PSM Supplement by Dr Vivek Jain

SUPPLEMENT

Review of Preventive and Social Medicine (7th Edition 2015) 1. Categorization of H1N1 Cases in India 2014-15 Category A patients: Mild fever plus cough/sore throat with or without body ache, headache, diarrhea and vomiting • Do not require Oseltamivir • Treat symptomatically • Patients be monitored for their progress and reassessed at 24–48 hours • No testing of the patient for H1N1 is required • Patients should confine themselves at home and avoid mixing up with public and high risk members in the family. Category B patients: In addition to all the signs and symptoms mentioned under Category-A, if the patient has, 1. High grade fever and severe sore throat –– Home isolation and Oseltamivir 2. One or more of the high risk conditions: Children with mild illness but with predisposing risk factors/ Pregnant women/ Persons aged 65 years or older/ Patients with lung diseases, heart disease, liver disease, kidney disease, blood disorders, diabetes, neurological disorders, cancer and HIV/AIDS/Patients on long term cortisone therapy –– Oseltamivir –– No tests for H1N1 is required –– Patients should confine themselves at home and avoid mixing with public and high risk members in the family. Category C patients: In addition to the above signs and symptoms of Category-A and B, if the patient has, 1. Breathlessness, chest pain, drowsiness, fall in blood pressure, sputum mixed with blood, bluish discoloration of nails 2. Children with influenza like illness who had a severe disease as manifested by the red flag signs (Somnolence, high and persistent fever, inability to feed well, convulsions, shortness of breath, difficulty in breathing, etc) 3. Worsening of underlying chronic conditions –– Testing, immediate hospitalization and treatment. (Source: MOHFW Guidelines, Government of India) 2. Mission Indradhanush 2014 Launch 25 December 2014 Description Indradhanush depicting seven colors of the rainbow, aims to cover all those children by 2020 who are either unvaccinated, or are partially vaccinated against 7 vaccine preventable diseases (7 VPD’s) • Diphtheria • Pertussis • Tetanus • Childhood Tuberculosis • Poliomyelitis • Hepatitis B • Measles. Strategy • Focused and systematic immunization drive: “Catch-up” campaign mode to cover all the children who have been left/ missed out. • 4 special vaccination campaigns: January-June 2015 with intensive planning and monitoring. • Learning of Polio program: Apply in planning and implementation. • Coverage:

Review of Preventive and Social Medicine –– –– ––

First phase: 201 districts Second phase: 297 districts 82 districts in 4 states of UP, Bihar, Madhya Pradesh and Rajasthan.

(Source: Mission Indradhanush, MoHFW, Government of India) 3. New Revised Guidelines for Treatment of MDR-TB and XDR-TB (RNTCP 2015) I. MDR-TB Regimen Intensive Phase: 6-9 (K L C Z E Et) + Continuation Phase: 18 (L C E Et) (K Kanamycin; L Levofloxacin; C Cycloserine; Z Pyrazinamide; E Ethambutol; Et Ethionamide). II. XDR-TB Regimen Intensive Phase: 6-12 (H Cm Cz L A M P) + Continuation Phase: 18 (H Cz L A M P) (H High dose Isoniazid; Cm Capreomycin; Cz Clofazimine; L Linezolid; A Amoxy-Clav; M Moxifloxacin; P PAS). (Source: Resistant TB Programmatic Management Guidelines in India, MOHFW, GOI) 4. New Revised Definitions under RNTCP (2014-15)

Supplement

4 A. NEW CASE DEFINITIONS • Presumptive TB: Patient who presents with symptoms or signs suggestive of TB (previously known as a TB suspect) • Bacteriologically confirmed TB: A biological specimen is positive by smear microscopy, culture or WRD (such as Xpert MTB/RIF) • Clinically diagnosed TB: Does not fulfil the criteria for bacteriological confirmation but has been diagnosed with active TB by a clinician or other medical practitioner (includes cases diagnosed on the basis of X-ray abnormalities or suggestive histology and extrapulmonary cases without laboratory confirmation). 4 A1. Classification based on anatomical site of disease • Pulmonary tuberculosis (PTB):Any bacteriologically confirmed or clinically diagnosed case of TB involving the lung parenchyma or the tracheobronchial tree (E.g. Miliary TB) • Extrapulmonary tuberculosis (EPTB): Any bacteriologically confirmed or clinically diagnosed case of TB involving organs other than the lungs (E.g. Tuberculous intra-thoracic lymphadenopathy, Tuberculous pleural effusion). 4 A2. Classification based on history of previous TB treatment (Patient registration group) • New patients: Have never been treated for TB or have taken anti-TB drugs < 1 month. • Previously treated patients: Have received > 1 month or more of anti-TB drugs –– Relapse patients: Previously been treated for TB, were declared cured or treatment completed, and is now diagnosed with a recurrent episode of TB –– Treatment after failure patients: Who have previously been treated for TB, and treatment failed at the end of treatment –– Treatment after loss to follow-up patients: Previously been treated for TB and were declared lost to follow-up at the end of treatment. 4 A3. Classification based on HIV status • HIV-positive TB patient: Any bacteriologically confirmed or clinically diagnosed case of TB who has a positive result from HIV testing conducted at the time of TB diagnosis or other documented evidence of enrolment in HIV care, such as enrolment in the pre-ART register or in the ART register once ART has been started. • HIV-negative TB patient: Any bacteriologically confirmed or clinically diagnosed case of TB who has a negative result from HIV testing conducted at the time of TB diagnosis. • HIV status unknown TB patient: Any bacteriologically confirmed or clinically diagnosed case of TB who has no result of HIV testing and no other documented evidence of enrolment in HIV care.

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Supplement 4A4. Classification based on drug resistance based on drug susceptibility testing (DST) • • • •

Monoresistance: Resistance to one first-line anti-TB drug only. Polydrug resistance: Resistance to more than one first-line anti-TB drug (other than both isoniazid and rifampicin). Multidrug resistance: Resistance to at least both isoniazid and rifampicin. Extensive drug resistance: Resistance to any fluoroquinolone and to at least one of three second-line injectable drugs (capreomycin, kanamycin and amikacin), in addition to multidrug resistance. • Rifampicin resistance: Resistance to rifampicin detected using phenotypic or genotypic methods, with or without resistance to other anti-TB drugs. 4B. Treatment outcome definitions 4B1. Treatment outcomes for TB patients (excluding patients treated for RR-TB or MDR-TB) • Cured: Pulmonary TB patient with bacteriologically confirmed TB at beginning of treatment who was smear- or culturenegative in the last month of treatment and on at least one previous occasion. • Treatment completed: TB patient who completed treatment without evidence of failure BUT with no record to show that sputum smear or culture results in the last month of treatment and on at least one previous occasion were negative, either because tests were not done or because results are unavailable. • Treatment failed: TB patient whose sputum smear or culture is positive at month 5 or later during treatment. • Died: TB patient who dies for any reason before starting or during the course of treatment. • Lost to follow-up: TB patient who did not start treatment or whose treatment was interrupted for 2 consecutive months or more. • Not evaluated: TB patient for whom no treatment outcome is assigned (Includes Cases “transferred out”, and “Outcome unknown”). • Treatment success: Sum of cured and treatment completed. 4B2. Outcomes for RR-TB/MDR-TB/XDR-TB patients treated using second-line treatment Supplement

