Monday, December 22, 2014

Chandigarh has Bird flu cases, will taking the seasonal flu vaccine help?

Recently it has been reported that Chandigarh is having Avian Flu (Bird Flu H5N1) cases. 
I have received numerous calls and parents who have asked me whether they should take the Seasonal Influenza vaccine now, and whether it would prevent the Bird Flu disease?
Here is what I have found.
The short answer is NO, seasonal flu vaccine cannot directly prevent bird flu, since they are different strains of the same virus, against which the vaccine will not work.
However, the situation is a little bit more complicated than this
As per Wikipedia listing on prevention of bird flu
Notwithstanding possible mutation of the virus, the probability of a "humanized" form of H5N1 emerging through genetic recombination in the body of a human co-infected with H5N1 and another influenza virus type (a process called reassortment) could be reduced by widespread seasonal influenza vaccination in the general population. I"
And here is what the CDC has to say on this situation as well
CDC website "Seasonal influenza vaccination will not prevent infection with avian influenza A viruses, but can reduce the risk of co-infection with human and avian influenza A viruses. "

So here is what I conclude

Taking the Seasonal Influenza vaccine cannot directly prevent Avian Flu (H5N1), since they are antigenically different.
However, it can assist in a couple of situations
1. It can prevent co-infections with seasonal flu & bird flu together - kind of obvious since it will prevent seasonal flu.
2. It can thus help prevent a humanized form of bird flu virus happening, since if the bird flu virus and the seasonal flu together infect someone, they may exchange/ share their genes, leading to increased transmission of the bird flu disease to humans.
This is the basic rationale for doing flu vaccine in situations where bird flu exists.

Tuesday, December 09, 2014

Can we give Measles/ MMR vaccine in mild cold cough and fever?

Q: My baby completed 9 months of age, measles vaccine is due. we took the baby to govt vaccine centre, but they told us, as the baby is suffering from cold and cough, measles vaccine should not be given. Is that true?
A: For mild cold cough and other minor illnesses, vaccines should NOT be routinely postponed. You can take the measles vaccine in this situation. However, you should talk to a child specialist if there is any doubt regarding the actual illness in your baby.

Monday, December 08, 2014

100 % effective ways to prevent Dengue (HUMOR)

Dengue Prevention…….
Dengue cases are on rise.Few steps to prevent yourself from mosquito bites :
Burn camphor in the room.. The camphor does nothing to the mosquitoes but burns your eyes so much that you are wide awake and alert thru the night to kill them with your bare hands.
Grow a papaya tree in your backyard. The mosquitoes will realize you already know the cure for dengue so they will leave you alone.
If you are married - Keep a self attested copy of your marriage certificate on your bedside table. The mosquitoes will realize what torture you are already going thru and will leave you alone.       
Issued in public interest…..

Is Kajal / Kohl/ Surma application in eyes harmful for babies in India?

No. It's recommended that your baby's eyes be kept free of kajalsurma or kohl.  Using kajal can lead to watery eyes, itchiness, and even allergies. When kajal is washed off during a bath, it can pass down the small and narrow opening between the eyes and the nose. This opening can get blocked, causing infections
Most commercially produced kajal and surma brands contain high levels of lead that is harmful for your baby. The ingredients or packaging could also be contaminated if safety and hygiene norms haven't been followed. Even if some brands claim they are lead-free or 100 per cent natural it's difficult to be sure and they may be just as unsafe. 
Prolonged application may result in excessive lead storage in the body. This could affect your baby's brain, organs and bone marrow formation. Some experts think that lead poisoning can also result in anaemia, low IQ and convulsions. 
Also, the cornea or the central, black part of the eye, is very sensitive to dirt and irritation. Dirty fingers, sharp and uneven fingernails can hurt a baby’s eyes. Prolonged or repeated exposure to lead may cause pain and discomfort, and in severe cases, can also affect your baby's vision
Applying kajal to a newborn's eyes is an age old tradition practised in many parts of the country. Well-meaning relatives and friends may advise you to apply surma or kajal to your newborn's eyes to ward off the evil eye or buri nazar. According to an old wives' tale, applying kajal or surma will help your baby's eyes become bright, large and attractive. But there is no evidence to suggest this is true. If you wish to apply kajal or surma on your baby, why don't you try applying it somewhere other than the eye? Some mums put a small tika on the sole of the foot, behind one of the ears or at the hairline on the forehead. These are safer options.

The traditional home recipe for kajal is discussed below...

How to Make Kajal at Home?

The easiest way of preparing home-made kajal is as follows:

  • Take a clean, white, thin muslin cloth of 4x4 size and soak it in sandalwood paste and dry it in shade; this sip-and-dry process must be done throughout the daytime.
  • In the evening, roll the cloth into a thin wick and lit a mud lamp with this filled with castor oil.
  • Keep a brass plate smeared with garlic juice over the lamp leaving a little gap enough for the oxygen to aid the burning of the lamp overnight.
  • Next morning, scrape off the carbon powder that is deposited on the brass plate into a clean dry box and mix it with few drops of pure ghee or castor oil and store it.
This can be used on daily basis as the ingredients you use for this preparation have medicinal values. You can even enjoy keeping the old beliefs intact using this home-made kajal cutting out the risks of the harmful effects of kajal for eyes. Though home-med Kajal is deemed to be safe, it is not good to play with your baby’s eyes. It is advisable to keep your baby’s eyes free from kajal or any other substance which can prove harmful for baby’s eyes.

There are some studies that suggest that most problems suggested due to kajal are theoretical in nature, rather than seen in practice, however the general consensus is to avoid putting ANYTHING in the sensitive eyes of a baby.
Read more here

Saturday, December 06, 2014

Now Spain ends Ebola Transmission

World Heatlh Organization: Media Centre: December 2, 2014
Today the World Health Organization (WHO) officially declares the Ebola outbreak in Spain over and commends the country on its diligence to end transmission of the virus.
On 6 October 2014, the Spanish National Reference Laboratory confirmed the first human-to-human transmission of Ebola virus disease outside Africa in a healthcare worker. The healthcare worker had been part of a team at La Paz-Carlos III Hospital providing medical care for a person with Ebola virus disease repatriated from Sierra Leone on 22 September.
On 21 October the healthcare worker tested negative for the second time and was consequently considered free of Ebola infection. Today, 2 December 2014, marks 42 days since the healthcare worker tested negative. There have been no further cases since the healthcare worker was confirmed to be negative for Ebola virus, so today the outbreak is over in Spain.
Spanish authorities identified and monitored 87 people who had been in contact with the healthcare worker. All were actively monitored and 15 high-risk contacts were put under quarantine at La Paz-Carlos III Hospital. All finished the 21-day follow-up period by 31 October 2014.
In addition, 145 hospital employees were in contact with the patient during her stay at the hospital. They were also actively monitored and all completed their 21-day monitoring period without developing Ebola virus disease.
WHO commends Spain for the measures put in place to identify potential cases and prevent further transmission of the Ebola virus. These measures included exhaustive contact tracing of both high- and low-risk contacts, daily active monitoring of all contacts, training in and monitoring of correct use of personal protective equipment for all healthcare workers caring for the patient infected with Ebola virus.

Friday, December 05, 2014

Storing vaccine at home refrigerator - is it a good idea?

Query : 
IPV vaccine store in room temperature in house hold refrigerator which was given to my baby.3 times ..i want to know its efficacy due wrong storage _? please give me details if IPV store more than 8 degree C temperature.

It is NEVER a good idea to store vaccines in the home refrigerator.
That being said, Inactivated vaccines (not live) are not affected by heat to a very large extent, and would remain effective even if the temperature goes slightly above the recommended 8 degrees Celsius.

Thursday, December 04, 2014

Does the new Pneumonia vaccine PCV 13 - Prevenar, reduce rates of hospital admission due to pneumonia? Results from US data

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Comment: While the Pneumonia vaccine has been introduced relatively later in India, and still faces a lot of resistance due to its high price (almost 4000 INR ~ 70 USD), this is good evidence that shows that it really reduces the risk of Invasive Pneumonia in the children. Data from India would be better, but is unsurprisingly unavailable.

Wednesday, December 03, 2014

20 day old baby with small amount of bloody discharge from belly button (umbilicus)

Q: I have a 20 day old newborn baby with small amount of bloody discharge from belly button (umbilicus), is this anything serious?

A: Generally speaking NO, small amounts of blody discharge that is of minimal quantity is normal during this period, due to the wound left after the stump falls off. This can last for 1-2 weeks.
However, bleeding from any other site, local pus / foul smelling discahrge and redness / pain locally is abnormal. Also bleeding that persisits for more than 15 minutes continuously, needs to be evaluated by your doctor.
Read more at Dr Sears

Monday, December 01, 2014

Weaning food for 8 month old baby in Kerala, India

Q: Hi sir.Im Frm Kerala. I read ur profile n decided to seek advice.I hav a son of 8 th month. And Im very confused in his food habituats, as its my first experience. In dis mnth I dnt knw wt to gv hm n wt not to. Actually I strtd Frm one f da powder Humana vch is bought Frm Dubai..n I used to gve him banana, boiled n den pureed. N den rice n ny veg lyk carrot Ya beetroot Ya potato boild n pureed.. I wnt to get a full n perfect timetabl Vch will help me. N more advices in health care .....
Thank you

A: Thanks for contacting me,
I understand your concern,
There is no full & perfect timetable :) for feeding a baby.
This is because the baby will NOT follow any time table!
You seem to be going on the right track, since we want to feed basically home made food in a slightly liquid consistency to the baby.
I would recommend using home cooked food, without any significant spices, and then mashing them up, and feeding the child,
There is no need for a specific timetable for most babies.
Check for weight gain, and talk to your pediatrician for any concerns,
You can get some more ideas here

Warm regards
Dr Gupta

Confused about "Optional Vaccinations" for Indian children

Q: My baby was born in 29.9.2014 it almost crossed age of 2 months. My doctor had told me to take Rota virus vaccine and Pneumococcal Vaccine , it is necessary to take the same, otherwise it is optional, so i am confused please help me . for taking the vaccines

A: From 2011 onward, the Indian Academy of Pediatrics no longer uses the older classification of routine and optional vaccines. 
Now all the vaccines are divided as Recommended vaccines & "Vaccines in Special Situations" .
You can find the IAP 2013 vaccine recommendations here
Both Rotavirus & Pneumococcal vaccines are Recommended vaccines and should be provided to ALL children whose parents can afford them.
This is because diarrhea and pneumonia are the commonest causes of admission & deaths in children under the age of 5 years in India, and any vaccination that can reduce this burden substantially should be taken by the largest number of children possible.
In fact, Sh Narender Modi has recently announced that along with MMR & Polio Injection, Rotavirus would be provided free of charge to all children in India as soon as feasible, through the government health care systems.
So the short answer is, if you can afford it, take both the rotavirus & pneumonia vaccines for your baby. Remember Rotavirus vaccine cannot be started after the age of 4 months.

Thursday, November 27, 2014

Measles vaccine - correct age of administration?

Query : 
Measles vaccine should be give at start of 9 months or at completion of 9 months?

A: At completion of 9 months.
Since October 2014, the Indian Academy of Pediatrics (IAP) is in fact recommending using MMR in place of measles at 9 months

To avoid any confusion, you can subscribe to a free service by IAP for SMS reminders for vaccination for all parents, 
just do the following

How to register for the service

Parents opt-in to the service by sending a text message by SMS to the national shortcode 566778 from any mobile phone in India, in the following format*** :

Immunize < Space>   
Example : Immunize Rekha 04-11-2013

The phone will immediately receive a confirmation message.
Text message reminders** will  be sent to the phone for 12 years, following the IAPCOI prescribed immunization schedule.  
3 reminders are sent, at 2 day intervals, for each vaccination that is due. An example of a reminder is - "Rekha is due for a vaccination this week, please do not forget to visit your doctor"**

Wednesday, November 19, 2014

Use of TdaP in pregnancy found to be safe - does not cause Preterm deliveries of smaller baby size

New Study Finds Tdap Vaccine During Pregnancy Not Associated With Increased Risk of Preterm Delivery or Small Birth Size
A study looking at safety of the Tdap vaccine during pregnancy was published in theJournal of the American Medical Association in Nov 2014.
Researchers used administrative and electronic health record data from two CaliforniaVaccine Safety Datalink sites to study whether maternal Tdap vaccination during pregnancy is associated with increased risks of health problems for the mother or baby.
The study found that Tdap vaccination during pregnancy was not associated with increased risk for hypertensive disorders of pregnancy, preterm birth, or having a baby who is small for his or her gestational age.
This study adds important information on the safety of Tdap vaccination during pregnancy, following continued widespread pertussis transmission and current recommendations to routinely vaccinate during pregnancy.
For more information on Tdap vaccination during pregnancy, see
For more information on Tdap vaccine safety, see:

Commmunicated in Adolescent India forum by Dr Alok Gupta MD FIAP, Jaipur - India

Chicken Pox vaccination - Can it be done in older children / adults?

Question : 
my daughter age is 12 years and son is 08 years. Please let me know if they can be vaccinated against chicken pox now? Can adult also get vaccinated against chicken pox?

Ans: Anyone who has NOT had a definitely diagnosed Chicken Pox disease can get vaccination against Chicken Pox, whether a child or an adult. The minimum age is 1 year, while there is no maximum age.
So all of you can get vaccinated against Chicken Pox.

Tuesday, November 18, 2014

Are Odomos mosquito repellant bands effective?

Q: I would like to know if the mosquito bands available are really effective?

A: They are probably using Citronella which is not very effective in preventing mosquito bites.
You can find user reviews here
I would recommend using additional protection like the cream as well, especially if the child is playing during the evening time in the park or in an area with a large number of mosquitoes,

Warm regards
Dr Gaurav Gupta

300 Doctors Summoned By MCI For Accepting Bribe From Pharma Company

The Medical Council of India has summoned about 300 doctors from across the country to Delhi to answer questions on an anonymous complaint that they had been bribed by a pharmaceutical firm. About 100 of these doctors appeared before MCI's ethics committee on Monday.

According to the complaint, the Ahmedabad-based pharma company has been paying doctors lakhs of rupees as well as gifting them cars and flats and sponsoring family foreign trips in return for prescribing its medicines even though cheaper alternatives from better known companies are available.

Of the 150 doctors summoned to appear at the last meeting of the ethics committee, 109 appeared. The rest were summoned on Monday. "About 135 are left and they have been asked to appear at the next meeting of the committee in December. According to the rules, they have to be given three chances," explained Dr KK Aggarwal, a member of the panel.
The letter asking doctors to appear before the committee on Monday said: "Please bring your ITR, bank statement for the last three years, passport in original, as well as a set of photocopies of the said documents." The letter also warned that "in case you fail to appear on the above said date and time, the ethics committee will proceed for ex parte decision against you on the basis of available records in the council office".

That had about 100 doctors thronging MCI's office. They were asked to give a response in writing. While many submitted their responses and documents immediately, others chose to wait and talk to their lawyers. "The letter sent to us with a copy of the complaint did not include the details of the charges against us though the complaint did mention that it included details of charges against each doctor. Without knowing the exact allegation against us, how can we be expected to respond?" said a doctor.

Dr Ajay Kumar, who chaired Monday's meeting, said, "They have a week to respond. We did not want to reveal the exact allegations against them in the letters. But when they appeared today, the complaint against them was read out. Now they know the content of the complaint and they have been given a proforma to fill as response."

The anonymous complaint was received by the department of pharmaceuticals in August. "The vigilance division of the department was of the view that since it involved such a large number of doctors, it ought to be examined in detail. So, they sent it to MCI in the first week of September, though anonymous complaints are usually disregarded," said Dr Aggarwal.
According to the complaint, one of the ways in which the firm would bribe doctors would be by paying lakhs of rupees for running advertisements on a TV installed in their clinics. The letter gave the name of each doctor with his or her address and the bribe given to him or her.

It alleged that the doctors were violating basic norms and claimed that the turnover of the company had grown from zero to Rs 400 crore in just five years. The letter alleged that company's brands were priced 15% to 30% higher than those of well-established companies like Cipla, Ranbaxy, Sun, Aristo, Alkem, Zydus and Cadila but still doctors were prescribing its products as the company "was buying doctors by way of offering various means of bribes".

The complainant claimed that the firm was adding the cost of bribes to its products, forcing the patient to pay up. The complainant sought an I-T probe since doctors who allegedly accepted these bribes were evading income tax.
Comment: I believe that this and cash backs from labs are two endemic problems that should be tackled by MCI.
There is certainly a case for small tokens (like pens, stationery items etc.) that can remind the doctor to prescribe a certain brand - without a significant financial value attached. This has been suggested by the American Medical Association as well. However, scientific studies have shown that when large gifts are given by pharma companies, including travel grants, this does influence doctor dispensing, even if the doctors feel that they are being neutral. Of course, cars, houses and similar extremely high cash value items are completely wrong, as is being suggested in the present case.

Friday, November 14, 2014

Punjab to start providing 5 in 1 vaccine free through government dispensaries from December 2014

Yesterday, the Hindustan times paper reported that Punjab government will provide 5 in 1 vaccine containing DPT, Hep B & Hib (brain fever vaccine) free of charge at government facilities in the state. 
This is good news especially for the lower to middle class which were primarily taking the government vaccines, It will not only provide protection against a dreaded disease - hib, that can cause meningitis, ear infections and blood infections, BUT it will also lead to a lesser number of injections being given to the child (3 instead of 6 in the govt at present).
For the government as well, it will lead to less wastage and less time needed per child, since the number of injections, needles and syringes are reduced.
The 5 in 1 vaccine has been proven to be safe in large scale government programs across the country and internationally.
How would this impact private practitioners? 
Doctors in practice have a weird problem, the 'healthy season' when kids are well, is actually bad for the business :)
Plus one of our target customer base was the people whose children had taken the govt vaccines only, and not taken Hib yet. 
However, given that Hib can lead to very serious diseases, it is good step in the right direction, and while there is controversy regarding the burden of hib disease in our country I believe that this vaccine would be a success in our country, and help achieve better health for our children.
As far as practising pediatricians are concerned, this may help increase our vaccination rates too, since Hib vaccine will become de facto standard rather than being an additional vaccine, and we do claim to have better storage & vaccination techniques than most government centers. Over a period of time, since Modi government has already announced that they would be rolling out Rotavirus & MMR (or MR) vaccines too, we private practising pediatricians would probably need to focus more on the special situation vaccines like Influenza, the 'luxury/ lifestyle vaccines' like CP & Hep A, & Typhoid which for some strange reason is still not in the government of India's horizon.
Also, our practice in the coming generations would move more towards preventive pediatrics, and non infectious diseases in children.

Punjab government introduces 5 in 1 vaccine shortly - HT

Indian government to introduce 4 new vaccines - BBC

Thursday, November 13, 2014

Clinical pearls learnt in the tricity Chandigarh's Pediatric meeting - newborn Inborn error of metabolism screening in India

While many accuse doctors of spending most of their time wining & dining in meetings, there is always opportunity to pick up some very useful tidbits that can impact our day to day OPD practice as well.
In our recent meeting of the pediatricians of Chandigarh, Panchkula & Mohali this is what I learnt regarding screening our newly born babies in India for certain serious & life threatening diseases.
The talk was by an eminent neonatologist from a leading corporate hospital, and was simple and quite useful.
While in the west, neonatal screening is taken as a given, and routinely done, in India this is an emerging concept, and many big hospitals, and most small hospitals and clinics do not do this routinely. 
Here is what I remember .... 
There is a lot of data that has emerged from India in the last 10 years regarding the utility of newborn screening, including from Goa - the first state to start newborn screening, and even our own city of Chandigarh where GMCH 32 is doing a pilot project for the last many years now.
Every child should be screened for the commonest three disorders ...

1. Congenital Hypothyroidism
2. Congenital Adrenal Hyperplasia
3. G6PD deficiency (especially common in North India)

As the incidence of these diseases in India is very common and approaches 1:1000 in most studies, & these conditions can be treated if detected on time, it makes a lot of sense to screen for these 3 conditions in India

Ideal time for heel prick screen - 2 days to 7 days age
If screening done before 2 days - repeat around 2 weeks age.
Cost of screening - in most private labs between 900 to 1700 rupees.
For affording parents, a much more detailed TMS screen can be done that costs upwards of 4,000 rupees and screens for 40 diseases, most of them rare and not easily treatable.
Turn around time - 4-7 days.
Screening to be done by simple drops of blood to be taken on filter paper, and then dried and put in an envelope and sent to the lab, mentioning details of anything special including the day of life of the baby when the screening sample was taken.
I have done the TMS (40 disease) screen for my daughter when she was born, and got back normal results

Tuesday, November 11, 2014

What I learnt in the last Pediatric Meeting - using Rifaximin in Indian Children - clinical pearl by Dr B R Thapa

I am just going to discuss a clinical pearl of wisdom that I learnt from Dr B R Thapa regarding using a relatively new antibiotic Rifaximin  (available in India as SIBOFIX - Dr Reddy's) during his talk in August 2014 at our Chandigarh quarterly meeting of Pediatricians from the tricity of Chandigarh Panchkula & Mohali.
When I asked him about when to use this particular antibiotic in children with diarrhea, here is what he said - as I understood it...

"In the monsoon months, there is a higher incidence of bacterial diarrhea due to water and food contamination, in India. hence if my clinical judgement I feel that the child is having a bacterial diarrhea - high fever, significant stomach pain, unwell look, then it may be possible to use Rifaximin. The benefits of using Rifaximin are that it is completely non-absorbable, hence the chances of side-effects are less, and it is very safe for kids (licensed above 2 years age at present in India). Also, there is little chance of antibiotic resistance developing given that there is no absorption in the body. Finally, since it stays in the body for a long time, ONLY three days of medicine is good enough to treat most infections"

I have been using this medicine in my practice after this discussion, and have found good results in diarrhea with possible bacterial infection.
I would be happy to know the experience of other pediatricians who have used this drug, especially in Indian children.
Just as an aside, Rifaximin is also recommended for use in cases of traveler's diarrhea, for people traveling across the world.
Please remember that this is just my opinion, and how I remember the conversation. Any errors are mine.

Monday, November 10, 2014

Vaccination FAQs - Reaction to Pentaxim and mixing different vaccines, what to do?

Query : 
My baby D.O.B is 26th October 2014.

He got Pentaxim{DTaP},Rotavirus,Heb B2 ,prevenar 13 {PCV13} and Polio drop on 8th Oct 2014. But he was crying so much and there was so much swelling in his leg where injection has been injected.

My current paed has given Hept B2 plus DTap plus prevenar in a single shot by mixing all the vaccine in single syringe.

Did this practice is approved or not because this time i went to another doctor on 9th Nov 2014 for vaccine and he said it is not good to mix all the vaccine in one shot. Kindly guide me what is correct way to inject vaccine.

Ans :
It is NOT correct to give different vaccines like Dtap & Prevenar mixed in a single syringe.
This may lead to problems in the efficacy of the vaccines (they may not work well) and may lead to more side-effects too,
The vaccines should be injected separately. If there was a significant reaction to Pentaxim, you could try taking QUINVAXEM - a DTwP brand that may have possibly lower or similar reaction, or you may try taking Pentaxim again.

Dr Gupta, MD

Friday, November 07, 2014

New guidelines for managing bronchiolitis (Double Pneumonia in common Indian Parlance) issued by AAP, Oct 2014

A new clinical practice guideline that offers physicians guidance for the diagnosis and management of infants with bronchiolitis was published online Oct. 27 in Pediatrics.
Shawn L. Ralston, M.D., from the American Academy of Pediatrics Subcommittee on Bronchiolitis, and colleagues evaluated published evidence to revise the 2006  relating to diagnosis and management of .
The researchers note that bronchiolitis should be diagnosed based on history and physical examination; risk factors for severe disease should be assessed when physicians are making decisions about evaluation and management of children with bronchiolitis. Radiographic and laboratory studies should not be obtained routinely. For and children with a diagnosis of bronchiolitis, albuterol (or salbutamol) and epinephrine should not be administered; nebulized hypertonic saline should not be administered to infants in the emergency department but may be administered to infants and children who are hospitalized. Systemic corticosteroids should not be administered to infants in any setting. For prevention of bronchiolitis, palivizumab should not be administered to otherwise healthy infants with a gestational age of 29 weeks or older and should be administered to infants with hemodynamically significant heart disease or  of prematurity during the first year of life.
"The goal of this guideline is to provide an evidence-based approach to the diagnosis, management, and prevention of bronchiolitis in children from 1 month through 23 months of age," the authors write.
More information: Abstract
Full Text
Journal reference: Pediatrics  
Comment: After reading these guidelines, I am actually confused as to what will work in bronchiolitis. Everything that we use, from Adrenaline, to Salbutamol & steroids have been shown to be not effective! I guess moving forward we need to look at more options to manage this vexing condition.

Tuesday, October 28, 2014

Vaccination FAQ - JE (Japanese Encephalitis Vaccine)

Q: We have given the first dose of Encephalitis some two months ago to our daughter. So do we have to give the second dose now or later?
Ans: Two doses of JE vaccine vaccines are needed at a gap of minimum 28 days.
Hence you should take the second dose of JE vaccine now,
Warm regards

Dr Gupta

Wednesday, October 22, 2014

A New Indian Vaccine for Rotavirus enters final stage of trials

LYON, France: A new made-in-India vaccine against Rotavirus, the most common cause of severe dehydrating diarrhoea in Indian infants, has entered a crucial final stage of trials. 

Hyderabad-based Shantha Biotechnics' investigational Rotavirus vaccine has entered Phase III clinical trials across 12 different sites in India. 

In an interview to TOI, Sanofi Pasteur's associate vice-president of research and development sites and hubs Jacques Volckmann said, "It is a vaccine which is being developed in India for Indians. Close to 1,200 volunteers are being sought at the trial sites to test the safety and efficacy of the vaccine that will specifically protect Indian children against the strains G1, G2, G3 and G4 that circulate extensively across the country". 

Among children under five, Rotavirus has been estimated to be responsible for two million hospitalizations and 500,000 deaths worldwide each year, the majority of which occur in the Indian subcontinent, sub-Saharan Africa and South America. 

It is estimated that one of every 260 children born each year will die from diarrhea caused by rotavirus infection by their fifth birthday. 

Recent studies indicate that rotavirus causes approximately 40% of childhood diarrheal hospitalizations worldwide, 40.7% in Sub Saharan African countries, 33% in Nepal, 34% in Pakistan ,40-50% in Japan and around 39% in India in children less than 5 years of age. 

India, with more than 1 billion people, 11% of whom are less than 5 years of age, has an especially large population at risk of clinically significant infection. 

There is no specific drug approved to cure rotavirus gastroenteritis. Since virtually all infants and young children will suffer at least one rotavirus infection and many will become infected two or more times, even in settings where good hygiene is practiced, universal immunization of infants with a vaccine is clearly the way to reduce rotavirus related morbidity, mortality, and associated medical costs. 

Shantha's investigational vaccine is designed to prevent severe rotavirus gastroenteritis in infants and children when administered as a 3-dose series to infants between the ages of 6 to 32 weeks. 

Each dose is an all-in-one formulation containing an antacid. The vaccine is a live-attenuated bovine-human reassortant comprising four serotypes, G1, G2, G3 and G4, and is targeted to be safe, confer non-inferior immunogenicity to already licensed vaccines and have the ability to prevent rotavirus gastroenteritis. 

The trial is designed to show non-inferiority against a currently licensed vaccine with the use of three, ready-to-use liquid doses administered orally, starting from six-to-eight weeks of age, with the subsequent doses administered at 4 weeks intervals. 

A phase I/II study was carried out with the long-term aim to produce a locally licensed vaccine that is safe and able to protect children against rotavirus gastroenteritis. 

Overall, the results showed that all three doses of the vaccine evaluated in the study were safe, well tolerated and displayed good immunogenicity (dose-response) in healthy Indian infants. 

"We aim to provide an affordable vaccine to meet the still significant medical need in emerging markets, like India, and through partnerships with organizations like Gavi, the Vaccine Alliance," said Olivier Charmeil, Sanofi Pasteur's President & CEO. 

The World Health Organization (WHO) recommends that vaccination with rotavirus vaccines should be included in all national immunization programs. Gavi, has established an accelerated vaccine introduction initiative with the objective of driving the sustainable introduction of rotavirus vaccine in 30 Gavi-eligible countries by 2015. 

In addition, PATH, an international, non-profit organization to improve public health, is working to accelerate access to rotavirus vaccines and sustain their implementation and use in countries where children need them most urgently. 

Rotavirus infections are prevalent in human populations worldwide. Although the virus can and does infect older individuals, illness caused by rotavirus can be quite severe in infants and young children. In low income countries, the median age at the primary rotavirus infection ranges from 6 to 9 months (80% occur among infants less than 1 year old) whereas in high income countries the first episode may occasionally be delayed until the age of 2-5 years, though the majority still occur in infancy (65% occur among infants less than 1 year old). 

The WHO estimates that in 2008 approximately 453,000 rotavirus gastroenteritis (RVGE) -associated child deaths occurred worldwide. These fatalities accounted for about 5% of all child deaths and a cause-specific mortality rate of 86 deaths per 100,000 population aged less than 5 years. About 90% of all rotavirus-associated fatalities occur in low income countries in Africa and Asia and are related to poor healthcare.


Comment: This is interesting news, since the Bharat Biotech vaccine for Rotavirus (116 E) made in India has already undergone the necessary testing & is likely to be launched in the next couple of months (possibly Jan 2015). Among all the newer vaccines, rotavirus is the only one where we have large amount of Indian data available regarding the disease from India through the IRSN - Indian Rotavirus Surveillance Network. This is probably one of the reasons why we are getting India specific vaccines for this disease. It is important to start vaccinating children early against this disease so as to prevent significant disease burden, since almost EVERY child will suffer from Rotavirus diarrhea if they are not vaccinated, probably by the age of 2 years.

Wednesday, October 15, 2014

What is causing the deaths in Muzaffarnagar children due to brain fever - is it an infection or a toxin in Lychee?

Written by Pritha Chatterjee | New Delhi | Posted: October 13, 2014 4:20 am
A two-year-long investigation into the “mystery” disease termed Acute Encephalitis Syndrome (AES) that kills tens of young children in Muzaffarpur, Bihar, every year has found no evidence of infectious microbes in the victims.
Instead, the investigators have said, their findings suggest “toxin mediated illness”, with a hypothesis of a toxin in the prevalent litchi fruit in the area.
The joint report, by the Centers for Disease Control (CDC), Atlanta, and National Centre for Disease Control (NCDC), under the Union Health Ministry, compares the outbreak to ackee fruit poisoning reported in the Carribean islands and West Africa.

Correction of hypoglycemia, or low blood glucose, in patients as per their recommendations, adds the report, has helped reduce mortality from 44 per cent last year to 26 per cent in 2014.
In an article in the latest internal newsletter of the NCDC, Dr Padmini Srikantiah of the CDC’s India wing and Dr Aakash Shrivastava of the NCDC’s epidemiology division say, “Based on the 2013 findings, we concluded that the outbreak appeared to be more consistent with a non-inflammatory encephalopathy rather than infectious encephalitis.”
Encephalopathy is a general term used to describe neurological symptoms while encephalitis indicates infection as a cause for the same. Explained a scientist, “We are saying the presentation indicates a generalised cause rather than an infection.”
Comparing the annual disease to ackee fruit poisoning, the authors have suggested the “potential presence of a toxin, Methylene Cyclopropyl Glycine (MCPG), with hypoglycemic activity that is found in the litchi seed”.
The CDC-NCDC team points out that hypoglycemia, not identified as a common symptom till now, was present in a majority of the cases, which the authors have said could be sparking the neurological symptoms.
In 2013, of the 303 children tested, including the control group, “hypoglycemia in 94 per cent of the children trended towards an increased risk of death”, according to the findings.
This year, 63 per cent of the 390 patients between May 26 and July 17 showed blood glucose less than 70 mg/dL.
However, various studies, including by the National Research Centre for Litchi (NRCL) in Muzaffarpur, have discounted any toxins in the litchi fruit pulp, root of the crop, seeds and skin as causing the symptoms. Litchi is a common fruit in the area.
According to the CDC-NCDC authors, “It is possible that exposure or ingestion of this toxin (MCPG) may have the potential to lead to acute hypoglycemia and precipitate the seizures that seem to be the clinical hallmark of this illness… Animal studies suggest that ingestion of MCPG may have the potential to cause acute hypoglycemia and encephalopathy, similar to ackee food poisoning described in the Carribean and West Africa.”
The investigators have advised the Bihar government to supply glucometers to hospitals to monitor sugar levels of affected children, ensure rapid treatment of hypoglycemia, and conduct a “detailed field study” to evaluate potential toxins.
The joint NCDC investigation team is, meanwhile, conducting a field study to identify toxins in pesticides, heavy metals, naturally occurring plant or fruit-based agents in Muzaffarpur area. Laboratory samples from patients are also being tested for toxin metabolites and residues.
AES affects young children between the ages of one and five, resulting in fever, sudden seizures and altered mental status. It was earlier characterised by over 90 per cent mortality.
This year, a team of the National Vector Borne Disease Control Programme had found a pesticide, Alphacyphermethrin, to be above minimum safe limits in a chemical analysis of litchi samples in Malda in West Bengal, but said it was too early to “confirm its toxicity in humans”.
Researchers, however, continue to deny the presence of any toxins in litchis. According to Dr Vishal Nath, director of the National Centre for Litchi under the Indian Council of Agricultural Research, based in Muzaffarpur, “We have been working on investigating a corelation between litchi and AES cases for years, and have performed hundreds of toxicology studies. We have established no association between the two.”
He adds that every year AES cases start surfacing in June, by when 90 per cent of the litchi crop in Muzaffarpur has already been “picked, sold and disposed of”.
Comment: We see a large number of patients from poor socio-economic status coming to PGI Chandigarh as well. Many of them die, while others are left paralysed. If we can find the root cause of these symptoms, this may help in avoiding these fatalities. Trying to find the pieces of this fascinating medical jig saw puzzle is also a great challenge. I am hopeful that Indian scientists will be able to rise above their egos, and together find the reasons for these cases of 'brain fever'

Tuesday, October 14, 2014

Updated Influenza vaccine policy by the AAP - any relevance to India?

Highlights of updated AAP policy on influenza

  1. Henry H. Bernstein, D.O., M.H.C.M., FAAP

The beginning of autumn reminds us that it is time to prepare for the 2014-’15 influenza season. The Academy’s updated recommendations for the prevention and treatment of influenza in children are available will be published in the November issue of Pediatrics.
The 2013-’14 influenza season was less severe than the 2012-’13 one, with a lower percentage of outpatient visits for influenza-like illness, lower rates of hospitalization, and fewer deaths attributed to pneumonia and influenza. Still, providers must remain vigilant since the influenza virus is unpredictable.
The influenza season may start early in the fall/winter, have more than one disease peak in a community and even extend into late spring. Therefore, as soon as the seasonal influenza vaccine is available locally, health care personnel should be immunized, parents and caregivers should be notified about vaccine availability, and immunization of all children 6 months and older, especially children at high risk of complications from influenza, should begin.
Dr. Bernstein
Following are key messages from the updated policy statement.


The 2014-’15 influenza vaccine will be available in both trivalent and quadrivalent formulations. (Neither the Centers for Disease Control and Prevention [CDC] nor the Academy has a preference.)
The trivalent vaccine contains the following three virus strains:
  • A/California/7/2009 (H1N1)-like virus
  • A/Texas/50/2012 (H3N2) virus
  • B/Massachusetts/2/2012-like virus (B/Yamagata lineage)
The quadrivalent influenza vaccine includes the same three strains as the trivalent vaccine plus an additional B strain: B/Brisbane/60/2008-like virus (B/Victoria lineage).


Optimal protection is achieved through annual immunization. Antibody titers wane to 50% of their original levels six to 12 months after vaccination. Although the vaccine strains for the 2014-’2015 season are unchanged from last season, a repeat dose this season is critical for maintaining protection in all populations.
Outreach efforts should be made to vaccinate people in the following groups:
  • all children 6 months of age and older, especially those with conditions that increase the risk of complications from influenza (e.g., asthma, diabetes mellitus, hemodynamically significant cardiac disease, immunosuppression or neurologic and neurodevelopmental disorders);
  • children of American Indian/Alaska Native heritage;
  • all household contacts and out-of-home care providers of:
    • children with high-risk conditions, and
    • children younger than 5 years, especially infants younger than 6 months;
  • all health care personnel;
  • all child care providers and staff; and
  • all women who are pregnant, are considering pregnancy, are in the postpartum period or are breastfeeding during the influenza season.


This consideration is based on a Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis done by the CDC, which concluded that there is an increased relative efficacy of LAIV as compared with inactivated influenza vaccine (IIV) against laboratory-confirmed influenza among younger children.
If LAIV is not readily available, IIV should be used; vaccination should not be delayed in order to obtain LAIV.


  • Children 6 months through 8 years of age receiving the seasonal influenza vaccine for the first time should receive a second dose this season at least four weeks after the first dose.
  • Children 6 months through 8 years of age need only one dose of vaccine in 2014-’15 if they have received it according to any one of the following scenarios (otherwise they need two doses):
    • At least one dose of 2013-’14 seasonal influenza vaccine.
    • Two or more doses of seasonal vaccine since July 1, 2010.
    • Two or more doses of seasonal influenza vaccine from any prior season and at least one clearly documented dose of a pH1N1-containing vaccine (i.e., any seasonal vaccine since July 1, 2010, or a monovalent pH1N1 vaccine during the 2009-’10 season).


Treatment should be offered for:
  • any child hospitalized with presumed influenza or with severe, complicated or progressive illness attributable to influenza, regardless of influenza immunization status or whether onset of illness has been greater than 48 hours prior to admission; and
  • influenza infection of any severity in children at high risk of complications of influenza, such as children younger than 2 years.
Treatment should be considered for:
  • any otherwise healthy child with influenza infection for whom a decrease in duration of clinical symptoms is felt to be warranted by his or her pediatrician. The greatest impact on outcome will occur if treatment can be initiated within 48 hours of illness onset but still should be considered if later in the course of illness.
The neuraminidase inhibitors oral oseltamivir and inhaled zanamivir are the only antiviral medications routinely recommended for treatment or chemoprophylaxis of influenza for the 2014-’15 season. Chemoprophylaxis should never be a substitute for immunization.
Given preliminary pharmacokinetic data and limited safety data, oseltamivir can be used to treat influenza in both term and preterm infants from birth as benefits of therapy are likely to outweigh possible risks of treatment. Chemoprophylaxis should be considered only in term infants.


  • Dr. Bernstein is Red Book Online associate editor and an ex officio member of the AAP Committee on Infectious Diseases.

Comments: As far as India is concerned, we are using Influenza vaccine for selected 'high risk' cases. These would include children between 6 months to 2 years ( & possibly up to 5 years), and children with chronic illnesses like diabetes, heart, lung, liver & kidney problems. Since the LAIV (nasal flu vaccine) called Nasovac S has recently become available, it is preferable to use this vaccine in children between 2-8 years age as it is found to be more effective in many western studies.