What you wanted to know about Dengue fever

What is Dengue fever (DF)? What are Dengue haemorrhagic fever and Dengue shock syndrome?

Dengue [pronounced Den' gee] infection is caused by a virus. There are 4 types of Dengue viruses,namely DENV 1, DENV 2, DENV 3, and DENV 4. It occurs commonly as dengue fever. Occasionally the patient suffering from dengue may develop bleeding. Common sites for bleeding are nose, gums or skin. Sometimes, the patient may have coffee ground vomiting or black stools. This indicates bleeding in gastro intestinal tracts and it is serious. The patient with dengue who has bleeding has dengue haemorrhagic fever (DHF ). Rarely the patient suffering from dengue may develop shock because of low blood pressure, then it is called dengue shock syndrome ( DSS). DHF and DSS are common in persons who had a previous infection with another type of Dengue virus.

How do one get infected with Dengue virus?

The Dengue viruses are transmitted to humans by the bite of an infected mosquito. The Aedes aegypti mosquito is the most important transmitter or vector of dengue viruses, although many of the recent outbreaks were transmitted by Aedes albopictus. It is estimated that there are over 100 million cases of dengue worldwide each year.

Aedes aegypti has a peculiar white spotted body and legs and is easy to recognize even by laymen. It breeds in clean water and has a flight range of only 100 – 200 metres.The mosquito gets the Dengue virus after biting a human being infected with dengue virus.

 When does dengue develop after getting the infection?

After the entry of the virus in the person, it multiplies in the lymph glands in the body. The symptoms develop when the virus has multiplied in sufficient numbers to cause the symptoms. This happens generally about 4-6 days ( average) after getting infected with the virus.

Can people suffer from dengue and not appear ill?

Yes. There are many people who are infected with the virus and do not suffer from any signs or symptoms of the disease. For every patient with symptoms and signs there may be 4-5 persons with no symptoms or with very mild symptoms.

When should I suspect Dengue?

Dengue should be suspected when you have sudden onset of fever WITHOUT cough,cold,pain on urination etc. The fever is high 103-105 degrees F or 39-40 degrees C. It is accompanied with severe headache (mostly in the forehead), pain behind the eyes, body aches and pains, rash on the skin and nausea or vomiting. The fever lasts for 5-7 days. In some patients, fever comes down on 3rd or 4th day but comes back. All the above symptoms and signs may not be present in the patient. The patient feels much discomfort after the illness.

How does Dengue fever differ from other type of fevers?

Fever is usually abrupt in onset and very high.There wont be any running nose,cough etc.Slowly rising fever peaking only in few days time is unlikely to be Dengue fever.The characteristics of dengue that make it different from other causes of fever are the pain behind the eyes, severe pains in the muscles, severe bone and joint pains, and skin rashes. These features make the diagnosis of suspected Dengue likely. Even though there is joint pains there wont be any joint swellings as in Chikungunya fever.The severe bone pains caused by DF is the reason why DF is also called break-bone fever.

Generally, younger children and those with their first dengue infection have a milder illness than older children and adults.

Dengue hemorrhagic fever is characterized by a fever that lasts from 2 to 7 days, with general signs and symptoms consistent with dengue fever. When the fever declines, symptoms including persistent vomiting, severe abdominal pain, and difficulty breathing, may develop. This marks the beginning of a 24- to 48-hour period when the smallest blood vessels (capillaries) become excessively permeable (“leaky”), allowing the fluid component to escape from the blood vessels into the peritoneum (causing ascites) and pleural cavity (leading to pleural effusions). This may lead to failure of the circulatory system and shock [lack of blood supply/oxygen to tissues], followed by death, if circulatory failure is not corrected. In addition, the patient with DHF has a low platelet count and hemorrhagic manifestations, tendency to bruise easily or other types of skin hemorrhages, bleeding nose or gums, and possibly internal bleeding.

How is the diagnosis of dengue is confirmed?

There are laboratory tests that provide direct or indirect evidence for dengue fever. These tests provide evidence for the occurrence of dengue infection. There are some additional tests that can help to identify the type of dengue infection. The tests for confirmation of Dengue should be done in reliable laboratories.

The method used for diagnosis varies depending on its availability,cost, speed of obtaining the result and reliability. It also very much depend on when during the course of the disease blood sample is taken.

Can dengue fever be treated at home?

Most patients with dengue fever can be treated at home. They should take rest, drink plenty of fluids that are available at home and eat nutritious diet. Whenever available, Oral Rehydration Salt/ORS (commonly used in treating diarrhoea) is preferable. Sufficient fluid intake is very important and becomes more important in case DF progresses into DHF or DSS where loss of body fluid / blood is the most salient feature.It is important to look for danger signs and contact the doctor as soon as any one or more of these are found.

What is the treatment?

Like most viral diseases dengue fever can subside on its own.Paracetamol is the main stay to reduce fever.Pain killers/anti inflammatory agents like Aspirin/Brufen should be avoided  since they can increase the risk of bleeding.. Antibiotics do not help. Doctors should be very careful when prescribing medicines. Any medicines that decrease platelets should be avoided.

 Symptomatic management is the main stay of treatment.

When should a patient suffering from Dengue go to the hospital or consult a doctor?

Generally the progress towards dengue haemorrhagic fever or dengue shock syndrome occur after 3-5 days of fever. At this time, fever has often come down. This may mislead many of us to believe that the patient is heading towards recovery. In fact, this is the most dangerous period that requires high vigilance from care-givers. The signs and symptoms that should be looked for are severe pain in the abdomen, persistent vomiting, bleeding from any site like, bleeding in the skin appearing as small red or purplish spots, nose bleed, bleeding from gums, passage of black stools like coal tar. Bring the patient to the hospital whenever the first two signs, namely, severe pain in the abdomen and persistent vomiting are detected. Usually it is too late if we wait until bleeding has occurred.

The most dangerous type of dengue is the dengue shock syndrome. It is recognized by signs like excessive thirst, pale and cold skin (due to very low blood pressure), restlessness and a feeling of weakness.

Can dengue fever become dangerous?

The infection can become dangerous since it may cause damage to the blood vessels. The damage may range from increased permeability of the blood vessels, causing leakage of blood fluid/plasma into various organs to completely broken blood vessels that causes bleeding.The symptoms and signs of dengue haemorrhagic fever and dengue shock syndrome are related to damage to the blood vessels and derangement in functioning in components of blood that help it to clot. Mortality in DSS is around 1-5%.

What should the doctors treating dengue do ?

Patients suspected to be suffering from dengue haemorrhagic fever or dengue shock syndrome should be admitted to a hospital without delay.

The progress of these patients should be monitored regularly at 1-2 hours interval.

Platelet counts and haematocrits should be monitored repeatedly to review the progress of patients.


If the haematocrit levels fall dangerously then a blood transfusion should be considered. A fall of more than 20 % as compared to previous levels may be an indication for transfusion.


If the haematocrit values rise the patient should be given fluids intravenously and the fluids carefully monitored to ensure that the patient does not get excess fluids. A rise of Hematocrit more than 20 % as compared to previous levels may be an indication for IV fluids. The doctor should decide based on best judgement of patient's condition.

What should the doctors treating dengue avoid?

Do not prescribe aspirin and brufen or any other medicine that reduces the platelets or increases the tendency to bleed.

Avoid giving too much IV fluids unless the patient is bleeding or the haematocrit level is rising progressively.

Avoid rushing into giving blood transfusion unless the haematocrit is falling dangerously.
Do not give platelet transfusion unless the platelet count is very low or unless there is bleeding.

Can you get dengue again after suffering from it once?

It is possible to get dengue more than once. Dengue can occur because of 4 different but related strains of dengue virus. If a person has suffered from one virus, there can be a repeat occurrence of dengue if a different strain is involved subsequently. Being affected by one strain offers no protection against the others. Recovery from infection by one provides lifelong immunity against that virus but confers only partial and transient protection against subsequent infection by the other three viruses. There is good evidence that sequential infection increases the risk of developing DHF because this partial immunity produces severe immune reaction in the body.

What is the Global incidence of dengue?

The incidence of dengue has grown dramatically around the world in recent decades. It is a disease of the tropical and sub-tropical regions Some 2.5 billion people – two fifths of the world's population – are now at risk from dengue. WHO currently estimates there may be 50 million dengue infections worldwide every year.The disease is now endemic in more than 100 countries Before 1970 only nine countries had experienced DHF epidemics, a number that had increased more than four-fold by 1995.

 Where does the mosquito that spreads dengue live?

What is the incidence and mortality of DHF?

An estimated 500 000 people with DHF require hospitalization each year, a very large proportion of whom are children and young adult. About 2.5% of those affected die.

Why there is an increasing incidence of severe Dengue infection World-wide?

Rapid and disorganised Urbanisation,poor solid waste management and lack of running water, leading to  storage of water in households etc are some of the factors that is causing an enormous increase in Dengue infections.

The highly domestic mosquito Aedes aegypti rests indoors, in closets and other dark places. Outside it rests where it is cool and shaded. The female mosquito lays her eggs in water containers in and around the homes, and other dwellings. These eggs will develop, become larvae, and further develop into adults in about 10 days.

How can the multiplication of mosquitoes be reduced?

Dengue mosquitoes breed in stored, exposed water collections. Favoured places for breeding are barrels, drums, jars, pots, buckets, flower vases, plant saucers, tanks, discarded bottles, tins, tyres, water coolers etc.

To prevent the mosquitoes from multiplying, drain out the water from desert coolers/window air coolers (when not in use), tanks, barrels, drums, buckets etc. Remove all objects containing water (e.g. plant saucers etc.) from the house. Collect and destroy discarded containers in which water collects e.g. bottles, plastic bags, tins, used tyres etc.
In case it is not possible to drain out various water collections or to fully cover them, use TEMEPHOS, an insecticide, ( brand name Abate) 1 part per million according to the local guidelines to prevent larvae from developing into adults.

How can I prevent mosquito bites to prevent dengue?

There is no way to tell if a mosquito is carrying the dengue virus. Therefore, people must protect themselves from all mosquito bites.

Dengue mosquitoes bite during the day time throughout the day. Highest biting intensity is about 2 hours after sunrise and before sunset.
Wear full sleeves clothes and long dresses to cover as much of your body as possible.

Use repellents- be careful in using them in young children and old people. Use mosquito coils and electric vapour mats during the daytime also to prevent dengue.

Use mosquito nets to protect children, old people and others who may rest during the day. The effectiveness of these nets can be improved by treating them with permethrin (pyrethroid insecticide). This bed-net is called Insecticide Treated Nets and are widely used in the prevention of malaria.

Is there any advice for the patient with dengue fever to prevent the spread of the disease to others?

The spread of dengue from a patient to others is possible. The patient should be protected from contact with the mosquito. This can be achieved by ensuring that the patient sleeps under a bed-net. Effective mosquito repellents are used where the patient is being provided care. This will prevent the mosquito from biting the patient and from getting infected and spreading it to others.

I am sure there will be many more questions about Dengue fever. Feel free to ask them in the comments column of this post.I will try my best to answer.

This post is dedicated to all those who tragically succumbed to Dengue infection and their families, especially to this young woman. blogger .

Links

http://www.who.int/mediacentre/factsheets/fs117/en/

http://www.cdc.gov/dengue/fAQFacts/index.html

http://www.searo.who.int/en/Section10/Section332/Section1026.htm#2

http://malayalidoc.blogspot.com/2010/08/tips-for-prevention-of-breeding-of.html

http://malayalidoc.blogspot.com/2009/07/feverish-rainy-season.html

http://malayalidoc.blogspot.com/2009/09/what-could-be-her-diagnosis-part-2.html

http://malayalidoc.blogspot.com/2008/11/non-medical-reasons-for-referring.html

 http://malayalidoc.blogspot.com/2008/12/non-medical-reason-for-referring.html

Better care than at home?

The other day I was able to visit an Old age home and was amazed at the care the inmates are getting.

It is a small venture run by a young widow, a trained nurse. She runs the institution in a small rented house.

She started by taking care of an old woman who was abandoned in the Hospital where she was working. She took the old lady to her house to take care. Soon the inmates began to increase.

Many were orphaned old women roaming around the streets, finally ending up in hospital wards. Some were abandoned by the family. Most of these women are in their 70s or 80s. They come from all parts of Kerala. They belong to many religions. Some are mentally not all right. Most of them are suffering from physical ailments. But it seemed all of them were happy living there.

Whenever I see old people as patients, I feel dissatisfied with the level of care they are getting in their homes. Medicines are never given as prescribed and doctor appointments are often delayed and missed. When the family is tight financially the old people's medicines are not bought for few days to weeks. Now this does not happen everywhere but in a large number of homes.

But I was happily surprised at the level of care given at this old age home. Though the inmates were only around 12 the nurse knew each and every detail of their ailments and medicines they were taking. They were given food and medicines in time. Their personal hygiene were well looked after. Whenever a doctor consultation is needed she will call me or someone else she know. She ensures doctor visits and sees the inmates at least once in 2 months.

The inmates were so happy to get such a level of care that they were not coming out to me with any physical complaint, though most of them were very ill.

Spending your last years in your house with the family taking good care of you is the best option any one can have. These women were not fortunate enough to get that. But they are lucky enough to have very good care and love during their final years, something many old people do not get even from their homes.

Too much work

I have not been posting in this blog for some time now. Thought I should revive it with more posts.




I left the Government service thinking I will be able to give more time, deserving time, to each of my patient when I work as a private consultant. 7 years as a private consultant and I am not happy with the amount of time I am able to give to each patient. This is particularly true during this busy Fever season. As the time I stay in the same place and see patients increases the number of Patients/families who have absolute faith in me increases. Thus a large pool of patients are created who just want an opinion from me. Many a time I am not able to give deserving time for each patient, still they are satisfied. I am now trying to consciously to reduce the number of patients I see, and it is difficult. I will have to make a large number of people unhappy with this, but I feel I do not have a choice. Let me see how it works.

Is 'honor' more important than your wife's health?

Few days ago a doctor who is well known to me called to ask the diagnosis of one of his distant relative who is under my treatment.
 I hesitated.
 I asked him why you were asking that question.
He said that the guy was admitted in a critical condition in another hospital.I asked further details and realised that the patient is in deep coma and not in a position to give consent  to reveal his diagnosis.
Then I told the doctor that his relative was under my treatment for last 5 years for HIV related illnesses. He was very surprised.Nobody in the family it seems know about it. But I was not surprised.

Let us call this guy Mr K.
He was referred to me 5 years ago by another doctor after he was found to be HIV positive while he was being investigated for recurrent fever. He came alone to me and was mentally a wreck. I could make out that he was thinking about taking his life.
It was very difficult for me to convince him that there is treatment for this and everything is not lost. I told him you can live as near normal life as others if you take proper care and regular medicines. Then I told him that his wife has to be tested.
 He said he cannot tell this to his wife as she will be shattered and the family life will be doomed.
" It is better for me to take my life than to tell this to my wife".
"OK you should tell this after some time.But meanwhile do not have any sexual contact,I warned".
He agreed.
Every time he come to me I used to ask him about informing his wife and he was adamant that he cannot.
I continued to prescribe medicines and monitor him. He was doing fairly well continuing his job and doing everything he need to do as the head of the family.
He did not attend my OPD for last few months and I was wondering what happened to him. I was afraid he was not taking medicines properly and his illness must have exacerbated.
What I was afraid of happened.
Just now I received a more dreaded news. His wife was also tested positive for HIV, though she appears relatively healthy at present.
Was she positive at the time of her husband's diagnosis? Or did Mr K broke the promise he gave to me and had sexual contact with her even after knowing he is positive.I hope it was the former.
 If she was already positive and I knew it I would have been able to manage her health better.Should I have insisted on bringing the wife and telling the truth before prescribing medicines for Mr K?
Why Mr K refused to tell the truth and test his wife?

Is 'honor' more important than your wife's health? 

What is your speciality?

"What is your speciality?"

I was attending a Party in a relative's house in a City far away from my workplace. I had to face this question more than once that night. I was speechless for a moment.

I am asked that question whenever I am among strangers not connected to Medical profession and always find it difficult to make people understand my area of work.

Should I say I am a General Physician?

Then they will say 'Oh you are a General Practitioner" which is not quite correct though many consider us as glorified General Practitioners.

Should I say I am an Internist?

Then they will ask what that is and I will have to explain that an internist is a doctor who specializes in identifying and treating diseases which do not need surgery. Many will still not understand.

Sometimes I say I am a Diabetologist. I have trained myself to be one and most of my patients are Diabetics thanks to high incidence of Diabetes in Kerala.

But am I just a Diabetologist?

No I do not want to be considered only as a Diabetologist. I also had some training in Rheumatology and also in HIV/AIDS.

Many well wishers have asked me why you are not concentrating on one sub-speciality/super-speciality.

"Why don't you take a DM in Cardiology or Neurology? You can earn double for the same amount of work"


But I never wanted to confine myself to one organ or organ system. Also after spending almost 10 yrs in training in Medicine I did not want another 3 years in Medical College. Being an MD in Internal Medicine I believed I am competent enough to tackle most of the cases that come to me. I could also work in smaller towns without much infrastructure unlike a sub-specialist. I also felt that work of an Internist is more exciting, dealing with a large variety of disease conditions.

So I never tried for a DM.

We the Internists always used to say jokingly that a Sub-specialist [we never call them super-specialist] is a doctor who knows more and more about less and less. Sub-specialists will say we are just jealous.

Now after 14 years of practice as an Internist, when I look back I do not have any regrets.

But I am still speechless when that question is asked.

"What is your speciality?"

Fake therapies.How can we stop it?

"Doctor, can I take 'Abcdxyz' for control of my Diabetes?"


The patient in front of me was asking about one of those numerous alternative 'medicines' for Diabetes advertised all over the media.

Iam asked such questions very often and my standard reply was I am a practioner of Modern Medicine and had little or no knowledge of other Medicinal Systems.

"Is there any harm in taking such medicines?" will be the next question and I will reply that I do not know.

Do I really do not know anything about such alternative medicines? If so why? Should I have been able to guide my patients better about the usage of alternative medicines?

Modern medicine is the science that tries to use all the new knowledge and technology available for mankind to improve the health of human beings. Being a practitioner of Modern Medicine and a keen follower of all research that is taking place in this field I should be able to tell whether a therapeutic method is superior, inferior or useless in comparison to currently accepted treatment method.

So how can I research the data regarding these so called ‘wonder alternative medicines’ for Diabetes? Is there any research ever done for these drugs?

The truth is no good quality research takes place before such products come into market. The Company that produces and markets such drugs never provides any research data. Just plain logic should make all of us realise that these medicines are ineffective because a medicine that can be proven to reduce blood sugar even by few milligrams can make billions if it was scientifically approved. The mere fact that no effort is made to get scientific approval for such products by conducting scientific studies tells us that these products are just placebos sold to unsuspecting public with massive advertisement budgets.

Should we stop such Fake therapies?

Many will say that even though such therapies are ineffective they can do no harm, so why one should try to stop them.

The Companies are fooling unsuspecting people using the name of ancient Indian science Ayurveda. People are wasting their hard earned money by buying and consuming useless products. They could have used this money for a much more useful purpose in bettering their lives.

Also how can one surely say that there are no harmful effects for such products without any proper studies? So stopping of such fake therapies is important for society's health.

How can we stop such Fake therapies?

Most important step should come from the Government. All such alternative medicines and supplements should undergo rigorous scientific testing before they are sold in the market. Advertisements with exaggerated or false claims should be severely curbed.

As a practising doctor I should strongly discourage patients from taking such unproven therapies. I should explain to them that their money will be wasted and no one has any idea of the side effects that it can produce.

With increasing awareness among Indian consumers I feel that people of our country cannot be taken for granted any more. Useless [and maybe harmful] products minting money for unscrupulous Companies should be stopped.

UK Govt continues support for Homeopathy despite lack of evidence of efficacy

United Kingdom Parliamentary Committee on Science and Technology was asked to review the efficacy and the policy of Govt funding for Homeopathy last year. On February 22,2010, the committee submitted a report to the Government. The report,one of the most comprehensive evaluation of Homeopathy by a Government Body recommended discontinuation of State funding for Homeopathy.
Here are some excerpts from the report:


...We conclude that the principle of like-cures-like is theoretically weak. It fails to provide a credible physiological mode of action for homeopathic products. We note that this is the settled view of medical science....


....We consider the notion that ultra-dilutions can maintain an imprint of substances previously dissolved in them to be scientifically implausible.....
....In our view, the systematic reviews and meta-analyses conclusively demonstrate that homeopathic products perform no better than placebos.....
...There has been enough testing of homeopathy and plenty of evidence showing that it is not efficacious. Competition for research funding is fierce and we cannot see how further research on the efficacy of homeopathy is justified in the face of competing priorities.
 It is also unethical to enter patients into trials to answer questions that have been settled already.


...We do not doubt that homeopathy makes some patients feel better. However, patient satisfaction can occur through a placebo effect alone and therefore does not prove the efficacy of homeopathic interventions...
..For patient choice to be real choice, patients must be adequately informed to understand the implications of treatments.
For homeopathy this would certainly require an explanation that homeopathy is a placebo. When this is not done, patient choice is meaningless. When it is done, the effectiveness of the placebo—that is, homeopathy—may be diminished. We argue that the provision of homeopathy on the NHS, in effect, diminishes, not increases, informed patient choice.


...The Government should stop allowing the funding of homeopathy on the NHS.
We conclude that placebos should not be routinely prescribed on the NHS. The funding of homeopathic hospitals—hospitals that specialise in the administration of placebos—should not continue, and NHS doctors should not refer patients to homeopaths.


Govt Response


 Even though the UK Government agreed to most of the points raised by the Committee report,it did not agree to stop NHS funding for homeopathy.Instead the Government is trying to put the ball in the local hospital/clinician's court.

 The Govt response said:

We agree with many of the Committee’s conclusions and recommendations. However, our continued position on the use of homeopathy within the NHS is that the local NHS and clinicians, rather than Whitehall, are best placed to make decisions on what treatment is appropriate for their patients - including complementary or alternative treatments such as homeopathy - and provide accordingly for those treatments.

In its response to the report, the Government also said that it will keep the position on NHS funding under review.
 "However, we believe that providing appropriate information for patients should ensure that they form their own views regarding homeopathy as an evidence-based treatment," it said.

Scientists point out, however, that if patients are told clearly that there is no credible evidence to support homeopathic treatments, this may undermine the only benefit that homeopathy is likely to provide, namely the well-established "placebo effect" where someone feels and gets better because they believe a treatment is working.

My view

I fully agree that Homeopathy is just a glorified placebo. At the same time it has an important role to play in the society as a pseudo scientific placebo [some may compare it with the good effects of God/religion in society]
In Indian situation it is more relevant. With Modern medicine practise as un-regulated as in India misuse of antibiotics is very wide spread. Many self limiting viral infections when presented to a modern medicine practitioner receives an antibiotic prescription.If all such mild illnesses gets treated by a homeopathic placebo,the emergence of antibiotic resistance could be delayed.
Moreover for many mild illnesses modern medicines with varying toxicity profiles are prescribed instead of reassurance. Here a homeopathic consultation will provide reassurance in the form of harmless homeopathic drugs.
  My conclusion is that what ever be its lack of efficacy homeopathy should continue as a harmless placebo.

Links
Parliament Committee report
Govt Response

Tips for prevention of breeding of Aedes mosquito in your urban neighbourhood

Dengue fever is an acute febrile illness which can be life threatening.The WHO says some 2.5 billion people, two fifths of the world's population, are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year.
Dengue is transmitted by Aedes mosquitoes, particularly A. aegypti and A. albopictus.So it is very important for us to know about these mosquitos and to learn how to prevent its breeding in our neighbourhood.

Dengue Virus Transmission


Dengue viruses are transmitted to humans through the bites of infective female Aedes mosquitoes. The mosquitoes generally acquire the virus while feeding on the blood of an infected person. After virus incubation for eight to ten days, an infected mosquito is capable, during probing and blood feeding, of transmitting the virus for the rest of its life. There is no way to tell if a mosquito is carrying the dengue virus. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission, but the role of this in sustaining transmission of the virus to humans has not yet been defined.

Aedes aegypti goes through a complete metamorphosis with an egg, larvae, pupae, and adult stage. The adult life span can range from two weeks to a month depending on environmental conditions. The life cycle of Aedes aegypti can be completed within one-and-a-half to three weeks
 


After taking a blood meal, female Aedes aegypti mosquitos produce on average 100 to 200 eggs per batch. The females can produce up to five batches of eggs during a lifetime. The number of eggs is dependent on the size of the bloodmeal. Eggs are laid on damp surfaces in areas likely to temporarily flood, such as tree holes and man-made containers like barrels, drums, jars, pots, buckets, flower vases, plant saucers, tanks, discarded bottles, tins, tyres, water cooler, etc. and a lot more places where rain-water collects or is stored. The female Aedes aegypti lays her eggs separately unlike most species. Not all eggs are laid at once, but they can be spread out over hours or days, depending on the availability of suitable substrates. Eggs will most often be placed at varying distances above the water line. The female mosquito will not lay the entire clutch at a single site, but rather spread out the eggs over several sites.


The eggs of Aedes aegypti are smooth, long, ovoid shaped, and roughly one millimeter long. When first laid, eggs appear white but within minutes turn a shiny black. In warm climates eggs may develop in as little as two days, whereas in cooler temperate climates, development can take up to a week. Laid eggs can survive for very long periods in a dry state, often for more than a year. However, they hatch immediately once submerged in water. This makes the control of the mosquito very difficult.

Prevention of breeding of Aedes mosquito

Aedes mosquito lay their eggs in clear,clean water and not in contaminated water.As they fly only a few metres their breeding place is usually in our house itself.

Most common breediing places and tips to prevent breeding

Water storage tank/cistern ---should have mosquito proof lids
water coolers/collection pans in Fridge/ACs ------ water should be drained out periodically 

Drum   ------tight lids
Flower vase with water  [least in brass vase]----------change water frequently,use sand
Potted plants with saucers ------- change water frequently
Ornamental pool/fountain ---------water changed once a week
Roof gutter/sun shades------------check frequently for drain block
Animal water container----------- empty and clean periodically
Ant trap--------------------------use oil/salt
Used tyres-----------------------keep it under roof
Discarded large appliances-------bury or keep it under roof 
Discarded buckets,plastic cups,tin cans etc-----bury


Whenever piped water supply is inadequate and available only at restricted hours or at low pressure, the storage of water in varied types of containers is encouraged, thus leading to increased Aedes breeding.It is essential that potable water supplies be delivered in sufficient quantity, quality and consistency to reduce the necessity and use of water storage containers that serve as the most productive larval habitats.

Chemical and biological agents can also be used for prevention of breeding of Aedes mosquito.

from
Denguevirusnet
WHO

'Superbug' scare. Myths and facts

A scientific article in the Lancet has created big commotion in the media both in India and outside.It is being said that a bacteria which is resistant to all known antibiotics is wide spread in India and Pakistan and is being spread to other countries including U.K through medical tourism.This bacteria termed the 'superbug' is supposed to bring an end to the antibiotic era. Indian Government has come out with a clarification saying the media scare in UK is unwarranted.
Let me try to separate facts from myths in this issue.
Fact 1
WHO has identified antibiotic resistance as one of the greatest threats to human health. In the European Union (EU), about 25 000 patients die every year from infection with multidrug-resistant bacteria, and such infections result in health-care costs and lost productivity totalling at least €1·5 billion per year. Methicillin-resistant Staphylococcus aureus alone infects more than 94 000 people and kills nearly 19 000 in the US every year, more deaths than are caused by HIV/AIDS, Parkinson's disease, emphysema, and homicide combined.
Fact 2
Bacteria with Carbapenemase  activity is a fast emerging threat in the field of antibiotic resistance all over the World as you can see from this article. India is actually a late entrant in this field.
Fact 3
There are 4 classes of Carbapenemase A,B,C and D.Each have different sub groups.So there are a large number of such bacteria producing different Carbapenemase isolated from all over the World.
Fact 4
New Delhi metallo-beta-lactamases[ NDM-1] belonging to B sub group of Carbapenemase was first detected in a Klebsiella pneumoniae isolate from a Swedish patient of Indian origin in 2008.It was given such a name assuming that the patient got it while hospitalized in New Delhi.
Fact 5
Further study in India indicated that NDM 1 enzyme producing bacteria are fairly common in a tertiary hospital in Mumbai.
Fact 6
In short NDM1 enzyme  is the major cause for antibiotic resistance in Ecoli and Klebsiella species in India.In other countries enzymes are different and are named differently like    VIM-1 (for “Verona integron-encoded metallo-β-lactamase” first isolated in Verona, Italy,)       SPM-1 (for “Sao Paulo metallo-β-lactamase”),         GIM-1 (for “German imipenemase”)    SIM 1 (for Seoul imipenemase)   etc.
Fact 7
The Lancet article in question is only about NDM 1 producing bacteria. It is a good attempt to find out the extend of spread of antibiotic resistance in bacteria in India.
Fact 8
It showed NDM in UK not only in those who had surgical procedures in India but also in many who have never visited India..Out of the 37 samples with NDM1 collected in UK, only 17 samples had history of travel to India or Pakistan.
Myth
The article in Lancet says
'It is disturbing, in context, to read calls in the popular press for UK patients to opt for corrective surgery in India with the aim of saving the NHS money. As our data show, such a proposal might ultimately cost the NHS substantially more than the short-term saving and we would strongly advise against such proposals'.
This is an unscientific comment not based on any data.The authors have not proved that NDM 1 enzyme producing bacteria in UK was imported from India. More than 50% of patients in UK detected to have NDM 1 has never traveled to South Asia.Also the comment is not taking into consideration other groups and sub groups of Carbapenemase enzyme producing bacteria which are more prevalent in UK than in India.

Read more at: http://www.ndtv.com/article/india/was-the-superbug-imported-into-india-44285?trendingnow&cp

         The author of the article in Lancet seems to show undue haste in blaming medical tourism for antibiotic resistance in UK.

It is true that Indian health system abuses antibiotics like most other 3 rd World countries.While protesting the unfair conclusion of the author of the article let us hope that the concerned authorities will open their eyes to the lack of antibiotic policies in most health care centers of India and implement strict regulations so that patients both native and foreign are protected from emergence of resistant bacteria.

Two births that made me happy

Last week two births made me very happy.

I had blogged about one of the mother before. She was a type 1 Diabetic dependent on Insulin for more than 12 years now. I had blogged about my interview with her to-be-husband  in 'Strange Interview' . Also I had posted about the first time she became pregnant in 'Happy News' and about her abortion in 'Sad News'. Now she has delivered a healthy baby. She recently came to me with her husband and the new born and we were all smiling.
Many type 1 Diabetics deliver normal healthy babies but  still it is a difficult task. Perinatal mortality and still birth rates are 4 to 5 times of normal pregnancies. That is why we were smiling.

The other birth was the planned conception and delivery of a  baby for an HIV positive couple.The couple were my patients for last 5 years.They had asked me the possibility of parenting a child before .Initially I did not encourage them because I did not knew how compliant they will be with the treatment.schedule. They were regular in their follow up and very compliant in taking medicines in time. When they asked me again after 3 years of Anti retro viral therapy I was more positive.I directed them to a suitable center for guidance. After a lot of counseling they were ready to accept the risks involved. They did everything as told and the mother delivered by cesarian section a healthy baby recently.

This proved that nothing is impossible for a 'positive' couple.
Read more about HIV and Pregnancy here

Is alcohol good or bad for the Heart?

Is alcohol good or bad for the heart?
I am asked this question many a time in my practice. I usually answer without committing myself. I will reply that in very small amounts it may not be harmful.
I am aware that many studies from the West have shown that mild to moderate intake of alcohol,especially Red wines are somewhat protective to the heart. At the same time I know that many who ask this question are alcoholics who just want a positive response from the doctor to continue to indulge in  spirits.

A recent study in Indian males disapproves the theory that alcohol in mild to moderate doses has a protective effect on Heart. In a large retrospective survey based study [being the first of it kind in India looking at this question] conducted in 10 centers showed that alcohol consumption even in low amounts increased coronary artery disease risk. Heart attacks were more seen in those who are regular drinkers, occassional drinkers and even ex-drinkers when compared to life long abstainers.


Why Indian male drinkers are more prone to heart disease than Western drinking population?

The reasons are not clear and even lack of protective effect has to be proved with large prospective randomised controlled  studies. But some theories are postulated.
1. Indians are more prone to binge drinking than Caucasian population.Binge drinking can cause Heart attack. In the above study around 55% were binge drinkers.
2. Indians tend to drink more stronger spirits that Caucasians. We drink more whiskey and Rum than wine and beer.
3. There may be genetic/racial difference in effect of alcohol on human body. African American drinkers  also do not have that much protective effect on Heart as Caucasians.

So in conclusion let me state that the so called protective effect of alcohol on Heart is under a big question mark especially for  Indians.
So please do not drink to live.

Pregnant but HIV positive

 The other day I received a call from a Gynaecologist of a nearby Hospital.


'I have an ante-natal [pregnancy] patient who is HIV positive. Should I send her to you now or after delivery?'

The doctor was asking me.

I was happy that she called to inform me, but was disappointed with her question. I had spend some effort as an HIV/AIDS trainer to make doctors aware that pregnant women need anti-HIV treatment to prevent the birth of a 'positive' child. I am not sure whether the above-mentioned doctor attended the training, but I expected her to know the importance of ART [anti HIV treatment] in pregnancy.

'You should send her to me immediately. She needs treatment to prevent the birth of a 'positive' child.' I replied.

The next day the patient came with her husband. I explained the situation to them in detail and asked them to attend the Govt ART center as early as possible. I telephoned the ART Medical Officer about this patient and fixed a suitable time for the patient to reach the center.

That lady will get the treatment, which will greatly reduce the chance of the birth of a 'positive' child from about 40% to less than 5%.

All pregnant females should be tested for HIV and if found positive should immediately receive treatment so that we can eliminate the chance of birth an HIV positive child

Should I give the cervical cancer vaccine to my daughter?

A mother of a 12-year-old girl was asking me this question the other day.


"Should I give my daughter cervical cancer vaccine?"

I was not prepared for the question. Though I know such a vaccine is available I have not studied it in detail. So my answer was little bit evasive.

' It is a new vaccine. Needs to be studied more .........."

I was curious why she asked the question.

"My sister who lives in USA gave her daughter the vaccine. I was wondering whether I should give it to my daughter too."



I realized that I would be asked similar questions again and again as the vaccine has been launched in India. More over I may have to take a decision about it personally since I have a daughter of about same age.

This post is an attempt by me to answer the question raised by that mother after considering all the facts available at present.



What is cervical cancer?

The cervix is another name for the neck of the womb. It is the opening to the womb from the vagina. It is really a strong muscle. Normally it is quite tightly shut, but during labour it opens up to let the baby out.



The cervix has a layer of skin-like cells on its outer surface. When these cells become cancerous it is called squamous cell cervical cancer.

There are glandular cells lining the inside of the cervix. The glandular cells produce mucus. Cancer of these cells is called adenocarcinoma of the cervix.



The area where cervical cells are most likely to become cancerous is called the transformation zone. It is the area around the opening of the cervix that leads on to the narrow passageway running up into the womb.



What causes cervical cancer?



HPV infection



Human papilloma virus or HPV is the major cause of cervical cancer. There are many different types of HPV. It is sometimes called the genital wart virus as some types of HPV cause genital warts. In fact, the types that cause warts are not the types that cause cervical cancer. But there are other types of HPV that are considered 'high risk' for cancer of the cervix. HPV is passed on from person to another through sexual contact.



Women who get cervical cancer have had past infections with HPV. High risk types of HPV can cause changes in the cells covering the cervix that make them more likely to become cancerous in time. It is said that around 50 to 80 % of women get infected with HPV some time in their lifetime.

Most people with HPV do not develop symptoms or health problems from it. In 90% of cases, the body’s immune system clears HPV naturally within two years.



But most women infected with these viruses do NOT develop cervical cancer. So other factors must also be needed for someone with HPV infection to develop cervical cancer.

HPV is passed on through genital contact, most often during vaginal and anal sex. HPV may also be passed on during oral sex and genital-to-genital contact. HPV can be passed on between straight and same-sex partners—even when the infected partner has no signs or symptoms.



A person can have HPV even if years have passed since he or she had sexual contact with an infected person. Most infected persons do not realize they are infected or that they are passing the virus on to a sex partner. It is also possible to get more than one type of HPV.



HPV can cause normal cells on infected skin to turn abnormal. Most of the time, you cannot see or feel these cell changes. In most cases, the body fights off HPV naturally and the infected cells then go back to normal. But in cases when the body does not fight off HPV, HPV can cause visible changes in the form of genital warts or cancer. Warts can appear within weeks or months after getting HPV. Cancer often takes years to develop after getting HPV.


Other risk factors for Cervical Cancer

Women who smoke are more likely to get cervical cancer than those who do not. Taking the birth control pill could increase a woman’s risk of cervical cancer. It is not clear why this is. Women with a weakened immune system are also more likely to get cervical cancer, as are those who have had a large number of children.

Preventive measures against HPV infection

For those who choose to be sexually active, condoms may lower the risk of HPV. To be most effective, they should be used with every sex act, from start to finish. Condoms may also lower the risk of developing HPV-related diseases, such as genital warts and cervical cancer. But HPV can infect areas that are not covered by a condom - so condoms may not fully protect against HPV.



People can also lower their chances of getting HPV by starting sexual activity at a later age, being in a faithful relationship with one partner; limiting their number of sex partners; and choosing a partner who has had no or few prior sex partners. But even people with only one lifetime sex partner can get HPV. And it may not be possible to determine if a partner who has been sexually active in the past is currently infected. That's why the only sure way to prevent HPV is to avoid all sexual activity.



Preventive measures against Cervical Cancer

Screening/PAP smear

Cervical screening is very important because we can stop cervical cancer from developing in the first place. This is one of the few cancers that are preventable because pre-cancerous cell changes can be picked up before they have a chance to develop into a full-blown cancer.

The screening test is often called a cervical smear. A nurse or doctor takes a small sample of cells from the surface of your cervix and spread straight onto a glass slide or put into a liquid. When it reaches the lab, your sample is put under a microscope. The cells are examined and any abnormal ones reported.

The smear test picks up pre-cancerous changes. If you have an abnormal result, it does NOT mean you have cervical cancer. But you may need further tests or treatment for an abnormal smear.

You have to be screened like this every 3 to 5 years from 25 years of age.



Vaccine against HPV

Now I come to the topic I wanted to discuss.

How good are these vaccines in preventing Cervical Cancer?

Are there any risks in taking this vaccine?

Though they are marketed as cervical cancer vaccines, they only prevent the infection of few types of HPV that are responsible for about 70% of cervical cancers. The studies that were conducted were for a period of about 2 to 3 years only. No long-term study results are available yet. Also no studies were conducted in girls less than 16 years of age. The studies had shown that the Vaccine can prevent abnormal cell changes for 2 to 3 years, but long-term effectiveness is not known.

Cervical intra epithelial neoplasia (abnormal cell growth) is graded from 1 to 3. Grade 1 indicates active HPV infection and is not considered to be pre-cancerous; current guidelines discourage treatment of this condition. Grade 2 is treated in most women but is not considered as true marker of developing cancer, as up to 40 percent of such lesions regress spontaneously; current guidelines suggest that some young women with such lesions do not need treatment. Grade 3 cervical neoplasia has the lowest likelihood of regression and the strongest potential to become cancerous.

In the HPV vaccine trials not much efficacy was reported in Grade 3 disease. This was attributed to other types of HPV, [against which we do not have vaccines] taking over and producing Cancer.

Though 3 doses are currently recommended whether there is a need for booster dose is not known

In conclusion the overall efficacy is only about 17 to 20 %.

Even after taking the vaccine the Women should undergo routine screening and safe sex practices to get maximum benefits.

Although it was licensed for use in the United States in June 2006, the first phase 3 trials of the HPV vaccine with clinically relevant end points — cervical intraepithelial neoplasia grades 2 and 3 (CIN 2/3) — were not reported until May 2007,

Why the US FDA and CDC was in such a hurry to give approval to this vaccine?


The editorial in the New England Journal of Medicine [NEJM] said:

The vaccine was highly successful in reducing the incidence of precancerous cervical lesions caused by HPV-16 and HPV-18, but a number of critical questions remained unanswered.
For instance, will the vaccine ultimately prevent not only cervical lesions, but also cervical cancer and death?
 How long will protection conferred by the vaccine last?
Since most HPV infections are easily cleared by the immune system, how will vaccination affect natural immunity against HPV, and with what implications?
How will the vaccine affect preadolescent girls, given that the only trials conducted in this cohort have been on the immune response? ......

.....In the meantime, there has been pressure on policymakers worldwide to introduce the HPV vaccine in national or statewide vaccination programs. How can policymakers make rational choices about the introduction of medical interventions that might do good in the future, but for which evidence is insufficient, especially since we will not know for many years whether the intervention will work or — in the worst case — do harm?

....... serious questions regarding the overall effectiveness of the vaccine in the protection against cervical cancer remained to be answered, and more long-term studies were called for before large-scale vaccination programs could be recommended.

Is the vaccine safe?

.Even though most of the reported adverse events were not serious, there were some reports of hypersensitivity reactions including anaphylaxis, Guillain-Barré syndrome, transverse myelitis, pancreatitis, and venous thromboembolic events. The editorial in the JAMA [Journal of American Medical Association] says, "it is also difficult to conclude that a serious event is not caused by the vaccine". That means the safety is not fully assured.



Should I recommend the HPV Vaccine?

The JAMA editorial says:

When do physicians know enough about the beneficial effects of a new medical intervention to start recommending or using it? When is the available information about harmful adverse effects sufficient to conclude that the risks outweigh the potential benefits? If in doubt, should physicians err on the side of caution or on the side of hope? These questions are at the core of all medical decision making. It is a complicated process because medical knowledge is typically incomplete and ambiguous. It is especially complex to make decisions about whether to use drugs that may prevent disease in the future, particularly when these drugs are given to otherwise healthy individuals. Vaccines are examples of such drugs, and the human papillomavirus (HPV) vaccine is a case in point.


........Whether a risk is worth taking depends not only on the absolute risk, but on the relationship between the potential risk and the potential benefit. If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to a woman is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened. So rationally she should be willing to accept only a small risk of harmful effects from the vaccine.


When weighing evidence about risks and benefits, it is also appropriate to ask who takes the risk, and who gets the benefit. Patients and the public logically expect that only medical and scientific evidence is put on the balance. If other matters weigh in, such as profit for a company or financial or professional gains for physicians or groups of physicians, the balance is easily skewed. The balance will also tilt if the adverse events are not calculated correctly.


My conclusion is like this.

I will not recommend HPV Vaccine with the present available scientific evidence due to the fact that the efficacy in preventing invasive cervical cancer is not much and there is a small but considerable risk of adverse events.
Even though India reports more than 70000 deaths yearly due to cervical cancer,this coslty vaccine [around 10000 Rs for 3 shots] is highly unlikely to make any change in incidence of Cervical cancer in India due low efficacy and prohibitive cost.

Links and references
NEJM editorial
JAMA editorial
Controversy on cancer vaccine
more on cervical cancer

Life style changes in the New Year

I do not practice what I preach.

I preach to my patients about

'the importance of regular exercise in maintaining good health'.

I preach about

'importance of eating less fatty food'

I preach about

'reducing weight to reach an ideal BMI'

I preach about

'eating plenty of fruits and vegetables'

I preach about

'cutting down on snacks'.



I do not practice what I preach.



I never do regular exercise. Never cut down on fatty foods. Eat fruits rarely but snacks frequently.

May be it is time for me to practice what I preach starting from this year.I aim to achieve a BMI of 25 by the end of this year. Currently it is 28.4.

Let me try my best.

To calculate your BMI and to know more about a healthy BMI click the link below.
http://www.nhlbisupport.com/bmi/bmi-m.htm

A very 'Positive' news from Pakistan

Cricket is the national sport in Pakistan as it is in India, but what makes the First Positive Cricket Team stand out from all the other Karachi-based clubs is that its members are all HIV positive.


The team was put together a year ago by the Pakistan Society, an NGO working for the rights of people living with HIV. They played -- and won -- their first match in August, and haven't looked back.

Dr. Saleem Azam, president of the Pakistan Society, told CNN, "Every time they play the players have a boost physically, emotionally and psychologically, and they feel a lot better."

Azam says that there is a considerable stigma in Pakistan surrounding HIV/AIDS and he hopes the team can help combat discrimination towards HIV sufferers.

"People assume the team must be very sick-looking, like walking skeletons, but when they see them playing and winning matches they have to think again," said Azam.

"We've given them a very strong message that having HIV does not mean you must retire from life and become helpless. You can have HIV and live a very happy life if you take your antiretroviral treatment regularly.
 When the team won handsomely, leaving their opponents and the fans amazed that HIV-positive players could be so active - one of the team members was asked whether antiretroviral medication was also a form of performance-enhancing drugs.



"The stigma is the worst consequence of this illness, so it will be the greatest service to people with HIV if we are able to help them overcome this stigma. The change is coming, but it's very, very slow."

While changing attitudes takes time, Azam says the team has already built bridges between the players and their estranged families. He told CNN that some players who had been ostracized by their families were now back in contact with them, with one family requesting to travel to matches with the team.




First Positive has already played a match in Hyderabad, about 200 km (125 miles) from Karachi, and next month they will take to the road for two more matches, which will see them spread their message elsewhere in the country.

"This is how the team will be known the country over," said Azam.

"People will come to know more and more about the team, and I hope eventually they will be successful in combating this stigma and discrimination."

Abdul Lateef is captain of the FPCT. He contracted HIV six years ago and told CNN that the team is helping to change others' attitudes towards people with HIV.

"We are reaching the minds of the people," he said.

"Everybody thinks there are things that HIV positive people cannot do. We have shown we can play and we have proved to everybody we can do anything they can do."

We are thankful that the authorities were so cooperative with us, and provided us with the space that was needed for the match without any discriminatory attitude. Rather, their attitude was positive and encouraging," said Azhar Hussain Magsi, a manager at the Pakistan Society.


"More matches are scheduled to take place all over Pakistan in the coming weeks ... We are also having talks with other NGOs in India, and look forward to having an international HIV-positive cricket match.

Having personally witnessed the wonders that anti retro viral therapy can produce in many patients, I cannot think a better way of illustrating the fact that HIV/AIDS is treatable and HIV positive patients are as human as we all are than the site of a 'Positive' cricket team winning a match against the 'negative' team on the cricket field.


An India-Pakistan cricket match between HIV positive players!!!

That will be a great event.

adapted from
CNN
AIDS Portal

World AIDS Day 2009.A statistical update

Another World AIDS Day is here.Let me update you with the current statistics and trends.
New figures released by the World Health Organization and UNAIDS estimate the number of new HIV infections have declined each year by about 17% from 2001 to 2008.
The number of new infections in sub-Saharan Africa is approximately 15% lower, which is about 400,000 fewer infections in 2008.
In East Asia new HIV infections declined by nearly 25% and in South and South East Asia by 10% in the same time period.
In Eastern Europe, after a dramatic increase in new infections among injecting drug users, the epidemic has leveled off considerably.
However, in some countries there are signs that new HIV infections are rising again.


But for every five people infected, only two start treatment.
The UN report noted about 4 million people were receiving AIDS drugs at the end of 2008, compared with 3 million the previous year. Nonetheless, an additional 5 million people need treatment and are not receiving it.

Number of people living with HIV in 2008


Total 33.4 million [31.1 million–35.8 million]

Adults 31.3 million [29.2 million–33.7 million]

Women 15.7 million [14.2 million–17.2 million]

Children under 15 years 2.1 million [1.2 million–2.9 million]


People newly infected with HIV in 2008

Total 2.7 million [2.4 million–3.0 million]

Adults 2.3 million [2.0 million–2.5 million]

Children under 15 years 430 000 [240 000–610 000]

AIDS-related deaths in 2008

Total 2.0 million [1.7 million–2.4 million]

Adults 1.7 million [1.4 million–2.1 million]

Children under 15 years 280 000 [150 000–410 000]

There are more people living with HIV than ever before as people are living longer due to the beneficial effects of antiretroviral therapy and population growth.
However the number of AIDS-related deaths has declined by over 10% over the past five years as more people gained to access to the life saving treatment.
 UNAIDS and WHO estimate that since the availability of effective treatment in 1996, some 2.9 million lives have been saved.
 
Antiretroviral therapy has also made a significant impact in preventing new infections in children as more HIV- positive mothers gain access to treatment preventing them from transmitting the virus to their children. Around 200 000 new infections among children have been prevented since 2001.
 Indian Statistics
 There are 3 million persons in India living with HIV, equivalent to approximately 0.36 percent of the adult population. The revised national estimate reflects the availability of improved data rather than a substantial decrease in actual HIV prevalence in India.
 
The transmission route is still predominantly sexual (87.4 percent); other routes of transmission by order of proportion includes perinatal (4.7 percent), unsafe blood and blood products (1.7 percent), infected needles and syringes (1.8 percent)
and unspecified and other routes of transmission (4.1 percent)2.
 
In India also there is a declining trend in new infections in southern states and Maharashtra while the epidemic is yet to level in Northern States.
 
 
This year’s World AIDS Day theme of Universal Access and Human Rights, highlights the critical link between universal access to HIV prevention, treatment, care and support and respect for human rights in the response to the global AIDS epidemic. Without addressing human rights abuses, many of the populations most vulnerable to or living with HIV will lack access to prevention and treatment services.

What Diabetic patients should know

Another World Diabetes day has come and gone. It was a day of free blood sugar testing,free or subsidised testing for complications of Diabetes,Run for Diabetes,Seminars and Awareness classes etc etc.

In my own way I was also giving free consultation to Diabetes patients.When the testing and consultation are free there will be a rush of patients and I had the same experience.So it was an exhausting day.

Not all who had come were very poor. Many test their blood sugars only occasionally even though they could very well afford it. Many have never tested their Cholesterol,eyes or Kidney functions. Lack of knowledge about Diabetes and its complications were evident in most of the patients. The theme of World Diabetes day UNDERSTAND DIABETES; TAKE CONTROL is so relevant for this group of patients who came rushing to my Hospital for free testing and consultation.
To know more about World Diabetes Day click here

What Diabetic patients should know

Targets for Diabetics
Fasting Blood Sugar 70-120mg/dl
Post meal[after 90 mts] less than 180mg/dl
HbA1c less than 7 percent
Blood Pressure less than 130/80
HDL Cholesterol more than 40 mg/dl
LDL Cholesterol less than 100mg/dl
Triglycerides less than 150mg/dl

What and When to test

1.Test Blood sugar as frequently as possible. At least twice or thrice a month if well controlled.Test HbA1c every 6 months

2.Check Blood Pressure every 3 to 6 months. More frequently if high or low.

3.Lipid Profile [cholesterol test] at least every 6 months if found high once.Otherwise once a year.

4. Cardiac check up [ECG and Tread Mill test and if needed Angiography] once on diagnosis and then every 2-4 years if first examination was normal and there are no symptoms. More frequently if first tests are abnormal or if there are cardiac symptoms.

5.Kidney tests like Urine micro albumin and Serum creatinine every year.

6. Eye check up including retina examination after putting an eye drop to dilate the pupil on diagnosis of Diabetes and then once every 1-2 years.

7. Neuropathy testing on diagnosis and every 2 years if there are no symptoms.

Mass drug prophylaxis against filariasis

To eliminate lymphatic filariasis, the Kerala State Government Health Department has launched a  mass drug administration (MDA) programme  in 11 districts in the State on Novemeber 11,2009.
A lot of confusion is there in the minds of many among the public about the need and possible side effects of this mass drug administration.

Why this mass anti-filarial drug administration in healthy persons?

Let me try to clarify.

What is Lymphatic filariasis?

Lymphatic filariasis is a parasitic disease caused by microscopic, thread-like worms. The adult worms only live in the human lymph system. The lymph system maintains the body's fluid balance and fights infections. Lymphatic filariasis is spread from person to person by mosquitoes.

People with the disease can suffer from lymphedema and elephantiasis and in men, swelling of the scrotum, called hydrocele. Lymphatic filariasis is a leading cause of permanent disability worldwide

Disease burden

Although lymphatic filariasis very rarely causes death, it is a major cause of clinical suffering, disability and handicap. More than 1.3 billion people in 83 countries and territories (Map) — approximately 18% of the world's population — live in areas at risk of infection with lymphatic filarial parasites. Approximately one third of those at risk live in India, one third in Africa and the remainder in Asia, the Pacific and the Americas.
It is estimated that around 120 million people in tropical and subtropical areas of the world are infected. Almost 25 million men suffer from genital disease (most commonly hydrocoele); an estimated 15 million people — the majority of them women — have lymphoedema or elephantiasis of the leg.

Indian Situation

Filariasis is endemic in 19 States/union territories in India. Estimates based on surveys by Filariasis Survey Units suggested that: about 454 million people (120 million in urban areas) are living in known endemic areas; there are 29 million filariasis cases in the country and 22 million micro-filaria carriers.

The magnitude of infection in children has become much better understood in recent years; indeed, most infections appear to be acquired in childhood, with a long period of subclinical asymtomatic period  that progresses to the characteristic, clinical manifestations of adults.

Global Programme to Eliminate Lymphatic Filariasis

 In 1997, as a result of advances in the diagnosis and treatment of lymphatic filariasis (LF), the disease was classed as one of six infectious diseases considered to be “eradicable” or “potentially eradicable”. Consequently, the World Health Assembly adopted resolution 50.29, calling for elimination of the disease as a global public health problem.
 
Elimination strategy


The strategy proposed by WHO to achieve the goal of elimination comprises two components:
1.interruption of transmission of filarial infection in all endemic countries through drastic reduction of microfilariae prevalence levels;

2.prevention and alleviation of disability and suffering in individuals already affected by LF.

Interruption of transmission of infection can only be achieved if the entire population at risk is covered by mass drug administration (MDA) for a period long enough to ensure a reduction in the level of microfilariae in the blood to a point where transmission can no longer be sustained.
That's why mass administration of anti filarial drugs are advised in healthy individuals living in areas of risk.

The following recommended drug regimens must be administered once a year for at
least 5 years, with a coverage of at least 65% of the total at-risk population:

a.6 mg/kg diethylcarbamazine citrate (DEC) + 400 mg albendazole; or

b.150 µg/kg ivermectin + 400 mg albendazole (in the case of co-endemicity with onchocerciasis).

c.A third option is to follow a treatment regimen using DEC-fortified cooking salt daily for a period of 12 months.

As a part of this programme 11 Districts in Kerala has started the second round of MDA this Novemeber using DEC and Albendazole.

Side effects of the drugs.

There has been reports in the media about children becoming sick after taking the tablets. Is this true? Is it serious?

Both DEC and Albendazole is best taken in full stomach. Many temporary side effects can be prevented by taking care to eat well before ingesting the medicines.
Side effects due to these medicines are rare, not serious and lasts for few minutes to hours only.
Most common side effects are dizziness,nausea,vomiting,headache and fatigue. Some may develop fever and skin rashes which may indicate succesful elimination of microfilaria.

Children below 2 years and elderly people above 65 are not required to take the drugs.
All others are advised to take the drugs.

 Let us try to eliminate the dreaded elephantiasis from our community.

H1N1 Flu 2009 - Epidemiological and Clinical data from India

The 2009 H1N1 Influenza [Swine flu] pandemic is continuing to spread in India, may be with less virulence. The Indian Health authorities have published the initial epidemiological and clinical data of this pandemic.I am publishing some of the data here for wider dissemination.
Here is the link for the information I am publishing here.

 

As of November 10th 2009 there has been 505 deaths out of a total of 14680 confirmed cases.

Total Lab confirmed cases     1468   

       Total number of Deaths          505            

States            Number of Deaths

                                     Maharashtra           209

                                     Karnataka              118

                                     Andhra Pradesh       49

                                     Gujarat                    40

                                     Kerala                      22

                                     Rajasthan                 17

                                     Delhi                        16

    Rest of the States reported less than 10 deaths.