PSM: Important facts

Concepts to be remembered:

Social medicine: Study of man as a social being in his environment i.e effect of social
factors on health

State medicine: Provision of free medical services to the people at govt. expense

Socialized medicine: Provision of medical services & professional education by the

state as in state medicine, but the programmme is being regulated by a professional
body for good clinical practice.

Theory of contagion: Fracastorius

Tridosha theory of disease: Ayurveda
Germ theory of disease: Louis Pasteur
Spontaneous generation theory: Aristotle
Multifactorial disease causation: Pattenkofer
Father of Indian surgery: Sushruta
Father of surgery: Ambroise Pare
Father of Medicine: Hippocrates
Father of Public Health: Cholera
Father of Epidemiology: John snow

Concept of Disability:

Disease Impairment Disability Handicap

Impairment: Loss or abnormality of structure or function e.g loss of foot, defective vision
Disability: Inability to carry out a function considered normal for the age, sex, or level of
training e.g unable to walk
Handicap: The disadvantages in life experienced by the person as a result of his
disability or inability to fulfill the social roles e.g unemployed

Serial interval: time interval between the onset of primary & secondary case
Incubation period: time interval between the receipt of infection and appearance of first
signs & symptoms
Generation time: Receipt of infection & development of maximum infectivity
Communicable period: Till the time infection can be directly or indirectly transmitted to
the others

SOME IMPORTANT POINTS

 Epidemiology: Study of disease distribution & determinants

 Descriptive Epidemiology: Describes time, place & person distribution
 Analytical epidemiology: Helps prove a hypothesis or establish cause effect
relationship
 Case Control Study: Always retrospective (proceeds from effect to cause)
 Cohort Study: Cab be prospective, retrospective or mixed
 Nested Case Control Study: Prospective design
 Incidence can be calculated from: Any prospective or longitudinal study
 Prevalence can be calculated from: Cross Sectional study
 Best Study design: Randomized Controlled trial
 Best method to establish Causal Inference: Metanalysis
 Metanalysis is not a study design but only a method of analysis
 Randomization: Eliminates Selection Bias, may or may not make the group
comparable on baseline characteristics
INDICATORS OF HEALTH

Mortality indicators

 Crude Death rate: Number of deaths per 1000 mid year population per year in a
given geographical area. Not a perfect measure of health status, but a useful tool
for measuring overall improvement
 Expectation of Life: The average no. of years that will be lived by those born alive
into a population if the current age specific mortality persists. LE at birth is most
commonly used
 Infant mortality rate: One of the most universally accepted indicators of health
status not only for infants, but also of whole population & of socioeconomic
conditions under which they live. Sensitive indicator of availability, utilization &
effectiveness of health care particularly perinatal care
 Child mortality rate: no longer used now. Replaced by U5MR
 Under 5 proportionate mortality rate: along with IMR, one of the key indicators of
health status. UNICEF uses this indicator
 MMR
 Disease specific mortality
 Proportional mortality rate: indicates magnitude of preventable mortality

Morbidity Indicators

 Prevalence
The proportion of persons suffering from a specific disease out of the population
normally residing in that area, at a particular point in time, is called the prevalence. It
includes both the new cases as well as the old cases occurring in the area at the
point in time when the examination was undertaken. It should be seen that the
numerator is part of the denominator.
  Incidence
Incidence rate refers to the number of new cases occurring in a population over a
specified period of time. The numerator should be part of the denominator as in
prevalence rate but unlike as in prevalence rate only new cases are considered.
Incidence rate is generally depicted as per 1000 or 100,000.

Relationship between prevalence and incidence

Prevalence of a disease is the product of incidence and the duration of disease ( P= I

xD). Therefore, prevalence of a disease depends not only on the actual number of
people who develop a disease but also on the duration of a disease.

Prevalence is most appropriate in long-standing or chronic diseases as the window

period in which a diagnosis can be established is much higher and therefore, cases will
not be missed during a survey.

Incidence is most appropriate in disease of a short duration as such diseases may

occur more than once during a reference period and all the episodes may not be
captured if the prevalence of the disease were to be measured.

 Attendance rate at in & out patient departments

 Discharge rate, Readmission rate
 Duration of stay in the hospital

Disability indicators

 Sullivan’s index: Expectation of life free from disability, computed by subtracting from life
expectancy the probable duration of bed disability & inability to perform major activities
according to cross sectional data
  Disability adjusted life years: Measures the burden of disease in the population & years
lived with disability adjusted for the severity of the disability. One DALY is “one lost year
of healthy life”

Nutritional Status indicators

Weight, height, mid arm circumference, prevalence of low birth weight

Health care Delivery indicators

Doctor population ratio, doctor nurse ratio, population bed ratio, population per health /
subcentre, population per TBA

Socioeconomic status indicators

 Per capita GNP

 Per capita calorie availability
 Literacy rate
 Level of unemployment
 Dependency ratio
 Housing
 Family size

Analytical studies

Type Also known as Unit of study

Ecological studies Correlation studies Populations

 Cross –sectional Prevalence studies Individuals

Case control studies Case reference studies Individuals

Cohort studies Follow-up studies Individuals

Experimental studies (interventional studies)

Type Also known as Unit of study

Randomized Control Clinical trials Patients

trials

Field trials Community intervention Healthy people

studies

Community trials Communities

 Advantages of case control studies

o Relatively quick and easy to undertake.
o Relatively cheap to undertake.
o Only method useful in rare diseases.
o Not enmeshed in problems of follow-up as the data is collected at one
point in time.
o Can be used to study the effect of many exposure variables on a single
disease outcome.
 Drawbacks of case control studies
o Prone to selection and recall bias.
 o Can’t measure relative risk or provide incidence estimates Q. ( Only odd’s
ratio can be calculated from the type of study, which is a rough estimate
of relative risk. But when the disease in question is a rare one odd’s ratio
is almost equal to relative risk.)
o Sometimes the occurrence of the exposure in terms of time, i.e. whether it
occurred before the disease may be difficult to estimate.
o Can’t be used for rare exposures.
 Advantages of Cohort Study:
- Can calculate the incidence rate and hence relative risk can be
computed(AI’09)
- Temporality of association can be established
- Can be used to study multiple outcomes of one type of exposure
 Types of cohort studies
o Prospective
o Retrospective
o Mixed

Phases of Randomized Controlled Clinical Trials

1. Phase I: Drug toxicity trials - done on "Healthy Volunteers" for side effects, tolerable
dose of drug, drug availability and bio metabolism. Typically requires about 20-80
subjects or patients

2. Phase II: Initial clinical investigation for treatment effect - Done on patients + some
healthy volunteers. Primary aim is to ratify the phase I findings, and also determine the
dosage schedule and group of patients who are benefited by drug. Sample size 100 -
200.

3. Phase III: Full Scale evaluation of treatment - Comparing with standard regimens
and/or placebo synonymous with "Clinical Trials".

4. Phase IV: Post Marketing Surveillance - Done after 'Drug' launched for large scale
data on efficacy, safety, and long term side effects etc.

5. Phase V: Re-efficacy trials. This is seldom done. Usually high degree of adverse
effects from data in phase IV is the driving point for these.

Preference of Studies for establishing causation:

1. Metanalysis
2. RCT
3. Cohort study
4. Case control study
5. Cross sectional studies
6. Ecological studies

Best Study Design: RCT

Criteria for Causal Association

 Strength of association
 Temporality of association
 Biological gradient: dose and duration response relationship
 Consistency of association
 Specificity of association
 Biological plausibility
 Cessation Experiment
  Coherence
When most if not all of these criteria are met only then an association is said to be
causal

Important Points and Definitions to be mugged up:

1. Epidemic
 The occurrence of a disease clearly in excess of normal expectancy is
called an epidemic.
 In an area where a disease has not been seen for many years, even the
occurrence of a single case may be sufficient to call it an epidemic.
 To call a disease as an epidemic it must be more than 2SD of previous
year.

Types of Epidemic: -

a. Common Source Epidemic: -

1. Single exposure: -
Q
 All cases within one incubation period
 Epidemic curve rises and falls rapidly Q
 No secondary waves Q
 Clustering of cases within narrow interval of time eg. Bhopal Gas tragedy
2. Continuous or Multiple Exposure: - Exposure is multiple eg. CSW and Legionnaires
d/s in Philadelphia

b. Propagated Epidemic

 Results from person to person transmission eg. Polio epidemic

 Gradual rise and fall in epidemic curve over a period of time.
  Spread of d/s depends upon the herd immunity, opportunities for contact and
SAR
c. Slow (Modern) Epidemic: -

Secular trend

If the pattern or trend of disease frequency changes only over many years then it is
called a secular trend. A secular trend implies a consistent tendency to change in a
particular direction or a definite movement in one direction. Eg: Coronary heart disease,
lung cancer & diabetes which have shown a consistent upward trend in the developed
countries over the past 50 years.

Cyclic trend

If the occurrence of disease changes over a short duration of time like a year, it is called
a cyclic trend.

Some diseases change in frequency over seasons and such changes are referred to as
seasonal changes – Measles and chickenpox are examples of such diseases.

2. Endemic diseases

The constant, continuous or usual presence of a disease in a defined geographic area

or delimited territory is called an endemic disease.

Hyper endemic refers to a persistent intense transmission in an area while

Holoendemic means a disease staring early in life and affecting most of the

Population. An endemic disease may become an epidemic if the number of cases

usually seen suddenly increase in proportion. Malaria, tuberculosis, leprosy, filariasis,
etc.
Primary case

The first case of a disease which occurs in a community/area is called the primary case.
In disease like acute conjunctivitis a number of primary cases may occur almost at the
same point in time in such case the primary cases are referred to as “Co–primaries”

Index case

The first case, which comes to the attention of the health authorities in an area, is
referred to as the index case. Such a case may or may not be the primary case.

Secondary Attack Rate

The secondary attack rate refers to the number of cases occurring among contacts of a
primary case within the known incubation period of the disease. The denominator refers
to the number of susceptible contacts who are in close touch with the primary case.
However, if a person among the contacts has previously suffered from the specific
disease and developed immunity is not known, then all the contact should be
considered in the denominator.

SAR = No. of individuals developing disease within one incubation period X 100

Total no. of susceptibles in close contact

Herd immunity

The immune status of a group of people/community is called herd immunity as it is the

immune status of the ‘herd’ of people. For many communicable diseases,
An outbreak of disease is only possible if the level of immunity is sufficiently low and
there are a large number of susceptible in the population. In diseases like poliomyelitis,
diphtheria, measles etc., herd immunity plays an important role. However, in a disease
like tetanus or rabies where every individual is at risk unless specifically protected, herd
immunity plays no role.

CONCEPT OF PREVENTION
No risk factors

Primordial prevention(prevention OF EMERGENCE of risk

factors)

Appearance of risk factors

Pre pathogenesis phase of disease

Primary prevention – Health promotion & Specific protection

(Best method of prevention)

Appearance of disease

Secondary prevention – Early diagnosis & Disease treatment

Late pathogenesis phase

Tertiary prevention – Disability limitation & Rehabilitation

Disability and complications

BIOSTATS

Some Important Points

 Quantitative data: Continuous, interval & ratio variables are always quantitative
 Qualitative data: Discrete, nominal variables always qualitative
 Mean is the only measure of central tendency affected by extreme or outlying
values
 In right sided or positive skew: Mean > Median > Mode
 In left sided or negative skew: Mean < Median < Mode
 Standard error is inversely proportional to sample size
 Z score = X - 


 Correlation is relationship between variables

 Co-efficient of correlation is always between –1 and +1
 Type I error: also known as false positive error; rejecting a null hypothesis which
is true
 Type II error: also known as false negative error; accepting a null hypothesis
which is false
 P-value: probability of committing type I error
 Power: (1 – β error)
 Tests of significance:

Questions Concerning Nominal Ordinal Interval/Ratio

Differences in proportion X2 test - -

One or two means ‘t’ or ‘z’ test

 When n≤ 100: T
test

When n > 100: Z

test

More than two means ANOVA with F test

 Demography

Stage of Meaning E.g.

demographic
cycle
First High stationary High Birth rate (BR) & high Death -
stage rate (DR) which cancels each other
and population remains stationary.
Second Early expanding DR decreasing but BR high -
stage
Third Late expanding DR decreasing still further BR also E.g. India
stage starts declining.
Population continues to grow as
BR>DR.
Forth Low stationary Low BR & low DR. E.g. UK,
stage Population is stationary. Denmark,
Sweden,
Belgium.
Fifth Declining BR < DR . e. g. Germany,
stage Population is decreasing Hungary

The NPP was formulated by the GOI in the Year 2000 with three main objectives:

Immediate objective: to Adress the unmet needs for basic RCH services, supplies &
infrastructure

Midterm objective: to achieve the replacement level of TFR by the year 2010

Long term objective: to attain a stable population by the year 2045

The other national socio-demographic goals to be achieved by the year 2010 are as
follows:
- Adress the unmet needs for basic RCH services, supplies & infrastructure.
- Make school education upto the age of 14 free & compulsory and reduce
dropouts at primary & secondary school levels to below 20% for both boys & girls.
- Reduce IMR to < 30 / 1000 live births
- Reduce MMR to < 100/ 100000 live births
- Achieve universal immunization of children against all vaccine preventable
diseases.
- Promote delayed marriage for girls, not earlier than age 18 and preferably after
20 yrs of age.
- Achieve 80% institutional deliveries & 100% deliveries by trained persons.
- Achieve 100% registration of births , deaths, marriages & pregnancy.
- Achieve universal access to information / counseling, and services for fertility
regulation & contraception with a wide basket of choices.
- Contain the spread of AIDS, & promote greater integration between the
management of RTI & STI and the National AIDS Control Organization.
- Prevent & Control communicable diseases .
- Integrate Indian System of Medicine in the provision of RCH services & in
reaching out to the households.
- Promote vigourously the small family norm to achieve the replacement level of
TFR.
- Bring about convergence in implementation of related social sector programs so
that family welfare program becomes a people centred program.

Contraceptives

Contraceptive of choice for a newly married couple: OCP

Contraceptive of choice for a lactating woman: POP

Contraceptive of choice for a couple meeting occasionally: Condom

Emergency Contraceptive of choice : IUD

MC complication of IUD: Bleeding

MC complication of IUD resulting in discontinuation of IUD: Pain

Progesterone only pills are advocated usually in older women (age > 40 yrs), lactating
women in the first 6 months of lactation or even in young women with risk of neoplasia.
But these pills could not become very popular due to poor cycle control and risk of
pregnancy and definitely not a contraceptive of choice in newly married couple.

OCPs are by far the contraceptive of choice in a young newly married couple wherein
the wife does not suffer from any of the contraindications. The single most significant
benefit of the pill is its almost 100 % effectiveness in preventing pregnancy and thereby
removing the anxiety about the risk of unplanned pregnancy. Another advantage of
OCPs is that the contraceptive effect is fully reversible and nearly 98% of women
conceive within 3 months of discontinuation of these pills which is most desirable in
newly married couples. However, its use is still very limited in the developing countries.

Although barrier methods and to be more precise condoms are the most commonly
used method of contraception worldwide, its failure rate (ranging from 4 to 14 per HWY )
is very high if not used appropriately, which precludes its usefulness in a newly married
couple.

In 1985, the American college of Obstetricians & Gynaecologists stated that IUDs are
“not recommended for women who have not had children or who have multiple partners,
because of the risk of PID and possible infertility.”

Contraceptive efficacy is generally assessed by measuring the number of unplanned

pregnancies that occur during a specified period of exposure & the use of a
contraceptive method. Two methods are in common use – Pearl index & life table
analysis. Pearl index is defined as the number of failure per 100 women years of use.

Calendar method/ safe period/ rhythm method

 Calendar method/ safe period/ rhythm method is a miscellaneous method.

 First described by Ogino in 1930.
 It is based on fact that ovulation occurs from 12 to 16 days before the onset of
menstruation.
 The shortest cycle minus 18 days gives the first day of fertile period.
 The longest cycle minus 10 days gives the last day of the fertile period.

Total Fertility Rate (TFR)

Total fertility rate represents the average number of children a women would have if
she were to pass through her reproductive years bearing children at the same rates as
the women now in each age group give the approximate magnitude of “completed
family size”.

Current value for India: 2.3

Gross Reproduction rate = ½ X TFR

Crude Birth Rate = (TFR x 8) + 1

Net Reproduction Rate (NRR)

Net reproduction Rate (NRR) is defined as the number of daughters a newborn girl
will bear during her lifetime assuming fixed age-specific fertility and mortality rates.

Couple protection rate (CPR):

 It is an indicator of the prevalence of contraceptive practice in the community.
 It is defined as the percent of eligible couples effectively protected against childbirth
by one or the other approved methods family planning.
 Sterilization accounts for over 60% CPR.
 Net reproduction rate (NRR)=1 can be achieved only if the CPR exceeds 60%.
ENVIRONMENT

Some Important Points

 Water required for drinking purpose: 2LPCPD

 Bacteriological indicators of water quality: Coliforms, Fecal streptococci, Cl.

Perfringens

 E.coli & F. streptococci & Cl. Perfringens together denote recent fecal
contamination of water

 Cl.perfringens alone in the absence of E.coli & F.streptococci denote remote

fecal contamination of water

 Amount of residual chlorine in water is measured by: Chloroscope

 Presence of residual chlorine in water is demonstrated by: OT & OTA tests

 Most active form of chlorine: Hypochlorous acid

 Most common air pollutant: CO

 Indicators of air pollution: Smoke, SO2, NO2, SPM

 Most important indicator of air pollution: SO 2

 Level of sound tolerated by human ear: 85 dB

 Level of sound causing permanent hearing loss: 100 dB

 Level of sound causing rupture of ear drum: 160 dB

 Sewage: waste water from community containing solid & liquid excreta

 Sullage: waste water from community devoid of excreta

 Strength of sewage is measured in terms of : BOD, COD & Suspended solids

  BMW:

Insecticides

DDT is primarily a contact poison, acting on the nervous system of insects. It does not
cause immediate death but takes several hours to kill.

The residual action may last as long as 18 months depending upon the treated surface.
It has no repellant action.

Most space sprays contain pyrethrum & DDT or other synthetic insecticides which are
added for synergistic action.

Some imp facts about DDT: the technical DDT contains 70-80% of para-para isomer
which is the most active fraction of DDT. As a residual spray, DDT is applied in the
dosage of 100-200 mg per square foot area. As a dust, it is used in 5-10% strength for
the control of lice, fleas, ticks & bugs. In the recent years DDT has been incriminated as
an environmental pollutant because of its persistence in the living organisms & plants &
hence many countries have banned its use.

But the benefits of its application in health programs far outweighs its hazards & hence
WHO does not prohibits its use.

• Pyrethrum is extracted from the flowers of Chrysanthemum cinerariifolium. It is an

excellent space spray.

Paris Green is a stomach poison. Till the introduction of DDT, Paris green was widely
used in the control of Anopheline Larvae,

Malathion is used in the doses of 100-200 mg square foot for, every three months. It
has least toxicity of all organophosphorus compounds.

Anti – larval measures are broadly grouped into:

1) Larvicides:
a) Chemicals – larvicidal oils, paris green, temephos Q

b) Biolarvicides – fishes like gambusia, lebister etc Q

Q
2)Source reduction: drainage or filling, deepening or flushing, management of water
level, changing the salt content of water & intermittent irrigation

3) Integrated control: bioenvironmental as well as personal protective measures.

DDT is not used as a larvicide. It is an anti-adult measure of vector control.

Some very important facts about climate change:

‘Climate change’ is generally used when referring to changes in our climate.

The energy from the sun warms land, water and air. In turn the warmed up land, water
and air give off heat, which rises up towards the sky. Gases such as water vapor
present in earth’s atmosphere capture some of that heat and prevent it from escaping
into space. This heat trap keeps the earth warm and make our planet a habitable world.

This process is known as greenhouse effect. It is a natural phenomenon. However,

adding more greenhouse gases increases the warming effect to the point that it is no
longer beneficial but has negative consequences for life on earth. For over 10,000 years
the earth has had relatively stable temperatures. But for the past 150 years our planet
has been warming up fast.

This phenomenon is called global warming. This change is result of human activities.

MAIN GREENHOUSE GASES:

  Water vapor: one of the most abundant gases in atmosphere and builds up with
evaporation from water bodies on earth.

 Carbon dioxide: produced by combustion of fossil fuels and from forest fires is
the next most important gas responsible for global warming. (option A )

 Methane: released from animal husbandry, irrigated agriculture and oil extraction.

 Nitrous oxide: by-product of burning fossil fuels and also released when
ploughing farm soils
 Ozone: main element of protective layer in upper atmosphere, which
shields earth from the sun’s harmful UV radiation.(option B) Ozone is both
natural and man made gas. Produced in excess as a result of smog and severe
air pollution, becomes harmful to health.

 Chlorofluorocarbons: used for refrigerators, air conditioners, aerosol

sprays etc. they cause depletion of ozone layer. (Option c)

Global atmospheric concentrations of carbon dioxide, methane and nitrous oxide have
increased markedly as a result of human activities since 1750.

 Average global temperature is expected to rise by 0.2 degree Celsius per

decade over the next 100 years.
A warmer atmosphere also disrupts wind and rain patterns leading to excessive floods
and/or prolonged droughts. When sea level rises, it may be due to thermal expansion,
from melting of glaciers or due to changes in salinity
 Kyoto Protocol lays down the norms for cutting down the CO2 emmision. In fact it lays
down separate norms for the developed and the developing countries in tune of
emission cuts ranging up to 5%.

Montreal protocol was also laid down with regard to global warming but in contrast to Kyoto protocol it
talks about the harmful effects of the depleting ozone layer rather than about emission cuts.

Sources of indoor air pollutants

Pollutant Sources

Respirable particles Tobacco smoke; Stove; Aerosol sprays

Carbon Monoxide Combustion equipment, Stove, Gas heaters

Nitrogen dioxide Gas cookers, cigarettes

Sulphur dioxide Coal combustion

Carbon dioxide Combustion, respiration

Formaldehyde Particle board, carpet adhesives, insulation

Other organic vapours Solvents, adhesives, resin products, aerosol sprays

(benzene, toluene)
Electric arcing, UV light sources
Ozone
Building material
Radon and "daughters"
Insulation, fireproofing
Asbestos
Appliances
Mineral fibres

Chlorination
  The disinfecting action of chlorine is mainly due to the hypochlorous acid, and to
a small extent due to the hypochlorite ions.
 The hypochlorous acid is the most effective form of chlorine for water
disinfection. It is more effective (70-80 times) than the hypochlorite ion.
 Chlorine acts best as a disinfectant when the pH of water is around 7 because of
the predominance of hypochlorous acid.
 When the pH value exceeds 8.5 it is unreliable as a disinfectant because about
90 per cent of the hypochlorous acid gets ionized to hypochlorite ions. It is
fortunate that most waters have a pH value between 6-7.5.

 To kill bacteria and viruses, a minimum residual free chlorine concentration of

0.5mg/lit. for a contact period of at least one hour is essential.

 Viruses like Hepatitis & polio, Bacterial spores protozoal cysts and helminthic ova
are resistant to chlorination (except at high doses of chlorine).

Water – related disease can be classified into 4 major categories, as follows:

1: Water-borne Infections spread through contaminate drinking water eg.

disease Cholera, Typhoid etc.

2. Water-washed Diseases due to the lack of proper sanitation and hygiene eg:
diseases: scabies, worm infestation

3: Water-based Infections transmitted through an aquatic invertebrate

diseases: organism eg. Schistosomiasis, guinea worm, paragonimiasis,
clonorchiasis etc.
 4. Water – related Diseases transmitted by insects that depend on water for their
vector borne propagation e.g malaria, filaria etc.
disease

The maximum recommended concentration of nitrates in drinking water is below 50

mg/lit.

Constituents Recommended maximum concentration in drinks water

(mg/lit)

Lead 0.01

Nitrate 50

Nitrite 3

Manganese 0.5

Fluoride 1.5

Hardness 300

Biological water quality standards set out by WHO

A. The WHO has set out the following criteria for water quality:

 No sample should have E. coli in 100 ml.

 No sample should have more than 3 coliforms per 100 ml.
 Not more than 5% samples throughout the year should have coliforms in 100 ml.
 No two consecutive samples should have coliform organisms in 100 ml.

Chemical water quality standards

A. The WHO has set out three chemical quality standards:

a. Toxic substances – The upper permissible levels of lead, selenium, arsenic, cyanide, cadmium, and
mercury are 0.01, 0.01, 0.01, 0.07, 0.003, and 0.006 mg / litre in domestic drinking water

b. Substances that may affect health

 Fluorine should be present in a concentration of 0.5 – 0.8 mg/l

  Nitrates should not exceed 45 mg/l
 Polynuclear aromatic hydrocarbons should not exceed 0.2 micrograms per litre
c. Substances that may affect water acceptability

 Upper permissible limits have been set out for a number of substances like iron, calcium,
chloride, sulphate, etc.
 Total hardness should not exceed 2 meq/ liter
 Turbidity <5 nephelometric turbidity units
 Chloride: 200mg / L
 Ammonia: Indicator of bacterial , sewage pollution, compromises the disinfection ability
by forming nitrites, also causes failure of Mn ion removal from filtration system
 pH: Acidic water <7 pH causes elevated Pb levels & >8 causes chlorination to be
ineffective
 hydrogen sulphide : prominent in ground water
 Iron: Ferric ion causes objectionable reddish brown colour
 Manganese: stains sanitary wares; forms coating on pipes
 Radiological aspects:
o Somatic effects (carcinogenesis): probability of effect rather than severity is a
function of dose without a threshold – Stochastic effect
o For other effect the severity varies with the dose, a threshold may exist – Non
stochastic effect

Purification of water
• Purification of water on a large scale: method of t/t depends upon the nature of raw water &
desired standards of water quality. Components:
• Storage
• Filtration removes 98-99% of bacteria.
• Disinfection
Storage: water is impounded in natural or artificial reservoirs.

This natural purification offers many advantages viz:

Physical: About 90% of suspended impurities settle down in 24 hrs by gravity. Water becomes clearer &
allows better penetration of light & reduces the work of filters.

Chemical: Aerobic bacteria oxidize the organic matter with the aid of dissolved oxygen which reduces
free ammonia & raises the nitrate level.

Biological: tremendous drop occurs in bacterial count ( >90% in first 5-7 days for river water). Optimum
recommended period for storage of river water is 10-14 days. Longer period of storage results in growth
of algae imparting bad colour & taste to water.
 Filtration

Slow sand filter / Biological filter

• Slow Sand or Biological filters: Elements:

• Supernatant raw water
• Bed of graded sand
• Under drainage system
• System of filter control valves

 Vital layer: surface of sand is covered with slimy growth known as Schmutzdecke/ vital/ zoogleal
or biological layer.
 Formation of vital layer is known as ripening of filter.
 Filtration rate lies between 0.1- 0.4 m3 /hour/ per square meter
 Removes organic matter, holds back bacteria & oxidizes ammoniacal nitrogen in to nitrate.

 Pre treatment by plain sedimentation

 Water head of 1.0 – 1.5 meters depth
 Sand bed (1.25 meters thick) composed of sand particles of 0.15 – 0.35 mm in diameter
supported on a layer of fine and coarse gravel
 Drainage system for the filtered water
 Filter control valves in the outflow pipe which helps to regulate the outflow of water.
 Removes 99.99% of bacteria
 Occupies a larger space
Advantages: simple to construct & operate, cheap to construct

Physical, chemical & bacteriological quality of water is very high

Rapid sand filter / Mechanical filter

Water+ alummixing chamberflocculation chambersedimentation tankfilterchlorine

addedclear water storageconsumption.
Rate of filtration is 5-15 m3 / m2/ hour

Effective size of sand particle is 0.4-0.7mm

 Back washing: cleaning of filter.

 Treatment by chemical coagulation & sedimentation

 Before the water comes to the filter it is subjected to a process of coagulation with alum.
 The filter bed is essentially similar to slow sand filter with two differences:
o The sand is coarser
o The biological membrane in slow filter is replaced by a layer of alum floc
 The rate of filtration in a rapid filter is 4000- 7500 liters per square meter as against 100 – 400
liters in a slow sand filter .
 Removes 98-99% bacteria
 Occupies very little space
Advantages: can deal with raw water directly, filter beds occupy less space, filtration is rapid, washing of filters is easy,
more flexibility in operation

Disinfection

Chlorination

 Chlorine kills pathogenic bacteria but has no effect on certain spores, protozoal cyst, helminthic
ova and virus (polio & viral hepatitis)
 Oxidises iron, manganese and hydrogen sulphide.
 Destroys odour and taste producing constituents
 Control algae & slime organism and aid coagulation.
 Action of chlorine is due to hypochlorous acid. And acts best at pH 7.

 Action: H2O + Cl2  HCl + HOCl  Disinfectant activity

HOCl  [H]+ + [OCI]-

Principles of chlorination

 Water should be clear as turbidity impedes effective chlorination.

 Chlorine demand of water:
Amount of chlorine added- residual chlorine (after contact period of 60 minutes) Q

 Break point chlorination point at which chlorine demand of the water is met and if further
chlorine is added free chlorine appears in water.
  Minimum recommended concentration of free chlorine is 0.5mg/L
 Chlorine dose= chlorine demand of water+ free residual chlorine.

Method of chlorination
1) Chlorine gas
2) Chloramines (loose compound of chlorine & ammonia)
3) Perchloron: HTH (high test hypochlorite); 60-70% of available chlorine.
4) Super-chlorination
 Followed by de-chlorination.
 Addition of large amount of chlorine to water followed by removal of excess amount of
chlorine.
 Suitable for heavily polluted water whose quality fluctuates.
5) Ozonation & Ultraviolet irradiation: no residual effect.

Orthotolidine test: estimates free and combined chlorine together

Orthotolidine- Arsenite test: estimates free and combined chlorine separately.

OT Test: orthotolidine test allows both free & combined chlorine in water to be determined with speed
& accuracy; reagent consist of analytical grade o-tolidine dissolved in 10% solu of HCL which reacts
immediately (10sec) with free chlorine producing yellow colour depending on the level of free chlorine
but reacts slowly with combined chlorine(15-20min)

Orthotolidine Arsenite Test: determines levels of free & combine chlorine separately & errors due to
presence of Fe, Mn & nitrites which produce yellow colour with OT are also overcome.

Household purification of water

1) Boiling: roll boiling for 5-10 minutes.
2) Bleaching powder: 33% of available chlorine.
Stabilized bleach: bleaching powder+ excess lime

3) Chlorine solution: 4 kg bleaching powder+ 20 litres water5% chlorine solution.

4) Chlorine tablets: 0.5 g for 20 litres of water.
5) Filtration: Chamberland filter, Berkfeld filter & Katadyn filter.
6) Disinfection of wells: double pot method.
Double pot method – to ensure constant dosage of chlorine to well water in emergency situations; can
be left for 2-3wks containing 4500L of water with daily draw of 360 – 450L
 Bacteriological indicators for water quality
1) Coliform organism: faecal group; E coli & non-faecal group; Klebsiella aerogens.
2) Faecal streptococci: resistant to drying.
3) Cl. perfringens: remote faecal contamination. (AI’09)

Increase in nitrate level due to farming practices.

Comparison of rapid and slow sand filters

Rapid sand filter Slow sand filter

1. Space: Occupies very little space Occupies large area

2. Rate of Filtration: 200 m.g.a.d 2-3 m.g.a.d

3. Effective size of sand: 0.4-0.7mm 0.2-0.3 mm

4. Preliminary treatment: Chemical coagulation & Plain sedimentation

sedimentation
5. Washing: By scraping sand bed
By back-washing
6. Operation:

99.9-99.99 per cent

98-99 per cent
7. Removal of bacteria:

A “problem village” has been defined as one where no source of safe water is
available within a distance of 1.6 km ,
or where water is available at depth of more than 15 meters ,
or water source has excess salinity, iron, fluorides and other toxic elements
or where water is exposed to the risk of cholera.

PRESUMPTIVE COLIFORM TEST

The test is done to assess whether the water has been contaminated or not. Presence
of coliform organisms (E coli) suggests a fecal contamination of the water.

Multiple tube method: 100 ml of water is taken and different quantities of this
water are inoculated in tubes of MacConkey’s Lactose Bile Broth (0.1, 1.0, 10, 50 ml)
and incubated for 48 hrs. From the number of tubes showing presence of acid and gas
an estimate of most probable number of coliforms in 100 ml is obtained. This is done by
consulting the Macardy’s chart.

Confirmatory test: to confirm the presence of coliform organisms (only done for
chlorinated water) the tubes positive in the earlier test are subculture in 2 tubes each of
brilliant green bile broth; one of which is incubated at 37 degrees and the other at 44
degree Celsius. E coli is the only organism that can produce gas from lactose at 44 deg
C.

E.coli can be tested by indole test and is the only organism producing gas from lactose
at 44 degree C.

HARDNESS OF WATER

 Bicarbonates of Ca & Mg: Temporary hardness

 Sulphates of Ca & Mg: Permanent hardness
 Fe, Mn, Al can all cause hardness

Classification

Soft water - <1meq / L (<50 mg / L)

Moderately hard water – 1-3 meq / L (50 - 150mg / L)

Hard water – 3-6 meq / L (150 - 300 mg / L)

Very Hard water - >6 meq / L (>300 mg / L)

Methods used for removing hardness of water are:

Temporary hardness
 a) Boiling
b) Addition of lime
c) Addition of NaHCO3
d) Permutit process

Permanent hardness
a) Addition of Na2CO3
b) Base exchange process
Light

Good lighting is essential for effective vision

• Essential factors:
– Sufficiency: 15 -20 foot candles is accepted as a basic min for satisfactory vision
– Distribution: uniform having same intensity over whole field of work
– Absence of glare: glare is excessive contrast
– Absence of sharp shadows
– Steadiness
– Colour of light
– Surroundings: ceilings & roofs should have a reflection factor of 80%, walls 50-60%,
furniture 30-40%, floor not >15 – 20 %.

 Basic minimum for satisfactory vision: 15-20 foot candles.

 DF (day light factor): instantaneous illumination indoors X 100
Simultaneous illumination outdoors

Measured by modified photo electric meter – Daylight factor meter

Biologic effects of light: degradation of bilirubin, rhythms of body temp, phy activity, stimulation of
melanin synthesis, activation of precursors of vit D, adrenocortical secretion & food consumption

 Recommended illumination
Visual task Illumination (lux)

Casual reading 100

General office work 400

Fine assembly 900

Very severe task 1300-2000

Watch making 2000-3000

NOISE

• Def: Unwanted sound, Wrong sound in wrong place at the wrong time
• Sources
• Properties:
– Loudness: intensity depends upon the amplitude of vibrations which initiated the noise; a daily exposure
of 85 dB is the limit people can tolerate without damage to hearing; measured by Sound level meter

– Frequency: denoted as Hertz or Hz; human ear can hear frequencies b/w 20 – 20000 Hz; measured by
Octave band frequency analyzer

– Audiometer is used to measure the hearing ability. Zero line at the top in the audiogram represents
normal hearing; noise induced hearing loss shows a characteristic dip in the curve at the 4000 Hz
frequency
Acceptable levels

a) Educational Class room ; 30-40 db

b) Library – 35-45 db
c) Office – 35-45
d) Conference-40-45
e) Industrial workshop-40-60
f) Hospital-20-35
Remember

Upper limit of tolerance of noise is less than 90 decibels

At 160 db there is rupture of tympanic membrane

Repeated exposure of 100 db there is permanent damage to the hearing ability.

 Recommended maximum is 85 dB

Strength of sewage is expressed in terms of

1) Bio-Chemical Oxygen demand (BOD): amount of oxygen absorbed by a sample of

sewage during a specified period (5 days) at 20 degree C for aerobic destruction or
use of organic matter by living organism.
 2) Chemical Oxygen Demand (COD): measures the oxygen equivalent of that portion of
the organic matter in a sample which is susceptible to oxidation by a strong chemical
oxidizer
3) Suspended solids

Sludge: organic matter, which settles down.

Medical Entomology
Arthropod-borne disease Q

S.N Arthropod Diseases transmitted

1 Mosquito

 Anopheles Malaria, filaria.

 Culex
Bancroftian filariasis, Japanese encephalitis, West Nile fever, viral
arthritis
 Aedes
Yellow fever, dengue, dengue haemorrhagic fever, Chikungunia fever,
Chikungunia haemorrhagic fever, Rift valley fever, filaria
 Mansonoides
Malayan filariasis, Chikungunia fever

2 Housefly Typhoid & paratyphoid fever, diarrhoea, dysentery, cholera, gastro-

enteritis, amoebiasis, helminthic infestation, poliomyelitis,
conjunctivitis, trachoma, anthrax, yaws etc.

3 Sand fly Kala-azar, oriental sore, sand fly fever and oraya fever

4 Tsetse fly Sleeping sickness

5 Louse Epidemic typhus, relapsing fever, trench fever & pediculosis

6 Rat flea Bubonic plague, endemic typhus, chiggerosis, Hymenolepis diminuta

7 Black fly Onchocerciasis

8 Reduviid bug Chagas disease

9 Hard tick Tick typhus, viral encephalitis, viral fever, viral hemorrhagic fever e.g.
Kyasanur forest disease, tularemia, tick paralysis, human Babesiosis.

10 Soft tick Q fever, relapsing fever

11 Trombucid mite Scrub typhus, rickettsial pox

12 Cyclops Guinea worm diseases, fish tape worm

Extrinsic Incubation period: time for development of disease agent in arthropod host.

Transmission of arthropod borne disease

Direct contact Directly transferred Pediculosis, scabies

Mechanical Diarrhoea, dysentery, typhoid, food poisoning &

trachoma

Biological

Propagative Disease agent only multiplies Plague bacilli in rat flea Q

Cyclo- Cyclic change and Malaria parasite in anopheles mosquito

propagative multiplication

Cyclo- Only cyclic change Filarial parasite in culex mosquito, guinea worm
developmental embryo in Cyclops.

Insecticides classification

Contact Natural Pyrethrum, rotenone, mineral oil

poison
Synthetic

1.organo- DDT, BHC, Methoxychlor, lindane, chlordane, aldrin, dieldrin

chlorine

2. Organo- Chlorothion, diazinon, dioxathion, malathion, fenthion, methyl parathion,

phosphorus parathion, abate, dichlorvos, trichlorfon, chlorpyrifos, fenitrothion

3. Carbamates Carbaryl, dimetilan, propoxur

Stomach poison Paris green, sodium fluoride

Fumigants Hydrogen cyanide, methyl bromide

Mosquito control

Anti-larval: mineral oil, Paris green, fenthion, chlorpyrifos and abate. (AIIMS Nov’08)

Biological control: Gambusia affinis, Lebistes reticulates.

Anti-adult:

Residual spray: DDT (AIIMS Nov’08)

Space spray: pyrethrum

ULV (ultra low volume) space spray: Malathion & fenitrothion.

Toxicant DDT Lindane Malathion OMS-33

Average duration of 6-12 3 3 3

effectiveness (months)

Mosquito net: size should not exceed 0.0475 inch.

Rodenticide: barium carbonate, zinc phosphide,

 Multi-dose poison: warfarin, diphacinone, coumafuryl, pindone.

 Fumigation: calcium cyanide, calcium disulphide, methyl bromide, sulphur dioxide.

NUTRITION

Some Important Points

 RDA: Mean of minimum requirement + 2SD

 Richest source of Vit A & D: Halibut liver oil

 Richest source of saturated fatty acids: Coconut oil

 Richest source of PUFA & Linoleic acid: Safflower oil

 Richest source of MUFA: Groundnut oil

  Richest source of alpha Linolenic acid: Flaxseed oil > Soyabean oil

 Maximum output of breast milk: 5 – 6 months of lactation

 Breast milk has highest amount of lactose, Vit C, Fe, Copper, Cobalt & selenium
as compared to other types of milk

 Breast milk has lowest amount of Fat, Protein, sodium & calcium as compared to
other types of milk

 Exclusive breast feeding recommended for first 6 months of life

 Test not applied on Pasteurized milk: Methylene Blue reduction test

 Main type of protein present in breast milk: Whey protein or lactalbumin

 Not a marker of Vit A deficiency: Conjunctival Xerosis

 Prevalence criteria for determining xerophthalmia problem (WHO):

Prevalence in
population at
risk
Night-blindness More than 1 %

Bitot's spots More than 0.5%

Cornealxerosis/corneal
More than 0.01 %
ulceration/keratomalacia

Corneal ulcer More than 0.05%

Serum retinol (less than

More than 5%
10 mcg/dL)

Cereal proteins are poor in nutritive quality, being deficient in the essential amino acid,
lysine and threonine. Pulse proteins are poor in methionine and to a lesser extent in
cysteine. On the other hand they are rich in lysine. If cereals are eaten with pulses,
cereals and pulse proteins complement each other and provide a more balanced and
complete protein intake.

• The proteins of maize are deficient in tryptophan and tysine; while some strains
contain an excess of leucine. Excess of leucine or deficiency of tryptophan causes
decreased synthesis of niacin in the body. This explains the pellagragenic action of
maize.

Egg protein is best among food proteins because of their high biological value and
digestibility coefficient. They are used in nutrition studies as a 'reference protein'. It
contains all essential amino acids and its NPU is highest

• Dose of iron and folic acid to be given to a pregnant mother under RCH programme is
100mg 0f elemental Fe and 500 µg of Folic acid daily for 100 days.

Children up to 12 yrs of age get one – fifth of the adult dose

Food toxicants
Name of the Derived From Grains infested Disease
toxicant

Aflatoxin Aspergillus flavus Groundnut, maize, Human liver

parboiled rice, cirrhosis
Aspergillus
sorghum, wheat,
parasiticus (Attempts are made
rice, cotton seeds
to relate)
(Storage fungus) and tapioca

Ergot Claviceps fusiformis Bajra, rye, sorghum Ergotism

and wheat
(Field fungus)

Sanguinarine Argemone mexican Mustard oil Epidemic dropsy

Pyrolizidine Crotolari / Endemic ascites

Jhunjhunia seed
Recommended energy requirement:-revised guidelines for the indian population

Adult male:- ref. Body wt: 60 kg

For light work : 2320 k cal
Moderate work: 2730 k cal
Heavy work : 3490 k cal

Adult female:- ref. Body wt: 55 kg

For light work : 1900 k cal

Moderate work: 2230 k cal
Heavy work : 2850 k cal

Extra energy :-
Pregnancy : 2nd & 3rd trimester + 350 k cal
Lactation : first 6 months + 600 k cal
Lactation : 6-12 months +520 k cal

C. Proteins: (Park, 23rd edition, page 634-635)

1. Important Points
a. constitute 20 % of body wt
b. 9 Essential amino acids (EAA): Methionine, Threonine, Tryptophan, Valine, (Mnemonic = TTPM VILL)
Isoleucine, Leucine, Phenylalanine, histidine and Lysine.
c. Foods containing all EAA: Milk, meat, egg, cheese, fish and fowl.
d. Reference Protein: Egg
e. Main source of proteins in Indian diet: Cereals and pulses.
f. Limiting amino acid in cereals: lysine and Threonine & pulses : Methionine
i. Protein efficiency ratio :- Is the weight gain per unit volume of protein consumed.
ii. Biological value of proetins:- the % of N2 absorbed in the body from proteins consumed
iii. Digestible coefficient of proetins :- is the % of N2 retained out of N2 absorbed from the diet.
iv. Best method to compare the protein quality is by Biological value.
 v. In calculating the protein quality, 1 gm of protein is assumed to be equivalent to 6.25 gms of
Nitrogen.
vi. Net protein utilization (NPU):
NPU = Biological value X Digestibility co-efficient (AIIMS Nov’08)
100

NPU= Nitrogen retained by body x 100

Nitrogen intake
Proportion of ingested protein that is retained in the body under specific conditions for the
maintenance and growth of tissue.
NPU for egg: 96 and NPU for pulses: 65
More complete expression of protein quality than amino acid score.
NPU for Indian diet varies b/w 50-80.

g. Amino Acid Score:

measure of concentration of amino acid in test protein.
= No. of mg of one Amino acid per gm of protein x 100
No. of mg of the same amino acid per gram of egg protein
i. Amino acid score for starch: 50-60 and for animal foods: 70-80.

h. Assessment of protein quantity by Protein Energy Ratio:

Protein Energy Ratio/ percentage= Energy from protein X 100
Total energy in diet
What % of energy value is supplied by protein content

i. Assessment of Protein Nutrition status

i. Serum albumin concentration > 3.5 g/dl (normal)

1.5 g/dl –mild malnutrition
< 3 g/dl- severe malnutrition
i. Mid-arm circumference
ii. Creatinine Height Index
iii. Total Body Nitrogen

j. Protein requirement
Group PROTEIN Required Group PROTEIN Requirement
(GMS/KG) (GMS/Kg)
Infants Adolescent
0-3 Months 2.30 10-12 1.83
3-6 `` 1.80 13-15 1.56
6-9 `` 1.65 16-18 1.35
9-12 `` 1.50
children
1-3 years 1.24
4-6 1.10
6-9 0.90

2. Protein energy malnutrition (PEM)

 a. Incidence in preschool children is around 1-2%. Affects weaklings and children in the first year of life.
b. Gomez classification: It compares the weight of a child with a normal child of the same age. The ‘normal’
reference child is in the 50th percentile of Boston standards. It is as follows:
i. 90 – 110% of normal: normal nutritional status
ii. 75 – 89% of normal: 1st degree, mild malnutrition
iii. 60 – 74% of normal: 2nd degree, moderate malnutrition
iv. Under 60% of normal: 3rd degree, severe malnutrition

c. Mclaren’s classification: it uses height as the measuring criteria

i. 93% height for expected age – Normal
ii. 80 – 93% height for expected age – Short
iii. < 80% height for expected age – Dwarf

d. Water low’s classification: it combines height for age (H/A) and weight for height (W/H)
i. H/A (Stunting) W/H (Wasting)
ii. Normal >=95% Normal >90%
iii. Mild – 87.5 – 95% Mild – 80 – 90%
iv. Moderate – 80 – 87.5% Moderate – 70 – 80%
v. Severe - <80% Severe - <70%

W/H > Mean-2SD < Mean-2SD

H/A
> Mean-2SD Normal Wasted
<Mean-2SD Stunted Wasted & stunted

e. Childhood Nutritional Indicators

i. Stunting (Height for age): 2SD below the mean of the population are considered stunted. Indicates
chronic malnutrition; also known as indicator of duration of malnutrition.
ii. Wasting (weight for height): 2SD below the mean of the reference population are considered wasted;
indicates acute or recent malnutrition; also known as indicator of severity of malnutrition
iii. Underweight: indicates both acute and chronic malnutrition
iv. NFHS III: children <3 yrs: Stunted: 44.9%; Wasted: 22.9%; Underweight: 40.4%
v. Common to both acute & chronic malnutrition is Weight for age

f. Rapid Assessment of Malnutrition

i. Bangle test: 4cm diameter
ii. Quac stick: Measures malnutrition by comparing MAC with height
iii. Shakir’s tape: useful field instrument for 1-5 yrs ( MAC remains practically unchanged during this
period
iv. Drop in height for age: shortness/ stunting  chronic malnutrition.
v. Low weight for normal height rapid weight loss  wasting  acute malnutrition.

