Definition. Immunization is the process by which a person is made immune or resistant to an infectious disease, usually by giving a vaccine. The vaccine stimulates the body's immune system to produce antibodies and memory cells, so the person is protected against later infection with that disease.

Immunization schedule of Nepal (National Immunization Programme, NIP)

Notes: all doses are free of cost at government health facilities and outreach clinics, and the full course should be completed within the first year of life (fully immunized child) with MR 2 and the remaining vaccines at 15 months.

Supportive Supervision (5 marks)

1. Supportive supervision (1 mark)

Supportive supervision is a process of guiding, helping and encouraging health workers to improve their performance, rather than merely inspecting or finding faults. The supervisor works together with the health worker as a colleague and mentor — observing work, giving on-the-spot feedback, solving problems jointly, providing on-the-job training and arranging needed resources (drugs, equipment, guidelines). Its main aim is to improve the quality of health services through capacity building and motivation, not through punishment. It is regular, planned and two-way (dialogue between supervisor and supervisee).

2. Difference between monitoring and evaluation (2 marks)

In short, monitoring asks "Are we doing things right?" while evaluation asks "Are we doing the right things, and did they work?"

3. Reasons for conducting a micro health project (2 marks)

1. To solve a specific, local health problem identified by the community itself (e.g., diarrhoea, worm infestation, low immunisation coverage).
2. To increase community participation and self-reliance in health activities.
3. To make health services accessible and acceptable to the local people, especially the poor and disadvantaged groups.
4. To test or demonstrate a new approach/technology on a small scale before expanding it.
5. To use locally available resources (money, labour, materials) and build local capacity.
6. To develop the skill of health workers and community leaders in planning, implementing and managing projects.
7. To meet the felt needs of the target group within a short time and at low cost.
8. To support and strengthen the national health programme at the grassroots level (e.g., PHC/health post level).

Functions of Health Logistics Management Centre (HLMC), Gandaki Province — 5 marks

The Health Logistics Management Centre (HLMC) is the provincial body responsible for the procurement, storage and distribution of health commodities in Gandaki Province. Its main functions are:

1. Procurement of health commodities — Purchases medicines, vaccines, contraceptives, surgical items, equipment and other health supplies required by provincial and local health facilities as per the annual need forecast.

2. Storage and warehousing — Maintains central stores (cold chain and dry stores) with proper storage conditions, stock records and stock cards to keep commodities safe and unexpired.

3. Distribution and supply — Distributes drugs and supplies to district health offices, hospitals, primary health care centres, health posts and other service sites on the basis of requisitions and consumption data, ensuring no stock-out at service points.

4. Cold chain management — Manages vaccine cold chain (refrigerators, cold boxes, vaccine carriers, ice packs), monitors temperature and ensures vaccine potency from store to service site.

5. Quantification and inventory control — Prepares need estimates, maintains buffer stock, conducts physical verification, and manages expiry and near-expiry items through redistribution or disposal.

6. Quality assurance — Ensures drugs and supplies are of standard quality, procured from qualified suppliers, and stored and transported as per national standards.

7. Logistics Management Information System (LMIS) — Collects, compiles and reports stock and consumption data (e.g., through LMIS/eLMIS) to the Ministry of Health and Population and other concerned bodies for informed decision-making.

8. Capacity building and supervision — Provides orientation and technical support to district and local level store staff on store management, reporting and rational use of commodities, and monitors their performance.

9. Coordination — Coordinates with the Department of Health Services, Central Medical Store, Nepal Army/other agencies, development partners and local levels for timely supply of health logistics during normal times and emergencies.

In short, the HLMC ensures the right quantity of the right quality of health commodities at the right place and right time in Gandaki Province.

Mobilizing Local Health Leaders in the Working Health Post (5 marks)

1. Identification and mapping of local health leaders First, I will identify and map the existing local health leaders of the catchment area — Female Community Health Volunteers (FCHVs), Mothers' Group members, ward health committee members, school teachers, religious leaders, traditional healers (dhami/jhankri), and youth club representatives. A simple register with their name, ward, contact number and area of influence will be maintained.

2. Orientation and capacity building I will orient them on the basic health services available at the health post (immunization, ANC/PNC, family planning, nutrition, TB and leprosy referral, sanitation) and on their specific roles. Short, simple training sessions and refresher meetings will be held so that they can give correct information and refer cases properly.

3. Formation and activation of committees I will activate the Health Post Management Committee, Ward Health Committee and Mothers' Groups, and hold regular monthly/quarterly meetings. These committees will help in planning, budgeting, monitoring and solving local health problems such as low immunization coverage or open defecation.

4. Clear division of roles and task sharing FCHVs will be given responsibility for home visits, growth monitoring, ORS distribution and referral; teachers for school health and hygiene education; religious leaders for advocacy from the pulpit; and traditional healers for early referral of complicated cases. Each will be given a simple checklist and reporting format.

