Epi

demi
ologi
cal
exer
cisesi
ncommuni
cabl
edi
seases.

1.Af
emale(nonpregnant)
ofage35y rscametoPHCwi t
hcomplai
nts
di
schar
geperv agi
na,geni
tali
tchi
ng,l
owbackachesi
nce1mont h.
Her
menstr
ualhist
oryisnormal
.Suggestthemanagementundersy
ndr
omic
appr
oach.

Ans:Thewomancamewi thcomplai
ntsofdischar
geperv
agi
na,
geni
tal
i
tchi
ng,l
owbackache.Hermenst
rualhist
oryisnormal
.

Askfor–Natureandtypeofdischargeindet
ailandanyot
herassociated
geni
talcomplai
nts.Askf
orhistoryofgeni
talcomplai
ntsf
rom hersexual
part
ner.

Undert
hesy
ndr
omi
cappr
oach,

1.
Ident
if
icat
ionofsy
ndr
ome:

Dependi
ngupont
hepr
esent
ingcompl
aint
s,

Eg:
Ift
hedi
schar
geperv
agi
nai
s-cur
dywhi
te-
Candi
diasi
s
gr
eeni
shf
rot
hy-
Tri
chomoni
asi
s
Perspecul
um examinat
ioncanbedoneiff
aci
l
iti
esareavai
l
abl
etoconf
ir
m
whet
heriti
scervi
cit
isorvagi
nti
sandty
peofdischar
ge.
2.Caseholdi
ngandTr
eatment
:Forv
agi
nit
is:ForCandi
diasi
s:Tab
Fl
uconazol
e150mgorall
ysi
ngl
edose orl
ocalClot
ri
mazole500mgvagi
nal
pessar
iesonce.

Forvagini
ti
s(KI
T2green)
:TabSecni
dazol
e2gm or
alsi
ngl
edoseand
cap.
Fluconazol
e150mgODst at

ForCer
vici
ti
s(KI
T1grey)
:TabCefixi
me400mgor
all
y,si
ngl
edose.and
Azi
thr
omy ci
n1gm or
alsi
ngledose.

I
fvagi
nit
isandcer
vici
ti
sar
epr
esentt
reatf
orbot
hwi
thki
t1and2.

3.
Par
tnernot
if
icat
ionandmanagement
:

Cont
actt
raci
ng:
ident
ifyi
ngthesexualcont
act
softhecli
entf
ort
hel
ast3
mont
hsandtr
eatthem accor
dingl
yift
heyaresymptomati
c.

Cl
ust
ertesti
ng:Cl
i
enti
saskedtonameotherper
sonsofei
thersexwho
movei
nt hesamesoci
osexual
envir
onment.

4.
Heal
theducat
ionandcounsel
l
ing:

-
Adv
isesexual
abst
inencedur
ingt
hecour
seoft
reat
ment
.

-Thecl
ientandthepar
tnerofthecli
entshoul
dbeeducatedregar
dingsaf
e
sexbehaviourl
i
kecorr
ect,consi
stentusageofbar
ri
ercontr
acept
ives.

1
-Cl
i
entshouldbeadv i
sedt ovisi
tICTCtocheckHIVstat
us-ifthe
symptomsper si
stsevenaftertr
eatmentandalsoi
fthecli
enthashi
stor
yof
multi
plesexualpar
tners.

5.
Foll
owup:af
teroneweek-I
fthecondi
ti
onper
sist
sthecl
i
enti
sref
err
edt
o
hi
gherheal
thf
acil
i
ty.

Advantagesofsyndromicapproach-Costeffect
ive,
comprehensive,
singl
e
dose,easytoadmini
ster,sci
enti
fi
call
yproven,noneedofexpert
consult
ati
onorlabtests,
incl
udescounsell
ingandcl i
enteducat
ion.

2.
Amal
ecl
i
entcamet
oPHCwi
thgeni
tal
ulcer
.

Suggestt
hel
i
neofmanagementundersy
ndr
omi
cmanagement
.

Ans:Takethehi
stor
yofcomplai
ntsf
rom thecli
ent-r
egar
dinggeni
talul
cer
,
pai
n,vesi
clesi
ngenit
alar
ea.Takehi
stor
yr egar
dinghi
ghri
sksexualbehav
iour
.

Onexami
nat
ion,
Typeoful
cer
-si
ngl
eormul
ti
ple,
pai
nful
orpai
nless

Lookf
orPr
esenceofv
esi
clesandpal
pabl
eingui
nal
lymphnodes.

Casemanagement
:

I
fthecli
entcomplai
ntsofmult
ipl
eorsingl
eulcerwi
thorwi
thoutv
esi
cl
es,
pai
nful
-Condi
ti
onisHERPETIC-Treatwi
thKIT5(Redcol
our
)-
TabAcycl
ovi
r
400mgf or7days.

Ot
hercondi
tions,
NON-HERPETI
C-KI
T3(
Whitecol
our)
-Inj
Benzat
hinepenci
l
li
n
2.
4MU1v i
alandTabAzit
hromy
cin1gm si
ngl
edose.

I
ftheper
sonisal
l
ergict
openici
l
li
n,giveKIT4(Bl
ue)
-Doxy
cycl
i
ne100mgBD
f
or15daysandAzit
hromyci
n1gm singledose.

Par
tnernot
if
icat
ion&management

Heal
theducat
ion&Counsel
l
ing Ref
ert
oAns1

Fol
l
owupandRef
err
al.

3.Mor enumberofcaseswer er
eport
edatOPDwi t
hfever,
chill
s,bodyaches,
sorethroat
,non-product
ivecough,
runnynoseandheadache.Keepinginvi
ew
ofseasonalinf
luenzaoutbreak,
Suggestt
hemeasurestobet aken.

Ans:

1.
Categor
izati
onofcasesdonet
opr
eventandcont
ainout
breakof
I
nfl
uenzavirus:

2
CategoryA:Pat i
entswithmildfever,cough/sorethr
oat,headache,
diarr
hoeaandv omiti
ng.Theydonotr equi
reOselt
amivirandshouldbe
givensymptomat i
ctreatment.Monitoredfor24to48hour sbythedoct
or.
Not est
ingofthepatientforI
nfl
uenzai srequi
red.Pati
entsshouldconf
ine
themselvesathomeandav oi
dmi xingupwi thpubl
icandhighrisk
member sinthefami l
y.

Categor
yB: I
nadditi
ontoall
thesignsandsympt
omsment i
onedunder
Categor
y-A,undert
hefol
lowingcondi
ti
ons,t
hepati
entshoul
dbegiven
Oselt
amivir
.

(
foradul
ts-
75mgBDf
or5day
s)

-hi
ghgr
adef
everandsev
eresor
ethr
oat

Children,Pr
egnantwomen;aged>65y ears,Pati
ent
swithlungdiseases,
hear tdi
sease,l
iv
erdi
sease,metabol
icdiseases,i
mmunosuppr essi
on.All
thesef or
m highri
skgr
oup.Not est
sforInfl
uenzaisrequi
redforCategory-
B

Al
lpat
ientsofCat
egor
y-Bshoul
dconf
inet
hemselv
esathomeandav
oid
mi
xi
ngwi t
hpubli
candhighri
skmembersi
nthefamil
y.

Category-
C:I naddit
iontot heabov esignsandsy mptomsofCat egory-
A
andB, i
fthepat i
enthas:Breat hlessness, chestpain,
drowsiness,
falli
n
bl
oodpr essure,Chil
drenwithi nfluenzalikeill
nesswhohadasev ere
di
seaseasmani fest
edbyt her edflagsigns( highandpersi
stentfever
,
i
nabili
tytofeedwel l
,convulsions, short
nessofbr eat
h,di
ffi
cult
yin
breat
hing,etc).

-
Requi
ret
est
ing,
immedi
atehospi
tal
i
zat
ionandt
reat
ment
.

Confi
rmati
onofseasonal i
nfl
uenza(i
ncludi
ngHIN1)i
nfect
ionisthrough:
•
Realt
imeRTPCRor•I solat
ionofthevir
usincul
tur
eor•Four-
fol
dr i
sein
vi
russpeci
fi
cneutr
ali
zingantibodi
es.

Earl
yimpl
ement
ati
onofinf
ectioncontr
olprecaut
ionst
omi
nimi
ze
nosocomi
cal
/househol
dspreadofdisease:

I
-sol
ati
onf
aci
l
iti
es,
Int
ensi
vecar
efaci
l
iti
esshoul
dbeav
ail
abl
eathospi
tal
.

-Per
sonalpr
otect
ionmeasures:handwashingpract
ices,Tri
plel
ayer
sur
gical
mask,N95Respirat
or,gowns,goggles,
gloves,capandshoecov
er.

Support
ivet
her
apy:I
VFlui
ds.Parent
eralnut
ri
ti
on.Oxy gent
her
apy
/
vent
il
ator
ysuppor
t.Ant
ibi
oti
csforsecondar
yinfect
ion

Vacci
nat
ion:Year
lyf
or-hi
ghr
iskgr
oup,
Heal
thCar
ewor
ker
s,Labor
ator
y
per
sonnel
.

Ther
ecommendedTr
ival
entv
acci
nebyI
CMRf
ory
ear2017-
2018ar
e-

3
 A/
Michi
gan/45/
2015(H1N1)pdm09-
;A/
HongKong/
4801/
2014(
H3N2)
;
B/
Bri
sbane/
60/2008.

Thesevacci
nesareexpect
edtooffergoodef
fect
ivenessagai
nstcur
rent
ly
ci
rcul
ati
ngsubty
pesofInfl
uenza.

Chemoprophyl
axi
s-Oseltamivi
risgiv
enforhi
ghriskindi
vi
duals-Healt
hcare
pr
ov i
der
s,cl
osecontactofpati
ent.I
tisgiv
enfor10daysfrom thedayof
l
astexposur
e
Dischar
gePoli
cy:Adultpati
entsshouldbedi
scharged7daysaf ter
symptomshavesubsided.Chi l
drenshoul
dbedischarged14day saf
ter
symptomshavesubsided.

Int
ernati
onalHealt
hRegulati
onstobefoll
owedli
kerest
ri
cti
onoft
rav
el
acr
ossbor der
s,scr
eeni
ngoft r
avel
ler
satport
s,quar
anti
nemeasur
es,
i
solat
ionofcases,not
if
icat
ionofcases.

Monitori
ngandsurvei
ll
ance:Rout
inesurvei
l
lanceforI
nfl
uenzalikei
l
lness
(
ILI
)andSev er
eacuterespi
rat
oryi
llness(
SARI).St
rongsurv
eil
lancesystem
t
opr eventt
hediseaseentr
y.

4.Ramar aoofage45y ear

scamet oPHCwi t
hcomplai
ntsofcough,f
ever
si
nce20day s.Nohi st
oryofsimil
arcompl
aint
sinpastornohist
oryofAnt
i
TBtreatment.Suggestthemanagement(i
fsputum smeari
spositi
ve,
HIV
negati
veandhi sweightis62kgs).

Ans:Thecasei
snewcaseandmicr
obi
ologi
cal
l
yconf
ir
med.Hence
underFDC-
Dail
ydoser
egi
menunderRNTCP,

For62kgCAT1(
newcase)f
orwei
ghtband55-
69kgs

I
ntensi
vephase-
2(HRZE)-
4tabperday
.

Cont
inuat
ionphase-
4(HRE)
-4t
abperday
.

Thepati
entwi
l
lbegi
vent
reat
mentcar
dandTBI
Dcar
d,Fol
l
owupat2,
4,
6
months.

