December 5   2015, Saturday
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EDITORIAL
Dr KK AggarwalDr KK Aggarwal 19% cesarean delivery rates associated with lower maternal or neonatal mortality

National cesarean delivery rates of approximately 19 per 100 live births are associated with lower maternal or neonatal mortality. This figure has come up after analysis of data from 194 WHO member states from 2005 to 2012, including cesarean section rates, health expenditure per capita, fertility rate, and life expectancy. However, this figure is in contrast to the current WHO recommendation for cesarean delivery rates ranging from 10% to 15%. The study is published in the December 1 issue of JAMA.

There has been an increase in cesarean sections across the world. In 2013, more than one-third births in the US were cesarean births. Almost complete elimination of vaginal breech delivery coupled with significant decline in operative vaginal deliveries and vaginal birth after cesarean are some factors that have led to the rise in cesarean sections. Also, many women are opting for cesarean delivery.

(Source: Medscape)
EMEDINEXUS STATEMENT
Amit Sharma and Nilesh Aggarwal

We are extremely happy to have been part of IMA Satyagraha campaign and would like to congratulate the Indian doctor community as a whole. We are aiming to be a digital voice of all Indian doctors and will continue to work towards raising such important issues. Currently, we are in our Beta phase and we will soon be introducing features such as interesting cases, online CME's, conference updates etc. Please do register and read eMediNews, eIMANews as well as other engaging content on the website/app. You can also add other doctors to your network, find long lost alumni, chat and discuss cases, post questions for the medical fraternity, create your detailed medical resume and lots more.
Breaking News
One-third deaths from foodborne diseases are in children under 5 years

The first ever global estimates of foodborne diseases by the WHO have found that almost 30% of all deaths from foodborne diseases are in children under the age of 5 years. One in 10 people fall ill annually after consuming contaminated food and 420 000 die, including 125 000 children under the age of 5 years. WHO African and South-East Asia Regions have the highest burden of foodborne diseases. “Estimates of the global burden of foodborne diseases" is the most comprehensive report to date on the impact of contaminated food on health and well-being and estimates the burden of foodborne diseases caused by 31 agents including bacteria, viruses, parasites, toxins and chemicals. The major food borne diseases are diarrheal diseases, which constitute more than 50% of all foodborne diseases, typhoid fever, hepatitis A, Taenia solium and aflatoxin (produced by mould on grain that is stored inappropriately)… (WHO)

Health Ministry to enhance autonomy for nurses in midwifery

The Union health ministry will soon enhance clinical autonomy for Nurse Practitioner in Midwifery (NPM) as an independent practitioner for addressing the longstanding issue of shortage of doctors, especially at delivery points. A consultation on enhancement of autonomy for Nurse Practitioner in Midwifery in India was organized in July this year, which was attended by officials of ministry of health and family welfare and office-bearers of Indian Nursing Council among others. It was recommended that the NPM assessment report provides evidence about the effectiveness of NPM as an independent practitioner; so states may consider the option of replacing doctors or addressing the shortage of doctors through deployment of NPMs especially at delivery points. (Pharmabiz - Ramesh Shankar)
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Specialty Updates
• A man's weight affects the heritable information contained in sperm, suggested a study published in Cell Metabolism, thus explaining why children of obese fathers are more likely to suffer from obesity.

• The speed at which elderly people walk may indicate their likelihood of developing Alzheimer's disease, suggested new research published in Neurology. Researchers found an association between slow walking speed and amyloid in several areas of the brain, including the putamen, a key region involved in motor function.

• Transradial access for PCI is associated with a small but significant increase in operator and patient radiation exposure during both diagnostic and interventional procedures compared with access via the transfemoral route, reported a meta-analysis published in The Lancet.

• Antibiotic use during the third trimester of pregnancy leads to an increased risk of childhood wheeze, suggest new findings published online December 3 in the European Respiratory Journal.

• A combination of detailed CT imaging and 3-D printing technology has been used for the first time in the surgical planning for separation of conjoined twins, reported a study presented at the annual meeting of the Radiological Society of North America (RSNA). Specialists at Texas Children's Hospital in Houston used this new approach to surgically separate conjoined twins who were connected from the chest all the way down to the pelvis.

• Breaking up prolonged sitting with 5 minutes of standing every half hour can improve postprandial glucose metabolism just as well as can 5-minute walking bouts among overweight, postmenopausal women with prediabetes, suggested a new study presented at the World Diabetes Congress 2015.

• A new study published in The Journal of the American Osteopathic Association revealed that periarticular injections reduced postoperative hospital stay and number of inpatient physical therapy sessions in patients who underwent bilateral total knee arthroplasty (TKA). Patients given periarticular injections of analgesic medication fared better than those given femoral nerve block.

• Watching television for 3 hours or more a day in young adulthood, coupled with low levels of physical activity almost doubled the risk of performing poorly on the same measures of cognitive function in midlife, suggests a study published online December 2 in JAMA Psychiatry.
eSpiritual
Signs of Spiritual Awakening

All those out there who feel you are at your wits’ end wondering how things don’t ever work out for you, can now relax and dwell on all those failures that life has taken you through and turn failure into success.

• Failure doesn’t mean you are a failure. But it does mean you haven’t succeeded yet.
• Failure doesn’t mean you have accomplished nothing. It does mean you have learned something.
• Failure doesn’t mean you have been a foolish. It does mean you had a lot of faith.
• Failure doesn’t mean you’ve been discouraged. It does mean you were willing to try.
• Failure doesn’t mean you don’t know what to do. It does mean you have to do it in a different way.
• Failure doesn’t mean you are inferior. It does mean you are not perfect.
• Failure doesn’t mean you have wasted your life. It does mean you have a reason to start afresh.
• Failure doesn’t mean you should give up. It does mean you must try harder.
• Failure doesn’t mean you’ll never make it. It does mean it will take a little longer.
• Failure doesn’t mean God has abandoned you. It does mean God has a better idea.
Legal Quote
Jacob Mathew vs State of Punjab and Anr: 5th day of August 2005: 334/2005/SCI/ 144-145 of 2004

“A private complaint may not be entertained unless the complainant has produced prima facie evidence before the Court in the form of a credible opinion given by another competent doctor to support the charge of rashness or negligence on the part of the accused doctor.”
Medical Breakthroughs that were initially ridiculed or rejected
Helicobacter pylori

In the mid-80s, Dr Barry Marshall, a gastroenterologist from Western Australia put forth that ulcers were caused by bacteria and not by stress, spicy foods, and too much acid as was believed at that time. His efforts were met with great resistance, which he described as "Everyone was against me. But I knew I was right." Marshall himself felt compelled to drink a Petri dish containing an estimated thousand million bacteria, including cultured H. pylori. Within a week he began experiencing symptoms including achlorhydric (no acid) vomiting; biopsies showed severe damage to the mucosa of his stomach. He would later link this initial infection with the development of ulcers. In 2005, Dr Barry Marshall was awarded the Nobel Prize for his discovery… (Medscape)
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eIMA NEWS
IMA National Health Scheme (Contd.)

Scrutinizing Committee of the scheme

It has the power of discretion to fix the upper limit of reimbursements for various medical conditions/ surgical/diagnostic procedures after considering the existing expenses of treatment in side India.

a) Diagnosis and treatment costing less than Rs.5000/ will not be covered under this scheme

b) It is mandatory that member have to submit original papers as well as attested Photo copies( if the member need originals back) of treatment certificate, Discharge summery breakup of bills – Professional charges, cost of medicine and investigations etc and any other documents upon which a claim is based within 60 days of discharge from hospital. The member shall also give additional information and assistance as the scheme may require in dealing with any claim. If a claim in any manner fraudulent or supported by any fraudulent means of device ( whether by a member or any other person acting on his/her behalf), the scheme shall not be liable to make any payment and may lead to termination of membership if the scrutinizing committee feels it is purposefully done for monetary gains from the scheme. Original bills and papers will be given back to the member after verification.

c) Permissible reimbursement will be reimbursed within 90 days from the submission of the original bills, papers and other documents upon which the claim is based. After verifying all the facts as prescribed by the managing committee, all payment shall be made by A/c Payee cheque. Managing committee will have the discretion to pass / reject payment of bill in cases where they are not satisfied about the genuineness of the bills.

d) Members will be given reimbursement of 75% of total amount of the bill not exceeding the sum limited to each diseases.

e) A member will get a maximum of benefit of Rs.2 Lakhs in one year.

