PUBLIC HEALTH AND PREVENTIVE MEDICINE

1. Introduction:

The Department of Public Health and Preventive Medicine is providing Primary Health care services through a network of 1399 Primary Health Centres that includes 59 Community Health Centres and 8682 Health Sub Centres spread over the entire State. The Community Health Centres / Primary Health Centres / Health Sub Centres functioning in the rural areas are manned by medical, para medical, nursing and other ancillary staff. The department provides technical, financial and administrative support for the urban health infrastructure in the Municipal Corporations, Municipalities and Town Panchayats. The Department is responsible for the implementation of various National and State Health Programmes and to formulate strategies to prevent the occurrence of diseases thereby reducing the level of morbidity and mortality in the state.

2. Activities of the department:

The activities undertaken by the department of Public Health and Preventive Medicine are provision of primary health care that includes Maternity and Child Health Services, Immunisation of children against vaccine - preventable diseases, Control of Communicable diseases, Control of Malaria, Filaria, Japanese Encephalitis, elimination of Leprosy, Prevention of Food Adulteration, Vazhvoli Thittam, Varumun Kappom Thittam, Health Education of the Community and Collection of Vital Statistics under Birth and Death Registration System, Iodine Deficiency Disorder Control Programme etc.

3. Primary Health Care:

Towards providing Primary Health Care facilities to the people of Tamil Nadu especially to those in the rural areas under different health programmes are formulated through strengthening the preventive, promotive, curative and rehabilitative health care services, and are implemented through the Community Health Centres, Primary Health Centres and Health Sub centres.

3.1. Network of Primary Health Centres and their services:

As per the norms prescribed by the Government of India, one Primary Health centre is to be set up for every 30,000 population in the plains and for every 20,000 population in the hill areas. Accordingly at present there are 1399 Primary Health centres including 59 Community Health Centres in Tamil Nadu. There are 2875 Medical Officers who along with other public health staff provide curative, preventive, promotive and rehabilitative services in the rural areas. The drugs required for these health centres are procured and supplied through the Tamil Nadu Medical Services Corporation Limited. During the year 1999, 299.8 lakhs of out patients and 58,230 inpatients were treated in these Primary Health Centres.

3.2. Buildings of the Primary Health Centres:

Out of the 1399 Primary Health Centres, 652 were functioning in private buildings. The Government as a policy have decided to provide own buildings for all the Primary Health Centres in the State within a period of two years. Accordingly the Government sanctioned the construction of buildings for 300 Primary Health Centres during 1996-97 and for 352 Primary Health Centres during 1997-98. The total cost of construction of these buildings is Rs. 51.13 crores. Construction of buildings for 600 Primary Health centres has been completed. Tamil Nadu is the only state to take up construction of buildings for all the Primary Health Centres with its own funds.

3.3. Other infrastructural facilities:

All the Primary Health Centres are provided with the basic facilities like cold chain equipment, surgical equipment for minor surgeries and deliveries, laboratory facilities for conducting basic investigation, essential and emergency drugs and beds for inpatients at the rate of 6 per Primary Health Centre and 30 for upgraded Primary Health Centres and 10 per 24 hours Primary Health Centres. All the main Primary Health Centres have been provided with ophthalmic equipment for the detection of cataract cases and treatment of minor eye ailments. The upgraded Primary Health Centres are provided with X-ray plant and operation theatre. Ultra Sound Scans are also provided in Chennimalai (Erode) and Ilampillai (Salem) Primary Health Centres.

3.4. Staff Pattern for Primary Health Centres/ Community Health Centres:

The staff pattern for a Primary Health Centre is two Medical officers, three paramedical staff and five ministerial and basic service staff. As per Government of India norms to provide referral and specialised medical care facilities to the rural people, upgraded Primary Health Centres and Community Health Centres have to be established at the rate of one per every four Primary Health Centres (serving around 80,000 to 1,20,000 population). There are 59 such centres functioning in the state at present.The pattern of staff includes one Civil Surgeon and one Doctor with post graduation (MS or DGO). The Government have also upgraded the post of Medical Officer in charge of Block Primary Health Centres to the level of Senior Civil Surgeon.

