PARK (21st Edition)
Chapter-Epidemiology and Vaccines :
MILESTONES IN VACCINATION
2009: Influenza A (H1N1) vaccine approved
Chapter – Communicable and Non-communicable diseases:
SMALL POX
· Case (confirmed) definition for notification under IHRs (2005) : [Mnemonic:FRALL]
o Fever (≥38.3º C/101º F) acute onset at any age, malaise, prostration, headache, backache occurring 2-4 days prior to onset of rash AND
o Rash maculo-papular starting from face & forearms, evolving to vesicles (48 hours) and pustules (umblicated/confluent) later AND
o Lesions at same stage of development at any part of body AND
o Absence of Alternative diagnosis to explain illness AND
o Laboratory confirmation.
Chapter- Preventive Medicine in Obstettris, Paediatrics and Geriatrics:
MEASLES
· Coverage of 1st dose of Measles vaccine in world: 82% [2007]
· Proportional mortality rate in children <5 years: 1% [2008]
· Children in difficult circumstances includes:
INFLUENZA: PANDEMIC (H1N1) 2009 INFLUENZA
· WHO declaration of Influenza pandemic: 11 June 2009
· World is now post-pandemic EXCEPT: INDIA & NEW ZEALAND (locally intense transmission)
· Problem statement India: 37000 cases, 1833 deaths [May 2009- August 2010]
· Incubation period : 2-3 days
· Clinical features:
o Uncomplicated influenza: Influenza like illness (Fever, cough, sorethroat, rhinorrhoea, headache, muscle pain), GIT illness (diarrhoea WITHOUT dehydration)
o Complicated/severe influenza: Pneumonia, CNS involvement, Severe diarrhoea, Secondary complications, Exacerbation of chronic diseases.
o Progressive disease: Oxygen impairment/cardiopulmonary insufficiency, CNS complications, Invasive secondary bacterial infection, Severe dehydration.
· Risk factors of severe disease:
o Infants & children < 2 years
o Pregnant females
o COPD
o Chronic cardiac disease
o Metabolic disorders
o Chronic renal/hepatic/neurological/hemoglobinopathies/immunosuppression (INCLUDING HIV) disorders
o Children on aspirin therapy
o Persons aged ≥ 65 years
o Morbid obesity.
· Laboratory diagnosis:
o Most timely & sensitive detection: RT-PCR test
o Samples: Nasopharyngeal + throat swabs [Tracheal/bronchial aspirates in lower respiratory tract infection cases]
o Point-of-care/Rapid diagnostic tests: Not recommended.
· Duration of isolation: for 7 days after onset of illness OR 24 hours after resolution of fever/respiratory symptoms whichever is longer.
· H1N1 Inactivated vaccine: Single i/m injection
o Strain : A/California/7/2009 (H1N1) V like strain
o Storage temperature: +2º to +8 º C
o Contraindications: History of anaphylaxis/severe reaction/Guillian Barre Syndrome, Infants <6 months, Moderate-to-severe illness with fever.
o Protective immunity: Develops after 14 days (NOT 100%).
· H1N1 Live attenuated vaccine: Nasal spray
o Side effects: Rhinorrhoea, nasal congestion, cough, sore throat, fever, wheezing, vomiting
· Priority groups (in order) for Influenza vaccines:
o Pregnant women
o Age > 6 months with chronic medical conditions
o 15-49 years healthy young adults
o Healthy young children
o Healthy adults 49-65 years
o Healthy adults >65 years.
· Antiviral therapy:
o Severe/progressive clinical illness: Oseltamivir (if not available or resistance, use Zanamivir)
o High risk of severe/complicated illness: Oseltamivir OR Zanamivir
o Not high risk OR Uncomplicated confirmed/suspected illness: No need of treatment.
