Psalm 121

Thank you for this Psalm ( A song of ascents) and the song by Brian.

Psalm 121 (NIV)

I lift up my eyes to the mountains-- where does my help come from?

My help comes from the LORD, the Maker of heaven and earth.

He will not let your foot slip-- he who watches over you will not slumber;

indeed, he who watches over Israel will neither slumber nor sleep.

The LORD watches over you-- the LORD is your shade at your right hand;

the sun will not harm you by day, nor the moon by night.

The LORD will keep you from all harm-- he will watch over your life;

the LORD will watch over your coming and going both now and forevermore.

Psalm 121 with Brian Doerksen

I lift my eyes up
unto the mountains.
Where does my help come from?
My help comes from You,
Maker of heaven
Creator of the earth.

Oh, how I need You, Lord
You are my only hope.
You're my only prayer.
So I will wait for You
to come and rescue me.
Come and give me life.

Waiting for the dawn

We have been walking in the dark for long. We have been patiently waiting for the light. When do we see the break of dawn? When do we get to see the light coming? It is nowhere to be seen and we can’t hold much longer. The hope of the bright rays has kept us thus far. How much longer do we have to wait? Let the dawn breaks and the light shines on us.

Killer Mosquitoes

I sometime wonder what role the mosquitoes have in the world. They seem to be more of a problem than useful. In fact I can’t think of any meaningful role they play except perhaps may be being food for some other insects. On the other hand the havoc they create is huge compared to their tiny size. It was for this the theme for 2014 World Health Day was “Small bite, big threat,” highlighting the importance of vector-borne diseases of which mosquito is the most important one. The mosquitoes are one of the deadliest animals in the world. They kill millions of people every year. In 2015 malaria alone caused 438000 deaths in the world. Some of the popular and notorious mosquitoes that cause diseases and death in man are: Anopheles (causes Malaria), Culex (causes Japanese Encephalitis, Filariasis), Aedes (causes Dengue, Chikungunya, Yellow fever, Filariasis, Zika) and Mansonia (causes Filariasis). 

Now, let us not jump to conclusion and blame the whole population of mosquitoes. Only female species are the ones responsible for transmission of diseases!! It is so because only female species bites human beings for drawing blood. A meal of blood is required by the female species for the developmental process of the eggs. The male species survives on nectars and fruits and they won’t bother us. Mosquitoes actually don’t bite with teeth like other animals or humans do, but with a special structure called as proboscis. They have four cutting edges with which they pierce the tough skin like an injecting needle. In the process of biting their saliva serves as the chemical that prevents the blood from clotting. It is their saliva that produces so much itching/swelling when they bite. This is how they also transmit deadly organisms like parasites, viruses in the blood stream of humans. 

You might also have observed that in the evening time a whole lot of mosquitoes hover over your head or over some animals like cow/buffalo. This is what is called as swarming. This swarming is basically for mating purpose. This swarm is produced by the male species where female species enters for mating.

Who says the sound that the mosquitoes produce is music? To me it is more of an annoying sound that produces immediate hand movement reflex for whatever known purposes. Have you ever wondered how the mosquitoes are able to produce that high pitch sound? Researches have concluded that mosquitoes can flap their wings 200-1000 times per second. It is predominantly the Culex mosquitoes that can flap their wings on an average of 600 times per second which produces that peculiar humming sound when it passes near your ear and get your immediate reaction. It is also said that the sound is so important for the mosquitoes to identify the other partner. The pitch is so unique and specific that if they miss that pitch they will not get their partner. So, sounding correct is important for them.

Mosquitoes can easily find you out even if you are hiding. This is because they have a strong attraction for the odour of carbon dioxide that is released when we breathe out. Perhaps they also have a visual and thermal sense to detect you wherever you are. Mosquitoes are also more attracted towards the people with blood group type O. The principle behind using the mosquito repellents containing ‘DEET’ is to dull the senses of the mosquito so that they don’t smell you and find you.

Oh mosquito so tiny creatures and yet so powerful. The fight against them is so challenging. The best way to protect ourselves from their deadly bite is by preventing them from biting us.

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.