5. Support, supervision and motivation I will provide regular supportive supervision, feedback and logistic support (bags, registers, ORS, IEC materials). Their work will be recognized publicly on occasions like FCHV Day, and non-financial and financial incentives will be recommended so that motivation is sustained.

6. Coordination and networking I will link them with the local government (palika), health section, NGOs/FMGs and other stakeholders, and use them during campaigns (immunization, vitamin A, deworming, MDA) and health education activities.

7. Monitoring and evaluation Monthly reporting, review meetings and simple indicators (number of referrals, home visits, mothers attending ANC) will be used to assess their performance and to revise the mobilization plan accordingly.

Conclusion In this way, by identifying, training, involving, supporting and motivating local health leaders, they can be converted into an effective link between the community and the health post, which increases service utilization and community ownership.

Disaster

Definition: A disaster is a serious disruption of the functioning of a community or society, caused by a natural or human-made hazard interacting with conditions of vulnerability, which causes widespread loss of life, injury, property damage, and destruction of livelihoods, exceeding the affected community's own capacity to cope using its own resources.

The World Health Organization (WHO) defines disaster as "any occurrence that causes damage, ecological disruption, loss of human life or deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the affected community or area."

Types of Disasters

Disasters are broadly classified into two main types:

1. Natural Disasters — caused by natural forces or processes:

• Geological: Earthquake, landslide, flood, avalanche, glacial lake outburst flood (GLOF)
• Meteorological/Climatic: Cyclone, storm, hailstorm, drought, heat wave, cold wave, thunderstorm
• Biological: Epidemic (cholera, dengue, COVID-19), pandemic, insect infestation, animal disease outbreak

2. Human-Made (Man-Made) Disasters — caused by human activity, negligence, or intent:

• Technological/Industrial: Fire, explosion, chemical leak, building collapse, road, air and rail accidents, dam failure
• Intentional/Social: War, terrorism, civil conflict, riot, arson
• Others: Famine, refugee crisis, environmental pollution, nuclear accidents

Note: Some disasters are complex emergencies, where natural and human-made factors combine (e.g., famine following drought and conflict). In Nepal, the most common disasters are earthquakes, landslides, floods, fires, and epidemics.

Waste management in a health post (1+4 = 5 marks)

Introduction (1 mark): Health-care waste is any waste generated during diagnosis, treatment or immunization of patients. It is potentially infectious and hazardous, so it must be segregated at source, stored safely, transported and finally disposed of scientifically as per the National Health Care Waste Management Guidelines of Nepal.

Management of waste in the working health post (4 marks):

1. Segregation at source (colour-coded bins):

   • Red bin/bag: infectious and anatomical waste — used gloves, dressings, cotton, placenta, blood-soaked items.
   • Yellow bin/bag: sharp and metallic waste — needles, syringes, blades, ampoules, broken glass.
   • Blue/white bin: non-infectious general waste — paper, packaging, leftover food.
   • Black bin: general non-hazardous waste. Segregation is done at the point of generation, never mixed later.

2. Collection and storage: Waste is collected daily in covered, puncture-proof, labelled containers. Sharp waste is collected in a puncture-proof safety box filled only up to three-fourths. A separate, locked, shaded and ventilated temporary storage room is used, and waste is kept for not more than 24–48 hours in a cool place.

3. Transportation: Waste is carried in closed trolleys or covered containers by trained staff wearing gloves, mask, apron and boots. The route avoids patient-care areas and the collection time is fixed so that it does not clash with OPD hours.

4. Treatment and final disposal:

   • Infectious waste: disinfected by autoclaving or chemical disinfection (1% sodium hypochlorite), then buried in a pit or handed over to a certified service provider.
   • Sharps: mutilated/destroyed and buried in a sharp pit or encapsulated in concrete.
   • Placenta and anatomical waste: buried in a deep pit at least 1 m deep, away from water sources.
   • General waste: disposed of through the local municipality system or safe on-site burial.
   • Liquid waste: treated in a soak pit or septic tank, never drained into open ground or streams.

5. Safety of staff and waste handlers: All staff are oriented on waste handling; personal protective equipment (gloves, mask, apron, boots) is provided; hepatitis B vaccination is given; hand washing is done after handling waste; and needle-stick injuries are reported and managed immediately.

6. Monitoring, recording and community role: Daily recording of waste generated and disposed, periodic supervision by the health facility in-charge, display of waste management charts, health education to patients and the community, and coordination with the local health office and municipality for regular monitoring and support.

Conclusion: Proper colour-coded segregation, safe storage, trained handling and scientific disposal reduce infection, protect health workers and keep the health post and its surroundings clean and safe.

