Disease burden transition in “better” states, shows 1st state level report

MediBulletin Bureau
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Disease burden transition in “better” states, shows 1st state level report

The first ever state level disease burden study of India has turned on its head the concept of some states being better than others in terms of health. While states like Bihar, Jharkhand, MP, Chhatisgarh, Orissa, Rajasthan, UP and Uttaranchal continue to battle child and maternal malnutrition, “better’ states like Tamil Nadu, Kerala, Punjab and Goa are becoming the hubs of non-communicable diseases (NCD). So, while states like Bihar and UP are still battling diarrhoea deaths in kids, those that have won that war, now have newer battles to fight. The report was released last week in New Delhi.

“Among the leading NCD individual causes, the DALY rate for ischaemic heart disease was highest in Punjab and Tamil Nadu, followed by Haryana, Andhra Pradesh, Karnataka, Gujarat, and Maharashtra. For COPD, the highest DALY rates were in Rajasthan, Uttarakhand, and Uttar Pradesh, followed by Himachal Pradesh, Haryana, and Jammu and Kashmir. The DALY rate for stroke was highest in West Bengal, followed by Odisha, Tripura, Assam, and Chhattisgarh. Tamil Nadu had the highest DALY rate for diabetes, followed by Punjab, Karnataka, Kerala, Goa, and Manipur,” the report says. DALYs for a disease or health condition are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences. It is an internationally recognised metric for analysing disease burden.

Here’s what the picture looks like in infectious diseases or conditions that are caused by malnutrition. “Among the leading CMNND ( communicable, maternal, neonatal, and nutritional diseases individual causes, the DALY rate for diarrhoeal diseases was highest in Jharkhand, Odisha, and Bihar, followed by Uttar Pradesh and Assam in 2016. The DALY rate for lower respiratory infections was highest in Rajasthan, Bihar, Uttar Pradesh, Madhya Pradesh, and Assam, followed by Uttarakhand and Chhattisgarh. Bihar, Assam, and Jharkhand had the highest DALY rate for iron-deficiency anaemia, followed by Rajasthan, Madhya Pradesh, and Uttar Pradesh. The DALY rate for neonatal preterm birth complications was highest in Rajasthan, Chhattisgarh, Madhya Pradesh, and Assam. For tuberculosis the DALY rate was highest in Uttar Pradesh, followed by Assam, Gujarat, Rajasthan, Odisha, Chhattisgarh, Jharkhand, and Madhya Pradesh,” the report notes.

The inclusion of states like Tamil Nadu, kerala and Punjab in the highest bracket for NCDs like diabetes and heart disease is an interesting revelation because prevention is known to be one of the primary strategies for bringing down the NCD burden. States with better health systems as borne out by their infant mortality rates, immunisation rates etc, are failing on the prevention front. According to the latest National Family Health Survey, IMR in Tamil Nadu for example is 20 per 1000 live births against a national average of 41, in Punjab it is 29 and in Kerala it is 6. Percentage of fully immunised children in TN is 69, in Kerala it is 89 and in Punjab it is 82. The figure for the entire country is 61%.

A senior ICMR official said: “NCD burden is high in the southern states and Punjab. Lifestyle is a factor. But it is also possible that because for years, especially since the National (rural) Health MIssion was started in 2005 the focus of primary health centres and sub centres has been on reproductive and child health because infant and maternal mortality rates were among the MDGs. So they have not been focussing on prevention or on spreading awareness about dietary requirements. That is why the National Health Policy talks about shifting towards tackling NCDs.”

That India lives in many states was clear from many other aspects too. The report found that life expectancy at birth had improved in India from 59.7 years in 1990 to 70.3 years in 2016 for females, and from 58.3 years to 66.9 years for males. There were, however, continuing inequalities between states, with a range of 66.8 years in Uttar Pradesh to 78.7 years in Kerala for females, and from 63.6 years in Assam to 73.8 years in Kerala for males in 2016.

The contribution of injuries to the total disease burden has increased in most states since 1990. The highest proportion of disease burden due to injuries is in young adults. Road injuries and self-harm, which includes suicides and non-fatal outcomes of self-harm, are the leading contributors to the injury burden in India. The DALY rate for road injuries was highest in Jammu and Kashmir, Uttarakhand, Haryana, and Punjab, followed by Rajasthan and Uttar Pradesh. For self-harm, the highest DALY rates were in Tripura, Karnataka, and Tamil Nadu, followed by Andhra Pradesh, West Bengal and Telangana.

Cinnamon may help lose weight

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Cinnamon may help lose weight

If you associate cinnamon with rich, often unhealthy foods, here is a new twist to that story.

Researchers at University of Michigan have found that cinnamon through its active ingredient cinnamaldehyde (CA) can trigger higher metabolism in fat cells which in turn could explain its role in countering obesity.

“CA activates thermogenic and metabolic responses in mouse and human primary subcutaneous adipocytes in a cell-autonomous manner, giving a mechanistic explanation for the anti-obesity effects of CA observed previously and further supporting its potential metabolic benefits on humans. Given the wide usage of cinnamon in the food industry, the notion that this popular food additive, instead of a drug, may activate thermogenesis, could ultimately lead to therapeutic strategies against obesity that are much better adhered to by participants,” the study concluded. It has been published in the December issue of the journalism Metabolism.

CA has in the past been associated with an anti-obesity role and also possible role against hypoglycaemia – a condition in which the blood sugar level can drop to levels at which normal metabolism may be affected. In the present study it was found to increase the expression of genes that have create te environment for greater energy consumption by the cells.

Injectable contraceptives: what is it all about?

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Injectable contraceptives: what is it all about?

Whatever Strap you want to give

What are injectable contraceptives?

Many experts believe that contraceptives that are injected and long lasting could be the solution to India’s inherently gender unequal society where women are rarely partners in the decision to have a child; in most cases they merely carry out the wishes of the husband. Deoxymedroxy progesterone acetate (DMPA) is the commonest injectable drug that prevents pregnancy by stopping ovulation – which is the release of an egg from the ovary. It is given in a dose of 150 mg intra-muscularly every three months. It is marketed as Depo-Provera in India. There are other kinds of injectable contraceptives such as Norethindrone Enanthate (NET-EN) and Combined Estrogen and Progestin (monthly Injections) but neither is currently available in India.

How does DMPA work?

DMPA blocks the Luteinising Hormone (LH) surge that causes ovulation. Unless ovulation happens, it is not possible for the egg and sperm to meet and form a zygote which when implanted marks the beginning of pregnancy. It also makes both the processes of fertilisation and implantation more difficult.

When can DMPA be administered?

It can be started at any time during the menstrual cycle but the best period to ensure optimum effect is within the first five days. It can be started as early as six weeks after childbirth and can also be given to a lactating mother. However if a woman wants to get pregnant after having been on DMPA for a certain period, it can take upto 8-9 months from the last shot.

Where will injectable contraceptives be available?

Minister of state for health Anupriya Patel told the Lok Sabha some time back that injectable contraceptives will first be available in medical colleges and then in a phased manner in district hospitals. At a later stage they will be available in sub-district hospitals, community health centres and primary health centres. Government health centres and hospitals will not charge for the injections. Outside, various brands sell the injection for anywhere between Rs 50-Rs 230 in India.

What are the side-effects of DMPA?

Primary side-effects are changes in menstrual bleeding patterns, acne, weight gain and depression. It prevents ectopic pregnancies, endometrial cancer and uterine fibroids, part of the reason why it is preferred, apart from the fact that it is long lasting and even if an injection is missed chances of pregnancy remain low.

Why are injectable contraceptives controversial?

Activists say that in introducing DMPA, government is shirking its own obligation of ensuring that women are able to assert their reproductive rights. Moreover some studies in Africa raise the spectre of heightened risk of HIV infection in DMPA users.

Are India’s sterilisation figures skewed?

Women constitute 98 per cent of the sterilised population in India, even though the procedure is less complicated for men. Of the total 41,41,502 sterilisations done in India in 2015-16 under government programmes, 40,61,462 were tubectomies. In 2014-15, out of a total 40,30,409 sterilisations, 39,52,043 were tubectomies and, in 2013-14, the corresponding numbers were 43,03,568 and 42,13,172. The commonest reason given for the skew is social resistance to vasectomies the process of tying up of the male vas deferens that prevents the sperm from entering the female body.

Green light for dengue vaccine clinical trials in India

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Green light for dengue vaccine clinical trials in India

Drug Controller General of India (DCGI) has finally given permission to an Indian drug maker, Panacea Biotec for conducting early phase clinical trials in humans  (phase 1 & 2) for the dreaded Dengue virus. A single shot of the experimental vaccine developed by Panacea Biotec in collaboration with National Institutes of Health (NIH), US has shown to be effective against all four types of Dengue virus in all age groups according to early clinical trials conducted by NIH.

The disease is caused by four closely related viruses, called the Dengue viruses 1-4. Globally the  only Dengue vaccine developed by French drug major Sanofi Pasteur company which was given the green light by WHO in July 2016 was denied introduction  into our market by the Indian health ministry as it sought a waiver of the phase 3 clinical trials for the vaccine. The data supporting the waiver  was deemed insufficient as the 3 dose vaccine was effective only in age group of 9  to 45 years  in areas with high disease burden.The vaccine which was initially given license in 11 countries was subsequently withdrawn by early starter countries like Philippines.

The mosquito borne disease causes high grade fever associated with severe headache, BODY ACHE, vomiting, muscle pain, skin rashes  and a fall in total white blood cell  and platelet count.

The mosquito borne disease causes high grade fever associated with severe headache, bodyache ,vomiting, muscle pain, skin rashes  and a fall in total white blood cell  and platelet count. Infants, children,senior citizens, people with other chronic disease and pregnant women with weakened immune system are at increased risk of developing Dengue Haemorrhagic Fever , a rare complication which can cause massive bleeding and shock leading to death in 24hrs also called Dengue Shock Syndrome.

A dengue vaccine would therefore represent a major shot in the arm  in the control of the disease and save significant cost to the Government and common man

The disease has suddenly come into limelight in India since 2015 when the number of cases and deaths suddenly spurted in Delhi and Punjab. The disease subsequently spread to other states like Uttar Pradesh, West Bengal, Tamilnadu, Kerala and Karnataka in 2016 and 2017 as they registered the maximum number of cases and deaths. About 140000 cases and  216 deaths have been reported so far  in 2017 due to Dengue fever. According to WHO the reported numbers could only be the tip of the iceberg as most cases pass of asymptomatically and widespread laboratory facilities are not available in most developing nations. Dengue cases are expected to rise significantly due to higher  temperatures in most parts of the world as a result of  global warming.

There are no specific treatment for dengue and prevention is currently limited to vector control measures. A dengue vaccine would therefore represent a major shot in the arm  in the control of the disease and save significant cost to the Government and common man.

Sun Pharma recalls contaminated Metformin batches

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Sun Pharma recalls contaminated Metformin batches

Fearing microbial contamination, Sun Pharmaceutical Industries Ltd. has recalled two batches of its anti-diabetic drug  Riomet (Metformin Hydrochloride Oral Solution).

Sun Pharma which is the biggest Indian drug manufacturer by volume and the fourth largest generic drug producer in the world found the oral solution to be contaminated with Scopulariopsis brevicaulis. It is a type of fungus (mold) which can cause infections starting from nail infections to severe life threatening infections like pneumonia , sepsis and widespread disease in the immunocompromised groups like people with cancer, leukemias , diabetes etc. It recalled two lots of  500 mg/5mL vials from retailers.This product is manufactured by  SPII, a wholly owned subsidiary of Sun pharmaceutical Industries Ltd.  The products with NDC Code 10631-206-01 Lot A160031A, Exp: 01/2018, and NDC 10631-206-02 Lot: A160031B, Exp.: 01/2018 have been recalled.. Consumers who are in possession of these batch numbers and expiry dates  have been asked to stop using the medication immediately and hand over the vials to retailers. Consumers have also been advised to contact their physician or healthcare provider if they are experiencing any problems that they suspect may be related to taking or using this drug product.

Metformin Hydrochloride Oral Solution is used for treating Diabetes Mellitus (Type 2) in adults and children above 10 years of age. It is the most widely used first line anti-diabetic medication for patients of diabetes that is usually detected late in the life.

The contamination was discovered during sample preparation for the Antimicrobial Preservative Effectiveness Testing (AMPET) being performed as part of the 12 month stability study interval.   This is the latest in a string setbacks Sun Pharma has suffered in recent years.It has already suffered huge financial losses due to issuance of a warning letter by the U S Drug Regulator  in December 2015 for violations with Sun’s quality control system after a Food and Drug Administration inspection found lapses  at its Halol plant in  Gujarat  and was subsequently barred from new product launches in US which is the world’s largest drug market. It continues to suffer from quality control issues. The company was again found wanting in quality control processes by the U.S. Food and Drug Administration (FDA) after repeat inspection in Nov -Dec 2016 at the Halol plant.

