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I am awfully delighted to present you community medicine solved past papers SEQs of KMU. Most of
the time these questions are repeated in KMU exams. So I solved it to help students, I thoroughly
revised it and try to make it error free I hope this will help the students through their preparation for
exams. I am extremely thankful to Almighty ALLAH, who helped me a lot to complete this task I am also
thankful to Salman Khan, Dr.Samin khan, Dr.Naseem Sherzad and Dr.Riaz Ahmad.
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Ejaz Ahmad, RMC
4. Immunology 34
5. Screening 39
6. Demography 43
8. Occupational health 51
10. Entomology 64
14. Nutrition 92
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Ejaz Ahmad, RMC
Characteristics of good health indicators are/ good health indicators should be:
Valid: they should actually measure what they are supposed to measure
Reliable: the result should be the same when they are measured by different people at
the similar circumstances
Sensitive: they should be sensitive to changes in situation concerned
Specific: they should reflect changes only in the situation concerned
Feasible: they should have the ability to obtain data when needed
Relevant: they should contribute to the understanding of the phenomenon of interest.
Long term health program: coordinated plan of medical, nursing and rehabilitative care
provided at home to disabled person who are medically eligible for placement in nursing home.
Short term health program: program include certified nurse aid (assistant) certified medication
assistant (CMA) and home health assistant (HHA).short term program is completed in just eight
weeks.
Biomedical concept
Ecological concept
Psychological concept
Holistic concept
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Ejaz Ahmad, RMC
Gradient of infection: the range of possible host reaction to an invading pathogenic organism
from unapparent subclinical through mild clinical to severe to fulminating and overwhelming
generalized fatal bacteremia.
Health adjusted life expectancy: life expectancy at birth but includes an adjustment for time
spent in poor health .it is equivalent number of years in full health that anew born can expect
to live based on current rates of ill health and mortality .
Health (WHO definition 1948): Health is a state of complete physical, mental and social
wellbeing and not merely an absence of disease or infirmity.
Biological.
Behavioral and sociocultural conditions.
Environmental (external, internal).
Socioeconomic (economic status, education, occupation, political system).
Health services.
Aging of the population.
Gender.
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Ejaz Ahmad, RMC
Other factors.
Mortality indicators:
Morbidity indicators:
Ice berg phenomenon of disease: A concept closely related to the spectrum disease is the
concept of ice berg phenomenon of disease, according to this concept disease in a community
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Ejaz Ahmad, RMC
may be compared with an iceberg. Floating tip of iceberg present what the physician see in the
community i.e. clinical case The vast submerged portion of ice berg represent the hidden mass
of disease latent, pre symptomatic, in apparent, and undiagnosed cases and carriers in the
community Water line represent the demarcation between apparent and in apparent diseases
In some disease the unknown morbidity (submerged portion of ice berg) far exceeds the known
morbidity.
Vertical program (community): A single program of health services for community e.g. EPI,
AIDS control program, Malaria control program, staff is concerned only with one activity.
Horizontal program (community+ person): A health services delivery program which covers the
two dimensions of health i.e. personal and community health e.g.
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Ejaz Ahmad, RMC
Health education: A process that inform ,motivate ,and help people to adopt and maintain
healthy practices and life style, advocate environmental changes as needed to facilitate the
goal and conduct professional training and research to same end is called health education OR
Health education is part of health care that is concerned with promoting health behavior.
Disease control: the term disease control describes operation aimed at reducing
Incidence of disease
The duration of disease , and consequently the risk of transmission
The effects of infection , including both the physical and psychological complications
The financial burden to the community
In disease control the disease agent is permitted to persist in the community at a level
where it ceases to be a public health problem e.g. polio
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Ejaz Ahmad, RMC
Disease eradication: it means tear out by roots eradication of disease implies termination of all
the transmission of the infection by extermination of the infectious agent .the word eradication
is reserved for cessation of infection and disease from whole world the only eradicated disease
is small pox.
Chain of infection, it, is made up of six different links: pathogen (infectious agent), reservoir,
portal of exit, means of transmission, portal of entry, and the new host.
Significance of chain of infection is that breakage at any point stops the transmission of
infection.
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Ejaz Ahmad, RMC
A person currently visiting Pakistan from neighboring country was presented with severe
generalized aches and pain .a maculopapular rash was found on the body with petechial
and purputic spots .he also has meningococcal meningitis what is diagnosis and gives the
protective strategies to control the disease at national level.
Education and awareness: through print media, electronic media, and social
media by arranging conferences and walks.
Mosquito control: vector i.e. Ades aegypti can be controlled by mass spraying
and other measures.
Vaccines: so far there are no satisfactory vaccines available.
Isolation: diseased patients should be isolated under bed nets.
Dengue control cell: should be working at district level.
Research work: should be done on dengue.
Environmental measures: detection and elimination of mosquito breeding
places, management of roof tops and proper covering of stored water.
Carrier: defined as infected person or animal that harbors specific infectious agents in the
absence of discernible clinical disease and serve as a potential source of infections for other.
Classification of carrier:
a) By type :
incubatory
Convalescent
healthy
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Ejaz Ahmad, RMC
b) By portal of exit :
Intestinal
Respiratory
urinary
others
c) By duration:
Temporary
chronic
Incubatory carrier: Those who shed infectious agent during incubation period of disease i.e.
they are capable of infecting other before the onset of illness e.g. measles, mumps, polio,
influenza, diphtheria, and hepatitis B.
Convalescent carrier: those who continue to shed the disease agent during the period of
convalescence (time spent from recovery to illness) e.g. typhoid fever, cholera, diphtheria,
pertussis.
Healthy carrier: victims of subclinical infections who have developed carrier state without
suffering from disease but are now nevertheless shedding the disease e.g. Polio, cholera,
diphtheria.
Chronic carrier: shed infectious agents for indefinite period of time e.g. typhoid, hepatitis B,
and malaria.
Significance of carrier:
Q: define incubation period and what are the factors which determine incubation period/on
which incubation period depends
Incubation period: time period between invasion of infectious agent and appearance of the
first sign and symptom of disease.
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Ejaz Ahmad, RMC
infective dose
portal of entry
individual susceptibility
A gate keeper of a house was brought to clinic with history of high grade continuous fever
for the last five days and epistaxis. On measuring his blood pressure the physician noted
patchier. Other signs noted by the physician were tenderness at right costal margin,
maculopapular rash and enlarged liver. What is your diagnosis? Write disease agent and
vector? Write investigations and their findings? Write management? What are preventive
measures?
Investigations:
Management:
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Ejaz Ahmad, RMC
PERTUSIS:
Mode of transmission:
Prevention:
SCABIES:
Mode of transmission:
Prevention:
health education
Proper cleanliness
Avoid contact
scabicides
Host: Man
LEISHMANIASIS:
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Ejaz Ahmad, RMC
Prevention:
ECHINOCOCCUS GRANULOSIS:
Mode of transmission: when man eats sheep, goat, and swine, infected by dog feces.
Antigenic shift: process by which two or more different strains of virus or strains of two or
more different viruses combine to form a new subtype having of the surface antigens of two or
more original strains .Term often applied to influenza .It is sudden, complete and major change.
Antigenic drift: It is Antigenic change which is gradual over period of time.it involves
accumulation of mutations within the genes that code for antibody binding sites.
A class of fourth year MBBS gave farewell party to final year in hotel. salads with BBQ was in
menu which they ate for dinner with in four hours after dinner 16 students developed
vomiting, profuse diarrhea with mild fever and chills.
Give the diagnosis?
How will you investigate to find the cause of disease?
Which health preventive control measures will you adopt for above mentioned
disease?
Describe various steps in investigation of epidemic.
Investigations
Data analysis
Lab investigations :stool ,vomiting , food sample, to look for causative agent
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Ejaz Ahmad, RMC
Food sanitation:
Meat inspection
Food handlers :those suffering from infections should be excluded from food
handling
Personal hygiene
Sanitary improvement
Health education
Food handling techniques
Refrigeration: temperature below 4c.
1. Verification of diagnosis
2. Confirmation of existence of an epidemic
3. Defining population at risk
4. Rapid search of all cases and there characteristics
5. Data analysis
6. Formulation of hypothesis
7. Testing the hypothesis
8. Evaluation of ecological factor
9. Further investigation of population at risk
10. Writing the report
A young person is suffering from hemoptysis, night sweats, and fever. On X-ray chest
examination there are shadows in right upper zone.
Give the diagnosis?
What is the diagnostic tool to confirm the disease?
What are strategies of national control program in this disease?
Diagnostic tests:
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Ejaz Ahmad, RMC
Culture on L J medium
Luciferase assay
Interferon gamma release assay(IGRA)
Q: what are the current strategies to eradicate polio from Pakistan by WHO?
Mechanism of herd immunity: vaccine progeny is secreted in the feces and secondary spread
occur to the house hold contact and susceptible individual in the community. Non immunized
person may therefore be immunized.
A young boy was bitten by a known rabid dog on right forearm. the boy is brought to you in
BHU
How will you manage the case immediately?
What immunization will you use and how?
What is the case fatality rate and what it is in case a person develops rabies?
Management:
General consideration: neutralized the inoculated virus before it enters the wound
Case fatality rate: it represent killing power of disease. It is the ratio of death to disease.
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Ejaz Ahmad, RMC
Q: describe agent, host, and vector, mode of transmission and source of malignant tertian
malaria, filariasis and anthrax.
FILARIASIS:
Host: man
ANTHRAX
Host: man
Vector: spores
Prevention:
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Ejaz Ahmad, RMC
CHOLERA
A young man was brought to emergency department of Saidu teaching hospital with the
history of high grade fever for 4 days and severe ache in summer 2013. After taking the
blood pressure of the patient doctor noted hemorrhagic spots on the arm of the patient
after inflating the cuff. His platelet count is 80,000.he is shopkeeper in swat.
a) What is the diagnosis?
b) How will you confirm the diagnosis?
c) How it is transmitted from person to person?
a).Diagnosis: Dengue
b).Diagnosis can be done by the history, general examination in which we will see hemorrhagic
spots and investigations .lab investigation shows thrombocytopenia(platelet count less than
150,000) and increase hematocrit, decrease WBC, elevated LFTs,
c).Dengue is spread through the bite of the female mosquito (Aedes aegypti). The mosquito
becomes infected when it takes the blood of a person infected with the virus. After
about one week, the mosquito can then transmit the virus while biting a healthy person.
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Ejaz Ahmad, RMC
Street virus: viruses recovered from naturally occurring cases of rabies. Produces negri bodies.
Incubation period is 20-60 days.it cannot be used for preparation of vaccine.
Fixed virus: it has short, fixed, reproducible incubation period .It is prepared from repeated
culture in brain of rabbit. They doesn’t produce negri bodies.it is used in preparation of vaccine.
A 30 years old man presented with fever OFF AND ON .he is giving the history of similar
attack one year back. He is belonging to an area where mosquitos are present. On
examination no signs of infection were found and he was anemic.
a) What is your diagnosis?
b) How will you confirm your diagnosis?
c) How will you protect the people of the area from the disease?
a)Diagnosis: malaria
Thick blood smears are most useful for detecting the presence of parasites, because they
examine a larger sample of blood. (Often there are few parasites in the blood at the time the
test is done.) A thin blood smear: thin blood smear shows that which specie of parasite is
present.
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Ejaz Ahmad, RMC
Use insect repellent with DEET (N,N diethylmetatoluamide). You can buy repellents
in different strengths. The American Academy of Pediatrics (AAP) and other experts
suggest that it is safe to use a repellent that contains 10% to 30% DEET on children
older than age 2 months.
Use bed nets (mosquito netting) sprayed with or soaked in an insecticide such
as permitherin or deltamethrin. But make sure that these insecticides still work
against the mosquitoes where you are. In some areas, mosquitoes have become
resistant to permethrin and deltamethrin. So the bed nets do not offer much
protection.
Avoid areas where malaria and mosquitoes are present if you are at higher risk (for
example, if you are pregnant, very young, or very old).
Other steps that may be helpful in reducing the risk of malaria include wearing protective
clothing, using aerosol insecticides in your house, and taking certain antimalarial medicines.
Q: write about transmission and prevention of mumps, diphtheria, cholera and tetanus.
MUMPS:
Transmission:
Prevention:
Exclude the person with mumps from childcare, preschool, school and work for 5
days after the onset of swelling
tissues and other objects soiled with nasal secretions should be disposed of
appropriately
mumps is best prevented by the measles, mumps and rubella (MMR)
combination vaccine or the measles, mumps, rubella and varicella (MMRV)
combination vaccine
DIPTHERIA:
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Ejaz Ahmad, RMC
Prevention:
Vaccination
isolation of patient
disinfection of patient article
Sources:
Clinical/subclinical infection
Nasopharyngeal secretion
Clothes soiled with secretions
CHOLERA
Transmission: eating contaminated food and water, contact with infected food and
persons
Prevention:
Personal hygiene
Chemoprophylaxis (tetracycline)
Sanitation measures
Vaccination
Health education
TETANUS:
Prevention: by immunization
A person of 25 years old comes to OPD with pain full ulcer on left leg .He has history of
being bitten by fly. Give the likely diagnosis .What is the mode of transmission .what
method of prevention can be applied for future?
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Ejaz Ahmad, RMC
Prevention:
Isolation: Separation for the period of communicability of infected person or animal from
others in such place and under such conditions as to prevent or limit direct or indirect
transmission of the infectious agents from those infected to those who are susceptible or who
may spread the agent to other.
Quarantine: quarantine has been defined as the limitation of freedom of movement of such
well persons or domestic animals exposed to a communicable disease for a period of time not
longer than the longest usual incubation period of the disease, in such manner as to prevent
effective contact with those not so exposed.
Quarantine may comprise (a) absolute quarantine as defined above (b) modified quarantine
e.g. a selective partial limitation of freedom of movement such as exclusion of children from
school and (c) segregation: which has been defined as The separation for special consideration,
control of observation of some part of group of persons or (domestic animals) from the other to
facilitate control of communicable disease e.g. removal of susceptible children to homes of
immune persons
There was a news in local newspaper about the death of father and three of his sons who
have a butcher shop .although they were admitted to the hospital but could not survive
because of severity of disease .virus isolated from their blood confirmed that they suffered
from Crimean Congo hemorrhagic fever (CCHF).Answer the following questions about CCHF
a. Name the causative agent and vector?
b. Which domestic animal is reservoir of CCHF?
c. Which preventive measures are taken to prevent spread of CCHF in hospital?
d. Name four hemorrhagic fevers?
a. Causative agent: Virus of nairo virus group, Vector: Tick
b. Reservoir: domestic animals i.e. sheep, buffalo, goat (cattle’s)
c. Preventive measures in hospitals:
isolate the patients
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Ejaz Ahmad, RMC
Doctors and staff should take preventive measures by using masks ,gloves, glasses,
and coats
Patients clothing and fomites should be carefully handled
d. Four hemorrhagic fevers are Dengue, Ebola, Yellow fever, Lassa fever.
Corona virus
Rota virus
Adenovirus
Enterovirus
Q: what is reduced osmolarity ORS? What is the recommended dose and schedule of IV fluid to
be given to the children suffering from severe dehydration?
Reduced osmolarity ORS: reducing concentration of glucose and sodium chloride in the
solution to avoid adverse effect of hyper tonicity.
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Ejaz Ahmad, RMC
Disease surveillance: continuous scrutiny of the factors that determine the occurrence and
distribution of disease and other conditions of ill health.
AFP surveillance (Acute flaccid paralysis surveillance): it is the gold standard for detecting
cases of polio.it consists of four steps.
Serial interval: the gap in time between occurrence (onset) of primary case and secondary case
is called serial interval.
Generation time: interval of time between receipt of infection by a host and maximal infectivity
of that host.
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Ejaz Ahmad, RMC
Health promotion: the process of enabling people to increase control over and to improve
health .it is not directed against any particular disease but is intended to strengthen the host
through a variety of approaches (interventions) the well-known interventions are:
Health education: people are informed about different disease and encourage to take
necessary precautions in time
Environmental notifications: such as provision of safe water, installation of sanitary
latrine, control of insect and rodent, improving of housing etc.
Nutritional interventions :comprises food distribution and nutritional improvements
Lifestyle and behavior change
Q: classify the mosquito borne diseases in terms of causative agents in tabulated form
MOSQUITO BORN DISEASE INTERM OF CAUSATIVE AGENT
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Ejaz Ahmad, RMC
Multi factorial disease: a great number of diseases such as diabetes, congenital heart disease
and cancer are called multifactorial because they are not caused by single gene mutation but by
combination of genes, environmental and other factors.
1. Related to vaccine :In many far areas vaccines are not available .vaccine should be
placed in cold places which is not available in many areas
2. Related to child
Immunocompromised child
Inhibitors in saliva
3. Related to mode of transmission
Faulty technique
Spitting out of vaccine on first attempt
4. Related to mother
Interference by antibodies present in breast milk
Lack of education
5. Related to immunizing staff :not properly trained
6. Related to health sector
Not providing vaccine in adequate amount according to the need
Lack of establishment of vaccine center
7. Lack of community participation
Q: define case fatality rate; proportional mortality rate and life expectancy at birth also give
their significance.
Case fatality rate: it is number of deaths due to a particular disease t total number of cases
due to same disease.
Significance of case fatality rate is that it shows various aspects or properties of disease
such as pathogenicity, severity or virulence .it can also be used in poisonings, chemical
exposure or other short term non disease cause of death.
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Ejaz Ahmad, RMC
Proportionate mortality rate: it express the number of deaths due to a particular cause (or
in specific age group) per 100 or 1000 total deaths
Life expectancy at birth: it indicates the average number of years that a person can expect
to live from the time of birth
Q: Sexually transmitted diseases: see Robbins pathology page 671 table 17-3
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Ejaz Ahmad, RMC
Obesity
Salt intake
Saturated fat
Dietary fibers
Alcohol
Physical inactivity
Environmental stress
Socioeconomic status
Age
Sex
Genetic factors
Ethnicity
WHO expert committee identifies the following five requirements to be satisfied by the health
information system:
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Ejaz Ahmad, RMC
History:
Time of bite
Description of snake
Signs/symptoms
Examination:
Of bite site
Neurological examination
Diagnosis of bite:
Fang marks
Cholinesterase is present in washing in case of elapid bite
Thromboplastin in case of viper bite
Sea snake bite: hyperkalemia is detected at ECG
Treatment:
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Ejaz Ahmad, RMC
Q: DEFINE WHO?
WHO: Specialized agency of United Nations that is concerned with international public health it
was established on 7th April 1948 headquartered in Geneva Switzerland
A patient presents to eye OPD with complaints of night blindness and dryness in eyes on
examination there were Xerophthalmia and keratomalacia in eyes.
a. Diagnosis?
b. Mechanism for night blindness?
c. What are Preventive dietary measures?
a. Diagnosis: Vitamin A deficiency
b. Mechanism for night blindness: lack of vitamin A causes impairment in dark adaptation
because vitamin A is required for production of retinal pigments which are needed for
vision in dim light.
c. Preventive dietary measures:
Animal food :Fish liver oil(richest source),Liver, egg, butter, milk, fish, meat
Plant food: Carrot ,Green leafy vegetables
Vitamin A capsule
Blue capsules :contains 1lac units
Red capsules : contain 2 lac units
A young person from emergency department of hospital. He was breathless ,weakened, and
there was bloody discharge from 2 needle like puncture wound on right leg .that rural area
is located near Indus river and is notorious of snakes
a. What is specific therapy in this case?
b. What are the routes of administration of this specific therapy?
c. What precautions would you suggest to avoid such accidents in future?
a. Specific therapy is Antivenom. Because this is the case of venomous snake, venomous snake
bite has two needle like puncture wound.
Antivenoms are prepared by immunizing horses with venom from poisonous snakes and
extracting the serum and purifying it. Antivenoms or antivenins may be species specific
(monovalent) or effective against several species (polyvalent). Monovalent antivenom is ideal
but the cost and non-availability, besides the difficulty of accurately identifying the offending
species - makes its use less common.
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Ejaz Ahmad, RMC
c. Precautions:
PRIMARY PREVENTION
Population strategy: small changes in risk factors in total population result in biggest
reduction in mortality in whole population:
Assessment of obesity:
1. Body weight
Body mass index= weight in Kg/height in meter square
BMI =30-35 is obese class I
BMI=35-40 is obese class II
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Ejaz Ahmad, RMC
Antioxidant: As the free radical can damage DNA and causes cancer .Antioxidant can neutralize
free radicals and prevent cancer.
Phytochemical: It inhibits growth of cancer cells, destroy carcinogenic cells and inhibit binding
of carcinogenic substances to genetic material.
Abrasion:
Abrasions are superficial wounds, such as scratches and cuts. Abrasions are the most minor
type of dog bite injury.
Laceration:
Lacerations are deep open cuts. Typically, lacerations appear irregular and tear-like. In most
cases, deep lacerations will cause excessive bleeding
Puncture:
Puncture wounds occur when the dog’s teeth pierce the skin. Punctures are among the most
common dog bite injuries to become infected
Crushing:
Dog bites may cause the bones or tissues to be crushed. Crushing injuries involving the bones
often result in bone breaks or fractures.
Avulsion:
Avulsion is among the most severe types of dog bite injuries. During avulsion, tissues or body
parts are partially or completely torn from their normal position
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Ejaz Ahmad, RMC
WHO promotes wider access to appropriate post-exposure treatment using the cost-
effective multi-site intradermal regimen with modern tissue culture or avian embryo-
derived rabies vaccines
Public health educational strategies at the community level within endemic regions
WHO promotes organization of sustainable mass dog vaccination campaigns and dog
population management through reduction of stray populations (by implementing
animal-birth-control programs); control of trade and movement of dogs
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Ejaz Ahmad, RMC
IMMUNOLOGY
Q: define active immunity and how it is acquired?
Naturally by disease or clinical infections e.g. chicken pox and measles and sub clinical
infections e.g. polio and diphtheria
Artificially by immunization with an antigen which may be killed or live attenuated vaccine and
toxoid
BCG: It is live attenuated vaccine. There are two types of BCG vaccine
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Ejaz Ahmad, RMC
Generalized eczema
Infective dermatitis
Hypogammaglobulinemia
Immunocompromised patient
Patient under immunosuppressive therapy
pregnancy
Q: give types of polio vaccines; write contraindications and properties of polio vaccine.
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Ejaz Ahmad, RMC
Q: briefly describes reservoirs of rabies, types of vaccines used for rabies and post exposure
vaccination schedule for rabies.
Reservoir of rabies
Launch: in 1988 , the forty –first world health assembly adopted a resolution for the worldwide
eradication of polio .it marked the launched of the global polio eradication initiative(GPEI)
,spearheaded by national governments ,WHO, rotary international, the US center for disease
control and prevention ,UNICEF, and supported by key partners including the bill and Melinda
gates foundation. This followed the certification of eradication of small pox in 1980 ,progress
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Ejaz Ahmad, RMC
during 1980s towards elimination of polio virus in the Americas and rotary international’s
commitment to raise funds to protect all children from the disease.
Progress: overall since GPEI was launched, the number of cases has fallen by over 99%, only
three countries in the world remain polio endemic: Nigeria, Pakistan and Afghanistan.
In 1994, the WHO region of the Americas was certified polio free, followed by WHO western
pacific region in 2000 and the WHO European region in June 2002. Of the three types of polio
virus (type 1, type2, type3) type 2 polio virus transmission has been successfully stopped (since
1999)
More than 10 million people are today walking, who would otherwise have been paralyzed. An
estimated more than 1.5 million childhood deaths have been prevented through the systematic
administration of Vitamin A during polio immunization activities.
Opportunity and risk : an emergency approach ; the strategies for polio eradication work when
they are fully implemented .this is clearly demonstrated by Indians success in stopping polio in
January 2011 , in arguably the most technically challenging place however failure to implement
strategic approaches leads to ongoing transmission of virus .endemic transmission is continuing
Nigeria, Pakistan, and Afghanistan. Failure to stop polio in these last remaining areas could
result in as many as 200000 new cases every year.
Recognizing the epidemiological opportunity and significant risks of potential failure, the world
health assembly in May 2012 adopted a resolution declaring the completion of polio
eradication a programmatic emergency for global public health.
Subsequently, the three remaining endemic countries launched national polio emergency
action plans overseen in each case by the respective head of state and the partner agencies of
the GPEI also moved their operation to emergency footing, working under the auspices of the
global emergency action plan 2012-2013.
As mid of 2012, the impact of the emergency approaches is being seen, with the lowest number
of reported cases in fewer districts of fewer countries than at any previous time
Full financing and implementation of the global emergency action plan 2012-2013 can
realistically rapidly achieve a lasting polio free world. But achieving success is a global
responsibility, and is now a question of political and social will the benefits of a polio free world
will be shared equally by all countries and peoples everywhere.
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Ejaz Ahmad, RMC
Q: write down schedule followed by EPI in tabulated form mentioning name, age, dose, form
and route of administration.
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Ejaz Ahmad, RMC
SCREENING
Q: how will you evaluate a screening test?
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Percentage of false positive
Percentage of false negative
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Ejaz Ahmad, RMC
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Ejaz Ahmad, RMC
Objectives of IMCI:
Components of IMCI:
Improvement in the case management skill of health staff through the provision of
locally adopted guidelines on IMCI and through activities to promote their use
Improvement in health management system required for effective management of
childhood illness
Improvement in family and community practices
Principles of IMCI:
1. All sick patients must be examined for general danger sign which indicate the need for
immediate referral or admission to hospital.
2. All sick patients must routinely assessed for major symptoms (for children age 2 months
up to 5 years cough or difficult breathing, diarrhea, fever ,ear problem and for young
infants )they must also routinely assessed for nutritional and immunization status
,feeding problem and other potential problems.
3. Only limited numbers of carefully selected signs are used based on evidence of their
sensitivity and specificity to detect disease.
4. The IMCI guidelines address most ,but not all of the major reasons a sick child is brought
to a clinic the guidelines do not describe the management of trauma or other acute
emergencies due to accidents or injuries.
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Ejaz Ahmad, RMC
5. IMCI management procedures use a limited number of essential drugs and encourage
active participation of caretaker in treatment of children.
6. An essential component of the IMCI guidelines is the counseling of caretaker /mothers
about home care feeding ,fluids and when to come back for follow up.
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Ejaz Ahmad, RMC
DEMOGRAPHY
Q: define population growth rate and contraceptive prevalence rate.
Population growth rate: rate at which a given population is expected to increase in a given
period of time it is shown in percentage per year.
Significance: it gives the rate at which population is growing. A positive rate indicates that
population is increasing, while a negative growth rate indicates that population is decreasing. A
zero growth rate indicates that there are same numbers of individuals at the beginning and end
of the period.
Contraceptive prevalence rate: percentage of women who are practicing or whose life partners
are practicing any form of contraceptive it is usually measure for married women age 15-49
only.
Demographic trap: High birth rate and low death rate (increase fertility and decrease mortality)
leads to demographic trap. e.g. Pakistan is in state of demographic trap.
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Ejaz Ahmad, RMC
Demographic transition: moving from old balance (high birth and high death rate) to new
balance (low birth and low death rate) is called demographic transition.
Population doubling time: refers to the time that would take for a population to double.
Population: number of peoples or animals of a particular kind that live in a place at a specific
time.
Dependency ratio: ratio of population who are economically not active to those who are
economically active.
Working age
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Ejaz Ahmad, RMC
Fertility: number of live births a woman has had i.e. actual reproductive behavior of female.
Determinants of fertility
Life expectancy at birth: it indicates average number of years that a person can expect to live
from the time of birth.
Significance: it is one of the best indicators of a country’s level of development and of the
overall health status of a population.
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Socioeconomic indicators
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Ejaz Ahmad, RMC
Q: What are reasons for increase in life expectancy of the people globally especially in
developed countries?
Cleaner water: Clean water and improved sanitation greatly reduced deaths due to
infectious disease. Systems for filtering and chlorinating public water supplies are
believed to have reduced urban mortality by half during the first part of the 20th
century.
Technological advancement: Technology for diagnosing disease improved exponentially
during the 20th century. Developments in serologic, or blood, testing that began in the
early 1900s led to the ability to accurately diagnosis disease-causing bacteria.
Subsequent technology to isolate and identify viruses led to an increasing understanding
of how viruses work and spread.
Improved treatments: The combination of identifying disease-causing agents like
viruses, major advances in medical technology and scientific discoveries in molecular
biology all led to vastly improved treatment for disease throughout the 20th century. By
midcentury, immunization programs for deadly childhood diseases such as polio,
smallpox, diphtheria, measles and others saved numerous lives and contributed
significantly to higher life expectancy
Understanding diseases: Winning the battle over many infectious diseases led to
increased life expectancy.
Hygiene: improved hygiene decreases incidence of diseases
Health education: increase awareness about health problems decreases incidence of
diseases
Early marriages
Lack of family planning
Lack of education
Poverty
Desired to have male child
In most of the societies the bigger families leads to higher social status and man power
The children in lower economic group very soon start helping their parents in earning
their living
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Primary health care: is an essential health care made universally accessible to individuals and
families in the community by means acceptable to them through their full participation and at a
cost that a community and a country can afford.
Principles of PHC
I. Political climate and low budget for health: due to high budget for defense little is left
for health.
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II. Disregard of human right: ethnic violence and social evils seem to be raging during the
current decade this necessitates diversion of large amount for maintenance of law and
order.
III. Political commitment: those holding authority for resource allocation are influenced by
high level professionals towards large spending or sophisticated technology in utter
disregard of PHC requirement.
IV. Lack of appreciation of multifaceted approach: investment merely in health sector are
not conductive towards a healthy life style, environmental degradation arising as a
result of scanty rainfall, agricultural crop failure, deforestation, soil erosion, as well as
poverty and illiteracy are to be considered as health related components.
V. Doctors are not going to far areas BHU,s: but now they are going due to high salaries
by new government.
Q: briefly differentiate between comprehensive health care and selective health care.
Selective primary health care: focuses on using specific interventions to target specific health
problems such as immunization and oral rehydration therapy to promote child survival. Health
care providers are doctors and other health professionals. Strategies are medical intervention.
Comprehensive primary health care: focuses on the broader social determinants of health such
a poverty and economic inequality, gender inequality and community development. Health
care providers are multidisciplinary teams and strategies are multisectoral collaboration.
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Primary level of prevention: is concerned with preventing the onset of disease it aim is to
reduce the onset of disease i.e. Reducing risk of disease by immunization.
Secondary level of prevention: includes procedures that detect and treat pre-clinical
pathological changes and there by control disease progression i.e. by screening procedure.
District health system: is the mean to achieve the end of an equitable, efficient and effective
health system based on the principles of the primary health care (PHC) approach. This means
that the DHS is more than just a structure or form of organization. It is the manifestation of a
set of activities that includes community involvement, integrated and comprehensive health
care delivery, intersectoral collaboration and a strong bottom-up approach to planning, policy
development, and management.
The PHC approach and the DHS model apply to the whole of the health system and at all levels
of health care delivery. They do not just apply to the primary level of the health system, or just
to the district level. In a DHS, the organization and management of the entire health system is
district-based, meaning that even policy areas such as health sector financing, utilization of
regional and tertiary hospitals, the relationship with the private sector and governance should
be DHS-based.
The underlying essence of the DHS is the organization of health care according to geographic
sub-divisions of a country, which are managed through a decentralized management structure.
The district management structure is supposed to be the point and level at which different
health service activities are integrated into a comprehensive and holistic approach to health
care.
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OCCUPATIONAL HEALTH
OCCUPATIONAL DISEASES AND THERE RELATED OCCUPATIONS:
Occupation related with silicosis is: pottery, ceramics, sand blasting, mining, abrasive soap,
metal grinding, and boiler scaling, building construction work.
Occupations related to asbestosis are: roof tiles, brick lining, shipyard worker, asbestos cement,
gas kit, fire proof textiles.
BAGGASSOSIS (mottling in lungs): are found in farmer dealing with SUGAR CANE, and in
workers of paper, cardboard and rayon industries
Q: define pneumoconiosis and give medical, engineering and legislative measure for prevention
of pneumoconiosis
Prevention of pneumoconiosis:
Medical measure
Application of ergonomics
Regular medical checkup
Health education
Notification of disease and research on it
Health education
Engineering measure
Proper building design and architecture
Good house keeping
Mechanization
Substitution
Control at source
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Isolation
Protective device
Monitoring
Research
Ans: Organization works for labor rights: international labor organization (ILO).
Ergonomics: Fitting of jobs to workers, its objective is to achieve best mutual adjustment of
man and his work for improvement of human efficiency and well being
Peri bronchial
Diffuse
Basal in location
Due to mechanical irritation
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A 50 years old textile mills worker presented with complaints of cough, breathlessness of
long duration which is progressively increasing .he is non-smoker.
a) In contest of his occupation what is most likely cause of his complaint?
b) What preventive measures should be taken?
c) What will be the responsibilities of medical officer working in this industry to
control this condition?
a) It is a case of Byssinosis which is due to inhalation of cotton fiber
b) Preventive measures
Wearing protective masks
Proper ventilation
Regular medical checkup
Good house keeping
substitution
c) Responsibilities of medical officer to control this condition
Periodic examination: regular checkup is essential ,X-ray chest should be done
Medical and health care services: proper care should be given
Notification: information of disease is passed to high authorities
Maintenance and analysis of health record
Health education and counseling
A 45 year old man working in a pottery industry presented with cough ,dyspnea , and chest
pain .X-ray chest confirmed fibrosis and hilar lymphadenopathy.
a. What is the most probable diagnosis and which factor in this this particular industry led
to this condition
b. Enumerate engineering measure to prevent this condition
a. it is case of silicosis which is due to inhalation of fine crystalline silicon dioxide dust or quarts
(free crystalline silica) particles
Good ventilation
Dust control
isolation of the process
substitution if possible
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A middle age worker of ceramic industry presented with cough, fever, dyspnea, X-ray lung
confirms fibrosis and hilar lymphadenopathy.
a. What is the most probable cause of his condition in this trade?
b. What are the complications?
c. What the preventive measures?
a. Silicosis
b. Complications of silicosis are: Lung cancer, Progressive massive fibrosis,
Respiratory failure, Tuberculosis, Connective tissue disease, including
rheumatoid arthritis, scleroderma (also called progressive systemic sclerosis),
and systemic lupus erythematous.
c. Given above
A 45 years old man was brought to you with the complaints of severe dyspnea, productive
cough, and cardiac distress for last 10 days. The man is working in a fire proof clothing
factory for the last 15 years.
A patient age 40 comes to OPD having increasing dyspnea, nonproductive cough finders
clubbing and weight loss. on inquiry he told that he is working in an industry manufacturing
fire proof textiles and gasket for the last 15 years.
a. Name the disease and causative agent
b. Describe characteristics of lung fibrosis of this disease
c. Name other profession whose workers have this disease
d. What are the preventive measure
ANSWER:
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Ejaz Ahmad, RMC
c. Other professions whose workers have this disease are: roof tiles, brick
lining, shipyard worker, asbestos cement.
A 45 years old man who is farmer by profession is suffering from cough and fever for
several months
a. What are the most probable diagnosis
b. What are the preventive measures
c. List the indoor air pollutants and diseases caused by them
ANSWER:
a. Bagasossis
c. Indoor air pollutants there source and diseases (effect) caused by them are
given in the table;
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A high-risk pregnancy is one that threatens the health or life of the mother or her fetus
Too young (less than 18 years) and too old (more than 35 years) primigravida.
prematurity ( less than 37 weeks ) or post maturity (more than 41 weeks)
grand multipara (more than 5 children)
short statured primigravida less than 5 feet
twin pregnancies
mal presentation e.g. breach
pregnancy associated with anemia
toxemia of pregnancy
Past bad obstetric history i.e. abortion, stillbirth, antepartum hemorrhage, caesarian
section.
Pregnancy associated with diseases i.e. DM, epilepsy, heart disease etc.
Q: what are the risk factors which lead to high maternal mortality rate in Pakistan?
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Q: briefly describes perinatal mortality rate and measure to reduce perinatal mortality rate
Perinatal mortality rate: it includes both fetal death (still birth) and early neonatal deaths.
PMR=late fetal deaths (28 weeks of gestation)+early neonatal death(first week) x1000
OR
PMR= late fetal and early neonatal death weighing over 1000 gm at birth x1000
Uses of GMP:
Q: define domiciliary care and write advantages and disadvantages of domiciliary care.
Domiciliary care: care provided at home is called domiciliary care mother with normal obstetric
history may be advised to have domiciliary care.
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Less expensive
No tension of going to hospital
Mother deliver in familial surrounding
Convenient psychologically satisfactory
Chances of cross infection are rare
No chances of mixing of children
Q: A mother with normal obstetric history delivered a baby at her home bay a midwife. This
birth attendant was in close liaison with the doctor at rural health center. Name the type of
health service?
Q: what are the causes and factors effecting infant mortality rate Pakistan.
a) Biological factors
Birth weight :increased risk in low birth weight
Age of mother: increased risk in too old and too young mother
Order of birth: increased risk in 1st and after 5th baby
Multiple births: increases risk
Family size: increased risk in large family
High fertility
b) Economic factors: increased risk of mortality in socioeconomic families
c) Culture and social factors
Illiteracy
Ignorance of child care
Broken families
Illegitimacy
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Overcrowding
Early marriages
Safe motherhood
Fertility regulation
Infertility
Prevention and control of reproductive tract infection
STD,s
Newborn care
Q: write WHO strategies for safe mother hood/pillars of safe mother hood.
1. Family planning
2. Antenatal care
3. Clean and safe delivery
4. Essential obstetric care
Mnemonic FACE
Safe motherhood: continuous care provided to the mother started from pregnancy period,
throughout pregnancy, delivery, and postpartum period and it should include family planning
services.
Growth: increase in physical size of a body. It is due to increase in size and number. Increase in
cell number takes place within a specified time while increase in size continue.
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Growth monitoring
Diagnostic tool: for mortality and morbidity
Planning and policy making
Educational tool for educating mother
Tool for action helps in type of intervention
Evaluation: provides a good method to evaluate the effectiveness of corrective
measures
Tool for teaching :
growth chart gives information like birth date and weight
immunization of child
immunization of mother
child health record
helpful in ORS preparation at home
Neonatal breast policy: breast milk is ideal for babies the health facilities should do the
following to promote breast feeding:
All health staff should form a team that ensure implementation of this breast feeding
policy
Relevant health staff should be trained in the skills necessary to implement this policy
Expected mother should be educated on benefits of breast feeding and dangers of
bottle feeding
At delivery newborn should be put to breast feed within 30 minutes
Exclusive breast feed should be promoted from birth up to 4-6 months
Feeding bottles should not be allowed in hospitals
Promotional materials about formulas should not be allowed in hospitals
Health staff will not receive gifts from formula manufacturers
Mother will be informed to seek help in case of lactation problem
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Unmet need of contraception: women with unmet needs are those who are sexually active but
are not using any method of contraception and also they do not want more children.
Q: what are intrauterine contraceptive devices and what are their types?
Intrauterine contraceptive devices: devices which are exerted into uterus to exerted
pregnancies. Types are
Objectives of MCH:
Q: what are the modern methods of family planning that are recommended during post natal
period?
Modern methods of family planning that are recommended during post natal period are:
Hormonal methods
Oral pills
Combined pills
Progesterone only pills
Post coital contraceptive pills
Long acting pills
Depot formations
Injectable
Subdermal
Vaginal rings
IUCD,s
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Longitudinal assessment: longitudinal assessment of growth entails measuring the same child
at regular intervals this provide a valuable data about a child progress.
Cross sectional assessment: it compares child growth with that of his peers .cross sectional
comparison involves large number of children at same age .the children are measured and the
range of their measurement (e.g. weight, height,)is plotted usually in percentile chart.
Child survival initiative: Aim is to reduce child mortality by training front line health workers
on care for pregnant women, newborns, and young children.
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ENTOMOLGY
Q: write insects included in order Dipteral of class insects:
Crane flies
Granes flies
Midges flies
Horse flies
robber flies
Bee flies
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Propagative: when disease agent undergo no cyclical changes but multiply in the body
of vector e.g. Plague bacilli in rat flea.
Cyclopropagative: disease agent undergoes cyclical changes and multiply in the body of
arthropod e.g. malaria, parasite in mosquito.
Cyclodevolopmental: disease agent undergoes cyclical changes but does not multiply in
the body of arthropod e.g. filarial parasite in Culex mosquito.
I. Anti-larval measure :
Environmental control
Chemical control
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Biological control
II. Anti adult measure
Residual spray
Space spray
Genetic control
III. Protection against mosquito bite
Mosquito net
Screening
repellents
Flea Index: the number of fleas of different species found on various species of hosts. This raw
data can be used to calculate various indices.
General flea indices: average number of fleas of all species per rodent (rat).
Specific flea indices: (Xenopsylla cheopis index, Xenopsylla astia index)average number
of fleas of each species found per rodent.
Percentage incidence of flea specie: percentage of fleas of each species found per
rodent.
Rodent infestation: percentage of rodent infested with the various flea specie
Q: write short note on medical control measure in Itch mite (sacroptes scabiei)
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Information
Education
Motivation
Persuasion
Counseling
Raising morals
Health development
Organization
2. Service approach: this approach was tried by basic health services in 1960s. It
aimed at providing all the health services needed by the people at their door
steps on the assumption that people would use them to improve their own
health. This approach proved a failure because it was not based on the felt needs
of the people. For example, when water seal latrines were provided by the
government, free of cost, many people in the rural areas did not make use of
them because it was not their habit to use latrines.
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4. Primary health care approach: this is radically new approach starting from the
people wit there full participation and active involvement in the planning and
delivery of health services based on principles of primary health care, viz.
community involvement and intersectoral coordination.
Q: what are the factors that you would take care to ensure effective dissemination of health
education message?
Message must be
Communication barriers are specific items that can distort or prevent communication within an
organization. These are:
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Q: define mental health and what are common mental health problems in Pakistan?
Mental health: mental health is defined as state of well-being in which every individual realizes
his or her own potential can be cope with normal stresses of life ,can work productively and
fruitfully and is able to make a contribution to his/her community.
Depression
Schizophrenia
Epilepsy
Obsessive compulsive disorder
Bipolar disorder
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Credibility
Interest
Participation
Motivation
Comprehension
Learning by doing
Known to unknown
Setting an example
Good human relationship
Feed back
Q: what is the best approach to discuss personal hygiene issue to teen age college girl?
Best approach to discuss personal hygiene issue to teen age college girl is group approach.
1. Lectures
2. demonstration
3. Discussion method
Group discussion
Panel discussion
Symposium
work shop
Conferences
Seminar
Role play
Health education: According to Alma Ata definition: It is a process aim at encouraging people
to want to be healthy, to know how to stay healthy, to do what they can do individually or
collectively to maintain health and to seek help when needed.
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Definition of health education by national conference in USA: Health education is a process that
informs, motivates, and helps people to adopt and maintain healthy practices and life styles,
advocate environmental changes as needed to facilitate the goal and conduct professional
training and research to same is called health education
Q: describe rehabilitation.
PMDC OATH:
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I will not permit considerations of age, disease or disability, creed, ethnic origin, gender,
nationality, political affiliation, race, sexual orientation, or social standing to intervene
between my duty and my patient;
I will protect human life in all stages and under all circumstances, doing my utmost to
rescue it from death, malady, pain and anxiety. To be, all the way, an instrument of
Allah’s mercy, extending medical care to near and far, virtuous and sinner and friend
and enemy.”
I make these promises solemnly, freely and upon my honor
Ability to see ahead and plan accordingly ,planning for the future while managing the
present
Ability to produce and accept new and creative ideas being an agent of change
Willingness to take risks to get the new ideas accepted and implemented
Ability to coordinate ,bringing about harmony collaboration organizing , allocating
resources and controlling
Ability to analyze ,synthesize and integrate diverse information
Sense of equity, fairness and social justice in all dealings with in and outside the
hospital.
Knowledge ,skills and experience
Ability to delegate ,making effective use of own time and that of others
Good personal motivation and ability to motivate the people working in the hospital
Ability to review and evaluate ,making adjustment as necessary
Medical ethics is a system of moral principles that apply values and judgments to the
practice of clinical medicine and in scientific research. These values include the respect for
autonomy, non-maleficence, beneficence, and justice.
Significance of ethics in medical field: the study of ethics prepares medical professionals to
recognize difficult situation and to deal with them in a rational and principle manner. Ethics
is also important in physician interaction with society and their colleagues and for the
conduct of medical research. Ethics are important for doctors to know their rights and
duties. Ethics are important for medical personnel to deal medico legal cases.
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DISASTER MANAGEMENT
Q: define disaster and classify disaster.
Disaster: defined as any occurrence that cause damage, ecological disruption, loss of human
life, or deterioration of health and health services on a scale sufficient to warrant an extra
ordinary response from outside the affected community or area.
Classification/types of disaster:
Disaster preparedness: a program of long term developmental activities whose goals are to
strengthen the overall capacity and capability of a country to manage efficiently all types of
emergencies.
Triage: Principle of First come First treated is not followed in mass emergencies.
Triage consists of mass emergencies the injuries are categorized on the basis of severity of their
injuries and the likely hood of their survival with prompt medical interventions.
High priority is granted to the victim whose immediate or long term prognosis can be
dramatically affected by simple intensive care. Moribund patient who require greatest deal of
attention with questionable benefits have the lowest priority .it uses four color code system
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Disaster response
Disaster preparedness
Disaster mitigation
Pre disaster management: it involves the following steps .POST CORB (mnemonic )
Planning
Organization
Staffing
Training
Coordination
Reporting
Budgeting
During disaster management: (disaster response) consists of:
Search ,rescue and first aid
Field care
Information center
Triage
Tagging
Identification of dead
Transportation
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Hazard: any phenomenon that has the potential to cause disruption or damage to people and
their environment.
Physical hazards are conditions or situations that can cause the body physical harm or
intense stress. Physical hazards can be both natural and human made elements.
Chemical hazards are substances that can cause harm or damage to the body, property
or the environment. Chemical hazards can be both natural and human made origin.
Biological hazards are biological agents that can cause harm to the human body. Some
biological agents can be viruses, parasites, bacteria, food, fungi, and foreign toxins.
Psychological hazards are created during work related stress or a stressful environment
.A person can be a hazard when he/she is affected psychological disturbance through -
stress, shift patterns and also can be a hazard when a person is under the influence of
alcohol, illness and lack of training.
Ergonomic Hazard is a physical factor within the environment that harms the
musculoskeletal system .ergonomic hazards include themes such as repetitive
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Ejaz Ahmad, RMC
Types of radiation:
Somatic
a) Immediate
Radiation sickness
Acute radiation syndrome
b) Delayed
Leukemia
Carcinogenesis
Fetal developmental abnormalities
Shortening of life
Genetic:
chromosomal mutation
Q: what are the effects of pressure on human body in air and in water?
At sea level atmospheric pressure is 760 mm Hg this is called 1 atmospheric pressure written as
1atm.the atmospheric pressure falls as altitude increases and rises as altitude decreases.
Effect of pressure on human body in air: at high altitude air pressure decreases. This in turn
decreases oxygen and so hemoglobin concentration increases and also heart rate increases.
Reason is, the air is less dense at high altitude and so partial pressure of oxygen is also less.
Man cannot survive at an altitude of 25000 feet without breathing equipment when there is
sudden exposure to high altitude, following two conditions occur:
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Ejaz Ahmad, RMC
High altitude pulmonary edema: this appears on 3rd day. Initially symptoms are of acute
mountain sickness; gradually patient develops cough, mental confusion, hallucinations
and Cheyenne-stokes breathing.
Effect of pressure in water: atmospheric pressure increases by 1atm for every 33 feet depth
below sea level. This effect of high pressure called caisson disease is observed in persons
working in diving bells, compressed air chamber or mines.
Caisson disease (compressed air sickness): at high pressure in depth the gases are
dissolved in the blood. Excess concentration of nitrogen exerts a narcotic action leading
to loss of mental function. Excess of carbon dioxide increases the action of nitrogen
leads to convulsion and death. Initial symptoms are euphoria, fever, nasal voice,
tachypnea, bradycardia, fatigue, weakness and hemorrhages. The symptoms of sudden
decompression are called bends and screws by workers.
Answer: immediate line of management is disaster response which includes the following
steps:
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Causes of ozone depletion: ozone layer is depleted mainly by chlorofluorocarbons which are
present in air conditioners, refrigerators, aerosol spray .other causes are cosmic rays, sulpher
put in the atmosphere, jet travel and deforestation.
Harmful effect of ozone destruction on human health: ultraviolet rays if come directly with all
wave lengths they cause skin cancer and cataract if there is 1% fall of ozone then there is
1. Physical quality
Must be free from turbidity
Must be free from color
Should have no disagreeable odor
Taste must be palatable
Temperature should be acceptable
Must be clear
2. Chemical quality
PH = 6.5 to 8.5
Hardness must be less than 300 mg /L
Chloride standard level is 200mg/L ,but maximally is up to 600mg/L
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3. Microbiological aspects:
Bacteriological indicators :presence of E.coli , Fecal streptococci, coliform group,
clostridium perfringens shows fecal contamination
Virological aspects: water should be free from viruses
Protozoa: water should be free from protozoa
Helminthes: adult , larva , fertilized egg should be absent
4. Radiological standard: radioactivity is number of nuclear disintegration per unit time its
unit is Becquerel, 1 Bq= 1 disintegration per second
Chlorination: the process in which chlorine is added to water for purification, effects of
chlorination are:
Action of chlorine: Chlorine reacts with water and produce hydrochloric acid and hypochlorus
acid, H2O+Cl2 HCL +HOCL, HCL is neutralized by water, HOCL is most effective form for
disinfection when PH increases HOCL dissociate to hydrogen ion and hypochlorite ion.
HOCL H + OCL
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Ejaz Ahmad, RMC
The contact period of free residual chlorine for killing bacteria and viruses should be at
least 1 hour
Minimum recommended concentration of free chlorine is 0.5 mg/L for an hour
The sum of chlorine demand of the specific water plus the free residual chlorine of 0.5
mg /L constitute the correct dose of chlorine to be applied
Chloramines are loose compounds of chlorine ammonia in a ratio of 4:1 .they have slower
action than chlorine and give more persistent types of residual chlorine . They have less
tendency to produce chlorine’s taste .in this method ammonia is first added to water and then
chlorine is added.
Break point chlorination: the point at which residual chlorine appears and when all chlorine in
combine form has been completely destroyed the corresponding dosage is called the break
point dosage.
When chlorine is added to water it will react with natural ammonia in water to form chloramine
.amount of chloramine increase as we increases dose of chlorine and a point will come when all
free ammonia present is used up after which further addition of chlorine will destroy
chloramine. The break point will reached when chloramine is completely destroyed by excess
chlorine.
Biological layer: when the sand bed of sand filter gets covered with slimy growth this is called
biological layer, vital layer, zolgeal layer or Schmutzdecke layer, this consists of thread like
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Ejaz Ahmad, RMC
algae, plankton ,and bacteria. Formation of this layer is called ripening of filter and formed with
in 3 to 5 days
Purification of water on small scale: household water and wells are purified by small scale
purification of water
1. Boiling: boiling of water for 5 to 10 minutes kill bacteria, spores, cysts and ova. boiling
remove temporary hardness .Taste is utter but is harmless
2. Chemical disinfection
a) By bleaching powder :
It is chlorinated lime in amorphous powdered form
Produced by action of chlorine on slacked lime
On exposure to light , air , moisture, it rapidly loses chlorine contents
When mixed with excess of lime it retain its strength called stabilized
bleach
For 100 gallons of water 30 grains of bleach powder is required
D= W x R x 7.2 /X
D=quantity of bleaching powder
W=quantity of water to be chlorinated
R=chlorine dose
350 g of bleach is added to 750 ml of water to make one liter solution then
3 drops of solution is added to 1 liter of water for disinfection with
contact period of 30 to 60 minutes 6 drops are used for badly polluted
water.
b) Chlorine solution
c) Chlorine tablets: 0.5 gm. tablet for 20 liter of water
d) Iodine :two drops of 2% ethanol solution of iodine for 1 liter of water
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e) Potassium permanganate: is powerful oxidizing agent but altering the taste, odor,
color.
3. Filtration:
Pasteur chamber land filter
Berkefeld filter
Meta and stellar filter
4. Ultraviolet radiation
5. Multi-stage reverse osmosis purification of water
B: Disinfection of well:
6) During emergency and for a constant dosage of chlorine to well water double pot method
is used.
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1) Sanitary survey : on the spot survey of water system by a qualified person for the
purpose of detection and correction of deficiencies.
2) Sampling: should be done with aseptic precautions. Carried out by trained personal in
accordance with method prescribe in WHO.
3) Bacteriological surveillance
I. Presumptive coliform test:
a. Multiple tube method: this test is based on estimating the most probable
number (MPN) of coliform organism in 100ml of water. The test is carried out
by inoculating measured quantities of the sample water (0.1, 1.0, 10, 50ml)
into tubes of McConkey,s lactose bile salt broth with bromcresol purple as an
indicator. the tubes are incubated for 48 hours. From the numbers of tubes
an estimate of MPN of coliform organisms in 100 ml of the sample water can
be obtained from statistical tables. This result is known as presumptive
coliform count, the presumption being each tube showing fermentation,
contains coliform organisms, the reaction may occasionally be due to thr
presence of some other organisms or combination of organisms.
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II. Detection of fecal streptococci and clostridium perfringens: the presence of these
organism shows fecal contamination of water
III. Colony count: colony count on natural agar at 37c and 22 degree centigrade
provide estimate of general bacterial purity of water.
5) Chemical surveillance :
Test for PH
Test for color , turbidity , chloride , ammonia chlorine demand and residual
chlorine
Test for iron and manganese
Analysis for toxic metals , pesticides , organic chemicals , and radioactivity
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Greenhouse effect: It is the capacity of certain gases in the atmosphere to trap heat radiation
emitted from earth surface there by insulating and warming the earth.
Mechanism of greenhouse effect: when light falls on earth’s surface ,some rays are reflected
and some are refracted to atmosphere having no increase in temperature .however certain
gases form layer in the atmosphere which entrap heat radiation and increasing the
temperature of the earth.
Global warming: It is due to enhance effect of greenhouse effect. It is observed century scale
rise in average temperature of earth’s climate system and its related effects.
3) Costal resources: global warming causes rise in sea level ,1.5 m rise in sea level
inundates 5000sq miles of dry land.
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4) Polar regions: Global warming causes reduction of sea ice and snow in arctic region .It
will leads to rising of sea level.
Sewage: sewage is waste water from community containing solid and liquid excreta derived
from houses, street, and factories.
Sullage: waste water which does not contain human excreta, i.e. water from kitchens and
bathrooms.
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Biological oxygen demand: the amount of oxygen absorbed by a sample of sewage during a
specified period (5 days) at specified temperature (20degree centigrade) for the aerobic
destruction of organic matter by living organisms .BOD range is 1mg/L in natural water to 300
mg/L in untreated domestic sewage .if BOD is more than 300 mg/L it is strong sewage .if BOD is
less than 100 mg/L it is then a weak sewage.
Chemical oxygen demand: Amount of oxygen equivalent of that portion of organic matter in a
sample which is susceptible to oxidation by strong chemical oxidizer.
Figure shows activated sludge process. P.S.T (primary sedimentation tank). S.S.T
(secondary sedimentation tank)
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Sanitation barrier: community medicine aims at breaking the disease cycle at vulnerable points.
The disease cycle may be broken at various levels i.e. segregation of feces, protection of water,
protection of food, personal hygiene and control of flies. Of these the most effective step would
be to segregate the feces, arrange for its proper disposal so that the disease agent cannot reach
the new host directly or indirectly.
Figure shows the segregation of the excreta by imposing a barrier called sanitation barrier .in
simple terms this barrier can be provided by sanitary latrines and a disposal pit .the more
elaborate schemes envisage installation of sewerage system and sewage treatment plant.
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1. Dumping
2. Controlled tipping
3. Incineration
4. Compositing
5. Manure pits
6. Burial
It is a method of combined disposal of refuse and night soil or sludge. It is a natural process. In
this organic matter breaks down under bacterial action, resulting in the formation of relatively
stable humus like material called compost which has considerable manorial value for the soil.
By products are carbon dioxide, water, heat, nitrate, and phosphates methods of compositing
used are:
Anaerobic
Aerobic
Environment and urban affairs division of the government of Pakistan, established during the
past ,reviewed the major environmental problems of the country and the impact of the
development process upon resources and the environment and carried out by a detailed study,
consequently it led to the preparation of comprehensive profile of Pakistan.
The profile will provide direction in future efforts to deals with the management, conservation
and rehabilitation of the environment and natural resources, as the pattern of economic
growth may not be sustainable for a long period unless due recognition is given to the linkages
between population ,resources environment and development following are the main
problems that are facing as far as environmental deterioration in Pakistan is concerned.
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The basic causes for environmental problems in Pakistan are numerous and complex. however
they can be summed up to include our past tendency to emphasize quantitative growth at the
expense of quality ,the failure of our economy to provide full accounting for the social costs of
environmental population , the failure to take environmental profile into account as a normal
and integral part of our planning and decision making is dependent on experiences without
regard to their impacts on environment and more fundamentally the inadequacy and failure of
our institutions to perceive the environment in its totality and to understand or recognize the
fundamental interdependence of man ,resources environment and development.
18.1% or 11.2 million hectares of Pakistan’s surveyed soils are subject to water erosion , 7.6%
to wind erosion and 8.6 % to salinity and sodacity.in 1985 alone , motor vehicles in Lahore
generated 123,054 metric tons of carbon monoxide 14,564 metric tons of nitrogen dioxide ,two
of the most toxic common air pollutants .Pakistan generates 47,920 metric tons of solid waste
per day i.e. 17.5 million metric tons per year .Pakistan consumes energy at the same rate per
dollar of GNP as the united states but produces less of what the consumes. Some 29.9 million
hectares or some 30.6% of the country is under the threat of desertification. over all more than
two third of the farm house holds do not have enough land to support themselves at
subsistence level from what they can produce from the land alone.
