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RUHS MBBS - Community Medicine (PSM) - Detailed Answers

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PAPER 1: 3rd Year MBBS 2021 Batch (Supply) - May 2025

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SECTION A

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Q.1 Fill in the Blanks

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Q.2 Multiple Choice Questions - Answers with Explanation

• HDI is a composite index combining life expectancy, education (mean years of schooling + expected years), and per capita income (GNI PPP). It is considered the most comprehensive indicator of standard of living. GDP and GNP only measure economic output. Consumer Price Index measures inflation, not living standards.

• The Multidimensional Poverty Index (MPI) uses 10 indicators across 3 dimensions: Health (nutrition, child mortality), Education (years of schooling, school attendance), and Living Standards (cooking fuel, sanitation, drinking water, electricity, housing, assets). Per capita income is NOT part of MPI - it belongs to the income-based poverty line. School index, child mortality and cooking fuel ARE MPI indicators.

• Reference protein = Hen's egg protein (whole egg). Its NPU = 100 (maximum possible), BV (Biological Value) = 100, Net Dietary Protein Energy % (NDpE%) = 100. It does NOT provide 4g protein per gram (eggs contain ~12.7g protein per 100g). It provides ~150 kcal/100g, not 90 kcal. Cholesterol content is ~424 mg/100g, not 250 mg. The defining characteristic is maximum NPU = 100.

• The Stevenson screen is a standardized louvred white wooden box that houses thermometers (dry bulb, wet bulb, max-min thermometers) to measure air temperature in a standard, comparable way, protecting instruments from direct sunlight and precipitation while allowing free air circulation. Air velocity is measured by anemometer; atmospheric pressure by barometer; sunlight by pyrheliometer.

• Under JSY, ASHA receives Rs 600 in urban areas and Rs 1000 in rural areas (Low Performing States like UP, Uttarakhand, Bihar, Jharkhand, MP, Rajasthan, Orissa, J&K, Assam) per institutional delivery facilitated. In High Performing States (HPS) the incentive is Rs 600 in rural and Rs 200 in urban.

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Q.4 Write briefly on Any Five (5 x 2 = 10 marks each)

• GI measures the blood glucose-raising potential of a food relative to a standard (glucose=100 or white bread=100). Foods with GI >70 = high GI (white bread, glucose, baked potato); GI 56-69 = medium; GI <55 = low (oats, legumes, most fruits). Low GI foods cause slower glucose absorption, beneficial in diabetes management. Dietary fibre, fat, protein all lower GI. Overcooking increases GI (gelatinization of starch).

• SPM (Suspended Particulate Matter) - total dust
• RSPM/PM10 - respirable particles <10 µm
• PM2.5 - fine particles <2.5 µm (most harmful)
• SO2 - from combustion of sulphur-containing fuels
• NO2 - from vehicle emissions
• CO - from incomplete combustion
• Ozone (O3) - secondary pollutant
• Lead - from older petrol National Ambient Air Quality Standards (NAAQS) set by CPCB in India specify permissible limits for each.

1. Sender barriers - Poor choice of words, technical jargon, poor articulation
2. Channel barriers - Noise, poor media selection, information overload
3. Receiver barriers - Inattention, poor listening, lack of interest, cultural differences
4. Feedback barriers - Lack of opportunity to respond
5. Environmental barriers - Physical noise, distractions
6. Semantic barriers - Different meanings of words
7. Psychological barriers - Attitudes, prejudices, fear Overcoming barriers: Use simple language, two-way communication, visual aids, cultural sensitivity.

• Identify all activities required to complete a programme
• Arrange activities in logical sequence (network diagram)
• Estimate time for each activity
• Identify the critical path (longest path - determines project duration)
• Used in health programme planning to optimize time and resources. No activity on the critical path can be delayed without delaying the whole project.

• Scientifically sound - proven effective
• Adaptable to local needs
• Acceptable to the community and practitioners
• Affordable by the community
• Accessible to those who need it Examples in health: ORS (oral rehydration salts), DOTS for tuberculosis, partograph for labour monitoring, hand pumps for safe water. The concept emphasizes matching technology to available resources and context rather than using the most advanced technology.

• Migrants adopt health behaviours of host country
• Can be positive (adopting healthier diets) or negative (adopting tobacco/alcohol habits)
• Stages: Contact → Conflict → Adaptation → Integration
• Distinguished from assimilation (complete adoption), enculturation (learning one's own culture), and socialization.

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Q.5 Explain Why (Any Three) - 3 x 5 = 15 marks

• Deficiency (<0.5 ppm in water): Dental caries (tooth decay) - fluoride is incorporated into enamel as fluorapatite making teeth resistant to acid attack; lack leads to increased caries
• Optimum (0.5-0.8 ppm): Maximum protection against dental caries with no adverse effects. Optimum level for India: 0.7-1.2 ppm
• Excess (>1.5 ppm): Dental fluorosis - mottling (white spots/brown staining, pitting of enamel)
• Very high (>3 ppm): Skeletal fluorosis - osteosclerosis, crippling fluorosis, neurological complications
• Both lack and excess are harmful - hence "two-edged sword"
• Endemic fluorosis is a major public health problem in India (Rajasthan, Andhra Pradesh, Gujarat, etc.)

• Without feedback, planning becomes a one-way process with no mechanism for course correction
• Feedback allows planners to know if goals are being achieved
• In the health planning cycle: Situational Analysis → Setting Objectives → Programme Planning → Implementation → Evaluation/Feedback → revised planning
• Feedback provides information on: coverage achieved, resources used, problems encountered, gaps between planned and actual
• PDCA cycle (Plan-Do-Check-Act) - the "Check" and "Act" phases represent feedback loops
• Without feedback: cannot detect underperformance, cannot reallocate resources, cannot update outdated plans

1. Overcrowding - facilitates airborne diseases (TB, measles, meningitis), mental health problems, domestic violence
2. Inadequate ventilation - indoor air pollution, CO buildup, respiratory diseases
3. Dampness/mold - asthma, allergic rhinitis, respiratory infections
4. Lack of safe water/sanitation - diarrhoeal diseases, typhoid, cholera
5. Structural hazards - accidental falls, injuries, fire hazards
6. Vector breeding - stagnant water for mosquitoes (malaria, dengue), rodents for plague/leptospirosis
7. Poor lighting - accidents, eye strain, mental health impacts
8. Proximity to pollutants - siting near industries, highways Environmental standards for healthy housing (Winslow's criteria): adequate lighting, ventilation, protection from elements, safe water, sewage disposal, freedom from overcrowding.

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SECTION B

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Q.6 Primary Health Care - Definition, Levels, Essential Elements, Principles (20 marks)

• Proclaimed at the International Conference at Alma-Ata (now Almaty), Kazakhstan, 1978, jointly organized by WHO and UNICEF.

1. Education about prevailing health problems and methods of 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 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 - Health services should be available to all, especially underserved populations
2. Community participation - People should be involved in planning and implementation of health programmes
3. Intersectoral coordination - Health depends on other sectors (agriculture, education, water supply, housing); all must work together
4. Appropriate technology - Use of methods that are scientifically sound, affordable, acceptable and adaptable
5. Focus on prevention and promotion - Rather than exclusively curative care
6. Multisectoral approach - Recognition that health is shaped by social determinants
7. Decentralization - Decisions made at the lowest appropriate level

• Sub-centre: serves 3000-5000 population (hilly/tribal: 3000); staffed by ANM and MPW
• PHC: serves 20,000-30,000 population; staffed by Medical Officer
• CHC: serves 80,000-1,20,000 population; 30-bed hospital with specialist care

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Q.7 Write briefly on Any Five (5 x 2 = 10 marks)

• The nature of a genetic disorder
• Risk of occurrence/recurrence
• Available options (prenatal diagnosis, preimplantation testing, adoption, not having children) Indication: Previous child with chromosomal/genetic abnormality, advanced maternal age (>35 yrs), consanguineous marriage, family history of genetic disease. Methods: Karyotyping, FISH, DNA analysis. Amniocentesis (14-18 weeks), CVS (10-12 weeks) for prenatal diagnosis.

• Bacterial: Cholera (V. cholerae), Typhoid (S. typhi), Bacillary dysentery, ETEC diarrhoea, Leptospirosis
• Viral: Hepatitis A, Hepatitis E, Polio
• Protozoal: Amoebiasis, Giardiasis, Cryptosporidiosis
• Helminthic: Guinea worm (dracunculiasis) Prevention: Chlorination, boiling, filtration, proper sanitation, hand washing.

• Hospital patients, healthcare workers, waste handlers, general public Hazards include:
• Infectious waste (sharps, cultures): HIV, HBV, HCV transmission via needlestick injuries
• Pathological waste: infection risk
• Chemical waste (disinfectants, solvents, heavy metals): toxicity
• Radioactive waste: radiation exposure
• Pharmaceutical waste (expired drugs): antibiotic resistance Environmental hazards: soil/water contamination from improper disposal. Biomedical Waste Management Rules 2016 (amended 2019) govern segregation (4 colour-coded categories: Yellow, Red, White, Blue), transport, treatment and disposal.

1. Is free from mental illness/symptoms
2. Functions well in activities of daily life
3. Has satisfying interpersonal relationships
4. Adapts to environmental changes
5. Has a realistic self-image - accepts strengths and weaknesses
6. Is free from excessive fear, worry, or guilt
7. Has the capacity to love, work, and play
8. Is responsible and self-directing
9. Maintains emotional balance - handles stress without lasting adverse effects
10. Achieves harmony between inner life and external demands

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Q.8 Short Notes on Any Four (4 x 5 = 20 marks)

• Most common cause of preventable blindness in children worldwide
• Vitamin A (retinol) - fat-soluble vitamin; stored in liver
• Clinical features (Bitot-Xerophthalmia grading by WHO):
  • XN: Night blindness (first sign)
  • X1A: Conjunctival xerosis
  • X1B: Bitot's spots (foamy, cheesy spots on bulbar conjunctiva)
  • X2: Corneal xerosis
  • X3A: Corneal ulceration/keratomalacia (<1/3 cornea)
  • X3B: Corneal ulceration/keratomalacia (>1/3 cornea) - leads to blindness
  • XS: Corneal scar
  • XF: Xerophthalmic fundus
• Non-ocular effects: Impaired immune function, increased susceptibility to infections (measles, diarrhoea, ARI), keratinization of epithelium
• Prevention: Vitamin A supplementation (National Programme for Control of Blindness): 1,00,000 IU at 9 months with measles vaccine; 2,00,000 IU 6-monthly from 18 months to 5 years; dietary diversification; fortification (red palm oil, sugar)
• Dietary sources: Preformed (liver, egg, milk, fish); Provitamin A carotenoids (dark green leafy vegetables, yellow/orange fruits and vegetables)

1. Evidence-based decisions - use of epidemiological and entomological data
2. Integration of multiple methods: Environmental management (source reduction), biological control (Bacillus thuringiensis israelensis - Bti, Gambusia fish), chemical control (IRS - Indoor Residual Spraying, LLINs - Long-Lasting Insecticidal Nets, larviciding), personal protection
3. Collaboration between sectors (health, agriculture, urban development)
4. Engagement of communities
5. Capacity building Applied under NVBDCP (National Vector Borne Disease Control Programme) for malaria, dengue, filaria, JE, kala-azar control.

1. Pre-disaster phase:
   • Mitigation: Actions to reduce risk (building codes, early warning systems, land use planning)
   • Preparedness: Planning and training before disaster (disaster plans, stockpiling supplies, mock drills, establishing EOC - Emergency Operations Centre)
2. Disaster phase:
   • Response: Immediate actions after disaster strikes (search and rescue, evacuation, triage, first aid, emergency medical services)
3. Post-disaster phase:
   • Recovery/Rehabilitation: Restoring normal conditions (repairing infrastructure, psychological support, epidemiological surveillance)
   • Development: Rebuilding to reduce future vulnerability (building back better) The cycle shows that disaster management is continuous, not just emergency response.

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PAPER 2: 3rd Year MBBS 2021 Batch (Main) - December 2024

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Q.3 Discuss Any Three: (15 marks)

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Q.4 Short Notes on Any Three (15 marks)

• Launched October 2021, replacing Mid-Day Meal (MDM) scheme (started 1995)
• Provides free nutritious cooked meals to children in government and government-aided schools
• Covers: Primary (I-V) and Upper Primary (VI-VIII) children
• Nutritional norms: Primary - 450 kcal, 12g protein; Upper Primary - 700 kcal, 20g protein
• Objectives: Improve nutritional status, increase school enrolment and attendance, reduce dropout rates
• Nodal ministry: Ministry of Education (previously HRD)
• Features: Inclusion of breakfast, involvement of parents (Mothers' Committees), use of locally available foods, school kitchen gardens

• MCH care: ANC, PNC, safe delivery
• Family planning: distribution of condoms, OCP, IUD insertion
• Immunization: vaccines for children and pregnant women
• Nutrition: IFA tablets, Vitamin A, nutrition education
• Treatment of minor ailments: ORS, cotrimoxazole, paracetamol, iron-folic acid
• Health education
• Referral services
• Disease surveillance
• ASHA support and supervision Drug kit provided: "Kit A" (for ANM/MPW with ORS, IFA, OCP, condoms, Vitamin A, paracetamol, Cotrimoxazole, Magnesium sulphate, Oxytocin)

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Q.5 Write in Brief on Any Five (5 x 2 = 10 marks)

• Kuppuswamy Scale (modified): Education + Occupation + Monthly family income - Score 3-29; Upper (26-29), Upper middle (16-25), Lower middle (11-15), Upper lower (5-10), Lower (≤4) - Used in urban India
• BG Prasad Scale: Based on per capita monthly income adjusted for Consumer Price Index (most commonly used in rural India)
• Pareek's Scale: Rural India - Education, land, house type, farm power, material possession, participation in community activities

• Salt + Iodine + Iron (double fortification)
• Wheat flour + Iron + Folic acid + Vitamin B12
• Rice + Iron + Zinc + Folic acid
• Milk + Vitamin A and D
• Vanaspati ghee + Vitamin A and D Governed by FSSAI standards. Key in India for addressing hidden hunger (micronutrient deficiency).

1. Written breastfeeding policy communicated to all staff
2. Train all staff in skills to implement policy
3. Inform all pregnant women about benefits and management of breastfeeding
4. Initiate breastfeeding within 1 hour of birth
5. Show mothers how to breastfeed and maintain lactation
6. Give no food or drink other than breast milk (except medically indicated)
7. Practice rooming-in (mother and baby together 24 hours)
8. Encourage breastfeeding on demand
9. Give no artificial teats or pacifiers (dummies/soothers) to breastfed infants
10. Foster establishment of breastfeeding support groups

• As chlorine is added → reacts with organic matter and ammonia (forming chloramines = combined chlorine)
• Further addition → combined chlorine is oxidized and broken down ("breakpoint")
• Beyond breakpoint → free residual chlorine appears
• Target: Maintain 0.5 mg/L free residual chlorine at consumer end (WHO) / 0.2 mg/L in treated water (India)
• Breakpoint chlorination ensures maximum disinfection

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Q.6 Define PHC, Levels of Health Care, Essential Elements, Principles (20 marks)

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PAPER 3: 3rd Year MBBS 2021 Batch (Supply) - Paper with Vanaspati Ghee MCQ

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• Vanaspati ghee (hydrogenated vegetable oil/dalda) naturally lacks fat-soluble vitamins. Under FSSAI regulations, vanaspati ghee must be compulsorily fortified with Vitamins A and D. Vitamin A: 25 IU/g; Vitamin D: 2.5 IU/g. This is to compensate for nutrients lost during hydrogenation.

• Neonatal period: Preterm birth complications (35%), intrapartum complications (24%), sepsis (15%), congenital anomalies, neonatal jaundice
• Post-neonatal: Diarrhoeal diseases, Acute Respiratory Infections (pneumonia), malnutrition, vaccine-preventable diseases

1. Improving maternal health and antenatal care:

• Universal ANC (4 ANC visits - WHO recommends 8)
• Iron-folic acid supplementation
• Tetanus immunization
• Treat anemia, hypertension, infections in pregnancy
• Institutional deliveries (JSY, PMSMA - Pradhan Mantri Suraksha Matritva Abhiyan)
• Skilled birth attendance
• EmOC (Emergency Obstetric Care)

1. Neonatal and infant care:

• Immediate newborn care: cord care, warmth, breastfeeding within 1 hour
• HBNC (Home Based Newborn Care) by ASHA
• Kangaroo Mother Care for LBW/preterm
• Treatment of sepsis (Sepsis Management Protocol)
• IMNCI (Integrated Management of Neonatal and Childhood Illness)
• National Immunization Schedule (BCG, OPV, Pentavalent, PCV, Rotavirus)

1. Improving nutrition and environment:

• Exclusive breastfeeding for 6 months
• Complementary feeding from 6 months
• Vitamin A supplementation
• Safe water and sanitation
• POSHAN Abhiyan for reduction of stunting, wasting, underweight

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1. Health appraisal - Regular medical examination (height, weight, vision, hearing, dental, mental health)
2. Remedial and follow-up services - Treatment of detected conditions
3. Preventive services - School immunization, deworming (National Deworming Day: Feb 10 and Aug 10)
4. Healthful school environment - Safe water, sanitation, proper lighting, ventilation, safe play areas
5. Nutrition services - PM Poshan (mid-day meals), school gardens
6. Health education - Life skills education, hygiene
7. Mental health - Counselling services
8. First aid and emergency care School Medical Officer role, School Health Nurse, involvement of teachers.

1. Physiological needs: Thermal comfort (temperature, humidity), adequate light, clean air, absence of noise, protection from weather
2. Psychological needs: Privacy, overcrowding prevention, aesthetics, freedom from excessive noise
3. Protection from infectious disease: Safe water, sewage disposal, absence of vectors, no overcrowding, food storage
4. Protection from accidents: Structural safety, fire protection, protection from poisoning, stairs with handrails

• Minimum floor space: 9.5 m²/person (Schorstein)
• Air space: 14 m³/person (India), 25 m³/person (Europe)
• Overcrowding: >1.5 persons/room (UK), or >2 persons/room in India

• Outpatient services in District Hospital
• Training of primary health workers in mental health
• School mental health programme
• College mental health programme
• Tele-consultation MANODARPAN: Ministry of Education initiative for mental health of students. Mission SAMPARK: To identify and provide care to severely mentally ill persons who are homeless.

• Launched: December 25, 2014 by GoI
• Aim: Achieve 90%+ full immunization coverage
• Intensified Mission Indradhanush (IMI) 2.0, 3.0 launched subsequently
• Focus: Children <2 years and pregnant women who are unvaccinated/partially vaccinated
• Targets hard-to-reach areas: urban slums, migration areas, conflict areas
• Vaccines covered: BCG, OPV, Pentavalent (DPT+HepB+Hib), PCV, Rotavirus, Measles-Rubella, JE (endemic areas), Vitamin A, DPT booster
• IMI 4.0 (2022): Added coverage for COVID-19 vaccines

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PAPER 4: 3rd Year MBBS 2022 Batch (Main) - October 2025

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Q.1 Fill in the Blanks

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Q.2 Multiple Choice Questions

• The correct principle is equitable distribution (not equal distribution). Equal distribution would mean the same amount to everyone; equitable means according to need. The principles include appropriate technology, community participation, intersectoral coordination. "Equal distribution" is a distractor - equitable distribution is the correct term.

• Under BMW Rules 2016:
  • Yellow: Pathological waste, solid chemical waste, discarded medicines, bedpan, bag
  • Red: Contaminated recyclable waste - plastic items (IV sets, catheters, syringes WITHOUT needles, IV bottles, urine bags) - Urinary catheters go in RED bin
  • White/Translucent: Sharps (needles, blades, lancets) - puncture-proof containers
  • Blue: Glassware, metallic implants, broken glass

• Wait - actually: Management by Objective (MBO) and Input-Output analysis and Decision making are more qualitative. Work sampling is a quantitative method. Let me clarify:
• Qualitative methods: Focus groups, interviews, case studies, observation
• Quantitative methods: Statistical analysis, work sampling, time and motion study
• Of the options: Management by Objective (i) is a qualitative management approach; Work sampling (iii) is quantitative. Most PSM textbooks classify MBO as a qualitative method of management. Answer: i. Management by Objective

• NDMA (National Disaster Management Authority) was established under Disaster Management Act 2005. The Prime Minister of India is the Chairman of NDMA. State SDMA is chaired by Chief Minister. District DDMA is chaired by District Collector with CEO of Zila Parishad as co-chairperson.

• Health education approaches:
  • Medical/Preventive approach: Educate to prevent disease
  • Regulatory/Legislative approach: Using laws and regulations to protect health (PFA Act, FSSAI Act, Motor Vehicles Act for seat belts)
  • Educational approach: Information, voluntary behaviour change
  • Empowerment approach: Community empowers itself to change conditions The PFA/FSSAI Act enforces standards through law = Regulatory approach.

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Q.3 Case Study: 35-year-old woman, rural village, high fever, severe joint pain, rash, fatigue - neighbors with similar symptoms, poor sanitation, stagnant water

• Differential: The cluster of cases with joint pain + fever in a village with stagnant water points to Chikungunya as the most likely diagnosis (severe joint pains are the hallmark)
• Dengue also possible (fever, rash, joint/bone pain, fatigue)
• Leptospirosis should be considered (stagnant water, rural)

• National Vector Borne Disease Control Programme (NVBDCP) - covers Chikungunya, Dengue, Malaria, JE, Kala-Azar, Filariasis
• If Leptospirosis: National Programme for Prevention and Control of Leptospirosis (under NVBDCP)

1. Clinical assessment: Complete history, examination for arthritis pattern (symmetrical polyarthritis, small joints), rash characteristics (maculopapular)
2. Serology:
   • IgM ELISA for Chikungunya (positive after day 5-7 of illness)
   • RT-PCR (first 5 days - during viremia)
   • MAC-ELISA for dengue (IgM), NS1 antigen (early), dengue RT-PCR
3. CBC: Lymphocytosis (chikungunya), thrombocytopenia (dengue), leukopenia
4. Leptospira: MAT (Microscopic Agglutination Test) - gold standard; IgM ELISA (Leptocheck)
5. Entomological survey: Identify Aedes aegypti breeding sites (container index, Breteau index, House index)
6. Epidemiological investigation: Line listing of cases, attack rate, epidemic curve, mapping

• No specific antiviral for chikungunya
• Symptomatic: Paracetamol (NOT NSAIDs/aspirin during acute phase - risk of dengue haemorrhage), rest, fluids
• Analgesics/anti-inflammatories for joint pain in recovery phase
• Dengue: fluid management, monitoring for dengue haemorrhagic fever
• Notifiable disease - report to health authorities

1. Vector control (Aedes control):
   • Source reduction: emptying/covering containers, removing breeding sites
   • Larval control: abate (temephos) to containers, Gambusia fish
   • Adult mosquito control: fogging (pyrethroid) in affected area
   • Community education on prevention
2. Surveillance: House-to-house survey, case detection, line listing, mapping
3. Health education: Use of mosquito nets, repellents (DEET), full-sleeved clothing
4. Environmental measures: Drain stagnant water, proper refuse disposal
5. Reporting: Notify NVBDCP, complete outbreak investigation

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Q.4 Write briefly on Any Five (5 x 2 = 10 marks)

• Launched in 2018 under POSHAN Abhiyan
• Target: Reduce anemia prevalence by 3 percentage points per year
• 5x5 strategy: 5 target beneficiary groups × 5 interventions
• 5 beneficiaries: Children 6-59 months, 5-9 years, 10-19 years, women of reproductive age 15-49 years, pregnant women
• 5 interventions: Prophylactic iron-folic acid supplementation, deworming, SBCC (Social-Behaviour Change Communication), testing/treatment, delaying age of marriage
• Dosing: 6-59 months = 1 mg/kg/day iron; 5-9 yrs = 1 tablet/week (45 mg iron + 400 mcg folic acid); 10-19 yrs = 1 tablet/week; Adults = 1 tablet/week

1. Activity-passivity: Doctor active, patient completely passive (e.g., anaesthetized patient)
2. Guidance-cooperation: Doctor guides, patient cooperates (acute illness)
3. Mutual participation: Both participate equally as partners (chronic disease management) Styles: Paternalistic (doctor decides), Informative (doctor informs), Interpretive (doctor interprets values), Deliberative (doctor guides values) Key attributes: Empathy, respect, confidentiality, honesty, non-abandonment, cultural sensitivity.

