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National Health Programs for MBBS University Exams (PSM)

From Park's Textbook of Preventive and Social Medicine

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PART A: COMMUNICABLE DISEASE PROGRAMS

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1. Revised National Tuberculosis Control Programme (RNTCP) / National TB Elimination Programme (NTEP)

Background & History

• National TB Control Programme: 1962 (used mass X-ray, BCG vaccination)
• RNTCP launched: 1993 (pilot), nationwide rollout: 1997-2006
• Renamed National TB Elimination Programme (NTEP): 2020
• Goal: Eliminate TB by 2025 (ahead of global target of 2030)

Strategy: DOTS (Directly Observed Treatment, Short course)

1. Political and administrative commitment
2. Diagnosis by quality-assured sputum smear microscopy (passive case finding)
3. Standardized short-course chemotherapy under direct observation
4. Uninterrupted supply of drugs (quality-assured)
5. Standardized recording and reporting system

Case Finding

• Passive case finding: Patients self-report with symptoms (cough >2 weeks, fever, hemoptysis, weight loss) - most common method
• Active / Intensified case finding (ICF): Provider-initiated, targeting vulnerable groups (HIV+, contacts of TB patients, prisoners, migrant workers, diabetics)
• Diagnostic tools: Sputum smear microscopy (gold standard at primary level), CB-NAAT/TrueNat (molecular testing), X-ray, culture

Treatment Categories (RNTCP)

• H = Isoniazid, R = Rifampicin, Z = Pyrazinamide, E = Ethambutol, S = Streptomycin

Definitions (Revised 2013)

• New case: Never treated or treated for <1 month
• Relapse: Previously declared cured, now sputum-positive again
• Treatment failure: Sputum-positive at 5th month or beyond
• Defaulter (Lost to follow-up): Interrupted treatment for >2 consecutive months

Treatment Outcomes

• Cured / Treatment completed / Treatment success
• Treatment failure / Died / Lost to follow-up / Not evaluated

Key Points for Exam

• Nikshay Poshan Yojana: Rs. 500/month nutritional support to TB patients
• Pradhan Mantri TB Mukt Bharat Abhiyaan (2022): community support, Ni-kshay Mitras
• India contributes ~27% of global TB burden
• Rifampicin resistance = MDR-TB proxy
• BCG vaccine: preventive component (protects against severe childhood TB, miliary TB, TB meningitis)

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2. National Vector Borne Disease Control Programme (NVBDCP)

• Malaria, Dengue, Chikungunya, Kala-azar (Visceral Leishmaniasis), Lymphatic Filariasis, Japanese Encephalitis

A. National Anti-Malaria Programme (NAMP) - under NVBDCP

Objectives

• Reduce morbidity and mortality due to malaria
• Prevent re-establishment in areas where eliminated

Case Detection Methods

1. Active surveillance (Mass Blood Survey - MBS): Health workers go house-to-house to collect blood smears
2. Passive surveillance (MFBS - Malaria Fever Blood Survey): Any fever patient reporting to health facility gets tested
3. Sentinel surveillance: At fixed sites to monitor trends

Slide Positivity Rate (SPR)

• Annual Blood Examination Rate (ABER) = blood slides examined per 100 population per year (target: >10%)
• Annual Parasite Index (API) = confirmed malaria cases per 1000 population per year
• API >2 = high-risk zone; API <1 = low-risk

Treatment

• P. vivax: Chloroquine 3 days + Primaquine 14 days (radical cure)
• P. falciparum: Artesunate + Sulphadoxine-Pyrimethamine (AS+SP) + Primaquine single dose
• Severe malaria: IV Artesunate

Vector Control

• Indoor Residual Spraying (IRS): DDT, Malathion, Pyrethroid
• Long-Lasting Insecticidal Nets (LLINs)
• Anti-larval measures: Paris green, Gambusia fish (biological control), source reduction

B. Kala-azar (VL) Elimination Programme

• Target: Eliminate Kala-azar (Visceral Leishmaniasis) from India
• Goal: Reduce annual incidence to <1 per 10,000 population at sub-district level
• Leishmania donovani, transmitted by Phlebotomus argentipes (sandfly)
• Endemic states: Bihar, Jharkhand, West Bengal, UP

Key Indicators (Exam important)

• Annual incidence <1 per 10,000 at block level = elimination target
• Treatment: Liposomal Amphotericin B (single dose) - first line
• Miltefosine (oral), Paromomycin also used
• Vector control: IRS with DDT; sandfly-proof nets
• PKDL (Post-Kala-azar Dermal Leishmaniasis): a reservoir for re-infection

C. National Filaria Control Programme (NFCP) - 1955

• Wuchereria bancrofti (98%): lymphatic filariasis; vector = Culex quinquefasciatus (urban)
• Brugia malayi: vector = Mansonia species (rural)
• Brugia timori: rare

Mass Drug Administration (MDA)

• Annual single dose: Diethylcarbamazine citrate (DEC) + Albendazole to ALL eligible people in endemic districts (not just infected)
• Goal: Interrupt transmission by reducing microfilaria load in community
• Morbidity management: elevation, hygiene, surgery for hydrocoele
• Target: Eliminate by reducing microfilaria rate <1%

Key Points

• Microfilaria rate = key indicator
• Night blood survey (10 PM - 2 AM) used for diagnosis (nocturnal periodicity of microfilariae)
• Immunochromatographic card test (ICT) for antigen detection

D. Dengue / Chikungunya Control

• Vector: Aedes aegypti (day-biting mosquito), breeding in clear, stagnant water in domestic containers
• No specific treatment; supportive care
• Control: source reduction (emptying containers, covering water storage), temephos larvicide, community participation
• Warning signs of dengue: abdominal pain, vomiting, bleeding, rapid deterioration
• NS1 antigen: early diagnosis (day 1-5); IgM ELISA: after day 5

E. Japanese Encephalitis (JE) Control

• Vector: Culex tritaeniorhynchus (breeds in paddy fields)
• Reservoir: Pigs and ardeid birds; humans are dead-end hosts
• SA 14-14-2 live attenuated vaccine: given in endemic areas (part of UIP in endemic districts)
• Prevention: vector control, pig vaccination, human vaccination

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3. National AIDS Control Programme (NACP)

History

• NACP Phase I: 1992-1999 (sentinel surveillance, blood safety, awareness)
• NACP Phase II: 1999-2006 (prevention among high-risk groups)
• NACP Phase III: 2007-2012 (scale-up, ARTCP integration)
• NACP Phase IV: 2012-2017
• Now under National AIDS and STI Control Programme

Objectives

• Reduce new HIV infections by 80%
• Reduce AIDS-related deaths
• Eliminate stigma and discrimination

Key Strategies

A. Prevention of Parent to Child Transmission (PPTCT) - formerly PMTCT

• All HIV+ pregnant women offered ART (Option B+)
• Elective C-section if viral load high
• Replacement feeding (formula) if safe, feasible, affordable
• Infant: Nevirapine prophylaxis for 6 weeks

B. Antiretroviral Therapy (ART)

• Free ART provided at ART centres
• First-line: TDF + 3TC + EFV (Tenofovir + Lamivudine + Efavirenz)
• CD4 <200 = AIDS-defining; ART started at all CD4 counts (regardless of count since 2017)
• Opportunistic infection prophylaxis: Cotrimoxazole

C. Targeted Interventions (TI)

• High-risk groups: FSW, MSM, IDU, transgender persons, truckers, migrants
• Services: condom promotion, STI treatment, behavior change communication, needle exchange

D. Blood Safety

• Mandatory HIV testing of all blood donations
• 100% voluntary blood donation goal
• NACO oversees National Blood Transfusion Council

E. Integrated Counselling and Testing Centres (ICTC) / PPTCT

• Confidential HIV testing with pre and post-test counselling

Key Indicators

• HIV prevalence (adult: 15-49 years)
• MTCT rate
• ART coverage
• Condom use rate

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4. National Leprosy Eradication Programme (NLEP)

History

• National Leprosy Control Programme: 1955
• Renamed NLEP: 1983 (after MDT became available)
• India declared elimination (prevalence <1/10,000): 2005

Leprosy Classification (WHO - for Treatment)

MDT Regimens

• Monthly supervised: Rifampicin 600 mg + Dapsone 100 mg
• Daily unsupervised: Dapsone 100 mg

• Monthly supervised: Rifampicin 600 mg + Clofazimine 300 mg + Dapsone 100 mg
• Daily unsupervised: Clofazimine 50 mg + Dapsone 100 mg

Key Indicators

• Prevalence rate: Cases on MDT per 10,000 population
• New Case Detection Rate (NCDR): New cases per 100,000 population per year
• Grade 2 disability rate: % of new cases with Grade 2 disability (indicates delay in detection)
• Elimination target: Prevalence <1 per 10,000

Key Points for Exam

• Leprosy is caused by Mycobacterium leprae (acid-fast bacillus)
• Incubation period: 2-5 years (longest for any bacterial disease)
• MDT is provided free of cost through all health facilities
• Disability prevention: physiotherapy, protective footwear, self-care

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5. Integrated Disease Surveillance Programme (IDSP)

• Launched: 2004; implemented by National Centre for Disease Control (NCDC)
• Objective: Strengthen/maintain a decentralized disease surveillance system for early detection of disease trends and outbreaks

Three Types of Reporting Forms

• S (Syndromic) form: Filled by health workers at community level (fever, diarrhea, jaundice, etc.)
• P (Presumptive) form: Filled by clinicians at PHC level
• L (Laboratory confirmed) form: Filled at district hospitals

Structure

• Central Surveillance Unit (CSU) - national level
• State Surveillance Unit (SSU)
• District Surveillance Unit (DSU)

Important Features

• Weekly reporting of disease trends
• Rapid Response Teams (RRT) deployed during outbreaks
• Covers 33 diseases under surveillance

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6. Universal Immunization Programme (UIP)

History

• EPI (Expanded Programme on Immunization): WHO 1974; launched India 1978
• UIP: launched November 19, 1985 (dedicated to Indira Gandhi's memory)
• Mission Indradhanush: 2015 (intensified immunization to reach unimmunized/under-immunized children)
• Intensified Mission Indradhanush (IMI) 4.0: 2022

National Immunization Schedule (Key for Exam)

• Pentavalent vaccine: DPT + Hep B + Hib (5-in-1)
• RVV: Rotavirus vaccine
• fIPV: Fractional dose IPV

Cold Chain

• Temperature maintained throughout (2-8°C for most vaccines; -15 to -25°C for OPV)
• Cold chain equipment: Walk-in coolers, ILR (Ice-Lined Refrigerator), deep freezers, vaccine carriers, ice packs
• Vaccine vial monitors (VVM): Detects heat exposure

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PART B: ENVIRONMENTAL HEALTH PROGRAMS

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7. National Rural Drinking Water Programme (NRDWP) / Jal Jeevan Mission

History

• Accelerated Rural Water Supply Programme: 1972
• Rajiv Gandhi National Drinking Water Mission (RGNDWM): 1986
• NRDWP: 2009
• Jal Jeevan Mission (JJM): 2019 - target to provide piped water supply (Har Ghar Jal) to every rural household by 2024

Water Quality Standards (WHO / BIS)

Purification of Water Supply

1. Sedimentation: Removes suspended particles (plain or with coagulants)
2. Coagulation / Flocculation: Alum (Al₂SO₄) added → forms flocs
3. Filtration: Slow sand filtration (removes bacteria, protozoa) and Rapid sand filtration
4. Chlorination: Disinfection; chlorine demand + residual (0.5 mg/L after 30 min contact)
5. Fluoridation / Defluoridation: 1 mg/L optimal for dental health

Key Concepts

• Presumptive Coliform Test: most probable number (MPN) method
• Turbidity test, pH test are routine water quality checks
• Imhoff cone for sedimentation test in field
• Break-point chlorination: quantity needed to oxidize all organic matter and leave residual

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8. Swachh Bharat Mission (SBM) / National Sanitation Program

• SBM (Gramin) launched: October 2, 2014
• Objective: Achieve Open Defecation Free (ODF) India; construct household toilets
• SBM Phase II: ODF Plus - sustainability + solid/liquid waste management
• IHHL (Individual Household Latrine): incentive of Rs. 12,000 per household (BPL/SC/ST)

Types of Latrines (for Exam)

Characteristics of Safe Excreta Disposal

• Prevents contamination of soil, water, food
• Inaccessible to flies and rodents
• Odor-free, aesthetically acceptable
• Inexpensive to construct and maintain

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9. National Urban Sanitation Policy (NUSP) - 2008

• 100% safe sanitation for urban areas
• Open defecation free cities
• Scientific solid waste management
• Community/public toilet blocks for slum populations

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10. Solid Waste Management

Municipal Solid Waste (MSW) Rules, 2016

• Mandatory source segregation: 3 bins - Wet (green), Dry (blue), Hazardous (black/red)
• Processing: composting, biomethanation, RDF (refuse-derived fuel)
• Sanitary landfill for non-recyclables

Hospital Waste Management (Biomedical Waste Rules, 2016)

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11. Air Pollution Control

National Ambient Air Quality Standards (NAAQS)

• Set by Central Pollution Control Board (CPCB)
• Key pollutants: PM2.5 (annual: 40 µg/m³), PM10 (annual: 60 µg/m³), SO₂, NOₓ, CO, Ozone

National Clean Air Programme (NCAP) - 2019

• Target: 20-30% reduction in PM2.5 and PM10 by 2024
• 132 non-attainment cities identified
• City action plans, continuous monitoring

Health Effects of Air Pollution

• PM2.5: respiratory and cardiovascular disease, lung cancer
• CO: headache, cherry-red lips, carboxyhemoglobinemia
• SO₂: acid rain, respiratory irritation
• Lead: neurotoxicity, especially in children
• Ozone: eye and respiratory irritation

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PART C: OCCUPATIONAL HEALTH PROGRAMS

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12. National Programme for Prevention and Control of Occupational Diseases

Key Legislation

• Factories Act, 1948: Governs health and safety in factories
  • Cleanliness, overcrowding, lighting, ventilation, disposal of wastes
  • Prohibition of children <14 years; women's work hours restricted
  • Occupational health services, first aid
• Mines Act, 1952: Safety in mining operations
• Dock Workers Act, 1986
• Building and Other Construction Workers Act, 1996

Important Occupational Diseases

A. Pneumoconioses (Dust Diseases)

B. Occupational Cancers

C. Occupational Skin Diseases

• Most common occupational disease
• Contact dermatitis (most common): irritant (cement, oils) or allergic (nickel, chromates)
• Occupational acne: oils, tars, chloracne (dioxins/chlorinated compounds)

D. Occupational Noise-Induced Hearing Loss (NIHL)

• Permissible noise limit: 90 dB(A) for 8 hours (India Factories Act)
• Safe limit: 85 dB(A) per WHO
• NIHL first affects 4000 Hz (C5 dip on audiogram)
• Prevention: engineering controls (noise enclosures), PPE (earplugs, earmuffs)

E. Heavy Metal Poisoning

F. Occupational Poisonings

• Organophosphate poisoning (agricultural workers): cholinergic crisis; Rx: Atropine + Pralidoxime
• Carbon monoxide (mines, blast furnaces): cherry-red skin; Rx: 100% O₂, hyperbaric O₂
• Carbon disulfide (viscose rayon): atherosclerosis, psychiatric symptoms

Occupational Health Services (ILO/WHO)

• Pre-employment medical examination
• Periodic health surveillance
• Environment monitoring (dust, noise, chemical levels)
• First aid and emergency care
• Health education and worker training
• Biological monitoring (e.g., blood lead, urinary metabolites)

Ergonomics in Occupational Health

• Study of human-work interface
• Musculoskeletal disorders: back pain, carpal tunnel syndrome (repetitive motion)
• Work-related upper limb disorders (WRULDs): VDU workers

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13. Employee State Insurance Scheme (ESIS) - Occupational Social Security

• Launched: 1952 under ESI Act, 1948
• Applies to workers earning ≤Rs. 21,000/month in factories and establishments
• Benefits: medical, sickness, maternity, disablement, dependent's benefit, funeral expense
• Contribution: Employer 3.25%, Employee 0.75% of wages
• ESI hospitals and dispensaries provide comprehensive medical care

Workmen's Compensation Act (1923) / Employees' Compensation Act

• Compensation for occupational injuries and diseases
• Schedule of occupational diseases that attract compensation
• Notifiable occupational diseases must be reported

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Quick Revision Summary Table

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Most Frequently Exam Questions (University Level)

1. Write short note on DOTS / RNTCP - treatment categories, regimens, outcomes
2. NVBDCP - components, malaria API, vector control
3. MDT in leprosy - drugs, duration, PB vs MB classification
4. Universal Immunization Schedule - vaccines at each age
5. Kala-azar elimination indicators and treatment
6. Water purification steps with slow vs rapid sand filtration
7. Biomedical waste categories and color coding
8. Pneumoconioses table - silicosis, asbestosis, byssinosis
9. Lead poisoning features and sources
10. IDSP - S, P, L forms
11. NACP strategies - PPTCT, ART, Targeted Interventions
12. Noise-induced hearing loss - permissible levels, audiogram findings
13. Mission Indradhanush - purpose and targets
14. Occupational cancers table
15. Factories Act 1948 - key provisions

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Note: India renamed RNTCP to NTEP in 2020 with a goal to eliminate TB by 2025. The NACP now operates as the National AIDS and STI Control Programme. MDA under filaria now uses the Triple Drug Therapy (TDT) - DEC + Albendazole + Ivermectin in some states (2018 onwards). Always check the latest NHM circulars as programme names and drug regimens are periodically updated.