PMDC-COMMUNITY.pdf

8/10/2019 PMDC-COMMUNITY.pdf

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SECTION 8: COMMUNITY MEDICINE

Written by:

Dr. Rana Faizan Ali

M.B.B.S (Dali University, Yunnan, P.R China)

PM&DC (I,II,III)

Note: This section is not yet revised by anyone. Excuse me for some spellingmistakes.

Community Medicine Curriculum given by PMDC for Step 1:

I. Food & Nutrition 1 SEQ

2. Control and prevention of non-communicable and communicable diseases 1 SEQ

3. MCH/Reproductive Health/STI 1 SEQ

Division of Marks: Total 30 Marks

3 SEQ = 15 Marks (5 marks for each SEQ)

15 MCQs = 15 Marks (1 mark for each MCQ)

Community Medicine SEQs asked in Last 4 PMDC Papers:

[email protected]


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Q1: Classify Food? What are macronutrients and micronutrients?

Q2: How you can prevent and control Epidemic?

Q3: Prevention of Mother - Child transmission of HIV?

----------------------------------------------------------------------

Q1: Water borne diseases, their prevention and control?

Q2: What is sterilization and disinfection? Name some disinfectants.

Q3: Write the names of STDs. how will you prevent it in a community?

------------------------------------------------------------------------

Q1: What are the Principles of Integrated Child Care? [5]

Q2: Communicable Diseases:

a. Mode of Transmission of: [2.5]

i. Filariasis ii. Dengue iii. Enterobiasis

b. Prevention of: [2.5]

i. Scabies ii. Teniasis iii. Rabies

Q3: Nutrition:

a. How will you do Nutritional Assessment of General Population? [2.5]

b. How will you do Nutritional Assessment of Child/Child under 5 years age? [2.5]

--------------------------------------------------------------------------

Q: Protein energy malnutrition prevention under 5 years,

Q: IHD risk factors and their Prevention.


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COMMUNITY MEDICINE

According to WHO: A system of delivery of comprehensive health care to the

individual or family at the level of community by a health team in order to

promote physical, mental and social wellbeing.

Aims & Objective of Community Medicine:

-To provide skill, knowledge, attitude to the students, concerning delivery of

comprehensive healthcare.

-To bring whole spectrum of health services to all segments of community.

-Being expert, how to carry out immunization.

-Ability to identify noticeable health problems and disease.

-To know sign/symptoms of common diseases for diagnosis and treatment.

-Knowledge on public health administration

-To acquired clinical skill at all levels for diagnosis, screening, referral . Treatment

and follow up.

Importance of Community Medicine:

It has involvement with:-

-Public needs and demand

-Treads of diseases

-Nature of diseases

-Regional ecology


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-National policy

-International agreement.

Community Participation:

The process by which individual and families assumes responsibility for their own

health and welfare and for those of the community and develop the capacity to

contribute their and the communitys development.

Benefits of community participation:

-It leads to a sense of responsibility for the project.

-More will be accomplished.

-Participation guarantees that a felt need is involved.

-Services can be provided at a lower cost.

-Participation has an intrinsic value for participants.

-It is catalyst for further development effort.

-Participation ensures everything is done in the right way.

-Use indigenous knowledge and expertise.

-Freedom from dependence on professionals.

Health Care of the Community:

According to the World Health Organization, health care embraces -


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All the goods and services designed to promote, maintain, monitor or restore

health, including preventive, curative and palliative interventions, whether

directed to individuals or to populations.

It is not limited to medical care.

Providers: A health care provider could be a government institution such as a

hospital or medical laboratory, physicians, support staff, nurses, therapists,

psychologists, veterinarians, dentists, pharmacists or even a health insurance

company.

Characteristic of health care:

-Appropriateness-services is needed in relation to essential human needs,

priorities and policies.

-Comprehensiveness- there is optimum mix of preventive, curative and

promotional services.

-Adequacy-i.e. service is proportional to requirement.

-Availability-i.e. ratio between population of administrative unit and the healthfacility.

-Accessibility-i.e.it may b geographical, economical or cultural accessibility.

-Affordability- i.e. the cost of health care should be within the means of the

individual and the state.

-Feasibility-i.e. operational efficiency of certain procedures and material

recourses.

Food & Nutrition


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Food is a composite mixture of substances, which when consumed perform

certain function in the body.

Constitute of food are:-

-Protein

-Fat

-Carbohydrates

-Vitamins

-Minerals

-Water

Functions of food:-

-Energy yielding.

-Helps to building and maintaining the body.

-Protects the body from various types of diseases.

-Regulates the tissue function.

Classification of foods:-

1. According to origin: a. plant origin

b. animal origin

2. According to chemical composition:-

a. Protein b. fat c. carbohydrate

d. Vitamins e. minerals


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3. According to function:-

a. energy yielding food-rich in carbohydrate.

b. body building food-rich in protein.

c. protective food-rich in protein, vitamins and minerals.

Nutrition:is the process by which, living organism utilize food for maintenance of

life, growth, the normal functioning of tissue and organ, and production of

energy.

Nutrientsare the constituents in food, that must be supplied to the body in

suitable amounts.

Nutrients may be:-

1. Macro-nutrients:-they form main bulk of food. They are protein, fat,

carbohydrate.

2.

Micro-nutrients:-They are required in small amount. They are vitamins and

minerals.

Protein:

Proteinsare complex organic compounds, composed of carbon, hydrogen,

oxygen, nitrogen and sulphur in varying amount.

Amino acids:-Protein are made up of simpler substances which are the building

blocks of protein , called amino acids.

Essential amino acids

Non-essential amino acids

Sources of protein:-


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1.

Animal source-egg, fish, meat, milk

2.

Plant source- pulses, nuts, beans.

Types of protein:-

1. First class protein:-protein that provide all the essential amino acids needed for

body. e.g. protein of animal sources.

2. Second class protein:-protein that lacks one or more essential amino acids. E.g.

protein of plant sources

Function of protein:-

1. Building of new cell and maintain or repair of injured cell.

2.

Provide energy 4 kcal/gm.

3. Takes part in defense mechanism of body.

4.

Helps to synthesize antibody, enzymes, hormones.

Daily requirement of protein:-

Adults-1gm/kg body weight.

Pregnancy- +14gm.

Lactation- +25gm

Effects of protein deficiency:-

1.

During pregnancy:- still birth,

premature birth,


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anemia.

2.

Infancy and early childhood:- kwashiorkor

marasmus

mental retardation

3. Adults:- loss of weight

under weight

poor musculature

delay wound healing.

Fats/lipid:

Fats are composed of fatty acids, triacylglycerol, phospholipids, glycolipids etc.

Classification:-

-Simple lipidstriglycerides.

-Compound lipidphospholipids.

-Derived lipids-cholesterol.

-Most of body fat(99%) in the adipose tissue are triglycerides.

-Human body can synthesis triglycerides and cholesterol endogenously.

-Liver plays a central role in bodys cholesterol balance.

Sources of fats:-

1. Animal sources:-ghee, butter, milk, cheese, eggs, fats of meat and fish.

2.

Vegetable sources:-seeds of groundnut, mustard, sesame, coconut etc.

Daily requirement of fat:-10-20gm


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Functions of fat:-

1. Supply energy (9 kcal/gm).

2. Supply essential fatty acids.

3. Carries fat soluble vitamins-A, D, E & K.

4. Stimulates the secretion of bile, hormones.

5. Helps formation of cell membrane.

6. Gives support to viscera.

7. Protect body from cold and acts as insulator.

Disease due to fats:-

obesity,

coronary heart disease

cancer of colon and breast.

Carbohydrates:

are composed of carbon, hydrogen and oxygen.

Cheapest source of energy(4kcal/gm).

Classification of carbohydrates:-

1.

monosaccharide:-glucose.

2.

Disaccharides:-sucrose, lactose.

3.

Polysaccharides:-starch, glycogen.

Sources of carbohydrates:-

1.

starches:-cereals, millets, roots, tubers.


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2.

Sugars:-monosaccharide &disaccharides.

3.

Cellulose:-fibers from fruit, vegetables and cereals.

Daily requirement of carbohydrate:-400-600gm.

Function of carbohydrates:-

1.

Source of energy.

2. Helps the body to use protein and fat efficiently.

3.

Fiber present in carbohydrate form bulk and thus helps in digestion.

Carbohydrate deficiency results in:-

-Ketone body production.

Food hygiene:

The WHO has defined food hygiene as all conditions and measures that are

necessary during the production, storage, distribution and preparation of food to

ensure that it is safe, sound wholesome and fit for human consumption.

Food borne diseases:- A infectious or toxic disease, caused by agents that enter

the body through the ingestion of food.

Classification of food borne diseases:-

1. Food borne infections:-

a. Bacterial:- Typhoid, Cholera, Salmonellosis, Shigellosis.


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b. Viral:- Viral hepatitis, Gastroenteritis.

c. Parasitic:-Ascariasis, Amebiasis.

2.Food borne intoxications:-

a. Staphylococcus poison

b. Botulism

c. Aflatoxins

Food preservation methods:-

1. Cooking-preserve food for some time.

2.

Refrigeration-most of cooked & uncooked food.

3.

Deep freeze-raw food items.

4.

Drying-meat, fish.

5.

Smoking- meat.

6.

Salting-meat, fish.

7.

Pickling- achar, jam, jelly.

8. Concentrated sugar solution-fruits, sweets.

9.

Chemicals-vinegar.

Milk hygiene:

Milk is an ideal vehicle for disease transmission.

Milk can be contaminated by:-

1.

Dairy animals


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2.

Human handler

3.

Contaminated vessels

4.

Dust, flies

5.

Milk adulteration

Milk borne diseases:-

1.

Tuberculosis(bovine)

2. Staphylococcal enterotoxins

3.

Typhoid

4. Cholera

5.

Shigellosis

Preservation methods of milk:-

1.

Boiling

2.

Sterilization

3.

Pasteurization

4.

Drying

5. Condensing

Boiling:-

The commonest method use in house. By boiling all the pathogenic

organism killed except spore. To make milk free of germ boiling for 30minute is necessary.

Sterilization:-

Milk is heated at temperature of 100 degree centigrade for 15 minute in a

close container. It kills all germs including spore.


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Pasteurization :-

According to WHO, pasteurization is defined as, heating of milk to such

temperature and for such periods of time as are required to destroy any

pathogens that may be present while causing minimal changes in thecomposition, flavor and nutritive changes.

Methods:-

1.

Holder method:- In this process, milk is kept at 63-66 degree C. for at least

30 minute, and then quickly cooled to 5 degree C.

2.

Elash method:- milk is rapidly heated to a temperature of 72 degree C for

15 seconds and then rapidly cooled to 4 degree C. It is most widely used

method.

Food adulteration:

Extraction of valuable component from food and addition of something of lower

price which is absent in food normally, with an evil motive which lowers the food

value and has injurious effect to health is called food adulteration.

Form of adulteration:-

mixing, substitution, abstraction, putting decomposed food for sale,

addition of poison.

Commonly adultering foods are:-

Milk:- Adding water, removing cream, adding powder milk.

Flours:-Mixed with chalk powder.

Butter:- Add starch, animal fat.

Ghee:- Add vanaspati.

Food additives:-


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Non-nutritious substances are added to food to improve its appearance,

flavour, texture and storage properties.

Classification:-

1.

Coloring agents:- Saffron

2.

Flavoring agents:- Essences like vanilla, strawberry, banana.

3.

Sweaters:- Saccharin

4.

Preservatives:- Sorbic acid

5.

Acidity imparting agents:- Citric acid, acetic acid.

Food fortification:-

The process whereby nutrients are added to food to maintain or improve the

quality of the diet of a group, a community, or a population.

Indication of food fortification:-

1.

When the nutritive value is lost in the food processing. e.g.:- vit. D adding in

wheat.

2.

To improve the quality of food.eg. Adding vit. A & D in milk.

3.

To prevent the specific diseases. e.g.:- Adding of iodine to prevent endemic

goiter.

Vitamin & Minerals:

Vitaminsare vital accessory food factors present in minute quantities in various

food, required by the body in very small quantity for normal growth and

development of the body.


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Classification of vitamins:-

Fat soluble:-A,D,E and K.

Water soluble:- vitamin B complex & vitamin C.

B complexes are:-thiamine, riboflavin, nicotinic acid, biotin, pyridoxine,

pantothenic acid, folic acid, lipoic acid, vitamin B12.

Vitamin A:

Vitamin A is also known as growth promoting and anti-infective vitamin.

Sources:-

-Animal source:-liver, egg yolk, cheese, whole milk, fish, meat.

-Plant source:-dark green leafy vegetables, colored vegetables like carrot and

pumpkin, yellow fruits.

Daily requirements:-Infant:-300-400microgm

Children:-250-600microgm

Male/Female/Pregnancy:-750microgm

Function of vitamin A:-

-Play a major role in normal vision.

-Growth and development, especially bone.

-Has anti-infective action and immunological defense mechanism.

Effect of vitamin A deficiency:-

-Night blindness

-Xerophthalmia- Means dryness of eye. Eye changes are conjunctival xerosis,

bitots spots, corneal xerosis, corneal ulceration, keratomalacia.


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Treatment:-

All the early stages of xerophthalmia can be treated by administration of 200,000

IU retinol palmitate orally on two successive days.

Prevention:-

-Diet rich in vitamin A.

-Prophylactic use of high potency of oral vitamin A capsule to high risk children.

Vitamin D:

Forms of vitamin D:-

Vitamin D2 or calciferol

Vitamin D3 or cholecalciferol

Sources:-

-Natural source:-7-dehydrocholesterol present in skin convert in D3 in exposure

to sun.

-Animal source:-fish liver oil, egg yolk, liver, butter, milk.

Daily requirement:-Adults:-100 IU

Infant & children:-200 IU

Pregnancy & lactation:-400 IU.

Function of vitamin D:-

-Formation of healthy bone and teeth.

-It stimulate intestinal cells to synthesize calcium binding protein, which helps in

calcium absorption.


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-Increase renal reabsorption of phosphorus.

Effect of vitamin D deficiency:-

-Ricketsdisease of children 6 months to 2 years characterized by growth failure,

bone deformity, muscle hypotonia, tetany and hypocalcaemia.

-Ostomalacia-adults.

Prevention:-

-Exposure children regularly to sunshine.

-Periodic dosing with vitamin D.

-Vitamin D fortified food.

Vitamin E/ Tocopherol:

Sources:-

-Plant source:-vegetable oils, wheat germ oil, fruits and vegetables.

-Animal source:-egg yolk, fish, meat, milk.

Daily requirement:- 10mg/day.

Function:-

Acts as antioxidant.

Vitamin K:

Forms of vitamin K:- K1 & K2.


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Sources:-

-Source of vitamin K1:-dark green leafy vegetables, fruits.

-Source of vitamin K2:-endogenous synthesis by intestinal bacteria.

Daily requirement:- 0.03mg/kg.

Function of vitamin K:-

-Stimulates the production and release of certain clotting factor.(stable factor-vii).

-Helps in blood clotting.

Effect of vitamin K deficiency:-

-Prolonged clotting time.

-Generalized bleeding manifestation due to hypoprothombinemia.

Thiamine/Vitamin B1:

Sources:-

Plant source:-whole grain, wheat germ, pulses, nuts, vegetables, fruits.

Animal:-meat, fish, eggs.

Functions:-

Utilization of carbohydrate in body.

Essential for proper functioning of the nervous system.

Daily requirement:- Male:-1.5mg

Female:-1mg

Effect of thiamine deficiency:-


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1. Beriberi:-exist in 3 forms.

-Wet beriberi/ cardiac beriberi:-heart enlargement with CCF.

-Dry beriberi/ neuritic beriberi

-Infantile beriberi

2. Wernicks encephalopathy:- Characterized by ophthalmoplegia, polyneuritis,

ataxia and mental deterioration.

Riboflavin/vitamin B2

Sources:-

Animal source:-liver, kidney, fish, meat, eggs.

Plant source:-green leafy vegetables and pulses.

Daily requirement:- Male:-1.6mg

Female:-1.4mg

Functions:-

-Helps in cellular oxidation.

-Acts as co-factors in metabolism.

Effect of deficiency:- Angular stomatitis, Glossitis, Cheilosis.

Niacin:

Sources:-


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Animal :-liver, kidney, fish, meat, milk.

Plant :-legumes, groundnut.

Daily requirement:- male:-18mg, female:-14mg

Functions:-

-Essential for metabolism of carbohydrate, protein and fat.

-Essential for normal functioning of skin, intestinal tract, nervous system.

Effect of deficiency:-

Pellagra:-characterized by 3 Ds. diarrhea, dermatitis, dementia.

Glossitis

Stomatitis

Pyridoxine/vitamin B6:

Sources:-

Animal :-meat, fish, milk, egg.

Plant :-vegetables, whole grain.

Daily requirement:-2mg.

Function:-Helps in metabolism.

Effect of deficiency:-Peripheral neuritis.

Folate:


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Sources:-

Animal :-liver, meat, milk, egg.

Plant :-leafy vegetables, fruits.

Daily requirement:-

Adult/children:-100 microgm.

Pregnancy:-300 microgm.

Lactation:-150 microgm.

Function of folate:-

Synthesis of nucleic acid.

Needed for development of blood cell in bone marrow.


Megaloblastic anemia.

Glossitis.

GIT disturbances:-diarrhea, distension.

Infertility.

Cyanocobalamin/vitamin B12:

Sources:-

Animal source:-liver, kidney, meat, fish, milk, cheese.

No plant source.

Daily requirement:-Adult:-1 microgm


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Pregnancy:-1.5 microgm.

Functions:-

Synthesis of DNA.

Synthesis of fatty acid in myelin.


Megaloblastic anemia.

Demyelinating neurological lesions in spinal cord.

Vitamin C/ Ascorbic acid:

Vitamin C is most sensitive of all vitamins to heat.

Daily requirement:-

Adult/pregnancy/children:-40mg

Lactation:-80mg

Sources:-

Plant source:-citrus fruit, green leafy vegetables.

Animal source:-meat, fish, milk.

Functions:-

-Enzymatic role

-Wound healing

-Hemorrhage

-Iron absorption


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-Maturation of RBC.

Effect of vitamin C deficiency:-

Scurvy-characterized by swollen and bleeding gums, bleeding from skin and joints,

delayed wound healing and anemia.

Minerals:The human body contains more than 50 chemical elements which

required for growth, repair and regulation of vital body functions, called minerals.

1.

Major minerals:-calcium, sodium, potassium, phosphorous, magnesium.

2. Trace minerals:-iron, iodine, fluoride, zinc, copper, cobalt, chromium,

manganese, molybdenum, nickel, tin, silicon and vanadium.

3.

Trace contaminants with no known function:-mercury, barium, boron and

aluminium.

Calcium:

The body of an adult normally contains about 1200 gm of calcium.

At least 99% of this is present in skeleton.

Sources:-

Milk &milk products, eggs, fish eaten with bone, green leafy vegetables, some

nuts-almond.

Daily requirement:-Adult:-400-500 mg

Pregnancy:-1000 mg

lactation:-1200 mg


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Infants:-500-600 mg

Function of calcium:-

-Formation of bone and teeth.

-Coagulation of blood.

-Controls many life processes, like muscle contraction, cardiac action, cell division,

metabolism of enzyme & hormones.

-Transformation of light energy to electrical impulses in the retina.

Effect of calcium deficiency:-

-Decreased rate of growth

-Osteoporosis

-Tetany

Iron:

There are 2 forms of iron. Heme iron & non heme iron.

Sources:-

Heme iron:-animal source(liver, meat, fish).

Non heme iron:-animal source(green leafy vegetables & dry fruits).

Daily requirements:- Infant/children:-20-25mg

Male:-24mg

Female:-32mg

Pregnancy:-40 mg


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Function of iron:-

-Formation of hemoglobin.

-Brain development.

-Oxygen transport and cell respiration.

Routes of iron loss:-

-Hemorrhagic loss:-whenever blood is loss iron is loss. Causes are:-

-Physiological loss:-menstruation, delivery.

-Pathological loss:-hookworm infestation, malaria, hemorrhoids, peptic ulcers.

-Basal loss:-loss through urine, sweat, bile.

Effects of iron deficiency:-

-Anemia

-Impaired cell mediate immunity

Iodine:

Iodine has heaviest atomic weight of all essential elements.

Source of iodine:-

-Best sources are:-sea foods like sea fish, sea salt, cod liver oil.

-Milk, meat, vegetables contain iodine in small amount.

-Artificial source:-iodized table salt.

Daily requirements:- Children:-100microgm

Adults:-150 microgm


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Function of iodine:-

-Synthesis of thyroid hormones- thyroxine (T4), triiodothyronine (T3).

-It is essential in normal growth and development.

Effects of iodine deficiency:-

-Hypothyroidism.

-Retarded physical development and mental function.

-Chances of spontaneous abortion and still birth.

-Cretinism.

-Endemic goiter.

NUTRITION & MALNUTRITION:

Balance Diet: A balance diet is one, which contains different types of food in such

quantities and proportion that is needed for energy, maintaining health, vitality

and general well-being and also makes a small provision for extra nutrients to

withstand short duration of leanness.

Criteria of a balance diet:

-Easily available.

-Sufficient to satisfy taste and appetite.

-It should be easily digestible, absorbable.

-Protein and fat should be obtained from both animal and plant sources.

-It should contain sufficient vegetables and fruits.


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-Vitamins and mineral should be in sufficient quantities.

Diet of pregnant mother:

-Energy intake:-An additional minimum intake of 200 kcal/day.

-Proteins:- An additional allowance of 14gm/day.

-Other nutrients:- A regular and adequate intake of all other nutrients,

specially iron, folic acid and calcium.

Diet of lactating mother:

-Energy intake:-An additional minimum intake of 550 kcal/day for the first 6

months and 400 kcal/day from 6 months to 1 year.

-Proteins:- An additional allowance of 25 gm/day.


specially vitamin C.

Diet of growing children:

-Energy intake:-With advance in age there is increase in calorie

requirement. A child aged 1 year, energy requirement is 1000 kcal/day.After 1 year addition 100kcal required for every year of life. Thus at age 5

yrs 1500kcal/day.

-Proteins:- Extra protein needed to ensure proper growth of tissue.


specially calcium, iron.

Milk an ideal food:

Milk is unique in nutritive value and contains all the food factors of a well

balanced diet required for human body.

It is an ideal food for infants up to 6 months.


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The food factors present in milk are:-

1. protein:-casein, lactalbimin and lactglobulin. Milk protein contains all

essential amino acids.

2.

Fats:-milk fat is good source of vitamin A and vitamin D.

3.

Carbohydrate:- lactose is milk sugar, which is found no where in nature.

4.

Minerals:- milk contains almost all the minerals needed by the body.

5.

Vitamins:-milk is good source of all vitamins except vitamin E.

6.

Water:- milk contains 87% water.

7.

Enzymes:- amylolytic, proteolytic and lipolytic are present.

Humanization of cows milk:

Cows milk is suitably changed to make it comparable to mothers milk and make

suitable drink for new born baby.

Principle:-

-The insoluble caseinogens of cows milk must be reduced to thelevel as

present in human milk.

-The amount of lactogen must be increased to the right proportion and the

resulting mixture mast be pasteurized.

Procedure of humanization:-

1.

Adding one part of water to one part of cows milk, this will bring down the

protein content to that of mothers milk. This will cause sugar and fat to

come down.

2.

So, add 1 oz of milk sugar and 1 oz of ordinary centrifuged cream should be

added to 1 pint of diluted milk.

3. Vitamin C (10 cc of orange or tomato juice)should be added.


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(1 pint=16 ounce=473ml, 1cc=1ml)

Nutritional Status:

Nutritional status is the end result of utilization of the nutrients by the body.

Nutritional status can be assess by:-

1.

Nutritional anthropometry

2.

Clinical examination

3.

Bio-chemical evaluation

4. Dietary survey

5.

Functional assessment

6. Vital and health statistics

Nutritional anthropometry:-

1.Height (cm) and weight(kg):-

a. Weight for age- index for malnutrition.

b. Height for age-gives a picture of past nutritional history.

c. Weight for height-index of current nutritional status.

2.Area circumference- like mid arm circumference.

3. Skin fold thickness-measure skin calipers over triceps.

Clinical examination:-

Bitots spot, angular stomatitis,

rickets, goiter, Megaloblastic anemia.


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Biochemical evaluation:-

Hemoglobin - anemia

Dietary survey:-

Assessment of food consumption

Calculation of nutritive value of food.

Functional assessment:-

Specific function is seen.

Vitamin Kprothrombin time

Vital and health statistics:-

IMR, still birth, perinatal mortality rate.

Malnutrition:

Malnutrition is an impairment of health resulting from a deficiency, excess or

imbalance of nutrients.

Malnutrition comprises 4 forms:-

1. Under nutrition:- due to insufficient food intake for long period.

2. Over nutrition:- due to excess food intake for certain period.


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3. Imbalance:-disproportion among essential nutrients.

4. Specific deficiency:-relative or absolute deficiency of any nutrients

Major health problems:

-Protein energy malnutrition

-Vitamin A deficiency

-Iron deficiency

-Iodine deficiency

Protein energy malnutrition:

Types of PEM: Kwashiorkor

Marasmus

Cause of PEM:-

1.

Inadequate diet

2.

Infection and parasitic diseases

3. Failure lactation

4.

Poor environmental condition


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Difference between Kwashiorkor and Marasmus:

Features Marasmus Kwashiorkor

1.Cause

2.Clinical features:-

a.

Edema

b.

Muscle wasting

c.

Growth retardation

d.

Hepatomegalye.

Skin changes

f.

Mental changes

3. Appearance

4. Usually occur in

1. Deficiency of calories.

2.

a.

Absent

b.

Severe

c.

Severe

d.

Absente.

Absent

f.

absent

3. Old mans face

4. First year of life.

1. Deficiency of protein.

2.

a.

Present in legs.

b.

Less

c.

Less

d.

Presente.

Scaly, discoloration

f.

Present

3. Moon face

4. Second year of life.


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Picture of Marasmus:

Picture of kwashiorkor


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Xerophthalmia: (Vit A Deficiency)

The meaning of Xerophthalmia is disease due to dry eye.

The term Xerophthalmia refers to all the ocular manifestation of vitamin A

deficiency, from night blindness to complete corneal destruction.

WHO classification of Xerophthalmia:

XN :- Night blindness

XIA :- Conjunctival xerosis

XIB:- Bitots spots

X2:- Corneal xerosis

X3A:- Keratomalacia/ corneal ulceration 1/3rd

surface.

XS:- Corneal scar.

XF:- Corneal fundus.

WHO treatment schedule of Xerophthalmia for child 1-6 years of age:

1. Immediately on diagnosis:- 200,000 I.U. vitamin A orally.

2. The day following diagnosis:- 200,000 I.U. vitamin A orally.

3. 4 weeks later :- 200,000 I.U. vitamin A orally.

WHO treatment schedule of Xerophthalmia prevention:

1.

Infants 6 -12 months:- 100,000 I.U. of vitamin A orally every 3-6 months.

2.

Child 1-6 years age :- 200,000 I.U. of vitamin A orally every 3-6 months.

3. Lactating mothers :-200,000I.U. of vitamin A orally once at delivery or

during next 2 months.


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MATERNAL & CHILD HEALTH

Definition:- The promotive, preventive, curative and rehabilitative health care formother and children up to pre school ager.

Components of MCH:-

1. Antenatal /prenatal care

2.

Intra natal care

3. Post natal care

4.

Family planning

5.

Care of the new born

Aims and objective of MCH:-

1.

To provide adequate antenatal, intra natal and postnatal care.

2.

To ensure proper equipments, drugs and other facilities.

3. Health education to the pregnant women and mothers.

4.

MCH care should include family planning.

5.

Well baby care clinic for immunization, treatment of baby.


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Maternal health care:

WHO definition of maternal mortality:-

The death of a woman while pregnant or within 42 days of termination of

pregnancy, irrespective of the duration and site of pregnancy, from any cause,

related to or aggravated by the pregnancy or its management but not from

accidental or incidental causes.

Maternal cycle:-

1.

Fertilization

2.

Antenatal

3.

Intra natal

4.

Post natal

5.

Inter conceptional period.

Antenatal care(ANC):

Care of the woman during pregnancy.

Aim:- To achieve healthy mother and healthy baby at the end of pregnancy.

Importance of ANC:-

1.Promote, protect & maintain health during pregnancy.

2.Detect high risk cases during ANC examination and take proper action during

delivery.

3.Many maternal diseases diagnosed and treated, which prevent transmission to

infant. e.g syphilis, hepatitis.


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4.Tetanus immunization to mother can prevent tetanus neonatorum to infant.

ANC visit:-

Standard:- Total 14 visits

Every 4 week up to 32 weeks.

Every 2 week from 32-36 weeks.

Every week from 36 weeks till delivery.

Intermediate:- Total 5 visits

1st

: before 12 week

2nd

: 20-22week

3rd

: 28-32 week

4th

: 34-36week

5th

: 38- till delivery

Minimum:- Total 3 visits

1stvisit: 4-12 weeks

2nd

visit: 24-26 weeks

3rd

visit: 36-38 weeks.

Activities during Antenatal visit:

1.

Registration of the pregnant women.

2.

History taking

3.

Antenatal examination

4.

Essential investigation


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5.

Advice

History taking:-

a. History about current pregnancy:- LMP, menstrual cycle, bleeding P/V.

b.

Past obstetric history for multipariety:- pervious pregnancy and labour,

abortion, premature labour, intra-uterine death, eclampsia, still birth.

c.

General medical and surgical history:- heart disease, asthma, diabetes,

epilepsy, STDs.

d.

Family history:-diabetes, hypertension, genetic disease, twin birth.

e. Social history:- education, social status.

Antenatal examination:-

a. General examination:- height, weight, anemia, B.P., edema, jaundice, any

deformities.

b.

Obstetrical examination:-breast & nipples, fundal height, lie, presentation

& position of baby, FHS, vaginal examination.

Antenatal investigation:-

Hb, BG. RBS, pregnancy test, urine sugar, urine albumin, VDRL for syphilis, rubella

antibodies, tuberculin test, hepatitis B antigen, USG.

Antenatal advice:-

diet, personal hygiene, rest, sleep, exercise, drugs, avoid radiation, warning signs,

regular follow up, family planning, health education, child care.


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Warning signs:- mothers are advice to report immediately incase of following

warning signs:-

Swelling of feet, convulsion, blurring of vision, headache, per vaginal bleeding.

High risk pregnancy:

Pregnancy with added risk for complication of mortality and morbidity to be

faced by the mother and her unborn baby.

Causes of high risk pregnancy:-

1.Obstetric causes:-

Gravidity:- all Primigravida, grand multipara, elderly Primigravida

Age:- more than 35 yrs and less than 18yrs.

Height :- less than 5 feet.

Multiple pregnancy

Bad obstetric history:-previous repeated premature labour and abortion, Pre

eclamptic toxaemia, IUD, CPD, still birth.

Current pregnancy complication:- threatened abortion, PET, APH, twin pregnancy,

IUGR, low lying placenta.

2. Medical causes:-

HTN, DM, PTB, pyelonephritis, anemia, syphilis, hepatitis, psychiatric disorder.

Intra natal care:

Care of the mother at the time of delivery.


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Objective of intra natal care:-

1.

To ensure that mother receives the best available care during delivery.

2.

To prevent maternal mortality and morbidity.

Types of intra natal care:-

1.

Domiciliary/ home care

2.

Institutional/hospital care

1.Domiciliary/ home care:-

Mothers with normal obstetric history can be advice to have their confinement

in their own homes, provided the home condition are satisfactory. Such delivery

may be conducted by health worker, trained dai is known as domiciliary care.

Advantages :-

1.

Homely environment.

2. Cross infection less.

3.

Mother will be able to look after domestic works.

Dis advantages:-

1.

Less medical or nursing supervision.

2.

Mother will have less rest.

3.

Early bound with domestic works.

2.

Institutional/hospital care:-This recommended for all high risk pregnancy and where home condition is not

suitable.

The length of hospital stay vary with the nature of cases.

Advantages :-


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1.

More medical and nursing supervision.

2.

Mother gets more rest, better diet.

Dis advantages :-

1.

Cross infection more.

2.

Fear or nervousness to mother.

Postnatal care:

Care of mother and baby after delivery.

Importance of PNC:-

1.Helps in early detection & prevention of complication.

2.Helps to restore mothers health through rest and balance diet.

3.Educate and encourage mothers for breast feeding.

4.Counseling about spacing and family limitation.

Complication during postnatal period:-

Puerperal sepsis, thrombo-phlebitis, secondary PPH, UTI, mastitis.

Child health:

Live birth:- means that the child show signs of live when only part of the child is

out of mother, during delivery process.


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Still birth:-is one, which is born after 28 weeks of gestation, and did not breath or

show any other sign of life, after being completely born.

Dead birth:-is one, which has died in uterus and may shows sign of rigor mortis,

maceration or mummification after birth.

Perinate:- Period from 28 wks of gestation to 7 days of life.

Perinatal death:- death of fetus after 28 wks of gestation till 7 days of life.

Neonate:- period from birth to 28 days of life.

Neonatal death:-death of baby within 28 days of life.

Infant :- period from 7days of life till 1 year.

Infant death:- death of baby from 7 days till 1 year.

A. Immediate care of new born:

-Immediately after head is born, wipe eye, mouth and nose of baby.

-After baby is fully born wrap baby by warm cloth and keep in tray in warm

place.

-Care of airways:-clean mouth & nasopharynx. If secretion is present

cleaned by mucus sucker. Look for cry of baby, which initiate respiration.

-Resuscitation:-if baby dont cry for 1 minute, there is no respiration. Then

immediately resuscitation to be started by oxygen.

-Care of cord:-cut and ligate umbilical cord 5 cm away from base of

umbilicus and have to clean daily by antiseptics.

-Care of eye:-cleaned by sterile wet swab.

-Baby bath:- by Luke warm water.

-Feeding :-exclusive breast feeding.


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B. Assessment of the physical status of newborn by Apgar score:

A quantitative rating test based in activity, pulse, grimace, appearance,

respiration of a newborn a minute or so after birth. A score greater than 7

signifies good health with a maximum of 10.

Apgar scoring chart

C. Examination for abnormalities

-Cyanosis of lips & skin.

-Any difficulty in breathing.

-Imperforated anus.

-Persisting vomiting.


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-Signs of cerebral irritation. E.g.:-twitching, convulsion, neck rigidity, bulging of

anterior fontanel and temperature instability.

At risk babies:

Criteria of at risk babies:-

A.

Related to baby:-

1. Twin, low birth weight

2. Insufficient or absence of Breastfeeding.

3. Fail to gain weight during 3 successive months.

4. Loss of weight during 2 successive months.

5. Birth order more than 5.

6.Spacing less than 2 yrs.

B.Related to parents:-

1.Child with single parents.

2.H/O death of 2 or more siblings within 2 yrs.

Low birth weight:

According to WHO, a low birth baby is one with a birth weight of less than 2500gm, within the first hours of life, before significant postnatal weight loss.

Causes of LBW:-

A.

