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Community

8 Medicine

1. How frequently should the well water in a


village be chlorinated?
(A) Daily
(B) Once a week
(C) Every 3 months
(D) Every 6 months
2. National institute of occupational health is
located at:
(A) Jaipur
(B) Ahmedabad
(C) Mumbai
(D) Lucknow
3. Penicillin injection is recommended every
3 weeks for diagnosed cases of rheumatic
heart disease. This is an example of:
(A) Health promotion
(B) Specific protection
(C) Early diagnosis and treatment
(D) Disability limitation
4. A five-year follow up study was done to
determine, whether or not smokers, who
had previous heart attacks, were at a risk
of dying after 5 years, if they continued
smoking or quit smoking. For this purpose
a cohort of 156 patients of ischemic heart
disease was taken. All of them were
smokers till they experienced heart attack.
Community Medicine 81

75 patients continued smoking after heart


attack and 81 patients quit smoking. Out of
those who continued smoking 27 died and
out of those who quit smoking 14 died.
What is the risk ratio amongst those who
continued smoking and those who quit
smoking?
Heart Attack Patients
Status after Continued Quit smoking Total
5 years smoking
Died 27 14 41
Survived 48 67 115
Total 75 81 156

(A) 0.17
(B) 1.1
(C) 2.1
(D) 3.1

5. The human genome project is an interven-


tion which can be termed as an example of
what type of prevention?
(A) Primordial
(B) Primary
(C) Secondary
(D) Tertiary

6. In a village with a population of 5000, the


infant mortality is 100 and the birth rate as
30/1000. Calculate the number of doses of
measles vaccine required for the number
of eligible children in the village, if the
wastage factor of measles vaccine is two:
(A) 135
(B) 150
(C) 270
(D) 300
82 MP–PPG 2010

7. Which of the following committees


promoted the concept of urban primary
health care?
(A) Bhore
(B) Shrivastav
(C) Kartarsingh
(D) Krishnan
8. As per the Central Births and Deaths
Registration Act, 1969, what is the upper
limit, in days for registering an event of
birth?
(A) 7
(B) 14
(C) 21
(D) 28
9. National Institute of Epidemiology is located
at:
(A) New Delhi
(B) Ahmedabad
(C) Chennai
(D) Kolkata
10. A new triage system was set up in an
emergency unit of general hospital. To
evaluate the new system, the waiting time
of patients was measured and compared
with the waiting time at a comparable nearby
hospital for a period of 6 months. The type
of study (research design) in above
mentioned example is:
(A) Cross-sectional study
(B) Longitudinal study
(C) Case control study
(D) Clinical trial
11. With reference to the demographic cycle,
India is in which of the following phases?
(A) Early expanding
(B) Late expanding
(C) Low stationary
(D) Declining
Community Medicine 83

12. For one case of measles, the subclinical


case/s expected in the community is/are:
(A) Zero
(B) 10
(C) 100
(D) 1000
13. Daily requirement of water, in liters, per
person, per day, for all purposes ideally is:
(A) 40-50
(B) 50-100
(C) 100-150
(D) 150-200
14. The approximate calorific value of 2 slices
of bread, in kilocalories, is:
(A) 70
(B) 170
(C) 270
(D) 370
15. The founder of epidemiology is:
(A) Fracastorius
(B) Edwin Chadwick
(C) John Snow
(D) James Lind
84 MP–PPG 2010

ANSWERS
1. (A) Daily
(Ref: Park: Textbook of Preventive and
Social Medicine, 20th edition, pages 627,
628)
The question is definitely incomplete. The question
should be like this “How frequently should the
well water in a village be chlorinated during
epidemics of cholera?”
Park quotes that: “During epidemics of cholera,
wells should be disinfected every day.” This
clearly implies that while there is no epidemic,
daily chlorination is not recommended. Provided
with “Daily” as answer from VYAPAM, I
suppose, the examiner missed the phrase
“epidemics of cholera” in the question.

Also Know
• Most effective and cheapest method of
chlorination of wells is by bleaching
powder.
• Chlorine demand of well water is estimated
by Horrock’s Apparatus.
• Roughly 2.5 gms of bleaching powder is
required to disinfect 1000 lit of water.
• This will give an approximate dose of 0.7
mg of applied chlorine per liter of water.
• A contact period of 1 hr. is allowed before
the water is drawn for use.
• At the end of 1 hr., the residual chlorine is
tested by “ORTHOTOLIDINE
ARSENITE TEST”.
• If free residual chlorine level is less than
0.5 mg/litre, the chlorination procedure
should be repeated before any water is
drawn.

2. (B) Ahmedabad
(Ref: http://icmr.nic.in/institute.htm#Perma-
nent% 20Institutes/Centres)
Community Medicine 85

National ICMR and health institutes:


National Institute of Health and Family New Delhi
Welfare (NIHFW)
National Institute of Malaria Research New Delhi
(NIMR)
National Institute of Medical Statistics New Delhi
(NIMS)
National Institute of Epidemiology Chennai
Tuberculosis Research Centre (TRC) Chennai
National JALMA Institute for Leprosy and Agra
Other Mycobacterial Diseases (NJILOMD)
National Institute of Occupational Health Ahmedabad
(NIOH)
National Institute for Research in Bhopal
Environmental Health (NIREH)
National Institute of Nutrition (NIN) Hyderabad
National Centre of Laboratory Sciences Hyderabad
Food and Drug Toxicology Research Centre Hyderabad
National Institute of Cholera and Kolkata
Enteric Diseases (NICED)
Centre for Research in Medical Madurai
Entomology (CRME)
National Institute for Research in Mumbai
Reproductive Health (NIRRH)
National Institute of Immuno- Mumbai
hematology (NIIH)
Vector Control Research Pudducherry
Centre (VCRC) (Pondicherry)
National Institute of Virology (NIV) Pune
National AIDS Research Institute (NARI) Pune

3. (D) Disability limitation


(Ref: Park: Textbook of Preventive and
Social Medicine, 20th edition)
I would like to categorize this as a very tricky
question.
Page 331, Primary prevention: “Aim of
primary prevention is to prevent the first attack
of rheumatic fever, by identifying all patients with
streptococcal throat infection and treating them
with penicillin”
Secondary prevention of rheumatic fever:
Secondary prevention (i.e., the prevention of
86 MP–PPG 2010

recurrences of RF) is more practised approach,


especially in developing countries. It consists in
identifying those who have had RF and giving
them one intramuscular injection of benzathine
benzyl penicillin (1.2 million units in adults and
600,000 units in children) at intervals of 3 weeks.
This must be continued for at least 5 years or
until the child reaches 18 years whichever is
later.”
At first look it appears that the answer must be
secondary prevention (or early diagnosis and
treatment), however if we look into the question
carefully, it is not about rheumatic fever but
rheumatic heart disease so there is no point of
secondary prevention.
Page 329: “Rheumatic fever (RF) and rheumatic
heart disease (RHD) cannot be separated
epidemiological point of view. Rheumatic fever
often leads to RHD which is a crippling disease”.
That is after RHD only tertiary prevention
(disability limitation) can be done.
(See Table 8.1 on the next page)
However there are no direct lines quoting such
situation but as the question is about RHD not
RF and the answer provided by VYAPAM is
disability limitation, the explanation holds good.

