46

CorrespondenceTHE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 8, NO.1, 1995

Awareness of AIDS among doctors in Jaipur

The acquired immunodeficiency syndrome(AIDS) is rapidly evolving into a major publichealth problem in India as increasing numbersof human immunodeficiency virus (HIV)positive patients are being detected. I Epidemio-logical studies from India have shown that HIVinfection is already widely prevalent amongvarious high-risk groups such as female sexworkers, drug addicts, truck drivers, sexuallypromiscuous males and those who havereceived multiple blood transfusion.>'

The prevalence rates of the HIV infectionnow vary from 1% to 15% in these high-risksubgroups.t+ More alarming is the rise of HI Vpositivity among voluntary blood donors andin the general population.t=" The gravity ofthe oncoming crisis in this part of the worldhas been recently expressed by the WorldHealth Organization Regional Committee forSoutheast Asia which states that if effectivepreventive measures are not taken now, thisregion might end up having 9 million HIVinfected cases by the year 2000 and this willcause grave health as well as social andeconomic problems. 1.9

Various agencies have started massive publiceducation programmes to disseminate know-ledge of the preventive measures for AIDS.I.IOHowever, it is imperative that doctors be fullyaware of all aspects of HIV infection includingprevention, early recognition and management.

To gauge this awareness among doctors, werecently performed a questionnaire based studyin Jaipur.

We used a detailed proforma containing38 multiple choice questions with regard to the •aetiological agent, pathogenesis, preventivetechniques, diagnostic methods, clinical pre-sentation and treatment of HIV infection.

The proforma was circulated among 300qualified doctors randomly selected from a listof doctors who were working in governmentdispensaries or in private practice. Onehundred and sixty (53%) doctors responded tothe questionnaire.

We then analysed the data using simplemathematical models and descriptive statisticsand the overall responses were classified asgood (>70% correct), fair (50-69% correct)and poor «50% correct).

Seventy-nine per cent correctly named theaetiological agent for AIDS, 89% the target ofinfection (lymphocytes), 96% were aware ofthe value of using condoms and 91 % thoughtthat high-risk groups and blood productsshould be screened to contain the spread ofAIDS. Seventy-four per cent knew that thosewho had other sexually transmitted diseaseshad a higher chance of being HIV positive thanthose who did not.

Ninety-three per cent knew that the mostefficient and practical way of diagnosing HNwas by enzyme linked immunosorbent assay

(ELISA) but only 65% knew the confirmatorytest to be a Western blot assay.

The knowledge' of the prevalence of HIVinfection in India was poor. Thirty-eight per centcorrectly identified the seropositivity rate (10-20%) for HIV in female sex workers in India andonly 36% considered homosexuality important.

Knowledge of the clinical course of HIVinfection, symptoms of latent HIV infectionand of full blown AIDS, and its treatment wasalso poor. The majority of respondents werenot aware that there was a latent period betweenHIV infection and the clinical presentation ofthe disease.

Similarly, they were not aware of the drugsused for the treatment of the disease or theassociated opportunistic infections.

An awareness of the extent of the problemof HIV infection, its clinical manifestations andtreatment is still poor among doctors in Jaipur.This may be because they rarely see patientswith AIDS; there is a low prevalence of HIVpositivity in Rajasthan and no case of AIDS hasbeen reported from any of the state hospitals.However, the data supplied by the Directorateof Medical and Health Services, Rajasthanshows that the incidence of HIV positivity isincreasing (personal communication) and,therefore, dissemination of knowledge ofvarious aspects of the disease among all medicalpersonnel is important.

The various ways of preventing HIV infec-tion and AIDS have been highlighted by thenewspapers and television and the NationalAIDS Control Organization'? has emphasizedthe importance of doctors being informed ofthe proper use and interpretation of HIV tests,the danger of blood transfusion and otheraspects of AIDS prevention. The disseminationof information to doctors on how HIV infectionmight be prevented seems to have been fairlysuccessful. However, they were generallyunaware of the need for an investigation toconfirm an ELISA positive result nor did theyknow about the drugs used in treatment. Moreeffort is needed to fill these gaps.

17 November 1994 V. D. MaheshwariRaman Sharma

Rajeev GuptaG. L. SharmaS. K. Sharma

Department of MedicineS. M. S. Medical College

laipurRajasthan

REFERENCES

Anonymous. AIDS-The Indian scene. IndianCouncil Med Res Bull 1991;21:125-44.

2 John TJ, Babu PG, layakumari H, Simoes EAF.Prevalence of HIV infection in risk groups inTamilnadu, India. Lancet 1987;1:160-1.

3 John TJ,BabuPG,Pulimood BR,JayakumariH.Prevalence of human immunodeficiency virusinfection among voluntary blood donors. IndianJ Med Res 1989;89:1-3.

4 Malaviya AN. Human immunodeficiency virusinfection and AIDS in India. In: Ahuja MMS (ed).Advances in Clinical Medicine-I. New Delhi:B.1.Churchill Livingstone, 1991:28-70:

5 Malaviya AN, Seth P, Singh RR, Tripathy SP,Chaudhari K, Singh YN, et al. AIDS and HIV-lscreening in northern India. Natl Med J India1989;2:22-5.

6 Kaur A, Babu PG, Jacob M, Narasimhan C,Ganesh A, Saraswathi NK, et al. Clinical andlaboratory profile of AIDS in India. J AIDS1992;5:883-9.

7 Sehgal S, Verma S, Sharma BK, Sakhuja V,Chugh KS, Dhanoa J. Blood borne HIV infectionin Punjab. Ann Natl Acad Med Sci (India) 1992;28:43-8.

8 Kamat HA, Banker DD. Human immuno-deficiency virus-I infection among patients withsexually transmitted diseases in Bombay. NatlMed J India 1993;6:11-13.

9 Anonymous. AIDS-A threat to development.World Development Report I993-Investing inhealth. New York:World Bank, 1993:99-107.

10 Lal S, Thakur BB. Proposed national HIV testingpolicy. Indian J Med Res 1993;97:223-4.

Health is a fundamental right

In an otherwise well written article on chronicrenal failure, Dr M. K. Mani makes certaindebatable observations. I He feels that 'the careof end-stage renal failure patients should notbe a part of the activity of the government atall'. He believes that 'the treatment of renalfailure should remain within the ambit of theprivate sector. If a person can pay for it, itshould be available, but not out of governmentfunds'.

Every year around 85000 people in Indiadevelop chronic renal failure and the majorityof them are very poor. For them the cheapestand most appropriate treatment, at present, isa renal transplant. However, only about 2000to 2500 patients undergo renal transplantationannually and the procedures are done in privatehospitals. The rest probably die. Even inthe private sector about 56%, according toDr Mani, have to take loans or sell their landand other assets to get treatment. We feel thatthe government cannot disown 85 000 Indiancitizens every year just because the treatmentof chronic renal failure is expensive.

In the Government General Hospital,Madras, the Nephrology department has donemore than 300 live-related renal transplantsat no cost to the patient. Our results are com-parable to any other centre in India and wehave not drawn any money from the stateexchequer for its programme. We feel that ifone government hospital can do this, there isno reason why others should not follow. Infact, wherever there are nephrology andurology departments and an operation theatre,renal transplantation is eminently feasible. Wefeel that all the government teaching hospitalsshould begin renal transplantation immediately.

CORRESPONDENCE

We also feel that treatment should not bedecided by cost alone. That is the World Bank'sway of doing things. We feei it is the duty ofthe state to take care of its citizens. Health isa fundamental right. Even the poorest of thepoor pay taxes (indirect taxes are greater thandirect taxes) and they are entitled to the besttreatment available. There cannot be one treat-ment protocol for the rich and another for thepoor. Such apartheid is against the very spiritof our constitution. If certain diseases are notto be treated on the basis of cost only the majorityof them will be outside the purview of govern-ment hospitals. The advances in medicine(most of which are technology-dependent) areall costly and thanks to the GAIT agreementnew drugs will also soon become very expen-sive. In this situation, where will the majorityof patients go for treatment if the state turnsthem down. Does Dr Mani want more andmore people to sell whatever little they haveor get into the grips of loan sharks just becausethe government denies them the treatment thatis their right?

There is no reason for the health budget tostay at a paltry Rs 74 per annum per head.When the nation spends thousands of crores ofrupees on its nuclear and missile programmes,all in the name of national security, when wecan spend hundreds of crores of rupees everyyear on the security of the so called VIPs, surelyour health budget can and should be increased.Our total health budget for 1993-94 wasRs 483.30 crores. This is about 1.5% of thegross domestic product. The World HealthOrganization recommends that this should beat least 5% if equity and universal coverage ofhealth are to be achieved. 2 It is the duty ofmedical professionals to demand such anincrease so that the the poor can get good treat-ment in a government hospital. Justifying thegovernment's parsimony on health will·justifythe deaths of nearly a hundred thousandpatients from renal failure and many more fromother diseases.

23 November 1994 . S. ShivakumarJ. AmalorpavanathanMadras Medical College

MadrasTamil Nadu

REFERENCES

Mani MK. Chronic renal failure in India. Natl MedJ India 1994;7:80--4.

2 Gargi PSP. Plagued by inadequacies. The Hindu1994 Oct 2:7.

Need for poison information servicesin India

Management of acute poisomng in India posesmajor problems to physicians working inemergency departments mainly because verylittle information is obtained regarding thenature and amount of the substance ingestedat the time of presentation. With laboratoryservices for toxicological analysis not beingreadily available, diagnosis and treatmentremain largely empirical. Thus, dischargeor death summaries with entries such as

SILOFUonf E.O:a. ~mpvres can be f&lmi atedl'H ctlvelv I n the Storage- Bins of r-ood graiti$ (wheat,~ra:TJ, Rice) for preservaoon & pest control.

DIRECTIONS &. PRECAUJIONS1. I=lre~k...Silofume E O.B Ampvle from the surface ofthe <:loth bag witl'l some stone etc. But without takinglt1 ~mpu(e.out from the bag and insert it in the centreOl ,r.e grains. . .'., Break E.D 3. ~'TIpuleg.e.nly to aVQldspi11i.lge. Whileorca~lng Ampule if thech~micat comes in contccr withhands, bod" eyes, eydids o~ wearing ·cl<Jthe:..of thl)operator, lash atonce mose portions and cloths withsufficient water and take affected parson- in opef. air.3. The gOiOW'i5, Bins, etc. in y. hieh groins have beentreated with E. D-.B. Ar/tp;t: ••s • must he made Air Tight

. immediatly after inserting'fl;e Ampule..' 4. The grains treated with c.D.B. should be u£&d ·for

eming only aft!'r Seven davs. the gru:n should only bewell exposed to the open air before use. '5. Sleeping or keeping cattle in the treated godown OJmom ,is Sll ietlv ...•roh,ipit~ -:.. ." ..,.....--;-:-::-:--,..,..:,-.,6. 00 not use Ampules on OIl seeds, utses i$ • cur..7: To smelt or taste ;lnt! rob-on skin or body conteet off.O.e. chemical is d2imgerous. •8. !,<EEf'£:: D. B AMPULES eJJ:J' OF TH~ R~A~H '!ifCHILOE,;f\' !f :·'.vailowed and in case of PQI OI\!1'19

'cali your cuctcr immedl? It.Follow all the dlloctions. .

ANTIDOTE;- ";?F": s'or,l<)!:fI with ,:5000 PotaSi~!"p';~ml{;:l€tI}or (;.2·1 cupric .suip!late. Provide vItam!";" ,~nd.1\ropine .•fj:fi~jfllly carry patic;')t in open Air.Apflly artfficiat nCCj)l{~,:" •

'i A a t E------~----------~~~~-----------------.-~Number of Ampotes.to be used

1 cu. Grains 1 Ampul of 3 ML".2, 'f. 2"5 ., •5• H." II b 5 " .. 6 ML

AAfe b~ :- A B. . (R,I.) BiolQgic..lA PUR, 245101 (l' P.)

\..Gr.ins Quar..IlY·

f

r

'poisoning' are commonplace. Further, variousantidotes required for managing certain typesof poisoning are unobtainable in our country.In fact, activated charcoal which forms thebackbone of the initial management of somecases! is not manufactured by any pharma-ceutical company here.

In some instances the trade name of the drugor poison ingested is the only information avail-able and it is impossible to expect theemergency physician to remember the tradenames of all the potential poisons. On the rareoccasion when there is a 'fact-sheet' providedby the manufacturer of the ingested substance,it contains grossly inadequate information. Weobtained such a 'fact-sheet' from a patientrecently who ingested 'silofume EDB'. This'fact-sheet' apart from being poorly legiblecontained no details regarding either the'chemical nature' of the substance ingested orthe quantity of active chemical present in oneampoule (we later found out that EDB standsfor ethylene dibromide). In cases of exposureto EDB, the recommended directions writtenon the 'fact-sheet' were totally outdated--itmentioned the use of cupric sulphate for gastriclavage and atropine as an antidote.

We suggest that:

1. Legislation be enacted to ensure that the

47

" ." I,

nature of chemical present along with adequatetoxicological information (including toxic dose,clinical features of poisoning and management)is provided with all drugs and poisons.2. Regional poisons information centres shouldbe set up. They should be available for consul-tation round-the-clock on toll-free telephonelines to health professionals as well as the laypublic. Various antidotes should be stocked inthese centres from where they can be distributedto any hospital whenever the need arises.3. Regional laboratories equipped withfacilities for toxicological screening andanalysis should be made available to theemergency physician for rapid processing anddetection of poisons in various body fluids.

Only then will we be able to manage patientswith acute poisoning in a rational and effectiveway.

12 December 1994 Alladi MohanPraveen Aggarwal

Department of Emergency MedicineAll India Institute of Medical Sciences

New Delhi

REFERENCE

Park GO, Spector R, Goldberg MJ, Johnson GF.Expanded role of charcoal therapy in the poisonedand overdosed patient. Arch Intern Med 1986;146:969-73.

48

Emergency care ofVIPs: Need for a protocol

The All India Institute of Medical Sciences(AIIMS) being a premier medical institutioncarries the obligation to provide medical cover-age to VVIPs (Very very important persons) aswell as VIPs. The Institute has a protocol forthe management of WIP medical emergenciesbut none for VIPs. Moreover, I have been toldthat the VVIP management protocol shouldnot be invoked for VIPs. VIPs visit a hospitalmuch more frequently than VVIPs and Isuggest that to streamline functioning ourhospital should have a protocol for theiremergency care.

Here is a scenario that is commonly witnessedduring the visit of a VIP to the emergencyservice of AIIMS. The hospital authorities areinformed that a VIP is being brought from anearby state. A private room is kept ready, theemergency staff are told that the concernedconsultant should be called as soon as thepatient arrives. The VIP patient then arrivesalong with at least 20 attendants. Though thepatient is walking and does not require anyemergency treatment, his entourage stays withhim inside the limited space of the emergencyroom. This not only disrupts the routine casualtyactivity but hampers the care of other patients.

Notices

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 8, NO.1, 1995

The VIP is, according to me, anyone whohas, by virtue of his fame or the level of publicinterest in him, the capacity to substantiallydisrupt routine patient care. He may be aminister, senior bureaucrat, local politicianor even a businessman well known to theauthorities. Most problems arise not becauseof the VIP himself but because his entouragehas unreasonable expectations, makes im-possible demands and takes the efforts of thetreating doctors for granted.

VIPs are here to stay and their managementand that of other patients can be made muchmore efficient if we pay attention to a fewdetails.

1.1t must be made explicit to everybody work-ing in the casualty department exactly who isin charge.2.The clinican should follow standard clinicalprocedures in the evaluation and managementof the medical problem of the VIP. He or sheshould not allow himself to get entangled withadministrative issues or be swept away by theVIP's aura.3.While making clinical decisions it is probablysafest to give the benefit of doubt to the patient,i.e. pander a little to his whims but the physicianshould not ask for too many consultations justto protect himself. There is a well known

phenomenon of senior faculty members, whoare usually not seen around the casualty depart-ment, interfering with the work of the casultyteam so that the VIP registers their presence.4. The VIP's personal security guards shouldhave close and effective liason with the hospitalsecurity staff so that all those who are notneeded in the emergency department are keptout. This will minimize the circus-like atmos-phere that is quite often generated by powerfulclinical administrators, physicians and other

. personnel who get attracted towards theemergency room.5. Though hospitals have their own designatedspokesmen to brief the press about the medicalproblems of a VIP, the primary responsibilityof the casualty team is to safeguard the patient'sprivacy. The other patients or hospital staffhave no right to know the medical details ofthe VIP and they must not be divulged evenin a casual manner.6. It is against fundamental medical ethics tocare for one patient at the cost of others. Thephysician incharge should see that the human.and material resources are evenly distributed.

30 November 1994 L. R. MurmuDepartment of Emergency Medicine

All India Institute of Medical SciencesNew Delhi

1. X Annual Convention of the IndianVirological Society, Trivandrum,Kerala 16-18 January 1995Information:

J. ShanmugamDepartment of MicrobiologySree Chitra Tirunal Institute of

Medical Science and TechnologyTrivandrum 695011KeralaIndia

2. First International Conference onLifestyle and Health, New Delhi20-21 January 1995Information:

Bimal K. ChhajerDepartment of PhysiologyAll India Institute of Medical

SciencesAnsari NagarNew Delhi 1100291I1dia

3. Second International Conference onDietary Assessment Methods, Boston,Massachusetts, USA22-24 January 1995Information:

Conference on Dietary AssessmentMethods

Harvard School of Public Health677 Huntington Avenue LL-23Boston, MA 02115-6023USA

4. Third International Congress onBiological Response Modifiers,Cancun, Mexico 26-29 January 1995Information:

CME Inc.POBox 712Princeton JunctionNJ 08550USA

5. Forty-ninth Indian DentalConference, Ludhiana, Punjab27-31 January 1995Information:

Bahgwant SinghA-6 Gurudwara Shaheedan RoadModel TownLudhianaPunjabIndia

6. Fifth International Congress onAnti-Cancer Chemotherapy:Neoadjuvant, adjuvant, andexperimental, Paris, France31 January-3 February 1995Information:

David KhayatSOMPS-Hopital de la

pitie-salpetriere. 47 Boulevard del'Hopital75651 Paris Cedex 13France

7. Fifty-third All India OphthalmologicalSociety Conference, Bombay,Maharashtra 2-5 February 1995Information:

Kirit K. ModySalil Eye Clinic506 Om Chambers123 August Kranti MargKemps CornerBombay 400036Maharashtra

8. Molecular Biology of Cancer:Implications for Prevention andTherapy, Maui, Hawaii13-18 February 1995Information:

American Association for CancerResearch

Public Ledger Bldg620 Chestnut StSuite 816 PhiladelphiaPA 19106USA

9. XII International Conference onCalcium Regulating Hormones,Melbourne, Australia1~19 February 1995Information:

Secretary, XlIth ICCRHclo St Vincent's Institute of

Medical Research411 Victoria ParadeFitzroy Victoria 3065Australia