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

Rare diseases and rare drugs

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1. “Spinal Muscular Atrophy (SMA)” is a rare genetic disease.
2. In India, there are families whose children are suffering from this progressive disease.
3. Due to SMA, children cannot walk, and, the nightmare does not end here as it is a progressive degenerative disease which means the kids may potentially see deterioration in function of their other limbs – hands, spines and even lungs.
4. Limited data suggest that survival has increased in patients with SMA type 1 born from 1995 through 2006 compared with those born from 1980 to 1994
5. Ventilation for >16 hours a day, use of mechanical insufflation-exsufflation device, and gastrostomy tube feeding were significantly and independently associated with prolonged survival, while year of birth was not. Thus, longer survival in the later time period appears to be related to more aggressive care.
6. Treatments that enhance the level of SMN protein may be available in the future
7. Gene therapy using an adeno-associated virus vector to augment spinal cord SMN expression has shown promise in a mouse model of SMA
8. Another promising approach involves intracerebroventricular or systemic injection of antisense oligonucleotides that effectively restore SMN expression
9. Drugs that selectively modify the splicing of the survival motor neuron gene 2 (SMN2) messenger RNA also have a potential therapeutic role
10. There is a FDA approved drug viz. “Nusinersen” under development
11. The Drug has shown promising results after under going clinical trials.
12. Bogen (the company which has developed this drug)
13. The drug is not yet launched in India
14. Estimated cost >$100,000 per year
15. No Health Insurance Company in India covers such kind of disease or costs

Once introduced how to make such drugs affordable in India.

Should CRS, insurance companies and government subsidy under one roof be the answer for such diseases and drugs?

Give anti-hypertensive drugs at night

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Anti-hypertensive drugs should be taken at night.

Uncontrolled blood pressure can lead to heart attacks, paralysis and heart failure. Most such attacks occur in the early morning hours. Pulse, blood pressure and thickening of platelets are all higher in the early morning hours.

Controlling early morning blood pressure can reduce cardiovascular mortality.

Among patients with chronic kidney disease and high blood pressure, taking at least one antihypertensive drug at bedtime significantly improves blood pressure control, with an associated decrease in risk for cardiovascular events, according to a study published in the Journal of the American Society of Nephrology.

The study included 661 patients with chronic kidney disease who were randomly assigned either to take all prescribed anti BP drugs on awakening or to take at least one of them at bedtime. Patients were followed for a median of 5.4 years; during that time, patients who took at least one BP–lowering drug at bedtime had approximately one third of the cardiac risk compared with those who took all medications on awakening.

A similar significant reduction in cardiac deaths, heart attacks and paralysis was noted with bedtime dosing. Patients taking their medications at bedtime also had a significantly lower mean BP while sleeping.

For each 5 mmHg decrease in mean sleep–time systolic upper BP, there was a 14% reduction in the risk for cardiovascular events during follow–up.

Potential explanation for the benefit of night time treatment may be associated with the effect of night time treatment on urinary albumin excretion levels. Urinary albumin excretion is significantly reduced after bedtime, but not morning, treatment.

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