‘Avatar’ therapy could reduce schizophrenia symptoms, study finds

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‘Avatar’ therapy could reduce schizophrenia symptoms, study finds

What would happen if the voices schizophrenia patients often hear, were to encounter them in person. They would get better apparently.

An experimental therapy which involves a face-to-face discussion between a person with schizophrenia and an avatar representing their auditory hallucination may help reduce symptoms, when provided alongside usual treatment, according to a study published in the journal Lancet Psychiatry. The randomised controlled trial comparing the avatar therapy to supportive counselling found that the avatar therapy was more effective at reducing hallucinations at 12-week follow-up, and had a large effect size.

Around 60-70% of people who have schizophrenia experience auditory hallucinations that are typically insulting and threatening. For most people, drug treatments reduce these symptoms, but approximately one in four people continue to experience voices. According to lead author Professor Tom Craig from King’s College London, and the South London and Maudsley NHS Foundation Trust, UK: “A large proportion of people with schizophrenia continue to experience distressing voices despite lengthy treatment, so it is important that we look at newer, effective and shorter forms of therapy.”

This type of therapy was tried for the first time in a largescale controlled trial in people with schizophrenia who had had persistent and distressing auditory hallucinations for more than a year. The treatment participants were originally receiving continued during the trial.

Professor Craig added: “Our study provides early evidence that avatar therapy rapidly improves auditory hallucinations for people with schizophrenia, reducing their frequency and how distressing they are, compared to a type of counselling. So far, these improvements appear to last for up to six months for these patients. However, these results come from one treatment centre and more research is needed to optimise the way the treatment is delivered and demonstrate that it is effective in other NHS settings.”

After 12 weeks, the avatar group’s symptoms were rated as less severe than those who received counselling

During the trial patients who had had schizophrenia for approximately 20 years and heard 3-4 voices on an average were given six sessions of therapy using a computer simulation of the voice that they heard. There was one 50-minute session each week . Of these, 75 people had the avatar therapy and the other 75 people had a form of supportive counselling designed for this study. Therapy involved a three-way conversation between the patient, therapist, and avatar, with the therapist speaking as themselves and also voicing the avatar.

In each session, after discussing the targets for that day’s work, patients spent 10-15 minutes speaking face-to-face with the avatar, practising standing up to it, correcting any misconceptions it had about them, and taking control of the conversation, so that power shifted from the avatar to the patient. The avatar came to recognise the patient’s strengths and good qualities, and the patient’s greater control and power in the relationship. The sessions were recorded, and an audio recording was given to the patient to take home to listen to when they heard the voices.

After 12 weeks, the avatar group’s symptoms were rated as less severe than those who received counselling.

ICMR to conduct clinical trials, toxicity tests for Ayurveda drugs

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ICMR to conduct clinical trials, toxicity tests for Ayurveda drugs

In keeping with the NDA government’s stated objective of promoting alternative systems of medicine, the country’s premier medical research council has signed a Memorandum of Understanding with the Ayush ministry for conducting clinical trials of Ayurvedic formulations so that they become more acceptable on a global stage.

The first such trial is already on in Maharashtra for an Ayurvedic formulation for dengue. Talks are on for a second trial on a formulation used in Tamil Nadu for dengue and Chikungunya. However while the council is calling it a clinical trial the actual process would include all the usual steps of drug development including toxicity tests, animal testing and pre-clinical trials so that the medicines are at par with global standards.

“One problem with Ayurvedic formulations is that the composition varies from one person to the next. So we told them that the first requirement is standardisation, to ensure that every person who takes the drug actually gets the same medications So they took about a year to standardise the drug and come back with the medicine in the form of a pill. We will test not just the efficacy of the drug but its composition too. We will also do the toxicity tests etc it is like the usual process of drug development,” said ICMR director general Dr Soumya Swaminathan.

