Wednesday, December 2, 1998

World AIDS Day was observed on December 1

HIV Infection: a thought for health care professionals
By Dr Ajay Wanchui
IMAGINE yourself as a doctor or a nurse working in the emergency area of a big hospital for an hour. You are looking after 20 to 30 patients who are seriously sick for various reasons — ranging from head injury in an accident to heart attack. For each patient there are between three and six anxious relatives or friends many of whom may be trying to seek your attention.

Dynamic of continuing pandemic
By Mangai Balasegaram
LONDON: It has been almost two decades since doctors in a Los Angeles hospital picked up a fatal disease that was ravaging the human immune system, yet the human onslaught of AIDS has still not abated.

A shot, and nerve pain is gone!
JAIPUR-based skin specialists claim to have developed a new method for treating a painful viral disease affecting nerves.

Yet another anti-HIV drug
THE battle against AIDS in India has acquired a new potent weapon with the recent introduction of Lamivudine. This drug is vital to the combination therapy approach that is now being used across the world to combat HIV, the virus that causes AIDS. Lamivudine is the third anti-HIV drug from Cipla after Zidovudine and Stavudine.

Learned homage to Dr P.N. Chhuttani
THE Supercon '98 Superspeciality Conference organised by the Indian Medical Association, Chandigarh, on November 28 and 29 was a befitting tribute to the memory of Dr P.N. Chhuttani, a former President of the Tribune Trust. The P.N. Chhuttani Memorial IMA Complex was inaugurated by Prof I.C. Pathak, a former Director of the PGI, Chandigarh.

HIV Infection: a thought for health
care professionals

By Dr Ajay Wanchui

IMAGINE yourself as a doctor or a nurse working in the emergency area of a big hospital for an hour. You are looking after 20 to 30 patients who are seriously sick for various reasons — ranging from head injury in an accident to heart attack. For each patient there are between three and six anxious relatives or friends many of whom may be trying to seek your attention.

In the hour or so that you are a health care professional you could end up drawing their blood samples, injecting medications, using life-support systems or performing an operation or a resuscitative procedure. Since the persons who have been brought to you on a stretcher are total strangers and since you handle their blood samples or body secretions that could carry potentially life threatening infections, you could end up regretting why you imagined yourself to be a doctor or a nurse in the first place!

What is imagination for you is a hard reality for thousands of health care professionals working in all areas of the hospital including the wards, operation theatres, laboratories, etc. In the vast majority, the fear of acquiring an infection like the human immunodeficiency virus (HIV) is always there at the back of the mind.

Since viruses like HIV and Hepatitis B and C can be transmitted by blood, the risk of transmission of these to the health care professionals by a needle stick injury is always there. On an average, the risk of getting infected by HIV following a needle stick injury is 0.3-0.4%. Similar figures for Hepatitis B and C are 9-30% and 3-10%, respectively, in different studies.

Very few cases of HIV transmission have been reported after the exposure of mucous membranes like the mouth and the eyes or broken skin to infected blood. The risk of acquiring HIV infection by this route is much lower than the risk from a needle-stick injury. However, the message that goes with this data is that the risk of occupational exposure to HIV is real.

As in the West, suggestions have been made that the virus is “delicate” and the risk to health care professionals is low. The basic problem of suggesting that the risk of transmission of infection is low is that it is a comparative term. For an individual who does not indulge in behaviour that puts him at risk of acquiring the infection in his personal life this so-called “low” risk is all the risk that he has.

It is also suggested that health care professionals are at a much greater risk for hepatitis infection at their workplace. This overlooks the fact that viral Hepatitis carries a substantially lower mortality than HIV and one can at least be protected to a great extent from Hepatitis B with a vaccine. Therefore, a convincing argument for a “low” risk of HIV infection does not allay the fears of health care professionals from acquiring AIDS. It is easier to deal with individuals who are known to be HIV positive as one can take adequate precautions. The real risk comes from those who are HIV positive but this is not known to those who are looking after them. The latter group represents a large chunk of the HIV positive individuals.

What, then, is the solution? It lies in addressing health care professional’s fear of getting AIDS without allowing it to compromise the quality of patient care and also threatening his own well-being. The only solution is to adopt strategies that help minimise their risk of acquiring an infection.

A set of precautions called universal precautions will minimise the risk of transmission of HIV and other blood-borne infections. These are based on the assumption that all blood is potentially infectious regardless of who it belongs to and what his HIV status is. These also apply to other body fluids like faeces, urine, sputum, etc, which may contain other agents that can infect those who handle such material.

The salient features of these precautions are as follows:

Handwashing should be performed before and after patient contact, after removing gloves and immediately if the hands are grossly contaminated with blood. Gloves should be worn whenever the hands are likely to come into contact with blood or body fluids.

Gowns, protective eyewear, and masks should be worn when splashing of blood is likely to occur. Sharp objects should be handled with care and needles should never be manipulated, bent or recapped.

Blood spills should be handled via initial absorption of the spill with disposable towels, cleaning the area with soap and water, followed by disinfecting the area with 1:10 solution of household bleach. Contaminated reusable equipment should be decontaminated with heat sterilisation.

Other simple measures in case of injury with a used needle are to encourage bleeding by squeezing the part, washing it thoroughly with soap and water and covering it with waterproof dressing. If there are splashes to the mouth and eyes, it would be useful to rinse thoroughly with plenty of running water.

In spite of scrupulous use of infection-control measures, it is possible that one can get a needle-stick injury from a person infected with HIV. In that situation it may be prudent to use drugs meant to destroy HIV depending on the risk involved. For all practical purposes out of a dozen or so drugs available in the West and five in India only upto three need to be used. These drugs are zidovudine (AZT), lamivudine (3TC), and saquinavir (SQR).

Preventive therapy is recommended when there is a large volume of blood (e.g. a deep injury with a large-bore needle containing an HIV positive patient’s blood) and blood is likely to have a high concentration of the virus (e.g. end-stage AIDS). In that situation all the three drugs will have to be given. However, if there is exposure of the mucous membrane to blood, or either because of a needle-stick injury there is large volume of blood or a high concentration of the virus in the source patient, a combination of two drugs (AZT+3TC) is enough.

Recommendations involving a combination of these two drugs is also made if there is a penetrating injury or exposure of the mucous membrane to body fluids like those from body cavities, vagina, etc. Such preventive therapy should be initiated promptly, preferably within two hours after the exposure. Even in the best of centres this may not be possible for logistic reasons. However, if therapy is started more than 24-36 hours after the exposure, it may not be beneficial. These drugs should be administered for four weeks.

Their doses are: AZT — 200 mg three times a day; 3TC — 150 mg twice daily, SQR — 600 mg three times a day. Furthermore, these workers should be tested for HIV antibodies soon after exposure and then at six weeks, 12 weeks and six months. In the meantime, they should observe precautions to prevent possible transmission to others. The cost of AZT and 3TC for four weeks is Rs 3,000 each and for SQR it is Rs 11,000.

On the brighter side of things is the fact that the average risk after needle punctures involving HIV has been 21 individuals infected after 6,498 exposures. Initially AZT alone was used for preventive therapy and prompt use of this drug resulted in a 79% reduction in the likelihood of HIV transmission. When more than one drug is given, the likely benefit is expected to be higher.

If the goal is to reduce as much as possible the occurrence of occupational blood-borne infections not only HIV, but also Hepatitis B and C a combined set of actions is necessary. Specifically efforts should be made to train health care professionals to comply strictly with infection control measures.

Refresher courses are virtually non-existent and periodic updating of knowledge is vital for day-to-day working.

Finally, it is imperative for the administrators to ensure an adequate supply of disinfectants, gloves, etc, to help the workers comply with infection control recommendations. While these may not eliminate the fear of health professionals getting an HIV or Hepatitis infection completely, it may prevent a compromise of quality of patient care.

(Dr Wanchu, MD, DM, is a clinical immunologist and an Assistant Professor in the Department of Internal Medicine, PGI, Chandigarh.)

Dynamics of continuing pandemic

By Mangai Balasegaram

LONDON: It has been almost two decades since doctors in a Los Angeles hospital picked up a fatal disease that was ravaging the human immune system, yet the human onslaught of AIDS has still not abated.

Despite the enormous scientific and social progress made in the field — the virus and its modes of transmission have long been identified; breakthrough drugs to fight the disease have been discovered; the best prevention methods have been studied in detail — the burden of AIDS still weighs heavily on humanity.

There are 10 per cent more infected people worldwide since a year ago, according to estimates released for World AIDS Day on December 1 by the Joint UN Programme of HIV and AIDS (UNAIDS).

“The epidemic hasn’t lost any of its steam,” UNAIDS Director Peter Piot told a press conference in London.

This year, says UNAIDS, an average of 16,000 people were infected every day — or 11 persons a minute — and half of them were young people, aged between 15 to 24 years.

Women now account for 43 per cent of all infected people over 15 and, as a consequence. 10 per cent of new infections are among children infected from their mothers.

Tragically, 90 per cent of those infected have no idea they are carrying HIV, the Human Immunodeficiency Virus, and may thus transmit it unknowingly.

But the burden of AIDS is not equally balanced around the globe. Indeed, it rests almost exclusively on the developing world, which is home to 95 per cent all of those infected. In particular, sub-Saharan Africa bears the brunt of the disease with 70 per cent of all cases. This year, there were an average of 5,500 funerals per day in Africa.

While the epidemic is acute in Africa and rapidly rising in Asia, it has been controlled in Western Europe and Australia, although not yet stopped. These regions have also seen a fall in deaths from AIDS due to the arrival two years ago of protease inhibitor drugs which can seemingly beat HIV in the bloodstream back to undetectable levels.

The fact that these drugs are prohibitively expensive for most people in the developing world again reinforces the fact that AIDS is a disease of unequals.

Indeed, even in North America and Western Europe, the disease is limited to pockets within the populations — ethnic minorities, drug-users and homosexual men.

Why are some areas and some countries so much more affected.?

Clearly the shape and scale of the disease has nothing to do with biology because stopping the transmission of HIV involves nothing very scientific but from dynamics related to society.

Poverty is evidently a factor that fuels the epidemic. Poor countries may be less able to afford to test their blood supply and have mass awareness campaigns.

And certainly, in most countries, it is the poor who are affected most, they are invariably less educated and less able to afford the regular use of condoms or treatment for sexually transmitted diseases (STDs).

STDs can greatly increase the risk of HIV infection by several times. Furthermore, an STD indicates someone having unsafe sex — and therefore a potential HIV infection.

War and armed conflicts, as do movements of people, also generate fertile conditions for the spread of HIV.

But all these reasons still don’t provide a complete answer to the pattern of the pandemic.

They don’t explain why some countries are doing relatively well or at least better than before such as Thailand, Uganda and Northern Tanzania. Senegal has also maintained low infection rates at two per cent.

One of the most important factors, said Piot, was “political commitment at the highest level.” Many governments have simply not been committed enough.

Also, there has simply been a reluctance to deal with the problem, particularly because it usually involves commercial sex and drug use — activities that are often clandestine and illegal.

Even when drug users or sex workers and their clients may be the most at risk or at the centre of the local epidemic, governments may still be unwilling to deal with them.

Indeed, they may prefer arresting or criminalising those involved rather than embarking on proven prevention programmes — namely education programmes, condom promotion, provision of sterile injecting equipment and drug treatment programmes such as methadone.

The Unites States of America, for example, has long been resisting programmes for drug users such as needle exchange. Indeed, it was only quite recently that UNAIDS started to directly support programmes for injecting drug users (IDUs). Efforts are now being directed towards East Europe, where an explosion of HIV is occurring among IDUs.

But even the most sincere government efforts may not be enough. What may be required is an upheaval of age-old ideas held by men. A briefing issued by Panos, London-based non-governmental organisation, for World AIDS Day this year concludes that men are at the heart of the problem.

Men are the driving force because “they have more sexual partners than women and because they tend to control the frequency of intercourse”.

“It is men’s behaviour which determines how quickly, and to whom, the virus is transmitted,” the report notes. Indeed it adds: “Without men, there would be no AIDS epidemic”.

“Men’s behaviour is strongly influenced by perceptions of masculinity. Most cultures expect men to be sexually active.... Attitudes towards risk-taking lead many men to reject condoms as unmasculine or consider sexually transmitted infections as no more than an inconvenience,” the report says.

These same attitudes also lead to experimentation and addiction to drugs, the report says, adding four out of five injecting drug users are men.

The report continues: “The question now is whether men can be persuaded to change and whether widely held concepts of masculinity will allow men to be responsible and protective. It may be that deeper changes are needed before the AIDS epidemic can be contained”.

(The author, Mangai Balasegaram, is a Malaysian journalist (formerly with The Star of Malaysia) who now works for Gemini News Service.)

A shot, and nerve pain is gone!

JAIPUR-based skin specialists claim to have developed a new method for treating a painful viral disease affecting nerves.

“Post therapeutic neuralgia” is caused by the reactivation of a dormant virus Varicella zoster in the body due to waning of immunity. It usually occurs after an attack of Herpes zoster infection or through skin lesions.

The affected patients complain of sharp, intermittent pain on one side of the head or face.

The new injection therapy, “Jaipur block”, consists of three anaesthetic agents — xylocaine, bupivacaine and dexamethasone solutions — in appropriate concentrations, team leader Rishi Bhargava from the Sawai Mansingh Hospital in Jaipur, who has been working for the last 19 years on the treatment, told PTI.

The Jaipur block is given in combination or alone in a scheduled time frame and works by anaesthetising the nerves carrying pain impulses to the brain, he said.

About 96 per cent of the patients obtained complete relief after the treatment in his study with 3960 patients.

While 28 per cent of patients were relieved of pain after a single dose of injection, 57 responded after two injections and 11 per cent after three injections, Bhargava reported in the International Journal of Dermatalogy.

“The trials probably involved the largest group of patients, and some side-effects like giddiness and sweating were observed occasionally in a few patients,” Bhargava said.

The new anaesthetic product would come into the market as soon as all the trials are completed, he added.

While available therapies for treating herpes infection are based on anti-viral drugs and pain killers, they are usually found ineffective for longterm treatment, Bhargava said.

Herpes is common in adults with low immunity or malignancy like those infected with human immunodefficiency virus (HIV). It is 50 to 100 times more common in children suffering from blood cancer (leukemia) than healthy ones of the same age, he added.

— Yash Goyal

Yet another anti-HIV drug

THE battle against AIDS in India has acquired a new potent weapon with the recent introduction of Lamivudine. This drug is vital to the combination therapy approach that is now being used across the world to combat HIV, the virus that causes AIDS. Lamivudine is the third anti-HIV drug from Cipla after Zidovudine and Stavudine.

The manufacturers claim that they have "taken the lead in pioneering the basic manufacture of Lamivudine in India. What this means for the estimated four million HIV-infected people in the country is regular availability of the drugs that offer them hope at a fraction of international prices. Lamivudine is priced at Rs 50 per tablet as against the prevailing price of Rs 120-250 per tablet of internationally available product."

The claim needs verification — Health Tribune Monitor.

Learned homage to Dr P.N. Chhuttani

THE Supercon '98 Superspeciality Conference organised by the Indian Medical Association, Chandigarh, on November 28 and 29 was a befitting tribute to the memory of Dr P.N. Chhuttani, a former President of the Tribune Trust. The P.N. Chhuttani Memorial IMA Complex was inaugurated by Prof I.C. Pathak, a former Director of the PGI, Chandigarh. The inauguration was followed by a talk by Prof N.K. Ganguli, Director-General of the ICMR. he spoke on the "Global scenario in diarrhoeal diseases". He said that the oral cholera vaccine developed by IMTECH, Chandigarh, would be available in the market soon after it underwent human trials. He added that the incidence of entero-haemorrhagic E-coli transmitted from cattle to man was increasing as cattle were now being given new combinations in their daily feed. A diarrhoeal vaccine was being tested and was expected soon in the market. The other highlights of the conference included talks by experts in their fields from the AIIMS, Maulana Azad Medical College, the PGI and Government Medical College, Chandigarh.

Prof Subrat a Acharya, from the Department of Gastroenterology, AIIMS, spoke on the treatment of chronic hepatitis B with interferon, a costly drug. With the easy availability of lamivudine, the treatment of hepatitis B has become easier because the new drug is cheaper than interferon and can be taken orally.

Prof P.Kar of Maulana Azad Medical College highlighted the role of the bile acid therapy in liver diseases. Prof Piyush Sahni, Department of GI Surgery, AIIMS, highlighted the problems in getting brain dead donors for organs like liver. Public awareness needed to be generated for organ donation.

Prof Raj Bahadur, Head of the Department of Orthopaedics, GMCH, spoke on the management of cervical spinal injuries, while Dr A.S.Bawa discussed the role of unreterorenoscopy in urological practice. Prof K.K. Gomber, Head of the Department of Anaesthesia, GMCH, highlighted the role of anaesthesia in minimally invasive abdominal surgery.

Prof R.K. Suri, former Head of the Department of Cardiothoracic Surgery, PGI, explained the benefit-risk ratio of various modes of treatment for angina patients admitted with heart attack, namely, thrombolysis, angioplasty and intraluminal stenting, conventional coronary bypass surgery and new modes of endocoronary surgery.

Prof Sudha Suri, Head of the Department of Radiology, PGI, dwelt upon the relative place of CT scan and MRI in the investigations of neurological diseases. She clarified that CT scan was ideally suited for patients with head trauma and acute brain haemorrhage while MRI was specifically required in spinal diseases; brain tumours and infections like neurocysticercosis.

Dr Madhu Gulati of the PGI spoke on the usefulness of imaging in chest diseases.

Dr S. Sodhi, a cardiologist, spoke on the current status of primary angioplasty in patients with ischaemic heart disease; while Dr V.Sarwal, a cardiothoracic surgeon, highlighted the facts and realities of coronary artery bypass grating. Dr Rohit Grower spoke on the latest trends in the treatment of refractive errors. Dr S.P.S. Grewal explained same marvels of modern medical technology. Dr O. P. Sharma discussed the use of the internet in the medical profession.

Dr Randhir Sud, a senior gastroenterologist from Delhi, said that metal stents could be safely used for managing patients with the cancer of the oesophagus and bile ducts.

Dr Muralidharan from the PGI discussed the management of diabetes mellitus in special situations like surgery, myocardial infarction, stroke, renal failure and old age.

Dr Anil Bhansali of the PGI said that the global burden of diabetes was on the rise with around 300 million people likely to be affected by 2025.

Dr Archana Sud of the PGI said that health care workers faced the risk of acquiring HIV infection from patients if there was a needle-stick injury with infected blood or large mucosal exposure to infected fluids or blood.

Dr Ashok Attri (GMCH) said that early detection of cancer was necessary.

Dr K.C. Bhargava, President of the IMA, and Dr Y.Chawla of the PGI (who was the Chairman of the scientific sessions ) made their singular contribution through their apt remarks and superior organising ability.