The Learning Enemy - Ticking Time-Bomb within us...!

                    Have you ever imagined why defence and offence strategies of our security forces are so Top Secret!? It’s simple because we  don’t want our enemies to be prepared for what all we have in our stock!!! 

                   Same principle applies to the vast world of microbes (pathogenic - disease causing microbes to be specific). We would not like the Salmonellas (typhoid causing bacteria) Vibrios (cholera causing bacteria), E. colis (many gut and urinary tract infection causing bacteria) and many others to be prepared for the gamut of antimicrobial agents (mainly antibiotics) that we today have and which we use in patients suffering form these diseases.

                 Therefore, need of the hour for we as doctors is to use antibiotics (for that matter any antimicrobial agent!) judiciously and cautiously… It’s really distressing to see the use of higher/next generation antibiotics for simple infections that too without any evidence (e.g. Culture sensitivity reports etc). But we all health care providers are more or less aware of this monstrous problem…and frankly speaking bit scared too…at least I am.. Specially after the emergence of ‘SuperBug’ few years back…!

We medical professionals need to USE ANTIBIOTICS WISELY, NOT WIDELY!

                   So, with this article I basically intend to enlighten the 'non-medico’ segment of the society. Why today? Because, Indian Academy of Paediatrics has undertaken this MISSION AAA (Avoid Antimicrobial Abuse) and is celebrating the Rational Antibiotic Use Day (28 September 2014) and Antimicrobial Awareness Week (28 September 2014 - 05 October 2014).

               Most of the common illnesses like Common Cold, Flu, Diarrhoea are basically caused by viruses…and hence use of antibiotics are redundant. They will not help you get back to office any sooner…! And so, for you- as patients its of utmost importance that you get over this inherent urge to buy prescription medicine over the counter from the pharmacist. ALL ANTIBIOTICS ARE PRESCRIPTION MEDICINES meaning thereby, its illegal to buy them without a valid prescription… and its rightly been that way.  Text below will make you understand why its important.

                      In 1953, there were more than 7,50,00,000 cases of malaria per year! And it was a huge public health burden. Govt. of India launched NMEP (National Malaria Eradication Program) and there was free lance use of DDT to kill the mosquitoes. It did work, temporarily though, bringing malaria cases to all time low of  50,000 cases per year in 1962!! But in next 10 years the number of cases rose 12times…leading to catastrophic failure of program. This happened because of the natural selection! Use of DDT killed the susceptible mosquitoes but spared the once which were resistant to DDT and in next 10 years these multiplied and led to increase in cases of malaria. Had other strategies would not have been undertaken, malaria and death due to malaria would have risen back to same 1953 level. Life subsists and so does mosquitoes and malaria. And by the way, this led to change in approach by govt. which reflects in name of malaria programs over the years: started with NMEP---> National Malaria Control Program (NMCP)---> Intensified Malaria Control Program (IMCP)!!

                        There was a period when we, kind of, lost our track as we were so goal oriented.! In order to decrease the cases of malaria and malaria related death we started giving presumptive treatment of malaria to all cases of fever suspected to be due to malaria, specially in malaria endemic regions. And we used Chloroquine the most common drug for malaria. As expected, it did bring the cases down initially but soon number of cases started to rise due to development of Chloroquine resistant Plasmodium spp. (parasite that causes malaria) but fortunately, this time we were intelligent enough to see the trend early and literally stopped the presumptive treatment. Now we use anti-malarials only in proven cases of malaria (either by microscopy or by RDT- rapid diagnostic test Kit). 

                        Another example where inadequate treatment (mainly premature stoppage of medicines prescribed) leading development of such a dreadful disease is: Tuberculosis!! Once easily treatable under DOTS (directly observed treatment short-course) program, TB is now rapidly transforming into difficult to treat MDR (multi drug resistant) TB, even more difficult to treat XDR (eXtremely drug resistant) TB and now there is TDR TB on the horizon...! (totally drug resistant, though WHO avoids the use of acronym TDR as it gives hint of hopelessness!). This is all because we as patient don't stick to the prescribed regimens...the moment we start feeling well we tend to forget about medicines...and leave the treatment mid way!! And remember is a contagious disease. If one has MDR TB, one will spread MDR TB!!! 

                  Similarly, when we take antibiotics irrationally we put selection pressure over microbial population. Sensitive microbes die…resistant ones survives…and now whole resource is available for the resistant ones which flourish rampantly…and the worst part is Resistant bug replicate into Resistant BugS!! 

             Also, Its important to take antibiotics for prescribed duration and in prescribed dosages. Most of the time you start feeling better just after few doses of medicine. Its because majority (NOT all) of disease causing bacteria are killed by the first few doses of antibiotics (provided right antibiotic has been prescribed!!). But you need to take the complete dose of medicine so that the infection is completely eradicated. If you take meds for sub-optimal duration there is always risk of relapse of illness with greater severity. 

REMEMBER, If we SAVE Antibiotics TODAY, They will SAVE us TOMORROW!!”

                    Other important thing is, microbes are enormous in number. Just 1gram of your faeces may have somewhere around 100 million-1trillions of them!!! And even though rate of mutation (random change in genetic material of an organism leading to change in its characteristics) is very low, mere number of these little bugs make it a significant event for them. Its nature’s experimentation for betterment of the organism. 100 experiment may fail, 1000 may fail, may be million experiments fail…which is unfair for them…but they are in trillions..!! Someday some random iteration in genetic material may work… and nature’s experiment continues creating newer forms of bacteria…some of which are inherently resistant to our antibiotics…but as long as these are in the company of their own 'cousins and nephews’ we have no problem as they have to compete with trillions of bugs to grow and survive with limited resource! 

Problem occurs when we use antibiotics irrationally and sub-optimally! This creates favourable condition for resistant ones by wiping out the billions of competitive sensitive bacteria…now all the resource is available for these dangerous bugs and they multiply!!! 

The other worrisome fact is we have already made antibiotics which act on all known targets of bacterium…there are hardly any novel antibiotics in pipeline. Also, in past decade or so there were only a few antibiotics which were produced. On the other hand bugs have developed resistance to all known antibiotics…fortunately they all are not present in same single bug so far…but if we continue like this with antibiotic abuse that SUPER BUG is not very far from reality…!

            So, irrational-sub-optimal and rampant use of antibiotics must stop. Otherwise, there will be so many superbugs that we probably will not be able to contain them! Instead of self medicating seek the expert and get optimal treatment…

Stay active…stay healthy…Do well!!!

Dr. Virat Kuntalam

Medical Officer

New Delhi Municipal Council

Parliament Street, New Delhi 110001

The Exercising Habit...

         Early morning yesterday...by early morning I mean- around 7-7:30am and please, don’t take it any other way..7:30am is early morning! At least for me!!! :-) I was at Talkatora Garden. Although, I was there for the physical fitness test of security personnels that NDMC (New Delhi Municipal Council, which happens to be my employing body as well) is recruiting and before all the equipments could be set up I had some time to explore the beautiful garden…after all, I had not been an early bird of late…specially on a weekend…! ;-)

         The garden is really beautiful and soul comforting. The chirps of birds, and playful shouts of children, that routine-synchronised-animated but altogether necessary loud laughters which you can hear in any garden/park of Delhi by the group of people mainly in their 60s and beyond…the sound of water at water fountain….the footsteps of jogging individuals…the excerpts of political chat by mostly older people while taking their break after certain amount of physical activity…the panting of competitive youngsters who just dashed the extra 50 meters-or-so after their self-set distance for the day...

          I really had forgotten that there are still so many people who are not only awake but fully functional that too so early!!! And among all these hustle-bustle

of early morning...I saw another of group of individuals at the far east corner of the garden near the cricket ground…this is that side of garden which is adjacent to Mother Teresa Crescent Road…There were individuals of all age groups…The sight at first amazed me..and later pleased me as a doctor! 

          I saw three generations of a family: the Grandfather, the Father and the Son working out together..and no need to mention that this habit inculcates in the younger generation from older generation itself. If you are active, likelihood that your son will lead an active and healthy life is fairly high..and so it is for your grandson provided your son is active too…! 

           Having said this and due credit given to the individual/family…I would not be just if I don’t mention the efforts taken by the NDMC and its staffs to provide and maintain the equipments at public parks/gardens like this one which make exercising fun and not something which is tedious and brings wrinkles on forehead…! These are the equipments which NDMC recently purchased from Garden Gym.

           Its amazing how simple basic facility encourages people to be active and thereby healthy… Though, initially it may seem like futile investment but as a doctor I can say this small initiative will translate into a greater good for I know a healthier society is a productive society… Not only this initiative will reduce the burden on heath care delivery system but also increase the outcome from each and every involved individuals.

           I would be happier to see more sets of such equipment in different corners of Talkatora Garden and also in other parks/gardens of NDMC and Delhi as well…! :-)

Stay Active...Stay Healthy...!! 

Dr. Virat Kuntalam
Medical Officer,
Palika Kendra,
NDMC