IMA Policy on Antibiotics

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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.�

Will we be ready to tackle future epidemics?

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In the public debate on the Gorakhpur tragedy, several reasons were put forth as to why these deaths occurred. That several factors collectively led to this tragedy is the undeniable truth. Rather than trying to pinpoint who is to be blamed, our focus instead should be preventing further outbreaks in the future.

Dealing with the aftermath of a tragedy is important as also, how we choose to deal with it. And the question that we all should be asking ourselves in this regard is “what can we do to prevent future epidemics” and not “what should have been done and was not done”.

Will we be ready to tackle future epidemics? The answer to this depends on what corrective measures we take today.

A long-term strategy needs to be formulated to deal with such outbreaks. A well-planned surveillance and response system should be in place, which can be mobilized quickly when needed. We need better investment in preparedness.

We have to work together to stop the next outbreak, not only in Gorakhpur, but also any epidemic in the country. Dengue, for example, occurs in epidemic proportions every year.

The Indian Medical Association (IMA) has suggested the following to avoid more incidents like the Gorakhpur tragedy.

• There should be no shortage of staff – doctors, nurses and other supporting staff. Staff deficit affects patient care. Shortage of staff should be supplemented with the services of locum doctors.
• Private doctors can be hired, but only for locum jobs, not as regular doctors.
• The practice of “moonlighting” as is prevalent in the US should be allowed in India.
• There should be a uniform system for Govt. doctors: either practice is allowed or it is not allowed.
• All patients who are denied treatment at government hospitals should be reimbursed for the cost of treatment in the private sector at predefined rates.
• All hospitals should have back up of at least one-week supply of all essential drugs, investigations and oxygen.
• To reduce the cost of treatment, essential drugs and investigations – not non-essential drugs and tests – should constitute the bulk of the expenditure of the allocated budget.
• All payments for health care services should be made either in advance or in time.
• Insurance Regulatory and Development Authority (IRDA) has made it mandatory for all private hospitals to get NABH accreditation. The same should be extended to all government set ups.
• Every death should be audited to find out the probable cause of death and whether it was a preventable death so that future such deaths can be prevented from occurring.
• In any case of negligence, one should differentiate between administrative negligence and medical negligence.

Disclaimer: The views expressed in this write up are entirely my own.

Dr KK Aggarwal

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