CMAAO CORONA FACTS and MYTH BUSTER 92: CDC ICMR WHO

CMAAO CORONA FACTS and MYTH BUSTER 92: CDC ICMR WHO

Dr K K Aggarwal

President Confederation of Medical Associations of Asia and Oceania, HCFI, Past National President IMA, Chief Editor Medtalks

With inputs from Dr Monica Vasudev

835: CDC and WHO differences are harmful to the society

CDC: “everyone wear cloth face coverings when leaving their homes, regardless of whether they have fever or symptoms of COVID-19.”

WHO: “Currently there is not enough evidence for or against the use of masks (medical or other) for healthy individuals in the wider community. WHO continues to recommend that medical masks be worn by individuals who are sick or those caring for them. WHO is actively studying the rapidly evolving science on masks and continuously updates its guidance."

835: WHO and Government Differences

The coronavirus pandemic has exposed the inherent weaknesses of the World Health Organization, which has no authority to force foreign governments to divulge medical information or open doors to its hospitals and labs.

836: Classifying deaths ICMR

1.     Deaths with inconclusive test results, but in which coronavirus symptoms are present will be recorded as “probable COVID-19” fatalities.

2.     Deaths in which tests are awaited with the presence of symptoms will be recorded as suspected deaths

3.     While those testing negative but have symptoms will be mentioned as clinically-epidemiologically diagnosed COVID-19

837: famotidine and COVID

Patients who took famotidine while hospitalized for Covid-19 were more than twice as likely to survive the infection, according to a paper posted Friday on a pre-publication website. But it's unclear whether the patients fared better because of the famotidine or if it was a coincidence. "Based on what we've learned in this study, it's encouraging," said Dr. Joseph Conigliaro, a coauthor of the paper and a physician at Northwell Health. "This association is actually really compelling."

Among the 1,536 patients in the study who were not taking famotidine, 332, or 22%, either died or were intubated and put on a ventilator. Among the 84 patients who were taking famotidine, 8, or 10%, died or were put on a ventilator. Compared to the rest of the patients, those who received famotidine had a greater than 2-fold decreased risk of either dying or being intubated. The patients who were taking famotidine started the drug within 24 hours of being admitted to the hospital. Some took it orally and some intravenously, at varying dosages. About 15% of them were already taking it at home.

Northwell and Columbia are now doing a clinical trial where some patients are receiving intravenous famotidine at a dosage nine times higher than what is given for heartburn. Others are receiving a placebo, or a drug that does nothing. Conigliaro, who's heading up that trial, said preliminary results would likely be announced in a few months. He said 233 patients have been enrolled in the study, and Northwell had planned to announce preliminary results when they enrolled 390 patients. However, since the number of patients with coronavirus in New York has declined, they might decide to announce the preliminary results with fewer patients.

838: New train travel

Passengers with no symptoms of any influenza like illness

Hand sanitisers will be issued at both entry and exit, as well as coaches and wearing of face masks will be compulsory.

Passengers will be required to reach at least 90 minutes before the scheduled departure time

Social distancing, of minimum 6 feet, will need to be maintained during boarding and travel.

This means not just long queues but also possibly fewer passengers per coach.

839: Air Travel

Domestic air travel could start before May 15.

Middle seat will not be filled

Reducing contact between their crew and passengers by up to 80% :No in-flight meal service for economy and premium economy passengers, no in-flight reading material, thermal screening of crew before and after departure

840: Airports

Use ultra-violet (UV) rays to disinfect all surfaces, through mobile towers, handheld torches and baggage tunnels.

Shoe-sanitiser mats that will be soaked with a chemical to disinfect passengers' shoes.

A sit and wait policy for the security clearance wherein a passenger will be called for a security check, rather than queueing up — the security check itself being conducted without any physical touch.

Reaching the airport more than a few hours ahead of the scheduled departure time.

Passengers, who have to necessarily wear face masks and gloves, will be allowed entry only after thermal screening — after possibly passing through sanitisation tunnels at entry points, which will also be mandatory for crew and airport staff.

Cardio-pulmonary Resuscitation: Easing Death

Reproduced from: https://www.indialegallive.com/viewpoint/cardio-pulmonary-resuscitation-easing-death-77719 published December 8, 2019

The Indian Council of Medical Research will soon have guidelines for doctors on whether to perform cardio-pulmonary resuscitation on patients with low survival chances. But are they needed when the MCI and the apex court have already given extensive guidelines?

Whether to pull the plug or not on a terminally ill patient is often a vexed ethical question for both relatives and physicians. The Indian Council of Medical Research (ICMR) is soon set to finalise principles that will guide physicians on whether to perform cardio-pulmonary resuscitation (CPR) and put the patient on a ventilator if he has an incurable disease where the survival chances are slim.

Currently, the law applicable in this regard is MCI ethics regulation 6.7 which deals with euthanasia. It says that practising euthanasia shall constitute unethical conduct. However, on specific occasions, the question of withdrawing supporting devices to sustain cardio-pulmonary function even after brain death shall be decided only by a team of doctors and not merely by the treating physician.

A team of doctors shall declare withdrawal of the support system and shall consist of the doctor in charge of the patient, the chief medical officer/medical officer in charge of the hospital and a doctor nominated by the in-charge of the hospital from the staff there or in accordance with the provisions of the Transplantation of Human Organs Act, 1994.

In Common Cause versus Union of India, 2018, a Constitution bench of the Supreme Court led by then CJI Dipak Misra held that an advance medical directive (AMD) would serve as a good means to facilitate the fructification of the sacrosanct right to life with dignity. The said directive will dispel many doubts during the course of treatment of the patient. That apart, it will strengthen the mind of the treating doctors as they will be in a position to ensure that they are acting in a lawful manner. However, AMD cannot operate in abstraction. The judgment has enumerated various safeguards and procedures of AMD, including who can execute it and its contents. Some of the safeguards are:

·                     In the event the executor becomes terminally ill and is undergoing prolonged medical treatment with no hope of recovery and cure, the treating physician when made aware about AMD shall ascertain the genuineness and authenticity of it from a first class judicial magistrate before acting on the same

·                     Instructions in the document must be given due weight by the doctors. However, this should be given effect only after there is full satisfaction that the executor is terminally ill and undergoing prolonged treatment or is surviving on life support and that his illness is incurable or there is no hope of him getting cured.

·                     If the physician treating the patient (executor of the document) is satisfied that the instructions given in it need to be acted upon, he shall inform the executor or his guardian/close relative about the nature of illness, the availability of medical care and alternative forms of treatment and the consequences of remaining untreated. He must also ensure that he believes on reasonable grounds that the person in question understands the information provided, has thought about the options and come to a firm view that withdrawal or refusal of medical treatment is the best choice.

·                     The physician/hospital where the executor has been admitted for medical treatment shall then constitute a medical board consisting of the head of the treating department and at least three experts from the fields of general medicine, cardiology, neurology, nephrology, psychiatry or oncology with experience in critical care and with overall standing in the medical profession of at least 20 years. They, in turn, shall visit the patient in the presence of his guardian /close­relative and form an opinion whether to certify carrying out the instructions of withdrawal or refusal of further medical treatment. This decision shall be regarded as a preliminary one.

There is a distinction between the administration of lethal injection/certain medicines to cause painless death and non-administration of certain treatments which can prolong the life in cases where the process of dying is not reversible. The first is an overt act, whereas the second would be informed consent and authorised omission. An omission of such a nature will not invite any criminal liability if it is guided by certain safeguards. The concept is based on non-prolongation of life where there is no cure and where the patient under no circumstances would have liked to be in such a degrading state.

In Common Cause versus Union of India, the Constitution bench held that euthanasia is basically an intentional premature termination of another person’s life, either by direct intervention (active euthanasia) or by withholding life-prolonging measures and resources (passive euthanasia) on the express or implied request of that person or in the absence of it. Active euthanasia also includes physician-assisted suicide, where injection or drugs is supplied by the physician. But the act of administration is undertaken by the patient himself. Active euthanasia is not permissible in most countries.

Passive euthanasia occurs when medical practitioners do not provide life-sustaining treatment or the patient is removed from such treatment. This could include disconnecting life-support machines or feeding tubes or not carrying out life-saving operations or providing such drugs. In such cases, the omission by the medical practitioner is not treated as the cause of death; instead, the patient is understood to have died because of his underlying condition.

With such extensive guidelines, we as medical professionals fail to understand the need to frame more guidelines in this regard. We are now in a dilemma about whether to follow MCI’s guidelines or the Supreme Court’s legal guidelines.

The national consultation meeting on “Do Not Attempt Resuscitation” (DNAR) under the chairmanship of Prof Balram Bhargava, Director General, ICMR, and Secretary, Department of Health Research, is scheduled soon. Dr Bhargava reportedly said: “There are many terminally-ill patients who know they are not going to make it, their relatives also know that they are not going to make it. The DNAR is just a way for them to exercise the option of not being put on ventilator. Many other countries have DNAR guidelines.”

DNAR is different from physician-assisted dying where medication, a prescription, information or other interventions are given to the patient with the understanding that he intends to use them to commit suicide.

The World Medical Association (WMA) this month reaffirmed its long-standing policy of opposing euthanasia and physician-assisted suicide. After an intensive process of consultation with physicians and non-physicians around the world, the WMA adopted a revised declaration on euthanasia and physician-assisted suicide. It stated: ‘The WMA reiterates its strong commitment to the principles of medical ethics and that utmost respect has to be maintained for human life. Therefore, the WMA is firmly opposed to euthanasia and physician-assisted suicide.”

It added: “No physician should be forced to participate in euthanasia or assisted suicide, nor should any physician be obliged to make referral decisions to this end.”

The declaration said: “Separately, the physician who respects the basic right of the patient to decline medical treatment does not act unethically in forgoing or withholding unwanted care, even if respecting such a wish results in the death of the patient.”

The revised declaration defines euthanasia as “a physician deliberately administering a lethal substance or carrying out an intervention to cause the death of a patient with decision-making capacity at the patient’s own voluntary request”. It says that physician-assisted suicide “refers to cases in which, at the voluntary request of a patient with decision-making capacity, a physician deliberately enables a patient to end his or her own life by prescribing or providing medical substances with the intent to bring about death”.

Dr KK Aggarwal

Padma Shri Awardee

President 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

Virtual autopsy will be a reality: An IMA success story

New Delhi: AIIMS Delhi and Indian Council of Medical Research have joined hands to work on a technique for post-mortem without dissecting the body and it is likely to be functional within the next six months, Health Minister Dr Harsh Vardhan said in Rajya Sabha Tuesday. India will be the first country to start “virtual autopsy” in the South-East Asian region.

During my presidential tenure at the Indian Medical Association in 2017, we suggested and asked for virtual autopsy to be included in all post-mortems. We even suggested this to be included in the private sector to find out the unexplained cause of death, in routine cases and in all cases where the relatives are not satisfied with the treatment.

We thank Dr Harsh Vardhan for taking up this issue. Virtual autopsy includes post death whole body CT with or without post death MRI and post death genetics blood tests. I recall having discussed this with Dr Harsh Mahajan to have one CT machine dedicated for postmortems.

The virtual autopsy is cost and time effective as it takes less than 30 minutes to complete one autopsy as against two-and-half hour in normal post-mortem. The ICMR has provided INR 5 crore to AIIMS for this purpose and the process is in an advance stage for getting a CT machine.

Way back in 1979-83, we used to do mini post-mortems in every unexplained case of death in MGIMS Sewagram, that used to take less than five minutes. We used to do brain, heart, lungs, kidney, muscle, spleen and live needle biopsies in such cases.

Click the links below for more information.

http://blogs.kkaggarwal.com/2017/01/in-every-death-give-an-option-for-virtual-autopsy-ima/

https://www.business-standard.com/article/pti-stories/ima-for-virtual-autopsy-to-find-cause-in-unexplained-deaths-117010501159_1.html

https://www.indiatoday.in/pti-feed/story/ima-for-virtual-autopsy-to-find-cause-in-unexplained-deaths-851910-2017-01-05

https://drugtodayonline.tumblr.com/post/155434229723/have-option-for-virtual-autopsy-in-every

Dr KK Aggarwal

Padma Shri Awardee

President 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

Bhopal gas victims update

Ahead of the 35^th anniversary of the Bhopal gas tragedy, organizations representing survivors have accused the Indian Council of Medical Research (ICMR) of suppressing a crucial study depicting comparatively higher rate of birth defects in babies of mothers exposed to the methyl isocyanate gas that killed thousands and maimed lakhs in December 1984.

“The documents they obtained from NIREH (National Institute for Research on Environmental Health) show that its parent organization ICMR decided to not publish the results of a study that found that birth defects in babies of gas-exposed mothers was several times higher compared to those of non-exposed mothers.

According to the documents, Dr Ruma Galgalekar, the principal investigator of the study conducted by NIREH, found that 9 per cent of the 1,048 babies born to gas-exposed mothers reported congenital malformations (birth defects), while in 1,247 babies born to unexposed mothers, only 1.3 per cent had congenital malformations. The study, costing little over INR 48 lakh, was carried out from January 2016 to June 2017 following approval by three successive meetings of the Scientific Advisory Committee (SAC) of the ICMR from December 2014 to January 2017.

As per the minutes of the expert group’s meeting on April 4, 2018, (obtained through RTI) the group strongly recommended that, "this data, due to its inherent flaws, should not be put in public domain and shared at any platforms.” According to the four experts, the “inherent flaws” of the study were “various methodological issues, problems of invalidated data and outcome assessment bias”.

At the eighth SAC meeting in October 2018, the members agreed that “as the said project had flaws… the results are erroneous and thus should not be brought in the public domain”.

Our thoughts: Even today the victims can be followed up to know the scientific truth.

Dr KK Aggarwal

Padma Shri Awardee

President 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

All major heart hospitals in Delhi-NCR should take up the Mission Delhi project

On Thursday (25.4.19), the Indian Council of Medical Research (ICMR) has launched ‘Mission DELHI’, an emergency medical service, as part of which a motorbike-borne assistance unit can be quickly summoned for a person suffering heart attack or chest pain.

The pilot project has been launched in a radius of 3 kms around All India Institute of Medical Sciences (AIIMS), New Delhi and would be linked with Centralized Ambulance Trauma Services (CATS).

Under Mission DELHI (Delhi Emergency Life Heart-Attack Initiative), a pair of motorcycle-borne trained paramedic nurses would be the first responders for treating heart attack patients.

On getting a call, the pair would rush to the spot, gather basic information on the patient’s medical history, conduct a quick medical examination, take the ECG, and establish a virtual connect with the cardiologists at AIIMS and deliver expert medical advice and treatment.

While the emergency treatment is being provided, a CATS ambulance will arrive and take the patient for further treatment.

Even as the patient is on way to the hospital, doctors at AIIMS control center will evaluate the data received from the nurses to establish further course of treatment.

The attempt is to reach patients within 10 minutes. In this project, the clot buster will be given very soon even at home.

This project should not just be limited to ICMR and AIIMS.

Every major heart hospital in Delhi-NCR should take up this project and adopt area of 3 km around their hospital. All should be interlinked.

ICMR should provide them with the working model for implementation of the project for wider reach of this much-needed emergency medical assistance.

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

Time for National Essential Diagnostics List

ICMR publishes India’s first draft National Essential Diagnostics List

The Indian Council of Medical Research (ICMR) is steering the process of compilation of National Essential Diagnostics List (NEDL) for the country.

The draft NEDL, which has been collated with contributions from all relevant stakeholders is now available for comments on ICMR website at https://www.icmr.nic.in/sites/default/files/whats_new/Draft_NEDL.pdf

The NEDL builds upon the Free Diagnostics Service Initiative and other diagnostics initiatives of Health ministry (Indian Public Health Standards, Health and Wellness Centers etc.) to provide an expanded basket of tests at different levels of the public health system. 

EDL has been developed for all levels of health care – village level, Sub-center/Heath & Wellness Centers, Primary Health Center (PHC), Community Health Center (CHC), Sub District Hospital (SDH) and District Hospital (DH). 

Tests for each level of care have been proposed based on the utility and requirement of tests at that level, infrastructure, training available or proposed to be made available through other parallel initiatives of Government of India.  

NEDL consists of 130 general lab tests required for routine patient care and for diagnosis of a wide array of both communicable and non-communicable diseases. 

The 26 disease-specific tests are for diagnosis of specific diseases like Malaria, Dengue, Chikungunya, endemic diseases like Filariasis, Scrub typhus, Japanese Encephalitis and diagnostic tests for TB, HIV and Hepatitis among others.

Tests in the list have been prepared with the description of test category (e.g., Hematology, Biochemistry, Microbiology, Pathology and Serology), specimen type for each test and the product/equipment on which the test is best conducted at the respective level of health care. 

An option of following a ‘hub and spoke model’ has been also suggested for implementing the EDL for certain tests. This will ensure availability of the required number of tests at different levels of facilities in a cost-efficient way.

Availability of comprehensive diagnostic services at all levels will improve patient care and minimise referral of patients because of unavailability of tests.

The list has been put up on ICMR website and comments are solicited from the wider audience by 31st January, 2019.

Read our earlier published story on this at http://blogs.kkaggarwal.com/2018/08/who-list-of-essential-diagnostic-tests-in-primary-healthcare/

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

Immediate Past National President IMA