The Cold Chain System

What is it?

The "cold chain" is a system of storage and transport of vaccines at low temperatures from the manufacturer to the actual vaccination site. 

What is the need?

The cold chain system is necessary because 

• Vaccine failure may occur due to failure to store and 
• Transport under strict temperature controls 

This is of concern because of the fairly frequent reports of vaccine-preventable disease occurrence in populations thought to have been well immunized. 

The success of a national immunization program is highly dependent on a supply chain system for the delivery of vaccines and equipment, with a functional system that meets 

6 rights of the supply chain - 

1. The right vaccine
2. In the right quantity 
3. At the right place 
4. At the right time 
5. In the right conditions (no temperature breaks in the cold chain) and 
6. At the right cost

Temperature requirements for vaccines:

• Vaccines are sensitive biological products. Some vaccines are sensitive to freezing, some to heat, and others to light.  
• Vaccine potency, meaning its ability to adequately protect the vaccinated patient, can diminish when the vaccine is exposed to inappropriate temperatures. 
• Once lost, vaccine potency cannot be regained. 
• To maintain quality, vaccines must be protected from temperature extremes. Vaccine quality is maintained using a cold chain that meets specific temperature requirements. 
• All those who handle vaccines and diluents must know the temperature sensitivities and the recommended storage temperature for all the vaccines in the national schedule.

Sensitivity to heat and freezing:

The vaccines are grouped into six categories. 

• Within each of these six categories, the vaccines are arranged in alphabetical order, not in order of sensitivity to heat, within the group. 
• The most heat-sensitive vaccines are in group A and the least heat-sensitive vaccines are in group F. 
• The heat stability information shown for freeze-dried vaccines applies only to unopened vials; 
• Most freeze-dried vaccines rapidly lose potency after reconstitution. 

It is important to keep opened multi-dose vaccine vials (that do not contain preservatives - whether lyophilized or liquid) - cooled at a temperature between +2°C and +8°C during the immunization session, or used within 4 hours after opening, whichever comes first. 

Vaccines that are sensitive to freezing and should be protected from sub-zero temperature are: - 

1. Cholera 
2. DTaP-hepatitis B-Hib-lPV (hexavalent) 
3. DTwP or DTwP-hepatitis B-Hib (pentavalent)
4. Hepatitis B (Hep B) 
5. Hib (liquid) 
6. Human papillomavirus (HPV) 
7. Inactivated poliovirus (IPV) 
8. Influenza 
9. Pneumococcal 
10. Tetanus, OT, Td 
11. Rotavirus (liquid and freeze-dried) 

Sensitivity to light:

Some vaccines are very sensitive to light and lose potency when exposed to it. Such vaccines should always be protected against sunlight and strong artificial light. 

Vaccines sensitive to light are:

1. BCG, 
2. Measles, 
3. Measles-rubella, 
4. Measles-mumps-rubella, and 
5. Rubella. 

These vaccines are supplied in dark glass vials that give them some protection, but they should be kept in their secondary packaging for as long as possible during storage and transportation. 

At the health facility level (usually health centers and health posts), health workers can adequately protect vaccines by doing the following : 

1. Keep vaccines in appropriate vaccine refrigeration equipment; 
2. Use a temperature monitoring device to ensure temperatures remain between +2°C and +8°C; 
3. Transport vaccines to immunization sessions in a vaccine carrier, correctly packed, using coolant packs that have been properly prepared; and 
4.  During immunization sessions, fit a foam pad (if available) at the top of the vaccine carrier. 

At the health facility, one person must have overall responsibility for managing the vaccine cold chain. A second person can fill in when the primary person is absent. Their responsibilities should include : 

1. Checking and recording vaccine temperatures twice daily; typically in the morning and at the end of the session or day; 
2. Properly storing vaccines, diluents, and water packs; and 
3. Handling preventive maintenance of cold chain equipment. 

All health workers in a facility should know how to monitor the cold chain and what to do if the temperature is out of range. 

Electrical Cold Chain Equipment:

There is equipment of different capacities for the storage of vaccines at different levels, which are dependent on an electric supply to maintain the recommended temperature.

 

1. Walk-in-freezers {WIF):  

The Walk-in-freezer is a pre-fabricated modular polyurethane foam (PUF) insulated panel assembled cold room with two identical refrigeration units and a standby generator set to provide an uninterrupted power supply. 

• The generator set starts automatically as soon as the power cuts off. 
• It maintains a temperature between - 15°C to - 25°C. 
• WIF is usually installed at national, state, and regional vaccine stores. 
• It is used for bulk storage of OPV vaccine and for preparation of frozen ice packs for vaccine transportation. 

 2. Walk-in-coolers {WIC):  

The walk-in cooler is a pre-fabricated modular polyurethane (PUF) insulated panel assembled cold room. 

• They maintain a temperature of +2°C to +8°C.
• In India, under UIP usually WIC with capacities of 16.5, 32 and 40 Cubic meters are in use. 
• These are used for the storage of large quantities of all UIP vaccines like BCG, hepatitis B, DPT, pentavalent, IPV, measles, and TT. 
• They have two identical cooling units and a standby generator with automatic start and stop functions. 
• These Walk-in-coolers are installed at government medical store depots, and state, and regional vaccine stores. 
• The WICs have been installed in some district vaccine stores based on the target beneficiary and requirement. 

 WIC and WIF come with a continuous temperature recorder and alarm system. Once the temperature of WIC/ WIF exceeds the recommended storage temperature the alarm system gives an alarm loudly. 

3. Deep freezer (DF):

The Deep freezer is equipment, which operates on a vapor compression system similar to any conventional type of refrigerator operating on 220 volts A.C. mains supply. 

• However, DF has a top opening lid to prevent loss of cold air during door opening. The cabinet temperature is maintained between -15° to - 25°C. 
• This is used for storing OPV vaccine for 3 months (district level and above only) and also for freezing ice packs (at sub-district level only). 
• Unlike the ice-lined refrigerator (ILR), the DF has little or limited hold-over time which is dependent on the number of frozen ice packs in it and the frequency of opening. 
• These are available in different sizes. 
• The DF which is used for storing vaccines should not be used for the preparation of icepacks, as it may increase the cabinet temperature and can be potentially harmful to the vaccines (OPV). 

However adequate frozen icepacks can be kept permanently inside the vaccine storing DF for increasing the hold-over time.

4. lce lined refrigerator {/LR):  

One of the most important links in the cold chain is ice ice-lined refrigerator (!LR). 

This is equipment that operates on a vapor compression system similar to any conventional type of refrigerator operating on 220 volts A.C. mains supply. 

• ILRs are to maintain a cabinet temperature between +2°C to + 8°C and are used to store vaccines at district and sub-district levels. 
• These types of refrigerators are top openings because they can hold the cold air inside better than a refrigerator with a front opening. 
• It can keep vaccines safe with a minimum of 8 hours of continuous electricity supply in 24 hours. 
• The ILRs are categorized based on vaccine storage capacity. 
• These are available in different sizes. Usually, the larger ILR is supplied to district headquarters and the smaller ILR to PHC headquarters, based on the size and population. 
•  Inside the ILR there is a lining of water containers (ice packs or tubes) fitted all around the walls and held in place by a frame. 
•  When the refrigerator is functioning the water in the containers freezes and cools the cabinet. 
• When the electricity supply fails, the ice lining maintains the inside temperature of the refrigerator at a safe level for vaccines. 
• Therefore, the temperature is maintained in ILR for a much longer duration than in deep freezers and domestic refrigerators. 
• Thus ILR is an ideal option for safe storage of vaccines. 
•  Based on the temperature zone, the inside of the ILR can be divided into 2 parts, the upper part, and the lower part. 
• In most of the ILR models, the lower part is cooler compared to the upper part, as the cooler air is heavier and settles down at the bottom of ILR. 
• Hence upper part is the preferred location for storing the freeze-sensitive vaccines. 

Where to keep the vaccines:

All the vaccines should be kept in the basket provided with the ILR. 

• Vaccines like OPV, BCG, measles, and JE (in the sub-district stores, OPV is kept in ILR, unlike higher-level vaccine stores, where it is kept in DF) can be kept at the bottom of the basket 
• while DPT, TT, hep B, IPV, and pentavalent vaccines and diluents are kept in the upper part of the basket. 
• These vaccines should never be kept directly on the floor of the refrigerator as they can freeze and get damaged. 
• In case a basket is not available, two layers of empty ice packs can be laid flat on the bottom of the ILR. 

Hold-over time of the equipment: 

In the event of power failure, hold-over time is defined as 

•  "the time taken by the equipment to raise the inside cabinet temperature from its temperature at the time of power cut, to the maximum temperature limit of its recommended range." 
• For example, in the case of ILR if the cabinet temperature is +4°C at the time of power-cut, then the time taken to reach +8°C from +4°C will be hold-over time for that ILR. 
• Hold-over time depends on the following factors : 

1.  Ambient temperature: More the ambient temperature less the hold-over time; 
2. Frequency of opening of the lid and use of basket; 
3. Quantity of vaccines kept inside with adequate space between the containers (Equipment empty/ loaded); and 
4. Condition of the ice-pack lining (Frozen/ partially frozen/melted)

5. Domestic refrigerator (front load refrigerator):

Domestic refrigerators can also maintain the cabinet temperature between +2°C to +8°C, but the hold-over time and capacity to store vaccines/freeze icepacks is limited. 

They can be used for storage of vaccines at private clinics and nursing homes, provided continuous power supply is ensured. Load a domestic refrigerator as follows: 

1. Freeze and store ice packs in the freezer compartment, they should be kept vertically to avoid leaking with a space of at least 2 mm. Ice packs should be taken out from the left; 
2. All the vaccines and diluents should be stored in the refrigerator compartment. 
3. Arrange the boxes of vaccines in stacks so air can pass between them. 
4. Placement of vaccines in the refrigerator with freezer on top is as follows:

• measles, BCG, rotavirus vaccine, and OPV on the top shelf. 
• DPT, pentavalent vaccine, TT, IPV, hepatitis B, and JE vaccine on the middle shelf, and diluents next to the vaccine with which they are supplied; 
• Keep ice packs filled with water on the bottom shelf and at the door of the refrigerator. 
• They help to maintain the temperature in case of power-cut, and 
• Closer expiry date vaccines should be kept in front. 
•  A dial thermometer should be kept in the ILR and temperature recorded twice a day. 
• At the time of defrosting the vaccines are shifted to the cold boxes containing the required number of frozen ice packs. 
• In case of equipment failure or electric supply failure, vaccines should be transferred to ice boxes and then to alternate vaccine storage. 

DOs and DONTs for the use of ILR/ freezer. 

D0s: 

1. Keep the equipment in a cool room away from direct sunlight and at least 10 cm away from the wall; 
2. Keep the equipment leveled; 
3. fix the equipment through a voltage stabilizer; 
4. keep vaccines neatly with space between the stacks for circulation of air; 
5. Keep the equipment locked and open only when necessary; 
6. defrost periodically, supervise the temperature record; and 
7. If vaccines are kept in cartons, make holes on the sides of the cartons for cold air circulation. 

DONTs: 

1. do not keep any object on these equipments; 
2. Do not store any other drug; 
3. Do not keep drinking water or food in them; 
4. Do not keep more than one month's requirements at the PHC level, and 
5. Do not keep date expired vaccines. 

Reconstituted BCG, Rotavirus vaccine,  and measles vaccines can be kept at +2°C to +8°C for a maximum of 4 hours and JE vaccine for 2 hours. 

To be on the safe side, write the time of reconstitution on the label of these vaccine vials and discard them after 4 hours (2 hours for JE vaccine). 

Do not keep any used vials in the cold chain. 

Return the unused vaccine vials from the session site to the PHC on the same day in the cold chain through alternative vaccine delivery. 

Keep the box labeled "returned unused" in the ILR for all unused vaccines that can be used in the subsequent session, but discard vaccines that have been returned unopened more than three times.

6. Cold boxes:

Cold boxes are supplied to all peripheral centers. 

• These are used mainly for transportation of the vaccines. 
• Before the vaccines are placed in the cold boxes, fully frozen ice packs are placed at the bottom and sides. 
• The vaccines are first kept in cartons or polythene bags. 
• The vials of DPT, OT, TT, vaccines, and diluents should not be placed in direct contact with the frozen ice packs. 

7. Vaccine carriers: 

 

• Vaccine carriers carry small quantities of vaccines ( 16-20 vials) for the out-of-reach sessions.
•  4 fully frozen ice packs are used for lining the sides, and vials of DPT, OT, TT, and diluents should not be placed in direct contact with frozen ice packs. 
• The carriers should be closed tightly. 

 8 . Day carriers:  

Day carriers carry small quantities of vaccines (6-8 vials) to a nearby session. 

• Two fully frozen packs are to be used. 
• It is used only for a few hours. 9. Ice packs 
• The ice packs contain water and no salt should be added to it. 
• The water should be filled up to the level marked on the side. 
• If there is any leakage such ice-packs should be discarded. 
• The risk of cold chain failure is greatest at the sub-center and village level. 
• For this reason, vaccines are not stored at the sub-center level and must be supplied on the day of use.

Solar cold chain equipment:

Solar systems used in UIP are mainly of two types. 

1. Solar refrigerator battery drive. 

2. Solar refrigerators direct drive. 

1. Solar refrigerator battery drive:

A solar refrigerator operates on the same principle as a normal compression refrigerator but incorporates low voltage (12 or 24V) DC compressors in place of mains AC voltage-operated compressors. 

• The battery is charged with solar energy. 
• A solar refrigerator has good PUF insulation around the storage compartments to maximize energy efficiency. 
• Battery, charge controller, and solar panels are the major additional components associated with solar refrigerators. 

