Community Medicine - Ashan Bopitiya -

Batch 02(F)
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1 The incidence of Type 2 diabetes mellitus in Sri Lanka has increased to such an extent that it has become a major
problem of health

1.1 List the reasons for this situation (20 marks)

1. Obesity 6. Psychological stress

2. Fetal malnutrition 7. Physical inactivity
3. Lack of sleep 8. Smoking
4. Maternal smoking 9. Unhealthy Lifestyle
5. Family History 10. Fast Food/Fizzy Drinks

1.2 If you were a medical officer of health (MOH) what steps would you take to bring down the incidence of this
disease in your MOH area (80 marks)

Prevention of Diabetes Mellitus

Health education on avoidance of risk factors and adoption of a healthy lifestyle, look for chronic inflammation
especially in the oral cavity, education about healthy diets which are rich in fiber , low in sugar and fats. This can be
done by the MOH and team through visits to Home, school & Workplaces.
Screening to Provide secondary prevention
Avoid cigarette smoke and promote oral heath – Bacteria growth leads to chronic inflammation.
Lead a stress free life through Relaxation , meditation, music, pets , watching sunsets etc.
Adequate sleep
Healthy diet of fiber rich food like Whole fruits.- Juices should be avoided since it has a high Glycemic index than
whole fruits. And also avoid refined Carbohydrates and Fizzy drinks. Increase frequency of meals like 3 Square meals
and 2 round meals while avoiding Gorging , fast foods and pastries. Take plenty of anti-oxidants.
Avoid central obesity
Promoting Physical activity – Muscle strengthening exercises.
Adequate intake of Chromium
Promote earthing and Grounding since it has various benefits such as : Suppress chronic inflammation, Reduces
stress , improves sleep etc.

2 Write short notes on the following

2.1 Control of dengue fever in Sri Lanka (40 marks)

Dengue prevention strategies are 1. Preventing Breeding places , 2. Destroy Larvae , 3. Destroy Adult Mosquito , 4.
Prevent mosquito bites , 5.Health education & Promotion.
Indicators used in Dengue control are House index , Container index and the Bretaux Index.
House index is the percentage number of houses with larvae to the total number of houses checked. If one or more
containers are present in a house containing larvae that house is taken as Possitive.
Container Index is the percentage number of containers with Larvae to the total number of containers within the
household.
Bretaux Index is the percentage number of containers with larvae to the total number of houses checked. Therefore
in other words its basically the number of Larvae bearing Possitive containers per 100 Houses examined. A Bretaux
index over 5 indicates an impending outbreak and need to implement strict control measures where as a BI of more
than 20 indicates and emergency situation needing Urgent control measures including mass fogging of the high risk
areas.
Prevention of Mosquito breeding is carried out by cleaning the environment , preventing water collection in the
garden & outside the house , in the gutters , drains , slabs of buildings , Vases , Fridges , A/C Units covering wells and
tanks with Meshes and nets.
Destroying the Larvae is carried out by using larvivorous fish in tanks and wells , Using BTI bacteria. Regularly
changing water in Vases, bird baths and other ornamental containers. Using oils in water collecting containers would
be another option to destroy the larvae.
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Controlling adult mosquitos can be carried out by cleaning the environment by cleaning the bushes , shrubs any
overgrown plants. Keeping indoors cleaned and exposed. Fogging & Fumigation plus Indoor Residual spraying.
Preventing Mosquito Bites is carried out by wearing Protective clothing like long trousers and long sleeved shirts.
Using of Bed Nets and mosquito repellents. By closing the doors and windows in the afternoon and early mornings to
prevent mosquitos from entering the house. Prevent mosquito bites on patients with DF.
Health education and Promotion should be carried out by targeting groups and individuals and educating them
about symptoms & signs of DF and the importance in seeking medical advice. Stress the importance of dengue
prevention and give the basic prevention messages. Using of ComBI (Communication for Behavior Impact) – It is an
integrated marketing communication approach aimed at encouraging communities to adopt desirable behavior to
attain health goals.
Challenges in Dengue control – Dengue control involves a lot of inter-sectoral collaboration since it is a disease with
lot of environmental associated factors. Seasonality of the disease – It is mainly increased after a period of rain
specially in the monsoon season. Solid waste disposal problem and lack of proper garbage disposal mechanism
within most local government areas. Negative attitude of public in maintaining a clean environment and preventing
mosquito breeding.

2.2 Importance of taking occupational history from a patient (30marks)

Occupational history is a chronological list of all the patient’s employments with dates expanded as necessary to
detail out any evidence of occupational exposure to potentially hazardous agents and resulting effects on health.
Occupational history should consist of :
1. Current occupation History – Type of work , duration/day , Exposed environment etc.
2. Previous occupational History
3. Part time occupations
4. Leisure time activities
Occupational history is important because :
1. Work can precipitate some illness
➢ Eg: Too much work in the working place of a worker (Sawing mill) can lead to hearing loss
2. Exacerbation of already existing illnesses
➢ Eg: Exacerbation of asthma in a person working in a textile industry
3. Health and illness can interfere with work
➢ Eg: A Driver who has epilepsy can cause major accidents and put a lot of lives at risk
4. The income of the patient is important since it determines the affordability for health care facilities and
medication depends on the occupation.
➢ Eg: A Daily paid manual worker gets a very poorn income compared to an engineer
➢ The diet and the access to health care also differs depending on the income and it can play a huge
role and have a great impact on the health of a person.
5. The predisposition to an illness depends on the type of work:
➢ Eg. An executive officer who lives a sedentary life has a higher risk of getting DM than a manual
labourer who works hard and exerts daily.
6. The timing and the dosage of the drugs should be adjusted according to the patients job to achieve
maximum benefit and increase the patient compliance.
➢ Eg: A Fisherman cant come to the chest clinic daily for TB DOTS Rx
7. Sometimes patients present with somatic signs and symptoms which are caused by the stress due to their
occupation
➢ These illnesses can be misdiagnosed and mistreated if the occupation history is not taken properly.
8. The other main importance is for notification of occupational related diseases – Research purposes.
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2.3 Control of road traffic accidents in Sri Lanka (30marks) –

P.S - Detailed Answer

Road Traffic Accident is an undesired/unintended happening which can occur

1. Between a Vehicle and another vehicle
2. Between a vehicle and a person
3. Between a Vehicle colliding with a Movable/Unmovable property
4. When a vehicle goes off the road
5. A Person being knocked down by another person
6. Due to natural or man-made disaster.

RTA is the leading cause of death by injury and the 10th leading cause of all deaths globally. Approximately 1.2 million
people killed in car accidents each year. It is known as the biggest man-made 20th century epidemic leading to a loss
of young productive life and increase in the pool of permanently incapacitated young people. This puts out a huge
burden on developing countries and increases the need for long term expensive care.
The risk factors of RTAs fall under 3 main categories (Triad) :
1. Road User (Human Factors) 2. Vehicle Factors 3. Environmental Factors

Human Factors
• Driver Fatigue – Avoid Driving when fatigued and tired
• Drink and Drive – avoid driving when drunk. Test drivers for alcohol (Breathalyzer test)
• Negligence by Pedestrians – Drunk pedestrians, Not adhering to rules like use of pavements, pedestrian
crossing and crossing behind parked vehicles. Inexperience (6 to 14Y) and impaired (Elderly) age groups on
roads.
• Violation of road rules
• Inexperienced drivers – Teens less than 15Y
• Driving at High Speed
• Negligence in over taking vehicles
• Riders not wearing helmets
• Cell Phone use
• Use of Drugs (Medical/Street drugs) – Antihistamines, Cannabis etc
• Drivers with poor eye sight
• Non use of seat belts – Occupants are thrown about like missiles during RTAs which could result in severe
head injury.
• Psychological factors (Stress) – people with Road rage , Anxiety , Recent adverse life events , should be
discouraged from driving
• Medical condition of the driver – Epileptic driver

Vehicle Factors
• Vehicles with a high speed capacity – avoid speeding and speed traps should be implemented
• Two Wheelers – unstable with little protection and rider should not unnecessarily speed and should wear
crash helmets and leather clothing and boots to reduce extensive superficial tissue injuries.
• Old & Poorly maintained vehicles – Regular checking should be done
• Colour of the vehicle – Red , Blue and Black is of poor visibility while Yellow is most visible.
• Ordinary Glass windscreen – Could have serious soft tissue injuries therefore a laminated glass should be
used
• Ordinary Door Locks – During RTAs there is a chance that doors could open and the occupants being thrown
out. Therefore antiburst door looks should be used.

Environmental factors
• Poor Road conditions in sri lanka – Uneven , slippery roads – Construct and maintenance of roads in good
condition should be implemented.
• Building Schools near highways – Should be avoided
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• Lack of pedestrian foot paths and pavments , poor lighting and lack of traffic lights also play a role as risk
factors of the environment.
Road traffic safety systems, emphasizes involvement at all levels of the roads.
1. Managing risk exposure with land use
2. Planning and designing roads for safety
3. Providing visible cross worthy , smart vehicles
4. Setting road safety rules, Securing compliance & Improving transport policy

Dept. of police in SL has some key recommendations to prevent RTAs

➢ All Road users to act with civil responsibility
➢ Educate community on Traffic safety
➢ Safe driving programs to be conducted for drivers/riders & also conductors to be educated on safety.
➢ Road infrastructure defects to be identified & rectified by RDA
➢ Discipline driving methods to be taught and Examination of driving knowledge and the knowledge of rules
and Regulations and assessment of medical fitness before issuing the Driver’s license.
➢ Identify risk drivers and cancel or suspend their license by judiciary or by the demerit system via the
controller of Motor Traffic.
➢ To increase the insurance premium of Risk drivers
➢ Deterrent punishment for offenders committing fatal grievous & serious accidents.
➢ Renewal of drivers license every 3Y having rechecked the knowledge on rules and regulations, health, driving
skills & driving records.
➢ To include traffic road safety in school curriculum
➢ To have special driving programs for school leavers
➢ Advance traffic management & road safety centers on mobile for education and enforcement purpose on
highways.
➢ Reflectors and other accessories to be fitted on peddle cyclists.
➢ Educate to wear reflective material at night to increase visibility
➢ Public transport system to be improved and necessary recognition given.
➢ Alcohol ignition interlock systems that detect alcohol on breath

3.1 Outline the antenatal care services provided through medical officer of health unit (25 marks)

The purpose of an antenatal care is to have healthy mother and a good healthy baby after a normal vaginal delivery.
And to prevent mortality and morbidity during the antenatal period owing to the development of complications
during pregnancy.
Antenatal care consist of:
1. Assessment : Maternal risk factors, ongoing assessment of feto-maternal well being, screening for maternal
complications.
2. Care Provision
3. Health promotion
The antenatal care services are carried out in 2 forms at the MOH level. Antenatal care by the Public Health
Midwife(PHM) and through the MOH Clinic.
Antenatal care by the PHM
If a newly married couple with a pregnant wife or a pregnant mother hasn’t reported their presence to the MOH, the
PHM would usually come into contact with this during her routine field work. She would pay them a visit and get
their details. The woman would be entered in the eligible couple register and assigned a number. Her pregnancy
would also be recorded & a number given. Once this is done the PHM would contribute her Antenatal care service as
follows :
1. She would provide information and counselling of selfcare at home , nutrition , safer sex , HIV . Breast
feeding, family planning, Healthy life style including harmful effects of smoking & alcohol use, and use of
insecticide treated bed nets.
2. Birth planning, advice on labor, danger signs & emergency preparedness
3. Support for woman living with HIV/AIDS
4. Assessment of signs of domestic violence and referral
5. Education and support for compliance with Preventive Rx
6. Give advice regarding pregnancy – Diet, mental health, avoiding complications, also educating the family.
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7. Clear any doubts and any misconceptions or myths regarding pregnancy.
P.T.O Continued …

8. Home visits : (3 Visits)

➢ 6 to 12 weeks : 1 Visit
➢ 22 to 24 weeks : 1 Visit
➢ 34 to 36 weeks : 1 Visit
9. Asses risk factors and increase the number of visits accordingly
10. Examine the breast for any breast lumps and in the later stages measure SFH & listen to fetal heart sounds.

Antenatal care at the MOH clinic - 1st Level facility

Registration at the MOH clinic should be done ideally before 8 weeks. Can be done on the Booking visit too.(6 to 8
weeks)
The main services carried out are
1. Confirmation of pregnancy
2. Monitoring of progress of pregnancy and assessment of maternal and fetal well being including the nutrional
status
3. Detection of problems complicating pregnancy (Anemia , HTN disorders, bleeding, mal presentations,
multiple pregnancy)
4. Responds to other reported needs
5. Tetanus immunization
6. Anemia prevention and control (Iron and folic acid supplementation and worm Rx) plus nutrition counselling
7. Syphilis Rx and Rx of Syphillis (woman and her partner)
8. Rx of mild to moderate pregnancy complications (Mild to moderate anemia, UTI, vaginal infection)
9. Abortion , Post-Abortion care, & family planning
10. Mx of ectopic pregnancy
11. Pre-referral Rx of severe complications (Pre-eclampsia , bleeding, infection and complicated abortion)
12. Antibiotics for premature rupture of membranes
13. Support for women living with violence and HIV

Situational Level – added points

1. HIV testing and counselling, prevention of mother to child transmission of HIV by anti-retroviral therapy,
infant feeding counselling, mode of delivery advice.
2. Antimalarial intermittent preventive therapy (IPT) and promotion of insecticide treated nets (ITN)
3. Deworming
4. Assessment of female genital Mutilation
5. Rx of Mild to moderate opportunistic infections
6. Rx of simple malarial cases
Regular followups are essential
Give mothers the opportunity to discuss issues and ask questions and clarify them.

3.2 Describe the role of public health staff in preventing infant deaths in the community (25 marks)

Infant is a child less than 1 year

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ𝑠 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑠 𝑙𝑒𝑠𝑠 𝑡ℎ𝑎𝑛 1 𝑌𝑒𝑎𝑟

Infant mortality rate(IMR) = 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝐿𝑖𝑣𝑒 𝐵𝑖𝑟𝑡ℎ𝑠 𝑖𝑛 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟
× 1000

This is the most important indicator of health status in a community and an important indicator of the level of living.
It indicates the effectiveness of MCH services (Maternal Child Health)
It is the largest single age category of diseases and condition to which the adult population is less vulnerable.
It is affected quickly by specific health programs so it can be changed very quickly and it has declined drastically on a
global scale.
➢ Perinatal death – 28/52 of POA to 7Days after ➢ Early Neonatal death – Birth to 7 days
birth ➢ Late neaonatal death 7 days to 28 days
➢ Neonatal Death – Birth to 28 days ➢ Post Neonatal death – 28 days to 1 year
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➢ Neonatal death = Early N. Death + Late N. ➢ Infant Death = Neonatal death + Post
Death Neonatal death
Common causes of infant mortality
1. Neonatal mortality
• Low Birth weight • Condition of placenta and cord
• Birth injuries/ difficult labor • Diarrhoeal disease
• Congenital anomalies • Acute respiratory infection
• Hemolytic disease of the new born • Tetanus

2. Post neonatal mortality

• Diarrhoeal disease • Malnutrition
• Acute respiratory infection • Congenital anomalies
• Other communicable diseases • Accidents

Factors affecting infant mortality are broadly divided into 3 categories.

1. Biological Factors –
➢ Low/High Birthweight, Age of the mother, birth spacing, multiple births, family size, fertility
2. Economic factors
➢ Determines the access and availability of quality health care
3. Cultural and Social factors
➢ Breast feeding, cleanliness & eating habits, early marriages, sex of child, quality of mothering,
maternal education, broken families , brutal habits, bad environment etc.

Public health staff play a major role in prevention of infant mortality since the Aetiology is multifactorial
Under ideal health conditions, no baby should die except babies with congenital defects.

Antenatally the PHM & MOH/MO/RMO look after maternal nutrition in order to prevent any complication that can
occur due to lack of nutrients.
1. Nutritional education
2. Food Supplementation – Triposha 750g
3. Drugs –
➢ Folate 5mg daily – to prevent neural tube defects
➢ Iron Folate – 200mg/ daily – tp prevent anemia
➢ Calcium lactate
➢ Vit. C 50mg
➢ Mebendazole – warm Rx
- Mother is vaccinated antenatally for control of infections
- Risk factors are assessed antenatally on each visit by the MO and Follow up is carried out by the PHM until
delivery
- Postnatally the PHM and MO takes over to look after the normal growth of the body. PHM registers children
for clinic attendance and immunization. (Baby has to be registered within a month).
- Babies Hight and weight are also measured and monitored and recorded in the CHDR. This is followed the
PHM throughout child growth to identify any lags in their development.
- BMI is also calculated and at risk babies are directed towards an MO
- Length is measures at 4, 9, & 18 months by the PHM/MO
- Baby undergoes MOH examination and if there is any growth delays the MOH excludes error in breast
feeding , lactose intolerance, cleft palate, formula feeding pattern.
- For children over 6 months dietary advices are given.
- If unsatisfactory health conditions are present – necessary interventions are carried out and referred to a
consultant pediatrician for consultation
- At clinic immunization process is carried out. They are stored , prepared and efficacy ensured.
- A neonate should attend the clinic after 1 month(Before that the PHM visits and monitor the baby) Every
month they have to visit the clinic.
- PHM is responsible to look for whether the baby is well breast fed (Because breast feeding prevents GI, and
respiratory diseases to a huge extent)
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- PHM also helps and educates the mother on family planning(at least 3y spacing) because spacing between
children improves the quality of care given to the infant.
- Sanitation
- Provision of primary care : Socio-economic development by the PHI
- Provision of safe water, housing, & agricultural development, communication , transport, education.
- Apart from them all the regional health officers, divisional and national level directors of health & health
ministry collect data on annual infant mortality, identify common risk factors & implement new strategies to
reduce infant mortality rate.

3.3 List the responsibly of a public health inspector with respect to school health Programme (25 marks)

School health Programme was established to ensure that children are healthy and capable of promoting their own
health and the health of their family and community.
The main components of a School health Programme are :
1. Health related school policies – morning exercises etc
2. School medical services along with the School medical inspection (Provides counselling, medical
examination/screening, vaccination, preventive Rx, & Nutrition supplementation)
3. Healthy School Environment
4. Life based health education
5. School community participation

It is conducted usually by the MOH with the involvement of the MO, PHNS(Public health nursing sister), PHM(Public
Health Midwife) , and the PHI (Public Health Inspector)
Responsibilities of the PHI :
Before the School medical inspection the PHI usually pays a visit to the school and performs the School health survey
with the help of the principal and the teachers.
1. Background information of the school
2. Name. address, No. of children (Boys, Girls & total in different grades)
3. School buildings
4. Staff room
5. Health promoting unit
➢ Availability of a health promoting unit
➢ First aid services
➢ Trained personal for first aid service
6. Toilet facilities
7. Water supply
➢ Source
➢ Adequate supply or not
➢ Safe or Not
8. Waste Management : Classification, Disposal, Composting
9. School Premises
➢ Clean or not ➢ Accident prone sites
➢ Any Health hazardous sites ➢ Stray animals
➢ Mosquito breeding sites ➢ Space for playing
➢ Fly breeding sites ➢ Home gardening
10. School canteen
➢ Availability of a canteen or not
➢ Whether it monitors by H800
➢ Grading according to the H800 classification
➢ Canteen policy Adopted or not
11. Preparation of mid day meals
12. School Kitchen / Home science unit
13. Hostel facilities
14. Health promotion
15. Children with defects are followed up the the PHI and class teacher
16. Records and monthly returns are maintained and prepared
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3.4 Describe the services provided through a well woman clinic (25 marks)

- Women have particular health needs that needs to be addressed. So Well Womens clinic is a medical
practice specializing in the unique healthcare needs of women.
- It is conducted for women over 35Y old.
- These women are directed towards the clinic by the PHMs who are aware of the women in the area that
would benefit from these services.
- After the patients are registered in the clinic, many services are provided for free of charge with the hope of
maintaining good health in older women. This is basically done by solving current problems, identifying risk
factors and taking preventive measures.
- If any abnormality is detected, they are referred to specialist clinics for further appropriate care and
management.

The services provided are :

1. Screening for Cancers
• Breast CA :
➢ Women are trained for self breast examination
➢ Breast examination carried out by PHM or PHNS (Public health nursing sister)
➢ If an abnormal lump is detected, they are referred for mammographic/FNAC
• Cervical CA
➢ Basic Visual examination
➢ Pap smears are done, once in 5Y and sent to the nearest provincial hospital. Takes upto 1 to
2 months for results
➢ Borderline abnormalities – Reassessment in 6/12
➢ CA staging 2 or 3 – referred to a VOG for colposcopic examination
2. Screening for other non-communicable diseases
• DM – Benedicts test is done for urine and if Possitive , FBS is requested. BMI is calculated and advice
on dietary habits and exercise are given
• HTN – Routine BP measurement and if BP is over 140/90 – referral
3. Routine CVS and RS examination by the MO
4. Family planning advice on contraceptives and insertion of IUCDs
5. Health education using flash cards
• Regarding malnutrition – anemia
• Over nutrition – obesity
• Osteoporosis
• STIs
• NCDs
6. Preparation for menopause
• Patient is given information on what menopause is and the signs to expect
• Daily bath
• Exercise
• Balanced, low fat diet
• Medication
• Relaxations
Well womans clinics provide medical services, information, counselling, referral and education to all women. Many
women lead hectic lives and hardly find the time to look after their health.
So these clinics provide a very important service
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4.1 Describe the ‘’epidemiological surveillance ‘’ (10 marks)

It is a systemic , ongoing process which involves collection, compilation & analysis of data that is linked to public
health and is converted into useful information. This information is then distributed to make use of for further
prevention and control.

4.2 List 3 surveillance systems available within the Sri Lankan health system ( 30 marks) – Extended answer of
all the surveillance systems.

1. Routine Surveillance (Notifiable disease reporting)

- Under public health laws some diseases are deemed notifiable. Treating Physicians and labs should
notify to public health authorities
2. Lab Based Surveillance
- This is basically using the information generated in the labs for surveillance
- Advantages are: Immediate information on rare or significant diseases, reporting of confirmed
diagnosis and the ability to obtain information of patients seen by many physicians
3. Special surveillance
- These are surveillance networks that are developed to meet information needs that exceed the
capabilities of routine approaches.
- Advantages are: The ability to collect in depth & complete information, ability to collect information
on disease that is deemed not reportable through the routine system, enhances the coverage of
routine surveillance
4. Sentinel site surveillance
- Active surveillance approach and collection of data is done at a selected sentinel surveillance site
such as sentinel sites for polio.
- Expansion for other diseases (Dengue – all hospitals and diseases like rubella, measles NNT,
leptospirosis, and HepB are carried out in selected hospitals)
- Can also be expanded to non-communicable diseases
5. Disease Registers
- List of all occurrences of diseases within a defined area.
- Collection of relatively detailed information such as demographic, exposures, characteristics of the
disease, treatment and outcome. This also helps to identify the patients that needs long term follow
up.
6. Behavioral risk factor surveillance
- This is an active system of surveys that monitors the Behaviors associated with a disease, the
personal attributes related to disease risks and monitors the knowledge, attitudes, and practices
affecting behaviors.
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4.3 List the roles of the following persons in the expanded programme on immunization
4.3.1 Regional epidemiologist (30 marks)

The regional epidemiologist works in the provincial level, under the regional director of health services. It is the duty
of the RE to communicate between the RDHS and the MOH areas in his region.
Collects previous months usage from each MOH area and their remaining stock details & reserve the amount
required for each MOH area for the next month. These details are received from the district office.
Cold chain maintenance of vaccines before issuing and proper transportation when supplying.
Collect adverse effects of immunization from MOH areas of each district and the inform the epidemiological unit.
Monitor cold chain maintenance at district level
Storing and keeping of additional buffer stock
Inform the epidemiological unit and any additional requirement of vaccination/ as stocks ends.
Supply districts with adequate amount of vaccination in any epidemic.
Supply the district staff with new implications of the vaccine use.

4.3.2 Public health nursing sister (30 marks)

PHNS or the public health nursing sister is an important member of the MOH team. She in under the charge of
MOH/AMOH and is in charge of the SPHM & PHM.
These are her responsibilities
➢ Planning and organizing of all MCH activities
- Antenatal and child welfare clinics
- Antenatal classes
- Distribution of triposha
- Vaccination programmes
- PHM duties
➢ Guidance, supervision and performance evaluation
➢ Training of Public health midwives
➢ Insertion of IUD, withdrawal of blood for VRDL

5 5.1 List the current activities carried out by the ministry of health to prevent and control iron deficiency anaemia
in Sri Lanka. (40 marks)

Nutritional status through out the life cycle is inter-related. Fetal malnutrition due to poor maternal nutrition sets up
a vicious cycle affecting all the stages of life. Even future generations.
Therefore Nutritional approach is carried out in all stages of life using both indirect and direct interventional
methods by the ministry of health and one particular intervention is to prevent and control Iron Deficiency anemia in
Sri lanka.
Indirect interventions aim to increase the production, accessibility, affordability and equal distribution of nutrient-
rich food by making changes in the political and economic framework. With government intervention, houses are
given nutritious foo. Legislation on food quality and nutrition are made so that adequate nutrition including iron is
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available for consumption. These iron rich foods include green leaves which are grown well in all areas of the
country.
Direct interventions that have been done include diet fortification with Iron containing/Iron added food that are
available in the market. Sri Lanka will receive wheat flour fortified with Iron soon, as per legislation. Iron
supplements are also given. This is done very commonly as a iron sulphate tablet that is given to people of various
age groups.
For Pregnant mothers - During the antenatal clinic –
- Mothers are examined and the micronutrient supplementation which includes Iron sulphate is given for free
of charge
- Mother is educated on Iron deficiency anemia and the risks associated with it and thereby encouraged to
have a balanced diet with Iron rich food.
- Mothers are screened for anemia in the Booking visit

Neonates –
- Hospital care : An initial Blood count could be done to see signs for anemia and the mother is educated
about the correct techniques of Breast Feeding and the importance of beast feeding to prevent Iron
deficiency anemia since the breast milk contains all the nutrients essential for the baby
- PHM Visits – Post delivery the PHM visits the mother and the baby and monitors them accordingly while
checking for the technique of breast feeding and educating them about it. Furthermore she checks the baby
for skin color, Conjunctiva palor and other signs for anemia and signs of nutritional deficiency. Mother is also
checked for anemic signs.
- She visits 2 times within the first 10 days and once from 1th day to the 28th day and another visit within 42
days.

