Diseases

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Rotavirus
Rotavirus is the most common cause of severe diarrhoea among infants and young
children and is one of several viruses that cause infections often called stomach flu,
despite having no relation to influenza. It is a genus of double-stranded RNA virus in
the family Reoviridae. By the age of five, nearly every child in the world has been
infected with rotavirus at least once. However, with each infection, immunity
develops, and subsequent infections are less severe; adults are rarely affected.
There are five species of this virus, referred to as A, B, C, D, and E. Rotavirus A, the
most common, causes more than 90% of infections in humans. The virus is
transmitted by the faecal-oral route. It infects and damages the cells that line the
small intestine and causes gastroenteritis. Although rotavirus was discovered in
1973and accounts for up to 50% of hospitalisations for severe diarrhoea in infants
and children, its importance is still not widely known within the public health
community, particularly in developing countries. In addition to its impact on human
health, rotavirus also infects animals, and is a pathogen of livestock.
Close to one lakh children below the age of five years died of diarrhea attributable
to rotavirus infection in 2008, accounting for 22 per cent of the total deaths reported globally. Efficacy trials were still on in India on the rota viral vaccines and till
these trials are over there is little data to prove the efficacy or otherwise of these
new vaccines. Secondly and critically, these patented vaccines are so far being
produced by a handful of private pharmaceutical companies and are hugely
expensive. Introducing these vaccines in the public health system will involve huge
resources.
Update: the Department of Biotechnology (DBT), Program for Appropriate
Technology in Health (PATH), Bharat Biotech (BBIL) and National Institute of Health
(NIH) have jointly developed Rotavirus Vaccine in India. ROTAVAC which is
developed under this endeavour will be produced on an affordable cost of $1 per
dose against the currently available vaccines developed by pharma MNCs which
cost $45 per dose. This this a true model of successful global partnership between
India and USA; involvement of international funding agencies like PATH; scientific
experts and appropriate industrial partner; and inter-ministerial involvement with
active participation of ICMR, M/o Health & Family welfare. The vaccine has already
shown very positive results in Phase III trial.
This will indeed be the first-ever truly Indian vaccine: an Indian strain, an Indian
manufacturer, clinical trial data in the Indian context and funding by the Indian
government. Two foreign vaccines have already been licensed for marketing in
India: Rotarix of GlaxoSmithKline and RotaTeq of Merck. They have already been
introduced in more than 40 countries.

Non-communicable diseases
Big killers
Non-communicable diseases such as diabetes and high blood pressure lead to
cardio-vascular diseases and cancer. There is a shift away from risks for
communicable diseases in children to-wards those for non-communicable diseases
in adults. The three leading risk factors for global disease burden in 2010 were high
blood pressure, tobacco smoking, including second-hand smoking, and alcohol
use. Outdoor air pollution in the form of fine particles is a much more significant
public health risk than previously known. Other NCDs are hypertension, chronic
respiratory diseases, cholesterol, abdominal obesity, and tobacco and
alcohol use.
The non-communicable diseases are the leading causes of preventable morbidity
and disability, and currently cause over 60 per cent of global deaths, 80 per cent of
which occur in developing countries. By 2030, the NCDs are estimated to contribute
to 75 per cent of global deaths.
Much of the burden of non-communicable diseases is linked to the consumption of
tobacco. While tobacco and alcohol are receiving close scrutiny as key factors
influencing disease burdens, including cancer, the role of ultra-processed packaged
food is not getting the attention it deserves. Alcohol, and ultra-processed food and
drink (which are energy dense but nutrient poor).

Mental Disorder as NCDs
India played a key role in getting mental disorders included in the noncommunicable diseases (NCDs) list at the first Ministerial Conference on Healthy
Lifestyles and Non-communicable Disease Control in Moscow last year. Pleading for
its case, India argued that “like all non-communicable diseases, mental disorders
required long term treatment and affected the quality of life.

Neglected Tropical Diseases
Rapid-growing economies such as India still had a high proportion of morbidity, with
more than 290 million Indians suffering from Neglected Tropical Diseases (NTDs).
These NTDs include visceral leishmaniasis, also known as “kala-azar”; lymphatic
filariasis which causes elephantiasis; leprosy; dengue fever; rabies; Buruli ulcer,
trachoma, rheumatic fever and soil transmitted helminth. There strong link between
NTDs and poverty
In 2010, three diseases received most of the global funding for R&D: HIV/AIDS,
tuberculosis and malaria. Despite being the leading child-killer in developing
countries, diarrhoeal diseases received less than 5 per cent of global R&D funding in
2010. Leprosy, Buruli ulcer, trachoma — an eye infection that can lead to
irreversible blindness — and rheumatic fever are among the neglected diseases of

poverty that occur in overcrowded, remote and poor areas. They received less than
$10 million each.
. Serum Institute of India was the first institution globally to create a meningococcal
A-vaccine. Similarly, the Hyderabad-based Shantha Bio-technics Ltd. had launched
an oral vaccine for preventing cholera. While mass drug-administration programmes
for lymphatic filariasis, worms and leprosy could help completely eliminate these
NTDs. A good example of international coordination in this regard was a partner-ship
between India, Bangladesh and Nepal in a drive to control leishmaniasis, which
occurred heavily in the border areas between these nations.

Resolution on mental health at World Health Assembly
India has achieved a major victory at the just concluded 65th World Health
Assembly as it managed to push through a resolution on mental health, asking
member-states to acknowledge the need for a comprehensive, coordinated
response to addressing mental disorders from health and social sectors at the
country level.
The World Health Assembly is the decision-making body of WHO. It is attended by
delegations from all WHO member-states and focuses on a specific health agenda
prepared by the Executive Board.
Mental disorders account for 13 per cent of the global burden of the diseases and, in
keeping with latest thinking, the resolution recognises the importance of early
identification, care and recovery, the problems of stigma, poverty and
homelessness and the need for community based intervention including deinstitutionalised care. It is clearly recognised that all countries must take steps to
promote mental health and empower persons with mental disorders to lead a full
and productive life in the community.
It calls for developing, as appropriate, surveillance frameworks that include risk
factors as well as social determinants of health to analyse and evaluate trends
regarding mental disorders; and to give appropriate priority and to streamline
mental health, including the promotion of mental health, the prevention of mental
disorders, and care, support and treatment in programmes addressing health and
development, and to allocate appropriate resources in this regard and to collaborate
with the WHO Secretariat in the development of a comprehensive mental health
action plan. It includes programmes to reduce stigma and discrimination,
reintegration of patients into workplace and society, support for care providers and
families, and investment in mental health from the health budget.

Pneumonia

















Pneumonia continues to be the number one killer of children around the world
—causing 18 per cent of all child mortality, an estimated 1.3 million child
deaths in 2011 alone, according to UNICEF figures. Nearly all pneumonia
deaths occur in developing countries. India leads the global mortality rate of
pneumonia deaths in children under-five years of age. In 2010, 3.96 lakh
children died of pneumonia in the country, of which 7 per cent die of flurelated pneumonia.
The Global Action Plan for Prevention and Control of Pneumonia
(GAPP) target was announced by the WHO and UNICEF in 2009 for
interventions in three areas: vaccination, breastfeeding and access to care
and antibiotic treatment. If 90 per cent of coverage is reached, these
interventions could prevent two-thirds of all childhood pneumonia deaths.
15 developing countries account for three-quarters of the world’s total
pneumonia deaths. According to the IVAC report, none of the 15 countries
have reached the 90 per cent GAPP target.
Only 46 per cent of children receive exclusive breastfeeding for the first six
months in India. Though 69 per cent children suspected with pneumonia are
taken to an appropriate health care provider, only 13 per cent receive
antibiotics.
Preventing pneumonia is essential to achieving Millennium Development
Goals of reducing under-five mortality goal.
One notable area of progress is on the coverage of two vaccines that can
help prevent pneumonia, the Hib vaccine and the measles vaccine.
While the Hib vaccine uptake has been slow in India’s public sector, the
momentum is now shifting. This has been possible following efforts to add
Hib to the Universal Immunisation Programme (UIP). Two States, Tamil
Nadu and Kerala have already introduced the Hib vaccine (in the form of
pentavalent vaccine) last year, and six more States will do it shortly.
As another positive signal, India has joined other WHO member states in
introducing a second dose of measles vaccines into the UIP to ensure
that its children are protected from the virus, which contributes to the burden
of pneumonia.
Measles was once one of the leading causes of death among children, but
global measles deaths have declined dramatically because of the widespread
coverage of two doses of measles vaccine. India began a phased introduction
of the second dose in 2010. By the end of the first year, the second dose of
measles vaccine had been added to routine immunisation in 21 states and
catch-up campaigns were completed in 197 districts in 14 states, according
to the report.
While India has made considerable stride in introducing the Hib vaccine, it
still has much to do to strengthen its comprehensive approach in fighting
pneumonia infection, including introduction of a pneumococcal conjugate
vaccine.

Cancer











An estimated 800,000 new cancer cases occur in India annually, imposing
huge costs on state and society in providing tertiary care for advanced
chronic cases. Mortality due to the scourge is projected to go up from
730,000 in 2004 to 1.5 million in 2030. There are about 27 lakh cancer
patients in the country. India has the world's highest number of oral cancers,
linked to the tobacco chewing habit.
Key policy goals — preventing new cases, offering low or no-cost treatment,
improving quality of life or palliation.
Arguably, the single biggest intervention that public policy can make is to
tighten curbs on the use of tobacco. In general, screening and early diagnosis
for cancer will benefit both men and women.
India cannot quickly scale up screening in a cost-effective manner, and must
therefore focus on early detection to enhance survival rates. The imperative
is to improve access to diagnosis within the country, and subsidise costly
medication. It is relevant to point out that effective prevention programmes,
detection and advances in treatment have reduced cancer death rates
significantly in America. India needs more ultrasound machines, endoscopes
and training for doctors in district hospitals, to drive down death rates.
The Centre should equip health sub-centres in all areas to screen and refer
patients to Primary Health Centres for detailed examination, laboratory
sampling, breast and cervical examination. District hospitals and higher
institutions in the public system should be equipped to offer surgery, therapy
and palliative care. Essential medicines be made available free to all patients,
and paid for through enhanced public procurement.
Punjab and Tripura have made cancer a notifiable disease.

NCRP








The NCRP was started in 1982 with three population-based cancer registries
and three hospital-based cancer registries which has now expanded to 27
population-based and nine hospital-based registries, and 17 collaborating
centres under Patterns of Care and Survival Studies in addition to scores of
other institutions connected with the Centre.
The National Cancer Registry Programme has developed a cancer atlas
forIndia as well as Punjab where the burden of cancer is very high,
particularly in the Malwa region. The incidence of cancer is also high in the
North Eastern states.
Over the years the network of NCRP has widened and it now receives primary
data on cancer from various sources. As of now, the estimates of cancer are
based on incidence rates of six older urban registries. But now with the
NCDIR in place and expected to be connected with all 154 medical colleges in
the country in the 12th Plan, more accurate data would be made available.
The main objective of Bangalore-based National Centre for Disease
Informatics and Research (NCDIR)is to develop a national research data-

base on NCDs through advances in electronic information technology with a
national collaborative network, so as to undertake aetiological,
epidemiological, clinical and control research in these areas. It also maintains
the National Cancer Registry Programme (NCRP).

Encephalitis






Acute Encephalitis Syndrome (AES) is caused by wide range of bacteria and
virus. Japanese encephalitis is the leading viral cause of in Asia. West Nile
Virus and St. Louis Encephalitis Virus are other causal agents.
viral encephalitis (caused by a water-borne enterovirus) and Japanese
encephalitis (caused by mosquito bite)- Both are classified as acute
encephalitis syndrome, or AES
The JE virus is transmitted by the Culex mosquitoes. Water birds and pigs
play a major role as amplifying hosts. Humans get infected following a bite by
an infected mosquito. However, as human are dead end hosts (unlike
malaria), further spread from human to human does not take place

The enteroviruses are second only to the "common cold" viruses, the rhinoviruses,
as the most common viral infectious agents in humans. Enteroviruses can be found
in the respiratory secretions (e.g., saliva, sputum, or nasal mucus) and stool of an
infected person. Other persons may become infected by direct contact with
secretions from an infected person or by contact with contaminated surfaces or
objects, such as a drinking glass or telephone. Parents, teachers, and child care
center workers may also become infected by contamination of the hands with stool
from an infected infant or toddler during diaper changes. It enters the body through
the gastrointestinal tract and thrives there, often moving on to attack the nervous
system. The polioviruses are enteroviruses. In addition to the three different
polioviruses, there are 61 non-polio enteroviruses that can cause disease in
humans.








The JE disease affects mostly children below the age of 15 years, of which 25
per cent die, and among the survivors about 30-40 per cent suffer from
physical and mental impairment. Between 70 and 75 per cent of the cases
are from Uttar Pradesh.
The disease burden is high in 171 districts, spread across 19 States-Tarai
region of Poorvanchal, esp. Gorakhpur district as its nucleus,
The disease is also endemic in areas where paddy is cultivated, as this crop
needs large amounts of water. Flooding of low-lying areas following
unseasonal rains and cyclonic storms also leads to mosquitogenic conditions.
The epidemic is amplified by the presence of large numbers of pigs, which act
as hosts.
One can expect JE-type epidemics year after year in States where prolonged
drought-like conditions are followed by heavy monsoons. In scrub forests



conducive to the nesting and breeding of Ardeid birds, heavy rains result in
large water pools with algal growth. In peninsular India, one canfind such
waterbodies in large numbers; egrets and herons are seen nesting and
feeding in them. These waterbodies simulate the conditions existing in paddy
fields. They are ideal for the breeding of the JE vector. The mosquitoes, the
avian hosts and the human victims in the adjacent villages with their cattle,
poultry and pigs provide the deadly setting for an outbreak of JE.
Experts estimate that up to 30,000 people may have been left disabled by
the diseases since they were first detected in 1978

Issues















4G (gaon, gareebi, gandagi, garmi)
Lack of rehabilitation and therapy facilities (necessary as it leads to disability)
Ill equipped hospitals and untrained staffs (Gorakhpur, where more than one
child is assigned to the same hospital bed during an epidemic, also needs
rapid expansion of its infrastructure),
Severe shortage of bag valve masks (commonly called Ambu bags)
Japanese Encephalitis represents only about 15 per cent of the fatal cases,
and it would take more research to isolate the other viruses
The disease is less lethal —but involves a longer recovery time, which means
greater pressure on hospital infrastructure and staff. In JE cases, the patient
dies within a week or is permanently disabled. The symptoms are high fever
and stiffness of the joints. In enteroviral cases, it takes a longer time for the
progression of the disease but the side effects are equally debilitating and
devastating; there can even be an organ failure or an unpredictable heart
failure.
JE vaccine has been available since 1941, but because of small production
capacity and its relatively high cost, the vaccine has remained out of reach
for most countries.
Malnourishment increases vulnerability
Water levels in Terai region are high. Contamination (due to open
defecation) of this source is very easy- causes enterovirus induced AES.
Therefore, it is generally advised that for drinking water, handpumps or wells
need to be dug atnot less than 80 feet so as to prevent contamination from
the upper reaches. But most villages have very few government-installed
handpumps for drinking water.
Disease of poor, unlike jet-age disease like H1N1 which attracts a lot of
attention



Solution
Prevention through vector control, behavior modification etc is likely to be the more
effective approach to curb the spread of encephalitis in India.











conduct a systematic survey to estimate disability burden
Improve personal hygiene
proper sanitation facilities
access to clean drinking water
State-wide massive prevention campaign that should consist of three parts:
distributing insecticide-treated bed nets, free or subsidised, to protect against
mosquito bites; creating awareness on the need to keep pigs away from
habitations; and persuading people to avoid outdoor movement when the
mosquito is most active. Relocating pigs is a sensitive issue in the
encephalitis-hit districts, and calls for measures that inspire confidence in the
community. Andhra Pradesh has carried out such a programme successfully
and may offer important lessons.
establish rehabilitation units at district level, set up special schools for
mentally challenged children in JE/AES-affected areas
Fix monthly compensation for below poverty line families having children with
disabilities due to JE/AES
Drinking boiled water, eating lot of jiggery to maintain glucose level,
preventing children from walking bare-chested

National Programme for Prevention and Control of Japanese
Encephalitis (JE) and Acute Encephalitis Syndrome (AES)











in the 60 worst-affected districts in U.P., Bihar, Assam and Tamil Nadu.
monitored and supervised by an inter-departmental committee chaired by the
Union Health Secretary
The cost-sharing for the implementation of the programme between the
Centre and States will be on a 90:10 basis.
The Rs. 3,355-crore programme, to be rolled out in phases, will be jointly
implemented/financed by the Ministries of Health and Family Welfare,
Drinking Water and Sanitation, Social Justice and Empowerment, and Women
and Child Development.
two main components – vaccine delivery and health intervention and water
supply and sanitation
will deal with strengthening and expansion of JE vaccination in affected
districts, strengthening surveillance, vector control, timely referral of serious
cases and increasing access to safe drinking water and proper sanitation
facilities to the target population in affected rural and urban areas.
In the first phase, the programme will be implemented in 60 districts in Uttar
Pradesh, Assam, Bihar, Tamil Nadu and West Bengal.
establish a physical medicine and rehabilitation department at 10 identified
medical colleges in the five priority States. The departments will be equipped
to provide specialised care to persons with locomotor and neurological
disorders with the objective of reducing disability and handicap.







Draw up a tailor-made curriculum for children with special needs and also set
up special schools and training centres in 60 districts based on the needs of
affected children.
special measures to train and sensitise anganwadi workers and their
supervisors regarding JE/AES,
additional take-home rations to moderately undernourished children enrolled
under the Integrated Child Development Schemes in these districts.
install deep bore hand pumps, mini water supply schemes in habitations
where JE/AES cases are reported, ensure solid and liquid waste management
and provide water-quality testing of all public sources in all the affected 60
districts along with sample testing for virological examination.

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