· Dosage:
o Oseltamivir 75 mg BD X 5 days
o Zanamivir 2 inhalations (2 X 5 mg) BD X 5 days
ARI/PNEUMONIA: KEY INDICATORS (INDIA)-
· % under-five deaths due to Pneumonia: 20%
· % under-weight children : 46% (moderate to severe); 18% (severe)
· % exclusive breast-fed infants <6 months:46%
· % 1-year old immunised against Measles: 67%
· % under-five taken to appropriate health care provider for Pneumonia: 69%
TUBERCULOSIS
Daily self-administered Non-DOTS regime: ONLY if there are adverse reactions to drugs or patients compliance is not possible.
| Non-DOTS regime 1 (ND1) |
|
| o Pulmonary (SS+ve) seriously ill | 2 (SHE) + 10 (HE) |
| o Extra-pulmonary seriously ill | |
|
|
|
| Non-DOTS regime 2 (ND2) |
|
| o Pulmonary (SS-ve) not seriously ill | 12 (HE) |
| o Extra-pulmonary not seriously ill |
|
· DOTS-PLUS (Category IV DOTS MDR-TB treatment):
| Cat IV* MDR- TB | IP | CP | Duration |
| 6(KOCZEEt)* | 12-18 (OCEEt) | 18-24 months |
(* IP extended by 3 months if culture +ve at end of 4 months treatment
Follow-up sputum smears: 4, 6, 12, 18, 24 months of treatment)
POLIOMYELITIS
· WHO Strategic Plan 2010-2012: Is based on fact that >95% immunity is required (among under-five children)
In India/Pakistan and 80-85% in Sub-saharan Africa. Approaches indicated: [Mnemonic: BUS ME SCRAP]
o Bivalent OPV (P1, P3) in some SIAs + Trivalent OPV in Routine immunization & some SIAs + Monovalent OPV in some MOP-ups & few SIAa as appropriate.
o Under-served population; special teams/tactics
o Short-interval additional dose (SIAD) strategy (increase immunity + terminate outbreaks)
o Monitoring SIA coverage
o Expanded Environmental sampling
o Serological surveys (program status, prospects, adjustment)
o Communication/mobilization enhanced in priority areas
o Rehabilitation of Polio-affected individuals
o AFP surveillance enhanced
o Plans specific for state/district/block (endemic/re-established transmission areas)
· 107 Block Plan : Approaches for persistent transmission area:
o Optimize SIA coverage and additional activities against WPV transmission
o Newborn tracking data for routine immunization
o Special strategies for mobile population
o Supplementary approaches to reduce force of infection, increase mucosal gut immunity, and reduce risk factors.
CHOLERA: ORAL VACCINES
o Monovalent formalin/heat killed whole cells (Classical, El Tor, Inaba & Ogawa) + recombinant cholera toxin B subunit
o 3 ml single dose vials + bicarbonate buffer: Shelf life 3 years (2º - 8 º C) or 1 year (37 º C)
o In children aged 2-5 years: 3 doses more than 7days apart (1 booster every 6 months)
o In children ≥6 years: 2 doses more than 7days apart (1 booster after 2 years)
· Sanchol and mORCVAX:
o Bivalent oral cholera vaccines based on serogroups 01 and 0139
o 2 liquid doses 14days apart for age more than 1 year (1 booster after 2 years)
· CVD103-HgR:
o Single dose live attenuated vaccine NO LONGER PRODUCED
DENGUE HEMORRHAGIC FEVER
· Febrile phase:
o Incubation period 4-6 days
o Maculopapular rash less common than classical dengue fever
o Rising hematocrit + Moderate to marked thrombocytopenia
· Critical phase: Shock, hemorrhage, organ damage may occur
· Recovery phase: If patients survives 24-48 hours of critical phase
· Severe dengue:
o Shock and/or fluid accumulation with/without respiratory distress
o Severe bleeding, and/or
o Severe organ impairment
· Treatment guidelines:
o Group A (Patients with uncomplicated disease who may be sent home): Encourage ORS + PCM + Tepid sponge + Immediate visit to hospital if no improvement or worsening
o Group B (Patients for in-hospital management): Assess hematocrit + Fluid therapy with 0.9% Saline/RL/Hartmann’s + Maintain good perfusion, urine output 0.5ml/kg/hr.
o Group C (Patients who require emergency treatment and urgent referral): Admission to hospital + intravenous fluid resuscitation [isotonic crystalloid solution or colloid dextran solution (for shock)]
MALARIA
· Six primary Malaria vectors in India:
o Anopheles culicifacies: Rural and peri-urban areas [Species A-P, vivax & P, falciparum; Species B-P.falciparum]
o Anopheles stephensi : Urban and industrial areas
o Anopheles fluviatilis: Hilly, forest and forest fringe areas
o Anopheles minimus: Foot-hills of NE states
o Anopheles dirus : Forests of NE states
o Anopheles epiroticus: Andaman & Nicobar islands
· Diagnosis of Malaria in India:
o Microscopy: Thick smear (High sensitivity in searching for parasite, parasite load estimation) + Thin file (for species identification, stages)
o Serological testing: Malaria Fluorescent Antibody Test (MFAT) necomes +ve after 2 weeks of infection (not indicative of current infection)
o Rapid diagnostic test (RDT): Detect circulating parasite antigens.
· Active intervention measures for Malaria control:
o Micro-stratification of problem
o Vector control strategies
1) Anti-adult measures: Indoor residual spray (DDT/Malathion,Fenitrothion), Space
2) Anti-larval measures: Larvicides (temephos), Source reduction, Integrated control.
· Changes in WHO recommendations for Malaria control [2008] :
o New ACT recommended: Dihydroartemisin-piperaquine
o Artemisin derivatives should not be used as montherapies for uncomplicated malaria
o Single dose of Primaquine (anti-gametocyte) added to ACT treatment of P, falciparum.
JAPANESE ENCEPHALITIS: MANAGEMENT OF ACUTE ENCEPHALITIS SYNDROME (AES) & JE :
· Case definition of suspected case: Acute onset fever, <5-7 days duration + Change in mental status with/without new onset of seizures (EXCEPT febrile) or enhanced irritability/somnolence/abnormal behaviour
· Case classification:
o Laboratory confirmed case: IgM in CSF/serum OR 4-fold antibody titre rise in paired sera OR viral isolation from brain tissue OR antigen detection by immunofluorescence OR nucleic acid detection by PCR.
o Probable case: Suspected case in close geographic and temporal relationship to a lab-confirmed case in outbreak
o AES due to some other agent: Suspected case + diagnostic testing + some other agent identified.
o AES due to unknown agent: Suspected case + No diagnostic testing/ No etiological agent/Indeterminate test results.
o Management : Symptomatic.
LEPROSY
· LEPRA reactions:
o Signs of severe reversal reaction : Loss of nerve function, Pain/tender nerve, Silent neuritis/nerve-paralysis, Red swollen skin patch on face/over nerve trunk, Ulcerated skin lesion, Marked edema of hands/feet/face.
o Signs of severe reversal reaction: Pain/tender nerve, Ulceration of ENL nodule, Pain of eyes, orchitis/dactylitis, Marked arthritis/lymphadenitis.
o Treatment of lepra reactions: Bed rest + Splint to rest nerves + Analgesics + Prednisolone (Add Clofazimine in ENL)
o Follow-up after steroid treatment:
1) For patients on MDT: Monthly check-up of Nerve function
2) For patients MDT completed : 3 months and 6 months after course.
o Steroids contraindicated in (without starting treatment): TB, Diabetes, Deep ulcers, Osteomyelitis, Corneal ulcers, Other serious conditions.
· INDICATORS IN LEPROSY CONTROL:
o Epidemiological indicators:
1) Incidence: ONLY measure of effectiveness of measures taken
2) Prevalence: Case-load
o Main/core indicators to monitor progress:
1) Number and rate of new cases detected per 100,000 population per year
2) Rate of new cases with Grade-II disabilities per 100,000 population per year
3) Treatment completion/cure rate
o Main/core indicators to evaluate case detection:
1) Proportion of new cases with Grade-II disabilities.
