An outbreak of Crimean-Congo Hemorrhagic Fever recurs in Gujarat?

Dr KK Aggarwal and Dr Adit Desai

Ahmedabad, Aug 28 (PTI) Three women from Gujarat have fallen victims to Congo Fever in one week while as many new cases have come to light, the state government said on Wednesday. Of the three, two women from Surendranagar district died earlier this week while another woman succumbed to the infection late on Tuesday night, said deputy Chief Minister Nitin Patel in Gandhinagar. The latest deceased hailed from Bhavnagar district. "A total of three women have died due to Congo fever, which spreads through ticks in humans. Three new cases were also reported till now. Among the three, a woman is currently undergoing treatment at civil hospital in Ahmedabad while two male patients are admitted to SVP hospital," he said. Health Commissioner Jayanti Ravi said since cattle-rearers are more susceptible to the Crimean-Congo Hemorrhagic Fever (CCHF) virus, which is responsible for the infection, preventive measures are being taken.  Ahmedabad, TNN | Aug 29, 2019: Deputy CM and state health minister Nitin Patel confirmed that the three deaths in the state were due to CCHF virus. “A total 17 people including two from Halvad in Morbi district have tested positive for the virus while 11 samples tested negative. The health administration is taking all measures to control further spread of the disease,” Patel said. In Ahmedabad, three medical personnel treating Congo fever patients from Surendranagar at SVP Hospital have tested negative.

CCHF was first described in the Crimea (former USSR) in 1944 and given the name Crimean hemorrhagic fever.

In India, the first confirmed case of CCHF was reported during a nosocomial (Infections caught in hospitals) outbreak in Ahmadabad, Gujarat, in January 2011. During 2012–2015, several outbreaks and cases of CCHF transmitted by ticks via livestock and several nosocomial infections were reported in the states of Gujarat and Rajasthan (National Health Portal of India).

Crimean-Congo hemorrhagic fever: A quick recap

Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic disease and is endemic in parts of Africa, the Middle East, Asia and southeastern Europe. It has been listed as a WHO Priority disease, which means “diseases that pose a public health risk because of their epidemic potential and for which there are no, or insufficient, countermeasures”.

·         Etiology: It is a viral hemorrhagic fever caused by the CCHF virus.

·         Transmission:  The CCHF virus is transmitted via ticks or direct contact with blood/body fluids or tissues of infected animals; nosocomial transmission can also occur. Transmission of the virus usually occurs between May and September; ticks survive most readily in relatively warm, dry habitats.

·         High risk groups: Persons in rural endemic areas working in animal husbandry

·         Incubation period: 1-3 days following tick bite; 3-7 days after contact with blood and body fluids.

·         Clinical features: Sudden onset of fever, headache, malaise, myalgia, sore throat, dizziness, conjunctivitis, photophobia, abdominal pain, nausea, vomiting. In severe cases, hemorrhagic manifestations (petechiae, ecchymoses, epistaxis and gum bleeding) occur.

o    Suspect CCHF in patients with fever and bleeding with relevant geographic and epidemiologic risk factors.

·         Biochemistry: Thrombocytopenia, leukopenia, hyperbilirubinemia with elevated transaminases, prolongation of prothrombin time and partial thromboplastin time.

·         Diagnostic tests: Serology (IgM and IgG antibodies, which appear 5 days from symptom onset); reverse-transcriptase polymerase chain reaction (RT-PCR) (which detects CCHFV RNA)

·         Management: Supportive care; fluid and electrolytes, antipyretic (paracetamol), avoid ibuprofen and aspirin. Severe cases may need mechanical ventilation, hemodialysis, vasopressor and inotropic agents.

o    Observe infection control precautions (including standard, contact and droplet precautions) i.e. use of personal protective equipment (an impervious gown, gloves, mask, and eye/face protection); respiratory protection (N95 mask or FFP3 respirator); shoe covers; dispose off all sharps and needles in hard containers and at the point of use.

o    Platelet transfusion to maintain platelet count >50,000/mm3 if bleeding occurs and for patients with platelet count <20,000/mm3 in the absence of bleeding 

o     Patients with suspected or confirmed CCHF should be treated in isolation rooms 

·         Prognosis: Symptoms usually resolve in 7-10 days in nonsevere cases. Mortality rate is 2-80%.

·         Post-exposure management: Monitor the person for clinical manifestations of CCHF for 2 weeks. Measure body temperature every day and do complete blood count (CBC) every week; no quarantine is required

·         Prevention: Avoid tick bites and contact with bodily fluids of infected animals; there is no vaccine for CCHF.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Mera Bharat Mahan 15: The origin of strings theory is in Vedas

Dr KK Aggarwal

In Vedic language, the body is divided into three parts:

1.         Sthool sharira (physical body)

2.         Sukshma sharira (Subtle body)

3.         Karan sharira (Soul)

The physical body (bahya karana or externalization) is made up of Tanmatras and five basic elements. It has five Karmendriyas.

The sukshma sharira has the Gnanendriyas and the antaha karana – manas (mind), buddhi (intellect), ahamkar (ego), chitta (pure intelligence).

Karan sharira is the soul. It is the unmanifest and is omnipotent, omniscient and omnipresent.

In terms of quantum mechanics, sukshma sharira and Karan sharira, after the physical body ends (fermions and bosons), merge into wave particle duality, then the wave, then quantum field and ultimately to the strings (present in 10 dimensions).

As per the theory of everything, the strings are the subtlest of the subtle in the body.

·         In Bhagavad Gita the description of field comes in the very first shloka in the form of kshetre which means the field

dhṛtarāṣṭra uvāca

dharma-kṣetre kuru-kṣetre

samavetā yuyutsavaḥ

māmakāḥ pāṇḍavāś caiva

kim akurvata sañjaya

·         There is the story of Karkati in Yoga Vasishta (3.27); when she asks the boon of becoming subtlest of the subtle, she became Suchika and Visuchika (needle and mobile needle), which means strings in quantum field [3.35: the demoness became smaller and smaller, of the size of a grain (fermion) and then of the size of a needle)

·         In Kena Upanishad (3.6, 3.10), when the Brahman (GOD) asked Agni and Vayu Devta to burn or move the straw / dried grass like a thread they could not burn it or move it. This again means the string state of the Sukshma sharira. 

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Five doctors summoned in 2012 infant death case under section 304

Dr KK Aggarwal

Additional Chief Metropolitan Magistrate Anuj Agrawal summoned four doctors of two different private hospitals and the medical superintendent of one of the government hospitals in East Delhi district under Section 304 (culpable homicide) of the Indian Penal Code. The court noted that the Medical Council of India (MCI) had also ordered the removal of their names from its register for three months. The case refers to the death of a 10-month-old baby in 2012. The court also pulled up police officers probing the case for not taking into consideration the ethics committee report, which had clearly directed that names of the guilty doctors be removed from the Medical Council of India’s register for a period of three months (Hindustan Times).

Commentary

Section 304. Punishment for culpable homicide not amounting to murder.—Whoever commits culpable homicide not amounting to murder shall be punished with [imprisonment for life], or imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine, if the act by which the death is caused is done with the intention of causing death, or of causing such bodily injury as is likely to cause death, or with imprisonment of either description for a term which may extend to ten years, or with fine, or with both, if the act is done with the knowledge that it is likely to cause death, but without any intention to cause death, or to cause such bodily injury as is likely to cause death.

Section 304 applicable only if:

·         There was an intention to cause death, or

·         The act was done with the knowledge that it is likely to cause death, but without any intention to cause death

If the MCI report has something categorical with regard to any of these two aspects, only then can a case be filed under section 304.

Suspension of license to practice does not mean criminal negligence.

Punishment and disciplinary actions are described in Chapter 8 (Regulations 8.2 and 8.5) of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002.

·          “…If the medical practitioner is found to be guilty of committing professional misconduct, the appropriate Medical Council may award such punishment as deemed necessary or may direct the removal altogether or for a specified period, from the register of the name of the delinquent registered practitioner…” (8.2)

·         During the pendency of the complaint the appropriate Council may restrain the physician from performing the procedure or practice which is under scrutiny (8.5) 

Both do not qualify it to be a criminal negligence.

Professional indemnity

The Professional Indemnity policy for doctors protects against claims arising out of bodily injury or death caused by error, omission, negligence; legal liability including defense costs (costs, fees, expenses) incurred during investigation, cost of representation, compensation etc.

The very fact that professional indemnity covers medical negligence, all cases of negligence cannot be criminal negligence.

What to do:  IMA or DMA should become a party to it and protect the doctors from 304.

These comments are based on the media report. We will be able to expand the comments further once we study the actual judgment.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Mera Bharat Mahan 14: Never hurt the ego of a person three times in a row

Dr K K Aggarwal

स होवाच पितरं तत कस्मै मां दास्यसीति ।
द्वितीयं तृतीयं तँ होवाच मृत्यवे त्वा ददामीति ॥

sa hovāca pitaraṃ tata kasmai māṃ dāsyasīti ।
vitīyaṃ tṛtīyaṃ tam̐ hovāca mṛtyave tvā dadāmīti ॥

"Dear father, to whom will you give me away?"
He said it a second, and then a third time.
The father, seized by anger, replied: "To Death, I give you away."

— Nachiketa, Katha Upanishad, 1.1.4

Commentary

One must learn to manage and control the ego. Controlled ego is the need but an uncontrolled ego can cause devastating effect on the body and the environment.

In Katha Upanishad, when Nachiketa hurts the ego of his father for the third time in a row, his (father’s) ego went out of control.

The Vedic message is if someone’s ego gets hurt just say sorry or change the topic and come out. Even if you hurt the ego twice it may still be ok but not the third time in a row.

Anger is like benign postural vertigo, which lasts only for few seconds for up to a minute (average 10 seconds). If you can control your anger for 10 seconds you can control your ego.

In Sunder Kanda, when Hanuman meets Sursa (ego) on his way to Lanka, he wins her by humility (becomes small) and not by confronting her.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Microplastics in the atmosphere: Are they a health risk?

Dr KK Aggarwal

(Medscape excerpts): Microplastic particles have already been detected in seawater, mussels, seafood and fish, as well as in drinking water. Now researchers have found high concentrations of microplastics even in the snow of the Arctic and the Alps.

A study by Dr Melanie Bergmann and Dr Gunnar Gerdts from the Alfred Wegener Institute (AWI), Helmholtz Centre for Polar and Marine Research in Germany shows that the atmosphere absorbs these tiny particles, transports them over long distances and then washes them out of the air again through snow. The study results were published on the 14th August in Science Advances.

A study published in Nature Geosciences in April this year showed that in a remote mountainous region in the Pyrenees, it rained more than 350 microplastic particles per day per square metre – even though there are no large cities or industrial facilities nearby. In 2015, French scientists were able to prove that rain and sewage in Paris contained microplastic particles.

A large quantity of microplastics gets into snow through the air. Some of it probably comes from Europe. The theory is supported by older studies on pollen grains. These, too, can reach the Arctic through the air. Pollen is similar in size to microplastic particles. Saharan dust is also capable of covering distances of 3500 km or more, as far as the Northeast Atlantic.

Inhalation risk?

Microplastics not only reach humans via the seas, but also through the air.

Prof Kelly and colleagues examined 50 pupils at Lordship Lane Primary School in Haringey, north London, and concluded that children's lung development was being inhibited by the release of microplastics from car tyres.

One of the few works is a Danish study published in Scientific Reports in June. Whether, and to what extent, indoor atmospheres are contaminated with microplastic particles, was investigated using a breathing thermal manikin (an anatomical model of the human body). Samples were taken from three flats and analysed using Fourier Transformation Infrared Spectroscopy (FTIR Spectroscopy). All samples were contaminated with microplastics, with concentrations between 1.7 and 16.2 particles per cubic metre.

The study suggested that microplastic particles represent a non-negligible proportion of indoor air particles that can be inhaled and have negative health effects. Polyester was the predominant synthetic polymer in all samples (81%), followed by polyethylene (5%) and nylon (3%).

On the 22nd August 2019, the World Health Organisation (WHO) issued an assessment on the risk of microplastics in drinking water. It concluded there is no evidence so far that they pose a risk to humans.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Mera Bharat Mahan 13: Life after death as explained in Chandogya Upanishad

Dr KK Aggarwal

Life after death is the most difficult subject. Firstly, you, must be a believer of rebirth, have faith in Vedas and have some knowledge of Sankhya philosophy and Advaita Vedanta. You must also understand the concept of unmanifest God and manifest God.

Both Prashna and Chandogya Upanishad answer some of the unanswered questions in modern medicine.

What make life reversible with CPR even after hours if the body temperature is low?  Why food is considered Brahman in Vedas? How soul travels in the universe?  But also raise some questions which are difficult to understand as on today.

6.8.6 तस्य क्व मूलं स्यादन्यत्राद्भ्य्ऽद्भिः सोम्य शुङ्गेन तेजो मूलमन्विच्छ तेजसा सोम्य शुङ्गेन सन्मूलमन्विच्छ सन्मूलाः सोम्येमाः सर्वाः प्रजाःसदायतनाः सत्प्रतिष्ठा यथा तु खलु सोम्येमास्तिस्रो देवताः पुरुषं प्राप्य त्रिवृत्त्रिवृदेकैका भवति तदुक्तं पुरस्तादेव भवत्यस्य सोम्य पुरुषस्य प्रयतोवाङ्मनसि सम्पद्यते मनः प्राणे प्राणस्तेजसि तेजः परस्यां देवतायाम् ॥

tasya kva mūlaṃ syādanyatrādbhy'dbhiḥ somya śuṅgena tejo mūlamanviccha tejasā somya śuṅgena sanmūlamanviccha sanmūlāḥ somyemāḥ sarvāḥ prajāḥ sadāyatanāḥ satpratiṣṭhā yathā tu khalu somyemāstisro devatāḥ puruṣaṃ prāpya trivṛttrivṛdekaikā bhavati taduktaṃ purastādeva bhavatyasya somya puruṣasya prayato vāṅmanasi sampadyate manaḥ prāṇe prāṇastejasi tejaḥ parasyāṃ devatāyām ||

Meaning: Where else, except in water, can the body have its root? O Somya, when water is the sprout, search for fire as the root; when fire is the sprout, O Somya, search for Sat [Existence] as the root. O Somya, Sat is the root, Sat is the abode, and Sat is the support of all these beings. As to how, O Somya, these three deities (fire, water, and earth) enter a body and each becomes threefold, this has already been explained.

O Somya, as this person is dying, his speech merges into the mind, his mind into prāṇa, his prāṇa into fire, and then fire merges into Brahman, the Supreme Deity.

Commentary: Death is an active process and not a passive process. At the time of death, Karmendriyas (speech) merge together as Vakvriti, which gets merged as Mano Vriti (Gnanendriyas and Mind Intellect Ego and Chitta). This merges into Prana and then Prana merges into Tejas and finally to sat. This explains that till the Tejas remains in the body, life is reversible. In Vedic language, tejas is the Udana Vayu and in modern medicine, it is the metabolism. Once the Prana Vriti merges into the Sat, we say brain death and irreversible death. In modern medicine it is well known that if the tejas is frozen, the period of CPR can be extended.

Now what let us see what happens to Tejas after death.

5.10.6: अभ्रं भूत्वा मेघो भवति मेघो भूत्वा प्रवर्षति त इह व्रीहियवा ओषधिवनस्पतयस्तिलमाषा इति जायन्तेऽतो वै खलु दुर्निष्प्रपतरं यो यो ह्यन्नमत्तियो रेतः सिञ्चति तद्भूय एव भवति ॥

abhraṃ bhūtvā megho bhavati megho bhūtvā pravarṣati ta iha vrīhiyavā oṣadhivanaspatayastilamāṣā iti jāyante'to vai khalu durniṣprapataraṃ yo yo hyannamatti yo retaḥ siñcati tadbhūya eva bhavati ||

Meaning: Having become mist, it changes into clouds. Then from clouds, it becomes rain and falls to the earth. Finally, it grows as paddy, barley, plants, trees, sesame, beans, and so forth. The change from this state is very difficult. Those who eat these things produce children just like themselves.

Commentary: As per Vedas, also as per Chandogya Upanishad as described in this shloka the Sukshma Sharira (the senses and the mind) attached to the soul becomes a mist and clouds. Mist and cloud behave like a carrier.

It enters through the rains and falls to the earth. In the earth, it enters the plant life.  So, this Upanishad talks about an intermediate stage between two human lives.

Only when the appropriate human eats the plant, it enters the body through the sperms (or the ova?) to be born again.

Probably this explains why food is called Brahman in Vedas. And destroying food or agriculture is called Brahma Hatya.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA