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COMPREHENSIVE ANSWERS - K. Park's Textbook of Preventive and Social Medicine

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LONG ESSAYS (2 x 10 = 20 Marks)

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Q1. Causes of Road Traffic Accidents (RTA) & Educational Content for School Children

1. Driver factors:

• Speeding / rash driving
• Driving under the influence of alcohol or drugs
• Fatigue and drowsiness
• Inexperience / lack of skill
• Visual defects (poor night vision, colour blindness)
• Use of mobile phones while driving
• Non-use of seat belts and helmets
• Emotional disturbances

1. Pedestrian factors:

• Jaywalking / crossing at wrong places
• Walking on the wrong side of the road
• Children running onto the road unexpectedly
• Inattention

1. Passenger factors:

• Overloading of vehicles

• Defective brakes, lights, tyres, or steering
• Poor vehicle maintenance
• Overloading
• Absence of safety devices (airbags, seatbelts)

• Poor road design (sharp curves, poor visibility, uneven surfaces)
• Absence of road signs, signals, and markings
• Poor lighting on roads at night
• Adverse weather conditions (rain, fog)
• Encroachments on roads
• Stray animals on roads

• Rapid motorization without adequate infrastructure
• Inadequate enforcement of traffic laws
• Inadequate emergency medical services

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• Always walk on the LEFT side of the road, on the footpath if available
• Cross the road ONLY at zebra crossings or pedestrian signals
• Look LEFT, then RIGHT, then LEFT again before crossing
• Never run onto the road suddenly
• Make eye contact with the driver before crossing

• Red = Stop; Yellow = Get ready; Green = Go
• Obey traffic lights and police signals always

• Always wear a helmet when riding a bicycle or two-wheeler
• Wear a seatbelt in a car at all times

• Never play on the road
• Do not use mobile phones or earphones while walking on the road
• Wear bright or reflective clothing at night
• Never hang on the back of moving vehicles (tempos/buses)

• Do not travel in overloaded vehicles
• Never ride in the back of open trucks
• Do not distract the driver

• Encourage classmates to follow road safety rules
• Reporting unsafe road conditions to teachers/parents

• Call emergency services (108 ambulance) immediately after an accident
• Do not move an injured person unless absolutely necessary

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Q2. Causes of Infant Mortality & Preventive/Social Measures to Reduce IMR in India

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1. Low birth weight and prematurity
2. Birth injury and difficult labour
3. Sepsis
4. Congenital anomalies
5. Haemolytic disease of newborn
6. Conditions of placenta and cord
7. Diarrhoeal diseases
8. Acute respiratory infections
9. Neonatal tetanus

1. Diarrhoeal diseases
2. Acute respiratory infections
3. Other communicable diseases
4. Malnutrition
5. Congenital anomalies
6. Accidents

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• (a) Birth weight - LBW (<2.5 kg) is a major risk
• (b) Age of mother - extremes of age (too young / too old)
• (c) Birth order and birth interval - high parity and short intervals
• (d) Sex of the child - male neonatal deaths > female
• (e) Quality of mothering

• (f) Maternal education - illiteracy is the greatest barrier
• (g) Quality of health care - inadequate prenatal care
• (h) Broken families
• (i) Illegitimacy
• (j) Brutal customs - denying colostrum, application of cowdung to umbilical cord, early weaning
• (k) Indigenous dai (untrained midwife)
• (l) Bad environmental sanitation

• Socio-economic status is one of the most important variables affecting IMR
• Poverty leads to malnutrition, poor health care, overcrowding

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• Food supplementation for pregnant women (ICDS programme)
• Additional 500 kcal and 10 g protein in last trimester improves birth weight

• Universal Immunization Programme (UIP) protecting against 9 vaccine-preventable diseases
• Mission Indradhanush to reach unvaccinated/partially vaccinated children

• Promotion of exclusive breast-feeding for 6 months
• Baby Friendly Hospital Initiative (BFHI)
• Breast-feeding protects against GI and respiratory infections and PEM

• Monthly weighing of infants
• Use of growth charts (Road to Health chart)
• Early identification of malnourished children

• Spacing births at least 2-3 years apart
• Limiting family size
• Delayed marriage and childbearing

• Safe water supply
• Improved housing and drainage
• Fly control
• Personal hygiene

• Accessible health services at village level through ASHAs
• Management of ARI with cotrimoxazole and diarrhoea with ORS + zinc
• Oral Rehydration Therapy (ORT)

• Antenatal care (at least 4 ANC visits)
• Institutional deliveries
• Training of dais (traditional birth attendants)
• JSSK - Janani Shishu Suraksha Karyakram (free services for mother and child)

• Female literacy and women's education (Kerala model)
• Poverty alleviation
• Prevention of child marriage (PCMA Act)
• Awareness of harmful customs and beliefs

• IMNCI (Integrated Management of Neonatal and Childhood Illnesses)
• NSSK (Navjaat Shishu Suraksha Karyakram)
• HBNC (Home Based Newborn Care through ASHAs)
• India Newborn Action Plan (INAP)
• NRCs (Nutritional Rehabilitation Centres) for severe acute malnutrition

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SHORT ESSAYS (6 x 5 = 30 Marks)

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Q3. Planning Cycle (K. Park, Chapter on Health Planning and Management)

• Collection and interpretation of data on: population age-sex structure, morbidity and mortality statistics, epidemiology of diseases, medical care facilities, manpower, training facilities, attitudes of population

• Objectives guide action and serve as a yardstick to measure work
• Objectives may be short-term or long-term
• Modern techniques like cost-benefit analysis are used

• Resources = manpower, money, materials, skills, knowledge, techniques
• Balance struck between what is required and what is available

• Since resources always fall short, priorities are set based on:
• Financial constraints
• Mortality and morbidity data
• Diseases preventable at low cost
• Political and community interests

• Detailed plan prepared for each programme
• Resources (inputs) related to expected results (outputs)
• Each stage defined, costed, and time-specified
• "Built-in" evaluation system incorporated

• Roles and tasks defined
• Selection, training, motivation, and supervision of manpower
• Organization and communication established

• Day-to-day follow-up of activities during implementation
• Ensures activities are proceeding as planned and on schedule
• Continuous process of observing, recording, and reporting

• Systematic assessment of the relevance, adequacy, progress, efficiency, effectiveness, and impact of a programme
• Feeds back into the next planning cycle

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Q4. Types of Cancer Registries (K. Park)

• Includes all cancer patients (inpatients and outpatients) treated at a particular institution
• Collects uniform minimum data set recommended in WHO Handbook for Standardized Cancer Registers
• If long-term follow-up is done, useful for evaluating diagnostic and treatment programmes
• Limitation: Hospital population is always a selected population; limited use for epidemiological purposes
• Use: Useful for monitoring quality of cancer care, treatment outcomes, and survival

• Aims to cover the complete cancer situation in a given geographic area
• Optimum base population: 2-7 million
• Provides incidence rates of cancer
• Useful for:
• Epidemiological enquiries into causes of cancer
• Surveillance of time trends
• Planning and evaluation of operational activities in all areas of cancer control
• Examples in India: National Cancer Registry Programme (NCRP) by ICMR includes population-based registries in cities like Bangalore, Chennai, Mumbai, Delhi, Bhopal

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Q5. National Blindness Control Programme (NBCP) / National Programme for Control of Blindness (NPCB)

1. Continue three signature activities:

• 66 lakh cataract operations per year
• School eye screening and distribution of 9 lakh free spectacles to children with refractive errors
• Collection of 50,000 donated eyes per year for keratoplasty

1. Reduce backlog of avoidable blindness
2. Develop strategy for "Eye Health for All"
3. Strengthen Regional Institutes of Ophthalmology (RIOs)
4. Develop human resources for comprehensive eye care in all districts
5. Enhance community awareness on eye care
6. Expand research for prevention of blindness
7. Secure participation of voluntary organizations and private practitioners

1. Free cataract surgery through health care delivery system + NGO sector + private practitioners
2. Comprehensive eye care covering diabetic retinopathy, glaucoma, corneal transplantation, vitreo-retinal surgery, paediatric blindness
3. Active screening of population above 50 years
4. Screening of children for refractive errors - free spectacles for BPL children
5. Coverage of underserved areas through public-private partnership
6. Capacity building of health personnel
7. IEC activities for community awareness
8. Eye donation fortnight: 25th August to 8th September every year

• Tertiary Level: Regional Institutes of Ophthalmology and Centres of Excellence
• Secondary Level: District Hospitals and NGO Eye Hospitals
• Primary Level: Sub-district hospitals/CHCs, Mobile Ophthalmic Units, Upgraded PHCs

• 6-7% of children aged 10-14 years have eyesight problems
• Children screened by trained teachers; those with suspected refractive error seen by ophthalmic assistants
• Free spectacles given to BPL children

• Global initiative to eliminate avoidable blindness by 2020
• Target diseases: Cataract, refractive errors, childhood blindness, corneal blindness, glaucoma, diabetic retinopathy
• Four-tier structure: Centres of Excellence (20), Training Centres (200), Service Centres (2000), Vision Centres (20,000)

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Q6. Salient Points to Address School Children on Adverse Effects of Poor Lifestyle on Health

• Excessive consumption of junk food, fast food, processed food
• High salt, sugar, and saturated fat intake leads to: obesity, hypertension, diabetes type 2, dyslipidaemia, dental caries
• Skipping breakfast affects concentration and academic performance
• Adequate fruits, vegetables, whole grains, and water are essential

• Prolonged screen time (TV, mobile, computer) = sedentary behaviour
• Lack of exercise causes: obesity, cardiovascular diseases, musculoskeletal problems, mental health issues
• Minimum 60 minutes of moderate-to-vigorous physical activity per day recommended for children

• Experimentation often begins in school age
• Causes: lung cancer, oral cancer, COPD, cardiovascular disease
• Second-hand smoke is also harmful
• All forms of tobacco - cigarettes, beedis, gutka, khaini - are dangerous

• Alcohol damages the liver, brain, and social functioning
• Gateway effect - leads to harder drug use
• Impairs judgement leading to accidents

• Less than 8-10 hours of sleep in adolescents impairs growth, learning, and immunity
• Late-night screen use disturbs sleep patterns

• Academic pressure, social media comparison cause anxiety and depression
• Coping strategies: exercise, talking to trusted adults, hobbies

• BMI > 25 (overweight), > 30 (obese)
• Linked to type 2 diabetes, hypertension, joint problems, poor self-esteem
• "Small changes" - replace a cold drink with water, use stairs instead of lift

• Unprotected sex leads to STIs and unwanted pregnancies
• Age-appropriate education on safe practices

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Q7. Job Responsibilities of ASHA Worker (K. Park)

1. Active promoter of good health practices and community support
2. Awareness on essential RCH services
3. Promotion of family planning - contraception adoption, sterilization, spacing methods
4. Awareness on gender equality, age at marriage/pregnancy

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Q8. Components of Baby Friendly Hospital Initiative (BFHI)

1. Have a written breastfeeding policy that is routinely communicated to all health care staff
2. Train all health care staff in skills necessary to implement the breastfeeding policy
3. Inform all pregnant women about the benefits and management of breastfeeding
4. Help mothers initiate breastfeeding within 30 minutes of birth (early initiation - "skin to skin" contact)
5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants
6. Give newborn infants no food or fluid other than breast milk, unless medically indicated (no prelacteal feeds, no water/glucose)
7. Practice "rooming-in" - allow mothers and infants to remain together 24 hours a day
8. Encourage breastfeeding on demand (unrestricted, whenever the baby wants)
9. Give no artificial teats or pacifiers (dummies or soothers) to breastfeeding infants
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

• Reduces neonatal mortality and morbidity
• Protects against diarrhoeal diseases, respiratory infections, otitis media
• Promotes mother-infant bonding
• Economical and always available

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SHORT ANSWERS (10 x 3 = 30 Marks)

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Q9. Cost-Effective Analysis (K. Park, Chapter on Health Planning)

• Cost-effective analysis is a management technique for evaluation of health programmes
• It is similar to cost-benefit analysis except that benefit, instead of being expressed in monetary terms, is expressed in terms of results achieved - e.g., number of lives saved, number of days free from disease, disability-adjusted life years (DALYs) averted
• It is a more promising tool for application in the health field than cost-benefit analysis
• Helps compare two or more alternative programmes to determine which achieves the desired result most economically
• Limitation: Even cost-effective analysis is not possible in many cases
• Example: Comparing the cost per case of tuberculosis cured under DOTS vs. non-DOTS regimen
• Used in: PPBS (Planning-Programming-Budgeting System), Health Technology Assessment

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Q10. Zinc Supplementation in Acute Diarrhoea

• Zinc is a micronutrient essential for immune function, protein synthesis, and cell division
• Zinc deficiency is common in developing countries, especially in children with malnutrition
• WHO/UNICEF recommend zinc supplementation as a universal standard of care for acute diarrhoea in children

• Zinc deficiency impairs intestinal mucosal integrity and immune response
• Zinc supplementation reduces duration and severity of diarrhoeal episode
• Reduces risk of subsequent diarrhoeal episodes for 2-3 months

• Children < 6 months: 10 mg/day for 10-14 days
• Children ≥ 6 months: 20 mg/day for 10-14 days
• Given along with ORS

• Reduces duration of diarrhoea by approximately 25%
• Reduces stool volume and frequency
• Reduces risk of recurrence of diarrhoea
• Reduces all-cause mortality

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Q11. PCPNDT Act (K. Park / Forensic Medicine perspective)

• Full form: Pre-Conception and Pre-Natal Diagnostic Techniques Act
• Enacted in 1994 in India; amended in 2003
• Objective: To prevent sex-selective abortions and female foeticide by regulating prenatal diagnostic techniques
• Prevents misuse of technology for sex selection (ultrasound, amniocentesis, chorionic villus sampling, etc.)

1. No sex determination of foetus for any purpose
2. All genetic counselling centres, laboratories, clinics using prenatal diagnostic techniques must be registered
3. Prohibition of advertisement offering sex determination
4. The pregnant woman cannot be compelled to undergo such tests
5. Offence and penalty:

• First conviction: imprisonment up to 3 years + fine up to Rs. 10,000
• Subsequent conviction: imprisonment up to 5 years + fine up to Rs. 50,000

1. Appropriate Authority constituted to monitor and enforce the Act
2. The 2003 amendment extended coverage to pre-conception sex selection techniques (sperm sorting, etc.)
3. The Act was renamed from PNDT Act to PCPNDT Act after 2003 amendment

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Q12. Disaster Mitigation (K. Park)

• Construction of earthquake-resistant buildings
• Flood embankments and dykes
• Cyclone shelters
• Retrofitting of existing structures

• Land use planning and zoning regulations
• Building codes and their enforcement
• Public awareness and community education
• Early warning systems
• Disaster preparedness training

• Hazard: A potentially damaging physical event
• Vulnerability: Degree to which a community is at risk
• Risk = Hazard × Vulnerability
• Mitigation reduces vulnerability

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Q13. DASH (Dietary Approaches to Stop Hypertension)

• DASH is a dietary pattern specifically designed to prevent and treat hypertension
• Developed through clinical trials; endorsed by WHO, JNC-8, and major cardiology guidelines

• High in: Fruits, vegetables, whole grains, low-fat dairy, nuts, seeds, legumes, fish, poultry
• Low in: Saturated fat, total fat, red meat, sweets, sugar-containing beverages
• Reduced sodium: 1500-2300 mg/day

• High potassium, calcium, magnesium (natural vasodilators)
• High dietary fibre
• Low sodium

• Reduces systolic BP by 8-14 mmHg in hypertensive patients
• Reduces systolic BP by 2-4 mmHg in normotensive individuals
• Particularly effective when combined with sodium restriction

• Reduces LDL cholesterol
• Helps prevent type 2 diabetes
• Reduces risk of cardiovascular disease
• Useful in weight management

• Grains: 6-8 servings
• Fruits: 4-5 servings
• Vegetables: 4-5 servings
• Low-fat dairy: 2-3 servings
• Meat/poultry/fish: ≤6 oz
• Nuts/seeds/legumes: 4-5 per week

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Q14. Indian Red Cross Society (K. Park)

• Founded: 1920 under the Indian Red Cross Society Act
• Affiliated with: International Committee of the Red Cross (ICRC) and International Federation of Red Cross and Red Crescent Societies (IFRC)
• Headquartered in New Delhi

1. To supplement the work of medical and nursing services of the Armed Forces in wartime
2. To perform humanitarian work in peacetime

• Maintains blood banks and promotes voluntary blood donation
• Blood donation drives and awareness campaigns

• Relief work during floods, earthquakes, cyclones, droughts, and other disasters
• Provides food, clothing, shelter, and medical aid to victims

• Medical first aid training and certification
• School first aid training
• Ambulance services

• Maternity and child welfare services
• Tracing services for missing persons (prisoners of war, separated families)

• School-based programme to train students in first aid, hygiene, and community service
• Motto: "I will try"

• Trains nurses and paramedical staff
• Maintains emergency nursing reserve

• Links Indian citizens with relatives abroad during emergencies
• Participates in international humanitarian operations

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Q15. Incineration (K. Park, Chapter on Solid Waste Management / Biomedical Waste)

1. Fixed hearth (single chamber): Simple but incomplete combustion; not recommended
2. Rotary kiln: Most effective; used for chemical and hazardous waste
3. Double chamber (pyrolytic incinerator): Recommended for biomedical waste

• Primary chamber: 800°C - waste is burnt
• Secondary chamber: 1000°C - gases are combusted

• Reduces volume of waste by 90-95%
• Destroys pathogens effectively
• Suitable for anatomical waste, sharps, blood products, chemotherapy waste
• Can generate heat/electricity (waste-to-energy)

• Air pollution - emissions of dioxins, furans, heavy metals, particulate matter
• High capital and operating cost
• Requires skilled operators
• Produces toxic ash that needs proper disposal
• Not suitable for all waste types (radioactive, pressurized containers)

• Yellow bags: Anatomical waste, expired medicines - to be incinerated
• Red bags: Recyclable waste (IV sets, tubes) - not to be incinerated
• Blue/white containers: Sharps

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Q16. Counterfeit Medicines (K. Park)

• With the correct ingredients but wrong quantity
• Without active ingredients
• With wrong ingredients
• With substandard active ingredients
• With fake packaging

• Estimated 10-15% of medicines in circulation in India may be counterfeit
• Affects both branded and generic medicines
• Both developed and developing countries are affected

• Treatment failure - patient doesn't recover
• Drug resistance - subtherapeutic levels of antibiotics promote AMR
• Adverse drug reactions - toxic ingredients
• Death - in severe cases (e.g., counterfeit antiretrovirals, antimalarials)
• Economic loss to pharmaceutical industry and patients
• Erosion of trust in health systems

1. Strengthening drug regulatory authorities (CDSCO in India)
2. Track and trace systems (barcoding, holograms, serialization)
3. Random sampling and testing of medicines
4. Mobile technology for verification (e-verify systems)
5. Severe legal penalties under Drugs and Cosmetics Act
6. International cooperation (WHO IMPACT - International Medical Products Anti-Counterfeiting Taskforce)
7. Public awareness campaigns
8. Prescription-only drugs to be dispensed only from licensed pharmacies

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Q17. ICTC (Integrated Counselling and Testing Centre)

• Set up under the National AIDS Control Programme (NACP) of NACO (National AIDS Control Organization)
• Provides HIV counselling and testing services in an integrated manner

1. Pre-test counselling - information about HIV, risk assessment, implications of testing
2. HIV testing - ELISA / Rapid tests
3. Post-test counselling:

• Negative: risk reduction counselling, condom promotion
• Positive: disclosure, referral, positive living, ART linkage

1. PPTCT (Prevention of Parent to Child Transmission): All pregnant women offered HIV testing
2. Referral services - to ART centres, STI clinics, social support groups
3. Condom distribution

• Standalone ICTC: Independent facility in district hospitals, medical colleges
• Facility-Integrated ICTC (FICTC): Co-located with OPD, ANC, TB clinics
• Mobile ICTC: For hard-to-reach populations

• Voluntary (client-initiated)
• Confidential
• Free of cost
• Informed consent mandatory before testing
• The "3 Cs" - Consent, Confidentiality, Counselling

• Entry point into the HIV care and treatment cascade
• Key strategy for prevention and care of HIV/AIDS

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Q18. Body Mass Index (BMI) (K. Park, Chapter on Nutrition)

1. Assessment of nutritional status of individuals
2. Epidemiological surveys of obesity prevalence
3. Identifying risk for: diabetes, hypertension, CVD, sleep apnoea, osteoarthritis
4. Monitoring weight management programmes
5. Risk stratification in clinical practice

• Does not distinguish between fat mass and lean mass (muscle)
• Does not indicate fat distribution (visceral vs. subcutaneous)
• May overestimate obesity in muscular persons (athletes)
• Does not apply to children (use BMI-for-age percentiles instead)
• Does not apply to pregnant women and elderly
• Ethnic variations in cut-offs

• < 5th percentile: Underweight
• 5th-84th: Normal
• 85th-94th: Overweight
• ≥ 95th percentile: Obese

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Summary of Answers

LONG ESSAYS (10 marks each)

SHORT ESSAYS (5 marks each)

SHORT ANSWERS (3 marks each)

COMPREHENSIVE ANSWERS - K. Park's Textbook of Preventive and Social Medicine

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LONG ESSAYS (2 x 10 = 20 Marks)

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Q1. Dog Bite Case Management + Contraindications to Vaccination + Urban Rabies Control (6+1+3)

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• Thorough washing of all bite wounds with soap and water for a minimum of 15 minutes under running water
• Application of a viricidal agent: 70% alcohol, tincture iodine, or povidone-iodine
• Do NOT suture the wound immediately (if suturing is necessary, give RIG first and suture after minimum 2 hours)
• Avoid occlusive dressings
• Local wound care alone reduces the risk of rabies by 50%

• Equine RIG (ERIG): 40 IU/kg body weight after sensitivity test
• OR
• Human RIG (HRIG): 20 IU/kg body weight (preferred - no sensitivity test needed)
• Maximum available amount should be infiltrated into and around the wound
• Remaining dose given IM at a site distant from vaccine
• RIG must be given within 7 days of starting vaccine; if not given on Day 0, give up to Day 7

1. Cell Culture Vaccines (CCVs) - preferred:

• PCECV (Purified Chick Embryo Cell Vaccine)
• PVRV (Purified Vero Cell Rabies Vaccine)
• HDCV (Human Diploid Cell Vaccine)

• Days 0, 3, 7, 14, and 28
• Site: Deltoid (or anterolateral thigh in children)
• DO NOT inject in gluteal region

• 0.1 ml ID at 2 sites on Days 0, 3, 7, and 28

• 2 injections on Day 0, then 1 each on Days 7 and 21

• Tetanus toxoid (TT) injection if not immunized recently
• Tetanus immunoglobulin (TIG) if unimmunized + heavily contaminated wound

• Prophylactic antibiotics to prevent bacterial infection (amoxicillin-clavulanate preferred)
• This is particularly important for facial wounds

• Since dog whereabouts are unknown, assume dog is rabid
• If dog was available, it would be observed for 10 days
• If dog remains healthy after 10 days - vaccine can be stopped after Day 7 dose

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• No absolute contraindication to PEP - rabies is 100% fatal once symptoms appear; therefore vaccination is MANDATORY even in:
• Pregnant women
• Infants
• Immunocompromised individuals
• Relative precautions:
• History of hypersensitivity to egg protein (for PCECV - consult specialist)
• Previous severe reaction to rabies vaccine (switch to another cell culture vaccine)
• Avoid live vaccines within 4 weeks of rabies PEP
• Note: Old nerve tissue vaccines (NTV/Semple vaccine) are contraindicated due to neurological complications; only cell culture vaccines should be used

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• Mass dog vaccination: Immunization of at least 70% of the dog population breaks the chain of transmission (herd immunity threshold for rabies in dogs)
• Animal Birth Control (ABC) Programme: Sterilization of stray dogs to reduce dog population over time (endorsed by WHO - killing of dogs is NOT effective as population rebounds)
• Registration and leashing of owned dogs
• Compulsory rabies vaccination of pet dogs (pre-exposure prophylaxis)

• For high-risk persons: veterinarians, animal handlers, laboratory workers, forest officers
• Schedule: 3 doses on Days 0, 7, 21 or 28
• Regular booster doses as per titre monitoring

• Awareness of cat/dog bite first aid (wash wound immediately)
• Knowing where to seek PEP
• Community awareness about stray dog management

• Reporting of animal bites and suspected rabies deaths
• Lab confirmation of rabies (Negri bodies, FAT - Fluorescent Antibody Test)
• Monitoring vaccination coverage in dogs

• Prevention of Cruelty to Animals Act
• Animal Birth Control (Dogs) Rules 2001
• Municipal regulations on stray dog management

• Widespread availability of CCVs in government hospitals
• Free PEP under National Programme

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Q2. Mortality Indicators of MCH Care + Causes & Prevention of Maternal Mortality (2+3+5)

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1. Maternal Mortality Rate (MMR) = Maternal deaths per 1,00,000 live births
2. Infant Mortality Rate (IMR) = Deaths under 1 year per 1000 live births
3. Neonatal Mortality Rate (NMR) = Deaths in first 28 days per 1000 live births

• Early NMR: Deaths in first 7 days
• Late NMR: Deaths from day 7-28

1. Perinatal Mortality Rate (PMR) = (Stillbirths + Early neonatal deaths) per 1000 total births
2. Under-5 Mortality Rate (U5MR) = Deaths under 5 years per 1000 live births
3. Stillbirth Rate = Stillbirths per 1000 total births
4. Child Mortality Rate (CMR) = Deaths 1-4 years per 1000 children aged 1-4 years
5. Proportional Mortality Rate (PMR) = Deaths in a specific group/Total deaths × 100

• MMR: 97 per 1,00,000 live births (SRS 2018-20)
• IMR: 32 per 1000 live births (2018)
• U5MR: 36 per 1000 live births

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1. Haemorrhage (most common - 38%): Antepartum haemorrhage (APH), postpartum haemorrhage (PPH)
2. Sepsis/Infections (puerperal sepsis) - 11%
3. Hypertensive disorders of pregnancy - Pre-eclampsia and eclampsia - 11%
4. Obstructed/prolonged labour
5. Unsafe abortion
6. Ectopic pregnancy
7. Embolism

• Anaemia (most important indirect cause in India - contributes to ~20% of maternal deaths)
• Cardiac disease
• Hepatitis
• Malaria
• Tuberculosis
• Diabetes

• Delay 1: Delay in recognizing the need to seek care (lack of education, low status of women)
• Delay 2: Delay in reaching care (poor transport, distance, poverty)
• Delay 3: Delay in receiving care once at facility (inadequate staff, drugs, equipment)

• Early marriage and early pregnancy
• High fertility and short birth intervals
• Malnutrition and anaemia (70% of pregnant women in India are anaemic)
• Lack of skilled attendance at delivery
• Poor antenatal care

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• Minimum 4 ANC visits (WHO now recommends 8 contacts)
• Early registration of pregnancy (before 12 weeks)
• Screening for anaemia, hypertension, gestational diabetes, infections
• Iron and Folic Acid (IFA) supplementation - 180 tablets during pregnancy
• Tetanus toxoid immunization (2 doses or booster)
• Detection and management of high-risk pregnancies
• Nutritional counselling

• Promotion of institutional deliveries
• Janani Suraksha Yojana (JSY): Cash incentive for institutional delivery
• Janani Shishu Suraksha Karyakram (JSSK): Free drugs, diagnostics, blood, diet for pregnant women at government facilities
• Training of ANMs and nurses in skilled birth attendance
• Emergency Obstetric Care (EmOC) facilities at FRUs (First Referral Units)

• Postnatal visits within 48 hours, 7 days, and 42 days
• Detection and management of postnatal infections and haemorrhage
• Family planning counselling

• Implementation of MTP Act 1971 (amended 2021)
• Ensuring access to safe abortion at certified facilities
• Medical abortion with mifepristone + misoprostol up to 20 weeks

• Weekly Iron Folic Acid Supplementation (WIFS) for adolescent girls
• Deworming
• Dietary counselling

• Magnesium sulphate (MgSO4) at PHC level
• Antihypertensive therapy (methyldopa, labetalol, nifedipine)
• Calcium supplementation during pregnancy reduces eclampsia risk

• Active Management of Third Stage of Labour (AMTSL): oxytocin 10 IU IM within 1 minute of delivery of baby
• Misoprostol distribution to ASHA workers for home deliveries

• Raising age at marriage (PCMA Act - minimum 18 for girls, 21 for boys)
• Women's education and empowerment
• Poverty alleviation
• Improving transport and referral systems
• Surakshit Matritva Aashwasan (SUMAN) initiative

• Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA): Free ANC on 9th of every month
• LaQshya Programme: Quality improvement in Labour Rooms and OTs
• Midwifery Services Initiative

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SHORT ESSAYS (6 x 5 = 30 Marks)

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Q3. Demography, Demographic Gap, and Stages of Demographic Cycle (1+4)

• Demography: Derived from Greek words "demos" (people) + "graphos" (writing). It is the scientific study of human population - its size, composition, distribution, density, growth, and the factors causing changes in it (fertility, mortality, migration).
• Demographic Gap: The gap between the birth rate and death rate. When the death rate falls faster than the birth rate, the population grows rapidly. This widening gap between birth rate and death rate (before birth rate starts to decline) is called the demographic gap. This is responsible for the "population explosion" seen in developing countries.

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• Both birth rate and death rate are HIGH (35-40/1000)
• Population remains stationary (no growth)
• Characteristic of primitive/pre-agricultural societies
• High fertility compensates for high mortality
• Example: Tribal/isolated populations

• Death rate begins to FALL (due to improvements in sanitation, nutrition, medical care)
• Birth rate remains HIGH
• Population begins to GROW rapidly
• Demographic gap is WIDEST here
• Example: Most of Sub-Saharan Africa, parts of Asia

• Death rate falls further to moderate levels
• Birth rate begins to FALL (due to urbanization, education, family planning)
• Population still grows but at a slower rate
• Example: India currently in transition between Stage 3 and 4

• Both birth rate and death rate are LOW (around 10-15/1000)
• Population is stationary again
• Example: Western Europe, USA, Japan

• Death rate exceeds birth rate
• Population DECLINES
• Example: Some Eastern European countries (Germany, Russia)

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Q4. Primary Health Care - Definition, Elements, Principles (1+2+2)

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1. M - Maternal and Child Health including family planning
2. E - Education about prevailing health problems and methods of prevention
3. C - Control of locally endemic diseases
4. C - Communicable disease control (Immunization against major infectious diseases)
5. A - Adequate nutrition and food supply
6. F - Food supply and proper nutrition
7. E - Essential drugs
8. E - Essential drugs availability (simplified 8 elements):
9. Education about prevailing health problems and methods of their prevention and control
10. Promotion of food supply and proper nutrition
11. Adequate supply of safe water and basic sanitation
12. Maternal and child health care including family planning
13. Immunization against the major infectious diseases
14. Prevention and control of locally endemic diseases
15. Appropriate treatment of common diseases and injuries
16. Provision of essential drugs

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1. Equitable distribution: PHC must reach all people including the most underserved - rural poor, urban slum dwellers, marginalized groups
2. Community participation: The community must be actively involved in planning, organizing, operating, and controlling PHC. Health is not just a gift from government - people must participate
3. Intersectoral coordination: PHC cannot be achieved by the health sector alone. It requires collaboration with agriculture, education, housing, public works, communications, and other sectors
4. Appropriate technology: Technology should be scientifically valid, adaptable to local needs, acceptable to those who use it, and affordable (e.g., ORS over IV fluids, oral vaccines)
5. Decentralization: Decision-making and resource allocation should be at the lowest appropriate administrative level

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Q5. Levels of Communication in Doctor-Patient Relationship

• Communication within oneself - internal thought processes, reasoning, decision-making
• Example: Doctor reasoning through a diagnosis mentally before speaking to patient

• Face-to-face communication between two individuals - the most common and important in medicine
• Direct, personal, and allows immediate feedback
• Example: Doctor taking history, explaining diagnosis to patient
• Key elements: sender, message, channel, receiver, feedback, noise
• This is the PRIMARY level in doctor-patient relationship

• Communication within small groups (3-12 people)
• Example: Group health education sessions, family counselling, ward rounds with multiple patients

• Reaching large populations through media channels (TV, radio, newspapers, social media)
• One-way, no immediate feedback
• Example: Health awareness campaigns on tobacco, vaccines
• Used for creating awareness at population level

• Communication through formal channels within organizations
• Vertical (top-down / bottom-up) and horizontal communication
• Example: Referral letters, discharge summaries, interdepartmental communication

• Language barriers (medical jargon)
• Cultural differences
• Psychological barriers (fear, anxiety, denial)
• Physical barriers (noise, distance)
• Perceptual barriers (different understanding of illness)

• Clarity, simplicity
• Active listening
• Empathy and non-judgmental attitude
• Feedback and verification of understanding
• Use of appropriate non-verbal cues

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Q6. Objective and Goal + Network Analysis (1+4)

