IMA Policy on Antibiotics

Health Care, Medicine Comments Off

At the Antimicrobial Resistance Conference held in New Delhi yesterday to discuss the IMA Antibiotic Policy the following decisions were taken. Doctors should write the antibiotic in a box to differentiate it from other drugs in the prescription. The role of antibiotics should be discussed in an informed consent. When prescribing antibiotics clear instructions should be given to the patient about no refill of antibiotic prescription without signature of the doctor. No antibiotic cover or prophylactic antibiotic should be given without a high degree of clinical suspicion. No antibiotics should be prescribed in following conditions o Small bowel diarrhea o Fever with cough and cold o Dengue o Chikungunya o Malaria o Fever with rash Early initiation of antibiotics is the rule in suspected sepsis bacterial pneumonia meningitis and confirmed TB. Food Safety and Standards Authority of India FSSAI should make it mandatory for food companies to label all poultry and agriculture products as Antibiotic free . IMA will be writing to the Health Ministry to formulate clear guidelines about safer disposal of left over antibiotics.

Dengue Revisited

Health Care, Heart Care Foundation of India, Medicine Comments Off

Mosquito Menace: How to win over our collective failure Napoleon Hill once said that “Most great people have attained their greatest success just one step beyond their greatest failure.” Its time for all of us to convert our biggest failure, to control mosquito menace, into success. Today dengue is in alarming condition in Kerala, West Bengal, Karnataka and a mysterious illness in Indore (? Zika ? Alpha Virus) with arthritis. We all must agree that collectively we have failed in controlling the mosquito menace. Any mosquito container index above 5% requires community integrated cluster approach for mosquito density reduction together with effective anti-larval measures. Mosquito repellent impregnated mosquito nets are not available to patients. Anti-larval measures such as temephos (an organophosphate larvicide) and mosquito fish or Gambusia (a freshwater fish) also are not available to a common man. Then what is the answer? We need a paradigm shift in our thinking. We need to over report and act in time. There is no point acting when the cases have started. Often the civic bodies publically act during monsoon season. They may be planning ahead but public awareness and public involvement must start much ahead of time. Even the recent CAG report mentions that under reporting of dengue is disastrous to the society. We need to act on all mosquitos – Aedes, Culex and Anopheles. Acting only on Aedes will not work. The campaign that “Aedes is a day biter and only breeds in indoor fresh water” will not work. Even if this is true, then by killing Aedes you may end up increasing the density of Culex and malaria causing Anopheles mosquito. But the fact is that Aedes can breed and bite in the evening or night also. Culex mosquito, which causes filarial and Japanese encephalitis, is already rampant in many states. Aedes, which causes Chikungunya, West Nile, Zika and Dengue can spread by the bite of infected female Aedes aegypti (indoor) or A. albipecto (outdoor) mosquito. It is true that Aedes aegypti are more dangerous because they can fly up to 200 m and only feed on human blood whereas the Aedes albopictus that thrives outdoors can only fly as far as 80 m and feed on animal blood other than human blood. However, the outdoor Aedes cannot be ignored. The entire campaign until now has focused on Aedes being a day biter, wear long sleeved clothing during the day and no need to use night mosquito nets. But precautions need to be taken all through the day. The mosquito only recognizes the light and not day or night. That the mosquito only breeds in clear water also needs to be re-learnt. Aedes breeds in stagnant water anywhere inside or outside the house. Rain water is the most important source and can collect in any plastic container inside or outside the house. Even collected garbage in open areas can have left over plastic cups or tiny bottle caps with collected rainy water collections providing ideal atmosphere for mosquito breeding. It is true that disease-spreading mosquitoes do not make noise but noise-producing nuisance mosquitoes unless addressed will not create a public movement. The law says that dengue and Chikungunya are notifiable diseases, but one can notify within seven days of diagnosis. Aedes mosquito takes up to three meals in a day and by seven days will bite over 21 people in the vicinity. Municipal anti-mosquito and anti-larval actions must occur within hours of its detection. The very purpose of notification is lost if the disease is not notified within hours of even suspected cases. All suspected cases must be reported without waiting for confirmation of the diagnosis. We have failed because the government has been insisting on notification of only ELISA confirmed cases. An SMS should be sent to all doctors practicing in that PIN code area with a case so that they can become a part of the public health action chain. All public health measures should start right when the first case is suspected in a state, colony or house. An SMS should go to the local councillor, MLA, MPs, all practicing doctors, local chemists, NGOs, RWAs, local IMA Branch, State IMA Branch, IMA Headquarters and other Specialty Organizations to join the public health chain efforts. It has taken over a decade for us doctors to understand that dengue 1 and 3 strains are not dangerous and causes only platelet deficiency with thinning of blood and dengue 2 and 4 strains are dangerous as they lead to platelet destruction along with thickening of blood due to capillary leakage and rise in hematocrit. Platelet transfusion is not required in absence of active bleeding and thickening of blood. Timely fluid resuscitation is more important and not platelet resuscitation. Remember a raid fall in platelets along with a rapid rise on hematocrit is dangerous and not rapid fall of platelets alone. Dengue becomes serious when fever is subsiding. We admit dengue cases with high fever and always are in an urgency to discharge them when fever was subsiding. Now we know that the machine reading of platelet count can be defective. There can be an error of 20%. A platelet count of 10,000 by machine reading can mean that the platelet count is actually 50,000. Hospital beds should be reserved only for severe dengue and severe Chikungunya cases. Just because one can claim reimbursement in Mediclaim or PSU, one should not be admitted. If it was the US, Medicare by now would have come out with admission guidelines. The message has been going that fogging has no answer. But at this stage of container index of > 40, we need not just ground fogging, but also aerial fogging. When Zika threat came up Brazil, they deployed army to join and made it a public movement. All political parties reach every house during election process then why can�t each one of them reach every house and make the anti-mosquito and anti-larval measures more effective. Breeding checkers are only with Municipal Corporation and they also have regulatory powers to put fine. We need breeding checkers in private sector also. The Skill development Ministry should start courses so that anyone can hire a breeding checker on weekly basis to check their premises. Community approach means that 100% of the society talks about dengue. Every premise must write that their premises are mosquito free. When you are invited to someone you should ask �I hope your premises are mosquito free� and when you invite somebody write �Welcome to my house and it is mosquito free�. Even today most hospitals do not provide mosquito nets to dengue or Chikungunya patients. It is true they may be having anti- larval mesh doors or mesh windows but for secondary prevention of dengue or Chikungunya we need to ensure that medial establishments are certified as mosquito-free. In flats or apartments, the mosquitoes may be breeding in the roof top belonging to one of the owners and if he is out of station for a holiday, the anti-larval measures may remain deficient. The RWAs may use their powers to check all unoccupied or closed premises including hostels, hotels and construction places in that premises. One of the five great vows of Jainism is Non-attachment/Non-possession or Aparigraha. It talks about not storing unwanted things. But in today�s era our roofs, verandas and courtyards are full of left over tires, utensils, plastic utensils etc. We buy a new car tire and keep the old one on our roof top. We need to change this habit. We have forgotten to plant Tulsi and Peepal in our premises and stopped the daily Yagna, all which have anti-mosquito properties. The new strategy must focus on small collections of water like in bottle caps, finding mosquitoes lower in the room under the table or the bed, to look for them in all three parts of the house roof tops, verandas and inside the rooms, including unused toilets accessories. Also, the slogan to check your house once a week needs a change. One needs to be alert every day. It should be a part of your daily routine. You do not clean your premises once a week. Make it a habit to look for the breeding places every day. The innovative approach should be a war against indoor or outdoor mosquitoes; fresh stagnant or dirty water mosquitoes; in small containers like bottle caps or large containers like overhead tankers; made of mud or plastic; throughout the day (early morning fogging when pupa hatch for Aedes, late night for malaria); rub cleaning the utensils Indian Medical Association (IMA) and Heart Care Foundation of India (HCFI) slogan is �Katwayega to nahi� i.e. whenever you someone ask �I hope your premises are mosquito free�. Also, when you invite somebody at home say, �You are invited at my home and I have checked there are no mosquitos�. Remember the slogan: �Ghar ke andar or ghar ke bahar; din me or rat me, deewaron ke niche or upar, chote pani or bade pani ke collection me, eggs larve or mosquito, teeno ko maro.�

Aao School Chalen: A national project undertaken by IMA

Health Care Comments Off

School health is very important as schools are not just centers that impart formal education, they also influence overall development of a child. To enjoy good health during adulthood, healthy lifestyle including hygiene habits must be inculcated during childhood. These habits learned during childhood last through to adulthood and all their lives. Moreover, children are naturally inquisitive and keen learners. So, they are both beneficiaries of any health-related activity and agents of change in their family.

To this end, the Indian Medical Association (IMA) has adopted “Aao School Chalen Project” initiated by Delhi Medical Association in the recent past as a National Project. The 5th of every month has been designated for any activity related to this project.

Visit your old school if you can or any nearby school during the school assembly and interact with students and teachers to sensitize them on issues of public health importance. Speak to the principal of the school beforehand about this. It need not be long-drawn talk, but should be a short talk of 10-15 min duration. Get a certificate (proforma) signed by the Principal. Send the proforma to IMA HQs along with the photographs taken with students during assembly for records.

We have identified few topics for the coming months and there will be common points for discussion for uniformity.

The first topic for 5th August is “vector-borne diseases”. The 10 uniform messages for first lecture are as follows:

1. Mosquito-borne diseases are preventable and manageable if detected early.
2. Do not allow water to stagnate in or around the houses, particularly in plastic containers.
3. Wear full sleeves clothes during monsoon season.
4. All patients suffering from dengue, malaria, chikungunya, Japanese encephalitis should use bed nets while sleeping.
5. Treatment of malaria should be started early; it can be for 3 days or 14 days depending on the type of malaria.
6. All patients with dengue do not require platelet transfusion.
7. IMA Slogans: “Katwaieyga to nahi” (I hope you will not get me bitten by a mosquito) or “My premises are mosquito-free, you are invited at my premises”.
8. Look for mosquitoes: inside or outside the house; both small and big containers, during day or night; in the room or on the roof; floor or up on the walls; larvae or the mosquito.
9. Let all schools be declared by the principal as being mosquito-free.
10. Let every child speak a slogan: “From now onwards my house will be mosquito free”.

The schedule of the talks is as under:

• 5th September: Lifestyle
• 5th October: Menstruation myths
• 5th November: Health and Hygiene
• 5th December: Substance Abuse

States and Local Branches of IMA are requested to circulate this information to all the members.

Since, this is a national health project, IMA requests all its members to participate to make it a success.

Dr KK Aggarwal
National President IMA & HCFI

Recipient of Padma Shri, Dr BC Roy National Award, Vishwa Hindi Samman, National Science Communication Award & FICCI Health Care Personality of the Year Award
Vice President Confederation of Medical Associations of Asia and Oceania (CMAAO)
Past Honorary Secretary General IMA
Past Senior National Vice President IMA
President Heart Care Foundation of India
Gold Medalist Nagpur University
Limca Book of Record Holder in CPR 10
Honorary Professor of Bioethics SRM Medical College Hospital & Research Centre
Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand
Editor in Chief IJCP Group of Publications & eMedinewS
Member Ethics Committee Medical Council of India (2013-14)
Chairman Ethics Committee Delhi Medical Council (2009-15)
Elected Member Delhi Medical Council (2004-2009)
Chairman IMSA Delhi Chapter (March 10- March 13)
Director IMA AKN Sinha Institute (08-09)
Finance Secretary IMA (07-08)
Chairman IMAAMS (06-07)
President Delhi Medical Association (05-06)

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