Q: A well in village is located within 100 feet of a waste dump. People using this well water are
frequently suffering from stomach disorders.
a. How will you confirm that this particular waste dump is the source of
contamination of the well?
b. What test will you perform on water to confirm that it is biologically
contaminated and why only coliform are chosen as indicator of biological
pollution of water?
c. What measure will you adopt o disinfect the well water and make it safe for
drinking?
ANSWER:
a. if the waste dump is in 50 – 100 feet of the well then it will be the source of contamination
of well.
b. coliform test will perform on water to confirm that it is biologically contaminated There are
several reasons that only coliform are chosen as indicator these are:
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the coliform organisms are constantly present in human intestine it is estimated that an
average person excretes 200-400 billion of these organisms per day these organisms
are foreign to potable waters and hence their presence in water is looked upon as
evidence of fecal contamination.
they are easily detected by culture methods–as small as one bacteria in 100ml of water,
whereas the methods for detecting pathogenic organisms are complicated and time
consuming.
they survive longer than the pathogens, which tends to die out more rapidly than
coliform bacilli.
The coliform bacilli have greater resistance to the forces of natural purification than the
water borne pathogens. If the coliform organisms are present in a water sample , the
assumption is the probable presence of intestinal pathogens.
c.explained above
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NUTRITION
Q: define and enlist micronutrients in each group
Micronutrients: a chemical element or substance required in trace amounts for the normal
growth and development of living organisms.
Vitamins are classified into fat soluble vitamins that are Vitamin A, D, E, K and water soluble
vitamin which are Vitamin B1, B2, B3,B6, B12 and Vitamin C
Minerals are calcium, phosphorus, sodium, potassium, iron, magnesium, sulpher and chlorine
Scurvy: deficiency of vitamin C results in scurvy the signs of which are swollen and bleeding
gums, subcutaneous bruising or bleeding into the skin or joints delayed wound healing, anemia
and weakness.
Scurvy can be prevented by a diet that includes vitamin C-rich foods such as lemons, oranges,
papaya, and strawberries, bell peppers (sweet peppers), blackcurrants, broccoli, guava,
kiwifruit, and parsley and Vitamin C tablets.
1) Body weight : +2SD (standard deviation) from the median weight for height is cut off
point for obesity calculated as
a) Body mass index (BMI) =weight in kg /height in meter square
b) Broca index = height in cm - 100
2) Skin fold thickness : measure by harpenden skin caliper at the following sites :
Mid triceps, biceps, subscapular, and supra iliac regions .ideally it should be <40mm in
boys, and <50 mm in girls
3) Waist circumference and waist hip ratio: waist circumference is measured at the
midpoint between the lower border of the rib cage and the iliac crest. It is a convenient
and simple measurement that is unrelated to height, correlates closely with BMI and
waist hip ratio and is an approximate index of intra-abdominal fat mass and total body
fat .changes in waist circumference reflects changes in risk factors for cardiovascular
disease and other form of chronic diseases. There is an increased risk of metabolic
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complications for men with a waist circumference >102 cm and women with a waist
circumference > 88cm.
Q: classify malnutrition
Malnutrition classification:
Q: describe protein energy malnutrition and factors responsible for protein energy
malnutrition.
II. Marasmus: it is the condition of total calorie malnutrition in which food intake or
utilization is deficient and wasted appearance developed.
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1. main factors :
Nutritional imbalance /deficiency
Bacterial and parasitic infections
Failure in providing essential nutrients
Deprivation of child from breast feeding
Cultural factors and type of food consumed.
2. Contributory factors :
Erroneous weaning by ignorant mother
Early weaning due to second pregnancy
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3. Other factors:
High cost of protein diet
Shortage of food in community
Poor environmental sanitation
Shortage of curative and preventive services
1) Health promotion:
Measure directed to pregnant and lactating women (education and distribution
of supplements )
Promotion of breast feeding
Development of low cost weaning product
Nutrition education
Family planning and spacing of birth
2) Specific protection:
Child diet must contain balance nutrients
Immunization
Food fortification
4) Rehabilitation :
Nutritional rehabilitation services
Hospital treatment
Follow up care
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II. Height for age: comparing height measurement with reference standard of height of
children of the same age.
III. Weight for height: weight of a child expressed as percent of weight of standard child of
same height.
IV. Skin fold thickness: determine amount of body fat, measure from triceps, inferior
angle of scapula with skin fold caliper.
VI. An arm circumference: it detects early PEM .flexible steel or fiber glass tap is used for
measurement .if >13.5 cm it is well nourished .if between 12.5 to 13.5 cm it will be mild
to moderate malnutrition. if <12.5 cm it will be severe malnutrition
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Biological complete protein: A protein is said to be biological complete if it contains all the
essential amino acids in amount corresponding to human needs .e.g. protein from animal
sources i.e. milk and egg.
Body building
Repair and maintenance
Maintenance of osmotic pressure
Synthesis of antibodies , plasma proteins , hemoglobin , enzymes , hormones,
coagulation factors
Source of energy, it gives 4 kcal/gm.
1) Gomez classification: it is based on weight retardation .it locate the child on the basis of
his/her weight in comparison with normal child’s weight of the same age
Weight for age (%) =weight of the child x 100
Weight of normal child of same age
Disadvantages:
Cut off point which is 90 is very high therefore some normal children are classified as 1 st
degree malnourished
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It is difficult to know whether the low weight is due to sudden acute episode of
malnutrition or long standing chronic under nutrition
Role in vision i.e. production of retinal pigments which are needed for vision
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Maintain the integrity and normal glandular epithelial tissue which lines intestinal
respiratory , urinary tract and eyes
It supports skeletal growth
Role as anti-infective ,enhance immune response
Protect epithelial cancers
Pasteurization: heating of milk for such temperature and for such period of time as are
required to destroy any pathogen that may be present while causing minimal changes to
composition, flavor, and nutritive values.
Disease caused by niacin (vitamin B3) is pellagra. Symptoms of pellagra are 3Ds i.e. Diarrhea,
Dermatitis, Dementia In addition glossitis and stomatitis occur.
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Incineration
Chemical disinfection
Wet and dry thermal treatment
Microwave radiation
Land disposal
Inertization
3. Hazards from genotoxic waste: inhalation, absorption through skin and ingestion of
food contaminated with cytotoxic drugs, chemicals and waste have destructive effect on
genetic material of cell.
4. Hazards from radioactive waste: These radiations are genotoxic and causes damage to
genetic material damage depends upon type and exposure time.
5. Public sensitivity : visual impact of health care waste particularly anatomical waste
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Dumping
Controlled tipping
Incineration
Compositing
Manure pits
Burial
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Health information and management system (HIMS): a mechanism for collection, processing,
analysis, and transmission of information required for organizing and operating health services
and also for research and training .
Q: what are causes of failure of health information and management system (HIMS).
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To measure health status of people and to quantify their health problems and health
care needs.
For local, national and international comparison of health status for such comparison
the data needed to be subjected to rigorous standardization and quality control.
For planning, administration and effective management of health services programs.
For assessing whether health services are accomplishing their objectives in terms of
their effectiveness and efficiency.
For assessing their attitude and degree of satisfaction of the beneficiaries with health
system.
For research into particular problems of health and disease
Census
Registration of vital events
Sample registration system
Notification of disease
Hospital record
Disease register
Record linkage
Epidemiological surveillance
Other health services
Environmental health data
Health man power status
Population survey
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Types:
simple hypothesis
complex hypothesis
null hypothesis
alternative hypothesis
empirical hypothesis
logical hypothesis
statistical hypothesis
The Millennium Development Goals (MDGs) were the eight international development goals
for the year 2015 that had been established following the Millennium Summit of the United
Nations in 2000, following the adoption of the United Nations Millennium Declaration. All 189
United Nations member states at that time, and at least 22 international organizations,
committed to help achieve the Millennium Development Goals by 2015.
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The Sustainable Development Goals (SDGs), officially known as transforming our world: the
2030 Agenda for Sustainable Development is a set of 17 "Global Goals" with 169 targets
between them. Spearheaded by the United Nations through a deliberative process involving its
193 Member States.
THE END
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