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Issue 2

J u n -Dec 2007

p p 9 - 20

Editorial International Health Security Siddhartha Yadav


vian ifluenza in 20061 and Severe Acute Respiratory Syndrome (SARS)2 in 2003 spread from one country and region to the next. HIV/ AIDS is also racing across nations, adversely impacting their economies and threatening their stability. Patterns of infectious disease outbreaks have changed3 and old ones have reemerged as to present an acute threat to life. Climate change, natural disasters, chemical and nuclear accidents and bioterrorism also hold the potential to threaten international public health security. In context of today’s globalized world, it is easier for these challenges to go far beyond any national border and have an impact on the collective security of all the people over the world. This year’s World Health Day on April 7th clearly highlighted this fact. It was observed with the slogan, “Invest in health, build a safer future” under the theme of ‘International Health Security’. Health security is defined as guaranteeing minimum protection from disease and unhealthy lifestyles, along with food, environmental, economic, community and political security4. Global health security has repeatedly been challenged by naturally occurring emerging and re-emerging diseases, environmental changes, natural and man made disasters. The only way to counteract such J-Med 2007

threats is to be prepared in advance which means strengthening the public health system of the country to the extent that it is able to identify and deal with potential threats. This will require major investments in disease surveillance, prevention and education. About 6.47% of the total budget of Nepal has been allocated to the health sector for the fiscal year 2006/075. While coordination within the nation is important, international partnership is equally essential in combating health security threats. This has led to inclusion of health in foreign policy of many nations as opposed to the past trend in which health was deemed to be an issue of domestic concern only6. While there are many issues related to international health security, discussed below are some issues of interest to most of the countries in the world and particularly in reference to Nepal. 1.Emerging and Re-emerging Infectious Diseases: Recently, Nepal was on alert due to the spread of SARS and avian influenza in its neighbouring countries, India and China. However, no case was reported from Nepal. The huge population mobility and migration between Nepal and India provides optimal opportunities for transfer of infectious diseases Page 9

J-MED across the borders. One such example is HIV/ AIDS. A major challenge to HIV control in Nepal is the trafficking of Nepalese girls and women into commercial sex work in India, and their return to Nepal7. The prevalence of HIV/ AIDS is also high in the migrant population. According to a study, HIV prevalence is nearly 8% in migrants returning from Mumbai7. At the same time diseases like poliomyelitis which is endemic in neighbouring states of India8, constantly threaten Nepal’s eradication efforts. 2.International Health Regulations (IHR, 2005): Centrepiece to this year’s discussion on world health day was international health regulation which entered into force in June 2007. The International Health Regulations (2005), seeks to “prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade9.” Countries bound by the IHR (2005), which includes Nepal, need to develop, strengthen and maintain their capacity to detect, report and respond to public health events and to provide routine inspection and health control activities at international airports, ports, and some ground crossings10. The investment required to build a safer future is the responsibility of the health sector in partnership with other sectors (agriculture, defense, transportation, tourism, etc.) as well as by the community at large. 3. Public Health Infrastructure: To be prepared in advance is the best defence against any public health threat. This includes development of a well defined policy and involves all essential public health activities, including surveillance, health care services, laboratory capacity, human resources, and communication between various actors and the J-Med J-Med 2007 2007

general public. For example, in advance preparation for the Avian influenza the government of Nepal had prepared The National Avian Influenza and Influenza Pandemic Preparedness and Response Plan11. However, all infrastructure required to combat a public health emergency may not be locally available. Resources from an intersectoral and inter-institutional alliance may be required in today’s inter-dependent -world, where a local epidemic event can rapidly turn into a global event and economic threat. For example, the international response to the SARS outbreak was an extreme test of public health systems. WHO’s success in coordinating the containment of this previously unknown disease was mainly due to the detection and response mechanisms already in place2. The World Health Organization also has the Global Outbreak Alert and Response Network (GOARN) which is a technical collaboration of existing institutions and networks who pool human and technical resources for the rapid identification, confirmation and response to outbreaks of international importance12. 4.Other Issues: Natural and man-made disasters, such as earthquakes, floods, tsunamis, chemical and nuclear spills, bioterrorism are receiving increasing attention in a shared international public health agenda. In a globalized world, large scale disasters not only result in a large loss of lives but also leads to a collective sense of vulnerability and insecurity in communities. Recent experiences with tsunami and earthquakes (northern India and Pakistan) has further emphasized the need to work together between various countries. Conclusion: International health security requires a larger and more effective interaction between Page 9