• Goal: A broad, long-term aim or desired state. It is general in nature and may not be precisely measurable. Example: "Health for All"
• Objective: A specific, measurable, time-bound statement of what is to be achieved. It is more precise and operational than a goal. Objectives translate goals into concrete targets. Example: "Reduce IMR to 25/1000 live births by 2017"

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• A management technique that makes possible more detailed planning and more comprehensive supervision
• Essence: Constructing an Arrow Diagram - representing the logical sequence in which events must take place
• "Every housewife who plans a meal so that each part of the menu is completed at the same time is using the basic technique of PERT" (K. Park)

1. Identify all activities required to complete the project
2. Determine the sequence and interdependence of activities
3. Draw the network diagram (arrows = activities; circles = events)
4. Estimate time for each activity (optimistic, pessimistic, most likely)
5. Calculate the critical path
6. Monitor and control

• Aids in planning, scheduling, and monitoring
• Allows better communication between management levels
• Identifies potential problems early
• Furnishes continuous, timely progress reports
• Identifies activities that are critical to timely completion
• Helps in better resource allocation

• The Critical Path is the longest path through the network
• If any activity along the critical path is delayed, the entire project will be delayed
• Activities NOT on the critical path have "float" time - can be delayed without affecting project completion
• CPM uses deterministic time estimates (unlike PERT's probabilistic estimates)

• Construction of hospitals/health centres
• Training programmes
• Disease eradication campaigns
• Drug procurement and supply chain management
• Vaccination campaign planning

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Q7. WHO Guidelines for Measuring Blood Pressure + Non-pharmacological Management of Hypertension (2+3)

1. Patient preparation:

• Patient should be seated comfortably for at least 5 minutes before measurement
• No smoking, coffee, or exercise for 30 minutes before measurement
• Bladder should be empty
• Patient should not talk during measurement

1. Position:

• Seated with back supported, feet flat on floor
• Arm at heart level (level of 4th intercostal space)
• Arm should be bare and unsupported

1. Cuff size:

• Cuff bladder should encircle at least 80% of the arm circumference
• Standard adult cuff: 12-13 cm wide, 35 cm long
• Large adult cuff for obese (arm circumference >32 cm)
• Child cuff for children

1. Measurement technique (auscultatory method):

• Palpate brachial artery, place cuff 2-3 cm above antecubital fossa
• Inflate to 20-30 mmHg above palpatory SBP
• Deflate at 2-3 mmHg/second
• Systolic BP = Korotkoff sound Phase I (first sound)
• Diastolic BP = Korotkoff sound Phase V (disappearance of sounds) - in children use Phase IV (muffling)

1. Number of readings:

• Take at least 2 readings 1-2 minutes apart
• If readings differ by >5 mmHg, take additional readings and average

1. Both arms:

• Measure in both arms at first visit; use arm with higher reading subsequently

1. Documentation:

• Record to nearest 2 mmHg
• Note time, arm used, position, cuff size

• SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg on two separate occasions

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• High in fruits, vegetables, whole grains, low-fat dairy
• Reduces SBP by 8-14 mmHg

• Reduce sodium intake to < 2.4 g/day (6 g common salt)
• Reduces SBP by 2-8 mmHg

• Maintain BMI 18.5-24.9 kg/m² (Asian cut-off: < 23)
• Weight loss of 10 kg reduces SBP by 5-20 mmHg

• Regular aerobic exercise: 30-45 minutes, 5 days/week (brisk walking, cycling, swimming)
• Reduces SBP by 4-9 mmHg

• Nicotine causes acute BP rise and accelerates atherosclerosis
• Stopping smoking reduces cardiovascular risk

• Limit to ≤ 2 drinks/day for men, ≤ 1 drink/day for women
• Reduces SBP by 2-4 mmHg

• Yoga, meditation, relaxation techniques, biofeedback
• Reduces sympathetic activity and BP

• Increase dietary potassium (fruits, vegetables)
• Reduces SBP by 2-4 mmHg

• Replace saturated fats with polyunsaturated and monounsaturated fats

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Q8. Nikshay + End TB Strategy (1+4)

• Nikshay is a web-based case notification and monitoring system for TB patients in India
• Launched by the Central TB Division, Ministry of Health & Family Welfare
• It is a patient-centric IT system for management of TB cases
• All TB patients (public and private sector) must be notified on Nikshay
• Serves as the backbone for TB notification, tracking, and monitoring under NTEP (National Tuberculosis Elimination Programme)
• Features: Real-time data entry, electronic case records, drug supply management, monitoring of treatment outcomes
• Nikshay Poshan Yojana: DBT (Direct Benefit Transfer) of Rs. 500/month to TB patients for nutritional support, directly linked to Nikshay

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• 95% reduction in TB deaths
• 90% reduction in TB incidence rate (to < 10 per 1,00,000 population)
• Zero TB-affected families facing catastrophic costs due to TB

1. Early diagnosis of TB including universal drug susceptibility testing; systematic screening of contacts and high-risk groups
2. Treatment of all patients with TB including drug-resistant TB, with patient support
3. Collaborative TB/HIV activities and management of co-morbidities
4. Preventive therapy for persons at high risk; vaccination against TB

• Target: Eliminate TB (incidence < 1/1,00,000 population) by 2025 (5 years ahead of global target)
• "TB Harega, Desh Jeetega" campaign
• Universal Drug Susceptibility Testing (UDST)
• Four strategic pillars: Detect - Treat - Prevent - Build (DTPB)

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SHORT ANSWERS (10 x 3 = 30 Marks)

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Q9. Malaria Vector Control Measures (K. Park)

1. Source reduction - elimination of breeding places (drainage of stagnant water, filling of pools/pits, proper solid waste disposal)
2. Intermittent irrigation (alternate wetting and drying of rice fields)
3. Biological control:

• Larvivorous fish: Gambusia affinis, Poecilia reticulata (Guppy) - released in ponds, wells, water bodies
• Bacillus thuringiensis israelensis (Bti) - a bacterial larvicide

1. Chemical larvicides:

• Temephos (abate) - applied to water bodies
• Oils and Paris green (less used now)

1. Indoor Residual Spraying (IRS):

• DDT still used in India for IRS (approved by WHO for malaria control)
• Synthetic pyrethroids (deltamethrin, alpha-cypermethrin) where DDT resistance exists
• Applied to inner walls and ceilings of all rooms in affected areas

1. Space spraying (fogging):

• Malathion fog/pyrethrum spray for rapid knockdown in outbreaks

1. Long Lasting Insecticidal Nets (LLINs):

• Bed nets treated with pyrethroids lasting 3+ years
• Reduces indoor biting and provides personal protection

• Insect repellents (DEET, permethrin)
• Protective clothing (full sleeve shirts, long trousers) especially at dusk/dawn
• Mosquito nets (untreated and treated)
• Window/door screens

• Sterile insect technique (SIT)
• Genetic manipulation of mosquitoes (experimental)

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Q10. Prevention and Control of Plague in India (K. Park)

• Rat-proofing of buildings, granaries, and food stores
• Poisons (rodenticides): zinc phosphide, warfarin
• Trapping
• Elimination of rat harborage (clearing rubbish, plugging burrows)
• Important: Rat control must be done ONLY AFTER flea control to avoid fleas deserting dead rats and biting humans

• DDT or BHC dusting of rat runs, burrows, homes
• Insecticide dusting of dead rats before handling
• Spraying insecticides in premises

• Rodent surveillance - monitoring rat populations
• Reporting of sudden mass death of rats ("rat fall") - warning sign of plague
• Epidemiological surveillance and reporting (plague is a notifiable disease under IHR 2005)

• Contacts of pneumonic plague cases: Doxycycline 100 mg BD × 7 days
• Or tetracycline, co-trimoxazole

• Streptomycin (drug of choice historically) OR Gentamicin
• Doxycycline, tetracycline, chloramphenicol as alternatives

• Killed whole-cell plague vaccine (TAB vaccine) - limited use; gives only 6-month protection
• Recommended for high-risk individuals and endemic areas

• Warn public about "rat fall"
• Avoid contact with sick/dead rodents
• Use insect repellents in endemic areas

• Isolation of pneumonic plague cases
• Quarantine of contacts

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Q11. Danger Signals of Cancer + Cancer Registration (1+2)

1. C - Change in bowel or bladder habits
2. A - A sore that does not heal
3. U - Unusual bleeding or discharge
4. T - Thickening or lump in breast, testis, or elsewhere
5. I - Indigestion or difficulty in swallowing
6. O - Obvious change in a wart or mole
7. N - Nagging cough or hoarseness of voice

• Unexplained weight loss
• Persistent fatigue
• Unexplained pain

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• Records all cancer cases treated at a specific institution
• Useful for evaluating treatment outcomes and quality of care
• Limitation: Selected/biased population; limited epidemiological utility

• Records all cancer cases occurring in a defined geographic area
• Optimal base population: 2-7 million
• Provides cancer incidence rates
• Used for epidemiology, time trend surveillance, and planning
• Examples: NCRP registries in Bangalore, Chennai, Mumbai, Delhi, Bhopal

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Q12. Lepra Reaction (K. Park, Chapter on Leprosy)

• Occurs in borderline leprosy (BT, BB, BL types)
• Mechanism: Cell-mediated immunity (Type IV hypersensitivity) - sudden increase in delayed-type hypersensitivity
• Features:
• Erythema and edema of existing skin lesions
• New lesions may appear
• Nerve swelling and pain - acute neuritis (commonest cause of nerve damage)
• Fever (variable)
• Acute nerve function impairment
• Treatment: Prednisolone 40-60 mg/day, tapered over 12-24 weeks; continue MDT

• Occurs in lepromatous and borderline lepromatous (BL/LL) leprosy
• Mechanism: Immune complex (Type III hypersensitivity) - antibody-antigen complex deposition
• Features:
• Tender erythematous nodules appear on skin (crops of nodules)
• Fever, malaise, systemic illness
• Neuritis, uveitis, orchitis, arthritis, lymphadenopathy, nephritis
• May recur in crops
• Treatment:
• Thalidomide (drug of choice for males) - 100-400 mg/day
• Clofazimine (in females/where thalidomide not available) - 300 mg/day
• Prednisolone for acute severe reactions
• Continue MDT

• Rare; seen in diffuse lepromatous leprosy
• Necrotizing skin lesions with vascular damage

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Q13. Advantages of Breastfeeding to Newborn and Mother (2+1)

1. Nutritional: Breast milk is species-specific - ideal nutritional composition with right balance of protein, fat, lactose, vitamins, and minerals
2. Immunological protection:

• Colostrum (first milk) rich in secretory IgA - protects GI mucosa
• Lactoferrin - bacteriostatic
• Lysozyme - antibacterial
• Macrophages and lymphocytes
• Protects against diarrhoea, respiratory infections, otitis media, meningitis

1. Prevention of malnutrition: Protection against PEM (Protein Energy Malnutrition)
2. Brain development: DHA, AA in breast milk support brain and retinal development
3. Always available: Right temperature, no preparation needed, no contamination
4. Reduces risk of SIDS (Sudden Infant Death Syndrome)
5. Promotes bonding: Skin-to-skin contact, eye contact enhance mother-infant attachment
6. Long-term benefits: Lower risk of obesity, type 1 diabetes, asthma, eczema in later life
7. Correct jaw development through suckling

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1. Lactational Amenorrhoea: Exclusive breastfeeding suppresses ovulation - natural birth spacing (LAM - Lactational Amenorrhoea Method)
2. Involution of uterus: Oxytocin released during suckling contracts uterus, reducing PPH
3. Reduces risk of breast and ovarian cancer
4. Weight loss: Helps mother return to pre-pregnancy weight
5. Psychological: Sense of satisfaction, bonding, reduced postpartum depression
6. Economical: No cost of formula milk or feeding equipment

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Q14. Different Levels of Health Care in India (K. Park)

• Sub-Centre (SC): Lowest health unit; 1 per 5000 population (plains), 1 per 3000 (hilly/tribal). Staffed by ANM + MPW (Male). Provides maternal and child health, family planning, immunization, first aid
• Primary Health Centre (PHC): 1 per 30,000 population (plains), 1 per 20,000 (hilly). Staffed by Medical Officer + paramedical staff. Provides OPD, MCH, family welfare, disease control, health education
• Community Health Centre (CHC): 1 per 1,20,000 population. Staffed by 4 specialists (surgeon, physician, OBG, paediatrician) + 21 paramedical staff. 30-bed hospital. Acts as First Referral Unit (FRU)

• Urban Health Posts, Dispensaries, Urban PHCs (under NUHM)

• District Hospital (DH): 100-500 beds; specialist services; serves district population (~2 million)
• Sub-district hospitals (Taluka/SDH): 50-100 beds

• Medical Colleges and Teaching Hospitals: Specialized and super-specialized care
• AIIMS, PGI, JIPMER, State medical college hospitals
• National Institutes (NIMHANS, SGPGI, AIIH&PH)

• Private sector: Majority of curative care in India (~70% of outpatient visits)
• Voluntary/NGO sector
• Indigenous systems: AYUSH (Ayurveda, Yoga, Unani, Siddha, Homeopathy)

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Q15. Measures for Prevention of Neonatal Tetanus (K. Park)

• Tetanus Toxoid (TT) vaccination:
• Women with no previous immunization: 2 doses - TT1 (as early as possible in pregnancy) + TT2 (4 weeks after TT1)
• If TT2 given in previous pregnancy < 3 years ago: 1 booster dose
• Provides protection through placental transfer of maternal antibodies to fetus
• Td (Tetanus-diphtheria) vaccine now recommended over plain TT

• Clean hands (delivery attendant's hands washed with soap)
• Clean delivery surface
• Clean cord cutting: sterile blade or scissors for cutting cord
• Clean cord care: Do NOT apply cowdung, oil, ghee, or any substance to the cord stump - keep it dry and clean (WHO recommends dry cord care or chlorhexidine 7.1% gel in high-risk settings)

• Training in clean delivery techniques
• Supply of clean delivery kits

• JSY and JSSK schemes to encourage hospital deliveries
• Availability of skilled birth attendants

• DPT (Diphtheria-Pertussis-Tetanus) - first dose at 6 weeks
• Does not protect against neonatal tetanus (too late) but prevents childhood tetanus

• Neonatal tetanus is a notifiable disease
• Community-based surveillance to track cases
• "Zero reporting" from PHCs monthly

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Q16. DOTS Strategy (K. Park)

1. Government commitment:

• Sustained political and administrative commitment
• Dedicated funding for TB control
• Prioritization of TB as a public health problem

1. Case detection by sputum smear microscopy:

• Passive case finding - examination of sputum of symptomatic patients attending health facilities
• Diagnosis by Ziehl-Neelsen (ZN) stained sputum smear microscopy
• Now supplemented by CBNAAT/GeneXpert for drug-resistant TB

1. Standardized short-course chemotherapy under direct observation:

• Treatment supervised by a health worker, treatment supporter, or community member
• Category I (new cases): 2(HRZE)/4(HR) - 2 months intensive phase + 4 months continuation phase
• Category II (retreatment cases): 2(HRZES)/1(HRZE)/5(HRE)
• Direct observation ensures adherence and prevents drug resistance
• Thrice-weekly (intermittent) or daily dosing schedules

1. Regular, uninterrupted supply of quality anti-TB drugs:

• Reliable drug procurement and distribution
• Use of Fixed Dose Combinations (FDCs)
• Cold chain maintained where needed

1. Standardized recording and reporting system:

• Case registration, treatment outcome recording
• Cohort analysis - quarterly reports
• Programme evaluation using standardized indicators
• Nikshay web-portal for case notification

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Q17. Recent Trends in MCH Care (K. Park)

• Pre-conception → Antenatal → Delivery → Postnatal → Newborn → Infant → Child → Adolescent
• Care provided across the lifecycle and across different levels of health system

• Shift from untrained TBAs to skilled birth attendants
• All deliveries at health facilities with trained staff (Janani Suraksha Yojana, JSSK)

• ASHAs trained to visit newborns at home (6 visits in first 42 days)
• Early detection of danger signs and referral of sick neonates

• Skin-to-skin contact for low birth weight/preterm babies
• Promotes warmth, breastfeeding, and bonding
• Recommended even in health facilities (KMC wards)

• WHO/UNICEF strategy integrating assessment and management of sick children
• Community IMNCI (C-IMNCI) for community-level workers

• SNCUs (Special Newborn Care Units) at district level
• NBSUs (Newborn Stabilization Units) at CHC level
• NBCCs (Newborn Care Corners) at delivery points

• Mother and Child Tracking System (MCTS) - name-based tracking
• ANMOL App for ANM field work

• RKSK (Rashtriya Kishor Swasthya Karyakram)
• Weekly Iron Folic Acid Supplementation (WIFS)
• Menstrual hygiene management

• Target: Reduce NMR to ≤ 10 and stillbirth rate ≤ 10 by 2030

• Free ANC on 9th of every month
• Quality ANC with specialist care

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Q18. Ideal IUD Candidate (K. Park, Chapter on Family Planning)

1. Parous woman (woman who has delivered at least one child) - uterine cavity better accommodates IUD; less risk of expulsion
2. Woman wanting long-term contraception (3-10 years) but wishing to retain fertility
3. Woman in a stable mutually monogamous relationship (reduces risk of STIs/PID)
4. Postpartum insertion:

• Within 48 hours of delivery (before uterus begins involuting) - PPIUCD (Postpartum IUCD)
• Or after 6 weeks postpartum
• PPIUCD has been widely promoted under national FP programme

1. Post-abortion insertion:

• Immediately following uncomplicated abortion (if no infection)

1. Women with contraindication to hormonal methods:

• Hypertension, diabetes, smokers over 35, migraine with aura, liver disease

1. Breastfeeding women (Cu-T does not affect milk production)

• Pregnancy (or suspected pregnancy)
• Unexplained vaginal bleeding
• Active PID or STI in last 3 months
• Distorted uterine cavity (fibroids, congenital anomalies)
• Copper allergy or Wilson's disease (for Cu-IUD)
• Malignancy of genital tract
• Current puerperal sepsis

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Summary of All Answers

LONG ESSAYS (10 marks each)

SHORT ESSAYS (5 marks each)

SHORT ANSWERS (3 marks each)

COMPREHENSIVE ANSWERS

Yenepoya University - Community Medicine Paper II (Dec 2023)

K. Park's Textbook of Preventive and Social Medicine

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LONG ESSAYS (2 x 10 = 20 Marks)

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Q1. STI OPD Case (25-year-old married female with vaginal discharge) - WHO Syndromic Approach: Name, Advantages, Management Plan, STD Community Control (1+2+4+3)

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1. Accessible and immediate treatment - No need to wait for laboratory results; treatment begins at first visit
2. Cost-effective - Cheaper than laboratory-based diagnosis, especially in resource-limited settings
3. Efficient - Covers all common organisms causing a particular syndrome (dual therapy)
4. Reduces transmission - Immediate treatment reduces the window period of infectivity
5. Treats partner simultaneously - Partner notification and treatment integrated
6. Applicable at PHC level - Does not require sophisticated lab infrastructure
7. Covers asymptomatic infections - Partner treatment reaches those without symptoms
8. Standardized - Uniform treatment protocols reduce errors

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• Duration, colour, odour, amount of discharge
• Associated symptoms: itching, dysuria, lower abdominal pain
• Sexual history, contraceptive use
• History of similar episodes and prior treatment

• Husband is a truck driver - occupationally high-risk for STIs
• Last contact: 1 week ago (visited for family event)
• No fever or lower abdominal pain (rules out PID initially)

• Speculum examination: cervical discharge - assess if cervicitis present
• Bimanual examination: check for cervical motion tenderness (CMT), adnexal tenderness

• Check for lower abdominal pain - absent here
• Check for cervical infection risk factors (partner is truck driver = YES)

• Tab. Cefixime 400 mg orally, single dose (for gonorrhea)
• Plus Tab. Azithromycin 1 g orally, single dose (for chlamydia)

• Tab. Metronidazole 400 mg orally, twice daily for 7 days OR Tab. Secnidazole 2 g single dose
• If candidiasis suspected: Clotrimazole 500 mg vaginal pessary, single dose OR Tab. Fluconazole 150 mg

• Husband must be treated simultaneously (even though asymptomatic)
• Contact slip/partner notification card provided
• Treat husband for gonorrhea + chlamydia on same lines

• Provide condoms and educate about consistent and correct use
• "ABC" strategy - Abstinence, Be faithful, Condom use

• Explain nature of disease, importance of completing treatment
• Advise sexual abstinence during treatment period
• Follow-up after 7 days

• Offer HIV testing (and Hepatitis B, syphilis screening) at ICTC
• PPTCT counselling

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• STD clinics at PHC/CHC level using syndromic flowcharts
• Integration of STI services with MCH and ANC clinics
• Free drugs for STI treatment at government facilities

• All recent sexual contacts treated simultaneously
• Contact tracing and partner management

• Free condom distribution through government channels
• Social marketing of condoms (Nirodh, Moods, etc.)
• Condom vending machines at high-risk areas
• Female condom availability

• High-risk populations: Female sex workers (FSWs), truck drivers, migrant workers, injecting drug users (IDUs), men who have sex with men (MSM)
• Peer-led education and outreach
• Targeted condom distribution and STI management

• Awareness about STIs - symptoms, transmission, prevention
• IEC activities (posters, radio, TV campaigns)
• Reduce stigma attached to STIs

• STI control is a key strategy for HIV control (STIs increase HIV transmission 3-5 times)
• ICTC linked to STI clinics for HIV testing

• Screening of all blood donations for HIV, HBV, HCV, syphilis, malaria
• Voluntary blood donation promoted; professional donation banned

• Harm reduction for IDUs
• Needle/syringe exchange programmes

• Preventing unwanted pregnancies that may arise from STI-associated risky behavior

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Q2. Objectives of ICDS + Beneficiaries + Services + Road to Health Chart (2+1+5+2)

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1. To improve the nutritional and health status of children in the age group 0-6 years
2. To lay the foundation for proper psychological, physical and social development of the child
3. To reduce the incidence of mortality, morbidity, malnutrition and school dropout
4. To achieve effective coordination of policy and implementation among various departments to promote child development
5. To enhance the capability of the mother to look after the normal health and nutritional needs of the child through proper nutrition and health education

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1. Children 0-6 years of age
2. Pregnant women
3. Lactating mothers
4. Women in 15-45 years age group (for nutrition and health education)
5. Adolescent girls (under Kishori Shakti Yojana / SABLA programme)

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• Provided for 300 days/year
• Children 6m-3yr: 500 kcal + 12-15 g protein/day
• Children 3-6yr (malnourished): 800 kcal + 20-25 g protein/day
• Pregnant/lactating women: 600 kcal + 18-20 g protein/day
• Severe malnutrition: 1200 kcal + 35-40 g protein/day
• Types: Take-home ration, hot cooked meals

• BCG, OPV, DPT, Measles, Vitamin A supplementation
• Delivered by ANM at AWC during fixed health days

• Measurement of weight and height
• Screening for anaemia, vitamin deficiencies
• Ante-natal check-up for pregnant women
• Identification of sick/malnourished children

• Sick/severely malnourished children referred to PHC/CHC
• High-risk pregnancies referred for specialist care
• Children with developmental delays referred to DEIC

• School readiness activities for 3-6 year olds
• Play-based learning, cognitive stimulation

• For women 15-45 years
• Topics: infant feeding, child care, hygiene, nutrition

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1. Growth monitoring: Longitudinal follow-up of child's physical growth and development - detects growth faltering early
2. Nutritional assessment: Weight-for-age plotted against reference curves; children below -2 SD are underweight
3. Identifying at-risk children: Children whose weight curve flattens or falls are at risk of malnutrition
4. Communication tool: Visual display easily understood by mothers and health workers - motivates mothers
5. Immunization record: Schedule of vaccines recorded on the same card
6. Feeding guidance: Records introduction of complementary feeding, breastfeeding duration
7. Health worker guidance: Enables timely referral of malnourished children
8. Programme monitoring: Used in ICDS to track nutritional status of children in the community

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SHORT ESSAYS (6 x 5 = 30 Marks)

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Q3. Classification of Contraceptive Methods + Barrier Methods (1+4)

1. Barrier methods (condom, diaphragm, cervical cap, spermicides)
2. Hormonal methods (OCP, injectables, patches, rings)
3. Intrauterine devices (Cu-T, LNG-IUS)
4. Natural/traditional methods (safe period, LAM, coitus interruptus, abstinence)
5. Emergency contraception (ECPs, Cu-IUD)

1. Female sterilization (tubectomy/tubal ligation)
2. Male sterilization (vasectomy)

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• Made of latex, polyurethane, or natural membrane
• Failure rate: 2-15 per 100 woman-years (varies with correct/consistent use)
• Advantages:
• Only method that protects against both pregnancy AND STIs/HIV
• Widely available, inexpensive, no medical prescription needed
• No hormonal side effects
• Promotes male participation in family planning
• Disadvantages: Requires motivation, may reduce sensation, latex allergy possible
• In India: Nirodh (free under national FP programme)

• Polyurethane pouch inserted into vagina before intercourse
• Advantages: Female-controlled; protects against STIs
• Disadvantages: More expensive, less aesthetically acceptable

• Dome-shaped rubber cap inserted into vagina to cover cervix
• Should be used with spermicidal cream/jelly
• Inserted up to 6 hours before intercourse and kept for 6-8 hours after
• Failure rate: 5-20 per 100 woman-years
• Requires fitting by healthcare provider
• Does not protect against STIs

• Thimble-shaped cap that fits directly over the cervix
• Smaller than diaphragm; used with spermicide
• Can be left in place for up to 48 hours
• Slightly less effective than diaphragm in parous women

• Chemical agents that kill sperm: nonoxynol-9 most common
• Available as creams, foams, jellies, films, suppositories, sponges
• Failure rate: 20-30 per 100 woman-years when used alone (high)
• Best used in combination with other barrier methods
• Do NOT protect against HIV (may increase risk with frequent use)

• Polyurethane sponge containing nonoxynol-9
• Inserted before intercourse; provides protection for 24 hours (multiple acts)
• Failure rate: 9-20%

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Q4. ASHA and ANM - Full Forms, Roles and Responsibilities of ASHA (1+4)

• ASHA = Accredited Social Health Activist
• ANM = Auxiliary Nurse Midwife

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• Resident woman (married/widow/divorced) of the village
• Preferably 25-45 years of age
• Minimum 8th class education
• Good communication skills and leadership qualities
• Norm: 1 ASHA per 1000 population (1 per habitation in tribal/hilly areas)

1. Promoter of good health practices with community support
2. Create awareness on essential RCH services, sexuality, gender equality, age at marriage
3. Motivate community for positive health behaviours

• ASHA accompanies woman to facility and receives incentive
• Rural BPL: Rs. 1400 to mother + Rs. 600 to ASHA

1. Facilitate nutritional care during pregnancy (IFA tablets, diet counselling)
2. Postnatal care - identify complications, motivate for PNC visits

• Assess newborn for danger signs (hypothermia, jaundice, feeding difficulty, sepsis)
• Promote exclusive breastfeeding for 6 months

1. Ensure complete immunization of children
2. Distribute ORS and Zinc for diarrhoea management
3. Identify and refer severely malnourished children (SAM)

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Q5. Levels of Communication in Doctor-Patient Relationship

• Communication within oneself (internal reasoning, decision-making)
• Doctor processes information before communicating with patient
• Patient processes diagnosis and decides whether to comply

• Primary and most important level in doctor-patient relationship
• Face-to-face, direct, allows immediate two-way feedback
• Non-verbal cues (eye contact, posture, facial expression, touch) are important
• History-taking, counselling, breaking bad news, obtaining consent
• Quality depends on: active listening, empathy, clarity, cultural sensitivity

• Communication in groups of 3-12 people
• Family counselling sessions, ward rounds, group health education
• Focus group discussions at community level

• Formal communication within health institutions
• Referral letters, discharge summaries, interdepartmental notes
• Vertical (hierarchy) and horizontal (peers) channels

• Reaching large, heterogeneous populations through media
• TV, radio, newspapers, social media, IEC materials
• One-directional (no immediate feedback)
• Used for health awareness campaigns (e.g., "TB Harega Desh Jeetega")

• Use of plain language (avoid medical jargon)
• Active listening - allow patient to complete story
• Empathy - acknowledge patient's emotions
• Open-ended questions initially, then closed questions
• Summarizing and checking understanding
• Appropriate non-verbal behaviour

• Language and literacy barriers
• Cultural and religious beliefs
• Patient fear, anxiety, denial
• Physical environment (noise, lack of privacy)
• Time pressure
• Physician's attitude (paternalistic approach)

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Q6. Definition of Planning + Steps in Planning Cycle (1+4)

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• Collection and interpretation of data on: population structure, morbidity/mortality statistics, disease epidemiology, health facilities, manpower, training facilities, community attitudes
• Identifies health problems, needs, and demands

• Objectives must be SMART (Specific, Measurable, Achievable, Relevant, Time-bound)
• Set at all levels - general at top, specific at lower levels
• Short-term and long-term objectives formulated

• Manpower, money, materials, skills, knowledge, time
• Balance between what is required and what is available

• Since resources fall short of needs, priorities are fixed based on: mortality/morbidity data, cost of prevention, social and political factors, diseases affecting younger populations

• Detailed plan for each programme
• Resources (inputs) matched to expected results (outputs)
• Each stage costed and time-specified
• Built-in evaluation mechanism

• Plan approved by policy-making authorities
• Roles and tasks defined for all workers
• Selection, training, motivation, supervision of staff
• Organization and communication structures set up

• Day-to-day follow-up of activities during implementation
• Continuous process: observing, recording, reporting
• Ensures activities are on schedule and proceeding as planned
• Tools: supervisory visits, logbooks, MIS reports

• Systematic assessment of relevance, adequacy, progress, efficiency, effectiveness, and impact
• Compares outcomes against stated objectives
• Feeds back into the next cycle (hence "cycle")
• Types: process evaluation, outcome evaluation, impact evaluation

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Q7. Physical and Abdominal Examination of Pregnant Women + Investigations at Subcentre (4+1)

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1. Haemoglobin estimation - Sahli's haemoglobinometer or colour scale (detect anaemia)
2. Urine for albumin - Detect pre-eclampsia/proteinuria
3. Urine for sugar - Detect gestational diabetes mellitus (GDM)
4. Blood group and Rh typing (where facility available, or referred to PHC)
5. Blood pressure measurement (using sphygmomanometer)
6. Weight measurement (weighing scale)
7. Urine pregnancy test (UPT) for confirmation of pregnancy
8. VDRL/RPR for syphilis (at higher levels if not available at SC)

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Q8. Prevention of Human Rabies (K. Park, Chapter on Zoonoses)

• For high-risk groups: veterinarians, animal handlers, laboratory workers, forest officers, spelunkers (cave explorers)
• Schedule: 3 doses of cell culture vaccine (PCECV/PVRV) IM on Days 0, 7, and 21 or 28
• Booster doses when titre falls below protective level (every 2 years for high-risk)
• Simplifies post-exposure regimen if bitten later (only 2 booster doses needed)

1. Local wound treatment - Thorough washing with soap and water for 15 minutes + viricidal agent (povidone-iodine)
2. Anti-Rabies Immunoglobulin (RIG):

• HRIG: 20 IU/kg (preferred) OR ERIG: 40 IU/kg
• Infiltrated into and around the wound
• For Category III exposures (bites on face, neck, fingers; multiple/deep wounds)

1. Vaccination:

• Cell culture vaccines: PCECV, PVRV, HDCV
• Essen regimen (IM 5-dose): Days 0, 3, 7, 14, 28 (deltoid)
• Zagreb regimen: Days 0 (×2), 7, 21
• Thai Red Cross ID regimen: 0.1 ml ID at 2 sites on Days 0, 3, 7, 28

• Category I: Touching/feeding animal - wash hands; no vaccine
• Category II: Minor scratches without bleeding - vaccine only
• Category III: Transdermal bites/licks on broken skin - RIG + vaccine

• Mass vaccination of dogs - ≥70% coverage breaks transmission
• Animal Birth Control (ABC) programme - sterilization of stray dogs
• Registration and compulsory vaccination of pet dogs
• Elimination of stray dogs from certain areas (legal challenges)

• First-aid: immediate wound washing
• Knowing where to seek PEP
• Warning signs of rabies (hydrophobia, aerophobia, agitation)
• Not to handle sick/dead animals

• Laboratory diagnosis: FAT (Fluorescent Antibody Test) on brain tissue
• Negri bodies on histopathology
• Reporting of animal bites and suspected rabies deaths

• Rabies is 100% fatal once symptomatic
• No absolute contraindication to PEP
• Old nerve tissue vaccines (Semple/NTV) are obsolete - only cell culture vaccines to be used

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SHORT ANSWERS (10 x 3 = 30 Marks)

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Q9. Key Populations Affected with HIV in India + Modes of Transmission (1+2)

1. Female Sex Workers (FSWs) - Prevalence ~2.2%
2. Men who have Sex with Men (MSM) - Prevalence ~4.3%
3. Injecting Drug Users (IDUs) - Prevalence ~7.2% (highest risk group)
4. Hijras/Transgenders - Prevalence ~8.8%
5. Truck drivers and migrant workers (bridge populations)
6. Partners of above groups (direct risk)
7. People with TB (HIV-TB co-infection)

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• Unprotected heterosexual intercourse (most common route in India)
• Anal intercourse (highest risk per act)
• Oral sex (low risk)
• Risk increases with: presence of STIs, multiple partners, non-use of condoms, high viral load

• Sharing of needles/syringes among IDUs
• Blood transfusion and blood products (before screening)
• Needle-stick injuries (healthcare workers) - risk ~0.3% per exposure
• Unsterilized medical/dental equipment
• Tattooing and skin piercing with contaminated instruments

• During pregnancy (transplacental)
• During delivery (most common - ~65% of MTCT)
• Through breastfeeding (~14-22% risk of transmission via breast milk)
• Without intervention, overall MTCT risk = 25-45%
• PPTCT programme reduces this to <2% with ARV prophylaxis + safe delivery + replacement feeding

• Casual contact (hugging, handshakes)
• Coughing, sneezing
• Food, water, utensils
• Mosquito bites or other insects
• Sweat, tears, saliva (in normal quantities)

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Q10. Nosocomial Infection - Definition + Measures to Prevent (1+2)

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• Handwashing with soap and water for 20 seconds
• Alcohol-based hand rub (ABHR) - 5 moments of hand hygiene (WHO): before patient contact, before aseptic procedure, after body fluid exposure, after patient contact, after contact with patient surroundings

• Treat all blood and body fluids as potentially infectious
• Gloves, gown, mask, eye protection as appropriate
• Dispose sharps in puncture-proof containers immediately
• No recapping of needles

• Sterile technique for invasive procedures (catheterization, IV lines, wound dressing)
• Clean and sterile fields maintained in OT

• Autoclaving (steam under pressure) for heat-stable instruments - most reliable
• Chemical disinfection for heat-labile equipment
• Single-use disposables where possible

• Regular cleaning of ward surfaces, floors, beds
• Biomedical waste management (segregation, safe disposal)
• Proper ventilation and air exchange in OTs

• Source isolation: infectious patients in single rooms (contact/droplet/airborne precautions)
• Cohort isolation: grouping patients with same infection together

• Rational use of antibiotics
• Avoid unnecessary broad-spectrum antibiotics
• Follow antibiotic policies to reduce multidrug-resistant organisms (MDROs)

• Active HAI surveillance and feedback to clinical staff
• Infection control committees in hospitals
• Regular microbiological monitoring

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Q11. Self-care in Diabetes Management (K. Park)

• Regular self-monitoring of blood glucose (SMBG) using glucometer
• Fasting target: 80-130 mg/dl; 2-hour post-prandial: <180 mg/dl
• HbA1c monitoring every 3 months (target <7%)
• Recognizing and managing hypoglycemia (symptoms: sweating, tremor, confusion)

• Follow the "diabetes plate method" - half plate vegetables, quarter complex carbs, quarter lean protein
• Fixed meal timing - 3 main meals + 2-3 snacks
• Avoid refined carbohydrates, sugary beverages, saturated fats
• High-fibre diet (vegetables, whole grains, legumes)
• Reduce portion sizes; calorie restriction for overweight diabetics
• DASH or Mediterranean diet pattern recommended

• 150 minutes/week of moderate aerobic activity (brisk walking)
• Resistance training 2-3 times/week
• Check blood glucose before and after exercise
• Avoid vigorous exercise during hypoglycemia or very high glucose

• Take oral hypoglycaemics (metformin, sulfonylureas, etc.) as prescribed
• Insulin injection technique (correct site rotation, storage)
• Never skip medications

• Daily inspection of feet for blisters, cuts, swelling
• Keep feet clean and dry
• Moisturize (not between toes)
• Wear well-fitting, comfortable footwear - no bare feet
• Trim toenails straight across
• Avoid hot water bottles, heating pads on feet

• Blood pressure monitoring (target <130/80)
• Annual eye examination (fundoscopy for diabetic retinopathy)
• Annual urine microalbumin (early nephropathy)
• Annual foot examination by clinician
• Lipid profile monitoring

• Yoga, meditation, breathing exercises
• Depression screening (comorbid with diabetes)

• Smoking significantly accelerates diabetic complications (cardiovascular, renal)

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Q12. BCG Vaccination (K. Park)

• A live attenuated vaccine derived from Mycobacterium bovis (bovine tuberculosis bacillus)
• Developed by Albert Calmette and Camille Guérin at Pasteur Institute, Paris (1921)

• Single dose at birth (or as early as possible after birth, before 1 month)
• If not given at birth, given up to 5 years of age (after which tuberculin testing should be done)
• No booster dose required

• 0.05 ml intradermally (newborn), 0.1 ml intradermally (children > 1 year)
• Site: Left upper arm (insertion of deltoid)
• Strict intradermal injection - produces a bleb; NOT subcutaneous

• Against tuberculous meningitis and miliary TB in children: 75-86%
• Against pulmonary TB in adults: variable (0-80%) - controversial
• Does NOT prevent primary infection with TB
• India's UIP relies on BCG primarily for preventing severe childhood TB (meningitis, miliary)

• Immunodeficiency states (HIV with low CD4, congenital immunodeficiency)
• Active TB (relative)
• High-dose corticosteroid therapy

• A papule appears at 2-3 weeks → ulcerates → heals leaving a scar by 6-12 weeks
• Scar confirms successful vaccination

• BCG converts Mantoux test (tuberculin skin test) to positive
• Conversion indicates immunological response, but does not distinguish BCG from natural TB infection

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Q13. Exclusive Breastfeeding + Baby Friendly Hospital Initiative (1+2)

• Breast milk provides all nutrients and water the infant needs
• Protects against diarrhoea, respiratory infections, otitis media
• WHO/UNICEF global recommendation since 2001

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1. Have a written breastfeeding policy communicated to all health care staff
2. Train all health care staff in skills to implement the policy
3. Inform all pregnant women about the benefits and management of breastfeeding
4. Help mothers initiate breastfeeding within 30 minutes of birth (skin-to-skin contact)
5. Show mothers how to breastfeed and maintain lactation (even if separated from infant)
6. Give no food or fluid other than breast milk (no prelacteal feeds, no glucose water)
7. Practice "rooming-in" - mother and infant together 24 hours/day
8. Encourage breastfeeding on demand (unrestricted)
9. Give no artificial teats or pacifiers to breastfeeding infants
10. Foster breastfeeding support groups; refer mothers on discharge

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Q14. Basic Resources Required for Providing Health Care (K. Park)

• Doctors, nurses, paramedical staff (ANM, LHV, ASHA), health workers
• Administrative and technical staff
• The most critical resource - quality of care depends on trained, motivated staff
• Skill mix: Appropriate number of each category for population size

• Government budgetary allocation for health
• Insurance, user fees, donor funding
• India's health expenditure: ~2.1% of GDP (target: 2.5% by 2025)
• Financial resources determine availability of drugs, equipment, infrastructure

• Drugs and vaccines: Essential medicines list (NLEM), cold chain for vaccines
• Equipment and instruments: Diagnostic equipment, surgical instruments, laboratory
• Infrastructure: Buildings (hospitals, PHCs, sub-centres, anganwadis)
• Transport: Ambulances (108), mobile health units

• Health information systems (HMIS, Nikshay, ANMOL)
• Epidemiological surveillance data
• Research and evidence base for decision-making
• Training materials and guidelines

• An often underestimated resource
• Sufficient time for patient consultations, community health activities
• Programme timelines and deadlines

• Appropriate technology matched to the health system's capacity
• Point-of-care diagnostics, telemedicine
• Renewable energy for health facilities

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Q15. Prevention and Control of Soil-Transmitted Helminths (STH) (K. Park)

• Safe disposal of human faeces (latrines, toilets) - prevents soil contamination with feces
• Swachh Bharat Mission (SBM) - construction of toilets, elimination of open defecation
• Safe water supply - prevents faecal-oral transmission
• Avoid using human excreta (night soil) as fertilizer

• Handwashing with soap and water after defecation and before eating
• Wearing footwear (especially for hookworm - prevents larval skin penetration)
• Keeping nails short and clean (Ascaris, Trichuris eggs under nails)
• Not eating raw/unwashed fruits and vegetables

• Washing fruits and vegetables thoroughly
• Avoid eating soil-contaminated raw vegetables
• Cooking food properly

• National Deworming Day (NDD): 10th August and 10th February every year
• Albendazole 400 mg single dose chewable tablet to all children aged 1-19 years (government, aided, and private schools)
• Under RBSK and school health programme
• Reduces worm burden, anaemia, malnutrition
• WHO recommends periodic deworming in areas where STH prevalence >20%
• Pregnant women: deworming in 2nd trimester (mebendazole 500 mg single dose)

• Importance of sanitation and personal hygiene
• Danger of playing in contaminated soil barefoot
• Signs of worm infestation (abdominal pain, anaemia, failure to thrive)

• Albendazole 400 mg single dose (for Ascaris, Trichuris, hookworm)
• Ivermectin 200 mcg/kg for Strongyloides
• Mebendazole 100 mg twice daily × 3 days (alternative)

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Q16. Control of Japanese Encephalitis (K. Park)

1. Larvicides - Temephos or Bacillus thuringiensis israelensis (Bti) in rice fields, water bodies
2. Insecticides - Malathion space spraying during outbreaks
3. Environmental management - proper drainage of paddy fields (alternate wetting/drying)
4. Biological control - larvivorous fish in water bodies

• Bed nets (insecticide-treated nets/LLINs)
• Protective clothing (long sleeves, long trousers) at dusk/dawn
• Mosquito repellents (DEET-based)
• Window and door screens

• SA-14-14-2 live attenuated vaccine (manufactured by Chengdu Biologics, China)
• Used in India's national immunization programme
• 2 doses: at 9 months and 16 months (since 2014, JE vaccine added to UIP in endemic districts)
• Inactivated Vero cell-derived vaccine (IXIARO) for travelers
• JE vaccine is part of UIP in endemic states/districts: Assam, Bihar, Karnataka, Maharashtra, Tamil Nadu, Uttar Pradesh, West Bengal, etc.

• Separation of piggeries from human habitation
• Not possible to eliminate wild bird reservoirs

• No specific antiviral treatment
• Supportive care (ICU, anti-convulsants, mannitol for cerebral oedema)
• Case fatality rate: 20-30%; neurological sequelae in 30-50% of survivors

• Sentinel surveillance in endemic areas
• Vector surveillance

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Q17. Rashtriya Bal Swasthya Karyakram (RBSK) (K. Park)

• Launched: February 2013 under NHM
• Full name: Rashtriya Bal Swasthya Karyakram (National Child Health Programme)
• Provides Child Health Screening and Early Intervention Services

1. Defects at birth (30 selected birth defects)
2. Deficiencies (anaemia, vitamin deficiency, malnutrition)
3. Diseases (childhood diseases - dental, hearing, vision problems, rheumatic heart disease, etc.)
4. Development delays including disability (cerebral palsy, autism, hearing impairment, vision impairment, cleft lip/palate, developmental delay)

• 1 MHT per block covering 30 schools
• 4 members: AYUSH doctor, staff nurse, ANM, pharmacist
• Screen 30 conditions

• Children identified with conditions → referred to District Early Intervention Centre (DEIC) for management
• Services at DEIC provided at zero cost to the family

• Weekly Iron Folic Acid Supplementation (WIFS) for school children
• National Deworming Day (Albendazole distribution)
• School eye screening and free spectacles
• Menstrual hygiene management

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Q18. Sex Ratio - Definition + Reasons for Low Sex Ratio in India (1+2)

• India's sex ratio (2011 Census): 943 females per 1000 males (overall)
• Child Sex Ratio (CSR) / 0-6 years (2011 Census): 914 females per 1000 males (most alarming indicator)
• K. Park's textbook gives: Sex ratio (females per 1000 male) - 2016-18: 899
• At birth (natural/biological): ~105 males born per 100 females (sex ratio at birth = ~950 females per 1000 males)

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• Misuse of prenatal diagnostic techniques (ultrasound, amniocentesis) to determine sex and selectively abort female foetuses
• Results in skewed sex ratio at birth
• Despite PCPNDT Act 1994 (amended 2003), selective abortion continues especially in Punjab, Haryana, Rajasthan, Gujarat, Uttar Pradesh
• Child sex ratio has DECLINED from 945 (2001) to 914 (2011) - evidence of female foeticide

• Deep-rooted patriarchal attitude - son preferred for economic support, carrying family name, last rites
• Daughter viewed as financial burden (dowry system)
• Leads to neglect of girl child in feeding, healthcare, education

• Killing of girl infants immediately after birth (historical and still occurring in some communities)
• More common in Tamil Nadu, Rajasthan

• Girls given less food, less health care, less medical attention when ill
• Higher female mortality from preventable causes due to neglect
• Malnutrition more common in girl children

• High maternal mortality disproportionately reduces female population
• Pregnancy-related deaths contribute to lower female numbers in reproductive age group

• Early marriage and early childbearing → increased maternal mortality → reduces female numbers

• PCPNDT Act - prevents sex-selective abortion
• Beti Bachao Beti Padhao (BBBP) scheme - launched 2015 to improve CSR; focused on 100 districts with lowest CSR
• Conditional cash transfers: Dhanalakshmi, Ladli, etc.
• Female education and empowerment programmes (Kishori Shakti Yojana, SABLA, RKSK)

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Summary of All Answers

LONG ESSAYS (10 marks each)

SHORT ESSAYS (5 marks each)

SHORT ANSWERS (3 marks each)

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Your Answers Are Already Written Above - Here's a Guide:

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Paper 1 (IMG_0782) - First paper in this conversation

• Long Essays: Road Traffic Accidents, Infant Mortality
• Short Essays: Planning Cycle, Cancer Registries, NBCP, Poor Lifestyle Effects, ASHA Worker, BFHI
• Short Answers: Cost-Effective Analysis, Zinc in Diarrhoea, PCPNDT Act, Disaster Mitigation, DASH, Indian Red Cross, Incineration, Counterfeit Medicines, ICTC, BMI

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Paper 2 (IMG_0783 + IMG_0784) - Second paper in this conversation

• Long Essays: Dog Bite/Rabies Management, MCH Mortality Indicators + Maternal Mortality
• Short Essays: Demography/Demographic Cycle, Primary Health Care, Doctor-Patient Communication, Objective/Goal + Network Analysis, WHO BP Guidelines + Non-pharmacological HTN, Nikshay + End TB Strategy
• Short Answers: Malaria Vector Control, Plague Prevention, Cancer Danger Signals, Lepra Reaction, Breastfeeding Advantages, Levels of Health Care, Neonatal Tetanus Prevention, DOTS, Recent MCH Trends, Ideal IUD Candidate

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Paper 3 (IMG_0786) - Third paper in this conversation

• Long Essays: STI Syndromic Approach (vaginal discharge case), ICDS + Road to Health Chart
• Short Essays: Contraceptive Methods + Barrier Methods, ASHA + ANM Roles, Doctor-Patient Communication, Planning + Planning Cycle, ANC Examination + Subcentre Investigations, Prevention of Rabies
• Short Answers: HIV Key Populations + Transmission, Nosocomial Infection, Self-care in Diabetes, BCG Vaccination, Exclusive Breastfeeding + BFHI, Basic Resources for Health Care, Soil-Transmitted Helminths, Japanese Encephalitis, RBSK, Sex Ratio

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PAPER 1 (IMG_0782) - COMPLETE ANSWERS

K. Park's Textbook of Preventive and Social Medicine

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LONG ESSAYS (2 x 10 = 20 Marks)

Q1. Causes of Road Traffic Accidents + Educational Content for School Children (10 marks)

• Speeding and rash driving
• Driving under influence of alcohol/drugs
• Fatigue and drowsiness
• Inexperience and lack of skill
• Visual defects (poor night vision, colour blindness)
• Use of mobile phones while driving
• Non-use of seatbelts and helmets
• Emotional disturbances and stress

• Jaywalking / crossing at wrong places
• Walking on the wrong side of the road
• Children running onto road unexpectedly
• Inattention to traffic

• Overloading of vehicles

• Defective brakes, lights, tyres, steering
• Poor vehicle maintenance
• Absence of safety devices (airbags, seatbelts)
• Overloading beyond capacity

• Poor road design (sharp curves, narrow roads)
• Absence of road signs, signals, markings
• Poor night-time lighting
• Adverse weather (rain, fog, mist)
• Encroachments on roads
• Stray animals on roads

• Rapid motorization without adequate infrastructure
• Inadequate enforcement of traffic laws
• Inadequate emergency medical services

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• Always walk on the LEFT side of the road / footpath
• Cross ONLY at zebra crossings or pedestrian signals
• Look LEFT, then RIGHT, then LEFT again before crossing
• Never run onto the road suddenly
• Make eye contact with driver before crossing

• Red = Stop; Yellow = Ready; Green = Go
• Always obey traffic lights and police signals

• Always wear a helmet on a bicycle/two-wheeler
• Wear seatbelt in a car at ALL times

• Never play on the road
• Do not use mobile phones/earphones while walking on road
• Wear bright/reflective clothing at night
• Never hang on the back of moving vehicles

• Do not travel in overloaded vehicles
• Never ride in back of open trucks
• Do not distract the driver

• Call 108 (ambulance) immediately after accident
• Do not move an injured person unless absolutely necessary
• Inform nearest police station

• Encourage classmates to follow road safety rules
• Report unsafe road conditions to teachers and parents

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Q2. Causes of Infant Mortality + Preventive and Social Measures to Reduce IMR in India (10 marks)

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1. Low birth weight and prematurity
2. Birth injury and difficult labour
3. Sepsis
4. Congenital anomalies
5. Haemolytic disease of newborn
6. Conditions of placenta and cord
7. Diarrhoeal diseases
8. Acute respiratory infections
9. Neonatal tetanus

1. Diarrhoeal diseases
2. Acute respiratory infections
3. Other communicable diseases
4. Malnutrition
5. Congenital anomalies
6. Accidents

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• (a) Birth weight - LBW <2.5 kg is major risk
• (b) Age of mother - extremes of age (very young/old)
• (c) Birth order and birth interval - high parity, short intervals
• (d) Sex of child
• (e) Quality of mothering

• (f) Maternal education - illiteracy greatest barrier
• (g) Quality of health care - inadequate prenatal care
• (h) Broken families
• (i) Illegitimacy
• (j) Brutal customs - denying colostrum, cowdung on cord, early weaning
• (k) Indigenous (untrained) dai
• (l) Bad environmental sanitation

• Poverty leads to malnutrition, poor healthcare, overcrowding

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1. Prenatal Nutrition: Food supplementation (ICDS); additional 500 kcal + 10g protein in last trimester
2. Prevention of Infection: Universal Immunization Programme - 9 vaccine-preventable diseases; Mission Indradhanush
3. Breast-feeding: Exclusive breastfeeding for 6 months; BFHI
4. Growth Monitoring: Monthly weighing; Road to Health chart; early identification of malnourished children
5. Family Planning: Spacing births 2-3 years; limiting family size
6. Sanitation: Safe water supply, improved housing, drainage, fly control
7. Primary Health Care: ASHA at village level; ORS+zinc for diarrhoea; cotrimoxazole for ARI
8. Maternal Health Care: 4+ ANC visits; institutional deliveries; training of dais; JSSK
9. Social Measures: Female literacy (Kerala model); poverty alleviation; prevent child marriage
10. National Programmes: IMNCI, NSSK, HBNC, India Newborn Action Plan (INAP), NRCs for SAM

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SHORT ESSAYS (6 x 5 = 30 Marks)

Q3. Planning Cycle (5 marks)

• Collection/interpretation of data: population structure, morbidity/mortality, disease epidemiology, health facilities, manpower, community attitudes

• Objectives = SMART (Specific, Measurable, Achievable, Relevant, Time-bound)
• Short-term and long-term; general at upper levels, specific at lower levels

• Manpower, money, materials, skills, knowledge, techniques
• Balance between what is required and what is available

• Based on: mortality/morbidity data, cost of prevention, financial constraints, political/community interests

• Detailed plan for each programme; resources (inputs) matched to expected results (outputs)
• Each stage costed and time-specified; built-in evaluation mechanism

• Roles and tasks defined; selection, training, motivation, supervision of manpower

• Day-to-day follow-up during implementation; continuous observing, recording, reporting

• Systematic assessment of relevance, adequacy, progress, efficiency, effectiveness, impact
• Feeds back into the next planning cycle

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Q4. Types of Cancer Registries (5 marks)

• Records all cancer patients (inpatients + outpatients) treated at a specific institution
• Collects uniform minimum data set per WHO Handbook for Standardized Cancer Registers
• Useful for: evaluating treatment outcomes, quality of cancer care, survival analysis
• Limitation: Hospital population = selected/biased; limited epidemiological use

• Records ALL cancer cases occurring in a defined geographic area
• Optimal base population: 2-7 million
• Provides cancer incidence rates
• Uses: epidemiological enquiries, time trend surveillance, planning and evaluation of cancer control
• Examples in India (NCRP - ICMR, since 1981): Bangalore, Chennai, Mumbai, Delhi, Bhopal

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Q5. National Blindness Control Programme (NPCB) (5 marks)

1. Continue 3 signature activities: 66 lakh cataract operations/year; school eye screening + 9 lakh free spectacles/year; 50,000 donated eyes/year
2. Reduce backlog of avoidable blindness
3. Develop strategy for "Eye Health for All"
4. Strengthen Regional Institutes of Ophthalmology (RIOs)
5. Develop human resources for comprehensive eye care in all districts
6. Enhance community awareness on eye care
7. Expand research for prevention of blindness
8. Secure participation of voluntary organizations and private practitioners

1. Free cataract surgery through health system + NGO + private sector
2. Comprehensive eye care (diabetic retinopathy, glaucoma, corneal transplant, paediatric blindness)
3. Active screening of population >50 years
4. Screening children for refractive errors; free spectacles to BPL children
5. Public-private partnership for underserved areas
6. Capacity building of health personnel
7. IEC activities for community awareness
8. Eye donation fortnight: 25th August to 8th September every year

• Tertiary: Regional Institutes of Ophthalmology + Centres of Excellence
• Secondary: District Hospitals + NGO Eye Hospitals
• Primary: Sub-district hospitals/CHCs, Mobile Ophthalmic Units, Upgraded PHCs

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Q6. Adverse Effects of Poor Lifestyle on Health - Salient Points for School Children (5 marks)

• Excessive junk food, fast food, processed food
• High salt, sugar, saturated fat → obesity, hypertension, diabetes type 2, dyslipidaemia, dental caries
• Skipping breakfast → poor concentration and academic performance
• Adequate fruits, vegetables, whole grains, water are essential

• Prolonged screen time (TV, mobile, computer) = sedentary behaviour
• Lack of exercise → obesity, CVD, musculoskeletal problems, mental health issues
• Recommended: minimum 60 minutes of moderate-to-vigorous activity per day for children

• Experimentation begins in school age
• Causes: lung cancer, oral cancer, COPD, cardiovascular disease
• Second-hand smoke also harmful
• All forms - cigarettes, beedis, gutka, khaini - are dangerous

• Alcohol damages liver, brain, social functioning
• Gateway to harder drugs
• Impairs judgement → accidents

• Children need 8-10 hours of sleep
• Late-night screen use disturbs sleep; impairs growth, learning, immunity

• Academic pressure, social media → anxiety, depression
• Coping: exercise, talking to trusted adults, hobbies, yoga

• BMI >25 (overweight), >30 (obese)
• Linked to diabetes type 2, hypertension, joint problems, poor self-esteem
• Small changes: replace cold drinks with water, use stairs

• Unprotected sex → STIs, unwanted pregnancies
• Age-appropriate education on safe practices

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Q7. Job Responsibilities of ASHA Worker (5 marks)

• Promoter of good health practices
• Awareness on RCH services, sexuality, gender equality, age at marriage

• Early registration of pregnancies
• Motivate for minimum 4 ANC visits
• Motivate institutional delivery under JSY (escort woman + receive incentive)
• Nutritional care during pregnancy; IFA tablets distribution
• Postnatal care - identify complications

• HBNC: 6 postnatal home visits (days 1,3,7,14,21,28) - assess newborn, promote exclusive breastfeeding
• Ensure complete immunization of children
• Distribute ORS and Zinc for diarrhoea
• Identify and refer severely malnourished children (SAM) to NRCs

• Counselling on contraception
• Distribute OCPs, condoms, emergency contraceptive pills
• Motivate for sterilization where appropriate

• Identify TB suspects (>2 weeks cough); refer for sputum examination
• DOTS support for TB patients
• Malaria - distribute LLINs, collect blood smears
• HIV/AIDS awareness; referral to ICTC

• Community screening for hypertension, diabetes, cancer

• Maintain village health register
• Escort patients to health facilities
• Facilitate Mahila Arogya Samiti (MAS) meetings

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Q8. Components of Baby Friendly Hospital Initiative (BFHI) (5 marks)

1. Have a written breastfeeding policy communicated routinely to all health care staff
2. Train all health care staff in skills necessary to implement the policy
3. Inform all pregnant women about the benefits and management of breastfeeding
4. Initiate breastfeeding within 30 minutes of birth - skin-to-skin contact
5. Show mothers how to breastfeed and maintain lactation even if separated from infants
6. Give no food or fluid other than breast milk - no prelacteal feeds, no glucose/water (unless medically indicated)
7. Practice rooming-in - mother and infant together 24 hours a day
8. Encourage breastfeeding on demand - unrestricted, whenever baby wants
9. Give no artificial teats or pacifiers (dummies/soothers) to breastfeeding infants
10. Foster breastfeeding support groups - refer mothers to them on discharge

• Reduces neonatal morbidity and mortality
• Protects against diarrhoea, respiratory infections, otitis media
• Promotes mother-infant bonding
• Economical and always available at correct temperature

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SHORT ANSWERS (10 x 3 = 30 Marks)

Q9. Cost-Effective Analysis

• A management technique for evaluation of health programmes
• Similar to cost-benefit analysis except benefit expressed not in monetary terms but in results achieved - e.g., number of lives saved, number of days free from disease, DALYs averted
• More promising tool for application in health field than cost-benefit analysis
• Helps compare alternative programmes to determine which achieves desired result most economically
• Limitation: Even cost-effective analysis is not possible in many cases
• Example: Cost per case of TB cured under DOTS vs. non-DOTS regimen
• Used in PPBS (Planning-Programming-Budgeting System) and Health Technology Assessment

Q10. Zinc Supplementation in Acute Diarrhoea

• Zinc is essential for immune function, protein synthesis, cell division
• Zinc deficiency common in developing countries, especially malnourished children
• WHO/UNICEF recommend zinc as universal standard of care for acute diarrhoea in children
• Dose: Children <6 months = 10 mg/day for 10-14 days; Children ≥6 months = 20 mg/day for 10-14 days
• Given along with ORS
• Benefits: Reduces duration of diarrhoea by ~25%; reduces stool volume and frequency; reduces risk of recurrence for 2-3 months; reduces all-cause mortality
• India: Intensified Diarrhoea Control Fortnight (IDCF) observed in July-August with ORS + zinc distribution

Q11. PCPNDT Act

• Full form: Pre-Conception and Pre-Natal Diagnostic Techniques Act
• Enacted 1994, amended 2003; renamed from PNDT Act
• Objective: Prevent sex-selective abortions and female foeticide
• Regulates use of ultrasound, amniocentesis, CVS for prenatal diagnosis
• Key provisions:
  • No sex determination of foetus for any purpose
  • All genetic labs/clinics must be registered
  • No advertisement offering sex determination
  • Pregnant woman cannot be compelled to undergo tests
  • First conviction: imprisonment up to 3 years + fine Rs. 10,000
  • Subsequent conviction: up to 5 years + Rs. 50,000
  • 2003 amendment extended to pre-conception sex selection techniques

Q12. Disaster Mitigation

• Definition: Any action taken to reduce or eliminate long-term risk to human life and property from disasters
• Risk = Hazard × Vulnerability - mitigation reduces vulnerability
• Types:
  • Structural: Earthquake-resistant buildings, flood embankments, dykes, cyclone shelters, retrofitting
  • Non-structural: Land use planning/zoning, building codes, early warning systems, public awareness, disaster preparedness training
• Key concepts: Hazard = potentially damaging physical event; Vulnerability = degree of risk; Mitigation = first phase (before preparedness, response, recovery)
• India: NDMA set up under Disaster Management Act 2005; Sendai Framework (2015-2030)

Q13. DASH (Dietary Approaches to Stop Hypertension)

• Dietary pattern designed to prevent and treat hypertension; endorsed by WHO, JNC-8
• High in: Fruits, vegetables, whole grains, low-fat dairy, nuts, seeds, legumes, fish, poultry
• Low in: Saturated fat, red meat, sweets, sugar-containing beverages, sodium
• Key nutrients: High potassium, calcium, magnesium (natural vasodilators), high fibre; low sodium (1500-2300 mg/day)
• Effect on BP: Reduces SBP by 8-14 mmHg in hypertensives; 2-4 mmHg in normotensives
• Other benefits: Reduces LDL cholesterol, prevents type 2 diabetes, reduces CVD risk, weight management

Q14. Indian Red Cross Society

• Founded: 1920 under the Indian Red Cross Society Act
• Affiliated with: ICRC (International Committee of the Red Cross) and IFRC
• Activities:
  1. Blood Bank Services: Maintains blood banks; promotes voluntary blood donation
  2. Disaster Relief: Food, clothing, shelter, medical aid during floods/earthquakes/cyclones
  3. Medical First Aid Training: First aid courses and certification; school first aid training
  4. Ambulance Services
  5. Junior Red Cross (JRC): School-based; trains students in first aid, hygiene; Motto: "I will try"
  6. Nursing Services: Trains nurses; maintains emergency nursing reserve
  7. Tracing Services: Links separated families/missing persons (war, disasters)
  8. Social Welfare: Maternity and child welfare services

Q15. Incineration

• High-temperature dry oxidation converting combustible waste to ash, flue gas, heat
• Types: Fixed hearth (simple), Rotary kiln (most effective for chemical/hazardous waste), Double-chamber pyrolytic incinerator (recommended for biomedical waste)
  • Primary chamber: 800°C (waste burnt)
  • Secondary chamber: 1000°C (gases combusted) - minimum 2-second residence time
• Advantages: Reduces waste volume by 90-95%; destroys pathogens; suitable for anatomical waste, sharps, blood products
• Disadvantages: Air pollution (dioxins, furans, heavy metals); high cost; toxic ash; skilled operators needed
• BMW Rules 2016: Yellow bags (anatomical waste, expired medicines) - incinerated; Red bags (recyclable) - not incinerated

Q16. Counterfeit Medicines

• WHO Definition: Medicine deliberately and fraudulently mislabelled with respect to identity and/or source
• May contain: wrong/absent/substandard active ingredients, wrong quantity, toxic ingredients, fake packaging
• Consequences: Treatment failure; drug resistance (subtherapeutic antibiotics → AMR); adverse reactions; death; economic loss; erosion of trust
• Control measures:
  1. Strengthen drug regulatory authorities (CDSCO in India)
  2. Track and trace systems (barcoding, holograms, serialization)
  3. Random sampling and testing of medicines
  4. Severe penalties under Drugs and Cosmetics Act
  5. WHO IMPACT (International Medical Products Anti-Counterfeiting Taskforce)
  6. Public awareness campaigns
  7. Prescription-only drugs from licensed pharmacies only

Q17. ICTC (Integrated Counselling and Testing Centre)

• Set up under National AIDS Control Programme (NACP) by NACO
• Provides HIV counselling and testing in an integrated manner
• Services:
  1. Pre-test counselling (HIV info, risk assessment, implications)
  2. HIV testing - ELISA/Rapid tests
  3. Post-test counselling (negative: risk reduction; positive: disclosure, referral, ART linkage)
  4. PPTCT - All pregnant women offered HIV testing
  5. Referral to ART centres, STI clinics
  6. Condom distribution
• Types: Standalone ICTC, Facility-Integrated ICTC (FICTC), Mobile ICTC
• Principles - "3 Cs": Consent (voluntary, informed), Confidentiality, Counselling; free of cost

Q18. Body Mass Index (BMI)

• Formula: BMI = Weight (kg) / Height (m²) - devised by Adolphe Quetelet
• WHO Classification:

• Asian/Indian cut-offs (ICMR): Normal: 18.5-22.9; Overweight: 23-24.9; Obese: ≥25
• Uses: Nutritional assessment, epidemiological surveys, CVD risk stratification, monitoring weight management
• Limitations: Does not distinguish fat from muscle; does not indicate fat distribution; not for children (use BMI-for-age percentiles), pregnant women, elderly

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PAPER 2 (IMG_0783 + IMG_0784) - COMPLETE ANSWERS

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LONG ESSAYS

Q1. Dog Bite Case Management + Contraindications + Urban Rabies Control (6+1+3)

• Thorough washing with soap and water for minimum 15 minutes under running water
• Apply viricidal agent: 70% alcohol OR tincture iodine OR povidone-iodine
• Do NOT suture immediately; if suturing needed, give RIG first, suture after 2 hours
• Avoid occlusive dressings
• Local wound care alone reduces rabies risk by 50%

• HRIG (Human RIG): 20 IU/kg body weight (preferred - no sensitivity test needed)
• ERIG (Equine RIG): 40 IU/kg (after sensitivity test)
• Maximum dose infiltrated INTO and AROUND the wound
• Remaining dose given IM at site distant from vaccine
• Must be given within 7 days of starting vaccine

• Cell culture vaccines: PCECV, PVRV, HDCV

• Essen IM regimen (5-dose): Days 0, 3, 7, 14, 28 - deltoid (NOT gluteal)
• Zagreb IM (2-1-1): 2 injections Day 0, then Days 7 and 21
• Thai Red Cross Intradermal: 0.1 ml ID at 2 sites on Days 0, 3, 7, 28

• TT injection if not recently immunized
• TIG if unimmunized + heavily contaminated wound

• Prophylactic amoxicillin-clavulanate (especially important for facial wounds)

• NO absolute contraindication to PEP - rabies is 100% fatal once symptomatic
• PEP mandatory even in pregnant women, infants, immunocompromised
• Old NTV/Semple nerve tissue vaccines = contraindicated (neurological complications)
• History of hypersensitivity to egg protein (PCECV) = use another vaccine
• Avoid live vaccines within 4 weeks of rabies PEP

1. Mass dog vaccination: ≥70% coverage breaks transmission (herd immunity)
2. ABC Programme (Animal Birth Control): Sterilization of stray dogs (WHO-endorsed - killing causes population rebound)
3. Registration and compulsory vaccination of pet dogs
4. Pre-exposure prophylaxis (PrEP): For veterinarians, animal handlers, lab workers, forest officers - Days 0, 7, 21/28
5. Health education: Immediate wound washing; where to seek PEP; handling sick animals
6. Surveillance: FAT (Fluorescent Antibody Test) for diagnosis; reporting of bites; monitoring dog vaccination coverage
7. Legislation: Prevention of Cruelty to Animals Act; ABC (Dogs) Rules 2001

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Q2. MCH Mortality Indicators + Causes + Prevention of Maternal Mortality (2+3+5)

1. Maternal Mortality Rate (MMR) = Maternal deaths per 1,00,000 live births (India: 97/1,00,000 - 2018-20)
2. Infant Mortality Rate (IMR) = Deaths <1 year per 1000 live births (India: 32)
3. Neonatal Mortality Rate (NMR) = Deaths in first 28 days per 1000 live births
4. Early NMR = Deaths in first 7 days; Late NMR = Deaths days 7-28
5. Perinatal Mortality Rate (PMR) = (Stillbirths + Early neonatal deaths) per 1000 total births
6. Under-5 Mortality Rate (U5MR) = Deaths <5 years per 1000 live births (India: 36)
7. Stillbirth Rate = Stillbirths per 1000 total births
8. Child Mortality Rate (CMR) = Deaths 1-4 years per 1000 children aged 1-4 years

1. Haemorrhage (38%) - APH, PPH (most common)
2. Sepsis/Puerperal infections (11%)
3. Hypertensive disorders - pre-eclampsia, eclampsia (11%)
4. Obstructed/prolonged labour
5. Unsafe abortion
6. Ectopic pregnancy
7. Embolism

• Anaemia (most important in India - contributes to ~20% deaths)
• Cardiac disease, hepatitis, malaria, tuberculosis, diabetes

• Delay 1: Delay in seeking care (lack of education, low status of women)
• Delay 2: Delay in reaching care (poor transport, distance, poverty)
• Delay 3: Delay in receiving care at facility (inadequate staff, drugs, equipment)

1. ANC: Minimum 4 visits (WHO: 8 contacts); early registration <12 weeks; IFA 180 tablets; TT immunization; screening for anaemia/HTN/GDM
2. Skilled Attendance: JSY (cash incentive for institutional delivery); JSSK (free drugs, diagnostics, blood, diet); training ANMs in skilled birth attendance; EmOC at FRUs
3. Postnatal Care: Visits at 48h, 7 days, 42 days; detect PPH, infection
4. Safe Abortion: MTP Act 1971 (amended 2021); mifepristone + misoprostol up to 20 weeks
5. Anaemia Management: WIFS for adolescent girls; deworming; dietary counselling
6. Pre-eclampsia/Eclampsia: MgSO4 at PHC level; antihypertensives; calcium supplementation
7. PPH Prevention: AMTSL - oxytocin 10 IU IM within 1 minute of delivery; misoprostol to ASHAs for home deliveries
8. Social Measures: Raise age at marriage (PCMA Act); women's education; poverty alleviation; improve transport
9. National Programmes: PMSMA (free ANC on 9th of every month); LaQshya; SUMAN; Midwifery Services Initiative

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SHORT ESSAYS

Q3. Demography + Demographic Gap + Demographic Cycle Stages (1+4)

• Demography: Scientific study of human population - its size, composition, distribution, density, growth, and factors causing changes (fertility, mortality, migration). From Greek "demos" (people) + "graphos" (writing).
• Demographic Gap: The widening difference between birth rate and death rate when death rate falls faster than birth rate - causes "population explosion." Widest gap = maximum population growth = Stage 2 of demographic cycle.

• Both BR and DR are HIGH (35-40/1000); population remains stationary
• Characteristic of primitive/pre-agricultural societies

• DR begins to FALL (better sanitation, nutrition, medical care); BR remains HIGH
• Population GROWS RAPIDLY; Demographic gap is WIDEST
• Example: Sub-Saharan Africa

• DR falls further; BR begins to FALL (urbanization, education, FP)
• Population still grows but at slower rate
• Example: India (currently in transition between Stage 3 and 4)

• Both BR and DR LOW (~10-15/1000); population stationary again
• Example: Western Europe, USA, Japan

• DR exceeds BR; population DECLINES
• Example: Germany, Russia

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Q4. Primary Health Care - Definition + Elements + Principles (1+2+2)

1. Education about prevailing health problems and methods of their prevention and control
2. Promotion of food supply and proper nutrition
3. Adequate supply of safe water and basic sanitation
4. Maternal and child health care including family planning
5. Immunization against the major infectious diseases
6. Prevention and control of locally endemic diseases
7. Appropriate treatment of common diseases and injuries
8. Provision of essential drugs

1. Equitable distribution - reach all including most underserved
2. Community participation - active community involvement in planning and operating PHC
3. Intersectoral coordination - collaboration with agriculture, education, housing, public works
4. Appropriate technology - scientifically valid, locally adaptable, affordable (e.g., ORS over IV fluids)
5. Decentralization - decision-making at lowest appropriate administrative level

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Q5. Levels of Communication in Doctor-Patient Relationship

1. Intrapersonal Communication: Within oneself - internal reasoning, decision-making (doctor reasoning through diagnosis; patient deciding whether to comply)
2. Interpersonal Communication (PRIMARY LEVEL): Face-to-face between two individuals; direct, personal, allows immediate two-way feedback; history taking, counselling, breaking bad news, consent; quality depends on active listening, empathy, cultural sensitivity
3. Small Group Communication: Groups of 3-12 people; family counselling, ward rounds, group health education sessions
4. Organizational Communication: Formal institutional channels; referral letters, discharge summaries, interdepartmental notes; vertical (hierarchy) and horizontal (peers)
5. Mass Communication: Large heterogeneous populations via media (TV, radio, newspapers, social media); one-directional; health awareness campaigns

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Q6. Objective and Goal + Network Analysis (1+4)

• Goal: Broad, long-term aim; general, not precisely measurable. Example: "Health for All"
• Objective: Specific, measurable, time-bound statement; operational translation of goal; must be SMART. Example: "Reduce IMR to 25/1000 live births by 2017"

• Makes detailed planning and comprehensive supervision possible
• Essence: Constructing an Arrow Diagram representing logical sequence of events
• "Every housewife who plans a meal so that each part is ready at the same time is using PERT" (K. Park)
• Steps: Identify activities → determine sequence → draw network → estimate time → calculate critical path → monitor
• Advantages: Aids planning/scheduling/monitoring; better communication between management levels; identifies potential problems early; continuous progress reports; better resource allocation
• Uses 3 time estimates: optimistic, pessimistic, most likely

• Critical Path = longest path through the network
• Any delay along critical path = entire project delayed
• Activities NOT on critical path have "float" time
• Uses deterministic time estimates (vs PERT's probabilistic)

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Q7. WHO Guidelines for BP Measurement + Non-pharmacological Management of Hypertension (2+3)

1. Patient seated, comfortably for 5 minutes before measurement
2. No smoking, coffee, exercise for 30 minutes before
3. Arm at heart level (4th ICS), bare and unsupported
4. Cuff bladder encircles ≥80% of arm circumference; standard adult: 12-13 cm wide × 35 cm long
5. Inflate 20-30 mmHg above palpatory SBP; deflate at 2-3 mmHg/second
6. SBP = Korotkoff Phase I (first sound); DBP = Phase V (disappearance)
7. Take at least 2 readings 1-2 minutes apart; average if >5 mmHg difference
8. First visit: measure both arms; use higher reading arm subsequently
9. Record to nearest 2 mmHg

• Hypertension: SBP ≥140 mmHg and/or DBP ≥90 mmHg on two separate occasions

1. DASH Diet: High fruits/vegetables/whole grains/low-fat dairy → reduces SBP by 8-14 mmHg
2. Sodium restriction: <2.4 g/day (6 g common salt) → reduces SBP by 2-8 mmHg
3. Weight reduction: BMI <23 (Asian); 10 kg weight loss → reduces SBP by 5-20 mmHg
4. Physical activity: 30-45 min aerobic exercise, 5 days/week → reduces SBP by 4-9 mmHg
5. Cessation of smoking: Reduces CVD risk; nicotine causes acute BP rise
6. Moderation of alcohol: ≤2 drinks/day men, ≤1/day women → reduces SBP by 2-4 mmHg
7. Stress management: Yoga, meditation, relaxation, biofeedback
8. Potassium supplementation: Increase dietary potassium (fruits, vegetables)

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Q8. Nikshay + End TB Strategy (1+4)

• Web-based case notification and monitoring system for TB patients in India
• Launched by Central TB Division, Ministry of Health & Family Welfare
• Mandatory notification of ALL TB patients (public and private sector)
• Features: Real-time data entry, electronic case records, drug supply management, treatment outcome monitoring
• Nikshay Poshan Yojana: DBT of Rs. 500/month to TB patients for nutritional support

• 95% reduction in TB deaths
• 90% reduction in TB incidence (<10/1,00,000 population)
• Zero TB-affected families facing catastrophic costs

1. Early diagnosis + universal drug susceptibility testing; systematic screening of contacts
2. Treatment of ALL TB including drug-resistant TB, with patient support
3. Collaborative TB/HIV activities and management of co-morbidities
4. Preventive therapy for high-risk persons; vaccination against TB

• Target: Eliminate TB (incidence <1/1,00,000) by 2025 (5 years ahead of global target)
• "TB Harega, Desh Jeetega" campaign
• Four pillars: Detect - Treat - Prevent - Build (DTPB)

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SHORT ANSWERS

Q9. Malaria Vector Control

• Environmental: Source reduction - drain stagnant water, fill pits; intermittent irrigation of rice fields
• Biological: Larvivorous fish (Gambusia affinis, Poecilia reticulata/Guppy); Bacillus thuringiensis israelensis (Bti)
• Chemical larvicides: Temephos (abate) in water bodies
• Indoor Residual Spraying (IRS): DDT (still used in India per WHO approval); synthetic pyrethroids (deltamethrin, alpha-cypermethrin) where DDT resistance exists
• Space spraying/fogging: Malathion for rapid knockdown during outbreaks
• LLINs (Long Lasting Insecticidal Nets): Treated with pyrethroids; last 3+ years
• Personal protection: DEET repellents, protective clothing (long sleeves at dusk/dawn), window screens

Q10. Prevention and Control of Plague

• Flea control FIRST (before rat control - to prevent fleas deserting dead rats and biting humans)
• DDT/BHC dusting of rat runs, burrows, homes; insecticide dusting of dead rats before handling
• Rat control: Rodenticides (zinc phosphide, warfarin); trapping; rat-proofing buildings/granaries
• Surveillance: Monitor rat populations; "rat fall" (sudden mass death of rats) = warning sign; plague is notifiable under IHR 2005
• Chemoprophylaxis: Contacts of pneumonic plague: doxycycline 100 mg BD × 7 days
• Treatment: Streptomycin/Gentamicin; alternatives: doxycycline, tetracycline, chloramphenicol
• Vaccination: Killed whole-cell plague vaccine - for high-risk individuals and endemic areas
• Quarantine: Isolation of pneumonic plague cases; quarantine of contacts

Q11. Cancer Danger Signals + Cancer Registration (1+2)

1. C - Change in bowel or bladder habits
2. A - A sore that does not heal
3. U - Unusual bleeding or discharge
4. T - Thickening or lump in breast/testis/elsewhere
5. I - Indigestion or difficulty swallowing
6. O - Obvious change in wart or mole
7. N - Nagging cough or hoarseness

• Hospital-Based: Records all cases at specific institution; evaluates treatment outcomes; limited epidemiological use (selected population)
• Population-Based: Records all cancer in a defined geographic area; base population 2-7 million; provides incidence rates; used for epidemiology, time trends, planning
• India: NCRP by ICMR since 1981 - 30+ registries

Q12. Lepra Reaction

• Leprosy type: Borderline (BT, BB, BL)
• Mechanism: Type IV CMI hypersensitivity - sudden increase in delayed-type hypersensitivity
• Features: Erythema and oedema of existing skin lesions; new lesions; acute neuritis (commonest cause of nerve damage); nerve pain and swelling
• Treatment: Prednisolone 40-60 mg/day, tapered over 12-24 weeks; continue MDT

• Leprosy type: BL/LL (lepromatous)
• Mechanism: Type III immune complex (antibody-antigen complex deposition)
• Features: Tender erythematous nodules (crops); fever, malaise; neuritis, uveitis, orchitis, arthritis, lymphadenopathy
• Treatment: Thalidomide (DOC for males); Clofazimine (females/where thalidomide unavailable); Prednisolone for acute severe cases; continue MDT

Q13. Advantages of Breastfeeding to Newborn (2 marks) and Mother (1 mark)

1. Nutritional - species-specific, ideal composition
2. Immunological - colostrum rich in secretory IgA; lactoferrin, lysozyme, macrophages - protects against diarrhoea, ARI, otitis media
3. Prevents PEM and malnutrition
4. DHA/AA support brain and retinal development
5. Always available, correct temperature, sterile
6. Reduces risk of SIDS
7. Promotes mother-infant bonding
8. Long-term: lower risk of obesity, type 1 diabetes, asthma

1. Lactational Amenorrhoea - natural contraception (LAM method)
2. Uterine involution - oxytocin contracts uterus, reduces PPH
3. Reduces risk of breast and ovarian cancer
4. Helps return to pre-pregnancy weight
5. Economical - no cost of formula

Q14. Levels of Health Care in India

• Sub-Centre: 1/5000 population (plains), 1/3000 (hilly); ANM + MPW; MCH, FP, immunization, first aid
• PHC: 1/30,000 population (plains); Medical Officer; OPD, MCH, FP, disease control, health education
• CHC: 1/1,20,000 population; 4 specialists (surgeon, physician, OBG, paediatrician); 30 beds; FRU

• District Hospital: 100-500 beds; specialist services; serves ~2 million population
• Sub-district/Taluka hospitals: 50-100 beds

• Medical colleges and teaching hospitals; national institutes (AIIMS, PGI, JIPMER, NIMHANS)

Q15. Prevention of Neonatal Tetanus

1. TT vaccination of pregnant women (MOST IMPORTANT):
   • Women with no prior immunization: TT1 (as early as possible) + TT2 (4 weeks after TT1)
   • Previous pregnancy <3 years: 1 booster dose
   • Maternal antibodies transferred to fetus via placenta
2. Three Cleans: Clean hands, clean delivery surface, clean cord cutting (sterile blade)
3. Dry cord care: Do NOT apply cowdung, ghee, oil - keep cord dry and clean (chlorhexidine 7.1% gel in high-risk settings)
4. Training of TBAs/Dais in clean delivery techniques; supply of clean delivery kits
5. Institutional deliveries: JSY and JSSK schemes
6. Surveillance: Neonatal tetanus is notifiable; "zero reporting" from PHCs monthly

Q16. DOTS Strategy

1. Government commitment: Sustained political, administrative, and financial commitment
2. Case detection by sputum smear microscopy: Passive case finding; ZN-stained smear; CBNAAT/GeneXpert for DR-TB
3. Standardized short-course chemotherapy under direct observation:
   • Category I (new): 2(HRZE)/4(HR)
   • Category II (retreatment): 2(HRZES)/1(HRZE)/5(HRE)
   • Supervised by health worker; Fixed Dose Combinations (FDCs) used
4. Regular, uninterrupted supply of quality anti-TB drugs: Reliable procurement; cold chain; FDCs
5. Standardized recording and reporting: Case registration; cohort analysis; quarterly reports; Nikshay portal

Q17. Recent Trends in MCH Care

1. Continuum of Care approach (pre-conception → antenatal → delivery → postnatal → newborn → infant → child → adolescent)
2. Skilled Birth Attendance (SBA) - institutional deliveries through JSY/JSSK
3. HBNC (Home Based Newborn Care) - 6 ASHA home visits in first 42 days
4. Kangaroo Mother Care (KMC) - skin-to-skin for LBW/preterm babies
5. IMNCI/C-IMNCI - integrated assessment and management of sick children
6. SNCUs, NBSUs, NBCCs - facility-based newborn care
7. MCTS/ANMOL App - digital mother and child tracking
8. RKSK - Rashtriya Kishor Swasthya Karyakram for adolescents
9. India Newborn Action Plan (INAP) 2014 - NMR ≤10, stillbirth ≤10 by 2030
10. PMSMA - free quality ANC on 9th of every month; LaQshya for quality labour room care

Q18. Ideal IUD Candidate

1. Parous woman - uterine cavity accommodates IUD; less expulsion
2. Wants long-term contraception (3-10 years) but wishes to retain fertility
3. Stable mutually monogamous relationship (low STI risk)
4. Postpartum: PPIUCD within 48 hours of delivery (widely promoted under national FP programme)
5. Post-abortion: Immediately following uncomplicated abortion
6. Women with contraindication to hormonal methods (hypertension, DM, smokers >35, migraine with aura, liver disease)
7. Breastfeeding women (Cu-T does not affect milk production)

• Pregnancy; unexplained vaginal bleeding; active PID/STI in last 3 months; distorted uterine cavity; copper allergy/Wilson's disease; genital malignancy; puerperal sepsis

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PAPER 3 (IMG_0786) - COMPLETE ANSWERS

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LONG ESSAYS

Q1. STI OPD Case - Syndromic Approach: Name + Advantages + Management + STD Community Control (1+2+4+3)

1. Accessible - immediate treatment at first visit; no waiting for lab results
2. Cost-effective - cheaper than laboratory-based diagnosis
3. Covers dual infection - treats all organisms causing a syndrome simultaneously
4. Reduces transmission - immediate treatment reduces infectivity window
5. Partner treatment integrated into the approach
6. Applicable at PHC level without sophisticated lab infrastructure
7. Standardized flowcharts reduce treatment errors
8. Covers asymptomatic partners through contact tracing

• Tab. Cefixime 400 mg orally, single dose
• Plus Tab. Azithromycin 1 g orally, single dose

• Tab. Metronidazole 400 mg BD × 7 days OR Tab. Secnidazole 2 g single dose

• Clotrimazole 500 mg vaginal pessary single dose OR Tab. Fluconazole 150 mg

• Husband MUST be treated simultaneously (for gonorrhea + chlamydia)
• Contact notification card given

• ABC strategy (Abstinence, Be faithful, Condom use)
• Advise sexual abstinence during treatment
• Follow-up after 7 days

• Offer HIV testing + HBV + syphilis (VDRL) at ICTC

1. Syndromic management at STD clinics at PHC/CHC level; free drugs
2. Partner notification - all recent contacts treated simultaneously
3. Condom promotion - free distribution + social marketing (Nirodh); vending machines at high-risk areas; female condom
4. Targeted Interventions (TIs) for high-risk populations: FSWs, truck drivers, migrant workers, IDUs, MSM - peer-led education, outreach, STI management
5. Health education - awareness about symptoms, transmission, prevention; reduce stigma
6. Integration with HIV control - STIs increase HIV transmission 3-5 times; ICTC linked to STI clinics
7. Blood safety - mandatory screening of all blood donations for HIV, HBV, HCV, syphilis, malaria
8. Safe injection practices/harm reduction for IDUs - needle/syringe exchange

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Q2. ICDS - Objectives + Beneficiaries + Services + Road to Health Chart (2+1+5+2)

1. Improve nutritional and health status of children 0-6 years
2. Lay foundation for proper psychological, physical, and social development of the child
3. Reduce incidence of mortality, morbidity, malnutrition, and school dropout
4. Achieve effective coordination of policy and implementation among departments
5. Enhance capability of the mother to look after normal health and nutritional needs of the child

1. Children 0-6 years
2. Pregnant women
3. Lactating mothers
4. Women 15-45 years (nutrition and health education)
5. Adolescent girls (under SABLA/Kishori Shakti Yojana)

• Children 6m-3yr: 500 kcal + 12-15 g protein/day
• Children 3-6yr (malnourished): 800 kcal + 20-25 g protein/day
• Pregnant/Lactating women: 600 kcal + 18-20 g protein/day
• 300 days/year

• Designed by David Morley, later modified by WHO
• India adopted WHO Child Growth Standards 2006 (MGRS data) as national standard since February 2009
• Plots weight-for-age as primary indicator (weight = most sensitive measure of growth)

1. Growth monitoring - longitudinal follow-up; detects growth faltering early
2. Nutritional assessment - children below -2 SD = underweight
3. Identifying at-risk children - flat/falling weight curve = at risk
4. Communication tool - visual display understood by mothers and health workers
5. Immunization record - vaccine schedule recorded on same card
6. Feeding guidance - records introduction of complementary feeding
7. Health worker guidance - enables timely referral of malnourished children
8. Programme monitoring - tracks nutritional status of children in community

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SHORT ESSAYS

Q3. Classification of Contraceptive Methods + Barrier Methods (1+4)

• Spacing (Temporary): Barrier methods; Hormonal methods (OCP, injectables, patches, rings); IUDs (Cu-T, LNG-IUS); Natural methods (safe period, LAM, coitus interruptus); Emergency contraception
• Terminal (Permanent): Female sterilization (tubectomy); Male sterilization (vasectomy)

• Latex/polyurethane; failure rate 2-15/100 woman-years
• ONLY method providing dual protection against pregnancy AND STIs/HIV
• Advantages: no hormonal side effects, widely available, inexpensive, promotes male participation
• India: Nirodh (free under national FP programme)

• Polyurethane pouch inserted into vagina; female-controlled; protects against STIs
• More expensive, less aesthetically acceptable

• Dome-shaped rubber cap covering cervix; used WITH spermicidal cream/jelly
• Inserted up to 6 hours before, kept 6-8 hours after intercourse
• Failure rate: 5-20/100 woman-years; requires fitting by healthcare provider

• Thimble-shaped cap fitting directly over cervix; smaller than diaphragm
• Used with spermicide; can be left in place up to 48 hours

• Chemical agents (nonoxynol-9) as creams, foams, jellies, films, suppositories
• Failure rate: 20-30/100 woman-years when used ALONE (high)
• Best combined with other barrier methods; do NOT protect against HIV

• Polyurethane sponge containing nonoxynol-9; provides protection for 24 hours (multiple acts)
• Failure rate: 9-20%

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Q4. ASHA and ANM Full Forms + Roles and Responsibilities of ASHA (1+4)

• ASHA = Accredited Social Health Activist
• ANM = Auxiliary Nurse Midwife

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Q5. Levels of Communication in Doctor-Patient Relationship

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Q6. Definition of Planning + Steps in Planning Cycle (1+4)

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Q7. ANC Physical and Abdominal Examination + Subcentre Investigations (4+1)

1. Haemoglobin estimation (Sahli's haemoglobinometer/colour scale)
2. Urine for albumin (detect pre-eclampsia)
3. Urine for sugar (detect GDM)
4. Blood pressure measurement
5. Weight measurement
6. Urine pregnancy test (UPT)

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Q8. Prevention of Human Rabies

• For: veterinarians, animal handlers, lab workers, forest officers
• Schedule: 3 doses of CCV on Days 0, 7, and 21/28 (IM deltoid)
• Regular booster when titre falls below protective level

• Category I: Touching/feeding animal - wash hands; no PEP
• Category II: Minor scratches, no bleeding - wound treatment + vaccine
• Category III: Transdermal bites/bleeding/mucous membrane - wound treatment + RIG + vaccine

1. Wound washing with soap and water 15 minutes + povidone-iodine
2. RIG: HRIG 20 IU/kg or ERIG 40 IU/kg - infiltrate into and around wound
3. Cell culture vaccine: Essen IM 5-dose (Days 0,3,7,14,28) or Zagreb (2-1-1) or Thai ID regimen
4. TT + antibiotics

• Mass vaccination of dogs ≥70% coverage; ABC programme (sterilization); registration of pet dogs; compulsory vaccination

• Immediate wound washing; where to seek PEP
• No absolute contraindication to PEP; rabies 100% fatal once symptomatic

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SHORT ANSWERS

Q9. Key Populations + HIV Transmission (1+2)

1. Sexual (87% in India): Unprotected heterosexual (most common); anal intercourse (highest risk per act); STIs increase risk 3-5 times
2. Parenteral (~1.5%): Sharing needles (IDUs); blood transfusion (before screening); needlestick injuries (HCW - 0.3% risk); unsterilized instruments; tattooing
3. MTCT/Vertical (~5%): Pregnancy (transplacental); delivery (most common - 65%); breastfeeding (14-22%); without intervention overall MTCT 25-45%; PPTCT reduces to <2%

Q10. Nosocomial Infection + Prevention (1+2)

1. Hand hygiene (MOST important) - WHO 5 Moments; ABHR or soap + water
2. Standard precautions - gloves, gown, mask, eye protection as needed; dispose sharps immediately
3. Aseptic technique - for catheterization, IV lines, wound dressing
4. Sterilization/disinfection - autoclaving; chemical disinfection; single-use disposables
5. Environmental sanitation - regular cleaning; biomedical waste management; proper ventilation in OTs
6. Isolation - source isolation (infectious patients); cohort isolation
7. Antibiotic stewardship - rational use; follow antibiotic policies to reduce MDROs
8. Surveillance - active HAI surveillance; infection control committees

Q11. Self-care in Diabetes Management

1. SMBG - regular self-monitoring; fasting target 80-130 mg/dl; HbA1c <7%
2. Diet - diabetes plate method; fixed meal timing; avoid refined carbs/sugary drinks; high fibre; DASH/Mediterranean pattern
3. Physical activity - 150 min/week aerobic; resistance training 2-3 times/week; check glucose before/after exercise
4. Medication adherence - oral hypoglycaemics; insulin technique; correct site rotation
5. Foot care - daily inspection; clean and dry feet; well-fitting footwear; no bare feet; trim nails straight across
6. Regular check-ups - BP (target <130/80); annual fundoscopy; annual urine microalbumin; lipid profile
7. Smoking cessation - accelerates diabetic complications
8. Stress management - yoga, meditation

Q12. BCG Vaccination

• BCG = Bacillus Calmette-Guérin - live attenuated vaccine from Mycobacterium bovis (Calmette and Guérin, 1921)
• Strain in India: Danish 1331 (Serum Institute of India)
• Schedule: Single dose at birth (or up to 5 years); no booster needed
• Route/Dose: 0.05 ml intradermally (newborn); 0.1 ml ID (>1 year); Left upper arm (deltoid insertion); strict ID - produces bleb
• Efficacy: 75-86% against TB meningitis and miliary TB in children; variable against pulmonary TB (0-80%)
• Reaction: Papule at 2-3 weeks → ulcerates → scar by 6-12 weeks = confirms successful vaccination
• Contraindications: Immunodeficiency states (HIV with low CD4); high-dose corticosteroids
• Storage: 2-8°C; protected from light; discard within 4 hours of reconstitution

Q13. Exclusive Breastfeeding + Baby Friendly Hospital Initiatives (1+2)

1. Written breastfeeding policy communicated to all staff
2. Train all health care staff in breastfeeding skills
3. Inform all pregnant women about benefits of breastfeeding
4. Initiate breastfeeding within 30 minutes of birth (skin-to-skin)
5. Show mothers how to breastfeed and maintain lactation
6. No prelacteal feeds - no food/fluid other than breast milk (unless medically indicated)
7. Rooming-in - mother and infant together 24 hours/day
8. Breastfeeding on demand - unrestricted
9. No artificial teats or pacifiers
10. Foster breastfeeding support groups; refer mothers on discharge

Q14. Basic Resources for Health Care

1. Manpower - doctors, nurses, paramedics (ANM, ASHA), administrative staff; most critical resource
2. Money - government budget, insurance, user fees, donor funding; India: ~2.1% GDP on health (target 2.5%)
3. Materials/Supplies - drugs (NLEM), vaccines (cold chain), instruments, equipment, infrastructure (hospitals, PHCs)
4. Information/Knowledge - health information systems (HMIS, Nikshay), epidemiological surveillance, research evidence, guidelines
5. Time - sufficient time for consultations, community health activities
6. Technology - appropriate technology (POC diagnostics, telemedicine, renewable energy for health facilities)

Q15. Prevention and Control of Soil-Transmitted Helminths

• Major STH: Ascaris lumbricoides, Trichuris trichiura, hookworm (Ancylostoma duodenale/Necator americanus), Strongyloides stercoralis

1. Environmental sanitation (most important): Safe disposal of faeces (toilets); Swachh Bharat Mission - ODF; safe water supply; avoid night soil as fertilizer
2. Personal hygiene: Handwashing with soap after defecation/before eating; wearing footwear (hookworm - prevents larval skin penetration); short nails
3. Food hygiene: Wash fruits/vegetables; avoid raw/soil-contaminated vegetables; cook food properly
4. Mass Drug Administration (National Deworming Day): 10th August and 10th February every year; Albendazole 400 mg chewable single dose to all children 1-19 years in schools; under RBSK; WHO recommends in areas where STH prevalence >20%
5. Health education: Importance of sanitation, footwear, personal hygiene

Q16. Control of Japanese Encephalitis

• Causative agent: JE virus (Flavivirus); Vector: Culex tritaeniorhynchus; Reservoir: Pigs, water birds

1. Vaccination (MOST IMPORTANT): SA-14-14-2 live attenuated vaccine; part of UIP in endemic states; 2 doses at 9 months and 16 months; endemic states: Assam, Bihar, Karnataka, Maharashtra, TN, UP, WB
2. Vector control: Larvicides (temephos, Bti) in rice fields/water bodies; IRS (malathion); environmental management (alternate wetting/drying of paddy fields); biological control (larvivorous fish)
3. Personal protection: LLINs, DEET repellents, protective clothing at dusk/dawn, window/door screens
4. Reservoir control: Separation of piggeries from human habitation
5. Surveillance: Sentinel surveillance in endemic areas; vector surveillance
6. Case management: No specific antiviral; supportive care (ICU, anti-convulsants, mannitol)

Q17. Rashtriya Bal Swasthya Karyakram (RBSK)

• Launched: February 2013 under NHM
• Purpose: Child Health Screening and Early Intervention Services; early identification and intervention for children birth to 18 years
• 4 Ds: Defects at birth, Deficiencies, Diseases, Development delays (including disability)
• Screening by Mobile Health Teams (MHTs): 1 MHT per block; 4 members (AYUSH doctor, staff nurse, ANM, pharmacist); cover 30 schools; screen 30 conditions
  • 0-6 weeks: by ASHA/AWW at home
  • 6 weeks to 6 years: at AWC
  • 6-18 years: at government/aided schools
• Referral: To DEIC (District Early Intervention Centre) - services at zero cost to family
• Additional: WIFS, National Deworming Day, school eye screening, menstrual hygiene management
• Significance: Largest child health screening programme in the world; covers ~270 million children

Q18. Sex Ratio + Reasons for Low Sex Ratio in India (1+2)

• India (2011 Census): 943 females per 1000 males
• Child Sex Ratio (CSR, 0-6 years, 2011): 914 females per 1000 males (most alarming indicator; declined from 945 in 2001)

1. Female foeticide (primary cause): Misuse of prenatal diagnostic techniques (ultrasound) for sex determination and selective abortion of female foetuses despite PCPNDT Act 1994
2. Son preference: Deep-rooted patriarchal attitude - son preferred for economic support, family name, last rites; daughter seen as burden (dowry)
3. Female infanticide: Killing of girl infants after birth; more common in some communities (Tamil Nadu, Rajasthan)
4. Differential neglect of girls: Less food, healthcare, medical attention; higher preventable mortality
5. High maternal mortality: Pregnancy-related deaths disproportionately reduce female numbers
6. Child marriage: Early marriage → early pregnancy → increased maternal mortality

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