Community medicine

solved past papers

SEQs of KMU
By: Ejaz Ahmad (RMC)
 Ejaz Ahmad, RMC

©copy rights are reserved with author. Editing is not allowed. Printing and photocopying for
sale purpose is not allowed.

I am awfully delighted to present you community medicine solved past papers SEQs of KMU. Most of
the time these questions are repeated in KMU exams. So I solved it to help students, I thoroughly
revised it and try to make it error free I hope this will help the students through their preparation for
exams. I am extremely thankful to Almighty ALLAH, who helped me a lot to complete this task I am also
thankful to Salman Khan, Dr.Samin khan, Dr.Naseem Sherzad and Dr.Riaz Ahmad.

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COMMUNITY MEDICINE PAST SEQS, KMU

CONTENTS

Chapter page number

1. Man and medicine /concept of health and disease 3

2. Epidemiology of communicable diseases 9

3. Non communicable diseases 28

4. Immunology 34

5. Screening 39

6. Demography 43

7. Primary health care 48

8. Occupational health 51

9. MCH/reproductive health/family planning 57

10. Entomology 64

11. Health education and mental education 67

12. Disaster management 73

13. Environment and health 78

14. Nutrition 92

15. Hospital waste management 100

16. Health information and management system 102

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MAN AND MEDICINE/CONCEPT OF HEALTH AND DISESASE

Q: What are characteristics of good health indicators?

A Health indicator is a characteristic of an individual, population, or environment which is

subject to measurement (directly or indirectly) and can be used to describe one or more
aspects of the health of an individual or population (quality, quantity and time). e.g. mortality
indicators, morbidity indicators, health care delivery indicators, socioeconomic indicators etc.

Characteristics of good health indicators are/ good health indicators should be:

 Valid: they should actually measure what they are supposed to measure
 Reliable: the result should be the same when they are measured by different people at
the similar circumstances
 Sensitive: they should be sensitive to changes in situation concerned
 Specific: they should reflect changes only in the situation concerned
 Feasible: they should have the ability to obtain data when needed
 Relevant: they should contribute to the understanding of the phenomenon of interest.

Q: Differentiate between long term and short term health program

Long term health program: coordinated plan of medical, nursing and rehabilitative care
provided at home to disabled person who are medically eligible for placement in nursing home.

Short term health program: program include certified nurse aid (assistant) certified medication
assistant (CMA) and home health assistant (HHA).short term program is completed in just eight
weeks.

Q: Enlist changing concepts of health:

Changing concepts of health are:

 Biomedical concept
 Ecological concept
 Psychological concept
 Holistic concept

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Q: What is new philosophy of health?

New philosophy of health stated as:

 Health is fundamental human right.

 Health is essence of productive life and not the result of over expenditure on medical
care.
 Health is intersectoral.
 Health is integral part of development.
 Health is central to the concept of quality of life.
 Health involves individuals, state, and international responsibilities.
 Health and its maintenance is major social investment.
 Health is worldwide social goal.

Q: What is gradient of infection?

Gradient of infection: the range of possible host reaction to an invading pathogenic organism
from unapparent subclinical through mild clinical to severe to fulminating and overwhelming
generalized fatal bacteremia.

Q: what is health adjusted life expectancy?

Health adjusted life expectancy: life expectancy at birth but includes an adjustment for time
spent in poor health .it is equivalent number of years in full health that anew born can expect
to live based on current rates of ill health and mortality .

Q: Give WHO definition of health.

Health (WHO definition 1948): Health is a state of complete physical, mental and social
wellbeing and not merely an absence of disease or infirmity.

Q: Write determinants of health.

Determinants of health are:

 Biological.
 Behavioral and sociocultural conditions.
 Environmental (external, internal).
 Socioeconomic (economic status, education, occupation, political system).
 Health services.
 Aging of the population.
 Gender.

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 Other factors.

Q: Enumerates mortality and morbidity indicators.

Mortality indicators:

 Crude death rate

 Expectations of life
 Infant mortality rate
 Child mortality rate
 Under five proportionate mortality rate
 Maternal mortality rate
 Disease specific mortality rate

Morbidity indicators:

 Incidence and prevalence

 Notification rate
 Attendance rate at outpatient department health centers
 Admission, Readmission, Discharge rate
 Duration of stay in hospital
 Spells of sickness and absence from work or school

Q: What are socioeconomic health indicators?

Socioeconomic health indicators are:

 Rate of population increase

 Per capita GNP
 Level of unemployment
 Dependency ratio
 Literary rate especially female literary rate
 Family size
 Housing ,number of person per room
 Per capita “calorie” availability

Q: What is ice berg phenomenon of disease?

Ice berg phenomenon of disease: A concept closely related to the spectrum disease is the
concept of ice berg phenomenon of disease, according to this concept disease in a community

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may be compared with an iceberg. Floating tip of iceberg present what the physician see in the
community i.e. clinical case The vast submerged portion of ice berg represent the hidden mass
of disease latent, pre symptomatic, in apparent, and undiagnosed cases and carriers in the
community Water line represent the demarcation between apparent and in apparent diseases
In some disease the unknown morbidity (submerged portion of ice berg) far exceeds the known
morbidity.

Q: Differentiate between vertical and horizontal program.

Vertical program (community): A single program of health services for community e.g. EPI,
AIDS control program, Malaria control program, staff is concerned only with one activity.

Horizontal program (community+ person): A health services delivery program which covers the
two dimensions of health i.e. personal and community health e.g.

 Social action program I (SAP I)

 Social action program II(SAPII)
 Benazir income support program

Q: Describe millennium developmental goal four along with its indicators

Millennium developmental goal four: Reduced child mortality rate

Indicators of millennium developmental goal four:

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 Under five mortality rate

 Infant mortality rate
 Proportion of one year old children immunized against measles

Q: What are three dimensions of human developmental index?

Three dimensions of human developmental (HDI) are:

 Longevity (life expectancy at birth)

 Knowledge (adult literacy rate and mean year of schooling)
 Income (real GDP per capita)

Q: Define health education and enlist approaches to health education.

Health education: A process that inform ,motivate ,and help people to adopt and maintain
healthy practices and life style, advocate environmental changes as needed to facilitate the
goal and conduct professional training and research to same end is called health education OR
Health education is part of health care that is concerned with promoting health behavior.

Approaches to health education:

 Regulatory approach: Any government intervention directly or indirectly designs to

alter human behavior.
 Service approach: Aimed at providing all the health services needed by the people at
their door steps.
 Health education approach: people must be educated through planned learning
experiences what to do and be informed, educated and encourage making their own
choice for healthy life.
 Primary care health approach: based on principles of primary health care i.e.
community involvement and intersectoral coordination.

Q: Differentiate between disease control and disease eradication.

Disease control: the term disease control describes operation aimed at reducing

 Incidence of disease
 The duration of disease , and consequently the risk of transmission
 The effects of infection , including both the physical and psychological complications
 The financial burden to the community

In disease control the disease agent is permitted to persist in the community at a level
where it ceases to be a public health problem e.g. polio

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Disease eradication: it means tear out by roots eradication of disease implies termination of all
the transmission of the infection by extermination of the infectious agent .the word eradication
is reserved for cessation of infection and disease from whole world the only eradicated disease
is small pox.

Q: Define chain of infection.

Chain of infection, it, is made up of six different links: pathogen (infectious agent), reservoir,
portal of exit, means of transmission, portal of entry, and the new host.

Significance of chain of infection is that breakage at any point stops the transmission of
infection.

figure shows chain of infection

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EPIDEMIOLOGY OF COMMUNICABLE DISEASES

 A person currently visiting Pakistan from neighboring country was presented with severe
generalized aches and pain .a maculopapular rash was found on the body with petechial
and purputic spots .he also has meningococcal meningitis what is diagnosis and gives the
protective strategies to control the disease at national level.

Diagnosis: this is case of dengue

Protective strategies to control dengue at national level:

 Education and awareness: through print media, electronic media, and social
media by arranging conferences and walks.
 Mosquito control: vector i.e. Ades aegypti can be controlled by mass spraying
and other measures.
 Vaccines: so far there are no satisfactory vaccines available.
 Isolation: diseased patients should be isolated under bed nets.
 Dengue control cell: should be working at district level.
 Research work: should be done on dengue.
 Environmental measures: detection and elimination of mosquito breeding
places, management of roof tops and proper covering of stored water.

Q: Describe briefly malaria eradication program.

Malaria eradication program: According to WHO expert committee on malaria in 1957

malaria eradication program means the ending of transmission of malaria and the
elimination of reservoir of infective cases in a campaign limited in time and carried to such
a degree of perfection that when it comes to an end there is no resumption of transmission.

Q: Define and classify carrier.

Carrier: defined as infected person or animal that harbors specific infectious agents in the
absence of discernible clinical disease and serve as a potential source of infections for other.

Classification of carrier:

a) By type :
 incubatory
 Convalescent
 healthy

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b) By portal of exit :
 Intestinal
 Respiratory
 urinary
 others
c) By duration:
 Temporary
 chronic

Incubatory carrier: Those who shed infectious agent during incubation period of disease i.e.
they are capable of infecting other before the onset of illness e.g. measles, mumps, polio,
influenza, diphtheria, and hepatitis B.

Convalescent carrier: those who continue to shed the disease agent during the period of
convalescence (time spent from recovery to illness) e.g. typhoid fever, cholera, diphtheria,
pertussis.

Healthy carrier: victims of subclinical infections who have developed carrier state without
suffering from disease but are now nevertheless shedding the disease e.g. Polio, cholera,
diphtheria.

Temporary carrier: shed infectious agents for short period of time.

Chronic carrier: shed infectious agents for indefinite period of time e.g. typhoid, hepatitis B,
and malaria.

Significance of carrier:

 carrier may outnumber cases

 carrier can reintroduce infection and contribute to endemecity
 carriers are mobile
 it is difficult to recognize because mostly don’t know that they are infected

Q: define incubation period and what are the factors which determine incubation period/on
which incubation period depends

Incubation period: time period between invasion of infectious agent and appearance of the
first sign and symptom of disease.

Factors which determine incubation period are:

 generation time of particular pathogen

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 infective dose
 portal of entry
 individual susceptibility
 A gate keeper of a house was brought to clinic with history of high grade continuous fever
for the last five days and epistaxis. On measuring his blood pressure the physician noted
patchier. Other signs noted by the physician were tenderness at right costal margin,
maculopapular rash and enlarged liver. What is your diagnosis? Write disease agent and
vector? Write investigations and their findings? Write management? What are preventive
measures?

Diagnosis: Dengue fever

Disease agent: Flavivirus

Vector: Ades aegypti mosquito

Investigations:

 Complete blood count (CBC).

 Serology testing for dengue virus-specific antibodies, types IgG and IgM, can
be useful in confirming primary or secondary diagnosis.
 LFTs
 ELISA and PCR

Findings: Thrombocytopenia(platelet count less than 150,000), increase hematocrit,

decrease WBC count, anti bodies IgG and IgM, elevated LFTs, positive PCR.

Management:

 Oral rehydration solution i.e. juices, electrolytes containing fluids etc.

 Paracetamol and tepid sponging for fever
 IV fluids
 Platelet transfusion
 Aspirin is contraindicated because it further decrease platelet count

Preventive measure against dengue:

 Use mosquito nets

 Anti mosquito spraying
 Using mosquito repellent lotion
 Wearing clothes fully covering the body
 Keep water pots and tires dry.

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Q: give mode of transmission and prevention of pertussis, scabies, echinococcus and

leishmaniasis.

PERTUSIS:

Mode of transmission:

 Direct i.e. through droplet infection

 Indirect: by contact with articles freshly soiled with discharge of patient

Prevention:

 vaccination (DPT) I/M 6, 10, 14th weeks

 Chemoprophylaxis (erythromycin)

SCABIES:

Mode of transmission:

 Direct: prolong closed contact.

 Indirect: contact with clothes and other contaminated objects of patients.

Prevention:

 health education
 Proper cleanliness
 Avoid contact
 scabicides

Host: Man

Agent: Sarcoptes scabiei

Vector: female parasite

Source: Oak tree, infected person

LEISHMANIASIS:

Mode of transmission: by sand fly

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Prevention:

 sand fly control by DDT

 personal prophylaxis

ECHINOCOCCUS GRANULOSIS:

Mode of transmission: when man eats sheep, goat, and swine, infected by dog feces.

Prevention: prevent feeding of dogs with entrails of slaughter sheep.

Q: what is antigenic shift and antigenic drift?

Antigenic shift: process by which two or more different strains of virus or strains of two or
more different viruses combine to form a new subtype having of the surface antigens of two or
more original strains .Term often applied to influenza .It is sudden, complete and major change.

Antigenic drift: It is Antigenic change which is gradual over period of time.it involves
accumulation of mutations within the genes that code for antibody binding sites.

 A class of fourth year MBBS gave farewell party to final year in hotel. salads with BBQ was in
menu which they ate for dinner with in four hours after dinner 16 students developed
vomiting, profuse diarrhea with mild fever and chills.
 Give the diagnosis?
 How will you investigate to find the cause of disease?
 Which health preventive control measures will you adopt for above mentioned
disease?
 Describe various steps in investigation of epidemic.

Diagnosis: Food poisoning

Investigations

 secure complete list of people involved and there history

 Environmental study
 inspection of eating place /kitchen
 Inspection of food

 Data analysis
 Lab investigations :stool ,vomiting , food sample, to look for causative agent

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Prevention and control:

 Food sanitation:
 Meat inspection
 Food handlers :those suffering from infections should be excluded from food
handling
 Personal hygiene
 Sanitary improvement
 Health education
 Food handling techniques
 Refrigeration: temperature below 4c.

Steps in investigation of epidemic:

1. Verification of diagnosis
2. Confirmation of existence of an epidemic
3. Defining population at risk
4. Rapid search of all cases and there characteristics
5. Data analysis
6. Formulation of hypothesis
7. Testing the hypothesis
8. Evaluation of ecological factor
9. Further investigation of population at risk
10. Writing the report

 A young person is suffering from hemoptysis, night sweats, and fever. On X-ray chest
examination there are shadows in right upper zone.
 Give the diagnosis?
 What is the diagnostic tool to confirm the disease?
 What are strategies of national control program in this disease?

Diagnosis: Pulmonary tuberculosis

Diagnostic tests:

 PPD skin test

 Sputum microscopy for acid fast bacilli

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 Culture on L J medium
 Luciferase assay
 Interferon gamma release assay(IGRA)

National TB program strategies (1993):

 Reducing reservoir of infection:

 Sputum examination
 Tuberculin test
 Chest X-RAY

 Improving the resistance: vaccination

 Minimizing the chances of spread

Q: what are the reasons of new cases of polio?

Reasons of new cases of polio:

 Lack of education and awareness

 uncooperated parents
 improper vaccination
 terrorism
 technical faults

Q: what are the current strategies to eradicate polio from Pakistan by WHO?

Current strategies to eradicate polio from Pakistan by WHO are:

 Introduction of bivalent polio vaccine

 Improvement in the monitoring system through introduction of finger marking and
independent monitoring
 Development of comprehensive district specific plan
 Intersectoral collaboration in polio eradication
 At the same time emphasis is placed on monitoring a comprehensive surveillance
system supported by well function polio laboratory

Q: define herd immunity; give its importance and mechanism?

Herd immunity: It is the level of resistance of a community or group of a people to a particular

disease. It implies group protection beyond that afforded by the protection of immunized
individual. This has been achieved in diseases such as polio and diphtheria.
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Importance of herd immunity:

 it provides an immunological barrier to spread of disease

 if 2/3 is immunized against polio the rest 1/3 will also be immunized

Mechanism of herd immunity: vaccine progeny is secreted in the feces and secondary spread
occur to the house hold contact and susceptible individual in the community. Non immunized
person may therefore be immunized.

 A young boy was bitten by a known rabid dog on right forearm. the boy is brought to you in
BHU
 How will you manage the case immediately?
 What immunization will you use and how?
 What is the case fatality rate and what it is in case a person develops rabies?

Management:

 Isolate patient in quiet and dark room

 Relive anxiety by sedatives
 If spastic muscle contraction are present relive it by curare like drugs
 Respiratory ,cardiac support

General consideration: neutralized the inoculated virus before it enters the wound

Local treatment of the wound:

 Cleaning :washing with plenty of water

 Chemical treatment: irrigation with veridical agent(alcohol, iodine)
 Anti-rabies serum locally around the wound
 Anti-biotic and anti-tetanus measures

Immunization: Active immunization: Human diploid cell vaccine 1ml I/M

Schedule: 0, 3, 7, 14, 28th day and booster at 90th day

Case fatality rate: it represent killing power of disease. It is the ratio of death to disease.

CFR=TOTAL NUMBER OF DEATH DUE TO PARTICULAR DISEASE x100

TOTAL NUMBER OF CASES DUE TO PARTICULAR DISEASE

Case fatality rate in persons developing rabies is 100%

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Q: describe agent, host, and vector, mode of transmission and source of malignant tertian
malaria, filariasis and anthrax.

MALIGNANT TERTIAN MALARIA

Agent: plasmodium falciparum

Host: Mosquito, human

Vector: female anopheles mosquito

Mode of transmission: mosquito bite

Source: Infected host

FILARIASIS:

Agent: Wuchereria bancrofti, W malayi, W timori

Host: man

Vector: infected mosquito

Mode of transmission: bite of infected mosquito

Prevention: Vector control, chemotherapy (diethyl carbamazine)

Source: infected person/animals

ANTHRAX

Agent: bacillary anthraces

Host: man

Vector: spores

Mode of transmission: spores inhalation or spores infecting cutaneously

Prevention:

 incinerating animals died of anthrax

 prophylaxis: ciprofloxacin/ doxyfloxacin
 Vaccination

Source: soil, domestic animals.

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Q: write source, reservoir, and mode of transmission of cholera.

CHOLERA

Source: contaminated food and water

Reservoir: infected person, contaminated food and water, flies

Mode of transmission: contact with infected person, eating contaminated food

 A young man was brought to emergency department of Saidu teaching hospital with the
history of high grade fever for 4 days and severe ache in summer 2013. After taking the
blood pressure of the patient doctor noted hemorrhagic spots on the arm of the patient
after inflating the cuff. His platelet count is 80,000.he is shopkeeper in swat.
a) What is the diagnosis?
b) How will you confirm the diagnosis?
c) How it is transmitted from person to person?

a).Diagnosis: Dengue

b).Diagnosis can be done by the history, general examination in which we will see hemorrhagic
spots and investigations .lab investigation shows thrombocytopenia(platelet count less than
150,000) and increase hematocrit, decrease WBC, elevated LFTs,

However it is confirmed by positive PCR and anti dengue antibody titer.

c).Dengue is spread through the bite of the female mosquito (Aedes aegypti). The mosquito
becomes infected when it takes the blood of a person infected with the virus. After
about one week, the mosquito can then transmit the virus while biting a healthy person.

Q: write preventive measures for Congo hemorrhagic fever.

Preventive measures for Congo hemorrhagic fever are:

I. Reducing risk of Tick to human transmission

 Wear protective clothing
 Tick repellents
 Avoid areas where ticks are abundant
II. Reducing of risk of Animal to human transmission: wear gloves and protective clothing
while handling animals in endemic areas during slaughtering, butchering.
III. Reducing risk of human to human transmission:
 Avoid close personal contact with infected persons
 Personal hygiene

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IV. Properly disposing entrails of animals

Q: how hepatitis B and C can be prevented?

Hepatitis B and C prevention:

 Avoid coming in contact with or body fluids of infected persons

 Avoid sharing personal items i.e. needles and razors
 Screening of blood before transfusion
 Health care workers should use gloves and masks
 Avoid sexual contact with infected persons
 Health education and awareness about hepatitis B and C
 Vaccination

Q: differentiate between street virus and fixed virus?

Street virus: viruses recovered from naturally occurring cases of rabies. Produces negri bodies.
Incubation period is 20-60 days.it cannot be used for preparation of vaccine.

Fixed virus: it has short, fixed, reproducible incubation period .It is prepared from repeated
culture in brain of rabbit. They doesn’t produce negri bodies.it is used in preparation of vaccine.

 A 30 years old man presented with fever OFF AND ON .he is giving the history of similar
attack one year back. He is belonging to an area where mosquitos are present. On
examination no signs of infection were found and he was anemic.
a) What is your diagnosis?
b) How will you confirm your diagnosis?
c) How will you protect the people of the area from the disease?

a)Diagnosis: malaria

b)To confirm diagnosis: thick and thin smears of infected person.

Thick blood smears are most useful for detecting the presence of parasites, because they
examine a larger sample of blood. (Often there are few parasites in the blood at the time the
test is done.) A thin blood smear: thin blood smear shows that which specie of parasite is
present.

c)How to protect the people of the area from disease:

 Educate the people and make awareness about malaria

 Stay inside when it is dark outside, preferably in a screened or air-conditioned room.

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 Wear protective clothing (long pants and long-sleeved shirts).

 Use insect repellent with DEET (N,N diethylmetatoluamide). You can buy repellents
in different strengths. The American Academy of Pediatrics (AAP) and other experts
suggest that it is safe to use a repellent that contains 10% to 30% DEET on children
older than age 2 months.

 Use bed nets (mosquito netting) sprayed with or soaked in an insecticide such
as permitherin or deltamethrin. But make sure that these insecticides still work
against the mosquitoes where you are. In some areas, mosquitoes have become
resistant to permethrin and deltamethrin. So the bed nets do not offer much
protection.

 Use flying-insect spray indoors around sleeping areas.

 Avoid areas where malaria and mosquitoes are present if you are at higher risk (for
example, if you are pregnant, very young, or very old).

Other steps that may be helpful in reducing the risk of malaria include wearing protective
clothing, using aerosol insecticides in your house, and taking certain antimalarial medicines.

Q: write about transmission and prevention of mumps, diphtheria, cholera and tetanus.

MUMPS:

Transmission:

 Direct contact and droplet infection

 Indirectly through freshly soiled articles of infected persons

Prevention:

 Exclude the person with mumps from childcare, preschool, school and work for 5
days after the onset of swelling
 tissues and other objects soiled with nasal secretions should be disposed of
appropriately
 mumps is best prevented by the measles, mumps and rubella (MMR)
combination vaccine or the measles, mumps, rubella and varicella (MMRV)
combination vaccine

DIPTHERIA:

Transmission: droplet infection, fomite born, infected cutaneous lesion

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Prevention:

 Vaccination
 isolation of patient
 disinfection of patient article

Sources:

 Clinical/subclinical infection
 Nasopharyngeal secretion
 Clothes soiled with secretions

CHOLERA

Transmission: eating contaminated food and water, contact with infected food and
persons

Prevention:

 Personal hygiene
 Chemoprophylaxis (tetracycline)
 Sanitation measures
 Vaccination
 Health education

TETANUS:

Transmission: by contamination of wound by tetanus spores

Prevention: by immunization

 Active : (DPT) vaccine

 Passive: Anti tetanus serum and human tetanus hyper immunoglobulin
 Active and passive
 Antibodies

 A person of 25 years old comes to OPD with pain full ulcer on left leg .He has history of
being bitten by fly. Give the likely diagnosis .What is the mode of transmission .what
method of prevention can be applied for future?

Diagnosis: Cutaneous leishmaniasis

Transmission: bite by Female sand fly

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Prevention:

 Health education and awareness

 Sand fly control
 Nets
 Repellents
 Drugs i. e sodium stibogluconate

Q: define isolation and quarantine:

Isolation: Separation for the period of communicability of infected person or animal from
others in such place and under such conditions as to prevent or limit direct or indirect
transmission of the infectious agents from those infected to those who are susceptible or who
may spread the agent to other.

Quarantine: quarantine has been defined as the limitation of freedom of movement of such
well persons or domestic animals exposed to a communicable disease for a period of time not
longer than the longest usual incubation period of the disease, in such manner as to prevent
effective contact with those not so exposed.

Quarantine may comprise (a) absolute quarantine as defined above (b) modified quarantine
e.g. a selective partial limitation of freedom of movement such as exclusion of children from
school and (c) segregation: which has been defined as The separation for special consideration,
control of observation of some part of group of persons or (domestic animals) from the other to
facilitate control of communicable disease e.g. removal of susceptible children to homes of
immune persons

 There was a news in local newspaper about the death of father and three of his sons who
have a butcher shop .although they were admitted to the hospital but could not survive
because of severity of disease .virus isolated from their blood confirmed that they suffered
from Crimean Congo hemorrhagic fever (CCHF).Answer the following questions about CCHF
a. Name the causative agent and vector?
b. Which domestic animal is reservoir of CCHF?
c. Which preventive measures are taken to prevent spread of CCHF in hospital?
d. Name four hemorrhagic fevers?
a. Causative agent: Virus of nairo virus group, Vector: Tick
b. Reservoir: domestic animals i.e. sheep, buffalo, goat (cattle’s)
c. Preventive measures in hospitals:
 isolate the patients

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 Doctors and staff should take preventive measures by using masks ,gloves, glasses,
and coats
 Patients clothing and fomites should be carefully handled
d. Four hemorrhagic fevers are Dengue, Ebola, Yellow fever, Lassa fever.

Q: Name viruses responsible for diarrhea?

Viruses responsible for diarrhea:

 Corona virus
 Rota virus
 Adenovirus
 Enterovirus

Q: what are the characteristics of cholera epidemic?

Characteristics of cholera epidemic are:

 Epidemic of cholera is abrupt and often create a public health problem

 They have high potential to spread fast and cause death
 Epidemic reaches a peak and subsides gradually as the force of infection subsides
 Cholera epidemic in community is self-limiting it tends to decline after reaching its peak
 It involves both adults as well as children

Q: what is reduced osmolarity ORS? What is the recommended dose and schedule of IV fluid to
be given to the children suffering from severe dehydration?

Reduced osmolarity ORS: reducing concentration of glucose and sodium chloride in the
solution to avoid adverse effect of hyper tonicity.

Recommended dose =100ml/kg

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 Ejaz Ahmad, RMC

Schedule of IV fluid in children

Age First give 30 ml/kg in Then give 70ml/kg in

Infant under 12 1hour 5hour

month

Older 30min 2 ½ hour

Q: define disease surveillance?

Disease surveillance: continuous scrutiny of the factors that determine the occurrence and
distribution of disease and other conditions of ill health.

Q: what is AFP surveillance?

AFP surveillance (Acute flaccid paralysis surveillance): it is the gold standard for detecting
cases of polio.it consists of four steps.

 Finding and reporting children with acute flaccid paralysis

 Transporting stool samples for analysis
 Isolating and identifying polio virus in laboratory
 Mapping the virus to determine the origin of virus strain

Q: define serial interval?

Serial interval: the gap in time between occurrence (onset) of primary case and secondary case
is called serial interval.

Q: define generation time?

Generation time: interval of time between receipt of infection by a host and maximal infectivity
of that host.

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Q: what is health promotion?

Health promotion: the process of enabling people to increase control over and to improve
health .it is not directed against any particular disease but is intended to strengthen the host
through a variety of approaches (interventions) the well-known interventions are:

 Health education: people are informed about different disease and encourage to take
necessary precautions in time
 Environmental notifications: such as provision of safe water, installation of sanitary
latrine, control of insect and rodent, improving of housing etc.
 Nutritional interventions :comprises food distribution and nutritional improvements
 Lifestyle and behavior change

Q: classify the mosquito borne diseases in terms of causative agents in tabulated form
MOSQUITO BORN DISEASE INTERM OF CAUSATIVE AGENT

Disease Mosquito Causative agent

Malaria Anopheles Plasmodium

Dengue Aedes aegypti Flavivirus

Yellow fever Aedes and hemogogus Yellow fever virus

Japanese encephalitis Culex Japanese encephalitis virus

West Nile fever Culex West Nile virus

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Q: what is multifactorial disease?

Multi factorial disease: a great number of diseases such as diabetes, congenital heart disease
and cancer are called multifactorial because they are not caused by single gene mutation but by
combination of genes, environmental and other factors.

Q: what are the causes of failure of polio vaccines?

Causes of failure of polio vaccines:

1. Related to vaccine :In many far areas vaccines are not available .vaccine should be
placed in cold places which is not available in many areas
2. Related to child
 Immunocompromised child
 Inhibitors in saliva
3. Related to mode of transmission
 Faulty technique
 Spitting out of vaccine on first attempt
4. Related to mother
 Interference by antibodies present in breast milk
 Lack of education
5. Related to immunizing staff :not properly trained
6. Related to health sector
 Not providing vaccine in adequate amount according to the need
 Lack of establishment of vaccine center
7. Lack of community participation

Q: define case fatality rate; proportional mortality rate and life expectancy at birth also give
their significance.

Case fatality rate: it is number of deaths due to a particular disease t total number of cases
due to same disease.

CFR= Total number of deaths due to a particular disease x 100

Total number of cases due to same disease

Significance of case fatality rate is that it shows various aspects or properties of disease
such as pathogenicity, severity or virulence .it can also be used in poisonings, chemical
exposure or other short term non disease cause of death.

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Proportionate mortality rate: it express the number of deaths due to a particular cause (or
in specific age group) per 100 or 1000 total deaths

PMR=number of deaths from specific disease in a year x 100

Total deaths from all causes in that year

Significance of proportionate mortality rate is that it is simplest measure of estimating

burden of disease. Proportional mortality rate from communicable disease has been
suggested as a useful health status indicator, it indicates the magnitude of preventable
mortality.

Life expectancy at birth: it indicates the average number of years that a person can expect
to live from the time of birth

Significance of life expectancy at birth is that it is a good indicator of socioeconomic

development in general. An increase in the expectation of life is regarded, inferentially as an
improvement in health status.

Q: Sexually transmitted diseases: see Robbins pathology page 671 table 17-3

Q: write complications of STDS

Complications of STDS are

 Discomfort in the genital area.

 Infertility.
 Complications related to pregnancy, such as ectopic pregnancy or transmission of
infection to a fetus.
 Reproductive system cancers.
 Pelvic Inflammatory Disease (PID)
 Enhanced transmission of HIV.
 Epididymitis.

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NON COMMUNICABLE DISASES

Q: define risk factors and give risk factors of hypertension.

Risk factor: factors that make occurrence of disease more probable.

Risk factors of hypertension

Modifiable risk factors:

 Obesity
 Salt intake
 Saturated fat
 Dietary fibers
 Alcohol
 Physical inactivity
 Environmental stress
 Socioeconomic status

Non modifiable risk factors:

 Age
 Sex
 Genetic factors
 Ethnicity

Q: Write down criteria to establish a well-designed health management information system

WHO expert committee identifies the following five requirements to be satisfied by the health
information system:

 System should be population based

 System should avoid unnecessary agglomeration of data
 System should be problem oriented
 System should imply function and occupational terms (e.g. episodes of illness, treatment
regimens , laboratory tests)
 System should make provision for the feedback of data

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Q: give the management of snake bite.

Management of snake bite:

History:

 Time of bite
 Description of snake
 Signs/symptoms

Examination:

 Of bite site
 Neurological examination

Diagnosis of bite:

 Fang marks
 Cholinesterase is present in washing in case of elapid bite
 Thromboplastin in case of viper bite
 Sea snake bite: hyperkalemia is detected at ECG

Treatment:

 Allying anxiety and fright

 First aid
 Immobilization
 Apply tourniquet :remove for 1min after 30 min
 Wash the wound
 Apply cold packs
 Use specific antivenom
 General measures
 Bed rest
 Adrenaline injection in paralytic cases
 Artificial respiration
 Antibiotics
 Black coffee
 Antihistamine
 Aspirin and short acting barbiturate
 Tetanus prophylaxis
 Fluid and electrolyte balance

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Q: DEFINE WHO?

WHO: Specialized agency of United Nations that is concerned with international public health it
was established on 7th April 1948 headquartered in Geneva Switzerland

 A patient presents to eye OPD with complaints of night blindness and dryness in eyes on
examination there were Xerophthalmia and keratomalacia in eyes.
a. Diagnosis?
b. Mechanism for night blindness?
c. What are Preventive dietary measures?
a. Diagnosis: Vitamin A deficiency
b. Mechanism for night blindness: lack of vitamin A causes impairment in dark adaptation
because vitamin A is required for production of retinal pigments which are needed for
vision in dim light.
c. Preventive dietary measures:
 Animal food :Fish liver oil(richest source),Liver, egg, butter, milk, fish, meat
 Plant food: Carrot ,Green leafy vegetables
 Vitamin A capsule
 Blue capsules :contains 1lac units
 Red capsules : contain 2 lac units
 A young person from emergency department of hospital. He was breathless ,weakened, and
there was bloody discharge from 2 needle like puncture wound on right leg .that rural area
is located near Indus river and is notorious of snakes
a. What is specific therapy in this case?
b. What are the routes of administration of this specific therapy?
c. What precautions would you suggest to avoid such accidents in future?

a. Specific therapy is Antivenom. Because this is the case of venomous snake, venomous snake
bite has two needle like puncture wound.

Antivenoms are prepared by immunizing horses with venom from poisonous snakes and
extracting the serum and purifying it. Antivenoms or antivenins may be species specific
(monovalent) or effective against several species (polyvalent). Monovalent antivenom is ideal
but the cost and non-availability, besides the difficulty of accurately identifying the offending
species - makes its use less common.

b. Antivenom can be administered either by slow intravenous injection at a rate of 2 ml/min or

by intravenous infusion (antivenom diluted in 5–10 ml per kilogram body weight of normal
saline or D5 W and infused over 1 h).

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c. Precautions:

 Wearing knee high boots

 Use torches at night
 Stay out of tall grass
 Alert during climbing rocks
 Leave snake alone
 Mass public education in first aid management of snake bite

Q: suggest control and strategies for prevention of coronary heart diseases.

Control and strategies for prevention of coronary heart diseases:

 PRIMARY PREVENTION

Population strategy: small changes in risk factors in total population result in biggest
reduction in mortality in whole population:

 Dietary changes i.e. decrease fat intake

 Achieve smoking free society
 Reduce mean population blood pressure
 Promote exercise in whole population
 Weight reduction
 Reduction in alcohol consumption
High risk strategy:

 Identifying risk individuals by measuring BP, blood sugar level, serum

cholesterol level, etc.
 Specific advice: motivate high risk individual to take positive action
 SECONDARY PREVENTION: Aim is to prevent recurrence and progression of CHD.

Q: write short note on the assessment of obesity:

Assessment of obesity:

1. Body weight
 Body mass index= weight in Kg/height in meter square
 BMI =30-35 is obese class I
 BMI=35-40 is obese class II

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 BMI=40-45 is obese class III

 Broca index: ideal weight =height in cm -100.e.g ideal weight of a
person of a height 170cm will be 170-100=70 kg
2. Skinfold thickness: measure by herpenden skin calliper
3. Other :total body water ,total body potassium ,body density

Q: what is the role of antioxidant and phytochemicals in prevention of cancer?

Role of antioxidant and phytochemicals in prevention of cancer:

Antioxidant: As the free radical can damage DNA and causes cancer .Antioxidant can neutralize
free radicals and prevent cancer.

Phytochemical: It inhibits growth of cancer cells, destroy carcinogenic cells and inhibit binding
of carcinogenic substances to genetic material.

Q: categorize dog bites on the basis of intensity.

On the basis of intensity dog bite are categorize as:

Abrasion:

Abrasions are superficial wounds, such as scratches and cuts. Abrasions are the most minor
type of dog bite injury.

Laceration:

Lacerations are deep open cuts. Typically, lacerations appear irregular and tear-like. In most
cases, deep lacerations will cause excessive bleeding

Puncture:

Puncture wounds occur when the dog’s teeth pierce the skin. Punctures are among the most
common dog bite injuries to become infected

Crushing:

Dog bites may cause the bones or tissues to be crushed. Crushing injuries involving the bones
often result in bone breaks or fractures.

Avulsion:

Avulsion is among the most severe types of dog bite injuries. During avulsion, tissues or body
parts are partially or completely torn from their normal position

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Q: give the management of rabies patient.

Management of rabies patient:

 Mange airway ,breathing and circulation

 Isolate patient in a quiet room protected from external stimuli such as bright light ,noise
or cold air
 Relive anxiety and pain by liberal use of sedatives
 If spastic muscular contractions are present use drugs with curare like action
 Ensure hydration and diuresis
 Clean the wound ,apply a sterile bandage to the wound and apply antibiotic ointment
to the injury to prevent infection
 Vaccinate the patient there are three types of vaccine i.e. nervous tissue vaccine
(NTV),duck embryo vaccine (DEV),cell culture vaccine

Q: Enlist specific preventive measure against rabies

WHO strategies for human rabies prevention:

 WHO promotes wider access to appropriate post-exposure treatment using the cost-
effective multi-site intradermal regimen with modern tissue culture or avian embryo-
derived rabies vaccines

 Possible domestic production of rabies immunoglobulin, which are in critical short

supply globally

 Continual education of health and veterinary professionals in rabies prevention and

control

 Public health educational strategies at the community level within endemic regions

WHO strategies for dog rabies control and eventual elimination

 WHO promotes organization of sustainable mass dog vaccination campaigns and dog
population management through reduction of stray populations (by implementing
animal-birth-control programs); control of trade and movement of dogs

 Oral vaccination of domestic carnivores as dog accessibility to vaccination by the

parenteral route is one of the major obstacles for dog rabies control in many different
parts of the world.

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IMMUNOLOGY
Q: define active immunity and how it is acquired?

Active immunity: Definition. A type of immunity or resistance developed in an organism by its

own production of antibodies in response to an exposure to an antigen, a pathogen or to a
vaccine. It is acquired:

Naturally by disease or clinical infections e.g. chicken pox and measles and sub clinical
infections e.g. polio and diphtheria

Artificially by immunization with an antigen which may be killed or live attenuated vaccine and
toxoid

Q: how hepatitis B infection can be prevented in new born of carrier mother?

Hepatitis B infection in a new born of carrier mother can be prevented by:

A. Give hepatitis B immunoglobulin to child immediately after birth

Dose 0.05 -0.07 mg/kg body weight
Schedule 0 and 30th day
B. Immunization :plasma derived vaccine
At 6th week =Hepatitis B vaccine I/M
At 10th week=Hepatitis B vaccine I/M
AT 14 week=Hepatitis B vaccine I/M

Q: what are the reasons that lead to eradication of small pox?

Reasons that lead to eradication of small pox are:

 No known animal reservoir

 No long term carrier of virus
 Lifelong immunity after recovery
 Typical rash makes diagnosis earlier
 Subclinical cases doesn’t transmit disease
 Highly effective vaccine
 International cooperation

Q: write types, contraindications and properties of BCG vaccine.

BCG: It is live attenuated vaccine. There are two types of BCG vaccine

a) Liquid (fresh) vaccine

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b) Solid(freeze) ,more stable

Contraindications for BCG

 Generalized eczema
 Infective dermatitis
 Hypogammaglobulinemia
 Immunocompromised patient
 Patient under immunosuppressive therapy
 pregnancy

Properties of BCG vaccination

 provides immunity against TB

 given at birth
 given intradermally
 produces scar

Q: give types of polio vaccines; write contraindications and properties of polio vaccine.

Polio vaccine has two types

 Oral polio vaccine (OPV): it is live attenuated. administered Orally

 Inactivated polio vaccine (IPV): it killed form administered Intravenous or
subcutaneously.

Contraindications of polio vaccine

 Live vaccines are not usually given to immunocompromised patients.

 Patients suffering from leukemia and malignancy and those receiving corticosteroid may
not be given OPV.

Properties of polio vaccine:

 May be live attenuated or killed

 Provides herd immunity
 Freeze at -20degree centigrade
 Administered orally, IV ,S/C
 When magnesium chloride is added to OPV they can kept without losing potency for
years at 4c and for month at 25 degree centigrade.

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Q: what are limitations of artificial immunization?

Limitation of artificial immunization:

 Any acute illness

 Severe malnutrition
 In immunocompromised individual patient, receiving immunosuppressive therapy
 Chronic malignancy i.e. leukemia ,lymphoma

Q: How will you administer diphtheria antitoxin to a case of diphtheria?

Answer: ½ ml antitoxin is administered intramuscularly at anterolateral aspect of thigh.

Q: briefly describes reservoirs of rabies, types of vaccines used for rabies and post exposure
vaccination schedule for rabies.

Reservoir of rabies

 Rabid dogs in case of urban rabies

 Jackals ,fox in case of wild rabies

Types of vaccine used for rabies:

 Nervous tissue vaccine(NTV)

 Duck embryo vaccine(DEV)
 Cell culture vaccine (CCV)
 Human diploid cell vaccine
 Second generation tissue culture vaccine (animal cell vaccine)

Post exposure vaccination schedule for rabies

Day: 0, 3, 7, 14, 28th day and a booster at 90th day

Q: Can polio be eradicated:

Answer: THE GLOBAL POLIO ERADICATION INITIATIVE:

Launch: in 1988 , the forty –first world health assembly adopted a resolution for the worldwide
eradication of polio .it marked the launched of the global polio eradication initiative(GPEI)
,spearheaded by national governments ,WHO, rotary international, the US center for disease
control and prevention ,UNICEF, and supported by key partners including the bill and Melinda
gates foundation. This followed the certification of eradication of small pox in 1980 ,progress

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 Ejaz Ahmad, RMC

during 1980s towards elimination of polio virus in the Americas and rotary international’s
commitment to raise funds to protect all children from the disease.

Progress: overall since GPEI was launched, the number of cases has fallen by over 99%, only
three countries in the world remain polio endemic: Nigeria, Pakistan and Afghanistan.

In 1994, the WHO region of the Americas was certified polio free, followed by WHO western
pacific region in 2000 and the WHO European region in June 2002. Of the three types of polio
virus (type 1, type2, type3) type 2 polio virus transmission has been successfully stopped (since
1999)

More than 10 million people are today walking, who would otherwise have been paralyzed. An
estimated more than 1.5 million childhood deaths have been prevented through the systematic
administration of Vitamin A during polio immunization activities.

Opportunity and risk : an emergency approach ; the strategies for polio eradication work when
they are fully implemented .this is clearly demonstrated by Indians success in stopping polio in
January 2011 , in arguably the most technically challenging place however failure to implement
strategic approaches leads to ongoing transmission of virus .endemic transmission is continuing
Nigeria, Pakistan, and Afghanistan. Failure to stop polio in these last remaining areas could
result in as many as 200000 new cases every year.

Recognizing the epidemiological opportunity and significant risks of potential failure, the world
health assembly in May 2012 adopted a resolution declaring the completion of polio
eradication a programmatic emergency for global public health.

Subsequently, the three remaining endemic countries launched national polio emergency
action plans overseen in each case by the respective head of state and the partner agencies of
the GPEI also moved their operation to emergency footing, working under the auspices of the
global emergency action plan 2012-2013.

As mid of 2012, the impact of the emergency approaches is being seen, with the lowest number
of reported cases in fewer districts of fewer countries than at any previous time

Full financing and implementation of the global emergency action plan 2012-2013 can
realistically rapidly achieve a lasting polio free world. But achieving success is a global
responsibility, and is now a question of political and social will the benefits of a polio free world
will be shared equally by all countries and peoples everywhere.

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 Ejaz Ahmad, RMC

Q: write down schedule followed by EPI in tabulated form mentioning name, age, dose, form
and route of administration.

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 
Ejaz Ahmad, RMC

SCREENING
Q: how will you evaluate a screening test?

Evaluation of screening test can be done by:

 Sensitivity
 Specificity
 Positive predictive value
 Negative predictive value
 Percentage of false positive
 Percentage of false negative

Q: tabulate the difference between screening and diagnostic test.

Difference between screening and diagnostic test:

SCREENING TEST DIAGNOSTIC TEST

1. Done on apparently healthy 1. Done on sick individuals

individuals
2. Applied to groups 2. Apply to single patient
3. Test results are final 3. Diagnosis is not final
4. Based on cut off points 4. Based on signs /symptoms
5. Less accurate 5. More accurate
6. Less expensive 6. More expensive
7. Not a basis of treatment 7. Use as basis for treatment
8. Initiative comes from 8. Initiative comes from patient
investigation or agency
providing care

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Q: what is the importance for screening of blood?

Importance for screening of blood:

 Reduces chance of transmission of infectious disease

 Help in early diagnosis of disease
 Reduces chances of spread of disease
 Require in occupational selection

Q: what are the criteria of a disease to be introduced in screening program?

Criteria of disease to be introduced in screening program are:

 Disease should be important health problem

 There should be recognizable latent or early asymptomatic stage
 Natural history of the condition
 There is a test that can detect the disease prior to onset of signs/symptoms
 There is an effective treatment
 There is good evidence that early detection and treatment reduces mortality and
morbidity
 The expected benefits (e.g. no of lives saved)of early detection exceeds the risk and
cost

Q: what are the factors affecting sensitivity?

Factors affecting sensitivity are:

 Cut off level test

 Measuring instrument

Q: write four principles of ethics

Four principles of ethics:

 Principles of respect for autonomy

 Principle of non-maleficence
 Principle of beneficence
 Principle of justice

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Q: what are the advantages of screening of disease?

Advantages of screening of disease are:

 Early diagnosis of disease

 Reduces chances of malignancy
 Reduces chances of spread
 Prenatal diagnosis of genetic disorder

Q: write objectives, components and principles of IMCI.

IMCI: integrated management of childhood illness is the strategy combines improved

management of childhood illness with aspect of nutrition, immunization and other important
disease prevention and health promotion elements.

Objectives of IMCI:

 To reduce death frequency

 To reduce severity of illness and disability
 To improve growth and development

Components of IMCI:

 Improvement in the case management skill of health staff through the provision of
locally adopted guidelines on IMCI and through activities to promote their use
 Improvement in health management system required for effective management of
childhood illness
 Improvement in family and community practices

Principles of IMCI:

1. All sick patients must be examined for general danger sign which indicate the need for
immediate referral or admission to hospital.
2. All sick patients must routinely assessed for major symptoms (for children age 2 months
up to 5 years cough or difficult breathing, diarrhea, fever ,ear problem and for young
infants )they must also routinely assessed for nutritional and immunization status
,feeding problem and other potential problems.
3. Only limited numbers of carefully selected signs are used based on evidence of their
sensitivity and specificity to detect disease.
4. The IMCI guidelines address most ,but not all of the major reasons a sick child is brought
to a clinic the guidelines do not describe the management of trauma or other acute
emergencies due to accidents or injuries.

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 Ejaz Ahmad, RMC

5. IMCI management procedures use a limited number of essential drugs and encourage
active participation of caretaker in treatment of children.
6. An essential component of the IMCI guidelines is the counseling of caretaker /mothers
about home care feeding ,fluids and when to come back for follow up.

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DEMOGRAPHY
Q: define population growth rate and contraceptive prevalence rate.

Population growth rate: rate at which a given population is expected to increase in a given
period of time it is shown in percentage per year.

Growth rate =total birth –total death in a year in a place

Midyear population of the same place

Significance: it gives the rate at which population is growing. A positive rate indicates that
population is increasing, while a negative growth rate indicates that population is decreasing. A
zero growth rate indicates that there are same numbers of individuals at the beginning and end
of the period.

Contraceptive prevalence rate: percentage of women who are practicing or whose life partners
are practicing any form of contraceptive it is usually measure for married women age 15-49
only.

CPR= number of users of contraceptives x 100

Married women of reproductive age

In 2013 at Pakistan CPR% was 35.40%

Q: what are the causes of demographic imbalance in Pakistan?

Causes of demographic imbalance in Pakistan:

 High birth rate

 Low mortality rate
 High fertility rate
 Early marriages
 Over population
 Urbanization
 Low health education

Q: define demographic trap and demographic transition.

Demographic trap: High birth rate and low death rate (increase fertility and decrease mortality)
leads to demographic trap. e.g. Pakistan is in state of demographic trap.

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Demographic transition: moving from old balance (high birth and high death rate) to new
balance (low birth and low death rate) is called demographic transition.

Q: define population doubling time and population.

Population doubling time: refers to the time that would take for a population to double.

 Population doubling time =70/growth rate

 Population doubling time of Pakistan =70/1.49 =47 years
 Population doubling time world =70/1.1=63 years

Population: number of peoples or animals of a particular kind that live in a place at a specific
time.

Q: define dependency ratio, give rate and significance

Dependency ratio: ratio of population who are economically not active to those who are
economically active.

Dependency ratio= children +elderly x100

Working age

Dependency ratio of Pakistan is 84.4%

Significance of dependency ratio: it is used to study dependency burden of a population .It is a

key factor underlying rapid economic development.

Q: write short note on population pyramid.

Population pyramid: graphical presentation of population of an area or a country in terms of its

composition by age and sex at a point in time it provides demographic statement of age and sex
distribution of a population

 Male is on left side

 Female on right side
 Children form the base elder form the tip

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 Ejaz Ahmad, RMC

Figure shows Population pyramid

Q: differentiate between fertility and fecundity and write determinants of fertility.

Fertility: number of live births a woman has had i.e. actual reproductive behavior of female.

Fecundity: physiological ability of woman to reproduce or to bear children during reproductive

life cycle. A woman can bear maximum of 42 Childs

Determinants of fertility

 General fertility rate

 Age specific fertility rate
 Total fertility rate
 Net fertility rate
 Child women ratio
 Pregnancy rate
 Abortion rate
 Marriage rate

Life expectancy at birth: it indicates average number of years that a person can expect to live
from the time of birth.

In Pakistan life expectancy of females is 63 years while male is 61 years

Significance: it is one of the best indicators of a country’s level of development and of the
overall health status of a population.

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Q: write the socioeconomic indicators?

Socioeconomic indicators

 Population growth rate

 Literacy rate
 Per capita income
 gross national income (GNI)
 gross domestic product (GDP)
 life expectancy
 population per square mile
 mortality rates/morbidity rates
 urban/rural population
 import/export of a country

Q: describe population pyramid of developing country.

Population pyramid of developing countries: is also known as expansive population pyramid.

Expansive population pyramids are used to describe populations that are young and growing.
They are often characterized by their typical ‘pyramid’ shape, which has a broad base and
narrow top. Expansive population pyramids show a larger percentage of the population in the
younger age cohorts, usually with each age cohort smaller in size than the one below it. These
types of populations are typically representative of developing nations, whose populations
often have high fertility rates and lower than average life expectancies. Pakistan is also a
developing country population pyramid of Pakistan is given in the figure below:

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 Ejaz Ahmad, RMC

Q: What are reasons for increase in life expectancy of the people globally especially in
developed countries?

 Cleaner water: Clean water and improved sanitation greatly reduced deaths due to
infectious disease. Systems for filtering and chlorinating public water supplies are
believed to have reduced urban mortality by half during the first part of the 20th
century.
 Technological advancement: Technology for diagnosing disease improved exponentially
during the 20th century. Developments in serologic, or blood, testing that began in the
early 1900s led to the ability to accurately diagnosis disease-causing bacteria.
Subsequent technology to isolate and identify viruses led to an increasing understanding
of how viruses work and spread.
 Improved treatments: The combination of identifying disease-causing agents like
viruses, major advances in medical technology and scientific discoveries in molecular
biology all led to vastly improved treatment for disease throughout the 20th century. By
midcentury, immunization programs for deadly childhood diseases such as polio,
smallpox, diphtheria, measles and others saved numerous lives and contributed
significantly to higher life expectancy
 Understanding diseases: Winning the battle over many infectious diseases led to
increased life expectancy.
 Hygiene: improved hygiene decreases incidence of diseases
 Health education: increase awareness about health problems decreases incidence of
diseases

 Food supply and nutrition

Q: what are the causes of high fertility?

 Early marriages
 Lack of family planning
 Lack of education
 Poverty
 Desired to have male child
 In most of the societies the bigger families leads to higher social status and man power
 The children in lower economic group very soon start helping their parents in earning
their living

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PRIMARY HEALTH CARE

Q: define primary health care write its components/elements/cornerstones and principals.

Primary health care: is an essential health care made universally accessible to individuals and
families in the community by means acceptable to them through their full participation and at a
cost that a community and a country can afford.

Elements /components /corner stone of PHC:

 Promotion of food supply ,water supply, and sanitation

 education about prevailing health problems
 promotion of mental health
 immunization
 mother child health and family planning
 provision of essential drugs
 treatment of common disease
 control of locally endemic disease

Principles of PHC

 equity and equitable distribution of health services

 community participation
 intersectoral coordination
 appropriate technology which must be Available, Affordable, Acceptable, Accessible

Q: briefly describe intersectoral coordination.

Intersectoral coordination: health cannot be attained by health sector alone it requires

coordination and cooperation between health sector and other related groups e.g. housing,
sanitation, food, agriculture, and social welfare department.

An important element of intersectoral approach is planning with other sectors to avoid

unnecessary duplication.

Q: briefly describes constraints/limitations in primary health care.

Constraints in PHC/Limitation in PHC:

I. Political climate and low budget for health: due to high budget for defense little is left
for health.

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II. Disregard of human right: ethnic violence and social evils seem to be raging during the
current decade this necessitates diversion of large amount for maintenance of law and
order.
III. Political commitment: those holding authority for resource allocation are influenced by
high level professionals towards large spending or sophisticated technology in utter
disregard of PHC requirement.
IV. Lack of appreciation of multifaceted approach: investment merely in health sector are
not conductive towards a healthy life style, environmental degradation arising as a
result of scanty rainfall, agricultural crop failure, deforestation, soil erosion, as well as
poverty and illiteracy are to be considered as health related components.
V. Doctors are not going to far areas BHU,s: but now they are going due to high salaries
by new government.

Q: write short note on national health system.

National health care system consists of following major systems

I. Public health sectors

 Primary health care
 Hospitals /health centers
 Health insurance scheme
 Other agencies i.e. defense services and railways
II. Private health sectors
III. Indigenous system of medicine: i.e. Hakeem, homeopathy, Unani and Tibbi
IV. Voluntary health agencies
V. National health program

Q: briefly differentiate between comprehensive health care and selective health care.

Selective primary health care: focuses on using specific interventions to target specific health
problems such as immunization and oral rehydration therapy to promote child survival. Health
care providers are doctors and other health professionals. Strategies are medical intervention.

Comprehensive primary health care: focuses on the broader social determinants of health such
a poverty and economic inequality, gender inequality and community development. Health
care providers are multidisciplinary teams and strategies are multisectoral collaboration.

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Q: briefly differentiate between primary and secondary level of prevention.

Primary level of prevention: is concerned with preventing the onset of disease it aim is to
reduce the onset of disease i.e. Reducing risk of disease by immunization.

Secondary level of prevention: includes procedures that detect and treat pre-clinical
pathological changes and there by control disease progression i.e. by screening procedure.

Q: explain district health system

District health system: is the mean to achieve the end of an equitable, efficient and effective
health system based on the principles of the primary health care (PHC) approach. This means
that the DHS is more than just a structure or form of organization. It is the manifestation of a
set of activities that includes community involvement, integrated and comprehensive health
care delivery, intersectoral collaboration and a strong bottom-up approach to planning, policy
development, and management.

The PHC approach and the DHS model apply to the whole of the health system and at all levels
of health care delivery. They do not just apply to the primary level of the health system, or just
to the district level. In a DHS, the organization and management of the entire health system is
district-based, meaning that even policy areas such as health sector financing, utilization of
regional and tertiary hospitals, the relationship with the private sector and governance should
be DHS-based.

The underlying essence of the DHS is the organization of health care according to geographic
sub-divisions of a country, which are managed through a decentralized management structure.
The district management structure is supposed to be the point and level at which different
health service activities are integrated into a comprehensive and holistic approach to health
care.

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OCCUPATIONAL HEALTH
OCCUPATIONAL DISEASES AND THERE RELATED OCCUPATIONS:

SILICOSIS: (snow storm appearance)

Occupation related with silicosis is: pottery, ceramics, sand blasting, mining, abrasive soap,
metal grinding, and boiler scaling, building construction work.

ANTRACOSIS: is found in COAL workers

ASBESTOSIS: (ground glass appearance on X-ray)

Occupations related to asbestosis are: roof tiles, brick lining, shipyard worker, asbestos cement,
gas kit, fire proof textiles.

BAGGASSOSIS (mottling in lungs): are found in farmer dealing with SUGAR CANE, and in
workers of paper, cardboard and rayon industries

FARMER,S LUNG :is due to GRAIN DUST or MOULDY HAY

PLUMBISIM: is found in workers of LEAD BATTERY workers

Q: define pneumoconiosis and give medical, engineering and legislative measure for prevention
of pneumoconiosis

Pneumoconiosis: group of disease resulting from inhalation of respirable fraction of chemical

dust (organic/inorganic) leading to irreversible lung fibrosis is called pneumoconiosis.

Prevention of pneumoconiosis:

 Medical measure
 Application of ergonomics
 Regular medical checkup
 Health education
 Notification of disease and research on it
 Health education
 Engineering measure
 Proper building design and architecture
 Good house keeping
 Mechanization
 Substitution
 Control at source

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 Isolation
 Protective device
 Monitoring
 Research

 Legislation: laws in the favor of worker must be established

Q: name the organization works for labor rights?

Ans: Organization works for labor rights: international labor organization (ILO).

Q: define ergonomics, write characteristics of fibrosis in asbestosis and give preventive

measures in asbestosis.

Ergonomics: Fitting of jobs to workers, its objective is to achieve best mutual adjustment of
man and his work for improvement of human efficiency and well being

Characteristics of fibrosis in Asbestosis:

 Peri bronchial
 Diffuse
 Basal in location
 Due to mechanical irritation

Preventive measure in Asbestosis:

 Use of safer type of asbestos

 Dust control
 Periodic examination of worker
 Continuous research
 Substitution of asbestos by other less harmful material

Q: write preventive measure for silicosis.

Preventive measure for Silicosis:

 Dust control measure

 Isolation
 Good house keeping
 Substitution
 Personal protective measures
 Complete enclosure

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 Regular medical check up

 A 50 years old textile mills worker presented with complaints of cough, breathlessness of
long duration which is progressively increasing .he is non-smoker.
a) In contest of his occupation what is most likely cause of his complaint?
b) What preventive measures should be taken?
c) What will be the responsibilities of medical officer working in this industry to
control this condition?
a) It is a case of Byssinosis which is due to inhalation of cotton fiber
b) Preventive measures
 Wearing protective masks
 Proper ventilation
 Regular medical checkup
 Good house keeping
 substitution
c) Responsibilities of medical officer to control this condition
 Periodic examination: regular checkup is essential ,X-ray chest should be done
 Medical and health care services: proper care should be given
 Notification: information of disease is passed to high authorities
 Maintenance and analysis of health record
 Health education and counseling

 A 45 year old man working in a pottery industry presented with cough ,dyspnea , and chest
pain .X-ray chest confirmed fibrosis and hilar lymphadenopathy.
a. What is the most probable diagnosis and which factor in this this particular industry led
to this condition
b. Enumerate engineering measure to prevent this condition

a. it is case of silicosis which is due to inhalation of fine crystalline silicon dioxide dust or quarts
(free crystalline silica) particles

b. Engineering measures to prevent silicosis are:

 Good ventilation
 Dust control
 isolation of the process
 substitution if possible

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 good house keeping

 A middle age worker of ceramic industry presented with cough, fever, dyspnea, X-ray lung
confirms fibrosis and hilar lymphadenopathy.
a. What is the most probable cause of his condition in this trade?
b. What are the complications?
c. What the preventive measures?
a. Silicosis
b. Complications of silicosis are: Lung cancer, Progressive massive fibrosis,
Respiratory failure, Tuberculosis, Connective tissue disease, including
rheumatoid arthritis, scleroderma (also called progressive systemic sclerosis),
and systemic lupus erythematous.
c. Given above

 A 45 years old man was brought to you with the complaints of severe dyspnea, productive
cough, and cardiac distress for last 10 days. The man is working in a fire proof clothing
factory for the last 15 years.

 A patient age 40 comes to OPD having increasing dyspnea, nonproductive cough finders
clubbing and weight loss. on inquiry he told that he is working in an industry manufacturing
fire proof textiles and gasket for the last 15 years.
a. Name the disease and causative agent
b. Describe characteristics of lung fibrosis of this disease
c. Name other profession whose workers have this disease
d. What are the preventive measure

ANSWER:

a. Disease is asbestosis caused by inhalation of asbestos.

b. Characteristics of lung fibrosis of asbestosis

• Peri bronchial
• Diffuse
• Basal in location
• Due to mechanical irritation

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c. Other professions whose workers have this disease are: roof tiles, brick
lining, shipyard worker, asbestos cement.

d. Preventive measures in asbestosis are:

• Use of safer type of asbestos
• Dust control
• Periodic examination of worker
• Continuous research
• Substitution of asbestos by other less harmful material

 A 45 years old man who is farmer by profession is suffering from cough and fever for
several months
a. What are the most probable diagnosis
b. What are the preventive measures
c. List the indoor air pollutants and diseases caused by them

ANSWER:

a. Bagasossis

b. Preventive measures for bagassosis

 Dust control: measures for the prevention and suppression of dust such
as wet process, enclosed apparatus, exhaust ventilation, etc. should be
used.
 Personal protection: personal protective equipment (masks or
respirators with mechanical filters or with oxygen or air supply) may be
necessary.
 Medical control: initial medical examination and periodical medical
checkups of the workers are indicated
 Bagasse control: by keeping the moisture content above 20 percent and
spraying the bagasse with 2 percent propionic acid, a widely used
fungicide, bagasse can be rendered safe for manufacturing use.

c. Indoor air pollutants there source and diseases (effect) caused by them are
given in the table;

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pollutant source effect

Radon gas Uranium in soil May cause lung cancer

Tobacco Smokers Respiratory ailments

smoke
Asbestos Fire insulation, Lung cancer, lung
floor tiles diseases

Fungi, bacteria Humidifiers, air Allergies, asthma,

conditioners legionnaires disease

Carbon Stoves, heating Headache, drowsiness,

monoxide, system nausea, in high
nitrogen concentration carbon
oxides monoxide is fatal

Formaldehyde Plywood, board Irritates eye, skin and

particles causes lung cancer

Benzene Solvent cleaner Suspected of causing

leukemia

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MCH/REPRODUCTIVE HEALTH/FAMILY PLANNING

Q: what is high risk pregnancy and what are the causes of high risk pregnancy?

A high-risk pregnancy is one that threatens the health or life of the mother or her fetus

Causes of high risk pregnancy:

 Too young (less than 18 years) and too old (more than 35 years) primigravida.
 prematurity ( less than 37 weeks ) or post maturity (more than 41 weeks)
 grand multipara (more than 5 children)
 short statured primigravida less than 5 feet
 twin pregnancies
 mal presentation e.g. breach
 pregnancy associated with anemia
 toxemia of pregnancy
 Past bad obstetric history i.e. abortion, stillbirth, antepartum hemorrhage, caesarian
section.
 Pregnancy associated with diseases i.e. DM, epilepsy, heart disease etc.

Q: what are the risk factors which lead to high maternal mortality rate in Pakistan?

Risk factors which lead to high maternal mortality rate in Pakistan:

 Hemorrhage due to abortion , ectopic pregnancy , placenta previa, placental abruption

and post-partum hemorrhage ,rupture of uterus due to obstructed labor ,retained
placenta and membranes
 Hypertension
 Puerperal sepsis
 Anemia in pregnancy
 Pulmonary embolism and amniotic fluid embolism
 Malnutrition
 Anesthesia accidents i.e. cardiac arrest , inhalation of gastric content
 Social factors : age at child birth , parity , too close pregnancies ,malnutrition , poverty ,
illiteracy , lack of maternal services , delivery by untrained dais , poor environmental
sanitation , poor communication and transport facilities , social customs etc.

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Q: briefly describes perinatal mortality rate and measure to reduce perinatal mortality rate

Perinatal mortality rate: it includes both fetal death (still birth) and early neonatal deaths.

PMR=late fetal deaths (28 weeks of gestation)+early neonatal death(first week) x1000

Live births in a year

OR

PMR= late fetal and early neonatal death weighing over 1000 gm at birth x1000

Total live births weighing over 1000gm at birth

In Pakistan PMR is 49/100 live birth

Measures to reduce perinatal mortality are:

 Improving antenatal care

 Diagnosis and treatment of maternal infections(STD,S ,UTI, TB, MALARIA, RUBELLA)
 Maternal immunization(tetanus, pneumonia)
 Prevention of anemia
 Care during delivery and early neonatal period
 Prevention and treatment of neonatal infections

Q: define growth monitoring program, and write there uses.

Growth monitoring program (GMP): GMP is regular measurement, recording, and

interpretation of child growth change in order to counsel act and follow up result

Uses of GMP:

 A management tool for individual recipient

 A program management tool for decision making
 A promotive tool for improvement
 A promotive tool for community action and advocacy

Q: define domiciliary care and write advantages and disadvantages of domiciliary care.

Domiciliary care: care provided at home is called domiciliary care mother with normal obstetric
history may be advised to have domiciliary care.

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Advantages of domiciliary care:

 Less expensive
 No tension of going to hospital
 Mother deliver in familial surrounding
 Convenient psychologically satisfactory
 Chances of cross infection are rare
 No chances of mixing of children

Disadvantages of domiciliary care:

 Less medical care at home

 Not fully safe
 Less rest for mother
 Her diet may be neglected

Q: A mother with normal obstetric history delivered a baby at her home bay a midwife. This
birth attendant was in close liaison with the doctor at rural health center. Name the type of
health service?

Answer: domiciliary health care service.

Q: what are the causes and factors effecting infant mortality rate Pakistan.

Causes and factors effecting infant mortality rate Pakistan are:

a) Biological factors
 Birth weight :increased risk in low birth weight
 Age of mother: increased risk in too old and too young mother
 Order of birth: increased risk in 1st and after 5th baby
 Multiple births: increases risk
 Family size: increased risk in large family
 High fertility
b) Economic factors: increased risk of mortality in socioeconomic families
c) Culture and social factors
 Illiteracy
 Ignorance of child care
 Broken families
 Illegitimacy

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 Overcrowding
 Early marriages

Q: define reproductive health and write components of reproductive health.

Reproductive health care: defined as condition in which reproductive process is accomplished

in a state of complete physical mental and social wellbeing and not merely the absence of
disease or disorder of reproductive process.

Components of reproductive health are:

 Safe motherhood
 Fertility regulation
 Infertility
 Prevention and control of reproductive tract infection
 STD,s
 Newborn care

Q: write WHO strategies for safe mother hood/pillars of safe mother hood.

WHO strategies for safe motherhood /pillars of safe mother hood

1. Family planning
2. Antenatal care
3. Clean and safe delivery
4. Essential obstetric care
Mnemonic FACE

Q: define safe motherhood?

Safe motherhood: continuous care provided to the mother started from pregnancy period,
throughout pregnancy, delivery, and postpartum period and it should include family planning
services.

Q: define growth and development?

Growth: increase in physical size of a body. It is due to increase in size and number. Increase in
cell number takes place within a specified time while increase in size continue.

Development: Attainment of skills and functions of body organs.

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Q: what are uses of growth chart?

Uses of growth chart:

 Growth monitoring
 Diagnostic tool: for mortality and morbidity
 Planning and policy making
 Educational tool for educating mother
 Tool for action helps in type of intervention
 Evaluation: provides a good method to evaluate the effectiveness of corrective
measures
 Tool for teaching :
 growth chart gives information like birth date and weight
 immunization of child
 immunization of mother
 child health record
 helpful in ORS preparation at home

Q: describes neonatal breast policy.

Neonatal breast policy: breast milk is ideal for babies the health facilities should do the
following to promote breast feeding:

 All health staff should form a team that ensure implementation of this breast feeding
policy
 Relevant health staff should be trained in the skills necessary to implement this policy
 Expected mother should be educated on benefits of breast feeding and dangers of
bottle feeding
 At delivery newborn should be put to breast feed within 30 minutes
 Exclusive breast feed should be promoted from birth up to 4-6 months
 Feeding bottles should not be allowed in hospitals
 Promotional materials about formulas should not be allowed in hospitals
 Health staff will not receive gifts from formula manufacturers
 Mother will be informed to seek help in case of lactation problem

Q: what meant by contraception and unmet needs for contraception?

Contraception: use of methods or techniques to prevent pregnancy as a consequence of sexual

inter course.

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Unmet need of contraception: women with unmet needs are those who are sexually active but
are not using any method of contraception and also they do not want more children.

Q: what are intrauterine contraceptive devices and what are their types?

Intrauterine contraceptive devices: devices which are exerted into uterus to exerted
pregnancies. Types are

I. First generation: None medicated made up of polyethylene or other polymers e.g.

Lippe’s loop.
II. Second generation: it is medicated ,T shaped with copper because metallic copper have
strong anti-fertility effect.
III. Third generation: they are hormone releasing device e.g. progesterate.

Q: what re the objective of MCH

Objectives of MCH:

 Reduction in maternal, perinatal, infant and childhood mortality and morbidity

 Promotion of reproductive health
 Promotion of physical and psychological development of child and adolescent with in
the family

Q: what are the modern methods of family planning that are recommended during post natal
period?

Modern methods of family planning that are recommended during post natal period are:

 Hormonal methods
 Oral pills
 Combined pills
 Progesterone only pills
 Post coital contraceptive pills
 Long acting pills
 Depot formations
 Injectable
 Subdermal
 Vaginal rings
 IUCD,s

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Q: differentiate between longitudinal and cross sectional assessment of child.

Longitudinal assessment: longitudinal assessment of growth entails measuring the same child
at regular intervals this provide a valuable data about a child progress.

Cross sectional assessment: it compares child growth with that of his peers .cross sectional
comparison involves large number of children at same age .the children are measured and the
range of their measurement (e.g. weight, height,)is plotted usually in percentile chart.

Q: what is child survival initiative?

Child survival initiative: Aim is to reduce child mortality by training front line health workers
on care for pregnant women, newborns, and young children.

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ENTOMOLGY
Q: write insects included in order Dipteral of class insects:

 Crane flies
 Granes flies
 Midges flies
 Horse flies
 robber flies
 Bee flies

Q: write short note on metamorphosis in mosquito?

Metamorphosis is a biological process by which an animal physically develops after birth or

hatching, involving a conspicuous and relatively abrupt change in the animal's body structure
through cell growth and differentiation.

Mosquitoes undergo complete metamorphosis; they go through four distinct stages of

development during a lifetime. The four stages are egg, pupa, larva, and adult. The full life-
cycle of a mosquito takes about a month

Metamorphosis in mosquito: Adult  Egg  Larva  Pupa  Adult

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Q: define vector? Briefly describe transmission of arthropod borne diseases.

Vector: Arthropods or other invertebrates which transmit infection by inoculation into or

through the skin or mucous membrane by biting or by deposit of infective material on skin or
on food or other object.

Transmission of arthropod born disease:

Direct contact: transfer from man to man through close contact.

Mechanical transmission: disease agent is transmitted mechanically by arthropod i.e.

Transmission of diarrhea, dysentery, typhoid, food poisoning, and trachoma by the house fly
are examples of mechanical transmission.

Biological transmission: when disease agent multiplies or undergoes some developmental

changes with or without multiplication in arthropod host. They are three types:

 Propagative: when disease agent undergo no cyclical changes but multiply in the body
of vector e.g. Plague bacilli in rat flea.
 Cyclopropagative: disease agent undergoes cyclical changes and multiply in the body of
arthropod e.g. malaria, parasite in mosquito.
 Cyclodevolopmental: disease agent undergoes cyclical changes but does not multiply in
the body of arthropod e.g. filarial parasite in Culex mosquito.

Q: discuss briefly principles of control of vector born disease?

 Environmental control: best approach to the control of arthropod involves elimination

of the breeding places (source reduction) proper disposal of refuse and other waste.
 Chemical control: by using insecticides
 Biological control: use of larvivorous fish control mosquito
 Genetic control:
 chromosomal transmission
 cytoplasmic incompatibility
 sterile male technique

Q: briefly describes mosquito control measures.

Mosquito control measures are:

I. Anti-larval measure :
 Environmental control
 Chemical control

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 Biological control
II. Anti adult measure
 Residual spray
 Space spray
 Genetic control
III. Protection against mosquito bite
 Mosquito net
 Screening
 repellents

Q: briefly describe flea index.

Flea Index: the number of fleas of different species found on various species of hosts. This raw
data can be used to calculate various indices.

 General flea indices: average number of fleas of all species per rodent (rat).
 Specific flea indices: (Xenopsylla cheopis index, Xenopsylla astia index)average number
of fleas of each species found per rodent.
 Percentage incidence of flea specie: percentage of fleas of each species found per
rodent.

Rodent infestation: percentage of rodent infested with the various flea specie

Q: write short note on medical control measure in Itch mite (sacroptes scabiei)

Medical control measure in Itch mite (sacroptes scabiei):

 Benzyl benzoate : effective sarcopticides

 TETMOSOL
 Sulpher ointment
 HCH

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HEALTH EDUCATION AND MENTAL EDUCATION

Q: illustrates components of communication process with the help of diagram.

Components of communication process by diagram. This is also called Shannon weaver

communication model.

Sender  Message  Channel  Receiver  feedback to Sender.

Q: enlist functions of health communication.

Functions of health communication are:

 Information
 Education
 Motivation
 Persuasion
 Counseling
 Raising morals
 Health development
 Organization

Q: briefly describe approaches to health education:

There are four well known approaches to health education:

1. Regulatory approach: regulation in context of health education may be defined

as any governmental intervention, direct or indirect, designed to alter human
behavior regulations may be promulgated by the state by a variety of
administrative agencies. Regulations may take many forms ranging from
prohibition to imprisonment.

2. Service approach: this approach was tried by basic health services in 1960s. It
aimed at providing all the health services needed by the people at their door
steps on the assumption that people would use them to improve their own
health. This approach proved a failure because it was not based on the felt needs
of the people. For example, when water seal latrines were provided by the
government, free of cost, many people in the rural areas did not make use of
them because it was not their habit to use latrines.

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3. Health education approach: there are many problems e.g. (cessation of

smoking, use of safe water supply, fertility control) which can be solved through
health education. People must be educated through planned learning
experiences what to do, and be informed, educated and encouraged to make
their own choice for a healthy life.

4. Primary health care approach: this is radically new approach starting from the
people wit there full participation and active involvement in the planning and
delivery of health services based on principles of primary health care, viz.
community involvement and intersectoral coordination.

Q: what are the factors that you would take care to ensure effective dissemination of health
education message?

Message must be

 In line with objective

 Meaningful
 Based on felt needs
 Clear and understandable
 Specific and accurate
 Timely and adequately
 Fitting the audience
 Interesting
 Culturally and socially appropriate

Q: write short note on communication barriers:

Communication barriers are specific items that can distort or prevent communication within an
organization. These are:

 Physiological barrier : difficulties in hearing ,expression

 Psychological barrier: emotional disturbances, neurosis, level of intelligence, language
or comprehension difficulties
 Environmental barrier: noise , invisibility , congestion
 Cultural barrier: Illiteracy , customs , believes, level of knowledge , and understanding
religion, language variation

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Q: define mental health and what are common mental health problems in Pakistan?

Mental health: mental health is defined as state of well-being in which every individual realizes
his or her own potential can be cope with normal stresses of life ,can work productively and
fruitfully and is able to make a contribution to his/her community.

Common mental health problems in Pakistan are:

 Depression
 Schizophrenia
 Epilepsy
 Obsessive compulsive disorder
 Bipolar disorder

Q: elaborate WHO strategies to improve mental health.

WHO strategies to improve mental health:

 Provide treatment in primary

 Assuring psychotropic medicines availability at all the levels of health care the drugs
includes antidepressants ,antipsychotics, anti epileptics and anxiolytic
 Providing care in the community. medical health services should be provided in the
community rather than mental hospital
 Educating the public
 Involving communities , families ,consumers, in the planning of mental health
policies programs and services
 Establishing national policies , programs , and legislation
 Developing human resources
 Linkage with other sectors
 Monitoring community mental health
 Supporting more research
 Early child hood interventions
 Support to children
 Socioeconomic empowerment of women
 Social support for elderly population
 Mental health promotional activities in school
 Violence prevention programs
 Housing policies
 Community development programs
 Poverty reduction and social protection for the poor

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 Antidiscrimination laws and complain

 Promotion of the right

Q: what are the principals of health education?

Principles of health education are:

 Credibility
 Interest
 Participation
 Motivation
 Comprehension
 Learning by doing
 Known to unknown
 Setting an example
 Good human relationship
 Feed back

Q: what is the best approach to discuss personal hygiene issue to teen age college girl?

Best approach to discuss personal hygiene issue to teen age college girl is group approach.

Group approach comprises of:

1. Lectures
2. demonstration
3. Discussion method
 Group discussion
 Panel discussion
 Symposium
 work shop
 Conferences
 Seminar
 Role play

Q: define health education?

Health education: According to Alma Ata definition: It is a process aim at encouraging people
to want to be healthy, to know how to stay healthy, to do what they can do individually or
collectively to maintain health and to seek help when needed.

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Definition of health education by national conference in USA: Health education is a process that
informs, motivates, and helps people to adopt and maintain healthy practices and life styles,
advocate environmental changes as needed to facilitate the goal and conduct professional
training and research to same is called health education

Q: write treatment of drug abuser

Treatment of drug abuser:

 identification of drug addicts and their motivation for detoxification

 detoxification (requires hospitalization)
 post detoxification counseling and follow up base on clinically and home visits
 rehabilitation

Q: describe rehabilitation.

Rehabilitation: it is a process of medical or psychotherapeutic treatment for dependency or

psychoactive substance.

Rehabilitation requires setting up of a welfare home in a well-protected building outside the

city it should have the following units.

 vocational training unit

 medical and psychotherapy unit
 educational and recreational unit
 management unit

Q: explain Hippocratic Oath or PMDC oath

PMDC OATH:

 I solemnly pledge myself to consecrate my life to the service of humanity;

 I will give to my teachers the respect and gratitude which is their due;
 I will practice my profession with conscience and dignity;
 The health of my patient will be my first consideration;
 I will respect the secrets which are confided in me, even after the patient has died;
 I will maintain by all the means in my power, the honor and the noble traditions of the
medical profession;
 My colleagues will be my sisters and brothers; and I will pay due respect and honor to
them.

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 I will not permit considerations of age, disease or disability, creed, ethnic origin, gender,
nationality, political affiliation, race, sexual orientation, or social standing to intervene
between my duty and my patient;
 I will protect human life in all stages and under all circumstances, doing my utmost to
rescue it from death, malady, pain and anxiety. To be, all the way, an instrument of
Allah’s mercy, extending medical care to near and far, virtuous and sinner and friend
and enemy.”
 I make these promises solemnly, freely and upon my honor

Q: write about the qualities of hospital administrators.

Qualities of hospital administrator are:

 Ability to see ahead and plan accordingly ,planning for the future while managing the
present
 Ability to produce and accept new and creative ideas being an agent of change
 Willingness to take risks to get the new ideas accepted and implemented
 Ability to coordinate ,bringing about harmony collaboration organizing , allocating
resources and controlling
 Ability to analyze ,synthesize and integrate diverse information
 Sense of equity, fairness and social justice in all dealings with in and outside the
hospital.
 Knowledge ,skills and experience
 Ability to delegate ,making effective use of own time and that of others
 Good personal motivation and ability to motivate the people working in the hospital
 Ability to review and evaluate ,making adjustment as necessary

Q: what is medical ethics and give its significance in medical field?

Medical ethics is a system of moral principles that apply values and judgments to the
practice of clinical medicine and in scientific research. These values include the respect for
autonomy, non-maleficence, beneficence, and justice.

Significance of ethics in medical field: the study of ethics prepares medical professionals to
recognize difficult situation and to deal with them in a rational and principle manner. Ethics
is also important in physician interaction with society and their colleagues and for the
conduct of medical research. Ethics are important for doctors to know their rights and
duties. Ethics are important for medical personnel to deal medico legal cases.

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DISASTER MANAGEMENT
Q: define disaster and classify disaster.

Disaster: defined as any occurrence that cause damage, ecological disruption, loss of human
life, or deterioration of health and health services on a scale sufficient to warrant an extra
ordinary response from outside the affected community or area.

Classification/types of disaster:

 Meteorological disaster: i.e. storms

 Topological ; e.g. flood and land slides
 Telluric and tectonic :earth quakes , volcanic eruptions
 Accidents :failure of structures i.e. dams and buildings
 Atomic explosion: e.g. in Nagasaki and Hiroshima in Japan
 Bioterrorism

Q: what is disaster preparedness?

Disaster preparedness: a program of long term developmental activities whose goals are to
strengthen the overall capacity and capability of a country to manage efficiently all types of
emergencies.

Q: briefly describe Triage?

Triage: Principle of First come First treated is not followed in mass emergencies.

Triage consists of mass emergencies the injuries are categorized on the basis of severity of their
injuries and the likely hood of their survival with prompt medical interventions.

High priority is granted to the victim whose immediate or long term prognosis can be
dramatically affected by simple intensive care. Moribund patient who require greatest deal of
attention with questionable benefits have the lowest priority .it uses four color code system

 RED: indicates high priority treatment or transfer

 Yellow: medium priority
 Green: ambulatory patient
 Black: dead or moribund

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Q: briefly describes man-made disasters?

Man-made disasters: these are disasters caused by human these are:

 Sudden disaster: Accidents at nuclear reactors

 Collapse of building due to inappropriate material or emergency
 Wars and civil conflict
 Insidious disaster: global warming , greenhouse effect

Q: what are fundamental aspects of disaster management?

Fundamental aspects of disaster managements are:

 Disaster response
 Disaster preparedness
 Disaster mitigation

Q: write steps of disaster management.

Steps of disaster management are:

 Pre disaster management: it involves the following steps .POST CORB (mnemonic )
 Planning
 Organization
 Staffing
 Training
 Coordination
 Reporting
 Budgeting
 During disaster management: (disaster response) consists of:
 Search ,rescue and first aid
 Field care
 Information center
 Triage
 Tagging
 Identification of dead
 Transportation

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 Post disaster management (public health intervention)consists of:

 Epidemiological surveillance
 Vaccination
 Nutrition
 Rehabilitation: consists of
 Water supply
 Food supply
 Vector control
 Psychological treatment
 Basic sanitation and personal hygiene

Q: define hazard and classify hazard with examples.

Hazard: any phenomenon that has the potential to cause disruption or damage to people and
their environment.

Classification of hazard with examples/Types of hazard

Hazards are generally labeled as one of five types

 Physical hazards are conditions or situations that can cause the body physical harm or
intense stress. Physical hazards can be both natural and human made elements.

 Chemical hazards are substances that can cause harm or damage to the body, property
or the environment. Chemical hazards can be both natural and human made origin.

 Biological hazards are biological agents that can cause harm to the human body. Some
biological agents can be viruses, parasites, bacteria, food, fungi, and foreign toxins.

 Psychological hazards are created during work related stress or a stressful environment
.A person can be a hazard when he/she is affected psychological disturbance through -
stress, shift patterns and also can be a hazard when a person is under the influence of
alcohol, illness and lack of training.

 Ergonomic Hazard is a physical factor within the environment that harms the
musculoskeletal system .ergonomic hazards include themes such as repetitive

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movement, manual handling, workplace/job/task design, uncomfortable workstation

height and poor body positioning

Q: classify different types of radiation.

Types of radiation:

 Electromagnetic radiation: X-rays ,Gamma rays

 Corpuscular radiation: Alpha particles ,beta particles
 acoustic radiation: such as ultrasound, sound, and seismic waves (dependent on a
physical transmission medium)
 gravitational radiation: radiation that takes the form of gravitational waves, or ripples in
the curvature of space time

Q: what are the effects of ionizing radiation of human body?

Effects of ionizing radiation on human body:

 Somatic
a) Immediate
 Radiation sickness
 Acute radiation syndrome
b) Delayed
 Leukemia
 Carcinogenesis
 Fetal developmental abnormalities
 Shortening of life
 Genetic:
 chromosomal mutation

Q: what are the effects of pressure on human body in air and in water?

At sea level atmospheric pressure is 760 mm Hg this is called 1 atmospheric pressure written as
1atm.the atmospheric pressure falls as altitude increases and rises as altitude decreases.

 Effect of pressure on human body in air: at high altitude air pressure decreases. This in turn
decreases oxygen and so hemoglobin concentration increases and also heart rate increases.
Reason is, the air is less dense at high altitude and so partial pressure of oxygen is also less.
Man cannot survive at an altitude of 25000 feet without breathing equipment when there is
sudden exposure to high altitude, following two conditions occur:

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 Acute mountain sickness: it is characterized by Dizziness, headache, muscle aches,

insomnia, nausea and vomiting, irritability, loss of appetite, swelling of the hands, feet,
and face, rapid heartbeat, shortness of breath with physical exertion.

 High altitude pulmonary edema: this appears on 3rd day. Initially symptoms are of acute
mountain sickness; gradually patient develops cough, mental confusion, hallucinations
and Cheyenne-stokes breathing.

 Effect of pressure in water: atmospheric pressure increases by 1atm for every 33 feet depth
below sea level. This effect of high pressure called caisson disease is observed in persons
working in diving bells, compressed air chamber or mines.

 Caisson disease (compressed air sickness): at high pressure in depth the gases are
dissolved in the blood. Excess concentration of nitrogen exerts a narcotic action leading
to loss of mental function. Excess of carbon dioxide increases the action of nitrogen
leads to convulsion and death. Initial symptoms are euphoria, fever, nasal voice,
tachypnea, bradycardia, fatigue, weakness and hemorrhages. The symptoms of sudden
decompression are called bends and screws by workers.

Q: what should be the immediate line of disaster management?

Answer: immediate line of management is disaster response which includes the following
steps:

 Search, rescue, and first aid

 Field care
 Information center
 Triage
 Tagging
 Identification of dead
 Transportation

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ENVIRONMENT AND HEALTH

Q: write the causes of ozone depletion

Causes of ozone depletion: ozone layer is depleted mainly by chlorofluorocarbons which are
present in air conditioners, refrigerators, aerosol spray .other causes are cosmic rays, sulpher
put in the atmosphere, jet travel and deforestation.

Q: what are the harmful effects of ozone depletion on human health?

Harmful effect of ozone destruction on human health: ultraviolet rays if come directly with all
wave lengths they cause skin cancer and cataract if there is 1% fall of ozone then there is

 4 to 6% more chances of skin cancer

 0.8 to 1.5 % increase in melanomas
 0.2 to 0.6 % increase in cataract cases

Q: what is safe and whole some water?

Safe and whole some water are:

 Free from pathogenic agents

 Free from harmful substances
 Pleasant to taste, free from color and odor
 Usable for domestic purposes

Q: write criteria for quality of water.

Criteria for quality of water:

1. Physical quality
 Must be free from turbidity
 Must be free from color
 Should have no disagreeable odor
 Taste must be palatable
 Temperature should be acceptable
 Must be clear

2. Chemical quality
 PH = 6.5 to 8.5
 Hardness must be less than 300 mg /L
 Chloride standard level is 200mg/L ,but maximally is up to 600mg/L

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 Recommended maximum limit of nitrates is 50mg/L

 Recommended maximum limit of nitrites is 3mg/L
 Normal level of ammonia is 0.2 mg/L while maximum limit is 1.5mg/L
 Oxygen absorbed should not more than 1mg/L

3. Microbiological aspects:
 Bacteriological indicators :presence of E.coli , Fecal streptococci, coliform group,
clostridium perfringens shows fecal contamination
 Virological aspects: water should be free from viruses
 Protozoa: water should be free from protozoa
 Helminthes: adult , larva , fertilized egg should be absent

4. Radiological standard: radioactivity is number of nuclear disintegration per unit time its
unit is Becquerel, 1 Bq= 1 disintegration per second

Q: briefly describe chlorination.

Chlorination: the process in which chlorine is added to water for purification, effects of
chlorination are:

 Germicidal effect but no effect on spores and certain viruses

 Oxidizes iron, manganese hydrogen sulphide
 Destroy odor producing constituent
 Control algae growth and slime organism
 Aid in coagulation

Action of chlorine: Chlorine reacts with water and produce hydrochloric acid and hypochlorus
acid, H2O+Cl2 HCL +HOCL, HCL is neutralized by water, HOCL is most effective form for
disinfection when PH increases HOCL dissociate to hydrogen ion and hypochlorite ion.

HOCL  H + OCL

OCL have disinfecting action up to a small extent

Q: write the principals of chlorination

Principals of chlorination are:

 Water should be clear and free from turbidity

 Chlorine demand of water should be estimated

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 The contact period of free residual chlorine for killing bacteria and viruses should be at
least 1 hour
 Minimum recommended concentration of free chlorine is 0.5 mg/L for an hour
 The sum of chlorine demand of the specific water plus the free residual chlorine of 0.5
mg /L constitute the correct dose of chlorine to be applied

Q: briefly describes chlorination by means of chloramines

Chlorination by means of chloramines:

Chloramines are loose compounds of chlorine ammonia in a ratio of 4:1 .they have slower
action than chlorine and give more persistent types of residual chlorine . They have less
tendency to produce chlorine’s taste .in this method ammonia is first added to water and then
chlorine is added.

Q: what is break point chlorination?

Break point chlorination: the point at which residual chlorine appears and when all chlorine in
combine form has been completely destroyed the corresponding dosage is called the break
point dosage.

When chlorine is added to water it will react with natural ammonia in water to form chloramine
.amount of chloramine increase as we increases dose of chlorine and a point will come when all
free ammonia present is used up after which further addition of chlorine will destroy
chloramine. The break point will reached when chloramine is completely destroyed by excess
chlorine.

Q: what is super chlorination?

Super chlorination: super chlorination followed by de chlorination comprises the addition of

large doses of chlorine to the water and removal of excess of chlorine after disinfection this
method is applicable for heavily polluted water whose quality fluctuates greatly.

Q: what is biological layer and give importance of biological layer

Biological layer: when the sand bed of sand filter gets covered with slimy growth this is called
biological layer, vital layer, zolgeal layer or Schmutzdecke layer, this consists of thread like

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algae, plankton ,and bacteria. Formation of this layer is called ripening of filter and formed with
in 3 to 5 days

Importance of biological layer:

 it remove organic matter

 it holds back bacteria
 it oxidizes ammonical nitrogen into nitrates and help in yielding bacteria free water

Q: explain purification of water on small scale.

Purification of water on small scale: household water and wells are purified by small scale
purification of water

A: Household purification of water:

1. Boiling: boiling of water for 5 to 10 minutes kill bacteria, spores, cysts and ova. boiling
remove temporary hardness .Taste is utter but is harmless
2. Chemical disinfection
a) By bleaching powder :
 It is chlorinated lime in amorphous powdered form
 Produced by action of chlorine on slacked lime
 On exposure to light , air , moisture, it rapidly loses chlorine contents
 When mixed with excess of lime it retain its strength called stabilized
bleach
 For 100 gallons of water 30 grains of bleach powder is required
D= W x R x 7.2 /X
 D=quantity of bleaching powder
 W=quantity of water to be chlorinated
 R=chlorine dose

 350 g of bleach is added to 750 ml of water to make one liter solution then
3 drops of solution is added to 1 liter of water for disinfection with
contact period of 30 to 60 minutes 6 drops are used for badly polluted
water.
b) Chlorine solution
c) Chlorine tablets: 0.5 gm. tablet for 20 liter of water
d) Iodine :two drops of 2% ethanol solution of iodine for 1 liter of water

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e) Potassium permanganate: is powerful oxidizing agent but altering the taste, odor,
color.
3. Filtration:
 Pasteur chamber land filter
 Berkefeld filter
 Meta and stellar filter
4. Ultraviolet radiation
5. Multi-stage reverse osmosis purification of water

B: Disinfection of well:

Steps of disinfection of well are:

1) Find the volume of water in well

2) Find the amount of bleaching powder for disinfection

 Find through horrock's apparatus
 Roughly 2.5 gm. bleach will require for 100 liter

3) Dissolve the bleaching powder in water to make chlorine solution

 Bleaching powder is mixed with water in a bucket
 Make a thin paste
 Add more water and stirred it
 When lime settled down, the supernatant solution which is chlorine solution
transfer it into another bucket

4) Delivery of chlorine solution into well:

 Lower the bucket below the surface
 The well water is agitated by moving bucket up and down

5) Contact period is one hour

6) During emergency and for a constant dosage of chlorine to well water double pot method
is used.

Q: describe surveillance of water.

Surveillance of water: Intended to protect public from water borne disease.

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1) Sanitary survey : on the spot survey of water system by a qualified person for the
purpose of detection and correction of deficiencies.

2) Sampling: should be done with aseptic precautions. Carried out by trained personal in
accordance with method prescribe in WHO.

3) Bacteriological surveillance
I. Presumptive coliform test:

a. Multiple tube method: this test is based on estimating the most probable
number (MPN) of coliform organism in 100ml of water. The test is carried out
by inoculating measured quantities of the sample water (0.1, 1.0, 10, 50ml)
into tubes of McConkey,s lactose bile salt broth with bromcresol purple as an
indicator. the tubes are incubated for 48 hours. From the numbers of tubes
an estimate of MPN of coliform organisms in 100 ml of the sample water can
be obtained from statistical tables. This result is known as presumptive
coliform count, the presumption being each tube showing fermentation,
contains coliform organisms, the reaction may occasionally be due to thr
presence of some other organisms or combination of organisms.

Confirmatory test: to confirm that organism showing a presumptive positive

reaction is E.coli or other Coliform organism. This is done by sub culturing
each presumptive positive tube in 2 tubes of brilliant green bile broth.
Incubate 1 tube at 37c for 48 hours for confirmation of the presence of
coliform organism. Incubate the second tube at 44 degree centigrade and
inspect after 6 to 24 hours to decide whether or not E.coli is present. Mostly
E.coli produce gas from lactose at 44 degree centigrade while rest of coliform
can’t.

b. Membrane filtration technique:

A measured volume of sample is filtered through cellulose ester paper. All
bacteria retain on filter paper face. Inoculate the membrane face upward on
suitable media and at appropriate temperature, it is possible to count the
colonies and obtain result with in 20 hours as compared to 72-96 hours
required for the usual multiple tube technique

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II. Detection of fecal streptococci and clostridium perfringens: the presence of these
organism shows fecal contamination of water
III. Colony count: colony count on natural agar at 37c and 22 degree centigrade
provide estimate of general bacterial purity of water.

4) Biological examination: the degree of pollution is assessed by qualitatively and

quantitatively by noting type and number of organisms in water. These organisms are
algae , fungi , yeast , protozoa , crustaceans , worms collectively called plankton.

5) Chemical surveillance :
 Test for PH
 Test for color , turbidity , chloride , ammonia chlorine demand and residual
chlorine
 Test for iron and manganese
 Analysis for toxic metals , pesticides , organic chemicals , and radioactivity

Q: describes water related diseases.

Water related disease classification:

1) Noninfectious water related disease

a) Due to chemicals
 Goiter is due to iodine deficiency
 Dental fluorosis is due to fluoride excess
 Dental caries is due to fluoride deficiency
 Diarrhea is due to excess inorganic salts
 Hypertension is due to excess sodium
b) Due to heavy metals :
 Lead poisoning is due to lead
 Lung cancer is due to arsenic
 Nephropathy is due to cadmium and mercury
2) Infectious water disease
a) Feco-oral disease: diarrhea ,polio ,hepatitis A
b) Water borne disease: contamination of water by human feces i.e.
cholera, typhoid
c) Water washed disease: are due to water deficiency and lack of
personal hygiene e.g. scabies and trachoma

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d) Water based disease: water act in transmission of liver fluke,

schistosomiasis
e) Water related insect disease: water act as habitat for mosquitos,
insects i.e. malaria, dengue, viral infections, and filariasis.
f) Water dispersed disease : i.e. Legionella causes pneumonia

Q: describe greenhouse effect and its mechanism.

Greenhouse effect: It is the capacity of certain gases in the atmosphere to trap heat radiation
emitted from earth surface there by insulating and warming the earth.

Mechanism of greenhouse effect: when light falls on earth’s surface ,some rays are reflected
and some are refracted to atmosphere having no increase in temperature .however certain
gases form layer in the atmosphere which entrap heat radiation and increasing the
temperature of the earth.

Greenhouse gases are: CO2, CO, CH4, CCL4, NO2, CFC,s

Q: describe global warming and its effects.

Global warming: It is due to enhance effect of greenhouse effect. It is observed century scale
rise in average temperature of earth’s climate system and its related effects.

Effects of global warming on:

1) Health : global warming causes

 Causes sun stroke , heat exhaustion
 Damage to lung tissues
 Asthma
 Increase risk of infectious disease i.e. spread of mosquitos
 Heart patients are more risk

2) Water resources: global warming causes

 Dry soil
 Fall in lake water level
 Decrease hydroelectric power generation
 Poor water quality
 Overall decrease in water quantity

3) Costal resources: global warming causes rise in sea level ,1.5 m rise in sea level
inundates 5000sq miles of dry land.

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4) Polar regions: Global warming causes reduction of sea ice and snow in arctic region .It
will leads to rising of sea level.

5) Forests: global warming leads to deforestation.

6) Agriculture: global warming causes reduction in agricultural products. Poor countries

are at more risk.

Q: what is sewage and sullage?

Sewage: sewage is waste water from community containing solid and liquid excreta derived
from houses, street, and factories.

Sullage: waste water which does not contain human excreta, i.e. water from kitchens and
bathrooms.

Q: draw sewage treatment flow diagram.

Sewage treatment flow diagram (K.PARK page 763, 23rd edition)

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Q: describe biological oxygen demand and chemical oxygen demand.

Biological oxygen demand: the amount of oxygen absorbed by a sample of sewage during a
specified period (5 days) at specified temperature (20degree centigrade) for the aerobic
destruction of organic matter by living organisms .BOD range is 1mg/L in natural water to 300
mg/L in untreated domestic sewage .if BOD is more than 300 mg/L it is strong sewage .if BOD is
less than 100 mg/L it is then a weak sewage.

Chemical oxygen demand: Amount of oxygen equivalent of that portion of organic matter in a
sample which is susceptible to oxidation by strong chemical oxidizer.

Q: describe activated sludge process.

Activated sludge process:

 it is a process of aerobic oxidation of organic matter in effluent

 the effluent from primary sedimentation tank is mixed with activated sludge
 activated sludge is present in final settling tank i.e. sludge of secondary sedimentation
tank
 activated sludge is rich in aerobic cultures of bacteria
 the mixture is subjected to aeration in aeration tank
 aeration is done through mechanical agitation or compressed air is forced from the
bottom the latter is called diffuse aeration
 this aeration is done for 6 to 8 hours
 during aeration the aerobic bacteria of activated sludge oxidizes the organic matter into
water, carbon dioxide and nitrate
 cholera and typhoid organisms are destroyed
 coliform organisms are greatly reduced

Figure shows activated sludge process. P.S.T (primary sedimentation tank). S.S.T
(secondary sedimentation tank)

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Q: write WHO standard for safe water supply

WHO standard for safe water supply:

 no sample of water should contain E.coli

 no sample of water should contain more than three coliform organisms per 100 ml of
water
 coliform organisms should not be detected in 100 ml of any two conservative samples
 no more than 5% of samples throughout the year have coliform in 100 ml of water

Q: describe sanitation barrier.

Sanitation barrier: community medicine aims at breaking the disease cycle at vulnerable points.
The disease cycle may be broken at various levels i.e. segregation of feces, protection of water,
protection of food, personal hygiene and control of flies. Of these the most effective step would
be to segregate the feces, arrange for its proper disposal so that the disease agent cannot reach
the new host directly or indirectly.

Figure shows the segregation of the excreta by imposing a barrier called sanitation barrier .in
simple terms this barrier can be provided by sanitary latrines and a disposal pit .the more
elaborate schemes envisage installation of sewerage system and sewage treatment plant.

Figure Sanitation barrier to transmission of fecal borne diseases

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Q: what are the methods of waste/refuse disposal?

Methods of waste/refuse disposal:

1. Dumping
2. Controlled tipping
3. Incineration
4. Compositing
5. Manure pits
6. Burial

Q: describe compositing method for refuse disposal.

It is a method of combined disposal of refuse and night soil or sludge. It is a natural process. In
this organic matter breaks down under bacterial action, resulting in the formation of relatively
stable humus like material called compost which has considerable manorial value for the soil.
By products are carbon dioxide, water, heat, nitrate, and phosphates methods of compositing
used are:

 Anaerobic
 Aerobic

Q: describe environmental profile of Pakistan.

ENVIRONMENTAL PROFILE OF PAKISTAN:

Environment and urban affairs division of the government of Pakistan, established during the
past ,reviewed the major environmental problems of the country and the impact of the
development process upon resources and the environment and carried out by a detailed study,
consequently it led to the preparation of comprehensive profile of Pakistan.

The profile will provide direction in future efforts to deals with the management, conservation
and rehabilitation of the environment and natural resources, as the pattern of economic
growth may not be sustainable for a long period unless due recognition is given to the linkages
between population ,resources environment and development following are the main
problems that are facing as far as environmental deterioration in Pakistan is concerned.

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The basic causes for environmental problems in Pakistan are numerous and complex. however
they can be summed up to include our past tendency to emphasize quantitative growth at the
expense of quality ,the failure of our economy to provide full accounting for the social costs of
environmental population , the failure to take environmental profile into account as a normal
and integral part of our planning and decision making is dependent on experiences without
regard to their impacts on environment and more fundamentally the inadequacy and failure of
our institutions to perceive the environment in its totality and to understand or recognize the
fundamental interdependence of man ,resources environment and development.

18.1% or 11.2 million hectares of Pakistan’s surveyed soils are subject to water erosion , 7.6%
to wind erosion and 8.6 % to salinity and sodacity.in 1985 alone , motor vehicles in Lahore
generated 123,054 metric tons of carbon monoxide 14,564 metric tons of nitrogen dioxide ,two
of the most toxic common air pollutants .Pakistan generates 47,920 metric tons of solid waste
per day i.e. 17.5 million metric tons per year .Pakistan consumes energy at the same rate per
dollar of GNP as the united states but produces less of what the consumes. Some 29.9 million
hectares or some 30.6% of the country is under the threat of desertification. over all more than
two third of the farm house holds do not have enough land to support themselves at
subsistence level from what they can produce from the land alone.

Q: A well in village is located within 100 feet of a waste dump. People using this well water are
frequently suffering from stomach disorders.

a. How will you confirm that this particular waste dump is the source of
contamination of the well?
b. What test will you perform on water to confirm that it is biologically
contaminated and why only coliform are chosen as indicator of biological
pollution of water?
c. What measure will you adopt o disinfect the well water and make it safe for
drinking?

ANSWER:

a. if the waste dump is in 50 – 100 feet of the well then it will be the source of contamination
of well.

b. coliform test will perform on water to confirm that it is biologically contaminated There are
several reasons that only coliform are chosen as indicator these are:

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 the coliform organisms are constantly present in human intestine it is estimated that an
average person excretes 200-400 billion of these organisms per day these organisms
are foreign to potable waters and hence their presence in water is looked upon as
evidence of fecal contamination.
 they are easily detected by culture methods–as small as one bacteria in 100ml of water,
whereas the methods for detecting pathogenic organisms are complicated and time
consuming.
 they survive longer than the pathogens, which tends to die out more rapidly than
coliform bacilli.
 The coliform bacilli have greater resistance to the forces of natural purification than the
water borne pathogens. If the coliform organisms are present in a water sample , the
assumption is the probable presence of intestinal pathogens.

c.explained above

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NUTRITION
Q: define and enlist micronutrients in each group

Micronutrients: a chemical element or substance required in trace amounts for the normal
growth and development of living organisms.

Micronutrients are vitamins and minerals

Vitamins are classified into fat soluble vitamins that are Vitamin A, D, E, K and water soluble
vitamin which are Vitamin B1, B2, B3,B6, B12 and Vitamin C

Minerals are calcium, phosphorus, sodium, potassium, iron, magnesium, sulpher and chlorine

Q: describe scurvy and its prevention.

Scurvy: deficiency of vitamin C results in scurvy the signs of which are swollen and bleeding
gums, subcutaneous bruising or bleeding into the skin or joints delayed wound healing, anemia
and weakness.

Scurvy can be prevented by a diet that includes vitamin C-rich foods such as lemons, oranges,
papaya, and strawberries, bell peppers (sweet peppers), blackcurrants, broccoli, guava,
kiwifruit, and parsley and Vitamin C tablets.

Q: describe measures uses for assessment of obesity.

Measures uses for assessment of obesity are:

1) Body weight : +2SD (standard deviation) from the median weight for height is cut off
point for obesity calculated as
a) Body mass index (BMI) =weight in kg /height in meter square
b) Broca index = height in cm - 100
2) Skin fold thickness : measure by harpenden skin caliper at the following sites :

Mid triceps, biceps, subscapular, and supra iliac regions .ideally it should be <40mm in
boys, and <50 mm in girls

3) Waist circumference and waist hip ratio: waist circumference is measured at the
midpoint between the lower border of the rib cage and the iliac crest. It is a convenient
and simple measurement that is unrelated to height, correlates closely with BMI and
waist hip ratio and is an approximate index of intra-abdominal fat mass and total body
fat .changes in waist circumference reflects changes in risk factors for cardiovascular
disease and other form of chronic diseases. There is an increased risk of metabolic

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complications for men with a waist circumference >102 cm and women with a waist
circumference > 88cm.

Q: classify malnutrition

Malnutrition classification:

I. Primary malnutrition : is due to external factors i.e. food availability , food

intake , food habits.
II. Secondary malnutrition: is due to internal factors, conditions or diseases
interfere with normal digestion, absorption, utilization and excretion of
components of balance diet.

Q: write forms of malnutrition

i. Under nutrition i.e. protein energy malnutrition

ii. Over nutrition i.e. obesity
iii. Imbalance i.e. taking one food in large quantity while other in small quantity e.g.
vegetarians.
iv. Specific deficiency i.e. vitamin deficiency

Q: describe protein energy malnutrition and factors responsible for protein energy
malnutrition.

Protein energy malnutrition: a range of pathological conditions arising from simultaneous

deficiency of proteins and calories and commonly associated with infections, there are two
main types:

I. Kwashiorkor: a condition of protein energy malnutrition in which intake of proteins is

deficient and generalized muscle wasting, edema and hypo proteinemia ensues.

II. Marasmus: it is the condition of total calorie malnutrition in which food intake or
utilization is deficient and wasted appearance developed.

Difference between Kwashiorkor and marasmus are given in the table:

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Feature kwashiorkor Marasmus

Deficiency Protein Energy

Edema Present Absent

Wasting Present Markedly present

Appetite Good Poor

Activity Active Apathic

Growth Retarded Retarded

Mental changes Common Uncommon

Hepatomegaly Absent Present

Infections More prone Less prone

Hair changes Common Uncommon

Face Moon shape Monkey shape

Subcutaneous fat reduced absent

Responsible factors for protein energy malnutrition:

1. main factors :
 Nutritional imbalance /deficiency
 Bacterial and parasitic infections
 Failure in providing essential nutrients
 Deprivation of child from breast feeding
 Cultural factors and type of food consumed.

2. Contributory factors :
 Erroneous weaning by ignorant mother
 Early weaning due to second pregnancy

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 Poor MCH due to careless parents

 Wrong distribution of food among family members

3. Other factors:
 High cost of protein diet
 Shortage of food in community
 Poor environmental sanitation
 Shortage of curative and preventive services

Q: what are the preventive measures for protein energy malnutrition?

Preventive measures for protein energy malnutrition:

1) Health promotion:
 Measure directed to pregnant and lactating women (education and distribution
of supplements )
 Promotion of breast feeding
 Development of low cost weaning product
 Nutrition education
 Family planning and spacing of birth

2) Specific protection:
 Child diet must contain balance nutrients
 Immunization
 Food fortification

3) Early diagnosis and treatment:

 Periodic surveillance
 Diagnosis of disease, infection
 Deworming of highly infested children

4) Rehabilitation :
 Nutritional rehabilitation services
 Hospital treatment
 Follow up care

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Q: describe assessment of malnutrition in under five children.

Assessment of malnutrition in under five children:

I. Weight for age: repeated measurement at intervals up to 5 years .then comparing

these measurements with reference standards of weight of children of the same age.

II. Height for age: comparing height measurement with reference standard of height of
children of the same age.

III. Weight for height: weight of a child expressed as percent of weight of standard child of
same height.

IV. Skin fold thickness: determine amount of body fat, measure from triceps, inferior
angle of scapula with skin fold caliper.

V. Chest /head circumference ratio: it determine PEM in early childhood

VI. An arm circumference: it detects early PEM .flexible steel or fiber glass tap is used for
measurement .if >13.5 cm it is well nourished .if between 12.5 to 13.5 cm it will be mild
to moderate malnutrition. if <12.5 cm it will be severe malnutrition

Q: differentiate between longitudinal and cross sectional growth assessment.

I. Longitudinal growth assessment:

 Measurement of same child at regular interval
 This provide data about child progress

II. Cross sectional growth assessment:

 Compare child growth with his/her peer
 Comparison involve large number of children of the same age
 The measurement of these children are plotted on percentile charts

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Q: what are biological complete protein and biological incomplete protein?

Biological complete protein: A protein is said to be biological complete if it contains all the
essential amino acids in amount corresponding to human needs .e.g. protein from animal
sources i.e. milk and egg.

Biological incomplete protein: a protein is said to be biological incomplete if it lacks one or

more essential amino acid e.g. proteins from plant sources i.e. vegetable proteins

Q: what is complementary action of protein?

Complementary action of protein:

 Body building
 Repair and maintenance
 Maintenance of osmotic pressure
 Synthesis of antibodies , plasma proteins , hemoglobin , enzymes , hormones,
coagulation factors
 Source of energy, it gives 4 kcal/gm.

Q: describe protein energy malnutrition according to Gomez classification and Waterlow

classification.

1) Gomez classification: it is based on weight retardation .it locate the child on the basis of
his/her weight in comparison with normal child’s weight of the same age
Weight for age (%) =weight of the child x 100
Weight of normal child of same age

Values and interpretation

 Between 90 and 110% is normal nutrition

 Between 75 and 89 % is 1st degree , mild malnutrition
 Between 60 and 74 % is 2nd degree moderate malnutrition
 Below 60% is 3rd degree severe malnutrition

Disadvantages:

 Cut off point which is 90 is very high therefore some normal children are classified as 1 st
degree malnourished

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 It is difficult to know whether the low weight is due to sudden acute episode of
malnutrition or long standing chronic under nutrition

2) WATERLOW,S classification :this classification define two groups of protein energy

malnutrition
i. Malnutrition with retarded growth : in which there is drop in height /age ratio
Height /age % = height of the child x 100
Height of the normal child
at same age
This percentage will show stunting

ii. Malnutrition with low weight for normal height

Weight /height % = weight of the child x 100
Weight of the normal child
at same height

it indicates acute condition of rapid weight loss

Q: what are signs and symptoms of vitamin A deficiency?

Signs and symptoms of vitamin A deficiency are:

 Night blindness i.e. impaired dark adaptation

 Conjunctival xerosis i.e. dry non wettable conjunctiva
 Bitot,s spot i.e. foamy pearly white spots on bulbar conjunctiva
 Corneal xerosis i.e. Corneal ulcer covering less than 1/3 of the cornea
 Keratomalacia i.e.=which is liquefaction of cornea

Extra ocular complications are: follicular hyperkeratosis, anorexia, growth retardation in

children, and degeneration of myelin sheath of nerves.

Q: write functions of vitamin A.

Functions of vitamin A are:

 Role in vision i.e. production of retinal pigments which are needed for vision

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 Maintain the integrity and normal glandular epithelial tissue which lines intestinal
respiratory , urinary tract and eyes
 It supports skeletal growth
 Role as anti-infective ,enhance immune response
 Protect epithelial cancers

Q: briefly describes pasteurization.

Pasteurization: heating of milk for such temperature and for such period of time as are
required to destroy any pathogen that may be present while causing minimal changes to
composition, flavor, and nutritive values.

Methods of pasteurization are:

 Holder method: in which milk is heated for 30 minutes at 60 to 65 degree centigrade.

 High temperature short time method: milk is heated for 15 seconds at 72degree
centigrade.
 Ultra high temperature method: milk is heated at 125 degree centigrade for short
duration under pressure.

Pasteurization kills bacteria up to 90%

Q: name the disease and its main symptoms caused by niacin.

Disease caused by niacin (vitamin B3) is pellagra. Symptoms of pellagra are 3Ds i.e. Diarrhea,
Dermatitis, Dementia In addition glossitis and stomatitis occur.

Q: name nutritional problems of public health importance.

Nutritional problems of public health importance are:

 Low birth weight

 Protein energy malnutrition
 Xerophthalmia
 Nutritional anemia
 Iodine deficiency disorders
 Endemic fluorosis

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HOSPITAL WASTE MANAGEMENT

Q: write various methods of health care waste treatment and disposal

Methods of health care waste treatment and disposal are:

 Incineration
 Chemical disinfection
 Wet and dry thermal treatment
 Microwave radiation
 Land disposal
 Inertization

Q: describe direct and indirect impact of inappropriate hospital waste disposal.

Direct and indirect impact of inappropriate hospital waste disposal:

1. Hazards from infectious waste and sharps

 HIV, hepatitis B and C
 Bacterial infections resistant to antibiotics
 Person get infected through puncture , abrasion , through mucous membrane
,inhalation or by ingestion

2. Hazard from chemical and pharmaceutical waste :

 Chemicals and pharmaceutical agents are toxic ,genotoxic, corrosive , flammable,
and explosive
 They cause chronic injuries and toxicities

3. Hazards from genotoxic waste: inhalation, absorption through skin and ingestion of
food contaminated with cytotoxic drugs, chemicals and waste have destructive effect on
genetic material of cell.

4. Hazards from radioactive waste: These radiations are genotoxic and causes damage to
genetic material damage depends upon type and exposure time.

5. Public sensitivity : visual impact of health care waste particularly anatomical waste

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Q: describe waste management plan:

Waste management plan:

 Disposal point for every ward and department

 Each point show whether it is for risk waste or non-risk waste
 A plan for central storage of risk and non-risk waste
 Details of containers, trolleys, and numbers required and lost
 Time table for collection of waste
 An estimation of the number of staff required procedure of segregation ,storage and
handling of waste
 Training sources and programs
 Emergency procedures

Q: what are the methods of waste/refuse disposal?

Methods of waste/refuse disposal:

 Dumping
 Controlled tipping
 Incineration
 Compositing
 Manure pits
 Burial

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HEALTH INFORMATION AND MANAGEMENT SYSTEM

Q: what is health information and management system (HIMS).

Health information and management system (HIMS): a mechanism for collection, processing,
analysis, and transmission of information required for organizing and operating health services
and also for research and training .

Q: what are causes of failure of health information and management system (HIMS).

Causes of failure of health information and management system (HIMS).

 Lack of demographic data and statistics of Pakistan

 Lack of funding
 Inappropriate registration of disease
 No proper system for notification of disease
 Lack of proper record of disease
 Lack of technical facilities

Q: write criteria/requirements of health information and management system (HIMS).

Criteria/requirements of health information and management system (HIMS) are:

 The system should be population based

 The system should avoid unnecessary agglomeration of data
 The system should be problem oriented
 The system should employ functional and occupational terms e.g. episodes of illness,
treatment regimens, and laboratory tests.
 The system should express information briefly and imaginatively (e.g. tables ,charts,
percentages)
 The system should make provision for the feedback of data

Q: write components of health information system.

Components of health information system are:

 Demography and vital events

 Environmental health statistics

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 Health status :mortality ,morbidity, disability and quality of life

 Health resources ,facilities ,beds , men power
 Utilization and non-utilization of health services :attendance ,admission ,waiting lists
 Incidences of outcome of medical care
 Financial status (cost ,expenditure) related to particular objective

Q: write uses of health information.

Uses of health information:

 To measure health status of people and to quantify their health problems and health
care needs.
 For local, national and international comparison of health status for such comparison
the data needed to be subjected to rigorous standardization and quality control.
 For planning, administration and effective management of health services programs.
 For assessing whether health services are accomplishing their objectives in terms of
their effectiveness and efficiency.
 For assessing their attitude and degree of satisfaction of the beneficiaries with health
system.
 For research into particular problems of health and disease

Q: write sources of health information.

Sources of health information are:

 Census
 Registration of vital events
 Sample registration system
 Notification of disease
 Hospital record
 Disease register
 Record linkage
 Epidemiological surveillance
 Other health services
 Environmental health data
 Health man power status
 Population survey

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Q: define hypothesis and give its types.

Hypothesis: a supposition or proposed explanation made on basis of limited evidence as a

starting point for further investigation.

Types:

 simple hypothesis
 complex hypothesis
 null hypothesis
 alternative hypothesis
 empirical hypothesis
 logical hypothesis
 statistical hypothesis

Q: what are the criteria for research problem identification?

Criteria for research problem identification:

 is the problem interesting

 will the research contribute to the solution of socioeconomically important problems
 will the research generate new information
 is the research novel
 do I have the skills or knowledge necessary to conduct research or can I learn them with
in the time I have
 is the research feasible in terms of
 time required to finish the research
 expenses involved in conducting the research
 availability of materials for experimentation
 accessibility for materials for experimentation
 risk and hazard involving in conducting experiments
 is the research reproducible

The Millennium Development Goals (MDGs) were the eight international development goals
for the year 2015 that had been established following the Millennium Summit of the United
Nations in 2000, following the adoption of the United Nations Millennium Declaration. All 189
United Nations member states at that time, and at least 22 international organizations,
committed to help achieve the Millennium Development Goals by 2015.

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The Sustainable Development Goals (SDGs), officially known as transforming our world: the
2030 Agenda for Sustainable Development is a set of 17 "Global Goals" with 169 targets
between them. Spearheaded by the United Nations through a deliberative process involving its
193 Member States.

THE END

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