Vaccination efforts need to be intensified in India

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Measles and rubella in particular need to be curtailed

New Delhi,12 January 2019: Delhi will witness the roll out of its largest immunization drives offering 55 lakh children in the age group of 9 months to less than 15 years measles-rubella (MR) vaccination additional cover. Starting on 16 January 2019, the five-week MR campaign aims to offer vaccination to children in the 11 districts of Delhi covering all pre-school children, school students (government and private) and out-of-school children.

Children will be provided with an additional dose of MR vaccine regardless of previous vaccination status or history of measles/rubella-like illness. The campaign will include orientation for officers/principals, teachers and students by experts from the Health Department. The MR campaign will be conducted within a period of 3-4 weeks.

Speaking about this Padma Shri Awardee, Dr KK Aggarwal, President, HCFI, said, “Measles is serious and highly contagious and lead to debilitating or fatal complications. Some of them include encephalitis (an infection that leads to swelling of the brain), severe diarrhea and dehydration, pneumonia, ear infections and permanent vision loss. Babies and young children with malnutrition and weak immune systems are particularly vulnerable to complications and death. Unlike measles, rubella is a mild viral infection that mainly occurs in children. A woman who is infected with the rubella virus during the early stage of pregnancy has a 90% chance of transmitting it to the fetus. Some issues that the virus can cause include hearing impairments, eye and heart defects and brain damage in newborns. It can also lead to spontaneous abortion and fetal deaths.

The number of reported measles cases spiked in 2017, as multiple countries experienced severe and protracted outbreaks of the disease. This is according to a new report published by leading health organizations.

Adding further, Dr Aggarwal, who is also the Group Editor-in-Chief of IJCP, said, “There is still reluctance, opposition, and slow acceptance of vaccination apart from other operational challenges. The challenges faced in delivering lifesaving vaccines need to be addressed from the existing knowledge and lessons must be learnt from past experiences.”

The Vaccination Schedule under the UIP is as follows.

  • BCG (Bacillus Calmette Guerin) 1 dose at Birth (upto 1 year if not given earlier).
  • DPT (Diphtheria, Pertussis and Tetanus Toxoid) 5 doses; Three primary doses at 6weeks,10weeks and 14 weeks and two booster doses at 16-24 months and 5 Years of age.
  • OPV (Oral Polio Vaccine) 5 doses; 0 dose at birth, three primary doses at 6,10 and 14 weeks and one booster dose at 16-24 months of age.
  • Hepatitis B vaccine 4 doses; 0 dose within 24 hours of birth and three doses at 6, 10 and 14 weeks of age.

·   Measles 2 doses; first dose at 9-12 months and second dose at 16-24months of age.

  • TT (Tetanus Toxoid) 2 doses at 10 years and 16 years of age
  • TT – for pregnant woman two doses or one dose if previously vaccinated within 3 Year

In addition, Japanese Encephalitis (JE vaccine) vaccine was introduced in 112 endemic districts in campaign mode in phased manner from 2006-10 and has now been incorporated under the Routine Immunisation Programme.

Decapitation of fetus during the delivery process

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JAISALMER (TNN, Jan 11, 2019): The Rajasthan health minister Raghu Sharma ordered an inquiry into an incident in which the nursing staff of a health centre in Jaisalmer pulled out a baby with brutal force, severing its head.

Two male nurses have also been suspended. The incident occurred on Monday at Ramgarh primary health centre (PHC) in Jaisalmer. The compounder allegedly pulled out the baby during delivery using force, leaving the baby’s head in the womb.

Late on Thursday night, the department sent Dr Nikhil Sharma, in-charge of the Ramgarh PHC, to awaiting posting order. Health minister Raghu Sharma said, “Those guilty will be punished and strict action will be taken after investigation.” The incident happened on January 7, when two male nurses posted at Ramgarh PHC, pulled the baby out so fiercely that the infant’s head remained inside the uterus of the woman. The woman, 24-year-old Deeksha Kanwar, had to be rushed to Jodhpur, where the doctors operated upon her and removed the baby’s head

Delivery conducted sans presence of a doctor

On Wednesday, a case was filed under IPC sections 304 A (causing death by negligence) and 336 (act endangering life or personal safety) against the two staffers of Ramgarh PHC. A mother of three kids, this was Deeksha’s fourth delivery. The staff did not inform the family about her situation and referred her first to Jaisalmer. She was then sent to Jodhpur in a serious condition.

Despite being a high-risk case, the two nurses on duty—Amritram and Jhunjhar Ram—tried to deliver the chid of seven-month pregnant Deeksha without the presence of a doctor.

After the incident, they asked family members to take the woman to Jaisalmer claiming that the opening of the womb had closed and it was difficult to take the umbilical cord out. They hid the body of the baby and handed it over only after a police complaint was registered by the family. The family came to know about it after they were informed by the doctors in Jodhpur, who surgically removed the baby’s head. The family reached Ramgarh police station on Wednesday and lodged a case against the two nurses.

Chief medical health officer, Jaisalmer, Dr B L Bunkar said, “I visited Ramgarh and investigated the matter. There were two male nurses present when the woman was brought to the PHC before midnight, on the intervening night of January 6 and 7. Since the gynaecologist was on leave, the nursing staff handled the case. The baby was half out when the pregnant woman was brought to the PHC.It was a pre-term baby,” he added. Health department joint director (Jodhpur) Dr S K Parmar on Thursday rushed to Jaisalmer from Jodhpur to investigate the matter. “I will prepare a complete report on the incident and hand it over to health directorate,” he said.

Our views

Rare, cases of fetal decapitation, occurring intrauterine or during delivery process have been reported in literature.

Fetal decapitation can be spontaneous or accidental (occur by force). It can also be therapeutic (for a nonviable fetus), where it has to be done only by an experienced obstetrician as it is a radical procedure.

  • The case of decapitation of a live fetus during vacuum-assisted delivery was reported in the American Journal of Forensic Medicine in 2011, where excessive traction on the head of the full-term macrosomic fetus with shoulder dystocia resulted in overstretching of the neck up to the point of decapitation (Am J Forensic Med Pathol. 2011 Sep;32(3):245-7).
  • Congenital malformation may present as spontaneous intrauterine decapitation as has been described in a case report of an acephalic fetus in the Archives of Disease in Childhood.  According to the author, decapitation must occur during the 3rd month of gestation or later and is thought to be due to strangulation by a band of tissue of amniotic or chorionic origin (Arch Dis Child. 1967;42(226):636-41).
  • Ledall et al have also reported subtotal decapitation of a fetus in the course of normal delivery with very peculiar bone dystrophy due to disturbance of intrauterine metabolism of tissue polysaccharides. (Bull Fed Soc Gynecol Obstet Lang Fr. 1964 Nov-Dec;16:549-51).
  • Lymphangioma of the axilla as an obstacle to delivery has also been reported (Geburtshilfe Frauenheilkd. 1956 Aug;16(8):706-8).

Decapitation can also be therapeutic. Marsden et al reported four cases of impacted transverse lie in late labor as illustrative of clinical situations where decapitation of a dead fetus in a transverse lie is a practical alternative to Caesarean section (Aust N Z J Obstet Gynaecol. 1982 Feb;22(1):46-9).

We have discussed here the causes of fetal decapitation and not gone into the merits of the case.

It may not be right to straightaway allege criminal medical negligence in this case without ascertaining the facts.

The case needs to be examined in detail. A thorough scrutiny of the facts and circumstances is required before ascribing blame. The training and skill or competency of the doctor/nurses or the hospital has to be taken into account.

However, this case re-emphasizes the significance of transparency, documentation/video recording in day to day practice. If the nursing staff has withheld information from the family, then this is a blunder.

Fetal decapitation has been described in literature; this means that it is a known complication of delivery. And, complications are always lessons learned.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA