PART I

CLINICO SOCIAL CASE STUDY

(HOSPITAL)

1. Model Pro Forma

2. Mother and Child Health
3. Communicable Diseases
4. Non-communicable Diseases
 Chapte
r Model Pro Forma

This pro forma can be used for all cases with relevant modifications.

PART I - GENERAL INFORMATION

Name and address of the patient: Ward No: Unit:
IP/OP No:
Date of Admission:
Mode of admission: Self/Referral

Telephone No:

INDIVIDUAL PROFILE
Age: Education:
Sex: Occupation:
Religion: Income:
Caste: Languages known:
Habitation: Urban/Rural/Urban slum
H/o Migration:Yes/No Details (if migrated):

Blood group:
Drug sensitivity:
Sero positivity:

Marital Status
Married/Unmarried:
Number of living children: M ,F

Immunization Status (if relevant)

Important Health Events
Long hospital stay: Regular medications with details:
Operations: Addiction to drugs:
Blood transfusion: Suicide attempt:
4 Part I: Clinico Social Case Study
(Hospital)
Chronic diseases/Health distortion: Poisoning:
Injuries/Burns/Accidents: Others:

Personal Hygiene
Clothes: Oral hygiene:
Hair: Nails:
Bath/Hand wash: Foot wear usage:

Lifestyle
Diet: Veg/ Non-veg/ Mixed
Food habit: Regular/Irregular
Physical activity:
Other habits: Alcohol/Smoking/Tobacco chewing
Sexuality (as relevant):

Social Relationship
1. With family members
2. With society
3. Family members with patient

FAMILY PROFILE
Family Structure
Age (in completed years) Number Total
Male Female
< 1 yr
(Infants) 1–5
yr
6–15 yr
16–64 yr
> 65 yr

Family Composition
Family type: Nuclear/Joint/Three generation Total members:
Sl No Name Age in Sex Marital Education Occupation Income Medico so-
years status cial status *
 Model Pro Forma 5

Total family income

Per capita monthly income =
Number of members

Socioeconomic Class
(According to modified BG Prasad classification )

Medico Social Status

Infant Leprosy Disability
Children under 5 yr HIV/STD Mental retardation
Pregnancy Cancer Psychiatric problems
Lactation Diabetes Alcohol addiction
Old age BP/Cardiac Problem Social evils

Living Conditions (Housing)

House is a dwelling structure used by man for settlement, which provides physical, mental and social health needs of an indi-
vidual and of the family.
Sl No Housing standards Score: 1 for Satisfactory criteria
0 for Poor criteria
1. Construction: Locality, Safety, Protection
2. Space: Spatial sufficiency to prevent over crowding
3. Light and Ventilation
4. Water: Adequacy, accessibility and safe storage of water
5. Sanitation: Washing, bathing, toilet facilities,
sanitary disposal of kitchen waste, garbage and excreta.
6. Kitchen: Facilities for hygienic cooking and storage of food,
smoke outlet
7. Environment Disturbances: Noise, air pollution, weather
inclemency toxic fumes, dust, odor, moisture, open drain, etc.
Vector like fly, mosquito, rodent and other nuisance.
8. Animals: Pet, cattle, poultry keeping
9. Cleanliness of persons and premises
10. Connectivity: Road, transportation, communication, schools,
hospital cultural, social, recreational, fire, police, etc.
Assessment of living condition: Score: 6–10 Satisfactory, 0–5 Poor

Vital Events in the Family

Birth:
Adoption:
Marriage/Divorce:
Death with cause:

Social Status of the Family

Education:
Occupation:
Living condition:
Social relationship:
Socioeconomic status:
6 Part I: Clinico Social Case Study
(Hospital)
Social condition assessment: Satisfactory/Poor
Nutritional Intake of the Family

Food items Intake of the family (gm) RDA for the family (gm) Remarks/Inference
Cereals
Pulses
Green leafy vegetables
Roots and tubers
Other vegetables
Fruits
Oil
Sugar and Jaggery
Milk
Meat/Fish
Coefficient Unit (CU) required by the family:
Health Status of the Family (in brief)
Physical health:
Mental health:
Social health:
Spiritual health:

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

History of Present Illness
Chief complaints Onset Duration Description of symptoms
(in chronological order) (sudden/gradual)

1.
2.
3.
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:

Diet history (as relevant)

Epidemiological History For Communicable Diseases
Any similar case in the family: Yes/No
Any similar case in neighborhood:
Yes/No Any contact with similar case:
Yes/No
Existence of similar disease in the locality/district:
Other relevant information:
 Model Pro Forma 7

Family (Hereditary) History For Non-communicable Diseases

Non-communicable disease: Present/Absent
If yes, specify:
Genetic background of non-communicable disease: Present/Absent
If yes, specify:
Degree of relationship:
Existence of similar disease in the locality:

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Epidemiological Diagnosis
Lab Investigations
Sl No Examinations required Report
1.
2.
3.
4.

Clinical Diagnosis

Criteria for

1. Diagnosis:

2. Classification:
8 Part I: Clinico Social Case Study
(Hospital)

MEDICO SOCIAL DISCUSSION

Identification of the factors responsible for/influencing the present condition

Agent factors Host factors

Biological Age
Nutritiona Sex
l Physical Ethnicit
Chemical y
Mechanic Migration
al Others Inheritanc
e
Nutrition
Immunity
Others
Environmental factors Social factors
(Physical, Biological, Psychosocial) Economic conditions
Poor housing Sociocultural practices/Superstitions
Lack of potable water supply Prejudice/Taboos/Stigma
Improper sanitation Religious practices
Flies and pests nuisance Lack of education
Occupational environment Unemployment
Stress Incorrect knowledge, attitude and practice
Bad personal hygiene
Malnutrition
Habit and lifestyle
Non-availability and utilization of health services

Risk Factors for Non-communicable Diseases (modifiable)

Smoking: Alcohol:
Tobacco use: Obesity:
Lack of activity/Lifestyle: Hormones:
Personality: Use of oral pill:
Miscellaneous:

Levels of prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation
 Model Pro Forma 9

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice

(beliefs and customs)
Cause
Treatment
Prevention
Health
services
Others

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of
Family:
Community:
Nation:

Medico Social Diagnosis

MANAGEMENT
General and Specific Measures
Treatment Plan

1. Case:

2. Contact/Carrier (as relevant):

3. Other Family Member (as relevant):

National Health Programme Regarding the Disease

Recent Advances/Modifications in Medico Social Management of the Condition

ADVICE
(Preventive, Promotive and Curative)
Patient

Family

Community
 SECTION I

CLINICO SOCIAL CASE STUDY

(HOSPITAL)

1. Model Pro Forma

2. Mother and Child Health
Antenatal Care
Postnatal Care
Undernutrition (PEM/Marasmus)

3. Communicable Diseases
Typhoid
Diarrhea
 Hepatitis-
A
Tuberculo
sis
Leprosy
Hepatitis-
B
Sexually Transmitted Disease

4. Non-communicable Diseases
Diabetes
Mellitus
Hypertension
 Chapte
r Model Pro Forma

This pro forma can be used for all cases with relevant modifications.

PART I - GENERAL INFORMATION

Name and address of the patient: Ward No: Unit:
IP/OP No:
Date of Admission:
Mode of admission: Self/Referral

Telephone No:

INDIVIDUAL PROFILE
Age: Education:
Sex: Occupation:
Religion: Income:
Caste: Languages known:
Habitation: Urban/Rural/Urban slum
H/o Migration: Yes/No Details (if migrated):

Blood group:
Drug sensitivity:
Sero positivity:

Marital Status
Married/Unmarried:
Number of living children: M ,F

Immunization Status (if relevant)

4 Section I: Clinico Social Case Study
(Hospital)
Important Health Events
Long hospital stay: Regular medications with details:
Operations: Addiction to drugs:
Blood transfusion: Suicide attempt:
Chronic diseases/Health distortion: Poisoning:
Injuries/Burns/Accidents: Others:

Personal Hygiene
Clothes: Oral hygiene:
Hair: Nails:
Bath/Hand wash: Foot wear usage:

Lifestyle
Diet: Veg/Non-veg/Mixed
Food habit: Regular/Irregular
Physical activity:
Other habits: Alcohol/Smoking/Tobacco chewing
Sexuality (as relevant):

Social Relationship
1. With family members
2. With society
3. Family members with patient

FAMILY PROFILE
Family Structure
Age (in completed years) Number Total
Male Female
< 1 yr
(Infants) 1–5
yr
6–15 yr
16–64 yr
> 65 yr

Family Composition
Family type: Nuclear/Joint/Three generation Total members:
Sl No Name Age in Sex Marital Education Occupation Income Medico
years status social status*
 Model Pro Forma 5

Total family income

Per capita monthly income =
Number of members

Socioeconomic Class
(According to modified BG Prasad classification )

Medico Social Status

Infant Leprosy Disability
Children under 5 yr HIV/STD Mental retardation
Pregnancy Cancer Psychiatric problems
Lactation Diabetes Alcohol addiction
Old age BP/Cardiac problem Social evils

Living Conditions (Housing)

House is a dwelling structure used by man for settlement, which provides physical, mental and social health needs
of an individual and of the family.
Sl No Housing standards Score: 1 for Satisfactory criteria
0 for Poor criteria
1. Construction: Locality, Safety, Protection
2. Space: Spatial sufficiency to prevent overcrowding
3. Light and Ventilation
4. Water: Adequacy, accessibility and safe storage of water
5. Sanitation: Washing, bathing, toilet facilities,
sanitary disposal of kitchen waste, garbage and excreta.
6. Kitchen: Facilities for hygienic cooking and storage of food,
smoke outlet
7. Environment Disturbances: Noise, air pollution, weather
inclemency toxic fumes, dust, odor, moisture, open drain, etc.
Vector like fly, mosquito, rodent and other nuisance.
8. Animals: Pet, cattle, poultry keeping
9. Cleanliness of persons and premises
10. Connectivity: Road, transportation, communication, schools,
hospital
cultural, social, recreational, fire, police, etc.
Assessment of living condition: Score: 6–10 Satisfactory, 0–5 Poor

Vital Events in the Family

Birth:
Adoption:
Marriage/Divorce:
Death with cause:

Social Status of the Family

Education:
Occupation:
Living condition:
6 Section I: Clinico Social Case Study
(Hospital)
Social relationship:
Socioeconomic status:
Social condition assessment: Satisfactory/Poor

Nutritional Intake of the Family

Food items Intake of the family (gm) RDA for the family (gm) Remarks/Inference
Cereals
Pulses
Green leafy vegetables
Roots and tubers
Other vegetables
Fruits
Oil
Sugar and Jaggery
Milk
Meat/Fish
Coefficient Unit (CU) required by the family:

Health Status of the Family (in brief)

Physical health:
Mental health:
Social health:
Spiritual health:

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

History of Present Illness
Chief complaints Onset Duration Description of symptoms
(in chronological order) (sudden/gradual)

1.
2.
3.
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:

Diet history (as relevant)

Epidemiological History For Communicable Diseases
Any similar case in the family: Yes/No
Any similar case in neighborhood:
Yes/No
 Model Pro Forma 7

Any contact with similar case: Yes/No

Existence of similar disease in the locality/district:
Other relevant information:

Family (Hereditary) History For Non-communicable Diseases

Non-communicable disease: Present/Absent
If yes, specify:
Genetic background of non-communicable disease: Present/Absent
If yes, specify:
Degree of relationship:
Existence of similar disease in the locality:

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1.
2.
3.
4.

Criteria
Clinicalfor
Diagnosis
1. Diagnosis:

2. Classification:
8 Section I: Clinico Social Case Study
(Hospital)

MEDICO SOCIAL DISCUSSION

Identification of the Factors Responsible for/Influencing the Present Condition

Agent factors Host factors

Biological Age
Nutritiona Sex
l Physical Ethnicit
Chemical y
Mechanic Migration
al Others Inheritanc
e
Nutrition
Immunity
Others
Environmental factors Social factors
(Physical, Biological, Psychosocial) Economic conditions
Poor housing Sociocultural practices/Superstitions
Lack of potable water supply Prejudice/Taboos/Stigma
Improper sanitation Religious practices
Flies and pests nuisance Lack of education
Occupational environment Unemployment
Stress Incorrect knowledge, attitude and practice
Bad personal hygiene
Malnutrition
Habit and lifestyle
Non-availability and utilization of health services

Risk Factors for Non-communicable Diseases (modifiable)

Smoking: Alcohol:
Tobacco usage: Obesity:
Lack of activity/Lifestyle: Hormones:
Personality: Use of oral pill:
Miscellaneous:

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation
 Model Pro Forma 9

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice

(beliefs and customs)
Cause
Treatment
Prevention
Health
services
Others

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of
Family:
Community:
Nation:

Medico Social Diagnosis MANAGEMENT

General and Specific Measures
Treatment Plan

1. Case:

2. Contact/Carrier (as relevant):

3. Other Family Member (as relevant):

National Health Programme Regarding the Disease

Recent Advances/Modifications in Medico Social Management of the Condition

ADVICE
(Preventive, Promotive and Curative)
Patient

Family

Community

Review Questions
 Comment on the model pro forma
 What have you understood regarding
Epidemiological diagnosis
Clinical diagnosis
Medico social diagnosis
 Chapte
r Mother and
Child Health
2

ANTENATAL CARE
Antenatal Care is the care from the date that pregnancy is confirmed to the onset of true labor pain.

GENERAL INFORMATION
Name of the mother: Ward No: Unit:
Husband’s name and Address: IP/OP No:
Date of Admission:
Mode of admission: Self/Referral

Telephone No:
Age: Education:
Religion: Occupation: Homemaker/Employed
Locality: Urban/ Rural/ Urban slum Income:
Reason for admission: Safe delivery/Antenatal problems/Others
Place opted for delivery: Home/Hospital/Not decided
Willingness for family planning: Yes/No/Not
decided Family planning methods adopted earlier:

FAMILY PROFILE
Type of family:
Total members:
Social conditions:
Economical status:
Educational status:
Occupational status:
Living environment:
 Mother and Child Health
11
PART II - MEDICAL (CLINICAL) DETAILS AND EXAMINATION
Chief Complaints—Antenatal Symptoms

First trimester Second trimester Third trimester

Vomiting Palpitation
Fever Giddiness/Fatigue
Fatigability Edema
Others

Maternity Information
Age at menarche: Menstrual history:

Obstetric History
Age at marriage: Duration of married life:
Age at first pregnancy: Interval between previous and present pregnancy:
Last menstrual period: Expected date of delivery:
Gravidity: Parity: Abortion: Living issues:

Gynecological History
Any relevant history:

Medical and Surgical History (as relevant)

Fever with rash:
TORCH infection:
HIV/STD:
Diabetes/Hypertension:
Any other Surgical/Medical problems:
History of drug intake:
History of drug reaction:

H/O Previous Pregnancies

Pregnancies (in chronological order)

Particulars
1st 2nd 3rd 4th
Age of women during
pregnancy Duration of
gestation
Spacing duration
Place of delivery:
Hospital/Home Nature of
delivery:
Person conducted delivery
Outcome: Abortion /Premature/Full term
If death of any child, mention – Age, Sex and cause of
death
Age and Sex of living child
12 Part I: Clinico Social Case Study
(Hospital)
Genetic History
Family History Mother Father
Diabetes
Hypertension
Twin (multiple) pregnancy
Congenital anomalies
Any other

Personal History
• Diet: Veg/Non-veg/Mixed
• Food habit: Regular/Irregular
• Appetite: Normal/Decreased/Increased
• Sleep: Normal/Disturbed
• Bladder and Bowel habit: Regular/Irregular
• Physical activity: Sedentary/Moderate/Heavy
• Other habits: Alcohol/Smoking/Tobacco chewing
• Weight: Normal/Decreased/Increased
• Medicine/Drugs being used, specify:

General Physical Examination

Built: Anemia:
Height: Jaundice:
Weight: Clubbing:
Nutritional status: Cyanosis:
Pulse: Lymphadenopathy:
Blood pressure: Edema:
Temperature: Oral hygiene:
Respiration rate: Thyroid swelling:
Psychological status: Breasts:
Varicose veins:

Obstetric Examination
Inspection: Linea nigra
Striae gravidarum
Scars
Umbilicus
Palpation: Abdominal girth
Height of uterus (fundal height)
Fundal grip
Lateral grip
1st pelvic grip
2nd pelvic grip

Auscultation: Fetal heart sound

(Fetal heart sound heard after 20 weeks, 120–140 beats/minute is normal)
 Mother and Child Health
13
Important clinical findings:
1.
2.

Systemic Examination
RS:
CNS:
CVS:
GIT:

Dietary Assessment
Food items Actual intake per day (gm) Intake recommended per Assessment
day (gm)* Excess/Deficiency
Cereals 445
Pulses 55
Leafy vegetables 100
Other vegetables 40
Roots 50
Milk 200
Oil/Fat 20
Sugar 30
*Recommended intake given here is for sedentary pregnant women

Antenatal Visits and Checkup

Particulars 1st trimester 2nd trimester 3rd trimester
Number of visit
Objective of the visit
Weeks of pregnancy
Checkup by: Doctor/Health
worker
Findings:
•Height
•Weight
•BP
•Edema
•Fundal height
• Abdominal girth
•Position and presentation
•Hb%
•Urine
Nutritional supplements
Treatment
Health advice/education given
Immunization against tetanus: Received/Not received
Details about Tetanus Toxoid (TT) doses: 1st dose week of pregnancy, 2nd dose week of pregnancy
If TT is not taken, reasons:
14 Part I: Clinico Social Case Study
(Hospital)
Iron folic acid supplementation
Iron: mg, Folic acid: mg, Number of days:
If Iron folic acid (IFA) is not taken, reasons:

Specific Health Protection

Particulars Needed Obtained
Anemia
Toxemias
Tetanus
Syphilis
German measles
Rh status
HIV

High Risk Assessment

Elderly primary (> 30 years) • Previous birth > 4000 gm twins/hydramnios
Short stature (< 140 cm) • Recent still birth, IU death, Placenta removal
• Other bad obstetric history
Malpresentations • Elderly nullipara
• Recent neonatal death
Antepartum hemorrhage • Prolonged pregnancy > 14 days from EDD
• Contracted pelvis
Preeclampsia/Eclampsia • History of — Previous cesarean section
— Previous preeclampsia
Previous difficult delivery • Disease—Renal/Liver, TB, HIV, etc.
• Precious pregnancy: Conceived after long sterility
• Low socioeconomic status
• Unwed pregnant women
Need of referral services: Yes/No If yes, why

Lab Investigations
Sl No Examinations required Trimester and Report
1. Hb%
2. Urine— Albumin
Sugar
Microscop
3. y
4. Stool examination
5. Blood grouping and Rh
6. factor TC/DC/Complete
7. hemogram Serological
8. tests
9. Cervical smear— PAP
10. test Gonococci culture
11. STD/HIV/Others
Radiology— Chest X-ray/Ultrasonography
Others
 Mother and Child Health
15
Clinical Diagnosis

MEDICO SOCIAL DISCUSSION

Identification of the Adverse Factors Present in the Mother

Medical Factors:

Social Factors:

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Knowledge, Attitude and Practice (KAP) Regarding Pregnancy

Particulars Knowledge Attitude Practice Practices in earlier
(Beliefs and customs) pregnancy
Food taboos
Food requirement
Place of delivery
Family planning
Growth monitoring
Oral rehydration
Breast feeding
Immunization
KAP of husband is also assessed

MEDICO SOCIAL DIAGNOSIS

Socioeconomic Impact of Pregnancy on

Family:

Community:

Nation:

National Programme for “Antenatal Care”

Any Recent Developments/Modifications in “Antenatal Care”

16 Part I: Clinico Social Case Study
(Hospital)
ADVICE
Mother
Health promotion:
Diet Personal hygiene
Drugs/Radiation Child care
Self care Breast feeding
Family planning Anxiety reduction
Mental preparation Anganwadi attending
Using under 5 clinic Using social
benefits Registration of birth
Specific Protection:
Tetanus toxoid: 1st 12–20 weeks
2nd 30–36 weeks
Iron folic acid tab: 100 tablets
Early Diagnosis:
Warning sign/Foresee complications: Swelling of feet, fits, headache, blurring of vision/
Bleeding or discharge per vagina
Any other unusual symptoms.

Family

Community
Postnatal care is the care of the mother and newborn soon after delivery till the end of puerperium, i.e. six weeks after deliv-
ery.
 Mother and Child Health
17

POSTNATAL CARE

GENERAL INFORMATION
Name of the mother: Ward No: Unit:
Husband’s name and address: IP/OP No:
Date of Admission:
Mode of admission: Self/Referral

Telephone No:
Age: Education:
Religion: Occupation: Housewife/Employed
Locality: Urban/Rural/Urban slum Income:
Reason for admission: For delivery/Postnatal problems/Others
Place of delivery: Home/Hospital
Willingness for family planning: Yes/No/Not
decided Family planning methods adopted earlier:

FAMILY PROFILE
Type of family:
Total members:
Social conditions:
Economical status:
Educational status:
Occupational status:
Living environment:

MEDICAL (CLINICAL) DETAILS AND

EXAMINATION
History of Present Illness
Chief complaints (in chronological order) Description of symptoms
Bleeding per vagina (P/V)
Primary/Secondary/Reactio
nary White discharge
Pain and tenderness in
abdomen Fever
Tender leg/Swollen
leg Burning
micturition Breast
pain/Swelling Breast
feeding problems
Any other

Antenatal Resume
Antenatal care: Taken/Not taken
18 Part I: Clinico Social Case Study
(Hospital)
Iron folic acid tab: Taken/Not
taken Tetanus toxoid: Taken/Not
taken Antenatal problems:

Parturient Resume (Intranatal)

Delivery:
Date , Time , Duration
Sex of baby: Male/Female
Nature: Normal/Instrumental/Cesarean
Mode of delivery: Induced/Elective/Emergency
Place of delivery: Home/Hospital
If home delivery, conducted by: Doctor/Trained Dai/Untrained personnel
Delivery kit: Used/Not used

Intranatal Problems
• Abdomen girth > 1 meter • Blood loss > 240 ml
• No pain— No progress • Late expulsion of placenta
• Rupture and leakage of membrane > 24 hrs • Perineal tear
• Meconium stained liquor • Collapse
• Malpresentation/Prolapse of cord or hand • Temperature > 35°C

Neonatal Resume
Birth weight: Cry after birth:
Birth length: Body temperature:
Birth injury: Skin color:
Congenital defect: Cyanosis, difficulty in breathing:
Imperforate anus: Vomiting:
Convulsion— Neck rigidity:
Difficulty in feeding:
Bulging of anterior fontanel:

Perinatal Care
Baby care:
Cleaning of skin
Cleaning of eyes
Cleaning the airways
Cord care: Instruments used for cutting, Ligature used, Cord stump
APGAR score: 0–3 depressed
4–6 moderate
7–10 Normal
Use of oxygen mask:
If child is dead: Age , Sex , Cause
Birth registration: Done/Not done
Family and social support: Good/Satisfactory/Nil
Rooming in: Satisfactory/Unsatisfactory
 Mother and Child Health
19
Personal History
Diet: Veg/Non-veg/Mixed
Food habit: Regular/Irregular
Appetite: Normal/Decreased/Increased
Sleep: Normal/Disturbed
Bladder and Bowel: Regular/Irregular
Physical activity: Nil/Moderate/Good
Other habits: Alcohol/Smoking/Tobacco chewing
Weight: Normal/Decreased/Increased
Medicine/Drugs being used:
Fever with rash:
HIV/STD:
Any other surgical/medical problems:

Previous Postnatal Examinations

Time of examination Not done Done Findings
Soon after delivery
First 3 days— Twice daily
3rd to 7th day— Daily

General Physical Examination

Built: Anemia:
Weight: Jaundice:
Height: Cyanosis:
Nutritional status: Clubbing:
Pulse: Lymphadenopathy:
Blood pressure: Edema:
Respiratory rate: Oral hygiene:
Temperature: Thyroid swelling:
Breasts: Varicose veins:
Psychological condition (Postpartum psychosis):

Obstetric Examination
Uterus (Fundus): Subinvolution/Non-retroverted/Prolapse
Vulva:
Lochia Reddish (Rubra)/Pale red (Serosa)/White (Alba)
Perineum:

Systemic Examination
RS:

CNS:

CVS:

GIT:
20 Part I: Clinico Social Case Study
(Hospital)
Examination of Baby
Body proportion and size: Head:
General condition: Skin:
Umbilical cord: Temperature:
Engorgement of breast: CVS:
Reflex: RS:
Cyanosis: Abdomen:
Jaundice: Limbs:
Cephalohematoma: Spine:
Congenital anomalies: Genitalia:
BCG given: Rectum:
Bladder and bowel: Feeding:
Infections:

Assessment of Postnatal Complications

Puerperal sepsis (up to 3 weeks of delivery):
Thrombophlebitis
Secondary hemorrhage (6 hours after delivery to 6 weeks):
Mastitis
Urinary tract infection

Dietary Assessment
Food items Actual intake per day Intake recommended per day Assessment
(gm) (gm)* Excess/Deficiency
Cereals 470
Pulses 70
Leafy vegetables 100
Other vegetables 40
Roots 50
Milk 200
Oil/Fat 30
Sugar 30
*Recommended dose given here is for sedentary lactating women

Lab Investigations
Sl No Examinations required Report
1.
2.
3.
 Mother and Child Health
21
Clinical Diagnosis

MEDICO SOCIAL DISCUSSION

Identification of Medico Social Factors Present in Mother and Baby

Medical Factors
Mother Baby
Unhygienic delivery Low birth weight < 2.5 kg
Complications of delivery Twins
Infection Artificial feeding
Septicemia Neonatal tetanus
Postpartum psychosis TORCH infections
Blood loss, severe anemia Birth injury
Medical conditions: Congenital anomalies
Hypertension
Diabetes HIV mother
Tuberculosis Respiratory and GI infections
Cardiac Tetanus
Renal Others
Malignancy

Social Factors
Early age at child birth Prejudice
Too close pregnancies Customs
Poverty Lack of antenatal, intranatal and postnatal care
Malnutrition Parity - Primi > 5 Grand multi
Illiteracy
Ignorance
Working mother

Levels of prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation
22 Part I: Clinico Social Case Study
(Hospital)
Knowledge, Attitude and Practice (KAP) Regarding Postnatal Period
Particulars Knowledge Attitude Practice Practices in earlier
(beliefs and customs) puerperium
Food taboo
Food requirement
Personal hygiene
Family planning
Growth monitoring
Oral rehydration
Breast feeding
Immunization
Postnatal services
KAP of husband is also assessed

Socioeconomic impact of pregnancy on

Family:

Community:

Nation:

Medico Social Diagnosis

National programme for PNC

Any recent developments/Modifications in PNC

ADVICE
Mother

Family

Community

Family Planning Details

Particulars Husband Wife
Family planning used previously
Method advised now
Reasons for advising particular method
Time of IUD insertion
Problems/complaints, If any
Willingness to undergo—
Tubectomy
— Vasectomy

Protein-Energy Malnutrition (PEM)

Marasmus is one of the consequences of PEM.
 Mother and Child Health
23

MALNUTRITION

GENERAL INFORMATION
Name of the child: Ward No: Unit:
Age: Sex: IP/OP No:
Mother’s name: Date of Admission:
Mode of admission: Self/Referral

Telephone No:

FAMILY PROFILE
Type of family: Total members:
Habitation: Urban/Rural/Urban Slum
H/o Migration: Yes/No if migrated, details:
Religion/Caste:
Educational status: Father Mother
Occupation: Father Mother
Income: Father Mother
Socioeconomic status of the family:
(According to modified BG Prasad classification)
Living condition: Satisfactory/Poor

MEDICAL (CLINICAL) DETAILS AND EXAMINATION

History of Present Illness
Chief Complaints Details
(in chronological order)
Growth failure
Emaciated
Edema
Not taking food
Distressed/Pathetic
Distended abdomen
Diarrhea
Fever
Excess cry, irritable
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
Previous history of same/similar illness:
Previous hospitalization for the same illness:
24 Part I: Clinico Social Case Study
(Hospital)
Past history (as relevant)
Birth weight:
Birth order:
Breast feeding and weaning practices:
Milestones:
Immunization:
History of infection like diarrhea, TB, measles, etc.:

Epidemiological History
Any similar case in the family: Yes/No
Any similar case in neighborhood: Yes/No
Existence of similar condition in the locality/district:
Other relevant information:

Examination of Relevant System

Head to Toe Examination:

Stature :
Built : Normal/Short
Appearance : Normal/Sick/Cachexia
Hair : Normal/Lusterless/Depigmented/Sparse/Easily pluckable/Flag sign
Face : Moon face/Hallowing of cheeks/Pointed chin/Prominent bones/Depigmentation/
Seborrhea around the nose
Eyes : Bitot’s spots/Dry/Sunken
Lips : Cheilosis/Angular stomatitis
Tongue : Pale/Red magenta
Nails : Koilonychia
Skin : Wrinkled/Peeling skin/Flaky paint like
patches Subcutaneous tissue : Maintained/Emaciated
Muscles : Normal/Wasting
Chest : Prominence of ribs
Abdomen : Distended/Flat emaciated/Ascites/Enlarged
liver Leg : Edema on dorsum of feet and leg
Hips : Normal/Loss of shape due to loss of fats
Alertness : Dull/Disinterested/Stays in same position for long time/Irritable/Crying excessively fretful

Anthropometric Examination
Weight in kg:
Weight of the child
Weight for age % × 100
= Weight of normal child of same
age
 Mother and Child Health
25
Height in cm:
Measurements:
Head: Chest:
Mid arm:
Skin fold thickness:
Triceps: Biceps:
Suprailiac: Subscapular:

Epidemiological Diagnosis

Lab Investigations

Sl No Examinations required Report

1. Hb, Peripheral smear
2. Urine: Albumin, sugar, microscopy
3. Stool: Ova, Cyst, pH (Lactose intolerance)
4. PPD: For tuberculosis
5. Total serum protein
6. Total serum albumin
7. Plasma amino acid ratio
8. Blood: Urea/Creatinine
9. Hydroxyproline/Creatinine ratio

Clinical Diagnosis with Classification/Type

Criteria for Diagnosis and Classification

Percentage weight for age Edema Present Absent

80–60 Kwashiorkor Under nutrition
< 60 Marasmic Kwashiorkor Marasmus
Grading of malnutrition—Reference to weight for age (W/A): 50th percentile (median) weight of Harward standards (Interna-
tionally accepted)
Weight (in %) Grade
70–79.9 I
60–69.9 II According to Indian academy of
< 60 III pediatrics classification
< 50 IV
26 Part I: Clinico Social Case Study
(Hospital)
MEDICO SOCIAL DISCUSSION
Identification of Factors Influencing the Condition

Medical Social Environmental

Susceptibility: Poverty, poor living condition Natural calamities
Age— 1–5 years/toddler Maternal malnutrition Famine
Sex Maternal illness Unhygienic environment
Feeding: Broken family Advertisements of baby food
Breast feeding/prolong Alcoholic parents
Weaning: Early/Very late Parental negligence
Dilute, dirty milk Harmful practices (religious,
Less energy and protein food social, cultural)
Nutritional need: Taboos, cooking practice
Increased demand Unequal distribution
Excessive loss Starvation therapy
Infections: Poor food sanitation
Diarrhea Big families
Upper respiratory Social prejudices
Malaria Availability and utilization
of the services
Measles
Poor personal hygiene
Tuberculos
is
Worm infestation

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection
and prompt
treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Knowledge Attitude Practice
(beliefs and customs)
Growth
monitoring Oral
rehydration
Breast feeding
Immunization
Family planning
Food hygiene
Child feeding

Social factors involved in this condition

Cause:
 Mother and Child Health
27
Diagnosis:

Treatment:

Socioeconomic impact of this condition on

Child:

Family:

Community:

Medico Social Diagnosis

MANAGEMENT
Individual Level
Child is admitted to the nutritional rehabilitation center (if needed)
Treatment of underlying infections
Thorough examination of the child for precipitating factors
Diet therapy:
Diet requirements is calculated as per the expected weight
Giving more enriched food (oil, ghee, milk, egg, etc.)
4 gm/kg wt good quality of protein is given
200–300 Kcal/Kg wt energy is provided
Supplementation of vitamins and minerals, especially vitamin A and B.
Severe Cases:
Child is admitted to the hospital, intragastric feeding is given
Vigilance and meticulous management of
Dehydration
Hypothermia
Hypoglycemia
Dyselectrolytemia
Congestive cardiac failure

ADVICE
Health Promotion
Promotion of antenatal and postnatal care
Nutritional supplementation to mother and children
Promotion of breast feeding
Female literacy and empowerment
Food policy— Production, distribution, availability, low price, fortification
Poverty alleviation, socioeconomic developments, improving the living conditions
Increasing the food buying capacity by income generation activities
Controlling endemic infections— ARI, Diarrhea, TB
Protected water supply, Sanitary facilities
Primary health care
28 Part I: Clinico Social Case Study
(Hospital)
Food and personal hygiene
Oral rehydration
Breast feeding
Nutrition education to the Community

Specific Protection
Immunization
Energy and protein rich food to children (oil, ghee, egg, milk,
etc.) Nutritional education
National nutritional programmes
Using multipurpose food like Hyderabad mix, bala-ahar, Indian multipurpose food based on cereals, pulses, oil seeds,
sugar, fruits and vegetables (Idli vada, kichdi, kheer, payasam, dal-rice, roti-dal, etc.)

Early Diagnosis and Treatment

Nutritional surveillance
Growth monitoring
Supplementary feeding
Periodic worming
Hospital treatment
Follow up

Rehabilitation:
Nutritional rehabilitation center: Motivation of mother in feeding the child with home constraint food.

Review Questions
 Write briefly the National health programme oriented to prevent malnutrition.
 What are the recent advances/modifications in medico social management of the condition?
 List home available energy and protein rich foods.
 List the common beliefs and practices during malnutrition.
 Chapte
r Mother and
Child Health
2

ANTENATAL CARE
Antenatal care is the care from the date that pregnancy is confirmed to the onset of true labor pain.

GENERAL INFORMATION
Name of the mother: Ward No: Unit:
Husband’s name and Address: IP/OP No:
Date of Admission:
Mode of admission: Self/Referral

Telephone No:
Age: Education:
Religion: Occupation: Homemaker/Employed
Locality: Urban/Rural/Urban slum Income:
Reason for admission: Safe delivery/Antenatal problems/Others
Place opted for delivery: Home/Hospital/Not decided
Willingness for family planning: Yes/No/Not
decided Family planning methods adopted earlier:

FAMILY PROFILE
Type of family:
Total members:
Social conditions:
Economical status:
Educational status:
Occupational status:
Living environment:
 Mother and Child Health
11
MEDICAL (CLINICAL) DETAILS AND EXAMINATION
Chief Complaints—Antenatal Symptoms

First trimester Second trimester Third trimester

Vomiting Palpitation
Fever Giddiness/Fatigue
Fatigability Edema
Others

Maternity Information
Age at menarche: Menstrual history:

Obstetric History
Age at marriage: Duration of married life:
Age at first Interval between previous and present pregnancy:
pregnancy: Last Expected date of delivery:
menstrual period: Abortion: Living issues:
Gravidity: Parity:

Gynecological History
Any relevant history:

Medical and Surgical History (as relevant)

Fever with rash:
TORCH infection:
HIV/STD:
Diabetes/Hypertension:
Any other Surgical/Medical
problems: History of drug intake:
History of drug reaction:

H/O Previous Pregnancies

Pregnancies (in chronological order)

Particulars
1st 2nd 3rd 4th
Age of woman during
pregnancy Duration of
gestation
Spacing
duration
Antenatal care
Tetanus toxoid
Iron folic acid tablet
Place of delivery:
Hospital/Home Nature of
delivery:
Person conducted delivery
Outcome: Abortion/Premature/Full term
If death of any child, mention — Age, sex and cause of
death
Age and sex of living child
12 Section I: Clinico Social Case Study
(Hospital)
Genetic History
Family History Mother Father
Diabetes
Hypertension
Twin (multiple) pregnancy
Congenital anomalies
Any other

Personal History
• Diet: Veg/Non-veg/Mixed
• Food habit: Regular/Irregular
• Appetite: Normal/Decreased/Increased
• Sleep: Normal/Disturbed
• Bladder and Bowel habit: Regular/Irregular
• Physical activity: Sedentary/Moderate/Heavy
• Other habits: Alcohol/Smoking/Tobacco chewing
• Weight: Normal/Decreased/Increased
• Medicine/Drugs being used, specify:

General Physical Examination

Built: Anemia:
Height: Jaundice:
Weight: Clubbing:
Nutritional status: Cyanosis:
Pulse: Lymphadenopathy:
Blood pressure: Edema:
Temperature: Oral hygiene:
Respiration rate: Thyroid swelling:
Psychological status: Breasts:
Varicose veins:

Obstetric Examination
Inspection: Linea nigra
Striae gravidarum
Scars
Umbilicus
Palpation: Abdominal
girth
Height of uterus (fundal height)
Fundal grip
Lateral grip
1st pelvic grip
2nd pelvic grip
 Mother and Child Health
13
Auscultation: Fetal heart sound
(Fetal heart sound heard after 20 week, 120–140 beat/minute is normal)
Important clinical findings:
1.
2.

Systemic Examination
RS:
CNS:
CVS:
GIT:

Dietary Assessment
Food items Actual intake per day (gm) Intake recommended per Assessment
day (gm)* Excess/Deficiency
Cereals 445
Pulses 55
Leafy vegetables 100
Other vegetables 40
Roots 50
Milk 200
Oil/Fat 20
Sugar 30
*Recommended intake given here is for sedentary pregnant woman

Antenatal Visits and Checkup

Particulars 1st trimester 2nd trimester 3rd trimester
Number of visit
Objective of the visit
Weeks of pregnancy
Checkup by: Doctor/Health
worker
Findings:
•Height
•Weight
•BP
•Edema
•Fundal height
• Abdominal girth
•Position and presentation
•Hb%
•Urine
Nutritional supplements
Treatment
Health advice/education given
14 Section I: Clinico Social Case Study
(Hospital)
Immunization against tetanus: Received/Not received
Details about Tetanus toxoid (TT) doses: 1st dose week of pregnancy, 2nd dose week of pregnancy
If TT is not taken, reasons:
Iron folic acid supplementation
Iron: mg, Folic acid: mg, Number of days:
If Iron folic acid (IFA) is not taken, reasons:

Specific Health Protection

Particulars Needed Obtained
Anemia
Toxemias
Tetanus
Syphilis
German measles
Rh status
HIV

High Risk Assessment

Elderly primi (> 30 year) • Previous birth > 4000 gm twins/Hydramnios/Oligohydramnios
Short stature (< 140 cm) • Recent still birth, IU death, Placenta removal/Ectopic pregnancy
Weight (< 40 kg) • Other bad obstetric history/Recurrent abortions (2 in 1st, 1 in mid trimester)
Age (< 18 year)
Malpresentations at 9th month • Elderly nullipara > 35 year
Weight gain < 5 kg > 20 kg • Recent neonatal death/LBW/Short-large for date/Congenitally malformed
Antepartum hemorrhage • Prolonged pregnancy > 14 day from EDD prolong labor
Hyperemesis gravidarum • Contracted pelvis
Pre-eclampsia/Eclampsia • History of — Previous cesarean section
Multiparity > 4 — Previous pre-eclampsia
Previous difficult delivery • Disease—Renal/Liver, TB, HIV, cardiac, diabetics, thyroid, seizure,
hypertenion, etc.
Rh negative • Precious pregnancy: Conceived after long sterility
Severe anemia • Low socioeconomic status
• Unwed pregnant women
 Mother and Child Health
15
Need of referral services: Yes/No If yes, why

Lab Investigations
Sl No Examinations required Trimester and Report
1. Hb%
2. Urine— Albumin
Sugar
Microscop
3. y
4. Stool examination
5. Blood grouping and Rh
6. factor TC/DC/Complete
7. hemogram Serological
8. tests
9. Cervical smear— PAP
10. test Gonococci culture
11. STD/HIV/Others
Radiology— Chest X-ray/Ultrasonography
Others

Clinical Diagnosis MEDICO SOCIAL DISCUSSION

Identification of the Adverse Factors Present in the Mother

Medical Factors:

Social Factors:

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Knowledge, Attitude and Practice (KAP) Regarding Pregnancy

Particulars Knowledge Attitude Practice Practices in earlier
(Beliefs and customs) pregnancy
Food taboos
Food requirement
Place of delivery
Family planning
Growth monitoring
Oral rehydration
Breast feeding
16 Section I: Clinico Social Case Study
(Hospital)

Particulars Knowledge Attitude Practice Practices in earlier

(Beliefs and customs) pregnancy
Immunization
KAP of husband is also assessed
Socioeconomic
MEDICO SOCIALImpact of Pregnancy on
DIAGNOSIS
Family:

Community:

Nation:

National Programme for “Antenatal Care”

Any Recent Developments/Modifications in “Antenatal Care”

ADVICE
Mother
Health promotion:
Diet Personal hygiene
Drugs/Radiation Child care
Self care Breast feeding
Family planning Anxiety reduction
Mental preparation Anganwadi attending
Using under 5 clinic Using social
benefits Registration of birth
Specific Protection:
Tetanus toxoid: 1st 12–20 week
2nd 30–36 week
Iron folic acid tab: 100 tablet
Early Diagnosis:
Warning sign/Foresee complications: Swelling of feet, fits, headache, blurring of vision/
Bleeding or discharge per vagina
Any other unusual symptoms.

Family

Community

Review Questions
 Critise on Medical termination of pregnancy (MTP) Act and female infanticide.
 What do you suggest for pregnant mother regarding air-travelling, sexual intercourse?
 What are the diseases transmitted from mother to child?
 Write a note on warning signs, risk scoring.
 Mother and Child Health
17

POSTNATAL CARE

Postnatal care is the care of the mother and newborn soon after delivery till the end of puerperium, i.e. 6 week
after delivery.

GENERAL INFORMATION
Name of the mother: Ward No: Unit:
Husband’s name and address: IP/OP No:
Date of Admission:
Mode of admission: Self/Referral

Telephone No:
Age: Education:
Religion: Occupation: Housewife/Employed
Locality: Urban/Rural/Urban slum Income:
Reason for admission: For delivery/Postnatal problems/Others
Place of delivery: Home/Hospital
Willingness for family planning: Yes/No/Not
decided Family planning methods adopted earlier:

FAMILY PROFILE
Type of family:
Total members:
Social conditions:
Economical status:
Educational status:
Occupational status:
Living environment:

MEDICAL (CLINICAL) DETAILS AND

EXAMINATION
History of Present Illness
Chief complaints (in chronological order) Description of symptoms
Bleeding per vagina (P/V)
Primary/Secondary/Reactio
nary White discharge
Pain and tenderness in
abdomen Fever
Tender leg/Swollen
leg Burning
micturition Breast
pain/Swelling Breast
feeding problems
Any other
18 Section I: Clinico Social Case Study
(Hospital)
Antenatal Resume
Antenatal care: Taken/Not taken
Iron folic acid tablet: Taken/Not
taken Tetanus toxoid: Taken/Not
taken Antenatal problems:

Parturient Resume (Intranatal)

Delivery:
Date , Time , Duration
Sex of baby: Male/Female
Nature: Normal/Instrumental/Cesarean
Mode of delivery:
Induced/Elective/Emergency Place of delivery:
Home/Hospital
If home delivery, conducted by: Doctor/Trained Dai/Untrained
personnel Delivery kit: Used/Not used

Intranatal Problems
• Abdomen girth > 1 meter • Blood loss > 240 ml
• No pain— No progress • Late expulsion of placenta
• Rupture and leakage of membrane > 24 hour • Perineal tear
• Meconium stained liquor • Collapse
• Malpresentation/Prolapse of cord or hand • Temperature > 35°C

Neonatal Resume
Birth weight: Cry after birth:
Birth length: Body temperature:
Birth injury: Skin color:
Congenital defect: Cyanosis, difficulty in breathing:
Imperforate anus: Vomiting:
Convulsion— Neck rigidity:
Difficulty in feeding:
Bulging of anterior fontanel:

Perinatal Care
Baby care:
Cleaning of skin
Cleaning of eyes
Cleaning the airways
Cord care: Instruments used for cutting, ligature used, cord stump
APGAR score: 0–3 depressed
4–6 moderate
7–10 Normal
Use of oxygen mask:
 Mother and Child Health
19
If the child is dead: Age , Sex , Cause
Birth registration: Done/Not done
Family and social support: Good/Satisfactory/Nil
Rooming in: Satisfactory/Unsatisfactory

Personal History
Diet: Veg/Non-veg/Mixed
Food habit: Regular/Irregular
Appetite: Normal/Decreased/Increased
Sleep: Normal/Disturbed
Bladder and Bowel: Regular/Irregular
Physical activity: Nil/Moderate/Good
Other habits: Alcohol/Smoking/Tobacco chewing
Weight: Normal/Decreased/Increased
Medicine/Drugs being used:
Fever with rash:
HIV/STD:
Any other surgical/medical problems:

Previous Postnatal Examinations

Time of examination Not done Done Findings
Soon after delivery
First 3 day—Twice daily
3rd to 7th day—Daily

General Physical Examination

Built: Anemia:
Weight: Jaundice:
Height: Cyanosis:
Nutritional status: Clubbing:
Pulse: Lymphadenopathy:
Blood pressure: Edema:
Respiratory rate: Oral hygiene:
Temperature: Thyroid swelling:
Breasts: Varicose veins:
Psychological condition (Postpartum psychosis):

Obstetric Examination
Uterus (Fundus): Subinvolution/Non-retroverted/Prolapse
Vulva:
Lochia Reddish (Rubra)/Pale red (Serosa)/White (Alba)
Perineum:
20 Section I: Clinico Social Case Study
(Hospital)
Systemic Examination
RS:
CNS:
CVS:
GIT:

Examination of Baby
Body proportion and size: Head:
General condition: Skin:
Umbilical cord: Temperature:
Engorgement of breast: CVS:
Reflex: RS:
Cyanosis: Abdomen:
Jaundice: Limbs:
Cephalohematoma: Spine:
Congenital anomalies: Genitalia:
BCG given: Rectum:
Bladder and bowel: Feeding:
Infections:

Assessment of Postnatal Complications

Puerperal sepsis (up to 3 week of delivery):
Thrombophlebitis
Secondary hemorrhage (6 hour after delivery to 6 week):
Mastitis
Urinary tract infection

Dietary Assessment
Food items Actual intake per day Intake recommended per day Assessment
(gm) (gm)* Excess/Deficiency
Cereals 470
Pulses 70
Leafy vegetables 100
Other vegetables 40
Roots 50
Milk 200
Oil/Fat 30
Sugar 30
*Recommended dose given here is for sedentary lactating woman
 Mother and Child Health
21
Lab Investigations
Sl No Examinations required Report
1.
2.
3.

Clinical Diagnosis MEDICO SOCIAL DISCUSSION

Identification of Medico Social Factors Present in Mother and Baby

Medical Factors

Mother Baby
Unhygienic delivery Low birth weight < 2.5 kg
Complications of delivery Twins
Infection Artificial feeding
Septicemia Neonatal tetanus/Jaundice
Postpartum psychosis TORCH infections
Blood loss, severe anemia Birth injury
Medical conditions: Congenital anomalies
Hypertension
Diabetes HIV mother
Tuberculosis Respiratory and GI infections
Cardiac Tetanus
Renal Others
Malignancy
Social Factors
Early age at child birth Prejudice
Too close pregnancies Customs
Poverty Lack of antenatal, intranatal and postnatal care
Malnutrition Parity - (> 5) Grand multi
Illiteracy
Ignorance
Working mother

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation
22 Section I: Clinico Social Case Study
(Hospital)
Knowledge, Attitude and Practice (KAP) Regarding Postnatal Period
Particulars Knowledge Attitude Practice Practices in earlier
(beliefs and customs) puerperium
Food taboo
Food requirement
Personal hygiene
Family planning
Growth monitoring
Oral rehydration
Breast feeding
Immunization
Postnatal services
KAP of husband is also assessed

Socioeconomic Impact of Pregnancy on

Family:

Community:

Nation:

National
Medico Programme for PNC
Social Diagnosis
Any Recent Developments/Modifications in PNC

ADVICE
Mother

Family

Community

Family Planning Details

Particulars Husband Wife
Family planning used previously
Method advised now
Reasons for advising particular method
Time of IUD insertion
Problems/Complaints, If any
Willingness to undergo—
Tubectomy
—Vasectomy

Review Questions
 What are the common postnatal problems and how you solve them?
 List the social benefits available for postnatal mothers
 Write a note on Janani Suraksha Yojna and Vande Mataram Scheme
 Discuss the impact of maternal deaths on society.
 Mother and Child Health
23

UNDERNUTRITION—PEM/MARASMUS

GENERAL INFORMATION
Name of the child: Ward No: Unit:
Age: Sex: IP/OP No:
Mother’s name: Date of Admission:
Mode of admission: Self/Referral
Informant:

Telephone No:

FAMILY PROFILE
Type of family: Total members:
Habitation: Urban/Rural/Urban Slum
H/o Migration:Yes/No if migrated, details:
Religion/Caste:
Educational status: Father Mother
Occupation: Father Mother
Income: Father Mother
Socioeconomic status of the family:
(According to modified BG Prasad
classification) Living condition:
Satisfactory/Poor

MEDICAL (CLINICAL) DETAILS AND EXAMINATION

History of Present Illness
Chief Complaints Details
(in chronological order)
Growth failure
Emaciated
Edema
Not taking food
Distressed/Pathetic
Distended abdomen
Diarrhea
Fever
Excess cry, irritable
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
Previous history of same/similar illness:
Previous hospitalization for the same illness:
24 Section I: Clinico Social Case Study
(Hospital)
Past history (as relevant)
Birth weight:
Birth order:
Breast feeding and weaning practices:
Milestones:
Immunization:
History of infection like diarrhea, TB, measles, etc.:

Epidemiological History
Any similar case in the family: Yes/No
Any similar case in neighbourhood: Yes/No
Prevalence of similar condition in the locality/district:
Other relevant information:

Examination of Relevant System

Head to Toe Examination:

Stature :
Built : Normal/Short
Appearance : Normal/Sick/Cachexia
Face : Moon face/Hallowing of cheeks/Pointed chin/Prominent bones/Depigmentation/
Seborrhea around the nose
Eyes : Bitot’s spots/Dry/Sunken
Lips : Cheilosis/Angular stomatitis
Tongue : Pale/Red magenta
Nails : Koilonychia
Skin : Wrinkled/Peeling skin/Flaky paint like
patches Subcutaneous tissue : Maintained/Emaciated
Muscles : Normal/Wasting (Fig. 2.1)
Hair : Normal/Lusterless/Depigmented/Sparse/Easily pluckable/Flag sign (Fig.
2.2) Chest : Prominence of ribs
Abdomen : Distended/Flat emaciated/As-
cites/Enlarged liver

Fig. 2.1: Extreme wasting in marasmus Fig. 2.2: ‘Flag sign’ in PEM
 Mother and Child Health
25
Leg : Edema on dorsum of feet and leg
Hips : Normal/Loss of shape due to loss of fats
Alertness : Dull/Disinterested/Stays in same position for long time/Irritable/Crying excessively fretful

Anthropometric Examination
Weight in kg:
Weight of the child
Weight for age % = Weight of normal child of same × 100
age

Height in cm:
Measurements: Circumference
Head: Chest:
Mid arm:
Skin fold thickness:
Triceps: Biceps:
Suprailiac: Subscapular:
Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Hb, Peripheral smear
2. Urine: Albumin, sugar, microscopy
3. Stool: Ova, Cyst, pH (Lactose intolerance)
4. PPD: For tuberculosis
5. Total serum protein
6. Total serum albumin
7. Plasma amino acid ratio
8. Blood: Urea/Creatinine
9. Hydroxyproline/Creatinine ratio

Criteria
Clinicalfor Diagnosis
Diagnosis andClassification/Type
with Classification
Percentage weight for age Edema Present Absent
80–60 Kwashiorkor (Fig. 2.3) Undernutrition
< 60 Marasmic Kwashiorkor Marasmus (Fig. 2.4)
Grading of malnutrition—Reference to weight for age (W/A): 50th percentile (median) weight of Harward stan-
dards (Internationally accepted)
Weight (in %) Grade
70–79.9 I
60–69.9 II According to Indian academy of
< 60 III pediatrics classification
< 50 IV
Since 2009, India has adopted the new WHO growth standards in NRHM, ICDS and Research.
26 Section I: Clinico Social Case Study
(Hospital)

Fig. 2.2: Kwashiorkor Fig. 2.3: Marasmus

MEDICO SOCIAL DISCUSSION

Identification of Factors Influencing the Condition

Medical Social Environmental

Susceptibility: Poverty, poor living condition Natural calamities
Age: 1–5 year/toddler Maternal malnutrition Famine
Sex Maternal illness Unhygienic environment
Feeding: Broken family Advertisements of baby food
Breast feeding/prolong breast Alcoholic parents
feeding
Weaning: Early/Very late Parental negligence
Dilute, dirty milk Harmful practices (religious,
Less energy and protein food social, cultural)
Nutritional need: Taboos, cooking practice
Increased demand Unequal distribution
Excessive loss Starvation therapy
Infections: Poor food sanitation
Diarrhea Big families
Upper respiratory Social prejudices
Malaria Availability and utilization
of the services
Measles
Poor personal hygiene
Tuberculos
is
Worm infestation

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection
and prompt
treatment
Tertiary Disability limitation
Rehabilitation
 Mother and Child Health
27
Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease
Knowledge Attitude Practice
(beliefs and customs)
Growth
monitoring Oral
rehydration
Breast feeding
Immunization
Family planning
Food hygiene
Child feeding

Social Factors Involved in this Condition

Cause:
Diagnosis:
Treatment:
Socioeconomic Impact of this Condition on

Child:
Family:
Community:

Medico Social Diagnosis MANAGEMENT

Individual Level
Child is admitted to the nutritional rehabilitation center (if needed)
Treatment of underlying infections
Thorough examination of the child for precipitating factors

Diet Therapy
Diet requirements is calculated as per the expected weight
Giving more enriched food (oil, ghee, milk, egg, etc.)
4 gm/kg wt good quality of protein is given
200–300 Kcal/Kg wt energy is provided
Supplementation of vitamins and minerals, especially vitamin A and B.

Severe Cases
Child is admitted to the hospital, intragastric feeding is given
Vigilance and meticulous management of
Dehydration
Hypothermia
Hypoglycemia
Dyselectrolytemia
Congestive cardiac failure
28 Section I: Clinico Social Case Study
(Hospital)
ADVICE
Health Promotion
Promotion of antenatal and postnatal care
Nutritional supplementation to mother and children
Promotion of breast feeding
Female literacy and empowerment
Food policy— Production, distribution, availability, low price, fortification
Poverty alleviation, socioeconomic developments, improving the living conditions
Increasing the food buying capacity by income generation activities
Controlling endemic infections—ARI, Diarrhea, TB
Protected water supply, sanitary facilities
Primary health care
Food and personal hygiene
Oral rehydration
Breast feeding
Nutrition education to the community

Specific Protection
Immunization
Energy and protein rich food to children (oil, ghee, egg, milk, etc.)
Nutritional education
National nutritional programmes
Using multipurpose food like Hyderabad mix, bala-ahar, Indian multipurpose food based on cereals, pulses, oil
seeds, sugar, fruits and vegetables (Idli vada, kichdi, kheer, payasam, dal-rice, roti-dal, etc.)

Early Diagnosis and Treatment

Nutritional surveillance
Growth monitoring
Supplementary feeding
Periodic de-worming
Hospital treatment
Follow up

Rehabilitation:
Nutritional rehabilitation center: Motivation of mother in feeding the child with home constraint food.

Review Questions
 Write briefly the National health programme oriented to prevent malnutrition.
 What are the recent advances/modifications in medico social management of malnutrition?
 List home available energy and protein rich foods.
 List the common beliefs and practices during malnutrition.
 What is nutritional rehabilitation?
28 Section I: Clinico Social Case Study
(Hospital)
ADVICE
Health Promotion
Promotion of antenatal and postnatal care
Nutritional supplementation to mother and children
Promotion of breast feeding
Female literacy and empowerment
Food policy— Production, distribution, availability, low price, fortification
Poverty alleviation, socioeconomic developments, improving the living conditions
Increasing the food buying capacity by income generation activities
Controlling endemic infections—ARI, Diarrhea, TB
Protected water supply, sanitary facilities
Primary health care
Food and personal hygiene
Oral rehydration
Breast feeding
Nutrition education to the community

Specific Protection
Immunization
Energy and protein rich food to children (oil, ghee, egg, milk, etc.)
Nutritional education
National nutritional programmes
Using multipurpose food like Hyderabad mix, bala-ahar, Indian multipurpose food based on cereals, pulses, oil
seeds, sugar, fruits and vegetables (Idli vada, kichdi, kheer, payasam, dal-rice, roti-dal, etc.)

Early Diagnosis and Treatment

Nutritional surveillance
Growth monitoring
Supplementary feeding
Periodic de-worming
Hospital treatment
Follow up

Rehabilitation:
Nutritional rehabilitation center: Motivation of mother in feeding the child with home constraint food.

Review Questions
 Write briefly the National health programme oriented to prevent malnutrition.
 What are the recent advances/modifications in medico social management of malnutrition?
 List home available energy and protein rich foods.
 List the common beliefs and practices during malnutrition.
 What is nutritional rehabilitation?
 Chapte
r
Communicable
Diseases
3

TYPHOID

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

Part I of the model pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Description of symptoms
(in chronological order) (sudden/gradual)
Fever (step ladder)
Chills
Abdominal discomfort
Pea soup stools
Toxic look
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as Relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:

Diet History (as Relevant)

H/o food and water taken in past 15 day (Incubation period of typhoid—15 day )

Epidemiological History
Any similar case/carrier in the family: Yes/No
Any similar case/carrier in neighbourhood: Yes/No
Any direct/indirect contact with similar case/carrier:
Yes/No Prevalence of similar disease in the locality/district:
Other relevant information:
30 Section I: Clinico Social Case Study
(Hospital)
General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Clinical Findings Suggestive of Typhoid

Fever—Step ladder fashion Relative bradychardia
Diarrhea—Pea soup like Rashes—Rose spots
Abdominal pain, distention Toxic look
Coating of tongue—V shape Features of hemorrhage, shock
Dicrotic pulse

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Widal test
2. Culture of urine and stool

Criteria
Clinicalfor Diagnosis
Diagnosis
MEDICO SOCIAL DISCUSSION
Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors Host factors
Biological agent—Salmonella typhi Age
Reservoir—Cases/Carriers Sex
Source of infection Ethnicity
Primary—Cases/Carriers Migration
Secondary—Contamination of Immuni
Fluid, food, fingers, flies, fomite ty
Others
 Communicable Diseases
31
Environmental factors Social factors
(Physical, Biological, Open air defecation
Psychosocial) Rainy season Poor standard of personal and food
Increase in fly population—Flies nuisance hygiene Sewage forming
Pollution of drinking water—Lack of potable water Ignorance—Incorrect knowledge, attitude and
supply Poor housing—Poor quality of life practice Economic conditions
Improper sanitation Sociocultural
Occupational practices/Superstitions
environment Religious practices
Non-availability and utilization of health services

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice
(beliefs and customs)
Cause of
typhoid
Treatment
Food
sanitation
Hand
washing
House flies
Sanitary latrine

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease

Impact of the Disease on Socioeconomic Status of

Family:

Community:

Nation:

Medico Social Diagnosis MANAGEMENT

General and Specific Measures
1. Control of reservoir
Identification (early
diagnosis)
Isolation—Till three urine/stool specimen on different days are negative for bacilli
32 Section I: Clinico Social Case Study
(Hospital)
Treatment
Disinfection
Follow up
2. Improvement of sanitation
3. Immunization

Treatment Plan
1. Case
Bed rest
Antibiotics
Chloromphenicol—500 mg (50 mg/kg/day) 6th hourly for 14 day
Ciprofloxacin —500 mg BD for 14 day
Hydrocortisone (if indicated)
2. Contact/Carrier (as relevant)
Identification
Duodenal drain culture—For S. typhi
Serological examination —For V1 antibodies
Treatment
6 week intensive course: Ampicillin 4–6 gm/day+Probenecid—2 gm/day
Surgical: Cholecystectomy with concomitant Ampicillin therapy
3. Other family member
Immunization (as relevant)
Surveillance for three weeks
Disinfection: Stool/Urine: 5% Cresol for two hours in a closed container
Linen: Soaking in 2% Chlorine, followed by steam sterilization

Surveillance

National Health Programme Regarding the Disease

Recent Advances/Modifications in Medico Social Management of the Condition

ADVICE
Individual Level
Follow up of medical advice (drugs—food—rest)
Disinfection of Urine and stools, soiled clothes, linen
Follow up examination—3rd and 12th month after discharge (to rule out the carrier state)

Family Level
Motivate the patient to adhere medical advice
Undergoing follow up examination
Maintaining food and water hygiene
Keep food covered; Eat hot foods
Use of sanitary latrine
Hand washing practices
 Communicable Diseases
33
Community Level
Provision of safe water
Sanitary drainage
Control of house flies
Food hygiene at hotel establishment
Screening and surveillance of food handlers and carriers
Typhoid vaccination
Health education:
Healthy food practices
Need of safe water and latrine
Washing the hands with soap after toilet and urination, before handling the
food Causes and spread of typhoid
Importance of early diagnosis
Not eating cut fruits, sweets, ice cream, sold at road side (as there is a possibility of contamination)

Immunization
Advice for:
• Those living in endemic areas
• Those visiting endemic areas
• Those visiting melas and yatras
• School children, hospital staff
• Contacts.
Typhoid vaccine Primary dose Booster dose
Monovalent: 0.5 ml SC at an interval of 4–6 week (2 Every 3 year
1000 million [Link] doses)
Heat killed or Acetone killed
(AKD) Phenol preserved
Bivalent: Children:1–10 year (0.25 ml)
[Link]—1000 million Site: outer aspect of the upper arm, behind
[Link]—500 million the posterior border of the distal part of the
deltoid
Heat or Acetone killed (AKD)
Phenol preserved
Stored 2–4 °C not frozen
Capsular (V1) polysaccharide IM Every 2 year
Oral (TY21a) vaccine Children above 6 year Every 3 year
Enteric coated capsule Lyophilized Orally (1-3-5 day)
> 102 viable attenuated 1st, 3rd and 5th day with cold water or milk
[Link] strain TY21a

Review Questions
 What are the recent advances/modifications in medico social management of typhoid?
 List the common beliefs and practices during typhoid.
 Write about recent developments of typhoid vaccine.
 Comment on drug resistance in typhoid.
 DIARRHEA

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

Part I of the model pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Description of symptoms
(in chronological order) (sudden/gradual)
Diarrhea
Vomiting
Thirst
Low urine output
Fever
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:
H/o low birth weight
Feeding practices—Breast/Bottle
Weaning practices
Immunization
Poor living standard and poor socioeconomic status
Poor personal, domestic and kitchen hygiene
Infections: Measels, TB, etc.

Diet History (as relevant)

H/o food and water taken in past 15 day

Epidemiological History
Any similar case in the family: Yes/No
Any similar case in neighbourhood:
Yes/No Any contact with similar case:
Yes/No
Prevalence of similar disease in the locality/district:
Other relevant information:

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
 Communicable Diseases
35
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant examination: For associated infections like pneumonia, malaria, others

Clinical Findings Suggestive of Diarrhea

Assessment of Dehydration
Epidemiological Diagnosis
Dehydration
Sl No Particulars
No Some Severe
By History (ask)
1. Stools per day <2 2–10 > 10
2. Vomiting Nil Nil Often
3. Thirst Normal Thirsty Morbid thirst but unable to drink
4. Urine output Normal Reduced Scanty/Markedly reduced
5. Tears Present Reduced Absent
By Examination (look)
1. General condition Well, alert Well, alert Dull
2. Mouth and tongue Moist Dry Very Dry (parched)
3. Eye Normal Sunken Markedly sunken
4. Skin pinch (turgor) Normal Lost Prominent
5. Pulse Normal Normal/Rapid Rapid feeble
6. BP Normal Normal Systolic < 80 or non-recordable
7. Breathing Normal Normal Rapid
8. Temperature Normal/May Normal/May Usually Increased
be increased be increased
9. Anterior fontanelle Normal Depressed Markedly depressed
10. Consciousness Normal Lethargic Lethargic to unconsciousness
11. Irritability Slight More irritable Morbid, apathetic
36 Section I: Clinico Social Case Study
(Hospital)
Lab Investigations
Sl No Examinations required Report
1. Stool Naked eye examination
Microscopic examination—Pus cells, cysts, red cells, cellular exudates,
vegetative form pH, culture and sensitivity
Electron microscopy for rotavirus
2. Urine Microscopy, sugar and albumin
3. Blood Electrolytes,
osmolality ELISA
Test for presence of toxins

Criteria
Clinicalfor Diagnosis
Diagnosis
Classification:
1. Acute watery diarrhea
2. Dysentery—Diarrhea with blood or mucus or both
3. Persistent diarrhea—Diarrhea runs > 14 day

MEDICO SOCIAL DISCUSSION

Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors Host factors
Biological agent—Bacteria, Virus, Parasite Age—Oral
Infections—ENT, Respiratory, Urinary, phase/teething Sex
Malaria, etc. Reservoir—Human cases Malnutriti
Source of infection— on
Feces Transmission— Infection
Feco-oral By Prematuri
Contamination of ty
Fluid, food, fingers, flies, fomite Migration
Immunity
Others
Environmental factors Social factors
(Physical, Biological, Bottle feeding, incorrect feeding
Psychosocial) Rainy season practices Fairs, festivals and
(July–August) pilgrimages
Increase in fly population—Flies Open air defecation
nuisance Water scarcity Poor standard of personal and food
Pollution of drinking hygiene Sewage forming
water Lack of potable Ignorance—Incorrect knowledge, attitude and
water supply Poor practice Poverty
housing Sociocultural
Improper sanitation practices/Superstitions
Occupational Religious practices
environment Movement of
population Poor
quality of life
Non-availability and utilization of health services
 Communicable Diseases
37
Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice
(beliefs and customs)
Cause of
diarrhea
Management
Food sanitation
Hand washing
House flies
Sanitary latrine
Availability of services

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of
Family:
Community:
Nation:

Medico Social Diagnosis MANAGEMENT

Treatment Plan
1. Rehydration 2. Nutrition 3. Chemotherapy

1. Rehydration—Fluid and Electrolyte Management

Early replacement of fluid loss is the important part in managing diarrhea.
Treatment for Diarrhea with no Dehydration
Offer home available fluids frequently as much quantity as the child can take
orally. Home fluid: Butter milk Coconut water
Rice Ganji or Kanji Fruit juice
Weak tea Lemon sherabat with salt
Homemade rehydration solution (HRS):
Prepared at home by mixing
8 level tea spoon of sugar—40 gm (closed fist full)
1 level spoon full of table salt—5 gm (3 finger pinch up to 1st
crease) Potable water—1 liter
Puffed rice powder 50 gm can be substituted for sugar.
38 Section I: Clinico Social Case Study
(Hospital)
Treatment for some Dehydration
(Fig. 3.1)
Oral rehydration solution (ORS) composition as ap-
proved by the World Health Organization is as given
below:
Fig. 3.1: Moderate dehydration

Glucose—13.5 gm Sodium (Na)—75 mEq/L

Sodium chloride—2.5 gm Potassium (K)—20 mEq/L
Trisodium citrate—2.9 gm or Chloride—65 mEq/L
Sodium bicarbonate—2.5 gm Bicarbonate—10 mEq/L
Potassium chloride—1.5 gm Glucose—75 mEq/L
Potable water—1 liter
During the first four hour ORS given in ml = Weight of child in kg ×
75 For each diarrheal stool, extra 100 ml of ORS is given
Assessment of hydration is done after 4 to 6 hour
• If the child is still severely dehydrated
• Signs of moderate dehydration continues
• Child is drowsy, pulse is weak, not passed urine
• Extremities are cold
Then, child is considered as having severe dehydration
Treatment for severe dehydration
Child is admitted to hospital and intravenous drip of Ringer’s lactate solution is given.
• 30 ml/kg body weight in the first hour
• 20 ml/kg body weight in the next 3 hour
If the child passes urine, then rehydration is complete
Once the child’s condition improves (starts taking orally), intravenous drip is discontinued but ORS is
continued Gradually, the child resumes usual food and fluids.

2. Nutritional Management
• Mother should be assured about benefits of nutrition.
• Child should be given regular formula milk
• Easily digestible, food must be selected
• Small but frequent feeding is given
• Well cooked rice, dal, bananas, fruit juice and small quantities of nutritionally rich foods are given. High
sugar content is avoided for time.
During Convalescence:
More food is given to restore, to compensate the loss and to promote early recovery.

3. Chemotherapy (Treatment of cause)

Usually, diarrhea (except for Shigella, Vibrio, E. coli, Entamoeba, Giardia) does not require any
drug. Symptomatic treatment is given if there is vomiting, abdominal distention, convulsion.
 Communicable Diseases
39
Preventive and Promotive Measures
Breast feeding Immunization
Nutritional supplementation Sanitation
Fly control Health education
Food hygiene Potable water supply
Surveillance

ADVICE
(Preventive, Promotive and Curative)

Individual Level
Family Level
Community Level
Review Questions
 Write briefly the National health programme regarding diarrhea.
 What are the recent advances/modifications in medico social management of diarrhea?
 List five home available fluids.
 Write the composition of ORS and recent modifications of ORS.
 List the common beliefs and practices during diarrhea.
 HEPATITIS-A

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

Part I of the model pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Progress
(in chronological order) (sudden/gradual)
Fever
Malaise, Myalgia,
Tiredness
Anorexia, Nausea,
Vomiting
Epigastric pain
Yellow discoloration of
sclera
Weight loss
Skin itching
Altered consciousness
Flapping tremors
Dark colored urine
Clay colored stools
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:

Diet History (as relevant)

H/o food and water taken in past 30 day (Incubation period of Hepatitis-A is 30 day)

Epidemiological History: For Communicable Diseases

Any similar case in the family: Yes/No
Any similar case in neighbourhood:
Yes/No Any contact with similar case:
Yes/No
Prevalence of similar disease in the locality/district:
Other relevant information:

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
 Communicable Diseases
41
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Clinical Findings Suggestive of Hepatitis-A

Symptoms: 1.
2.
3.
4.
Sclera: Yellow discoloration
Abdomen: Distension
Tender, Enlarged
liver Lymphadenopathy: Rarely

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Liver function test SGOT
SGPT
2. Serum Bilirubin > 1 mg (Normal: 0.3–0.5
mg%) IgM antibody to HAV (new
infection)
IgG (past infection)
3. Urine Bile salt
Bile pigment
4. Stool Virus/Viral particle/Antigen

Criteria for diagnosis: 1. Clinical symptoms

Clinical Diagnosis
2. HAV—Specific IgM antibodies
42 Section I: Clinico Social Case Study
(Hospital)
MEDICO SOCIAL DISCUSSION
Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors Host factors
Biological agent—Hepatitis-A Age—Younger
virus Reservoir—Human age Sex—Both
Cases Infective material— Migration
Stool, urine Immuni
Infective period—2 week before or 1 week after the ty
onset of jaundice Others
Transmission—Feco oral
route Direct contamination
Indirect contamination of Fluid, food, fingers, flies,
fomite
Environmental factors Social factors
(Physical, Biological, Open air defecation
Psychosocial) Season—Heavy Low standard of personal, food and kitchen
rain fall (July-Sept) Poor hygiene Sewage forming
sanitation Illiteracy, Ignorance
Overcrowding Incorrect knowledge, attitude and practice
Sewage contamination of Eating raw and improper cooked food and food sold
water Lack of potable water in open place
supply Food and milk Poor economic
contamination conditions Poor quality
Increase in fly population—Flies nuisance of life
Poor housing Sociocultural
Occupational practices/Superstitions
environment Religious practices
Non-availability and utilization of health services

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice
(beliefs and customs)
Cause of
Hepatitis-A
Treatment
Food
sanitation
Hand
washing
House flies
Sanitary
latrine
 Communicable Diseases
Health services 43
44 Section I: Clinico Social Case Study
(Hospital)
Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of

Family;

Community:

Nation:

Medico Social Diagnosis MANAGEMENT

General and Specific Measures

1. Control of Reservoir
Identification (early
diagnosis) Isolation
Treatment
Follow up

2. Control of Transmission
Disinfection
Improvement of sanitation

3. Control of susceptible population

Immunization

Treatment
1. Control of Reservoir
Case: Bed rest
Sufficient fluids, high carbohydrate
diet Symptomatic management
Regular follow up, avoidance of alcohol
Fulminant hepatitis: Admission, meticulous care
Course of corticosteroids

2. Control of Transmission
• Sanitary disposal of excreta: Sanitary latrine
• Super chlorination of water: 1 mg/liter residual chlorine
• Fly control
• Boiling of drinking water: 100° C for 5 minute
• Washing hands with soap: After defecation
Before food handling
• Surveillance of public water quality
• Health education
• Vaccination
 Communicable Diseases
45
3. Control of Susceptible Host
Passive immunization:
Human normal immunoglobulin: 0.2 ml (3.2 mg)/kg—IM
Followed by active immunization
Pre-exposure (within 2 week of Contact)
• Household contacts
• Traveling to endemic areas
• Epidemic outbreaks
• Institutional outbreak
Post-exposure
• Cases
• Family contact
Active immunization:
HM 175 tissue cultured inactivated vaccine
Age: Above 1 year (2 to 40 year)
Route: IM
Site: Deltoid
Dose: 2 doses at 6–18 week interval
Booster: Every 6 month

Hepatitis-A and Hepatitis-B Combination Vaccine

Schedule: 3 doses at 0, 1 and 6 month of age

Surveillance

Review Questions
 Write briefly the National health programme regarding the Hepatitis-A.
 What are the recent advances/modifications in medico social management of Hepatitis-A?
 List the common beliefs and practices during Hepatitis-A.
46 Section I: Clinico Social Case Study
(Hospital)

TUBERCULOSIS
MEDICAL (CLINICAL) DETAILS OF THE PATIENT
Part I of the model pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Description of symptoms
(in chronological order) (sudden/gradual)
Continuous Fever
Persistent cough
Chest pain
Hemoptysis
Weight loss
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:
Age at onset:
Duration between onset and diagnosis:
Duration between the onset and start of the treatment:
Diet history (as relevant):

Epidemiological History
Any similar case in the family: Yes/No
Any similar case in neighbourhood:
Yes/No Any contact with similar case:
Yes/No
Prevalence of similar disease in the locality/district:
Other relevant information:

Epidemiological Indices of Tuberculosis (TB) in the

Locality/District General Examination

Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:
46 Section I: Clinico Social Case Study
(Hospital)
Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Clinical Findings Suggestive of Tuberculosis

Fever for > 15 day
Evening rise of temperature associated with sweating
Persistent cough for > 2 week
Chest pain
Hemoptysis
Weight loss
Others

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Sputum examination (2 sample—1 on spot
and 1 in the morning)
2. Sputum culture
3. Chest X-ray
4. Tuberculin test (for children < 2 year)
5. HIV (as relevant)

Criteria for
Clinical Diagnosis
1. Diagnosis
2. Categorization for the purpose of treatment

MEDICO SOCIAL DISCUSSION

Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors Host factors
Biological—[Link] Age, Sex, Race, Ethnicity
Reservoir and source—Human, bovine Migration
Mode of transmission—Droplet (air borne) Inheritance/Heredity
Infective material—Sputum Nutrition—Malnutrition
Infectivity period—As long as the person is Immunity
untreated (open case) Natural infection
Drug resistance strain Unimmunized—BCG
Silicosis, Diabetes, HIV, Others
 Communicable Diseases
47
Environmental factors Social factors
(Physical, Biological, Psychosocial) Indiscriminate spitting
Poor housing Sharing hukka,
Poor ventilation Smoking
Occupational environment Feeding from same plate
Overcrowding Pardha system, early marriage
Stress Economic conditions—Poverty
Religious, sociocultural practices
Prejudice/Taboos/Stigma
Illiteracy, ignorance
Urbanization, industrialization
Incorrect knowledge, attitude and practice
Irregular treatment
Availability, utilization of health services

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondar Early detection and
y prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice
(beliefs and customs)
Cause
Treatment
Prevention
Health
services
Others

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of

Family:

Community:

Nation:

Medico Social Diagnosis

48 Section I: Clinico Social Case Study
(Hospital)
MANAGEMENT
Treatment Plan

1. Case
• Patient is registered and treated under Revised national TB control programme (RNTCP)
• Sputum examination report is recorded
• Direct observed therapy short term (DOTS) is given
Patient is stratified into different categories and treated according to the RNTCP guidelines
Category Type of patient Regimen
I New sputum smear 2HRZE3 intensive
positive Seriously ill
4HR3 continuation
sputum negative
Seriously ill extra
pulmonary
II Previously treated 2HRZES3 intensive
Sputum positive 1HRZE3
relapse Sputum 5HRE3 continuation
positive failure
Sputum positive
default

HRZES—Isoniazid (H) Rifampicin (R) Pyrazinamide (Z) Ethambutol (E) [HRZE] Streptomycin (S)
Prefix—Duration in month, Suffix—Number of times in a week
Intensive phase—3 doses/week (on every alternative days), all doses are supervised
Continuation phase—3 doses/week, 1st dose of every week is supervised, Rest of the doses are self-
adminis- tered
Sputum examination is repeated at the end of intensive phase, (i.e. 2 month), then at 4th and 6th month in continu-
ation phase.