Maternal factors:-

-Nutrition:-malnutrition, iron & folic acid deficiency.


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-Infection:- UTI, syphilis, hepatitis.

-Chronic diseases:-DM, HTN, heart & renal diseases.

-Tumor:-ovarian

-Drugs:- phenobarbitone, methyl dopa, steroids.

B.

Obstetr ic factors:-

-Toxaemia of pregnancy

-Ante partum hemorrhage

-Premature rupture of membrane

C.

Uterine factors:-

-Uterine malformation, like bicornuate, septate.

D. Fetal factors:-

-Multiple pregnancy

-Hydramnious

-Intrauterine infection

-Congenital anomalies.

GOBI-FFF:

The UNICEF has put forward a set of 7 strategies for child health revolution,

popularly known as GOBI-FFF.

G:- growth monitoring (by growth chart)


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O:- oral rehydration(Rx. mild-moderate dehydration)

B:- breast feeding

I:- immunization

F:- female education

F:- frequent feeding

F:- family planning

Breast feeding:

Breast milk is ideal food for baby up to the age of 6 months.

The amount of milk required by the baby is 170ml/kg/day for the first 6 months.

Types of breast feeding:-

1. Demand feeding:- Breast milk is feed, whenever baby cries due to hunger.

2.

Regular feeding:- Breast milk is feed every 3 hourly during day time and 6

hourly during night time.

3.

Advantages of breast feeding

1. To baby:- Remember BREAST FEEDING

B:- Best for baby.

R:- Require no preparation.

E:- Economic.

A:- Antimicrobial factors like, lysozyme, lactoferrin.

S:- Sterile, safe, hygienic.

T:- Temperature accurate.


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F:- Free of infectious agent.

E:- Easily digestible.

E:- Easily available.

D:- Diarrhea prevention .

I:- Immunoglobine like, Ig G, Ig A, Ig D, Ig E, Ig M.

N:- Nutrient sufficient.

G:- Growth of jaw by suckling.

2. To mother :-

a. Psychological bonding between mother and baby.

b. Prevent ovulation and acts as contraceptives.

c. Prevent carcinoma of breast.

d. Removes excess fat deposition in body as fat goes to milk.

e. Suckling stimulate oxytocin release and helps evolution of genital organs.

Disadvantages of breast feeding:-

1.Maternal proximity i.e. bound with child.

2.Complication like breast abscess, crack nipple.

Contra-indication of breast feeding:-

Maternal cause :-

1.

Mother with severe psychiatric disorder.


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2.

Disease like:- active tuberculosis, chronic nephritis, septicemia, eclampsia,

breast tumor.

3.

Mother treated with anti cancer drugs.

Child cause :-

1.Galactosemia

2. Phenylketonuria

3. Gross prematurity of baby.

Difficulties in breast feeding:-

Maternal cause:-

1. Cracked nipple

2.

Breast abscess

3.

Poor health of mother

Baby cause:-

1.

Cleft palate.

2.

Cleft lip.

3. Cerebral trauma.

Colostrums:

It is the secretion of breast during first 2-3 days of delivery, which contains

greater amount of protein, calorie, antibodies and lymphocytes.

Contents of colostrum:-


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1.

Protein ( high)

2.

Sugar (less)

3.

Minerals (high)

4.

Antibody esp. Ig A

5.

Fat (less)

Importance of colostrum:-

1.Antibody esp. Ig A protect against infection.

2.Colostrum helps to sterile the small intestine, if it is contaminated by infected

swallowed during birth.

Weaning:

It is the process of gradual withdrawal of breast milk from breastfeeding child and

introduction of soft supplementary foods like soft rice, smashed potato, eggs

from 6 months of age.

Importance:-

1.To prevent from malnutrition like kwashiorkor, marasmus, immunodeficiency.

2.To prevent from infection like diarrhea, ARIs.

3.To prevent growth failure.

Artificial feeding:

It is a condition, when baby is completely deprived of mothers milk due to some

maternal or other factors and entirely dietary demand of baby is met from other

source of food.


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Causes of artificial feeding:-

1.

Failure of breast milk.

2.

Contraindication of breast milk.

3.

Death of mother.

Breast milk substitutes:-

Powder milk, cows milk, goats milk, vegetable milk.

Milk injury:

It is a condition developed when a baby is only breastfeed for prolong period of 1-

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years.

Due to deficiency of iron and vitamin C. Because, though milk is ideal food it

contains less vitamin-C and iron. So baby first develop iron deficiency anemia and

scurvy.

Baby become apathetic, dull, flabby, anemic, susceptible of infection, swollen

joints and bleeding manifestation.

Indicators of MCH care

1.

Maternal mortality rate (MMR)

2. Infant mortality rate (IMR)

3.

Neonatal mortality rate

4. Post- neonatal mortality rate

5.

Perinatal mortality rate

6. Under 5 (1-4yrs) mortality rate


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Maternal mortality rate (MMR):

It is the total number of death of woman during pregnancy, delivery or post

partum period not related with medical , surgical or accidental causes per 1000

live birth per a year in a given population.

Cause of high MMR:-

1.

Toxaemia of pregnancy

2.

Hemorrhage:- APH, PPH

3.

Obstructed labour

4.

Septic abortion

5. Poor ANC

6.

Severe anemia

Prevention of MMR:-

1.

Dietary supplementation including correction of anemia.

2.

Prevention of hemorrhage.

3.

Prevention of complication.

4.

Treatment of medical conditions like hepatitis.

5.

Promotion of family planning.

Infant mortality rate (IMR):

The total number of death of infant per 1,000 live births in one year.


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It is one of the most universally accepted indicator of health status.

Cause of high IMR:

A.

Neonatal cause (0-4 weeks):-

1.

Prematurity

2.

IUGR

3.

Birth injury and asphyxia

4. Congenital anomalies

5.

Neonatal tetanus

B. Post-Neonatal cause (1-12 months):-

1.

Lower respiratory tract infection.

2.

Gastro-intestinal and diarrheal disease.

3.

Communicable diseases.

4.

Sudden infant death syndrome.

Cause of under-5 mortality & their prevention:

Causes: Prevention1. Diarrheal disease2.

Measles

3. Acute respiratory infection

4. Malaria

5.

Tetanus

1. ORS2.

Measles vaccination

3. Antibiotics

4. Anti malarial drugs and

prevention of mosquito bite5.

TT immunization


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SEXUALLY TRANSMITTED INFECTIONS (STI):

Sexually transmitted infections (STIs) are infections whose primary route oftransmission is through sexual contact.

STIs can be caused by mainly bacteria, viruses, or protozoa.

In the developed world, viral diseases have become increasingly common and

important, whereas bacterial STIs are more common in developing countries, but

even this is changing with the increasing recognition of viral diseases.

The three most common presenting symptoms of an STI are urethral discharge,genital ulceration, and vaginal discharge with or without vulval irritation.

Trichomoniasis, pediculosis pubis, genital warts, chlamydial infections,

gonococcal infections and genital herpes are common

Scabies and vaginal candidiasis often are diagnosed in STI clinics, although they

are not usually acquired sexually.

Why STIs are important?

-Common

-Often asymptomatic

-Major complications and sequelae

-Expensive

-Synergy with HIV


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Protozoal STDs:Trichomoniasis

Viral STDs:HPV, HIV, Hepatitis B, Herpes simplex

Bacterial STDs: Gonorrhea, Syphilis, Chlamydia

Major sequel of STIs:

WOMEN MEN INFANTS

Cancers -cervical cancer

-vulval cancer

-vaginal cancer

-anal cancer

-liver cancer

-T cell leukemia

-kaposis sarcoma

-penile cancer

-anal cancer

-liver cancer

-T cell leukemia

-kaposis sarcoma

Reproductive health

problem

-Pelvic

inflammatory

disease

-infertility

-ectopic pregnancy

-spontaneous

abortion

-Epididymitis

-Prostatitis

-Infertility

Pregnancy related

problems

-preterm delivery

-premature rupture

of membranes

-puerperal sepsis

-postpartum

infection

-Still bith

-low birth weight

-pneumonia

-acute hepatitis

-congenital

abnormalities

Neurological

problems

neurosyphilis Neurosyphilis -cytomegalovirus

-herpes simplex

virus

-syphilis associated

neurological

problems

Other common

health

-Chronic liver

diseases

-Chronic liver

diseases

-Chronic liver

diseases


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consequences -Cirrhosis -Cirrhosis -Cirrhosis

Role of STIs in the acquisition of HIV

-HIV acquisition increases by twofold to fivefold in the presence of other STIs

-Ulcers disrupt mucosal integrity and increase the presence or activation, or both,

of HIV susceptible cells

-Non-ulcerative STIs (such as gonorrhoea, chlamydia,Trichomonas vaginalis, and

bacterial vaginosis) increase the presence or activation, of HIV susceptible cells

Size of the problem:

-The World Health Organization (WHO) has estimated a total of 340 million new

cases of curable STIs in adults per annum, mainly in South East Asia(151 million

new cases per year)and Africa(69million).

-In eastern Europe and Central Asia, the estimate is 22 million, and 17 million in

western Europe.

-The prevalence and incidence per million of the population varies regionally, for

example between sub-Saharan Africa and western Europe it is eightfold and

fourfold, respectively.

Why are STIs increasing?

-Attitudes towards sex and sexual behaviour have changed(Like many othermedicosocial conditions, suicide,alcoholism, cancer, and heart disease)

-Age at first intercourse has declined, and half of all teenagers have sex before

they are 17 years of age

-The number of lifetime male and female heterosexual partners has increased


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-The proportion of men and women who have concurrent relationships (having

more than one sexual partner at the same time) has increased

-Unsafe sex in homosexual men has increased

-Populations are now more mobile nationally and internationally.

-Certain groups (tourists, professional travellers, members of the armed forces,

and immigrants) are at risk.

-In addition, poverty, urbanisation, war,and social migration often result in

increased levels of prostitution.

Principles of control:

-Prevention can be aimed at uninfected people in the community to prevent them

from acquiring infection (primary prevention) or at infected people to prevent the

onward transmission of the infection to their sexual partners (secondary

prevention).

-The three basic elements of primary prevention are: health education,provision

of condoms, and social, cultural and economic interventions

Principles of effective STI control:

-Reduce infectiousness of STIs

-Condoms

-Reduce duration of infection

-Encourage diagnosis and treatment of symptomatic infection(encourage health

seeking behaviour) and asymptomatic infection (screening, partner notification,

and mass or targeted treatment)

-Reduce risky behaviour


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-Reduce rate of partner change

-Delay onset of sexual intercourse

-Improve selection of partners

Primary prevention:

-Behavioural interventions are aimed at enhancing knowledge,skills, and attitudes

to help people protect themselves against infection (for example, health

promotion to decrease partner change and increase condom use)

-Structural interventions are aimed at broader societal and economic issues that

drive the spread of STIs

-Biomedical interventions include condoms, vaccines, vaginal microbicides, or

male circumcision to prevent the acquisition of infection.

Ways for an individual to reduce their risk of contracting an STI:

-Abstain

-Have a mutually monogamous relationship with someone who is uninfected.

-Select partners whose past and current behaviour puts them at low risk of

infection.

-Consider both being screened for infection before unprotected sex

-Reduce the numbers of sexual partners

-Avoid sex with people who have symptoms of a STI or oral coldsores

-Use condoms consistently on every occasion with all partners

-In open relationships couples agree to have only non-penetrative or protected

sex outside their main relationship


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Structural interventions:

-Community level (for example, legislating to change the age of consent for

homosexual men or inheritance laws)

- Organisational level (for example, providing reproductive health clinics in

schools or the workplace)

- Individual level (for example, microfinance initiatives that seek to train women

to become less economically dependent

Secondary prevention:

-Enhancing health seeking behaviour

-Improving access to for STIs diagnosis and treatment

- Ensuring appropriate case management

- Early detection and treatment of symptomatic and asymptomatic infection

-Partner notification (contact tracing)

Specialist services for STIs:

- Genitourinary medicine

- Features of service

- Open access and free

- Confidential

- Screening and treatment for STIs

- Screening and treatment for HIV


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- Contraception and psychosexual problems

- Miscellaneous care (for example, for urinary tract infections and genital

dermatological conditions)

- Partner notification

- Health promotion, counselling, and advice

- Outreach and special services

- Training and research

Sexual history taking:

- Symptoms (including duration)

- Last sexual intercourse

- Sex of partner

- Relationship with partner (casual, long term,traceable, etc)

- Use of barrier contraception

- Sites of exposure (oral, vaginal, or anal)

- Last previous partner or partner change (with site of exposure and barrier

contraception history as above)

- Partners symptoms

- Previous STIs or testing for STIs including HIV

Control of Sexually Transmitted Infections:

The main principles of the control of STIs are to:


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- prevent new infections;

- treat those with symptoms of infection and interrupt onward transmission

such treatment should prevent the development of disease complications and

sequelae;

- identify and treat those without symptoms by screening and partner

notification;

- motivate health seeking behavior among those who may know they are infected

but who delay or avoid seeking treatment.

-high rates of infection among young adults, adolescents and certain groups (e.g.

commercial sex workers, truck drivers);

-asymptomatic infection;

-long-term morbidity, particularly in women;

- increased acquisition of HIV in transmission;

- disadvantaged and disempowered women;

-the complex mix of social, political, cultural, demographic and economic factors

Prevention & Control:

(I)

Prevention:The goals of medicine are to promote health, to preserve health, to restore health

when it is impaired, and to minimize suffering and distress.


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These goals are embodied in the word "prevention"

Definition:Actions aimed at eradicating, eliminating or minimizing the impact of

disease and disability, or if none of these are feasible, retarding the progress of

the disease and disability.

The concept of prevention is best defined in the context of levels, traditionally

calledprimary, secondary and tertiary prevention. A fourth level, called

primordial prevention, was later added.

Determinants of Prevention:

Successful prevention depends upon:

-a knowledge of causation,

-dynamics of transmission,

-identification of risk factors and risk groups,

-availability of prophylactic or early detection and treatment measures,

-an organization for applying these measures to appropriate persons or groups,

and

-continuous evaluation of and development of procedures applied

Preventable Causes of Disease:

Remember BEINGS

-Biological factors and Behavioral Factors

-Environmental factors


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-Immunologic factors

-Nutritional factors

-Genetic factors

-Services, Social factors, and Spiritual factors

Levels of Prevention:

1.Primordial Prevention2.

Primary Prevention

3. Secondary Prevention

4.

Tertiary Prevention

Primordial Prevention:

Primordial prevention consists of actions and measures that inhibit the

emergence of risk factors in the form of environmental, economic, social, and

behavioral conditions and cultural patterns of living etc.

It is the prevention of the emergence or development of risk factors in countriesor population groups in which they have not yet appeared

For example, many adult health problems (e.g., obesity, hypertension) have their

early origins in childhood, because this is the time when lifestyles are formed (for

example, smoking, eating patterns, physical exercise).

In primordial prevention, efforts are directed towards discouraging children from

adopting harmful lifestyles

The main intervention in primordial prevention is through individual and mass

education.

Primary Prevention:


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Primary prevention can be defined as the action taken prior to the onset of

disease, which removes the possibility that the disease will ever occur.

It signifies intervention in the pre-pathogenesis phase of a disease or health

problem.

Primary prevention may be accomplished by measures of Health promotion and

specific protection

It includes the concept of "positive health", a concept that encourages

achievement and maintenance of "an acceptable level of health that will enable

every individual to lead a socially and economically productive life".

Primary prevention may be accomplished by measures designed to promote

general health and well-being, and quality of life of people or by specific

protective measures.

Health promotion:

Health promotion is the process of enabling people to increase control over the

determinants of health and thereby improve their health.


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Approaches for Primary Prevention:

The WHO has recommended the following approaches for the primary prevention

of chronic diseases where the risk factors are established:

a. Population (mass) strategy

b. High -risk strategy

Population (mass) strategy:

Population strategy" is directed at the whole population irrespective of

individual risk levels.

For example, studies have shown that even a small reduction in the average blood

pressure or serum cholesterol of a population would produce a large reduction in

the incidence of cardiovascular disease

The population approach is directed towards socio-economic, behavioral and

lifestyle changes.

High -risk strategy:

The high -risk strategy aims to bring preventive care to individuals at special risk.

This requires detection of individuals at high risk by the optimum use of clinical

methods.

Secondary Prevention:

It is defined as action which halts the progress of a disease at its incipient stage

and prevents complications.


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The specific interventions are: early diagnosis (e.g. screening tests, and case

finding programs.) and adequate treatment.

Secondary prevention attempts to arrest the disease process, restore health by

seeking out unrecognized disease and treating it before irreversible pathologicalchanges take place, and reverse communicability of infectious diseases.

It thus protects others from in the community from acquiring the infection and

thus provides at once secondary prevention for the infected ones and primary

prevention for their potential contacts.

Tertiary prevention:

It is used when the disease process has advanced beyond its early stages.

It is defined as all the measures available to reduce or limit impairments and

disabilities, and to promote the patients adjustment to irremediable conditions.

Intervention that should be accomplished in the stage of tertiary prevention are

disability limitation, and rehabilitation.

Disability limitation:

Diseaseimpairmentdisabilityhandicap

Impairment: is any loss or abnormality of psychological, physiological or

anatomical structure or function.


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Disability: is any restriction or lack of ability to perform an activity in the

manner or within the range considered normal for the human being.

Handicap: is termed as a disadvantage for a given individual, resulting from an

impairment or disability, that limits or prevents the fulfillment of a role in thecommunity that is normal (depending on age, sex, and social and cultural factors)

for that individual.

Rehabilitation: is the combined and coordinated use of medical, social,

educational, and vocational measures for training and retraining the individual to

the highest possible level of functional ability.

(II) CONTROL:

Concept of control:

-The term disease control describes ongoing operations aimed at reducing:

-The incidence of disease

-The duration of disease and consequently the risk of transmission

-The effects of infection, including both the physical and psychosocial

complications

-The financial burden to the community.

-Control activities focus on primary prevention or secondary prevention, but most

programs combine both.

Disease Elimination:

Between control and eradication, an intermediate goal has been described, called

"regional elimination"


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The term "elimination" is used to describe interruption of transmission of disease,

as for example, elimination of measles, polio and diphtheria from large

geographic regions or areas

Regional elimination is now seen as an important precursor of eradication

Disease Eradication:

Eradication literally means to "tear out by roots".

It is the process of Termination of all transmission of infection by extermination

of the infectious agent through surveillance and containment.

Eradication is an absolute process, an "all or none" phenomenon, restricted to

termination of an infection from the whole world. It implies that disease will no

longer occur in a population.

To-date, only one disease has been eradicated, that is smallpox.

Monitoring:

Monitoring is "the performance and analysis of routine measurements aimed at

detecting changes in the environment or health status of population" (Thus we

have monitoring of air pollution, water quality, growth and nutritional status, etc).

It also refers to on -going measurement of performance of a health service or a

health professional, or of the extent to which patients comply with or adhere to

advice from health professionals.

Surveillance:

Surveillance means to watch over with great attention, authority and often with

suspicion


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According to another, surveillance is defined as "the continuous scrutiny

(inspection) of the factors that determine the occurrence and distribution of

disease and other conditions of ill-health"

Objectives of Surveillance:

The main objectives of surveillance are:

(a) to provide information about new and changing trends in the health status of

a population, e.g., morbidity, mortality, nutritional status or other indicators and

environmental hazards, health practices and other factors that may affect health

(b) to provide feed-back which may be expected to modify the policy and the

system itself and lead to redefinition of objectives, and

(c) provide timely warning of public health disasters so that interventions can be

mobilized.


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Evaluation of control:

Evaluation is the process by which results are compared with the intended

objectives, or more simply the assessment of how well a program is performing.

Evaluation should always be considered during the planning and implementation

stages of a program or activity.

Evaluation may be crucial in identifying the health benefits derived (impact on

morbidity, mortality, sequelae, patient satisfaction).

Evaluation can be useful in identifying performance difficulties.


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Evaluation studies may also be carried out to generate information for other

purposes, e.g., to attract attention to a problem, extension of control activities,

training and patient management, etc.

COMMUNICABLE DISEASES:

An illness due to a specific infectious agent or its toxic products capable of being

directly or indirectly transmitted from man to man, animal to animal or from the

environment to man or animal is termed as communicable disease.

Classification:

1.

Ar thropod-Borne I nfections:

a) Malariab)

Filariasis

c) Dengue

2.

Respiratory I nfections:

a)

Small pox

b) Chicken poxc)

Measles

d) Rubellae)

Mumps

f) Influenzag)

Diphtheria

h) Whooping cough

i)

Meningococcal meningitisj) Tuberculosis

3.

I ntestinal I nfections:

a)

Poliomyelitis

b) Viral hepatitisc)

Cholera


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d)

Typhoid fever

e) Food poisoningf)

Amoebiasis

g) Ascariasis

h) Hook worm infection

4.

Zoonsois: Those diseases and infections which are naturally transmitted

between vertebrate animals and man.

Zoonotic diseases may be due to viruses, bacteria, rickettsiae, fungi,

helminths, protozoa, arthropods or insects.

Viral:Rabies, Yellow FeverBacterial:Tuberculosis, Plaque, Brucellosis, Human SalmonellosisRickettsial:Scrub typhus, Tick typhus, Q feverProtozoal: Amebiasis, Toxoplasmosis, LeishmaniasisArthropod: ScabiesHelminthic: Hydatid DiseaseFungal: Dermatophytosis, Ring worm

5.

Sur face Infections:

a. Trachomab.

Leprosy

c.

Sexually transmitted diseasesd.

AIDS

e. Tetanus


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Common Water/Food Borne diseases:


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Malaria:

Malaria is a protozoan disease transmitted by the bite of infectedAnopheles

mosquitoes.

The disease is endemic in most of the tropics, including much of South and

Central America, Africa, the Middle East, the Indian subcontinent, Southeast Asia.

The four species of malaria parasites that affect humans differ in their geographic

distributions

P. falciparumis most common in sub-Saharan Africa and Melanesia

P. vivaxis found mainly in Central and South America, North Africa, the

Middle East and within the Indian subcontinent;

P. ovaleis found predominantly in West Africa but also in Asia; and

P. malariaeoccurs worldwide, although most cases occur in Africa.

Mode of Transmission:

-By bite of infected female Anopheles mosquito.

-Malaria may uncommonly be transmitted from mother-to-infant (congenital

malaria),

-by blood transfusion,

-and in non endemic areas by mosquitoes infected after biting infected

immigrants or travelers

Clinical Findings:


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-An acute attack begins with a prodrome of headache and fatigue, followed by

fever.

-A classic malarial paroxysm includes chills, high fever, and then sweats.

-Headache, malaise, myalgias, arthralgias, cough, chest pain, abdominal pain,

anorexia, nausea, vomiting, and diarrhea are common.

-Seizures may represent simple febrile convulsions or evidence of severe

neurologic disease.

Physical findings:- signs of anemia, jaundice, splenomegaly, and mild

hepatomegaly.

Regimens for the Treatment of Malaria:

Uncomplicated Malaria:

Chloroquine

OR

Amodiaquine

Multidrug-resistant P. falciparum malaria:-

Artesunateplus Mefloquine

Second-line treatment/treatment of imported malaria:-

Artesunateplus 1 of the following :1. Tetracycline2. Doxycycline

3. Clindamycin

Severe Falciparum Malaria:


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Quinine dihydrochloride

Control & Prevention:

Prevention requiresA, B, C and D.

Awareness of risk.

Bite avoidance.

Chemoprophylaxis (taking preventive medicines if you are travelling to or living in

a malaria region).

Diagnosis made promptly with early treatment of an infected case.

An Ecan be considered for remote adventure trips. The E stands for 'Emergency

treatment with safe drugs', such as Artemesin combined with Lumefantrine.

-Use of insecticides to kill the mosquito vector.

-Use of mosquito repellents Creams,

-Use of mosquito nets

Dengue fever:

Dengue fever is a disease caused by a flavivirus that are transmitted by

mosquitoes.

Dengue has been called the most important mosquito transmitted viral disease in

terms of morbidity and mortality. Dengue fever is a benign acute febrile

syndrome occurring in tropical regions. In a small proportion of cases, the virus

causes increased vascular permeability that leads to a bleeding diathesis or

disseminated intravascular coagulation (DIC) known as dengue hemorrhagic fever

(DHF).

Types:


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- Classical

- Dengue hemorrhagic fever

- Dengue shock syndrome


The dengue virus infections from the bite of an infected Aedes mosquito.

Mosquitoes become infected when they bite infected humans, and later transmit

infection to other people they bite. Two main species of mosquito, Aedes aegypti

and Aedes albopictus, have been responsible for all cases of dengue transmitted

in this country. Dengue is not contagious from person to person.

Clinical feature:

Classical: High fever:-up to 105F , Severe headache,Retro-orbital (behind the

eye) pain, Severe joint and muscle pain, Nausea and vomiting,Rash

Dengue hemorrhagic fever:-Symptoms of dengue hemorrhagic fever include all of

the symptoms of classic dengue plus, Marked damage to blood and lymph vessels,

Bleeding from the nose, gums, or under the skin, causing purplish bruises

Dengue shock syndrome:- Symptoms of dengue shock syndrome--the most

severe form of dengue disease--include all of the symptoms of classic dengue and

dengue hemorrhagic fever plus, Fluids leaking outside of blood vessels, Massive

bleeding, Shock (very low blood pressure)

Clinical criteria to hospitalize with Dengue fever:

-Severe abdominal pain

-Passage of black stool


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-Bleeding into the skin or from the nose or gums

-Sweating

-Cold skin

Treatment:

-The management of dengue fever is symptomatic and supportive, including

careful management of fever, bed rest, fluid balance, electrolytes and clotting

parameters, is crucial for the case management of dengue hemorrhagic fever.

-It is important to maintain hydration. Avoid aspirin.

-Dengue hemorrhagic fever is a potentially lethal complication, affecting mainly

children. Early clinical diagnosis and careful clinical management by experienced

physicians and nurses increase survival of patients.

Prevention:

Personal protective measuresare aimed at preventing mosquito bites during theday, particularly early morning and late afternoon.

-use personal insect repellents

-use insecticide mats to kill mosquitoes

-screen living and sleeping areas

-wear long, loose clothing when outdoors

-spray indoors in dark places (eg.behind cupboards, under beds)with knockdown

spray

-The best form to control is to get rid of dengue mosquito breeding sites around

the home.


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-Dengue mosquitoes breed in containers that hold water.

-These include buckets, tyres, pot plant bases, vases, boats and coconut shells.

-Roof guttering, rainwater tanks are also potential breeding sites.

Recommendations to control breeding include:

-tipping out containers which can hold water

-storing containers in a dry place

-throwing out rubbish that collects water

Filariasis:

There are eight different types of thread-like nematodes that cause filariasis.

Most cases of filaria are caused by the parasite known as Wuchereria bancrofti.

Depending on the area which the worms affect, filariasis is classified as:Lymphatic filariasis (Elephantiasis)which affects the lymphatic system,

including the lymph nodes.

Subcutaneous filariasis-which affects the subcutaneous layer of the skin.

Serous cavity filariasis-which affects the serous cavity of the abdomen.


Filariasis is a parasitic disease transmitted by blood -feeding arthropods, mainly

black flies and mosquitoes.


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Treatment:

Diethylcarbamazine (DEC) are available to treat filariasis.

Prevention:

Protect from the bites of filarial-spreading mosquitoes by using mosquito

repellent creams, mats, coils, aerosols and prevent breeding of mosquitoes with

better practice of hygiene and sanitation.

Chicken Pox:

Is highly infectious, acute contagious disease predominantly of children, though it

may occur at any age. It is characterized by fever and a rash, it is caused by

vericella zoaster virus. Chicken pox is the skin lesions to boiled chick- peas.

Epidemiology:

Occurance:Occurs world while in both epidemic and endemic forms.

Ecological Triad:

Agent: vericella zoaster (DNA virus member of herpes virus).

Host: children under 10 years of age, both sexes are susceptible.

Natural History:

Reservoir: Is a case of chicken pox.

Infective materials:Oropharyngeal secretions, lesions of the skin and mucosa.

Mode of transmission:

Respiratory droplets, direct contact.

Clinical Features:


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Prodormal symptoms: Fever, Malaise, Anorexia.

Fist sign:Appearance of a characteristic rash in crops on the trunk on second

day of illness.

The rashes spread to head and extremities. Macule- papules- vesicles-

pustules- crusts. Itching is marked.

Prevention and Control:

Prevention:

Notification.

Isolation in early first week.

Disinfection of discharges from nose, throat, skin, lesions.

Immunization.

Treatment:

Antiviral therapy for immunocompromised.

Local antiseptic: Dettol, betadine, savion etc if secondary infections.

Symptomatic therapy: Analgesic, antipyretics, anti uritics.

Influenza:

commonly called "the flu," is an illness caused by RNA viruses that infect the

respiratory tract of many animals, birds, and humans. In most people, the

infection results in the person getting fever, cough, headache, and malaise (tired,


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no energy); some people also may develop a sore throat, nausea, vomiting, and

diarrhea.

Type:

Influenzavirus A

Influenzavirus B

Influenzavirus C

Route of transmission:

The virus is transmitted easily from person to person via droplets and small

particles produced when infected people cough or sneeze. Influenza tends to

spread rapidly in seasonal epidemics.

Treatment:

Treatment is usually symptomatics

Amatadine and rimantidine are active only against influenza A.

Prevention:

Vaccination: H1N1 vaccine

Controlling the spread of infection:

The influenza vaccine isn't 100 percent effective, so it's also important to takemeasures to reduce the spread of infection:

Wash your hands.

Contain your coughs and sneezes.Cover your mouth and nose when you

sneeze or cough.


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Avoid crowds.

Measles:

is an acute highly infectious disease of childhood caused by paramyxovirus and is

clinically characterized by fever, symptoms of upper respiratory tract (coryza,

cough) followed by typical rash.

Ecological Trait:

Agent: measles ( paramyxo virus RNA virus),

Age:Children( 6 months3 years).

Measles tend to be very serious in malnutritionised children, mortality is 400

times higher. Both sexes are affected.

Immunity:One attack of measles gives immunity for life infant acquired

immunity transplacentaly from mothers who have had measles or measles

immunization. This immunity is usually completed for first 4-6 months of life.

Environment:Incidence is higher in spring and winter.

Incidence is higher in densely populated urban areas.

Natural history:Reservoir is a case of measles.

Source of infection:Nasopharyngeal secretions, lacrimal secretions, urine.


Directly from person to person by droplet infection, droplet nuclei (non-living

substances). Fomites, air borne.


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Prevention and Control:

Control measures:

1) isolation

2) bed rest

3) supportive treatment (vit A, vit.A/B)

4) immunization of contacts within 2 days of exposure.

Preventive measures:

1) active immunization (9months,0.5cc,intramuscular/sc,deltoid).

2) passive immunization (human gamma globulin

0-25ml/kg intramuscular within 5 days of exposure.

Vaccines:-Doses and schedule (0.5ml - s/c - 9months.)

Mumps:

Mumps (epidemic parotitis) is an acute contagious disease caused by a

paramyxovirus that has a predilection for glandular and nervous tissue. It occurs

most commonly in children, is usually self-limited, and is clinically characterized

by nonsuppurative parotitis.


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Epidemiology:

Mumps, historically known as epidemic parotitis, was one of the most

common early childhood infections,

Reported cases of mumps have dropped 98% when compared with the

prevaccine era.

It spreads primarily in late winter and early spring

Common in both sexes,5-15 years but all are susceptible

Infectivity is lost heating at 55 to 60C for 20 minutes and after exposure toformalin or to ultraviolet light.

Infectivity is maintained for years at temperatures of -20 to -70C.

Natural history:

Reservior is the source of infection

Infective material : salivary secretion


Direct contact,droplet infections


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Entry via nose and mouth,Exit via salivary secretion

Treatment:

Conservative measures to provide symptomatic relief and adequate hydration

and nutrition.

There is currently no established role for antiviral drugs, corticosteroids, or

passive immunotherapy in the treatment of mumps

Control of Mumps:

Vaccine:Live-virus mumps vaccine is administered 0.5 cc ; commonly given in

combination with MMR (measles, mumps, rubella) vaccine

First dose is recommended at from 12 to 15 months of age

Second dose is recommended at school entry (age 4 to 6 years)

If no preschool dose is given, the second dose should be administered before

age 12

MMR Vaccine Contraindications:

Pregnancy

Febrile illness

Planned pregnancy within 3 months

Severe immunocompromised state

Blood product or immune globulin within 3 to 6 months (dose dependent)

Anaphylaxis to neomycin


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MMR Vaccine Should Be Used with Caution in These Situations:

Seizure disorder

Thrombocytopenia

Egg allergy

Isolation Precautions:

Respiratory isolation should be maintained for 9 days after onset of parotitis

Infected children should be excluded from school and daycare during this

period

Pertusis:

Whooping cough(pertusis) - is a bacterial infection of the respiratory system,

caused by B. Pertusis and is clinically characterised by an insidious onset with mildfever and an irritating cough.

Whooping cough got its name because kids who had pertusis cough a lot, and in

between coughs, they'd make a "whoop" sound when they tried to get a breath.

The child is short of breath, inhales deeply and quickly between coughs. These

breaths frequently make a whooping sound. (loud crowing inspiration)

Note:-In china this disease referred as 100 day cough, so parents can understand .

Epidemiology


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Causative agent: Bordetella pertussisa gram negative bacilli which attacks

the lining of the breathing passages, producing severe inflammation and

narrowing of the airways.

Source of infection: A case of pertusis.

Infective material:Nasopharyngeal and bronchial secretions.

Host Age: It occurs at all ages but 90% of cases are children under 5 years of

age.

Sex-Female children are affected more than a male children

Environmental factors:Common in winter season, due to overcrowding, socio-

economic condition


Mainly by droplet infection, (through nasopharyngeal and bronchial

secretions) and by direct contact with infected person.

Risk groups: Children who are too young to be fully vaccinated and those who

have not completed the primary vaccination series are at highest risk for

severe illness.

Pertussis is highly contagious with up to 90% of susceptible household

contacts developing clinical disease following exposure to an index case.

Adolescents and adults become susceptible when immunity wanes.

Treatment:

is based on antibiotic therapy, which may also be prescribed to other members

of an infected person's household to prevent the spread of infection.


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Symptomatic:

Admission criteria:-If < 6 months of age. If older child who has apnoeic or

cyanotic spells.

Antibiotic treatment in whooping cough:

antibiotics are effective, but do not alter the clinical course of the illness

3 days of azithromycin.

Seven days of clarithromycin.

Seven or 14 days of erythromycin.

Complication like Bronchopneumonia should be treated according to C/S.

O2 Inhalation for cyanosis.

Some time mild sedation may be necessary for spasms.

Fluid and nutritional should be appropriate.

Steroids some time said to reduce disease course.

Control:

Early diagnosis, isolation and treatment of cases and disinfection of the

discharge from nose and throat.

Avoid contacts

Active immunization. DPT immunizations are routinely given in 3 doses, each

0.5 ml at 6, 10 and 14 weeks intramuscularly.

Following immunization, a gradual drop in immunity takes plac

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