Epidemiological Determinants of Dengue

Dengue is an acute mosquito-borne viral (arboviral) disease caused by the dengue virus (DENV serotypes 1–4) of the family Flaviviridae, transmitted mainly by the Aedes aegypti mosquito. Its epidemiological determinants are the factors that influence its occurrence and spread, and they are grouped as follows:

1. Agent factors

• Agent: Dengue virus, an RNA virus of the genus Flavivirus, with four serologically distinct serotypes (DENV-1, 2, 3, 4). Infection with one serotype gives lifelong immunity to that serotype only, so a person can be infected up to four times. Secondary infection with a different serotype increases the risk of severe dengue (dengue haemorrhagic fever/dengue shock syndrome).
• Reservoir: Man is the main reservoir; in some areas monkeys act as a sylvatic reservoir.
• Source of infection: Infected humans (viraemic phase — from about 1 day before to 5 days after the onset of fever).
• Period of communicability: During the viraemic period, i.e. roughly 2 days before to 5 days after fever onset.

2. Host factors

• Age: All ages are susceptible, but in endemic areas it mainly affects children and young adults.
• Sex: Both sexes are affected; males are often more exposed due to outdoor activity and clothing habits.
• Immunity: No cross-protective immunity between serotypes; hence repeated epidemics occur.
• Occupation and behaviour: People storing water in open containers, working or sleeping outdoors, and those in crowded urban settlements are more at risk.
• Nutrition and co-morbidities: Malnutrition, diabetes, hypertension and other chronic diseases increase the risk of severe dengue.

3. Environmental factors

• Breeding sites: Aedes aegypti breeds in clean, stagnant water collected in artificial containers — water jars, tanks, tyres, flower pots, discarded bottles, tin cans, roof gutters and broken drains. It is a domestic and peri-domestic mosquito.
• Temperature: The mosquito and virus thrive at 20–30 °C; high temperature shortens the extrinsic incubation period and increases transmission.
• Rainfall and humidity: The rainy season (June–September in Nepal) creates abundant breeding sites; high humidity prolongs mosquito survival.
• Urbanisation and environment: Unplanned urbanisation, inadequate water supply (forcing household water storage), poor solid waste management and construction activities favour breeding.
• Altitude: Rare above about 1,200 m; hence mostly a Terai and inner-Terai problem in Nepal.

4. Time factors

• Season: Peak transmission in the rainy season and a few weeks after it (July–October in Nepal).
• Biting time: Aedes is a day-biter, with peak biting in the early morning and late afternoon.
• Place: More common in urban and semi-urban areas, and in areas with a high density of Aedes mosquitoes.

5. Mode of transmission

• Vector transmission: Bite of an infective female Aedes aegypti (also Ae. albopictus).
• Rare routes: Transplacental (mother to fetus), blood transfusion and needle-stick injury.

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Prevention of Dengue

Dengue has no specific treatment, so prevention and control are the mainstay. Prevention is directed at breaking the chain of transmission by controlling the vector and protecting people from mosquito bites. It is carried out at three levels:

A. Anti-larval measures (vector control)

1. Environmental sanitation: Remove or empty all artificial water containers weekly; destroy discarded tyres, bottles, tin cans and coconut shells; fill up pits and depressions; keep roof gutters and drains clean.
2. Covering water containers: Keep household water jars, tanks and drums tightly covered; use lids or mosquito-proof netting.
3. Biological control: Introduce larvivorous fish (Gambusia, Poecilia) in ponds and large water bodies; use Bacillus thuringiensis israelensis (Bti) as a larvicide.
4. Chemical control: Apply larvicides such as temephos (Abate) to water containers and spray insecticides (malathion, permethrin) in and around houses during outbreaks.

B. Anti-adult measures

1. Indoor residual spraying of houses with insecticides.
2. Space spraying (fogging) in epidemic situations to kill adult mosquitoes.
3. Personal protection:
   • Use mosquito nets (especially during day-time naps), screens on doors and windows.
   • Apply mosquito repellents (DEET, picaridin) on exposed skin.
   • Wear full-sleeved clothes and long trousers, especially in the morning and late afternoon.
   • Use mosquito coils, mats or vaporizers.

C. Other measures

1. Health education: Educate the community about breeding sites, weekly "dry day" (emptying water containers once a week), and early reporting of fever.
2. Surveillance: Regular entomological surveillance (larval indices — House Index, Container Index, Breteau Index), case surveillance and outbreak investigation.
3. Early diagnosis and treatment: Detect cases early by NS1 antigen/IgM ELISA, isolate the patient under a mosquito net during the viraemic period, and give supportive treatment to prevent complications.
4. Intersectoral coordination: Involvement of municipalities, local government, water supply, waste management and education sectors in vector control.
5. Community participation: "Search and destroy" campaigns, cleaning campaigns and source reduction at the household level.

Conclusion: Dengue prevention depends mainly on source reduction (eliminating breeding sites) and protection from mosquito bites. Since Aedes aegypti is a day-biting, domestic mosquito, community participation and sustained vector control are essential to prevent outbreaks.

