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QUESTION PAPER 2 - COMPLETE ANSWERS

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LONG ESSAYS

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Q1. Perinatal Mortality Rate - Justification, Factors, and Prevention (2+4+4 = 10 marks)

Part A: Justify that PMR has assumed greater significance as a yardstick of MCH care (2 marks)

1. With declining infant mortality rates, especially in developed countries, PMR has become the more sensitive indicator of the quality of maternal and child health care.
2. PMR reflects the quality and quantity of obstetric and perinatal care before and around the time of birth - more directly than infant or neonatal mortality rate.
3. It combines stillbirths and early neonatal deaths because the causative factors are the same - operating before and around birth. This avoids misclassification errors where some live births followed by quick death are recorded as stillbirths.
4. Though the perinatal period is less than 0.5% (<168 hours) of average lifespan, it accounts for more deaths than the next 30-40 years of life in developing countries.
5. PMR reflects pregnancy wastage and helps measure maternal care outcomes more clearly than neonatal death rate alone.

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Part B: Social and Biological Factors Associated with Perinatal Mortality (4 marks)

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Part C: Preventive and Social Measures to Reduce Perinatal Deaths (4 marks)

• Early registration of pregnancy and regular antenatal check-ups (minimum 4 ANC visits under PMSMA)
• Screening and management of high-risk pregnancies (anaemia, hypertension, diabetes, previous obstetric complications)
• Nutritional supplementation - Iron-folic acid tablets, Calcium, Vitamin D
• Tetanus toxoid immunization
• Treatment of infections (malaria, UTI, STIs)
• Detection and management of Rh incompatibility

• Institutional delivery (under Janani Suraksha Yojana)
• Skilled birth attendance at every delivery
• Proper management of prolonged and obstructed labour
• Emergency obstetric care facilities
• Prevention of birth asphyxia and birth trauma

• Immediate newborn care - resuscitation, warmth, breastfeeding within 1 hour
• Kangaroo Mother Care (KMC) for low birth weight babies
• Management of sepsis, respiratory distress
• Neonatal screening programs

• Raising female literacy and education
• Improving socioeconomic status and nutrition of women
• Spacing of pregnancies (family planning services)
• Improving housing, sanitation, and environmental conditions
• Strengthening referral services and ASHA network

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Q2. Primigravida with Hb 10 g/dL at 2 months amenorrhea - Anaemia in Pregnancy (1+2+7 = 10 marks)

Part A: Nutritional Deficiency (1 mark)

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Part B: Management of This Specific Case (2 marks)

1. Oral Iron Therapy: Elemental iron 100-200 mg/day in divided doses (as ferrous sulphate 200 mg TDS). Continue throughout pregnancy and for 3 months postpartum.
2. Folic Acid: 5 mg/day (higher dose given anaemia is already present).
3. Dietary counseling: Encourage iron-rich foods (green leafy vegetables, jaggery, meat, pulses). Avoid tea/coffee with meals (inhibit iron absorption). Promote Vitamin C-rich foods with meals.
4. Follow-up: Re-check Hb after 4-6 weeks of treatment to assess response.
5. Treat underlying causes: Deworm with Albendazole 400 mg single dose after first trimester (hook worm infestation causes iron loss).
6. Malaria prophylaxis if in endemic area.

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Part C: Six Interventions under National Health Programme for Prevention and Management of Iron Deficiency Anaemia (7 marks)

1. Children 6-59 months
2. Children 5-9 years
3. Adolescents 10-19 years
4. Women of reproductive age (WRA) 20-49 years
5. Pregnant women
6. Lactating mothers

1. Prophylactic Iron-Folic Acid (IFA) Supplementation:

• Infants 6-59 months: Iron drops (25 mg elemental iron/ml) - 1 ml/day for 6 months then on/off
• Children 5-9 yrs: IFA small tablets (45 mg + 400 mcg folic acid) weekly
• Adolescents 10-19 yrs: IFA large tablets (100 mg + 500 mcg folic acid) weekly (WIFS programme)
• Pregnant women: IFA tablets (180 tablets over 6 months) - 100 mg elemental iron + 500 mcg folic acid
• Lactating mothers: IFA supplementation for 6 months postpartum

1. Deworming Programme (National Deworming Day):

• Biannual deworming with Albendazole 400 mg for children 1-19 years
• Removes hookworm (major cause of iron-loss anaemia), given on fixed dates (February 10 and August 10)

1. Intensified year-round IFA Supplementation in High-burden Districts:

• Focus on districts with anaemia prevalence >40%
• Supervisory support, monitoring, supply chain strengthening

1. Mandatory Provision of IFA + Calcium Supplementation in Anganwadis and Schools:

• Integration with ICDS and mid-day meal programme
• Anganwadi workers and ASHA deliver supplementation

1. Dietary Diversification and Nutrition Education:

• Promoting consumption of iron-rich foods
• Promotion of animal-source foods, pulses, green leafy vegetables
• Education on enhancers (Vitamin C) and inhibitors (tea, phytates) of iron absorption
• Cooking in iron vessels

1. Address Non-Nutritional Causes of Anaemia (Treatment of Infections):

• Malaria prevention and control (in endemic areas) - ITNs, ACT treatment
• Management of haemoglobinopathies (sickle cell disease, thalassaemia) - screening
• Treatment of chronic infections contributing to anaemia of chronic disease
• Fluorosis management in endemic areas

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SHORT ESSAYS (5 marks each)

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Q3. Biological Hazards to Raju (Radiology Technician) and Preventive Measures

Biological Hazards:

• Carcinogenesis: Increased risk of leukemia (most common), thyroid cancer, lung cancer, skin cancer
• Cataracts: Radiation-induced lens opacification
• Bone marrow depression: Pancytopenia, aplastic anaemia with chronic low-dose exposure
• Radiation dermatitis: Chronic skin changes - erythema, thickening, ulceration
• Radiation sickness (acute): Nausea, vomiting, hair loss (with high accidental doses)
• Accelerated aging: Shortening of life expectancy
• Infertility/gonadal damage: Suppression of spermatogenesis

• Mutations in germ cells leading to hereditary effects in offspring
• Chromosomal aberrations

• Chemical hazards: developer and fixer solutions (formalin, hydroquinone) - dermatitis, chemical pneumonitis
• Ergonomic hazards: prolonged standing

Preventive Measures:

• Distance: Maintain maximum distance from radiation source (inverse square law)
• Shielding: Lead aprons, lead gloves, lead thyroid shields; lead-lined walls of X-ray rooms
• Duration: Minimize exposure time

• Lead aprons (0.25-0.5 mm Pb equivalent) mandatory during fluoroscopy
• Thyroid shields, lead goggles
• Dosimetry badges (TLD - Thermoluminescent Dosimeters) worn at all times for monitoring

• Radiation dose limits: 20 mSv/year averaged over 5 years (ICRP) for occupational workers
• Regular medical surveillance - CBC, ophthalmologic examination
• Rotation of workers to limit cumulative dose
• Training and awareness on radiation safety (ALARA principle - As Low As Reasonably Achievable)
• Proper labeling, warning signs, restricted access zones
• Annual health check-up including CBC

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Q4. Newer Initiatives under National Tuberculosis Elimination Programme (NTEP)

Key Newer Initiatives:

1. Nikshay Poshan Yojana (NPY): Direct Benefit Transfer of Rs. 500/month to all TB patients for nutritional support during treatment.
2. Nikshay Mitra: Voluntary support initiative where donors (individuals, NGOs, corporates) adopt TB patients/villages/facilities for food, nutrition kits, diagnostic support, and vocational help.
3. Universal Drug Susceptibility Testing (UDST): All TB patients get drug sensitivity testing (Cartridge-Based NAAT/CBNAAT/TrueNat) before treatment initiation to detect drug-resistant TB early.
4. Shorter Regimen for DR-TB (BPaL/BPaLM): Bedaquiline-Pretomanid-Linezolid (+/- Moxifloxacin) regimen - 6-9 month regimen replacing older 18-24 month regimens for MDR/XDR-TB.
5. TrueNat Machine Rollout: Point-of-care molecular testing for TB and Rifampicin resistance at district and subdistrict level - decentralizes diagnosis to PHC level.
6. Active Case Finding (ACF): House-to-house surveys in high-risk communities (slums, tribal areas, prisons, migrant workers, PLHIV) to detect missed TB cases.
7. Pradhan Mantri TB Mukt Bharat Abhiyaan: Launched 2022 by the President - community engagement and multi-stakeholder approach to eliminate TB by 2025 (5 years ahead of global SDG target of 2030).
8. TB Preventive Therapy (TPT): Systematic screening of household contacts (especially children <5 years and PLHIV) with Isoniazid Preventive Therapy (6H) or 3HP regimen.
9. Digital tools: 99DOTS (medication adherence via missed calls), NIKSHAY portal for patient tracking, AI-based CXR reading tools.
10. Airborne Infection Control (AIC): Infection control measures in health facilities - natural ventilation, UV lights, N95 masks.

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Q5. Sources of Health Information - List and Explain One

Various Sources of Health Information:

1. Vital Statistics - birth, death, marriage, divorce registrations
2. Census - population size, age-sex distribution, literacy
3. Disease Notification/Surveillance Systems - IDSP (Integrated Disease Surveillance Programme)
4. Hospital Records - morbidity, case fatality rates
5. Epidemiological studies - surveys, cohort, case-control
6. Health Surveys - NFHS (National Family Health Survey), DLHS
7. Disease Registries - cancer, TB registries
8. Vital Event Registration - Civil Registration System (CRS)
9. Health Management Information System (HMIS) - routine reporting
10. International sources - WHO, UNICEF, World Bank publications

Explanation: NFHS (National Family Health Survey)

• A large-scale, nationally representative household survey conducted in India under the Ministry of Health & Family Welfare; International Institute for Population Sciences (IIPS) is the nodal agency.
• Provides data on: fertility, infant and child mortality, maternal and child health, nutrition, family planning, HIV/AIDS awareness, domestic violence.
• Conducted periodically: NFHS-1 (1992-93), NFHS-2 (1998-99), NFHS-3 (2005-06), NFHS-4 (2015-16), NFHS-5 (2019-21).
• NFHS-5 covered all 28 states, 8 UTs, and 707 districts, providing district-level estimates for the first time.
• Uses: Program planning, policy formulation, monitoring SDG health indicators, tracking IMR, MMR, immunization coverage, anaemia prevalence.

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Q6. Levels of Prevention with Modes of Intervention and Examples

Level 1: Primordial Prevention

• Definition: Prevention of the emergence of risk factors themselves
• Mode: Social and economic policies, lifestyle changes, health promotion
• Example: Policies to reduce tobacco advertising; healthy city planning to encourage physical activity; reducing air pollution to prevent emergence of risk factors for cardiovascular disease

Level 2: Primary Prevention

• Definition: Preventing the occurrence of disease in a susceptible (healthy) person
• Modes of Intervention:
  • Health Promotion: Nutrition education, health education, regular exercise
  • Specific Protection: Immunization (polio vaccine), use of condoms (HIV), fluoridation of water (dental caries), use of helmets (road traffic accidents), chemoprophylaxis (malaria prophylaxis with chloroquine)
• Example: Immunization against measles, BCG for TB, use of insecticide-treated bed nets for malaria

Level 3: Secondary Prevention

• Definition: Early detection and prompt treatment to halt disease progression
• Modes of Intervention:
  • Early diagnosis: Screening tests (Pap smear for cervical cancer, blood pressure measurement, blood sugar screening)
  • Prompt treatment: Treatment of detected cases to prevent complications
  • Disability limitation: Treatment before irreversible damage occurs
• Example: Pap smear screening for cervical cancer; sputum microscopy for TB diagnosis and starting DOTS; blood pressure measurement in community camps

Level 4: Tertiary Prevention

• Definition: Rehabilitation of a person who has already been disabled by disease
• Modes of Intervention:
  • Rehabilitation: Physical, social, psychological, vocational rehabilitation
  • Disability limitation: Preventing further disability
• Example: Physiotherapy after stroke to restore function; prosthetics for amputees; vocational training for leprosy-cured patients with deformities

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Q7. Monitoring and Surveillance - Definitions with Suitable Examples

Monitoring:

• Definition: The continuous and periodic measurement of the progress of a programme toward its objectives and the performance of activities toward their targets.
• It is an internal management tool used by program managers.
• Focus: Are activities being carried out as planned? Are targets being met?
• Example: Monthly monitoring of immunization coverage (% children vaccinated) under the Universal Immunization Programme (UIP); checking cold chain maintenance; monitoring IFA tablet distribution rates under AMB programme.

Surveillance:

• Definition (CDC/WHO): The ongoing, systematic collection, analysis, interpretation, and dissemination of health data essential for planning, implementation, and evaluation of public health action.
• It is an intelligence system - it watches over the population's health to detect trends, outbreaks, and changes in disease patterns.
• Focus: What is happening in the community with respect to disease/risk factors?

• Passive surveillance: Routine reporting by health facilities (IDSP weekly reporting)
• Active surveillance: Active case-finding, e.g., AFP surveillance for polio (surveillance officers visit hospitals weekly)
• Sentinel surveillance: Selected sentinel sites reporting - e.g., HIV Sentinel Surveillance at ANC clinics

• IDSP (Integrated Disease Surveillance Programme) monitors disease trends across India - weekly S (syndromic), P (presumptive), and L (laboratory-confirmed) data from all districts
• Polio surveillance: AFP (Acute Flaccid Paralysis) surveillance - every child <15 years with AFP is investigated and two stool samples sent to WHO-accredited labs. India was certified polio-free in 2014 partly due to robust AFP surveillance

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Q8. Artificial Intelligence (AI) in Public Health

Definition:

Importance and Applications in Public Health:

1. Disease Surveillance and Outbreak Detection:

• AI algorithms analyze social media, news reports, and search trends to detect outbreaks early
• Example: HealthMap, BlueDot (detected COVID-19 signals before official WHO announcement)
• IDSP data analytics using machine learning for outbreak prediction

1. Diagnosis and Screening:

• AI-based X-ray reading (CAD4TB, qXR) for TB and pneumonia screening - deployed at PHC level in India
• AI-powered retinal imaging for diabetic retinopathy screening
• AI for Pap smear analysis to screen cervical cancer in low-resource settings

1. Contact Tracing and Epidemic Management:

• Aarogya Setu app (COVID-19 contact tracing using Bluetooth/GPS)
• AI-driven modeling of transmission dynamics

1. Drug Discovery and Repurposing:

• AI reduces time to identify drug candidates (e.g., AlphaFold protein structure prediction)
• Faster vaccine development pipelines

1. Predictive Analytics for Healthcare Planning:

• Predict disease burden, hospital admissions, ICU demand
• Allocate health resources efficiently

1. Health Information Systems:

• Natural Language Processing (NLP) to extract data from clinical notes
• Chatbots for patient triage and health promotion (e.g., MyGov Helpdesk for COVID-19)

1. Vector Control:

• AI-based satellite imagery to identify mosquito breeding sites for malaria/dengue control

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Q9. High-Risk Approach in Antenatal Care - Six High-Risk Conditions

High-Risk Approach:

Six High-Risk Conditions:

1. Anaemia - Hb <7 g/dL (severe); Hb <11 g/dL (mild): Increased risk of maternal mortality, preterm labour, low birth weight
2. Hypertensive disorders of pregnancy - Pre-eclampsia (BP ≥140/90 mm Hg + proteinuria), eclampsia: Risk of maternal/foetal death
3. Antepartum Haemorrhage (APH) - Placenta praevia, abruptio placentae: Major cause of maternal mortality
4. Malpresentation - Breech, transverse lie at term: Risk of obstructed labour, birth trauma
5. Multiple pregnancy - Twins, triplets: Preterm labour, maternal anaemia, malpresentation
6. Previous obstetric complications - Previous caesarean, previous stillbirth/neonatal death, previous PPH

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Q10. Biomedical Waste from Routine Immunization - Segregation and Terminal Disposal

Waste Generated in Routine Immunization:

• Used syringes and needles (sharps)
• Vaccine vials (empty, partially used, or expired)
• Cotton swabs (non-contaminated/contaminated with blood)
• Cold-chain packaging waste

Segregation Plan:

Terminal Disposal Methods:

1. Needles and Sharps:

• Hub cutter/needle destroyer at the point of use - destroys the needle hub immediately after injection (prevents re-use and needle-stick injuries)
• Sharps waste placed in puncture-proof containers (PPC - auto-disable syringe collection boxes)
• Sent for autoclaving and then shredding/encapsulation, or directly to Common Biomedical Waste Treatment Facility (CBWTF)

1. Live Vaccine Vials (OPV, BCG, MR):

• Must be autoclaved or chemically disinfected (1% hypochlorite) before disposal because they contain live organisms
• Then buried in lined pits or sent to CBWTF for incineration

1. Inactivated Vaccine Vials (Pentavalent, IPV, Hepatitis B):

• Empty vials are relatively low-risk
• Can be defaced, placed in puncture-proof containers and sent to CBWTF
• Deep burial or encapsulation acceptable

1. Cotton swabs/waste:

• Yellow bag → incineration at CBWTF or deep burial in lined pit

1. Hub Cutters/Needle Destroyers:

• After the hub cutter is full (indicated by the "full" mark), it is sealed and sent to CBWTF for treatment
• Manual burning/open burning is strictly PROHIBITED

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SHORT ANSWERS (2-3 marks each)

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Q11. Self-Care in Diabetes

1. Medical Nutrition Therapy (MNT): Calorie-controlled diet, reduced simple sugars, high fibre, regular meal timings; plate method (50% vegetables, 25% complex carbohydrates, 25% protein)
2. Regular Physical Activity: 150 minutes/week of moderate aerobic exercise; reduces insulin resistance, helps weight management
3. Self-Monitoring of Blood Glucose (SMBG): Regular home glucose testing using glucometer; helps adjust diet/medication
4. Medication Adherence: Taking oral hypoglycemics/insulin as prescribed; never skip doses
5. Foot Care: Daily inspection of feet, moisturizing, proper footwear, never walk barefoot - prevents diabetic foot ulcers
6. HbA1c Monitoring: Target <7% - tested every 3 months
7. Eye and Dental Care: Annual ophthalmologic examination for retinopathy
8. Stress Management: Yoga, meditation - stress raises blood glucose
9. Sick-Day Rules: Know how to manage blood sugar during illness
10. Education: Recognize hypoglycemia symptoms; carry glucose tablets

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Q12. ICDS - Beneficiaries and Services

Beneficiaries:

1. Children 0-6 years (especially 6 months-3 years and 3-6 years)
2. Pregnant women
3. Lactating mothers (up to 6 months postpartum)
4. Adolescent girls (Kishori Shakti Yojana - in selected blocks)

Services (Package of Six Services):

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Q13. Risk Factors for Hypertension

• Age (>45 years men, >55 years women)
• Family history/genetic predisposition
• Race/ethnicity (higher in Black populations)
• Male sex (pre-menopause)

• Dietary: High sodium intake (>5 g/day), low potassium, high saturated fat, excess alcohol
• Obesity: BMI >30 kg/m² - central obesity (waist >90 cm men, >80 cm women in Asians)
• Physical inactivity: Sedentary lifestyle
• Smoking and tobacco use: Nicotine causes vasoconstriction
• Stress: Chronic psychosocial stress activates sympathetic nervous system
• Diabetes mellitus
• Dyslipidaemia
• Sleep apnoea

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Q14. Ecological Factors Related to Malnutrition

1. Dietary inadequacy: Insufficient food intake in quantity and quality; monotonous diets; poor breastfeeding practices
2. Poverty: Low purchasing power, food insecurity
3. Infections and disease: Repeated diarrhoea, respiratory infections, malaria, parasitic infestations - increase nutrient losses, reduce absorption, increase metabolic demand ("infection-malnutrition cycle")
4. Ignorance and wrong food beliefs: Cultural taboos (e.g., eggs not given to children), food fads
5. Large family size: Limited food available per child; competition for resources
6. Poor environmental sanitation: Contaminated water and food sources causing infections that worsen malnutrition
7. Agricultural factors: Poor crop yield, food storage losses, seasonal food insecurity
8. Maternal factors: Low birth weight babies, young maternal age, short birth intervals, maternal malnutrition
9. Rapid population growth: Food demand exceeds supply
10. Social factors: Gender discrimination - girls fed last and least; caste/socioeconomic inequalities

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Q15. Types of Cancer Registry

Types:

1. Population-based Cancer Registry (PBCR):

• Covers all cancer cases in a defined geographical population
• Provides incidence rates, survival data, geographic distribution
• Example: ICMR's National Cancer Registry Programme (NCRP) - Bengaluru, Mumbai, Delhi PBCRs
• Gold standard for cancer epidemiology

1. Hospital-based Cancer Registry (HBCR):

• Covers all cancer cases treated at a specific hospital
• Provides data on clinical features, stage at diagnosis, treatment, outcomes
• Example: Registries at Tata Memorial Hospital (Mumbai), Regional Cancer Centres
• Cannot provide population incidence rates

1. Pathology-based Registry:

• Uses histopathological diagnoses only
• Useful where population registration is incomplete

1. Special Purpose Registries:

• Focus on specific cancers (e.g., childhood cancer registry, breast cancer registry)

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Q16. Food Fortification - Definition and Criteria

Definition:

Criteria for the VEHICLE (food carrier) to qualify:

1. Widely and regularly consumed by the target population in consistent amounts
2. Centrally processed - to ensure uniform fortification
3. Low cost and accessible to the poor (staple food)
4. Does not alter the organoleptic properties (colour, taste, smell, texture) of the food
5. Chemically compatible with the added nutrient (does not degrade it)
6. Long shelf life - nutrient should be stable during storage
7. Example vehicles: wheat flour, rice, salt, edible oil, milk

Criteria for NUTRIENTS to qualify:

1. Nutrient is deficient in a large segment of the population (public health relevance)
2. Safe at the levels added (no risk of toxicity)
3. Bioavailable in the food matrix
4. Stable under normal processing and storage conditions
5. Does not adversely affect the food vehicle

Example:

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Q17. Four Benefits under Employee State Insurance (ESI) Act

Four Benefits:

1. Sickness Benefit:

• Cash benefit @ 70% of wages for up to 91 days per year during certified illness
• Extended sickness benefit for specified long-term diseases (TB, malignancy, psychiatric disorders) for up to 2 years @ 80% wages

1. Maternity Benefit:

• Full wages for 26 weeks for insured women (12 weeks for adoption/surrogacy)
• Extended benefit in case of miscarriage, medical termination of pregnancy

1. Medical Benefit:

• Full medical care for insured person and family members from the first day of insured employment
• Includes outpatient, inpatient, specialist, emergency care at ESI hospitals and dispensaries
• No ceiling on expenditure

1. Disablement Benefit:

• Temporary Disablement Benefit (TDB): 90% of wages during temporary work incapacity from employment injury
• Permanent Disablement Benefit (PDB): Monthly payment proportional to extent of disability (assessed by Medical Board)

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Q18. Elements of Primary Health Care (PHC)

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Q19. Uses of Growth Chart

Uses:

1. Monitoring child growth: Tracks whether a child is growing adequately over time (growth trajectory)
2. Early detection of malnutrition: Identifies children falling below the 3rd centile (underweight, stunting, wasting) before clinical features appear
3. Screening at community level: ICDS workers use it to identify Grade III/IV malnutrition for referral
4. Health education tool: Educates mothers about nutrition and importance of weight monitoring
5. Assessment of development milestones: Road to Health card combines growth with developmental milestones
6. Evaluation of interventions: Assess impact of nutritional interventions - is the child's weight "crossing centile lines" upward (catch-up growth)?
7. Immunization record: The card also serves as an immunization tracking tool
8. Program monitoring: Coverage of weighing sessions, trends in malnutrition rates at AWC/district level
9. Legal document: Proof of age, immunization status
10. Research: Population-level data on nutritional status

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Q20. UNESCO

• Established: November 4, 1946 (constitution came into force)
• Headquarters: Paris, France
• Governing body: General Conference (meets every 2 years)
• Current Director-General: Audrey Azoulay (since 2017)

1. Education: Promotes universal access to quality education, literacy programmes - directly impacts health literacy, maternal education (key determinant of child health)
2. Water and Sanitation: UNESCO's IHP (International Hydrological Programme) manages freshwater science and policy
3. Bioethics: UNESCO's Bioethics and Ethics of Science programme - Universal Declaration on Bioethics and Human Rights (2005)
4. Health-promoting schools: Joint UNESCO-WHO initiative for school health
5. Science: Funds research programmes relevant to public health (COVID-19 scientific cooperation)
6. SDGs: UNESCO coordinates Education for Sustainable Development (ESD) contributing to SDG 4 (Quality Education) and indirectly to SDG 3 (Good Health)

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