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 EXTRACTS FROM THE
MAIN BOOK

MASTERING PRACTICALS

COMMUNITY
MEDICINESECOND EDITION

Poornima Tiwari • Shashank Tiwari

As per Competency-Based Medical Curriculum

Extracted pages
 Note from the Publishers
This booklet is designed by extracting pages from the book Mastering Practicals: Community
Medicine, 2nd edition, for promotional purpose. This book is intended to help the students
prepare for practical examinations with an extensive coverage of a wide variety of spots in
question and answer format along with photographs of important specimens. The book has
been thoroughly revamped and updated as per the new competency-based curriculum for
Indian Medical Graduates introduced by the MCI.
This booklet is meant to provide you with an advance flavor of the main book. We sincerely hope
you like the work and are encouraged to buy the main text. We would be delighted to hear your
feedback. Please write to us at marketing@wolterskluwerindia.co.in

Thank you!

RACTICALS
Poornima Tiwari

Y MEDICINE
DITION

o help students prepare for practical examinations.

estion and answer format along with photographs

Shashank Tiwari

ed as per the new competency-based curriculum

mation to make the most out of the visits to water

ernal and Child health (MCH), Environment and

d
ent” and “Food Quality Regulation in India” as per
Standards Act, 2006
and nursing students and health workers.

Price:
(Community Medicine)
(V.M.M.C.) and Safdarjung hospital, New Delhi. Actively
ompetency-based curriculum introduced by MCI, she is
COMMUNITY MEDICINE

d PG students—www.ihatepsm.com. She has authored

blished numerous research articles in several indexed
h Association and Indian Association of Preventive and
MASTERING PRACTICALS

MASTERING PRACTICALS
` 499
ng as the Head of Department and Senior Consultant at
ety of Anaesthesiology and Clinical Pharmacology.

for this outstanding

ommunity medicine.”
Prof M S Swaminathan COMMUNITY
MEDICINE
ber of Parliament (Rajya Sabha)
minathan Research Founda on

to the prac cal examina on at MBBS

ct I will recommend this book to the
of MD (Community Medicine). I found
gments very informa ve and useful.”
radeep Kumar MD, FIAPSM
& Research Centre, Ahmedabad
SECOND EDITION
unity Medicine but hardly any
mina ons. This book fills this
s of prac cal examina on.”
Dr Umesh R Dixit SECOND
EDITION
Poornima Tiwari • Shashank Tiwari
tment of Community Medicine
tal, Sa ur, Dharwad, Karnataka

ISBN-13: 978-93-88696-85-2 As per Competency-Based Medical Curriculum

9 789388 696852

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Extracted pages
marketing@wolterskluwerindia.co.in
www.lwwindia.co.in
 Preface to the
Second Edition

It gives us immense pleasure to come out with the second edition after the outstanding
success of the first edition. Built on the foundation of the previous edition, it incorporates
the exponential number of new developments that have happened in the field of Community
Medicine.
This book is meant to serve as a course book covering the skill-based core competencies as
outlined in the new curriculum of Community Medicine.
It includes the latest advances and guidelines issued for the field practice of the subject
which are usually scattered across numerous different manuals and are otherwise difficult to
find at one place. This edition presents not only the relevant recent advances in this field but
also several new photographs for the benefit of the readers and to help them understand the
text easily. This edition is brought in multicolor format so that the photographs can be well
appreciated.
The topics covered in the previous edition have been retained, expanded, and refurbished.
The section dealing with vaccines and immunization has been totally revamped keeping with
the vast changes and introduction of additional vaccines in the National Immunization Program.
A new section on Educational Visits has been added. This includes information required to
make the most out of the visits to water and sewage treatment plants.
We warmly welcome feedback, comments, and suggestions from faculties and students, and
would gratefully acknowledge the same in subsequent editions.

Poornima Tiwari
Shashank Tiwari

Extracted pages
 Reviewers

Faculty Reviewers

Ajeet V Saoji Kulwant Lakra

Professor and Head of Community Medicine Assistant Professor of Community Medicine
NKP Salve Institute of Medical Sciences and Veer Surendra Sai Institute of Medical Science
Research Center and Research
Nagpur, Maharashtra Sambalpur, Odisha

Amitav Banerjee L R Lakshman Rao

Professor and Head of Community Medicine
Professor and Head of Community Medicine
Dr D Y Patil Medical College
Osmania Medical College
Pune, Maharashtra
Hyderabad, Telangana

Arun Padmanandan
Assistant Professor of Community Medicine Naresh Godara
PSG Institute of Medical Sciences & Research Professor and Head of Community Medicine
Coimbatore, Tamil Nadu Parul Institute of Medical Sciences and
Research
Bhavna P Joshi Vadodara, Gujarat
Associate Professor of Community Medicine
MGM Medical College and Hospital Niraj Pandit
Aurangabad, Maharashtra Professor and Head of Community Medicine
Smt. B.K. Shah Medical Institute and Research
Deepa Velankar Center
Professor of Community Medicine Sumandeep Vidyapeeth
School of Medicine Vadodara, Gujarat
D Y Patil University
Navi Mumbai, Maharashtra
Pradeep Kumar
Professor of Community Medicine
Deepak Phalke
Dr. M. K. Shah Medical College & Research
Professor and Head of Community Medicine
Centre, Ahmedabad, Gujarat
Rural Medical College
Loni, Maharashtra
Pragyan Paramita Parija
Deepak N Tayade Senior Resident
Associate Professor of Community Medicine Department of Community Medicine
MGM Medical College and Hospital All India Institute of Medical Sciences
Aurangabad, Maharashtra Raipur, Chhattisgarh

