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Q1. Strategic Action Plan for Malaria Control in India [10 Marks]

Introduction

Key Objectives

1. Reduce malaria-related morbidity and mortality, especially in tribal and remote areas
2. Achieve universal coverage of malaria prevention and curative services
3. Strengthen surveillance, monitoring and evaluation systems
4. Prevent development and spread of drug and insecticide resistance
5. Promote implementation of evidence-based strategies through partnerships

Strategic Pillars / Interventions

1. Early Diagnosis and Prompt Treatment (EDPT)

• Universal access to diagnosis using Rapid Diagnostic Tests (RDTs) and microscopy
• Effective treatment with Artemisinin-based Combination Therapy (ACT) - Artesunate + SP for P. falciparum
• Chloroquine for P. vivax cases

2. Vector Control

• Long-Lasting Insecticidal Nets (LLINs): Scale-up planned in high-risk areas; targeting children under 5 and pregnant women
• Indoor Residual Spraying (IRS): Continued in high-endemic zones with rotation of insecticides to prevent resistance
• Source Reduction: Environmental management, anti-larval measures

3. Surveillance Strengthening

• Strengthening district-level surveillance through IDSP linkage
• Active surveillance in tribal, forest, and hard-to-reach areas
• Use of HMIS data for tracking API trends
• Epidemic preparedness and rapid response teams (RRTs)

4. Human Resource Development

• Training of ASHAs, ANMs, MPWs in malaria case detection and RDT use
• Capacity building at district and sub-district levels

5. Information, Education and Communication (IEC/BCC)

• Community awareness about personal protection, early treatment seeking
• Social mobilization involving panchayati raj institutions

6. Operational Research

• Conducted by ICMR and medical colleges
• Identifying new tools, evaluating drug efficacy, insecticide resistance monitoring

7. Public-Private Partnership (PPP)

• Engaging private sector providers for mandatory notification of malaria cases
• Supply of RDTs and ACT to private practitioners

8. Inter-Sectoral Coordination

• Involvement of Tribal Welfare, Education, Water & Sanitation ministries
• WHO and Global Fund technical and financial support

Categorization of States (National Framework 2016-2030)

• Category 1: Elimination phase (API < 1)
• Category 2: Pre-elimination phase (API 1-2)
• Category 3: Intensified control phase (API > 2)

Current Update (NSP 2023-2027)

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Q2. Telemedicine [6 Marks]

Definition

Types of Telemedicine

1. Synchronous (Real-time): Live video consultations, telephone calls
2. Asynchronous (Store-and-forward): Patient data/images transmitted to a specialist later (e.g., teledermatology, teleradiology)
3. Remote Patient Monitoring (RPM): Continuous monitoring of vital signs via wearables/devices

Applications

• Teleconsultation for rural patients
• Teleradiology (X-rays, CT scans sent to radiologists)
• Telepsychiatry and tele-mental health
• Teledermatology
• Tele-ophthalmology (diabetic retinopathy screening)
• Chronic disease management (diabetes, hypertension follow-up)
• Follow-up of post-surgical patients

Advantages

• Overcomes geographical barriers - reaches rural/remote areas
• Reduces patient travel costs and time
• Reduces hospital overcrowding
• Enables specialist consultation in primary care settings
• Continuity of care during emergencies (e.g., COVID-19 pandemic)

Limitations

• Digital divide - lack of internet access in rural areas
• Cannot replace physical examination
• Privacy and data security concerns
• Requires technical literacy from patients
• Medico-legal issues regarding liability

India - Telemedicine Practice Guidelines 2020

• Any registered medical practitioner (RMP) can provide teleconsultation
• Can prescribe certain drugs via telemedicine (not listed Schedule X drugs by audio-only)
• Platforms like eSanjeevani have provided millions of teleconsultations across India

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Q3. Integrated Vector Control [6/10 Marks]

Concept

Components of Integrated Vector Control

1. Biological Control

• Use of larvivorous fish (e.g., Gambusia affinis, Lebistes reticulatus) in water bodies
• Use of biological larvicides: Bacillus thuringiensis israelensis (Bti) and Bacillus sphaericus

2. Chemical Control

• Indoor Residual Spraying (IRS): DDT, malathion, synthetic pyrethroids
• Space spraying: Fogging/misting with insecticides (adult mosquito control)
• Larviciding: Application of temephos to water bodies

3. Environmental Management

• Source reduction: elimination of breeding sites
• Drainage of stagnant water, proper disposal of tyres, containers
• Sanitary landfills, proper sewage management

4. Physical Measures

• Use of bed nets - Long Lasting Insecticidal Nets (LLINs)
• Window and door screens
• Wearing protective clothing

5. Genetic Control

• Sterile Insect Technique (SIT)
• Release of genetically modified sterile males

6. Legislation and Regulations

• Enforcement of anti-larval measures
• Town and country planning to prevent water stagnation

WHO Recommendations

• It maximizes cost-effectiveness
• Reduces insecticide use and resistance
• Is environmentally sustainable
• Is tailored to local ecologies

Application in India

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Q4. NIKSHAY [6 Marks]

Definition

Objectives

• Universal notification of all TB cases (public and private sector)
• Real-time tracking of every TB patient from registration to treatment outcome
• Facilitate direct benefit transfers (DBT) to patients and providers

Key Features

1. Case Notification

• Mandatory notification of TB cases by all health facilities (public and private)
• Gazette notification mandates all private practitioners to register TB patients on NIKSHAY

2. Patient Tracking

• Unique ID assigned to every patient
• Tracks diagnosis, treatment initiation, adherence, and outcome

3. Direct Benefit Transfer (DBT) Schemes

• Nikshay Poshan Yojana (NPY): Rs. 1000/month for nutritional support to TB patients during treatment (earlier Rs. 500)
• Energy Dense Nutritional Supplements (EDNS) for underweight patients (BMI <18.5)
• Incentive to Treatment Supporters: Rs. 500
• Incentive to Private Providers: Rs. 500 for notification + Rs. 500 for reporting outcome
• Transfers done via PFMS (Public Financial Management System)

4. Drug-Resistant TB (DRTB) Management

• Programmatic Management of DR-TB cases tracked separately

5. Private Sector Integration

• Private providers get unique Health Facility ID (HF-ID) upon registration
• Mobile app available (Android-based)

Significance

• India has achieved near-complete online notification through NIKSHAY
• Over 24 lakh patients notified in recent years (11% increase year-on-year)
• Supports India's goal of TB Elimination by 2025 (5 years ahead of global target)

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Q5. Vatsayan Kendra (ICTC) [6/10 Marks]

Definition

Background / Evolution

• Originally existed as VCTCs (Voluntary Counselling and Testing Centres) and separate PPTCT centres
• These were merged into ICTCs for integration of services
• The National AIDS Control and Prevention Policy 2002 mandated this integration

Components

1. Vatsayan Kendra (VK): Serves general clients
2. Mamta Clinic: Serves ANC (Antenatal Care) clients specifically for PPTCT

Services Provided

1. Pre-test counselling: Information on HIV transmission, testing procedure, implications
2. HIV Testing: Three sequential tests (ELISA/rapid tests) as per national protocol
3. Post-test counselling: Disclosure, coping, risk reduction
4. Referral services: Linking to ART centres, TB programme, STI clinics, TI-NGOs
5. PPTCT services: Testing and follow-up of HIV-positive pregnant women
6. Follow-up counselling

Key Principles

• Confidentiality: Results not disclosed without patient consent
• Voluntary: Informed consent prior to testing
• Free of cost: All services provided free

Functions

• Early detection of HIV
• Promoting behaviour change
• Prevention of Parent-to-Child Transmission (PPTCT)
• Reducing stigma and discrimination
• Linking positive individuals to care and treatment

Types of ICTC

1. Standalone ICTC: Independent facility
2. Facility ICTC (FICTC): Attached to government hospitals/PHCs
3. PPP mode ICTC: Public-private partnership model

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Q6. PPTCT (Prevention of Parent-to-Child Transmission) of HIV [6/10 Marks]

Introduction

Routes of Transmission from Mother to Child

1. In utero (transplacental) - during pregnancy: 5-10%
2. Intrapartum (during labour and delivery): 10-20%
3. Postpartum (through breastfeeding): 5-20%

• Without any intervention: overall risk is 25-45%

Components of PPTCT Programme

1. Antenatal Care Integration

• All pregnant women attending ANC offered HIV counselling and testing at Mamta Clinic (ICTC)
• Opt-out approach used (testing routine unless refused)

2. Testing Protocol

• Three rapid tests done sequentially
• Results disclosed with counselling

3. Antiretroviral Prophylaxis (HAART for all HIV+ pregnant women)

• Option B+: All HIV-positive pregnant women started on lifelong ART regardless of CD4 count or WHO clinical stage
• Drugs: TDF + 3TC + EFV (Tenofovir + Lamivudine + Efavirenz)
• Started as early as possible in pregnancy

4. Prophylaxis for the Baby

• Nevirapine syrup given to the newborn for 6 weeks (if mother is on ART)
• Extended NVP (12 weeks) if mother not on ART

5. Safe Delivery Practices

• Avoid unnecessary episiotomy, forceps delivery
• Elective caesarean may reduce intrapartum transmission

6. Infant Feeding Counselling

• If ARVs available: Exclusive breastfeeding for 6 months recommended
• If no ART: Replacement feeding advised

7. Follow-up of HIV-Exposed Infants (HEI)

• Early Infant Diagnosis (EID) using DNA PCR at 6 weeks of age
• ART initiated if child found positive

Goal

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Q7. IPV (Inactivated Polio Vaccine) [10 Marks]

Background

Why IPV was Introduced

• VDPVs (Vaccine-Derived Poliovirus): 97% of global VDPV cases are due to type-2
• VAPP (Vaccine-Associated Paralytic Polio): 40% due to type-2
• The Polio Endgame Strategic Plan recommended:
  • Replace tOPV with bOPV (bivalent - types 1 and 3)
  • Introduce IPV before the switch to protect against type-2 VDPV risk

Introduction in India

• India introduced IPV from 30 November 2015
• The tOPV to bOPV switch occurred in April 2016
• Administered as fractional IPV (fIPV): 0.1 ml intradermal (instead of full 0.5 ml IM dose)
• Given at 6 weeks and 14 weeks of age under the UIP

Types of Polio Vaccines

Advantages of IPV

1. No risk of VAPP
2. No risk of VDPV
3. Provides excellent humoral immunity
4. Safe in immunocompromised individuals
5. Protects against all 3 serotypes

Fractional IPV (fIPV)

• 0.1 ml intradermal is immunologically equivalent to full 0.5 ml IM dose
• Cost-saving: 5 doses from one vial (vs. 2 doses IM)
• Induces both humoral and mucosal immunity better when combined with OPV

Current Schedule under UIP (India)

• fIPV: at 6 weeks and 14 weeks (intradermal)
• bOPV: at birth (OPV0), 6, 10, 14 weeks, and booster at 16-24 months
• Combined strategy ensures broad protective immunity

Pulse Polio Programme

• Launched in 1995
• NIDs covered ~172 million children annually
• House-to-house mopping-up conducted from 1999-2000 onwards
• Led to elimination of wild poliovirus from India by 2014

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Q8. NPCDCS [10 Marks]

Full Form

Background

• Diabetes + hypertension prevalence: 62.47 and 159.46 per 1000 population
• Cancer cases: ~25 lakh
• IHD prevalence: 37 per 1000 population

• NCCP (National Cancer Control Programme)
• NPDCS (National Programme for Prevention and Control of Diabetes, CVD and Stroke)

Launch

Components

1. Cancer Component
2. DCS Component (Diabetes, Cardiovascular Diseases and Stroke)

Objectives

1. Prevent and control common NCDs through behaviour and lifestyle changes
2. Provide early diagnosis and management of common NCDs
3. Build capacity at various health care levels for prevention, diagnosis, treatment
4. Train human resources (doctors, paramedics, nurses) to manage NCDs
5. Establish capacity for palliative and rehabilitative care

Activities / Strategies

Health Promotion

• Behaviour Change Communication (BCC/IEC)
• Community awareness, mass media campaigns
• Lifestyle modification promotion

Screening (Opportunistic)

• Outreach camps at sub-centre and above for early detection of:
  • Diabetes (fasting blood glucose, HbA1c)
  • Hypertension
  • Common cancers (oral, cervical, breast)
• Cervical cancer: Visual Inspection with Acetic acid (VIA)
• Breast cancer: Clinical Breast Examination (CBE)

Management

• NCD Clinics set up at District and CHC level
• Cardiac Care Units (CCUs) for emergency cardiac care
• Day Care Centres for cancer chemotherapy
• Referral linkages to tertiary care

Infrastructure Development

• NCD Cells at National, State, and District levels
• Tertiary Cancer Centres (TCCs): Financial support up to Rs. 6 crores each (Centre:State = 80:20 ratio)

Capacity Building

• Training of health workers at all levels
• Telemedicine for remote specialist consultation

Funding

• Funds provided under NCD Flexi-Pool of NHM
• Centre:State share = 60:40

Update: NPNCD (2023-2030)

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Q9. National Tobacco Control Programme (NTCP) [6/10 Marks]

Background

Launch

Objectives

1. Create public awareness about harmful effects of tobacco
2. Reduce the prevalence of tobacco use
3. Establish and strengthen the regulatory framework for tobacco control
4. Build capacity at different levels for tobacco control activities
5. Facilitate implementation of COTPA (Cigarettes and Other Tobacco Products Act)

Components

1. Policy and Legislation - COTPA 2003

• Section 4: Prohibits smoking in public places
• Section 5: Bans tobacco advertising, promotion, and sponsorship
• Section 6a: No sale to minors (<18 years)
• Section 6b: No sale within 100 metres of educational institutions
• Section 7: Mandatory pictorial health warnings on tobacco product packages (covering 85% of packet)

2. Tobacco Cessation Services

• National Tobacco Cessation Helpline: 1800-11-2356 (toll-free)
• Tobacco Cessation Centres (TCCs): Set up at district hospitals and medical colleges
• Behavioural counselling + pharmacotherapy (NRT - Nicotine Replacement Therapy, Varenicline, Bupropion)

3. IEC / Mass Media

• Regular mass media campaigns on anti-tobacco theme
• School programmes, community awareness drives

4. Capacity Building

• Training of health workers, teachers, law enforcement officers
• Integration with health system at all levels

5. Enforcement

• State and District Tobacco Control Cells established
• Violations of COTPA reported and penalized

6. Research and Surveillance

• GATS (Global Adult Tobacco Survey) India - major national surveys on tobacco use
• National and sub-national data collection

Key Achievements

• Pictorial health warnings increased from 40% to 85% of packet area
• Smokeless tobacco regulation strengthened
• Significant reduction in tobacco use prevalence (GATS India 2009 to 2016-17)

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Q10. IDSP - Syndromes, Presumptive and Control [10 Marks]

Introduction

Structure

• Central Surveillance Unit (CSU): NCDC, Delhi
• State Surveillance Units (SSUs): All state/UT headquarters
• District Surveillance Units (DSUs): All districts Weekly data submitted from >90% of 741 districts

Surveillance Formats: S, P, L

"S" - Syndromic (Suspected Cases) - Filled by Health Workers

"P" - Presumptive/Probable Cases - Filled by Clinicians

"L" - Laboratory Confirmed Cases - Filled by Laboratory Staff

Diseases Under IDSP Surveillance

• Vector-borne: Malaria, dengue, chikungunya
• Water-borne: Diarrhoea, cholera, typhoid, jaundice
• Respiratory: TB, ARI
• Vaccine-preventable: Measles, polio
• International concern: Plague, yellow fever
• Unusual syndromes: Meningoencephalitis, haemorrhagic fever, undiagnosed conditions causing death

Outbreak Detection and Response

1. Weekly data analysis for rising trends (Early Warning Signal - EWS)
2. When rising trend detected - Rapid Response Teams (RRTs) deployed
3. RRT investigates, diagnoses, and initiates control measures
4. Daily updates during outbreaks

Control Measures for Outbreaks

1. Case management: Treatment of cases, isolation if needed
2. Contact tracing and surveillance
3. Vector control (for vector-borne diseases)
4. Water purification and food safety measures (water-borne)
5. Vaccination campaigns (measles, cholera, meningitis)
6. IEC for community awareness and hygiene
7. Inter-sectoral coordination (Health, Water Supply, Sanitation)

IHIP (Integrated Health Information Platform)

• Case-based, real-time reporting (replaces aggregated weekly reports)
• Links S, P, and L forms for the same patient
• Monitors 33+ health conditions
• Mobile and electronic device access
• India offering IHIP as a digital public health good to other nations

Significance

• Pioneer in digital disease surveillance in India
• Has detected and controlled hundreds of outbreaks annually
• Critical during COVID-19 pandemic for surveillance

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Q11. END TB Strategy [6 Marks]

Introduction

Vision

Goals (WHO End TB Strategy by 2030)

• 90% reduction in TB incidence (compared to 2015 baseline)
• 95% reduction in TB deaths (compared to 2015 baseline)
• Zero TB-affected families facing catastrophic costs due to TB

Three Pillars of End TB Strategy

Pillar 1: Integrated Patient-Centred Care and Prevention

• Early diagnosis of TB including drug-resistant TB
• Universal drug susceptibility testing (DST)
• Treatment of all forms of TB including MDR-TB
• TB Preventive Treatment (TPT) for latent TB infection (LTBI) contacts
• Management of co-morbidities (TB-HIV, diabetes)
• Infection control in health facilities
• BCG vaccination

Pillar 2: Bold Policies and Supportive Systems

• Political commitment and funding
• Universal health coverage (UHC) for TB services
• Social protection to address poverty - reduce catastrophic costs
• Regulatory frameworks for medicines, surveillance
• Engagement of civil society and communities

Pillar 3: Intensified Research and Innovation

• Discovery and rapid uptake of new tools, diagnostics, drugs, and vaccines
• Implementation research for scale-up
• Operational research

Milestones (Intermediate Targets)

• By 2020: 20% reduction in incidence, 35% reduction in deaths
• By 2025: 50% reduction in incidence, 75% reduction in deaths
• By 2030: 80% reduction in incidence, 90% reduction in deaths
• By 2035: 90% reduction in incidence, 95% reduction in deaths (Elimination goal: <10 cases/100,000)

India's End TB Mission

• NTEP (National TB Elimination Programme): Renamed from RNTCP
• National Strategic Plan (NSP) 2017-2025
• NIKSHAY portal for universal notification
• Free DSTB and DRTB treatment
• Nikshay Poshan Yojana (nutritional support)
• Universal DST (Xpert MTB/RIF at all districts)
• Private sector engagement through mandatory notification

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