Last Minute Revision: High-Yield PSM Concepts for NEET PG

The revision session covers the following major areas, emphasizing essential points, updates, and common exam questions:

1. Healthcare Delivery System

Asha Workers 

Discussed as a "must must question," ASHA (Accredited Social Health Activist) roles include counseling on birth preparedness, safe delivery, community mobilization for health awareness, and providing DOTS for TB. They cannot administer vaccines or conduct deliveries, though they carry delivery kits. ASHAs are local women residents (25-45 years), selected by the village panchayat, accountable to it, and receive 23 days of training. Their educational criterion is 10th pass, and the population norm is one ASHA per 1,000 population. They play a vital role in formulating village health plans.

Primary Health Center (PHC)

An Ayush officer is desirable but not essential. A Type A PHC has a delivery load of less than 20 deliveries per month, while a Type B PHC has more than or equal to 20 deliveries per month. Recommended bed counts are four for Type A and six for Type B PHCs.

Rural vs. Urban Healthcare

• Primary Level (Rural): PHC and Subcenters (now Health and Wellness Centers/Arogia Mandr under Ayushman Bharat).
• Primary Level (Urban): Urban PHC and Urban Health and Wellness Centers.
• Secondary Level (Rural): CHCs, Sub-district Hospitals, District Hospitals.
• Secondary Level (Urban): Urban CHC (for metro and non-metro cities).
• Tertiary Level: Medical Colleges and Super Specialty Hospitals.
• Key Distinction: The term "subcenter" is not used in urban areas; instead, it's "urban health and wellness centers".

Population Norms

• Subcenter: 1 per 5,000 (plain), 1 per 3,000 (hilly).
• PHC: 1 per 30,000 (plain), 1 per 20,000 (hilly).
• CHC: 1 per 120,000 (plain), 1 per 80,000 (hilly).
• Urban Health and Wellness Center: 1 per 15,000 to 20,000.
• Urban PHC: 1 per 50,000.
• Urban CHC: 1 per 5 lakh (metro), 1 per 2.5 lakh (non-metro).
• Usha Worker (urban ASHA): 1 per 1,000 to 2,500 (or 2,000 as a single number).

Healthcare Worker Roles

• Multi-purpose Worker Male (Health Worker Male): Posted at subcenters. Responsibilities include active malaria surveillance, chlorination, and collecting sputum samples.
• Multi-purpose Worker Female (ANM): Posted at subcenters. Main responsibilities include registering pregnant females, conducting deliveries, maintaining eligible couple registers, and collecting blood/urine samples.
• LHV (Health Assistant Female): Posted at PHCs. Population norm is 1 per 30,000 (plain) / 1 per 20,000 (hilly).
• Workers not working at village level include LHV and ANM (as they are at PHC/subcenter, a step higher than "grassroot" village level).

2. Vaccines and Immunization

Biomedical Waste Management

• Hub Cutter: Used to cut the needle part of syringes, not vaccine vials.
• Empty Plastic Syringes: Go into a red bag.
• Expired Vaccines (with content): Biotechnological waste, go into a yellow bag.
• Empty Vaccine Vials (Glass): Go into a blue bag. Broken vaccine vials also go blue unless they contain vaccines.
• Blood Spills: Managed with sodium hypochlorite (1-10%).
• Mercury Spills: Collect with cardboard, put in a tube half-filled with water, sent to the manufacturer. Floor cleaned with sodium thiosulfate.

Cold Chain

• Longest Temperature Maintenance: Cold box (48-96 hours).
• Vaccine Carrier: Supplies vaccines to outreach programs, capacity 16-20 vials, lined with 4 ice packs (24-48 hours).
• Day Carrier: Lined by 2 ice packs, carries 6-8 vials.
• Ice Pack Holes: Meant for keeping heat-sensitive vaccines (e.g., Measles, OPV, reconstituted BCG).
• Domestic Refrigerator Storage: Heat-sensitive vaccines (OPV, Measles, reconstituted BCG) kept on the top shelf (next to freezer). Freeze-sensitive vaccines (DPT, DT, TD, Hepatitis B) kept on the middle shelf. Diluents on the lowest shelf.
• ILR (Ice Lined Refrigerator) Storage: Cold air settles at the bottom. Heat-sensitive vaccines (OPV) kept at the bottom-most. Freeze-sensitive (Hepatitis B) at the top-most.
• Dial Thermometer: Monitors ILR temperature twice per day, based on thermocouple principle.

National Immunization Schedule (NIS)

Beneficiaries are 0-16 years and pregnant females.

• Birth Doses: BCG, OPV-0, Hepatitis B.
• 6, 10, 14 Weeks: OPV 1/2/3, Penta 1/2/3, Rotavirus 1/2/3, PCV-1, fIPV 1/2.
• 9 Completed Months: Measles-Rubella (MR) 1st dose, JE 1st dose (killed vaccine also given), fPCV booster, fIPV 3rd dose, Vitamin A (1ml/1 lakh IU, then every 6 months till 5 years - 2ml/2 lakh IU).
• 16-24 Months: MR 2nd dose, JE 2nd dose, DPT 1st booster, OPV booster.
• 5-6 Years: DPT 2nd booster.
• 10 & 16 Years: TD1 and TD2 (TT is given for trauma).
• JE Killed Vaccine: Given in left thigh.

Delayed Immunization

• OPV-0: Till 15 days.
• Hepatitis B birth dose: Till 24 hours.
• BCG, Penta, Rotavirus, IPV, PCV: Till 1 year.
• OPV, MMR, Vitamin A: Till 5 years.
• DPT: Till 7 years.
• JE: Till 15 years.
• TT/TD: Lifelong.

Pregnancy Vaccination (TD)

• Two Doses: Primigravida or multigravida with last childbirth more than 3 years ago.
• Single Booster Dose: Multigravida with last childbirth within 3 years (given around 7th month).

Mission Indra Dhanush

Protects from 12 diseases. JE is given only in endemic states, not pan-India. Currently, Mission Indra Dhanush 5.0 is running. (Distinguished from Abhyan Indra Dhanush for hospital bed sheet changes).

IT Initiatives under Mission Indra Dhanush

eVIN (Electronic Vaccine Intelligence Network): App for vaccine stock management.

• UWIN: Online immunization card for 0-5 year olds.
• Anmol: Tablet-based software for ANMs to track pregnant females and children (real-time data entry).
• SAFE (Surveillance and Action for Events Following Vaccination): WH's initiative for AEFI.
• Kilkari App: Information sent to pregnant females.

Vaccine Vial Monitor (VVM)

Heat-sensitive chemical indicator. Inner square lighter than outer circle: use. Inner square the same color or darker than outer circle: discard. On body for liquid vaccines, on neck/cap for freeze-dried/reconstituted vaccines.

Vaccine Side Effects & Contraindications

• Rotavirus: Intussusception.
• BCG: The most common side effect is ulcer formation (scar forms in 8-12 weeks).
• Pertussis: Inconsolable cry and convulsions are no longer absolute contraindications.
• Measles: Toxic shock syndrome.
• Tetanus Toxoid: Brachial neuritis.
• Live Vaccines: Contraindicated in pregnancy (except Yellow Fever) and immunosuppressed individuals (except Measles and OPV in symptomatic HIV).
• Egg Allergy: Yellow Fever and Influenza vaccines contraindicated.
• Live Vaccine Pneumonic: I LOVE CHICK EMBRYO (Influenza Live, Oral Polio, Love, Chickenpox, Yellow Fever, Measles, Mumps, BCG, Rubella, Rotavirus).
• Killed Vaccine Pneumonic: KILLED (KFD, IPV, Influenza Killed, JE Killed, Rabies).

Open Vial Policy

Opened vaccine vials can be reused for up to 4 weeks (28 days) if expiry date not passed, cold chain maintained, no contamination, and VVM not discarded.

• Follow Open Vial Policy: All T-series vaccines (TT, TD, DPT, Pentavalent, Hepatitis B) + IPV + OPV + JE Killed.
• Do NOT Follow Open Vial Policy (Reconstituted Vaccines): BCG, Measles, JE Live, Yellow Fever. These must be used within 4 hours (BCG, Measles), 2 hours (JE Live), or half an hour (Yellow Fever).

3. Concepts of Health and Disease

• Virulence: Measured by Case Fatality Rate (e.g., Rabies 100%).
• Communicability: Measured by Secondary Attack Rate.
  • Secondary Attack Rate Formula: (Total secondary cases / Total susceptibles - Primary cases) * 100.
• Important Terms:
  • Incubation Period: Time from organism entry to first sign/symptom.
  • Latent Period: For non-communicable diseases.
  • Primary Case: First infectious case in population.
  • Secondary Case: Cases developing after primary case exposure.
  • Serial Interval: Time between primary and secondary case onset.
  • Index Case: First case to come to investigator's notice.
  • Generation Time: Time from organism entry to maximum infectivity.
  • Median Incubation Period: Time from organism entry for 50% of cases to occur.
  • Window Period: Time from organism entry to lab positivity (detecting viral markers).
• Incidence: (New cases / Total population at risk) * 1,000.
• Prevalence: (Total existing cases / Total population) * 100.
• P = I x D: Prevalence is dependent on Incidence and Duration. If a drug prolongs life but doesn't cure, duration (D) increases, so Prevalence (P) increases, while Incidence (I) remains unchanged.
• Indicators for Health Assessment:
  • Overall Country Development/Population Health: IMR (Infant Mortality Rate). The UN indicator is the Under-five Mortality Rate.
  • Best Measure for Burden of Disease: Daly (Disability-Adjusted Life Years).
  • Simplest Measure for Burden of Disease: Proportional Mortality Rate.
  • Best Measure of Cost-effectiveness of Interventions: Qualy (Quality-Adjusted Life Years).
  • Quality of Healthcare Delivery Services: Maternal Mortality Ratio (MMR).
  • Combined Pediatrics and Obs Care: Perinatal Mortality Rate (PMR).
  • Standards of Therapy/Assessment: Survival Rates (Kaplan-Meier Curve).
  • Efficacy of Health Programs: Incidence.
• Morbidity Indicators: Attendance rate at OPD, duration of hospital stay, notification rate, admission rates, sickness absenteeism.
• Disability Indicator: Number of days of restricted activity.
• Daly (Disability-Adjusted Life Years): Years of Life Lost to Premature Death (YLL) + Years Lived with Disability (YLD).
• Qualy (Quality-Adjusted Life Years): Years of life added due to a medical intervention (utility value).
• Sullivan's Index: Life expectancy free of disability (Life expectancy - Duration of disability).
• Hail: Buzzword is "full health".
• Standard of Living Indicators:
  • Best Measure: HDI (Human Development Index).
  • PQLI (Physical Quality of Life Index): Based on Infant Mortality Rate, Life Expectancy at age 1, Literacy Rate.
  • HDI (Human Development Index): Based on Knowledge Index (expected and mean years of schooling), Gross National Income (PPP), Life Expectancy at birth. India's current TFR is 2.
  • Global Hunger Index (GHI): Includes Inadequate Food Supply (undernourishment), Child Undernutrition (wasting, stunting), and Child Mortality (under-five mortality). Does not include Infant Mortality Rate. India's GHI rank is 105th (serious level of hunger).

4. Epidemiology and Study Designs

Epidemic Curves

• Common Source Single Exposure (Point Source): Rapid increase and decrease, cases clustered quickly, occur within a single incubation period. Example: Food poisoning, Bhopal Gas Tragedy.
• Common Source Continuous Exposure: Cases rise slowly, fall slowly, occur over multiple incubation periods, multiple peaks. Example: Contaminated well, infected milkman.
• Propagated Epidemic: Person-to-person transmission, bumpy rise, very tall peak, cases occur over multiple incubation periods. Example: Polio, Hepatitis A.

Classification of Study Designs

• Observational:
  • Descriptive: Case report, Case series.
  • Analytical: Cohort, Case-control, Cross-sectional, Ecological.
• Experimental (Intervention): Randomized Control Trials (RCTs), Field Trials (vaccine trials on healthy people), Community Trials.

Bias in Case-Control Studies

 Recall bias, Selection bias, Buronian bias (due to different hospital admission rates). Hawthorn bias (subjects modify behavior when observed) is seen in cohort studies. Bias is a systematic error, eliminated by blinding.

Evidence-Based Medicine Hierarchy

• Lowest: Descriptive Epidemiology (Case report).
• Increasing Importance: Case series, Ecological, Cross-sectional, Case-control, Prospective Cohort, Retrospective Cohort, RCT.
• Gold Standard: Meta-analysis.

Study Design Choice Based on Purpose

• Natural History of a Disease: Cohort study.
• Establish Temporality (Cause precedes effect): Cohort study.
• Evaluate Effect and Outcome (Causality/Intervention): Meta-analysis (highest) or RCT.
• Demonstrate Association (Exposure and Outcome): Cohort study.
• Burden of a Disease (Prevalence/Proportion): Cross-sectional study.
• Population Study (Country/City Level, Secondary Data): Ecological study.
• Incidence Study: Cohort study.
• Multiple Exposures: Case-control study.
• Multiple Outcomes: Cohort study.
• Rare Disease: Case-control study.
• Rare Exposure (Occupational): Cohort study.
• Matching: Done in case-control studies (eliminates known confounders).
• Past Records: Buzzword for retrospective cohort.
• Personal Histories/Interview: For case-control studies.

• Relative Risk (RR): (Incidence among exposed / Incidence among non-exposed). RR > 1 is a risk factor; RR = 1 is no association; RR < 1 is a protective factor.
• Attributable Risk (AR): Difference between incidence among exposed and incidence among non-exposed.
• Odds Ratio (OR): (AD / BC) in a 2x2 table (cross-product ratio). Interpretation similar to RR. Calculated from case-control studies.
• Project Monica: Related to CVD (Cardiovascular Disease).
• Systematic Review & Meta-Analysis Reporting Formats:
  • Consort: For RCTs.
  • Prisma, Cororum, Cochrane: For Systematic Reviews.
  • Care: For Case Reports.
• Funnel Plot: Checks for publication bias in systematic reviews and meta-analyses.
• Forest Plot: Drawn only in meta-analysis. Shows individual study results and overall effect (rhombus). Significant if interval does not include 1.

5. Medical Entomology and Disease Vectors

Mosquito Identification

• Culex: Hunchback, short body, long legs. Larvae have a longer siphon tube. Eggs laid in clusters. Breeds in dirty, polluted water, paddy fields. Vector for Japanese Encephalitis, Malayan Filariasis.
• Aedes: Hunchback, wide stripes on black body (tiger mosquito). Larvae have a shorter siphon tube. Eggs are cigar-shaped, laid singly. Breeds in artificial water collections. Biting time: 2 hours after sunrise and 2 hours before sunset. Vector for Dengue, Chikungunya.
• Anopheles: Rests at a 45-degree angle, has spotted wings. Larvae have no siphon tube, rest parallel to the water surface. Eggs are boat-shaped with lateral floats. Breeds in clean, stagnant water. Vector for Malaria.
• Mansonia: Large body, long legs, squatting appearance. Eggs are star-shaped. Breeds under aquatic plants (Pistia). Vector for Bruggian Filariasis.
• Sandfly: Hairy wings. Vector for Kala-azar (Visceral Leishmaniasis).

6. Population Health Indicators & Family Planning

Maternal Mortality Rate (MMR)

• Formula: (Total maternal deaths / Total live births) * 100,000.
• Maternal Death: Death during pregnancy, delivery, or up to 6 weeks (42 days) postpartum, excluding accidental/incidental causes.

Neonatal Mortality Rate (NMR)

 Deaths from 0-28 days per 1,000 live births. (Denominator is live births, so subtract stillbirths from total births).

Stillbirth Definition

Gestational age beyond 28 weeks, or weight 1 kg, or length 35 cm.

Fertility Indicators

• Crude Birth Rate (CBR): Total live births per 1,000 mid-year population.
• General Fertility Rate (GFR): Total live births per 1,000 women in reproductive age (15-49 years).
• General Marital Fertility Rate (GMFR): Total live births per 1,000 married women in reproductive age.
• Total Fertility Rate (TFR): Total number of children a woman is expected to have throughout her reproductive lifespan. Indicator of family size. The desired TFR for population stabilization is 2.1. India's current TFR is 2.0.
• Gross Reproduction Rate (GRR): Number of girls a woman is expected to have.
• Net Reproduction Rate (NRR): Number of girls expected to survive and replace their mother. Mortality-dependent fertility indicator. NRR = 1 indicates population stabilization.

Dependency Ratio

• (Children < 15 years + Elderly > 65 years) / Working Class (15-64 years). Can be multiplied by 100 for percentage.

Contraceptives

• Emergency Contraceptives: Ulipristal, Mifepristone, Levonorgestrel (I-pill). IUDs are the best emergency contraception (up to 5 days of unprotected intercourse).
• Missed Oral Contraceptive Pills (OCPs):
  • 1-2 Pills Missed: Take 2 pills at scheduled time, no risk of pregnancy, no barrier method needed.
  • 3+ Pills Missed (1st/2nd week): Take 1 pill ASAP, continue the schedule, use a barrier method for 7 days, consider emergency contraception of unprotected sex in the last 72 hours.
  • 3+ Pills Missed (3rd week): Take 1 pill ASAP, finish hormonal pills, discard non-hormonal pills, use a barrier method, consider emergency contraception.
• OCP Benefits: Reduce risk of ovarian and endometrial cancers. Increase risk of cervical and breast cancers.
• OCP Contraindications (Absolute): Breast/genital cancer, cardiac abnormalities (due to estrogen), congenital hyperlipidemia, undiagnosed abnormal uterine bleeding, liver disease, thromboembolism (past or present).
• Government-Provided OCPs: Mala-N (no cost), Mala-D (social marketing scheme).
• Contraception in Breastfeeding Women:
  • Within 6 weeks postpartum: Progesterone-Only Pills (POP).
  • After 6 weeks postpartum: IUCD (Copper T 380A, 375), DMPA (Injectable). Combined OCPs only after 6 months.
• IUCD (IUD) Common Side Effects: Most common is bleeding (reassure, don't remove); second most common is pain. The most common cause of removal is pain.
• IUCD Contraindications (Absolute): Vaginal bleeding, current PID. Previous ectopic pregnancy is relative.
• Government-Provided IUCDs: Copper T 380A (10 years shelf life), Copper T 375 (5 years shelf life). LNG-20 (Mirena) shelf life 5-7 years.
• Vaginal Sponge: Made of polyurethane foam saturated with nonoxynol-9 spermicide. Brand name: Today. Must be left for 6 hours after intercourse. Higher failure rate in multiparous women (available in one size only). Offers no protection from STIs.
• Vasectomy: Most cost-effective, least failure rate contraception.
  • Eligibility: Male client age 22-60 years, married, with at least one child older than one year.
  • Post-Vasectomy: Use barrier method for 3 months or 20 ejaculations.
• Most Prevalent Contraceptive in India: Tubectomy.
• MTP Act (Contraceptive Failure): Allowed up to 20 weeks.
• Contraception Choice (Newly Married Healthy Couple): OCPs (for lower failure rate).
• Contraception Choice (Long-Distance Couple): IUCDs (due to lower failure rates).
• Family Cycle: Stages include Formation (marriage), Extension (birth of first child), Complete Extension (birth of last child), Contraction (first child leaves home), Complete Contraction (last child leaves), and Dissolution.

7. National Health Programs and Diseases

NITI Aayog (National Institution for Transforming India)

Replaced Planning Commission on Jan 1, 2015. Known as India's "think tank." Chaired by the Prime Minister. Develops the Health Index.

Rabies (Post-Exposure Prophylaxis - PEP)

• Categorization of Bites:
  • Category I: Touching, licks on intact skin – wash only.
  • Category II: Nibbling, minor scratches without bleeding – local treatment + vaccine.
  • Category III: Single/multiple bites, licks on broken skin, mucous membrane contact, bleeding present – local treatment + vaccine + Rabies Immunoglobulin (RIG).
• India's Preferred Regimen: Intradermal (ID) "Thai Red Cross" regimen (4 visits: Day 0, 3, 7, 28).
• Intramuscular (IM) Regimen: Essen (5 visits: Day 0, 3, 7, 14, 28).
• Re-exposure Prophylaxis: If within 3 months, just wash the wound. If beyond 3 months, two visits (Day 0, 3) without RIG. RIG is usually given once in a lifetime.
• RIG: Human RIG preferred (20 IU/kg), given around wound site. Can be given up to 7 days from Day 0.
• Best way to control dog rabies: Vaccinate stray dogs (85% accessible).
• Rabies PEP is the Primary Level of Prevention.

Measles

• Rash: Retro-auricular in origin, maculopapular, confluent.
• Koplik Spots: Occur in buccal mucosa (opposite lower second molar), appear before rash and disappear by rash onset.
• Most Common Complication (Young Child): Otitis Media.
• Most Common Complication (Overall): Diarrhea.
• Most Common Cause of Death: Pneumonia.
• Rare Cause of Death: SSPE (Subacute Sclerosing Panencephalitis).

Mumps

The most common complication is Aseptic Meningitis (in young adults: orchitis/oophoritis).

Diphtheria

Presented with a "bull neck".

STI Kits (Syndromic Management)

• Kit 1 (Gray): Urethral/Cervical discharge.
• Kit 2 (Green): Vaginitis.
• Kit 3 (White): Non-herpetic genital ulcer (penicillin-sensitive).
• Kit 4 (Blue): Non-herpetic genital ulcer (penicillin-resistant).
• Kit 5 (Red): Herpetic genital ulcer.
• Kit 6 (Yellow): Lower Abdominal Pain.
• Kit 7 (Black): Inguinal Bubo.
• Kit 8 (Brown - NEW): Anorectal Discharge.

Nutritional Deficiencies

• Phrynoderma ("Toad-like skin"): Deficiency of essential fatty acids (linoleic, linolenic), Vitamin A, Vitamin E.
• Acrodermatitis Enteropathica: Inherited defect in zinc uptake.
• Prudent Diet: Specifically to prevent cardiovascular diseases, with reduced fat (<30%), saturated fat (<7%), cholesterol (<200mg), and salt (<5g) intake.
• Bad Oils (High Saturated Fat): Coconut oil, butter.
• Essential Fatty Acids (PUFA):
  • Linoleic Acid (Omega-6): Most essential. Richest source: Safflower oil, Sunflower oil.
  • Linolenic Acid (Omega-3): From Soya bean oil.
  • Cardioprotective: Omega-6 is more cardioprotective than Omega-3.
• Indian Reference Man/Woman: Age 19-39 years. Man: 65 kg, 1.77m height. Woman: 55 kg, 1.62m height.
• Recommended Dietary Allowance (RDA): Satisfies the nutritional needs of 97-98% population.
  • Adult Man: Sedentary (2100 kcal), Moderate (2700 kcal), Heavy (3400 kcal).
  • Adult Woman: Sedentary (1660/1700 kcal), Moderate (2100 kcal), Heavy (2700 kcal).
  • Pregnancy: +350 kcal daily (all trimesters). Specifically: 1st trimester (+70-85 kcal), 2nd trimester (+250-290 kcal), 3rd trimester (max, +390-450 kcal).
  • Lactation: First 6 months (+600 kcal), Next 6 months (6-12 months) (+520 kcal).
• Vitamin A Deficiency:
  • First Symptom: Night blindness.
  • First Sign: Conjunctival xerosis.
  • Most Specific Finding: Bitot spots.
  • Public Health Problem Criteria: Prevalence of Bitot spot >0.5%, Night blindness >1% (among 6 months-6 years old).
  • Vitamin A Dosage (Signs of Deficiency):
    • Up to 6 months: 50,000 IU (Day 1, 2, 14).
    • 6 months - 1 year: 100,000 IU (Day 1, 2, 14).
    • 1 year: 200,000 IU (Day 1, 2, 14).
      
      
    • If malnourished (weight <8kg): 100,000 IU regardless of age.
• Niacin Deficiency (Pellagra): Caused by excess leucine (in maize/jowar eaters), which inhibits tryptophan conversion to niacin.
• Fluorine in Water:
  • Optimal Level: 0.3-0.5 ppm (prevents dental caries).
  • Dental Caries: Caused by lower fluorine levels (<0.3 ppm).
  • Dental Fluorosis: Fluorine >1.5 ppm (mottling of upper incisors).
  • Skeletal Fluorosis: Fluorine >3 ppm.
  • Crippling Fluorosis: Fluorine >10 ppm.
  • Nal-Gonda Technique: Removes excess fluorine.
• Food Adulteration:
  • Neurolathyrism: Caused by Khesari Dal (Lathyrus sativus), leading to progressive muscle weakness, stiffness, paralysis of lower limbs. Mgmt: Vitamin C.
  • Epidemic Dropsy: Caused by mustard oil adulterated with argemone oil. Toxin: Sanguinarine. Presents with non-inflammatory edema. Tests: Nitric acid test, Paper chromatography.
  • Aflatoxicosis: Caused by Aflatoxins (from Aspergillus flavus in groundnut, cereals, maize), leading to hepatocellular carcinoma.
  • Ergotism: Caused by Claviceps fungus (in sorghum, rye, bajra), leading to GI complaints and ergotism (gangrenous/convulsive).