Extracted pages
 Reviewers v

Prasad D Pore Sushama Thakre

Professor of Community Medicine
Bharati Vidyapeeth Medical College
Pune, Maharashtra
Purushottam A Giri
Professor and Head of Community Medicine
Indian institute of Medical Science and
Research
Jalna, Maharashtra
Associate Professor of Community Medicine
Indira Gandhi Government Medical College
and Hospital
Nagpur, Maharashtra
Vani Madhavi K
Professor and Head of Community Medicine
Konaseema Institute of Medical Sciences
Amalapuram, Andhra Pradesh

Shobha B Salve Umesh R Dixit

Professor and Head of Community Medicine Associate Professor of Community Medicine
MGM Medical College and Hospital SDM College of Medical Sciences and Hospital
Aurangabad, Maharashtra Dharwad, Karnataka

PVVK Subba Rao Viral R Dave

Associate Professor of Community Medicine Associate Professor of Community Medicine
GSL Medical College & General Hospital GCS Medical College, Hospital and Research
Rajahmundry, Andhra Pradesh Centre
Ahmedabad, Gujarat

Student Reviewers

Ayush Agarwal Pragya Tiwari

Intern Intern
Maulana Azad Medical College Rabindra Nath Tagore Medical College
New Delhi Udaipur, Rajasthan

Extracted pages
 Detailed
Table of Contents

Preface to the Second Edition v

Preface to the First Edition vii
Acknowledgments ix
Reviewers xi
Table of Contents at a Glance xiii

Section I Spots 1

1. Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Condom 5
Diaphragm 6
Spermicidal Jelly and Vaginal Pessary 7
Female Condom 8
Intrauterine Devices 9
Copper–T/Multiload 9
Lippes Loop 12
Oral Contraception 13
Injectable Contraceptives (DMPA) 17
Terminal Methods of Contraception (Sterilization) 19
References 26

2. Maternal and Child Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Iron and Folic Acid (IFA) Tablets 28
Oral Rehydration Salt (ORS) 33
IMNCI Wall Charts 36
Growth Charts 38
Baby Weighing Scales 41
Sahli’s Hemoglobinometer 42
Disposable Delivery Kit 43
Partograph 44
Shakir Tape 45
References 46

3. Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Milled Rice 47
Parboiled Rice 48

Extracted pages
 Detailed Table of Contents vii

Brown Rice (Husked Rice) 49

Wheat 50
Maize 50
Bajra 51
Ragi 51
Jowar 52
Bengal Gram (Chana Dal) 53
Red Gram (Tuvar or Arhar) 54
Green Gram 55
Black Gram Dal (Urad Dal) 55
Rajma 56
Soya Bean 56
Soya Chunks 57
Groundnut 58
Fruits and Vegetables 59
Milk 61
Egg 62
Sugar 63
Jaggery 63
Groundnut Oil 64
Coconut Oil 64
Ghee (Clarified Butter) 65
Vanaspati Ghee 65
Butter 66
Iodized Salt 66
Animal Foods 67
Meat 68
Food Quality Regulation in India 68
References 69

4. Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
General Points and FAQs Regarding Vaccines 72
Bacille Calmette Guerin (BCG) Vaccine 73
Pentavalent Vaccine 75
Rotavirus Vaccine 77
Inactivated Poliovirus Vaccine 80
DPT, DT, and TT Vaccines 84
Facts Common for DPT and TT Vaccines 86
Oral Polio Vaccines (OPV) 87
Measles Containing Vaccines (MCV) 90
Hepatitis B Vaccine 93
Japanese Encephalitis (JE) Vaccine 94
Pneumococcal Conjugate Vaccine (PCV) 95
Rabies Vaccine 97
Concentrated Vitamin A Solution 101

Extracted pages
viii Detailed Table of Contents

Vaccine Vial Monitor 102

References 107

5. Vaccine-Related Spots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Mother and Child Protection Card 109
Tuberculin Syringe 111
Distilled Water 112
Vaccine Carrier 113
Day Carrier 114
Cold Box 114
Ice Pack 115
Dial Thermometer and Stem Thermometer 116
Ice Lined Refrigerator (ILR) 117
Deep Freezer 120
Autodisable (AD) Syringes 121
Hub Cutter 122
References 123

6. Entomology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Mosquitoes 124
Identification of Mosquito Larva 127
Identification of Mosquito Eggs 128
Identification of Pupa 130
Identification of the Mouth Parts of a Mosquito 131
Housefly 134
Sandfly 135
Head Louse (Pediculus Capitis) 136
Pubic Louse (Phthirus Pubis) 138
Rat Flea (Xenopsylla Cheopis) 138
Hard Tick (Ixodidae) 140
Soft Tick (Argasidae) 140
ITCH Mite (Sarcoptes Scabiei) 141
Cyclops (Water Flea) 142
References 142

7. Insecticides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
DDT 144
BHC (HCH) 144
Malathion 145
Pyrethrum 145
Mineral Oil 146
Paris Green 146
Temephos (Abate) 147
References 148

Extracted pages
 Detailed Table of Contents ix

8. Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Minimum and Maximum Thermometer 149
Dry Bulb Thermometer 150
Dry and Wet Bulb Hygrometer 150
Sling Psychrometer 151
Kata Thermometer 152
Globe Thermometer 153
Chloroscope 154
Horrock’s Apparatus 155
Bore–Hole Latrine 156
Sanitary Well 156
Sand Filter 157
Septic Tank 157
Biomedical Waste Management 158
Incinerator 160
Yellow Nonchlorinated Bag 161
Red Nonchlorinated Bag 162
Blue Cardboard Box 162
White Translucent Container 163
References 163

9. Antisepsis and Disinfection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

Soap 164
Crude Phenol 165
Dettol 166
Lime (Slaked Lime) 166
Bleaching Powder 167
Povidone Iodine 168
Ethyl Alcohol 168
Savlon 169
Formalin 169
References 170

10. National Health Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Dots (Directly Observed Treatment Short Course) Regime Box 171
MDT (Multidrug Therapy) for Leprosy 173
Rifampicin 174
INH 175
Streptomycin 176
Ethambutol 176
Dapsone 177
Clofazimine 177
Rapid Diagnostic Test (RDT) Kit for Diagnosis of Malaria 178
Chloroquine 179
References 179

Extracted pages
x Detailed Table of Contents

11. Miscellaneous Spots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Egg of Hookworm 181
Statistics 181
Cigarette 184
Occupational Health 185
Harpenden Calipers 186
References 186

Section II Family Health Study 189

12. Family Health Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

Purpose of Family Health Study in Undergraduate Curriculum 191
Family Study Format 191
Determining the Socioeconomic Status of the Family 201
References 203

13. Definitions and Explanations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Definitions of Terms Used in Family Health Study 205
Determining the Socioeconomic Status (SES) of the Family 205
Assessment of Overcrowding 208
Checking Adequacy of Lighting in a Room 209
Assessment of Adequacy of Ventilation 209
Mosquito Breeding Areas 210
Fly Breeding Areas 210
Piped Water Distribution 210
Definitions of Terms Mentioned Under Maternal and Child Health 211
References 211

Section III Project Conduction and Presentation 213

14. An Overview of the Process of Project Conduction . . . . . . . . . . . . . . . . . . . . . . . 215

Aims of Community Medicine Project 215
Steps of Project Conduction 215
References 219

15. An Overview of Project Write-Up and Presentation . . . . . . . . . . . . . . . . . . . . . . . 220

Title 220
Introduction 220
Objectives 221
Review of Literature (ROL) 221
Material and Methods (Methodology) 221
Results 223
Discussion 223

Extracted pages
 Detailed Table of Contents xi

Conclusion 224
Recommendations 224
References 224
Appendix 225
References 225

Section IV Clinico-Social Case Review 227

16. Clinico-Social Case in Community Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

References 230

17. Format for Clinico-Social Case Taking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

Identification and Family Information 231
Medical History and Examination 232
Family Health Study 232
Clinico–Social Diagnosis 233
Management Suggested 234
References 234

Section V Exercises 235

18. Measurements in Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

Exercises for Practice 239
References 239

19. Relative Risk and Odds Ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

Relative Risk 240
Odds Ratio 240
Exercises for Practice 241
References 241

20. Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

Sensitivity 242
Specificity 243
Positive Predictive Value 243
Negative Predictive Value 243
Effect of Disease Prevalence on Screening Values 243
Exercises for Practice 244
References 245

Extracted pages
xii Detailed Table of Contents

21. Tests of Significance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

Tests for Qualitative Data 246
Tests of Significance for Quantitative Data 248
Exercises for Practice 250
References 252

Section VI Educational Visits 253

22. Sewage Treatment Plant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

Primary Treatment 255
Secondary Treatment 256
References 257

23. Water Treatment Plant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

Storage 258
Filtration 258
Reference 260

Appendix: Growth Charts Based on WHO Child Growth Standards, 2006 . . . . . . . . . . . . . . . . . . . . . . . . 261

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

Extracted pages
 Chapter 1 Ÿ Contraceptives 25

– Complicated heart disease levels of health system:

– Chronic lung diseases (asthma or • IUCD 380 A and Cu IUCD 375
emphysema) • Injectable contraceptive DMPA (Antara)
– Endometriosis • Combined oral contraceptive (Mala-N)
– Pelvic tuberculosis
• Centchromen (Chhaya)
– Fixed uterus due to previous surgery or
• Emergency contraceptive pill (Ezy pill)
infection
– Abdominal wall or umbilical hernia • Progesterone-only pill (POP)
– Postpartum or post abortion uterine • Condoms (Nirodh)
rupture or perforation • Female sterilization
– Hyperthyroidism – Laparoscopic
– AIDS22 – Minilap
• Male sterilization
Choice of Contraception – No scalpel vasectomy
List the contraceptive choices available – Conventional vasectomy
under the National program. Above services are provided at various
At present the public sector provides the levels of public sector facilities as shown in
following contraceptive methods at various Table 1.1.

Table 1.1 Contraceptive Choices Available Under the National Program

Family planning method Service provider Service location

Spacing methods
IUCD 380 A, IUCD 375 Trained and certified ANMs, LHVs, SNs, Sub centre and higher level
and doctors
Oral contraceptive pills Trained ASHAs, ANMs, LHVs, SNs, and Village level, sub centre, and
doctors higher level
Condoms Trained ASHAs, ANMs, LHVs, SNs, and Village level, sub centre, and
doctors higher level
Emergency contraception
Emergency contraceptive pills Trained ASHAs, ANMs, LHVs, SNs, and Village level, sub centre, and
(ECPs) doctors higher level
Limiting methods
Minilap Trained and certified MBBS doctors and PHC and higher level
specialist doctors
Laparoscopic sterilization Trained and certified MBBS doctors and CHC and higher level
specialist doctors
No scalpel vasectomy (NSV) Trained and certified MBBS doctors and PHC and higher level
specialist doctors
Note: Contraceptives like OCPs, condoms are also provided through social marketing organizations.
Source: NHM, MoHFW, GOI website: http://www.nhm.gov.in/nrhm-components/rmnch-a/family-planning/background.
html. Accessed 27th November 2017; Annual Report of Department of Health and Family Welfare 2017-18. New Delhi:
MoHFW. Available at: https://mohfw.gov.in/basicpage/annual-report-department-health-and-family-welfare-2017-18.

Extracted pages
68 Mastering Practicals: Community Medicine
MEAT
Comment on the proteins present in it.
• Protein content is 15–20 g per 100 g.
• Protein contains all the EAA.
• Protein has high biological value.
Comment on the iron content.
• Meat is rich in iron.
FOOD QUALITY REGULATION IN INDIA
Which organization regulates food quality in
India?
The “Food Safety and Standards Authority of
India” (FSSAI)  is responsible for protecting
and promoting  public health through
the  regulation  and supervision of  food safety.
It is an autonomous body established under
the  Ministry of Health & Family Welfare,
Government of India. The FSSAI has been
established under the “Food Safety and
Standards Act, 2006.” FSSAI helps to regulate
and it also supervises the functioning of the food
businesses in India. It is mandatory for all the
food business operators, distributors, retailers,
and the storage houses to get an FSSAI license.
FSSAI is located in five regions:  •
1. Northern region with head office in New
Delhi
2. Eastern region
3. North eastern region
4. Western region
5. Southern region
FSSAI has been mandated by the FSS Act,
2006 for performing the following functions:
• Lay down the standards and guidelines in
relation to articles of food.
• Laying down mechanisms and guidelines
for certification of food safety management
for food businesses.
• Laying down procedure and guidelines
for accreditation of laboratories and
notification of the accredited laboratories.
• To provide scientific advice and technical
support to central government and state
Extracted pages
• The iron in meat is of heme variety which
has high bioavailability.
Mention the disadvantages of consuming
meat.
• Meat has a high content of fat which is
mainly of saturated type.
• Meat is relatively expensive.1,2
governments in the matters of framing
the policy and rules in areas which have
a direct or indirect bearing on food safety
and nutrition.
• Collect and collate data regarding food
consumption, incidence and prevalence
of biological risk, contaminants in food,
residues of various contaminants in foods
products, identification of emerging risks,
and introduction of rapid alert system.
• Creating an information network across
the country so that the public, consumers,
panchayats, etc. receive rapid, reliable, and
objective information about food safety
and issues of concern.
Provide training programs for persons who
are involved or intend to get involved in
food businesses.
• Contribute to the development of
international technical standards for food,
sanitary, and phytosanitary standards.
• Promote general awareness about food
safety and food standards.
What is the Food Safety and Standards Act?
An Act to
• Consolidate the laws relating to food
• Establish the “Food Safety and Standards
Authority of India”
– To lay down science-based standards for
articles of food
– To regulate their manufacture, storage,
distribution, sale, and import, to ensure
availability of safe and wholesome food
for human consumption.
100 Mastering Practicals: Community Medicine
Pre-exposure prophylaxis
• One dose (IM or ID) each on day 0, 7, and
21 (or 28)
• Booster doses of rabies vaccines are
not required after a complete pre or
postexposure prophylaxis with a CCV
Instead of routine boosters, antibody
monitoring of personnel at risk is preferred, a
booster is recommended only if the antibody
titers fall to < 0.5 IU/mL.
Management of re-exposure in previously
vaccinated individuals
Those who can document full pre- or
postexposure prophylaxis (either by IM or ID
route) with a cell-culture vaccine or PDEV:
• Two booster doses IM or CCVs ID (0.1 ml
at 1 site) on days 0 and 3
• Proper wound toilet should be done
• Treatment with RIG (rabies
immunoglobulin) is NOT required
Those who have previously received full
postexposure treatment with nerve tissue
vaccine or vaccine of doubtful potency or
cannot document complete prophylaxis
previously should be treated as fresh case and
given treatment.
Who are the candidates for pre-exposure
prophylaxis (PrEP)?
Pre-exposure vaccination may be offered to
high-risk groups such as
• Laboratory staff handling the virus and
infected material
• Clinicians and persons attending to human
rabies cases
Extracted pages
Chapter 4 Ÿ Vaccines 100
• Veterinarians
• Animal handlers and catchers
• Wildlife wardens
• Quarantine officers
• Travellers from rabies-free areas to rabies-
endemic areas1,31
The Indian Academy of Pediatrics (IAP)
has recommended pre-exposure prophylaxis
of children. This may be considered on
voluntary basis.32 Pre-exposure vaccination
is administered as one full intramuscular
dose or 0.1 ml intradermally on days 0, 7, and
either day 21 or 28.
Which types of vaccines are recommended
for the intradermal schedules?
Only cell culture vaccines are recommended
for the intradermal schedules.1,31
What needs to be done if an intradermal
injection becomes subcutaneous?
If the vaccine is injected too deeply into the
skin (subcutaneous), the classical bleb is not
seen. Then the needle needs to be withdrawn
and another ID dose should be given at an
adjacent site.
Is it recommended to switch over from IM
to ID route of administration or vice versa
during PEP?
Shifting from one route to other, i.e., IM
to ID or vice versa, during postexposure
prophylaxis is not recommended as there is
no sufficient scientific evidence on vaccine
immunogenicity following changes in the
route of vaccine administration during PEP.31
 Table 4.2 Type of Vaccine, Dose, Route, Site of Administration and Side Effects of Vaccines under NIS

Name of Type of vaccine Diluent Recommended age Dose, route, Side effects Storage
vaccine used under NIS and site
BCG Live, attenuated Normal At birth (0.05 ml until Severe ulceration, Long term: −15°C to −20°C
bacterial saline 1 month) lymphadenitis; rarely 2°C to 8°C for a few weeks
0.1 ml beyond osteomyelitis, disseminated at the place of use
the age of BCG infection During session: In the well
1 month; of ice pack
intradermal;
left arm just
above deltoid
insertion
105 Mastering Practicals: Community Medicine

Hepatitis B Killed; None At birth (birth dose) 0.5 ml; Pain, swelling, redness at 2–8°C
recombinant intramuscular; injection site Do not freeze
type anterolateral Anaphylaxis
side of mid-
thigh—left
bOPV Live, attenuated None • At birth—OPV0 2 drops; oral Mild diarrhea For long-term storage:
virus • At 6, 10, and 14 Rarely vaccine-induced −15°C to −20°C
weeks for primary paralytic polio (VAPP) in At health center: 2–8°C
immunization recipient (1/million vaccines) During immunization
• Booster at 16–24 or contact (1 in 5 million session—on the surface of
months vaccines) ice pack
Pentavalent Killed; Diphtheria None 6th, 10th, and 0.5 ml; Pain, swelling, redness at 2–8°C

Extracted pages
vaccine toxoid 14 weeks of age intramuscular; injection site Do not freeze
Tetanus toxoid anterolateral Severe: Persistent (>3 hours) During session: Outside ice
B. pertussis aspect of mid- inconsolable screaming pack; on the table
(whole cell) thigh—left Seizures
HBsAg (rDNA) Hypotonic, hyporesponsive
Purified episode (HHE)
capsular Hib Anaphylaxis encephalopathy
Polysaccharide
(PRP)
(Continued)
Chapter 4 Ÿ Vaccines 105
 (Continued)
Name of Type of vaccine Diluent Recommended age Dose, route, Side effects Storage
vaccine used under NIS and site
IPV Killed None Fractional doses at 0.1 ml; Local reaction 2–8°C
(inactivated ages 6 weeks and intradermal; Fever Do not freeze
polio vaccine) 14 weeks deltoid area— During session:
NO right side Outside ice pack; on the table
Rotavirus Live, attenuated None At 6 weeks, 10 weeks, 5 drops; oral Mild: Vomiting, diarrhea, 2–8°C
vaccine and 14 weeks cough, runny nose, fever, During session:
Irritability and rash On the ice pack
Severe: Intussusception
Measles/MR Live, attenuated Distilled First dose: At 9 Subcutaneous; Mild fever, rash, conjunctivitis 2–8°C
water completed months upper arm— Severe: Febrile seizures, During session:
supplied to 12 months right thrombocytopenia, Inside the well of the ice
with the Second dose: At
106 Mastering Practicals: Community Medicine

Anaphylaxis, encephalopathy pack

vaccine 16–24 months
Japanese Live, attenuated Manufacturer First dose: At 0.5 mL; S/C; Local reaction +2°C to +8°C
encephalitis vaccine supplied 9 months to left upper arm Transient fever, rash and During session:
(in endemic Diluent 12 months irritability On the surface of the ice
districts) (phosphate Second dose: At pack
buffer 16–24 months
solution) of age
DPT Killed; diphtheria None Two boosters at: 0.5 mL; deep Fever ≥ 39°C +2°C to +8°C
and tetanus are 16–24 months and I/M; first Swelling and induration or pain Do not freeze
toxoids and 5–6 years age booster: Neurological side effects During session:
pertussis is anterolateral (encephalitis/encephalopathy, On the table; outside the

