58

The last three chapters deal with the concept of medical audit,ISO 9002 certification and a case study on the same aspect. Thecoverage of these chapters is commendable with useful informa-tion and insight on how to develop and implement quality para-meters in any hospital setting.

Overall, the book is eloquently written and organized in asystematic manner. The printing in bold type is pleasing to the eye.The language is simple and lucid.

However, some illustrations and schematic diagrams couldhave been incorporated at strategic places. One of the shortcom-ings is the non-inclusion of chapters on various support serviceareas such as linen and laundry services, dietary services, etc. The

Correspondence

THE NATIONALMEDICAL JOURNAL OF INDIA VOL. 14, NO.1, 2001

chapter on waste management is an eyesore and needs to beentirely revamped.

This book will be of interest to all hospital administrators,directors of private hospitals, nursing homes, clinicians withadministrative responsibilities, entrepreneurs in the health carebusiness and, most importantly, students of hospital administra-tion. The price is a bit too stiff for individuals. A soft paper coveredition at a more affordable price would be definitely welcome.

SIDHARTHA SATPATHYDepartment of Hospital AdministrationAll India Institute of Medical Sciences

New Delhi

Myelodysplastic syndrome terminating in leukaemiain spouses

Though the simultaneous occurrence of cancer is reported in spouses, Isimultaneous leukaemia is rarely seen.v' The simultaneous occur-rence of acute leukaemia in marital partners was reported on twooccasions." and also, acute non-lymphocytic leukaemia and acuteaplastic anaemia.' Although adult leukaemia is not contagious, thepossibility of contact with an unknown similar leukaemogenic agenthas been considered.

Our report concerns a 50-year-old man employed in an iron orepelleting factory for more than 5 years, who complained of weaknessand mild jaundice of 2 months' duration. Marked pallor, mildjaundice and splenomegaly were seen on physical examination.Investigations revealed the following-haemoglobin 7.6 g/dl; WBCcount: 4200/cmm; 10% reticulocytes; platelet 40 OOO/cmm; indirectbilirubin fraction 1.6 mg/dl; and a negative Coombs' test. Theperipheral smear showed dimorphic anaemia, 8 erythroblasts/100WBCs, Pelger-Huet and hypo granular leucocytes, and 7% myelo-blasts. The marrow was hypercellular with a trilineage dysplasia andshowed 80 blasts per 1000 nucleated non-erythroid cells. As theAVER rod was seen in only one blast, a diagnosis of myelodysplasticsyndrome (MDS)-refractory anaemia with excess blasts in trans-formation-was made.

After 2 months of low-dose C-arabinoside (200 mg/m-), thepatient was placed on a maintenance regimen, to obtain an optimalgranulocyte response and haemoglobin count. This was supported byantibiotics and blood transfusions. Myeloblastic transformationoccurred eight months later with 90% blasts in the marrow, forwhich high dose C-arabinoside was initiated. He developed high-grade fever and multiple perianal abscesses, and died of bonemarrow failure. The immediate medical cause of death was cardiacarrest.

Six months after his death, his wife presented with complaints ofweakness and pallor. She had no history of consanguinity, and wasa housewife. The couple used to live away from the factory. Thesmear was pancytopenic and the marrow hypoplastic, with trilineagedysplasia and 6% myelomonoblasts. A diagnosis of MDS-refrac-tory anaemia with excess blasts-was made. She refused hospital

admission and took ayurvedic treatment. Two months later, shedeveloped severe oral ulceration and high-grade fever, and died.Investigations at the time of her death revealed the following-haemoglobin 2 g/dl; WBC 2200/cmm;3 platelets <5000/cmm; andmore than 90% myelomonoblasts in the blood and bone marrow. Theblasts were weakly myeloperoxidase-A and Sudan black B-positive.

Cancer in the relatives of children with myeloid leukaemia hasbeen documented," and the first-degree relatives of adults with MDShave a 15 times greater risk of developing MDS. Epidemiologicalstudies suggest the possibility of a transmissible agent playing anaetiological role in acute leukaemia. Schimpff et al,7.8reported closepersonal associations in 61 % to 75% of leukaemia or lymphomapatients in defined areas. Timonen and Ilvonen? found that 40% ofleukaemia patients were in close contact with the hospitalhaematological personnel prior to their illness, compared to 13% ofcontrols. List and Jacob'? concluded that multiple factors includinghost susceptibility, age and cumulative exposure to leukaemogensinfluence the risk for MDS. Rigolin et al." showed that occupationalexposure to myelotoxic agents results in an increased risk of MDS.Occupational activities entailing the frequent use of pesticides andorganic solvents may act in a cumulative manner, preferentiallytargeting some specific chromosome regions. As there is a similaritybetween the cytogenetic patterns of MDS in 'exposed' patients andof therapy-related MDS, it is reasonable to assume that similarmolecular events may underlie the transformation in myeloidneoplasias.

20 December 2000 V rmila N. KhadilkarJyothi R. Kini

Department of PathologyKasturba Medical College

MangaloreKamataka

REFERENCESNash FA. The occurrence of cancer in husbands and wives. Br J Cancer 1959;13:577-88.

2 Milham S Jr. Leukaemia in husbands and wives. Science 1965;148:98-100.3 Amos DA, Willman WE, Walter Bowie EJ, Linman JW. Acute leukaemia in a husband

and wife. Mayo Clin Proc 1967;42:468-72. .4 Ly B, Stavem P, Saltvedt E. Acute myelogenous leukaemia occurring at the same time

in husband and wife. Scand J HaematoI1978;21:376--8.

CORRESPONDENCE

5 Stewart FM, Hess CEo Acute nonlymphocytic leukaemia and acute aplastic anaemia.The simultaneous occurrence in marital partners. Arch IntemMed 1983;143:1156--8.

6 Hasle H, OlsenJH. Cancerin relatives of children with myelodysplastic syndrome, acuteand chronic myeloid leukaemia. Br J HaematoI1997;97: 127-31.

7 SchimpffSC, SchimpffCR, Brager D, WiemikPH. Leukaemia and lymphoma patientsinterlinked by prior social contact. Lancet 1975;1: 124-9.

8 SchimpffSC, Brager DM, SchimpffCR, Comstock GW, Wiemik, PH. Leukaemia andlymphoma patients linked by prior social contact: Evaluation using a case-controlapproach Ann Intern Med 1976;84:547-50.

9 Timonen Tf'.Hvonen M. Contact with hospital, drugs and chemicals as aetiologicalfactors in leukaemia. Lancet 1978;1:350-2.

10 ListAF, Jacobs A. Biology and pathogenesis of the myelodysplastic syndromes.SeminOncoI1992;19:14-24.

II Rigolin GM, Cuneo A, Roberti MG, Bardi A, Bigoni R, Piva N, et al. Exposure tomyelotoxic agents and myelodysplasia: Case-control study and correlation withclinicobiological findings. Br JHaematoI1998;103: 189-97.

Intensive pulse polio immunization workers andvaccine vial monitors

The vaccine vial monitor (VVM) is a heat-sensitive label that isplaced on a vaccine vial to register its cumulative heat exposure overa period of time.' The VVM has a heat-sensitive component thatregisters a gradual colour change with exposure to heat. Oral poliovaccines (OPV) used in the intensive pulse polio immunizationprogramme (IPPI) have a VVM. A knowledge, attitude and practices(KAP) survey was conducted to find out the health workers' inter-pretation of VVMs and to determine the benefits and consequencesof using VVMs.

This study was conducted as a part of the assessment of thequality of IPP!. As part of the orientation on IPPI, all post-coordina-tors were trained in reading, interpreting and using VVMs. Eightycentres were studied. In each selected centre a post-coordinator wasinterviewed in the third and fourth rounds of IPPI in 1999-2000.Forty-four rural centres in the Naraingarh block of Haryana and 36urban centres in Chandigarh were visited. These centres wereselected because our institution was coordinating the supervisionwork with the local health authorities. A pre-tested structuredinterview schedule was used and the interviews were conducted byresident doctors and nursing students trained in data collection bythe interview technique.

The respondents included 34 (42.5%) health workers, 25 (31.3%)anganwadi workers, 18 (22.5%) teachers and 3 (3.7%) doctors. Allthe 80 respondents were aware of VVMs. Sixty-nine (86.2%) hadprevious work experience in PPI and 77 (96%) in IPP!. This findingis contrary to the observations of a survey in 1998 wherein theawareness of the staff was only 67%.2 The respondents were askedabout the guidelines for interpreting the VVM.3 The results areshown in Table I.

An interesting observation was that the vaccine was beingadministered in the shade and the vials were placed in vaccinecarriers even between administration of doses.

The universal awareness regarding VVM is a positive develop-ment. However, more time needs to be devoted in training sessionson the interpretation of VVMs. Special emphasis should be laid onthe discard point. In the training sessions, special attention shouldbe paid to anganwadi workers and teachers for interpretation ofVVM. Hand-outs in the local language regarding VVM interpreta-tion could also solve this problem. The fact that the expiry date onthe vaccine needs to be considered and the need for the maintenanceof the cold chain should be emphasized during training. VVMs had

59

TABLE!. Responses of post-coordinators regarding interpretationof vaccine vial monitors

Question Correct respcnse (%)

Vaccine may be used if inner square is lighterthan outer ring *

Vaccine should not be used if inner square isdarker than outer ring*

Discard point (inner square matches colour of outer ring)Vaccine can be used if no colour change even if past

its expiry dateVaccine does not need to be kept in the cold box during the

outreach session if the inner square is lighter than the outerring

Colour of vaccine vial monitor changes in minutes after being kept 29 (36.3)at room temperature

Improved confidence because administering a potent vaccineKnew which vials should be used first

74 (92.5)

74 (92.5)

60 (75)52 (65)

69 (86.2)

71 (88.8)55 (68.8)

• 2 respondents not aware of the interpretation and 4 interpreted it incorrectly

definitely improved the confidence level of the workers and had alsoimproved the cold chain maintenance. When the goal of a healthprogramme is to eradicate disease, training of the provider in criticalareas should aim at covering everybody associated with theprogramme. Otherwise it might take longer to achieve the target.

22 December 2000 S. S. PrasadM. Duggal

A. K. AggarwalR. KumarDevidayal

Department of Community Medicine and PaediatricsPostgraduate Institute of Medical Education and Research

Chandigarh

REFERENCESAnonymous. Pulse polio immunisation in India: Revised operational guide forintensification in 1999-2000. New Delhi:Ministry of Health and Family Welfare,Govemmentoflndia, 1999:49.

2 Thakur JS, Swami HM, Bhatia SPS. Staff awareness of oral polio vaccine vial monitorin Chandigarh.lndian J Pediatr 2000;67:253-4.

3 Anonymous. Vaccine vial monitor and opened vial policy. Geneva:World HealthOrganization, 1996: 1-8.

Cervical cancer screening: Is it a priority amongnurses?

Cervi val cancer is the most common cancer among women in India!and in Chennai city.' Screening for this cancer using Pap smear is aneffective control strategy. Despite these facts, voluntary screeningrates among women in and around Chennai appear to be low.v' Arecent study by us showed that even in an educated, affluentcommunity in the city, only about 15% of women had ever beenscreened." This low percentage was probably due to socio-culturaland communication barriers rather than affordability. In order toexplore this issue of low screening rates, we conducted a survey ofscreening practices among nurses. We chose to study nurses becausewe anticipated high levels of awareness and uptake rates amongthem, and because they have traditionally played an important role

60

in advocating and implementing screening programmes.' Our surveywas designed to estimate the Pap smear coverage, and to describe theperceptions and practices of nurses with respect to screening.

This cross-sectional survey was done at the Sundaram MedicalFoundation hospital, a private, non-profit, 120-bed hospital in Chennai.An attempt was made to contact all nurses in the hospital, includingstaff nurses, head nurses, and auxiliary nurse midwives (ANMs).Data were collected by personal interviews using a pre-tested, stan-dardized questionnaire. Face-to-face interviews were carried out by ateam of doctors. Data were entered in Microsoft Excel and analysedusing Epi Info (version 6.04b) statistical software.

We interviewed a total of 116 nurses (response rate 95%). Theirmean age was 28 years and a majority (76%) of them were diplomaholders. About 9% of the nurses had a bachelor's degree in nursingand 14% were ANMs. The mean number of years in nursing servicewas 7. About half the group (54%) were ever-married, and a familyhistory of any cancer was reported by 22% of the participants.

When asked to rank the first and second most important cancersamong women in India, 63% of the nurses reported breast cancer tobe the first, most important cancer, and 57% of them reportedcervical cancer as the second. While the majority had heard of a Papsmear, when asked to state the reasons for not getting one done, themost commonly stated reasons (in decreasing frequency) were: theirdoctors did not advise them to get Pap smears done, they did notbelieve the test was necessary, they did not think cervical cancer wasof concern for them, and they were embarrassed to get the test done.Reasons such as affordability, lack of transportation, lack of timeand poor access were rarely given. When asked to opine about howoften Indian women should get Pap smears done, 41 % of the nursessaid that Indian women should not get Pap smears done routinely butonly if they had symptoms. Yet a large majority (83%) felt that theprognosis for cervical cancer was good if detected and treated early.However, this belief is not consistent with what they practice.

In this group of young nurses with limited nursing experience, thevery low uptake rate could partly reflect a low risk profile-younger age,and the fact that nearly half the group was unmarried. However, thegeneral attitude appeared to be one favouring intervention for symptomsrather than prevention through early detection by screening.

In general, awareness levels were poorer among ANMs ascompared to those who had had more training. This is an obviousarea for educational intervention. In addition, the hospital couldmotivate nurses to undergo screening by organizing special screen-ing days, and offering the test free or at a very low cost.

In conclusion, this limited data from one group of health profes-

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 14, No.1, 2001

sionals raises the concern that cervical cancer screening may notalways be perceived as a priority, even among those who ought to bepractising and propagating it. Despite having access to the screeningtest, most nurses chose not to get screened. It would be interestingto find out whether this is true among nurses in other hospitals andalso among women physicians in India. The perception of healthprofessionals is an important factor in the success (or failure) of anynational disease prevention effort. It is, therefore, important that theplanning for a population-based national cancer screening programme,if and when it is initiated, be based on a sound understanding of thecurrent situation as well as the anticipated barriers to the initiationand implementation of the programme. If larger-scale researchreveals similar patterns, extensive educational programmes to changethe behaviour and attitudes of the public would be needed, beforeany national programme is launched. This intervention shouldperhaps be aimed first at health professionals.

ACKNOWLEDGEMENTSWe are grateful to all the nurses who participated in the survey.

24 December 2000 Madhukar PaiNitika Pai

Sheena BilalM. Ashok

P. RadhikaDepartment of Community Medicine and Epidemiology

Dr Rangarajan Memorial HospitalSundaram Medical Foundation

Anna NagarChennai

Tamil Nadumadhukarpai@hotmail.com

REFERENCESMurthy NS, Juneja A, Sehgal A, Prabhakar AK, Luthra UK. Cancer projection by theturn of the century-Indian scene. Indian] Cancer 1990;27:74-82.

2 Shanta V, Gajalakshmi CK, Swaminathan R. Cancer incidence and mortality inChennai: Biennial Report, 1996-1997. Chennai:Population Based Cancer Registry.Cancer Institute (WIA), 2000: 1-6.

3 Madhavi S, Malarvizhi KN. Assessment of disease awareness and prevention ofcMIcercervix among rural Indian women. In: Abstract Book of the XV Asia Pacific CancerConference, Chennai. 1999:181.

4 Pai M, Shanker S, Visvanathan K. Low rates of cervical and breast cancer screening inan educated, affluent community in Madras City. In: Abstract book of the XV AsiaPacific Cancer Conference, Chennai. 1999: 125.Gajalakshmi CK, Krishnamurthi S, Ananth R, Shanta V. Cervical cancer screening inTamil Nadu, India: A feasibility study of training the village health nurse. CancerCauses Control 1996;7:520-4.