Sunday, December 26, 2010

Vitamin A Prophylaxis Programme

The programme was launched in 1970 with the objective of reducing the disease and preventing blindness due to Vitamin A deficiency. It was initially started in 7 states with severe problems. Later it was extended to the entire country.

Under the programme, children aged 6 months to 6 years were to be administered a mega dose of vitamin A at 6 monthly intervals. To prioritize Vitamin A administration, the programme was revised to give 5 mega doses at 6 months intervals to children 9 months to 3 years of age. In view of adequate supplies of Vitamin A, the target group has been revised to cover children 9 months- 5 years, since 2007.

Objectives: to decrease the prevalence of Vitamin A deficiency from current 0.6% to less than 0.5%.

Strategy:

  • Health and nutrition education to encourage colostrum feeding, exclusive breast feeding for the first six months, introduction of complementary feeding thereafter and adequate intake of Vitamin A rich foods.
  • Early detection and proper treatment of infections
  • Prophylactic Vitamin A as per the following dosage schedule:

100000 IU at 9 months with measles immunisation

200000 IU at 16-18 months, with DPT booster

200000 IU every 6 moths, up to the age of 5 years.

Thus a total of 9 mega doses are to be given from 9 months of age up to 5 years.

Sick Children:

  • All children with xerophthalmia are to be treated at health facilities.
  • All children having measles, to be given 1 dose of Vitamin A if they have not received it in the previous month.
  • All cases of severe malnutrition to be given one additional dose of Vitamin A.


Baby Friendly Hospital Initiatives

The original 1992 BFHI guidelines were prepared by the staff of the United Nations Children's Fund(UNICEF), the World Health Organization (WHO), with assistance from Wellstart International in developing The Global Criteria.

TEN STEPS TO SUCCESSFUL BREASTFEEDING
Every facility providing maternity services and care for newborn infants should:
1. Have a written breastfeeding policy that is routinely communicated to all
health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of
breastfeeding.
4. Help mothers initiate breastfeeding within a half-hour of birth.
5. Show mothers how to breastfeed, and how to maintain lactation even if they
should be separated from their infants.
6. Give newborn infants no food or drink other than breastmilk unless
medically indicated.
7. Practise rooming in - allow mothers and infants to remain together - 24 hours
a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to
breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers
to them on discharge from the hospital or clinic.

The baby friendly hospitals of India are also expected to adopt and practice guidelines on other interventions critical for child survival including antenatal care, clean delivery practices, essential new born care, immunization and ORT.

The BFHI has proved to be highly successful in encouraging proper infant feeding practices, starting at birth.



Saturday, December 25, 2010

National Nutritional Anaemia Prophylaxis Programme

At present, the National nutritional Anaemia Prophylaxis Programme is operated as part of the RCH programme. under the revised policy, the target group has been expanded to include infants 6-12 months, school children 6-10 years and adolescents 11-18 years of age, clinically found to be anaemic. For infants and children, liquid formulation having 20 mg elemental iron and 100 ug folic acid per ml, will be made available. Dosage schedule for various age groups is given below:

  • Children 6-60 months: 2o mg elemental iron + 100 ug folic acid(one tablet of pediatric IFA or 5 ml of IFA syrup or 1 ml of IFA drops) for a total of 100 days if the child is clinically found to be anaemic.
  • School children 6-10 years: 30 mg elemental iron + 250 ug folic acid for 100 days.
  • Adolescents 11-18 years: 100 mg elemental iron + 500 ug folic acid for 100 days. Adolescent girls to be given greater priority in the programme.
  • Pregnant women: one tablet of 100 mg elemental iron + 500 ug folic acid prophylactically daily and if clinically anaemic, 2 such tablets to be given daily for 100 days.
  • Nursing mothers and acceptors of family planning: one tablet containing 100 mg elemental iron + 500 ug folic acid daily for 100 days.

The programme strategy also includes health and nutrition education to improve overall dietary intakes and promote consumption of iron and folate rich foods as well as food items that promote iron absorption.



Indira Gandhi Matritva Sahyog Yojana (IGMSY)

To improve maternal and child health, the Cabinet Committee on Economic Affairs on October 20, 2010 approved the Indira Gandhi Matritva Sahyog Yojana (IGMSY) — a monetary scheme for pregnant women and lactating mothers — on a pilot basis in 52 districts in this Five-Year Plan.

The scheme, to be implemented through the Integrated Child Development Services (ICDS) Scheme infrastructure and personnel, will cost Rs. 1,000 crore. Some personnel will be hired on a contractual basis.

The scheme will be fully funded by the Centre and Rs. 390 crore and Rs. 610 crore have been allocated for 2010-11 and 2011-12 respectively.

Under the scheme, cash transfers will be made to all pregnant and lactating women as incentives based on fulfilment of specific conditions relating to mother and child health and nutrition. Each pregnant and lactating woman will receive Rs. 4,000 in three instalments between the second trimester of pregnancy until the child is six months old. However, government employees and Central and State Public Sector employees have been excluded from the scheme as they are entitled to paid maternity leave.

Each beneficiary has to open an individual account (if she does not have one already) in the nearest bank or the post office for cash transfer.

It is expected that in the initial years, about 13.8 lakh pregnant and lactating women in 52 districts could avail themselves of the benefit.

The beneficiaries will be pregnant women of 19 years and above and for the first two live births (benefits for still births will be as per the norms of the scheme).

Since the IGMSY will be implemented by the States through the existing ICDS system and supported by additional contractual staff, anganwadi workers and helpers will receive an incentive of Rs. 200 and Rs. 100 respectively a pregnant and lactating woman after all the due cash transfers are made.

There will be steering and monitoring committees at all levels to oversee the scheme. A special cell to monitor the scheme will be set up within the Ministry of Women and Child Development.



Social Security Schemes Of India

The Government of India has implemented several social security schemes with an aim to reach out and support its citizenry.  Enumerated below are a few major programmes:

(1)  National Social Assistance Programme (NSAP):   This scheme was launched in 1995-96 as a centrally sponsored scheme, administered by the Ministry of Rural Development. But with effect from 2002-03 NSAP was transferred to the State Plan. Funds for the scheme are now provided as Additional Central Assistance (ACA) to the States.

NSAP comprises of following schemes:

  • Indira Gandhi National Old Age Pension Scheme (IGNOAPS)
  • National Family Benefit Scheme (NFBS)
  • Annapurna Scheme
  • Indira Gandhi National Widow Pension Scheme (IGNWPS):  Introduced in February 2009, this scheme is applicable to below poverty line widows in the age group of 40-64 years.
  • Indira Gandhi National Disability Pension Scheme (IGNDPS):  Introduced in February 2009, it is applicable to below poverty line persons with severe or multiple disabilities in the age group of 18-64 years. 

(2)  Swarna Jayanti Shahari Rozgar Yojana (SJSRY):  This scheme seeks to provide gainful employment to the urban unemployed or underemployed poor by encouraging setting up of self-employment ventures or provision of wage employment. SJSRY is a centrally sponsored schemes funded on a 75:25 basis between the Centre and the States. To avail benefits under this scheme the Municipal Board of the respective State should be contacted.

(3)  Provident Fund Benefits, Pension and Monetary Assistance under the Employees’ Provident Funds & Miscellaneous Provisions Act,1952

(4)  Health care and Cash benefit payments in the case of sickness, maternity and employment injury under the Employees’ State Insurance Act, 1948.

(5)  Welfare funds for different sections of unorganized workers on matters relating to:

  • life and disability cover
  • health and maternity benefit
  • housing assistance
  • scholarship to the children of beneficiaries and recreation
  • old age protection under the Unorganized Workers’ Social Security Act, 2008

(6)  Schemes for rural poor including landless labourers such as Swarnjayanti Gram Swarojgar Yojana, Sampoorna Grameen Rozgar Yojana and Pradhan Mantri Gram Sadak Yojana.

(7) Employment guarantee under National Rural Employment Guarantee Act, 2005 :  The NREGA is a Peoples Act in several sense. The Act empowers ordinary people to play an active role in the implementation of employment guarantee schemes through Gram Sabhas, social audits, participatory planning and other means. The objective of the programme is to enhance livelihood security in rural areas by providing at least 100 days of guaranteed wage employment to every household whose adult members volunteer to do unskilled manual work.

(8)  Schemes for Elderly and disabled :   Ministry of Social Justice & Empowerment runs an Integrated Programme for Older Persons which includes schemes for Old Age Homes, Day Care Centres and Mobile Medicare Units.  Similarly, schemes for the disabled include providing assistance to Disabled Persons for purchase or fitting of Aid’s/Appliances (ADIP) and providing grant-in-aid for rehabilitation/empowerment of persons with disabilities through projects such as Special Schools for Mentally Retarded/Hearing Impaired/Visually Handicapped, Vocational Training Centres etc. under The Deendayal Disabled Rehabilitation Scheme.

(9)  Schemes for rehabilitation of victims of substance (Drugs) abuse.



Iodine

Iodine is an essential micronutrient. It is required for the synthesis of the thyroid hormones, thyroxine and triiodothyronine. Iodine is essential in minute quantities for the normal growth and development and well being of all humans.

Sources: sea foods(sea fish, sea salt) and cod liver oil

Goitrogens: These are chemical substances leading to the development of goitre. they interfere with iodine utilization by the thyroid gland.The brassic group of vegetables(eg., cabbage, cauliflower) may contain goitrogens. Most important among the dietary goitrogens are probably cyanoglycosides and the thiocyanates.

Spectrum of IDD in order of increasing severity:

Disorders Levels of severity
goitre grade I
grade II
grade III
hypothyroidism varying combination of clinical signs
subnormal intelligence
delayed motor milestones
mental deficiency
hearing defects
speech defects
variable severity
strabismus unilateral or bilateral
nystagmus  
spasticity spastic diplegia,
spastic quadriplegia
neuromuscular weakness muscle weakness in legs, arms, trunk
endemic cretinism hypothyroid cretinism,
neurological cretinism
intrauterine death(spontaneous abortion, miscarriage)  

In 1992, the Central Council of Health, took a policy decision to iodize the entire edible salt in the country by the year 1992. In August 1992, the NGCP was renamed as National Iodine Deficiency Disorders Control Programme (NIDDCP) taking into its ambit control of the wide spectrum of IDD like mental and physical handicap and reproductive wastage. The Goal of the NIDDCP is to reduce the prevalence of IDD below 10% in endemic districts of the country.

The programme has the following components;

  • Surveys to assess the magnitude of Iodine Deficiency Disorders
  • Production and supply of iodised salt to the whole country
  • Health education and publicity
  • Resurvey in the goitre endemic areas after 5 years of continuous supply of iodised salt, to assess the impact of the control programme
  • Laboratory monitoring of iodized salt and urinary iodine excretion

1.Iodized Salt: The iodization of salt is now the most widely used public prophylactic measure against endemic goitre. In India, the level of iodization is fixed under the Prevention of Food Adulteration (PFA) Act and is not less than 20 ppm at the production point and not less than 15 ppm at the consumer level. Under the NIDDCP, the Govt of India proposed to completely replace common salt with iodized salt in a phased manner.

Another method which has demonstrated its efficacy for controlling goitre is intramuscular injection of iodized oil(mostly poppy-seed oil).

2.Iodine monitoring: a network of laboratories have been set up across the country for iodine monitoring and surveillance. These laboratories are essential for: a)iodine excretion determination, b)determination of iodine in water, c)determination of iodine in salt for quality control.

3.Manpower training: It is vital for the success of the IDDCP that health workers and others engaged in the programme be fully trained in all aspects of goitre control including legal enforcement and public education.

4.Mass communication: Mass communication is a powerful tool for nutrition education. It should be fully utilized in goitre control work. Activities through song and drama division have been taken up in 8 states viz., UP, Bihar, Rajasthan, Madhya Pradesh, Orissa, Chattisgarh, Jharkhand and Uttaranchal. Besides this, activities are being carried out through 268 units of the Directorate of Field Publicity in nearly 500 districts.The activities include film shows, group discussions and other special programmes. IDD spots are also being telecast at prime time through the national network of Doordarshan and AIR. DAVP has been actively involved in bringing out messages in the newspapers, radio spots and print materials in the form of posters and pamphlets.

Hazards of iodization: A mild increase in the incidence of thyrotoxicosis has been observed following the implementation of IDDCP.



Maternal Mortality In India

Major causes of maternal mortality in India are:

  1. Haemorrhage(29%)
  2. Anaemia(19%)
  3. Sepsis(16%)
  4. Obstructed labour(10%)
  5. Abortion(9%)
  6. Toxaemia(8%)
  7. Others(9%)

Maternal mortality in India is very high. Health action can reduce maternal mortality to about half in a 5 to 10 year-period. Other factors such as income, nutrition, education, women’s status and equity are important, but improvements can be seen in the long term.

The three Es to reduce maternal mortality are:

  • E1: Essential obstetric care for all
  • E2: Early detection of complications
  • E3: Emergency services for those who need it

Essential Obstetric Care for All:

All pregnant women are at risk of complications. One or more risk factors are observed in 50% of the maternal deaths. therefore, all pregnancies should be treated as potentially at risk and essential obstetric care is provided to all pregnancies. This includes:

  • Early registration of pregnancy
  • 3 or more ante-natal check-ups during pregnancy
  • Anaemia prophylaxis and treatment: For prophylaxis, 1 tablet containing 100 mg elemental iron and 500 ug Folic acid daily and in case of anaemia, 2 such tablets daily for at least 100 days. Mebendazole(2nd/3rd trimester) for those with history of passing worms.
  • 2 doses of Tetanus toxoid or a booster
  • Skilled care at birth: Institutional deliveries and deliveries by skilled birth attendants observing five cleans during delivery- clean hands, clean surface, clean razor blade, clean cord tie and clean cord stump. Provision for disposable safe delivery kits for the same, in addition to IEC and reorientation training efforts.
  • Birth spacing and birth timing: To avoid pregnancies before 20 years and after 30 years. Birth interval to be at least 3 years.
  • Home-based postnatal care alongwith the care of the newborn. This will be provided through TBAs, AWWs and link workers. These workers will visit on days 1,2,7,14 and 28.