Vaccine refrigerator/freezer: 

It is a refrigerator cum freezer having a basket for storing of vaccine and freezing of ice-packs. It has two separate compartments: 

 1. Vaccine storage compartment maintains a temperature range of + 2°C to + 8°C. 

 2. The Freezer compartment is for storing frozen ice packs maintaining temperatures up to -7°C.  

• For each refrigerator and freezer compartment, it has a separate DC compressor. The refrigerator is designed for continuous operation, therefore an ON/OFF switch is not provided, as it is not necessary. 
• The freezer, however, does have an ON/OFF switch to allow for defrosting. during the night and on cloudy days. 
• These refrigerators are wired directly to the photovoltaic generators. 

MBI KIT

Multibus Interface Kit (MBI Kit):

• It is a very essential and useful monitoring tool.
• It is also a very powerful tool for the advocacy of the Universel Salt iodisation (a mission to combat the lack of iodine in the daily diets of millions across the world). 
• Monitoring the iodine content at various points is the key to the success of this mission. 

Purpose:

The Field Test Kits allow Iodised salt manufacturers, quality controllers, health inspectors, social workers, NGO activists and even school children to assess the amount of iodine in iodised salt.

Field testing has become easier now how?

• The MBI KITs are coming in a handy pack that allows the user to carry them around during field visits. 
• These are inexpensive, completely user friendly and offer a simple method of monitoring iodine in salt at field level.

What does the kit contain?

The Field Test Kit consists of:

• 2-3 ampoules of 10ml each containing test solution.
• In some cases, 1 red ampoule containing a recheck solution.
• A detailed instruction sheet in the local language.
• A colour chart with circular colour spots.
• One small container.

all fitting into a handy pocket-size kit

How to use the kit?

• A few spoons of the salt for testing is filled a small cup and spread flat.
• The test solution ampoule is opened by piercing it with a pin and the test solution is dropped on the salt surface till the surface is flooded.
• The reaction liberates the iodine in the salt, and depending on the content of iodine, the solution changes the colour of the salt.
• The intensity of the colour varies with the amount of iodine and by matching it with the colour chart the range of iodine can be ascertained.
• In the absence of the colour formation, a few drops of the recheck solution is to be spread on the salt surface before using the test solution.

PPM level of iodine in salt:

Different ppm levels of iodine in salt are used in different regions. From 50 ppm iodine for Asian countries to 100 ppm iodine in African countries. Customised test kits are used to cover the diverse range.

Iodising agent-Iodate/Iodide

• Different types of test kits are used to cater to the different needs of countries. 
• Like using Potassium Iodide as an iodising agent in South American countries to using Potassium Iodate as an agent in Asian countries. 

PH level of salt:

Recheck solution that has been developed for the kit help in giving accurate results, irrespective of alkalinity levels in the salt that may be caused due to the addition of free-flow agents like light basic magnesium carbonate or even due to natural causes.

Language:

As these kits are used at all levels and cater to diverse linguistic regions, instructional manuals are povided in over 25 different languages that include: English, French, Spanish, Chinese, Burmese, Vietnamese, Thai and 10 regional languages in India.

Evaluation:

These test kits have been evaluated by the multi-centric study conducted by the All India Institute of Medical Sciences. 

The kits were distributed to eight different centres in India and over 6300 salt samples were tested on a blind basis.

The comparison between the results of the Iodometric Titration and the test kits were made, and there was an excellent agreement between the two.

The Sensitivity averaged at 89.8%.

The Specificity averaged at 65.6%.

The Positive Predictive Value averaged at 80.9%.

The Negative Predictive value averaged at 79.7%.

These points prove that the salt testing kits offer a good semi-quantitative estimation of iodine in salt.

References:

1. http://www.mbikits.com/the-mbi-kit/
2. https://supply.unicef.org/s0008193.html 

Disposable delivery kit

Disposable Delivery Kit: 

Basic Delivery Kit/ Disposable Delivery Kit (DDK) increases awareness and use of clean delivery practices. The kits are designed for use in the home by untrained and trained birth attendants (TBAs) and women delivering alone. Basic delivery kits contain supplies that are essential for supporting clean delivery practices and providing clean cord care immediately after birth. While DDKs are designed for use in the home, they can also be used in resource-poor medical facilities such as health posts or health centers.

Features:

• Portable in nature

• Compact design

• Easily Disposable

Contents of DDK:

• 1pcs disposable non Woven gown

• 1pair shoe cover non Woven

• 1 pcs disposable cap

• 1 pcs face mask

• 1 pair latex surgical gloves

• 1 pcs underpad (Under sheet)

• 1 pcs drape sheet (perineal sheet)

• 1 pcs mops

• 2 pcs cord clamp

• 1 pcs baby receiving sheet

• 1 pcs feeding tube

• 1 pcs sterile surgical blade

Principles of Clean Delivery:

According to WHO’s Six Principles of Cleanliness at Birth, 

• “The hands of the birth, the attendant must be washed with water and soap, as well as the perineum of the woman. 
• The surface on which the infant is delivered must be clean. Instruments for cutting the cord and cord care (razor blade, cutting surface, cord ties) should be clean. 
• Nothing should be applied either to the cutting surface or to the stump. The stump should be left uncovered to dry and to mummify.” 

The six principles of cleanliness include: 

1. Clean hands 
2. Clean perineum 
3. Nothing unclean introduced into the vagina 
4. Clean delivery surface
5. Clean cord-cutting instrument 
6. Clean cord care (including cord ties and cutting surface).

Why Are Delivery Kits Important?

• Promotion of clean delivery practices
• Reduction of maternal sepsis
• Reduction of neonatal tetanus, sepsis, and cord infection
• Reinforcement of maternal and newborn health programs and 
• Provision of a convenient source of clean supplies.

References:

1. https://path.azureedge.net/media/documents/MCHN_BDKG.pdf
2. https://www.indiamart.com/proddetail/disposable-delivery-kit-4461948112.html
3. https://www.indiamart.com/proddetail/disposable-delivery-kit-12878976588.html photo credit

Safe injection Practices

Safe injection practices prevent transmission of infectious diseases from one patient to another, or between a patient and health care personnel(HCP) during preparation and injection of medications. A safe injection 

• Does not harm the recipient (e.g. no abscess formation.)
• Does not expose HCP to any avoidable risks (e.g. needle stick injury)
• Does not harm the community (e.g. unsafe disposal of waste)

What are unsafe injection practices?

Unsafe injection practices are caused by avoidable risky situations and practices including: 

• Lack of awareness of the risks of unsafe injections. 
• Overuse of injections for illnesses for which effective oral medications exist. 
• Needle-stick injuries to health care workers from recapping needles. 
• Lack of clean workspaces. 
• Re-use of syringes because of shortages of syringes. 
• Unsafe sharps collection and waste management.

What are safe injection practices recommendations?

1. Prepare injections using an aseptic technique in a clean area.
2. Disinfect the rubber septum on a medication vial with alcohol before piercing.
3. Do not use needles or syringes for more than one patient (this includes manufactured prefilled syringes and other devices such as insulin pens).
4. Medication containers (single and multidose vials, ampules, and bags) are entered with a new needle and new syringe, even when withdrawing additional doses for the same patient.
5. Use single-dose vials for parenteral medications when possible.
6. Do not use single-dose (single-use) medication vials, ampules, and bags or bottles of intravenous solution for more than one patient.
7. Do not combine the leftover contents of single-use vials for later use.

The following apply if multidose vials are used:

• Dedicate multidose vials to a single patient whenever possible.
• If multidose vials will be used for more than one patient, they should be restricted to a centralized medication area and should not enter the immediate patient treatment area to prevent inadvertent contamination.
• If a multidose vial enters the immediate patient treatment area, it should be dedicated for single-patient use and discarded immediately after use.
• Date multidose vials when first opened and discard within 28 days, unless the manufacturer specifies a different date.
• Do not use a fluid infusion or administration sets (e.g., IV bags, tubings, connections) for more than one patient.

Injections should only be used:

• For serious and life-threatening illness where they are recommended by treatment guidelines. 
• When patients are unable to swallow. 
• When patients vomit profusely. 
• When there is no effective oral medication or the absorption process is significantly altered. 

References:

1. https://www.cdc.gov/oralhealth/infectioncontrol/faqs/safe-injection-practices.html
2. https://www.who.int/occupational_health/activities/1bestprac.pdf
3. https://www.who.int/infection-prevention/tools/injections/IS_HealthCareProviders_Leaflet.pdf
4. https://www.ncdc.gov.in/WriteReadData/l892s/Handbook%20on%20Safe%20Injection%20Practices.pdf
5. https://www.cdc.gov/injectionsafety/ip07_standardprecaution.html
6. https://vikaspedia.in/health/sanitation-and-hygiene/handbook-on-safe-injection-practices/techniques-of-safe-injections
7. https://www.cdc.gov/injectionsafety/PDF/Injection-Safety-Guidelines-P.pdf

Problem Based Learning: Anaemia

Anemia is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet the body’s physiological requirements, which vary by age, sex, altitude, smoking habits, and during pregnancy.

Here are some problems related to anemia:

1. Problem: 

A poor anemic woman of gravida 3, and in the 3rd trimester of pregnancy has attended PHC for the 1st time. Her Hb% is 7.5 gm/dl, weight is 50 kg. How will you manage?

