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Violence against Doctors: Causes, Effects, and Solutions

Violence directed against the physician and the health-care workers seems to be a common phenomenon world-wide. However, this phenomenon has been given a scarce consideration and minimal lip service not only in lay public, media and law administrators but even in medical community.

Dr Sundeep Mishra

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Violence against Doctors: Causes, Effects, and Solutions

Dr Sundeep Mishra

Violence can never be justified, least of all against someone

who is ostensibly attempting to save a person’s life.

– Sumanth Raman

INTRODUCTION

Sacrifice is part of the great tradition of medicine, a tradition that compels doctors into one of the mosthazardous occupations. The list of dangers is actually quite long; risk for communicable illnesses, bothcommon and rare, stresses that lead to extremely high rates of burnout, depression, substance abuse andsuicide that outpace other professions (of similar level of education, gender, generation), serious occupational hazards like workplace violence both physical and verbal. Each and every practicing doctor has been touched by these issues, either directly or as witness. As per an Indian Medical Association study, more than 3/4th of physicians have witnessed some form of violence at workplace. On the other hand, individuals entering the profession are either completely unaware or have only limited understanding of the potential long-term consequences that are often understated or ignored. Some occupational hazards have indeed been studied, but there is no comprehensive analysis of workplace risk for physicians like those that have been done for other professions especially those related to workplace violence.

Violence directed against the physician and the health-care workers seems to be a common phenomenon world-wide. However, this phenomenon has been given a scarce consideration and minimal lip service not only in lay public, media and law administrators but even in medical community. As a matter of fact, the subject of aggression and violence against physicians and its remedies does not figure anywhere either in medical curriculum or continuing medical education. Multiple anecdotal reports suggest that the problem is increasing globally but systematic data is lacking. However, it is likely to be more prevalent in those health-care settings like India, which were traditionally socialistic but have recently turned to capitalistic model of health-care.

Although violence is common in many work-place settings especially those dealing with social and financial sectors it can under no circumstance be condoned in hospitals. Although in reality in-hospital violence is just a superficial symptom of a deeper malady afflicting overall health-care system, the hospitals cannot be allowed to become battlegrounds for the simple reason that sick people need a peaceful environment where they can get sympathy, empathy, support etc. At the same time, the health-care professionals also need a stable and peaceful environment if they are ever able to give self-less care (rather than worry about their personal safety). On a long term basis, the threats and violence could have a bad impact on the physician’s psychology leading to Post-Traumatic Stress Syndrome (PTSD) in majority of the physicians, something which is akin to a problem faced by war veterans. This manifests as a physician feeling helpless, becoming irritable, introverted and having thoughts of abandoning medicine or even contemplating suicide. Even more stable personalities might be forced to practice defensive medicine, intent on saving their own skin rather than considering for the patient.

DEFINITION

Many people think of violence as a physical assault. However, violence in healthcare setup is a much broader problem; it is any act of aggression, physical assault, or threatening behavior that occurs in a health-care setting and causes physical or emotional harm to a health worker. It can range from telephonic threats, intimidation, actual verbal abuse, physical but non-injurious assault, sexual harassment, and physical assault causing injury; simple or grievous, weaponry attacks, and homicide to vandalism and / or arson. Verbal abuse is the most common type of violence encountered but there seems to be some gender bias as well, sexual abuse being nearly exclusive in female workers.

FACTORS PREDISPOSING TO VIOLENCE

The root cause of the problem is the growing distrust between health-care sector and lay community compounded by poor patient-doctor communication. The whole society is getting materialistic and health-care sector is no exception to this. With private capital being infused into health-care sector; corporate hospitals, pharmaceutical and device industry, business professionals in the hospital administrator seat, the mentality of physicians has also changed from a charitable to a profit making. Instead of quality of patient care, the focus has shifted to numbers and “targets being achieved” in terms of patients seen in OPD, investigations and therapeutic procedures done and often the doctor’s re-imbursement is based on these numbers. However, health-care is unlike any other capitalistic profession due to several factors but the most important is that for its proper conduct it relies on empathy and communication skills. Unfortunately while doctors and health-care staff are trained in their own technical profession they often lack training in communication skills or empathy skills. Currently no medical curriculum teaches communication skills or gives lessons on empathy. The basic instinct of an intellectual is to have freedom, i.e. freedom of choice, which comes only through information. While in internet-age a lot of information is available online, the patients/attendants still depend on the treating physician to give them accurate and honest information about the cause of disease, the disease process, the options for investigation and treatment, the course and prognosis and finally the costs involved in the therapy. However, when this information is not adequately communicated to them it leads to trouble. Thus, the crux of whole problem in majority of cases is a lack of proper communication.

SITUATION UNIQUE TO INDIA

  1. General low awareness of health issues.
  2. The primary health-care infrastructure in the country is eroding perhaps related to general lack of awareness, low priority accorded to it, low investment in this area and perhaps a peculiar tendency to directly consult the specialists / super-specialists has led to the fact that patients who could have been diagnosed in the earliest stages of their disease often slip through the primary care net to present at some super-specialist / tertiary hospitals with disease far advanced, even incurable.
  3. Low coverage of population with health insurance.
  4. Lack of communication skills in physicians which contributes very tenuous patient-doctor relationship which isespecially prone to breaking down into violence.
  5. Rudimentary health insurance structure.

WHAT LEADS TO VIOLENCE BY ATTENDANTS/RELATIVES?

  1. Physician related factors
  2. Misunderstandings: Miscommunication at any level from explanation of etiology, disease course, prognosis, need for investigations and treatment options.
  3. Mis-happenings: When the disease course and prognosis is not properly communicated to the patient, if a mishap occurs the treating doctor and staff may be perceived as callous or inconsiderate.
  4. Dissatisfaction with the course of treatment.
  5. Disagreement with physician on modalities, option and course of treatment.
  6. Malpractice.
  7. Conflict of interest: Inability to obviate the feeling that many doctors prescribe unnecessary investigations and medicines to obtain undue benefits from medical industry.
  8. Perceived lack of communication (collaboration) or inability to share information between doctor and patient
  9. Casual opinion: Criticism by other/2ndopinion doctor.
  10. Patient related factors

The second problem is that the patient and their attendants are in a most vulnerable phase of their existence, i.e. faced with temporary or permanent disability even death. In this state they are fearful, anxious and in doubt. Here what they require is empathy and humane behavior and not challenge by the doctor or staff.

  1. In many government hospitals there is overcrowding, long waiting time to meet doctors, absence of a congenial environment, multiple visits to get investigations done and then subsequently to consult doctors, concept of bed sharing by two and sometimes three patients, floor beds and poor hygiene and sanitation.
  2. Even in private hospitals there could be prolonged waiting times: delay in attention or admission of sick patient or perceived delay in investigation and treatment.
  3. Perceived (and real) lack of availability of doctor (senior doctor). Currently, there is a shortage of trained specialists. Furthermore, even in the available specialists there is a skew in distribution in favor of urban areas. As a consequence, very few experts are available in low resource setting which has even led to quacks occupying this medical space.17
  4. Perceived lack of caring by physician or staff. Many physicians especially in governmental sector are overburdened by the clinical load due to twin reasons of paucity of staff and inability of private sector to cater for really poor and low middle-class. Hugely overburdened OPDs, casualty and wards in governmental hospitals are a common sight which contributes to overstretching not only infrastructure but also medical manpower, contributing to a perception of a lack of caring by the hospital staff.
  5. Altered states of attendants: intoxication, mental illness, severe anxiety or stress.
  6. Problems of public hospitals: dysfunctional equipment, poor quantity and quality of paramedical and supportive staff (and doctors being at apex have to take blame for it).
  7. Low insurance cover of the general population is also a big contributing factor, being one of the commonest causes of leading a previously middle class family into poor class. It is a common knowledge that most incidents of violence occur at the time of preparing and payment of the medical bill.
  8. Low health related literacy. While overall literacy has improved in the country, health-care literacy still remains very low. Many care-givers fail to understand the disease process and even more importantly the available therapeutic options.
  9. Hospital related factors

Hospitals are a home to medical equipments and facilities but often do not pay much attention to security. At least most government hospitals in India are deficient in security.

  1. Lack of security personnel in casualty, ICU and other risk prone areas. Lack of police post nearby, and even when available ineffective so much so that it is more often than not completely useless.
    1. Lack of security equipment; metal detectors, scanning devices etc.
    1. Lack of security protocols. Who will respond when?
    1. Percentage expenditure in health-care is amongst the lowest all over world. This has led to very few government hospitals in the country and it has been estimated that less than 20% of health needs are catered to by government hospitals. Furthermore, even these government hospitals are at present plagued by poor infrastructure and lack of adequate manpower undertaking health-care. Thus, majority of lay public is forced to go to private sector for health needs. Despite few large corporate hospitals bulk of health-care service is provided by small and medium private healthcare establishments (accounting for 7/6th of private healthcare institutions)which isolated, disorganized and woefully lack in security arrangements.
  2. Role of community
    1. Weak and ineffective laws. While some laws are present they are ineffective for the protection and safety of the medical personnel in private arena. In government sector while it is a non-bailable offense to assault a any uniformed public servant like a government doctors, the rules are hardly ever strictly enforced and lay public being aware of this weak implementation has no qualms in “exacting revenge” from the doctor and the hospital staff in any eventuality of mishap with their patient. Rather, since these acts go regularly unpunished it provokes mob violence, one incident after another.
    1. Community leaders. Another problem could be small time community leaders/troublemakers – This is more of a problem in government hospitals or employee insurance hospitals who cater to a significant population of working class (unlike corporate hospitals which deal nearly exclusively with intellectual or elite class). These individuals might consider the health crisis an opportunity to “show off” their leadership skills or they may grudge the perceived power enjoyed by the physicians (at that point of time) and feel that their own power is in jeopardy and may feel slighted. They may react by organizing others from patients’ relatives and friends, inciting violence against so called established power i.e. the heath-care professionals including doctors. On the other hand what the professionals being an intellectual class dislike most is ego basing and thus the doctors respond back even more vehemently to the perceived slight starting a vicious cycle.
    1. Lack of faith in judicial process. In India, lay public does not have adequate faith in the legal process of the country. Society, in general, believes that the doctorsareoften‘well connected’ and will get away with anything, forcing a common man to take law into his/her own hand.21
  3. Role of Media

The media is forever in search of a good story. The story of an underdog fighting a huge establishment is ever popular. In this whole schema the poor, defenseless patients become an underdog fighting against the huge and established but corrupt medical system led by highly intellectual and “powerful” physicians. This is a good recipe for any successful journalistic endeavor but gives a very poor image to an average doctor. Thus, press indulges in the sensationalization of every related news item, often completely ignoring the real facts.

HOW TO ANTICIPATE VIOLENCE IN HEALTHCARE SETTING?

The key is to remain alert to this eventuality. There are certain tell-tale signs which can be looked forto anticipate any violence, easily identified as an acronym STAMP:

SStaring / Lack of Eye Contact
TTone & Volume of Voice
AAnxiety 
MMumbling
PPacing
  • Undue staring is an important early indicator of possible violence. This is generally deployed on mid-level health workers like nurses to intimidate them into improper action, but if they refuse can culminate into violence.
  • Lack of eye contact / shifty gaze is another important cue which is reflective of anger and passive resistance although there could be some cultural reasons to avoid eye contact.
  • Tone and volume of voice is a very important clue to impending outburst but caustic and sarcastic replies with a normal tone are also important.
  • Signs of anxiousness, frequently rubbing hands, tapping hands or feet, non-seasonal perspiration should be accounted for before they reach a dangerous level.
  • Signs or substance abuse or drug intoxications should be kept in mind and appropriate steps taken.
  • Mumbling, using slurred / incoherent speech or repeatedly asking the same question or making the same statements are important signs to be recognized. Mumbling can be interpretive of mounting frustration and a cue for violence.
  • Pacing is another indication of mounting agitation as well as staggering, waving arms or pulling away from healthcare personnel attempting to treat them.

HOW TO MANAGE VIOLENCE IN HEALTHCARE SETTING?

At the Time of Violence

If violence is impending or actually occurring:

  1. Remain calm in the face of provocation and don’t raise your voice but try let things blow over.
  2. Obtain all the documentary evidence of violence. It is a good idea to earmark some hospital staff who will take photographs, audio/video records of the violence.
  3. Immediately all medical record of the patient should be photocopied because there is a huge possibility that interested person / mob could carry away the original record.
  4. Inform the legal counsel / lawyer immediately.
  5. Inform the police immediately by phone, sending someone to police post, sms but importantly keep a record of such attempts to contact law enforcing agency.
  6. Identify the troublemakers/ community leader / s inciting violence.
  7. Get written, signed statements from all individuals present (physicians, nurses and other para-medical staff, patients, relatives, and other bystanders) in context of the violence.
  8. Lodge an First Information Report with the police.
  9. While registering a complaint make sure that it is registered under the relevant act i.e. Protection of Medical Personnel.
  10. It is very important not to try to ‘settle’ the issue by paying hush money which seems more as an admission of guilt than otherwise.