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J-MED countries, governments, institutions, communities, and citizens. All sectors of society and all citizens share responsibility for health security. Renewed efforts in building basic public health infrastructure and preparation serve as key to the response, and the better prepared a society is as a whole, the more organized and effective the response. Siddhartha Yadav. MBBS Fourth Year Student, Maharajgunj Campus, Institute of Medicine. Email:

References: 1.Avian influenza — updates (updated compendium). Geneva: World Health Organization. Available from: http:// avian_influenza/updates/en/. (Accessed on March 27, 2007) 2. WHO guidelines for the global surveillance of severe acute respiratory syndrome (SARS). Updated recommendations, October 2004 (WHO/CDS/CSR/ARO/ 2004). Geneva: World Health Organization; 2004. Available from: WHO_CDS_CSR_ARO_2004_1.pdf (Accessed on March 27, 2007) 3. Knobler S, Mahmoud A, Lemon S, editors. The impact of globalization on infectious disease emergence and control: exploring the consequences and opportunities, workshop summary — forum on microbial threats.Washington, DC: Institute of Medicine; 2006.

4. United Nations Development Program (1994) Human Development Report 1994. New York: Oxford University Press, in http:/ (Accessed on March 26, 2007) 5. Ministry of Finance. Budget speech of the fiscal year 2006/07. Kathmandu: Ministry of Finanace, Government of Nepal, 2006. 6. Walt G. Health Policy, process and power. London: Zed; 1994 7. HIV/AIDS in Nepal. The World Bank Report. November 2006. (Accessed on March 29, 2007) 8. Global Polio Eradication Initiative. Global Situtation: Wild Polio Virus Weekly Update. casecount.asp (Accessed March 20, 2007) 9. Revision of International Health Regulations. Agenda item 13.1 The fifty- eighth World Health Assembly.23 May 2005. 10. International Health Regulations (2005): Guidance for national policy-makers and partners. Western Pacific Region, World Health Organization, 2006. 11. Health Action in Nepal. Health Newsletter Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division World Health Organization-Emergency and Humanitarian Action - Issue IV, December 2005. 12. World Health Organization. Epidemic and Pandemic Response (EPR): The Global Outbreak Alert and Response Network. http: // /entity/ csr/outbreaknetwork/ en/ (Accessed on March 23, 2007)

Soliloquy Studying abroad after MBBS? (Inspite of studying MBBS in government funding?)

The governments of the Indian subcontinent have been providing subsidies to students for studying MBBS. But, these countries have always suffered the deficit of doctors. Why do doctors choose to move abroad when Nepal, for example, desperately needs them? Poor pay, lack of adequate (or even basic) infrastructure and limited opportunities for research and personal development are just a few reason. It is a all very well to talk about spirits of altruism and patriotism, but in failing to tackle these problems, many governments are in denial about why people emigrate, when otherwise they might stay. At the heart of the matter lies the tension between brain drain and brain gain. The UK, the US and most recently, Australia have welcomed this migration to fill gaps in their national health services. The US has also eased restriction on visas for graduates who are willing to practice in rural areas. Doctors actually work hard for the fulfillment of what they desired for long. Unfortunately for those from the Indian subcontinent, the scenario is not that favourable because the color of their passport counts. This will increase the space between the developed and third world countries. Would focusing on allied subjects be fruitful now? - Santosh Neupane. MBBS second year student, Maharajgunj Campus, IOM. J-Med 2007 Page 9Med 11 2007 Page 9


Soliloquy Studying abroad after MBBS? (Inspite of studying MBBS in government funding?)

It’s a new and rising trend among medical students after they complete their MBBS to go abroad for further studies. First of all, I must admit, I am not strictly against it. You may disagree, but again, one is free to express his thoughts, isn’t he? Medicine is one of the few fields of science that advances in no time. Things have advanced so much in developed countries like America, Australia etc. Many diseases which were once thought to be impeccable can readily be cured now. On the other hand, our country lags a lot behind in this regard. We have been practicing what has been followed since decade. Isn’t it imperative for us to adopt these trends? Should we turn a blind eye to all the recent developments, practice same old outdated trends and let our patients suffer? The answer I think is NO! By sending our new generation of doctors abroad to developed countries, we will have them better trained, better skilled and well informed of recent developments in medicine. That will further strengthen our health system; make our quality of life better. But there are those of us who prefer never to return back. Many get lost in amusements and fun of urbanization and dare never to turn back. I think the latter trend should be curtailed and former encouraged. So where now, is my stance? A bit of yes and a bit of no. - Smith Giri. MBBS third year student, Maharajgunj Campus, IOM I belong to the world and not just a small part of it. Doesn’t mean I’m being disloyal to my country, but I’ve got to make the best out of me so that I can offer the best when it’s my turn to serve the world. I don’t want to become a doctor, who just has the degree, wears apron and walks in the corridors of a hospital losing himself between the white walls. His diagnosis isn’t proper and he isn’t confident about his treatment. I want to become a doctor who really understands the disease and is sure about his treatment. For this, I will need to acquire knowledge, a colossal amount of knowledge. Knowledge, its everywhere and not just Nepal and I guess we’ve got to truly accept that we’re still lagging hundreds of years behind others in this aspect. Who invented the telephone?....well, not a Nepali; doesn’t mean we can’t. We won’t belittle ourselves by learning from others because learning good things from others is not bad at all. So, in this quest for knowledge, if I’ll have to cross the boundary, I won’t hesitate and the thought of government funding me for MBBS studies won’t weaken me in making my decision. In fact, i will feel stronger for I’ve been fairly thought capable of becoming a doctor. Service to your country, your people when you acquire ample amount of knowledge shouldn’t be forgotten either. So, as students, voracious feeders of knowledge, we should ALWAYS think big and NEVER limit ourselves in our thoughts because the sky is not the limit, we’ve got to reach higher. - Prativa Phuyal. MBBS first year student, Maharajgunj Campus, IOM

J-Med Editorial Board Editor in Chief: Siddhartha Yadav Associate Editors: J-Med 2007

Nirmal Kharel Ashish Lohani

Nishant Dhakal Pranab Koirala Page 12


Education Hepatitis-E Sudan Thapa


Hepatitis-E Virus (HEV) is the most common cause of enterically transmitted hepatitis, water-borne infection that occurs primarily in young to middle aged adults. It was not recognized as a distinct human disease until 1980 but is now viewed as a significant health problem 1 . It occurs sporadically and in epidemics, causing substantial rates of death and complications, especially in pregnant women2. Hepatitis E virus (HEV): HEV is a nonenveloped, single-strand, positivesense RNA virus of Caliciviridae family and is approximately 27 to 34 nm in diameter2,3. It has a genome comprising three overlapping open reading frames (ORFs); There are four HEV genotypes. Nevertheless, all HEVs can be considered to belong to one serotype. Therefore, a vaccine that is shown to be efficacious in one country should provide protection against hepatitis E elsewhere2. Incidence and Prevalence A large epidemic of waterborne viral hepatitis was reported from India in 1955 and 1956; when raw sewage from the flooding Yamuna river resulted in 30,000 cases of jaundice4. Epidemic disease is geographically distributed around the equatorial belt including Central America, Africa and the Middle East, subcontinental India, Asia and the Southeast Pacific.The largest reported outbreak occurred in the Xinjiang region of China between 1986 and 1988 and involved 120,000 cases4. The disease is common among persons 15 to 40 years of age, a pattern that contrast with HAV infection, in which children have the highest attack rates4. In the endemic areas, outbreaks have a periodicity of 5 to 10 years, which in part reflects the pattern of heavy rainfall. HEV J-Med 2007

accounts for up to 50% of the cases of acute sporadic hepatitis in adults and children in some endemic areas4. In nonendemic countries, cases of acute HEV infection are uncommon and occur primarily in travelers returning from endemic areas. Secondary transmission has not been reported in these cases. Acute hepatitis E without a history of travel has also been described and the source of HEV infection in such cases has not yet been determined. A characteristic feature of HEV infection is the high mortality rate among pregnant women,5 approaching 20%3. Survivors have high rates of spontaneous abortion and stillbirth 2,3. On the basis of seroprevalence, an estimated one third of the world’s population has been infected with HEV2. In India, the lifetime infection risk is more than 60%, which translates to hundreds of thousands of illnesses annually. Consequently, the true burden of hepatitis E is unknown. Transmission: HEV is transmitted via the faecal-oral route. Contaminated water or food supplies have been implicated in major outbreaks. Ingestion of raw or uncooked shellfish has been the source of sporadic cases in endemic areas. There is a possibility of zoonotic spread of the virus, since several non-human primates, pigs, cows, sheep, goats and rodents are susceptible to infection. Person-to-person transmission is uncommon. There is no evidence for sexual transmission or for transmission by transfusion1.Reported secondary attack rates in households of HEV-infected persons ranges from 0.7% - 2.2%, in contrast to secondary attack rates of 50% to 75% in households of HAV infected persons. Page


J-MED Pathogenesis: HEV replication in the liver is the initial event that allows early detection of HEV Ag in the liver and bile. A rise in serum ALT level and presence of mild histologic injury at this time would be consistent with a direct cytopathic effect of the virus or an early immune mediated effect. Later, hepatic HEV Ag becomes undetectable, indicating that viral replication has stopped, and during this time the histologic changes are more pronounced, suggesting that the injury at this time is primarily immune mediated. The loss of HEV Ag from the liver coincident with the rise in antibody production4 In general, hepatitis E is a self-limiting viral infection followed by recovery. Occasionally, a fulminant form of hepatitis develops, with overall patient population mortality rates ranging between 0.5% - 4.0%. Fulminant hepatitis occurs more frequently in pregnancy1. Clinical manifestation4,6: The incubation period ranges from 15 days to 60 days. The course of infection has phases termed prodromal and preicteric phase; and icteric phase. Most of the symptoms of Hepatitis E are similar to other hepatitis. Prodromal and preicteric-phase symptoms include the following: Myalgia, Fever with mild temperature elevations (25-97%) Anorexia (66-100%) ,Nausea/vomiting (30-100%), Weight loss (typically 2-4 kg), Dehydration, Right upper quadrant pain that increases with physical activity. Icteric-phase symptoms include the following: Jaundice, serum bilirubin level is greater than 3 mg/dL; scleral icterus is present., dark tea coloured urine, Light-colored stools(20-40%), Pruritus (50%). When or how long the patient is infectious cannot be determined, but infectivity may relate to the presence of the virus in the stool. Diagnosis Since cases of hepatitis E are not clinically distinguishable from other types of acute viral hepatitis, diagnosis is made by blood tests which J-Med 2007

detect elevated antibody levels of specific antibodies to hepatitis E in the body or by reverse transcriptase polymerase chain reaction (RT-PCR). Unfortunately, such tests are not widely available1. Lab Studies: Western blot and enzyme immunoassays detect anti-HEV antibodies. Testing to detect anti-HEV immunoglobulin M (IgM) and immunoglobulin G (IgG) differentiates acute and chronic infection. The IgM titer falls rapidly after infection, becoming virtually undetectable within 6 months4,6. Anti-HEV IgG persists for longer than 6 months. IgG anti-HEV appears to afford protection against reinfection4,6.Serum, liver, and stool samples can be tested for HEV RNA with a polymerase chain reaction assay. These tests are not available commercially.Aminotransferase levels (AST, ALT) are elevated several days before the onset of symptoms but generally return to normal within 1-2 months after the peak severity of the disease has passed. Whether the magnitude of elevation correlates with the histological severity is not clear 4,6.Serum bilirubin elevations occur in both the total and direct fractions. Hemolysis is unusual. In most cases, bilirubin levels take longer to return to normal than aminotransferase levels. Many patients develop a mild leukocytosis. If associated with fever, bacteremia should be suspected. More commonly, WBC counts are decreased. Differential counts may show atypical cells and lymphocytosis. Imaging StudIies: Abdominal ultrasonography helps to rule out biliary obstruction in cases with significant nausea, vomiting, or fever. Liver biopsy usually is not necessary6. Histologic Findings: The pathology picture is cholestatic, with stasis of canalicular bile and marked proliferation of intralobular bile ductules. Parenchymal changes are less severe and include swollen hepatocytes, foam cells, and acidophil bodies. Inflammatory infiltrate of mononuclear cells Page 14

J-MED is present, resulting in expanded portal areas and possible piecemeal necrosis. Prevention Good personal hygiene, high quality standards for public water supplies and proper disposal of sanitary waste have resulted in a low prevalence of HEV infections in many well developed societies1.For travelers to highly endemic areas, the usual elementary food hygiene- avoiding drinking water and/or ice of unknown purity and eating uncooked shellfish, uncooked fruits or vegetables that are not peeled or prepared by the traveler4,7. Vaccine The first vaccine against hepatitis E has proved highly effective in protecting people from the disease, according to preliminary study in Nepalese army recruits 8.2000 Nepalese soldiers in Kathmandu were recruited for the drug trial and split into two groups. One group was given three doses of the vaccine over the course of six months, while the other received placebo injections8. The vaccine’s efficacy was 95.5 percent, according to the study9. It’s still not clear when the vaccine might become available. Treatment Supportive therapy is the cornerstone of medical management. Antibiotics are of no value in the treatment of the infection. There is no hyperimmune E globulin available for preor post-exposure prophylaxis. Immunoglobulin from infected patients is not effective in preventing outbreaks or sporadic cases.HEV infections are usually self-limited, and hospitalization is generally not required. No available therapy is capable of altering the course of acute infection. Hospitalization is required for fulminant hepatitis and should be considered for infected pregnant women. Diet: The acute illness may result in anorexia, nausea, and vomiting, predisposing patients to dehydration. These symptoms tend to be worse in the afternoon or evening. Patients should attempt to ingest significant calories in the J-Med 2007

morning. Frequent small meals may be better tolerated. Hospitalization should be considered for patients with dehydration. Neither multivitamins nor specific dietary requirements are required6. Activity: Patients should be allowed to function at whatever levels they can tolerate.No evidence indicates that bedrest hastens recovery. It actually may retard recovery6. Sudan Thapa. MBBS Second Year Student, Maharajgunj Campus, Institute of Medicine. References: 1. World Health Organization. Fact sheet No.280: Hepatitis E. WHO media centre, January 5, 2005. mediacentre/factsheets/fs280/en/ (Accessed March 12, 2007) 2.Shrestha MP, Scott RM, Joshi DM, Mammen MP, Thapa GB, Thapa N, et al. Safety and Efficacy of a Recombinant Hepatitis E Vaccine. N Engl J Med 2007;356:895-903. http:/ / (Accessed March 14, 2007) 3. Kumar V, Cotran RS, Robbins SL. Robbins basic pathology. 7th ed. New Delhi: Harcourt India Private Ltd, 2003. 4. Feldman M, Friedman LS, Sleisenger MH, editors. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 7th Edition. Philadelphia: Saunders,2002:1328-1332 5.Macfween RNM, Anthony PP, Scheuer PJ, Burt DA, Portmann BC. Pathology of liver. Third edition.Churchill Livingstone,1994:262 6.Schwartz JM, Ingram K. Hepatitis E. E-medicine, June 16, 2006. 995.htm (Accessed March 13,2007) 7. Sherlock S, Dooley T. Diseases of the liver and Biliary System. Tenth edition. London: b.Blackwell Science,1997:296-297 8. Kharnasi R. First Hepatitis E vaccine appears highly effective. New Scientist, March 01, 2007. (Assessed March 14,2007) 9. Anon. Hepatitis E Vaccine Called Highly Effective. The National Women’s health Information Centre, US Department of Health and Human services, March 01, 2007. (Accessed March 14,2007)




Education Extensively Drug Resistant Tuberculosis (XDR-TB): A Global Threat Nirmal Kharel