• Cured: Treatment completed as recommended by the national policy without evidence of failure AND three or more consecutive cultures taken at least 30 days apart are negative after the intensive phase. • Treatment completed: Treatment completed as recommended by the national policy without evidence of failure BUT no record that three or more consecutive cultures taken at least 30 days apart are negative after the intensive phase. • Treatment failed: Treatment terminated or need for permanent regimen change of at least two anti-TB drugs because of: –– Lack of conversion by the end of the intensive phase, or –– Bacteriological reversion in the continuation phase after conversion to negative, or –– Evidence of additional acquired resistance to fluoroquinolones or second-line injectable drugs, or –– Adverse drug reactions (ADRs). • Died: Patient who dies for any reason during the course of treatment. • Lost to follow-up: Patient whose treatment was interrupted for 2 consecutive months or more. • Not evaluated: Patient for whom no treatment outcome is assigned (Includes cases “transferred out”and “outome unknown”. • Treatment success: Sum of cured and treatment completed. (Source: Definitions and Reporting Framework for Tuberculosis – 2013 Revision. updated December 2014, World Health Organization) 5. Endorsed TB Diagnostics under RNTCP 2015 • Smear microscopy for AFB: –– ZN staining –– Fluorescence stains examined under Microscopy with/ without LED. • Culture methods: –– LJ media (Solid) –– Middle Brook media (Liquid) using Bactec/ MGIT. • Rapid diagnostic molecular tests: –– Conventional PCR based Line-probe-assay for MTB complex –– Real-time PCR based NAAT for MTB complex (GeneXpert). (Source: MOHFW Annual Report 2013-14, Government of India)

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Review of Preventive and Social Medicine 6. New Indices Used in Public Health 6A. Global Hunger Index (GHI) Description • Importance: Comprehensive tool for measurement and tracking of hunger in World by region and country • Agency: International Food Policy Research Institute. Components • Undernourishment • Child underweight • Child mortality. Calculation of GHI % Undernourishment + % Child underweight + % Child mortality GHI = 3 • GHI Score: –– Lies between 100 to 0 –– 0 best (no hunger) –– 100 worst. (Source: Challenge of hunger, The Global Hunger Index 2008, 2014) 6B. Gross National Happiness (GNH) Supplement

Description Gross National Happiness (GNH) measures the quality of a country in more holistic way [than GNP] and believes that the beneficial development of human society takes place when material and spiritual development occurs side by side to complement and reinforce each other. Component domains Domain

Indicators

1.

Psychological well-being

4

2.

Health

4

3.

Time-use

2

4.

Education

4

5.

Cultural diversity and resilience

4

6.

Good governance

4

7.

Community vitality

4

8.

Ecological diversity and resilience

4

9.

Living standards

3 Total

(Source: A Short Guide to Gross National Happiness Index, The Centre for Bhutan Studies 2012) 7. New Post-Exposure Guidelines for HIV 2014-15 (Proposed) • Adolescents and Adults: –– Preferred backbone regimen: TDF + 3TC (or FTC) –– Preferred third drug: LPV/r or ATV/r –– Alternate options: RAL, DLV/r or EFV

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Supplement • Children less than 10 years old: –– Preferred backbone regimen: AZT + 3TC –– Alternate regimens: ABC + 3TC or TDF + 3TC (or FTC) –– Preferred third drug: LPV/r –– Alternate options according to age-appropriateness: ATV/r, RAL, DRV, EFV, NVP). • Prescribing frequency: 28 day prescription. (Source: Guidelines on Post-Exposure Prophylaxis for HIV and Use of Cotrimoxazole, World health Organisation 2014) Printing errors in 7th Edition Review of PSM by Dr Vivek Jain Dear Students, With the help of PG-aspirants, I have been able to find few printing/ typing errors in current 7th Edition of PSM book. I do not want to wait for 8th edition for corrections. I am sharing them with you to avoid any error in the most important exam of your life. Please take out few minutes and mark these corrections in your book before reading. Correction

Thanks to Doctors

48

India declared smallpox free: April 1977 July 1975

Dr Shahshank Singh

86

Ans 119 B & C; 123 C

Dr Amit Ilamkar, GMC, Nagpur

87

Ans 133 A

Dr Ronak Patel, SSG Hospital, Vadodara

346

Ans 29 B

Dr Amit Yadav

393

Ans 584: Cholesterol/ CHD ratio > 3.5

Dr Avishek Amar, Patna

396

Delete table in Ans 603 (Refer to Page 298)

Dr Musaib Muhammad, GMC & SMHS, Srinagar

491

Ans 257 A, D

Dr Akash Patel, SMIMER, Surat

541/674/687

BPL (