1.Solution:

As we can see from the case history, the risk factors we can recognize are:

• Moderate anemia
• Poverty, lack of nutrition
• Multigravida
• Lack of health-seeking behavior
• Not taken antenatal care

Investigations for the cause of anemia:

• History
• Cause of blood loss if any
• Diet practices
• Lab investigations: Complete hemogram(CBC & ESR), Stool examination for hookworms & occult blood, Iron saturation (TIBC), Serum ferritin levels. 

Management:

• A pregnant mother should have a minimum of 11 gm/dl of hemoglobin.
• Here, the woman is having only 7.5 gm/dl of hemoglobin.
• Hence, anemia should be corrected immediately by parental iron therapy.

Treatment plan for moderate anemia in pregnancy:

Calculation of Iron requirement in mg:

= (Normal Hb%➖ Patient's Hb%) ✖ Weight in kg ✖ 2.21➕ 1000

= (11-7.5) ✖ 50 ✖ 2.21 ➕ 1000

= 3.5 ✖ 50 ✖ 2.21➕ 1000

= 386.75 ➕ 1000

= 1386.75 (to round up to 1400 mg)

Hence, iron requirement is 1400 mg.

Inferon (100 mg) is given IM daily for 15 days.

Oral treatment is continued for 3 months after Hb% has returned to normal.

Assessment of hemoglobin periodically.

Preventive measures: 

The woman is advised to 

• Take more iron rich foods: Green leafy vegetables, jaggery, etc.
• Attend supplementary nutrition programmes at Anganwadi (ICDS).
• Take antenatal care (ANC).
• Take Albendazole 400 mg.
• Health education regarding anemia & it's complications.
• Improvement of socioeconomic problems.
• Plan for institutional delivery.
• Plan for undergoing tubectomy.

2. Problem:

What are the anatomic sites to be examined for detecting pallor?

2. Solution:

• Lower palpebral conjunctiva
• Tongue and oral mucosa
• Nails
• Palms of hands

3. Problem:

What are the advices to be given to a recipient taking the IFA tablet?

3. Solution:

• The IFA tablet should be consumed after meals to avoid gastric discomfort and nausea.
• Black stools may be passed after consuming IFA tablets.
• One can experience loose stools or constipation for some time but this will settle after some days.
• Do not take the tablets with tea, coffee or milk as these may interfere with absorption of iron.
• Do not take Calcium tablets at the same time as calcium inhibits absorption of iron.
• Pregnant or lactating women must consume the tablets daily.

4. Problem:

What are the contraindications for IFA prophylaxis?

4. Solution:

Prophylaxis with iron should not be given in case of

• Acute illness (fever, acute diarrhea, pneumonia, etc.)
• Severe acute malnutrition (SAM)
• Known case of hemoglobinopathy
• History of repeated blood transfusion.

5. Problem:

What are the measures to prevent anaemia in children?

5. Solution:

Besides the supplementation, the following measures should be taken simultaneously as long-term measures to prevent IDA in children:

• Exclusive breastfeeding promotion for the first 6 months of life.
• Adequate & appropriate complementary feeding with iron-rich foods till 2 years of age.
• Different variety of foods rich in absorbable vitamins and minerals to be included. 
• To increase the bioavailability of iron in usual diets altering the meal patterns. 
• Diagnosis, treatment & prevention of parasitic infections.
• Screening of target groups for moderate/severe anaemia and referring these cases to an appropriate health facility.

6. Problem:

How will you manage mild & severe anemia in pregnancy at PHC?

6. Solution:

7. Problem:

What are the doses of IFA for different age groups for prophylaxis of anemia?

7. Solution:

8. Problem:

What are the doses of Albendazole for different age groups for deworming?

8. Solution:

9. Problem:

What are the foods which enhance the absorption of iron & inhibit iron absorption?

9. Solution:

Enhancers of  the iron absorption:

1. Haem iron: present in meat, poultry, fish, and seafood.
2. Ascorbic acid or vitamin C: present in fruits, juice, potatoes and some other tubers and other vegetables such as green leaves, cauliflower, and cabbage.
3. Fermented or germinated food.

Inhibitors of iron absorption:
1. Cereal bran, cereal grains, high-extraction flour, legumes, nuts, and seeds.
2. Tea, coffee, cocoa, herbal infusions in general, certain spices (e.g. oregano).
3. Calcium, particularly from milk and milk products.

Clinico-social-case format (Index case- Under five)

1. Identification & demographic details:

Name: 

Age: 

Sex: 

Religion and caste:

Education: 

Informant:

Reliability:

Address: 

Nearest health facility: 

(Ward no:____, Unit:___, IP/OP No:______, Mode of admission: Self/ Referral; if in hospital)

2. Presenting/ Chief complaints:

Complaints of____________since______days/ months/ years. (In chronological order)

(Main complaints are Failure to gain weight, Fever, Cough, Respiratory difficulty, Diarrhea, symptoms suggestive of measles, Presence of danger signs like convulsions, loss of consciousness, inability to feed, distress, distended abdomen, Excess cry, irritability, etc.)

3. History of presenting illness:

My patient was apparently alright then he developed _____________(name of the symptom) which was insidious/ sudden in onset, progressive/ non-progressive in nature. (describe each symptom in detail with treatment history if taken). There is no history of _______________________. (Ask & write the negative history based on probable causes.)

(Ask about h/o

• Recurrent infections (respiratory and skin to be especially enquired)
• Worm infestation
• Decreased appetite
• Chronic conditions especially TB
• Ear discharge)

4. Past history: 

Write down if any history of past surgeries, illnesses, blood transfusions, allergies, or trauma, treatment history (undergoing any treatment for a chronic condition, for the present condition, h/o treatment in the past)

(Hospitalisation, Measles, Chickenpox, ARI/Diarrhea)

5. Birth history: 

• Term/ preterm
• Normal/assisted/CS
• Birth weight:_______kg
• Incubator/ NICU care: Yes/ No
• Pre Lacteal feeds: Yes__________________/No
• Time of initiation of breastfeeding:_____
• EBF till what age:________
• Time of start of complimentary food:_________ 
• Nature of complementary food:_____________
• H/o use of artificial feeds

6. Antenatal, natal, and Postnatal history:

Trimester-wise history 1st, 2nd, and 3rd. Weight gain during pregnancy increased food intake during the pregnancy.

First trimester:

• Registration details_____________
• Excessive vomiting: Yes/ No 
• Bleeding p/v: Yes/ No  
• Fever with rashes: Yes/ No 
• Drug intake: Yes_______________________/ No
• Weight gain: __________Kg
• Investigations-Hb%, CBC, Urine routine & microscopy, USG , blood grouping & Rh typing, VDRL, HBsAg, HIV, RBS, TFT, LFT, etc.
• Folate supplementation: Yes since______/ No
• TT: Taken/ Not taken/ 1st dose/ Both doses

Second trimester:

• Quickening: Felt at_________ weeks/ Not felt
• Weight gain: Yes__________Kg/ No
• Blurring of vision: Yes/ No 
• Epigastric pain: Yes/ No 
• Pedal edema: Yes/ No 
• Headache: Yes/ No 
• Iron and calcium supplementation: Taking daily OD/ BD/ No
• Side effects because of IFA supplementation: Yes Nausea/  vomiting/ loss of appetite/ change in the colour of stools/ No
• Hours of sleep/rest: Afternoon___hours and night___hours
• Tetanus toxoid immunization: Yes 1st dose/ 2nd dose/ No
• Investigations: Hb%, CBC, Urine routine & microscopy, Blood suger-FBS & PPBS, USG Abdomen, LFT, KFT, TFT, etc.

Third trimester:

ANC visits: Yes ______times/ No

Weight gain: Yes_____Kg/ No

Warning signs: Present/ Absent

• Pain abdomen: Yes/ No
• Decreased perception of fetal movements: Yes/ No
• Leaking / Bleeding PV: Yes/ No
• Any high risk status: Yes_____________/ No

(Complications during pregnancy like

• Hyperemesis
• Pre-eclampsia
• Eclampsia
• Infections
• Preterm delivery
• Antepartum hemorrhage

Investigations did during pregnancy:

• Hemoglobin estimation
• Blood grouping,
• Ultrasound scanning.)

7. Developmental history:

Gross motor: As per age/ Delayed/ _____________

Fine motor: As per age/ Delayed/  ______________

Language:As per age/ Delayed/  _______________

Personal social: As per age/ Delayed/ ___________

8. Immunization history: 

• Vaccines are given appropriate for age: Yes/ No 
• BCG scar: Present/ Absent
• (reports of immunization like immunization card to be seen)
• Ascertaining whether measles vaccine and vitamin A was given: Yes/ No 
• Delay in immunization: Yes/ No
• If yes, the reason for the delay:________
• the optional vaccines administered:____________

9. Personal history:

Diet: Veg/ Mixed/ Vegan

Appetite: Normal/ Increased/ Decreased

Bowel & bladder: Regular/ Irregular

Sleep: Normal/ Increased/ Decreased

10. Family history: 

Family type: Nuclear/ Joint/ 3 generation

Family composition (draw a family tree)

Any history of consanguinity: Yes/ No

Family relationships: Good/ Not good

The response of family towards the illness:_____________

h/o chronic condition in the family especially tuberculosis, 

h/o Similar case in other children of the family/ Locality/ District: Yes/ No 

h/o contraception usage by the couple.

(No need to write if it is included in the family details)

11. Environmental history:

Housing:

Toilet:

Waste disposal:

Drinking water:

Animals/ pets:

Occupational environment:

(No need to write if it is included in the family details)

12. Socio-economic history:

Interaction with society: Yes/ No

The response of society towards the person: Good/ Bad/____ 

Presence of stigma: Yes/ No

if yes specify____________________

Participation in festivals, marriages and other social activities & involvement in social groups: Yes/ No

Total family income:______________

Expenditure on diet and medical care:__________

Savings or debts_____________________

Family tensions due to the economic situation: Yes/ No

(No need to write if it is included in the family details)

13. Nutritional history (as relevant to the case):

Calculation of calories, carbohydrates, proteins & fats (& salts) being supplied to the person by 24-hour diet recall method (tabular format for breakfast, lunch, evening snacks & dinner) and required amount by the person through diet. Mention the deficiency or excess.

(Anganwadi services utilization: Yes/ No)

(No need to write if it is included in the family details)

14. Psychosocial history:

Mental changes: Memory loss/ Depression/ Any other______

Living with: Parents/ Grand-parents/ Relatives/ Shelter home/ Others

15. General physical examination:

Vitals:

Blood pressure (BP): ___________ mm Hg, 

Pulse rate(PR): __________ beats/ min

Respiratory rate (RR): __________ cycles/ min

Temperature: ___________ degree F

Pallor: Yes/ No

Icterus: Yes/ No

Clubbing: Yes/ No

Cyanosis: Yes/ No

Lymphadenopathy: Yes/ No

Edema: Yes/ No

Anthropometry: 

Built: Normal/ Short

Nourishment: Normal/ Thin/ ____

Height/ Length: _________m

Weight: ________kg

BMI:__________ kg/ m2

Head to toe examination:

(Head to toe examination to look for evidence of PEM likefontanneles, eye changes, skin infections, dermatosis, hair changes, nail changes, signs of rickets like potbelly, wrist widening, richitic rosary, harrisons sulcus, bow legs, knock knees. Oral cavity examination for dental hygiene and assessing dentition.

Also, keep in mind the IMNCI format.) 

General cleanliness: Good/ Bad

Hair: Clean/Unclean/ Combed/ Uncombed/ Lusterless/ Depigmented/ Sparse/ Easily pluckable/ Flag sign

Face: Moon face/ Hallowing of cheeks/ Pointed chin/ Prominent bones/ Depigmentation/ Seborrhea around the nose

Eye: Vision: Normal/ Decreased; Conjunctiva: Normal/ Bitot's spots/Dry/ Sunken; Using spectacles: Yes/ No; 

Ear: Hearing: Normal/ Decreased; if decreased ,type of hearing loss: Conductive/ SNHL/ Mixed; Ear discharge: Yes/ No

Lips: Normal/ Cheilosis/ Angular stomatitis

Oral: No of teeth:______

Oral hygiene: Good/ Poor

Tongue: Pale/ Red magenta

Nails: Normal/ Pale/ Koilonychia/ ___________

Skin: Wrinkled/ peeling skin/ Flaky paint like patches

Subcutaneous tissue: Maintained/ Emaciated

Muscles: Normal/ Wasting

Chest: Prominence  of ribs

Abdomen: Distended/ Flat emaciated/ Ascites/ Enlarged liver

Leg: Edema on dorsum of feet & leg

Hips: Normal/ Loss of shape due to loss of fats

Alertness: Dull/ Disinterested/ Stays in same position for long time/ Irritable/ Crying excessively fretful

Any other significant finding____________________

13. Systemic examination:

Respiratory system:

Inspection:

Palpation:

Percussion:

Auscultation: 

Cardiovascular system:

Inspection:

Palpation:

Auscultation: 

Gastrointestinal system:

Inspection:

Palpation:

Percussion:

Auscultation: 

CNS examination:

Inspection:

Palpation:

Musculoskeletal system: 

Inspection:

Palpation:

Provisional clinical diagnosis:

Laboratory investigations:

Hb%; Peripheral smear; Urine routine & microscopy; Stool examination for ova, cyst, pH(lactose intolerance); PPD (for TB); Total sr protein & albumin; Blood urea/ creatinine 

(already done and planned in future)

Clinico-social diagnosis:

This is the family of Mr.____________residing in ________ (name of the area), having nuclear/ 3-generation/ joint family,  belonging to socioeconomic status class __________ according to _____________ (name of the classification), a BPL/ APL card holder. The health problems, health demands & health needs of the family are _______________________. (Disease with/without complication, Social problem, Mental problems). The vulnerable individuals identified in the family are ________ (why are they vulnerable?)

Comprehensive management plan: