1. GOLDEN POINTS IN ENVIRONMENTAL HEALTH PROBLEMS

POLLUTION  

• Pollution is introduction of contaminants into the natural environment that cause adverse change (Wikipedia). These contaminants are called pollutants. Pollutants can be natural or man-made.
• Pollution can be of several types e.g. air pollution, water pollution, soil pollution, noise and radiation pollution. Each type of pollution has its own characteristic health hazards.

AIR POLLUTION

• The term air pollution signifies the presence in the surrounding atmosphere of the substances (e.g. gases, mixture of gases and particulate matters) generated by human activities in concentrations that interfere with human health, safety or comfort, or injurious to vegetations, animals & other environmental media. (K Park, 27th edition).
• Air pollution now a days is a big public health problem throughout the world including India. Air pollutants are either or both emitted into the atmosphere (Primary air pollutants) or formed in the atmosphere itself (Secondary air pollutants). One can measure the amount of pollutants emitted at the source but it is not possible for secondary air pollutants. Air pollutants can be gaseous or particulate matters.
• HEALTH HAZARDS OF AIR POLLUTION

• Acute bronchitis
• Chronic bronchitis
• Lung cancer 
• Emphysema
• Respiratory allergies
• Respiratory tract infections
• Impaired children’s neuro-psychological development  (lead pollutants)
• Exacerbations of COPD & asthma

WATER POLLUTION

• In India, water pollution is becoming a serious problem due to rapid urbanization and industrialization. Water pollution is the contamination of water bodies, resulting from human activities, so that it negatively affects its uses.
• HEALTH HAZARDS OF WATER POLLUTION 

Health hazards due to water pollution can be broadly classified as biological,   chemical & other hazards.

1. BIOLOGICAL HAZARDS

Due to presence of an infective agent or an aquatic host in the water.

1. DUE TO PRESENCE OF INFECTIVE AGENTS

• Viral diseases

• Viral hepatitis A & E
• Poliomyelitis
• Rotavirus diarrhoea

• Bacterial Diseases 

• Typhoid fever
• Paratyphoid fever
• Cholera
• Bacillary dysentery
• E.coli diarrhoea

• Protozoal diseases

• Amoebiasis
• Giardiasis

• Helminthic diseases

• Ascariasis
• Enterobiasis
• Trichuriasis
• Hydatid disease

• Leptospiral diseases 

• Weil’s disease

1. DUE TO PRESENCE OF AQUATIC HOSTS

1. Snail – Schistosomiasis (Bilharziasis)
2. Cyclops – Guinea-worm & Fish tapeworm diseases.

1. CHEMICAL HAZARDS

Due to presence of certain harmful substances or presence of higher or lower concentration in water.

• Deficiency of fluorides – Dental caries
• Excess of fluorides – Dental fluorosis (in children) & Skeletal fluorosis (in adults & elderly)
• Deficiency of iodine – Goiter
• Excess of nitrates – Cyanosis in infants
• Dissolved organic & inorganic substances (sulphates, chlorides & mica) – Diarrhoea & GI upset
• Salts of lead, iron & zinc – Constipation & colicky abdominal pain
• Excess of lead – Lead poisoning (Plumbism)  

1. OTHER HAZARDS

• Contact with contaminated water

• Infections of eye, ear, nose and throat
• Ringworm infections of foot
• Vulvo-vaginitis

• Diseases due to inadequate use of water  (water washed disease) 

• Trachoma
• Conjunctivitis
• Scabies
• Shigellosis

• Due to breeding of vector in water – Mosquito borne diseases

• Malaria
• Filaria
• Dengue fever
• Chikungunya fever
• Japanese encephalitis

• Hardness of water – 

• Soft water – Cardiovascular diseases

HAZARDS OF NOISE POLLUTION

Can be broadly grouped as auditory and non-auditory.

1. AUDITORY HAZARDS

1. QUANTIFIABLE AUDITORY HAZARDS

• Threshold shift
• Auditory fatigue
• Deafness 

• Temporary (4000-6000 Hz)
• Permanent (>100 dB continuous exposure)

• Rupture of tympanic membrane leading to permanent deafness (exposure to >160 dB)

1. NONQUANTIFIABLE AUDITORY HAZARDS

• Tinitus
• Vertigo

1. NON-AUDITORY HAZARDS

• Interference with speech communication
• Annoyance
• Lack of concentration
• Decreased work efficiency
• Physiological Changes 

• Rise in BP
• Disturbance in sleep
• Headache
• Fatigue etc.

HAZARDS OF RADIATION POLLUTION

May have acute and chronic effects – 

ACUTE EFFECTS 

• Acute radiation syndrome
• Death due to cerebral oedema or cardiac failure

CHRONIC EFFECTS

1. SOMATIC EFFECTS

• Cataract
• Foetal malformations
• Skin lesions (erythema, oedema, blister, ulcer)
• Hyperkeratosis of skin
• Atrophy of sebaceous glands
• Cancers of lung, skin, blood 
• Aplastic anemia & tumors

1. GENETIC EFFECTS – when gonads are exposed.

Chromosomal & point mutations.

SAFE & WHOLESOME WATER

Water to be used for human consumption should be both safe and wholesome. Safe & wholesome water is defined as – 

1. Free from harmful chemical substances
2. Free from pathogenic agents
3. Pleasant to the taste
4. Free from colour, odour & turbidity
5. Useful for domestic purposes

If water does not follow above norms, it is said to be polluted or contaminated. (Park 27th edition).

SANITARY SOURCES OF WATER

There are three main sources of water which can be abstracted from any point in Water Cycle. These sources are – 

1. Rain Water
2. Surface water

• Impounding reservoirs
• Rivers & streams
• Sea 
• Tanks, ponds & lakes

1. Ground water

• Shallow well water
• Deep well water
• Sanitary well water
• Springs

• Rain water

• Purest water in nature.
• Very soft water containing traces of dissolved solids.
• Corrosive to lead pipes.
• Relatively free from pathogenic agents.
• Becomes impure while passing through the atmosphere.
• Not a good source of safe & wholesome water unless treated after collection.

• Surface water

• Originates generally from rain water.
• Main source of water supply in many towns and areas e.g. Varanasi, Haridwar, Kanpur etc.
• Examples include rivers, tanks, lakes, ponds, reservoirs and sea.
• Prone for contamination by human and animal activities.
• This source has higher chance of organic, chemical, bacterial or biological contamination.
• Becomes safe & wholesome water only when water undergoes water purification process.
• Sea water should be first desalted, demineralized and purified before consumption. Demineralization of sea water is a costly affair.

• Ground Water

• Formed by percolation of rain water into ground.

• Main source of water in majority of areas.

• Most cheap & practical way for providing water to small communities.

• Far superior than surface water as ground acting as an effective filtering medium.

• Advantages include – 

1. Free from pathogenic agents
2. Regular supply (yield) even during hot season
3. Less chance of contamination
4. No treatment required

• Disadvantages include – 

1. High mineral content
2. Requires uplifting of water

• Sources of ground water are shallow/deep well, dug/bore well and springs.

• WELLS 

• Wells are an artificial pit or hole, immersed into the ground to reach the subsoil water.
• Shallow wells create a health hazard to the community as it generally gets contaminated from neighbourhood areas e.g. latrines, urinals, drains soakage pit etc.
• Both shallow and deep wells, when made sanitary, becomes a good source of safe and wholesome water.
• ARTESIAN WELLS, a type of deep well, is not common in India.

                            (Difference between Shallow well & deep well)

• Tube wells are important source of water supply in rural India. Tube well has a pipe sunk into the water bearing stratum with a strainer at the bottom and a hand pump at the top. A water tight concrete platform with a surrounding drain is generally provided.

• Most of the tube wells which were shallow wells are being replaced by deep tube wells with India Mark II hand pump at the top.

• In all kinds of well, to avoid contamination, there should be no source of liquid or solid wastes at least 15 meter (50 feet) surrounding the well. 

• Springs

• In springs, ground water comes to the surface under the natural pressure and flows freely.

• May be shallow or deep springs

• Exposed to contamination

• Should be protected from contamination by well-built protective structures.

• Sanitary well

• It is an ideal well which is located appropriately, well-constructed, protected against contamination and yields safe water.

• It should be located preferably in an elevated area, at least 60 meter (not more than 100 meter) away from human community.

• Should be lined by stones and cement up to a depth of 6 meter so that water comes in well from the bottom, not from sides.

• Parapet wall lining should be extended up to 1 meter above the ground level so that surface washings could not enter well directly.

• A concrete platform of about 1 meter, around the well, sloping towards periphery and having a pucca drain should be constructed so that surface washings drained to a distance beyond the core of filtration.

• Well should be covered to avoid animal and human contamination.

• A hand pump should be fitted at top with a pump to uplift the water.

• Cleanliness around well should be maintained.

PURIFICATION OF WATER ON SMALL SCALE

HOUSEHOLD PURIFICATION OF WATER

Aim is to provide safe and wholesome water. Three methods are used – 

• Physical methods
• Chemical disinfection
• Mechanical methods

PHYSICAL METHODS 

• Boiling
• Ozonation
• Ultraviolet irradiation

• BOILING 

• Less costly and best method.
• Nearly all organisms, spores, ova, cysts etc. are destroyed.
• To sterilize the water, rolling boil for 5-10 minutes are required.
• Removes temporary hardness.
• Resulting water is tasteless.
• No residual protection of water from contamination.
• Should be boiled in same container in which to be stored to protect from contamination during storage.

• Ozonation 

• Ozone is an unstable compound and a powerful oxidizing agent.

• Ozone air is passed through water.

• Destroys the pathogens including viruses.

• Also destroys phenolic substances responsible for bad odour, colour and taste.

• No residual protection provided.

• Costly affair.

• Dose of Ozone – 0.2 to 1.5 mg/L of water.

• Ultraviolet Irradiation

• Direct exposure of 1.5 cm thick film of water with UV rays of mercury vapour quartz lamp.

• On shorter exposure, destroys pathogens.

• On longer exposure, destroys spores.

• Thinner the water film, rapid will be UV rays absorption.

• No residual protection.

• Highly costly.

• Colour, turbidity and iron in water reduces absorption of UV rays.

CHEMICAL DISINFECTION

• Bleaching powder (CaOCl2)

• Have pungent smell of chlorine.

• When fresh, contains about 33% of available chlorine.

• Loses its chlorine content on exposure to light, moisture and air.

• Stabilized bleach 1) retains strength of available chlorine 2) prepared by mixing with excess of lime.

• Should be stored at dry, cool and dry place in a corrosion resistant closed container.

• Frequently chlorine content of stored bleaching powder should be checked.

• Highly turbid & polluted water is not suitable for it.

• The principle is to ensure a free residual chlorine of 0.5 mg/L after one hour contact period.

• Chlorine solution

• May be prepared from mixing bleaching powder with water.
• Different strengths of solution are available in the market.
• Loses its chlorine content on prolonged storage or exposure to light.
• Storage condition is similar to bleaching powder.

• High test hypochlorite (perchloron)

• A calcium compound which contains 60-70% of available chlorine.
• More stable.
• Less loss of chlorine on storage.
• Solutions are used for water disinfection.

• Chlorine tablets

• Useful in disinfecting small quantity of water.

• A single tablet of 0.5 gram disinfects 20 liters of water.

• May be used in small camps.

• Iodine 

• Useful for emergency disinfection of water.

• 2 drops of 2 % ethanol solution of iodine disinfects one liter of clean water.

• A contact period of 20-30 minutes is required for effective disinfection.

• Active iodine activity (Thyroid activity) and higher costs are major disadvantages.

• Potassium permanganate

• Not recommended now for water disinfection.

• Not effective in killing all types of organisms and spores.

• Alters the colour, smell and taste of water.

MECHANICAL METHODS

1. Pasteur Chamberland filters
2. Berkefeld filter
3. Katadyn filter
4. Aqua guard
5. Multi-stage Reverse Osmosis Purification Machine

• Makes water chemically & microbiologically potable.
• Reduces the total dissolved solids, hardness and heavy metals and removes pathogens (reverse osmosis cartridge).
• Removes suspended particles e.g. dust, mud & sand (clarity cartridge).

The essential part of the first three filters, is called ‘Candle’, or ‘Tube’, which is made up of porcelain in the P-C filter and of kieselgarh or infusorial earth in the Berkefeld filter and a coat of silver catalyst on the candle in Katadyn filter (Suryakanth 3rd edition).

PURIFICATION OF WATER ON LARGE SCALE

• Aim is to provide safe and wholesome water to consumers.
• Generally ground water does not require any treatment except disinfection.
• River water or other surface water generally undergo all steps of purification process.
• Steps of water purification comprise of one or more of the following measures – 

1. Storage
2. Filtration
3. Disinfection

• STORAGE – 

• Water to be purified is stored in natural or artificial reservoirs or storage tanks.
• Water is stored generally 1-2 days in these tanks.
• As a result, water is purified physically, chemically and biologically to some extents.
• Physical purification results from settlement at bottom of the heavier particles and suspended impurities by the gravitational force.
• Chemical purification takes place when anaerobic bacteria oxidizes the organic matter with the help of dissolved oxygen.
• Biological purification results from the natural death of some of the pathogens.

• FILTRATION – 

• Second step of purification of water.

• Aim is to remove the pathogens and suspended impurities which are left in water after storage.

• Sand is found to be effective filtering medium.

• Two types of filter are generally used –

1. Slow Sand Filters
2. Rapid Sand Filters

• Slow Sand filters (Biological Filters)

• Historically, method was first used in England in 1804.

• These filters require large area and constructed below the ground to a depth of about four meters.

• It is a rectangular masonary tank, measuring about 0.1 to 1.0 acre area.

• Two or more of such tanks are constructed ensuring at least one or more tanks remain functional for maintaining water supply.

• Components of a slow sand filter are (Suryakanth 3rd edition) – 

1. Supernatant raw water column
2. A bed of graded sand & graded gravel
3. An underdrainage system
4. A system of filter control valves

• Supernatant raw water column 

• There is supernatant raw water column above the sand bed with a depth of 1 to 1.5 meters.

• This level of supernatant raw water is always maintained.

• This serves two functions – 

• By providing constant overhead of water helps to overcome the resistance of filter bed and promote the downward flow of water through the sand bed.

• Providing waiting period of 3-12 hours allowing partial purification of water by sedimentation, oxidation and particle agglomeration.

• Sand bed & bed of graded gravel

• Most important part of the filter.

• Thickness of sand bed is about 1 meter.

• Sand particles have effective diameter of 0.2 to 0.3 mm.

• Sand should be free from clay & organic matter.

• Sand bed is protected from loss by undercover graded gravel (fine & coarse), 30 – 40 m deep.

• Sand bed represents a vast surface area, one cubic meter of filter sand represents a surface area of 15000 sq. m.

• Slowly water percolates through sand bed taking 2 or more hours.

• As water passes through sand bed, it undergoes physical, chemical and biological purification.

• Designed rate of filtration is 0.1 to 0.4 meter cube per meter square per hour.

• When installed, initially it is a mechanical filter till the biological/ vital / zoogleal layer is formed on the sand bed. 

• This vital layer is the heart of the slow sand filter.

• This layer consists of threadlike algae, plankton, diatoms and bacteria.

• After its formation, biological and chemical purification of water starts.

• Formation of vital layer is also termed as ripening of filter.

• One has to discard the filtered water till vital layer is fully formed.

• Filter removes 99.99% bacteria from water.

• Under drainage system

• Under drainage system consisting of porous or perforated pipes, remains present at the bottom of filter bed.
• It not only supports the filter medium above but also provides an outlet of filtered water.

        FILTER BOX –  (park 27th edition page 839)

• It is an open box, usually rectangular in shape, 2.5 to 4 meter deep and build partially or completely below the ground.
• Walls are made up of stones, brick or cement.
• Consists of supernatant raw water (1-1.5 m deep), Sand bed & gravel bed (1.5 m deep) and under drainage system (0.16 m).

• Filter control valves

• To maintain a constant rate of filtration, filter contains valves & devices in the outlet pipe system.
• Venturimeter which measures bed resistance or loss of head is an important component of regulation system.
• When resistance of filter bed is high, operator opens the regulating valve to maintain steady rate of filtration.
• When the loss of head exceeds 1.3 meter, it is not useful to run the filter.

        Advantages of slow sand filter – 

        It is still the preferred method of water purification in many countries because – 

• Simple to construct & operate
• Cost of construction is cheaper
• Quality of water produced is of high standards in terms of physical, chemical & bacteriological quality.

         Disadvantages of slow sand filter – 

• Occupy large area.
• Rate of filtration is slow.
• Not very effective in removing colour & colloidal matter.
• Some standards of water quality cannot be met.
• Long period required for filtration.

• RAPID SAND FILTERS (MECHANICAL FILTERS)

• First used in USA in 1885.

• Based on the finding that pretreatment of water with a coagulant (alum) to remove the turbidity followed by sedimentation process not only improves the quality of water but also increases rate of filtration.

• Generally of two types – 

• Paterson’s gravity type – water gets filtered through the sand bed by its own weight.

• Candy’s pressure type – under pressure (more than atmospheric pressure) water is passed through sand bed.

1. PRELIMINARY TREATMENT 

• Preliminary treatment raw water is done before passing it to sand bed of rapid sand filter.
• Steps of preliminary treatment are – 

1. Aeration with oxygen
2. Coagulation & rapid mixing with alum
3. Flocculation for 30 minutes
4. Sedimentation for 5-6 hours.

• Advantages of preliminary treatment of raw water are – 

1. Removes colour, taste & odour producing compounds.
2. Oxidizes iron and manganese.
3. Removes CO2 & hydrogen sulphide.
4. Aluminum hydroxide floccules entangles the bacteria, colloidal the bacteria, colloidal particles, fungi, algae etc.
5. Improves overall quality of water.
6. Increases rate of filtration.

1. TYPES OF RAPID SAND FILTERS 

• GRAVITY FILTERS – 

• Constructed in 90 sq. m. area.
• Height of sand bed (fine & coarse) is about 1 meter.
• This is supported by a layer of 0.5 m height of coarse gravel.
• Height of water column (supernatant raw water) is 1.5 meter.
• At the bottom porous or perforated pipes are present.
• Function of perforated pipes is to support the gravel bed and drain the filtered water.
• Rate of filtration is 5-15 meter cube /meter square /hour.

• PRESSURE FILTERS

• Filtering media is divided into 3 layers – 

1. Sand & Gravel – Top layer
2. Polarites – Middle layer
3. Fine grit – bottom layer.

• Lower layer is again of sand & gravel.

1. FILTRATION

• A slimy layer is formed on the top of sand beds due to deposition of Aluminum hydroxide floccules in the sand bed.
• This slimy layer helps in purification of water similar to vital or biological layer in slow sand filter.
• As the time passes, layer becomes thick to thicker ultimately clogging the filter.
• As a result, resistance to the filtration of water increases slowly and steadily.
• Loss of hydraulic head denotes resistance to filtration.
• As a result, filters are stopped & cleaned by BACK-WASHING, when loss of hydraulic head approaches 7-8 feet.

Difference between slow sand filter and rapid sand filter

DISINFECTION OF WATER

• It is the final step of water purification.
• Disinfection of water is done by adding chlorine following filtration.
• Mr. G A Johnson in 1908 started the use of chlorine compound for disinfection of water.
• Chlorine is an effective disinfectant as well as strong oxidizing agent.
• It destroys nearly all the pathogens present in water except spores, ova, cysts and certain viruses such as Hepatitis A & Polio virus, requiring high concentration of chlorine for their destruction.
• Chlorine also destroys algae & fungi, which are responsible for bad odour & taste in water.
• Chlorine also oxidizes organic substances such as excreta, sewage etc. & ammoniacle substances. It also oxidizes iron, manganese & hydrogen sulfide.
• Chlorine is available in gaseous (Chlorine gas), liquid (chloramine) & solid (bleaching powder, perchloron or high test hypochlorite & Dihydrochlorite of calcium) forms.

Chlorine Gas – 

• Chlorine gas is highly toxic in high concentration therefore released slowly during disinfection of water by using a regulator known as CHLORONOME APPARATUS.

• Chlorine gas is used for purification of water in big plants in big cities.

Chloramine – 

• Chloramine is a mixture of chlorine with ammonia.

• Chloramine releases chlorine slowly over a prolonged period of time thus providing a long duration protective action.

• Disadvantage is that it’s use is expensive.

Bleaching Powder – 

• Also known as monohypochlorite of calcium.
• It is the chlorinated lime.
• Prepared by passing chlorine gas over hydrated lime.
• It is a white, amorphous, hygroscopic powder having smell of chlorine.
• It is an unstable compound and fresh preparation contains 33.3% of available chlorine.
• The entire chlorine content of bleaching powder is lost over a period of 3 months.
• Bleaching powder should be stored in cool, dry and dark place in brown coloured bottles with air tight lids.
• Nearly 2.5 gram of bleaching powder is required to disinfect about 1000 liters of water.
• Exact amount of bleaching powder required to disinfect a set of water can be calculated by HORROCK’S APPARATUS.
• When large amount of lime is mixed with bleaching powder in the ratio of 4:1, it stabilizes the chlorine content of bleaching powder & is called a Stabilized Bleach.
• Stabilized bleach retains its chlorine content up to 1 year.

High test hypochlorite (HTH) or Perchloron – 

• A calcium compound, provides 70-75% of available chlorine.
• Highly stable.
• Dose for disinfection of water is 1 gram per 1000 liters of water.
• On storage, chlorine depletes very slowly. 

Dihydrochlorite of calcium – 

• Contains double chlorine in comparison to bleaching powder.
• There is less tendency to lose its chlorine content on exposure to air.

Action of chlorine – 

• When chlorine is added to water, hydrochloric acid (HCL) and hypochlorous acid (HOCL) are formed. 

• HCL is neutralized by alkalis present in water. Hypochlorous acid ionizes to form hydrogen ions & hypochlorite ions.

• Effect of chlorine as disinfectant is mainly due to hypochlorous acid and to a small extent due to hypochlorite ions.

• Chlorine acts best when pH of water is around 7. Low temperature and high pH reduces the efficiency of disinfectant chlorine.

• As the pH of water increases, hypochlorous acid gets ionized rapidly to hypochlorite ions, becoming unavailable for disinfectant action

Principles of Chlorination – 

• Water requiring chlorination should be clear and free from turbidity.
• CHLORINE DEMAND – 

• Chlorine demand of the water to be disinfected should be estimated.
• Chlorine demand is the amount of chlorine required by the water for its purification.
• Estimated indirectly by calculating the difference between the amount of chlorine added to water and the amount of residual chlorine remaining at the end of contact period.

• BREAKPOINT CHLORINATION – 

• The point at which chlorine demand is met and free residual chlorine is met and free residual chlorine just starts appearing is called as breakpoint chlorination.
• When chlorine is further added, beyond breakpoint, it remains in the free state as free residual chlorine.

• CONTACT PERIOD – 

• It is the time required for the chlorine to disinfect the water.
• Contact period of one hour is optimum.

• FREE RESIDUAL CHLORINE – 

• The minimum recommended concentration of free residual chlorine is 0.5 mg/L for one hour.
• Free residual chlorine protects from subsequent contamination during storage and distribution.

• CORRECT DOSE OF CHLORINE FOR DISINFECTION – 

• Chlorine demand of water + Free residual chlorine.

• SUPERCHLORINATION – 

• Super-chlorination followed by dechlorination consist of adding large amount of chlorine to water and then removing excess of chlorine after disinfection.
• Suitable for heavily polluted water.

Orthotolidine (OT) Test – 

• Determines both free and residual chlorine in water with accuracy.
• Reagent is analytical grade orthotolidine dissolved in 10% solution of HCL.
• Test is done by adding 0.1 ml of the reagent to 1 ml of water. Yellow colour produced is matched against suitable colour discs.
• Reading within 10 seconds after reagent addition gives estimates of free chlorine in water while reading at 15-20 minutes, estimates both free and combined chlorine.
• Sometimes error is caused by presence of interfering substances such as nitrites, iron and manganese (all producing yellow colour with reagent).
• This error has been removed in a new test called ORTHOTOLIDINE –ARSENITE (OTA) TEST which measures free and combined chlorine separately.

WATER QUALITY STANDARDS

The guidelines for drinking water quality given by WHO (2011), recommend the following variables to monitor – 

1. Acceptability aspects

• Physical parameters
• Inorganic parameter

1. Microbiological aspects 

• Bacteriological indicators
• Virological aspects
• Biological aspects

1. Chemical aspects

• Inorganic parameters
• Organic parameters

1. Radiological aspects

• ACCEPTABILITY ASPECTS

• PHYSICAL PARAMETERS – 

Acceptability of water is related with certain physical parameters. These are as follows – 

1. TURBIDITY – 

• Drinking water should be free from turbidity.
• It interferes with disinfection and microbiological examination of water.
• Water with turbidity of more than 1 Nephelometric turbidity unit (NTU) is not acceptable for drinking water purpose. 
• Turbidity of water is measured by JACKSON CANDLE TURBIMETER.

1. COLOUR – 

• Drinking water should be free from colour.
• Colour in water is due to metals (Iron & Manganese), organic matter and industrial wastes.
• Colour above 15 TCU (True Colour Unit) can be noticed by the eyes.

1. TASTE & ODOUR – 

• Drinking water should be free from odour and good in taste.
• Taste & odour in water is due to natural or biological processes, chemical contamination or as a product of water treatment e.g. chlorine or due to improper storage or distribution of water.

1. TEMPERATURE – 

• Cool water is generally more acceptable for drinking purposes.
• Normal temperature water increases efficiency of water treatment process and have no bad effect on drinking water quality.

      One cannot judge the water quality by its physical appearance only. For complete assessment the chemical & microbiological examination is must.

• INORGANIC PARAMETERS – 

12. Hardness – 

• Water with a hardness of 200 mg/L causes scale deposition in the distribution system and will further cause excessive soap consumption and scum formation.
• Soft water (hardness of less than 100 mg/L) causes more corrosion in water pipes.

13. pH of water – 

• In a water distribution system, acceptable pH levels are 6.5 to 8.5 of water.
• If pH of water is less than 7, there will be marked corrosion of pipes of water distribution system & elevated chemical substances e.g. lead in water.
• If pH of water is more than 8, this will lead to progressive decrease in chlorination process.

14. Dissolved Oxygen – 

• It is affected by raw water temperature, composition, treatment and any chemical or biological processes in water distribution system.
• No health based guidelines are available.

• MICROBIOLOGICAL ASPECTS

• Bacteriological Indicators – 

• Ideally drinking water should be free from pathogenic microorganisms. It should not contain any bacteria indicative of pollution of water with excreta.
• Failure to control it, may lead to outbreak of bacterial water borne diseases.
• The primary bacterial indicators of faecal contamination are coliform group of organisms while supplementary bacterial indicators are faecal streptococci and sulphite-reducing clostridium.

1. COLIFORM ORGANISMS – 

• Coliform organisms include all aerobic & facultative anaerobic, gram negative, non-sporing, motile and non-motile rods capable of fermenting lactose at 35-37 degree C in less than 48 hours. (Park 27 edition).
• Can be of both faecal and non-faecal in origin. 
• Faecal group of coliform organisms is represented by E.coli while non-faecal group by Klebsiella aerogens.
• The reasons for exclusively choosing the coliform organism (especially E. coli) as an indicator of faecal pollution are as follows –

• These are present in large intestine in substantial quantity.
• A human body excretes daily around 200-400 billion of these organisms.
• Can be easily detected by culture method.
• The method of detecting micro-organisms other than coliform group is difficult and time consuming.
• These micro-organisms tend to live longer.
• Have greater resistance to water purification than other pathogens.

• If coliform organisms are present in a sample of water, it indicates probable presence of intestinal pathogens.

1. FAECAL STREPTOCOCCI – 

• Occur regularly in faeces but in small number than E.coli.
• Its presence in water indicates recent faecal pollution of water.
• A supplementary bacterial indicator of faecal pollution of water.

1. CLOSTRIDIUM PERFRINGENS – 

• Occur regularly in faeces but in smaller number.
• Spores of Cl. Perfringens are long lived and resistant to normal chlorination process.
• Its presence in water indicates faecal contamination.
• Their presence in the absence of E.coli in water indicates remote contamination of water.

The bacteriological tests carried out to check bacterial contamination of water are as follows – 

1. Plate count (Colony Count)
2. Standard tests 

• Presumptive coliform test
• Confirmatory test
• Completed test

1. Tests for the presence of faecal streptococci & Cl. Perfringens.

Bacteriological Quality of Drinking Water (WHO Guidelines)

(WHO (2011), guidelines for drinking water quality Vol. I & Vol. II Recommendations, 4th edn)

• Virological Aspects – 

• Drinking water should be free from any viruses ideally.
• Enteroviruses, reoviruses & adenoviruses have been found in water.
• Enteroviruses are more resistant to the chlorination.
• Water is considered safe for drinking, if enteroviruses are absent in the given sample.
• WHO has fixed the upper limit of viruses as one PFU (plaque forming unit) per liter of water.

• Biological Aspects – 

• Protozoa like Entamoeba histolytica, Giardia & rarely Balantidium coli are likely to be transmitted by ingestion of contaminated drinking water.
• Helminthes like roundworms & flatworms are likely to be transmitted through contaminated drinking water
• Source protection is the best method of prevention.

• CHEMICAL ASPECTS – 

                                          Inorganic chemicals of health significance in drinking water 

*Provisional

(WHO (2011), guidelines for drinking water quality Vol. I & Vol. II Recommendations, 4th edn)

                             Organic chemicals of health significance in drinking water

                                      Guideline values of pesticides in drinking water

                                                                                                                    (*Provisional)

• RADIOLOGICAL ASPECTS

• Pollution of water with radioactive materials causes health hazards.
• Radioactivity is expressed as micro-micro curies i.e. picocuries – pci /liter of water.
• WHO has proposed the following standards as accepted upper limit – 

Gross alpha activity – 3 pci/L.

Gross beta activity – 30 pci/L

CONCEPTS OF WATER CONSERVATION – 

• Proper utilization, avoiding wastage, avoiding any damage to water quality and maintaining the amount of water in its different resources is called water conservation.
• There is shrinkage of surface water e.g. river, ponds, lakes etc. due to modernization, rapid urbanization, industrialization and population explosion resulting in increased extraction of subsoil or underground water.
• Therefore underground water which is depleting fast, need its conservation.
• Water conservation has two components – 

1. Protection of water resources – 

• Water resources can be protected by preventing the wastage of water.
• This can be done by improving community awareness by educating them extensively.

1. Buildup of subsoil water reserve (Water Harvesting) – 

• This can be done by draining rain water by using PVC pipes from top of the buildings and courtyards in to soaking pits or trenches.
• This is followed by filtration by using sand and gravel of collected rain water and then letting in to existing tube-wells or wells.
• UNICEF, World Bank, Central Groundwater Board etc. have suggested various economic designs.
• Rain water harvesting systems consists of the following components – 

1. Catchment – used to collect & store the captured rain water.
2. Transportation – Used to transport the harvested water from the catchment to  the recharge zone.
3. Flush – used to flush out the first spell of rain.
4. Filter – used for filtering the collected rain water and removing pollutant.
5. Tanks/wells – used to store the filtered water which is ready to use.

• Thus rain water harvesting is the process of accumulation and storage of rain water for reuse rather than allowing it to run off.
• Different methods of rain water harvesting are – 

1. Rooftop rain water harvesting
2. Surface run off harvesting

The factors affecting the amount of rain water harvested are – 

1. Catchment features 
2. Quantum of runoff
3. Capacity of storage tank
4. Availability of the technology
5. Frequency, quantity & quality of rain fall.

Etiology & basis of water borne diseases – 

• Water borne diseases are the conditions (illness or disorders, death & disability) caused by pathogenic micro-organisms due to water use and consumption.
• These diseases are transmitted while bathing, washing, drinking water or by eating foods exposed to contaminated water.
• These are important public health problem in rural areas amongst developing countries all over the world.
• About 2.3 billion people in the world suffer from diseases that are linked to water.
• Diarrhoea & vomiting are the most commonly reported symptoms of water borne diseases. Other symptoms may include skin, ear, respiratory or eye problems.
• Lack of clean water supply, sanitation and hygiene (WASH) are the etiological determinants of spread of water borne diseases in a community.
• According to WHO, water borne diseases account for an estimated 3.6% of the total DALY global burden of disease and cause about 1.5 million human annual deaths annually.
• WHO estimates that 58% of the burden, or 842000 deaths per year can be averted by provision of safe drinking water supply, sanitation and hygiene (WASH).
• In India, about 1.5 lakh children die of diarrhoeal diseases every year and may suffer from malnutrition and disabilities.
• Providing safe water supply, proper sanitation, and hygiene measures can save millions of lives by reducing the prevalence of water borne diseases.
• Water borne diseases include diarrhoeal diseases, typhoid and paratyphoid, cholera, polio, dysentery and hepatitis A & E etc.
• Improved water supply reduces diarrhoea morbidity by 6-25%.

Water borne diseases as per causative agents – 

• Viral diseases

• Viral hepatitis A & E
• Poliomyelitis
• Rotavirus diarrhoea

• Bacterial Diseases 

• Typhoid fever
• Paratyphoid fever
• Cholera
• Bacillary dysentery
• E.coli diarrhoea

• Protozoal diseases

• Amoebiasis
• Giardiasis

• Helminthic diseases

• Ascariasis
• Enterobiasis
• Trichuriasis
• Hydatid disease

• Leptospiral diseases 

• Weil’s disease

1. DUE TO PRESENCE OF AQUATIC HOSTS

• Snail – Schistosomiasis (Bilharziasis)
• Cyclops – Guinea-worm & Fish tapeworm diseases.

SWACHH BHARAT ABHIYAN was launched in 2014 to reduce water and vector borne diseases and improved solid & human waste management.

Standards of housing and effect of housing on health – 

Housing includes not only the physical structure providing the shelter, but also the immediate surroundings and the related community services and facilities.

A WHO Expert Group (1961) on public health aspects of housing prefers to use the term residential environment in place of housing. The term conceptualizes and focuses on physical, mental and social wellbeing of the individual and family inhabiting such residential environment.

It is the place where the members of the family or individual spend most of their life time and are reared, thus determining the social and civil life of the family.

The social goals of the housing are – 

• To provide sanitary shelter.
• To provide amenities and space for family life.
• To enable access to community services and facilities.
• To ensure family participation in community life.
• To provide economic stability & wellbeing of the family.

An expert committee of WHO (3, park 27th edn) recommends the following criteria for healthful housing – 

• It provides physical protection and shelter.
• It provides adequate space for cooking, eating, washing and excretory functions.
• It is designed, constructed, maintained and used in such a manner to prevent the spread of communicable diseases.
• It provides protection from hazards of exposure to noise, radiation and pollution.
• It is free from unsafe physical arrangements and toxic or unsafe materials.
• It has overall implication on promoting mental health of the family and individual.

HOUSING STANDARDS

These vary from country to country depending upon socio-economic status, family size and composition, cultural practices and climatic conditions. The standards in India are those recommended by the EHC (1947). These are given below – 

1. SITE – 

• The site should be elevated from its surroundings so that not affected by flooding during rains.
• The site should have an independent access to a wide road.
• It should be situated in pleasing surroundings.
• It should be away from bleeding places of flies and mosquitoes.
• It should be away from dust, smoke, smell, excessive noise & traffic.
• The soil on which house is constructed should be dry & safe.
• The subsoil water should not be very deep (ideally located 10 feet deep).

1. SETBACK – 

• It is the open space all around the house.
• The purpose of setback is to provide adequate lighting and ventilation.
• In rural areas, the buildup area should not exceed 1/3rd of the total area whereas in urban areas, the buildup area may extend up to 2/3rd of the total area. This difference is due to costly land in urban area.

1. FLOOR – 

• The floor should be pucca and impermeable so that it can be easily washed and kept clean & dry.
• The floor must be smooth and free from cracks and crevices to prevent the breeding of insects and avoid dust and collection of dusts.
• It should be damp proof.
• The height of the plinth should be 2-3 feet.

1. WALLS – 

• The walls should be reasonably strong.
• Should have a low heat capacity.
• Should be weather resistant.
• Should be unsuitable for harborage of rodents and vermin.
• It should not be easily damaged.
• The walls should be 9 inch thick & smooth.

1. ROOF – 

• The height of the roof should not be less than 10 feet in the absence of air-conditioning.
• The roof should have a low heat transmittance coefficient.

1. ROOMS – 

• At least two living rooms should be there.
• The number and area of rooms should be increased depending on size of the family so that recommended floor space per person may be made available.

1. FLOOR AREA – 

• Minimum floor area per person should be 50 square feet, 100 square feet being optimum.
• The floor area of a living room should be 120 square feet for double occupancy and at least 100 square feet for single occupancy.

1. CUBIC SPACE – 

• Rooms of the house should provide an air space of at least 500 cubic feet space per capita.
• Optimum air space per capita is 1000 cubic feet.

1. WINDOWS – 

• Living rooms should contain at least two windows with facility for cross ventilation.
• These should be situated at a height of not more than 3 feet above the ground in the living rooms.
• Area of the windows should be 1/5th of the floor area.
• Doors & windows combined area should be 2/5th of the floor area.

1. DAYLIGHT – 

• It is recommended that in living rooms, the daylight factor should be at least 8% and in kitchen about 10% (4, park 27 edn, p 868).

1. KITCHEN – 

• Every house should have a separate kitchen.
• The floor of the kitchen should be impervious.
• The kitchen must be protected from dust & smoke.
• Following provisions in kitchen are must – 

• Adequate light & ventilation
• Arrangement for food storage & fuel
• Water supply
• Sink for washing utensils
• Proper drainage.
• Space for cooking

1. PRIVY – 

• A sanitary privy should be there in each house.

1. GARBAGE & REFUSE – 

• Collected daily from house & disposed off in a sanitary manner.

1. BATHING & WASHING – 

• Facilities for bathing and washing should be present in each house with privacy.

1. WATER SUPPLY – 

• A safe and adequate water supply is must.

STANDARDS OF RURAL HOUSING – 

• Build up area should be about 1/3rd of the total land area.
• There should be sufficient space around the house for adequate lighting and ventilation.
• The area of doors and windows should be about 25% of the floor area.
• Preferably two living rooms should be present.
• Provision of separate kitchen with facilities of washing utensils.
• Provision for washing of clothes.
• Presence of soakage pit for disposal of sullage water coming out from kitchen & bathroom.
• Provision of kitchen garden.
• Provision of RCA latrine for excretory function.
• Water source should be within the reach of about 400 meters.
• Live stocks like cattle, pigs should be away from the house.
• There must be provision of manure pit for the disposal of kitchen waste and domestic refuse.

EFFECTS OF HOUSING ON HEALTH

Poor housing can lead to following health problems – 

• Respiratory infections e.g. TB, ARI, COVID 19 etc.
• Skin infections e.g. scabies, ringworm, leprosy etc.
• Rat infestations may lead to plague.
• Houseflies, mosquitoes, fleas & bugs borne diseases.
• Accidents
• Increased morbidity & mortality
• Psychological Hazards

 OVERCROWDING 

• Overcrowding in human house is said to exist based on the following 3 criteria – 

• Floor area: person ratio
• Room: person area
• Sex separation

• Accepted standards for floor area are – 

110 square feet or more – 2 persons

90-110 square feet – 1 & ½ persons

70-90 square feet – 1 person

50-70 square feet – ½ person

A child between 1-10 years is considered as ½ person while a child below one year is not counted.

• Accepted standards for room: person ratio are – 

1 Room – 2 persons

2 Rooms – 3 persons

3 Rooms – 5 persons

4 Room – 7 persons

5 Room or more – 10 persons

Additional 2 persons for each further room.

• On the basis of sex separation, overcrowding is considered, if 2 persons, over 10 years of age, of opposite sex, unless husband and wife, are obliged to sleep in the same room.

PRADHAN MANTRI AAWAS YOJANA (PMAY-Urban)

• It is a flagship mission of government of India being implemented by Ministry of Housing & Urban affairs (MoHUA).
• Launched on 25th June 2015.
• The mission addresses urban housing shortage among EWS/LIG & MIG categories including the slum dwellers by ensuring a pucca house to all urban households by the year 2022.

VENTILATION – 

• It is recommended that there should be 2-3 air changes in one hour in the living rooms while 4-6 air changes in the work room or assemblies.
• It is now accepted that a space of 1000-1200 cubic feet per person is quite sufficient.
• Air changes per hour is calculated by dividing the total hourly supply to the room by the cubic capacity of the room.
• Floor space per person is more important than the cubic space. The optimum floor space required is 50-100 square feet per person.
• Two types of ventilation – 

• Natural Ventilation
• Mechanical Ventilation

1. Exhaust Ventilation
2. Plenum Ventilation
3. Balanced ventilation
4. Air-conditioning

• Exhaust Ventilation is provided generally in large halls & auditorium for removing vitiated air.
• Local Exhaust Ventilation is also used in the industries to remove dust, fumes & other concentrated contaminants at their source.
• In PLENUM VENTILATION fresh air is blown into the room by centrifugal fans so as to create a positive pressure & displace the vitiated air.
• BALANCED VENTILATION combines both exhaust & plenum system of ventilation.

LIGHT – 

• An illumination of 15-20 foot candles has been accepted as a basic minimum for satisfactory vision.
• One foot candle = 10.76 Lux.
• Ceilings & roofs should have a reflection factor of 80% walls 50-60 % and furniture 30-40%.
• Brightness of point source (Luminous Intensity) is measured in recommended unit CANDELA.
• Flow of light (luminous Flux) is measured in standard unit LUMEN.
• Amount of light reaching surface (Illumination/Illuminance) is measured in standard unit LUX. Other unit being FOOT CANDLE.
• Amount of light re-emitted by surface (Brightness/ Luminance) is measured in standard unit LAMBERT.
• Measurement of Day light is done in DAY LIGHT FACTOR. Day light factor is measured by an equipment called DAY LIGHT FACTOR METER.
• It is recommended that in living rooms, the daylight factor should be at least 8% while in KITCHENS about 10%.
• DF = Instantaneous Illumination indoors / Simultaneous illumination outdoors * 100.
• Why fluorescent lamps are better than filament lamps? 

• Consumes less electricity
• User friendly
• Absorb practically all U-V radiation & remit the radiation in the visible range.

• For Casual Reading, recommended illumination is 1000 Lux while for general office works, recommended illumination is 400 Lux.

HUMAN EXCRETA DISPOSAL – 

• Human excreta is not only the source of infection but is also important cause of environmental pollution.

• The health hazards of improper excreta disposal are – 

1. Soil pollution
2. Water pollution
3. Contamination of foods & 
4. Propagation of flies

• Human excreta of a sick person carrying various infectious agents may be transmitted to a new host through variety of channels – 

• Water

• Flies

• Fingers

• Soil

• Food

• This disease cycle may be broken at various points – 

• Segregation of faeces

• Protection of water supplies
• Protection of foods
• Personal hygiene
• Control of flies

• The most effective step is segregation of faeces & its proper disposal so that disease agent cannot infect new host directly or indirectly. This barrier is also called SANITATION BARRIER & a disposal pit.
• SANITARY LATRINES – these are non-service type & include – 

1. Bore hole latrine
2. Dug well or pit latrine
3. Water seal type latrines 

1. PRAI type
2. RCA type
3. Sulabh Shauchalaya

1. Septic tank
2. Aqua privy

• Latrines suitable for camps & temporary use are – 

• Shallow trench larine
• Deep trench latrine
• Pit latrine
• Bore hole latrine

• A sanitary latrine follows the criteria given below – 

1. Does not allow excreta to contaminate the surface or ground water.
2. Does not allow excreta to pollute the soil.
3. Does not make excreta accessible to flies, rodents & other vehicles of transmission.
4. Does not make excreta create a nuisance due to odour or appearance.

• WATER SEAL performs two functions – 

1. Prevents access by flies
2. Prevents escape of odour or foul gases thus prevents nuisance by smell.

• Two types of water seal latrines are commonly used – 

1. PRAI type
2. RCA type – has been accepted as a suitable design for wide acceptance.

• Any latrine should not be located within 15 meter (50 feet) from source of water supply and should be at lower location to avoid bacterial contamination of water supply.
• RCA latrine contains following parts – 

• Squatting plate
• PAN
• Trap
• Connecting pipe
• Superstructure

• Trap holds water and provides the necessary water seal. Trap is connected to pipe.
• WATER SEAL is the distance between the level of water and the lowest point in the concave upper surface of the trap. The depth of water seal in the RCA latrine is 2 cm or ¾ inch.
• SEPTIC TANK is a water tight masonary tank into which household sewage is admitted for treatment.
• It is a satisfactory method of human waste disposal for individual houses in a community.
• Pre-requisite of Septic tank – 

1. Should have adequate water supply
2. Don’t have access to public sewerage system 

• Two stages are involved in the purification of sewage using septic tank – 

1. Anaerobic digestion – In septic tank proper.
2. Aerobic oxidation – Outside septic tank in sub soil.

• SULABH SHAUCHALAYA is an improved version of the standard hand flush latrine e.g. RCA type, developed by Sulabh International. The method requires very little water. 
• Sulabh International, not only built but also maintain the system of Sulabh Community Latrines.
• CHEMICAL CLOSET consists of a metal tank containing a disinfectant fluid. The active ingredients of the fluid are formaldehyde & quaternary ammonium compounds.
• WATER CARRAIGE SYSTEM or SEWAGE SYSTEM – 

• Implies collecting and transporting of human excreta & waste water from residential, commercial & industrial areas, by a network of underground pipes called SEWERS to the place of ultimate disposal.
• It is the method of choice for collecting & transporting sewage from cities & towns where population density is high.
• Two types of water carriage system are – 

1. Combined Sewer system
2. Separate sewer system

• In the combined sewer system, the sewers transport both the sewage and surface water.
• In the separate sewer system, only sewage is transported, not allowing surface water.
• The separate sewer system is considered the system of choice now.
• A water carriage system consists of the following elements – 

1. Household sanitary fittings 
2. House sewers
3. Street or trunk sewers
4. Sewer appurtenances – manholes, traps etc.

• The usual household sanitary fittings are – 

1. Water closet
2. Urinal
3. Wash basin

• Ideal Water Closet is WESTERN TYPE & for its efficient performance – 

1. The water seal area should not be more than 7.5 cm 
2. There should not be any sharp corners in the trap design.
3. Volume of water in trap should not exceed 1.75 liters to maintain a minimum of 50 mm deep water seal.
4. The interior of the bowel should be vertical at least 50 to 75 mm just above the surface of the water seal.
5. The water closets are provided with a flushing rim.

• BIO-TOILET is an environment friendly complete waste solution which reduces the solid human waste to bio-gas & water with the help of bacterial inoculum.
• BIO-TOILET is an innovative technology for disposal of solid human waste in an eco-friendly, economical & hygienic manner.
• Types of environment friendly toilets are – 

1. Bio-toilets
2. Vacuum toilets
3. Zero discharge toilet system

• SEWAGE is the waste water from community, containing solid and liquid excreta, derived from residential, commercial & industrial establishments.
• SULLAGE refers waste water which does not contain human excreta e.g. waste water from wash rooms and kitchen.
• DRY WEATHER FLOW is the average amount of sewage which flows through the sewerage system in 24 hours.
• Improper sewage disposal leads to following environmental problems – 

1. Creation of nuisance, unsightliness & unpleasant odour.
2. Breeding of flies & mosquitoes
3. Pollution of soil & water supplies
4. Contamination of foods & 
5. Increase in incidence of helminthic & enteric diseases.

• The average adult person excretes daily some 100 grams of faeces.
• There is estimation that 1 gram of faeces may contain about 1000 million of E.coli, 10-100 million of faecal streptococci & 1 to 10 million spores of Cl. Perfringens besides several others.
• The aim of sewage treatment is to stabilize the organic matter for safe disposal and to convert the sewage water into an effluent of an acceptable standard of purity for safe disposal to land, rivers and sea.
• A standard test which is an indicator of the organic content of the sewage is BIOCHEMICAL OXYGEN DEMAND (BOD).
• STRENGTH OF SEWAGE is expressed in terms of – 

1. Biochemical Oxygen Demand (BOD)
2. Chemical Oxygen Demand (COD)
3. Suspended solids.

• BIOCHEMICAL OXYGEN DEMAND (BOD) – 

• Most important test among three above mentioned tests.
• It is the amount of oxygen absorbed by a sample of sewage during a specified period (5 days) at a specific temperature (20 degree C) for the aerobic destruction of organic matter by living organisms.
• Strong sewage – BOD equal to or more than 300 mg/L
• Weak sewage – BOD equal to or less than 100 mg/L.

• CHEMICAL OXYGEN DEMAND (COD) is the only practical method to determine oxygen load of the sewer.
• SUSPENDED SOLIDS – 

1. Amount varies from 100 to 500 mg/L (ppm)
2. Weak Sewage – Suspended solids equal to or less than 100 mg/L
3. Strong Sewage – Suspended solids equal to or more than 500 mg/L.

• Decomposition of organic matter in sewage takes place by 2 pressures – aerobic & anaerobic processes.
• MODERN SEWAGE TREATMENT –  

1. Primary Treatment 

• Screening
• Grit Chamber
• Primary Sedimentation

1. Secondary Treatment 

• Trickling Filter Method
• Activated Sludge Process
• Followed by secondary sedimentation & sludge digestion.

1. Disposal of Effluent 

• Disposal by dilution
• Disposal on land

• OTHER METHODS OF SEWAGE DISPOSAL – 

1. Sea outfall
2. River outfall 
3. Land treatment (Sewage farming)
4. Oxidation pond
5. Oxidation Ditches

• OXIDATION POND – 

• Cheap method of sewage treatment.
• Bhilai, India constructed & used the first oxidation pond.
• It is an open, shallow pool with an inlet & outlet.
• Criteria for oxidation pond – 

1. Presence of Algae
2. Presence of certain bacteria feeding on decaying organic matter
3. Presence of sunlight.

• During day it is aerobic & in night anaerobic predominantly.
• For small communities, it is an established method.

• LAND TREATMENT (SEWAGE FARMING) – 

• Applicable when sufficient & suitable land made of porous soil is available.
• An acre of land is required to treat the sewage of 100-300 persons.
• Land is first laid into ridges & furrows.
• Crops are grown on ridges & furrows are fed by sewage intermittently.
• Should be closed in rainy season because of sewage sickness & alternate method is used.

SOLID WASTE MANAGEMENT 

• Solid waste, comprises of food waste (garbage), rubbish, demolition products, sewage treatment residue, manure & other discarded materials.
• It generally does not contain human excreta.
• In different countries, per capita daily solid waste produced varies between 0.25 to 2.5 kg.
• HEALTH HAZARDS OF SOLID WASTES – 

If not disposed properly health hazards are as follows – 

• Favours fly breeding
• Attracts rodents & vermin
• Contamination of food through flies and dust
• Water & Soil pollution
• Creates an unsightly appearance & nuisance from bad odour.

• House to house collection is by far the best method of collecting refuse.
• METHODS OF SOLID WASTE DISPOSAL – 

• DUMPING
• CONTROLLED TIPPING (SANITARY LANDFILL)
• COMPOSTING
• INCINERATION
• MANURE PITS
• BURIAL

• DUMPING – 

• Solid wastes dumped in the low lying area and after reclamation, used for cultivation purpose.
• One of the most insanitary method of solid waste disposal.

• CONTROLLED TIPPING (SANITARY LANDFILL) – 

• It is the dumping or burial of the solid waste in a sanitary way.
• Dumping site should be away from source of water & located outside the city.
• After dumping, solid waste is covered by a layer of soil on the top daily.
• Three methods – 

1. Trench Method – No low lying area available.
2. Ramp Method – Where terrain is moderately sloping.
3. Area Method.

• The maid soil produced at the end of 4-6 months is suitable for gardening.

• COMPOSTING – 

• Solid waste is disposed of along with the night soil or sewage.
• Two methods are available – 

1. Biological (Bangalore or Anaerobic) Method 
2. Mechanical (Aerobic) Method

• INCINERATION – 

• Process of burning solid waste is the most sanitary way of solid waste disposal especially the hospital wastes.
• Following features are present in an incinerator – 

1. A Furnace or Combustion Chamber
2. A platform for tipping the solid waste
3. Stockers
4. A baffle plate to drive off all fumes.

• MANURE PITS – 

• Suited for rural areas where each household uses a separate manure pit to dispose off the solid wastes.
• After 4-6 months, compost is formed which can be used in the field as manure.

• BURIAL – Suitable for small camps.

2.Golden points in Health Care of the Community 

• Health care is a public right and it is the responsibility of STATE GOVERNMENT to provide it equitably to its people.
• Primary Care level – 

• First level of contact of health system with community 
• Provided by Primary Health Centres, its sub-centres & Health & wellness centres (Ayushman Arogya Mandir) both in rural & urban areas.

• Secondary Care level – 

• First referral level
• Provided by Community Health Centres & District hospitals.

• Tertiary Care Level – 

• Provided by Medical College hospitals, Regional & apex hospitals & All India Institutes.

• The term COMPREHENSIVE HEALTH CARE was first used by the BHORE Committee in 1946.
• The term BASIC HEALTH SERVICES was first used by WHO/UNICEF in 1965 in their joint health policy.
• The drawbacks of Comprehensive Health Care & Basic Health Services were – 

• Lack of Community Participation
• Lack of inter-sectoral coordination
• Dissolution from socio-economic aspects of health

• The approach of PRIMARY HEALTH CARE came into existence in 1978, following the international conference in Alma Ata (USSR).
• The concept of Primary Health Care was accepted by all the member countries as the key to attain Health for All (HFA) by 2000 AD. It was accepted as integral part of health system of India.
• There are 4 principles of Primary Health Care – 

• Equitable distribution
• Community Participation
• Inter-sectoral coordination
• Appropriate technology

• In 1977, World Health Assembly decided to launch a movement known as HEALTH FOR ALL by 2000 AD. The fundamental principle of movement was equity i.e. an equal health status for the people and countries, ensured by equitable distribution of health resources.
• WHO established 12 global indicators for assessment of progress towards HFA by 2000 AD. 
• In September 2000, Millennium Developmental Goals (MDG) were launched for the next 15 years. 3 of the 8 goals, 8 of the 18 targets, required to achieve MDG & 18 out of 48 indicators were health related.
• In September 2015, Sustainable Developmental Goals (SDG) were launched for transforming the world by 2030. There are 17 goals in SDG.
• An assessment of the health problems & health status of the community (Community Diagnosis) is the first requisite for any planned effort to develop health care services.
• Young population below 15 years of age in India is about 26.2% of the population.
• In India, dependency ratio for the year 2020 is 48.73 %. It means every economically productive member supports almost one dependent.
• Death rate in India has steadily declined from 21 (1965) to 7.2 (2022). The life expectancy at birth as gone up to an estimated 67 years for males and 70 years for females during 2020.
• HEALTH PROBLEMS OF INDIA – 

• Non- communicable disease problems
• Nutritional problems
• Communicable disease problems
• Environmental sanitation problems
• Population explosion
• Health Care problems

• In 2016, NCDs accounted for 63% of all deaths thus emerging as a major public health problems.
• In India tobacco related cancers are responsible for ½ of cancer deaths in men & 20% cancer deaths in women. About 1 million deaths occur every year due to tobacco use, making tobacco related health issues a major public health concern.
• Cataract (62.6%) is the major reason of blindness in India followed by refractory errors (19.70%).
• MAJOR NUTRITIONAL PROBLEMS IN INDIA – 

• Protein Energy Malnutrition
• Nutritional Anaemia
• Low birth Weight (LBW)
• Nutritional Blindness (Xerophthalmia)
• Iodine deficiency Disorders (IDD)
• Endemic Fluorosis

• Major health care problem in India is inequitable distribution of available health resources between urban and rural areas and lack of penetration of health services to last mile, last community, and last person of the country.
• The basic resources required for providing health care in the country are – 

• Health manpower
• Money & materials
• Time

• Health manpower requirements of a country are based on – 

• Health needs and demands of the population
• Desired outputs

• Health needs of a population depends upon health situation, health problems and aspirations of the people.
• Studies indicate that 73.6% doctors are concentrated in urban areas where around 27% of the population live. The factors responsible for this maldistribution are – 

• Absence of amenities in rural areas
• Lack of job satisfaction
• Professional isolation
• Lack of rural experience
• Inability to adjust to rural life

• Health man power in India (2010-18)

• Doctors per 10,000 population – 7.8 (Norm is 1/1000 population)
• Beds per 10,000 population – 7.0 
• Nurse & Midwifes per 10,000 population – 20.9 (Norm is 1/5000 population)

• At present, India is spending about 3% of GNP on health & family welfare programs.
• CHARACTERISTICS OF HEALTH CARE SERVICES – 

• Comprehensive
• Accessible
• Acceptable
• Provide scope of community participation
• Available at a cost which is affordable

• One of the aim of PRIMARY HEALTH CARE is UNIVERSAL COVERAGE & EQUITABLE DISTRIBUTION of health resources.
• In India, in primary health care, at village level following schemes are operational 

1. ASHA Scheme
2. ICDS Scheme

Previous scheme of training of local dais has become insignificant due to promotion of institutional delivery by skilled birth attendants.

• SELECTION CRITERIA OF ASHA – 

• She must be resident of the village
• Should be a woman (married/widow/divorced)
• Preferably in the age group of 25 to 45.
• Should have an education up to 10th class
• Should have communication skills and leadership qualities
• Should have adequate representation from the disadvantaged population group.

• Generally one ASHA (Accredited Social Health Activist) caters a population of 1000 but in hilly, tribal and desert areas the norm could be relaxed to one ASHA per habitation.
• AWW will guide ASHA in performing following activities – 

• Organize village health day once/twice a month.
• ANMs & AWWs (Anganwadi Workers) will act as resource person for training of ASHAs.
• Doing IEC activities on health day.
• AWW will be depot holder for drug kits and will be issuing it to ASHA & will replenish drugs of ASHA kit as & when required.
• AWW will update list of eligible couples and also the children less than one year of age in the village with the help of ASHA.
• ASHA will help AWWs in community mobilization of pregnant & lactating women and infants & children for nutrition supplement, immunization & health check-ups.

• Auxiliary Nurse Midwife (ANM) will guide ASHA in performing following activities – 

• Supervise her and handhold her in ASHA’s day to day activities.
• ANM & AWW will be the resource person for training of ASHAs.
• ANM will inform ASHA about the date of outreach activities in the village and guide her for community mobilization.
• ANM will participate and guide in organizing health days at AWC.
• ANM will take help of ASHA in updating eligible couple register of the concerned village.
• ANM will guide ASHA for community mobilization of beneficiaries for health day or other specific outreach activities.
• ASHA under the guidance of ANM will motivate pregnant and lactating women in regular consumption of IFA, calcium tablets and for Td vaccine administration.
• ANMs will orient ASHA about dose schedule & side effects of oral pills.
• ANMs will educate ASHA about danger signs of infants, pregnancy & labour.

• Under the ICDS scheme, an AWW caters for a population of 400-800. There are 100 such workers in each ICDS project.
• AWW is a part time worker and is paid a honorarium of Rs. 1500/- per month for the service provided.
• AWW provides following services – 

• Health check-ups including maintenance of growth charts
• Immunization
• Supplementary nutrition
• Health & nutrition education
• Pre-school education
• Referral services 
• Distribution of take home ration (THR)

• The introduction of Comprehensive Primary Health Care through upgraded Sub-centres & PHCs (also known as Health & Wellness Centres or Ayushman Arogya Mandir) and similarly in urban areas, Urban Health & Wellness Centres & UPHCS is the new focus area for health system strengthening.
• Now GoI has given a new name to Health & Wellness Centres which is the AYUSHMAN AROGYA MANDIR.
• Modified Sub health Centres (HWCs) and urban health and wellness centres (UHWC) are the first point of contact between the primary health care system and the community in rural and urban areas respectively. These health facilities provide Comprehensive Primary Health Care in the most peripheral parts of the community.
• Revised IPHS 2022 guidelines classify the HWC as follows – 

• HWC – Primary Health Centres (PHC)

1. HWC-PHC in rural areas
2. HWC-UPHC in urban areas

• HWC – Sub Health Centres (SHC)

1. HWC – SHC in rural areas
2. UHWC – in urban areas

• UCHC/Polyclinics in urban areas & CHCs/FRUs at block level & District hospitals (DHs) will provide secondary care services in the new settings.
• All rural & urban HWCs should have a National Identification Number (NIN-Id) & register on the AB-HWC portal.
• A citizen Charter must be displayed at the entrance of each facility.
• Expanded range of services under Comprehensive Primary Health Care (to be provided by HWCs in both urban & rural areas) are as follows – 

• Care in pregnancy & child birth
• Neonatal & Infant health care
• Childhood & adolescent health services
• Family planning, Contraceptive services & other reproductive health care services.
• Management of Communicable diseases – National Health Programs
• Management of common communicable diseases and outpatient care for acute simple illnesses and minor ailments
• Screening, Prevention, control & Management of Non-Communicable diseases (NCDs)
• Care of common ophthalmic & ENT problems
• Basic oral health care
• Elderly & palliative health care services
• Emergency Medical services including Burns & trauma
• Screening & Basic management of Mental health ailments

• In addition to above, HWCs are also to be utilized as a platform for teleconsultation and expanding the range of diagnostics.
• HWC- SHC in rural areas will cover 5000 population in plain areas and 3000 population in hilly, tribal & desert areas.
• UHWC will cover 15000-20000 population in urban areas and will serve predominantly to poor & vulnerable populations, residing in slums or other such pockets.
• HEALTH INSURANCE FOR PEOPLE – 

• RASHTRIYA SWASTHYA BIMA YOJANA (RSBY) 

• Provided health insurance cover of 30,000/- INR per family per annum on family floater basis.
• Provided to BPL family & 11 other categories of unrecognized workers e.g. MGNEREGA workers, construction and sanitation workers etc.
• Launched by Ministry of Labour & Employment in 2008
• Transferred to MOHFW on 01.04.2015.
• Both government & empanelled private hospitals services may be utilized.
• More than 8000 hospitals network was developed.
• With the launch of PMJAY on 23.09.2018, RSBY was merged in it.

• AYUSHMAN BHARAT – PRADHAN MANTRI JAN AROGYA YOJANA (PMJAY)

• Launched on 23rd September 2018.
• Designed to provide financial risk protection against catastrophic health expenditure to 40% of poor people in India.
• A flagship scheme of GoI that provides a health cover of up to INR 5 lakhs per family per year for secondary and tertiary hospitalizations to over 50 crore people.
• Cashless access to hospitalization services.
• No cap for family size, age or gender.
• Benefits are portable across the country in all empanelled hospitals.
• 1685 procedures covering treatment, food, drug, supplies and diagnostic procedures.
• Covers cost of hospitalization, treatment, up to 3 days of pre-hospitalization and 15 days of post hospitalization follow up care.
• Ayushman card is mandatory to avail benefits.

3. GOLDEN POINTS IN MATERNAL & CHILD HEALTH (MCH)

• Community Obstetrics deals with the care, status & the behaviours of women in a given community during pregnancy, childbirth & within 6 weeks of delivery.
• Aim of Community Obstetrics is promotion, protection & preservation of well-being of the women.
• Social Obstetrics is defined as the study of effect of Social & Environmental factors on human reproduction even in pre-conceptional or premarital period.
• SOCIAL & ENVIRONMENTAL FACTORS affecting human reproduction are as follows – 

• Age at marriage
• Child spacing 
• Child bearing
• Family size
• Fertility patterns
• Level of education
• Economic status
• Custom & beliefs
• Role of women in society

• • Social Obstetrics comprises of delivery of comprehensive maternity and child health care services including family planning.

• Preventive Paediatrics includes efforts to prevent rather than cure disease and disabilities.

• Aim of Preventive Paediatrics is prevention of disease and promotion of physical, mental and social well-being of the children.

• Social Paediatrics is not only related with social factors which influence the health of the child but also influence of these factors on child health care services.

• MCH Problems of the developing countries like India are – 

• High maternal & child mortality & morbidity

• Spacing of pregnancies

• Large family size

• Communicable diseases

• Malnutrition

• Poor acceptance of health practices

• Broadly MCH problems may be categorized as – 

• Malnutrition
• Infection
• Consequences of unregulated fertility

• Pregnant women, lactating women & children are particularly vulnerable for malnutrition.
• Adverse effects of Maternal Malnutrition are – 

• Maternal depletion
• Low birth weight (LBW)
• Intrauterine Growth Retardation (IUGR)
• Anaemia
• Toxaemia of pregnancy
• Post-Partum Haemorrhage (PPH)
• High Mortality & Morbidity

• Infants with adequate birth weight survive mostly even under adverse environmental conditions.
• Two most crucial phases of child in which he/she is prone to develop malnutrition are – a) Intrauterine life b) At the time of start of complementary foods i.e. 6 months of age.
• Measures employed to combat malnutrition in mother & children are categorized into DIRECT & INDIRECT MEASURES.
• DIRECT MEASURES to combat maternal & child malnutrition are as follows – 

• Supplementary Nutrition Programs
• Distribution of IFA & Calcium tablets
• Fortification of food items
• Nutritional Education
• Nutritional Surveillance & Rehabilitation.

• INDIRECT MEASURES to combat maternal & child malnutrition are as follows – 

• Control of Communicable diseases
• Immunization
• Improving environmental sanitation
• Provision of safe drinking water
• Family planning
• Food hygiene
• Health & nutrition education
• Improving accessibility and coverage of primary health care.

• Adverse effects of maternal infections include – 

• Foetal growth retardation
• LBW
• Embryopathy
• Abortions
• Puerperal Sepsis.

• • In India, 2-10% pregnant women suffer from asymptomatic bacteriuria.

• Consequences of unregulated fertility include LBW, Anaemia, and Abortion, PPH, APH & high maternal & perinatal mortality.

• The term Maternal & Child Health comprises of promotive, preventive, curative & rehabilitative health care to the mothers & children.

• PREGNANCY DETECTION KITS – 

• Available in government health system with the brand name of NISCHAY.
• Provided to ASHA & other link workers to detect pregnancy using urine of the pregnant woman coming with complaints of Amenorrhoea & other features of pregnancy.
• Kit detects pregnancy by the presence of human chorionic gonadotrophin (hcg) hormone in the urine.
• Test is performed soon after missed period.
• Easy to perform.
• After positive test, women is advised for early registration for antenatal care. Early registration of pregnancy within 12 weeks is promoted by GoI.

• Components of Antenatal Care include – 

• Identification of high risk pregnancies
• Identification & management of pregnancy related diseases & complications
• Health Education
• Health Promotion.

• Objectives of antenatal care are achieved by following health care services – 

• Antenatal Visits
• Prenatal advices
• Specific Health Protection
• Mental preparation
• Family Planning

• Government of India (GoI) recommends minimum 4 antenatal visits covering the entire period of pregnancy.

1st Visit – Within 12 weeks or as early as pregnancy detected.

(In 1st visit, registration of pregnancy for antenatal care is done).

2nd visit – between 14 to 26 weeks

3rd visit – between 28 to 34 weeks 

4th visit – between 36 weeks to term.

• Minimum one visit, preferably 3rd visit, is done to Medical Officer posted at PHC or CHC & investigation required is done at the facility.
• Estimation or calculation of no. of pregnancies in a given community at a given time is important for – 

1. Inference that how good is registration of pregnancy in the jurisdiction of ANM.
2. Estimating the adequate stock of supplies required to provide antenatal care (e.g. Td injections, syringes, IFA tablets, Calcium & Vit D3 tablets & MCP cards).

• • Tracking of pregnancy in a given area is the responsibility of ANM.
  • MCTS (Mother & Child Tracking System) tracks the pregnant woman by her name and her children for ANC & Immunization.
  • Expected Date of Delivery (EDD) = 1st day of last menstrual period + 9 months + 7 days.
  • Normally a woman gains 9-11 kg weight during pregnancy but poor Indian women have shown a average weight gain of 6.5 kg.

• Excessive weight gain (>3 kg/month) during pregnancy arises suspicion of twins, eclampsia and diabetes.

• Foetal Heart Sounds (FHS) – Can be heard after 24 weeks of gestation. Foetal Heart Rate (FHR) varies between 120-140 beats per minute. After 28 weeks position of FHS may change due to change in position & lie of the foetus.

• Foetal Movements – are normally felt between 18-22 weeks by gently palpating the abdomen.

• Foetal Parts – Can be felt after 22 weeks of gestation. After 22 weeks, one can palpate head, back & limbs.

• Foetal Lie & Presentation – can be checked only after 32nd week of pregnancy.

• Assessment of Gestational age – 

• Using LMP
• Using per abdominal examination for fundal height
• Ultrasonography
• Combined method – USG + LMP

• Pregnant women should undergo following investigations – 

1. At the Sub Health Centre – 

• Pregnancy detection test 
• Haemoglobin examination
• Urine test for presence of albumin & sugar
• Rapid malaria test.

1. At the CHC/PHC/FRU – 

• Blood grouping including Rh factor
• VDRL/RPR
• HIV testing
• Rapid Malaria test (if unavailable at sub health centre)
• Blood sugar testing
• HBsAg for hepatitis B infection

• Following activities/services are carried out in each antenatal visits – 

• Recording of weight & BP
• Necessary lab investigations
• Per abdominal examination of pregnant women
• Immunization with Td vaccine to eligible pregnant women & other vaccination of her children
• IFA supplementation
• Calcium Supplementation
• Group or individual instructions on nutrition, family planning, self-care, delivery & parenthood
• Referral services, where necessary.

• Mother & Child Protection (MCP) Card – 

1. Jointly developed by MOHFW & MOWCD to ensure uniformity of record keeping.
2. MCP card should be duly completed for every registered woman.
3. Contains a registration no., identifying data, previous health history and main health events.
4. MCP card information should also be recorded in an antenatal register as per the Health Management Information System (HMIS) format.

• • Around 60,000 extra calories above normal requirement is needed for entire pregnancy.
  • Child survival depends upon child’s birth weight while birth weight of child depends upon the weight gain by mother during pregnancy.
  • An adequate and balanced diet is essential during the pregnancy & lactation to meet the increased need of the mother & to combat nutritional stress.
  • Normally an extra meal is advised to pregnant and lactating women.
  • During pregnancy, hard physical labour and mental & emotional stress are to be avoided as these may affect the growth of foetus.
  • The perinatal mortality increases 10-40% in pregnant woman who smoke regularly.
  • Heavy alcohol intake during pregnancy leads to intrauterine growth retardation and developmental delays.
  • Maternal alcohol intake in pregnancy may cause increased spontaneous abortions.
  • Sexual intercourse should be especially restricted in the last trimester.

• Exposure to radiation – 

• It is dangerous for developing foetus.
• Abdominal X-ray during pregnancy is the most common source of radiation.
• Exposed to intrauterine X-ray, children may develop congenital malformations, leukaemia & other malignancies.
• Only on definite indication, X-ray of pregnant woman should be done with reduced X-ray doses.
• Elective X-ray should be avoided in all women in reproductive age group during the 2 weeks preceding the menstrual period.

• Warning/Danger signs of Pregnancy – 

• Swelling of the feet
• Fits
• Headache
• Blurring of the vision
• Bleeding or discharge from vagina
• Any other unusual symptoms

• • Pregnant women should report immediately to nearest health facility on observing any of the above features.

• Mother Craft Education – consists of nutrition education, advice on hygiene and child bearing, cooking demonstrations, family budgeting, family planning education etc.

• Anaemia in Pregnancy – 

• Anaemia in pregnancy causes premature birth, abortions, post-partum haemorrhage (PPH), puerperal sepsis & thrombo-embolism in mother.
• Government of India (MOHFW) through Anaemia Mukt Bharat Program provides 180 IFA tablet @ 1 tablet per day containing 60 mg elemental iron & 500 mcg of folic acid, for entire duration of pregnancy starting at 2nd trimester onwards.
• IFA tablet should be consumed once daily for anaemia prophylaxis one hour after any major meal at a fixed time.

• Calcium Supplementation during pregnancy – 

• Calcium supplementation should be started at 14 weeks twice daily till pregnancy is over.
• Each calcium tablet contains 500 mg of elemental calcium 250 IU of Vitamin D3.
• Total 360 tablets of calcium and vitamin D3 @ 2 tablets per day are provided to pregnant women during entire period of pregnancy.
• Calcium tablets should be taken immediately after a major meal as intake on empty stomach causes gastritis.
• Preferred formulation for calcium is calcium carbonate.

• Asymptomatic Bacteriuria (ASB) during pregnancy – 

• Pregnant women are more prone for UTI due to physiological changes during pregnancy.
• Diagnosed by Culture of urine or gram staining of mid-stream urine.
• Pregnant women should be promptly treated for ASB/UTI as it may lead to pyelonephritis in mother, preterm birth, LBW & increased perinatal mortality in baby.

• Gestational Diabetes Mellitus (GDM) – 

• Gestational Diabetes Mellitus (GDM) is defined as impaired glucose tolerance (IGT) with onset or first recognition in pregnancy.
• Consequences of GDM on maternal health are – polyhydramnios, pre-eclampsia, prolonged labour, obstructed labour, caesarean section, uterine atony, PPH & infections.
• Foetal consequences of GDM are – spontaneous abortion, IUD, still birth, congenital malformation, birth injuries, shoulder dystocia, neonatal hypoglycaemia & RDS in Infants.
• 1st testing for GDM – 1st antenatal visit

2nd testing for GDM – 24-28 weeks of pregnancy

There should be at least 4 weeks gap between the two tests. If plasma glucose level is equal or more than 140 mg/dl; diagnosis of GDM is confirmed.

• Medical Nutrition Therapy (MNT) for 2 weeks is started in diagnosed cases. After two weeks of MNT, a 2 hour post prandial plasma glucose (PPPG) should be done.
• If 2 hrs PPPG < 120 mg/dl, repeat test every 2 weeks in 2nd trimester & every week in 3rd trimester.
• If 2 hrs PPPG equal to or > 120mg/dl, medical treatment is started.
• Insulin is the DOC for treatment of Gestational Diabetes Mellitus (GDM).

• Maternal Hypothyroidism – 

• Primary maternal hypothyroidism is defined as the presence of elevated TSH levels during pregnancy.
• Screening of hypothyroidism in pregnancy should be done at the time of first visit of pregnant women to the facility.
• Screening for hypothyroidism is recommended in high risk pregnant women.
• Pregnancy specific & trimester specific reference levels of TSH are – 

1st trimester – 0.1 to 2.5 m IU/L

2nd trimester – 0.2 to 3.0 m IU/L

3rd trimester – 0.3 to 3.0 m IU/L

• Estimated prevalence of hypothyroidism in pregnancy in India is 4.8 to 12%.
• Consequences of untreated hypothyroidism on mother’s health are – 

Miscarriage in early pregnancy, recurrent abortion, Anaemia, pre-eclampsia, GDM, abruptio placentae, PPH and increased Caesarean section due to foetal distress.

• Consequences of untreated hypothyroidism on foetal healthy are – preterm birth, IUGR, IUD, Respiratory distress, increased perinatal mortality rate, cognitive, neurological & developmental impairments in new-borns.
• DOC for management of hypothyroidism is Levothyroxine. This should be taken in morning early stomach. At least half an hour after the intake of medicine, pregnant women should eat something. 

• Toxaemias of pregnancy – 

• It is indicated by presence of albumin in urine and a high blood pressure.
• Early detection & management are necessary for well-being of pregnant women and foetus.
• Efficient antenatal care has the potential to reduce risk of toxaemias of pregnancy.

• Tetanus & adult diphtheria – 

• Tetanus & adult diphtheria (Td) vaccine if given during pregnancy can prevent them.
• In unimmunized mother, two doses of Td vaccine should be given; the first dose at 16-20 weeks & 2nd dose 20-24 weeks of pregnancy.
• There should be a gap of minimum 4 weeks between two doses.
• In immunized mothers (within 3 years of immunization), a booster dose of Td vaccine is indicated in this pregnancy.
• Once booster dose is given, pregnant woman is protected for 5 years.
• Do not vaccinate pregnant women in every pregnancy because of risk of hyper immunization and side effects.

• Syphilis – 

• If pregnant woman is suffering from syphilis, she can transmit the infection to the foetus after 6 months of intrauterine life.
• Syphilis is an important preventable cause of pregnancy wastage in India.
• Syphilis in pregnant women may cause spontaneous abortion, still birth, perinatal death or congenital syphilis.
• Infection to foetus is more common if mother has primary or secondary syphilis.
• Investigation done is VDRL/RPR both in early and late pregnancy as mother may get infected at any time.
• 10 daily injection of procaine penicillin in the doses of 6 lakh units is adequate treatment.

• Rh status – 

• If mother is Rh-negative and baby is Rh-positive, the first child will be unaffected but in subsequent pregnancy foetal haemolysis may occur if baby is again Rh-positive.
• Clinically haemolytic disease manifests as hydrops foetalis, icterus gravis neonatorum and congenital haemolytic anaemia. 
• In antenatal care blood of pregnant women should be tested for Rh status at the facility.
• If mother is Rh-negative and father is Rh-positive, Rh anti D immunoglobulin should be given at 28 weeks of gestation to prevent sensitization in mothers.
• If baby is Rh-positive, Rh anti D immunoglobulin is given again within 72 hours of delivery and abortion.
• Estimated incidence of haemolytic disease in India is one for 400-500 live births.

• HIV Infection – 

• HIV infection of the mother may be transmitted to foetus either through placenta, or during delivery or through breastfeeding.
• Around 1/3 of children of mother with HIV/AIDS suffer from HIV infection.
• In antenatal care, HIV testing is mandatory in early pregnancy. 
• Mass screening of pregnant women for HIV is recommended.

• Hepatitis B infection – 

• Hepatitis B infection can be transmitted to the baby from HBV carrier mother during delivery of baby.
• This transmission can be prevented by birth dose of hepatitis B vaccine to newborn and administration of Hepatitis B immunoglobulins post-delivery.
• During ANC, testing of HBsAg for hepatitis B is mandatory during facility visit.

• Prenatal & Genetic Screening – 

• Woman aged 35 years and above and those who have genetically affected are at risk.
• Most common screening is for trisomy 21 (Down’s syndrome) and severe neural tube defects.

• Family planning – 

• Attempt should be made that each pregnant women after delivery choose a family planning method by voluntary decision and practice it.
• Women after delivery are more receptive for family planning.
• Those who have completed family size, should be encouraged to undergo postpartum sterilization (PPS) within 7 days of the delivery.

• The aim of good intra-natal care are – 

• Thorough asepsis
• Safe delivery with minimum injury to mother and newborn.
• Readiness to deal with complications e.g. PPH, Prolonged labour, sepsis, asphyxia in newborn.
• Care of the newborn at delivery – essential newborn care, Newborn resuscitation, care of the cord and care of the eye etc.

• Danger signals during labour are – 

• Sluggish pain or no pain after rupture of membrane
• Good pain initially after rupture of membrane but no progress
• Prolapse of the cord or hand 
• Meconium or blood stained liquor
• Slow, sluggish, irregular or excessive fast foetal heart rate.
• Excessive show or bleeding during labour
• Maternal collapse or exhaustion during labour
• A placenta not separated within ½ an hour after delivery
• PPH & shock
• A temperature of 38 degree C or over during labour.

• GoI recommends that all deliveries including high risk deliveries should be institutional so that proper care can be provided to both mother and newborn.
• After a normal delivery, mother should be discharged from the facility after 48 hours stay so that immediate complications should be dealt properly.
• After a caesarean section, mother should be discharged ideally after 7 days.
• After delivery, newborn should be kept close to mother for skin to skin contact and initiation of breast feeding.
• Breast feeding should be started within one hour of birth after normal delivery & within 4 hours after caesarean section.
• Care of the mother and newborn after delivery is known as postpartum or postnatal care.
• The objectives of the postpartum care of the mother is – 

• To prevent the complications during this period
• To provide care for the rapid restoration of mother’s health
• To check adequacy of breastfeeding
• To provide family planning services
• To provide health education to mother regarding newborn care, feeding and danger signs, birth registration, hygiene etc.

• Complications of postpartum period in mother are – 

• Puerperal sepsis (common within 3 weeks of delivery)
• Thrombophlebitis
• Secondary PPH (6 hours to 6 weeks of delivery)
• UTI
• Mastitis & breast abscess.

• Puerperal sepsis is the infection of the reproductive tract within 3 weeks of delivery. Commonly associated with improper aseptic precautions.
• Postpartum or postnatal examination help to detect following conditions in mother – 

• Sub-involution of the uterus
• Retroverted uterus
• Prolapse of uterus and 
• Cervicitis

• Routine haemoglobin examination should be done in each postnatal visit to detect anaemia. A prophylactic course of 1 IFA tablet per day for 180 days, each IFA tablet containing 60 mg elemental iron & 500 mcg of folic acid, should be given to lactating women.
• A prophylactic course of 360 tablets (2 tablets per day) of 500 mg calcium carbonate and 250 IU of vitamin D is recommended for first 6 months after delivery.
• Every woman should be encouraged to breastfeed her baby. Every baby should be only breastfed for first 6 months (Exclusive breast feeding).
• Complementary food supplementing breastfeeding should be started in infants at the age of 6 months.
• Indian women secrete 400-600 ml breast milk per day.
• In India, 61.3% of infant deaths occur within 1st month after delivery. The first week of life after delivery is the most crucial period in the life of an infant. Maximum deaths of newborns take place on 1st day after delivery.
• The objectives of the early neonatal care is the – 

• Establishment and maintenance of cardio-respiratory functions
• Maintenance of body temperature
• Prevention of infection
• Establishing complete and satisfactory nutrition
• Early detection & treatment of congenital & acquired disorders.

• Congenital infections with TORCHES agents (Toxoplasmosis, Rubella, Cytomegalo virus, herpes simplex & others – syphilis & Hepatitis B) are associated with high mortality rates in newborns.
• Establishing & maintaining breathing after birth of the newborn is the most important step in essential newborn care. For this, airways should be cleared of mucus and other secretions.
• Neonatal resuscitation becomes necessary if natural breathing fails to establish within 30 seconds.
• APGAR SCORE – 

• It is taken at 1 minute & 5 minutes after birth.
• It is important especially in LBW babies.
• It observes heart rate, respiration, muscle tone, reflex of the newborn & colour of the body. Each sign is given a score 0, 1 or 2.
• Informs about immediate physical condition of the newborn.
• Interpretation – No depression – 7-10

                             Moderately depressed – 4-6

                                Severely depressed – 0-3

                                Perfect physical condition – 9-10

• A score below requires prompt action as these babies are more prone to complications and death.

• CARE OF THE CORD – 

• Delayed cord cutting practices (within 1-3 minutes after birth and when cord has stopped pulsating) are recommended by GoI/MOHFW.
• This practice ensures, transfer from mother to newborn, nearly 10 ml extra blood. Thus helping in reducing anaemia in newborn.
• Nothing should be applied on umbilical stump and it should be left dry.

• CARE OF THE EYES – 

• After birth of the newborn, his both eyes including lid margins should be cleaned with a wet swab from inner to outer side.
• A single drop of freshly prepared 1% silver nitrate solution or a single application of tetracycline ointment should be applied to both eyes of newborns to prevent gonococcal conjunctivitis.
• Any unusual discharge from the newborn eyes is pathological & should be treated immediately.

• CARE OF THE SKIN – 

• After securing breathing of newborn, his/her drying is important as newborn is wet with mother’s secretions and delayed drying may lead to significant heat loss.
• Vernix caseosa should not be cleaned from the body of newborn as it is protective.
• After drying, newborn is wrapped in cloth with cap on head and shocks in feet and handed over to mother for breastfeeding.
• Bathing should be delayed up to one week.

• Maintenance of body temperature – 

• Normal body temperature of newborn is 36.5 to 37.5 degree C.
• Pre-term and LBW babies are more prone to hypothermia as they loose much heat because of presence of low subcutaneous fat for insulation. 

• BREASTFEEDING – 

• Breastfeeding of newborn should be initiated within 1 hour of birth.
• Feeding on demand should be encouraged.
• First milk, COLOSTRUM, should not be discarded instead should be given to newborns as these contain anti-infective factors & prevents child from various diseases in future e.g. diarrhoea, ARI etc.
• Feeding bottles should be avoided.

• NEONATAL EXAMINATIONS – 

• First examination is done in labour room, soon after birth of the newborn.
• The examination is done to find out – a) Birth injuries 2) Malformations & 3) Maturity.
• The following abnormalities should be immediately attended – 

1. Cyanosis of lips & skin
2. Difficulty in breathing
3. Imperforated anus
4. Persistent vomiting
5. Signs of cerebral irritation
6. Hypo or hyperthermia

• Second neonatal examination should be ideally done by paediatrician within 24 hours of delivery.
• This examination should be carried out in good light from head to toe.

• Trans-placental transmission is one of the important cause of infection in newborns e.g. syphilis, HIV, HBV, Rubella etc.
• Risk of transmission of HBV is 20% from mother to child, if mother has HBs antigen only and around 90% if mother has HBe antigen.
• Transmission of HBV occurs either through blood or mother’s genital secretions.
• ANTHROPOMETRY OF NEWBORN – 

• Birth weight should be recorded preferably within the first hour of birth, as after this newborn looses around 10% of its body weight.
• Child is weighed by using digital weighing machine in grams (nearest 50 gram) in institutional deliveries & by using Salter weighing scale in home delivery.
• Average birth weight of newborns in India vary from 2.7 to 2.9 Kg. Newborn with a birth weight of < 2500 gm is considered as Low birth weight (LBW) baby.
• Length of the newborn should be recorded using Infantometer within first 3 days. Length of the newborn is taken to the nearest 0.1 cm.
• Ideally a newborn should be 50 cm in length.
• Head & chest circumference should be recorded within first 3 days of birth. Initially Head Circumference (34-35 cm) is more than chest circumference. Chest circumference crosses the head circumference at the age of 9-12 months.
• Skin fold thickness should be assessed at following sites – Triceps, Biceps, Suprailiac & suprascapular.

• AT RISK INFANTS – 

• Birth weight < 2.5 Kg
• Twins
• Birth order 5 or more
• Artificial feeding
• Weight below 70% of the expected weight (II & III degree malnutrition)
• Failure to gain weight during 3 consecutive months
• Children with PEM & Diarrhoea
• Working mother/single parent

• Two main types of low birth weight (LBW) babies are – 

• Premature or preterm (Short gestation) babies
• Short for date babies (Babies with IUGR) – more common in India.

• Preterm babies are born before the end of 37 weeks gestation.
• Subcategories of preterm babies are – 

• Moderate to late preterm (32-37 weeks)
• Very preterm (28- <32 weeks)
• Extremely preterm (<28 weeks)

• In preterm babies, their weight, length & development may be within normal limits for the duration of pregnancy.
• These preterm babies catch up growth and become normal size and development if proper care is provided.
• Prematurity is the second leading cause of death among under 5 children. Incidence of prematurity is around 10%.
• Causes of preterm birth can be classified into – 

• Spontaneous preterm birth
• Provider initiated preterm birth

• Causes of spontaneous preterm births are –  

• Teen age pregnancy
• Advanced maternal age
• Short inter-pregnancy interval
• Multiple pregnancy
• Infections e.g. UTI, Syphilis, HIV, Malaria etc.
• Chronic medical conditions e.g. DM, HT, Anaemia etc.
• Malnutrition
• Smoking & alcohol/drug abuse
• Hard physical labour 
• Poor mental health
• Genetic diseases
• Cervical incompetence

• Small for date (SFD) babies weigh less than 10th percentile for the gestational age.
• SFD babies may born at term or preterm and are the result of intrauterine growth retardation (IUGR).
• Maternal causes of SFD babies are almost same as for spontaneous preterm births except genetic causes and cervical incompetence.
• Foetal causes of SFD babies are foetal abnormalities, intrauterine infections, chromosomal abnormalities & multiple gestation.
• Placental causes of short for date babies are placental insufficiency & placental abnormalities.
• Most of the SFD babies become victim of malnutrition & infections.
• Direct interventions for prevention of LBW babies are – 

• Increasing food intake & supplementation
• Controlling infections
• Early detection and treatment of medical disorders e.g. HT, DM, Hypothyroidism, Toxaemias etc.

• The Kangaroo Mother Care (KMC) provide best care to low birth weight babies.
• The 4 components of KMC are – 

1. Prolonged Skin to skin contact
2. Proper & adequate breast feeding
3. Ambulatory care as a result of early discharge from hospital
4. Support to the mother & family in the care of the baby.

• Leading cause of death in LBW babies are – 

• Atelectasis
• Malformations
• Pulmonary Haemorrhage
• Intracranial bleeding secondary to anoxia/ birth injury
• Pneumonia & other infections

• Breastfeeding – 

• Human milk provides 70 Kcal & 1.1 gm protein per 100 ml.
• A breastfed baby has greater chances of survival than artificially fed babies.
• Advantages of breastfeeding to mothers – 

1. Protects from ovarian  and breast cancer
2. Reduces osteoporosis
3. Fastens involution of uterus
4. Reduces PPH & anaemia
5. Enhances mother’s immunity
6. Delays next pregnancy
7. Reduces dose of insulin in diabetic mother.

• ARTIFICIAL FEEDING – 

• Indications of artificial feeding are failure to secrete breast milk, chronic illnesses and death of the mother.
• In these conditions breast milk substitutes should be fed to newborn.
• Breast milk substitutes include dried whole milk powder, fresh milk from a cow or other animals and commercial formulations.
• Energy requirement of infants – 100 kcal/kg/day (about 150 ml of milk/kg/day)
• Protein requirement of infants in first 6 months – 2 gm/KBW/day
• Protein requirement in next 6 months – 1.5 gm/KBW/day 
• A total of 13-14 gm protein daily will suffice.
• Carbohydrate requirements of infants – 10 gm/KBW/day
• Generally 8-10% of calories are given as proteins.
• From 5th month of age, undiluted boiled and cooled milk should be given.
• Infant initially requires feeding 6-8 times a day.
• Calorie requirement is increased during illnesses and should be met.
• WHO has recommended dilution of cow’s milk during the first 2 months in order to decrease solute load on newborn kidney.

• Infant Milk Substitutes, Feeding Bottles & Infant Food (Regulation of production, supply and distribution) Act 1992 came into force on 1st August 1993.
• As GoI is committed to promote breast feeding, this act prohibits the promotion of infant food, infant milk substitutes and feeding bottles.
• GROWTH & DEVELOPMENT – 

• The term growth denotes increase in physical size of the body while development denotes maturation of skills and functions.
• Factors affecting growth and development of a child are – 

1. Genetic factors
2. Nutrition
3. Age
4. Sex/gender
5. Physical environment
6. Psychological factors
7. Infections and infestations
8. Economic factors
9. Other factors e.g. birth weight, birth order etc.

• Surveillance of Growth & development – 

1. The main aim of growth surveillance is to identify those children with affected growth.
2. This also refers the effectiveness of child health services viz. nutrition, sanitation and prevention and control of infections.
3. Growth surveillance deals with following parameters – 

1. Physical Growth – 

• Weight for age
• Height for age
• Weight for height
• Head & Chest Circumference

1. Behaviour Development – 

• Motor development
• Personal-social development
• Adaptive development
• Language development

• Average birth weight in India – 2.7 to 2.9 kg

Birth weight gets doubled – 5 months of age

Birth weight gets tripled – one year of age

Birth weight gets quadrupled – 2 years of age

From 3rd year to puberty – Weight gain @ 2 kg/year

• Length at birth in India – 50 cm

Length increment in 1st year – 25 cm

Length increment in 2nd year – 12 cm

Height increment in 3rd year – 9 cm

Height increment in 4th year – 7 cm

Height increment in 5th year – 6 cm

• Low height for age is also known as NUTRITIONAL STUNTING or DWARFISM. It tells about PAST or CHRONIC MALNUTRITION.
• The cut-off point commonly taken for the diagnosis of stunting is 90% of the United States NCHS height for age values. Waterlow recorded the use of 2SD below the median reference as the cut of point.
• Low weight for height is also known as NUTRITIONAL WASTING or ACUTE MALNUTRITION.
• A child who is less than 70% of the expected weight for height is classified as severely wasted.
• Head Circumference at birth is 34 cm while chest circumference at birth is 32 cm.
• At 6-9 months, head and chest circumference become equal and in a normal child, chest circumference crosses head circumference in 9-12 months. In malnourished children, this crossing over gets delayed significantly.
• Developmental Milestones – 

6-8 weeks – looks at mother and smiles.

3 months – holds head erect

4-5 months      –     listening

• Begins to reach out objects
• Recognizes mother

              6-8 months     –     sits without support 

• Experimenting with noises
• Transfers objects hand to hand
• Enjoys hide & seek

              9-10 months   –     crawling

• Increasing range of sounds
• Releases objects
• Suspicious of strangers

             11-12 months  –     stands with support

• First words

             12-14 months  –     walks wide base

• Builds blocks

             18-21 months  –     walks narrow base, beginning to rain

• Joining words
• Beginning to explore

             24 months       –      runs

• Short sentences

• GROWTH CHART – 

• Growth chart was first designed by David Morley and later modified by WHO.
• It is a visual display of the physical growth & development of a child. It is meant for longitudinal follow up of a child.
• Weight of the child is monitored as weight is the most sensitive indicator of the growth.
• Growth chart in India has adopted new WHO child growth standards (2006) for monitoring the growth of children under NHM & ICDS. 
• The growth chart shows normal zone of weight for age, undernutrition (-2SD) & severe underweight zone (-3SD).
• It is the direction of the growth that is more important than the position of dots on the line.
• Growth chart is embedded in Mother & Child Protection (MCP) Card.
• Flattening or falling of child’s weight curve reflects growth failure, which is the earliest indication of protein-energy malnutrition.
• ICDS program through its AWC provides supplementary nutrition to such children.

• Care of the pre-school children – 

• Preschool children (1-4 years) represent about 9.7% of the general population in India.
• Preschool mortality in India is 2.3% of all deaths.
• Malnutrition is directly or indirectly act as the cause of death in 50% cases.
• Malnutrition & Infections are the important causes of morbidity & mortality in Preschool children (1-4 years) in India.
• Child health problems are as follows – 

1. Low birth weight
2. Malnutrition
3. Infections and infestations
4. Accidents and poisoning
5. Behavioural problems

• If mother is malnourished, child health is adversely affected.
• Other maternal factors affecting child’s health are maternal age (under 18 & more than 35), too close pregnancies (< 2 years spacing), birth order (> 4 ) & lack of pregnancy care.
• Family & social environment affects speech development, personality development & intellectual potentials.

• RIGHTS OF THE CHILDREN – 

• Article 24 – Prohibition of employment of < 14 years children in factories.
• Article 39 – Prevention of abuse of children of tender age.
• Article 45 – Provision of free & compulsory education till 14 years of age.

• Universal Children’s day – 14th November.
• As per SDGs, The targets to be achieved are – 

• Neonatal mortality per 1000 live births – < 12.
• Maternal mortality per 1 lakh live births – 70.
• Under 5 mortality – equal to or <25.

• INDICATORS OF MCH CARE – 

• Maternal mortality ratio
• Perinatal mortality rate
• Neonatal mortality rate 
• Post-neonatal mortality rate
• Infant mortality rate
• 1-4 years mortality rate
• Under 5 mortality rate
• Child survival rate

• MATERNAL DEATH has been defined by WHO as – 

The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of duration and site of pregnancy, irrespective of duration and site of pregnancy, from any cause related or aggravated by the pregnancy or its management but not from unintentional or incidental causes.

• Type of Maternal Death – 

1. DIRECT OBSTETRIC DEATHS – because of obstetric complications and its poor management.
2. INDIRECT OBSTETRIC DEATHS – because of pre-existing diseases or disease aggravated by pregnancy.

• MMR, Direct obstetric death rate & Indirect obstetric death rate are fine measures of the quality of maternity services.
• LATE MATERNAL DEATH is the death of a woman from direct or indirect obstetric causes, after more than 42 days but less than 1 year after termination of pregnancy.
• Maternal Deaths & Late Maternal Deaths are combined in the 11th revision of ICD under the new grouping of COMPREHENSIVE MATERNAL DEATHS.
• The number of maternal deaths in a population reflects 2 factors – 1) Fertility Level 2) Risk of mortality associated with pregnancy or birth.
• MATERNAL MORTALITY RATIO is defined as the number of maternal deaths during a given time period per 1 lakh live births during the same time. It covers the risk of mortality associated with pregnancy or birth.
• MATERNAL MORTALITY RATE is defined as the number of maternal deaths divided by person years lived by women of reproductive age in a population. It reflects both factors – fertility & maternal death per pregnancy or per birth.
• CAUSES OF MATERNAL DEATHS – 

• Current Maternal Mortality Ratio (MMR) is 97 per one lakh live births (SRS 2018-20).
• From year 2000 onwards SRS included a new method for enumeration of MMR which is called RHIME (Representative, re-sampled, Routine household interview of mortality with Medical Evaluation).
• In India (SRS 2018-20), ASSAM has the highest MMR (195/1 lakh) & Kerala has the lowest MMR (19/1 lakh).
• Interventions that lower the MMR include – 

• Early pregnancy registration
• At least 4 ante-natal check-ups
• Dietary supplementation including IFA & Calcium
• Prevention of infection & haemorrhage during puerperium
• Prevention of complications e.g. ruptured uterus, eclampsia etc.
• Treatment of Medical Conditions e.g. HT, DM, TB etc.
• Anti-malaria, adult diphtheria & tetanus prophylaxis.
• Clean delivery practices
• Promoting institutional deliveries
• Promotion of family planning
• Maternal death audit
• Safe abortion services

• Foetal death is defined as the death prior to complete expulsion or extraction from its mother of a product of conception, irrespective of duration of pregnancy.
• Still birth rate is defined as the death of a foetus weighing 1000 gm (equivalent to 28 weeks of gestation) or more occurring during one year time period in every 1000 total births (Live + Dead).
• Still birth rate worldwide is 14/1000 total births while in India is 3/1000 total births (SRS 2020).
• Perinatal Mortality = Late foetal deaths (Still births) + Early neonatal deaths (Within 7 days of delivery).
• Perinatal period ranges from 28th week of gestation to 7th day after birth.
• Perinatal Mortality in India (SRS 2020) is 18/1000 live & still births.
• Social & biological factors affecting perinatal mortality are – 

• Low socio-economic status
• High maternal age (>35 years)
• Low maternal age (<16 years)
• High parity
• Heavy smoking
• Short height of mother
• Bad Obstetric history
• Malnutrition & severe anaemia
• Multiple pregnancy.

• The main causes of perinatal mortality are – 

• Intrauterine or birth Asphyxia
• LBW
• Birth Injuries
• Intrauterine or neonatal infections.

• Neonatal deaths are deaths during the neonatal period, from birth to 28 days after birth. 
• Neonatal mortality rate is the number of neonatal deaths in a given year per 1000 live births in that year.
• CAUSES OF NEONATAL DEATHS (2017) in INDIA are – 

• Prematurity & LBW – 48.1%
• Birth asphyxia & birth trauma – 12.9%
• Pneumonia – 12%
• Other non-communicable diseases – 7.1%
• Sepsis – 5.4%
• Unknown cause – 5%
• Congenital Anomalies – 4%
• Diarrhoea – 3.1%
• Other causes – 2.3%

• Neonatal Mortality Rate (NMR) (2020) – 20/1000 live births in India.
• Proportion of neonatal deaths to Infant deaths – 71.9%.
• It is estimated that 40% of still births & neonatal deaths occur during labour & the day of birth & about 75% of total neonatal deaths occur within first week of life. Nearly half of maternal deaths also occur during this period.
• POST NEONATAL MORTALITY RATE is defined as the ratio of post neonatal deaths in a given year to the total number of live births in the same year, usually expressed as rate per 1000.
• NEONATAL MORTALITY is dominated by ENDOGENOUS FACTORS while POST NEONATAL MORTALITY is dominated by EXOGENOUS (e.g. environmental & Social) FACTORS.
• DIARRHOEA & ARI are the main causes of deaths during the post-neonatal period.
• Malnutrition is a additional factor affecting the post neonatal deaths.
• POST NEONATAL MORTALITY RATE in India (SRS 2020) is 8/1000 live births.
• INFANT MORTALITY RATE (IMR) is the most important indicator of the health status of a community. It not only reflects level of living of people in general but also effectiveness of MCH services in particular.
• NMR in INDIA (SRS 2020) is 28/1000 live births.
• Factors responsible for decline in IMR are as follows – 

• Improved obstetric & perinatal care
• Improvement in quality of life 
• Better control of communicable diseases
• Advances in chemotherapy, antibiotics & insecticides
• Better nutrition
• Better family planning services
• Increasing female literacy
• Better primary health care services

• Principal causes of IMR in India are – 

1. LBW – 57%
2. ARI – 17%
3. Diarrhoea – 4%
4. Congenital malformations – 5%
5. Cord Infection – 2%
6. Birth Injuries – 3%
7. Other causes – 18%

• BIOLOGICAL FACTORS AFFECTING INFANT MORTALITY are – 

• Birth Weight (< 2500 gm weight babies are more prone)
• Age of the mother (<19 years & >35 years)
• Birth order (5th or more)
• Birth spacing (<2 years)
• Multiple births
• Family Size (Large family size)
• High Fertility

• Cultural & Social factors affecting infant mortality are – 

• Breast feeding
• Religion & Caste
• Early Marriages
• Sex of the child
• Quality of mothering
• Maternal Education
• Quality of Health Care
• Broken families
• Illegitimacy
• Brutal habits & customs
• Untrained dais
• Bad Environmental Sanitation

• Preventive & Social measures to REDUCE IMR are as follows – 

• Prenatal maternal nutrition
• Prevention of infection including Immunization
• Promotion & Continuation of Breast feeding
• Regular growth monitoring
• Appropriate family planning measures
• Improving basic sanitation
• Provision of Primary Health Care
• Socio-economic development
• Female education promotion

• Leading causes of 1-4 year mortality of children are – 

• Diarrhoeal diseases
• Respiratory Infections
• Malnutrition
• Infectious diseases
• Other febrile diseases
• Accidents &
• Injuries.

• UNDER 5 MORTALITY RATE (CHILD MORTALITY RATE) is defined by the UNICEF as the Annual number of deaths of children age under 5 years, expressed as a rate per 1000 live births.
• It is the best indicator for social development and well-being in comparison to other indicators e.g. per capita GNP.
• UNDER 5 MORTALITY RATE in INDIA (2020) is 33/1000 live births.
• CHILD SURVIVAL INDEX in INDIA (2020) is 96.7.
• Child Survival Index can be calculated as – 1000 – under 5 mortality rate /10.
• INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESSES (IMCI) – 

• WHO & UNICEF developed this strategy.
• The strategy combines improved management of childhood illnesses with aspects of nutrition, immunization and other important disease prevention and health promotion elements.
• The objectives are to reduce the deaths and frequency and severity of illness and disability to promote growth and development.
• Strategy – 

1. Improvement in case management skills of the health staff through the provision of locally adopted guidelines on IMCI and through activities to promote their use.
2. Improvements in health system required for effective management of childhood illnesses and
3. Improvement in family and community practices.

• The core of IMCI strategy is integrated case management of the most common childhood problems, with the focus on most important causes of death i.e. diarrhoea, ARI, Malaria, Measles & Malnutrition.
• The Complete IMCI case management process involves the following elements – 

1. Assess
2. Classify
3. Identify specific treatment for the child
4. Provide practical treatment
5. Counsel & assess for feeding
6. Follow up care

• The Indian version of IMCI is known as IMNCI (Integrated Management of Neonatal & Childhood illnesses) as it includes the first 7 days of age in the program.

• CONGENITAL DISORDERS are defined as those diseases that are substantially determined before or during birth and which are in principle recognizable in early life.
• Congenital malformations includes only anatomical defects.
• Congenital anomaly includes all biochemical, structural and functional disorders present at birth.
• Congenital anomalies may lead to long term disability having enormous impact on individuals, family, health system and society.
• The most common serious congenital disorders are DOWN’S SYNDROME, HEART DEFECTS & NEURAL TUBE DEFECTS.
• GENETIC CAUSES OF CONGENITAL DISORDERS – 

• Chromosomal Anomalies e.g. Down’s Syndrome, Turner’s syndrome & Klinefelter’s syndrome.
• Inborn errors of metabolism e.g. PKU, Tay-sachs disease & galactosemia.
• Others – e.g. Sickle cell disease, Haemophilia, Thalassemia & Huntington’s chorea.
• Those with probable genetic etiology – Congenital dislocation of hip, club foot & neural tube defect.

• Environmental Factors causing congenital disorders – 

• Intrauterine Infections e.g. Rubella, Cytomegalovirus, Syphilis, Toxoplasmosis.
• Drug Intake during pregnancy e.g. Thalidomide, Stilboestrol, Anti-convulsant, Tobacco, High dose of Vitamin A, alcohol etc.
• Maternal diseases e.g. Diabetes, Cardiac failure
• Irradiation
• Dietary factors e.g. lack of folic acid in diet.

• Risk factors strongly associated with congenital malformations are – 

• Advanced maternal age at conception – Down’s syndrome possibility in foetus increases.
• Consanguinity – High chance of mental retardation & congenital anomalies in the foetus.

• Following techniques may be used for prenatal diagnosis of congenital malformations 

1. Alpha fetoprotein
2. Ultrasound
3. Amniocentesis – Done in 2nd trimester
4. Chorionic villi sampling – done in 9-11 weeks of gestation

• PREVENTION OF CONGENITAL ANOMALIES – 

• Avoidance of risk factors e.g. advanced maternal age & consanguinity
• Avoiding exposure to environmental factors responsible for congenital anomalies.
• By discouraging further reproduction after the birth of a malformed baby.
• Avoiding drugs and radiation in pregnancy
• Rubella vaccination.

• Health problems of school child are – 

• Malnutrition
• Infectious disease
• Intestinal parasites
• Diseases of skin, ear & eye
• Dental caries

• Objectives of school health services are – 

• Promotion of positive health
• Prevention of diseases
• Early diagnosis, treatment & follow up of defects
• Awakening health consciousness in children
• Provision of healthy environment

• Aspects of School Health Services – 

• Health appraisal of school children & school personnel
• Remedial measures & follow up
• Prevention of communicable diseases
• Healthy school environment
• Nutritional services 
• First Aid & Emergency care
• Mental Health
• Dental health
• Eye health
• Health education
• Education of handicapped children
• Proper maintenance & use of school health records

• IMPAIRMENT – 

It is defined as “Any loss or abnormality of psychological, physiological or anatomical structure or function” e.g. loss of a lower limb

• DISABILITY – 

It is defined as “any restriction (resulting from impairment) of ability to perform an activity in a manner or within the range considered normal for a human being” e.g. inability to walk.

• HANDICAP – 

It is defined as a disadvantage for a given individual that limits or prevents the fulfilment of a role that is normal for that individual e.g. Inability to attend school.

• Nearly 83 million of the world’s population are estimated to be mentally retarded making it 4th leading cause of disability.
• In India, about 16.15 million persons (1.9%) suffer from some or other physical disability.
• About 3% child population in 1-14 years age group is affected by development delays.
• Physically handicapped children fall into three broad causative groups – 1) Birth defects 2) Accidents & 3) Infections.
• Categories of Mental Retardation – 

• The CHILDREN ACT, 1960 provides for the “Care, protection, maintenance, welfare, training, education and rehabilitation of the handicapped children”.
• BEHAVIOURAL DISORDERS (TYPES) – 

1. Antisocial behaviour – stealing, gambling, destructiveness, cruelty & Sexual offences.
2. Habit disorders – Bed-wetting, nail biting etc.
3. Personality disorders – Shyness, jealousy, fears etc.
4. Psychosomatic disorders – Tremors, headache, delusion, hallucination, asthma etc.
5. Educational difficulties – School phobia, School failure, learning difficulty etc.

• JUVENILE DELINQUENCY – 

These are the boys & girls who have not attained 16 & 18 years of age respectively & have committed an offence.

The term includes all deviations from normal youthful behaviour.

• Prevention of Juvenile Delinquency – 

• Improvement of family life
• Schooling or proper education
• Social Welfare services e.g. Parent counselling, Child guidance, children recreation & education facilities & adequate health care.

• UJJAWALA – 

A scheme that is implemented through NGOs to prevent child trafficking. Launched on 4th December 2007 by the Ministry of Women & Child Development. Scheme has 5 components – 

1. Prevention
2. Rescue
3. Rehabilitation
4. Reintegration
5. Repatriation of victims.

• INSPIRE – 

Seven strategies for ending violence against children – launched in 2016.

I – Implementation & enforcement of law

N – Norms & Values

S – Safe Environments

P – Parent & Caregiver support

I – Income & Economic strengthening

R – Response & Supportive services

E – Education & Life Skills

SUGGESTED FURTHER READINGS – 

• K. Park; Park’s textbook of Preventive & Social Medicine, 27th edition, 2023

• AH Suryakantha; Community Medicine with Recent Advances, 3rd Edition.

• Mahajan & Gupta; Textbook of Preventive & Social Medicine; 4th edition