The Ayush ministry which is the nodal ministry for alternative systems of medicine such as Ayurveda, Siddha, homoeopathy, Unani etc, has taken a number of steps in the last few years for the promotion of Ayurveda. Prime minister Narendra Modi sometime back dedicated to the nation All India Institute of Ayurveda (AIIA) in Sarita Vihar built along the lines of the All India Institute of Medical Sciences. On Wednesday the National Medicinal Plant Board of AYUSH along with medicinal and aromatic plants stakeholders jointly organized a one day review meeting to examine the draft of National Policy of Medicinal and Aromatic Plants. Addressing the inaugural session of the review meeting, minister of state for AYUSH, Sripad Yesso Naik said that the Medicinal Plant Sector is an ancient as well as a sunrise Sector and it provides diverse opportunities to the country. He said that India could play a leading role in the global market of herbal product and herbal drugs.

The minister also launched the “Voluntary Certification Scheme of Medicinal Plants Produce (VCSMPP)”, designed by NMPB through Quality Councils of India (QCI).

Three-four cups of coffee may be more beneficial than harmful

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Three-four cups of coffee may be more beneficial than harmful

If coffee keeps you going, then this one is for you. Mind though, moderation is the key.

New Delhi: A review published in the British Medical Journal has found that three to four cups of coffee a day can have beneficial effects. In fact in nonpregnant people or women at increased risk of fracture – of which post menopausal osteoporotic women would form a large cohort –  it could actually be tried as an intervention. “Coffee consumption seems generally safe within usual levels of intake, with summary estimates indicating largest risk reduction for various health outcomes at three to four cups a day, and more likely to benefit health than harm. Robust randomised controlled trials are needed to understand whether the observed associations are causal. Importantly, outside of pregnancy, existing evidence suggests that coffee could be tested as an intervention without significant risk of causing harm. Women at increased risk of fracture should possibly be excluded,” the study concluded. It was conducted by researchers from the Faculty of Medicine, University of Southampton and the Medical Research Council University of Edinburgh Centre for Inflammation Research

Largest risk reduction for various health outcomes at three to four cups a day, and more likely to benefit health than harm

The study that reviewed a range of published studies on the health effects of coffee – 201 meta-analyses of observational research with 67 unique health outcomes and 17 meta-analyses of interventional research with nine unique outcomes – came to a favourable conclusion overall but the rider that randomised controlled trials are needed to understand the interaction of coffee with the human physiology fully is a significant one. Studies on coffee in the past have had mixed outcomes but what is interesting is the fact that a person’s genes and the kind of microorganisms s/he has in the gut could change the way they react to coffee by changing the character of coffee metabolites.

Coffee is a complex compound – roasted coffee is a mixture of over 1000 bioactive compounds, some with potentially therapeutic antioxidant, anti-inflammatory, antifibrotic, or anticancer effects. Key active compounds include caffeine, chlorogenic acids, and the diterpenes, cafestol and kahweol. Some of the recorded effects of coffee that the review took note of include – coffee consumption was consistently associated with a lower risk of mortality from all causes of cardiovascular disease, coronary heart disease, and stroke, a 10% less chance of mortality from any cause. In non-smokers there was a 2% lower risk of mortality from cancer for exposure of one extra cup a day (0.98, 0.96 to 1.00). For smokers, the article provided results only from a non-linear analysis, and the risk. Coffee consumption was consistently associated with a lower risk of Parkinson’s disease, even after adjustment for smoking.

2.5% GDP a far cry, India slashes funding for flagship health mission

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2.5% GDP a far cry, India slashes funding for flagship health mission

Despite assurances on the contrary since NDA was voted to power three years ago,  the Indian government has slashed funding for its flagship health programme the National Health Mission.

Expenditure Finance Committee a crucial decision making body on government expenses has approved Rs 85,217 crore for NHM  for a period of three years. This is a little over 25% less than the NHM allocation for the 12th five year plan which was s 1.94 lakh crore for the 2012-17 plan period. Along with the 40% contribution of the state, the actual spend on NHM over the next three years will come to about Rs 1.33 lakh crore.

The Union health ministry had sought Rs  1.59 lakh crore when it moved in March this year for the extension of the flagship health programme. The fund cut is significant because the National Health Policy adopted earlier this year commits to increase health spend to 2.5% GDP.  Interestingly though health minister J P Nadda has told in multiple fora, that there is no dearth of funds for health, only states are not in a position to absorb a 2.5% health spend, his own ministry clearly thought otherwise, when it sought a more than 75% increase in NHM budget. Health being a state subject NHM is actually implemented by the states through programme implementation plans approved by the Centre.

The final NHM allocation was conveyed to the ministry of health by the finance ministry through a letter dated October 17. During the preceding consultation Niti Ayog came down heavily on the health ministry for lack of convergence, the vertical diseases approach and the Rs 500 crore administrative cost of the mission. A mission cannot be continuing forever, the Ayog told the ministry in a tersely worded communication.

Started in 2005 as the National Rural Health Mission and expanded into an additional urban component in 2013, the National Health Mission has for years been the most important programme run by the ministry of health. Niti Ayog comments on the EFC note for the continuation of NHM from April 1, 2017 to 31.3.2020 read:  “Time limit for the Mission needs to be clearly defined (i.e. end of the EFC period) and a Mission should not be continuing forever, more so when there is huge unrest across the country among health workers about the (wage) disparities”.

Science & an US study, Mr minister, say lifestyle causes cancer not sins

Dr O P Choudhury
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Science & an US study, Mr minister, say lifestyle causes cancer not sins

Assam health minister Himanta Biswa Sarma may subscribe to the view that cancer is “divine justice” for the sins of our father – or of ourselves – but scientific evidence suggests otherwise.

Sarma’s comments coincide with the publishing of the results of an analysis by American Cancer Society of the causes of the disease in in the United States that found that  42% of cancer cases and 45% of cancer deaths (which is more than 4 out of 10 total cases including deaths ) in the United States are linked to modifiable risk factors – and thus could be preventable. In other words lifestyle causes half of cancer deaths, at least in the US.

Sarma had said on Wednesday: “”God makes us suffer when we sin. Sometimes we come across young men getting inflicted with cancer or young men meeting with accidents. If you observe the background you will come to know that it’s divine justice. Nothing else. We have to suffer that divine justice.”

He may be loathe to accept the findings of a foreign association but there is no dearth of research to prove that India’s experience with cancer is comparable and that lifestyle indeed is a top cause of cancer. In a paper in The Lancet in 2014, researchers from a slew of centres across the country summed up India’s predilection. “…an estimated 600 000–700 000 deaths in India were caused by cancer in 2012. In age-standardised terms this figure is close to the mortality burden seen in high-income countries. Such figures are partly indicative of low rates of early-stage detection and poor treatment outcomes. Many cancer cases in India are associated with tobacco use, infections, and other avoidable causes. Social factors, especially inequalities, are major determinants of India’s cancer burden, with poorer people more likely to die from cancer before the age of 70 years than those who are more affluent.”

That many of the causes of cancer are preventable is all the more reason why statements such as the current one from a health minister are detrimental to India’s fight against the dreaded disease. Data compiled by the Central Bureau of Health Intelligence (CBHI) shows that in 2012 the total number of cancer cases reported in India were 10,57,204. In 2013 that figure rose to 10,86,783, in 2014 it was 11,17,269, and in 2015 it stood at 11,48,692. More recent data from the cancer registry run by the Indian Council of Medical Research also shows that the northeast – where Sarma comes from – reported the highest number of cancer cases in both males and females. Aizawl district in Mizoram reported the highest number of cases among males while Papumpare district in Arunachal Pradesh recorded the highest number among females. According to ICMR, cancer of breast with estimated 1.5 lakh (over 10 per cent of all cancers) new cases during 2016, is the number one cancer overall. Cancer of the lung is the next with estimated 1.14 lakh (83,000 in males and 31,000 in females) new cases during 2016 and 1.4 lakh cases in 2020. Cancer of the cervix is the third most common cancer with estimated 1 lakh new cases in 2016 and about 1.04 lakh during 2020. Cancers associated with the use of tobacco account for about 30 per cent of all cancers in males and females.”

The US cancer study meanwhile found that cigarette smoking is still the number one risk factor followed by excess body weight, drinking alcohol, eating red and processed meat, lack of physical activity, diet low in fruits and vegetables (low fibre diets), ultraviolet radiation exposure and infections caused by Helicobacter pylori, Hepatitis B virus, Hepatitis C virus ,Human immunodeficiency virus, Human papillomavirus & Human herpesvirus type 8. Small percentage of cancers are however genetically inherited from parents to children.

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