Categories
Healthcare Delivery

Causes and Management of Drug Resistant Epilepsy

Epilepsy is a disorder of the Central Nervous System which causes the brain to act differently or abnormally. In this disorder one may experience seizures, loss of awareness and certain sensations. It is one of the most common neurological disorders and can affect people of any age or race. In most cases, Epilepsy can be managed and controlled using anti-epileptic drugs but in some cases, patients fail to gain from these. This type of epilepsy is known as Drug Resistant Epilepsy or Refractory Epilepsy.

Drug Resistant Epilepsy (DRE), as the name suggests is that form of epilepsy in which the patient doesn’t respond to drug therapy as expected. Some other names by which this treatment is known are medically refractory epilepsy, intractable or pharmacoresistent epilepsy. It is rather surprising to know that as many as 20-40% cases of Epilepsy are refractory Epilepsy. However, it is recommended that a patient takes a few drug trials before DRE is established just to be sure so that the further treatment can be hence recommended by the doctors.

Treatment options for Drug Resistant Epilepsy patients:

–   Once DRE is established, doctors may refer the patient for a presurgical evaluation that is generally done at an Epilepsy center or healthcare facility. This is done in order to find out whether or not the patient is suitable for epilepsy operation.

–   If surgery is the way to go, then two options are available-resective procedure and disconnective procedure.

–   In case, the patient is not a suitable candidate for surgery or if the patient declines epilepsy surgery, the next step could be either a proper diet program or vagus nerve stimulation.

–   Vagus nerve stimulation is a procedure in which a pacemaker type of a device is implanted in the chest area to send electrical impulses to the vagus nerve. This inhibits the generation of seizures through the brain.

–   It has been a known fact that diet can help with Epilepsy and may reduce the occurrence of seizures. Those who do not benefit from medication or drugs thus rely on a high fat content low carbohydrate content diet. Some diets which epilepsy patients swear by include ketogenic diet, MCT-ketogenic diet, modified Atkins diet and others.

DRE or refractory epilepsy is not totally incurable but one has to undergo trials and different forms of treatments to be able to identify which fits best in their case. Deep brain stimulation as well as responsive neuro-stimulation is approved in certain countries and may prove beneficial for Drug resistant epilepsy patients.

Categories
Wellness

AROGYA WORLD HEALTHY WORKPLACE PROGRAM

As we continue to evolve into an interconnected world, the emphasis continues to be on how we can retain our health and vitality. While we might have achieved success over infectious diseases, the focus now shifts to Non-Communicalble Diseases (NCD). To add to it a lot of us spend more than 8-10 hours at the workplace, which determines the source of our health and vitality. Arogya World has been working in this space for a while.

Introducing Arogya World

Arogya World (www.arogyaworld.org) is a global health non-profit working to prevent non-communicable diseases (NCDs).   We strive to achieve our mission – to change the course of chronic disease – through a focus on partnerships and innovative technology, and by implementing scalable, sustainable programs with measurable impact. 

The Problem

Non-communicable diseases, NCDs, which include heart disease, diabetes, cancer and chronic lung diseases, are among the top health and development challenges of the century.  2 out of 3 deaths in the world are due to NCDs with 80% of them in developing countries. India has an alarming diabetes burden – 80 million people live with the disease and 1 million die from it each year.

Our Solution – Prevention is key

At the core of all our work is disease prevention through healthy living.  According to the World Health Organization, 80% of heart disease, 80% diabetes and 40% cancer can be prevented by avoiding tobacco, increasing physical activity and eating healthy foods.   These lifestyle changes are what we promote. 

With half of India’s 1 billion plus people less than 25 years of age, we have to find ways to reach young people and teach them prevention.  Mobile technology and leveraging schools and workplaces are smart solutions and these are the platforms our programs are built on.    

Our Work in India

We implement scalable diabetes prevention programs, educating and empowering housewives and farmers, working adults and school children to take definitive steps towards leading healthier lives.  With our India-based programs we are taking the first steps towards building a chronic disease prevention model for the developing world. To further advance this work, an affiliate Arogya World India Trust has been set up as a separate entity. 

Arogya World follows a doorstep health model, which takes prevention to people where they live, learn and work. Our focus is on scalable, science-based programs designed to reach a large population. These are deployed in schools, workplaces, and bringing information right up to people’s phones. Our programs are aligned with sustainable development goals and Government of India’s priorities (Ayushman Bharath, Fit India, Eat Right Campaign and Potion Abhiyan). We believe our work will help India meet SDG #3 which is Good Health and Wellbeing.

Healthy Workplace Initiative was developed with the intent of advancing the workplace health movement in India. We motivate companies in India to invest in workplace wellness through pioneering awards. This innovative approach leverages workplaces, where working Indians spend so much of their day, as a platform for chronic disease prevention. Public Health Foundation of India, IAOH Delhi, CII, iNFHRA, GACS and others have joined us as Commitment Partners.

Employees spend a significant part of their lives at the workplace. Many working professionals have become increasingly sedentary, contributing to inactive lifestyles and unhealthy living.  Employers have the opportunity and responsibility to improve the health and wellness of their staff, while simultaneously improving productivity.

As part of our program we urge employers and leaders to do more to help employees lead healthier lives, to shape their company’s culture to becoming health promoting, and to become data driven around health so that they can improve their employee health programs year on year. We also provide some tools to help individual employees make better and smarter lifestyle choices. 

Corporates have to seriously consider an employer approach to improve employee health, which will help them mitigate sick leave and absenteeism, reduced productivity and increased healthcare costs. Arogya World’s Healthy Workplace Program focuses on employee wellness, the investments companies are making in health and productivity strategies, and the effort towards increasing engagement in health and wellness programs internally.

Company sponsored wellness programs have to include activities such as company-sponsored exercise, weight-loss competitions, educational seminars, tobacco-cessation programs and health screenings that are designed to help employees eat better, lose weight and improve their overall physical health. A healthy workforce means a better bottom line, more productivity, greater competitive advantage.

What are the challenges at workplaces?

Challenges of a Corporate Employee often puts them at risk of NCDs

1. Unhealthy eating, smoking, and drinking,

2. Busy lifestyle and low awareness to health risks

3. Sedentary lifestyle and mental stress

4. Low compliance to annual health check-up

Arogya World’s Healthy Workplace Assessment is direct, robust and transparent.  The process of assessment for the Bronze, Silver and Gold level starts with initial awareness sessions where the organization is taken through the criteria ( http://arogyaworld.org/healthy-workplaces-criteria/ ) and its implications- banning tobacco use, healthy eating, increasing physical activity, and improving work-life balance. Emphasis is also placed on changing the mind-set of management at all levels towards promoting employee wellness.

The company then submits an application highlighting its employee health initiatives by submitting a questionnaire that has been developed based on the set of criteria. Subsequently, a 3-person team (which includes a medical doctor, an industry expert, and an Arogya leader) visits the organization’s facilities, evaluates the initiatives taken, and has a meeting with the coordinating department (which is usually the HR department). This year, the assessments will be conducted virtually.

The findings are compiled and after a good discussion among the assessors, a decision is made as to whether the organisation is at Bronze, Silver or Gold category. To qualify, companies must meet 80% of the criteria in each level.

During the assessment, the strengths of the company are highlighted and areas of improvement are brought forward, as also the best practices adopted by peer companies. This gives the company a good opportunity to benchmark itself against industry standards, understanding of where they are and how they can advance to the higher level. We guide the companies  to improve employee well-being, including physical and mental health, along with tackling workplace and personal stress

More than 134 companies have been onboarded as Healthy Workplaces on our program from 2013-2020, out of which 33 companies have reached the Platinum level, leadership and data-driven initiative beyond the Gold level.

We felicitate our winning companies in front of their peers at our annual Healthy Workplace Conference which is usually held during first week in November- near World Diabetes Day. The event has a workplace wellness Best Practices workshop and an award event.  This year it will be organized virtually.

What are the benefits of our Healthy Workplace Program?

Employee Benefits

1.         Better equipped for and more aware of NCD prevention

2.         Better performance and reduced number of workdays lost

3.         Better quality of life

4.         Fewer health complications

Employer Benefits

1.         Better Corporate Health

2.         Improved productivity 

3.         Decreased reimbursements and healthcare costs

4.         Fewer sick leaves and reduced absenteeism

5.         Lower insurance premiums and lower hospital admissions

We believe a multi-sectoral approach is needed to advance the fight against NCDs and we believe it is our generation’s responsibility to fix NCDs.  Arogya World is determined to use public private partnerships and smart technology to make measurable and significant public health impact.

We aspire to develop a framework for the whole ecosystem of prevention of NCDs by integrating efforts being undertaken by various organizations and professionals in the domain. We would like to build Healthy Workplaces into a robust community and engage more deeply with them offering more programs and services.

By Usha Chander, Arogya World

Categories
Public Health

In pursuit of a Vaccine for Covid-19

Covid-19 pandemic has brought vaccines under limelight once again. Research laboratories and pharma/biotech companies are working overtime to develop a vaccine against coronavirus at the earliest. As of July 31st, 2020, more than 100 efforts to develop a vaccine for Covid-19 are underway in different parts of the world, and at least four of these are in phase III trials – three in China and one in the UK. As per some unverified reports, some phase III trials are underway in Russia also, but not much is known about these trials at the moment.

We have two promising candidate vaccines here in India also – one at Bharat Biotech in collaboration with ICMR and the other at Zydus Cadila. The Drugs Controller General of India (DCGI) has allowed both of them to start human clinical trials. Besides the early stage trials of these two indigenous candidate vaccines, Serum Institute of India received the regulatory approval on July 31st, 2020 to conduct a large multicentric phase III trial for the AstraZeneca/Oxford vaccine in India.

Every small or big news coming out of the laboratories is getting dissected endlessly – not always in the most logical manner and often with more political rather than scientific context. For example, there have been claims by eminent people in India, US and other countries that a vaccine for Covid-19 could be available by or before the last quarter of 2020. In fact, just this week Russian news agencies announced that two candidate vaccines there are in the last phase of development and that Russia will launch a vaccine by August 12th itself.

I have discussed this in a detailed point of view here.

We need to be careful while setting any timelines for Covid-19 vaccine. Going by the history of vaccine development, this seems a rather aggressive timeline. Till date, Mumps vaccine is the fastest developed vaccine, which took four years in development – from the time of initial sample collection in 1963 to its licensing for mass consumption in 1967. Despite all the scientific advancements since then, Mumps vaccine remains the only vaccine ever to be developed in less than five years. So, to have a vaccine for Covid-19 thoroughly tested, approved and readied within under one year may actually be a wee bit too ambitious a goal.

By Dr Lalit Singh , Managing Director – McGraw Hill Education, India

Categories
Public Health

India and COVID19 – The Story So Far and the Road Ahead

Late January, a medical student fleeing from Wuhan became the first confirmed cases of SARS-Cov-2 in India.1 Couple of her classmates also contracted the virus and India made its initial entry into a leader board no country wants to lead. The three students largely remained asymptomatic and recovered with a month, ending India’s first tryst with the virus.

The second wave started at the end of February. By now, SARS-Cov-2 had spread to 64 countries / regions across the world, with South Korea and Italy reporting over 1,000 confirmed cases. But it is quite possible there were cases in India long before that. It was only in in May that we found that the virus had already reached France in late December itself.2 It is quite possible that the virus had reached India from Europe long before we started screening the flights coming from Europe.

Nevertheless, as confirmed cases started gradually increasing in India, the Central Government took a bold step in locking the country down for three weeks to prevent the spread of the virus. Many countries were opting for lockdown to tackle the virus, but the step by India was a bold one for two reasons:

  1. Lockdown is a strategy for the rich. It meant many will have to live off their savings and those who can’t will have to be protected by the government. US alone has provided for over 3 million via unemployment benefits.3 India, with perhaps the largest number of poor people in the world, would have struggled to provide for those getting unemployed due to lockdown.
  2. It would have taken a phenomenal effort to enforce the lockdown given the size of the country and population density in certain parts. The only comparable country is China, which can rely on heavier surveillance than India could enforce.

By 14th April, Goa, the North East and East India excluding West Bengal were largely unaffected by the virus and had limited the number of cases to less than 100. States like Haryana, Karnataka and Kerala had managed to control the spread as well and showcasing more than one-fourth recoveries.

But it was already evident by then that many places in the country where the infection had reached the community.

Though India officially denied community reach of the virus, on 10th April, Indian Council of Medical Research (ICMR), which was coordinating India’s Covid19 response (Which in itself was odd since there was already another organization fitted for it – Integrated Diseases Surveillance Programme (IDSP) 4) had recommended 36 districts be prioritized to target Covid-19 containment activities. This was based on the Sentinel Surveillance study done till 2nd April.5

By 3rd April, India recorded a little over 3,000 cases of SARS-Cov-2. This was spread across 255 districts in 30 states and union territories. Incidentally, only 66 districts had reported more than 10 SARS-Cov-2 cases then.

And ICMR was recommending stricter containment in 36 districts.

As the economic cost of the lockdown became more apparent, India went on a period of staggered release of lockdown after 14th April. But as expected from a country with community transmission of a virus, India showed a consistent increase in cases as norms got relaxed. What was 104 districts on 24th March, when lockdown started, it became 379 on 14th April, 489 on 4th May, 564 on 17th May and with the last release on 31st May – 654 districts have seen confirmed cases of SARS-Cov-2 across the country.

The Road Ahead

Image 1 – Italy

Image 2 – India

After a long three month struggle, Europe is finally starting to hope they can move beyond Covid. While most of the European countries peaked in cases late March, they have seen a gradual decline in cases over two months.

This long tail foreshadows what we may see in India. But for that, we have to reach the peak first. So, we can expect considerable pain, both from Covid and the economy, for at least the next two months before things start to get better.

The 66 districts that saw more than 10 cases on 3rd April, now account for 66% of the SARS-Cov-2 cases in the country.

As cases increase, hospitals get stressed and treatment gets delayed. This leads to an increase in fatality rate. While India is doing remarkably well with around 7,500 dead from 267,000 SARS-Cov-2 cases (2.8%), there are over 100 districts with a fatality rate of 3.7% and above. The ones to watch out for over the coming weeks:

Jalgaon (Maharashtra), Dhule (Maharashtra), Kolkata (West Bengal), Solapur (Maharashtra), Aligarh (Uttar Pradesh), Meerut (Uttar Pradesh), Dewas (Madhya Pradesh), Patan (Gujarat), Khargone (Madhya Pradesh), Amravati (Maharashtra), Nashik (Maharashtra), Mathura (Uttar Pradesh), Gorakhpur (Uttar Pradesh), Sagar (Madhya Pradesh) and North 24 Parganas (West Bengal).

All these districts have shown consistent growth the past week and has high fatality rate. With more testing, it may be possible to weed out the SARS-Cov-2 carriers and catch patients early, although districts like Kolkata and Nashik may already be stressed, given the high number of cases there.

Ujjain (Madhya Pradesh), Anand (Gujarat) and Panchmahal (Gujarat) have seen low growth in cases recently, but has an overall high fatality rate. Increasing testing in such places may reveal the extent of the spread, since high fatality rate may be due to late stage discovery of the disease.

On a positive note, there are 48 districts that show a high growth rate in cases with a less than 1% fatality rate. This would indicate better testing and good potential to keep a check on the virus. These include Chennai (Tamil Nadu), Chengalpattu (Tamil Nadu) and Gurugram (Haryana). All of the three districts have recorded over 1,000 SARS-Cov-2 cases

Among the 25 districts that have over 1,000 cases, Indore (Madhya Pradesh) and Jaipur (Rajasthan) have shown the slowest growth rate the past week, indicating a positive road ahead.

Late March, George Gao of the Chinese Center for Disease Control spoke to Science Magazine about the road ahead with SARS-Cov-2 – Trace all SARS-Cov-2 carriers with mass testing, Isolate the carriers and trace out their close contacts, Quarantine and isolate the close contacts.6 As we officially start to slowly unlock our economy in June, despite the numbers on the rise, it will be a difficult road ahead for all of us in India.

A century ago, the Indian subcontinent was the biggest graveyard for the Spanish flu virus. In all probability, we are again headed there and the only way to have some form of control is to trace the infected early by mass testing and ensuring strict quarantine of the infected and their contacts. We also need a workable serological test7 to determine who have already been infected (and not initially traced) so that they can get back to work.

By Ranjith Kollanur

Bout the Author

Ranjith Kollanur is the Managing Parter with the Unseen Ink,

1https://www.outlookindia.com/magazine/story/india-news-wuhan-to-kochi-an-indian-medical-students-great-escape-from-epicentre-of-coronavirus/302922

https://www.bbc.com/news/world-europe-52526554

3https://www.marketwatch.com/story/a-staggering-number-of-laid-off-workers-are-receiving-more-money-from-unemployment-benefits-than-when-they-were-employed-2020-05-26?mod=article_inline

4https://idsp.nic.in/index1.php?lang=1&level=1&sublinkid=5778&lid=3707

5https://www.businesstoday.in/latest/trends/icmr-sentinal-surveillance-finds-39-percent-coronavirus-patients-without-travel-history/story/400629.html

6https://www.sciencemag.org/news/2020/03/not-wearing-masks-protect-against-coronavirus-big-mistake-top-chinese-scientist-says

7https://www.cdc.gov/coronavirus/2019-ncov/lab/serology-testing.html

Categories
Public Health

Covid19 Test. Trace. Treat… Are We Doing Enough?

We have been hearing this advice from many sources for the management of Covid19 effectively. For understanding more about Covid19, I went on to check for a simple metric i.e. percentage of confirmed Covid19 cases vis-a-vis a total number of tests conducted by various countries affected with Covid19. My data sources are shared at the end of the article. I have used a different data source for the month of May; the reason being comparable dataset was not available with the earlier source.

March Numbers

CountryDateTotal TestsTotal Confirmed Cases%Confirmed
SpainMar 18, 2020300001117837.26
ItalyMar 20, 20202068864103519.83
IranMar 14, 2020800001136414.21
United StatesMar 19, 202010394594159.06
IndiaMar 20, 2020145411911.32

May Numbers

CountryDateTotal TestsTotal Confirmed Cases%Confirmed
SpainMay 24, 202035565672823707.93
ItalyMay 24, 202033911882293276.76
IranMay 24, 202078128613352117.08
United StatesMay 24, 202014357969166682911.60
IndiaMay 24, 202029434211326744.50

Just to mention, the source which I used earlier did not have the data for China so I could not include the same. Apart from China, I have shown the data for the countries which have got the maximum number of confirmed cases to date (in March) for illustration purpose and I also included our own country to put this in perspective. Now, if we compare the data for two instances; it shows different positivity rate (i.e. percentage of total confirmed cases / total test)

As we all know that lockdown was imposed in our country for preparing ourselves for fighting this long battle against Covid19 and a very important aspect in this battle is to increase our daily testing capacity as it’s the only way available to us to understand the spread of the virus in any particular community.

We have come close to daily testing capacity of 1 lakh+ tests a day which is almost 100 times increase from the initial days but still we are way behind when we see tests per million vis-à-vis other developed countries. Just to put this in perspective; India is doing 2135 tests / million population whereas Iran which has almost similar number of confirmed cases has been doing 9544 tests/ million population. And if we compare this with developed countries this number is in the range of 20000 – 75000 tests/ million population.

At the same time; we should not forget that various studies world over suggest that actual number of infected individuals are always higher than number of confirmed cases the reason being each country depending upon their testing strategies are able to identify the confirmed cases. Also, we should not forget that number of confirmed cases is a lagging indicator to understand the spread as the symptoms start to emerge only after 2 to 14 days from the day an individual got infected with the virus.

I am writing this article at a time when we are in lockdown 4.0 and have got relaxation in many parts of the country. This would be the real test of our healthcare infrastructure which we have managed to build during the national lockdown.

Key Points:

  1. Positivity rate for India is less vis-à-vis other nations which also got impacted with Covid19 (which is a good sign)
  2. We need to improve our testing capabilities to understand the level of community spread (as it is done in other countries); the reason being based on the historical evidence and current developments globally pandemic strikes in waves so we should not discard the possibility in our case as well.
  3. We should also increase the use of rapid antibody test to ascertain the level of community spread.
  4. We should be more concerned about deaths happening due to Covid19 as it is believed that 80% of the cases would be mild in nature; 15% would need hospital support and 5% would need ventilator support.

In our country, one can also debate the number of deaths happening because many of deaths happening in our country are not certified medically. But that is something we should discuss separately.

Again as always, questions and clarifications are welcome.

About the author

Yatindra Jha is a healthcare consultant with a focus on public health policy.

Sources

Data Source: https://ourworldindata.org/covid-testing – March Data

Data Source: https://www.worldometers.info/coronavirus/ – May Data