2. Contacts/Family members
Periodic screening Isonicotinylhydrazine (INH) prophylaxis, (if indicated)
Mantoux test in children Bacille Calmette-Guerin (BCG), if indicated

ADVICE
(Preventive, Promotive and Curative)

To Patient
Take drugs regularly and completely Undergo periodic follow up
Cover the mouth with cloth while coughing Stop smoking
Take good food, do regular walking/exercise Hygienic disposal of sputum
Avoid indiscriminate spiting Test for diabetes

To Family Members
Motivate to take drugs regularly and completely, going for periodic
examination Motivate to take good food, do regular walking/exercise
Helping for hygienic disposal of sputum
Screening of all family member
 Communicable Diseases
49
To Community
Health education is given to the community through Information education and communication (IEC) about
cause, cure, treatment, and availability of services
Motivation for early detection
BCG immunization for children
Removal of stigma

Review Questions
 Write briefly the need of National health programme regarding tuberculosis.
 What are the recent advances/modifications in medico social management of tuberculosis?
 List the common beliefs and practices during tuberculosis
 Explain the meaning of:
Case Reregistered case
Sputum positive Sputum negative
Drug defaulter Relapse
Treatment failure Cured
Transferred in Transferred out
Multi drug resistance Extensive drug resistance
Extra pulmonary DOT provider
Supervised therapy Tuberculin conversion
Dots plus
 Write a note of Multi-drug resistant tuberculosis (MDR-TB) and Extensively drug-resistant
tuberculosis (XDR-TB)
 Explain the epidemiological impact of HIV and TB combination
 LEPROSY

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

Part I of the model pro forma has to be filled before starting this Part

History of Present Illness

Chief complaint Onset Duration Progress
(in chronological order) (sudden/gradual)
Skin lesion
Loss of sensation
Glove and
stocking
anesthesia
Ulcer
Deformity
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
Previous hospitalization/complications for same illness:
Age at onset:
Duration between onset and diagnosis:
Duration between the onset and start of the treatment:

Epidemiological Information
Any similar case in the family: Yes/No
Any similar case in neighbourhood:
Yes/No Any contact with similar case:
Yes/No
Any other relevant information:
Prevalence of leprosy in the: Locality: District: State:
Family history of leprosy

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Examination of Leprosy Features

Examination for leprosy is done in a good daylight, from top to bottom, both front and back with minimal
clothing for the evidence of features of leprosy.
 Communicable Diseases
51
Skin Lesions
Number: One/two to five/Numerous
Distribution: Symmetrical/Asymmetrical
Situation: Localized/Generalized
Appearance: Macule/Plaque
Size: Small/Big/Variable
Shape: Irregular/Circular—oval
Color: Erythematous /Hypopigmented
Surface: Shiny/Dry, rough
Margins: Ill-defined/Well demarcated,
Raised Feel: Soft/Firm
Sweating: Present/Impaired/Absent
Hair: Present/Sparse/Lost
Infiltration: Present/Absent
Sensation: Impaired/Lost
Sensation lost: Light touch/Pressure/Heat/Cold

Face
Leonic facies: Loss of eyebrows:
Loss of eyelashes: Weakness of eyelids—Ptosis:
Lagophthalmos: Corneal anesthesia:
Corneal ulcer: Nasal discharge:
Depression of nose: Nasal perforation:
Involvement of larynx: Facial paralysis:
Ear thickening:
Elongated lobules:
Nodules:

Hand
Wasting of muscles: Weakness:
Claw hand: Wrist drop:
Absorption of digits: Thumb contraction:
Ulcers:

Feet
Wasting of muscles: Weakness:
Plantar ulcer: Foot drop:
Inversion: Absorption of toes:
Collapse of foot: Swollen foot:

Other Organs
Testes: Epididymis:
Breast: Liver, Kidney, Adrenal:
52 Section I: Clinico Social Case Study
(Hospital)
Intercurrent Infection
Examination of Nerve
Nerve Site Thickening Tenderness Consistency Findings
Ulnar Groove •Wasting of small muscles
behind of hand
medial •Loss of sensation in ulnar
epicondyle part of hand
(Forearm is
kept •Contraction (clawing) of
flexed) 4th and 5th finger
•Weakness in 2nd and
3rd finger
Lateral popliteal Finger is •Loss of sensation in foot
hooked behind
the neck of
fibula
Great auricular Head is •Cosmetic problem
turned to
opposite side.
Nerve
stretches
across
posterior edge
of
sternomastoid
Facial Stylomasto •Loss of taste in anterior
id foramen, 1/3rd of tongue
Zygomat •Mask face
ic •Lagophthalmos
process
Trigeminal Correspondi •Corneal anesthesia
ng foramen
Median Antecubital •Thenar wasting
fossa proximal •Palmar anesthesia
to carpal
tunnel at wrist
Radial Radial groove •Wrist drop (drop)
of humerus
posterior to
deltoid
insertion
Near the
radius at
wrist
Posterior tibial Between •Plantar anesthesia
medial •Clawing of toes
malleolus and
heel
Superficial peroneal Near the neck •Foot drop
of
fibula
Supraorbital Running •Lagophthalmos
finger across
the forehead

Examination of Muscle Strength*

Muscle tested S W P
1.
2.
 Communicable Diseases
3. 53
54 Section I: Clinico Social Case Study
(Hospital)

Fig. 3.2: The sites of peripheral nerves most commonly enlarged and palpable in leprosy

* Muscle strength
S—Able to move against gravity W—
Able to move towards gravity only P—
Not able to perform movements

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant examination:

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Skin smear/biopsy
2. Bacteriological—Bacteriological
index
—Morphological index
3. Immunological—Lepromin test*
4. Histamine test
5. Immunological LTT, LMIT**
* Lepromin test is done to classify leprosy and assess prognosis
**LTT—Lymphocyte transformation test, LMIT—Leukocyte migration inhibition test
 Communicable Diseases
55
Classification (for the purpose of treatment)
Cardinal features SSLPB PB MB
Skin lesion number 1 2–5 >5
Number of nerve involved Nil 1 >2
Skin smear -ve -ve +ve
SSLPB: Single skin lesion, PB: Pauci bacillary, MB: Multibacillary
In the doubtful condition, patient is classified as MB.

Deformities Grading
Site Grade 0 Grade I Grade II
Hand/Feet No anesthesia Anesthesia +ve Visible deformity
No visible deformity No visible deformity
Eyes No loss of vision Eye problem present Severe visual
No eye problem Vision not severely Impairment (< 6/60)
affected

Criteria for
Clinical Diagnosis
Diagnosis with Classification/Type
1. Hypopigmented patches
2. Loss of sensation
3. Thickened nerves
4. Presence of M. leprae
5. Deformity

MEDICO SOCIAL DISCUSSION

Identification of the factors responsible for/influencing the present condition
Agent factors Host factors
Biological agent—M. leprae Age
Reservoir—Cases Sex
Source of infection—Multi bacillary cases Race
Mode of infection—Airborne/Close contact Migration
Immuni
Infective material—Respiratory
ty
secretions Portal of exit—Nose,
Others
mouth
Period of infectivity—As long as the patient is
untreated
Environmental factors Social factors
(Physical, Biological, Psychosocial) Low standard of living
Presence of infection in the community Substandard housing
Occupational environment Overcrowding
Endemic region Poor hygiene
Temperature and Humidity Illiteracy, ignorance
Concealing the disease due to stigma
56 Section I: Clinico Social Case Study
(Hospital)
Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude, and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice

(beliefs and customs)
Cause of
leprosy
Treatment
Prevention
Health
services
Stigma

Influence of Medico Social Factors in Diagnosis, Treatment, and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of

Family:

Community:

Nation:

Medico Social Diagnosis MANAGEMENT

Treatment plan

1. Case:
Drugs
Type Duration
Rifampicin Dapsone Clofazimine
MB 12 month 600 mg once a 100 mg daily (self) 300 mg once a
month month
(supervised) (supervised) 50 mg
daily (self)
PB 6 month 600 mg once a 100 mg daily (self) Nil
month
(supervised)
Single skin lesion: Rifampicin-600 mg + Ofloxacin-400 mg + Minocycline-100 mg (ROM therapy)

2. Contact:
Chemoprophylaxis—Dapsone (1–4 mg/kg/week for 3 month)

3. Other family members:

Periodic examination
 Communicable Diseases
57
Surveillance:
Once in a year for 5 year after treatment

ADVICE
(Preventive and Promotive

Advice) Patient
Primary
• Adopt good nutrition and healthy lifestyle
• Raising socioeconomic educational level
• Health Education
• Avoid alcohol, smoking
• Protection from burns, injuries
• Care during lepra reaction
• Self care: Ulcer, eye, hand, foot
• Hygienic disposal of nasal and wound secretions
• Using microcellular footwear

Secondary
• Take drugs as per
• schedule Go for periodic

Tertiary checkup
•

Family Using the rehabilitation (medical, social, surgical, psychological, vocational) facility
Accept the patient and do not isolate/outcast
Motivate to take drugs regularly
Motivate to go for periodic checkup
Motivate to adopt good nutrition and healthy lifestyle
Periodic examination of all family members/contacts

Community
Early detection of case by—Contact tracing, mass survey, examination of school children, slum population
Efforts to remove the social stigma through IEC
Creating awareness regarding scientific knowledge of leprosy through
IEC Providing services through Primary health care (PHC)
58 Section I: Clinico Social Case Study
(Hospital)
Review Questions
 Write briefly the National health programme regarding leprosy
 What are the recent advances/modifications in medico social management of leprosy?
 List the common beliefs and practices during leprosy
 What is your opinion regarding the conversion of leprosy vertical programme into horizontal programme?
 Mention the social benefits available for cured leprosy patients.
 Explain the meaning of—
Case of leprosy
New case of leprosy
Reregistered case
Drug defaulter
Release from treatment
Released from register
Cured
Transferred in/Transferred out
 Name 5 persons who has fought to remove the stigma of leprosy.
 Communicable Diseases
59

HEPATITIS-B

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

Part I of the model pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Progress
(in chronological order) (sudden/gradual)
Fever
Malaise, Myalgia,
Tiredness
Anorexia, Nausea,
Vomiting
Epigastric pain
Yellow discoloration of
sclera
Weight loss
Skin itching
Altered consciousness
Flapping tremors
Dark colored urine
Clay colored stools
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:
H/o the following for the past > 6 month of duration: (Incubation period—6 month)
Blood transfusion, dialysis, injections
Needle piercing—Nose/ear pricking, tattooing
Surgery, tooth extraction, injury with sharps
Sexual exposure
Baby delivered by Hepatitis-B mother

Epidemiological History: for Communicable Diseases

Any similar case/carrier in the family: Yes/No
Any similar case/carrier in neighbourhood: Yes/No
Any contact with similar case/carrier: Yes/No
Prevalence of similar disease in the locality/district:
Other relevant information—Risk behavior: Multiple sexual partners
Unsafe sex
Exposure to sharp needle injuries
Carrier mother
 Communicable Diseases
59
General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Clinical Findings Suggestive of Hepatitis-B

Symptoms: 1.
2.
3.
4.
Sclera - For yellow discoloration
Abdomen - Distension
Tender, Enlarged liver
Lymphadenopathy - Rarely

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Serum HBsAg
Bilirubin > 1 mg (Normal: 0.3–0.5
mg%) IgM antibody to HBV (new
infection) IgG (past infection)
2. Liver function test SGOT
SGPT
3. Urine Bile Salt
Bile pigment

Clinical Diagnosis
60 Section I: Clinico Social Case Study
(Hospital)
Criteria for Diagnosis
1. Clinical symptoms
2. HBsAg reactive
3. HBV—Specific IgM antibodies

MEDICO SOCIAL DISCUSSION

Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors Host factors
Biological agent—Hepatitis B virus Age—Active sexual age (20–40 year)
Reservoir—Human cases/carriers Sex—Both
Infective material—Blood, serum, semen, vaginal fluid High risk group—FSW, MSM, truckers, etc.
Infective period—1 month prior to jaundice to Migration
too many years Immunity
Transmission—Blood contact, sexual contact, Blood transfusion, dialysis
mother to child IM/IV drug use
Others
Environmental factors Social factors
(Physical, biological, psychosocial) Illiteracy, ignorance
Occupational environment—Sex work, transportation, Incorrect knowledge, attitude and
etc. practice Poor economic conditions
Poor quality of life
Socio cultural practices/superstitions
Religious practices
Use of unsterilized needles
Non-availability and utilization of health services

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice

(beliefs and customs)
Cause of
Hepatitis-B
Treatment
Injection
safety Safe
sex
Health services
 Communicable Diseases
61
Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of

Family:

Community:

Nation:

Medico Social Diagnosis MANAGEMENT

Preventive Measures

Passive Immunization:
Hepatitis B immunoglobulin (HBIG)
• Within 6 hour maximum 48 hour of exposure
• To newborn of carrier mother
• Dose—0.05 to 0.07 ml/kg (8–11 mg/kg)
• 2 doses, 30 day apart

Active Immunization:
Inactivated subunit vaccine
• 1 ml (20 mcg surface antigen) for adults, 0.5 ml for children
• At 0,1 and 6 month interval, Intramuscular
• Preferably given to Newborn (birth dose)—Within 24 hour of birth

ADVICE
(Preventive, Promotive and Curative)

Patient
Avoid alcohol
Practice healthy lifestyle
Go for periodic checkup
Do not donate blood
Safe sex practice by using barrier method
Reveal the status to your health care provider

Family
Motivate the patient to lead healthy life
Motivate him for periodic checkup
Do not outcast the Hepatitis-B infected person
Do not share the sharp materials used by the patient
Take precautions during injections, sharp pricking, blood transfusion,
etc. Practice safe sex
62 Section I: Clinico Social Case Study
(Hospital)
Community
Take Hepatitis-B immunization
Alertness regarding sharps, injury and blood contact
Safe sex practices
Regulations on blood bank
Encouragement for voluntary blood donation

Health Care Provider

Following the universal precautions
Strict sterilization practices
Screening of the blood and blood products
During accidental injury, immediate Hepatitis-B immunoglobulin followed by active immunization is adminis-
tered

Surveillance

Review Questions
 Write briefly the need of National health programme regarding Hepatitis-B
 What are the recent advances/modifications in medico social management of Hepatitis-B?
 List the common beliefs and practices during Hepatitis-B
 SEXUALLY TRANSMITTED DISEASE

SEXUALLY TRANSMITTED DISEASE (Except Hepatitis-B and HIV)

MEDICAL (CLINICAL) DETAILS OF THE PATIENT
Part I of the model pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Description of symptoms
(In chronological order) (sudden/gradual)
Urethral Discharge
Scrotal Swelling
Inguinal Swelling
Genital Ulcer/Itching
Vaginal Discharge/Itching
Anal Discharge/Itching
Lower Abdominal Pain
Pharyngitis
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:

Epidemiological History: for Communicable Diseases

H/o unprotected sexual exposure (in detail):
Age, sex, address of sexual partner:
Any similar case in friends/peer group: Yes/No
Any sexual contact with similar case: Yes/No
Prevalence of similar disease in the locality/district:
Other relevant sexual risk behavior

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:
64 Section I: Clinico Social Case Study
(Hospital)
Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Discharge—Microscopy, culture
2. Blood—Serology
3. Other

Criteria
Clinicalfor
Diagnosis
Diagnosis:

Classification:

MEDICO SOCIAL DISCUSSION

Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors Host factors
Biological—Pathogens spread by sexual contact Age—sexually active
life Sex—both
Migratio
n
Immunit
y
Sexual risk behavior—MSM, FSW, truck drivers, etc.
Others
Environmental factors Social factors
Population explosion Social disruption
Increase in younger population International travel
Rural-urban migration Changing behavioral pattern
Delaying in the age of marriage Alcoholism
Opportunities of sexual exposure Low socioeconomic conditions
Urbanization/Industrialization Social stigma
Commercial sex work Unemployment
Broken home Incorrect knowledge, attitude, and practice
Sexual disharmony Habit and lifestyle
Easy money Non-availability and utilization of health services
Emotional immaturity
 Communicable Diseases 65

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice

(beliefs and customs)
Cause of
STD
Treatment
Prevention
Safe sex
practice Health
services
Others

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of

Family:

Community:

Nation:

Medico Social Diagnosis MANAGEMENT

Treatment plan

Case :
Full course of appropriate antibiotics
Follow up of the patients
Health education

Contacts :
Partner treatment—Full course of appropriate antibiotics

Community :
Screening
Contact tracing
Cluster tracing
Case holding and treatment
Personal prophylaxis
66 Section I: Clinico Social Case Study
(Hospital)
Establishment of sexually transmitted disease (STD) clinics
Health education—Information education and communication (IEC)
Legislation
Social welfare measures
Monitoring and evaluation

ADVICE
(Preventive, Promotive and Curative)
Patient
Risk of STD infections to the patient, partners and contacts
Motivation for the complete treatment
Initiate the partner to take the treatment
Safe sex practices

Community
Efforts are made to remove the social stigma through IEC
Incultation of complete curability of STD
Availability of
services Safe sex
practices
Sex education at high schools and college levels

Review Questions
 National health programme regarding STD
 Recent advances/modifications in medico social management of STD?
 Write the flow diagram of syndromic management of STD
 Discuss MSM (male having sex with male) activities in your city. What is their contribution for HIV
and STD.
 Chapte
r
Communicable
Diseases
3

TYPHOID

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

Part I of the model pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Description of symptoms
(in chronological order) (sudden/gradual)
Fever (step ladder)
Chills
Abdominal discomfort
Pea soup stools
Toxic look
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as Relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:

Diet History (as Relevant)

H/o food and water taken in past 15 day (Incubation period of typhoid—15 day )

Epidemiological History
Any similar case/carrier in the family: Yes/No
Any similar case/carrier in neighborhood:
Yes/No
Any direct/indirect contact with similar case/carrier:
Yes/No Existence of similar disease in the locality/district:
Other relevant information:
30 Section I: Clinico Social Case Study
(Hospital)
General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Clinical Findings Suggestive of Typhoid

Fever—Step ladder fashion Relative bradychardia
Diarrhea—Pea soup like Rashes—Rose spots
Abdominal pain, distention Toxic look
Coating of tongue—V shape Features of hemorrhage, shock
Dicrotic pulse

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Widal test
2. Culture of urine and stool

Criteria
Clinicalfor Diagnosis
Diagnosis
MEDICO SOCIAL DISCUSSION
Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors Host factors
Biological agent—Salmonella typhi Age
Reservoir—Cases/Carriers Sex
Source of infection Ethnicity
Primary—Cases/Carriers Migration
Secondary—Contamination of Immuni
Fluid, food, fingers, flies, fomite ty
Others
 Communicable Diseases
31
Environmental factors Social factors
(Physical, Biological, Open air defecation
Psychosocial) Rainy season Poor standard of personal and food
Increase in fly population—Flies nuisance hygiene Sewage forming
Pollution of drinking water—Lack of potable water Ignorance—Incorrect knowledge, attitude and
supply Poor housing—Poor quality of life practice Economic conditions
Improper sanitation Sociocultural
Occupational practices/Superstitions
environment Religious practices
Non-availability and utilization of health services

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice
(beliefs and customs)
Cause of
typhoid
Treatment
Food
sanitation
Hand
washing
House flies
Sanitary latrine

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease

Impact of the Disease on Socioeconomic Status of

Family:

Community:

Nation:

Medico Social Diagnosis MANAGEMENT

General and Specific Measures
1. Control of reservoir
Identification (early
diagnosis)
Isolation—Till three urine/stool specimen on different days are negative for bacilli
32 Section I: Clinico Social Case Study
(Hospital)
Treatment
Disinfection
Follow up
2. Improvement of sanitation
3. Immunization

Treatment Plan
1. Case
Bed rest
Antibiotics
Chloromphenicol—500 mg (50 mg/kg/day) 6th hourly for 14 day
Ciprofloxacin —500 mg BD for 14 day
Hydrocortisone (if indicated)
2. Contact/Carrier (as relevant)
Identification
Duodenal drain culture—For S. typhi
Serological examination —For V1 antibodies
Treatment
6 week intensive course: Ampicillin 4–6 gm/day+Probenecid—2 gm/day
Surgical: Cholecystectomy with concomitant Ampicillin therapy
3. Other family member
Immunization (as relevant)
Surveillance for three weeks
Disinfection: Stool/Urine: 5% Cresol for two hours in a closed container
Linen: Soaking in 2% Chlorine, followed by steam sterilization

Surveillance

National Health Programme Regarding the Disease

Recent Advances/Modifications in Medico Social Management of the Condition

ADVICE
Individual Level
Follow up of medical advice (drugs—food—rest)
Disinfection of Urine and stools, soiled clothes, linen
Follow up examination—3rd and 12th month after discharge (to rule out the carrier state)

Family Level
Motivate the patient to adhere medical advice
Undergoing follow up examination
Maintaining food and water hygiene
Keep food covered; Eat hot foods
Use of sanitary latrine
Hand washing practices
 Communicable Diseases
33
Community Level
Provision of safe water
Sanitary drainage
Control of house flies
Food hygiene at hotel establishment
Screening and surveillance of food handlers and carriers
Typhoid vaccination
Health education:
Healthy food practices
Need of safe water and latrine
Washing the hands with soap after toilet and urination, before handling the
food Causes and spread of typhoid
Importance of early diagnosis
Not eating cut fruits, sweets, ice cream, sold at road side (as there is a possibility of contamination)

Immunization
Advice for:
• Those living in endemic areas
• Those visiting endemic areas
• Those visiting melas and yatras
• School children, hospital staff
• Contacts.
Typhoid vaccine Primary dose Booster dose
Monovalent: 0.5 ml SC at an interval of 4–6 week (2 Every 3 year
1000 million [Link] doses)
Heat killed or Acetone killed
(AKD) Phenol preserved
Bivalent: Children:1–10 year (0.25 ml)
[Link]—1000 million Site: outer aspect of the upper arm, behind
[Link]—500 million the posterior border of the distal part of the
deltoid
Heat or Acetone killed (AKD)
Phenol preserved
Stored 2–4 °C not frozen
Capsular (V1) polysaccharide IM Every 2 year
Oral (TY21a) vaccine Children above 6 year Every 3 year
Enteric coated capsule Lyophilized Orally (1-3-5 day)
> 102 viable attenuated 1st, 3rd and 5th day with cold water or milk
[Link] strain TY21a

Review Questions
 What are the recent advances/modifications in medico social management of typhoid?
 List the common beliefs and practices during typhoid.
 Write about recent developments of typhoid vaccine.
 Comment on drug resistance in typhoid.
 DIARRHEA

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

Part I of the pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Description of symptoms
(in chronological order) (sudden/gradual)
Diarrhea
Vomiting
Thirst
Low urine output
Fever
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:
H/o low birth weight
Feeding practices—Breast/Bottle
Weaning practices
Immunization
Poor living standard and poor socioeconomic status
Poor personal, domestic and kitchen hygiene
Infections: Measels, TB, etc.

Diet History (as relevant)

H/o food and water taken in past 15 day

Epidemiological History
Any similar case in the family: Yes/No
Any similar case in neighborhood:
Yes/No Any contact with similar case:
Yes/No
Existence of similar disease in the locality/district:
Other relevant information:

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
 Communicable Diseases
35
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant examination: For associated infections like pneumonia, malaria, others

Clinical Findings Suggestive of Diarrhea

Assessment of Dehydration
Epidemiological Diagnosis
Dehydration
Sl No Particulars
No Some Severe
By History (ask)
1. Stools per day <2 2–10 > 10
2. Vomiting Nil Nil Often
3. Thirst Normal Thirsty Morbid thirst but unable to drink
4. Urine output Normal Reduced Scanty/Markedly reduced
5. Tears Present Reduced Absent
By Examination (look)
1. General condition Well, alert Well, alert Dull
2. Mouth and tongue Moist Dry Very Dry (parched)
3. Eye Normal Sunken Markedly sunken
4. Skin pinch (turgor) Normal Lost Prominent
5. Pulse Normal Normal/Rapid Rapid feeble
6. BP Normal Normal Systolic < 80 or non-recordable
7. Breathing Normal Normal Rapid
8. Temperature Normal/May Normal/May Usually Increased
be increased be increased
9. Anterior fontanelle Normal Depressed Markedly depressed
10. Consciousness Normal Lethargic Lethargic to unconsciousness
11. Irritability Slight More irritable Morbid, apathetic
36 Section I: Clinico Social Case Study
(Hospital)
Lab Investigations
Sl No Examinations required Report
1. Stool Naked eye examination
Microscopic examination—Pus cells, cysts, red cells, cellular exudates,
vegetative form pH, culture and sensitivity
Electron microscopy for rotavirus
2. Urine Microscopy, sugar and albumin
3. Blood Electrolytes,
osmolality ELISA
Test for presence of toxins

Criteria
Clinicalfor Diagnosis
Diagnosis
Classification:
1. Acute watery diarrhea
2. Dysentery—Diarrhea with blood or mucus or both
3. Persistent diarrhea—Diarrhea runs > 14 day

MEDICO SOCIAL DISCUSSION

Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors Host factors
Biological agent—Bacteria, Virus, Parasite Age—Oral
Infections—ENT, Respiratory, Urinary, phase/teething Sex
Malaria, etc. Reservoir—Human cases Malnutriti
Source of infection— on
Feces Transmission— Infection
Feco-oral By Prematuri
Contamination of ty
Fluid, food, fingers, flies, fomite Migration
Immunity
Others
Environmental factors Social factors
(Physical, Biological, Bottle feeding, incorrect feeding
Psychosocial) Rainy season practices Fairs, festivals and
(July–August) pilgrimages
Increase in fly population—Flies Open air defecation
nuisance Water scarcity Poor standard of personal and food
Pollution of drinking hygiene Sewage forming
water Lack of potable Ignorance—Incorrect knowledge, attitude and
water supply Poor practice Poverty
housing Sociocultural
Improper sanitation practices/Superstitions
Occupational Religious practices
environment Movement of
population Poor
quality of life
Non-availability and utilization of health services
 Communicable Diseases
37
Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice
(beliefs and customs)
Cause of
diarrhea
Management
Food sanitation
Hand washing
House flies
Sanitary latrine
Availability of services

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of
Family:
Community:
Nation:

Medico Social Diagnosis MANAGEMENT

Treatment Plan
1. Rehydration 2. Nutrition 3. Chemotherapy

1. Rehydration—Fluid and Electrolyte Management

Early replacement of fluid loss is the important part in managing diarrhea.
Treatment for Diarrhea with no Dehydration
Offer home available fluids frequently as much quantity as the child can take
orally. Home fluid: Butter milk Coconut water
Rice Ganji or Kanji Fruit juice
Weak tea Lemon sherabat with salt
Homemade rehydration solution (HRS):
Prepared at home by mixing
8 level tea spoon of sugar—40 gm (closed fist full)
1 level spoon full of table salt—5 gm (3 finger pinch up to 1st
crease) Potable water—1 liter
Puffed rice powder 50 gm can be substituted for sugar.
38 Section I: Clinico Social Case Study
(Hospital)
Treatment for some Dehydration
(Fig. 3.1)
Oral rehydration solution (ORS) composition as ap-
proved by the World Health Organization is as given
below:
Fig. 3.1: Moderate dehydration

Glucose—13.5 gm Sodium (Na)—75 mEq/L

Sodium chloride—2.5 gm Potassium (K)—20 mEq/L
Trisodium citrate—2.9 gm or Chloride—65 mEq/L
Sodium bicarbonate—2.5 gm Bicarbonate—10 mEq/L
Potassium chloride—1.5 gm Glucose—75 mEq/L
Potable water—1 liter
During the first four hour ORS given in ml = Weight of child in kg ×
75 For each diarrheal stool, extra 100 ml of ORS is given
Assessment of hydration is done after 4 to 6 hour
• If the child is still severely dehydrated
• Signs of moderate dehydration continues
• Child is drowsy, pulse is weak, not passed urine
• Extremities are cold
Then, child is considered as having severe dehydration
Treatment for severe dehydration
Child is admitted to hospital and intravenous drip of Ringer’s lactate solution is given.
• 30 ml/kg body weight in the first hour
• 20 ml/kg body weight in the next 3 hour
If the child passes urine, then rehydration is complete
Once the child’s condition improves (starts taking orally), intravenous drip is discontinued but ORS is
continued Gradually, the child resumes usual food and fluids.

2. Nutritional Management
• Mother should be assured about benefits of nutrition.
• Child should be given regular formula milk
• Easily digestible, food must be selected
• Small but frequent feeding is given
• Well cooked rice, dal, bananas, fruit juice and small quantities of nutritionally rich foods are given. High
sugar content is avoided for time.
During Convalescence:
More food is given to restore, to compensate the loss and to promote early recovery.

3. Chemotherapy (Treatment of cause)

Usually, diarrhea (except for Shigella, Vibrio, E. coli, Entamoeba, Giardia) does not require any
drug. Symptomatic treatment is given if there is vomiting, abdominal distention, convulsion.
 Communicable Diseases
39
Preventive and Promotive Measures
Breast feeding Immunization
Nutritional supplementation Sanitation
Fly control Health education
Food hygiene Potable water supply
Surveillance

ADVICE
(Preventive, Promotive and Curative)

Individual Level
Family Level
Community Level
Review Questions
 Write briefly the National health programme regarding diarrhea.
 What are the recent advances/modifications in medico social management of diarrhea?
 List five home available fluids.
 Write the composition of ORS and recent modifications of ORS.
 List the common beliefs and practices during diarrhea.
 HEPATITIS-A

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

Part I of the pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Progress
(in chronological order) (sudden/gradual)
Fever
Malaise, Myalgia,
Tiredness
Anorexia, Nausea,
Vomiting
Epigastric pain
Yellow discoloration of
sclera
Weight loss
Skin itching
Altered consciousness
Flapping tremors
Dark colored urine
Clay colored stools
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:

Diet History (as relevant)

H/o food and water taken in past 30 day (Incubation period of Hepatitis-A is 30 day)

Epidemiological History: For Communicable Diseases

Any similar case in the family: Yes/No
Any similar case in neighborhood:
Yes/No Any contact with similar case:
Yes/No
Existence of similar disease in the locality/district:
Other relevant information:

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
 Communicable Diseases
41
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Clinical Findings Suggestive of Hepatitis-A

Symptoms: 1.
2.
3.
4.
Sclera: Yellow discoloration
Abdomen: Distension
Tender, Enlarged
liver Lymphadenopathy: Rarely

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Liver function test SGOT
SGPT
2. Serum Bilirubin > 1 mg (Normal: 0.3–0.5
mg%) IgM antibody to HAV (new
infection)
IgG (past infection)
3. Urine Bile salt
Bile pigment
4. Stool Virus/Viral particle/Antigen

Criteria for diagnosis: 1. Clinical symptoms

Clinical Diagnosis
2. HAV—Specific IgM antibodies
42 Section I: Clinico Social Case Study
(Hospital)
MEDICO SOCIAL DISCUSSION
Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors Host factors
Biological agent—Hepatitis-A Age—Younger
virus Reservoir—Human age Sex—Both
Cases Infective material— Migration
Stool, urine Immuni
Infective period—2 week before or 1 week after the ty
onset of jaundice Others
Transmission—Feco oral
route Direct contamination
Indirect contamination of Fluid, food, fingers, flies,
fomite
Environmental factors Social factors
(Physical, Biological, Open air defecation
Psychosocial) Season—Heavy Low standard of personal, food and kitchen
rain fall (July-Sept) Poor hygiene Sewage forming
sanitation Illiteracy, Ignorance
Overcrowding Incorrect knowledge, attitude and practice
Sewage contamination of Eating raw and improper cooked food and food sold
water Lack of potable water in open place
supply Food and milk Poor economic
contamination conditions Poor quality
Increase in fly population—Flies nuisance of life
Poor housing Sociocultural
Occupational practices/Superstitions
environment Religious practices
Non-availability and utilization of health services

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice
(beliefs and customs)
Cause of
Hepatitis-A
Treatment
Food
sanitation
Hand
washing
House flies
Sanitary
latrine
 Communicable Diseases
Health services 43
44 Section I: Clinico Social Case Study
(Hospital)
Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of

Family;

Community:

Nation:

Medico Social Diagnosis MANAGEMENT

General and Specific Measures

1. Control of Reservoir
Identification (early
diagnosis) Isolation
Treatment
Follow up

2. Control of Transmission
Disinfection
Improvement of sanitation

3. Control of susceptible population

Immunization

Treatment
1. Control of Reservoir
Case: Bed rest
Sufficient fluids, high carbohydrate
diet Symptomatic management
Regular follow up, avoidance of alcohol
Fulminant hepatitis: Admission, meticulous care
Course of corticosteroids

2. Control of Transmission
• Sanitary disposal of excreta: Sanitary latrine
• Super chlorination of water: 1 mg/liter residual chlorine
• Fly control
• Boiling of drinking water: 100° C for 5 minute
• Washing hands with soap: After defecation
Before food handling
• Surveillance of public water quality
• Health education
• Vaccination
 Communicable Diseases
45
3. Control of Susceptible Host
Passive immunization:
Human normal immunoglobulin: 0.2 ml (3.2 mg)/kg—IM
Followed by active immunization
Pre-exposure (within 2 week of Contact)
• Household contacts
• Traveling to endemic areas
• Epidemic outbreaks
• Institutional outbreak
Post-exposure
• Cases
• Family contact
Active immunization:
HM 175 tissue cultured inactivated vaccine
Age: Above 1 year (2 to 40 year)
Route: IM
Site: Deltoid
Dose: 2 doses at 6–18 week interval
Booster: Every 6 month

Hepatitis-A and Hepatitis-B Combination Vaccine

Schedule: 3 doses at 0, 1 and 6 month of age

Surveillance

Review Questions
 Write briefly the National health programme regarding the Hepatitis-A.
 What are the recent advances/modifications in medico social management of Hepatitis-A?
 List the common beliefs and practices during Hepatitis-A.
46 Section I: Clinico Social Case Study
(Hospital)

TUBERCULOSIS
MEDICAL (CLINICAL) DETAILS OF THE PATIENT
Part I of the pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Description of symptoms
(in chronological order) (sudden/gradual)
Continuous Fever
Persistent cough
Chest pain
Hemoptysis
Weight loss
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:
Age at onset:
Duration between onset and diagnosis:
Duration between the onset and start of the treatment:
Diet history (as relevant):

Epidemiological History
Any similar case in the family: Yes/No
Any similar case in neighborhood:
Yes/No Any contact with similar case:
Yes/No
Existence of similar disease in the locality/district:
Other relevant information:

Epidemiological Indices of Tuberculosis (TB) in the

Locality/District General Examination

Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:
46 Section I: Clinico Social Case Study
(Hospital)
Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Clinical Findings Suggestive of Tuberculosis

Fever for > 15 day
Evening rise of temperature associated with sweating
Persistent cough for > 2 week
Chest pain
Hemoptysis
Weight loss
Others

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Sputum examination (2 sample—1 on spot
and 1 in the morning)
2. Sputum culture
3. Chest X-ray
4. Tuberculin test (for children < 2 year)
5. HIV (as relevant)

Criteria for
Clinical Diagnosis
1. Diagnosis
2. Categorization for the purpose of treatment

MEDICO SOCIAL DISCUSSION

Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors Host factors
Biological—[Link] Age, Sex, Race, Ethnicity
Reservoir and source—Human, bovine Migration
Mode of transmission—Droplet (air borne) Inheritance/Heredity
Infective material—Sputum Nutrition—Malnutrition
Infectivity period—As long as the person is Immunity
untreated (open case) Natural infection
Drug resistance strain Unimmunized—BCG
Silicosis, Diabetes, HIV, Others
 Communicable Diseases
47
Environmental factors Social factors
(Physical, Biological, Psychosocial) Indiscriminate spitting
Poor housing Sharing hukka,
Poor ventilation Smoking
Occupational environment Feeding from same plate
Overcrowding Pardha system, early marriage
Stress Economic conditions—Poverty
Religious, sociocultural practices
Prejudice/Taboos/Stigma
Illiteracy, ignorance
Urbanization, industrialization
Incorrect knowledge, attitude and practice
Irregular treatment
Availability, utilization of health services

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondar Early detection and
y prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice
(beliefs and customs)
Cause
Treatment
Prevention
Health
services
Others

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of

Family:

Community:

Nation:

Medico Social Diagnosis

48 Section I: Clinico Social Case Study
(Hospital)
MANAGEMENT
Treatment Plan

1. Case
• Patient is registered and treated under Revised national TB control programme (RNTCP)
• Sputum examination report is recorded
• Direct observed therapy short term (DOTS) is given
Patient is stratified into different categories and treated according to the RNTCP guidelines
Category Type of patient Regimen
I New sputum smear 2HRZE3 intensive
positive Seriously ill
4HR3 continuation
sputum negative
Seriously ill extra
pulmonary
II Previously treated 2HRZES3 intensive
Sputum positive 1HRZE3
relapse Sputum 5HRE3 continuation
positive failure
Sputum positive
default

HRZES—Isoniazid (H) Rifampicin (R) Pyrazinamide (Z) Ethambutol (E) [HRZE] Streptomycin (S)
Prefix—Duration in month, Suffix—Number of times in a week
Intensive phase—3 doses/week, all doses are supervised (on every alternative days)
Continuation phase—3 doses/week, 1st dose of every week is supervised, Rest of the doses are self-
adminis- tered
Sputum examination is repeated at the end of intensive phase, (i.e. 2 month), then at 4th and 6th month in continu-
ation phase.

2. Contacts/Family members
Periodic screening Isonicotinylhydrazine (INH) prophylaxis, (if indicated)
Mantoux test in children Bacille Calmette-Guerin (BCG), if indicated

ADVICE
(Preventive, Promotive and Curative)

To Patient
Take drugs regularly and completely Undergo periodic follow up
Cover the mouth with cloth while coughing Stop smoking
Take good food, do regular walking/exercise Hygienic disposal of sputum
Avoid indiscriminate spiting Test for diabetes

To Family Members
Motivate to take drugs regularly and completely
Motivate to take good food, do regular walking/exercise
Helping for hygienic disposal of sputum
Screening of all family member
 Communicable Diseases
49
To Community
Health education is given to the community through Information education and communication (IEC) about
cause, cure, treatment, and availability of services
Motivation for early detection
BCG immunization for children
Removal of stigma

Review Questions
 Write briefly the need of National health programme regarding tuberculosis.
 What are the recent advances/modifications in medico social management of tuberculosis?
 List the common beliefs and practices during tuberculosis
 Explain the meaning of:
Case Reregistered case
Sputum positive Sputum negative
Drug defaulter Relapse
Treatment failure Cured
Transferred in Transferred out
Multi drug resistance Extensive drug resistance
Extra pulmonary DOT provider
Supervised therapy Tuberculin conversion
Dots plus
 Write a note of Multi-drug resistant tuberculosis (MDR-TB) and Extensively drug-resistant
tuberculosis (XDR-TB)
 Explain the epidemiological impact of HIV and TB combination
 LEPROSY

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

History of Present Illness
Chief complaint Onset Duration Progress
(in chronological order) (sudden/gradual)
Skin lesion
Loss of sensation
Glove and
stocking
anesthesia
Ulcer
Deformity
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
Previous hospitalization/complications for same illness:
Age at onset:
Duration between onset and diagnosis:
Duration between the onset and start of the treatment:

Epidemiological Information
Any similar case in the family: Yes/No
Any similar case in neighborhood:
Yes/No Any contact with similar case:
Yes/No Any other relevant information:
Prevalence of leprosy in the: Locality: District: State:
Family history of leprosy

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Examination of Leprosy Features

Examination for leprosy is done in a good daylight, from top to bottom, both front and back with minimal
clothing for the evidence of features of leprosy.
 Communicable Diseases
51
Skin Lesions
Number: One/two to five/Numerous
Distribution: Symmetrical/Asymmetrical
Situation: Localized/Generalized
Appearance: Macule/Plaque
Size: Small/Big/Variable
Shape: Irregular/Circular—oval
Color: Erythematous /Hypopigmented
Surface: Shiny/Dry, rough
Margins: Ill-defined/Well demarcated,
Raised Feel: Soft/Firm
Sweating: Present/Impaired/Absent
Hair: Present/Sparse/Lost
Infiltration: Present/Absent
Sensation: Impaired/Lost
Sensation lost: Light touch/Pressure/Heat/Cold

Face
Leonic facies: Loss of eyebrows:
Loss of eyelashes: Weakness of eyelids—Ptosis:
Lagophthalmos: Corneal anesthesia:
Corneal ulcer: Nasal discharge:
Depression of nose: Nasal perforation:
Involvement of larynx: Facial paralysis:
Ear thickening:
Elongated lobules:
Nodules:

Hand
Wasting of muscles: Weakness:
Claw hand: Wrist drop:
Absorption of digits: Thumb contraction:
Ulcers:

Feet
Wasting of muscles: Weakness:
Plantar ulcer: Foot drop:
Inversion: Absorption of toes:
Collapse of foot: Swollen foot:

Other Organs
Testes: Epididymis:
Breast: Liver, Kidney, Adrenal:
52 Section I: Clinico Social Case Study
(Hospital)
Intercurrent Infection
Examination of Nerve
Nerve Site Thickening Tenderness Consistency Findings
Ulnar Groove •Wasting of small muscles
behind of hand
medial •Loss of sensation in ulnar
epicondyle part of hand
(Forearm is
kept •Contraction (clawing) of
flexed) 4th and 5th finger
•Weakness in 2nd and
3rd finger
Lateral popliteal Finger is •Loss of sensation in foot
hooked behind
the neck of
fibula
Great auricular Head is •Cosmetic problem
turned to
opposite side.
Nerve
stretches
across
posterior edge
of
sternomastoid
Facial Stylomasto •Loss of taste in anterior
id foramen, 1/3rd of tongue
Zygomat •Mask face
ic •Lagophthalmos
process
Trigeminal Correspondi •Corneal anesthesia
ng foramen
Median Antecubital •Thenar wasting
fossa proximal •Palmar anesthesia
to carpal
tunnel at wrist
Radial Radial groove •Wrist drop (drop)
of humerus
posterior to
deltoid
insertion
Near the
radius at
wrist
Posterior tibial Between •Plantar anesthesia
medial •Clawing of toes
malleolus and
heel
Superficial peroneal Near the neck •Foot drop
of
fibula
Supraorbital Running •Lagophthalmos
finger across
the forehead

Examination of Muscle Strength

Muscle tested S W P
1.
2.
 Communicable Diseases
3. 53
54 Section I: Clinico Social Case Study
(Hospital)

Fig. 3.2: The sites of peripheral nerves most commonly enlarged and palpable in leprosy

S—Able to move against gravity W—

Able to move towards gravity only P—
Not able to perform movements

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant examination:

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Skin smear/biopsy
2. Bacteriological—Bacteriological
index
—Morphological index
3. Immunological—Lepromin test*
4. Histamine test
5. Immunological LTT, LMIT
* Lepromin test is done to classify leprosy and assess prognosis
LTT—Lymphocyte transformation test, LMIT—Leukocyte migration inhibition test
 Communicable Diseases
55
Classification (for the purpose of treatment)
Cardinal features SSLPB PB MB
Skin lesion number 1 2–5 >5
Number of nerve involved Nil 1 >2
Skin smear -ve -ve +ve
SSLPB: Single skin lesion, PB: Pauci bacillary, MB: Multibacillary
In the doubtful condition, patient is classified as MB.

Deformities Grading
Site Grade 0 Grade I Grade II
Hand/Feet No anesthesia Anesthesia +ve Visible deformity
No visible deformity No visible deformity
Eyes No loss of vision Eye problem present Severe visual
No eye problem Vision not severely Impairment (< 6/60)
affected

Criteria for
Clinical Diagnosis
Diagnosis with Classification/Type
1. Hypopigmented patches
2. Loss of sensation
3. Thickened nerves
4. Presence of M. leprae
5. Deformity

MEDICO SOCIAL DISCUSSION

Identification of the factors responsible for/influencing the present condition
Agent factors Host factors
Biological agent—M. leprae Age
Reservoir—Cases Sex
Source of infection—Multi bacillary cases Race
Mode of infection—Airborne/Close contact Migration
Immuni
Infective material—Respiratory
ty
secretions Portal of exit—Nose,
Others
mouth
Period of infectivity—As long as the patient is
untreated
Environmental factors Social factors
(Physical, Biological, Psychosocial) Low standard of living
Presence of infection in the community Substandard housing
Occupational environment Overcrowding
Endemic region Poor hygiene
Temperature and Humidity Illiteracy, ignorance
Concealing the disease due to stigma
56 Section I: Clinico Social Case Study
(Hospital)
Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude, and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice

(beliefs and customs)
Cause of
leprosy
Treatment
Prevention
Health
services
Stigma

Influence of Medico Social Factors in Diagnosis, Treatment, and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of

Family:

Community:

Nation:

Medico Social Diagnosis MANAGEMENT

Treatment plan

1. Case:
Drugs
Type Duration
Rifampicin Dapsone Clofazimine
MB 12 month 600 mg once a 100 mg daily (self) 300 mg once a
month month
(supervised) (supervised) 50 mg
daily (self)
PB 6 month 600 mg once a 100 mg daily (self) Nil
month
(supervised)
Single skin lesion: Rifampicin-600 mg + Ofloxacin-400 mg + Minocycline-100 mg (ROM therapy)

2. Contact:
Chemoprophylaxis—Dapsone (1–4 mg/kg/week for 3 month)

3. Other family members:

Periodic examination
 Communicable Diseases
57
Surveillance:
Once in a year for 5 year after treatment

ADVICE
(Preventive and Promotive

Advice) Patient
Primary
• Adopt good nutrition and healthy lifestyle
• Raising socioeconomic educational level
• Health Education
• Avoid alcohol, smoking
• Protection from burns, injuries
• Care during lepra reaction
• Self care: Ulcer, eye, hand, foot
• Hygienic disposal of nasal and wound secretions
• Using microcellular footwear

Secondary
• Take drugs as per
• schedule Go for periodic

Tertiary checkup
•

Family Using the rehabilitation (medical, social, surgical, psychological, vocational) facility
Accept the patient and do not isolate/outcast
Motivate to take drugs regularly
Motivate to go for periodic checkup
Motivate to adopt good nutrition and healthy lifestyle
Periodic examination of all family members/contacts

Community
Early detection of case by—Contact tracing, mass survey, examination of school children, slum population
Efforts to remove the social stigma through IEC
Creating awareness regarding scientific knowledge of leprosy through
IEC Providing services through Primary health care (PHC)
58 Section I: Clinico Social Case Study
(Hospital)
Review Questions
 Write briefly the National health programme regarding leprosy
 What are the recent advances/modifications in medico social management of leprosy?
 List the common beliefs and practices during leprosy
 What is your opinion regarding the conversion of leprosy vertical programme into horizontal programme?
 Mention the social benefits available for cured leprosy patients.
 Explain the meaning of—
Case of leprosy
New case of leprosy
Reregistered case
Drug defaulter
Release from treatment
Released from register
Cured
Transferred in/Transferred out
 HEPATITIS-B

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

Part I of the proforma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Progress
(in chronological order) (sudden/gradual)
Fever
Malaise, Myalgia,
Tiredness
Anorexia, Nausea,
Vomiting
Epigastric pain
Yellow discoloration of
sclera
Weight loss
Skin itching
Altered consciousness
Flapping tremors
Dark colored urine
Clay colored stools
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:
H/o the following for the past > 6 month of duration: (Incubation period—6 month)
Blood transfusion, dialysis, injections
Needle piercing—Nose/ear pricking, tattooing
Surgery, tooth extraction, injury with sharps
Sexual exposure
Baby delivered by Hepatitis-B mother

Epidemiological History: for Communicable Diseases

Any similar case/carrier in the family: Yes/No
Any similar case/carrier in neighborhood: Yes/No
Any contact with similar case/carrier: Yes/No
Existence of similar disease in the locality/district:
Other relevant information—Risk behavior: Multiple sexual partners
Unsafe sex
Exposure to sharp needle injuries
Carrier mother
 Communicable Diseases
59
General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Clinical Findings Suggestive of Hepatitis-B

Symptoms: 1.
2.
3.
4.
Sclera - For yellow discoloration
Abdomen - Distension
Tender, Enlarged liver
Lymphadenopathy - Rarely

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Serum HBsAg
Bilirubin > 1 mg (Normal: 0.3–0.5
mg%) IgM antibody to HBV (new
infection) IgG (past infection)
2. Liver function test SGOT
SGPT
3. Urine Bile Salt
Bile pigment

Clinical Diagnosis
60 Section I: Clinico Social Case Study
(Hospital)
Criteria for Diagnosis
1. Clinical symptoms
2. HBsAg reactive
3. HBV—Specific IgM antibodies

MEDICO SOCIAL DISCUSSION

Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors Host factors
Biological agent—Hepatitis B virus Age—Active sexual age (20–40 year)
Reservoir—Human cases/carriers Sex—Both
Infective material—Blood, serum, semen, vaginal fluid High risk group—FSW, MSM, truckers, etc.
Infective period—1 month prior to jaundice to Migration
too many years Immunity
Transmission—Blood contact, sexual contact, Blood transfusion, dialysis
mother to child IM/IV drug use
Others
Environmental factors Social factors
(Physical, biological, psychosocial) Illiteracy, ignorance
Occupational environment—Sex work, transportation, Incorrect knowledge, attitude and
etc. practice Poor economic conditions
Poor quality of life
Socio cultural practices/superstitions
Religious practices
Use of unsterilized needles
Non-availability and utilization of health services

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice

(beliefs and customs)
Cause of
Hepatitis-B
Treatment
Injection
safety Safe
sex
Health services
 Communicable Diseases
61
Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of

Family:

Community:

Nation:

Medico Social Diagnosis MANAGEMENT

Preventive Measures

Passive Immunization:
Hepatitis B immunoglobulin (HBIG)
• Within 6 hour maximum 48 hour of exposure
• To newborn of carrier mother
• Dose—0.05 to 0.07 ml/kg (8–11 mg/kg)
• 2 doses, 30 day apart

Active Immunization:
Inactivated subunit vaccine
• 1 ml (20 mcg surface antigen) for adults, 0.5 ml for children
• At 0,1 and 6 month interval, Intramuscular
• Preferably given to Newborn (birth dose)—Within 24 hour of birth

ADVICE
(Preventive, Promotive and Curative)

Patient
Avoid alcohol
Practice healthy lifestyle
Go for periodic checkup
Do not donate blood
Safe sex practice by using barrier method
Reveal the status to your health care provider

Family
Motivate the patient to lead healthy life
Motivate him for periodic checkup
Do not outcast the Hepatitis-B infected person
Do not share the sharp materials used by the patient
Take precautions during injections, sharp pricking, blood transfusion,
etc. Practice safe sex
62 Section I: Clinico Social Case Study
(Hospital)
Community
Take Hepatitis-B immunization
Alertness regarding sharps, injury and blood contact
Safe sex practices
Regulations on blood bank
Encouragement for voluntary blood donation

Health Care Provider

Following the universal precautions
Strict sterilization practices
Screening of the blood and blood products
During accidental injury, immediate Hepatitis-B immunoglobulin followed by active immunization is adminis-
tered

Surveillance

Review Questions
 Write briefly the need of National health programme regarding Hepatitis-B
 What are the recent advances/modifications in medico social management of Hepatitis-B?
 List the common beliefs and practices during Hepatitis-B
 SEXUALLY TRANSMITTED DISEASE

SEXUALLY TRANSMITTED DISEASE (Except Hepatitis-B and HIV)

MEDICAL (CLINICAL) DETAILS OF THE PATIENT
Part I of the pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Description of symptoms
(In chronological order) (sudden/gradual)
Urethral Discharge
Scrotal Swelling
Inguinal Swelling
Genital Ulcer/Itching
Vaginal Discharge/Itching
Anal Discharge/Itching
Lower Abdominal Pain
Pharyngitis
Others
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:

Epidemiological History: for Communicable Diseases

H/o unprotected sexual exposure (in detail):
Age, sex, address of sexual partner:
Any similar case in friends/peer group: Yes/No
Any sexual contact with similar case: Yes/No
Existence of similar disease in the locality/district:
Other relevant sexual risk behavior

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:
64 Section I: Clinico Social Case Study
(Hospital)
Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Lab InvestigationsDiagnosis
Epidemiological
Sl No Examinations required Report
1. Discharge—Microscopy, culture
2. Blood—Serology
3. Other

Criteria
Clinicalfor
Diagnosis
Diagnosis:

Classification:

MEDICO SOCIAL DISCUSSION

Identification of the Factors Responsible for/Influencing the Present Condition
Agent factors Host factors
Biological—Pathogens spread by sexual contact Age—sexually active
life Sex—both
Migratio
n
Immunit
y
Sexual risk behavior—MSM, FSW, truck drivers, etc.
Others
Environmental factors Social factors
Population explosion Social disruption
Increase in younger population International travel
Rural-urban migration Changing behavioral pattern
Delaying in the age of marriage Alcoholism
Opportunities of sexual exposure Low socioeconomic conditions
Urbanization/Industrialization Social stigma
Commercial sex work Unemployment
Broken home Incorrect knowledge, attitude, and practice
Sexual disharmony Habit and lifestyle
Easy money Non-availability and utilization of health services
Emotional immaturity
 Communicable Diseases 65

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice

(beliefs and customs)
Cause of
STD
Treatment
Prevention
Safe sex
practice Health
services
Others

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of

Family:

Community:

Nation:

Medico Social Diagnosis MANAGEMENT

Treatment plan

Case :
Full course of appropriate antibiotics
Follow up of the patients
Health education

Contacts :
Partner treatment—Full course of appropriate antibiotics

Community :
Screening
Contact tracing
Cluster tracing
Case holding and treatment
Personal prophylaxis
66 Section I: Clinico Social Case Study
(Hospital)
Establishment of sexually transmitted disease (STD) clinics
Health education—Information education and communication (IEC)
Legislation
Social welfare measures
Monitoring and evaluation

ADVICE
(Preventive, Promotive and Curative)
Patient
Risk of STD infections to the patient, partners and contacts
Motivation for the complete treatment
Initiate the partner to take the treatment
Safe sex practices

Community
Efforts are made to remove the social stigma through IEC
Incultation of complete curability of STD
Availability of
services Safe sex
practices
Sex education at high schools and college levels

Review Questions
 National health programme regarding STD
 Recent advances/modifications in medico social management of STD?
 Write the flow diagram of syndromic management of STD
 Discuss MSM (male having sex with male) activities in your city. What is their contribution for HIV
and STD.
 Chapte
r
Non-communicable
Diseases
4

DIABETES MELLITUS

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

Part I of the pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Description of symptoms
(in chronological order) (sudden/gradual)
Polyuria
Polydipsia
Polyphagia
Loss of weight
Weakness, fatigue
Non-healing wound
Pruritus vulvae
Others

Treatment before admission: Yes/No

If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:

Diet History (as relevant)

Epidemiological History (as relevant)
Age at onset of symptoms:
Duration between onset and diagnosis:
Duration between diagnosis and start of treatment:
Existence of similar disease in the locality:
 Non-Communicable Diseases
67
Family (Hereditary) History:
Non-communicable disease: Present/Absent
If yes specify: DM/HTN/CHD/Cancer/Others
Genetic background of diabetes mellitus: Present/Absent
If present, degree of relationship:

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Examination Pertinent to Diabetic

Eyes: Foot:
Skin: Ulcer/Infection:
Body mass index (BMI): Waist-hip circumference
ratio: Others:

Epidemiological Diagnosis

Lab Investigations

Investigations Required Done (Method used) Report

Urine: Sugar
Albumin
Microscopy
Protein
Ketone
bodies
Blood: FBS
GTT
Lipid profile
Glycosylated hemoglobin
Clinical Diagnosis
68 Part I: Clinico Social Case Study
(Hospital)
Criteria for

Diagnosis:
Symptoms—
Lab findings—

Classification:
Insulin-dependent diabetes mellitus IDDM (type I)
Non insulin-dependent diabetes mellitus NIDDM (type II)
Impaired glucose tolerance IGT
Malnutrition-related diabetes mellitus MRDM
Gestational diabetes mellitus GDM
Others, specify

MEDICO SOCIAL DISCUSSION

Identification of the Factors Responsible for/Influencing the Present Condition
Environmental factors Biological risk factors Social factors
Age, sex Ethnicity/Inheritance
(Physical, biological, psychosocial) Economic conditions
Metabolic—Insulin deficiency (absolute/relative)
Occupational environment Marital status
Genetic markers Nutritional—Obesity Physical—Inactivity Biological—Infections of pancreas Migration
Stress and
Immune strain Maternal diabetes Syndrome X
mechanism Religious practices
Others
Chemical agents affecting pancreas Lack of education
Urbanization
Alcohol intake
Unemployment
Incorrect knowledge, attitude and practice
Malnutrition
Habit and lifestyle
Social stigma
Non-availability and utilization of health services
 Non-Communicable Diseases
69
Levels of prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice

(beliefs and customs)
Cause of Diabetes
Mellitus Treatment
Prevention
Health
services
Others

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease

Impact of the Disease on Socioeconomic Status of

Family:

Community:

Nation:

Medico Social Diagnosis

MANAGEMENT
General Measures

Primordial Prevention:
Population strategy
High risk strategy—Reduction of risk factors

Secondary Prevention:
Early detection and treatment

Tertiary Prevention:
Organizing specialized diabetic rehabilitation clinics

Treatment Plan
Diet
Exercise
Drugs
Diabetes knowledge
70 Part I: Clinico Social Case Study
(Hospital)
Diet:
What to eat:
What not to eat (Prohibited foods):
When to eat—Time/frequency:
How much to eat (Amount of food)
• Liberally (desired):
• Moderate:
• Restriction:
Proportion of nutrients in diet:
• Carbohydrate: %
• Fat: %
• Protein: %

Exercise:
Type and Frequency:

Drugs:
Drug:
Dosage:
Frequency:

Diabetes education/knowledge:
Does the patient require reference to higher center
If yes, reasons

ADVICE
(Preventive, Promotive and Curative)

Patient
Adherence to diet, exercise
Follow drug regimens
Periodic examination and follow up

Family
Motivate the patient to take proper diet and drugs
Motivate the patient for periodic checkup
Family members—To undergo screening for diabetes

Community
Early diagnosis and prompt treatment
Genetic counseling
Healthy lifestyle
Regular monitoring of weight, BP, Blood sugar
 Non-Communicable Diseases
71
Review Questions
 National health programme regarding the disease.
 Prevalence of diabetes in your district/state.
 Recent advances/modifications in medico social management of the condition.
 Write the importance of glycosylated hemoglobulin.
 What are all the health care facilities necessary for the diabetic patients?
72 Part I: Clinico Social Case Study
(Hospital)

HYPERTENSION
MEDICAL (CLINICAL) DETAILS OF THE PATEINT
Part I of the pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Description of symptoms
(in chronological order) (sudden/gradual)

Headache
Dizziness
Dyspnea
Angina
Palpitation
Blurred vision
Edema
Tremors
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:

Diet History (as relevant)

Salt intake:
Saturated fat intake:

Epidemiological History (as relevant)

Age at onset of symptoms:
Duration between onset and diagnosis:
Duration between diagnosis and start of treatment:
Existence of similar disease in the locality:

Family (Hereditary) History

Non-communicable disease: Present/Absent
If yes, specify: DM/HTN/CHD/Cancer/Others
Genetic background of Diabetes mellitus/Hypertension: Present/Absent
If present, degree of relationship:

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
 Non-Communicable Diseases
73
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Examination Pertinent to Hypertension

Eyes:
Renal system:
Endocrinal:
BP recording at various posture:
BMI: Waist-hip circumference:
Others:

Epidemiological Diagnosis

Lab Investigations

Examinations Required Done (Method used) Report

ECG—LV hypertrophy and IHD
Echocardiogram—LV functions
and coarctation of aorta
Urine analysis—Protienuria, hematuria
X ray chest—Aorta
Lipid profile
IVP—Renal tumor and stones
Abdominal Sonography—Polycystic
kidney
Clinical Diagnosis

Criteria for
Diagnosis
Primary/Essential:
Secondary/Non-essential:
Categorization of Blood Pressure
Category BP measurements
Systolic Diastolic
Normal 120–130 80–85
High normal 131–139 86–90
Hypertension
•Mild 140–159 90–99
•Moderate 160–179 100–109
•Severe > 180 > 110
74 Part I: Clinico Social Case Study
(Hospital)
MEDICOSOCIAL DISCUSSION
Identification of the Factors Responsible for/Influencing the Present Condition
Biological risk factors
Age, sex Ethnicity/Inheritance Family history Personality—Type ‘A’ Genetic markers
Nutritional—Obesity, faulty diet, high salt, high saturated fat, low-fiber diet intake
Physical—Inactivity Migration Syndrome X
Oral contraceptives
Others

Environmental factors Social factors

(Physical, biological, psychosocial) Economic conditions
Occupational environment Lack of education
Noise, temperature, humidity, vibration Urbanization
Stress and strain Alcohol intake, smoking
Incorrect knowledge, attitude and practice
Habit and lifestyle
Social stigma
Non-availability and utilization of health services

Levels of Preventions
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Particulars Knowledge Attitude Practice
(beliefs and customs)
Cause of
Hypertension
Treatment
Prevention
Health
services
Stigma
 Non-Communicable Diseases
75
Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of
Family:
Community:
Nation:
Medico Social Diagnosis

MANAGEMENT
General Measures
Primordial Prevention:
Population strategy
High risk strategy—Reduction of risk factors

Secondary Prevention:
Early detection and Treatment

Tertiary Prevention:
Organizing specialized rehabilitation clinics

Treatment Plan
Individual Level
Non-Pharmacological:
Lifestyle modifications:
Salt restriction: < 6 gm/day
Weight reduction: Reduction of 1 kg body weight will reduce 1.6/1.3 mmHg of
BP Stop smoking
Diet:
• Food rich in poly unsaturated fat, potassium, calcium, magnesium is selected
• Saturated fat and cholesterol is reduced
• Fruits, vegetables, green leafy vegetables are taken more
• Limit of alcohol: < 30 ml/day
Relaxation
Regular exercise

Pharmacological:
Drug Dosage and frequency Instructions
Diuretics
Beta
blockers
Calcium channel
blockers ACE
inhibitors Angiotensin
II blockers Alpha
blockers Vasodilators
Other new drugs
76 Part I: Clinico Social Case Study
(Hospital)
Hypertension education/knowledge:
Does the patient requires reference to higher center?
If yes, reasons

ADVICE
(Preventive, Promotive and Curative)

Patient
Adherence to diet, exercise
Follow drug regimens
Periodic examination and follow up

Family
Motivate the patient to take proper diet and drugs
Motivate the patient for periodic checkup
Family members—To undergo screening for hypertension

Community
Preventing emergence of risk factors (primordial prevention)
Early diagnosis and prompt treatment
Genetic counseling
Healthy lifestyle
Periodic health checkup
Regular monitoring of weight, BP and blood sugar

Review Questions
 National health programme regarding the disease
 Prevalence of hypertension in your district/state
 Recent advances/modifications in medico social management of the condition
 What is rule of halves?
 What is the importance of blood pressure tracking?
 Note the long standing hazards of hypertension other than stroke
 Chapte
r
Non-communicable
Diseases
4

DIABETES MELLITUS

MEDICAL (CLINICAL) DETAILS OF THE PATIENT

Part I of the pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Description of symptoms
(in chronological order) (sudden/gradual)
Polyuria
Polydipsia
Polyphagia
Loss of weight
Weakness, fatigue
Non-healing wound
Pruritus vulvae
Others

Treatment before admission: Yes/No

If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:

Diet History (as relevant)

Epidemiological History (as relevant)
Age at onset of symptoms:
Duration between onset and diagnosis:
Duration between diagnosis and start of treatment:
Existence of similar disease in the locality:
68 Section I: Clinico Social Case Study
(Hospital)
Family (Hereditary) History:
Non-communicable disease: Present/Absent
If yes specify:
DM/HTN/CHD/Cancer/Others
Genetic background of diabetes mellitus: Present/Absent
If present, degree of relationship:

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Examination Pertinent to Diabetes

Eyes: Foot:
Skin: Ulcer/Infection:
Body mass index (BMI): Waist-hip circumference
ratio: Others:

Lab InvestigationsDiagnosis
Epidemiological
Investigations Required Done (Method used) Report
Urine: Sugar
Albumin
Microscopy
Protein
Ketone
bodies
Blood: FBS
GTT
Lipid profile
Glycosylated hemoglobin
 Non-communicable Diseases
69

Clinical Diagnosis
Criteria for
Diagnosis:
Symptoms—
Lab findings—

Classification:
Insulin-dependent diabetes mellitus IDDM (type I)
Non insulin-dependent diabetes mellitus NIDDM (type II)
Impaired glucose tolerance IGT
Malnutrition-related diabetes mellitus MRDM
Gestational diabetes mellitus GDM
Others, specify

MEDICO SOCIAL DISCUSSION

Identification of the Factors Responsible for/Influencing the Present Condition
Biological risk factors
Age, sex
Ethnicity/Inherita
nce
Metabolic—Insulin deficiency
(absolute/relative) Genetic markers
Nutritional—Obesity Physical
—Inactivity Biological—
Infections of pancreas
Migration
Immune
mechanism
Maternal diabetes
Syndrome X
Others
Environmental factors Social factors
(Physical, biological, Economic
psychosocial) Occupational conditions Marital
environment status Religious
Stress and strain practices Lack of
Chemical agents affecting pancreas education
Urbanization
Alcohol
intake
Unemployme
nt
Incorrect knowledge, attitude and
practice Malnutrition
Habit and
lifestyle Social
stigma
Non-availability and utilization of health services
70 Section I: Clinico Social Case Study
(Hospital)
Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation

Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease

Attitude
Particulars Knowledge Practice
(beliefs and customs)
Cause of Diabetes
Mellitus Treatment
Prevention
Health
services
Others

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of

Family:

Community:

Nation:

Medico Social Diagnosis MANAGEMENT

General Measures

Primordial Prevention:
Population strategy
High risk strategy—Reduction of risk factors

Secondary Prevention:
Early detection and treatment

Tertiary Prevention:
Organizing specialized diabetic rehabilitation clinics

Treatment Plan
Diet
Exercise
Drugs
Diabetes knowledge
 Non-communicable Diseases
71
Diet:
What to eat:
What not to eat (Prohibited foods):
When to eat—Time/frequency:
How much to eat (Amount of food)
• Liberally (desired):
• Moderate:
• Restriction:
Proportion of nutrients in diet:
• Carbohydrate: %
• Fat: %
• Protein: %

Exercise:
Type and Frequency:

Drugs:
Drug:
Dosage:
Frequency:

Diabetes education/knowledge:
Does the patient require reference to higher
center If yes, reasons

ADVICE
(Preventive, Promotive and Curative)

Patient
Adherence to diet, exercise
Follow drug regimens
Periodic examination and follow up

Family
Motivate the patient to take proper diet and drugs
Motivate the patient for periodic checkup
Family members—To undergo screening for diabetes

Community
Early diagnosis and prompt treatment
Genetic counseling
Healthy lifestyle
Regular monitoring of weight, BP, Blood sugar
72 Section I: Clinico Social Case Study
(Hospital)
Review Questions
 National health programme regarding diabetes mellitus.
 Prevalence of diabetes in your district/state.
 Recent advances/modifications in medico social management of diabetes mellitus?
 Write the importance of glycosylated hemoglobin.
 What are all the health care facilities necessary for the diabetic patients?
 HYPERTENSION
MEDICAL (CLINICAL) DETAILS OF THE PATIENT
Part I of the pro forma has to be filled before starting this Part

History of Present Illness

Chief complaints Onset Duration Description of symptoms
(in chronological order) (sudden/gradual)

Headache
Dizziness
Dyspnea
Angina
Palpitation
Blurred vision
Edema
Tremors
Treatment before admission: Yes/No
If yes, nature of treatment (in brief):
If treatment has discontinued, reasons:

Past History (as relevant)

H/o previous illness/hospitalization for similar complaint:
Time of illness: Nature: Hospitalization:
Complications: Treatment:

Diet History (as relevant)

Salt intake:
Saturated fat intake:

Epidemiological History (as relevant)

Age at onset of symptoms:
Duration between onset and diagnosis:
Duration between diagnosis and start of treatment:
Existence of similar disease in the locality:

Family (Hereditary) History

Non-communicable disease: Present/Absent
If yes, specify:
DM/HTN/CHD/Cancer/Others
Genetic background of diabetes mellitus/hypertension: Present/Absent
If present, degree of relationship:

General Examination
Built: Anemia:
Height: Clubbing:
Weight: Cyanosis:
74 Section I: Clinico Social Case Study
(Hospital)
Nourishment: Jaundice:
Temperature: Lymphadenopathy:
Pulse: Edema:
Blood pressure:
Respiration:

Systemic Examination
RS:
CNS:
CVS:
Abdomen:
Other relevant system:

Examination Pertinent to Hypertension

Eyes:
Renal system:
Endocrinal:
BP recording at various posture:
BMI: Waist-hip circumference:
Others:

Lab InvestigationsDiagnosis
Epidemiological
Examinations Required Done (Method used) Report
ECG—LV hypertrophy and IHD
Echocardiogram—LV functions
and coarctation of aorta
Urine analysis—Protienuria, hematuria
X ray chest—Aorta
Lipid profile
IVP—Renal tumor and stones
Abdominal Sonography—Polycystic
kidney

Criteria for
Clinical Diagnosis
Diagnosis
Primary/Essential:
Secondary/Non-essential:
Categorization of Blood Pressure
 Non-communicable Diseases
75
Category BP measurements
Systolic Diastolic
Normal 120–130 80–85
High normal 131–139 86–90
Hypertension
•Mild 140–159 90–99
•Moderate 160–179 100–109
•Severe > 180 > 110

MEDICO SOCIAL DISCUSSION

Identification of the Factors Responsible for/Influencing the Present Condition
Biological risk factors
Age, sex
Ethnicity/Inheritan
ce Family history
Personality—Type
‘A’ Genetic
markers
Nutritional—Obesity, faulty diet, high salt, high saturated fat, low-fiber diet intake
Physical—Inactivity
Migration
Syndrome
X
Oral contraceptives
Others
Environmental factors Social factors
(Physical, biological, Economic
psychosocial) Occupational conditions Lack of
environment education
Noise, temperature, humidity, Urbanization
vibration Stress and strain Alcohol intake, smoking
Incorrect knowledge, attitude and
practice Habit and lifestyle
Social stigma
Non-availability and utilization of health services

Levels of Prevention
Levels of prevention Which level has failed? How it could have been prevented?
Primary Health promotion
Specific protection
Secondary Early detection and
prompt treatment
Tertiary Disability limitation
Rehabilitation
76 Section I: Clinico Social Case Study
(Hospital)
Assessment of Knowledge, Attitude and Practice (KAP) Towards the Disease
Particulars Knowledge Attitude Practice
(beliefs and customs)
Cause of
Hypertension
Treatment
Prevention
Health
services
Stigma

Influence of Medico Social Factors in Diagnosis, Treatment and Prevention of the Disease
Impact of the Disease on Socioeconomic Status of
Family:
Community:
Nation:

Medico Social Diagnosis MANAGEMENT

General Measures
Primordial Prevention:
Population strategy
High risk strategy—Reduction of risk factors

Secondary Prevention:
Early detection and Treatment

Tertiary Prevention:
Organizing specialized rehabilitation clinics

Treatment Plan
Individual Level
Non-Pharmacological:
Lifestyle modifications:
Salt restriction: < 6 gm/day
Weight reduction: Reduction of 1 kg body weight will reduce 1.6/1.3 mmHg of
BP Stop smoking
Diet:
• Food rich in poly unsaturated fat, potassium, calcium, magnesium is selected
• Saturated fat and cholesterol is reduced
• Fruits, vegetables, green leafy vegetables are taken more
• Limit of alcohol: < 30 ml/day
Relaxation
Regular exercise
 Non-communicable Diseases
77
Pharmacological:
Drug Dosage and frequency Instructions
Diuretics
Beta
blockers
Calcium channel
blockers ACE
inhibitors Angiotensin
II blockers Alpha
blockers Vasodilators
Other new drugs

Hypertension education/knowledge:
Does the patient requires reference to higher center?
If yes, reasons

ADVICE
(Preventive, Promotive and Curative)

Patient
Adherence to diet, exercise
Follow drug regimens
Periodic examination and follow up

Family
Motivate the patient to take proper diet and drugs
Motivate the patient for periodic checkup
Family members—To undergo screening for hypertension

Community
Preventing emergence of risk factors (primordial prevention)
Early diagnosis and prompt treatment
Genetic counseling
Healthy lifestyle
Periodic health checkup
Regular monitoring of weight, BP and blood sugar

Review Questions
 National health programme regarding the disease
 Prevalence of hypertension in your district/state
 Recent advances/modifications in medico social management of hypertension?
 What is rule of halves?
 What is the importance of blood pressure tracking?
 Note the long standing hazards of hypertension other than stroke
 Section II

SPOTTERS

5. Food Items
6. Immunizing Agents
7. Family Planning Appliances
8. Vectors
9. Chemicals in Public Health
10. Models
11. Diagrams
 Chapte
r Food Items

RICE
Introduction : Staple cereal of man.
Predominant function : Energy and protein providing.
RDA* : 460 gm for sedentary male.
410 gm for sedentary female.
Nutrients (per 100 gm) : Micronutrients are highly concentrated in outer layer (brawn).
Protein 6.5 gm
Carbohydrate 75 gm
Fat 0.5 gm
Energy 350 Kcal
Macronutrients : Rice provides better quality of protein (rich in amino acid—Lysine). About 50 percent
of the daily requirement of protein is provided by rice.
Micronutrients : Rich—Thiamine, Niacin, pyridoxine and riboflavin (B group vitamins).
Poor—Vitamin A, C, D, calcium and iron.
Public health aspects : Maximum benefits can be obtained by eating rice along with pulses in 8:1 ratio as pulses
supply amino acids lacking
in rice (Mutual supplemen-
tation of amino acids).
Polishing, washing, cook-
ing with excess of water
and draining deprives
nutrients.
Using under milled rice in
place of highly polished
rice is advised.
Highly polished rice predis-
poses beriberi.
Preparations : Rice (Fig. 5.1) is used in su-
per ORS
Rice, dosa, idly, roti, rice
flakes, puffed rice and many
more. Fig. 5.1: Rice
82 Section II:
Spotters
Nutritive value and other
properties of puffed rice
and rice flakes is almost
similar to that of rice.
* To achieve nutritional adequacy as per
Recommended dietary allowances (RDA).
RAGI
Introduction : Cheapest millet.
Staple food for South Indi-
ans (Main source of protein
and energy).
Predominant function : Energy and protein provid-
ing.
RDA : 460 gm for sedentary male.
410 gm for sedentary fe-
male.
Nutrients (per 100 gm) : Protein 7 gm Fig. 5.2: Ragi
Carbohydrate 72 gm
Fat 1 gm
Energy 330 Kcal
Macronutrients : Deficient in essential amino acid—Lysine.
Micronutrients : Rich—Calcium (340 mg/100 gm), iron (4 mg/100 gm), contains iodine also.
Public health aspects : Advised for diabetics and obese.
Used as a multipurpose food.
Maximum benefit (mutual supplementary effect of amino acids) can be obtained by
eat- ing this millet along with pulses in 5:1 proportion.
Preparations : Ragi (Fig. 5.2) flour is used in preparations like porridge, roti, halwa, balls, etc.
JOWAR (MILLETS)
Introduction : Staple diet for many people.
Predominant function : Main source of energy and
protein.
RDA : 460 gm for sedentary male.
410 gm for sedentary fe-
male.
Nutrients (per 100 gm) : Protein 10 gm
Carbohydrates 72 gm
Fat 1.9 gm
Energy 350 Kcal
Macronutrients : Millet protein is deficit in
amino acids—Lysine and
threonine.
Micronutrient : Rich—Iron (4 mg/100 gm),
phosphorus.
Poor—Vitamin C, Fig. 5.3: Jowar (millets)
calcium.
 Food Items 83

Public health aspects : High leucine contents interfere in conversion of tryptophan into niacin. Hence, excess
of consumption causes ‘pellagra’.
Fungi (Aspergillus flavus) will infest during improper storage and produces aflatoxins,
which is potent hepatotoxin and carcinogenic.
Properly dried (moisture below 10%) and kept. Contaminated grain should not be con-
sumed.
Preparations : Jowar (Fig. 5.3) flour is used in preparations like roti, balls, etc.

WHEAT
Introduction : Important staple cereal used worldwide.
Predominant function : Energy and protein providing.
RDA : 460 gm for sedentary male.
410 gm for sedentary female.
Nutrients (per 100 gm) : Protein 12 gm
Carbohydrate 72 gm
Fat 1.5 gm
Energy 350 Kcal
Macro nutrients : Wheat protein is deficit in lysine and threonine.
Micronutrients : Rich—B group and D vitamin, iron, calcium, phosphorus and other minerals.
Poor—Thiamine, riboflavin, niacin.
Public health aspects : Refined wheat flour (maida) is flour minus husk, it is poor in nutrients and fiber.
Whole grains furnish all nutrients. Hard milling discarding bran is discouraged.
Sticky and spongy properties of gluten enables to prepare bread, biscuits, cake, semo-
lina, etc.
Wheat protein (Gluten) may be allergic to few.
Wheat (Fig. 5.4) should be used as a whole and eaten along with pulses (5:1 ratio) to get
maximum benefit.
Preparations : Atta, maida, suji, baby food,
chapati, puri, roti, bread,
biscuit, noodles, etc.

PULSES (LEGUMES)
Introduction : Pulses (legumes) are indis-
pensable in Indian diet, less
expensive than animal pro-
tein.
Pulses (Fig. 5.5) can be
eaten as whole grain or as
pulses.
Palatable and brings variety
to food.
Predominant function : Body building.
RDA : 40 gm for sedentary male/
female.
Fig. 5.4: Wheat
84 Section II:
Spotters
Nutrients (per 100 gm) : Protein 22 gm
Carbohydrate 60 gm
Fat 2 gm
Energy 330 Kcal
Macronutrient : Pulse protein is rich in
lysine.
Deficient in methionine and
cystine.
Biological value of protein
is better than cereals but,
poor than animal protein.
Micronutrients : Rich—B group vitamins
(thiamine, riboflavin and
pyridoxine), iron and cal-
cium.
Poor—Minerals. Fig. 5.5: Red Gram Dal

Nil—Vitamin A and C.
Public health aspects : Oligosaccharides of pulses cause flatulence.
Antinutrient factors (tannins and phytate) in pulses adversely affects on bioavailability
of nutrients, but can be destroyed by heat.
Pulses are adulterated with kesari dal. Toxin beta-oxalylamino-alanine (BOAA) of ke-
sari dal causes neurolathyrism.
Sprouting increases riboflavin, niacin, choline, biotin and vitamin C, destroys antinutri-
ents and toxic factors.
Fermentation improves digestibility, palatability, bioavailability of essential amino acids
and enhances B-group vitamins—thiamine, riboflavin and niacin.
Maximal benefit is obtained by eating whole pulses along with cereals in 1:8 ratio, as
cereals provide amino acids lacking in pulses (supplementary action of protein).
Preparations : Sambar, gravy, sweets, dosa, idly, etc.
Roasted bengal gram dal is used in multipurpose food.

SOYA BEANS
Introduction : Soya bean is a pulse which is richest in protein than any other food item. Soya is
‘Queen of pulses’.
Predominant function : Body building.
RDA : 40 gm for male/female.
Nutrients (per 100 gm) : Protein 43 gm
Carbohydrate 20 gm
Fat 19 gm
Energy 430 Kcal
Macronutrients : Rich in protein, but quality of protein is inferior to that of animal protein.
Limiting amino acid is methionine.
Micronutrients : Rich—Iron, calcium and phosphorus.
 Food Items 85

Poor—Vitamin B6 and C.
Public health aspects : Soya (Fig. 5.6) should be
introduced and popularized
for the prevention of protein
deficiency.
Preparations : Flour, dal, milk, curd, sauce,
powder baby food, etc.

GROUNDNUT (PEANUT)
Introduction : Most commonly used oil
seed often called ‘King of
nuts’.
Predominant function : Energy and fat providing.
RDA : Taken in restricted amount.
Nutrients (per 100 gm) : Protein 25 gm
Carbohydrate 25 gm
Fig. 5.6: Soya Beans
Fat 40 gm
Energy 560 Kcal
Macronutrients : Concentrated source of protein, fat and energy.
Protein is rich in lysine.
Groundnuts eaten along with cereals and pulses will provide good quality of proteins.
Micronutrients : Rich—Thiamine, nicotinic acid, calcium, phosphorus and iron.
Poor—B6 and vitamin C
Public health aspects : Used mainly for oil extraction. De oiled meal (cake) is used in preparation of protein
rich children food, cattle feed, and malt.
Groundnut (Fig. 5.7) gets affected with fungus if not dried and stored properly. Afla-
toxin produced by aspergillus flavus fungi is carcinogenic and hepatotoxic.
Preparations : Cooking oil, peanut butter,
snacks, Indian multipurpose
food, etc. Oil is highest in
Monounsaturated fatty acids
(MUFA) (50%), low cost,
high nutritive value, deli-
cious, favorite to all.

COW’S MILK
Introduction ; Milk is a complete food
(Fig. 5.8).
Promotes and maintains
growth and development.
Ideal for children. Best suit-
able for all ages and both
sex, advised for infant,
children, pregnancy,
lactation, illness,
and vulnerable Fig. 5.7:
Groundnut
population.
86 Section II:
Spotters
Predominant function : Body building.
RDA : 150 ml for sedentary adult.
100 ml for sedentary fe-
male.
250 ml for pregnancy and
lactation.
Nutrients (per 100 ml) : Protein 3 gm
Fat 4 gm
Energy 70 KCal
Macronutrients : Milk protein-casein (85%),
lactoalbumin (12%), lacto-
globulin (3%) has high bio-
logical value.
Rich in cysteine,
tryptophan. Carbohydrate in
milk is lac-
tose. Fig. 5.8: Milk

Micronutrient : Rich—calcium (milk alone (250 ml) provides calcium requirement (500 mg) of the day),
vitamin A (retinol), thiamine, riboflavin and vitamin D.
Poor—Vitamin C nicotinic acid and iron.
Milk has phosphorus, potassium, cobalt, sodium, copper, iodine and all known
minerals. One liter of milk provides 50 gm of lactose, 1200 mg of calcium.
Milk fat is good source of retinol. Rich in linoleic and oleic acids.
Public health aspects : Lactose is not easily digested, rarely induces lactose intolerance diarrhea.
Good media for growth of microbes, poor keeping qualities. Vehicle for transmission
of diseases like bovine tuberculosis, brucellosis, staphylococcal food poisoning,
staphylo- coccal infection, salmonellosis, Q fever, anthrax, typhoid, cholera, etc.
Milk is very frequently adulterated.
Pasteurized milk is the safest milk.
Preparations : Curd, buttermilk, butter, ghee, cheese, khoa, ice cream, skimmed milk powder, toned
milk, coffee, tea, soft drink and sweets.

EGG
Introduction : Suitable for children, pregnant and lactating mothers as it contains nutrients for
embryo, convalescing patients, malnutrition and other vulnerable group.
Egg consists of shell—12 percent, white—58 percent, yellow (yolk)—30 percent.
Predominant function : Body building.
RDA : One egg can be taken unless contraindicated.
Nutrients (per 100 gm) : Protein 13 gm
Carbohydrate Nil
Fat 13 gm
Energy 170 Kcal
Macronutrients : Egg protein is the best quality of protein (reference protein).
It contains all nine essential amino acids.
 Food Items 87

Micronutrients : Rich—All vitamins and

minerals like iron, zinc, cal-
cium, phosphorus (excellent
source of vitamin A and D,
egg white is richest in ribo-
flavin).
Poor—Vitamin C
Egg is an excellent source
of all nutrients except
carbohy- drate and vitamin
C.
Public health aspects : Easily digested, totally ab-
sorbed, biological value is
100 for egg.
: Antinutrient factor avidin
(makes biotin unavailable)
is present in raw egg. Ovo- Fig. 5.9: Egg

mucoid present in egg

white
contains trypsin inhibitor. Both can be easily destroyed by boiling.
Egg protein may cause allergy.
Egg yolk is rich in fat and cholesterol (fat 7 gm, cholesterol 250 mg per egg) thus
diabet- ics, hypertensives and hypercholestrides and cardiac patients have to avoid
yellow part of the egg.
Cracked and rotten egg will be contaminated with salmonella, unsafe for consumption.
Egg can be preserved well by refrigeration and by glazing.
Boiled and unopened egg is safe food for travelers.
Egg (Fig. 5.9) should be eaten only after cooking as it destroys nutritional inhibitors
and microbes.
Preparations : Boiled egg, omelette, fooding, bakery products like cake, etc.
Can be mixed with any type of food.
Egg is used as a culture media and in the preparation of vaccines.

GREEN LEAFY VEGETABLES

Introduction : Available throughout the year, can be consumed by all age, both sex and in all physi-
ological and physical conditions.
Many types are available which gives variety to our food.
Predominant function : Protective.
RDA : 50 gm for sedentary male.
100 gm for sedentary female.
Nutrients (per 100 gm) : Protein 2–4 gm
Carbohydrates 1–5 gm
Fat < 1 gm
Energy 25–40 Kcal
Macronutrients : Poor in protein, fat, carbohydrate and calorie.
Micronutrients : Rich—Beta carotene, riboflavin, thiamine, folic acid, vitamin C, phosphorus, zinc cal-
cium, iron and antioxidants.
88 Section II:
Spotters
Poor—B12 and fiber.
Public health aspects : Some leafy vegetables con-
tain oxalic acid, which
makes calcium unavailable
for absorption.
High oxalates and fibers re-
duce the bioavailability of
minerals.
Fiber helps in preventing
hyperglycemia and hyper-
lipidemia. Green leafy veg-
etable (Fig. 5.10) is advised
for obesity reduction, vita-
min A deficiency, pregnant
and lactating mother,
person with constipation.
Iron defi- ciency leads to
anemia. Fig. 5.10: Green Leafy Vegetables

Commonly used : Spinach (palak), cabbage, coriander, curry leaves, fenugreek (methi), amaranth, drum
stick, mint.

FRUITS
Introduction : Fruits are seasonal, highly nutritious, holds a special place in nutrition.
Predominant function : Protective
RDA : 85 gm or more
Nutrients (per 100gm) : Carbohydrate 5 to 10 gm
Proteins 0.5 to 1.5 gm
Fat 0.1 to 1 gm
Energy 25 to 100 kcal
Macronutrients : Rich—cellulose, fiber, water.
Poor—nutrients.
Micronutrients : Abundant in vitamins, minerals, phytochemicals/anti-oxidants
Fruits are rich in specific
nu- trients, e.g.
Vitamin C: Guava, amla,
or- ange, lime, lemon,
musam- bi, pineapple,
strawberry, papaya.
Vitamin A: Papaya, mango,
yellow peaches, apricot, or-
ange
Folate: Tomato
Calcium: Apricots, lime,
guava, figs, dried fruits
(dates-120 mg), wood
apple,
custard apple (sitaphal). Fig. 5.11: Fruits
 Food Items 89

Iron: Watermelon, custard apple, apricots, dried fruits (dates and raisins) – 7.5 mg,
straw- berry, peaches, pineapple, pomegranate.
Potassium: Musambi, musk melon, peaches, bael fruit, red cherries, lemon
Phosphorus: Raspberry, wood apple
Public Health Aspects : Seasonally and locally available fruits are advised for daily consumption
Fiber in fruits are helpful in preventing hyperglycemia, hyperlipidemia.
Openly sold cut fruits which comes in contact with flies and dust should not be con-
sumed.
Highest hygiene is advocated about fruits.
Preparations : Fruits (Fig. 5.11) can be eaten raw and fresh. Fruits can be used in preparations like
juice, salad, dessert, jam, jelly and many more.

FISH
Introduction : Fish is an animal food (Fig. 5.12).
Predominant function : Body building.
RDA : 40 gm (50% can be substituted with pulses).
Nutrients (per 100 gm) : Protein 15–20 gm
Carbohydrate 0–2 gm
Fat 1–3 gm
Energy 100 Kcal
Macronutrients : Fish protein has good biological value.
Fish contains negligible amount of carbohydrates.
Fish fat is rich in polyunsaturated fatty acids (PUFA—Cardioprotective).
Micronutrients : Rich—Vitamin A, vitamin D, calcium, phosphorus, omega 3 fatty acids.
Poor—Fiber and vitamins.
Public health aspects : Fish substitution enhances the nutritive value of other food.
Consumption of fish should
be promoted for prevention
of vitamin A, D, iodine,
pro- tein deficiency and
cardiac diseases. Sea fish
provides iodine.
Care should be taken while
purchasing, cooking, stor-
age and distribution of fish
to prevent fish borne diseas-
es.
Preparations : Fish fry, dry, sambar, etc.

MEAT
Introduction : Meat is an animal food rich
in high quality protein.
Predominant function : Body building.
RDA : 40 gm (50% can be substi- Fig. 5.12: Fish
tuted with pulses).
90 Section II:
Spotters
Nutrients (per 100 gm) : Protein 25 gm
Carbohydrate < 1 gm
Fat 13 gm
Energy 225 Kcal
Macronutrients : Meat protein has all essen-
tial amino acids and in right
proportions.
Amino acids have high bio-
logical value.
Meat contains more saturat-
ed fat.
Meat contains negligible
amount of carbohydrates.
Micronutrients : Rich—Iron, folic acid, zinc,
vitamin B12 (meat iron
(Heme) is well absorbed), Fig. 5.13: Meat
phosphorus.
Poor—Calcium, fiber (nil).
Public health aspects : Meat (Fig. 5.13) substitution enhances the nutritive value of other food.
Care should be taken while purchasing, cooking, storage and distribution of meat to
prevent meat borne diseases.
Meat fat contains more saturated fatty acids which is a risk for the cardiovascular sys-
tem.
Preparations : Fry, dry, sambar, etc.

COOKING OIL/FAT
Introduction : Commonly used cooking media (Fig. 5.14). Fat which is liquid at room temperature is
called oil.
Predominant function : Energy, fat and fat-soluble
vitamins providing.
RDA : 40 gm for male.
20 gm for female.
Nutrients (per 100 ml) : Protein Nil
Carbohydrate Nil
Fat 100 gm
Energy 900 Kcal
Macronutrients : Saturated and unsaturated
fatty acids in various pro-
portion
Micronutrients : Rich—Fat-soluble vitamins
(vitamin A, D, E and K).
Poor—Vitamin B and C.
Vegetable oil is poor in vita-
min A.
Fig. 5.14: Cooking Oil
 Food Items 91

Public health aspects : Total (visible and invisible) fat intake should not exceed 20 percent of total energy in-
take.
Fat gives satiety to meal.
Hydrogenated oil is vanaspathi.
Fat can be fortified with vitamin A and D.
Consumption of excess oil and saturated fatty acid (SFA) leads to the risk of
developing ischemic heart diseases and dyslipidemia.
Repeatedly heating the oil (trans fatty acid) liberates free radicals which is
carcinogenic and atherogenic.

SUGAR/JAGGERY
Introduction : Sweetening agent (Fig. 5.15).
Predominant function : Energy providing.
RDA : 30 gm for male.
20 gm for female.
Nutrients (per 100 gm) : Protein Nil
Carbohydrate 99.5 gm
Fat Nil
Energy 400 Kcal
Macronutrients : Contains only simple carbohydrates (pure sucrose) provides blank calories.
Micronutrients : Rich—Jaggery is rich in iron, carotene and calcium.
Poor—Sugar is poor in iron, calcium and phosphorus.
Public health aspects : Consumption of excess sugar leads to obesity and dental caries.
Diabetics must avoid all types of sweets.
Preparations : All types of sweets, ORS, etc.

ALCOHOL
Introduction : Alcohol provides 7 Kcal/gm.
Alcohol content ranges
from six percent in beer to
45 per- cent in whisky.
Public health aspects : Chronic consumption of al-
cohol leads to cirrhosis, car-
diac disease, peptic ulcer,
country liquor (containing
methyl alcohol) leads to
loss of vision.

COFFEE/TEA
Introduction : Coffee/Tea is stimulant and
refreshing relieves fatigue.
Coffee contains caffeine, a
volatile oil and tannic acid.
Tea contains caffeine, Fig. 5.15: Jaggery
tannic
92 Section II:
Spotters
acid, theophylline and a volatile oil (theobromine).
Nutrients (per 100 ml) : Energy mainly comes from milk and sugar added to coffee/tea.
Nutrient Coffee Tea
Protein 2 gm 1 gm
Carbohydrate 18 gm 6 gm
Fat 3 gm 1 gm
Energy 100 Kcal 80 Kml
Public health aspects : Excess of coffee consumption increases blood pressure, uses insomnia, tachycardia,
gastritis increase in blood cholesterol. Anti-oxidants in tea have health benefits.

SOFT DRINKS
Introduction : Soft drinks are carbonated drinks and non-carbonated fruit juice.
Main ingredients are carbon dioxide, sugar, citric acid or tartaric acid, coloring and fla-
vouring agents.
Public health aspects : Majority of the soft drinks provide only empty calories but not nutrients.

COCOA
Introduction : Cocoa is the product of cocoa beans which is rich in fat and stimulant (theobromine).
Nutrients (per 100 gm) : Protein 7 gm
Carbohydrate 25 gm
Fat 9 gm
Energy 200 Kcal

BUTTER
Predominant function : Rich in vitamin A—3200 µg/100 gm (carotene) and vitamin D.
Nutrients (per 100 gm) : Protein Nil
Carbohydrate Nil
Fat 80 gm
Energy 720 Kcal
Public health aspects : Contains saturated fat-Atherogenic.
Becomes rancid easily. Excess consumption leads to dislipidemia.

GHEE
Predominant function : Contains 200 µg carotene per 100 gm.
Nutrients (per 100 gm) : Protein Nil
Carbohydrate Nil
Fat 100 gm
Energy 900 Kcal
Public health aspects : It contains saturated fatty acids which leads to the development of cardiovascular dis-
eases.
Ghee is not advised in hypertension, cardiovascular disease, diabetes,
obesity. No other vitamins and minerals are present.
 Food Items 93

PAR BOILED RICE

Introduction : Par boiling is partial cook-
ing of rice in steam.
In par boiling technique,
paddy is soaked in hot
water (60–70º) for 4 hour.
Water is drained, paddy is
steamed for 10 minute.
Later dried and milled.
Public health aspects : Par boiling preserves the
nutrients of brawn layer,
im- proves keeping quality
and insect resistance.

MAIZE
Introduction : Maize is a cereal (Fig. 5.16).
Staple diet in Africa and
Central Asia.
Fig. 5.16: Maize
Nutrients (per 100 gm) : Protein 12 gm
Carbohydrate 65 gm
Fat 3.5 gm
Energy 345 Kcal
Protein is deficient in lysine and tryptophan.
Maize is good in carotenoids.
Public health aspects : Excessive consumption leads to pellagra (excess leucine in maize interferes in conver-
sion of tryptophan into niacin leading to niacin deficiency, pellagra) (60 mg tryptopan
is needed to produce 1 mg niacin).
Preparations : Corn flakes, custard, desserts, rava, cattle feed, poultry feed, etc.

Note: Following figures of selected food items have been given for your reference.
94 Section II:
Spotters
Selected food items

Dry fruits Sprouted green gram

Bajra Bengal gram

Black gram/dal Green gram

 Food Items 95

Weight and size of selected food items

96 Section II:
Spotters
Weight and size of selected food items
 Food Items 97

Relation of chapati size to weight of flour

20 gm chapati 35 gm chapati

50 gm chapati
98 Section II:
Spotters
Weight and measurement of food items

Keep the glass at the eye level and read the volume of liquid

Take a flat knife or the flat edge of the

spoon and level the heap neatly

The amount left in the spoon is

the amount which it can measure
 PART II

SPOTTERS

5. Food Items
6. Immunizing Agents
7. Family Planning Appliances
8. Vectors
9. Chemicals in Public Health
10. Models
11. Diagrams
 Chapte
r Food Items

RICE
Introduction : Staple cereal of man. Main source of protein and energy.
Predominant function : Energy and protein providing.
RDA : 460 gm for sedentary male.
Nutrients (per 100 gm) : Nutrients are highly concentrated in outer layer (brawn).
Protein 6.5 gm
Carbohydrate 75 gm
Fat 0.5 gm
Energy 350 Kcal
Macronutrients : Rice provides better quality of protein (rich in amino acid—Lysine).
Micronutrients : Rich—Thiamine, Niacin, pyridoxine and riboflavin (B group vitamins).
Poor—Vitamin A, C, D, calcium and iron.
Public health aspects : Maximum benefits can be obtained by eating rice along with pulses in 5:1 ratio as pulses supply
amino acids lacking in rice (Mutual supplementation of amino acids).
Polishing, washing, cooking with excess of water and draining away deprives nutrients.
Using under milled rice in
place of highly polished rice is
advised.
Highly polished rice predis-
poses beriberi.
Preparations : Rice is used in super ORS
Rice, dosa, idly, roti, rice
flakes, puffed rice and many
more.
Nutritive value and other
properties of puffed rice and
rice flakes is almost similar
to that of rice.

RAGI
Introduction : Cheapest millet.
Staple food for South Indians.
Main source of protein and
energy. Fig. 5.1: Rice
80 Part II:
Spotters
Predominant function : Energy and protein providing.
RDA : 460 gm for sedentary male.
Nutrients (per 100 gm) : Protein 7 gm
Carbohydrate 72 gm
Fat 1 gm
Energy 330 Kcal
Macronutrients : Deficient in essential amino
acid—Lysine.
Micronutrients : Rich—Calcium (340 mg/100
gm), iron (4 mg/100 gm),
contains iodine also.
Public health aspects : Advised for diabetics and
obese.
Used as a multipurpose food.
Maximum benefit (mutual
supplementary effect of amino
acids) can be obtained by
eating this millet along with
Fig. 5.2: Ragi
pulses in 5:1 proportion.
Preparations : Ragi flour is used in preparations like porridge, roti, halwa, balls, etc.

JOWAR (MILLETS)
Introduction : Staple diet for many people.
Predominant function : Main source of energy and
protein. RDA : 460 gm for sedentary male.
Nutrients (per 100 gm) : Protein 10 gm
Carbohydrates 72 gm
Fat 1.9 gm
Energy 350 Kcal
Macronutrients : Millet protein is deficit in amino acids—Lysine and threonine.
Micronutrient : Rich—Iron, phosphorus.
Poor—Vitamin C, calcium.
Public health aspects : High leucine contents interfere
in conversion of tryptophan
into niacin.
Hence, excess of consumption
causes pellagra.
Fungi (Aspergillus flavus) will
infest during improper storage
and produces aflatoxins,
which is potent hepatotoxin
and carcinogenic.
Properly dried (moisture
below 10%) and kept. Con-
taminated grain should not be
consumed.
Preparations : Roti, balls.
Fig. 5.3: Jowar (millets)
 Food Items 81

WHEAT
Introduction : Important staple cereal used
worldwide.
Predominant function : Energy and protein providing.
RDA : 460 gm for sedentary adult
male.
Nutrients (per 100 gm) : Protein 12 gm
Carbohydrate 72 gm
Fat 1.5 gm
Energy 350 Kcal
Macro nutrients : Wheat protein is deficit in
lysine and threonine.

Micronutrients : Rich—B group and D vitamin,

iron, calcium, phosphorus and
other minerals.
Fig. 5.4: Wheat

Poor—Thiamine, riboflavin, niacin.

Public health aspects : Refined wheat flour (maida) is flour minus husk, it is poor in nutrients and fiber.
Whole grains furnish all nutrients.
Sticky and spongy properties of gluten enables to prepare bread, biscuits, cake, semolina, etc.
Wheat protein (Gluten) may be allergic to few.
Wheat should be used as a whole and eaten along with pulses (5:1 ratio) to get maximum
benefit.
Preparations : Atta, maida, baby food, chapati, puri, roti, bread, biscuit, etc.

PULSES (LEGUMES)

Introduction : Pulses (legumes) are indis-

pensable in Indian diet, less
expensive than animal protein.
Pulses can be eaten as whole
grain or as pulses.
Palatable and brings variety to
food.
Predominant function : Body building.
RDA : 40 gm for sedentary male.
Nutrients (per 100 gm) : Protein 22 gm
Carbohydrate 60 gm
Fat 2 gm
Energy
330 Kcal
Macronutrient : Pulse protein is rich in lysine.
Deficient in methionine and
cystine.
Fig. 5.5: Red Gram Dal
82 Part II:
Spotters
Biological value is better than cereals but, poor than animal protein.
Micronutrients : Rich—B group vitamins (thiamine, riboflavin and pyridoxine).
Poor—Minerals.
Nil—Vitamin A and
C.
Public health aspects : Oligosaccharides of pulses cause flatulence.
Antinutrient factors (tannins and phytate) in pulses adversely affects on bioavailability of nutri-
ents, but can be destroyed by heat.
Pulses are adulterated with kesari dal. Toxin beta oxalylamino alanine (BOAA) of kesari dal
causes neuro lathyrism.
Spurting increases riboflavin, niacin, choline, biotin and vitamin C, destroys antinutrients and
toxic factors.
Fermentation improves digestibility, palatability, bioavailability of essential amino acids and
enhances B-group vitamins.
Maximal benefit is obtained by eating whole pulses along with cereals in 1:5 ratio, as cereals
provides amino acids lacking in pulses (supplementary action of protein).
Preparations : Sambar, gravy, sweets, dosa, idly, etc.
Roasted bengal gram dal is used in multipurpose food.

SOYA BEANS
Introduction : Soya bean is a pulse which is richest in protein than any other food item.
Predominant function : Body building.
RDA : 40 gm
Nutrients (per 100 gm) : Protein 43 gm
Carbohydrate 20 gm
Fat 19 gm
Energy 430 Kcal
Macronutrients : Rich in protein but quality of protein is inferior to that of animal protein.
Limiting amino acid is methionine.
Micronutrients : Rich—Iron, calcium and phosphorus.

Poor—Vitamin B6 and C.
Public health aspects : Soya should be introduced and
popularized for the prevention
of protein deficiency.
Preparations : Floor, dal, milk, curd, sause,
powder baby food, etc.

GROUNDNUT (PEANUT)
Introduction : Most commonly used oil seed.
Predominant function : Energy and fat providing.
RDA : Taken in restricted amount.
Nutrients (per 100 gm) : Protein 25 gm
Carbohydrate 25 gm
Fat 40 gm
Energy 560 Kcal
Fig. 5.6: Soya Beans
 Food Items 83

Macronutrients : Concentrated source of pro-

tein, fat and energy.
Protein is rich in lysine.
Groundnuts eaten along with
cereals and pulses will provide
good quality of proteins.
Micronutrients : Rich—Thiamine, nicotinic
acid, calcium phosphorus and
iron.
: Poor—B6 and vitamin C
Public health aspects : Used mainly for oil extraction.
De oiled meal (cake) is used
in preparation of protein rich
children food, cattle feed, and
malt.
Groundnut gets affected with
fungus if not dried and stored
properly. Aflatoxin produced
by aspergillus flavus fungi is Fig. 5.7: Ground nut
carcinogenic and hepatotoxic.
Preparations : Cooking oil, peanut butter, snacks, Indian multipurpose food, etc.

COW’S MILK
Introduction ; Milk is a complete food
Promotes and maintains growth and development.
Ideal for children. Best suitable for all ages and both sex, advised for infant, children, in preg-
nancy, lactation, illness, and vulnerable population.
Predominant function : Body building.
RDA : 150 ml for sedentary adult.
250 ml for pregnancy and lactation.
Nutrients (per 100 ml) : Protein 3 gm
Fat 4 gm
Energy 70 KCal
Macronutrients : Milk protein (casein, lactoal-
bumin, lactoglobulin) has high
biological value.
Rich in cysteine, tryptophan.
Carbohydrate in milk is lac-
tose.
Micronutrient : Rich—calcium (milk alone
(250 ml) provides calcium
requirement (500 mg) of the
day), vitamin A (retinol), thia-
mine, riboflavin and vitamin
D.
Poor—Vitamin C and iron.
Milk has phosphorus, potas-
sium, cobalt, sodium,
copper,
iodine and all known Fig. 5.8: Milk
minerals.
84 Part II:
Spotters
Milk fat is good source of retinol.
Public health aspects : Lactose is not easily digested, rarely induces lactose intolerance diarrhea.
Good media for growth of microbes, poor keeping qualities. Vehicle for transmission of
diseases like bovine tuberculosis, brucellosis, staphylococcal food poisoning, staphylococcal
infection, salmonellosis, Q fever, anthrax, typhoid, cholera, etc.
Milk is very frequently adulterated.
Pasteurized milk is the safest milk.
Preparations : Curd, buttermilk, butter, ghee, cheese, khoa, ice cream, skimmed milk powder, toned milk,
cof- fee, tea, soft drink and sweets.

EGG
Introduction : Suitable for children, pregnant and lactating mothers, convalescing patients, malnutrition
and other vulnerable group.
Egg consists of shell—12 percent, white—58 percent, yellow (yolk)—30 percent.
Predominant function : Body building.
RDA : One egg can be taken unless contraindicated.
Nutrients (per 100 gm) : Protein 13 gm
Carbohydrate nil
Fat 13 gm
Energy 170 Kcal
Macronutrients : Egg protein is the best quality of protein (reference protein).
It contains all nine essential amino acids.
Micronutrients : Rich—All vitamins and minerals like iron, zinc, calcium, phosphorus (excellent source of vita-
min A and D, egg white is richest in riboflavin).
Poor—Vitamin C
Egg is excellent source of all nutrients except carbohydrate and vitamin.
Public health aspects : Easily digested, totally absorbed, biological value is 100 for egg.
: Anti nutrient factor avidin (makes biotin unavailable) is present in the raw egg. Ovomucoid
present in egg white contains
trypsin inhibitor. Both can be
easily destroyed by boiling.
Egg protein may cause
allergy.
Egg yolk is rich in fat and
cholesterol (fat 7 gm, choles-
terol 250 mg per egg) thus
diabetics, hypertensives and
hypercholestrides and cardiac
patients have to avoid yellow
part of the egg.
Cracked and rotten egg will be
contaminated with salmonella,
unsafe for consumption.
Egg can be preserved well by
refrigeration and by glazing.
Boiled and unopened egg is
safe food for travelers.
Fig. 5.9: Egg
 Food Items 85

Egg should be eaten only after

cooking as it destroys nutri-
tional inhibitors and microbes.
Preparations : Boiled egg, omelette, fooding,
bakery products like cake, etc.
Can be mixed with any type of
food.
Egg is used as a culture media
and in the preparation of vac-
cines.

GREEN LEAFY VEGETABLES

Introduction : Available throughout the year,
can be consumed by all age,
both sex and in all physiologi-
cal and physical conditions.
Many types are available
which gives variety to our
food. Fig. 5.10: Green Leafy Vegetables

Predominant function : Protective.

RDA : 50 gm for sedentary adult male.
Nutrients (per 100 gm) : Protein 2–4 gm
Carbohydrates 1–5 gm
Fat < 1 gm
Energy 25–40 Kcal
Macronutrients : Poor in protein, fat, carbohydrate and calorie.
Micronutrients : Rich—Beta carotene, riboflavin, thiamine, folic acid, vitamin C, calcium and iron.
Poor—B12.
Public health aspects : Some leafy vegetables contain oxalic acid, which makes calcium unavailable for absorption.
High oxalates and fibers
reduce the bioavailability of
minerals.
More green leafy vegetable is
advised for obesity reduction,
vitamin A deficiency, pregnant
and lactating mother, person
with constipation.
Commonly used : Spinach (palak), cabbage, cori-
ander, curry leaves, fenugreek
(methi), amaranth, drum stick,
mint.

FISH
Introduction : Fish is an animal food.
Predominant function : Body building.
RDA : 40 gm (50% is substituted
with pulses).
Nutrients (per 100 gm) : Protein 15–20 gm
Fig. 5.11: Fish
86 Part II:
Spotters
Carbohydrate 0–2 gm
Fat 1–3 gm
Energy 100 Kcal
Macronutrients : Fish protein has good biological value.
Fish contains negligible amount of carbohydrates.
Fish fat is rich in polyunsaturated fatty acids (PUFA—Cardioprotective).
Micronutrients : Rich—Vitamin A, vitamin D, calcium and phosphorus.
Poor—Fiber and vitamins.
Public health aspects : Fish substitution enhances the nutritive value of other food.
Consumption of fish should be promoted for prevention of vitamin A, D, iodine,
protein deficiency and cardiac diseases.
Care should be taken while purchasing, cooking, storage and distribution of fish to prevent fish
borne diseases.
Preparations : Fish fry, dry, sambar, etc.

MEAT
Introduction : Meat is an animal food rich in protein.
Predominant function : Body building.
RDA : 40 gm (50% is substituted with pulses).
Nutrients (per 100 gm) : Protein 25 gm
Carbohydrate < 1 gm
Fat 13 gm
Energy 225 Kcal
Macronutrients : Meat protein has all essential amino acids and in right proportions.
Amino acids have high biological value.
Meat contains more saturated fat.
Meat contains negligible amount of carbohydrates.
Micronutrients : Rich—Iron, folic acid, zinc, vitamin B12 (meat iron is well absorbed).
Poor—Calcium, fiber.
Public health aspects : Meat substitution enhances the
nutritive value of other food.
Care should be taken while
purchasing, cooking, storage
and distribution of meat to
prevent meat borne diseases.
Preparations : Fish fry, dry, sambar, etc.

COOKING OIL /FAT

Introduction : Commonly used cooking me-
dia.
Predominant function : Energy, fat and fat-soluble
vitamins providing.
RDA : 40 gm
Nutrients (per 100 ml) : Protein Nil
Carbohydrate Nil
Fat 100 gm Fig. 5.12: Meat
 Food Items 87

Energy 900 Kcal

Macronutrients : Saturated and unsaturated fatty
acids in various proportion
Micronutrients : Rich—Fat soluble vitamins
(vitamin A, D, E and K).
Poor—Vitamin B and C.
Public health aspects : Total (visible and invisible) fat
intake should not exceed 20
percent of total energy intake.
Fat gives satiety to meal.
Hydrogenated oil in vanas-
pathi.
Fat can be fortified with vita-
min A and D.
Consumption of excess oil and
saturated fatty acid (SFA) is
associated with ischemic heart
diseases.
Fig. 5.13: Cooking Oil
Repeatedly heating the oil
liberates free radicals which is carcinogenic and atherogenic.

SUGAR/JAGGERY
Introduction : Sweetening agent.
Predominant function : Energy providing.
RDA : 30 gm
Nutrients (per 100 gm) : Protein Nil
Carbohydrate 99.5 gm
Fat Nil
Energy 400 Kcal
Macronutrients : Contains only simple carbohydrates (pure sucrose).
Micronutrients : Rich—Jaggery is rich in iron, carotene and calcium.
Poor—Sugar is poor in iron,
calcium and phosphorus.
Public health aspects : Consumption of excess sugar
leads to obesity and dental
car- ies.
Diabetics must avoid all types
of sweets.
Preparations : All types of sweets, ORS, etc.

ALCOHOL

Alcohol provides 7 Kcal per gram.

Alcohol content ranges from six percent in beer to 45
percent in whisky.
Chronic consumption of alcohol leads to cirrhosis, cardiac
disease, peptic ulcer, country liquor (containing methyl alco-
hol) leads to loss of vision. Fig. 5.14: Jaggery
88 Part II:
Spotters
COFFEE/TEA
Nutrients per 100 ml
Nutrient Coffee
Tea
Protein 2 gm
1 gm
Carbohydrate 18 gm
6 gm
Fat 3 gm
1 gm
Energy 100 Kcal
80
Kml
Coffee contains caffeine, a volatile oil and tannic acid.
Tea contains caffeine, tannic acid, theophylline and a
volatile oil.
Energy mainly comes from milk and sugar added to
coffee. Coffee/Tea is stimulant and refreshing.
Excess of coffee consumption increases blood pressure and
blood cholesterol.

SOFT DRINKS
Soft drinks are carbonated drinks and non-carbonated fruit juice.
Main ingredients are carbon dioxide, sugar, citric acid or tartaric acid, coloring and flavouring agents.
Majority of the soft drinks provide only empty calories but not nutrients.

COCOA
Nutrients per 100 gm : Protein 7 gm
Carbohydrate 25 gm
Fat 9 gm

Energy 200 Kcal

Cocoa is the product of cocoa beans which is rich in fat and
stimulant (theobromine).

BUTTER
Nutrients (per 100 gm) : Protein Nil
Carbohydrate Nil
Fat 80 gm
Energy 720 Kcal
Contains saturated fat.
Rich in vitamin A—3200 µg/100 gm (carotene).
Becomes rancid easily.

GHEE
Nutrients (per 100 gm) : Protein Nil
Carbohydrate Nil
 Food Items 89

Fat 100 gm
Energy 900 Kcal
It contains saturated fatty acids.
Ghee is not advised in hypertension, cardiovascular disease, diabetes, obesity.
Contains 200 µg carotene per 100 gm. No other vitamins and minerals are present.

PAR BOILED RICE

Par boiling is partial cooking of rice in steam.
Par boiling preserves the nutrients of brawn layer, improves keeping quality and insect resistance.
In par boiling technique, paddy is soaked in hot water (60–70º) for four hours. Water is then drained and steamed for 10 min-
utes. Later dried and milled.

MAIZE
Maize is a cereal.
Nutrients (100 gm) : Protein 12 gm
Carbohydrate 65 gm
Fat 3.5 gm
Energy 345 Kcal
Protein is deficient in tryptophan and lysine.
Maize is good in carotene.
Excessive consumption leads to pellagra (excess leucine in maize interferes in conversion of tryptophan into niacin leading to
niacin deficiency, pellagra).
Corn flakes, custard, desserts, rava, cattle feed, poultry feed, etc.
 Chapte
r Immunizing
Agents
6

BACILLE CALMETTE-GUERIN (BCG) VACCINE

Type : Live bacterial, lyophilized
Composition : Bovine strain Danish – 1331 (BCG strain)
1×106 and 33×106 Colony forming unit (CFU) BCG strain
Minimum of 0.1 to 0.4 million bacilli/dose Diluent—
Normal saline
Schedule
Primary : At birth, if not given, within or < 12 month
Postprimary—After Mantoux test
Booster : None
Administration
Dose : 0.05 ml for < 1 month, 0.1 ml for > 1 month
Route : Strictly intradermal
Site : Upper left arm just above the insertion of deltoid
Unwanted reaction : Prolonged ulceration, local abscess, sinus, lymphadenitis.
Contraindications : Symptomatic HIV infection, immunodeficiency, pregnancy, generalized
eczema Tuberculin purified protein derivative (PPD) +ve > 5 mm
Special precautions : Only tuberculin syringe and needle is used.
Correct intradermal injection is given. No other injections are given for 6 month to that
arm
Unused reconstituted vaccine is discarded after 6 hour or at the end of the session
which- ever is earlier, protect the vaccine from direct exposure to sunlight
Storage : 2 to 8 °C
Protective value : 15–20 year (for several forms of childhood TB) up to 80
percent PPD becomes positive 12 week after vaccination
Availability : Freeze-dried powder form along with diluents—Normal saline
Vial of 10 doses (1 ml = 1 mg).
100 Part II:
Spotters
ORAL POLIO VACCINE (OPV)
Type : Live Trivalent (TOPV)
Composition : Type 1: 3,00,000 Tissue culture infection doses (TCID) 50
Type 2: 1,00,000 TCID 50
Type 3: 3,00,000 TCID 50
Magnesium chloride is used as a stabilizer
Schedule
Primary : 4 doses (completed before 6 month)
At birth, 6 week, 10 week and 14 week of age
Additional : 2 doses
1st dose at 12–18 month with Diphtheria-tetanus-pertussis vaccine (DTP)
2nd dose at 5th year with Diphtheraia-tetanus vaccine (DT)
Supplementary : Given in all pulse polio and national immunization days regardless of previous doses
Administration
Dose : 2 drops (each drop of 0.05 ml)
Route : Oral
Site : Mouth
Unwanted reaction : Almost nil
Vaccine associated paralysis (two in one million—Due to type 3)
Contraindications : Symptomatic HIV infection, immunodeficiency (in immunodeficiency, Inactivated po-
liovirus vaccine (IPV) is preferred)
Special precautions : Hot milk, food or water is withheld for half an hour
Cold-chain is maintained
Vaccine is administered in cool place
Potency is monitored by Vaccine vial monitor (VVM)
Storage : 2 to 8 °C, may be frozen for long duration
Protective value : Lifetime
Availability : 2 ml (20 dose) vial with dropper.

DIPHTHERIA-TETANUS-PERTUSSIS VACCINE (DTP)

Type : Triple antigen containing Diphtheria toxoid+Tetanus toxoid+Killed whole cells of the
organism that causes pertussis
Composition : Each 0.5 ml contains—
Diphtheria toxoid—20 Lf (Limit of flocculation)
Tetanus toxoid—0.5 Lf
Pertussis killed—20,000 million
Adjuvant: Aluminium phosphate—2.5 mg
Preservative: Thiomesol—0.01 percent
Schedule
Primary : 6, 10 and 14 week of age
Booster : 18 month—DTP, 5 year (school entry)—DT only
 Immunizing Agents 101

Administration
Dose : 0.5 ml
Route : Deep intramuscular
Site : Outer mid thigh (infants), outer upper arm
Gluteal region in old child
Unwanted reaction : Mild local, fever, rarely convulsions
Contraindications : Anaphylactic reaction to previous dose, progressive neurological disease
Special precautions : Never freeze
Shake the vial to mix before vaccination
DTP is not given over 6 year age
Storage : 2 to 8 °C
Not kept over a long time at room temperature
Protective value : Durable
Antibody level > 1 IU/ml is maintained up to 10 year of age
Availability : 10 ml vial.

MEASLES VACCINE
Type : Live attenuated, Freeze-dried
Composition : 1000 TCD 50 Edmonston-Zagreb (EZ) strain per 0.5 ml
Schedule
Primary : 1 dose in 9th month in non-endemic area
6th and 9th month in endemic area and risk group
Booster : Nil. Infants vaccinated below 9 month deserve another dose at 12th month
Administration
Dose : 0.5 ml
Route : Subcutaneous
Site : Upper arm/Outer mid thigh
Unwanted reaction : Mild fever and rash (5–12 day)
: Rarely toxic shock syndrome (TSS), encephalitis, anaphylaxis
Contraindications : Severe reaction to previous dose, pregnancy, untreated active TB, immune disorder
(symptomatic HIV)
Special precautions : Reconstituted vaccine should be used in the same day
Storage : 2 to 8 °C, may be frozen during long storage
Protective value : Lifetime
Availability : Vial with powder and separate diluent (distilled water).

MEASLES–MUMPS–RUBELLA (MMR)
Type : Live attenuated viral, trivalent
Composition : Measles: 1000 TCID 50 EZ strain HDC cultured
Mumps: 5000 TCID 50 Jeryl Lynn mumps vaccine (JL) strain chick embryo fibroblast
culture
Rubella: 1000 TCID 50 Wistar RA 27/3 HDC cultured strain
102 Part II:
Spotters
Schedule
Primary : 9 month (15 to 18 month is optimal age)
Booster : Not given
Administration
Dose : 0.5 ml
Route : Subcutaneous
Site : Outer mid thigh or upper arm
Unwanted reaction : Fever and rashes
Rarely febrile convulsions. Aseptic meningitis
SSPE—Subacute sclerosing pan encephalitis
Contraindications : Untreated TB, immunodeficiency, pregnancy
Special precautions : Strictly subcutaneous route
Delayed up to 3 month after human gamma globulin or blood transfusion
Storage : 2 to 8 °C may be frozen in long storage
Protective value : Durable, high efficacy
Availability : Powder form with diluent (distilled water).

TETANUS TOXOID VACCINE (TT)

Type : Toxoid monovalent, inactivated toxin
Composition : Tetanus toxoid: 5 Lf
Adsorbed aluminium phosphate (PTAP)
Schedule
Routine : Apart from DTP and DT, 2 doses of TT given at 10th year and 16th
year Previously unimmunized—5 doses given
1st dose on elected day, next doses on 4th week, 6th month, 1st year and 5th year.
Later every 10 year
Pregnancy—
2 doses in first pregnancy, 4 to 6 week apart
1 dose in second pregnancy, if within 3 year
Administration
Dose : 0.5 ml
Route : Intramuscular (IM)
Site : Outer upper arm
Unwanted reaction : Mild local
Unnecessary excessive doses may cause hyperimmunization syndrome
Contraindications : H/o previous allergy
Acute and severe infections
Outbreak of polio
HIV is not a contraindication
Special precautions : Unnecessary excessive doses are avoided
Storage : 2 to 8 °C, never freeze. Withstands up to 37
ºC Protective value : 20 year (after 5 dose schedule)
 Immunizing Agents 103

Availability : Liquid in vials/ampoule

HEPATITIS-B (HEP-B) VACCINE

Type : Monovalent antigen, subunit genetically engineered
Plasma derived vaccine (PDV)
Composition : 20 micrograms of 22 nm surface antigen particles (HBsAg) per ml
Schedule
Primary : 3 doses at 0, 1 and 6 month
Booster : Every 5 year
Administration
Dose : 0.5 ml for children < 10 year, 1 ml for > 10
year Route : Intramuscular (IM)
Site : Outer mid thigh/Outer upper arm
Unwanted reaction : Negligible, one of the safest vaccine
Rarely local redness and fever
Contraindications : Hypersensitivity to previous dose
Known allergy to yeast
Special precautions : Not administered to gluteal region, as the response is poor
Combination vaccine should not be used at birth
Immunosuppressed needs large dose
Shake the vial before use
Neonates born to HBsAg carrier mother, Hepatitis B immunoglobulin (HBIG) is given
prior to vaccination
Storage : 2 to 8 °C, never freeze
Protective value : Over 95 percent for 5 year
Helps in preventing mother to child and child to child transmission
Availability : Cloudy liquid in single/multi dose vials often as prefilled auto-disable (AD) injection.

MENINGOCOCCAL VACCINE
Type : Quadrivalent
Composition : Purified bacterial polysaccharide antigen
50 mcg of polysaccharide for each of the sero groups (ACY and W135)
Schedule
Primary : Above 3 month—Single dose
Booster : After 3 year, if primary dose given < 1 year of age
After 1 year, if primary dose given 1–4 year of
age After 5 year, if primary dose given > 4 year of
age
Administration
Dose : 0.5 ml
Route : Subcutaneous
Site : Upper arm
104 Part II:
Spotters
Unwanted reaction : Mild, local reaction, low grade fever
Contraindications : Severe reactions to previous dose
Special precautions : Not given to children below 3 month
Vaccine is reserved for high risk groups like military camps and travelers
Storage : 2 to 8 °C
Protective value : 90 percent for 3 year
Recommended for curtailing epidemics
Availability : Powder with diluent—Single and multi-dose vials.

HAEMOPHILUS INFLUENZAE TYPE B (HIB) VACCINE

Type : Conjugate and monovalent
Composition : Capsular polysaccharide of [Link] type B
10 mcg per 0.5 ml
Schedule
Primary : 3 doses at 6, 10, 14 week of age
Booster : May be given at 15 month of age
Administration
Dose : 0.5 ml
Route : Intramuscular (IM)
Site : Outer mid thigh/Outer upper arm
Unwanted reaction : Safest vaccine
No known serious reactions
Mild local reaction and fever
Contraindications : Hypersensitivity to previous dose
Special precautions : None
Storage : 2 to 8 °C
Protective value : Long-lasting
Provides herd immunity by nasopharyngeal colonization of HIB
Availability : Liquid and freeze dried form.

JAPANESE ENCEPHALITIS (JE) VACCINE

Type : Inactivated mouse brain derived, lyophilized
Composition : Nakayama strain
Schedule
Primary : 3 doses, first on elected day, second on 7th day and third on 30th day
Booster : Before 1 year of primary
Revaccination : Every 3 year
Administration
Dose : 0.5 ml for 1 to 3 year of age, 1 ml for > 3 year of age
Route : Subcutaneous
Site : Upper arm
 Immunizing Agents 105

Unwanted reaction : Mild local reactions and fever

Rare serious allergic reaction (one in one lakh) within minute to 17 day, at vaccination
site
Contraindications : Hypersensitivity to previous dose less than 12 month of age/pregnancy/lactation/in-
fants
Special precautions : Reconstituted vaccine should be used within 6 hour
Storage : 2 to 8 °C
Protective value : About 3 year
Availability : Powdered vaccine with diluent

RUBELLA VACCINE
Type : Live attenuated, produced on human diploid fibroblast cells
Composition : Wistar RA 27/3 strain of rubella virus
1000 Cell culture infective dose (CCID)—50 per 0.5 ml
Schedule
Primary : Single dose (minimal age is 12–15 month)
Booster : 10 to 14 year in seronegative girls
Administration
Dose : 0.5 ml
Route : Subcutaneous or intramuscular
Site : Not specific
Unwanted reaction : Burning at site
Mild fever, lymphadenopathy
Contraindications : Pregnancy,
H/o previous hypersensitivity
Children below one year, HIV
cases
Special precautions : Advice not to become pregnant for 3 month after vaccination
Postpone the vaccine in acute illness, blood transfusion and immunoglobulin
therapy. Priority is given to the female, of child bearing age
Storage : 2 to 8 °C
Protective value : > 15 year
Availability : Freeze-dried powder

HEPATITIS-A
Type : Formaldehyde inactivated human diploid cell cultured vaccine
Composition : HM 175 strain F
160 (80) antigen unit Glioblastoma multiforme (GBM) strain per 0.5 ml
IML contain 720 Elisa units, formalin inactivated
Aluminium hydroxide absorbed
Schedule
Primary : 2 doses at 6 to 8 month interval
Booster : After 6 to 12 month
106 Part II:
Spotters
Administration
Dose : 0.5 ml
Route : Intramuscular/Subcutaneous
Site : Upper arm, deltoid
Unwanted reaction : Mild local inflammation, fever
Contraindications : Acute severe febrile illness
Hypersensitivity to earlier dose
Special precautions : Not given for children below 1 year
Epinephrine (1:1000) kept ready
Storage : 2 to 8 °C
Protective value : 7 to 8 year
Availability : 0.5 ml ampoule

TYPHOID AND PARATYPHOID A AND B VACCINE (TAB)

Type : Heat killed and dried, bivalent
Composition : [Link]—1000 million/organism
[Link]—500 million/organism
Schedule
Primary : 2 doses with 4 to 6 week interval (children ½ dose)
Revaccination : Every 3 year in endemic areas
Administration
Dose : 0.5 ml for > 10 year, 0.25 ml for < 10
year Route : Subcutaneous
Site : Outer aspect of upper arm at posterior deltoid border
Unwanted reaction : Mild local reactions and fever
Contraindications : Hypersensitivity to earlier dose
3rd trimester of pregnancy
Special precautions : Should not be frozen
Special diluted vaccine is used for children
Storage : 2 to 8 °C
Protective value : 70 percent for 3 year
Availability : 10 or 5 dose vial

TYPHOID – ORAL
Type : Live attenuated, lyophilized
Composition : 109 viable organisms S. typhi (Ty 21a strain)/capsule
Schedule
Primary : 3 doses, one on elected day, second on 3rd and third on 5th
day Booster : Revaccination every 3 year
Administration
Dose : 1 capsule on three alternative days, on 1-3-5th day
Route : Oral
Site : Mouth
 Immunizing Agents 107

Unwanted reaction : Not reported

Contraindications : Pregnancy
Immunodeficiency, immunosuppressive
drugs Acute febrile and intestinal infection
Mefloquine or antibiotic treatment
Special precautions : Given only for children older than 6 year of age
Given one hour before meal with cold water/milk
Storage : 2 to 8 ºC
Protective value : 70 to 80 percent for 3 to 5 year
Mainly for intestinal immunity
Availability : Capsular form

CHOLERA
Type : Killed, whole cell vaccine
Composition : 6000 million classical ogawa
6000 million classical inaba of serotype of [Link]/0.1 ml
0.5 percent phenol preserved
Schedule
Primary : 2 doses at 4 to 6 week interval
Booster : Every 6 month
Administration
Dose : 0.5 ml for > 10 year, 0.25 ml for 1–10
year Route : Subcutaneous
Site : Not specific
Unwanted reaction : Local inflammation
Fever
Contraindications : Acute illness
Previous hypersensitivity
Safety in pregnancy is not established
Special precautions : Not given to children below 1 year
Not given IM in persons with coagulation disorder
Storage : Room temperature
Protective value : Only 50 percent for a period of 3 to 6 month
No value in controlling epidemics
Availability : Vial

RABIES VACCINE—BETA PROPIOLACTONE (BPL)

Type : Inactivated nervous tissue vaccine
Composition : Fixed virus grown on sheep brain (semple)
Five percent emulsion
Schedule
Primary : Daily for 7 to 10 day
108 Part II:
Spotters
Booster : If passive immunization is given, three additional post-primary doses on 10th, 20th and
90th day is recommended
Administration
Dose : 2–5 ml daily for 7–10 day (depending upon wound type)
Route : Deep subcutaneous using 1.5 inch long needle
Site : Anterior wall of abdomen around the umbilicus
Unwanted reaction : Severe, even fatal reactions
Local allergic reactions
Neuroparalysis
Contraindications : Nil
Special precautions : Different sites are choosen for each injection
Abstain from mental strain, sleepless night and alcohol
Corticosteroid and immunosuppressive drugs
Storage : Room temperature
Protective value : 6 month
Availability : Now BPL vaccine is replaced by more safe and potent cell cultured
vaccine Government of India has discontinued using BPL vaccine, since
2004

RABIES—CELL CULTURED VACCINE (PCEC)

Type : 1. Cell cultured—Human diploid cell cultured vaccine
2. Non-human propagated in primary chick fibroblast cell culture, lyophilized
Composition : Inactivated rabies virus, flury low-egg-passage (LEP) strain
2.5 IU/dose
Schedule
Primary : 0, 3, 7, 14, 28 day
Started : As soon as possible after exposure
Booster : 90 day (Category III bites)
Administration
Dose : 1 or 0.5 ml (containing 2.5 IU)
Dose independent of age, sex and weight
Route : Intramuscular
Site : Deltoid region
Unwanted reaction : Local redness, Fever
Rarely immune complex disease for booster dose
Contraindications : Nil
Special precautions : To be used immediately after reconstitution
Diluent is added slowly along the side of the wall of the vial
Not to be injected to the gluteal region, as the immunogenicity is poor
Storage : 2 to 8 ºC, should not be freezed
Protective value : 15 day to 3 month
Availability : Ampoule with sterile water and syringe
Recent developments have occurred in the cell cultured vaccine regarding composition,
frequency of dose and route of administration.
 Immunizing Agents 109

CHICKEN POX (VARICELLA)

Type : Live attenuated lyophilized
Composition : OKA strain of Varicella zoster (VZ) virus
3.310 plaque forming units (PFU) per vial (0.5 ml)
Schedule
Primary : Single dose up to 1 year, 2 doses > 1 year at eight week
interval Booster : Not applicable
Administration
Dose : 0.5 ml
Route : Subcutaneous
Site : Outer aspect of upper arm
Unwanted reaction : Mild local reactions
Fever and rash within 4 week
Contraindications : Lymphocytes < 1200 per mm3
Neomycin hypersensitivity
Pregnancy, immunodeficiency
Active untreated TB
Symptomatic HIV
Special precautions : Salicylates should not be used for 6 week after vaccination
Not given intradermally
Pregnancy is postponed for 3 month after vaccine
Not mixed with other vaccine in same syringe
Used within 30 minute of reconstitution
Storage : -15 ºC
Protective value : For 10–20 year
Availability : Freeze-dried form

DTP + HEP B + HIB

Type : Pentavalent, freeze-dried
Composition : Diphtheria, tetanus, pertussis, hepatitis B, haemophilus influenzae B
Schedule
Primary : 6, 10, 14 week of age (before 6 year of age)
Booster : None
Administration
Dose : 0.5 ml
Route : Intramuscular
Site : Outer mid thigh
Unwanted reaction : Local inflammation
Mild fever
Contraindications : Severe reaction to previous dose
Special precautions : Not given at birth and after 6 year, used within 6 hour of reconstitution
Storage : 2 to 8 °C
110 Part II:
Spotters
Protective value : Not known
Availability : 2 dose vial.

INFLUENZA VACCINE
Type : Trivalent, killed
Composition : Type A: H3N2, H1N1
Type B
15 mcg of each strain/dose
Schedule
Primary : 2 doses at 4 week interval
Booster : Every year
Administration
Dose : 0.5 ml
Route : Subcutaneous
Site : Not specific
Unwanted reaction : Local irritation, fever
Contraindications : Less than 6 month of age
Acute febrile illness
Special precautions : Care is taken in case of persons allergic to egg protein
Storage : 2 to 8 °C
Protective value : 90 percent for 3 to 6 month
Availability : Aqueous or saline suspension.

ROTAVIRUS VACCINE
Type : Tetravalent rhesus rotaviral (RRV-TV)
Composition : 4 serotypes G1 to G4
Schedule
Primary : Rotateq—3 doses at 2, 4 and 6 month of age
Rotateq—2 doses at 2 and 4 month of age
Unwanted reaction : Mild diarrhea, vomiting,
Intussusception (1 in 10,000)
Contraindications : Age less than 6 week
Special precautions : Nil
Storage : 2 to 8 ºC
Protective value : 80 percent
Availability : Vial.

PNEUOCOCCAL VACCINE
Type : Polyvalent (23-valent)
Composition : Purified capsular polysaccharide antigen of 23 pneumococcal serotype
Schedule
 Immunizing Agents 111

Primary : 3 doses at 4 week interval for > 2 year of age

Booster : After 1 to 2 year
Administration
Dose : 0.5 ml
Route : Intramuscular/Subcutaneous
Site : Anterolateral part of thigh
Unwanted reaction : Less
Contraindications : < 2 year
In HIV it is controversial
Special precautions : Care is taken in case of persons with known hypersensitivity
Storage : 2 to 8 ºC
Protective value : 60 to 90 percent
Availability : Sterile liquid.

HEPATITIS-B IMMUNOGLOBULIN (HBIG)

Type : Immunoglobulin
Composition : Specific immunoglobulin
Indication : Single dose soon after exposure (< 12 hour)
Newborn of infected mother
Administration
Dose : 0.06 mg/kg body weight (10 mg)
Route : Intramuscular
Site : Deltoid
Unwanted reaction : Mild reaction at the site of injection
Special precautions : Never given intravenously
Person allergic to immunoglobulin preparation
Storage : 2 to 8 ºC
Availability : Sterile liquid.

HEPATITIS-A IMMUNOGLOBULIN
Type : Normal immunoglobulin
Composition : Specific human immunoglobulin (gamma globulin)
Indication : Single dose within 1 to 2 week after exposure
Susceptible persons
Travelers to endemic
area Close contacts of
patients
Contacts of institutional outbreaks
Administration
Dose : 0.02 to 0.05 ml/kg body weight
Route : Intramuscular
Site : Deltoid
112 Part II:
Spotters
Unwanted reaction : Rare
Special precautions : Not used on a very large scale
Storage : 2 to 8 ºC
Protective value : 80 percent, if given within 2 week of exposure
Availability : Sterile liquid.

TETANUS IMMUNOGLOBULIN
Type : Specific immunoglobulin
Composition : Tetanus immunoglobulin
Indication : Immediately after exposure/diagnosis of tetanus
Administration
Dose : 250 unit
Route : Intramuscular
Site : Deltoid
Unwanted reaction : Anaphylactic reaction (rare)
Special precautions : Continued with active immunization
Protective value : Up to 30 day
Availability : Vial.

RABIES IMMUNOGLOBULIN
Type : Specific immunoglobulin
Composition : Human rabies immunoglobulin
Indication : Exposure to rabid dog/animal
Administration
Dose : Totally 20 IU/kg body weight (more at local site) after local administration, left over Ig
is given IM
Route : Intramuscular
Site : Gluteal region
Unwanted reaction : Anaphylactic reactions (rare), local mild reaction
Special precautions : Complete vaccine course must be continued
Protective value : Short duration
Availability : Vial.
 Chapte
r Immunizing
Agents
6

BACILLE CALMETTE-GUERIN (BCG) VACCINE

Type : Live bacterial, lyophilized
Composition : Bovine strain Danish – 1331 (BCG strain)
1×106 and 33×106 Colony forming unit (CFU) BCG strain
Minimum of 0.1 to 0.4 million bacilli/dose Diluent—
Normal saline
Schedule
Primary : At birth, if not given, within or < 12 months
Postprimary—After Mantoux test
Booster : None
Administration
Dose : 0.05 ml for < 1 month, 0.1 ml for > 1 month
Route : Strictly intradermal
Site : Upper left arm just above the insertion of deltoid
Unwanted reaction : Prolonged ulceration, local abscess, sinus, lymphadenitis.
Contraindications : Symptomatic HIV infection, immunodeficiency, pregnancy, generalized
eczema Tuberculin purified protein derivative (PPD) +ve > 5 mm
Special precautions : Only tuberculin syringe and needle is used.
Correct intradermal injection is given. No other injections are given for six months to that arm
Unused reconstituted vaccine is discarded after six hours or at the end of the session whichever
is earlier, protect the vaccine from direct exposure to sunlight
Storage : 2 to 8 °C
Protective value : 15–20 years (for several forms of childhood TB) up to 80 percent
PPD becomes positive 12 weeks after vaccination
Availability : Freeze-dried powder form along with diluents—Normal saline
Vial of 10 doses (1 ml=1 mg).

ORAL POLIO VACCINE (OPV)

Type : Live Trivalent (TOPV)
Composition : Type 1: 3,00,000 Tissue culture infection doses (TCID)
50 Type 2: 1,00,000 TCID 50
 Immunizing Agents 91

Type 3: 3,00,000 TCID 50

Magnesium chloride is used as a stabilizer
Schedule
Primary : 4 doses (completed before 6 months)
At birth, six weeks, 10 weeks and 14 weeks of age
Additional : 2 doses
1st dose at 12–18 months with Diphtheria-tetanus-pertussis vaccine (DTP)
2nd dose at five years with Diphtheraia-tetanus vaccine (DT)
Supplementary : Given in all pulse polio and national immunization days regardless of previous doses
Administration
Dose : 2 drops (each drop of 0.05 ml)
Route : Oral
Site : Mouth
Unwanted reaction : Almost nil
Vaccine associated paralysis (two in one million—Due to type 3)
Contraindications : Symptomatic HIV infection, immunodeficiency (in immunodeficiency, Inactivated poliovirus
vaccine (IPV) is preferred)
Special precautions : Hot milk, food or water is withheld for half an hour
Cold-chain is maintained
Vaccine is administered in cool place
Potency is monitored by Vaccine vial monitor (VVM)
Storage : 2 to 8 °C, may be frozen for long duration
Protective value : Lifetime
Availability : 2 ml (20 dose) vial with dropper.

DIPHTHERIA-TETANUS-PERTUSSIS VACCINE (DTP)

Type : Triple antigen containing Diphtheria toxoid+Tetanus toxoid+Killed whole cells of the organism
that causes pertussis
Composition : Each 0.5 ml contains—
Diphtheria toxoid—20 Lf (Limit of flocculation)
Tetanus toxoid—0.5 Lf
Pertussis killed—20,000 million
Adjuvant: Aluminium phosphate—2.5 mg
Preservative: Thiomesol—0.01 percent
Schedule
Primary : 6, 10 and 14 weeks of age
Booster : 18 months—DTP, 5 years (school entry)—DT
only Administration
Dose : 0.5 ml
Route : Deep intramuscular
Site : Outer mid thigh (infants), outer upper arm
Gluteal region in old child
Unwanted reaction : Mild local, fever, rarely
convulsions
92 Part II:
Spotters
Contraindications : Anaphylactic reaction to previous dose, progressive neurological disease
Special precautions : Never freeze
Shake the vial to mix before vaccination
DTP is not given over six years age
Storage : 2 to 8 °C
Not kept over a long time at room temperature
Protective value : Durable
Antibody level > 1 IU/ml is maintained up to 10 years of age
Availability : 10 ml vial.

MEASLES VACCINE
Type : Live attenuated, Freeze-dried
Composition : 1000 TCD 50 Edmonston-Zagreb (EZ) strain per 0.5 ml
Schedule
Primary : 1 dose in ninth month in non-endemic area
Sixth and ninth month in endemic area and risk group
Booster : Nil. Infants vaccinated below nine months deserve another dose at 12th month
Administration
Dose : 0.5 ml
Route : Subcutaneous
Site : Upper arm/Outer mid thigh
Unwanted reaction : Mild fever and rash (5–12 days)
: Rarely toxic shock syndrome (TSS), encephalitis, anaphylaxis
Contraindications : Severe reaction to previous dose pregnancy, untreated active TB immune disorder
(symptomatic HIV)
Special precautions : Reconstituted vaccine should be used in the same day
Storage : 2 to 8 °C, may be frozen during long storage
Protective value : Lifetime
Availability : Vial with powder and separate diluent (distilled water).

MEASLES–MUMPS–RUBELLA (MMR)
Type : Live attenuated viral, trivalent
Composition : Measles: 1000 TCID 50 EZ strain HDC cultured
Mumps: 5000 TCID 50 Jeryl Lynn mumps vaccine (JL) strain chick embryo fibroblast culture
Rubella: 1000 TCID 50 Wistar RA 27/3 HDC cultured strain
Schedule
Primary : Nine months (15 to 18 months is optimal age)
Booster : Not given
Administration
Dose : 0.5 ml
Route : Subcutaneous
Site : Outer mid thigh or upper arm
Unwanted reaction : Fever and rashes
Rarely febrile convulsions. Aseptic meningitis
SSPE—Subacute sclerosing pan encephalitis
 Immunizing Agents 93

Contraindications : Untreated TB, immunodeficiency, pregnancy

Special precautions : Strictly subcutaneous route
Delayed up to three months after human gamma globulin or blood transfusion
Storage : 2 to 8 °C may be frozen in long storage
Protective value : Durable, high efficacy
Availability : Powder form with diluent (distilled water).

TETANUS TOXOID VACCINE (TT)

Type : Toxoid monovalent, inactivated toxin
Composition : Tetanus toxoid: 5 Lf
Adsorbed aluminium phosphate (PTAP)
Schedule
Routine : Apart from DTP and DT, 2 doses of TT given at 10th year and 16th
year Previously unimmunized—5 doses given
1st dose on elected day, next doses on fourth week, sixth month, first year and fifth year. Later
every 10 years
Pregnancy—
2 doses in first pregnancy, four-six weeks apart
1 dose in second pregnancy, if within three years
Administration
Dose : 0.5 ml
Route : Intramuscular (IM)
Site : Outer upper arm
Unwanted reaction : Mild local
Unnecessary excessive doses may cause hyperimmunization syndrome
Contraindications : H/o previous allergy
Acute and severe infections
Outbreak of polio
HIV is not a contraindication
Special precautions : Unnecessary excessive doses are avoided
Storage : 2 to 8 °C, never freeze. Withstands up to 37
ºC Protective value : 20 years (after 5 dose schedule)
Availability : Liquid in vials/ampoule

HEPATITIS-B (HEP B) VACCINE

Type : Monovalent antigen, subunit genetically engineered
Plasma derived vaccine (PDV)
Composition : 20 micrograms of 22 nm surface antigen particles (HBsAg) per ml
Schedule
Primary : 2 doses at zero, one and six months
Booster : Every five years
Administration
Dose : 0.5 ml for children < 10 years, 1 ml for > 10 years
Route : Intramuscular (IM)
94 Part II:
Spotters
Site : Outer mid thigh/Outer upper arm
Unwanted reaction : Negligible, one of the safest vaccine
Rarely local redness and fever
Contraindications : Hypersensitivity to previous dose
Known allergy to yeast
Special precautions : Not administered to gluteal region, as the response is poor
Combination vaccine should not be used at birth
Immunosuppressed needs large dose
Shake the vial before use
Neonates born to HBsAg carrier mother, Hepatitis B immunoglobulin (HBIG) is given prior to
vaccination
Storage : 2 to 8 °C, never freeze
Protective value : Over 95 percent for five years
Helps in preventing mother to child and child to child transmission
Availability : Cloudy liquid in single/multi dose vials often as prefilled auto-disable (AD) injection.

MENINGOCOCCAL VACCINE
Type : Quadrivalent
Composition : Purified bacterial polysaccharide antigen
50 mcg of polysaccharide for each of the sero groups (ACY and W135)
Schedule
Primary : Above three months—Single dose
Booster : After three years, if immunized < 1 year of age
After one year, if immunized 1–4 years of age
After five years, if immunized > 4 years of age
Administration
Dose : 0.5 ml
Route : Subcutaneous
Site : Upper arm
Unwanted reaction : Mild, local reaction, low grade fever
Contraindications : Severe reactions to previous dose
Special precautions : Not given to children below three months
Vaccine is reserved for high risk groups like military camps and travelers
Storage : 2 to 8 °C
Protective value : 90 percent for three years
Recommended for curtailing epidemics
Availability : Powder with diluent—Single and multi-dose vials.

HAEMOPHILUS INFLUENZAE TYPE B (HIB) VACCINE

Type : Conjugate and monovalent
Composition : Capsular polysaccharide of [Link] type
B 10 mcg per 0.5 ml
Schedule
Primary : 3 doses at six, 10, 14 weeks of age
 Immunizing Agents 95

Booster : May be given at 15 months of age

Administration
Dose : 0.5 ml
Route : Intramuscular (IM)
Site : Outer mid thigh/Outer upper arm
Unwanted reaction : Safest vaccine
No known serious reactions
Mild local reaction and fever
Contraindications : Hypersensitivity to previous dose
Special precautions : None
Storage : 2 to 8 °C
Protective value : Long-lasting
Provides herd immunity by nasopharyngeal colonization of HIB
Availability : Liquid and freeze dried form.

JAPANESE ENCEPHALITIS (JE) VACCINE

Type : Inactivated mouse brain derived, lyophilized
Composition : Nakayama strain
Schedule
Primary : 3 doses, one on elected day, second on 7th day and third on 30th
day Booster : Before one year of primary
Revaccination : Every three years
Administration
Dose : 0.5 ml for 1–3 years of age, 1 ml for > 3 years of age
Route : Subcutaneous
Site : Upper arm
Unwanted reaction : Mild local reactions and fever
Rare serious allergic reaction (one in one lakh) within minutes to 17 days, at vaccination
site Contraindications : Hypersensitivity to previous dose less than 12 months of age/Pregnancy/Lactation/Infants
Special precautions : Reconstituted vaccine should be used within six hours
Storage : 2 to 8 °C
Protective value : About three years
Availability : Powdered vaccine with diluent

RUBELLA VACCINE
Type : Live attenuated, produced on human diploid fibroblast cells
Composition : Wistar RA 27/3 strain of rubella virus
1000 Cell culture infective dose (CCID)—50 per 0.5 ml
Schedule
Primary : Single dose (minimal age is 12–15 months)
Booster : 10–14 years in seronegative girls
Administration
Dose : 0.5 ml
Route : Subcutaneous or intramuscular
96 Part II:
Spotters
Site : Not specific
Unwanted reaction : Burning at site
Mild fever,
lymphadenopathy Contraindications :
Pregnancy,
H/o previous hypersensitivity
Children below one year, HIV
cases
Special precautions : Advice not to become pregnant for three months after vaccination
Postpone the vaccine in acute illness, blood transfusion and immunoglobulin
therapy. Priority is given to the female, of child bearing age
Storage : 2 to 8 °C
Protective value : > 15 years
Availability : Freeze-dried powder

HEPATITIS-A
Type : Formaldehyde inactivated human diploid cell cultured vaccine
Composition : HM 175 strain F
160 (80) antigen unit Glioblastoma multiforme (GBM) strain per 0.5 ml
IML contain 720 Elisa units, formalin inactivated
Aluminium hydroxide absorbed
Schedule
Primary : 2 doses at six to eight months interval
Booster : After six to 12 months
Administration
Dose : 0.5 ml
Route : Intramuscular/Subcutaneous
Site : Upper arm, deltoid
Unwanted reaction : Mild local inflammation, fever
Contraindications : Acute severe febrile illness
Hypersensitivity to earlier dose
Special precautions : Not given for children below one year
Epinephrine (1:1000) kept ready
Storage : 2 to 8 °C
Protective value : Seven to eight years
Availability : 0.5 ml ampoule

TYPHOID AND PARATYPHOID A AND B VACCINE (TAB)

Type : Heat killed and dried, bivalent
Composition : [Link]—1000 million/organism
[Link]—500 million/organism
Schedule
Primary : 2 doses with four to six weeks interval (children ½ dose)
Revaccination : Every three years in endemic areas
Administration
Dose : 0.5 ml for > 10 years, 0.25 ml for > 10 yrs
 Immunizing Agents 97

Route : Subcutaneous
Site : Outer aspect of upper arm at posterior deltoid border
Unwanted reaction : Mild local reactions and fever
Contraindications : Hypersensitivity to earlier dose
3rd trimester of pregnancy
Special precautions : Should not be frozen
Special diluted vaccine is used for children
Storage : 2 to 8 °C
Protective value : 70 percent for three years
Availability : 10 or 5 dose vial

TYPHOID – ORAL
Type : Live attenuated, lyophilized
Composition : 109 viable organisms S. typhi (Ty 21a
strain)/capsule Schedule
Primary : 3 doses, one on elected day, second on 3rd and third on 5th
day Booster : Revaccination every three years
Administration
Dose : 1 capsule on three alternative days
Route : Oral
Site : Mouth
Unwanted reaction : Not reported
Contraindications : Pregnancy
Immunodeficiency, immunosuppressive
drugs Acute febrile and intestinal infection
Mefloquine or antibiotic treatment
Special precautions : Given only for children older than six years of age
Given one hour before meal with cold water/milk
Storage : 2 to 8 ºC
Protective value : 70 to 80 percent for three to five years
Mainly for intestinal immunity
Availability : Capsular form

CHOLERA
Type : Killed, whole cell vaccine
Composition : 6000 million classical ogawa
6000 million classical inaba of serotype of [Link]/0.1 ml
0.5 percent phenol preserved
Schedule
Primary : 2 doses at four to six weeks interval
Booster : Every six months
Administration
Dose : 0.5 ml for > 10 years, 0.25 ml for 1–10 years
Route : Subcutaneous
98 Part II:
Spotters
Site : Not specific
Unwanted reaction : Local inflammation
Fever
Contraindications : Acute illness
Previous hypersensitivity
Safety in pregnancy is not established
Special precautions : Not given to child below one year
Not given IM in persons with coagulation disorder
Storage : Room temperature
Protective value : Only 50 percent for a period of three to six months
No value in controlling epidemics
Availability : Vial

RABIES VACCINE – BETA PROPIOLACTONE (BPL)

Type : Inactivated nervous tissue vaccine
Composition : Fixed virus grown on sheep brain (sample)
Five percent emulsion
Schedule
Primary : Daily for 7–10 days
Booster : If passive immunization is given, three post-primary doses on 10th, 20th and 90th day is recom-
mended
Administration
Dose : 2–5 ml daily for 7–10 days (depending upon wound type)
Route : Deep subcutaneous using 1.5 inch long needle
Site : Anterior wall of abdomen around the umbilicus
Unwanted reaction : Severe, even fatal reactions
Local allergic reactions
Neuroparalysis
Contraindications : Nil
Special precautions : Different sites are choosen for each injection
Abstain from mental strain, sleepless night and alcohol
Corticosteroid and immunosuppressive drugs
Storage : Room temperature
Protective value : Six months
Availability : Now BPL vaccine is replaced by more safe and potent cell cultured
vaccine Government of India has discontinued using BPL vaccine, since
2004

RABIES – CELL CULTURED VACCINE (PCEC)

Type : Cell cultured—Human diploid cell cultured vaccine propagated in primary chick fibroblast cell
culture, lyophilized
Composition : Inactivated rabies virus, flury low-egg-passage (LEP) strain
2.5 IU/dose
Schedule
Primary : 0, 3, 7, 14, 28 days
Started : As soon as possible after exposure
Booster : 90 days (Category III bites)
 Immunizing Agents 99

Administration
Dose : 1 or 0.5 ml (containing 2.5 IU)
Dose independent of age, sex and weight
Route : Intramuscular
Site : Deltoid region
Unwanted reaction : Local redness, Fever
Rarely immune complex disease for booster dose
Contraindications : Nil
Special precautions : To be used immediately after reconstitution
Diluent is added slowly along the side of the wall of the vial
Not to be injected to the gluteal region as the immunogenicity is poor
Storage : 2 to 8 ºC, should not be freezed
Protective value : 15 days to three months
Availability : Ampoule with sterile water and syringe
Recent developments have occurred in the cell cultured vaccine regarding composition, fre-
quency of dose and route of administration.

CHICKEN POX (VARICELLA)

Type : Live attenuated lyophilized
Composition : OKA strain of Varicella zoster (VZ) virus
3.310 plaque forming units (PFU) per vial (0.5 ml)
Schedule
Primary : Single dose up to one year, 2 doses > 1 year at eight weeks
interval Booster : Not applicable
Administration
Dose : 0.5 ml
Route : Subcutaneous
Site : Outer aspect of upper arm
Unwanted reaction : Mild local reactions
Fever and rash within four weeks
Contraindications : Lymphocytes < 1200 per mm3
Neomycin hypersensitivity
Pregnancy, immunodeficiency
Active untreated TB
Symptomatic HIV
Special precautions : Salicylates should not be used for six weeks after vaccination
Not given intradermally
Pregnancy is postponed for three months after vaccine
Not mixed with other vaccine in same syringe
Used within 30 minutes of reconstitution
Storage : -15 ºC
Protective value : For 10–20 years
Availability : Freeze-dried form
100 Part II:
Spotters
DTP + HEP B + HIB

Type : Pentavalent, freeze-dried

Composition : Diphtheria, tetanus, pertussis, hepatitis B, haemophilus influenzae B
Schedule
Primary : 6, 10, 14 weeks of age (before six years of age)
Booster : None
Administration
Dose : 0.5 ml
Route : Intramuscular
Site : Outer mid thigh
Unwanted reaction : Local inflammation
Mild fever
Contraindications : Severe reaction to previous dose
Special precautions : Not given at birth and after 6 years, used within 6 hours of reconstitution
Storage : 2 to 8 °C
Protective value : Not known
Availability : 2 dose vial.

INFLUENZA VACCINE
Type : Trivalent, killed
Composition : Type A: H3N2, H1N1
Type B
15 mcg of each strain/dose
Schedule
Primary : 2 doses at four weeks interval
Booster : Every year
Administration
Dose : 0.5 ml
Route : Subcutaneous
Site : Not specific
Unwanted reaction : Local irritation, fever
Contraindications : Less than six months of age
Acute febrile illness
Special precautions : Care is taken in case of persons allergic to egg
protein Storage : 2 to 8 °C
Protective value : 90 percent for three to six months
Availability : Aqueous or saline suspension.

ROTAVIRUS VACCINE
Type : Tetravalent rhesus rotaviral (RRV-TV)
Composition : 4 serotypes G1 to G4
Schedule
Primary : Rotateq—3 doses at two, four and six months of age
 Immunizing Agents 101

Rotateq—2 doses at two and four months of age

Unwanted reaction : Mild diarrhea, vomiting,
Intususseption (1 in 10,000)
Contraindications : Age less than 6 weeks
Special precautions : Nil
Storage : 2 to 8 ºC
Protective value : 80 percent
Availability : Vial.

PNEUOCOCCAL VACCINE
Type : Polyvalent (23-valent)
Composition : Purified capsular polysaccharide antigen of 23 pneumococcal serotype
Schedule
Primary : 3 doses at four weeks interval for > 2 years of age
Booster : After one to two years
Administration
Dose : 0.5 ml
Route : Intramuscular/Subcutaneous
Site : Anterolateral part of thigh
Unwanted reaction : Less
Contraindications : < 2 years
In HIV controversial
Special precautions : Care is taken in case of persons with known hypersensitivity
Storage : 2 to 8 ºC
Protective value : 60 to 90 percent
Availability : Sterile liquid.

HEPATITIS B IMMUNOGLOBULIN (HBIG)

Type : Immunoglobulin
Composition : Specific immunoglobulin
Indication : Single dose soon after exposure (< 12 hrs)
Newborn of infected mother
Administration
Dose : 0.06 mg/kg body weight (10 mg)
Route : Intramuscular
Site : Deltoid
Unwanted reaction : Mild reaction at the site of injection
Special precautions : Never given intravenously
Person allergic to immunoglobulin preparation
Storage : 2 to 8 ºC
Availability : Sterile liquid.

HEPATITIS A IMMUNOGLOBULIN
Type : Normal immunoglobulin
Composition : Specific immunoglobulin
102 Part II:
Spotters
Indication : Single dose within one to two weeks after exposure
Susceptible persons
Travelers to endemic
area Close contacts of
patients
Contacts of institutional outbreaks
Administration
Dose : 0.02 to 0.05 ml/kg body weight
Route : Intramuscular
Site : Deltoid
Unwanted reaction : Rare
Special precautions : Not used on a very large
scale Storage : 2 to 8 ºC
Protective value : 80 percent if given within two weeks of exposure
Availability : Sterile liquid.

TETANUS IMMUNOGLOBULIN
Type : Specific immunoglobulin
Composition : Tetanus immunoglobulin
Indication : Immediately after exposure/diagnosis of tetanus
Administration
Dose : 250 Units
Route : Intramuscular
Site : Deltoid
Unwanted reaction : Anaphylactic reaction (rare)
Special precautions : Continued with active immunization
Protective value : Up to 30 days
Availability : Vial.

RABIES IMMUNOGLOBULIN
Type : Specific immunoglobulin
Composition : Human rabies immunoglobulin
Indication : Exposure to rabid dog/animal
Administration
Dose : Totally 20 IU/kg body weight (more at local site) after local administration, left over Ig is
given IM
Route : Intramuscular
Site : Gluteal region
Unwanted reaction : Anaphylactic reactions (rare), local mild reaction
Special precautions : Complete vaccine course is must
Protective value : Short duration
Availability : Vial.
 Chapte
r
Family Planning
Appliances
7
MALE CONDOM (NIRODH)
Method : Spacing, physical barrier/conventional
Device : Thin latex (rubber sheath) device
Mechanism of action : Prevents the semen being deposited in vagina
Eligible candidate : All men
Instructions to us : Use new condom for each act
Fitted by unrolling on erect penis
Proper care is taken during the use
Advantage : Easy to use, safe, less expensive, accessible, available under commercial and
social marketing
Disadvantage : Decreases the sex sensation
Side effects : Allergy to latex
Additional benefit : Protects against Sexually transmitted disease (STD), HIV
Failure rate : 12–14 per Hundred women-years of exposure (HWY)

FEMALE CONDOM
Method : Spacing, physical barrier/conventional
Device : Soft, thin, transparent pouch
Made of polyurethane plastic, latex
Pre-lubricated with silicon
Condom fits loosely inside the
vagina. It has flexible rings at both
ends.
Internal ring is small and anchors the cervix.
Outer ring is large and stays outside.
Mechanism of action : Forms a barrier, prevents semen being deposited in vagina.
Eligible candidate : All women
Instructions to use : Use a new condom for each act
Inserted just before and removed soon after sex
114 Part II:
Spotters
Outer ring should remain outside the vagina
Ensure that penis enters inside the condom.
Remove the condom by holding outer ring and twisting.
Male and female condom should not be used together.
Advantage : Easy to use in first experience itself
Disadvantage : Costly, high failure rate
Side effects : Mild irritation and latex allergy
Additional benefits : Protects from HIV and STD
Failure rate : 20–25 per Hundred women-years of exposure (HWY)

COMBINED ORAL PILL

Method : Spacing, low-dose hormonal contraceptive
Device : Blister pack, contains 21 hormonal pills and 7 IFA tablets. Each hormonal
pill contains—
Progestin: Norgestrel 0.3 mg
Estrogen: Ethniyl estradiol 0.03 mg
Mechanism of action : By inhibiting ovulation
Prevents sperm entry by making cervical secretions thick
Eligible candidate : Any women after screening
Instructions to use : Consultation and screening before starting
New pack for each cycle starting at 5th day
Take one tablet orally every day, at fixed
time
Any missed pill should be taken as soon as possible
Periodic follow up
Advantage : Easy to use, effective and
cheap Controlled by women
herself
Can be started at any time (except pregnancy) and stopped at any time
Reversible and does not interfere with sex
Available under social marketing and free distribution
HIV infected women on Antiretroviral therapy (ART) can use Oral contraceptive
pills (OCP) along with condom for additional protection
Disadvantage : Adverse effects on lactation, long term use may cause non-communicable
dis- eases
Side effects (adverse) : Breast tenderness
Weight gain, disturbance in serum
lipids Mood changes
Increase in blood pressure
Deep vein thrombosis
Cervical cancer
Contraindication : Age more than 40 year
Breast feeding mother
 Family Planning Appliances
115
Breast cancer
Treatment on anticonvulsants or
rifampicin Hyperlipidemia
Hypertension, diabetes, cardiac problems, stroke
Active liver/gall bladder diseases
Thrombophlebitis
Additional benefit : Prevents—
(Non-contraceptive benefit) Endometrial and ovarian cancer
Anemia
Pelvic inflammatory diseases
Menstrual cramps, ovulation pain
Benign breast disorders
Ovarian cysts
Ectopic pregnancy
Ovarian cancer
Failure rate : Less than 1 per Hundred women-years of exposure (HWY)
Brand Name : MALA-D, MALA-N

COPPER - T
Method : Spacing, second generation intra-uterine device.
Device : Small, flexible plastic frame of silver core, wrapped with copper wire (TCu-
380 A)
Mechanism of action : By foreign body reaction, it alters the bio-chemical changes in the uterus, dis-
turbs sperm and egg union and implantation.
Eligible candidate : All women of reproductive life
Not a method of choice for nulliparous
Insertion : Within 10 day of menstrual
bleeding Within 5 day after
unprotected sex Within 48 hour
after delivery
6 to 8 week after delivery
12 week after abortion
Insertion into uterus by trained person after pregnancy is ruled out
Instructions : Check the strings regularly
Follow up visit one month after insertion and once a year afterwards
Advantages : Simple insertion, inexpensive, reversible
Less side effects, low risk,
Long time protection (10 year)
No continued motivation is needed
Can be used within three to five day as postcoital (emergency)
contraceptive No interruption in the sex
Disadvantage : Needs trained person for insertion
116 Part II:
Spotters
Periodic replacement
Needs yearly follow up
Side effects : Irregular bleeding, expulsion
Pain, backache during monthly bleeding
Perforation, infection
Pelvic infection and inflammatory
disease Anemia, ectopic pregnancy
Additional benefit : Prevents endometrial cancer
(Non-contraceptive benefit)
Contraindication : Suspected pregnancy
Nulliparous and women having multiple partners
Anemia, abnormal bleeding
Cervix and uterine fibroid
Pelvic inflammatory
diseases
Cervix, uterus and ovarian cancer
HIV without treatment
Systemic lupus erythematosus (SLE)—Severe thrombocytopenia
Previous ectopic pregnancy
Congenital uterine malformation
Effectiveness failure : 1.5 per Hundred women-years of exposure (HWY) up to 10 year.

