Indian Health Care Sector

SSridhar · Post by **SSridhar** » 28 Sep 2012 18:22

Acknowledging that rabies is a major public health challenge in India, the government proposes to make it a priority disease for control under the 12th Five Year Plan.

A viral zoonotic disease primarily infecting domestic and wild animals, rabies spreads to people through close contact with infected saliva via bites and scratches. There is no treatment available globally after the disease develops. An estimated 20,000 deaths occur annually in India due to rabies.

While dogs are the main host and transmitters, others responsible for the disease are cat, mongoose, monkeys and such other warm-blooded animals.

But the disease is preventable.

Strategies to prevent death due to rabies were developed through a pilot project during the 11th Plan and these strategies are proposed to be implemented countrywide in the 12th Plan, officials in the Ministry of Health and Family Welfare told The-Hindu. The 11th Plan targeted reduction of rabies deaths in humans by at least 50 per cent by the end of the Plan period in the pilot project that covered Ahmedabad, Bangalore, Pune, Madurai and Delhi.

As of now, India does not have a comprehensive national rabies control programme. Various organisations are involved in control activities without any inter-sectoral coordination. The existing prevention activities are being carried out by municipal bodies, but no tangible results have been achieved.

Experience gained from the implementation of the pilot project indicates that the strategy is feasible, reproducible and implementable. It is now proposed to roll out a comprehensive control strategy for both human and animal components in the 12th Plan. All 35 States/UTs will be covered for the human component and the animal component will be piloted in selected 30 cities.

The programme will include training health professionals to deal with animal bites, awareness creation and minimising animal bites. On the veterinary side, the focus is on sterilisation and vaccination of dogs, with a larger involvement of civil society and municipal bodies.

Advocating the need for greater awareness of the disease, the World Health Organisation (WHO) says children and poor people are particularly vulnerable.

The disease claims 55,000 human lives across the world every year, mostly in Africa and Asia. The number of animal bites in India, however, is not reliably known, though some studies have estimated it to be as high as 17.4 million a year. The last survey conducted by the Association for Prevention and Control of Rabies in India in 2003 was supported by the WHO and it put the number of deaths at 20,000. About 90 per cent of the mortality and morbidity here is associated with dog bites.

Modern, safe and effective anti-rabies cell culture vaccines are being used for post-exposure treatment in India after the government banned the production and use of nervous tissue vaccine in December 2004. Intradermal rabies vaccination has been promoted at the State level in designated rabies clinics.

The WHO says prevention of human rabies is possible through mass dog vaccination, promotion of responsible dog ownership and dog population control programmes with a partnership approach. Many countries in South America and Asia have successfully used this strategy to eliminate transmission of rabies.

However, this is a challenge for India as it has a large population of dogs (around 25 million) and very low vaccination coverage.

SSridhar · Post by **SSridhar** » 12 Oct 2012 15:52

Institutional Deathbeds
Talks about maternal mortality even in hospitals, in some states.

SSridhar · Post by **SSridhar** » 15 Oct 2012 09:00

eICU to the rescue of remote hospitals

“One of the biggest challenges… today is access to healthcare. There are an estimated five million ICU admissions a year in this country, and not even 500 trained intensivists. In 25 years, the facilities in the metros have improved, but they continue to be a huge issue in Tier-II and Tier-III cities/towns,” says Amit Verma, Director, Critical Care Medicine, Fortis Escorts Heart Institute. There continues to be lack of adequate talent and the attempt is to improve the position by providing expert care through dedicated 5-mbps LAN lines.

The remote hospital is connected to the Central Command Centre, where specialists offer expert advice. Critinext equipment is wired to the devices in the local hospital’s ICU, ventilator pumps, patient monitors and the local health information system, if any.

Anurag Mishra, business leader, GE Healthcare-IT, explains that the equipment captures critical data relating to a patient at the local hospital, digitises close to 100-data points and transmits all information to the Central Command Centre real time. “With this, a doctor sitting in the super-speciality hospital can do as much as the medical personnel in the local hospital,” he says.

“The Command Centre works through the year, 24/7,” Dr. Verma says. “We provide guidance based on the inputs received by us through the software, can look at the patient on video monitors, grade the average length of stay in the ICU, guard against administration of unnecessary high-end antibiotics.”

The eICU has been a blessing many times, he adds. Last month, a five-year-old, diagnosed with Acute Respiratory Distress Syndrome at the partner hospital in Raipur, was managed with ventilator support at the local hospital itself. He was able to walk home in just over 72 hours. Similarly, an elderly gentleman who collapsed at the Dehra Dun partner hospital had to be shifted to the ICU. While he could not have stood the rigours of travel to a higher institution, the eICU came to his rescue. “Since they had access to us at a critical time, we were able to save the patient,” Dr. Verma recalls.

“Unless there is a situation where there are insufficient equipment to handle the case, the need to shift the patient is eliminated. It is, however, a call that the medical experts have to take,” Mr. Mishra adds.

Currently, eICU links the Central Command Centre at Fortis Hospital, Delhi, to its institutions in Amritsar, Agra, Raipur and Dehra Dun, servicing 100 ICU beds. There are grand plans for taking this further. The big advantage is that the know-how requirements at remote hospitals are simple: “It is enough to know how to send an e-mail. Everything else is done by the software,” Dr. Verma says.

SSridhar · Post by **SSridhar** » 16 Oct 2012 07:24

Eye surgery innovation in Chennai goes global

Like any girl her age, ten-year-old Anandi relishes a good anecdote.

But, the story of the little girl who suffered trauma in one eye in a firecracker accident is probably no less fascinating than anything she would have come across.

In fact, the innovative surgery that restored perfect vision to this Villupuram girl is now a world-famous case study as well as source material for a textbook in ophthalmology.

When Anandi first came to Dr. Agarwal’s Eye Hospital in Chennai as a four-year-old with an injury that had completely damaged an eye, there was virtually no tissue scaffold for suturing in an intraocular lens (IOL) implant.

“In such cases, suturing in an IOL implant would have been wrought with problems ranging from shaky vision, displacement of the lens or disintegration of the suture. This girl became one of the first paediatric cases where we performed a glued IOL using gum derived from human tissue,” said Dr. Amar Agarwal, chairman and managing director of the hospital group.

The suture-free technique perfectly addresses many of the problems associated with suturing an IOL in an inadequately supported posterior chamber and the glued IOL moves in complete sync with human movement, he said.

The fibrin glued intrascleral haptic fixation of a posterior chamber IOL pioneered in Chennai is now an accepted global standard for cataract or trauma patients who lack adequate posterior chamber support for an IOL device implantation.

According to Dr. Amar, apart from trauma and cataract cases there is a third category of patients with congenitally compromised posterior chamber support for the eye lens — the offspring of consanguine parents. Invariably, these patients who have lenses that are moving all the time are ideal candidates for the procedure.

SSridhar · Post by **SSridhar** » 09 Nov 2012 08:45

Indian Surgeon's Cheaper Kidney Transplant Protocol - The Hindu

A treatment protocol that drastically reduces the cost of kidney transplants, developed by a Hyderabad-based nephrologist, has been adopted successfully in several developing countries.

The Philippines, Cuba, Guatemala and the Dominican Republic have already implemented Dr. K.S. Nayak’s treatment approach, while several other Latin American countries are in talks with him to firm up the modalities to incorporate it in their surgery protocols. The protocol, Dr. Nayak said, would bring down the cost of therapy for those undergoing transplants. “The one-time cost of the equine-based drug is Rs. 35,000. The rabbit-derived drugs meant for the same purpose cost more than Rs. 1 lakh. Moreover, the rabbit-based antibodies have to be administered multiple times, escalating the cost for the patient. Our management protocol involves administering low doses of equine-based drug and managing the patient carefully,” Dr. Nayak told The Hindu . The drastic reduction of the cost of therapy was acknowledged in an article published in the latest issue of ‘Harvard Business Review’, he said.

Expensive

According to him, drugs account for the high cost of kidney transplants. To ensure that the body accepts a foreign organ and to avoid rejection, patients are given antibodies that suppress immunity. Right now, these antibodies are usually derived from horses and rabbits. “The rabbit-origin drugs are expensive and multiple doses are usually given. If the same antibodies derived from horses are given, the cost would come down drastically and a single dose would be sufficient,” he says. “This is a proven technology but the procedure is not getting due recognition in western countries now. Even in India, there are only four or five centres that employ this method.”

Dr. Nayak, Director of Renal Services at Lazarus Hospital, laments that pharma firms shy away from producing equine-based drugs despite their success. “Only one Indian company, Bharat Serums and Vaccines, manufactures this drug.”

So far, close to 75 patients in Hyderabad, 120 in the country and 400 patients worldwide have successfully received transplants using Dr. Nayak’s approach. “Worldwide, the acceptable rejection ratio for kidney transplants is 20 per cent. Evidence shows that our technique has a rejection rate of [only] seven per cent. Even among the seven per cent, there is 90 per cent chance of reversal of rejection,” says the senior nephrologist.

Dr. Nayak’s evidence-based studies were published in the 2007 issue of the prestigious medical journal, Transplantation Proceedings .

SSridhar · Post by **SSridhar** » 16 Nov 2012 17:55

Public Health System in India has Collapsed: Jairam Ramesh

Union Rural Development Minister Jairam Ramesh on Friday said public health system in the country had “collapsed”, noting that even poorer countries like Bangladesh and Kenya have superior health indicators.

In a candid assessment of the country’s health sector, Mr Ramesh also said 70 per cent of the health expenditure is met from private sources, making it a “unique” country. This was the “single most important” reason for indebtedness in rural areas, he added.

“Today the single most important reason for rural area indebtedness is expenditure on health. We all know that the health system in India has collapsed. India is unique country in the world where 70 per cent of the health expenditure is private expenditure,” he said at the Hindustan Times leadership summit in New Delhi.

In many part of India, he said, public health system simply does not exist.

Mr Ramesh also noted that countries all over the world are debating the issue of increasing public spending on health.

To improve the social indices, the outspoken Minister wanted States to make a fundamental commitment for creating elected institutions and institutions of participation, noting that such measures has helped States which have abided by this commitment.

In this regard, he noted that in large parts of India where elected representatives are strong or participating institutions are strong, they have better social outputs.

He said the secret of success of Bangladesh and Kenya who have superior infant mortality rates and sanitation facilities are due to empowerment of women. “They have been able to deliver than richer country like India“.

Asserting that health would remain his top priority, Mr Ramesh said improvement in hygiene and sanitation has led to improvement in infant mortality rates.

SSridhar · Post by **SSridhar** » 17 Nov 2012 04:57

WHO eases norms on Serum Institute of India's meningitis vaccine

In a breakthrough, a key India-made meningitis vaccine can now be transported or stored for up to four days without refrigeration, which could help combat the disease in poor countries.

According to researchers, the meningitis A vaccine known as MenAfriVac, created to meet the needs of Africa’s meningitis belt, can now be kept in a controlled temperature chain (CTC) at temperatures of up to 40° Celsius for up to four days.

Costing less than $0.50 per dose, the innovative vaccine is manufactured by Serum Institute of India Ltd (SIL).

SIIL has dramatically reduced the disease burden in the first countries to introduce it, according to recently published findings.

The decision could help increase campaign efficiency and coverage and save funds normally spent maintaining the challenging cold chain during the “last mile” of vaccine delivery.

The outcome of the review and decisions of the Drugs Controller General of India (DCGI), supported by a Health Canada analysis and confirmed by the World Health Organisation (WHO) Vaccines Pre-qualification Programme, was revealed during the ASTMH conference in Atlanta by Godwin Enwere, Medical Director for the Meningitis Vaccine Project.

The regulatory approval has the effect of permitting the re-labelling of MenAfriVac, while ensuring that the vaccine remains effective and safe throughout its life cycle.

MenAfriVac is the first vaccine designed specifically to help health workers eliminate meningococcal A epidemics from Africa’s “meningitis belt,” which includes 26 countries from Senegal to Ethiopia.

“The potential for some vaccines to remain safely outside the cold chain for short periods of time has been widely known for over 20 years,” said Dr Michel Zaffran, Director of Optimise, the PATH-WHO collaboration aimed at improving immunisation systems and technologies.

“But this is the first time that a vaccine intended for use in Africa has been tested and submitted to regulatory review and approved for this type of use. And we expect this announcement to build momentum for applying the CTC concept to other vaccines and initiatives, allowing us to save more lives in low-income countries,” Zaffran said.

Evidence of the heat stability of MenAfriVac was validated by a team of experts from WHO, PATH, SIIL, and Health Canada.

SSridhar · Post by **SSridhar** » 17 Nov 2012 13:43

Little Indian Presence at World Meet on Lung Disease

In spite of India carrying the major burden of tuberculosis in the world, there is little presence of top-level policymakers at the 43r{+d}Union World Conference on Lung Diseases that has a focus on TB.

Talking to The Hindu , Blessina Kumar, public health consultant and vice-chair, Stop TB Partnership, said the lack of Indian presence was most noticeable. Most of the African countries had their top- level officials in the national TB programme management presenting their cases.

Out of the total 90 lakh cases the world over, India accounted for 20 lakh cases in the WHO estimates in 2009. Of the 13 lakh people who died, India had accounted for nearly 3 lakh.

Speaking on the TB scourge in India, Ms. Kumar said with the bottlenecks of diagnosis and treatment seen as major hurdles, the government should have a relook at the Directly Observed Treatment Short course (DOTS) under the Renewed National Tuberculosis Control Programme. It is over 12 years that the scheme has been running and the government, instead of being defensive about the programme, should review it for the sake of better implementation practices.

Certain aspects of TB control can be enforced without delay, said Ms. Kumar. Controlling the availability of TB drugs over-the-counter is the first step and it will bring down the number of multi-drug resistant TB. The statistics on multi-drug resistant TB in the country could be much higher than what the government figures reveal, she added.

SSridhar · Post by **SSridhar** » 18 Nov 2012 08:35

Finding bone morrow donors, challenge of the morrow - Ramya Kannan, The Hindu

N.K. Mehra, Head, Department of Transplant Immunology and Immunogenetics, All India Institute of Medical Sciences, New Delhi, is acknowledged by all in the sector as the leader in Human Leucocyte Antigen (HLA) typing in the country. He says, “Research carried out at AIIMS has shown that the population of India, even though similar in broader terms with the Caucasian population, has many novel HLA genes not occurring in that population.” The diversity of HLA genes in the Indian population is extremely vast, he adds.

Therefore, the existing pool of 19.6 lakh bone marrow donors across the world is not of much use to India, Dr. Mehra reasons. In actual terms, this means that Persons of Indian Origin have a one-tenth chance of finding a donor from this pool, compared to a Caucasian. “In a diverse country like India, we need a registry of one million donors, if we are to meet over 40 per cent of the requirements for bone marrow donors,” he adds. “There are probably just over 50 donor registries worldwide, with about 20 million registered donors,” explains Raghu Rajagopal, CEO, Datri Blood Stem Cell Donors Registry. As of today, India has four registries, and an estimated under 40,000 enrolled donors.

nawabs · Post by **nawabs** » 21 Nov 2012 01:58

Novartis vs. India: Battle the world watches, restarts

http://www.governancenow.com/news/regul ... s-restarts

Beginning November 20, two of India’s most respected judges, Justice Aftab Alam and Justice Ranjana Prakash Desai, begin to hear Gopal Subramaniam, lead counsel for Swiss drug maker Novartis and former Solicitor-General, for his final arguments. The other side, Harish Salve and Prathiba Singh, finished theirs some weeks back.

So, here are the two scenarios.

If the judges say Novartis indeed deserves a patent for imatinib mesylate (marketed as Glivec and priced up to $90,000 or about Rs 50 lakh per year) innovation companies across the world will salute Indian judiciary for protecting what they claim are rights that have been hurt recently in two cases. One involved Bayer and the other Roche. Both losses in India’s courts have been liberally used to paint the entire judicial system as uncaring for folks who spend billions of research dollars to create new molecules that, ironically, save Indian lives. By implication, Indian judges, these commentators crib, are ready to turn their eyes away from theft that home-grown patent busters inflict on what bona fide inventors take decades to create. This group pitches a potential Novartis win as a huge leg-up for the India story, a compelling case for foreign drug makers not being forced to overfly India. Who would risk their new blockbuster in a country that’ll rip them off! A Novartis win will end fears that prolonged litigation notwithstanding (Novartis took Indian patent authorities to court in 2006!) not all Indian judges favour the somewhat emotional “access” argument. Conversely, there’s place under the sun for the original owner. After all, Novartis (and Bayer and Roche before them) in any case shares part of its social contract giving the poor free medicines.

Scenario (B) on the other hand, emerges if judges Alam and Desai find themselves on the side of Salve and Singh. Both have drilled serious holes in the Glivec ship. That India's patent law (Section 3-d being the most contentious section) must be read in a language that the poor understand. And not only is the Novartis molecule no big deal, the free medicine part is a PR exercise with no corresponding coverage to the millions who are left out. What Salve and Singh have sought to prove is that not just the poor in India, but the entire planet wherever cheaper generics manufactured in India make a difference, see the apex court defining society’s choice between life and death.

Which of these scenarios work better for us?

To help you take sides, here’s some of the legalese crunched for dummies.

A new form of a known medicine can only be patented only if it shows significantly improved therapeutic efficacy over existing compounds; Novartis and the “innovator’s gang” are being accused of trying to run with the common industry practice of extending, or 'evergreening’, their patent monopolies for routine modifications of known compounds.  

Medecins Sans Frontieres (MSF-Doctors without Borders) claims Novartis' patent application was on a new form of the imatinib molecule already described several years previously in patents in the US and other developed countries.  They term the case in India as Novartis’ final bid to undermine a key public health safeguard in our patent law presciently designed to prevent those like Novartis from abusive patenting practices which keep medicine prices high.  

“If successful, the move would have a devastating impact on access to essential medicines across the developing world,” MSF said Monday.Understandable. These folks rely on affordable generic drugs produced in India to carry out their work in 68 countries.

India, both warring sides appreciate, is the developing world’s pharma factory. The stakes therefore run several times of India’s $12-billion market, 90 per cent of it being in generics.

It bears repetition that “3(d)” led to Novartis being denied a patent for chronic myeloid leukemia and intestinal cancer. Novartis is contesting the Indian patent office’s and the appellate body’s decisions to reject its application for a patent on the salt form of imatinib.

MSF says a win for Novartis will set a dangerous precedent, severely weakening India’s legal norms against “evergreening.” “A single medicine can have several applications for separate patents, each relating to a different aspect of the same medicine. This would inevitably lead to patents being granted far more widely in the country, blocking the competition among multiple producers which drives down prices, and restricting access to affordable medicines for millions in India and across the developing world,” MSF said.Besides arguments from generic companies and the counsel for the government, the Cancer Patients Aid Association also deposed to defend India’s strict patentability criteria.

Those supporting the Novartis claim say Glivec is a sign of pioneering pharmaceutical research. Above all, Novartis’s is a ‘life-saving’ drug, just as Roche’s anti-cancer drug Tarceva (Rs 140,000 per month versus Cipla’s Erlocip for Rs 25,000 pm was) or Bayer’s Nexavar.

I would recommend a robust counter argument, including explanatory interpretations on “3-d” and the role Novartis may be overplaying in the evolution of Glivec, by Prof Dwijen Rangnekar of the University of Warwick

Also, I would question lawyers/advisors to multinationals who are scaring their clients by painting Indian judges with a broad brush. Which judge won’t be put off by imported drugs costing an arm and a leg? A firmer footing is to demonstrate local manufacturing (eg what Gilead has done with Viread via voluntary, non-exclusive licences to Indian manufacturers) and thereby show the judges an economic multiplier within India.

Indian courts don’t kill innovation and patents. They balance between the extreme polarities of access and innovation.

That said, surely, there’s a lot more billing in threat construction. But the truth, albeit a relatively unpublicised one, is that Indian companies have won several patent dharmayuddhas!

SSridhar · Post by **SSridhar** » 04 Dec 2012 07:23

280% increase in incidence of cancer in 3 decades in Kerala

The Regional Cancer Centre (RCC) here has reported a 280 per cent increase in the number of cancer cases in the past three decades in the State, a cause for concern especially as environmental and lifestyle changes are believed to be behind the huge disease burden. In those 30 years, 2,49,362 new patients reported at the hospital for treatment. If in 1982 only 3,696 new patients came to the hospital, the number shot up to 14,016 in 2011.

While a reason for the huge increase can be better awareness and improved medical facilities prompting more patients to seek treatment, cancer incidence has increased in the State without doubt.

The data have been released by the hospital-based cancer registry of the centre, which is completing 30 years after being set up under the National Network for Cancer Registry Programme of the Indian Council for Medical Research.

The hospital handles more than one-third of the cancer cases reported in the State. The registry data show that breast and thyroid cancers have become the predominant cancers in women in the State, unlike 30 years ago, when cancer of the uterine cervix affected them most.

In 1982, the most common cancers among women were cervical, breast, oral and thyroid cancers in that order. However, in the 30 years, if cancer of the uterine cervix declined significantly, breast cancer incidence, especially among younger women, rose steeply. As of 2011, breast cancer is the leading cancer among women, accounting for 28.1 per cent of all cancers among women reported in the hospital.

Thyroid cancer accounts for 13.2 per cent, cervical cancer, 8.2 per cent and oral cancer, 6.8 per cent.

The huge increase in the number of breast and thyroid cancers among women here puzzles epidemiologists.

Among men, though oral cancer continues to be the most common cancer, its number has shown a decline from 29.3 per cent in 1982 to 13.9 per cent in 2011. However, lung cancer incidence has remained more or less constant during the period, even showing a marginal increase from 11.9 per cent in 1982 to 13.6 per cent in 2011.

Over the years, the highest proportional increase of patients has been found for leukaemia, followed by cancers of the prostate, rectum and thyroid. Aleyamma Mathew, Additional Professor, who heads the Epidemiology Division of the hospital, says cancer registration is an important component of a cancer-control programme, as it helps in the assessment of the pattern and magnitude of cancer incidence in society. It helps researchers monitor the variation in cancer incidence over time by organ of affliction, stage at diagnosis, patient management and survival.

SSridhar · Post by **SSridhar** » 06 Dec 2012 08:44

India should devise plans to tackle anti-microbial resistance

Chennai: India needs to take urgent initiatives to formulate an effective national policy to control the rising trend of antimicrobial resistance, including a ban on over-the-counter sale of antibiotics, and changes in the medical education curriculum to include training on antibiotic usage and infection control.

‘The Chennai Declaration: A roadmap to tackle the challenge of antimicrobial resistance’ published in the latest edition of Indian Journal of Cancer has recommended that an Infection Control Team (ICT) be made mandatory in all hospitals. Regulatory authorities and accreditation agencies such as the National Accreditation Board for Hospitals and ISO must insist on a functioning ICT during the licensing and accreditation process.

The recommendations include offering Post-MD/DNB (internal medicine) sub-specialisation in Infectious Diseases at all post-graduate centres that offer sub-speciality training, compulsory training in infection control and infectious diseases training in under-graduate and post graduate curriculum in all specialities. The Medical Council of India should introduce one-week antibiotic stewardship and infection control training in the third, fourth and final year of MBBS and two-week training at the PG level.

Recommending the setting up of a National Task Force to guide and supervise the regional and State infection control committees, the paper suggests that the National Accreditation Board for Hospitals & Healthcare Providers (NABH) insist on strict implementation of hospital antibiotic and infection control policy, during hospital accreditation and re-accreditation processes.