Infancy –
- PHM house visits
- Well baby Clinic (Child well fare clinic)
- Educates the importance of Complimentary feeding and how to initiate it.
- Continues screening for signs of anemia

Pre-School Child
- PHM visits
- Well Baby Clinic
- Educates on importance of a good healthy diet
- Iron Supplements are given free of charge to prevent Iron deficiency anemia
- CHDR is monitored carefully for any abnormalities

Adolescents
- School medical inspection Programme is carried out and screening for anemic signs are done.
- Iron Supplements are given free of charge for Grades 1. 4. 7 & 10th grade children if the School is big and
has students over 200. If the student count is less than 200 – Iron Sulphate is given to all the students.
- Health education of a balanced healthy diet including the importance Iron rich green leaves.

Elderly
- No adequate direct service available to target the elderly but indirectly the govt. provides elderly a good
nutritional practice education via different health program projects
- Financial support for elderly by
➢ Pension schemes
➢ Social security for elderly
➢ Public assistance monthly schemes
- Both Govt. and Non. Govt. Institutes providing money to elderly will encourage them to have healthy meals.
 Community Medicine - Ashan Bopitiya -

5.2 A medical officer of health (MOH) has observed that a 2-year-old child is having a weight below -2SD in
the Child Heath and Development Report (CHDR). Describe the action you as the MOH would take to
address this problem. (60 marks)

The MOH has to look into and manage growth faltering, underweight and overweight children. Growth faltering
children could be of 3 categories:
1. Children in the green zone with growth faltering – Mx is the same as Without Growth Faltering
2. Underweight children without Growth faltering
3. Underweight children with Growth Faltering.
A -2SD child can be either Underweight without or with growth faltering.
The MOH would get a detailed history and do a thorough examination in order to identify an underlying cause such
as Infections(UTI, URTI, Diarrhoea, etc) , Metabolic/Genetic/Congenital/chronic disorders (eg:Asthma).
If a cause cannot be identified the patient is referred to a pediatrician
If a medical condition is suspected, advice and management of simple conditions such as URTI and diarrhoea is done
and referred to a Pediatrician accordingly.
If a dietary cause is identified a 24h dietary recall is obtained, advice on diet and exercise is given and followed up
monthly. If weight is improving regular follow up monthly.
If No improvement after 2 Consecutive months in underweight children without faltering and no improvement after
1 month in underweight children with growth faltering – they are referred to a pediatrician
Children less than -3SD are Referred to a pediatrician straightaway !

Additional Notes –
PHM’s role
If a PHM comes across Children with growth faltering who are in the green zone (+SD to -2SD) in her field visits, she
should always look for a cause at the first instance for inadequate weight gain / and if flattening of weight is
detected. A Thorough hx is obtained of illnesses, feeding practices , and a 24h dietary recall is done to assess the
adequacy of nutrients (Quality and Quantity) .
She Tried to identify the most likely cause and if no identifiable cause or if there is an illness and unable to manage
the problem the patient is referred to the MOH.
If the cause is a dietary problem a discussion is made with the mother on how to improve the child’s feeding and is
reviewed in a month. If weight gain is observed regular monthly follow ups are carried out, but if the Growth
faltering persists the patient is referred to an MOH.
Situations where the PHM has to refer the patient to the MOH Immediately
➢ The first instance a drop of weight is detected
➢ GF in a child whose weight is in the light green zone
➢ If weight shifts to the orange zone
➢ If PHM comes across a child with ling standing GF (more than 3 consecutive weight measurements)
➢ Underweight children (Less than -2SD)
➢ Over weight children (Over+2SD)