IMPLANT
Method : Spacing hormonal—Depot
Device : Small flexible, silastic plastic rods having progesterone
Mechanism of action : By thickening cervical mucus, it blocks sperm entry and prevents ovulation
Eligible candidate : All women
Implantation : Implanted under the skin by minor surgical procedure by trained provider.
Inner (medial) side of the upper arm is preferred
Implanted within 7 day of starting of menstrual cycle
Advantage : Long-lasting, reversible
Do not interfere in sex
Protects against iron deficiency anemia
Disadvantage : Not reported
Side effects : Menstrual irregularities
Breast tenderness
Enlarged ovarian
follicles Weight gain
Contraindication : Liver, gall bladder disease
Breast cancer
Unexplained bleeding
Failure rate : 0.2 per Hundred women-years of exposure (HWY) using 3 to 7 year (depending
upon the type).
 Family Planning Appliances
117
SAHELI (CENTCHROMAN)
Method : Spacing—Non-hormonal
Device : Non-steroidal, non-hormonal oral weekly pill
Contains centchroman 30 mg/pill
Mechanism of action : Disrupts hormones needed for preparation in uterus for implantation of fertilized
egg.
Accelerates ovum transport
Eligible candidate : All women of reproductive age
Instructions to use : One tablet on the first day of menstruation, then one tablet twice a week
(same day) for 3 month and then once a week on the same day as long as
desired
Advantage : Few side effects
Social marketing
Reversible
Side effects : Prolongation of menstrual cycle
Additional benefit : Beneficial in breast cancer
(Non-contraceptive benefit)
Contraindication : Chronic illness
Nursing mothers
Liver disease
Polycystic ovarian disease
Effectiveness : Highly effective, pearl index is 1.83 per Hundred women-years of exposure
(HWY)
Brand Name : Saheli, Centron.

EMERGENCY CONTRACEPTION
Method : Emergency contraception after unprotected intercourse
Device : Tablet of levonorgestrel 1.5 mg
Mechanism of action : Disturbs ovum release, fertilization and implantation
Eligible candidate : Women who has underwent unprotected sex or contraceptive failure
Instructions to use : To be used within 12 hour (maximum 72 hour) of unprotected
sex Tablet is taken along with food
Advantage : Avoids unwanted pregnancy
Disadvantage : Does not protect from STD/HIV
Side effects : Lower abdominal pain, nausea, vomiting, tenderness in breast, headache, irregu-
larity in menstrual bleeding
Contraindication : Allergy to ingredients
Effectiveness : Highly effective if used on time.
 Chapte
r
Family Planning
Appliances
7

CONTRACEPTIVE
MALE CONDOM (NIRODH)
Method : Spacing, physical barrier/conventional
Device : Thin latex (rubber sheath) device
Mechanism of action : Prevents the semen being deposited in vagina
Eligible candidate : All men
Instructions to us : Use new condom for each act
Fitted by unrolling on erect penis
Proper care is taken during the use
Advantage : Easy to use, safe, inexpensive, accessible, available under commercial and social
market- ing
Disadvantage : Decrease the sex sensation
Side effects : Allergy to latex
Additional benefit : Protects against Sexually transmitted disease (STD), HIV
Failure rate : 12–14 per Hundred women-years of exposure (HWY)

FEMALE CONDOM
Method : Spacing, physical barrier/conventional
Device : Soft, thin, transparent pouch
Made of polyurethane plastic, latex
Pre-lubricated with silicon
Condom fits loosely inside the
vagina. It has flexible rings at both
ends.
Internal ring is small and anchors the cervix.
Outer ring is large and stays outside.
Mechanism of action : Forms a barrier, prevents semen being deposited in vagina.
Eligible candidate : All women
Instructions to use : Use a new condom for each act
Inserted just before and removed soon after sex
104 Part II:
Spotters
Outer ring should remain outside the vagina
Ensure that penis enters inside the condom.
Remove the condom by holding outer ring and twisting.
Male and female condom should not be used together.
Advantage : Easy to use in first experience itself
Disadvantage : Costly, high failure rate
Side effects : Mild irritation and latex allergy
Additional benefits : Protects from HIV and STD
Failure rate : 20–25 per Hundred women-years of exposure (HWY)

COMBINED ORAL PILL

Method : Spacing, low-dose hormonal contraceptive
Device : Blaster pack, contains 21 hormonal pills and 7 IFA tablets. Each hormonal pill con-
tains—
Progestin: Norgestrel 0.3 mg
Estrogen: Ethniyl estradiol 0.03 mg
Mechanism of action : By inhibiting ovulation
Prevents sperm entry by making cervical secretions thick
Eligible candidate : Any women after screening
Instructions to use : Consultation and screening before starting
New pack for each cycle starting at 5th day
Take one tablet orally every day, at fixed time
Any missed pill should be taken as soon as possible
Periodic follow up
Advantage : Easy to use, effective and
cheap Controlled by women
herself
Can be started at any time (except pregnancy) and stopped at any time
Reversible and does not interfere with sex
Available under social marketing and free distribution
HIV infected women on Antiretroviral therapy (ART) can use Oral contraciptive pills
(OCP) along with condom for additional protection
Disadvantage : Adverse effects on lactation, long term may cause non-communicable
diseases Side effects (adverse) : Breast tenderness
Weight gain, disturbance in serum lipids
Mood changes
Increase in blood pressure
Deep vein thrombosis
Cervical cancer
Contraindication : Age more than 40 years
Breast feeding mother
Breast cancer
Treatment on anticonvulsants or rifampicin
Hyperlipidemia
 Family Planning Appliances
105
Hypertension, diabetes, cardiac problems, stroke
Active liver/gall bladder diseases
Thrombophlebitis
Additional benefit : Prevents—
(Non-contraceptive benefit) Endometrial and ovarian cancer
Anemia
Pelvic inflammatory diseases
Menstrual cramps, ovulation pain
Benign breast disorders
Ovarian cysts
Ectopic pregnancy
Ovarian cancer
Failure rate : Less than 1 per Hundred women-years of exposure (HWY)
Brand Name : MALA-D, MALA-N

COPPER - T
Method : Spacing, second generation intra-uterine device.
Device : Small, flexible plastic frame of silver core wrapped with copper wire (TCu-380 A)
Mechanism of action : By foreign body reaction, it alters the bio-chemical changes in the uterus, disturbs sperm
and egg union and implantation.
Eligible candidate : All women of reproductive life
Not a method of choice for nulliparous
Insertion : Within 10 days of menstrual bleeding
Within five days after unprotected
sex Within 48 hours after delivery
Six to eight weeks after delivery
12 weeks after abortion
Insertion into uterus by trained person after pregnancy is ruled out
Instructions : Check the strings regularly
Follow up visit one month after insertion and once a year
Advantages : Simple insertion, inexpensive, reversible
Less side effects, low risk,
Long time protection (10 years)
No continued motivation is needed
Can be used within three to five days as postcoital (emergency) contraceptive
No interruption in the sex
Disadvantage : Needs trained person for insertion
Periodic replacement
Needs yearly follow up
Side effects : Irregular bleeding, expulsion
Pain, backache during monthly bleeding
Perforation, infection
Pelvic infection and inflammatory disease
Anemia, ectopic pregnancy
106 Part II:
Spotters
Additional benefit : Prevents endometrial cancer
(Non-contraceptive benefit)
Contraindication : Suspected pregnancy
Nulliparous and women having multiple partners
Anemia, abnormal bleeding
Cervix and uterine fibroid
Pelvic inflammatory
diseases
Cervix, uterus and ovarian cancer
HIV without treatment
Systemic lupus erythematosus (SLE)—Severe thrombocytopenia
Previous ectopic pregnancy
Congenital uterine malformation
Effectiveness failure : 1.5 per Hundred women-years of exposure (HWY) up to 10 years.

IMPLANT
Method : Spacing hormonal—Depot
Device : Small flexible, silastic plastic rods having progesterone
Mechanism of action : By thickening cervical mucus, it blocks sperm entry and prevents ovulation
Eligible candidate : All women
Implantation : Implanted under the skin by minor surgical procedure by trained provider.
Inner (medial) side of the upper arm
Implanted within 7 days of starting of menstrual cycle.
Advantage : Long-lasting, reversible
Do not interfere in sex
Protects against iron deficiency anemia
Disadvantage : Not reported
Side effects : Menstrual irregularities
Breast tenderness
Enlarged ovarian
follicles Weight gain
Contraindication : Liver, gall bladder
disease Breast cancer
Unexplained bleeding
Failure rate : 0.2 per Hundred women-years of exposure (HWY) using three to seven years (depending
upon the type).

SAHELI (CENTCHROMAN)
Method : Spacing—Non-hormonal
Device : Non-steroidal, non-hormonal oral weekly pill
Contains centchroman 30 mg/pill
Mechanism of action : Disrupts hormones needed for preparation in uterus for implantation of fertilized egg.
Accelerates ovum transport
Eligible candidate : All women of reproductive age
Instructions to use : One tablet on the first day of menstruation, then one tablet twice a week (same days) for
 Family Planning Appliances
107
three months and then once a week on the same day as long as desired
Advantage : Few side effects
Social marketing
Reversible
Side effects : Prolongation of menstrual cycle
Additional benefit : Beneficial in breast
cancer (Non-contraceptive benefit)

Contraindication : Chronic illness

Nursing mothers
Liver disease
Polycystic ovarian disease
Effectiveness : Highly effective, pearl index is 1.83 per Hundred women-years of exposure
(HWY) Brand Name : Saheli, Centron.

EMERGENCY CONTRACEPTION
Method : Emergency contraception after unprotected intercourse
Device : Tablet of levonorgestrel 1.5 mg
Mechanism of action : Disturbs ovum release, fertilization and implantation
Eligible candidate : Women who has underwent unprotected sex or contraceptive failure
Instructions to use : To be used within 12 hours (maximum 72 hrs) of unprotected
sex Tablet is taken along with food
Advantage : Avoids unwanted pregnancy
Disadvantage : Does not protect from STD/HIV
Side effects : Lower abdominal pain, nausea, vomiting, tenderness in breast, headache, irregularity in
menstrual bleeding
Contraindication : Allergy to ingredients
Effectiveness : Highly effective if used on time.
 Chapte
r Vectors

ANOPHELES FEMALE
Identification : Proboscis and palpi are equal in length
Palpi are pointed
Proboscis is in straight line with the body
Wings are spotted
Antennae are not hairy
Habits : Prefers human blood for oviposition
Bites in the evening and at night
Rests inside the house
Obscure in dark, cool and shady corners
Life span is one week to one month
Breeding places : Clean water, without organic matter
For example well, roof tanks, flood water, dams, etc.
Disease transmitted : Malaria—plasmodium species
Control : Environmental—source reduction
Chemical—Insecticide spray
Genetic—gene and sex distortion
Personal protection—mosquito net, coils, liquid, repellent creams and spray
National Programme : National anti-malaria programme
for Control National vector borne disease control programme
Body parts of mosquito are as shown in Fig. 8.1.

CULEX FEMALE
Identification : Palpi are smaller than proboscis
Proboscis makes an acute angle with body
Wings are unspotted
Habits : Domestic, prefer animal and human blood
Bites in the midnight, prefer legs below the knee
Rests inside the house
 Vectors 119

Fig. 8.1: Body parts of mosquito

Obscure in dark, cool and shady corners

Breeding places : Breeds in dirty water—stagnant and blocked drains, cesspools, sludge and
sewage water
Dispersal—up to 11 km
Disease transmitted : Filariasis—Wuchereria bancrofti
Japanese encephalitis—Arbovirus
Viral arthritis
Control : Environmental—source reduction
Chemical—insecticide spray
Genetic—gene and sex distortion
Personal protection—mosquito net, coils and repellents
National Program : National filaria control programme
for Control National vector borne disease control programme

SEX DIFFERENCE IN MOSQUITOES

Anopheles Mosquito
Particulars Male (Fig. 8.2) Female
Morphology Palpi club shaped Pointed
Antennae hairy Not hairy
Feeding Feeds on plant juice Needs blood for oviposition
Disease transmitted Does not transmit Transmits malaria
Control Needed, as male Essential
mosquitoes takes part in
procreation
120 Section II:
Spotters

Fig. 8.2: Mouth parts of anophiline male of mosquito Fig. 8.3: Mouth parts of culicine female of mosquito

Culex Mosquito
Particulars Male Female (Fig. 8.3)
Morphology Palpi longer than proboscis pointed Palpi smaller than
and everted tip proboscis Not hairy
Antennae has bushy hairs
Feeding Feeds on plant juice Needs blood for oviposition
Disease transmitted Does not transmit Transmits – filariasis, JE
Control Needed, as male mosquitoes take Essential
part in procreation

Larvae of Mosquitoes
Particulars Anopheles Culex (Fig. 8.4)
Breathing apparatus Absent Present on 8th abdominal segment
Siphon tubes Represented by aperture Two thin and long tubes
Palmate hairs Present Absent
Anterior clypeal hair Two pairs One pair
Control Anti-larval measures Anti-larval measures

Fig. 8.4: Larvae of culicine mosquito Fig. 8.5: Pupae of anophiline mosquito
 Vectors 121

Pupa of Mosquitoes
Particulars Anopheles (Fig. 8.5) Culex
Shape Deep comma shaped Comma shaped—Large eyes
Morphology Large cephalothorax narrow Large cephalothorax narrow
abdomen abdomen
Accessory paddle hair Lies above the paddle hair Lies below the paddle hair or
absent
Siphon tubes Short and broad Long and narrow
Funnel shaped Trumpet shape
Control Not necessary as pupal stage Not necessary as pupal stage
is of short duration is of short duration

AEDES FEMALE
Identification : Satiny appearance
Palpi are smaller than proboscis
Wings—Not spotted
Ornamented with white stripes on black body (Tiger mosquitoes)
Broad, flat, imbricated scales
Habits : Peri-domestic
Rests in dark quite rooms, bathrooms, bed rooms, hanging articles
Flight range—Less than 100 meter
Bites throughout the day (day biter mosquito).
Breeding places : Artificially collected water in receptacles—discarded tin, bottle, tyres, coconut
shell, flower pots, etc.
Disease transmitted : Dengue and dengue hemorrhagic fever—Arbovirus ‘B’
Chikungunya
Yellow fever
Control : Environmental—Removal of artificial water collecting receptacles
Chemical—Insecticide—space spray, Ultra-low volume fogging during epidem-
ics
Genetic-Gene and sex distortion
Personal protection—Mosquito net, coils and repellents (mosquito net 25 mesh
holes per sq cm
Aedes aegypti index : Is the percentage of houses in the area showing of breeding places of Aedes ae-
gypti
This index should be kept less than one percent (Zero is ideal)
National program : National vector born
for control disease control programme.
Aedes female mosquito is as shown in figure 8.6.

HOUSE FLY
Identification : Mouse gray in color
Body is covered with sticky hair (tenet hair)
Large compound eyes
Retractile proboscis
122 Section II:
Spotters
Dark longitudinal
stripes on thorax
Dark and light mark-
ing on abdomen
Leg has a pair of pads.
Mouth parts of house-
fly is as shown in fig-
ure 8.7.
Habits : Lives close to breed-
ing places
Restlessly moves from
filth (sputum, feces,
wound, pus) to food
Vomits, defecates Fig. 8.6: Aedes mosquito
feeds and cleans its
body very frequently, has remarkable capacity to
reproduce Not lives more than 48 hour without water
Disperses up to 6 km, lives for 1 month
Breeding places : Human and animal excreta
Dumps, decaying garbage
Disease transmitted : By mechanical transmission – typhoid, cholera, gastroenteritis, amoebiasis, polio,
anthrax, trachoma, yaws. Maggots cause myiasis
Control : Improvement of environmental and general sanitation
Hygienic disposal of refuse and human and animal excreta
Screening mesh—14 holes per square inch, fly traps, swatting, fly paper
Insecticides : DDT – 5%
Mixed with sugar and sprayed in
Methoxychlor – living and breeding places of flies
Lindane – 0.5%
Poisons—Fly baits, ribbons, fly
papers Larvicides: Diazinon – 2%
Dichlorovos – 2%
Dimethoate – 1%
25 to 50 liter/square meter in breeding places
Health education regarding diseases transmission and fly awareness.

EGGS OF VECTORS
Anopheles : White to black in col-
or minute dust size
(< 0.5 mm)
Single and separate
Boat shaped
Has lateral floaters (air
cells) Fig. 8.7: Mouth parts of house fly
 Vectors 123

Culex : Size of caraway seeds with micro polar process at one end
Eggs are cemented in rafts (in cluster)
No lateral floaters
Brownish black in color
Aedes : Minute size, single, elongated
Cigar shaped
No lateral floaters
Black in color
Mansonoid : Arranged in star shaped manner
Attached to pistia plant
House fly : Visible to naked eye—0.5 mm in
length Glistening pearly white in color
Sand fly : Torpedo (ovoid) shape
Wavy line markings on the surface
Convex dorsally, flat or concave
ventrally
Lice (Nits) : Ovoid in shape, white in color
1/25 x 1/60 inch in size (0.5 mm size)
Pointed at one end, operculated at the
other.

RAT FLEA
Identification : Dark brown in color
Bilaterally compressed wingless body
Head is conical, attached directly to thorax (no neck).
Exoskeleton with bristles directed backward.
Three pairs of spiny strong limbs
Foot end (claws) turned opposite direction (Fig. 8.8).
Habits : Lives on rat, in rat burrows, store house, cracks, crevices, carpet
Xenopsylla cheopis, common rat flea of India which is a powerful multiplier of
plague bacilli

Disease transmitted : Bubonic plague is

transmitted by bite of
blocked flea (x cheo-
pis)
Endemic (murine)
typhus – is transmit-
ted by contamination
of skin with feces of
fleas.
Chiggarosis
Both male and female
suck the blood and
transmit the plague
ba- cilli from rat to rat
Fig. 8.8: Rat flea
and rat to man
124 Section II:
Spotters
Control : Both rat and rat flee should be destroyed together
Insecticide: DDT 10% (dust where rodent moves and
burrows) 5% indoor spray
Dichlorors resin strip
Insufflation (Disinfection) of ship, aircrafts
Rat destruction: Poisonous bait, trapping, emitting hydrocyanic acid gas, rat
proof- ing
Personal protection: Repellents-Diethyltoluamide, Benzyl benzoate
Flea index : Is the measurement of density of fleas per rat. Kept below-1
Useful in evaluation of control measures
And forecast potentiality of plague epidemic.

HEAD LOUSE
Identification : Dark grayish in color (color of hair)
1 mm in size having head, thorax and abdomen
Body is flattened dorso-ventrally
Three pairs of legs, no wings (Fig. 8.9)
Habits : Ectoparasite of man, infestation is called pediculosis
Head louse lives in hair of scalp
Body louse lives in hair of body and clothing, pubic louse in pubic region.
Both sexes lives on the host.
Dissemination : Directly by contact with lousy person
Indirectly by using cloth, bedroom of lousy person
Overcrowding (school, jail, hostel—closed communities) favors the spread. In
women and children, spread is more
Diseases transmitted
Disease Causative agent Mode of spread
Epidemic typhus Rickettsia prowazeki Contact of lice feces through abrasion or unbroken skin
Relapsing fever Borrelia recurrentis Crushed fluid
Trench fever Rickettsia Quintana Louse feces

Heavy infestation : Causes dermatitis due

to scratching and sec-
ondary infection
Skin pigmentation
(Vagabond disease),
urticaria
Insomnia due to irrita-
tion
Delousing : Head louse—0.5 per-
cent malathion lotion
is applied to head after
hot bath, 12 to 24 hour
Fig. 8.9: Head louse
 Vectors 125

later second applica-

tion is done
Body louse—carbaryl
50 gm/person is
dusted on body and
clothing
Repeated after 2 day
to destroy hatching
lice (Nits)
Mass delousing is ad-
vocated
Anti lice shampoos
Fentrothion 0.2 to 0.4 Fig. 8.10: Sand fly
percent
Deltomethrin 0.03
per- cent
Emulsifiable concentrated NBIN (Benzyl benzoate 68%, DDT 6%, Benzocaine
12% and Tween 80–14%)
Prevention : Regular bath, washing of cloths, maintaining personal hygiene
Health education
Improving living standards
Avoiding contact with infected person
Hair should be cut short and kept clean.

SAND FLY
Identification : Dark brown hairy body, Smaller than mosquito
Antennae are long and
filamented Lanceolate shaped
wings
Second vein of the wing divides twice
Three pairs of very long and slender legs
Pair of large compound eyes (Fig. 8.10)
Habits : Lives in cervices, holes, stone, rock in hills, tables, store rooms, etc.
Breeds in Cattle shed, poultry, near bath room, refuse, etc.
Organic matter, shady place and loose soil is essential for
breeding Avoids light, bites mainly at night—bites the wrist and
ankle
It hops, does not fly
Only females are blood-suckers
Disease transmitted
Disease Organism Mode of transmission
Kala Azar Leishmania donovani (Protozoa) Bite
Sand fly fever Virus Wound contamination with regurgitated saliva
Oriental sore Leishmania tropica Bite
Control : Insecticide DDT 1–2 gm/m2
Indane 0.25 mg/m2 (spraying is done in all breeding places)
126 Section II:
Spotters
Source reduction Clearing, filling of cracks and cervices
Keeping cattle and poultry outside the house
Personal protection Sand fly net (45 mesh/inch) impregnated with permethrin
Not walking in bare foot, using gumboots and
Repellents to leg.

SOFT TICK
Identification : Oval shaped leathery body, sufficiently big
Head lies ventrally, not visible from
above No antennae, four pairs of legs no
wings Scutum is absent
Habits : Ectoparasites on multiple host
Intermittently sucks the blood of mammals
Soft tick (Fig. 8.11) lives in cracks, crevices, bedding, cattle sheds, human dwell-
ings. Withstands starvation for long time
Disease transmitted : Q fever
Relapsing fever
Kyasanur forest disease (KFD)—rarely
Both sex transmits the disease
Trans-ovarian transmission of infection to progeny is present
Control : Environment Filling up the cracks and crevices
Chemical Insecticide indane, malathion, DDT
Pyrethrum dusting on infested animal
Personal protection Insecticide repellents like
Dibutylphthalate (DBP)
Diethyltolumide (DEET)
Benzylbenzoate
Examination of body frequently
Wearing full clothing.

HARD TICK
Identification : Body is oval, gray
white in color
Rectangular head at
anterior end
Head, thorax,
abdomen are fused
(indistinct)
Four pairs of legs, No
antennae, No wings
Dorsum is covered
by Chitinous shield
(Scutum) (Fig. 8.12)
Fig. 8.11: Soft tick
 Vectors 127

Habits : Both sexes bite and

transmit the disease
Blood sucking ec-
toparasite having three
hosts—monkey, dog
and cattle remain at-
tached to host
Trans-ovarian trans-
mission of infection to
progeny is present
Disease transmitted : KFD, typhus and spot-
ted fever. Encephalitis
and tularemia
Also causes Tick pa-
ralysis Fig. 8.12: Hard tick
Control : Insecticides Malathion

Lindane
DDT } Dusted on animals, vegetations, premises

Personal protection
Repellents Indalone, Diethyl toluamide, Benzyl benzoate
Periodic examination of body and removal of tick by persons visit-
ing tick infested area.

ITCH MITE (SARCOPTES SCABIEI)

Identification : Dirty white colored small, tortoise (oval) shaped insect
Round above, flat below four short stumpy legs, no
wings No demarcation of body segments
Body is wrinkled covered with bristles (Fig. 8.13)
Habits : Burrows in epidermis of skin
Spreads by close contact
Disease : Scabies
By close contact with
infected person, over-
crowding, poor hy-
giene favors spread
Treatment : Using sarcopitcidal
Benzyl benzoate 25%
HCH (linden) 0.5%
Gamma-amino butyric
acid (GABA) 5%
Applied to the body
below the chin after
scrub bath
Application is Fig. 8.13: Itch mite
repeated after 12 hour
128 Section II:
Spotters
12 hour after the sec-
ond application, bath
is given
All infested and close
contacts are treated si-
multaneously and sim-
ilarly (Blanket treat-
ment)
Post-treatment, laun-
dering of clothes, mat-
tress is done.

CYCLOPS
Identification : Pear shaped
(cephalothorax and
abdomen), semi-trans-
parent body Fig. 8.14: Cyclops
Forked tail, one small pigmented eye (Fig. 8.14)
Just visible to naked eye – 1 mm size
Two pairs of
antennae Five pairs of
legs
Habits : Lives in fresh water and acts as intermediate host
Disease transmitted : Guinea worm dracunculosis (eradicated in India)
Fish tapeworm diphyllobothrium latum.
Control : Physical Straining in muslin/nylon strainer
Boiling the drinking water to 60°C
Chemical Chlorination – 5 ppm
Lime 60 grain/gallon
Abate – 1 mg/liter
Permanent Conversion of step well
Providing safe drinking water
Health education.

CONTROL OF MOSQUITO
Environmental : Source reduction
Chemical : DDT Dose mg/m2 Effectiveness
DDT 1–2 6–12 month
Lindane 0.5
Malathion 2 3 month
OMS 33 2
Pyrethrum 0.1%
Genetic : Sterile male technique
Cytoplasmic incompatibility
 Vectors 129

Chromosomal translocation
Sex distortion
Gene replacement
Biological : Using larvicidal fish—Gambusia affinis, Lebister reticulates
Personal protection : Mosquito nets: 150 holes/sq inch of size 0.0475 inch
Mosquito coils
Fumigation mats
Repellents: Diethyltoluamide
Mosquito to screening guaze—16 meshes/inch
Anti larvidial : Crude oil 10–15 gallon/acre once in a week to breeding water
Pairs green: 2% (with soap powder and slaked lime)
One pound per acre (for anopheles)
Abate—once in 15 day (for culex)
Integrated control : Environmental
Biological
Physical/mechanical
Chemical
Legislative

Note: Following figures of mosquitoes have been given for your reference.
130 Section II:
Spotters
Mosquitoes

Larva of anophiline mosquito Larva of culicine mosquito

Pupa of anophiline mosquito Pupa of culicine mosquito

Adult female anopheles mosquito Adult female culex mosquito

 Chapte
r Vectors

ANOPHELES FEMALE
Identification : Proboscis and palpi are equal in length
Palpi are pointed
Proboscis is in straight line with the body
Wings are spotted
Antennae are not hairy
Habits : Prefers human blood for oviposition
Bites in the evening and at night
Rests inside the house
Obscure in dark, cool and shady corners
Life span is one week to one month
Breeding places : Clean water, without organic matter
For example well, roof tanks, flood, water, dams, etc.
Disease transmitted : Malaria—plasmodium species
Control : Environmental—source reduction
Chemical—Insecticide spray
Genetic—gene and sex distortion
Personal protection—mosquito net, coils, liquid, repellents cream and spray
National Programme : National anti-malaria programme
for Control : National vector borne disease control programme
Body parts of mosquito are as shown in Fig. 8.1.

CULEX FEMALE
Identification : Palpi are smaller than proboscis
Proboscis makes an acute angle with body
Wings are unspotted
Habits : Domestic, prefer animal and human blood
Bite—Midnight, prefer legs below the knee
Rest—Inside the house
Obscure in dark, cool and shady corners
Breeding places : Breeds in dirty water—stagnant and blocked drains
 Vectors 109

Fig. 8.1: Body parts of mosquito

Dispersal—up to 11 km
Disease transmitted : Filariasis—Wuchereria bancrofti
Japanese encephalitis—Arbovirus
Viral arthritis
Control : Environmental—source reduction
Chemical—insecticide spray
Genetic—gene and sex distortion
Personal protection—mosquito net, coils and repellents
National Program : National filaria control programme
for Control : National vector borne disease control programme

SEX DIFFERENCE IN MOSQUITOES

Anopheles Mosquito
Male Female
Morphology Palpi club shaped Pointed
Antennae hairy Not hairy
Feeding Feeds on plant juice Needs blood for oviposition
Disease transmitted Does not transmit Transmits-malaria
Control Needed as male Essential
mosquitoes takes part in
procreation

Culex Mosquito
Male Female
Morphology Palpi longer than proboscis pointed Palpi smaller than
and everted tip proboscis Not hairy
Antennae has bushy hairs
Feeding Feeds on plant juice Needs blood for oviposition
Disease transmitted Does not transmit Transmits – filariasis, je
Control Needed as male mosquitoes takes Essential
part in procreation
110 Part II:
Spotters

Fig. 8.2: Mouth parts of anophilini male of mosquito Fig. 8.3: Mouth parts of culicine female of mosquito

Larvae of Mosquitoes
Anopheles Culex (Fig. 8.3)
Breathing apparatus Absent Present on 8th abdominal segment
Siphon tubes Represented by aperture Two thin and long tubes
Palmate hairs Present Absent
Anterior clypeal hair Two pairs One pair
Control Anti-larval measures Anti-larval measures

Pupa of Mosquitoes
Anopheles (Fig. 8.4) Culex
Shape Deep comma shaped Comma shaped
Morphology Large cephalothorax narrow Large cephalothorax narrow
abdomen abdomen
Accessory paddle hair Lies above the paddle hair Lies below the paddle hair or
absent
Siphon tubes Short and broad Long and narrow
Funnel shaped Trumpet shape
Control Not necessary as pupal stage Not necessary as pupal stage
is of short duration is of short duration

Fig. 8.3: Larvae of culicine mosquito Fig. 8.4: Pupae of anophilini mosquito
 Vectors 111

AEDES FEMALE
Identification : Satiny appearance
Palpi are smaller than
proboscis
Wings—Not spotted
Ornamented with white
stripes on black body
(Tiger mosquitoes)
Broad, flat,
imbricated scales
Habit : Peri-domestic
Rests in dark quite
rooms, bathrooms, bed
rooms, hanging articles
Fig. 8.8: Aedes mosquito
Flight range – Less than
100 meters
Bites throughout the day. (day biter
mosquito)
Breeding places : Artificially collected water in receptacles—discarded tin, bottle, tyres, coconut
shell, flower pots, etc.
Disease transmitted : Dengue and dengue hemorrhagic fever—Arbovirus ‘B’
Chikungunya
Yellow fever
Control : Environmental—Removal of artificial water collecting receptacles Chemical—
Insecticide—space spray, Ultra-low volume fogging during epidemics Genetic-
Gene and sex distortion
Personal protection—Mosquito net, coils and repellents
Aedes aegypti index : = % of houses in the area showing of breeding places of Aedes aegypti
This index should be kept less than one percent (Zero is ideal)
National program for control : National vector borne disease control programme.

HOUSE FLY
Identification : Mouse grey in color
Body is covered with sticky hair (tenet hair)
Large compound eyes
Retractile proboscis
Dark longitudinal stripes on thorax,
Dark and light marking on abdomen
Leg has a pair of pads
Habit : Lives close to breeding
places
Restlessly moves from
filth (sputum, feces,
wound, pus) to food
Vomits, defecates and
cleans its body very
frequently Fig. 8.9: Mouth parts of house fly
112 Part II:
Spotters
Disperses up to six km, lives for one month
Breeding places : Human and animal excreta
Dumps, decaying garbage
Disease transmitted : By mechanical transmission – typhoid, cholera, gastroenteritis, amoebiasis, polio, an-
thrax, trachoma, yaws.
Control : Improvement of environmental and general sanitation
Hygienic disposal of refuse and human excreta
Screening mesh—14 holes per square inch
Insecticides : DDT – 5%
Methoxychlor 5% Mixed with sugar and sprayed in
Lindane 0.5% Living and breeding places of
flies Poisons—Fly baits, ribbons, fly papers
Larvicides – diazinon – 2 percent, dichlorovos – 2 percent, dimethoate – 1 percent
25-50 liters/square meters in breeding places
Health education regarding diseases transmission and fly awareness.

EGGS OF VECTORS
Anopheles : White to black in color
Minute dust size (< 0.5 mm)
Single and separate
Boat shaped
Has lateral floaters (air cells)
Culex : Size of car a way seeds with micro polar process at one end
Eggs are cemented in rafts (in cluster)
No lateral floaters
Brownish black in color
Aedes : Minute size, single, elongated
Cigar shaped
No lateral floaters
Black in colour
Mansonoid : Arranged in star shaped manner
Attached to pistia plant
House fly : Visible to naked eye—0.5 mm in
length Glistening pearly white in color
Sand fly : Torpedo (ovoid) shape
Wavy line markings on the surface
Convex dorsally, flat or concave
ventrally
Lice (Nits) : Ovoid in shape, white in color
1/25 x 1/60 inch in size (0.5 mm size)
Pointed at one end, operculated at the
other.

RAT FLEA
Identification : Dark brown in color
(Fig. 8.10) Bilaterally compressed wingless body
 Vectors 113

Head is conical, attached

directly to thorax (no
neck).
Exoskeleton with bris-
tles directed backward.
Three pairs of spiny
strong limbs
Foot end (claws) turned
opposite direction.
Habit : Lives on rat, in rat
burrows, store house,
cracks, crevices, carpet
Xenopsylla cheopis,
common rat flea of India Fig. 8.10: Rat flea
which is a powerful mul-
tiplier of plague bacilli
Disease transmitted : Bubonic plague bite is transmitted by bite of blocked flea
Endemic (murine) typhus – is transmitted by contamination of skin with feces of
fleas. Chiggarosis
Both male and female suck the blood and transmit the plague bacilli from rat to rat and
rat to man
Control : Both rat and rat flee should be destroyed together
Insecticide: DDT 10 percent dust where rodent moves and burrows
Five percent indoor spray
Dichlorors resin strip
Insufflation (Disinfection) of ship, aircrafts
Rat destruction: Poisonous bait, trapping, gassing – hydrocyanic acid gas, rat
proofing Personal protection: Repellents-Diethyltoluamide, Benzyl benzoate
Flea index : Is the measurement of density of fleas per rat
Useful in evaluation of control measures
And forecast potentiality of plague epidemic.

HEAD LOUSE
Identification : Dark grayish in color (color of hair)
(Fig. 8.11) 1 mm in size having
head, thorax and abdo-
men
Body is flattened dorso-
ventrally
Three pairs of legs, no
wings
Habit : Ectoparasite of man,
infestation is called
Pediculosis
Head louse lives in hair
of scalp
Body louse lives in hair
of body and Fig. 8.11: Head louse
clothing
114 Part II:
Spotters
Dissemination : Directly by contact with lousy person
Indirectly by using cloth, bed room of lousy person
Overcrowding (school, jail, hostel – closed communities) favours the spread. In women
and children, spread is more
Diseases transmitted:
Disease Causative agent Mode of spread
Epidemic typhus Rickettisia Contact of lice faeces
prowazeki through abrasion or
unbroken skin
Relapsing fever Borrelia recurrentis Crushed fluid
Trench fever Rickettsia Quintana Louse feaces
Heavy infestation : Causes
Dermatitis due to Scratching and secondary infection
Skin pigmentation (Vagabond disease)
Insomnia due to irritation
Delousing : Head louse - 0.5 percent malathion lotion is applied to head after hot bath, 12 to 24 hours
later second application is done
Body louse carbaryl 50 gm/person is dusted on body and clothing
Repeated after two days to destroy hatching lice (Nits)
Mass delousing is advocated
Anti lice shampoos Fentrothion 0.2-0.4 percent
Deltomethrin 0.03 percent
Emulsifiable concentrated NBIN (Benzyl benzoate 68%, DDT 6%, Benzocaine 12%
and Tween 80-14%)
Prevention : Regular bath, washing of cloths, maintaining personal hygiene
Health education
Improving living standards
Avoiding contact with infected person
Hair should be cut short and kept clean.

SAND FLY
Identification : Dark brown hairy body, Smaller than
mosquito Antennae are long and
filamented
Lanceolate shaped wings
Second vein of the wing
divides twice
Three pairs of very long
and slender legs
Pair of large compound
eyes
Habit : Lives in cervices, holes,
stone, rock in hills,
stables, store rooms, etc.
Breeds in Cattle shed,
poultry, near bath
room,
refuse, etc. Fig. 8.12: Sand
fly
 Vectors 115

Organic matter, shady place and loose soil is essential for

breeding Avoids light, bite chiefly at night – bite the wrist and
ankle
It hops, does not fly
Disease transmitted: Only females are blood – suckers
Disease Organism Mode of transmission
Kala Azar [Link] (Protozoa) Bite
Sand fly fever Virus Wound contamination
with regurgitated
saliva
Oriental sore Leishmania tropica Bite
Control : Insecticide DDT – 1-2 g/m2
Indane 0.25 mg/m2 (spraying is done in all breeding places)
Source reduction Clearing, filling of cracks and cervices
Keeping cattle and poultry outside the house
Personal protection Sand fly net impregnated with permethrin
Not walking in bare foot, using gumboots and
Repellents to leg.

SOFT TICK
Identification : Oval shaped leathery body, sufficiently
big Head lies ventrally, not visible from
above No antennae, four pairs of legs no
wings Scutum is absent
Habit : Ectoparasites on multiple host
Intermittently sucks the blood of mammals
Lives in cracks, crevices, bedding, cattle sheds, human dwellings. With stand starvation
for long time
Disease transmitted : Q fever
Relapsing fever
KFD—rarely
Both sex transmits the disease
Trans ovarian transmission of infection to progeny is present
Control : Environment Filling up the cracks and crevices
Chemical Insecticide indane, malathion, DDT
Pyrethrum dusting on infested animal
Personal protection Insecticide repellents -
Dibutylphthalate (DBP)
Diethyltolumide (DEE)
Benzylbenzoate
Examination of body frequently
Wearing full clothing.

HARD TICK
Identification : Body is oval, grey white in color
116 Part II:
Spotters
Rectangular head at
anterior end
Head, thorax, abdomen
are fused (indistinct)
4 pairs of legs, No an-
tennae, No wings
Dorsum is covered
by Chitinous shield
(Scutum)
Habit : Both sexes bite and
transmits the disease
Blood sucking ectopara-
site having three hosts
- monkey, dog and cattle
Trans ovarian trans-
mission of infection to Fig. 8.13: Hard tick
progeny is present
Disease transmitted : KFD
Typhus and spotted fever
Encephalitis and tularemia
Also causes Tick paralysis
Control : Insecticides Malathion
Lindane Dusted on animals
DDT
Personal protection –
Repellents Indalone, Diethyl toluamide, Benzyl benzoate
Periodic examination of body and removal of tick by persons visiting tick
infested area.

ITCH MITE (SARCOPTES SCABIEI)

Identification : Dirty white colored small, tortoise (oval) shaped insect
(Fig. 8.14) Round above, flat below 4 short stumpy legs, No
wings
No demarcation of body segments
Body is wrinkled cov-
ered with bristles
Habit : Burrows in epidermis of
skin
Spreads by close contact
Disease : Scabies
By close contact with
insected person, over-
crowding, poor hygiene
favors spread
Treatment : Using sarcopitcidal
Benzyl benzoate 25%
HCH (linden) 0.5%
GAB 5% Fig. 8.14: Itch mite
 Vectors 117

Applied to the body

below the chin after bath
Application is repeated
after 12 hours
12 hours after the second
application, bath is given
All infested and close
contacts are treated
simultaneously and simi-
larly. (Blanket treatment)
Post treatment
launder- ing of clothes,
mattress is done. Fig. 8.15: Cyclops

CYCLOPS
Identification : Pear shaped
(Fig. 8.15) (cephalothorax and abdomen), semi-transparent body
Forked tail, one small pigmented eye
Just visible to naked eye – 1mm size
Two pairs of antennae
Five pairs of legs
Habit : Lives in fresh water and acts as intermediate host
Disease transmitted : Guinea worm dracunculosis (eradicated in India)
Fish tapework Diphyllobothnium lata.
Control : Physical Straining in muslin/nylon strainer
Boiling the drinking water to 60°C
Chemical Chlorination – 5 ppm
Lime 60 grain/gallon
Abate – 1 mg/liter
Permanent Conversion of step well
Providing safe drinking water
Health education.

CONTROL OF MOSQUITO
Anti Adult

Environmental
source reduction

Chemical
DDT Dose of/m2 Effectiveness
DDT 1-2 1-12 months
Lindane 0.5
Malathion 2 3 months
OMS 33 2
Pyrethrum 0%
118 Part II:
Spotters
Genetic
Sterile male technique
Cytoplasmic incompatibility
Chromosomal translocation
Sex distortion
Gene replacement

Biological
Using larvicidal fish - Gambasia affinis, Lebister reticulates

Personal protection
Mosquito nets: 150 holes/sq inch of size 0.0475 inch
Mosquito coils:
Fumigation mats:
Repellents: Diethyltoluamide

Anti Larvidial
• Crude oil 10-15 gallon/acre once in a week to breeding water
• Pairs green: 2% (with soap powder and slaked lime)
One pound per acre (for anopheles)
• Abate – once in 15 days (for culex)
 Chapte
r Chemicals in
Public Health
9

DISINFECTANTS
PHENOL
Identification : Phenol (Carbolic acid)
Nature : Dark oily liquid with aromatic smell
Crude phenol is a mixture of phenol and cresol
Action : Chemical disinfectant
Two percent of phenol destroys and inhibits the growth of harmful microbes (out-
side the body) by coagulating the protoplasm of bacteria.
Uses : Used as disinfectant and deodorant (> 10%)
Used on inanimate objects and excreta
Used as Deodorant (10%) in toilets and for mopping floors (5%)
Pure phenol is used as a standard to compare the germicidal activity of disinfec-
tants. (Rideal-Walker coefficient).

DETTOL
Identification : Dettol
Nature : Chloroxylenol—Antiseptic (used on living tissues)
Action : Active against gram +ve but not on gram –ve bacteria.
Inactivated by organic matter.
Uses : To clean wounds and ulcers.
5 percent is used for general disinfection of—Instruments, plastic equipment
(con- tact period 15 minute).

SAVLON
Identification : Savlon
Nature : Disinfectant—Quaternary ammonium compound
Combination of Cetavlon and Hibitane
Action : Surface disinfectant
Uses : Disinfection of plastics (20 minute), thermometer (3 minute)
Disinfection of wounds.
13 Part II:
2 Spotters
BLEACHING POWDER
Identification : Bleaching Powder (CaOCl2)
Nature : White amorphous powder with pungent smell of chlorine
: Chlorinated lime is called bleaching powder
Fresh bleaching powder contains 33 percent of available chlorine
Rapidly loses its chlorine content on exposure to air, light and
moisture
Hence, stored in dark, cool and dry place in closed, non-erosive containers
Action : Germicidal-effect is by hypochlorous acid, nascent oxygen and chlorine
Uses : Disinfection of water
Disinfection of feces, urine and pus
Used as a toilet deodorant.

HALOGEN TABLETS
Identification : Halogen tablets (Chlorine tablets)
Nature : White tablets containing chlorine
Action : Germicidal-effect is by hypochlorous acid, nascent oxygen and chlorine
Uses : Disinfection of the water during travel, camps and emergency
Dose : 0.5 gm for 20 liter of water
Less effective on turbid water.

LIME
Identification : Lime
Nature : White in color, stony in consistency
Action : Disinfectant, quick lime (freshly burnt) is a powerful disinfectant
10–20 percent aqueous suspension is “milk of lime” (lime:water,
1:4)
Uses : Disinfection of feces, urine, 10–20 percent for two hour
Used for smearing the walls
Deodorant—Cattle sheds, stables, public urinals, latrines
Can be used for disinfecting the water, but it increases the hardness of water and
gives objectionable taste.

POTASSIUM PERMANGANATE
Identification : Potassium permanganate
Nature : Reddish brown crystals with no smell
Action : Disinfectant and oxidizing agent
By oxidizing organic matter, it destroys bacteria
Action is not continuous and is unreliable
Uses : Weak solution (1 in 1000 strength) is used to disinfect vegetables and fruits.

POVIDONE IODINE
Identification : Povidone iodine
Nature : Complexes of iodine, water soluble
Action : Active bactericidal agent with sporicidal action. Also acts on fungi, virus, protozoa
 Chemicals in Public Health

and yeast
Non-irritant, does not stain the skin
Action is reduced in the presence of organic matter
Uses : Wound and skin disinfection.

COPPER SULPHATE
Identification : Copper sulphate
Nature : Blue colored crystal
Action : Destroys algae
Uses : 1.0 ppm concentration is used to destroy algae in stagnant water.

TINCTURE IODINE
Identification : Tincture iodine
Nature : Liquid disinfectant
Action : Effective skin antiseptic
Quick in action, cheap, stains the skin
May produce allergic reactions
Kills cholera and enteric organisms effectively
Uses : Solution used for disinfection of skin
Disinfection of plastic appliance (1 in 2500 aqueous solution)
Disinfection of water in camps (1 in 20,000 aqueous solution).

ALUM
Identification : Alum
Nature : Alum is aluminum sulphate, stony in consistency, white in color
Action : Acts as a chemical coagulant
Helps in sedimentation (settles down the impurities and bacteria in water)
Uses : Used to remove turbidity of water before subjecting to rapid sand
filtration (5–40 mg/liter)
: Used in defluoridation of water (Nalgonda technique).

CETAVLON
Identification : Cetavlon
Nature : Disinfectant
Action : Cationic detergent and bactericide
Uses : Cleaning the skin, washing the hands, cleaning and disinfecting the wounds,
steril- izing surgical instruments

SOAP
Identification : Soap
Nature : Detergent, cleansing agent
Action : Lather formed with water, removes adhering bacteria
Poor disinfecting power
Uses : Hand washing, bathing and sanitary measures.
 INSECTICIDES

PARIS GREEN
Identification : Paris green
Nature : Copper-aceto-arsenite
Emerald-green, micro crystalline powder
Insoluble but floats on water
Contains 50 percent of arsenious oxide
Action : Larvicidal—Stomach poison for anopheline larvae
No ill effect on fish
Does not render water unsuitable for domestic use
Uses : Larvicidal—250 to 500 gm/acre of water to kill anopheles larvae
Paris green is mixed with diluent like road dust/soap stone powder in 1:5 ratio and
dusted over breeding places once in a week

DICHLORO-DIPHENYL-TRICHLOROETHANE (DDT)
Identification : Dichloro-diphenyl-trichloroethane (DDT)
Nature : White amorphous crystalline powder with fruity odor
Insoluble in water, dissolves in organic solvents
Action : Contact poison, acts on the nervous system of insects
Residual action lasts up to 6 month
Para-isomer is the active fraction
Uses : Widely used insecticide to destroy mosquito, lice, fleas, ticks,
bugs Application : Residual spray—100 to 200 mg/sq foot area
Suspension (5%)—One gallon over 1000 sq feet
Environmental pollution, insecticidal resistance, unknown effects on human be-
ings restricts the indiscriminate use of DDT.

MOSQUITO COIL/LIQUID
Identification : Mosquito coil/liquid
Nature : Insecticide
Coil contains allethrin—One percent
Liquid contains permethrin, transfluthrin
Action : Smoke/Vapor generated acts as an insecticide (kills mosquito)
May cause allergic reactions to some

MOSQUITO REPELLENT
Identification : Mosquito repellent
Nature : N-methylphthalate, N-diethylbenzamide
Action : Repels adult mosquitoes, mites, ticks, sand flies
Acts by discouraging arthropods from attacking.
Use : For personal protection from mosquito bite
35 percent solution/cream is applied to exposed skin
5 percent solution is used to impregnate nets/clothes.
 Chemicals in Public Health 135

HEXACHLOROCYCLOHEXANE (HCH)
Identification : Benzene hexachloride (Gammexane)/BHC
Nature : White colored powder with a musty smell
Insoluble in water, but soluble in organic solvent
Action : Insecticide, acts as contact poison
Gamma isomer is the active constituent
Insecticidal action is effective for < 3 month
Uses : Used as insecticide
: Application—20 to 50 mg (gamma-Hexachlorocyclohexane (HCH)) per square
foot of spraying surface.
 MEDICINES
CHLOROQUINE
Identification : Chloroquine
Action : Excellent plasmodial schizonticide
Not useful in radical treatment of vivax and ovale. Since there is no action on
hyp- nozoites (persistent tissue phase)
Indication : Drug of choice in malaria treatment and prophylaxis
Dose 10 mg/kg (600 mg for adult) on first and second
day 5 mg/kg (300 mg for adult) on third day
Chemoprophylaxis-300 mg once a week on the same day and time
Started one week before entering and continued for 6 week after leaving the ma-
larious area.

IRON AND FOLIC ACID TABLETS

Identification : Iron and folic acid tablets
Action : Iron is essential for formation of hemoglobin
Folic acid is essential for prevention of neural tube defects in newborn and for
development of fetal tissues
Indication : Prevention of anemia
Provides specific protection from iron deficiency anemia in children, pregnant and
lactating mothers
Tablets are given free of cost at all PHC sub centers and all government agencies
Doses : Mothers—100 mg elemental iron, 500 mcg folic acid tablets daily for 100 day.
Pregnant women has to take 100 tablets per pregnancy
Children—20 mg elemental iron, 100 mcg folic acid tablet
Children has to take 100 tablets per year.

RIFAMPICIN
Identification : Rifampicin
Action : Powerful bactericidal drug
Effective against intracellular, extracellular and dormant TB bacilli
Single dose kills 99.9 percent of viable leprae bacilli
Indication : Antibacterial therapy in tuberculosis and leprosy
To convert infectious case into non-infectious in short
time Always used in combination with other drugs
Carriers and contact (chemoprophylaxis) of meningococcal meningitis
Hepatotoxicity, red color of urine are some unwanted effects
Doses : Orally, 10–12 mg/kg one hour before food
450–600 mg in daily dose, 900 mg in intermittent therapy
If stopped for any reason, restarted within 3 week
 Chemicals in Public Health 137

DAPSONE
Identification : Dapsone
Action : Weak bactericidal action against [Link]
Indication : Important drug in Multi-drug therapy (MDT) of leprosy
Cheap and effective, well tolerated
Hemolytic property is the side effect. So, iron tablets are given along with dapsone
to prevent anemia
Dose : 1–2 mg/kg orally— Strictly weight based
100 mg daily for six month in pauci bacillary leprosy and 12 month in multi
bacil- lary leprosy.

VITAMIN ‘A’ SOLUTION

Identification : Vitamin A solution
Action : Useful for vision
Indication : Intervention in nutritional blindness
: Therapeutic and prophylactic use in vitamin A deficiency
Dose : 2,00,000 IU of vitamin A, oil suspension (retinol palmitate) every 6
month For infants, half of the dose is given (Under RCH II programme)
9 oral doses from one to five year at 6 month interval
Can be administered by multipurpose health worker and anganwadi workers.

COTRIMOXAZOLE
Identification : Cotrimoxazole
Action : Antibacterial
Indication : Drug of choice for pneumonia with cure rate of 95 percent
Less expensive, least side effects
Contraindicated in premature child and in neonatal jaundice
Dose : < 2 month, 20 mg (one tablet) twice daily for 5 to 7 day
2–12 month, 40 mg (two tablets) twice daily for 5 to 7 day
1–5 year, 60 mg (three tablets) twice daily for 5 to 7 day
Can be administered by health workers

ISONIAZID
Identification : Isoniazid (INH) tablets
Action : Bactericidal drug against TB
Active against intracellular, extracellular and active multiplying bacilli
Easy administration (oral), less toxic, low cost
Peripheral neuropathy is a side effect. Prevented by giving pyridoxine (10–20
mg) daily along with INH
Indication : Tuberculosis
Dose : Given in a single dose (not as divided doses)
4–5 mg/kg, maximum 300 mg/day in daily schedule 14–
15 g/kg, maximum 700 mg in twice a week schedule.
13 Part II:
8 Spotters
ORAL REHYDRATION POWDER
Identification : Oral Rehydration Powder
Composition
Ingredients Functions
Sodium chloride 2.5 gm Prevents hyponatremia
(NaCl, common
salt)
Sodium bicarbonate 2.5 gm Prevents acidosis and renal failure, increases
(Baking Soda) or sodium absorption
Trisodium citrate 2.9 gm Makes compound stable
Increases absorption of sodium and water
Reduces volume and frequency of stool
output
Potassium chloride (Kcal) 1.5 gm Prevents hypokalemia
Dextrose (Glucose) 13.5 gm Promotes salt and water absorption
Potable water 1 ltr Helps in hydration
Action : Absorption of glucose in the small intestine is an enzyme mediated physiological
process. Glucose enhances the absorption of sodium minerals and water, thus
cor- rects electrolyte and water deficit.
Osmolality of ORS is similar to plasma
Indication : Used for treating dehydration and maintaining rehydration
Doses : Treatment phase: First four hour or till disappearance of dehydration signs—
75ml/kg in 4 hour

}
1 year – 500 ml
2 year – 750 ml in 4 hour till rehydration has been achieved
3 year – 1000 ml
4 year – 1500 ml
Maintenance phase: 100 ml/kg in 24 hour
 Chapte
r Chemicals in
Public Health
9

DISINFECTANTS

PHENOL
Identification : Phenol (Carbolic acid)
Nature : Dark oily liquid with aromatic smell
Crude phenol is a mixture of phenol and cresol
Action : Chemical disinfectant
Two percent of phenol destroys and inhibits the growth of harmful microbes outside
the body by coagulating the protoplasm of bacteria.
Uses : Used as disinfectant and deodorant (> 10%)
Used on inanimate objects and excreta
Used as Deodorant (10%) in toilets and for mopping floors (5%)
Pure phenol is used as a standard to compare the germicidal activity of disinfectants.
(Rideal-Walker coefficient).

DETTOL
Identification : Dettol
Nature : Chloroxylenol—Antiseptic (used on living tissues)
Action : Active against gram +ve but not on gram –ve bacteria.
Inactivated by organic matter.
Uses : To clean wounds and ulcers.
: Five percent is used for general disinfection of—Instruments, plastic equipment (contact
period 15 minutes).

SAVLON
Identification : Savlon
Nature : Disinfectant—Quaternary ammonium compound
Combination of Cetavlon and Hibitane
Action : Surface disinfectant
Uses : Disinfection of plastics (20 minutes), thermometer (3 minutes)
Disinfection of wounds.
120 Part II:
Spotters
BLEACHING POWDER
Identification : Bleaching Powder (CaOCl2)
Nature : White amorphous powder with pungent smell of chlorine
: Chlorinated lime is called bleaching powder
Fresh bleaching powder contains 33 percent of available chlorine
Rapidly loses its chlorine content on exposure to air, light and
moisture
Hence, stored in dark, cool and dry place in closed, non-erosive containers
Action : Germicidal-effect is by hypochlorous acid, nascent oxygen and chlorine
Uses : Disinfection of water
Disinfection of feces, urine and pus
Used as a toilet deodorant.

HALOGEN TABLETS
Identification : Halogen tablets (Chlorine tablets)
Nature : White tablets containing chlorine
Action : Germicidal-effect is by hypochlorous acid, nascent oxygen and chlorine
Uses : Disinfection of the water during travel, camps and emergency
Dose : 0.5 g for 20 liters of water
Les effective on turbid
water.

LIME
Identification : Lime
Nature : White in color, stony in consistency
Action : Disinfectant, quick lime (freshly burnt) is a powerful disinfectant
10–20 percent aqueous suspension is “milk of lime” (lime:water,
1:4)
Uses : Disinfection of feces, urine, 10–20 percent for two hours
Used for smearing the walls
Deodorant—Cattle sheds, stables, public urinals, latrines
Can be used for disinfecting the water but, it increases the hardness of water and gives
objectionable taste.

POTASSIUM PERMANGANATE
Identification : Potassium permanganate
Nature : Reddish brown crystals with no smell
Action : Disinfectant and oxidizing agent
By oxidizing organic matter, it destroys
bacteria Action is not continuous and is
unreliable
Uses : Weak solution (1 in 1000 strength) is used to disinfect vegetables and fruits.

POVIDONE IODINE
Identification : Povidone iodine
Nature : Complexes of iodine, water soluble
Action : Active bactericidal agent with sporicidal action. Also acts on fungi, virus, protozoa
and yeast
 Chemicals in Public Health 121

Non-irritant, does not stain the skin

Action is reduced in the presence of organic matter
Uses : Wound and skin disinfection.

COPPER SULPHATE
Identification : Copper sulphate
Nature : Blue colored crystal
Action : Destroys algae
Uses : 1.0 ppm concentration is used to destroy algae in stagnant water.

TINCTURE IODINE
Identification : Tincture iodine
Nature : Liquid disinfectant
Action : Effective skin antiseptic
Quick in action, cheap, stains the skin
May produce allergic reactions
Kills cholera and enteric organisms effectively
Uses : Solution used for disinfection of skin
Disinfection of plastic appliance (1 in 2500 aqueous solution)
Disinfection of water in camps (1 in 20,000 aqueous solution).

ALUM
Identification Alum
Nature Alum is aluminum sulphate, stony in consistency
Action Acts as a chemical coagulant
Helps in sedimentation (settles down the impurities and bacteria in water)
Uses Used to remove turbidity of water before subjecting to rapid sand filtration (5–40
mg/liter) Used in defluoridation of water (Nalgonda technique).

CETAVLON
Identification : Cetavlon
Nature : Disinfectant
Action : Cationic detergent and bactericide
Uses : Cleaning the skin, washing the hands, cleaning and disinfecting the wounds, sterilizing
surgical instruments

SOAP
Identification : Soap
Nature : Detergent, cleansing agent
Action : Lather formed with water, removes adhering
bacteria Poor disinfecting power
Uses : Hand washing, bathing and sanitary measures.
122 Part II:
Spotters

INSECTICIDES

PARIS GREEN
Identification : Paris green
Nature : Copper-aceto-arsenite
Emerald-green, micro crystalline powder
Insoluble but floats on water
Contains 50 percent of arsenious oxide
Action : Larvicidal—Stomach poison for anopheline larvae
No ill effect on fish
Does not render water unsuitable for domestic use
Uses : Larvicidal—250 to 500 gm/acre of water to kill anopheles larvae
Paris green is mixed with diluent like road dust/fine/soap stone with 1:5 ratio and dusted
over breeding places once in a week

DICHLORO-DIPHENYL-TRICHLOROETHANE (DDT)
Identification : Dichloro-diphenyl-trichloroethane (DDT)
Nature : White amorphous crystalline powder with fruity odour
Insoluble in water, dissolves in organic solvents
Action : : Contact poison, acts on nervous system of insects
Residual action lasts up to six months
Para-para isomer is active fraction
Uses : Widely used insecticide to destroy mosquito, lice, fleas, ticks,
bugs Application : Residual spray—100 to 200 mg/sq foot area
Suspension (5%)—One gallon over 1000 sq feet
Environmental pollution, insecticidal resistance are known and unknown effects on
hu- man beings are the factors that restricts the indiscriminate use of DDT.

MOSQUITO COIL/LIQUID
Identification : Mosquito coil/liquid
Nature : Insecticide
Coil contains allethrin—One percent
Liquid contains permethrin,
transfluthrin
Action : Smoke/Vapor generated acts as an insecticide (kills
mosquito) May cause allergic reactions

MOSQUITO REPELLENT
Identification : Mosquito repellent
Nature : N methylphthalate, N diethylbenzamide
Action : Repels adult mosquitoes, mites, ticks, sand flies
Acts by discouraging arthropods from attacking.
Use : For personal protection from mosquito bite
35 percent solution/cream is applied to exposed skin
5 percent solution is used to impregnate nets/clothes.
 Chemicals in Public Health 123

HCH
Identification : Benzene hexachloride (Gammexane)/BHC
Nature : White colored powder with a musty smell
Insoluble in water but soluble in organic
solvent
Action : Insecticide, acts as contact poison
Gamma isomer is active constituent
Insecticidal action is effective, but not prolonged (< 3 months)
Uses : Used as insecticide
: Application—20 to 50 mg (gamma Hexachlorocyclohexane (HCH)) per square foot of
spraying surface.
124 Part II:
Spotters

MEDICINES
CHLOROQUINE
Identification : Chloroquine
Action : Excellent plasmodial schizonticide
Not useful in radical treatment of vivax and ovale. Since there is no action on hypnozo-
ites (persistence tissue phase)
Indication : Drug of choice in malaria treatment and prophylaxis
Dose 10 mg/kg (600 mg for adult) on first and second
day 5 mg/kg (300 mg for adult) on third day
Chemoprophylaxis-300 mg once a week on the same day and time
Started one week before entering and continued for six weeks after leaving the malarious
area.

IRON AND FOLIC ACID TABLETS

Identification : Iron and folic acid tablets
Action : Iron is essential for formation of hemoglobin
Folic acid is essential for prevention of neural tube defects in newborn and for develop-
ment of fetal tissues
Indication : Prevention of anemia
Provides specific protection from iron deficiency anemia in children, pregnant
and lactating mothers
Tablets are given free of cost at all PHC sub centers and all government agencies
Doses : Mothers—100 mg elemental iron, 500 mg folic acid tablets daily for 100 days. Pregnant
women has to take 100 tablets per pregnancy
Children—20 mg elemental iron, 100 mg folic acid tablet
Children has to take 100 tablets per year.

RIFAMPICIN
Identification : Rifampicin
Action : Powerful bactericidal drug
Effective against intracellular, extracellular and dormant TB
bacilli Single dose kills 99.9 percent of viable leprae bacilli
Indication : Antibacterial therapy in tuberculosis and leprosy
To convert infectious case into non-infectious in short
time Always used in combination with other drugs
Carries and contact (chemoprophylaxis) of meningococcal meningitis
Hepatotoxicity, red color of urine are some unwanted effects
Dose : Orally 10–12 mg/kg one hour before food
450–600 mg in daily dose, 900 mg in intermittent therapy
If stopped for any reason, restarted within three weeks
 Chemicals in Public Health 125

DAPSONE
Identification : Dapsone
Action : Weekly bactericidal action against [Link]
Indication : Important drug in Multi-drug therapy (MDT) of leprosy
Cheap and effective, well tolerated
Hemolytic property is the side effect. So, iron tablets are given along with dapsone to
prevent anemia
Dose : 1–2 mg/kg orally— Strictly weight based
100 mg daily for six months in pauci bacillary leprosy and 12 months in multi bacillary
leprosy.

VITAMIN “A” SOLUTION

Identification : Vitamin ‘A’ solution
Action : Useful for vision
Indication : Intervention in nutritional blindness
: Therapeutic and prophylactic use in vitamin A deficiency
Dose : 2,00,000 IU of vitamin A, oil suspension (retinol palmitate) every six
months For infants, half of the dose is given (Under RCH II programme)
9 oral doses from one to five years at 6 months interval
Can be administered by multipurpose health worker and anganwadi workers.

COTRIMOXAZOLE
Identification : Cotrimoxazole
Action : Antibacterial
Indication : Drug of choice for pneumonia with cure rate of 95 percent
Less expensive, least side effects
Contraindicated in premature child and in neonatal jaundice
Dose : < 2 months, 20 mg (one tablet) twice daily for five to seven days
2–12 months, 40 mg (two tablets) twice daily for five to seven
days 1–5 years, 60 mg (three tablets) twice daily for five to seven
days Can be administered by health workers

ISONIAZID
Identification : Isoniazid (INH) tablets
Action : Bactericidal drug against TB
Active against intracellular, extracellular and active multiplying bacilli
Easy administration (oral), less toxic, low cost
Peripheral neuropathy is a side effect. Prevented by giving pyridoxine (10–20 mg) daily
along with INH
Indication : Tuberculosis
Dose : Given as a single dose (not as divided dose)
4–5 mg/kg, maximum 300 mg/day in daily schedule 14–
15 g/kg, maximum 700 mg in twice a week schedule.
126 Part II:
Spotters
ORAL REHYDRATION POWER
Identification Oral Rehydration Powder
Composition
Ingredients Functions
Sodium chloride 2.5 gm Prevents hyponatremia
(NaCl, common
salt)
Sodium 2.5 gm Prevents acidosis and renal failure, increases sodium
bicarbonate absorption Makes compound stable
(Baking Soda) or
2.9 gm Increases absorption of sodium and water
Trisodium citrate
Reduces volume and frequency of stool output
Potassium chloride 1.5 gm Prevents hypokalemia
(Kcal)
Dextrose (Glucose) 13.5 gm Promotes salt and water absorption
Potable water 1 Helps in hydration
ltr
Action : Absorption of glucose in the small intestine is an enzyme mediated physiological process.
Glucose enhances the absorption of sodium minerals and water, thus corrects electrolyte
and water deficit.
Osmolality of ORS is similar to plasma
Indication : Used for treating dehydration and maintaining rehydration
Dose
Treatment phase: First four hour or till disappearance of dehydration signs –
75ml/kg in 4 hours
1 year – 500 ml
2 year – 750 ml in 4 hours
3 year – 1000 ml
4 year – 1500 ml
Maintenance phase: Till rehydration has been achieved
100 ml/kg in 24 hours
 Chapte Models
r

10
HORROCKS APPARTUS
Identification : Horrocks apparatus
Description : Used to find the required amount of bleaching powder for water disinfection
For preparing stock solution—2 gm (1 spoon) of bleaching powder is used
Starch-iodine is used as indicator
Earliest cup showing blue color is considered to calculate bleaching powder
requirement to disinfect 455 liter (100 gallon) of water
Uses : Estimation of bleaching powder requirement.

INCINERATOR
Identification : Incinerator
Description : Plant constructed for hygienic burning of refuse
Best for burning hospital refuse, as incineration destroys infectious agents and
reduces the volume of waste
Uses : Hygienic disposal of health care waste.

P-TRAP
Identification : P-Trap
Description : It is a bent pipe used in water seal latrine
Connected with the pan and connecting pipe
It holds water and acts as water seal
Water seal prevents smell and access of feces to flies.
Uses : Construction of hygienic latrine.

MINUS DESK
Identification : Minus desk
Description : Vertical line from desk falls on the seat
Thighs remain horizontal, legs remain vertical
Feet rest flat on the foot rest/floor
Provides proper posture
Provides proper back rest and supports the lumbar spines
14 Part II:
0 Spotters
Distance between the seat and desk allows schooler to read and write without
much leaning
Uses : To maintain proper posture of schooler (Ergonomics).

VACCINE CARRIER
Identification : Vaccine carrier
Description : Thick walled boxes with lids, which will not allow heat passing through it
Maintains the cold chain of vaccine for short time
Fully frozen ice packs are used for lining
Lid should be closed tightly
Diphtheria-tetanus-pertussis vaccine (DTP), PT, TT are not placed directly in
contact with the frozen ice packs
Vaccines are covered with paper and placed in polythene bags before placing
in vaccine carriers
Uses : Transportation of small quantities of vaccine for 48 hours during out reach
activi- ties.

ICE PACKS
Identification : Ice packs
Description : Flat plastic sealed bottles
Filled with water and frozen by keeping in deep freezer.
Uses : Lining the walls of the vaccine carriers

SANITARY WELL
Identification : Sanitary well
Description : Well possess proper location, construction and protection
It is ideal in the view of getting safe and potable water
Uses : To protect the well water from pollution.

DOMESTIC FILTER
Identification : Domestic filter
Description : Porous tubes (candle) used in the filter is made up of unglazed porous
ceramic (porcelain) material
Filter acts mechanically by the pressure of water
Filters fine dust particles and bacteria but not
viruses
Tubes are frequently cleaned by brushing with hard brush using hot water and
boiled for some time
If not maintained properly, pores often get plugged and forms nidus for
bacterial growth
Muddy water is strained and clarified before pouring into the filter
Uses : To get safe and wholesome water at domestic level.
 Chapte Models
r

10
HORROCKS APPARTUS
Identification : Horrocks apparatus
Description : Used to find the required amount of bleaching powder for water disinfection
For preparing stock solution—2 gram (1 spoon) of bleaching powder is
used Starch-iodine is used as indicator
Earliest cup showing blue color is considered to calculate bleaching powder requirement
to disinfect 455 liters (100 gallons) of water
Uses : Estimation of bleaching powder requirement.

INCINERATOR
Identification : Incinerator
Description : Plant constructed for hygienic burning of refuse
Best for burning hospital refuse as incineration destroys infectious agents and reduces the
volume of waste
Uses : Hygienic disposal of health care waste.

P-TRAP
Identification : P-Trap
Description : It is a bent pipe used in water seal latrine
Connected with the pan and connecting pipe
It holds water and acts as water seal
Water seal prevents smell and assess of feces to flies.
Uses : Construction of hygienic latrine.

MINUS DESK
Identification : Minus desk
Description : Vertical line from desk falls on the seat
Thigh remain horizontal, legs remain vertical
Feet rest flat on the foot rest/floor
Provides proper posture
Provides proper back rest and supports the lumbar spines
Distance between the seat and desk allows schooler to read and write without much lean-
ing
Uses : To maintain proper posture of schooler (Ergonomics).
12 Part II:
8 Spotters
VACCINE CARRIER
Identification : Vaccine carrier
Description : Thick walled boxes with lids, which will not allow heat passing through it
Maintains the cold chain of vaccine for short time
Fully frozen ice packs are used for lining
Lid should be closed tightly
Diphtheria-tetanus-pertussis vaccine (DTP), PT, TT are not placed directly in contact
with the frozen ice packs
Vaccines are covered with paper and placed in polythene bags before placing in
vaccine carriers
Uses : Transportation of small quantities of vaccine for 48 hours during out reach activities.

ICE PACKS
Identification : Ice packs
Description : Flat plastic sealed bottles
Filled with water and frozen by keeping in deep freezer.
Uses : Lining the walls of the vaccine carriers

SANITARY WELL
Identification : Sanitary well
Description : Well possess proper location, construction and
protection It is ideal in the view of getting safe and
potable water
Uses : To protect the well water from pollution.

DOMESTIC FILTER
Identification : Domestic filter
Description : Porous tubes (candle) used in the filter is made up of unglazed porous ceramic
(porcelain) material
Filter acts mechanically by the pressure of water
Filters fine dust particles and bacteria but not
viruses
Tubes are frequently cleaned by brushing with hard brush using hot water and boiled for
some time
If not maintained properly, pores often get plugged and forms nidus for bacterial
growth Muddy water is strained and clarified before pouring into the filter
Uses : To get safe and wholesome water at domestic level.
 SECTION III

EXERCISES
(Problems and their
solutions)

12. Calculations for Disinfecting Water

13. Nutrition/Balanced Diet Calculations

14. Common Problems Faced in Public Health

and their Solutions

15. Calculations in Biostatistics

16. Calculations Based on Vital Statistics

 Chapte
r Calculations for
Disinfecting Water
12

1. In a medical college hostel, there is a tank which holds 45,500 liter of water. Horrocks test shows blue
color in 5th cup. Calculate the required amount of bleaching powder for disinfection. Describe the pro-
cedure and principle of finding bleaching powder demand of water by Horrocks test.

Solution:
Step 1: Finding the bleaching powder demand by Horrocks test
Horrocks apparatus is devised to find bleaching powder requirement to disinfect 100 gallon (455 liter) of
water. Contents of Horrocks apparatus
1 black cup 1 pipette
6 white cups of 200 ml each 2 metal spoon—2 gm each
7 stirring rods—1 for each cup 2 droppers
Indicator: Starch-iodine solution Instruction folder
Step 2: Finding the quantity of bleaching powder requirement
5th cup is the earliest cup showing blue color in Horrocks test indicates that 5 level spoon (5 x 2) = 10 gm of
bleach- ing powder is required to disinfect 455 liter of water
455 liter of water requires—10 gm of bleaching powder
For 45,500 liter—How much bleaching powder is required?
10
 455  45500

455000
 455
= 1,000 gm (1 kg)
1 kg bleaching powder is required to disinfect the tank water.
Procedure
• With 2 gm (1 level spoon) of bleaching powder and little water, thin paste is made in the black cup
• More water is added to the black cup up to the circular mark, vigorous stirring is done and allowed to
settle. This is ‘stock solution’
• All 6 white cups are arranged in order. Water to be tested is filled, up to a cm below the brim in all 6 cups
• With pipette stock solution is added to white cups—1 drop to first cup, 2 drops to second cup, 3 drops
to third cup and so on
152 Section III: Exercises (Problems and Their
Solutions)
• Water in all 6 cups is stirred well by using separate glass rod
• Cups are left undisturbed for half an hour for bleaching powder action, i.e. liberation of free chlorine
• Three drops of freshly prepared starch-iodine indicator is added to all white cups and stirred again
• Development of blue color indicates the presence of free residual chlorine
• Note the first cup showing blue color
• 5th cup is the first cup showing blue color, 5 level spoon, i.e. 5 × 2 = 10 gm of bleaching powder
is required to disinfect 100 gallon (455 liter) of water.
Principle
Indicator contains potassium iodide + starch + NaCl
Free chlorine reacts with potassium iodide; iodine is left free which reacts with starch and gives blue color.

2. A circular well of 10 meter diameter with 15 meter depth of water is to be chlorinated. Horrocks test
shows blue color in 3rd cup onwards. Calculate the quantity of bleaching powder (CaOCl 2) required to
disinfect the well? Explain the procedure of well disinfection?

Solution:
Step 1: Finding the volume of the well water
Volume of water in the circular well =  × r2 × h × 1000
22
Where,    3.14
7
= π × r2 × h × 1000 r = radius = 5 mt (half of the diameter)
= 3.14 × 52 × 15 × 1000 h = height = 15 mt water column
= 3.14 × 25 × 15 × 1000 1000 = Volume of water per 1 m3
= 1,177,500
Volume of water in the well is = 1,177,500 liter
Step 2: Finding the amount of bleaching powder requirement
3rd cup is the earliest cup showing blue color
3rd cup means—3 level spoon (3 × 2 gm) = 6 gm of bleaching powder is required to disinfect 455 liter of
water. 455 liter of water requires—6 gm of bleaching powder
For 1177500 liter—How much bleaching powder is required?
6
 455  1177500

7065000
 455
= 15,527.5 gm (roughly 15.5 kg)
15 kg 527gm (to round up 15.5 kg) of bleaching powder is required to disinfect the well water.
Step 3: Well disinfection procedure
• Required amount of bleaching powder is mixed with little water in a bucket (not more than 100 gm at a
time) to make thin paste
• 3/4th of the same bucket is filled with water, stirred well, allowed 10 minute for sedimentation
• Supernatant clear chlorine solution is transferred to another bucket; lime CaO sediment is discarded. Not
poured into the well because sediment increases hardness of the water
 Calculations for Disinfecting Water
153
• Bucket is lowered into the well below the water level
• Well water is violently agitated by lowering and drawing movements for homogenous mixing of
chlorine solution in water
• This completes chlorination of well
• Residual chlorine should be tested after half an hour, by orthotolidine arsenite test. It should be at least
0.5 mg/liter
• Subsequent to chlorination, water is used only after a contact period of 1 hour
• Wells are best disinfected once in a week at night
• During epidemics wells should be disinfected every day.

3. In a slum, there is a circular katcha dug well which is measuring 4 meter in diameter. Depth of the
water is 10 meter. Calculate the amount of bleaching powder required to disinfect the well? (In
Horrocks test, 5th cup shows blue color). Explain the action of bleaching powder. What action do you
take to protect the well against contamination.

Solution:
Step 1: Finding the volume of the well water
Volume of water in the circular well = π × r2 × h × 1000
22
Where,    3.14
7
= π × r2 × h × 1000 r = radius (½ of the diameter) = 2 mt
2
= 3.14 × 2 × 10 × 1000 h = height = 10 mt
= 3.14 × 4 × 10 × 1000 1000 = volume of water in 1 m3
= 125,600
Volume of water in the well is 125,600 liter.
Step 2: Finding the amount of bleaching powder requirement
Earliest cup showing blue color is 5th cup. Fifth cup means 5 level spoon (5 × 2 gm) = 10 gm of bleaching powder
is required to disinfect 455 liter of water.
455 liter of water require—10 gm of bleaching powder
For 125,600 liter—how much bleaching powder is required?
10
 455  125600

1256000
 455
= 2,760 gm
2 kg 760 gm of bleaching powder is required to disinfect the well.
Action of Bleaching Powder
When bleaching powder is added to water, hydrochloric and hypochlorous acids are formed.
• Hydrochloric acid is neutralized by alkalinity of water
• Hypochlorous acid ionizes to form hydrogen ions and hypochlorite ions
CaOCl + H O  CaO (settled lime is discarded) + Hcl + HOCl (Active principle).
2
H O + Cl  HCl + HOCl
2
HOCl  H + OCl
154 Section III: Exercises (Problems and Their
Solutions)
• Hypochlorous acid and to a small extent hydrochloric acid by their germicidal action, kills pathogenic
bacteria and viruses, controls algae, thus disinfects water.
• Apart from germicidal action, it oxidizes iron manganese and hydrogen sulphide.
Protecting the well from contamination
• Lining the side wall of the well with stones and set with cement up to a depth of 20 feet. So that, wall
will be impermeable to seeping water and micro-organisms
• Parapet wall is constructed 2 to 3 feet above the ground level
• 3 feet around the well, cement concrete platform is constructed
• Slope is made for draining the spilled water
• Mouth of the well is maximally covered with cement concrete cover to prevent the fall of impurities
• Trusting the common bucket and rope to draw water is advised
• Provision of hand pump is best
• Washing of clothes, animals, dumping the refuse around the well should be prohibited
• People should be educated about maintaining well sanitation
• Water quality is tested periodically. Chlorination is done regularly (weekly).

4. A square tank of 8 meter length and 8 meter breadth with 10 meter depth of water is to be disinfected.
Horrocks test shows blue color in 6th cup. Calculate the amount of bleaching powder required to disin-
fect the tank.

Solution:
Step 1: Finding the volume of water in the square tank
Volume of water in square tank = L × b × h × 1000
Where, L = length = 8 mt
= 8 × 8 × 10 × 1000 b = breadth = 8 mt
= 640,000 liter h = height of water = 10 mt
1000 = volume of water per 1 m 3
Volume of water in the tank is 640,000 liter
Step 2: Finding the amount of bleaching powder requirement
6th cup is the earliest cup showing blue color in Horrocks test indicates that 6 level spoon (6 x 2gm) = 12 gm of
bleaching powder is required to disinfect 455 liter of water.
455 liter of water require—12 gm of bleaching powder
For 640,000 liter—How much bleaching powder is required?
12
 455  640000

7680000
 455
= 16,879 gm
16 kg 879 gm of bleaching powder is required to disinfect the tank.
 Calculations for Disinfecting Water
155
5. A swimming pool having 100 meter length, 60 meter breadth, with 10 meter depth of the water is to be
disinfected. Calculate the amount of bleaching powder required to disinfect the swimming pool. Hor-
rocks test shows blue color in 4th cup. What measures you advice for swimming pool sanitation.
Solution:
Step 1: Finding the volume of water in the swimming pool
Volume of water in swimming pool = L × b × h × 1000
Where, L = length = 100 mt
= 100 × 60 × 10 × 1000 b = breadth = 60 mt
= 60,000,000 h = height = 10 mt
1000 = volume of water per 1 m3
Volume of water in the swimming pool is 60,000,000 liter
Step 2: Finding the amount of bleaching powder requirement
4th cup is the earliest cup showing blue color in Horrocks test indicates that, 4 level spoon (4 × 2) = 8 gm of
bleach- ing powder is required to disinfect 455 liter of water
455 liter of water requires—8 gm of bleaching powder
For 60,000,000 liter—How much bleaching powder is required?
8
 455  60000000

480000000
 455

= 1,054,945 gm
1054 kg 945 gm (roughly 1055 kg) of bleaching powder is required to disinfect the swimming pool.
Step 3: Maintaining swimming pool sanitation
• People suffering from skin disease, sore eye, nasal or ear discharge, upper respiratory, GI infections
and any communicable disease should not be allowed to swim.
• Swimmers are instructed to empty the bladder, bowel and to take shower bath before entering the
pool. They should not spit blow the nose, urinate and defecate in the pool.
• Surrounding environment of the pool should be maintained well.
• Pool is cleaned once in 15 day. Water is changed frequently or best subjected for continuous purification.
• Pool water is frequently tested for any contamination.
6. In a medical college hostel, there is a rectangular tank measuring 6 meter in length 4 meter in breadth,
depth of water is 8 meter. How much bleaching powder is needed to disinfect the water? Horrocks test
shows blue color in 3rd, 4th and 5th cup.
Solution:
Step 1: Finding the volume of water in the tank
Volume of water in the rectangular tank = L × b × h × 1000
Where, L = Length = 6 mt
= 6 × 4 × 8 × 1000 b = breadth = 4 mt
= 192,000 liter h = height = 8 mt
1000 = water per 1 m3
Volume of water in the rectangular tank is 192,000 liter.
156 Section III: Exercises (Problems and Their
Solutions)
Step 2: Calculating the bleaching powder demand
Though third, fourth and 5th cup shows blue color, always earliest (first) cup showing blue color is considered in
Horrocks test which is 3rd cup.
3rd cup means, 3 level spoon (3 × 2) = 6 gm of bleaching powder is required to disinfect 455 liter of
water. 455 liter of water require—6 gm of bleaching powder
For 192,000 liter—How much bleaching powder is required?
6
 455  192000

1152000
 455
= 2,531.86 gm
2.53 kg bleaching powder is required for disinfection of tank water
7. A house tank containing 9000 liter of water is to be disinfected. You are provided with bleaching powder
containing 11% chlorine. Horrocks 5th cup shows blue color. How much bleaching powder is to be
used for disinfection?
Solution:
5th cup is the earliest cup showing blue color in Horrocks test indicates that 5 level spoon (5 × 2) = 10 gm of
bleach- ing powder is required for disinfect of 455 liter of water.
455 liter of water requires—10 gm of bleaching powder
For 9000 liter—How much bleaching powder is required?
10
 455  9000

90000
 455
= 197.80
197 gm (roughly 200 gm) bleaching powder is required to disinfect the tank
As the provided bleaching powder containing 11% chlorine is used to prepare stock solution in Horrocks test,
there is no need to calculate for the bleaching powder containing 33% chlorine.

8. Overhead tank with 1000 liter of water in your house has to be disinfected. Bleaching powder demand
was found to be 2 gm in Horrocks test. Calculate the amount of bleaching powder required to disinfect
the tank. Answer the questions given below.
Which indicator is used in Horrocks Test?
How much contact period do you recommend after disinfection and before use of
water? If Horrocks test is not available, how do you estimate bleaching powder
demand?

Solution:
Calculating the required bleaching powder
Horrocks test shows the bleaching powder demand is 2 gm, which indicates that 2 gm of bleaching powder is re-
quired to disinfect 455 liter of water.
455 liter of water require—2 gm of bleaching powder
For 1000 liter—How much bleaching powder is required?
 Calculations for Disinfecting Water
157

2
 455  1000

= 4.39 gm
4.39 gm of bleaching powder is required to disinfect the tank
water. Freshly prepared Starch-iodine solution is used as indicator
Recommended contact period is 1 hour after mixing bleaching powder and before use.
If Horrocks test is unavailable, roughly 2.5 gm of bleaching powder (33% chlorine) is used to disinfect 1000 liter
of water.

9. Famous annual mela is going to be held on the river bank where 3 lakh people will gather. River is the
only source of water for the mela. How do you disinfect the river water and confirm satisfactory
disinfec- tion.

Solution:
River disinfection
• Volume of the out flowing running water is estimated
• Bleaching powder requirement is calculated or as emergency, an empirical procedure 2.5 mg/liter
is administered to the water.
• Required amount of bleaching powder is mixed with sand and sealed in cloth bags. Bags are immersed in
the places where
Streams are sluggish
Higher up in the course of the stream
Nearer to the river banks where pollution is concentrated.
• During the period of mela, continuous chlorination is done.
• After 1 hour of contact period, residual chlorine of the water is estimated by orthotolidine arsenite test to
confirm effectiveness of chlorination.
• Residual chlorine should be > 0.5 mg/ltr after 1 hour of contact period in successful disinfection.
Orthotolidine arsenite test (OTA)
• 1 ml of water to be tested is filled in the test tube provided in orthotolidine out fit
• 0.1 ml of orthotolidine reagent (orthotolidine dissolved in 10% hydrochloric acid) is added
• The development of yellow to orange color in 10 second and after 5 minute is observed
• OTA confirms proper chlorination.
Inference
Test reading within Color development Chlorine present
10 second Yellow Free
15 second Deep yellow to Orange Free + combined

10. Water from a well situated in a village was sent for analysis. Results are given to you.
Hardness 370 mg/lt
Chloride 800 mg/lt
Fluoride 5.4 mg/lt
DDT 5 µgm/lt
Free saline ammonia 0.1 mg/lt
Albuminoid ammonia 0.2 mg/lt
158 Section III: Exercises (Problems and Their
Solutions)
What is your opinion regarding the quality of water? What advice do you give to ensure the safety of
drinking water?

Solution:
Level in the village well
Substance Desirable level Inference
water
Hardness < 150 mg/lt 370 Very hard water
mg/lt
Chloride < 600 mg/lt 800 Indicates sewage contamination
mg/lt
Fluoride < 1 mg/lt 5.4 mg/lt Fluoride content is very high, long
term consumption leads to
fluorosis
DDT < 2 µgm/lt 5 µg/lt Water is polluted by using excess of
DDT in agricultural activities
Free saline ammonia < 0.5 mg/lt 0.1 mg/lt Decomposing organic matter is
present
Albuminoid ammonia < 0.1 mg/lt 0.2 mg/lt Under-composing organic matter
is present
Opinion
Water from the well is not suitable for drinking as
• Water is very hard
• Fluoride content is very high
• Water is contaminated by sewage
• Water contains DDT
Advice to ensure the safety of water
Regarding Fluoride
The well water has excess of fluoride, long time consumption will lead to fluorosis “Crippling condition”. Hence,
villagers are asked not to use the well water and go for an alternative water source with low fluoride content, i.e.
0.5–0.8 mg/lt.
• As a long term measure, defluoridation of well water is done by installation of defluoridation plant.
• Adding phosphate to water will also reduce the fluoride level.
• Adding lime and alum (Nalgonda technique) is also useful for defluoridation.
• People already affected by fluorosis are advised -
1. To discontinue the use of well water and go for an alternative source
2. To eat more vegetables, fruits and citrus fruits, to take vitamin C
3. Not to use fluoride containing substances (e.g. tooth paste)
Regarding hardness
• Hard water affects durability of cloth, causes wastage of soap, encrustation of utensils, needs more
fuel for heating.
• No evidence regarding its ill effect on health.
• Hardness is removed by
• Boiling • Adding lime • Adding sodium carbonate
Regarding sewage contamination
• Open air defecation should be stopped 50 feet surrounding to the well.
• Well should be converted into sanitary well. strict cleanliness is maintained in the vicinity of the well
• Well water should be chlorinated regularly (weekly)
• Water quality should be confirmed periodically.
 Calculations for Disinfecting Water
159
Regarding DDT contamination:
• Judicious use of DDT in agriculture should be stopped
• Seepage of water from cultivation area should be prevented.

11. A village having two sources of water, one lake and another well. Sample of water both from the lake and
well was analyzed. The results are presented here.
Particulars Lake water Well water
Turbidity 20 unit 2 unit
Hardness 100 mg/lt 300 mg/lt
Chloride 500 mg/lt 500 mg/lt
Lead 0.2 mg/lt Nil
Coliform count 3/100 ml 1/100 ml

Which source of water do you recommend for drinking? Give reasons for your recommendation and
sug- gest measures to ensure water quality.

Solution:
Lake Water
Turbidity is more, desirable level is less than 5 unit. Turbidity interferes with natural purification it also affect on
chlorination.
Hardness is within acceptable limit (moderately hard–50–150 mg/lt).
Chloride though within limit (limit is 300–600 mg/lt), it indicates contamination with human excreta.
Lead concentration is more (normal 0.05 mg/lt), it indicates lake water is contaminated with industrial
effluent. Coliform count presence of 3/100 ml suggest that lake water is contaminated with human excretes.
Inference: Because of high lead concentration, water consumption will cause plumbism. Symptoms of plumbism
are colic, constipation, loss of appetite, foot drop, wrist drop, blue lines on gum, anemia, stippling of RBC.
• Leaving industrial effluents to lake should be stopped. Till that time lake water should not be used
for drinking purpose
• Turbidity should be reduced by filtering the water through slow sand filter
• Sanitary well is to be constructed beside the lake
• Lake should be fenced to prevent contamination by human and animal activities
• People are not allowed to wash clothes, bath and defecate in and around the lake
• Surrounding environment should be kept clean
• Lake water is often subjected for physical, chemical and bacteriological analysis.
Well Water
Turbidity

}
Chloride
Coliform count Within acceptable limit
Lead
Hardness of water is more (300 mg/lt very hard)
160 Section III: Exercises (Problems and Their
Solutions)
Hardness is removed by
• Boiling
• Adding lime
• Adding sodium carbonate
Well sanitation
• Well should be converted into sanitary well
• Vicinity of the well should be maintained clean
• Defecation should not be done around 50 feet from the well
• Well water should be periodically tested and proper corrective measures should be undertaken
• Water in the well should be periodically (weekly) chlorinated

12. Boarding school having 500 students is depending on well water, it also gets water from tap (Public
sup- ply) students also drink water from nearby river. Students are repeatedly suffering from diarrhea.
Prin- cipal of the school wants your suggestion regarding
Sending all three sample of water for laboratory
Chlorination of well
Volume of water in the well is roughly 2 lakh liter. Horrocks test is not available. How do you estimate
the bleaching powder requirement and how do you collect and send the water samples?

Solution:
Step 1: Estimation of bleaching powder requirement:
In the absence of Horrocks apparatus, bleaching powder requirement is approximated
2.5 gm per 1000 liter in usual conditions
5.0 gm per 1000 liter during epidemics
10 gm per 1000 liter where virus, cyst and cyclops destruction is needed.
In this boarding school, students are repeatedly suffering from episodes of diarrhea. Hence, bleaching powder re-
quirement is 5.0 gm per 1000 liter.
Disinfection of 1000 liter require—5.0 gm of bleaching powder is required
For disinfection of 2,00,000 liter— How much bleaching powder is required?
5
 1000  200000

= 1,000 gm (1 kg)
1 kg of good quality (33% available chlorine) is needed to disinfect the well.
Step 2: Collection of water samples for analysis:
• For physical and chemical analysis—Winchester Qvart Bottle (2 liter, with glass stopper is used)
• For bacteriological analysis, sterile McCartney bottle of 250 ml (8 Ounce) is used.
• Sterile string is tied to the bottle neck to collect water form well or river.
• Bottle should be rinsed twice with the same water which is to be examined
• To fill the water sample, bottle should be downed with string below the surface of water.
• In case of pond or river, sample is to be taken 2 meter or at a reasonable distance from the shore.
• For collection of tap water, tap should be in use for at least 2 day. Sample should be collected after
letting the water runoff for 2 minute.
 Calculations for Disinfecting Water
161
• Water sample is best collected after 2 day in use.
• Bottle is closed with glass stopper, covered with cloth, rubber and sealed.
• Sample for bacteriological examination is placed in ice pack, if analysis is delayed more than 2 hour.
• Along with samples, information’s like source of water, date and time of collection, purpose of
analysis, conditions of water source pollution, method of water collection, existing water borne disease
and other particulars should be forwarded.

13. In a health camp at remote village, where Horrocks apparatus is not available, you have to disinfect
tank water of 45,500 liter. You will be provided bleaching powder of 21% chlorine. How do you
estimate the bleaching powder requirement to disinfect the tank water. Explain the basis of your
calculation.

Solution::
Even without Horrocks test, bleaching powder requirement can be calculated by using the following formula
84
Bleaching powder requirement in gm per 100 gallon of water 
X
Where, 84 = constant number
X = % of chlorine in bleaching powder
84
  4 gm
21
Thus, 4 gm of bleaching powder is required to disinfect hundred gallon (455 liter) of water.
455 liter of water requires—4 gm bleaching powder
For 45,500 liter—How much bleaching powder is required?
4
 455  45500

= 400 gm
400 gm of bleaching powder required to disinfect the tank.
Explanation of the formula
14
Old formula: Bleaching powder required in grain per gallon (4.55 liter) of water 
X
Where, 14 = constant number
X = % of chlorine in bleaching powder

84
Modified (Raju & Kiran)* formula: Bleaching powder required in gm per 100 gallon 
X
Where, 84 = constant number
X = % of chlorine in bleaching powder
Modification of the formula by conversion of grain into gram
1 grain = 0.06 gm
14 grain = 14 × 0.06 = 0.84 gm
1 gallon = 4.5 liter = 0.84 gm per 1 gallon
100 gallon = 455 liter = 84 gm per 100 gallon
162 Section III: Exercises (Problems and Their
Solutions)
84
Thus, Modified formula is 
X
*Prof. Dr. D.K. Mahabalaraju, Dr. Kiran D.

14. A katcha well of tribal area, containing 45,500 liter of water is suspected to be contaminated, as the
chil- dren defecates in the vicinity of the well. Horrocks test is failing to show blue color in any of the 6
cups. How do you calculate the bleaching powder requirement to disinfect the well?

Solution:
In Horrocks test, none of the 6 cups showing blue color indicates that water is highly contaminated and thus needs
more amount of bleaching powder.
In such conditions –
Horrocks test is further continued, by repeating the procedure by adding stock solution.
7 drops to first cup; 8 drops to second cup and so on.
Here, first cup is considered as seventh cups; second cup as eighth cup and so on.
Suppose, fourth cup shows blue color.
4th cup is considered as 10th cup in continued test. Thus, the calculation is
10th cup is the earliest cup showing blue color in Horrocks test indicates that 10 levels spoon (10 x 2) = 20 gm of
bleaching powder is required to disinfect 455 liter of water.
Thus,
455 liter of water requires—20 gm of bleaching power is needed.
For 45500 liter—How much bleaching powder is required?
20
  45500
455
= 2,000 gm
2 kg bleaching powder is required to disinfect the well.

15. Bheemappa is having a small household well in his village. He wants a method for constant disinfection
of water. What do you suggest for Bheemappa?

Solution:
For constant disinfection of water of house hold well, we suggest “double pot” method, devised by the National
Environmental Engineering Research Institute, Nagpur (NEERI).
Requirement
Two cylindrical pots of size (1) Height 30 cm diameter 25 cm
(2) Height 28 cm diameter 16 cm
Big pot should have a hole of 1cm diameter 4 cm above the bottom.
Smaller pot should have a hole of 1cm diameter in the upper portion near the rim.
Procedure
1 kg Bleaching powder is mixed with 2 kg of coarse sand, this mixture is slightly moistened and filled in the small
pot. Smaller pot is placed inside the bigger. Mouth of the outer pot is closed with polyethylene foil.
Double pot is tied with rope and immersed 1 meter below the water level.
‘Double pot’ method satisfactorily disinfects the well for 2 to 3 week.
Same procedure is repeated every 3 week.
 Chapte
r
Nutritions/Balanced
Diet Calculations
13
1. Prescribe a balanced diet for

yourself Solution: For male

I am an adult male, aged years weighing kg,
An Indian reference man. Activity is sedentary (medical student)
Recommended energy consumption unit (CU) for me is 1.0
Energy requirement is = 2400 Kcal per day (1 CU = 2400 Kcal)

Diet schedule (balanced diet) prescription

Food groups Intake/day
Cereals and millets 460 gm
Pulses 40 gm
Green leafy vegetables 40 gm
Other vegetables 60 gm
Roots and tubers 50 gm
Milk 150 ml
Oils and fats 40 gm
Sugar and jaggery 30 gm
50% pulses can be exchanged with one egg or 30 gm meat + 5 gm of fat
100% pulses can be exchanged with two eggs or 50 gm meat + 10 gm oil or fat

Solution: For female

I am an adult female, aged years weighing kg,
An Indian reference woman. Activity is sedentary (medical student)
Recommended energy consumption unit (CU) for me is 0.8
Energy requirement is = 1875 Kcal per day (1 CU = 2400 Kcal)
 Nutritions/Balanced Diet Calculations
165
Diet schedule (balanced diet) prescription
Food groups Intake/day
Cereals and millets 410 gm
Pulses 40 gm
Green leafy vegetables 100 gm
Other vegetables 40 gm
Roots and tubers 50 gm
Milk 100 ml
Oils and fats 20 gm
Sugar and jaggery 20 gm
50% pulses can be exchanged with one egg or 30 gm of meat + 5 gm oil or fat.
100% pulses can be exchanged with two egg or 50 gm of meat + 10 gm oil or fat

2. Prescribe a balanced diet and mention protein and energy requirement for a pregnant women doing
sed- entary work

Solution:
Diet schedule (balanced diet) prescription in gm
Food groups Requirement for sedentary Additional requirement Balanced diet for sedentary
women (in gm) (in gm) pregnant women (in gm)
Cereals and millets 410 + 35 44
5
Pulses 40 + 15 55
Green leafy vegetables 100 10
0
Other vegetables 40 40
Roots and tubers 50 50
Milk 100 + 20
100 0
Oils and fats 20 20
Sugar and jaggery 20 + 10 30

Protien and energy requirement

Energy Consumption unit (CU) for sedentary women 0.8
Energy requirement for sedentary women is 1875 Kcal
Additional requirement for pregnancy is 300 Kcal
Energy requirement for this pregnant women 2175 Kcal/day
Protein requirement (50 + 15) 65 gm/day

3. Prescribe a balanced diet and mention protein and energy requirement for a sedentary lactating
mother, who is breast feeding her 5 month infant.

Solution:
166 Section III: Exercises (Problems and Their
Solutions)
Balanced diet for lactating mother (in gm)
Food groups Requirement for Additional requirement Balanced diet for
sedentary women for lactation sedentary lactating women
(in gm) (in gm) (in gm)
Cereals and millets 410 + 60 470
Pulses 40 + 30 70
Green leafy vegetables 100 100
Other vegetables 40 40
Roots and tubers 50 50
Milk 100 + 100 200
Oils and fats 20 + 10 30
Sugar and jaggery 20 + 10 30

Protien and energy requirement

Energy consumption unit (CU) for sedentary women : 0.8
Energy requirement for sedentary women is : 1875 Kcal
Additional requirement during first 6 month of lactation is : 550 Kcal
Energy requirement for this lactating mother (0–6 month) : 2420 Kcal
Protein requirement (50 + 25) : 75 gm

4. In a diet survey conducted by using oral questionnaire method, a sedentary pregnant woman of 3rd tri-
mester weighing 50 kg was taking the following food items in 24 hour .
Rice-300 gm, red gram-10 gm, bengal gram-10 gm, egg-1, banana-1, milk-100 ml, brinjal-70 gm, oil-
1gm, sugar-20 gm.
What is your opinion regarding her nutritional adequacy in terms of proteins and energy suggest for the
improvement of food intake if necessary.

Solution:
Consumption of food Items Quantity Nutrients available
(in gm) Protein (gm) Calories (Kcal)
Rice 300 21 1050
gm
Red gram 10 gm 2.5 35
Bengal gram 10gm 2.5 35
Egg 1 6 90
Banana 1 1 100
Milk 100 ml 3 70
Brinjal 70 gm 1 6
Oil 10 gm - 90
Sugar 20 gm - 40
Total 37 gm 1516 Kcal
 Nutritions/Balanced Diet Calculations
167
Nutritional requirement of the pregnant women
Particulars Protein Energy
Requirement of sedentary women 50 1875
Additional requirement for +1 +300
pregnancy 5
Total requirements 65 gm 2175 (2200)
Kcal

Differences between intake and requirements

Nutrient Requirement Actual intake Difference
Protein 65 gm 37 gm (57%) 28 gm (-43%)
Energy 2200 Kcal 1516 Kcal (69%) 684 Kcal (28%)
Woman is taking only 57% of protein and 72% energy requirements.
Her food is deficient of 43% protein and 28% energy
To provide adequate protein and energy, women is advised to take additional food suggested below:

Suggestion: Woman is advised to add the following food items to make her food balanced.

Addition of food items suggested

Additional requirement Nutrients available
Additional food items
(in gm) Protein (gm) Energy (Kcal)
Rice 150 12 425
gm
Pulses 30 gm 8 105
Milk 100 ml 3 70
Green leafy vegetable 100 3 25
gm
Oil 5 ml - 45
Total 26 670

Thus, pregnant women has to take (usual intake plus additional food suggested)
Rice-450 gm, pulses-50 gm, green leafy vegetables-100 gm, other vegetables-70 gm, milk-200 ml, oil-15 ml,
sugar-20 gm, egg-1, banana-1

5. Energy consumption unit of a family is 5. Compute the nutrients required for the

family. Solution:
Energy consumption unit (CU) of the family = 5
1 dietary coefficient = 2400 Kcal
5 dietary coefficient = 2400 × 5 = 12000 Kcal
Family requires = 12000 Kcal/day
168 Section III: Exercises (Problems and Their
Solutions)
Allocation of energy to nutrients
Total energy allocation Calculation of energy distribution * Nutrients (gm)
% of nutrients (required)
12000 ×15
Protein 15% = 1800 Kcal 1800
100 4 = 450
12000 × 20
Fat 20% = 2400 Kcal 2400
100 9 = 266
12000 × 65 7800
Carbohydrate 65% = 7800 Kcal = 1950
100 4
*Protein and carbohydrates provide 4 Kcal/gm
Fat provides 9 Kcal/gm

Calculation
Protein: To get 4 Kcal—1 gm of protein is required
To get 1800 Kcal—How much protein is required?
1
 × 1800 = 450 gm
4

Fat: To get 9 Kcal—1 gm of fat is required

To get 2400 Kcal—How much protein is required?
1
 × 2400 = 266 gm
9

Carbohydrate: To get 4 Kcal—1 gm of carbohydrate is required

To get 7800 Kcal—How much carbohydrate is required?
1
 × 7800 = 1950 gm
4
Thus, for this family having 5 CU, we recommend the following amount of nutrients
Protein 450 gm
Fat 266 gm
Carbohydrate 1950 gm
Energy 12000 Kcal

6. A diet survey was conducted on 40 male stone cutters, by oral questionnaire method. Data regarding the
mean daily intake of food items is given below.
Food item Mean intake (in gm)
Cereals 600
Pulses 50
Green leafy vegetables 40
Roots and tubers 60
Other vegetables 60
 Nutritions/Balanced Diet Calculations
169
Milk 50
Oil 50
Sugar/Jaggery 55
Find out whether stone cutters are taking sufficient calories.

Solution:
Stone cutters are heavy workers
Energy consumption unit—1.6 1 CU = 2400 Kcal
Energy requirement—3800 Kcal/person/day 1.6 CU = 2400×1.6 = 3840 Kcal
Round up = 3800 Kcal

Calculation of energy intake

Food intake (in gm) Energy provided/gm of food Energy intake by stone cutter
Cereals 600 × 3.5 2100
Pulses 50 × 3.5 175
Leafy vegetables 40 × 0.5 20
Other vegetables 60 × 0.5 30
Roots and tubers 60 × 0.8 48
Milk 50 × 0.7 35
Oil 50 × 9.0 450
Sugar/Jaggery 55 × 4.0 220
Total 3078

Inference: Energy requirement for stone cutters—3800 Kcal

In the given example actual energy intake—3078 Kcal
Hence, the diet is deficient by—722 Kcal (19%)

7. Analysis of cow’s milk supplied to a medical hostel shows the following report
Fat-1.6 gm, protein-2 gm, specific gravity-1008, plate count-37000/ml, coliform-6/ml, phosphatase test
-positive
Comment on the quality of milk provided.

Solution:

Comparison of the quality of milk

Particulars Standard milk Milk supplied to hostel Remarks
Fat 4.1 gm 1.6 gm Decreased
Protein 3.2 gm 2 gm Decreased
Specific gravity 1030 1008 Decreased
Plate count 30,000/ml 37000/ml Increased
Coliform Negative 6/1 ml Contaminated
Phosphatase test Negative Positive Not Pasteurized
170 Section III: Exercises (Problems and Their
Solutions)
Comments: Cow’s milk should have 3.2 gm of protein and 4 gm of fat.
Milk supplied to hostel is lacking in normal protein and fat content.
Specific gravity is also less
All these points indicate that milk is adulterated by adding more water.
Coliform count and plate count, both have exceeded the prescribed limits which indicates milk has
been contaminated by unhygienic practices.
Positive phosphatase test also supports that milk is not pasteurized or post-pasteurization contamina-
tion has happened by addition of raw milk or water

Conclusion: Milk is not fit for consumption.

However after pasteurization, it can be used.
Milk vendor is strictly instructed not to adulterate the milk.

8. A sample of cow’s milk was analyzed. Results of the analysis is given below
Fat-2%, protein—3%, specific gravity—1010, plate count—25000/ml, coliform—0/ml, phosphatase test-
positive.
Comment on the quality of the milk
Solution:

Quality of cow milk

Particulars Hostel supplied Remarks
Standard milk
milk
Protein 3.2% 3% Acceptable
Fat 4% 2% Fat is removed
Specific gravity of water 1030 1010 Low specific gravity
Plate count 30,000/ml 25,000/ Acceptable
ml
Coliform count 0/ml 0/ml Acceptable
Phosphatase test Negative Positive Not pasteurized
Low specific gravity indicates water is mixed to the milk
Low fat indicates fat is removed from the milk
Positive phosphatase test denotes, milk is not pasteurized or raw milk is mixed after pasteurization.
Milk is suitable for consumption after pasteurization.

9. Some houses in the city are getting raw milk from village milk-vendor
i. How do you confirm the milk is free from bacteria?
ii. What are the pathogenic organisms transmitted through milk?
iii. How do you prevent milk borne infections?
iv. What are the differences between pasteurized milk and home boiled milk?

Solution:
i. Methylene blue reduction test is done for detection of micro-organisms present in the
milk: Methylene blue is added to 10 ml of milk in a test tube.
Test tube is kept at 37 °C for some time.
Milk which retains blue color for longest period is considered as the milk free from bacteria.
 Nutritions/Balanced Diet Calculations
171
ii. Pathogenic organisms transmitted through milk
are: Bovine tuberculosis Staphylococcal toxin
Brucella abortus Salmonellosis
Streptococcal infections Q Fever
iii. Prevention of milk borne infections:
Registration and regulation on dairies and milk vendors
Periodic inspection of dairies and health of milking cattle
Medical examination of persons working in milk business
Regulation of packing, labeling, using receptacles
Enforcement of food adulteration act
Health education to public regarding milk safety.

Difference between pasteurized and home boiled milk

Particulars Pasteurized milk Boiled milk
Method used Holder method—heated Heated in an open vessel till scum layer
up to 63–66°C for 30 forms
minute. OR
HTST—heated up to 72° for
15 second and cooled
rapidly to 4°C
Taste/Appearance/color/ Not altered Altered
consistency
Bacteria Destroyed, but lactic acid Completely sterilized, but lactic acid bacilli
forming bacilli are reduced are killed
Protein Partially decomposed Totally coagulates
Cream formation No Calcium, fat and protein together forms
scum layer
Nutrient Not much affected Nutrients are reduced, iodine is completely
lost
Keeping quality Improves Better than pasteurized milk
Souring Delayed Delayed than pasteurized milk

10. A primary school is using rice-5 kg, dal-1 kg, vegetables-3 kg, and oil-1 kg each day for preparing of
midday meal for 100 students. What is your opinion and advice regarding the adequacy of nutrients
pro- vided.

Solution:
Aim of mid-day meal is to provide

}
50% of protein
33% of energy Requirement of the child.

Nutrient requirement of the child

Nutrient Requirement for primary school children To be provided in mid-day meal*
(7 to 9 year)
Protein 40 gm 20 gm (50% RDA)
Energy 1950 650 Kcal (1/3 of RDA)
Kcal
* Mid-day meal is supplement and not a substitute to home food.
172 Section III: Exercises (Problems and Their
Solutions)
Protein and energy provided in mid-day meal
Availability of nutrient per child
Food item Used per 100 children
Food item in gm Protein in gm Energy in Kcal
Rice 5 kg 50 gm 3.5 175
Dal 1 kg 10 gm 2.2 33
Vegetables 5 kg 50 gm 1.5 20
Oil 1 kg 10 gm - 90
7.2 gm 318 Kcal

Comparison between provided and recommended nutrients in mid-day meal

Nutrient Recommended in mid-day meal Provided in mid-day meal Deficiency of nutrients
Protein 20 gm 7.2 gm 12.8 gm
Calorie 650 Kcal 318 Kcal 332 Kcal
Inference: In mid-day meal, each child is getting 12.8 gm less protein and 332 Kcal less energy than recommended.

Advice
We advise to include additional food items to make up the observed deficient nutrients in the mid-day meal.

Addition of foods suggested for each child

Available Nutrients
Addition of food items Requirement
Protein (gm) Energy (Kcal)
Rice 20 gm 1.4 70
Pulse 10 gm 2.2 35
Vegetables 100 gm 3.0 40
Egg 1 7.4 70
Oil 10 gm - 90
Total 14 305

Total availability of nutrients

Particulars Protein ( gm) Energy (Kcal)
Provided in the mid-day meal 7.2 318
Additional food suggested 14 305
Total 21.2 623
By addition of suggested food items, each child is getting addition of 14 gm protein, 305 Kcal of energy and pro-
vides recommended nutrients. Thus, a child’s requirement of nutrients will be met by mid-day meal.
 Nutritions/Balanced Diet Calculations
173
11. In a study, left mid arm circumference (MAC) of 500 children aged 3 to 5 year, attending different An-
ganwadi centers of a taluk was measured. Data obtained is given here:
MAC (in cm) Number of children
14 100
13.5 150
13 150
12.5 50
12 50
Total 500

How you will interpret the nutritional status of children and give your advice

Solution:
Mid arm circumference (MAC) measurement is the easiest method of assessing malnutrition status in children of
2 to 5 year.
It is a reliable measurement.

Stratification of nutritional status by mid arm circumference

MAC (in cm) Number of Anganwadi children Nutritional status
> 13.5 250 Satisfactory
12.5–13.5 200 Mild to moderate
malnutrition (Borderline)
< 12.5 50 Severe malnutrition
Interpretation
From the data we can interpret,
Out of 500 children studied, nutritional status of 250 children (50%) is satisfactory.
200 children (40%) are having borderline malnutrition
Only 50 children (10%) are severely malnourished.

Advice for supplementation

According to Integrated child development services (ICDS) revised guidelines, 2008
Regular nutrition supplementation providing 500 Kcal and 15 gm of protein is continued for normal children
Additional supplementary nutrition of 300 Kcal and 5–10 gm protein is provided to borderline and severely mal-
nourished children.
Malnourished children should be regularly kept under supervision.
Referral services if needed

Additional measures required

All children must be provided with
Iron and folic acid tab
Vitamin A solution
Deworming treatment.
Followup care and Periodic surveillance.
174 Section III: Exercises (Problems and Their
Solutions)
Nutritional education to mothers
Nutritional rehabilitation services for needy.

Coefficient for computing calorie requirements

Work Male Female

Sedentary 1.0 0.8
Moderate work 1.2 0.9
Adults
Heavy work 1.6 1.2
Adolescent (12–21 1.0 1.0
year)
1–3 year 0.4 0.4
3–5 year 0.5 0.5
Childre 6–7 year 0.6 0.6
n 8–9 year 0.7 0.7
9–12 year 0.8 0.8
1.0 CU = 2400 Kcal
 Chapte
r Common Problems
Faced in Public Health
14 and their Solutions

1. 23 adults and 2 children had sudden vomiting and abdominal colic within 12 hour of consuming food
at a marriage party. Describe the steps of investigation and control.

Solution:

From the case history, it is evident that food poisoning has occurred which needs to be investigated.

Investigation
Objectives
To know:
Type of food
poisoning Food items
responsible Source of
poison
Mode of entry of poison/toxin into food
Offending organism/toxin.

Data collection
By visiting the place

A) Out break details:

Time—When did it occur?
Place—Where did it occur?
Person—Who all were affected?
Cause—Why has it occurred?
Mode—How has it occurred?
Control—What should be done?

B) Food consumption details

List of all persons who consumed food with their age and sex
Date and time of food consumption.
Food items consumed during the meal
Number of persons affected
Date and time of onset of symptoms (illness)
176 Part III: Exercises (Problems and Their
Solutions)
Time interval between food consumption and onset of illness (incubation period)
Food consumed during previous 72 hour, with time and place.

Treatment (if taken earlier) details

Diagnosis: Nature of treatment:

Clinical details of person affected

Name:
Age:
Sex:

Symptoms
Nausea Fever/chills Blurring of vision
Vomiting Abdominal cramps/discomfort Constipation
Retching Headache Difficulty in speaking
Prostration Dizziness Other.
Diarrhea Diplopia

Predominant symptom

Summary of epidemiological case histories

Abdominal discomfort

Lab investigations
Incubation period

Nausea/Vomiting

Fever/Headache
Name of person Date and Food items actu-

Diarrhea
Date and hour

Others
who consumed time of food ally consumed ill or
of onset of first
the suspected consump- in the specified Not ill symptom
food or drink tion meal

A B C D

Confirmation criteria of an outbreak:

Occurred following ingestion of common food
Suddenly affected a large number of persons
Similar manifestations in most of them

Finding the type of food poisoning: By studying the

Features of poisoning
Incubation period
Signs, symptoms
Lab report
By the process of exclusion—cholera, bacillary dysentery, arsenic poisoning.
 Common Problems Faced in Public Health and Their
Solutions 177
Differentiation of food poisoning:
Causative Agent Incubation Symptoms Food item
period (in hour)
Staphylococcus aureus <6 Vomiting, abdominal pain Milk, custard, fried rice,
uncooked meat
Bacillus cereus <6 Emetic/diarrheal form, vomiting, Fried rice, reheated food
abdomi- nal pain
Clostridium perfiringens 6–12 Abdominal pain, diarrhea Cooked meat kept for long
time
Salmonella 12– Fever and chills abdominal pain, Meat, poultry, egg, dairy
24 diarrhea, vomiting food, processed food
Clostridium botulinum 18– Dysphagia, diplopia, dysarthria, Canned, preserved food and
36 blurring of vision, motor weakness, low acidic food
consciousness is retained

Identification of responsible food item

Group A Group B
Food item
Persons who consumed specified food item Persons who did not consume specified food item
ill Not ill Total Attack rate ill Not ill Total Attack rate (%)
(%)

Sanitary inspection of premises used for

Preparation
Storage
Consumption
Cleanliness of premises
Storage facility and quality
Fly, rodent and poultry proofing
Cleanliness of utensils and crockery used

Details about food used

Food items used Hygienic details
Raw items Washed thoroughly Yes/No
Fish/marine/meat/poultry Certification in slaughter house Yes/No
Custard, canned tinned Proper packing and storage time Yes/No
Milk Pasteurization Yes/No
Other items
Cooking and serving
Method of preparation: Proper/Improper
Cooking: Adequate/Inadequate
Food covering: Proper/Improper
Prepared food kept at room temperature for longtime: Yes/No, if yes, how
long Reheating before consumption: Yes/No
Refrigeration (if done details):
178 Part III: Exercises (Problems and Their
Solutions)
Food served: With bare
hand/spoons Water served:
Potable/Unpotable

Examination of food handlers and cook

Personal hygiene Respiratory infections
Hands, nails, hair hygiene Skin lesions, infections
Hand washing after toilet and before touching food ENT infections
Any acute illness—cough, sneeze, etc. Other clinical findings
Diarrhea Habits—smoking, pan chewing, spitting, putting fingers
in mouth, nose, ear, hair

Laboratory examinations
Vomitus and stool samples—Aerobic and anaerobic culture
Food sample—Appearance, smell, chemical reaction, deviation from normal
Swabs from food handlers—Throat, nose, skin lesions, hands, rectum
Isolation of salmonella among food handlers in three successive stool culture to rule-out carrier state
Blood examination for antibodies—After 1 week
Animal experiment—Feeding/Animal inoculation

Summary of epidemiological case histories

Epidemiological analysis: Time/Place/Person
Confirmation of out break: Sudden rise and sudden fall in number of cases. No secondary cases
Epidemiological association: By case control study

Study of Morbidity
Number of persons
Attack rate =
affected × 100
Number of persons
exposed
Number of details
Case fatality rate CFR =
Number of persons × 100
affected

Association of exposure and outcome

Food exposure Number exposed to food Illness No illness Total
Yes
No

Final Report

Control measures
Providing supportive treatment to sick
Relieving anxiety and reassurance of all concerned
Maintenance of food sanitation and kitchen hygiene
Infected food handlers should not be allowed to handle food items
Food handlers health examination
Observing the rules of hygiene including hygienic food handling
 Common Problems Faced in Public Health and Their
Solutions 179
Health education regarding observing hygiene in selection, cooking, storage and serving.
Periodic training of food handlers
Continuing surveillance

Hygienic Food Handling and Storage

Minimize the use of hands in preparation and serving
Refrigeration of food item in a clean condition
No spoilt food is placed in refrigerator
Cook the food for sufficient time and temperature high enough to destroy the bacteria
Do not keep the food exposed for long time after cooking, if the food is to be consumed later, it should be cooled
and then put in the refrigerator (< 4 ºc)
Refrigerated food should be reheated before consumption
Food stuffs like custard—canned food, bakery products should be reheated in an oven over 200 °C before
consump- tion.
Areas used for food storage, cooking and serving should be kept clean.
Maintaining personal hygiene and hygienic food handling
In the absence of refrigerator, food should be stored in hygienic condition—below 10 º or above 50 ºC.
Use of gloves while serving large number of person
Use of clean containers, potable water
Thorough washing of utensils

2. In a boarding school, 14 out of 50 students are suffering from scabies. Discuss the line of
management. Solution:
Information collected by visiting the boarding school
List of children residing: Age and sex Personal hygiene practices
Residential facilities Close contact of children
Presence of overcrowding Sleeping, playing together
Regular bathing facilities Sharing cloth, mattress, linen, etc.

Epidemiological history:
Previous occurrence of same illness
Same illness in warden, cook and other
staff. H/o visit and stay by outsider
H/o student visited and stayed outside.
Primary case: First case who introduced infection.
Index case: First case noticed by the investigator.

Diagnosis of disease by
Complaint: Itching, worse at night
Clinical examination of all inmates:
Follicular lesions and secondary infections at:
Hand Buttocks
Wrist Lower abdomen
180 Part III: Exercises (Problems and Their
Solutions)
Extensor aspect of elbow Feet, ankles
Axilla Genitals
Excluding the other conditions that mimic scabies.

Management
Confirmation of the diagnosis
Microscopic demonstration of itch mite.

Treatment:
Secondary infections is treated promptly
All residents are treated simultaneously (Blanket treatment)
First, all infested inmates are given a good scrub bath
After bath, 25 percent benzyl benzoate (sarcopticide) is applied all over the body, below the chin. Allowed to
dry Application is repeated after 12 hour
Thorough bath is given 12 hour after the second application
All under clothes, towels, bedsheets and linens should be boiled, washed, sun dried and ironed.

Prevention
Taking bath daily, washing the clothes
regularly Maintaining personal hygiene
Improving the standard of living conditions
Prevention of overcrowding
Avoiding sharing the fomites like clothes, bedsheets,
etc. Avoiding contact with scabies person
Prompt early diagnosis and treatment
Health education regarding the cause and prevention of scabies.

3. Morbidity of parasite infestations are frequently reported among slum children. Explain the
procedures you adapt to control the problem.
Solution:
Collection of baseline data
By visiting the slum
Name and location of the slum:
Total population of the slum:
Children population of the slum:
Availability of health services:
Water supply:
Toilet facility: At house/At public place/Nil
Sewage disposal
Environment i. Temperature iii. Type of soil—Sandy/Friable/Clay
ii. Moisture iv. Soil, contamination
 Common Problems Faced in Public Health and Their
Solutions 181
Human habits:
Open air defecation Agricultural labor as occupation
Child defecation around the house Using untreated sewage for agricultural land
Children playing with soil in bare hand and foot Using soil contaminated vegetables without washing
Walking bare foot (not using footwear) Improper cooking
Social factors:
Illiteracy Low socioeconomic condition
Low standard of living Ignorance

Clinical details of all children of the slum:

Name:
Age:
Sex:
Nutritional status: Anemia, vitamin deficiency, protein deficiency
Personal hygiene:
Clinical features: Anorexia Dull aching abdomen
(complaints) Vomiting Diarrhea
Allergic manifestations Loss of weight
Cough, fever Dyspnea
Dermatitis—ground itch Worm in
stools

Laboratory examination
Blood: Hb
Eosinophilia
Stool: Naked eye examination for parasites
Microscopic examination—Iodine preparation, using gram’s iodine for ova and cyst

Diagnosis:

Assessment of the problem

Number of children affected with specific ailment
Number of children studied
 100

Finding the endemic index for hook worm

Chandler index
Average number of eggs per Inference
gram of stool
< 200 Not much significant
200–250 Potential danger
250–300 Minor public health problem
> 300 Important public health problem

Prevention and control measures

182 Part III: Exercises (Problems and Their
Solutions)
Short term measures
To reduce the worm load and transmission

Deworming
Using any one of the antihelminthic drug
Albendazole 400 mg all ages above 2 year
Piperazine 75 mg/kg orally for 2 day (maximal dose 3.5 gm)
Mebendazole 100 mg twice daily for 2 day
500 mg single dose
Levamisole (Tetramisole) 2.5 mg/kg body weight (max dose 150 mg)
single dose
Pyrantel pamoate 10 mg/kg (maximum 1 gm) single dose or 3 day

Long term measures

Interruption of transmission
Sanitary disposal of human excreta Improvement in economic status
Provision of safe drinking water Improvement of education
Food hygiene habits Improvement in living condition
Use of sanitary latrines Improvements in quality of life
Personal hygiene

Treatment of anemia
With oral iron and folic acid tablets
3 month after treatment, hemoglobin should reach 12 gm

Correction of nutritional deficiencies

During convalescence, extra food should be given to ensure nutritional recovery.

Health education programmes

Prevention of soil pollution with human excreta
Change in farming practices—Not using untreated raw feces/sewage as fertilizer
Community involvement and participation
Wearing foot wear: Foot hygiene
Using health facilities for early diagnosis and treatment

4. A primary school teacher is having a wife and a breast feeding baby. Teacher is suspected to be
suffering from pulmonary tuberculosis. How will you manage this situation?
Solution:
Baseline data collection
Name and Address of the teacher: Socioeconomic class:
Age: Housing/living condition:
Sex: School (occupation) environment:
Religion: Habits: Smoking/Alcohol
Occupation: Education:
 Common Problems Faced in Public Health and Their
Solutions 183
Epidemiological Data
Family history of TB: Yes/No
Any TB case in the neighbourhood:
Yes/No Any contact with TB cases:
Yes/No Epidemiological indices of TB in
the area

General examination
Weight
Nutritional assessment

Medical details
Symptoms Duration/Details
Cough
Fever
Weight
loss
Others
Previous treatment (if taken), details:
If discontinued, reasons for discontinuation

Laboratory examination
Three sputum examinations for AFB (Z-N stain)
First examination on-the-spot
Second examination on next day morning (over night) (From April 2009, only first two sputum examination is
advised)
Third examination on next day spot
Blood examination: FBS
ESR

Confirmation of Diagnosis
Clinical history
Sputum positivity
If school teacher is an open case, he is spreading the infection:
To school children
To co-workers in the
school Family members
Others
Hence, highest priority should be given for early diagnosis and treatment.

Treatment
Sputum examination report is recorded
Teacher is registered and treated under
RNTCP
Direct observed therapy short term (DOTS) is given
According to the DOTS, teacher is stratified under category I for treatment schedule.
184 Part III: Exercises (Problems and Their
Solutions)
2 month intensive and 4 month continuation therapy is advised.
1. Isoniazid-600 mg 2. Rifampicin-450 mg
3. Pyrazinamide-1500 mg 4. Ethambutol-1200 mg
H-Isoniazid
R-Rifampicin
Z-Pyrazinamide
E-Ithambutol

Intensive phase (2 month)

3 doses/week, all doses are supervised

Continuation phase (4 month)

3 doses/week, first dose of every week is supervised, rest of the doses are self administered
Sputum examination is repeated at the end of intensive phase, (i.e. 2 month), then at 4th and 6th month in continu-
ation phase.

Advice to patient
Take drugs regularly and completely Undergo periodic
followup Cover the mouth with cloth while coughing, sneezing Stop smoking
Take good food, do regular walking/exercise Hygienic disposal of sputum
Avoid indiscriminate spitting

Screening of school children

Examination of BCG scar, clinical symptoms—Fever, cough, weight loss
Suspected child is subjected for
Three sputum examination (when child can expectorate)
Chest x-rays
Gastric lavage and other procedure.
- Students found positive, should be promptly treated
- Health education is given to children along with their parents.

Family members
Wife and infant is screened for tuberculosis. If positive, prompt treatment is given
INH prophylaxis to baby. If indicated, BCG vaccination is given to the baby if not given earlier.

5. A PHC catering 30,000 population has given the data about tuberculosis from January 2008 to Decem-
ber 2008
Particulars Tuberculin +ve Sputum +ve
Old cases 11,160 76
New cases 540 25
Total 11,700

Calculate the relevant epidemiological indices and write the validity of these indices.
 Common Problems Faced in Public Health and Their
Solutions 185

Solution:

Epidemiological indices of tuberculosis

1. Number of new people showing tuberculin positive
Incidence of infection = Total population under study  1000

(Annual infection rate/Tuberculin conversion index)

540
 30, 000 1000  18

= 18 per thousand population per year

2. Number showing tuberculin positive (old + new)
Prevalence of infection = Total population under study  100

11,160  540
 30, 000  100

11, 700
 30, 000  100

= 39%
3. Number of new sputum positive cases
Incidence of disease = Total population  1000

25
 30,000  1000

= 0.8 per thousand population

4. Number of sputum positive (old + new) cases
Prevalence of disease = Total population  1000
76  25
 1000
30, 000
101
30,  1000
000
= 3.36 per thousand population

Validity of epidemiological
indices Prevalence of infection
High coverage of BCG—Interferes with identification of true prevalence
Cross sensitivity by a typical mycobacteria—Over estimate the prevalence
Age—Specific prevalence is far superior indictor than mere prevalence of positive reactors.

Prevalence of disease (case rate)

It is a best index to estimate the case load.
Age specific prevalence is much more relevant index.
186 Part III: Exercises (Problems and Their
Solutions)
Incidence of infection
Reflects the risk of infection in the community
It expresses the attack force of TB
It is the best indicator for evaluating the problem and trend of infection

Incidence of new cases (disease)

It reflects the new cases, but not total case load
Reveals the impact of programme as well as the direction of the disease
Difficult to measure unless case detection is high and reliable

Inference
All the indicators should be considered together in interpreting the tuberculosis situation of a community

6. An anganwadi teacher 30 year is having hypopigmented anesthetic patches on both arms. How do you
proceed and provide necessary remedial measures required?

Solution:
Clinical history suggests the possibility of leprosy lesions in anganwadi teacher.

Case taking
Basic details of the patient
Name: Address:
Age: Sex:
Education: Occupation: Income:
Socioeconomic status:
If migrated, details:
Living (housing) conditions:

Epidemiological data
Family history of leprosy:
Any similar cases in the family, neighbourhood:
H/o contact with similar case:
If diagnosed and started treatment, earlier details of treatment:
If treatment is discontinued, reason for discontinuation:
Duration between onset and diagnosis:
Duration between diagnosis and treatment:
Total duration between onset and treatment:
Leprosy prevalence:

Clinical examination
Examination for leprosy is done in good day light, from head to toe. Both from front and behind for the evidence
of features of leprosy

A. Examination of skin lesions

Number: Distribution:
Size, shape: Pigmentation:
Situation: Hair and sweating:
 Common Problems Faced in Public Health and Their
Solutions 187
Testing for sensation in skin lesions
Touch: Heat:
Pain: Cold:

Muscle testing
Muscle Condition Muscle tested

Paresis
Paralysis
Movement:
Able to move against
gravity Able to move
towards gravity Not able
to perform movement

B. Peripheral nerve examination

Nerve Thickening Tenderness
Greater
auricular Ulnar
Median
Dorsal branch of
radial Lateral
popliteal
Other nerve

C. Examination for deformity and hallmarks of leprosy

Face Testes
Hand Breast
Feet

D. Laboratory investigations
Skin smear: Site Number of plus*
1. First Skin lesion
2. Second Skin lesion
3. Third Skin lesion
4. Fourth Skin lesion
5. Left ear lobe
6. Right ear lobe
7. Nasal smear
Total positives
Bacteriological index (BI) =
Total number (7) of sites examined
*Negative No bacilli in 100 fields
One plus (+) One or less than one bacilli in each
field Two plus (++) Bacilli found in all fields
188 Part III: Exercises (Problems and Their
Solutions)
Three plus (+++) Many bacilli found in all
fields Classification by BI >2 <2
Morphological index: Ratio of solid staining bacilli to total number of bacilli
Histamine test:
Biopsy:
Foot pad culture:
Immunological tests:
Lepromin test—For detecting Cell-mediated immunity (CMI)

Diagnosis of leprosy criteria

Hypopigmented patches
Loss of sensation
Thickened/tender nerves
Presence of bacteria

Classification of leprosy
Features Number of skin lesion Number of nerves involved Skin smear
Single Skin Lesion leprosy (SSL) 1 - -ve
Pauci Bacillary Leprosy (PBL) 2–5 1 -ve
Multi Bacillary Leprosy (MBL) >5 2 or more +ve

Deformity grading (WHO)—0, 1, 2

Treatment
Patient is registered and treated under the National leprosy eradication programme (NLEP).

Objectives of treatment (MDT)

To interrupt
transmission To cure the
case
To prevent drug resistance

Treatment schedule

Duration of Drugs
Type of leprosy
treatment (month) Rifampicin-600 mg Dapsone-100 mg Clofazemine
MBL 12 Once a month supervised Daily self 300 mg once a
month supervised,
50 mg daily self
PBL 6 Once a month supervised Daily self Nil
During treatment patient is observed for lepra reaction.

Follow up surveillance
After completion of treatment
Paucibacillary once a year for 2 year
Multibacillary once in a year for 5 year
Patient who does not show evidence of relapse (clinical and bacteriological) during the period of surveillance is
released from treatment/control.
 Common Problems Faced in Public Health and Their
Solutions 189
For close contacts
Periodic examination
Chemoprophylaxis: Dapsone-4 mg/kg weight per week for 3 year
Immunoprophyalxis: BCG (as relevant)

Advice
Patient: Take drugs regularly and
completely Go for periodic check
up
Hygienic disposal of nasal secretion
To use Microcellular foot wear
Family: Accept the patient, do not discriminate
Motivate for treatment
Community: Health education about cause, cure and availability of services
Removal of the stigma attached to leprosy
Improvements in living standards
Creating awareness regarding NLEP

Community level activities (Education)

Leprosy is not due to sin, it is caused by bacteria
Leprosy can be completely cured
Early detection of cases by
Mass surveys Contact survey
School children examination Voluntary referral
Examination of slum population Registration of cases for treatment
Motivation of affected for early diagnosis and treatment

Social support
Assistance—Travelling, food, etc. Job replacement
Vocational training Abolishing social evils

7. In a tribal area where Annual parasite incidence (API) is more than 2, falciparum malaria cases have
been reported, 2 deaths have occurred. As a medical officer of PHC what action will you take for con-
tainment of malaria in that area.
Solution:
Containment of malaria
a. Stratification of the problem
Tribal area
API > 2
P. falciparum reported
Deaths reported due to Malaria
Under modified plan of operation, given area is categorized as
Area with API more than 2 (High risk area)
190 Part III: Exercises (Problems and Their
Solutions)
b. Antimalarial activities undertaken
Spraying: Regular insecticidal spray
Insecticide gm/sq meter Number of rounds at 6 week interval
DDT 1 2
Malathion 2 3
Synthetic pyrethroid 0.25 2

Surveillance
Both active and passive surveillance is done

Active surveillance
Surveillance worker visits each house every fort nightly, enquires about
a. Fever case in the house at that time
b. Any fever case since 15 day (Including guest visitors)
If answer is ‘yes’ to any question:
Collects blood film—thick and thin on the same slide
Gives presumptive treatment—600 mg chloroquine
If smear is positive for malaria, surveillance worker returns to the patient and provides radical treatment

Passive surveillance
Blood smear is taken from all fever cases attending the OPDs.
Presumptive treatment is given
If smear is positive, radical treatment is given

Treatment
Presumptive
To all suspected cases
Day 1—Chloroquine 600 mg single dose + Primaquine 45 mg
Day 2—Chloroquine 600 mg
Day 3—Chloroquine 300 mg
Children 10 mg/kg body weight chloroquine
0.75 mg/kg body weight primaquine

Radical
After microscopic confirmation
[Link]—Tablet primaquine-15 mg daily for 5 day
[Link]—Not required

Resistant Cases—Chloroquin resistant falciparum

Artesunate-4 mg/kg body weight daily for first 3 day
Combination of sulphadoxine-25 mg/kg and Pyrimethamine-1.25 mg/kg single dose on first day
(1500 mg + 75 mg)
Primaquine-45 mg single dose on first day—not given for pregnant mother, infants, G6 deficiency
 Common Problems Faced in Public Health and Their
Solutions 191
Severe, Complicated and Unconscious Cases
Refer to the higher center and hospitalize where the best facilities are available
Quinine dihydrochloride 10 mg/per kg weight IV injection in 5% dextrose run over 4
hour Repeat every 8th hour till patient regains consciousness
Switch over to oral drugs after gaining consciousness
OR
Mefloquine-750 mg for those resistant to chloroquine and ring stage of falciparum
Artemisinin-10 mg/kg once daily for 5 day

Followup
All positive cases after treatment are followed up by blood smear examination monthly for 12 month.

Vector control
Antiadult measures
Antilarval measures
Source reduction
Integrated control
Individual protection
Entomological assessment
Done by entomologist who suggest appropriate insecticides.

Health education
Regarding cause, spread, symptoms, treatment and prevention of malaria

8. A primary health center with a population of 30,000 has examined 4000 peripheral blood slides during
1 year. 55 slides were positive for P. vivax. 15 slides were positive for falciparum. Calculate the possible
malarial parameters.
Solution:
Blood examination
Annual blood examination rate recommended is 10% of the population in a year. In this PHC, 13% of the
population is examined. Hence, sample is adequate and acceptable.
Data given,
Population under surveillance = 30,000
Number of slides examined = 4000
Malaria cases (Confirmed)
Vivax = 55
Falciparum = 15
Total = 70
Parameters of malaria
Confirmed cases during one year
1. Annual parasite incidence (API) =  1000
Population under surveillance

70
 30,000  1000

= 2.3 per thousand population

192 Part III: Exercises (Problems and Their
Solutions)
Number of falciparum cases
2. Annual falciparum incidence (AFI) =
Population under ×1000
surveillance

15
 30, 000  1000

= 0.5 per thousand population

Number of slides examined
3. Annual blood examination rate (ABER) =
Population under ×100
surveillance

4000
 30, 000  100

= 13.3%
Number of slides positive of malaria
4. Slide positivity rate (SPR) = ×100
Number of slides examined

70
 4, 000  100

= 1.75%
Number of slides positive for
5. Slide falciparum rate (SFR) =
falciparum × 100
Number of slides examined

15
 4, 000  100

= 0.37%
6. Number of falciparum cases
[Link] rate = Total malaria cases ×100
15
  100
70
= 21.4%

9. During the year 2009, Ramapura primary health center covering 30,000 population has collected 4,000
peripheral smears by house to house visit. Another 400 slides were collected in the OPD. Results of the
microscopic examination of these 4400 slides are given to you

Plasmodium vivax positive 41

Plasmodium falciparum positive 9

Total positive 50

Calculate the possible malarial parameters and suggest the remedial measures in brief.
 Common Problems Faced in Public Health and Their
Solutions 193
Solution:
Malarial parameters
Confirmed cases in one year
1. Annual parasite incidence (API) =
Population under × 1000
surveillance

50
 30, 000  1000

= 1.6 per thousand population

Number of cases due to
2. Annual falciparum incidence (AFI) =
falciparum × 100
Population under surveillance

9
 30, 000  1000

= 0.3 per thousand population

Number of slides examined
3. Annual blood examination rate (ABER) =
Population under × 100
surveillance
4, 400
  100
30, 000
= 14.6%
Number of slides positive for
4. Slide positivity rate (SPR) =
malaria × 100
Number of slides examined

50
 4400  100

= 1.13%
5. Number of slides positive for P.
Slide falciparum rate (SFR) =
falciparum × 100
Number of slides examined

9
 4400  100

= 0.20%
Number of slides positive for P.
6. P. falciparum rate (PFR) =
falciparum × 100
Total number of positive slides
9
  100
50
= 18%

Control measures
Ramapura PHC can be classified as area with API less than 2
According to modified plan of operation (MPO) measures required
are: Focal spraying in and around P. falciparum detected house.
194 Part III: Exercises (Problems and Their
Solutions)
Active and passive surveillance: (once in 15 day)
Mass blood survey of people living around patients home.
Treatment: Prompt treatment is given to all detected
cases.
Follow up: After completion of radical treatment, monthly blood examination should be carried out for 12 month
Epidemiological investigation: All +ve cases are to be investigated.

10. A routine clinical survey for filariasis was carried out in a community health center, serving 1 lakh popu-
lation, data collected is given to you
Night blood smears collected 30,000
Persons showing only mf positive 300
Persons showing mere signs of filariasis 80
Persons showing both mf positive and signs 10
Calculate the possible filarial indices? And suggest the control measures.

Solution:
Sample size: For routine filarial survey, sample size recommended is 5 to 7%. In this survey, 30% sample is
exam- ined hence the sample is adequate and acceptable.

Calculation of filarial indices

1. Number showing mf positivity
Microfilarial rate (mf) = Number of person (slides) × 100
examined

300
 30, 000  100

= 1%
2. Number showing filarial disease
Filarial
symptoms disease rate = × 100
Number of person examined

80
 30, 000  100

= 0.26%
Number having disease
signs + Number of mf positives +
3. Filarial endemicity rate × 100
= Both Number of person
examined
80  300  10
 30, 000  100

390
 30, 000  100

= 1.3%

Control measures
Against the parasite
Mass chemotherapy
 Common Problems Faced in Public Health and Their
Solutions 195
Given to all in endemic area
Given only for cases and carriers in low endemic area
Drug—Diethylcarbamazine (DEC) (Hetrazan) Dose
—6 mg/kg/day divided doses after meal Duration—6
day in a week for 2 week, i.e. 12 day Total dose—72
mg/kg.

Medicated salt
Common salt medicated with 1–4 gm of DEC/kg

Recent schedule

}
DEC
Or ivermectin Single dose per year
Or combination of both
Plus albendazole as a supplement.
0.1% DEC mixed salt and distributed to all

Vector control
Antilarval measure: Urban area including 3 km peripheral belt (flight range of culex is about 3 km)
Chemical: Application of selected insecticides once in a week on all breeding places
Mosquitos larvicidal oil (MLO)
Pyrosene oil E-0. 1 to 0.2%, pyrethrins diluted with water (1:4)
Fenthion 1 ppm
Organophosphorus—Temephos, fenthion
Anti-adult measures:
Pyrethrum space spray/Insecticidal spray in and around
Open underground sewage system
Neighbourhood at human dwelling
Use of polystyrene beds to seal latrines and roof top tanks
Environmental measures: Source reduction
Integrated vector control:
Personal prophylaxis:

Other measures
Maintenance of local hygiene of affected organ
(leg) Primary health care approach
Periodic night blood examination: Positive persons should be given early course of diethyl carbamazine.
Blood examination: By taking capillary blood (20 cm) by deep finger prick between 8.3 pm and 12 midnight
Health education: Dynamic health education, campaign is organized to motivate the people, to cooperate in anti-
filarial activities and to take complete treatment.

Surveillance
196 Part III: Exercises (Problems and Their
Solutions)
11. In a town with 1 lakh population, about 20 children were admitted for high fever during first week of
June. 3 children were showing hemorrhagic manifestation, one child was having manifestation of
shock. Discuss how do you investigate and manage this problem.
Solution:
Given clinical illness makes us think about the possibility of a dengue epidemic.
Hospital cases represent only the tip of an iceberg. Large number of cases are hidden in the community. This
should be explored by Epidemiological investigations.

Investigation
General information
Collected by visiting the place
Name of the place:
Address: District: State:
Health services available:
List of person affected: By age, sex, address, other
details Environmental factors:
ncreased mosquito (Aedes) population:
Rainy season:
Artificial collection of water in discarded container:
Preparation of spot map:
Recognition of high, medium, low and nil affected areas:

Entomological surveillance—aedes aegypti indices

House index percent houses showing actual breeding places (kept < 1%)
Container index percent of water container that are positive
Breteau index: Number of positive containers in 100 houses inspected

Case definition
Suspected case
Probable case
Confirmed case

Examination
Temperature chart Pulse
BP Tourniquet test
Liver palpation

Studying the symptoms

Fever, biphasic Mucosal bleeding
Arthralgia, severe body pain, myalgia Hematemesis and melena
Rash—Scattered petechiae, purpura, ecchymosis Hepatomegaly
Headache Low systolic and diastolic blood pressure
Retro-orbital pain With pulse pressure < 20 mm Hg
Profuse sweating Lymphadenopathy
 Common Problems Faced in Public Health and Their
Solutions 197
Nausea, vomiting Tourniquet test positive
Febrile convulsion Shock

Case definition: Dengue hemorrhagic fever (DHF)

To define DHF, there should be fever (biphasic) lasting for 2 to 7 day plus two or more other symptoms plus any
one lab test positive
Hemorrhagic manifestations (at least one of the following)
Positive tourniquet test Petechiae, ecchymoses, purpura
Bleeding from mucosa, GIT Hematemesis or melena
3
Thrombocytopenia (< 100000 platelets per mm )
Evidence of plasma leakage (due to increase in vascular permeability).
Rise in the hematocrit ≥ 20 percent for age and sex
Fall in the haematocrit ≥ 20 percent following volume replacement treatment

Dengue shock syndrome (DSS)

Symptoms of DHF plus evidence of circulatory failure like
Rapid and weak pulse
Narrow pulse pressure (< 20 mm Hg)
Hypotension for age
Cold, clammy skin and restlessness.

Differential diagnosis
Chikungunya
Other arboviral infection.

Lab confirmation
1. Isolation of virus
2. Serological—four-fold rising titer of serum antibodies, IgG or IgM in paired
serum Dengue virus antigen detection in tissues—In autopsy by
immunohistochemistry Polymerase chain reaction (PCR)—Detection of viral
genome
Hemagglutination inhibition test (antibody response)
IgM ELISA
3. Biochemical—Hypoproteinemia
Clotting factors
4. Clinical—ECG, ST-T wave
change Radiological changes.

Epidemiological Study
Confirmation of epidemic
Identification of affected and vulnerable population by rapid survey
Analysis of data by place, person and time
Finding the attack rate—mortality rate.
198 Part III: Exercises (Problems and Their
Solutions)
Management
Grading of dengue
I Uncomplicated dengue
II With spontaneous
hemorrhage III Shock
IV Profound shock, imperceptible pulse, unrecordable BP

Treatment
DHF and DSS cases are considered as medical emergencies
Patients are hospitalized and treated under bedrest
Antipyretics, salicylates should not be given
Analgesics are used
Oral/Parenteral fluids—As needed
Patient is monitored till—Platelet and Hematocrit becomes normal.

Dengue shock syndrome

Admitted in a well equipped hospital
Rapid fluid replacement
Oxygen
Blood transfusion
Plasma substitutes—5% albumin IV.

Vector control
Source reduction
Environmental: Modification and manipulation

Antilarval measures
1 percent temephos

Anti-adult vector measures

Following measures are taken—In and around the habitat

Space spraying to knockdown the vector
Thermal fog—Malathion fogging
Ultra-low volume aerosols
Mists

Personal protection
Impregnant bed nets and curtains
Insect repellents

Health education
Surveillance
Monitoring the suspected cases
Case reporting
Epidemiological and entomological investigations.
 Common Problems Faced in Public Health and Their
Solutions 199
12. 1 or 2 children from each villages surrounding the pig-rearing area are reported to have high fever,
vomiting and becoming unconscious. Discuss the problem and its management.
Solution:
From the case history, it is evident that the children are suffering from Japanese Encephalitis (JE).

Baseline information
Details about place
Total population.
Number of people developed illness by age, sex, social status, living condition
Availability of health services
Environmental study
Entomological study Increase in mosquito population
Type of vector, xenodiagnosis
Pig, bird migration
Activities surrounding the villages: Agriculture: Farm land, paddy fields, cattle grazing and rearing areas, pig rear-
ing, poultry farmland, etc.

Clinical data
Symptoms
Fever Headache
Malaise Nuchal rigidity
Convulsion Altered sensorium

Laboratory investigation
JE antibodies in paired sera—4 fold rise in paired sera ELISA
Demonstration of virus in Cerebrospinal fluid (CSF)
Demonstration of IgM and IgG Antibody
Case definition:
1. Suspect—Having symptoms
2. Probable—Symptoms + presumptive lab report
3. Confirmed—Confirmed lab report
Management:
Early diagnosis:
By screening high fever cases
Admitting and investigating fever cases
Treatment:
Symptomatic

Vector control
Malathion—Arial or ground fogging with ultra low-volume spraying
Indoor residual spray in all affected village, house and survey area
Breeding sites
Animal shelters
200 Part III: Exercises (Problems and Their
Solutions)
Villages proximate (2–3 km) to affected
villages Piggeries—Animal shelters
Use of mosquito nets—Repellents, full clothing
Pigs must be driven out of villages and quarantined
Vaccine: 2 doses 0.5 ml S.C./IM at 7–14 day interval
Third booster dose to be given 6 month
later.
Vaccination is best done during inter-epidemic periods in high risk area.

13. During a family visit, Muniyamma’s son Ramu, aged 4 year was having diarrhea since morning. Mu-
niyamma’s daughter Shweta aged 20 month is also suffering from diarrhea for the past 3 day. She is
passing loose stools, 10 per day. Her eyes are sunken. Mouth and tongue are dry. She is eager to drink
water, but Muniyamma has withheld water and food to her children because of an erroneous belief.
How will you manage this situation.
Solution:
From the case history, it is understood that the children are suffering from
diarrhea Management of diarrhea in order of priority is:
Assessment of dehydration
Fluid and electrolyte management
Nutritional management
Treatment of cause
Preventive measures.

Fluid management
Assessment of dehydration:
By history and examination
Ramu Shweta
On History
Stools per day 2 10
Vomiting Nil Often
Thirst Normal More
Urine output Normal Scanty/reduced
Tears Present Absent

On examination
General condition Well, alert Dull/irritable
Mouth and tongue Moist Dry
Eye Normal Sunken
Skin pinch—going back Quickly Slowly
Pulse Normal Rapid, feeble
Breathing Normal Rapid
Temperature Normal Increased
Anterior fontanelle Normal Sunken
Inference No dehydration Some dehydration
 Common Problems Faced in Public Health and Their
Solutions 201
Collection of contributory factors
Age of the child H/o prematurity
Breast feeding Proper weaning
Immunization Growth and development
Socioeconomic status Flies in and around the house
Water supply Use of latrine
Hygiene—personal, domestic and food Infection—
TB, malaria, pneumonia, etc.

Fluid and electrolyte management

Early replacement of fluid losses is the most important part in managing childhood diarrhea.

For Ramu (Diarrhea with no dehydration)

Offer fluids frequently at home, as much quantity as the child can take
orally. Home fluid Butter milk Coconut water
Rice kanji Fruit juice
Weak tea Lemon sherabat with salt
Homemade rehydration solution (HRS)
Prepared at home by mixing
8 level tea spoon of sugar 40 gm (closed fist full)
1 level spoonful of table salt 5 gm (3 finger pinch up to 1st
crease) Potable water 1 liter
Puffed rice powder 50 gm can be substituted for sugar.

For Shweta (Some dehydration)

Oral rehydration solution (composition very recently approved by WHO) i.e.
Glucose 13.5 gm Sodium 75 mEq/L
Sodium chloride 2.5 gm Potassium 20 mEq/L
Trisodium citrate 2.9 gm or Chloride 65 mEq/L
Sodium bicarbonate 2.5 gm Bicarbonate 10 mEq/L
Potassium chloride 1.5 gm Glucose 75 mEq/L
Potable water 1 liter
ORS once prepared, should not be boiled
Fresh solution is to be prepared each time
Extraneous contamination is to be avoided
Fluid to be used within 6 hour after preparation
Left over fluid must be discarded
ORS is given frequently, in small amounts by using clean cup and spoon.
During the first 4 hour, ORS given in ml = weight of child in kg × 75
For each diarrheal stool, extra 100 ml of ORS is given
Normal feeding (breast feeding is continued for breastfed babies).
202 Part III: Exercises (Problems and Their
Solutions)
Assessment of hydration is done after 4 to 6 hour
If the child is still severely dehydrated
Signs of moderate dehydration continue
Child is drowsy, pulse is weak, has not passed
urine Extremities are cold
Child is admitted to hospital and intravenous drip of Ringer’s lactate solution is given.
30 ml/kg body weight in the first hour
20 ml/kg body weight in the next 3 hour
(if child has passed urine) rehydration is completed
Once the child’s condition improves and starts taking liquid orally, IV drip is to be discontinued. ORS is to be
kept in continuation

Nutritional management
Mother should be enlightened about benefits of nutrition
The child should be given regular formula milk
Easily digestible food should be selected
Small but frequent feeding is to be given
Well cooked rice, dal, bananas, fruit juice and small quantities of nutritionally rich food are to be given.

During convalescence
More food is given to restore and compensate the loss and promote early recovery.

Treatment of cause
Usually diarrhea (except for Shigella, Vibrio, E-coli, Entamoeba, Giardia) does not require any drug. (Most com-
mon cause of diarrhea in India is viral infection)
Symptomatic treatment is given if there is vomiting, abdominal distention, convulsion, etc.

Clinical Approach
For diagnosis—By signs and symptoms, nature of stool
Finding the cause—By laboratory investigation
Laboratory investigation is not essential for effective
management But essential for academic interest -
Naked eye examination of stool Reaction (pH) of stools
Blood—Electrolytes, osmolality ELISA
Test for presence of toxins
Microscopic examination for pus cells, red cells, cellular exudates, cysts, vegetative form and rotavirus
(Elec- tron microscopy).

Prevention
At home level
Proper washing of hands with soap and water before feeding and after toilet.
Good food hygiene and personal hygiene practices
Using potable, preferably boiled water
Clean utensils and containers are to be used for food and water
 Common Problems Faced in Public Health and Their
Solutions 203
Vegetables and fruits should be washed, cooked before being fed to the child
Protection of food from contamination with dust, flies, cockroaches, rodents during preparation, storage and at the
time of eating
Good water supply, adequate sewage and garbage disposal.
Avoid consumption of sweets, cut fruits kept open and sold in
roadside Clean the drinking watertank once in 15 day

At community level
Improving nutritional status of children
Routine immunization
IEC - Information, education, communication
Health, education and communication
a. To treat diarrhea at home by using home available fluids and ORS.
b. Environmental sanitation and food hygiene.
Promotion of exclusive breast feeding and proper weaning.
Primary health care approach–Child survival and safe motherhood (CSSM), ‘GOBI’ campaign of Unicef
Keep public water tap clean
Keep home and surroundings clean
Construction and use of sanitary latrines
Improving maternal nutrition and MCH care
Fly control measures
Periodic epidemiological surveillance of diarrhea.

14. A community health center of 100,000 population has conducted house to house survey for detecting
lameness (of the leg) among children aged 5 to 10 year. 200 children out of 1,000 children in that age
group are lame. How do you express the quantum of disease.
Solution:
Poliomyelitis lameness survey
Prevalence of lameness due to polio (Lameness rate-LR)
Number of lame children
LR = Number of children × 100
examined
20
=
1000  100
=2
Prevalence of residual paralysis due to polio = Prevalence of lameness due to polio (LR) × 1.25
= 2 × 1.25
= 2.5 per thousand
Prevalence of all clinical cases of poliomyelitis = Prevalence rate of residual paralysis × 1.33
= 2.5 × 1.33
= 3.3
Annual incidence of paralytic cases = Prevalence rate of residual paralysis × 1.25
= 2.5 × 1.25 = 3.12
204 Part III: Exercises (Problems and Their
Solutions)
Annual rate of poliomyelitis incidence in the population = Prevalence of lameness × 0.2
= 2 × 0.2 = 0.4
= Annual rate in children x 0.2

15. A Mother has brought her 2 year son with the following
complaints: Cough since 3 day
Fever—2 day
Not taking food or fluids—1 day
Sleepy—1 day
Difficulty in breathing since—6 hour
Convulsion—1 episode
On examination you will find
Wheezing and stridor
Indrawing of chest
Fever
Respiratory rate 60 per minute

How do you manage the illness of the child?

Solution:
On the basis of history and clinical presentation, child is diagnosed as having acute respiratory infection and clas-
sified as -

Very severe pneumonia based on the following signs

Not able to drink
Convulsions
Drowsy
Stridor
Wheezing
Child is treated according to the guidelines of World health organization (WHO)

Basic information collection

Name: Age: Sex:
Address: Details of earlier treatment (if taken):
 Common Problems Faced in Public Health and Their
Solutions 205
Identification of risk factors
Host factors Socio-environmental factors
H/o low birth weight Living area—Urban/Urban slum
Younger age Poor housing
H/o malnutrition Overcrowding
Immunization status Indoor smoke by coal/firewood use
Severe illness Tobacco smoked at home
Low socioeconomic status
Lack of education
Absence of health seeking behavior
Child attending any school/day care centers
Exposure to Industrial pollution
Climate

Epidemiological details
Any similar cases: At home/neighbourhood
H/o contact with similar case:
Duration between onset of symptoms and start of treatment:

Management
As the child is suffering from very severe disease, child is urgently referred to a well equipped hospital.

At subcenter
Before referring the case
First dose of antibiotic is given: Benzyl penicillin/Ampicillin/Chloromphenicol
Treatment for fever is given.
Oxygen and IV fluids if available.

At referral center
District hospital with pediatrician
Oxygen therapy
Symptomatic treatment for fever,
wheezing Intensive monitoring
Maintaining fluid—Electrolyte and nutrition
Chloromphenicol IM (drug of choice): 2.5 mg/kg/dose - 6th hourly
After 24 hour, if the condition improves oral chloromphenicol is given for 10 day
If condition does not improve, injection of cloxacillin and gentamicin is given

Preventive measures
Home level
Prevention of indoor smoke pollution
Better nutrition to the child
Immunization to the child
206 Part III: Exercises (Problems and Their
Solutions)
Improvement of living conditions
Developing early health seeking behavior
Teaching home management of acute respiratory infections

Community level
Health education activities
Prevention of air pollution
Better MCH care
Early detection and treatment
National programmes implementation
CSSM programme
Acute respiratory infection (ARI) control programme
Integrated management of neonatal and childhood infection (IMNCI)

16. In an antenatal clinic of the medical college hospital, a primi aged 21 year was found HIV positive.
Her husband works in Mumbai, and currently came home because of his illness. What measures do
you sug- gest?
Solution:
Referring the woman to Voluntary counseling and testing center (VCTC) where following help is
given. At counseling center:
Post-test counseling is done
Prepares the women psychologically to understand the situation
Enable her to take appropriate decisions regarding continuing pregnancy
Changing the risk behavior
Treatment and methods to reduce the risk of transmission to
child Encouraging her to tell her spouse
Advising her to attend followup counseling
Advise for CD4 count and lab services
Advising, about availability of treatment and supportive services for people living with HIV/AIDS (PL-
WHA).
Convincing the women to utilize all the available services.
Prompting the women to take anti-retroviral treatment for preventing the transmission of HIV to the yet to be
born child through Prevention of parent to child transmission (PPTCT).

Nevirapine
To baby—Within 72 hour of
birth To mother—At onset of
labor

Advice to mother
Decision on breast feeding
Safe sexual practices—Using condom (male or female—But both are not used simultaneously)
About BCG—Not given to offspring of HIV positive mother.
 Common Problems Faced in Public Health and Their
Solutions 207
Suggestion for husband
Attend voluntary counseling and testing center
Undergo pre-test and post-test counseling.
Safe sex practices

If test is positive
CD4 count is done
Advise to take treatment at ART
center Good nutrition and exercises
Healthy lifestyle
Early health seeking behavior even for minor illnesses
Safe sex practice
Encourage to tell spouse.

If test is negative
Information is given about staying negative
Undergoing test again after window period (if there is h/o recurrent exposure).

17. In a village, untrained dai conducted delivery on a primigravida. Baby, who was normal up to a week,
could not take feeds, developed convulsions, spasm of limbs. Discuss the problem and outline the man-
agement.
Solution:
From case history, it is understood that the baby is suffering from neonatal
tetanus. Information collected

Baby
Name: Age: Sex: Address:
Birth: Date: ,Time: , Place:
Person conducted delivery:

Mother:
Occupation
Education
Income
Ecological surroundings: Animals/Soil
Availability of health services
Health seeking behavior
Knowledge of infection
Antenatal care received:
Yes/No TT injections taken:
Yes/No Delivery practices
1. Application of cow dung to cord stump
2. Using unhygienic sharps to cut
3. Delivery by untrained person
208 Part III: Exercises (Problems and Their
Solutions)
Epidemiological information:
Neonatal tetanus in the district /1000 live births
TT coverage in pregnant mothers percent
Proportion of clean deliveries by trained person percent
Neonatal tetanus in male child
(Total number of cases in the district is considered to be twice the reported number of male cases)
Neonatal tetanus reporting (to the district medical officer) system in the hospitals.
Surveillance system at district level:

Classification of district according to risk of tetanus

Particulars Classification
High risk Control Low risk
Incidence of neonatal tetanus per 1000 live births >1 0.1–1 < 0.1
TT 2 dose coverage < 70% 70– > 90%
90%
Delivery by trained person < 50% 50– > 75%
75%

Management
The child is immediately admitted to district hospital/referral center for treatment.

Passive and active immunization

(Best given within 6 hour of birth)

Passive
Tetanus hyper immunoglobulin (TIG) 250 IU to 500 IU is given by IM route.
Tetanus antitoxin neutralizes the circulating toxins, but not the toxin already fixed to the nerve roots. Passive
protec- tion lost up to 30 day only.
If human TIG is not available
Antitetanus serum (ATS) given subcutaneously 1,500 IU after test
dose. It gives passive protection for 7 day

Active
Along with human hyper immunoglobulin
First dose of 0.5 ml tetanus toxoid is given to an other site.
6 week later, second dose of tetanus toxoid is given.
1 year later, third dose is given.

General Treatment and Supportive Measures

The child is nursed in well-lighted, (to observe the changes), but quiet room.
IM injections and handling of child is minimized as it will provocate spasm.
Maintenance of airway–sucking secretions, oxygen is given, if necessary.
Nutrition (oral feeding is stopped) intravenous/nasogastric tube feeding is given.
Fluid and electrolyte are maintained. Temperature maintained.
Control of spasm–diazepam IV 0.5 to 1 mg/kg every 3 to 4
hour. Antibiotic–penicillin.
Tracheostomy, assisted ventilation—if indicated.
 Common Problems Faced in Public Health and Their
Solutions 209
Prevention
Utilization of health services
Clean delivery practices—Institutional
Trained attendants
Providing home delivery kit
Educating pregnant women about clean delivery
• Clean hands • Clean blade
• Clean surface • Clean tie
• Clean cord care • No application to cord stump
Tetanus toxid to pregnant
women First dose: As early as
possible
At least 3 week before delivery (No pregnant mother should be deprived of at least 1 dose even if she
is seen late in pregnancy)
Tetanus toxoid 2 doses to all women of child bearing age at 1 month interval.

18. Postoperative cases developing tetanus, is reported in a district hospital. Give the guidelines to prevent
this problem.
Solution:
Data Collection
By visiting the hospital
Name and address of the hospital
Environment of the hospital - premises and surrounding area
Hospital policy
Waste disposal policy
Disinfection practices
Animals grazing around the hospital.

Examination of operative theater (OT)

Cleanliness of the room
Exposure to open field
Cleanliness of instruments, dressing materials
Sterilization/disinfection practices in the OT
Frequency of fumigation practices
Movement of persons inside the OT.

Tetanus Cases
How frequently postoperative tetanus is occurring.
How many cases had been reported the in the last 1 year?
Details of cases occurred in last 3 month:
Age: Socioeconomic class:
Sex: Operation undergone:
Occupation: Preoperative TT:
210 Part III: Exercises (Problems and Their
Solutions)
Duration between operation and occurrence of tetanus
Treatment given after development of tetanus
Total outcome

Prevention of postoperative tetanus

Immediate measures
• Closing the OT for few day
• Specimens (3–5) collected from different corners, are sent for microbiological examination and culture.
• Disinfection of OT: Formaldehyde fumigation by boiling formalin or pouring formaldehyde over
potassium permanganate crystals (potassium permanganate should not be put on formalin as explosion may
occur)
5 ounce of potassium permanganate, 10 + ounce of 40% formalin, diluted in water, is used for disinfecting
1,000 cubic feet of space
For this process, a pan or bucket is to be used
Fire generation equipment (electricity) is put
off
All openings, and cracks should be sealed with paper
Room is kept closed for 6 to 12 hour for effective
fumigation After fumigation, all doors and windows should
be open.
• After disinfection, specimens from different parts of OT are collected and sent for culture.

Ongoing Procedures
• Floor and walls of the OT are swabbed with carbolic acid daily and after each operation
• Thorough autoclaving of instruments used, and sterilization of dressing materials
• Disinfection of OT is supervised frequently and regularly
• Importance is given for preoperative preparation
• TT prophylaxis is given to all patients undergoing operation
• All aseptic procedures should be followed by OT staff
• Unnecessary entry to OT should be restricted. Sterilized and contaminated materials should not be
trans- ported in the same door, window, passage and lift
• Persons coming to visit postoperative patients must leave their footwears, and wear sterilized socks be-
fore entering into the ward
• Surrounding environment should be kept clean, animal grazing around hospital is prohibited
• If any postoperative case develops tetanus, thorough investigation should be done and corrective proce-
dures are to be adopted immediately.

19. You are posted to a PHC where tetanus is occurring freqently. How do you manage the
situation? Solution:

Baseline Information
PHC: Population coverage
Details about persons affected: Age, sex, occupation, education, social class, etc
Distribution of disease by time, place, person
Cultural practices in the area favoring tetanus.
 Common Problems Faced in Public Health and Their
Solutions 211
Management
Wound treatment
All injuries will be treated at PHC/SC
Proper cleaning of wound
Suturing, if necessary
Sterile dressing
TT prophylaxis

Delivery practices
Clean delivery practices (5 clean) by trained dai and PHC staff, under aseptic
precautions Institutional deliveries are encouraged.

Sterilization in hospitals
• Autoclaving of instruments
• Regular fumigation
• Sterile bandage.

TT immunization is advised for:

• Antenatal mothers—2 doses at pregnancy at 16 and 36 week, (1 dose, if subsequent pregnancy occurs
with- in 3 year. Even if the pregnant mother is not immunized, at least 1 dose is given 3 week before
delivery)
• Infants and children—routine immunization schedule
• Women of childbearing age
• Wound burns, ulcers, otorrhea, piles, nose pricking and any injury
• Tooth extraction, circumcision and other minor procedures
• People working with soil
• Patients recovered from tetanus
• Infant born to unimmunized mother—TT is given along with immunoglobulin within 6 hour of birth
and followed with regular immunization.

Regular immunization advice for all adults

0 Elected day
1 1 month after
2 6 month after
3 1 year
4 5 year

Active immunization
For all population

Passive immunization
For all exposed, but unimmunized cases
Anti-tetanus serum (ATS)-1,500 unit/human gammaglobulin 250–500 unit (TIG).
212 Part III: Exercises (Problems and Their
Solutions)
Health education
• Hygienic keeping of animals and animal shelter
• Preventing indiscriminate fouling of soil with human and animal excreta
• Avoiding playing, and walking in bare foot, in contaminated soil
• Avoiding smearing the wound with soil
• Treatment of wound should not be neglected
• Taking proper immunization
• Maintenance of menstrual and puerperal hygiene
• Avoiding unhygienic ear, nose pricking, branding, circumcision, tattoo, etc.
• Motivating deliveries by trained dai under aseptic conditions
• Reducing domesticated animals by replacing them with machines
• Reporting to the health authority regarding the disease.

Monitoring
Checking Antenatal care (ANC) registration/TT coverage
Supply of delivery kit and promotion of clean delivery practices
Undertaking health education activities for the community
Field monitoring: Wound management in hospital
Delivery conducted by trained dai
Tetanus sessions for ANC.

Surveillance

20. In an area of a city, many people including a pregnant women and a HIV person have been bitten by a
dog. As a medical officer, how will you manage the situation?
Solution:
Dog bite is considered as a serious public health problem. If timely treatment is not provided, dog bite victims
may die of Rabies. Death is certain in rabies.

Baseline data collection

Area details
Name of the area:
Population living:
Dog population:
Type of dogs present: Own/Street/Stray/other
Any incidence of wild animals attacking dogs:
Previous instances of dog bites:
Number of deaths occurred due to dog bite in the previous year:
Cultural practices for dog bite:
Treatment facility
available: Person bitten by dog
Name:
Age:
Sex:
 Common Problems Faced in Public Health and Their
Solutions 213
Previous history of dog bite: Duration Prophylaxis taken

Details of dog bite

Contact of animal: Lick on intact skin or broken skin or bite
Bite: Provoked/Non-provoked
Site of bites: Face, head, hands, others
Number of bites: Single/Multiple
Details of the incidence:
Depth of wound:
Intervention by clothing: Yes/no
Biting dog: Pet dog/street dog/others
Watching the dog for 10 day: Possible/Not possible
Immunization status of the dog: Immunized/Unimmunized/Unknown

Management of dog bite

Wound treatment
After dog bite, wound treatment must be done immediately or as early as possible
Washing of the wound by using soap and plenty of water (under running tap water is best), for at least 5 minute
Removal of dirt, foreign bodies is essential
Virucidal agents like povidone iodine, or antiseptics like Savlon or Dettol is to be applied to the cleaned wound
Suturing and dressing are generally avoided or postponed.

Classification of wound
Class Type of Contact Management
I Mouth contact, feeding, lick on intact None, if history is reliable
skin
II Nibbling of uncovered skin having Start rabies vaccination
minor scratch or abrasions without
Observe animal for 10 day. If animal is alive
bleeding
and healthy, vaccination is stopped
III Transdermal bites, lick on broken Rabies immunoglobulin + Vaccine
bleeding skin
Vaccine stopped, if animal remains healthy
after 10 day

Postexposure prophylaxis
• Tetanus toxoid
• Systemic antibiotic
• Rabies prophylaxis
As per WHO recommendations, the new generation of antirabies vaccine should be administered immediately to
persons of class II and III exposure.
Along with vaccine, Rabies immunoglobulin (RIG) is also given to class III exposure.

Vaccine Schedule
Day: 0, 3, 7, 14, 28
Route: IM at deltoid region
Dose: Same to all persons (independent of age, sex, body weight)
214 Part III: Exercises (Problems and Their
Solutions)
Rabies virus neutralizing antibody (RVNA) titer in the serum is estimated, which should be ≥ 0.5 IU/ml.
Protective value (0.5 IU/ml) is attained by 10 to 14 day, which last for 3 month.

Rabies immunoglobulin (RIG)

Indication
All bleeding bites (class III)
When animal is showing—rabid behavior or suspected rabid or laboratory confirmed rabies.

Immunoglobulin schedule
Rabies Immunoglobulin Preparation concentration Dose/kg body weight Maximal dose
per ml
HRIG 150 IU 20 IU 1500 IU
ERIG 300 IU 0.134 ml 10 ml

Administration
• Patient is admitted. Immunoglobulin (IG) is administered immediately or within 24 hour of bite
• Patient should not be in the empty stomach
• Emergency drugs and facilities for managing reactions must be available
• Test dose: 0.1 ml of ERIG (1:10 dilution in normal saline)
Injected intradermally into the flexor aspect of forearm raising 5 to 6
mm Test is taken as positive, if there is erythema of > 10 to 12 mm
Negative skin test is a green signal for giving full dose. Reaction to the dose may or may not appear later
• Using insulin syringe with 26 G needle, a large dose of Ig is injected to the edges and base of wound
with minimal trauma
• Systemic administration is of very little benefit, hence a large dose is given at wound site
• Not giving immunoglobulin (ERIGs/HRIGs) in class III bite amounts to medical negligence and the doctor
can be sued.
If person is sensitive to immunoglobulin:
• As an alternative, two additional doses of vaccine is to be given along with the regular schedule
First additional dose on 0 day
Second additional dose on 90th day
• Alternatively, patient is admitted to a specialized hospital. Immunoglobulin is to be given under
premedication If RIG is not given immediately (within 7 day of vaccine), additional dose of vaccine is
suggested.

Recognition of rabies in a dog

Observation of symptoms:
Profuse salivation Red eyes
Restlessness, aggressive Changes in bark
Hallucination Unprovoked attack on man and animals
Wrinkled forehead Biting unusual objects
Lab confirmation:
Animal inoculation Fluorescent antibody test
If animal is died or is killed, head should be sent for examination of negri bodies in brain.
 Common Problems Faced in Public Health and Their
Solutions 215
Control of disease in dogs
• Regular course of prophylactic antirabies (veterinary) vaccine to all pet dogs must be made compulsory
• Destruction of all ownerless dogs and restraint for all dogs in public places
• Owners are to be made legally responsible for damages done by their dogs
• Compulsory notification to everybody concerned with suspected rabies
• Registration, licensing and mass immunization of all dogs
• Muzzling and restraining dogs, wherever and whenever necessary
• Quarantine of imported animals till observation and certification is complete
• Health education—public awareness campaigns about animal bite, developing health-seeking behavior
• Discouraging faulty practices like applying tea/coffee powder on wounds, etc.
• Education about antiseptic management of the wound.

Preparedness to manage dog bite

Training medical and nursing staff, regarding proper management of animal bite
Keeping sufficient stock of antirabies vaccine and immunoglobulin.

Management of pregnant women

Same management holds good for pregnant mother
If pregnant mother develops rabies, if possible, induction of labor or cesarean section is advised
The obstetrician has to take immunoprophylaxis (5 doses of antirabies vaccine)
The new born has to be given 5 doses of antirabies vaccine as postoperative prophylaxis (Rabies virus is not
known to cross placental barrier).

Management of HIV person

On 0 day, two doses of vaccine is given at two different sites
On 90th day, two doses of vaccine is given again at two different
sites It is also recommended to give RIGs even for category II
exposure.

Advice to patient/attendant
• Take complete and timely treatment
• No contraindications for rabies vaccine
• Avoid steroids, chloroquine, and immunosuppressive drugs
• Avoid physical and mental strain, and late nights
• Report immediately in case of fever, pain, stiffness in neck and limbs
• People are informed about and encouraged to seek treatment for all dog bites, even if it is by a small pup
• There is no secondary prevention, except ensuring a comfortable death.

21. A boy of 7 year was brought to you with history of dog bite on the hand and fingers with bleeding, 2 hour
back. How do you manage this case as a medical officer?
Solution:

Taking history in detail

Name, age, address, locality
Time and place of bite
216 Part III: Exercises (Problems and Their
Solutions)
Type of dog: Pet, street, domestic, stray,
wild Other persons bitten by the same dog
Provoked or unprovoked bite
Possibility of watching the bitten dog for 10 day
Animal showing signs of rabies.

Wound details
Site of wound, distance from the brain
Type of Bite—Superficial, deep or mere lick
Number of bites
Bite—Bare skin or interposing cloth.

Classification of bite
As bite is on hand and fingers, bite is considered as class III bite.

Management
Wound management
Antibiotics and tetanus toxoid: To prevent infection and
tetanus Antirabies immunoprophylaxis
Watching the dog for 10 day.

Wound management

Aim
Removal and destruction of rabies virus in the wound
To remove the saliva remains, dirt and foreign bodies

Methods adopted
Physical
Chemical
Immunological.

Physical
Wound treatment is of paramount
importance Wound treatment is given as
early as possible Wound is cleaned
Flushing and washing the wound and adjoining area with plenty of soap and water, under running tap water for at
least 5 minute
Punctured wound is irrigated by using catheters.

Chemical
To inactivate remaining virus, following chemicals are used-
Tincture
Iodine
Povidine iodine } 0.01%
 Common Problems Faced in Public Health and Their
Solutions 217
To inactivate/destroy remaining virus in the wound spirit, alcohol tincture iodine can be used as they act by
dissolv- ing the lipid membrane of the virus.
Quaternary ammonium compounds like Savlon Cetavlon should not be used. Cauterization by using
carbolic/nitric acid should not be done.
Suturing causes further trauma, and helps in spread of virus into deeper tissues. Hence, suturing should not be done
immediately. If necessary, suturing is done after 48 hour of applying immunoglobulin.
Bandage: Wound is left open, unbandaged.

Immunological: Immunoglobulin
Immunoglobulin is the best prophylaxis for rabies exposure
Prevents the replication of virus
Prolongs the incubation period
Given after sensitivity test
Complete protection is ensured only by giving immunoglobulins immediately after exposure, followed by
complete course of vaccine.

Passive immunization
Immunoglobulin schedule
Rabies Immunoglobulin Preparation concentration Dose/kg body weight Maximal dose
per ml

HRIG 150 IU 20 IU 1500 IU

ERIG 300 IU 0.134 ml 10 ml
HRIG - Human rabies immunoglobulin, ERIG-Equine rabies immunoglobulin
Major part of the dose is administered around the wound as palm and finger bite is class III bite. Rest is injected
intramuscularly to the gluteal region.

Active immunization
Cell cultured vaccine like purified inactivated duck embryo vaccine (PDEV) or human diploid cell vaccine
(HDCV) or purified chick embryo vaccine (PCEV), purified vero cell cultured vaccine (PVCV) is used
Vaccine is given as prophylactic, prevents establishment of virus in peripheral
nerve Intramuscular injections are given to deltoid region not to gluteal region .
Dose—0.5 to 1 ml Schedule
—0, 3, 7, 14, 28, 90

Advice to patient/attendant
Take complete treatment timely
Avoid steroid, chloroquin, and immunosuppressive
drugs Avoid physical and mental strain and late nights
Report immediately in case of fever, pain, stiffness in neck and limbs
People are educated to seek treatment for all dog bites, even if it is a small pup.
There is no secondary prevention, except ensuring a comfortable death.
218 Part III: Exercises (Problems and Their
Solutions)
22. Problem of dog bite incidences are increased in a city. As a municipal medical officer, what measures will
you undertake to prevent the problem
Solution:
Dog bite is considered as a serious health problem because dog bite victims may develop rabies and die.

Baseline data collection

Place
Name and address of the city:
Population living:
Dog population:
Type of dogs present: Owned/Street/Stray/Migrated/Others
Any incidence of wild animals biting the dogs
Previous instances of dog bite
Number of deaths occurred due to rabies:
Cultural practices for dog bite
Number of dog specimens sent for laboratory examination:
Number of specimens positive for rabies:

Person
Person bitten by dog: Name, age, sex, occupation and previous history of dog bite/prophylaxis

Time
Time of bite: Morning/Evening/Night
Place of bite: Busy place/Dark place/Lonely place
Circumstantialities: Irritating/provocating/stone throwing on dog/carrying food/giving food to dog.

Bite details
Type of dog: Pet/Street
Immunization status of dog:
Type of contact: Lick on intact/Broken
skin Site of bite: Face, Head, Hands, Leg,
Other Number of bites: Single/Multiple
Depth of wound:
Intervention by clothing:
H/o same dog biting others:
Possibility of watching the dog for 10 day:

Information collected from healthcare providers

Number of dog bite cases attended by the doctor
Management of dog bite—details
Availability of antirabies serum, vaccine, antibiotics, tetanus toxoid, etc.

Providing standard guidelines for postexposure prophylaxis

• Prompt and adequate wound treatment
 Common Problems Faced in Public Health and Their
Solutions 219
• Administration of tetanus toxoid and antibiotics
• Categorization of dog bite
• Local and systemic administration of immunoglobulins
• Administration of antirabies vaccine
• Giving advices to the patient.

Preparedness
• Conducting meeting of all health staff
• Training the medical and paramedical persons in dog bite management
• Keeping veterinary vaccines stock in veterinary hospitals
• Keeping and indenting sufficient stock of vaccine, immunoglobulin, emergency drugs and others
• All medicals shops are requested to keep all vaccines and drugs required to treat dog bite
• Identification and reporting about stray dogs
• Sending specimens (dog head) for laboratory examination.

Creating public awareness

Through mass media: TV, newspaper, handouts,
announcement Removal of fear in the panic stricken
population
Advice for seeking immediate treatment for dog bite
Immediate management of wound
Identification of stray dogs/dog bite incidences and reporting
Not touching dog saliva, or dog bitten socks, shoes, wounds, etc.
Not applying mud, coffee powder, etc. to the wound
Not setting the life in risk by taking unscientific treatment from the traditional healer
Awareness regarding seriousness of the dog bite.

Education to children
Do not give food to stray dogs
Do not provacate/irritate/throw stones on the dogs
Keep away from dogs
Do not hide dog bite from members of family.

Control of rabies in dogs

• System of licensing and putting badge on the neck coller of pet dogs is to be made compulsory
• Quarantine of imported dogs and other animals till necessary and certification is done
• Regular vaccination to the dogs
• Pet dogs should not be allowed to mingle with stray and street dogs
• If pet dog is bitten by any other dog, immediate treatment and vaccination is to be provided to the dog
• Owners are made legally responsible for bite/damages by their dogs
• Prevent the wild animals from entering into the human dwelling places
• Arrangements to be made to vaccinate forest animals by expert
• Muzzling and restraining in dogs
• Destruction of ownerless stray dogs (painless killing, subject to legal, ethical bindings)
220 Part III: Exercises (Problems and Their
Solutions)
• Isolation of suspected dogs and they should be kept under supervision
• Catching and keeping stray dogs in temporary sheds for some time
• Dogs which are caught or kept under supervision should be vaccinated. Male dogs are to be
sterilized (vasectomy) and handed over to the needed person or left back.

Community activity
Cooperation, involvement, participation of the community with the civil authorities in controlling dog bite and
rabies problem.

Surveillance
By veterinary experts
By public health experts.

23. On March 20th 2009, an outbreak of A/H1N1 influenza occurred in Mexico. By 29th April
neighboring nine countries have reported 148 confirmed cases including seven deaths. WHO has
declared it as pan- demic imminent (phase 5). Outline the measures to be taken in the country.
Solution:
India is a influenza A/H1N1 receptive area
Population of the country is susceptible to A/H1N1 virus
Infection can enter through clinical/subclinical travelers
International health regulations of WHO are adopted to restrict the entry and spread of infection
Strict aerial and marine traffic regulation is undertaken.

Regulations for travelers

Restriction of travel in close borders
Examination of all travelers from affected countries
Quarantine for longest incubation period for such travelers
If any infected case is noticed, all the copassengers and their contacts should be traced and examined for the dis-
ease.

Outbreak response and pandemic preparedness plans

Identification of hospitals for treatment
Reserving beds for isolation of patient in government, private hospitals
Utilization of doctors specialized in treating chest infections
Arrangements for sufficient drugs, equipment, manpower, transport, communication, etc.
Notification of disease
Request for national and international assistance and support
Containment for affected country. Alert phase to other countries
Detaining high-risk population.

Early detection and treatment

Screening of all travelers at airport
Cotravelers of the suspects are identified and screened.
 Common Problems Faced in Public Health and Their
Solutions 221
Defining the disease
Individuals with positive test for influenza A/H1N1
Clinical compatible illness or having died with unexplained acute respiratory illness linked to be probable or con-
firmed case.

Clinical description
Acute febrile (> 38 0c) respiratory illness, ranging from influenza like illness to pneumonia.

Laboratory confirmation
Sample has to be flown by air to National Institute of Virology (NIV), Pune or National Institute of Communicable
Diseases (NICD), Delhi.
Confirmation tests:
Real time RT-
PCR Viral culture
Four-fold increase in swine influenza (A/H1N1) virus neutralizing antibodies

Case management
Isolation
Drug (treatment): Tamiflu—Recommended only for confirmed cases
In non-confirmed cases: Tamiflu is not administered, as the drug has serious side
effects Every case of influenza or pneumonia is rigorously isolated
Rapid containment measures are adopted
Reviewing and revising pandemic plans by periodic comprehensive assessment
Vaccination: No vaccine available, human seasonal flu vaccine will not give any protection.

Assessment of situation
Rapid but detailed investigation by epidemiological experts
Assessment of disease: Virological, epidemiological,
clinical Geographic analysis: Trend, spread, intensity,
impact.

Health education, awareness and advice

Given throughout the country through mass media
Reassurance and relieving anxiety is essential as people will be panic during the pandemic
Preventing exposure to pigs and infected humans
Do not shake hands, hug or kiss socially
Do not practice indiscriminate spitting, coughing, sneezing, hawking in public places
Cover mouth and nose with handkerchief while talking, coughing or sneezing
Wash hands frequently, thoroughly with soap and water, before and after touching nose, mouth,
eyes Avoid overcrowded places
Work, sleep in a ventilated room
Drink potable water, eat nutritious food, manage stress, avoid alcohol
Stay at home and limit contact with people
Use close woven muslin gauze of three to six layers mask which is compulsory for family members of the person
affected. Volunteers, medical personnel and others who come in contact with the sick must use mask (N 95
particu- late filter)
222 Part III: Exercises (Problems and Their
Solutions)
Do not take drugs (medicines) without consulting physician
If necessary, schools, offices, etc may be closed to limit the gathering.

Monitoring and surveillance

Routine surveillance for Influenza like illness (ILI) and Severe acute respiratory illness (SARI)
Changes in phases of pandemic
Strong surveillance system to prevent the disease entry.

24. In a rural primary school, large number of children are having Bitot’s spots. What advice can you give
for managing the problem?
Solution:
Bitot’s spot denotes vitamin ‘A’ deficiency.
Managing steps are the following.

Immediate measures
Early diagnosis and treatment.

Diagnosis
All children of the school are examined for the evidence of Bitot’s spots and other manifestations of vitamin ‘A’
deficiency.

Treatment
Immediately after diagnosis:
Massive dose of vitamin ‘A’ (2 lakh IU > 1 yr, 1 lakh IU < 1 yr) is given
One more dose is given 4 week later.

Long term measures

Health promotion
Promotion of vitamin ‘A’ rich foods
Regular and adequate intake of retinol/vitamin ‘A’ rich foods like dark green leafy vegetables, carrot, drumstick
leaves, mango, papaya, milk, egg, butter, oil, fish, etc. Children require 400 to 600 µg of vitamin A per day
Promotion of breast feeding
Control of infections (that precipitates vitamin A deficiency) like
Respiratory infections
Measles
Diarrhea.

Specific protection
To prevent occurrence and recurrence of vitamin ‘A’ deficiency, vitamin ‘A’ prophylaxis is given
 Common Problems Faced in Public Health and Their
Solutions 223
National vitamin ‘a’ prophylaxis (under
CSSM) Schedule
Dose number Age (month) Oral dose (IU)
1 9 100,000
2 18 200,000
3 24 200,000
4 30 200,000
5 36 200,000
Every child between 9 month and 3 year of age is given vitamin A prophylaxis
Recently, prophylaxis has been extended up to the age of 5 year and given every 6 month
One spoon of 2 ml concentrate contains 2 lakh IU (equivalent to 100 mg of retinol palmate)
Once the bottle is opened, it is to be utilized within 2 month
Fortification: Fortification of oil, dalda, atta, sugar with vitamin ‘A’
Nutritional education: To school children and the community
Socioeconomic and educational developments
Evaluation of the program.

25. Poor anemic women of gravida 3, and in third trimester of pregnancy has attended PHC for the first
time. Her Hb is 7.5 gm/dl, weight is 50 kg. How do you manage?
Solution:
From the case history, we can recognize following risk factors.
Severe anemia Poverty, lack of
nutrition
Multigravida Lack of health-seeking
behavior. Not taken antenatal care

Investigations for the cause of anemia

History:
Cause of blood loss:
Diet practice
Lab investigations:
Stools: For hookworm
Occult blood
Blood: Complete hemogram

Management
Pregnant mother should have minimum 12 gm/dl of hemoglobin.
Here women is having only 7.5 gm/dl
Anemia should be corrected immediately by parental iron therapy.
224 Part III: Exercises (Problems and Their
Solutions)
Treatment plan
Hb Severity of Anemia Treatment
< 10 g/dl High Parenteral iron or
Blood transmission
10-12 Low Oral iron supplementation
gm/dl

Calculation of iron requirement in mg

= Normal Hb - patient Hb x weight in kg x 2.21 + 1000
= (12 gm/dl - 7.5) × 50 × 2.21 + 1000
= 4.5 × 50 × 2.21 + 1000
= 497.25 + 1000
= 1497.25 mg, to round up 1500 mg
Iron requirement is 1,500 mg
Inferon (100 mg) is given IM daily for 15 day
Oral treatment is continued for 3 month after Hb has returned to normal
Assessment of hemoglobin periodically.

Preventive measures
Woman is advised to take more iron-rich foods: Leafy vegetables
Advised to attend supplementary feeding programme, at Anganwadi (ICDS)
Advised to take antenatal care
Health education regarding anemia
Improvement of socioeconomical problems
Advised for institutional delivery
Advised to undergo tubectomy.

26. In a subcenter of 5,000 population, ASHA has registered 80 antenatal women.

Particulars are as follows
30 women are in third trimester
36 women are in second trimester
14 women are in first trimester
6 women are in fourth gravida - having three living
children 30 women are anemic
3 women are short (< 140 cm height).
How will you organize antenatal services under the CSSM program?
Solution:
Antenatal care is to be given to all (80) pregnant mothers -
1. Regular antenatal checkups: Physical examination,
Laboratory tests

Antenatal examination
General: Built BP
Nourishment Height
 Common Problems Faced in Public Health and Their
Solutions 225
Anemia Weight
Edema Breasts
Systemic: CVS, RS, CNS, alimentary, genitourinary
systems Abdominal: Position
Presentation
Fetal heart sounds
Investigations: Blood: Hb% Urine: Albumin
VDRL Sugar
Rh typing Microscopy
HBsAg and HIV Stool: Ova
Cyst
2. 100% coverage of 2 doses of TT at 1 month interval
3. 100% coverage with 100 tablets of iron and folic acid
4. Identification of high-risk group and special attention is given to provide skilled care. If necessary, referred to
higher centers.
5. Advise about diet, hygiene, rest, exercise, habits, sexual act, warning signs, child care, mental preparation and
family planning.
Emphasis is given for clean delivery—Clean hands, clean surface, clean cord, clean tie, clean blade and
avoid- ing harmful practices.
Selection of institutional delivery where midwifery kits, sterile instruments and skilled attendants are avail-
able. In case of home delivery, use of disposal delivery kits is advocated.
Selection of trained dai for conducting delivery.

For 6 women who are of fourth gravida and having 3 living children:
Those six women are considered as improvident maternity (having 3 children and again pregnant). They are con-
sidered as risk group -
• Risk approach is chosen for management
• Mothers are advised to attend first referral centers for delivery
• Advised to undergo tubectomy.

For 30 women in third trimester

Monitored for development of
Complications like - Pre-eclamptic toxaemia (PET), antepartum hemorrhage (APH), cephalopelvic
dispropor- tion (CPD), malpresentation, etc.
If any risk factors identified they are referred to higher centers.
If there is no risk factors, providing proper antenatal care is to be continued, directions are given for safe de-
livery. Psychological support is essential.

For 30 anemic women

• Therapeutic dose of iron folic acid tablets - 2 tablets daily for 100 day
• If anemia is severe, then parenteral iron is given
• Blood transfusion is given if necessary. Mothers are best treated at referral center.
226 Part III: Exercises (Problems and Their
Solutions)
For 3 short stature women
These women may develop Cepharopelvic disproportion (CPD) during delivery, may need Lower segment
cesarian section (LSCS). Hence, referred to centers where specialty is available.

27. In a village of 4000 population, all 580 eligible couples are registered. How will you provide health ser-
vices to them under the RCH program?
Solution:

Organization of RCH services

Eligible couple: Married women of reproductive age group (15-45 year)
Target couple: Eligible couples having two or more children
(National average of ‘eligible - couple’ is 150–180/1000 population)
Categorization of eligible couples -
Category 1: With two or more children (priority group—target
couple) Category 2: With one child
Category 3: With no child

For category 1
Permanent family planning methods advised
For women : Tubectomy by minilap method
Laparoscope sterilization
For male (husband) : Vasectomy by no scalpel method.

For category 2
Spacing methods are advised
Condom
Copper T
Oral pills (if not lactating)
Safe period (in educated women)
Female condom

For pregnant and lactating

mothers Pregnant mothers
Antenatal examination monthly
Minimum of three visits at 20, 32 and 36 week
Early detection of risk factors/complications and management
Referral services if necessary
Relieving the anxiety and preparing mentally
Iron and folic acid supplementation (100 mg elemental iron, 500 mcg folic acid tablets) daily for 100 day.
Immunization against tetanus
First dose : 16 to 20 week
Second dose : 20 to 24 week
 Common Problems Faced in Public Health and Their
Solutions 227
Parental advise:
Nutrition, child care, family planning, self care, safe delivery
Environmental sanitation, safe water ORS, etc.
Motivation for
Hospital delivery
Using safe delivery—five cleans
Using Disposable delivery kit (DDK)
Using trained birth attendants service

For postnatal mother:

Examination of mother by obstetrician
Examination of child by pediatrician
Attention given to postnatal complication:
• Puerperal sepsis
• Thrombophlebitis
• Secondary hemorrhage
• Mastitis, urinary tract infections
Restoration of mother’s health:
Health check-up Once in a month during first 6 month
Once in 2 to 3 month till the end of one year
Treatment of anemia
Advice for Nutrition
Exercises
Psychosocial support

Postnatal education
Growth monitoring
Oral rehydration
Breast feeding
Immunization
Family planning—birth spacing
Women are advised to utilize services provided under various programmes.
1) Baby friendly hospital initiative (BFHI)
2) Anganwadi centers

For childless women

Fertility advices

For all women

PAP smear examination at least once in 3
year Screening and treatment for STI
Antiretroviral therapy for HIV affected mother under
PPTCT Sex education/parenthood education
228 Part III: Exercises (Problems and Their
Solutions)
Counseling: Genetic
Premarital
Marriage
HIV
Services for unmarried mothers
Medical termination of pregnancy (MTP) services.

28. You are posted as medical officer to a primary health center covering 25,000 population. How do you
organize and provide health services.
Solution:
Health services provided in PHC
Curative services: Treatment of health problems related to -
Medical
Minor surgical
Obstetrical
Pediatric
Other emergency services
Preventive and promotive services
Maternal and child health (MCH) Family planning
School health services Environmental sanitation
Potable water supply Health education
Surveillance of communicable diseases Preventive services like immunization
Prevention of communicable diseases and non-communicable diseases
Other activities: Containment of locally endemic and epidemic diseases
Active participation in implementation of national health programmes
Record maintaining: Collection and reporting required data
Laboratory services:
Sputum—TB Stools—Ova and Cyst
Blood—Hb, PBS, FBS Urine—Albumin, sugar, microscopy
Referral services:

Organisation of health services

Morning 9 to 12 noon and OPD and inpatient services
Evening 4 to 6 pm
After noon: Visiting and supervising field work
Night: Emergency services and conducting deliveries.
On fixed dates on rotation: Visiting subcenters of PHC area
Prefixed day in a month: Monthly meeting with all staff
Reviewing the progress
Discussion of problems and finding solutions
Developing coordination with health team.
 Common Problems Faced in Public Health and Their
Solutions 229
Training: Training of health workers—Dais, ANM, ASHA and
others Other activities: Planning for implementation of health
programs
Anganwadi visit
Visit to schools
Family planning camps
Health education activities
Clinics on specified day: Immunization at PHC and subcenters
Antenatal checkup
Other clinics
Co-ordination and participation: NGO, village leaders, mahila mandals, community and departments concerned
with the health

29. In a school, 8 children are suffering from severe sore throat and fever. How do you investigate and
man- age the situation?

Solution:
Above situation suggests the possibility of rheumatic fever in school children.

Investigation
Collection of basic information
By visiting the school
List of school children by age and sex

Identification of risk factors

Age: 5 to15 year
Poor socioeconomic status
Poor living condition: Slum, closed community
Presence of overcrowding
Absence of expertise health providers
Lack of awareness
Lack of health-seeking behavior.

Clinical history and examination of all school children

1. Fever for long duration with profuse sweating
2. Joint pain in: Knee, ankle, elbow, wrist
3. Pain coming spontaneously and subsiding quickly.
4. Cardiac changes:
ECG changes—first degree AV block Cardiac enlargement
Tachycardia Pericarditis
Cardiac murmurs Cardiac failure
5. Nodules: Small, painless, non-tender nodules below the
skin. Nodules appear and disappear.
230 Part III: Exercises (Problems and Their
Solutions)
Laboratory examination
Throat swab for
Grams stain
Culture

Diagnosis
Presence of two major manifestations of Jones criteria
or
One major + Two minor criteria + Evidence of Group A streptococcal infection.
Major criteria Carditis Erythema marginatum
Polyarthritis Subcutaneous nodules
Chorea
Minor criteria Fever
Polyarthralgia
Elevated ESR
Supporting evidence ECG Prolonged PR interval
Elevated antistreptolysin-O
Positive throat culture

Management
Primary prevention Single IM injection 12 lakh unit (6 lakh unit for children) of Benzathine Penicillin
(to prevent the first attack)
Secondary prevention Benzathine penicillin 12 lakh unit (6 lakh unit for children) once in a month
(to prevent recurrence) For at least 5 year or until child reaches 18 year whichever is later
If there is second attack, prophylaxis is for life time
Erythromycin prophylaxis (If person is allergic to
penicillin).
Preventive measures
• Improving the living standard
• Periodic throat swab culture examination of school children for early diagnosis and treatment
• Prevention of recurrence by penicillin prophylaxis.

Surveillance
Periodic surveillance of school age (5 to 14 year) children at schools and slums at 5 year interval.

30. In a metro city of 10 lakh population, police records showed 450 two wheeler accidents during the year
2010. The affected being mostly-medical student. Discuss how you investigate and find the solution.
Solution:
Baseline data collection
Number of two wheelers in the town
Number of two wheelers with medical student
Number of two wheelers met with accident
Details about the accident
Study of accidents by time, place and person
 Common Problems Faced in Public Health and Their
Solutions 231
Place of accidents
Road condition Procession/obstruction in road
Road defects Cyclist, children and animal movement on road
Very narrow roads Lack of familiarity
Excess of traffic Bad illumination
Curves
Lack of speed breakers

Person met with accident

Age Defective and delay in decision
Sex Accident proneness excess speed
Ill health Poor driving standards
Defect in vision, hearing Risk behavior: Fantasy, impulsive, aggressiveness, emotional
tension Poor Psychological status Poor perception
Lack of sleep, fatigue Family/personal problems
Influence of medicine, drug, alcohol Social pressure
Sudden ill health like epilepsy/Myocardial infarction (MI)

Time of accident
Month, week, day, time.

Environment
Fog, rain, natural calamities and sudden damage of roads
Excess heat or cold.

Vehicle involved in
accident Condition of
vehicle Maintenance of
vehicle Break, tier, signals
Safety device

Social factors
Trend of license
issuing Supervision by
parents Traffic
control/Signals
Use of protective device/Safety devices
Enforcement of law.
232 Part III: Exercises (Problems and Their
Solutions)
Measurement of the problem
Number of deaths due to
Proportional
accident mortality = × 1000
Total deaths

Accident rate per 1000 two Number of two wheeler × 1000

 accident Total number of two
wheelers
wheelers

Identification of factors involved in the accident

Human, vehicle and environmental factors.

Prevention
General measures
• Accident prevention education
• Improvement of roads
• Application of all road safety measures, improvement of road conditions/signals
• Proper control on traffic
• Supervision by the elder
• Engineering measure to make safe vehicles
• Survey and research on road accidents
• Notification
• Celebrating awareness campaign like Road safety week.

Medical measures
• Providing medical care:
Mobile van like suraksha kavacha (phone–108)
Emergency transport services
• Periodic counseling and behavioral modification
• Training medical and paramedical staff in first aid resuscitation and trauma care.

Legal measures
1. Licensing regulation 5. Timely inspection of vehicles for road fitness
2. Limiting the speed 6. Prohibition of driving after alcohol
3. Separation of fast/slow tracks 7. Prohibiting animals in road.
4. Use of protective device like helmet

31. Many villages near the river bank are affected by flood. Medical college is sending your team to that
area. Explain the measures that you undertake.
Solution:
Identification of affected area and those likely to be affected one
Estimating the magnitude of the problem.

Measures undertaken to reduce and modify the flood hazards

Structural: By engineering and technological measures by expert
To prevent flood water reaching the dwelling places
 Common Problems Faced in Public Health and Their
Solutions 233
Non-structural: To minimize the damages, deaths, illness and other
hazards Protection of affected population.

Emergency measures
• Rapid identification of the affected population
• Triage of victims
• Providing appropriate treatment
• Transporting the critically ill persons to the higher centers.

Mitigation of population affected

Evacuation of people to safer places
Raising temporary shelters above the flood level with minimum facilities for affected persons and cattle
Arrangements for safe water, wholesome food supply
Providing facility for waste disposal and basic sanitation
Fly, mosquito proofing the shelters
Regular insecticide sprays to destroy flies and mosquitoes
Distribution of chlorine tablet/bleaching powder.

Preparedness
• Estimation and procurement of the requirements for drug, disinfectants, vaccine, etc.
• Arrangement for extra manpower—doctors, paramedical staff, volunteer
• Sufficient drugs, vaccine, stretchers for transport of sick persons
• Establishment of treatment center, medical stores, mobile camps, control room, etc.
• Setting of police outpost
• Stocking of flood relief materials
• Establishment of rehabilitation center
• Publicity of precautionary measures and availability of health and other services.
• Health education through media like radio, TV, pamphlets, newspaper about
Personal hygiene
Safe food consumption
Safe drinking water consumption
Disinfection of water at sources and distribution points
At home-
By boiling the water for 10 to 15 minute and stored in covered container
Adding chlorine tab 2.5 mg/liter
Bleaching powder 22% —40 gm
Residual chlorine should be at least 0.5 ppm.

Medical measures
Arrangements are made to manage the possible medical problems like -
Drowning Water-borne infection
Respiratory infections Cardiac arrest
234 Part III: Exercises (Problems and Their
Solutions)
Hypothermia Psychological disturbances
Injuries, wound infection Vector-borne diseases
Dermatitis Rodent-borne diseases
Conjunctivitis Electrocution
Gastrointestinal infection Snake bite, scorpion sting
ENT infection Chemical effects

Non-medical measures
Provision of clothing, bedding and other essentials
Protection from bad climate
Transport facilities to transport critically ill persons to higher level referral centers
Communication facilities.

Epidemiological measures
Setting up epidemiological unit
Investigation of diseases occurring and spreading
Defining the disease
Identification of affected population/area/person
Finding the source and spread
Isolation of the source
Early diagnosis and treatment
Immediate preventive measures
Health check up giving more attention to high-risk group
Immunization: Specific immunization for vulnerable
group Nutrient supplementation.

Management
A senior medical officer/officer having special skill will be identified for exclusively tackling the flood situation
Delegation of work and coordination in the group
Meetings of health personnel periodically to review the situation and developing skills in management.

Close surveillance/monitoring
Collection, analysis of information
Identifying the trends, impending epidemic
Periodical and frequent supervision
Monitoring of drinking water
Feedback information
Strengthening the reporting system.

Preventive (long term) measures

• Establishment of flood relief cell to take anticipatory, preventive measures
• Office—for coordination and monitoring
• Training of health personnel regarding flood management
 Common Problems Faced in Public Health and Their
Solutions 235
• Surveillance team consisting bacteriologist
• Structural measures to prevent the occurrence of flood
• Zoning (identifying) flood-prone areas
• Developing flood forecasting and warning system
• Flood insurance
• Flood preparedness during pre-monsoon time
• Stocking of relief material
• Coordination of National, International and State Government in flood control activities
• Preparation and distribution of model action plan
• Public education regarding floods.

32. A large number of adults are affected by a disease. Number of persons affected is clearly in excess than
usual expectation. How will you investigate and control the situation?
Solution:
Same disease occurring in excess than usual means, it is an epidemic. Epidemic is to be investigated.

Investigation of an epidemic
(Same procedures holds good for any epidemic)

Objectives of investigation
• To detect the magnitude of the epidemic
• To know the distribution by time, place, person
• To identify the agent, host, environment factors responsible for the condition
• To find out the measures to control and halt the epidemic
• To reduce mortality, and morbidity
• Protection of population
• Prevention of further recurrence
• To gain the knowledge essential to control any epidemic elsewhere.

Baseline data
Collected by visiting the place
Name of the place/area:
State: District:
Total population:
Health services available:
Communication available:
Detailed geographic map:
Other relevant details:

Resources required
Man power:
Investigator Local person Entomologist
Team leader Lay public Statistician
236 Part III: Exercises (Problems and Their
Solutions)
Supervisor Media person Environmentalist
Public relation officer Lab technician Veterinarian
Material: Stationary, computers, vehicles, drugs, etc.
Money: To meet the expenses

Step-by-step approach
Defining the case
Clinical criteria is given preference over laboratory reports.

Confirmation of the diagnosis

By studying a small representative sample
Symptoms and signs
Combination of signs and symptoms
Clinical and laboratory examinations
Knowledge gained in earlier experiences
Collateral, reliable information.

Confirmation of existence of epidemic

A large number being affected in specified time and area
Affected having same or similar complaints
Cases exceeding than the earlier recorded (reliable) level at same time.

Identification of the risk population

Collection of relevant information

Factors disturbing the equilibrium between agent - host and environment
Environmental changes : Cold/hot wave, air pollution, industrial pollution
Unusual changes in : Water source, water treatment, food sources, agricultural activity, vector/rodent
density Population mobility : Mela, pilgrimage, local events, migration, etc.
Discussion about the disease
Is the disease endemic?
Is it introduced from outside?
Is it totally new?

Rapid and systematic survey on affected population

(Using especially designed schedules)
A. Base line data: Age, sex, occupation, social status, etc.
B. Case-history (previous 7 day)
Places visited
Places where food/water taken in details
Contact with similar cases, where when
Similar illness in family/neighbourhood
Bite by vector, animal
 Common Problems Faced in Public Health and Their
Solutions 237
C. Sanitary survey:
Water: At source
At treatment
At transport
At home
D. Clinical history:
Date, time, place of onset of symptoms
Clinical manifestations
1. 6.
2. 7.
3. 8.
4. 9.
5. 10.
Treatment details (if taken)
E. Laboratory tests
Specimen Date and time of collection Report

Outcome of cases: Recovered/Died

If died: Date and time of death
Is death attended by doctor:
Yes/No Postmortem report:

Analysis of data
In context to place, person, and time
Place
Current geographical map of the locality showing wards, houses, roads, water supply, milk distribution, animal,
inhabitation, drainage system, etc. is used for plotting the cases.
Localities Affected/Not affected
Area of Low/High/Nil/Affected
Geographic spread: Spreading/Not spreading
Type of spread Centrifugal
Linear
Other
Place where person became ill Place of residence
Place of occupation
Other
238 Part III: Exercises (Problems and Their
Solutions)
Time
Plotting the graph (epidemic curve)
Number of cases against time of occurrence
Sudden rise-Sudden fall
Sudden rise-Gradual fall
Gradual rise-Gradual fall

Person
Characteristic of persons affected
Age, sex, race, religion, any sub group population
Nutrition, diet habits
Personal hygiene
Occupation
Socioeconomic class
Length of stay
Migration
Closed community

Number of cases in specified

Finding
group the attack rate = × 100
Number of persons in same group

Number of cases died

Case fatality = Number of persons × 100
affected
Frequent efforts are made to know the changes (progression and regression of epidemic in relation to time, place,
person).

Formulation of tentative hypotheses (based upon the information collected)

Explaining
1. Epidemic behavior of the disease
2. Circumstances leading to the epidemic - cause and association.
3. Association between attack rate among exposed - not exposed
4. Different variables
5. Occurrence of unusual case
By:

Review of findings
Clinical
Laboratory results
Epidemiological features
Review of the existing literature
 Common Problems Faced in Public Health and Their
Solutions 239
Confirmation of hypothesis
Exposure illness present illness absent
Yes a b
No c d
a
Exposure rate among cases =
a+c
b
Exposure rate among controls =
b+d
a
If
b
a + > b + d = Accept the hypothesis
c
a b
If < b + d = Reject the hypothesis
a+
c

Control measures:
Taking necessary action For treatment
To prevent the
spread To halt the
epidemic.
Care of the sick Isolation
Disinfection
Chemotherapy/Treatment
Referral if required
Protection of community Food hygiene
Safe water
Sanitary disposal of excreta
Vector control
Specific immunization
Chemoprophylaxis
Arrangement for special clinics
Drug availability

Final report
1. Background
Place of epidemic.
2. Previous occurrence of epidemics of the same disease, locally or elsewhere
Occurrence of related disease, if any in the same area/in the other area
Discovery of the first cases of the present outbreak.
3. Methodology of investigation
Case definition
Questionnaire used in epidemiological investigation
Survey methods
Collection of laboratory specimens.
240 Part III: Exercises (Problems and Their
Solutions)
4. Analysis of data

Clinical data
Frequency of signs and symptoms
Course of disease
Differential diagnosis
Death or sequealae of illness

Epidemiological
data Mode of
occurrence In time
By place
By population groups

Mode of transmission
Source(s) of infection
Route(s) of excretion and portal(s) of entry
Factor influencing transmission

Laboratory data
Isolation of agent(s)
Serological confirmation
Significance of results

Interpretation of data
Comprehensive picture of the outbreak
Hypotheses
Formulation and testing of hypothesis by statistical analysis

5. Control measures:

Definition of strategies, methodology and implementation

Constraints
Results

Evaluation
Significance of
results
Cost/effectiveness
Preventive measures
 Chapte
r
Calculations
in
15 Biostatistic
s

1. Left mid arm circumference (in cm) of 15 male children aged 3 year was found to be
13, 11, 11, 12, 12, 10, 10, 13, 13, 12, 11, 14, 10, 13, 15. Calculate the mean, median and mode

Solution:
Calculation of mean:
Mean is the central value of distribution
To calculate the mean, formula used is,
x
X= n
Where, X = Mean, pronounced as ex-bar
 = Sigma, i.e. summation
X = Individual values
n = Number of observations
Summation (adding) of all individual values in the series
X= Actual number of observations in the series

Step 1: Adding all individual values (  X)

 X = 13+11+11+12+12+10+10+13+13+12+11+14+10+13+15 = 180
 X = 180
Step 2: Dividing sum of individual values by actual number of observations

Sum of individual values (  X)

X= Number of observations (n) a
180
 15

X = 12
Thus, mean is 12
242 Section III: Exercises (Problems and Their
Solutions)
Calculation of median:
Median is the middle (central) value, after arranging all values in an ascending or descending order. It divides the
series into 2 equal groups.
Step 1: Arranging the data in order.

10 10 10 11 11 11 12 12 12 13 13 13 13 14 15
Step 2: Location of middle value
 n+1
=   th value in the series
 2  Where, n = Number of observations
15  1 16
 2 2

= 8th value
8th value in this series is 12
10 10 10 11 11 11 12 12 12 13 13 13 13 14 15
↓
Middle value
Thus, median is 12
Calculation of mode:
Mode is most repeatedly appearing number in the series.
13, 11, 11, 12, 12, 10, 10, 13, 13, 12, 11, 14, 10, 13, 15.
In this series, 13 is more frequently (4 times) appearing than other value.
Thus, mode is 13.

Mid arm circumference of children

Mean is 12
Median is 12
Mode is 13

2. Age at first delivery of 10 rural women was 18, 20, 19, 20, 18, 20, 16, 28, 23, 18 year. Find out the
differ- ent central values. What is the central value.
Solution:
Most commonly used central values are:
Arithmetic mean
Median
Mode

Calculation of mean
Mean is the central value of distribution
To calculate the mean, formula used is,
 Calculations in Biostatistics
243

x
X= n Where, X = Mean, pronounced as ex-bar
 = Sigma, i.e. summation
X = Individual values
n = Number of observations
Summation (adding) of all individual values in the series
X= Actual number of observations in the series

Step 1: Adding all individual values (  X)

 X = 18+20+19+20+18+20+16+28+23+18 = 200
 X = 200
Step 2: Dividing all individual values by actual number of observations
Sum of individual values (  X)
X= Number of observations (n) a

200
 10

X = 20
Thus, Mean is 20

Calculation of median
Median is the middle (central) value, after arranging all values in an ascending or descending order. It divides the
series into two equal groups.
Step 1: Arranging the data in order.
16 18 18 18 19 20 20 20 23 28
Step 2: Location of middle value

 n+1
  th value in the series
 2 
Where, n = Number of observation
10  1 11
 2 2

= 5.5
In the even number of data, mean of two central values (5th and 6th) is taken into account.
5th and 6th values in this series are 19 and 20.
16 18 18 18 19 20 20 20 23 28
↓
Middle value

19  20
So, Mean of two central values   19.5
2
Thus, Median is 19.5
244 Section III: Exercises (Problems and Their
Solutions)
Calculation of mode
Mode is most repeatedly appearing number in the series.
18, 20, 19, 20, 18, 20, 16, 28, 23, 18
In this series, 18 and 20 are more frequently (3 times each) appearing than other value.
Thus, Mode is 18 and 20. (A series may have 2 or more modes or no mode at all)
Age at first delivery of rural mother is
Mean is 20 year
Median is 19.5 year
Mode is 18 and 20 year

3. Duration of stay in the hospital after cardiac surgery of 10 persons is 9, 7, 8, 10, 73, 5, 6, 4, 11, 12. Find
the Mode, Median and Mean duration of hospital stay. Discuss the relative merits and demerits of this
averages.
Solution:
Calculation of mean:
Mean is the central value of distribution
To calculate the mean, formula used is
x
X= n Where, X = Mean, pronounced as ex-bar
 = Sigma, i.e. summation
X = Individual values
n = Number of observations
Summation (adding) of all individual values in the series
X= Actual number of observations in the series

Step 1: Adding sum of individual values (  X)

 X = 9+7+8+10+73+5+6+4+11+12 = 145
 X = 145
Step 2: Dividing sum of individual values by actual number of observations
Sum of individual values (  X)
X= Number of observations (n) a
145
  14.5
10
Mean ( X ) = 14.5
Mean duration of hospital stay is 14.5 day

Merits: Easy to calculate

Based on all observations
 Calculations in Biostatistics
245
Demerits: Affected very much by extreme values (73 in this example). As mean is not a central value. Durations
will not clusters around mean—14.5 day.
Extreme values completely vitiates the mean. Thus when extreme values are present, mean is not a
good calculation to obtain central value.

Calculation of median:
Median is the middle (central) value after arranging all values in an ascending or descending order. It divides the
series into 2 equal groups.
Step 1: Arranging the data in order.
4 5 6 7 8 9 10 11 12 73
Step 2: Location of middle value
 n + 1  th value in the series
 
 2 
10  1 11
 2 2

= 5.5
In the even number of data, mean of two central values (5th and 6th) is taken into account.
5th and 6th values in this series are 8 and 9.
4 5 6 7 8 9 10 11 12 73
↓
Middle value
8 9
Mean of two central values   8.5
2
Thus, Median is 8.5

Merits: Median is more representative central value and more nearer to the truth than mean
Can be calculated in a grouped series
Not distorted by extreme values
In a series with extreme value the median is most representative.

Demerits: Cannot be calculated by raw data with out arrangement.

Range cannot be understood
Cannot be plotted graphically
The median is not used as central in analytic calculation
The median of different series (median of median) cannot be combined.

Calculation of mode
Mode is most repeatedly appearing number in the series
9, 7, 8, 10, 73, 5, 6, 4, 11, 12
In this series, there is no mode, because here there is no repeatedly occurring value. (A series may have no mode
at all)

Merits: Easy to obtain and useful in epidemiological work

Not affected by extreme values.
246 Section III: Exercises (Problems and Their
Solutions)
Demerit: Need not be a central value
No analytic concepts are based on the mode
Duration of hospital stay is
Mean 14.5 day
Median 8.5 day
Mode Nil

4. In school health checkup, hemoglobin level was estimated in 300 children. Data is given in the
table. Calculate the mean hemoglobin level of the school children.
Hb level Number of children
6–8 gm% 150
9–11 gm% 140
12–14 gm% 10

Solution:
Calculation of mean in a grouped series:
 f×
Using the formula
m Where,

 f
 = adding (summation)
f = frequency
m = middle point
Hb level Midpoint of the class No of children (frequency) Multiplication of frequency
(Class interval) interval (f) with midpoint
(m) f×m
6–8 gm % 7 150 1050
9–11 gm % 10 140 1400
12–14 gm % 13 10 130

 = 300  f × m = 2580
 f×m
Mean hemoglobin level of the children =

f
2580
300
= 8.6 gm %
Therefore, mean hemoglobin level of the school children is 8.6 gm %.

5. Respiratory rate of 10 asthma patients is given to you. Find the mean, mean deviation and standard
deviation of the respiratory rate—18, 20, 19, 20, 18, 19, 16, 25, 23, 17.

Solution:
Calculation of mean
Mean is the central value of distribution
 Calculations in Biostatistics
247

 x
Formula used X =
n
Where, X = Mean, pronounced as ex-bar
 = Sigma i.e. summation
X = Individual values
n = Number of observations
Summation (adding) of all individual values in the series
X= Actual number of observations in the series
Step 1: Adding all individual values (  X)
 X = 18+20+19+20+18+19+16+25+23+17 = 195
 X = 195
Step 2: Dividing sum of individual values by actual number of observations

Sum of individual values (  X)

X= Number of observations (n) a

195
 10

Mean ( X ) = 19.5
Mean respiratory rate is 19.5

Calculation of mean deviation

Step 1: Arithmetic mean ( X ) is written against each value shown in column 1 of the table.
Step 2: Deviation of each value from the arithmetic mean (X– X ) is calculated in column 2.
Column 1 Column 2
Respiratory Rate Column 3
Sl No Arithmetic mean Deviation from the
(X)
(X) mean (X- X ) (X- X )2

1 18 19.5 -1.5 2.25

2 20 19.5 0.5 0.25
3 19 19.5 -0.5 0.25
4 20 19.5 0.5 0.25
5 18 19.5 -1.5 2.25
6 19 19.5 -0.5 0.25
7 16 19.5 -3.5 12.25
8 25 19.5 5.5 30.25
9 23 19.5 3.5 12.25
10 17 19.5 2.5 6.25
Total 195 19.5 20 66.50

Step 3: Summation (adding) of all deviations  (x - X ) (± signs are ignored)

Step 4: Dividing the results with number of observations (n), (n-1) is used when number of observations are less
than 30.
248 Section III: Exercises (Problems and Their
Solutions)
 (X  X)
Calculating mean deviation MD =
n
20
MD = =2
10
So, mean deviation is 2

Calculation of standard deviation (SD)

SD is root-mean-square-deviation
Step 1: Arithmetic mean ( X ) is written against each value as shown in column 1 of the table.
Step 2: Deviation of each value from the arithmetic mean (X– X ) is calculated in column 2.
Step 3: Each deviations (X - X ) are squared in Column 3.
Step 4: Summation (adding) of all squared deviations  (X - X )2
Step 5: Dividing the results with number of observations (n), (n-1) is used when number of observations are less
than 30.
 ( X  X )2
Calculating standard deviation (SD) = SD1  n 1

66.50 66.50
 10 1  9  7.38  2.7

Thus, respiratory rate of asthma patients is 19.5 ± 2.7 (mean ± standard deviation) (± denotes the spread of disper-
sion on either side of mean)

6. The pulse rate per minute of 12 normal individuals are given to you. Calculate the mean, mean
devia- tion (MD), standard deviation (SD), coefficient of variation (CV) and range of pulse rate.
59, 62, 64, 65, 68, 73, 74, 75, 78, 80, 80, 86
Solution:
Calculation of mean:
Mean is the central value of distribution
 x
Formula used X =
n
Where, X = Mean, pronounced as ex-bar
 = Sigma i.e. summation
X = Individual values
n = Number of observations
Summation (adding) of all individual values in the series
X= Actual number of observations in the series

Step 1: Adding all individual values (  X)

 X = 59+62+64+65+68+73+74+75+78+80+80+86 = 864
 X = 864
 Calculations in Biostatistics
249
Step 2: Dividing sum of individual values by actual number of observations
Sum of individual values (  X)
X= Number of observations (n) a

864
= 12
Mean ( X ) = 72
Calculation of mean deviation
Step 1: Arithmetic mean ( X ) is written against each value shown in column 1 of the table.
Step 2: Deviation of each value from the arithmetic mean (X - X ) is calculated in column 2.
Column 1 Column 2 Column 3
Sl Pulse rate
Arithmetical mean Deviation from the
No (X) (X - X )2
(X) mean (X - X )
1. 59 72 -13 169
2. 62 72 -10 100
3. 64 72 -8 64
4. 65 72 -7 49
5. 68 72 -4 16
6. 73 72 +1 1
7. 74 72 +2 4
8. 75 72 +3 9
9. 78 72 +6 36
10. 80 72 +8 64
11. 80 72 +8 64
12. 86 72 +14 196
Total 864 84 772

Step 3: Summation (adding) of all deviations  (x - X ) (± signs are ignored)

Step 4: Dividing the results with number of observations (n), (n-1) is used when number of observations are less
than 30.
 (X  X)
Calculating mean deviation MD =
n
84
Mean deviation =  7
12

So, mean deviation is 7

Calculation of standard deviation

(root-mean-square-deviation)
Step 1: Arithmetic mean (X) is written against each value shown in column 1 of the table.
Step 2: Deviation of each value from the arithmetic mean (x - X ) is calculated in column 2.
Step 3: Each deviations (x - X ) are squared in Column 3.

Step 4: Summation (adding) of all squared deviations  (x - X )2

250 Section III: Exercises (Problems and Their
Solutions)
Step 5: Dividing the results with number of observations (n), (n-1) is used when number of observations are less
than 30.

 ( X  X )2
SD1  n 1
Calculating standard deviation (SD) =

 772  772  70.18  (Take the square root to get SD)

8.412 1 11

Thus, pulse rate is 72 ± 8.4 (mean ± standard deviation)

Calculation of Coefficient of Variation

Coefficient of variation is the ratio of the standard deviation of series to the mean of series.

Coefficient of Variation =  100
X
Where,  = Standard Deviation (SD)
X = Arithmetic Mean
8.4
  10
0
72
Co-efficient of variation = 11.6%

Calculation of Range
Range is the difference between highest and lowest figures in
series. Highest is 86
Lowest is 59

Range 59 to 86

7. Incubation period of 10 SARS cases was 6, 7, 5, 4, 3, 4, 5, 6, 7, 8 day. Calculate the mean

incubation period and standard deviation. Write interpretation about the findings.
Solution:
Calculation of Mean
Mean is the central value of distribution
To calculate the mean formula used is
x Where, X = Mean, pronounced as ex-bar
X= n
 = Sigma i.e. summation
X = Individual values
n = Number of observations
Summation (adding) of all individual values in the series
X= Actual number of observations in the series

Step 1: Adding all individual values (  X)

 X = 6+7+5+4+3+4+5+6+7+8 = 55
 X = 55
 Calculations in Biostatistics
251
Step 2: Dividing all individual values by actual number of observations
Sum of individual values (  X)
X= Number of observations (n)
55
  5.5
10
Mean ( X ) = 5.5 day
So, mean incubation period of SARS is 5.5 day.

Calculation of standard deviation (SD)

SD is (root-mean-square-deviation)
Step 1: Arithmetic mean ( X ) is written against each value shown in column 1 of the table.
Step 2: Deviation of each value from the arithmetic mean (X- X ) is calculated in column 2.
Step 3: Each deviations are squared in Column 3.
Step 4: Summation (adding) of all squared deviations  (X- X )2
Step 5: Dividing the results with number of observations (n), (n-1) is used when number of observations are less
than 30.
Column 1 Column 2 Column 3
Incubation period
Sl No Deviation from the
(X) (X - X )2
Arithmetic mean X mean (X - X )
1. 6 5.5 0.5 0.25
2. 7 5.5 1.5 2.25
3. 5 5.5 – 0.5 0.25
4. 4 5.5 – 1.5 2.25
5. 3 5.5 – 2.5 6.25
6. 4 5.5 – 1.5 2.25
7. 5 5.5 – 0.5 0.25
8. 6 5.5 0.5 0.25
9. 7 5.5 1.5 2.25
10. 8 5.5 2.5 6.25
Tota 22.50
l

 ( X  X )2
SD1  n 1
Calculating standard deviation (SD) =

 22.5  22.5 2.5

10 1 (Take the square root to get SD)
 9

= 1.58
Thus, Incubation period of SARS is 5.5 ± 1.58 (mean ± standard deviation)
252 Section III: Exercises (Problems and Their
Solutions)
Interpretation
Standard Variations on Mean ± SD Incubation Period in Coverage of patients
Deviation (SD) either side day
(according to SD)
1 (1.6×1=1.6) 5.5 + 1.6 = 7.1 (3.9 to 7.1) 68%
5.5 - 1.6 = 3.9
2 (1.6×2=3.2) 5.5 + 3.2 = 8.7 (2.3 to 8.7) 95%
5.5 - 3.2 = 2.3
3 (1.6×3=4.8) 5.5 + 4.8 = 10.3 (0.7 to 10.3) 99%
5.5 - 4.8 = 0.7

8. Mean weight of rural girls (N=105) was 58.6 kg with SD-8.3 and that of urban girls (N=101) was 56
kg with SD-6.2. Is the difference in weight between rural and urban girls significant?
Solution:
Data given:
Particulars Rural girls Urban girls
Number (n) n1 = 105 n2 = 101

Mean weight ( X) X1= 58.6 X2 = 56.0

Standard Deviation (SD) SD1 = 8.3 SD2 = 6.2

Formulation of Null hypothesis (H0): No difference in the mean weight of urban and rural girls.
Formulation of Alternate hypothesis (H1): There is a difference between the mean weight of urban and rural girls.
To test the hypothesis: Find whether the difference is by chance or not.

Calculation of Standard error of difference (SED)

SD2 SD22
SED = 1
+
n1 n2

8.32 6.22
 105  101

68.89 38.44
 105  101

 0.65  0.38

 1.03
SED = 1.014
So, SED is 1.014

Applying the Z Test

2.6
X1  X2 58.6  56
Z= =  2.56

SED 1.014 1.014
 Calculations in Biostatistics
253
Interpretation of the Z Value
If the calculated Z value is more than two, the difference is significant.
If the calculated Z value is less than two, the difference is not
significant.
As the value of ratio (Z) is more than two, Null hypothesis is rejected. It is concluded that the difference in the
mean weight of rural and urban girls is significant. This shows that the weight of rural girls is higher compared to
urban girls.

9. Among the newly diagnosed hypertensives 9 were on salt free diet, another group of 7 patients
were without any salt restriction diet for 1 month. Reduction of diastolic BP of patients in mm is
given.

Reduction in Diastolic BP
Without salt restriction With salt restriction
(Group A) (Group B)
2 3
3 5
4 6
5 7
5 7
7 8
9 8
9
10

Find out whether salt restriction is associated in reducing diastolic BP

Solution:
Step 1: Arithmetic mean X is written against each value shown in group 1 and 2 of table
 x1  x2
X1 = X2 =
n1 n2

X1 = 35/7 = 5 X2 = 63/9 = 7
Finding the mean deviation (X1  X2 )and
Squared deviation is summed in both groups separately.
2 2
Add sum deviation of group A and B.  (X1  X1 ) +  (X2  X2 )
Squaring the X- X2 Squaring the
Group A (n = 7) X1 - X1 Deviation deviation Group B (n = 9)
2
deviation
from mean Deviation from (X - X 2)2
(X - X )2
1 1 mean 2

2 -3 9 3 -4 16
3 -2 4 5 -2 4
4 -1 1 6 -1 1
5 0 0 7 0 0
5 0 0 7 0 0
7 2 4 8 1 1
9 4 16 8 1 1
9 2 4
10 3 9
Total 35 34 63 36
254 Section III: Exercises (Problems and Their
Solutions)

 ( X  X )2
SD1  n 1

34 34
 7 1  6  5.6

= 2.4

 ( X  X )2
SD2  n 1

36 36
 9 1  8  4.5

= 2.1
Group A Group B
Particulars
Without salt restriction With salt restriction
Number (n) n1 = 7 n2 = 9

Mean ( X) X 1= 5 X2=7
Standard Deviation SD1 = 2.4 SD2 = 2.1
(SD)

SD2 SD2
Standard error of difference (SED)  1  2
n1 1 n2 1

2.42 2.12
 7 1  9 1

5.76 4.41
 6  8

 0.96  0.55

 1.51 
1.23 (Take the square root to get SD)
SED = 1.23
Now, ‘t’ test is applied

X1  X2
t= SED

57
 1.23

2
= 1.23

= 1.62 (- signs are ignored)

 Calculations in Biostatistics
255
Degree of freedom = n1 + n2 - 2
= 7+9-2
= 14
Refer to the table, to get ‘t-value’
Calculated t value (1.62) is lesser than table value (2.14). Hence the difference is not significant.
Difference in reduction of diastolic blood pressure is by chance but not by salt reduction.

10. Out of 250 diarrhea cases with dehydration, 150 were treated with homemade fluid and remaining 100
were treated with ORS. 30 have not recovered from each group. Find out is there any difference be-
tween treatment outcome of ORS and homemade fluid.
Solution:
Step 1: Formulation of hypothesis
Formulation of Null hypothesis (H0): We shall presume that there is no significant difference in the proportion of
recovery between two groups (ORS and homemade fluid treatment).
Formulation of Alternate hypothesis (H1): We shall presume that there is a significant difference in the proportion
of recovery between two groups.
To test the hypothesis: We shall apply Chi - square (X2) test.
Step 2: Construction of contingency table
Preparation of 2×2 contingency table by using observed data.
Outcome of treatment Treatment used Total
Homemade fluid ORS
Not A 30 B 30 60
Recovered
Recovered C 12 D 70 190
0
Total 150 100 250
Step 3: Calculation of expected values for each cell:
Now we have to find the expected values (E) for each cell
Ignoring the type of treatment (ORS and homemade fluid)

A cell
Out of 250 study subjects 150 have received Homemade fluid
Out of 60 not recovered how many are expected to have received homemade fluid?
150 9000
  60   36
250 250
So, E = 36

B cell
Out of 250 100 have received ORS
Out of 60 not recovered how many are expected to have received ORS?
100 6000
  60   24
250 250
So, E = 24
256 Section III: Exercises (Problems and Their
Solutions)
C Cell
Out of 250 150 have received homemade fluid
Out of 190 recovered how many are expected to have received homemade fluid?
150 28500
  190   114
250 250
So, E = 114

D Cell
Out of 250 100 have received ORS
Out of 190 recovered how many are expected to have received ORS?
100 19000
  190   76
250 250
So, E = 76
Alternative method for calculating expected values in cells
Corresponding row total × Corresponding column total
Formula for any cell = Grand total

Step 4: Expected values (E) are entered in the contingency table against observed values (O)
Outcome of treatment Treatment used Total
Homemade fluid ORS
Not A O = 30 B O = 30 60
Recovered
E = 36 E = 24
Recovered C O = 120 D O = 70 190
E = 114 E = 76
Total 15 100 250
0
Step 5: Calculation of chi-square (X2) value by using formula:
 (O  E)2
X2 =
E
Where, X2 = Chi-square
 = Summation
O = Observed value
E = Expected value
A + B + C + D cells
(30  36)2 (30  24) (120 114)2 (70  76)2
2
2
X =   
36 24 114 76
(6)2
= (6)2 (6)2 (6)2
36  
24 76

114

36 36 36 36
= 36  24  114  76
 Calculations in Biostatistics
257
= 1 +1.5 + 0.3 + 0.5
2
X = 3.3
Step 6: Calculation of degrees of freedom (df)
Formula (No of rows - 1) × (No of columns - 1)
=r-1 × c-1
= (2 - 1 ) × (2 - 1)
=1 × 1
=1
So, Degree of freedom is 1

Interpretation
Calculated X2 (3.3) is lesser than the X2 table value (3.84) at 1 df at 0.05, i.e. 5% level of significance. Thus, The
null hypothesis is accepted.

Conclusion
We can conclude that there is no statistically significant difference between the homemade fluid and ORS in the
treatment of diarrhea.
Significance of p value
p = 0.05 Just significant
p < 0.05 Significant
p < 0.01 More significant
p < 0.001 Highly significant

11. Among 200 alcoholics, 50 have developed cirrhosis. Among 300 non-alcoholics, 50 have developed cir-
rhosis in a cohort study. Find out is there any association between alcohol and cirrhosis.
Solution:
Step 1: Formulation of hypothesis
Formulation of Null hypothesis (H0): We shall presume that there is no association between alcohol and cirrhosis
Formulation of Alternate hypothesis (H1): We shall presume that there is an association between alcohol and cir-
rhosis
To test the hypothesis: We shall apply chi-square(X2) test.
Step 2: Construction of contingency table
Preparation of 2×2 contingency table by using observed data.
Particulars Cirrhosis No Cirrhosis Total
Alcoholic A 50 B 150 200
Non - C 50 D 250 300
Alcoholic
Total 100 400 500
Step 3: Calculation of expected values for each cell:
Now we have to find the expected values (E) for each
cell Ignoring the use of alcohol

A Cell
Out of 500 of study subjects 100 have developed cirrhosis
258 Section III: Exercises (Problems and Their
Solutions)
Among 200 alcoholics How many are expected to have developed cirrhosis?
100 20000
  200   40
500 500
So, E = 40

B Cell
Out of 500 400 did not develop cirrhosis
Among 200 alcoholics How many are expected not to have developed cirrhosis?
400 8000
  200   160
500 500
So, E = 160

C Cell
Out of 500 100 have developed cirrhosis
Out of 300 non-alcoholics How many expected to have developed cirrhosis?
100 30000
  300   60
500 500

So, E = 60

D Cell
Out of 500 400 have not developed cirrhosis
Out of 300 non-alcoholics How many expected not to have developed cirrhosis?
400 12000
=  300   240
500 500

So, E = 240
Step 4: Expected values (E) are entered in the contingency table against observed values (O)
Particulars Cirrhosis No Cirrhosis
Alcoholic A O = 50 B O = 150
E = 40 E = 160
Non- C O = 50 D O = 250
alcoholic
E = 60 E = 240
2
Step 5: Calculation of chi-square (X ) value by using formula:

 (O  E)2
X2
= E
Where, X2 = Chi square
 = Summation
O = Observed value
E = Expected value
 Calculations in Biostatistics
259
(50  40)2
 (150 160)2 (50  60)2 (250  240)2
  
2 40 160 60 240
X
2
(10)
 (10)2 (10)2 (10)2
 
 160 60 240
40
100 100 100 100
 40 160  60 240

= 2.5 + 0.6 + 1.6 + 0.4

X2 = 5.1
Step 6: Calculation of degrees of freedom (df)
Formula (Number of rows - 1)×(Number of columns - 1)
=r-1 × c-1
= (2 - 1) × (2 - 1)
=1 × 1
=1
So, degree of freedom is 1

Interpretation
Calculated X2 (5.1) is higher than the X2 table value (i.e. 3.84) at 1 df at 0.05 i.e. 5% level of significance. Thus, null
hypothesis is rejected.

Conclusion
We can conclude that there is statistically significant association between the alcohol intake and cirrhosis. It sug-
gests that, alcohol consumption will lead to cirrhosis.

12. The distribution of eye color by sex of 500 american children is given in the contingency table.
Eye color Sex Total
Male Female
Blue A 50 B 100 150
Brown C 150 D 200 350
Total 200 300 500
Find out is there any association between the color of the eye and sex.

Solution:
Step 1: Formulation of hypothesis
Formulation of Null hypothesis (H0): We shall presume that there is no association between eye color and sex
Formulation of Alternate hypothesis (H1): We shall presume that there is an association between eye color and sex
To test the hypothesis: We shall apply chi-square (X2) test.
260 Section III: Exercises (Problems and Their
Solutions)
Step 2: Calculation of expected values for each cell
Corresponding row total × Corresponding column total
Formula for any cell = Grand total

200  150
Expected value for A cell 
500

30000
 500  60
So, E = 60
300  150
Expected value for B cell 
500

45000
 500  90
So, E = 90
200  350
Expected value for C cell 
500

70000
 500  140
So, E = 140
300  350
Expected value for D cell 
500

105000
 500  210
So, E = 210
Step 3: Expected values (E) are entered in the contingency table against observed values (O)
Eye color Sex
Male Female
Blue A O = 50 B O = 100
E = 60 E = 90
Brown C O = 150 D O = 200
E = 140 E = 210
Step 4: Calculation of chi-square (X2) value by using formula:
 (O  E)2
X 2 Where, X2 = Chi square
= E  = Summation
O = Observed value
E = Expected value
 Calculations in Biostatistics
261

(50  60)2 (100  90)2 (150 140)2 (200  210)2

2
X =   
60 90 140 210
(10)2 (10)2 (10)2
(10)2
   
60 90 140 210

100 100 100 100

 60  90 140 210

= 1.7 + 1.1 + 0.7 + 0.5

2
X =4
Step 5: Calculation of degrees of freedom (df)
Formula (Number of rows - 1) × (Number of columns - 1)
=r-1 × c-1
= (2 - 1 ) × (2 - 1)
=1 × 1
=1
So, Degree of freedom is 1
Interpretation
Calculated X2 (4) is higher than the X2 table value (i.e. 3.84) at 1 df at 0.05 i.e. 5% level of significance. Thus, The
null hypothesis is rejected.
Conclusion
We can conclude that there is a statistically significant association between the eye color and the sex of children.

13. In a boarding school, 80 children were given oral typhoid vaccine. 120 children were given injectable
typhoid vaccine. Typhoid outbreak occurred after one year. Among the oral vaccine received children 20
got typhoid. Among the injectable vaccine received children 20 developed typhoid. Find whether there is
any difference in the efficacy between the two vaccines.
Solution:
Step 1: Formulation of hypothesis
Formulation of Null hypothesis (H0): We shall presume that there is no difference between efficacy of 2 vaccines.
Formulation of Alternate hypothesis (H1): We shall presume that there is a difference between efficacy of 2 vac-
cines.
To test the hypothesis: We shall apply chi-square (X2) test.
Step 2: Construction of contingency table
Preparation of 2 × 2 contingency table by using observed data.
Type of vaccine received Typhoid disease occured Total
Yes No
Oral A 20 B 60 80
Injectable C 20 D 100 120
Total 40 160 200
262 Section III: Exercises (Problems and Their
Solutions)
Step 3: Calculation of expected values for each cell:
Now we have to find the expected values (E) for each
cell Ignoring the type of vaccine

A Cell
Out of 200 study subjects 40 have developed typhoid
Among 80 received oral vaccine How many are expected to get typhoid?
160
 80  16
200
So, E = 16

B Cell
Out of 200 study subjects 160 have not developed typhoid
Among 80 received oral vaccine How many are expected not to have developed typhoid?
160
 80  64
200
So, E = 64

C Cell
Out of 200 study subjects 40 have developed typhoid
Among 120 received injectable vaccine How many are expected to have typhoid?
40
 120  24
200

So, E = 24

D Cell
Out of 200 study subjects 160 have not developed typhoid
Among 120 received injectable vaccine How many expected not to have developed typhoid?
160
 120  96
200
So, E = 96

Step 3: Expected values (E) are entered in the contingency table against observed values (O)
Type of vaccine Typhoid disease
Yes No
Oral A O = 20 B O = 60
E = 16 E = 64
Injectable C O = 20 D O = 100
E = 24 E = 96
Step 4: Calculation of X2 value by using formula:
 (O  E)2
X2 Where, X2 = Chi square
= E
 = Summation
O = Observed value
E = Expected value
 Calculations in Biostatistics
263

X2 (60  64)2 (20  24)2 (100  96)2

(20 16)2
   
16 64 24 96
(4)2
 (4)2 (4)2 (4)2
 
 64 24 96
16

16 16 16 16
 16  64  24  96

= 1 + 0.25 + 0.7 + 0.17

X2 = 2.12
Step 5: Calculation of degrees of freedom (df)
Formula: (No of rows -1) × (No of columns -1)
=r-1 × c-1
= (2 - 1 ) × (2 - 1)
=1 × 1
=1
So, Degree of freedom is 1

Interpretation
Calculated X2 (2.12) is lower than the X2 table value (i.e. 3.84) at 1 df at 0.05, i.e. 5% level of significance. Thus,
null hypothesis is accepted.

Conclusion
We can conclude that there is no statistically significant difference between the efficacy of oral and injectable ty-
phoid vaccine.

14. Out of 482 OCP users, 27 developed hypertension while among 1908 non-OCP users, 77 developed hy-
pertension. Find the relative risk and attributable risk of oral pill.
Solution:
Incidence of BP among exposed oral contraceptive pill (OCP user)
27
 482  1000  56.01 / 1000

Incidence of BP among non-exposed (non-OCP users)

77
 1908 1000  40.35 / 1000

Incidence of BP among exposed

Relative risk = Incidence of among non-exposed

56.01
 40.35

= 1.38
264 Section III: Exercises (Problems and Their
Solutions)

Incidence among exposed  Incidence among non-exposed

Attributable risk = Incidence among exposed  100

56.01  40.35
 56.01  100

56.66
  100
56.01
= 27.9%

Interpretation
Incidence of BP is higher (56.01/1000) in OCP users than non-users (40.35 / 1000)
Relative risk—1.38 means OCP users are 1.3 times more likely to develop hypertension than non-OCP users.

Attributable risk
27.7 percent mean 27.7 percent of hypertensives among OCP users can be attributed to OCP usage alone.

15. A screening test (PAP smear) was done for cervical cancer. Results are given below,
Screening test PAP smear Disease positive Disease negative Total
Positive 400 (a) 150 (b) 550
(a+b)
Negative 100 (c) 4350 (d) 4450
(c+d)
Total 500 (a+c) 4500 (b+d) 5000

Calculate the sensitivity, specificity of the test. Find the false positive, false negative rate. Also calculate
predictive value of positive and negative test.

Solution:
In the table, a = True positive
b = False positive
c = False negative
d = True negative
a
Sensitivity =  100
a
c
400
= 400   100
100
= 80% (Positives identified as positive result)
d
Specificity =  100
(b  d
)
4350
=
150   100
4350
= 96.66% (Negatives identified as negative
result) False positive rate = 100 - 96.6 = 3.34%
 Calculations in Biostatistics
False negative rate = 100 - 80 = 20% 265
266 Section III: Exercises (Problems and Their
Solutions)

a
 100
Predictive value of positive test a
=
b
400
=
400  150  100
= 72.7% (Probability of disease in positive result)
d
Predictive value of negative test =  100
(c  d
)
4350  100
=
100  4350
= 97.75% (Probability of disease in negative result)

16. A Primary health center covering 30,000 population has crude birth rate 25/1000 mid-year population,
infant mortality rate is 70/1000 live births. As a medical officer, how do you estimate the requirement of
routine vaccines for 1 year period and organize routine immunization programme.
Solution:
Step1: Estimating the number of vaccine beneficiaries in PHC area
a. Estimation of mothers = Estimated number of pregnant women + abortions (10%)
Total population × Birth rate
Number of pregnant women =
1000

30000  25
 1000
= 750
Total number of mothers = Number of pregnant women + fetal wastage of 10%
= 750 + 75
= 825
b. Estimation of infants
Total population × Birth rate × 1  Infant mortablity rate (IMR)
Number of infants = 1000

30000  25
 70
 1 1000
1000

30000  25
 1000  1  0.07

30000  25
 1000  0.9

750000
 1000  0.9

= 750 x 0.9
= 675
 Calculations in Biostatistics
267
Step 2: Calculation of annual vaccine requirement
Number of doses = Number of beneficiaries × Frequency of dose × Wastage multiplication

factor TT for pregnant women = 750 × 2 × 1.33 = 1995

BCG & Measles = 675 × 1 × 2 = 1350

DPT & OPV = 675 × 3 × 1.33 = 2693

Note - Wastage multiplication factor (WMF) is 1.33 for all vaccines, 2 for BCG &

Measles. Calculation of number of vials required:

Number of doses required
Number of vials required =
Number of doses in vial

Organization of immunization programme

Annual requirement is divided into four quarters and quarterly indent is made (Vaccines should not be stored at
PHC for more than 3 month)
Only required quantity of vaccines are supplied on the day of immunization at village level as maintaining the
cold chain at village level is difficult.
Supervision of immunization activities in the field.
Training of staff regarding maintenance of cold
chain.
Preparing and sending monthly reports regarding achievements and deficiencies in immunization activities.
Surveillance of vaccine preventable diseases.
Vaccine carrier must have frozen ice
packs. Only one vial is taken out at a time.
Unused and unopened vials must be returned to the PHC on the same day.
Reconstituted measles, BCG vial should be used within 4 hour. Remaining vaccine is discarded at the end of the
session.
Opened OPV, DPT, TT can be used in the next session. Hence, returned to PHC.
Vaccines are maintained at +2 0c to +8 0c during immunization, by using cold chain equipments like thermocol
boxes, vaccine carriers with fully frozen ice packs.

17. In a study, out of 60 hypertensives 30 were using OCP. Among 70 non-hypertensives, 25 were using oral
contraceptives. Find the association between OCP and hypertension.

Solution:
Step 1: Construction
Construction of 2×2 table by the given data.
Hypertension
Particulars Total
Present Absent
OCP used 30 (a) 25 (b) 55 (a+b)
OCP not used 30 (c) 45 (d) 75 (c+d)
Total 60 70 130
(a+c) (b+d) (a+b+c+d)
268 Section III: Exercises (Problems and Their
Solutions)
Finding the exposure rate:
a
Exposure rate among hypertensives (cases) =  100
(a 
c)
30
 100
60
=
= 50 %
b
Exposure rate among non-hypertensives (controls) =
(b  d )  100
25
=  100
70
= 35.7 %
Exposure rate is higher (50%) among hypertensives than among non-hypertensives (35.7%)

Estimation of risk
Incidence among exposed
Relative risk = Incidence among non-exposed

a b
 (a  c)  (b  d )

30
= 60 ÷ 25
70

= 0.5 / 0.36
= 1.39

Odds ratio
ad 30  45 1350
Odds ratio   
bc 25  750
30
= 1.8

Attributable
risk
Incidence among exposed  Incidence among non-exposed
Attributable risk = Incidence among exposed  100


 a  a
b   100

 b d a c
a c


 30  25  30 × 100
= ÷
 
 60 70  60
 Calculations in Biostatistics
269

0.5  0.36
= 0.5  100

0.14
= 0.5  100
= 28%

Population attributable risk

Population attributable risk = incidence in total population − incidence among non-exposed
(c - b)
= c  100
(30  25)
= 30  100
= 16.6%

Interpretation
Exposure rate The incidence of hypertension is higher among OCP users
(50/100) compared to that among non-users (35.7/100)
Relative risk OCP users are 1.39 times at greater risk of developing hypertension than OCP non-
users.
Odds ratio OCP users showed a risk of having hypertension 1.8 times that of OCP non-users.
Attributable risk 28% of hypertension among OCP users was due to their OCP usage.
Population attributable risk 16.6% cases of hypertension development from OCP usage could be avoided if the
risk factor of OCP usage is prevented.
270 Section III: Exercises (Problems and Their
Solutions)

Chapte
r
Calculations Based
on Vital
16 Statistics

1. In a town with mid-year population of 150,000 following vital events occurred

Total live births 3200
Total deaths 1400
Infant deaths 270
Maternal deaths 10
Calculate (1) Crude birth rate (2) Crude death rate (3) Infant mortality rate and (4) Maternal mortality
rate.
Solution:
Number of live births during the year in the
Crude
town birth rate (CBR) = × 1000
Mid-year population of the town

3, 200
=
150, 000  1000
= 21.3 per thousand population per year

Number of deaths in given place during the

Crude
year death Rate (CDR) = × 1000
Mid-year population of the same place and
time

1, 400
=
150, 000  1000
= 9.3 per thousand population per year

Number of deaths of infants under 1 year of

Infant
age mortality rate (IMR) = × 1000
Number of live births

270
=
3, 200  1000
= 84.4 per thousand live births
270 Section III: Exercises (Problems and Their
Solutions)
Number of maternals
Maternal mortality rate (MMR) =
deaths × 1000

Total live births

10
=
3, 200  1000
= 3.1 per thousand live births

2. A primary health centre with 30,000 population, gives the following data of 1 year
Age groups Number of women Number of live births in 1 year
15 – 24 2000 500
25 – 34 1800 250
35 – 44 1400 90
Total 5200 840

Calculate the fertility rates, mention the validity of each rate.

Solution:
Number of live birth in the year
General fertility rate (GFR) =
Number of women of 15 to 44 × 1000
year
840
=
5, 200  1000
= 161.5 per thousand women

Number of live birth in 1

Crude
year birth rate = × 1000
Mid-year population

840
=  1000
30,
000
= 28 per thousand population

Number of live births in specific age

Age
groupspecific fertility rate = × 1000
Mid-year population of same age

500
15–24 year =  1000  250
2,
000
250
25–34 year =  1000  138.8
1,800
90
35–44 year =  1000  64.3
1,
400
 Calculations Based on Vital Statistics
271
Note : In India, 15 to 44 year is considered for fertility related statistics ; 5 to 10 year of age grouping is adopted
272 Section III: Exercises (Problems and Their
Solutions)

Sum of all age specific fertility rate*

Total fertility rate (TFR) = × *Sum of age special ferility rate
10
1000
(10 is the age group interval in year)
453.1
=  10 
4.53 1, 000
= 4.53
 Calculations Based on Vital Statistics
Age group Fertility rate 273
15–24 250
25–34 138.8
35–44 64.3
Total 453.1
Thus, a woman would have 4.5 children, if she passes the same fertility rate in each age group.

Validity of rates
Crude birth rate : Unsatisfactory measure, since all population is not taking part in child bearing
General fertility rate : Better measure than crude birth rate, because it is restricted to female population of child
bearing age. However, not all women are exposed to pregnancy.
Total fertility rate : Gives average number of children a women would have, if she passes the same fertility
pattern. It gives a picture of complete family size.

3. Data computed in a primary health center is given to you. Calculate the all possible mortality rates.
Total live births 4500
Total still births (weighing 100 gm) 44
Death under 7 day 100
Death between 7 day and 28 day 75
Death between 28 day and 1 year 165
Solution:
Still births
Still birth rate =
× 1000
Live births + Still
births

44
=  1000
4, 500 
44
= 9.68 per thousand total births

Number of deaths of < 28 day

Neonatal mortality rate (NMR) =
children × 1000
Live births

Number of deaths < 28 day = Number of deaths under 7 day + Number of deaths between even and 28 day
= 100 + 75 = 175

100  75
= 4, 500 1000
= 38.8 per thousand live births
274 Section III: Exercises (Problems and Their
Solutions)

Number of deaths between 28 day and 1

Post-neonatal
year mortality rate = × 1000
Number of live births

165
=
4, 500  1000
= 36.6 per thousand live births
Still births + Perinatal
Perinatal mortality rate (PMR) =
deaths × 1000

Number of live births

44  100
 1000 144
 1000
= 4500
4500
= 32 per thousand live births

Number of deaths of infants under 1 year of age*

Infant mortality rate (IMR) = × 1000
Number of live births *

340 Death < 1 year

=  100
4500 0 < 7 day 100
7 to 28 day 75
= 75.5 per thousand live births 28 day to 1 165
year
Total 340
4. Mid-year population of a city in 2001 was 1,020,000. The following events occured during 2001.
Total live births 30,000
Total deaths 12,000
Maternal deaths 120
Infant deaths 1600
Death within 28 day 850
Still births 280
Death within 1 week 500
Calculate relevant rates
Number of live births during the year in the
Crude
town birth rate (CBR) = × 1000
Mid-year population of the town

30, 000
=  1000
1, 020,
000
= 29.4 per thousand MYP
 Calculations Based on Vital Statistics
275

Number of deaths during the year in the

Crude
town death rate (CBR) = × 1000
Mid-year population of the town

12, 000
= 1, 020, 000  1000

= 11.76 per thousand mid-year population (MYP)

Number of infant
Infant mortality rate (IMR) =
deaths × 1000

Number of live births

1600
=
30, 000  1000
= 53.33 per thousand live births

Number of maternal
Maternal
deaths morality rate = × 1000
Number of live births

120
=  1000
30,
000
= 4 per thousand live births

Infant deaths within 28 days

Neonatal mortality rate = Total live births

850
=  1000
30, 000
= 28.3 per thousand live births

Post-neonatal mortality rate

(28 day up to 1 year) = Infant deaths - death < 28
day Total live births

1600  850
= 30, 000 1000

750
 30, 000  1000

= 25 per thousand live births

276 Section III: Exercises (Problems and Their
Solutions)
Early neonatal
Early neonatal mortality rate =
deaths × 1000

Total live births

500
=
30, 000  1000
= 16.6 per thousand live births

Late neonatal mortality rate

(1 week to 28 day) = Neonatal deaths  Early neonatal
Total live births

850  500
= 30, 000  1000

350
 30, 000  1000

= 11.6 per thousand live births

Still births + Early Neonatal

Perinatal mortality rate = Total live births

280  500
 30, 000 1000

780
 30, 000  1000

= 26 per thousand live births

5. A city with mid-year population of 10,00,000 in 2005 has reported following vital events. Calculate all
possible vital rates of the city. Comment on the results.
Births (live) 40,000
Infant Deaths 3600
Deaths within 28 day 1700
Death within first week of life 900
Still births 1000
Solution:
Number of live births during the
Crude birth rate =
year × 1000
Mid-year population

40, 000
=  1000
1, 000,
000
= 40 per thousand mid-year population (MYP)
 Calculations Based on Vital Statistics
277

Deaths of infants of under 1 year of age in a

Infant
year mortality rate = × 1000
Total Number of live births in the same year
3600
=
40, 000  1000
= 90 per thousand live births

Number of deaths of infants under 28 day of age in a

Neonatal
year mortality rate = × 1000
Number of live births in the same year
1700
=
40, 000  1000
= 42.5 per thousand live births

Late fetal + Early neonatal

Perinatal
deaths mortality rate = × 1000
Total live births in the same year
1000  900
= 1000
40, 000

1900
 40, 000  1000

= 47.5 per thousand live births

Number of deaths after 28 day up to 1

Post-neonatal mortality rate = year × 1000
Number of live birth

3600 1700
= 40, 000  1000
1900
 40, 000  1000

= 47.5 per thousand live births

Infant mortality rate = Neonatal mortality + Post-neonatal mortality rate

= 42.5 + 47.5

= 90 per thousand live births

Rates Maternal & child health services (MCH)

goal by 2010
90 <
30
42.5 35
40 21
278 Section III: Exercises (Problems and Their
Solutions)
Comments
There is a high infant mortality rate (IMR) in this area
There is a high mortality rate among the neonates
Crude birth rate is also very high.

Advice
Maternal and child health (MCH) services should be made available to all mothers and children of the area.

6. Find the relevant rates from the data given below.

Total live births 9000
Total deaths under 1 year 1080
Total still births 80
Death under 7 day of age 200
Death between 7 day to 28 day 150
Death between 28 day to 1 year 730
Solution:
Number of late fetal and early neonatal
Perinatal
deaths mortality rate = × 1000
Total live births

80  200

 1000
9000
280
  1000
9000
= 31.1 per thousand live births

Number of Infant deaths in the

Infant
year mortality rate = × 1000
Number of live births in same year

1080
=  1000
9000
= 120 per thousand live births
Still births
Still birth rate =
Total live births + Still × 1000
births

80
 9000  80  1000

80
 9088  1000

= 8.81 per thousand total births

 Calculations Based on Vital Statistics
279

Number of deaths under 28 day of age in a

Neonatal
year mortality rate = × 1000
Number of live births in same year
200 (< 1 week) + 150 ( 1 week to 28
day) × 1000
=
9000
350
=  1000
9000
= 38.8 per thousand live births

Number of deaths after 28 day up to 1 year in a

Post-neonatal
year mortality rate = × 1000
Total number of live births in same year
730
=  1000
9000
= 81.1 per thousand live births

Comments
As all infant mortality rates are high, strengthening of MCH and general health services in essential.
Availability, utilization and effectiveness of the services should be monitored.

7. In a town with 1 lakh population, there were 2000 births, 200 infant deaths in the year 1992. 80 infants
died within 28 day of life, while 40 of them died in the 1st week of life. There were 110 still births in the
same year. Calculate all vital rates and ratio.
Population of the town 100,000
Live birth 2000
Infant death 200
Deaths within 28 day of life 80
Infant death in first week of life 40
Still births 110

Solution:
Number of deaths under 1 year of
Infant
age mortality rate = × 1000
Number of live births
200
=  1000
2000
= 100 per thousand live births
Number of deaths below 28 day of life
Neonatal mortality rate = Number of live births
80
=
2000  1000
= 40 per thousand live births
280 Section III: Exercises (Problems and Their
Solutions)

Still births + Death within one

Perinatal
week mortality rate = × 1000
Number of live births

110  40
=
 1000
2000
150
=
2000  1000
= 75 per thousand live births

Number of deaths between 28 day and 1 year of

Post-neonatal mortality rate =
life × 1000
Number of live births

Number of Infant deaths  Deaths within 28 day of life

= Number of live births × 1000

200  80
= 2000  1000
120
=
2000  1000
= 60 per thousand live births

Number of still births

Still birth rate = Number of still births + Live × 1000
births

110
=  1000
110 
2000
110
=
2110  1000
= 52.13 per thousand total births
Number of live births in the city during the
Crude
year birth rate = × 1000
Mid-year population

2000
=  1000
100,
000

= 20 per thousand mid-year population (MYP)

8. Mortality observed in villages of India, Japan and USA is given. Calculate the proportional mortality
rate. Give your remarks.
Place Total Deaths 0–5 year Death
India 500 156
USA 80 4
 Calculations Based on Vital Statistics
Japan 50 1 281
282 Section III: Exercises (Problems and Their
Solutions)
Number of deaths in 0 to 5 year
Proportional mortality (0-5 year) = ×100
Total number of deaths
156
Proportional Mortality (India) =  100  31.2%
500
4
Proportional Mortality (USA) =  100  5.0%
18
Proportional Mortality (Japan) =  100  2.0%
50

Proportional mortality of under fives in India is 15 times higher than in Japan and 6 times higher than in USA.

9. The census population of India in 2001 census was 1027 million, it was 844 million in 1991 census. Esti-
mate the mid-year population of India for 2009.

Solution:
Estimation of mid-year population
Census population is the actual (censused) population as on March 1st of the census year. Census is carried out
once in 10 year since 1881.
Mid-year population is the population estimated as on July 1st (Mid Point) of the year.
Population projection is estimation of population of any future year
Mid-year population is calculated by arithmetic progression mentioned using the formula.
P P  1  P2  P1 
P  P2  2 1  d 
  
 n 3  n 

 Where, P = Population being estimated–Mid-year (June) population of 2009
P1 = Earlier census population—1991 census (March) population
P2 = Latest census population—2001 census (March) population
n = Number of year between earliest and latest census
= March 1991 to March 2001 = 10 year
d = Number of year between latest census (P2) and mid-year population
estimating year = 9 year
1/3rd* = Adding 4 month population (March 1st 2009 to June 31st 2009)
* It is necessary to add 4 month (1/3rd of year) population as we are calculating population up to census month
(March 1st) of the year. But mid-year population is as on July 1st, thus interval between March to June is 4 month
should be added.

Calculation of mid-year population of 2009

Population of India in 1991, P1 = 844 million
Population of India in 2001, P2 = 1027 million
Population of India in 2009, P = to be calculated
 Calculations Based on Vital Statistics
283
 P2  P1  1  P2  P1 
PP  d
2    
 n  3  n 
 1027  844  1  1027  844 
 1027  9
   
 10  3  10 
 183  1  183 
 1027   9
   
3  10 
 10 
1
 1027  18.3 9  18.3
3

 1027  164.7  6.1

= 1197.8
Therefore, mid-year population of 2009 is 1197.8 million

Calculation of mid-year population by arithmetic progression method

1. Rate of increase in population per year

Growth of population for 10 year (between 1991 and 2001)
Population of India in 2001 = 1027 million
Population of India in 1991 = 844 million
Population growth for 10 year =1027 − 844 = 183 million
183
So, growth of population in 1 year =
10
= 18.3 million

2. Time gap between March 2001 (census year) and July (mid-year) 2009 is 9 year and 4 month
Population growth for 1 year is 18.3 million.
So, what is the growth for 9 year and 4 month?
1
 18.3 9  (18.3)
3
= 18.3 x 9 + 6.1
= 164.7 + 6.1
= 170.8 million
Population of India in 2009 = Population in 2001 + growth in 9.25 year
= 1027 million + 170.8 million
= 1197.8 million

Therefore, mid-year population of India in 2009 is 1197.8 million.

284 Section III: Exercises (Problems and Their
Solutions)
10. A town reveals the following data,
Population of town in 1991 37,000
Population of town in 2001 40,000
Total live births during 2001 1,080
Total deaths during 2009 450
Infective hepatitis cases 180
Deaths due to hepatitis 10
Calculate the crude birth rate, crude death rate, case fatality rate, cause specific death rate and propor-
tional death rate due to hepatitis-B for 2009.
Solution:

Calculation of mid-year population of the town in 2009

Population of the town in 1991, P1 = 37,000
Population of the town in 2001, P2 = 40,000
Population of the town in 2009, P = to be calculated
n = number of year between earliest and latest census = 10
d = number of year between latest census and mid-year population = 9
P P  1  P2  P1 
PP  2 1 d
2    
 n  3  n 
 40, 000  37, 000  1  40, 000  37, 000 
 40, 000   9
   
 10  3  10 
 3000  1  3000 
 40, 000   9
   
 10  3  10 
1
 40, 000  300  9  (300)
3
 40, 000  2, 700  100

= 42,800
Therefore, mid-year population of the town in 2009 is 42,800.

Number of births during the year

Crude
2009 birth rate = × 1000
Mid-year population

1080
=
42,800  1000
= 25.23 per thousand mid-year population
Number of deaths during the year 2009
Crude death rate = × 1000
Mid-year population

450
=
42,800  1000
= 10.5 per thousand mid-year population
 Calculations Based on Vital Statistics
285

Number of deaths from hepatitis-B during the year

Specific
2009 death rate = × 1000
Mid-year population

10
=
42,800  1000
= 0.2 deaths per thousand mid-year population

Case fatality rate Total number of deaths due to particular disease × 100
 (Hepatitis) Total number of same illness
(ratio)
(Hepatitis)

10
= 1800  100

= 5.5 %

Proportional mortality rate from hepatitis

Total number of deaths due to a particular
 disease Total number of deaths due to all × 100
cause

10
= 450  100
= 2.2
286 Section III: Exercises (Problems and Their
Solutions)

PART IV

FIELD STUDY

17. Family Study

18. Village or Community

19. Anganwadi Visit

20. Subcenter

21. Primary Health Center

22. Hospital

23. RNTCP Cell

24. Urban Leprosy Unit

25. ICTC Integrated Counselling and Testing Center

26. District Malaria Office

27. Public Water Purification System

28. Milk Dairy

29. Industry or Factory

30. School
 Chapte
r Family Study

17

Family—A group of persons related by marriage, blood and adoption residing together and sharing common shelter, kitchen
and property.
Name of the students: Institution:
Date of study: Time:

GENERAL INFORMATION
Name of the village/city ward: Subcenter: PHC:

Family Studied
Head of the Family: Address:
Habituated since: years
If migrated, details: Duration , Previous Place , Reason for migration
Nationality:

FAMILY PROFILE
Family Structure
Age Number Total
(in completed years)
Male Female
Infants (< 1
yr) 1–5
years
6–15 years
16–64 years
> 65 years

Family Size
Total number of persons in the family:

Demographic Family Size

Number of children a woman has given birth at a point of time:

Dependency Status
Total dependency=(Members of < 15 yr + > 65 yr):
264 Part IV: Field
Study
Number of children (< 15 yr):
Number of geriatrics (> 65 yr):
Dependency Ratio
Persons < 15 yr + > 65 yr : Persons 15–64 yr= :

Family Composition
Family type: Nuclear/Joint/Three generation Total members:
Sl Name Age Sex Marital status• Education Occupation Income Immunization Medico social
No (yrs) status(< 5 yr) conditions*

Total family income

Per capita monthly income
= Total family members

 Martial status: Married, unmarried, window/widower

* Medico social conditions
Physiological conditions: Infant, pregnancy, lactation, improvident maternity, old
age Medical conditions: Leprosy, TB, cancer, hypertension, diabetics, HIV, etc
Social conditions: Disability, mental retardation, psychiatric conditions, alcoholic, unwed pregnancy, divorce, etc.

Vital Events in the Family

Vital events during Number Age Sex Other details
last one year
Birth
Adoption
Marriage
Divorce
Death Cause of death:
Serious
sickness 1.
2.
3.

SOCIOECONOMICAL STATUS (SES) ASSESSMENT

Social Status of the Family
Religion : Hindu/Muslim/Christian/Others
Caste: SC/ST/Others
Language known: Local, Hindi, English, Others
Social recognition: Yes/[Link] yes, recognized
as:
 Family Study 265

Social harmony: Good/Not so good

Social participation: Present/[Link] present, how:
Social interaction: Present/Absent
Social rejection: Yes/[Link] yes, reason for rejection:

Literacy Status of the Family

Family head: Literate/Illiterate. Education level:
Literacy rate of the family: Male: %
Female: %
Total: %

Occupational Status of the Family

Family occupation: Agriculture/Agricultural laborer/Others
Nature of occupation: Unskilled/Semiskilled/Skilled/Professional

Ecomonic Status
Job availability: Sufficient/Insufficient
Possession: Land Cattle House Tractor
Radio TV Vehicle Bank deposit
Economic strata: BPL/APL/Poor/Landless
Income: Sufficient/Just to meet/Insufficient for food and basic
needs Expenditure towards: Food:%
Health: %
Savings and debts:
Socioeconomic class (According to modified BG Prasad/Kuppuswamy classification) BPL
—Calorie intake of a person < 2400 Kcal in rural area, 2100 Kcal in urban area (Planning commission of India)

Privileges
Financial benefits from government: Old age pension
Widow pension
Handicap pension
Ration at subsidized rate
Others
Health insurance benefits (cards) from Government: 1.
2.
Utilization of social services: 1. Health
2. Others
266 Part IV: Field
Study
CULTURAL PRACTICES
Family Cultural Practices
Practices Details of practice Remarks
Cow dung smearing to floor
White wash and DDT spray to
home Taking bath regularly
Washing hands
Oral hygiene (Brushing)
Sharing towel, soap, brush,
bedding Eating from common
plate
Smoking with common hucca
Indiscriminate spitting in and
around the house
Smoking and drinking

Practices among Women and Children

Practices Details of practice Remarks
Menstrual hygiene
Age at female marriage
Consanguineous marriage
Pregnancy care seeking
Delivery place and person
opting Breast feeding
Weaning
Immunization
Family
planning
Preference for male
child Neglecting girl
child Pardha system
Child defecation in and around
the house
Smoking and drinking of
women Women eating after
male Family size decision

LIVING ENVIRONMENT
Physical Environment (Housing)
House is a dwelling structure used by man for settlement, which provides physical, mental and social health needs of an indi-
vidual and of the family
Perimeter of the house:
Locality of house: Congested/Non-congested area
Environmental pollution: Air, noise, toxic fumes, odour, dust, others
Environmental disturbances: Weather inclemency, moisture, open drain,
others Connectivity: Road, School, hospital, social, cultural, recreational
places, etc.
 Family Study 267

House
Tenure: Own/Rent
Type of house: Independent/Attached
Attachment: Side to side/Back to back/Both
Set back: Adequate/Inadequate/Nil

Construction
Roof: RCC/Tile/Zinc
sheet/Thatched/Other Floor:
Mud/Cement/Stone/Others
Walls: Mud/Brick/Cement/Stone/Others
Construction safety: Yes/No
Spatial (living space): Sufficient/Insufficient
Living space (rooms): Adequate/Inadequate
Overcrowding: Present/Absent
Doors and windows space:
Sufficient/Insufficient Lighting:
Sufficient/Insufficient
Ventilation: Sufficient/Insufficient
Cross ventilation: Present/Absent
Dampness: Present/Absent
Bath room: Separate/Not seperate
Bathroom drainage: Hygienic/Unhygienic

Kitchen
Separate: Yes/No
Space: Spacious/Congested
Light: Adequate/Inadequate
Ventilation: Adequate/Inadequate
Fuel used: Wood/Coal/Gas/Others
Chullah used: Smokeless/Smoke letting
Smoke ventilation: Present/Absent
Raw and cooked food kept: Hygienic/Unhygienic

Water Supply
Water source: Public/Private/Well/River/Bore well
Pollution at Source: Present/Absent
Purification of public water: Done/Not
done Distance to walk to get water: km
Drinking water being used: Boiled/Filtered/Chlorinated/Not
purified Water sufficiency: Yes/No
Water storage and handling: Hygienic/Unhygienic
Amount of water used: liter/person/day

Waste Disposal
Garbage disposal: Hygienic/Unhygienic
268 Part IV: Field
Study
Waste water drainage: Hygienic/Unhygienic
Solid waste disposal: Hygienic/Unhygienic
Toilet: Present/Absent
Toilet maintenance: Hygienic/Unhygienic

Biological Environment
Cockroaches, rat problem: Present/Absent
Snakes, scorpion: Present/Absent
Mosquitoes, flies: Present/Absent
Animals kept: Cattle/Poultry/Pets/Others
Animal living: Inside/Outside the house
Maintenance of cattle shed: Hygienic/Unhygienic
Cleanliness of premises: Clean/Unclean
Surroundings of house: Water collection/Flies and mosquitoes breading/Children excreta/Dogs/Poultry/Pig/Rats/Others

Psychosocial Enviornment
Stressful situation in the family
1.
2.
3.
Prepare a sketch of the house:

DIETARY (NUTRITIONAL) ASSESSMENT

Food practices
Food Habits: Vegetarianism/Non-vegetarianism
Meal pattern: Bed tea, breakfast, mid morning lunch, evening tea, dinner, bed time drink

Diet Survey
(By oral questionnaire method)
Food items Family Consumption per Nutrients available
day (gm)
Protein Carbohydrate Fat Energy
(gm) (gm) (gm) (Kcal)
Cereals
Pulses
Vegetables
Milk
Oil and fat
Sugar and
jaggery
Total
 Family Study 269

Calculation of energy consumption unit (CU) for the family:

Family member Sex Occupational activities CU × Number of person
Male Sedentary 1 × =
Male Moderate 1.2 × =
Male Heavy 1.6 × =
Female Sedentary 0.8 × =
Female Moderate 0.9 × =
Female Heavy 1.2 × =
Children (Age group)
1–3 0.4 × =
3–5 0.5 × =
5–7 0.6 × =
7–9 0.7 × =
9–12 0.8 × =
12–21 1.0 × =
Total consumption units of the family is
1 consumption unit = 2400 Kcal/day

Calculation of Nutrient Requirements

Energy requirement of family = Family CU units × 2400 Kcal
= ×
= Kcal
Nutrient Percentage of total energy required Requirement (in gm)
Protein 15% Kcal
Fat 20% Kcal
Carbohydrate 65% Kcal
Note: 1 gm of protein provides: 4 Kcal
1 gm of fat provides: 9 Kcal
1 gm of carbohydrate provides: 4 Kcal

Assessment of Adequacy of Dietary Intakes

Balanced diet Family requirement Family Consumption Quantification

RDI Deficient Excess

Cereals
Pulses
Vegetables
Milk
Oil and fat
Sugar and jaggery
270 Part IV: Field
Study

Nutrients
• Protein
• Carbohydrate
• Fat
• Energy

Inference

Individual Food Practice

Family members Taboos, restriction and prejudice Inference

Healthy/Unhealthy
Infant
Children
Pregnancy and lactation
Adolescent
Girls
Others

Family Food Practices

Particulars Inference
Major nutrient used Protein/Carbohydrate/Fat
Using Greens, vegetables, fruits Yes/No
Fermentation of grains Yes/No
Sprouting of grains Yes/No
Use of iodized salt Yes/No
Cooking and storing practices Nutritious/Non-nutritious

FAMILY HEALTH PROFILE

Examine and interview all persons present during your visit, by giving priority to vulnerable individuals. Briefly summarize
the findings:
Pregnant women not registered Family planning non-acceptors
Seriously/Chronically ill persons Low birth weight child
Severely malnourished child Unimmunized child
Maternal, neonatal or child death Severe anemia
Pneumonia, diarrhea, vitamin A deficiency in child
 Family Study 271

Availability and Utilization of Health Care Services

Particulars of health care services Awareness regarding Utilization of health Reason for non-utilization
availability of services care services
Yes/No
Women
Antenatal
examination Iron
folic acid tablets
Tetanus toxoid
Delivery by trained
Dai Postnatal
services
Contraception
Health education
Children
Growth
monitoring
Immunization
Oral rehydration therapy (ORT)
Anganwadi services
Supplementary nutrition
Breast feeding promotion
Family health services
Family health awareness campaign
(FHAC)
Common illness
Malaria, TB, HIV, others

Home Visit by Health Care Provider

Health care provider Frequency of Home visit Services provided
1. Accredited social health activist (ASHA)
2. Junior health assistant female (JHAF)
Health worker female
3. Trained birth attendant (TBA)
4. DDT Sprayer
5. Medical officer
6. NGOs, mahila mandals, women
groups and others
7. Family health awareness campaign
(FHAC)

Treatment Seeking Priority

Traditional healer Home remedies
Private clinic and hospital Going to temple
Primary health care system Self medication
Aurveda, homeopathy and other indigenous health system Drug store
272 Part IV: Field
Study
Assessment of Knowledge, Attiude and Practice (KAP)
Health particulars Knowledge Attitude Practices
(Beliefs and customs)
Growth
monitoring Oral
rehydration
Breast feeding
Immunization
Family planning services
Food in pregnancy
and childhood
Causes and cure of
common illness like
measles, diarrhea
Sanitation and
hygiene Psychiatric
condition Pregnancy
—Delivery
Emergency

FELT NEEDS OF THE FAMILY

Health needs General needs
Free medical services Housing
Free dental services Water
Cataract camps Toilet and drainage
Specialist services Education facilities
Services during night and emergency Food—Availability
Ambulance (transport) services Government benefits
Others Others

SUMMARY OF THE FAMILY STUDIED

1. Socioeconomic status 5. Health profile
2. Cultural practices 6. Utilization of health services
3. Living environment 7. KAP regarding health
4. Nutritional status 8. Felt health needs

ADVICE
Write your recommendation for improvement of
family Living conditions
Lifestyle
Hygiene practices
Health seeking behavior
Utilization of health services.
Physical, mental and social health of the family.
 SECTION IV

FIELD STUDY

17. Family Study

18. Village or Community

19. Anganwadi Visit

20. Subcenter

21. Primary Health Center

22. Hospital

23. RNTCP-DMC

24. Urban Leprosy Unit

25. ICTC Integrated Counselling and Testing Center

26. District Malaria Office

27. Public Water Purification System

28. Milk Dairy

29. Industry or Factory

30. School
 Chapte
r Family Study

17

Family—A group of persons related by marriage, blood and adoption residing together and sharing common shel-
ter, kitchen and property.
Name of the students: Institution:
Date of study: Time:

GENERAL INFORMATION
Name of the village/city ward: Subcenter: PHC:

Family Studied
Head of the Family: Address:
Habituated since: year
If migrated, details: Duration , Previous place , Reason for migration
Nationality:

FAMILY PROFILE
Family Structure
Age Number
Total
(in completed years) Male Female
Infants (< 1
year) 1–5
year
6–15 year
16–64 year
> 65 year

Family Size
Total number of persons in the family:

Demographic Family Size

Number of children a woman has given birth at a point of time:

Dependency Status
Total dependency=(Members of < 15 yr + > 65 yr):
286 Section IV: Field
Study
Number of children (< 15 yr):
Number of geriatrics (> 65 yr):
Dependency Ratio
Persons < 15 yr + > 65 yr : Persons 15–64 yr = :

Family Composition
Family type: Nuclear/Joint/Three generation Total members:
Sl Name Age Sex Marital status• Education Occupation Income Immunization Medico social
No (yrs) status (< 5 yr) conditions*

Total family income

Per capita monthly income =
Total family members
 Marital status: Married, unmarried, widow/widower
* Medico social conditions
Physiological conditions: Infant, pregnancy, lactation, improvident maternity, old age
Medical conditions: Leprosy, TB, cancer, hypertension, diabetics, HIV, etc
Social conditions: Disability, mental retardation, psychiatric conditions, alcoholic, unwed pregnancy, divorce, etc.

Vital Events in the Family

Vital events during Number Age Sex Other details
last one year
Birth
Adoption
Marriage
Divorce
Death Cause of death:
Serious
sickness 1.
2.
3.

SOCIOECONOMICAL STATUS ASSESSMENT

Social Status of the Family
Religion: Hindu/Muslim/Christian/Others
Caste: SC/ST/Others
Language known: Local, Hindi, English, Others
 Family Study 287

Social recognition: Yes/[Link] yes, recognized as:

Social harmony: Good/Not so good
Social participation: Present/[Link] present, how:
Social interaction: Present/Absent
Social rejection: Yes/[Link] yes, reason for rejection:

Literacy Status of the Family

Family head: Literate/Illiterate. Education level:
Literacy rate of the family: Male: %
Female: %
Total: %

Occupational Status of the Family

Family occupation: Agriculture/Agricultural laborer/Others
Nature of occupation: Unskilled/Semiskilled/Skilled/Professional

Economic Status
Job availability: Sufficient/Insufficient
Possession: Land Cattle House Tractor
Radio TV Vehicle Bank deposit
Economic strata: BPL*/APL/Poor/Landless
Income: Sufficient/Just to meet/Insufficient for food and basic needs
Expenditure towards: Food: %
Health: %
Savings and debts:
Socioeconomic class (According to modified BG Prasad/Kuppuswamy classification)
*BPL— Per day calorie intake of a person < 2400 Kcal in rural area, 2100 Kcal in urban area (Planning commission
of India) and per capita daily income < ` 15 in rural area, < ` 20 in urban area.

Privileges
Financial benefits from government: Old age pension
Widow pension
Handicap pension
Ration at subsidized rate
Others
Health insurance benefits (cards) from Government: 1.
2.
Utilization of social services: 1. Health
2. Others
288 Section IV: Field
Study
CULTURAL PRACTICES
Family Cultural Practices
Practices Details of practice Remarks
Cow dung smearing to floor
White wash and DDT spray to
home Taking bath regularly
Washing hands
Oral hygiene (Brushing)
Sharing towel, soap, brush,
bedding Eating from common
plate
Smoking with common hucca
Indiscriminate spitting in and around the
house Smoking and drinking

Practices Among Women and Children

Practices Details of practice Remarks
Menstrual hygiene
Age at female marriage
Consanguineous marriage
Pregnancy care seeking
Delivery place and person
opting Breast feeding
Weaning
Immunization
Family
planning
Preference for male
child Neglecting girl
child Pardha system
Child defecation in and around the
house Smoking and drinking of
women
Women eating after male
Family size decision

LIVING ENVIRONMENT
Physical Environment (Housing)
House is a dwelling structure used by man for settlement, which provides physical, mental and social health needs
of an individual and of the family
Perimeter of the house :
Locality of house : Congested/Non-congested area
Environmental pollution : Air, noise, toxic fumes, odor, dust, others
Environmental disturbances : Weather inclemency, moisture, open drain, others
Connectivity : Road, School, hospital, social, cultural, recreational places, etc.
 Family Study 289

House
Tenure : Own/Rent
Type of house : Independent/Attached
Attachment : Side to side/Back to back/Both
Set back : Adequate/Inadequate/Nil

Construction
Roof : RCC/Tile/Zinc sheet/Thatched/Other
Floor : Mud/Cement/Stone/Others
Walls : Mud/Brick/Cement/Stone/Others
Construction safety : Yes/No
Spatial (living space) : Sufficient/Insufficient
Living space (rooms) : Adequate/Inadequate
Overcrowding* : Present/Absent
Doors and windows space : Sufficient/Insufficient
Lighting : Sufficient/Insufficient
Ventilation : Sufficient/Insufficient
Cross ventilation : Present/Absent
Dampness : Present/Absent
Bath room : Separate/Not seperate
Bathroom drainage : Hygienic/Unhygienic
* Overcrowding : Floor area of living room < 50 sq ft/person ( < 1 year is counted as 0; 1–10 year as
½) Two opposite sexes > 9 year not couple are obliged to sleep in the same room.
Kitchen
Separate : Yes/No
Space : Spacious/Congested
Light : Adequate/Inadequate
Ventilation : Adequate/Inadequate
Fuel used : Wood/Coal/Gas/Others
Chullah used : Smokeless/Smoke letting
Smoke ventilation : Present/Absent
Raw and cooked food kept : Hygienic/Unhygienic

Water Supply
Water source : Public/Private/Well/River/Bore well
Pollution at Source : Present/Absent
Purification of public water : Done/Not done
Distance to walk to get water : km
Drinking water being used : Boiled/Filtered/Chlorinated/Not purified
Water sufficiency : Yes/No
Water storage and handling : Hygienic/Unhygienic
Amount of water used : Liter/person/day
290 Section IV: Field
Study
Waste Disposal
Garbage disposal : Hygienic/Unhygienic
Waste water drainage : Hygienic/Unhygienic
Solid waste disposal : Hygienic/Unhygienic
Toilet : Present/Absent
Toilet maintenance : Hygienic/Unhygienic

Biological Environment
Cockroaches, rat problem : Present/Absent
Snakes, scorpion : Present/Absent
Mosquitoes, flies : Present/Absent
Animals kept : Cattle/Poultry/Pets/Others
Animal living : Inside/Outside the house
Maintenance of cattle shed : Hygienic/Unhygienic
Cleanliness of premises : Clean/Unclean
Surroundings of house : Water collection/Flies and mosquitoes breading/Children excreta/Dogs/Poultry/
Pig/Rats/Others
Psychosocial Enviornment
Stressful situation in the family
1.
2.
3.
Prepare a sketch of the house:

DIETARY (NUTRITIONAL) ASSESSMENT

Food practices
Food Habits: Vegetarianism/Non-vegetarianism
Meal pattern: Bed tea, breakfast, mid morning lunch, evening tea, dinner, bed time drink

Diet Survey
(By oral questionnaire method)
Nutrients available
Family Consumption per
Food items Protein Carbohydrate Fat Energy
day (gm)
(gm) (gm) (gm) (Kcal)
Cereals
Pulses
Vegetables
Milk
Oil and fat
Sugar and
jaggery
Total
 Family Study 291

Calculation of Energy Consumption Unit (CU) for the Family

Family member Sex Occupational activities CU × Number of person
Adults Male Sedentary 1 × =
Male Moderate 1.2 × =
Male Heavy 1.6 × =
Female Sedentary 0.8 × =
Female Moderate 0.9 × =
Female Heavy 1.2 × =
Children (Age group)
1–3 0.4 × =
3–5 0.5 × =
5–7 0.6 × =
7–9 0.7 × =
9–12 0.8 × =
12–21 1.0 × =
Total consumption units of the family is
1 consumption unit = 2400 Kcal/day

Calculation of Nutrient Requirements

Energy requirement of family = Family CU units × 2400 Kcal
= × 2400
= Kcal
Nutrient Percentage of total energy required Requirement (in gm)
Protein 15% Kcal
Fat 20% Kcal
Carbohydrate 65% Kcal
Note: 1 gm of protein provides: 4 Kcal
1 gm of fat provides: 9 Kcal
1 gm of carbohydrate provides: 4 Kcal

Assessment of Adequacy of Dietary Intakes

Family requirement Quantification

Balanced diet Family Consumption
RDI Deficient Excess

Cereals
Pulses
Vegetables
Milk
Oil and fat
Sugar and jaggery
Nutrients
•Protein
•Carbohydrate
•Fat
•Energy
292 Section IV: Field
Study
Inference

Individual Food Practice

Family members Taboos, restriction and prejudice Inference
Healthy/Unhealthy
Infant
Children
Pregnancy and lactation
Adolescent
Girls
Others

Family Food Practices

Particulars Inference
Major nutrient used Protein/Carbohydrate/Fat
Using Greens, vegetables, fruits Yes/No
Fermentation of grains Yes/No
Sprouting of grains Yes/No
Use of iodized salt Yes/No
Cooking and storing practices Nutritious/Non-nutritious

FAMILY HEALTH PROFILE

Examine and interview all persons present during your visit, by giving priority to vulnerable individuals. Briefly
summarize the findings:
Pregnant women not registered Family planning non-acceptors
Seriously/Chronically ill persons Low birth weight child
Severely malnourished child Unimmunized child
Maternal, neonatal or child death Severe anemia
Pneumonia, diarrhea, vitamin A deficiency in child
 Family Study 293

Availability and Utilization of Health Care Services

Utilization of health
Awareness regarding
Particulars of health care services care services Reason for non-utilization
availability of services
Yes/No
Women
Antenatal
examination Iron
folic acid tablets
Tetanus toxoid
Delivery by trained
Dai Postnatal
services
Contraception
Health education
Children
Growth
monitoring
Immunization
Oral rehydration therapy (ORT)
Anganwadi services
Supplementary nutrition
Breast feeding promotion
Family health services
Family health awareness campaign
(FHAC)
Common illness
Malaria, TB, HIV, others

Home Visit by Health Care Provider

Sl No Health care provider Frequency of Home visit Services provided
1. Accredited social health activist (ASHA)
2. Junior health assistant female (JHAF)
Health worker female, ANM
3. Trained birth attendant (TBA)
4. DDT Sprayer
5. Medical officer
6. NGOs, mahila mandals, women
groups and others
7. Family health awareness campaign
(FHAC)

Treatment Seeking Priority

Traditional healer Home remedies
Private clinic and hospital Going to temple
Primary health care system Self medication
Ayurveda, homeopathy and other indigenous health system Drug store
294 Section IV: Field
Study
Assessment of Knowledge, Attitude and Practice (KAP)
Attitude
Health particulars Knowledge Practices
(Beliefs and customs)
Growth
monitoring Oral
rehydration
Breast feeding
Immunization
Family planning services
Food in pregnancy
and childhood
Causes and cure of
common illness like
measles, diarrhea
Sanitation and
hygiene Psychiatric
condition Pregnancy
—Delivery
Emergency

FELT NEEDS OF THE FAMILY

Health needs General needs
Free medical services Housing
Free dental services Water
Cataract camps Toilet and drainage
Specialist services Education facilities
Services during night and emergency Food—Availability
Ambulance (transport) services Government
benefits
Others Others

SUMMARY OF THE FAMILY STUDIED

1. Socioeconomic status 5. Health profile
2. Cultural practices 6. Utilization of health services
3. Living environment 7. KAP regarding health
4. Nutritional status 8. Felt health needs

Review Questions
 Write your recommendation for improvement of
family Living conditions
Lifestyle
Hygiene practices
Health seeking behavior
Utilization of health services.
Physical, mental and social health of the family
 Discuss the role of family in health and disease.
 Chapte
r
Village or
Community
18
A group of individuals and families habituating together in a defined geographic area.
Name of the students visiting:
Date of visit:

GENERAL INFORMATION
Name of the village/city: Area/Ward:
Address for location:
Nearest road: Nearest city: Nearest health center:
Distance from head quarters of taluk: District: State:
Topography: Altitude Latitude
Rainfall Soil
Landscape: Plain/Hilly/Mair land/Dry land.
Ecological condition:
Languages spoken:
Main occupation of people:
Main production:
Status of the place:
Backward/Slum/Tribal Major fairs and
festivals:
Main food grown/eaten:
Leadership pattern: Grama panchayat/Panchayat samithi/Zilla parishat/Mahila mandal/Youth group

FACILITIES
Health Care
PHC Sub-center Anganwadi
Emergency services, Mobile units,
Medial practitioner, Drug stores, Dental Care

Education
Anganwadi, primary, middle, high school,
college Job oriented training center (specify):
Adult education:

Water Supply and Sanitation

274 Part IV: Field
Study
Water supply:
Latrine: Community/Individual/Open field defecation
Drainage: House drainage (soakage pit)/Public drainage
Solid waste/garbage disposal: Sanitary/Indiscriminate
Cattle shed location: In dwelling place/Separate
Cattle shed maintenance: Hygienic/Unhygienic
Fuel used:
Animal excreta disposal:
Menace of: Dogs, rats, flies, mosquitoes, pigs, wild animals
Vector control activities: Present/Absent
Immunization coverage:
Birth and death registration:

Other Facilities
Income generation: Poultry, animal husbandry, piggeries, dairy, industries, small scale
industries Financial: Bank, Cooperative society
Electricity:
Fuel availability/used:
Media: Library, TV, newspaper, radio
Transport: Bus, train, others
Communication: Postal, telephonic, internet
Social needs: Worship places—Temple, Church, Masjid,
others Cinema houses, recreation places, play
ground Slaughter houses, wine shops, hotels, etc.
Voluntary organization: Youth club, mahila mandal, srisakthi,
others Community development/Self help group:

COMMUNITY DIAGNOSIS
Demoraphic Profile
Total population: Number of houses:
Average persons in a family:
Age and sex composition of population:
Age in years Male Female Total
< 1 year
1–5 years
6–14 years
15–45 years
46–64 years
> 65 years
Total
Sex ratio: Females per thousand males
Dependency ratio = No of persons < 15 yr + > 65 yr : 15–64 yr
= :
 Village or Community
275
Social Profile
Housing: Pucca %, kutcha %
Type of family: Joint %, nuclear %, three generation %
Religion: Hindus %, muslims %, christians %, others %
Socioeconomic strata: Upper %, middle %, poor %, below poverty line %
Literacy rate: Male %, female %, total %
(Above 7 years)
Families below poverty line:
Underweight/LBW children:
Common illness:
Communicable:
Non-communicable:
Endemic diseases:
Childhood illness:
Important killer diseases:

Health and Family Welfare Indicators

Crude birth rate:
Crude death rate:
Crude growth rate:
Eligible couples:
Contraceptive users:
Sex ratio:
Number of marriages in one year
General marriage rate (women) =
Number of unmarried of 15-45 years

Number of female deaths duee to pregnancy,

delivery and with in 42 days after
Maternal mortality rate (MMR) 1000
= delivery Total number of live birth in
that year
Number of deaths of children < 1 year
Infant mortality rate (IMR) = 1000
Number of live birth in one year
Number of live births in an area
General fertility rate (GFR) =
1000
Mid-year population of 15 �44 years

Confirmed cases of malaria in one year

Annual parasite index (API) = Population under surveillance 1000

TB case load (prevalence)%

Percentage of total expenditure on health:
Doctor population ratio:

Common Practices of the Community

Marriage at younger age < 18 years
Contraception
276 Part IV: Field
Study
Antenatal checkup
Delivery practices
Child bearing and rearing practices
Breast feeding initiation and continuation
Weaning
Immunization
Child feeding
Treatment of minor
illness Dietary practices
Food practices for pregnancy and lactation
Food cooking and storage practices

Treatment seeking priority

Government agencies Private agencies
Traditional medicine Others

Health Care Providers of the Community

Village health guide School teacher
Trained birth attendant Village leaders
Anganwadi worker Women group
ASHA Health Staff
Health worker male/female Private practitioner
Others
Nutrition and other health care programmes operating:

Community Health Care Services—Assessment

providers and
Accessibility

Coordination

beneficiaries

Intersectoral

participation
coordination
Affordability

Coverage of

Community
Availability

services

between
Utilization
vulnerable

Components
of
group

Sate water
Sanitation
Child nutrition
Mother child care and family
planning
Treatment of common illness
Essential drugs
Health education

Intersectoral Coordination
(Collect the information from community leaders)
Agricultural, animal husbandry, food, industries,
education Housing, public work, communication, others
Coordination between provider and beneficiaries
 Village or Community
277
Community participation
Resource generation
Planning implementation monitoring and evaluation
Creating awareness
Utilizing the services
Felt needs of the community.

List of Needs According to Priority

Health needs Other needs
1. 1.
2. 2.
3. 3.
4. 4.

ADVICE
Prepare a detailed epidemiological map of the community visited
During village/community study, students are advised to visit nearby subcenter, PHC, etc. and inspect the activities of health
worker and others health activities, to have comprehensive knowledge about the community.
 Chapte
r
Village or
Community
18
Village or community—A group of individuals and families habituating together in a defined geographic area.
Name of the students visiting:
Date of visit:

GENERAL INFORMATION
Name of the village/city: Area/Ward:
Address for location:
Nearest road: Nearest city: Nearest health center:
Distance from head quarters of taluk: District: State:
Topography:Altitude Latitude
Rainfall Soil
Landscape: Plain/Hilly/Rainy land/Dry land.
Ecological condition:
Languages spoken:
Main occupation of people :
Main production:
Status of the place:
Backward/Slum*/Tribal Major fairs and
festivals:
Main food grown/eaten:
Leadership pattern: Grama panchayat/Panchayat samithi/Zilla parishat/Mahila mandal/Youth group
* Slum: Congested living area of > 300 population/> 60 households where basic facilities are lacking.

FACILITIES
Health Care
PHC Subcenter Anganwadi
Emergency services, mobile units,
Medical practitioner, drug stores, dental Care

Education
Anganwadi, primary, middle, high school,
college Job oriented training center (specify):
Adult education:
296 Section IV: Field
Study
Water Supply and Sanitation
Water supply: Water problem*
Latrine: Community/Individual/Open field defecation
Drainage: House drainage (soakage pit)/Public drainage
Solid waste/garbage disposal: Sanitary/Indiscriminate
Cattle shed location: In dwelling place/Separate
Cattle shed maintenance: Hygienic/Unhygienic
Fuel used:
Animal excreta disposal:
Menace of: Dogs, rats, flies, mosquitoes, pigs, wild animals
Vector control activities:
Present/Absent Immunization coverage:
Birth and death registration:
* Water problem
• Difficult to get even 150–200 liter in urban area and 40 liter in rural area/per person
• Safe water not available close to the home (< 1.6 km distance < 15 meter depth).

Other Facilities
Income generation: Poultry, animal husbandry, piggeries, dairy, industries, small scale
industries Financial: Bank, cooperative society
Electricity:
Fuel availability/used:
Media: Library, TV, newspaper, radio
Transport: Bus, train, others
Communication: Postal, telephonic, internet
Social needs: Worship places—Temple, Church, Mosque,
others Cinema houses, recreation places, play
ground Slaughter houses, wine shops, hotels, etc.
Voluntary organization: Youth Club, Mahila Mandal, Srisakthi, others
Community development/Self help group:

COMMUNITY DIAGNOSIS
Demoraphic Profile
Total population: Number of houses:
Average persons in a family:
Age and sex composition of population:
 Village or Community
297
Age in year Male Female Total
< 1 year
1–5 year
6–14 year
15–45 year
46–64 year
> 65 year
Total
Sex ratio : Females per thousand males
Dependency ratio = Number of persons < 15 year + > 65 year : 15–64 year
= :

Social Profile
Housing: Pucca %, kutcha %
Type of family: Joint %, nuclear %, three generation %
Religion: Hindus %, Muslims %, Christians %, others %
Socioeconomic strata: Upper %, Middle %, Poor %, Below poverty line %
Literacy rate: Male %, Female %, Total %
(Above 7 year)
Families below poverty line:
Underweight/LBW children:
Common illness:
Communicable:
Non-communicable:
Endemic diseases:
Childhood illness:
Important killer diseases:

Health and Family Welfare Indicators

Crude birth rate:
Crude death rate:
Crude growth rate:
Eligible couples:
Contraceptive users:
Sex ratio:
Number of marriages in 1 year
General marriage rate (women) =
Number of unmarried of 15  45 year
Number of female deaths due to pregnancy,
delivery and with in 42 day after
Maternal mortality rate (MMR)  1000
= delivery Total number of live birth in
that year
Number of deaths of children < 1 year
Infant mortality rate (IMR) =  1000
Number of live birth in 1 year
298 Section IV: Field
Study
Number of live births in an area
General fertility rate (GFR) =
 1000
Mid-year population of 15 to 44
year

Confirmed cases of malaria in 1 year

Annual parasite index (API) = Population under surveillance 1000

TB case load (prevalence)%

Percentage of total expenditure on health:
Doctor population ratio:

Common Practices of the Community

Marriage at younger age < 18 year
Contraception
Antenatal checkup
Delivery practices
Child bearing and rearing practices
Breast feeding initiation and continuation
Weaning
Immunization
Child feeding
Treatment of minor
illness Dietary practices
Food practices for pregnancy and lactation
Food cooking and storage practices
Treatment seeking priority
Government agencies Private agencies
Traditional medicine Others

Health Care Providers of the Community

Village health guide School teacher
Trained birth attendant Village leaders
Anganwadi worker Women group
ASHA Health staff
Health worker male/female Private practitioner
Others
Nutrition and other health care programmes operating:
 Village or Community
299
Community Health Care Services—Assessment

providers and
Accessibility

Coordination

beneficiaries

Intersectoral

participation
coordination
Affordability

Coverage of

Community
Availability

services

between
Utilization
vulnerable
Components

of
group
Sate water
Sanitation
Child nutrition
Mother child care and family
planning
Treatment of common illness
Essential drugs
Health education

Intersectoral Coordination
(Collect the information from community leaders)
Agricultural, animal husbandry, food, industries,
education Housing, public work, communication, others
Coordination between provider and beneficiaries

Community Participation
Resource generation
Planning implementation monitoring and evaluation
Creating awareness
Utilizing the services
Felt needs of the community.

List of Needs According to Priority

Health needs Other needs
1. 1.
2. 2.
3. 3.
4. 4.

Review Questions
 Prepare a detailed epidemiological map of the community visited
 During village/community study, students are advised to visit nearby subcenter, PHC, etc and inspect the activi-
ties of health worker and others health activities to get comprehensive knowledge about the community.
 Describe the health problems of villagers? Suggest the measures to prevent them.
 Chapte
r
Anganwadi
Visit
19
Anganwadi is the heart of Integrated child development services (ICDS) system which lays the foundation for
over- all development of a child.
Name of the student: Date and time of visit:

GENERAL INFORMATION
Name of Anganwadi: Address:
Working under ICDS project: PHC: Subcenter:
Population covered:

Staff Pattern
Particulars Anganwadi teacher Helper Mukya sevika
Name
Qualificati
on
Training
Residence
Duties

WORKING DAYS
Working Hours
Inspection
Building and Environment: Light, ventilation, toilet, water, cleanliness, safety
Food details: Observation of food preparation and distribution
Food supply: Continuous/Intermittent
Number of days food is supplied
Menu prepared:
Timing and method of food distribution:
Food hygiene: Preparation, storage, distribution
Nutritious (protein + calorie) food given:

MEDICINE AVAILABLE
Vitamin ‘A’ syrup, iron and folic acid tablets, others
 Anganwadi Visit 301

EQUIPMENTS AVAILABLE
Weighing machine Stadiometer (to measure height)
Mid arm tape Growth chart
Others
Educative materials: Pictures Games Toys

BENEFICIARIES OF ANGANWADI
Beneficiaries Estimated number and coverage Current utilization of services
norms
Number Percentage
0–3 year
3–6 year
Pregnant
mother
Lactating
mother
Adolescent girls (10–19 year)
Women of reproductive age (15–45
year)

NUTRITIONAL SERVICES PROVIDED

Supplementary nutrition programme (SNP) (300 days/year, according to revised policy, 2008)
Beneficiaries Energy (Kcal) Protein (gm)
Children (well nourished) 500 12–15
Malnourished children 800 20–15
Mothers 600 18–20
Other supplementation: Vitamin A, iron folic acid, others
Health education: Non-formal education to children
Nutritional education to mothers
Growth monitoring:

Malnutrition Grading
Particulars Number Percent Causes Action taken
Grade 2 < 2 SD*
Grade 3 < 3 SD
No malnutrition
Total
* < 2 SD—Malnourished
< 3 SD—Severely malnourished

Immunization
Done by:
Number of children fully immunized:
Number of children partially immunized:
Number of children not immunized:
Number of mothers immunized (TT):
Actions taken for non-immunized:
Routine health checkup:
302 Section IV: Field
Study
Treatment of Minor Ailments
Provider
Common ailments observed
Treatment given
Referral links: Referral center
Nutritional rehabilitation center
Subcenter

Feedback from Referral Centers

Nutrition education: Beneficiaries:
Method of education:

Other Activities
Community/Village mapping:
Enlisting beneficiaries:
Planning and implementation of ICDS programme:
Coordination: NGO, Mahila Mandal, Other department
Women literacy:
Environmental activities:
Women’s empowerment:
Programme for adolescent girls: Operating/Non-operating
Village health nutrition day:

Health Team Visits

Particulars Frequency of supervision Corrective action
Mukya
sevika
Medical
officer
Child development project officer
(CDPO)
Others

Records Maintained
1.
2.
3.

ROLE OF ANGANWADI
Increase in child weight
Increase in immunization coverage
Reduction in malnutrition
Reduction in school dropouts
Reduction in maternal and child mortality
Others.
 Anganwadi Visit 303

Review Questions
 Discuss about the services of Anganwadi under following headings
Accessible
Affordable
Equitable
Effective
Reliable
Accountable
 Describe administration of ICDS project. List six functions of anganwadi.
 Find the nutritive value of anganwadi food
 Comment on current growth chart used in anganwadi. What do you understand by Z score?
GROWTH CHART IN INDIAN ANGANWADIS
• Growth chart is called “Mother and child protection card”
• Chart is separate for boys and girls
• Chart shows: (i) Normal zone
(ii) Undernutrition (below 2 SD)
(iii) Severe undernutrition (below 3 SD)
• Direction of the growth curve is more important
• Flattening of curve is the earliest sign of Protein-energy malnutrition (PEM)
304 Section IV: Field
Study
 Chapte
r Subcenter

20

Name of the student: Date of visit:

GENERAL INFORMATION
Name of the subcenter: Address:
Concerned PHC: District: State:
Coverage population: Villages: Anganwadies:
Birth rate: Eligible couple of subcenter:

STAFF PATTERN
Particulars Health worker Helper Link worker Others
Male Female
Name
Qualification
Training
Stay (HQ)

OBSERVATION OF STRUCTURE
Building: Own (government), rental.
Accommodation for HWF: Present/Absent
Cleanliness of the center, ventilation
Basic facilities: Space for sitting, water, toilet, light, electricity,
etc. Room for clean and safe delivery
IEC material: Poster, models, flip charts
Display of area map and charts on health education

Furniture and Equipment

Examination table Bench for clients
Cleaning equipments Container for water storage
Sterilizer Delivery kit
Torch Stove
Fuel
282 Part IV: Field
Study
Equipment for Clinical Examination
Weighing scale Stethoscope
Height Foetoscope
BP apparatus Vaccine carrier
Hemoglobinometer Others
Family planning devices: Condom OC pills
IUD Others
Medicines: Iron folic acid tablets Tetanus toxoid
Vitamin ‘A’ solution ORS packets
Drugs for minor illness Others
Lab facilities: Urine, Hb %, blood smear collection, sputum examination, others
Health worker female kit: Note the contents of health worker kit.

ACTIVITIES AT SUBCENTER
Working days Working hours
Treatment of minor illness Lab examination: Urine, Hb %, MP, sputum
DOTS Health education
Maternal and child health (MCH) Immunization
and family planning clinics
First aid for emergencies Referral services
Referral linkage Ambulance linkage

Duties Of HWF/Junior Health Assistance Female (JHAF)

Number of field working days of HWF Number of hours spent in field/day
Mode of transport Time spent on transportation

Field Activities
Registration of pregnancy
Antenatal visits
Post-delivery visits (at least three)
Referral of antenatal and postnatal women with health problems
Distribution of contraceptives
Follow up of family planning adopters
Medical termination of pregnancy (MTP), advices for needy
Assessment of growth and development of children
Immunization
Breast feeding promotion
ORS advices
Distribution of medicines
Follow up care of referred and discharged
patients Blood smear collection
Collection of data on vital events
School health check up
Health need assessment
Participation in the National programme
 Subcenter 283

RTI/STI—Detection/Referral
Health need assessment

ASSESSMENT OF MATERNAL CARE ACTIVITIES (CSSM)

Particulars Estimated Registered (%)
Eligible
couple
Target
couple
Pregnant women
Eligible couple: Married and women aged between 15 and 45 years
(Roughly 170/1000 population)
Target couple: Couple who have two to three living children
Pregnant women: Number estimated by the formula, Population × Birth rate

DETAILS OF ANTENATAL VISITS

Number of visits No. of women Services provided
0
1
2
3
Number and % of pregnant women received iron and folic acid 100 tablets
Number and % of pregnant women received Tetanus Toxoid (TT)
Number and % of clean deliveries conducted by HWF/TBA
Number and % of deliveries conducted by untrained person at home
Number and % of home and institutional deliveries
Number and % of pregnant mothers referred

FAMILY PLANNING SERVICES

Family planning method Number of beneficiaries Percentage
OCP
Copper T
Condom
Tubectomy
Vasectomy

CHILD SURVIVAL ACTIVITIES

Growth monitoring Oral rehydration
Breast feeding promotion Immunization
Treatment of minor illness Nutritional supplementation

HEALTH EDUCATION
Topics Beneficiaries Method of education
MCH
Family health
Family planning
Child care
284 Part IV: Field
Study
Nutrition
Hygiene
Immunization
ORT
Breast feeding
Minor ailments

Coordination of Other Health Personnel

Medical Officer Women leaders
Mahila mandal Health worker male
Dai’s Village leaders

Training Activities
Dai/ASHA/Others

Attending Meeting
PHC, CD block, Mahila mandal

Records Maintained
Maternity record: Antenatal/Postnatal
Eligible couple categorizing
Under 5 children by age, sex, immunization, nutrition, and other details
Infants register:
Birth and deaths: Sending to registrar for registration and supervisor
Field visit and home visit register:
List of Dai’s in area:
Family planning: Copper-T, oral pill, sterilization, other
Notifiable diseases identified:
Subcenter clinical record:
Malaria blood smear register
Stock and issue register

HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS)

Monthly plan activities-schedule
Monthly reports sent to PHC
Feedback received on information
Evaluation
• Number of outreach session
• ANC 3 visits
• Home/institutional deliveries
• Number of TBA trained
• Infant fully immunized
• Number of ANC/Infants referred
 Subcenter 285

SUBCENTER DATA
Note the following data of last one year of the subcenter
Number of births: Number of deaths:
Number of maternal deaths: Number of infant deaths:
Number of smears taken for malaria: Number having
tuberculosis: Number of smear positive: MP:
Pf :
Number of persons having chronic diseases (communicable and non-communicable)
1.
2.
3.
Notifiable diseases identified
1.
2.
National health programme implemented in the subcenter
TB Immunization
Malaria Diarrhea disease
Pulse Polio Blindness
Others
Environmental sanitation activities
• Chlorination
• Preventing open air defecation
Health education: Basic sanitation, nutrition, immunization, etc.

SUPERVISION AND SUPPORT

Particulars Consultation of subcenter Frequency
Panchayat
Anaganwadi/Trained birth attendant (TBA)
Mahila mandal
Families

COMMUNITY NEED ASSESSMENT (CNA) REPORT

Observe and Make a Note on CNA Report
Vaccines
Family planning—Contraceptives
Iron folic acid tablets
Vitamin A
Others
Number of beneficiaries (not utilizing subcenter services)
Reasons of non-utilization of services
Corrective actions taken

Note the Activities of Health Worker Male

Make a list of short coming of subcenter observed, give your suggestions for improvement
 Chapte
r Subcenter

20

Name of the student: Date of visit:

GENERAL INFORMATION
Name of the subcenter: Address:
Concerned PHC: District: State:
Coverage population: Villages: Anganwadis:
Birth rate: Eligible couple of subcenter:

STAFF PATTERN
Particulars Health worker Helper Link worker Others
Male Female
Name
Qualification
Training
Stay (HQ)

OBSERVATION OF STRUCTURE
Building: Own (government), rental.
Accommodation for Health worker female (HWF): Present/Absent
Cleanliness of the center, ventilation
Basic facilities: Space for sitting, water, toilet, light, electricity,
etc. Room for clean and safe delivery
IEC material: Poster, models, flip charts
Display of area map and charts on health education

Furniture and Equipment

Examination table Bench for clients
Cleaning equipments Container for water storage
Sterilizer Delivery kit
Torch Stove
Fuel
306 Section IV: Field
Study
Equipment for Clinical Examination
Weighing scale Stethoscope
Height Fetoscope
BP apparatus Vaccine carrier
Hemoglobinometer Others
Family planning devices: Condom OC pills
IUD Others
Medicines:Iron folic acid tablets Tetanus toxoid
Vitamin ‘A’ solution ORS packets
Drugs for minor illness Others
Lab facilities: Urine, Hb%, sugar, blood smear collection, sputum examination, others
Health worker female kit: Note the contents of health worker kit.

ACTIVITIES AT SUBCENTER
Working days Working hours
Treatment of minor illness Lab examination: Urine, Hb%, MP, sputum
DOTS Health education
Maternal and child health (MCH) Immunization
and family planning clinics Referral services
First aid for emergencies Ambulance linkage
Referral linkage

Duties Of HWF/Junior Health Assistant Female (JHAF)

Number of field working days of HWF Number of hour spent in
field/day Mode of transport Time spent on transportation

Field Activities
Registration of pregnancy
Antenatal visits
Post-delivery visits (at least three)
Referral of antenatal and postnatal women with health problems
Distribution of contraceptives
Follow up of family planning adopters
Medical termination of pregnancy (MTP), advices for needy
Assessment of growth and development of children
Immunization
Breast feeding promotion
ORS advices
Distribution of basic medicines
Follow up care of referred and discharged patients
Blood smear collection
Collection of data on vital events
 Subcenter 307

School health check up

Health need assessment
Participation in the National programme RTI/STI—
Detection/Referral
Health need assessment

ASSESSMENT OF MATERNAL CARE ACTIVITIES (CSSM)

Particulars Estimated Registered (%)
Eligible
couple
Target
couple
Pregnant women
Eligible couple: Married women aged between 15 and 45 year
(Roughly 160/1000 population)
Target couple: Couple who have two to three living children
Population × Birth
Pregnant women: Number estimated by the formula, (roughly 18/1000 population
rate
1000

DETAILS OF ANTENATAL VISITS

Number of visits Number of women Services provided
0
1
2
3

}
Number and % of pregnant women received iron and folic acid 100 tablets
Number and % of pregnant women received Tetanus Toxoid (TT)
Number and % of clean deliveries conducted by HWF/TBA

Number
Number and
and %
%of
ofdeliveries
home andconducted bydeliveries
institutional untrained person at home Previous year
Number and % of pregnant mothers referred
FAMILY PLANNING SERVICES
Family planning method Number of beneficiaries Percentage
OCP
Copper T
Condom
Tubectomy
Vasectomy

CHILD SURVIVAL ACTIVITIES

Growth monitoring Oral rehydration
Breast feeding promotion Immunization
Treatment of minor illness Nutritional supplementation
308 Section IV: Field
Study
HEALTH EDUCATION
Topics Beneficiaries Method of education
MCH
Family health
Family planning
Child care
Nutrition
Hygiene
Immunization
ORT
Breast feeding
Minor ailments

Coordination of Other Health Personnel

Medical Officer Women leaders
Mahila mandal Health worker male
Dai’s Village leaders/Teachers

Training Activities
Dai/ASHA/Others

Attending Meeting
PHC, CD block, Mahila mandal

Records Maintained
Maternity record: Antenatal/Postnatal
Eligible couple categorizing
Under 5 children by age, sex, immunization, nutrition, and other details
Infants register:
Birth and deaths: Sending to registrar for registration and supervisor
Field visit and home visit register:
List of Dai’s in area:
Family planning: Copper-T, oral pill, sterilization, other
Notifiable diseases identified:
Subcenter clinical record:
Malaria blood smear register
Stock and issue register

HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS)

Monthly plan activities-schedule
Monthly reports sent to PHC
Feedback received on information
Evaluation (Last year)
 Subcenter 309

• Number of outreach session

• ANC 3 visits
• Home/institutional deliveries
• Number of TBA trained
• Infant fully immunized
• Number of ANC/Infants referred

SUBCENTER DATA
Note the following data of last 1 year of the subcenter
Number of births: Number of deaths:
Number of maternal deaths: Number of infant deaths:
Number of smears taken for malaria: Number having tuberculosis:
Number of smear positive: MP:
Pf :
Number of persons having chronic diseases (communicable and non-communicable)
1.
2.
3.
Notifiable diseases
identified 1.
2.
National health programme implemented in the subcenter
TB Immunization
Malaria Diarrhea disease
Pulse Polio Blindness
Others
Environmental sanitation activities
• Chlorination
• Preventing open air defecation
Health education: Basic sanitation, nutrition, immunization, etc.

SUPERVISION AND SUPPORT

Particulars Consultation with subcenter Frequency
Panchayat
Anaganwadi/Trained birth attendant
(TBA)
Mahila mandal
Families
310 Section IV: Field
Study
COMMUNITY NEED ASSESSMENT (CNA) REPORT
Observe and Make a Note on CNA Report
Vaccines
Family planning—Contraceptives
Iron folic acid tablets
Vitamin A
Others
Number of beneficiaries (not utilizing subcenter services)
Reasons of non-utilization of services
Corrective actions taken

Review Questions
 Note the activities of health worker male and female
 Make a list of short coming of subcenter visited, give your suggestions for improvement
 Describe the administration of subcenter
 Chapte
r Primary Health Center
—PHC
21

Name of the student: Date of visit:

GENERAL INFORMATION
Name of PHC: Address:
Coverage: Population: Villages:
Subcenters: Anganwadi:
Connectivity with the area served:
Working hours: Round the clock/Fixed time
Emergency working hours: Round the clock/Fixed
time Ayush: Present/Absent

EXAMINATION OF THE PHC INFRASTRUCTURE

Building
Structure: Pucca/Kutcha
Space: Sufficient/Insufficient
Light/Ventilation: Sufficient/Insufficient
Water and Sanitation: Satisfactory/Poor
Annex building for tubectomy camp:
Staff quarters: Present/Absent
Dormitories (Interns): Present/Absent

Surrounding Environment
Facilities: Waiting hall for the patients MCH and FW service
room Consultation rooms Minor operation theater
Labor room Laboratory
Drug dispensaries Store room
Record room Office room
Cold chain equipments
Number of beds: Maternity General Total
 Primary Health Center—PHC 287

STAFF PATTERN
Staff Number Duties and Responsibilities
Medical officer
Additional medical officer|
(community health officer - CHO)
Lady medical officer
Block extension educator (BEE)
Staff nurse
Pharmacist
Health worker male and female
Health Assistant male and female
Lab technician
Refractionist
Clerk
Driver
Class IV staff
Account manager

OBSERVATION OF THE ONGOING FUNCTIONS:

Medical treatment: OPD
MCH - Immunization clinic
Inpatient
Emergency
Management of
Communicable diseases: Fever, malaria, TB, diarrhea, etc.
Non Communicable diseases: Diabetes, hypertension, cardiovascular disease, cancer,
etc. Referral centers:
Free drug dispension:
CSSM services: Antenatal, intranatal, postnatal,
Emergency obstetric care
Family welfare—contraceptive /MTP
Sterilization camps
Care of newborn, under five children
Laboratory services: Acid fast bacillue (AFB) Peripheral blood smear
(PBS) Hb Urine - Sugar
School health services:
Training programmes: Dai’s/Anganwadi workers/Others
National health programmes:
Adolescent health clinics:
Environmental sanitation:
Health and nutritional education:
IEC activities:
Collection of health information:
288 Part IV: Field Study

Birth and death registration:

Administrative activities:
Staff meetings Planning and implementation
Salary drawing and distribution Financial management
Drug indent Supervision of field work
Intersectoral coordination Confidential reports
Periodic reporting Stock verification
Note the existing schemes in maternal health service package:
1. 3.
2. 4.
Registers maintained:
OPD register ANC/PNC Immunization
Eligible couple Malaria—Blood smear RNTCP
Leprosy Birth and death Stock
Attendance House survey Salary/Service
Others
Local administrative committee:
Supervision of PHC by : Person Frequency
1.
2.

Summarize the Important Functions Observed under the Following Headings

Preventive services
Promotive services
Curative services

Interview Few OPD Patients, Make a Note on

Client satisfaction
Felt needs

Discuss with Medical Officer in Charge to Know

Any new programmes implemented recently
Any modifications done in existed
programmes Make note on -
Shortcomings of PHC
Limitations of PHC
Suggestions to improve the PHC services
 Chapte
r Primary Health Center
—PHC
21

Name of the student: Date of visit:

GENERAL INFORMATION
Name of PHC: Address:
Coverage: Population: Villages:
Subcenters: Anganwadi:
Connectivity with the area served:
Working hour: Round the clock/Fixed time
Emergency working hour: Round the clock/Fixed
time Ayush: Present/Absent

EXAMINATION OF THE PHC INFRASTRUCTURE

Building
Structure: Pucca/Kutcha
Space: Sufficient/Insufficient
Light/Ventilation: Sufficient/Insufficient
Water and Sanitation: Satisfactory/Poor
Annex building for tubectomy camp:
Staff quarters: Present/Absent
Dormitories (Interns): Present/Absent

Surrounding Environment
Facilities: Waiting hall for the patients MCH and FW service
room Consultation rooms Minor operation theater
Labor room Laboratory
Drug dispensaries Store room
Record room Office room
Cold chain equipments
Number of beds: Maternity General Total
312 Section IV: Field Study

STAFF PATTERN
Staff Number Duties and Responsibilities
Medical officer
Additional medical
officer/Community health officer
- CHO)
Lady medical officer
Block extension educator (BEE)
Staff nurse
Pharmacist
Health worker male and female
Health Assistant male and female
Lab technician
Refractionist
Clerk
Driver
Class IV staff
Account manager

OBSERVATION OF THE ONGOING FUNCTIONS:

Medical treatment: OPD
MCH—Immunization clinic
Inpatient
Emergency
Management of: Communicable diseases: Fever, malaria, TB, diarrhea, etc.
Non-communicable diseases: Diabetes, hypertension, cardiovascular disease, cancer, etc.
Referral centers:
Free drug dispension:
CSSM services: Antenatal, intranatal, postnatal,
Emergency obstetric care
Family welfare—contraceptive/MTP
Sterilization camps
Care of newborn, under five children
Laboratory services: Acid fast bacillae (AFB) Peripheral blood smear (PBS)
Hb Urine: Sugar
School health services:
Training programmes: Dai’s/Anganwadi workers/Others
National health programmes:
Adolescent health clinics:
Environmental sanitation:
Health and nutritional education:
IEC activities:
Collection of health information:
Birth and death registration:
 Primary Health Center—PHC 313

Administrative activities:
Staff meetings Planning and implementation
Salary drawing and distribution Financial management
Drug indent Supervision of field work
Intersectoral coordination Confidential reports
Periodic reporting Stock verification
Note the existing schemes in maternal health service package:
1. 3.
2. 4.
Registers maintained:
OPD register ANC/PNC Immunization
Eligible couple Malaria—Blood smear RNTCP
Leprosy Birth and death Stock
Attendance House survey Salary/Service
Others
Local administrative committee:
Supervision of PHC by : Person Frequency
1.
2.

Review Questions
 Summarize the important functions observed under the following headings
Preventive services
Promotive services
Curative services
 Interview few OPD patients, make a note on
Client satisfaction
Felt needs
 Discuss with medical officer in charge to know
Any new programmes implemented recently
Any modifications done in existed
programmes Make note on:
Shortcomings of PHC
Limitations of PHC
Suggestions to improve the PHC services
 Describe in detail regarding cold-chain maintainance in PHC
 Chapte
r Hospital

22
Hospital is a establishment, that provides medical services for the needy
Name of the student: Date of visit:

GENERAL INFORMATION
Name and address of the hospital:
Type of hospital:
Accreditation/ Certification of the hospital:
Timings of hospital: From To
Timings for emergency services:
Timings for visitors:
Direct catchment area: Population
Extensive catchment area: Population
Medical care charges: Complete/Nominal /Free

INSPECTION
Hospital building
Surrounding environment
Reception hall
Reception counter
Sitting and waiting provision
Directions for different departments
Display of hospital policies
Display of health educative materials
Lift and transport facilities (wheel chair, trolley
etc) Water, toilet, TV facilities for waiting
Communication - telephone, etc.

Services Available
(Visit each service center and make salient
note) Critical medical care:
Out patient services:
Inpatient services:
290 Part IV: Field
Study
Laboratory services:
Blood bank:
Various diagnostic services:
Health insurance services:
Outreach services:
Ambulance:
Tele medicine services:

Observation of Different Sections

(visit each section and note important activities)
Major OT: Minor OT:
Labor room: Office room:
Isolation ward: Medical record cell:
RNTCP: ART:
Store room: Drug store:
Vaccine storage room: Critical care unit:
Sterilization unit: Counseling room:
Injection room: Mortuary and Postmortem center:
Rehabilitation center: Psychiatric wards:
AYUSH: Waste management plant:
Kitchen: Laundry:

PATIENT DETAILS
Outpatient Details
Department Daily OPD attendance
Number Percentage
Medicine
Pediatrics
Surgery
Orthopedics
OBG
ENT
Ophthalmology
Skin
Psychiatry
Tuberculosis
Dental
Others
Total 100
Total departments
 Hospital 291

Inpatients Details
No. of wards: Environment of the ward, ie. light, ventilation,
Cleanliness, mosquitoes, fly proofing.
Bed strength: Bed occupancy: % of bed occupancy
Distance between each bed:
No of admissions:
No of discharges:
Other details:
Bed occupancy rate: Average length of stay:
Caesarian section rate: Hospital acquired infection rate:
Gross death rate: Autopsy rate:
Specific death rate—Anesthetic/Postoperative/Maternal/Neonatal

STAFF DETAILS
Number of doctor: Doctor: Bed ratio
Number of nurses: Nurse: Bed ratio
Doctor: Nurse ratio
Student: Bed ratio (in teaching hospital)
Number of other staff (specify) :

HOSPITAL KEEPING
Frequency of floor moping:
Frequency of bed making :
Disinfectants used:
Floor mopping Linen
Feces Sputum
Vomits Urine
Thermometers OT
Hands

Universal Precautions Observed

1.
2.
3.

Hospital Administration
Administrator pattern:
Supervising (regulating) authority:
Monthly meeting:
Mortality meeting:
Computation and presenting hospital data:
Hospital committee:
292 Part IV: Field
Study
ASSESSMENT OF SERVICES
Interview the patients under the following headings to assess the services and client satisfaction
Appropriateness Acceptability
Adequacy Comprehensiveness
Availability Feasibility
Affordability

BIOMEDICAL WASTE MANAGEMENT

(Assessment of hospital is incomplete without assessing biomedical waste management)
Waste generated: kg per bed
Types of waste: Infectious Anatomical
Sharps Pharmaceutical
Chemicals Radioactive
Containers
Collection of waste: Method used in collection and disposal of waste:
Storage of waste: Method Frequency
Transportation of waste:
Treatment of waste (methods):
Caution/Instruction and Emblem on waste container:

Segregation Of Waste
Container color code Type of waste collected
1. White/Blue
2. Yellow
3. Red
4. Black
Periodic training for staff regarding waste
management: Is there any hospital waste management
committee: Rules regarding biomedical waste:
Authorities for controlling biomedical waste:
Recent developments/modifications in hospital biomedical waste:
List the noticed short comings in the hospital:
List the noticed short comings in waste management:
Suggest the measures for improvement:
 Chapte
r Hospital

22
Hospital is a establishment, that provides medical services for the needy
Name of the student: Date of visit:

GENERAL INFORMATION
Name and address of the hospital:
Type of hospital:
Accreditation/Certification of the hospital:
Timings of hospital: From To
Timings for emergency services:
Timings for visitors:
Direct catchment area: Population
Extensive catchment area: Population
Medical care charges: Complete/Nominal/Free

INSPECTION
Hospital building
Surrounding environment
Reception hall
Reception counter
Sitting and waiting provision
Directions for different departments
Display of hospital policies
Display of health educative materials
Lift and transport facilities (wheel chair, trolley,
etc) Water, toilet, TV facilities for waiting
Communication—telephone, etc.
 Hospital 315

Services Available
(Visit each service center and make salient
note) Critical medical care:
Out patient services:
Inpatient services:
Laboratory services:
Blood bank:
Various diagnostic services:
Health insurance services:
Outreach services:
Ambulance:
Tele medicine services:

Observation of Different Sections

(visit each section and note important activities)
Major OT: Minor OT:
Labor room: Office room:
Isolation ward: Medical record cell:
RNTCP: ART:
Store room: Drug store:
Vaccine storage room: Critical care unit:
Sterilization unit: Counseling room:
Injection room: Mortuary and postmortem center:
Rehabilitation center: Psychiatric wards:
AYUSH: Waste management plant:
Kitchen: Laundry:

PATIENT DETAILS
Outpatient Details
Department Daily OPD attendance
Number Percentage
Medicine
Pediatrics
Surgery
Orthopedics
OBG
ENT
Ophthalmology
Skin
Psychiatry
Tuberculosis
Dental
Others
Total 100
Total departments
316 Section IV: Field
Study
Inpatients Details
Number of wards: Environment of the ward, ie. light, ventilation, cleanliness, mosquitoes, fly proofing, etc.
Bed strength: Bed occupancy: % of bed occupancy
Distance between each bed:
Number of admissions:
Number of discharges:
Other details:
Bed occupancy rate: Average length of stay:
Caesarian section rate: Hospital acquired infection rate:
Gross death rate: Autopsy rate:
Specific death rate—Anesthetic/Postoperative/Maternal/Neonatal

STAFF DETAILS
Number of doctor: Doctor: Bed ratio
Number of nurses: Nurse: Bed ratio
Doctor: Nurse ratio
Student: Bed ratio (in teaching hospital)
Number of other staff (specify) :

HOSPITAL KEEPING
Frequency of floor
moping: Frequency of bed
making: Disinfectants
used:
Floor mopping Linen
Feces Sputum
Vomitus Urine
Thermometers OT
Hands

Universal Precautions Observed

1.
2.
3.

Hospital Administration
Administration pattern:
Supervising (regulating) authority:
Monthly meeting:
Mortality meeting:
Computation and presenting hospital data:
Hospital committee:
 Hospital 317

ASSESSMENT OF SERVICES
Interview the patients under the following headings to assess the services and client satisfaction
Appropriateness Acceptability
Adequacy Comprehensiveness
Availability Feasibility
Affordability

BIOMEDICAL WASTE MANAGEMENT

(Assessment of hospital is incomplete without assessing biomedical waste management)
Waste generated: kg per bed
Types of waste: Infectious Anatomical
Sharps Pharmaceutical
Chemicals Radioactive
Containers
Collection of waste: Method used in collection and disposal of waste:
Storage of waste: Method Frequency
Transportation of waste:
Treatment of waste (methods):
Caution/Instruction and Emblem on waste container:

Health Care Waste

CHART FOR SEGREGATION

• Plastic syringes • Human tissues, • Needles • Ash from
• IV sets organs, body parts, • Syringes incineration of any
• Catheters placenta • Scalpels biomedical waste
• Tubings • Items contaminated • Blades • Chemicals used in
with blood, and body production of
• Urosacs, • Glass, etc.
fluids including biologicals
• Blood bags cotton, dressings, That may cause
puncture and cuts. • Chemicals
• Laboratory cultures, soiled plaster cast. used in
stocks, specimens of This includes both used disinfection, as
micro-organisms live and unused sharps. insecticides,
of attenuated • Opened ampoules etc.
vaccines, human and
• Vasofix. • Waste comprising of
animal cell culture and
in research and outdated
industrial laboratories, contaminated and
dishes and devices discarded medicines.
used for transfer of
cultures.

RED YELLOW BLUE BLACK

318 Section IV: Field
Study
Segregation of Waste
Container color code Type of waste collected
1. White/Blue
2. Yellow
3. Red
4. Black
Periodic training for staff regarding waste
management: Is there any hospital waste management
committee: Rules regarding biomedical waste:
Authorities for controlling biomedical waste:

Review Questions
 What are the recent developments/modifications in hospital biomedical waste?
 List the noticed short comings in the hospital.
 List the noticed short comings in waste management.
 Suggest the measures for improvement.
 Chapte
r RNTCP Cell

23

Revised National Tuberculosis Control Programme (RNTCP)

Name of the student: Date of visit:

GENERAL INFORMATION
Location of RNTCP cell: Address:
Catchment area:
Population served:
TB indices in the city:
OPD Attendance/day:
Display in the reception hall:
1. IEC (information, education, communication) material:
2. Statistical data
3. Others

STAFF PATTERN
Sl No Staff Designation Qualification and Duties/ Responsibilities

Training in RNTCP
1.
2.
3.
4.

MICROSCOPY CENTER
Number of microscopes:
Number of technicians:
Method of sputum collection:
Method of slide preparation and staining:
Method of microscopic examination:
Supervisory authority/staff of lab :
Frequency of supervision:
Percentage of positive slides re-examined:
Percentage of negative slides re-examined:
294 Part IV: Field
Study
ENQUIRIES
Enquire and Know the Meaning of the Following Terms
• Smear-positive TB • Return after default
• Smear-negative TB • Transfer in
• New case • Transfer out
• Relapse case • Treatment completed
• Failure case • Cured case
• MDR-TB • DOTS-plus
• XDR-TB

TB INDICES
Note the Following TB Indices

1. Number of people showing tuberculin positive

Incidence of infectgion = Total population under study 1000

2. Number of people showing tuberculin positive (old + new)

Prevalence of infection = Total population under study 1000

3. Number of new sputum positive cases

Incidence of disease = Total population 1000

4. Number of sputum positive cases (old + new)

Prevalence of disease = Total population 1000

CASE FINDING
In the Last One Month
Case finding methods used Number of cases detected
Passive case finding
By sputum
examination By x-
ray
By chest symptoms
Total
Cases detected in pediatric age (0-14 years):

CATEGORIZATION
Enquire and Note the Categorization of the Patients

Number of Patients on Treatment

(note from the register)
Regimen Category I Category II Category III
R1
R2
R3
R4
 RNTCP Cell 295

Make a Note on Patient-Wise Medicine Boxes

1. Category I
2. Category II
3. Category III

DISCUSSION
Discuss with the Medical Officer Regarding Reasons of
• Drug defaultering
• Drug resistance
• Referral of patient to specialized institutions

RECORD MAINTENANCE
Registers Maintained in the Cell
1.
2.
3.

Details about Patients on Register (in one year)

Particulars Number Percentage
Sputum positive
Sputum negative
Suspects
X-ray positives
TB/HIV co-infected
Total

Reports of the Cell in the Last One Year

Particulars No
Attendance (OPD)
Sputum examined
Cases detected
Cases cured
Transfer in
Transfer out
Died
Sputum conversion
Treatment interrupt (defaulter)
Cases referred to specialized institutions

OTHER ACTIVITIES
Regarding Other Activities of the Center
• IEC
• Involvement of NGO’s
• Involvement of private practitioner
296 Part IV: Field
Study
• Involvement of international agencies
• DOTS provider - “Agent”
• Training activities
• Surveillance of multidrug resistant TB
• Chemoprophylaxis
• Rehabilitation of the cured patient

ACHIEVEMENTS OF THE CENTER

Indices Target Achieved
Cure rate 85 %
Case detection 70 % of
expected
Reduction in annual risk of infection 50 %
Reduction in TB mortality per 1 lakh 20
population
Reduction in relapse <5%
Reduction drug resistance <5%

Review Questions
 Write about the authorities regulating the RNTCP programme
 Explain the recent advances or modifications in RNTCP programme
 Identify the shortcomings and make a list
 List out your advises for the improvement of the programme
 Chapte
r
Urban Leprosy
Unit
24
Name of the student: Date of visit:

GENERAL INFORMATION
Location of the center: Address:
Population served:
Prevalence of leprosy in the area: High/Moderate to low/Very low
Display in the reception hall:
IEC (information, education, communication) material:
Statistical data:
Others:

STAFF PATTERN
Sl No Staff designation Qualification and Duties/Responsibilities
training in leprosy
1.
2.
3.
4.

LABORATORY SERVICES
Observe and note in detail about laboratory methods and procedures
Technique of skin smear:
Staining and examination:
Finding bacteriological index:
Finding morphological index:

OBSERVATION OF CASE SHEETS

Diagnostic criteria: 1. 3.
2. 4.
Classification of leprosy:
298 Part IV: Field
Study
ENQUIRIES
Enquire and Note about the Following Terms
Case definition: New leprosy case:
Registration: Re-registered case:
Cured case: Release from treatment:
Release from register: Drug defaulter:
Transferred in: Transferred out:

REPORTS OF THE CELL

In the Last One Year
Particulars Multi bacillary (MB) Pauci bacillary (PB) Total
Number of cases registered
Number of cases on treatment (MDT)
Number of paediatric cases
Number of cases with deformity
Number of cases with reaction
Number of drug defaulter
Number of patient treated in hospital
Number of cases cured
Number of cases relapsed
Proportion of MB and PB cases:
Proportion of child (0-14) among newly detected cases:

CASE FINDING
In the Last One Year
Case finding method Frequency Number of cases detected
Population survey
School survey
Contact examination
Voluntary reported cases (VRC)
Total

TREATMENT
Drug dosage schedule
Particulars Drugs Dose Frequency Duration
MB
PB
Single skin lesion
Type 2 reaction
Observe the drugs and make a note.
 Urban Leprosy Unit 299

Deformity Details

Note the Type of Deformity

Deformity grading Number Management
(according to WHO)
0
1
2

Rehabilitation Details
Rehabilitation Activities in brief
a. Medical
b. Surgical
c. Vocational
d. Physiotherapy

Voluntary Organization Involved

Voluntary organization Role
National 1
2
3
International 1
2
3
Recording and reporting system: In brief
Achievements of the center:
1.
2.
3.

Supervision, Guidance, Monitoring of Anti-Leprosy Activities

National level:
State level:
District level:
Peripheral level:

Evaluation
Case detection ratio:
Ratio of children below 14 years among total newly detected cases:
Proportion of MB cases on regular treatment:
Relapse rate:
Incidence of leprosy among school children:

Recent Changes/Advances in the Programme

1. 2. 3.
300 Part IV: Field
Study
Review Questions
 Explain about the regulatory authorities of the RNTCP programme.
 What are the social assistance available to cured patients?
 When anti-leprosy day is celebrated?
 Who all are the dedicated persons worked to remove the stigma of leprosy?
 What is vertical programme? Explain the difference between vertical and horizontal programme.
 What is your opinion regarding integration of leprosy programme in general health programme?
 Chapte
r ICTC Integrated
Counseling and
25 Testing Center

Name of the student: Date and time of the visit:

GENERAL INFORMATION
Location and address of the center:
Catchment area-direct: Indirect:

EXAMINATION OF THE PREMISES

Cleanliness:
Disturbances: Sound, temperature, overcrowding
Facilities in: Waiting room:
Sitting arrangements:
Water, TV, health education material:
Video based health education:

Counseling Room
Space: sufficiency
Environment: cleanliness, undisturbed environment, privacy, closeness of seating arrangement for client and counselor

STAFF PATTERN
Sl No Name Designation Training
1.
2.
3.
Services provided:
Linked departments: OBG, TB, microbiology, laboratory,
others: Working days: Working hours:
Number of counselor -Male: Female:
Number of counseling sessions per day per counselor:
Number of clients counseled by one counselor:

COUNSELING ACTIVITIES
Some Questions
Does some counselor counsel the particular client?
302 Part IV: Field
Study
Does counselor know the local language?
Does counselor have latest knowledge on the subject?
Is peer counseling arranged?

Peer Counseling
Is a specially-trained HIV reactive person who shares his experience, which enables other HIV reactive patients to learn self-
help skills.

Type of Clients
Voluntary reported: Homosexuals:
Referred-pregnant mother, HIV/STI: Commercial sex workers:
Patients of other departments: Risk behavior group:
Victims of sex abuse: Any other special groups:

Counseling
Face-to-face communication in which information is given, to help the client to choose proper decision to solve the problem.

Aims:
• To bring positive changes in lifestyle
• Making to understand their needs, strengths, limitations
• Support for avoiding disturbing movements
• Clarifying the doubt

Elements of Counseling—“GATHER”
G - Greeting the clients
A - Ask the needs
T - Telling the options
H - Helping to make volunteer decisions
E - Explain the chosen path
R -Return for followup

Steps of Counseling
Determination of high-risk behavior
• Helping the clients to understand his behavior pattern
• Explaining the adverse effects of their behavior
• Help potentiality for changing behavior
• Help to adopt and sustain the modified behavior
• Creating the awareness of his risk behavior.
Advise the ways by which he can prevent the spread of infection: Not donating the blood, regular use of condom, not
sharing the needles.
Providing the emotional support and helping in decision-making
Removal of stigma and fear
Skills of living with HIV, knowledge of medical support, community resources
Counseling session:
If possible observe a counseling session. Note the effective practice of skills of counseling -
• Greeting the client
• Make the client to sit comfortably
• Gaining trust, assuring confidentiality
 ICTC Integrated Counseling and Testing Center 303

• Allowing the client to talk and listen without interruption

• Giving full attention, showing interest, expressing empathy
• Sympathetic towards client
• Giving respect to clients dignity and boosting self-confidence
• Encouraging to talk about client’s problem
• Providing time to share the facts and feelings
• Reflecting the feeling of understanding the problems
• Eliciting more information
• Providing required information
• Asking open-ended questions
• Paraphrasing (summarizing) the clients words and checking with the client
• Helping the client to reach a decision
• Non-judgmental attitudes
• Reducing the anxiety by humor
• Encouraging the client about communicating his problem to the spouse and family members
• Encouraging the community relationship
• Encouraging some other virtues
• Extending the counseling session for number of times and followup
Consent: Does the written/verbal consent is taken from the client?
Counseling

Pretest counseling Post-test counseling

Reactive Non-reactive

Pretest Counseling
Explaining the importance of the test, assurance of confidentiality of the results

Posttest Counseling
If result is non-reactive
Retesting after 3-6 months (window period) of exposure and safe behavior is advocated
If result is reactive,
• Told about their result in privacy
• Time is allowed to accept the results
• After adjustment to the results, client is explained about what is positivity and explaining the availability of re-
sources for treatment
• Explain about building self-esteem and positive thinking ability
• Explaining to cope up with positive result and live the positive life
• Sharing the result with spouse and family members.

FUNCTIONS
Main Functions of ICTC
• Early detection of STI/HIV
• Providing accurate information, behavioral changes, reducing vulnerability
• Link people with HIV prevention, treatment and care activities, acts as an entry point for all clients.
 Chapte
r ICTC-Integrated
Counseling and
25 Testing Center

Name of the student: Date and time of visit:

GENERAL INFORMATION
Location and address of the center:
Catchment area-direct: Indirect:

EXAMINATION OF THE PREMISES

Cleanliness:
Disturbances: Sound, temperature,
overcrowding Facilities in: Waiting room:
Sitting arrangements:
Water, TV, health education material:
Video based health education:

Counseling Room
Space: Sufficiency
Environment: Cleanliness, undisturbed environment, privacy, closeness of seating arrangement for client and
coun- selor

STAFF PATTERN
Sl No Name Designation Training
1.
2.
3.
Services provided:
Linked departments: OBG, TB, microbiology, laboratory,
others. Working days: Working hour:
Number of counselor: Male: Female:
Number of counseling sessions per day per counselor:
Number of clients counseled by one counselor:
328 Section IV: Field
Study
COUNSELING ACTIVITIES
Some Questions
Does the same counselor counsel particular client?
Does the counselor know local language?
Does the counselor have latest knowledge on the subject?
Is peer counseling arranged?

Peer Counseling
Is a specially-trained HIV reactive person who shares his experience, which enables other HIV reactive patients to
learn self-help skills.

Type of Clients
Voluntary reported: Homosexuals:
Referred: Pregnant mother, HIV/STI: Commercial sex workers:
Patients of other departments: Risk behavior group:
Victims of sex abuse: Any other special groups:

Counseling
Face-to-face communication in which information is given, to help the client to choose proper decision to solve the
problem. It is a scientific and psychological approach.

Aims:
• To bring positive changes in lifestyle
• Making to understand their needs, strengths, limitations
• Support for avoiding disturbing movements
• Clarifying the doubt

Elements of Counseling—“GATHER”
G-Greeting the clients
A-Ask the needs
T-Telling the options
H-Helping to make volunteer decisions
xplain the chosen path
R-Return for followup

Steps of Counseling
Determination of high-risk behavior
• Helping the clients to understand his behavior pattern
• Explaining the adverse effects of their behavior
• Help potentiality for changing behavior
• Help to adopt and sustain the modified behavior
• Creating the awareness of high risk behavior.
Advice the ways by which they can prevent the spread of infection: Not donating the blood, regular use of
condom, not sharing the needles.
 ICTC Integrated Counseling and Testing Center 329

Providing the emotional support and helping in decision-making

Removal of stigma and fear
Skills of living with HIV, knowledge of medical support, community resources
Counseling session:
If possible, observe a counseling session. Note the effective practice of skills of counseling -
• Greeting the client
• Make the client to sit comfortably
• Gaining trust, assuring confidentiality
• Allowing the client to talk and listen without interruption
• Giving full attention, showing interest, expressing empathy
• Sympathetic towards client
• Giving respect to clients dignity and boosting self-confidence
• Encouraging to talk about client’s problem
• Providing time to share the facts and feelings
• Reflecting the feeling of understanding the problems
• Eliciting more information
• Providing required information
• Asking open-ended questions
• Paraphrasing (summarizing) the clients words and checking with the client
• Helping the client to reach a decision
• Non-judgmental attitudes
• Reducing the anxiety by humor
• Encouraging the client about communicating his problem to the spouse and family members
• Encouraging the community relationship
• Encouraging some other virtues
• Extending the counseling session for number of times and followup
Consent: Does the written/verbal consent is taken from the client?
Counseling

Pretest counseling Post-test counseling

Reactive Non-reactive

Pretest Counseling
Explaining the importance of the test, assurance of confidentiality of the results

Post-test Counseling
If result is non-reactive
Retesting after 3-6 month (window period) of exposure and safe behavior is advocated
330 Section IV: Field
Study
If result is reactive,
• Tell their result in privacy, with consent
• Time is allowed to accept the results
• After adjustment to the results, client is explained about what is positivity and explaining the availability
of resources for treatment
• Explain about building self-esteem and positive thinking ability
• Explaining to cope up with positive result and live the positive life
• Sharing the result with spouse and family members.

FUNCTIONS
Main Functions of ICTC
• Early detection of STI/HIV
• Providing accurate information, behavioral changes, reducing vulnerability
• Link people with HIV prevention, treatment and care activities, acts as an entry point for all clients.

Review Questions
 Explain legal and ethical dimensions of HIV
 What are all the health and disease events counseling is used
 What is mobile ICTCs?
 Chapte
r District Malaria
Office
26

Name of the student: Date and time of visit:

Office location (address):

GENERAL INFORMATION
Name of the district: Population covered:
Number of PHC: Subcenter: Village: Tribal area:

DISPLAY IN THE OFFICE

Epidemiological map showing
Unit boundaries High-risk areas
Places of API > 2 and API < 2 Malaria foci
Pf foci Fever treatment depots
Drug dispensary centers Malaria clinic
Community health volunteers
Statistical data: Charts, graphs
Timetable of anti-malarial
activities Health education
materials

MALARIA PARAMETERS OF THE DISTRICT

Note the following parameters and their
significance Annual blood examination rate:

Number of blood smears examined in a year

ABER = Total population under surveillance 100

= ≥ 10% or < 10%

Annual parasite incidence:

Number of positive smears in a year

API = Total population uunder surveillance1000

= > 2 or < 2
Annual falciparum incidence:

Number of Pf positive smears in a year

AFI = Total populatioon under surveillance 1000
 District Malaria Office 305

Slide positivity rate:

Number of smears positive

SPR = Number of smears 100
examined
Plasmodium falciparum percentage:
Total number of Pf 100
Pf % =
cases
Total number of malaria
cases Slide falciparum rate:

Number of Pf positive slides

SFR = Total blood smears examined100

Infant parasite rate:

Number of infants positive for malaria 100

IPR = Number of infannts blood smears
collected
Child parasite rate:

Number of children (2-9 years) positive for malaria

CPR = Number of children (2-9 years) blood smears 100
collected

MALARIA SITUATION OF THE DISTRICT

Cases reported form January to December
Taluk [Link] [Link] Total Deaths
•
•
•
•
•
•
Total
Epidemiological situation of malaria in the district:
Note previous five years data (year wise, month wise)
Pv, Pf, Death other points, and plot bar diagram, graph, pie chart.

OBSERVATION OF ANTIMALARIA ACTIVITES

Malaria team:
Malaria team Coverage Important activities
District malaria officer (DMO) Whole district Execution and evaluation
Assistant malaria officer Whole district Assisting DMO
Primary health center (PHC) PHC Planning, supervision, technical
medical officer advice and administration in PHC
Malaria inspectors PHC allotted Field supervision
Lab technicians Microscopic center Examination of slides
Health supervisor Sub centers/PHC Supervision
Surveillance worker MPW (male 5000 Population (2000 houses) Passive surveillance blood film
and female) sub- counter level collection presumptive radical
treatment
306 Part IV: Field
Study

Malaria team Coverage Important activities

Surveillance inspector (health For every 4 surveillance worker Supervision of surveillance work
assistant)
Spray staff
Volunters link workers

DETAILS
Know the Details Regarding
Fever treatment depots Drug distribution centers
Entomological unit Malariologist

AVAILABLE FACILITIES
Note the Availability of the Following Facilities in the District
• Treatment of severe and complicated malaria
• Treatment of falciparum malaria in pregnancy and children
• Facilities for immediate containment measures during likely epidemic situation
• Referral links - in the district, outside the district
• Pf containment measures
• Urban malaria scheme (UMS)
• Enhanced malaria control projects
• Investigation of death due to malaria
• Reorientation and trainings
• Intersectoral coordination.

Stocks: Note how the Availability and Distribution of the Following

Items Distribution
Drugs
Chemicals
Reagents
Microscopes
Microscopes slides
Insecticide
Spray equipments
Others
Study the activities under national antimalaria programme (NAMP) in detail:
Case finding activities: early case detection and treatment, to eliminate
reservoir.

SURVEILLANCE

Active Surveillance
Who will do: Multipurpose worker
Method: Door to door visit
Frequency: Once in 15 days
Enquires: 1. Fever case in the home
 District Malaria Office 307

2. Fever case in between the visits (15 days)

3. If answer is ‘yes’ to any of the questions blood smear is taken.

Passive Surveillance
Agencies : PHC Subcenter
Hospitals Dispensaries
Medical practitioners Fever treatment depot
Frequency : Every day
Blood smear taken : For all fever cases

Mass Survey
To known the incidence and spread
Criteria: Sudden break out of malaria (especially Pf) in low endemic areas
Place: Around Pf houses
Migrated population
Blood smear taken: Blood smear is collected from all people, irrespective of fever

Contact Survey
To know the spread of disease in the family
All family members of malaria case are included.

Rapid Fever Surveillance (RFS)

Malaria reported in new places and places where active surveillance is not done properly
Method: Survey of large number of population by many surveillance workers in short time
Immediate smear examination, by establishing a lab in the surveillance place.

BLOOD SMEAR
When blood smears are taken:
Active surveillance:
Passive surveillance:
Follow up blood smear - six days after radical treatment for all Pf cases
Finger selected: Left hand ring finger tip
Procedure of making smear: Sterilizing (Dettol or Savlon) the finger
Pricking by using sterile Hegdnor (No.12) needle
Collecting three drops of blood on slide nearby
Collect one more drop at the center
By using another clean slide, first thin,
then thick smear is made and allowed to
dry
Mark the Sl No and other details. Fill form MF-2.
Quality of the smear: Thick smear should be around one centimeter diameter
Thin smear should be single layered and tongue shaped
Both thick and thin smear are taken on the same slide
Dispatch of slides: To nearest microscopic center (usually PHC)
Smear inputs to
microscopic center: Surveillance workers (MPW)
Subcenters
308 Part IV: Field
Study
Fever treatment depots
Private hospitals and clinics
Drug distribution centers
Person collects and brings: Surveillance worker (MPW)
Frequency of slide dispatch: Twice weekly
Quantity of slides collected:
In Active surveillance - one percent of population in month or 10 percent in
year In Passive surveillance - 15 percent of the attendance in year

Supervision of Field Activities

Field activity: Population coverage
Periodicity of visit
Adequacy of number of smear collection from all places (from MF 9)
Timely dispatch of slides

Supervision of Laboratory Services

Who will do the supervision: Medical Officer
Frequency of supervision:
What are all supervised:
Lab: Enough space, light, microscopic work table,
Sitting stool, condition of microscope, staining,
Chemicals, slides cleaning materials
Records: Maintenance of chemicals, fungal growth in stain
Skill and work load of technician
Slides: Cleanliness of slides,
Quality of smears and staining
Legibility of numbering
Backlog of smear examination
Cross examination: 20 to 25 slides of preceding week by random selection
All slides of severe and complicated Pf cases
Recoding and Reporting: Inspection of MF-2, MF-7, MF-8 forms to note
Period between staining and examination
Delay in transmission from periphery to laboratory
Time lag in dispatch of results to periphery
Percentage of negative slides (with code number) sent for central lab.

TREATMENT/PROPHYLAXIS
Presumptive Treatment
Day All area High risk area PF resistant
1 Chloroquine 600 mg Chloroquine 600 mg Sulfadoxine 1500 mg
+ + Pyrimethamine 75 mg
Primaquine 45 mg
2. Nil Chloroquine 600 mg
3. Nil Chloroquine 300 mg
 District Malaria Office 309

Radical Treatment
Primaquine is given for 14 days as per Antimalaria Drug Policy 2008
Low-risk areas High-risk areas
[Link] and mixed [Link] [Link] [Link]
Chloroquin 600 mg only Chloroquin 600 mg only Nil Nil
on first day on first day
Primaquine 15 mg for Primaquine 15 mg Primaquine 15 mg for Nil
14 days single dose 14 days
(Treatment protocols are subjected to change according to the review of programme periodically)

Treatment of Severe and Complicated Malaria

Hospitalize the patient
Qunine injection 10 mg/kg IV in 5% dextrose or Injectable form of artemisinin
Switch over to oral dose as soon as possible

Chemoprophylaxis
Indications: Traveler to endemic area like soldiers, police, laborer, serving in endemic
area Pregnant women in high-endemic area
Schedule: Begin one week before entry to malarious area
Continued for at least four to six weeks after leaving the area
Drugs used: Short term visit - Tab Doxycycline
Long term visit - Tab Mefloquine.

REFERRAL SYSTEM
Referral centers: PHC, CHC, taluk and district hospitals, others

Criteria for Referral

Persistence of fever, headache after 48 hours of initial treatment Too weak to walk
Vomiting, inability to retain food and drugs Change in sensorium
Severe dehydration Convulsions, muscle twitching
Hypothermia Bleeding, clotting disorders
Jaundice, severe anemia

Essential Requirements in Referral Center

IV infusion of quinine Facilities for blood transfusion and examination
Life-saving drugs Well-equipped lab
Special nursing staff Oxygen and respirator

INTERVENTION OF TRANSMISSION
Spray operations: All areas with API ≥ 2 (Priority is given to ‘high-risk’
areas) Insecticides used:

Insecticide Dose per 150 Sq meter (one Number of rounds in a year

house) per round
DDT 50% WP 300 gm 2
Malathion 25% WP 1200 gm 3
310 Part IV: Field
Study

Insecticide Dose per 150 Sq meter (one Number of rounds in a year

house) per round
Synthetic pyrethroids 120 2
Deltamethrin 2.5% WP gm
Cyfluthrin 10% WP 37.5 gm 2
Lambdacyhalothrin 10% WP 37.5 gm 2

SPRAY STAFF
Spray Squad
one pump man, one spray man, two men for mixing - total four unskilled workers
One supervisor/record keeper (skilled worker)

Requirement
Number of houses in the village
Spray squads required per village =
600

Coverage
Each spray squad covers 60 to 80 houses/day (using two pumps simultaneously)

Preparation for the Spray

• Collecting malaria indices
• Selecting the spray places.
• Calculation of required insecticide
• Houses and villages should be informed in advance.
• Taking community participation.

Precautions Taken During the Spray

• Using glows, rods to mix, clothes and other protective device
• Covering food material of the house
• Care during transport and storage of insecticides
• Empty insecticide container should be destroyed
• After work, washing the equipments and body, with soap and water
• Washed water should not leak into drinking water.

Supervision Personnel of Spray Operations

Multipurpose worker Health supervisor
Malaria inspector Medical offices
Assistant malaria officer District malaria officer (over all supervision)

Recording and Reporting by Health Worker Male

Insecticide used:
Spray squads worked:
Number of houses sprayed:
Left out/locked houses:
Rejected houses:
 District Malaria Office 311

Bio-environmental Control Strategy

Aim: To control mosquito breeding
by Biocidal use,
Environmental manipulation

Components
Source reduction: Elimination of breeding places
Environmental manipulation: filling (leveling of land)
Covering the unused wells
Biological: Larvivorous fishes
Gambusia affinis
Lebistes reticulatus
Biocides
Bacillus sphaericus
Bacillus thuringiensis

Biocides
Quantity: 250 gm - B. Thuringiensis powder/ltr
500 gm - B. sphaericus powder/ltr
Spraying dose: One liter over 50 sq. mt using knap - sack sprayer
Frequency: once in one or two weeks
Site of spray: Tank, seepage, stream, unused well, irrigation pit, channel, borrow pit, paddy field, and other breed-
ing places.

Personal Protection
Use of impregnated bed nets
Material: Polyester > 75 denier (Denier - Unit of weight in gm according to length)
Nylon nets (durable, takes drug quickly, insecticide stays longer)
Hole size: Less than 1.2 to 1.5 mm (25 meshes per sq inch)
Dose: Deltamethrin 25 mg/54 meter
Lambdacyalothrin 25 mg/59 meter
Cyfluthrin 50 mg/59 meter
Residual effect: Six months to one
year Retreatment: within a year
Impregnating method:
Surface area of the bed net is calculated
Insecticide quality is determined
Net is soaked in insecticide solution and dried in shade
Person impregnating should use all protective devices and after work he should wash his body with soap and water.

Distribution
Socioeconomically deprived communities
Tribal, forest and unreachable population
Pregnant women and young children
Migrant worker
312 Part IV: Field
Study
Disaster affected communities
Social marketing
Subsidized retreatment

MONITORING AND SURVEILLANCE

1. Activities:
Discussion in monthly meetings in PHC, regarding adequacy, achievement of assigned targets
Fortnightly preparation of the master chart from the reports received (form MF-8; MF-9 and master charts)
2. Vigilance of epidemiological parameters
3. Monitoring of spray operations
4. Vigilance of focal malaria out-break
5. Early prediction of malaria by -
Parasite load Marked changes Number of fever cases
Number of positive Species distribution
Vector dynamics Increase in mosquito density Vector species
Man-mosquito contact
Population dynamics Migrants Labor projects
Large labor movement Foods and drought
Environmental Early and heavy rain fall Increase in humidity
Natural disasters

Note the Following

Recent changes/modifications in the antimalaria
activities Rapid diagnostic tests for malaria
National drug policy of malaria treatment, 2008
Early treatment failure
Malaria goals for tenth plan

Recording and Reporting System

Observe the various forms used for recording and reporting of malaria at various levels. Some of the forms are given below
for your study.

Reporting Formats Used in Malaria

MF-1 Family health register
MF-2 Blood smear collection
MF-3 Tour report
MF-4 Monthly report of PHC
MF-5 Monthly report of PHC remedial activity
MF-6 Progress and assessment of spraying
MF-7 Positive register
MF-8 Subcenter blood smears report
MF-9 Epidemiological evaluation
MF-10 Monthly passive case detection (PCD) report
MF-11 Weekly savingram from primary health care (PHC) on blood smears examined (BSE) and Fives
 District Malaria Office 313

MF-1
Name of head of Names of other
Sl No House number Age Sex Remarks
household members

MF-2
For reporting of blood smears by multipurpose worker/passive agency:
Name of subcenter: Name of the PHC:
Code number:
Number Name Name of Age Sl No of Number of
Sl Date of
Village of (Head of patient/ and blood chloroquine Result Remarks
No collection
house family) person sex smear tablets given

Note: This pro forma should be in triplicate and three copies forwarded to PHC laboratory technician, who will retain one
copy and send the other two to MPW/Senior health Inspector/Malaria Inspector.

Signature of Date of examination Signature of MPW/

microscopist by the microscopist Passive agency

MF-4
Primary Health Centre (PHC) Taluk
Active
Mass and
blood Passive Detail of the Radical
contact Total BS Pv Incidence Pf incidence
smear BS parasite treatment
BS
(BS)

Subcentre
Examined

Examined

Examined

Examined
Collected

Collected

Collected

Collected

5-14 year

> 15 year

5-14 year
Positive

Positive

Positive

Positive

0-1 year

1-4 year

0-1 year

1-4 year

15 year

Pf (Rg)
Pf (R)

Total

Total
Mix
Pv

Pv
Pf
314 Part IV: Field
Study

MF-5
Monthly Reporting Format
For the month of
Number of Mass therapeutic

Total focal spray rooms

Species Balance tablets

without 4AQ
positive measures

RT given

Fever cases d
Sl

RT5 days
4AQ/8AQ

Quinine
Name of subcentre
Female

Others
Pf (rg)
Pf (R)

No

4AQ

8AQ
Total

Total
Male

SP
SP
Pv
 Active

Total
of the
Name

with SC
number

Passive
subcenter
BS Collected
Pv
Pf
MIx
January

Total
BS Collected
Pv
Pf
MIx
February

Total
BS Collected
Pv
Pf
March

Mix
Total
B/ Collected
Pv
Pf
April

MIx
Total
BS Collected
Pv
Pf
May

MIx
Total
BS Collected
Pv
Pf
June

MIx
Total
BS Collected
Pv
MF-6

Pf
July

Mix
Total
BS Collected
Chart showing the blood smears collected from active and passive agencies at PHC for the year

Pv
Pf
MIx
August

Total
BS Collected
Pv
Pf
MIx
September

Total
BS Collected
Pv
Pf
MIx
October

Total
BS Collected
Pv
Pv
MIx
November

Total
BS Collected
Pv
Pf
MIx
December

Total
Remarks

District Malaria Office

 MF-7

3
Positive Register

Part IV: Field

Sl Date of BS Date of BS Date of RT Follow-up smear
Name of patient Age Sex Result Remarks
No collection examination intimation From To Date Result

MF-8
Register of blood smears received and examined (subcenter wise)
Name of subcenter PHC:
Sl Section N./ Total smears Blood smears number Date of collection Date of
Date of receipt Remarks
No Hospital received From To From To examination

MF-9
Epidemiological Evaluation Master Register
(Subcenter wise, village wise and month wise)
Month PHC
Name of the First fortnight Second fortnight Total for
Subcenter/Village male health 1 2 3 4 5 6 7 8 9 10 11 12 Total 1 2 3 4 5 6 7 8 9 10 11 12 Total the
assistant
month
 MF-11
Weekly Savingram Reports Under National Malaria Eradication Programme
Week report Primary Health Centre (PHC) Taluk, From Date To Date
Blood smears During the week From Detail of balance Sent outside Received from outside
Subcentre number

MP cases RT given Malarial RT Balance RT given RT given

Subcenter

parasit given

Sent outside
Examined
Collected

Pregnant

Sent out
(MP)

Balance

Under
Child

Total

Total
Not
OB

cases

Pf

Pf
Total

Total

Total
Total

Total

Total

Total

Pf
Pf

Pf

Pf

Pf

Pf

Pf
Signature of the Medical Officer

District Malaria Office

 Chapte
r District Malaria
Office
26

Name of the student: Date and time of visit:

Office location (address):

GENERAL INFORMATION
Name of the district: Population covered:
Number of PHC: Subcenter: Village: Tribal area:

DISPLAY IN THE OFFICE

Epidemiological map showing
Unit boundaries High-risk areas
Places of Annual parasite incidence (API) > 2 and API < 2 Malaria foci
Pf foci Fever treatment depots
Drug dispensary centers Malaria clinic
Community health volunteers
Statistical data: Charts, graphs
Timetable of anti-malarial
activities Health education
materials

MALARIA PARAMETERS OF THE DISTRICT

Note the following parameters and their
significance Annual blood examination rate
(ABER):
Number of blood smears examined in a year
ABER = Total population under surveillance  100

= ≥ 10% or < 10%

Annual parasite incidence (API):
Number of positive smears in a year
API = Total population uunder surveillance 1000

= > 2 or < 2
332 Section IV: Field
Study
Annual falciparum incidence (AFI):
Number of Pf positive smears in a year
AFI = Total populatioon under surveillance  1000
Slide positivity rate (SPR):
Number of smears positive
SPR = Number of smears  100
examined
Plasmodium falciparum percentage (PF%):
Total number of Pf cases
Pf % = Total number of malaria  100
cases
Slide falciparum rate (SFR):
Number of Pf positive slides
SFR = Total blood smears examined 100

Infant parasite rate (IPR):

Number of infants positive for malaria
IPR = Number of infants blood smears  100
collected
Child parasite rate (CPR):
Number of children (2-9 years) positive for malaria
CPR = Number of children (2-9 years) blood smears  100
collected

MALARIA SITUATION OF THE DISTRICT

Cases reported form January to December
Taluk [Link] [Link] Total Deaths
•
•
•
•
•
•
Total
Epidemiological situation of malaria in the district:
Note previous 5 year data (year wise, month wise)
Pv, Pf, Death and plot bar diagram, graph, pie
chart.
 District Malaria Office 333

OBSERVATION OF ANTIMALARIA ACTIVITES

Malaria team:
Malaria team Coverage Important activities
District malaria officer (DMO) Whole district Execution and evaluation
Assistant malaria officer Whole district Assisting DMO
Primary health center (PHC) PHC Planning, supervision, technical
medical officer advice
and administration in PHC
Malaria inspectors PHC allotted Field supervision
Lab technicians Microscopic center Examination of slides
Health supervisor Subcenters/PHC Supervision
Surveillance worker MPW (male 5000 population (2000 houses) Passive surveillance blood film
and female) sub- collection presumptive radical
center level treatment
Surveillance inspector (health For every 4 surveillance worker Supervision of surveillance work
assistant)
Spray staff
Volunteers link workers

DETAILS
Know the Details Regarding
Fever treatment depots Drug distribution centers
Entomological unit Malariologist

AVAILABLE FACILITIES
Note the Availability of the Following Facilities in the District
• Treatment of severe and complicated malaria
• Treatment of falciparum malaria in pregnancy and children
• Facilities for immediate containment measures during likely epidemic situation
• Referral links: In the district, outside the district
• Pf containment measures
• Urban malaria scheme (UMS)
• Enhanced malaria control projects
• Investigation of death due to malaria
• Reorientation and trainings
• Intersectoral coordination.

Stocks: Note the Availability and Distribution of the Following

Items Availability Distribution details
Drugs
Chemicals
Reagents
Microscopes
Microscope slides
Insecticide
Spray equipments
Others
334 Section IV: Field
Study
Study the activities under National antimalaria programme (NAMP) in detail:
Case finding activities: early case detection and treatment to eliminate
reservoir.

SURVEILLANCE
Active Surveillance
Who will do: Multipurpose worker
Method: Door to door visit
Frequency: Once in 15 day
Enquires: 1. Fever case in the home
2. Fever case in between the visits (15 day)
3. If answer is ‘yes’ to any of the questions, blood smear is taken.

Passive Surveillance
Agencies : PHC Subcenter
Hospitals Dispensaries
Medical practitioners Fever treatment depot
Frequency : Every day
Blood smear taken : For all fever cases

Mass Survey
To known incidence and spread
Criteria: Sudden break out of malaria (especially Pf) in low endemic areas
Place: Around Pf houses
Migrated population
Blood smear taken: Blood smear is collected from all people, irrespective of fever

Contact Survey
To know the spread of disease in the family
All family members of malaria case are included.

Rapid Fever Surveillance (RFS)

Malaria reported in new places and places where active surveillance is not done properly
Method: Survey of large number of population by many surveillance workers in short time
Immediate smear examination, by establishing a lab in the surveillance place.

BLOOD SMEAR
When blood smears are taken:
Active surveillance:
Passive surveillance:
Followup blood smear: 6 day after radical treatment for all Pf cases
Finger selected: Left hand ring finger tip
Procedure of making smear: Sterilizing (Dettol or Savlon) the finger
Pricking by using sterile Hegdnor (No12) needle
Collecting three drops of blood on slide edge
 District Malaria Office 335

Collect one more drop at the center

By using another clean slide, first thin,
then thick smear is made and allowed to
dry
Mark the Sl No and other details. Fill form MF-2.
Quality of the smear: Thick smear should be around 1 centimeter diameter
Thin smear should be single layered and tongue-shaped
Both thick and thin smear are taken on the same slide.
Dispatch of slides: To nearest microscopic center (usually PHC)
Smear inputs to
microscopic center: Surveillance workers (MPW)
Subcenters
Fever treatment depots
Private hospitals and clinics
Drug distribution centers
Person collects and brings: Surveillance worker (MPW)
Frequency of slide dispatch: Twice weekly
Quantity of slides collected:
In Active surveillance, 1 percent of population in month or 10 percent in year
In Passive surveillance, 15 percent of the attendance in year

Supervision of Field Activities

Field activity: Population coverage
Periodicity of visit
Adequacy of number of smear collection (from MF 9)
Timely dispatch of slides

Supervision of Laboratory Services

Who will do the supervision: Medical Officer
Frequency of supervision:
What are all supervised:
Lab: Enough space, light, microscopic work table,
Sitting stool, condition of microscope, staining,
Chemicals, slides cleaning materials
Records: Maintenance of chemicals (fungal growth in stain is prevented)
Skill and work load of technician
Slides: Cleanliness of slides,
Quality of smears and staining (JSB)
Legibility of numbering
Backlog of smear examination
Cross examination: 20 to 25 slides of preceding week by random selection
All slides of severe and complicated Pf cases
336 Section IV: Field
Study
Recoding and Reporting: Inspection of MF-2, MF-7, MF-8 forms to note
Period between staining and examination
Delay in transmission from periphery to laboratory
Time lag in dispatch of results to periphery
Percentage of negative slides (with code number) sent for central lab.

TREATMENT/PROPHYLAXIS
Presumptive Treatment
Day All area High risk area Pf resistant
1 Chloroquine-600 mg Chloroquine-600 mg + Sulfadoxine-1500 mg
Primaquine-45 mg + Pyrimethamine-75 mg
2. Nil Chloroquine-600 mg
3. Nil Chloroquine-300 mg

Radical Treatment
Primaquine is given for 14 day as per Antimalaria Drug Policy 2008
Low-risk areas High-risk areas
[Link] and mixed [Link] [Link] [Link]
Chloroquin-600 mg only Chloroquin-600 mg only Nil Nil
on first day on first day
Primaquine-15 mg for 14 Primaquine-45 mg single Primaquine-15 mg for 14 Nil
day dose day
(Treatment protocols are subjected to change according to the review of programme periodically)

Treatment of Severe and Complicated Malaria

Hospitalize the patient
Qunine injection 10 mg/kg IV in 5% dextrose or Injectable form of artemisinin
Switch over to oral dose as soon as possible

Chemoprophylaxis
Indications: Traveler to endemic area like soldiers, police, laborer, serving in endemic
area Pregnant women in high-endemic area
Schedule: Begin 1 week before entry to malarious area
Continued for at least 4 to 6 week after leaving the area
Drugs used: Short term visit—Tab Doxycycline
Long term visit—Tab Mefloquine.

REFERRAL SYSTEM
Referral centers: PHC, CHC, taluk and district hospitals, others
 District Malaria Office 337

Criteria for Referral

Persistence of fever, headache after 48 hour of initial treatment Too weak to walk
Vomiting, inability to retain food and drugs Change in sensorium
Severe dehydration Convulsions, muscle twitching
Hypothermia Bleeding, clotting disorders
Jaundice, severe anemia

Essential Requirements in Referral Center

IV infusion of quinine Facilities for blood transfusion and examination
Life-saving drugs Well-equipped lab
Special nursing staff Oxygen and respirator

INTERVENTION OF TRANSMISSION
Spray operations: All areas with API ≥ 2 (Priority is given to ‘high-risk’
areas) Insecticides used:

Insecticide Dose per 150 Sq meter Number of rounds in a year

(one house) per round
DDT 50% WP 300 gm 2
Malathion 25% WP 1200 gm 3
Synthetic pyrethroids 120 gm 2
Deltamethrin 2.5% WP
Cyfluthrin 10% WP 37.5 gm 2
Lambdacyhalothrin 10% WP 37.5 gm 2

SPRAY STAFF
Spray Squad
one pump man, one spray man, two men for mixing—totally four unskilled workers
One supervisor/record keeper (skilled worker)

Requirement
Number of houses in the village
Spray squads required per village =
600

Coverage
Each spray squad covers 60 to 80 houses/day (using two pumps simultaneously)

Preparation for the Spray

• Collecting malaria indices
• Selecting the spray places.
• Calculation of required insecticide
• Houses and villages should be informed in advance.
• Taking community participation.
338 Section IV: Field
Study
Precautions Taken During the Spray
• Using gloves, rods to mix, clothes and other protective device
• Covering food material of the house
• Care during transport and storage of insecticides
• Empty insecticide container should be destroyed
• After work, washing the equipments and body, with soap and water
• Washed water should not leak into drinking water.

Supervision Personnel of Spray Operations

Multipurpose worker Health supervisor
Malaria inspector Medical officer
Assistant malaria officer District malaria officer (over all supervision)

Recording and Reporting by Health Worker Male

Insecticide used:
Spray squads worked:
Number of houses sprayed:
Left out/locked houses:
Rejected houses:

Bio-environmental Control Strategy

Aim: To control mosquito breeding
by Biocidal use,
Environmental manipulation

Components
Source reduction: Elimination of breeding places
Environmental manipulation: Filling (leveling of land)
Covering the unused wells
Biological: Larvivorous fishes (Fig. 26.1)
Gambusia affinis
Lebistes reticulatus
Biocides
Bacillus sphaericus
Bacillus thuringiensis

Biocides
Quantity: 250 gm - B. Thuringiensis powder/ltr
500 gm - B. sphaericus powder/ltr
Spraying dose: 1 liter over 50 sq. mt using knap - sack sprayer
Frequency: Once in 1 or 2 week
Site of spray: Tank, seepage, stream, unused well, irrigation pit, channel, burrow pit, paddy field, and other breed-
ing places.
 District Malaria Office 339

Fig. 26.1: Larvivorous fish used in malaria control

Personal Protection
Use of impregnated bed nets
Material: Polyester > 75 denier (Denier - Unit of weight in gm according to length)
Nylon nets (durable, takes drug quickly, insecticide stays longer)
Hole size: Less than 1.2 to 1.5 mm (25 meshes per sq inch)
Dose: Deltamethrin 25 mg/54 meter
Lambdacyalothrin 25 mg/59 meter
Cyfluthrin 50 mg/59 meter
Residual effect: 6 month to one year
Retreatment: Within a year
Impregnating method:
Surface area of the bed net is calculated
Insecticide quantity is determined
Net is soaked in insecticide solution and dried in shade
Person impregnating should use all protective devices and after work, he should wash his body with soap and
water.

Distribution of Nets
Socioeconomically deprived communities
Tribal, forest and unreachable population
Pregnant women and young children
Migrant worker
Disaster affected communities
Social marketing
Subsidized retreatment
340 Section IV: Field
Study
MONITORING AND SURVEILLANCE
1. Activities:
Discussion in monthly meetings in PHC, regarding adequacy, achievement of assigned targets
Fortnightly preparation of the master chart from the reports received (form MF-8; MF-9 and master charts)
2. Vigilance of epidemiological parameters
3. Monitoring of spray operations
4. Vigilance of focal malaria out-break
5. Early prediction of malaria by:
Parasite load Marked changes Number of fever cases
Number of positive Species distribution
Vector dynamics Increase in mosquito density Vector
species Man-mosquito contact
Population dynamics Migrants Labor projects
Large labor movement Floods and drought
Environmental Early and heavy rain fall Increase in humidity
Natural disasters

Note the Following

Recent changes/modifications in the antimalaria
activities Rapid diagnostic tests for malaria
National drug policy of malaria treatment, 2008
Early treatment failure
Malaria goals for tenth plan

Recording and Reporting System

Observe the various forms used for recording and reporting of malaria at various levels. Some of the forms are
given below for your study.

Reporting Formats Used in Malaria

MF-1 Family health register
MF-2 Blood smear collection
MF-3 Tour report
MF-4 Monthly report of PHC
MF-5 Monthly report of PHC remedial activity
MF-6 Progress and assessment of spraying
MF-7 Positive register
MF-8 Subcenter blood smears report
MF-9 Epidemiological evaluation
MF-10 Monthly passive case detection (PCD) report
MF-11 Weekly savingram from primary health care (PHC) on blood smears examined (BSE)
 District Malaria Office 341

MF-1
Name of head of Names of other
Sl No House number Age Sex Remarks
household members

MF-2
For reporting of blood smears by multipurpose worker/passive agency:
Name of subcenter: Name of the PHC:
Code number:
Number Name Name of Age Sl No of Number of
Sl Date of
Village of (Head of patient/ and blood chloroquine Result Remarks
No collection
house family) person sex smear tablets given

Note: This pro forma should be in triplicate and three copies forwarded to PHC laboratory technician, who will
retain one copy and send the other two to MPW/Senior health Inspector/Malaria Inspector.

Signature of Date of examination Signature of MPW/

microscopist by the microscopist Passive agency
 342

Subcentre
Study

Collected
Examined

(BS)
blood
smear
Active

Positive
Section IV: Field

Collected
Examined
Primary Health Centre (PHC)

BS

Positive
contact
Mass and

Collected
Examined
BS
Passive

Positive

Collected
Examined
Taluk

Positive
Total BS

0-1 year
MF-4

1-4 year

5-14 year
Pv Incidence

> 15 year

0-1 year

1-4 year

5-14 year
Pf incidence

15 year

Pv

Pf (R)

Pf (Rg)
parasite
Detail of the

Mix

Total
Pv
Pf
Radical
treatment

Total
 District Malaria Office 343

MF-1
Monthly Reporting Format
For the month of
Number of Mass therapeutic

Total focal spray rooms

Species Balance tablets

without 4AQ
positive measures

RT given

Fever cases d
Sl

4AQ/8AQ

RT 5 day

Quinine
Name of subcenter

Female

Others
Pf (rg)
Pf (R)
No

4AQ

8AQ
Total

Total
Male

SP
SP
Pv
 Active

Total
of the
Name

with SC
number

Passive
subcenter
BS Collected
Pv
Pf
MIx
January

Total
BS Collected
Pv
Pf
MIx
February

Total
BS Collected
Pv
Pf
March

Mix
Total
B/ Collected
Pv
Pf
April

MIx
Total
BS Collected
Pv
Pf
May

MIx
Total
BS Collected
Pv
Pf
June

MIx
Total
BS Collected
Pv
MF-6

Pf
July

Mix
Total
BS Collected
Pv
Pf
MIx
August

Total
Chart showing the blood smears collected from active and passive agencies at PHC for the year

BS Collected
Pv
Pf
MIx
September

Total
BS Collected
Pv
Pf
MIx
October

Total
BS Collected
Pv
Pv
MIx
November

Total
BS Collected
Pv
Pf
MIx
December

Total
Remarks

Section IV: Field 3

 MF-7
Positive Register

Sl Date of BS Date of BS Date of RT Follow-up smear

Name of patient Age Sex Result Remarks
No collection examination intimation From To Date Result

MF-8
Register of blood smears received and examined (subcenter wise)
Name of subcenter PHC:
Sl Section N./ Total smears Blood smears number Date of collection Date of
Date of receipt Remarks
No Hospital received From To From To examination

MF-9
Epidemiological Evaluation Master Register
(Subcenter wise, village wise and month wise)
Month PHC
Name of the First fortnight Second fortnight Total for
Subcenter/Village male health 1 2 3 4 5 6 7 8 9 10 11 12 Total 1 2 3 4 5 6 7 8 9 10 11 12 Total the
assistant
month

District Malaria Office

 MF-11

3
Weekly Savingram Reports Under National Malaria Eradication Programme

Section IV: Field

Week report Primary Health Centre (PHC) Taluk, From Date To Date
Blood smears During the week From Detail of balance Sent outside Received from outside
Subcentre number

MP cases RT given Malarial RT Balance RT given RT given

Subcenter

parasit given

Sent outside
Examined
Collected

Pregnant

Sent out
Balance
(MP)

Child

Unde

Total

Total
Not
OB

Pf

Pf
cases

r
Total

Total

Total
Total

Total

Total

Total

Pf
Pf

Pf

Pf

Pf

Pf

Pf
Signature of the Medical Officer
 District Malaria Office 347

Review Questions
 Prepare your state map showing malaria endemicity
 How and when is anti-malaria week/month celebrated?
 Chapte
r Public Water
Purification System
27

Name of the student: Date and time of visit:

Place and address of the plant:

STAFF PATTERN
Sl No Staff designation Number Duties

Water testing laboratory: present/absent

Water Testing
Sl No Tests done Instruments used Procedure Purpose
1.
2.
3.
4.

Records
• Log book
• Others

OBSERVATIONS OF WATER PURIFICATION STEPS

Raw water:
Source of raw water:
Pollution in and around the source:
Quality of the raw water- Turbidity: Odour:
Color: pH:
 Public Water Purification System
319
Amount of water pumped in:
Pumping method:

Water Purification Steps

1. Storage 2. Purification 3. Disinfection

STORAGE (RESERVOIR)
Artificial/Natural: Capacity:
Sedimentation tanks: Number: Capacity:
Sedimentation period - Duration of storage: Less than seven days More than seven days
Penetration of sunlight: Good Bad

Observe the Natural Purification in Storage

1. Physical: Water becomes clear by sedimentation of 90 percent substances
2. Chemical: Oxidation of organic matter
3. Biological: Reduction in bacterial count up to 90 percent

FILTRATION
Aim
Removal of bacteria and other impurities
Purification in filtration process
• Agglomeration • Sedimentation
• Absorption • Oxidation
• Bacterial reduction

Type of Filters
slow sand filter/rapid sand filter

Slow Sand (Biological) Filter

Layers Depth Purification
Raw water 1.5 meter
Graded sand 1 meter
Gravel 40 cm
Under drain
Control valve
Filtration rate: 1to 4 m3/hr/sq meter (2 to 3 million gallon/acre/day)
Study the details about vital layer (Heart of the filter): “Schemutzdecke”
Thickness: 2 to 3 cm
Action: • Removes organic matter
• Holds back bacteria
• Oxidizes ammonial nitrogen into nitrates

Filter control
Maintain constant flow
Venturi meter: Measures bed resistance (loss of head)
320 Part IV: Field
Study
Cleaning of filter
When cleaning is done?
What is the indication for cleaning?
Method of cleaning: Manual/Mechanical
Indication for closing the filter bed:
Quality of the filtered water in slow sand filter:

Rapid Sand Filter (Mechanical)

Preliminary treatment:
Purpose Substance used Method Place/chamber and
Manual/Mechanical duration
1. Coagulation
2. Mixing
3. Flocculation
4. Sedimentation
Removal of flocculent (sludge) How it is done?
Frequency:

Filter bed
Surface of unit: 80 to 90 m2 (900 sq feet)
Layers Depth Purification
Water 1 to 1½ meter
Sand bed 1 meter
Graded gravel 1 - 1½ feet
Under drain
Filtration rate: 5 - 15 m3/hr/sq meter (200 mg/a/d)

Washing of the filter

Washing is done - when loss of head approaches 7 to 8 feet
Method of washing - Back washing by water compression
Duration - 15 minutes
Quality of filtered water - Turbidity
Colour
Bacteria

DISINFECTION
Observe and note the following
Disinfectant used:
Concentration of disinfectant:
Calculating the amount (demand):
Application procedure:
Contact period: Residual action:
Test used to confirm proper disinfection:
Test used to determination of chlorine
demand: Storage of disinfectant:
 Public Water Purification System
321
Does the Disinfectant used Fulfills the Following Ideal Disinfectant Criteria
• Capable of destroying pathogens, with in contact time and not much influenced by physical and chemical properties
of water
• Should be safe and non toxic
• Should not alter the taste colour
• Cheap, easily available
• Have residual effect
• Easily and accurately detectable by simple tests and even in small sample.

Distribution System
Sl No System Advantages Disadvantages
1. Intermittent
2. Continuous
3. Dual water supply

Discussion
Discuss with the staff and note regarding regulatory authority of water purification plants.

Fill up the Blanks

Breakpoint chlorination means
Residual chlorine after half an hour contact period should be
What is super chlorination?
When super chlorination is done?
Explain the procedure of Horrocks test.
Explain the procedure of Orthotolidine test.
What are the other disinfectants used in public water
purification? 1. 3.
2. 4.
Most modern methods practiced in public water treatment
1. India:
2. Developed countries:
Methods used in disinfection of
1. Well: 3. Rivers: 5. House tanks
2. Tube well: 4. Swimming pool
How bottled (packed) water is disinfected
Methods used in purification of water at house level:
1. Boiling minutes
2. Filtering filter
3. Others
Method used in your house
Method used for disinfection in camps and in travel
Dose of Halozane (parasulfone dichlor aminobenzoid acid) tablets: 0.004 to 0.008 mg per liter
What you advise for travelers regarding drinking water?
Best method of purification of water:
What is the per capita water requirement/day for
322 Part IV: Field
Study
1. Drinking:
2. All purposes:
What is water problematic place?

SYNOPSIS ON WATER PURIFICATION

Natural Purification
• Evaporation and condensation - Rain water
• Storage and settlement
• Air, sunlight/ultraviolet/oxidation/dissolved oxygen
• Nitrification, competition with biological lives
• Self purification of streams - dilution, sedimentation
• Fish and lower bio lives - feeding organic impurities
(Natural purification cannot be relied upon. Thus artificial purification is essential.)

Basic Methods of Water Purification

Mechanical : Storage
Mechanicochemical : Storage with coagulation and flocculation
Physical : Boiling, aeration
Chemical : Disinfection
Biological : Slow sand filter
Physiochemical : Rapid sand filter
Combination of above methods

Purposes of Water Purification

• Hygienic: Removing bacteria
• Biological: Control of algae and unwanted organisms
• Aesthetic: Removal of unwanted colour, taste, odour

Public Water Treatment Objectives

• Removal of pollutant which causes waterborne disease
• Removal of suspended and dissolved matters and minerals

Advantages and Disadvantages of Artificial Purification Methods

1. Distillation: Expensive
Not practicable in large
scale Objectionable taste
2. Boiling: Pathogens are destroyed
Temporary hardness is removed
Unless aerated, it is flat and
insipid.
3. Sedimentation: Removal of suspended matter
Reduction in bacteria
Reduces the load on filtration
4. Coagulation: Removal of coloring and fine colloidal substances
5. Aeration: Get rid of dissolved gases (CO2), chlorine, iron algae odor
Increases dissolved O2 content
Corrosive and acidic nature is reduced
 Public Water Purification System
323
6. Adsorption: Removes color, bacteria, odor in small scale
7. Activated carbon, chlorination : Removal of bacteria, taste and odor
8. Disinfection: Destroys the pathogenic organisms after filtration and during transportation

Water Quality Surveillance (WQS)

• Residual chlorine at consumer level
• Regular testing of water samples
• Monitoring of waterborne infections
• Sanitary inspection of water sources
• Rapid bacteriological testing of water (H2S strip)
• IEC

Quality Of Water
Method of purification to
Sl No Particulars Desirable quality/quantity
reach the desirable quality
1. Turbidity <5 NTU Storage, sedimentation, coagulation and
rapid sand filtration
2. Color <15 TCU Coagulation and rapid sand filtration
3. Odors and tastes Not unusual Aeration, use of activated carbon, algal
removal/ destruction
4. Hardness Boiling and application of lime
1-3 mEq
a. Temporary
b. Permanent 50-150 mg/l Lime and soda ash, zeolite, distillation
and condensation
5. Other minerals Precipitation with lime, rapid sand
< 0.3 mg/l filtration, aeration
a. Iron
b. Lead < 0.01 mg/l Neutralization with lime, filtration
6. Microorganisms: Nil Storage, sedimentation, coagulation,
a. Bacteria rapid and slow sand filtration, domestic
filters.
Boiling, distillation and condensation,
use of chlorine, other chemical and
physical agents.
b. Algae (Plankton) Nil Use of activated carbon
Use of copper sulphate, screening
NTU: Nephelometric turbidity units
TCU: True color units
 Chapte
r Public Water
Purification System
27

Name of the student: Date and time of visit:

Place and address of the plant:

STAFF PATTERN
Sl No Staff designation Number Duties

Water testing laboratory: Present/absent

Water Testing
Sl No Tests done Instruments used Procedure Purpose
1.
2.
3.
4.

Records
• Log book
• Others

OBSERVATION OF WATER PURIFICATION STEPS

Raw water:
Source of raw water:
Pollution in and around the source:
Quality of the raw water: Turbidity: Odor:
Color: pH:
 Public Water Purification System
349
Amount of water pumped in:
Pumping method:

Water Purification Steps

1. Storage 2. Purification 3. Disinfection

STORAGE (RESERVOIR)
Artificial/Natural: Capacity:
Sedimentation tanks: Number: Capacity:
Sedimentation period—Duration of storage: Less than 7 day More than 7 day
Penetration of sunlight: Good Bad

Observe the Natural Purification in Storage

1. Physical: Water becomes clear by sedimentation of 90 percent substances
2. Chemical: Oxidation of organic matter
3. Biological: Reduction in bacterial count up to 90 percent

FILTRATION
Aim
Removal of bacteria and other impurities
Purification in filtration process
• Agglomeration • Sedimentation
• Absorption • Oxidation
• Bacterial reduction

Type of Filters
Slow sand filter/rapid sand filter

Slow Sand (Biological) Filter

Layers Depth Purification
Raw water 1.5 meter
Graded sand 1 meter
Gravel 40 cm
Under drain
Control valve
Filtration rate: 1to 4 m3/hr/sq meter (2 to 3 million gallon/acre/day)
Study the details about vital layer (Heart of the filter): “Schemutzdecke”
Thickness: 2 to 3 cm
Action: • Removes organic matter
• Holds back bacteria
• Oxidizes ammonial nitrogen into nitrates
350 Section IV: Field
Study
Filter control
Maintain constant flow
Venturi meter: Measures bed resistance (loss of head)

Cleaning of filter
When cleaning is done?
What is the indication for cleaning?
Method of cleaning: Manual/Mechanical
Indication for closing the filter bed:
Quality of the filtered water in slow sand filter:

Rapid Sand Filter (Mechanical)

Preliminary treatment:
Purpose Substance used Method Place/chamber and
Manual/Mechanical duration
1. Coagulation
2. Mixing
3. Flocculation
4. Sedimentation
Removal of flocculent (sludge) How it is done?
Frequency:

Filter bed
Surface of unit: 80 to 90 m2 (900 sq feet)
Layers Depth Purification
Water 1 to 1½ meter
Sand bed 1 meter
Graded gravel 1 to 1½ feet
Under drain
Filtration rate: 5–15 m3/hr/sq meter (200 million gallon/acre/day)

Washing of the filter

Washing is done - when loss of head approaches 7 to 8 feet
Method of washing : Back washing by water compression
Duration : 15 minute
Quality of filtered water : Turbidity
Color
Bacteria

DISINFECTION
Observe and note the following
Disinfectant used:
Concentration of disinfectant:
Calculating the amount (demand):
Application procedure:
 Public Water Purification System
351
Contact period: Residual action:
Test used to confirm proper disinfection:
Test used for determination of chlorine demand:
Storage of disinfectant:

Does the Disinfectant used Fulfils the Following Ideal Disinfectant Criteria
• Capable of destroying pathogens, within contact time and not much influenced by physical and chemical
properties of water
• Should be safe and non-toxic
• Should not alter the taste, color
• Cheap, easily available
• Have residual effect
• Easily and accurately detectable by simple tests even in small sample.

Distribution System
Sl No System Advantages Disadvantages
1. Intermittent
2. Continuous
3. Dual water supply

Discussion
Discuss with the staff and note regarding regulatory authority of water purification plants.

Review Questions
 Fill up the Blanks
Breakpoint chlorination means
Residual chlorine after half an hour contact period should be
 What is super chlorination? What is Water sterilizing powder (WSP)?
 When super chlorination is done?
 Explain the procedure of Horrocks test.
 Explain the procedure of Orthotolidine test.
 What are the other disinfectants used in public water
purification? 1. 3.
2. 4.
 Most modern methods practiced in public water treatment
1. India:
2. Developed countries:
 Methods used in disinfection of
1. Well: 3. Rivers: 5. House tanks
2. Tube well: 4. Swimming pool
 How is bottled (packed) water disinfected
 Methods used in purification of water at house level:
1. Boiling minute
2. Filtering filter
352 Section IV: Field
Study
 Method used in your house
 Method used for disinfection in camps and in travel
 Dose of Halozane (parasulfone dichlor aminobenzoid acid) tablets: 0.004 to 0.008 mg per liter
 What do you advise for travelers regarding drinking water?
 Best method of purification of water:
 Per capita water requirement/day for Indians (rural and urban)
1. Drinking:
2. All purposes:
 What is water problematic place?
 Explain in detail how do you undertake a project of water quality testing of a city?
 Visit a sewage treatment plant and prepare a report on your observation.

SYNOPSIS ON WATER PURIFICATION

Natural Purification
• Evaporation and condensation—Rain water
• Storage and settlement
• Air, sunlight/ultraviolet/oxidation/dissolved oxygen
• Nitrification, competition with biological lives
• Self purification of streams—Dilution, sedimentation
• Fish and lower bio lives—Feeding organic impurities
(Natural purification cannot be relied upon. Thus artificial purification is essential.)

Basic Methods of Water Purification

Mechanical : Storage
Mechanicochemical : Storage with coagulation and flocculation
Physical : Boiling, aeration
Chemical : Disinfection
Biological : Slow sand filter
Physiochemical : Rapid sand filter
Combination of above methods

Purposes of Water Purification

• Hygienic: Removing bacteria
• Biological: Control of algae and unwanted organisms
• Aesthetic: Removal of unwanted color, taste, odor

Public Water Treatment Objectives

• Removal of pollutant which causes water-borne disease
• Removal of suspended and dissolved matters and minerals
 Public Water Purification System
353
Advantages and Disadvantages of Artificial Purification Methods
1. Distillation : Expensive
Not practicable in large scale
Objectionable taste
2. Boiling : Pathogens are destroyed
Temporary hardness is
removed
Unless aerated, it is flat and insipid (tasteless).
3. Sedimentation : Removal of suspended matter
Reduction in bacteria
Reduces the load on filtration
4. Coagulation : Removal of coloring and fine colloidal substances
5. Aeration : Get rid of dissolved gases (CO2), chlorine, iron algae odor
Increases dissolved O2 content
Corrosive and acidic nature is reduced
6. Adsorption : Removes color, bacteria, odor in small scale
7. Activated carbon, chlorination : Removal of bacteria, taste and odor
8. Disinfection : Destroys the pathogenic organisms after filtration and during transportation

Water Quality Surveillance (WQS)

• Residual chlorine at consumer level
• Regular testing of water samples
• Monitoring of water-borne infections
• Sanitary inspection of water sources
• Rapid bacteriological testing of water (H2S strip)
• IEC
354 Section IV: Field
Study
Quality Of Water
Method of purification to
Sl No Particulars Desirable quality/quantity
reach the desirable quality
1. Turbidity < 5 NTU Storage, sedimentation, coagulation and
rapid
sand filtration
2. Color < 15 TCU Coagulation and rapid sand filtration
3. Odors and taste Not unusual Aeration, use of activated carbon, algal
removal/ destruction
4. Hardness Boiling and application of lime
1–3 mEq
a. Temporary
b. Permanent 50–150 mg/l Lime and soda ash, zeolite, distillation
and condensation
5. Other minerals Precipitation with lime, rapid sand filtration,
< 0.3 mg/l aeration
a. Iron
b. Lead < 0.01 mg/l Neutralization with lime, filtration
6. Micro-organisms: Nil Storage, sedimentation, coagulation, rapid
a. Bacteria and
slow sand filtration, domestic filters.
Boiling, distillation and condensation,
use of chlorine, other chemical and
physical agents.
b. Algae (Plankton) Nil Use of activated carbon
Use of copper sulphate, screening
NTU: Nephelometric turbidity units
TCU: True color units
 Chapte
r Milk Dairy

28
Name of the student: Date of visit:
Name and Address of the dairy:

GENERAL INFORMATION
Distance from the city:
Area occupied by the plant:
Amount of milk processed/day:
Number of staff members
working: Certification of standards
of diary:
STAFF PATTERN
Sl No Designation Number Working nature
1.
2.
3.

EXAMINATION OF THE PREMISES

Cleanliness of
Premises:
Surrounding area:
Milk handling:

DETAILS REGARDING MILK COLLECTION

Collection of raw milk: Milk producers/ Cooperative societies
Timings of collection:
Volume of milk in liters collected/day:
Cleanliness of containers used to collect the milk:
Time lag between milking and milk reaching the
dairy: Time lag between milk collection and
processing:
Time lag between processing and reaching the consumer:
 Milk Dairy 325

MILK QUALITY TESTING AT COLLECTION POINT

Particulars (Quality) Test done Desirable Standards
Physical
•Colour
•Taste
•Smell
•Specific gravity
•Insoluble dirt
Chemical
Acidity
Bacteriological
•Coliform count
•Methylene blue test
Contents
•Fat
•Water
•Total solids
•Solid non-fat (SNF)
Adulteration
•Sugar
•Starch
Others

Examination of Laboratory
Equipments used for milk testing:
Percentage of samples tested: Frequency of testing:
Criteria adopted to reject the milk:

Chilling and Storage

Milk is chilled to °C temperature, within hour of collection
Procedure used for chilling:
Storage of chilled milk:
Regeneration of chilled milk to room temperature:

Pasteurization
Method adopted for pasteurization:
0
Heating temperature: c
Holding time: sec Cooling
0
temperature: c

PACKING
Packing is done by: Machines/Manual
Material used for packing:
Storage of packed milk:
326 Part IV: Field Study

DIFFERENT STRENGTH OF MILK PRODUCED

Sl No Type Content
Fat SNF Lactometer Rating
reading
1.
2.
3.
4.
5.

LABELING
1. Contents of milk
2. Date of packing
3. Expiry time
4. Instructions for user
5. Food standard certification
6. IEC

TRANSPORTATION
Mode of milk transportation to distribution point:

EXCESS
What they do if excess of milk is collected:
By-products of the dairy:
1.
2.
3.

QUALITY TESTING ON PROCESSED MILK

What are the tests done?
1. 2. 3.
Frequency of tests done:
Percentage of samples tested:

CLEANLINESS
• Cleaning the milk containers and carry crates
• Cleaning of the premises

RECORDS MAINTAINED
• Registers
• Complaints received from customers
• Number of complaints in last month:
• Nature of complaints:
• Corrective action taken:
 Milk Dairy 327

MANAGEMENT/ADMINISTRATION DETAILS
• Collect the information regarding the administrative/regulatory authorities of dairies
• List the short coming observed and write the solution for solving it
Sl No Short coming Solutions
1.
2.
3.
• Write the composition of cow’s milk
Particulars Value per 100 gm
Moistur
e
Protein
Fat
Carbohydra
te Calcium
Energy

Review Questions
 What is homogenized milk?
 What are the recent advances in milk processing?
 What are the substances used in milk adulteration?
 Chapte
r Industry or Factory

29

Name of the students: Date and Time of visit:

Name of the factory: Address:

GENERAL INFORMATION
Established since: years. Distance from human dwelling: km
Number of adult workers -- Male: Female:
Children < 14 years: Pregnant/lactating mothers:
Timing of work: Number of shifts: Duration of shift:
Space occupied by the factory building: Set back:
Amount of electricity used: Amount of water used:
Raw material used: Amount per day:
Main production of the industry: By products:
Main pollutant generated:
Criteria to call it as industry/factory:

STAFF PATTERN
Health and safety staff
Staff Number Designation (Training in industrial health) Service provided
Medical officer
Safety officer
Others

EXAMINATION
Environment of the Factory
Particulars Working place Passage Stairs Toilet Rest room
Structural safety
Ventilation/Lighting
Temperature
Humidity
Noise vibration
Cleanliness
 Industry or Factory 329

Particulars Working place Passage Stairs Toilet Rest room

Dust, fumes, radiation
Overcrowding

Facilities for Employee

• Drinking water • First Aid kit
• Canteen (subsidized) • Medical Treatment
• Toilet • Recreation
• Rest room • Job security
• Washing and bathing

Working Condition
• Long working hours • Monotony of work
• Fatigability work • Lack of security
• Faulty posture, • Faulty light
• Working with dangerous machinery • Handling of toxic substance
• Working in dangerous place

Human Relations
• Among fellow workers
• Employees and Employer

Industrial Pollution
Pollutants generated:
Disposal of pollutants:
Indicators used to measure the pollutant:

Working Atmosphere
Pollutants Measures adopted
Dust - cane, cotton, tobacco, jute, organic grain, floor
Inorganic - coal, silica, asbestos, iron
Metals - lead, mercury, arsenic, zinc
Gases - carbon dioxide, carbon monoxide
Biological agents
Chemicals
Radiation
Noise
Vibration
High/low temperature
Bad light
Air pressure
Air movements
330 Part IV: Field Study

SAFETY MEASURES ADAPTATION

Particulars Safety measures adopted
Dangerous machinery- Moving
Sharp
Protrudin
g
Electricity connections
Handling toxic chemicals
Handling dangerous bioagents

PERSONAL PROTECTION
Particulars Equipments provided
Protection of body
Ear
Eye
Respiratory system
Hand and legs

HEALTH CARE FACILITIES

• Nutrition • Dental health
• Communicable diseases • Health education
• Environmental sanitation • Family planning
• Mental health • Others

PREVENTIVE MEASURES
• Preplacement examination • Providing good environment
• Periodic examination • Good housekeeping
• Healthcare services • Health education and counseling

Benefits Provided under ESI Act

Particulars Details
Medical
Sickness
Maternity
Disablement
Dependents
Funeral
Rehabilitation
Social security
Social assistance

RECORD MAINTENANCE
Registers Maintained in the Factory
1.
2.
3.
 Industry or Factory 331

HAZARDS
List the Hazards of the Industry Visited
• Physical • Mechanical
• Chemical • Psychological
• Biological

DISEASES
Discussing with the officers and observing the register, note the common diseases prevailing in the factory workers
Diseases Number of cases in last year Whether notified or not
Poisoning- Lead
Phosphorus
Mercury
Manganese
Nitrous fumes
Carbon
disulphide
Benzene
Other- Anthrax
Pneumoconios
is Silicosis
Radiation
Toxic anemic
Toxic jaundice
Accidents- Grievous hurt
Minor accidents

INTERVIEW
Interview of Nearby Inhabitants and Know about the Following Things
1. Health problems to employees and surrounding inhabitants by the factory
2. Health problems by the industrial waste
3. Environment pollution
4. Loss of bio-diversity

Review Questions
 Note about regulating authorities of the factory.
 Note the relevant legislative measures under Factories Act 1948.
 List the observed shortcomings in the factory and give your suggestions for improvement.
 Chapte
r School Visit

30

SCHOOL VISIT
Name of the student:
Date of visit: Time of visit:
Name of the school visited: Locality and address:

GENERAL INFORMATION
Type of school: Government/Private/Other
Primary/Middle/High school
Boys/Girls/Both
Number of schoolers
Boys:
Girls:
Total:
Number of staff
Teaching:
Non-teaching:

SCHOOL ENVIRONMENT
Situation: Is at fair distance from factory, traffic, cinema, railway and other busy
places Space: Sufficient building space
Sufficient premises
Structure: Pucca/Non-pucca
Structural safety: Present/Absent

Physical Facilities
Class rooms : Adequate (one room for 40 schoolers)/Not adequate
Windows and doors : Sufficient (20% of floor area)/Not sufficient
Cross ventilation—Present/Absent
Painting of class rooms :
Lighting : Adequate/Inadequate
 School Visit 365

Light falling from : Left side/Right side

Glare : Present/Absent
Audibility : Poor/Adequate/Resounding (Echoing)
Sitting desk type : Minus/Plus/Zero
Chairs : With back rest/No back rest
Mosquito screening : Done/Not done
Potable water : Yes/No
Urinals/Latrines : Present/Absent
If yes,
Latrines : Number per 100 students
Urinals : Number per 100 students
Separate latrine/Urinals for Schoolers/Teachers/Gents and
Ladies Maintenance : Good/Poor
Refuse disposal : Indiscriminate/Bin
Fly and mosquito breeding in and around school:
Yes/No Overcrowding : Yes/No
Eating facilities : Yes/No
Play ground facilities : Yes/No

Services Provided (pertinent to health)

Nutritional services (mid-day meal): Yes/No.
If yes, describe briefly:
Physical education: Minute/ day
First aid facilities: Yes/No.
If yes, note the content of first aid box
School Health Examination Person Conducting Frequency
General
physical Clinical
Mental/Dental/E
ye
Others
Are teachers trained in health aspects: Yes/No

Health Education
Methods used to give health education
Topics given priority:
Health education programs conducted in the previous year:
1.
2.
3.
Health related topics present in syllabus
Hygiene, Healthy habits, Environmental health,
Family life, HIV, Others specify
366 Section IV: Field Study

Sex Education
Given/Not given

Records
List the records (pertinent to health) maintained
1.
2.
3.
Observe the previous medical examination register and note the common health problems of school children:
1.
2.
3.
4.
Note the organization involved in school health services.

NB: As a part of school visit, students are informed to visit

Blind schools
Disabled schools
Certified schools

Review Questions
 What are the most common health problems of school children?
 Write a detailed report regarding the mid-day meal programme in the school you visited.
 Write synopsis on conducting school health examination in your city.