703 Revision Lorima&Liua

Adolescent Health Development

List the six main adolescent health development challenges in young people in the pacific. (6marks)

 ↑ STI prevalence
 ↑ HIV prevalence
 Teenage pregnancies
 Suicidal tendencies
 ↑ Drugs and substance abuse
 Sexual orientation and gender identity issues

WHO SRH Strategies

Discuss 5 priority targets and aspects of SRH that countries need to strategize and implement. (5marks)

 Improve antenatal, delivery, post-partum and newborn care:

- Provision of antenatal clinics
- Training health personnel for safe delivery and post-partum care
- EMOC training
 Provision of high quality family planning services:
- Availability and easy access to contraceptive methods with proper counselling provided
- Cafeteria approach
- Oxfam clinic, family planning clinics at health centers

 Elimination of unsafe Abortion:

- Good sexual education
- Provision of FP
- Prevention of unintended pregnancies through use of effective contraceptives (including
emergency contraceptives)
- Provision of safe and legal abortion facilities to handle complications of abortion

 Combat HIV/STI’s/RTI’s:
- STI clinics at all subdivisions with screening and treatment provided
- Provision of ART to those who have HIV

 Promotion of Sexual Health:

-Mainly to adolescents in schools and mass media
Post-Disaster SRH Issues
Discuss specific SRH issues in post-disaster PH management situation including evacuation centers
(5marks)
1. Sex abuse within center due to overcrowding and lack of security for women
2. ↓ access to contraceptives leading to unintended pregnancies, HIV/STI’s
3. ↓ accessibility to STI/RTI management
4. Unsafe abortions due to unwanted pregnancies. Births attended by unskilled attendants
5. Adolescent sexual health and sexual health education
6. Post-disaster → physical disability and/or chronic illness → impact on sexual wellbeing

Male in SRH
Discuss the 4 strategies that a primary care physician can implement to enhance male involvement in
SRH. (4marks)
1. Educating men on their roles in contraception – male contraceptive methods (e.g. condoms &
vasectomy). Discuss with female partner on family planning methods
2. ↓ STL transmission to women – advocate use of condoms, practice safe sex, faithful
monogamous relationships.
3. Improve the role of men in pregnancies and delivery – encourage their presence in antenatal
clinics, delivery room, help in breastfeeding and educating them on their role as fathers and
husbands.
4. Educating men on signs and symptoms of RT cancers (e.g. Prostate CA), the importance of
screening and early intervention.
5. Bring information to where mainly gather (e.g. social clubs, sporting events)

Motivational Interview in SRH

Discuss two situations where you as a doctor, can utilize motivational interview activities in the stages
of change in a SRH program in primary care setting. (6marks)

 The goal of MI is to help resolve ambivalence in order to change unhealthy or problematic

behaviors
 4 core skills (OARS): use Open-ended questions, Affirmation, Reflections, Summaries
 4 principles of MI (DARES): Develop discrepancies, Avoid arguments, Roll with resistance, Express
empathy, Support self-efficacy.
 4 processes to achieve them (FEEP): Focusing, Engaging, Evoking, Planning
Violence Against Women and Girls (VAWG)
The 4 ways in which a primary care physician can advocate, prevent and eliminate violence against
women and girls in primary care settings. (4marks)
1. Setting up family counselling centers
2. Education and awareness among women – tell women about their rights, report violence
immediately, to seek help and that there is always help available.
3. Engage men and boys in violence against women programs – change societies perception about
using violence to deal with problems, award men who participate and promote VAWG.
4. Involvement with other sectors/ organizations (e.g. FWCC, Ministry of Women, Police,
etc.)-------raise awareness that all forms of violence against women is discriminated.
5. Encourage women to be self-sufficient (financial reliance on partners is a risk factor for intimate
partner violence)

HIV
32yr old pregnant woman, booked at ANC at Vunidawa sub-divisional hospital at 22 weeks. Blood
results came back after 4 weeks, which confirmed HIV. First 2 two pregnancies from previous husband
had no issues. Current partner had previous relationships. There were no remarkable findings on
physical examinations.