3.5. Tribal Welfare Scheme:

Under this scheme, 12 blocks viz, Alangayam, Jamnamarudur, Sankarapuram, Kalrayan Hills, Uppiliapuram, Yercaud, Ayodhiyapattinam, Peddanaickenpalayam, Gangavalli, Kolli Hills, Pappireddipatty and Thiruvattar have been identified as tribal areas in the State. 14 Primary Health Centres are functioning under the Tribal Sub Plan Scheme. In addition 11 more Primary Health Centres are located in tribal areas including the two Community Health Centres at Alangayam and Kariyalur.

3.6. Introduction of 24 Hours Service:

As per the avowed policy of the Government to expand the services, all the block level Primary Health Centres are to be converted as 24 Hours Primary Health Centres. Accordingly 250 Primary Health Centres have started functioning as 24 Hours Primary Health Centres. The laboratory facilities have been strengthened at a cost of Rs 53 lakhs in these Primary Health Centres. The remaining 174 block Primary Health Centres including Community Health Centres will be converted in a phased manner. As part of strengthening of the 24 hours services in the Primary Health Centres, the Government have sanctioned 250 posts of Additional Medical Officers and 250 posts of ANMs. 224 ambulances have been purchased at a cost of Rs. 7.83 crores to transport emergency cases for higher level treatment.

3.7. Treatment of medico legal cases in Primary Health Centres:

With a view to avoiding the hardship and providing quick and immediate treatment to all Medico legal cases, the Government have ordered that all the 24 hours Primary Health Centres will attend to such cases except conducting post-mortem. The Medical Officers of the Primary Health Centres have been given one day training in handling medico legal cases.

3.8. Participation of Industries in the maintenance of Primary Health Centres:

In pursuance of the Policy of the Government to involve leading and reputed industrialists in the maintenance of the Primary Health Centres and Government Hospitals, several industrialists have come forward to participate and to improve the infrastructural facilities in the Primary Health Centres and hospitals for the benefit of the people. So far 51 industrialists have come forward to maintain 24 Government Hospitals, 69 Primary Health Centres and 5 Health Sub centres.

4. Universal Immunisation Programme (UIP):

The Government of India launched the Universal Immunisation Programme in 1985 with a view to ensuring 100% coverage of pregnant women against Tetanus and infants against vaccine preventable diseases and the entire State of Tamil Nadu came under Universal Immunisation Programme in a phased manner. The programme is very successful and pregnant women and infants are getting the benefits continuously.

1. The details of coverage under various Immunisations are as under (upto March 2000).

Immunisation Performance in Tamil Nadu

(Fig. in Lakhs)

NOTE: T à Annual Target A à Achievement

T* à Annual Tentative Target Adapted as per G.O.I.

4.2. As a result of the Improved and sustained coverage of various Immunisation Programmes the incidence of vaccine preventable diseases has been brought under control as shown below:

4.3. Tamil Nadu has already achieved the target of elimination of Neonatal Tetanus and reduction of morbidity and mortality due to measles. The state is almost nearing the stage of eradication of poliomyelitis.

