Beware of data on the web

Beware of data on the web 

Dr K K Aggarwal, National President IMA

A lab accidentally released the medical reports of 43,000 people, including HIV patients. Some patients included in the breach are as young as 17. 

UPDATE: The reports appear to have been taken down.

Originally posted on Dec. 2, 2016, at 1:54 p.m/ Updated on Dec. 2, 2016, at 7:11 p.m.

Pranav Dixit, BuzzFeed News Reporter

BuzzFeed News was able to access the folder containing the reports via a simple search. Google

The medical records of over 43,000 people have been accidentally made public after being put online by a pathology lab in Mumbai. The reports contain confidential details like names, addresses, dates of birth, and blood test results. They also include details of patients who have had blood tests done for HIV detection. Some included in the breach are as young as 17.

The reports, which the pathology lab Health Solutions was storing in an unprotected folder on its website, were accessible to anyone with the right URL. 

Worse, since the reports were exposed, they have already been indexed by Google and likely other search engines too. BuzzFeed News was able to access the folder via a simple search.

The confidential blood test reports included one, which was done for HIV determination, from the Health Solutions website. 

The breach was first discovered by web security expert Troy Hunt, who told BuzzFeed News that reports were stored in a folder with directory listing enabled. “What this meant was that there was literally a folder describing all the 43,000-plus files,” said Hunt. “This also means we have no idea of how many people have seen the files — they could have been viewed within cache.” Hunt was also able to find out that the reports were sitting on a server located in Provo, Utah.

None of the reports were password protected or had any kind of access control on them, which means that anybody could download anybody else’s pathology reports. “It’s about as bad as it gets, security-wise,” Hunt said.

When BuzzFeed News contacted Rodrigues Kustas, administrator at Health Solutions, he denied any knowledge of the breach before disconnecting the call. Kustas called BuzzFeed News back 30 minutes later, saying he was now aware of the breach. He said Health Solutions was moving to a new website in January because its current one had been “hacked” several times. Due to the move, he said there wasn’t any way the lab could fix the problem right now.

 “Look, we are not the doctors, we merely do blood tests for patients. We also have more than 250 franchisees all over Mumbai who do tests for us,” Kustas said. “So maintaining doctor–patient privacy is not something that we as the lab are concerned with.”

Kustas also said that the lab’s website was built by a third-party developer who he described as a personal friend, but refused to provide any more details.

The pathology reports are organized by folder. BuzzFeed News blurred every entry in the folder for privacy reasons. 

Unlike the United States, where the Health Insurance Portability and Accountability Act (HIPAA) mandates doctor–patient confidentiality, India does not have a strong legal framework around medical privacy or even a privacy law in general.

Doctors who BuzzFeed News spoke to said that each hospital follows its own guidelines around maintaining patient privacy in the absence of an umbrella framework.

The only reference to privacy comes in the Code of Ethics and Regulations published by the Medical Council of India (MCI), a statutory body that enforces medical standards in the country. It says: “Confidences concerning individual or domestic life entrusted by patients to a physician and defects in the disposition or character of patients observed during medical attendance should never be revealed unless their revelation is required by the laws of the State.”

BuzzFeed News has reached out to all nine members on the executive committee of the MCI for comment.

A Google spokesperson pointed BuzzFeed News to the search engine’s page for removal policies, and provided the following statement: “Google Search generally reflects what’s on the web, so we ask that if people want content removed from the web, they start by contacting the site hosting the content. After the content is taken down, it will drop out of search engines’ web results.”

 “This serves as a reminder that once we digitize anything, there’s a far greater risk of it being inadvertently disclosed,” Hunt said. “It’s another case like so many others we’ve seen where there’s large amounts of sensitive data exposed and the owner is totally unaware.”

Update

A few hours after BuzzFeed News published this story, the main folder full of patients’ reports is no longer accessible. It appears as though Health Solutions has taken down the directory. Dec. 2, 2016, at 7:11 p.m.

All About extra corporeal membrane oxygenation

All About extra corporeal membrane oxygenation

 What is ECMO?

ECMO or extra corporeal membrane oxygenation is a type of prolonged mechanical cardiopulmonary support that is usually delivered in the intensive care unit.  ECMO is performed by clinicians with training and experience in its initiation, maintenance, and discontinuation.

How does it function?

During ECMO, blood is drained from the native vascular system, circulated outside the body by a mechanical pump and re-infused into the circulation. While outside the body, the blood passes through an oxygenator and heat exchanger. In the oxygenator, hemoglobin becomes fully saturated with oxygen, while carbon dioxide (CO2) is removed. Oxygenation is determined by flow rate, whereas CO2 elimination can be controlled by adjusting the rate of countercurrent gas flow through the oxygenator.

What are the types of ECMO?

ECMO can be venovenous (VV) or venoarterial (VA):

·         In VV ECMO, blood is extracted from the vena cava or right atrium and returned to the right atrium. It provides respiratory support, but the patient is dependent upon his/her own hemodynamics.

·         In VA ECMO, blood is extracted from the right atrium and returned to the arterial system, bypassing the heart and lungs. It provides both respiratory and hemodynamic support. The additional benefit of hemodynamic support comes with additional risks. 

VV ECMO is used in patients with respiratory failure, while VA ECMO is used in patients with cardiac failure.

 Which patients are suitable candidates for ECMO?

 ECMO is indicated for patients with severe, but potentially reversible, acute respiratory or cardiac failure that is unresponsive to conventional management.

 What is the procedure?

 Once it has been determined that ECMO will be initiated, the patient is anticoagulated. Cannulae are then inserted and the patient is connected to the ECMO circuit. The blood flow is increased until respiratory and hemodynamic parameters are satisfactory. Once the initial respiratory and hemodynamic goals have been achieved, blood flow is maintained, ventilator support is minimized, and vasoactive drugs are decreased to minimal levels.

 The patient's readiness for weaning from ECMO should be evaluated frequently. Prior to discontinuing ECMO permanently, one or more trials should be done during which the patient is off ECMO. Such trials provide an opportunity to the clinician to determine whether conventional supportive care is sufficient for the patient.

What are the complications?

 Bleeding is the most common complication (30-40%) of ECMO. Thromboembolism and cannula complications are rare (<5%).

 What are the contraindications?

 The only absolute contraindication to ECMO is a pre-existing condition, which is incompatible with recovery (severe neurologic injury, end stage malignancy). Relative contraindications include uncontrollable bleeding and very poor prognosis from the primary condition. Results in respiratory failure are better when ECMO is instituted within 7 days of intubation.

 Have studies been conducted in cardiac arrest?

 VA ECMO can provide acute support in cardiogenic shock or cardiac arrest in adults.  Assuming that the brain function is normal or only minimally impaired.

 ECMO is provided until the patient recovers or receives a long-term ventricular assist device as a bridge to cardiac transplantation. Observational studies and case series have reported survival rates of 20 to 50 percent among patients who received ECMO for cardiac arrest, severe cardiogenic shock, or failure to wean from cardiopulmonary bypass following cardiac surgery.

 In two observational studies, ECMO performed for cardiac arrest was associated with increased survival compared to conventional cardiopulmonary resuscitation (Crit Care Med. 2011;39(1):1-7 and Lancet 2008;372(9638):554-61).

 In a systematic review of adults with refractory out of hospital cardiac arrest, survival was 22% in the 833 patients who received ECMO during resuscitation and half of these had good neurological recovery (Resuscitation 2016;101:12-20).

 Which is the largest study in cardiac arrest?

 A systematic review and meta-analysis of cohort studies comparing mortality in patients treated with and without ECLS support in the setting of refractory cardiac arrest and cardiogenic shock complicating acute myocardial infarction was conducted by Ouweneel et al (Intensive Care Med. 2016 Dec;42(12):1922-1934).

 Purpose: Veno-arterial extracorporeal life support (ECLS) is increasingly used in patients during cardiac arrest and cardiogenic shock, to support both cardiac and pulmonary function. We performed a systematic review and meta-analysis of cohort studies comparing mortality in patients treated with and without ECLS support in the setting of refractory cardiac arrest and cardiogenic shock complicating acute myocardial infarction.

 Methods: We systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the publisher subset of PubMed updated to December 2015. Thirteen studies were included of which nine included cardiac arrest patients (n = 3098) and four included patients with cardiogenic shock after acute myocardial infarction (n = 235). Data were pooled by a Mantel-Haenzel random effects model and heterogeneity was examined by the I (2) statistic.

 Results: In cardiac arrest, the use of ECLS was associated with an absolute increase of 30 days survival of 13 % compared with patients in which ECLS was not used (95 % CI 6-20 %; p < 0.001; number needed to treat (NNT) 7.7) and a higher rate of favourable neurological outcome at 30 days (absolute risk difference 14 %; 95 % CI 7-20 %; p < 0.0001; NNT 7.1). Propensity matched analysis, including 5 studies and 438 patients (219 in both groups), showed similar results. In cardiogenic shock, ECLS showed a 33 % higher 30-day survival compared with IABP (95 % CI, 14-52 %; p < 0.001; NNT 13) but no difference when compared with TandemHeart/Impella (-3 %; 95 % CI -21 to 14 %; p = 0.70; NNH 33).

 Conclusions: In cardiac arrest, the use of ECLS was associated with an increased survival rate as well as an increase in favourable neurological outcome. In the setting of cardiogenic shock there was an increased survival with ECLS compared with IABP.

IMA-MR Campaign

IMA-MR Campaign 

India, along with other WHO-SEAR countries, in September 2013, resolved to eliminate measles and control rubella/congenital rubella syndrome (CRS) by 2020. 

Accordingly, Ministry of Health & Family Welfare is introducing Rubella vaccine in its Universal Immunization Programme (UIP) as Measles-Rubella (MR) vaccine. 

The vaccine will be introduced as MR Campaign, targeting children from 9 months up to 15 years, in a phased manner over 2 to 3 years, followed by inclusion of the vaccine in routine immunization.

The campaign targets a large birth cohort of approximately 41 crore children, starting in the 1st quarter of 2017. The campaign will be conducted over a period of 3-4 weeks, where vaccination will first be conducted in schools and later in community through outreach. 

The campaign aims to rapidly build up immunity against measles and rubella, and also provides a second opportunity for vaccination against measles for children left out in routine immunization.

·         Sensitize patients and their relatives.

·         Use IMA PvPI number – 9717776514 – to report adverse events.

You can make your clinic a part of the vaccination center.

Stop NMC Amend MCI

Stop NMC Amend MCI 

Dr K K Aggarwal

National President IMA

‘Stop NMC Amend MCI’ is the updated slogan. First of all we congratulate all the state and local branches for the success of the November 16^th Stop NMC Satyagraha. It has made the necessary impact with the Government of India. IMA’s strength in organising the doctors on an All India basis has positioned it as the rightful leader of the medical profession.

The right way to proceed now is to offer amendments to the MCI Act to address the concerns expressed by the Parliamentary committee while resisting the formation of National Medical Commission. The following is the plan of action for the state branches:

1.     Awareness about NMC bill amongst members

·         A common PowerPoint is being made and will be provided by IMA HQs.

·         A State level emergency Presidents/ Secretaries meet is suggested to be called to sensitize local branch officials on NMC. This may be combined with a state level workshop on amendments in MCI Act. The recommendations of the workshop may be drafted with clarity and forwarded to the undersigned as early as possible before the central council. These shall address the concerns of the Government and public in the functioning of MCI.  This will include presumed corruption of inspection in medical colleges as well as kickbacks and commissions received by a section of medical fraternity from Scan Centers, Laboratories and other clinical establishments.

·         All local branches should discuss NMC bill in their December meeting. A brief note about NMC may be sent along with the meeting notice itself so that even members who do not attend the meeting are sensitised.

2.    Lobbying

·         Meet your MP programme: All local branches will be issued a standard memorandum and briefing on NMC and encouraged to meet their MPs. Wherever applicable branches can combine action.