ne in three people in the world is infected with dormant TB germs (i.e. TB bacteria). Only when the bacteria become active do people become ill with TB. Bacteria become active as a result of anything that can reduce the person’s immunity, such as HIV, advancing age, or some medical conditions. TB can usually be treated with a course of four standard, or first-line, anti-TB drugs. If these drugs are misused or mismanaged, multidrug-resistant TB (MDR-TB) can develop. MDR-TB takes longer to treat with second-line drugs, which are more expensive and have more sideeffects. The term Extensively Drug Resistant Tuberculosis (XDR-TB) was used for the first time in March 2006, in a report jointly published by the US Centers for Disease Control and Prevention (CDC) and WHO to describe a disease caused by strains of Mycobacterium tuberculosis that were resistant not only to isoniazid and rifampicin (i.e. MDR-TB) but also to at least three of the six classes of second-line anti-TB drugs (aminoglycosides, polypeptides, fluoroquinolones, thioamides, cycloserine and para-aminosalycilic acid) 1 . As the definition is dependent on difficult-toperform drug susceptibility testing (DST) and as some forms of drug resistance are less treatable then others, it was eventually modified at a meeting of the WHO XDR-TB Task Force, on 10–11 October 2006, in Geneva (Switzerland). Thus, XDR-TB is now defined as: “resistance to at least rifampicin and isoniazid (which is the definition of MDRTB), in addition to any fluoroquinolone, and to at least one of the three following injectable J-Med 2007

drugs used in anti-TB treatment: capreomycin, kanamycin and amikacin.2,3” Extensively drug resistant tuberculosis was first reported in South Africa by Dr.Tony Moll. He discovered this new strain of Mycobacterium Tuberculosis in a South African region KwaZulu-Natal. In an interview, he said the new variant was” very highly troubling and alarming because of high fatality rate”.Some patients might have contracted this resistant strain in the hospital. Dr. Moll thinks at least two were hospital health workers. In one year’s time, an infected person may infect 10 to 15 close contacts. However, the percentage of XDR-TB in the entire group of people with tuberculosis still seems to be low. XDR-TB can develop when the secondline drugs are also misused or mismanaged and therefore also become ineffective. Because XDR-TB is resistant to first- and second-line drugs, treatment options are seriously limited. It is therefore vital that TB control is managed properly. The typical symptoms of TB (like prolonged coughing, fever, night sweats, weight loss and chest pain), and signs on Xray are identical for XDR-TB. To ascertain the presence of this resistant form, a laboratory test on the patient’s sputum, is necessary, but these tests are often too expensive in the poor countries where TB is present. The CDC study1 reported that XDR-TB had been observed in all continents. Unpublished analysis of that data reveals that some 17 countries had at least one case of XDR-TB. To assess the frequency and distribution of extensively drug-resistant (XDR) TB cases, CDC and the World Health Organization (WHO) surveyed an international network of TB laboratories. The Report summarizes the results of the survey, Page 16

J-MED which determined that, during 2000–2004, of 17,690 TB isolates, 20% were MDR and 2% were XDR1. In addition, population based data on drug susceptibility of TB isolates were obtained from the United States (for 1993– 2004), Latvia (for 2000–2002), and South Korea (for 2004), where 4%, 19%, and 15% of MDR-TB cases, respectively, were XDR1.More representative information from some countries has described the frequency of XDR-TB. In Asia, data are available from South Korea1, where 15% of the MDR-TB strains isolated in 2004 were XDR, and also Iran4, where 12 (10.9%) of 113 MDR-TB strains isolated were XDR. In Hong Kong, nine out of the 75 MDR-TB strains (12%) had extensive drug resistance, defined as simultaneous resistance to ethionamide, amikacin, ofloxacin and cycloserine5. In africa, data are currently only available from South Africa. In the Msinga district, KwaZulu Natal (KZN), out of 1,539 TB cases diagnosed between January 2005 and March 2006, 542 were culture positive, 221 were MDR with 53 “possible” XDR cases. Out of the 53 XDR patients, 52 died with a median survival time after sputum smear sample collection of only 16 days6. Recently, cases of XDR-TB have been confirmed in Italy, with the identification of eight samples of the highly drug-resistant form of TB.All G8 countries have now confirmed the presence of XDR-TB. Italian researchers studying all culture-confirmed TB cases diagnosed between 2003 and 2006 by national TB reference centers found links between XDRTB and five-fold increase in the risk of death, longer hospitalization, longer treatment duration and delayed microbiological conversion. G8 countries and other donors are being urged to reaffirm their commitment to the Global Plan to Stop TB, 2006–2015 and emergency efforts to ensure there is a global coordinated response to XDR-TB, to protect public health and security and to serve poor and vulnerable population. XDR TB has emerged worldwide as a threat to public health and TB control, raising J-Med 2007

concerns of a future epidemic of virtual untreatable TB. New anti-TB drug regimens, better diagnostic tests, and international standards for Second line drugs-susceptibility testing are needed for effective detection and treatment of drug-resistant TB. Focusing on the WHO stop TB strategy which includes expanding high-quality DOTS programs, addressing HIV-associated tuberculosis and drug resistance, strengthening health care systems and primary care services, encouraging all providers to follow good practices, empowering patients and communities to improve health, and enabling and promoting research may be useful in combating extensive drug resistance7. WHO officers are to begin assisting the KwaZulu-Natal authorities in South Africa in late March 2007 in the investigations into the origin and spread of XDR-TB in the province. These investigations are likely to last several months. Is Science enough to tackle this epidemic? Nirmal Kharel. MBBS fourth-year Student. Maharajgunj Campus, Institute of Medicine. References: 1. Centre for Disease Control. Emergence of Mycobacterium tuberculosis with extensive resistance to second line drugs- worldwide, 2000-20004. MMWR Morb Mortal Wkly Rep March 24 2006;55(11):301-305. 2. World Health Organization. Extensively drug-resistant tuberculosis (XDR.TB): recommendations for prevention and control. Weekly Epidemiol Record 2006;81:430–432. 3. The tuberculosis X factor. Lancet Infect Dis 2006;6:679 4. Masjedi MR, Farnia P, Sorooch S, et al. Extensively drug-resistant tuberculosis: 2 years of surveillance in Iran. Clin Infect Dis 2006;43:841–847. 5. Toungoussova OS, Mariandyshev AO, Bjune G, Caugant DA, Sandven P. Resistance of multidrug-resistant strains of Mycobacterium tuberculosis from the Archangel oblast, Russia, to second-line anti-tuberculosis drugs. Eur J Clin Microbiol Infect Dis 2005;24:202–206. 6. Zignol M, Hosseini MS, Wright A, et al. Global incidence of multidrug-resistant tuberculosis. J Infect Dis 2006;194:479–485. 7. Raviglione MC, Smith IM. XDR TuberculosisImplications for global public health. New Engl J Med 2007;356(7):656-659.

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Style All articles submitted to the J-Med must be adequately referenced in the Vancouver system. Given below are the examples of this taken from the website of National Library of Medicine, posted by International Council of Medical Journal Editors(ICMJE).

International Committee of Medical Journal Editors Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Sample References International Council of Medical Journal Editors

Articles in Journals

4. No author given

1. Standard journal article

21st century heart solution may have a sting in the tail. BMJ. 2002;325(7357):184.

List the first six authors followed by et al. 5. Article not in English Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002 Jul 25;347(4):284-7.

Ellingsen AE, Wilhelmsen I. Sykdomsangst blant medisin- og jusstudenter. Tidsskr Nor Laegeforen. 2002;122(8):785-7.

More than six authors: 6. Issue with no volume Rose ME, Huerbin MB, Melick J, Marion DW, Palmer AM, Schiding JK, et al. Regulation of interstitial excitatory amino acid concentrations after cortical contusion injury. Brain Res. 2002;935(1-2):40-6.

Banit DM, Kaufer H, Hartford JM. Intraoperative frozen section analysis in revision total joint arthroplasty. Clin Orthop. 2002;(401):230-8.

2. Organization as author

7. No volume or issue

Diabetes Prevention Program Research Group. Hypertension, insulin, and proinsulin in participants with impaired glucose tolerance. Hypertension. 2002;40(5):679-86.

Outreach: bringing HIV-positive individuals into care. HRSA Careaction. 2002 Jun:1-6.

3.Both personal authors organization as author

Tor M, Turker H. International approaches to the prescription of long-term oxygen therapy [letter]. Eur Respir J. 2002;20(1):242. . Other Published Material



Vallancien G, Emberton M, Harving N, van Moorselaar RJ; Alf-One Study Group. Sexual dysfunction in 1,274 European men suffering from lower urinary tract symptoms. J Urol. 2003;169(6):2257-61. J-Med 2007

9. Type of article indicated as needed

10. Newspaper article Tynan T. Medical improvements lower Page 18

J-MED homicide rate: study sees drop in assault rate. The Washington Post. 2002 Aug 12;Sect. A:2 (col. 4).

electronic atlas of hematology [CD-ROM]. Philadelphia: Lippincott Williams & Wilkins; 2002.