3. PEM Clinical Features:- (Park, 23rd edition, page 639)

Features Marasmus Kwashiorkor
Clinical (Always present)
Muscle wasting Obvious Sometimes hidden by fat & oedma
Oedma None Present mainly in lower limb, face
Mental changes Quite & apathetic Irritable , moaning, apathetic
Fat wasting Severe loss of sub Fat often retained but not firm
cutaneous fat
Weight for height Very Low ↓↓ Low but masked by oedma ↓
Clinical (Sometimes present)
Hair changes Seldom Sparse, silky, pluckable
Appetite Good Poor
Diarrohea Often Often
Liver enlargement Not present Present
Skin changes None Diffuse pigmented skin
Plasma / Amino acid ratio Normal Elevated

D. Mid arm circumference

1. Can’t be used before the age of 1 year.
2. Between 1-5 years it hardly varies.
3. 13.5 cm or more: normal, 12.5-13.5 cm indicates mild- moderate malnutrition and below 12.5 cm, severe
malnutrition.
4. Shakir’s TAPE is used to measure mid-aim circumference. Q

E. Fats

1. Fatty acids
a. Saturated: Lauric, Palmitic and Stearic acid (LPS)
b. Unsaturated: MUFA (monounsaturated fatty acid) e.g. Oleic acid.
i. PUFA (polyunsaturated fatty acid) e.g. Linolenic acid and α-linolenic acid
ii. PUFA are found in vegetable oil.
c. Coconut and palm oil : high Percentage of saturated FA
d. Fish oil (animal oil) : PUFA and MUFA.
e. Invisible fat: Rice : 3%, wheat: 3%, jowar 4% and bajara 6.5%.
f. Ideal fat: ratio of PUFA/saturated FA=0.8-1.0
Linoleic/ α-linolenic(n-6/n3)=5-10 in total diet.
g. Cereal based diet: to ensure balance of FA→ ↑ intake α-linolenic acid and ↓ Linoleic acid. (↑W3, ↓ W6)

Fats Saturated FA MUFA PUFA

Coconut oil 92 6 2
Palm oil 46 44 10
Ground nut oil 19 50 31
Safflower oil 10 15 75
Sunflower oil 8 27 65
Com oil 8 27 65
Soya bean oil 14 24 62
Butter 60 37 3
Margarine 25 25 50

2. Hydrogenation:
a. Unsaturated fatty acid→ saturated FA and EFA content is reduced
b. Liquid oil→ semi-solid or solid fat .
c. Vanaspati ghee lacks in fat soluble vitamins.
d. It is fortified with 2500 IU of Vit a and 175 IU of Vit D per 100 gm.
 3. Trans Fatty Acids:
a. Geometric isomers of cis- unsaturated fatty acids.
b. Partial hydrogenation : increases shelf life of PUFAs
i. Creates trans-FA
ii. Removes critical double bond in EFA
c. Trans FAs→ plasma lipid profile more atherogenic than saturated FA
d. ↓ HDL cholesterol and doesn’t elevate LDL cholesterol.
e. Years are needed to flush them from body.
4. Refined oil:
a. Treatment with alkali to remove free FA and rancid material.
b. No change in the content of unsaturated FA
c. It improves quality and taste and increases cost.

5. Choice of cooking oil

a. A variety of cooking oils are to be chosen instead of one.
b. Mixture of two or more oils with different composition: equal mixture of PUFA rich sunflower oil,
Safflower oil or corn oil with MUFA rich groundnut oil, supplemented with occasional use of mustard oil for
adequate intake of omega 3 PUFA.
c. Rice bran oil with sunflower oil, canola oil and sesame oil.
d. Mustard oil contains erucic acid which is detrimental to health.

Extra Edge: Foods rich in α- linolenic acid(n3): wheat, bajara, black gram, lobia, rajmah, soyabean, green leafy
Vegetables, fenugreek and mustard seeds and fish .

F. Carbohydrate

1. Three main sources:

a. starch,
b. sugars
c. cellulose.

2. Carbohydrate reserve (glycogen) of human adult is 500 g.

3. Dietary Fibre
a. Non-starch polysaccharide: cellulose and non-cellulose
b. Two types: Insoluble fibres ; cellulose, hemi-cellulose and lignin
Soluble fibres: pectins, gums and mucilages.
c. Resistant to digestion
d. Absorbs water and increases the stool bulk.
e. Intestinal bacteria cause emulsification of fibres, softens the stool and make the passage easy.
f. Reduces intestinal transit time of food and reduces chances of putrefaction and formation of gases and
toxic substances.
g. Reduces incidence of cancer stomach, colon and CHD.
h. Binds to bile salts, reduces their re-absorption and reduces cholesterol level.
i. Gums and pectins reduce post prandial glucose levels.
j. Fenugreek seeds contain 40% gum and thus effective in reducing blood glucose and cholesterol
k. Fibres have no metabolic effect
l. They decrease absorption of vitamins and minerals like iron and zinc.
m. Recommended daily intake 40 gm.
 n. Indian diet: 50-100 gm / day.
4. Types
a. High fibres (>10 g/100gm); wheat, maize, jowar, bajra, ragi, pulses and fenugreek
b. Medium ( 1-10 g/100gm); rice, vegetables, fruits, coconut, seasam, almond and dates
c. Low (<1 g/100gm) refined and processed sugar
d. Nil: sugar, fat & oil, milk and meat.

G. Vitamin A :

1 IU of vitamin A = 0.3 microgram of retinol

= 0.55 microgram of retinol palmitate
1. Sources of vitamin A
a. Animal food: liver, eggs, butter, cheese, whole milk, fish and meat.
Halibut liver oil is the richest source of vitamin A (900,000 RE ) followed by cod liver oil, ox liver margarine
b. Plant foods: Green leafy vegetables. Darker the leaves, more is the carotene content.
Green and yellow fruits and vegetables; papaya, mango, pumpkin, carrots.
Most important carotenoid is beta-carotene.
c. Fortified foods: vanaspati, margarine and milk.
A normal person has vit A reserves for 6-9 months.

2. Vitamin A Deficiency: prevalence in India is 6.01% in children < 6 year of age.

a. Night blindness is caused first due to lack of Vit A
b. Conjunctival Xerosis: first clinical sign to appear.
c. Bitot’s spots are indicative of vitamin A deficiency in children not in adults.
d. Corneal Xerosis
e. Keratomalacia is one of the major causes of blindness in India.
f. Vitamin a deficiency disorders :- (xerophthalmia)
i. Refers to all ocular manifestations of vitamin A deficiency.
ii. Most common in children aged 1-3 years.
g. WHO classification of xerophthalmia:
i. Primary changes:
 X1A Conjunctival xerosis
 X1B Bitot’s spots
o X2 Corneal xerosis
o X3A Corneal ulceration / Keratomalacia <1/3
o X3B Corneal ulceration / Keratomalacia >1/3

ii. Secondary changes:

 XN Night blindness (1st symptom)
o XF Fundal changes
o XS Corneal scarring

h. Prevention & Control

i. Short-term action:
  Treatment- Administer 2 lakh IU orally on 2 successive days & repeat after 4 weeks if needed
(WHO guideline is immediate dosing, with the same dose repeated next day & the after 2 weeks)
Q
 Prophylactic- For children <1year – 1 lakh IU
o For children >1 year- 2 lakh IU every 6 months. Q
ii. Medium-term action:
 Fortification of foods such as vanaspati ghee and toned milk
 Remember : 2500 IU of Vit A and 175 IU of Vit D is present in dalda
iii. Long-term action:
 Change in nutritional habits with inclusion of vitamin A rich foods.
 Breast feeding for as long as possible
 Immunization against infectious diseases such as measles
 Prompt treatment of diarrhea and other associated infections.

3. Assessment of vitamin A deficiency: (Park, 23rd edition, page 615-6)

a. Surveys are done in preschool children between 6 months to 6 years.
b. Prevalence criteria for determination of xerophthalmia problem Q

Criteria Prevalence in population at risk (6 months -6 years

Night blindness >1%
Bitot’s spot >0.5%
Corneal xerosis/corneal ulceration/keratomalacia > 0.01%
Corneal ulcer >0.05%
Serum retinol (less than 10 mcg/dl) >5%

c. Daily intake of Vitamin A recommended by ICMR

Group Retinol (mcg)
Adult: Man 600
Women 600
Pregnancy 600
Lactation 950
Infants 350
Children: 1-6 years 400
7-12 years 600
Adolescent 600
d. Intake values recommended by ICMR
Folate requirement per day Vitamin B12 requirement per day
Healthy adult 100 mcg 1 mcg
Pregnancy 400 mcg 1.5 mcg
Lactation 150 mcg 1.5 mcg
Children 100 mcg 0.2 mcg

4. Vitamins & their deficiency diseases

Vitamins Chemical name Deficiency

A Retinol Xerophthalmia, VADDs

B1 Thiamine Beriberi, Wernicke’s Korsakoff psychosis
B2 Roboflavin Ariboflavinosis (cheilosis, glossitis, stomatitis)

B3 Niacin Pellagra (diarrhea, dermatitis, dementia& death), Casal’s

necklace
B5 Pantothenic Acid Burning feet syndrome (Grierson Gopalan syndrome)

B6 Pyridoxine, Pyridoxal Anemia

B7 Biotin Dermatitis, Entritis
B9 Folic acid Megaloblastic anemia, Neural tube defects

B12 Cyanocobalamin Megaloblastic anemia

C Ascorbic acid Scurvy

D Cholecalciferol Rickets & osteomalacia

E Tocopherol Hemolytic anemia in newborns

K Menaquinone, Phylloquinone Hemorrhagic disease of newborn

II. Nutritional anaemia

(Park, 23rd edition, page 642-3)
A. Iron
1. Important Points
a. Adult human body contains between 3-4g of iron
i. 60-70% of iron of human body is present in blood
ii. 1-1.5g as storage iron

iii. Each gm of Hb contains 3.34 mg of iron.

iv. Average iron content of breast milk is less than 0.2mg/dl and is well utilized.
v. Iron absorption from normal Indian diet is less than 5%
vi. IUD increase blood loss by 35-146%
vii. Hormonal contraceptives decrease menstrual blood loss by about 50%

2. Sources of iron:
a. Haem-iron:
i. liver
ii. meat
iii. poultry
iv. fish.
Also improves the absorption of non-haem iron

b. Non-haem iron: vegetable origin

Important source of iron for Indian diet
c. Phytates, oxalates, carbonates, phosphates and dietary fibers interfere with iron absorption
d. Milk, egg and tea inhibit iron absorption
 e. Phytates in bran, phosphate in egg yolk, tannin in tea, oxalates in vegetables inhibit iron absorption.

3. Iron deficiency Anemia:

a. India:
i. Incidence is 60-70 % in women and young children.
ii. Folate deficiency anemia in 25- 50% pregnant women.
iii. 20-40% maternal deaths are contributed by anemia.

b. Interventions
i. National Nutritional Anemia Prophylaxis programme
ii. Beneficiaries: pregnant, lactating women and children between 1-12 years (at risk)
c. Eligibility criteria
i. Hb 10-12 gdaily supplementation with IFA tablets
ii. Less than 10 grefer to nearest PHC

Prevalence of anaemia in women of reproductive age is 52% and in pregnant women is 50%. In children aged 6mnth
-3 years, it is 74%.

e. Interventions:
i. Iron and folic acid supplementation:
 In pregnant women, IFA tablets are given prophylactically containing 100mg elemental iron
(ferrous sulphate) and 500 mcg folic acid for 100 days during antenatal and postnatal periods.
 Remember :- Start the intervention only in SECOND TRIMESTER.
 The dosage for children contains 20 mg iron and 100 mcg elemental iron.
ii. Iron fortification:
 Addition of ferrous sulphate with sodium bisulphate or Ferric orthophosphate to salt has been
done. Double fortified salt contains both iodine and iron.

B. Fluorine
1. Sources: drinking water, sea fish, cheese, tea
2. Inadequate intake causes dental caries
3. Fluorine content of drinking water in fluorosis- endemic area: 3-12 mg/l

4. Toxic manifestations of fluorosis

a. Dental fluorosis
i. Occurs during first 7 years of life
ii. Characterized by mottling of dental enamel
iii. Best seen on upper incisors
iv. First sign: Loss of shiny appearance of teeth and chalky white patches
v. Reported at levels above 1.5 mg/L

b. Skeletal fluorosis
i. Associated with lifetime daily intake of 3.0 to 6.0 mg/L
 ii. Crippling fluorosis at concentration above 10 mg/L
5. Genu valgum associated with sorghum (jowar) based diet. Q
Recommended content of fluoride in drinking water: 0.5 –0.8 mg/l
And in temperate countries: 1-2 mg/L
6. Endemic fluorosis
a. This occurs in places with high levels of fluorine in water (3 – 5 mg/L)
b. However the Safe limit of Fluorine in drinking water in India is – 0.5 to 0.8 mg / dl.
c. Remember :- Dental Fluorosis if F2 above 1-2 mg/l
i. Skeletal Fluorosis if F2 3-6 mg/l
ii. Crippling if Fluorosis above 10 mg/l

Extra Edge: Deans index to grade dental fluorosis

d. Intervention:-
i. Change the source of water
ii. Nalgonda technique: For defluoridation Lime and Alum are added to water followed by flocculation,
sedimentation and filtration.
iii. Avoid using Flouride toothpaste in endemic areas.
C. Zinc

1. Suggested daily intake for

a. Adult man: 15 mg/day
b. Adult woman: 12 mg/day
c. Children: 10 mg/day
d. Infant: 5 mg/day

2. Clinical features of zinc deficiency

a. Severe maternal zinc deficiency: spontaneous abortion, congenital malformation
b. Milder zinc deficiency: Low birth weight, IUGR and pre-term delivery.
Estimated copper requirement for adult: 2.2 mcg/day
3. Dietary Antioxidants: vitamins A, C, E and mineral selenium

D. Iodine
1. Adult human contains 50 mg of iodine
2. Blood level: 8-12 mcg/ dl
3. Best source of iodine is seafood. Smaller amounts are found in milk, meat, vegetables and cereals.
4. RDA: 150 microgram / day

5. Iodine deficiency disorders

Remember :-
a. Spectrum of IDD includes (direct questions are asked over this)
b. Goitre (most common)
c. Hypothyroidism
d. Subnormal intelligence including delayed mile stones , Mental deficiency , hearing defect , Speech defect.
e. Squint (Strabismus)
f. Nystagmus
g. Spasticity ( Extrapyramidal type)
h. Neuromuscular weakness
i. Endemic cretinism
 j. IUD ( Spontaneous abortion)

6. Indicators for epidemiological assessment of iodine deficiency

a. Prevalence of goiter
b. Prevalence of cretinism
c. Urinary iodine excretion: best indicator of surveillance or impact of the control program
d. Thyroid function test by determination of serum levels of T4 and TSH
e. Prevalence of neonatal hypothyroidism: sensitive indicator of environmental iodine deficiency or
measuring IDD in the community.
f. Iodized salt: level of iodization fixed by PFA; 30 ppm at production point
15 ppm at consumer level
7. One question always debated is
a. Most common measure on estimating impact of IDD Control Program is Urinary Iodine excretion BUT
b. Most common method of measuring IDD in a community is Neo-natal hypothyroidism. Q
c. Control of IDD by
i. Iodized Salt :- Iodization not less than 30 ppm at production level and 15 ppm at consumer level
ii. Iodized oil :- Intra muscular injection of POPPY SEED IODIZED OIL 2 ml which provides a pr otection
for 4 years.
iii. Iodized oil oral :- Sodium Iodate tablet.

III. Nutritional profiles of principal foods:

A. Cereals
1. provide 70-80% of total energy intake & 50% of total protein intake in Indian diet.
2. Energy: 350 Kcal/ 100 gm
3. Protein: 6-12 g/100 gm
4. Minerals and B group vitamins
5. Limiting amino acid: lysine and threonine. Q

B. Rice
1. Good source of B group vitamin especially thiamine and devoid of vitamin A, D & C.
2. Milling deprives the rice of 15% of protein, 75 % of thiamine and 60% of riboflavin and niacin.
3. Washing of rice in large quantity of water  60 % loss of water-soluble minerals and vitamins.

Parboiling (Hot Soaking Process)

Soaking of paddy in hot water at 60-70 degree C for 3-4 hrs grains swell  drain the water
¯
Steaming of paddy for 5-10 min in same container

(Minerals and vitamins in outer aleuronic layer  inner endosperm)

¯
Dried
a. Rice grains get hardened
b. Resistant to insect invasion
c. Suitable for storage
¯
Milled.
C. Wheat: limiting amino acids are lysine and threonine. Q

D. Maize
1. Deficient in lysine and tryptophan.
2. Some strains contains excess of leucine
3. Leucine interferes with conversion of tryptophan to niacin.

E. Millets
1. Small grains that are grounded and eaten without removing the outer layer.
2. Jowar / Kaffir corn/ Milo: contains high leucine
3. Bajra contains B group vitamins, calcium and iron.
4. Ragi is rich in calcium.
F. Pulses
1. 20-25 % proteins
2. Limiting amino acid: methionine and cysteine Q
3. Excess of lysine
4. Rich in minerals and B group vitamins riboflavin and thiamine
5. Dry pulse lack vitamin C
6. Germination of pulses contain higher concentration of vitamin C& B
7. Fermentation enhances riboflavin, thiamine and niacin.
8. Raw pulses contain phytates and tannins
9. Oligosaccharides cause flatulence.
10. Soya beans: 432 Kcal of energy, 40% protein, 20% fat, 240 mg of Ca , 10.4 mg of Fe and 4% mineral. Q

G. Green leafy vegetables

1. Rich source of carotene, calcium, iron and vitamin with exception of vitamin B12.
2. Fairly good source of riboflavin, folic acid and lysine
3. Deficient in sulphur containing amino acid (Cysteine)
4. Energy value: 20-25 kcal/100g and recommended daily intake: 40 g for adult

H. Nuts &oil seeds

1. Groundnuts contain 26.7% proteins
2. Pistachio is richest source of iron containing 14 mg of iron per 100 g.

I. Fruits
1. Vitamin C content per 100 g of fruits; Orange 68, Guava 212 and Amla 600.
2. Carotene content per 100 g of fruit: mango 2210, orange 2240 and papaya 2240.
3. Custard apple is rich in Ca
4. Recommended daily intake of fruits is 85 gm.

J. Milk
1. Animal milk contains 3 times more protein than human milk per 100 gm
(Buffalo milk: 4.3, cow milk: 3.2, goat milk 3.3 and human milk 1.1)
2. Human milk contains higher amount of tryptophan and sulphur containing amino acid especially cysteine.
3. Fat content of human milk is 3.4% compared to 8.8% in buffalo milk.
4. Human milk contains higher percentage of linolenic and oleic acid than animal milk.
5. Human milk contains more sugar.
6. Skimmed milk is free from fat
 7. Toned milk: 1 part water + 1 part natural milk+ 1/8th part of skimmed milk powder
Equivalent to cow milk

Comparison
Buffalo Cow Goat Human
Fat (g) 6.5 4.1 4.5 3.4
Protein (g) 4.3 3.2 3.3 1.1
Lactose (g) 5.1 4.4 4.6 7.4
Calcium (mg) 210 120 170 28
Iron (mg) 0.2 0.2 0.3 -
Vito C (mg) 1 2 1 3
Minerals (g) 0.8 0.8 0.8 0.1
Water (g) 81.0 87 86.8 88
Energy (kcal) 117 67 72 65

K. Difference between cow milk and human milk

1. Human milk has only one third of the protein concentration compared to cow milk. Q
2. Human milk has slightly more fat than cow milk. Also, human milk contains a lipase enzyme because of which
human milk fat is digested easily.
3. Human milk has almost double the amount of lactose compared to cow milk. Lactose provides an easily
digestible source of energy. High lactose content helps in myelination in the growing nerve tissue of the baby.
Also, part of lactose is converted to lactic acid in the intestine, which prevents growth of undesirable bacteria in
the intestine.
4. Human milk contains the bifidus factor, which is a nitrogen-containing carbohydrate. Bifidus factor is necessary
for the growth of Lactobacillus bifidus, which converts lactose to lactic acid.
5. Human milk, especially the colostrum, contains large amounts of Immunoglobulin A, which is not absorbed but
acts in the intestine against certain bacteria [such as E. coli] and viruses.
6. Lysozyme, an enzyme, is present in human milk in concentrations several thousand times that of cow milk.
Lysozyme breaks down certain harmful bacteria and also protects against various viruses.

L. Egg
1. Contains all nutrients except carbohydrate and vitamin C.
2. 12 % egg comprises shell, 58% egg white and 30% egg yolk.
3. 1 egg: 60 gm, 6 gm protein, 6 gm fat, 30 mg calcium, 1.5 mg iron and 70 Kcal.
4. NPU = 100
5. Cholesterol is 250 mg/ egg
6. Boiling destroys avidin a substance that that prevents absorption of biotin.

M. Fish
1. 15-25% proteins
2. Rich in unsaturated FA and vitamin A & D
3. Fish bones are rich in Ca, Fluorine and phosphorus
4. Oyster and lobster are rich in iodine.
5. Rich in eicosapentaenoic acid. Q
6. Fresh water fish do not contain iodine
a. Fish is a relatively poor source of iron as compared to meat(AIIMS Nov’08)
N. Meat
1. 15-20% protein but good source of essential amino acid.
2. Iron: 2-4-mg/100 g, which is easily absorbable.
3. Poor in Ca and rich in phosphorus.

O. Fats & oils

1. Vegetable origin
2. Rich in poly-unsaturated fatty acids, except coconut and palm oil.
3. Devoid of vitamin A & D excepting red palm oil (extremely rich in carotene).
4. Animal origin: Poor source of essential amino acid.

P. Chemical composition of tea, coffee and cocoa (values per cup of 150ml)
Coffee Tea Cocoa
Protein (g) 1.8 0.9 7.2
Fat (g) 2.2 1.1 8.8
Carbohydrate (g) 17.8 16.4 26.2
Kcal 98.0 79.0 213.0
Others Caffeine, coffeol (volatile oil) and Caffeine, tannic acid, Theobromine
tannic acid theophylline and essential
volatile oil

Q. Alcohol
Alcohol content of beverages 5-6 % in beer, 40-45% in gin, rum and brandy and provides 7 kcal per gm.
Vinegar: 3.7% acetic acid.

R. Dietary goals
1. Dietary fat should be limited to approximately 15-30% of total daily intake.
2. Saturated fats should not contribute more than 10% of total energy intake.
3. Proteins should contribute 10-15 % of total daily intake.
4. Excessive intake of refined carbohydrate should be avoided.
5. Intake of fat and alcohol should be avoided.
6. Salt intake on an average 5 g/day and in tropical countries 15 g/day
7. Junk foods to be restricted

S. Lathyrism
1. Neurolathyrism in humans and Osteolathyrism in animals.
2. Prevalent in MP, UP, Bihar, Orrisa, Maharashtra, West Bengal, Rajasthan, Assam and Gujarat.
3. Occurs in adults consuming Lathyrus sativus/ Khesri Dhal/ Teora Dhal/ Lak Dhal/ Batra/ Gharas/ Matra
4. Toxin BOAA – Beta oxalyl Amino Alanine.
5. Disease
Age: 15-45 years
Characteristic: Spastic paralysis of lower limbs
Latent stageNo stick stage One stick stage Two stick stage Crawler stage.
a. Interventions
Vitamin C prophylaxis: Daily administration of 500-1000 mg for 1 week.
Removal of toxin
i. Steeping method: pulse is soaked in hot water for 2 hourswater drained.
 Domestic method
ii. Parboiling: large scale operation
Soaking of pulse in limewater overnight boiling.
iii. Genetic approach and education.

T. Indian Reference Man and Woman (AI’09, AIIMS MAY & Nov’08) : Revised
Ref: Park, 23rd edition page, 632
Man Woman
Age in years 18-29 18-29
Weight in Kg 60 55
Height 1.73 m 1.61 m
BMI 20.3 21.2
Time spent in hours:
Work 8 8 (general house hold/ light industry/
moderately active
Bed 8 8
Sitting & moving 4-6 4-6
Walking/recreation/ household 2 2
Others Free from disease Healthy
Physically fit for active work
Energy allowance per day
 Light work 2320 1900
 Moderate work 2730 2230
 Heavy work 3490 2850
Recommended protein intake g/day 60 55

1. Energy requirement for basal metabolism is 1 kcal/hour for every kg of b. wt. for an adult.
2. 2% decline of resting metabolism for each decade for adult.
3. After 40 years of age energy requirement is reduced by 5% each decade until 60 years of age and 10%
thereafter.

IV. Role of nutritional factors in Diseases

A. Cardiovascular disease
1. Uppermost acceptable level of cholesterol is 240 mg/dl
2. Optimum level should be less than 200 mg/dl
3. C12, C14, C16 acids produce cholesterol raising effect; stearic acid and FA less than 12 C have smaller effect on
plasma cholesterol.
4. Unsaturated FA with 2 or more double bond lowers plasma cholesterol.
5. PUFA e.g. linolenic and arachidonic acid inhibit platelet aggregation and prevents thrombus formation.
6. Consumption of complex carbohydrate decreases risk of CHD.
7. Hypertension can be significantly treated with low sodium diet i.e. less than 10 mmol/day.

B. Diabetes
1. Diabetics eat on an average 1000 kcal more than non-diabetics.
2. Deficiency of zinc, copper and chromiumDiabetes
3. Malnutrition / protein deficiency / alcohol intake diabetes

3. Nutritional factors associated with Cancer

Nutritional factors Cancer
High fat intake Colon cancer, breast cancer
Dietary fibers Colon cancer is inversely related to dietary fiber intake
Alcohol Liver cancer and cancer rectum.
Food additives and contaminants
Nitrosamines Gastric carcinoma
Saccharine & cyclamate Ca Bladder
Coffee Ca Bladder, pancreatic cancer

Micronutrients
Low intake of vitamin A Lung cancer
Deficiency of vitamin C Stomach cancer

C. Assessment of Dietary intake (Park, 23rd edition, page 650)

1. Weighment of raw food

a. Duration of survey 1-21 days.
b. Dietary cycle: 7 days.
c. Weighment of cooked food

2. 24 hours recall oral questionnaire method

a. Diet survey of large number of people in short time.
b. If carried out properly it gives reliable results.
c. Data collected is translated
i. Mean intake of nutrients (grams)
i. Mean intake of nutrients per adult man value/ consumption unit.

3. Assessment of ecological factors

a. Food balance sheet is cheap and simple.
b. Indirect method of assessing food consumption.
c. Supplies are related to census population.

D. Growth monitoring and nutritional surveillance

1. Growth monitoring
a. Oriented to individual child.
b. Focuses on normal nutrition
c. Promotes continued growth and good health.
d. Monthly recording
e. Infants are enrolled in first 6 months.

2. Nutritional Surveillance
a. Oriented to representative sample from community.
b. Gives nutritional status of community whether it is improving or deteriorating.
c. It helps to diagnose malnutrition
d. It assesses the impact of occurrence like drought or measures to alleviate malnutrition in community.
E. Milk Hygiene (Ref: Parks, 23rd edition, page 654)

1. Milk borne diseases

a. Infections of animals transmitted to man Q
i. Primary importance: Tuberculosis, Brucellosis, Streptococcal infection, Staphylococcal
ii. enterotoxin poisoning, Salmonellosis and Q fever.
iii. Lesser importance: Cowpox, Foot & mouth disease, Anthrax, Leptospirosis and Tick borne
encephalitis.

b. Infections primary to man that can be transmitted through milk

Typhoid and Para-typhoid fever, Shigellosis, Cholera, Enteropathogenic E coli
Non-diarrheal diseases: Streptococcal infection, Staphylococcal food poisoning, Diphtheria,
Tuberculosis, enterovirus and Viral hepatitis.

F. Test

1. Methylene blue reduction test

a. Indirect method for detection of microorganism in milk.
b. Carried out on milk accepted for pasteurization.
c. Methylene blue is added to 10 ml milk and sample is held at 37 degree C until blue color has disappeared.
d. Milk that remains blue longer is good quality.
e. Bacteria growing in the milk bring about a decrease in colour.
f. Cheap and time saving.

2. Pasteurization of Milk
a. Holder (Vat) method: milk is heated at63-66 degree C for at least 30 minutes
¯
Cooled to 5 degree C.
b. HTST method (High Temperature and Short Time method)
72 degree C for not less than 15 seconds rapidly cooled to 4 degree C.
c. UHT method (Ultra High Temperature Method)
Milk is rapidly heated in two stages to 125 degree C for few seconds only
Second stage is under pressure rapidly cooled and bottled.

d. Pasteurization
Kills 90% of bacteria including more heat resistant tubercle bacillus and Q fever organism Q.
It doesn’t kill thermoduric bacteria or the bacterial spores.

e. Test of pasteurized milk (AIIMS Nov’08)

i. Phosphatase test: raw milk contains phosphatase which is destroyed on heating
ii. Standard plate count: a limit of 30,000 bacterial count per ml
iii. Coliform count: coliforms be absent in 1 ml of milk

Q
D. Food toxicants (Ref: Parks, 23rd edition, page 657)

Name of the toxicant Fungus from which it is Grains infested Disease

derived
Aflatoxin Aspergillus flavus Groundnut, maize, Human liver cirrhosis
Aspergillus parasiticus parboiled rice, sorghum, (Attempts are made to
(Storage fungus) wheat, rice, cotton seeds relate)
and tapioca
Ergot Claviceps fusiformis Bajra, rye, sorghum and Ergotism
(Field fungus) wheat
Fusarium F.incamatum Sorghum, rice

1. Epidemic dropsy

a. Contamination of mustard oil with argemone oil (from Argemone mexicana or prickly poppy)
b. Toxic alkaloid: Sanguinarine
c. Tests for detection of argemone oil
i. Nitric acid test: positive only when argemone oil is 0.25%
ii. Paper chromatography is most sensitive. It can detect contamination up to 0.0001% Q

2. Endemic ascites:
a. Millets get contaminated with the seeds of Crotalaria/ jhunjhunia.
b. Toxic alkaloid is pyrrolidine a hepatotoxic alkaloid. Q

3. Food additives
a. Non-nutritious substance
b. Added intentionally to food
c. Small quantity
d. Improve appearance, flavour, texture or storage.
e. First category: colouring agent, flavouring agent, sweeteners, preservative and acid imparting agents.
f. Second category: contaminants during packing, processing, faming practices and other environmental
conditions.

4. Food fortification
a. The vehicle fortified should be consumed regularly, consistently by considerable section of total population.
b. Amount of nutrient added must provide effective supplementation to low consumers without having any
toxic hazard in high consumers.
c. No change in taste, smell, appearance or consistency.
d. No rise in the cost.

5. Prevention of Food Adulteration (PFA) Act

a. Enacted in 1954 and amended in 1964, 1976 and 1986.
b. Minimum imprisonment 6 months and 1000 rupees fine for proven case of adulteration.
c. Life imprisonment and fine not less than rupees 5000 if adulteration leads to death.
d. 1986 amendment: consumers and voluntary organizations can take samples of food.

Obesity
Indicators to measure obesity:

Broca's index: the individual's height ( in cms ) -- 100=max. Weight (in kg)
Body mass index ( Quetelet's index) (BMI) :-

wt (in kg)

BMI = (ht in meters)2

For the Indian population these guidelines have been revised by the WHO

 Normal: BMI – 18.5 – 22.99

 Overweight: BMI – 23 – 24.99
 Obese: BMI - > 25

Corpulence index :- actual wt (in kg)

desirable wt (in kg)

In obesity this should exceed 1.2

Ponderal index = ht (in cm)

3√wt (in kg)

Lorenz formula :

Male = [ ht ( cms ) - 100 ] - [ ht ( cms ) - 150 ] / 4

Female = [ ht ( cms ) - 100 ] - [ ht ( cms ) - 150 ] / 2

Fat fold thickness (skin fold thickness)

Measured by skin caliper’s

Sites- mid-triceps, biceps, sub-scapular and supra-iliac region.

Sum of the above four site measurements: Should not be more than 40 mm. for adult
males and 50 mm for adult females.

Food standards

Food standard Set by

Purpose
Codex Alimentarius Joint FAO/WHO Food For international market
Standards Programme

PFA standards Central Committee for Food Minimum level of quality of

Standards foodstuff attainable under
Indian conditions

Agmark standards Directorate of Marketing Quality assurance

and inspection, GOI
Not mandatory purely
voluntary

Bureau of Indian standards Bureau of Indian standards Guarantee of good quality

Not mandatory purely

voluntary
OCCUPATIONAL HEALTH

OCCUPATIONAL HAZARDS
Industrial worker may be exposed to five types of hazards, depending on the
occupation:

Physical, chemical, biological, mechanical and psychosocial hazards.

 Effects of exposure to heat include – heat exhaustion, heat stroke, heat cramps and
burns. Radiant heat is the main problem in foundry; glass and steel industry while
heat stagnation is the main problem in jute and cotton industry.
 Chronic effect of poor light leads to “miner’s nystagmus”.
 Long term exposure to vibrations in the range of 10 to 500 Hz lead to increased
spasms of fine blood vessels of fingers – “white fingers”.
 Occupational exposure to ultra-violet radiation (e.g. in arc welding) leads to intense
conjunctivitis and keratitis – “welder’s flash”.
 The maximum permissible level of occupational exposure to ionizing radiation is set
at 5 rem per year for the whole body.

PNEUMOCONIOSIS

It is a group of chronic lung conditions caused by the inhalation of dust particles of 0.3
to 3 microns in Diameter.

Agents causing pneumoconiosis

 Coal dust------------- Anthracosis
 Silica dust------------ Silicosis
 Cotton dust---------- Byssinosis
 Sugar cane dust-----Bagassosis
 Iron dust--------------Siderosis
 Grain dust------------Farmer's lung
 Asbestos dust--------Asbestosis

* Although conventionally included under pneumoconiosis Farmer’s lung & baggasosis do

not meet the classical definition criteria of pneumoconiosis because they are actually a
hypersensitive reaction to a fungal infection. Hence, should be remembered as an
exception.

SILICOSIS
Also known as

 Dust Consumption / Ganister disease / Grinder's Asthma / Rock T.B. / Miner's

Asthma / Stonemason's disease
 Incubation period maybe a few months to 6 years – shortest incubation period for
any pneumoconiosis.
 Silicosis are prone to TB – a condition called as “silicotuberculosis”.

Occupations involved
 Mining—Quarry / Gun flint Industry/ Granite Industry / Pottery Industry / Gold
Mining / Tin Mining / Hematite iron ore mining / Coal mining- silica content 40-60 % /
Graphite mining / Sand blasting / Mill stone dressing / Grinding of metals/ Iron and Steel
foundries

Manifestations
 As of Pneumoconiosis

Special investigation
 X-ray: - Snow Storm appearance
 More prone to tuberculosis-Sputum AFB usually negative
 Eggshell calcification of hilar nodes is seen
 Mostly it is the upper lung field which is affected. (Contrast it with asbestosis in
which the lower lung field is predominantly affected.

Preventive measures As shown in Pneumoconiosis

ANTHRACOSIS: - Due to inhalation of coal dust

 Risk of death among coal miners is nearly TWICE that of general population
 Associated with the Ranking of coal--i.e. Amount of volatile material present in coal-
Higher the percentage of volatile material in coal less will be the Risk of anthracosis
 Marked by progressive dyspnea-ending in chronic Bronchitis and Emphysema
 Two stages observed
 Simple pneumoconiosis-require twelve years of exposure-reversible
 Progressive Massive Fibrosis-non reversible

Preventive Measures: -
1. Dust Control: -Wet process, Enclosed apparatus, Exhaust Ventilation etc.
2. Personal Protection: - use of Respirator and Mask
3. Medical Control: - Initial health check up & Periodic health checkup of workers.
4.
BYSSINOSIS (means fine linen)

Also known as

 Stripper's Asthma / Grinder's Asthma / Cotton Card room Asthma

Characteristics
 Due to inhalation of fine cotton dust
 Textile Industry in India employs nearly 35 % of total work force
 Reported Incidence of Byssinosis is 7-8 %
 THREE stages of illness
 First stage-- Feeling of uneasiness and FEVER on Monday--experienced on resuming
work after a no work day--known as Monday Fever
 Second stage- symptoms seen over more days in a week-recovery possible if
exposure to cotton dust ceases
 Third stage-Feeling of tightness in chest, dyspnea-disability
Specific control measure:

 Dust control-by spraying 1 % Mineral Oil on cotton in the hopper bale breaker
Preventive Measures: as shown in Pneumoconiosis

ASBESTOSIS

 They are Silicate salt of various metals such as Magnesium, Iron, Calcium, Sodium,
Aluminum
TYPES:

 Serpentine --90 % production--Crysolite

 Amphibole---10 % Production--Crocidolite and Amosite
Industries involved

 Asbestos Cement / Fire proofing / Brake lining / Gaskets

Health risk

 Bronchial Carcinoma / Symptoms of Pneumoconiosis

Investigations

 Sputum- presence of Asbestos bodies

 X-ray shows Ground Glass appearance in lower two third of lungs
PREVENTIVE MEASURES

 Substitution-by Glass fibers, Mineral wool and Calcium Silicate etc.

 Other measures as suggested in Pneumoconiosis

BAGASSOSIS
Due to inhalation of fine cane sugar fibers

SOURCES

 Paper industry / Card board industry / Rayon industry

Causative agent

 Believed to be caused by a Fungus- 'Thermo actinomycosis Sacchari'

Clinical features

 Breathlessness, Cough, Hemoptysis & Fever

 Signs of diffused Bronchiolitis ending in fibrosis, emphysema and Bronchiectasis.
X-Ray: Diffuse Mottling Shadows.

 Preventive Measures: -
Dust Control: -Wet process, Enclosed apparatus, Exhaust Ventilation etc.

Personal Protection: - use of Respirator and Mask

 Medical Control: - Initial health check up & Periodic health checkup of workers.

Bagasse Control: - By keeping the moisture content below 20 % and spraying the
bagasse with 2% Propionic Acid-Fungicide

Silicosis, Anthracosis, Asbestosis and Byssinosis are all notifiable disease.

Farmers’ lung
 Is due to inhalation of moldy hay or grain dust associated with moisture content
of more than 30%.
 Thermophilic actinomycetes – Micropolyspora faeni is the main cause.

Occupational Cancers

The sites of the body most commonly affected by occupational cancer are –

Skin
Lungs
Bladder
Blood forming organs

The characteristics of occupational cancers are –

They appear after prolonged exposure

The period between exposure and development of the disease may be as long as 10-25
years.
The diseases may develop even after the cessation of exposure.
The average age incidence is earlier than that for the cancer in general.
The localization of the tumors is remarkably constant in any one occupation.
THE FACTORIES ACT, 1948 (amended in 1976)

It describes factory as an establishment employing 10 or more workers where power is

used or 20 or more workers where power is not used. It applies to all states except J&K.

 Minimum of 500 cu.ft. of space is prescribed per worker but for a factory
established before 1948, the minimum space prescribed per worker is 350 cu.ft. per
capita.
 Appointment of Safety officers in factories employing >1000 workers
 There should be a Canteen where >250 workers are employed, creche where
>30 women are employed & a Welfare officer where >500 workers are employed
 It prohibits employment of children below 14 years of age and declares persons
between 15 and 18 years to be adolescents as certified by “certifying surgeons”.
Adolescents can work only between 6A.M to 7 P.M.
 It prescribes 48 working hours per week, not exceeding more than 9 hours a day
(for adolescents it is 4 and half hours).
 The total nos of hours including overtime should not exceed 60 hrs.
 The act is applicable to all parts of India except J&K

THE EMPLOYEES STATE INSURANCE ACT, 1948 (amended in 1975, 1984 and1989)

 This act extends to all over India.

 With effect from October 2016, this act covers all employees – manual, clerical,
supervisory and technical, getting upto Rs 21000/- per month. It can be extended to
any agricultural or commercial establishment.
 This act is not applicable to mines, railways & defence establishments

BENEFITS TO EMPLOYEES
The act has made provision for the following benefits to insured persons or their
dependants

 Medical benefit – Full medical care, also includes – dentures, spectacles,

hearing aids, artificial limbs for employment related injuries.
 Sickness benefit – Cash payment for sickness for a maximum period of 91
days, daily rate of payment being 70% of average daily wage. Extended sickness
benefit @ 80% of daily wage is being provided for 38 diseases for a period of 2
years if the insured person has been in continuous service for 2 yrs.
 Maternity benefit – Full wage payment for confinement/pregnancy (duration of
benefit is 12 weeks), miscarriage (duration of benefit is 6 weeks), and sickness
arising out of confinement (duration of benefit is 30 days)
 Disablement benefit – Cash payment and medical treatment for
temporary/permanent disability. Rate of payment for temporary disability is 90% of
wage for the duration of disability. For permanent disability – full pension given for
lifetime.
 Dependents benefit - In case of death dependants are eligible for periodical
payments at the rate of 90% of the average daily wage.
 Extra benefits – these include
 Extended sickness benefit
 Artificial limbs, dentures and family planning etc
 Family medical care
 Protection against dismissal or discharge from service, during the period
of sickness
 Funeral expenses – not more than 10000/-
 Rehabilitation allowance
 Retirement benefits

Please remember :-

1. Brown induration of lungs is caused by cotton dust.

2. Rate of absenteeism in India is 8-10 days per head per year.
3. Lead poisoning in India is a notifiable and composable disease.
4. Exposure to Benzol ,X-rays , Radioactive substance gives rise to LEUKEMIA
5. B-nepthalamine , Benzidine , Para amino diphenyl auramine , megenta gives rise
to Ca Bladder.
6. Benzpyrine , Cigarettes , Nickel , Coal tar gives rise to Ca Lung.
7. ESI Doctor population ratio is 1:585
8. ESI Bed Population ratio is 2.62:1000 employees.
 9. Asbestosis especially Crocidolite is associated with both Pleura and peritoneal
mesothelioma.
10. Indian Factory Act 1976 includes Byssinosis , Asbestoses , occupational
dermatitis and noise induced hearing loss amongst the list of notifiable disease.
11. Carpet weavers are at risk of Anthrax.
12. Full wage benefit for Maternity under ESIS act is 12 weeks for confinement, 42
days for miscarriage and 30 days for sickness arising out of confinement.
13. In Silicosis the Total Lung Capacity is decreased but Timed lung capacity is
normal.
14. A condition known as WHITE FINGURE is because of vasospasm because of
Vibrations if exposed for long time.
15. Minamata disease in Japan was because of Organic mercury.

PRIMARY HEALTH CARE

Primary health care has 8 essential elements which are as follows:

- 1. education concerning prevailing health problems and the methods of

preventing and controlling them;
- 2. promotion of food supply and proper nutrition;
- 3. an adequate supply of safe water and basic sanitation;
- 4. maternal and child health care, including family planning;
- 5. immunization against major infectious diseases;
- 6. prevention and control of locally endemic diseases;
- 7. appropriate treatment of common diseases and injuries; and
- 8. provision of essential drugs.

Students must not confuse elements of PHC with the principles of primary health care
which are four in number viz: Equitable distribution, Community participation,
intersectoral coordination & use of appropriate technology.
Primary health care has undergone a lot of architectural and qualitative improvement
under the national rural health mission with the formulation of Indian Public health
standards for the subcentres, PHC, CHC and up to the sub district hospital level.

Indian Public Health Standards are means of describing the level of Quality that
health care organizations are expected to meet or aspire to.
For achieving desired targets, first step is to lay down norms and standards.

• To provide optimal health care to the community

• To achieve and maintain an acceptable standard of quality care
• To make services more receptive and sensitive to the needs of community
IPHS: Components

• Assured services
• Manpower
• Physical Infrastructure
• Equipments
• Drugs
• Support Services: diagnostic, electricity, water, telephone, kitchen, laundry,
sanitation, waste disposal, referral service, record maintenance
• Quality assurance and accountability
• Standard Operative Procedures and other guidelines
• Rogi Kalyan Samiti / Hospital Management Committee: Involving PRI/Community
in management
• Charter of Patients Rights
• Monitoring Mechanism: Internal & External
• Service facility survey check-list

Man Power at Subcentre Existing Proposed

Health worker (female) 1 2

Health worker (male) 1 1 ( funded and appointed

by the state government)
Voluntary worker to keep 1 ( optional ) 1 (optional)
the sub-centre clean and

Each primary health centre covers a population of 30,000 in rural and 20,000 in tribal or
hilly areas.

• Each subcentre covers a population of 5,000 in rural and 3,000 in tribal or hilly areas.

• Each community health centre covers a population of 80,000 - 1,20,000.

Health committees and their recommendations:

 Recommendations of some committee

1. Bhore Committee, 1946

 Integration of preventive & curative services.

 Establishment of PHC in 40,000 population in rural areas (short term measure).
 Setup of long term program (3 million plan)
 3 months training in PSM for interns to prepare' Social Physicians'.

2. Mudaliar committee, 1962

 Advised strengthing of existing PHCs and also district hospitals.

 Each PHC should not serve >40,000 population.
 Constitution of all India health services on the pattern of Indian administrative services.

3. Chadah Committee, 1963

 'Vigilance' operations in respect to NMEP (Malaria eradication).

4. Jungalwala Committee, 1967

 Defined integrated health services.

5. Kartar Singh, 1973

 Concept of FHW & MHW in place of ANM

6. Shrivastav Committee, 1975

 It was a Group on Medical education & support manpower

 It recommended creation of paraprofessionals and Semiprofessionals
 Development of 'Referral services complex'.

BIOSAFETY LEVELS

The different biosafety levels developed for microbiological and biomedical laboratories
provide increasing levels of personnel and environmental protection.

BIOSAFETY LEVEL 1
 BSL-1 is appropriate for working with microorganisms that are not known to
cause disease in healthy human humans. This is the type of laboratory found in
municipal water-testing laboratories, in high schools, and in some community colleges
teaching introductory microbiology classes, where the agents are not considered
hazardous.
BIOSAFETY LEVEL 2
 The facility, the containment devices, the administrative controls, and the
practices and procedures that constitute BSL-2 are designed to maximize safe working
conditions for laboratorians working with agents of moderate risk to personnel and the
environment. The agents manipulated at BSL-2 are often ones to which the workers
have had exposure to in the community, often as children, and to which they have
already experienced an immune response. Unlike the guidelines for BSL-1, there are a
number of immunizations recommended before working with specific agents. Most
notable is Hepatitis B virus immunization which is recommended by the Occupational
Safety and Health Administration for persons, including laboratorians, at high risk of
exposure to blood and blood products. These agents are generally transmissible
following ingestion, exposure of mucous membranes, or intradermal exposure. Eating,
drinking and smoking are prohibited in BSL-2 laboratories, and extreme precautions are
taken while handling needles and other sharp instruments.
BIOSAFETY LEVEL 3
 BSL-3 is suitable for work with infectious agents which may cause serious or
potentially lethal diseases as a result of exposure by the inhalation route. BSL-3
laboratories should be located away from high-traffic areas.
  Examples of agents that should be manipulated at BSL-3 are M. tuberculosis
(research activities), St. Louis encephalitis virus, and Coxiella burnetii.

Genetics & Health

The Hardy-Weinberg law states that "the relative frequencies of each gene allele tends
to remain constant from generation to generation" in the absence of forces that change
the gene frequencies. Thus, the study of gene frequencies and the influences which
operate to alter the "gene pool" and their long-term consequences is the central theme
in population genetics.

Factors which influence the gene frequencies –

(a) Mutation: Mutation implies a change in the genetic material of an organism

which results in a new inherited variation.

(b) Natural selection: Darwin proposed the theory of natural selection or survival of
the fittest to explain evolution. Natural selection is the process whereby harmful
genes are eliminated from the gene pool and genes favourable to an individual
tend to be preserved and passed on to the offspring.

(c) Population Movements: Because of industrialization, increased facilities for

earning, ways of living and education, people are moving - sometimes on a large
scale - from rural to urban areas. There is also a migration of people between
countries. Such population movements will lead to changes in the distribution of
genes, affecting both the areas of immigration and emigration. The intermixing of
people makes new genetic combinations possible.
 (d) Breeding Structure: If all marriages were to occur in a random fashion, the
effect would be the attainment of a genetic equilibrium.

(e) Public Health Measures: Advances in public health and medical care services
do affect the genetic endowment of people as a whole. More lives are now being
saved by advances in medical sciences than ever before. Public health
measures are thus decreasing the selection rates and increasing the genetic
burden. This has led some scientists to prophesy that "medicine will harm people
in the long run by helping them in the short run"

DISASTER MANAGEMENT

There are three fundamental aspects of disaster management: –

 Disaster response,
 Disaster preparedness,
 Disaster mitigation.

Response  response after disaster.

 Include rescue, first aid, triage etc.
Preparednes  objective to ensure that appropriate systems,
s procedures and resources are in place to provide prompt
effective assistance to disaster victims.
Mitigation  measures to prevent hazards or lessen likely effect of
emergencies.

TRIAGE SYSTEM
 Triage system is followed to decrease burden on health system in case of disaster.
 By applying triage system the serious patient who is need of treatment will get
treatment early as compared to ambulatory patients.
 Colour coding is used to differentiate the patients as per their severity and need for
treatment.
o Red: - high priority treatment and/or transfer
o Black: - Dead or moribund patients
o Yellow: - medium priority
o Green:- ambulatory patients

URBAN Socio-economic scale :

 Modified Kuppuswami scale

 Kulshreshta scale
 Shrivastawa scale
 Jalota scale

RURAL socioecomomic scale :

 Udai Pareek scale

 Modified B.G.Prasad scale
 Radhukar scale
 Shirpurkar scale
 Students scale : Bharadwaj scale

 ICF (International Classification of Functioning, Disability and Health)

 • International Classification of Functioning, Disability and Health, also
known as ICF, is a classification of the health components of functioning and
disability.
 • After nine years of international revision efforts coordinated by the World
Health Organization (WHO), the World Health Assembly on May 22, 2001,
approved the International Classification of Functioning, Disability and Health and
its abbreviation of "ICF."
  • This classification was first created in 1980 (and then called the
International Classification of Impairments, Disabilities, and Handicaps, or ICIDH)
by WHO to provide a unifying framework for classifying the health components of
functioning and disability.
 • The ICF classification complements WHO’s International Classification of
Diseases-10th Revision (ICD), which contains information on diagnosis and
health condition, but not on functional status. The ICD and ICF constitute the
core classifications in the WHO Family of International Classifications (WHO-
FIC).
 • The ICF is structured around the following broad components:
 • Body functions and structure
 • Activities (related to tasks and actions by an individual) and participation
(involvement in a life situation)
 • Additional information on severity and environmental factors


ICIDH 2 (International Classification of Impairments, Activities, and Participation)

• Developed to define the consequences of disease which ICD failed to describe.

• Concept:

A. sequences of illness related phenomenon;

B. Diseases>impairment>disability>handicap

C. impairment

D. disability

E. handicap

• SECTIONS

A. Imp with body function

 B. Imp with body structure

C. Activity limitation

D. Participation restriction

E. Environmental factors

F. Other contextual factors

IDEAS: Indian Disability Evaluation & Assessment Scale

• Brief scale for Indian setting

• Developed to identify and quantify disability produced by mental disorders

• Purpose: determining eligibility for welfare programmes.

• Items: 4, self care, interpersonal activities, communication and understanding,

and work.

• Rated on 4 point scale

RECENT UPDATES IN PUBLIC HEALTH : IMPORTANT FOR EXAMINATION
 SUSTAINABLE DEVELOPMENT GOALS:
The principle theme on which SDGs are aimed revolves around: People, Planet, Prosperity,
Peace and Partnership (5 – P)….. There are 17 Goals and 169 Targets in SDG.
Health related goal is Goal No. 3 with Nine targets and four sub targets. Reducing Maternal,
Neonatal and Child Mortality is still target number 1 & 2.
New focus areas for SDG in contrast to MDG are: Non-communicable disease, Road traffic
accidents, Substance abuse, Universal health coverage, Hazardous chemicals & Indoor air
pollution.
SDG : Goal 3. Ensure healthy lives and promote well-being for all at all ages
3.1 by 2030 reduce the global maternal mortality ratio to less than 70 per 100,000 live births
3.2 by 2030 end preventable deaths of newborns and under-five children
3.3 by 2030 end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases
and combat hepatitis, water-borne diseases, and other communicable diseases
3.4 by 2030 reduce by one-third pre-mature mortality from non-communicable diseases (NCDs)
through prevention and treatment, and promote mental health and wellbeing
3.5 strengthen prevention and treatment of substance abuse, including narcotic drug abuse and
harmful use of alcohol
3.6 by 2020 halve global deaths and injuries from road traffic accidents
3.7 by 2030 ensure universal access to sexual and reproductive health care services, including
for family planning, information and education, and the integration of reproductive health into
national strategies and programmes
3.8 achieve universal health coverage (UHC), including financial risk protection, access to quality
essential health care services, and access to safe, effective, quality, and affordable essential
medicines and vaccines for all
3.9 by 2030 substantially reduce the number of deaths and illnesses from hazardous chemicals
and air, water, and soil pollution and contamination
3.a strengthen implementation of the Framework Convention on Tobacco Control in all
countries as appropriate
3.b support research and development of vaccines and medicines for the communicable and
non-communicable diseases that primarily affect developing countries, provide access to
affordable essential medicines and vaccines, in accordance with the Doha Declaration which
affirms the right of developing countries to use to the full the provisions in the TRIPS agreement
regarding flexibilities to protect public health and, in particular, provide access to medicines for
all
3.c increase substantially health financing and the recruitment, development and training and
retention of the health workforce in developing countries,
3.d strengthen the capacity of all countries, particularly developing countries, for early warning, risk
reduction, and management of national and global health risks

1) The Swachh Bharat Abhiyan, which is already in place, would be supported, and whose
success would be measured by the reduction of water and vector borne diseases and declines
in improperly managed solid waste.
2) Balanced and Healthy Diets: This would be promoted through action in Anganwadi centers
and schools and would be measured by the reduction of malnutrition, and improved food
safety.
3) Addressing Tobacco, Alcohol and Substance Abuse: (Nasha Mukti Abhiyan) Success would
be judged in terms of measurable decreases in use of tobacco, alcohol and substance abuse.
4) Yatri Suraksha: Deaths due to rail and road traffic accidents should decline through a
combination of response and prevention measures that ensure road and rail safety-. This
concept could be expanded to include injuries on account of other causes.
5) Nirbhaya Nari- Action against gender violence ranging from sex determination, to sexual
violence would be addressed through a combination of legal measures, implementation and
enforcement of such laws, timely and sensitive health sector responses, and working with
young men.
6) Reduced stress and improved safety in the work place would include action on issues of
employment security, preventive measures at the work place including adequate exercise and
movement, and occupational health- strengthening understanding of occupational disease
epidemiology and demonstrate measurable decreases.
7) Promotion of Yoga at the work-place, in the schools and in the community would also be an
important form of health promotion, that has a special appeal and acceptability in the Indian
context.

 NATIONAL HEALTH ASSURANCE MISSION

List of diseases and conditions drawn up for the preventive campaign are: measles -
rubella, malaria, cancer, diabetes, hypertension, TB and chronic pulmonary diseases,
leprosy, obesity, cataract, deafness, geriatric and AIDS.
Lifestyles are also a focus. In this area, tobacco and alcohol consumption are named
others include the merits of sanitation, public and personal hygiene, the importance of
organ donation, the promotion of blood donation and awareness of health care of the
elderly
 NPCB : Goal To reduce preventable blindness to 0.3 % by 2020 , presently it is 1%.
Types of Blindness:

Economic blindness: Inability of a person to count fingers from a distance of 6 meters or 20 feet
technical Definition

Social blindness: Vision 3/60 or diminution of field of vision to 10°

Manifest blindness: Vision 1/60 to just perception of light

Absolute blindness: No perception of light

Curable blindness: That stage of blindness where the damage is reversible by prompt management e.g.
cataract

Preventable blindness: The loss of blindness that could have been completely prevented by institution
of effective preventive or prophylactic measures e.g. xerophthalmia, trachoma and glaucoma

Avoidable blindness: The sum total of preventable or curable blindness is often referred to as avoidable
blindness.
 “MISSION--INDRADHANUSH” : “To achieve full immunization coverage for all children by 2020
through a Catch-Up campaign” depicting seven colours of the rainbow, aims to cover all those
children by 2020 who are either unvaccinated, or are partially vaccinated against seven vaccine
preventable diseases which include diphtheria, whooping cough, tetanus, polio, tuberculosis,
measles and hepatitis B.

 2015 onwards three new vaccines to be included are rotavirus, rubella and inactivated
poliovirus vaccine (IPV) will be made available to all children through India’s Universal
Immunization Programme (UIP), while Japanese encephalitis vaccines will be introduced in 179
endemic districts across nine states.

 IMPORTANT DATA
1. HDI, : 0. 640
2) GFR: 2.3
3) SR in India= 940/1000 / 4) 0-6 Sex ratio= 914/100
5) Lowest Sex Ratio overall= Delhi
6) Highest Sex Ratio overall= Kerala
7) Highest Sex Ratio 0-6 = Mizoram
8) Birth Rate= 21.3 9) Death Rate = 7
10) Growth Rate= 1.43%
11) IMR=34 /1000 LB
12) MMR=134 /Lac LB

13) < 5 Mortality = 52/1000 LB

14) % Expenditure of GDP on Health = 4.05

16) The prevalence of HIV among Pregnant women aged 15-24 years 0.39% in 2010-11.

17) The annual incidence rate (cases of malaria/1000 population) of Malaria 0.88 cases per 1000
population in 2012.

18 ) The malaria death rate in the country was 0.04 deaths per lakh population in 2012.

19) Prevalence rate of TB 249 in 2011 per 100, 000 population.

 20) Mortality due to TB has reduced from 24 per lakh population in 2011.

21) During 2012, in rural India, 88.5% households had improved source of drinking water while in
urban India 95.3% households had improved source of drinking water.

22) HIV prevalence :0.27 % (2013)

23) Prevalence of Blindness = 1.1% (2012) TARGET is to be 0.3% by 2020

24) RSBY : Funded by Ministry of Health and F Welfare

25 ) SC = 148366 , PHC = 24049 , CHC = 4833 , Medical College= 356

 ICDS Recent update

No.Category [Pr-revised] [Revised] (per beneficiary per day)
Cal(K Cal)Protein (g) Cal(K Cal) Protein (g)
1. Children (6-72 Months) 300 8-10 500 12-15
2. Severely malnourished children (6-72 months) 600 20 800 20-25
3. Pregnant & Nursing Female 500 15-20 600 18-20

 NATIONAL URBAN HEALTH MISSION (NUHM)

 Covers all cities and towns with more than 50,000 population as well as District
headquarters and State headquarters.
 Urban Primary Health Centres (U- PHCs) and Urban Community Health Centres (U-CHCs). U-
PHCs for app. 50,000 population, preferably located near slums
 U-CHCs for providing in-patient care in cities having population above five lakhs have been
envisaged.
 NUHM also provides for engagement of ANMs for conducting outreach services to target groups
particularly slum and the vulnerable population through ASHA and Mahila Arogya Samiti (MAS).
 MAS for every 50-100 households having 250-500 population .
 One ASHA per 1000-2500 population covering approximately 200-500 households would serve
as an effective, demand-generating link between the health facility and the urban slum
population.
GOALS OF NATIONAL HEALTH MISSION
1. Reduce MMR to 1/1000 live births
2. Reduce IMR to 25/1000 live births
3. Reduce TFR to 2.1
4. Prevention and reduction of anaemia in women aged 15–49 years
5. Prevent and reduce mortality & morbidity from communicable, non- communicable; injuries
and emerging diseases
6. Reduce household out-of-pocket expenditure on total health care expenditure
7. Reduce annual incidence and mortality from Tuberculosis by half
8. Reduce prevalence of Leprosy to <1/10000 population and incidence to zero in all districts
9. Annual Malaria Incidence to be <1/1000
10. Less than 1 per cent microfilaria prevalence in all districts
11. Kala-azar Elimination by 2015, <1 case per 10000 population in all blocks
The Nobel Prize in Physiology or Medicine 2015 was divided, one half jointly to William C. Campbell and
Satoshi Ōmura "for their discoveries concerning a novel therapy against infections caused by roundworm
parasites" and the other half to Youyou Tu "for her discoveries concerning a novel therapy against
Malaria". William C. Campbell and Satoshi Ōmura discovered a new drug, Avermectin, the derivatives of
which have radically lowered the incidence of River Blindness and Lymphatic Filariasis, as well as
showing efficacy against an expanding number of other parasitic diseases. Youyou Tu discovered
Artemisinin, a drug that has significantly reduced the mortality rates for patients suffering from Malaria.
 The Vaccination Schedule under the UIP

National Immunization Schedule

Vaccine When to give Dose Route Site

For Infants

0.1ml (0.05ml
At birth or as early as possible
BCG until 1 month of Intra -dermal Left Upper Arm
till one year of age
age)

Hepatitis B Birth At birth or as early as possible Anterolateral side of

0.5 ml Intramuscular
dose within 24 hours mid thigh-LEFT

At birth or as early as possible

OPV Birth dose 2 drops Oral -
within the first 15 days

At 6 weeks, 10 weeks & 14

OPV 1,2 & 3 2 drops Oral -
weeks

IPV (inactivated Anterolateral side of

14 weeks 0.5 ml Intramuscular
Polio Vaccine) mid thigh-RIGHT

Pentavelant 1,2 & At 6 weeks, 10 weeks & 14 Anterolateral side of

0.5 ml Intramuscular
3 weeks mid thigh-LEFT

At 6 weeks, 10 weeks & 14

Rota Virus Vaccine 5 drops Oral -
weeks

9 completed months-12
months. (give up to 5 years if
Measles 1st Dose 0.5 ml Subcutaneous Right Upper Arm
not received at 9-12 months
age)

Vitamin A, 1 ml (1 lakh
At 9 months with measles Oral -
1st Dose IU)

For children
 Anterolateral side of
DPT 1st booster 16-24 months 0.5 ml Intramuscular
mid thigh-LEFT

OPV Booster 16-24 months 2 drops Oral

Measles 2nd dose 16-24 Months 0.5 ml Subcutaneous Right Upper Arm

16 months with DPT/OPV

nd
Vitamin A (2 to booster, then, one dose every 2 ml (2 lakh
Oral -
9thdose) 6 month up to the age of 5 IU)
years)

DPT 2nd Booster 5-6 years 0.5 ml. Intramuscular Left Upper Arm

TT 10 years & 16 years 0.5 ml Intramuscular Upper Arm

For Pregnant Women

TT – 1 Early in pregnancy 0.5 ml Intramuscular Upper Arm

TT – 2 4 weeks after TT – 1 0.5 ml Intramuscular Upper Arm

If received 2 TT doses during

TT - Booster 0.5 ml Intramuscular Upper Arm
pregnancy within last 3 years

Minimum time gap between two doses of any vaccine must be 4 weeks; two live vaccines can be
given at the same time but at different sites.

14.7.2 Introduction of Inactivated Polio Vaccine (IPV)

The planned introduction of IPV for polio eradication will represent the fastest global
introduction of any routine vaccine in recent history by a factor of 4—5X. From January 2013 to
May 2015, the number of countries making a commitment to introduce IPV has increased by
126.
In January 2013, as we have already read above, the Global Polio Eradication Initiative (GPEI)
launched the Polio Eradication & Endgame Strategic Plan 2013-2018 which was developed with
an approach to tackle both wild and vaccine virus eradication in parallel rather than sequential
manner. A coordinated withdrawal of the type 2 component of trivalent oral polio vaccine
(tOPV) from immunization programmes by April 2016 was recommended. For countries which
use only tOPV in their routine infant immunization programmes, this will require switching from
tOPV to bOPV (containing only types 1 and 3) for that purpose. Prior to this switch, it is
recommended that all countries introduce at least one dose of inactivated poliovirus vaccine
(IPV) into their infant immunization schedules as a risk mitigation measure by providing
immunity in case a type 2 poliovirus re-emerges or is reintroduced.

Initially, introduce IPV at least 6 months in advance to the proposed switch date in order to
provide adequate time to enhance population immunity against type 2. It is recommended
that one dose of IPV should be administered at or after 14 weeks of age through routine
immunization (RI), in addition to the 3-4 doses of OPV.

Three main risks are identified following type 2 poliovirus removal. These include immediate
time-limited risk of circulating vaccine-derived poliovirus type 2 (cVDPV2) emergence;
medium- and long-term risks of type 2 poliovirus re-introduction from a vaccine manufacturing
site, research facility, diagnostic laboratory or a bioterrorism event; and spread of virus from rare
immune-deficient individuals who are chronically infected with OPV2. All these risks have the
potential to cause substantial polio outbreaks or even re-establishment of polio virus transmission
in polio-free regions.

GOVERNMENT OF INDIA INITIATIVES: Government of India (GoI) has taken following

decisions regarding polio immunization during implementation of endgame strategies in India:
• Introduction of at least single dose (0.5 ml) of intramuscular IPV (IM-IPV)
administration on antero-lateral aspect of right thigh at 14 weeks or first contact
afterwards in the Routine Immunization along with 3rd dose of DTP and OPV in 6 states
viz Bihar, Uttar Pradesh, Madhya Pradesh, Gujarat, Punjab and Assam;
 • Nationally coordinated switch from tOPV to bOPV all over the country on 25th April
2016 associated with cessation of use, withdrawal, destruction and validation of all
available tOPV stocks from all over the country.
• Introduction of fractional dose (0.1 mL) intradermal IPV (ID-fIPV) at 6 and 14 weeks in
Orissa, Andhra Pradesh, Telangana, Tamil Nadu, Kerala, Karnataka, Maharashtra and
Puducherry from April, 2016. This change in approach from single-dose intramuscular
IPV to fractional-dose intradermal IPV is mainly due to scarcity of IPV.
Inactivated Polio Vaccine (IPV) is an injectable form of polio vaccine which can be administered
alone or in combination with other vaccines like OPV (oral polio vaccine), diphtheria, tetanus,
pertussis, hepatitis B, and haemophilus influenza.

Contraindications for IPV:

There are two contraindications for IPV:

- If anyone has a history of an allergic reaction

- If any infant has known allergy to streptomycin, neomycin, or polymyxin B as these are
inactive components for IPV

Safety of IPV: IPV is safe for premature infants. IPV can be safely administered to children with
immune deficiencies (e.g., HIV, congenital or acquired immunodeficiency, sickle cell disease). In
fact, because of the elevated risk of vaccine-associated paralytic polio after the use of OPV in
patients with immune deficiencies, IPV is universally recommended in these children.

National Health Policy - 2017

Health Status and Programme Impact

2.4.1.1 Life Expectancy and healthy life
a. Increase Life Expectancy at birth from 67.5 to 70 by 2025.

b. Establish regular tracking of Disability Adjusted Life Years (DALY) Index as a measure of burden
of disease and its trends by major categories by 2022.

c. Reduction of TFR to 2.1 at national and sub-national level by 2025.

2.4.1.2 Mortality by Age and/ or cause
a. Reduce Under Five Mortality to 23 by 2025 and MMR from current levels to 100 by 2020.

b. Reduce infant mortality rate to 28 by 2019.

c. Reduce neo-natal mortality to 16 and still birth rate to “single digit” by 2025.
2.4.1.3 Reduction of disease prevalence/ incidence
a. Achieve global target of 2020 which is also termed as target of 90:90:90, for HIV/AIDS i. e,- 90%
of all people living with HIV know their HIV status, - 90% of all people diagnosed with HIV
infection receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral
therapy will have viral suppression.

b. Achieve and maintain elimination status of Leprosy by 2018, Kala-Azar by 2017 and Lymphatic
Filariasis in endemic pockets by 2017.

c. To achieve and maintain a cure rate of >85% in new sputum positive patients for TB and reduce
incidence of new cases, to reach elimination status by 2025.

d. To reduce the prevalence of blindness to 0.25/ 1000 by 2025 and disease burden by one third from
current levels.

e. To reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory
diseases by 25% by 2025.

2.4.2 Health Systems Performance

2.4.2.1 Coverage of Health Services
a. Increase utilization of public health facilities by 50% from current levels by 2025.

b. Antenatal care coverage to be sustained above 90% and skilled attendance at birth above 90% by
2025.

c. More than 90% of the newborn are fully immunized by one year of age by 2025.

d. Meet need of family planning above 90% at national and sub national level by 2025.
e. 80% of known hypertensive and diabetic individuals at household level maintain „controlled
disease status‟ by 2025.

2.4.2.2 Cross Sectoral goals related to health

a. Relative reduction in prevalence of current tobacco use by 15% by 2020 and 30% by 2025.

b. Reduction of 40% in prevalence of stunting of under-five children by 2025.

c. Access to safe water and sanitation to all by 2020 (Swachh Bharat Mission).

d. Reduction of occupational injury by half from current levels of 334 per lakh agricultural workers
by 2020.

e. National/ State level tracking of selected health behaviour.

2.4.3 Health Systems strengthening

2.4.3.1 Health finance
a. Increase health expenditure by Government as a percentage of GDP from the existing 1.15% to 2.5
% by 2025.

b. Increase State sector health spending to > 8% of their budget by 2020.

c. Decrease in proportion of households facing catastrophic health expenditure from the current
levels by 25%, by 2025.

2.4.3.2 Health Infrastructure and Human Resource

a. Ensure availability of paramedics and doctors as per Indian Public Health Standard (IPHS) norm in
high priority districts by 2020.

b. Increase community health volunteers to population ratio as per IPHS norm, in high priority
districts by 2025.

c. Establish primary and secondary care facility as per norms in high priority districts (population as
well as time to reach norms) by 2025.

2.4.3.3 Health Management Information

a. Ensure district-level electronic database of information on health system components by 2020.

b. Strengthen the health surveillance system and establish registries for diseases of public health
importance by 2020.

c. Establish federated integrated health information architecture, Health Information Exchanges and
National Health Information Network by 2025.

3. Policy Thrust
3.1 Ensuring Adequate Investment The policy proposes a potentially achievable target of raising
public health expenditure to 2.5% of the GDP in a time bound manner. It envisages that the resource
allocation to States will be linked with State development indicators, absorptive capacity and
financial indicators. The States would be incentivised for incremental State resources for public
health expenditure. General taxation will remain the predominant means for financing care. The
Government could consider imposing taxes on specific commodities- such as the taxes on tobacco,
alcohol and foods having negative impact on health, taxes on extractive industries and pollution cess.
Funds available under Corporate Social Responsibility would also be leveraged for well-focused
programmes aiming to address health goals.

3.2 Preventive and Promotive Health The policy articulates to institutionalize inter-sectoral
coordination at national and sub-national levels to optimize health outcomes, through constitution of
bodies that have representation from relevant non-health ministries. This is in line with the emergent
international “Health in All” approach as complement to Health for All. The policy prerequisite is for
an empowered public health cadre to address social determinants of health effectively, by enforcing
regulatory provisions.

The policy identifies coordinated action on seven priority areas for improving the environment for
health:
o The Swachh Bharat Abhiyan

o Balanced, healthy diets and regular exercises.

o Addressing tobacco, alcohol and substance abuse

o Yatri Suraksha – preventing deaths due to rail and road traffic accidents
o Nirbhaya Nari –action against gender violence

o Reduced stress and improved safety in the work place

o Reducing indoor and outdoor air pollution

IV. Maternal Health

A. New Initiatives
a. Training of MBBS doctors in Anesthetic Skills for Em Obs Care at FRU s 18 weeks training Programme
b. Obstetric Management Skills training of MBBS doctors in Obstetric Management Skills FOGSI training for 16 weeks in
all obstetric management skills
c. Setting up of Blood Storage Centres (BSC) at FRU s
d. Drugs and Cosmetics Act have been amended
e. Developing a cadre of Community Level Skilled Birth Attendant
f. Trained in midwifery for one year
g. To provide maternal care at the community level
h. Selected from the community
i. Set up her practice after completion of her training
j. Will not be a financial or administrative obligation to the health system in any way
k. Left in the villages to practice the skills provided
l. Serve in the same community for a minimum period of three years
m. They will be given stipend for the training period and hostel facility will be provided at anm training centres

School health Service

1. No class room should accommodate more than 40 students
2. Per capita space for students in a classroom should not be less than 10 sq ft
3. Desks should be minus type
4. Window area should be at least 25 percent of the floor space; windows should be placed on different walls for cross
ventilation
5. Ventilators should not be less than 2 % of floor area
6. One urinal for 60 students and one latrine for 100 students
7. School Health Committee – 1961
8. Child labor (prohibition and regulation) act 1986- below 15 children
9. Child Marriage restraint act, 1978
10. Child guidance clinic- deal with all children or adolescents who for one reason or other, are no fully adjusted to their
environment (juvenile delinquency)
11. Orphanages- children who have no home or who for some reason could not be cared for by their parents are placed
in orphanages
12. Foster homes- several type of facilities for rearing children other than in natural families. Child is provided with love,
security, affection.
13. Borstal homes- boys over 16 yrs who are too difficult to handle in a certified school or have misbehaved there- are
sent to borstal home, sentence for 3 yrs, 6 homes in India, governed by State Inspector General of India
14. Remand Homes- child is placed under the care of doctors, psychiatrist and other trained personnel- to improve the
mental and physical well being of the child.

D. Baby friendly hospital Initiative WHOI UNICEF- 10 steps

1. Helping the mother initiate breast feeding within the first hour of birth in a normal delivery and 4 hours following
caesarean section
2. Encourage breast feeding on demand
3. Allow mothers and infants to remain together for 24 hours a day except for medical reasons
4. Give newborn infants no food or drink other than breast milk, unless medically indicated
5. EBF to be promoted til14-6 months
6. No advertisement, promotional material or free products for infant feeding should be allowed in the facility.

JANANI-SHISHU SURAKSHA KARYAKRAM (JSSK)

Government of India has launched the Janani-Shishu Suraksha Karyakram (JSSK), a new national initiative, to make
available better health facitlies for women and child.
The new initiatives provide the following facilities to the pregnant women:
a. All pregnant women delivering at public health institutions to have absolutely free and no expense delivery, including
caesarean section.
b. The entitlements include i. free drugs and consumables, free diet upto 3 days during normal delivery and upto 7 days
for C-section, ii. free diagnostics, iii. free blood wherever required. iv. Free transport from home to institution, between
facilities in case of a referral and drop back home.
c. Similar entitlements have been put in place for all sick newborns accessing public health institutions for treatment till
30 days after birth.
d. The scheme is estimated to benefit more than 12 million pregnant women who access government health facilities for
their delivery.
e. e.it will motivate those who still choose to deliver at their homes to opt for institutional deliveries.
Facilities based newborn care
a. As more sIck children are screened at the peripheries through IMNCI and referred to the health facilities, care of the
Sick newborn and child at CHCs, FRUs, district hospitals and medical college hospitals assumes priority.
b. Equipping the facilities to provide the requisite level of care and simultaneously enhancing the capacity of the medical
officers at these facilities to handle such Cases thus becomes important.
c. The setting up of SNCUs at district hospitals, stabilization units at CHCs and newborn care corners at all facilities
offering delivery facilities, is thus a key activity.
d. In the overall planning of facility, based care it is important to understand the level of care that is provided at the
various facility levels.

The newborn care facilities at different levels are as follows:

Health facility All newborns at birth Sick newborns
Primary health centre Newborn -care corner Prompt referral
(PHC)/Sub-centre (SC) in labor rooms
identified as MCH level I
Community health centre Newborn care corner Newborn
(CHC)/First referral unit in labor rooms and in stabilization unit
(FRU) identified as operation theatre (SNBU)

District hospital Newborn care corner Special newborn identified as in labor room and in care unit

MCH Level III operation theatre (SNCU)

Newborn Care Corner (NBCC)
a. NBCC is a space within the delivery room in any health facility where immediate care is provided to all newborns at
birth
b. This area is MANDATORY for all health facilities where deliveries are conducted.

Newborn Stabilization Unit (NBSU)

a. NBSU is a facility within or in close proximity of the maternity ward where sick and low birth weight newborns can be
cared for during short periods.
b. All FRUs/CHCs need to have a neonatal stabilization unit, in addition to the newborn care corner.
c. It requires space for 4 bedded unit and two beds in post-natal ward for rooming-in.

Special Newborn Care Unit (SNCU)

a. SNCU is a neonatal unit in the vicinity of the labor room which is to provide special care (all care except assisted
ventilation and major surgery) for sick newborns.
b. Any facility with more than 3,000 deliveries per year should have an SNCU (most district hospitals and some sub-
district hospitals would fulfil this criteria).
c. The minimum recommended number of beds for an SNCU at a district hospital is 12,
d. if the district hospital conducts more than 3,000 deliveries per year, 4 beds should be added for each 1,000 additional
deliveries. A 12 bedded
e. unit will require 4 additional adult beds for the step down.

Navjat Shishu Suraksha Karyakram (NSSK)

a. NSSK is a programme aimed to train health, personnel in basic newborn care and resuscitation.
b. It has been launched to address care at birth issue i.e. prevention of hypothermia, prevention of infection, early
initiation of breast-feeding and basic newborn resuscitation.
c. The objective of the new initiative is to have a trained health person in basic newborn
d. care and resuscitation unit at every delivery point.

Some important definitions to be mugged up:

1. An objective is a planned end point of all activities; it may or may not be achieved.(AI;09)

2. Target often refers to discrete activity that has to be achieved within a given time frame. These are small measurable
component of the entire goal. They permit the concept of degree of achievement.

3. Goal is define as the ultimate desired state towards which objectives and resources are directed. Goals are not
constrained by time or the existing resources nor are they necessarily attainable.

4. Mission in turn refers to attainment of a certain goal within a stipulated time period with added impetus to the
program wherein all resources and activities are to be utilized to its fullest extent to achieve the desired result. Lot of
attention is also given to the supervisory and evaluation aspect; in a nutshell it is the mode in which we function to attain
the target.

Attitudes are acquired characteristics of an individual. They are more or less permanent ways of behaving. Attitudes are
not learnt from books, they are acquired by social interaction, e.g., attitude towards persons, things, situations and
issues. Once formed attitudes are difficult to change. (AIIMS May’09)

6. Belief is the psychological state in which an individual holds a proposition Values are considered subjective, vary across
people and cultures and are in many ways aligned with belief and belief systems. Types of values include ethical/moral
values, doctrinal/ideological (religious, political) values, social values, and aesthetic values. It is debated whether some
values are intrinsic.
 "Values are beliefs and attitudes about the way things should be. They involve what is important to us. Values are
applied appropriately when they are applied in the right area. For example, it would be appropriate to apply religious
values in times of happiness as well as in times of despair. "A way of measuring what people value is to ask them what
their goals are.

I. Health committees and their recommendations:

1. Bhore committee, 1946 q
a. Setting up of national programs for health system development in the country.
b. Integration of preventive and curative services.
c. Setting up of primary health centres (PHCs).

2. Mudaliar committee, 1962

a. Looked into progress made since the Bhore committee report.
b. Strengthening of district hospitals and regional health services.

3. Chadah committee, 1963

a. Looked into the activities of the National Malaria Eradication Programme.
b. Introduced the concept of a basic health worker per 10,000 population.
Mukerji committee, 1965
a. Recommended separate staff for family welfare programme.
b. Recommended de linking of malaria activities from family planning activities.

5. Jungalwalla committee, 1967

a. Recommended integration of health services at all levels.

6. Kartar singh committee, 1973

a. Recommended that auxiliary nurse midwifes (ANMs) be replaced by ‘Female Health Workers’.
b. Introduced the concept of ‘Multipurpose Workers’.
c. One primary health center per 50,000 population, each divided into 16 sub centers of 3000 population each.

7. Shrivastav committee, 1975

a. Creation of bands of paraprofessional and semiprofessional workers from the community itself.
b. Reforms in health and medical education.

II. Health system setup

1. At central level
a. Union ministry of health and family welfare.
b. Directorate General of Health Services (DGHS).
c. Central Council of Health.

2. At state level
a. State ministry of health
b. State Health Directorate

3. At district level
It is the principal unit of administration in India. Within district there are 6 types of administrative areas –
a. Sub-divisions
b. Tehsils
c. Community Development Blocks in rural areas (100,000 population)
d. Municipalities and Corporations in urban areas
e. Villages
f. Panchayats