Miscellaneous Topics in Community Medicine😊

Miscellaneous Topics in Community Medicine

Biosafety Levels

Bioterrorism

Category A

• Highest priority – easily transmitted, high mortality
• Anthrax
• Smallpox
• Plague
• Botulism
• Tularemia
• Viral Hemorrhagic Fevers (e.g., Ebola, Marburg)

• Mnemonic: Anthrayil (anthrax) Smallkids (smallpox) Play (Plague) cheythirunna Boatil (botu) terrorist (A) Tula ittu → Viral (VHF) ayi

Category B

• Moderately easy to disseminate, moderate morbidity, low mortality
• Brucellosis
• Psittacosis
• Typhus fever
• Salmonella
• Diarrheagenic E. coli
• Hepatitis A
• Caliciviruses
• Ricin toxin
• West Nile virus

Category C

• Emerging pathogens with potential for mass dissemination in future
• Mnemonic: Enta Nippah
• Nipah virus
• Hantavirus
• Covid

Lattice Theory

Levels of Prevention

Levels of Prevention	Prevents	Examples
Primordial Prevention/ Health promotion (Ideal)	Risk factor	- Lifestyle modification  - Health education  - Sanitation  - Safe water
1° Prevention / Specific protection/ Presumptive/ Prospective/ Predictive (Best)	Disease	- Specific protection  - Immunization  - Pre-employment checkup  - Pre-exposure prophylaxis  - Chemoprophylaxis  - Food fortification Screening - HIV screening: ◦ In mothers in ANC: Opt-out testing. ◦ During blood donation: Unlinked anonymous - COVID screening in airports - Immigrant screening protocol
2° Prevention / Prescriptive (m/c)	Complication	- disability (or complication) prevention - Early diagnosis  - Prompt treatment  - Screening for disease, - Fecal occult blood test - Mammography - PAP smear - Urinary ALA levels - VDRL
3° Prevention	Disability/death	- Disability treatment/rehabilitation/limitation  - Prosthesis  - Transplants

According to the NACO guidelines, what level of prevention is achieved when an HIV patient
undergoes counselling and screening for TB at an ICTC clinic?
A. Primordial
B. Primary
C. Secondary
D. Primary & secondary

ANS

Counselling for TB here is primary level as a risk factor is present and screening for TB is a secondary level of prevention as we are trying to do early diagnosis and treatment

Q. Hand washing during COVID-19 is what level of prevention?
A. Primordial prevention
B. Primary prevention
C. Secondary prevention
D. Tertiary prevention

ANS

B

Q. A government plans to outline tobacco control laws. What is the level of prevention here?
A. Primordial prevention
B. Primary prevention
C. Secondary prevention
D. Tertiary prevention

ANS

B

Vaccination & Mass chemoprophylaxis represent
A. Health promotion
B. Specific protection
C. Early diagnosis and treatment
D. Rehabilitation

ANS

B

Hand Hygiene/ Steps of Hand Washing

• Steps: Wet hands → Soap → Rub palms → Right palm over left dorsum (interlaced) → Palms to palm (interlaced) → Backs of fingers to opposing palms → Rotational rubbing of thumbs → Rotational rubbing of clasped fingers → Rinse → Dry → Use towel to turn off faucet.

• Areas missed:
• Thumb,
• Inter digital areas,
• Finger tips.

• 5 moments:
• "2 Before":
• Before touching patient.
• Before clean/aseptic procedure.
• "3 After":
• After body fluid exposure.
• After touching patient.
• After touching patient's surroundings.

• Soap and water/sanitizer:
• C/I for sanitizer:
• After toilet visit.
• Visibly soiled hands.

Essential PPE:

• Gown, Gloves, Mask, Goggles, Face shield

Step	Sequence
1. Donning (Putting on PPE)	Gown → Mask → Goggles/Face Shield → Gloves
2. Doffing (Removing PPE)	Gloves → Goggles/Face Shield → Gown → Mask

Health & Development Indicators

1. Physical Quality of Life Indicator (PQLI) = 1

• WHO

Dimensions (3)	Indicators (3)
Health	Life expectancy at 1 year
Knowledge	Effective literacy rate (>7 years)
Health Care Delivery & Utilization	Infant mortality rate

2. Human Development Index (HDI)

• UNDP

Dimensions (3)	Indicators (4)	Min	Max
Health	Life expectancy at birth (in years)	20	85
Knowledge	Mean school years (years of schooling at age of 25 years)	0	18
ㅤ	Expected school years (expected years of schooling till 25 years)	0	15
Income/Standard of Living	Gross national income (GNI) per capita GDP is not a critera Income generated by a citizen of a country	100	75000

• Dimension index (Di) (of individual indicators)
• (Actual value - minimum value) / (maximum value - minimum value)

• Geometric mean (DI of all 4 indicators)
• ³√(Li × Ki × Ii) 
• Better indicator due to inter-dimensional inequalities.
• Li (Life index): Di of health.
• Ki (Knowledge index): Di of knowledge.
• Ii: Di of income.

3. Global Hunger Index (GHI)

• Proportion of population that is undernourished (%) + Prevalence of underweight in children under 5 yrs (%) + mortality rate of children under age of 5 yrs (%)
  3
• → Arithmetic mean

 

• GHI: Arithmetic mean
• (Undernourishment + underweight + U5 mortality rate) / 3

 

Parameter	Weightage in GHI
Under 5 mortality rate	1/3
Child undernutrition	-
- Wasting	1/6
- Stunting	1/6
Inadequate food supply (Adult & child)	1/3

4. Multidimensional Poverty Index (MPI)

In India

Q. Life expectancy of two different countries can be compared using which of the following demographic indicators?

Disability Indicators

• Important terms:
• Impairment:
• Anatomically impaired
• Loss of anatomical organ or physiological function.
• Eg: Loss of vision
• Disability:
• Personal disability
• Loss of activity or work.
• Eg: I cant see, Blindness
• Handicap:
• Socially handy
• Loss of occupation or job (Social role), money, or position.

• QALY (Quality Adjusted Life Years):



• QALY =
  (life expectancy with intervention - life expectancy without intervention) × utility value
• Score between 0 (death) and 1 (perfect health)
• Expressed in terms of utility value
• Measures quality of life in health gain
• Most important measure of effectiveness of an intervention.
• Best measure of cost-effectiveness of intervention
• Positive indicator.
• No. of years of life added due to the medical intervention.
• Gain in quality life years with an intervention.

• HALE (Health Adjusted Life Expectancy):
• Equivalent number of years in 'full health' that a new-born can expect to live based on current rates of ill health and mortality.
• Positive indicator.
• Indicates health status or sickness burden in a population.
• Best measure of healthy life expectancy (No. of years in good health, free from disability).

The average life expectancy for a woman in Japan is 87 years. Due to recent advances in testing for cervical cancer, there is an increase in life expectancy by 15 years. The healthcare utility value is 0.8. Which of the following can be calculated from the parameters given?

Due to recent advances in testing for breast cancer, life expectancy has reportedly increased by 20 years in a country X. The healthcare utility value for the country was 0.7. Which indicator can be calculated from the parameters given?

Q. All are disability indicators except:

Q. Life expectancy of two different countries can be compared using which of the following demographic indicators?

Utilisation Indicators

• Utilisation indicators
• Bed occupancy rate = Average daily in-patient census / Average number of bed days
• Average length of stay = No. of days of care rendered / No. of discharges
• Bed turnover ratio = No. of discharges / Average no. of beds
• No. of ANC visit

• PNMR: Perinatal mortality rate.

• MPI: Multidimensional Poverty Index.

Health Communications, Family & SE Scales

Information & Communication

• Types of communication:
• One way → Didactic communication.
• Two way → Socratic communication.

• Total communication
• Used for Hearing impaired children
• Incorporates oral, aural and manual mode of communication

• Communication loop:
• Sender → message → Channel → Receiver
• Feedback:
• most important component
• component of receiver

Levels/Methods of Communication

Demonstration

• Two-way Communication
• Socratic method used for interaction.

• Principle
• Relies on:
• "Seeing is believing"
• "Learning by doing"

• Examples
• ORS preparation/demonstration
• Scabies ointment application
• Hand washing technique

Communication approaches:

1. GATHER: Interview tool.
• Adopted for contraceptive counselling
• Greet → Ask → Tell → Help → Educate → Review.

2. Cafeteria approach:
• We give menu and options like cafeteria
• Earlier used to promote family planning.
• Choice of contraceptive lies with the individual.

3. SPIKES protocol: Delivering bad news.

4. Roleplay:
• Asha worker and mother
• Type of group communication

Learning

• Psychomotor learning:
• Involves learning motor skills through practice and repetition
• Example: Intern performing knee reflex test

• Cognitive learning:
• Involves understanding and knowledge

• Affective learning:
• Related to attitudes, emotions, values

Family

• Family cycles:
• Formation: Couple meets
• Extension: Birth of 1st child
• Complete extension: Birth of 2nd child
• Contraction: 1st child leaves home
• Complete contraction: 2nd child leaves home
• Dissolution: Death of 1 parent
• Extinction: Death of both parents

• Types of families:

Type	Description
Nuclear family	Children live with their parents.
3 generation family	Children live with parents and grandparents.
Joint family	All children and grandchildren live with grandparents

Socioeconomic Scales

Social Medicine

Opinion vs. Belief

Crowd vs. mob vs. Herd

Attitude vs. Habits

Miscellaneous terms

• Folkways: Right way of doing things.

• Mores: Stringent customs.

• Sociology
• Study of human relationships and behavior.

• Society
• A group of individuals sharing common values and interests.
• Leads to a certain way of life.

• Community
• Group of people within a defined geographical boundary.

• Acculturation
• Cultural contact or exchange of culture.
• Examples:
• Marriage
• Conquest
• Migration
• Industrialization

• Socialization
• Process where individuals adopt cultural traits and become part of a society.

• Social Structure
• Pattern of interrelationships among members of society.

• Social Pathology
• Study of social causes that lead to disease.
• Examples:
• Unemployment
• Illiteracy
• Poverty

• Culture
• Learned behaviour patterns and ways of doing things.
• Acquired over generations.

• Customs
• Established pattern of behavior in a society.

Health Propaganda

• Information promoting a health viewpoint or cause,

• often biased or misleading.

Characteristics & Aims

• Appeals to emotions & Persuasive (not reflective)
• Uses fear, urgency, empathy, or hope
• Aims to persuade, not encourage independent judgment or critical thinking
• Influences attitudes and behaviors

• Promotes specific actions such as:
• Exercise
• Balanced diet
• Immunizations
• Smoking cessation

Dissemination

Behaviour Change Model

• Ex: Smoking cessation

The stages of change model (cyclical):

• Mnemonic: PC addicted says DARM

• Stages
1. Enter
2. Precontemplation
• No
• Affected by motivation → can change to maybe
3. Contemplation
• Maybe
4. Determination (Exit & re-enter at any stage)
• Prepare
5. Action
• Action
6. Relapse (Exit & re-enter at any stage)
7. Maintenance

Disaster Medicine

National Disaster Response Force (NDRF)

• Under Ministry of Home Affairs

• Chairman: Prime minister

Disaster management Cycle

Planning/pre-disaster preparedness phase:

• Disaster mitigation
• Legal action to ↓ impact of disaster
• Long-term measures
• Includes
• structural modifications,
• disaster risk reduction strategies,
• environmental policies.

• Disaster preparedness.
• Ensure readiness
• Training, Mock drills, emergency stockpiling, and early warning systems.

Post disaster response phase:

• Response
• Early response phase (0-6 hrs)
• most crucial

• Rehabilitation.
• Longest phase
• Water supply restoration
• Basic sanitation and personal hygiene
• Food safety measures
• Vector control

Note:

• Haddon matrix: Injury prevention using epidemiological tools.

• m/c type of disaster: Hydrological > Geological.

• m/c disease post disaster: Acute gastroenteritis.

• m/c long-term sequelae post disaster: malnutrition.

• m/c vaccine preventable disease outbreak: measles.

• Vaccine coverage to be ensured: measles & vit. A.

• Vaccine for general population: No vaccine recommended

• Vaccine for health professionals:
• TT, Hep B, Outbreak specific vaccine

Triage

• Red: Immediate attention.

• Yellow: Unlikely to deteriorate for a few hrs.

• Green: Unlikely to deteriorate for a few days.

• Black: Dead persons.

Biomedical Waste Management (BWM)

• Done by Central Pollution Control Board (CPCB).

• Under Ministry of Environment, Forest & Climate Change.

BWM Does Not Cover

• Solid waste.

• E-waste.
• Lead acid batteries.

• Radioactive wastes.

• Construction and demolition waste.

• Hazardous chemicals.

• Hazardous wastes.

• Hazardous microorganisms, genetically engineered microorganisms and cells.
• covid nipa bioterrorism agents
• While normal microbiological agents like staph srep clostridum are biomedical waste

Categories of BWM

Yellow Category (Pretreatment Not Required)

NOTE:

• A → E
• No pretreatment required
• Incineration

• F, G, H
• Pretreatment required → incineration

• Blood spilled on surface
• Mop with absorbable material, discard in yellow bag
• Decontaminate surface with sodium hypochlorite
• < 10 ml spill → 1:100 dilution
• > 10 ml spill OR culture spill
• 1:10 for first application f/b 1:100 diltution

• Mercury Spill (Broken thermometer)
• Switch off fans
• Remove metallic ornaments
• Do not Broom
• Collect with 2 cardboard piece (Or Xray film)
• Put in tube half filled with water
• Send to Manufacturer
• Wipe floor with Sodium thiosulfate

Black category:

• General waste

• Plastic wrapper of foley’s

Red Category: 

• Foley's catheter,

• Urosac bag,
• Blood bag → yellow H

• IV Bottle & Drip Set,

• Heavy duty rubber gloves & surgical gloves,
• With or without blood

• Syringe without needle

• Vacutainer (empty)
• Vacutainer with blood → Yellow H

• Ryle's tube.

Blue Category: 

• Broken glass

• Broken ampoules

• Empty vial
• Unopened vial /Live vaccines → Yellow H

• metallic body implants, screws & plates.
• Ortho + Pacemaker

White Category: 

• Scalpels,

• Razor blade,

• Suture needle,

• Syringe with fixed needle,
• Syringe without needle → Red

• Lumbar puncture needle,

• Needles from syringe.

Occupational Health

Pneumoconiosis

Plumbism/Lead Toxicity

Mnemonic: ABCDEFG

• Saturn → Leading planet → 2 rings (cabots, cirum oral pallor)

• Abdominal pain

• Blue gums → Burtonian line

• Drop

Letter	Symptom/Sign
A	• Anemia with coarse basophilic stippling ↳ ⛔ rRNA degradation • Lead a course NOTE: Fine Basophilic stippling: • Megaloblastic anemia, Thalassemia
B	• Burtonian lines: ↳ (Bluish lines over gums.)
C	Constipation, abdominal colic ↳ (AKA painter's colic, Saturnine colic/Dry belly ache) Calcification Bone line (Calcium deposition) ↳ Metaphyseal dense opacity
D	Drop (Motor nerve palsy) ↳ (wrist drop, foot drop – neuropathy)
E	Encephalopathy ↳ (infants: ataxia, vomiting, stupor, seizures, coma)
F	Facial pallor ↳ earliest sign ↳ Most consistent finding ↳ Circumoral
G	Gout ↳ Saturnine gout

Health Planning, Planning Committees and Health Management Techniques

Health Planning

• An orderly process for:
• Defining community health problems
• Identifying unmet needs
• Surveying resources
• Establishing realistic priority goals
• Projecting administrative action for program purposes

Steps of Planning Cycle

• Analysis of health situation

• Set goals and objectives

• Assessment of resources:
• Manpower
• Money
• Material

• Deciding priorities

• Formulate plan

• Programing and implementation

• Monitoring:
• Analysis of daily routine activities
• Process-directed
• Done by an internal body

• Evaluation:
• Done at the end
• Done by an external body
• Periodic assessment
• Outcome-oriented

Goal vs Objectives vs Target

Monitoring & Evaluation

Mental Health Care Act: MHCA 2017

• New legislation for treatment and rights of patients with mental illness.

• Decriminalisation of suicide
• Earlier punished under section 309 of IPC.

National Mental Health Programme

• Covers all types of mental illness.

• National Mental Health Policy: 2014

• Mental health clinics established at district level.

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Criteria for Mental Health (IQ)

• Wechsler intelligence scale

• IQ formula: (Mental age / Chronological age) × 100

• Average for child = 90

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Wing’s Comprehensive Handicaps, Behaviour and Skills Schedule (HBS)

• Measures:
• abilities
• disabilities