·         Meet your State Government programme: The states have played a major role in endorsing NMC. All state branches should meet their respective state Governments and lobby for stopping NMC and amending IMC act.

3. Shaping public opinion: NMC opens at least 60% of the seats in private medical colleges to bidding by market forces. What is worse is that this could be even as high as 90% to 95%. The stakeholders in this issue are the students who wish to take up medical career and their parents. This is a very large constituency. Press conferences, statements, articles in print media and effective intervention in visual media are suggested.

4. Medical Colleges: The next focus of action shall be the medical colleges in the country. The State President and State Secretary of the States shall function as Coordinators for the action in the medical colleges. A common document to address the students shall be sent by IMA HQs. Medical students in every medical college of the States shall be addressed. A call for action in the medical colleges of the country in the 2^nd week of January 2017 will be given. 

5. Service Organisations: Efforts to post Ayush doctors in PHCs are already spreading. Madhya Pradesh and Karnataka have issued orders to this effect. Service organisations of the states should be taken into confidence about NMC and its implications. Their support and cooperation should be solicited.

6. State Medical Councils: State Medical Councils should be briefed and sensitised. They may pass resolution against NMC. 

A weekly report from the states is expected .This would help in preparing an All India Report which in turn shall keep up the momentum.

50 Facts on HIV/AIDS

50 Facts on HIV/AIDS

Dr KK Aggarwal

National President IMA

1.     AIDS is caused by the human immunodeficiency virus (HIV), which damages the immune system, lowering the resistance of the body to fight off infections.

2.     AIDS is the advanced stage (stage 4) of HIV infection.

3.     Progression from HIV infection to AIDS, if untreated, may take 8-10 years. In young children, it usually develops much faster.

4.     HIV-positive people may remain asymptomatic but can still pass on the virus to others.

5.     78 million (69.5 million–87.6 million) people have become infected with HIV since the start of the epidemic (end 2015).

6.     35 million (29.6 million–40.8 million) people have died from AIDS-related illnesses since the start of the epidemic (end 2015).

7.     36.7 million (34.0 million–39.8 million) people globally were living with HIV (end 2015).

8.     1.1 million (940 000–1.3 million) people died from AIDS-related illnesses (end 2015).

9.     2.1 million (1.8 million–2.4 million) people became newly infected with HIV (end 2015).

10.  18.2 million (16.1 million–19.0 million) people were accessing antiretroviral therapy (June 2016)

11.  People with HIV are at risk of developing active TB disease.

12.  Transmission of HIV/AIDS can be prevented.

13.  HIV spreads through unprotected sex with an HIV–positive person.

14.  HIV spreads through transfusions of unscreened (HIV–positive) blood.

15.  HIV can spread from an infected woman to her child during pregnancy and childbirth.

16.  HIV infection can be passed from a mother to her child through breastfeeding.

17.  HIV spreads by unsterilized infected needles or syringes, especially those used for injecting drugs.

18.  Used infected razor blades, knives or tools that cut or pierce the skin also carry some risk of spreading HIV.

19.  Touching, hugging, shaking hands, coughing and sneezing will not spread the virus.

20.  HIV/AIDS cannot be transmitted through toilet seats, telephones, plates, glasses, eating utensils, towels, bed linen, swimming pools or public baths.

21.  Up to 70 % of partners of people with HIV are also HIV positive.

22.  Practicing safe sexual behaviors such as using condoms prevents HIV transmission.

23.  All pregnant mothers should get HIV test done.

24.  A blood test is the most accurate way to tell if someone is infected with HIV.

25.  Most tests for HIV/AIDS check for the presence of antibodies to the virus.

26.  If the result of an HIV/AIDS test is negative, this means the person tested is not infected or it is too early to detect the virus.

27.  Infection may not be detected up to the first few weeks to few months.

28.  Even if the first test is negative, the test should be repeated 6 months after any possible exposure to HIV infection.

29.  The time period when an infected person does not test as HIV positive is called ‘window period’.

30.  All people, including children, are at risk for HIV/AIDS, including occupational risk.

31.  People who have a sexually transmitted infection (STI) are at greater risk of getting HIV and of spreading HIV to others.