4.4. Intensified Pulse Polio Immunisation for eradication of Poliomyelitis.

The state has successfully conducted 4 campaigns of Pulse Polio Immunisation during 1995-96, 1996-97, 1997-98, 1998-99 covering 65 lakhs to 70 lakhs under 5 years children administering 2 doses of Oral Polio Vaccine in each round, with active involvement of all departments and voluntary organisation. During the year 1999-2000, 4 rounds of Pulse Polio Immunisation were conducted covering around 70 lakhs of children under 5 years of age in each round. To achieve 100% coverage of all children under 5 years, Intensified Pulse Polio Strategy is adopted. According to this strategy Polio drops are administered in established immunisation booths on the first day and house to house verification done on the next two subsequent days to immunise the children who did not turn up on the first day at the booth. The successful implementation of the Pulse Polio Immunisation for the past five years has resulted in the reduction of polio cases. During 1999 only 29 cases have been reported due to suspected polio. Of these, only 8 are positive for wild polio virus. The AFP Surveillance is adopted for the children below 15 years of age instead of 5 years as followed previously. Laboratory investigation by stool collection for all AFP cases is strengthened to rule out Polio infection with the assistance of World Health Organisation. Government of India have established National Polio Surveillance Project (NPSP) and appointed 4 Surveillance Medical Officers for Tamil Nadu to assist and coordinate the Polio Eradication activities in the state. All Primary Health Centres and Government Hospitals in Municipalities are provided with Cold Chain equipments in order to preserve the potency of the vaccines. 3 walk-in freezers and 9 walk-in coolers have also been established in various parts of the state to store vaccines.

4.5. Programme for Maternal and Child Welfare:

Programmes for maternal and child welfare are implemented to promote the Health and Social Status of the mother and children. The maternal and child welfare activities are carried out through Health Sub Centres established at the rate of one per 5000 population in plain areas and one per 3000 population in hilly and difficult terrains. The following are the major activities whose current status are given below:-

The Details of performance under MCH activities are as follows:

4.6. A post of Commissioner for Maternal and Child Health has been created in the cadre of super time scale of I.A.S to coordinate the activities of various departments involved in Maternal and Child Health Care such as Public Health and Preventive Medicine,Medical and Rural Health Services, DANIDA assisted Tamil Nadu Area Health Care Project and Reproductive and Child Health Project.

4.7. To achieve the Family Welfare goals through improving the quality of Maternal and Child Health Services, decentralised participatory planning approach is being followed to fix the target for the field health functionaries. In this process the grass root level workers decide their targets taking into account the Health Status of the local population in consultation with their co workers, supervisors and community. The top down approach has now been replaced by bottom up approach in respect of all Maternal and Child Health activities which has improved the quality of services to a great extent. Health Sub Centre is the peripheral unit close to the villages taking care of the health needs of the population in the villages. At present there are 8682 Health Sub Centres in the state of which 5572 Health Sub Centres function in government buildings. Government has sanctioned Rs 9 crores for the construction of 200 Health Sub Centres under State plan during 1997-98. Construction for 85 Health Sub Centres are over and for the remaining Health Sub Centres constructions will be completed soon. Out of the 8682 Health Sub Centres, 76 Health Sub Centres are functioning in tribal areas. A mobile medical unit is functioning under the control of the Deputy Director of Health Services, Salem for providing Primary Health Care Services with its head quarters at Karumanthurai (Kalrayan Hills).

5. National Iodine Deficiency Disorders Control Programme:

5.1. The National Iodine Deficiency Disorder Control Programme is implemented in the State from 1991 and the State Iodine Deficiency Disorder cell started functioning from 1.7.94 onwards. The objective of the programme is to identify the areas with Iodine Deficiency Disorders and take control measures through dietary supplementation of iodised salt through IEC activities. For the effective implementation of the programme, the coordinating officers of the Public Health, Education, Municipal Administration, Civil Supplies were covered under advocacy programme.

5.2. The goitre surveys conducted in all the districts have shown that Iodine Deficiency Disorders are prevalent in all the districts. A notification under the Prevention of Food Adulteration Act has been issued banning the sale of non-iodised salt for edible purposes. Spot testing of the salt samples for the retailers and spot testing of the kitchen salt samples are being done to access the presence of iodine and know the availability and use of iodised salt. Non statutory salt samples are lifted and tested to know the iodine content in salt. During the year 1999-2000 1723 non-statutory salt samples were lifted and analysed in the Food Analysis Laboratory. 61,800 samples were lifted and analysed through field tests. Government have issued orders for sale of iodised salt through fair price shops by both Tamil Nadu Civil Supplies Corporation and Co-operatives at Rs. 2.50 per kg in pouches in Thiruchirappalli, The Nilgiris, Coimbatore, Salem, Karur, Perambalur, Namakkal and Thanjavur districts.

