AES outbreaks in Muzaffarpur: Lessons to be learnt

Health Care Comments Off

In 2015, in a letter to the Principal Secretary (Health), Government of Bihar, Dr Jagdish Prasad, the then Director General Health Services had shared the findings of a study carried out in 2013 on the outbreaks of AES in Muzaffarpur including the plan and implementation of the study in the year 2014 with an aim to reduce the associated mortality and morbidity. This study was carried out jointly by NCDC, NVBDCP and ICMR. The US CDC provided technical support for the study.

Hypoglycemia came up as a distinctive finding of the study and it was observed that its management improved prognosis. Hence, it was advised to monitor blood sugar in these patients. This necessitates availability of glucometer with all Asha workers and primary health care centers.

Another fruit similar to litchi is Ackee fruit (Blighia sapida) a common food source in West Africa and the Caribbean, especially among impoverished and malnourished children. The unripe fruit contains high concentration of the toxin, hypoglycin A, which, when metabolized, inhibits long chain fatty acid breakdown and transport into the mitochondria. Toxicity manifests as a Reye-like syndrome with vomiting, hypoglycemia, seizures, and coma occurring between 2 and 48 hours after ingestion of unripe ackee fruit. Without rapid correction of hypoglycemia, the death rate approaches 100%. Pathologic findings on liver biopsy include cholestasis and centrilobular necrosis.Symptoms of hypoglycemia include neurogenic (autonomic) and neuroglycopenic symptoms. Severity of symptoms may or may not predict the severity of the hypoglycemia. Neuroglycopenic symptoms typically occur at lower plasma glucose levels than autonomic symptoms. However, with repeated episodes of hypoglycemia, the threshold glucose concentration for adrenergic symptoms decreases, such that they may not appear before the onset of neuroglycopenic symptomsAutonomic symptoms of hypoglycemia in children and adults are due to increased adrenergic activity, and include sweating, weakness, tachycardia, tremor, and feelings of nervousness, and/or hunger.Neuroglycopenic symptoms include lethargy, irritability, confusion, behavior that is out of character, and hypothermia. In extreme hypoglycemia, seizure and coma may occur.In infants, symptoms of hypoglycemia are nonspecific and include jitteriness, irritability, feeding problems, lethargy, cyanosis, and tachypnea.

When hypoglycemia is suspected, a rapid (bedside) plasma glucose determination should be performed. If it is low (≤50 mg/dL for this initial bedside measurement), critical samples should be obtained before treatment, if this can be done without delaying treatment. Obtaining critical samples before the initiation of therapy, and collecting the first voided urine sample, can dramatically improve the ability to diagnose the etiology of the hypoglycemia and simplify the subsequent diagnostic evaluation. These symptoms and signs occur at plasma glucose concentrations between 10 and 50 mg/dL. Severe and repeated episodes of hypoglycemia can result in permanent central nervous system damage, and occasionally in death.Treatment of hypoglycemia is IV dextrose; till it is given, 1 tsf sugar with one drop of water should be given sublingually every 20 minutes.

The letter further says that “the morbidity may further be averted if the parents are sensitized to provide children a good quantity of complex carbohydrate meals before bed time such as to maintain normal levels of glucose throughout the night hours.” Malnutrition in the rural low socioeconomic group children needs to be prevented or reduced.

In the last few days I have also been talking about starting a evening day meal’, to rural children on the lines of mid-day meal in these months.

Metabolites of certain compounds (hypoglycin A and methylenecyclopropylglycine or MCPG), which are naturally present in litchi fruits, were found in the urine of the patients. These compounds cause hypoglycemia. Children, especially in rural areas of Muzarffarpur should avoid eating litchi fruits

These cases mostly present in early morning hours; hence, a trained doctor or a nurse should be posted from May to July, especially during the night.

The need to strengthen diagnostic and critical care capacity at all levels of health care was also emphasized upon to facilitate timely diagnosis and management of such cases.

Following were a few of the recommendations:

Recommendations to reduce mortality

Recommendations
1. Rapid assessment and correction of hypoglycaemia

•          Through IEC and sensitisation workshops – Increase awareness among community, field level health workers (ASHAs, Balwadi/Anganwadi workers, Auxiliary Nurse Midwives, Multipurpose workers, School health staff etc.) and health staff at PHCs/CHCs/referral treatment centres on – symptoms of this illness for early detection, – about availability of free ambulatory services for early transportation, – about availability of facilities for rapid assessment and correction of glucose at nearest government health facility as well as – about availability of specialised treatment facilities at identified referral centres for early life saving interventions.
•          Provision of adequate numbers of glucometers to all PHCs/CHCs/referral treatment centres for timely detection of low blood glucose
•          Train PHCs/CHCs/referral treatment centres staff on assessment of glucose using glucometer in children presenting with history of seizures and/or altered sensorium
•          Provide and train staff of PHCs/CHCs/referral treatment centres on protocol for correction of hypoglycaemia in children with suspected outbreak illness/ altered sensorium
2. Strengthen diagnostic and critical care capacity at all levels of health care

•          As characteristically most cases report sickness in early morning hours, availability of a trained medical doctor during night in the outbreak season months of May to July at all PHCs/CHCs in the district is essential for early detection and management of cases.
•          Provide and train staff of PHCs and CHCs on protocol for first line of life saving health care
•          Strengthen diagnostic facilities at all identified referral treatment centres for timely and appropriate diagnosis

o     Strengthen laboratory facilities for electrolytes, liver function tests, CSF cytology/biochemistry and bacteriology tests

o     Post adequate number trained pathologists/laboratory technicians for round the clock specimen collection, testing and reporting

o     Provide adequate numbers of pulse oximeters

o     Provide facilities of EEG and post EEG trained technicians

o     Provide facilities of CT Scans and MRI brain and post trained Radiologists/Technicians

o     Encourage collecting biopsy specimens and histopathology testing to confirm a tissue diagnosis of encephalopathy

•          Strengthen specialised manpower for assessment and treatment of cases

o     Post adequate number of paediatricians at each of the identified referral treatment centres to handle increased case load during outbreak season

o     Short term deputation of a neurologist and a critical care specialist during outbreak season

o     Provide treatment guidelines and train paediatricians of the identified referral treatment centres on this treatment protocol

o     Provide training in critical care to paediatricians of the identified referral treatment centres

Purpose: Reduce illness

Recommendations
3. Through IEC – Increase awareness among community on providing at night-time a full meal of home-made complex and low glycemic index carbohydrate (whole intact grains – such as barley (Jav) and oats (Jai); this would help maintain a stable postprandial blood glucose and possibly minimise risk of early morning fasting hypoglycemia.
4. Improve general nutritional status

- Undertake projects to reduce malnutrition among young children, especially the rural children of low socioeconomic status

5. Considering the finding of detection of hypoglycin and MCPG (natural hypoglycemic compounds known to be present in fruits of litchi family) metabolites in urine specimens of a large proportion of case-patients, it would be advisable to make efforts by IEC to minimise consumption of litchi fruits among young children in rural areas of affected district, pending further investigations in this regards.

It is difficult to understand why these recommendations did not get implemented.

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

What do we want: Pink tokens for free rides or green token for free and available health and medical facility?

Health Care Comments Off

On Friday i.e. 07.06.2019 in Hindustan Times newspaper it was published that “DMRC may issue pink tokens for free rides”. Women wanting to avail free Metro rides, a scheme announced by the Delhi Government, may be able to do so only by taking pink tokens from Metro stations, transport minister Kailash Gahlot said Thursday…

A metro official, on a condition of anonymity, said the scheme does not mean female passengers can just walk into a Metro train without a card or token. “Those who want to avail of this will be asked their destination and the ticketing staff will top up the token with the requisite amount. The Delhi Government is likely to pay the cost incurred by this scheme beforehand to DMRC, the official said…”

On Monday, Delhi Chief Minister Arvind Kejriwal said that women will be allowed to travel without charge on buses and metro trains in NCR.

It is quite shocking that Delhi Government in the name of right to equality under Article 14 of the Constitution of India is providing free rides to females, but Delhi Government has forgotten the preamble of the Constitution of India, which strives to provide for welfare state with socialistic patterns of society under the Article 21 of the Constitution, guarantees the right to life & personal liberty. The concept of democratic socialism aims to improve the condition of health care of the people.

Part IV of the Indian Constitution which is Directive principles of State Policy imposed duty on states. Articles 38 of the Constitution impose liability on state that state secure a social order for the promotion of welfare of the people but without public health we can’t achieve it.

Article 39(e) related with workers to protect their health. Article 41 imposed duty on state to public assistance basically for those who are sick & disable. Article 42 says that it is a primary responsibility of the state to protect the health of infant & mother by maternity benefit. Article 47 spells out the duty of the state to raise the level of nutrition & the standard of living of its people as primary responsibility.

On 05.02.2018, Heart Care Foundation of India (HCFI) a registered charitable trust had filed an application under the Right to Information Act with Delhi Metro Rail Corporation (DMRC) asking about various questions relating to the medical facility at the metro stations and inside the metros.

Vide reply dated 09.03.2018 DMRC stated that there is no dispensary available in any metro station, not even in intersecting metro stations. Automated External Defibrillator (AED) machine is not being installed neither in any metro station nor in any metro train. However, some of the DMRC employees have been trained in First Aid including Cardiopulmonary Resuscitation.

DMRC has tied up with CATS Ambulance for the purpose of emergencies, however, DMRC does not have information as to in how many minutes the ambulance would reach the metro station.

A pharmacy / chemist shop is available only in some metro stations. However, the DMRC does not have the information relating to the availability of First Aid medicines for Sudden Cardiac Arrest at the metro stations and inside the metros and also information relating to the availability of the doctors at the metro stations.

DMRC does not have the information relating to the number of people died in the last 5 years at the metro stations.

The question wise answers received by HCFI from DMRC are reproduced hereunder:

Sr. No. RTI Questions Reply by DMRC
1. Whether there is a dispensary available / functioning in all metro stations? If so, what are the timings of such dispensary? No, there is no dispensary in metro stations
2. Whether there is any dispensary available / functioning in the major intersecting metro stations? If yes, what are the timings of such dispensary? No, there is no dispensary in metro stations
3. Are all the staff / employees / security personnel of Delhi Metro trained in Cardiac First Aid including Cardiopulmonary Resuscitation (CPR)?

(CPR: if a person stops breathing effectively, CPR is a lifesaving technique used to restore oxygenated blood flow to the vital organs?

No, not all but many DMRC employees have had undergone First Aid training including Cardiopulmonary Resuscitation (CPR).
4. Is there any “Automated External Defibrillator” (AED) being installed at the metro stations? If yes, how many? At present, Automated External Defibrillator (AED) are not being installed at Metro Stations / Metro Trains.
5. Is there any “Automated External Defibrillator” (AED) being installed inside the metros? If yes, how many? At present, Automated External Defibrillator (AED) are not being installed at Metro Stations / Metro Trains.
6. Are First Aid medicines for Sudden Cardiac Arrest (SCA) available at the metro stations?

Requested information on “Are first Aid medicines for sudden Cardiac Arrest (SCA) available at Metro station’ is not available in any material form and hence cannot be provided in terms of section 2(f) of the RTI Act, 2005.
7. Are First Aid medicines for Sudden Cardiac Arrest (SCA) available inside the metro? Requested information on “Are first Aid medicines for sudden Cardiac Arrest (SCA) available at Metro station’ is not available in any material form and hence cannot be provided in terms of section 2(f) of the RTI Act, 2005.
8. Is there any tie-up of the metro stations with ambulance services for the purposes of emergencies and if so, in how many minutes such ambulance can reach the metro station?

Yes, DMRC has tie up with CATS ambulance for the purpose of emergencies. Further, requested information is not available in any material form and hence cannot be provided in terms of section 2(f) of the RTI Act, 2005.
9. Whether there is a doctor available in the working hours of Delhi Metro at the metro stations?

Requested information on ‘whether there is a doctor available in the working hours at Delhi Metro at the Metro Stations’ is not available in any material form and hence cannot be provided in terms of section 2(f) of the RTI Act, 2005
10. Is there any pharmacy / chemist shop available at the metro stations? Yes, there is pharmacy/chemist shop available at some of the metro station.
11. How many people have died in the last 5 years at the metro station?

Cases of attempted suicides are subjected to investigation by concerned police authorities and the death of an individual in the metro premises is subjected to confirmation by concerned authorities. As such cases of suicides attempts & deaths since 2013 are not available with DMRC in any material form with DMRC Ltd.
12. How many people have died in the last 5 years at the metro station?

Cases of attempted suicides are subjected to investigation by concerned police authorities and the death of an individual in the metro premises is subjected to confirmation by concerned authorities. As such cases of suicides attempts & deaths since 2013 are not available with DMRC in any material form with DMRC Ltd.

Instead of providing proper medical facility, Delhi Government is giving free rides only to females.

Providing proper medical facility and taking care of health of a person is the paramount duty of the state. In Delhi, public transports like buses, Delhi metro, etc. are used by not only females but also by the elderly, minors, pregnant women, physically disabled person, patients, who need a medical facility.

Further, travelling by public transport itself is a stressful act. Hundreds of people push each other while entering and exiting the train or bus. Many a times, people fall down, even get hurt/injured while travelling, but there is no immediate medical facility for them. Many a times, Delhi metro gets stuck causing respiratory problems, blood pressure problems to the public. None of the buses, Delhi metro have first aid box, which is the basic need.

The need of the hour is not free travel but free and available medical facility.

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

Both active and passive smoking are major risk factors for hypertension: HCFI

Health Care, Heart Care Foundation of India Comments Off

High blood pressure can lead to several health complications and even premature death

New Delhi, 15th May 2019: Recent research has suggested that passive smoking at home or work is linked with a 13% increased risk of hypertension. Living with a smoker after age 20 may be associated with a 15% greater risk. Exposure to passive smoking can lead to hypertension over time with men and women equally affected.

High blood pressure accounts for almost 10 million deaths around the world. The need of the hour is to raise awareness on the fact that smoking is a leading risk factor for this condition and therefore, it is imperative to quit the habit at the earliest. There is a need to stay away from secondhand smoke, and not just reduce exposure, to prevent hypertension.

Speaking about this, Padma Shri Awardee, Dr KK Aggarwal, President, HCFI, said, “Smoking can raise blood pressure by as much as 10 mmHg especially in susceptible individuals. The effect is most prominent with the first cigarette of the day in habitual smokers. High blood pressure imposes an up-front burden in people who know they have it and who are working to control it. Apart from adding to health woes, it alters what you eat and how active you are, since lifestyle changes are important in keeping blood pressure under check. Some people need medication and may need to take one or more pills a day, which can prove costly. Uncontrolled high blood pressure can lead to heart attack or stroke, aneurysm, heart failure, organ malfunction, vision loss, metabolic syndrome and memory problems.”

Hypertension is defined as a repeatedly elevated blood pressure exceeding 140/90 mmHg. It generally doesn’t cause any outward signs or symptoms but silently damages blood vessels, and other organs.

Adding further, Dr Aggarwal, who is also the Group Editor-in-Chief of IJCP, said, “It is recommend for everyone to get an annual checkup after the age of 30 even in the absence of a no family history of hypertension, diabetes or heart disease.

The old saying ‘prevention is better than cure’ holds true today more than ever. To live above the age of 80, one needs to maintain ideal health parameters and lead an ideal lifestyle. The HCFI Formula of 80 describes certain preventive measures that can be undertaken.

  • Keep your lower BP, fasting sugar, waist circumference, resting heart rate and low- density lipoprotein LDL or the ‘bad’ cholesterol levels all <80.
  • Walk 80 minutes a day; brisk walk 80 minutes a week with a speed of 80 (at least) steps per minute.
  • Keep kidney and lung function more than 80%.
  • Eat less; not more than 80 g/80 mL of caloric food in one meal. Do not eat refined carbohydrates 80 days in a year.
  • Take vitamin D through sunlight 80 days in a year.
  • Do not drink alcohol and if you drink, take less than 80 mL of whiskey (80 proof 40% alcohol) in a day or less than 80 g (240 mL) of whiskey in a week.
  • Do 80 cycles of Pranayama in a day with a speed of 4 breaths/minute.
  • Do not smoke or be ready for heart surgery costing Rs. 80,000/-. Donate blood 80 times in a lifetime.
  • Avoid exposure to >80 dB of noise pollution.

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