The paper on The Chennai Declaration has been written by A. Ghafur, D. Mathai, A Muruganathan, J.A Jayalal, R. Kant, D. Chaudhary, K. Prabhash. O.C. Abraham, R. Gopalakrishnan, V. Ramasubramanian, S.N. Shah, R. Pardeshi, A. Huilgol, A. Kapil, J.P.S. Gill, S. Singh, H.S. Rissam, S. Todi, B.M. Hegde and P. Parikh, all experts in their respective fields.

Surveillance

“The Indian Council of Medical Research should broaden the antimicrobial resistance surveillance network, incorporating hospitals from government and private sectors in addition to providing funds for research on antimicrobial resistance, drug development and infection control,” the paper says. There is an urgent need to standardise microbiology laboratories in India, the paper points out while highlighting the role of media and non-governmental organisations in creating awareness on the dangers of misuse of antibiotics.

The paper also speaks of the need to regulate antibiotic usage in veterinary practice.

Antimicrobial resistance is a serious global challenge. Every continent and country face the menace of antibiotic resistant ‘super bug,’ though the extent and the severity of the problem varies.There is at present no functioning national antibiotic policy or a national policy to contain antimicrobial resistance in India. The policy published in 2011 has been put on hold due to non-availability of major recommendations.

India, with more than 20,000 hospitals, more than a billion population, wide cultural diversity, and a large medical community, will find the resistance problem an issue very difficult to tackle unless wholehearted and joint efforts are initiated to tackle it on a war footing, the Chennai Declaration says.

The paper was drafted at the pre-conference symposium of the second annual conference of the Clinical Infectious Disease Society (CIDSCON) held in Chennai in August.

SSridhar · Post by **SSridhar** » 06 Dec 2012 16:48

New gene causing Type-2 diabetes found

The discovery of a new gene causing Type 2 diabetes in the Indian population by an entirely Indian cast of researchers has opened up a hitherto unknown and new line of enquiry into the mechanism of the disease.

According to a paper published in the December edition of Diabetes, the gene was identified after running through a massive sample size of over 12,500 persons in the Indian subcontinent. “The new gene that was identified is a neuro gene, with no known association with Diabetes. So what is it doing in Type 2 Diabetes?” the principal investigator of the study, Dwaipayan Bharadwaj, said. He is with the Genomics and Molecular Medicine Unit, Council for Scientiﬁc and Industrial Research-Institute of Genomics and Integrative Biology, Delhi.

“Among the common variants, this is the major variant in the Indian population. So it certainly has a role to play. My hypothesis is, perhaps, diabetes is more a neurological disorder – it probably explains the temptation to eat when you see a plate of good food in front of you,” Dr. Bharadwaj added. This gene increases the risk of developing Type 2 Diabetes to 1.6 times higher in the Indian population.

The involvement of a neuro gene opens up a spectacularly new area, said Nikhil Tandon, one of the authors, who is a professor of Endocrinology at AIIMS. It facilitates a potentially new line of enquiry into understanding of the mechanism of this disease. “This gene is a synaptic transporter. Maybe there is an issue with the way insulin is being transported? Various functional studies have been lined up down the road,” he said. Understanding the mechanism will translate to better diagnostics and treatment methods, though that is still in the distant future, he added.

The association of this gene with diabetes in the Indian population is higher and stronger than any other gene, the authors explain.

The other key point in this study, Dr. Bharadwaj explains, is that it is entirely Indian with a massive sample size. The two groups that were studied included North Indians, and Dravidians, the latter sample provided from the Chennai-based Madras Diabetes Research Foundation – Indian Council for Medical Research Advanced Centre for Genomics of Diabetes.

Dr. Tandon said, “If you look at all collaborative research in genetics, most of them are initiated and driven by developed country partners. Even if there are Indians, they are possibly one of a large body of investigators. It is an important point that a study of this magnitude has been conceived in India, funded by Indian money (CSIR), and was completely executed by Indians.”

Bringing to play all the 60 known genes causing diabetes still explains only about 10 per cent of the risk of diabetes, Dr. Bharadwaj says. There is a huge role for environmental and lifestyle risk factors on the disease. Dr. Tandon added, “It does mean that even if you have bad genes, you can sort yourself out.”

SSridhar · Post by **SSridhar** » 08 Dec 2012 07:52

Mechanical device offers an alternative to heart transplant

A mechanical heart implant device, which has, among its beneficiaries, former US Vice President Dick Cheney, is set to play a larger role as an alternative to transplant for patients with severe heart failure in India.

Doctors at Fortis Malar Hospital on Thursday successfully implanted the HeartMate II Left Ventricular Assist Device (LVAD) on a 58-year-old patient.

The device takes over the function of the left ventricle in pumping blood to vital organs and is the most sophisticated technology available for offering a permanent solution to advanced heart failure, the doctors said.

Advantages

Unlike the first generation pulsatile pumps on pneumatic drive, which have been associated with valve failure, this device is a rotary-assist pump that provides continuous blood flow once placed just beneath the diaphragm. One end is connected to the left ventricle and the other to the aorta, the main artery carrying oxygenated blood to the entire body. The ensemble also has an external controller unit worn under clothing.

“The striking thing about the LVAD is that the 90 per cent survival rate of ten years or more is better than the gold standard of heart transplants and almost replicates the natural survival phenomena,” said Dr. K. R. Balakrishnan, Director, Cardiac Sciences, who led the surgery team.

Some of the improved features of LVAD, which has been scaled up from a “bridge to transplant” procedure to a “destination therapy” by the US Food and Drug Administration, include thrombo resistance (no clotting), less trauma to blood components, and unimpeded blood flow.

The patient was off the ventilator in three days, his renal and liver functions were restored in 10 days and he was walking in just two weeks, said Dr. K.G. Suresh Rao, head of cardiac anaesthesia. The LVAD as a bridge to transplant procedure would have required the patient to be tethered to a large console until a donor organ was secured, he pointed out.

However, there are downsides too, such as the exorbitant cost (upwards of Rs. 50 lakh), the discomfort of wearing the power source under clothes and the pre-requisite of a functional right ventricle for this assist device to work, Dr. Balakrishnan said.

In spite of the high cost of the imported device, doctors believe that there could be a pool of patients who could afford to benefit from the LVAD as it offers a viable alternative to a heart transplant. An estimated 1.5 million new cases of heart failure emerge every year in India and 50 per cent of them die within five years, making survival rates for the disorder much worse than even cancer. Mortality risks for advanced heart failure are more acute with 90 per cent of patients dying in two years, doctors pointed out.

“The device could meet a largely unmet demand in a country like India, which only does about 2,000 heart transplants a year due to donor organ shortage,” Dr. Balakrishnan said.

SSridhar · Post by **SSridhar** » 08 Dec 2012 09:45

Taluka Hospital Doctors perform complicated procedure on 8-day old baby
It is heartening to see many such reports from such hospitals.

Doctors at the Government Hospital (GH) at Tirupattur performed an ‘emergency procedure’ on an eight-day-old-boy baby suffering from tension ‘pneumothorax,’ a condition in which air is trapped in the pleural cavity between the lungs and chest wall.

A team of doctors of the Special Neonatal Care Unit (SNCU) of the Tirupattur GH performed the procedure on the son of Kabila of Periyagaram on Thursday. The baby was born in the hospital.

Two days ago, the family had given some medicine to the baby.

The medicine was aspirated by the baby and this caused chemical pneumonitis leading to secondary infection and caused alveoli rupture causing tension ‘pneumothorax,’ R. Senthilkumaran Assistant Surgeon Paediatrics of Tirupattur GH said.

The child was brought to the GH on Thursday evening and was critical.

In this condition, the baby was under distress with poor oxygenation.

The air compresses the lungs and prevents it from expanding. He was sweating badly. We used a diagnostic needle to confirm the presence of air in the pleural cavity, he added.

A team of doctors including Dr. Senthilkumaran and paediatricians Palani and Madhu performed the intercostal chest drainage procedure on the baby at about 11.30 p.m.

“This procedure is very complicated. It involved insertion of tube into the pleural cavity to remove the trapped air through it. The air was released into an underwater seal and as the lungs started to expand, the baby was relieved of the distress,” he explained.

Such a procedure was first of its kind to be performed at taluk-level hospitals such as the Tirupattur GH, he added.

Varoon Shekhar · Post by **Varoon Shekhar** » 11 Dec 2012 19:53

And it's nice to see it being done in a government hospital, rather than in a super specialty, private one( nothing instrinsically wrong with those, of course)

SSridhar · Post by **SSridhar** » 18 Dec 2012 11:49

WHO clearance could boost export of India-made vaccines - The Hindu

In a major boost to the country’s private vaccine manufacturing pharmaceutical companies, the World Health Organisation (WHO) has said that India’s national regulatory authority — Central Drugs Standard Control Organisation (CDSCO) — and its affiliated institutions meet the prescribed international standards.

India is a major vaccine producer with 12 major vaccine manufacturing facilities. These vaccines are used for the national and international market, reaching nearly 150 countries. Every second child in the world is vaccinated for measles using a vaccine produced in India.

India is the first country in the 2012 round of assessment to have passed the strict levels of seven indicators which are made more stringent every time in a single round of assessment which is done by a team of 12 international experts headed by a WHO member.

Passing of this test means that 12 private vaccine manufacturing units from India are eligible and retain the pre-qualification status for supplying vaccines to international bodies like the WHO, UNICEF and the World Bank. WHO pre-qualification is a guarantee that a specific vaccine meets international standards of quality, safety and efficacy.

The clearance by the WHO is expected to boost investment in the pharmaceutical sector and push exports higher, which touched $13 billion last year and is expected to touch $26 billion this year. Two-thirds of the vaccines produced in India are exported.

The WHO has established benchmarks that define international expectations for a functional vaccine regulatory system.

It also conducts regular external audits of national regulatory systems and ensures they meet the necessary standards. The regulatory functions of India’s National Regulatory Authority (NRA) — the CDSCO — and its affiliated institutions were assessed for compliance against the WHO indicators and marketing authorisation and licensing, post-marketing surveillance, including adverse events following immunisation and so on.

In 2007, when the CDSCO had failed to meet the WHO-prescribed standards, it had led to the WHO suspending manufacturing licenses of three public sector vaccine manufacturing units — Central Research Institute (CRI), Kasauli; Bacillus Calmette-Guérin Vaccine Laboratory (BCGVL), Guindy; and Pasteur Institute of India (PII), Coonoor, on account of non-compliance of good manufacturing practices (GMP) norms.

sanjaykumar · Post by **sanjaykumar** » 18 Dec 2012 23:43

This procedure is very complicated. It involved insertion of tube into the pleural cavity to remove the trapped air through it. The air was released into an underwater seal and as the lungs started to expand, the baby was relieved of the distress,” he explained.

Sigh.....only in India.

SSridhar · Post by **SSridhar** » 19 Dec 2012 13:33

sanjaykumar wrote:This procedure is very complicated. It involved insertion of tube into the pleural cavity to remove the trapped air through it. The air was released into an underwater seal and as the lungs started to expand, the baby was relieved of the distress,” he explained.

Sigh.....only in India.

Not being a medical professional, I wasn't aware that it was such an easy procedure that these doctors were making a big fuss about.

SSridhar · Post by **SSridhar** » 19 Dec 2012 13:37

Re-drawing India's disease Map - G.Ananthakrishnan, The Hindu

The insights from the Global Burden of Disease Study 2010 published recently by The Lancet , underscore significant public health challenges before India. The headline message from the research data is that public health policy must, in coming years, be directed as much towards non-communicable diseases as infectious ones. There is considerable scope to build on the GBD analysis by adopting sound epidemiological approaches at the national level.

