Friday, May 26, 2017

Why it may be a good thing that the Dengue vaccine is NOT available in India right now?



I am a Pediatrician, and a large percentage of my work involves preventive pediatrics and counseling. I am also a big fan of vaccines, so why am I saying that NOT having Dengue vaccines in India is a good thing? Read on….
I understand that Dengue is a very serious problem, and as a pediatrician I have personally diagnosed and treated many kids with Dengue in Chandigarh and surrounding areas.
The problem, in my opinion, is the way new vaccines are generally launched in India. Previously the drug controlling authority (DCGI) used to ask for small trials on 150 to 200 people and we used to test if the vaccine was leading to good antibody response after 3 months in these people. Once this was confirmed, the vaccine was allowed to be used without any further research in our kids.
On the other hand, most developed countries would ask any vaccine company to do large studies in their own country/ continent before allowing use of a newer vaccine.
For the first time, it appears that the Govt of India is asking the Vaccine Company (Sanofi Pasetur) to do large scale trials in our country for the Dengue vaccine before launching it. The scientific data thus generated will help us to recommend the vaccine far more effectively.
However, if the permission is given by the GOI to launch the vaccine with small amount of data (as before), then we will end up with limited data. This means we will have to rely on studies from foreign countries to decide how effective this vaccine will be in our situation. For a new vaccine like Dengue, I believe this is NOT the right way to go.
Sure, large studies will take at least 2-3 years, but the results will help us get a better idea on how and when to use the vaccine for kids & adults in the future. This is why I am recommending waiting and watching and getting high quality data from India for the Dengue vaccine, before launching it.
What do you feel as a parent or a doctor?

Tuesday, January 31, 2017

MR vaccine by Govt of India, IAP recommendations, Jan 2017

Date: January 27, 2017
Dear All,This is to inform you that a mass campaign (Supplementary Immunization Activity (SIA) to provide a single dose of Measles-Rubella (MR) vaccine is going to start from February 2017 in five states/UTs namely, Goa, Karnataka, Tamil Nadu, Lakshadweep and Puducherry.
It is our utmost duty to support this activity by encouraging parents of eligible children to participate in these campaigns. We need to offer our clinics/ hospitals/ nursing homes, or other facility to function as “Adverse Event Following Immunization (AEFI) management site/centre” in case any serious AEFI is encountered during the campaign. Furthermore, we need to fully support and cooperate with the local health authorities to counteract any misinformation against these campaigns.
 
What is MR campaign?
  • MR campaign is a special campaign to vaccinate all children of 9 months to <15 age="" br="" nbsp="" of="" years="">group with one dose of MR vaccine.

  • The MR campaign dose is given to all targeted children, both immunized and unimmunized,
    irrespective of prior measles/rubella infection.

  • The goal of a MR campaign is to accelerate population immunity by reaching 100% target
    children with MR vaccine that will reduce cases and deaths from measles and disabilities from
    Congenital Rubella Syndrome (CRS).
Rationale for MR campaign
  • Country Population Immunity is insufficient to stop ongoing MR transmission as evident form
    MR surveillance data

  • MR outbreaks wide spread across the entire country

  • Population immunity has waned after the last MCV (Measles containing vaccine) campaign

  • Rubella vaccine introduction requires high level of population immunity to prevent the paradoxical effect as a risk mitigation strategy

  • NTAGI has recommended wide age range MR vaccination campaign targeting 9 months-<15 all="" before="" immunization="" in="" india="" introducing="" li="" of="" routine="" rubella-containing="" states="" the="" vaccine="" years="">
  • MR vaccine will be available for administration under the routine immunization (RI) programme after the completion of MR Campaign.
Who should be vaccinated?
  • All children who have completed 9 months of age and are below 15 years of age regardless of previous vaccination status with measles/rubella vaccine and regardless of measles/rubella infection in the past

  • Every child who is eligible for either 1st dose or 2nd dose of measles vaccine in his/her RI schedule will be provided with combined MR vaccine .

  • Malnourished children should be vaccinated on a priority basis, as they are more likely to have complications like diarrhea and pneumonia

  • Children with minor illnesses such as mild respiratory infection, diarrhea, and low grade fever

  • Even those children who have documentation of receiving one dose of Measles/MMR at 9 months and/or MMR at 15 and/or again at 4-6 years MUST also be offered this vaccine!!
Where will the children be vaccinated?
  • From fixed posts only. No house-to-house vaccination

  • During the first week in schools

  • Non-school-going and left out children will be vaccinated in the following two weeks in fixed outreach sessions and mobile posts in villages and urban areas

  • If, at any place, 4 or >4 children have been found missed during Rapid Convenience Monitoring, the MR campaign activity should be repeated in the area during fourth week of the MR campaign to cover these missed children.
Why MR and not MMR (measles, mumps & rubella) vaccination?
  • Though IAP has strongly recommended inclusion of MMR instead of MR in UIP, the Government of India (GoI) still do not consider mumps as a serious public health problem in the country. Therefore only MR vaccine is being introduced.
 
 
  
Dr. Anupam Sachdeva
PresidentIAP 2017
Dr. Bakul Jayant Parekh
Hon. Secretary General

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Wednesday, January 25, 2017

Doing Nothing And Doing It Well, Not Easy, guest post from Dr Gunreddy, docplexus

At the risk of trivializing my profession, the majority of patients seen by pediatricians would be just fine without us. When I first discovered this, I was somewhat disappointed. But then, I realized this doesn’t mean that pediatricians are irrelevant. On the contrary, one of a pediatrician’s primary responsibilities is reassuring parents about normal or mildly abnormal conditions. A couple of weeks ago, I took care of a 12-month-old boy with a cough. He had been seen by three other doctors over the last two days. Initially, he was seen by his pediatrician, who told his mother that it was “just a virus” and that his symptoms would go away on their own. Unsatisfied with this answer, she left the pediatrician’s office and drove immediately to another care facility, where they told her that her son had pneumonia, and he started on an antibiotic. The next day, he was coughing more. So his mother took him to a different Doc care facility, where a second antibiotic was started. On the third day, she brought the child to the pediatric emergency where I worked. She was very concerned that his cough was worsening, despite the two antibiotics he was on. She was worried that he had now developed diarrhea, in addition to his primary symptoms. And more than anything, she was irate that his pediatrician had done “nothing.” Everything about his history and physical exam screamed: “bronchiolitis” (a common viral respiratory infection in young children that does, in fact, go away on its own). Worsening over the first three to four days is precisely what I would expect from this illness. And more than likely, his diarrhea was a result of the antibiotics he was on. As far as bronchiolitis cases go, his was mild. He was eating well and breathing comfortably just coughing a lot and dripping snot everywhere. According to the most current treatment guidelines, he truly needed nothing but nasal suction and maybe a humidifier. Eventually, I was able to explain all of this to his mother, convince her that he would be better, even without the antibiotics, and arrange follow-up with his pediatrician the following day. But it took time. Doing “nothing” and doing it well, isn’t easy. In reality, doing “nothing” involves quite a bit of work. Choosing to do “nothing” presumably involves the doctor listening to the patient’s symptoms, gathering relevant details, performing a physical exam and reaching the conclusion that no further testing or treatment is warranted. In many cases, doing “nothing” is the most appropriate course of action. And in these cases, doing more would place the patient at risk for harm from unnecessary tests or treatments (like my patient’s diarrhea or worse, a life-threatening allergic reaction to a medication). But providing this reassurance requires a great deal of knowledge about those things that would be more concerning. Vomiting could be due to a viral illness, a head injury, a bowel obstruction or new-onset diabetes (among many other possibilities). A fever could be caused by a self-limited illness or an overwhelming infection. Doing “nothing” involves discerning the sometimes subtle differences between the common and the complex, sorting out the few who really need us from the many who don’t. And it requires a level of confidence sufficient to send the patient home, knowing that being wrong could have disastrous results. Most people who seek medical care for themselves or their children especially in emergency settings expect testing or treatment. After all, if they thought that doing nothing would be sufficient, many of them would have stayed home. Convincing them that they don’t need these things, and effectively explaining why can require far more time than simply writing the prescription. Many physicians today, due to a shortage of time or concerns about low patient satisfaction scores, over-diagnose, and over-prescribe to avoid this situation altogether. But a doctor who always gives patients what they want either has remarkably well-informed patients, or practices poor medicine. “Doing no harm” frequently means doing nothing at all. But doing “nothing” well is more than saying “it’s just a virus.” It requires expertise, confidence, and communication and it’s much easier if the doctor has already developed a relationship of trust with the patient or family. The doctor must know enough to make an accurate diagnosis (or at least rule out the scary ones) when working with children, this means having sufficient training and experience with childhood illnesses. The diagnosis should be explained to the family in a way that they can understand. The family should know what to expect, what changes would be truly concerning, and what to do if one of those concerning things happens. They should leave the visit understanding why “nothing” was done and ideally, being grateful for a doctor that cares enough to do nothing. Please share your experiences in this context.

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