ISSN 2395 -2113 (Print)
Indian Journal of Community & Family Medicine Volume 4, Issue 2, Jul – Dec, 2018
www.aiimsbhubaneswar.edu.in/otherpublication/ijcfm Editorial Office
Department of Community and Family Medicine All India Institute of Medical Sciences, Bhubaneswar, Odisha-751019 Ministry of Health & Family Welfare Under The Aegis of Government of India
Submit your [email protected] for consideration of publication to:
Disclaimer
The information and opinions presented in the Journal reflects the views of authors and not of the Journal or its Editorial Board or the Publisher. Publication does not constitute endorsement by the journal. Neither the Indian Journal of Community & Family Medicine nor its publishers nor any one else involved in creating, producing or delivering the Indian Journal of Community & Family Medicine or material contained therein, assumes any liability or responsibility for the accuracy, completeness, or the usefulness of any information provided in the Indian Journal of Community & Family Medicine, nor shall they be liable for any direct, indirect, incidental, special, consequential or punitive damage arising out of the use of Indian Journal of Community & Family Medicine. Indian Journal of Community & Family Medicine, nor its printer and distributor, nor any other party involved in the preparation of material contained in the Indian Journal of Community & Family Medicine represents or warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such material. Readers are encouraged to confirm the information contained herein with the other sources. Design & Printed by: Siva Prasad Patra (Bindu Creative, 09438668784, 7008575985)
Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018 Indian Journal of Community & Family Medicine
Patron VolumeEditor- 4, Issue 2,In Jul-Dec, - Chief 2018 Editor
Gitanjali Batmanabane Vikas Bhatia Sonu H Subba
Editorial Team Editorial Advisers
Neeraj Agarwal Deputy Editor International Pankaja R Raghav Deputy Editor Hayato Uchida Japan Abhiruchi Galhotra Associate Editor Jaideep Sood New Zealand Binod Kumar Patro Associate Editor Derek Hellenberg South Africa Surya Bali Associate Editor Raj Bhopal UK Amit Arora UK Preetam B Mahajan Assistant Editor Satish K Gupta UNICEF Pankaj Bhardwaj Assistant Editor Richard Cash USA Swayam Pragyan Parida Assistant Editor Erich B Schneider USA Klea D. Bertakis USA Editorial Board Members Neena Raina WHO
National Surekha Kishore Uttarakhand Manisha Ruikar Chattisgarh A K Mahapatra New Delhi Arti Ahuja Odisha Sanjay K Rai Delhi Rajesh Kumar Chandigarh Arun M Kokane Madhya pradesh Rakesh Sehgal Chandigarh Amit Dias Goa B S Chavan Chandigarh Sitanshu S Kar Puducherry C S Pandav Delhi S K Rasania Delhi P R Mohapatra Odisha Sunil Gomber Delhi Swagata Tripathy Odisha Adarsh Kumar Delhi Subhashree Mahapatra France Praveen Vashist Delhi J L Meena Gujarat Parvathy Nair USA D V Bala Gujarat Shilpa Bhardwaj USA Sunil Kumar Gujarat Geeta Gathwala Haryana Managing Editors S R Mazta Himachal Pradesh S M Kadri Jammu & Kashmir Prahalad Kumar Karnataka Prajna Paramita Giri G Gururaj Karnataka Arvind Kumar Singh S Chhabbra Maharashtra Additional Managing Editors B S Garg Maharashtra Th. Achouba Singh Manipur Anil Phukan Meghalaya Binod Kumar Behera Gautam Roy Puducherry Manish Taywade Tejinder Singh Punjab Editorial Production Assistants A Muruganathan Tamil Nadu Sanjay Mehendale Tamil Nadu Kalpagam Polasa Telangana Prem Sagar Panda V K Srivastava Uttar Pradesh Durgesh Prasad Sahoo C M Pandey Uttar Pradesh I S Gambhir Uttar Pradesh C P Mishra Uttar Pradesh G K Pandey West Bengal
Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
I IJCFMIndex Medicus is fornow South East Indexed Asia Region (WHO) in
J-Gate
International Scientific Indexing
Scientific Indexing Services
CNKI
Indian Science Abstracts
Indian Citation Index
Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
II Editorial Developing the underdeveloped: Aspirational Districts Program from Public Health Point of View 2 CONTENT
Review Article AdaptingVikas Bhatia, the Rama Stepped Shankar Care Rath, Approach Arvind for Kumar Providing Singh Comprehensive Mental Health Services in Rural India:Tapping the Untapped Potential 5
Priyamadhaba Behera, Senthil Amudhan R, Rishab Gupta, Anindo Majumdar, Arun M, Kokane, CME MohanAcute Osteomyelitis Bairwa 11 Commentary RMicroplastics- B Kalia All We Know till Now and the Way Out 19 Original Article UtsavLevels Raj, and Puneet Determinants Kumar, Abhiruchi of Glycosylated Galhotra Hemoglobin (HbA1c) Status among Reproductive Age Women of Tripura, North East India 22
SubrataNeck Circumference Baidya, Rituparna as a DasMarker of Malnutrition among Children Attending the Under Five Clinic of a Tertiary Care Hospital in Nagpur, Maharashtra 27
ChaitanyaVaccine Hesitancy R Patil, Ketan and RAttitude Dagdiya, Towards Prithvi B Vaccination Petkar, Abhijit among Kherde Parents of Children Between 1-5 Years of Age Attending a Tertiary Care Hospital in Chennai, India 31
SahanaEpidemiology Sankara of Narayanan, Ovarian Tumours Aparna Jayaraman, in Northern Vijayaprasad India –A Tertiary Gopichandran Hospital based Study 37 SoniaShared Puri, Risk Veenal Factors Chadha, of Non-Communicable A K Pandey Diseases: A Community based Study among Adults in an Urban Resettlement Colony of Delhi 42
AnshuDepression Singh, and Anita its Shankar Correlates Acharya, among Balraj Geriatric Dhiman People: A Community Based Study from Southern Haryana, India 49
Perspective SurajConcept Chawla, of Primary Neeraj Gour,PawanEye Care & SchoolKumar Goel,Health Ravi in RohillaIndia Anjan Kumar Giri, Sunita Behera, Abhiruchi Galhotra 55 Role of Artificial Intelligence (AI) in Public Health
60 Short PremStudy Sagar of Morbidity Panda, Vikas Pattern Bhatia in Readymade Denim Factory Workers in Suburban Slum of Communication Maharashtra: A Cross-sectional Overview 63
Diagnostics In SunilSickle Kumar Cell Anemia: Panigrahi, An Parmeshwar Update on Diagnosis, Satpathy, Vineeta Management Singh, Sulabha and Prevention V. Akarte Strategies Clinical Setting 67 Case Report ShrutiFoot Gangrene Mishra, Gaurav Following Chhabra Dorsalis Pedis Artery Cannulation. Risk Versus Benefit Of Arterial Cannulation In Polytrauma Patient 72
Public Health RiteshPublic Panda,Health Chitta Updates Ranjan (July Mohanty -November 2018) Update 74 Dinesh P Sahu, Susmita Dora, Madhushree Acharya, Kavi Nila D R Pradnya Chandanshive, Student Corner AkshayaLepromatous R Leprosy with Erythematous Nodosum Leprosum: A Public Health Challenge 77
Dinesh Prasad Sahu, Prajna Paramita Giri, Debjyoti Mohapatra Binod Kumar Behera, Sonu H Subba Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
1 EDITORIAL
Developing the underdeveloped: Aspirational Districts
1 2 3 1ProgramEditor in Chief, IJCFM, from Dean, Professor Public and HOD, Health2Assistant Professor, Point Department of of ViewCommunity and Family Medicine, 3Public Health Specialist, Aspirational Districts Support Program,Vikas AIIMS, Bhatia Bhubaneswar, Rama Shankar Rath , Arvind Kumar Singh
Under National Health Mission (NHM) each district has Financial inclusion and Skill Development by 49 core become the planning programming and financial unit on indicators and 81 data points on a monthly basis. [Figure-1] which the health program of the district depends. So, it All these domains are linked to the Human Development depends up on the district leadership and functionaries Index of the districts. Health receives the highest priority how well the plan to improve the status of the district. Since along with education followed by Agriculture and water inception of NHM in 2005 although the districts worked1 as resources. In health the major components include the special entity but the focus was at the state level. Thus, the maternal and child health component with health the states with maximum poor performing districts were infrastructure and tuberculosis. A dash board named named as “Empowered Action Group” (EAG) although few “Champions of Change” is also prepared to monitor the districts in these states are more well performing than district progress round the clock is functional and districts3 the well performing districts of well performing states. also can monitor their progress in various domains. In 2018, Govt. of India planned to dig dipper in to the of Convergence causes and to do focused activity in these poor performing CollaborationAspirational District program under the basic principles districts so as to include them in to the main2 stream thus (StateCompetitive and National Government), Aspirational Districts Program was lunched. (between citizens and officials)Here the state and Creation of healthy environment2 between Each Aspirational district are being monitored in six the districts where all can move forward. basic domains including Health and Nutrition, Education, will act as the main drive for improving the district after AgricultureFigure-1: Key & Waterdomains Resources, of Aspirational Basic Infrastructure, Districts identifying the core strengths and weaknesses of the Program along with weightage provided to each district so that the district can become nations one of the domain best districts. So, the poor performing districts which are aspiring to become the best districts of the nation are called as the Aspirational Districts. Initially, the poorest performing 117 districts were included under this program based on their performance in various national surveys and other published district wise data for various programs. For health and nutrition indicators the surveys used was4 fourth round of National Family Health Survey (NFHS). A higher score indicates more backward district. Monitoring of progress of the districts are done by key core indicators. The source of all monitoring related data is the routine reporting from the districts in various programs. Thus, the quality of data collected and reported by districts in various programs should be of high quality.
Key indicators related to Health are listed in Table-1. Indicators mainly targeted towards monitoring the maternal, child health, tuberculosis component in order to decrease the basic indicators of national importance i.e. Maternal Mortality Rate (MMR), Infant Mortality Rate Address for Correspondence: Dr. Vikas Bhatia, Dean, Professor and HOD, Department of Community and Family Medicine, All India Institute of Medical Sciences, BBSR 751019, Odisha, Email:
Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
2 Table-1: Domains and indicators related to health in Aspirational Districts Program
Sl. No Sub-Domain Indicator Pre and Post Natal 1. 1. Percentage of pregnant women receiving 4 or more antenatal care check-ups to the total no. of pregnant women registered for antenatal care 2. Percentage of ANC registered within the first trimester against Total ANC Registration 3. Percentage of pregnant women (PWs) registered for ANCs to total estimated pregnan- cies 4. Percentage of pregnant women regularly taking Supplementary Nutrition under the ICDS programme 5. Percentage of Pregnant women having severe anaemia treated, against PW having se- vere anaemia tested cases 6. Percentage of pregnant women tested for Haemoglobin 4 or more times in respective ANCs to total ANC registration 7. Percentage of institutional deliveries to total estimated deliveries 8. Percentage of deliveries at home attended by an SBA (Skilled Birth Attendance) trained health worker to total home deliveries 9. Percentage of First Referral Units (FRU) with labour rooms and obstetrics OT NQAS Gender and certified (meet LaQShya guidelines) Social Equity 2. 1. Sex Ratio at Birth Infant Health
3. 1. Percentage of new borns breastfed within one hour of birth 2. Percentage of low birth weight babies (less than 2500g) 3. Percentage of live babies weighed at birth 4. Percentage of children fully immunized (9-11 months) (BCG+ DPT3 + OPV3 + Mea- Child Health 1. sles1) 2. 4. Percentage of underweight children under 6 years 3. Percentage of stunted children under 6 years 4. Percentage of Severe Acute Malnutrition (SAM) 5. Percentage of Moderate Acute Malnutrition (MAM) 6. Percentage of Breastfeeding children receiving adequate diet (6-23 months) 7. Non-breastfeeding children receiving adequate diet (6-23 months) 8. Percentage of children under 5 years with diarrhoea treated with ORS 9. Percentage of children under 5 years with diarrhoea treated with Zinc Percentage of children under 5 years with ARI taken to the health facility in last 2 Tuberculosis 1. weeks Tu 5. 2. Tuberculosis notification rate as against the estimated cases Health berculosis treatment success rate Infrastructure 6. 1. Proportion of Sub centres/ PHCs converted into Health & Wellness Centres (HWCs) 2. Proportion of Primary Health Centres compliant to Indian Public Health Standards 3. Proportion of functional FRUs (First referral units) against the norm of 1 per 5,00,000 population (1 per 3,00,000 for hilly terrain) 4. Proportion of specialist services available in District hospitals against 10 core special- ist services 5. Percentage of Anganwadi centres/urban PHCs reported to have conducted at least one village health sanitation and nutrition day (VHSND) respectively in the last one month 6. Proportion of Anganwadi’s with own buildings
Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
3 Bhatia V: Developing the underdeveloped
(IMR), Under Five Mortality Rate (U-5MR) and tuberculosis5 Districts with these problems may take longer time than the incidence listed in Sustainable Development Goals (SDG). other districts as getting adequately trained man power is a Similarly, the fourth domain i.e. health infrastructure will4 time-consuming procedure. At this point hand holding and be helpful in achieving Universal Health Coverage (UHC). mentoring by Public Health Institutions specifically at the state level and national level may provide additional boost Based on these core indicators district has to identify a in training the manpower and monitoring the progress. thrust activity and the related programs to it and also Similarly, financial constrains related to recruitment and identify the loop holes, cross cutting issues and fix them. training will become critical in districts facing human Many of the activities are linked with each other like Health resource issues. Another problem the districts may face is is linked to basic infrastructure and financial inclusion. So the lack of skilled manpower do multitasking at each level integrated approach to address the issues remains the key as multiple activities will be going on simultaneously for to the success of the program. To perform these activities many thrust activities. Here the role of quality program smoothly and to coordinate the activities between state managers becomes important. This can be handled by fine and center NITI Aayog has identified Joint Secretory or tuning the human resource allocation and appropriation. Additional Secretory to serve as Guardians of the districts. When we analyze from the health specific point of view Various partner agencies have been identified by the central2 majority of the maternal health indicators are well included government for helping the districts in various domains. in the program but the neonatal care component is not The role of the partner agencies will be to do independent appropriately covered. Home Based Post-Natal Care is one evaluation of the program. Funding for all these activities such critical link missed in the indicator list. Majority of has to be channelized from the funds provided for the the neonatal deaths and maternal deaths occur when they program implementation plan only. Additional funds have are discharged from the hospital7-8 due to infections in this to be pooled from state funds and innovative methods like era of institutional deliveries. In such cases improving Corporate Social Responsibility (CSR), Dist. Mineral Fund the quality of the home-based care is critical to improve etc. the maternal and child health. Such home based care is also more important in home deliveries. Universal Health In this programme, the focus is more inclined at the district Coverage (UHC) is an important public health concept in level than being centralized, which is indeed a positive recent times. Many of the indicators for UHC are covered sign. Similarly, coordination between state and center on a under aspirational district program but the indicators mutually agreeable point of development is also a positive related to Non-Communicable Diseases, HIV and financial sign. Few hurdles that the program may face at the outset protection were not included. is non-reporting or poor reporting when we are planning for real time monitoring of the districts progress. Before From public health point of view health cannot be a jumping in to the program per se the district has to identify stand-alone agenda. It is always linked to other non- such inactive reporting units and start reporting to get the health domains like education, financial inclusion and actual baseline data. Second point will be the resources. basic infrastructure. Thus, the program well addresses Many health centers in state lack the appropriate manpower6 the health & its related domains and may provide a long- including basic field level workers like ANM and MPWs. lasting impact on the health indicators.
References:
1.
Framework for Implementation National Health Mission, Govt. https://www.who.int/gho/publications/world_health_ of India. Available at: http://nhm.gov.in/images/pdf/NHM/ 6. statistics/2016/EN_WHS2016_Chapter6.pdf [Last Accessed on: 02/01/2019] 2. NHM_Framework_for_Implementation__08-01-2014_.pdf [Last Accessed on: 02/01/2019] Rural health Statistics -2017, available at: https://data.gov. Deep Dive, Insights from Champions of Change Dashboard, 7. in/catalog/rural-health-statistics-2017 [Last accessed on: Available at: http://niti.gov.in/writereaddata/files/ 02/01/2019] Million Death Study Collaberators: Nationally Representative 3. FirstDeltaRanking-May2018-AspirationalRanking.pdf [Last Accessed on: 02/01/2019] 8. Mortality Survey, Causes of Neonatal and Child Mortality in India, Lancet. 2010; 376 (9755) 4. Champions of Change available at www.championsofchange.gov. in [Last Accessed on: 02/01/2019] Montgomery AL, Ram U, Kumar R, Jha P, for The Million Death Aspirational Districts: Unlocking Potentials, available at: http:// Study Collaborators (2014) Maternal Mortality in India: Causes and Healthcare Service Use Based on a Nationally Representative 5. niti.gov.in/writereaddata/files/AspirationalDistricts-Book.pdf [Last Accessed on: 02/01/2019] Survey. PLoS ONE 9(1): e83331. doi:10.1371/journal. SDG Health and Health Related Targets, World Health Organization pone.0083331
Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
4 REVIEW ARTICLE
Adapting the Stepped Care Approach for Providing Comprehensive Mental Health Services in Rural India: Tapping the Untapped1 Potential2 3 4 4 5 1DepartmentPriyamadhaba of Community & BeheraFamily Medicine,, Senthil AIIMS, Amudhan Bhubaneswar, R , RishabOdisha, India Gupta 2Department, Anindo of MajumdarEpidemiology, ,NIMHANS, Arun M Bangalore, India, 3Department of Psychiatry, AIIMS, New Delhi, India, 4Department of CommunityKokane & Family, Mohan Medicine, Bairwa AIIMS, Bhopal, Madhya Pradesh, India, 5Department of Public Health & Epidemiology, IIHMR University, Jaipur, India
Abstract
Recent National Mental Health Survey (2015-16) reported a prevalence of 13.7% for any mental disorders excluding tobacco use disorders in India. Translating it into real numbers, nearly 150 million people need active mental health interventions, disproportionately more in rural areas. Major challenges in delivering comprehensive mental health services in rural India are: a) lack of a well-defined strategy; and b) lack of trained mental health manpower. To fill this gap, the global mental health community has increasingly realized the importance of Community Health Workers (CHWs) and role of stepped care approach in mental health service delivery. We propose a model of stepped care approach to fulfil the need of rural India, utilizing the existing health system components for improving mental health knowledge, reducing social stigma for mental disorders, screening for priority mental disorders at community level, ensuring compliance to treatment, timely follow-up, and community-based rehabilitation by mobilising community support for diagnosed cases. This stepped care approach will integrate mental health into Ayushman Bharat’s Health and Wellness Centres (HWCs) for the provision of comprehensive primary health care. Integration of new age Keytechnologies Words: such as telepsychiatry, e-health, and mHealth into the proposed model will make it feasible and cost- efficient for inaccessible parts of the country. Community Health Workers (CHWs), Stepped care approach, Priority mental disorders, Rural India Introduction 4 of the global estimate) affected by depression. Translating the magnitude of mental disorders into real numbers, Mental disorders are the leading causes of disability nearly 150 million Indians2 are in need of active mental globally. One in four people in the world are affected by health interventions. mental1 or neurological disorders at some point in their lives. The high incidence of mental illness and substance In order to achieve universal health coverage (UHC), India abuse disorders in low- and lower-middle-income has launched its ambitious Ayushman Bharat (Healthy countries can lead to an economic trap of disease burden India) programme5 in the alignment with its National Health and social decline. The term, “mental disorders” is often Policy 2017. Ayushman Bharat has two components; used synonymously with mental morbidity, mental health health and wellness centres, and national health insurance conditions, mental illness, and mental health issues. In protection scheme. In the charter of health and wellness India, the recent National Mental Health Survey (NMHS) centres, a list of 12 services are identified including mental 2015-16 revealed a prevalence of 13.7% for any mental health services which have been neglected in the past. This disorders excluding2 tobacco use disorders related to becomes important at this juncture of time as the burden of tobacco use. Earlier epidemiological studies documented mental disorders are rising although provision for mental that the prevalence of various mental disorders3 varies health services are not improving. Not only the burden of from 9.5 to 370 per 1000 population in India. India is also mental disorders is high, but their impact on individuals regardedAddress for as Correspondence:home to an estimated Dr. Anindo 57 millionMajumdar, people Assistant (18% Professor,Department and society is of alsoCommunity widespread & Family and Medicine, greater AIIMS, than Bhopal many – 462020, Madhya Pradesh, India, Email: Received:11/11/2018, Accepted: 23/11/2018 [email protected]
Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
5 Behera P: Stepped care approach for mental health services in rural India
6 11 major medical conditions. For instance, India accounted be easy to tackle by currently existing psychiatrists alone. for 16.4% of global disability-adjusted life years (DALYs) At the same time, the insufficient training (1.4% of the attributable to 7 mental and substance use disorders (28 total lecture time) of psychiatry during the undergraduate million DALYs). Due to the prevailing stigma, mental medical curriculum renders non-psychiatrist physicians12 life.disorders often are hidden by the society, and consequently, unprepared to competently deal with mental disorders. persons2 with mental disorder live with a poor quality of Studies from India have reported that primary health-care With significant disability and functional impairment, disordersprofessionals . are often inadequately trained, and reluctant the economic burden associated with mental disorders or unable to2 detect, diagnose, or manage common mental is expected to be high, mainly due to loss of productivity. In addition, there is a great disparity in the Therefore, we proposed a cost-effective model of stepped distribution of psychiatrists among cities and villages care approach based on existing cadres of the community in India. This leads to inadequate treatment services, health workers, which may help the country to achieve continued suffering and premature deaths, stigmatization, the goals of NHP 2017 and sustainable development goals and poor investment in mental health. This warrants for (SDGs) through universalization of comprehensive mental a rational redistribution of mental health services, known Treatmenthealth care. gap for mental disorders remains very high as task-sharing, from mental health specialists including psychiatrists, psychologists, and psychiatric nurses to non- specialist health workers in primary care and community settings through13 the integration of mental health into Globally, 76% to 85% of people with severe mental no treatment for their mental disorders. primary care. disorders in low and middle-income countries8 receive A similar gap is Even though India was the first country in the world to reflected in India as well. Although several cost-effective attempt to integrate mental health services at the primary interventions demonstrated a significant decrease in care level through National Mental Health Programme the burden of mental disorders, associated treatment (NMHP and District Mental Health Program (DMHP), its gap remains very high due to reasons ranging from non- momentum.endeavor to bridge the treatment gap and decrease the availability of services to prevailing stigma. Recent NMHS deficits in human3 resources failed to gain the desired findings reported an overall2 treatment gap of 83% for Community-based participatory research to any mental disorders. Only about 10% of people with address mental health has been tried in various studies mental disorders are2 thought to receive evidence-based in different countries. In these studies, community health treatmentsMental health in India. is still a low priority despite its global workers (CHWs) educated up to 10 years of schooling were implications disorders.trained to provide non-pharmacological interventions in patients12,14 with both severe as well as common mental Such interventions are effective in improving Mental disorders have received poor attention in the the clinical outcome as compared to those receiving ‘care health programmes in India. In addition, limited reach and Humanas usual’. resources availability in primary health care slow expansion of mental health programmes and services also existed due to inequitable distribution2 and inefficient use of resources for mental health care. Addressing the Since the launch of National Rural Health Mission, now mental health care needs of India’s vast population with known as National Health Mission (NHM) in 2005, limited resources will have global implications towards trained manpower [Accredited Social Health Activists the achievement of mental health-related sustainable (ASHAs), Multipurpose workers15 (MPWs), Doctors, etc.] development goals. This calls for scale-up mental health has increased enormously. Under the NHM,16 around services in India, by adapting successful models and 0.9 million ASHAs have been selected so far. By 2016, developing and integrating innovative, cost-effective and there were 2,12,185 female MPWs, 55,657 male MPWs, self-sustainable interventions within these models in the 12,646 male Health Assistant (HA) and 13,372 female 17 HAs HumanIndian context. resource gap: a critical challenge working in Primary Health Centres (PHCs) in India. ASHA is a voluntary community health worker who is selected from the village itself and accountable to it, she is trained The severe deficit of mental health workforce remains a to work as an interface between18 the community and the major challenge in delivering comprehensive mental health health care delivery system. Both male and female MPWs services in rural India. For instance, there is fewer9 than work at sub-centre which is the lowest level of the health one psychiatrist (0.3) for 100,000 population. Whereas care delivery system. The minimum qualification for MPW (Male) is 12 years of schooling with biology or science population.the average national deficit of psychiatrists is estimated to be 77%, it is10 more than 90% for one-third of the country’s as a subject, and for MPW (female) is 2 years Auxiliary This clearly implies that the huge burden and Nurse-midwifery19 (ANM) course following 10-12 years treatment gap associated with mental disorders would not of schooling. These courses focus predominantly on Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
6 Behera P: Stepped care approach for mental health services in rural India Figure 1: Stepped care approach for comprehensive mental health services in rural India Steps What are the focus Who are the persons/ What are the proposed activities? domains? resourcesresponsible? Step 1 Mental health promotion
ASHAs Improve mental health literacy and generate Well Stigma reduction community awareness through IEC activities, population mobileinterpersonal and other communications mass media and through relevant audio-visual messages through
Provide support system to link person, Mass communication family and community to health system for media (TV, Radio, Mobile management of mental disorder and Newspaper) Social media (Twitter, Step 2 Facebook, WhatsApp etc.) At risk mentaldisorders groups Early identification for Non-professional Screening and assessment for priority priority mental disorders peripheral healthcare further assessment providers [ MPWs (male Active monitoring and referral for Basic mental health care for and female)/ANMs] priority mental disorders Low-intense psychosocial intervention/ Step 3 Lay counseling/mental health first aid Mild mental disorders disordersStandardised mental health PHC medical officers Medication care for priority mental Medical officers- Taluka Treatment and monitoring Hospital/ CHCs Facilitate referral to specialists DMHP-team Encourage self-monitoring (Psychiatrists, Psychiatric Collaborative care and attention to overall Social workers, well-being Clinical Psychologists) Counselling Psychological interventions Step 4 Flexible and accessible mental health Moderate services mental Specialised mental health Psychiatrist at tertiary/ Medication, illness/ care involving coordinated advanced care facilities Treatment and monitoring Severe multi-sectoral and inter- (psychiatrist at district Inpatient care mental departmental services hospitals, medical colleges Severe and complex intervention (e.g., crisis disorders (risk to life; severe self- etc.) service,emergency care, ECT etc) neglect, treatment-resistant, Combined treatments and Multi-professional recurrent, atypical cases, care(High-intensity psychological Step 5 non-priority mental interventions,Counselling, Psycho-education After care disorders) etc.) Continuity of mental ASHAs Ensure compliance to treatment for the rehabilitationhealthcare Technology based diagnosed cases Community based applications Timely follow-up for diagnosed cases MPWs (male and female) / supportSupport community-based rehabilitation ANMs by mobilising and providing family/social
* Cross-cutting issues Functional PHCs providing integrated mental health care can be critical at each step for successful implementation of this comprehensive mental health services model. Technology in various forms can be used to support resources at each stepStepped care approach for providing comprehensive mental health services in rural areas maternal and child health (midwifery) and communicable diseases with a minimal focus on mental health. Under the supervision of the Medical Officer-in-charge of a primary health centre (PHC), ASHA at the village level, MPWs at the There is an urgent need to address the large gap in sub-centre level, and HAs at PHC level provide promotive, human resources in mental health. In addition, improving preventive and curative services as appropriate for that the knowledge about mental health and elimination of level. However, there is no specific training as far as mental social stigma and discrimination associated with mental health issues are concerned. Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
7 Behera P: Stepped care approach for mental health services in rural India disorders is another major challenge to address the MPWs would carry out the responsibilities assigned to mental health needs. The early identification of major them- a scope to identify people with mental disorders. mental disorders with appropriate linkage to evidence- The screening for the priority mental disorders in the informed management and timely follow-up remains community by trained MPWs and establishing appropriate the key to improved mental health care. The stepped linkage between persons identified with mental disorders care approach is a successfully tested model that can be and the doctors at the PHCs and the psychiatrist at adapted and integrated with primary health care in rural the district level -a critical step to strengthen mental settings20,22 in India, with appropriate modifications (Table health services in the rural areas of India. This new -1). A stepped care approach improves the coverage of role can be integrated with duties assigned under the mental health services, making the best use of available non-communicable diseases program, i.e. the National local workforce and technologies for a better match with Program for Prevention and Control of Cancer, Diabetes, individual and population needs. Subsequently, increased cardiovascular diseases, and Stroke (NPCDCS) making it community engagement acts as a mean of advancing cost-effective. One cost-effective strategy would be testing inclusion and opportunities for community participation. and developing a validated intervention package23 for India, It thus provides an appropriate mechanism for people based on the WHO mhGAP intervention guide. to avail mental health services at their doorstep with affordable cost compared to the conventional clinic- The potential role of HAs as a health counselor in mental12 based approach. Community health workers i.e. CHWs service has been already explored in Indian settings. (ASHAs, MPWs, and ANMs) have a very important role in HAs (male and female) if trained, can act as counselors for the stepped care approach. Next section summarizes how priority mental disorders (depression, anxiety etc.) at PHC these CHWs can fit into the stepped care approach playing level. Thus, the involvement of ASHA at the village level, ASHAs:unique roles. MPWs at the sub-centre level, HAs and doctors at PHC level and psychiatrist (psychiatric clinics) at district level Given their vast numbers and immense penetration along with their appropriate linkage will be able to provide into the community health affairs, ASHAs can make a comprehensive mental health services in rural India. This significant impact on the mental health care. They, if may be integrated with currently ongoing health sector appropriately trained in handling mental health issues, reforms in India under Ayushman Bharat specifically may be able to provide the ideal linkage between the Catalysinginvented health the role and ofwellness CHWs usingcentres. emerging technology community and the mental health services at the PHCs (now Health and Wellness Centres), and further referrals to specialty psychiatry clinics. ASHAs can work in tandem Cutting-edge technologies can play a pivotal role in with MPWs (both male and female) to improve knowledge bridging the “mental health gap” in rural India. Mass about mental disorders (mental health literacy) and mental disorders. communication media (TV, Radio, Newspaper etc.), social reduce social stigma and discrimination associated with media (Twitter, Facebook, WhatsApp etc.) and relevant audio-visual messages through mobile phones can be ASHAs are cognizant of the socio-cultural milieu of the used to spread community awareness to improve mental community (which is vital for identifying mental disorders health literacy and reduce stigma. Telepsychiatry, tele- with varied cultural interpretations and understanding the mental health, e-psychiatry approach and mobile mental precise psychological phenomenon) and have help-seeking health support approach have been already explored24,25,26,27,28 and dynamics and regular contact with the families to ensure found to be successful and cost-effective in India. compliance with the treatments administered. ASHAs, These technologies can cross-cut at various steps of the being a part of the mental health workforce, do not need to stepped care approach for integration of mental health into spend additional time on the potential psychiatric patients, primary care and take it to the doorstep of patients in the since they are already engaged with the entire community. community, especially in remote and inaccessible areas. A support system can be developed to help ASHAs ensure Telepsychiatry is a useful technique for direct patient that already diagnosed patients reach PHCs and are timely care (diagnosis and management), consultation, training, followed-up subsequently. Medical officer, in the PHCs, education, and mental health promotion. It reduces out diagnose the disorders and initiate proper management. of pocket expenditure (time and cost of transport cost, They may further refer only those cases which require the wage loss.) for patients. Telepsychiatry is an economical attention of a trained psychiatrist (at the district hospitals) model mental health service delivery connecting tertiary MPWs:and thereafter receive them back in their own care. centre and a primary health-care28 centre compared to There are unique advantages for training of traditional psychiatric clinics. While using telepsychiatry MPWs in mental health. MPWs (male and female) are the it is required that the pharmacological treatment should suitable workers for the screening due to their community be prescribed only by the trained doctor, and non- penetration and educational background. Trained pharmacological treatment can be provided by the CHWs Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
8 Behera P: Stepped care approach for mental health services in rural India whenever recommended. In the context of increasing use skills and competencies, and training them in line with the of smartphone use, mobile mental health support with training of medical officers at peripheral centres through appropriate app integrated with telepsychiatry will be strategic framework and model becomes critical. This will useful and cost-effective interventions for mental health not only keep the momentum gained for mental health in promotion, training of community health workers (ASHAs, India in recent years but also will align with the stepped MPWs, and HAs), screening for priority mental disorders, care approach for successful integration of mental health to improve the treatment compliance along with referral, into Ayushman Bharat’s Health and Wellness Centres and timely follow-up of diagnosed cases. The appropriate (HWCs) for the provision of comprehensive primary health mobile app will be handy for CHWs to fulfill the community care. Fortunately, mental health has been able to secure a Incorporatinglevel tasks “what the to stepped do”, “when care to approachdo” and “how within to do”. mental birth in the package of HWCs, although, there is a long way health policy framework Conclusionto go.
The Government of India has recently unveiled the Mental Although the burden of mental disorders is high, the Health Policy with an accompanying mental health action trained mental health workforce is critically deficient in inplan. a phased It has anmanner. ambitious proposal for expanding the rural India. Stepped care approach is a cost-effective and District Mental Health [21]Program to more than 300 districts time-tested strategy which can be adapted and integrated In the existing health systems, within the framework of Ayushman Bharat’s health and ASHAs and other health workers are an important link for wellness centres to provide comprehensive primary health delivery of services, but their roles and responsibilities care. Community Health Workers (CHWs) are a potentially for mental health care has not been delineated. Recently, useful and large pool of unqualified but trainable that the Ministry of Health and Family Welfare, Government utilized into the stepped care approach. As we make of India has brought out a training module on essential striking progress towards the unfinished agenda of psychiatry to impart standardized short-term training to communicable diseases and reproductive and child health, medical officers at peripheral centres. Thus, prioritizing tapping their potentials appropriately to deliver mental the mental disorders, delineating the roles and health services will ensure achievement of health-related responsibilities of ASHAs, MPWs and HAs as per their Sustainable Development Goals (SDGs).
References
1. 2. World Health Report. World Health Organisation. Available from: 12. http://www.searo.who.int/india/topics/mental_health/about_ 3. http://www.who.int/whr/2001/media_centre/press_release/ mentalhealth/en/.(Last Accessed on 11 feb 2018) en/.( Last Accessed on 11 feb 2018) Thirunavukarasu M, Thirunavukarasu P. Training and National 4. National Mental Health Survey of India. Ministry of Health and 13. deficit of psychiatrists in India - A critical analysis. Indian J Family Welfare Government of India 2015-16. Available from: Psychiatry. 2010 Jan;52(Suppl 1):583-88. 5. http://indianmhs.nimhans.ac.in/Docs/Summary.pdf. ( Last WHO World Mental Health Survey Consortium. Prevalence, Accessed on 11 feb 2018) severity, and unmet need for treatment of mental disorders in the 6. Math SB, Chandrashekar CR, Bhugra D. Psychiatric epidemiology 14. World Health Organization World Mental Health Surveys. Journal in India. Indian J Med Res. 2007 Sep;126(3):183–92. of the American Medical Association 2004;291:2581–2590. National Commission on Macroeconomics and Health, Patel V, Weiss HA, Chowdhary N, Naik S, Pednekar S, Chatterjee S, Government of India. NCMH_Burden of disease. Available et al. Effectiveness of an intervention led by lay health counsellors from:http://www.who.int/macrohealth/action/Report%20 for depressive and anxiety disorders in primary care in Goa, India 7. of%20the%20National%20Commission.pdf . ( Last Accessed on 15. (MANAS): a cluster randomised controlled trial. Lancet. 2010 Dec 11 feb 2018) 18;376(9758):2086–95. 8. Patralekha Chatterjee. India launches Ayushman Bharat’s Mendenhall E, De Silva MJ, Hanlon C, Petersen I, Shidhaye R, Jordans secondary care component. Lancet. 2018 Sep. 22; 392(10152):997. M, et al. Acceptability and feasibility of using non-specialist health Depression in India Let’s Talk. World Health Organisation. [cited workers to deliver mental health care: Stakeholder perceptions 9. 2018 Feb 11]. Available from: http://www.searo.who.int/india/ 16. from the PRIME district sites in Ethiopia, India, Nepal, South depression_in_india.pdf. Africa, and Uganda. Soc Sci Med 2014 Oct;118:33–42. 10. GBD Results Tool | GHDx. Available from: http://ghdx.healthdata. Chatterjee S, Patel V, Chatterjee A, Weiss HA. Evaluation of a org/gbd-results-tool. (Last Accessed on 17 feb 2018) 17. community-based rehabilitation model for chronic schizophrenia Global burden of mental disorders and the need for a in rural India. Br J Psychiatry J Ment Sci. 2003 Jan;182:57–62. comprehensive, coordinated response from health and social 18. NRHM - Governnment of India. Available from: http://nhm.gov. sectors at the country level. World Health Organisation. Available in/nhm/nrhm.html (Last Accessed on 11 feb 2018) 11. from: http://apps.who.int/gb/ebwha/pdf_files/EB130/B130_9- Update-on-ASHA-Programme-January-2015.pdf.Available from: en.pdf. (Last Accessed on 11 feb 2018) http://ashavani.org/images/docs/Update-on-ASHA-Programme- Mental health in India,World Health Organisation. Available from: January-2015.pdf. (Last Accessed on 11 feb 2018)
Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
9 Behera P: Stepped care approach for mental health services in rural India 19.
Government of India Ministry of Health and Family Welfare Organisation. Available from: http://apps.who.int/iris/bitstre Statistics Division. Rural Health Statistics 2014-15. Available 26. am/10665/250239/1/9789241549790-eng.pdf?ua=1. (Last 20. from:http://wcd.nic.in/sites/default/files/RHS_1.pdf. (Last Accessed on 11 feb 2018) Accessed on 11 feb 2018) Moirangthem S, Rao S, Kumar CN, Narayana M, Raviprakash N, About ASHA - Governnment of India.Available from: http://nhm. Math SB. Telepsychiatry as an Economically Better Model for 21. gov.in/communitisation/asha/about-asha.html. (Last Accessed 27. Reaching the Unreached: A Retrospective Report from South on 11 feb 2018) India. Indian J Psychol Med. 2017 May-Jun;39(3):271-275. MPHW-M-2010-Guideline.pdf. Available from: http://www. Maulik PK, Tewari A, Devarapalli S, Kallakuri S, Patel A. The 22. health.mp.gov.in/fw/2015/MPHW-M-2010-Guideline.pdf. (Last Systematic Medical Appraisal, Referral and Treatment (SMART) Accessed on 11 feb 2018) Mental Health Project: Development and Testing of Electronic WHO | Policy options on mental health: a WHO-Gulbenkian Mental Decision Support System and Formative Research to Understand Health Platform collaboration WHO.Available from: http://www. 28. Perceptions about Mental Health in Rural India. PLoS One.2016 23. who.int/mental_health/evidence/policy_options_gulbenkian_ Oct 12;11(10):e0164404. paper/en/. (Last Accessed on 11 feb 2018) 29. Yellowlees P, Chan S. Mobile mental health care-an opportunity for Bower P, Gilbody S. Stepped care in psychological therapies: India. Indian J Med Res. 2015 Oct;142(4):359-61. 24. access, effectiveness and efficiency. Narrative literature review. Br Wang J, Lam RW, Ho K, Attridge M, Lashewicz BM, Patten SB et al. J Psychiatry. 2005 Jan;186:11-7. Preferred Features of E Mental Health Programs for Prevention Van Straten A, Tiemens B, Hakkaart L, Nolen WA, Donker MC. 30. of Major Depression in Male Workers: Results From a Canadian Stepped care vs.matched care for mood and anxiety disorders: a National Survey. J Med Internet Res. 2016 Jun 6;18(6):132. 25. randomized trial in routine practice. Acta Psychiatr Scand. 2006 Malhotra S, Chakrabarti S, Shah R, Sharma M, Sharma KP, Malhotra Jun;113(6):468-76. A et al. Telepsychiatry clinical decision support system used mhGAP Intervention Guide Mental Health Gap Action by non-psychiatrists in remote areas: Validity & reliability of Programme Version 2.0 for mental, neurological and substance diagnostic module. Indian J Med Res. 2017 Aug;146(2):196-204. use disorders in non-specialized health settings. World Health
Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
10 CME
AcuteAdditional Professor, Osteomyelitis Dept. of Orthopaedics, All India Institute of Medical Sciences, Rishikesh R.B. Kalia
Abstract
Acute osteomyelitis requires careful clinical evaluation, a high index of suspicion as it is an uncommon but devastating disease that affects largely previously healthy children. Management of osteomyelitis is a formidable challenge as success of antibiotics in soft tissues has not been replicated in bony tissue due to peculiar anatomy and physiology of the bone. Illness, malnutrition and decreased immunity predispose children to develop acute osteomyelitis. Absence of phagocytic cells in the metaphysis may explain predilection in children. Recently the trend in treatment strategy includes a rapid transition from intravenous to oral antimicrobial therapy and a shortened overall course of therapy. Many new therapeutic options are on the horizon that will likely impact the management of this and other childhood bacterial infections. This review will focus on recent advances in the management of acute hematogenous osteomyelitisKey Words: in children. Osteomyelitis, Antimicrobial therapy, Hematogenous Introduction 4 paediatric hospitalizations. In high-income countries, acute osteomyelitis occurs in about 8 of 100,000 children Acute osteomyelitis is the inflammation of bone caused by per year, but it is considerably more common in low-income pyogenic organisms typically the duration of symptoms countries. Boys are 5 affected with acute osteomyelitis is less than two weeks. Haematogenous spread is the twice as often as girls. Acute hematogenous osteomyelitis most common source of infection in children typically is particularly common in young children, typically in affecting the metaphysis of long bones where blood flow metaphyseal ends of long bones, due to the highly vascular is rich but sluggish. Other sources of infection are tracking nature of the growing bone. Less common aetiologies of from adjacent foci of infection and direct inoculation osteomyelitis include trauma, surgical6 complications, or from trauma or surgery. The femur1 and tibia are most extensionEtiology from adjacent soft tissue. commonly affected (27% and 26%) . In long bones where the metaphysis is intracapsular the shoulder, ankle, hip, and elbow, in decreasing order of incidence the infective foci may extend into the2 joint space, resulting Staphylococcus aureus is the most frequently causative in concurrent septic arthritis. In paediatric patients pathogen in patients with acute osteomyelitis7 being cultured under 18 months of age, anatomical transphyseal vessels in 70-90% of culture positive cases .Other causative facilitate translocation of bacteria from the metaphysis to pathogens include Streptococcus pyogenes, Streptococcus infect the epiphysis and adjacent joint, increasing the risk pneumoniae, and Kingella kingae. Salmonella especially of concurrent septic arthritis. the non-typical serotypes (S typhimurium, S enteriditis, S choleraesius) can be an important8 causative pathogen in Over the last decade, our understanding of the etiology of children with sickle cell disease. Patients with sickle cell this infection has changed, with increased recognition of disease and suspected osteomyelitis require a completely Kingella kingae and the dramatic increase in community- different antibiotic regimen, and infectious disease advice associated Methicillin-resistant Staphylococcus aureus should be sought. It has been suggested that tiny infarctions markers.(MRSA) infections. There is a need for the optimization of in the gastrointestinal tract lead9 to salmonella bacteraemia diagnostic3 strategies, such as MRI and serum inflammatory and ultimately to osteomyelitis. Resistant strains emerging Acute osteomyelitis is problem in the paediatric with changing pattern of causative organisms over the past population, affecting approximately 5/10,000 children few decades are a matter of concern. eachAddress year for and Correspondence: accounting forDr.R.B. approximately Kalia, Additional 1% Professor, of all Dept. of Orthopaedics, All India Institute of Medical Sciences, Virbhad- ra Marg, Rishikesh,Uttarakhand-249203.E-mail: Received: 20/03/2018, Accepted: 12/07/2018 [email protected]
Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
11 Kalia RB: Acute Osteomyelitis
Previously the most common Gram-negative organism in The coincidence of large tribal populations with the ‘sickle paediatric osteomyelitis was Haemophilus influenzae has10 cell belt’ of Central India and northern Kerala and Tamil now become rare because of the vaccination programmes. Nadu has given rise to the assumption that tribal people The incidence of community11 acquired MRSA is increasing are more prone to the Hbs gene although this seems18 in many parts of the world. MRSA is a causative agent in widely distributed among tribal and non-tribal people. is9-30% different. of children with osteomyelitis and needs altered Sometimes striking differences have been reported, antibiotic treatment12 regimens as the severity of disease a tribal population in Valsad having milder disease MRSA osteomyelitis can cause a more than a non-tribal population in Nagpur. Little is known aggressive and complicated infection, with higher fever and about many other aspects of sickle cell disease in India, an increased likelihood for repeated surgical debridement, including which infections19,20 are important, and the role prolonged hospital stays compared with other pathogens, of antibiotic prophylaxis. It is difficult to differentiate associated with many complications, including multiorgan a vaso-occlusive crisis-which is far more common from failure, deep vein thrombosis (10%), septic pulmonary osteomyelitis in children with sickle cell anemia as both emboli, multifocal infection, subperiosteal abscesses,13 often present with fever and a painful, swollen limb with fractures (20%), and progression to chronic osteomyelitis. Diagnosisrestricted joint motion. Cases of osteomyelitis have been documented of PVL- MRSA (Panton-Valentine Leukocidin Methicillin Resistant14 Staphylococcus Aureus), an extremely virulent strain. The classical clinical picture of an unwell, febrile child Primary deficiencies of cell mediated immunity are rare. unable to walk due to limb pain21 with a high white cell count Secondary causes like steroid use, malnutrition, SLE, is increasingly uncommon. The onset of osteomyelitis can lymphoma and autoimmunity deficiency syndrome can be insidious, the clinical presentation variable, and the sometimes be responsible for osteomyelitis. Children physical findings non-specific. No single test can confirm with malnourishment, diabetes, malignancy, HIV, on or rule out acute osteomyelitis. A combination of careful prolonged steroid therapy are immunocompromised history and examination, accompanied by a high index of which makes them susceptible to infections like clinical suspicion, and followed by laboratory and imaging osteomyelitis. Hospitalized premature infants are studies are key to an early diagnosis. predisposed to osteomyelitis owing to their immature The commonest presenting features are pain, swelling immune systems and exposure to repeated invasive and erythema, fever, reduced joint movement or pseudo- intravenous or intraarterial procedures providing a paralysis, and reduced weight bearing or a limp. Fever portal for haematogenous spread. The systemic signs of in immunocompromised group is not a major symptom, infection may be subtle,15 however pronounced leucocytosis and the infection, particularly in premature infants, may is typically seen. In the clinical setting of patients with be multifocal. Multifocal disease is rare but presents as Diabetes, hematological malignancies, cytotoxic drugs multiple acute foci of infection, affecting mainly the22 femur organisms like Staphylococcus aureus, aspergillus, gram and tibia, or the tibia and humerus simultaneously. negative and candida infections are common. In patients with Hypogammaglobulinemias and post splenectomy Traditionally erythrocyte sedimentation rate (ESR) and patients- Hemophilus, streptococcus pneumoniae and leukocyte cell count have been used, whereas C-reactive Niesseria infections are common. protein (CRP) has gained in popularity. CRP normalizes faster than23 ESR, providing a clear advantage in monitoring Osteomyelitis caused by atypical organisms are often recovery. Declining levels of CRP usually suggest a termed atypical osteomyelitis. Microvascular obstruction favourable response to treatment even if the fever by the sickled red blood cells in patients with sickle cell continues. Acute osteomyelitis due to MRSA causes greater24 disease result in tissue ischaemia and infarction. This, in elevations in the CRP level, ESR and white-cell count. combination with impaired immune function and splenic Procalcitonin levels are sensitive as diagnostic tests but dysfunction, leads to an increased risk of osteomyelitis, measurements of procalcitonin are more expensive and with Salmonella the most common causative organism. rarely outperform CRP and is used infrequently. Salmonella is commonly considered in the differential diagnosis of osteomyelitis in children with sickle cell A systematic review found that only 36% of children anemia but Salmonella osteomyelitis and septic arthritis will have a raised white cell count on presentation, 91% 16 are rare in immunocompetent children who do not have an increased erythrocyte sedimentation25 rate, and 81% sickle cell disease or trait. Salmonella is an encapsulated, an increased C reactive protein value. The sensitivity is motile, facultative anaerobic bacillus, gram negative, highest when both the erythrocyte sedimentation rate coliform group bacteria belonging to the family of and C reactive protein are increased (98%). C reactive enterobacteraciae. The reported incidence of Salmonella protein values >100 mg/L are particularly significant for osteomyelitis is 0.45% in normal population17 and it is 70% concomitant septic arthritis and are also the best predictor in children with sickle cell disease. of a complicated course and the need for prolonged Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
12 Kalia RB: Acute Osteomyelitis
Pathologyintravenous antibiotics. suppurative arthritis, which can cause destruction of the articular cartilage and permanent disability. A similar process involves the vertebrae, in which the infection destroys the hyaline cartilage end plate and intervertebral Acute hematogenous osteomyelitis most commonly disc and spreads into adjacent vertebrae producing affects long bones which account for about ¾ th of cases spondylodiscitis.Table 1- Systemic or Local Factors predisposing to of osteomyelitis. Lower extremity bones femur (23- Osteomyelitis. 29%), tibia (19-26%), and fibula (4-10%)—slightly more commonly involved than the upper extremity locations— Systemic Local humerus (5-13%), radius (1-4%), and ulna (1-2%).Other Malnutrition Chronic lymphedema bone infections occur with a reported incidence are- pelvic Renal, hepatic failure Venous stasis osteomyelitis (3-14%), calcaneal osteomyelitis (4-11%), hand involvement25,26,27 (1-2%), and vertebral spondylodiscitis Diabetes mellitus Major vessel compromise (1-4%). The predisposing factors for osteomyelitis Chronic hypoxia Arteritis are mentioned in Table 1. Malignancy Radiation fibrosis Most commonly by hematogenous spread bacteria Extremes of age Small vessel disease proliferate after getting lodged in the metaphysis and Immune deficiency induce an acute inflammatory reaction. In the neonate the Neuropathy metaphyseal vessels penetrate the growth plate, resulting in Asplenia/Sickle cell disease Extensive scarring frequent infection of the metaphysis, epiphysis, or both. In HIV children, localization of microorganisms in the metaphysis is typical. After growth plate closure, the metaphyseal Ethanol and/or tobacco vessels reunite with their epiphyseal counterparts and abuse provide a route for the bacteria to seed the epiphyses and subchondral regions in the adult. Microbiogical and Pathological Investigations Bone is a closed tube and the bacteria and inflammation spread within the shaft of the bone. If infection continues purulent material works its way through Haversian system Samples for blood cultures should be taken before and Volkmann’s canals to reach the periosteum. The antibiotics are started as it may be the only positive source entrapped bone undergoes varying degrees of necrosis of identification of the pathogen. Blood cultures may be within the first 48 hours. In children the periosteum is positive in only 50% of cases. If positive, cultures should be thick and acts as a barrier to further spread of the purulent repeated daily until two consecutive cultures are reported material into the soft tissues. However, the periosteum is negative. Aspirates from soft tissue, sub periosteal or joints loosely attached to the cortex and sizable sub periosteal can have a higher yield (70%) and can be obtained even abscesses may form that can track for long distances after antibiotics have been administered. along the bone surface. Lifting of the periosteum further impairs the blood supply to the affected region, and Positive culture yields can be improved if specimens can both the suppurative and the ischemic injury may cause be obtained guided by ultrasound, computed tomography segmental bone necrosis; the dead piece of bone is known or surgery; and should be sent for urgent Gram stain and as a sequestrum. Rupture of the periosteum leads to a soft- culture in commercially available blood culture bottles. tissue abscess and the eventual formation of a draining Special culture media especially in immune-compromised sinus. Sometimes the sequestrum crumbles and forms settings, patients with suspicion of penetrating inoculation small fragments that pass through the sinus tract classical or failed primary treatment may be necessary for the of chronic osteomyelitis. isolation of mycobacteria,28 fungi, and less common anaerobic pathogens. In some cases, histopathologic After the first week chronic inflammatory cells become examination of biopsy specimens may be the only way to more numerous and their release of cytokines stimulates Plainmake aRadiographs diagnosis. osteoclastic bone resorption, ingrowth of fibrous tissue, and the deposition of reactive bone in the periphery by the periosteum. When the newly deposited bone forms a sleeve of living tissue around the segment of devitalized High-quality plain radiographs in two orthogonal planes infected bone, it is known as an involucrum. should be obtained in all cases to evaluate for deep soft tissue swelling, joint effusions, and skeletal lesions. Plain x In neonates, epiphyseal infection can spread through rays often 29show soft tissue swelling but are unremarkable the articular surface or along capsular, tendinous and otherwise. In some instances, joint space widening is ligamentous insertions into a joint, producing septic or discernable due to fluid accumulation in the joint. For bony Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
