Pediatrics In Rural North India

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Pediatric and Healthcare Systems in India by Dr. Sheetal Ajmani

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Pediatrics In Rural North India

  1. 1. Pediatrics and Healthcare Systems in India Sheetal Ajmani, MD
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. Child’s Hospital of Central India (Private)
  7. 7. Child’s Hospital of Central India (Private)
  8. 8. Sawangee Medical College Hospital (Semi-Private)
  9. 9. Sawangee Medical College Hospital (Semi-Private)
  10. 10. Sawangee Medical College Hospital (Semi-Private)
  11. 11. Sawangee Medical College Hospital (Semi-Private)
  12. 12. Resident’s Areas at Sawangee
  13. 13. Resident’s Areas at Sawangee
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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.
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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%
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. Dharamsala Expedition
  27. 27. Preventive Medicine  Malnutrition  PICA  Sun protection  Car seats  Seat belts  Helmets
  28. 28. Top 3 Pediatric Diagnoses
  29. 29. Pruritic rash affecting multiple family members
  30. 30. 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
  31. 31. Scabies  Diagnosis: History and physical exam; family members typically affected; can microscopically visualize mites from skin scraping, but not necessary for diagnosis
  32. 32. 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
  33. 33. Round lesions with associated alopecia
  34. 34. 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
  35. 35. 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
  36. 36. “I see worms when I go to the bathroom”
  37. 37. 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
  38. 38. Miscellaneous Cases
  39. 39. 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
  40. 40. Other Benefits of International Electives…
  41. 41. Resources  www.himalayanhealth.com  www.physiciansforpeace.org  www.uptodate.com  www.searo.who.int/LinkFiles/ WHD_05_- _Fact_File_India_Fact_File_in dia.pdf

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