The emphasis of the GBD is on well-known risk factors such as tobacco use, alcohol consumption, deficient diet and exposure to air pollutants, all of which display unhealthy trends in the country.

Hypertension is third on the risk chart based on attributable disease burden in 2010. But household air pollution caused primarily by burning unclean fuels is right at the top. Metabolic disorders and other traditional concerns such as infectious diseases, underweight children and dietary deficiency also rank high. Diabetes, a major issue in India, requires a lot more epidemiological surveillance work in order to present strong conclusions.

Again, there is a rise in the number of people dying in road traffic accidents globally — a rise of almost 50 per cent over a 20-year period — and the trend is equally true for India. Without strong intervention, that risk factor also continues to grow.

If national public health policy is to be turned around, the country has to embark on a mission to turn tobacco fields into fruit orchards, as one expert puts it. That is necessary because tobacco use, including second-hand smoke, is linked to the rising incidence of various cancers and absence of sufficient fruit in the diet and consumption of high levels of salt are raising the risk of cardiovascular diseases. Fruits with potassium help stabilise blood pressure at healthy levels, while salt, which is commonly added to packaged foods, produces the opposite, negative effect.

The coming shock

Alcohol consumption is part of the growing national problem of NCDs. From an epidemiological standpoint, it is a risk factor for many cancers, ischaemic heart disease, and gastrointestinal problems including irreversible organ failure. State governments that view growing alcohol sales as a revenue-spinner are obviously unable to see the coming health crisis. For instance, in Tamil Nadu, government-owned Tasmac declared provisional revenues of Rs.18,081 crore for 2011-12 from liquor trade. That represents 20-per-cent growth over the previous year. The Associated Chambers of Commerce and Industry of India (Assocham) projects a 30-per-cent year-on-year national growth in liquor consumption, more than doubling the present offtake by 2015. The size of the market for beer, wine and spirits stood at Rs. 50,700 crore in 2011. More and more young people are getting initiated into drinking early and the problem is therefore not confined to older adults.

In the case of tobacco, a well-known disease agent causing a great deal of social distress, India has a massive market although consumption patterns differ from other countries. Published data from the Global Adult Tobacco Survey indicate that the number of tobacco users (age 15 and higher) in India is 274.9 million, compared to 300.8 million in China. The intensity of smoking is 6.1 cigarettes a day, while various other forms such as bidi , chewing tobacco and snuff are consumed heavily, often as a combination.

India’s public health policy is thus pitted against three powerful sectors with enormous political influence: tobacco, alcohol and the packaged food industry. Can the government then muster the will to tighten controls on agents of harm and unhealthy products, including high-sodium food that is promoted aggressively? Both tobacco and alcohol are now accessible to adolescents and young adults, with a strong influence on their entire life course. The policy response must therefore adopt a far-sighted approach and focus on prevention and management.

It is important to note that disease burdens attributable to tobacco use and hypertension are on the decline in the West, but increasing in India. By regulating sodium levels in packaged food, for instance, the risk of heart disease, stroke, hypertensive heart disease, and kidney failure, among others, can be significantly lowered. This calls for regulation of salt content and compulsory labelling to encourage salt-free or low sodium products.

The GBD project also highlights gaps in top-level programmes such as the Millennium Development Goals. The approach to disability is one. This area, which did not enjoy a high profile when the MDGs were formulated, needs extensive study, given that disability caused by multiple factors — musculoskeletal problems, back and neck pain — is now reported by people living in both rural and urban areas in India.

Mental health as a form of disability is also acutely missing from such evaluations. The role of social determinants such as education, income, safe transport access, water and sanitation, and good housing in reducing exposure to risk factors needs to be analysed rigorously.

The weakest link in the Indian approach to assessing disease burdens is its surveillance system for non-communicable diseases. As it stands, it is unable to determine mortality, actual disease burden, morbidity and risk factors with any degree of clarity, because statistical pathways are not robust. Patients often do not report for follow-up and fall off the map for a variety of reasons including high costs that they must bear out-of-pocket. The Lancet ’s reports serve as a base on which to build a strong national system to assess the burden of disease.

SSridhar · Post by **SSridhar** » 20 Dec 2012 04:48

A New Therapy for Autoimmune Disorder

Hyderabad: Doctors at a city hospital have found a new method more useful to treat the patients suffering from Guillain-Barre Syndrome (GBS), a rare disorder where antibodies in the body fail to distinguish between the own and foreign cells.

Left untreated, this could lead to medical emergency in a span of a few weeks. This, however, is referred to a syndrome or disorder and not a disease because it is not clear that a specific disease-causing agent is involved to trigger it.

The disorder, which impacts only one in a population of one lakh, is caused when the body’s immune system attacks part of the peripheral nervous system. “The first symptoms include varying degrees of weakness or tingling sensations in the legs,” Dr Naveen Kumar, a neurologist with Global Hospitals, said.

Addressing a press conference here on Wednesday, he said the present treatment regimen included prescribing a course of injections that could cost the patients Rs 4.5 lakh.

He said his team had started using a method that is used widely in the West that brings down the cost of treatment to under Rs 1 lakh.

“After doing necessary tests, we will replace the plasma containing antibodies from the patients with that of cleaner plasma, completely removing the faulty antibodies. This we will do it over a period of five-seven days,” he said.

Comparatively, this procedure could consume more time.

The hospital had performed 35 procedures so far.

SSridhar · Post by **SSridhar** » 20 Dec 2012 12:05

A complication of trauma that needs radiology intervention

Chennai: Casualties that swing into life-saving procedures when an accident-related head injury patient is admitted might never see a manifest case of caroticocavernous fistula (CCF), an engorgement of the eye caused by the shearing of an arterial pathway to the brain. But, with a gestation period of a few weeks, CCF manifests long after a patient has been discharged from the Casualty.

Though by itself a non-lethal condition, CCF, if left untreated, could cause pain, a throbbing sensation inside the head called “vascular murmur,” or even loss of vision, said Swatee Halbe, Chief of Radiology, SRM Institute for Medical Sciences, who recently treated a 24-year-old accident victim who had a bulged eye and fading vision.

Treatment of CCF falls within the domain of interventional radiology procedure and is done at a Cathlab, once the condition is confirmed through angiography. It involves the insertion of a catheter through the femur bone to access the site of sheared artery. The rent is then sealed using a set of platinum coils through an embolisation procedure guided by fluoroscopy imaging.

In the case of this patient, one of the main arteries supplying blood to the brain had been ruptured; because the artery is encased in a vein, blood does not escape outside to cause clots but gushes toward the eye leading to a CCF.

“Immediately after the rent was sealed with 23 platinum coils, blood stopped flowing into the vein of the eye and resulted in dramatic reduction in the redness of the eye,” Dr. Swatee said.

However, the degree of improvement in vision hinges more on the extent of damage that has occurred to the optic nerve than embolisation. In this case, the patient’s peripheral field of vision was back within 10 days of treatment, she said.

One of the developments in the management of CCF has been the emergence of platinum coils which facilitate a far better control than the latex balloons that were used earlier, Dr. Swatee said.

Given the large number of road traffic accidents happening in Chennai, the radiologist suggests sensitising other physicians, including ophthalmologists, and the general public to CCF condition so that patients get timely referral to a radiology facility.

SSridhar · Post by **SSridhar** » 24 Dec 2012 10:30

Device to detect anaemia - The Hindu

Doctors Abhishek Sen and Yogesh Patil, who interned in different districts in western and central India, have first-hand experience of the issue. They realised that often the real problem was not just diagnosis or treatment but lack of active monitoring,data and feedback to the patient and the caregiver on how they are responding to treatment.

It was to address this issue that they, along with Myshkin Ingawale, a Ph.D from IIM Calcutta, created ToucHb, a hand-held needle-free battery operated device that enables screening of anaemia and simplifies monitoring of treatment on a regular basis.

ToucHb works by shining light of different wavelengths through the tissue of the patient’s finger. Haemoglobin has a characteristic absorbance. Understanding the spectrum and understanding what signals to filter out, ToucHb determines the concentration of haemoglobin in the tissue.

The technique is similar to the one used in pulse oximeters, for the estimation of oxygen saturation.

Oximeters are instruments that measure oxygen in arterial blood.

ToucHb measures total haemoglobin which a pulse oximeter can’t do. Besides haemoglobin, it measures oxygen saturation, temperature and pulse rate as well. The total blood haemoglobin is used for anaemia diagnosis.

The WHO qualifies any pregnant woman with a Hb level of less than 11 grams a decilitre of blood as anaemic.

“It took us 32 attempts before the results satisfied us,” says Dr. Ingawale. “We’re excited by the words ‘non-invasive’ and ‘point of care.’ I truly believe that there is a revolution underway in medical technologies similar to what mobile phones have enabled.”

ToucHb, now being tested out in different hospitals, is marketed by Biosense Technologies, formed by Dr. Ingawale, Dr. Abhishek Sen and Dr. Yogesh Patil and Aman Midha, a former interior designer from Tata Motors.

“ToucHb makes sense for resource poor population that takes anaemia for granted among women,” says Dr. Ingawale.

“Compliance is shocking is most parts. Anaemia is not a condition that is well understood. Its symptoms of lethargy, nausea, tiredness are often mistaken as natural for pregnant women.”

The team ultimately hopes that such simple tools of motoring will enable preventive healthcare in a meaningful way for a large proportion of populations living in the developing countries.

“We are planning to scale the production from 30-40 a batch to more than 1000 a batch. But this involves making process, putting in place quality management systems and that will take time,” says Dr. Ingawale.

SSridhar · Post by **SSridhar** » 26 Dec 2012 04:47

Frugal Innovation: Cost of heart surgeries in India at World's cheapest rates - Economic Times

Narayana Hrudayalaya, a pioneer in low-cost cardiac care, is building a chain of hospitals that will carry out heart surgeries at the cheapest rates in the world, buttressing India's reputation as the Mecca for frugal innovation.
A series of design and operational advancements, ranging from construction techniques to post-operative care, will mean that an open heart surgery can be performed for as low as Rs 65,000, or about one-fourth the cost in a corporate hospital.

The Bangalore-based healthcare provider aims to reach 100 towns with a population of 500,000 to one million in the next seven years. The first multi-specialty hospital at Mysore - in which the government of Karnataka has a 26% stake - will start operations this week.

Over the years, India has proven its expertise in creating world-class products and services at low cost, gaining from economies of scale. Tata Motors' small car Nano, the Aravind Eye Care System, Jaipur Foot prosthetic as well as Narayana Hrudayalaya hospital in Bangalore have been hailed as examples of frugal innovation.

The 200-bed, 1.5-lakh-square-foot Narayana Hrudayalaya hospital, set up with an investment of about Rs 45 crore - 80% cheaper than similar multi-specialty facilities - is built on a nine-acre plot. To begin with, the hospital, which has nine operation theatres, will have 23 doctors and about 40 nurses. "Charity is not sustainable, there has to be a business model," said Devi Prasad Shetty, cardiac surgeon and founder of Narayana Hrudayalaya. "Innovations have to be affordable; a magic pill will not do."

Right from design and construction, Narayana Hrudayalaya has sought new ways to cut costs. It has kept the design compact, reduced empty spaces and used prefabricated structures. Also, instead of marbles and expensive furniture, the hospital has used simple tiles and low-cost seating, reducing the cost per bed to Rs 12-18 lakh, compared with Rs 60-80 lakh at other corporate hospitals.

"This is the lowest that is humanly possible; we have cut every bit of flab in the system," said Viren Prasad Shetty, 28, senior vice-president for strategy and planning at Narayana Hrudayalaya Hospitals.

He is the son of Devi Shetty and an alumnus of Stanford Graduate School of Business.

The high cost of infrastructure is a major limiting factor for healthcare providers. To bring down costs, Narayana Hrudayalaya is running the Mysore facility like a startup. "We have a concept of producing a profit-and-loss account daily," said Viren Shetty. "Every system is a creature of desperation and we feel this model is one of them. In India, we have been for long time selling family jewellery and land to pay for healthcare."

Though 2.5 million heart surgeries are required in India every year, only 90,000 are performed. The country needs 3 million additional beds to serve the current needs of the population. Narayana Hrudayalaya aims to add 30,000 beds in small-to-medium towns in the next five years.

The cost of an open heart surgery at the Mysore facility, which is expected to also treat patients from north Kerala and parts of Tamil Nadu, will be 20% cheaper than the main Narayana Hrudayalaya hospital in Bangalore.

Ashwin Naik, co-founder and CEO of Vaatsalya Hospitals, a chain of affordable healthcare facilities in semi-urban and rural areas, said there is a big gap in quality healthcare in India. "As government hospitals are not funded enough, this is throwing up opportunities for entrepreneurs."

"Aravind Eye Care System and Narayana Hrudayalaya have a history of pioneering low-cost approaches," he said, observing that he expects Narayana Hrudayalaya to be successful with this model as well. "An affordable healthcare model is sustainable because it offers volumes," said Dr Shetty.

Larsen & Toubro, India's biggest engineering company that built the Mysore hospital, was initially sceptical about undertaking the project under such a tight budget. "At first they said, it is not possible," said Viren Shetty, who expects the hospital to treat around 210,000 outpatients and perform 3,750 surgeries in the first year for revenues of Rs 18 crore. "We will break even in eight months."

Narayana Hrudayalaya also reduced capital expenditure by buying low-cost medical equipment from small Indian firms and having a pay-per-use model for the more expensive ones. Also, the electricity bill is expected to be much lower due to the absence of elevators and air-conditioning as well as better use of natural light. "Back at the main hospital, we get Rs 1 crore as electricity bill," said Shetty.

The hospital will also outsource some activities requiring special skill-sets like tele-radiology to its main hospital to ensure optimal utilisation of specialists. Similarly, activities such as claims processing, discharge summary preparation would also be outsourced to the larger Narayana Hrudayalaya facilities.

After Mysore, Narayana Hrudayalaya will open a similar hospital in Bhubaneshwar, Orissa. "Once we are successful, this model can be easily replicated across varied geographies," said Viren Shetty.

SSridhar · Post by **SSridhar** » 26 Dec 2012 11:07

Primary neglect - Edit, The Hindu

The large number of unfilled vacancies in Primary Health Centres in many States is proof that any plan to provide universal health coverage in India is going to be a major challenge. Availability of human resources for health, be it doctors, nurses, or support staff, is far from optimal. In the WHO’s Global Atlas of the Health Workforce for 2010, India is 52 among 57 countries facing a critical HR crisis in health. A well-functioning health system should have at least 23 health workers per 10,000 people, while the statistic for India is 19. Even this national performance is not uniform, as the statistics on PHCs show. It is unconscionable that as per 2011 figures, some States have staggering levels of vacancies of doctors at the most basic access level. Chhattisgarh tops the list with 71 per cent; West Bengal, Maharashtra, Uttar Pradesh, Madhya Pradesh, Gujarat, Odisha and even Tamil Nadu have significant number of vacant doctor posts. These statistics strengthen the argument that many more medical and nursing colleges, and institutions for health worker training should be opened on a war footing. It is true that legislation in this regard is pending, and the Parliamentary Standing Committee on Health and Family Welfare has recently submitted its report. The Centre must now move forward through democratic consensus involving stakeholders.

The litany of human resource shortages is not peculiar to the PHCs. Vacant posts are found in the even more basic unit of Health Sub-Centres (HSCs), besides hospitals at higher levels. What this highlights is the patchy performance of the National Rural Health Mission in several States. Unfortunately, these States have failed to grasp the importance of PHCs and HSCs to reduce the country’s notorious maternal and infant mortality rates. Unless they act with determination, it will be impossible to achieve the growth in primary care so essential to cater to a much higher population just a decade from now. The Planning Commission’s High Level Expert Group on universal health coverage projects a need for 3.14 lakh HSCs (more than double the present number) and over 50,000 PHCs by 2022. To staff them with trained manpower, a robust plan to augment human resources must be pursued. Towards this end, the National Commission for Human Resources for Health Bill, 2011 provides an enabling framework. Yet, it can make progress only when all stakeholders, including the medical community and civil society, are agreed on the way forward. What is unarguable is the need for a rapid scaling up of training facilities for doctors, nurses and auxiliary workers, and filling up of vacancies in all States. Without this, universal health coverage cannot make much headway.

SSridhar · Post by **SSridhar** » 28 Dec 2012 08:24

How to swat mosquito-borne diseases - Jyothi Dutta, Business Line

Long-winding queues of people sitting late into the night outside Government health centres in Kolkata. The haunting image, from a visit to the city a couple of months ago, is reality for several people across the country.

Hospitals beds are packed to capacity and intensive care units not available — the rush, we are told, is because of dengue and malaria patients.

Anti-repellent creams and lotions are in short-supply at chemists and the most popular anti-mosquito device is the trusty, old-fashioned mosquito net.

Though the Centre has managed to get a grip on polio, and is making some effort to get a handle on tuberculosis, there is still much ground to cover when it comes to vector-borne diseases such as malaria, dengue, chikungunya or Japanese Encephalitis (JE).

And adding a fatal turn to the disease is the resistance that patients are developing to medicines used to treat malaria, for instance, a fall-out of the irrational use of these drugs. There are no specific drugs to treat the other mosquito-borne illnesses, though there are vaccines against JE.

But not all ills can be solved by popping a pill. That the Government needs to take a wider, more integrated view of public health, rather than a narrow disease-specific approach, is a view rapidly gaining currency among health-activists working in different parts of the country.

Urban development, the laying of roads or agricultural policies, for instance, need to be laced with an impact study of how it would affect public health as well.

Otherwise, the fogging that municipal corporations undertake in different cities to control mosquito breeding will come to no good, as pools of stagnant water continue to dot plots where the next high-rise is being built. Administrators, in a hurry to make their cities the next Shanghai, London or Manhattan, seem to be losing sight of the impact on the health of their residents.

There are enough scientific resources in the country to help plan urban or irrigation projects, ensuring that they do not leave behind breeding grounds for disease, says Anurag Bhargav, physician and epidemiologist, working in Uttarakhand.
Simple solutions

Simple things make the difference, he says. But presently, prevention has broken down and the focus is largely on treatment, where drugs are available. An overarching strategy to tackle vector-borne diseases is required, he observes.

Interventions are needed at schools and in residential areas. Even among the educated, there are those who think greenery causes malaria, he says, illustrating the prevailing ignorance.

The cost of ignoring public health is escalating, he says, pointing to the resistance patients are developing to malaria medicines. So, the next time they get the disease they could die, as the medicine will not be effective. Other features being witnessed with malaria, are that it is migrating to newer locations as people do, and the incidence of a more virulent form of malaria is increasing, he observes.

Tricky numbers

The prevalence of vector-borne illnesses, as estimated by Government, does not reflect the real picture, or the view from the ground. And this was borne out by a study published in Lancet in 2010, that said that the number of malaria-deaths was grossly understated. A reason for this is that malaria deaths in India take place at home and hence go unrecorded. The study pegs malaria deaths in India at over 1,50,000. The World Health Organisation’s number was 10,000, while authorities in India had estimated malaria deaths at over a 1,000, in 2010.

The range is a “mockery in the harshest way,” says Yogesh Jain of Jan Swasthya Sahyog. It is difficult to estimate the mosquito-borne disease burden in the country, as public infrastructure does not exist to capture prevalence and deaths.

In Bilaspur district of Chattisgarh, he says, when they estimated that 300 people died of malaria, the official numbers were nine. “Malaria death starts where political influence ends,” he observes.

Plotting the numbers is tricky as these diseases are cyclical and surface about every three years. These diseases generally peak between October and December.

In fact, public health parameters being as bad as they are, it is a wonder that epidemics have not broken out in the country, says public health activist Sunil Kaul. “We are getting away with a lot,” he says, adding that there are enough laws in the country, but as always the implementation is off the mark.

Integrated approach

Kaul pitches for a shift from the present illness-specific vertical programme, calling instead for a comprehensive health outlook. This helps focus resources on the problem of a particular location, he observes, since health is a State subject. Otherwise, there is a mismatch between funds released from the Centre for a particular reason, while the State may require funds for something else. Things improve when norms are followed, even with 50 per cent efficiency, he adds.

Public health expert Srinath Reddy agrees: “No vertical programme, however well designed, can fit into a weak public health system”.

Kaul further points out, drug resistance in patients is a fall-out of poor implementation and irrational use of drugs. Doctors treat patients, but are unable to ensure that they take the full course of medicines. Patients too stop taking medicines the moment they feel better, again leading to a situation where the virus or microbes adapt and stop being affected by a medicine — leading to resistance.

In cities, patients can still be treated. But in interiors parts of, say, the North East, blood samples need to be sent to Kolkata, he points out, and this may not be possible all the time. And as a result, doctors may treat dengue, for instance, empirically.

Mosquito-borne diseases are best dealt with by the public healthcare infrastructure in terms of surveillance and other steps; once identified, it needs intensive intervention, says Kaul.

Monitoring water stagnation, improving nutrition and personal protection (including mosquito nets), hand-in-hand with public-health consciousness, can cause a serious dent in the prevalence of mosquito-borne diseases — provided there is political interest in tackling the problem.

SSridhar · Post by **SSridhar** » 01 Jan 2013 07:14

Rural Patients Flock to Primary Health Centres (PHCs)
This is excellent news.

Coimbatore: Deputy Director of Health Services R. Damodharan says this reflects the increase in people’s trust in government’s health institutions and rejects popular perception that they are not reliable.

The strengthening of the trust can also be seen in the drop in infant mortality rate and maternal mortality rate.

It stood at 16.5 per 1,000 in 2011, and that was lower than the State average of 28. The maternal mortality rate was 0.50 per 1,000.

And, again, below the State average of 0.9. The Department of Health has undertaken a number of measures to reduce the mortalities. They include the increase in financial assistance for pregnant women to encourage delivery at government centres and vaccination to the newborn, vehicle support for the women prior to the delivery date and nutritious meal to the women and attendant during their stay at the centres.

The Department sends vehicles three days prior to the expected date of delivery to transport pregnant women to the nearby PHC to ensure timely medical care.

All the PHCs have medical personnel round the clock.

Result

The result of such a system has been that Coimbatore district has achieved 100 per cent institutional delivery.

The figure for the district, inclusive of both government and private institutions, has risen from 5,551 births in 2011 to 7,280 in 2012. Of this, more than 65 per cent is in government institutions, is Dr. Damodharan’s estimation.

All maternal deaths in the district, both at government or private hospitals, are investigated by a committee headed by the Collector.

It is empowered to suggest recommendations for improvement or appropriate departmental action, says Dr. Damodharan.

While Tamil Nadu has a birth rate of 16.3 per 1,000 and death rate of 7.6 per 1,000, Coimbatore has better figures on both counts, recording a birth rate of 15.2 and death rate of 5.4.

The Valparai Government Hospital has a ‘birth-waiting’ room.

Expectant mothers and attendants can stay for seven days, during which food would be provided free of cost, he adds.

The four additional days are due to the hilly terrain. Besides the 12 blocks of Coimbatore revenue district, the Department of Health Services office here also includes two blocks from Tirupur Revenue district – Sulthanpet and Annur.

SSridhar · Post by **SSridhar** » 01 Jan 2013 12:13

Iraqi boy gets a new look, thanks to a Chennai hospital

An Iraqi boy with a malformed face has been given a whole new beautiful look by reconstruction surgeons in a Chennai hospital.