32.  Persons suffering from STIs have a 5–10 times higher risk of becoming infected with HIV if they have unprotected sexual intercourse with an HIV–infected person.

33.  If both partners are not treated for a STI, they will continue infecting each other with the sexually transmitted infection.

34.  The more sex partners people have, the greater the risk that one of them will have HIV/AIDS and pass it on.

35.  Antiretroviral therapy (ART) should be started at the earliest to prevent HIV transmission to sexual or drug using partner/s or from the mother to the infant during pregnancy or breastfeeding.

36.  People with STIs should seek prompt treatment and avoid sexual intercourse or practice safe sex.

37.  Men with HIV are less likely to be diagnosed and put on ART and are more likely to die of HIV-related causes than women.

38.  Internal secretions, which can harbor HIV virus, are blood (including menstrual blood, semen, vaginal secretions, breast milk, peritoneal fluid, brain fluid, pleural lung fluid, pericardial heart fluid etc. These secretions, when mixed with secretions of another person infected with HIV transmit HIV.

39.  External secretions, which do not harbor the HIV virus are saliva, tear, sweat, urine and feces. The mixing of these secretions with secretions of an HIV-positive person does not transmit HIV.

40.  HIV does not spread by mosquitoes or other insects.

41.  HIV counseling and testing can help in the early detection of HIV infection, to get the support services for those who are infected.

42.  Counseling helps to manage other infectious diseases they might have, and learn about living with HIV/AIDS and how to avoid infecting others.

43.  Counseling and testing can also help those not infected to remain uninfected through education about safer sex.

44.  Pre-exposure prophylaxis with tenofovir-emtricitabine in high risk patients and who are committed to medication adherence and close follow-up can reduce the risk of HIV infection by 48 to 75%.

45.  Drinking alcohol or taking drugs interferes with judgment. Even those who understand the risks of AIDS and the importance of safer sex may become careless after drinking or using drugs.

46.  Young people need to be educated that there is no vaccination and no cure for HIV/AIDS.

47.  WHO recommends innovative HIV-self-testing and partner notification approaches to increase HIV testing services among undiagnosed people.

48.  Prevention is the only protection against HIV/AIDS.

49.  ABC for safe sex: Abstain, Be faithful to your partner and if you cannot, use Condoms.

50.  90–90–90 is a treatment target to help end the AIDS epidemic. By 2020, 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression.

Patient Solidarity Day and need for Universal Health care for all

Patient Solidarity Day and need for Universal Health care for all

Dr KK Aggarwal

National President IMA

In consumer market, the consumer is the most important and in healthcare, a patient is our asset and that too, the most important one. As doctors, we need to lend our ears to his sufferings, practice empathy and not sympathy and be available to him at all times of need. We need to maintain the honor and dignity of the medical profession and treat patients with the same dignity, honor and due respect. 

In September 2015, the 194 Member States of the United Nations agreed to develop and put in place practical actions and national frameworks to achieve Universal Health care and other targets, as part of the 2030 Agenda for Sustainable Development (Resolution A/RES/70/1).

On this Patient Solidarity Day (PSD), Saturday 3rd December 2016, the Indian Medical Association (IMA) calls on our members, state and local branches, institutions and stakeholders to support the call for universal health coverage (UHC) for all. UHC can be defined as affordable, high-quality and accessible healthcare for everyone

Sustainable, patient-centered UHC will need significant efforts and firm commitment over the next 14 years from the key actors in the healthcare system: governments, the pharmaceutical industry, healthcare providers and patients’ organizations.

Patient-centered UHC means that all people receive the health services they need, without suffering financial hardship.

The following are the core principles of universal health coverage

·         Accessibility: All patients have the right to access the healthcare they need and when they need it.

·         Patient-centeredness and equity: All people, regardless of disease or condition; age, gender, race or ethnic background; sexual orientation; geographic location; socio-cultural background, economic or legal status, must have fair and impartial access to quality healthcare.

·         Choice and empowerment: All patients have the right to know about the healthcare services that are available. Patients must be able to be meaningfully involved in healthcare decision-making in a variety of ways at the local, national, regional and global level.

