Preterm babies don’t gain growth by early initiation of complementary food

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Babies started early on complementary food tend to suffer more due to diarrhoea and lower tract infections.

Babies born preterm (before 37 completed weeks of gestation) have a higher energy requirement than babies born full term and therefore fail to gain weight adequately. Parents of preterm babies and doctors alike are not sure whether breast milk or formula milk alone will meet the energy requirements after the first four months and whether preterm babies should be started on complementary food. While normal babies are given solids and semi-solids only from six months of age, early initiation of complementary food, which has a higher calorie density, in preterm babies appears to be a good idea to meet their energy needs and improve their growth (weight and length).

Till recently there was little evidence of whether earlier introduction of complementary feeding (prior to six months of corrected age) would improve growth of preterm babies.

No gain in growth

A study published a few days ago in The Lancet Global Health has found an answer to this vexatious issue — early initiation of complementary feeding in preterm babies born before 34 weeks of gestation does not improve growth.

Doctors from the All India Institute of Medical Sciences (AIIMS), Safdarjung Hospital and Kasturba Hospital, all in New Delhi, enrolled 403 babies born before 34 weeks of gestation and randomly assigned them to two groups — one in which they were started on complementary feeding at four months of corrected age and the other group of babies where complementary feeding was initiated at six months of corrected age. The corrected age refers to age that is corrected for the period of prematurity — for a baby born at 32 weeks of gestation, which is approximately two months earlier than the normal gestation period, the corrected age is 10 months at the end of one year of birth.

Complementary feeding was standardised in both the groups in terms of frequency, consistency, type of food, preparing food hygienically, and ways of feeding. Complementary foods were given in addition to breastfeeding/other milk feeding.

“Even though one group of babies was started on complementary feeding at an earlier age of four months of corrected age, there was no difference in growth compared with babies who were started on complementary feeding at six months of corrected age,” says Dr. Ramesh Agarwal from the Department of Paediatrics at AIIMS, one of the corresponding authors of the paper.

Some health risks

On the other hand, the study indicates that early initiation of complementary feeding had some negative fallout. “There were more hospitalisations in the group that started on complementary feeding at four months of corrected age,” he says. Though overall hospital admission in both the groups was low, babies in the four-month group were at increased risk of hospital admission due to diarrhoea and lower respiratory tract infections. “There could be several reasons for this increased risk, including potential contamination of complementary foods due to inadequate hygiene or having less breast milk,” he says.

“Our study shows that there is no difference in growth whether complementary feeding is started at four or six months of corrected age. But there are more infections when complementary feeding is started earlier. So it is advisable that complementary feeding is started only at six months of corrected age in preterm babies less than 34 weeks of gestation,” says Dr. Agarwal. However, studying the difference in growth and not infection was the primary objective of the study.

Published in The Hindu on May 7, 2017

Can health spending of 2.5% of GDP only by 2025 help achieve the goals set by India’s National Health Policy?

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The National Health Policy wants to reduce infant mortality rate to 28 per 1,000 live births by 2019.

The long awaited National Health Policy announced a few days ago proposes to raise public health expenditure as a percentage of GDP from the current 1.15% to 2.5% by 2025. The resource allocation to individual States will be linked with their development indicators, absorptive capacity and financial indicators. “There will be higher weightage given to States with poor health indicators and they will receive more resources. The Policy aims to end inequity between States. But at the same time, States will be incentivised to increase public health expenditure,” says Manoj Jhalani, Joint Secretary — Policy, Ministry of Health and Family Welfare.

The catch

While public health expenditure as a percentage of GDP will reach 2.5% only by 2025, many of the goals listed in the Policy have a deadline of 2025 and some of them even earlier.

The Policy stresses on preventive healthcare by engaging with the private sector to offer healthcare services and drugs that are affordable by all. It wants to reduce out-of-pocket “catastrophic” health expenditure by households by 25% from current levels by 2025.

The focus is on providing free, comprehensive care in primary care for the most prevalent communicable and non-communicable diseases, and increased affordability of care at secondary and tertiary care services by a combination of public and not-for-profit private providers wherever necessary. It wants to increase the utilisation of public health facilities by 50% from the current levels by 2025.