PREVENTING VIOLENCE IN HEALTHCARE SETTING

Preventive Tips for the physicians

  1. Better communication: This is the most workable strategy with the intellectual class:
    1. The physicians have to understand that patients and relatives are going through extra-ordinary fear, anxiety and doubt and may not thus behave rationally. Further the doctors have to understand that patients come from a variety of background, class, educational and economic status.
    1. Patient / their care-givers should always be kept in loop at each and every medical step: investigation, diagnosis or treatment.
    1. Don’t make the patient feel that the doctor is in a big hurry and that patient is wasting his time, rather devise a strategy to over-come the problems of time constraints suffered (by physicians) probably by having more supportive staff specializing in counseling.
    1. Avoid inculcating fear in patient or make them feel that they are somehow responsible for their state (to which patients respond by putting the blame on doctors).
    1. Patient satisfaction comes from being heard and being understood.
    1. In case of complications/death a senior doctor should talk to patients/relatives which gives them assurance that best treatment is being/was given to the patient.
    1. Doctor–patient communication is a two-way street. While it is the patient’s right to get accurate medical information, it is their responsibility as well. The way doctors can facilitate this process is by prescribing information: i.e. by providing patients with educational handouts, putting up their own websites, or referring them to health libraries. This way the patients will know more about their conditions and available options and also obtain realistic expectations of what their doctor can do for them. At the same time it is the patients / attendants responsibility to give accurate information to the health-care providers and not hide inconvenient facts from them. There should be no use of either hyperbole or at the same time under-statement. As far as possible exact situation must be communicated.
  2. Incorporating discussion on philosophy of medicine, ethics and empathy training in medical curriculum. Medical philosophy needs to be reoriented towards changed structure and accompanying perceptions of society. Classic parental doctor–patient relationship no longer works, now it has to be a participatory approach. It has to be effectively communicated that doctors can’t perform miracles, indeed they can modify disease process but they cannot prevent eventual mortality. At best they can help patients to adjust with disease its morbidity and mortality. Likewise, the importance of teaching empathy to budding doctors cannot be over-stressed. Studies reveal that good empathy training could lead to good doctors.  It is particularly important to show empathy for suffering and sympathy in financial dealings. The patient should be treated as a fellow human and not some abstract problem or worse made fun of or treated with ridicule.
  3. Proper and written consent in word and spirit in the patients’ own dialect and language with witnesses must be obtained before undertaking major investigations or treatments especially of interventional nature. The consent should delve upon the purpose of investigation/intervention, its possible outcome, clearly detailing commonly occurring life-threatening/non-life-threatening complications, the available alternatives, advantages/ disadvantages of each one of them. In case the patient refuses, the consequences of refusal must be discussed and mentioned explicitly in the consent form. While performing an intervention only those procedures be done for which consent has been obtained unless it is life-saving.
  4. Second opinion should be given very carefully, with careful choice of words. At the same time patient may be encouraged to seek a second opinion as a strategy to build confidence. If second opinion is different from your own opinion, the reasons for difference must be discussed and the final choice strictly left to the patients / care-givers.
  5. Effective management strategy should be put in place: a damage control plan, when violence against heath staff seems imminent (not to react tit for tat – anger for anger) and address patient grievances.
  6. Give a sense of security to the patient and relatives: a sense that everything is going as per plan. In other words, they should try not to frequently change the treatment plan as well as the cost. The cost of managing complications should as far as possible be incorporated in the initial costing.
  7. It is important never to over-reach in attempts to treat a patient. One should realize the limits of what medicine can do as well as limit of available infrastructure and most importantly of self. Never do any procedure beyond the scope of one’s training and facilities. The dictum “do no harm” holds true for entire medical specialty.
  8. Proper documentation is the key to all successful modern medical practice. Accurate and proper documentation may not directly prevent violence but after violence records may be seized by police. Unfortunately, in very sick patients the focus is entirely on saving life and documents are not in order but it is always important to keep this in mind, even keep photocopies of important documents because they might be lost in the chaos of ensuing violence. It may be a good idea to employ a staff or at least delegate the work of record keeping to one of the medical staff, so that this aspect is not overlooked.
  9. Certain safety habits can be suggested;
  10. Play a close attention to surroundings when you come out of office; avoid looking at your phone as you walk in hospital area.
  11. Pay close attention to the cars parked around when coming and leaving the hospital premises
  12. Lock the car door immediately after entering.

Preventive Tips for the Hospital Administrators

  1. Strengthening theSecurity.
  2. Security personnel (preferably army background) should be posted at the entrance of every hospital, ICU and operation theaters and should not let anyone through without checking for appropriate identification. 
  3. Weapons / weapon like objects should be confiscated before allowing passage to anyone. 
  4. All attendants must register at the front desk and be given a visitor badge to be worn at all times.                                               
  5. Restrict entry of attendants to clinical workplace.  No more than two attendants should be allowed with the patient.
  6. Establish a Hospital Committee (PRO) specializing in effective communication which can satisfy the patients/attendants.
  7. Trained Psychologists (counselors) should be available to cater for emotional needs of patients and their care-givers when required. 
  8. Since India is a diverse country with several official languages and also medical tourism is showing a huge growth, language translators should be available who can prevent incidences of miscommunication. 
  9. Hospital workplaces should establish a policy for assessing and reporting threats, which would allow employers to track them to see whether prevention strategies are working.
  10. Reduce the waiting times for everything and if they cannot be done at least explain why these times are there in the first place.
  11. Every hospital should have an emergency algorithm including an evacuation plan in case of a major act of violence.
  12. At the time of designing a hospital attention should be directed to workplace’s landscaping, parking lot and outdoor lighting keeping in mind security aspects.
  13. Displaying information and also the laws governing the safety of doctors up-front:
  14. To satisfy the intellectual class
  15. To make them aware of consequences of violence against doctors
  16. Involving media in their activities.
  17. Health care personnel must have some training in martial arts, which might save their life in some instances.

STRONG &EFFECTIVE LAWS: Essential in fight against Violence.

1. Strengthening theLaw against Violence:

It is very important to make ‘violence against doctors’, a non-boilable offence for all medical areas; private or public. There is indeed a need to modify the Indian Penal Code to allow for tougher penalty against the perpetrators of such violence.

2. Implementation of Effective Laws:

Often, the real challenge faced in preventing violence against doctors is poor implementation of existing laws. A lack of implementation of existing laws has obstructed efforts to protect doctors from the menace of violence.Law meant for protection of doctors against violence needs to be stricter and should be implemented promptly and effectively.Law enforcing authorities should be particularly sensitized to this aspect and must realize that their mandate is to maintain law and order. The Rule of Law must be respected and adhered to by the society at large.

Role of Media in preventing Violence:

Media has a very important role to play: They should also write positive things about the profession or at least both sides of the issue in situations like this; they should avoid journalism of sensationalism and avoid provocative head-lines. While in short term these kinds of reports get a few eye-balls but in long run might prove counter-productive for the society.

Health related Literacy

There is a need to educate not only lay public but even fist-contact physicians in some cases for example myocardial infarction. There is need to be clear guidelines and management algorithms forlay public and even physicians.

Insurance Schemes

Mass insurance schemes should be offered to cover the whole population. Several states have their own schemes but National schemes like the currently launched PM JAY scheme and older RashtriyaAyraogya Nidhi for BPL patients are revolutionary steps in this direction.

CONCLUSIONS

In a predominantly capitalistic society health-care and primary education are perhaps the only remaining professions in India, which lay public expects to function on socialistic model. This would ensure a cost-effective, high class health-care delivery to practically entire population. However, in reality medicine (as also education) is no longer treated as a welfare activity but rather a profit making venture, at least by corporate sector. This difference in perception between the society in general and the health-care deliverers has led to serious gap between what is expected and what is delivered on health front. One of the outcomes of this mis-match is violence against doctors (among other problems) which is seriously threatening the status quo in this profession. On the other hand while violence on road (road rage), public places, even schools is common (though not condone-able), it can under no circumstance be acceptable in hospitals. The hospitals simply cannot be allowed to become battlegrounds for the simple reason that sick people need a peaceful environment where they can get sympathy, empathy, support etc. Even health-care professionals need a stable and peaceful environment if they are ever able to give self-less care rather than worry about their personal safety. Thus, if the hospital environment is exposed to violence its practitioners might start practicing defensive medicine, and focusing on saving their own skin rather than treating a patient. One of the major factors contributing to violence is not only monetary considerations but also a lack of communication and a failing doctor-patient bonding. Solution lies in not only in changing attitudes and practices of physicians and hospitals but also regulators, media and even lay public.

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Research finds breastfeeding is being overtly discouraged by infant formula websites

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Despite public health efforts to support breastfeeding and informed choice, during a news study, an analysis of websites for baby formula manufacturers found that their messages and images discourage breastfeeding while touting the benefits of the formula.

The study, led by researchers at the NYU School of Global Public Health and published in the journal Public Health Nutrition, is the first to compare information and portrayals of breastfeeding with infant formula feeding on manufacturer websites directed at U.S. consumers. “Many factors influence parents’ decision to breastfeed or use formula, including breastfeeding support and work schedules. But we also know that marketing and advertising play a critical role,” said Jennifer Pomeranz, assistant professor of public health policy and management at NYU School of Global Public Health and the study’s lead author. “It is important to understand the messages caregivers are receiving directly from formula companies, whose websites are targeting pregnant women and new parents with marketing claims disguised as feeding advice and support.”

Breastfeeding has many well-documented benefits for infants and mothers. Because breast milk is a complete source of nutrition for babies and can protect them from infections and certain diseases later in life, the U.S. and global health authorities recommend breast milk as the sole source of nutrition during a child’s first six months and encourage continued breastfeeding.

Previous research shows that marketing from formula companies can influence norms and attitudes around infant feeding and may use unsubstantiated health claims to promote formula and diminish confidence in breast milk. To prevent this, the World Health Organization urges countries to ban the marketing of formula to consumers; while the U.S. still allows it, the Surgeon General recommended that infant formula be marketed in a way that does not discourage breastfeeding.

Pomeranz and her colleagues analyzed the websites of three major formula brands that make up 98 per cent of the U.S. market, as well as two organic brands, to compare messages and images about breastfeeding and breast milk with those about infant formula feeding.

The researchers found that substantial messaging on the five formula manufacturers’ websites focused on discouraging breastfeeding. The websites actually contained more messages about breastfeeding or breast milk than formula, but much of the breastfeeding content (40 per cent) focused on challenges, such as having a low supply of breast milk or difficulty latching.

The websites were significantly more likely to mention the benefits of formula (44 per cent)–for instance, statements that formula provides brain and gastrointestinal benefits–than benefits of breastfeeding or breast milk (26 per cent).

Moreover, manufacturers compared formula feeding to breastfeeding, rather than comparing their brands positively to other brands.

