Recent concepts in Community Medicine

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Recent concepts in Community Medicine
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• Large numbers of the worlds people, perhaps more
  than half, have no access to health care at all,
  and for many of the rest the care they receive
  does not answer the problems they have.

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Health Care

• Magnitude of services rendered to individuals,
  family or communities by the agents of the health
  services or professionals for the purpose of
  promoting, maintaining, monitoring or restoring
  health

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Characteristics

• Appropriateness
• Comprehensiveness
• Adequacy
• Availability
• Accessibility
• Affordability
• Feasibility

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Primary level of Health Care

• First level of contact between the individual and
  the health system where essential health care is
  provided.
• Majority of health complaints and problems can be
  satisfactorily dealt.
• Care is provided by primary health centre and
  subcentres.

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Measuring the baby

• Birth wt-
• Length / ht- infantometer
• Head circumference occipito frontal dm.

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Anthropometric measure

• Wt kgs
• Length total ht, sitting ht, heel knee ht,
• Perimeters head, chest, abd, arm, calf
• Diameters biacromial, biepicondylar, bistyloid,
  bicondylar
• Skinfold thickness-

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Neonatal screening

• 10-15 ml of cord blood should be collected at
  birth
• PKU,- def of enzyme phyenyl alaninehydrozylase.
  PAH
• CLINICALLY seizures, MR
• GUTHRIE TEST.
• Diet free phenyl alanine.

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• Neonatal hypothyroidism.
• Coombs test- rh neg mothers
• Sickle cell hb pathies- agar gel electrophoresis
• Cong dislocation of hip

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Secondary care level

• More complex problems are dealt
• Provided in district hospitals, community health
  centres

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Tertiary Care Level

• Offers super specialist care
• Provided by regional /central level institution
• Supports and complements the action carried out
  the primary level

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Primary Health Care

• Primary health care is essential health care
  made universally accessible to individual and
  acceptable to them, through their full
  participation and at the cost the community and
  country can afford.

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Primary health care and its implementation

• Report of Bhore committee -1946
• Alma Ata declaration in 1978
• National Health Policy of India -1983
• Health For All by 2000 A.D
• New Revised National Health Policy -2002
• Goals to be achieved at 2005, 2010, 2015
• Millennium Development Goals

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• Alma-Ata Declaration called on all the
  governments to formulate national health policies
  according to their own circumstances to launch
  and sustain primary health care as a part of
  national health system.

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Goals to be achieved by 2015

• Eradicate polio and yaws by 2005
• Eliminate leprosy 2005
• Eliminate kala-azar 2010
• Eliminate lymphatic filariasis 2015
• Achieve zero level of growth in HIV / AIDS by
  2007
• Reduce mortality by 50 on account of TB, Malaria
  and other vector and water born diseases - 2010

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• 7. Reduce prevalence of blindness to 0.5 - 2010
• 8. Reduce IMR to 30 per thousand and MMR to 100
  per lakh by 2010
• 9. Increase utilization of public health
  facilities from current level of less than 20 to
  more than 75 by 2010
• 10. Establish an integrated system of
  surveillance, national health accounts and health
  statistics by 2005

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• 11.Increase health expenditure by government as a
  percentage of the GDP from existing 0.9 to 2 -
  2010
• 12.Increase share of central grants to constitute
  at least 25 of the total health spending 2010
• 13.Increase state sector health spending from
  5.5 to 7 of the budget - 2005 and then to 8 -
  2010

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Millennium Development Goals-MDG

• September 2000 representatives from 189
  countries met at summit in New York to adopt
  Millennium development declaration.
• MDGs place health at the heart of development
  and represent commitments by government

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• Government have set a date of 2015 by which they
  would meet the goals like
• - Eradicate poverty and hunger
• Promote gender equality
• Improve maternal health
• Combat HIV / Aids, Malaria and other communicable
  diseases.
• ?Assist in
• - development of national policies
• - help track performance of health programmes
  and systems.

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Health related Goals

• Goal(1). Eradicate extreme poverty and hunger
• Goal (4). Reduce child mortality
• Goal (5). Improve maternal health
• Goal (6). Combat HIV / AIDS, malaria and other
  diseases
• Goal (7). Ensure environmental sustainability
• Goal (8). Develop a global partnership for
  development

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Other recent concepts in Community Medicine

• RNTCP and DOTS
• RCH including treatment of reproductive tract
  infections
• PPTCT and PEP in HIV/AIDS
• HAART therapy In HIV/AIDS
• Elimination of Leprosy
• AFP surveillance for Polio
• ASHA- Accrdted social health activist

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RNTCP and DOTS

• Failure of NTP due to
• inadequate compliance
• emergence of drug resistance
• no quality in Sputum microscopy
• cure rate was less
• so the programme was revised as RNTCP

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WHAT IS DOTS?

• Directly Observed Therapy Shorterm
• DOTS was successful in some countries
• So it was included in RNTCP
• Advantage of supervised treatment in DOTS
• Use of DOT agent
• DOTS plus was also started for MDR - TB

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What is RCH?

• Reproductive and Child Health
• inclusion of reproductive tract infections
• Target free approach
• Community need assessment approach
• All deliveries to be institutional

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What is PPTCT?

• Prevention of Parent to Child transmission of
  HIV
• Use of anti retroviral drugs to the mother and to
  the child
• Mode of delivery
• Avoiding breastfeeding
• PPTCT Centers
• Voluntary testing and counseling centers

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PEP in HIV

• Post exposure prophylaxis to betaken in exposure
  to HIV
• 3 drugs to be taken for 1 month in exposures
• persons are classified depending on exposure
  status and HIV status of the patients

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HAART

• Highly Active Anti Retroviral Therapy
• Use of 3 drugs in combination
• Strict adherence to the regimen
• Follow up visits
• lead to the extent of zero viral loads
• reversal of CD4 counts
• no Opportunistic infections
• Symptom free life

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Leprosy elimination

• As a result of the hard work and meticulously
  planned and executed activities, the country has
  achieved the goal of elimination of leprosy as a
  public health problem, defined as less than 1
  case per 10,000 population, at the National Level
  in the month of December, 2005.  As on 31st
  December 2005, Prevalence Rate recorded in the
  country was 0.95/10,000 population.    

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Modified Leprosy Elimination Campaign (MLEC)

•  Modified Leprosy Elimination Campaign (MLEC)
  approach was first started in India during
  1997-98 with the objective to generate mass
  awareness about leprosy in the General
  Population, to give training to the General
  Health Care Service staff who were not involved
  for leprosy service delivery so far and to detect
  the hidden leprosy cases in all the States/ UTs
  and to put them under Multiple Drug Therapy
  (MDT). The campaign was a roaring success and
  helped in detection of as high as 4.5 lakh new
  leprosy cases who received treatment with MDT
  immediately

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• As on 31st December 2005, leprosy cases on record
  comes down to 1.07 lakh giving Prevalence Rate of
  0.95 cases per 10,000 population.  Less than 1
  case per 10,000 population is considered as the
  level of elimination as a public health problem.

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• The status on 31st December 2005 is that there
  are 6 States viz. Bihar, Chhattisgarh, Jharkhand,
  Orissa, Uttar Pradesh and West Bengal with PR
  between 1 and 3 per 10,000 population. These 6
  States with 41 of countrys population now
  contribute 60 of the countrys case load.  3
  State/ UTs viz. Chandigarh UT, Dadra Nagar
  Haveli and Delhi have PR between 2 and 3 /10,000
  population. 

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Acute flaccid paralysis Surveillance for Polio

• Conducted to identify all remaining infected
  areas,
• Monitor progress
• Evaluated by 2 key indicators-
• ?the sensitivity of reporting.
• ?completeness of specimen collection.
• conducted through a network of surveillance
  medical officers.

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• PPIs are when OPV is given to all children 0-5
  yrs of age in the country on a single day
  regardless to previous immunizations.
• Occur as 2 rounds, 4-6 weeks apart.
• Given during low transmission season of polio-
  Nov Feb.
• Dose of OPV during PPIs are extra doses which
  only supplement, but do not replace the doses
  received during routine immunization.
• There is no min. interval b/w PPI scheduled OPV
  doses.

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• Preventive medicine in GERIATRICS

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OLD AGE..

• NORMAL
• INEVITABLE
• BIOLOGICAL PHENOMENON

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WHEN OLD AGE?

• Biological age of a person is not identical with
  his chronological age.
• No body grows old merely by living a certain no
  of years.
• Years wrinkle the skin, but worry, doubt, fear,
  anxiety, and self distrust wrinkle the soul.

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• OLD AGE IS AN INCURABLE DISEASE.

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SIR JAMES STERLING ROSS

• You do not heal old age. You protect it, you
  promote it, you extend it

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Gerentology

• Study of physical and psychological changes in
  old age
• Clinical gerentology.
• Social g
• Experimental G..
• Geriatric gynaecology.
• Preventive geriatrics.

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Size of the problem..

• 2002- 605 old persons in the world.
• 400 million- developing countries
• India 7.2 of total population- aged

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Health problems of the aged

• 1. PROBLEMS DUE TO AGEING PROCESS
• Senile catarract
• Glaucoma
• Nerve deafness
• Osteoporosis.
• Emphysema
• Failure of special senses
• Changes in mental outlook.

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2. Problems associated with long term illness

• Degenerative disease of the heart and blood
  vessels.
• Cancer
• Accidents ..fracture
• Diabetes
• Disease of locomotor system.
• Respiratory illnesses
• Genitourinary system

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3. Psychological problems

• 1. mental changes- imp memory, dislike of change,
• 2. sexual adjustment
• 3. emotional disorders

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Life style and healthy aging

• Diet and nutrition
• Exercise
• Weight
• Smoking
• Alcohol
• Social activities

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Health status of the aged in india.

• Visual 88
• Locomotive 40
• Neurological -18.7
• CVS- 17.4
• Respiratory 16.1
• Skin 13.3
• GIT- 9
• Psychiatric 8.5
• Hearing loss- 8.2
• GUS- 3.5

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Govt support

• National policy on older persons- 1999
• National council for older persons
• Old age pension- more than 4 millions
• OASIS- OLD AGE SOCIAL AND INCOME SECURITY
• IT CONCESSIONS, HEALTH INSURANCE ETC.

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HelpAge India

• Since 26 yrs
• 6 million senior citizens
• 3084 projects
• Free catarract surgeries
• Mobile medicare units
• Income generation and micro credit
• Old age homes and day care centres
• Disaster mitigation.

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Prevention

• Primary
• Secondary
• Tertiary

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Intranatal care

• Though asesis
• Minimum injury to the infant and the monther
• Readiness to deal with the complications
• Care of the baby at delivary

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Domicilliary care

• Advantage
• Disadvantage

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Institutional care

• Rooming in- keeping the babys crib at the side of
  the mother.

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Post natal care

• 1. complications of the post partal period.
• Puerperal sepsis
• Thrombophlebitis
• Sec he
• Mastitis
• UtI

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2. Restoration of mother to optimum health

• Post natal examination-
• Anemia
• Nutrition
• Post natal exercise
• Psychological
• Social

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Breast feeding

• Family planning

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Care of the children

• 0-14 yrs40 percent
• Childhood-
• 1. infancy - neonatal and post neonatal
• 2. pre school age- 1upto 4
• 3. school age.5-14

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• Infancy
• Neonatal care
• Immediate care- clearing the airway, apgar score-
  HMCRR
• 9-10 good.
• Care of the cord
• Care of the eyes
• Care of the skin
• Breast feeding.

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First examination

• Injuries
• Malformation imper anus
• Maturity
• Abnormalities require immed attention
• Cyanosis of lips and skin
• Breathing diff
• Persistent vomit
• Sings of cerebral irriation
• Temp instability

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II examination

• Within 24 hrs after birth
• Body size, wt,crown heel length, body temp, skin-
  cyanosis,
• Cardiorespiratory
• Muscle tone, tendon reflex
• Head and face
• Ears
• Eyes
• Mouth and lip

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Abdomen

• Limbs and joints
• Spine
• Ext genitalia

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The infected new born

• Contributing factors- environment
• Course of preg- PROM, const fragility-
  prematurity, small for date.

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Neonatal tetanus

• Vaccinate the mother
• Sero vaccination of new born.

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Cong syph

• new born with HBV po p0sitive mother
• 20 - HBsAg
• 90 HBeAg
• Perinatal trans or transmission can be prevented
  by- IM inj of 2 ml of specific anti HBs gamma
  globulin along with anti HB immunization using
  0.5 ml of hevac B or genevac B within 12 hrs of
  birth. Repeated at 1 and 2 months and then at 1
  yr of age.

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New born with HIV posit mother

• 30 chance in the last trimister
• More in AIDS than HIV positive mothers
• Breast feeding- contraindicated ?
• BCG vaccination should not be given unless it is
  confirmed that baby is positive

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Behavioural problems in children

• Antisocial children- stealing, lying, gambling,
  cruelty, sexual offences, destructiveness.
• Habit disorders thumb sucking, nail biting, bed
  wetting, masturbtation.
• Personality dis- jealousy, temper tantrums, shy,
  anxiety, unsociability, hysterical mani.
• Psychosomatic tremors, head ache, asthma,
  depression, delusion, hallucination.
• Educational problems- backwardness in studies,
  school phobia, school failure.

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Juvenile delinquency

• Delinquent child committed an offence.
• Juvenile below 16 boys and below 18 girls.
• Incorrigible, ungovernable, making friendship
  with immoral people.
• Deviations natural youthful behaviour
• Juvenile courts.
• Western countries more, but india Increaseing.
• More boys than girls.

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causes

• Biological causes
• Social causes- broken homes, death of parents,
  step mothers, too many children, ignorance about
  child care, alcoholism.
• Other causes- absence of recreational facilities,
  cheap recreation, sex thrillers, urbaniz and
  industri, cinemas, tv..

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Preventive measure

• Improvement in family life.
• Schooling
• Social welfare services.

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BATTERED BABY SYNDROME.

• Young children under 3 yrs of age and have
  received non accidental wholly inexclusable
  violence or injury on one or more occasions

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Child abuse

• Cruelty to children- physical violence, sexual
  abuse, mental and emotional maltreatment,
  neglect, deprivation,
• Death, blindness, mental and emotional
  retardation, growth stunting.
• Poverty, alcohol, loneliness and overcrowding at
  home.

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Street children

• At risk of TB, malnutrition, Hiv d stds,skin and
  parasitic infestat
• Source major losses in their lives
• Natural and man made disasters, product of war
  and riots, poverty, sexual abuse at home.
• 100 million street children throght the globe,
  out of which 25 million in asia.
• Drug trafficking like cannabis, heroin,
• CRY- CHILD RELIEF AND YOU,, AN ORGANIZATIO

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Refugee and displaced children

• Seperation from their families, lose their home

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CHILD LABOUR AND EXPLOITATION

• India- largest no of child labour in the world.
• Age below 15
• ILO- INT LABOUR ORG
• Forced child labour
• Paid little, health hazards, mental torture
• Highest in JK- CARPET WEAVING.
• Over time work.

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• Poverty, unemployement and lack of education.

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The child labour act, 1986

• Not permitted esply in
• Carpet weaving, transports, cloth industry,
  printing, cashew descaldinga , beedi rolling,
  construction.

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Child trafficking

• Some forcibly abucted, others are tricked and
  still others opt to let themselves trafficked by
  promise of earnings, but not suspecting the level
  of exploitation
• Involves journey- inside or outside.

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Post trafficking..

• Forced labour
• Mining
• Prostitution
• Begging

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Child marriage

• Long established custom in india
• 1929- sharda act
• Rajastan, MP and UP
• 18 girls and 21 for boys- legally

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Child placement

• Orphanages
• Foster homes
• Adoption
• Borstals training and reformation centre for
  difficult children for 3 years- police dept
• Remand homes- care of drs, psych, nurse,
  elementatary schooling, games, recreation. Etc.

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Social welfare programmes

• Child welfare agencies
• 1. ICCw- ind council for child welfare
• 2. central social welfare board
• 3. kasturba gandhi memorial trust
• 4. Indian red cross society

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activities

• Day care services- infants and toddlers
• Balwadis
• Holiday homes 12-16 yrs in some hill stations
• Recreation facilities- bal bhavan, national
  museums, hobby classes

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Integrated child devot services- ICDS

• Initiated by govt of india in the ministry of
  social and womens welfare in 1975.
• 5671 projects have been sanctioned
• 5422 are materialised
• 578457 anganwadi centres are functioning
• One ANC for 1000 people in rural and urban and
  one ANC PER 700 persons in the tribal projects.
• So reqd ANC is 14 lacs for rural and tribal areas
  /

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Aims

• Supplementary nutrition
• Immunization
• Health check up
• Medical referral services
• Nutrition and health education for women
• Non formal education of children up to the age of
  6 years and pregnant and nursing mother in rural,
  urban and tribal ares.

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Objectives

• To improve the nutrition and health status of the
  children 0-6 yrs
• Proper psychological, physical and social devot
  of a child
• To reduce mortality, morbidity, and malnutrition
  and school drop out.
• To achieve an effective coordination of policy
  and implementation among the various depts
  working for the promotion of child devot.
• Health education to mothers about nutrition

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Services

• 1. preg women
• Nursing mothers
• 3. women- 15-45 yrs- nutrition and health
  education
• 4. children less than 3 yrs- supp nutrition,
  immunization, helath check up, referral services.
  
• Children-3-6 yrs- sup nutrition, immunization,
  helath check up, non formal education,