Introduction • NTCP- National Tobacco Control

Programme• Trauma and Road Safety• NPPMBI- National Programme for Prevention

& Management of Burn Injuries • National Programme for Prevention &

Control of Fluorosis• National Iodine Deficiency Disorders

Control Programme. • Oral Health • Palliative/Congenital Blood Disorder

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Tobacco use is the major risk factor for major noncommunicable diseases

Tobacco use

Unhealthy Diet

Physical inactivity

Harmful use of alcohol

Heart Disease and stroke

Diabetes

Cancers

Chronic obstructive pulmonary disease

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Nearly 7-8 lakh persons die every year in India due to diseases associated with tobacco use. (Report on Tobacco Control 2004)

30% of cancer deaths, majority of cardio-vascular and lung disorders; 40% of TB and other related diseases are attributed to tobacco consumption.

About 90% of oral cancers are caused due to tobacco use.

Total economic cost of the 3 major diseases (Cancer/COPD/Lung disorder) due to tobacco use in India was Rs. 30,833 crores in 2002-03.

BURDEN OF TOBACCO USE (INDIA)

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STRATEGY FOR TOBACCO CONTROL• Supply Reduction Strategy

• Demand Reduction Strategy–Enforcement of law–Awareness Generation–Raising prices

• Prevention will substantially reduce cost of management

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MAIN PROVISIONS OF THE ACT (Tobacco Control Act 2003)

• Prohibition on smoking in public places. (Section 4)

• Prohibition of advertisement, sponsorship and promotion of tobacco products (Section 5)

• Prohibition on sale of tobacco products to minors (Section 6(a))

• Prohibition on sale of tobacco products near educational institutions (Section 6(b))

• Mandatory Display of pictorial health warning on tobacco products packs (Section 7)

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Actions to be taken at state level

Formation of State and District Level Co-ordination Committees – Responsible for overall implementation of NTCP and COTPA in the state - holding periodic meetings

Inclusion of COTPA in the monthly crime review meeting.

Opening an account in State and/or District Health Societies for deposit of fines

Making compliance to COTPA an essential condition for :

Issue of licenses to eateries and shopsIssue of tenders by the State Transport Department for advertisement on the bus panels.

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States not spending NTCP allocations

State

Funds Released Remarks

2007-08 2008-09

West Bengal 17,24,000 --- No UC/SoE received

Madhya Pradesh 17,24,000 --- No UC/SoE received

Jharkhand --- 12,12,000 No UC/SoE received

Bihar --- 12,12,000 No UC/SoE received

Maharashtra --- 12,12,000 No UC/SoE received

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Ban on Gutka/Pan Masala etc.

• Inclusive Definition of “Food” in the Food Safety and Standards Act, 2006 as any substance, whether processed, partially processed or unprocessed, which is intended for human consumption, ….. and other specified categories.

• Definition of food wide enough to include products like gutkha and other smokeless tobacco products taken orally.

• Godawat Pan Masala Products I.P. Ltd. & Another v Union of India & Others, (2004) 7 SCC 68: Supreme Court held that pan masala, gutka or supari are food since they are eaten for taste and nourishment

• Food Safety and Standards (Prohibition and Restriction on sales) Regulation, 2011, came into force on 05.08.2011

• Regulation 2.4.3 reads:“Product not to contain any substance which may be injurious to health: Tobacco and nicotine shall not be used as ingredients in any food products.”

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Ban on Gutka/Pan Masala etc.

• The Pan-India ban is effective through this regulation

• States to enforce the ban by prohibiting manufacture, sale or storage of Gutka and Pan Masala containing tobacco and/or nicotine

• Governments of Madhya Pradesh, Kerala, Bihar, Rajasthan, Maharashtra, Haryana, Chhatisgarh, Jharkhand, Mizoram and Gujarat have so far issued orders/notifications to enforce the ban

• Lal Babu Yadav vs State of Bihar & Ors. (CWJC No. 10297/2012), Order dated 10.07.2012 – Hon’ble Patna High Court upheld the state order for implementing the regulation imposing the ban on sale of gutka.

• Writ Petitions 12352, 12932, 13271 and 13773 of 2012 – Order dated 02.08.2012 - Hon’ble Kerala High Court upheld the order dated 22.05.2012 issued by the Commissioner of Food Safety, Kerala, and declined to stay its operation.

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Trauma, Road Safety: Initiatives

• Road accident is a major public health problem. 1.43 lakh deaths due to road accidents in 2011 (NCRB) which is highest in the world. This figure may go upto 5.46 lakh by 2020, without intervention, as per WHO projection

• These deaths are preventable to a large extent if timely, appropriate medical care is provided.

• A trauma scheme “ Assistance for capacity building for development of trauma care facilities in identified Govt. hospitals on national highways” (GQ and NS& EW) was initiated during 11th plan.

• The aim was to establish 140 trauma care facilities to reduce morbidity, mortality and disability.

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Achievements during 11th plan• 140 centres to be developed on the golden quadrilateral & North South &

East West Corridor• 20 are being funded through PMSSY scheme, 2 from own sources and rest

118 are being funded from the scheme• 34 centres have been made operational.• Remaining are in various stages of development• Training modules and curriculum for doctors, nurses and paramedics were

developed• 223 ambulances have been deployed for pre hospital trauma care on

different streches and 70 advanced support life care ambulances deployed in different hospitals in collaboration with Ministry of Road transport and highways

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Road Safety Project ( RS-10)

• India is one of the 10 countries with highest incidence of road accidents/ consequences

• The project was initiated in 2010 is supported by a consortium of 6 partners• Aim is to test the impact of evidence based interventions in respect of risk

factors like Over Speeding, Drunken driving and non wearing of helmets. Jalandhar and Hyderabad were selected on a pilot basis for the study.

• Awareness generation and advocacy campaign was made and legal provisions were examined.

• The positive observation are required to be replicated in other cities• A national advisory committee has been constituted in Ministry of Health &

FW to oversee the implementation of the project.

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Proposed Programme Activities during 12th plan

• Completion of spill over work of 140 trauma centres of 11th plan

• Establishment of 160 new trauma centres during 12th plan• National injury surveillance, trauma registry & capacity

centre • Establishment of rehabilitation units in trauma centres• Information, education & communication (IEC)

activities• Quarterly review meetings and annual conferences • Bilateral agreement for sharing knowledge, developing

skill with NTRI Australia and CDC Atlanta • Establishment of trauma cell at Dte.GHS . • Mid term /terminal evaluation

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Criteria for development of 160 new trauma centres during 12th plan

• 160 Institutions are being identified for developing trauma care facilities in state Government hospitals located on highways other than (golden quadrilateral & North South & East West Corridors) on following category of highways:

– connecting two major cities.– Connecting two Capital cities.– connecting capitals with Sea / Airport.– connecting major industrial Township to capitals.

Priority will be given to :-

- States/UTs which were not covered during 11th plan

- Hilly & tribal areas and north East regions with difficult terrain and access .

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Strategies

Upgrade and strengthen the existing state Government hospitals to develop trauma care facilities,

Provide a rapid mode of transportation of trauma victims under medical supervision so as to reach the hospital within the golden hour,

Establish communication linkages with the ambulances located on highway and the designated trauma centres.

To develop, state-wide and National Trauma Information Management System (Trauma registry & Injury Surveillance system) for developing preventive interventions & improvement of quality care

To Develop training curricula for doctors, nursing staff and paramedics for capacity building.

To monitor and evaluate the efficiency, effectiveness of the Trauma Care services.

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Expectations from State Governments

• To expedite the identification of hospitals for new trauma centres in respective states

• Provide audited UC and SOE from state auditing authority/ empanelled CA of all pending cases

• To expedite the construction, procurement of equipment, recruitment of manpower activities left over of 11th plan to make the Trauma centres operational

• Identify the manpower including Doctors, Nurses and Paramedics for training

• To hold review meetings and provide progress report at 2 months interval• To enhance/ delegate financial power of Deans/ MS of identified hospitals

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BURN INJURIES –PUBLIC HEALTH PROBLEM BURN INJURY IS A MAJOR PUBLIC HEALTH PROBLEM WHICH IS NOT

RECOGNISED IN THE COUNTRY AS A NATIONAL PROBLEM

NO TREATMENT FACILITIES IN THE DISTRICTS

MORTALITY RATE OF BURN INJURY PATIENTS IS QUITE HIGH

VICTIMS OF BURN INJURY MAINLY BELONG TO THE POOR SEGMENT OF THE SOCIETY ESPECIALLY THE VULNERABLE GROUP EG: WOMEN , CHILDREN & OTHERS MAINLY IN THE PRODUCTIVE AGE GROUP

UNLIKE OTHER INJURIES BURN INJURIES ARE ACCOMPANIED BY TRAUMA /DISFIGUREMENT /DISABILITY /DEFORMITY

PATIENTS ARE PHYSICALLY AND PSYCHOLOGICALLY TRAUMATISED 17

Magnitude of the Problem

DEATH (1.4 lakhs)

CRIPPLED (2.5 lakhs)

ADMISSIONS (7 lakhs annually)

MINOR INJURIES (EMERGENCY & OPD)

7 Million

7 Million cases annually.

7 Lakh need hospital

admissions.

2.5 Lakhs get crippled.

1.4 Lakhs die annually.

CRIPPLED (2.5

The data are extrapolated based on the figures of 3 burns units of SJH, RML & LNJP Hospital 18

Objectives

1.To reduce incidence of burn injuries and resultant, disabilities morbidity and mortality due to Burn Injuries.

2.To generate awareness amongst the masses and vulnerable groups specially the Women & Children, Industrial and Hazardous occupational workers.

3.To establish adequate infrastructural facility and network for, burn management, rehabilitation for BCC.

4.To carry out Formative Research for assessing behavioral, social and other determinants of Burn Injuries for effective planning & implementation of the programme.

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Components of the Programme

Four major components:

1. Prevention Programme

2. Treatment Programme

3. Rehabilitation Programme

4. Training Programme

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Strategy for implementation• Burn injury management protocol needs to be developed. • IEC strategies. • Infrastructure, Equipment and Material & Supplies to be

provided to Medical Colleges/District Hospitals.

• Additional space to be located in Medical College/District Hospitals for establishment of burn unit where such facility do not exist. Strengthen burn units were they already exist.

• Provide financial support for recruitment of contractual manpower for specified period.

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Expectations from State Government

• Identify Medical Colleges for implementing the programme after assessing the facilities available in the medical colleges & burn cases load in the district

• Commitment regarding sustaining services after 12th Plan through MoU with GOI.

• Identify space in the medical college for establishment of burn’s unit

• Support for carrying out civil works, procurement of equipments & recruitment of contractual manpower

• Delegation of administrative & financial powers to implementing agency for programme implementation

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WHAT IS FLOURINE?

• FLOURINE IS AN ESSENTIAL MICRONUTRIENT

REQUIRED DAILY FOR BONES & TEETHS

• FLUOROSIS IS A PATHOLOGICAL CONDITION

CAUSED DUE TO EXCESS INTAKE OF FLOURINE

• MOST EXCESS INTAKE IS FROM GROUND WATER

• SAFETY LIMIT : 1 MG/LITRE OF WATER (1PPM)

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TYPES OF FLUOROSIS

THREE TYPES:-

• SKELETAL FLUOROSIS, • DENTAL FLUOROSIS,• NON-SKELETAL FLUOROSIS,

DENTAL & SKELETAL CHANGES ARE IRREVERSIBLE.

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FLUOROSIS IN INDIA

NUMBER OF STATES AFFECTED 19

NUMBER OF DISTRICTS AFFECTED 230

THE STATES ARE:

ASSAM, ANDHRAPRADESH ,BIHAR, CHHATTISGARH,GUJARAT, HARYANA, UTTRAKHAND, JHARKHAND,KARNATAKA, KERALA, MAHARASHTRA,MADHYA PRADESH, MEGHALAYA, ORISSA, PUNJAB,

RAJASTHAN,TAMIL NADU, UTTAR PRADESH & WEST BENGAL. 

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OBJECTIVES

• TO COLLECT, ASSESS AND USE BASELINE DATA OF FLUOROSIS OF DEPT. OF DRINKING WATER FOR STARTING THE PROGRAMME.

• COMPREHENSIVE MANAGEMENT OF FLUOROSIS IN SELECTED AREAS.

• CAPACITY BUILDING FOR PREVENTION, DIAGNOSIS & MANAGEMENT OF FLUOROSIS CASES.

• GOAL: TO PREVENT AND CONTROL FLUROSIS IN THE COUNTRY.

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National Iodine Deficiency Disorders Control Programme (NIDDCP)

• Iodine Deficiency is hidden hunger, micronutrient required daily for entire population.

• Can result in abortions, stillbirth, perinatal death, loss of IQ, compromised school performance related to HRD & productivity and MDG I & IV

• Iodated salt is the cheapest & best source to supplement it• It is present in all States / UTs• 51% people are consuming adequately iodated salt in the

country as per NFHS-III.(2005-06).

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OJECTIVES & GOALSOBJECTIVES 

SURVEYS TO ASSESS MAGNITUDE OF THE IODINE DEFICIENCY DISORDERS.

SUPPLY OF IODATED SALT IN PLACE OF COMMON SALT.

RESURVEYS TO ASSESS THE EXTENT OF IODINE DEFICIENCY DISORDERS AND THE IMPACT OF IODATED SALT AFTER EVERY 5 YEARS.

LABORATORY MONITORING OF IODATED SALT AND URINARY IODINE EXCRETION.

HEALTH EDUCATION & PUBLICITY 

GOALS• To reduce prevalence of IDD below 5% in the entire country by 2017 AD.• To ensure 100% consumption of adequately iodated salt (15 PPM) at the household level.

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MILESTONES ACHIEVED

• Visible goitre which was ranging 3 to 10 % in nineties reduced to 0.75% to 2.5%

• Cretins due to nutritional iodine deficiency are now rarely born.

• The production & supply of iodated salt has achieved target of 58lakh tons in 2010-11 from 5 lakh tons in 1985-86 for entire population.

• The household consumption of adequately iodated salt is about 71% as per coverage evaluation survey 2009-10.

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Key Issues & Way Forward• Establishment of IDD cell and IDD monitoring

laboratory with all sanctioned staff.• To complete district IDD survey of all districts.• To enforce Central ban on sale of salt other than

iodated salt for direct human consumption under FSS Act, Rules / Regulation 2011.

• Community level monitoring and creating awareness about IDD and consumption of adequately iodated salt through salt testing kits.

• SOE & UC of fund released.

Oral Health Programme• National programme is intended to assist states to take it

forward where state program is in progress and kick start the programme in other states who need to include it in their PIP.

• During 2012-13, 16 States have been given Rs.29crore through State PIP under NRHM for strengthening oral health

services. • National capacity building scheme has been proposed to

assist the State by providing Training of Trainers (ToT), IEC prototype material and Monitoring and Evaluation (M&E).

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Palliative Care• Palliative care is for terminal illnesses e.g. cancer, AIDS etc.

• Morphine is effective pain killer, least expensive and without much side effects

• Morphine can control pain effectively (regulated -NDPS Act)

• Clinic for Palliative care OPD and some beds (or even ward ) should be for palliative care

• Training for Palliative care required for doctors/Nurses

• Coordination is required between various agencies e.g. Medical, narcotics, drugs, excise etc. for Morphine availability

• Hospice may also be established for dying patients which can not be treated at home/hospital

• Awareness is required that pain can be controlled with Opiods including Morphine

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Palliative care - II

• 13 states and 1 UT has simplified the NDPS rules so far

• Supreme Court case WP (civil) 76 of 2007 IAPC Vs UOI & Others incl. all states

• Expert Group on Palliative care constituted.• Amended NDPS Act (Deptt. of Revenue)• New Model rules applicable uniformly throughout India• At least 2 Registered Medical Institutions per district

for Morphine and later more nos.• Healthcare professionals learning and executing

effective pain management

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District Level Palliative care•4 – 6 beds Palliative care ward for terminally ill

patients

•OPD for Palliative care (may be afternoon clinic)

•4 Nurses required exclusively for admitted patients and OPD

 • 1 Doctor and one Nurse to be trained in Palliative care

course ( one month training) 

• Doctors and nurses may undergo sensitisation training (1-3 days) in Palliative care  •Access to availability of Morphine for palliative care to

be ensured

Genetic Blood Disorders like Thalasmia, Sickle Cell Anemia, Hemophilia and other

NCD.• Although not a national phenomenon yet it is very distressing for

people in areas where the disease is prevalent.

• Under NRHM/RCH the states have been asked to give specific need based proposal for strengthening of hospitals in their PIP for components like human resource, training, reagents, equipments etc.

• National Blood Transfusion Council (NBTC) under NACO has issued guidelines to all States that Blood Transfusion to patients of such life threatening disease be provided free by all Blood Banks.

• State Govt. need to also cater to patients suffering from Chronic Kidney Disease and Chronic Obstructive Lung Disease and submit the need based proposal in their PIP to strengthen the hospitals to provide special services including beds, ICU, equipment, reagents, Lab support, radiological support as also employ specialists and train necessary manpower.

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Action by States on the above

• Include proposals in state PIP, if not included. • Assess additional requirement for establishing

proper referral services, diagnosis, management of patient.

• Make available super-specialty services in regional and state level

• States should emphasize on Training of Doctors, Nurses and paramedics.

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