f) Private hospitals have to apply for being included in the list of a recognized institution.

g) The managing committee is empowered to add or alter or delete the name of the list of institutions for treatment.

h) However, cost of treatment of members /beneficiary members shall be reimbursed regardless of whether they are recognized or not, provided the managing committee have not debarred them under any circumstances for any fraudulent action/ s made in record / s given to members / beneficiary members.

i) No advance payment will be made to the members

j) Managing committee of the schemes hall be empowered to decide about the claims on the above diseases. Central working of National IMA shall be the appellate body. No disputes can be challenged in any court of law.

k) Members of the scheme, who joins before the age of 60 years will get benefit only after completion of one year of joining the scheme.

l) Members who join after completion of 60 years of age will get benefit only after completion of 2 years of joining the scheme.

m) Charges of engaging a special nurse or attendant will not be reimbursed.

n) Expense incurred on travel or ambulance will not be allowed

o) Food ,laundry and telephone bills will not be reimbursed

p) Treatment in other systems other than Modern Medicine will not be allowed.

q) The following bills of charges will not be reimbursed: cost of cosmetic treatment including dental procedures, cost of external appliances like spectacle, hearing aids etc.

r) Room rent up to Rs. 1000/- will only be considered for reimbursement

Management of the Scheme: Office of the scheme will function at Thiruvananthapuram. The scheme shall be managed by the Managing Committee. The Managing Committee shall consist of:

1. National President - Ex- officio member
2. Hony. Secretary General - Ex - officio Member
3. Chairman
4. Vice Chairman
5. Hony. Secretary
6. Hony. Treasurer
7. Hony. Joint Secretary
8. Thirty state co-coordinators
9. Founder chairman and Founder Secretary

Vigilance Officer: Hony. Finance Secretary of National IMA/Joint Finance Secretary of National IMA

(To be contd.)
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22nd MTNL Perfect Health Mela, the annual flagship event of the Heart Care Foundation of India
Cigarette/Bidi Butts are also quite harmful

NGT notice to seek a response from the Government on the issue of prohibition on consumption of tobacco in all public places and their proper disposal

More than 34.6% percent of the adults in India use tobacco in some or the other form. Thus, one can estimate the large number of tobacco waste generated adversely affecting the quality of life in the state, due to the cigarette/Bidi butts. Dr. Dilip Kumar Acharya, National Chairman, IMA Cancer & Tobacco Control Committee & Patron VOTV said “Cigarette butts consist of: un-smoked remnant tobacco, the filter of filtered cigarette and a paper wrap. They also contain carcinogens, nicotine and toxins and toxic metals such as cadmium, arsenic and lead in a highly concentrated form. All these pose high risk to public health. Action must be taken at the earliest to contain such hazardous litter.”

Cigarettes have become a cause of serious concern for environmentalists. More than 100 billion cigarette butts are discarded in India every year which contain harmful and cancer-causing chemicals.

Research has shown that about 25-50 percent of litter accumulated from the streets comprises tobacco residues. While India is working towards Swachh Bharat, 100 billion non-biodegradable cigarette butts are getting disposed off into environment every year. There are no known processes of segregating or collecting cigarette butts in the world.

In the Order of the National Green Tribunal in the matter of Doctors For You Vs. MoEF dated 02/11/2015 The Union Ministry of Environment and Forests (MoEF), the Ministry of Health and Family Welfare and the Central Pollution Control Board (CPCB) have been asked to file their response on the harm caused by cigarette/bidi butts and chewing tobacco to the environment. The NGO, Doctors for You, an organisation working towards cancer care, had moved the NGT praying that the Centre be directed to declare cigarette and bidi butts “toxic waste”. The petitioner also brought forth the findings of the Kerala State Forest Department, which revealed that around 60 hectares of forest was lost between February 2009 and March 2010 due to fires started by carelessly thrown cigarette butts. In Hyderabad, from Jan 2010 to March 2013, 1333 cases of cigarette caused fires were reported.

Regarding tobacco spitting, the petitioner said they not only ruin aesthetics, leading to wastage of public money on upkeep and maintenance, but also spread diseases. It cited the example of Howrah Bridge, whose pillars are reportedly corroding due to acids in tobacco spit. The saliva of tobacco users is laden with carcinogens and toxic chemicals, which contaminates the environment. Dr.Acharya said, in our state too, more & more people (25.9% of population) are using smokeless tobacco in one or the other form.

In their application to National Green Tribunal the applicants: Doctors for You, a non-profit organization has requested for:

• Directing the respondent authorities to declare the discarded cigarette and bidi butts as toxic waste and thus take requisite action under the appropriate regulations and to formulate and place on record strategy/scheme to ensure compliance of the declaration.

• Consumption of tobacco in any form in all public places should be prohibited and people should be allowed to smoke and chew (and spit) in only designated areas where norms for disposal of cigarette/bidi butts and toxic saliva should be made. Such designated areas should be licensed and monitored jointly by Ministry for Environment and Ministry of health.

• NGT should direct the respondent Authorities to conduct a collective impact study on rampant violation of environment standards by the industry. Based on the finding of the study and as per the ‘polluter pays” principal, the tobacco industry should be held liable for environmental and ecological damages till date.

The prohibition on use of plastics for packing smokeless tobacco should be extended to filters used in cigarettes under the Plastic Waste (Management and Handling) Rules.
Centre launches ‘Accessible India Campaign’ for differently-abled

The government has launched the “Accessible India Campaign” (Sugamya Bharat Abhiyan) which seeks to make at least 50 percent of all government buildings in the national capital and all state capitals “fully accessible” for the disabled by July 2018. Similar deadlines have been set to make airports and railway stations accessible to the disabled … (Indian Express)
A biomarker for early detection of lung cancer identified

Researchers have identified a biomarker, Huntingtin interaction protein-1 (HIP1), which detects non-small cell lung cancer in its earliest stage. With early detection of non-small cell lung cancer, the 5-year survival is about 70%. When NSCLC is detected at an advanced stage, this 5-year survival is less than 10%. According to the study reported in the American Journal of Respiratory and Critical Medicine, HIP1 repressed the mobility of lung cancer cells in laboratory studies and suppressed metastasis in a mouse model of the cancer in addition to serving as a biomarker. Patients in the earliest stages of the diseases expressed more HIP1 vs those in the later stages of the disease. These patients also had a significant correlation with longer survival… (ET Healthworld)
Half of adults in US eligible for cholesterol-lowering medications are not taking them

CDC has reported in the current issue of Morbidity and Mortality Weekly Report (MMWR) that though 78.1 million (36.7%) Americans were already taking or are eligible for cholesterol-lowering medication under the current guidelines, nearly half of them were not taking their medications. Blacks and Mexican Americans are less likely than whites to be taking cholesterol-lowering medications… (CDC)
Outdated policies increase risk of drug-resistant TB

Findings of a survey conducted in 24 countries reveal that outdated tuberculosis (TB) policies and practices are risking the further spread of drug-resistant TB globally. The second edition of the "Out of Step" report released by Medecins Sans Frontieres (MSF), also known as Doctors Without Borders, and Geneva-based Stop TB Partnership, is a comprehensive survey of policies and practices used to guide the diagnosis and treatment of TB. The survey recommends a phase-out of mandatory hospitalization and re-treatment regimens that contribute to drug resistance. The report also defines 14 key policies and practices to meet the globally-endorsed goals to reduce TB incidence and death by more than 90 percent over the next 20 years … (Times of India)
HIV in India

The HIV Estimation-2015 show that India has been successful in achieving the MDG-6 of halting and reversing the HIV epidemic by 2015. New infections have declined by 66% from 2000 and 2015, and AIDS-related deaths fallen by 54% from 2007 to 2015. While India’s success story continues, the current estimates highlight key challenges that will need to be addressed with urgency as the programme moves ahead to achieve NACP IV goals in the short term, the 90-90-90 targets in the intermediate term, and to end the AIDS epidemic in the longer term. The slow-down identified in the rate of decrease of new HIV infections in last few years is a key issue, while scope of improvements in ART and PPTCT coverage exists… (PIB)
eWellness
Energy drinks may put heart at risk for sudden death

Energy drinks may raise blood pressure and prolong QT interval increasing the risk of sudden cardiac death. In a meta–analysis by Sachin A. Shah at University of the Pacific in Stockton, Calif, with a pooled analysis of 93 people who consumed energy drinks, the QT interval on an ECG was significantly prolonged by 10 ms. The threshold level of regulatory concern is around 5 ms. In another pooled analysis of 132 people by the same group, researchers found a significant increase in systolic blood pressure by 3.5 mmHg that was associated with the consumption of energy drinks.

Doctors are generally concerned if patients experience an additional 30 ms in their QT interval from baseline. QT prolongation is associated with life–threatening arrhythmias. Most energy drinks have caffeine. Drinks such as Monster, Red Bull, Rockstar, Full Throttle and AMP have three times the amount of caffeine as colas. A 16–oz. can of Monster Energy, for example, contains 160 mg of caffeine, which is almost as much as 5 cans of soda.
IMA JIMA

http://module.ima-india.org/ima/jima/2015/September/
WP(C) No.8706/2015 titled “Indian Medical Association Vs. Union of India & Anr (NCERT)” Delhi High Court, New Delhi

Click here to read the proposed changes
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Bioethical issues in medical practice
Duty as a parent

Smita N Deshpande
Head, Dept. of Psychiatry, De-addiction Services
PGIMER-Dr. Ram Manohar Lohia Hospital
Park Street, New Delhi

Rina is mother to Chini, an 11 year old girl with mental retardation. Chini can barely look after herself. Her mother is constantly worried as to how she will look after herself when her periods start. At present Chini has barely learnt to bather herself, speak intelligible sentences and move around by herself. However Chini has no idea about her own disability and loves watching romantic scenes on TV. Rina is worried that in these insecure times, Chini may end up being abused or taken advantage of due to her lack of understating. They approach you as a doctor to provide a certificate so that the parents can ask for a hysterectomy. You tell them that this is against human rights and in fact, there is a court judgment against this practice but they keep insisting, because they see you both as a doctor as well as a friend. What should you do?

a) Go all out to help them for the operation because you feel that times are actually bad and chances of (possible) rape and pregnancy are high?
b) Go by the book and say there is nothing you can do?
c) Suggest alternative treatments?

Any other suggestions and solutions? Do write in!

Responses received

It is the responsibility of the mother to protect her from sexual abuses and subsequent pregnancy as she cannot take care of herself. The best course would be to get a certificate from psychologist that she is mentally unfit and cannot take care of herself. Then she should get her operated for tubectomy to save her from subsequent pregnancy and then get her treated by some psychologist for her mental illness. If she recovers and becomes mentally fit she may get her operated for reversal of procedure, reuniting the tubes. This will give her a chance of getting pregnant which is very important factor for any lady. Hysterectomy will be a permanent failure to get the child of her own, which becomes unethical. Dr BR Bhatnagar
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Inspirational Story
Hide and Seek

One summer day a mother looked out the window of her house. There in the garden she saw her little daughter rolling around the grass in laughter. Intrigued she went outside to investigate. Approaching her daughter the mother asked, "My child, what do you find so amusing?" "I understand, I understand," replied the child among bursts of giggles. "What do you mean?" questioned the mother.

"Well," answered the child, "I was playing outside on the grass when I started thinking about God, and how I have heard people say that God is everywhere. But I looked around and couldn't see God anywhere. So I thought: of course! God must be playing a game of hide and seek. So I decided to try find God. I looked amongst the roses for I have heard that God is beautiful. But God was not there. I lay on my back and searched the skies for I have heard that God is up in the Heavens. But God was not there. I dug in the ground for I have heard that God supports us all. But God was not there. And I became very frustrated and I called out: Where are you God? Why have you left me? And then, all of a sudden, a sense of peace came over me and I realized the Truth!" Spellbound, the mother gently inquired, "What truth?" "That," giggled the little child, "It was not God who was hiding, it was me".

So much of our lives we stumble around lost trying to seek God, never realizing we are already Found. All we merely need to do is to stop hiding from God and to embrace Him fully.
eMedi Quiz
All are true except:

1. Similar to what has been observed with seasonal influenza, shedding of pandemic H1N1 influenza A is observed to begin the day prior to symptom onset and often to persist for 5 to 7 days or longer in immunocompetent individuals.
2. Even longer periods of shedding occur in children (especially young infants), elderly adults, patients with chronic illnesses, and immunocompromised hosts.
3. Delayed clearance of virus from the nasopharynx is observed in patients who developed acute respiratory distress syndrome or who had fatal disease.
4. The amount of virus shed is greatest during the second week of illness.

