Primary Health Centre (PHC) - Park's Textbook of Preventive and Social Medicine

Definition and Concept

Historical Background

• The Central Council of Health at its first meeting in January 1953 recommended establishment of PHCs in community development blocks.
• PHCs increased from 725 during the First Five Year Plan to 5,484 by end of Fifth Plan (1975-1980), each covering a population of 1,00,000 or more.
• The Mudaliar Committee (1962) recommended scaling down coverage to 40,000 population.
• The Alma-Ata Declaration (1978) "Health for All by 2000 AD" ushered in the primary health care approach.
• The National Health Plan (1983) proposed one PHC for every 30,000 rural population in plains and one for every 20,000 in hilly/tribal/desert areas.
• As of March 2018, 25,743 PHCs were functioning in the country, each supported by sub-centres (total 1,58,417 sub-centres).

Population Coverage (IPHS 2012 Norms)

Types of PHC (IPHS 2012)

• Type A PHC: Less than 20 deliveries per month
• Type B PHC: 20 or more deliveries per month

Functions of the PHC

1. Medical care
2. MCH including family planning
3. Safe water supply and basic sanitation
4. Prevention and control of locally endemic diseases
5. Collection and reporting of vital statistics
6. Education about health
7. National Health Programmes - as relevant
8. Referral services
9. Training of health guides, health workers, local dais and health assistants
10. Basic laboratory services

Indian Public Health Standards (IPHS) for PHC - Services

1. Medical Care

• OPD services: 4 hours morning + 2 hours afternoon/evening; minimum 40 patients/doctor/day
• 24-hour emergency services: first aid, management of injuries, dog bite/snake bite/scorpion bite, stabilization before referral
• Referral services
• In-patient services (6 beds)

2. Maternal and Child Health Care

• Antenatal care: Early registration, minimum 4 ANC check-ups; at least 1 visit seen by a doctor
• Intranatal care: 24-hour delivery services; management of complicated deliveries and referral
• Postnatal care: mother and newborn care
• Child health: Immunization, management of sick children, growth monitoring, IMNCI
• Family planning: All spacing methods + terminal methods (sterilization - laparoscopic services)
• RTI/STI: Diagnosis and treatment

3. National Health Programmes (at PHC Level)

• RNTCP (TB): Microscopy (sputum), DOTS
• NVBDCP (Malaria/Dengue/JE/Kala-azar/Filaria): Diagnosis, treatment, MDA
• National AIDS Control Programme: IEC, rapid HIV testing, PPTCT linkage
• National Programme for Control of Blindness: Diagnosis/treatment of common eye diseases, referral for cataract
• National Leprosy Eradication Programme: Diagnosis, MDT, disability prevention
• National Mental Health Programme: Diagnosis/treatment of psychosis, depression, epilepsy, referral
• NPCDCS (Cancer, Diabetes, CVD, Stroke): IEC, screening, management

4. Other Services

• Basic laboratory services
• Referral services
• Health education
• Vital statistics collection

Staffing Pattern (IPHS 2012)

Medical Officer of PHC - Responsibilities

• Planning, implementing, and evaluating all health activities of the PHC
• Supervision of all staff under the PHC
• Conducting OPD and in-patient care
• Organizing MCH and family planning services
• Implementation of national health programmes
• Coordination with community and local bodies
• Training and supervision of field staff (health workers and health assistants)
• Maintenance of records and reporting of vital statistics

Relationship to Health Hierarchy

Sub-centre (5,000 / 3,000 population)
        ↓
Primary Health Centre (30,000 / 20,000 population) ← 6 beds
        ↓
Community Health Centre (80,000-1,20,000 population) ← 30 beds
        ↓
Sub-Divisional / District Hospital

Key Points to Remember for Exam

IUCD (Intra-Uterine Contraceptive Device) - Park's Textbook of Preventive and Social Medicine

Introduction

Classification / Types of IUD

1st Generation IUDs - Inert (Non-Medicated)

• Made of polyethylene or other polymers
• Appeared in different shapes: loops, spirals, coils, rings, bows
• Lippes Loop is the best known
  • Double-S shaped device made of polyethylene
  • Contains barium sulphate (for X-ray visibility)
  • Has nylon tail projecting into the vagina for detection and removal
  • Exists in 4 sizes: A, B, C, D (D is largest)
  • Larger loops (C & D) more suitable for multiparous women

2nd Generation IUDs - Copper-Bearing

• Copper wire wound around the stem/arms of a T-shaped or other device
• Copper enhances contraceptive effectiveness and reduces side effects
• Examples: Cu-T 200B, Cu-T 380A, Cu-T 220C, Nova T, Copper 7, Multiload 375
• Cu-T 380A: ~380 mm² of copper - effective for 10 years; Pearl Index ~0.5-1%
• Multiload 375 (Cu-T 375): effective for 5 years

• Smaller size - easier insertion, less pain
• Lower expulsion rate
• Reduced side effects (less bleeding and pain than inert devices)
• Increased contraceptive effectiveness
• Effective as post-coital contraceptive if inserted within 3-5 days of unprotected intercourse

3rd Generation IUDs - Hormone-Releasing

• Release progestogens locally
• Progestasert: T-shaped, filled with 38 mg progesterone, releases 65 mcg/day; needs annual replacement
• LNG-20 (Mirena): T-shaped, releases 20 mcg levonorgestrel/day
  • Pearl Index: 0.2 per 100 women-years
  • Lower menstrual blood loss, fewer days of bleeding
  • Effective life: 10 years
  • Fewer ectopic pregnancies

Mechanism of Action

1. Foreign body reaction in the uterus - causes cellular and biochemical changes in the endometrium and uterine fluids, impairing gamete viability and reducing chances of fertilization (not merely implantation)
2. Copper ions: Enhance cellular response in endometrium; alter enzymes; alter biochemical composition of cervical mucus - affecting sperm motility, capacitation and survival
3. Hormonal devices: Increase viscosity of cervical mucus (prevents sperm entry); maintain high progesterone in endometrium, making it unfavourable for implantation

Effectiveness

• One of the most effective reversible contraceptive methods
• Theoretical effectiveness slightly less than oral/injectable hormonal contraceptives
• But since IUDs have longer continuation rates than pills, overall effectiveness is comparable
• Failure rate (Pearl Index):
  • Lippes Loop: ~2-3 per 100 women-years
  • Cu-T 380A: ~0.5-1 per 100 women-years
  • LNG-20 (Mirena): ~0.2 per 100 women-years

Advantages of IUCD

• Long-acting and reversible
• No systemic side effects
• Does not interfere with coitus
• High continuation rate
• Cost-effective
• No daily compliance required
• Fertility returns promptly after removal
• Can be used as emergency contraception (copper IUD within 3-5 days)

Contraindications

• Suspected pregnancy
• Pelvic inflammatory disease (PID)
• Vaginal bleeding of undiagnosed aetiology
• Cancer of cervix, uterus or adnexia; other pelvic tumours
• Previous ectopic pregnancy

• Anaemia
• Menorrhagia
• History of PID since last pregnancy
• Purulent cervical discharge
• Distortions of uterine cavity (congenital malformations, fibroids)
• Unmotivated person

Ideal IUD Candidate (PPFA Criteria)

• Has borne at least one child
• Has no history of pelvic disease
• Has normal menstrual periods
• Is willing to check the IUD tail
• Has access to follow-up and treatment
• Is in a monogamous relationship

IUD is not the method of first choice for nulliparous women - higher risk of expulsions, low abdominal pain, and pelvic infection.

Timing of Insertion

• Can be inserted at almost any time during reproductive years (except during pregnancy)
• Best time: During menstruation or within 10 days of beginning of menstrual period
  • Cervical canal diameter is greater
  • Uterus is relaxed, minimal myometrial contractions
  • Rules out existing pregnancy
• Post-partum insertion: Within 10 minutes to 48 hours after delivery (immediate post-placental insertion)
• Post-abortion: Immediately after first trimester abortion

Complications / Side Effects

Follow-up After IUCD Insertion

• Check after first menstrual period following insertion
• Then annually
• Woman should check the thread herself every month after menstruation
• If thread is not felt - visit health facility

IUCD in the National Family Planning Programme (India)

• Insertion is provided free of cost at all government health facilities
• Trained ANMs, nurses and medical officers can insert at the sub-centre/PHC level

Key Points for Exam

Pneumoconiosis - Park's Textbook of Preventive and Social Medicine

Definition

Factors Determining Hazardous Effects of Dust

1. Chemical composition of the dust
2. Fineness (particle size - 0.5 to 3 micron most hazardous)
3. Concentration of dust in the air
4. Period of exposure
5. Health status of the exposed person

Important: No cure for pneumoconiosis is known. Prevention is the only approach.

Types of Pneumoconiosis

1. Silicosis
2. Anthracosis (Coal Workers' Pneumoconiosis)
3. Byssinosis
4. Bagassosis
5. Asbestosis
6. Farmer's Lung

1. Silicosis

• Mining industry (coal, mica, gold, silver, lead, zinc, manganese)
• Pottery and ceramic industry
• Sand blasting, metal grinding
• Building and construction work
• Iron and steel industry

• Mica mines of Bihar: 34.1% miners affected
• Ceramic and pottery industry: 15.7%

• Insidious onset
• Irritant cough
• Dyspnoea on exertion
• Pain in chest
• Advanced: impairment of Total Lung Capacity (TLC)

• Rigorous dust control: substitution, complete enclosure, isolation, hydroblasting, good housekeeping, personal protective measures
• Regular physical examination of workers

2. Anthracosis (Coal Workers' Pneumoconiosis)

• PMF can develop without further exposure once simple pneumoconiosis is established.
• Risk of death among coal miners is nearly twice that of general population.

3. Byssinosis

• Chronic cough
• Progressive dyspnoea
• Ends in chronic bronchitis and emphysema

4. Bagassosis

• Breathlessness, cough, haemoptysis, slight fever
• Initially: acute diffuse bronchiolitis
• X-ray: mottling in lungs
• If untreated: diffuse fibrosis, emphysema and bronchiectasis

1. Dust control - wet process, enclosed apparatus, exhaust ventilation
2. Personal protection - masks/respirators
3. Medical control - initial and periodical medical check-ups
4. Bagasse control - keeping moisture content above 20%; spraying with 2% propionic acid (fungicide)

5. Asbestosis

• Serpentine / Chrysotile variety (90% of world production; hydrated magnesium silicate)
• Amphibole type: Crocidolite (blue), Amosite (brown), Anthophyllite (white)

1. Pulmonary fibrosis → respiratory insufficiency and death
2. Carcinoma of the bronchus (risk greatly increased with cigarette smoking)
3. Mesothelioma of pleura or peritoneum (strongly associated with crocidolite)
4. Cancer of the gastrointestinal tract

• Dyspnoea (out of proportion to signs)
• Clubbing of fingers
• Cardiac distress, cyanosis (advanced)
• Sputum shows "asbestos bodies" (asbestos fibres coated with fibrin)

1. Use of safer types - chrysotile and amosite
2. Substitution with glass fibre, mineral wool, calcium silicate, plastic foams
3. Rigorous dust control
4. Periodic examination of workers; biological monitoring (clinical, X-ray, lung function)
5. Continuing research

6. Farmer's Lung

• Acute: general and respiratory symptoms with physical signs
• Repeated attacks → pulmonary fibrosis → cor pulmonale

Comparison Table

General Prevention of Pneumoconiosis

1. Substitution of hazardous material with safer alternatives
2. Dust control - wet methods, enclosure, exhaust ventilation
3. Personal protective equipment (masks, respirators)
4. Pre-employment and periodic medical examinations
5. Chest X-ray and lung function tests at regular intervals
6. Worker education and training
7. Legislation - Factories Act 1948, Mines Act 1952, Workmen's Compensation Act
8. No smoking (especially in asbestos workers - greatly increases lung cancer risk)

Key reminder: Since no cure is available for any pneumoconiosis, prevention through dust control and early detection remains the only strategy.

Bio-Medical Waste (BMW) Management - Park's Textbook of Preventive and Social Medicine

Definition

"Bio-medical waste means any waste which is generated during the diagnosis, treatment or immunization of human beings or animals, or in research activities pertaining thereto or in the production or testing of biologicals."

Composition of Health-Care Waste

Sources of Bio-Medical Waste

• Government and private hospitals, nursing homes
• Physician's/dentist's offices and clinics
• Dispensaries, primary health centres
• Medical research and training establishments
• Mortuaries, blood banks, collection centres
• Animal houses, slaughter houses
• Laboratories, research organizations
• Vaccinating centres
• Bio-technology institutions/production units

Quantum of Waste Generated (Bangalore Survey)

• Total hospital waste in Bangalore: ~40 tonnes/day
• About 45-50% of this is infectious
• Only ~30% of hospitals practice segregation of infectious from non-infectious waste

Health Hazards of Bio-Medical Waste

At-Risk Groups

• Doctors, nurses, healthcare auxiliaries, hospital maintenance staff
• Patients in health-care establishments
• Visitors to health-care establishments
• Workers in laundries, waste handling and transportation
• Workers in waste disposal facilities (landfills, incinerators, scavengers)

1. Hazards from Infectious Waste and Sharps

• Pathogens enter via puncture/abrasion/cut in skin, mucous membranes, inhalation or ingestion
• Strong evidence of transmission of HIV and Hepatitis B and C via health-care waste
• Antibiotic-resistant bacteria contribute to hazards from poorly managed waste

2. Hazards from Chemical and Pharmaceutical Waste

• Many chemicals are toxic, genotoxic, corrosive, flammable, reactive, or explosive
• Can cause acute or chronic intoxication, burns
• Disinfectants are corrosive and may form toxic secondary compounds

3. Hazards from Genotoxic Waste

• Exposure via inhalation of dust/aerosols, skin absorption, or ingestion of contaminated food
• Main concern: cytotoxic drugs during preparation or administration

4. Hazards from Radio-Active Waste

• Ranges from headache, dizziness, vomiting to serious illness
• Genotoxic - may affect genetic material

5. Public Sensitivity

• General public is sensitive to visual impact of health-care waste, particularly anatomical waste

Bio-Medical Waste Management Rules, India

• BMW (Management and Handling) Rules, 1998 - came into force 28th July 1998
• Superseded by BMW Management Rules, 2016 - came into force 28th March 2016
• Applies to all who generate, collect, receive, store, dispose, treat or handle bio-medical waste

Categories of BMW - Colour Coding (BMW Rules 2016)

Segregation of waste at the point of generation is mandatory.

Treatment and Disposal Technologies

I. Incineration

• High-temperature dry oxidation process
• Reduces organic/combustible waste to inorganic incombustible matter
• Significant reduction in waste volume and weight
• Three types:
  1. Double-chamber pyrolytic incinerators - for infectious health-care waste (preferred)
  2. Single-chamber furnaces with static grate - when pyrolytic not affordable
  3. Rotary kilns - high temperature; can decompose genotoxic substances

• Pressurized gas containers
• Large amounts of reactive chemical wastes
• Silver salts and photographic/radiographic wastes
• Halogenated plastics (e.g., PVC)
• Waste with high mercury/cadmium content (thermometers, batteries)
• Sealed ampoules containing heavy metals

II. Chemical Disinfection

• Chemicals added to kill/inactivate pathogens (disinfection, not sterilization)
• Most suitable for liquid waste (blood, urine, stools, sewage)

III. Wet and Dry Thermal Treatment

• Wet thermal (steam disinfection/autoclave): Shredded infectious waste exposed to high-temperature, high-pressure steam
• Screw-feed technology (dry thermal): Waste shredded and heated in rotating auger; reduces volume by 80%, weight by 20-35%
• Not suitable for anatomical, cytotoxic or radioactive waste

IV. Microwave Irradiation

• Frequency of ~2450 MHz, wavelength 12.24 nm
• Water in waste is heated rapidly; infectious components destroyed by heat conduction
• Efficiency checked by bacteriological and virological tests

V. Land Disposal

• Sanitary landfills: Geological isolation, engineering preparation, staff on site, organized deposit with daily cover
• Health-care waste should NOT be deposited on open dumps

VI. Inertization

• Mixing waste with cement and other substances before disposal
• Typical mix: 65% pharmaceutical waste + 15% lime + 15% cement + 5% water
• Forms homogeneous mass (cubes/pellets) - prevents toxic substances from migrating to ground/surface water

Colour-Coded Containers Summary

COVID-19 and BMW Management

• Increased potentially infected waste requiring additional careful handling
• Foot-operated lids in colour-coded bins to avoid contact
• General solid waste should not be contaminated with secretions
• Waste handlers must follow hand washing, gloves, mask, and PPE protocols

Key Points for Exam