Images on the websites also illustrated the benefits of formula–including the ease of feeding, with babies holding their own bottles–while making breastfeeding look difficult and labour intensive.

“Infant formula manufacturers’ repeated communication about breastfeeding problems such as reduced breast milk supply or sore nipples, coupled with images of women holding their breasts to breastfeed, implies that breastfeeding is hard, painful work. These recurring messages may ultimately discourage breastfeeding,” said Pomeranz.

“Even if websites frame their ‘advice’ as providing solutions to the problems identified, it is completely inappropriate for a formula company to disseminate information–let alone negative information–about breastfeeding to new parents and mothers in particular,” added Pomeranz.

The researchers identified other marketing tactics on formula websites, including the use of discounts or coupons, contact information for sales representatives, and claims of health and nutritional benefits of infant formula over breast milk.

“These marketing practices directed towards U.S. consumers would be legally suspect in other countries, many of which follow W.H.O. recommendations and prohibit direct-to-consumer marketing of infant formula,” added Pomeranz.

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NEW INSIGHTS INTO FUNDAMENTAL WORKINGS OF IMMUNE SYSTEM IN RESPONSE TO SKIN CANCER THERAPY

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New research led by the University of Birmingham suggests that skin cancer patients could have a better prognosis if their T cells send messages from five specific genes in their immune response to drugs given to treat the disease.

The research, carried out in mice, cells in the laboratory, and using publicly available data from patients with advanced melanoma before and after treatment with Nivolumab therapy, was published in the journal Immunity. T cells are white blood cells that protect the body from harm from viruses, bacteria, and cancer cells and explore their environments by using their T cell receptor (TCR) to recognise fragments – called antigens – of microbes or damaged cancer cells.

The TCR controls the behaviour of the T cell and can send messages to the T cells’ command centre to kick-start an immune response. This process is important for vaccine research and treatment of autoimmune conditions but is particularly of interest for cancer treatments to improve the anti-tumour function of T cells.

The researchers carried out the study to better understand how the amount of antigen controls how the TCR sends messages to the T cells’ command centre, and how this affects the type of immune response. They wanted to explore how antigen amounts control the expression of so-called ‘immune checkpoints’ that act as brakes on immune responses. It is these immune brakes, such as one called PD1, that are the target of drugs that seek to increase the immune response in cancer immunotherapy.

Lead author Dr David Bending, of the University of Birmingham’s Institute of Immunology and Immunotherapy, explained: “Through our research, we discovered that the amount of antigen determined how many immune checkpoints or immune brakes a T cell had on its cell surface.

“When we exposed T cells to the highest amounts of antigen, they stopped sending signals to their command centre, and this was because they had increased the number of immune brakes, which shut down the messengers. This made these T cells unable to respond to antigens for a period.”

By blocking one of the immune brakes, called PD1, the researchers were able to re-awaken some of these ‘unresponsive’ T cells. They found that these re-awakened T cells not only started sending messages to their command centres, but the messages they sent were louder and clearer.

“The response from the command centre was that the T cells started to increase the number of messages from five specific genes,” added Dr Bending. “By looking for the messages from these five genes, we were able to show that these stronger and louder messages were increased in melanoma patients who survived for longer on drugs that block the immune brake PD1. We think that this means that those cancer patients whose immune cells can send messages from these five genes in response to drugs that target PD1, a good outcome is far more likely.”

The researchers said their finding shows that the immune system likely requires an optimal level of stimulation to mount the most effective immune response in skin cancer patients. Dr Bending added: “Our research gives us an interesting insight into fundamental workings of the immune system. It suggests that both the amount of antigen around a T cell and also the number of immune brakes the T cells have at their surface are very important in controlling immune responses. Furthermore, we have shown that we can alter the balance of the immune response through stopping some of these immune brakes, which results in a stronger T cell response.”

The study has generated a new potential readout to monitor patients on drugs targeting PD1 in cancer. It also may be useful for exploring the potential of combinations of drugs that target multiple immune checkpoints to try to further re-awaken T cells in cancer patients.

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Witnessing abuse of sibling can lead to mental health issues

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A new study from the University of New Hampshire showed that children who witness the abuse of a brother or sister by a parent can be just as traumatised as those witnessing violence by a parent against another parent.

According to the study, such exposure is associated with mental health issues like depression, anxiety and anger. The findings of the study were published in the journal ‘Child Abuse and Neglect’.

“When we hear about exposure to family violence, we usually think about someone being the victim of direct physical abuse or witnessing spousal assault,” said Corinna Tucker, professor of human development and family studies.

“But many children witness abuse of a sibling without being a direct victim and it turns out we should be thinking more about these dynamics when we tally the effects of family violence exposure,” added Tucker.

In their study, the researchers used the combined data from three national surveys to look more closely at the experiences of over 7000 children between the ages of one month to 17 years old.

This included any incident in which a child saw a parent hit, beat, kick or physically hurt (not including spanking) a sibling in their household over the course of their lifetime. Of the 263 (3.7 per cent) youth who had been exposed to parental abuse against a sibling (EPAS), more witnessed abuse by fathers (70 per cent) than mothers.

Exposure was greatest for boys and adolescents and for those whose parents had some, but not completed, college education. It was lowest in families with two biological or adoptive parents. Rates did not differ by race or ethnicity. Youth exposed to EPAS showed higher levels of mental distress like anger, anxiety and depression.

“In some families, EPAS may be part of a larger family climate of violence,” said Tucker. Tucker added, “As more family members are exposed to violence in the household, there can be less emotional security among family members and less opportunities for children to observe, learn and practice healthy responses to stress.”

Researchers said that this study highlights the unique contribution of EPAS to feelings of fear and mental health distress in youth. They hope it will broaden the thinking around domestic violence to recognize EPAS as a form of indirect exposure and calls for practical and clinical applications like intervening by asking siblings about their exposure to the violence, increased education and encouragement for parents, especially fathers and offering ways for exposed children to help by supporting siblings and feeling safe telling another adult.

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While risk factors for hospitalisation and poor outcomes are well documented in adults, less is known about the clinical factors associated with Covid-19 disease severity in children.

A new study attempted to determine the factors associated with severe coronavirus infection in children. The findings of the study were published in the ‘Journal of Hospital Medicine’. In an effort to aid mitigation strategies for children who are at high risk of developing severe Covid disease, a group of physicians at Monroe Carell Jr. Children’s Hospital at Vanderbilt studied data from 45 children’s hospitals around the country — 20,000 patients were included.

“This is one of the largest multicenter studies of children with Covid-19 in the United States,” said James Antoon, MD, PhD, FAAP, assistant professor of Pediatrics at Children’s Hospital and lead author of the study. “And given the recent, concerning increases in COVID cases nationwide and the fact that the vast majority of children remain unvaccinated and susceptible, these findings should be taken into account when considering preventive strategies in schools and planning vaccinations when available for children less than 12 years of age,” he said.

The study determined the factors associated with severe disease and poor health outcomes among children presenting to the hospital with Covid-19. These included older age and chronic co-morbidities such as obesity, diabetes and neurologic conditions, among others.

“These factors help identify vulnerable children who are most likely to require hospitalization or develop severe Covid-19 disease,” said Antoon.

“Our findings also highlight children who should be prioritized for Covid-19 vaccines when approved by the FDA,” added Antoon.

The retrospective cohort study noted that approximately 1 out of every 4 children admitted to the hospital with Covid developed severe disease and required ICU care during April and September 2020.

“Across the country there is a raging debate on how best to protect children and schools from Covid-19,” said Antoon. “Some children are at increased risk for more severe disease and many of them are not yet eligible for vaccination against Covid,” added Antoon.

Antoon further said, “With schools opening and some already in session, these children need to be protected by vaccinating as many people as possible while also using practical strategies to limit spread, such as masking, distancing and ventilation.”

Study investigators hope that the findings will buoy mitigation efforts that proved most beneficial for children and adolescents during the pandemic, including remote learning, social distancing, hand-washing and mask-wearing both for students and teachers.

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Will be able to inoculate entire population by the end of the year: NTAGI Chief NK Arora

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On Friday, India established a new milestone by administering more than 2 crore Covid-19 vaccinations in a single day. The country is the first in the world to reach such a large-scale vaccination target in one day.

Dr NK Arora, Chief of National Immunization Technical Advisory Group (NTAGI), praised the achievement saying, “I would like to congratulate India as a whole, as well as the citizens’ enthusiasm for immunisation. We know of nations like the United States and the United Kingdom that had large inventories of vaccines but individuals who were not ready to accept them. It’s happening at such a rapid speed that 1.37 lakh individuals may have already been vaccinated as we speak. This has been in the works since March 2020, and it will not be completed overnight.”

Taking into consideration the speed of vaccination, do you believe we are on the right track to vaccinate entire country by year end as previous government claims?

Dr NK Arora: People thought that it would take us 3 to 5 years to immunize the entire nation, but we achieved it. The reason behind this is that there are 4 to 5 sectors. Right from the beginning, there has been a philosophy of vaccine Atmanirbharta. Each and every vaccine administered in this country is Made In India and that is why we are not begging anyone else. Secondly, the preparation for rollout started in July when Corona vaccine centre planning was being done. Thirdly, we have a very expensive child immunization framework and infrastructure and this vaccination had been put on that. Fourthly, adults were being immunized for the first time and nobody was sure whether they will come up for vaccine or not. There was vaccine hesitancy even among the medical professionals for the first 6 to 8 weeks and there was a very proactive program to take care of that. Fifth, a major program for managing and keeping a record of this supply system was present.