• Weight-for-age (0-5 years): Determines underweight
• Height-for-age: Determines stunting (chronic malnutrition)
• Weight-for-height: Determines wasting (acute malnutrition)
• MUAC: Mid Upper Arm Circumference (malnutrition screening) India uses WHO Multicenter Growth Reference Study (MGRS) standards for <5 years. Under ICDS: Growth monitoring monthly for children under 3, quarterly for 3-6 years.

1. KAP model (Knowledge-Attitude-Practice): Assumes knowledge → attitude → practice
2. Health Belief Model (Rosenstock): Perceived susceptibility + severity → perceived benefits - barriers + cue to action → behaviour
3. Precede-Proceed Model (Green): Predisposing, enabling, reinforcing factors
4. Stages of Change Model (Prochaska): Pre-contemplation → Contemplation → Preparation → Action → Maintenance
5. Social Learning Theory (Bandura): Self-efficacy, observational learning

• Red (Immediate): Life-threatening but treatable; attend first
• Yellow (Delayed): Serious but stable; can wait
• Green (Minor): Walking wounded; minimal treatment
• Black (Expectant/Dead): Dead or unsurvivable injuries Used in mass casualty events, disaster response, ERs. SALT triage also used. Triage officer makes quick assessment without actual treatment.

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Q.5 Explain Why (Any Three) (3 x 5 = 15 marks)

• Governments may prioritize national political/economic interests over global health
• NGOs (MSF, Red Cross, CARE, PATH) can reach politically sensitive areas
• NGOs are often first responders in conflicts/disasters (neutrality advantage)
• They advocate for neglected diseases (NTDs) that lack commercial incentives for pharma
• They hold governments accountable (civil society role)
• Examples: Polio eradication required NGO networks; HIV/AIDS response - PEPFAR required NGO implementation partners
• Health has no borders (infectious diseases, climate change, antimicrobial resistance are global) - requires non-state actors

• Social capital: Strong community bonds, trust, cooperation → faster collective action
• Economic resources: Pre-existing wealth enables rebuilding, savings, insurance
• Preparedness: Communities with disaster plans, trained volunteers, stockpiles recover faster
• Leadership: Effective local leadership and governance speeds coordination
• Health infrastructure: Better health facilities → reduced morbidity from disaster
• Education: Higher literacy → better understanding of warnings, first aid, recovery actions
• Resilience: Prior disaster experience builds adaptive capacity (Resilience framework)
• Caste/gender equity: Less marginalization means more people participate in recovery

• Pre-independence: Health care was predominantly urban-based, curative-oriented, expensive
• Post-independence challenges: 80% rural population with no access; large infectious disease burden (malaria, TB, cholera, smallpox); poverty; low literacy
• Bhore Committee (1946): Recommended social medicine, rural health services, preventive focus
• Srivastava Committee (1975): Recommended community health workers (which became CHWs → ASHAs)
• Alma-Ata 1978 - India was a signatory
• PHC was most pragmatic: affordable, uses available technology, builds on community participation
• India's disease pattern requires preventive/promotive care, not just specialist hospitals
• Bajaj Committee and others emphasized PHC as the backbone of India's NHP (1983, 2002, 2017)

• RED (Urgent referral/treatment): Severe classification requiring hospital admission - e.g., Very Severe Disease, Severe Pneumonia, Severe Dehydration, Severe Acute Malnutrition
• YELLOW (Specific treatment + follow-up): Moderate illness treatable at outpatient level - e.g., Pneumonia, Some Dehydration, Moderate Malnutrition
• GREEN (Home care + counselling): Mild/no illness - e.g., No Pneumonia (cough/cold), No Dehydration Relevance:
• Standardizes clinical assessment by community health workers and nurses without extensive diagnostic equipment
• Prevents under-treatment (missing serious illness) and over-treatment
• Facilitates rapid decision-making
• Improves communication between healthcare providers
• Used in charts/job aids making it usable by semi-skilled workers

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Q.6 Milk-borne diseases, pasteurization methods, efficacy tests (20 marks)

1. Bovine tuberculosis (M. bovis)
2. Brucellosis (Brucella abortus)
3. Q fever (Coxiella burnetii)
4. Foot and mouth disease
5. Anthrax (rare)

1. Typhoid and paratyphoid (Salmonella typhi)
2. Scarlet fever, septic sore throat (Streptococcus pyogenes)
3. Diphtheria (Corynebacterium diphtheriae)
4. Staphylococcal food poisoning (Staph. aureus enterotoxin)
5. Dysentery (Shigella, Campylobacter)

1. E. coli O157:H7 (STEC) - hemorrhagic colitis, HUS
2. Listeriosis (Listeria monocytogenes) - especially in soft cheeses
3. Yersiniosis (Yersinia enterocolitica)

1. Phosphatase Test (Standard/most important): Milk contains alkaline phosphatase enzyme that is destroyed at 63°C/30 min. If phosphatase is absent after pasteurization → adequate pasteurization. Phosphatase still present → inadequate. Uses phenol-disodium phosphate substrate; blue colour = positive (inadequate).
2. Methylene Blue Reduction Test (MBRT): Indicator of bacterial load; not specifically for pasteurization efficacy
3. Turbidity Test: For sterilized milk - boiling protein (serum proteins) precipitate; turbidity = inadequate heat treatment
4. Standard Plate Count (SPC): <30,000 organisms/ml acceptable for pasteurized milk
5. Coliform Count: <10/ml acceptable; coliforms killed by pasteurization; if present = post-pasteurization contamination or inadequate pasteurization
6. Peroxidase Test: For UHT milk efficacy (peroxidase is more heat resistant than phosphatase)

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Q.7 Write briefly on Any Five (5 x 2 = 10 marks)

1. Providing leadership on global health matters
2. Shaping the health research agenda
3. Setting norms and standards
4. Articulating evidence-based policy options
5. Technical support to countries
6. Monitoring and assessing health trends Other roles: International Health Regulations (IHR), Global disease surveillance (GOARN), International Pharmacopoeia, Health technology assessment. India's WHO office: SEARO region (South-East Asia Regional Office, New Delhi).

• Minimum floor area: 9.5 m²/person
• Air space per person: 14 m³ (India)
• Window area: ≥10% of floor area
• Natural light: daylight factor ≥1%
• Ventilation rate: at least 20-30 m³ fresh air per person per hour
• Thermal comfort: 18-24°C
• Overcrowding: >1.5 persons/room (UK definition)

• Central level: Ministry of Health and Family Welfare (MoHFW); DGHS; NHM; directs national programmes
• State level: State MoHFW; State NHM Mission Director; District Health Society
• Peripheral level: District Hospital → Sub-District Hospital → CHC → PHC → Sub-Centre → ASHA at village level Private sector: accounts for ~70% of outpatient care, ~60% of inpatient care. Regulatory: Clinical Establishments Act, PCPNDT Act, MCI (now NMC - National Medical Commission), Pharmacy Council, Nursing Council.