11. Audiovisual material

17. Journal article on the Internet

Chason KW, Sallustio S. Hospital preparedness for bioterrorism [videocassette]. Secaucus (NJ): Network for Continuing Medical Education; 2002.

Abood S. Quality improvement initiative in nursing homes: the ANA acts in an advisory role. Am J Nurs [serial on the Internet]. 2002 Jun [cited 2002 Aug 12];102(6):[about 3 p.]. Available from: AJN/2002/june/Wawatch.htm

12. Legal Material Public law: Veterans Hearing Loss Compensation Act of 2002, Pub. L. No. 107-9, 115 Stat. 11 (May 24, 2001). Hearing: Arsenic in Drinking Water: An Update on the Science, Benefits and Cost: Hearing Before the Subcomm. on Environment, Technology and Standards of the House Comm. on Science, 107th Cong., 1st Sess. (Oct. 4, 2001). 13. Map Pratt B, Flick P, Vynne C, cartographers. Biodiversity hotspots [map]. Washington: Conservation International; 2000. 14. Dictionary and similar references Dorland’s illustrated medical dictionary. 29th ed. Philadelphia: W.B. Saunders; 2000. Filamin; p. 675. Unpublished Material 15. In press Tian D, Araki H, Stahl E, Bergelson J, Kreitman M. Signature of balancing selection in Arabidopsis. Proc Natl Acad Sci U S A. In press 2002. Electronic Material 16. CD-ROM Anderson SC, Poulsen KB. Anderson’s J-Med 2007

18. Monograph on the Internet Foley KM, Gelband H, editors. Improving palliative care for cancer [monograph on the Internet]. Washington: National Academy Press; 2001 [cited 2002 Jul 9]. Available from: . 19. Homepage/Web site [homepage on the Internet]. New York: Association of Cancer Online Resources, Inc.; c2000-01 [updated 2002 May 16; cited 2002 Jul 9]. Available from: http:// 20. Part of a homepage/Web site American Medical Association [homepage on the Internet]. Chicago: The Association; c1995-2002 [updated 2001 Aug 23; cited 2002 Aug 12]. AMA Office of Group Practice Liaison; [about 2 screens]. Available from: 1736.html International Council of Medical Journal Editors.

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News WHO recommends circumcision to combat HIV infection. The World Health Organization and UNAIDS have published the results of a recent expert symposium on circumcision and AIDS, which concluded that ‘there is now strong evidence from three randomised trials undertaken in Africa that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.’

A revolutionary test that reveals an unborn baby’s sex at six weeks The earliest couples had previously known the gender of their baby was at the 20-week scan. But now, a revolutionary test reveals an unborn baby’s sex at six weeks.The Pink or Blue Early Test Kit, launched on the internet by DNA Worldwide, is claimed to be 98 per cent reliable.Mums-to-be prick a finger to give a small blood sample. They put this on a filter paper and send it to a lab for testing. Lab technicians determine the sex by looking for the Y chromosome found in males in three tests. Each works because an unborn baby’s DNA is present in the mother for six weeks. However, there is widespread fear that the £189 kit will create a massive leap in abortions if would-be parents are not having the gender they want. (The Sun, May 20)

British Scientists grow part of a human heart Scientists under the leadership of Magdi Yacoub, Proffessor of cardiac surgery at Imperial College London, have grown a part of human heart from stem cells. Prof. Yacoub led a team at Harefield hospital which included Physicists, Pharmacologists, Clinicians and Cellular scientists. Animal trials are scheduled for later this year. (The Guardian, Apr 2)

HPV Vaccine in controversy in US Merck’s Gardasil, the Human Papilloma virus vaccine that promises protection against cervical cancer, has come up against strong opposition in the United States. Twenty US states are considering bills that would make the immunization a requirement for school attendance(The vaccine has to be given to girls as young as 10 before they become sexually active)- a move that critics say ignores parental choice and could promote underage sex. Merck has also been accused of using ‘strong arm’ marketing methods while lobbying for its product which if made mandatory for school attendance could net Merck billions of dollars. J-Med 2007