Preventive and Social Medicine (High-yield Points)

PREVENTIVE MEDICINE IN OBS/PEDS AND GERIATRICS

Maternal mortality ratio (MMR) = Number of Under RCH program, IFA to be given to mother is
F ACTS ‰‰

maternal death during a year / Total live birth in

‰‰

100 mg iron & 500 mg folic acid

a year x 100,000 ‰‰ Elemental iron and folic acid contents of pediatric
‰‰ Neonatal mortality rate = Total number of IFA tablets supplied under RCH is:
neonatal deaths / Total live births × 1000 •• Children 1- 5 yrs: 20 mg Iron & 100 mg folic
‰‰ Infant mortality rate (IMR) = Infants death in a acid
year / Total number of live births in the same •• Children 6- 11 yrs: 40 mg Iron & 200 mg folic
year x 1000 acid
•• It is a ratio ‰‰ Ideal no. of ANC checkup: 13
•• Most important indicator of the health status ‰‰ Min. no. of ANC checkup under RCH: 4
of a community ‰‰ ASHA is the out product of: NRHM
‰‰ Growth charts were 1st designed by David Morley ‰‰ Anganwadi centres were the out product of: ICDS
‰‰ Type of growth chart used by Anganwadi workers ‰‰ Essential Obstetrics Care:
(ICDS) for growth monitoring: WHO child •• Early Registration of pregnancy within 12-16th
growth standard also know as MGRS week
‰‰ PUFA present in Breast- milk: DHA •• At least 3 ANC checkup
‰‰ Breast milk is deficient in: Vitmin D •• Safe Delivery either at home or in an

1
‰‰ Breast feeding should be continued for a institution
minimum duration of 2 years •• At least 3 post natal checkup
Max. milk output is seen at: 6-7 months

l. MCC of maternal death in India: Hemorrhage

‰‰ ‰‰

Breast–feeding reduces the risk of:

Vo
‰‰ ‰‰ MCC of perinatal mortality: Birth asphyxia
•• Breast and Ovarian cancer ‰‰ MCC of IMR in India: LBW
•• Obesity ‰‰ MCC of neonatal mortality in India: Prematurity
Es

NUTRITION AND HEALTH

iM

Assessment of protein quality is best by Amino Defluoridation is done By: RO

PR

F ACTS
‰‰ ‰‰

acid score ‰‰ Excess of Fluorine intake can cause:

‰‰ Protein efficiency ratio Max→Whey protein •• Dental fluorosis (> 1.5 ppm)
‰‰ Extra caloric requirement of a pregnant lady: 350 •• Skeletal fluorosis (> 5 ppm)
kcal/ day ‰‰ Keshan syndrome (DCM) is due to deficiency of:
‰‰ Extra caloric requirement of a lactating mother: Selenium
600 kcal/ day ‰‰ Zinc excess can cause Pulmonary fibrosis
‰‰ 60 mg of tryptophan is needed to form 1 mg of ‰‰ Richest source of Vitamin A: Halibut liver oil >
niacin cod liver oil
‰‰ ATT causing vitamin B6 (pyridoxine) deficiency: ‰‰ Vitamins which aids an iron absorption: Vitamin
Isoniazid C and Vitamin B – 12
‰‰ RDA of folic acid in pregnancy: 0.5 mg/d ‰‰ Best test to detect iron deficiency in a community/
‰‰ RDA of calcium in pregnancy: 1200 mg/day screening test for Anemia: Hb estimation
‰‰ RDA of Sodium : 2g = 5 g of NaCl ‰‰ Mid-day meal program offers ½ of daily protein
‰‰ RDA of Iron during pregnancy : 35 mg/day requirement and 1/3rd of daily calorie requirement
‰‰ KI is used for iodination of salt in India ‰‰ Cereals are deficient in Lysine
‰‰ Main indicator used to assess the Iodine status of
a population: Median urinary Iodine   Remember
‰‰ Principle impact indicator recommended in
•• Pulses are deficient in Methionine (PM)
monitoring & evaluating IDD control program:
[Mn: PM]
Population median urinary iodine level
•• Gerber’s test: for estimation of fat in milk
‰‰ In screening programs for hypothyroidism in
[Mn: G = Ghee = fat]
neonates _____levels are measured: TSH
‰‰ Safe limit of Fluorine in drinking water: 0.5 – 0.8 ‰‰ Methylene blue test: Test for quality & bacterial 603
mg/l contamination of milk prior to pasteurization
 PRIMES (Volume I)

‰‰ Phosphatase test: Tests efficacy of Pasteurization

B MI Classification BMI
(South Asian)
Under weight < 18.5
Normal 18.5 – 23
Pre- obese 23 – 27.5
Obese > 27.5

W HO CRITERIA WHO Criteria SAM (ANY 1) Moderate acute malnutrition

FOR EVALUATING W/H < - 3SD - 2SD to – 3SD
MALNUTRITION MUAC < 11.5 cm 11.5 cm to 12.5 cm
Pedal edema Present Absent

ANTHROPOMETRIC Condition W/H H/A

PARAMETICS Acute malnutrition (Wasting ) Low N

1
FOR ASSESSING Chronic malnutrition (Stunting ) N Low
MALNUTRITION Acute on chronic malnutrition Low
l. Low
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W/H weight for heights H/A height for age
Es

MUAC GRADING MUAC COLOUR GRADING

TO EVALUATE > 12.5 cm Green Normal
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MALNUTRITION 11.5 cm to 12.5 cm Yellow Borderline

PR

< 11.5 cm Red SAM

* MUAC = mid upper arm circumference

CALORIE Group Work Category Calorie requirement (kcal/d)

REQUIREMENT Sedentory 2300
OF MALES AND Man Moderate 2700
FEMALES Heavy 3500
Sedentory 1900
Moderate 2200
Women Heavy 2850
Pregnant + 350
Lactation + 600

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 Preventive and Social Medicine (High-yield Points)

R EFERENCE Reference indian male Reference indian female

POPULATION 18-29 years 18 - 29 years; non pregnant, non lactating
60 Kg 55 kg
Height 1.73 M & BMI 20.3 Height 1.61 m & BMI 21.2
Free from disease
Fit for active work
8 hours of moderate work
8 hours in bed
4-6 hours Sitting & moving
2 hours in walking & active recreation

D EFICIENCY Deficiency Disease Manifestation

DISORDERS OF Vitamin A
Xeroph thalmia Night Blindness (Nyctalopia), Conjunctival Xerosis,
Bitot’s spot etc

1
IMPORTANT
Wet Beriberi ƒƒ Acute form
VITAMINS &

l.
ƒƒ Characterized by high output cardiac failure
MINERALS
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Dry Beriberi ƒƒ Chronic form
ƒƒ Characterized by progressive peripheral
Vitamin B1 neuropathy
(Thiamine) Infantile beriberi ƒƒ Infants appear plump due to water retention
Es

ƒƒ Seen in chronic alcoholics

Wernicke’s korsakoff
ƒƒ Characterized by ophthalmoplegia, confusion &
psychosis
gait ataxia
iM

Lactic acidosis ƒƒ Due to deficiency of Thiamine pyrophosphate

Vitamin B2 Cheilosis ƒƒ Inflammation of corners of mouth
PR

(Riboflavin)
ƒƒ Dermatitis → casal’s collar
Vitamin. B3 (Niacin / Pellagra / ƒƒ Diarrhea
Nicotinic acid) Asturian Leprosy ƒƒ Dementia
ƒƒ Death
Megaloblastic anemia ƒƒ Anemia with hyperpigmentation
Vitamin. B12
(Cyanocobalamin) Peripheral neuropathy ƒƒ Grierson- Gopalan syndrome/ Burning feet
syndrome
Megaloblastic anemia ƒƒ Anemia, hyperpigmentation, beefy tonzue
Folic acid
NTD ƒƒ Spina bifida and anencephaly
(Vitamin. M)
Hyper homocysteinemia ƒƒ Risk factor for CAD
Calcium ƒƒ Trosusseall sign
Tetany
(Factor IV) ƒƒ Chvostek sign
Selenium Keshan syndrome ƒƒ Dilated cardiomyopathy
Acrodermatitis ƒƒ Diarrhoea, hair loss
Zn
enteropathica ƒƒ Rash around the mouth/anus
Phosphorus Unlikely
Fluorine: Dental caries
Essential fatty acid Follicular keratosis ƒƒ Phrynoderma (Toad skin)
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 PRIMES (Volume I)

X EROPHTHALMIA Xerophthalmia as a public health problem

For assessment of Xerophthalmia, age group taken is 6 months – 6 years
Criteria Prevalence
XN Night Blindness (Nyctalopia) >1%
X1A Conjunctival Xerosis
X1B Bitot’s spot > 0.5 %
X2 Corneal Xerosis
X3A Corneal ulceration (<1/3) > 0.01 %

X3B Corneal ulceration (<1/3)

XS Corneal scar > 0.05 %
XF Xerophthalmic fundus

Biochemical Plasma retinol (< 10 mcg / dL) >5%

1
F OOD INTOXICANTS
l.
Vo
Clinical features Organism/ toxin Food involved Features

Neurolathyrism ƒƒ b oxalyl amino alanine ƒƒ Kesari dal / grass pea / ƒƒ Spastic paraplegia
(BOAA) ƒƒ L.sativus
Es

Aflatoxicosis ƒƒ A. flavus ƒƒ Cereals ƒƒ HCC

ƒƒ Aflatoxin ƒƒ Hepatits
iM

Ergotism / ƒƒ Claviceps fusiformis ƒƒ Cereals ƒƒ Abdominal cramps

St. Anthony’s fire ƒƒ Claviceps purpura ƒƒ Burning in extremities
PR

ƒƒ Ergotamine
ƒƒ Ergocristine

Epidemic dropsy ƒƒ Sanguinarine ƒƒ Argemone maxicana ƒƒ Bilateral pedal edema

ƒƒ Dihydro sanguinarine contaminated mustard oil ƒƒ CCF
* Toxin blocks Na – K ATPase ƒƒ * Tested by paper chromatography

Endemic ascites ƒƒ Pyrrolizidine alkaloid ƒƒ Crotalaria (jhunjhunia ) mixing ƒƒ Ascites

with godhli (panicummiliare) ƒƒ Jaundice

Endemic fluorosis ƒƒ Fluonine ƒƒ Drinking water ƒƒ Dental fluorosis – associated with

intake of > 1.5 mg/L
ƒƒ Skeletal fluorosis – associated with
intake of ≥ 3 – 6 mg/L
ƒƒ Genu valgum

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 Preventive and Social Medicine (High-yield Points)

ENVIRONMENTAL SCIENCE
Index of general sanitation: Enteric fever Bleaching powder contains 33 % of Chlorine
F ACTS ‰‰

‰‰ Sullage: waste water which does not contain

‰‰

‰‰ Residual levels of chlorine in water is tested by

human excreta Orthotolidine Arsenite test
‰‰ Sewage: waste water contaminated with excreta ‰‰ Accepted noise level in classroom: 30 – 40 dB
‰‰ Most reliable evidence of fecal contamination of ‰‰ Accepted noise level in hospital: 20 – 35 dB
water is provided by: Coliform bacteria ‰‰ Acceptable / Tolerable noise limits: 85 dB
‰‰ Confirmatory evidence of recent fecal pollution ‰‰ Auditory fatigue occurs with exposure of 90 dB
of water: Fecal streptococci / 4000 Hz
‰‰ Remote pollution of water is indicated by presence ‰‰ Permanent hearing loss occurs on repeated
of: Cl. perfringes also know as Cl. welchii exposure of > 100 dB
‰‰ Disinfection power of chlorine is due to release of ‰‰ Tympanic membrane rupture occurs with 160 dB
Hypochlorous ion ‰‰ Number of holes per sq.inch in a standard
‰‰ Minimum recommended concentration of free mosquito net: 150
chlorine: 0.5 mg/l for one hour ‰‰ Percentage of para isomer in DDT: 70 – 80 %

1
B IOLOGICAL Biological transmission

TRANSMISSION Cyclodevelopmental
l.
ƒƒ A part of the life cycle is completed in the vector
Vo
ƒƒ Ex → W. bancrofi in Culex
ƒƒ Undergoes developmental as well as multiplication in the vector
Cyclopropagative
ƒƒ Ex → Plasmodium in mosquitos
Propagative ƒƒ Simply grows and multiply in the vector
Es
iM
PR

I NDEX ‰‰ Endemic index / Chandler’s index:

•• Average number of hookworm eggs per gm of
the feces for the entire community
•• Index of >300 is indicative of major public
health problem
‰‰ Cheopis Index:
•• Average number of cheopis per rat
•• Index >1 is suggestive of potential
explosiveness should plague outbreak occur.
‰‰ Aedes aegypti Index: also know as House index
•• Should be <1% in Yellow fever endemic Zone
‰‰ Spleen rate:
•• Measure endemicity of malaria
‰‰ Infant parasite rate:
•• Indicates malarial problem is as area
•• Shows recent transmission
‰‰ Annual parasite incidence: (API)
•• Measure of malaria incidence is community
‰‰ Annual Blood Exam Rate: (ABER)
•• Index of operational efficiency (~10%)
‰‰ Bruti Index: For Aedes aegypti mosquito
•• Container Index: For Aedes aegypti mosquito

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 PRIMES (Volume I)

HEALTH PLANNING AND MANAGEMENT HEALTH CARE OF THE

COMMUNITY
Alma Ata conference ( 1978 ) gave the concept of •• Appropriate treatment of common diseases and
F ACTS
‰‰

primary health care & its 8 elements injuries

‰‰ Concept of primary health care delivery system •• Promotion of food supply and proper Nutrition
was first proposed by Bhore committee in 1946 •• Immunization against Major infectious
‰‰ Elements of primary health care: diseases
•• Education concerning the prevailing health •• An adequate supply of Safe water and basic
problems and methods of preventing and Sanitation
controlling them ‰‰ Principles of primary health care:
•• Prevention and control of Locally endemic •• Equitable distribution
diseases •• Community participation
•• Provision of Essential drugs •• Intersectoral coordination
•• Maternal and child health care, including •• Appropriate technology
family planning ‰‰ Cluster testing is done for: screening of STD

Health care personnel Population covered

1
Anganwadi Per 1000
Anganwadi in tribal area Per 700
ASHA
l.Per 1000
Vo
Health worker Per 5000
Sub-centre Every 5000 population
Every 3000 population in hilly, tribal and backward area
Es

Health planning in India

ƒƒ Proposed the concept of National Health Programs
iM

ƒƒ Integration of preventive and curative health services

ƒƒ Establishment of 1 PHC to a population of 40,000
1946 Bhore committee
ƒƒ 3 million plan
PR

ƒƒ Concept of social physician

ƒƒ Inclusion of 3 months training in PSM
ƒƒ Also know as health survey and planning committee
ƒƒ Strengthening of PHC & referral centers
1962 Mudaliar committee
ƒƒ Strengthening of district hospitals with specialist services
ƒƒ Constitution of an All India Health Service on the pattern of IAS
ƒƒ One basic health worker per 10,000 population
ƒƒ Basic health worker to carry out the vigilance operations in National
1963 Chadah committee
Malaria Eradication Program
ƒƒ Basic health workers were envisaged as multipurpose worker
ƒƒ Delinking of malaria activities from family planning
1965 Mukherjie committee
ƒƒ Separate staff for family planning programme
ƒƒ Integration of health services
Jungalwalla
1967 ƒƒ Recommendations for unified cadre, common seniority, equal pay
committee
for equal work & no private practices
ƒƒ Also know as The committee on Multipurpose workers
Kartar Singh ƒƒ ANM to be replaced by the Female Health Worker
1973
committee ƒƒ Basic health worker to be replaced by Male Health Worker
ƒƒ One PHC for a population of 50,000
ƒƒ Group on medical education and support manpower
ƒƒ Creation of bands of para-professional & semi-professional health
workers
1975 Shrivastav committee
ƒƒ Development of a Referral Services Complex
608 ƒƒ Establishment of a medical and health education commission on the
lines of University Grants Commission
1977 Rural health scheme ƒƒ Training of community health workers
 Preventive and Social Medicine (High-yield Points)

STATISTICS
MODE = Mean – (3 Mean – Median) T-test:
F ACTS ‰‰

‰‰ Standard error of mean = Standard Deviation /

‰‰

•• Paired → 1 group with 2 observation

√n •• Unpaired→ 2 group with 1 observation
•• 95% confidence interval = Mean ± 2 SE mean ‰‰ The response which is graded by an observer on
‰‰ Standard score / Z score: Indicates how many an agree or disagree continuum is based on Likert
SD an element is away from the mean scale
•• Z = X - µ / s ‰‰ APGAR score is an example of Numerical
(Z= Z-score, X= value of the element, µ = mean ordinal data
of the population, s = SD) ‰‰ In a bimodal series: Mode = 3 Median - 2 Mean
‰‰ Variance = A squared deviation from the ‰‰ Best method to compare the results obtained by a
population mean new test & a gold standard test Bland & Altman
•• S2 = ∑ (X i – X )2 / n – 1 analysis
 2 = variance, X = mean, X I = ith element from
S ‰‰ ROC curve is drawn between Sensitivity & 1-
the sample , n = number of element Specificity (FP).
‰‰ Standard deviation = Square root of variance ‰‰ Rejecting a null hypothesis when it is true is
‰‰ Chi- square test: χ2 = ∑ (O-E)2/ E called as Type I error
(O= observed frequency, E= expected frequency ‰‰ Berksonian bias is due to difference in rates of

1
= row total x column total/ grand total ) hospital admission
•• Degree of freedom = (Row – 1) (Column – 1) ‰‰ Best method to study relationship between two

l.
•• It is used to calculate the standard error variables: Scatter diagram
Vo
between proportions
Null hypothesis
‰‰ Coefficient of variation = SD × 100/ Mean
‰‰ Odds = Probability/ 1- probability True False
‰‰ Correlation coefficient: (r) Rejected Type 1 / a No error
Es

•• Measures the strength of relationship between error

2 quantitative variables Accepted No error Type II / b
•• Lies between -1 and +1
iM

error
‰‰ Pearson’s skewness coefficient: Mean – Mode /
SD OR 3 ( Mean – Median ) / SD
Positive / right skewed Negative /left skewed
PR

‰‰ Probability of Type –I error is given by P

‰‰ Probability of Type → II error is given by β Mean > median > mode Mean < median < mode
‰‰ Power of study is denoted by 1- b

S CREENING TIME

609
 PRIMES (Volume I)

MISCELLANEOUS
Corpulence index is used in Obesity. •• Rabies
F ACTS
‰‰

•• It does not take height into consideration •• Rubella

‰‰ Risk of HIV transmission through breastfeeding: ‰‰ Six vector Borne disease covered under
8-10% NVBDCP
‰‰ Risk of HIV transmission from mother to child: •• Japanese encephalitis
30% •• Filariasis
‰‰ Iceberg Phenomenon is not shown by: •• Kala-azar
•• Tetanus •• Dengue
•• Measles •• Chikungunya
•• Pertussis •• Malaria

Timeline
T IMELINE 1946 Bhore Committee

Definition of health by WHO

1
1948
The Employees State Insurance (ESI) Act
The Factories Act
1952 Family planning
l.
Vo
1953 National malaria central programme
1956 The Indian Medical Council Act
Es

1958 NMEP
1962 NTCP
1971 The Medical Termination of Pregnancy (MTP) Act
iM

1978 Alma ata declaration, elements of primary healthcare

1981 1st HIV case in world
PR

1986 1st HIV positive case in Chennai

RNTCP
1992
NACO established
Transplantation of human organ act was planned
1994
PCPNDT act
1997 AFP surveillance started in India
2000 MDG
2002 National health policy
2004 NVBDCB
2005-12 NRHM
2005 RTI act
RNTCP covers the entire county
2006
WHO launched STOP- TB strategy
2007 DOTS + for MDR-TB launched (PMDT)
2011 Last case of polio reported (13th Jan) by P1
2014 Eradication of polio from india

610
 Preventive and Social Medicine (High-yield Points)

N UTRITIONAL Programms Ministries

PROGRAMMER ICDS Women & child development
AND THEIR Midday meal Human resource development
RESPECTIVE National nutritional anemia meal prophylaxis programme Ministry of health & family welfare
MINISTERIES

I MPORTANTS Importants health days

HEALTH DAYS 30th January Anti-leprosy Day
8th March International Women’s Day
24th March Anti-TB Day
7th April World Health Day
25th April Malaria Day
8th May World Red Cross Day
31st May No Tobacco Day
5th June World Environment Day

1
1st July Doctors day
11th July

l.
World Population Day
Vo
8th September World Literacy Day
1st October National Voluntary Blood Donation Day
10th October World Mental Health Day
Es

15th October Handwashing day

24th October UN Day
iM

10th November Universal Immunization Day

1st December World AIDS Day
PR

3rd December International Day of Disabled Persons

10th December Human Rights Day
June Malaria Month

U SES OF VARIOUS Instruments Uses

INSTRUMENTS Anemometer Air velocity

Hygrometer
Air humidity
Sling Psychrometer
Mercurial Barometer
Atmospheric pressure
Anaeroid Barometer
Wind Vane Direction of wind
Chloroscope Measuring level of residual chlorine in drinking water
Winchester Quart bottle Physical & chemical quality of drinking water
Kata Thermometer Cooling power of air & air velocity
Salter’s scale Field Instrument for Low BirthWeight (LBW)
Infantometer Length of infants
Stadiometer Height of adults
611
Shakir’s Tape Mid Upper Arm Circumference (MUAC)