Adv
isest
obegi
ven:

1.Counsel
l
ingoff
ami
l
ymember
sforsuppor
tandt
reat
mentcompl
i
ance.
2.Counsel
l
ingofpat
ientf
ort
reat
mentadher
ence.
3.Lookforcomor bi
dcondi
ti
onsl
i
kediabet
es,
HIV.I
fHI
Vposi
ti
ver
efert
oART
centref
orinit
iat
ionofARTandCPT.
4.
Discour
ageuseoft
obaccopr
oduct
seg:
smoki
ngci
gar
ett
es.
5.
Moni
torwei
ghtgai
nforadj
ust
ingt
hedosesofdr
ugs.
6.Nut
ri
ti
onal
assessmentandadv
iser
egar
dingnut
ri
ti
ont
obegi
ven.

4
9.
Thepati
entisadvisedt
ocovert
hemout
hwhi
l
ecoughi
ng(
coughhy
giene)and
hy
gieni
cdisposalofsput
um.
10.
Otherf
ami
l
ymember
sar
eal
soscr
eenedf
orTB.

5.Pat
ientcamet oPHCwithfever
,coughsince1month.
Drawthediagnost
ic
al
gorit
hm forpresumpt
ivepulmonaryTBpat i
ent
sundernewergui
deli
nesand
suggesttheregi
mensfornewandpr et
reat
mentcases.
Ans:
Presumptiv
epulmonaryTBcaseisthepat
ientwi
thcough,
fev
er>2wks,
si
gni
fi
cant
weightl
oss,haemopt
ysisanyabnor
mali
tyi
nchestXray.

ForNewcase-I
P:2(
HRZE),
CP:
4(HRE)

Forpr
etr
eat
edcase:
IP-2(
HRZES)
+1(
HRZE)
,CP-
5(HRE)

6.Inat r
ibal ar
eaAr akuinVizagdistri
ct,whereAnnual parasit
eincidence
(API)ismor et han2andendemi cformal ar
ia,morenumberoff evercases
wer ereportedinmont hofJune. Asamedi caloff
icerofPHCwhatact i
on
willyoutakef orcontainmentofmal ari
aint hatar
ea
Ans:St ratif
icati
onoft heprobl
em: (r
ef:Nati
onalstrat
egicplan2017- 22)
TribalareaAPI >2per1000popul ati
on.Hencet heareaiscat egor
isedinto
i
ntensivecont rolphase(cat
egory3).
Ast hear eaisendemi cRDTki t
swi l
lbeusedwhenmi croscopyfacili
tyi
s
notav ai
lablewi t
hin24hrstoinit
iat
et r
eatment .
Diagnosisandmanagementofcases:

5
Strategi esf orcont ainmentofmal ari
aint hear ea:
1.Increaset heout reachact i
viti
esbypr ov i
dinghaml et
-wise
ASHAs, AWW, Local healthcar epr ov i
ders,PRIs,
School teacher s,NGOsar e
trainedf orr apiddiagnosi sbyRDTki tsatdoor st epandpr ov i
dingt r
eatment
formal aria.
2.St r
engt henAct iv
eandPassi v esur vei
llance-massscr eeni ngoft ri
bal
popul ation. Activecasedet ectioni sdone.
3.St r
enght eningofdi agnost icf acil
iti
es–RDTki ts,Qual
it
ymi croscopy.
4.Ear l
ydet ectionandr adicaltreatmentofcases
5.Identificationandr eferralofcompl icatedcases:
7.Integrat edv ectormanagement( API>2) :
-
Uni versal coveragewi t
hLLI Ns-
-
IRS-2r oundsofDDTor3r oundsofMal athion.
-
Inout breakaddi t
ionalroundofI RS
-Ant il
arvalmeasur es:larvicideslikeTemephos, Sour cer educti
on.
8.Ent omol ogi calsurv ei
ll
ancebyent omol ogistt osuggestf orappr opri
ate
i
nsect i
cide.
6
9.
Epidemicprepar
ednessandearl
yr esponse.
10.
Communi tymobil
izat
ionthr
oughbehav i
ouralchangecommuni
cati
on-
to
i
ncreasetheaccept
anceorcomplianceforLLINs(to80%)andI
RS(
to90%)
.
11.
Monitori
ngandev al
uati
on.

7.Inat ownwi th1l akhpopul at i

on, about20chi ldrenwer eadmi ttedf orhigh
fev erdur ingf irstweekofJune.3chi ldrenwer eshowi nghemor rhagic
mani festat i
on, onechi ldwashav ingmani fest at ionofshock.Di scusshow
doy oui nv estigat eandmanaget hispr oblem.
Ans:
Ans: From t hedescr ipt iongi ven, thedi seasecanbeDenguef everasi tis
endemi cinI ndia, responsi blef ort hemostofhospi tal admi ssionsduet o
haemor rhagi cmani fest at i
onsandshock.
Met hodol ogyofi nv est igat i
on:
1.Rapi df eversur v eybyhouset ohousev isitandcol lectionofser a
sampl esf rom suspect edcasesf orDengueI gM ELI SAt est.
2.Conf irmat ionofout break: Out br eakcasedef init
ionwasdef ined“ as
anyper sonwi thacut ef ebr i
lei ll
nessof2- 7day sdur ati
onwi tht woor
mor eoft hef ollowi ngcl inicalsi gnsandsy mpt oms( headache, retr
o-
orbitalpai n, my algi a,ar t
hr algiaorr ash)
3.Ent omol ogi cal inv est igat i
ons- adul t&l ar val sur veydonet o
under standt hev ect orspeci espr evalenti nt hear ea; Exami nat i
onof
wat erst oragepr act i
cesandv ect orbr eedi ngsi tes, calculateaedes
aegy pti i
ndi ces- Housei ndex, Cont ainerindex, Breteaui ndex.
4.Managementofcases:
-All denguef ev ercasesgi venpar acet mol forf ev er,ORS, referralifany
compl i
cat i
ons.
-Moni torBP, ur i
neout putandHaemat ocr i
t,Plat el etcountofpat i
ent .
-ForDengueHaemor rhagi cf ev er:(pl atelet<1l akh/ mm3and
heamat ocr i
t>20%) -gi veI Vcr y stalloids6ml /kg/ hrf or2- 4hr s.Discont i
nueI V
fluidsi fcondi ti
oni mpr ov esaf ter24- 48hr s.
-Prophy l
act icpl ateleti nf usi ongi v enwhenpl at eletcounti s<1000/ mm3.
-Incaseoff all i
nheamat ocr itgiv ebl oodt ransf usi on
-I
ncaseofshock- IVf lui ds, plasmaexpander s, oxy gent herapy .
-Criteriaf ordi schar ge: lookf orsi gnsofi mpr ov ementl ike
-Absenceoff ev erf orpast24hr s,goodur ineout put ,
recov eryfrom
shock, i
mpr ovementi npl at eletcount
-not ifi
cationofcases.
Cont rolmeasur es:
-Vect orcont rol:Ant iadul t:IRS; Ant i l
ar val-sour cer educt ion,chemi cal.,
dry
day; personal prot ect i
v emeasur es.
--Heal theducat i
onr egar dingv ectorcont rol ,i
mmedi ater epor tingofcases
tohospi tal,dengueawar eness.
-Thehospi talsshoul dbewel l equi ppedt omanagecasesdur i
ngout break
-RDTki t
ssuppl y
-Cont i
nuoussur vei l
lance.

8.Sati
shofage32y earscametoPHCduet odogbi
te.Onexaminat
ion
ther
earemulti
plebit
esonleftl
owerli
mbwithbl
eedi
ng(wtofper
sonis
65kgs)
.Suggestthestepsofmanagement
.

7
Ans: (
Ref
:WHOGui
del
i
nesf
orRabi
esPr
ophy
laxi
s-2014)

Woundcar
e:
-Immedi
atewashi
ngandf
lushi
ngwoundf
or15mi
nut
eswi
thsoapand
wat
er.
-
Chemical
treat
ment-
Disinf
ect
ionwit
hdetergent,et
hanol
(700ml/l
),i
odine
(
ti
nct
ureoraqueoussoluti
on)
,orot
hersubstanceswithvi
ruci
dal
activi
ty.
-Sut
uri
ngshoul
dnotbedoneandi
frequi
reddoneunderI
Glocal
l
yaf
ter24-
48hrs.
-
Admi
nist
rat
ionofant
ibi
oti
csandt
etanuspr
ophy
laxi
s.
Cl
assi
fi
cati
onofwound:Astherearemult
ipl
etr
ansder
mal
bit
eswi
th
bl
eedi
ngiti
sclassi
fi
edunderCategor
yII
I.
I
mmuni
zat
ion:
Forcat
egor
yII
I
1.UpdatedThai RedCrossSchedule(2-
2-2-
0-2)
.Thi
sinvolvesinj
ecti
on
of0.1ml ofr
econsti
tut
edv acci
neperIDsit
eandont wosuchI Dsites
pervisi
t(oneoneachdel t
oidarea,
aninchabovetheinsert
ionof
del
toidmuscle)onday s0,3,7and28.Theday0ist hedayoff i
rst
doseadmi ni
strat
ionofIDRV.
2.Admi ni
strati
onofIG: ThedoseofEquiner abiesIGi s40I Uperkg
bodywei ghtofpatientandisgivenaft
ertest i
ngf orsensiti
vi
ty,uptoa
maximum of3000I U.Thedoseoft hehumanr abi esIG(HRIG)i s20
IUperkgbodywei ght(maximum 1500I U).RIGshoul dbeinfi
lt
rated
aroundthewoundasmuchasanat omicallyfeasible. RemainingRIG
shouldbei nj
ectedatani nt
ramuscularsit
edi stantfrom thatof
vaccinei
nocul at
ion(e.g.i
ntotheanter
iorthigh).
I
nthepresentcasewei
ghtofpati
entis65kgshence,
doseofEqui
ne
I
mmunogl obul
inis40I
U/Kgx65=2600IU.
DoseofHumanRabiesI
Gis
1300I
U.

Adv
iset
othepat
ient
:-
-
Tocompl
etev
acci
nat
ionaccor
dingt
oschedul
e
-
Thepat
ienti
seducat
edr
egardi
ngthecar
eofdogsandpreventi
onof
r
abi
esli
keimmediat
ewoundcareandi
mport
anceofvacci
nation.
-Heisadv
isedt
ointi
matel
ocal
gov
ernmentaut
hor
it
yift
her
ear
eany
str
aydogsinhi
sarea.

9.MOofPHCwasi nformedt hat35chi

ldrenofaresi
denti
alschool
i
nt hePHCareahadsuddenv omiti
ngandabdominalcoli
cwithin12
hourofconsumi
ngfood.Descri
bethestepsofinv
esti
gati
onand
control
.