2) Proportion of child cases among new cases
3) Proportion of MBL cases among new cases
4) Proportion of female cases among new cases.
o Main/core indicators to assess quality of services:
1) Proportion of new cases verified as correctly diagnosed.
2) Proportion of treatment defaulters
3) Number of relapsers
4) Proportion of patients developing additional disabilities during MDT.
HIV/AIDS: WHO RECOMMENDATIONS ON ART (2010):
· Start ART: CD4≤350 cells/mm3
· First line therapy: 1 NNRTI + 2 NRTIs (including Zidovudine/Tenofovir)
· Second line therapy: PI + 2NRTIs (including Zidovudine/Tenofovir)
· Treatment 2.0:
o Is a new approach ‘to simplify the way HIV treatment is currently provided, and to scale-up access to life-saving medicines.
o Could reduce newly HIV+ upto 1 million annually and avert additional 10 million deaths by 2025
o Requires progress across five areas: [Mnemonic: C2D3]
1) Reduce Costs
2) Mobilize Communities
3) Optimize Drug regimes: “Smarter,better pill”
4) Adopt Delivery systems
5) Provide access to point of care Diagnostics.
HOSPITAL ACQUIRED INFECTIONS: NOSOCOMIAL INFECTIONS:
· Nosocomial infections: Infections acquired during hospital care (occurring AFTER 48 HOURS OF ADMISSION)
· Most common Nosocomial infections: Urinary tract (UTI) > Lower respiratory tract > Surgical sites > Skin & soft tissue > Respiratory tract > Bacteraemia > Eye/ENT > Others.
· Standard precautions for all patients:
o Wash hands promptly after contact with infective material
o Use no-touch technique
o Wear gloves when in contact with fluids/blood/secretions/excretions.
ACCIDENTS AND INJURIES
· Main causes of accidental deaths in India:
o Traffic accidents (Most common)
o Drowning
o Poisoning
o Sudden deaths
o Fires
o Falls
o Electrocution
o Collapse of structures
PROBLEM STATEMENT OF DISEASES IN INDIA
· Diphtheria : 3480 cases, 113 deaths, Case fatality rate 3.25% [2009]
· Whopping cough: 55074 cases [2009]
· Meningococcal meningitis: 6386 cases, 460 deaths
· Tuberculosis:
o Incidence: 170 cases/100000 population
o Incidence: 75 new sputum smear +ve cases/100000 population
o Prevalence: 185 cases/100000 population
o Mortality: 24 deaths/100000 population
o % TB with HIV: 5%
o % new cases TB with Multidrug resistance: 2%
· Poliomyelitis:
o AFP: 50350 [2009]
o Non-polio AFP rate: 10.89 [2009]
o AFP with adequate specimens: 83 [2009]
o Polio cases: 756 [2009]; 46 [2010]; 03 [upto April 2011]
· Dengue:
o Cases: 15509, Deaths 89 [2009]
o Case fatality rate: 0.57% [2009]
· Malaria:
o Cases: 1.52 million (Plasmodium falciparum: 49.56%); Deaths: 924
o API: 1.40
o SPR: 1.60
· Japanese encephalitis:
o Cases: 4482; Deaths: 774 [2009]
· Kala azar: Endemic in 52 districts of Bihar, WB, UP, Jharkhand
o Cases: 20478; Deaths: 70 [2009]
· Tetanus (other than NNT):
o Cases: 2051; Deaths: 160
o NNT: Cases:889; Deaths: 31 [2009]
· Leprosy:
o Prevalence: 0.72 per 10000 population [2009]
o ANCDR: 1.1 per 10000 population
o Cases: 86000; 48% MBL cases; 10.1% children; 35.2% females; 2.8% visible deformity
o Cure rate: 90% (MBL) to 95% (PBL)
· HIV/AIDS:
o WORLD: Total People living with HIV 33.3 million (children 2.5 million)
o INDIA:
1) Total people living with HIV 2.27 million
2) HIV prevalence: 0.29%
Heterosexual route: 87.1% cases.
Chapter-National Health Programmes, Policies and Legislations in India
NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAM (NVBDCP)- MALARIA:
· Operational principles:
o Delivery of malaria control services by ASHA at community level
o Supervision and monitoring by DVBDC consultants (district level) and Malaria technical Supervisors (MTS) (sub-district level)
o Strengthening of SPOs by project monitoring units
o Streamlined procurement and supply chain management
· Malaria Control Strategies: [Mnemonic: SIPS]
o Surveillance and case management
1) Case detection (Active + Passive)
2) Early diagnosis and complete treatment
3) Sentinel surveillance
o Integrated vector management:
1) Indoor residual spray
2) Insecticide treated bed nets (ITBN)/Long lasting Insecticidal nets (LLIN)
3) Antilarval measures (including source reduction)
o Epidemic: Preparedness and early response
o Supportive interventions:
1) Capacity building
2) Behaviour change communication (BCC)
3) Inter-sectoral collaboration
4) Monitoring and evaluation
5) Operational and applied field research.
· Surveillance:
o Active + Passive surveillance
o Pf Rapid diagnostic kits (RDT) are used where microscopy results are not available in 24 hours:
1) Test Falciparum Rate (TfR) ≥1%
2) Pf ≥30%
o Objective of program: >80% fever cases (suspected malaria) to be diagnosed either by RDTs or microscopy within 24 hours.
o Sentinel surveillance: 1-3 sentinel sites established in large hospitals for recording OPD/IPD cases + deaths.
· Criteria for Indoor Residual Spray (IRS): Village as UNIT OF INTERVENTION
o Spray all areas with API ≥ 5, where ABER ≥10% (Subcentre as unit)
o Spray all areas with SPR ≥ 5, where ABER ≤10%
o Pf > 50% proportion of cases
o Spray all areas with API/SPR < 5, in case of drug resistant foci, vulnerable migrant population
o Epidemics
o Entomological/ecological criteria.
· Goals for Strategic Plan 2007-12:
o ≥50% mortality reduction of malaria by 2010.
o ≥80% malaria sufferers get appropriate affordable treatment by 2012.
o ≥80% of those at high malaria risk protected by ITBN/LLIN or IRS by 2012.
NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAM (NVBDCP) – FILARIA :
· Definition of Elimination of Lymphatic filariasis (by 2015): No. of microfilaria carriers <1% + Children born later are free of circulating antigenemia.
· Strategy of Elimination of Lymphatic filariasis (by 2015):
o Annual Mass Drug Administration (MDA) of single dose of Anti-filarial drug for 5 years to eligible population (EXCEPT Pregnant, Child <2 years, Seriously ill)
o Home-based management of lymphoedema + Upscaling hydrocoele operations at higher levels.
NATIONAL LEPROSY ERADICATION PROGRAMME:
· Disability Prevention and Medical Rehabilitation (DPMR) 2009-10:
o Implementation of DPMR activities and reporting its outcome (treatment of reactions, ulcers, physiotherapy, reconstructive surgery, MCR footwear)
o Integration of DPMR activities
o Developing a referral system
NATIONAL AIDS CONTROL PROGRAMME:
· HIV sentinel surveillance round 2008:
| Item | General population | High risk groups (HRGS) | Special groups |
| Population group | 15-49 years pregnant females | FSW, MSM, IDU, Migrants, truckers, Eunuchs | 15-49 years STD clinic patients |
| Sample size | 400 | 250 | 250 |
| Sample collection | Routine i/v sample
| Dried blood spot (Finger prick) | Routine i/v sample |
| Testing strategy | Unlinked anonymous | ||
| Testing protocol | 2-test protocol | ||
UNIVERSAL IMMUNIZATION PROGRAMME:
· Introduction of Japanese Encephalitis vaccine:
o Introduced in 2006 to cover 104 endemic districts
o Stain used: SA-14-14-2 (import from China)
o Routine immunization: Single dose 16-24 months.