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Q.8 Short notes on Any Four (4 x 5 = 20 marks)

• Previously: Health and Wellness Centres (HWC) under PMJAY/Ayushman Bharat
• Renamed to Ayushman Arogya Mandir in 2023
• Target: 1,50,000 AAMs by 2022 (sub-centres and PHCs upgraded)
• Provides: 12 packages of Comprehensive Primary Health Care (CPHC):
  1. Care for pregnancy, childbirth, newborn and infant care
  2. Child health services
  3. Family planning services
  4. Adolescent health services
  5. Communicable disease management
  6. Management of Common NCDs
  7. Management of Oral Health
  8. Management of Mental Health
  9. Management of ENT conditions
  10. Ophthalmic care
  11. Elderly and palliative care
  12. Emergency and trauma care (basic)
• Staffed by: Community Health Officer (CHO) - a mid-level health provider (BSc Community Health/ Ayurvedic graduate with 6-month bridge course)
• Wellness activities: Yoga, meditation, health education

• Children: Intellectual disability, learning disabilities, behavioural problems (most sensitive) - irreversible
• Adults: Peripheral neuropathy (wrist drop - extensor muscles), encephalopathy, anaemia (basophilic stippling, inhibits ALA dehydratase and ferrochelatase → microcytic anaemia)
• Reproductive: Spontaneous abortion, male infertility
• Renal: Nephropathy (Fanconi syndrome), gout (saturnine gout)
• GI: Lead colic, constipation Diagnosis: Whole blood lead level; FEP (free erythrocyte protoporphyrin), urinary delta-ALA Treatment: Remove from exposure; Chelation: BAL (dimercaprol), DMSA (succimer), EDTA for severe cases Prevention: Source control, nutrition (calcium, iron reduce lead absorption)

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PAPER 5: 3rd Year MBBS 2022 Batch (Supply) - January 2026

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Q.1 Fill in the Blanks

• Levonorgestrel (Plan B) - 72 hours; more effective the sooner taken
• Ulipristal acetate (EllaOne) - within 120 hours (5 days)
• Cu-T IUD - within 5 days (most effective EC)

• Pearl Index = (Number of failures / Total months of exposure) × 1200
• Lower Pearl Index = higher efficacy
• Also measured by Life-table analysis

• GHI = Average of: % undernourished population + % child wasting + % child stunting + child mortality rate
• Published by IFPRI (International Food Policy Research Institute)

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Q.2 MCQs

1. Situational Analysis (Analysis of health situation) - first step
2. Establishment of objectives and goals
3. Fixing priorities
4. Formulating programme
5. Implementation
6. Evaluation (Feedback → back to step 1) Analysis of the existing health situation comes first - must know where you are before deciding where to go.

• Kata thermometer: measures cooling power of air (a combined measure of temperature + air movement)
• Hygrometer: measures humidity
• Anemometer: measures air velocity/speed
• Sling's Psychrometer: measures wet and dry bulb temperature to derive humidity

• Asbestos is used in brake linings and gaskets - exposure to asbestos fibres
• Ground glass appearance (bilateral basal fibrosis), "shaggy heart" appearance on CXR
• Lower zone involvement (compared to silicosis - upper zone, coal workers pneumoconiosis - upper zone)
• Asbestosis: pleural plaques, mesothelioma risk, lung cancer (especially with smoking - synergistic effect)
• Silicosis: upper zone, eggshell calcification of hilar nodes
• Anthracosis: coal workers, upper zone

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Q.3 Child 18 months, unable to see in dim light/late evening, dry conjunctiva on exam:

• Primary: Inadequate intake - lack of green leafy vegetables, eggs, liver, dairy, orange/yellow fruits in diet; early weaning from breast milk; prolonged exclusive breastfeeding without complementary feeding
• Secondary: Malabsorption (coeliac disease, Crohn's, cystic fibrosis), liver disease (impaired storage), infection (measles, diarrhoea increase utilization)
• Risk factors: Low socioeconomic status, low dietary diversity, poor infant feeding practices

• Severe VAD (corneal involvement): 200,000 IU Vitamin A orally immediately, repeat next day, repeat at 2 weeks
• Moderate VAD / Night blindness in children 1-5 yrs: 200,000 IU orally immediately, next day, at 2-4 weeks
• Child <1 year or <8 kg: Half dose (100,000 IU)
• India National Programme: 200,000 IU (2,00,000 IU) Vitamin A every 6 months from 9 months to 5 years
• Treat associated infections (measles, diarrhoea)
• Improve dietary intake - dark green leafy vegetables, orange/yellow foods, dairy, eggs, liver

• Affects ~250 million children worldwide; leading cause of preventable childhood blindness
• Affects children under 5; peak age 1-3 years
• India: Highly endemic; NFHS-5 data suggests ~18-19% children have VAD
• Vitamin A deficiency also increases risk of mortality from diarrhoea, measles (increases case fatality 2-3x)
• Sub-clinical VAD (low serum retinol <0.7 µmol/L) is far more prevalent than clinical VAD

1. Vitamin A Supplementation (VAS): National Immunization Programme - 1,00,000 IU at 9 months; 2,00,000 IU 6-monthly from 18 months to 5 years
2. Dietary diversification: Increase consumption of provitamin A (beta-carotene) foods - dark leafy vegetables, carrots, mangoes, papaya; preformed Vitamin A - eggs, liver, dairy
3. Fortification: Vitamin A fortification of cooking oil, sugar, flour
4. Nutrition education: Encourage breastfeeding, appropriate complementary feeding
5. Treatment of infections: Measles vaccination, ORS for diarrhoea (reduce consumption of vitamin A during illness)
6. ICDS programme: Targeted nutrition supplementation

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Q.4 Write briefly on Any Five (5 x 2 = 10 marks)

• ESIC (Employees' State Insurance Corporation): For organized sector workers with wages ≤21,000/month; covers medical, cash (sickness, maternity, disablement, dependants), rehabilitation benefits
• EPF (Employees' Provident Fund): Old age financial security for organized sector
• CGHS: Central Government Health Scheme for central government employees
• PMJAY (PM Jan Arogya Yojana)/Ayushman Bharat: Health insurance for BPL families - Rs 5 lakh per family per year for secondary/tertiary hospitalization
• NPS (National Pension System): For unorganized sector workers too now
• MNREGA: Employment guarantee for rural poor

• Private philanthropic organization founded 1913, New York
• Major contributions to global health:
  • Funded eradication of hookworm in southern USA
  • Controlled yellow fever in South America and Africa
  • Established first schools of public health (Harvard, Johns Hopkins)
  • Green Revolution (supported Borlaug's wheat research)
  • Malaria control programmes in Asia
  • Funding for WHO and international health infrastructure
  • Currently funds work on pandemic preparedness, food security, energy access

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Q.5 Explain why (Any Three)

• Iodine is an essential trace element; requirement: 150 µg/day (adults), 220 µg/day (pregnant women)
• Iodine deficiency causes: Goitre (enlarged thyroid), cretinism (severe neuro deficiency in fetus), intellectual disability, hypothyroidism, increased miscarriage
• India: ~350 million people at risk of IDD (Iodine Deficiency Disorders)
• Salt is chosen because: universally consumed, centrally produced (easy to fortify at factory), consumed in small amounts (so concentration can be controlled), inexpensive to fortify
• Target: 15 ppm iodine at production, ≥15 ppm at consumer level
• National Iodine Deficiency Disorders Control Programme (NIDDCP) mandates iodized salt
• Prevention of Food Adulteration Act/FSSAI: Sale of non-iodized salt in iodine-deficient areas is prohibited

• Faecal-oral diseases (typhoid, cholera, hepatitis A, polio, dysentery) transmit via contaminated water/food/hands
• F-diagram: Faeces → Field/Fingers/Flies/Fluids/Food → Host (susceptible)
• Sanitation (proper disposal of human excreta) creates a barrier that:
  • Prevents contamination of water sources, soil, and food
  • Eliminates breeding of flies (which carry organisms mechanically)
  • Reduces environmental contamination
  • Breaking just one F-link interrupts transmission
• WHO estimates improved sanitation could prevent 10% of all disease burden
• Sanitation ladder: Open defecation → Pit latrine → Improved latrine → Flush toilet

• Scientifically sound: Evidence-based; WHO recommended; achieves 85-95% cure rates
• Affordable: Generic drugs cost ~$10-15 per patient for full course
• Adaptable: Works in all settings - primary health centres, hospitals, community
• Acceptable: Community health workers can administer; no sophisticated equipment
• Accessible: Can be delivered at patient's doorstep by ASHA/DOT provider
• Compare to: Multi-drug resistant TB treatment requiring hospitalization - NOT appropriate technology
• DOTS was adopted by RNTCP (now NTEP - National TB Elimination Programme) in India from 1997

• Equal distribution: Same amount/resources to everyone regardless of need. Example: giving Rs 100 to every person in India.
• Equitable distribution: Distribution according to need; those with greater need get more. Example: Universal Health Coverage giving more services to poor/remote areas.
• In health: Equal distribution would mean the same number of hospitals everywhere; equitable would concentrate more in underserved areas.
• PHC principles advocate equitable distribution, not equal.
• Illustration: 3 people of different heights trying to see over a fence (equality = same box; equity = boxes of different sizes based on need)

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Q.6 Classification of occupational diseases and ESI Act 1948 (20 marks)

1. Dust diseases (Pneumoconioses):
   • Silicosis (crystalline silica - mining, quarrying, sandblasting)
   • Asbestosis (asbestos fibres - insulation, construction)
   • Coal Workers' Pneumoconiosis (coal dust - coal mining)
   • Byssinosis (cotton dust - textile industry)
   • Bagassosis (bagasse - sugar cane industry)
   • Farmer's lung (mouldy hay - extrinsic allergic alveolitis)
2. Chemical poisoning:
   • Lead poisoning (batteries, paint)
   • Mercury poisoning (chemical industry, thermometer manufacture)
   • Carbon monoxide (incomplete combustion, enclosed spaces)
   • Benzene (leukaemia)
   • Organophosphate (agriculture)
3. Skin diseases: Contact dermatitis (chromates, rubber chemicals, cement), oil acne, skin cancer
4. Occupational cancers: (See Paper 1, Q.8e above)
5. Noise-induced hearing loss: Exposure to >85 dB over 8 hours
6. Radiation injuries: Ionizing (leukaemia, aplastic anaemia); non-ionizing (cataracts from UV, skin burns)
7. Infectious diseases: Anthrax (abattoir workers), brucellosis (veterinary), HIV/HBV/HCV (healthcare workers)
8. Heat illness: Heat cramps, heat exhaustion, heat stroke
9. Musculoskeletal: Back injuries, carpal tunnel syndrome, vibration white finger

• Factories with ≥10 workers (with power) or ≥20 (without power) using power
• Now extended to many establishments; wage limit: ≤21,000/month (for persons with disability: ≤25,000)
• Administered by ESIC (Employees' State Insurance Corporation) under Ministry of Labour

• Employee: 0.75% of wages (was 1.75%)
• Employer: 3.25% of wages (was 4.75%)
• State government: 1/8 of medical benefit expenditure
• Some employers fully exempted workers with wages ≤176/day

1. Medical benefit: Full medical care for insured person and family; unlimited
2. Sickness benefit: 70% of wages for up to 91 days/year during sickness (after qualifying: 78 days insurance period)
3. Maternity benefit: 100% of wages for 26 weeks (8 weeks prenatal + 18 weeks post)
4. Disablement benefit:
   • Temporary: 90% of wages during temporary disablement
   • Permanent partial: Proportionate to degree of disability
   • Permanent total: 90% of wages for life
5. Dependants' benefit: 90% of wages to dependants on death of insured worker due to employment injury
6. Other benefits: Funeral expenses (Rs 15,000), vocational rehabilitation, old age medical care (RGHS/ESI scheme for retired)

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Q.7 Write briefly on Any Five

• Service delivery in underserved areas
• Health education and behaviour change communication
• Advocacy and policy influence
• Research and innovation
• Disaster relief and humanitarian assistance Major health NGOs in India: FRHS India, Voluntary Health Association of India (VHAI), Indian Red Cross Society (IRCS), CRY, HelpAge India Challenges: Sustainability of funding, accountability, coordination with government

• Structural mitigation: Building dams, flood embankments, earthquake-resistant construction, cyclone shelters
• Non-structural mitigation: Land use planning (not building in flood plains), building codes, early warning systems, insurance, public education Distinguished from preparedness (planning for response) and response (actions during disaster). Under NDMA: Mitigation Division plans long-term risk reduction measures.

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Q.8 Write short notes (Any Four)

1. Situational Analysis - Assess health status, needs, available resources, disease burden (SWOT analysis)
2. Setting objectives - SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound)
3. Fixing priorities - Prioritize health problems (magnitude, severity, feasibility, cost-effectiveness)
4. Formulating alternatives/strategies - Identify various approaches
5. Programme planning - Detailed implementation plan (who, what, when, where, with what)
6. Implementation - Execute the plan
7. Monitoring - Ongoing assessment of inputs and processes
8. Evaluation - Assessment of outcomes and impact → feeds back into next planning cycle "PDCA cycle" (Plan, Do, Check, Act) - Deming's cycle

• Kuppuswamy Scale (Urban): Education of head + Occupation of head + Monthly family income → total score 3-29 (Upper/Upper middle/Lower middle/Upper lower/Lower)
• Modified BG Prasad Classification (updated annually with CPI): Based on per capita monthly family income
• Udai Pareek's Scale (Rural): 7 variables - education, occupation, land, house type, farm power, material possession, participation in community organizations
• NSSO classification: Used in national surveys - household asset index

• Anthropometric surveys: Weight, height, MUAC, skinfold thickness
• Biochemical: Serum retinol, haemoglobin, urinary iodine, serum 25-OH Vitamin D
• Dietary surveys: 24-hour recall, food frequency questionnaire, food weighing
• Clinical surveys: Signs of deficiency diseases
• Vital statistics: IMR, MMR, birth weight Key systems in India: NFHS (National Family Health Survey), CNNS (Comprehensive National Nutrition Survey), NNMB (National Nutrition Monitoring Bureau), ICDS monitoring.

• Management of severe acute malnutrition (SAM) in children
• Community-based: Ready-to-use therapeutic food (RUTF - Plumpy'nut)
• Facility-based: Nutritional Rehabilitation Centres (NRC) in government hospitals
• F75 → F100 milk formula transition
• IMNCI criteria for SAM: WFH <-3 SD or MUAC <11.5 cm or bilateral pitting oedema

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Summary of Coverage

Paper 1 - 2021 Batch Supply (May 2025)

• Fill in the blanks (calcium in lactation, limiting AA in pulses, daylight factor, ASHA training)
• 5 MCQs (HDI, MPI, reference protein, Stevenson screen, JSY incentive)
• Brief notes on: Glycaemic index, Air pollution indicators, Communication barriers, Network analysis, Appropriate technology, Acculturation
• Explain why: Fluorine = two-edged sword, Food additives ≠ adulterants, Feedback in planning, Poor housing and health
• Long Q: PHC - definition, levels, 8 essential elements, principles
• Brief notes: UNICEF, Drug dependence, Genetic counselling, Water-borne diseases, Biomedical waste hazards, Mentally healthy person
• Short notes: Vitamin A deficiency, Integrated vector management, Group discussion, Disaster cycle, Occupational cancers

Paper 2 - 2021 Batch Main (Dec 2024)

• Eugenics vs Euthenics, Illusion/Delusion/Hallucination, Health education vs propaganda, Slow vs rapid sand filter
• PM POSHAN Shakti Yojana, Sub-centre services, SES scales, Food fortification, BFHI, Fecal-borne diseases, Breakpoint chlorination

Paper 3 - 2021 Batch Supply

• Vanaspati ghee nutrients (Vit A & D)
• Infant/childhood mortality rates, causes, 3 strategies to reduce IMR
• School health services, Housing criteria, PERT, Primary mental health, Mission Indradhanush, Disease control/elimination/eradication

Paper 4 - 2022 Batch Main (Oct 2025)

• Fill in the blanks (culture, farmer's lung, BMI of reference Indian male, workshop domain, emporiatrics)
• MCQs (PHC principle not applicable, catheter bin colour, NDMA head, regulatory approach)
• Clinical scenario: Chikungunya/vector-borne disease cluster management
• Brief/short notes: AMB strategy, Juvenile delinquency, Doctor-patient relationship, Growth chart, Health education models, Triage
• Long Q: Milk-borne diseases + pasteurization methods + phosphatase test
• Brief notes: WHO functions, Sickness absenteeism, Housing standards, Healthcare system in India, Food adulteration, Water-borne diseases
• Short notes: Notifiable diseases, Ayushman Arogya Mandir, BMW management, Lead poisoning, Refuse disposal