• Food Standards: FSSAI (Food Safety and Standards Authority of India) gives national standards. BIS (Bureau of Indian Standards) is the logo for quality certification.
• Tetanus Management: The source and reservoir are soil. Tetanus Prophylaxis depends on immunization status and wound type (clean/unclean). RIG is only added to unclean wounds.
• Malnutrition Assessment:
  • Acute Malnutrition (Wasting/Emaciation): Low Weight-for-Height.
  • Chronic Malnutrition (Stunting): Low Height-for-Age.
  • Underweight (Acute on Chronic): Low Weight-for-Age.
• Janani Shishu Suraksha Karyakram (JSSK): Oldest scheme, provides cash assistance to promote institutional deliveries.
  • Incentives (JSY): Asha always gets less than a pregnant woman. Rural areas get more than urban.
  • Low Performing States (e.g., MP): Mother (Rural: 1400, Urban: 1000). Asha (Rural/Urban: 600).
  • High Performing States: Mother (Rural: 700, Urban: 600). Asha (Rural/Urban: 400).
  • Services: Cash assistance, Maternal Death Review, Safe Abortion Services (Suraksha Clinic), Village Health & Nutrition Day. Does NOT include HIV counseling and testing (under NACP).
• RMNCH+A+N: The 'N' stands for Nutrition.
• SUMAN (Surakshit Matritva Ashwasan): Provides proper care with respect and dignity. Covers pregnant women, during delivery, and up to 6 months postpartum, and babies up to 1 year. Has a service guarantee charter.
• Lakshya: Labor room quality improvement.
• Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA): Free antenatal services on the 9th of every month for pregnant mothers. Uses colored cards for risk assessment (Red: high risk, Green: no risk, Blue: PIH, Yellow: other comorbidity).
• Pradhan Mantri Matru Vandana Yojana (PMMVY): Cash incentive of Rs. 5,000 for the first live birth (in two installments). If the second child is a girl, a single incentive of Rs. 6,000 is given.
• Dakshhata: Training health workers for intrapartum and immediate postpartum care.
• NSSK (Navjat Shishu Suraksha Karyakram): 2-day training in basic newborn care and resuscitation.
• Rashtriya Bal Swasthya Karyakram (RBSK): Early childhood screening for 0-18 years. Screens for 4 Ds: Defects, Deficiencies, Diseases, and Developmental Delays. TB and Leprosy have been added for screening. Congenital glaucoma is not screened.
• Home-Based Newborn Care (HBNC): Done by Asha workers. Visits: 7 for home delivery, 6 for hospital vaginal, 5 for C-section.
• Antenatal Care (ANC) Visits:
  • WHO Minimum: 8 visits.
  • Government of India Minimum: 4 visits.
  • Ideal: 13-14 visits.
• National Program for Prevention & Control of NCDs (NPCDCS): Tagline: "Health in your own hands." Now includes COPD, CKD, non-alcoholic fatty liver, non-ST elevation MI, bronchial asthma, and RHD.
• National Family Welfare Program: India was the first country to start this program and the blindness program.
• National Health Mission (NHM): Now known as Pradhan Mantri Samagra Swasthya Mission.
• Integrated Disease Surveillance Program (IDSP): Routinely reports 33 diseases.
• WHO STEPS Approach: Surveillance of NCD risk factors. Includes behavioral, psychological, physical, and biochemical steps. Does not include therapy.
• Tracking Phenomenon: If BP is low in childhood, it remains low in adulthood; if high, it remains high.
• Rule of Halves (Hypertension): Half know they are hypertensive, half of those are treated, half of those are adequately treated.
• Obesity Indicators:
  • BMI (Quetelet Index): Weight (kg) / Height (m)².
  • Height-Independent: Corpulence Index (Actual weight / Desirable weight, should not exceed 1.2).
• National Vector Borne Disease Control Program (NVBDCP): Covers 6 diseases (Malaria, Dengue, Chikungunya, JE, Filariasis, Kala-azar).
  • Permanent Vector Control: Source reduction (environmental measure).
  • Anti-Larval Measures: Gambusia fish (biological), Abate/Tephos (chemical).
  • Malaria Treatment: Varies by species and region. For P. falciparum in Northeastern states: ACT (Artemether-Lumefantrine). Other states: ACT + Primaquine. Primaquine is not given in pregnancy.
  • Malaria Prophylaxis: Short travel (Doxycycline), Long-term travel (Mefloquine).
• Kala-azar (Visceral Leishmaniasis): Diagnostic kit: RK39. Target for elimination: 2027. Insecticide of choice: Pyrethroids.
• Lymphatic Filariasis Elimination: Target: 2027. WHO recommends triple therapy (DC, Albendazole, Ivermectin). Considered eliminated when microfilaria carriers are less than 1%.
• Yellow Fever: Live vaccine (17D). Vaccination certificate valid from 10 days post-vaccination and lasts lifelong. Quarantine for travelers without vaccination: 6 days.
• National Leprosy Eradication Program (NLEP):
  • Criteria to initiate MDT: Hypopigmented patch with sensory loss, peripheral nerve thickening with sensory loss. Skin biopsy is for confirmation, not initiation.
  • Most Common Nerve Involved: Ulnar nerve.
  • Eliminated in India: Yes, prevalence <1 case per 10,000.
  • Sapna Initiative: A cured leprosy patient spreading awareness.
  • Leprosy Prophylaxis: With Rifampicin.
  • MDT (Multidrug Therapy): Now 3-drug regimen for both Paucibacillary (PB) and Multibacillary (MB) leprosy (Rifampicin, Clofazimine, Dapsone).
  • Leprosy Mukt Bharat Target: 2027.
• Sickle Cell Anemia Elimination Program: Target: 2047. Screening for 0-40 years.
• Snake Bite: Now a notifiable disease.
• National AIDS Control Organization (NACO): Headquarters: New Delhi. High-risk groups: Commercial Sex Workers, MSM, Injectable Drug Users, Transgenders. Industrial workers are not a high-risk group.
• HIV-TB Co-infection: The most common opportunistic infection is TB. Best management: Start ATT (Anti-Tubercular Therapy) first, followed by ART (Antiretroviral Therapy) after 2 weeks to prevent Immune Reconstitution Inflammatory Syndrome (IRIS).
• Needle Stick Injury PEP: Drug of choice: TLD (Tenofovir/Lamivudine/Dolutegravir). Start within 72 hours, best within 2 hours.
• Prevention of Parent-to-Child Transmission (PPTCT) of HIV: HIV positive pregnant woman on TLD irrespective of gestational age.
  • Low-risk Infant: Mother received ART for >4 weeks. Give Syrup Nevirapine or Zidovudine.
  • High-risk Infant: Mother did not receive ART for <4 weeks. Add Nevirapine and Zidovudine.
  • Feeding: Never mix feeding (either exclusive breastfeeding or replacement feeds).
  • Early Infant Diagnosis: At 6 weeks (DNA PCR test).
  • Cotrimoxazole Prophylaxis (for baby): From 6 weeks.
• National TB Elimination Program (NTEP): Target: 2025.
  • Cured TB: Treatment complete with negative sputum report at the end.
  • Nikshay Poshan Yojana: Nutritional incentive of Rs. 1,000 per month.
  • MDR TB Treatment: Now a 6-month regimen (Bedaquiline, Pretomanid, Linezolid, Moxifloxacin - BPaLM regimen).
  • TB Mukt Bharat: Initiative to accelerate elimination, introduced Nikshay Mitra (adopting TB patients).
  • Nikshay: Web-based portal for TB patients.
  • Nishchai: Free sputum kit by Asha workers.
• Ayushman Bharat: Health insurance coverage of Rs. 5 lakh per family per year. No restriction on family size or age. Covers secondary and tertiary care hospitalization. Includes Rashtriya Swasthya Bima Yojana and Senior Citizen Health Insurance Scheme. States have flexibility in implementation.

8. Environmental Health

• Fecal Pollution Indicators:
  • Most Reliable: E. coli.
  • Recent Contamination: Fecal Streptococci.
  • Remote Contamination: Clostridium perfringens.
• Chlorination (Horrock's Apparatus): Calculates chlorine demand. Formula: N x 2g of bleaching powder disinfects 455 L of water, where N is the first cup showing color change (indicator: starch iodide).
• Chlorine Tests:
  • OT (Orthotolidine) Test: Checks for free chlorine (yellow color in first 5-10 seconds).
  • OTAA Test: Better than OT, detects both free and combined chlorine separately.
• Air Velocity Measurement:
  • Low Air Velocity: Katathermometer.
  • Radiant Heat (Corrected Effective Temperature): Globe Thermometer.
  • Air Humidity: Hygrometer, Sling Psychrometer, Dry and Wet Bulb Hydrometer (most common), Asman Psychrometer.
• Sewage Disposal: Liquid waste (99.9% water, 0.1% solids).
  • Methods: River outfall, land treatment, oxidation pond/ditches, sewage farming.
  • BOD (Biological Oxygen Demand): Strong sewage has BOD >300 mg/L.
  • Suspended Particle Count: Strong sewage has SPC >500 mg/L.
  • Treatment Stages:
    • Primary Treatment: Screening, grit removal, plain sedimentation (anaerobic process).
    • Secondary Treatment: Trickling filters (aerobic, occupies large space, not preferred) or Activated Sludge Process (aerobic, less area, preferred).
• Solid Waste Disposal:
  • Bangalore Method: For solid waste disposal.
  • Trench Method (Controlled Tipping/Sanitary Landfill): Requires 1 acre of land per year for a population of 10,000 (trench 2m deep).
  • Deep Burial: For camping waste.
  • Manure Pits: For rural area solid waste.

9. Occupational Health

• Factories Act: Maximum work hours per week including overtime: 60 hours (otherwise 48 hours/week or 9 hours/day).
  • No child below 14 years.
  • Space: 500 cubic feet per worker.
  • Crèche/Daycare: >50 workers.
  • Canteen: 250 workers.
  • Welfare Officer: >500 workers.
  • Safety Officer: >1,000 workers.
• ESI Act (Employees' State Insurance Act, 1948): Under Ministry of Labor. For employees earning up to Rs. 21,000/month (disability up to Rs. 25,000).
  • Benefits: Medical benefit (cashless, full care - direct via ESI hospital, indirect via empanelled hospitals), Sickness benefit (70% for 91 days), Extended sickness benefit (for 2 years for 34 diseases), Enhanced sickness benefit (vasectomy/tubectomy - full wage), Maternity benefit (26 weeks confinement).
• Occupational Cancers:
  • Aniline Dyes: Bladder cancer (transitional cell carcinoma).
  • Benzene/Ethylene Oxide: Leukemia.
  • Most Common Occupational Cancer: Skin cancer (Squamous Cell Carcinoma).
• Pneumoconiosis:
  • Silicosis: Associated with TB, "snowstorm appearance," affects upper lung fields, nodular fibrosis. Most common pneumoconiosis.
  • Asbestosis: Dangerous, most common presentation is adenocarcinoma of lung, most specific is mesothelioma, "ground glass appearance".
  • Anthracosis: Coal mines.
  • Byssinosis: Cotton dust.
  • Bagassosis: Non-notifiable, associated with Thermophilic Actinomycetes (e.g., Thermoactinomyces saccharomyces) in sugarcane bagasse.
  • Farmer's Lung: From moldy hay.

10. Health Education & International Health

• Health Education Methods:
  • Workshop: Learning by doing.
  • Panel Discussion: 4-8 experts in front of an audience.
  • FGD (Focus Group Discussion): 6-12 members.
  • Symposium: Series of speeches, no intervention.
  • Best Method for Urban Slum (ORS): Demonstration (seeing is believing).
• Sustainable Development Goals (SDGs): Target for MMR: <70 maternal deaths per 100,000 live births. Neonatal mortality rate: <12 per 1,000. Under-five mortality rate: <25 per 1,000.
• International Health Organizations:
  • UNICEF: Applied Nutrition Program, COBF Campaign. Headquarter: New York.
  • UNDP: Framed SDGs, gave HDI. Headquarter: New York.
  • ILO (International Labour Organization): Headquarter: Geneva.
  • FAO (Food and Agriculture Organization): Headquarter: Rome.
  • WHO (World Health Organization): Headquarter: Geneva.
  • World Bank: Headquarter: Washington.
  • International Red Cross: Headquarter: Geneva.
  • Colombo Plan: Cancer treatment (setting up cobalt therapy units).
  • USAID: Helping in rural health (toilets, sanitation).

11. Disaster Management

• Triage (Color Coding):
  • Red: Highest priority (first 6 hours).
  • Yellow/Blue: Medium priority (6-24 hours).
  • Green: Ambulatory.
  • Black: Dead or moribund.
• Most Common Disease Post-Disaster: Gastrointestinal diseases.
• Vaccines Post-Disaster: All are contraindicated except Measles.

12. Biostatistics

• Variables:
  • Continuous (Quantitative): Measurable, has a unit (e.g., age, pulse rate, blood pressure).
  • Discrete (Qualitative): Countable, no unit (e.g., blood group).
• Mean and Median: If a high value is wrongly recorded as even higher, mean will increase, but median will remain the same (as it's the middle value).
• Statistical Tests:
  • Qualitative Variable: Use non-parametric test (e.g., Chi-square test, particularly for two or more groups).
  • Quantitative Variable: Use parametric test (e.g., Unpaired t-test for two independent groups, Paired t-test for before/after intervention).
  • Parametric Tests: T-test, ANOVA, Pearson correlation, Linear regression.
  • Non-Parametric Tests: Chi-square, Mann-Whitney U, Wilcoxon signed-rank, Kruskal-Wallis, Spearman rank correlation.
• Median Calculation: Arrange data in ascending order. For even number of observations, average the two middle values.
• Standard Error of Mean (SEM): Standard Deviation (SD) / sqrt(n).
• Skewness:
  • Right-Sided Skewness (Positive): Mean > Median > Mode (tail points to the right).
  • Left-Sided Skewness (Negative): Mean < Median < Mode (tail points to the left).
• Normal Distribution (Bell Curve):
  • Mean ± 1 SD: Covers 68% of observations.
  • Mean ± 2 SD: Covers 95% of observations.
  • Mean ± 3 SD: Covers 99% of observations.
• Data Presentation:
  • Bar Diagram: For qualitative variables, has gaps.
  • Histogram: For quantitative/continuous variables, no gaps (bars are joined).
  • Frequency Curve: Joins midpoints of histogram bars.
  • Line Diagram: Shows trends.
  • Ogive: Cumulative frequency curve.
  • Spot Map: Shows geographical distribution of cases.
  • Box and Whisker Plot: Shows distribution and outliers, indicates skewness.
  • Venn Diagram: Shows relationships between sets.
• Screening Tests:
  • Usual Time of Diagnosis (Y): When signs and symptoms are present.
  • Critical Point (X): When intervention is most effective.
  • Lead Time: Time from usual diagnosis to critical point.
  • Sensitivity: (True Positives / True Positives + False Negatives) * 100. Ability to identify those with the disease.
  • Specificity: (True Negatives / True Negatives + False Positives) * 100. Ability to identify those without the disease.
  • PPV (Positive Predictive Value): (True Positives / All positives) * 100. Probability of having the disease given a positive test.
  • NPV (Negative Predictive Value): (True Negatives / All negatives) * 100. Probability of not having the disease given a negative test.
• Type I and Type II Errors:
  • Type I Error (Alpha Error/False Positive): Rejecting a true null hypothesis (drug not good, but shown good). P-value relates to Type I error.
  • Type II Error (Beta Error/False Negative): Accepting a false null hypothesis (drug good, but couldn't show it).

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