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killed bacteria aspect of convulsions, infantile spasm, icepack
thigh, second and Reye’s syndrome) are
booster: upper primarily due to pertussis.
arm—left Incidence is only 1 in
1,70,000 doses
TT Killed; toxoid None First dose early in 0.5 mL; deep Local pain and induration +2°C to +8°C
pregnancy and I/M; upper Severe: Brachial neuritis, Do not freeze
second dose after arm—right anaphylaxis During session:
4 weeks On the table; outside the
Children: 10 and icepack
16 years of age
Chapter 4 Ÿ Vaccines 106
CHAPTER
6
MOSQUITOES
The important genera of mosquitoes that are
frequently asked in practical examinations are
Anopheles, Aedes, and Culex.
The stages of a mosquito’s life cycle, which
are put as exhibits for identification, are as
follows:
• Eggs
• Larva
• Pupa
• Adult mosquito
The larva, pupa, and egg are all displayed
on a slide under a microscope. An adult
mosquito may be displayed as such, or as a
mounted slide under microscope.
Sometimes, only the mouth parts of the
mosquito are kept for identification. When
the mouth parts are put as spots, they are
displayed under a microscope. Based on
his/her observation, an undergraduate MBBS
student is expected only to differentiate
between tribe Anophelini (represented by
Anopheles) and tribe Culicini, the prototype
for which most frequently is Culex.
Broad division of mosquitoes
There are two main “tribes” of mosquitoes:
1. Tribe Anophelini: It has only one genus,
i.e., Anopheles.
2. Tribe Culicini: It has many genera. The
important ones present in India are Culex,
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Entomology
Aedes, and Mansonia. Out of these three,
the ones which are put up for spotting
most commonly are Culex and Aedes.1
Steps for identification of an adult mosquito
If an adult mosquito is kept for identification,
it is most likely to be one of the three—
Anopheles, Culex, and Aedes.
1. First, look at the wings. Look at the
anterior border of the wings. If you see
spots at the anterior margin of the wings
(Fig. 6.1), the mosquito is an “Anopheles”
2. If no spots are seen on the wings (Fig. 6.2),
then look at the body of the insect. If there
are white stripes on a dark body including
the legs (Fig. 6.3), the mosquito is an
“Aedes”
3. If none of the above features are seen, the
displayed mosquito is a “Culex”
How to identify a male or female of any
genus?
Look at the mouth parts of the mosquito.
These consist of one proboscis for sucking
blood or vegetation juice. There is a pair of
antennae and a pair of palpi (singular: palpus).
The males of all the above three genera have
bushy antennae which resemble moustache
(Fig. 6.4) whereas the females have relatively
lesser hair on antennae (Fig. 6.5).2

Indian homes, this is not a very acceptable
thing. Hence, this is more appropriate for
dietary assessment of institutions, hostels, etc.
• 24-hour recall method (questionnaire
method) is explained in detail later
• Food frequency questionnaire method: This
is for assessing how frequently an item is
consumed during a fixed time period, e.g.,
in a week. It is more suitable for studying
the diet patterns and dietary habits of a
population
• Food balance sheet method: This method
is suitable when information regarding
the availability and consumption of food is
required at a macro level like at the global,
national, region, or state levels
• Duplicate sample method
24-Hour Recall (Questionnaire) Method
It is one of the easiest and most popular
methods for conducting a dietary survey.8–10
Studies have revealed that if properly
conducted, the 24-hour recall method reveals
reliable information regarding the food intake
amount and quality.11,12
The interviewer asks the homemaker to
recall all the foods consumed by the family
in the past 24 hours. Assuming that the
interview is done during late morning hours,
e.g., 11 a.m. to 12 p.m., the individual is asked
to think back in time and recall what was
cooked and consumed for the breakfast on the
day of the interview, for the dinner last night,
and the lunch on the previous day. In short, it
meant enquiring about all the food consumed
after the previous morning’s breakfast.
It is suggested that the recall should begin
from the most recent meal and proceed
backward in time.
In the first step, the individual is asked
to recall the items consumed during the last
24 hours.
After this, the amount that was consumed
is probed. This has to take into account the
leftover portion which is to be deducted from
the total amount cooked.
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Chapter 12 Ÿ Family Health Study 197
In the third step, the amount of each raw
ingredient that went into cooking of the
items is asked. Food models and household
measuring instruments can be used to guess
the portion sizes more accurately. Also, she/
he can be asked to demonstrate the spoon
and cups which were used to measure the
particular ingredient. The interviewer can
assess the volume by filling it with water
and pouring the same in a measuring cup.
It is a good idea to carry measuring spoons
set and other measuring instruments such as
measuring cups and cylinders.
Also examine the packages of the
prepackaged food items consumed. Read the
nutritional information per unit provided on
these and note down the amount actually
consumed out of these packets.
Some measures are suggested to obtain
complete and truthful information:
• Explain to the homemaker that you need to
know only what was actually eaten.
• Do not express either approval or
disapproval of any food item that is
mentioned, either by way of words or by
facial expressions. Do not appear to be
judgmental about any dietary item being
“good” or “bad.” No one can eat only the
approved foods all the time.
• Do not ask leading questions that may
suggest the homemaker that the family
“should” have consumed a certain item and
lead her/him to say, “Yes, we did.”13
Some items such as chapattis and bread slices
can be listed in terms of the number consumed.
The homemaker can also be requested to
display the amount of flour that she would
usually use for making 10 typical chapattis.
One can guess the raw flour weight used for
one chapatti. The number of calories in each
chapatti consumed in the family can then be
calculated on the basis of this amount. For
bread slices, the amount and ingredients can
be read off the label.
The amount of rice, wheat flour, pulses,
vegetables, etc., is entered in a table.
206 Mastering Practicals: Community Medicine

Table 13.1 Modified Kuppuswamy Scale for Urban Area (1976)

Education of head Score Occupation of Score Total family income per month Score
of family head of family (as given originally in 1976)
Professional degree 7 Professional 10 `2000 and above 12
Graduate 6 Semiprofession 6 `1000–1999 10
Intermediate/diploma 5 Clerical/shop/farm 5 `750–999 6
High school 4 Skilled worker 4 `500–749 4
Middle school 3 Semiskilled worker 3 `300–499 3
Primary school 2 Unskilled worker 2 `101–299 2
Illiterate 1 Unemployed 1 Less than `100 1

Per Capita Family Income

Table 13.2 Socioeconomic Class
Corresponding to the Total Score in The income from all the sources should be
Kuppuswamy’s SES added up. This is divided by the total number
of members of the family, regardless of the age
Total score Socioeconomic class of the individual. For example, even a baby
26–29 Upper class born on the same day is to be counted.5
16–25 Upper middle The income groups are revised from time
11–15 Lower middle
to time according to the prevailing All India
Consumer Price Index (AICPI). The student
5–10 Upper lower
should check for the latest cut offs. The last
Below 5 Lower revision before this article has been done
using price index of January 2019 (Table 13.3).
A formula has been developed for future
Income of The Whole Family regular updating of the income limits, which
Since the time Kuppuswamy scale has been uses the latest Consumer Price Index for
modified to determine the SES of the family
rather than an individual, confusion has
prevailed whether the income categories are
Table 13.3 Recalculated Family Income Groups
meant to represent the total family income or as in January 20198,9
per capita income. The general consensus is
that the original modification might have been Original income Revised by using Score
for the whole family income, even against group AICPI
the argument that this does not consider the
`2000 and above `47348 and above 12
family size and may misclassify large families.7
`1000–1999 `23674–47347 10
We suggest that the student may calculate the
socioeconomic class of the family by applying `750–999 `17756–23673 6
both, i.e. once by using “total family income” `500–749 `11837–17755 4
and next by using “per capita family income.” `300–499 `7102–11836 3
The resulting categories can be compared and `101–299 `2391–7101 2
any difference may be commented upon while
Less than `100 Less than `2390 1
presenting the family to the examiner.

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 Chapter 15 Ÿ An Overview of Project Write-Up and Presentation 225

APPENDIX
This section includes any additional
information that is considered important but
if included in the main body of the report can
divert attention from the main methodology.
For example, details of the scale used,
questionnaires, etc.
Some Tips for Presentation of the
Undergraduate Project Report
• All the members of the group should be
given a chance to present some part of the
project.
• All the members should be aware of all the
steps of the project work, even though each
member may have been responsible for one
step.
• Do not write everything on the slide and
then simply read out. Write in point form,
not complete sentences. That way the
audience will focus on what you are saying
rather than what is written on the slide.
• Present only four to five lines per slide.
Avoid using too many words. Use key
words and key phrases only and not
complete sentences.
• Use at least an 18-point font. Using a
smaller font will make it difficult for the
audience to read.
• The color of the font should be in sharp
contrast with the background. For example,
deep blue font on white background. If the
color contrast is not sharp, the viewers may
find it difficult to read.
• Do not use distracting animation, images,
or clip art.
• Use different size fonts for main points and
secondary points.
• Use a standard font such as Times New
Roman or Arial. Do not use complicated
fonts.
• Do not use only capital letters for the title
or the text. It makes reading difficult.
• Do not use colorful decoration or
distracting backgrounds. It distracts the
audience and can be annoying.

References
1. Indrayanan A. Choice of Title. Tips for Thesis Writing and Preparing Research Papers. Available at:
www.medicalbiostatistics.com/MainBodyOfReport.pdf. Accessed October 19, 2011.
2. Indrayanan A. Describing Methods; Tips for Thesis Writing and Preparing Research Papers. Available
at: www.medicalbiostatistics.com/InitialPartsOfManuscript.pdf. Accessed October 19, 2011.
3. Randolph J. A guide to writing the dissertation literature review. Pract Assess Res Eval 2009;14(13).
4. International Committee of Medical Journal Editors [homepage on the Internet]. Uniform
Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical
Publication. Available at: http://www.ICMJE.org. Accessed October 19, 2011.

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CHAPTER
21
Tests of Significance

Tests of significance let us know if the – Standard error of difference between

observed difference between any two groups
is significant or not.
By applying the tests of significance, we
calculate the probability (p value) of the null
hypothesis being correct. If this probability
is too low (p < 0.05), the null hypothesis
is rejected and the difference between the
groups is considered to be significant and not
by chance alone.
Null hypothesis assumes that the difference
between the two groups is purely due to
chance alone and is not significant.
Commonly applied tests of significance*
are as follows:
• For qualitative data
two proportions (SEP1 – P2)
– Chi-square test (χ2 test)
• For quantitative data
– Unpaired “t” test (t test)—Used for small
samples (<30 subjects in one or both
groups).
– “Z” test—Used for large samples
(>30 each).
– Paired “t” test—If we have both sets of
values (of the attribute) from one sample
only, e.g., mean heart rate before and
after treatment, these are known as
“paired values.”

TESTS FOR QUALITATIVE DATA

Standard Error of Difference Steps

Between Two Proportions Step 1: Calculate P1 and P2.
Here the value of “Z” is calculated using the (P1 is the proportion in one of the groups)
standard error of difference between two (P2 is the proportion in the second group)
proportions. It is used for comparing Step 2: Calculate Q1 and Q2.
• Qualitative data Q1 = 100 − P1
• Only two groups Q2 = 100 − P2
• Large samples (≥30) Step 3: Calculate the standard error of
The results of the observations are in terms difference between proportions or SEP1 – P2.
of proportions, e.g., 10% in one group and
16% in the other. P1Q1 P2Q2
SEP1 – P2 = +
n1 n2

* For detailed reading of qualitative and quantitative data, the tests of significance and their application, students
can refer to the book “Epidemiology made Easy,” New Delhi: Jaypee Publishers; 2009.

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 Chapter 22 Ÿ Sewage Treatment Plant 257

Activated Sludge Process incubated at the appropriate temperature and

The effluent from the primary sedimentation pH. This converts into water, carbon dioxide,
tank is oxidized by mixing it with air in an methane, and ammonia. This procedure takes
“aeration tank” (Fig. 22.4b). The aeration is 3–4 weeks.
done by a continuous stream of compressed The residue is much reduced in volume
air from the bottom of the tank. The aeration and non-offensive in smell. It dries easily and
may alternatively be accomplished by serves as an excellent source of manure.
mechanical agitation of the sewage. Hence the The methane gas which is produced during
contents remain suspended due to continuous sludge digestion can be used as a source of
mixing while the aerobic bacteria oxidize the energy for various purposes, e.g. lighting and
organic matter. heating.1–3
This method of aerobic oxidation requires
more skilled operation as compared to the
“trickling filter method.”
The oxidized sewage is led into the
secondary sedimentation tanks, also known
as “humus tanks.”
Figure 22.5 Secondary sedimentation tank.
Secondary Sedimentation Tank
In secondary sedimentation tank, the oxidized
sewage from trickling filter/aeration tank
is detained for 2–3 hours. Sedimentation
of semisolids occurs and forms sludge. The
sludge formed in secondary sedimentation
tank is called as “aerated sludge.” This can be
dried into valued manure (Fig. 22.5).
The aerated sludge is fed into “sludge
digestion tanks” (Fig. 22.6) where it is Figure 22.6 Sludge digestion tanks.

References
1. Park K. Environment and health. In: Park K. Park’s Textbook of Preventive and Social Medicine,
24th edn. Jabalpur, Madhya Pradesh: Banarsidas Bhanot Publishers, 2017; pp. 799–802.
2. Khopkar, S.M. Environmental Pollution Monitoring and Control. New Delhi: New Age International,
2004; p. 299. 
3. Bhargava A. Activated sludge treatment process—concept and system design. Int J Eng Dev Res
2016;4(2):890–96.

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260 Mastering Practicals: Community Medicine

Figure 23.5 Rapid sand filter bed.

Chlorination viruses and oxidize iron, manganese, and

hydrogen sulphide. Chlorine also destroys
The last step of treatment is chlorination. some taste and odor-producing organisms.1
Basic function of this is to kill bacteria and A chlorination tank is shown in Figure 23.6.

Figure 23.6 Chlorination tank.

Reference
1. Park K. Environment and Health. In: Park K. Park’s Textbook of Preventive and Social Medicine,
24th ed. Jabalpur, Madhya Pradesh: Banarsidas Bhanot Publishers, 2017; pp. 748–752.

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 MASTERING PRACTICALS

COMMUNITY MEDICINE SECOND EDITION

Mastering Practicals: Community Medicine is designed to help students prepare for practical examinations.
Key Features
• An extensive coverage of a wide variety of spots in question and answer format along with photographs
of important specimens
• The book has been thoroughly revamped and updated as per the new competency-based curriculum
for Indian Medical Graduates introduced by the MCI
• A new section on “Educational Visits” includes information to make the most out of the visits to water
and sewage treatment plants
• The chapters on Immunization, Contraception, Maternal and Child health (MCH), Environment and
nutrition have been completely rewritten and updated
• New topics include on “Biomedical Waste Management” and “Food Quality Regulation in India” as per
the Biomedical Waste Act, 2016 and Food Safety and Standards Act, 2006
A simple and easy-to-use book for medical, paramedical, and nursing students and health workers.

Poornima Tiwari, MBBS, Diploma in Child Health (DCH), MD (Community Medicine)

is a senior Professor at the Vardhman Mahavir Medical College (V.M.M.C.) and Safdarjung hospital, New Delhi. Actively
involved in the development of UG curriculum as per the new competency-based curriculum introduced by MCI, she is
also the founder of the popular educational website for UG and PG students—www.ihatepsm.com. She has authored
the well-known book “Epidemiology Made Easy,” and has published numerous research articles in several indexed
journals. She is also a life member of the Indian Public Health Association and Indian Association of Preventive and
Social Medicine (IAPSM).
Shashank Tiwari, MBBS, MD (Anaesthesia)
has over 25 years of clinical experience and is currently working as the Head of Department and Senior Consultant at
Kalra Hospital, New Delhi. He is a life member of the Indian Society of Anaesthesiology and Clinical Pharmacology.

“Congratula ons Dr Tiwari for this outstanding

contribu on to the field of community medicine.”
Prof M S Swaminathan
Pioneer of India's Green Revolu on, Former Member of Parliament (Rajya Sabha)
Emeritus Chairman and Chief Mentor, M S Swaminathan Research Founda on

“There are not many books available catering to the prac cal examina on at MBBS
and I have found this book very useful. In fact I will recommend this book to the
students of DPH and MPH and even to those of MD (Community Medicine). I found
its family health study and dietary survey segments very informa ve and useful.”
Prof Pradeep Kumar MD, FIAPSM
Dr. M. K. Shah Medical College & Research Centre, Ahmedabad

“There are many textbooks of Community Medicine but hardly any

from the perspec ve of prac cal examina ons. This book fills this
gap. The book deals with all aspects of prac cal examina on.”
Dr Umesh R Dixit
Associate Professor, Department of Community Medicine
SDM College of Medical Sciences and Hospital, Sa ur, Dharwad, Karnataka

ISBN-13: 978-93-88696-85-2

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9 789388 696852

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