Pup Vaccination Practices in India Leave People to the Risk of Rabies — Lessons from Investigation of Rabies Deaths Due to Scratch/Bite by Pups in Remote Hilly Villages of Himachal Pradesh, India

Rabies, a zoonotic disease, kills 55,000 persons every year globally and 20,000 persons in India. Two years back, we learnt of two deaths due to Rabies in remote village Shiv Shankar Garh of Arki block of District Solan and decided to investigate the deaths. Method: A rapid response team was constituted to investigate the deaths. We interviewed the villagers & family to conduct verbal autopsy. A line list of entire population of village and household contacts of the patients, who died, were made along with the line list of dogs and cattle. Results & Discussion: A-month-old stray pup brought home by the family and had caused an abrasion with its toes on the hands of both the deceased on June 2, 2011 while playing. The lady developed paralysis of the arm on July 3, 2011 and 3 days later developed symptoms of hydrophobia. She died on July 9, 2011. Her son had developed hydrophobia 10 days after that and died on July 19, 2011. Assumption that bite or abrasion by a small pup of one month cannot be fatal proved otherwise. Lack of awareness regarding the fatality of even a scratch and lack of knowledge regarding local treatment of the wound & vaccination of both human and pups, were the main reasons for the deaths. While such incidents keep on happening, and the veterinarians in India are refusing to vaccinate pups before three months of age, as pups may not develop immunity before that age, leaving unsuspecting people to the risk of rabies. Conclusions: Humans can be exposed to rabies even by pups below 3 months of age. Recommendation: Pup vaccination schedule in rabies endemic countries like India need revision. Veterinarians and public health experts need to strongly consider vaccinating pups at first contact with humans even if they are less than 3 months of age. A booster to the pup can be given at three months of age with subsequent yearly boosters.

Seroprevalence of varicella zoster virus in Colombo district, Sri Lanka

Objective: To determine the seroprevalence of varicella zoster virus(VZV) antibodies among the population residing in the Colombo district of Sri Lanka. Methods: A cross-sectional population-based study was conducted which included 1 258 participants. Blood samples were collected and questionnaires administered to obtain sociodemographic information and history of varicella and/or herpes zoster. Serum samples were assayed for VZV IgG antibodies using a commercial enzyme-linked immunosorbent assay kit. Results: Overall, the seroprevalence was 54.2%(95% CI= 51.5% 57.0%). Children below 1 year of age were seronegative, and only about 20.0% of children between 1 and 10 years of age were seropositive. Seropositivitiy increased with age and by the age of 40 years 74.3% were seropositive. Among women of childbearing age, the overall seroprevalence was about 62.0%(95% CI = 57.7%-66.1%) but was low 37.0% in the 15-19 age group. Conclusion: In this population, 45.8% lacked natural immunity against varicella. Of women of childbearing age, 39.9% lacked immunity and in the subgroup of women 15-19 years of age, 63.0% women lacked immunity. In light of the country's success with the control and high coverage of other vaccine preventable diseases and that the vaccine is available in the private sector, the inclusion of varicella vaccine in the national immunization program may be considered.

Analytic Study of Spinal Infections: Clinical Picture, Treatment, and Outcomes in King Fahad Military Medical Complex in Dhahran, Saudi Arabia

Objective: To evaluate the prevalence of spinal infection in a hospital located in the eastern region of Saudi Arabia through a retrospective review and to identify the associated etiological agents in terms of clinical picture, treatment, and outcomes. Design: Retrospective cross-sectional study. Setting: Single hospital in Dhahran, Saudi Arabia. Patients: Patients with any type of spinal infection and/or who had undergone neurosurgical intervention for spinal infection between January 2006 and December 2018. Methods: We collected data on all patients with an established diagnosis of spinal infection from January 2006 to December 2018 in the King Fahad Military Medical Complex in Dhahran, Saudi Arabia. A validated and structured checklist was used for data collection. Spinal infection diagnosis was based on the clinical manifestation, microbiological evidence, radiological findings, and antimicrobial therapy response. Results: Seventeen patients were included in this study, and their mean age was 54.93 years. Twelve of the patients were male and four were female. The approximate time from symptom onset to diagnosis was 2 - 6 months. Most of the patients experienced back pain, with lumbosacral spondylitis being the most commonly cited type (61.11%), followed by thoracolumbar spondylodiscitis (25%) and cervical spondylodiscitis (6.25%). The most frequently isolated organism was Mycobacterium tuberculosis (8 patients, 50%), followed by extended-spectrum beta lactamase (ESBL)-producing Escherichia coli (4 patients, 25%), Brucella spp (3 patients, 18.75%), Staphylococcus aureus (1 patient, 6.25%), and Quambalaria cyanescens (1 patient, 6.25%). Totally, in 50% of the patients with thoracolumbar and lumbosacra site involvement, tuberculosis spondylodiscitis was observed, while another 50% of the cases showed complications associated with paravertebral abscess that required surgical drainage. Conclusion: M. tuberculosis was found to be the major cause of infectious spondylodiscitis. Additionally, Quambalaria cyanescens was isolated;this is the second reported case of the organism being isolated and the first associated with spinal infection.

High Immunization Coverage but Delayed Immunization Reflects Gaps in Health Management Information System (HMIS) in District Kangra, Himachal Pradesh, India—An Immunization Evaluation

Background: Complete and timely childhood immunization is one of the most cost-effective interventions in improving child survival in developing countries. Computerized HMIS has been recently introduced to collect aggregated data on service beneficiaries in Himachal Pradesh. HMIS provides coverage estimates for immunization while information on timeliness is currently not available. Hence we conducted a study to validate coverage and assess the timeliness of immunization in Kangra District of Himachal Pradesh. We surveyed mothers (224) of children aged 12 - 23 months (as on January 2008) and selected 32 clusters in the district between January and March 2008. Design/Methods: We conducted a cross sectional survey and selected 32 clusters by probability proportional to size method whereas seven eligible children per cluster were randomly selected. We interviewed mothers using a structured interview schedule, examined immunization card & looked for Bacillus Calmette Guierre (BCG) Scar. Vaccination after 30 days from national schedule was considered “delayed”. We computed proportions of children completely immunized, immunization delayed, frequency of reasons for delay and 95% Confidence Interval (CI) for significance of associated factors. We conducted a case control analysis of factors associated with timely immunization by taking timely immunized children as cases and delayed immunized ones as controls. Results/Outcome: Reported coverage was universal (100%). Validated full immunization coverage was 94.2% by card/record & 99% by history. Only 29.5% (CI = 20.6% - 37.4%) of children were fully immunized as per schedule (delay less than 30 days). Median delay was 21 days for BCG, 28 days for Diptheria Pertussis Tetanus (DPT 3) and 25 days for measles. Among those with delayed vaccinations, reasons were forgetfulness (36%), lack of correct knowledge (27%) & mother gone to parents’ home (27%) & insufficient children in a camp to open full dose BCG vial (22%). Our case control analysis of timely vaccinated versus delayed vaccination revealed that “precall” (reminder) was significantly [OR = 0.1, CI = 0.2 - 0.5] protective against delayed vaccination. Logistic Regression of delay > 30 days revealed that having returned unimmunized from immunization camp earlier due to insufficient children to open vaccine vial (because of high wastage factor) was significantly associated with delayed immunization (p = 0.0000), while knowledge of date of immunization camp was significantly protective from delayed immunization (p = 0.0026). 68% of the children were having at least one immunization delayed over 30 days from recommended schedule, while the proportion of children whose immunization was delayed by over 90 days was 9.4%. Conclusions: Validated field coverage estimates are lower than reported which can be due to inclusion of children of migrants in numerator & not in the denominator. High proportion of children (>70%) were delayed, suggesting implications for WHO’s strategy of measles control & national Tuberculosis (TB) control programmes, as 4.5% of them had suffered from measles. To avoid delays we recommend (i) use of mono dose vials for BCG;(ii) precall notice to mothers;(iii) modification of HMIS software to track immunization status and timeliness of individual beneficiaries rather than aggregate numbers.