Chapter-Essential Medicines and Counterfeit Medicines
ESSENTIAL MEDICINES MODEL LIST (WHO 2010): NEW CATEGORIES
· No.28 Ear, Nose and Throat Conditions in Children
o Acetic acid, Budesonide, Ciprofloxacin, Xylometazoline
· No.29 Specific medicines for Neonatal care
o Caffeine citrate, Ibuprofen, Prostaglandin E, Surfactant
Chapter-Demography, Family Planning and Contraception
WORLD POPULATION TRENDS [2008]:
· Total population: 6734 million
· Annual growth rate: 1.2%
· Highest population: China (19.9%) [Second highest: India 17.5%]
INDIA POPULATION TRENDS [2008]:
· Total population: 1181 million TFR: 2.6
· Crude birth rate: 22.8 per 1000 mid-year population
· Crude death rate: 7.4 per 1000 mid-year population
· Most populous state: UP (16.8% of total population)
TOTAL DEPENDENCY RATIO:
· Formula= [Children 0-14 y + Population >65 y]/ Population 15-64 y X 100
· Dependency ratio India: 61.1% [2005]
DEMOGRAPHIC TERMS:
· Demographic bonus: Period when the dependency ratio in a population declines because of decline in fertility, until it starts to rise again.
· Demographic burden: Increase in total dependency ratio during any period of time (mostly by increase in old-age dependency ratio).
Chapter-Preventive Medicine in Obstetrics, Paediatrics and Geriatrics
WHO CHILD GROWTH STANDARDS:
· New standards generated for age 0-60 months: Percentiles and Z-score for length/height-for-age, weight-for-age, weight-for-height, weight-for-length and BMI-for-age
· Changes from OLDER NCHS/WHO reference:
* BMI-for-age has been added
* Greater stunting will be assessed
* Greater wasting will be assessed in infancy
* Greater prevalence of overweight
GROWTH CHART USED IN INDIA:
· India has adopted new WHO child growth standards (2006) in 2009 for NRHM + ICDS
· Direction of growth is MORE IMPORTANT than position of dots
· Zones in the growth chart:
o Normal zone (weight-for-age)
o Under-nutrition: Below – 2SD
o Severe under-weight zone: Below – 3SD
· Joint “Mother and Child Protection Card” provides space to record:
o Family Identification and registration
o Birth record
o Pregnancy record
o Institutional identification
o Care in pregnancy
o Delivery Preparation
o Registration in Janani Suraksha Yojana (JSY)
o Immunization
o Breast feeding
o Supplementary foods introduction
o Milestones
o Birth spacing (Contraception)
o Reasons for Special care
INTEGRATED CHILD PROTECTION SCHEME (ICPS 2009-10):
· Beneficiaries: Children in need of care and protection, Children in conflict, Children in contact with law, Children of migrant families, Children of prisoners/prostitutes, Working children, Street children, Trafficked children, Sexually-exploited children, Child drug abusers, Child beggars.
· Objectives of ICPS: [Mnemonic: Such Important Release Emerged Responsibly]
o Structures establishment at all government levels for children in difficult circumstances.
o Improve access to and quality of CPS
o Raise public awareness about rights of children
o Evidence based monitoring and evaluation system
o Responsibility and accountability of child protection articulated.
· Services under ICPS: [Mnemonic:Emergency WINGS]
o Emergency outreach service (Helpline 1098: 24-hour)
o Web-enabled child protection management system
o Institutional services (Shelter home, Child home, Observation home)
o Non-institutional family-based care (sponsors, adoption, foster-care, cradle-baby centres, after care)
o General grant-in-aid for need based interventions
o Shelters (open) for children in need in urban, semi-urban areas.
XI FIVE YEAR PLAN (2007-12): CHILD HEALTH GOALS/TARGETS
· Reduction of IMR < 28 per 1000 live births by 2012
· To raise child sex ratio (0-6 years) to
935 by 2011-12
950 by 2016-17
MCH INDICATORS INDIA [2008]
| Indicator | Value |
| Maternal mortality rate (MMR) | 254 |
| Infant mortality rate (IMR) | 58 |
| Neonatal mortality rate (NNMR) Early NNMR Post NNMR | 36 29 23 |
| Under five mortality rate (U5MR) | 69 |
| Still birth rate (SBR) | 37 |
| Perinatal mortality rate (PNMR) | 9 |
| Lifetime risk of maternal death | 1 in 140 |
| ≥ 3 antenatal visits | 51.1% |
| Institutional deliveries | 47% |
| Safe deliveries | 52.7% |
| 100 days IFA tablets consumption | 46.6% |
| Post-natal check-up within 2 days | 47.9% |
ICDS ANGANWADI NORMS:
o URBAN AREAS:
o 1 AWC for 400-800 population
o 2 AWCs for 800-1600 population
o 3 AWCs for 1600-2400 population
o 1 Mini-AWC for 150 population
o RURAL/TRIBAL AREAS:
o 1 AWC for 300-800 population
o 1 Mini-AWC for 150-300 population
Chapter-Nutrition and Health
WHO/FAO EXPERT GROUP FOR CVD PREVENTION:
· Total fat intake: 15-30% of total energy intake (minimum 20%)
· Total saturated fats: <10%
· PUFA: 6-10%
· n-6 fatty acids: 5-8%
· n-3 fatty acids: 1-2%
· Trans fatty acids: <1%
· MUFAs: by difference
· Total cholesterol: <300 mg/day
WHO/FAO EXPERT CONSULTATION ON FATTY ACIDS:
· Replacing SFAs with PUFAs: Decrease LDL + Decrease Total/HDL cholesterol + decrease CHD risk
· Replacing SFAs with Carbohydrates: Decrease LDL + Decrease HDL
· Replacing SFAs with TFAs: Decrease LDL + Increase Total/HDL cholesterol
· Replacing carbohydrates with MUFAs: Increase HDL
· Replacing SFAs with MUFAs: Decrease LDL + Decrease Total/HDL cholesterol
· TFAs (from partially hydrogenated vegetable oils): Increase CHD risk
· Minimum recommended intake for EFAs: 2.5% Linoleic acid + 0.5% alpha-linoleic acid
· Minimum recommended intake for PUFAs: 6%
· n-3 long chain PUFAs prevent CHD
· No role of n-3/n-6 ratio or n-3/linoeic acid ratios
· Replacement of TFA will be a challenge to food industry
GLYCAEMIC INDEX
· Definition : Area under the 2-hour glucose response curve (AUC)
· Low glycaemic index foods: Less readily digestible and lower absorption of sugar
· Classification of Glycaemic Index (GI):
| Classification | GI range | Examples |
| Low GI | ≤ 55 | Most fruits & vegetables (EXCEPT potato/water-melon/sweet potato), Whole grains, Beans, Pasta, Lentils |
| Medium GI | 56-69 | Sucrose, Basmati rice, Brown rice |
| High GI | ≥ 70 | Corn flakes, Baked potato, White bread, Candy bar, Syrupy food, Jasmine rice. |
REFERENCE BODY WEIGHTS
|
| Reference Indian Man | Reference Indian Woman |
| Age | 18-29 years | 18-29 years |
| Weight | 60 kg | 55 kg |
| Height | 1.73 metres | 1.61 metres |
| BMI | 20.3 | 21.2 |
| Others | Free from disease, fit for active work; engaged in 8 hours of occupation (usually moderate activity), 8 hours in bed, 4-6 hours in sitting & moving about and 2 hours in walking and in active recreation or household duties. | |
| Calculation | Average of values of age category 18-19 years, 20-24 years and 25-29 years. | |
· Infants:
o For computing reference weight 0-6 months: Average of weights at birth and 6 months
o For computing reference weight 6-12 months: Average of weights at 6 months and 12 months.