Paper 5 - 2022 Batch Supply (Jan 2026)

• Fill in the blanks (EC timing, Holder's method temp, Jules Guerin, Pearl index, GHI indicators)
• MCQs (first planning step, catheter bin, Kata thermometer, asbestosis, Horrocks apparatus)
• VAD case: diagnosis, etiology, treatment, epidemiology, prevention
• Brief notes: Social security, Ergonomics, Rockefeller Foundation, Triage, BMW
• Explain why: Salt + iodine, Sanitation barrier, DOTS = appropriate technology, Equal ≠ equitable
• Long Q: Occupational disease classification + ESI Act 1948
• Short notes: NGOs, Essential medicines, Communication barriers, Mitigation, Health planning cycle, Nutritional surveillance, SES scales

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What's inside (12 colour-coded sections, ~16 pages):

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RUHS 3rd Year MBBS 2022 Batch (Supply) — January 2026

Community Medicine Paper-II — Complete Answers

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Q.2(e) Horrocks Apparatus — Bleaching Power for 2275 Litres

• The Horrocks apparatus has 5 white porcelain cups (A–E) with increasing bleaching powder concentrations
• Starch-iodide indicator turns blue when free chlorine is present
• 3rd white cup (Cup C) turned blue = 0.5 ppm free residual chlorine is present at that dose

• Required chlorine dose = 0.5 mg/L (0.5 ppm) as a free residual
• Bleaching powder contains ~25–33% available chlorine
• For standard bleaching powder (25% available Cl): to achieve ~2.5 mg/L applied dose in 2275 litres:
  • Chlorine needed = 2.5 mg/L × 2275 L = 5687.5 mg ≈ 5.7 g of pure chlorine
  • Bleaching powder needed = 5.7 g / 0.25 = ~22.8 g ≈ 25 gm (standard answer)

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Q.3 Child 18 months, unable to see in dim light/evening, dry conjunctiva on examination (15 marks)

a) Identify the condition and write its etiology

• Specific stage: XN (Night blindness) + X1A (Conjunctival xerosis)
• Night blindness = inability to see in dim light (first clinical sign of VAD)
• Dry conjunctiva = conjunctival xerosis

• Inadequate intake of Vitamin A (retinol) or provitamin A carotenoids
• Lack of dark green leafy vegetables (spinach, methi), orange/yellow vegetables/fruits (carrots, mango, papaya)
• Lack of animal sources: liver, egg, milk, fish liver oils
• Early weaning from breast milk
• Low-fat diet (Vit A is fat-soluble — fat needed for absorption)

• Fat malabsorption: coeliac disease, Crohn's, cystic fibrosis, cholestasis
• Liver disease (impaired storage — liver is main storage organ)
• Infection: measles, diarrhoeal disease, severe ARI (increase catabolism and urinary loss)
• Protein-energy malnutrition (impairs retinol-binding protein synthesis)

• Age 6 months–6 years (peak age of VAD)
• Rural residence, low socioeconomic status
• Poor complementary feeding practices after 6 months

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b) How will you treat this condition?

• Treat associated infections (measles, diarrhoea, ARI) aggressively
• Correct protein-energy malnutrition if present
• Dietary counselling — introduce eggs, milk, green leafy vegetables, orange/yellow fruits
• Eye care: lubricating drops if corneal involvement
• Refer ophthalmologist if corneal lesions (X2/X3) present

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c) Write the epidemiology and preventive measures

• VAD affects approximately 250 million children worldwide (WHO)
• Leading cause of preventable childhood blindness globally
• India: NFHS-5 (2019-21) — ~18% children under 5 have VAD (serum retinol <0.70 µmol/L)
• Peak age: 1–3 years (18 months–3 years most vulnerable)
• Higher prevalence in: rural areas, tribal populations, low-income groups, states like UP, Bihar, Rajasthan
• Sub-clinical VAD (low serum retinol without eye signs) is far more common than clinical VAD
• Measles — most important precipitating infection for clinical VAD
• VAD increases case fatality from measles and diarrhoea by 2–3 times
• Bitot's spots prevalence >0.5% in under-5s indicates a public health problem

• Promote consumption of Vitamin A-rich foods:
  • Preformed Vitamin A: liver, egg yolk, full-fat milk, fish
  • Provitamin A (beta-carotene): dark green leafy vegetables (spinach, drumstick leaves), orange/yellow vegetables (carrots, pumpkin), fruits (mango, papaya)
• Ensure fat in diet for absorption
• Encourage breastfeeding (breast milk contains adequate Vit A for infants)

• Mandatory fortification of: cooking oil (30 µg RE/g), vanaspati ghee (25 IU/g), milk
• Sugar fortification in some states
• Rice fortification under PM-POSHAN

• Measles vaccination (prevents most severe VAD precipitation)
• ORS for diarrhoea (prevents loss of Vit A)
• Universal immunization under UIP

• Kitchen gardens (promotion of leafy vegetables)
• Behaviour Change Communication through ASHA, ANM, ICDS
• Anganwadi centres — supplementary nutrition, health education

• NFHS tracks VAD prevalence
• NNMB (National Nutrition Monitoring Bureau) surveillance
• ICDS monthly growth monitoring identifies at-risk children

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Q.4 Write briefly on Any Five (5 × 2 = 10 marks)

a) Social Security

• ESIC (Employees' State Insurance Corporation): Organized sector workers with wages ≤₹21,000/month. Benefits: medical, sickness (70% wages/91 days), maternity (100% wages/26 weeks), disablement, dependants, funeral (₹15,000)
• PMJAY (Ayushman Bharat): Health insurance ₹5 lakh/family/year for BPL — secondary and tertiary hospitalization
• CGHS: Central Government Health Scheme for central government employees
• EPF: Employees' Provident Fund — old age financial security
• MNREGA: Employment guarantee for rural poor (100 days/year)
• Social security for informal sector remains a major challenge in India

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b) Eugenics

• Coined by Francis Galton (1883), cousin of Darwin
• Positive eugenics: Encourage reproduction among those with "desirable" traits
• Negative eugenics: Discourage/prevent reproduction among those with "undesirable" traits
• Ethics: Highly controversial; grossly misused by Nazi Germany (forced sterilization, genocide)
• Modern acceptable form: Genetic counselling, prenatal diagnosis, preimplantation genetic testing — all voluntary, empowering rather than coercive
• Distinguished from Euthenics (improving human well-being through environmental improvement — ethically acceptable)

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c) Ergonomics

• Goal: Optimize human performance, reduce injury, fatigue, and discomfort
• Applications: Workstation design (computer height/chair), tool design, manual handling guidelines, shift scheduling
• Musculoskeletal disorders prevented: Carpal tunnel syndrome, low back pain, repetitive strain injury (RSI), work-related upper limb disorders
• Principles: Neutral body posture, minimize repetitive/forceful exertions, adequate rest breaks, job rotation, correct tool grip
• Cognitive ergonomics: Design of displays, controls, decision-support tools
• Relevant acts: Factories Act 1948 mandates safe and ergonomic working conditions

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d) Rockefeller Foundation

• Founded: 1913, New York, USA — by John D. Rockefeller Sr.
• A private philanthropic organization with major contributions to global public health:

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e) Triage

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f) Biomedical Waste Management

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Q.5 Explain Why (Any Three) — 3 × 5 = 15 marks

a) Salt is fortified with Iodine

• Iodine requirement: 150 µg/day (adults); 220 µg/day (pregnant); 290 µg/day (lactating)
• Iodine deficiency causes (IDD — Iodine Deficiency Disorders):
  • Goitre (enlarged thyroid — most visible sign)
  • Cretinism — irreversible intellectual disability, deafness, spasticity in offspring of iodine-deficient mothers
  • Hypothyroidism, increased miscarriage/stillbirth, low birth weight, impaired cognitive development
• India: ~350 million people at risk; all 28 states have iodine-deficient soil (mountain and flood-plain areas worst affected)
• Why SALT?
  • Universally consumed across all socioeconomic groups
  • Consumed in small, predictable amounts (10–15 g/day) → concentration can be controlled
  • Centrally produced at few factories → easy to fortify at source
  • Very inexpensive to iodize (fraction of a paisa per person per year)
  • Iodine does not alter taste, colour, or shelf-life of salt
• Standard: 15 ppm iodine at production; ≥15 ppm at consumer level (FSSAI)
• Legal mandate: FSSAI prohibits sale of non-iodized salt in iodine-deficient areas
• Programme: National Iodine Deficiency Disorders Control Programme (NIDDCP)

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b) Sanitation barrier breaks the disease cycle

• Faecal-oral diseases (cholera, typhoid, hepatitis A, polio, dysentery, amoebiasis) are transmitted through the F-diagram pathway:

• How sanitation creates a barrier:
  • Proper disposal of human excreta (latrines, sewers) prevents contamination of soil, water, and crops
  • Breaks the link between faeces and all 5 "F" transmission routes simultaneously
  • Eliminates open defecation (OD) — prevents ground contamination, fly breeding, soil-transmitted helminths
  • Prevents contamination of water bodies used for drinking/bathing/cooking
  • Reduces fly populations (flies breed in faecal matter and mechanically transfer pathogens to food)
• Evidence: WHO estimates improved sanitation could prevent ~10% of the global disease burden and ~1.5 million child deaths annually
• India: Swachh Bharat Mission (SBM) — Oct 2014 — targeted Open Defecation Free (ODF) India
  • Phase I (by Oct 2019): Constructed >100 million toilets; declared ODF
  • Phase II (SBM 2.0, 2021-26): ODF Plus — solid/liquid waste management, cleanliness
• Sanitation ladder (WHO/UNICEF JMP): Open defecation → Unimproved → Limited → Basic → Safely managed (highest level)

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c) DOTS is an example of Appropriate Technology

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d) Equal and Equitable Distribution is NOT synonymous

• Example: Building the same number of hospitals in every district regardless of population size, disease burden, or existing coverage

• Example: Allocating more PHCs to tribal/rural areas with high disease burden and poor existing infrastructure

• Imagine 3 people of heights 150 cm, 160 cm, and 170 cm trying to see over a 165 cm fence:
  • Equal = give each person a 10 cm box → only the tallest can see
  • Equitable = give the shortest a 20 cm box, middle a 10 cm box, tallest nothing → all can see
• In healthcare: equal would mean ignoring the greater health needs of the poor, rural, and marginalized
• Equitable distribution means more resources where need is greatest

• More health workers per capita in high-burden areas
• More immunization outreach in unserved villages
• More referral transport in remote areas
• NITI Aayog Aspirational Districts programme — concentrated investment in most backward districts

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Q.6 Classification of Occupational Diseases + Employee State Insurance Act 1948 (20 marks)

Classification of Occupational Diseases:

• Silicosis (crystalline silica — mining, quarrying; upper zone nodules; "eggshell" hilar calcification)
• Asbestosis (asbestos — insulation, brakes; lower zone ground-glass fibrosis; pleural plaques; mesothelioma risk)
• Coal Workers' Pneumoconiosis (coal dust; upper zone; PMF)
• Byssinosis (cotton dust — "Monday fever")
• Farmer's Lung (mouldy hay — thermophilic actinomycetes; hypersensitivity pneumonitis)
• Bagassosis (bagasse — sugarcane)

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Employee State Insurance (ESI) Act 1948:

• Factories ≥10 workers (power-using) or ≥20 (non-power)
• Wages ≤₹21,000/month (₹25,000 for persons with disability)
• Administered by ESIC under Ministry of Labour & Employment

• Employee: 0.75% of wages
• Employer: 3.25% of wages
• State government: 1/8th of medical benefit expenditure

• ESIC Headquarters: New Delhi
• Central Board → Corporation → Regional offices → ESIC hospitals + dispensaries
• ESIC hospitals in major industrial towns; empanelled private hospitals for areas without ESIC facilities

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Q.7 Write briefly on Any Five (5 × 2 = 10 marks)

a) Non-Government Organizations (NGOs)

• Role in health: Service delivery in underserved areas; health education/BCC; advocacy; research; disaster relief; community mobilization
• Strengths: Flexible, community-trusted, politically neutral, innovative, able to reach marginalized groups
• Major health NGOs in India: Voluntary Health Association of India (VHAI), Indian Red Cross Society, CRY, HelpAge India, LEPRA Society (leprosy), Sight Savers (blindness)
• FCRA (Foreign Contribution Regulation Act): Governs foreign funding to NGOs in India
• Partnership with government: PPP model; NGOs implement government schemes (ASHA support, tribal health, TB DOTS)

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b) Essential Medicines (EM)

• WHO's first EML published: 1977 | Updated every 2 years
• India's NEML (National Essential Medicines List) 2022: ~384 medicines
• Selection criteria: Public health relevance, proven efficacy + safety, quality evidence, cost-effectiveness, availability
• Benefits: Reduces costs, guides procurement, ensures availability, prevents irrational prescribing
• Jan Aushadhi Scheme (PM-BJPY): Generic EM available at ₹1–₹2 at Jan Aushadhi Kendras
• Pradhan Mantri Bhartiya Janaushadhi Pariyojana: >9,000 stores across India
• WHO Model List: ~460 medicines in 2023 edition; separate paediatric list

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c) Communication Barriers

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d) Mitigation (Disaster Management)

1. Structural mitigation: Physical construction measures
   • Flood embankments, dams, cyclone shelters
   • Earthquake-resistant building construction
   • Fire sprinkler systems, tsunami barriers
2. Non-structural mitigation: Policy, planning, and behavioural measures
   • Land use planning (avoiding construction in flood plains, landslide zones)
   • Building codes and enforcement
   • Early warning systems (cyclone, flood, earthquake)
   • Insurance and social protection systems
   • Public awareness and education about disaster risks

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e) Acculturation

• Distinguished from:
  • Enculturation: Learning one's own culture from birth
  • Socialization: Acquiring norms of one's own society
  • Assimilation: Complete adoption of new culture (loss of original)

• Migrants/immigrants adopt health behaviours of host country
• Positive acculturation: Adopting better hygiene, health-seeking behaviour, immunization acceptance
• Negative acculturation: Adopting tobacco, alcohol, high-fat diet, sedentary lifestyle of developed countries
• Health workers must understand acculturation when targeting immigrant or tribal communities
• Acculturation stress ("acculturative stress") can cause mental health problems in migrants

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f) Drug Dependence

• Tolerance: Need for increasing doses to achieve same effect
• Physical dependence: Withdrawal syndrome on abrupt cessation (opioids, alcohol, benzodiazepines, barbiturates)
• Psychological dependence: Compulsive craving without physical withdrawal (cocaine, cannabis, amphetamines)
• Compulsive drug-seeking behaviour

• Opioids: heroin, morphine (physical + psychological)
• Alcohol: physical + psychological; most common in India
• Cannabis: mainly psychological
• Cocaine/amphetamines: mainly psychological
• Benzodiazepines: physical dependence

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Q.8 Write short notes on Any Four

b) Health Planning Cycle

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c) Various scales/measures for classification of socio-economic status (SES) of households

• Variables (3): Education of head of family + Occupation of head + Monthly family income
• Scores: Education (1-7) + Occupation (1-10) + Income (1-12) = Total 3–29
• Classification: Upper (26-29) | Upper Middle (16-25) | Lower Middle (11-15) | Upper Lower (5-10) | Lower (≤4)
• Income component updated annually using Consumer Price Index (CPI)
• Most commonly used for urban populations

• Based on per capita monthly family income alone
• Adjusted annually for CPI
• 5 classes: I (highest) to V (lowest)
• Most widely used in community health research
• Simple, quick, single variable

• 7 variables: Education, Occupation, Land owned, House type, Farm power (tractors/animals), Material possession, Participation in community organizations
• Designed specifically for rural context where income may not reflect actual SES
• Best for rural populations

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d) Nutritional Surveillance

1. Identify populations at nutritional risk
2. Monitor trends in nutritional status over time
3. Provide early warning of deteriorating nutrition (famine early warning)
4. Evaluate effectiveness of nutrition interventions
5. Provide data for policy and programme planning

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