Hypoglycemic Therapy in Chronic Hepatic Disease Literature Review

Chronic liver disease (CLD) refers to a structural and functional change of the liver, which modifies the pharmacokinetics of multiple drugs, including hypoglycemic agents. This alteration depends on the severity degree of the liver disease, clinical characteristics of the patient, and comorbidities presence such as kidney disease and drug biochemistry. Insulin is considered a safe therapeutic strategy in patients with CLD, however, for many oral hypoglycemic agents, its use and dose adjustment will depend on the Child-Pugh score, based on the risk of hypoglycemia in this type of patient.

Epidemiology of fatal cases associated with pandemic influenza reported in Yemen

Objectives: This study describes the incidence of all fatal cases associated with Pandemic Influenza A (H1N1) in Yemen. It sets out to highlight the factors associated with poor prognosis *The authors declare that they have no competing interests. to enhance the implementation of prevention and control programs. Methods: The study is based on retrospective analysis of available data until 14 March 2010, as compiled by the disease control and surveillance team in Yemen. Results: Between 16 June 2009 and 14 March 2010, a total of 33 laboratory-confirmed death cases associated with pandemic influenza A (H1N1) were reported to the Diseases Control and Surveillance in the Ministry of Public Health and Population. During this period, a total of 6049 suspected influenza A (H1N1) cases were recorded. With this denominator, the case fatality rate (CFR) was 0.54%. During June through August, H1N1 confirmed cases were infrequently detected, including only 30;however, from September through December, over 200 confirmed cases were reported each month. Of the 33 cases recorded, 25 were male (76%) and 8 were female (24%), male to female ratio being 3:1. Overall median age of the death cases was 30.8 years (range 1 - 55). The most common diagnosis upon admission was pneumonia. Out of the deaths, twenty five (75.8%) had no documented underlying diseases. Chronic cardiovascular disease (9.1%) was the most commonly reported disease and 2 deaths (6.1%) were recorded as pregnant women. Conclusions: The most common diagnosis upon admission was pneumonia. Chronic cardiovascular diseases were the most commonly reported underlying conditions, while the most identified risk factor was pregnancy. These findings should be taken into consideration, when vaccination strategies are employed.

管理近视的实用建议

本文总结了近视诊断的实用方法,近视管理,回顾近视进展,为近视管理项目收集数据。

Success Story of a Low Cost Intra-Dermal Rabies Vaccination (IDRV) Clinic-Lessons Learnt over Five Years of 12,000 Patient Vaccinations “Without Failure” at DDU Hospital Shimla, Himachal Pradesh, India <br/>—“Saving a Drop of Rabies Vaccine and Immunoglobulins” 12 Innovations to Make Himachal Pradesh Rabies Free State by 2020

Background: Rabies is a dreaded disease and an estimated 55,000 people die of rabies every year. Himachal Pradesh is in the North bordering China and is predominantly rural and hilly. Villages are near forests, where wild reservoirs of rabies exist. Since health facilities are not accessible easily, we need to innovate on existing schedules of rabies vaccination keeping in view the compliance of the patients and affordability so as to give them the best possible option of treatment. In the year 2006 and 2007, we, at DDU Hospital Shimla, experienced a severe shortage of rabies vaccine and patients were running from pillar to post to fetch rabies vaccine. At the same time, we learnt that some of the patients died because either they were not able to purchase the vaccine, mostly because of its high cost, $35, or they ignored the animal bites and did not seek the treatment. Since last year, we have been experiencing non-availability of rabies immunoglobulins (RIGs) in the market and have to innovate new schedules and techniques to save lives of the patients. Methods: During shortage of rabies vaccine in 2008, we contemplated to start a low cost intra-dermal (ID) clinic so as to make rabies vaccine affordable as intramuscular (IM) vaccination cost five times more than ID vaccination. But, there were three main hurdles. One hurdle was the non-availability of rabies vaccine vials having written on them “For IM/ID use” and another hurdle was only fewer animal bite patients attending the DDU Hospital, sometimes only one or two per day, which was insufficient to open a vaccine vial and distribute among them. The third problem being faced was reluctance of the hospital doctors to prescribe ID vaccine as this was not the practice at higher teaching institutions, including medical colleges. We contacted a vaccine company and few vials labeled as “For IM/ID use” were sourced from Mumbai (1200 km away from here). We asked the Chief Medical Officer, Shimla district to write a letter to all health facilities around our Hospital to give first aid to animal bite patients and then refer them to DDU Hospital for vaccination. Now we were able to pool the patients and divide a single 1 ml vaccine vial among four patients. After continuous advocacy, our stress that WHO has given its approval for ID use of rabies vaccine and that subsequent approval has been granted by Government of India was enough for doctors to prescribe the vaccine as ID. Last Year, we got ethical approval to inject rabies Immunoglobulins (RIGs) only locally in and around the wound at times of scarcity of RIGs in the market. The subsequent follow up of patients proved life saving in crisis of shortage of RIGs. Due to shortage of RIGs we innovatively vaccinated people bitten by rabid dogs or people who had consumed rabid cow’s milk and followed them for outcome, apart from having Rabies Fluorescent Focus Inhibition Test (RFFIT) was done for few of the patiens for verification of protective titers. We innovated a technique of extraction of last drop of vaccine from the vial and also saved a drop of RIGs being used for test dose before giving RIGs to the patients. Results: The first low cost anti-rabies clinic was started on August 2, 2008 after long advocacy sessions with the authorities and the doctors. Since then, we have done many innovations based on local requirements and patients’ feedback and accessibility to treatment. We have given pre and post-exposure prophylaxis to more than 12,000 animal bite victims over more than five years period in this single clinic, saving lives as well as money without any failure even in difficult rabid animal bite cases. Our innovation helped us save the vaccine and immunoglobulins till the last drop. Conclusions: Innovative ways by health providers backed by extensive literature review and scientific evidence can help patients get low cost health deliverables that increase their compliance as medicines/vaccines become affordable to them. Third world countries need to innovate their own ways to solve their problems of scanty resources and find innovative solutions to conquer them, rather than looking elsewhere for solutions.

青霉素治疗儿童急性咽喉痛:随机、双盲临床试验

目的 对于小儿咽喉痛患者,应用青霉素治疗3天和7天,并与安慰剂相对照,以评价青霉素的疗效。 设计 随机、双盲、安慰剂对照试验。 设置 荷兰的43所全科医疗诊所。 对象 156例4～15岁的患儿,具咽喉痛症状<7天;至少符合4项主要诊断标准中的2项(有发热病史;无咳嗽;颈前淋巴结轻度肿大;扁桃体可见分泌物)。 干预措施 将病人随机分为3组:青霉素治疗7天组、青霉素治疗3天继而服用安慰剂4天组、安慰剂服用7天组。 衡量结局的主要指标 症状持续的时间;平均使用止痛剂的时间;因病休课的天数;链球菌感染后遗症的发生率;对病原体的根除率及6个月后咽痛的再发率。 结果 应用青霉素治疗咽喉痛患儿,与安慰剂比较并无明显优势,无论是对参与试验的所有患儿还是对有A组链球菌感染的96名患儿。随机分到青霉素治疗7天组有1名患儿出现了链球菌感染后遗症;青霉素治疗3天后继用安慰剂组有2例,而服用安慰剂7天组有8例患儿出现链球菌感染后遗症。 结论 在小儿咽喉疼痛平均持续时间方面,青霉素治疗并无明显优势。但是,它可能降低链球菌感染后遗症的发生率。

When are patients lost to follow-up in pre-antiretroviral therapy care? a retrospective assessment of patients in an Ethiopian rural hospital

Background:There is concern about the increasing rates of loss to follow-up(LTFU)among pre-antiretroviral therapy(pre-ART)patients in Ethiopia.Little information is available regarding the time when pre-ART patients are lost to follow-up in the country.This study assessed the time when LTFU occurs as well as the associated factors among adults enrolled in pre-ART care in an Ethiopian rural hospital.Methods:Data of all adult pre-ART patients enrolled at the Sheka Zonal Hospital between 2010 and 2013 were reviewed.Patients were considered lost to follow-up if they failed to keep scheduled appointments for more than 90 days.The Cox proportional hazards regression model was used to assess factors associated with time until LTFU.The Kaplan-Meier survival table was used to compare the LTFU experiences of patients,segregated by significant predictors.Results:A total of 626 pre-ART patients were followed for 319.92 person-years of observation(PYOs)from enrolment to pre-ART outcomes,with an overall LTFU rate of 55.8 per 100 PYOs.A total of 178(28.4%)pre-ART patients were lost to follow-up,93%of which occurred within the first six months.The median follow-up time was 6.13 months.The independent predictors included:not having been started on co-trimoxazole prophylaxis(adjusted hazard ratio[AHR]=1.77,95%confidence interval[CI],1.12–2.79),a baseline CD4 count of or above 350 cells/mm3(AHR=1.87,95%CI,1.02–3.45),and an undisclosed HIV status(AHR=3.04,95%CI,2.07–4.45).Conclusion:A significant proportion of pre-ART patients is lost to follow-up.Not having been started on co-trimoxazole prophylaxis,presenting to care with a baseline CD4 cell count≥350 cells/mm3,and an undisclosed HIV status were significant predictors of LTFU among pre-ART patients.Thus,close monitoring and tracking of patients during this period is highly recommended.Those patients with identified risk factors deserve special attention.

初级医疗机构的预警症状 该症状明显增加癌症患病风险,但是仍然很少确诊

在初级医疗机构很少能诊断新发癌症，全科医生（GPs）在诊断恶性肿瘤中的作用受到了挑战。在英国，每年每位全科医生接诊患者1500例，其中平均只有1．39例为肺癌，0．23例为食管癌，0．99例为大肠癌，0．45例为肾癌或膀胱癌。我们寻找一些诊断办法以使我们能够从众多担心自己患有癌症或无任何特异性表现的人群中将那些少数的肿瘤患者挑选出来。

医生表现的评定与公平性 将利益最大化和危害最小化,必须从一开始就建立起公平原则

医生表现的评定现已成为世界范围内临床医师所关注的事实，它包括用一系列标准化指标，对医疗保健质量进行评定和监测。有关医疗保健质量中的缺陷——即在知与行间的差距已有很多文献记载。在与社会性别、种族和社会经济状况相关的可及性、质量及结局等方面，同样也存在着这种不平等的现象并也有所记载。由于对不合乎标准或存在差异的服务质量的认识，对医护人员的公众责任感和卫生系统的改进提出了迫切的要求。

中年肥胖与远期患痴呆症的危险:一项随访27年的纵向人群研究

目的评价中年肥胖与远期患痴呆症危险性之间的关系,以体重指数(BMI)和皮褶厚度代表肥胖程度。设计前瞻性分析一个多种族人群的系列研究资料。背景北加利福尼亚州Kaiser长期医疗组是一个健康保护组织。参加者在1964至1973年间当时年龄在40～45岁间的男女共10276人参加详细健康检查者,在1994年仍参加该健康检查项目的成员。主要结局测定1994年1月至2003年4月确诊的痴呆症患者。确诊时间由Cox比例危险模型分析,从年龄、性别、种族、教育情况、吸烟、饮酒、婚姻状况、糖尿病、高血压、高脂血症、卒中和缺血性心脏病等方面进行了校正。结果在所有入选者中有713例(6.9%)诊断痴呆症。肥胖者(BMI≥30)患痴呆症的危险增加74%(危险比例1.74,95%可信区间1.34～2.26),而超重者(BMI25.0～29.9)患痴呆症的危险与那些正常体重者(BMI18.6～24.9)相比增加35%。以肩胛下或三头肌皮褶厚度的分布情况来评价,在第5百分位以下者与第95百分位以上者相比患痴呆症的危险分别增加72%和59%,数值分别为(1.72,1.36～2.18和1.59,1.24～2.04)。结论中年肥胖独立于其他因素增加远期患痴呆症的危险。

英国全科医疗数据库关于氯霉素滴眼液引起严重血液毒性危险的报告

BMJ 的一篇评论建议停止常规应用氯霉素滴眼液,其原因主要是有些与氯霉素应用有关的严重血液毒性病例报告,特别是再生障碍性贫血。尽管对这个建议有争议,但尚无对这些危险性大小的可靠估计来解决这个争论。英国大约400个全科医疗机构为全面的医疗研究数据库提供了不记名数据。