My experience as a Surveillance Medical Officer

On 2^nd March 2015 I joined World Health Organisation (WHO)/ National Polio Surveillance Project (NPSP) as a Surveillance Medical Officer (SMO). I was posted in one of the western district of Uttar Pradesh, the region which was considered the Polio belt of India. I had my initial induction training by the sub-regional team leader and later on received formal induction training conducted for a whole batch of the newly recruited SMOs. I had my high and low moments working as SMO, but overall the experience was immense and incomparable. One day you are in the village with dogs and buffaloes behind and beside you, and the next day you are called to a five star hotel.  The different responses given when you knock doors during house to house visit was something unforgettable. It was also an opportunity and challenge to cater to those migratory population working and residing at brick kiln fields. It was the real field work that generated so much information for action. This was an opportunity that opened my eyes to so many areas of concern in public health and also taught me the art of communication to people from all spheres of life. Today, when I look back I am grateful to have served as SMO, even though it was only for a short period of one year and five months.

The last case of Polio in India was reported from Howrah, West Bengal on 13^th January, 2011. The WHO South-East Asia region, of which India is a member, was declared Polio free on 27^rd March, 2014.  So, when I joined as SMO it was more like to maintain the system that has already been well established and effectively helped to stop the disease transmission. My perception is that many people including health professionals do not understand the efforts that went into achieving Polio free status. The general comment that I use to hear was that Polio requires only two drop of vaccine to prevent it, so, what is the difficulty in achieving the status. Only after working as SMO and involving in all the planning, training, implementation and monitoring activities, do I realize that it was a huge task and well thought of action strategy that went into achieving the Polio free status. In fact, the global effort to eradicate Polio is considered the largest-ever internationally-coordinated public health effort in history. When we have achieved the free status, may we not forget the contributions done by so many especially the field workers/vaccinators who went house to house, door to door to give Polio vaccine to make sure that every child was safe from the disease.

It was in the year 1988 during the World Health Assembly that a resolution was taken that Polio should be eradicated by the year 2000. India was also a signatory to that commitment but the effort of implementation started only in 1995. It was estimated that annual numbers of cases were 200,000 to 400,000 at that time. Four main strategies that eventually proves successful:

1.  Routine Immunization campaigns: maintain a very high level of routine immunization with Oral Polio Vaccine (OPV). OPV was introduced in the routine immunization since 1979. The introduction of bivalent OPV in January 2010 drastically changed the Polio scenario in India.

2.  National Immunization Days (NID) also called as Pulse Polio Immunization campaigns: all children below 5 years of age get OPV throughout the country. Supplementary Immunization Activities (SIA) was carried out as NIDs when it happens all over the country on a particular fixed days and Sub-National Immunization Days (SNIDs) in particular regions. First Pulse Polio Immunization campaign was started in the year 1995.

3.High quality Acute Flaccid Paralysis (AFP) surveillance: NPSP was established in 1997 to carry out the surveillance activity which recruited SMOs to implement the activity. A high quality and sensitive surveillance system was needed to detect the transmission in the community. For this a very sensitive case definition is used for selection of cases. Acute flaccid paralysis is defined as “sudden onset of weakness and floppiness any part of the body in a child less than 15 years of age or paralysis in a person of any age in whom polio is suspected.” A large reporting network was established involving all possible places where the cases might report. 

4.  Mop-up campaigns: done when foci of polio transmission are left. 

On the recommendations of the World Health Assembly, the Global Polio Eradication Initiatives (GPEI) developed the endgame strategy plan for 2013-18. The plan had four objectives:

1. Virus detection and interruption

2. Routine Immunization strengthening and OPV withdrawal

3. Containment and certification 

4. Legacy planning

I consider it a privileged to have taken part in the implementation process of the plan. Inactivated Polio vaccine was introduced in RI in August 2015. Initially it was started as a single intramuscular (IM) dose given to those primed with OPV only later to be changed to two doses by intradermal (ID). This was followed by SWITCH activity. As a country we observed the ‘Switch Day’ on 25^th April 2016 when trivalent OPV was replaced by bivalent OPV. It is hoped that by 2020 OPV will be phased out.

Since August 2016 I have moved on from the programme, but the cause is still dear to my heart. The things that I learnt and the experiences that I had during my short phase will stay with me for a very long time in the call to public health. 

Malaria: prevent it

There were few diseases that we know by name since childhood days. One was them was Malaria. We know this because it was such a common thing happening around in the village. I vividly remember that during my childhood days my dad suffered multiple times from malaria. He even had what is called as cerebral malaria which can be life threatening. He would usually have feelings of coldness and shivering (chills and rigor) and later on have high fever followed by profuse sweating. This occurred almost in a regular pattern with few days gap. We had to hold him down in the blanket when he had that kind of episode. Timely interventions at the hospital saved him. When I was in 11^th standard or what we called it pre-university days, my mom also suffered from cerebral malaria. She lost her consciousness and was admitted at Naga Hospital Kohima. We took turns to take care of her. I remember sleeping on the floor one night. We could only pray and hope that the medicine works. Thankfully she recovered from malaria after few days and was back healthy. It was a dreaded disease and one that we know we need to protect ourselves from.

Later on I learnt more about Malaria in detail. The name itself is a misnomer because literally it means ‘bad air.’ The name was given during the period when Miasma theory was popular which suggest that disease was caused by bad air. Later on it was Charles Louis Alphonse Laveran who found out that Malaria was caused by a Parasite, came to be known as Plasmodium. It was classified into P.vivax, P.falciparum, P.ovale and P. Malariae. Plasmodium falciparum was the one responsible for the cerebral malaria.  It was Ronald Ross who proved that mosquitoes are the insects responsible for transmission of malaria (vector for malaria) from one person to another. He was the one to show the complete life cycle of malaria parasite in mosquitoes. Interestingly, all the mosquitoes were not carrying the malaria parasite but a particular type known as female Anopheles mosquitoes were responsible for this deadly disease. Only female species are responsible because they require biting a person to draw blood for the development of the eggs. In the process, they transmit the malaria parasite.

Malaria has claimed so many lives. In fact, the World Health Organisation (WHO) estimates that in 2015 alone there were 212 million cases of malaria and 429000 deaths in the world. Closer to the country’s scenario, as per the National Vector Borne Disease Control Programme report (NVBDCP) there were 1.1 million cases and 384 deaths reported in 2015 alone in India. However, studies and estimates have shown that the actual malaria number cases and deaths are much higher than the actual report since it is underreported. 

There are many species of Anopheles mosquito responsible for malaria transmission in India:

Species	Distribution and special feature
An. culicifacies	Main vector for malaria in India. It is widely distributed in India and occurs sporadically in north-east (NE) India but not reported in A&N islands and Lakshadweep.
An. fluviatilis	Found in the foothill areas of both peninsular and NE India.
An. minimus	Restricted to the NE states and is the primary vector of malaria in NE India.
An. philippinensis	Major vector of malaria in deltaic West Bengal, but also found in NE India
An. dirus	Restricted to the forest areas of the NE states
An. stephensi	Found throughout India but sporadic in NE states and is the primary vector for urban malaria.
An.annularis	Occurs all over India except A&N islands and Lakshadweep.
An. varuna	Distributed widely in the country from north east plains peninsular India and the Lakshadeep
An.sundaicus	Restricted only to the Andaman and Nicobar islands.

Source: Malaria vectors in India. Dte National Anti Malaria Programme, Government of India-2002.

With lots of forest and natural vegetation, many species of Anopheles mosquitoes find their habitat in the NE India. Another interesting thing is that the three predominant vectors in the NE (An. dirus,    An. philippinensis and An. fluviatilis) seems to collaborate together to maintain a continuous transmission throughout the year. So, residing in one of the NE states makes us quite vulnerable to the attacks of malaria especially when many are involved in agriculture.  

The only way forward is prevention. On the World Malaria Day, 25^th April 2017, WHO called for efforts to prevent malaria and saves lives with the theme “Malaria prevention works: let’s close the gap.” The proven and still recommended methods are using personal protective measures and insecticide treated bednets along with other vector control measures. Good news is 7 countries have been certified by WHO as having eliminated malaria: United Arab Emirates, Morocco, Turkmenistan, Armenia, Maldives, Sri Lanka and Kyrgyzstan. India would require a concentrated effort to move forward. A much researched and awaited vaccine for malaria, an injectable vaccine known as “RTS,S.” is to go on pilot programme from 2018 coordinated by WHO. So, perhaps there is hope for those living in the remote villages to fight against malaria.

The pursuit of excellence

Excellence is defined as the quality of being outstanding or extremely good. It is A+ in our grade. To excel is to abound or to make progress. We are created to excel in life. In fact J. Hampton Keathley III says that the pursuit of excellence is both a goal and a mark of spiritual maturity.

Excellence should be differentiated from perfection. While perfection strives towards an ideal or without fault and can be frustrating but pursuit of excellence is giving our best shot in whatever we do and is healthy. Perhaps this is best conveyed by Paul in his letter to Colossians 3:23: “Whatever you do, work at it with all your heart, as working for the Lord, not for men”

Excellence should also be differentiated from success. The Olympic is held to showcase the mark of excellence. This is rightly expressed in the Olympic creed: “The most important thing in the Olympic Games is not to win but to take part, just as the most important thing in life is not the triumph but the struggle. The essential thing is not to have conquered but to have fought well.” Brian Harbour differentiates success and excellence as: “Success means being the best. Excellence means being your best. Success, to many, means being better than everyone else. Excellence means being better tomorrow than you were yesterday. Success means exceeding the achievements of other people. Excellence means matching your practice with your potential.” So success is more of outdoing others but excellence is doing our best with what we have with the purpose to grow, improve or learn. To succeed you compete with others but to excel you compete with yourself.

The pursuit of excellence must be motivated by the right values, priorities, and motives lest it becomes a pursuit for our own glory and for the recognition of men. The competitiveness to succeed and outdo others is evident in all spheres of life, be it in sports, science, arts, culture or market. This has led to so many setbacks and heartaches. The issue of doping in sports is taken very seriously and must be so because it goes against the very ethos of a true sportsmanship which is to excel. Perhaps the pursuit excellence is to not seek your own welfare by outdoing others but to seek the welfare of others. Paul in his letter directs the Corinthians to seek the glory of God: “So whatever you eat or drink or whatever you do, do it all for the glory of God (1 Corinthians10:31).”

The pursuit of excellence is a way of doing ordinary, common and everyday things in life in a very extraordinary way as a devotion to the creator. When everyday work becomes worship to your creator miracles can happen. Perhaps this is the reason Cavendish Laboratory in Cambridge University has produced the highest number of Noble Laureates from a single facility. Since the founding of the Nobel Prizes by Alfred Nobel in 1895, 29 members of the Cavendish have won one of the illustrious prizes. The oak door of the new Cavendish Laboratory have this inscription from the Book of Psalms in the Bible: “The works of the Lord are great, sought out of all them that have pleasure therein.” Thus the pursuit of excellence is not just fruitful but can be fulfilling. After all Man's chief  end is to glorify God, and to enjoy him forever as Westminster Shorter Catechism states.

The pursuit of excellence requires prioritization. This means many things which are good and important will have to go away in order to make way for what is best. There are so many things that require our attention and our time. It is the ability to focus on the goal that will make us excel in life. Rob Bell tells of a story where he and his son were walking on a beach. His son was picking up sea shells lying on the beach as they walk along. Out of nowhere a big starfish washed up on the beach. His son looks up and wants to grab it. Rob tells his son to go and get it but his son says he can’t. Rob tells his son to just ran into the water and grab it, but his son replies again out of frustration that he can’t. Rob says, “Why not?” and his son says, “My hands are full of sea shells.” The pursuit of excellence requires us to let go of the good like sea shells in order to get hold of the starfish. 

           

A prayer for those who make an impact in my life

We do not meet in life by chance. Our paths cross each other for a divine purpose. Many pass us by and we forget them, but few make positive and lasting impact in our life. They influence us and inspire us. We make connection with them and form a bond that is lasting. For those who have influenced me and make impact in my life I thank them and thank the Almighty for allowing our paths to cross each other. And to such a friend who have stood by my side through thick and thin, ups and down I pray this prayer for you. May the LORD bless you and keep you. May His face shine upon you and give you peace. May He be gracious to you all the days of your life. Amen

Introduction to HIV Surveillance System

The earliest documented case of Human Immunodeficiency Virus (HIV) infection dates back to 1959. Clinically, Acquired Immunodeficiency Disease Syndrome (AIDS) was first observed in 1981 in the United States. HIV was identified as the cause of AIDS in 1983 by research groups led by Dr. Luc Montagnier at the Pasteur Institute, Paris and Dr. Anthony Gallo of the National Cancer Institute, Washington.

Globally 36.7 million people are living with HIV and 1.1 million people died of AIDS related illnesses in 2015. World Health Organisation (WHO) proposed the introduction of HIV Sentinel Surveillance (HSS) system to monitor the extent and trends of the HIV epidemic. To better understand the course of the epidemic and its relationship to changes in the behaviours that spread it, United Nations for AIDS and WHO proposed the use of second generation surveillance tools. This aims to integrate the biological as well as the behavioural information.

HIV was first detected in India in 1986. As per the 2015 India HIV estimation, 21 lakh people are living with HIV and 67 thousand deaths occurred due to AIDS related causes in 2015. HIV Surveillance was initiated in 1985 by Indian Council of Medical Research (ICMR). With the establishment of National AIDS Control Organisation (NACO) in 1992 HSS was initiated in 1993-94 which was then formalized as an annual activity from 1998. From 2008-09 onwards it is conducted once in two years. So far 14 rounds of HSS have been completed. The 15^th Round is in process and is expected to be completed in 2017.

India has one of the world’s largest and most robust HSS. HSS measures the prevalence of HIV in a specific risk group in a specific region at specific time point. It monitors the HIV epidemic patterns among the High Risk Groups (HRG), the Bridge Population and General Population. In 2013-2015, National Integrated Biological and Behavioural Surveillance (IBBS) was carried out among the HRG and Bridge population.

The HIV surveillance is ever changing with expansion to include new sites, collection of new information and additional biomarkers for study.

The King rides into Jerusalem on a Donkey

           What kind of a King would ride on a donkey into the capital city?

Perhaps you would have expected some kind of chariots (in the olden times) or may be limousine (in today's time). Nothing of that flashy and mighty creature but a humble and silent donkey was chosen as the vehicle for this grand entrance.

          There were instances where leaders or kings rode on donkeys in the Old Testament like Judges 5:10; 10:4; 12:14. Solomon, considered the wisest king, rode on a donkey on the day he was anointed as the new king (1 Kings 1:33,45). Significantly, it is to be noted that in the ancient middle Eastern world, kings rode majestic horses if they rode to war, but donkeys when they come in peace.

           It was a calculated move by Jesus when he chose to ride into Jerusalem during the Passover time. He fulfilled the 500 years old prophecy of Zechariah (Zech 9:9) when he did that. He was not riding into Jerusalem as the conquering king, but as an envoy of peace. After all he was to be Prince of peace as prophesied by Isaiah (Isaiah 9:6-7). He was immediately recognised as the 'Son of David.' People cried out to him to save them perhaps from the hands of the mighty Romans.

Jesus indeed was a King, of Davidic descendant, who chose to ride a donkey to send across a message that he was coming in peace and to bring peace and not to fight their war for deliverance. He himself has said 'Blessed are the peacemakers, for they shall be called sons of God.' He knew very well what it cost to be a peacemaker, a messenger of peace and a Prince of Peace.      

Depression:Let's talk

Today, 7th April, is World Health Day. World Health Organisation (WHO) has chosen 'Depression: Let's talk' as the theme for 2017. What an appropriately chosen theme for campaign.

        I want to ask few questions. How many of us are suffering from depression? How many of us have suffered depression? How many of us knew we were in depression when we had it? How many of us have found someone to talk to when we were depressed? Do we have someone to talk to? Perhaps we already know the answer. I simply want to highlight how often it is neglected. Technological advances has not helped much either.

        Today we have so many 'social networking avenues' but I wonder if we are driven away from each other more than making real connection. These so called social medias seems to portray only one side of the story ie the so-called best of our lives. 

Thank you WHO for recognizing the importance to talk about something that is so common and yet so neglected. In short, all i am saying is i long for a real, meaningful, personal, face to face and engaging conversation rather than meeting/chatting over some bright screen.