· Children:
· For computing reference weight 1-3 years: Average of weights at 18 months, 30 months, 42 months of WHO median weight
· For computing reference weight 4-6 years: Average of weights at 4+, 5+, 6+ years.
· For computing reference weight for other age groups: From 95th percentile value of body weights from Rural India.
ENERGY, PROTEINS & FAT REQUIREMENTS:
· Energy requirements based on 3 components: [first component same for all]
o Energy required for basal metabolism (1 Kcal/kg/hour)
o Energy required for daily activities
o Energy expenditure for occupational work (light/moderate/heavy)
· Proteins requirements: 0.83 gm/kg/day
| Group | Body weight | Requirement | ||
|
|
| Energy | Proteins | Fat |
| Adult man Sedentary Moderate Heavy |
60 kg 60 kg 60 kg |
2320 Kcal/day 2730 Kcal/day 3490 Kcal/day |
60 grams/day 60 grams/day 60 grams/day |
20% of total energy 20% of total energy 20% of total energy |
| Adult woman Sedentary Moderate Heavy |
55 kg 55 kg 55 kg |
1900 Kcal/day 2230 Kcal/day 2850 Kcal/day |
60 grams/day 60 grams/day 60 grams/day |
20% of total energy 20% of total energy 20% of total energy |
| Pregnant woman | 55 kg + wt gain | +350 Kcal/day
| 78 grams/day | 20% of total energy |
| Lactating woman 0-6 months 6-12 months |
55 kg + wt gain |
+600 Kcal/day +520 Kcal/day |
74 grams/day 68 grams/day |
20% of total energy 20% of total energy |
| Infants 0-6 months 6-12 months |
5.4 kg 8.4 kg |
500 Kcal/day 670 Kcal/day |
1.16 gm/kg/d 1.69 gm/kg/d |
40-60% of total energy 35% of total energy |
VITAMIN-A REQUIREMENTS:
o Man/Woman: 600 mcg Retinol (4800 mcg beta-carotene)
o Pregnancy: 800 mcg Retinol (6400 mcg beta-carotene)
o Lactation: 950 mcg Retinol (7600 mcg beta-carotene)
o Infants (0-6 months): 350 mcg Retinol
o Infants (6-12 months): 350 mcg Retinol (2800 mcg beta-carotene)
CALCIUM REQUIREMENTS:
Pregnancy/Lactation: 1200 mg/day
FOLIC ACID REQUIREMENTS:
Pregnancy: 500 mcg/day
Lactation: 300 mcg/day
IODINE REQUIREMENTS:
Pregnancy: 250 mcg/day
IRON REQUIREMENTS:
| Group | Body weight | Requirement (mg/day to be absorbed) |
| Adult man | 60 kg | 0.84 |
| Adult woman | 55 kg | 1.65 |
| Pregnant woman | 55 kg | 2.80 |
| Lactating woman | 55 kg | 1.65 |
| Infants 0-6 months 6-12 months |
5.4 kg 8.4 kg |
46 mcg/kg/day 87 mcg/kg/day |
Chapter-Social Sciences and Health
SOCIO-ECONOMIC INDICATORS OF INDIA [2009-10]:
· Gross national income (GNI US$) : 1070
· GDP per capita (annual growth rate): 4.7%
· Human development index (HDI): 0.519
· Dependency ratio: 55.6%
· Adult literacy rate: 62.6%
· Gross primary school enrolment ratio: 113.1%
· Gross secondary school enrolment ratio: 57%
Chapter- Occupational Health
ESI ACT, INDIA 1948
· Beneficiaries: All employees- manual, clerical, supervisory, technical getting upto INR 15000/- per month.
· Beneficiaries total: 344 lakh beneficiaries, 143 lakh families, 138 lakh employees, 260 lakh females.
· Infrastructure: 143 hospitals, 43 hospital annexes, 27000 beds.
· Funeral expenses benefit: INR 5000/-
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