8
 Ans:(
Ref:
Foodbor
nedi
seaseout
breaks:
gui
del
i
nesf
ori
nvest
igat
ion
andcont
rol
.-
WHO).
1.
Prel
iminar
yassessmentoft
hesi
tuat
ion:Toconf
ir
m orr
efut
e
occur
renceofout
break.
-Byinter
viewingthecasesregar
dingf
oodconsumptionhist
ory,
H/ O
symptoms, (
past72hrs)withhel
pofquest
ionnai
reandalsocli
nical
examinati
onofpat i
entsisdone.
-
Linel
i
sti
ngofcases.
2.Casedef
ini
ti
on:Theoccurr
enceoft
woormor ecasesofasi
mil
ar
foodbor
nediseaseresul
ti
ngfr
om t
heingest
ionofacommonfood.
(Ifthepredominantsymptom i
sv omit
ingwithoutf
everandthe
i
ncubat ionperi
odis<8hour s)causati
veagentcanbe
St aphyl
ococcusaureus,
Clostr
idi
um perfr
ingensorBaci
ll
uscereus-
in
thepr esentcasescenar
io.
(I
fFeverintheabsenceofv
omiti
ngandanI
P>18hourspoi
ntst
oan
enter
icinf
ecti
onsuchasSalmonel
la,
Shi
gel
l
a,Campy
lobact
eror
Yersi
nia
3.
Managementofcasesaccor
dingl
y-
Oral
orI
Vfl
uidsandant
ibi
oti
cs.
Af
terconf
ir
mat
ionofout
break,
Out breakcont
rolteam:MO, Publi
cheal
thspeci
ali
st,
Labspeciali
st
(microbiol
ogi
st,
labtechni
cian)
,foodsaf
etycont
roloff
icer
,Logi
sti
c
suppor t
.
3.Conductsiteinvesti
gati
onatpr emises:Foodandenvi
ronment
al
i
nvesti
gations.Inspectstr
ucturalandoperat
ional
hygi
enein
i
mplicatedfoodpr emises.
Takeappr opr
iat
efoodandenvir
onment
al
samples.sourcesofwat ersupplyistobeexaminedandsampl
esto
bet
aken.
4.Labi
nvest
igat
ionofColl
ect
edcli
nical
speci
mensfrom cases(
faecal
sampl
es,vomit
usetc)andofCol
l
ectedfoodspeci
mens.
5.Exami nati
onoff oodhandl ers:-Forhy
giene,handwashingpracti
ces,
specif
icfood-handli
ngpr acti
ces,askf oranyhistoryofdi
arrhoea
,fev
eretc.Phy si
cal examinationoffoodhandlers.Labinvesti
gat
ion
ofsampl esfr
om t hem ifrequired.
6.Analysi
sandi nterpretati
on:Reviewal
lexi
sti
ngdataandconfir
m
hypothesisorexistenceofout br
eakandcommuni catet
othelocal
authori
ti
est opreventf ur
therspr
eadofit
.Calcul
atetheatt
ackrates
toidenti
fyincr
iminat i
vefood.
Fol
lowupandr ecommendat
ionsf
ort
hepr
event
ionofr
ecur
rencesof
si
milarout
breaks:
-
Foodsani
tat
ion-
prepar
ati
on,
stor
age,
consumpt
ion.
-
Per
sonal
hygi
eneofst
udent
sandf
oodhandl
ers

9
 -
Excl
udingt
hepersonssuf
feri
ngfrom i
nfect
edwounds,
dysenter
y,URTI
f
rom f
oodhandl
ing.Regul
arheal
thcheckupsoff
oodhandlers.
-Educat
ethef
oodhandl
ersregar
dingt
hecor
rectf
oodhandl
i
ngt
echni
que
andhandwashingpr
act
ices.
-
Ensur
efoodsaf
ety
-pr
epar
ati
on,
stor
age,
consumpt
ion.
-
Sani
ti
zat
ionofpr
emi
ses,
utensi
l
s.
-
Foodpr
emi
sesshoul
dbekeptf
reef
rom r
odent
s,f
li
es,
dustet
c.
-
Cont
inui
ngsur
vei
l
lance.

10.Ar out i
necl ini
cal surveyf orfil
ari
asiswascar ri
edouti nacommuni t
y
healthcent er,servi
ng1l akhpopul ation,datacol
lectedisgivent oyou
Nightbl oodsmear scol l
ected30, 000
Personsshowi ngonl ymfposi ti
ve300
Per sonsshowi ngmer esi gnsoff i
lari
asi
s80
Per sonsshowi ngbot hmfposi tiveandsigns10
Calcul at
et hepossi bl efi
lari
ali
ndi ces?Andsuggestt hecont rol
measur es.
Ans::Sampl esi ze:Forr outinefil
arialsurvey, sampl esi
ze
recommendedi s5 to 7%.I n t
hissur
vey ,
30% sampl eis
exami nedhencet hesampl eisadequat eandaccept able.
Calculationoff i
lari
al i
ndices:
1.Micr ofil
ar i
alrate( mf )=
Numbershowi ngmfposi ti
v i
ty/Numberofper son( sl
ides)
exami ned×100
=300/30000x100, =1%
2.Fil
ar i
al diseaser ate=
Numbershowi ngf i
larialdiseasesy mpt oms/ Numberofper sonexami ned
×100
=80/ 30000x100=0. 26%
3.Filarialendemi ci
tyr ate=
Numberhav i
ngdi seasesi gns+Numberofmfposi tives+Bot h/Numberof
personex ami ned×100

=80+300+10/30000 x100
=390/
30000 x100=1. 3%

Cont
rol
measur
es:
1.Chemot
her
apy2.Vect
orcont
rol
.

1.Chemotherapy :
DEC( Di
ethy
lcarbamazine):6mg/ kgperdayf or12daysin
di
v i
deddosesf atermeals.
Inendemi car
eastreatmentrepeat edever
y2y r
s.
Prevent
ivechemot herapy:Massdr ugadmi ni
str
ati
onofAl bendazol
e400mg
withDec6mg/ kg.I ti
sconductedannuallyfor4-6yrst
oi nterr
uptthe
tr
ansmissioncy cl
e.
DEC-medicatedsal t:
Commonsal tmedicatedwith1-4gm ofDecperkgi n
endemicareas.
Managementofl ymphoedema: Car eoftheskinofeffectedlimb,bywashing

10
anddr yi
ng;preventingandt reatingent
rylesions; pr
ovidi
ngly
mphdr
ainage
byelevati
nglimbandexer cising.
2.Vectorcontrol:
-Antil
arvalmeasur es:MLO( Mosqui tol
arvicidal
oil
),
Temephos. ;deweeding;sani t
arymeasur es;undergr
oundwast
ewater
disposalsyst
em. ;Fil
li
ngthedi tchesandcesspool s
-Antiadultmeasur es:Spacespr ayofPyrethr um.
Personalprotecti
on: mosqui tonets,mosqui torepell
ants.

I
MNCIMCHQUESTI
ONS

QUESTI
ON:
11

Jat
ini
s6weeksol
d.Hewei
ghs4.5kg.Hi
stemperat
urei
s37°C.Heisbroughttothe
PHCbyhi
smotherwi
thl
oosest
oolssi
nce3days.Thi
sisthei
nit
ial
visi
tfort
hisil
l
ness.

Whent hephysi
cianasksthemot heraboutJat
in’
sdiar
rhoea,
themot herrepli
esthati
t
began3day sago,andtherei
snobl oodinthestool
.Jati
niscry
ing.Hiseyeslook
sunken.Whentheskinofhisabdomeni spinched,i
tgoesbackslowly.Jati
n’
smot her
saysthatshehasnodiffi
cult
yfeedinghim.

Howdoy
oucl
assi
fyandmanaget
hechi
l
daccor
dingt
oIMNCIgui
del
i
nes.

11
Answer:
11

AssessandCl
assi
fy

Posi
ti
vesi
gnsofdehy
drat
ioni
nJat
in

1.sunkeney
es

2.ski
npi
nchgoi
ngbacksl
owl
y

Ot
herf
eat
ures

1.nof
eedi
ngpr
obl
ems

2.notl
ethar
gicorunconsci
ous

I
dent
if
ytr
eat
ment

Accor
dingt
oIMNCIgui
deli
nes,
thechi
l
discl
assi
fi
edassomedehy
drat
ion.The
managementwoul
dbePlanB.

Tr
eat
ment

1.Themot
heri
sadv
isedt
ost
ayi
nthePHCt
il
ldehy
drat
ioni
scor
rect
ed.

2.ORSi
sgi
venov
er4hour
sunderobser
vat
ion.

TheamountofORSt
obegi
veni
s75ml
perkgbodywei
ght
,so

75*4.
5=337.5mlORSsol
uti
oni
sgiv
enassmallf
requentsi
psf
rom acup.I
fthechi
l
d
vomit
swai
tfor10mi
nut
esandfi
vemoresl
owl
y.

3.
Breastf
eedi
nghast
obecont
inued.

4.
Zincsuppl
ement
ati
oni
stobegi
ven.½t
abdai
l
yfor14day
s,i
.e.
,
10mg.

Thetabl
ethast
obedissol
vedi
nasmal
lamountofexpr
essedbr
eastmi
l
korORSor
cl
eanwateri
nacup.

5.Reassesst
hechi
l
daf
ter4hour
s

A.I
fdehy
drat
ioniswor
seni
ngi.
e,Nomov ementint
hechil
dorsunkeneyesandski
n
pi
ncht
aki
nglongerl
i
ne>2sforr
etr
act
iont
hechil
dhastobeputonI
VFlui
dther
apy.

Counsel
themot
her

B.I
fdehydr
ati
oni
scorrect
edi.
e,t
hechil
ddoesnotshowsi
gnscor
respondingtoei
ther
someorsever
edehy
drati
onthemotheri
sadv
isedt
ogohomewitht
hef ol
lowingadv
ice:

1)Br
eastf
eedf
requent
lyandf
orl
ongerateachf
eed.Homeav
ail
abl
efl
uids

2)ORShast
obegi
ven:
upt
o2y
ear
s–50t
o100ml
aft
ereachl
oosest
ool
.

3)Mixi
ng ORS and showi
ng how much ORS mustbegi
ven t
ofi
nish 4 hour
s
t
reat
mentathomemustbet aught
.

Checkt
hemot
her
’sunder
standi
ng.
A.Someadv
icei
ssimple.Forexampl
e,y
oumayonl
yneedt
otel
lthemot
hert
o
ret
urnwi
ththei
nfantf
orfol
low-upi
n2days.
B.Ot
heradv
icerequir
esthatyout
eachthemotherhowtodoatask.Teachi
ng
howtodoat askrequi
ressev
eral
steps.Whenyouteachamot
herhowt otreat

12
 ani
nfant
,use3basi
cteachi
ngst
eps:
1.Gi
vei
nfor
mat
ion.Expl
aint
othemot
herhowt
odot
het
ask.

Forexampl
e,expl
aint
othemot
herhowt
opr
epar
eORS

2.Showanexampl
e:Showhowt
odot
het
ask.

Forexample,
showt
hemotherapacketofORSandhowtomixtheri
ghtamount
ofwaterwit
hORSLetherpr
act
ice:
Askthemot hert
odot
hetaskwhil
eyouwatch.

3.Letherpr
act
ice.Lett
ingamotherpracti
cei
sthemostimpor
tantpartoft
eachinga
task.I
famotherdoesat askwhil
eyouobserve,
youwil
lknowwhatsheunderst ands
andwhatisdif
ficul
t.Youcanthenhelpherdoitbet
ter
.Themotherismorelikelyto
remembersomet hi
ngthatshehaspracti
cedt
hansomethi
ngthatshehasheard

4)Tocont
inue½t
abofzi
nconcedai
l
y.

FOLLOW UP

5)Adv
isewhent
oret
urn

A)IMMEDI ATELYAdv iset

or etur
nimmediatel
yiftheinfanthasanyofthese
signs:Breastfeedi
ngordrinkingpoorl
y,Becomessi cker, Devel
opsafeveror
feelscoldtotouch,Fastbreathing,Di
ffi
cul
tbreathi
ng, Yellowpalmsandsoles
(i
fy ounginfanthasjaundi
ce), Di
arr
hoeawithbloodinst ool
B)FORFOLLOW-
UPVI
SIT
I
nani
nfantwhohadDI
ARRHOEA Ret
urnf
orf
oll
ow-
upnotl
atert
han2day
s
C)NEXTWELL-CHI
LDVISI
TAdv i
sewhent
oret
urnf
ort
henexti
mmuni
zat
ion
accor
dingt
oimmuni
zat
ionschedul
e
QUESTI
ON12

Fati
mai s18mont hsold.Sheweighs11. 5kg.Hertemperatureis37.5?C.The chil
dis
br
oughttoyourPHCwi t
hcoughsince6day s,
andsheishav i
ngt r
oublebreathingsi
nce
2days.Thi
sisthei ni
ti
alvisi
tfort
hisil
lness.Uponexamination,thechildhaschestin
dr
awingandst r
idor.Thet emperatur
eoft hechil
dis100˚ Fandr espir
ator
yr ateis45
br
eathsperminute.Howi sthechi
ldcl
assifi
edandmanaged?

Answer:
12

AssessandCl
assi
fy

Accor
dingt
oIMNCIgui
del
i
nes,
thechi
l
discl
assi
fi
edasSEVEREPNEUMONI
A.