4. (C) 2.1
(Ref: Park, Textbook of Preventive and
Social Medicine, 20th edition, page 69)
Relative risk/Risk ratio = Incidence among
exposed/Incidence among non-exposed
= (27/75)/(14/81)
= 2.082 or 2.1
5. (A) Primordial
(Ref: Textbook of Preventive and Social
Medicine, 20th edition, page 39, Encyclopedia of
Primary Prevention and Health Promotion, By
Thomas P. Gullotta, Martin Bloom, page 316, 317
Table 8.1

Normal Streptococcal First attack of Subsequent attacks Rheumatic heart Disability


population throat infection → rheumatic fever → of rheumatic fever → disease →
Primordial Primary Secondary Secondary Tertiary Tertiary
prevention prevention prevention prevention prevention prevention
Individual and Specific Early diagnosis Early diagnosis Disability Rehabilitation
mass education protection and treatment and treatment limitation
ADULTS: ADULTS: ADULTS: 1.2 ADULTS: 1.2
Single IM 1.2 1.2 million units million units benzathine million units benzathine

Community Medicine 87
million units benzathine benzyl benzyl penicillin benzyl penicillin,
benzathine penicillin, IM/3wk IM/3wk IM/3wkLife long
benzyl penicillin For 5 yrs or till For 5 yrs or till
18 yrs, whichever 18 yrs, whichever is
is later later
CHILDREN: CHILDREN: CHILDREN: CHILDREN:
single IM, 600,000 600,000 units 600,000 units 600,000 units
units benzathine benzathine benzyl benzathine benzyl benzathine benzyl
benzyl penicillin penicillin,IM/3wk penicillin, IM/3wk penicillin,
For 5 yrs or till 18 For 5 yrs or till 18 yrs, IM/3wk Life long
yrs, whichever is later whichever is later
88 MP–PPG 2010

PRIMARY PREVENTION OF CHRONIC


DISEASES, OLDER ADULTHOOD:
Strategies that Might Work
“Another strategy that might work is gene
therapy–the elimination or replacement of
defective genes with normal genes. While this
belongs to future, it is within the realm of possibility
that gene therapy may result in slowing down the
ageing process and a decrease in chronic
conditions. The human genome project, a project
of US government has uncovered the map of
entire sequence of gene on human chromosome.
In the near future, it is possible that gene therapy
may result in cures for such age related chronic
conditions and diseases like as Parkinson’s,
Alzheimer’s and cancers.”
Now coming to the definition of primordial
prevention from Park which says primordial
prevention is a type of primary prevention in its
purest form. It must be clear to you that human
genome project can be either primary of primordial
prevention.
To justify VYAPAM’s answer, I hereby give you
a simple example.
Primordial prevention is eliminating a risk factor,
now if BRCA gene is a risk factor of breast
carcinoma. Deletion or replacement of this
BRCA gene by virtue of gene therapy in that
particular individual is primary prevention but this
act of repairing the gene will further act as a
primordial prevention for all the future family tree
as it will prevent even the risk factor (BRCA
gene) to occur further.

6. (C) 270
(Ref: Textbook of Preventive and Social
Medicine, 20th edition, page 488, http://
www.who.int/immunization_delivery/
vaccine_management_logistics/logistics/
expected_wastage/en/index.html)
Community Medicine 89

“In the practice of immunization, the number of


vaccine doses consumed (used) is always higher
than the number of persons immunized. The
excess number of doses represents doses loosed”
In the question birth rate = 30/1000
So total number of births in a population of 5000
= 5000 × 30/1000 = 150
Infant mortality rate is 100 per thousand live births
So total infants deaths would be = 150 × 100/
1000 = 15
So total number of vaccine needed will be = (total
births – infant death) × wastage factor
= (150 – 15) × 2 = 270
7. (D) Krishnan
(Ref: Park: Textbook of Preventive and
Social Medicine, 20th edition, pages 776,
777, http://nihfw.org/NDC/Documentation
Services/Committee_and_commission.html,
http://www.ihmp.org/urban_health.html)
Krishnan Committee has not been described in
Park but has been asked several times in MP-
PPG. The last health planning committee that Park
mentioned was up till 1977 (Shrivastava
committee)
(See Table 8.2 on the next page)

8. (B) 14
(Ref: Park: Textbook of Preventive and
Social Medicine, 20th edition, page 743)
If you think Park cannot commit mistakes, then I
must tell you that park has not corrected/updated
itself on this point for a very long time. As Pre
Park “The time limit for registering the event of
births is 14 days and for deaths is 7 days” which
in fact was true at the time of framing the act,
but the act has not mentioned any time frame by
itself and has provided the powers to the registrar
general of India to direct state governments and
union territories on this matter. The time frame
Table 8.2

90 MP–PPG 2010
BHORE 1946 Before 1st five year plan Integration of preventive and curative services Primary Health Centre
COMMITTEE (short term plan-1 PHC/40,000 population and long-term plan aka-
3 million plan) Social physician

MUDALIAR 1962 By the end of 2nd five year Also known as “Health survey and planning committee”
COMMITTEE plan (1956-1961) All India health services like Indian administrative services
1 PHC/40,000 population

CHADAH 1963 To study maintenance phase of Basic health workers to work as Multipurpose health workers (1/10,000
COMMITTEE malaria eradication programme population, combine for malaria and family planning)

MUKERJI 1st–1965 To review strategies of Separate staff for family planning


COMMITTEE family planning Delink family planning and malaria
(1st and 2nd)
2nd–1966 To examine national health Basic health services
programmes

JUNGALWALLA 1967 Committee on integration of Unified cadre, common seniority, Integrated health services No private
COMMITTEE health services practice. Equal pay for equal work, special pay for special work.
Recognition of extra qualification

KARTAR SINGH 1973 Accepted for 5th five year plan, Single cadre of multipurpose workers, i.e., MPW (Female)-Female health
COMMITTEE committee on multipurpose workers (in place of nurse/midwifes) and MPW (Male) Male health
workers under health and family workers (in place of family planning assistant)1 PHC/50,000
planning population divided into 16 subcentres (one for 3000 to 3500 population)
Contd.
Contd.

SRIVASTAVA 1975 6th five-year plan “Group on “Referral Services Complex” Medical and health education
COMMITTEE Medical Education and Support commission ROME scheme (reorientation of medical education)
Manpower” Acceptance of the recommendations of the Shrivastava Committee led to
“Rural Health Service”

KRISHNAN 1982 To address the problems of Health post run by a doctor, a Public Health Nurse, 4 Auxiliary Nurse
COMMITTEE urban health Midwives, 4 multipurpose workers and 25 Community Health Workers for
a population of 50,000.

BAJAJ 1986 National medical and health education policy

Community Medicine 91
COMMITTEE Educational commission for health sciences (ECHS) like
UGC Health science universities, Vocationalization of education health
manpower cells at Centre and states
92 MP–PPG 2010

has been changed long time back to 21 days for


all registrations.
There is innumerable government of India/state
government/municipal corporation websites
which clearly says 21 days as cut off day for
registration of both birth and death.
(http://www.tnhealth.org/dphbd.htm,
http://cbmorar.org/birth_death.html,
http://www.bhopalmunicipal.com/Hindiversion/
how1.html,
http://119.226.51.104/rbd/detail.php?and
var=R2UMSLYwhx127wyGKtWpTQ)
Moral of the story; mark 21 days as AIPG never
commits mistakes like this and after being dragged
to High Court of MP, even VYAPM is not going
to commit same mistake again. Hallelujah!!!!

9. (C) Chennai,
(Ref: Q 2 of PSM)

10. (D) Clinical trial


(Ref: Park: Textbook of Preventive and
Social Medicine, 20th edition, pages 79, 80)
“For the most part, “clinical trials” have been
concerned with evaluating therapeutic agents,
mainly drugs.”
“Nevertheless, they are powerful tool and should
be carried out before any new therapy, procedure
or service is introduced.”
Clearly in the question we are talking about a
new triage system and before implementing it has
to be tested first with a clinical trial.

11. (B) Late expanding


(Ref: Park: Textbook of Preventive and
Social Medicine, 20th edition, page 411,
Exploring environmental issues: An
Integrated Approach, David D. Kemp, page
120, http://en.wikipedia.org/wiki/Demo-
graphic transition)
Community Medicine 93
High stationary Early expanding Late expanding Low stationary Daclining

Births/Deaths/1000 Population
Birth Rate

Death Rate

Total Population

Time

(See Table 8.3 on the next page)


Park has wrongly placed China and Singapore in
late expanding. They are now low stationary
(updates from Wikipedia).
Theoretically, when the TFR = 2, each pair of
parents just replaces itself. Actually it takes a
TFR of 2.1 or 2.2 to replace each generation —
this number is called the replacement rate —
because some children will die before they grow
up to have their own two children.

12. (A) Zero


(Ref: Park: Textbook of Preventive and
Social Medicine, 20th edition, page 137,
http://www.cdc.gov/measles/about/
complications.html)
This has been asked innumerable times. However
this time they have changed the language a bit.
What they want to ask is about subclinical cases
or carriers.
“The only source of infection is a case of measles.
Carriers are not known to occur.”

Also Know
• WHO’s measles elimination strategy
comprises a three part vaccination strategy,
i.e., catch-up, keep-up and follow-up.
Table 8.3

94 MP–PPG 2010
High stationary stage Early expanding stage Late expanding stage Low stationary Declining
stage

Birth rate high Birth rate high (remains Birth rate begins to fall Birth rate low Birth rate lower than
unchanged) death rate

Death rate high Death rate falling Death rate falling Death rate low
(declines further)

Population growth slow Population increasing Population increasing, Population stable Population growth
but less rapidly (Total Fertility negative (sub-
Rate <2.5) replacement
fertility<2.1)

India till 1920 Afghanistan, Palestinian, (Developing countries) (Industrialized nations) Germany, Hungary,
(pre-industrial society) Bhutan, Laos, Sub-Saharan India, South Africa, Asia Europe, USA, Russia
Africa (except South Africa) (except China) Canada, China,
Singapore, Australia,
New Zealand, Brazil,
South Korea, Turkey,
Mauritius
Community Medicine 95

• The period of communicability is


approximately 4 days before and 5 days after
the appearance of rash.
• WHO defines elimination of measles as
absence of endemic measles for a period of
>/= 12 months in presence of adequate
surveillance.
• The most effective age of immunization of
measles vaccine is as close to 9 months as
possible.
• The age can be lowered to 6 months if there
is measles outbreak. In this case a second
dose after the age of 9 months would be
needed.
• One dose of vaccine appears to give 95%
protection.
• Pneumonia, is the most common life
threatening complication of measles.
• Ear infections (otitis media) is the most
common complication of measles, occurring
in about 1 in 10 measles cases and permanent
loss of hearing can result.
• Diarrhea is reported in about 8% of measles
cases.
• SSPE (subacute sclerosing panencephalitis)
is a very rare/least common complication, but
fatal degenerative disease of the central
nervous system that results from a measles
virus infection acquired earlier in life.
• It is believed that measles, like smallpox, is
amenable to eradication. It requires achieving
immunization coverage of at least 96% of
children less than one year of age.

13. (D)150-200
However in my opinion it should be (a) 40-50.
Decision of High Court of Madhya Pradesh on
this matter is awaited. Hallelujah!!!!
96 MP–PPG 2010