"Global IDD Day" was celebrated on 21.10.99 throughout the State for the purpose of creating awareness among the community.

6. Vazhvoli Thittam:

6.1. Vazhvoli Thittam is being implemented in Tamil Nadu from July 1999. The objective of the scheme is to examine all the school children for detection of ailments and treat them early as some diseases may turn out to be a big problem when they grow up. Special emphasis is laid on Rheumatic heart problem, eye disorders, dental problems, hearing deficiency, etc.

6.2. Under the scheme all 'Thursdays' are observed as School Health days. The Medical Officer and the Para Medical Staff visit the schools in their jurisdictions, examine the students and provide them treatment. If necessary the students will be referred to Higher Medical Institutions for specialised and continued treatment. All Saturdays are observed as Referral Days at the Higher Medical Institutions.

6.3. Two teachers from each school are being identified to coordinate and assist in the effective implementation of the scheme. These identified teachers will be given training at a cost of Rs.14.0 lakhs in identifying certain common ailments and interact with doctors. School Health Cards are printed and supplied. A sum of Rs 60.00 lakhs have been provided in the first instance. These Health Cards will be maintained at the school and will be handed over to the student along with the Transfer Certificate when the students leave the school. Health appraisal register, referral register and Drug Stock registers are printed and supplied at a cost of Rs 20.00 lakhs. Medicines worth of Rs 300 lakhs are supplied through TNMSC Ltd. To meet the fuel charges and contingent expenditures Rs 26.00 lakhs have been provided. So far 72.00 lakhs students have been screened and 35.00 lakhs students have been treated. Besides, 80,000 students have been referred to the Institutions for specialised treatment.

7. Control of communicable diseases:

7.1. The control of Communicable Diseases is one of the major programmes under the Primary Health Care Services, especially for the diseases occurring in epidemic forms. Acute Diarrhoeal Diseases and suspected Cholera are common among the water borne diseases. Tamil Nadu is endemic for Acute Diarrhoeal Diseases with sporadic outbreak of cholera in most of the districts throughout the year, and, in epidemic proportions during the rainy seasons and peak summer periods. All the District level officials and executive authorities of local bodies have been asked to take necessary preventive measures including proper disposal of solid wastes and maintain sanitation and hygiene, chlorinate all water sources and undertake fly control measures. 4.43 lakhs of anti cholera inoculations were given and 52,494 water sources were chlorinated during the year 1999.

7.2. Administration of oral Rehydration Salt has been popularised through Health Education and the method of preparation of ORS Solution is also demonstrated by the field staff to the Public.

7.3. The following are the details of cases and deaths due to ADD / CHOLERA in Tamil Nadu during the past 3 years.

8. Industrial hygiene and health:

8.1. The Water Analysis Laboratories established at Chennai and Coimbatore collect and examine water samples from various protected water sources to control pollution and contamination of drinking water. These laboratories also assist the Tamil Nadu pollution Control Board in examining samples of Industrial Wastes and conduct field surveys to ensure the prevention and control of environmental and industrial pollution.

8.2. Air pollution surveys are also carried out around the industries to assess air quality. Efforts are also taken for abatement of nuisances and classifying the industrial and residential areas. During the year 1999-2000, 27,939 water samples have been tested by these laboratories.

9. Prevention of food adulteration:

The Government of Tamil Nadu is taking various measures to check and control the adulterations of food by implementing the prevention of Food Adulteration Act 1954 and Tamil Nadu prevention of Food Adulteration Rules 1955. The whole state is notified for the purpose of implementation of Food Adulteration Act and Rules and 481 local bodies are implementing the act. The food samples collected from the local bodies are analysed in 7 food analysis laboratories located at King Institute (Guindy), Coimbatore, Madurai, Thanjavur, Salem, Palayamkottai and Chennai Corporation. During the year 1999-2000, 4,122 samples were analysed out of which 295 samples were found adulterated. The percentage of adulteration is 7.16%. Prosecutions were launched in 201 cases and upto
March 2000, 93 cases were convicted of which 55 were fined and 38 were fined with imprisonment.

10. Vital Statistics:

10.1. The Registration of Births and Deaths at the place of occurrence is compulsory and is enforced throughout the State as per the provision of Registration of Births and Deaths Act 1969. The Government of India have revamped the Births and Deaths registration system from 1-1-2000. Accordingly Tamil Nadu Births and Deaths Registrations Rules 2000 have been notified and come into effect from 1-1-2000. Training of the officials connected with the births and deaths registration work in the revamped system of birth and death registration has been conducted in all the districts.

10.2. The sample Registration Scheme for the estimation of Vital rates at the State and National level implemented in 150 rural units by the department of Public Health has since been taken over by the Director of Census Operations, Tamil Nadu from 1995.

10.3. The Birth rate, Death rate and Infant mortality rate according to the sample Registration scheme for the State of Tamil Nadu over the years are as follows:-

11. Vector Borne Diseases Control Programmes:

11.1. The programme for the control of Vector borne diseases (Viz) Malaria, Filaria, Guineaworm and Japanese Encephalitis are implemented in the State. There is a separate post of Director of Public Health and Preventive Medicine (M&F) to oversee the implementation of these programmes.

11.2. Malaria: Malaria problem in Tamil Nadu can be classified as

1. Urban Malaria

2. Coastal Malaria

3. Riverine Malaria

11.3. Urban Malaria:-

Malaria is prevalent in Chennai, Thoothukudi, Dindigul, Salem, Erode, Vellore, Thiruchirappalli, Thiruchengode and Thiruvettiyur.

11.4. Coastal Malaria:-

Malaria is prevalent in the Villages of Coastal Ramanathapuram district and Kanyakumari district.

11.5. Riverine Malaria:-

The villages located on either banks of river Thenpennaiyar in Dharmapuri district Sathanur Dam area in Thiruvannamalai district and on the banks of river Cauvery in Pennagaram block are endemic for Malaria.

In Tamil Nadu 60 to 70% of the total Malaria cases occur in urban areas. The P.Vivax is the major species causing Malaria. The other species, P.Falsiparam is negligible in Tamil Nadu.

Malaria cases are detected through Active and Passive surveillance. The Malaria cases are radically treated with Chloroquine and Primaquine tablets. To check the transmission of Malaria, indoor residual spray with synthetic pyrethroids are being carried out in and around the houses in the villages of High Risk Areas. Fogging operations are also carried out to control Vector of Malaria and antilarval work done in select areas. In urban areas space spray with Pyrethrum extract is carried out in and around the houses of Malaria positive cases besides antilarval work. The operational cost of the Anti-Malaria programme is borne by the State while the Government of India supply Anti Malaria drugs Larvicides \ Insecticides as its 50% share of expenditure.

The incidence of Malaria in the State for the past 4 years are as follows:-

11.6. Japaneses Encephalitis:-

Japanese Encephalitis has emerged as an important public health problem in the State during the last few years. The Japanese Encephalitis control units at Cuddalore, Villupuram, Perambalur and the monitoring unit at Head Quarters carryout the Japanese Encephalitis Vector Control and monitoring activities. Japanese Encephalitis Immunization Programme has been carried out in selected villages in Perambalur district. 20,000 vials of Japanese Encephalitis vaccine was procured from Korea through the World Health Organisation and vaccination is being carried out in Perambalur district.

In order to prevent and control the incidence of Japanese Encephalitis, Deltamethrine impregnated curtains are being fixed in the houses of the villages of Nallur, Sirumangalam and Pennadam PHC areas. This is only a pilot project and it will be extended to other Japanese Encephalitis prone areas.

The incidence of Japanese Encephalitis for the past four years are as follows: