CONTENTS

CHAPTER 1. HEALTH & DISEASE

LEVELS OF HEALTH CARE –

Health services infrastructure in India is a 3- tier system consisting of Primary, Secondary & Tertiary health care, each level supported by a higher level to which the patients are referred. The levels of health care are –

• Primary level health care
• Secondary level health care
• Tertiary level health care

Primary level health care –

It is the first level of contact between population and health care system in India. Health services are delivered through Subcentres, Primary Health Centers & Health and wellness centers. This type of care is very near to door steps of houses of people. At this level Primary health care is being provided.

Secondary level health care –

It is the first referral level of health care in India. More complex problems are dealt at this level. Health services at this level are delivered through Community Health Centers & District Hospitals.

Tertiary level health care –

It is the second referral level of health care in India. At this level, Super Specialist care is provided. Health services at this level are delivered by Medical college hospitals, regional hospitals & Apex hospitals.

PRIMARY HEALTH CARE –

Concept of Primary Health Care was given in 1978 following Alma-Ata Conference in USSR. It was defined as –

Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-determination.

Components of primary health care are as follows –

• Education about prevailing health problems and methods of preventing and controlling them.
• Promotion of food supply and proper nutrition
• An adequate supply of safe water and basic sanitation
• Maternal & Child health care including family planning
• Immunization against infectious diseases
• Prevention & control of endemic diseases
• Appropriate treatment of common diseases and injuries and
• Provision of essential drugs

Principles of Primary Health Care are as follows –

• Social equity
• Inter-sectoral Coordination
• Appropriate technology
• Community Participation

As a signatory to the Alma-Ata declaration, Government of India, decided to provide Primary Health Care to attain Health for all by 2000 AD.

CHARACTERISTICS OF HEALTH INDICATORS –

Health indicators are the variables which help in measuring changes in the health status of an individual, community or country. If we consider a health indicator as an ideal health indicator, it should have following characteristics –

• Valid
• Reliable & objective
• Sensitive
• Specific
• Feasible
• Relevant

But in reality, only a few rare indicators have all above mentioned characteristics.

STANDARD OF LIVING & QUALITY OF LIFE –

Standard of living of people or community is the level of wealth, comfort, material goods & necessities available to them in a given area. It primarily depends on per capita GNP. Standard of living include factors like income and occupation, standards of housing, sanitation and nutrition, level of provision of health, education, recreation and other services.

Standards of living may vary from community to community and country to country.

WHO defines quality of life as the condition of life resulting from combination of the effects of the complete range of factors such as those determining health, happiness (including comfort in the physical environment & a satisfying occupation), education, social & intellectual attainments, freedom of action, justice and freedom of expression.

It can be summarized as – A complete measure of Physical, mental & social well-being as perceived by each individual or group of people.

There is increased demand of improved quality of life by people, as a result various country’s government are trying to improve the quality of life of their people.

POSITIVE HEALTH –

Health does not include only absence of disease but also a state of physical, mental & social wellbeing. In health sickness spectrum, positive health is on the top of table i.e. above the freedom from sickness and better health.

• Positive Health
• Better Health
• Freedom from sickness
• ———————————————————–
• Unrecognized sickness
• Mild Sickness
• Severe sickness
• Death

Spectrum shows that above the differentiating line, individuals progress towards positive health and below the differentiating line is the spectrum of illness, ultimately causing death of the person.

The state of positive health signifies the perfect functioning of the body and mind. Actually positive health concept in the modern era appears a bit strange as it is an ideal condition which can not be attained.

Positive health depends not only on medical action but on the other economic, cultural and social factors operating in the community in most ideal states. An alternative to positive health status is as a biologically normal state, based on statistical approaches.

Positive health, on the other hand, cannot be attained in a community where all factors contributing to a state of health are not in an ideal condition.

DISABILITY ADJUSTED LIFE YEAR –

The disability adjusted life year (DALY) is a measure of overall disease burden, expressed as the number of years lost due to ill health, disability or even death. It was developed in 1990s.

One DALY represents the loss of the equivalent of one year of full health. Using DALYs, the burden of the disease that cause premature death but little disability e.g. drowning can be compared to that of disease that do not cause death but do cause disability (e.g. cataract causing blindness).

Quality adjusted life year (QALYs) and Disability adjusted life years (DALYs) are common term. QALYs are measure of years lived in perfect health gained whereas DALYs are a measure of years in perfect health lost. They are the most frequently cited metrics for risk-benefit assessment.

DALYs are calculated by adding the number of years of life lost to the number of years lived with disability for a certain disease or disorder.

DALYs = Number of people with the disease * Duration of disease (or loss of life expectancy in case of mortality) * Severity (0 for perfect health & 1 for death).

HUMAN DEVELOPMENT INDEX (HDI) –

The Human Development Index (HDI) is a statistic composite index of life expectancy, education & per capita income indicators, which are used to rank countries into 4 tiers of human development.

As per annual HDI 2019 report, India stands at 129^th position, one rank above last year’s ranking, out of a total 189 countries. The 4 tiers of human development are Very High, High, and Medium & Low.

Pakistani Economist Mahbubul Haq created HDI in 1990 which was further used to measure the country’s development by UNDP.

Human Development Index (HDI) gives an overall index of economic development. It gives a rough ability to make comparisons on issue of economic welfare – much more than just using GDP statistics. HDI is important because it helps us to know how a country is doing. It is a better measure of country’s progress.

Three dimensions of HDI are as follows –

• A long & healthy life —— Measured by life expectancy at birth.
• Knowledge —— Measured by mean years of schooling and expected years of schooling
• A descent standard of living —– Measured by GNI per capita used to measure it

Life expectancy index, education index & GNI index together form Human development index (HDI).

MILLENNIUM DEVELOPMENT GOALS (MDG) –

The United Nations Millennium development goals are eight goals that all 191 UN member states have agreed to try to achieve by the year 2015. The United Nations Millennium Declaration, signed in September 2000 commits world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation and discrimination against women. The Millennium development goals are derived from this declaration, and all have specific targets and indicators.

The eight Millennium development goals are –

• To eradicate extreme poverty & hunger
• To achieve universal primary education
• To promote gender equity & empower women
• To reduce child mortality
• To improve maternal health
• To combat HIV/AIDS, malaria & other diseases
• To ensure environmental sustainability
• To develop a global partnership for development

The MDGs are independent, all MDGs influence health & health influences all MDGs. The MDGs were followed by Sustainable Development Goals (SDGs) which has to be achieved by 2030.

SUSTAINABLE DEVELOPMENT GOALS (SDGs) –

Sustainable Development Goals (SDGs) are a collection of 17 global goals designed to be a blue print to achieve a better and more sustainable future for all. The SDGs, set in 2015 by the UN General Assembly & intended to be achieved by the year 2030, are part of UN resolution 70/1, the 2030 agenda.

The goals are broad based and interdependent. Each goal has various indicators to measure the list of targets. The SDGs are as follows –

Goal 1 – No poverty

Goal 2 – Zero Hunger

Goal 3 – Good health & well being

Goal 4 – Quality Education

Goal 5 – Gender equality

Goal 6 – Clean water and sanitation

Goal 7 – Affordable & clean energy

Goal 8 – Decent work & economic growth

Goal 9 – Industry, Innovation & Infrastructure

Goal 10 – Reducing inequality

Goal 11 – Sustainable cities & communities

Goal 12 – Responsible consumption and production

Goal 13 – Climate Action

Goal 14 – Life below water

Goal 15 – Life on land

Goal 16 – Peace, Justice & Strong institutions

Goal 17 – Partnerships for the goals

HEALTH FOR ALL –

In May 1977, World Health Assembly declared that the main social goal of member country’s & WHO in coming years should be the –

Attainment by all the people of the world by the year 2000 AD of a level of health that will permit them to lead a socially & economically productive life.

This goal is popularly known as the Health for All by 2000 AD (HFA).

The essential principle of the HFA is the concept of equity in health, that is, all people should have an equal opportunity to enjoy good health.

The basis of HFA was growing concern about the unacceptably low levels of health status of the majority of the world’s population especially the rural poor and the gross disparities in health between the rich and poor, urban and rural populations, both between and within the countries.

Primary Health Care was accepted by the member countries of WHO as the key to achieving the goal of Health for All by the year 2000 AD.

ICEBERG OF THE DISEASE –

Concept of Iceberg of disease is closely related to spectrum of disease. In this concept, disease in the community may be compared with an iceberg. The floating tip of iceberg represents the clinical or symptomatic cases which are easily recognized by a Physician. The major submerged portion of the iceberg denotes the hidden burden of the disease i.e. carriers, asymptomatic, latent, subclinical and undiagnosed cases in the given community. The waterline represents the demarcation between apparent and inapparent diseases.

In some diseases e.g. Hypertension, Diabetes, Mental illness, Malnutrition & Anemia, the unknown or undetected cases (i.e. submerged portion of iceberg) far exceeds the known or detected cases (i.e. the floating tip of iceberg).

The hidden part of the iceberg constitutes an important, undiagnosed reservoir of infection or disease in the given community, and its detection and control is a challenge to modern techniques in preventive medicine.

SENTINEL SURVEILLANCE –

All cases of infection or disease cannot be identified by routine notification system. Therefore, a method of identifying the missing cases and thereby supplementing the notified cases is required. This is known as SENTINEL SURVEILLANCE. The sentinel data is used for entire population to estimate the disease prevalence in the community or given population.

Sentinel surveillance involve monitoring of key health indicators through sentinel –

• Sites
• Events
• Providers
• Vectors/animals

It involves reporting of health events by selected units/ professionals representing a geographic area. It may be active or passive surveillance. Only small number of units are selected. Selected units report all cases for a specific time period. Reports include additional information. Advantages of sentinel surveillance are as follows –

• Reporting biases are minimized.
• Feed-back information to the providers is simplified.
• More valuable and detailed information could be provided.

Sentinel surveillance for HIV & STI/STD are good example.

HEALTH SYSTEM RESEARCH

Health system research is also known as Health Policy & System Research (HPSR). It is a multidisciplinary scientific field that examines how people get access to health care practitioners & health care services, how much care costs, and what happens to patients as a result of this care.

The main goals of Health System Research are to identify the most effective ways to organize, manage, finance & deliver high quality care, reduce medical errors & improve patient safety.

Purpose –

• To solve health problems
• To improve the health of people through improvement of the various interrelated components of the health systems.
• To enhance efficiency & effectiveness of health system as an integral part of overall socio-economic development.
• Analysis of problem from technical & human angle and translation of research results into implementable solutions.

Priority areas for HSR in India –

• Adolescent Health
• Gerontology concerning problems
• Women’s health & empowerment
• Primary Health Care
• Improvement of referral systems etc.

It fills gap between the researchers, policy makers & other administrators responsible for implementation of health programs. It also acts as a tool for improved managerial & policy decision makings.

COMMUNITY DIAGNOSIS –

The community diagnosis depends upon understanding of social science, vital statistics & epidemiological investigations. Community diagnosis may be defined as determining the pattern of health problems in a given community, including the factors which influence this pattern. Or one can say community diagnosis is a comprehensive assessment of the state of an entire community in relation to its social, political, economic, physical & biological environment.

The purpose of community diagnosis are as follows –

• It helps in identification and quantification of health problems.
• Helps in identification of those individuals or groups at risk or those who need health care
• It helps to identify community needs and problems.
• It helps to decide strategies for community involvement.
• Effectively help in understanding the social, cultural, & environmental characteristics of community.
• Can be used to help aware the community about its problems & find solutions.

The focus is on the identification of the basic health needs & health problems of the community. The needs as felt by the community should be next investigated and listed according to priority for community treatment. It can be done by community analysis which is the process of examining the data to define needs, strengths, barriers, opportunities, readiness & resources. The product of the analysis is community profile.

REHABILITATION –

It is the process of helping a person to reach the fullest physical, psychological, social, vocational, advocational & educational potential consistent with his or her physiologic or anatomical impairment, environmental limitations, desires and life plans.

Phases of rehabilitation are as follows –

• Medical Rehabilitation
• Vocational Rehabilitation
• Economical Rehabilitation
• Psycho-social Rehabilitation

WHO defines rehabilitation as the combined and coordinated use of medical, social, educational and vocational measures for training the individual to the highest level of functional ability.

The aim of rehabilitation is basically social integration. Social Integration has been defined as the active participation of disabled and handicapped people in the mainstream of community life. Examples of rehabilitation are: establishing schools for the blind, provision of the aids for crippled, reconstructive surgery in leprosy etc.

RISK FACTORS –

Risk factor is a variable associated with an increased risk of disease or infection. It is an exposure or attribute that is significantly associated with the development of a disease. Risk factors can be modified by intervention, thus reducing the possibility of occurrence of disease or health outcomes.

Risk factors are often suggestive, but absolute proof of cause and effect between a risk factor and disease is usually lacking.

The term Risk Factor was first coined by former Framingham Heart Study Director, Dr William B. Kannel in 1961. When done thoughtfully & based on Research, identification of risk factors can be a strategy for medical screening. Risk factors may be truly causative (e.g. smoking for lung cancer); they may be merely contributory to the undesired outcome (e.g. lack of physical exercise is a risk factor for coronary heart disease), or they may be predictive only in a statistical sense (e.g. Illiteracy for perinatal mortality).

Some risk factors are modifiable while others are non-modifiable. The modifiable risk factors include smoking, hypertension, elevated serum cholesterol, physical activity, obesity etc. The non-modifiable risk factors include age, sex, race, family history, and genetic factors. Risk factors may characterize the individual, the family, the group, the community or the environment. Epidemiological methods are needed to identify risk factors and estimate the degree of risk. These studies are carried out in a population group among whom certain diseases occur much more frequently than other groups. 

HEALTH PROMOTION –

According to WHO, Health promotion is the process of enabling people to increase control over & to improve their health. It is intended to strengthen the host through a variety of interventions which are as follows –

• Health Education
• Environmental modifications
• Nutritional Interventions
• Lifestyle & Behaviour changes

Health education is one of the most cost-effective interventions. A large number of diseases may be prevented in a given community by proper provision of health education. The targets for health education include general public, patients, beneficiaries of health system, priority groups, health providers, religious and community leaders, PRI members & decision-makers.

Environmental modifications includes provision of safe water and basic sanitation, control of insects and rodents, improvement in housing etc. Many diseases in developed world has been controlled by environmental modifications.

Nutritional interventions include THR, nutrition improvement of vulnerable groups, child feeding programs, food fortifications, nutritional surveillance & nutrition education.

Giving responsibility to individual and community may successfully accomplish lifestyle & behavioural changes. It involves organizational, political, social & economic interventions designed to facilitate environmental & behavioural adaptations that will improve or protect health.

SPECIFIC PROTECTION – 

Specific protection is a mode of intervention which targets a type or group of diseases and complements the goal of health promotion. This along with Health promotion constitutes primary prevention. It includes following interventions –

• Immunization
• Use of specific nutrients
• Chemoprophylaxis
• Protection against occupational hazards
• Protection against accidents
• Protection against carcinogens
• Avoidance of allergens
• Control of pollution
• Safety of drugs & foods

Specific protection acts in places or population where risk factors for the disease is already established. It is not synonym with the health protection.

LEVELS OF PREVENTION –

In modern days, the concept of prevention has become broad based. There are 4 levels of prevention which are as follows –

• Primordial Prevention
• Primary Prevention
• Secondary Prevention
• Tertiary Prevention

Primordial Prevention –

This is a prevention of development of risk factors in a population group in which these have not appeared yet. Special attention is given in preventing chronic diseases especially non communicable diseases. Main intervention is health education. Efforts are dedicated towards discouraging people from adopting harmful lifestyles/habits through individual or mass education. Primordial prevention begins in childhood when health risk behaviour begins.

Primary Prevention –

Primary prevention can be defined as the action taken prior to the onset of the disease, which removes the possibility that the disease will ever occur. It signifies intervention in the pre pathogenesis phase of a disease or health problem. Intervention includes health promotion and specific protection. The WHO has recommended the following approaches for the primary prevention of chronic diseases where the risk factors are established –

• Population (mass) strategy
• High risk strategy

Secondary Prevention –

It is defined as an action that halts the progress of a disease at its incipient stage and prevents complications. The specific interventions are –

• Early diagnosis & Treatment
• Referral

Early diagnosis comprises of Screening tests, breast self-examination, pap smear test, radiological examinations etc.

It protects others in the community from acquiring the infection and thus provide at once secondary prevention for the infected ones and primary prevention for their potential contacts.

Tertiary Prevention –

It is used when the disease process has advanced beyond its early stage. It is defined as all the measures available to reduce or limit impairments and disabilities & to promote the patients’ adjustment to irremediable conditions. Interventions that should be accomplished in the stage of tertiary prevention are disability limitations and rehabilitations. It signifies intervention in late pathogenesis phase.

Chapter 2. NUTRITION  

INDIAN REFERENCE MAN AND WOMAN

The aim of nutritional policies and programs is to provide adequate nutrition to its entire population so that they can achieve full growth and development. Therefore, it is important to set standards for ideal weight and height in order to recommend nutritional intakes. Working in this area, ICMR recommended reference weights of 60 kg and 55 kg for adult man and woman respectively.

Reference Indian adult man is of 19-39 years age, weighing 60 kg with a height of 1.77 meters and a BMI of 20.75. He is free from disease and physically fit for active work. On each working day, he is engaged in 8 hours of occupation which usually involves moderate activity; while when not at work, he spends 8 hours in bed, 4-6 hours in sitting and moving about, 2 hours in walking, in active recreation or household duties.

Reference Indian adult woman is of 19-39 years age, non-pregnant non-lactating, weighing 55 kg with a height of 1.62 meters and a BMI of 20.95. She is free from disease and physically fit for active work. On each working day, she is engaged in 8 hours of occupation, which usually involves moderate activity, while not at work she spends 8 hours in bed, 4-6 hours in sitting and moving about, 2 hours in walking and in active recreation or household duties.

MALNUTRITION – INFECTION VICIOUS CYCLE

There has been an established close association between malnutrition and infection. This is a vicious cycle which cannot be broken in the settings of poverty, ignorance and paucity of health services. An inadequate dietary intake leads to weight loss, lowered immunity, mucosal damage, invasion by pathogens, and impaired growth and development in children. Childhood episodes of diarrhea, pneumonia & measles are exacerbated by undernutrition, which significantly contributes to death toll from these infections.

Malnutrition in childhood decreases the proper development of immune response mechanism leading to diminished cellular immune responses. This further leads to a higher mortality and morbidity from the seemingly common infections. Malnutrition underlines almost half of all deaths in children under 5 years of age. From malnutrition in this note we refer undernutrition which is defined as insufficient food intake – including calories and/or nutrients – to sustain growth and development. Undernutrition manifests in different ways as stunting, wasting, specific nutritional deficiencies of key vitamins and minerals that children need to grow and develop properly.

ESSENTIAL AMINO-ACIDS

Proteins comprises of smaller units called amino acids. Essential amino acids cannot be synthesized by the human body. As a result, they must come from food. Although all 20 amino acids are important, only nine are essential. The nine essential amino acids are –

Histidine, Isoleucine, Leucine, Lysine, Methionine, Phenylalanine, Threonine, Tryptophan & Valine.

Both essential & non-essential amino acids are required for synthesis of tissue proteins. New tissues cannot be formed unless all essential amino acids (EAA) are present in the diet. They play important role in the body –

• Phenylalanine – is a precursor for the neurotransmitters TYROSINE, DOPAMINE, EPINEPHRINE & NOREPINEPHRINE.
• Valine – helps stimulate muscle growth and regeneration
• Threonine – plays an important role in fat metabolism and immune function
• Tryptophan – is a precursor of SEROTONIN, a neurotransmitter
• Methionine – is required for absorption of Zinc and Selenium
• Leucine – is critical for protein synthesis and muscle repair
• Histidine – is a precursor of histamine etc.

BIOLOGICALLY COMPLETE PROTEIN 

Human body needs protein to build muscles, bones, cartilage & skin. It also needs protein to repair cells & tissues, produce & regulate hormones, supply oxygen to blood & key areas & aid in digestion.

A biologically complete protein or whole protein is a good source of protein that contains an adequate proportion of each of the nine essential amino acids, necessary in the human diet. Examples are red meat, poultry, fish, eggs, milk, cheese, yogurt, soya beans etc. Vegetable sources of biologically complete proteins are Quinoa, buckwheat & hempseed.

When one or more of the Essential Amino acids are lacking, the protein is said to be biologically incomplete. The quality of dietary protein is closely related to its pattern of amino acids. Biologically incomplete protein sources are as follows – Nuts & seeds, Whole grain (like brown rice or whole wheat bread), vegetables & legumes in the form of lentils, peas & beans.

Animal proteins are superior to vegetable proteins as they are biologically complete proteins.

REFERENCE PROTEIN

Egg protein is best among food proteins because of their high biological value and digestibility coefficient. They are used in nutrition studies as reference protein.

It contains all essential amino acids and its Net Protein Utilization (NPU) is highest.

A large egg contains 6.29 grams of high-quality protein, about 12.6% of Daily Reference Value (DRV) for protein and supplies about 70 Kcal of energy. Net Protein Utilization (NPU) for eggs are 100, highest among all animal foods.

SUPPLEMENTARY ACTION OF PROTEINS

When two or more of vegetarian foods are eaten together, their proteins supplement one another and provide a protein equivalent to animal protein in respect to essential amino acids. This is known as supplementary action of proteins. e.g. Pulses are deficient in methionine while cereal protein is deficient in Lysine and threonine. Eating rice – dal combination is an example of supplementary action of proteins.

This is the basis of counselling people to eat mixed diets.

Some other food combinations based on supplementary action of proteins are –

• Peanut Butter Sandwich
• Rice & Beans
• Macaroni and cheese
• Grilled cheese sandwiches
• Tofu with rice, quinoa, barley or buckwheat
• Hommus on bread or crackers

Thus, with proper planning, it is possible for a vegetarian to obtain a high-grade protein, at low costs, from mixed diets of pulses, cereals and vegetables.

ESSENTIAL FATTY ACIDS

Fat yields fatty acids and glycerol on hydrolysis. Essential fatty acids are those fatty acids which cannot be synthesized in human body thus these has to be derived only from the foods.

The most essential fatty acid is LINOLEIC ACID which helps in production of other essential fatty acids. These fatty acids are healthy fats that may support wellbeing of heart. One key benefit is helping to lower raised triglycerides.

There are three kinds of essential fatty acids –

1. Linoleic Acid (Omega 6 fatty acids)
2. Linolenic Acid (Omega 3 fatty acids)
3. Arachidonic Acid

Not all polyunsaturated fatty acids are essential fatty acids. Essential fatty acids are important structural component of cell membranes, serve as precursor to bioactive lipid mediators and provide a source of energy.

Foods that are rich in essential fatty acids are Fish & other sea foods, Nuts & seeds (such as flax seeds, chia seeds & walnuts) & plant oils such as flax seed oil, soya bean oil & canola oil. Dark green vegetables such as Kale, Collards, Chard, Sea weed, and cereal grasses (wheat & barley grasses) are also good sources because all green foods contain omega-3 fatty acids in their chloroplast.

Essential fatty acid deficiency is rare, occurring most often in infants fed diets deficient in essential fatty acids. Signs include scaly dermatitis, alopecia, thrombocytopenia and in children, intellectual disability. Diagnosis is critical. Dietary replenishment of essential fatty acids reverses the deficiency.

TRANS-FATTY ACIDS

Trans-fatty acids, also known as trans-fat, are unsaturated fatty acids that come from both natural and industrial sources. Naturally occurring trans-fatty acids come from ruminants (cows & sheep). Industrially-produced trans-fatty acids are formed in an industrial process that adds hydrogen to vegetable oil converting the liquid into solid, resulting in partially hydrogenated oil (PHO). Chemical process of hydrogenation of oils which increases shelf life of poly unsaturated fatty acids (PUFAs) creates trans-fatty acids and also removes the critical double bonds in essential fatty acids.

Trans-fatty acids, on consumption, increases LDL cholesterol and decreases protective HDL cholesterol, thus markedly increasing the risk of heart disease. It is also known as trans-fat. Average consumption of trans-fat globally was estimated to be 1.4% of total energy in 2010.

Assessing intake of trans-fat should be done through population surveys. Potential methods include dietary surveys and/or blood plasma/ serum assays. It is essential to mention tans-fat and saturated fat content on nutritional item levels.

Important sources of trans-fatty acids are as follows –

1. Deep fried fast foods
2. Cake mixes
3. Chips & crackers
4. Whipped toppings
5. Packaged cookies and candy
6. Packaged doughnuts, pies and cakes

REPLACE is an action package developed by WHO that supports the government to ensure the prompt, complete and sustained elimination of industrially produced trans-fat from the food supply. The steps involved in REPLACE are –

• Promotion of use and consumption of healthier fat and oils
• The elimination of industrially produced trans-fats, to be achieved through regulatory action
• Establishing solid monitoring systems
• Creating awareness among policy-makers, producers, suppliers and the public.

GLYCEMIC INDEX (GI)

Glycemic index is a relative ranking of carbohydrates in foods according to how they affect blood glucose level two hours after consuming that food. Index is a number from 0 to 100 assigned to a food, with pure glucose arbitrarily given the value of 100. Glycemic index can be classified as –

• Low GI —- 1 – 55
• Medium GI —- 56 – 69
• High GI —– 70 or above

Several factors influence the glycemic index of a food including its nutrient composition, cooking method, ripeness, and the amount of processing it has undergone. Some foods containing different types of soluble and insoluble fibers leads to slow release of sugar in to small intestine and its absorption into blood. These are termed low glycemic foods e.g. most fruits and vegetables (except potato, sweetcorn and watermelon), whole grains, pasta foods, lentils and beans.

High glycemic foods contain readily digestible and absorbable sugars leading to sudden peak in blood sugar levels, e.g. cornflakes, baked potato, Jasmine rice variants, white bread, candy bar etc. Examples of medium glycemic foods are sucrose, basmati rice and brown rice.

The concept of glycemic index has practical utility in management of Diabetes Mellitus, control of fatty liver and control of obesity. A low glycemic diet may help manage blood sugar levels, reduce serum cholesterol and boost short term weight loss.

DIETARY FIBERS

Dietary fiber is a type of carbohydrate that cannot be digested by our body’s gastrointestinal enzymes. It is found in edible plant foods such as cereals, fruits, vegetables, dried peas, nuts, lentils and grains.

Dietary fiber includes polysaccharides, oligosaccharides, lignin and plant substances. Organic acids (butyric acid) and polyols (sorbitol) are also considered as part of fiber.

Animal foods do not contain any fiber. Dietary fibers play important role in the followings –

1. Reducing post-prandial glucose level in blood
2. Helps in lowering the blood cholesterol
3. Helps in faecal bulking and softening
4. Improves bowel habits

A daily intake of about 30 grams of dietary fibers per 2000 Kcal is recommended. High intake of dietary fibers (>60 gm/day) can reduce the nutrient absorption and cause bowel irritation.

Dietary fibers are of following types –

1. Soluble (partly or fully)
2. Insoluble

These dietary fibers undergo fermentation in colon and yield short chain fatty acids which are utilized as a source of energy by the colon cells and by the liver. In general energy conversion factor for dietary fiber is 2.0 kcal/gm.

ASSESSMENT OF VITAMIN A DEFECIENCY

Assessment of vitamin A deficiency tells about magnitude and type of problem in relation to vitamin A deficiency. This is needed to formulate cost-effective and patient-centered intervention program for prevention of vitamin A deficiency in a given community.

This is done by population surveys employing both clinical and biochemical parameters. These surveys (prevalence surveys) are done on preschool children (6 months to 6 years) who are at special risk.

Prevalence Criteria (WHO) for determining the Xerophthalmia-

• Night blindness – More than 1% (Prevalence in population 6 months to 6 years)
• Bitot’s spots – More than 0.5% (Prevalence in population 6 months to 6 years)
• Corneal Xerosis/corneal ulceration/ Keratomalacia – More than 0.01% (do)
• Corneal Ulcer – More than 0.05% (Prevalence in population 6 months to 6 years)
• Serum Retinol (less than 10 mcg/dl) – More than 5%.

The presence of any one of the criteria should be considered as evidence of a Xerophthalmia problem in the community. The identified Xerophthalmia cases should be treated with vitamin A (2 lakh IU on alternate days, two doses) and should be encouraged to eat vitamin A rich fruits, vegetables & foods.

IRON DEFECIENCY

Iron deficiency results in nutritional anemia, called iron deficiency anemia. Iron deficiency anemia is the most common nutritional deficiency in the world. It is estimated that nearly ½ of all women and 2/3 of all pregnant women have anemia in developing countries.

Iron deficiency not only results in anemia but also leads to impaired cell mediated immunity, reduced resistance to infection, increased morbidity and mortality and diminished work performance.

Evaluation of iron status can be done using following parameters –

1. Hemoglobin Concentration – Value less than 11 g/dl indicate iron deficiency
2. Serum iron concentration – values less than 0.50 mg/L indicate iron deficiency
3. Serum ferritin – Values less than 10mg/L indicates absence of iron store as it reflects iron store of the body.
4. Serum transferrin saturation – should be above 16%

Three stages of iron deficiency are as follows –

1. Decreased storage of iron
2. Latent iron deficiency meaning that iron stores are exhausted without evidence of anemia.
3. Overt Iron deficiency meaning that decrease in concentration of circulating hemoglobin due to impaired synthesis.

Patients should be encouraged to wear slippers to avoid hook worm infection in endemic areas. They should wash hands with soap after latrine and before consumption of food. Those with mild and moderate anemia should be treated with Iron & folic Acid tablets & Vitamin C. Those with severe anemia may require I/M Iron, Iron Sucrose or blood transfusion.

EPIDEMIOLOGICAL ASSESSMENT OF IODINE DEFICIENCY

Iodine Deficiency Disorders (IDD) are one of the biggest worldwide public health problem of today. Their effect is hidden and profoundly affects the quality of human life. Iodine deficiency occurs when the soil is poor in iodine, causing a low concentration in food products and insufficient iodine intake in the population. When iodine requirements are not met, the thyroid may no longer be able to synthesize sufficient amounts of thyroid hormone. The resulting low-level of thyroid hormones in the blood is the principal factor responsible for the series of functional and developmental abnormalities, collectively referred to as IDD. Iodine deficiency is a significant cause of mental developmental problems in children, including implications on reproductive functions and lowering of IQ levels in school-aged children. The consequence of iodine deficiency during pregnancy is impaired synthesis of thyroid hormones by the mother and the foetus. An insufficient supply of thyroid hormones to the developing brain may result in mental retardation. Brain damage and irreversible mental retardation are the most important disorders induced by iodine deficiency. Daily consumption of salt fortified with iodine is a proven effective strategy for prevention of IDD.

Indicators used to assess the iodine deficiency are as follows –

1. Prevalence of goiter
2. Prevalence of cretinism
3. Urinary Iodine excretion – Used particularly in surveillance
4. Measurement of thyroid functions – serum T4 & TSH
5. Prevalence of neonatal hypothyroidism – Sensitive indicator of environmental iodine deficiency

These indicators should be measured before start of iodine deficiency control program in a given community as a baseline. Then measured at regular interval for surveillance of iodine deficiency control program.

TRACE ELEMENTS

Minerals can be classified as macro minerals & micro minerals (Trace elements).

Macro minerals are those minerals whose requirement in the body is more than 100 mg per day e.g. calcium, phosphorus, magnesium, sodium, potassium, chlorides and sulphur.

Micro minerals or trace elements is defined as those comprising less than 0.01% of total body weight or those which are needed in the concentration less than 1 ppm. Also known as trace elements because their concentration in tissues could not be easily ascertained by early analytic methods.

Examples of trace elements are iron, zinc, selenium, iodine, copper, manganese, molybdenum, chromium and fluorine. Examples of ultra-trace elements are cobalt, Nickel, tin, silicon, vanadium, arsenic and boron.

Various diseases of public health problem can be attributed to trace elements for example Iodine deficiency disorders, Iron deficiency anemia, dental caries, dental & skeletal fluorosis. Control measures for such deficiency diseases include Health education, Nutritional supplement of responsible trace element & consumption of trace element rich foods. For dental & skeletal fluorosis avoidance of fluorinated tooth paste is also an important control measure.

DIETARY ANTIOXIDANTS

Dietary antioxidants are present in human food and reduce the adverse effects of reactive oxygen species (ROS) and nitrogen species which are generated during physiological and pathological conditions and result in oxidant damage. Ageing is result of chronic exposure to ROS.

Examples of dietary antioxidants and their sources are as follows –

Benefits –

1. Prevents features of Ageing
2. Prevents Cancer & Heart Disease
3. Prevents build-up of plaques

PARBOILING

It is an ancient technique practiced in Indian households. It involves steaming of rice that renders it partially cooked. The rice is then dried, home pounded, and milled for final use.

The technique is now being used at a commercial level as well. The hot soaking process of parboiling has been recommended by the Central Food Technological Research Institute, Mysore.

ADVANTAGES OF PARBOILING –

1. Parboiling causes the B group vitamins in the outer layers (aleurone) to diffuse into the interior of the grain (endosperm) thus saving them from being lost during milling.
2. Drying the rice causes the germ to attach firmly to grain so that the germ is not lost during milling and polishing.
3. The heat hardens the grain as the starch gets gelatinized. This increases the keeping quality and storage capacity of rice.
4. The parboiled rice also becomes more resistant to insects.

DISADVANTAGES – It imparts an off flavour to rice.

DIETARY GOALS

The dietary goals recommended by the various expert committees of WHO are given below –

1. Dietary fat should contribute approximately 15-30% of total dietary intake.
2. Saturated fats should contribute not more than 10% of the total energy intake, unsaturated fats should contribute for the remaining fat requirement.
3. Excessive refined carbohydrate consumption should be avoided, some amount of carbohydrate rich in natural fiber should be taken.
4. Sources rich in energy such as fats and alcohol should be restricted.
5. Salt intake should be restricted to not more than 5 g/day.
6. Protein should contribute approximately 10-15% of the daily intake.
7. Junk foods such as colas, ketchups & other foods that supply empty calories should be reduced.

These recommendations don’t apply in following conditions –

1. Growth Period
2. Pregnancy
3. Lactation
4. Physical activity
5. Medical disorders such as Diabetes.

BALANCED DIET

A balanced diet is one that fulfils all the nutritional needs of a person. A balanced diet provides all the nutrients a person requires, without going over the recommended daily calorie intake. A balanced diet is defined as one which contains a variety of foods in such quantities and proportions that the need for energy, amino acids, vitamins, minerals, fats, carbohydrates and other nutrients is adequately met for maintaining health, vitality and general well-being and also makes a small provision for extra nutrients to withstand short duration of leanness. A balanced diet is an accepted means to safeguard a population from nutritional deficiencies.

Eating a balanced diet helps people maintain good health and reduce their risk of disease.

A healthful, balanced diet includes foods from these four groups –

1. Vegetables and fruits
2. Oils and fats, nuts and oilseeds
3. Grains
4. Dairy products, eggs, meat & fish

A balanced diet should provide around 50-60% of total calories from carbohydrates, preferably from complex carbohydrates, about 10-15% from protein and 20-30% from both visible and invisible fats. In addition, a balanced diet should provide other nutrients such as dietary fibers, anti-oxidants and phytochemicals which will show positive health benefits. Drink at least 6-8 liters of water & other fluids.

One should eat from the 5 food groups each day. The 5 food groups are –

• Vegetable & legumes (beans)
• Fruit
• Grains & cereals
• Lean meat, poultry, fish, eggs, legumes (beans), tofu, nuts, seeds
• Milk, cheese, yoghurt or alternatives

Each food group has important nutrients. Diet of a person will depend upon following factors –

• How much active he is
• Whether or not he is growing
• Whether or not she is pregnant or breastfeeding

LOW BIRTH WEIGHT (LBW)

Low birth weight (LBW) is defined by the World Health Organization (WHO) as a birth weight of a young infant of less than 2500 grams, regardless of gestational age. It is further categorized to very low birth weight i.e. less than 1500 grams and extremely low birth weight i.e. less than 1000 gram. Normal weight of the baby at term delivery is 2500 – 4200 gram.

Low birth weight is a major public health problem in many developing countries including India. In India 17.29 % of babies born are low birth weight while 6% are having very low birth weight as per NFHS 5 (2019-21).

In India & other developing countries, where LBW proportion is high, intrauterine growth retardation is major cause of low birth weight whereas in countries where LBW proportion is less, prematurity is the major cause.

Causes include –

• Maternal Malnutrition
• Anaemia
• Maternal Infections
• Hard physical labour during pregnancy
• Substance abuse
• Young age
• Multiple pregnancies
• Close birth intervals
• Insufficient antenatal care

Low birth weight may lead to foetal and perinatal mortality and morbidity inhibited growth and development and chronic diseases later in life. Low Birth Weight (LBW) contributes 60-80% of Infant Mortality Rate in developing countries. Early registration of pregnancy, Regular ANC checkups, management of high risk pregnancy, combating maternal malnutrition, cessation of smoking, tobacco use & alcohol intake are important preventive measures.

MARASMUS

It is a form of severe malnutrition characterized by deficiency of energy. It is more common in children. In Marasmus, weight of the child is less than 62% of the normal body weight for age. Marasmus is more common in children less than one year of age.

Features of Marasmus are as follows –

• Muscle wasting marked
• Severe loss of subcutaneous fat
• No oedema
• Weight for height very low
• Child is quite and apathetic
• Good appetite
• Serum albumin is normal or slightly decreased

It is a type of protein –energy malnutrition. The counterpart Kwashiorkor & this marasmus are considered two opposite poles of single continuum. Nutritional Marasmus is more frequent than Kwashiorkor in India. Kwashiorkor results from deficiency of protein in diet and it affects children commonly after 18 months. It is characterized by oedema, skin and hair changes. In Kwashiorkor, serum albumin is < 3gm/100 ml blood.

Treatment includes treatment of causes, frequent feeding and balanced diet. In children with marasmus, the following can also occur –

• Chronic diarrhoea
• Respiratory infections
• Intellectual disability
• Stunted growth

XEROPHTHALMIA (DRY EYE)

Xerophthalmia is a progressive eye disease which refers to all the ocular manifestations of vitamin A deficiency in man. It includes conjunctival and corneal xerosis, Bitot’s spots, Keratomalacia, nyctalopia and retinopathy.

Xerophthalmia is a major public health problem in developing countries and is leading cause of preventable blindness. Besides ocular signs and symptoms, it may be associated with increased morbidity, mortality, and can have adverse effects on the growth and development of the affected child. Xerophthalmia is most common in children aged 1-3 years and is often related to weaning. It is often accompanied by protein-energy malnutrition.

Risk factors associated with Xerophthalmia are as follows –

• Poverty
• Ignorance
• Faulty feeding practices
• Infections like measles and diarrhoea
• Mass distribution of skimmed milks

An estimated 5.7% children in India suffer from eye signs of vitamin A deficiency. Earliest sign of Xerophthalmia is conjunctival Xerosis while earliest symptom is Night blindness.

Prevention & Control of Xerophthalmia –

• Vitamin A supplementation at periodic intervals in high doses (9 months to 5 years, at every 6 months)
• Regular & adequate intake of vitamin A
• Vitamin A fortification
• Breast feeding practices
• Proper, adequate and timely complimentary feeding
• Improved environmental hygiene
• Vaccination with MR & Rotavirus vaccine

Thus prevention & control of Xerophthalmia must be an integral part of primary health care.

IODIZED SALT 

Iodized salt is table salt mixed with a minute amount of various salts of elemental iodine. It’s consumption prevents iodine deficiency disorders in a given community. In India, the level of iodization is fixed under the Prevention of Food Adulteration (PFA) Act and is not less than 30 ppm at the production point and not less than 15 ppm of iodine at the consumer level.

Iodine salt is the most cost effective means of mass prophylaxis in endemic areas. Monitoring the level of iodine in salt and the iodine status of the population are critical for ensuring that population needs are met and not exceeded.

There are two forms of iodine that can be used to iodize salts – iodine & iodide, usually as potassium salt. Iodate is less soluble and more stable than iodide and is therefore preferred for tropical moist conditions.

Use of iodized salt becomes more important with the fact that 71 million persons are suffering from goiter and other iodine deficiency disorders in our country.

ENDEMIC FLUOROSIS 

Endemic Fluorosis results from presence of excess fluorine in drinking water. Fluorine being a micronutrient is found in drinking water, sea foods, cheese and tea.

Permitted level of fluorine in drinking water is 0.5-0.8 mg/L. Fluorine is considered the double edged sword, excess results in dental and skeletal fluorosis while deficiency leads to dental caries.

Fluorosis is a disease caused by deposition of fluoride in the hard and soft tissues of the body. It is usually characterized by discoloration of teeth and crippling disorders depending upon water content of fluorine, duration and level of exposure. Fluorosis affects 20 states in the entire country with Rajasthan, Gujarat & Andhra Pradesh being most affected states.

Clinical manifestations of fluorosis are as follows –

• Dental Fluorosis in children
• Skeletal fluorosis in adults
• Genu Vulgum
• Non-skeletal fluorosis

Dental fluorosis is characterized by mottling of dental enamel which has been reported at levels above 1.5 mg/L intake. Skeletal fluorosis is associated with life time daily intake of 3.0 to 6.0 mg/L or more.

Interventions required –

• Change of Water Source
• Chemical treatment – Nalgonda technique & DE fluoridation of water
• Avoid use of Fluoride tooth paste in endemic areas

LATHYRISM

It is a paralyzing disease of humans, also known as Neuro-lathyrism. Neuro-lathyrism is a crippling disease of the nervous system with features of gradually developing spastic paralysis of lower limbs, mainly in adults due to consumption of Lathyrus Sativus or Khesari Dal in large quantities.

Disease is more common in UP, MP, Bihar & Odisha where this pulse is grown. Studies has shown that disease results after consumption of diet containing more than 30% Lathyrus Sativus pulse for a period of 2-6 months. The toxin present in pulse is responsible for the disease. The toxin is known as Beta Oxalyl amino alanine (BOAA). The disease mainly affects young men and its clinical spectrum varies as follows –

• Latent stage
• No-stick stage
• One-stick stage
• Two-stick stage
• Crawling stage

The possible interventions to prevent and control the disease are as follows –

• Banning the crop
• Vitamin C Prophylaxis
• Removal of toxins
• Health Education
• Genetic Approach
• Socio-economic developments

GROWTH MONITORING 

Weighing of the child at regular intervals, plotting of that weight on a graph (called a growth chart) enabling one to see changes in the weight, and giving advice to the mother based on this weight change is called Growth Monitoring. Generally done once every month, up to the age of three years and at least once in three months thereafter. It identifies under or over nutrition and help in every identification of growth disorders thus timely corrective interventions.

Methods of growth monitoring are as follows –

• Weight for age
• Height (Length) for age
• Weight for height
• Head & chest circumference
• Mid upper arm circumference

Growth monitoring is an essential part of primary health care in children. Growth Monitoring is oriented to the individual child & is a dynamic measure of its health from month to month. It focuses on normal nutrition and the means to promote continued growth of the child.

NUTRITIONAL SURVEILLANCE 

Nutritional Surveillance is a systematic approach used to detect malnutrition and identify population at risk of suffering from it.

Nutritional Surveillance can be carried out on a representative sample of children in the community. It not only measures malnutrition but also impact of various interventions to improve nutrition in the community.

The biggest challenge for all nutritional surveillance system is to ensure effective linkages between information &/ or action. Three different objectives of nutritional surveillance are as follows –

• To aid long term planning in health and development
• To provide input for program management and evaluation
• To give timely warning of the need for intervention to prevent critical deterioration in food consumption

Other features of nutritional surveillance are as follows –

• Detection of undernutrition as strategy
• Diagnostic & interventional approach
• Representative samples (50-100 most efficient)
• Done by trained workers
• Nutritional rehabilitation as response
• Food supplement and subsidy as intervention
• Linkages for referral in specific center for malnutrition rehabilitation e.g. NRC (Nutritional Rehabilitation Centre).

FOOD HANDLERS 

Food handlers or personnel working in the food establishments are important for food sanitation as they may transmit various diseases to the other persons such as diarrhoea, dysenteries, typhoid and paratyphoid fevers, enteroviruses, viral hepatitis, protozoal cysts, eggs of helminths, strepto & staphylococcal infections & salmonellosis.

Proper handling of foods, utensils and dishes together with emphasis upon the necessity for good personal hygiene are of great importance.

The control measures for the diseases transmitted through food handlers are as follows –

• Personal Hygiene
• Workplace hygiene
• Preplacement medical examination
• Periodic medical examination
• Health Education

OBESITY  

Obesity is a medical condition involving an excess deposition of fat in the body. Obesity is often expressed in terms of Body Mass Index (BMI). Obesity is perhaps most prevalent form of malnutrition.

Obesity increases the risk of diseases and health problems, such as heart disease, diabetes, high blood pressure and certain cancers. Obesity & overweight are the fifth leading risk of global deaths. A person with a BMI of 30 or more is generally considered obese. A person with a BMI equal to or more than 25 is considered overweight.

Obesity can be assessed by one of the following methods –

• Body Mass Index (BMI)
• Skinfold thickness
• Waist circumference & waist hip ratio
• Others such as bone density, total body water etc.

Complications /Hazards of Obesity –

• Diabetes
• Coronary Heart Disease
• Hypertension
• Cancers e.g. large bowel
• Gall bladder disease
• Osteoarthritis
• Hyperuricemia & Gout
• Increased mortality

Prevention & Control –

• Dietary Management
• Increased physical activity
• Health Education.

MEAT HYGIENE 

Meat Hygiene refers to a set of activities that require the implementation of specific standards, codes of practices and regulatory action by competent authority to ensure availability of safe, secure & suitable meat for consumption of the people.

Food safety & standards (food products standards and food additives) Regulations, 2011 also warrant that every product being sold in the Indian market must meet to legal standards of quality.

There are various principles of meat hygiene which are as follows –

• Prevention of microbial contamination during processing of meat.
• Minimizing microbial growth by proper and adequate storage.
• Reduction of risk of microbial contamination by applying suitable heat treatment and packaging.

Hazards –

1. Tapeworm infestations –

• Taenia solium
• Saginata
• Trichinella spiralis
• Fasciola hepatica

1. Bacterial Infections –

• Anthrax
• Actinomycosis
• Tuberculosis
• Food poisoning

Meat Inspection & Slaughter house regulations help control the spread of infections by consumption of meat.

PASTEURIZATION OF MILK 

Pasteurization of milk may be defined as the heating of the milk to such temperatures and for such periods of time as are required to destroy any pathogen present in milk without affecting its characteristics.

Pasteurization kills nearly 90% of the bacteria in milk including the more heat resistant tubercular bacilli and the Q fever organisms, but unable to kill bacterial spores and thermoduric bacteria. To stop the further growth of micro-organisms, pasteurized milk is rapidly cooled to 4-degree C & kept cold till it reaches the consumer level.

First developed by Louis Pasteur in 1864, pasteurization kills harmful micro-organisms responsible for such diseases as Listeriosis, typhoid & paratyphoid fevers, bovine tuberculosis, diphtheria & Brucellosis. Pasteurization is a preventive measure of public health importance and ensures supply of safe milk to consumers.

There are several methods of pasteurization of milk which are as follows –

• Holder (Vat) Method – Recommended for small & rural communities.
• HTST Method – Now the most commonly used method.
• UHT Method.

To check the efficacy of pasteurized milk, following tests are done –

• Phosphatase Test
• Standard plate count
• Coliform test

FOOD FORTIFICATION 

According to WHO, it is the process whereby nutrients are added to the foods (in relatively small quantities) to maintain or improve the quality of the diet of a given community or a population.

Examples of effective food fortification are as follows –

• Fluoridation of water to prevent dental caries
• Iodization of salts to prevent IDD
• Vanaspati ghee (Vit. A & Vit. D fortification)
• Milks
• Fortification of salts with iodine & iron.

Food fortification is a long term control measure for specific problems of malnutrition in the community. Main methods of food fortifications are as follows –

• Commercial & Industrial fortification (Wheat flour, corn meal, cooking oils)
• Bio fortification (breeding the crops to increase their nutritive values which can include both conventional selective breeding and genetic engineering).
• Home fortification (for example Vit. D drops).

An adequate system of surveillance and control is indispensable for the effectiveness of food fortification.

EPIDEMIC DROPSY

It is a clinical condition resulting from use of edible mustard oil adulterated with Argemone Mexicana seed oil. Toxic alkaloid, Sanguinarine, found in Argemone oil is responsible for this clinical condition. This toxic alkaloid interferes with the oxidation of pyruvic acid which accumulates in blood.

The symptoms of epidemic dropsy consist of sudden, non-inflammatory, bilateral swelling of legs, often associated with diarrhoea, dyspnoea, glaucoma, cardiac failure, & death may follow. The disease occurs in all age groups except breast fed infants. Mortality ranges from 5-50%.

The contamination of mustard or other oils with argemone oil may result from accidental mixing or by adulteration mechanism.

Following tests may be used to detect argemone oil in edible oils –

• Nitric Acid test
• Paper Chromatography test – most sensitive test. May detect argemone oil up to 0.0001% in all edible oils & fats.

Prevention –

• Health education
• Strict enforcement of the prevention of food adulteration act
• Remove argemone weeds growing among oil seed crops – to prevent accidental contamination

MID DAY MEAL PROGRAM  

Mid-day meal program was launched in 1961 throughout the country. The objective of the program was to attract more children to school and to retain them to improve the literacy status of the children. The meal provided in the school should be a supplement and not a substitute to the home diet. The meal provided should supply half of the protein requirement and one third of energy requirement of the children.

The meal provided should be prepared in schools and the cost of the meal should be reasonably low. As far as possible locally available food should be cooked thus reducing the cost of the meal. The menu should be changed regularly to maintain attraction of the children.

The National Institute of Nutrition, Hyderabad has prepared model recipe for the preparation of school meals suitable for north & south Indians. Minimum feeding days should be 250 under the mid-day meal program to have desired impact on the children.

The Mid Day Meal Program became part of the Minimum Needs Program in the fifth five-year plan. This program is being run by the Ministry of Education.

ADULTERATION OF FOOD 

Adulteration of food is commonly defined as “the addition or subtraction of any substance to or from food, so that the natural composition and quality of food substance is affected.”

Food adulteration includes mixing, substitution, concealing the quality, putting up decomposed food for sale, misbranding or giving the false levels and addition of toxicants.

Food adulteration has become a common practice in the societies of our country and people are consuming these foods almost every day. This is on increasing trend because of few legal controls of food quality and poor monitoring by authorities.

Few common adulterants are as follows –

Prevention –

• Health Education.
• Reinforcement of Prevention of food adulteration act.
• Strong monitoring mechanism by authorities.

INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)

The scheme was launched on 2^nd October 1975. It operates through Anganwadi centers (AWC) & mini-AWCs in combination with primary health care. It is an integrated package of early childhood services which includes –

• Supplementary Nutrition
• Immunization
• Health Check-ups
• Medical referral services
• Nutrition & Health Education for women
• Non formal education of children up to age of 6 years and pregnant & nursing mothers in rural, urban, slum & tribal areas.

ICDS scheme is designed both as preventive & development efforts. The services of immunization, health check-ups & referral services are provided through public health infrastructure i.e. Health Sub Centers, PHCs & CHCs.

Objectives –

• To improve the nutritional & health status of children in the age group of 0-6 years.
• To lay the foundation for proper psychological, physical and social development of the child.
• To reduce mortality & morbidity, malnutrition and school drop outs.
• To achieve an effective coordination of policy and implementation among the various departments working for the promotion of child development and
• To enhance the capability of the mother and nutritional needs of the child through proper nutrition and health education.

Beneficiaries are as follows –

• Pregnant & lactating women
• Children < 6 years’ age
• Adolescent girls 11-18 years’ age
• Other women 15-45 years (Only Nutrition & Health Education)

The scheme is operational under ministry of social Welfare.

The supplementary Nutrition Program under ICDS aims to fill the gap in nutrition amongst children under 6 years of age as well as pregnant and lactating women. Supplementary Nutrition program is delivered through two means – Hot cooked meal at AWC & Take home ration (THR). THR may be delivered in the form of raw ingredients or pre cooked packets.

Chapter 3. Contraceptives

Male Condoms –

INTRODUCTION –

A type of barrier device used by males which prevents live sperms from meeting the ovum. Popularly known as NIRODH in India. It is one of the methods of contraception which ensures male involvement in preventing unwanted births. Condom is a sheath made of mostly of Latex rubber. Some Condoms are coated with lubricants or with spermicides. Condoms may be available in different size, shape, colors & textures.

Condom protects the user from pregnancy as well as STDs including HIV/AIDS. Condom is used on erected penis during the sexual intercourse. For each act a separate condom is used. Used condom is discarded. By covering the penis, it prevents deposition of sperms or semen into the vagina. They prevent sperm & sexually transmitted infections entering the vagina or organisms from the vagina from entering the penis.

How effective are Condoms?

1) If the partners of 100 women start using condoms, with typical use there is likelihood of 14 of these women getting pregnant in the first year of use of condoms.

2) With correct & consistent use every time, there are 3 pregnancies per 100 women in the first year of use.

Most failures are due to incorrect and inconsistent use of condoms. Effectiveness of condom is increased if one uses spermicides along with it.

Advantages –

• Prevent STIs including HIV, as well as pregnancy when used correctly and consistently with every act of sexual intercourse.
• Can be used soon after child birth.
• Can be stopped at any time.
• Easy to keep at hand in case sex occurs unexpectedly.
• Can be used by men of any age.
• Often help to prevent premature ejaculation.
• Free from hormonal side effects
• Usually easy to obtain and sold at most places.

Disadvantages –

• More chances of incorrect use.
• May slip off or tear during the coitus.
• Interferes with Sexual sensations locally.
• Poor Compliance among males.
• Latex condoms may cause itching for a few people who are allergic to latex. Also some people may be allergic to the lubricants on some brands of condoms.
• If not properly stored or if used with oil based lubricants, condoms can go weak and break.

How to use a male condom?

• Carefully open the condom packet and remove the condom from packet.
• Place Condom on the tip of erect penis. If penis is uncircumcised, pull the foreskin first.
• Remove air out from the tip of condom.
• Unroll condom all the way down till the base of penis.
• After sex but before pulling out, hold the condom at the base. Then, pull out, while holding the condom in place.
• Carefully remove the condom and throw it in waste bucket.

NOTE –

• Don’t use condom without checking expiry date.
• Don’t use more than one condom at a time.
• Don’t use oil based products like baby oil or lotion, petroleum jelly or cooking oil as these can damage or break the condom.
• Don’t use nonoxynol – 9 (a spermicide) as this can cause irritation.
• Don’t reuse a condom.
• Don’t store condoms in wallets/purse as heat and friction can damage them.

Female condoms –

Introduction

It is made of polyurethane & lines the vagina. It is a pouch whose one end has internal ring that covers the cervix and other external ring remains outside the vagina. Spermicides are not used along with it as it is pre-lubricated with silicon. It protects not only pregnancy but also STDs including HIV/AIDS.

How effective is the female condom

Pregnancies per 100 women in the first year of use as commonly used is 21. If used correctly and consistently there are 5 pregnancies per 100 women.

Advantages –

• Female Controlled
• No medical condition limits use
• More comfortable to men, less decrease in sensation than male latex condoms. it also offers ease of use by men with erectile dysfunction
• offers greater protection as it covers both internal and external genitalia
• Stronger & therefore there is less frequent breakage(1% as compared to 4% for male condoms)
• Longer shelf- life even under unfavorable storage conditions.

Disadvantages –

• Higher cost.
• Poor acceptability
• High motivation required.
• Difficulty in insertion & removal

WHO recommends use of a new male or female condom for each act of intercourse, where there is a risk of unintended pregnancy and / or STI/HIV infection. Male & Female condom should not be used together. It can be inserted prior to intercourse (up to 8 hours before), not dependent on erection of male and does not require withdrawal immediately after ejaculation. Female condom has no known side effects or risks. Female condom should be disposed of in a waste container and not in the toilets.

How to insert female Condom?

1) Take a female condom

2) Put spermicide or lubricant on the outside of the closed end. Using spermicides along with the female condom can further reduce risk of pregnancy. Though the female condom will already be lubricated, extra lubricants can make it easier to insert & use condom.

3) find a comfortable position to have access to vagina and to insert the condom.

4) Squeeze the sides of inner ring together. Hold the sides of inner ring together similar to how a pencil is hold and then squeeze.

5) Insert the inner ring and condom into vagina. Inserted like a tampoon. Push it up with finger.

6) Push the inner ring into the vagina un till it reaches the cervix. Once it reaches cervix, it will naturally expand and won’t be able to feel it anyone. One can still feel it inside vagina if not put correctly

7) Pull out the finger and ensure that outer ring is hanging at least one inch outside the vagina.

8) Guide partner’s penis into the outer ring that is hanging outside the vagina. Make sure that the penis is actually going into the condom instead of touching one wall of vagina as well as the condom.

How to remove the female condom?

1) Grasp the female condom firmly.

2) Squeeze and twist the outer ring. This will keep the semen inside the pouch in the condom.

3) Gently remove the condom from vagina. Do this slowly while holding the twisted top of the condom together.

4) Throw the condom away. Just throw it in the garbage. Do not flush it in the toilet.  

Diaphragm –

Diaphragm is a type of barrier device used by females. It fits inside vagina and prevents sperm from passing through the cervix. It is a shallow cup made up of synthetic rubber or plastic  material. It has a diameter of 2 to 4 inches. Diaphragms come in different sizes, it must be fitted for the correct size by a trained doctor or nurse. Diaphragm is fitted in vagina before sexual intercourse and must remain there at least 6 hours after the act. After that it can be removed and washed (they are reusable). Spermicides jelly should be applied around the edges of diaphragm. The size of diaphragm is estimated by measuring the distance between posterior fornix and symphysis pubis. It is held in position in vagina partly by spring tension and partly by vaginal muscle tone.

Failure rate of it with spermicides is between 6 – 12 per hundred women years.

Advantages include total absence of side effects & medical contraindications.

Disadvantages include –

• Requires training for insertion by trained person.
• Practice of insertion is mandatory.
• Not suitable for rural women where privacy is important factor.
• Facilities for cleaning & storing may not be available in the house of users.
• Failure to remove the diaphragm for a long period may result in TOXIC SHOCK SYNDROME (because of staph. Pyogenes).
• Provides only limited protection against sexually transmitted infections (STIs)

It is not a popular method & use requires the medical advice by a medical or para medical personnel.

LOOKING AFTER DIAPHRAGM –

After use, one can wash diaphragm with warm water and mild unperfumed soap. Rinse it thoroughly, then leave it to dry. One can keep diaphragm in a container which should be kept in a cool, dry place.

Note –

• Never boil a diaphragm
• Don’t use disinfectant, detergent, oil based products or talcum powder to keep it clean, as these products can damage it.
• Diaphragm may become discolored as time passes, but its effectiveness does not decrease
• Always check diaphragm or cap for any signs of damage before using it.
• One need to get a different size of diaphragm, if she gains or loses more than 3 kg in weight, or if she have a baby, miscarriage or abortion.

Vaginal sponge – Today

It is a chemical barrier method. It is a small polyurethane foam sponge measuring 5 into 2.5 cm, incorporated with the spermicidal NONOXYNOL – 9, to immobilize sperm as it comes in contact with the sponge. It is kept in vagina prior to intercourse and removed from the vagina after intercourse.

Sponge prevents pregnancy by covering the cervix and blocking sperm from entering the uterus. It is less effective than the diaphragm. Failure rate is 9 to 20/HWY in nulliparous women & 20-40/HWY in parous women.

Advantages are –

• Easy to insert, safe and convenient
• Disposable
• No hormonal effect
• No prescription required
• Good for continuous use (can be re-used for up to a 24 hour period)
• Contains no estrogen (safe for women who are breastfeeding)

Disadvantages include –

• Privacy needed
• More expensive
• To be used with other barrier devices.
• Does not protect from STIs
• Vaginal Irritation

If Today is left in the vagina for over 30 hours, the risk for toxic shock syndrome is increased.

It should not be used in women –

• With allergies to sulfa drugs, polyurethane or spermicide
• Who have given recently birth
• Had an abortion
• Have history of toxic shock syndrome
• Have any reproductive tract infection

Intra-uterine contraceptive devices (IUCDs) –

Intrauterine contraceptive device (IUCD) is inserted into the uterine cavity to prevent conception. There are many types of IUCDs and are available in different shapes and sizes. Commonly used types are copper containing IUCDs. The device may be non-medicated or medicated one. Both the devices are made up of plastic materials or polyethylene. The difference is that non- medicated are inert and do not release any ion or hormone while medicated devices release copper, silver or progesterone preparations.

IUCDs may be classified as –

• First generation IUCDs e.g. Lippe’s loop, ring devices etc.
• Second generation IUCDs e.g. Copper Devices.
• Third generation IUCDs e.g. Hormone releasing devices.

First Generation IUCDs –   

Once used widely in National Family Planning Program has become outdated now as more efficient & convenient IUCDs are available now.

Second Generation IUCDs –

Copper devices are T- shaped devices made of polyethylene or any other polymer releasing mainly copper ions. Devices also contain barium sulphate for better X- ray visualization. Metallic Copper has strong antifertility action.

Various types of copper devices available are –

• Copper T- 200
• T Cu – 220 C
• T Cu – 380 Ag
• Nova –T
• Multiload Devices – a) ML-Cu- 250 & b) ML-Cu- 375.

Number mentioned in Copper Devices (e.g. Cu-T-200) refers the surface area(in Sq. mm) of the copper on the device. In Nova –T & T-Cu-380Ag copper devices, copper wire is wrapped around a silver core.

Copper devices play an important role in post coital contraception, if inserted within 3-5 days of unprotected coitus. It has got low expulsion rate & lesser side effects e.g. pain, menorrhagia etc. Acts by releasing Cu ions which reduces the motility & survival of sperms & produces inflammation of endometrium thus preventing the fertilized egg from getting attached to the wall of uterus, therefore preventing implantation.

Third Generation IUCDs –

Two types of Hormonal devices are available –

• Progestasert
• Levonorgestrel device.

Progestasert –

It is most commonly used hormonal device. It contains hormone progesterone in amount 38 mg. Hormone gets released at the rate of 65 microgram daily for a period of one year. It is a T –shaped device made of ethylene vinyl acetate co-polymer.

Levonorgestrel devices –

It is a T-shaped device releasing 20 micro gram of levonorgestrel per day. It is effective for 10 years. Devices are highly costly but have lesser side effects.

Hormonal devices act by releasing progesterone hormone which depresses the oestrogenic actions locally thus preventing maturation of endometrium and preventing finally the implantation of fertilized ovum. Menorrhagia gets treated by hormonal devices by regulation of menstrual cycles.

Advantages of IUCDs –

• Less complex insertion
• Insertion is done in no time
• Once inserted, protection for many years
• Less costly
• Reversible contraceptive effects
• No metabolic side effects
• Improves sexual relations as no fear of pregnancy

Not recommended for nulliparous women & women having multiple partners because of risk of infertility & PID.

Timing of Insertion –

The IUCD is best inserted towards the end of menstrual flow because at this time women are unlikely to be pregnant, and the cervix being softer and slightly open, makes insertion easier.

An IUCD can be inserted in following periods –

• Interval (6 weeks after delivery)
• Postpartum (Within 48 hours of delivery)
• Post-Caesarian
• Post abortion

Ask about information related with following contraindications –

• Pregnancy
• PID
• Undiagnosed irregular genital bleeding
• Previous ectopic pregnancy
• Cancer of genital tract
• H/O valve replacement or endocarditis.
• Distortion of uterine cavity
• Menorrhagia & Anaemia
• Purulent cervical discharge.

The women should check the threads weekly for first 6 weeks & then monthly.

Women should be warned about –

• Crampy pain 2-3 days after the insertion of IUCDs.
• Irregular Menses in first cycle following insertion.
• Menses may be prolonged and heavier following insertion.
• Vaginal discharge following insertion.

These problems usually disappear after 2-3 months.

Side effects of IUCDs include –

• Bleeding – most common.
• Pain
• Pelvic inflammation
• Perforation of uterus
• Expulsion of IUCD
• Lost threads.
• Ectopic pregnancy
• Intrauterine pregnancy

Failure rate ranges from 0.3 to 2/100 women years.

HORMONAL CONTRACEPTIVES –

Hormonal contraceptives contain Synthetic gonadal steroids –

• Oestrogen (mainly ethinyl oestradiol) &/ or
• Progestogens ( mainly Norethindrone & norgestrel)

Hormonal contraceptives are available as Oral Pills, Injectables, Subcutaneous implants & Vaginal rings.

Oral Combined Pills –

Available as monophasic, biphasic & Triphasic pills.

NOTE – Monophasic pills contain some amount of oestrogen & progestins in every hormonal pills. Biphasic pills contain one dose of oestrogen & progestin for first 10 pills and another dose for next 11 pills. Triphasic pills contain one dose for first 7 or so pills, another dose of oestrogen & progestin for next 7 pills and other dose for last 7 pills. Mode of action in preventing pregnancy is same for monophasic, biphasic & triphasic pills, the only difference is in side effects, effectiveness and compliance.

Most of the oral combined pills contain not more than 30-35 mcg. of a synthetic oestrogen & 0.5 to 1.0 mg of a progestogen. Commonly given for 21 consecutive days, started on day 5 of the menstrual cycle, followed by a gap of 7 days during which period bleeding occurs. When break through bleeding starts, this is considered the first day of the menstrual cycle. The bleeding is also called WITHDRAWAL BLEEDING. Withdrawal bleeding generally starts after the second course of oral combined pills.

OCPs should be taken preferably at night at the time of going bed. Although it can be taken at any fixed time during the day. On forgetting the pill intake on any day, one should take the pill as soon as one remembers and should take next day pill on time.

OCPs act by preventing the release of ovum from ovary i.e. ovulation by blocking the secretion of gonadotrophins from pituitary gland. The failure rate is in the range of 0.1 -3 / 100 women years. On perfect use, less than 1 pregnancy per 100 women using COCs over the first year (3 per 1000 women). On typical use, about 8 pregnancy per 100 women using COCs over the first year.

Side effects include-

• Break through bleeding
• Nausea, weight gain, breast tenderness, bloating, depression, vaginal discharge, headache, reduced libido, chloasma etc.

Special precautions include vomiting & Diarrhoea as these conditions lead to reduced hormonal absorption.

Beneficial effects –

• Preventing pregnancy.
• Protection against at least 6 diseases –
• Benign breast disorders( Fibroadenoma & Fibrocystic disease)
• Ovarian cysts
• Iron – deficiency Anaemia
• PID
• Ectopic Pregnancy
• Ovarian Cancer
• Decreases –
• Menstrual cramps
• Menstrual bleeding problems
• Ovulation pain
• Excessive hair on body or face
• Symptoms of endometriosis & Polycystic ovarian disease

Risks associated with OCPs –

• Smoking >15 cigarette per day, associated with CHD
• Vascular diseases increased by 3 times
• Chances of developing hypertension in OCP takers
• Chances of developing Ca breast

Absolute Contraindications include –

• Cancer of breast & genitals
• H/o thromboembolism
• Liver diseases
• Cardiac abnormalities
• Congenital hyperlipidemia
• Abnormal uterine bleeding

First follow up examination should be done at 3 months. Subsequent follow up should be done at 6-12 months interval. In each visit, one should check –

• Smoking status
• Weight gain
• Blood Pressure
• New risk factors
• Smear status

Women generally like it because –

• Can be controlled by women
• Can be stopped anytime without consulting health providers
• Does not interfere with sex

Before starting its use, prior consultation with doctor is mandatory.

MINI-PILLS (MICRO – PILLS) –

Also known as Progestogen – only pills (POPs). It is a safe and effective contraception. It is taken daily, irrespective of intercourse. Effectiveness depends on regular intake at the same time every day within a window period of 3 hours. Pills are taken without break throughout the menstrual cycle. As the name suggests it contains only progestogens, commonly used ones are Norethisterone & levonorgestrel. It is safe for breast feeding women as it does not affect quality and quantity of milk. POPs can be started in breastfeeding women earlier than 6 weeks.

Mini pills can be given to –

• Women suffering from cardio vascular diseases
• Lactating women as progestogen does not affect the secretion of milk.
• Young women with risk of cancers
• Older women(>35 years) who smoke
• Women with side effects from OCPs.

Women having regular menstrual cycles can start POPs any day within 5 days of menstrual cycle with no need for back-up method. It is very important to start the new pack on the next day at the same time.

It acts by making cervical mucus thick & scanty & thus inhibiting sperm penetration. Also hinders tubal motility.

Failure Rate varies from 0.3 to 10/100 women years. With perfect use, 0.3 pregnancy per 100 women in breastfeeding women while 0.9 pregnancy per 100 women among non-breastfeeding women. With typical use, 1 pregnancy per 100 women in breastfeeding women while 3-10 pregnancy per 100 women among non-breastfeeding women.

Side effects include –

• Irregular bleeding & amenorrhoea
• Weight gain
• Mood changes
• Headache
• Breast tenderness

INJECTABLE HORMONAL CONTRACEPTIVES –

Two types of injectable contraceptives are available –

1. Once a month combined injectable contraceptive
2. Progestogen only injectable contraceptive

• DMPA
• NET-EN
• DMPA-SC

Combined Injectable contraceptives –

Contain a Progesterone & an oestrogen. Given at monthly intervals, plus or minus 3 days. Acts mainly by suppression of ovulation. Progesterone makes the cervical mucus thick, thus penetration of sperms will be difficult. Endometrium also becomes unfavorable for implantation. Failure rate varies from 0.2 to 0.4 percent.

Contraindications include –

• Pregnancy
• Evidence of thromboembolic disorders
• Cerebrovascular or cardiovascular disease
• Focal Migraine
• Malignancy of breast
• Diabetes with vascular complications

Not suitable for lactating women for the first 6 months.

Progestogen- only Injectable Contraceptives –

1. Depot Medroxy Progesterone Acetate(DMPA)-

DMPA is being used since long back, contains synthetic hormone, progestogins, resembling natural female hormone. It is a safe contraceptive. Dose of one injection is 150 mg, given intramuscularly every three months. Composition of DMPA is pregnane 17 alfa-hydroxyprogesterone-derivative progestin, medroxy progesterone acetate.

Provides protection against pregnancy in 99.7 % recipients for a period of three months. Effectiveness depends on timing of first injection, taking injection regularly on time, the injection technique and post injection care. DMPA presents no overall risk for cancer, congenital malformations or infertility. It is being used in National family welfare program with the name ANTARA.

Acts by –

• Suppression of ovulation
• Making cervical mucus thick
• Indirect action on endometrium & direct action on fallopian tube

Advantages are as follows –

• Safe, effective and acceptable contraceptive
• Easy to use
• Acts for 3 months with additional protection of 4 weeks
• Completely reversible
• Does not interfere with sexual intercourse or pleasure
• Suitable for women who cannot use estrogen containing contraceptives
• Preferred in lactating women as does not affect lactation
• Requires minimum motivation
• Provides immediate postpartum (in non-breastfeeding women) and post abortion contraception
• Can be used by any fertile woman of any age or parity
• Reduces menstrual cramps and pre-menstrual tension or syndrome
• Reduces incidence of PID
• Minimum drug interactions

Side effects include –

• Weight Gain
• Irregular Menstrual bleeding
• Relatively prolonged infertility after its use

The return of fertility takes 7-10 months from date of last injection.

Given during the first 5 days of menstrual period. Injection site for DMPA is the upper arm, the buttocks or anterior outer aspect of thigh.

1. Norethisterone enantate (NET-EN)-

A Progestogen preparation, derived from testosterone & supplied in an oily preparation for slow release. In the body, NET-EN is converted into norethindrone (NET) which is the biologically active form. The dose of one injection is 150 mg every 2 months intramuscularly. Less extensively used than DMPA. Contraceptive effect appears to include inhibition of ovulation & effect on cervical mucus. Given during the first 5 days of the menstrual period. Failure rate is slightly more than DMPA. Side effects are similar to DMPA.

1. DMPA-SC 104 mg-

DMPA – SC 104 mg/0.65ml (dep-sub Q Provera 104) is a newer preparation of DMPA in a lower dose, which is injected under the skin (subcutaneously) and is therapeutically equivalent to the intramuscular formulation. Studies indicate that it effectively suppresses ovulation for at least 13 weeks and return of fertility is not more than DMPA – IM. Composition of DMPA SC is 17 alfa-hydroxy progesterone derivative progestin, medroxy progesterone acetate. It is given at 3 months interval. Sites of administration are abdomen, anterior outer aspect of thigh and back of upper arm. BMI does not affect efficacy of DMPA-SC

Mechanism of action – Subcutaneous DMPA acts by –

• Inhibiting ovulation
• Thickening of cervical mucus
• Thinning of endometrial lining

DMPA SC is available as a single dose in prefilled auto-disable injection device (uniject system). Effectiveness of DMPA-SC is 99.7%. Side effects are similar to DMPA. It should not be given intramuscularly.

Contraindications of progestogen only injectables include –

• Cancer of the Breast & other genital cancers
• Undiagnosed uterine bleeding
• Suspected Malignancy

Progestogen only injectables should not be started in women having high blood pressure, women breast feeding a baby less than 6 weeks old, certain conditions of heart, blood vessels or liver, H/o stroke or heart attack & current deep vein thrombosis. Progestogen only injectable is highly effective, long lasting & reversible contraceptives.

SUBDERMAL IMPLANTS –

Subdermal implants are small plastic rods or capsules, of matchstick size that releases a progestin like the natural hormone progesterone in a woman’s body. After small surgical procedure these are kept under the skin in women’s upper arm. These implants do not contain estrogen, and so can be used throughout breastfeeding and women in whom estrogenic contraceptives are contraindicated.

These implants act by –

• Thickening cervical mucus
• Suppression of ovulation
• Thinning of the endometrial linings

They are available in various forms and names in the market. Subdermal Implant, NORPLANT, is a long term contraceptive. It is made of 6 sialistic capsules, each containing 35 mg of levonorgestrel. NORPLANT(R)- 2 is a newer modification containing levonorgestrel into 2 small rods. It is easier to insert & remove. Capsules/Rods are implanted under the skin of forearm or upper arm. These are effective for 5-7 years. Effect on contraception is reversible after removal of capsules or rods. A 3 year pregnancy rate of 0.7 has been reported.

Advantages include –

• Once inserted, provides long term protection
• Do not interfere with sexual intercourse
• Help protect against symptomatic PID
• No delay in return of fertility on removal of implants

Disadvantages include –

• Surgery required for implantation.
• Irregular menstrual bleeding.
• Headache
• Abdominal pain
• Weight change
• Mood change
• Breast tenderness
• Infection at insertion site

Women who have HIV/AIDS, or are on ART can safely use norplants. Only advice to be given to such women is to use condoms along with implants. It should be inserted to a woman within first 7 days of menstrual bleeding without any backup support.

COMBINED VAGINAL RING –

It is a flexible ring that is placed in the vagina. Vaginal ring releases two hormones – a progestin and an estrogen, like the natural hormones progesterone and estrogen in a woman’s body. Hormones released in vagina are absorbed through its walls and reaches directly into the blood stream. Vaginal ring acts by primarily inhibiting ovulation in women’s body. Start each new ring on time for greatest protection. When a woman starts a new ring late, risk of pregnancy is greater.

Advantages are similar to that of combined oral contraceptive pills.

Disadvantages include –

• Change in pattern of monthly bleeding
• Headache
• Vaginitis (inflammation of Vagina)
• Vaginal discharge

The ring is used for three weeks of the cycle in vagina and removed for the fourth week of the cycle.

CENTCHROMAN

Centchroman is a non-steroidal, non-hormonal oral contraceptive pill, developed in India. It is a safe and effective method of contraception. On start, Centchroman has to be taken on fixed days twice a week for the first three months and from fourth month onwards, once a week on fixed days. Failure rate of Centchroman on perfect use is 1-2 pregnancy per 100 women. It is used by GoI in its national program with the name CHHAYA.

Schedule –

On start of Centchroman use, the first pill has to be taken on day 1 of menstrual bleeding and second pill on the fourth day of menstrual bleeding. These fixed days are followed on every week twice for the first three months.

From 4^th month onwards she has to take pill once weekly on the very first day of previous month’s weeks irrespective of her menstrual cycle. For Example, If Day 1 is on Sunday, then fourth day would be on Wednesday. Woman has to take the pill every Sunday & Wednesday for first three months. From fourth month onwards, in above scenario, day of taking pill every week would be Sunday.

Side Effects –

Centchroman has very few side effects. In some women, it causes delayed menstrual periods. Woman should be consoled that this is not harmful and will subside itself.

If a woman misses a pill, she should take the pill as soon as she remembers. If pill is missed by less than 7 days, the normal schedule of the pill should be continued. The only precaution woman has to take is to use condom as back up method.

Advantages include –

• Safe & Effective
• Safe in breastfeeding women as does not suppress lactation
• High motivation is not required
• Free from side effects of hormonal pills
• Easy to use and readily available
• Does not intervene the sexual intercourse or pleasure

CHAPTER – 4 – MISCELLANEOUS SHORT NOTES

SIX CLEAN

For safe aseptic delivery, instead of five cleans birth attendants should encourage six cleans.

Six cleans are –

• Clean hands
• Clean perineum
• Clean delivery surface
• Clean cord tie
• Clean cord cutting implement
• Clean cord stump (no applicant)

Six cleans encourages reproductive health in total.

Six cleans are applicable in both institutional and home delivery for sale aseptic delivery.

ReSoMal

• ReSoMal stands for rehydration solution for severely malnourished children.

              WHO recommends use of ReSoMal for treatment of dehydration in severely malnourished children.

• It contains –

                  Na – 45 mmol/ lit

                  K – 40mmol/lit

                  Mg – 3mmol/ lit

• It is quite useful for severely malnourished children
• It contains less sodium and more potassium than standard rehydration salts. It has to be administered under medical surveillance and should never be distributed to families
• Dissolve sachet of ReSoMal – 84.2gm rehydration salt in 2 liters of clean drinking water to obtain optimum concentration of nutrients and minerals
• Solution must only be given orally in smaller sips or by nasogastric tube. Never administrator the Resomal solution by IV infusion.

Micronutrient Malnutrition

• Micronutrient malnutrition is due to deficiency of essential vitamins and minerals such as Vit A, iodine, iron, calcium, zine etc.
• About a billion people affected by it.
• Micronutrient malnutrition is a global public health problem
• Micronutrient malnutrition not only leads to severe illness but also affect growth and development, behavior and susceptibility to infection
• Important disease due to micronutrient malnutrition are

1. Vit A deficiency and nutritional blindness
2. Nutritional Anaemia
3. Iodine deficiency disorder

• A pilot project against micronutrient malnutrition has started in the year 1995 in 5 states i.e. Bihar, Assam, West Bengal, Orissa, and Gujarat
• The problem can be controlled by measures like

1. Fortification of food items (e.g.:- salt, sugar, flour, cooking oil etc.)
2. Micronutrient supplementation

                        – inform of tablets, capsules and syrups to vulnerable groups

3. Nutritional education
4. Controlling certain communicable diseases like malaria, measles, diarrhea and parasitic infestations.

No Scalpel Vasectomy (NSV)

• It is a new techniques used for male sterilization
• In this method, no incision in made and therefore no stitches are required. Only a small hole is made through which vasectomy is done.
• It is a safe and simple procedure that can be performed in low tech, low resource settings.
• Failure rate is 0.2 to 1% .male are accepting their method currently in the country.
• This method is at present being promoted under a special project for men under the family welfare program.
• This project is being funded by UNFPA. Purpose of the project is to promote the male sterilization in the country.
• Side effect conventional vasectomy is less common with this method.
• NSV was developed by Dr. Shungiang Li in China in 1974.
• The No Scalpel Vasectomy starts with a more effective technique to anaesthetize the scrotum & vas. Two special instruments are used for their procedure without using a scalpel. It is a techniques for delivering VAS defers through a tiny midline puncture hole, which is dilated, pushing the potential blood vessels and nerves aside instead of cutting cross them. Once the Vas is delivered, its ends are sealed in the usual fashion.
• Benefits of NSV –

1. Ten times fewer complications – hematomas, injections and other complications
2. Less bleeding and pain
3. Quick and no sutures needed

National Rural Health Mission

• The NRHM is a pro-poor policy under the common minimum program of the It aims to provide effective health care to the entire rural population in the country with special focus on 18 states, having weak public health condition.
• Principles

1. Promote equity, efficiency, quality and accountability in public health systems
2. Enhance people orientation and community-based approaches
3. Ensure public health focus
4. Recognize value of traditional knowledge base of communities
5. Promote new innovations, method and process development
6. Decentralizes & involve local bodies

• Goals of NRHM

1. Reduction in infant mortality rate and maternal morality ratio by 50% from existing levels in next 7 years
2. Universalize access to public health services: such as women’s health, child health, water, sanitation, immunization, nutrition etc.
3. Prevention and control of communicable diseases, including locally endemic diseases.
4. Access to integrated comprehensive primary health care
5. Assuring population stabilization, gender and demographic balance and
6. Promotion of healthy lifestyles

• Objectives

1. Provision of trained and supported village health activist in underserved areas as – ASHA – Ensuring quality and close supervision of ASHA
2. Preparation of health action plan by panchayat as mechanism for involving community in health
3. Strengthening SC/PHC/CHC by developing Indian public health standards
4. Institutionalizing & substantially strengthening district level management of health
5. Increase utilization of first referral units from less than 20% (2002) to more than 75% by 2010
6. Strengthening sound local health traditions and local resources-based health                practices related to PHC and public health

• The main aim of NRHM into provide accessible, affordable, accountable, effective and reliable primary health care and bridging the gap in rural health care through ASHA.

Swine Influenza/ Flu

• Swine influenza is a contagious respiratory disease that normally affects pigs. While        it is not usual for people to get swine flu, human infections may occur, mainly after close contact with injected pigs. Person to person transmission may occur as seen in modern last pandemic of swine flu.
• It is commonly caused by H1N1 strains of swine influenza A virus.

      However other strains such as H1N1, H3N1 and H3N2 also circulate in pigs

• The last pandemic of swine flu in 2009 emerged in Mexico & later on spread to all over the world causing by a new strain of H1N1 swine influenza virus. It is still in circulation. This virus had capability to get transmitted to other person from infected persons.
• When people are infected with swine flu virus their symptoms are usually similar to those of normal seasonal influenza. These include fever, tiredness, and lack of appetite, coughing and sore throat, some may slow vomiting and or diarrhea. Some people may have similar illness and may die. Generally symptoms are mild and make full recovery.
• Antiviral medicines such as oseltamivir/zanamivir may shorten the duration of illness and reductive risk of complications.
• Prevention

1. Frequently wash your hands with soap and water
2. While coughing or sneezing cover your mouth and nose with a tissue paper with possible.
3. Dispose of used tissue papers promptly and carefully put them in a bag and then bin them.
4. Clean the surface (e.g. door handle) frequently
5. Ensure children follow these advice.

• Cleaning surfaces with detergent and water can remove germs from an item provided U scrub all the surfaces and rinse them thoroughly with clean water. Disinfectants may also be used.

Life Skills Education (LSE)

• Life skills approach promotes empowerment of the adolescents. This empowerment is today more essential as there is rapid globalization and urbanization with broken joint families and traditional support systems.
• The life skills, which should be taught to adolescents at the school level include:
• Critical thinking and creative thinking
• Decision making and problem solving
• Communication skills and interpersonal relations
• Coping with emotions and stress
• Self-awareness and empathy

Life skills educational is novel promotional program that can be used for health           promotion of adolescents

• It teaches generic life skills through participatory learning methods of games, debates, role-plays and group discussion. Conceptual understanding and practicing of the skills occur through experimental learning in a nonthreatening setting.
• It helps individual with a wide range of alternative and creative ways of solving problems pertaining of various health and psychological issues like drug abuse, sexual abuse, teenage pregnancy etc.
• Repeated practicing of these skills and he can control over the situation in real life situations easily.
• It is a promotional program that leads to positive health and attitude / self-esteem.

DIPSTICK TEST IN MALARIA

• Dipstick is a Rapid whole blood Immunochromatographic Test
• It is used for rapid diagnosis in case of falciparum malaria.
• The test is based on defection of circulating plasmodium Histidine rich protein particularly falciparum in whole blood.
• The test uses two antibodies specific for pf histidine rich protein 2antigen.
• The test card available in market can give the results in 3-5 minutes.
• Approximately 10 micro gram of whole blood is added to sample pad, if test is Positive, a pink line form. In a negative sample, no pink line forms.
• The specificity and negative predictive value of this test is 99%.
• Limitation of the test is that it gives more false positive results as PFHRPII antigen may persist in the blood for up to 2 weeks after parasite clearance

Mother –friendly child birth Initiative

Following criteria are selected for mother friendly hospitals: –

1) Offers all mothers giving birth

1. a) Unrestricted access to the birth companions of her choice, including fathers, partners, children, family members and friends.
2. b) Unrestricted access to continuous emotional and physical support from skilled women e.g. a labour support professional.
3. c) Access to professional midwifery care.

2) Provides accurate descriptive and statistical information and outcomes.

3) Provides culturally competent care.

4) Provides the women giving both with the freedom to walk, move about, and assume the positions of her choice during labour and birth (unless restriction is specifically required to correct a complication), and discourages the use of the lithotomy (flat on back with legs elevated) position

5)  Has clearly defined policies and procedures for:

1. a) Collaborating and consulting throughout the Perinatal period with other maternity services, including communicating with the original caregiver when transfer from one birth site to another is necessary.
2. b) Linking the mother and baby to appropriate community resources, including prenatal & post discharge follow up & breastfeeding support.
3. Does not routinely employ practice and procedures that are unsupported by scientific evidence including but not limited to the following:
4. a) Sharingb) enemas       c) IVs               d) Withholding nourishment
5. e) Early rupture of membrane f) Electric fetal monitoring.

Other interventions are limited as follows:

1. a) An induction rate of 10% or less
2. b) An episiotomy rate of 20% or less, with a goal of 5% or less
3. c) A total cesarean rate of 10% or less in community hospital, and 15% or less in tertiary care hospitals
4. d) A VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of 75% or more.
5. Educate staff in non-drug methods of pain relief and does not promote the use of analgesics or anesthetic drugs not specifically required to correct a complication.
6. Encourage all mothers and families, including those with sick or premature newborn or infants with congenital problems, to touch, hold, breast feed and care for their babies to the extent compatible with their conditions.
7. Discourage nonreligious circumcision of the newborn.
8. Strives to achieve the WHO – UNICEF “ten steps of Baby – friendly Hospital initiative” to promote successful breastfeeding.

DOTS STRATEGY

• The WHO recommended Directly observed treatment short course (DOTS) strategy was launched formally as National revised TB control program (RNTCP) in India in 1997 after pilot testing from 1993-1996. Since then dots has been widely advocated and successfully applied.
• It is a systematic strategy which 5 components. They are as follows

1. Political and administrative commitment
2. Good quality diagnosis, primarily by sputum smear microscopy
3. Uninterrupted supply of good quality of drugs
4. Directly observed treatment
5. Systematic monitoring and accountability

• The patient is VIP of the program and responsibility and observing regular and complete treatment of the patient lie with the health system.
• The DOTS strategy ensures that infectious TB patients are diagnosed and treated effectively till cure, by ensuring availability of the full course of drugs and a system for monitoring patient compliance to the treatment.

Tuberculosis Unit

• A team, comprising specifically designated medical officer – TB control (MOTC), senior treatment supervisor (STS) and Senior Tuberculosis Lab Supervisor (STLS) is based in a CHC, Taluk Hospital or Block PHC.
• TU covers a population of approximately 1.5 – 2.5 lakh in rural area and 1 lakh population in urban area.
• TU will have one microscopy center for every 1lakh population (0.5 lakh otherwise) referred to as the designated microscopy center (DMC)
• Key functions of the TU team are to

1. a) Maintain the tuberculosis register
2. b) Organize and ensure effective diagnosis and direct observation of treatment
3. c) Prepare quarterly reports on case finding sputum conversion, result of treatment and program management
4. d) Ensure adequate supply of drugs, reagents and logistics regularly
5. e) Involvement of other sectors in NTEP
6. f) Ensure effective IEC strategies

MCR SANDALS

• MCR (Micro Cellular Rubber) sheet are used in making of footwear and post-operative support for leprosy, diabetics and orthopedics patients.
• Protective footwear made of MCR is an important components of foot care
• MCR sandals are made up of inner soft sheet of MCR and outer sole of hard rubber or tire so that pin, nail or thorn can out penetrate it. Inner soft cushion made up of MCR provide support to anesthetic sole and protects it from pressure and friction.
• MCR cushioned insole distributes walking pressure more widely over the sole and thus minimize the risk of wounds at pressure sites.
• It is an important component of rehabilitation.

Women Empowerment and Child Development

• Women and children represent more than 2/3^rd of the total population of country and are important contributors of morbidity and mortality. Therefore, their group needs special attention.
• Discrimination against women in Indian society is reflected by adverse sex ratio. It begins with birth of female child and continuous thereafter
• The Indian constitution provides comprehensive safeguard of women. These are as follows
• Equality before the law – Article 14
• No discrimination by the state on grounds of sex, besides others like religion, race, caste, place of birth or any of these – Article 15 (1)
• Special provision made by the state in favor of women and children – Article 15(3)
• Equality of opportunity for all citizens in matters relating to employment or appointment to an office – Article 39
• Provision of justice and humane condition of work and maternity relief – Article 42
• Prohibit any practice derogatory to the dignity of women – Article 51(A) (e).
• In addition, article 243 D(3), 243 D(4), 243 T(3) and 243 T (4) of the constitution makes provision for reserving not less than 1/3 of the total seats of the women in the direct elections to local bodies viz. panchayath and municipalities.
• Besides, no. of legislations provides various rights and safeguards to women and children.
• Five years plans have formulated various plans for empowerment of women: eg

1. Development of national policy for employment of women
2. Gender development index
3. Reservation of seats in parliament and legislative assemblies.
4. Adopting special strategy of women’s component plan ensuring 30% funds/ benefits flow to women
5. Organizing self-helping groups
6. Prioritizing reproductive and child health
7. Easily accessible and equal and free education up to college level
8. Eliminating gender bias
9. Increase access to credit through setting up of a “Development Bank for women”.

TOBACCO FREE INITIATIVES (TFI)

• Tobacco free initiative was launched by WHO in 1998 with the mission to reduce the prevalence of smoking and Tobacco consumption in all countries, and among all groups and thereby reduce the burden of disease caused by TOBACCO consumption.
• Following are the goals of tobacco free initiatives:

1) Global support for evidence-based tobacco control policies and actions;

2) Build new partnership for action and strengthen existing ones.

3) Heighten awareness of the need to address tobacco issues at all levels of society.

4) Accelerate the implementation of national, regional and global strategies.

5) Commission policy research to support rapid, sustained and innovative actions.

6)  Mobilize Resources to support required action.

       In order to facilitate the implementation of Tobacco Control Laws, to create greater awareness about the harmful effects of tobacco & to fulfill the obligations of WHO tobacco free initiative, Government of India launched a new National Tobacco Control Program in the 11^th 5 year plan. The main components of the program are –

• Public awareness/ mass media campaigns for awareness building & for behavior change
• Establishment of tobacco product testing laboratories, to build regulatory capacity, as required under COTPA 2003.
• Mainstreaming the program components as a part of health delivery mechanism under the NRHM framework
• Mainstream research & training on alternate crops & livelihood, with other nodal ministries.
• Monitoring & Evaluation including surveillance e.g. adult tobacco survey
• Dedicated tobacco control cells
• Training of health & social workers, NGO, school teachers etc.
• School Program
• Provision of tobacco cessation facilities.

Chikungunya Fever

• It is caused by chikungunya virus and gets transmitted by the infected mosquito bite
• Virus belong to family Togaviridae and genus alpha- virus
• Disease resembles dengue fever and is characterized by severe, sometimes persistent, joint pain (arthritis) fever and rash. It is rarely life threatening
• This disease occurs in India, Africa, and South East Asia. It is primarily found in urban and peri urban areas.
• The state affected by chikungunya fever are AP, Karnataka, Maharashtra, Tamil Nadu, MP, Gujarat, Kerala, A&N Island, Delhi, Rajasthan, Pondicherry and Goa.
• The disease spread by the bite of an Aedes mosquito Primarily Aedes Aegypti
• Humans are the major source, or reservoir of chikungunya fever for mosquitoes
• An infected person cannot spread the injection directly to other persons. Aedes Aegypti mosquito bites during this day.
• Aedes Aegypti breeds in man-made containers e.g. discarded tires, flowerpots, old oil drums, animal water throughs, water storage vessels and plastic food containers.
• The time between the bite of mosquito carrying chikungunya virus and the start of symptoms ranges from 1-12days.
• Diagnosis is by Virus isolation

2. Serological test (ELISA)
3. Polymerase chain reaction (PCR)

• No specific treatment. Only supportive Tt is given, aspirin s/b avoided
• Prevention Eliminate breeding sites of mosquito around the human dwellings

2. Use mosquito repellants
3. When indoors, stay in well screened areas, use bed nets
4. When outdoors wear long sleeved shirts and long pants to avoid mosquito bites

• In absence of specific Tt and vaccine, avoiding mosquito bites in the best of preventive measures

Behavior Change Communication

• It is characterized by its direct approach towards changing behavior.
• Simply giving information about health issue and raising awareness is not sufficient and it should accompany direct messages that relate to identified desired behavior
• It is a process of working with individuals, families & communities through different communication channels to promote positive health behaviors and support an environment that enables the community to maintain positive behaviors taken on.
• Principles –
• Behavior must be adaptable in the context of people lives
• Behavior must be amendable to change
• BCC must be
• Benefit oriented
• Client centered
• Projectionally developed
• Research based
• Service linked
• Linked to behavior change
• There are several models of BCC e.g. Prochaska and DiClemente model
• Behavior change communication involves the following steps –
• State Program goals
• Involve stakeholders
• Identify target population
• Conduct formative BCC assessments
• Segment target populations
• Define behavior change objectives
• Define SBCC strategy & monitoring & evaluation plan
• Develop communication products
• Pretest
• Implement & monitor
• Evaluate
• Analyze feedback & revise

Social Marketing

• Social marketing is the practice of utilizing the philosophy, tools and practices of commercial marketing for health /social programs.
• It sells a behavior change to a targeted audience
• Accept a new behavior
• Reject a potential behavior
• Modify a current behavior
• Abandon an old behavior
• In India, principles of social marketing were first used in National Family Welfare program in form of social marketing program of condom in 1968.
• Then again it was done for oral pills in 1987.
• Department of family welfare had sanctioned for social marketing of contraceptives in various states.
• Under the program, current 3 govt. brands and 13 different social marketing organization brands of condoms are being sold.
• A project for installation of condom vending machines in high prevalence districts of HIV has been approved.

Comprehensive emergency obstetric care

• Basic emergency obstetric care includes services given below by skilled health personnel.
• Parenteral antibodies
• Parenteral oxytocic drugs
• Parenteral anticonvulsants
• Manual removal of retained placenta
• Assisted vaginal delivery
• In addition to services of basic emergency obstetric care, comprehensive emergency obstetric care includes –
• Vacuum extraction
• Caesarean section
• Administration of anesthesia
• Blood transfusion
• Suction curettage for incomplete abortion
• Insert IUDs
• Sterilization operation i.e. vasectomy/ tubectomy
• The comprehensive emergency obstetric care is being provided at first referral units (FRUs)
• Comprehensive emergency obstetric care prevents or reduces maternal & infant mortality & morbidity in all complicated or high risk pregnancy. It should be provided by a trained MBBS or MS/MD Gynecologist or obstetrician.

Vision 2020

• Vision 2020 is a global initiative to reduce (preventable & curable) blindness by the year 2020
• India is also committed to it
• Plan of action for the country in as follows: –

1. Targeted diseases are cataract, refractive errors childhood blindness, glaucoma & diabetic retinopathy
2. Human resource, infrastructure & technology development at various level of health care system.

The proposed plan includes a four tier structures –

• Centers of Excellence (20)
• Training centers (200)
• Service centers (2000)
• Vision centers (20000)
• Vision centers – provide primary eye care which include –
• Refraction & prescription of glasses
• School eye screening program
• Treatment of common eye problems
• Screening & referral services
• Service centers – provides secondary eye care which includes
• Cataract surgery
• Other common eye surgeries
• Facilities for refraction
• Referral services
• Training centers – Provide tertiary eye care including retinal surgery, corneal transplantation, glaucoma surgery & Training/CME
• Centers of excellence – will be involved in: –
• Professional leadership
• Strategy development
• Continued medical education (CME)
• Laying of standards & quality assurance
• Research

Pradhanmantri Swasthya Suraksha Yojana (PMSSY)

• Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) was approved in March 2006
• Objective of PMSSY is the correction of imbalance in affordability of reliable tertiary level health care in the country and to arrangement facility for quality medical education in the underserved state.
• PMSSY includes: –

1. Setting up of AIIMS like institution one each in Patna, Bhopal, Bhubaneshwar, Jodhpur, Raipur, and Rishikesh.

Cost involved per center was Rs. 322 crores.

2. Upgradation of 13 medical institutions with an outline of Rs 120 crores per institution, of which 100 crores would be borne by the central govt. and remaining by respective state govts.
3. States sets for upgradation of medical institutions are UP, J&K, WB, AP, TN, Jharkhand. Gujarat, Karnataka, Maharashtra and Kerala.

• The scheme was implemented in 2009-2010

Community Participation

• Community participation may be in form of 3 ways: –

1. Community can provide facilities, manpower, logistic support and even funds.
2. Community can be actively involved in planning management and evaluation
3. Community can contribute by joining in and using the health services.

• No public health program can be successful without community participation
• Constraints of community participation

1. Poor/ no appreciation for participation
2. Poor skills of health care staff in facilitating community involvement
3. Lack of accountability for the services being provided
4. Weak political commitment for community participation
5. Lack of planning in relation to community participation

• Policy guidelines on participation should be clear and available to the public to facilitate their role
• Community participation is not easy to obtain unless properly planned and executed
• Govt of India recognizes the need to involve communities, their elective representatives and the civil societies in the planning and monitoring of various proms and also in delivery of services and evaluation. E.g. RCH-II, NRHM etc.
• Community based organization (CBO) should be encouraged and motivated to take active part in the management of local services.
• Thus, emphasis has shifted from the “Health care for the people” to “Health care by the people”

Health tourism

• The national health policy strongly recommends health/medical tourism to develop economy and health services of the country.
• Health tourism is a concept where a patient travel to another country for medical Treatment in order to save costs or get Treatment faster or even to avail of better medical facilities.
• Recently large number of patients are coming from other countries to India for treatment
• Most common treatment are heart surgery, knee transplant, cosmetic surgery and dental care.
• The health tourism market in India, estimates at Rs.15.48lakh billion in 2004and its predicted reach Rs.93 billion a year by 2012.
• Steps taken by Govt of India to encourage Medical health tourism

1. Fast track clearance for the medical patients at the airport
2. Introduction of “Medical visa”
3. Developing strategies to open the Indian Health care sector to foreign tourists
4. Considering setting up of a National Accreditation Board for Hospitals.

ASHA – (Accredited Social Health Activities)

• Under NRHM, ASHA is a health activist in the community who creates awareness on health.
• ASHA, posted under NRHM, acts as the link between the people and sub center staff and be accountable to the panchayat
• ASHA is an honorary volunteer. She receives performance-based incentives for promoting health seeking behavior of general population
• ASHA must be resident of the given village. ASHA is a woman (widow/married/divorced) in the age group of 25-45yrs with formal education up to 8^th class, having leadership qualities and good communication skills.
• One ASHA caters a population of 1000. In tribal, hilly and difficult areas one ASHA per habitation is sufficient.
• ASHA’s are well trained (Training imparted after selection)
• Responsibilities of ASHA –

1. To create awareness & provide information to the community about various determinants of health
2. To counsel women on birth preparedness, importance of safe delivery, breast feeding and complementary feeding, immunization, contraceptives, prevention of RTI/STIs and care of young child.
3. To mobilize community for better utilization of various health services.
4. To work with the village health and sanitation committee of the gram panchayat
5. To arrange escort, accompany pregnant women and children during delivery and treatment respectively at govt. health centers.
6. To provide primary medical care for minor illness also acts as DOTS provider.
7. To act as depot holder for ORS, IFA tabs, disposable delivery kit, Oral pill, condoms etc.
8. To inform sub center/ PHC about birth and death
9. To promote construction of toilets within the households.

SWOT Analysis

• It is an analysis of a project, program or event based on its strength, weakness, opportunity and threat.
• This analysis is commonly employed now days.
• SWOT means
• S – strength
• W – weakness
• O- opportunities
• T- Threat
• For example, SWOT analysis of nation leprosy eradication program: –

Strength –

1. Good political commitment
2. Good cooperation by international agencies e.g. WHO, LEPRA, DANLEP etc.
3. Committed staff and officials
4. Good Integration
5. High quality and monitoring and supervision
6. High effective MDT

Weakness –

1. Lack of coordination between district nucleus and PHIs
2. Lack of rehabilitative services at district level
3. Comfort level in peripheral health workers

Opportunities

1. NHM
2. Various school health program
3. Presence of supportive environment

Threats

1. Pulse polio immunization
2. Overburdened health staff

• SWOT analysis is used for situation analysis and help accordingly in implementation of program after corrective measures
• Provides road map door future plan of action

Public-Private Partnership (PPP) in Health

• Public sector in health contributes to only 30% of burden of providing health care. More than 70% of the burden is on the private health care system (Government of India 2003)
• Therefore, it is realized more and more, the need for bringing private health sector and public health sectors under one umbrella and that is under the umbrella of ministry of health and family welfare for the success of public health programs
• Rapid urbanization and migration of rural population to urban/peri – urban areas is increasing demands on private health sectors
• National health programmers are being supported by private health sector including NGOs. Polio eradication, EPI, RCH, TB-DOTs, Patient Provider Support Agency (PPSA) in NTEP, HIV/AIDS, Leprosy treatment and malaria are some of the important area where PPP is increasing geographically patient coverage.
• IDSP will encourage PPP as more information will be required from private sectors
• Achieving sustained partnership between public private health sectors for the benefit of nation health programs in a challenging task. This demand is a lot of advocacy, flexibility in guidelines, simplifies reposting system and technical assistance.
• The need for PPP does not mean privatization of the health sector. It is a tool for augmenting the public health system
• Objectives of PPP

1. Universal coverage & equity for primary health care
2. Improving quality, acceptability, availability & efficiency of health services
3. Exchange of knowledge & skills b/w public & private sector
4. Mobilization of additional resources
5. Improvement in resources allocation and generation of additional resources
6. Widening the range of services and number of service providers
7. Community ownership.

• Public –Private – Partnership Models: –

1) Contracting in and contracting out

2) Social Marketing

3) Franchising

4) Voucher Schemes

5) Joint ventures

6) Hospital Autonomy

7) Involving Professional Associations

8) Partnership with NGOS/ Social Groups /Corporate Sector / Industrial Bodies/ Cooperative Societies.

9) Community based health insurance

10) Mobile health units.

FIRST REFERRAL UNIT (FRU)

• A Health facility can be declared as FRU if it has
• Availability of surgical interventions e.g. caesarean section etc.
• New bone care
• 24-hour blood storage facility.
• Following facilities are must for first referral unit (FRU)

1. A minimum bed strength of 20-30, in EAG and NE states, 10-12 beds are necessary
2. A functional operation theatre with Newborn Care Corner (NBCC)
3. A fully functional labour room
4. An area allotted and well equipped for new-born care in the labor room (NBCC) and near the ward – Newborn stabilization Unit (NBSU).
5. A functional laboratory
6. Blood storage facility
7. 24-hour water supply and electricity supply
8. Arrangement for waste disposal
9. Ambulance facility

• FRUs provide comprehensive emergency obstetric care
• FRUs were designated to all sub district community health centers (CHCs) , postpartum centers and centers and upgraded PHCs of all districts of the country
• It was decided that all FRUs in the country be made functional during RCH-II
• A fully functional FRU provides following minimum services.

1. Round the clock delivery services, both normal and assisted deliveries
2. Emergency obstetric services
3. Newborn care
4. Emergency care of sick children
5. All types of family planning services
6. Safe abortion services
7. Treatment of STI/RTI
8. Essential laboratory services and
9. Referral (transport) services

Integrated Management of Neonatal and childhood illness (IMNCI)

• IMNCI is the Indian adaptation of the WHO-UNICEF generic IMCI (Integrated management of childhood illness).
• It played an important role for child health interventions under the RCH II strategy.
• IMCI is a strategy for an integrated approach to the management of childhood illness.
• The core of IMCI strategy is integrated case management of the most common childhood problems e g: Diarrhea, ARI, malaria, measles and malnutrition.
• Indian adaptation of IMCI has special features

1. Infants up to 0-7 days age are included in program
2. Indian guidelines on malaria, anemia, vitamin A supplementation and immunization schedule are included in it.
3. Training begins with sick young infant up to 2 months for health staff /MO
4. Training time devoted to sick young infant and sick child is equal and
5. It is skill based

• IMNCI plus includes:
• IMNCI
• Care at birth
• Immunization
• In IMNCI child can be managed at home or referred to higher centers immediately in emergency.

Multi Drug Therapy (MDT)

• It is a combination of 2 or 3 anti-leprosy drug is (Rifampicin/ dapsone/ clofazimine) used for the treatment of leprosy.
• It is blister calendar pack of 28 days with supervised dose to be given on day 1
• MDT has reduced the duration of treatment of leprosy considerably with added advantage of better patient compliance, cost-effectiveness and decreased workload
• Objectives of MDT: –

1. To interrupt transmission of the infection in the immunity by converting infectious cases to non-infectious
2. To ensure early treatment of cases so that deformities cannot develop
3. To prevent drug resistance

• MDT is highly curative with less than 1% relapse rate
• MDT supplied free of cost by WHO to different countries
• MDT is available free of cost at each primary health centers & other government higher health facilities.

Advantages of MDT: –

1. Highly effective in curing leprosy
2. Stops transmission
3. Prevents disabilities if given early
4. Low relapse rate (<1%)
5. No resistance
6. Safe in pregnancy and lactation
7. Less side effects
8. Improves compliance of patient
9. Reduces duration of treatment
10. Can be given to HIV +ve patients
11. Reduces chances of Lepra reaction

• MDT Duration of Tt-

1. For multibacillary (MB)leprosy – 12 months
2. For paucibacillary (PB) leprosy – 6 months

• Four types of MDT BCPs are supplied –

MB adult, MB child, PB adult and PB child, child BCPs are given when the age is more than 14 years

Bioterrorism

• It has been defined as “the deliberate release of disease-causing germs with intent of killing large numbers of people – and of panicking many more”.
• Biological weapons are the real threat to the public health internationally. No country seems to be prepared for facing bioterrorism.
• In history biological weapons were widely used by Japan, US, Britain, Germany, and other countries in World War I & II.
• List of micro-organisms which can be used in bioterrorism are endless. But some important one is – Anthrax, influenza, smallpox, plague, cholera, yellow fever, rickettsia etc.
• The target population is likely to be big metropolitan cities, military camps and refugee camps and district having international borders. No part of country is immune to such attacks
• Biological weapons have an incubation period and it is the clinicians who are first faced with evidence of the results of a biological weapon.
• If the correct diagnosis is made and cause identified quickly control measures may be initiated soon and quickly, control measures may be initiated soon and impact of bioterrorism can be greatly reduced.
• Countermeasures against bioterrorism include

1. Prevention
2. Deterrence
3. Strengthening epidemiological surveillance
4. Medical management
5. IEC
6. Capacity building
7. Inter-sectoral collaboration
8. International peace and efforts

Universal Precautions

• Universal precautions are the specific precautions designed to prevent harmful bacteria & viruses from infecting people who are providing first aid or health care.
• As defined by the centers of disease control (CDC) “Universal precautions (UPI) are a set of practice designed to prevent transmission of HIV, Hepatitis B & other blood borne pathogens (bacteria and viruses)’’.
• Under university precautions (UP), blood and other body fluids of all patients are considered potentially infectious.
• Universal precautions recommend the use of personal protective equipment such as:
• Gloves
• Aprons
• Gowns
• Protective eyewear
• Face shields
• Masks
• Universal precautions also include

1. Proper handling and disposal of needles
2. Taking precautions to prevent injury from scalpels, needles and other sharp instruments
3. Washing hands before and after handling the patients for 2 minutes in 6 steps with each step of 20 seconds.

India Mix

• Under world food program in India a blend of precooked maize and soya’s fortified with micronutrients called CBS (Corn Soya Blend) has been developed in the name of India mix.
• It is distributed through existing infrastructure of the ICDS project
• The India mix project is working in Rajasthan, M.P, Gujarat, U.P, Bihar, Orissa, Assam, and Kerala.
• It is precooked nutritious food made from wheat (75%) and full fat soybeans (25%) or alternatively maize (40%), wheat (40%) and full fat soybeans (20%)
• India Mix contains all the nutrients required for growth and development in children in proportionate and adequate amount.
• Nutritive value of India mix-

Nutrients              Amount per 100 gm

Protein                                          20g

Fat                                                 6g

Crude fiber                                    2g

Carbohydrate                                60g

Energy                                           390 k calories

Calcium                                         191mg

Iron                                               15mg

Vit- A                                             1454mcg

Disability Prevention and Medical Rehabilitation in Lerprosy

• After elimination of Leprosy as a public health problem in our country, It is felt that prevention of deformities and disabilities need to be given greater emphasis during the 11th five-year plan period (2007-2012) & onwards.
• The DPMR activities are being carried out in a 3 –tier system, i.e. primary level care, secondary level care and territory level care institutions
• Objectives-

1. To prevent disabilities and worsening of existing deformities in all needy leprosy affected person, both patients on treatment and those released from treatment
2. To develop a referral system for providing Prevention of Deformity services to all leprosy disabled persons in an integrated setup.

• It has two components –

1. Disability prevention and
2. Medical rehabilitation

• Medical rehabilitation is death with Re-constructive Surgery (RCS)
• Disability prevention includes –
• Early diagnosis and treatment of cases
• Timely diagnosis of Lepra reaction/neuritis and their appropriate management
• POD services to needy patients

Childhood Obesity

• Childhood obesity is a condition where excess body fat negatively affects a child health or well being
• The diagnosis of obesity is often based on BMI for children 2 years of age & older. The normal range for BMI (body mass index) in children varies with age & sex. Center for disease control defines childhood obesity as a body mass Index (BMI) greater than 95^th
• Because of its rising prevalence &its many adverse health effects & serious public health effects it is considered as a serious public health problem.
• Effects on Health –

1. Endocrine – * Impaired glucose tolerance

                                                * Diabetes mellitus

                                                * Metabolic syndrome

                                                * Effects on growth & puberty

                                                * Nulliparity & Null gravidity

2. Gastrointestinal              * Nonalcoholic fatty liver disease

                                          * Cholelithiasis

3. Musculoskeletal              * Slipped capital femoral epiphysis

                                          * Tibia vera

4. Psychosocial * Distorted peer relationship

                                          * Poor self esteem

                                          * Anxiety

                                          * Depression

5. Cardiovascular * Hypertension

                                          * Hyperlipidemia

                                          * Increased risk of CHD as an adult

6. Respiratory * Obstructive sleep apnea

                                          * Obesity hypoventilation syndrome

7. Neurological * Idiopathic intracranial hypertension
8. Skin * Furunculosis

                                          * Intertrigo

• Causes –               Intake of high calorie diet

2. Sedentary lifestyles
3. Genetics e.g. Prader Willi syndrome
4. Home environment
5. Development factors

                                                            * Lack of breast feeding

                                                            * Overweight newborn

6. Medical illnesses

                                                            * Cushing’s syndrome

                                                            * Hypothyroidism

7. Psychological factors

                                                            * Low self esteem

                                                            * Stress

                                                            * Binge eating

• Prevention –

1. Reduction in weight

                                                            * Dietary modifications

                                                            * Drugs

                                                            * Exercise

2. Changes in lifestyle
3. Meditations, yoga etc.
4. Health education

Substance Abuse (Drug Abuse)

• It defined as the self –administration of a drug or substance in quantities and frequencies which may impair the ability of an individual to function normally and results in social physical and emotional harm.
• Among people aged 10 and 75 years of age about 14.6% of the population uses alcohol. After alcohol, Cannabis & opioids are the next commonly used substances (2.8% of the population) in India.
• Commonly abused substances /drugs are –

1. Alcohol
2. Amphetamine
3. Barbiturates
4. Cannabis
5. Cocaine
6. Caffeine
7. Heroin
8. LSD
9. Nicotine
10. Volatile solvents.

• Important factors responsible for substance abuse are: –

1. Unemployment
2. Rapid urbanization
3. Ignorance / Neglect
4. Group culture
5. Tourism
6. Sex workers
7. Urban migration
8. Family problems
9. School dropouts
10. Drug racket exposure
11. Delinquency

• Symptoms of drug addiction are –

1. Loss of interest in daily activities.
2. Loss of weight and gait.
3. Redness of eye, unclear vision.
4. Slurred speech.
5. Nausea, vomiting, body pain.
6. Drowsiness / Lethargy.
7. Profuse sweating / acute anxiety.
8. Changing moods / temperatures.
9. Depersonalization / emotional detachment.
10. Impaired memory.
11. Presence of needles, syringe, packets at home.

• Prevention-

1. Legislation
2. Health education
   • Individual
   • Community
   • High risk groups

3. Hospitalization and detoxication.
4. Post detoxication counseling
5. Vocational training and rehabilitation.
6. After care and prevention of relapses.

BABY FRIENDLY HOSPITAL INITIATIVE (BFHI)

• Baby friendly hospital initiative created and promoted by WHO and UNICEF, was launched in 1992.
• It aims at promoting successful breastfeeding in the facilities where deliveries take place.
• BFHI is supported by the major professional medical and nursing bodies in India.
• The global BFHI has a list of ten steps which must be fulfilled by a hospital.
• The ten steps recommended for BFHI are as follows: –

1. Have a written breast-feeding policy that is routinely communicated to all health staff.
2. Train all health care staffs with skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breast feeding.
4. Helps mothers initiate breast feeding within an hour of birth.
5. Show mothers how to breast feed, and how to maintain lactation even if separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming in. Allow mothers and infants to remains together 24 hours a day.
8. Encourage breast feeding or demand.
9. Give no artificial teats or pacifiers to breast feeding infants.
10. Foster the establishment of breast-feeding support groups and refer mothers to them or discharge from the hospital or clinic.

• In India, BFHI also includes practice in relations to antenatal care, clean delivery practices, essential newborn care, immunization and ORT.

A E F I (ADVERSE EVENT FOLLOWING IMMUNIZATION)

• An adverse event following immunization (AEFI) is defined as a medical incident that takes place after an immunization, causes concern, and is believed to be caused by immunization.
• AEFIs are genuine threat to the immunization program, in some cases, have effect on health of recipients.
• It is important that AEFIs are detected, investigated, monitored and promptly responded to for corrective interventions.
• Types of AEFI: –

1. Vaccine reaction

An event caused or precipitated by the active component or one of the other components of vaccine. This is due to the inherent properties of the vaccine. E.g. high-grade fever following DPT vaccination.

2. Program error

An event caused by an error is vaccine preparation, handling or administrators. E. g. Bacterial abscess due to un-sterile injection.

3. Coincidental

An event that occurs after immunization but is not caused by the vaccine. This is due to chance and because of other causes.eg. Pneumonia after OPV administration.

4. Injection reaction

Event caused by anxiety about, or pain from the injection itself rather than the vaccine e.g. fainting spell in a teenager after immunization.

5. Unknown

The cause of the event cannot be determined.

VACCINE VIAL MONITOR (VVM)

• A VVM is a label containing a heat- sensitive material which is a placed on a vaccine vial to register cumulative heat exposure over time.
• The combined effects of time and temperature cause the inner square of the VVM to darken gradually and irreversibly. Before opening a vial, check the status of the VVM.
• VVM does not directly measure the vaccine potency but it gives information about the main factor that affects potency: Heat exposure over a period of time.

The VVM does not, however, measure exposure to freezing that contributes to the degradation of freeze – sensitive vaccine.

• VVM consists of a circle in which a square is there. Generally the inner square color is lighter than the outer circle, if the vaccine is usable. If it is equal to or darker than the outer circle, do not use the vaccine.
• There are 4 different types of VVMs for different vaccines depending on their heat stability
• VVM 30: High stability, used on the least heat sensitive vaccines
• VVM 14: Medium stability
• VVM 7: Moderate stability
• VVM 2: least stable, used on the most heat sensitive vaccines.

District Mental Health Program

• It is an integral part of the National Mental Health Program (1982).
• It is based on the “Bellary Model” proposed by NIMHANS, Bangalore.
• It was started in 1997, initially four districts were taken.
• It consists of a DMHP team attached to a medical college. The team has

1. Psychiatrist/trained M.O – 1
2. Clinical psychologist – 1
3. Psychiatric social worker – 1
4. Psychiatric nurse – 1
5. Driver/Peon – 1

• The functions of DMHP team are –

1. Early diagnosis of cases
2. Proper treatment of diagnosed cases
3. Training of MOs and paramedical staff posted at peripheral centers
4. IEC
5. Reporting and record maintenance

• From 11^th five-year plan (2007-2012), DMHP team has also to do

1. School counseling
2. College student counseling
3. Suicide prevention
4. Drug de-addiction clinics
5. Workplace stress management

• DMHP is the building block of National Mental Health Program (NMHP). DMHP aims at decentralized community based mental health care through the existing primary health care system. DMHP will be further expanded to cover all districts by 2030.
• Objectives of DMHP –
• Providing sustainable basic mental health services to the community and integrate these services with general health services.
• Early detection & treatment of patients within the community itself.
• Taking pressure away from Mental hospitals.
• Reducing stigma attached to mental illnesses through changes in attitude and public education.
• Treatment & rehabilitation of mentally ill patients discharged from the mental hospital within the community.
• Continuing education (mental health literacy).

Emergency Contraception

• Emergency contraception is useful as a birth control method under the following conditions
• Contraceptive failure
• Unprotected sex
• Forced sex
• There are two types of emergency contraception

1. Progesterone containing pill (Emergency Pill)
2. IUD insertion

• Progesterone containing pill – Dose to be taken is 1.5mg of levonorgestrel. It should be taken as soon as possible, preferably within 12 hours and not later than 72 hours of unprotected sex.

If after taking pill, person vomits within 3 hours, she should take another pill.

There may be some irregularity in menstruation and nausea for some time after taking the emergency pill. It should not be given if there is pregnancy. Though it will not harm the fetus in womb.

• Emergency pill acts by inhibiting ovulation, fertilization, of ovum and implantation of fertilized ovum.
• IUD if inserted within 72 hours of unprotected sex is the best method of emergency contraception.
• Oral combined pills (EE 30 ug + LNG 150mg) can be used as emergency contraception. Lady has to take 4 pills as soon as possible after unprotected sex and 4 more pills after 12 hours.
• Emergency (progesterone only) pills are safe in breast feeding as it has no effect significantly on breast milk quality & quantity.

It does not have any long term or serious side effect. Nausea, vomiting and headache are some common side effects of emergency pills.

       Emergency pills are Available in the market by trade name E-pill, I-pill etc.

Wealth Index

• Wealth index is an index of economic status of households which was used first time in the National Family health survey -3
• It is an indicator of the level of wealth that is constant with expenditure and income measures.
• This index was developed using the following household data –
• Household electrification
• Type of windows
• Type of flooring
• Material of external wall
• Type of roofing
• Drinking water source
• Types of toilet facility
• Cooking fuel
• House ownership
• Overcrowding
• Ownership of bank or post office account
• Household facilities e.g. TV, Mobile, telephone, computer, refrigerator, fan, table, chair, mattresses, bicycle, cart, scooter, bite, water pump, thresher, tractor etc.
• Each household facility is provided a factor score and the resulting facility scores are standardized according to normal distribution. Each household is then provided with a score for each household. (Individuals got the score of households in which they were residing). The sample is then divided into quantities i.e. five groups with an equal no. of individual in each. The top 20% form the richest and the bottom 20% the poorest quintile.
• India’s urban population is tilted towards the top quintiles indicating a generally higher standards of living, but it has a striking contrast with rural areas. Only one in 4 rural Indians falls into these groups.
• Twelve states and Union territories have more than half of their population in the lowest two wealth quintiles. Assam has the highest such share (70%), followed by Bihar (69%) and Jharkhand (68%). Except Mizoram & Sikkim, all north east states fall under this category.

NATIONAL DIGITAL HEALTH MISSION (NDHM)

With an aim to create an ecosystem for providing better healthcare services in the country, the Hon’ble Prime Minister of India announced the National Digital Health Mission (NDHM) on 15^th August 2020, the 74^thIndependence Day of India.

NDHM aims to make India self-reliant in providing Universal Health Coverage to all the citizens in the country. It aligns with the goals and objectives of the National Health Policy (NHP) 2017 and the National Digital Health Blueprint to create a digital infrastructure for providing health care services across the country.

NDHM will implement following digital systems across the country –

• HEALTH ID – Implementation of a Unique Health ID (UHID) just like an Aadhaar ID to identify and authenticate an individual based on past health records. To create a wide network of health records, the data will be also shared with various stakeholders after getting an informed consent from the individual.
• DIGI DOCTOR – A repository of doctors with individual details will be created. The directory of doctors will be updated from time to time and mapped with the facilities those doctors are associated with.
• HEALTH FACILITY REGISTER (HFR) – A repository of health facilities across the country will be created. HFR will be centrally maintained and facilitate standardized data exchange of private and public health facilities in India.
• PERSONAL HEALTH RECORDS (PHR) – A PHR is an electronic record of an individual which would contain health-related information of that individual.
• ELECTRONIC MEDICAL RECORDS (EMR) – An App that contains medical and treatment history of a patient. EMR is envisaged to be a web-based system that would contain comprehensive health related information of a patient at a facility.

Some prominent examples of digital initiatives are –

• Bharat Interface for Money (BHIM)
• Indian Customs Electronic Gateway (ICEGATE)
• Government Electronic Marketplace (GeM)
• eSanjeevani OPD

ANEMIA MUKT BHARAT

Anemia Control Program in India started in 1970 as National Nutritional Anemia Prophylaxis Program (NNAPP) & evolved in 2018 as Anemia Mukt Bharat. Target is to achieve an annual rate of decline from one to three percent points in anemia prevalence.

Program is based on 6*6*6 strategy. The 6*6*6 strategy comprises of –

• 6 beneficiaries –
• Children 6-59 months
• Children 5-9 years
• Adolescent girls & boys (10-19 years)
• Women of reproductive age (15-49 years)
• Pregnant women
• Lactating women
• 6 Interventions –
• Prophylactic Iron & Folic acid supplementation
• Deworming
• Intensified year round BCC campaign including assured delayed cord clamping
• Testing of anemia using hospital digital methods & point of care treatment
• Mandatory provision of iron folic acid fortified food in public health program
• Addressing non-nutritional causes of anemia in endemic pockets with special focus on malaria, hemoglobinopathies & fluorosis.
• 6 Institutional mechanisms –
• Intra-ministerial coordination
• National Centre of excellence & advanced research on anemia control
• Strengthening supply chain & logistics
• National Anemia Mukt Bharat Unit
• Convergence with other ministries
• Anemia Mukt Bharat Dashboard & digital portal – one stop-shop for anemia.

HOME BASED NEWBORN CARE (HBNC)

India contributes to one fifth of global live births and more than a quarter of neonatal deaths. About 7.6 lakh infants die within the first 4 weeks of birth in India, highest for any country in world. About 3/4^th of total neonatal deaths occur in the first week of life. It has been observed that Neonatal Mortality Rate in rural areas is more than double of urban areas.

To overcome this, Government of India has adopted the strategy called Home Based Newborn Care (HBNC) to check the burden of newborn deaths in the first weeks of life & to reach the un-reached. It provides the continuum of care for newborn & post-natal mothers as envisaged under RMNCH+A strategy. HBNC introduced in 2011 is centered on ASHA workers & is the main community based approach to newborn health now. More than 5.6 lakhs ASHAs have been trained in module 6 & 7 (HBNC modules) of ASHA training & started making home visits.

The Objectives of HBNC are as follows –

The major objective of HBNC is to decrease neonatal mortality and morbidity through –

• The provision of essential newborn care to all newborns & the prevention of complications.
• Early detection and special care of preterm & low birth weight newborns.
• Early identification of illness in the newborn & provision of appropriate care and referral.
• Support the family for adoption of healthy practices and build confidence & skills of the mother to safeguard her health and that of the newborn.

 Key Activities in HBNC –

• Care for every newborn through a series of home visits by a ASHA in the first 6 weeks of life.
• Information & skills to the mother & family of every newborn to ensure better health outcomes.
• An examination of every newborn for prematurity & low birth weight (LBW).
• Extra home visits for preterm & LBW babies by the ASHA or ANM & referred for appropriate care as defined in the protocol.
• Early identification of illness in the newborn & provision of appropriate care at home or referral as defined in the protocol.
• Follow up for six newborn visits after they are discharged from the facilities after institutional delivery.
• Counselling the mother on the postpartum care, recognition of postpartum complications & referral.
• Counselling the mother for adoption of an appropriate family planning method.

ASHA will be paid incentive of Rs. 250/- for HBNC visits (For Twins – 500/- & for triplets – 750/-) if she completes 6 visits (3,7,14,21, 28, 42 days) in case of institutional delivery or If she completes 7 visits (1,3,7, 14, 21, 28, 42 days) in case of home delivery or if she completes 5 visits (7,14,21,28, 42 days) in case of C-section in a given household where newborn lives.

HOME BASED CARE FOR YOUNG CHILD (HBYC)

Within Indian context, the health system contact between 4 months to 2^nd year of life of the young child is a missed opportunity for promotion of various child caring and development practices during the critical period. Therefore, home visits by ASHAs starting from 2-3 months and continuing in 2^nd year till 15 months are implemented under homebased care of young child (HBYC) to plug the gap between health system contacts with family and provide platform to improve child nutrition, immunization, development, hygiene practices and reduce common childhood illnesses such as diarrhea and pneumonia.

Ministry of Health & Family Welfare and ministry of women & child development launched this program jointly. The objective of HBYC is to reduce child mortality & morbidity and improve nutrition status, growth and early childhood development of young child through structured, focused and effective home visits by ASHAs.

Salient features of HBYC program are as follows –

• Convergent action by MWCD & MOHFW, leveraging existing community level platforms.
• Evidence based interventions for child health & nutrition, bundled as service package.
• Convergence & integration across interdependent domains of health, nutrition, WASH & early childhood development.
• Five additional home visits by ASHA in coordination with AWW starting from 3^rd month & extending into 2^nd year of life (in 3,6,9,12 & 15^th month).
• Additional incentives of INR 250/- for 5 visits to be provisioned for ASHA under NHM & disbursed using existing ASHA payment mechanism.
• SBCC plan to focus on addressing adverse social norms in health care seeking especially for girl child.

From 2-3 month onwards, ASHAs will provide quarterly home visits & ensure exclusive & continued breastfeeding, adequate complementary feeding, age appropriate immunization & early childhood development. The quarterly home visits schedule for LBW babies, SNCU & NRC discharges will now be harmonized with the new HBYC schedule.

AWWs will continue to provide TAKE HOME RATION & nutrition specific counselling to the mothers. In addition, she will record weight of the young child and monitor growth & development using MCP cards as per guidelines. Based on growth chart, underweight children will be identified and taken up for further management.

In order to reinforce existing skills & provide new sets of skills, an additional round of 3 days training shall be conducted with adequate hands on practice.

SURAKSHIT MATRITVA AASHWASAN (SUMAN) –

Under SUMAN all existing schemes for maternal and infant health has been brought under the umbrella in order to create a comprehensive and cohesive initiative which goes beyond entitlements and provides a service guarantee for the entitlements. In order to operationalize the service guarantee & ensure zero tolerance for any negligence & denial of services several strategies have been adopted namely a responsive call center, for grievance redressal, a client feedback mechanism, special focus on community engagement, a mega IEC/BCC campaign on zero preventable maternal & newborn deaths & inter-sectoral convergence, responsive fund allocation to health facilities. 

Vision – To ensure that every women receives high quality of maternity care delivered with dignity and respect and the same is extended to her infant.

Goal – To end the all preventable maternal & early infant deaths.

Aim – Assured, dignified, respectful & quality health care at no cost and zero tolerance for denial of services for every woman and newborn visiting the public health facilities to end all preventable maternal and newborn deaths and morbidities and provide a positive birthing experience.

Objectives –

• Provide high quality medical and emergency services and referrals.
• Create a responsive health care system.
• Use institutional and other community based platforms like NGOs, SHGs, PRIs and elected representatives from community etc. to help spread awareness and mobilize community and facilitate 100% reporting and review of maternal deaths.
• Develop a system of continuous feedback & redressal of grievances for maternity services and establish it.
• Create awareness, build capacities and motivation of all service providers.
• Provide an interdepartmental platform for convergent action plans
• Create a steering committee for effective governance including formulating strategies, supervision and review of the program for corrective actions.

Platforms like MERA ASPATAL will be utilized to take regular feedback from the mothers and their families whether Respectful Maternity Care is being plasticized in the health facility or not.

A mega campaign on ZERO MATERNAL DEATH to spread the awareness of high number of maternal deaths due to preventable causes and aim of reducing such deaths to zero, will be launched.

SUMAN INITIATIVES are – 1) Free ANC, delivery & postnatal care 2) Free management of sick infants & newborns, 3) Assured delivery plan for high risk pregnant women & 4) Ensure quality standards at all level of delivery points.

Broad pillars of SUMAN initiative are –

• Service Guarantee
• Community Awareness
• Health system strengthening
• Monitoring & Reporting
• Incentives & Awards
• IEC/BCC

RESPECTFUL MATERNITY CARE (RMC)

Respectful Maternity Care (RMC) is an approach centered on an individual, based on principles of ethics and respect for human rights, and promotes practices that recognize women’s preference and women’s needs. Various components that define Respectful Maternity Care are –

• Privacy
• Freedom from physical & verbal abuse & pdite behaviour by service providers
• Relaxing environment (Dim light, quiet, physical comfort in Labour room)
• Presence of birth companion
• Option for alternate birthing positions
• Informed consent
• Avoiding unnecessary examinations
• Delayed cord clamping (not < 5 minutes or until cord pulsations ceases)
• Provision of proper & clean washroom facilities.

KANGAROO MOTHER CARE (KMC)

Kangaroo mother care (KMC) is a method of care of preterm newborns. The method involves newborns being carried, usually by the mother, with skin to skin contact. The important components of KMC are – prolonged Skin to skin contact & exclusive breast feeding. The pre-requisite of KMC are –

• Support to the mother in hospital & at home.
• Post discharge follow up.

Eligibility criteria includes – All stable low birth weight babies are eligible for KMC. However, very sick babies needing special care should be cared under radiant warmer initially. KMC should be started after the baby is hemodynamically stable.

KMC can be initiated in a baby who is otherwise stable but may still be on IV fluids, tube feeding &/or Oxygen. Short KMC sessions can be initiated during recovery with ongoing medical treatment (IV fluids, OXYGEN therapy).

Ensure that baby’s neck is not too flexed or too extended, breathing is normal & feet & hands are warm during KMC. When Mother is not available, other family members such as grandmother, father or other relatives can provide KMC.

DURATION OF KMC – Skin to skin contact should start gradually in the nursery with a smooth transition from conventional care to continuous KMC. Sessions that last less than one hour should be avoided because frequent handling may be stressful for the baby. The length of skin to skin contacts should be gradually increased up to 24 hours a day, interrupted only by change of diapers. When baby does not require intensive care, should be transferred to postnatal ward where KMC should be continued.

BENEFITS OF KMC are as follows –

• Temperature maintenance with a reduced risk of hypothermia
• Increased breast feeding rates
• Early discharge from health facility
• Less morbidities such as apnea & infections
• Less stress to both mother & newborn
• Better bonding between mother & newborn

VILLAGE HEALTH SANITATION & NUTRITION DAY (VHSND)

Village Health & Nutrition day was conceptualized under the National Rural Health Mission and is being implemented across the country since 2007 as a community platform, connecting the community and health systems and facilitating convergent actions. It attempts to bring health, early childhood development, sanitation & nutrition services at the doorsteps and promote community engagement for improved health and wellbeing.

VHSND is the critical platform for AYUSHMAN BHARAT, POSHAN ABHIYAAN & SWACHH BHARAT MISSION. Furthermore, it complements community level, multi-sectoral components of several newer programs such as HBNC, HBYC, PMSMA, Mission Parivar Vikash & Anemia Mukt Bharat. Besides there are newer beneficiary entitlements including maternity cash benefit scheme, Pradhan Mantri Matru Vandana Yojana, beneficiary cash incentives such as nutrition support to TB patients, family planning compensations and incentive or subsidy to build low cost good quality toilet under Swachh Bharat Mission for sanitation.

VHSND is organized in every village once a month at the Anganwadi Center and also organized in urban areas and will be called UHSND. This session is generally conducted for a minimum of 4 hours of this at least one hour should be devoted to group counselling sessions.

VHSND has 4 components namely Health, Nutrition, Sanitation & early childhood development. The health component includes basic health services & counselling for RMNCH+A, communicable diseases & NCDs. The nutrition component includes services as well as counselling related to growth monitoring, promotion of infant & young child nutrition including breastfeeding & complementary feeding, maternal nutrition, micronutrients & dietary diversity. Early childhood development emphasizes age appropriate play and communication for children. The focus of sanitation is on promoting hygiene, hand washing, safe drinking water & use of toilets.

MONKEY POX

Monkey pox is an illness caused by monkey pox virus. It is a viral zoonotic infection, meaning that it can spread from animals to humans. It can also spread from humans to other humans and from environment to humans.

The disease is called Monkey pox because it was first identified in colonies of monkeys kept for research in 1958. It was only later detected in humans in 1970.

Outbreak of monkey pox began to expand in May 2022 globally. The Director General of WHO declared on 23 July 2022 that the multi-country outbreak of monkey pox is a PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN (PHEIC). The Director General also issued temporary recommendations to help countries fight the outbreak & bring it under control.

The risk of monkey pox is not limited to people who are sexually active or men having sex with men. Anyone who has close contact close contact with someone who has symptoms is at risk. People who are at high risk for monkey pox include pregnant women, children & immunocompromised persons.

Common Symptoms are fever, headache, muscle ache, back pain, weakness & swollen lymph nodes, followed by development of rash & sores. Rashes may last for 2-3 weeks. Symptoms usually go away on their own or with supportive care, such as medications for pain and fever. However in some people, an infection can lead to medical complications and even death. People remain infectious until all the sores have crusted over, the scabs have fallen off & a new layer of skin has formed underneath.

Small pox vaccines may be used for prevention of monkey pox among people at risk.

JANANI SURAKSHA YOJANA (JSY)

Janani Suraksha Yojana (JSY) under the overall umbrella of National Health Mission (NHM) was initiated by modifying the existing National Maternity Benefit Scheme (NMBS). While NMBS was linked to provision of better diet for pregnant women from BPL families, JSY integrates the financial/cash assistance with antenatal care during the pregnancy period, institutional care during delivery period and postnatal care in immediate postpartum period in a health facility by establishing a system of coordinated care by ASHA, the field level worker. It is a fully centrally sponsored scheme.

The main objective of JSY is to reduce the maternal mortality ratio (MMR) & infant mortality rate (IMR) and to increase institutional deliveries. The JSY has identified ASHA, as an effective link between the government health institutions & the poor pregnant women. The success of scheme would be determined by increase in institutional deliveries among the poor families.

Each beneficiary registered under this Yojana generally have a JSY card along with a MCH card. ASHA/AWW/ any other identified link worker under the overall supervision of the ANM & the MO PHC should mandatory prepare a micro-birth plan. This will effectively help in monitoring antenatal check- up & the post-delivery care.

Eligibility for financial assistance in Low Performing states (LPS) –

All pregnant women delivering in government health facility like Sub-center, PHC, CHC/FRU, Sub-divisional, district & state hospitals and municipal hospitals & accredited hospitals.

Eligibility for Financial assistance in high performing states (HPS) –

Below poverty line women & the SC/ST pregnant women delivering in government health facility or accredited private institutions, only up to two live births.

Financial Assistance for institutional delivery –

• Low performing States –

1. Rural Area (Total package of INR 2000/-) – Mother – 1400/-; ASHA – 600/-.
2. Urban Areas (Total Package of INR 1400/-) – Mother – 1000/-; ASHA – 400/-.

• High Performing States –

1. Rural Areas (Total package of INR 1300/-) – Mother – 700/-; ASHA – 600/-.
2. Urban Areas (Total Package of INR 1000/-) – Mother – 600/-; ASHA – 400/-.

The Yojana subsidizes the cost of Caesarean section & for management of obstetric complications, up to INR 1500/- per delivery to the government institutions, where government specialists are not in position. Payment under the JSY are being made through Direct Benefit Transfer Mode.

If the mother or her husband, of their own will, undergoes sterilization, immediately after the delivery of child, compensation money available under the existing family welfare scheme would also be disbursed to the mother in her bank account.

JANANI SHISHU SURAKSHA KARYAKRAM (JSSK)

Reducing the maternal & infant mortality is a key goal of Reproductive & Child Health Program under the National Health Mission (NHM). Janani Suraksha Yojana (JSY) has helped government in increasing the institutional deliveries across the nation. However, even though institutional delivery has increased significantly, out of pocket expenses being incurred by pregnant women and their families are significantly high. This often acts as a major barrier for the pregnant women who still deliver at home as well as sick infants who die on account of poor access to health facilities.

Janani Shishu Suraksha Karyakram (JSSK) was launched on 1^st June 2011 and aimed to assure free services to all pregnant women and sick infants accessing public health facilities. The scheme envisages free and cashless services to pregnant women including normal delivery and caesarean section operations and also treatment of sick infants up to one year of age in all government health facilities across the nation.

The initiative was estimated to benefit more than one crore pregnant women and infants that access public health facilities every year in both urban and rural areas and also increased access to health care for the over 70 lakh women delivering at home.

Entitlements for Pregnant women –

• Free & zero expense delivery & caesarean section
• Free diagnostics & consumables
• Free essential diagnostics (Blood, urine test & USG etc.)
• Free diet during stay in the health facility (Up to 3 days for normal delivery & 7 days for Caesarean section)
• Free provision of blood
• Free transport from home to health facility
• Free transport between facilities in case of referral.
• Drop back from health facility to home after 48 hours
• Exemption from all type of user charges

Entitlements of Sick Infants –

• Free & zero expense treatment
• Free diagnostics & consumables
• Free essential diagnostics
• Free provision of blood
• Free transport from home to health facility
• Free transport between facilities in case of referral.
• Drop back from health facility to home after 48 hours
• Exemption from all type of user charges

LAQSHYA PROGRAM

Ministry of Health & Family Welfare (MOHFW) launched LaQshya program to improve quality of care in Labour room & maternity OTs in public health facilities in 2017. The LaQshya program is evidence based approach to improve quality of maternal & newborn care, particularly during intrapartum & immediate postpartum periods, which are the most vulnerable periods for a woman and contribute a significant proportion of maternal and newborn deaths.

Goal – Reduce preventable maternal & newborn mortality, morbidity & still births associated with care around delivery in Labour room & maternity OT end ensure Respectful Maternity Care (RMC).

Objectives –

• To reduce maternal & newborn mortality & morbidity due to APH, PPH, retained placenta, preterm, pre-eclampsia & eclampsia, obstructed Labour, puerperal sepsis, newborn asphyxia and sepsis etc.
• To improve quality of care during the delivery and immediate postpartum care, stabilization of complications & ensure timely referrals, and enable an effective two way follow-up system.
• To enhance satisfaction of beneficiaries visiting the health facilities & provide Respectful Maternity Care (RMC) to all pregnant women attending the public health facilities.

Its implementation involves improving infrastructure upgradation, ensuring availability of essential equipment, providing adequate human resources, capacity building of health care workers and adherence to clinical guidelines and improving quality processes in Labour room & maternity OT of DH, SDH, CHC (High case load) FRUs & Medical colleges.

In the beginning of program in various states, a baseline assessment of Labour room & Operation Theatre was conducted and plan for filling the gaps were identified. Six rapid improvement cycles of the two months each were conducted as per guidelines and were rigorously supervised & ensured to bring about the desired rapid improvement in next 18 months. Reward & recognition were incorporated in LaQshya to motivate, inspire & encourage stakeholders at each level.

Around 441 Labour rooms & 392 maternity OTs have achieved state quality certification. National certification for LaQshya has been achieved by 152 Labour Rooms & 127 maternity Operation theatres (OTs) till October 2019.

MISSION PARIVAR VIKAS (MPV)

Family planning is one of the most crucial interventions to address maternal & infant morbidities & mortalities. 146 districts with 3 or more total fertility rate (TFR) were identified from districts spanning over 7 high focus states (UP, Bihar, Rajasthan, MP, Chhattisgarh, Jharkhand & Assam). These districts were called High Fertility Districts (HFD). These districts constitute approximately 28% of India’s population and contribute to 30% of maternal deaths and almost 50% of infant deaths.

Considering this, the Government of India has conceived Mission Parivar Vikas with a stratified approach for substantially increasing the access to contraceptive and family planning services in these districts, which will also have a positive impact on the overall development parameters of these districts and consequently the states.

A five pronged strategy has, thus, developed which comprises –

• Delivering assured services
• Building additional capacity/ human resource development for enhanced service delivery
• Ensuring commodity security
• Implementing new promotional schemes
• Creating enabling environment

KEY STRATEGIC ACTION –

• Delivering assured services –
• Rollout of Injectable contraceptive DMPA (Antara) at one go till sub center level
• Augmentation of PPIUCD services
• Augmentation of sterilization services through HFD compensation scheme
• Condom boxes at strategic locations
• Social marketing of condoms & pills
• Mission Parivar Vikas Campaign (4/year)
• Promotional Schemes –
• NAYI PAHEL – a FP kit for newly weds
• Saas Bahu Sammelan
• SAARTHI – awareness on wheels
• Local radio spots with message from local actors
• Ensuring commodity Security –
• Logistics Management Information System (LMIS)
• A designated Family Planning logistic manager would be placed in all 7 High focus states
• Building additional capacity
• Creating enabling environment –
• Advocacy & Inter sectoral convergence to reduce TFR for a healthy mother & child.

NEWBORN CARE CORNER (NBCC)

NBCC is an earmarked space in the delivery room in any health facility where immediate care is provided to all newborns at birth. This area is mandatory for all health facilities where deliveries are conducted either in Labour room or maternity OT. Expanded services to be provided at Newborn care corner are –

• Care at birth –
• Prevention of infection
• Provision of warmth
• Resuscitation
• Early initiation of breast feeding
• Weighing the newborn
• Care of normal newborn –
• Breastfeeding/ feeding support
• Care of sick newborn –
• Identification & prompt referral of at risk & sick newborn

NBCC is earmarked in an area about 20-30 square feet in size within the labour room of all the facilities. For FRU & DH, NBCC is also set up in maternity OTs where C-section are conducted. All NBCCs are equipped with radiant warmer & resuscitation kits.

One doctor & one Staff nurse should be designated to NBCC to ensure appropriate functioning of the corner. All doctors & nurses who are likely to attend deliveries must be trained in NSSK. If NBCC is established at sub center, then ANM must also receive NSSK training.

Ayushman Bharat Yojana

Ayushman Bharat Yojana was launched on 23 September 2018 by the Ministry of Health & Family Welfare. The program is part of the Indian government’s National Health Policy and is means-tested.

Ayushman Bharat Yojana has two components –

• Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB – PMJAY)
• Ayushman Bharat Health & Wellness Centers (AB- HWC)

AB- PMJAY, also referred as Ayushman Bharat National Health Protection Scheme (AB-NHPS), is a national public health insurance fund of the Government of India that aims to provide free access to health insurance coverage for low-income earners in the country. Roughly, the bottom 50% of the country’s population qualifies for this scheme.

People using the program access their own primary care services from a family doctor cum Community Health Officer (HWC). When any one needs additional care, then PM-JAY provides free secondary health care for those needing specialist treatment & tertiary health care for those requiring hospitalization.

AB- PMJAY is a centrally sponsored scheme and is jointly funded by the both union government & the states. By offering services to 50 Crore (500 million) people it is the world’s largest government sponsored health care program. AB – PMJAY is having a defined benefit cover of Rs 5 Lakh per family per year. The beneficiaries can avail benefits in both public & empanelled private facilities. Covers up to 3 days of pre-hospitalization & 15 days of post hospitalization expenses. PM-JAY provides cashless assess to health care services.

AB – PMJAY will subsume the ongoing centrally sponsored schemes – Rashtriya Swasthya Bima Yojana (RSBY) & the Senior Citizen Health Insurance Scheme (SCHIS). National Health Authority (NHA) administers the program at central level.

AB- HWC is an attempt to move from a selective approach to health care to deliver comprehensive range of services spanning preventive, promotive, curative, rehabilitative and palliative care. Government of India aims to establish 1,50,000 health and wellness centres (HWCs), under the leadership of Community Health Officer (CHO), to deliver comprehensive primary health care, that is universal and free to focus, with a focus on wellness and the delivery of expanded range of services closer to the community.

COMPREHENSIVE PRIMARY HEALTH CARE – ESSENTIAL PACKAGE OF SERVICES – Provided by HWC –

• Care in pregnancy & child birth
• Neonatal & Infant Health care services
• Childhood & Adolescent Health Care services
• Family planning, Contraceptive services & other reproductive health care services
• Management of Communicable diseases: National Health Programs
• General out-patient care for acute simple illnesses & minor ailments
• Screening, Prevention, Control & Management of Non-Communicable diseases
• Care for 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

Suggested further Reading:

• Park; Park’s textbook of Preventive & Social Medicine, 26^th edition, 2021
• WHO; Nutrition, Trans fats; questions & answers; who.int, 13 may 2018
• Bhalwar; textbook of Public health & Community Medicine, AFMC-WHO, 1^st edition, 2009
• Government of India; Anaemia Mukt Bharat Guidelines; Ministry of Health & Family Welfare, GoI, 2018
• AH Suryakantha; Community Medicine with Recent Advances, 3^rd
• Mahajan & Gupta; Textbook of Preventive & Social Medicine; 4^th edition
• Government of India; LaQshya, labour room quality improvement initiative; National Health Mission, Ministry of Health & Family welfare, GoI, 2017
• Government of India; Surakshit Matritva Aashwasan (SUMAN); Ministry of Health & Family Welfare, GoI, November 2019.
• Government of India; Facility based newborn care operation guide; Ministry of Health & family welfare, GoI, 2011
• Government of India; operational guideline for implementation of JSY; Ministry of Health & Family welfare, GoI, 2005
• Government of India; Guidelines for Janani Shishu Suraksha Program (JSSK); MH division, Ministry of Health & family welfare, GoI, June 2011.
• Government of India; Home based newborn care operational guideline; Ministry of Health & family welfare, GoI, 2011.