The lack of restrictions on access to antibiotics and their irrational use, non-standardized microbiology laboratories, use of antibiotics in animal husbandry and fisheries, and lack of sanitation are leading to widespread antibiotic resistance in India, and there is a danger of the country slipping back into the pre-antibiotic era. The situation can become alarming considering that the crude infectious disease-related mortality rate in India is 416.75 per 100,000 persons, which is about twice the prevalent rate in United States (World Bank data). There is also a 15-times greater burden of infectious diseases per person in India than in the UK.
This was said by experts in antimicrobial resistance (AMR) from India and abroad who are in Kochi to participate in the two-day ‘International Conference on Antibiotic Stewardship and Infectious Diseases,’ to be held at Amrita Institute of Medical Sciences on October 27-28, 2018. They highlighted the importance of ‘Antibiotic Stewardship,’ which means a combination of practices to rationalize antibiotic use through the right dose, right drug, right duration, right frequency, right patient and right indication. Rationalizing the use of antibiotics is essential to reduce the burden of infectious diseases, the experts said at the event, which saw the participation of ten prominent international speakers from the UK, the US and South Africa.
Said Dr. Sanjeev K Singh, Medical Superintendent, Amrita Institute of Medical Sciences, Kochi: "Over-consumption of antibiotics is rampant in India. A recent study in Kerala has found that 89% of all doctors prescribe antibiotics on daily basis. Hence, when a patient suffers from, say, symptoms of upper-respiratory infection, diarrhoea or vomiting – which usually indicate a disease that is viral in nature and therefore should not be treated with antibiotics – the patient gets prescribed a course of antibiotics. It therefore comes as no surprise that India consumes the highest volume of antibiotics in the world.”
He added: “Internationally, the spread of antibiotic resistance is high too but the access to antibiotic drugs is controlled and a third party monitors their use and consumption, leading to rational practices. An Antimicrobial Stewardship Program along with good Antibiotic Prescription Practices (GAP) is an effective strategy for optimization and rationalizing the use of antimicrobials. All healthcare professionals in India need to be educated on rational antibiotic prescribing. This, along with effective patient education to not take antibiotics unnecessarily, can help optimize the use of antimicrobials in Indian hospitals. Such optimization is urgently needed considering that as many as 90% of the estimated antibiotic resistant deaths in the world come from low and middle income countries. However, the challenge is that, presently, there is a lack of data regarding infection control practices in Indian hospitals and their hygiene and sanitation is poor. There is also an absence of standardization around these aspects in hospitals across the country.”
Added Dr. Arjun Srinivasan, Associate Director, Healthcare Associated Infection Prevention Programs, Centers for Disease Control and Prevention, US Dept. of Health: “Antibiotic resistance poses an urgent threat to health of the world. The loss of effective antibiotic therapy threatens to make once-treatable infections deadly again and jeopardize the delivery of modern medicine. One of the best ways we can preserve the power of life-saving antibiotics is to improve the way we use them, a concept known as ‘antibiotic stewardship.’ Its goal is to ensure that everyone gets the right antibiotic when they need one. Improving access to effective antibiotics as well as the way we use them will require partnerships between the public and private sectors, as well as engagement from patients.”
Said Dr. Alison Holmes, Director of the NIHR Health Protection Research Unit at Imperial College, London, and Public Health England: “Individually and collectively, we all have responsibility in preserving the effectiveness of antibiotics, which means we must use them wisely and that we must also reduce the need for antibiotics by maximizing action to prevent infections from occurring.”
Talking about the challenges of early and accurate diagnostics of infectious diseases, Dr. Sanjeev Singh said: “The results of traditional bacterial cultures and antimicrobial susceptibility testing, which may take up to several days to obtain, remain one of the major barriers to providing optimal therapy. Currently available lab parameters like the white cell count and C Reactive Protein are non-specific. These surrogate markers may not lead to definitive treatment, but rather an empirical treatment. Advancements such as rapid diagnostics, the syndromic approach which uses multiplex Polymerase Chain Reaction (PCR) to rule out infections, better diagnostics for virology, and the use of better markers like procalcitonin can help in the early detection of infections.”
He added: “Despite the rising antibiotic resistance, I do not believe that the world will enter the post-antibiotic era due to improvements in technology and the use of rapid diagnostics. If indeed, such a state is reached, then measures like good hygiene practices, safe disposal of waste, vaccination for vaccine preventable diseases and good infection control practice can aid in treatment.”
The Amrita Institute of Medical Sciences instituted an Antibiotic Stewardship Program four years back, which has led to significant reduction in the use of high-end antibiotics. “We have achieved reduction of Colistin prescription by 74 %, Linezolid by 86%, and Dorpenum and Ertapenum by 34 and 38%, respectively. Mortality has been reduced by 24% and cost-benefit because of implementation of our Antibiotic Stewardship Program is Rs 2.3 crore in a year. In addition, the Healthcare Associated Infections have dropped significantly for ventilator Associated Pneumonia (64%), Blood Stream Infections (34%), Urinary Tract Infections (23%) and Surgical Site Infections (32%),” said Dr. Sanjeev Singh.
Amrita Institute of Medical Sciences is also playing a key role in the implementation of Kerala Antimicrobial Resistance Containment Plan along with the Indian Medical Association. It has till now trained 122 trainers and is going to run capacity building in all 14 districts of Kerala over the next six months.
One out of every five students in Kerala in the age group of 12-19 suffers from psychological distress, with its severity ranging from mild in 10.5% of students to moderate (5.4%) and severe (5%). Studies across the state have also revealed the prevalence of physical abuse (75%), emotional abuse (85%) and sexual abuse (21%) among school-going adolescents, which are prime factors in triggering mental illnesses. This was said by Dr. Dinesan N, Professor, Department of Psychiatry, Amrita Institute of Medical Sciences, Kochi, at a workshop on mental health problems among young people.
According to WHO, 10-20% of all adolescents worldwide (youngsters between 10 to 19 years) experience mental disorders. Half of all these mental illnesses begin by the age of 14 years, and three-quarters by the age of 20 years. Suicide is the leading cause of death among 15-20-year-old youth. The burden of depression has increased by 67% between 1990 – 2013; by 2025, it is projected to rise by another 22.5%.
Dr. Dinesan N said: “Most of the time, youngsters are not able to cope with stress and use a variety of coping mechanisms like substance abuse. In Kerala, the prevalence of alcohol among adolescents is found to be 15% (23% in boys and 6.5% in girls), with prevalence increasing with age. The prevalence of tobacco use is 6.9%, and the mean age of onset of use is 14 years. Bullying, depression, substance abuse, and suicide are major challenges facing today’s youth.”
He added: “Adolescent depression is on the rise, but most of the time, it goes undetected with symptoms like irritability, anxiety and poor performance in studies. Traumatic events in early childhood, frequent migration, negative life events, educational setbacks, early relationship problems and stress at school and family are all linked to depression among children and adolescents. Early identification and treatment are the key to improving the mental health and quality of life of such patients.”
Talking about suicides among youth, Dr. Dinesan N said:“Suicide is the second leading cause of death among youngsters in the age group of 15-29 years. About 78% of global suicides occur in low and middle income countries. Ingestion of pesticides and hanging are the most common methods to commit suicide among young people. The link between suicide and mental disorders is well established, but in adolescents, suicide mostly occurs on an impulse.”
Dr. Dinesan N also highlighted the menace of substance abuse among today’s youth, which is on the rise, with 40-70%of adolescents in India exposed to some form of substance abuse before the age of 18 years.“Addiction to drugs at an early age leads to many high-risk behaviors like gambling, stealing, fighting and other antisocial activities. Parents, teachers and friends of children facing substance abuse need to help enhance positive self-esteem among them and be supportive. It has also been found that the increased need for gadgets and technology in adolescents has given rise to impulsivity and reduced ability to concentrate. Children unable to delay gratification is predictive of low performance in later life.”
Talking about the importance of inculcating a spirit of resilience in today’s adolescents to overcome mental illnesses, Dr. Dinesan N said: “Resilience is the ability to successfully cope with the various challenges and opportunities in life. It does not mean that individuals do not suffer emotionally when faced with a life circumstance; it means they are able to apply competencies which they have learned to deal with challenging circumstances. By doing that, they are developing new skills which they will be able to apply in future situations. Having supportive relationships and an ability to manage emotions and ask for help contribute to resilience.”
A Donor-Recipient Meet involving families of organ-donors and recipients of the organ donation and their families was conducted at the Amrita Institute of Medical Sciences. The Hon. Health Minister of Kerala, Smt. K K Shailaja , presided over the function. Administration teams from local bodies who helped with the organ donations were also present.
Fr. Davis Chiramel , President, Kidney Foundation of India, Fr. Reju Kannampuzha, Asst. Director, Little Flower Hospital, Dr. Prem Nair , Medical Director, Amrita Institute of Medical Sciences and Dr. Subramania Iyer K., Head, Dept. of Head and Neck Surgery, Amrita Institute of Medical Sciences spoke at the event.
Speaking on the occasion, Hon. Health Minister Smt. K K Shailaja said: “Caring and interdependence among members of the society as well as proper communication and awareness are the basic factors that can encourage organ donation in Kerala. We have seen an increase in the number of complaints regarding organ donation recently. In the past 1-2 years, our statistics have shown a decline in organ donation numbers. Though the numbers for organ donation for live donors through informed consent have grown, there has been a marked decline in organ donation from brain-dead donors. To counter this, the process of regulating organ donations from brain dead donors has to be made speedy.”
Dr. Prem Nair, Medical Director, Amrita Institute of Medical Sciences, added: “The aim of this donor-recipient meet was to send out a positive message to the society that concerted efforts from everyone can encourage organ donation and help save several lives through this noble deed. This message is especially important since the organ donation drive in Kerala is at its lowest ebb in recent years.”
Said Dr. Subramania Iyer K, Head, Dept. of Head and Neck Surgery, Amrita Institute of Medical Sciences: “This Meet was very much needed because the instances of organ donation after brain-death have been very low in Kerala for the past few years. The main reason is several unnecessary and unhealthy misconceptions raised and publicized through social media regarding brain death. To counter this, the government brought in more stringent criteria for declaration of brain death. But this has not helped to improve the situation, as the general willingness of all concerned to encourage and facilitate organ donation has not picked up.”
The 29-year-old Arunraj, a donor, hailed from Ambedkar Colony in Vengoorkara, Angamaly, Ernakulam. Son of Mr. Rajan and Ms. Seetha, he was working as contract employee at Cochin airport. He was socially involved in activities related to DYFI. Arunraj became brain-dead after being involved in a road accident, and was being taken care of at the Little Flower Hospital, Angamaly. He was identified as a potential organ donor and his family consented for the same. His heart was transplanted to a patient in Chennai, liver to a patient at Amrita Institute, pancreas and one kidney to another patient at Amrita institute, other kidney to a recipient at Kottayam Medical College and both hands to a 49-year-old lady at Amrita Institute. All these transplanted organs and patients are now doing well.
This organ donation which saved five lives becomes noteworthy in today’s context, since it was made possible by the efforts of numerous agencies. Foremost, was the willingness of the donor family which was catalyzed by the efforts of family friends and social activists. The role of the Little Flower Hospital was another helpful factor.
The local body administration, from the ward member to the municipal chairperson and Angamaly MLA and the Kerala Network for Organ Sharing (KNOS) were involved throughout. The stellar role played by the office of the Kerala Health Minister in mobilising the government doctors’ support for certification and transfer of the organs, as well as sustaining the motivation of the family to tide over the delay in the release of the body was noteworthy.
During the meeting the mother of the donor Arunraj, his father and his brother were felicitated by the Hon. Health Minister and the recipients. All persons and institutions who helped to make this organ donation were felicitated for their role. The role of the Hon. Health Minister and her office in streamlining the process was also highlighted.
The Amrita Basic Hand Surgery course was held on 4th and 5th August 2018 under the aegis of Indian Society for Surgery of the Hand at Amrita Hospital, Kochi. The meeting was organised by the Department of Orthopaedics and Plastic Surgery of Amrita Hospital and focussed on training orthopaedic and plastic surgeons from all over Kerala and adjacent states.
Faculty from outside and within the state delivered lectures and demonstrations during the one and half day programme. The delegates were taken through interactive lectures and surgical procedures. The meeting was led by Dr. Anil K. Bhat (Professor and Head of Department of Orthopaedics, KMC Manipal), Dr. Hari Venkatramani (Consultant, Department of Plastic, Hand and Reconstructive Micro Surgery, Ganga Hospital Coimbatore), Prof. Chandrababu K.K. (Professor and Head of Orthopaedics, Amrita Hospital), Prof. V. K. Bhaskaran (Professor, Orthopaedics, Amrita Hospital), Dr. Jim F. Vellara (Consultant, Orthopaedics, Amrita Hospital), Dr. Mohit Sharma (Professor, Plastic and Reconstructive Surgery, Amrita Hospital), Dr. Binoy P. S. (Hand and Reconstructive Microvascular Surgeon), Dr. Anto Francis (Plastc Surgeon), Dr. Druvan S. (Assistant Professor, Orthopaedics, Amrita Hospital), Dr. Balu C. Babu (Assistant Professor, Orthopaedics, Amrita Hospital), Dr. Janarthanan R. (Assistant Professor, Plastic and Reconstructive Surgery, Amrita Hospital), Dr. Sibi Gopinath (Professor, Neurology, Amrita Hospital), and Dr. Mathew George (Associate Professor, Anaesthesiology and Critical Care Medicine, Amrita Hospital).
In addition to the featured curriculum of topic presentations and hands-on video demonstrations, the CME also sponsored a worthy cause. In an effort to be environmentally mindful, all delegates received reusable jute bags and pens embedded with seeds. These special pens can be planted once they’ve run out, furthering the green initiative.
Though no precise data on the incidence of heart failure exists in Kerala, statistics from the Trivandrum Heart Failure Registry show that the state has a much younger demographic profile – at least 12 years younger – suffering from heart failure compared to Western nations like the US. Coronary artery diseases are the most common cause of heart failure, accounting for 71% of all cases. This was stated by doctors at the Amrita Institute of Medical Sciences in the run up to the Amrita Heart Failure Update 2018, a one-day meet of cardiologists from India and abroad on the management of heart failure.
Heart failure happens due to the inability of the heart to pump blood as per the requirement of the body. It has several symptoms such as breathlessness, swelling of the ankles and fatigue. Diseases of the heart muscles, heart valves or heart covering are prominent causes. India has among the highest heart failure rates in the world.
Said Dr. K. U. Natarajan, Professor, Dept. of Cardiology, Amrita Institute of Medical Sciences, Kochi: “The estimated incidence of heart failure in India is about 1% of the adult population, which translates to at least 8 to 10 million patients across the country. Old age is associated with higher incidence of heart failure. While the incidence in people above the age of 65 is 1 in 100 people, for those above the age of 75, it is 7 in 100 people. Diabetes is the most common risk factor for developing heart failure in Kerala, and its rapidly increasing incidence is causing a spike in the incidence of heart failure too.”
Talking about the risk factors, Dr. Vijayakumar M., Professor, Dept. of Cardiology, Amrita Institute of Medical Sciences, said: “A variety of health conditions can heighten the risk of heart failure including hypertension and kidney diseases as well as smoking. We are also seeing large number of diabetic patients with heart failure, which shows that diabetes is also a prominent risk factor for the people of Kerala. In addition, there are large number of young people with coronary artery diseases (blockages in arteries supplying blood to heart muscles) who go on to develop heart failure. The most important thing in preventing heart failure is to identify the risk factors and try to halt the progression of these health conditions.”
Added Dr. Rajiv C., Professor, Dept. of Cardiology, Amrita Institute of Medical Sciences: “Female patients are more prone to death due to heart failure, and the mortality rate is about 9 percent for them during hospitalization. However, in a study, an additional 9.6 percent of female patients died during a 90-day follow-up period after hospitalization, making the cumulative mortality rate at 18.6 percent. At the end of one year after hospitalization for heart failure, the mortality rate for female patients was a whopping 31 percent. Compared to developed countries, the duration of hospitalization for heart failure patients is also longer in India.”
Talking about the latest treatment options for heart failure, Dr. Rajesh Thachathodiyl, Professor, Dept. of Cardiology, Amrita Institute of Medical Sciences, said that medical science has been progressing rapidly and heart failure can now be treated with many types of surgeries, including a heart transplant. He said: “Implantable devices like automated implantable cardioverter-defibrillator (AICD) which detects and corrects abnormal beating of the heart, and Cardiac Resynchronization Therapy (CRT) which helps coordinate the contraction of heart muscles, are used for patients of heart failure. Several artificial hearts are also in development across the world, such as by Carmat, a French company. SensiVest is another device which heart failure patients can wear over their clothes. It monitors fluid buildup in the lungs (a common problem among patients of heart failure) and gives doctors advance warning of the impending trouble. A soft robotic sleeve which fits around the heart and compresses it in sync with its natural rhythm is another innovation taking place.”
The doctors were unanimous that to reduce the incidence of heart failure, the government needs to intensify the campaign to detect and treat health conditions such as hypertension, diabetes and obesity and discourage people from smoking. They said that it should also provide proper infrastructure, manpower and financial support to treat acute heart attacks effectively to prevent damage to the heart muscle.