13 Kalia RB: Acute Osteomyelitis destruction to be discernable on x-rays requires persistent CT scans have a role in monitoring disease progression infection for 2-3 weeks as bony matrix must be destroyed after initial MRI scanning. MRI is as sensitive as the bone at least 30-50% for bony destruction to be visible. A normal scan for the diagnosis of acute osteomyelitis because it can radiograph on admission to the hospital by no means rules detect changes in the water content of marrow and offers out acute osteomyelitis, but it can be helpful in ruling out improved sensitivity and specificity than CT scanning. a fracture or detecting Ewing’s sarcoma or another type of Contrast-enhanced MRI does increase reader confidence Radionuclidemalignant condition. Imaging in the diagnosis of osteomyelitis and its complications in cases in which bone or soft-tissue edema is found on unenhanced images. In the clear absence of edema on needed. unenhanced images, however, contrast enhancement is not In 95% of cases, the technetium radionuclide scan using 32 99mTc diphosphonate is positive within 24 h of the onset of symptoms. Radionuclide scanning is useful when X-rays and MRI yields better anatomic resolution of epidural CT scan are normal. Technetium 99 is the most commonly abscesses and other soft tissue processes than CT and is used radioisotope for acute osteomyelitis. The uptake in currently the imaging technique of choice for vertebral different phases of the bone scan allows a distinction to osteomyelitis. MRI provides detailed information about be made as to the cause of the increased uptake. Falsely the activity and the anatomic extent of infection but does negative scans usually indicate obstruction of blood flow not always distinguish osteomyelitis from healing fractures to the bone. Because the uptake of technetium reflects and tumors. MRI is particularly useful in distinguishing osteoblastic activity and skeletal vascularity, the bone scan cellulitis from osteomyelitis in the diabetic foot; however, cannot differentiate osteomyelitis from fractures, tumors, no imaging modality consistently distinguishes infection infarction, or neuropathic osteopathy. from neuropathic osteopathy. A multidisciplinary approach Gallium citrate scan is more specific for infection as it of continuation from MRI scanning to the OR as a single is directly taken up by leucocytes and allows a clearer anaesthetic event can be safely performed33 and leads to differentiation to be made if both technetium and Gallium rapidClassification recovery and decreased hospital stay. scans are done. In patients with acute osteomyelitis- Gallium uptake is greater than Technetium uptake. The disadvantage is the slow clearance by the tissues and it Classification systems are important in documenting but may take 24 hours to get the scan results which may be too need reproducibility and are clinically useful if they guide late for acute infections. treatment or are helpful in prognostication. Cierny and colleagues proposed a classification system for chronic Indium 111- labelled leucocyte scan is sensitive for osteomyelitis34 based on host factors and anatomical acute osteomyelitis and for differentiating trauma and criteria. infections. 67Ga citrate- and 111In-labeled leukocyte or immunoglobulin scans, which have greater specificity This system is however for adults and has not been for inflammation, may help distinguish infectious from validated for children with normal immunity at the time noninfectious processes and indicate inflammatory of infection. Imagingchanges within bones. A classification system has been proposed to assess the severity of illness using clinical, radiological and laboratory parameters. This simple scoring system guides treatment, Ultrasound can be used to diagnose osteomyelitis by the prognosticate35 risk of complications and is easy to use detection of sub-periosteal fluid collections, soft tissue (Table 2). abscesses30 adjacent to bone, and periosteal thickening and elevation. Both CT scans and ultrasound are useful for The other system of classification which is useful is to guiding percutaneous aspiration of sub-periosteal and soft classify according to patient characteristics. This is useful tissue fluid collections. in guiding treatment and reduce variability of care. Patients are classified according to age into your groups – Infantile CT scanning although excellent for defining bony (2-18 months), early childhood (18 months-3 years), pathology has a limited application in the diagnosis and childhood (3-12 years) and adolescent (12-18 years) and management of osteomyelitis. Major disadvantages of CT Treatmenteither nosocomial orcommunity acquired. scanning are limited visualization of the anatomic and spatial extent of tissue inflammation due to infection and animals.radiation exposure. CT scans have a sensitivity of 66% and a specificity31 of 97% for osteomyelitis in experimental The treatment of patients with acute osteomyelitis is multidisciplinary involving paediatrics, infectious diseases, orthopaedics, microbiology and radiology to ensure early Indian Journal of Community & Family Medicine | Vol. 4 | Issue 02 | Jul-Dec, 2018
14 be used for parenteral administration. The advantage of cefuroxime is that it is available in parenteral
beand used oral forpreparations. parenteral administration. The advantage of cefuroxime is that it is available in parenteral andAs soon oral preparations.as the culture results are available antibiotic choice is guided by the susceptibility pattern of Asthe soonidentified as the org cultureanism results and local are availablemicrobiology antibiotic advice choice sought is whereverguided by possible the susceptibility to facilitate pattern a more of Kalia RB: Acute osteomyelitis theapprop identifiedriate therapeutic organism regimen.and local Most microbiology MRSA strains advice are sought susceptible wherever to clindamycin possible to andfacilitate it is a more Table 2- Modified severity of illness scoring system for Figure 1: Management of acute osteomyelitis approp riate therapeutic regimen. Most MRSA strains are susceptible to clindamycin and it is Acute hematogenous osteomyelitis. Suspicion of Acute Osteomyelitis Fever, swelling and pain in limb Scoring Parameter Criteria Points Suspicion Tenderness of Acute Osteomyelitis or induration Fever, swelling and pain in limb Initial CRP(mg/dl) 2 Tenderness or induration 1 >15 0 10-15 Plain Radiograph ESR, CRP CRP hospital day 2-3 (mg/dl) 2 <10 BloodPlain Radiograph culture ESR, CRP 1 >10 Blood culture 0 5-10 CRP hospital day 4-5 (mg/dl) 2 <5 1 >10 0 5-10 Abnormal Observation in IPD Band percentage of WBC’s 1 No <5 Radiographs? Repeat CRP, ESR after 0 AbnormalRaised CRP Observationone day in IPD >1.5% and ESR? No Repeat CRP, ESR after Radiographs? Febrile days on antibiotics 1 Raised CRP one day <1.5% and ESR? 0 2 or>2 ICU admission Yes 1 < 2 No 0 Yes
Disseminated Yes 1 Yes disease* No 0 Ultrasound, MRI Yes Persistent symptoms? Bone scan (If possible) Raised CRP, ESR? Grades: Mild 0-3, Moderate 4-7 and severe 8-10. Ultrasound, MRI Yes Persistent symptoms? Bone scan (If possible) Raised CRP, ESR? No
*Disseminated disease include-DVT, pulmonary embolism, No No pneumonia, endocarditis and multifocal osteomyelitis Features suggestive of osteomyelitis on imaging? Consider other diagnosis/ No Features suggestive of Discharge osteomyelitis on imaging? Consider other diagnosis/ diagnosis and effective management (Figure 1). Initial Discharge treatment of acute osteomyelitis is instituted empirically Yes 11 before the causative agent and its resistance pattern Yes are known in 2-3 days. Antibiotics in sufficient doses to 11