BI > 5 = epidemic risk
• BI > 20 = high epidemic risk

• Guides larvicidal operations
• Identifies high-risk localities
• Monitors effectiveness of vector control

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Q16. Radical Treatment for Vivax Malaria

• Purpose: To eliminate hypnozoites (dormant liver stage of P. vivax) and prevent relapses
• Drug: Primaquine 0.25 mg/kg/day for 14 days
• Given along with Chloroquine (3-day course)
• Must be given under supervision

• G6PD deficiency (causes hemolytic anemia)
• Pregnancy
• Infants < 6 months
• Severe renal/hepatic disease

• P. vivax relapses every few months (up to 3-5 years)
• Worsens anemia, keeps transmission going

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Q17. Factors Responsible for Resurgence of Malaria

• Insecticide resistance in vectors (DDT resistance in An. culicifacies)
• Drug resistance (P. falciparum - Chloroquine resistance)
• Change in vector behavior (outdoor resting - avoids IRS)

• Complacency after initial success
• Reduction in DDT spraying (due to environmental concerns)
• Shortage of funds, drugs, manpower
• Discontinuation of anti-larval operations

• Deforestation, irrigation expansion
• Construction projects creating breeding sites
• Climate change

• Migration of labor to/from endemic areas
• Urbanization - urban An. stephensi spread
• Civil unrest, natural disasters

• Shift from eradication to control mindset (1970s)
• Weak surveillance
• Poor inter-sectoral coordination

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Q18. Approaches of Malaria Control

• Early diagnosis (microscopy / RDT)
• Complete treatment (ACT / CQ + Primaquine)
• Mass Drug Administration (MDA) in selected areas
• Chemoprophylaxis for high-risk groups

• IRS (Indoor Residual Spraying)
• Larviciding
• Biological control (Gambusia, Bti)
• LLINs / ITNs
• Environmental management
• Personal protection

• Source reduction
• Drainage improvement
• Intermittent irrigation
• Land reclamation

• IEC/BCC - community education
• Surveillance and monitoring
• Research and capacity building

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Q19. Man-Made Malaria

• Irrigation projects - canals, rice fields create Anopheles breeding
• Dams and reservoirs - waterlogged margins
• Mining - open pits fill with water
• Construction sites - water accumulation, labor camps in forest areas
• Urbanization - overhead tanks for An. stephensi
• Deforestation - brings forest vectors into contact with humans
• Industrial projects - labor migration from non-endemic to endemic areas

• Environmental impact assessment before projects
• Mandatory anti-larval measures at construction sites
• Health screening of migrant workers
• Project Malaria Officer for large projects (dams, mines)

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Q20. Comment on Malaria Week

• When: Last week of April (25th April = World Malaria Day)
• Organized by: NVBDCP / Ministry of Health & Family Welfare
• Theme: Varies each year (e.g., "Zero Malaria Starts with Me")

• Mass awareness campaigns - street plays, rallies, posters
• School health education
• "Dry Day" - all water containers emptied on Friday
• Distribution of bed nets
• Free blood smear examination camps
• Training of health workers
• Inter-sectoral meetings (with municipalities, Panchayats)
• Cleaning of drains, removal of stagnant water

• Raises community awareness
• Promotes early treatment-seeking
• Mobilizes community for source reduction
• International solidarity - WHO World Malaria Day (25 April)

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Q21. Measures for Control of Urban Malaria

• Breeds in overhead water storage tanks, wells, coolers, ornamental fountains, construction sites

• Cover all overhead tanks, wells with lids
• Empty and scrub water coolers weekly
• Proper drainage of construction sites
• No waterlogging in low-lying areas
• Proper solid waste disposal (no discarded containers)

• Temephos (Abate) added to overhead tanks, wells (safe for drinking water)
• IRS in high-risk localities
• Space spraying / fogging during outbreaks

• Gambusia fish in ornamental ponds, open wells
• Bti application in water bodies

• Municipal bylaws against mosquito breeding
• Penalty for construction sites without anti-larval measures
• House-to-house inspection by municipal health workers
• Container index surveys

• Window/door screens in houses
• LLINs for high-risk families
• Repellents (DEET)

• Urban malaria clinics
• Fever treatment depots at ward level
• Rapid diagnostic tests
• Immediate treatment of positive cases

• Resident Welfare Associations (RWAs) involvement
• Friday "Dry Day" in all societies
• School children as change agents
• Malaria fortnight campaigns

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✅ ALL MALARIA QUESTIONS ANSWERED (Q1-Q21)

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🔴 AIDS / HIV & STIs — ALL QUESTIONS (Q22–Q51)

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LONG ESSAY QUESTIONS

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Q22. Epidemiology of AIDS

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• HIV-1 (worldwide, more virulent) and HIV-2 (West Africa, less virulent)
• Retrovirus - RNA virus with reverse transcriptase enzyme
• Belongs to Lentivirus family
• Attacks CD4+ T lymphocytes (helper T cells)
• AIDS defined when CD4 count < 200 cells/mm³

• Men who have sex with men (MSM)
• Injecting Drug Users (IDUs)
• Sex workers (Female Sex Workers - FSWs)
• Clients of sex workers
• Transgender persons
• Prisoners

• Truckers, migrant workers, uniformed services
• They connect high-risk groups to the general population
• Responsible for spread of HIV from concentrated to generalized epidemic

• Presence of other STIs (especially ulcerative - syphilis, herpes) - increase HIV transmission 3-5 times
• Uncircumcised males
• Malnutrition, immunosuppression
• Young women - cervical ectopy increases susceptibility
• Lack of education, poverty

• Window period (seroconversion): 3 weeks to 3 months (usually 6-8 weeks)
• Clinical latency: Average 8-10 years from infection to AIDS

• ~39 million people living with HIV globally (2022)
• Sub-Saharan Africa - most affected (67% of global burden)
• ~1.3 million new infections per year (2022)
• ~630,000 AIDS-related deaths per year

• ~2.4 million PLHIV (People Living with HIV) in India (2021)
• Adult HIV prevalence: ~0.22%
• High burden states: Andhra Pradesh, Telangana, Karnataka, Maharashtra, Tamil Nadu, Manipur
• National AIDS Control Programme (NACP) - 4 phases (current: NACP V)
• India has achieved >95% reduction in new infections since peak (1995)

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Q23. National AIDS Control Program (NACP) along with NACO

• Established in 1992 under Ministry of Health & Family Welfare
• Apex body for HIV/AIDS control in India
• Headquarters: New Delhi

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• 95% of all PLHIV know their status
• 95% of those diagnosed receive ART
• 95% of those on ART achieve viral suppression

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• Targeted Interventions (TI) for high-risk groups (FSW, MSM, IDU, truckers)
• Condom promotion and distribution
• ICTC (Integrated Counselling and Testing Centres)
• PPTCT (Prevention of Parent to Child Transmission)
• Safe blood supply - 100% voluntary blood donation
• Harm reduction for IDUs (needle/syringe exchange)
• School AIDS Education Programme

• Free ART (Antiretroviral Therapy) at ART centres
• CD4 count testing free at ART centres
• OI (Opportunistic Infection) treatment
• Link ART Centres (LAC) for last-mile delivery
• Community Care Centres (CCC)
• Nutritional support

• Integrated Counselling and Testing Centres at all DHs, CHCs
• Pre-test and post-test counselling
• Confidential HIV testing (ELISA)
• Referral to ART/PPTCT services
• Facility Integrated Counselling and Testing Centre (FICTC) at PHC level

