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GROUP A – LAQ MODEL ANSWERS (15 Marks Each)

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Q3. Dog Bite by a Street Dog [SRIMS]

i. Immediate Action (2 marks)

1. Stay calm and move your friend away from the dog.
2. Assess the wound - identify the type, location, and severity of bite.
3. Do NOT panic-suture the wound immediately.
4. Begin local wound treatment at once (see Part iii below).
5. Note the time, circumstances, and the dog's behavior (provoked vs. unprovoked, whether the dog ran away or was captured).
6. Take the friend to the nearest health facility as soon as possible.

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ii. Wound Categorization - WHO Exposure Categories (3 marks)

• The bite was unprovoked
• The dog is a stray (unvaccinated, unknown vaccination status)
• The animal ran away and cannot be observed

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iii. Management to Prevent Rabies (10 marks)

A. Local Wound Treatment (Most Important - First Line)

1. Cleansing: Flush and wash all wound(s) with copious soap and water under running tap for at least 15 minutes. If soap is unavailable, flush with plenty of water alone as first aid. For puncture wounds, use a catheter to irrigate deeply.
2. Chemical treatment: Apply virucidal agents to inactivate residual virus:
   • Alcohol (40-70%)
   • Tincture of iodine, OR
   • 0.01% aqueous povidone-iodine
3. Suturing: Do NOT suture immediately - this can spread the virus deeper. If suturing is unavoidable, wait 24-48 hours and use minimum stitches under cover of locally infiltrated RIG.
4. Antibiotics: Give amoxicillin-clavulanate (or appropriate antibiotic) to prevent secondary infection.
5. Anti-tetanus: Give tetanus toxoid and anti-tetanic serum if not previously immunized.

B. Post-Exposure Prophylaxis (PEP) - Immunization

• Administered once only, as soon as possible after exposure (not beyond Day 7 after first vaccine dose).
• Human RIG (HRIG): 20 IU/kg body weight
• Equine RIG (ERIG): 40 IU/kg body weight (skin test before use)
• Infiltrate maximum possible volume into and around the wound site(s); remaining volume given IM at a distant site from vaccine.

• Essen Regimen (5-dose): 1 dose on Days 0, 3, 7, 14, and 28 (into deltoid; thigh for children <2 years). This is the standard schedule.
• Zagreb Regimen (4-dose): 2 doses on Day 0 (one in each deltoid), then 1 dose on Days 7 and 21.

• 2-site ID regimen (2+2+2+0+2): 0.1 ml ID at 2 sites on Days 0, 3, 7, and 28 - used where nationally endorsed.

C. Patient Counseling and Follow-Up

• Advise patient to complete the full vaccine schedule.
• Monitor the dog (if captured) for 10 days - if it remains healthy, PEP may be discontinued.
• Report the bite to local health authorities.

D. Public Health Measures

• Notify the Animal Bite Treatment Centre and local health authorities.
• Register the case for Integrated Bite Case Management under the National Rabies Control Programme.

Source: Park's Textbook of Preventive and Social Medicine, pp. 323-326

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Q4. Acute Watery Diarrhoea Outbreak in Under-5 Children [SCCGMCH]

Part 1: Steps for Investigating the Outbreak (5 marks)

• Conduct a house-to-house medical survey to find unreported cases.
• Use an epidemiological case sheet to record: name, age, sex, time of onset, symptoms, food/water intake, common exposures, contact history.
• Case definition: Child under 5 with acute watery diarrhoea (≥3 loose stools in 24 hours) ± vomiting, with onset within the past 7 days.

• Time: Construct an epidemic curve (date/time of onset vs. number of cases). A sharp peak suggests a point-source (e.g., contaminated water supply).
• Place: Draw a spot map showing case locations relative to water sources, food stalls, etc.
• Person: Calculate attack rates by age group, sex, household, water source used.

• Treat cases (oral/IV rehydration)
• Chlorinate water supply or provide safe water
• Promote hand hygiene and proper sanitation
• Isolate/treat cases

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Part 2: IMNCI Classification of Dehydration for the Five Children (2 marks)

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Part 3: Management and Fluid Resuscitation - Plan C (5 marks)

• Reassess every 1-2 hours: If dehydration not improving, increase IV drip rate.
• Once the child can drink, start ORS (5 ml/kg/hour) alongside IV fluids.
• When child is no longer severely dehydrated, switch to Plan B or Plan A.

• Continue breastfeeding if the infant is breastfed.
• Give Zinc supplementation: 10 mg/day for infants <6 months; 20 mg/day for older children, for 14 days.
• If cholera is suspected in a child ≥2 years: give appropriate antibiotic (azithromycin).
• Monitor: pulse rate, respiratory rate, urine output, skin turgor, mental status.
• Referral: If IV access not possible, refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.

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Part 4: Preventive and Control Measures (3 marks)

1. Safe Water Supply: Chlorinate the village water source (0.5 ppm residual chlorine); provide ORS/boiled water. Collect water samples for bacteriological testing.
2. Food Safety: Identify any common food vehicle; stop sales from implicated sources; educate on food hygiene.
3. Hand Hygiene: Actively promote hand washing with soap after defecation and before food preparation; set up hand-washing stations.
4. Environmental Sanitation: Proper disposal of faeces; chlorinate latrines; remove garbage; prevent open defecation.
5. Case Management: Treat all cases with ORS, zinc; severe cases referred for IV fluids.
6. Health Education: Mobilize community via ASHA workers, AWWs; advise on signs of dehydration.
7. Surveillance: Maintain daily line list; report under IDSP; monitor for new cases for at least 2 incubation periods after the last case.

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Q5. Leprosy - Six Hypo-pigmented Lesions + Nerve Thickening [NBMCH]

1. Provisional Diagnosis (1 mark)

2. WHO Classification (4 marks)

• 6 hypo-pigmented lesions (on back and extremities)
• Thickening of BOTH ulnar AND median nerves (2 nerves)

• Tuberculoid (TT) - Paucibacillary end
• Borderline tuberculoid (BT) - Paucibacillary
• Mid-borderline (BB)
• Borderline lepromatous (BL) - Multibacillary
• Lepromatous (LL) - Multibacillary end

3. Treatment Regimen - WHO MDT for MB Leprosy, Adults (4 marks)

• Duration: 12 monthly supervised doses.
• If clofazimine is unacceptable (skin discoloration), replace with Ethionamide 250-375 mg daily.
• Regular treatment = at least 8 out of 12 doses received.
• Patient is declared released from treatment (RFT) after completing the regimen.

4. Complications of Leprosy (3 marks)

• Peripheral neuropathy (ulnar, median, common peroneal, radial nerves)
• Loss of sensation (touch, pain, temperature)
• Muscle weakness and paralysis

• Grade 0: No anaesthesia, no visible deformity
• Grade 1: Anaesthesia present, no visible deformity
• Grade 2: Visible deformity/damage (claw hand, foot drop, wrist drop, lagophthalmos, blindness)

• Lagophthalmos (inability to close eye) - risk of corneal ulceration and blindness

5. Management of ENL Reaction (New Inflamed Red Nodules + Fever + Malaise) (3 marks)

• New inflamed red subcutaneous nodules on limbs/trunk
• High fever and severe malaise
• Original leprosy patches remain unchanged

1. Continue MDT - do NOT stop multidrug therapy.
2. Mild ENL: Aspirin or NSAIDs (analgesics/antipyretics) for symptom relief.
3. Severe ENL (as in this case - fever + severe malaise):
   • Prednisolone is the drug of choice: Start at 40-60 mg/day, taper over weeks.
   • Monitor for steroid side effects: peptic ulcer, hyperglycaemia, hypertension, reactivation of TB.
4. Clofazimine at higher doses (100 mg three times daily for 3 months, then taper) is also effective for ENL, but takes 4-6 weeks to act - never use as sole agent in severe ENL.
5. Thalidomide (where available and in males only): 100-400 mg/day - highly effective for severe ENL; absolutely contraindicated in women of childbearing age.

Source: Park's Textbook of Preventive and Social Medicine, pp. 369-377

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Q6. Leprosy - Hypopigmented Patches + Right Ulnar Nerve [JMNMCH]

a. Provisional Diagnosis with Justification (2 marks)

1. Hypopigmented/erythematous skin patch with loss of sensation - PRESENT (hypopigmented, well-defined patches with loss of sensation to touch and temperature)
2. Thickened peripheral nerve - PRESENT (right ulnar nerve thickened and tender)
3. Acid-fast bacilli on skin smear - not tested

• Tingling and numbness in hands (ulnar nerve involvement)
• No fever or weight loss (distinguishes from TB/lymphoma)
• 6-month history (chronic, indolent course)

b. Classification as per National Guidelines (2 marks)

• Skin lesions: hypopigmented patches over right arm and back - likely ≤5 lesions (not clearly stated as ≥6)
• Nerve: Right ulnar nerve only (single nerve involvement)

c. Treatment Regimen - PB Leprosy, National Programme (NLEP) (5 marks)

• Duration: 6 monthly supervised doses
• Patient is released from treatment (RFT) after 6 doses
• Surveillance period: 2 years for PB leprosy after RFT (patient monitored for relapse)
• Drugs are provided free of cost through the NLEP under ASHA/PHC network

• Rifampicin 450 mg monthly; Dapsone 50 mg daily

d. Preventive and Control Strategies (6 marks)

1. Early diagnosis and complete treatment - prevents progression and transmission
2. Self-examination for new skin lesions and nerve tenderness
3. Care of anesthetic limbs: use of protective footwear, gloves; daily inspection
4. Prevention of disability: Eye care (protective glasses, lubricating drops), physiotherapy
5. Adherence to MDT to avoid relapse and drug resistance

1. Active case detection: Survey of household contacts of leprosy patients; school surveys; population surveys in endemic areas
2. BCG vaccination: Provides 20-80% protection against leprosy
3. Chemoprophylaxis: Single-dose rifampicin (SDR) to close contacts of newly diagnosed PB leprosy cases (WHO recommendation - contact tracing programme)
4. Health education: Reduce stigma; spread awareness that leprosy is curable; early presentation campaigns
5. NLEP (National Leprosy Eradication Programme): Provision of free MDT at PHC level; training of health workers; Leprosy Case Detection Campaign (LCDC)
6. Disability prevention and rehabilitation: Reconstructive surgery camps; self-care groups; socioeconomic rehabilitation
7. Surveillance: Monitor elimination targets (<1 case per 10,000 population at district level)

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Q7. Cerebral Malaria - Forest Area Resident [JHARGRAM]

1. Probable Diagnosis (1 mark)

2. National Programme Covering Malaria (1 mark)

3. Other Diseases Under NVBDCP (2 marks)

1. Malaria
2. Filariasis (Lymphatic filariasis)
3. Kala-azar (Visceral Leishmaniasis)
4. Japanese Encephalitis (JE)
5. Dengue
6. Chikungunya

4. Management Protocol (5 marks)

• Admit to ICU/ward with close monitoring
• IV access - secure two large-bore IV lines
• Correct hypoglycaemia (check blood glucose urgently - IV 50% dextrose if needed)
• Airway management: Position patient in recovery position; intubate if GCS ≤8
• Manage convulsions: IV diazepam 0.15 mg/kg slow IV; prevent aspiration
• Treat hyperpyrexia: Paracetamol, tepid sponging (avoid aspirin)
• Correct severe anaemia (Hb <5 g/dL): Blood transfusion
• Manage renal failure: IV fluids carefully; dialysis if needed

• 2.4 mg/kg IV at 0, 12, 24 hours, then once daily
• Continue until patient can take oral medication, then switch to ACT oral therapy

• IV Quinine: Loading dose 20 mg/kg diluted in 5% dextrose over 4 hours, then 10 mg/kg every 8 hours
• Monitor for cinchonism (tinnitus, deafness) and hypoglycaemia during quinine therapy

• Complete course of oral Artemisinin Combination Therapy (ACT) - Artemether-Lumefantrine or AS+SP (artesunate + sulfadoxine-pyrimethamine) as per national guidelines
• Primaquine 0.75 mg/kg single dose as gametocytocidal (to prevent transmission)

5. Preventive Aspects Under NVBDCP (4 marks)

• Early case detection using Rapid Diagnostic Tests (RDT) or microscopy
• Complete treatment with ACT; directly observed treatment where needed
• Epidemic preparedness and rapid response

• Indoor Residual Spraying (IRS): DDT/malathion/synthetic pyrethroids in high-risk areas
• Insecticide Treated Bed Nets (ITBNs)/Long-Lasting Insecticidal Nets (LLINs)
• Anti-larval measures: Larvivorous fish (Gambusia, Guppy) in water bodies; temephos larvicide
• Source reduction: Elimination of mosquito breeding sites
• Minor environmental engineering (drainage, filling of stagnant water)

• Behaviour Change Communication (BCC)
• JE vaccination in endemic areas
• Mass Drug Administration (MDA) for filariasis
• Human resource capacity building

6. Surveillance Measures for Malaria (2 marks)

1. Passive Surveillance: Cases reported by health facilities; blood slides/RDTs from fever cases
2. Active Surveillance: House-to-house fever surveys by MPW/ASHAs in high-transmission areas; Mass Blood Survey (MBS)
3. Slide Positivity Rate (SPR) and Annual Parasite Incidence (API) calculated at PHC level
4. Epidemic preparedness: Sentinel sites; weekly reporting under IDSP (P and L forms)
5. Web-based MIS: Reporting to NVBDCP portal
6. District Malaria Officers (DMO) supervise surveillance; respond to outbreaks

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Q8. Dog Bite - District Hospital OPD, 2 Hours Post-Bite [DMGMCH]

1. WHO Exposure Category Classification (4 marks)

• Puncture wounds (2 punctured wounds = transdermal bites) on left leg
• The stray dog was unprovoked and ran away (cannot be observed)
• Mild bleeding present (implies skin breach)

• Stray dog (unvaccinated, unknown status)
• Unprovoked attack
• Dog ran away (cannot monitor for 10 days)
• Patient is a manual labourer (forest/outdoor exposure possible)

2. Immediate Local Wound Management (4 marks)

1. Flush and wash all wounds with soap and water under running tap for at least 15 minutes (use catheter for deep puncture wounds)
2. Apply virucidal agent - povidone-iodine solution or 70% alcohol or tincture of iodine
3. Do NOT suture immediately; if necessary, suture only after 24-48 hours with minimum stitches under RIG cover
4. Antibiotics: Amoxicillin-clavulanate 625 mg TDS x 5-7 days (prophylactic)
5. Tetanus prophylaxis: Tetanus toxoid 0.5 ml IM; tetanus immunoglobulin if not previously immunized
6. Document wound site, size, and depth

3. Post-Exposure Prophylaxis Schedule (5 marks)

• HRIG: 20 IU/kg, OR ERIG: 40 IU/kg
• Infiltrate into and around wound; remainder IM (distant from vaccine site)
• Give on Day 0 only

• Doses on Days 0, 3, 7, 14, and 28 (1 dose each day = 5 doses total)
• Inject into deltoid muscle (1 ml or 0.5 ml depending on vaccine type)
• Do NOT inject into gluteal region (poor antibody response)

4. Public Health Measures for Rabies Prevention at Community Level (2 marks)

1. Dog population management: Mass vaccination of dogs (target ≥70% vaccination coverage to achieve herd immunity in dog population); responsible pet ownership; stray dog management.
2. Public awareness: Educate communities on immediate wound washing after bites; know the nearest Anti-Rabies Centre (ARC); discourage abandonment of pets.

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Q9. Dog Bite - 14-Year-Old Boy [DHGMCH]

1. WHO Exposure Category and Justification (2 marks)

• Three bleeding puncture wounds (transdermal bites) - skin completely breached
• Scratch marks present (licks on broken skin = Category III)
• Stray dog, unprovoked, ran away
• Child has not washed the wound - no immediate decontamination

2. Immediate Wound Management (2 marks)

1. Flush wounds immediately with soap and water under running tap for at least 15 minutes (use syringe/catheter for puncture wounds - they are deep)
2. Apply povidone-iodine or 70% alcohol to wound
3. Do NOT suture immediately
4. Give tetanus toxoid (child's age/immunization status unknown; assume needed)
5. Give antibiotics (amoxicillin-clavulanate)

3. Post-Exposure Prophylaxis Indicated (2 marks)

• HRIG 20 IU/kg (or ERIG 40 IU/kg) - infiltrate into and around wounds on Day 0
• Cell culture vaccine: Essen regimen - Days 0, 3, 7, 14, 28 (IM deltoid)
• No prior vaccination history = full 5-dose course mandatory

4. Anti-Rabies Vaccination Schedules Under National Rabies Control Programme (2 marks)

1. Essen Regimen (IM, 5-dose): Days 0, 3, 7, 14, 28 (1 full dose IM deltoid each visit)
2. Zagreb Regimen (IM, 4-dose): Day 0 (2 doses - one each deltoid), Day 7, Day 21
3. 2-site Intradermal (ID) Regimen: 0.1 ml at 2 sites on Days 0, 3, 7, 28 (endorsement-dependent)
4. Previously vaccinated: Only Days 0 and 3 (2 doses IM/ID); no RIG

5. Four Fatal Clinical Features of Human Rabies (2 marks)

1. Hydrophobia - severe spasms of the throat muscles on attempting to drink water (pathognomonic)
2. Aerophobia - spasms triggered by a puff of air
3. Ascending paralysis (Paralytic/Dumb rabies form) - progressing to respiratory failure
4. Brainstem encephalitis - autonomic dysfunction, cardiac arrhythmias, respiratory arrest, coma

6. Four Community-Level Prevention and Control Measures (2 marks)

1. Mass vaccination of dogs - ≥70% dog population vaccinated to interrupt transmission
2. Stray dog management - humane control of stray dog population; responsible pet ownership legislation
3. Public health education - awareness campaigns on immediate wound washing, seeking care at ARCs; school-based education
4. Strengthening Anti-Rabies Centres (ARCs) - ensure free PEP availability at PHC/CHC level under National Rabies Control Programme; adequate stock of vaccine and RIG

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Q10. High Fever + Retroorbital Pain + Body Ache in 10-Year-Old [SMCH]

1. Probable Diagnosis (2 marks)

2. Laboratory Tests for Confirmation (3 marks)

3. Management (5 marks)

• Rest and adequate oral hydration (ORS, coconut water, fruit juices - 2-3 litres/day)
• Paracetamol for fever and pain (10-15 mg/kg/dose, 4-hourly; max 5 doses/day)
• Avoid: Aspirin, NSAIDs (ibuprofen), steroids (increase risk of bleeding and gastritis)
• Monitor platelet count daily once fever starts
• Warning signs requiring immediate hospitalization: severe abdominal pain, persistent vomiting, bleeding manifestations, rapid breathing, lethargy, restlessness, drop in platelet <50,000

• IV Fluid therapy: Start with Ringer's lactate 10 ml/kg/hour; titrate based on haematocrit and clinical response
• Monitor haematocrit every 4-6 hours; if rising despite fluids, suspect plasma leakage
• Platelet transfusion: Only if platelet <10,000 AND active bleeding (not routine for low platelet alone)
• Treat dengue shock syndrome (DSS): Colloids (dextran/starch) + aggressive IV fluids for shock; vasopressors if refractory
• Monitor urine output (target >0.5 ml/kg/hr)

4. Prevention of Dengue in the Locality (5 marks)

1. Source reduction (most important):
   • Empty, clean, and cover all water storage containers weekly
   • Drain flower vases, coolers, old tyres, overhead tanks
   • Introduce larvivorous fish (Gambusia) in ornamental ponds
   • Enforce civic bye-laws for mosquito breeding prevention
2. Larviciding: Apply temephos (Abate) to water containers that cannot be emptied
3. Biological control: Bacillus thuringiensis israelensis (BTi) as biological larvicide
4. Personal protection:
   • Use mosquito repellents (DEET-based)
   • Wear full-sleeved clothing (Aedes bites during day)
   • Use mosquito nets; window/door screens
5. Community mobilization:
   • Weekly "Dry Day" campaign - search and destroy all water-collecting containers
   • School/Anganwadi-based awareness programmes
   • ASHA/ANM surveillance for fever clusters
6. Health system measures:
   • Rapid dengue diagnosis at PHC level (NS1 RDT)
   • Sentinel surveillance sites under NVBDCP
   • Reporting of clusters to District Health Officer for rapid response

Source: Park's Textbook of Preventive and Social Medicine, pp. 291-300; NVBDCP dengue guidelines

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Q11. Malaria Epidemic - Rural Block, Monsoon Season [ESIC JOKA]

a. Definition of Epidemic (2 marks)

• The excess is usually determined statistically as more than two standard deviations above the mean endemic occurrence.
• For rare diseases (e.g., smallpox), even a single case may constitute an epidemic.
• An epidemic may be caused by a single agent or may be of complex aetiology, and may occur in a geographically confined area or spread widely.

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b. Steps in Investigation of This Malaria Epidemic (8 marks)

• Examine a sample of fever cases clinically
• Perform peripheral blood smear (thick and thin films) for malaria parasites - identify species
• Use Rapid Diagnostic Tests (RDT) for Plasmodium falciparum (HRP-2 antigen)
• Collect samples for lab confirmation; do not delay investigation

• Calculate the Annual Parasite Incidence (API) and compare with previous years for the same block/season
• If current case count clearly exceeds the expected baseline (epidemic threshold), confirm epidemic
• In the case of malaria in an endemic region during monsoon, a sudden surge >2 SD above mean confirms epidemic

• Map the entire affected rural block; identify all villages
• Determine total population by age, sex; enumerate families by their water exposure, occupation (farm workers), proximity to breeding sites

• Active case detection: House-to-house survey for fever cases in the past 14 days
• Prepare an epidemiological case sheet/line list for each case: name, age, sex, village, date of onset, travel history, occupation, ITN use, type of housing
• Review hospitalization records; contact private practitioners
• Case definition: Person residing in the affected block with fever (axillary temp ≥37.5°C) AND blood smear/RDT positive for malaria parasites, within the past 4 weeks

• Time: Plot an epidemic curve (date of onset vs. case count). A progressive rise during monsoon suggests propagated/seasonal epidemic. If sudden spike, consider point-source (water contamination unusual for malaria; more likely linked to breeding site development after rains)
• Place: Draw a spot map marking case homes relative to vector breeding sites (stagnant water, ponds, rice fields, construction sites). Identify high-risk villages.
• Person: Calculate attack rates by age, sex, occupation, use of ITBNs. Identify if any specific group (farm workers, migrants) is disproportionately affected

• The monsoon creates ideal breeding conditions for Anopheles mosquitoes
• Hypotheses: Increased vector density due to waterlogging/rice fields; seasonal migration of infected workers from high-endemic forest zones; lapse in vector control activities
• Test by: Entomological investigation - larval survey (larval density per 10 dips); adult mosquito collection (man-hour density); malaria parasite rate (MPR) calculation

• Early treatment of all confirmed cases with ACT
• Conduct emergency IRS (indoor residual spraying) in affected villages
• Distribute LLINs to households
• Anti-larval operations (temephos, BTi, Gambusia)
• Health education - seek early treatment for fever

• Report epidemic via IDSP (P-form daily; L-form for lab confirmed; S-form for weekly summary)
• Notify District CMO/DVBDC Officer/NVBDCP; seek additional resources if needed
• Maintain daily situation report

• Monitor weekly case counts to assess if epidemic curve is declining
• Reassess IRS coverage; check if LLIN distribution was adequate

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c. Vector Control Measures for Malaria (5 marks)

• Application of residual insecticide to interior walls and ceilings where mosquitoes rest
• Insecticides used: DDT (1 g/m²), Malathion, Synthetic pyrethroids (alphacypermethrin, deltamethrin)
• Schedule: Twice yearly in high-transmission areas (pre-monsoon and post-monsoon)
• Covers 80% of households in targeted areas

• Nets impregnated with pyrethroid insecticide (deltamethrin, permethrin)
• Dual action: Physical barrier + insecticidal kill of Anopheles mosquitoes
• Particularly effective for children and pregnant women; free distribution under NVBDCP

• Biological: Larvivorous fish (Gambusia affinis, Poecilia reticulata/Guppy) in permanent water bodies
• Chemical: Temephos (Abate) 50% EC in non-potable water; Paris green in rice fields
• Bacterial: Bacillus thuringiensis israelensis (BTi) - safe for drinking water sources
• Microbial: Bacillus sphaericus for polluted water

• Drainage of stagnant water, waterlogged areas, marshes
• Filling of borrow pits and low-lying areas
• Proper management of rice fields (intermittent irrigation); lining of irrigation canals
• Construction of properly sealed water storage facilities

• Use of mosquito repellents (DEET, pyrethroid coils)
• Full-sleeved clothing during evening hours (peak Anopheles biting time - dusk to dawn)
• Window and door screens
• Behaviour change communication on consistent bed net use

• Use of Bacillus strains
• Introduction of larvivorous fish in water bodies unsuitable for drainage

All answers sourced from: Park's Textbook of Preventive and Social Medicine (NVBDCP, Rabies, Leprosy, Epidemic Investigation, Dengue, IMNCI chapters); Harrison's Principles of Internal Medicine 22E; WHO Guidelines on Rabies PEP (2018).