Health card roll out

The Centre is working on introducing a health card — an electronic health record of individuals. “The health card will be for retrieving and sharing health data by lower [PHC] and higher [secondary and tertiary] healthcare facilities. It will be helpful when patients move from primary to secondary or tertiary healthcare facilities,” says Mr. Jhalani. “It will be launched in six months to one year’s time. It will be launched in those States that show interest to roll it out in certain districts or across the State.”

Disease control and elimination

Like the Health Ministry’s National strategic plan for tuberculosis elimination 2017-2025 report, the Policy wants to reduce incidence of new TB cases to reach elimination by 2025. In a similar vein, the policy has set 2017 as the deadline to eliminate kala-azar and lymphatic filariasis in endemic pockets, and 2018 in the case of leprosy. In the case of chronic diseases such as diabetes, cancer, cardiovascular diseases, it envisages a 25% reduction in premature mortality by 2025.

The Policy “aspires” to provide secondary care right at the district level and reduce the number of patients reaching tertiary hospitals. For the first time, there is any mention of public hospitals and facilities being periodically measured and certified for quality.

Pipe dream

The Policy has sharpened its war on tobacco by indicating a 15% relative reduction in tobacco use prevalence by 2020 and 30% by 2025. But the most ambitious target is providing access to safe water and sanitation by all by 2020. As per January 2016 Ministry of Drinking Water and Sanitation country paper, sanitation coverage was only 48%.

Reducing IMR and MMR

Other challenging targets set by the Policy include reducing infant mortality rate to 28 per 1,000 live births by 2019 and under five mortality to 23 per 1,000 live births by 2025. According to the National family Health Survey 4, IMR was 41 in 2015-16; it took 10 years to reduce IMR from 57 to 41. Similarly, under five mortality was 50 in 2015-16 and it took 10 years to reduce it from 74. Over 38% children under five years were stunted according to the NFHS-4 report. The Health Policy wants to reduce this by 40% by 2025.

Increasing immunisation coverage

As against 62% children 12-23 months old who were fully immunised in 2015-16 according to the NFHS-4 data, the Policy has set a target of 90% by 2025. “Going up to 70% coverage is hugely a challenge of reaching the community. But beyond 70% coverage, other factors come in and it becomes a very big challenge,” says Dr. Pradeep Haldar, Deputy Commissioner — Immunisation, Ministry of Health. According to J.P. Nadda, the Union Health Minister, the Mission Indradhanush has increased the annual increase in full immunisation from 1% to 5-7%.

Published in The Hindu on March 19, 2017

Five-month-old babies know what’s funny

baby-optimizedBy Gina Mireault

Before they speak or crawl or walk or achieve many of the other amazing developmental milestones in the first year of life, babies laugh. This simple act makes its debut around the fourth month of life, ushering in a host of social and cognitive opportunities for the infant. Yet despite the universality of this humble response and its remarkable early appearance, infant laughter has not been taken seriously. At least, not until recently. In the past decade, researchers have started to examine what infant laughter can reveal about the youngest minds, whether infants truly understand funniness, and if so, how.

Prompted by observations of infant laughter made by none other than Charles Darwin himself, modern psychologists have begun to ask whether infant laughter has a purpose or can reveal something about infants’ understanding of the world. Darwin speculated that laughter, like other universal emotional expressions, serves an important communicative function, which explains why nature preserved and prioritised it. Two key pieces of evidence support Darwin’s hunch. First, according to the psychologist Jaak Panksepp of Bowling Green State University in Ohio, laughter is not uniquely human. Its acoustic, rhythmic, and facial precursors appear in other mammals, particularly in juveniles while they are at play, pointing to the role of evolution in human laughter.

Second, the pleasure of laughter is neurologically based. It activates the dopamine (‘reward’) centre of the brain. Laughing – in many ways – has the same effect on social partners as playing. While the pleasure of playing is a way for juveniles to bond with each other, the pleasure of laughing is a way for adults to do so, as across mammalian species, adults rarely ‘play’. Shared laughter is as effective as playing in finding others to be a source of joy and satisfaction. Thus laughter biologically reinforces sociability, ensuring the togetherness needed for survival.

Infants can employ fake laughter (and fake crying!) beginning at about six months of age. These little fake-outs show that infants are capable of simple acts of deception much earlier than thought.However, laughter is not only key to survival. It also is key to understanding others, including what it reveals about infants. For example, infants can employ fake laughter (and fake crying!) beginning at about six months of age, and do so when being excluded or ignored, or when trying to engage a social partner. These little fake-outs show that infants are capable of simple acts of deception much earlier than scholars previously thought, but which parents knew revealed infants’ cleverness. Similarly, the psychologist Vasu Reddy of the University of Portsmouth has found that, by eight months, infants can use a specific type of humour: teasing. For example, the baby might willingly hand over the car keys she’s been allowed to play with, but whip her hand back quickly, just before allowing her dad to take possession, all the while looking at him with a cheeky grin. Reddy calls this type of teasing ‘provocative non-compliance’. She has found that eight- to 12-month-olds use other types of teasing as well, including provocative disruption, as in toppling over a tower someone else has carefully built.

Teasing is the infant’s attempt to playfully provoke another person into interacting. It shows that infants understand something about others’ minds and intentions. In this example, the infant understands that she can make her father think that she will relinquish the car keys. The ability to trick others in this way suggests that infants are maturing toward a Theory of Mind, the understanding that others have minds that are separate from one’s own and that can be fooled. Psychologists have generally thought children don’t reach this milestone until about four and a half years of age. Infants’ ability to humorously tease reveals they are progressing toward a Theory of Mind much earlier than previously thought.

Additional evidence for this early Theory of Mind comes from studies showing that infants are quite capable of intentionally making others laugh, also by about the age of eight months. Infants do so by making silly faces and sounds, by performing absurd acts such as exposing hidden body parts or waving their stinky feet in the air, and by initiating games such as peekaboo that have previously invoked laughter. Knowing what another will find funny implies that infants understand something about another person, and use that understanding to their joyful advantage. This attempt to make others laugh is not seen among children and adults with autism, one feature of which is an impaired understanding of others’ social and emotional behaviours. Individuals with autism do laugh, but tend to do so in isolation or in response to stimuli that don’t elicit laughter in people without autism. They might mimic laughter, but not share it. In a sense, their laughter is non-social.

Perhaps because infants are so young, we have been reluctant to credit them with understanding ‘funniness’. Their laughs are more often attributed to ‘gas’ (a myth long ago dispelled) or imitation, or having been reinforced for laughing in response to certain events – like Mom singing in an ‘opera voice’. As it turns out, getting the joke doesn’t require advanced cognitive skills. And much of what it does require is within the infant’s grasp.

Although infants do imitate smiling, starting in the first few months of life, and prefer to look at smiles compared with negative emotional expressions, and although they might be reinforced for laughing at particular events, these are not sufficient explanations for infant laughter and humour. If they were, then imitation and reinforcement would need to account for most infant laughter, and this is simply not the case in life or in the research lab. In addition, it would suggest that infants are not capable of understanding new humorous events unless someone were available to interpret for them and/or to reinforce their laughter. Instead, research has shown that, within the first six months of life, infants can interpret a new event as funny all by themselves.

So how do they do it? Like children and adults, infants appear to rely on two key features to detect funniness. First, humour nearly always requires a social component. Using naturalistic observations, the psychologists Robert Kraut and Robert Johnston at Cornell, and later the neuroscientist Robert Provine at the University of Maryland, discovered that smiling is more strongly associated with the presence of other people, and only erratically associated with feelings of happiness. That is, smiling is more likely to be socially rather than emotionally motivated. Thus, the presence of a social partner is one key component of finding something funny. Recall that the point of laughter is to be shared.

But humour has a cognitive element too: that of incongruity. Humorous events are absurd iterations of ordinary experiences that violate our expectations. When a banana is used as a phone, when a large burly man speaks in a Mini Mouse voice, when 20 clowns emerge from a tiny car, we are presented with something bizarre and irrational, and are left to make sense of it. Infants, too, engage in this process.

We showed six-month-olds ordinary events (a researcher pretending to drink from a red plastic cup) and absurd iterations of those events (the researcher pretending to wear the red cup as a hat). In one condition, we instructed parents to remain emotionally neutral during the absurd event. Not only did infants find the absurd version of the event funny, they found it funny even when their parents remained neutral. That is, infants did not rely on their parents’ interpretation of the event as ‘funny’ to find it humorous themselves. When repeated with five-month-olds, we got the same results. Even with only a month of laughter experience under their belts, five-monthers independently interpreted the funniness of an event.

However, detecting incongruity isn’t the end of the story. Magical events are similarly incongruous, but adults, children and even infants do not laugh at them. Elizabeth Spelke of Harvard and Renée Baillargeon of the University of Illinois have observed that when natural laws are violated – a ball disappears into thin air or an object passes through a solid barrier – infants behave exactly as adults and children do: they don’t laugh, they stare. Why? Humour researchers theorise that although magic and humour both involve incongruity, only humour involves its resolution. In jokes, the resolution comes in the form of a punchline. It’s the ‘Ah-ha!’ moment when one gets the joke. It’s not known if infants are able to resolve incongruity, but that they laugh at humour and stare at magic suggests that they can. Perhaps they can simply distinguish that humorous events are possible and magical events are not, and this is enough to make the former funny. It’s up to researchers to solve this next piece of the puzzle. Until then, infants will have the last laugh.Aeon counter – do not remove

(Gina Mireault is a professor of psychology at Johnson State College in Vermont. Her research is focused on emotional development in childhood.)

This article was originally published at Aeon and has been republished under Creative Commons.

Non-communicable diseases killed more Indians in 2015

 

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Cardiovascular diseases were the leading cause of deaths in males and females in India in 2015. And high systolic blood pressure was the number one risk factor.

In 2015, India, like other developed countries, had more number of deaths caused by non-communicable diseases. In the case of males, deaths due to non-communicable diseases (3.6 million) were more than double that caused by communicable diseases (1.5 million), while it was nearly double in females (2.7 million due to non-communicable diseases and nearly 1.4 million deaths due to communicable diseases, neonatal, and nutritional diseases). Globally, 70 per cent (40 million) of deaths in 2015 were due to non-communicable diseases.

Cardiovascular diseases were the leading cause of death in both sexes in India — 1.6 million in males and 1.1 million in females. The next biggest cause of deaths was chronic respiratory diseases — 0.68 million in males and 0.5 million in females.

These are some of the Global Burden of Diseases results (here, here, here, here, here, here,  and here) published in seven papers in The Lancet on October 6.

Injuries killed 0.6 million males and 0.3 million females in 2015 alone. India had the highest number of suicide deaths in the world last year, with nearly 132,000 deaths in men and over 76,000 deaths in women. At 0.36 and 0.31 million, neonatal disorders killed nearly equal number of males and females. The other leading causes of deaths last year in both sexes were ischemic stroke, haemorrhagic stroke, TB, lower respiratory infections and diarrhoea.

India had the highest number of suicide deaths in the world in 2015.

Slower reduction in MMR

Along with Nepal and Bhutan, India has registered a slower reduction in maternal mortality rate (MMR). The MMR was reduced by a little over 50 per cent in 25 years (1990 to 2015), from over 130,000 deaths in 1990 to nearly 64,000 deaths in 2015.

In 2015 alone, the number of under-5 deaths in India was 1.26 million. The number of stillbirths alone was 0.53 million. “India recorded the largest number of under-5 deaths in 2015, at 1.3 million (1.2–1.3 million), followed by Nigeria (726,600) and Pakistan (341,700),” says a paper in The Lancet. Neonatal pre-term birth complications, lower respiratory infections, diarrhoeal diseases and measles were some of the leading causes of under-5 mortality.

The rate of under-5 deaths was 48.9 deaths per 1,000 live births. For every 1,000, live births there were 29.06 neonatal deaths (0-27 days after birth), 20.25 stillbirths, 11.74 post-neonatal (28 days to 1 year) deaths, and 8.80 deaths during the 1-4 years.

The Janani Suraksha Yojana conditional cash transfer programme was established when increasing number of women sought reproductive health services. “[The programme] has been successful at increasing reproductive health-care services, but even despite its popularity this programme has not been as effective at reaching poor rural women, the sociodemographic group that is already at highest risk of adverse pregnancy outcomes,” a paper notes.

Leading risk factors

For both sexes, the leading risk factors are high systolic blood pressure, fasting plasma glucose, ambient particulate matter, household air pollution, and unsafe water. According to The Lancet, smoking is a bigger risk factor for Indians than even cholesterol and iron deficiency. Childhood under-nutrition and lack of whole grains figure in the list.

Iron-deficiency anaemia is the leading cause for years lived with disability in the case of India, followed by lower back and neck pain, sense organ diseases, and depression.

Published in The Hindu on October 6, 2016

Zika: ‘I think WHO should declare an emergency’

Zika virus - photo - Cynthia Goldsmith, CDC - The arrow identifies a single virus particle

The arrow identifies a single Zika virus particle. – Photo: Cynthia Goldsmith, CDC

The World Health Organization faced flak for its delay by two months in 2014 in declaring the Ebola epidemic as a Public Health Emergency of International Concern (PHEIC). This might not happen in the case of Zika virus when the WHO convenes an emergency committee on Monday (February 1) to help determine the level of the international response to the outbreak.

It is alleged that WHO declared Ebola as a PHEIC only after a U.S. health care person was infected with the virus. Likewise, is it because the risk to the U.S. is very high in the case of Zika virus that WHO has convened the Committee meeting on Monday? “I think it is safe to assume two things. First, we do know that political considerations factored strongly into the delay in calling a PHEIC for Ebola, due to pressure from West African countries. Second, when a disease has potentially strong impacts on North America and Europe the political calculations change very quickly. That drives the media and pushes WHO to act”, Lawrence O. Gostin said in an email to this Correspondent. Prof. Gostin is from O’Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington DC and Director, World Health Organization Collaborating Center on Public Health Law & Human Rights.

But in the first place why should the Zika virus outbreaks be declared a Public Health Emergency of International Concern? PHEIC is defined as an “extraordinary event,” which is determined if both these conditions are met — constitute a public health risk to other States through the international spread of disease, and potentially requires a coordinated international response.

According to the 2005 International Health Regulations (IHR) agreement, this definition “implies a situation that is: serious, unusual or unexpected, carries implications for public health beyond the affected State’s national border, and may require immediate international action”.

The Zika outbreak in 23 countries meets these conditions. “Given the rapidly spreading Zika epidemic, I think WHO should declare an emergency and use all their powers under the International Health Regulations,” Prof. Gostin said. “Actually there is a detailed algorithm [based on which WHO declares PHEIC], but essentially if the disease has crossborder spread, if it is novel, and if it poses an international risk, it qualifies. All that applies to Zika in my view”.

Since its outbreak in Brazil in 2015, there have been nearly 4,000 suspected cases of microcephaly — a foetal deformation where infants are born with abnormally small heads. Officials are still investigating whether Zika causes microcephaly in newborns, but the link is “strongly suspected,” according to the WHO.

“Evidence of the virus has been found in the placenta and amniotic fluid of mothers and in the brains of foetuses or newborns. Yet causation between Zika virus and microcephaly is not yet established”, Prof. Gostin, Corresponding author writes in a paper published recently in the Journal of the American Medical Association (JAMA).

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Margaret Chan, Director-General of WHO has said Zika is spreading explosively through the Americas. – Photo: R. Prasad

The WHO estimates that 1.5 million people might have been infected in Brazil. “We can expect 3 to 4 million cases of Zika virus disease”, Marcos Espinal, an infectious disease expert at the WHO’s Americas regional office, told Reuters. And Dr. Margaret Chan, Director-General of WHO had said that the virus is “spreading explosively” through the Americas.

Since the first outbreak was reported in May 2015 in Brazil, the virus has already spread to 23 countries and territories in the Americas. It has spread even to Australia by travelers, and is anticipated to spread to rest of the Americas, Europe and Asia.

Even now under the IHR, the WHO communicates with member countries about public health risks. But things may change or work differently if PHEIC were to be declared. “If a PHEIC were declared, WHO would provide detailed guidance for States, mobilize resources, and provide technical assistance. It would place the epidemic within the framework of binding international law. It will inject major urgency into R&D [to develop therapies and/or vaccines]”, Prof. Gostin explained.

Prof. Gostin says convening an emergency committee does not mean that WHO will declare a PHEIC. For instance, in the case of the Middle East Respiratory Syndrome (MERS), the emergency committee was convened 10 times to take stock of the situation but WHO did not declare a PHEIC; it offered “detailed recommendations to guide member States.”

But the very process of convening the committee would “catalyze international attention, funding and research”. For instance, Anthony S. Fauci, Director of the National Institute of Allergy and Infectious Disease, has already announced that Phase I clinical trials of a possible vaccine against Zika virus may begin before the end of 2016. The National Institutes of Health launched a Zika vaccine initiative late last year. Brazil too has gone on an overdrive to find an effective vaccine. It may take as long as 10 years before a vaccine becomes widely available, Dr. Fauci cautioned.

Little attention was paid as long as the Zika infection remained asymptomatic and self-limiting. But “emerging data on foetal complications altered this equation” and all focus has been directed at finding an efficacious vaccine urgently.

The Zika virus infection usually is asymptomatic in nearly 80 per cent of the cases. As a result, many cases of Zika go undetected, making it difficult to estimate the true scale of the outbreak in the Americas. One in four people infected with Zika develop symptoms — mild illness, such as fever, rash, muscle/joint pain, and conjunctivitis.

Since the infection is spread through Aedes species mosquito (which bites during daytime) which is commonly seen in these countries, and since it causes foetal abnormalities, countries such as Colombia, Ecuador, and Jamaica have recommended that women delay pregnancy. El Salvador has asked women to delay pregnancy until 2018.

On January 15, the Centers for Disease Control and Prevention (CDC) advised pregnant women “to consider postponing travel to countries with ongoing Zika virus transmission”. Public Health England (PHE) has said men should wear condoms for 28 days after returning from any of the countries where Zika infection has been reported if their partner was at risk of pregnancy, or already pregnant. It also said that men should use condoms for six months following recovery if a clinical illness “compatible with Zika virus infection or laboratory confirmed Zika virus infection was reported.”

Published in The Hindu on February 1, 2016

 

 

Women live four years longer than men in India

People in India live significantly longer now compared with 1990. Life expectancy increased by 6.9 years for men and 10.3 years for women between 1990 and 2013, notes a study published in the British medical journal The Lancet .

In 1990, the figures were 57.25 for men and 59.19 for women. This rose to 64.16 and 68.48 respectively by 2013.

Healthy life expectancy too is for women. For men, it increased from 50.07 in 1990 to 56.52 in 2013, while for women it rose from 50.15 to 59.11. Ischemic heart disease, chronic obstructive pulmonary disease (COPD), lower respiratory tract infections, tuberculosis and neonatal disorders caused the most health loss.

In 2013, the top 10 causes of disability-adjusted life years in both sexes in India were from ischemic heart disease, COPD, TB, lower respiratory tract infections, neonatal pre-term birth, neonatal encephalopathy, diarrhoea, stroke, road injuries, and low back and neck pain.

For men, the leading causes of health loss between 1990 and 2013 were self-harm, ischemic heart disease and stroke, which increased at rates of 149.9, 79.9 and 59.8 per cent respectively. Self-harm did not figure among India’s top 10 causes in 1990 but was ranked 10th in men in 2013. Iron-deficiency anaemia, ranked ninth in 1990 in men, was no longer a cause by 2013.

For women, the largest increases among leading causes of disability-adjusted life years occurred owing to ischemic heart disease (69 per cent), depressive disorders (66.1 per cent), and stroke (36.8 per cent). Only ischemic heart disease was among the 10 leading causes of health loss for women in 1990. Stroke and depressive disorders were the causes of health loss recorded in 2013 but not in 1990 in Indian women. “More awareness of mental health issues and better detection and documentation could be one of the reasons for depressive disorders to show up in the list,” said Soumya Swaminathan, Director-General of the Indian Council of Medical Research and a co-author of the journal paper.

“The big jump in life expectancy is in keeping with the development of the country,” said Nobhojit Roy, surgeon and public health specialist from BARC Hospital, Mumbai, and a co-author. “But the downside is that diseases that were not seen in 1990 are seen now. India is transitioning and inheriting some of the diseases seen in the developed countries.”

In order to tackle the disease burden better, the ICMR and the Public Health Foundation of India, along with the Ministry of Health and Family Welfare, are planning a disease burden study at the State level. “It will help in better health planning, policy framing and fund allocation,” Dr. Swaminathan said. “We will also look at the risk factors for diseases in the States. This will help each State to know the major diseases and risk factors.”

Published in The Hindu on August 27, 2015

Why rural children in India die of diarrhoea and pneumonia

The reason why a large number of children under the age of five years die of diarrhoea and pneumonia, generally in rural India and especially in Bihar, has become abundantly clear. The results of a study were published a couple of days ago in the journal JAMA Pediatrics.

Diarrhoea and pneumonia are the biggest killer diseases in children aged under five years in India. With 55 per 1,000 live births, Bihar has the highest infant mortality rate in the country. But 340 health-care providers who were studied in rural Bihar rarely practised what little they knew about treating children suffering from these two diseases.

“Vignette” interviews were conducted to assess how they would diagnose and treat children with these diseases. Later, the actual treatment offered by the health-care providers was assessed by sending “patients” pretending to suffer from the same symptoms as in the interviews.

If the providers exhibited “low levels” of knowledge about the two diseases during the interviews, it was even worse during practice. Cheap, life-saving, widely available oral rehydartion salts (ORS) with zinc supplementation is the correct treatment for diarrhoea (2013 WHO recommendation).

During the vignette interviews, a paltry 3.5 per cent of providers offered the correct treatment for diarrhoea. Another 69 per cent offered ORS, but it was in addition to other unnecessary treatments. Some even prescribed antibiotics.

Shockingly, no health care provider prescribed the correct treatment for the “patients” with diarrhoea — only ORS. It was a few shades better in the case of pneumonia where the figure stood at 13 per cent.

Again, if nearly 21 per cent of practitioners prescribed potentially harmful treatment (including antibiotics) without ORS during the interviews, an alarming 72 per cent offered dangerous cocktails that included antibiotics during practice. Antibiotics have no role to play in the treatment of diarrhoea.

In the case of pneumonia, while 12 per cent prescribed antibiotics for pneumonia during interviews, the figure went up marginally to 15 per cent during practice. Severe pneumonia requires treatment with appropriate antibiotics.

“Our ongoing studies aim to understand why providers who know they shouldn’t be prescribing antibiotics for conditions like simple diarrhoea continue to do so,” Dr. Manoj Mohanan from Duke University, North Carolina said in a release.

Besides wrong treatment, the researchers found that the health-care providers asked very few pertinent questions that would enable correct diagnosis and understanding of the severity of the diseases during practice than they did during interviews.

Even the most basic diagnostic question of frequency of stools was asked only by 46 per cent during interviews and 30 per cent during practice. Similarly, in the case of pneumonia, only 27 per cent of the providers asked about rapid breathing and 25 per cent about signs of respiratory distress during practice.

Most distressing was that during practice, 76 per cent of practitioners offered treatment despite not seeing the “sick” child with diarrhoea. It was 79 per cent in the case of pneumonia.

Eighty per cent of the providers in the study did not have a medical degree from any system of medicine — allopathy, ayurveda, homeopathy or unani medicine. While those with formal medical training did have large gaps between what they knew and what they practised, they were “significantly less likely” to prescribe harmful drugs, the study found.

Published in The Hindu on February 17, 2015