Role of Female Community Health Volunteers (FCHVs) and Mothers' Groups in Uplifting Health Indicators in Nepal

Introduction

Nepal's health system has achieved remarkable progress in maternal and child health despite difficult geography and limited resources. A major reason for this success has been the effective use of community-based volunteers, especially Female Community Health Volunteers (FCHVs) and Mothers' Groups (MGs). The FCHV programme was launched in 1988 (2045 BS) and today there are more than 52,000 FCHVs — roughly one in every ward of every VDC/municipality. Mothers' Groups are local women's collectives that work alongside FCHVs. Together they form the backbone of primary health care at the community level.

Role of Female Community Health Volunteers (FCHVs)

1. Maternal and newborn care

• Identify pregnant women, counsel them on at least four ANC visits, iron/folate tablets, and institutional delivery.
• Promote birth preparedness and complication readiness (BPCR) — saving money, arranging transport, identifying a blood donor, and choosing a birth attendant.
• Counsel on exclusive breastfeeding for six months, complementary feeding, and postnatal care.
• Distribute Misoprostol (for prevention of postpartum haemorrhage) and counsel on its use.

2. Child health

• Promote full immunization; assist in immunization campaigns and defaulter tracing.
• Treat childhood pneumonia and diarrhoea through CB-IMNCI — distribute ORS and zinc, and refer severe cases.
• Distribute Vitamin A capsules and albendazole (deworming tablets) twice a year.
• Counsel on growth monitoring and nutrition, including Poshan (MCHN) counselling.

3. Family planning and reproductive health

• Provide information and refer for contraceptives; distribute oral pills and condoms in some districts.
• Counsel on birth spacing, safe abortion services, and adolescent health.

4. Disease prevention and health promotion

• Active case finding and referral for tuberculosis, leprosy, and leprosy-related disability.
• Promote hygiene, safe drinking water, and sanitation (ODF campaigns).
• Support COVID-19 and other outbreak responses — awareness, tracing, and vaccination mobilization.
• Distribute iron tablets to adolescent girls and pregnant women.

5. Linkage and referral

• Act as a bridge between the community and health facilities (HP, PHCC, hospital).
• Accompany and refer high-risk cases; follow up after discharge.

Role of Mothers' Groups

• Provide a platform for women's participation in health planning and decision-making.
• Conduct monthly health education sessions on maternal, child, and reproductive health.
• Run micro-credit and savings schemes that reduce financial barriers to seeking care.
• Support FCHV in immunization, weighing, and nutrition campaigns.
• Mobilize the community for health facility management committees, birth preparedness, and referral funds.
• Reduce harmful practices such as Chhaupadi, early marriage, and home delivery by untrained attendants.

Contribution to Health Indicators

These gains are directly linked to FCHV-led counselling, referral, and community mobilization, supported by Mothers' Groups.

Challenges

• Heavy workload with no regular salary (only small incentives).
• Limited refresher training and supply of commodities.
• Geographic difficulty in hill and mountain districts.
• Cultural barriers and gender discrimination in some communities.
• Weak supervision and monitoring, and high dropout of volunteers.

Conclusion

FCHVs and Mothers' Groups have played a decisive role in improving Nepal's health indicators by bringing basic health services, information, and referral to the doorstep of rural families. To sustain and further improve these gains, the government should provide regular training, adequate incentives, reliable supply of commodities, and strong supervision, and formally recognize their contribution within the national health system.

IMNCI (Integrated Management of Neonatal and Childhood Illness) Programme, Nepal

Goal

• To reduce neonatal, infant and under-five morbidity and mortality, and contribute to the SDG targets (neonatal mortality at most 12 and under-five mortality at most 20 per 1000 live births by 2030).

Objectives

• Integrate case management of the major childhood killers (pneumonia, diarrhoea, malaria, measles, malnutrition) and newborn problems into one approach.
• Improve skills of health workers in assessment, classification, treatment, counselling and follow-up.
• Improve referral, home care and care-seeking by families.
• Promote rational use of drugs.

Strategies

• Adaptation of the WHO/UNICEF IMNCI guidelines to Nepal.
• Training of health workers at health posts and PHCCs, and of FCHVs (community-based IMNCI, CB-IMNCI).
• Counselling of mothers and caregivers on feeding, danger signs and follow-up.
• Ensuring supply of essential drugs and logistics (cotrimoxazole/amoxicillin, ORS, zinc, vitamin A).
• Supportive supervision, monitoring and integration with EPI and nutrition programmes.

Targets

• Train all first-level health workers and FCHVs, and cover all districts with IMNCI/CB-IMNCI services.
• Ensure sick children are managed according to the IMNCI protocol, and reach the SDG mortality targets.

Achievements

• Started in Nepal in 1997-98 and expanded to all 75 districts; CB-IMNCI implemented nationwide through FCHVs.
• Large numbers of health workers and FCHVs trained.
• Under-five mortality fell from about 118 per 1000 (1990) to about 33 per 1000, and neonatal mortality fell substantially, with better treatment of pneumonia and diarrhoea.

Simple Physical Examination

Simple physical examination (also called general physical examination) is the quick, overall assessment of a patient using the examiner's senses — inspection, palpation, percussion and auscultation — without using special instruments or laboratory tests. It is done first, before any system-wise (systemic) examination, and gives a general impression of the patient's health.

Steps/components:

1. General appearance and consciousness — look at whether the patient is alert, drowsy or unconscious; note build, nutrition and posture.
2. Vital signs — temperature, pulse, respiration rate, blood pressure.
3. Inspection of the whole body — skin colour (pallor, cyanosis, jaundice), rash, oedema, dehydration, eyes (conjunctiva, pupils), tongue and mouth.
4. Anthropometry — height, weight, BMI, and in children, head and chest circumference.
5. Lymph nodes and thyroid — palpate neck and axilla for enlargement.
6. Brief systemic screening — anaemia, clubbing, koilonychia, finger clubbing, and gait.

Purpose: to detect obvious abnormalities, decide the general condition of the patient, and identify which body system needs detailed (systemic) examination.

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Systemic Examination

Systemic examination is the detailed, system-by-system examination of the body carried out after the simple physical examination. Each major system is examined separately in a fixed order, using inspection, palpation, percussion and auscultation, to find the exact site and nature of the disease.

Main systems examined:

1. Cardiovascular system — pulse, BP, heart sounds, murmurs, jugular venous pressure, oedema.
2. Respiratory system — chest shape, respiratory movements, percussion note, breath sounds, crepitations, wheeze.
3. Gastrointestinal system — abdomen inspection, palpation for organomegaly, tenderness, bowel sounds, liver and spleen.
4. Nervous system — consciousness, orientation, cranial nerves, motor and sensory function, reflexes, gait.
5. Musculoskeletal system — joints, bones, range of motion, deformity, swelling.
6. Genitourinary system — kidney tenderness, bladder distension, external genitalia.
7. Special senses and others — eyes, ears, nose, throat, and endocrine (thyroid) examination.

Purpose: to confirm or exclude disease in a particular system, determine severity, and plan further investigations and treatment.

Difference in brief: Simple physical examination is a quick, general, whole-body screening done first; systemic examination is a detailed, organised, system-wise examination done afterwards.

Emergency management of a closed fracture of radius (5 marks)

1. Assess and immobilise (first aid)

• Check airway, breathing, circulation; look for other injuries.
• Assess the limb: pain, swelling, deformity, loss of function, distal pulse (radial), capillary refill, sensation and finger movement.
• Do not attempt to straighten the bone. Immobilise in the position found.
• Apply a splint (wooden/plastic/rolled newspaper) from the elbow to the wrist, or a sling/arm pouch; support the arm across the chest.
• Apply cold pack over the swelling; keep the patient nil by mouth.

2. Analgesia and wound care

• Give analgesia (e.g. paracetamol/ibuprofen; stronger analgesic if available) for pain.
• If there is an open wound, cover with sterile dressing — but this is a closed fracture, so skin is intact; only clean the surface.
• Check and re-check distal neurovascular status after splinting.

3. Transport

• Shift the patient to the nearest health facility/hospital without delay, with the limb immobilised and elevated.
• Monitor pulse, sensation and finger movement during transport.

4. Hospital/definitive management

• X-ray (AP and lateral) of forearm to confirm site and type of fracture.
• Closed reduction under local/regional/general anaesthesia, followed by plaster of Paris (below-elbow or above-elbow cast) or splint.
• If reduction is unstable or fails, internal fixation (K-wire/plate and screws) is done.
• Prescribe analgesics and antibiotics if indicated; advise elevation and finger exercises.

5. Follow-up and counselling

• Review after 1 week, then at 2–3 week intervals; repeat X-ray to check position and union.
• Advise: keep the cast dry, do not scratch inside, move fingers, report immediately if pain increases, fingers become cold/blue or numb (signs of compartment syndrome/nerve compression).
• Remove cast after clinical and radiological union (usually 4–6 weeks in adults, less in children).

Common skin diseases (1 mark)

The skin diseases commonly seen in Nepal, especially in school-going children, are:

1. Scabies (caused by Sarcoptes scabiei mite) — intense itching, worse at night, with papules and burrows between fingers, wrists and waist.
2. Ringworm / Tinea (dermatophytes) — circular, itchy, scaly patches with a clear centre and raised red margin on the scalp, body or feet (tinea capitis, corporis, pedis).
3. Impetigo (Staphylococcus aureus / Streptococcus) — honey-coloured crusted sores around the nose and mouth.
4. Fungal infections of the skin folds (candidiasis) — red, moist, itchy patches in the groin, axilla and neck.
5. Eczema / atopic dermatitis — dry, itchy, inflamed skin.
6. Acne vulgaris — pimples on the face and back in adolescents.
7. Leprosy — pale, anaesthetic patches with loss of sensation.
8. Viral infections — warts, molluscum contagiosum, chickenpox, herpes.
9. Pediculosis (head lice) and scabies spread rapidly in schools.
10. Contact dermatitis and urticaria from irritants and allergens.

Prevention and control in school-going children (2 marks)

1. Personal hygiene: daily bathing with soap and clean water; regular hand washing with soap before eating and after using the toilet; keeping nails short and clean.
2. Clean clothing and bedding: wash clothes, towels and bedsheets frequently in hot water and dry them in sunlight; do not share combs, towels, clothes or caps.
3. Environmental cleanliness: clean classrooms, floors and toilets; ensure proper ventilation and sunlight; keep the school compound free of stagnant water and garbage.
4. Early detection and treatment: regular health check-ups and screening in schools; isolate and treat affected children; treat the whole family for scabies to prevent re-infection.
5. Health education: teach children about hygiene, mode of spread and the importance of completing treatment; involve teachers and parents.
6. Nutrition and immunity: balanced diet and vitamin A supplementation to keep the skin healthy.
7. Avoid contact: avoid sharing beds and close physical contact with infected children until treated.
8. Reporting: inform the health post/FCHV about outbreaks so that mass treatment can be arranged.

Difference between sterilization and disinfection (2 marks)

Note: Sterilization is a higher level of decontamination than disinfection; disinfection does not guarantee freedom from spores.

Dental Caries and its Management in a Health Post

Definition (2 marks)

Dental caries (also called tooth decay or dental cavity) is a chronic, progressive, multifactorial, infectious disease of the hard tissues of the tooth (enamel, dentine and cementum) characterised by demineralisation of the inorganic portion and destruction of the organic portion of the tooth, caused mainly by acids produced by cariogenic bacteria acting on fermentable carbohydrates in the presence of susceptible teeth and saliva over time.

In simple terms: it is the progressive destruction of tooth structure by acids produced by bacteria from dietary sugars, resulting in a cavity (hole) in the tooth.

Management in a health post (3 marks)

1. History and clinical examination Take history of pain, sensitivity to hot/cold/sweet, duration and swelling. Examine the tooth for discolouration, cavity, tenderness on percussion and mobility. Check for swelling of the face/gum, lymphadenopathy and fever to rule out complications.

2. Preventive and promotive measures (primary prevention)

• Advise brushing twice daily with fluoride toothpaste, using a soft brush and correct technique.
• Reduce intake of sugar, sweets, sticky foods and frequent snacking; encourage fibrous fruits and vegetables.
• Give fluoride application (fluoride varnish/gel) where available.
• Pit and fissure sealing of newly erupted permanent molars if the facility exists.
• Health education on oral hygiene, especially to school children, mothers and pregnant women.
• Advise routine dental check-up every six months.

3. Dental caries treatment (as per severity)

• Early (incipient) caries: fluoride application, dietary advice and follow-up.
• Cavitated caries: refer to a dental clinic/dental surgeon for filling (restoration) with GIC or composite.
• Deep caries with pulp involvement: refer for pulp therapy (pulpectomy/root canal treatment).
• Non-restorable tooth: refer for extraction.

4. Management of pain and infection

• Give analgesics (paracetamol/ibuprofen) for pain.
• If infection is present (abscess, cellulitis), give antibiotics (amoxicillin, or metronidazole if needed) and refer urgently.
• Warm saline rinses; drainage of abscess only if trained and equipped.

5. Referral Refer to the nearest primary health centre, district hospital or dental clinic when the case is beyond the scope of the health post (restoration, extraction, orthodontic or surgical needs).

6. Follow-up and record keeping Maintain the patient's record, follow up after treatment, and continue oral health education to prevent recurrence.

Conclusion In a health post, dental caries is managed mainly by prevention, early detection, symptomatic treatment of pain/infection and timely referral to a dental facility for definitive treatment.

Medical methods of abortion (medical abortion / medication abortion) means terminating a pregnancy by using medicines (drugs) instead of surgery. The medicines cause the embryo/foetus to be expelled from the uterus. It is a non-surgical, safe method when used correctly, up to 9 weeks (63 days) of pregnancy as per the Nepal safe abortion protocol.

How I will provide it in my health post:

1. Confirm pregnancy and duration — Take history, do urine pregnancy test (UPT) and, if available, ultrasound to confirm intrauterine pregnancy and gestational age (must be within 9 weeks/63 days).

2. Rule out contraindications — Check for ectopic pregnancy, severe anaemia, bleeding disorder, allergy to the drugs, IUD in place (remove first), and chronic illness. Exclude if pregnancy is beyond 9 weeks or if the woman has any danger sign.

3. Counsel the woman — Explain the method, its effectiveness, side effects (bleeding, cramping, nausea), danger signs (heavy bleeding, fever, foul discharge), the need for a follow-up visit, and the option of contraception. Take informed consent.

4. Provide the medicines (as per national protocol):

   • Mifepristone 200 mg orally on Day 1.
   • Misoprostol 800 mcg (buccal/sublingual or vaginal) after 24–48 hours, i.e., on Day 2 or Day 3.
   • If mifepristone is not available, use Misoprostol 800 mcg alone, repeated as per protocol.