Co-Win is a phenomenal platform and I believe country is very proud to have such digital platform for the management. Finally, we have a genomic surveillance program which is Cutting edge Technology, which is monitoring and picking up virus samples from all over the country to check how effective our vaccine is. I must recall here that we immunize 17 crore children every week under the Polio Immunisation Program, that is 2.5 crore children being immunized each day. If we can do that, we can do this also.

When can we expect children’s vaccination?

We are having meetings on prioritizing adults and children separately. We have 44 crore children below 18 years of age and 12 crore adolescents between the age of 12 to 17 years of age. From October onwards, we will prioritize those children who are likely to catch severe disease and possible unfortunate death. Healthy children do get infected just like adults but the possibility of severe infection and death is almost zero. Now schools are also opening, and once the parents, teachers and other adults are immunized, children will remain in a protective ring.

What is the status on the WHO approval on Covaxin?

Dr NK Arora: We should most probably get it by this week or the next week at maximum. Most of the paper work has been going on for quite some time and we have already provided the data for the safety of the vaccine and hope that it should be done as soon as possible and people might commute form October onwards.

Everyone is talking about the booster dose, what is the development on that front?

Dr NK Arora: In a meeting, we were just discussing about the efficacy of the vaccines and the vaccine tracker platform announced by the government last week. I would like to share that one dose is providing 97% protection from the virus, while two doses provide 98% efficacy and chances of hospitalization is reduced by 95%. Several parts of the country are conducting studies to see that it is not just the antibodies that provide protection because their decline is a natural process. We are looking at the ground situation and when the scientific evidence comes, we will start with the booster shots as well and we will also identify the subgroups that require special attention. We are regularly scanning through the scientific evidence of our country, not relying on data provided by USA or any other nation. We will work on this data only.

Indemnity was there regarding Pfizer and Moderna. Is that something that is under consideration or are we going to continue on the path of Atmanirbhar Bharat for the time being?

Dr NK Arora: We have our own DNA vaccine which is world’s first vaccine and we will have our own RNA vaccine by November most likely. Indemnity is a sticking issue but we have our own effective vaccines and the discussions are being carried out on our terms.

What would be your advice to the people this festive season?

Dr NK Arora: With folded hands, I would say that pandemic comes once in a century while festivals come each year. So we must have another year of discipline. Spend the days of festivities among your own family members which is safer. I may have been vaccinated but the virus can spread through me to others and similarly I could get infected too. Covid appropriate behaviour and social distancing does not only mean keeping an arm’s distance away from a person, but keeping away from the crowd. We have witnessed a spike during the festivities last time and hence I would really request that people celebrate festivals with discipline this year.

Would you second the claims on third wave or would you deny?

Dr NK Arora: 70 to 75 per cent of our population has already been infected will now. There will be a spike driven by lack of discipline. Whenever we have let our guards down, we will invite a surge. Fortunately, no new variant has come and it is a redeeming point. It will not be wise on our part to not be disciplined for the coming 6 to 8 weeks.

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Better mental health support needed for pregnant individuals during Covid-19

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A team of researchers suggested that more mental health supports are needed for pregnant women after a survey found nearly three-quarters of individuals who had been pregnant during the pandemic reported moderate to high levels of distress and one in five experienced depressive symptoms. The findings appeared in the journal ‘Canadian Family Physician’. The researchers, led by clinicians at Unity Health Toronto, surveyed nearly 1,500 participants online, 87% of whom were Canadian—who had been pregnant during the pandemic. Nearly 69% of respondents reported moderate to high levels of distress and 20% had depressive symptoms.

“The high levels of distress highlight the importance of considering mental health centrally in support for this population,” said Dr Tali Bogler, study lead author and family physician and chair of family medicine obstetrics at St. Michael’s Hospital of Unity Health Toronto. “The findings also highlight the overall impact the pandemic has had on families and the downstream impact this will have,” she added. A limitation of the study is it didn’t have comparable data on distress levels among pregnant people prior to the pandemic. However, a population-based survey conducted in Japan before the pandemic found 28% to 32% of pregnant people reported distress.

Researchers also sought to learn more about the common sources of concern for pregnant women during the pandemic. Participants were provided with a list of 27 concerns. The top five concerns included hospital policies regarding support persons in labour; not being able to introduce their baby to loved ones; getting sick from Covid-19 while pregnant; not being able to rely on family or friends after labour for support; and conflicting medical information on Covid-19 in pregnancy and newborns, especially early in the pandemic. First-time parents were more concerned about the cancellation of in-person prenatal classes and hospital tours whereas second or third-time parents were more concerned about the transmission of Covid-19 from older children in the home. The authors said that family physicians are well placed to support perinatal mental health and can engage in screening practices and offer appropriate treatment such as counselling, public health nursing, and psychiatric appointments. They also recommend hospitals better utilise technology to help address parents’ concerns by arranging more virtual check-ins and hospital tours and provide more online resources with evidence-based information on Covid-19 relevant to expectant and new parents.

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