Hallucinations linked to differences in brain structure

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The Hindu

A model of a Human brain.

The effect was observed regardless of whether hallucinations were auditory or visual in nature, consistent with a reality monitoring explanation.

People with schizophrenia who are prone to hallucinations are likely to have structural differences in a key region of the brain compared to healthy individuals, a new study has found.

The study shows that reductions in the length of the paracingulate sulcus (PCS), a fold towards the front of the brain, were associated with increased risk of hallucinations in people diagnosed with schizophrenia.

In a previous study, a team of researchers led by Jon Simons from the University of Cambridge in U.K., found that variation in the length of the PCS in healthy individuals was linked to the ability to distinguish real from imagined information, a process known as ‘reality monitoring’.

In this study, Simons and his colleagues analysed 153 structural MRI scans of people diagnosed with schizophrenia and matched control participants, measuring the length of the PCS in each participant’s brain.

As difficulty distinguishing self-generated information from that perceived in the outside world may be responsible for many kinds of hallucinations, the researchers wanted to assess whether there was a link between length of the PCS and propensity to hallucinate.

The researchers found that in people diagnosed with schizophrenia, a 1 cm reduction in the fold’s length increased the likelihood of hallucinations by nearly 20 per cent.

The effect was observed regardless of whether hallucinations were auditory or visual in nature, consistent with a reality monitoring explanation.

“By comparing brain structure in a large number of people diagnosed with schizophrenia with and without the experience of hallucinations, we have been able to identify a particular brain region that seems to be associated with a key symptom of the disorder,” said Simons.

The researchers believe that changes in other areas of the brain are likely also important in generating the complex phenomena of hallucinations, possibly including regions that process visual and auditory perceptual information.

In people who experience hallucinations, these areas may produce altered perceptions which, due to differences in reality monitoring processes supported by regions around the PCS, may be misattributed as being real.

For example, a person may vividly imagine a voice but judge that it arises from the outside world, experiencing the voice as a hallucination.

“We think that the PCS is involved in brain networks that help us recognise information that has been generated ourselves,” said first author Jane Garrison, from University of Cambridge.

“People with a shorter PCS seem less able to distinguish the origin of such information, and appear more likely to experience it as having been generated externally,” Garrison said.

The study was published in the journal Nature Communications.

Irrational topical steroid combinations can cause drug resistance

Steroid cocktails mixed with antifungals and anti-bacterials make the drugs extremely dangerous, irrational and may lead to the emergence of drug resistance. Photo: Mohammed Yousuf

Corticosteroids can be sold in India only on production of a registered medical practitioner’s prescription as they are included in schedule H of the Drugs and Cosmetics Rules 1945. However, a footnote in the Rules exempts eye ointments and topical preparations like skin creams and lotions from the list.

Thus topical preparations that contain steroids, including strong corticosteroids, prescribed by dermatologists and others can essentially be sold as “over the counter” (OTC) drugs.

“Even ofloxacin, which is a schedule H1 drug, is freely used in topical preparations,” said Abir Saraswat, dermatologists based in Lucknow and a member of the Indian Association of Dermatologists, Venereologists and Leprologists.

The schedule H1 category was introduced to prevent misuse of 46 third and fourth generation drugs and delay drug resistance from emerging. Since March 1, 2014, the schedule H1 drugs can be sold by chemists only on production of a valid prescription. The chemist has to maintain a separate register that has details of patients and prescribing doctors. The register has to be retained for at least three years.

Steroid cocktails, which are in fixed dose combinations, are mixed with various antifungal and anti-bacterials thus making the drugs extremely dangerous and irrational. Use of irrational topical steroid combinations can lead to drug resistance.

“Dermatologists are seeing increasingly widespread fungal diseases where the use of irrational combination drugs has been implicated. The fungal diseases do not respond to conventional drugs for conventional duration and dose,” said Dr. Shyam B Verma, dermatologist based in Vadodara, Gujarat.

“Indian doctors are witnessing a pandemic of adverse effects induced by topical corticosteroids,” Dr. Verma writes in a news piece published on Thursday (November 26) in the medical journal The BMJ.

Topical steroids can cause substantial and permanent damage, especially to thin skin such as on the face and groin, even if used for a short period of 15 days. Side effects include pigmentation and atrophy of the skin. “Misuse of steroid combinations can cause bacterial or fungal resistance, which can make infections difficult to diagnose and treat,” Dr. Verma writes.

According to a 2011 study, nearly 15 per cent of dermatology patients were found using topical corticosteroids. Of the 15 per cent, over 90 per cent had adverse effects.

Injectable vaccine to prevent re-emergence of polio launched

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Health and Family Welfare Minister J.P. Nadda along with MoS Shripad Yasso Naik (right) during the launch of Inactivated Polio Vaccine (IPV) in New Delhi on Monday. Photo: V. Sudershan

An injectable vaccine to prevent re-emergence of polio was launched today by the government and it will be administered in addition to polio drops to double the protection from the deadly virus, which has chances of coming back.

The Inactivated Polio Vaccine (IPV) will be introduced in the routine immunisation programme of the government to do away with the risk of re-introduction of the disease.

Health Minister J.P. Nadda said that though India was certified polio-free on March 27, 2014, the battle against polio is not over yet.

“The virus is still active in our neighboring countries — Pakistan and Afghanistan. Cases of polio still happen there.

So the risk of re-introduction of the disease remains, particularly through importation from these endemic countries,” he said.

“We are there to give them all kinds of support including technical, experience or vaccine-related assistance. But we will have to be vigilant till the virus is eradicated globally,” Mr. Nadda said at a function here to launch the vaccine.

“To ensure that our children are doubly protected from polio, the IPV is being introduced into the routine immunisation programme,” he said

In the first phase, the IPV injection is being introduced in six states — Assam, Bihar, Uttar Pradesh, Gujarat, Madhya Pradesh and Punjab.

However, the children will continue to receive OPV (polio drops) dose under routine immunisation and in pulse polio campaigns till they are 5 years of age.

“Even after receiving the IPV vaccine with the third dose of OPV (polio drops), the children must continue to receive OPV doses under routine immunisation and in pulse polio campaigns till they are five years of age,” Health Secretary B.P. Sharma said.

He said with the elimination of Type 2 polio from the country, the government is shifting from tOPV vaccine to bOPV vaccine in April 2016 and the introduction of new vaccine IPV in the immunisation programme will reduce the risk associated with the shift.

Managing a great epidemic

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AP

Today, over 300 million people live with diabetes.

Diabetes has now become a major public health concern especially in India because of several reasons.

Chronic conditions or non-communicable diseases are virtually lifelong diseases; they can be managed and controlled, but in most cases not cured fully. Examples are diseases of the heart and blood vessels, diabetes, lungs, chronic kidney disease, cancers and arthritis. Diabetes has now become a major public health concern especially in India because of several reasons. World Diabetes Day is observed on November 14. It was named in 1991 by the International Diabetes Federation and the World Health Organisation in response to growing concern about the threat posed by diabetes.

D. Prabhakaran

Today, over 300 million people live with diabetes. A similar number is at high risk. India has often been referred to as the “diabetes capital of the world” but has now ceded this position to China. According to the International Diabetes Federation, over 66 million people in India live with this metabolic disease; an almost equal number has pre-diabetes which is an immediate precursor to diabetes. The belief is that diabetes is an urban and rich man’s disease but we now know that the annual increase in the numbers of those with diabetes is much higher in the rural areas, poor individuals and those less educated.

Risk factors

Generally, the rise in numbers has been attributed to chaotic urbanisation, an ageing population, reduced physical activity/deskbound lifestyle and a change in diet patterns which includes consuming junk food. Other factors include genetic susceptibility, under-nutrition during foetal and early life and environmental pollutants. The rapidly changing lifestyle of children is equally important; they are now more sedentary than earlier generations. Most Indians also have abdominal obesity (“pot-belly”) which has a role in the development of diabetes.

If this continues unchecked, an already overloaded and inefficient health system will run out of solutions. What is needed are prevention and management strategies. These must include creating an environment of healthy living. There must be context specific health promotional messages that encourage physical activity and a balanced and healthy diet. For example, in hilly Himachal Pradesh, where physical activity is high, the focus must be on encouraging healthy diets. In Tamil Nadu or Kerala, a healthy diet and increased physical activity must be the aim.

Non-personal policy interventions also play an important role. These include taxation, enabling urban infrastructure development particularly in the new ‘Smart City’ plan, encouraging right agricultural practices and reducing sugar consumption, an increased and daily intake of fruits, vegetables and whole grain-based food and a promotion of physical activity. These are cost-effective and prventive strategies. For example, a 20 per cent increase in taxation on sweetened beverages helped reduce new cases of diabetes by 1.6 per cent over 2014-2023. This means that 400,000 type-2 cases of diabetes can be prevented during the same decade.

Second, strengthening health systems at the primary care level is imperative and involves providing low-cost generic drugs, long-term management of the disease with health counselling and a robust surveillance mechanism to study changing trends and progress. Here, innovations include developing a cadre of physician assistants to schedule and manage diabetes care, yoga as a lifestyle [improvement] package, self-care apps and innovative use of gaming technologies to improve physical activity. Third, partnerships must be built for research and development in preventing and managing the disease.

The medical fraternity needs to gear up to the challenge of preventing, diagnosing and treating diabetes in society and people. Several institutes have initiated in-service programmes to enhance the knowledge, skills and core competencies of primary care physicians to deliver standardised care. Unique initiatives such as (advanced) certificate courses in: evidence-based diabetes management, gestational diabetes management, prevention and management of diabetes and cardiovascular disease, management of thyroid disorders will help fight the rising burden of tackling diabetes in India.

(Prof. D. Prabhakaran is Vice-President, Research, Public Health Foundation of India.)

A setback for surrogacy in India?

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AP

“Almost all surrogate mothers and commissioning parents agree that foreign surrogacy should not be stopped.”

After a court ban and proposed changes to legislation, the lucrative industry could lose its best paying ‘customer’ — commissioning couples from other countries.

In India, the engine that drove the multi-billion surrogacy industry was globally falling birth rates, and over the past decade, India’s “liberal” laws further propelled the entirely unregulated sector to organise itself into a fast growing profitable venture.

Now, the rules are set to change.

On November 4, the Supreme Court imposed a ban on the customer in question — foreign nationals. Through the introduction of the proposed Assisted Reproductive Technology (ART) Bill, the Central Government now seeks to narrow surrogacy services to Indian couples or foreigners married to Indian citizens.

There is now unhappiness.

Bindu Shajan Perappadan

“It’s foul play,” a group of commercial surrogate mothers tells this correspondent. They believe they are doing a “noble job”. The money doesn’t hurt either.

“The couple of the child I am carrying have been trying to have kids for 15 years,” says ‘Y’, a 24-year-old commercial surrogate and a biological mother to her two-year-old child. Her husband is a driver and they are in the business “because it also pays well.’’

“I want to go back to my village, buy land and settle down,” she says. “This money is the only way out. My husband will never be able to earn enough for us to return home. But if become a surrogate mother, we will have enough money,” she explains.

Another surrogate, ‘X’, said she did this for her child’s future. “What is wrong in this?” ‘X’ has a seven-year-old biological son who she hopes to send to a good school and away from the rigours of city life. “After this delivery and sending my child to hostel, I will work full-time. If my husband and I work, we will be able to ensure that my child becomes a doctor and escapes this life of struggle,” she explains. “After all, we have no pension or government security in our old age. Who knows if our children will take care of us? It’s only prudent to save for the future. Motherhood and the ability to have children is a gift that nature has given to lucky women... I don’t think there is anything wrong in ‘gifting’ and ‘sharing’ this divine power and engaging in something that is mutually beneficially to all the parties involved,” she adds.

The arguments are not new. A group of surrogate mothers has moved the Supreme Court seeking a withdrawal of the November 4 circular banning foreign commissioning parents.

Grey area

Commercial surrogacy, largely an unregulated grey area, has been allowed in India since 2002. The Supreme Court (2008) called surrogacy a medical procedure legal in several countries including India. The surrogacy debate started with the Baby Manji Yamada case in which the commissioning parents divorced during the pregnancy and the commissioning mother refused to accept the baby. The court finally granted custody to the baby’s grandmother. In 2008, another case, on the citizenship of surrogate babies, led the Gujarat High Court to state that there is “extreme urgency to push through legislation” which addresses issues that arise out of surrogacy.

A draft ART Bill, pending in Parliament since 2010, is now expected to be taken up in the on-going winter session.

It is India’s first attempt at regulating the surrogacy industry which was earlier guided by the National Guidelines for Accreditation, Supervision and Regulation of ART Clinics in India, 2005, and subsequently amended in 2008, 2010 and 2013.

It is being seen as a setback for commissioning parents. After being married for over a decade, Dr. R, a British passport holder and a gastroenterologist of Indian-origin came back to India to “complete his family”.

“Adoption wasn’t an option,” says Mrs. L as she hugs her newborn child. Now a mother after a year of the surrogacy process was initiated at a Delhi clinic, she is very clear about why she and her husband came to India. “The country offers the best in terms of medical advancement, it’s reliable, cheap and world class. Besides, surrogate mothers are available here in India which isn’t the case in most parts of the world.”

Almost all surrogate mothers and commissioning parents this correspondent spoke to agree that foreign surrogacy should not be stopped. The association of medical practitioners providing fertility treatments are concerned that the government, instead of effecting better regulation, has imposed a blanket ban on a section of customers. Dr. Shivani Sachdev Gour, secretary, Indian Society for Third Party Assisted Reproduction (Instar) said, “We feel the new restrictions are too binding. You have to understand that surrogacy needs a more humane approach and more individual case-by-case attention. We cannot have a single blanket rule to govern the ethical and legal nuances of surrogacy.”

But women’s rights organisations say that “poor” women should not be exploited in the name of noble work. Dr. Ranjana Kumari, director, Centre for Social Research said, “There are many issues besides sex selection and exploitation of the poor surrogate mothers. There are countries that do not allow surrogacy. What would the nationality of the child be when the intended parents are from that country? About 48 per cent couples opting for surrogacy are foreigners.”

Dr. Kumari notes that surrogates aren’t given their due. “Though the couple who wants to have a baby through a surrogate mother pays anything between Rs.2 lakh to Rs.5 lakh to agents, the woman who delivers the baby gets only Rs.75,000 to Rs.1 lakh,” she says.

Cheap medical facilities, advanced reproductive technological knowhow, coupled with poor socio-economic conditions and a lack of regulatory laws in India are what make India an attractive option.

In India, the business of providing “wombs on rent” is now valued at $500 million. The number of cases of surrogacy is believed to be increasing at a galloping rate,” says Dr.Kumari.

Indian Council of Medical Research (ICMR) data says that approximately 2,000 babies are born every year through commercial surrogacy. Confederation of Indian Industry (CII) figures claim that surrogacy is a $2.3 billion industry in India, because it is largely unregulated and cheap. Clinics function in tight cliques; unrelated centres like dental clinics sometimes assist fertility clinics, say experts.

ICMR says that professional surrogates need to “protected against exploitation”. A senior official said, “We hope to ensure accountability of the ART banks and ensure that the malpractices — private clinics advertise for surrogates and the money paid is arbitrary — is eliminated altogether. Also, [the] rights of the commissioning couples will be protected and the industry will be streamlined and brought under the preview of proper rules and regulations.”

Taking health care to tribal heartland

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The Hindu

Instead of tribals going to New Delhi, New Delhi had come to the tribals. Photo: Singam Venkataramana

New Delhi travelled to tribal heartland. The expert group offers hope; an opportunity to ensure that the tribals have a say in policies that are framed for them.

Earlier this month, a motley group of 50 academicians, government officials and activists gathered at Shodhgram village in Maharashtra’s Gadchiroli district. This is an area known for malaria, malnutrition and Maoists, not necessarily in that order.

Everyone left technology behind (mobile phones and gadgets) to ensure that there were no distractions to the flow of conversation over three uninterrupted days. It was to talk about an ‘x’ number of India’s 100 million tribal population.

The Health Ministry had decided to hold the workshop on “Best Practices in Tribal Health” in tribal heartland; on a campus surrounded by lush forests and designed as a Gond village. Instead of tribals going to New Delhi, New Delhi had come to the tribals.

Gunjan Veda

What led to this meeting was another first: the government’s recognition of the differential and unique health needs of tribal communities. In October 2013, the Ministry of Health and Family Welfare and the Ministry of Tribal Affairs’s expert group was to frame a national policy on tribal health, given the unique socio-cultural realities of these communities.

Its chairperson, Dr. Abhay Bang, who along with his wife, Dr. Rani Bang, has, for almost three decades, led community-based action and research for and on the health of India’s neo-nates and tribal people.

Seeking scaleable solutions

As a result, we now have access to multidimensional, national level data; data that has not only been missing from our statistical databases but also from our consciousness. The results will be presented along with the group’s report at the end of this year.

The three days were fruitful. The group identified 26 areas that have the potential to break some of the biggest barriers to tribal health. Some are malaria, malnutrition, maternal and child mortality and fluorosis.

“In 1995, the district collector of Mandla contacted the National Institute for Research in Tribal Health (NIRTH) at Jabalpur. In Tilaipani village, all the children had knock-knees and severe pain. They had fluorosis,” said Dr. Tapas Chakma, senior scientist with NIRTH. His team then focussed on a commonly grown weed, rich in calcium, iron and vitamin C that could help mitigate fluorosis.

Dr. Sudarshan from the Karuna Trust showed how public-private partnerships with north-east Indian governments have taken health to the hinterlands. The Chhattisgarh government highlighted its outsourcing human resource recruitment, while doctors from Jan Swasthya Sahyog, Bilaspur, pushed for community-run crèches to fight malnutrition. Village women trained by the Society For Education, Action and Research in Community Health demonstrated how they treated sepsis and used ambubags to save newborn children.

Policy priorities

Each of the practices offered a ray of hope for a population that has long been relegated to the peripheries of India’s development story.

Now some key policy issues that could determine the state of tribal health in India. For instance, is outsourcing the answer to providing quality care in tribal areas? Is volunteerism in health services sustainable? Can Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homoepathy doctors or nurses fulfill the human resource gap created by lack of doctors in tribal areas? Most importantly, what are the priorities for tribal health and who determines them?

Dr. Soumya Swaminathan, Director General of the Indian Council of Medical Research (ICMR) called for greater collaboration between academia, civil society and government to conduct multi-centric evidence studies. “It is important to include anthropologists, sociologists and economists in health research,” she said, while asking for a sharing of ideas and evidence in tackling the sickle cell disease.

Sickle cell disease is an inherited condition where the hemoglobin in red blood cells is abnormal and may block the passage of oxygen, resulting in severe pain and gradual damage to vital organs. It can only be prevented, not cured. According to ICMR, the sickle cell gene is widely prevalent among some tribal groups, with a prevalence rate of 1-40 per cent.

“We have launched a screening programme in 18 States. This will enable us to know the problem. But what of the solution? At the end of the programme, lakhs of people would know that they carry the disease or the gene for it,” she said.

“What recourse will we offer them?” Dr. Swaminathan asked. She laid stress on the need for projects that reduce morbidity and mortality among sickle cell carriers.

Evidence from Gujarat, which initiated sickle cell screening in 2006, shows that pre-marital counseling to prevent transmission does not work. It also presents itself as an ethical conundrum. The State needs to ensure that carriers, particularly girls, do not face discrimination.

Perhaps the Bangs’s experience of sickle cell testing best frames the policy question. “When we started work in Gadchiroli in 1986, we detected sickle cell disease and tried to discuss the way forward with the tribals. They laughed and said, “Who told you this is our problem?” For them, malaria and child mortality are much bigger issues as most sickle carriers lead normal lives.”

So, who determined that sickle cell screening is a priority in tribal health? Did someone study the impact of sickle cell on the life and productivity of tribals?

This takes us back to the main question. Do our policies address the priorities of tribals or do they set priorities for them? Unfortunately, it has been the latter. But this time New Delhi travelled to tribal heartland. The expert group offers hope; an opportunity to ensure that the tribals have a say in policies that are framed for them.

Will we let it move forward? Only time will tell.

(Gunjan Veda is a former policymaker and co-author of Beautiful Country: Stories from Another India.)

A vaccine boost to India’s polio fight

The Hindu

NOW A JAB BEFORE THE DROPS: Picture shows a child in Bengaluru being given Pulse polio drops. — File Photo: K. MURALI KUMAR

The launch of the inactivated polio vaccine injection marks a shift in addressing vaccine derived poliovirus cases.

After nearly five polio-free years, and with the launch of the inactivated polio vaccine (IPV) injection in the national immunisation programme tomorrow (November 30), India will be pushing for “endgame polio”.

The injectable vaccine, which uses killed polio viruses, will be used alongside the oral polio vaccine (OPV).

For now, immunisation using IPV will be restricted to Bihar, Chhattisgarh, Gujarat, Madhya Pradesh, Uttar Pradesh and West Bengal. In the first quarter of 2016, it will be expanded to the other Northern and Northeastern States and in the second quarter, will encompass the four southern States and Maharashtra. “Immunisation using IPV injection is in a reverse order, with the well performing States getting it last,” said virologist Dr. Jacob John, formerly with the Christian Medical College, Vellore.

R. Prasad

Though cheap and easy to administer, OPV HAS an inherent safety issue —in rare cases, live viruses used in a weakened form can turn virulent, spread within communities and cause polio in unprotected children. In 2011, such a scenario caused seven vaccine-derived poliovirus (VDPV) cases in India.

IPV aims to prevent vaccine caused polio cases, where viruses used in OPV cause flaccid paralysis. Till date, India, like many other countries, has been relying on an OPV campaign-style programme several times a year to keep the naturally-occurring wild polioviruses at bay.

All three strains of the poliovirus (type 1, type 2 and type 3) are used in OPV. Of these, type 2 is responsible for more than 95 per cent of VDPV cases. Ironically, type 2 wild poliovirus had been eradicated since 1999. Since then, all type 2 cases have been caused solely by vaccine polioviruses.

The move also marks a shift in addressing vaccine-derived poliovirus cases, with the Global Polio Eradication Initiative removing the type 2 strain globally from OPVs.

To begin with, one dose of IPV will be administered along with the third dose of OPV and DPT to children who are 14 weeks old. Even after being immunised with IPV, it is essential that all children are immunised with OPV every time it is offered. IPV when used in combination with OPV can quickly boost immunity against poliovirus and offer double protection.

“One dose of IPV will prime the immune system and the immune response will be quicker whenever OPV or IPV is given subsequently”, said Dr. Pankaj Bhatnagar, Technical Officer of the WHO India National Polio Surveillance Project, New Delhi.

There is a scientific reason for choosing 14 weeks for IPV immunisation. “When IPV is given to children at 14 weeks and later, nearly 70 per cent of them will develop antibodies against polio viruses. It will be around 30 per cent if given to children younger than 14 weeks”, he said.

The switch from OPV with all three strains to only two strains (type 1 and type 3) will happen towards the end of April 2016. “India will make a switch from a trivalent [containing all three virus strains] to a bivalent [containing only two strains] on April 24,” Dr. John said.

“There are a risk when this switch is made,” he warned. “Vaccine-derived type 2 will spread silently and cannot be stopped and children will continue to shed type 2 strain for 4-6 weeks after the last OPV dose. [A] new crop of children who do not get the trivalent oral polio vaccine can get exposed to [the] type 2 strain shed by vaccinated children,” he said.

It is to minimise this that the Global Polio Eradication Initiative requires all countries using the three-strain to introduce at least one dose of the injectable vaccine before making the switch.

“We will be building the immunity of the community against type 2 through IPV and OPV immunisation so that at the time of switching from trivalent to bivalent OPV there will be no risk,” said Dr. Pradeep Haldar, Deputy Commissioner – Immunisation, Ministry of Health and Family Welfare, Government of India.

Since the injectable vaccine contains all three strains in a killed form, it cannot cause vaccine-derived poliovirus. Superior safety apart, IPV has other advantages. Nearly 60 per cent who receive IPV will develop immunity when compared with/to the 10 to 30 per cent when OPV is used.

The higher the injectable polio vaccine coverage, the lower the risk. Hence, routine immunisation coverage in States like Uttar Pradesh and Bihar must be stepped up for IPV to become effective.

“In the beginning of this year only 64 per cent of children were fully immunised. It will reach 82 per cent by the March 2016. Of the 9 million children who were not fully immunised, 40 per cent have already been covered and another 10 per cent will be covered by March 2016,” said Prof. Ramanan Laxminarayan, Vice President — Research and Policy at the Delhi-based Public Health Foundation of India. He established the Immunization Technical Support Unit that supports the immunisation programme of the Ministry of Health and Family Welfare.

India imports inactivated polio vaccine injections at a cost of $2 per dose. Since wild polioviruses are the raw material for IPV, no Indian manufacturer is allowed to make IPV in India. Companies now using biosafety level 3 facilities for IPV manufacturing will move to biosafety level 4 once wild polio is eradicated globally. After that all, OPV will be discontinued and IPV will remain the mainstay.

‘Delhi kids becoming an unfit lot’

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PTI

File picture of children on their way to school in New Delhi.

A survey has revealed that lack of appropriate playtime is leaving school-going children unfit

Two out of five school-going children in the National Capital Region have an unhealthy Body Mass Index (BMI), says a survey conducted by EduSports.

According to the survey, lack of appropriate playtime for children has rendered them unfit.

The survey, which was conducted on 16,164 children in 15 schools, shows that only 59.3 per cent of boys and 63.7 per cent of girls have a healthy BMI.

EduSports, a physical education and school sports company, tested students on their sprint capacity, flexibility, upper body strength, abdominal strength and BMI.

These parameters revealed that 1 in 2 children lack adequate lower body strength, 2 in 5 children do not possess adequate upper body strength, 1 in 5 children do not have the enough endurance capability, while 3 in 10 children do not have the desired sprint capacity.

Global recommendations on physical activity for children between 5 and 17 years of age call for at least 60 minutes of moderate to vigorous physical activity every day.

However, the time dedicated to physical activity for children of this age group is not enough.

The survey also found that while some schools offer three or more physical education periods per week, most offer just two.

It also found that students from schools which offer more than three periods are more fit and healthy.

Saumil Majumdar, CEO and co-founder of EduSports, said: “This survey, which is in its sixth year, is an eye opener for parents and schools who must come together to challenge the increasing levels of inactivity and sedentary lifestyles among school-going children. We believe that schools are the best sources of intervention to implement a structured sports programme that will help improve the fitness standard in children.”

“Our research shows that schools implementing a structured and age-appropriate sports programme show a substantial improvement in health and fitness levels of children, as compared to schools which have been running a non-inclusive programme. Research also shows that children who are active have a greater attention span and perform better academically,” Mr. Majumdar added.

Poor pay may see doctors desert government hospitals

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The Hindu

Non- Practising Allowance is given to doctors in States, where private practice along with government service is not allowed.

7th Pay Commission’s recommendations have been flayed by FORDA

Federation of Resident Doctors Association (FORDA) has strongly opposed the recommendations of the 7th Pay Commission on reducing the percentage of Non- Practising Allowance (NPA) from 25 to 20 per cent.

Calling this pay commission particularly discriminating to doctors Dr. Pankaj Solanki, president FORDA said: "The move will be a great blow on the retention of good doctors in government sector.’’

NPA is given to doctors in States, where private practice along with government service is not allowed.

"The 6th Pay Commission put NPA for doctors as part of basic salary and it was 25 per cent of basic salary. With the 7th Pay Commission the percentage has been reduced to 20 per cent of basic salary. Also with this commission’s recommendation NPA shall be treated as a separate allowance. This makes the final salary of the doctors lower than expected,’’ explained FORDA in their release.

FORDA also pointed out that there is over 50 per cent difference in the pay of a government doctor and a private one.

“The gap is only widening,” said Dr. Solanki.

"For example, the pay of an assistant professor at the Government Medical College in Delhi starts with Rs 85,000 p.m, while the pay of a junior consultant ( equivalent in degree and position ) in a private hospital in Delhi is Rs 2- 2.5 lakh. With this pay commission, there will be a higher discrepancy between government and private doctors,’’ said Dr. Ravinder Chauhan, general secretary, FORDA explained.

Members of FORDA maintained that they strongly reject this pay commission report on behalf of the medical profession, as it is strongly discriminatory in its recommendations and has got no visionary approach and shall cause strong deficit in quality of services and cause administrative difficulties.

Dr. Solanki noted that recommendations are against the interest of the medical profession. FORDA had demanded that NPA should be raised to 40 per cent.

Varied treatment	Government sector	Private sector
Entry level	Rs 85,000/pm	Rs 1.30-40 lakh
Junior sepcialist	Rs 85,000/pm (starting to one lakh plus)	Rs 1.75 lakh
Senior specialist	Rs 1.05 lakh (starting)	Rs 2 lakh plus

Drug-resistant bug Klebsiella causes worry

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• 
  Reuters

  File photo shows a plate coated with the antibiotic-resistant bacteria called Klebsiella, which is proving to be fatal in 30 to 40 per cent of the patients who have contracted it — usually during a long stay in the hospital, particularly in the intensive care unit.
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In some cases, even colistin has failed to kill it.

A bug that doctors until about three years ago treated with moderate-class antibiotics is now causing worry in intensive care units of hospitals across the country. Doctors report that third-generation antibiotics — carbapanems — are failing to treat the Klebsiella pathogen, leading to higher mortality in patients and peg the resistance at up to 50 per cent. In Mumbai, the bug is being recorded in 10-20 per cent of the patients in ICUs of major public hospitals.

Cases of colistin-resistant Klebsiella have started emerging, including four in Mumbai. Colistin is the last antibiotic available in the world for infections that the strongest antibiotics fail to treat.

Klebsiella causes urinary tract infections, ventilator-acquired pneumonias and blood stream infections (sepsis) among other conditions and is proving to be fatal in 30 to 40 per cent of the patients who have contracted it — usually during a long stay in the hospital, particularly in the intensive care unit.

“For the first time, we have seen Klebsiella resistant to colistin,” said Dr. V. Balaji, Head of Microbiology, Christian Medical College, Vellore, where six such cases have been recorded. Dr. Balaji, who also heads the antimicrobial stewardship and infection control and prevention of the Indian Council of Medical Research (ICMR), said it was difficult to find the resistance mechanism and that they were working on it. Citing a pan-India study the CMC has done, he pegged resistance to carbapanem between 50 and 60 per cent.

Referring to the four cases of colistin-resistant Klebsiella in different hospitals in Mumbai, consultant microbiologist at Hinduja Hospital, Dr. Camilla Rodrigues said with carbapanems failing to work on Klebsiella, colistin consumption has gone through the roof. “Organisms that are intrinsically resistant to colistin will now come back,” she said.

Double whammy
It is a double whammy for high-risk patients who have compromised immunities. “Patients such as those suffering from lymphoma or who have undergone transplants are particularly difficult to treat,” said Dr. Chand Wattal, head of the Microbiology Department at Sir Ganga Ram Hospital in Delhi. He said colistin-resistant Klebsiella has started showing up in the last three to four months in Delhi.

In Mumbai, cases of carbapanem-resistant Klebsiella are being routinely recorded, but resistance to colistin remains rare. At J J Hospital, Byculla, carbapanem resistance is being reported in 12 to 21 per cent of the total cases. “The concern is that we are getting less armour against Klebsiella,” said Dr. Abhay Chowdhury, head of the Microbiology Department at JJ Hospital. His counterpart at KEM hospital, Dr. Preeti Mehta said 20 per cent of the total ICU cases at any given time have contracted Klebsiella. “This has come up in the last two years. It is manageable, but if it is not detected early, then it leads to high mortality,” she said.

At Sion hospital, three to four such cases are being recorded every month. “Two to three years ago, there were no cases of carbapanem-resistant Klebsiella. There would be a few cases in between, but now 10 per cent or so of the total isolates are resistant,” said Dr. Sujata Baveja, head of the Department of Microbiology at Sion hospital.

Serious implication

The implication of the growing resistance is serious. Simply put, higher the level of resistance, higher the mortality.

“If Klebsiella is resistant to carbapanem, a higher dosage or combination therapy is the next step, but this requires careful laboratory evaluation and patient monitoring, which may not be possible in many hospital settings. Besides, a high level of resistance means many treatment failures and thus higher mortality,” said Dr. Kamini Walia from the Division of Epidemiology and Communicable diseases, ICMR.

Carbapanem usage is rationed. “It is a third-generation drug and is used when everything else has failed. Colistin is toxic and the only drug we have now (when everything else has failed). We have nothing left,” she said. According to her, better infection control practices are now an absolute necessity that hospitals need to follow.

But the concern is here to stay, and only getting graver. With resistance to colistin in other parts of the world much higher, it is only a matter of time when the last antibiotic fails on Klebsiella even in India, said Dr. Balaji.