(Ref: http://www.un.org/ecosocdev/geninfo/
sustdev/waterrep.htm, EARTH SUMMIT
+5, UN Assessment of Freshwater Resources
“High-intensity use in urban and industrial areas
may place severe stress on fresh water resources
in surrounding localities. The Assessment reports
an estimated household consumption in industrial
countries of 150 to 200 litres of water per day,
with an additional 150 to 200 litres per person per
day going for various municipal services.
Additional conservation measures could reduce
the per capita amount of usage. But in the
developing countries, it can be anticipated that
current per capita usage, which is about 50 litres/
person/day in many urban areas, is sure to
increase in the coming years. This will necessitate
additional water-treatment capacity and improved
water management capacity.”
(Ref:http://ddws.nic.in/popups/Rural
DrinkingWater 2ndApril.pdf Rajiv Gandhi
National Drinking Water Mission)
National Rural DrinkingWater Programme;
Annexure 1, A. Norms for Providing Potable
Drinking Water in Rural Areas “40 litres per
capita per day (lpcd) for humans to meet the
following requirements based on basic minimum
need as defined under the ARWSP guideline.”
Purpose Quantity (lpcd)
Drinking 3
Cooking 5
Bathing 15
Washing utensils 7
House ablution 10
Total 40
(Ref: Guidelines for drinking water quality,
2nd edition, volume 3, Surveillance and
control of community supplies, World Health
Organization Geneva, page 74)
“Measurements of the volume of water collected
or supplied for domestic purposes may be used
Community Medicine 97

as a basic hygiene indicator. Some authorities’


use a guideline value of 50 litres per capita per
day, but this is based on the assumption that
personal washing and laundry are carried out in
the home; where this is not the case, lower figures
may be acceptable.”
Ref: http://www.bvsde.paho.org/bvsacd/
cd17/basic_wate.pdf
Basic Water Requirements for Human Activities:
Meeting Basic Needs
By Peter H. Gleick, M. IWRA, Pacific Institute
for Studies in Development, Environment and
Security 1204 Preservation Park Way,
OAKLAND CA 94612, U.S.A.
“I recommend that international organizations,
national and local governments, and water
providers adopt a basic water requirement
standard for human needs of 50 liters per person
per day (l/p/d) and guarantee access to it
independently of an individual’s economic, social
or political status.”

14. (B) 170


The question seems to be incomplete, it is
important to mention the size and type of bread.
There are white bread (made from wheat flour
from which the bran and the germ have been
removed through milling) and brown bread (whole
wheat bread). Also there are different sizes of
breads available.
(Ref: O.P. Ghai: Textbook of Pediatrics,
page 112 Table 5.11)
“100 gms of white bread contains 245 calories,
and one slice contains around 25 gms.”
So two slices of white bread = 50 gms = 245/2
Calories = 122.5 Calories (1 Calorie = 1 kilo calorie,
note the difference between capital C and
small c).
Ref: American Diabetic Association
Complete Food and Nutrition Guide, 3rd
edition, page 63
98 MP–PPG 2010

“2 slices of bread contains 130 Calories.”


Ref:http://www.dietbites.com/calories/
calories-in-bread.html
“Calories in bread based on a one-ounce serving
unless noted (1 ounce = 28 grams).”
170 is the closest option if I have to choose one,
otherwise the question deserves cancellation.
Hallelujah!!!!

15. (A) Fracastorius


(Ref: Park: Textbook of Preventive and
Social Medicine, 20th edition, page 4)
Fracastorius (1483-1553), an Italian physician
enunciated the “theory of contagion”. He
envisaged the transfer of infection via minute
invisible particles and explained the cause of
epidemics. Fracastorius recognized that syphilis
was transmitted from person to person during
sexual relations. He became the founder of
epidemiology.
However, foreign authors invariably consider John
Snow as father/founder of epidemiology. Park
states John Snow as father of modern
epidemiology.
Ref: The Medical Detective: John Snow and
the Mystery of Cholera, Sandra Hempel,
Granta Books, London, 2006, ISBN-13: 978-
1-86207-842-0, http://www.ncbi.nlm.nih.gov/
pmc/articles/PMC1463927/
“John Snow is perhaps the only doctor ever to be
considered the founder of two medical disciplines:
epidemiology and anesthesiology.”