COMMUNITY MEDICINE - COMPREHENSIVE ANSWERS

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GROUP A (LAQ - 15 MARKS)

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Q1. Blindness: WHO Definition, Causes in India, Epidemiological Determinants, Prevention (2+3+4+6=15) [MMC]

WHO Definition of Blindness (2 marks)

• Near vision impairment: Presenting near visual acuity worse than N6 or M0.8 at 40 cm with existing correction.

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Causes of Blindness in India (3 marks)

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Major Epidemiological Determinants of Blindness (4 marks)

• Age: 82% of visually impaired are ≥50 years; risk rises with age (cataract, glaucoma, ARMD)
• Sex: Women more affected due to longer life expectancy and poor access to care
• Nutritional status: Vitamin A deficiency causes xerophthalmia and childhood blindness
• Genetic factors: Congenital conditions, retinitis pigmentosa, albinism
• Systemic disease: Diabetes (diabetic retinopathy), hypertension, sickle cell disease

• Chlamydia trachomatis - trachoma leading to corneal scarring
• Onchocerca volvulus - river blindness (onchocerciasis)
• Nutritional deficiency - Vitamin A deficiency
• Metabolic: uncontrolled diabetes, elevated intraocular pressure

• Poverty: Poor access to treatment, late presentation
• Illiteracy: Lack of awareness of treatable conditions
• Rural/remote location: Lack of ophthalmic facilities
• Occupational exposure: Welder's flash, chemical injuries, UV exposure (outdoor workers)
• Sanitation: Poor hygiene promotes trachoma transmission (flies, shared towels)
• Overcrowding: Promotes trachoma spread

• Shortage of ophthalmologists (especially rural areas)
• Inadequate cataract surgical rate
• Poor access to spectacles and refraction services
• Lack of screening programs

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Prevention of Blindness - National Programme Interventions (6 marks)

• A centrally sponsored scheme (60:40 in all states, 90:10 in NE states)
• Goal: Reduce prevalence of blindness to 0.3% by 2020

A. Primordial / Primary Prevention (Prevent occurrence)

B. Secondary Prevention (Early detection + prompt treatment)

C. Tertiary Prevention (Rehabilitation)

• Treatment of diabetic retinopathy, glaucoma, vitreo-retinal surgery, childhood blindness (beyond just cataract)
• District blindness control societies
• Eye banking and corneal transplantation program
• Convergence with NHM for universal health coverage

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Q2. 28-year-old HIV+ Truck Driver: Modes of Transmission, ICTC, NACP, PMTCT [TGMCH]

Modes of Transmission of HIV

• Unprotected heterosexual intercourse (most common route in India)
• Homosexual (men who have sex with men)
• Frequency of sexual contact, presence of STIs, and mucosal breaks increase risk
• Truck drivers are a high-risk "bridge population" due to long-distance travel and multiple sexual partners

• Intravenous drug users (needle/syringe sharing)
• Blood transfusion (before mandatory screening; now rare with NACO-mandated screening)
• Needle-stick injuries (healthcare workers)
• Sharing of contaminated instruments (razors, tattooing equipment)

• Antenatally: Through the placenta (in utero)
• Intrapartum: During delivery (most common)
• Postpartum: Through breastfeeding

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ICTC (Integrated Counselling and Testing Centre) Services

• Explanation of HIV, its transmission, and consequences
• Meaning of the test, window period (3 months for standard tests; 6 weeks for 4th generation tests)
• Voluntary and informed consent obtained
• Psychosocial assessment (risk behaviours, partner notification)
• Confidentiality assured

• 3-test strategy (NACO): Three ELISA-based rapid tests on whole blood
  • Test 1 (most sensitive) → if reactive, Test 2 (most specific) → if reactive, Test 3 (tie-breaker)
  • Result: Reactive = HIV positive; Non-reactive = HIV negative; Indeterminate = repeat after 2-4 weeks
• 4th generation tests (Ag/Ab combo) reduce window period to 2-4 weeks

• Disclosure of results confidentially
• Positive result: Emotional support, risk reduction counselling, referral to ART centre, partner notification counselling, disclosure to partner
• Negative result: Window period explanation, behaviour change counselling, condom promotion
• Both: Linkage to care and support services

• PPTCT (Prevention of Parent-to-Child Transmission) services for pregnant women
• Referral to ART centres, OST centres (for PWID), STI clinics
• Nutritional support guidance
• Psychosocial support

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NACP (National AIDS Control Programme) Guidelines

1. Targeted Interventions (TI): High-risk groups (FSW, MSM, IDU, transgenders, truckers like this patient) - peer educators, condom promotion, STI management, BCC
2. Blood Safety: Mandatory HIV testing of all donated blood; voluntary blood donation promotion; stringent screening
3. Prevention of Parent-to-Child Transmission (PPTCT): Testing all pregnant women; ART for HIV+ pregnant women
4. ART Services: Free first-line, second-line, third-line ART at ART centres; adherence counselling; viral load monitoring
5. ICTC Network: ICTCs for voluntary HIV testing; Facility Integrated Counselling and Testing Centres (FICTC) in hospitals
6. STI/RTI Control: Syndromic management of STIs (as STIs enhance HIV transmission)
7. Condom Promotion: Free condoms at PHC level; condom vending machines; social marketing
8. Stigma Reduction: Communication campaigns; support networks; legal protection
9. Treatment protocols (current):

• First-line regimen: TLE (Tenofovir + Lamivudine + Efavirenz) - once daily fixed-dose combination
• Initiating ART for all HIV+ individuals regardless of CD4 count ("Test and Treat" policy)
• CD4 count and viral load monitoring

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PMTCT (Prevention of Mother-to-Child Transmission)

1. Primary prevention of HIV in women of reproductive age
2. Prevention of unintended pregnancies in HIV+ women
3. Prevention of HIV transmission from HIV+ mothers to their infants
4. Providing appropriate treatment, care and support to HIV+ women and their families

• Universal HIV testing of all pregnant women at first ANC visit at ICTC/FICTC
• ART for all HIV+ pregnant women: Option B+ - Triple ARV for life (TLE regimen) regardless of CD4 count
• ARV prophylaxis for newborn: Nevirapine syrup for 6 weeks after birth
• Safe delivery practices: Minimise intrapartum HIV exposure
• Infant feeding counselling: Exclusive breastfeeding for 6 months with continued ARV cover (preferred in India over formula feeding due to gastroenteritis risk)
• Infant HIV testing: HIV DNA PCR at 6 weeks of age
• Cotrimoxazole prophylaxis for HIV-exposed infants

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Q3. Adolescent Health Problems, National Programmes, Description (4+4+7=15) [MldMCH]

Common Health Problems Among Adolescents (4 marks)

1. Nutritional problems: Iron deficiency anaemia (especially girls), protein-energy malnutrition, iodine deficiency, calcium/Vitamin D deficiency; obesity on the other hand in urban affluent
2. Reproductive and sexual health: STIs, unwanted pregnancy, unsafe abortion; menstrual irregularities (dysmenorrhoea, PCOS)
3. Communicable diseases: TB (India: adolescents 10-19 account for significant TB burden), typhoid, dengue
4. Skin problems: Acne vulgaris (extremely common)
5. Injuries and accidents: Road traffic accidents (leading cause of adolescent death globally)
6. Dental problems: Dental caries, gingivitis

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National Programmes Addressing Adolescent Health in India (4 marks)

1. RKSK (Rashtriya Kishor Swasthya Karyakram) - Launched 2014, flagship adolescent health programme
2. WIFS (Weekly Iron and Folic Acid Supplementation Programme) - For school-going and out-of-school adolescent girls and boys
3. School Health Programme under Ayushman Bharat / RBSK
4. SABLA (Rajiv Gandhi Scheme for Empowerment of Adolescent Girls) - Girls 11-18 years
5. ARSH (Adolescent Reproductive and Sexual Health) - now integrated into RKSK
6. NPE/Reproductive Health under RCH-II
7. Mid-day Meal Programme - Addresses nutritional needs of school-going adolescents
8. National Mental Health Programme (NMHP) - Includes adolescent mental health
9. National Programme for Prevention and Control of Substance Abuse
10. POCSO Act (Protection of Children from Sexual Offences) - Legal framework

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Detailed Description: RKSK (Rashtriya Kishor Swasthya Karyakram) (7 marks)

1. Nutrition
2. Sexual and Reproductive Health (SRH)
3. Non-communicable diseases prevention
4. Mental health
5. Prevention of substance abuse
6. Prevention of injuries/violence (including gender-based violence)

• Adolescent peer educators (APE) trained to reach peers with health information
• Peer Educator = 1 per 30 adolescents in community

• Held at health facilities
• Monthly AHD at AWC/SC level
• Provides: IFA supplementation, deworming, screening for anaemia, counselling

• Established at PHC/CHC/DH levels
• Provides confidential, non-judgmental, adolescent-friendly services
• Services: Nutrition counselling, SRH services, mental health support, substance abuse counselling, referral
• Staffed by trained MO and ANM
• Operating 2 days/week; one day designated for boys

• Launched 2012, integrated into RKSK
• Beneficiaries: School-going girls (6th-12th standard), school-going boys (6th-10th), and out-of-school girls 10-19 years
• Dose: Weekly IFA (Large Blue Tablet = 100 mg elemental iron + 500 mcg folic acid)
• Deworming tablet (Albendazole 400 mg) given every 6 months
• Supervised consumption in schools to ensure compliance

• Distribution of subsidised sanitary napkins (Freedays/Saathi brand) to adolescent girls in rural areas at ₹6 for a pack of 6
• Promotion of MHM (Menstrual Hygiene Management) behaviour change

• Half-yearly health check-ups in schools
• Screening for anaemia, vision defects, dental problems, skin diseases
• Referral of abnormal cases

• Percentage of adolescents attending AHD
• Percentage of girls who consumed IFA
• Anaemia rates in adolescents
• Percentage with adequate dietary diversity

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Q4. National Nutritional Programmes in India (3+3+3+6=15) [DMGMCH]

Different National Nutritional Programmes in India (3 marks)

1. ICDS (Integrated Child Development Services) - 1975; for children <6 years and pregnant/lactating women
2. POSHAN Abhiyaan (National Nutrition Mission) - 2018; convergent programme targeting stunting, undernutrition, anaemia
3. Mid-Day Meal Scheme (Pradhan Mantri Poshan Shakti Nirman) - School-going children
4. WIFS (Weekly Iron and Folic Acid Supplementation) - Adolescent girls and boys
5. National Iodine Deficiency Disorders Control Programme (NIDDCP) - Universal salt iodisation
6. National Vitamin A Prophylaxis Programme - Children 6 months-5 years
7. Iron and Folic Acid Supplementation under NRHM/NHM - Pregnant and lactating women; children 6 months-5 years
8. MAA (Mothers' Absolute Affection) Programme - Breastfeeding promotion
9. Pradhan Mantri Matru Vandana Yojana (PMMVY) - Maternity benefit for nutritional needs
10. National Programme for Prevention and Control of Fluorosis - Safe water, defluoridation

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Detailed Description: ICDS (Integrated Child Development Services) (3+3+6 marks)

1. Improve nutritional and health status of children in the age group 0-6 years
2. Lay the foundation for proper psychological, physical, and social development of the child
3. Reduce the incidence of mortality, morbidity, malnutrition, and school dropout
4. Achieve effective co-ordination of policy and implementation amongst various departments to promote child development
5. Enhance the capability of the mother to look after the normal health and nutritional needs of the child through proper nutrition and health education

1. Children below 6 years of age
2. Pregnant women
3. Lactating mothers
4. Women in the age group 15-44 years (adolescent girls in some projects)

• Primary beneficiaries: Children 0-6 years and pregnant/nursing mothers
• Secondary beneficiaries: Adolescent girls 11-18 years under Kishori Shakti Yojana (now SABLA)

• Anganwadi Worker (AWW) - primary functionary; trained community volunteer
• Anganwadi Helper (AWH) - assists AWW
• CDPO (Child Development Project Officer) - supervises a project
• Implemented under Mission POSHAN 2.0 (merged ICDS + POSHAN Abhiyaan + other schemes)

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Q5. 28-year-old Male with Cough 3 weeks, Fever, Weight Loss - TB Case (1+1+5+5+3=15) [RGMCH]

Most Likely Diagnosis (1 mark)

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National Programme Related to Disease (1 mark)

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Natural History of Disease (5 marks)

• Source: Open pulmonary TB case (expectorates bacilli via coughing, sneezing, talking)
• Mode: Inhalation of droplet nuclei (1-5 microns; can remain airborne for hours)
• Primary risk factors: Overcrowding, malnutrition, immunosuppression, close contact

• Inhaled bacilli reach alveoli → engulfed by alveolar macrophages
• Bacilli replicate → Ghon focus (subpleural focus, usually upper lobe)
• Spread to hilar lymph nodes → Ghon complex (primary complex)
• Tuberculin sensitivity develops in 4-8 weeks
• In 90-95% immunocompetent individuals: Primary complex heals (fibrosis/calcification) and infection is contained (LTBI - Latent TB Infection)
• In 5-10%: Progressive primary TB especially in children, malnourished, immunocompromised

• Occurs in latently infected individuals when immunity declines
• Most common: 1-2 years after primary infection; risk factors: HIV, malnutrition, diabetes, silicosis, immunosuppression
• Site: Apical and posterior segments of upper lobes (high O₂ tension favours bacillary multiplication)
• Pathology: Caseous necrosis → cavitation → spread via bronchi
• Clinical features: Constitutional symptoms + pulmonary symptoms

• Active PTB: Symptomatic; cough >2 weeks, haemoptysis, fever, night sweats, weight loss
• Extrapulmonary TB: Pleural, lymph node, bone/joint, CNS, renal, pericardial, miliary
• Miliary TB: Haematogenous spread → widespread nodular lesions in all organs
• TB meningitis: Most feared complication, especially in children

• 50% die within 5 years
• 25% self-heal with fibrosis/cavitation
• 25% remain as chronic infectious cases

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Initial Diagnostic Algorithm as per NTEP (5 marks)

Presumptive PTB case
         ↓
CBNAAT (Cartridge-Based Nucleic Acid Amplification Test) 
[Preferred first-line test at all levels]
         ↓
    ┌────────────────────────────────┐
    │                                │
MTB Detected                    MTB Not Detected
(+Rifampicin Sensitivity)           │
    │                        Chest X-ray + Clinical evaluation
    ↓                                │
Start Cat I                    ┌─────────────┐
  DSTB Regimen          X-ray abnormal    X-ray normal
                               │                │
                        Clinically TB       Re-evaluate
                          likely            for other
                               │            diagnoses
                        Start treatment
                        (with culture/LPA
                          if possible)

• CBNAAT (GeneXpert MTB/RIF) - WHO-endorsed, approved by NTEP as first-line
• Simultaneously detects M. tuberculosis AND rifampicin resistance (surrogate for MDR-TB)
• Results in ~2 hours

• MTB Detected, RIF Susceptible → Diagnose Drug-Sensitive TB → start DSTB treatment
• MTB Detected, RIF Resistant → Diagnose RR-TB → refer to DR-TB centre, start DR-TB regimen
• MTB Not Detected:
  • If chest X-ray strongly suggestive → clinical diagnosis of TB, start treatment
  • If not → consider other diagnoses; repeat sputum if needed; culture/LPA
  • Sputum smear microscopy (AFB smear) as adjunct

• Performed in all presumptive TB cases
• Findings: Upper lobe infiltrates, cavitation, fibrosis, hilar lymphadenopathy, pleural effusion
• Used for extent of disease and monitoring response

• TB Culture on LJ medium (gold standard, takes 6-8 weeks) or MGIT liquid culture (2-3 weeks)
• Line Probe Assay (LPA) for first-line (FL-LPA) and second-line drug resistance
• TrueNat MTB assay (alternative to CBNAAT at peripheral level)

• Sputum AFB smear (3 smears)
• FNAC/biopsy for lymph node TB
• Mantoux test (Tuberculin Skin Test) - not diagnostic in adults; limited use
• IGRA (Interferon Gamma Release Assay) - to diagnose LTBI

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Pre-Treatment Evaluations (3 marks)

• CBNAAT/sputum results (as above)
• Chest X-ray

• HIV testing - Mandatory (provider-initiated HIV testing for all TB patients per NACP-NTEP co-management)
• Liver Function Tests (LFT) - Baseline (critical: Rifampicin, Isoniazid, Pyrazinamide all hepatotoxic)
• Renal Function Tests (RFT/KFT) - Baseline (Streptomycin is nephrotoxic and ototoxic if used)
• Blood glucose (FBS/RBS) - Screen for diabetes mellitus (TB-DM co-morbidity; DM increases TB risk 3-fold)
• Complete Blood Count (CBC) - Baseline haemoglobin and leucocyte count
• Serum uric acid - Baseline before Pyrazinamide (causes hyperuricaemia)

• Body weight - For weight-based dosing of all anti-TB drugs
• Visual acuity - Baseline before Ethambutol (can cause optic neuritis - retrobulbar neuritis; risk with prolonged use)
• Colour vision assessment - Before Ethambutol
• Auditory assessment - Baseline before Streptomycin (aminoglycoside; can cause sensorineural hearing loss)
• Pregnancy test - In women of reproductive age (Streptomycin is teratogenic - absolute contraindication)
• ECG - Before Bedaquiline or Delamanid (QT prolongation risk) in DR-TB

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GROUP B (SAQ - 10 MARKS)

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B1. CBNAAT: MTB+ with Rifampicin Resistance - DR-TB Treatment Regimen (NTEP) [JNM]

• Duration: 6 months (or extended to 9 months if needed)
• Drugs: Bedaquiline (Bdq), Levofloxacin (Lfx), Clofazimine (Cfz), Pyrazinamide (Z), Ethambutol (E), High-dose Isoniazid (Hh)
• Eligible if: No resistance to fluoroquinolones and no prior second-line treatment >1 month

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B2. Drug-Sensitive TB: 36 kg body weight, 30-year-old male - Treatment [MMC]

• Intensive Phase: 3 tablets of FDC (each tablet = H75 + R150 + Z400 + E275) daily
• Continuation Phase: 3 tablets of FDC (each tablet = H75 + R150) daily

• Register on Nikshay portal (mandatory notification)
• Pyridoxine (Vitamin B6) 25-40 mg/day with INH (prevents peripheral neuropathy; especially important in malnourished, diabetic, alcoholic, HIV+, pregnant patients)
• Nikshay Poshan Yojana: ₹500/month direct benefit transfer for nutritional support during entire treatment
• HIV testing mandatory
• Baseline LFT, RFT, blood glucose, weight, visual acuity (for EMB), CBC
• Monthly clinical assessment; sputum examination at end of intensive phase (month 2), month 5, and month 6
• If smear positive at month 2: Extend intensive phase by 1 month → re-examine at month 3
• Adherence support: Treatment Supporter (family member or community volunteer); Ni-kshay Mitra (Adoption of TB patients)
• TB-99: Direct Benefit Transfer programme; patient receives ₹500/month
• Duration: Total 6 months; completed under Daily Regimen

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B3. Non-Communicable Disease National Programme in India (1+3+7=10) [MsdMCH]

Name of Programme (1 mark)

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Diseases Under NP-NCD (3 marks)

1. Cardiovascular diseases (CVD): Hypertension, coronary artery disease, heart failure, peripheral vascular disease
2. Diabetes Mellitus (Type 2)
3. Cancer: Oral, breast, cervical (priority cancers); others under National Cancer Control Programme (NCCP)
4. Chronic Obstructive Pulmonary Disease (COPD)
5. Stroke and cerebrovascular diseases
6. Common Risk Factors: Tobacco use, harmful alcohol use, unhealthy diet, physical inactivity (targeted under NP-NCD)

• Mental health conditions are addressed separately under NMHP but now under broader NCD umbrella

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Strategies to Combat Cardiovascular Diseases under NP-NCD (7 marks)

1. Population-based strategy:
   • NPCDCS/NP-NCD uses "whole-population approach" - address common CVD risk factors in entire population
   • Mass media campaigns: Anti-tobacco (Tobacco-free India, COTPA enforcement), physical activity promotion (Fit India Movement, Yoga), healthy diet (less salt, less saturated fat)
   • School health: Life skills education, health literacy on CVD risk factors
2. Individual high-risk approach:
   • 30-minute opportunistic screening at HWC/Sub-centre for hypertension, diabetes, BMI, waist circumference, tobacco use, alcohol use for all individuals ≥30 years
   • Population-based screening using CBAC (Community Based Assessment Checklist) - ASHAs screen all individuals ≥30 years in community for NCD risk

1. Health and Wellness Centres (HWC):
   • First point of contact for NCD screening
   • Services: Blood pressure measurement, blood glucose testing, BMI, waist circumference
   • Management of hypertension and diabetes at PHC level (task-shifting to CHOs - Community Health Officers)
   • Free essential medicines for hypertension (Amlodipine, Atenolol, Metformin, Aspirin, Statins) and diabetes under National Free Drugs Initiative
2. District NCD Clinics (DNCD Clinic):
   • At district hospital
   • Cardiologist, physician for complex CVD management
   • ECG, echo, stress tests
   • Referral from PHC/CHC
3. Cardiac Care Units (CCU):
   • At district/tertiary level for acute myocardial infarction, unstable angina
   • Thrombolysis for STEMI where PCI not available

1. Essential Medicines for CVD (Free at PHC/HWC):
   • Anti-hypertensives: Amlodipine, Atenolol, Hydralazine, Methyldopa, Thiazides
   • Antiplatelet: Aspirin
   • Statins: Atorvastatin
   • Anticoagulants: Warfarin
   • Polypill strategy for high-risk individuals (being evaluated)
2. Ayushman Bharat - PMJAY (Pradhan Mantri Jan Arogya Yojana):
   • Covers hospitalisation for cardiac procedures (PTCA, CABG, valve replacement) under PM-JAY for economically weaker sections
   • Health insurance cover of ₹5 lakhs per family per year

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B4. WHO Definition of Blindness + Causes + NPCB Actions (1+4+5=10) [SRIMS]

(i) Definition of Blindness - WHO (1 mark)

(ii) Common Causes of Blindness in India (4 marks)

1. Cataract - Most common cause (contributes ~50-80% in South-East Asia); un-operated cataract = #1 cause of preventable blindness in India; bilateral, painless, progressive loss of vision
2. Uncorrected Refractive Errors - Myopia, hypermetropia, astigmatism; treatable with spectacles; major cause of low vision
3. Glaucoma - Increased intraocular pressure → optic nerve damage → irreversible; "silent thief of sight"; open-angle type commonest
4. Corneal Opacity - Due to trachoma (Chlamydia trachomatis), vitamin A deficiency, corneal ulcers (bacterial, fungal), trauma
5. Diabetic Retinopathy - Emerging cause with rising DM prevalence; leading cause in working-age adults in urban India
6. Trachoma - Active infection leads to trichiasis → corneal scarring; still present in pockets (Rajasthan, MP, Bihar)
7. Vitamin A Deficiency / Xerophthalmia - Childhood blindness; declining with Vitamin A supplementation
8. Age-related Macular Degeneration (ARMD) - Elderly; no known cure for dry type

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(iii) Actions Under National Blindness Control Programme (NPCB&VI) (5 marks)

• Launched: 1976; Renamed NPCB&VI to include VI
• Goal: Reduce prevalence of blindness to 0.3%
• Centrally Sponsored Scheme: 60:40 (states); 90:10 (NE states)

1. Cataract Surgery Programme:
   • Free cataract surgery with IOL implantation at district hospitals
   • Targets high Cataract Surgical Rate (CSR)
   • Eye camps in rural and remote areas for case detection
   • Contractual ophthalmic surgeons deployed in deficient areas
2. Screening and Referral:
   • Village level: ASHA/Health Worker identifies and refers blind/cataract cases to PHC MO
   • School screening: Detection of refractive errors; free spectacles to school children
   • Sub-centre: Regular eye examination by ANM
3. Spectacle Distribution:
   • Free spectacles for refractive errors detected in school children and elderly
4. Mobile Ophthalmic Units:
   • Multipurpose district mobile ophthalmic units for remote/hilly/difficult areas
   • Provide diagnosis and medical management of eye diseases
5. Eye Banking and Corneal Transplantation:
   • Promotion of eye donation
   • Eye donation counsellors appointed
   • Corneal transplantation for corneal blindness
6. Expanded Services (beyond cataract):
   • Diabetic retinopathy screening and laser treatment
   • Glaucoma management
   • Vitreo-retinal surgery at tertiary centres
   • Childhood blindness programme (retinopathy of prematurity screening in NICUs, congenital cataract surgery)
   • Refractive error management (low-cost spectacles)
7. Human Resource Development:
   • Construction of dedicated eye units (especially NE states)
   • Training of ophthalmic assistants
   • Strengthening vision centres at PHC level
8. Rehabilitation:
   • Visual rehabilitation centres
   • Low-vision clinics with visual aids
   • Linkage with National Blindness Welfare schemes (disability certificates, social security)

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B5 & B6. Ayushman Bharat Programme - HWC Services for NCDs, Performance Indicators (3+4+3=10) [SSKM]

Major Structural Components of Ayushman Bharat (3 marks)

• 1,50,000 sub-centres and PHCs upgraded to HWCs
• Provide comprehensive primary health care (CPHC)
• Staffed by Community Health Officers (CHO) - BSc nurses/AYUSH doctors trained in primary care - at sub-centre HWCs
• Services: Expanded beyond RCH to include NCDs, mental health, elderly care, palliative care, ENT, ophthalmology, dental care
• Concept: "Bringing healthcare closer to home"

• Health protection scheme for economically vulnerable
• Cover: ₹5 lakh/family/year for secondary and tertiary care hospitalisation
• Beneficiaries: ~50 crore people (10.74 crore families - bottom 40% by SECC 2011)
• Cashless treatment at empanelled public and private hospitals
• No cap on family size or age; covers pre-existing conditions
• Implemented by National Health Authority (NHA)

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NCD Services Mandatorily Available at HWCs (4 marks)

1. Hypertension:
   • BP measurement and screening (all ≥30 years)
   • Diagnosis and initiation of treatment (Amlodipine, Atenolol - free)
   • Follow-up and monitoring
2. Diabetes Mellitus:
   • Fasting/Random Blood Glucose screening (all ≥30 years)
   • HbA1c monitoring
   • Initiation of Metformin; insulin referral
3. Cancer Screening (Oral, Breast, Cervical - CBAC-based):
   • Visual inspection of oral cavity for oral cancer
   • Clinical Breast Examination (CBE) for breast cancer
   • VIA (Visual Inspection with Acetic Acid) for cervical cancer screening
4. COPD:
   • Spirometry (at CHC level)
   • Smoking cessation counselling
   • Salbutamol and other bronchodilators
5. Mental Health (Basic):
   • GAD-7/PHQ-9 screening for anxiety/depression
   • Counselling
   • Referral to DMHP (District Mental Health Programme)
6. Cardiovascular Risk Assessment:
   • CVD risk score calculation (WHO/ISH charts)
   • Aspirin and statin for high-risk cases
7. Ophthalmic Services:
   • Vision screening
   • Referral for cataract
8. Point-of-care diagnostics available at HWC:
   • Hemoglobin, blood glucose, urine dipstick, pregnancy test, malaria rapid test, sputum smear for TB, lipid profile (at PHC-HWC)

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Six Performance and Quality Indicators for HWCs (3 marks)

1. Footfall / Utilisation Rate - Number of patients visiting HWC per month (target-based)
2. Hypertension Case Detection Rate - Number of new hypertension cases detected per population screened (%)
3. Diabetes Case Detection Rate - Number of new DM cases detected per population screened (%)
4. Cancer Screening Coverage - Percentage of eligible population screened for oral/breast/cervical cancer
5. Treatment Coverage/Linkage to Care - Percentage of detected NCD cases who were put on treatment and linked to follow-up
6. Essential Drug and Diagnostic Availability - Availability of free medicines and point-of-care diagnostics (stock-out days)

• Nikshay TB notifications from HWC catchment
• Immunisation coverage from the sub-centre
• Maternal health indicators (ANC, institutional delivery)
• Patient satisfaction scores (quality audit)
• Referral completion rate (tertiary referral with feedback)

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B7. Rule of Halves in Hypertension + Screening + NP-NCD Interventions (4+6=10) [NRS]

Rule of Halves (4 marks)

• Of all hypertensives in the community:
  • Half (50%) are unaware/undiagnosed (do not know they have hypertension)
  • Of those who know: Half (50%) are on treatment (only ~25% of total)
  • Of those on treatment: Half (50%) are adequately controlled (only ~12.5% of total)

• Hypertension is largely asymptomatic - "silent killer"
• Majority of hypertensive burden is untreated and uncontrolled
• Implies enormous potential for prevention of stroke, MI, renal failure through better screening and treatment
• In India: Studies show rule of halves approximately holds; recent data suggest slight improvement with awareness campaigns but control remains poor

• Screening is essential at population level
• Treatment initiation is not enough - adherence and follow-up are critical
• Need for task-shifting (CHOs/nurses initiating and managing hypertension)
• Lifestyle modification must accompany pharmacotherapy

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Screening Protocols and Key Interventions for Hypertension under NP-NCD (6 marks)

• CBAC (Community Based Assessment Checklist): ASHAs use this standardised tool to screen all individuals ≥30 years for HTN, DM, oral/breast/cervical cancer risk in the community (household visits)
• CBAC checklist questions include: family history of HTN/DM, tobacco/alcohol use, physical activity, obesity, symptoms of high BP

• BP measurement for all adults ≥30 years visiting HWC (opportunistic screening)
• BP measurement technique: Patient seated, rested 5 minutes; arm at heart level; appropriate cuff size; average of 2 readings
• Definition used: HTN = BP ≥140/90 mmHg on two separate occasions
• Grading: Stage 1 = 140-159/90-99; Stage 2 = ≥160/100

• Repeat BP measurement on at least 2 visits before starting treatment (unless BP very high or target organ damage present)
• ABPM (Ambulatory Blood Pressure Monitoring) for white coat HTN (at tertiary level)

• Salt reduction campaigns (WHO recommends <5g/day NaCl)
• Tobacco cessation: mCessation (SMS-based), iQuit programme, Quitline (1800-11-2356)
• Physical activity promotion (Fit India Movement, Khelo India)
• Diet: Increase fruits/vegetables (DASH diet principles), reduce saturated fat

• Lifestyle modification counselling for pre-hypertensives
• Weight reduction (BMI target <23 for Asians)
• Alcohol reduction

• Lifestyle modification for all hypertensives (first-line for Stage 1 uncomplicated)
• Free first-line drugs at PHC/HWC:
  • Amlodipine 5 mg (CCB) - first-line
  • Atenolol 50 mg (beta-blocker)
  • Hydrochlorothiazide (thiazide diuretic)
  • Enalapril/Ramipril (ACE inhibitor) especially with DM/proteinuria
• JNC 8 / Indian guidelines: Target BP <140/90 mmHg for most; <130/80 for DM/CKD
• CHO at HWC empowered to initiate and titrate antihypertensives (task-shifting)
• Aspirin + Statin for high CVD risk (10-year CVD risk >10%)

• Rehabilitation after stroke (physiotherapy, speech therapy)
• Renal replacement therapy for hypertensive nephropathy
• Referral: PHC → CHC → District NCD Clinic → Tertiary centre

• Annual BP measurement of all diagnosed cases
• Urinalysis, creatinine, ECG annually (target organ damage monitoring)
• IHIP-based NCD tracking at national level

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B8. Diagnosis per NTEP Guidelines + 4 Drugs + 4 Newer Initiatives (4+2+4=10) [RPHGMCH]

Diagnosis of Cough >2 Weeks, Fever, Haemoptysis (NTEP Guidelines) (4 marks)

• Any individual with: Cough ≥2 weeks AND/OR fever AND/OR haemoptysis AND/OR weight loss/night sweats = Presumptive TB case

• Collect 2 sputum samples (spot + morning sample)
• GeneXpert MTB/RIF assay
• Result in 2 hours
• Simultaneously detects M. tuberculosis and rifampicin resistance
• Positive → Diagnose TB (+ determine DS or RR)
• Negative → Chest X-ray + clinical evaluation

• Mandatory in all presumptive TB cases
• Classic findings: Upper lobe infiltrates, cavitation, fibrosis, consolidation, pleural effusion

• If CXR suggestive and clinically TB likely: Clinical diagnosis → start treatment
• AFB smear microscopy (fluorescence or ZN staining) as adjunct
• TrueNat MTB assay (alternate to CBNAAT at peripheral/primary level)
• Liquid culture (MGIT) - gold standard, 2-3 weeks

• Rule out other causes: Lung abscess, bronchiectasis, lung cancer, pulmonary infarction
• CXR and CBNAAT remain first investigations
• Consider bronchoscopy at tertiary level for persistent haemoptysis with negative CBNAAT

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4 First-line Drugs for Drug-Sensitive TB (2 marks)

1. H - Isoniazid (INH): Bactericidal; inhibits mycolic acid synthesis (InhA enzyme); dose 5 mg/kg/day; risk: peripheral neuropathy (give pyridoxine), hepatotoxicity
2. R - Rifampicin (RIF): Bactericidal and sterilising; inhibits RNA polymerase; dose 10 mg/kg/day; urine turns orange-red
3. Z - Pyrazinamide (PZA): Bactericidal (semi-dormant bacilli in acidic environment); inhibits fatty acid synthase I; dose 25 mg/kg/day; risk: hyperuricaemia, hepatotoxicity
4. E - Ethambutol (EMB): Bacteriostatic; inhibits arabinosyl transferase (cell wall); dose 20 mg/kg/day; risk: optic neuritis (check visual acuity before use)

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Four Newer Initiatives under NTEP (4 marks)

1. Nikshay Poshan Yojana (NPY):
   • All TB patients receive ₹500/month Direct Benefit Transfer (DBT) to their bank accounts during treatment
   • Addresses nutritional deficiency and incentivises treatment adherence
   • Linked to Nikshay portal (TB notification portal)
2. Ni-kshay Mitra (TB Patient Adoption Programme):
   • Individuals, organisations, industries adopt TB patients/families
   • Provide food support, nutritional supplements, vocational training, psychological support
   • Part of PM's "TB-Mukt Bharat Abhiyaan" (TB-Free India Campaign by 2025)
3. CBNAAT / TrueNat Scale-up:
   • Universal Drug Susceptibility Testing (UDST) - CBNAAT for ALL TB patients (not just certain categories as before)
   • TrueNat MTB assay deployed at sub-district level for molecular diagnosis
   • Aims to detect 100% of TB cases with drug susceptibility results at diagnosis
4. Bedaquiline and New Drug Regimens:
   • Bedaquiline (BDQ) and Delamanid (DLM) introduced for MDR/XDR-TB
   • BPaL (Bedaquiline + Pretomanid + Linezolid) regimen for XDR-TB/pre-XDR-TB (TB-PRACTECAL, ZeNix trials)
   • 6-month treatment instead of 18-24 months for drug-resistant TB

• Pradhan Mantri TB Mukt Bharat Abhiyan (launched September 2022)
• National Strategic Plan for TB Elimination 2017-2025
• Advance Molecular Diagnostics: WGS (Whole Genome Sequencing) for resistance mapping
• DSTB treatment shortening trials (4-month regimens being evaluated)

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B9. School Screening - Girls with Weakness, Lethargy, Decreasing Academic Performance [MJNMCH]

Underlying Problem and Confirmation (1+1 marks)

• History: Dietary history (low iron-containing food intake, pica), menstrual history (menorrhagia), socioeconomic history
• Examination: Pallor (conjunctival, palmer), koilonychia, cheilosis (angular stomatitis), glossitis, tachycardia, flow murmur
• Laboratory:
  • Haemoglobin (Hb): WHO criteria for anaemia in girls 12-14 years: Hb <12 g/dL; >15 years: <12 g/dL
  • Complete Blood Count: Microcytic hypochromic anaemia (low MCV <80 fL, low MCH, low MCHC)
  • Peripheral Blood Smear: Microcytic, hypochromic RBCs, pencil cells, target cells
  • Serum Ferritin: <12 ng/mL (most specific for IDA); <30 ng/mL with inflammation
  • Serum Iron: Low; TIBC: High; Transferrin saturation: Low (<16%)
  • Grade of anaemia: Mild (10-11.9), Moderate (7-9.9), Severe (<7 g/dL)

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Interventions at School and Family Levels (3 marks)

1. WIFS: Supervised Weekly Iron and Folic Acid Supplementation (large blue tablet: 100 mg elemental iron + 500 mcg folic acid) every Monday at school
2. Deworming: Albendazole 400 mg every 6 months (helminth infestation worsens iron deficiency)
3. Nutrition education: Iron-rich foods (green leafy vegetables, jaggery, legumes, meat/fish), Vitamin C to enhance absorption, avoid tea/coffee with meals (phytates/tannins inhibit absorption)
4. Mid-day Meal Scheme: Micronutrient-fortified food at school; iron-rich menu
5. Referral: Severely anaemic girls to PHC/CHC for further evaluation and treatment
6. Health talks by ANM/School Health Nurse: Menstrual hygiene, iron-rich diet, WIFS compliance

1. Dietary counselling: Increase iron-rich foods (green leafy vegetables, lentils, beans, fortified cereals, meat); cook in iron vessels (traditional remedy)
2. Food fortification: Use of iodised and iron-fortified salt; double-fortified salt
3. Vitamin C-rich foods: Amla, citrus fruits - taken with iron sources to enhance non-haeme iron absorption
4. Treat infections: Malaria (causes haemolysis), worm infestation (causes chronic blood loss)
5. Behaviour change: Delay early marriage (early pregnancy worsens anaemia); reduce teenage pregnancy
6. Supplemental therapeutic iron: Therapeutic IFA syrup/tablet under medical supervision for diagnosed cases

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Related National Programme (1 mark)

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Beneficiaries and Package of Services (5 marks)

1. School-going adolescent girls (Class 6-12, age 10-19 years)
2. School-going adolescent boys (Class 6-10, age 10-16 years)
3. Out-of-school adolescent girls (10-19 years) - delivered via AWW/ASHA

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B10. P. vivax Malaria Recurrence, Treatment, IVM Strategies (2+4+4=10) [JMNMCH]

Cause of Recurrence in P. vivax (2 marks)

• P. vivax forms dormant liver stages called hypnozoites (small dormant forms in hepatocytes)
• These hypnozoites reactivate weeks to months after primary infection
• Primaquine (which eliminates hypnozoites - radical cure) was not completed by this patient
• Without radical cure with Primaquine, hypnozoites persist and cause relapses (typically every 3-6 weeks in tropical strains - "Chesson-type"; or every 6-12 months in temperate strains)
• Relapse occurs even with adequate treatment of blood-stage infection if Primaquine is not given/completed

• He did not complete his antimalarial schedule → Primaquine course was incomplete → hypnozoites persisted in liver → reactivation after 2 months

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National Treatment Guidelines for Vivax Malaria (4 marks)

• Chloroquine (CQ): 25 mg/kg total dose over 3 days
  • Day 1: 10 mg/kg (max 600 mg base)
  • Day 2: 10 mg/kg (max 600 mg base)
  • Day 3: 5 mg/kg (max 300 mg base)
• Given as tablets (150 mg base each)
• For this patient (assumed ~60 kg): Day 1 & 2: 4 tabs; Day 3: 2 tabs of CQ 150 mg base

• Primaquine (PQ): 0.25 mg/kg/day × 14 days (Low dose regimen; India uses this)
• Or Primaquine 0.5 mg/kg/day × 7 days (alternative short course)
• Standard adult dose: 15 mg/day × 14 days (for most patients)

• Test for G6PD deficiency before prescribing (Primaquine causes haemolysis in G6PD-deficient individuals)
• Contraindicated in: Pregnant women, infants <6 months, G6PD-deficient patients (if unable to test, use supervised low-dose Primaquine weekly for 8 weeks as alternative)
• Monitor for haemolysis: Urine colour change (dark urine/haemoglobinuria), pallor, jaundice

• Restart full course: Chloroquine 3 days + Primaquine 14 days
• Supervise Primaquine intake (ensure compliance this time)

• Artesunate (AS) + Mefloquine (MQ) combination + Primaquine 14 days

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Integrated Vector Management (IVM) Strategies for Malaria Control (4 marks)

1. Larvivorous fish: Gambusia affinis and Lebistes reticulatus introduced into ponds, rice paddies, slow-moving water → eat Anopheles larvae
2. Bacillus thuringiensis israelensis (Bti): Biological larvicide applied to water bodies

1. Indoor Residual Spraying (IRS):
   • Dichlorodiphenyltrichloroethane (DDT), Malathion, Synthetic pyrethroids (Deltamethrin, Alphacypermethrin)
   • Applied to interior walls and roofs of all houses in endemic areas
   • Kills resting female Anopheles mosquitoes
   • Done twice yearly in high-endemic areas (before and after transmission season)
2. Insecticide-Treated Bed Nets (LLIN/ITN):
   • Long-Lasting Insecticidal Nets (LLIN) distributed free to households in tribal/high-endemic areas
   • Free ITN distribution under NVBDCP
3. Larval Source Management (LSM):
   • Temephos (Abate) - organophosphate larvicide for water bodies
   • Pyrethrum spray (space spray) for adult mosquito killing

1. Source reduction: Draining/filling of stagnant water collections (construction sites, overhead tanks, tyres, coolers)
2. Water management: Anti-larval measures in rice fields - intermittent irrigation, dry furrows
3. Community sanitation: Proper drainage, clearing of vegetation near water bodies

1. Mosquito repellents (DEET-based)
2. Protective clothing (full sleeves, long pants) at dusk/dawn
3. Screening of windows and doors
4. Bed nets (untreated or ITN)

1. ASHA-based community surveillance (early diagnosis and treatment)
2. IEC campaigns about eliminating mosquito breeding sites
3. Rapid Diagnostic Test (RDT) kits at village level for early diagnosis
4. Malaria surveillance - API (Annual Parasite Incidence), SPR (Slide Positivity Rate) monitoring

1. ABER (Annual Blood Examination Rate): Target ≥10% of population per year
2. P. falciparum (severe malaria) management: Artemisinin Combination Therapy (ACT = Artesunate + Sulphadoxine-Pyrimethamine)
3. Fever Treatment Depots (FTD): ASHAs maintain RDT kits and CQ+PQ for P. vivax treatment in remote areas
4. Surveillance under Integrated Disease Surveillance Programme (IDSP)

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B11. Pulmonary TB (CBNAAT-confirmed) - Short Answer Questions [DHGMCH]

Definition of Presumptive TB Case (1 mark)

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Two Objectives of NTEP (1 mark)

1. To achieve and maintain a case detection rate of ≥90% and treatment success rate of ≥90% of all diagnosed TB cases
2. To eliminate tuberculosis from India by 2025 - defined as incidence rate <1 per 10 lakh population per year (5 years ahead of the global End TB Strategy target of 2030)

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Role of CBNAAT in TB Diagnosis (1 mark)

• Simultaneously and rapidly detects:
  1. Presence of Mycobacterium tuberculosis DNA (diagnosis)
  2. Rifampicin resistance (as surrogate marker for MDR-TB) - via detection of mutations in rpoB gene
• Result available in 2 hours (vs weeks for culture)
• High sensitivity (~88%) and specificity (~99%) for pulmonary TB
• Used as first-line diagnostic test in NTEP for all presumptive TB cases (Universal DST)
• Replaces AFB smear as primary diagnostic in most settings

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Nikshay Poshan Yojana (1 mark)

• A Direct Benefit Transfer (DBT) scheme under NTEP launched in 2018
• All notified TB patients (both DS-TB and DR-TB) receive ₹500 per month directly into their bank account/Jan Dhan account during the entire period of treatment
• Purpose: Provide nutritional support (TB causes wasting and malnutrition worsens outcomes)
• Linked to Nikshay portal (national TB notification and management platform)
• Patient must be notified on Nikshay to avail the benefit
• Also linked with Ayushman Bharat for comprehensive support

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Summary / Navigation Guide

GROUP A (LAQ - 15 marks each)

GROUP B (SAQ - 10 marks each)