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🏥 Community Medicine - Complete Theory Study Guide

Based on Park's Textbook of Preventive & Social Medicine | MBBS Final Year

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TABLE OF CONTENTS

1. Concepts of Health & Disease
2. Epidemiology - Principles & Methods
3. Communicable Diseases
4. Non-Communicable Diseases (NCDs)
5. Nutrition & Health
6. Environmental Health
7. Demography & Family Planning
8. Maternal & Child Health (MCH)
9. National Health Programmes
10. Health Management & Planning
11. Occupational Health
12. Genetics & Health

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UNIT 1: CONCEPTS OF HEALTH AND DISEASE

1.1 Definition of Health

"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

• Physical health
• Mental health
• Social health
• Spiritual health
• Emotional health
• Vocational health

1.2 Determinants of Health

1. Biological/Genetic factors - sex, age, heredity
2. Behavioral/Lifestyle factors - most important modifiable determinant
3. Socioeconomic factors - education, occupation, income
4. Environmental factors - physical, biological, social environment
5. Health services - availability, accessibility, acceptability
6. Nutrition - direct determinant
7. Psychosocial factors

1. Human biology
2. Environment
3. Lifestyle
4. Health care organization

1.3 Concept of Disease

• Disease = physiological/psychological dysfunction
• Illness = subjective feeling of not being well (patient's perception)
• Sickness = state of social dysfunction (social role)

• Carriers
• Subclinical infections
• Early chronic diseases

1.4 Natural History of Disease

• Before disease enters host
• Agent, Host, Environment factors present but not yet interacting sufficiently
• "Man in the midst of disease"

• Starts with entry of agent into host
• Stages: Incubation → Early pathogenesis → Late pathogenesis → Outcome (recovery/disability/death)

• Health promotion: health education, nutrition, genetics counselling
• Specific protection: immunization, chemoprophylaxis, environmental sanitation

1.5 Epidemiological Triad (Triangle of Epidemiology)

1. Agent (cause of disease)
2. Host (susceptible person)
3. Environment (external factors)

• Biological: bacteria, virus, parasite, fungus
• Chemical: heavy metals, poisons
• Physical: heat, cold, radiation
• Nutritional: deficiency/excess
• Psychosocial: stress

• Age, Sex, Genetics
• Ethnicity/race
• Marital status
• Immunity, Occupation, Behavior/habits

• Physical: climate, geography, housing
• Biological: vectors, reservoirs, flora/fauna
• Social: crowding, poverty, education

1.6 Models of Causation

1. Organism must be found in every case of disease
2. Must be isolated from diseased host and grown in pure culture
3. Inoculation of culture must produce disease in healthy host
4. Organism must be recovered from experimentally infected host

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UNIT 2: EPIDEMIOLOGY - PRINCIPLES & METHODS

2.1 Definition & Scope

1. Study of disease distribution
2. Identify determinants/risk factors
3. Complete natural history of disease
4. Evaluation of health services
5. Health planning and evaluation

2.2 Measures of Disease Frequency

Incidence

• Incidence rate = (New cases in specified period / Population at risk) × 1000
• Measures risk of developing disease
• More useful for acute diseases

Prevalence

• Point prevalence = (Cases at a point in time / Population at that time) × 100
• Period prevalence = Cases during a period / Average population during period
• More useful for chronic diseases

Other Rates

2.3 Standardization

• SMR > 100 = excess mortality
• SMR < 100 = less mortality

2.4 Study Designs

Descriptive Studies

1. Case reports / Case series
2. Cross-sectional (prevalence) studies
3. Ecological (correlational) studies

Analytical Studies

Case-Control Study (Retrospective)

• Start with cases (people with disease) and controls (without disease)
• Look backward for exposure
• Measure: Odds Ratio (OR)
• OR = (a×d) / (b×c) using 2×2 table
• Good for rare diseases, quick, cheap
• Limitations: recall bias, selection bias

Cohort Study (Prospective)

• Start with exposed and unexposed groups
• Follow forward for disease development
• Measure: Relative Risk (RR)
• RR = Incidence in exposed / Incidence in unexposed
• Good for common diseases, multiple outcomes
• Limitations: expensive, time-consuming, loss to follow-up

Experimental/Interventional Studies

• Random allocation of subjects
• Parallel groups: intervention vs control
• Single blind, Double blind (gold standard), Triple blind
• Measures: Efficacy, Safety

Screening

1. Condition should be an important health problem
2. Accepted treatment available
3. Facilities for diagnosis and treatment available
4. Recognizable latent or early symptomatic stage
5. Suitable test available
6. Test should be acceptable to population
7. Natural history understood
8. Agreed policy on whom to treat
9. Cost-effective
10. Case-finding is a continuing process

• High sensitivity → few false negatives → good for ruling OUT disease (SnNOut)
• High specificity → few false positives → good for ruling IN disease (SpPIn)
• PPV increases with prevalence
• Shifting cut-off point: sensitivity and specificity inversely related

2.5 Causation in Epidemiology

1. Strength of association
2. Consistency
3. Specificity
4. Temporality (only absolute requirement)
5. Biological gradient (dose-response)
6. Plausibility
7. Coherence
8. Experiment
9. Analogy

2.6 Bias & Confounding

• Selection bias: Non-representative sample
• Information/Recall bias: Differential recall between cases and controls
• Lead time bias: In screening studies, apparent longer survival due to earlier detection

• Control: Randomization, restriction, matching, stratification, multivariate analysis

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UNIT 3: COMMUNICABLE DISEASES

3.1 Definitions

• Communicable disease: Illness caused by an infectious agent transmitted from man to man, animal to man, or environment to man
• Infection: Entry and development/multiplication of agent in host
• Infestation: Lodgment of arthropods on the body surface
• Colonization: Organisms present but not causing harm
• Infectious disease: Clinically manifest disease resulting from infection
• Contagious disease: Spread by direct contact (e.g., chickenpox)

3.2 Chain of Infection

Reservoir

• Human reservoir: cases, carriers (incubatory, convalescent, healthy, chronic)
• Animal reservoir: zoonoses
• Environmental: soil (tetanus, anthrax)

Modes of Transmission

• Direct contact (skin, mucous membrane)
• Droplet infection (>5 microns, <1 metre)
• Vertical transmission (mother to child)
• Direct inoculation

• Airborne (droplet nuclei <5 microns, travel >1 metre) - TB, measles
• Vehicle-borne (water, food, blood, fomites)
• Vector-borne - mechanical or biological
• Iatrogenic

• Propagative: agent multiplies in vector (plague)
• Cyclo-propagative: multiplies + change in form (malaria)
• Cyclo-developmental: changes form only (filaria)
• Transovarial: passed to offspring (scrub typhus)

3.3 Major Communicable Diseases

Tuberculosis

• Causative agent: Mycobacterium tuberculosis
• Transmission: Airborne (droplet nuclei)
• Infectious dose: 1-10 bacilli
• Incubation period: 4-12 weeks (primary) to years (reactivation)
• Diagnosis: Sputum smear (ZN stain), Culture (Lowenstein-Jensen medium), RNTCP/CBNAAT, Tuberculin test (Mantoux)
• Mantoux test: 5 TU (tuberculin units) intradermally; read at 48-72 hours; induration ≥10 mm = positive; ≥5 mm in immunocompromised/HIV
• Treatment: RNTCP DOTS - Category I (new): 2HRZE/4HR; Category II (retreatment): 2HRZES/1HRZE/5HRE

• Goal: Eliminate TB by 2025 (India's national target)
• DOTS: Directly Observed Treatment, Short course
• Universal Drug Susceptibility Testing (UDST)

Malaria

• Causative agent: Plasmodium vivax (most common), P. falciparum (most dangerous), P. malariae, P. ovale
• Vector: Female Anopheles mosquito
• Incubation period: P. vivax = 14 days; P. falciparum = 12 days; P. malariae = 28 days; P. ovale = 17 days
• Life cycle: Gametocytes in human blood → mosquito gut → sporozoites → liver → merozoites → RBCs
• Exo-erythrocytic phase (liver): P. vivax has hypnozoites (cause relapses)
• Clinical features: Cold → Hot → Sweating stage; P. falciparum = malignant tertian, most severe (cerebral malaria)
• Diagnosis: Peripheral blood smear (thick = detection, thin = species identification), RDT (rapid diagnostic test), PCR
• Treatment:
  • P. vivax: Chloroquine + Primaquine (14 days, kills hypnozoites)
  • P. falciparum: Artemisinin Combination Therapy (ACT) - Artesunate + SP or Artemether-Lumefantrine; add Primaquine single dose (gametocidal)
• Control: Vector control (DDT, LLIN = Long Lasting Insecticidal Nets), larvicides (gambusia fish, oil), personal protection, antimalarial drugs
• Entomological indices: Mosquito density indicators - Stegomyia (House index, Container index, Breteau index for Aedes), Spleen rate and Parasite rate for malaria endemicity