Describe how you will manage this patient during ANC period in Vunidawa sub-divisional hospital.
(4marks)

 (POST-TEST COUNSELLING)
- Motivational interview, assess patient’s readiness to receive results
- Disclosure (telling partner about her status) Maximum of 2 weeks and 3 counselling sessions for
pregnant women.
- Testing of partner.
- Refer to support services. Involve partner if possible – avoid blaming and arguments

 Continue receiving antenatal care (e.g. Iron and Folic acid supplements, tetanus immunization if >
than 20 weeks.
 Offer information on PPTCT intervention at all health care facilities (not just during ANC visits)
 Refer to HUB center for:
- Clinical staging
- Lab tests: other STI’s, TB (chest x-ray, AFB, GeneXpert), Hep B, CD4 count
- Other TB prophylaxis (Isoniazid 300mg PO OD x 6mnths, PLUS Pyridoxine 25mg PO OD
 - Offer PJP prophylaxis (Cotrimazole 2 single-strength (SMX 400mg + TMP 80mg) PO OD
- Start ART asap: Tenofovir 300mg PO OD + Lamivudine 300mg PO OD + Efavirenz 600mg PO OD

 Counsel patients on: safe sex (condom use is the only to prevent HIV spread), family planning,
pap smear, post-natal contraception, partner testing (if not already done), adherence to
treatment, HIV care and regular clinic follow up.
 Counsel on infant feeding choices; choose to either exclusively breastfeed, or exclusively infant
formula feed (mixed feeding has high risk of MTCT)

She has opted for an elective C-section, which you had facilitated and she delivered a live male baby.
They returned to your clinic after 1-week post-partum. Explain how you will follow up this baby of a
HIV (+ve) mother. (3marks)

 If baby received BCG vaccine at birth→ check for any adverse reactions (e.g. disseminated TB
infection).
 Ask how she is feeding the baby→ always continue this method throughout exclusively (no mix
feeding)
 Early infant diagnosis of HIV: HIV antibody testing cannot be done (due to presence of maternal
Ab’s) → HIV virological test (DBS for HIV DNA PCR) at 4-6 weeks of age→ If (+ve) start ARV.

 Infant ARV prophylaxis (PPTCT):

- If breast feeding→ if DBS HIV DNA PCR (+ve) → start Zidovudine 180-240mg/m 2 per dose PO
OD (max 300mg BD/ daily) x 6 weeks

- If not breast feeding and DBS HIV DNA PCR (-ve) → no prophylaxis required
- If not breast feeding but DBS HIV PCR (+ve) → start Zidovudine prophylaxis

 Infant Immunization:
- Oral polio not to be given
- BCG, measles, Hib → can be given (except if child is severely compromised)

Appraise the ethical considerations in this scenario. (3marks)

 Confidentiality – patient’s HIV status should be kept confidential between patients and doctor.
Even during the C-section procedure, health professionals should always practice universal
caution (i.e. assume all patients are HIV positive)
 Asking for consent from patient
 Power of autonomy – Patient has the right to refuse ARV treatment.
Reproductive Tract Cancers
The two main preventative strategies for reproductive tract cancers in women are:

 HPV vaccination – Gardasil (6,11,16,18) and Cervarix (16,18) – 3 doses within a 7-month
period (school girl’s classes 4-7)
 Screening of population at risk – (e.g. Pap smear for sexually active women, SBE for breast
cancer)
 Early intervention (e.g. Colposcopy and biopsy to confirm cervical cancer → Cone biopsy,
LEEP, LETZ, Hysterectomy)
Select 2 of the commonest reproductive tract cancers (RCT’s) in Fiji. Discuss the primary care
intervention for each of these 2 RTC’s which you can implement as a primary care physician in
the sub-division or district. (4marks)
A. Breast Cancer:
- Is the most common cancer amongst women, and 3rd most common cancer in
the world
- Primary Prevention (Aim: early diagnosis and referral
- Education about breast cancer
 Risk factors – first degree family Hx, age prolonged estrogen
exposure, nulliparity, smoking.
 Target audience: School girls mass media, Pinktober
awareness, women coming into health clinics.
- Teach women (>35yrs) how to perform SBE (axilla, both breasts, nipples)
- Seek health care advice if any lumps felt or any abnormalities of the breast.
- Investigations: Breast lump U/S (differentiates between solid and cystic breast
mass), mammography (if available)
- Refer to surgical for further investigations and management.
- Continuum of care: wound care, counselling, pain relief