• All pregnant women offered HIV testing at ANC
• HIV+ pregnant women given ART (Option B+: Lifelong ART regardless of CD4)
• Safe delivery practices
• Infant prophylaxis with NVP (Nevirapine) for 6 weeks
• Infant feeding counselling
• EID (Early Infant Diagnosis) - DNA PCR at 6 weeks

• 100% screening of blood for HIV, HBV, HCV, syphilis, malaria
• Voluntary blood donation promoted
• Rational use of blood
• Discouragement of paid/professional donation

• HIV Sentinel Surveillance (HSS) - annual, at sentinel sites
• IBBS (Integrated Biological and Behavioural Surveillance) - for HRGs
• NFHS data for national prevalence estimates

• Red Ribbon Club in schools/colleges
• National AIDS Day - 1st December
• SAKSHAM programme for youth
• Doordarshan, All India Radio campaigns

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Q24. Various Methods by which the Disease (HIV/AIDS) Can Be Prevented

• A - Abstinence (delay sexual debut)
• B - Be faithful (reduce number of partners)
• C - Condom use (correct and consistent)
• Treatment of STIs (reduces HIV transmission 3-5x)
• Male circumcision (reduces risk by ~60% in men)

• 100% safe blood supply (screening of all donated blood)
• Voluntary blood donation
• Disposable needles and syringes (single use)
• Harm reduction for IDUs - Needle Syringe Exchange Programme (NSEP), OST (Opioid Substitution Therapy with Methadone/Buprenorphine)
• Universal precautions in healthcare settings
• PEP (Post-Exposure Prophylaxis) for needle-stick injuries

• HIV testing of all pregnant women
• ART for HIV+ pregnant women (Option B+)
• Safe delivery (avoid unnecessary episiotomy, invasive procedures)
• Nevirapine for infant (6 weeks)
• Safe infant feeding (exclusive breastfeeding OR exclusive formula - avoid mixed feeding)
• EID at 6 weeks

• Daily oral Tenofovir + Emtricitabine (TDF/FTC) for high-risk uninfected individuals
• Reduces risk by >90% when taken correctly
• Given to MSM, sex workers, serodiscordant couples

• Voluntary Counselling and Testing (VCT)
• ICTC services
• HIV testing in ANC, TB, STI clinics
• Partner notification and testing

• ART to prevent progression to AIDS
• OI prophylaxis (Cotrimoxazole preventive therapy)
• Treatment of opportunistic infections
• Nutritional support
• Palliative care

• Reducing stigma and discrimination
• Empowerment of women
• Poverty alleviation
• Sex education in schools
• Legal protection for PLHIV
• Decriminalization of sex work and homosexuality (Section 377 reading down - 2018)

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Q25. Name of Common STDs, Measures for Prevention and Control with Reference to HIV/AIDS

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• STIs increase HIV susceptibility and transmissibility
• Ulcerative STIs (syphilis, herpes, chancroid) disrupt mucosal barrier - increase HIV risk 3-10x
• Non-ulcerative STIs (gonorrhea, chlamydia) cause inflammation - increase HIV risk 3-5x
• HIV+ with STI have higher viral load in genital secretions - more infectious
• Treating STIs reduces HIV transmission (Mwanza trial in Tanzania)

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• Condom use (male and female condoms) - most important
• Reduce number of sexual partners
• Abstinence/delay of sexual debut
• HPV vaccination (Gardasil/Cervarix) - prevent genital warts, cervical cancer
• Hepatitis B vaccination
• STI/HIV awareness campaigns
• Sex education

• Syndromic management (WHO recommended for resource-limited settings)
  • Treat based on presenting syndrome without waiting for lab results
  • Covers most common pathogens causing that syndrome
• Periodic STI screening for sex workers
• Partner notification and treatment (contact tracing)
• STI clinics integrated with HIV services

• Complete treatment to prevent complications
• PID treatment - prevent infertility, ectopic pregnancy
• Syphilis treatment in pregnancy - prevent congenital syphilis
• HIV treatment with ART

• NACP integrates STI/RTI services
• STI clinics at all DHs and CHCs
• Free syndromic management drugs at government facilities
• FSWs, MSM, IDUs targeted for STI screening and treatment

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Q26. Syndromic Approach in Management of STDs

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• Lab diagnosis is expensive, time-consuming, not available at peripheral levels
• Patients may not return for treatment after lab results
• Syndromic management allows same-day treatment
• Covers all organisms causing a particular syndrome

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• Same-day treatment - no return visit needed
• Higher treatment rates
• Simple - can be done by trained paramedics
• Cost-effective
• Prevents complications and further transmission
• Partner treatment also given simultaneously

• Over-treatment (treats for pathogens that may not be present)
• Misses asymptomatic infections
• Cannot diagnose HIV, HPV, herpes definitively
• Antimicrobial resistance concerns

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Q27. Role of Pre-test and Post-test Counselling in Controlling HIV/AIDS

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• Prepare individual for HIV testing
• Inform about HIV transmission, prevention
• Assess individual's risk behavior
• Ensure informed consent for testing
• Discuss implications of positive/negative result

• Explanation of HIV/AIDS, modes of transmission
• Meaning of the test and window period
• Confidentiality assured
• Discussion of risk behaviors
• Implications of positive result (treatment available, can live long healthy life with ART)
• Implications of negative result (may still be in window period)
• Informed written consent obtained
• Referral for testing

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• Explain meaning of negative result
• Remind about window period - repeat test after 3 months if recent exposure
• Reinforce prevention messages (condom use, safe behavior)
• Reassure and support

• Give result gently, with empathy
• Allow patient to absorb the news
• Assess immediate psychological reaction (denial, anger, grief)
• Explain that HIV is manageable with ART - not a death sentence
• Discuss need for partner testing
• Explain CD4 count and when to start ART
• Refer to ART centre
• Discuss disclosure to partner (partner notification)
• Discuss PPTCT if pregnant
• Safe sex practices to prevent transmission
• Confidentiality maintained
• Follow-up appointment given

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1. Increases testing uptake - counselling reduces fear of testing
2. Behavior change - pre-test counselling promotes safer behavior even before result
3. Early diagnosis - leads to early ART, prevents progression, reduces transmission
4. PPTCT - HIV+ pregnant women identified and given ART
5. Partner notification - positive result counselling leads to partner testing
6. Reduces stigma - supportive counselling helps PLHIV cope and disclose
7. Linkage to care - post-test counselling ensures linkage to ART centre
8. Prevention - negative result counselling reinforces safe behavior

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Q28. As a BMOH, Role of Arranging Health Education Programme in Your Area Regarding HIV

• Assess HIV burden in the block (data from ICTC, ART centre, HSS)
• Identify high-risk pockets (trucking routes, mining areas, migrant labor sites)
• Identify target audiences - HRGs, youth, general public, health workers
• Allocate resources (funds, manpower, IEC materials)

• Village-level meetings through ASHA, AWW, ANM
• Gram Sabha meetings - HIV awareness
• Nukkad nataks (street plays) at weekly markets, fairs
• Wall paintings, posters at prominent places
• Local cable TV, FM radio spots

• Peer educators among FSWs, MSM, truckers (Targeted Intervention approach)
• Drop-in centres (DICs) for HRGs - safe space for counselling, condoms, STI treatment
• Truckers: Awareness at highway dhabas, fuel stations
• Migrant workers: Health camps at brick kilns, construction sites

• School AIDS Education Programme (Class 9-12)
• Red Ribbon Clubs in schools/colleges
• Youth festivals - HIV awareness activities
• NSS/NCC programmes