Dengue

• Agent: Dengue virus (4 serotypes: DENV 1-4)
• Vector: Aedes aegypti (day-biting), also A. albopictus
• Transmission: Transovarian + transovarial in mosquito
• IP: 3-14 days
• Warning signs of Dengue: Abdominal pain, persistent vomiting, clinical fluid accumulation, mucosal bleeding, lethargy, liver enlargement >2cm, rapid rise of HCT with rapid fall in platelets
• WHO 2009 classification: Dengue without warning signs / Dengue with warning signs / Severe dengue
• Diagnosis: NS1 antigen (day 1-5), IgM ELISA (day 5 onwards), Dengue PCR
• Treatment: Supportive (no specific antiviral); paracetamol, avoid NSAIDs/aspirin; fluid management
• Control: Source reduction (Aedes breeding sites - stagnant water in containers)

Cholera

• Agent: Vibrio cholerae O1 (El Tor biotype) and O139
• Transmission: Fecal-oral; water-borne (most important)
• IP: Few hours to 5 days (usually 2-3 days)
• Clinical: "Rice water stools", painless watery diarrhea, vomiting, dehydration (hypovolemic shock); "Washerwoman's hands"
• Diagnosis: Dark-field microscopy (shooting-star motility), culture (TCBS medium)
• Treatment: ORS (oral rehydration solution) is mainstay; IV fluids (Ringer's lactate) for severe dehydration; Doxycycline (adults) or Azithromycin (children, pregnancy)
• Prophylaxis: Safe water and sanitation; oral cholera vaccine

Typhoid

• Agent: Salmonella typhi (S. paratyphi causes paratyphoid)
• Transmission: Fecal-oral; water/food borne
• IP: 10-14 days (range 3-60 days)
• Clinical: Stepladder fever, relative bradycardia, rose spots (abdomen), splenomegaly, coated tongue
• Diagnosis: Blood culture (best in 1st week), Widal test (titre >1:160 significant), Bone marrow culture (most sensitive)
• Complications: Intestinal perforation, hemorrhage (3rd week)
• Treatment: Ceftriaxone (IV), Azithromycin, Ciprofloxacin (if sensitive); Chloramphenicol (older standard)
• Prevention: Typhoid vaccine (Vi polysaccharide, or Ty21a oral)

Hepatitis

• HBsAg: Surface antigen (marker of infection, appears first)
• Anti-HBs: Immunity (after vaccination or recovery)
• HBeAg: High infectivity
• Anti-HBe: Low infectivity, seroconversion
• Anti-HBc IgM: Acute infection

HIV/AIDS

• Agent: HIV-1 (pandemic), HIV-2 (West Africa)
• Target: CD4+ T lymphocytes, macrophages, dendritic cells
• Transmission: Sexual, parenteral (blood/needles), MTCT (vertical)
• IP: 2-6 weeks to seroconversion; 8-10 years to AIDS (average)
• Staging (WHO): Stage 1 (asymptomatic), Stage 2 (mild), Stage 3 (advanced), Stage 4 (severe/AIDS)
• AIDS definition (CDC): CD4 <200/μL OR AIDS-defining illness
• AIDS-defining illnesses: PCP pneumonia, CMV retinitis, toxoplasmosis, Kaposi's sarcoma, MAC, esophageal candidiasis, cryptococcal meningitis, extrapulmonary TB, wasting syndrome
• Diagnosis: ELISA (screening), Western blot (confirmatory), CD4 count, viral load
• Treatment: ART (Antiretroviral Therapy) - TDF + 3TC + EFV (first-line in India under NACP)
• PMTCT (Prevention of Mother to Child Transmission): Option B+ = ART for all HIV+ pregnant women lifelong

Leprosy

• Agent: Mycobacterium leprae (cannot be cultured in vitro)
• Transmission: Prolonged close contact; nasal droplets (main route); humans are main reservoir
• IP: 2-5 years (range 6 months to 20+ years)
• Ridley-Jopling classification:
  • TT (tuberculoid): Few lesions, well-defined, hypopigmented, anesthetic, AFB negative
  • BT, BB, BL (borderline): Intermediate
  • LL (lepromatous): Many lesions, poorly defined, AFB positive, bilateral, "Leonine facies"
• WHO Classification (for treatment):
  • Paucibacillary (PB): ≤5 lesions, smear negative → 6 months MDT (Dapsone + Rifampicin monthly)
  • Multibacillary (MB): >5 lesions, smear positive → 12 months MDT (Rifampicin + Clofazimine monthly + Dapsone + Clofazimine daily)
• Lepromin test: Not diagnostic, measures immune response
• National Leprosy Eradication Programme (NLEP): Goal = elimination (<1 case/10,000 population); India declared elimination 2005 at national level

Filariasis

• Agent: Wuchereria bancrofti (90%), Brugia malayi, B. timori
• Vector: Culex quinquefasciatus (W. bancrofti)
• Transmission: Mosquito bite
• Microfilariae: Nocturnal periodicity (except in Pacific Islands - non-periodic)
• Diagnosis: Thick blood smear (10 PM to 2 AM), ICT card test, ELISA
• Clinical: Lymphadenitis, lymphangitis (retrograde), hydrocele, elephantiasis
• Treatment: DEC (Diethylcarbamazine) - drug of choice; Ivermectin; Albendazole
• National Programme for Elimination of Lymphatic Filariasis (NPELF): Annual mass drug administration (MDA) - DEC + Albendazole in 2-drug regimen; triple drug (IDA) = Ivermectin + DEC + Albendazole

Plague

• Agent: Yersinia pestis
• Reservoir: Rodents (rats)
• Vector: Rat flea (Xenopsylla cheopis)
• Types: Bubonic (most common), Septicemic, Pneumonic (most dangerous, person-to-person)
• Features: Buboes (swollen lymph nodes), high fever, "Black death"
• Treatment: Streptomycin (drug of choice), Doxycycline, Ciprofloxacin
• Prophylaxis: Doxycycline
• Rat-flea index: >1 indicates risk of plague epidemic

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UNIT 4: NON-COMMUNICABLE DISEASES (NCDs)

4.1 Overview

• Health promotion and education
• Legislation and fiscal policies
• Population strategy vs High-risk strategy (Rose's concept)

4.2 Cardiovascular Disease

• Modifiable: Hypertension, hyperlipidemia, smoking, diabetes, obesity, physical inactivity
• Non-modifiable: Age, sex (male), family history

4.3 Diabetes Mellitus

• FPG ≥126 mg/dL
• 2hr OGTT ≥200 mg/dL
• HbA1c ≥6.5%
• Random plasma glucose ≥200 + symptoms

4.4 Cancer Epidemiology

• Males: Oral cavity, lung, esophagus, stomach, colorectal
• Females: Cervical, breast, oral cavity, ovary, esophagus

• Most common gynecological cancer in India
• Cause: HPV (Human papillomavirus) - types 16, 18
• Screening: Pap smear (annually starting at 21 yrs or 3 yrs post-sexual activity), VIA (Visual Inspection with Acetic Acid) in low-resource settings
• Prevention: HPV vaccine (9-14 yrs females - 2 doses; >15 yrs - 3 doses)

• BRCA1, BRCA2 genes
• Screening: Self-examination, clinical breast exam, mammography (annually from 40 yrs)

4.5 Mental Health

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UNIT 5: NUTRITION AND HEALTH

5.1 Nutritional Assessment Methods (ABCD)

• A - Anthropometric: Weight, height, BMI, MUAC, skin-fold thickness
• B - Biochemical: Hemoglobin, serum albumin, ferritin, vitamin levels
• C - Clinical: Signs and symptoms of deficiency
• D - Dietary: Dietary recall, food frequency, dietary history

5.2 BMI (Body Mass Index)

5.3 Protein-Energy Malnutrition (PEM)

• Severe calorie deficiency
• "Old man's face", skin-and-bones, baggy-pants appearance
• Muscle wasting + fat loss
• No edema
• Alert child, always hungry

• Severe protein deficiency (with adequate calories)
• Edema (hallmark), moon face, hair changes (flag sign, reddish discoloration)
• Flaky paint skin dermatosis
• Fatty liver, anorexia, irritable child

• Grade I: 75-90% expected weight
• Grade II: 60-75%
• Grade III: <60%

5.4 Micronutrient Deficiencies

Iron Deficiency Anemia (IDA)

• Most common nutritional deficiency worldwide
• Stages: Depleted stores → Iron-deficient erythropoiesis → Iron deficiency anemia
• Lab: Low Hb, low serum iron, high TIBC, low ferritin (earliest indicator), microcytic hypochromic anemia
• Treatment: Ferrous sulfate
• Prevention: Iron-folic acid supplementation (IFA) under WIFS/ANEMIA MUKT BHARAT programme

• Adults (men): <13 g/dL
• Adults (women): <12 g/dL
• Pregnant women: <11 g/dL
• Children 6-59 months: <11 g/dL
• Children 5-11 years: <11.5 g/dL

Vitamin A Deficiency (VAD)

• Bitot's spots (conjunctival, most characteristic), night blindness (earliest symptom), xerophthalmia, keratomalacia (causes blindness)
• Bitot's spots = triangular, pearly-white, foamy spots on temporal conjunctiva
• Treatment & Prevention: Vitamin A supplementation
  • Children 6-11 months: 1 lakh IU
  • Children 12-59 months: 2 lakh IU every 6 months
• NPCB (National Programme for Control of Blindness) includes VAD control

Iodine Deficiency Disorders (IDD)

• Goitre (commonest manifestation), cretinism (hypothyroidism in neonate)
• Cretinism: Most severe consequence - irreversible mental retardation
• Prevention: Iodization of salt (15-30 ppm at production, >15 ppm at consumer level)
• National Iodine Deficiency Disorders Control Programme (NIDDCP)
• Excretion of iodine in urine <100 μg/L = deficiency; <20 μg/L = severe

Vitamin D Deficiency

• Rickets (children), Osteomalacia (adults)
• Symptoms: Bowing of legs, craniotabes, Harrison's sulcus, rachitic rosary
• Diagnosis: Low serum 25-OH Vitamin D (<20 ng/mL = deficiency; <12 = severe)
• Treatment: Vitamin D supplementation

Vitamin C Deficiency - Scurvy

• Perifollicular hemorrhages (earliest), gum bleeding (spongy gums), corkscrew hairs, "Woody leg" (bleeding into periosteum)
• Diagnosis: Plasma ascorbic acid levels

Pellagra (Niacin/Vitamin B3 deficiency) - 4 Ds

• Dermatitis, Diarrhea, Dementia, Death
• Casal's necklace (dermatitis around neck)
• Associated with corn/maize diet (niacin poorly bioavailable)

Thiamine (Vitamin B1) deficiency - Beriberi

• Wet beriberi: Cardiac failure, edema
• Dry beriberi: Peripheral neuropathy
• Wernicke-Korsakoff syndrome (alcoholics)

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UNIT 6: ENVIRONMENTAL HEALTH

6.1 Water and Health

1. Water-borne: Ingestion of contaminated water (typhoid, cholera, hepatitis A)
2. Water-washed (water-scarce): Insufficient water for hygiene (trachoma, scabies, dysentery)
3. Water-based: Aquatic intermediate host (schistosomiasis, guinea worm)
4. Water-related insect vector: Breeding in or near water (malaria, filaria, dengue, yellow fever)

• WHO guideline: 0 coliforms / 100 mL
• Most Probable Number (MPN) test / Multiple Tube Test: Presumptive + Confirmatory + Completed test
• Membrane filtration test: Faster, counts coliform colonies directly

• Chlorine demand = Amount of chlorine that reacts with impurities
• Residual chlorine = Free chlorine remaining after demand is satisfied
• Recommended residual chlorine: 0.2-0.5 mg/L
• Break-point chlorination: Adding chlorine until residual free chlorine appears
• Chlorine demand = Chlorine applied - Residual chlorine

• Temporary hardness: Bicarbonates (removed by boiling)
• Permanent hardness: Sulfates and chlorides (removed by ion exchange, lime-soda process)

• Optimal fluoride: 0.5-0.8 mg/L (prevents dental caries)

• 1.5 mg/L: Dental fluorosis

• 3-6 mg/L: Skeletal fluorosis

• Endemic fluorosis belt: Rajasthan, Andhra Pradesh, Telangana (India)

6.2 Air Pollution

• Respiratory: COPD, asthma, lung cancer (PM2.5, SO2, NO2)
• Cardiovascular: IHD, stroke
• Neurological effects (lead, mercury)

• Silicosis: Silicon dioxide dust; coal miners, stone cutters; eggshell calcification on X-ray
• Asbestosis: Asbestos fibers; shipbuilding, insulation; associated with mesothelioma and lung cancer; "Ferruginous (asbestos) bodies"
• Coal workers' pneumoconiosis (CWP): Coal dust; "Black lung"
• Byssinosis: Cotton dust; textile workers; Monday morning fever
• Bagassosis: Bagasse (sugarcane residue) dust; farmers
• Farmer's lung: Thermophilic actinomycetes in hay; hypersensitivity pneumonitis

6.3 Solid Waste Management

• Yellow: Anatomical waste, soiled items (incinerated)
• Red: Recyclable contaminated plastic (autoclaved, shredded)
• White/Translucent: Sharps (puncture-proof container, autoclaved)
• Blue: Glassware, metallic implants (autoclaved)

• Sanitary landfill (most common)
• Composting
• Incineration
• Vermicomposting

6.4 Housing and Health

• Floor space per person: <4.65 m² = overcrowded
• Air space per adult: minimum 14 m³ (old standard), now >8 m³

6.5 Noise Pollution

• Unit: Decibel (dB)
• Normal conversation: 60 dB; Threshold of pain: 120 dB
• Occupational safe limit (NIOSH): 85 dB for 8 hours
• Causes: Noise-induced hearing loss (NIHL), cardiovascular effects, psychological effects

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UNIT 7: DEMOGRAPHY AND FAMILY PLANNING

7.1 Demographic Concepts

• Crude Birth Rate (CBR): ~19.5 per 1000
• Crude Death Rate (CDR): ~6.2 per 1000
• IMR: ~35 per 1000 live births
• Total Fertility Rate (TFR): ~2.2 (replacement level = 2.1)
• Natural Growth Rate = CBR - CDR

• Crude Birth Rate (CBR) = Live births / Mid-year population × 1000
• General Fertility Rate (GFR) = Live births / Women 15-49 years × 1000 (better measure)
• Total Fertility Rate (TFR) = Sum of age-specific fertility rates × 5 (number of children per woman)
• Net Reproduction Rate (NRR) = TFR × proportion female births × survival probability; NRR = 1 means replacement-level fertility
• Gross Reproduction Rate (GRR) = TFR × proportion female births

7.2 Demographic Transition Theory

1. Stage I (High stationary): High birth rate + High death rate = Stable but low population (pre-industrial)
2. Stage II (Early expanding): High birth rate + Falling death rate = Rapid population growth (developing countries)
3. Stage III (Late expanding): Falling birth rate + Low death rate = Slow growth
4. Stage IV (Low stationary): Low birth rate + Low death rate = Stable population (developed countries)

7.3 Family Planning Methods

• Spacing methods: Condoms (male/female), OCPs (oral contraceptive pills), IUDs, injectable contraceptives, diaphragm, cervical cap
• Natural: Rhythm method (calendar), BBT, Billing's method (cervical mucus), LAM (Lactational Amenorrhea Method)

• Male: Vasectomy (NSV = No Scalpel Vasectomy)
• Female: Tubectomy (Laparoscopic sterilization = minilaparotomy)

• Levonorgestrel 1.5 mg (within 72 hours; more effective if taken sooner)
• Cu-IUD (within 5 days; most effective)

• Combined OCP: Estrogen + Progestin; inhibit ovulation (main mechanism)
• Mini-pill: Progestin only (suitable for breastfeeding mothers)
• Mechanism: Inhibit LH surge → no ovulation; alter cervical mucus; alter endometrium

• Cu-T 380A (10 years), LNG-IUS Mirena (5 years)
• MOA: Spermicidal (copper), foreign body reaction, prevents implantation
• Mission Parivar Vikas: Government initiative for family planning in high-fertility districts

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UNIT 8: MATERNAL AND CHILD HEALTH (MCH)

8.1 Antenatal Care (ANC)

• Blood: Hb, blood group + Rh, blood sugar, VDRL/RPR, HIV testing
• Urine: Albumin, sugar
• USG: Dating, anomaly scan (18-20 weeks), growth scan (28-32 weeks)

• 2 doses: TT1 (early pregnancy), TT2 (4 weeks after TT1)
• Protects against neonatal tetanus
• If previously immunized (within 3 years): Td booster 1 dose

• Pregnant women: 1 tablet/day (100mg elemental iron + 500 mcg folic acid) throughout pregnancy
• Folic acid supplementation before conception and in first trimester: Prevents neural tube defects

• Vaginal bleeding, Severe headache, Visual disturbances, Convulsions, Fever, Severe abdominal pain, Reduced fetal movements

8.2 Postnatal/Postpartum Care

• Warmth (kangaroo mother care, dry and wrap)
• Breastfeeding within 1 hour of birth
• Cord care (clean, dry)
• Eye care
• Resuscitation if needed

8.3 Immunization

• VVM (Vaccine Vial Monitor): Heat-sensitive label on vaccine; checks whether vaccine has been heat-exposed
• Vaccines must NOT be frozen: DPT, Hepatitis B, TT, IPV, Pentavalent, PCV, RVV
• BCG, MR, OPV: Can be frozen (freeze-dried)

• Mission Indradhanush: 90% full immunization coverage
• Intensified Mission Indradhanush (IMI) 3.0

• Active immunity: Body produces own antibodies (vaccination, natural infection); slower onset, longer duration
• Passive immunity: Ready-made antibodies transferred (maternal IgG, immunoglobulin injection); immediate onset, short duration

• Herd immunity threshold varies: Measles ~95%, Polio ~80-85%

8.4 Child Health Programs

• Launched: 1975
• Services (SINNHE): Supplementary Nutrition, Immunization, Non-formal education (pre-school), Nutrition and health education, Health check-up, referral services
• Beneficiaries: Children under 6 years, pregnant women, lactating mothers
• Anganwadi Centre (AWC): Delivery unit; run by Anganwadi Worker (AWW)
• Anganwadi worker: a trained female community worker (ECCE/ICDS)

• Medical inspection of school children
• Treatment of minor ailments
• Health education
• Maintenance of school environment

• Adolescent health programme (10-19 years)
• 6 components: Nutrition, Reproductive/sexual health, Substance misuse, NCDs, Mental health, Violence/injuries

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UNIT 9: NATIONAL HEALTH PROGRAMMES

9.1 National Health Mission (NHM)

• ASHA (Accredited Social Health Activist): 1 per 1000 rural population; female community health worker; incentive-based
• Sub-centre: 1 per 3000-5000 rural population; staffed by ANM + Male Health Worker
• PHC (Primary Health Centre): 1 per 20,000-30,000 population; 4-6 beds; staffed by Medical Officer
• CHC (Community Health Centre): 1 per 80,000-1,20,000; 30 beds; 4 specialists (obs/gyn, surgery, medicine, pediatrics) = IPHS (Indian Public Health Standards)

• Conditional cash transfer for institutional delivery
• LPS (Low Performing States): Higher incentive - Rural: ₹1400, Urban: ₹1000
• HPS (High Performing States): Rural: ₹700, Urban: ₹600

9.2 Revised National TB Control Programme (RNTCP) / NTEP

• NTEP (National Tuberculosis Elimination Programme): New name since 2020
• End TB Strategy: Targets 90% reduction in deaths and 80% reduction in incidence by 2030 (WHO)
• India's ambitious target: Eliminate TB by 2025
• DOTS: Directly Observed Treatment, Short course - community treatment supporter gives drug under observation
• Nikshay Portal: Mandatory notification of TB cases
• Ni-kshay Poshan Yojana: ₹500/month nutritional support to TB patients

9.3 National Vector Borne Disease Control Programme (NVBDCP)

• Agent: Leishmania donovani
• Vector: Phlebotomus argentipes (sandfly)
• Target: Elimination (< 1 case per 10,000 population at sub-district level)
• Treatment: Liposomal Amphotericin B (first-line), Miltefosine

• Agent: JE virus
• Vector: Culex tritaeniorhynchus (mosquito)
• Reservoir: Pigs, water birds
• JE vaccine under UIP: SA 14-14-2 live attenuated vaccine

9.4 National Programmes for NCDs

• Screening at Health and Wellness Centres (HWC)
• Oral cancer screening (VIA, FNAC), Breast (CBE, mammography), Cervical (Pap smear, VIA)

• District Mental Health Programme (DMHP) as operational arm
• Integration into primary healthcare

• Geriatric care at district hospitals, medical colleges

• Monitor water fluoride, promote safe water

9.5 Blindness & Eye Health

• Target: Reduce blindness prevalence to 0.3% by 2020 (currently ~1%)

1. Cataract (most common, ~62%)
2. Refractive errors
3. Glaucoma
4. Corneal blindness
5. Retinal diseases (diabetic retinopathy, AMD)

9.6 Other Important Programmes

• ORT (Oral Rehydration Therapy) promotion
• Low osmolarity ORS (WHO standard)
• Zinc supplementation (10-14 days with ORS in children with diarrhea)

• Albendazole 400 mg for children 1-19 years, twice yearly

• Health insurance ₹5 lakh per family per year
• Bottom 40% of families (SECC database)

• Upgraded sub-centres + PHCs
• Comprehensive Primary Health Care (CPHC)
• 12 service packages including NCD screening, mental health, dental

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UNIT 10: HEALTH MANAGEMENT AND PLANNING

10.1 Health Planning

• Planning: A predetermined course of action to achieve specific objectives
• PDCA Cycle (Deming): Plan → Do → Check → Act

10.2 Health Systems

• Primary: PHC, sub-centre, AWC - preventive, promotive, basic curative
• Secondary: District hospital, CHC - referral, surgical
• Tertiary: Medical colleges, AIIMS - super-specialty, research

10.3 Hospital Administration

• Standard: 80-85%

• Standard: 30-35 per year

• Should be decreasing trend

10.4 Health Education and Communication

• Individual: Counseling, interview, home visit
• Group: Lectures, discussions, demonstrations, role play
• Mass: Mass media (radio, TV, newspapers, social media)

10.5 Health Economics

• India spends ~1.2-1.5% of GDP on public health (target: 2.5% by 2025, as per NHP 2017)

• DALY (Disability-Adjusted Life Year): Years of healthy life lost = YLD + YLL
  • YLL = Years of life lost due to premature death
  • YLD = Years of life lived with disability
• QALY (Quality-Adjusted Life Year): Used in cost-effectiveness analysis
• HALE (Health-Adjusted Life Expectancy): Life expectancy adjusted for time in poor health

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UNIT 11: OCCUPATIONAL HEALTH

11.1 Definitions

11.2 Occupational Hazards

• Heat: Heat cramps, heat exhaustion, heat stroke
• Noise: NIHL (Noise-Induced Hearing Loss) - 85 dB for 8 hrs (NIOSH TLV)
• Vibration: Raynaud's phenomenon (hand-arm vibration syndrome)
• Radiation: Ionizing (x-rays, gamma) vs Non-ionizing (UV, IR, microwave)

• Lead poisoning: Battery workers, painters; blue line on gums (Burton's line), anemia, wrist drop (peripheral neuropathy), Basophilic stippling; Treatment: EDTA chelation, DMSA
• Mercury poisoning: Mad hatter's disease; tremors, gingivitis, erethism (personality changes)
• Arsenic poisoning: Keratosis, hyperpigmentation, Mees' lines (white lines on nails), Raindrop pigmentation
• Benzene: Aplastic anemia, leukemia (C6H6)
• Carbon monoxide: Combines with Hb (200x affinity of O2); Cherry red color; Treatment: 100% O2

• Anthrax (wool sorters' disease - Bacillus anthracis)
• Brucellosis (veterinarians, abattoir workers)
• Farmer's lung (thermophilic actinomycetes)

11.3 Pneumoconioses

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UNIT 12: GENETICS AND HEALTH

12.1 Genetic Epidemiology

• Single gene (Mendelian): Autosomal dominant (Huntington's, Marfan's), Autosomal recessive (PKU, sickle cell, CF), X-linked recessive (hemophilia, Duchenne MD)
• Chromosomal: Down syndrome (trisomy 21), Turner's (45,XO), Klinefelter's (47,XXY)
• Multifactorial: Hypertension, diabetes, congenital heart disease

12.2 Genetic Screening and Counseling

• Amniocentesis (15-18 weeks)
• Chorionic villus sampling (CVS) (10-13 weeks) - earlier but higher risk
• Fetal DNA in maternal blood (non-invasive prenatal testing, NIPT) - safest

• PKU (phenylketonuria), congenital hypothyroidism, sickle cell disease, G6PD deficiency

12.3 Down Syndrome (Trisomy 21)

• Most common chromosomal disorder
• Risk increases with maternal age
• Features: Intellectual disability, flat face, epicanthal folds, single palmar crease (simian crease), brushfield spots, hypotonia, cardiac defects (AVSD most common), duodenal atresia

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RAPID REVISION: HIGH-YIELD EXAM POINTS

Key Numbers to Remember

Important Committees and Their Contributions

Must-Know Definitions for Theory

1. Epidemic: Unusual increase in frequency of a disease above the expected (endemic) level in a given community/area
2. Endemic: Habitual presence of disease in a given area/population group
3. Pandemic: Worldwide epidemic affecting large numbers across countries/continents
4. Outbreak: More restricted epidemic affecting a small, localized group
5. Sporadic: Disease occurring irregularly, in isolated cases
6. Cluster: Aggregation of cases in a limited area/time
7. Herd immunity: Resistance of a group to invasion of an agent, due to immunity of high proportion of members
8. Carrier: Infected person/animal who harbors specific infectious agents without visible disease but capable of transmitting the agent

Important Vaccines - Types

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EXAM WRITING TIPS

• Start with definition
• Classification (if applicable)
• Epidemiology (distribution: person, place, time)
• Causation / Agent-Host-Environment
• Clinical features
• Diagnosis
• Treatment
• Prevention and control (focus: community-level)
• National programme (if applicable)

• Definition
• Key features (3-4 points)
• Control measures
• Diagram/flow chart if relevant

1. Malaria (epidemiology, control, national programme)
2. Tuberculosis (RNTCP/NTEP, DOTS)
3. Epidemiological study designs (case-control vs cohort)
4. Screening tests (sensitivity, specificity, predictive values)
5. Primary health care / Alma Ata Declaration
6. National Health Mission / ASHA programme
7. Family planning methods
8. Immunization schedule
9. PEM (marasmus vs kwashiorkor)
10. Water-borne diseases and purification
11. Maternal mortality and its causes
12. Demographic transition theory

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Source: Park's Textbook of Preventive and Social Medicine (available in the medical library)