Pediatrics and Healthcare Systems in India

Sheetal Ajmani, MD

Objectives

To recognize the importance of global health initiatives in pediatrics

To understand the universality of infant and child health and safety issues

To recognize some of the important differences and similarities in healthcare systems in a developing country

To develop increased cultural competence – increasing numbers of international travel, adoptions, and medical tourism

Physicians for Peace

Founded by Dr. Charles Horton in 1989 Mission: To develop sustainable programs in the

developing world based on the belief that health care can best be improved by training health professionals in that country, who then can continue to heal hundreds to thousands of people there

Programs designed by communicating with physicians indigent to the area with regards to educational activities they feel will most benefit their community

Physicians for Peace

NALS/PALS/nursing education Nagpur, Maharashtra, India In collaboration with Dr. Satish

Deopujari, pediatrician and co-founder of Child’s Hospital of Central India

Our mission consisted of: Dr. Ed Karotkin,

Neonatologist Ms. Karen Horton, Neonatal

Nurse Educator Dr. Sheetal Ajmani, PGY-3

Physicians for Peace

Specific Programs Completed: Nursing education to 125

nurses in Nagpur, India and 60 nurses at Sawangee Medical College

NALS reviewed with 15 pediatric residents at Sawangee Medical College

PALS workshop with 40 practicing pediatricians in Nagpur

Neonatology topic-specific updates given to 20 practicing pediatricians in Nagpur, as well as to 15 pediatric residents at Sawangee Medical College

Child’s Hospital of Central India (Private)

Child’s Hospital of Central India (Private)

Sawangee Medical College Hospital (Semi-Private)

Sawangee Medical College Hospital (Semi-Private)

Sawangee Medical College Hospital (Semi-Private)

Sawangee Medical College Hospital (Semi-Private)

Resident’s Areas at Sawangee

Resident’s Areas at Sawangee

Healthcare System in India Subcenter: staffed by 1

female worker and 1 male worker and covers a population of 3000-5000

Primary Health Center: staffed by 1-2 physicians, and 2 or more ancillary healthcare workers and serves a population of 30,000 Each PHC oversees

6-8 SCs Each CHC serves 3-4

PHC’s

Healthcare System in India

Hospitals Government vs. Private (Nursing Homes)

No good public medical transportation system At private hospitals, families must be actively involved

in all decision-making, since they must be able to directly pay for care (including all lab tests, radiology, and treatment plans)

1 relative must stay at bedside at all times If a new medication is needed, the family is given the

prescription to be filled at the pharmacy and bring it back to be administered

No family members allowed in ICU’s

Healthcare System in India

Infection control in ICU’s (hats, gowns, shoe covers) No incubators in NICU; only radiant warmers (and

use plastic wrap if needed) No consistent temperature control on the warmers in

the NICU Role of nurses is minimal Blood bank PALS

No manometers on BVM Broselow tape Workshops – airway opening maneuvers

Antenatal Care in India

Family planning education is lacking Contraception: sterilization accounts for 75%

of all contraceptive use 60% of women child-bearing age never heard

of AIDS (2003) 30,000 HIV+ infants born/year (by conservative

estimates) In 2007, 159 cases of HIV were diagnosed in

children under 13yo in the U.S.

Antenatal Care in India

Since pregnancy is ‘natural,’ use of prenatal services is considered unnecessary by many

Government hospitals provide financial incentive to mothers to deliver in hospital, including transportation

65% of deliveries are at-home 2% of families sought medical care for mother

or child within the first 2 days 17% sought medical care within 2 months of

delivery

Child and Infant Mortality

India contributes to 25% of the 10 million deaths under 5 years of age in the world

Neonatal mortality rates (per 1000 live births) U.S. 4:1000 India 39:1000

Child and Infant Mortality:Distribution of Causes of Death <5yo (2000)

India U.S.

Neonatal 45.2 56.9 HIV/AIDS 0.7 0.1 Diarrhea 20.3 0.1 Measles 3.7 0 Malaria 0.9 0 Pneumonia 18.5 1.3 Injuries 2.2 10.3 Other 8.5 31.3

Child and Infant Mortality

Primary causes of neonatal mortality (2004) Sepsis 52% Asphyxia 20% Prematurity 15% Others 13%

Primary causes of infant mortality (1998) Diarrhea 20% ARI 25% Sepsis 26% Asphyxia 10% Prematurity 8% Others 11%

Healthcare System Comparison

Physician to 10,000 population ratios U.S. 26:10,000 India 6:10,000

In India, 74% of physicians live in urban areas, where only 28% of population resides

Himalayan Health Exchange Mission: To provide medical and

dental care to the underserved people living in remote regions of the Indian and Nepal Himalayas

NGO based out of Atlanta, GA Founded by Ravi Singh in 1996 Eight expeditions/year

comprised of physicians, dentists, nurses, pharmacists, and medical students

Dharamsala Expedition April 2008 37 Health professionals: 7

physicians, 29 medical students, 1 RN

Also, 1 local pharmacist, 1-2 local physicians/each clinic site, staff of cooks, drivers, and translators

Provided care at 7 rural villages, and 2 monasteries

About 2700 patients seen; ¼ of which were pediatric

My role: Providing medical care at the attending level in the Pediatric medical tent. Supervision of 5-7 medical students/day in the Pediatrics tent

Dharamsala Expedition Triage 3 adult medicine tents, 1 pediatrics tent, 1 ob/gyn tent Pharmacy (pediatrics)

Bactrim Cefaclor Amoxicillin/Augmentin Cefuroxime Clindamycin Griseofulvin Mebendazole Tylenol/Ibuprofen Multivitamins

Laboratory Hb, CBC BUN, Cr, LFT’s RF, CRP, ESR VDRL, ASO, HBsAg, rapid HIV, sputum for AFB, urine pregnancy,

UA

Dharamsala Expedition

Preventive Medicine

Malnutrition PICA

Sun protection Car seats Seat belts Helmets

Top 3 Pediatric Diagnoses

Pruritic rash affecting multiple family members

Scabies

Species: Mite Sarcoptes scabiei; females are fertilized at skin surface, then burrow into the epidermis, traveling 2mm each day while laying a total of 10-12 eggs, female dies in 1-2months

Epidemiology: crowded areas, in colder and more humid conditions (long survival on fomites)

Transmission: person to person; direct contact; very contagious Clinical features: itching due to type IV delayed hypersensitivity

reaction, worse at night and out of proportion to visible dermatologic manifestations; secondary staph infections common

Scabies

Diagnosis: History and

physical exam; family

members typically affected;

can microscopically

visualize mites from skin

scraping, but not necessary

for diagnosis

Scabies

Treatment:-First line: Permethrin 5% cream (safe in infants; cotton mittens to prevent toxicity); Oral Ivermectin-Alternative Topicals: Benzyl Benzoate, Lindane, Malathion, Sulfur in Petrolatum-Treat all household and close contacts-Treat secondary reactions: anti-pruritics; secondary staph infections

Round lesions with associated alopecia

Tinea capitis

Gray patch tinea capitis: Microsporum Canis (bright green flourescence under Wood’s lamp); erythematous patches with scale; may develop into kerion (boggy, tender nodules with exudate) and/or secondary staph infection

Black dot tinea capitis: seen more in the U.S.; Trichophyton tonsurans; erythematous patches with “black dots” from hairs breaking off in affected areas

Treatment: Griseofulvin is the primary treatment choice (20-25mg/kg/day for 6 weeks); Other treatment options include terbinafine, itraconazole, fluconazole

Tinea corporis

Circular patch with central clearing and raised, erythematous border

Treatment:

-Local – topicals including miconazole, ketoconazole, clotrimazole

-Systemic – for widespread infection; griseofulvin, terbinafine, itraconazole, fluconazole

“I see worms when I go to the bathroom”

Pinworms

Enterobius vermicularis Humans are the only host Most commonly affects school-age children Present with itchy butt, worse at night

Female pinworms crawl out of the anus to deposit eggs at night

Spread by contact/fomites Scotch tape test – eggs will be visualized on a single

specimen 50% of the time; 90% if have 3 samples Treatment

Albendazole as single dose; or, mebendazole once and again 2 weeks later

Miscellaneous Cases

Summary

Participation in international health electives is an invaluable experience: PFP: Develop academic and professional networks

with international community of healthcare professionals

HHE: Gain experience practicing medicine with limited resources, and gain insight to different perspectives and opportunities for healthcare

Welcome Shruti Deapujari to CHKD

Other Benefits of International Electives…

Resources

www.himalayanhealth.com www.physiciansforpeace.org www.uptodate.com www.searo.who.int/

LinkFiles/WHD_05_-_Fact_File_India_Fact_File_india.pdf