• ANC education about PPTCT
• HIV testing offered to all pregnant women
• Education about breastfeeding and HIV

• Training of ASHAs, ANMs, MPWs on HIV counselling
• Training on universal precautions
• De-stigmatisation training

• HIV is preventable
• HIV is manageable with ART - not a death sentence
• ABC - Abstain, Be faithful, use Condom
• Early testing = early treatment = longer healthy life
• PPTCT prevents baby from getting HIV
• No discrimination against PLHIV

• Distribute pamphlets, flip books in local language
• Condom social marketing
• Promote ICTC services

• Track number of people reached
• ICTC testing rates
• Condom distribution data
• ART enrolment data

• World AIDS Day - 1st December (Red Ribbon campaign)
• National AIDS Control Week

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Q29. One Pregnant Woman Whose Husband Was Found to be HIV Positive, Came to OPD on 2nd Trimester - Management and Advice

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• Pre-test counselling - explain HIV, testing need, confidentiality
• Explain that husband being positive does not automatically mean she is positive
• Address her fears and concerns with empathy
• Obtain informed consent for HIV testing

• ELISA / Rapid test for HIV
• If negative: Repeat after 4 weeks (window period consideration)
• If positive: Post-test counselling, proceed with PPTCT

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• Start Lifelong ART regardless of CD4 count (Option B+)
• Preferred regimen: TDF + 3TC + EFV (Tenofovir + Lamivudine + Efavirenz) - once daily
• Continue ART for life (not just during pregnancy)
• 2nd trimester is safest to start ART - after organogenesis
• Regular CD4 count and viral load monitoring

• Regular ANC visits (monthly minimum)
• Monitor for ART side effects (TDF - renal toxicity, EFV - neural tube defects - but 2nd trimester is safe)
• Screen for OIs - TB screening mandatory
• Nutritional support (iron, folic acid)
• Screen for other STIs

• Aim for normal vaginal delivery (caesarean not routinely recommended if viral load undetectable)
• Avoid prolonged labour, amniotomy, invasive procedures
• Avoid artificial rupture of membranes unless essential
• Minimize episiotomy
• Avoid instrumental delivery if possible

• Nevirapine (NVP) syrup to baby for 6 weeks after birth
• If mother's viral load is high: NVP + AZT dual therapy for infant

• Exclusive breastfeeding (preferred in India - safest when mother is on effective ART)
• OR exclusive formula feeding (if affordable and safe water available)
• NEVER mixed feeding - increases transmission risk

• DNA PCR test at 6 weeks of age
• Repeat at 6 months and 18 months
• Rapid test at 18 months

• Counsel about contraception after delivery
• Condom use mandatory (even with same HIV+ partner - prevent reinfection with different strains)
• Spacing of pregnancies

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• Both to be on ART (husband already positive)
• Consistent condom use
• Regular follow-up at ART centre
• Disclose status to trusted family member (for support)
• Healthy diet, exercise, no alcohol/smoking
• Watch for signs of OIs (fever, cough, diarrhea)
• Baby's follow-up at EID centre
• Legal rights - no discrimination at workplace/hospital

• Explain negative result may be in window period - retest in 4-6 weeks
• Husband to be on ART (reduces his viral load = reduces transmission risk)
• PrEP (Pre-Exposure Prophylaxis) for her - TDF/FTC daily
• Consistent condom use
• Regular retesting during pregnancy

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SHORT NOTES — AIDS/HIV

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Q30. What do you mean by HIV/AIDS?

• Retrovirus (RNA virus) with reverse transcriptase
• Two types: HIV-1 (global) and HIV-2 (West Africa)
• Attacks CD4+ T lymphocytes - progressive immunodeficiency
• Lentivirus family - slow progressive infection

• End stage of HIV infection
• "Acquired" = not inherited, but acquired through exposure
• "Immune Deficiency" = failure of immune system
• "Syndrome" = collection of signs and symptoms

• CD4 count < 200 cells/mm³ (normal: 500-1500)
• OR presence of any AIDS-defining illness (regardless of CD4 count)

• PCP (Pneumocystis jirovecii pneumonia)
• Toxoplasma encephalitis
• CMV retinitis
• Cryptococcal meningitis
• Disseminated MAC (Mycobacterium avium complex)
• Pulmonary/extra-pulmonary TB
• Kaposi's sarcoma
• Invasive cervical cancer
• HIV wasting syndrome
• HIV encephalopathy

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Q31. Clinical Manifestations / WHO Criteria for Diagnosis of AIDS and its Control

• Asymptomatic
• Persistent Generalized Lymphadenopathy (PGL)

• Moderate unexplained weight loss (< 10% body weight)
• Recurrent URTI (sinusitis, tonsillitis, otitis media, pharyngitis)
• Herpes zoster
• Angular cheilitis
• Recurrent oral ulceration
• Papular pruritic eruptions
• Seborrhoeic dermatitis
• Fungal nail infections

• Unexplained severe weight loss (> 10%)
• Unexplained chronic diarrhea > 1 month
• Unexplained persistent fever > 1 month
• Pulmonary TB
• Severe bacterial infections (pneumonia, empyema, meningitis, bacteremia)
• Oral candidiasis
• Oral hairy leukoplakia
• Acute necrotizing ulcerative stomatitis/gingivitis
• Unexplained anemia (Hb < 8g/dL), neutropenia, thrombocytopenia

• HIV wasting syndrome
• PCP
• Toxoplasma encephalitis
• CMV disease (retinitis, esophagitis)
• Cryptococcal meningitis
• Disseminated non-TB mycobacteria
• Progressive multifocal leukoencephalopathy (PML)
• Kaposi's sarcoma
• Invasive cervical carcinoma
• HIV encephalopathy
• Cryptosporidiosis > 1 month
• Extrapulmonary TB
• Disseminated fungal infections (histoplasmosis, coccidioidomycosis)

• Universal ART for all HIV+ (regardless of CD4)
• Cotrimoxazole preventive therapy (CPT) for CD4 < 350
• OI prophylaxis and treatment
• TB-HIV collaborative activities (3Is: Intensified TB case finding, Isoniazid preventive therapy, Infection control)
• Viral load monitoring to ensure treatment efficacy
• ICTC services, PPTCT, blood safety

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Q32. What is ARC? (AIDS-Related Complex)

• ARC = AIDS-Related Complex (older term, now largely replaced by WHO staging)
• Refers to a constellation of symptoms in HIV-infected patients who do not yet meet full AIDS criteria
• Corresponds approximately to WHO Stage 2 and 3

• Unexplained weight loss (< 10%)
• Persistent fever, night sweats
• Chronic diarrhea
• Fatigue, malaise
• Persistent generalized lymphadenopathy
• Oral candidiasis
• Herpes zoster
• CD4 count between 200-500 cells/mm³

• Indicates progressive immunodeficiency
• Indicator to start ART evaluation
• Patient needs close monitoring for progression to AIDS
• Now clinical management guided by WHO staging rather than ARC classification

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Q33. Mention Modes of Transmission of HIV/AIDS

• Unprotected vaginal intercourse (heterosexual - most common in India)
• Anal intercourse (highest risk - receptive partner at greatest risk)
• Oral sex (low but not zero risk)
• Risk per act:
  • Receptive anal intercourse: 1-3%
  • Receptive vaginal intercourse: 0.1-0.2%
  • Insertive vaginal intercourse: 0.05-0.1%

• Blood transfusion with infected blood (very high risk - 90%)
• Sharing needles/syringes (IDUs) - 0.67% per sharing episode
• Needle-stick injury in healthcare workers - 0.3%
• Tattooing, piercing with contaminated instruments

• During pregnancy (transplacental) - ~5-10%
• During labor and delivery - ~10-20% (most common)
• Breastfeeding - ~5-15%
• Overall risk without intervention: 25-40%
• With PPTCT: Reduced to < 2%

• Casual contact (handshake, hugging, sitting together)
• Sharing food, utensils, toilet
• Mosquito or insect bites
• Coughing, sneezing
• Swimming pools
• Saliva, tears (unless blood present)

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Q34. List Vertically Transmitted Diseases, Prevention of Parent to Child Transmission of HIV

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• HIV testing offered to ALL pregnant women at first ANC visit
• If HIV+: Start Lifelong ART (Option B+) - TDF + 3TC + EFV
• Viral load monitoring
• Nutritional support

• Avoid prolonged labor
• Avoid unnecessary invasive procedures (amniotomy, instrumental delivery)
• Avoid scalp electrodes, episiotomy if possible
• Clean delivery

• Continue lifelong ART
• Condom use
• Family planning counselling

• Nevirapine (NVP) syrup for 6 weeks
• If high-risk: NVP + AZT for 6 weeks
• Exclusive breastfeeding (if mother on effective ART) OR exclusive formula
• EID (Early Infant Diagnosis) - DNA PCR at 6 weeks, 6 months, 18 months
• DPT/BCG vaccination at birth (avoid BCG if symptomatic HIV)
• Cotrimoxazole prophylaxis from 6 weeks until HIV-free status confirmed

• Without intervention: 25-40% transmission rate
• With full PPTCT: < 2% transmission rate
• India's Elimination of Mother to Child Transmission (EMTCT) target: < 5% vertical transmission

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Q35. Explain Role of High-Risk Group and Bridge Population in HIV Transmission / AIDS is No Longer Limited to High-Risk Population

• Groups with significantly higher HIV prevalence due to risk behaviors
• Female Sex Workers (FSWs)
• Men who have Sex with Men (MSM)
• Injecting Drug Users (IDUs)
• Transgender persons (Hijras/Kinnars)

• FSWs: ~2-5%
• MSM: ~4-7%
• IDUs: ~7-10%
• Truckers: ~1-2%
• General population: ~0.22%

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• Groups that connect HRGs to the general population
• They have sexual contacts with both HRGs and general population
• Examples:
  • Clients of sex workers (especially truckers, migrant workers)
  • Injecting drug users who also have regular sexual partners
  • MSM who also have female partners
  • Uniformed services (army, police) away from home
  • Long-distance truck drivers

• Trucker visits FSW → gets HIV → returns home → transmits to wife → wife transmits to baby
• This is the classic "bridge" transmission pattern in India
• Explains how HIV moved from concentrated epidemic (only in HRGs) to generalized epidemic

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• HIV prevalence among antenatal women (a proxy for general heterosexual population) is rising in some states
• In India: Several states have moved from concentrated to generalized epidemic
• Andhra Pradesh, Telangana, Karnataka, Maharashtra - general population prevalence > 1% in some districts
• Increasing heterosexual transmission in rural areas
• Women constitute 44% of new HIV infections in India (2021)
• Rural areas now significantly affected

• Prevention programs must go beyond HRGs
• General population awareness, testing, and prevention needed
• All pregnant women must be tested (not just HRG wives)
• "Know your status" campaign for everyone
• Linking HIV with general health services (ANC, TB, OPD)

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Q36. HIV is a Behavioral Disease

• Unprotected sexual intercourse (especially with multiple partners)
• Sharing needles/syringes
• Unsafe blood transfusion
• Unsafe healthcare practices (needle reuse)
• Unprotected breastfeeding by HIV+ mother

• Abstinence or delayed sexual debut
• Faithful single partner
• Correct and consistent condom use
• Clean needle use (never share)
• Voluntary blood donation + screening
• Universal precautions
• PPTCT adherence

• HIV control depends on behavior change - not vaccines or drugs alone
• Behavioral Interventions (BIs) are central to NACP
• Targeted Interventions (TIs) for HRGs focus on behavior change
• IEC/BCC programs aim to change risky behaviors
• Peer education most effective for behavior change in HRGs
• ART also acts as prevention (Treatment as Prevention - TasP) by reducing viral load

• TB, Malaria: Environmental/biological factors primary
• HIV: Behavior is the primary driver - hence behavioral disease

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Q37. Enumerate the Various RTI/STI Syndromes

• Bacterial vaginosis (endogenous)
• Vulvovaginal candidiasis (endogenous)
• Post-abortion/post-delivery infections (iatrogenic)

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Q38. Common Complications of STDs

• Infertility (male and female)
• Ectopic pregnancy
• Chronic pelvic pain
• Neonatal infections
• Increased HIV transmission

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Q39. Describe Risk Factors of HIV/AIDS

• Presence of other STIs (especially ulcerative) - increase risk 3-10x
• Male uncircumcised status
• High viral load in HIV+ partner
• Advanced HIV disease in source
• Receptive anal intercourse (highest risk route)
• Cervical ectopy (young women)
• Genetic factors (CCR5-Δ32 mutation - natural resistance to HIV-1)

• Multiple sexual partners
• Unprotected intercourse
• Injecting drug use with shared needles
• Sex work (commercial sex)
• Early sexual debut
• Alcohol/drug use (reduces inhibitions, promotes risky sex)
• Low condom use

• Poverty and economic vulnerability (transactional sex)
• Gender inequality (women unable to negotiate safe sex)
• Low education (poor awareness)
• Migration, displacement (separation from family, visiting sex workers)
• Marginalization (stigma prevents testing and treatment)

• Unsafe blood transfusion
• Reuse of needles/syringes
• Needlestick injuries in healthcare workers
• Unsafe surgical/dental procedures

• High HIV prevalence in community
• High STI prevalence
• Low ART coverage (untreated HIV = high viral load = high transmission)
• Low testing rates

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Q40. ICTC Should Be Supported by ART / Link ART Centre

• Available at all District Hospitals, Medical Colleges, CHCs
• Provides HIV counselling and testing
• First point of contact for PLHIV

• Available at District Hospitals and above
• Provides free ART, CD4 testing, OI treatment
• Managed by ART doctor, counsellor, pharmacist

• Established to improve access to ART in remote areas
• Located at CHC/PHC level
• Dispensing point for stable patients on ART
• Reduces travel burden for patients

---

1. Continuum of Care:
   • ICTC identifies HIV+ individuals
   • ART centre provides treatment
   • Without this linkage, PLHIV are lost to care
   • "Test and Treat" - same day ART initiation possible only with strong ICTC-ART linkage
2. Cascade of Care (90-90-90):
   • ICTC tests → ART centre treats → LAC maintains → Viral load monitors
   • Gaps in linkage = people falling off the cascade
3. Reduced Follow-up Loss:
   • Link ART Centre at community level prevents patients from defaulting
   • Stable patients collect drugs from LAC instead of traveling to district
4. Same-Day ART Initiation:
   • ICTC refers same day → ART centre enrolls same day
   • Reduces delay between diagnosis and treatment
5. Counselling Support:
   • ICTC counsellors support ART adherence counselling
   • Identifies patients who are lost to follow-up
6. Index Testing:
   • ICTC traces sexual contacts of HIV+ patients for testing
   • Feeds more patients into ART cascade

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Q41. Opportunistic Infections in AIDS

• Cotrimoxazole Preventive Therapy (CPT): Given to all HIV+ with CD4 < 350 - prevents PCP, Toxoplasma, bacterial infections
• INH Preventive Therapy (IPT): Isoniazid 300mg daily for 6 months - prevents TB
• ART: Best OI prevention - restores immunity

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Q42. What is Window Period?

• Standard ELISA: 6-12 weeks (usually 4-6 weeks)
• 3rd generation ELISA: 3-4 weeks
• 4th generation (combined p24 antigen + antibody): 2-3 weeks
• PCR (RNA/DNA): 10-14 days (not used for routine screening)

1. A person in window period:
   • Has HIV virus in blood
   • Is highly infectious (high viral load during acute infection)
   • Tests NEGATIVE on antibody test
   • Can unknowingly transmit HIV to others
2. Blood transfusion danger:
   • Blood donated during window period will test negative but is infectious
   • Residual risk of HIV from screened blood transfusion
3. Clinical implication:
   • If recent high-risk exposure and negative test - repeat test after 3 months
   • NACO recommends retesting at 6 weeks, 3 months after potential exposure
4. NAT (Nucleic Acid Testing):
   • Used in blood banks to reduce window period
   • Detects viral RNA/DNA before antibodies develop

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Q43. Contact Tracing in STIs

• Find people who may be infected but don't know
• Offer them testing and treatment
• Break the chain of transmission
• Prevent reinfection of the index case

• Patient is counselled and asked to inform their own contacts
• Contacts are asked to come to the clinic voluntarily
• Most common method

• Health worker contacts the patient's contacts directly
• Used when patient is unable/unwilling to notify contacts
• Requires maintaining confidentiality

• Patient agrees to notify contacts within a specified time
• If they don't, health worker steps in
• Combines above two methods

• Index testing (partner notification for HIV) is part of NACP V
• Sexual partners of HIV+ persons should be tested
• IDU contacts (needle sharing partners) should be tested
• Helps find HIV+ people who don't know their status

• Stigma and fear of disclosure
• Multiple casual partners difficult to trace
• Confidentiality concerns
• Social repercussions (domestic violence after disclosure)

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Q44. Screening for Diseases in Blood Bank

• HTLV I/II
• Chagas disease (not in India)

• Increasingly used in India at large blood banks
• Reduces window period for HIV, HBV, HCV
• Detects viral genetic material before antibodies develop

• 100% voluntary blood donation (no professional/paid donors)
• Donor selection - detailed questionnaire to exclude high-risk donors
  • Recent tattoo/piercing
  • Multiple sexual partners
  • IV drug use history
  • Fever, weight loss
• Deferral criteria for high-risk donors
• Discard blood if any test positive
• Quarantine period for repeat donors

• Before routine screening (pre-1986): Many transfusion-transmitted HIV cases
• With 100% screening: Transfusion-transmitted HIV reduced dramatically
• Residual risk remains due to window period (~1 in 1-2 million units in India)

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Q45. Universal Precaution

• Healthcare workers cannot always know who is infected
• HIV, HBV, HCV are often asymptomatic
• Treating all as potentially infectious protects HCW and patients

• Wash hands before and after every patient contact
• Before and after wearing gloves
• After contact with blood/body fluids
• Use soap and water OR alcohol-based hand rub

• Gloves: For all contact with blood, body fluids, mucous membranes, non-intact skin
• Mask: When splashing of blood/fluids is expected
• Goggles/Face shield: Splash protection
• Gown/Apron: When soiling with blood/fluids expected

• Never recap needles with two hands (single-hand scoop technique or no recap)
• Never bend or break used needles
• Immediately discard sharps in puncture-resistant containers
• Do not overfill sharps containers (< ¾ full)
• Safe disposal - incineration or deep burial

• One needle, one syringe, one patient - ONE TIME ONLY
• Never share multi-dose vials between patients without new needle

• Used equipment: Clean → Disinfect → Sterilize
• Spills: Cover with hypochlorite solution, clean after 30 minutes
• Linen: Handle without contact with skin/mucous membranes

• All specimens transported in sealed bags
• Spillage management protocols

• WHO/CDC now uses "Standard Precautions" - expanded to include:
  • Respiratory hygiene/cough etiquette
  • Safe injection practices
  • Environmental cleaning
  • Waste disposal

• After needlestick/splash exposure to HIV+ blood:
  • Wash wound immediately with soap and water
  • Report to occupational health
  • Start PEP within 72 hours (ideally within 2 hours)
  • PEP regimen: TDF + 3TC + LPV/r for 28 days
  • Test for HIV at baseline, 6 weeks, 3 months

---

Q46. Describe in Brief the Guidelines for PEP in HIV/AIDS (Post-Exposure Prophylaxis) in Healthcare Settings

---

• Occupational exposures:
  • Needlestick injury from HIV+ patient
  • Splash of HIV+ blood to eyes, mouth, broken skin
  • Cut with contaminated instrument
• Non-occupational exposures:
  • Unprotected sexual intercourse with HIV+ person
  • Sexual assault
  • Sharing needles with HIV+ person

---

• Deep needlestick (hollow bore needle, large volume)
• Visible blood on device
• Source patient with high viral load / AIDS

• Superficial scratch
• Splash on intact skin (PEP NOT needed for intact skin)
• Urine, saliva (no blood) exposure

---

• TDF (Tenofovir) 300mg + 3TC (Lamivudine) 300mg + LPV/r (Lopinavir/ritonavir) 400/100mg BD
• OR TDF + 3TC + EFV (for non-pregnant adults)

• AZT (Zidovudine) + 3TC + LPV/r (if TDF contraindicated)

• Weight-based dosing with AZT-based regimen

---

1. Immediate first aid:
   • Needlestick: Wash wound with soap and water for 5-10 minutes
   • Splash to eyes: Irrigate with clean water/saline for 15 minutes
   • Do NOT squeeze wound, do NOT apply bleach
2. Report immediately to Medical Officer/Occupational Health
3. Assess exposure - type, source patient status
4. Baseline investigations:
   • HIV test (baseline)
   • HBsAg, Anti-HCV
   • CBC, LFT, RFT (before starting PEP)
5. Informed consent for PEP
6. Start PEP within 2-72 hours
7. Follow-up:
   • Week 2 and 4: CBC, LFT to monitor ART toxicity
   • HIV test at 6 weeks, 3 months (4th gen test)
   • If negative at 3 months: PEP successful, not infected
8. Counselling:
   • Complete full 28-day course
   • Side effects: Nausea, fatigue (usually manageable)
   • Use condoms during PEP period
   • Avoid blood donation during PEP and follow-up

---

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Q47. Treatment 2.0 of HIV and AIDS

• Single-pill, once-daily regimens
• Fixed-Dose Combinations (FDCs) - e.g., TDF + 3TC + EFV in one tablet
• Less toxicity, fewer side effects
• Longer-acting injectables (future)
• Adapted for resource-limited settings

• Point-of-care CD4 testing
• Point-of-care viral load testing
• Simplified HIV diagnostic algorithms
• Task-shifting - nurses and CHWs can initiate ART

• Generic drug production
• Reducing cost of viral load testing
• Negotiating with pharmaceutical companies
• Differential pricing for low/middle income countries

• Community-based ART delivery
• Nurse-initiated and managed ART (NIMART)
• Multi-month dispensing (3-6 month drug supply for stable patients)
• Mobile health (mHealth) for adherence support
• Differentiated Service Delivery (DSD) - fast-track for stable patients, intensive for unstable

• Community involvement in service delivery
• Treatment literacy programmes
• Peer support groups
• Reducing stigma and discrimination
• Addressing gender inequalities

---

• India adopted Option B+ (universal ART in pregnancy) 2013
• Free ART programme with FDCs
• Link ART Centres for community-level dispensing
• CD4 count testing free at all ART centres
• Viral load testing scaling up
• 95-95-95 targets under NACP V
• Same-day ART initiation policy

• Adults: TDF + 3TC + EFV (once daily FDC)
• Pregnant women: Same (EFV safe after 1st trimester)
• Children: Weight-based AZT/ABC-based regimens
• Second-line: AZT + 3TC + LPV/r (if first-line failure)
• Third-line: DRV/r + RAL + ETV (at tertiary centres)

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🔴 TUBERCULOSIS — ALL QUESTIONS (Q52–Q64)

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LONG ESSAY QUESTIONS

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Q52. Discuss the Epidemiology of Tuberculosis

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• Mycobacterium tuberculosis (Koch's bacillus) - most common
• M. bovis - from cattle (bovine TB) - rare in India
• M. africanum - Africa
• MOTT (Mycobacteria Other Than Tuberculosis) - rare, in immunocompromised
• Characteristics:
  • Acid-fast bacillus (AFB) - stains with Ziehl-Neelsen stain
  • Non-motile, non-sporing
  • Very slow growing (generation time 18-24 hours)
  • Survives in dried sputum for weeks
  • Killed by sunlight, UV radiation, pasteurization

• Close household contacts of TB patients
• HIV-infected persons (40x higher risk)
• Malnourished individuals
• Diabetics (3x higher risk)
• Silicosis, renal failure, cancer patients
• Healthcare workers
• Prisoners, homeless persons
• Children < 5 years (vulnerable to severe forms)

• BCG vaccination (protects against severe/disseminated TB in children)
• Prior TB infection (partial immunity)
• Good nutritional status

• Overcrowded housing - most important environmental factor
• Poor ventilation
• Low socioeconomic status
• Indoor air pollution
• Urban slums

---

• Airborne - by inhalation of infectious droplet nuclei (1-5 microns)
• Generated by: Coughing, sneezing, singing, speaking by sputum-positive TB patient
• Droplet nuclei remain suspended in air for hours
• A single infectious person can infect 10-15 contacts per year
• NOT transmitted by: fomites, contaminated food (except M. bovis)

• Sputum smear positive = highly infectious
• Smear negative, culture positive = less infectious
• On treatment - infectivity drops dramatically within 2 weeks
• Extrapulmonary TB: Generally NOT infectious

• Primary infection: Ghon focus forms in lung
• 90% of immunocompetent → infection contained → latent TB
• 10% → progress to active TB
• Of those with LTBI: 5-10% develop active TB over lifetime

---

• 4-8 weeks (to develop positive tuberculin test)
• Reactivation: Years to decades after primary infection

• 10.6 million new TB cases globally (2022)
• 1.6 million TB deaths (2022) - including 0.18 million HIV-TB
• India: ~2.8 million cases/year; ~480,000 deaths

• High-burden states: UP, MP, Rajasthan, Maharashtra, Bihar, Chhattisgarh
• TB-HIV co-infection: ~6% of TB patients are HIV+
• MDR-TB: ~130,000 new cases/year
• India's target: END TB by 2025 (5 years ahead of global 2030 target)
• NSP (National Strategic Plan) 2017-2025: Nikshay Poshan Yojana (nutritional support), PMDT programme

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Q53. Define Goals and Objectives of RNTCP. Describe Various Components of DOTS Strategy

• Launched in 1997 (pilot from 1993)
• Based on WHO-recommended DOTS strategy
• Now renamed National TB Elimination Programme (NTEP) since 2020
• Target: Eliminate TB by 2025

---

1. Reduce TB incidence to < 44 per lakh by 2020 (milestone)
2. Reduce TB mortality to < 3 per lakh by 2030
3. Zero catastrophic expenditure due to TB
4. Eliminate TB by 2025 (< 1 case per million population)

1. Achieve and maintain > 85% cure rate for new sputum smear-positive TB patients
2. Detect at least 70% of estimated new SS+ TB cases
3. Provide free diagnosis and treatment to all TB patients
4. Prevent emergence of drug-resistant TB
5. Integrate TB services with general health system
6. Ensure equitable access including private sector

---

• Government commitment at all levels
• Dedicated funding and resources
• TB as national priority
• Legislation - TB a notifiable disease (2012)
• RNTCP in National Health Mission
• Nikshay portal for case-based tracking

• Two sputum specimens examined (spot + morning)
• Designated Microscopy Centres (DMCs) at PHC/CHC level
• One DMC per 100,000 population (100,000 in tribal areas)
• Quality assurance through panel slides
• CBNAAT/GeneXpert for MDR-TB diagnosis
• Culture and DST at IRL (Intermediate Reference Laboratory)

• All new cases: 2HRZE + 4HR (daily, not thrice weekly)
• Weight-based dosing
• DOTS provider gives daily treatment
• H = Isoniazid, R = Rifampicin, Z = Pyrazinamide, E = Ethambutol, S = Streptomycin

• Must observe patient swallowing every dose
• Can be: health worker, ASHA, community volunteer, NGO worker, employer
• NOT a family member (ideally)

• Central drug procurement by RNTCP
• Buffer stock maintained at all levels
• FDC (Fixed Dose Combinations) used
• No drug stock-out at any level
• Quality testing of all drugs

• Patient-wise case register at DMC
• Treatment card for each patient
• Quarterly cohort analysis
• Nikshay portal - online real-time reporting
• Outcome definitions:
  • Cured: Smear-negative at end of treatment
  • Treatment completed: Completed treatment without smear
  • Treatment failure: Smear positive at 5 months
  • Defaulted: Interrupted > 2 months
  • Died
  • Transferred out

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Q54. National Program on Control of Tuberculosis in India - Strategies and Components in RNTCP

• 1962: National TB Programme (NTP) - case-finding + treatment; limited success
• 1978: District TB Programme
• 1992: Study showing poor cure rates with NTP
• 1993: DOTS pilot in India (WHO-assisted)
• 1997: RNTCP launched nationally
• 2006: RNTCP Phase II - expanded to entire country
• 2012: TB made notifiable disease; PMDT integrated
• 2017: NSP 2017-25 - "End TB" strategy
• 2020: RNTCP renamed NTEP (National Tuberculosis Elimination Programme)
• 2025: Target - eliminate TB

---

• Passive case finding (patients presenting to health facilities)
• Active case finding (contact tracing, screening of high-risk groups)
• Universal drug susceptibility testing (UDST) - test all new TB patients for drug resistance
• Private sector engagement (Ni-kshay mandatory notification)

• Sputum smear microscopy (Ziehl-Neelsen)
• CBNAAT (Cartridge Based Nucleic Acid Amplification Test / GeneXpert) - for rapid detection and Rifampicin resistance
• LPA (Line Probe Assay) - for 1st and 2nd line drug resistance
• Culture and DST (MGIT / LJ medium) at IRLs
• Chest X-ray for smear-negative diagnosis
• FNAC, biopsy for extra-pulmonary TB

• Daily regimen (2HRZE/4HR) for all new patients
• PMDT (Programmatic Management of Drug-Resistant TB) for MDR, XDR
• Free drugs under NTEP
• Bedaquiline and Delamanid for pre-XDR/XDR TB
• All oral shorter MDR regimen (BPaL - Bedaquiline + Pretomanid + Linezolid)

• Ni-kshay Poshan Yojana: Rs. 500/month nutritional support to all TB patients on treatment
• Ni-kshay Mitra: Voluntary adoption of TB patients by donors/organizations
• Private sector notification: Mandatory; incentives for notifying private practitioners
• TB preventive therapy (TPT): Isoniazid preventive therapy for contacts of TB patients
• TB-HIV collaboration: All TB patients tested for HIV; all HIV patients screened for TB
• PMDT: MDR-TB treatment with 2nd line drugs at PMDT sites

• Web-based patient tracking system
• All TB patients registered online
• Real-time monitoring
• Adherence tracking (99DOTS - mobile-based DOTS)

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Q55. Diagnostic Process for Initiation of Treatment of TB under RNTCP

• Suspect TB in any patient with:
  • Cough ≥ 2 weeks
  • Fever ≥ 2 weeks
  • Significant weight loss
  • Night sweats
  • Haemoptysis
  • Chest pain

• Collect 2 sputum specimens:
  • Spot specimen (at clinic)
  • Morning specimen (next day)
• Smear examination by Ziehl-Neelsen staining
• Graded: Scanty, 1+, 2+, 3+

• Smear Positive (SS+): ≥ 1 AFB per 100 fields (or ≥ 2+ on scale)
• Smear Negative (SS-): No AFB on 2 specimens

• CBNAAT/GeneXpert - rapid molecular test
  • Detects TB DNA and Rifampicin resistance in 2 hours
  • Sensitivity ~85% for smear-negative TB
• Chest X-ray: Bilateral upper lobe infiltrates, cavitation, fibrosis
• Culture (MGIT or LJ medium): Gold standard, but takes 2-8 weeks
• Clinical assessment + imaging + response to treatment (empirical)

• Under NTEP: Universal DST for all TB patients
• CBNAAT: Rifampicin resistance (proxy for MDR-TB)
• LPA: Tests for INH, RIF, FQ, injectable resistance
• Liquid culture DST (MGIT): Takes 4-6 weeks

• Register on Ni-kshay portal before starting treatment
• Assign unique Ni-kshay ID
• Determine patient category:
  • New (never treated or < 1 month)
  • Previously treated (relapse, failure, lost to follow-up, other)

• Assign DOTS provider
• Explain treatment, side effects, importance of adherence
• Start daily regimen

• Sputum smear at end of 2 months (Intensive Phase):
  • If positive: CBNAAT to rule out MDR
• Sputum at end of treatment (6 months) for cure
• Monthly clinical assessment

• Cured / Treatment completed / Failed / Lost to follow-up / Died / Not evaluated
• Report quarterly cohort outcomes

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Q56. Category I and II and MDR, XDR TB

• Who: New SS+ patients, seriously ill SS- patients (extensive disease), severe extrapulmonary TB
• Regimen: 2HRZE + 4HR (6 months total)
  • Intensive Phase (2 months): HRZE daily
  • Continuation Phase (4 months): HR daily
• Target: Cure rate > 85%

• Who: Previously treated - Relapse, Treatment failure, Lost to follow-up (Default)
• Regimen: 2HRZES + 1HRZE + 5HRE (8 months)
  • 2 months: HRZE + Streptomycin injection
  • 1 month: HRZE
  • 5 months: HRE
• NOTE: Category II largely replaced now by CBNAAT-based approach (test for MDR before retreating with Cat II)

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• Definition: TB resistant to at least INH + Rifampicin (the two most important first-line drugs)
• Magnitude: ~130,000 MDR-TB cases/year in India
• Causes of MDR-TB:
  • Incomplete/irregular treatment
  • Inadequate drug supply
  • Poor quality drugs
  • Transmission of resistant strains

• CBNAAT: Detects Rifampicin resistance (RR-TB = treat as MDR-TB)
• LPA: Both INH and RIF resistance confirmed
• Culture + DST: Definitive

• Shorter MDR regimen (2019 onwards): 9-11 months
  • 4-6 months: Bedaquiline + Levofloxacin + Clofazimine + Pyrazinamide + Ethambutol
  • 5 months: Levofloxacin + Clofazimine + Pyrazinamide + Ethambutol
• Longer regimen: 18-20 months (individualized for resistance patterns)
• Managed at PMDT sites (District hospitals and above)

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• Old definition (until 2021): MDR-TB + resistant to any Fluoroquinolone + any injectable (Amikacin, Capreomycin, Kanamycin)
• New WHO definition (2021): MDR/RR-TB + resistant to any Fluoroquinolone + at least one of Bedaquiline or Linezolid
• Most difficult to treat; high mortality

• MDR/RR-TB + resistant to any Fluoroquinolone

• BPaL regimen: Bedaquiline + Pretomanid + Linezolid (6 months)
• Individualized regimens at national reference laboratories
• Very high cost, significant toxicity

• Bedaquiline-containing regimens
• Closely monitored at PMDT centres

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Q57. RNTCP in Bihar or Any State of India

• Bihar contributes ~10% of India's TB burden
• High poverty, overcrowding, malnutrition - all risk factors
• Large migrant population - TB imported from other states
• TB-HIV co-infection challenge

• Treatment success rate: ~86%
• Case notification rate improving
• GeneXpert machines at all district hospitals
• Ni-kshay Poshan Yojana: ~90% linkage
• TB-HIV testing: >90% HIV testing of notified TB patients

• Large private sector - under-notification
• High defaulter rates (seasonal migration)
• High rates of malnutrition (amplifies TB)
• Limited lab infrastructure at peripheral levels
• Poor awareness in rural communities

• JANSANKHYA STHIRATA KOSH: Additional support for TB patients
• Nikshay Mitra: Local businesses, MLAs adopting TB patients
• Active TB Case Finding in slums and tribal areas
• Mobile DOTS providers for migrant workers

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Q58. Cardinal Symptoms for Pulmonary TB and Organogram of RNTCP in a PHC Area

1. Cough - > 2 weeks duration (most important symptom)
   • Initially dry, later productive
   • May be blood-stained (haemoptysis)
2. Fever - Low-grade, typically evening rise; night sweats
3. Weight loss - Significant, unexplained
4. Haemoptysis - Coughing up blood (indicates cavitary disease)
5. Chest pain - Pleuritic (especially in pleural TB)
6. Dyspnoea - In extensive disease or pneumothorax
7. Fatigue and anorexia - Constitutional symptoms

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DISTRICT TB OFFICER (DTO)
         |
TUBERCULOSIS UNIT (TU)
(Serves 250,000 population)
Senior Treatment Supervisor (STS)
Senior TB Laboratory Supervisor (STLS)
         |
DESIGNATED MICROSCOPY CENTRE (DMC)
(At PHC level - serves 100,000 population)
- Medical Officer (MO-PHC)
- Lab Technician (for AFB smear)
- DOTS Centre In-charge
         |
SUB-CENTRE
- ANM / MPW
- Identifies presumptive TB cases
- Refers to DMC
         |
VILLAGE LEVEL
- ASHA - DOTS provider
- Community volunteer
- Employer / Family

• MO-PHC: Diagnoses TB, initiates treatment, signs treatment cards
• Lab Technician: Performs ZN staining, reads smears at DMC
• STS: Supervises DOTS providers, tracks defaulters, cohort analysis
• STLS: Supervises lab quality, panel slides
• ASHA: Directly observes treatment (DOTS), traces defaulters, sputum collection

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Q59. Different Levels of Prevention and Mode of Interventions as Applied to Pulmonary Tuberculosis

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• Prevent risk factors from emerging
• Poverty alleviation, improved nutrition, better housing
• Reduce overcrowding in slums
• Improve ventilation in homes and workplaces
• Social determinants of TB addressed

---

• BCG vaccination:
  • Given at birth
  • Protects against severe childhood TB (miliary TB, TB meningitis)
  • Efficacy: 0-80% (variable - protects better in children than adults)
  • Does NOT prevent pulmonary TB in adults
  • Part of Universal Immunisation Programme (UIP)

• Improve nutrition - malnourished have higher risk
• Reduce overcrowding
• Improve ventilation
• HIV treatment (ART) - HIV most important risk factor for TB reactivation

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• Passive case finding - patients presenting to health facilities
• Active case finding - contact tracing, household surveys
• Screening of high-risk groups (HIV+, diabetics, contacts)
• Symptom-based screening (cough > 2 weeks)
• CBNAAT at district level
• Universal DST for drug-resistant TB

• DOTS - free drugs under NTEP
• Daily regimen: 2HRZE/4HR
• Direct observation of treatment
• DOTS provider assigned to every patient
• Treatment within 7 days of diagnosis

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• Directly observed therapy prevents incomplete treatment → prevents MDR-TB
• Universal DST to detect and treat MDR-TB early

• Manage haemoptysis, spontaneous pneumothorax
• Surgery for complicated TB (destroyed lung, empyema)
• Manage sequelae: COPD, bronchiectasis, aspergilloma

• Nutritional rehabilitation (Nikshay Poshan Yojana - Rs 500/month)
• Social support
• Prevention of catastrophic costs
• Psychosocial support
• Vocational rehabilitation for those with disability

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SHORT NOTES — TUBERCULOSIS

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Q60. RNTCP Gives Priority on Detection of New Smear Positive Cases

1. Most infectious: SS+ cases expel millions of bacilli per cough - can infect 10-15 contacts/year
2. Most impact on transmission: Treating SS+ cases breaks the chain of transmission most effectively
3. Easy to diagnose: Sputum smear microscopy is simple, cheap, available at PHC level
4. Treatment success measurable: SS+ cases can be monitored by sputum conversion at 2 months and end of treatment
5. WHO/STOP TB strategy: Based on evidence that treating SS+ cases has maximum public health impact

• Detect ≥ 70% of estimated SS+ cases
• Cure ≥ 85% of detected SS+ cases
• These two targets together reduce incidence by ~10% per year

• NTEP now also prioritizing TB notification overall (not just SS+)
• Universal DST - all cases regardless of smear status
• Private sector notification of all TB cases
• Because SS- and extrapulmonary TB also cause morbidity and spread (especially in HIV)

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Q61. Sputum Smear Examination is the Method of Choice for Case Finding in TB

1. Simple technique: Can be done at peripheral DMC level, no sophisticated equipment
2. Inexpensive: Cost ~Rs 5-10 per slide
3. Rapid results: Available within 1-2 hours
4. High specificity: A positive smear is almost certainly TB (in high-burden settings)
5. Identifies most infectious cases: SS+ patients most important to find and treat
6. Quality-assured network: RNTCP has established DMC network with STLS quality assurance

• ZN (Ziehl-Neelsen) staining
• Carbol fuchsin → acid decolorization → methylene blue counterstain
• AFB appear as red/pink rods on blue background
• Read under oil immersion (100x)

• Sensitivity: Only 45-60% (requires 5,000-10,000 bacilli/mL)
• Cannot detect drug resistance
• Cannot distinguish viable from dead bacilli
• Poor for extrapulmonary TB
• Hence CBNAAT/GeneXpert now preferred for initial diagnosis under NTEP

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Q62. Passive Surveillance in Tuberculosis

• Patient develops symptoms → self-presents to health facility (PHC/hospital/private clinic)
• Health worker identifies presumptive TB → sputum examination → diagnosis
• Patient registered on Ni-kshay → treatment started

• Less resource-intensive than active case finding
• Cases are self-motivated - more likely to complete treatment
• Works well in areas with good health-seeking behavior

• Misses asymptomatic or mildly symptomatic TB
• Dependent on patient's health-seeking behavior
• Underdiagnosis in areas with poor access to healthcare
• Delays diagnosis - patient may spread TB before seeking care

• Case notification rate (CNR) - cases notified per 100,000 population
• If CNR low despite high estimated burden → poor passive surveillance

• Active case finding (community-based screening)
• Contact tracing of known TB patients
• Screening of high-risk groups (HIV+, diabetics, prisoners, healthcare workers)
• Private sector notification (mandatory since 2012)

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Q63. Collection of Sputum Sample in Tuberculosis

1. Spot specimen: Collected at clinic on day 1
2. Morning specimen: Deep cough specimen on waking, day 2

• Rinse mouth with plain water (NOT mouthwash)
• Do NOT eat or drink anything before morning specimen
• Collect in clean, wide-mouthed, leak-proof container

• Take 2-3 deep breaths
• Cough deeply from chest (NOT throat clearing or saliva)
• Spit directly into container
• Aim for 3-5 mL of sputum
• Seal container immediately

• Outdoors, away from others (open air)
• Away from food preparation areas
• In designated sputum collection booth if available (with UV light, ventilation)
• NEVER collect in a closed room

• Mucopurulent (thick, yellow-green)
• Volume ≥ 2-3 mL
• Not just saliva

• Watery, clear
• Repeat collection needed

• Transport same day to lab
• If delay: store in refrigerator (4°C) for up to 3 days
• In insulated cold box if transporting from remote area

• Health worker to wear mask during sputum collection
• Proper disposal of used sputum containers (incineration or autoclaving)

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Q64. Describe in Details DOTS Plus

• DOTS alone insufficient for MDR-TB (resistant to INH + RIF)
• DOTS Plus introduced by WHO/Green Light Committee to manage MDR-TB programmatically
• Now called PMDT (Programmatic Management of Drug-Resistant TB) in India

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• Government commitment to fund expensive 2nd line drugs
• PMDT integrated into RNTCP/NTEP
• DOTS Plus sites at district hospitals, medical colleges

• Culture and DST before starting DOTS Plus
• Individualized or standardized regimens based on resistance pattern
• Green Light Committee approved quality-assured drugs

• CBNAAT (GeneXpert) - rapid detection of RIF resistance (=MDR-TB)
• LPA (Line Probe Assay) - detects INH + RIF resistance + FQ/injectable resistance
• Liquid culture (MGIT) + DST - gold standard

• 4-6 months: Bedaquiline (Bdq) + Levofloxacin (Lfx) + Clofazimine (Cfz) + Pyrazinamide (Z) + Ethambutol (E)
• 5 months: Lfx + Cfz + Z + E

• Group A: Levofloxacin, Moxifloxacin, Bedaquiline, Linezolid
• Group B: Clofazimine, Cycloserine
• Group C: Ethambutol, Pyrazinamide, Imipenem, Amikacin, Ethionamide, PAS

• All doses observed (more critical than for drug-sensitive TB)
• DOTS provider trained for MDR-TB
• Hospitalization for initial 2 months (or until sputum conversion)

• Monthly sputum culture for first 3 months, then 3-monthly
• Culture conversion at 2 months (key milestone)
• Monthly clinical assessment
• ECG monitoring (Bedaquiline prolongs QT)
• LFT monitoring (hepatotoxic drugs)
• Audiometry (if Amikacin used)

• Nikshay Poshan Yojana (Rs 500/month)
• Nikshay Mitra (voluntary support)
• Psychosocial support - MDR-TB causes depression, social isolation
• Nutritional support critical

• MDR-TB register at PMDT site
• Cohort analysis of MDR-TB outcomes
• Quarterly reporting to CTD

• Treatment success rate in India: ~48-55% (much lower than drug-sensitive TB)
• High mortality, loss to follow-up are challenges

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