Mohammed Othman was born with a genetic abnormality that left him with half the face missing. A CT scan image revealed no sign of one half of the skull. The lips, cheeks and eye sockets were not formed on one side while a huge hole had to be assumed as his ill-formed mouth.

Dr. Ramzi Mansour, Director of Health, Government of Iraq, referred the child to the Balaji Dental and Craniofacial Hospital here.

“On examination, we found that the child had a rare combination of craniofacial cleft deformity with the total absence of the upper jaw, lower jaw, eye socket and nasal bones on the left side of the face,” said Dr. S.M. Balaji, director of the hospital.

Though the eye had been formed, the absence of eye socket left it embedded deep inside the skin leaving the child with normal vision only in the right eye.

The surgery team concluded that the child’s structural defect was rooted in absence of bone that was innervated by the trigeminal nerve and loss of chemical concentration of Bone Morphogenetic Proteins while the face was being formed.

The surgery was done in two stages and first involved creating a lip for the child to eat and to preserve the nature of tissues of the nose and mouth. Skin and lip tissue from the lower lip was mobilised to create the upper lip, cheek and nose. And, once the gaping hole was closed, the child was able to breathe normally and eat by himself.

The stage was now set for another procedure to provide growth centre transplantation from the rib to forge the missing lower jaw.

Dr. Balaji used the modified Y-plate canthopexy, a technique he pioneered, to pull the eye upward. The upper jaw creation was initiated using stem cells and growth factors and recombinant BMP-2 protein was used to stimulate bone forming cells to create new jaw bones. Tissues from the neck were moved to cover the newly formed cheek, jaws and eye. The craniofacial surgeon expects to soon be able to recreate the ear once the upper and lower jaws mature.

For now, little Othman can get back to his nursery school in Iraq and catch up on all the fun he missed.

SSridhar · Post by **SSridhar** » 03 Jan 2013 09:00

Polio free does not mean paralysis free - N.Gopal Raj, The Hindu

Identifying children who suddenly display muscle weakness, often not moving one or more of their limbs as a result, forms the cornerstone of polio surveillance. Such children could have “acute flaccid paralysis” (AFP) that is symptomatic of polio, a disease caused by a virus. But AFP can also arise for other reasons, including infection by non-polio pathogens.

No child in India has been diagnosed with polio for nearly two years now and all the indications are that the virus responsible for it is no longer circulating here. However, the country’s polio surveillance system has indicated a sharp increase during recent years in the number of non-polio AFP cases.

Alarming data

Data published by the World Health Organisation show that close to 8,000 non-polio AFP cases were identified in India during 2003. They went up to over 12,000 the following year, more than 26,000 in 2005 and crossed 40,000 by 2007. In 2011, there were more than 60,000 non-polio AFP cases.

A good polio surveillance system ought to pick up all AFP cases among children so that they can be screened for poliovirus infection. On average, only about one child out of every 200 children carrying the poliovirus develops AFP. Such cases must be identified so that appropriate immunisation measures can be undertaken.

India’s polio surveillance shows that the country is polio-free. But it also indicates that the country now has the world’s highest rate of non-polio AFP cases. According to data published in WHO’s Weekly Epidemiological Record , India’s annualised non-polio AFP rate for 2011 stood at 15.06 per one lakh children below 15 years of age, compared to a global rate that year of 5.48.

Moreover, most of the country’s non-polio AFP cases occur in just two States — Bihar and Uttar Pradesh. They accounted for about 61 per cent of the 53,000-odd non-polio AFP cases identified in the country in 2012, according to data from WHO’s National Polio Surveillance Project. As a result, the two States have far higher annualised non-polio AFP rates than other States — around 34 for Bihar and about 23 for Uttar Pradesh. The rate for the country as a whole is slightly over 12.

“The increased non-polio AFP rate is due to increased reporting of AFP cases due to deliberate efforts of the programme to increase the sensitivity of the surveillance system since 2004,” according to the WHO Country Office for India. In a written response provided to this correspondent, the health body said these efforts were more intense and closely monitored in the traditionally polio-endemic states of Bihar and U.P., resulting in even higher rates of reporting of AFP cases in those States.

In 2004, a number of steps were initiated to strengthen surveillance in order to accurately and more rapidly detect all polio cases in the country, it said. Those measures included expanding the definition of AFP; increasing the number of AFP reporting sites; increasing the number of active surveillance visits; and more training for health professionals on what constituted an AFP case.

Since then, the number of AFP cases that were reported and investigated continued to increase, it noted. This was not due to an increase in the incidence of a specific disease that might cause these symptoms. Rather, it was the direct result of surveillance activities for AFP cases being strengthened.

The programme in India had taken a much broader interpretation of what would qualify as an AFP case than other countries have. Although facial paralysis would not be part of a standard definition of AFP, it was included in that definition for India. Other similar examples were diseases like meningo-encephalitis, Bells palsy, post-diphtheria polyneuritis and spinal muscular atrophy. Data had shown that broadening the case definition led to the detection of some polio cases that would have otherwise been missed, the WHO Country Office noted.

Moreover, in the remaining polio-endemic countries of Nigeria, Pakistan and Afghanistan too, efforts to strengthen polio surveillance were resulting in increased non-polio AFP cases being reported, it added.

The high non-polio AFP rates in the country ought to be a “red flag”, remarked T. Jacob John, a leading virologist who was with Christian Medical College, Vellore, and is known for his work on polio eradication.

With heightened polio surveillance, sick children with suspected paralysis or possible neurological maladies were being identified and tested by the polio surveillance system, he remarked. However, the neurological disorders given by the WHO Country Office as examples of the expanded definition of AFP were likely to account for only a small part of the increase in non-polio AFP cases being seen in India.

No clear picture

Unfortunately, the cases of children with non-polio AFP were not being monitored by either the polio eradication programme or the larger state health care system. As a result, there was no clear picture of what was causing the AFP, the kind of diseases these children displayed, or how many of them were seriously affected, he pointed out.

A range of non-polio pathogens could produce AFP, said Dr. John. With many such pathogens, the paralysis they caused would often disappear in a short period of time. However, others were capable of causing quite serious diseases, disability and even death.

Two teams of Indian scientists recently studied the sorts of enteroviruses found in children with non-polio AFP. Enteroviruses are a diverse group, most of which replicate in the alimentary tract. The poliovirus is part of this group. Several non-polio enteroviruses have been associated with a range of acute and chronic human diseases, including polio-like paralysis.

In a study published in 2009, a team at the Sanjay Gandhi Postgraduate Institute of Medical Sciences in Lucknow tested over 46,000 stool samples from children with AFP in U.P., Bihar and other northern States between 2004 and 2007. In the other study, C. Durga Rao of the Indian Institute of Science, Bangalore, and his colleagues looked for enteroviruses in stool samples collected from more than 2,700 children with non-polio AFP in Kerala, Karnataka and Uttar Pradesh between 2007 and 2009.

Enteroviruses

Both groups found that only about 30 per cent of the non-polio AFP cases were associated with enteroviruses. These viruses could therefore only partially explain the non-polio AFP cases being detected.

In a paper published early last year in the Indian Journal of Medical Ethics , Neetu Vashisht and Jacob Puliyel of the St. Stephens Hospital, Delhi, gave another perspective on the issue. Children in Bihar and U.P. have received more doses of oral polio vaccine than elsewhere in the country. The oral vaccine, it was found, became less efficacious in the face of gut infections and diarrhoea that were widely prevalent in those States.

In their paper, Dr. Vashisht and Dr. Puliyel analysed the non-polio AFP rates across all States over 10 years up to 2010, and found that the rate “increased in proportion to the number of polio vaccine doses received in each area.” In 2012, the number of doses of oral vaccine given to children in Bihar and U.P. had come down and, for the first time, there was a decrease in the non-polio AFP cases in those States, Dr. Puliyel told this correspondent.

There was need for “a critical appraisal to find the factors contributing to the increase in non-polio AFP with increase in OPV [oral polio vaccine] doses — perhaps looking at the influence of strain shifts of entero-pathogens induced by the vaccine,” said Dr. Vashisht and Dr. Puliyel in the paper.

The non-polio AFP rate was not correlated with the number of oral vaccine doses that were administered, countered the WHO Country Office in its response. The largest number of oral vaccine doses given in India was in 2004, which had the lowest non-polio AFP rate in the last eight years. Moreover, although the number of oral vaccine doses given in the country had shown a continuous decline since 2007, the non-polio AFP rate had increased during the same period. In Bihar and U.P. too, there were similar trends of reduced oral vaccine doses and rising AFP rates during 2007-2011.

“The ICMR [Indian Council of Medical Research] is leading the investigations into non-polio causes of AFP,” the WHO Country Office stated.

SSridhar · Post by **SSridhar** » 12 Jan 2013 12:41

BRICS countries agree to collaborate on health issues - The Hindu

Recognising that multi-drug resistant tuberculosis (TB) is a major public health problem in Brazil, Russia, India, China and South Africa (BRICS) due to its high prevalence and incidence mostly among the marginalised and vulnerable sections of society, the health ministers of these countries on Friday agreed to collaborate and cooperate for development of capacity and infrastructure to deal with the disease.

Adopting Delhi Communique at the end of the two meeting of BRICS nations, the health ministers resolved to reduce the prevalence of TB through innovation for new drugs/vaccine, diagnostics and promotion of consortia of tuberculosis researchers to collaborate on clinical trials of drugs and strengthening access to affordable medicines and delivery of quality care.

The Ministers also agreed to adopt and improve systems for notification of TB patients, availability of anti-TB drugs at facilities by improving supplier performance, procurement systems and logistics and management of HIV-associated tuberculosis in the primary health care. They resolved to share experience and expertise in the areas of surveillance, existing and new strategies to prevent the spread of HIV, and in rapid scale up of affordable treatment.

Importantly, the nations committed to strengthen cooperation to combat malaria through enhanced diagnostics, research and development and to facilitate common access to technologies developed or under development in the BRICS countries.

These nations will also focus on the research and development, manufacturing of affordable health products and capability to conduct clinical trials while emphasising on the importance of child survival through progressive reduction in the maternal mortality, infant mortality, neo-natal mortality and under-five mortality, to achieve Millennium Development Goals.

SSridhar · Post by **SSridhar** » 13 Jan 2013 10:33

One more year of nil Polio and it will be 'Goodbye polio' . . . - The Hindu

It is two years since India has had a polio case. One more before the country can say ‘Goodbye, Polio!....’ The battle against the wild polio virus is poised interestingly in the nation that not long ago, in 2009, accounted for nearly half the world’s polio cases.

An 11-member Regional Certification Commission from World Health Organisation’s South East Asia Region is meeting regularly to review reports submitted by India’s National Certification Committee. Three years of absence of polio cases, caused by the wild polio virus (WPV), coupled with intense surveillance, is essential before India can be declared polio-free in 2014.

Surveillance system

Naveen Thacker, past president of the Indian Academy of Paediatrics who has been involved for nearly two decades in the fight against polio, says: “It is probably the biggest public health success story of this century. For us, this is very encouraging; it gives us a lot of confidence. It also gives other polio-endemic countries a lot of confidence.”

The team had thought the task of eradicating polio from India would be fairly easy when the Pulse Polio programme was initiated in 1995-1996. “We had about 1,006 cases then, and we thought it was going to be really easy. And then, my God! It was like the wild polio virus was always smarter than us.”

And now, after nearly two decades, the tide has turned. There is celebration in the air, but it is muted with wide-eyed caution. “The price of freedom is eternal vigilance,” says Dr. Thacker. “We need to sustain the campaign, and immunity. We also need to keep up our surveillance system. Our capacity to respond should be in place.”

T. Jacob John, who was professor of clinical virology in the Christian Medical College, Vellore, and has served on the National Technical Advisory Group on Immunisation, says: “Last year, the question was, ‘Is this for real?’ But two years is long enough to be sure that the WPV has been conquered. There have been two high seasons (for the virus) — the second half of the year in North India, and no cases. All sewage samples have also tested negative for the WPV.” From a position in the past when Indians travelling abroad exported the polio virus to many countries, it has come to India worrying about possible imports from countries that are still endemic to polio. These nations are Pakistan and Afghanistan, nearby, and Nigeria. Dr. John says, “But we are prepared. There are five border crossing areas with Pakistan — two in Jammu and Kashmir, two in Punjab and one in Rajasthan. Anyone coming across has to take the vaccine.” Additionally, every State has emergency action plans ready, along with good surveillance systems.

To prevent polio from re-emerging, the government has planned to keep up intensive campaigns, especially in high-risk areas. Two nationwide campaigns and four sub-national polio campaigns will take place in 2013. High-risk areas, including blocks in Uttar Pradesh and Bihar, and migrant populations, are being targeted. A mapping system has been developed to ensure that all newborns in these areas are vaccinated, and that no one slips through the net. While the success of the polio campaign is a model of focussed attention, the attention is now being turned on increasing routine immunisation coverage, according to those involved in public health administration.

A joint statement from the WHO, the CDC, the UNICEF, the End Polio Now campaign, and the Central government, indicates that the sensitivity of surveillance in India now surpasses the globally recommended standards.

Over 35,000 health facilities are reporting cases of Acute Flaccid Paralysis as part of polio surveillance. Over 1,20,000 stool specimens are tested annually in the eight WHO accredited labs in India. Surveillance has also been intensified along the international border, the statement adds.

Credit is being accorded to the commitment of the Centre for pushing ahead with the programme in the face of major hurdles. However, equally important is the seamless partnership between the government, and the Rotary International, the WHO, the UNICEF and private paediatricians – for it was the scale of this alliance that managed to mobilise vast quantities of field-level workers. In the final call, this probably swung the balance in favour of humans over the wild polio virus.

kish · Post by **kish** » 13 Jan 2013 23:47

This is good news, Kudos the DRDO scientists. Don't know the 2 Ps (Panda & Pig) across the border have such a capability. It would be of great help if BR health care experts could compare and contrast the Disaster management Health care capabalities of desh and panda.

Preparing to deal with any future chemical, biological, radiological and nuclear (CBRN) incidents, Indian scientists have devised 16 drugs that can be used for disaster management. These include an anti-cyanide drug, an anti-nerve gas drug and an anti-toxic gas drug.

Several radioactive decorporation agents and drugs for anti-cyanide, anti-nerve gas and toxic gas injuries have been approved by the Drug Controller General of India as trial drugs.

Developed by scientists at the Defence Research and Development Organisation (DRDO) Institute of Nuclear Medicine and Allied Sciences (INMAS) here, the drugs have passed the efficacy test and will be cheaper than those currently available in the market.

“Sixteen new drugs have been approved by the Drug Controller General of India (DGCI) as trial drugs for disaster management. These include an anti-cyanide drug, an anti-nerve gas drug, an anti-toxic gas drug and several radioactive decorporation agents,” Aseem Bhatnagar, in charge of the project at INMAS, told IANS.

These will be used as samples for the users, including the armed forces, the paramilitary, the National Disaster Management Authority (NDMA), the Department of Atomic Energy (DAE) and the Ministry of Health.

“Batch production of these drugs is being undertaken in collaboration with the pharmaceuticals industry through contract manufacturing. About 50,000-200,000 doses (licensed for human use) are expected to be manufactured by March 2013,” Bhatnagar said.

The DGCI approvals cover all-India use for 15 years for any number of victims.

Since there cannot be proper phase two trials of drugs useful in disasters, their use in any future incident has been approved as trial drugs due to a legality.

“These shall also be used for continuing clinical trials and for stockpiling. This is necessary to effectively plan stockpiling cost and perpetually (it is envisaged to provide the drug at cost price to the users). The average cost price is expected to be less than 15 percent of market price in all cases,” Bhatnagar said.

Several of these drugs have been patented by the defence ministry.

“The contract has been given to pharmaceutical companies to ensure that quality checks and pricing remains the prerogative of the defence ministry. Besides, adequate stocks can be retained in a cost-effective way and companies can initiate mass production in case of a disaster without any time wastage,” Bhatnagar said.

INMAS previously made and supplied drugs against nuclear, biological and chemical (NBC) incidents during the 2010 Commonwealth Games and to meet an emergency requirement of the Indian Navy.

“We also plan to keep some with the Delhi Metro Rail Corporation (DMRC) for usage during any disaster,” Bhatnagar said.

Scientists say that research and development and coordination will enhance the shelf life of NBC drugs by 60-100 percent and this project is planned in coordination with other government agencies.

“A mission mode project is planned to establish nuclear security in the national capital region by way of drugs, equipment and training to six echelons of medical services around Delhi under a project for seven years,” Bhatnagar added.

INMAS had developed a skin radioactivity decontamination kit (shudhika) that was given for production to a company in Pune.

“Its market cost is more than Rs.12,000 and we are developing it for just Rs. 1,000 (less than $2). Five hundred such kits will be made available to users, including the services, as samples by March,” Bhatnagar said.

SSridhar · Post by **SSridhar** » 21 Jan 2013 10:28

Ninth polio-free year for TamilNadu

Tamil Nadu is stepping into ninth polio-free year after recording nil polio cases for the past eight years, Health Minister V.S. Vijay said on Sunday.

“The main reasons for Tamil Nadu being polio free is awareness of polio and special camps held for immunisation,” Dr. Vijay said while inaugurating the first phase of intensified pulse polio immunisation campaign

“Apart from immunisation against polio, the government is also carrying out routine immunisation of children against other diseases. We have been able to achieve 98 per cent immunisation coverage and are looking at achieving 100 per cent coverage this year, ” he said.

Pentavalent vaccines have been introduced in Tamil Nadu and Kerala. “Tamil Nadu is in the forefront in immunisation of children,” he said, and urged women to bring their children to the camps.

SSridhar · Post by **SSridhar** » 25 Jan 2013 06:56

Govt. needs to 'clear the air' on pentavalent vaccine, say doctors - Business Line

Last week a group of paediatricians and academics had written to the Union Health Secretary, concerned over reports on “adverse events and deaths from the newly introduced Pentavalent vaccine.”

The following day, a group of public health advocacy groups under the All India Drug Action Network wrote to World Health Organisation (WHO) head Dr Margaret Chan, following up on an earlier letter they had written on the same issue.

A combination vaccine, the pentavalent vaccine was introduced into the Government’s universal immunisation programme in Kerala and Tamil Nadu in December 2011. And the Centre plans to introduce this additional vaccine into the immunisation programme in another nine-odd States, say doctors familiar with the development.

In the interest of consumer safety, the Government needs to “clear the air” on the pentavalent vaccine, doctors say. Specially so, since the medical community is divided in their opinion, with some doctors claiming the vaccine is safe.
Safety concerns

In their letter to the Health Secretary, the paediatricians and academicians point out, the pentavalent vaccine was introduced in only two States due to safety concerns. The National Technical Advisory Group on Immunization, that was part of the decision to stagger the vaccine’s introduction in States, was to review data from the two States before the programme was further expanded.

However, the vaccine was introduced in Haryana in late 2012, the letter said, before existing data from the two States was analysed.

“In the last three weeks, three more infants died in Kerala after receiving the vaccine. On the face of it there seems to have been no ‘alternate cause’ for these deaths. (Post-mortems have been done.) One baby has died in Haryana this week,” the letter added.
Nothing “untoward”

However, Dr Vipin M. Vashishtha, convenor with the Indian Academy of Paediatrics’ (IAP) committee on immunization, said that the vaccine has been used in the private market for about 10 years.

The IAP had conducted a study last January on the vaccine, across 1,000 paediatricians.

Their responses showed that 80 per cent of those reviewed found the Hib vaccine safe and over 40 per cent had not observed “untoward” side-effects. The reactions seen were those linked to the vaccine, such as fever and pain, he said.

Dr Nitin Shah, former head of IAP and consultant paediatrician at Mumbai’s Hinduja Hospital, further adds, there is constant monitoring and reporting of side effects when the vaccine is used and no direct link has been established between the deaths and vaccine.

Indian vaccine-makers Serum and Bharat Biotech supply the Government programme, the doctors said. Serum Medical Director Dr Prasad Kulkarni explains, the approval to sell in India and 113 other countries came after several levels of local and international scrutiny. There have been no safety concerns raised, he adds.

With the pentavalent vaccine attracting divergent opinion from the medical community, including a public interest litigation at the Delhi High Court – greater clarity on its safety will have to come from the Government.

SSridhar · Post by **SSridhar** » 26 Jan 2013 10:51

Melinda Gates effusive of India's conquest of Polio - The Hindu

If Bill Gates is talking about India’s achievement in making the country polio-free at the World Economic Forum at Davos, his wife is here saying, “To be done with it (polio) is really unbelievable and worth something.”

“Two years free of polio, India is quite something when we think of the scepticism of 2000. It strengthens the confidence that change can happen in other things in the health sector like surveillance, microplanning and routine immunisation. This is the accomplishment Bill will also highlight at Davos,” Melinda Gates told a select group of journalists here on Friday.

On resistance to inclusion of pentavalent vaccine in the routine immunisation programme, Ms. Gates said, “It happens across the countries that negative and opposing voices get more space. I think we need to get out more positive stories on vaccines.”

Speaking from her experience in Bihar, she said women there did realise that fewer children were dying because they were vaccine protected than was the case a couple of generations ago. “A grandmother knows how many of her children had died of childhood diseases and how fewer of her grandchildren are dying because they are immunised.” Ms. Gates has called for a groundswell of positive stories that could create a demand for vaccines.

“We have seen with HIV/AIDS that if we work upfront on prevention of a disease, we do succeed,” she said, citing the Bill and Melinda Gates Foundation’s experience in dealing with HIV/AIDS in India through the Avahan programme, which was its largest investment anywhere.

The Foundation was now focussing on tackling tuberculosis and runs several projects in Bihar and Uttar Pradesh to improve the lives of women and newborns. “We are working on TB because there are about two million cases reported every year and the focus is on diagnostics, surveillance and on new drugs including rolling out a vaccine.” The Foundation works with the government under the Revised National TB Control Programme.

This is in addition to the malaria eradication programme and childhood diseases. The Foundation “would like to see the government do something about these and it (Foundation) has a role to play.” Its Indian office has grown substantially since it started the Avahan programme here. “India is the only country in the world that has something going on in every sector of the Foundation except education.”

Impressive coordination

The Foundation is running a programme in eight Bihar districts focussing on mother and child health. Ms. Gates said she was impressed with the coordination among auxiliary nurse midwifes, anganwadi workers and accredited social health activists (ASHA) that had helped in improving infant mortality rates unlike in earlier years, when all the three served the same village but lacked coordination. “Now they support each other and plan together. ASHAs are much more confident in their job.”

SSridhar · Post by **SSridhar** » 29 Jan 2013 08:00

No sweetening this bitter pill - Sujatha Rao, The Hindu

The absence of a well thought out policy framework for strengthening the health system is the most important issue facing the health sector in India. In the government, there is no clarity on what the nation’s health system should be 10 years hence. Should it be a public sector dominated system like Brazil or China; or a regulated private-led like the U.S.; or one where both sectors function but have only one payer as in the U.K.? In Japan, delivery is private but the government sets the prices. Each option has its costs, benefits, tradeoffs and systems to ensure control on costs and quality.

Unregulated

India is a unique laissez faire model with a private sector-led health system that is unregulated and has no rules of the game spelt out, not even as minimal as those laid down for opening a liquor shop. And so, one can set up a nursing home in a residential colony; throw infectious waste anywhere, charge any amount that the market allows and have no systems of oversight to assure quality. The private sector is further incentivised by excise duty waivers, subsidised loans for establishing hospitals, tax breaks and a liberalised health insurance market with tax exemptions for the premium.

More recently, a new innovation has emerged known as government sponsored insurance schemes (Rashtriya Swasthya Bima Yojana, Arogyashri, Kalaignar {not any more, it is called 'Chief Minister’s Comprehensive Health Insurance Scheme'} , etc.) under which governments buy the insurance on behalf of the people/target group for providing cashless services for inpatient care, mainly surgeries. {Whatever may be said, these sdhemes, especially the one in TN that I know of, have saved lives which otherwise would be lost} Under this scheme, the providers charge on a DRG basis, the insurance companies have assured incomes and the entire risk is borne by the government. While such schemes have widened access by making private sector facilities available, their impact on addressing the three critical issues of the health sector — equity, quality, and efficiency — has not been addressed. Instead, pricing structures are distorted and new dimensions of fraudulent and corrupt practices have entered the health sector that continues to register inflation at 30 per cent, with negligible impact on reducing catastrophic expenditures, impoverishing millions in the process.

Privatisation of the health sector started in late 1980s, accelerated in the 1990s with the further withdrawal of the state under the punishing conditionality of the IMF structural adjustment, and got further emboldened with the extensive incentives provided. In 2005, the state bounced back with a three-fold increase in the budget to revitalise the rural health delivery systems under the National Rural Health Mission, running as a parallel track to the private eco system. It is this duality and dysfunctional policymaking that is haemorrhaging the sector and requires to be stopped without delay. The worn down public health infrastructure cannot be revitalised without changing the rules of the game, bringing in legal provisions to regulate further growth of the private sector, make it efficient and accountable and provide a level-playing field.

Bihar experiment

It is time to recognise the market failures inherent to this sector and the role of the political economy that is sustaining it, making it increasingly impossible to regulate and establish institutional mechanisms with the requisite capabilities to effectively manage the mess. Bihar’s recent experiment of outsourcing diagnostics to the private sector is telling — unqualified persons were employed at some centres, but no action was taken due to political pressure. It is scary to think that a number of innocent people might have been given the wrong diagnosis and put on needless medication. This is just a small example to illustrate the kind of mess we are in.

The policy confusion is worsened by the push for greater decentralisation without ensuring the availability of capacities at those levels to manage such complex systems. It is against this scenario that Chhattisgarh’s recent policy initiative needs to be viewed. The policy of contracting out diagnostic services to private sector networks in 379 public facilities for 10 years, guaranteeing a minimum patient load and permitting paying patients in addition and prices pegged to those paid for under the Central Government Health Scheme (CGHS), monitored and managed by a third party, is fraught with adverse implications for the strengthening of the public sector and huge costs for the government, should it choose to pay for them.

Absence of strategy

It is not the outsourcing that is wrong. It is the absence of a strategy to draw on the strengths of the public and private sectors. If the government is unable to recruit staff to establish laboratories in, say, an area like Bastar, it is unclear how the private sector can be lured to set up, for instance, a radiology unit, there unless huge amounts are paid to it to cover the sustainability risks involved. Likewise, outsourcing is being attempted in areas that already have laboratory facilities. While the value addition is not clear, it will undoubtedly result in the closure of the public sector services and also entail paying three times more to the private sector. And it will be three times as the CGHS prices that are being taken as a benchmark, based on the average of prices quoted on a tender basis. There is no scientific basis for CGHS rate-fixing and such a system will only result in overpaying the private sector in Chhattisgarh where the prices of inputs vary from those in Mumbai or Delhi and between Raipur and Bastar. More worrying are the qualifying criteria that only large private sector networks like corporate hospitals can meet. Small but excellent not-for-profit hospitals like the Shahid hospital in Dalli Raja in Durg or the Jan Swasthya Sahayog at Giniari in Bilaspur will both be disqualified.

What needs to be done

Knee-jerk solutions and unintelligent tinkering have had a disastrous effect on the health sector in India. The government needs to look at health system development and put in place requisite conditions, such as an institutional capacity to control provider behaviour through well laid down national protocols and standard operating procedures, penalties and incentive structures. It should explore cost-effective options such as the intensive use of technology that enables electronic transmission of samples for diagnosis at centralised laboratories, pricing of services, develop IT systems to closely monitor not quantitative but qualitative outcomes as well, put in place grievance redress systems, tightening and insulating the enforcement systems at all levels from political pressures to make individuals from the ANM to the specialist, the ward boy to the laboratory technician — public or private — accountable to outcomes and patients, before opening up partnerships with the private sector on such a large scale.

What needs to be done is known, but sadly how to do it is not. Governments, at the Centre and in the States, need to allow people with field experience and practical knowledge of the health system to contribute their expertise. What is also needed today more than ever is the need to listen to the ground — as patients, women in villages, front line workers, the hapless doctor in the PHC, all have a different story to tell. We cannot afford any more blundering!

(K. Sujatha Rao if former Secretary, Ministry of Health and Family Welfare, Government of India)

SSridhar · Post by **SSridhar** » 29 Jan 2013 08:31

Six Chosen for Cochlear Implant Surgery - the Hindu
This type of game-changing, life-changing surgery was unavailable until the government itself started using health insurance schemes.

Six children, who have been selected from different parts of the district to undergo cochlear implant surgery under the Chief Minister’s Comprehensive Health Insurance Scheme left for Chennai on Sunday.

According to the Deputy Director for Health, M.Madusoodhanan, children born with hearing impairment were often unable to speak. After the surgery, there was a possibility that these children would be able to hear and after a year of speech therapy they would be able to speak normally. The surgery would cost around Rs. 10 lakh in private hospitals. But it was free of cost under CMCHIS and the children below the age of six years could make use of it. For the first time in the State, 20 children have been selected for the cochlear transplant and among them six were from this district. Twelve children were identified and nine were taken to Chennai on December 18 and presented before a high-level committee. Six were selected to undergo the surgery. It would take place for two days from January 29. Collector S. Nagarajan said that people could contact the district administration at 04652-279090 and 279091 or the DD health services on 04652-275089 or CMCHIS on 7373004938 to get their children suffering from speech and hearing impairment, heart and other diseases treated.

Arav · Post by **Arav** » 30 Jan 2013 05:32

http://www.thehindu.com/news/states/oth ... 358261.ece

Doctors at a city hospital announced here on Tuesday that they had successfully performed a rare surgery for craniosynostosis, a complex skull disorder caused by premature fusion of sutures, on a six-month-old child last month.

A team of doctors at Fortis Hospital, Anandapur, operated on Sraboni Chatterjee, born with a deformed forehead and right eye larger than the left.

Explaining the medical condition of the child prior to the surgery, Dr. Amitabha Chanda, consultant neurosurgeon, said that instead of the child’s brain and skull growing together, the skull had stopped growing, resulting in high intracranial pressure that could have led to vision loss and other facial deformities.

The team performed the operation to relieve intracranial pressure and also corrected the deformity of the skull and the face in a five-hour-long surgery, he said.

“The craniofacial approach to the surgery has made it rare in this part of the country,” Dr. Chanda said, adding that the operation provided the child both neurological and aesthetical cure.

Srijon Mukherjee, consultant maxillofacial surgeon, said doctors had to fabricate real size 3D models of the cranial bones out of a CT scan to operate upon the child.

Other critical factors that they had to keep in mind were to keep the child warm and restrict blood loss during the surgery, he said.

“Even 100 cc of blood loss could have resulted in significant disturbance [during the surgery],” doctors said.

Moumita Chatterjee, the child’s mother, said that after being operated on in December 2012, her daughter has had no complications and her face now looks like any other child’s.

Stating that out of every 2,500 children, one suffers from craniosynostosis, Dr. Chanda expressed the hope that after the successful surgery, more parents would come forward for the treatment of their children suffering from this disorder.

SSridhar · Post by **SSridhar** » 31 Jan 2013 11:42

Indian researcher at Stanford paves way for total TB cure
This is important to India where TB is endemic, widespread and resistant to even multi-drug treatment.

In what is being perceived as a significant breakthrough in the fight against TB, Bikul Das, an Indian researcher at Stanford University has discovered why it is difficult to completely eliminate the TB bacteria even after rigorous treatment.

In a study published in the journal, Science Translational Medicine, Das, who has been researching the subject for the past 15 years, points out that TB bacteria hide in a group of stem cells inside the bone marrow beyond the reach of antibiotics and the body's own immune system. These, he says, might reappear once the coast is clear and do a lot of damage. In fact, the bacteria take advantage of the body's own mechanisms of self-renewal.

Deepjyoti Kalita, a professor of microbiology with Gauhati Medical College and co-author of the study, calls it a landmark find. "We never knew where TB bacteria used to hide; but now that we know that the bacteria invade and hide in stem cells in the bone marrow, it would be possible to hunt them down and kill them in future. The present medicines don't help much in this respect."

Although considered "curable" to a large extent, TB still kills 1.9 million people across the globe. At present, the most popular treatment for the disease in India is the DOTS regimen, which takes six months to ameliorate the symptoms. But it fails to completely wipe it out, which is why relapses years or decades after the initial treatment are commonplace.

In his research, Das and his team studied the Idu-Mishimi community of Arunachal Pradesh that has a very high occurrence of TB. The team not only found genetic material from bacteria inside the stem cells, they were also able to isolate active bacteria from the cells from TB patients who had undergone extensive treatment for the disease. They say the findings indicate that other infectious agents may also employ similar "wolf-in-stem-cell-clothing" tactics.

"We now need to learn how the bacteria find and infect this tiny population of stem cells, and what triggers it to reactivate years or decades after successful treatment of the disease," says Das.

Many physicians treating TB are upbeat about the findings. Ashwini Khanna of Loknayak Hospital, Delhi, says he hasn't seen the research, but terms it as 'being full of promise.' "This might propel further research and change the way TB is treated across the globe," he says.

However, Praveen Pandey, a pulmonologist with Escorts Hospital, advises caution. "It may be possible to identify, isolate and kill TB bacteria even before they cause any problem; but there is also the risk of over-treatment. There could be a rush of people willing to be treated without any need for it."

Prem · Post by **Prem** » 05 Feb 2013 00:25

Bayer Fights India's Compulsory Licensing Of Cancer Drug By Claiming It Spent $2.5 Billion Developing It
http://www.techdirt.com/articles/201301 ... g-it.shtml

Back in March last year, the Indian government announced that it was granting its first compulsory license, for the anti-cancer drug marketed as Nexavar, whose $70,000 per year price-tag put it out of reach of practically everyone in India. Nexavar's manufacturer, the German pharmaceutical giant Bayer, naturally appealed against that decision, and the hearing before the India Intellectual Property Appeals Board (IPAB) has now begun. Jamie Love has provided a useful report on the proceedings; here's his summary of what's at stake:
The outcome of this trial, which focuses on the cancer drug Nexavar, is a matter of first impression for the IPAB, and is expected to set precedents on a wide range of issues, including the permissible grounds for granting compulsory licenses, the relationship between the India patent law and the TRIPS Agreement, and the setting of terms and conditions for the compulsory license, including the royalty rates.
Clearly, then, this is a crucially important battle for both sides, and Bayer has started throwing around some huge R&D numbers in an attempt to convince the IPAB that it should be allowed to retain its monopoly in India to recoup those costs:
Bayer presented a January 9, 2013 affidavit from Harold Dinter which made the claim that from 1999 to 2005 Bayer had spent "2 billion euros (approximately US$ 2.5 billion) in the identification and development of anti-cancer molecules leading to the successful approval of Nexavar in 2005." Dinter did not provide detailed support for the numbers, but said they were based upon Bayer's general R&D outlays for anti-cancer drugs, including but not limited to Nexavar, and that the estimate was supported by a new December 2012 study by Jorge Mestre-Ferrandiz, Jon Sussex and Adrian Towse, published by the Office of Health Economics (OHE