Q.2 Case Based Scenario - Answers (Any 2 out of 3)

Question 1: Rabies - WHO Animal Bite Exposure Categories & Intradermal PEP Schedule

a) WHO Categories of Animal Bite Exposure (3 marks)

b) Intradermal (ID) Rabies Vaccination Schedule - PEP Protocol (3 marks)

Intradermal PEP Schedule (for unvaccinated individuals):

• Day 0: 0.1 mL ID at 2 sites (both deltoids)
• Day 3: 0.1 mL ID at 2 sites
• Day 7: 0.1 mL ID at 2 sites
• Day 28: 0.1 mL ID at 2 sites (single booster)

• Rabies Immunoglobulin (RIG):
  • Human RIG (HRIG): 20 IU/kg body weight
  • Equine RIG (ERIG): 40 IU/kg body weight
  • Maximum dose infiltrated into and around the wound; remainder given IM at a site distant from vaccine

1. Wash wound thoroughly with soap and water for at least 15 minutes
2. Apply antiseptic (povidone iodine or 70% alcohol)
3. Do NOT suture the wound immediately (delay if possible)

Question 2: HIV in Pregnancy - PMTCT & NACP Role

a) Public Health Measures to Prevent Mother-to-Child Transmission (MTCT) of HIV (3 marks)

• Universal HIV testing and counseling at first ANC visit (opt-out approach)
• Early initiation of Antiretroviral Therapy (ART) - the mother should receive TDF + 3TC + DTG (or EFV-based regimen) lifelong regardless of CD4 count (Option B+)
• Adherence counseling and psychosocial support
• Regular CD4 count and viral load monitoring

• Avoid unnecessary episiotomies, prolonged labour, and invasive fetal monitoring
• Elective Caesarean section if viral load is >1000 copies/mL at 34-36 weeks
• Intrapartum IV Zidovudine if viral load unknown

• Infant prophylaxis: Nevirapine syrup daily for 6 weeks (or 12 weeks if high risk) after birth
• Breastfeeding counseling: WHO recommends exclusive breastfeeding for 6 months WITH continued maternal ART (which reduces transmission risk to <1%)
• Avoidance of mixed feeding (increases transmission risk)
• DNA PCR test for the infant at 6 weeks of age (early infant diagnosis)
• Repeat HIV testing of infant at 18 months

b) Role of National AIDS Control Programme (NACP) in Management (3 marks)

• Free, confidential HIV testing at all ICTC (Integrated Counselling and Testing Centres) and PPTCT centres
• Integration with routine ANC services in all government health facilities
• Provision of free ART to the mother at ART centres lifelong
• Free infant NVP prophylaxis and early infant diagnosis (EID) services

• ICTC/FICTC (Facility ICTC) at district hospitals: pre/post-test counseling, HIV testing
• ART Centres (one per district): provide free first-line ART drugs
• Link ART Centres (LAC): closer to patients for ART collection
• OST centres and Drop-in centres (DIC) for key populations

• HIV sentinel surveillance tracks prevalence trends in ANC attendees
• Vital for monitoring MTCT rates and programme effectiveness

• Training of health workers in counseling and ART management
• Training of ANMs and nurses on PPTCT protocol

• Ensures uninterrupted supply of ARV drugs, reagents, and test kits

• NACP supports implementation of the HIV & AIDS (Prevention and Control) Act, 2017 which protects the rights of HIV-positive persons including confidentiality and non-discrimination

Question 3: Leprosy - Diagnosis and National Programme Management

Diagnosis (2 marks)

• WHO classifies leprosy based on number of skin lesions:
  • Paucibacillary (PB): 1-5 skin patches
  • Multibacillary (MB): >5 skin patches
• This patient has MORE than 5 patches, so it is Multibacillary Leprosy

1. Hypo-pigmented or erythematous skin patch(es) with definite loss of sensation
2. Thickened/enlarged peripheral nerve with sensory loss ± motor deficit
3. Positive slit-skin smear for AFB (Ziehl-Neelsen stain)

Management as per National Leprosy Eradication Programme (NLEP) (4 marks)

MDT Regimen for Multibacillary (MB) Leprosy - Duration: 12 months

Additional Management Steps under NLEP:

1. Registration: Patient registered under NLEP at PHC/CHC; MDT blister pack provided free of cost
2. Disability Assessment: Grade disability (Grade 0, 1, 2) at baseline
3. Prevention of Disability (POD):
   • Self-care instructions (soaking feet, oiling to prevent cracks)
   • Protective footwear for insensitive feet
   • Eye care (dark glasses, artificial tears if lagophthalmos)
4. Lepra Reactions Management:
   • Type 1 (Reversal reaction): Prednisolone 40-60 mg/day tapered over months
   • Type 2 (ENL - Erythema Nodosum Leprosum): Thalidomide (in males) or Prednisolone; Clofazimine increased
5. Contact Examination: All household contacts examined once a year
6. Counseling and Stigma Reduction: Community education, anti-stigma campaigns
7. Rehabilitation: Physiotherapy, reconstructive surgery (RCS) for deformities at referral centres
8. Release from Treatment (RFT): After completion of 12 doses

• MDT is provided free of charge in blister packs through health system
• Fixed Duration Treatment (FDT): No smear required before stopping treatment
• Single Lesion PB Leprosy: Single dose ROM (Rifampicin 600 mg + Ofloxacin 400 mg + Minocycline 100 mg)

Q.2 Case Based Scenario - Answers (Any 2 out of 3)

Question 1: 19-Year-Old with Fever, Tonsillitis, and Erythematous Rash

• Fever (38.5°C) + sore throat + inflamed tonsils with whitish exudates = GABHS pharyngitis/tonsillitis
• Fine erythematous rash on trunk and extremities = Scarlatinal rash from streptococcal erythrogenic exotoxin
• This is the classic picture of Scarlet Fever

a) Community-Based Management Measures (3 marks)

• First-line: Benzathine Penicillin G - single IM injection
  • Adults: 12 lakh units (1.2 million units) IM single dose
• Oral alternative: Phenoxymethylpenicillin (Penicillin V) 500 mg twice daily x 10 days (must complete full course)
• Penicillin allergy: Azithromycin 500 mg on Day 1, then 250 mg x 4 days OR Erythromycin 500 mg QID x 10 days
• Cephalosporins (cephalexin) are acceptable second-line alternatives
• Treatment reduces symptom duration, prevents complications, and renders the patient non-infectious within 24 hours of starting antibiotics

• Adequate rest, hydration, analgesics (paracetamol/ibuprofen) for fever and sore throat
• Warm saline gargles for throat comfort
• Soft diet as tolerated

• Isolate the patient at home for at least 24 hours after starting antibiotics
• Avoid school/college attendance until 24 hours after antibiotic initiation and fever-free
• Household contacts should be examined; close contacts (especially children) with sore throat should be screened and treated

• Watch for suppurative complications: peritonsillar abscess, otitis media, sinusitis, mastoiditis
• Watch for non-suppurative complications: Acute Rheumatic Fever (ARF) (2-4 weeks post-infection) and Post-streptococcal glomerulonephritis (1-3 weeks post-infection)
• Urine examination at follow-up to detect early nephritis

• Rapid Antigen Detection Test (RADT) or throat swab culture (5% sheep blood agar) confirms GABHS
• Throat culture is the gold standard (sensitivity ~96%)

b) Preventive Strategies for Scarlet Fever / Streptococcal Infections (3 marks)

1. Personal Hygiene:
   • Frequent handwashing with soap and water
   • Covering mouth and nose while coughing/sneezing (respiratory etiquette)
   • Avoid sharing utensils, cups, or personal items
   • Avoid close contact with infected individuals
2. Environmental Measures:
   • Adequate ventilation in classrooms, hostels, and crowded spaces
   • Avoidance of overcrowding
   • Disinfection of contaminated surfaces
3. Health Education:
   • Community awareness about early recognition of sore throat + fever + rash
   • Prompt medical consultation to prevent complications
   • Emphasis on completing the full 10-day antibiotic course
4. Chemoprophylaxis (Secondary Prevention - prevention of Acute Rheumatic Fever recurrence):
   • Benzathine Penicillin G 12 lakh units IM every 3-4 weeks for patients with history of ARF
   • Duration depends on cardiac involvement:
     • No carditis: 5 years or until age 21 (whichever is longer)
     • With carditis (no residual disease): 10 years or until age 21
     • With carditis + residual valvular disease: lifelong prophylaxis
   • This is a critical component of National Rheumatic Fever / Rheumatic Heart Disease Control Programme in India
5. Surveillance:
   • Notification of clusters of cases in schools or communities
   • School health programmes with regular throat inspection
   • Monitoring for rheumatic fever cases in endemic areas

Question 2: Food-Borne Outbreak After Wedding Feast

• Multiple persons affected after a common event (wedding feast)
• Symptoms: sudden nausea, vomiting, abdominal pain, diarrhoea
• Onset within 6 hours of eating - suggests short incubation period (pre-formed toxin) - likely Staphylococcus aureus or Bacillus cereus (emetic type)
• This is a Point Source Epidemic / Common Vehicle Outbreak

Steps of Outbreak Investigation (6 marks)

• Verify that the number of cases exceeds what is normally expected (baseline) for that area and time
• Confirm diagnoses clinically and/or by laboratory tests
• Rule out "pseudo-outbreaks" (laboratory artefact, misclassification)

• Clinical case definition: formulate a working case definition (e.g., "any person who attended the wedding feast on [date] and developed nausea, vomiting, abdominal pain and/or diarrhoea within 24 hours")
• Collect clinical specimens from affected persons:
  • Stool samples (for culture, microscopy)
  • Vomitus samples
  • Blood cultures (if systemic illness)
• Send to laboratory for microbiological and toxicological analysis

• Identify all cases using the case definition (active case finding)
• Collect information on: name, age, sex, address, symptoms, time of onset, foods consumed, attendance at the feast
• Draw the epidemic curve (cases vs. time) - a point source curve with rapid rise and fall confirms a common source
• Calculate the attack rate overall and by food item consumed

• Person: Who is affected? Age, sex, occupation; are certain groups more affected?
• Place: Did all cases attend the same wedding? Any geographic clustering?
• Time: When did symptoms begin? What was the incubation period? (6-hour incubation here points to pre-formed toxin - Staph. aureus, B. cereus emetic)
• Identify the index case and spot map if applicable

• Based on descriptive data, hypothesize the probable:
  • Source of infection (contaminated food item - e.g., cream-based dishes, rice, meat)
  • Vehicle of transmission (specific food consumed at feast)
  • Agent responsible (based on incubation period and symptoms)
  • Risk factors (food preparation practices, storage, handlers with skin infections)
• Incubation period clue:
  • < 6 hours: S. aureus toxin, B. cereus (emetic)
  • 6-24 hours: Clostridium perfringens, B. cereus (diarrhoeal)
  • 24-72 hours: Salmonella, Shigella, E. coli

• Conduct a cohort study (since all attendees are known): compare attack rates in those who ate specific food items vs. those who did not
• Calculate Relative Risk (RR) and attack rate for each food item
• The food with the highest attack rate in those who consumed it = suspected vehicle
• Conduct a case-control study if the total number of people at risk is unknown

• Inspect the kitchen, food preparation area, and storage conditions
• Collect food samples (leftover food, if available) for laboratory testing
• Interview food handlers: check for skin infections (boils/pustules), recent illness, hygiene practices, food handling certificates
• Check: refrigeration temperatures, cooking temperatures, time food was left at room temperature, water source

• Immediate:
  • Treat affected patients (oral rehydration, hospitalize severe cases)
  • Remove the suspected food from circulation; destroy contaminated food
  • Close or decontaminate the suspected food preparation area if needed
• Specific:
  • Treatment of food handlers who are carriers
  • Exclude ill food handlers from work until recovered
• General:
  • Safe food handling education to community and catering staff
  • Maintain food at safe temperatures (hot food >60°C, cold food <5°C)

• Report the outbreak to local health authorities (Chief Medical Officer, District Surveillance Unit)
• Submit an Outbreak Investigation Report including: nature, source, vehicle, agent, control measures taken
• Integrated Disease Surveillance Programme (IDSP) reporting under "S" (syndromic) and "P" (presumptive) forms
• Outbreak to be reported under the P-form of IDSP

• Monitor for new cases after control measures are implemented
• Ensure no secondary cases in the community
• Document lessons learned and recommend long-term preventive strategies (food safety training, hygiene standards for catering)

Question 3: 30-Year-Old Male with >5 Hypo-pigmented Patches - Leprosy

• Treatment is provided free of charge in blister packs through PHC/CHC
• Duration: 12 monthly doses (within 18 months)
• Disability assessment, prevention of disability (POD), contact tracing, and management of lepra reactions (Type 1: steroids; Type 2/ENL: thalidomide or steroids) are integral parts of NLEP management

Q.2 Case Based Scenario - Answers

Case (a): Riya, 12-year-old girl - Fever, Headache, Petechial Rash, Positive Tourniquet Test

1. Probable Diagnosis, Causative Agent and Mode of Transmission (2+2+2)

• High-grade fever (39.5°C) for 4 days
• Severe headache + retro-orbital pain (pathognomonic of dengue)
• Body ache, vomiting
• Petechial rashes on upper limbs
• Positive tourniquet test (Rumpel-Leede test) - indicates capillary fragility and thrombocytopenia
• Seasonal occurrence after heavy rainfall (stagnant water = mosquito breeding)
• Cluster of similar cases in locality - epidemiological evidence

• Dengue virus - an RNA virus of the genus Flavivirus, family Flaviviridae
• Four serologically distinct serotypes: DENV-1, DENV-2, DENV-3, DENV-4
• Infection with one serotype provides lifelong immunity to that serotype only
• Secondary infection with a different serotype increases risk of DHF (antibody-dependent enhancement)

• Vector-borne transmission by the bite of an infected female Aedes aegypti mosquito (primary vector)
• Secondary vector: Aedes albopictus
• The mosquito bites during daytime (peak activity: early morning and late afternoon)
• The mosquito acquires the virus by feeding on a viraemic (infected) human
• Extrinsic incubation period in mosquito: 8-10 days
• Intrinsic incubation period in humans: 3-14 days (typically 4-7 days)
• NOT transmitted person-to-person (no direct human-to-human spread)

2. Management Plan for Dengue Fever (3 marks)

• Adequate oral hydration (ORS, coconut water, juices)
• Paracetamol for fever and pain (do NOT use aspirin or NSAIDs - risk of bleeding)
• Rest
• Monitoring for warning signs

• Abdominal pain/tenderness
• Persistent vomiting
• Clinical fluid accumulation (ascites, pleural effusion)
• Mucosal bleeding
• Lethargy, restlessness
• Liver enlargement >2 cm
• Rapid fall in platelet count or rising haematocrit

1. IV Fluid Therapy:
   • Isotonic crystalloids (Normal Saline or Ringer's Lactate) for volume replacement
   • Rate adjusted based on haematocrit and clinical status
   • Avoid excessive fluids (risk of pulmonary oedema)
2. Monitoring:
   • FBC (Full Blood Count) every 12-24 hours: platelet count and haematocrit
   • Vital signs every 1-4 hours
   • Urine output monitoring
3. Platelet Transfusion:
   • Only if platelet count <10,000/µL with active bleeding
   • NOT recommended prophylactically
4. Dengue Shock Syndrome (DSS):
   • Rapid fluid resuscitation with crystalloids (10-20 mL/kg bolus)
   • Colloids if no response
   • ICU management if refractory
5. Laboratory Investigations:
   • NS1 antigen test (positive in first 5 days)
   • IgM/IgG ELISA (after Day 5)
   • CBC, haematocrit, liver function tests, coagulation profile
6. Avoid:
   • Aspirin, ibuprofen, diclofenac (increase bleeding risk)
   • Steroids (not recommended)
   • Antibiotics (unless secondary bacterial infection suspected)

3. Community-Based Preventive and Control Measures for Dengue (3 marks)

• Drain all stagnant water collections around homes (flower pots, tyres, coolers, buckets, drums)
• Cover water storage containers tightly
• Change water in flower vases/pet bowls weekly
• Proper solid waste disposal - remove old tyres, cans, containers
• Fill tree holes and roof gutters with sand or concrete

• Introduce Gambusia fish (larvivorous fish) in ornamental water bodies and ponds
• Use of Bacillus thuringiensis israelensis (Bti) - biological larvicide
• Release of Sterile Insect Technique (SIT) and Wolbachia-infected mosquitoes (newer strategies)

• Larviciding: Temephos (Abate) added to water containers that cannot be emptied
• Adulticiding (fogging/spraying): Malathion or pyrethroid-based insecticides during outbreaks
• Space spraying (cold fog/thermal fog) in affected localities

• Use of mosquito repellents (DEET-based) on exposed skin
• Wear full-sleeved clothing, especially during peak mosquito hours
• Use bed nets (insecticide-treated nets - ITNs) during daytime rest
• Install window and door screens

• IEC (Information, Education, Communication) campaigns on dengue prevention
• "Dry Day" observance - weekly checking and emptying of water containers
• Involvement of Asha workers, Anganwadi workers in community surveillance
• Schools and RWAs to conduct awareness drives

• Mandatory reporting of dengue cases under IDSP (P-form)
• Rapid Response Team (RRT) activation during outbreaks
• Entomological surveillance: House Index, Container Index, Breteau Index
• Early case detection through fever surveillance (ILI surveillance)

• Dengvaxia (CYD-TDV): WHO recommends only for seropositive individuals aged 9-45 years in high-endemic areas (India has not introduced routine dengue vaccination yet)

Case (b): Severe Acute Malnutrition (SAM) in a 2-year-old Child

1. Criteria for Identification of SAM (3 marks)

• Visible severe wasting (prominent ribs, "old man face", skin hanging loosely)
• Baggy pants appearance (loss of gluteal fat)
• Apathy, irritability
• Hair changes (depigmentation, flag sign in kwashiorkor)

• Green (≥12.5 cm): Normal
• Yellow (11.5-12.4 cm): Moderate Acute Malnutrition (MAM)
• Red (<11.5 cm): SAM

2. Management of a 2-Year-Old SAM Child (3 marks)

• Give 10% dextrose (50 mL) orally or NG tube if blood glucose <54 mg/dL
• Feed every 2-3 hours, day and night

• Keep child warm, skin-to-skin contact (Kangaroo care)
• Room temperature >25°C
• Avoid wet clothing/nappies

• Use ReSoMal (Rehydration Solution for Malnutrition) - NOT standard ORS (lower sodium, higher potassium and glucose)
• 5 mL/kg every 30 minutes x 2 hours orally/NG
• IV fluids only if shock: Ringer's Lactate 15 mL/kg over 1 hour (cautiously)

• Supplement: Potassium (3-4 mmol/kg/day), Magnesium (0.4-0.6 mmol/kg/day), Zinc, Copper
• Do NOT give high sodium (avoid Na-rich IV fluids)

• All SAM children receive antibiotics regardless of apparent infection
• Amoxicillin 40 mg/kg/day x 7 days (first-line)
• If severely ill: IV/IM Ampicillin + Gentamicin

• Vitamin A (Day 1): 200,000 IU (if no oedema); 50% of age-appropriate dose if oedema present
• Folic acid 5 mg on Day 1, then 1 mg daily
• Zinc 2 mg/kg/day
• Multivitamin supplement

• F-75 therapeutic milk (75 kcal/100 mL, 0.9 g protein/100 mL)
• 100 mL/kg/day in 8-12 feeds
• Given by NG tube if anorexic/weak

• Transition to F-100 therapeutic milk (100 kcal/100 mL, 2.9 g protein/100 mL)
• Increase to 150-220 mL/kg/day
• RUTF (Ready-to-Use Therapeutic Food - Plumpy'Nut) - 92 g/day for children 6-24 months (provided under POSHAN Abhiyaan/NRC in India)

• Structured play and stimulation (30 min twice daily)
• Affection and interaction from caregivers
• Age-appropriate toys and activities

• Nutrition counseling for mother/caregiver
• Home-based feeding plan
• Regular growth monitoring at AWC (Anganwadi Centre)
• Immunization catch-up

• MUAC ≥12.5 cm or WHZ ≥-2 SD
• No oedema for 2 weeks
• Good appetite and eating well
• No acute medical illness

Case (c): 28-Year-Old Nurse - Needle-Stick Injury

1. Important Blood-Borne Infections Transmitted through Needle-Stick Injury (2 marks)

• Hepatitis D (only in HBV-infected individuals)
• Malaria (Plasmodium spp.)
• Syphilis (Treponema pallidum)
• Cytomegalovirus (CMV)
• Epstein-Barr Virus (EBV)
• HTLV-1 and HTLV-2
• Ebola and other viral haemorrhagic fevers (in endemic settings)

2. Management and Post-Exposure Prophylaxis (PEP) (4 marks)

1. Do NOT squeeze or suck the wound
2. Immediately wash the puncture site with soap and water for 10-15 minutes
3. Allow wound to bleed freely under running water
4. Apply antiseptic (povidone iodine or 70% alcohol)
5. For mucous membrane exposure (eye/mouth): flush with large amounts of water or saline

• Report immediately to the Infection Control Officer / Occupational Health Department
• Document: nature of injury, depth, device involved, source patient details, time of injury
• Assess source patient: HIV status, HBsAg, HCV antibody (with consent)
• Assess the exposed healthcare worker: baseline HIV, HBsAg, HCV Ab, LFT

For HIV:

• Initiate PEP within 72 hours of exposure (the sooner, the better - ideally within 2 hours)
• Preferred PEP Regimen (CDC 2025 / NACO Guidelines):
  • Tenofovir (TDF) 300 mg once daily + Emtricitabine (FTC) 200 mg once daily + Dolutegravir 50 mg once daily
  • Alternative: TDF + 3TC + Raltegravir 400 mg BD
• Duration: 28 days (4-week course)
• PEP is NOT indicated if source patient is confirmed HIV-negative
• Follow-up HIV testing at: 6 weeks, 3 months, 6 months post-exposure

For Hepatitis B:

• Check exposed worker's vaccination and immune status:

• HBIG (Hepatitis B Immunoglobulin): 0.06 mL/kg IM - administer within 24 hours (ideally within 12 hours)

For Hepatitis C:

• No PEP available for HCV
• Baseline anti-HCV test of exposed worker
• Follow-up: anti-HCV and HCV RNA at 4-6 weeks and 4-6 months
• If seroconversion occurs, refer for early treatment with Direct-Acting Antivirals (DAAs)

• Psychological support and counseling
• Advise precautions during follow-up period (avoid blood donation, unprotected sex)
• Document and maintain occupational health records
• Review PEP adherence and side effects at Day 3, Week 2, and Week 4
• Incident report and root cause analysis to prevent future needle-stick injuries

• Always recap needles using the one-handed scoop method or use needle safety devices
• Use puncture-resistant sharps containers
• Never overfill sharps bins
• Double gloving in high-risk procedures
• Training in safe injection practices

Q.2 Case Based Scenario - Answers (Any 2 out of 3)

Case 1: 2-year-old child with Oedema, Moon Face, Sparse Hair, Irritability

A. Likely Diagnosis (2 marks)

B. Causes and Prevention of Kwashiorkor (4+2 marks)

Causes:

• Inadequate protein intake - weaning on a starchy, low-protein diet (e.g., maize gruel, rice water) after breastfeeding stops
• Sudden weaning due to a new pregnancy (the word "Kwashiorkor" in Ga language means "the disease of the deposed child" - second child gets mother's attention while first is weaned abruptly onto poor diet)
• Monotonous diet low in essential amino acids
• Abrupt cessation of breastfeeding without adequate replacement feeds

• Recurrent infections - gastroenteritis, measles, respiratory infections (increased catabolism, anorexia, reduced absorption)
• Poverty and food insecurity - inability to afford protein-rich foods (meat, eggs, pulses, milk)
• Lack of nutritional knowledge - cultural food taboos (withholding eggs, meat, fish from children)
• Large family size with inadequate food distribution
• Poor sanitation - repeated gut infections cause malabsorption and anorexia

• Low maternal education
• Low socioeconomic status
• Lack of access to healthcare and nutritional services
• Inadequate antenatal and postnatal care

Prevention:

• Promote exclusive breastfeeding for the first 6 months of life
• Timely introduction of complementary foods at 6 months while continuing breastfeeding up to 2 years and beyond
• Complementary feeding should include protein-rich foods: dal, egg, meat, fish, milk in every meal
• Dietary diversification - include all food groups in child's diet

• Educate mothers/caregivers on age-appropriate feeding practices
• Dispel food myths and taboos regarding protein foods for children
• Growth monitoring and promotion at Anganwadi Centres (AWC) - monthly weighing and plotting on growth chart
• IYCF (Infant and Young Child Feeding) counselling by ASHA/ANM

• POSHAN Abhiyaan (PM's Overarching Scheme for Holistic Nourishment): National nutrition mission targeting reduction of stunting, wasting, anaemia and low birth weight
• ICDS (Integrated Child Development Services): Supplementary nutrition, growth monitoring, health check-ups, referral for SAM children through AWCs
• NRC (Nutrition Rehabilitation Centres): Free in-patient treatment of SAM children
• RUTF distribution through health system
• MAA Programme (Mothers' Absolute Affection): Promotion of breastfeeding

• Immunization as per UIP (Universal Immunisation Programme) - especially measles vaccination (measles is a major precipitant)
• Safe water, sanitation and hygiene (WASH)
• ORS for diarrhoea management to prevent nutritional deterioration
• Deworming with Albendazole (National Deworming Day - twice yearly)

• Poverty alleviation programmes (PDS - Public Distribution System)
• Women empowerment and education
• Conditional cash transfers (Janani Suraksha Yojana, PM Matru Vandana Yojana)

Case 2: 18-month-old with Diarrhoea, Lethargy, Very Sunken Eyes, Unable to Drink

A. IMNCI Classification (2 marks)

B. Immediate Management (Severe Dehydration - Plan C) (3 marks)

• Reassess after first 30 mL/kg (after 30 minutes)
• If still showing severe dehydration signs - repeat 30 mL/kg bolus
• Once improving (able to drink) - switch to ORS

• Zinc 20 mg/day x 14 days (for children >6 months)
• Reduces duration and severity of diarrhoea and prevents recurrence for 2-3 months

• Continue breastfeeding throughout
• Resume age-appropriate feeding as soon as child can eat/drink
• Do NOT restrict diet - "feed through diarrhoea"

• Urine output (target ≥1 mL/kg/hr)
• Vital signs, level of consciousness
• Stool frequency and character
• Reassess dehydration status every hour initially

• Antibiotics only if: bloody diarrhoea (dysentery) → Ciprofloxacin or Azithromycin; or cholera suspected → Doxycycline/Azithromycin
• Routine antibiotics are NOT recommended for watery diarrhoea
• Antiparasitic treatment if Giardia or Entamoeba suspected (Metronidazole)
• No antidiarrhoeals (loperamide contraindicated in children)

• This child needs urgent referral to hospital with IV access maintained during transport

C. Use of ORS to Manage Diarrhoea at Home (Plan A) (2 marks)

• Child has diarrhoea with no signs of dehydration
• Or after rehydration is complete and child is well

• Sodium: 75 mmol/L
• Chloride: 65 mmol/L
• Glucose: 75 mmol/L
• Potassium: 20 mmol/L
• Citrate: 10 mmol/L
• Total osmolarity: 245 mOsm/L (hypotonic - reduces vomiting and stool output compared to old standard ORS)

• 1 litre of clean/boiled water + 6 level teaspoons of sugar + ½ teaspoon of salt

• For children <2 years: give 50-100 mL of ORS after each loose stool
• For children 2-10 years: give 100-200 mL after each loose stool
• Give sips slowly from a cup/spoon (NOT bottle)
• If child vomits, wait 10 minutes then resume more slowly (1 teaspoon every 2-3 minutes)
• Continue until diarrhoea stops

• 20 mg zinc/day for 14 days (>6 months); 10 mg/day (<6 months)
• Reduces severity, duration of episode and prevents future episodes

• Do NOT stop food
• Continue breastfeeding on demand
• Offer extra feeds after illness passes (catch-up feeding)
• Avoid fruit juices, sugary drinks, or carbonated drinks (worsen diarrhoea)

• Child cannot drink or is drinking poorly
• Child becomes more sick / lethargic
• Develops fever
• Blood in stool
• No improvement after 3 days

• Wash hands with soap before preparing food and after defecation
• Use safe drinking water (boiled/treated)
• Proper disposal of child's faeces
• Store ORS in cool, clean place; discard prepared solution after 24 hours

Case 3: Sudden Rise of Vomiting & Diarrhoea After Common Marriage Function (PHC Medical Officer)

• Receive the report - verify through phone calls, field visit, local health workers
• Confirm that cases exceed expected baseline (epidemic threshold)
• Establish a preliminary case definition: "Any person who attended the marriage function on [date] and developed vomiting/diarrhoea/abdominal pain within 24 hours"
• Do rapid head count of affected persons and estimate severity

• Set up treatment camp in the village or use PHC OPD
• Triage patients: mild (ORS at home), moderate (PHC observation), severe (hospitalise)
• Administer ORS to all patients with diarrhoea
• IV fluids (Ringer's Lactate or Normal Saline) for severely dehydrated
• Inform District Hospital to be on alert for referrals
• Notify CHC/District Medical Officer and CMHO immediately

• Report under IDSP (Integrated Disease Surveillance Programme):
  • Fill S-form (syndromic - same day): cluster of vomiting/diarrhoea cases
  • Fill P-form (presumptive - next day): suspected food poisoning
  • Fill L-form (lab-confirmed): after lab results
• Activate Rapid Response Team (RRT) from district level
• Inform District Surveillance Unit (DSU)
• Inform local Food Safety Officer (FSSAI)

• Interview all cases (and non-cases who attended) using a structured questionnaire:
  • Name, age, sex, address
  • Symptoms and time of onset
  • List of food items consumed at the function
  • Attendance at function (yes/no)
• Construct an epidemic curve - plot cases by time of onset
  • A sharply peaked curve indicates point source (common vehicle) exposure
  • Estimate incubation period range
• Incubation period clues:
  • <6 hours: Staphylococcus aureus toxin or Bacillus cereus (emetic)
  • 6-24 hours: Clostridium perfringens, B. cereus (diarrhoeal)
  • 8-22 hours: Vibrio cholerae
  • 24-72 hours: Salmonella, E. coli

• Conduct a cohort study (all attendees are a defined cohort):
  • Prepare a food-specific attack rate table
  • For each food item: calculate attack rate in those who ate it vs. those who did not
  • Calculate Relative Risk (RR) for each food item
  • The food with highest RR and statistically significant result = suspected vehicle
• If the total exposed population is unknown → case-control study

• Visit the venue of the marriage function
• Inspect kitchen, food preparation area, water source, storage conditions
• Interview food handlers: recent illness, skin infections (boils/pustules), hygiene practices
• Check: cooking temperatures, time food was left unrefrigerated, storage containers
• Collect samples for laboratory testing:
  • Stool/vomitus from cases
  • Leftover food samples (if available and stored)
  • Water samples
  • Rectal swabs from food handlers
  • Anal swabs/blood culture (if typhoid suspected)

• Send samples to District Public Health Laboratory
• Tests requested:
  • Stool culture and sensitivity (for bacterial pathogens)
  • Stool microscopy (for ova, cysts, parasites)
  • Food culture (for S. aureus, Salmonella, C. perfringens, B. cereus)
  • Water testing (coliform count, E. coli)

• Stop the source: Discard remaining contaminated food from the function
• Treatment: Continue ORS distribution; set up oral rehydration corners
• Food handler management: Exclude symptomatic food handlers from work; treat infections
• Environmental sanitation: Disinfect cooking area, water source if contaminated
• Safe water supply: Provide chlorinated water; supervise chlorination of village water source
• Health education: Talk to village community about food hygiene, safe water, handwashing

• Prepare a detailed Outbreak Investigation Report including:
  • Background and case definition
  • Epidemic curve
  • Attack rates by food item
  • Probable causative agent and vehicle
  • Control measures taken
  • Recommendations to prevent future outbreaks
• Submit to CMHO, IDSP State Unit, and District Collectorate

• Monitor for new cases daily for 2 incubation periods after last case
• Ensure all cases are recovering
• Confirm no secondary cases in the community
• Conduct hygiene training for local food handlers and caterers
• Recommend food safety regulations for future community functions (caterer licensing, food handler medical fitness certificate)

Q.2 Case Based Scenario - Answers (Any 2 out of 3)

Case 1: 2-year-old child - Swelling of feet, Irritability, Sparse Depigmented Hair, Skin Changes; Early weaning + Inadequate Complementary Feeding

A. Most Probable Diagnosis (1 mark)

B. Three Tier System Services for Malnutrition/Kwashiorkor (3 marks)

• Growth Monitoring and Promotion (GMP): Monthly weighing of children <5 years; plotting on growth chart; early identification of underweight/SAM/MAM
• Supplementary Nutrition Programme (SNP): Hot cooked meals + THR (Take Home Ration) for children 6 months - 6 years
• Nutrition and Health Education (NHE): Counselling of mothers on breastfeeding, complementary feeding, hygiene
• IYCF (Infant and Young Child Feeding) counselling by AWW and ASHA
• Referral of SAM children to NRC/health facility
• Deworming (Albendazole) twice yearly under National Deworming Day
• Vitamin A supplementation (every 6 months from 9 months to 5 years)
• Iron and Folic Acid supplementation (WIFS programme)
• POSHAN Abhiyaan activities: community mobilisation, nutrition awareness campaigns

• OPD assessment of malnourished children: anthropometric measurements (weight, height, MUAC), clinical examination
• Identification and classification of SAM (MUAC <11.5 cm, WHZ <-3SD, bilateral oedema)
• Management of MAM (Moderate Acute Malnutrition): take-home RUTF (Ready-to-Use Supplementary Food), dietary counselling
• NRC (Nutrition Rehabilitation Centre) - attached to CHC/FRU:
  • 14-day in-patient management of uncomplicated SAM
  • Therapeutic feeding: F-75 → F-100 → RUTF
  • Medical management (infections, micronutrient deficiencies)
  • Mother counselling for home feeding
  • Follow-up after discharge
• Immunisation catch-up
• ASHA/ANM home visits for follow-up of discharged SAM children

• Management of complicated SAM with medical complications:
  • Severe infection, hypoglycaemia, hypothermia, severe anaemia, oedema
  • Requires IV antibiotics, IV fluids, blood transfusion, ICU care
• Paediatric ward with dedicated malnutrition beds
• Specialist consultations: Paediatrician, Dietitian, Microbiologist
• Laboratory support: Blood glucose, electrolytes, culture and sensitivity, serum albumin
• WHO 10-step SAM management protocol in severe/complicated cases
• Nutrition Rehabilitation Ward (NRW) for prolonged in-patient care
• Referral back to CHC/NRC for rehabilitation after stabilization

C. Services Available at Community Level (2 marks)

1. Growth Monitoring and Promotion (GMP) - monthly weight monitoring, growth chart plotting, early detection
2. Supplementary Nutrition - hot cooked meals and THR (Take Home Ration) through ICDS
3. IYCF Counselling - breastfeeding promotion, complementary feeding guidance by AWW/ASHA
4. Vitamin A Supplementation - mega dose every 6 months (9 months to 5 years)
5. Iron and Folic Acid (IFA) supplementation - weekly IFA under WIFS
6. National Deworming Day - Albendazole 400 mg twice yearly (1-5 years)
7. Referral to NRC/PHC for SAM children identified at AWC
8. POSHAN Abhiyaan community activities - Jan Andolan, nutrition rallies, home visits
9. ASHA home visits - monitoring growth, feeding practices, follow-up after NRC discharge
10. Pradhan Mantri Matru Vandana Yojana (PMMVY) - cash incentive for pregnant/lactating mothers to improve nutrition

Case 2: 10-week-old infant coming for vaccination

A. Vaccines Due at 10 Weeks as per Current National Immunization Schedule (2 marks)

• Low-grade fever for 1-2 days is normal and expected
• Give paracetamol (15 mg/kg) if fever causes distress
• No need to stop or delay next vaccination
• Return if high fever (>39°C), inconsolable crying >3 hours, or convulsions occur

B. Universal Immunization Programme (UIP) and Mission Indradhanush (2 marks)

Universal Immunization Programme (UIP):

• Launched: 1985 (expanded from EPI - Expanded Programme on Immunization launched 1978)
• Objective: To provide free vaccines to all children and pregnant women across India
• Target: 100% immunization coverage for all children under 2 years and pregnant women
• Vaccines under UIP (currently): BCG, OPV, Hepatitis B, Pentavalent (DPT+HepB+Hib), PCV, Rotavirus, IPV, Measles-Rubella, JE (in endemic districts), DPT booster, OPV booster, TT/Td for pregnant women, MR-2nd dose, Td boosters
• UIP is the largest public health programme in the world in terms of number of vaccines and population covered
• Services delivered at sub-centre, PHC, CHC, AWC, hospitals and through outreach sessions
• Cold chain maintained from national to last mile (ANM level)

Mission Indradhanush:

• Launched: December 2014 by Union Health Ministry (GoI)
• Aim: To immunize all unvaccinated and partially vaccinated children (0-2 years) and pregnant women who have been left out or dropped out of the routine immunization programme
• Named after the 7 colours of the rainbow, representing 7 vaccines initially targeted (BCG, DPT, OPV, Measles, Hep B, TT, JE)
• Target areas: Districts with low immunization coverage, urban slums, remote areas, migrant populations, difficult terrains
• Works through intensive immunization drives (4-7 days per month for 4 consecutive months per round)
• Intensified Mission Indradhanush (IMI): Launched 2017 onwards with even stronger focus; IMI 5.0 (2023) continues
• Goal: Achieve and sustain ≥90% full immunization coverage at district and block level

C. Completely and Fully Immunized Child (2 marks)

• BCG (1 dose)
• OPV (3 doses: OPV 1, 2, 3)
• DPT (3 doses: DPT 1, 2, 3) - now as Pentavalent
• Measles (1 dose at 9-12 months)
• Hepatitis B (3 doses)

• All primary doses (BCG, OPV 0-3, Pentavalent 1-3, RVV 1-3, IPV 1-2, PCV 1-2, Hep B birth dose)
• Booster doses: DPT booster, OPV booster, Measles-Rubella 2nd dose (given at 16-24 months)
• PCV booster (at 9-12 months)
• Vitamin A 1st dose (at 9-12 months)

• Mild fever after Pentavalent/DPT is expected and reassure the mother - it is normal
• It reflects the child's immune system responding to the vaccine
• No need to withhold future vaccines for mild AEFI

Case 3: Medical Officer at PHC - 28 residents with Fever, Abdominal Pain, Headache, Diarrhoea over 10 days; 3 households sharing common hand pump; Heavy rainfall + flooding one week before

A. Definition and Principles of Primary Health Care (3 marks)

Definition of Primary Health Care:

Principles of Primary Health Care (Alma-Ata, 1978):

• Health services should reach all people regardless of social class, gender, religion, or geography
• Special attention to underserved, marginalized, and vulnerable populations

• Community members must be actively involved in planning, implementing, and evaluating health services
• People are not just passive recipients of care; they are partners

• Health is influenced by agriculture, education, water supply, housing, sanitation, economic development
• PHC requires coordinated action across multiple sectors, not health alone

• Use of methods, procedures, and technology that are scientifically valid, adaptable to local needs, and affordable
• Avoid over-medicalization; promote simple, effective, low-cost solutions

• Emphasis on preventing disease and promoting health rather than only treating illness
• Health education, immunization, sanitation, nutrition as core activities

1. Health education on prevailing health problems
2. Adequate food supply and proper nutrition
3. Safe water supply 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

B. Management of the Outbreak as Medical Officer (3 marks)

• Symptoms: fever + abdominal pain + headache + diarrhoea (10 days) - points to typhoid (prolonged)
• Cluster in 3 households sharing a common hand pump = common water source
• Heavy rainfall + flooding one week before = contamination of groundwater/hand pump with faecal matter
• 2 patients hospitalised (severe disease)

1. Treat all cases:
   • Set up treatment camp at PHC or in the village
   • ORS for all cases with diarrhoea/dehydration
   • For suspected typhoid: start Azithromycin (first-line, oral) or Ceftriaxone IV for hospitalised cases
   • Hospitalise severe cases: refer to District Hospital
   • Maintain vital signs monitoring, IV fluids as needed
2. SEAL THE WATER SOURCE:
   • Immediately shut down the suspected hand pump to prevent further exposure
   • Collect water samples from the hand pump for bacteriological testing
   • Provide safe alternate water supply (water tanker, chlorinated water distribution)
   • Advise all residents to boil drinking water until further notice
3. Notify:
   • Report to CMHO/District Medical Officer and District Surveillance Unit (IDSP)
   • Fill S-form (syndromic surveillance) same day
   • Activate Rapid Response Team (RRT) from district

1. Active Case Finding:
   • House-to-house survey in affected area
   • Case definition: "Any person in the village with fever + abdominal pain/diarrhoea for >3 days after [date of flooding]"
   • Identify all cases, prepare line listing (name, age, sex, onset date, symptoms, water source used)
2. Descriptive Epidemiology:
   • Plot epidemic curve (if prolonged curve = propagated/continuous source; if point peak = common source)
   • Person-Place-Time analysis
   • Calculate attack rates by household and water source used
3. Laboratory Investigation:
   • Blood culture (gold standard for typhoid - positive in 1st week)
   • Widal test (after 1st week) - though less specific
   • Stool culture and microscopy
   • Water sample testing: coliform count, E. coli, Vibrio culture
   • Rectal swabs from cases

1. Disinfect the water source:
   • Super-chlorinate the hand pump: pour concentrated bleach/chlorine solution into the well/borehole
   • Wait 12-24 hours, then flush
   • Re-test water before resuming use
   • Inspect for structural damage (casing cracks, drainage contamination from flooding)
2. Sanitation measures:
   • Identify open defecation areas around the hand pump
   • Ensure proper disposal of human waste
   • Clear flood water and debris around water source
   • Lime/bleaching powder application in affected area
3. Health Education:
   • Village-level meeting: educate on boiling water, hand hygiene, safe food handling
   • Distribution of ORS packets
   • Involve Gram Panchayat, ASHA, AWW for community mobilisation

1. Monitor daily for new cases for at least 3 weeks (incubation period of typhoid: 7-21 days)
2. Typhoid carriers: screen food handlers; treat carriers with Ciprofloxacin/Azithromycin for 4 weeks
3. Submit full Outbreak Investigation Report to District and State level
4. Long-term recommendations:
   • Permanent protected water source (piped water supply)
   • Improved sanitation (toilet construction - Swachh Bharat Abhiyaan)
   • Typhoid vaccination for high-risk groups (Vi-capsular polysaccharide vaccine or Typhoid Conjugate Vaccine)
   • Ensure regular bacteriological surveillance of drinking water sources