·         Quality: It is not enough for all patients to have access to healthcare. Provision needs to be safe, of the highest attainable standard and include a commitment to learning and improvement. Patients need to define what constitutes quality in healthcare.

·         Partnership and collaboration: Patients have a moral and ethical right to play a meaningful role at all levels; in health and in other areas that can have an impact on health and wellbeing.

·         Sustainability and the value of healthcare: All stakeholders need to recognize the value of healthcare when considering investing in universal health coverage.

·         Accountability and transparency: Accountability and transparency are vital to delivering safe, effective and affordable healthcare. All stakeholders need to be held accountable on commitments they have made to implement universal health coverage, and be accountable to the patients that they serve.

IMA initiative: Key messages

·         Leave no-one behind.

·         UHC is only truly patient-centered when health services are universally accessible, affordable, and of high quality.

·         IMA members to take responsibility for implementing robust national frameworks and appropriate measures to achieve patient-centered UHC.

·         Healthcare stakeholders to be held accountable for their commitments to achieve UHC.

·         Collaborative decision-making, based on genuine patient involvement, is key to ensuring that no-one is left behind.

As a board member of PSM (Partnership for Safe Medicine), both myself and IMA are committed to the patients.  

I will be taking over as the National President IMA on 28^th December and have included the important issues of ‘Patient Safety’ and ‘Patients’ Rights’ in my agenda. 

IMA will be closely working with Bejon as an advisor and PSM to take this forward. 

I am sorry I will not be able to join you all in Varanasi due to viral fever. But, I wish the event all success. 

(Speech at Varanasi, on the occasion of Patient Solidarity Day, Organized by PSM India)

Delhi High Court sets aside Centre's decision to ban 344 fixed dose combination medicines

Delhi High Court sets aside Centre's decision to ban 344 fixed dose combination medicines

The Delhi High Court has set aside the Centre's decision to ban 344 fixed dose combination (FDC) medicines, including well-known brands like Corex cough syrup, Vicks Action 500 Extra and D'Cold, reports TOI. 

The court gave the order after hearing arguments of companies like Pfizer, Glenmark, Procter and Gamble and Cipla, the central government and some NGOs like All India Drug Action Network (AIDAN).

The court had on March 14 stayed the Centre's March 10 ban on 344 FDC drugs and this interim order was passed in each and every case filed before it thereafter.

According to the drug companies, the government has not properly implemented the powers under section 26A (power to prohibit manufacture of drugs and cosmetics in public interest) of Drugs and Cosmetics Act, under which the ban was ordered. The ban order was passed without considering clinical data and the grounds that safer alternatives were available. The government had banned over 300 FDC drugs on the ground that they involve "risk" to humans and safer alternatives were available.

As per the March 10 notification, "On the basis of recommendations of an expert committee, the central government is satisfied that it is necessary and expedient in public interest to regulate by way of prohibition of manufacture for sale, sale and distribution for human use of said drugs in the country."

The Centre had argued that the FDC medicines are "new drugs" and thus, require licence from Drugs Controller General of India (DCGI) for sale and manufacture. Also there were no valid licences for making any of the banned FDCs and added it was difficult to implement any action at state level. However, it had also said that the lack of approval for these FDCs were a secondary issue and the primary focus was that they "lacked safety and efficacy" and thus, "ban was the only answer". According to them, the banned FDCs had no "therapeutic justification".

AIDAN, argued that there were nearly 40,000 FDC drugs in Indian market and since the regulatory control over such medicines was allegedly "illusory", the Centre's decision to ban some of them "was the only move". 

IMA View

IMA is only concerned with safety and quality of a drug. The job of DCGI is to maintain both. If the DCGI cannot take the guarantee of the quality and safety of any drug, how will doctors treat patients? 

In Malay Kumar Ganguly vs Sukumar Mukherjee & Ors on 7 August, 2009, the Supreme Court of India relied on the drug package insert, which is always cleared by the DCGI.

DCGI should either challenge the order or label these combinations as safe drugs.