1.PI
NK ,
SEVEREPNEUMONI
A:

Anygener
aldangersi
gnsorst
ri
dori
nacal
m chi
l
d
2.YELLOW,
PNEUMONI
A:

Chesti
ndr
awi
ngandf
astbr
eat
hing

2mont
hs-
12mont
hs-
--
--
--
-50br
eat
hspermi
nut
eormor
e
12ont
hs-
5year
s--
--
--
--
--40br
eat
hsormor
e

3.
GREEN,
NOPNEUMONI
A:COUGHORCOLD

13
 Nosi
gnsofpneumoni
aorsev
eredi
sease

I
dent
if
ytr
eat
ment

Managementofsev
erepneumoni
a--
--
REFERRAL

Tr
eat
ment

Gener
alManagement
1.Admi
tthechi
l
d.
2.Tr
eatf
everwi
thAnt
i-
pyr
eti
cs
3.Moni
torf
lui
dandf
oodi
ntake.
4.Ox
ygent
her
apyf
orsat
urat
ion<92%.
5.Gi
veproperposit
ioni
ngincaseofsever
erespi
rat
orydi
str
ess.
(pr
oppedup
posi
ti
onsupportedby,shoul
derpad).
6.St
artf
ir
stdoseofant
ibi
oti
cs:
Chl
orampheni
col
25mg/ kg/dosei
sstar
tedwi
thoracombinat
ionof
Ampici
ll
i
n50mg/kg/doseandGent amyci
n2.
5mg/kg/dose

Ur
gentpr
e-r
efer
ralt
reat
ment

Urgentpre-
ref
erral
treatment
sforayoungi
nfantar
esetoutbelow(Youwi
l
llear
nmor
e
abouttheseinyourpracti
cal
ski
ll
str
aini
ngsessi
ons.)Youshoul
d:

 Gi
vet
hef
ir
stdoseofi
ntr
amuscul
arant
ibi
oti
cs.
 Giveanappropr
iat
eoral
antibi
oti
c.I
fthei
nfantneedsanoral
anti
biot
icf
oralocal
bacter
ial
inf
ecti
on,gi
veafi
rstdosebefor
erefer
ri
ngtheinf
anttot
hehospit
al.
 Advisethemot herhowtokeeptheinfantwarm onthewaytothehospi
tal
.Ift
he
mot herisfamil
iarwit
hwrappi
ngherinfantnexttoherbody,
thi
sisagoodwayt o
keephi m warm onthewaytothehospital
.Keepi
ngasi cky
ounginf
antwarmis
veryimportant
.
 Tr
eatt
hey
oungi
nfantt
opr
eventl
owbl
oodsugar
.

ALLDETAI
LSMUSTBEI
NCLUDEDI
NTHEREFERRALSLI
P.
Name,
age,
sexoft
hechi
l
d
Thesy
mpt
omswi
thwhi
cht
hechi
l
dwasbr
oughtt
othePHC,
Thev
ital
dat
a,
Thepr
e–r
efer
ral
treat
mentgi
vent
othechi
l
d

Quest
ionNo:
13

A3yearol
dchi
ldofwei
ght12Kgwas brought t
othePHCwithcoughanddif
ficul
tyi
n
br
eat
hingsi
nce3days.Uponexami
nat
ion,thechi
ldhadwheeze.Thetemperatur
eof

14
thechildi
s101˚
Fandr espi
rat
oryr
atewas50br
eat
hspermi
nut
e.How i
sthechi
l
d
classi
fi
edandmanaged?

AnswerNo:
13

AssessandCl
assi
fy

Accor
dingt
oIMNCIgui
del
i
nes,
thechi
l
discl
assi
fi
edasPNEUMONI
A.

1.PI
NK ,
SEVEREPNEUMONI
A:

Anygener
aldangersi
gnsorst
ri
dori
nacal
m chi
l
d

2.YELLOW ,
PNEUMONI
A:
Chesti
ndr
awi
ngandf
astbr
eat
hing
2mont
hs-
12mont
hs-
--
--
--
-50br
eat
hspermi
nut
eormor
e
12mont
hs-
5year
s--
--
--
--
--40br
eat
hsormor
e

3.GREEN,NOPNEUMONI
A:COUGHORCOLD

Nosi
gnsofpneumoni
aorsev
eredi
sease

I
dent
if
ytr
eat
ment

ManagementofPneumoni
a

1.Sy
mptomati
cManagementoffev
erandwheezewi
thant
ipy
reti
csand
i
nhal
ati
onofbr
onchodi
l
ator
supto3t i
mes15-
20minut
esapartf
or5days.
2.Soot
het
het
hroatandr
eli
evet
hecoughwi
thasaf
eremedy
.
3.Or
alant
ibi
oti
cs:
Amoxci
l
li
nfor5day
s.10-
25mg/
kg/
dose6hr
lyORor
alcot
ri
moxazol
e.

Counsel
themot
her
.Checkt
hemot
her
’sunder
standi
ng.
A.Someadvi
ceissimple.Forexampl
e,y
oumayonl
yneedt
otel
lthemot
hert
o
ret
urnwi
tht
heinfantf
orf ol
l
ow-upin2days.
B.Otheradvi
cerequi
resthatyouteachthemot
herhowt odoatask.Teachi
ng
howt odoataskrequir
esseveralst
eps.Whenyouteachamotherhowt otr
eat
aninfant
,use3basicteachi
ngsteps:
1.Gi
vei
nfor
mat
ion.Expl
aint
othemot
herhowt
odot
het
ask.

Forexampl
e,expl
aint
othemot
herhowt
opr
epar
eant
ibi
oti
csy
rup

2.Showanexampl
e:Showhowt
odot
het
ask.

Forexample,
showthemotherthebot
tl
ewi
tht
hepowderofant
ibi
oti
candshow
howt omixtheri
ghtamountofwat
er.

3.Letherpr
acti
ce.Let
ti
ngamot herpract
icei
sthemostimpor
tantpar
tofteachinga
task.I
famotherdoesataskwhileyouobserv
e,youwil
lknowwhatsheunderstands
andwhatisdif
fi
cult
.Youcanthenhelpherdoitbet
ter
.Themotherismoreli
kelyto

15
r
emembersomet
hingt
hatshehaspr
act
icedt
hansomet
hingt
hatshehashear
d

FOLLOW UP

Adv
isewhent
oret
urn

A)IMMEDI ATELYAdv iset oret

urnimmedi at
elyiftheinf
anthasanyofthese
signs:eati
nganddr inkingpoor l
y,Becomessi cker,Devel
opsafeverorfeel
s
coldtotouch,Fastbreat hi
ng, Di
ffi
cul
tbreathi
ng, Yel
lowpalmsandsoles( i
f
younginfanthasjaundice),Diarr
hoeawithbloodi nstool
B)FORFOLLOW-
UPVI
SIT
I
nani
nfantwhohadpneumoni
aRet
urnf
orf
oll
ow-
upnotl
atert
han2day
s
C)NEXTWELL-CHI
LDVISI
TAdv i
sewhent
oret
urnf
ort
henexti
mmuni
zat
ion
accor
dingt
oimmuni
zat
ionschedul
e

Quest
ionNo:
14

A pregnantwomanaged29y ear
swi t
hobstet
ri
cformul
aG2 P1L1 hada
haemoglobinv
alueof7.
6g/
dli
nthesecondt
ri
mester
.Howwil
lyoumanage
thecase?

AnswerNo:
14

Di
agnosi
sofanaemi
ainpr
egnantwomen

Haemogl
obi
nlev
elst
odi
agnoseanaemi
a(g/
dl)i
npr
egnantwomen

1.NoAnaemi
a≥11

2.Mi
l
d10–10.
9

3.Moder
ate7–9.
9

4.Sev
ere<7

Source:Haemogl
obinconcent
rat
ionf
ort
hedi
agnosi
sofanaemi
aand
assessmentofsever
it
y.WHO

Accor
dingt
oWHOcl
assi
fi
cat
ion,
thewomanhasmoder
ateanaemi
a.

Thi
siscor
rect
edbyt
hef
oll
owi
ngway
s:

A.
Diet
arydi
ver
sif
icat
ion

Diet
arydiver
sifi
cati
onisencouragi
ngtheconsumpt i
onofmicr
onutr
ientr
ich
foods–ironrichfoodsshouldbeencouragedlikedarkgr
eenl
eaf
y
vegetabl
es,l
entil
s,gi
ngel
lyseeds,soy
abean,jaggery.

Cer
tai
nfoodscal
l
edEnhancer
shel
pinabsor
pti
onofi
ronf
orexampl
e

1.Haem i
ron,
presenti
nmeat
,poul
tr
y,f
ish,
andseaf
ood

2.Ascorbi
cacidorv i
taminC,presentinf
rui
ts,j
uices,
potat
oesand
someot hertuber
s,andothervegetabl
essuchasgr eenl
eaves,
caul
if
lower,andcabbage

16
 3.Fer
ment
edorger
minat
edspr
out
s.

Cert
ainf
oodscal
ledI
nhi
bit
orsr
educetheabsorpt
ionofi
ronsosuchf
oods
shoul
dnotbeconsumedal
ongwit
hironforexample

1.Cereal
bran,
cer
eal
grai
ns,
high-
ext
ract
ionf
lour
,legumes,
nut
s,and
seeds

2.Tea,coff
ee,cocoa,
her
bal
inf
usi
onsi
ngener
al,
cer
tai
nspi
ces
(e.
g.or
egano)

3.Cal
ci
um,
par
ti
cul
arl
yfr
om mi
l
kandmi
l
kpr
oduct
s

B.Suppl
ement
ati
on

TheMi
nist
ryofHeal
thandFami
l
yWel
far
e’sRev
isedSt
rat
egy:

I
ronandf ol
icacidtablet
sarebeingdi
str
ibutedt
hroughsub-cent
res,
pri
maryhealthcentres(PHCs),
communi tyheal
thcent
res(CHCs)and
di
stri
cthospit
als(DHs)toallpr
egnantwomenandl actat
ingmothers.

Doseandr
egi
men

IFAsuppl
ementati
on(100mgel emental
ironand500mcgoff oli
cacid)
ever
ydayforat
least100days,star
ti
ngaftert
hefi
rstt
ri
mester,at14–16
weeksofgest
ationfol
lowedbythesamedosef or100day
si npost-par
tum
peri
od.

ButhereastheHbleveli
sbetween7–8gm/dl
andthewomanisi
n
secondtr
imester
,PARENTERALTHERAPYhastobeadapt
ed.
.

Parent
eraltherapy:
Themainadv antageofparent
eral
ther
apyisthecertai
ntyofit
s
admini
str
ationtocorrectt
hehemoglobi
ndefici
tandt ofi
xupt heironstore.
Theexpectedriseinhemoglobi
nconcent
rati
onafterparent
eraltherapyis
0.7t
o1g/ 100ml /week.

(
A)I
ntr
avenousr
out
e:

DOSAGE

Ir
on(fer
rous)Sucr
ose:
(20mgel
ement
ali
ron/
mL)100mg/
dose,
usual
l
y
onedosedail
yfor10days.

Esti
mationofthetot
alr
equi
rement
:
(1kgis2.2pounds)

0.3×W (100–Hb%)mgofelementalir
on.Wher
eW =patient
’sweighti
n
pounds.Hb%=observ
edhemoglobinconcent
rat
ioni
npercentage.
Addit
ional
50%istobeaddedforpart
ialr
epl
eni
shmentofthebodystore
i
ron.

Thetot
alel
ement
ali
ronr
equir
edi
nananemicpat
ientwei
ghi
ng100l
bwi
th
hemogl
obi
n50%iscal
cul
atedasf
oll
ows:
0.3×100(100–76)=720mg.

17
Add50%=360mg.Tot
alel
ement
ali
ronr
equi
red1080mg=1.
08g

Ir
onsucr
osepreparati
onusav ailableasa2.5ml or5ml ampoules.
When5ml ampouleisinf
usedi n200ml of0.9%normalsal
ine,
theexpected
ri
seis0.
7to1mgandt herequiredrisei
nt hi
scaseis1.
08gweneedt o
i
nfuse7.
5ml oftheir
onsucr osepr epar
ati
on.Ini
tial
l
y5ml i
sinf
used,the
secondi
nfusi
onwith2.5mlhast obegi v
enaf t
er3days.

Procedur e:
—Thepat i
enti sadmi t
tedi nthemor ni
ngf orinfusi
on
—Ther equiredi roni smixedwi t
h0. 9%sal ine.
—Pr ecaut i
onsl iket hoseofbl oodt ransfusionar etobet akenbothpri
orto
anddur ingthei nf usionpr ocess
—Thedr iprat eshoul dbe10dr opspermi nut eduringthef i
rst20minut
es
andther eafterisi ncreasedt o40dr opspermi nute
—Anyadv erser eactionlikerigor,chestpai norhy potensioncall
sfor
omissionoft hedr i
p

Af
tert
hei
nfusi
on

a.I
fHbleveli
sbetween9–11gm/
dl,
samer
egi
menofor
alI
FAt
wice
dai
l
yprescri
bedfort
hisr
ange.

c.I
ftheHblevelhasnoti
mpr
oved,
thewomani
sref
err
edt
oFi
rstr
efer
ral
uni
tortot
erti
arycare.

•Ifwomanwi t
hHbbetween7–8gm/dl
comestoPHC/ CHCint
hethi
rd
tr
imesterofpr
egnancy
,ref
ert
oFRU/
MCf ormanagementwi
thbl
ood
tr
ansfusi
on.

Sour
ce:
Gui
del
i
nesf
orCont
rol
ofI
ronDef
ici
encyAnaemi
a

C.DEWORMI
NG:

Ast
hewomanisinthesecondtri
mester,
dewor
mingshoul
dbedone wi
th
asi
ngl
edoseof400mgofal bendazol
e.

•I
fthewomani
sinfir
sttr
imester
,thendewor
mingi
sdoneonl
yaf
ter
t
hewomanreachessecondtr
imester.

D.
WASH:

Itisimper
ativ
et hatsanit
ati
onmeasur esar
eencouragedinthecommuni t
y
thr
oughpropereducat i
onandcounsel i
ng(i
nal
lareas,i
rr
especti
veoft he
degreeofprevalenceofSoil
Transmitt
edHelmi
nthici
nfest
ation)
.Measur es
suchasWat er,Sanit
ati
onandHy giene(WASH)arecri
ti
calforsust
ainable
hel
mi nt
hcontrol.

SOURCE:
Nat
ional
Gui
del
i
nesf
orDewor
mingi
nPr
egnancy

Quest
ionNo:
15

18
Apr egnantwomanaged30y earswi
thobst
etr
icfor
mulaG3P2L2wasnor mo
tensivei
nt hef
ir
sttr
imester.Shehascomeforherregularant
enatalv
isi
tin
with36weeksandwasf oundto haveaBloodPr essurerecordi
ngof
150/ 90mm Hg.Shei sal socomplaini
ngofswoll
enf eetoverthepast3
days.Asamedi cal
offi
ceroft hePHC,howwil
lyoumanaget hi
scase?

AnswerNo:
15

Thewomani sfi
rstassessedandclassi
fied.Theter
m, “
Pregnancy-i
nduced
hypert
ension(PI
H) ”i
sdefinedasthehyper t
ensi
onthatdevelopsasadirect
resul
tofthegravidstat
e.Iti
ncl
udes—( i
)gestati
onalhy
pertension,
(ii
)
preecl
ampsiaand( ii
i
)eclampsia.

Ur
inei
stest
edf
orpr
otei
nur
ia.

Prot
einuria:Pr esenceoftotalproteinin24hoursur i
neofmor ethan0.3g
ormor ethanorequal t
o2+( 1.0g/ L)onatleasttworandom clean-cat
ch
uri
nesampl est estedmoret hanorequal to4hour saparti
ntheabsenceof
uri
narytracti nfect
ionisconsideredsignif
icant.
Testforpr oteininurinebymul ti
plereagentstri
p(dipst
ick)asfoll
ows:
Trace=0. 1g/ L;
1+=0. 3g/l
2+=1. 0g/ L;
3+=3. 0g/ L;
4+=10. 0g/ L

DIAGNOSTI CCRI TERIAOFPREECLAMPSI A

Hy per
tension:Anabsol uteriseofbl oodpressureofatl east140/ 90mm Hg,
i
ft hepreviousbloodpr essurei snotknownorar iseinsy stoli
cpr essureof
atleast30mm Hg, orar i
seindi ast oli
cpressureofatl east15mm Hgov er
thepreviouslyknownbl oodpr essur eiscall
edpr egnancy -induced
hypertension.
Edema:Demonst rati
onofpi tt
ingedemaov ertheankl esaf t
er12hour sbed
restorrapidgaini nweightofmor et han1lbaweekormor et han5l ba
mont hinthel at
ermont hsofpr egnancymaybet heear l
iestev idenceof
preeclampsia.
Protei
nuria:Presenceoft ot
alpr oteinin24hour sur i
neofmor ethan0.3g
ormor ethanorequal to2+( 1.0g/ L)onatleastt wor andom cl ean-cat
ch
urinesampl estestedmor ethanorequal to4hour sapartint heabsenceof
urinar
yt r
actinfectionisconsider edsi gni
fi
cant.

I
fthewomandoesnothav epr
otei
nuri
a,sheisclassif
iedasgest
ati
onal
hyper
tensi
on
Gestati
onal hyper
tensi
oni
sdefi
nedasBP>/ =140/90mm Hg, wi
thout
pr
otei
nuriabey ond20weeksofgestat
ion,whichreturnst
onormalwit
hin
42dayspost partum.

Managementofpr
e-ecl
ampsi
a

19
1.
Ant
ihy
per
tensi
ves:

Commonl yUseddrugsintheManagementofPreecl
ampsia
Drug ModeofActi
on dose
Methyl
-dopa Cent
ralandperi
pher
alant
iadr
ener
gicacti
on 250–500mg
t
idorqid

Labet
alol Adr
enocept
orant
agoni
st(
αandβbl
ocker
s)100mgt
idorqi
d

Ni
fedi
pine Cal
cium channel
blocker 10–20mgbi
d

Hy
dral
azi
ne Vascul
arsmoot
hmuscl
erel
axant 10–25mgbi
d

2.Admini
strat
ionofcort
icosteroidsimprovesper i
nat
al(↑pulmonary
maturi
ty,
↓IVHand↓necr oti
zingenterocoli
ti
s)andmat er
nal(↑
thr
ombocy t
ecount,↑uri
nar youtput)outcome.
Incaseofseverepreecl
ampsia/eclampsi awheredeliveryi
simperati
ve,
t
otaldoseof24mgofei therdrugcanbegi venwithi
n24hour s.

3.Antisei
zur
eprophy l
axiswi t
hmagnesi um sulf
atei sstar
ted
Int
ramuscular(Pri
tchard)14gstatdosedividedas4g( 20%
soluti
on)I
Vov er3–5mi nutefol
lowedby10g( 50%),deepIM(5
gm ineachbuttock)5g( 50%)IM 4hourl
yinalternatebutt
ock

Labetalol20mgI Vi sgiv
ent ocontr
olhypert
ensi
on.
Diuret
icisgiveni
ft hereispulmonaryedema.
Diazepam, i
fused,shouldbegi ven5mgsl owlyover1mi
nut
eper
iodt
o
avoidapneaorcar diacarrest
.

4.I mportantstepsintransportare:
Allmat er
nal r
ecordsandadet ail
edsummar yshouldbesentwitht
he
patient.
BPshoul dbestabili
zedandconv ul
sionsifanyshouldbearr
est
ed.
Onemedi calpersonnelorat r
ainedmidwif
eshoul daccompanythepati
ent
i
nt heambul anceequippedt opreventi
njur
y,recur
rentfi
tsandtocl
earai
r
passage

Quest
ionNo:
16

Apr
egnantwomanaged23y
ear
swasoft
hebl
oodgr
oupB-
ve.How wi
l
l
y
oumanagethi
scase

AnswerNo:
16
ANTENATALI NVESTI GATIONPROTOCOLOFRh- NEGATI
VEMOTHERS
I
nv esti
gati
onofbl oodforRhandABOgr oupi
ngbecomesalmostarouti
neduri
ngthe
fi
rstantenatal
visiti
nfir
sttri
mester
.
I
ft hewomani sf oundRh-negati
ve,
Rhgr oupi
ngofthehusbandist
obedonet ofi
ndout
whet hert
hepregnancyi saresul
tofincompatibl
eorcompati
blemati
ng.I
fthehusband

20
i
salsoRh-
negat
ive,
i.
e.compat
ibl
emat
ing,
ther
eisnopr
obl
em sof
arasRhf
act
ori
s
concer
ned

.Buti
fthehusbandi sfoundt obeRh-posit
ive,
fur
theri
nvest
igationsaretobecar r
ied
outwhi
chaim at:
 Todetectwhet hert hewomanhasal r
eadybeenimmuni zedt oRhantigen;
 Toforecastthelikelyaff
ect
ionofthebaby;
 Toantici
pateandf ormul
atethel
ineofmanagementofal ikel
yaff
ectedbaby

TOPREVENTACTI VEIMMUNIZATION:Rhanti
-Dimmunogl obuli
n(I
gG)isadminist
ered
i
nt r
amuscularl
ytot hemotherINADOSEOF100μgt ot
hemot herAT28weeksof
gestati
onAND300μgdosEwi t
hin72hour
sorpreferabl
yearli
erfol
l
owingdeli
veryor
aborti
on.Itshoul
dbegivenprovi
dedthebabybor
ni sRh-posi
tiv
eandthedirectCoombs’
testisnegati
ve.

Dose:Ant
iD-gammagl obuli
nisadmini
ster
ed.
.
Womenwi thpregnancybeyond12weeksshouldhav
eful
ldoseof300Gener
all
yewi
l
l
pr
otectawomanf r
om fetalhemor
rhageofupt
o30mLoffetalwhol
ebl
ood.

TOPREVENTORMI NI
MI ZEFETOMATERNALBLEED:
—Pr ecautionsdur i
ngcesar eansect i
on:(i
)topr eventbl oodspil
li
ngintotheperit
oneal
cavi
ty
(i
i)manual remov alofplacent ashouldnotbedoneasar outi
ne.
—Pr ophylacticer gometrinewi ththedeli
veryoft heant eri
orshouldershouldprefer
abl
y
bewi t
hheld, asitmayf aci l
it
atemor efetoplacentalbleed.
—Amni ocent esi
sshoul dbedoneaf t
ersonogr aphicl
ocal izat
ionoftheplacentato
preventit
si njury
.
—For cibl
eat temptt oper form exter
nalversionunderanest hesi
ashouldbeav oided.
—Manual remov alofplacentashoul dbedonegent ly.
—Tor efr
ainf rom abdomi nal palpat
ionasfaraspossi bleinabrupti
oplacentae.

BREASTFEEDING:
Therei
snocontrai
ndicat
ionofbreastf
eedi
ngini
mmunizedmot
her
s,
al
thought
raceamountofant
ibodi
esareexcret
edthroughthebr
eastmi
l
k.

Quest
ionNo:
17

Routi
neinv
est
igat
ioni
napregnantwomanaged25yearsofgest
ati
on30
weeksshowedHBsAg+ve.Howwill
youmanaget
hiscase?

AnswerNo:
17

ManagementofHBVdur ingpregnancy:
HBVi nf
ecti
oncanbepr eventedbyv acci
nati
onandther
ecombinantvaccineissafein
pr
egnancy .
Pregnantwomanwhoi sseronegati
ve,shoul
dhaveHBimmunoglobuli
n( HBIG),
0.06
ml/kgIM,soonfoll
owingexposur eandaseconddoseafter1month.Thensheshoul d
begivenrecombinantDNAv accineintr
amuscul
arl
y1ml,3dosesat0, 1and6mont hs.

All
infantsbor
ntoHBsAgposi t
ivemother
sshouldhav eHBIG0.
5ml IM wit
hin12hour
s
ofbir
th.Acti
veimmuni
zationwithHBvaccine(0.
5ml )i
salsogi
venIM ataseparat
esi
te
atthesamet i
meschedule.Thi
sisver
yeffecti
ve(85–95%)topr
otectthe
i
nfantfrom HBVinf
ect
ion.

Breast
feedingisnotcont r
aindicated.
Simil
artoHI V,
per i
natalt
ransmi ssionofHBVdependsonmat ernalv
iral
load.
LamivudineandHBI Gareeffecti
vet oreducethetr
anspl
acent
altr
ansmissionofHBVt
o
thefet
us.Lami vudineisgiv
en150mg/ dayfrom 34weeks.
21
Ther
eisnopl
acef
ort
ermi
nat
ionofpr
egnancy
.
Quest
ionNo:
18

Apri
miaged28y earscamet oy ourPHCf orregul
arantenat
alvi
si
tssi
nce
12weeksofpregnancy.Int
het hi
rdtri
mester,t
heRBSv aluewasshownto
be250mg/dl
.Howwi l
lyoufur
therproceedwiththi
scase?

AnswerNo:
18

Thewomani
ssuf
fer
ingwi
thGest
ati
onal
diabet
es.

1.Firstthediagnosi
sisconfi
rmedwi than75mgor algl
ucosetol
erance
test.Thethreshol
dbloodsugarlevelof=140mg/dL(morethanor
equal to140)istakenascutofffordiagnosi
sofGDM.

2.GUI
DELI
NESFORTREATMENT

A.I
ftheval
ueislesst
han140mg/
dl,
thewomani
str
eat
edasanor
mal
caseandretest
edlat
er.

B.
Ift
hev
aluei
smor
ethan140md/
dl

a.
Star
tHumanI nsul
inpr
emi
x30:70Subcutaneousi
nject
iononthe
Fr
ont/
Lateralaspectoft
het
highoroverabdomen30mi nbefor
e
br
eakfast
,onceaday

b.Doseofi
nsul
i
ncal
cul
atedbybl
oodsugarl
evel

Bl
oodsugarandDoseofi
nsul
i
n

Bet
ween120-
160 4uni
ts

Bet
ween160-
200 6uni
ts

Mor
ethan200 8uni
ts

c.
FBS(
Fast
ingBl
oodSugar
)&2hour
sPPBSev
ery3r
dFBSday

d.
Add2Upr
e-br
eakf
asti
fPPBSi
srai
sed

e.Add2Upr
e-di
nneri
fFBSi
srai
sed

f
.Cont
inuet
il
ldesi
redl
evel
sof95mg/
dLand120mg/
dLar
eachi
eved
f
orFBSandPPBSrespecti
vel
y

g.RepeatFBS&2hrPPBSev er
y3r
ddayt
il
ldoseofi
nsul
i
nadj
ust
edand
anopti
mal readi
ngi
sachi
eved.

If bl
oodsugarleveli
swellcontr
oll
ed&ther
eareno
compli
cati
ons,shouldconti
nuewit
hf or
tni
ghtl
y/weekl
yantenat
al v
isi
tsas
perhi
gh-r
iskpregnancyprot
ocolorasrecommendedbythephysici
an

I
f bloodsugarlev
eli
suncont
rol
l
edoranyothercompl
i
cat
ionof
pr
egnancydevel
ops,sheisref
err
edtohigherf
aci
l
ity.

22
3.DI
ETARYADVI
SE

A.
CARBOHYDRATES

Largeamount sofcarbohydr
atefoodsshoul
dbeavoided.I
tisbet
tert
o
spreadcarbohydrat
efoodsover3smallmealsand2–3snackseachday
thantaki
ng3l argemeals.

Complexcarbohy dr
ates(likewhole-graincereal
sl i
keoats,baj
ra,
jowar,
ragi
,wholepulses,veget
abl esandfruit
swi thskins)shouldbeprefer
red
oversi
mpl ecarbohydrat
esl ikesweets,cakes,puddings,sweetbi
scui
ts,
pastr
y,j
uice,softdr
inks,chips,whi
tebr ead,naan,pizzaetc.

.
B.FATS

Satur
atedf
atint
ake(sour
ces-ghee,but
ter
,coconutoi
l,
pal
m oi
l,r
edmeat,
organmeat,
full
cream mi
lket
c)shouldbelessthan10%oftot
alcal
ori
es.

C.
PROTEI
N

Pr
otei
nrequir
ementinpr
egnancyi
sincr
eased(
addi
ti
onal
23g/
day
)to
al
l
owf orf
etalgr
owth.

Atl
east3servi
ngofpr ot
einf
oodsarerequi
redever
ydayt
omeett he
i
ncreaseddemand.Sourcesofpr
otei
naremi l
kandmil
kproduct
s,egg,
fish,
chi
cken,pul
ses(dal
),nut
setc

D.
FIBRE:

Highfiberfoodsespeci al
lysolublefibremayhel pcont rol
bloodsugarby
delay
inggast ri
cempt yi
ng, ret
ardingt heentryofglucoseintotheblood
str
eam andl esseningthepost prandial r
isei
nbl oodsugar.Solubl
ef i
berin
fl
axseed, psyll
ium husk,oatbran, l
egumes( dr
iedbeansofal lki
nds,
peasandl enti
l
s) ,
andpect i
n( f
rom fruit,suchasappl es)andformsinr oot
vegetables(suchascar rots)arehelpf ul
.

4.MONI
TORI
NGFOROTHERCOMPLI
CATI
ONS

a.
Shehastobedi
li
gent
lymonit
oredf
orhy per
tensi
oni
npr
egnancy
,
pr
otei
nur
iaandot
herobst
etr
iccompl
icat
ions.

b.Shehastobemonit
oredforabnormalf
etalgr
owth
(
macr osomi
a/gr
owt
hrestr
ict
ion)andpol
yhydr
amnios

d.
Ifherconditi
onorfetalconditi
onwarrant
sanear l
ydelivery,antenatal
ster
oidsshouldbegiven-Inj.Dexamethasone6mgI M 12hour lyfor2days.
Morev i
gil
antmonit
oringofbl oodsugarlevel
sshouldbedonef ornext
72hoursfoll
owingi
njecti
on.Incaseofr ai
sedbloodsugarl evelsduringthi
s
peri
od,adjust
mentofinsulindoseshouldbemadeaccor dingly.
.

Post
-del
i
ver
yfol
l
owupofpr
egnantwomenwi
thGDM

Mat
ernal
glucosel
evel
susual
l
yret
urnt
onor
mal
aft
erdel
i
ver
y.

23
Subsequently,
ANM mustper
for
m 75gm OGTT( fasti
ngand2hrPP)at6
weekspost part
um t
oeval
uat
eglycemi
cstatusofwoman.Cutof ff
or
normalplasmaandabnormalbl
oodsugarlevel
sinthefast
ingand75gms
OGTTv al
uesar e:

Fast
ingbl
oodsugar
:=126mg/
dL

75gmsOGTT2hourbl
oodsugar

Nor
mal
:<140mg/
dL I
GT:
140-
199mg/
dLDi
abet
es:
=200mg/
dL

I
ftheTestisnormal
:Womani scounsel
l
edaboutl
if
estyl
emodi f
icat
ions,
weightmoni
tori
ng&exer
cise.Shei
sadvisedt
ogetannualscr
eeningfor
DM inNCDclini
c.

I
ftheTestisposi
ti
ve/I
GT:
Womanshoul
dbel
i
nkedwi
thNCDpr
ogr
am f
or
f
urthermanagement
.

Pregnantwomenwi t
hGDM andtheiroffspri
ngsar eati
ncreasedri
skof
developi
ngTypeIIDi
abet
esmelli
tusinlaterl
ife.Theyshouldbecounsel
l
ed
forhealt
hyl
if
esty
leandbehavi
our,part
icular
lyroleofdi
et&exer ci
se.

Quest
ionNo:
19

Whataret
he4Dst obescreenedinchi l
drenfr
om bir
thto18yearsofage
undert
heRashtr
iyaBalSwasthKaryakram?Givetwoexamplesforeachof
the4component
s.Whoar ethefunct
ionari
esresponsi
blef
orscr
eening?

AnswerNo:
19

The‘Chi l
dHeal thScr eeni
ngandEarlyI
nter
venti
onServi
ces’Pr
ogramme
underNat ionalHeal t
hMi ssi
onini
ti
atedbytheMini
str
yofHealthandFamily
Wel f
are,theref
or e,ai
msatear l
ydetecti
onandmanagementoft he4Ds
prevalentinchil
dr en.TheseareDefect
satbirt
h,Di
seasesinchi
ldren,
De¬
fi
ciencycondi t
ionsandDev el
opmentalDel
aysincl
udi
ngDisabil
i
ties.

1.
Def
ect
satbi
rt
h

1.
Neur
alTubeDef
ect

2.
Down’
sSy
ndr
ome

3.
Clef
tLi
p&Pal
ate/Cl
eftPal
ateal
one

4.
Tal
i
pes(
clubf
oot
)

5.
Dev
elopment
alDy
spl
asi
aoft
heHi
p

6.
Congeni
tal
Cat
aract

7.
Congeni
tal
Deaf
ness

24
8.
Congeni
tal
Hear
tDi
seases

9.
Ret
inopat
hyofPr
emat
uri
ty.

2.
Def
ici
encycondi
ti
ons

10.Anaemi
aespeci
all
ySev
ereAnaemi
a

11.Vi
tami
nADe¬ci
ency(
Bit
otspot
)

12.Vi
tami
nDDe¬ci
ency(
Ricket
s)

13.Sev
ereAcut
eMal
nut
ri
ti
on

14.Goi
terSev
ereAcut
eMal
nut
ri
ti
on(
SAM)
,Anaemi
a

3.Chi
l
dhoodDi
seases

15.Ski
ncondi
ti
ons(
Scabi
es,
Fungal
Inf
ect
ionandEczema)

16.Ot
it
isMedi
a

17.Rheumat
icHear
tDi
sease

18.React
iveAi
rwayDi
sease

19.Dent
alCar
ies

20.Conv
ulsi
veDi
sor
der
sRheumat
ichear
tdi
sease,
ast
hma

4.
Dev
elopment
alDel
aysi
ncl
udi
ngDi
sabi
l
iti
es

21.Vi
sionI
mpai
rment

22.Hear
ingI
mpai
rment

23.Neur
o-Mot
orI
mpai
rment

24.Mot
orDel
ay

25.Cogni
ti
veDel
ay

26.LanguageDel
ay

27.Behav
iourDi
sor
der(
Aut
ism)

28.Lear
ningDi
sor
der

29.At
tent
ionDe¬f
ici
tHyperact
ivi
tyDi
sor
derchi
ldhoodst
unt
ing poor
cogni
ti
veandeducat
ional
perfor
manceinchi
ldr
en

TheOperati
onalGuidel
i
nesoutli
nethefol
l
owi ngmechani
sm t
oreachal
l
thet
argetgroupsofchil
drenf
orhealt
hscreening-

1.Fornewbor
n:

Faci
l
itybasednewbor
nscr
eeni
ngatpubl
i
cheal
thf
aci
l
iti
es,
byexi
sti
ng
heal
thmanpower.

25
Communit
ybasednewbornscr
eeningathomet
hroughASHAsf
ornewbor
n
ti
l
l6weeksofagedur
inghomev i
sit
ati
on.

2.Forchi
l
dren6weekst
o6y
ear
s:

Anganwadi
Cent
erbasedscr
eeni
ng

3.Forchi
l
dren6y
ear
sto18y
ear
s:

Gov
ernmentandGov
ernmentai
dedschool
basedscr
eeni
ng
EPI
DEMI
OLOGI
CALEXERCI
SESCONTI
NUED

20.Cal
cul
atethequant
it
yofbleachi
ngpowderr
equi
redf
ordi
sinf
ect
ingt
hewat
eri
naci
rcul
ar
wellwi
thf
oll
owingdimensi
ons:

a) Di
ameterofwelli
s4met
ers,
dept
hofwat
eri
nthewel
li
s7met
ers,
hor
rockst
estshows
bl
uecol
ori
nthe3r dcup.

b) Di
ameterofwel
li
s6met
ers,
dept
hofwat
eri
nthewel
li
s14met
ers,
hor
rockst
est
showsbl
uecol
orin4t
hcup.

c) Di
ameterofwel
li
s8meter
s,dept
hofwat
eri
nthewel
li
s21met
ers,
hor
rockst
est
showsbl
uecol
orin2ndcup.

Answer
:

a) Tot
alamountofwat
eri
nthewel
l=πd2h/
4×1000

=88000l
i
tres.

6gms(
2gms×3cups)ofbl
eachi
ngpowderi
srequi
redf
ordi
sinf
ect
ing455l
i
tresofwat
er.

For88000l
i
tresofwat
er…….
.?

1160gmsar
eneededi
.e.1.
1kgsofbl
eachi
ngpowderi
srequi
red.

b) Tot
alamountofwat
eri
nthewel
l=3,
96,
000l
i
tres.

8gms(
2gms×4cups)ofbl
eachi
ngpowderi
sneededt
odi
sinf
ect455l
i
tresofwat
er.

For3,
96,
000l
i
tresofwat
er……?

6962.
6gmsar
eneededi
.e.6.
9kgsofbl
eachi
ngpowderi
srequi
red.

c) Tot
alamountofwat
eri
nthewel
l=10,
56,
000l
i
tres.

4gms(
2gms×2cups)ofbl
eachi
ngpowderi
srequi
redf
ordi
sinf
ect
ing455l
i
tresofwat
er.

For10,
56,
000l
i
tresofwat
er….
.?

9283.
5gmsar
eneededi
.e.9.
2kgsofbl
eachi
ngpowderi
srequi
red.

PROCEDURESFORDI
SINFECTI
NGAWELL:

26
Taket hetotalamountofbl eachingpowderi nabucket&makei tintoapast e.Thenfill
the
bucketwi t
hwat eruntili
tisful
l.All
owt hepastetoset tl
edown.Tr ansfert hesupernatant
solut
ionintoanot herbucket&t i
ear opetoit.Dipthebucketwitht hesol uti
onintothewel l
belowt hewat erlev
el&makebot hhor i
zontal&verticalosci
l
lat
ions.Thekeept hebucketbel ow
thewat erl
ev elfor1hour&t akeitout.Usuall
ywel lshouldbedisinfectedoncei nn15day s.In
caseofepi demi csli
kegastroenter
it
is,di
arrhoealdiseaseswellshoul dbedi si
nfectedevery
night
.

21.Asampl
eofdr
inki
ngwat
eri
ssubj
ect
edt
olabor
ator
yanal
ysi
swhi
chy
iel
dst
hef
oll
owi
ng
data.

Ecol
i2/
100ml

Col
i
for
ms20/
1000ml

Chl
ori
des650mg/
l

Fl
uor
ide0.
5mg/
l

Har
dness200mgs/
l

Commentonwat
erqual
it
y.Speci
fyt
hest
andar
dforabov
econst
it
uent
s.Suggestmeasur
est
o
i
mprov
ethequal
i
tyofwater
.

Answer:E.col
i&coli
for
msmustnotbepr
esenti
nwat
eri
ntendedf
ordr
inki
ng.I
fpr
esent
,it
i
ndicat
esfecalcont
aminat
ion.

Themini
mum quant i
tyofchlori
desthatshouldbepresentindr
inkingwateri
s200mgs/l.
maximum per
mi ssi
blelevel
is600mgs/ l.si
ncethechlor
idecontentofwatersampl
eishi
gher
thant
hesuit
ablelimi
titisnotsuit
ablefordri
nki
ng.

Fl
uor
idecont
entofabov
ewat
ersampl
eis0.
5mgs/
lwhi
chi
swi
thi
nnor
mal
range(
0.5t
o0.
8
mgs/
l).

Har
dnessi
s200mgs/ l
.dri
nki
ngwatershoul
dbemoder atelyhar
d.Thehar
dnessshoul
dbe50
t
o150mg/dl.Hencehar
dnessisabovetheper
missi
blelevel.

Astheabovesampl
econtainsE.coli&col
ifor
m or
gani
sms,
chl
ori
decont
ent&har
dnessar
e
hi
gh,t
hissamplei
snotf
itfordri
nking.

SPECI
FIEDSTANDARDSFORDRI
NKI
NGWATER:

AbsenceofE.col
i&col
i
for
m or
gani
sms

Chl
ori
decont
entnotmor
ethan600mg/
I

Fl
uor
idecont
entshoul
dbel
esst
han1.
5mg/
l

Har
dnessshoul
dbe50t
o150mg/
l.

MEASURESTOI
MPROVEQUALI
TYOFWATER:

a) Pur
if
icat
ionofwat
er:

Onsmal
lscal
e:byboi
l
ing,
chemi
cal
disi
nfect
ion,
andf
il
tr
ati
on.

Onl
argescal
e:bysandf
il
ter
s,chemi
cal
disi
nfect
ion.

b) Remov
alofhar
dnessofwat
er:

Temporar
yhardnesswhi
chi
sduetobi
car
bonatesofCa,
Mgi
sremov
edbyboi
l
ing,
addi
ti
onof
l
ime,addi
ti
onofNaHCO3,PERMI
TITpr
ocess.

27
Per
manenthar
dnessi
sduetochl
ori
des,sul
phat
es,
nit
rat
es,
nit
ri
tesofCa&Mgar
eremov
edby
NaHCO3addit
ion,
BaseEx
changeprocess.

c)
Ifwat
ercont
ainsexcessf
luor
ides,
def
luor
idat
ionofwat
eri
sdonebyNALGONDAt
echni
que.

22..Researchersconductacase-
cont
rolst
udyofpancreati
ccancer
.Thestudyi
ncluded200
casesand200cont rol
s.Ofthe160ofthecasesrepor
tedtheysmokedcigar
ett
es.Amongt he
contr
ols,100r epor
tedtheysmokedci
garet
tes.

a)Pr
epar
ea2x2t
abl
ewi
tht
hesedat
a

b)
Cal
cul
atet
heexposur
eoddsr
ati
o

c)
Whatdoest
heoddsr
ati
oindi
cat
e?

a)Pr
epar
ea2x2t
abl
ewi
tht
hesedat
a

b)Exposur
eoddsr
ati
o=(
a/c)
/(b/
d)=(
a*d)
/c*
b)=(
160*100)
/(40*
100)
=4.
0

c)Whatdoest
heoddsr
ati
oindi
cat
e?

Anoddsr
ati
oof4.
0indi
cat
est
hatci
gar
ett
esmoki
ngi
sposi
ti
vel
yassoci
atedwi
thpancr
eat
ic

28
cancer

23.Aninvestigat
orconductsast udytodet er
mi newhetherther
eisanassociati
onbetween
caff
einei
ntakeandPar kinson’sdisease.Heassembl es230i nci
dentcasesofPDandsampl es
455control
sf rom t
hegener alpopulat
ion.Afterint
erv
iewingallsubject
s,hefi
ndsthat64ofthe
caseshadhi ghdail
yintakeofcaffeine(exposed)pri
ortodiagnosisand277oft hecontr
olshad
l
owdai l
yintakeofcaffeine(unexposed)priortothedateofthemat chedcase’
sdiagnosis.

a.Assembl
ethe2x2t
abl
efort
hisst
udyusi
ngt
hei
nfor
mat
iongi
ven

b.Cal
cul
atet
heoddsrat
iofordi
seasegi
venexposur
e(hi
ghdai
l
yint
akeofcaf
fei
ne
ver
susl
owdail
yint
akeofcaff
eine)

c. Whatdoest
heoddsr
ati
oindi
cat
e?

Answer
:

a.Assembl
ethe2x2t
abl
efort
hisst
udyusi
ngt
hei
nfor
mat
iongi
ven.

b.Cal
cul
atet
heoddsrat
iofordi
seasegi
venexposur
e(hi
ghdai
l
yint
akeofcaf
fei
ne
ver
susl
owdail
yint
akeofcaff
eine)
.

OR=ad/
bc=17728/
29548=0.
60

c. Whatdoest
heoddsr
ati
oindi
cat
e?

TheORof0.60indi
catesthathi
ghcaff
eineintakei
snegat
ivel
yassoci
atedwi
thPar
kinson’
s
di
sease.Youcouldsayiti
saprotect
ivefactor.

24.Astudyenr
oll
s30,
000smokersand70,
000nonsmoker
s.Theyar
efol
l
owedfor1yearf
or
devel
opmentofpancr
eati
ccancer
.42ofsmoker
sand7ofnonsmokersdev
eloppancr
eat
ic
cancer

a. Assembl
ethe2x2t
abl
efort
hisst
udyusi
ngt
hei
nfor
mat
iongi
ven

b. Cal
cul
atet
her
elat
iver
isk

c. At
tr
ibut
abl
eri
sk

d. At
tr
ibut
abl
eri
sk%

29
 Cal
cul
ati
onoft
her
ater
ati
ofr
om ahy
pot
het
ical

Canceroft
he No.di
sease t
otal I
nci
dencer
ate
pancr
eas

smoker
s 42 29,
958 30000 1.
4/1000/
yr

Nonsmoker
s 7 69993 70000 0.
1/1000/
yr

49 99951 1,
00,
000

I
nci
dencer
ate amongsmoker
s=(42/
30000)*
1000=1.
4=1.
4/1000/
yr

From t
hedatai
ntabl
etakenfrom cohortst
udytoi
nvest
igat
etheassociati
onbet
weensmoki
ng
andcanceroft
hepancr
eastherel
ativeandatt
ri
but
abler
iskcanbecalculat
edasfol
l
ows;

Rel
ati
ver
isk(or)
rat
erat
io=

Rel
ati
ve
r
isk =1.
4/0.
1=14

Therel
ati
ver
iskof14indi
cat
esthatther
iskofcanceroft
hepancr
easi
s14t
imeshi
gher
amongsmokersthannon-
smokers.

=r
1-r
0=1.
4-0.
1=1.
3/1000/
yr

Theat
tri
but
abl
eri
skofcanceroft
hepancr
easduet
osmoki
ngi
s1.
3casesper1000pery
ear

=1.
4-0.
1 *100

1.
4

=93%

Thi
scanbeint
erpret
edas:
smoki
ngaccount
sfor93%ofal
lcasesofcanceroft
hepancr
eas
amongsmokers.

25.Youar eresearchi
ngt heeff
ectofbenzeneexposureandcancer.Yougot oworkplace
wheret her
eisknownpot enti
alf
orexposur
et obenzene.Ther
ear e483peoplei
ntheworkCentr
e.
Howev eronly212ar eexposedtobenzeneintheirworkduti
es.12%oftheworkcent
eremployees
eventuall
ycontractcancer.Yourdi
scover
yfindsthat40peoplewithcancerwer
einyourexposur
e
group.

a. Assembl
ethe2x2t
abl
efort
hisst
udyusi
ngt
hei
nfor
mat
iongi
ven

b. Cal
cul
atet
her
elat
iver
isk

c. At
tri
but
abl
eri
sk

d. At
tri
but
abl
eri
sk%

30
 di
sease Nodi
sease Tot
al

Ex
posed 40 172 212

Notexposed 18 253 271

Tot
al 58 425 483

Rel
ati
ve
r
isk

Rel
ati
ver
isk= (
40/
212)
/(18/
271)

= 18.
87/
6.64=2.
84

Therelat
iver
iskof2.
84indi
catesthatt
her
iskofcanceri
s2.
84t
imeshi
gheramongwor
ker
s
exposedtobenzenethannotexposed.

= 18.
87-6.
64 = 12.
23

Theatt
ribut
abl
eri
skof12.23i
ndicat
esthatther
iskofcanceri
s12.
23t
imeshi
gheramong
worker
sexposedt
obenzenethannotexposed

(
18.87–6.
64)
X100
18.87
=64%

Thiscanbeint
erpret
edas:
smoki
ngaccount
sfor64%ofal
lcasesofcanceramongwor
ker
s
exposedtobenzene.

26.On03- 01-1977,a60y earoldfemalewasadmi tt edwithastr

angul atedfemoralherni
awhi
ch
hadst ar
tedf ourdaysearli
er.Shecamecompl ai
ningofabdomi nalpai nandfecalvomi t
s.
th
Apparentlythesmal li
ntesti
neswereper for
atedev enbef or
eon04 Jan.Sheunder wenta
t
h
rel
easeofher ni
aandr esect
ionofintest
inewithanendt oendanastomosi s.On5 Janshe
start
eddev elopingsi
ngsofper it
onit
isandf ol
lowi
ngt hatdi
edon14- 01-1977.

Certi
fyt
hecauseofdeathasperInt
ernat
ionalDeat
hCer
ti
fi
cat
ionanddi
scusst
he
i
mportanceofhav
ingastandar
dizeddeat
hcertif
icat
e.

Deat
hcer
ti
fi
cat
e:

I
ssuedbychi
efmuni
cipal
heal
thof
fi
ceri
nur
banar
eaandt
ahsi
l
dari
nrur
alar
ea.

Uses:
1.I
nexpl
aini
ngt
rendsanddi
ff
erent
ial
sinov
eral
lmor
tal
i
ty.

2.
Indi
cat
ingpr
ior
it
iesf
orheal
thact
ionandal
l
ocat
ionofr
esour
ces.

31
3.
Indesi
gni
ngi
nter
vent
ionpr
ogr
ammes

4.
Theassessmentandmoni
tor
ingofpubl
i
cheal
thpr
obl
ems

5.
Giv
eimpor
tantcl
uest
oepi
demi
ologi
cal
resear
ch.

Li
mit
ati
ons:

1.I
ncompl
eter
epor
ti
ngofdeat
hs

2.
Lackofuni
for
mit
y

3.
Lackofadequacy

4.
Changei
ncodi
ngsy
stem

5.
Changei
npat
ter
nofdi
agnosi
s.

Causeofdeat
hcer
ti
fi
cat
e Cause I
nter
val
bet
weenonsetand
deat
h

PART-
I a)Acut
eper
it
oni
ti
s 9day
s

b)Perf
orati
onofsmal
l 10day
s
i
ntesti
nes

c) St
rangul
atedFemor
al
Herni
a 15day
s

PART-
II -
--
--
--
--
--
--
--

Expl
anat
ion:

PART-
I

a)Acut
eper
it
oni
ti
sleadt
odeat
hdi
rect
ly.

b)Per
for
ati
onofsmal
li
ntest
inei
sthei
mmedi
atecause.

c) St
rangul
atedf
emoral
her
niai
sunder
lyi
ngcausewhi
chi
nit
iat
edt
hechai
nofev
ent
s
l
eadingt
odeath.

PART-
II

Ther
ear
enoot
hercondi
ti
onswhi
chcont
ri
but
etodeat
h.

I
mpor
tanceofst
andar
dizeddeat
hcer
ti
fi
cat
e

1)Sour
ceofmor
tal
i
tydat
a

2)Toknowt
hef
requencyofdi
seasei
npopul
ati
on

3)Toensur
eNat
ional
andI
nter
nat
ional
compar
abi
l
ity

4)Tohav
eauni
for
m andst
andar
dizedsy
stem ofr
ecor
dingandcl
assi
fyi
ngdeat
hs.

5)Toassessandmoni
torpubl
i
cheal
thpr
ogr
ammes,t
odesi
gni
nter
vent
ionpr
ogr
am

6)Usef
uli
nepi
demi
ologi
cal
resear
ch

7)I
nIndi
adeat
hcer
ti
fi
cateconsistsofquest
ionsrel
atedtomater
nalandi
nfantdeat
hsso
t
hatdat
acanbeobt
ainedregardingmater
nalandinfantmor
tal
it
yandthatcanhel
pin

32
 i
mpr
ovi
ngser
vices.

27. A1480gr am malei nfantbor nat32wksgest at

iontoa20y roldpr i
mi parouswoman.The
i
nfantdev elopedrespiratorydi stresssy ndromeandr equir
edmechani calventi
lati
onfor7day s.
Despi t
er ecei v
ingadequat ecal oriesf orgrowth,theinfantgainedwei ghtpoor l
yandhad
persistentdi arr
heawi t
hst eat orrhea.Thepat i
enthadanel evatedsweatchl ori
deconcentrat
ion.
t
h
Ont he37 dayaf terbi
rth,thei nf antbecamel et
hargicandwasnot edt obeoedemat ous.
Escher i
chiacol iwascul t
uredf rom t heinfantscerebralspi
nal f
lui
d,totalserum protei
nswere
reportedt obel owandcl ot hingst udieswer eprol
onged.Thei nfantdiedat45day sofage
despiteappr opri
ateli
fesav ingef fort
s.Grossaut opsyconf i
rmedt hecl i
nicali
mpr essi
onof
cysti
cf ibrosis.

Cer
ti
fythecauseofdeathasperInt
ernat
ionalDeat
hCer
ti
fi
cat
ionanddi
scusst
he
i
mpor
tanceofhavi
ngast andar
dizeddeat
hcerti
fi
cate.

Answer
:

Causeofdeat
hcer
ti
fi
cat
e Cause I
nter
val
bet
weenonsetand
deat
h

PART-
I a)Escheri
chiacol
i 7day
s
meningit
is
45day
s
b)Cy
sti
cfi
brosi
s

c) -
--
--
--
--
--
--
--
--
-

PART-
II Prematuri
ty,
mal absor
pti
on,
respi
rat
orydist
ress
syndr
ome

Expl
anat
ion:

PART-
I

a)Escher
ichi
acol
imeni
ngi
ti
sist
hedi
rectcauseofdeat
h

b)Cy
sti
cfi
brosi
sist
heunder
lyi
ngcauseofdeat
h

PART-
II

Prematur
ity
,malabsor
pti
on,
respi
rator
ydist
resssy
ndr
omewoul dallbeconsi
der
edasfact
ors
contr
ibut
edtothedeat
h.Howevertheywoul
dnotbeindi
rectcausal
sequenceofpar
t1,sothey
wouldbeplacedi
nPartII
.

I
mpor
tanceofst
andar
dizeddeat
hcer
ti
fi
cat
e

1)Sour
ceofmor
tal
i
tydat
a

2)Toknowt
hef
requencyofdi
seasei
npopul
ati
on

3)Toensur
eNat
ional
andI
nter
nat
ional
compar
abi
l
ity

4)Tohav
eauni
for
m andst
andar
dizedsy
stem ofr
ecor
dingandcl
assi
fyi
ngdeat
hs.

33
 5)Toassessandmoni
torpubl
i
cheal
thpr
ogr
ammes,t
odesi
gni
nter
vent
ionpr
ogr
am

6)Usef
uli
nepi
demi
ologi
cal
resear
ch

7)I
nIndi
adeat
hcer t
if
icateconsistsofquest
ionsrel
atedtomater
nalandi
nfantdeat
hsso
t
hatdat
acanbeobt ainedregardingmater
nalandinfantmor
tal
it
yandthatcanhel
pin
i
mprovi
ngser
vices.

Deat
hcer
ti
fi
cat
e:

I
ssuedbychi
efmuni
cipal
heal
thof
fi
ceri
nur
banar
eaandt
ahsi
l
dari
nrur
alar
ea.

Uses:
1.I
nexpl
aini
ngt
rendsanddi
ff
erent
ial
sinov
eral
lmor
tal
i
ty.

2.
Indi
cat
ingpr
ior
it
iesf
orheal
thact
ionandal
l
ocat
ionofr
esour
ces.

3.
Indesi
gni
ngi
nter
vent
ionpr
ogr
ammes

4.
Theassessmentandmoni
tor
ingofpubl
i
cheal
thpr
obl
ems

5.
Giv
eimpor
tantcl
uest
oepi
demi
ologi
cal
resear
ch.

Li
mit
ati
ons:

1.I
ncompl
eter
epor
ti
ngofdeat
hs

2.
Lackofuni
for
mit
y

3.
Lackofadequacy

4.
Changei
ncodi
ngsy
stem

5.
Changei
npat
ter
nofdi
agnosi
s.

28.Anewscr eeni
ngtestf
oracer tai
ndiseasewasadmi ni
ster
edto490persons,60ofwhom
areknowntohav ethedi
sease.Thetestwaspositi
vein50personswit
hthedisease,
aswellas
i
n20per sonswithoutt
hedisease.Calcul
atethef
oll
owing

Sensi
ti
vi
tyoft
est

Speci
fi
cit
yoft
het
est

Pr
eval
enceoft
hedi
sease

Pr
edi
cti
vev
alueofaposi
ti
vet
est

Pr
edi
cti
vev
alueofnegat
ivet
est

Answer
:

Di
sease+v
e Di
sease-
ve

Test+v
e 50 20

Test–v
e 10 410

34
 Tot
al 60 430

Theabi
l
ityoft
estt
odet
ectt
rueposi
ti
ves–sensi
ti
vi
ty

50
Sensi
ti
vi
ty=TP x100 = x100=83.
3%
50+10

TP+FN

TN 410
Speci
fi
cit
y= x100= x100=95.
3%
TN+FP 410+20

60 6000
Pr
eval
ence= x1000= x100=12.
24%
490 49

TP 50
Posi
ti
vepr
edi
cti
vev
alue= x100= x100=71.
4%
TP+FP 50+20

TN 410
Negat
ivepr
edi
cti
vev
alue= x100= x100=97.
1%
TN+FN 410+10

 Sensit
ivi
ty:Abi l
it
yofatesttoi
denti
fycor
rectl
yallthosewhohav ethediseasei
.e.t
rue
posi
tives.Screeni
ngtest
swithhi
ghsensit
ivi
tygiv
ef ewerfal
senegat i
vesandthus
prev
entf alsereassur
ancetopati
ent
sactuall
yhavingthedisease.

 Specif
ici
ty:
Abili
tyofatesttoident
ifycor
rect
lyallt
hosewhodonothavethediseasei
.e.
tr
uenegatives.Scr
eeni
ngt estswit
hhighspecifi
cit
ygiv
efewerf
alseposi
ti
vesandhence
prev
entunnecessaryanxietyandexpenseforthosenothav
ingt
hedisease.

 Predi
cti
veval
ueofaposit
ivetest-
indi
cat
es: pr
obabi
l
ityt
hatapat
ientwi
thaposi
ti
ve
testr
esul
thas,i
nfactthediseaseinquest
ion.

 Predi
cti
veval
ueofanegati
vet
est-i
ndicat
es:probabi
l
ityt
hatapat
ientwi
thanegat
ive
testr
esul
t,doesn’
thav
ethedi
seaseinquest
ion.

 ThePredict
ivev
alueofaposi
ti
vet
esti
ncr
easesi
fthepr
eval
enceoft
hedi
seasei
smor
e
anddecreasesi
fitl
ess.

29.Ascr
eeni
ngt
est(
PAPsmear
)wasdonef
orcer
vical
cancer
.Resul
tsar
egi
venbel
ow

35
36
37