B. Cervical Cancer:
 Is the 2nd most common cancer amongst women (after breast cancer)
 Primary preventions:
 Vaccination of class 8 girls with 3 doses (Gardasil: HPV
6,11,16,18; or Cevarix: 16,18)
 Educate on safe sex habits (faithful monogamous relationships,
use of condoms)
 Regular screening (pap smear) of sexually active women, 1st
paps (3 yrs after 1st sexual intercourse):
→If normal- repeat after 1 year (in case abnormal cells are missed)→Normal→ Repeat every 3yrs
→If abnormal- refer for further investigations (colposcopy and biopsy)
 Continuum of care: Repeat paps screening, wound care, counselling, pain
relief
POST-NATAL CARE
List and explain any three recommendations from the WHO on post-natal care for mothers and
newborns. (3marks)
1. Assessment of mother within the 1st 24hrs: Vaginal bleeding, uterine contractions, fundal
height, vital signs, U/O.
2. Assessment of mother beyond 24hrs: wellbeing (urine incontinence, bowel function, pain,
lochia, emotional wellbeing, etc.)
3. Timing of discharge after an uncomplicated vaginal delivery, healthy mother and baby
should receive care in the facility for at least 24hrs post-partum.
4. Iron and folic acid supplementation: provided for at least 3 months’ post-partum.
5. Prophylactic antibiotics to prevent wound complications after 3rd or 4th degree perineal
tears.
6. Postnatal contacts (total of 4 visits), within 24hrs, 3rd day, between 7-14 days, 6 weeks.
7. Assessment of baby: - refer for further evaluation if → stops feeding well, Hx of
convulsions, fast breathing (>60/min), severe chest-indrawing, no spontaneous
movement, fever, low body temp and jaundice in 1st 24hrs
8. Cord care: daily chlorhexidine applied to umbilical stump during 1 st week of life.
9. Exclusive breast feeding (from birth to 6 months)
EXTENDED PROGRAM ON IMMUNIZATION (FIJI) EPI
The Fiji EPI system is one of the most successful activities in the Maternal Child Health Care in the
Pacific Island Countries.

Discuss the cold chain system for EPI storage. (1mark)

 The cold chain is a system of storage and transport of vaccines in low temperatures, from to
manufacture to the vaccine site. It involves three elements: People, Process and Equipment.
 Vaccines are delicate immunological substances that need to be stored at optimum
temperatures (2-4oC). They can become less effective if they are frozen, allowed to get to
hot, or exposed to direct sunlight.
 It important to maintain the cold chain system because vaccine failure can occur if storage
and transport are not carried out properly.
In pregnancy the tetanus toxoid immunization schedule given to a primigravida is given at:
FAMILY PLANNING
A 28 yr old G2P3 client presented to your clinic requesting for a long term family planning commodity as
she does not want to get pregnant. Hey youngest child is 3 yrs old, and she was on Mini-pills post-
partum, and Depo Provera injection, there no other remarkable findings in the history and examination
findings.
a) Explain the Cafeteria Approach in Family Planning and how this can be used in your FP clinic.

 Cafeteria approach is a method in family planning where all contraceptives available are
explained to the client, their duration, mechanism of action, advantages and
disadvantages, side effects, contraindications, etc.
 Its allows the client to choose from a list of options, much like from a cafeteria menu.
 A ‘GATHER’ approach is used: (Greet, Ask, Tell, Help, Explain, Return)
 Allows clients to make an informed decision without imposing beliefs/views of the
provider to the client.

b) Outline how you will manage this patient. (5.5marks)

 Greet patient – ensure privacy and confidentiality (e.g. private enclosed room)
 Ask patient about her previous experiences with family planning methods (likes and
dislikes). Also ask what other FP methods she knows of, or she wishes to have. When was
her last Depo shot, when is the next due?
 Tell patient about the other long-term methods of contraception:
 - Hormonal Vs Non-hormonal

- COC Pills:
 Failure rate of 1-9%. Must remember to take 1 everyday, around the same time.
 If 1 pill is forgotten → take it as soon as she remembers, and continue the packet (i.e.
2pills taken on one day).
 If >2 pills missed → take the last missed pill ASAP (i.e. 2 pills on that day).
 Emergency contraception if pill missed on 1st week of pack, No back-up required if
missed on 2nd week of pack. Skip placebo and start next pill pack if missed on 3 rd week
of pack.
 Advantages → Decrease risk of endometrial cancer and ovarian cancer. This method
may be unsuitable for her, as she is looking for a long-term method.

- Jadelle:
 Two rods are implanted under the skin of the inner arm by a trained personnel. One
of the most effective FP methods available (failure rate of 0.05%).
 Advantages → Private, Lasts for 5 years.
 Disadvantage → May cause weight gain, irregular menses (which may persist for the
duration of the method). May be less effective in women >80kg.
 When to use: can be inserted any time as long as pregnancy has been ruled out. If
switching from Depo, she can have it inserted when the repeat injection would have
been given, no need for a back-up method.
 Use back-up (e.g. condom) if inserted .5days after menses.

- IUCD (Cu & Hormonal):

 Failure rate of <1%. Lasts 10 years.
 Inserted into the uterus while she is on her menses. May cause heavy longer menses
initially, but improves within 6 months
 Contraindications: Uterine anatomical abnormalities, abnormal uterine bleeding,
menorrhagia, dysmenorrhea.
 Advantages → Continuation of cyclic menstruation

- Tubal Ligation:
 Is permanent method which involves surgical procedures with possible
complications.
 Not advised for her as she is still young and she may want children in the future

 Help patients reach an informed decision. Also educate her on other areas (e.g. use of condoms
to prevent STI’s; STI symptoms and their treatment).
 For her the best option would be Jadelle, or IUCD (if she wishes to avoid hormonal methods)
 Return for continuation of FP, any problems (e.g. Self-examination), checking strings if IUCD in
place, if she is happy with her FP method or wishes to change.
Remsy a 22yo mother G1P1 presented herself to the FP clinic at Malolo Health Center where you are
working, seeking contraceptive advice. She had previously used a combined a hormonal oral
contraceptive, but wants something different because she claims that she is forgetful in taking one
pill every day. Tania’s son is 2yo, she has no regular partner, has just started working in a new place,
and does not want to get pregnant again.
a) Using the Cafeteria approach, outline how you will manage Tania. Which FP commodity
will you prescribe? (7marks) [Refer to previous answer}

b) Explain how you would calculate contraceptive prevalence rate (CPR), and the CPR by
methods for Malolo Medical area which you are working in. (3marks)

- CPR = [No of women (age 15-49yrs) or their partner using any FP]
X 100
[ Total No of women (15-49yrs)]

- CPR by Methods = [ No of women (age 15-49yrs) or whose partner is using condoms] X 100
[ No of women or their partners using any FP}

c) Discuss ethical considerations in this scenario. (4marks)

 Privacy and confidentiality – balance the medical necessity of sexual history with
the patients concern for privacy.
 Principle of Autonomy – respect her personal choice, no coercion
 Beneficence and Non-maleficence – applied to the patient first and only to the
society. We have an obligation not harm other. Where harm cannot be avoided,
we are obliged to minimize the harm we do.
 Principle of Justice – resources should be given to those who need them, not
upon the ability to pay.
IMCI

Sala, 13 months old female was brought into the Balevuto Health Centre (in the interior of Ba subdivision by her mother with a Hx of fever, cough,
and loss of appetite for 3 days; with a sudden onset of SOB for 1 day. This is the 3rd time that Sala has suffered similar symptoms

O/E: Sala was irritable and very sick looking, temperature was 39 degrees Celsius, P- 100, RR- 60 and there were chest indrawings present. There
were crepitations heard bilateraly and over the lung fields

a) Using the IMCI guidelines, identify your Dx and justify your decision
- NO danger signs (unable to drink/ breastfeed, vomits everything, convulsion, lethargic/unconscious
- Cough + RR 60 (cut off is 40) + chest indrawings = severe pneumonia or very sever disease
- Fever (>37.5°C) with possible bacteria cause of fever present (pneumonia) → Fever, possible bacterial infection
b) Outline your clinical Mx of Sala
- Fast breathing or chest indrawing → give a trial of rapid acting inhaled bronchodilator for upto 3x (15-20 mins) apart →
count breath and look for chest indrawing → then classify as severe pneumonia/ pneumonia/no pneumonia
- Give 1st dose of appropriate antibiotics (Amox Elixir 15ml 125mg/5ml)
- Give 1 dose of PCT Elixir 5mls 120mg/5ml
- Treat child to prevent low blood sugar: 30-50ml milk or sugar water (4tspn sugar – 20g – in 200ml clean water)
- Refer urgently to hospital
c) Sala had defaulted her MCH clinic for 2months, and her immunization was not uptodate. No reason for the clinic default were given by
her mother. Outline how the catch up EPI schedule will be conducted for her
- She is 13 months old, therefore she missed her immunization at 12months old (MR 1)
- According to immunization schedule C (unimmunized or partially immunized children), MR1 is given if the child is >12
months and < school entry
- Give Sala 1 dose of MR 0.5ml IM at upper arm
d) After a thorough Hx taking and examination by the principal MO, more issues regarding Sala were revealed. Her mother is in a defacto
relationship and the man she is living with is not Sala’s father. There were also healed round scabs seen around Sala’s buttocks and
arms suspected of cigarette burns. Given the provision in the Child Welfare Decree, how would you manage this situation
3 R’s of child protection: Recognize, Respond and Record

i. Recognize: signs and symptoms of possible violence, abuse or neglect

- Hx: ask for any abuse or neglect of the child at home. Be aware of telltale signs (eg hx inconsistent with injury,
mental illness in parent, delay in seeking help, severe social stress)
- Physical Exam: bruises, welts, scalds, burn, cuts, fractures, STIs genital injuries, unexplained failure to thrive,
dehydration or malnutrition, retinal haemorrhage
- Behavioral and development signs: aggression, anxiety, frozen watchfulness, fear, sadness. Self-mutilation,
suicidal thoughts, substance abuse.
ii. Respond:
- Ask about child and parental wellbeing at home – financially burdened? Enough support?
- Consult with a more experienced colleague if unsure about safety/care of the child
- Report the possible/likely/actual harm to Department of Social Welfare using the Child Welfare Decree
Notification form – includes child’s name, DOB, parents name,address, details of harm or likely harm, phone
number of parents. This reporting is mandatory
- Also contact Sexual Offenses Unit if there are possible criminal matters for investigation
- If there is immediate risk to the child (if she leaves the health facility and return home) → Care and Treatment
Order → allows facilities to admit/retain the child for 48hrs (extension up to 96 hrs), with or without parental
consent
iii. Record
- Record details on Child Welfare Decree notification form → send (with medical record) to Department of Social
Welfare, Divisional Child Protection Focal Point/ Consultant Paediatrician. Inform head of health facility
- Relate to family member who can provide a safe place for the child
- Treat medical condition
- Department of Social Welfare will assess family and social environment, and determine the care plan for the child
MDG 6: Combat HIV AIDS, Malaria and other Diseases

The MDG 6 is to Combat HIV/AIDs, malaria, TB and other diseases. The targets are:

 6A: Have halted by 2015 and began to reverse spread of HIV/AIDs

 6B: To achieve universal access to treatment for HIV/AIDS for all those who need it by 2010
 6C: To have halted by 2015 and begun to reverse the incidence of malaria, TB and other major diseases

a) List 4 indicators that are used by Fiji and other Pacific Island Countries to assess the progress in achieving MDG 6 targets
Target 6A: Have halted by 2015 and begun to reverse spread of HIV/AIDS
Indicators:
- HIV prevalence among population aged 15-24 yrs (%)
- Condom use rate (from contraceptive to prevalence rate) (%). Condom use at last high risk sex
- Proportion of population (aged 15-24 yrs) with comprehensive correct knowledge of HIV/AIDS
- Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14yrs
Target 6B: To achieve universal access to treatment for HIV?AIDS for all those who need it by 2010

Indicators:

- Proportion of population with advanced HIV infection with access to ARVs

b) Discuss 4 of the 6 operational objectives for the WHO Global Health Sector Strategy on HIV AIDS for 2011-2015 to support PICs (and
other member countries) in developing and implementing activites in their national HIV and AIDS Strategic Plans to achieve the global
MDG 6 HIV targets
- Innovation in HIV prevention, diagnosis, treatment and care
- Strategic use of ARVs for HIV treatment and prevention (@ least 3 drugs from 2 classes to prevent resistance)
- Stronger links between HIV and related health outcomes (eg TB, RH, NCDs etc)
- Eliminating HIV in children and expanding access to paediatric treatment
- Improved health sector response to HIV among key populations
- Strategic information for effective scale up
c) Discuss 4 intervention Strategies that can be implemented in the PICs to address MDG 6
- TB: Screen high risk patients for HIV (with pre- and post-test counselling), availability and accessibility of ARVs
- Malaria: Improving surveillance system to track every case of malaria, fight against anti- malaria drug resistance
- TB: Pursue high-quality DOTS treatment for TB – secure financing, ensure early case detection, ensure effective drug supply,
patient supervision and support, monitor and evaluate DOTS program for performance and support
- Enable and promote research – more studies to be done, new drugs available etc

MDG 5: Improve maternal Health. Reduction of maternal mortality by ¾ between 1990-2015

Goal: Improve maternal Health

Target: - decrease by ¾ between 1990-2015, the maternal mortality ratio (5A)

-achieve by 2015, universal access to RH (5B)

Indicators:

5A:

- Maternal mortality ratio

- Proprtion of births attended by skilled health profession
5B:

- Contraceptive prevalence rate

- Adolescent birth rate
- Antenatal care coverage
- Unmet need for family planning

i. Maternal Mortality Ratio:

# of maternal death during pregnancy or within +2 days termination of pregnancy x 100,000

Total # of live births in the same year

Definition: Is the ratio of the number of maternal deaths during a given period of time per 100,000 live births during the
same time period
Maternal Death: female death from any cause related to or exacerbated by pregnancy or its management (excluding
accidents, incidents) during pregnancy or child birth
 Importance:
-A high MMR would indicate the need of more effective measures to reduce maternal mortality and morbidity
-Depicts the risk of maternal death relative to the frequency of childbearing
-Shows how effective our care system is with preventing and managing complications arising in pregnancy &
Childbirth
Causes: -Hemorrhage (25%)
-Infection (15%)
-Unsafe abortion (13%)
-Eclampsia (12%)

ii. Proportion of live births attended by skilled health workers:

# of births attended by skilled personnel during the reference period x 100

Total # of live birth occurring within the reference period

Definition: The percentage of births attended by skilled health personnel

Importance:
-the main purpose of an indicator of the skilled attendant @ delivery is to provide information on womens use
Of delivery care services
-It helps program management at district, national and international levels by indicating whether safe
motherhood programs are on target with making professional assistance at delivery available and used
-It is the measure of the health system’s functioning and potential to adequate coverage for deliveries

iii. Contraceptive Prevalence rate (CPR) ( 38.3% Fiji)

# of women (15-49) using/whose partner is using @ least 1 method of contraception (regardless of method) x100
Total # of women on contraception over the same period

Definition: The proportion of women of reproductive age who are using or whose partner is using a contraceptive in a
Given point in time
Importance: It is an indicator of health, population & development and womens empowerment. It also serves as a proxy
measure to access to reproductive health services that are essential for meeting MDGs

iv. Antenatal Coverage (98% Fiji)

# of women who have visited ANC 4-6 or more times x100%

Total # of women (target group) over same period of time

Definition: % of women who utilized antenatal care provided by skilled health personnel for reasons related to pregnancy
@ least once during the pregnancy as a % of live births in a given period of time

a) Discuss the MMR in Fiji of in your country, as one of the main health indicators used in the monitoring of the progress of MDG 5
 MMR is one of the indicators of MDG 5, with the target: dec MMR by ¾ (between 1990-2015)


 Deaths per 100,000 live births
- Maternal death is death of woman while pregnant, or within 42 days postpartum (regardless of duration and site
of pregnancy, from any cause related to pregnancy or its management; but not from accident or incidental
causes
- Live birth refers to the complete expulsion/extraction of a product of conception from its mother (irrespective of
duration of pregnancy); which after separation, breaths or shows any other evidence of life (eg beating of the
heart, pulsation of the umbilical cord, or definite movement of voluntary muscles) – whether or not the umbilical
cord has been cut of the placenta is attached
Complications during pregnancy and childbirth are leading cause of death and disability among women of reproductive age
in developing countries

Causes of MMR are hemorrhage, hypertension, sepsis, abortion

b) Describe 4 strategies that PIC can implement to address MMR

 Women must have access to skilled health care – before, during and after giving birth
- Accessibility to antenatal clinics/hospitals
- Improve antenatal services (eg screening test for GDM, syphilis, HIV, Hep B; monitoring fetal growth, provision of iron
supplements, tetanus immunizations)
- Skilled community-based birth attendants should be trained and posted to increase maternal coverage in remote areas
  Health care workers must be trained in emergency obstetric care – EmoC, health centres/clinics should have surgical
supplies to handle complications
 Provide ARVs to pregnant HIV(+) women
 Provide effective FP services to prevent unwanted//unplanned pregnancies
 Educate and empower women and girls about maternal health issues (eg marry later, birth spacing, have fewer healthier
children who are more likely to attend school)
 Evaluate and monitor maternal and child health policies – eg make maternal and child survival a core national and global
health concern.

MDG 4: Reduce child mortality by 2/3 between 1990-2015

Goal: Reduce child mortality

Target: Dec by 2/3 between 1990-2015 the under 5yrs mortality rate

Indicators :

- Under 5yrs mortality rate

- Infant mortality rate
- Proportion of 1yr old children immunized against measles

i. Under 5yrs mortality rate

# of deaths <5yrs in a year x 1000

Total # of live births in that year

Importance:
- Reflects social, economic and environmental conditions in which children live
- Reflects quality of health care (IMCI)
- U5MR influenced by:
 Poverty
 Nutrition
 Low level of education
 Availability and accessibility of health services
 Access to safe water and sanitation

ii. Infant mortality rate

# of deaths of children <1yr of age in a year x1000

Total # of live births in that year

Fiji IMR: -(2015): 12.6 per 1000 live births

-(2016): 9.7 per 1000 live births

3 FORMS OF INFANT MORTALITY

Perinatal mortality rate Post-natal mortality rate

Neonatal mortality rate

# of still births/(death from 22wks gestation-1wk post-partum) in a yr x1000

Total # of live births in that yr

Importance: (universally the most important indicator)

- Provides info on quality of Antenatal, delivery, postnatal care in primary health care settings
- Reflects allocation of government resources
- Community health status, poverty, socioeconomic status

iii. Proportion of 1yr old children immunized against measles (Fiji 94%)

# of vaccines administered x100

Total # of children in the age group

Importance:
- It is a (measles vaccine coverage) sub-indicator of U5MR
- Measles is one of the leading causes of child mortality
- Provides a measure of coverage & quality of child health-care system in the country
- Also provides an indirect measure of coverage of other vaccines (eg BCG, DPT, Polio) since these are given before
measles vaccine

SEXUALLY TRANSMITTED INFECTION

A 20yr old male presented in your clinic at Sigatoka Hospital (or Subdivisional Hospital) with Dysuria and Urethral Discharge for the past 2 days. He
is in a stable relationship and sometimes uses condoms. His last sexual contact was 2 days ago and this is the first time he has these symptoms. On
Examination, there were some suprapubic tenderness with urethral discharge seen. A urethral swab and blood tests were taken for microbiology,
culture and sensitivity. There were no other remarkable finding

a. What is your most likely diagnosis and justify your answer

- Syndromic diagnosis : Urethral discharge and or dysuria syndrome in men (UDS) 2° Gonorrhea/Chlamydia
- Syndromic discharge from urethra (incubation period for gonorrhea/ chlamydia 2-14 days
- Risky behavior: multiple casual partners doesn’t use condoms all the time
b. Outline your management for this patient
i. Counselling patient on his diagnosis
- Using motivational interview
- Ensure confidentiality and privacy – use in enclosed room
- Educate patient on risky serious behavior
- Ensure patient that his infection is treatable
ii. Syndromic treatment for urethral discharge (AAPA via DOTS)
- Amoxicillin 2.5g PO stat
- Augmenting 625mg PO stat
- Probenecid 1g PO stat
- Azithromycin 1g PO stat
iii. If any other illness present – treat accordingly
iv. Others
- Offer HIV pretest counselling testing
- Educate and counsel – practice safe sex (use condoms, faithful monogamous relationships)
- Provide patients with condoms
- Give partner referral card (s) – contact tracing, encourage patient to bring partner for treatment
- Treat partne(s) with the same DOT AAPA treatment
- Report as urethral discharge syndrome
- If client returns for persistent symptoms – take a urethral swab for gonorrhea culture and sensitivity, and add
Metronidazole 400mg PO BD with food x1/52 OR refer for specialist care if necessary

Jacob a 28y/o single sexually active male, presented himself to the STI clinic at Sigatoka hospital with dysuria and urethral discharge for 2 days. He
had an unprotected one night sexual relationship with someone he knew and met at the night club 2 days prior to having the above symptoms. He
always uses condoms but this particular night, he did not have any supply with him. He is a company executive and travels a lot on business
overseas. He is not in any stable relationship. He had similar episodes sometimes back and was treated with some injection. On examination, his
vitals were normal. There was mucopurulent discharge seen from the meatus, and small maculopapular rashes around the inguinal area

a. Identify your provisional diagnosis and justify your answer (2 marks)

b. Outline your clinical management for Jacob

c. While drawing Jacob’s blood in the clinic, you accidentally prick your finger with the needle after withdrawing his blood. Discuss how
you will manage the situation
i. Immediate management
- Immediate washing with soap and running water. Use alcohol based hand wash if no running water. Avoid
aspiration, forced bleeding and wound incision. Also avoid iodine solution
- Report occupational exposure incident immediately to supervisor – supervisor contact, infection control officer
- Document incident (occupational Exposure and Incident Form)
 Name of health care worker, where the incident happened
 Description of the exposure and initial care provided, whether exposure occurred while officialy
working or not
 Determine body fluid type (eg blood, CSF, serum) exposure type (percutaneous, mucosal membrane
exposure, intact skin and volume of exposure
ii. Risk assessment
- Completed form sent to infection control officer, who carries out a risk assessment
- Assess source (patient)
 If HIV+  determine clinical staging (WHO) and review drug adherence (if no ARV)
 If HIV status unknown  HIV pre-test counselling and testing (including HBsAg, anti-HBS, anti-HCV,
RPR(rapid plasminogen reagent) for syphilis)  if patient releases HIV testing  assume patient might
be HIV(+)
- Assess the exposed the health worker
 HIV counselling and testing other investigations (HBsAg, anti- HBS, anti-HCV, RPR for syphilis, FBC, LFTs,
UEcr, urine dipstick for glycosuria
  Assess HepB immune status of health care worker  if non immune (anti HBS –ve)  administer hepatitis
Ig 0.05ml/kg IM stat, and start hep B immunization 20mg IM/dose as soon as possible at 0, 1 & 6 months
 Consider tetanus immunization
iii. Post exposure Prophylaxis
- PEP for HIV (depending on risk assessment)  offered immediately (within 36hrs) without waiting for HIV test results
of source person
-

EXPOSURE TYPE AND HIV (+) AND LOW RISK HIV (+) AND HIGH RISK HIV STATUS UNKNOWN
VOLUME
Less severe Tenofovir 300mg PO OD + Lamuvidine Tenofovir 300mg PO OD + - Usually none
- Old needle, 300mg PO ODx 28 days Lamuvidine 300mg PO OD + - Consider Tenofovir
superficial Efavirena 600mg PO OD x 4/52 300mg PO OD +
Lamuvidine 300mg PO
OD x 4/52 if source is
high risk for HIV, or HIV
infection is most likely
More severe Tenofovir 300mg PO OD + Lamuvidine Tenofovir 300mg PO OD + - Usually none
- Large bore, deep 300 mg PO OD + Efavirena 600mg PO Lamuvidine 300mg PO OD + - Consider Tenofovir
injury, visible OD x 4/52 Feavirena 600mg PO OD x 4/52 300mg PO OD +
blood in device, Lamuvidine 300mg PO
needle inpatient OD x 4/52 if source is
artery/vein high risk for HIV, or HIV
infection is most likely

iv. Under the Public Health Act provision, describe the strategies you will implement in conducting contact tracing for Jacob
- Ensure all individuals who have had sexual contacts with the infected person seek examination and are noted
appropriately
- ……………… through early detection and treatment
- Inc incidence of STI and blood borne disease (eg HIV, HBV) in the community by interrupting transmission of the
disease
- Provide information and education to ecourage behavioral change towards safe sex practices amongst those infected
with OR at risk of STI or HIV