Early Detection of Complications:

This will be through regular check-ups, self-reporting based on danger signals or timely referral by TBAs and health workers. Common complications are: Bleeding(APH,PPH), anaemia, toxaemia, sepsis, abortion and obstructed labour. Deliveries will be promoted at institutions to not only ensure five cleans but also for reducing the time gap between onset of complications and reaching an institution for emergency care.

Emergency Care:

The complications like haemorrhage, severe anaemia, severe toxaemia, obstructed labour, ruptured uterus or abortions are obstetric emergencies and will be managed at First Referral Unit(FRU), details of which are given on a previous post on FRU.



Vaccine Vial Monitor

It is a heat sensitive square within a circle, which changes colour under the combined influence of heat and time.

If after exposure to heat for a certain amount of time, the square reaches the same colour or becomes darker than the circle, the vial should be discarded.

The VVM allows the user to see at any time if vaccine can still be used in spite of possible cold chain interruption. This helps to reduce vaccine wastage.

The use of VVM offers several advantages during national immunization days or mop-up campaigns. Field workers can carry OPV without ice for door-to-door vaccination. The need for large number of froz3en ice packs and re-supply of ice is reduced as one can know when the OPV vial has reached the discard point due to exposure to heat. This helps teams to cover longer distance and spend more time in field as they no longer have to carry bulky equipment or rely on resupply of ice. Because of this, it is also easier to organize immunization in areas that are difficult to reach or have weak cold chain. The need to expand cold chain facilities for the campaigns is greatly reduced. Thus VVM helps to plan a cold chain which is more flexible, less stringent and cheaper.



First Referral Unit

It is a district or sub-divisional hospital or community health centre which has the facilities for obstetric surgery, blood transfusion, anaesthesia, specialist pediatric care, operation theatre and required equipment. This centre also has the facilities for MTP, tubectomy, vasectomy and pediatric care for high risk neonates and other severe problems of early childhood. It provides specialist services in addition to all the services available at a PHC.

Specialist Services available at FRU:

Surgical:

  • Caesarian section
  • Laparotomy and repair of ruptured uterus
  • Surgical treatment of severe sepsis
  • Evaluation of incomplete abortion
  • Mid-trimester abortion
  • Repair of cervical and vaginal tears
  • Amniotomy with/ without oxytocin
  • Tubectomy/vasectomy

Medical Management of:

  • severe hypertensive disorders of pregnancy, eclampsia
  • hemorrhagic shock
  • severe anaemia
  • septicemia
  • use of iv oxytocin during labour

Manual:

  • Manual removal of placenta
  • Forceps delivery
  • Vacuum extraction
  • Partography

Anaesthesia:

  • general, spinal

Blood Transfusion:

  • bleeding a donor and blood transfusion
  • performing mandatory tests

Newborn and Pediatric Care:

  • Resuscitation
  • Management of sick newborns and severe illnesses of young children


Essential NewBorn Care

An important component of RCH-II is essential newborn care. As the majority of births in India still occur at home and 2/3 of all infant deaths occur during the 1st month of life, it is essential to ensure that skilled healthcare is provided to all babies at birth. Hence, field level workers are being trained in essential newborn care ie.,resuscitation at birth for birth asphyxia and care which every newborn needs like initiation of breastfeeding within half an hour of birth, rooming in, keeping the baby warm, no bathing at birth and immunisation. Under RCH II, home-based neonatal care is to be provided alongwith post-partum care through TBAs,AWWS and link workers like ASHA. These workers will pay home visits to the neonates on days 1,2,7,14 and 28. Besides these, there will be strengthening of institutions for newborn care for those needing referrals.



Micronutrients

These are vitamins and minerals. they are called micronutrients because they are required in small quantities, ranging from less than a milligram to a few grams.

Vitamins include the fat-soluble vitamins, Vitamin A, D, E and K as well as the water-soluble vitamins like Vitamin C and Vitamin B-complex.

Minerals may be major or trace elements. The major minerals include calcium, Phosphorus, Sodium, Potassium and Magnesium. The trace elements are required in very minute quantities(few milligrams) and include: Iron, Iodine, Fluorine, Copper, Cobalt, Chromium, Manganese, Molybdenum, Selenium, Nickel, Tin, Silicon and Vanadium.