5. Give follow-up and support — Ask her to return after 1–2 weeks for check-up (bleeding, UPT, or ultrasound) to confirm complete abortion. Provide contraceptives (pills, condoms, injectables, IUCD) if she wants. Refer immediately to a higher centre if there is heavy bleeding, severe pain, fever, or incomplete abortion.

6. Maintain records — Register the case, medicines given, and follow-up in the health post record as per HMIS/ Safe Abortion Service guidelines.

Undernutrition in Children in Nepal

1. Status (Magnitude of the Problem)

Undernutrition remains a major public health problem in Nepal, although it has improved over the last two decades.

• According to the Nepal Demographic and Health Survey (NDHS) 2022, among children under 5 years:
  • Stunting (height-for-age < −2 SD): about 25%
  • Wasting (weight-for-height < −2 SD): about 8%
  • Underweight (weight-for-age < −2 SD): about 19%
• Nepal has met the Millennium Development Goal target for underweight but is still off-track for the SDG target of reducing stunting to below 15% by 2030.
• Prevalence is higher in rural areas, the Terai and Karnali Province, among children of illiterate mothers, and in the lowest wealth quintile.
• Undernutrition contributes to about one-third of under-5 deaths in Nepal, mainly through increased susceptibility to pneumonia, diarrhoea and other infections.

2. Causes

A. Immediate causes

• Inadequate dietary intake (low quantity and poor quality of food, lack of exclusive breastfeeding, early or delayed complementary feeding)
• Repeated infections — diarrhoea, pneumonia, measles, intestinal worms, HIV, tuberculosis

B. Underlying causes (household/family level)

• Food insecurity and poverty
• Poor maternal health and nutrition (low birth weight, short maternal stature)
• Inadequate care practices — poor breastfeeding, late weaning, no supplementary feeding
• Poor hygiene and sanitation — open defecation, unsafe drinking water
• Large family size and closely spaced births
• Lack of health services, immunization and health education

C. Basic causes (societal level)

• Poverty, illiteracy, gender discrimination, social inequality and marginalization
• Weak health system, poor access to quality health care in remote areas
• Natural disasters, conflict and climate change affecting food production

3. Signs and Symptoms

General

• Failure to gain weight and height as expected (growth faltering)
• Weight and height below normal for age (underweight, stunting, wasting)
• Loss of subcutaneous fat, muscle wasting, prominent ribs and bones
• Sunken eyes, loose wrinkled skin, sparse thin hair
• Pale conjunctiva and palms (anaemia)
• Weakness, lethargy, irritability, poor concentration
• Delayed milestones, poor school performance
• Frequent infections, delayed wound healing

Specific deficiency diseases

• Marasmus: severe wasting, weight < 70% of expected, no oedema, "skin and bones" appearance, old man's face
• Kwashiorkor: oedema of feet and face, moon face, fatty liver, flaky paint dermatosis, hair changes, apathy, anorexia
• Marasmic-kwashiorkor: features of both
• Vitamin A deficiency: night blindness, Bitot's spots, xerophthalmia, keratomalacia
• Iron deficiency: anaemia, spoon nails
• Iodine deficiency: goitre, cretinism
• Vitamin D deficiency: rickets — bow legs, knock knees, delayed fontanelle closure
• Vitamin C deficiency: scurvy — bleeding gums, swollen joints

4. Management

A. Assessment

• History, dietary history, breastfeeding history
• Weight, height/length, mid-upper arm circumference (MUAC)
• Weight-for-age, height-for-age, weight-for-height (WHO growth standards)
• Look for oedema, anaemia, eye signs, infections
• Classify as mild/moderate or severe acute malnutrition (SAM)

B. General management

• Treat the underlying cause — infection, worms, tuberculosis, etc.
• Treat dehydration, hypoglycaemia, hypothermia, anaemia and infections
• Correct electrolyte imbalance
• Immunization as per national schedule
• Vitamin A supplementation, iron and folic acid, zinc, iodine
• Deworming (albendazole)

C. Nutritional management

• Mild/moderate: nutrition counselling, supplementary feeding, growth monitoring, follow-up
• Severe acute malnutrition (SAM):
  • F-75 (stabilisation phase) — low energy, low protein formula
  • F-100 / RUTF (Ready-to-Use Therapeutic Food) — rehabilitation phase
  • CMAM (Community-based Management of Acute Malnutrition) — OTC (Outpatient Therapeutic Care), NRC (Nutrition Rehabilitation Centre) for complicated cases
• Promote exclusive breastfeeding for 6 months, complementary feeding from 6 months with continued breastfeeding up to 2 years
• IYCF (Infant and Young Child Feeding) counselling

D. Preventive and community measures

• Growth monitoring and promotion (weighing at monthly health days)
• Food security and livelihood support
• Safe water, sanitation and hygiene (WASH)
• Female education and women's empowerment
• Multi-sectoral Nutrition Plan (MSNP) implementation
• Poshan programmes, FCHV home visits and health education

Conclusion

Undernutrition in Nepali children is still a public health problem with a multifactorial origin. Early detection through growth monitoring, prompt treatment of infections, appropriate feeding practices and multi-sectoral action through the MSNP are essential to reduce its burden and achieve the SDG target.

Ectopic Pregnancy — Causes, Signs and Symptoms, and Management at the Health Post Level

Introduction

An ectopic pregnancy is a pregnancy in which the fertilised ovum implants and develops outside the normal uterine cavity. In about 95–98% of cases it occurs in the fallopian tube (tubal pregnancy); other rare sites are the ovary, cervix, and abdominal cavity. It is a common and life-threatening obstetric emergency in the health post setting, and if it ruptures it can cause fatal intra-abdominal bleeding. Hence every health worker must be able to recognise it early and refer promptly.

Causes / Risk Factors

1. Tubal factors (most important):
   • Pelvic inflammatory disease (PID) and sexually transmitted infections, especially chlamydia and gonorrhoea, causing adhesions and damage to the cilia of the tube.
   • Previous pelvic or tubal surgery, e.g. tubal ligation, tubal recanalisation, salpingectomy.
   • Previous ectopic pregnancy (recurrence risk about 10–15%).
   • Congenital tubal abnormalities, diverticula, or adhesions from previous infection.
2. Assisted reproduction: In-vitro fertilisation (IVF) and other embryo transfer procedures.
3. Intrauterine contraceptive device (IUCD) in situ: Though it prevents intrauterine pregnancy, if pregnancy occurs it is more likely to be ectopic.
4. Hormonal factors: Use of emergency contraceptive pills, progestogen-only pills, and fertility drugs (clomiphene citrate) may delay ovum transport.
5. Smoking and increasing age of the mother (over 35 years).
6. Previous caesarean section or uterine surgery and endometriosis.
7. Tubal sterilization failure — pregnancy after tubal ligation is often ectopic.

Signs and Symptoms

Classical triad: amenorrhoea, abdominal pain, and vaginal bleeding.

A. Symptoms

• Amenorrhoea of 6–8 weeks (missed period).
• Sudden, severe, unilateral lower abdominal pain, often colicky, radiating to the shoulder tip (due to diaphragmatic irritation by blood).
• Vaginal bleeding — scanty, dark brown, "prune juice" like, irregular.
• Dizziness, fainting, weakness, and a sense of rectal pressure (bearing-down sensation).
• Nausea, vomiting, and breast tenderness (early pregnancy symptoms).

B. Signs

• General: Pallor, cold clammy skin, restlessness, tachycardia, hypotension, and shock in ruptured cases.
• Abdominal examination: Tenderness and guarding, rebound tenderness, distension, and shifting dullness (free fluid/blood).
• Pelvic examination: Cervical motion tenderness, adnexal mass or fullness, boggy and tender posterior fornix (blood in pouch of Douglas), and slightly enlarged uterus.
• Vital signs: Falling blood pressure and rising pulse indicate rupture with haemorrhage.

Management at the Health Post

A. Assessment and Immediate Steps

1. Take a quick history (LMP, pain, bleeding, previous ectopic/PID/surgery) and record vital signs.
2. Do a urine pregnancy test (UPT) if available; a positive UPT with pain and bleeding strongly suggests ectopic pregnancy.
3. Assess for signs of shock (pulse > 100/min, BP < 90/60 mmHg, pallor, cold sweat).
4. Keep the patient nil by mouth and in a supine position with legs elevated.

B. Emergency First Aid

• Secure two large-bore IV lines and start Ringer's lactate or normal saline rapidly.
• Give oxygen if available and keep the patient warm.
• Monitor pulse, blood pressure, and consciousness every 15 minutes.
• Do not give anything orally, including analgesics that may mask signs.
• Arrange immediate transport to a higher centre (district/zonal hospital) with surgical facilities; accompany the patient if possible.

C. Definitive Treatment (at hospital level)

• Surgical: Laparotomy or laparoscopy with salpingectomy (removal of the affected tube) or salpingostomy in selected cases; control of bleeding.
• Medical: Methotrexate therapy in early, unruptured, haemodynamically stable cases with low hCG levels.
• Supportive: Blood transfusion for severe anaemia, antibiotics, and analgesia after diagnosis.

D. Follow-up and Counselling

• Advise the woman to return for follow-up hCG testing and ultrasound as advised.
• Counsel on the risk of recurrence in future pregnancies and the need for early antenatal check-up.
• Advise treatment of PID and STIs, and avoidance of smoking.
• Provide information on family planning methods and safe motherhood practices.

Conclusion

Ectopic pregnancy is a life-threatening emergency that can be suspected at the health post by the triad of amenorrhoea, abdominal pain, and vaginal bleeding with a positive urine pregnancy test. Since definitive treatment requires surgery or methotrexate, the health worker's main role is early recognition, resuscitation for shock, and immediate referral to a hospital with surgical facilities. Timely referral saves the mother's life.