Yesterday’s Mind Teaser: Asymptomatic H1N1 infection is seen in

1. 9% cases
2. 20% cases
3. 30% cases
4. 40% cases

Answer for Yesterday’s Mind Teaser: 9% cases

Answers received from: Dr Jainendra Upadhyay, Dr Poonam Chablani, Dr B R Bhatnagar, Dr K Raju, Daivadheenam Jella, Dr Avtar Krishan.

Answer for 3rd December Mind Teaser: 4. All of the above

Answers received from: Dr Kailash Chandra Sharma, Dr Praneet Telukunta, Dr Jainendra Upadhyay, Daivadheenam Jella, Dr K V Sarma, Dr Avtar Krishan.
Humor
Blonde Stop

A police car pulled alongside a speeding car on the motorway. Glancing at the car he was astonished to see that the blond behind the wheel was knitting! Realizing that she was oblivious to his flashing lights and siren, the cop rolled down his window and shouted "Pullover!" The blonde rolled down her window and yelled back "No, it's a scarf!"
Readers column
Thanks for the education. Lot to learn and accept that with purity and sincerity, it is easier to reach near full achievement. God bless all. Kuldeep
Press Release
Pre-exposure prophylaxis can reduce the risk of HIV infection by 48 to 75% in high risk patients

Globally over 20 lakh new HIV infections are recorded each year
It is important to raise awareness about the effectiveness of pre-exposure prophylaxis in addition to regular condom use


With 20 lakh new HIV infections being recorded globally each year, pre-exposure prophylaxis is now recommended as an effective technique to prevent infection among high-risk patients. Several trials over the recent times have demonstrated a reduction in the risk of HIV infection by 48 to 75 percent with daily use of tenofovir-emtricitabine combination compared with placebo.

Speaking about this, Padma Shri Awardee Dr A Marthanda Pillai National President IMA and Padma Shri Awardee Dr KK Aggarwal Honorary Secretary General IMA and President HCFI said, “It is important that in addition to counseling patients on consistent condom use, pre-exposure prophylaxis with tenofovir-emtricitabine should be given to HIV-uninfected adults who are at high risk for sexually acquired HIV and are committed to medication adherence and close follow-up. The drug combination is available in India. All high-risk patients should ask their doctors for the same.”

In July 2012, the US FDA approved the combination for pre-exposure prophylaxis among confirmed HIV-negative individuals at high risk for sexually acquired HIV infection. The combination drug should be given once daily and continued for as long as the risk of infection persists. If a decision is made to prescribe the drug it should be dispensed as a 90-day supply, renewable only after HIV testing.

Prior to initiation of pre-exposure prophylaxis, all patients should have HIV antibody testing to be certain that they do not have unsuspected chronic HIV infection.

HIV/AIDS can be diagnosed with the help of a blood test. And if that blood test comes positive, an individual is advised to do follow up for the blood tests to be sure that the person is HIV positive. If that is the case, the person is suggested to undergo several other tests to see how far the disease has progressed for the suitable treatment. In cases where an individual comes in contact with an infected person, it is advised that he should take up the tests at the earliest. As per 2015 recommendation, every HIV-positive person should be started an anti-HIV drug at diagnosis.

Who are considered at high-risk of HIV?

• Men who have unprotected anal sex with men and have multiple or anonymous sex partners
• Heterosexual individuals who have multiple sex partners in areas of high HIV prevalence
• Partners of HIV-infected individuals who have not achieved viral suppression

How does HIV/AIDS spread?

Sexual Transmission: An individual can contact HIV/AIDS if he comes in sexual contact or with a person who is already infected with HIV through sexual secretions like rectal, genital or oral mucous membranes. It happens when two individuals indulge in unprotected sex or shares any object (sex toys) with a person who is infected.

Perinatal transmission: A child can come in contact with the HIV during pregnancy, childbirth and breastfeeding.

Blood Transmission: Contacting HIV through bloodstream and blood transfusion is although rare, can still happen despite staunch screening and precautionary measures. And one of the most common causes of this is sharing and reusing syringes contaminated with HIV. Additionally, individuals who use tattoo syringes without necessary precaution can also spread the infection.
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