Dr Niyaf's Online Clinic

When successful, bone marrow transplant can bring an end to the constant need for blood transfusions and over time, reduce the need for iron chelation therapy. Sadly, bone marrow transplant is not a viable option for many. And for many others [including some known to me personally] it not an option they would even consider.

My mentor, from whom I learnt much about the Thalassaemias, would often ask why bone marrow transplant is such an attractive option to some families. Why do we as people with Thalassaemia [their families and medical staff involved in their care] accept the risks involved in the procedure and go through the difficult treatment protocols?

Would we be as willing for bone marrow transplant if our Thalassaemia was better managed?

I recall the many conversations I had with a number of people with Thalassaemia in Melbourne. I saw in them individuals empowered to take hold of their lives, setting goals and carrying on with life with confidence and pride. Never considering themselves as anything less than most capable and normal people. They were normal people living normal lives, their medical condition being just a part of who they were.

It wasn’t denial; they accepted the medical condition they had and put in an effort to make sure that it wouldn’t hold them back in life. With this attitude and the amazing support structure they built around themselves they were able to achieve a healthy state of living from where the risks associated with bone marrow transplant were not worth it.

Sadly, the same is not true in many other places. Accessibility to care, the immense hardship individual people and their families have to go through to get much needed precious blood, the lack of a decent support structure that assist in managing the sometimes difficult chelation therapy and the overall poor results of the largely inadequate therapy makes these differences all too obvious.

Optimised blood transfusions beginning early in life has in those better managed centers reduced the bony changes that are still so visible on our faces. “They look like normal people” said this friend of mine with Thalassaemia upon meeting a middle aged woman with Thalassaemia from another country. And how true his statement was! The disappointment was not hidden in his voice when he later said, “My face tells others that I have Thalassaemia”. True again. His under-transfused body was trying to make more blood by expanding his facial bones causing the tell-tale facial features to appear. If we were to offer optimized (and personalized) blood transfusion regimes to cases with Thalassaemia in Maldives, we will be able to minimize the physical deformity associated with the condition. Accepting the fact that our blood donor pool is small and finding other ways of getting blood {say for example getting Red Cross in other countries to donate blood to us} would make it possible to provide adequate transfusions.

But perhaps the most significant difference that I noticed is that the chelation therapy is very well accepted as a part of the treatment in Melbourne. People used their pumps [yes they use pump and needles] diligently. One young girl from Melbourne said, “This is what will keep me well till you can find a cure”. Another said, “I have blood to keep me going just the same way as my car needs petrol to run and it is Desferal that keeps my body’s engines in tip-top shape to work”.

They keep themselves well by pumping Desferal in to pump iron out. Chelation is such an essential part of management that much of the treating physician’s time and effort is spent on that aspect of care. Again, we are failing very badly indeed in this aspect. Compliance with Desferal therapy is so very poor in a large number of people. The accumulating iron is slowly but surely poisoning the body organs.

This is, in my opinion, why bone marrow transplant is such an attractive treatment option for our cases. Not requiring difficult and time-consuming treatment on a regular basis is a blessing for anyone. What we at times fail to bring into the equation are the risks associated.

For those who do not have the bone marrow transplant option on the table, there is still life. These people from Melbourne with the same medical condition have shown me this.

Reproduced. This article was first published in 2006.

I have migrated by blog to Tumblr after having it managed on GoDaddy’s QuickBlogCast for several years.

The site had been in lock down for a while now but it should be up and running with the same URL from today.

Along with the blog, I am also relaunching the Q&A box, again Tumblr based.

Several children (and according to my adult physician colleagues; adults as well) have been seeking medical care for a severe diarrhoeal disease over the past many days. Among the children, several have required hospital admission for management of dehydration associated with the often very watery and high purge rate loose stools associated with this diarrhoeal disease. I have talked to a few of my colleagues working in the islands who tell me that they too are seeing similar cases.

It is quite possible that the number of cases seeking medical care actually represent only a small fraction of the total number of cases as many are likely to be managed at home with home remedies, especially among bigger kids and adults.

Most diarrhoeal diseases that occur in these types of outbreaks are usually viral in origin (caused by viruses). Similarly most of the cases, from the current outbreak, that I have been involved in management have also been, on investigations, identified to be of viral origin. However, a small but significant number have had evidence of bacterial infection.

Diarrhoeal disease often spread via contaminated food and water associated with poor hygiene or use of unclean water. While we wait for the epidemiological data to ring bells at the public health authorities I would like to alert readers of this blog to give extra care to safe and hygienic handling of all food and drinks including drinking water. Improved personal hygiene, especially after use of toilets (particularly by those who have diarrhoeal disease) could help prevent spread. Improving hand hygiene by proper hand washing using soap and water and improved hand hygiene by food handlers (at home and public eateries, etc) is strongly recommended.

Children with severe diarrhoea, especially the very young among them, are likely to become dehydrated very quickly. It is therefore very important to ensure rehydration fluids are used to prevent dehydration by replacing the diarrhoeal losses. WHO ORS packets can be used to rehydrate and maintain hydration. Other locally available fluids such as plain (unsweetened) coconut water is also widely accepted and used.

Please seek care if severe diarrhoea, especially in very young children.


NB:

How to make ORS

• WHO ORS packets are readily available in Male’ and most, if not all, inhabited islands.
• Measure and place 1 litre of boiled and cooled water in a clean container (1 litre= 4 “ordinary” sized glasses or 2 small -500ml -mineral water bottles).
• Add the entire contents of the WHO ORS packet to the container and mix till all ORS powder is dissolved.
• This makes 1 litre of ORS.
• DO NOT add anything else to the solution! DO NOT boil the solution! Use within 24 hours of preparing and DISCARD any unused solution.

(Source: blog.niyaf.com)

In the past couple of weeks my colleagues and I have been seeing increased number of cases of Hand Foot and Mouth Disease (HFMD) in Maldives. HFMD is a moderately contagious disease that can easily cause epidemics among infants and young children and from the number of cases my colleagues and I have been seeing, we maybe nearing one now.
Here I will quote some general information Q & A about the disease I wrote for the Maldivian Medical Association website a couple of years ago.

What is it?
Hand-foot-and-mouth disease is a mild, enteroviral disease characterized by a fever and vesicular eruption in the mouth and over the hands and feet. It occurs most frequently in children younger than age 5.

How do you get it?
An uninfected child gets the illness when respiratory droplets from an infected child are inhaled. Respiratory droplets are formed during coughing, sneezing and during speech. The virus also gets transmitted when spit or sputum contaminated objects (Eg: Toys) are handled by an uninfected child. Stool contamination (feco-oral) of food and drinking water has also been documented as a transmission mode.

What are it’s signs and symptoms?
After an incubation period of 3 to 6 days druing which the newly infected child remains well, the illness begins with mild fever ranging from 38° to 39° C, decreased appetite, malaise, and, often, a sore mouth. Within 1 or 2 days vesicular lesions appear in the oral cavity, most frequently on the inside of the cheeks and the tongue, but also on the inside of the lips, gums, and hard palate. In the majority of preschool children, but in only some of the infected adults, the oral lesions are accompanied by vesicular skin lesions, most often on the hands and feet and on the fingers and toes, but not infrequently on the palms and soles. Less often, lesions occur on the buttocks or more proximally on the extremities, and rarely on the genitalia. They are generally 3 to 7 mm in diameter and surrounded by a narrow zone of redness. They range from 2 or 3 to 30 or more.

How do you diagnose it?
Diagnosis is clinical, from the symptoms and signs.Blood tests are not required.

Home care:
Patient should be given bed-rest, plenty of oral fluids (not just plain water) and Paracetamol for the fever. In addition, patient’s with this disease should be kept separate from individuals without the disease.

How do you treat it?
Treatment is supportive. The lesions usually resolve in 1 week even without any treatment. Treatment mostly targets reducing discomfort while the body clears the infection by itself.

(Source: blog.niyaf.com)

Here is an information sheet published by CDC on H1N1 vaccine. It is in PDF form.http://bit.ly/3QmCcd

(Source: blog.niyaf.com)

I have had a long chat with a Minivan News journalist a short while ago. She is planning to write an article about the concerns that I have raised. Finally, some responsible journalism; or did I speak too soon.

Anyway, I hope the messages that need to get through does. We have had some very sick Dengue Fever cases in last few weeks. We have had some very close calls in that time. The number of cases we are getting are not small. They may not have reached a peak yet; meaning it could get worse before it gets better unless we act now. 
The rainy season IS here. We would be foolish to ignore the lessons from natural history of mosquito breeding. We must expect a boom in mosquito population just after the rain. The clear water “pools” that Aedes mosquito likes to use for breeding would be plenty. That could mean an increase in the mosquito responsible for spreading Dengue Viruses.

I hope the hospitals across the country would help Center for Community Health and Disease Control (CCHDC) in assessing the national and regional case incidence by reporting ALL cases that get diagnosed as Dengue Fever or are suspected as Dengue Fever. I suspect the present case reporting to be very weak - especially within Male’. I suspect that many cases that get screened at clinics and probably more at main hospitals don’t necessarily get reported to CCHDC. They must ALL be reported for CCHDC epidemiology unit to be aware of the actual scenario. Otherwise we face a discrepancy between what we as clinicians see and what the CCHDC analyzes our epidemiological status to be.

We should NOT wait till we actually reach the peak incidence before we take steps to stop disease spread. Why would we want to do that when we could act earlier and help prevent that peak from appearing in the first place?

Mosquito control need not be an expensive intervention. We have had some extremely positive responses from some of the island communities in past years. I have witnessed, first-hand, community action at Gaaf Alif Thinadhoo the year before last, when the public cleared all mosquito breeding areas from one end of the island to the other during the office weekend! I know many other communities did the same during that period. 

The public need to be informed and energized into action. As a clinician I too have a duty to my community. The least I could do in this situation would be to voice my concerns and get people to act to avert possible morbidity. I call on all communities to take steps to control mosquito population in their locality. Prevention is possible. All communities can prepare their own interventions. It does not have to be fogging the island with insecticide spray. That could help in the short term. It is not something that I would recommend. Removing mosquito breeding places is more effective in the long run. It is more cost-effective as well.

I also hope that some parents of kids who have had severe forms of Dengue Fever share their experiences; positive and negative with the public. Some of them have had very traumatic experiences with a few of them having to bear the sorrow of losing a loved one. Their words and they themselves could help pressure the authorities, get NGOs active and energize the public to work together.

I also got a message from the newly established Maldivian Red Crescentsociety that they too are planning activities in the islands to help educate the public about Dengue and also plan community action to control mosquito population. I welcome the news. I hope to contribute in any way that I can.

I just hope, like everything else these days, this public health issue does not get hijacked by anyone for political gain. I hope journalists would be aware of this dimension to our current socio political climate and take great care to deliver their end of the social responsibility to the community in a clear and responsible way.
There is hope. All is not lost. It never is.

(Source: blog.niyaf.com)

Like clock-work, whether the people monitoring such events take notice or not, we have been, year after year, exposed to September-November Dengue peaks for the past many years. 

The exact data is held elsewhere and not readily available to the public. Perhaps the numbers this year have not reached that critical level for the monitoring system to ring out alarms. What I am stating is a clear observation that my colleagues and I have been noting for the past many years. I was going to say that this year is no different. It is similar in that the peaks is here. But it is worryingly different too; the severity of the cases are significantly higher than usual. We have had more than a few cases already this year when we (and the families) literally held our breaths. We have largely done very well and we have been a bit lucky as well; we have escaped without a mortality. May Allah keep it that way, Ameen.

I am nonetheless very concerned. I fail to see an appropriate response from public health authorities, the media and even concerned public to this almost predictable public health emergency. I have talked to media personnel many times over the past few weeks. They are mostly interested in other, apparently news-worthy, topics and not so interested in information and concerns related to service-crisis at public healthcare institutes or emerging medical public health concerns such as this. I hope at least some of the reporters I have spoken to would write about these issues and increase public awareness and call them and the authorities to action. 

The control of Dengue fever requires mosquito control measures such as clearing their breeding micro-environments and use of personal mosquito repellents and barriers. I would urge all readers to share this information with their contacts and get everyone working towards prevention of mosquito breeding in their home environment. We can all do our bit. Prevent water-logging in our household; in empty cans, rooftops, drains, gardens, wells, construction sites, etc. Similar water-logging in public places such as state buildings, parks, construction and work sites must be addressed by the concerned authorities. Such water-logged micro-environments are used by mosquitoes to breed their progeny.

With Dengue peaks being so predictable we could come up with “pre-season” activities to create awareness and conduct activities to prevent the peaks rather than, year after year, just respond to a crisis.

The rainy season will soon be upon us. Perhaps it is not too late already.

Here are a few responses to I got:

Dudu [26 Oct 2009, 1355Hrs]: public shud know that this mosquito usually bites during daytime and its important to take measures in the afternoon and evening too…and i believe construction sites are the main source of the mosquitoes..

Scheroo [4 Nov 2009, 1143Hrs]: This is an important issue that needs to be addressed immediately. I will spread the message and hope that people take the measures to prevent the disease as you have described. Thank you. Found this blog through SImon’s blog. 

Aishath [9 Mar 2010, 1755Hrs]: a group of women came to my house and ordered my very salty water well to be covered as it might breed mosquitoes. my rain water tank is covered. but the drain outside on the road is waterlogged. i thought denque mosquitoes breeded in fresh water and not salt water. dont these people from public health know?

Dr Abdulla Niyaf [12 Apr 2010, 0841Hrs]: I believe this too to be an issue of miscommunication. Yes, Aedes preferentially breed in “clean, still fresh water”. The reason why the Vector Control Unit of DPH (which has now become CCHDC) used to recommend covering the house well was that it was a common breeding ground for mosquitoes. With the well water becoming highly saline this maybe less of a problem. However, unless very saline, it could still be a breeding ground! This is especially the case with rainy seasons when the wells also act as the “drainage” of the rain water caught by the house hold roofs.

(Source: blog.niyaf.com)

Weaning foods (more appropriately called Complementary Feeding) has been the topic on which I have received most questions in recent months (and perhaps always). I would therefore like to share with readers this document that is most useful to understand the basic principles that one must consider in starting and continuing complementary foods.

It is a WHO document: in PDF format.
Guiding Principles on Complementary Feeding

I would like to encourage everyone to read the entire document.

Core issues are discussed on pages 14, 18, 20 and 21.
Enjoy.

(Source: blog.niyaf.com)

I was one of the members of the Maldivian team that attended the WHO SEAR (South East Asia Region) consultation meeting in New Delhi to discuss whether the region could agree to set a Measles elimination target. Sitting in the same conference hall with highest authorities and experts on Measles from around the world was a huge learning experience for myself. I am sure it was the same for many of the other participants as well.

Most regions of the world have controlled Measles to pre-elimination levels already. SEAR remains the only region which is far, far behind in achieving that goal. One country in particular, India, for various geopolitical reasons is the stumbling block in this endeavor. The larger majority of measles cases and deaths from Measles at present occur in a few states of India. Much effort is being put in to tackle the problem. However, we came to the realization that much more needs to be done. 

According to available knowledge, Measles elimination is biologically possible and feasible. Many of the experts believed that provided a concerted effort is put in and sustained for a few years across the world; in particular in the hots spots of UP and Bihar of India, we would be able to eliminate measles from the region and then eradicate it from the world. An estimated 130,000 kids continue to die in India from Measles every year; a number that could well be prevented by use of currently available measles vaccines.

Well, the meeting decided to advice the regional high level meeting - which will be underway in Nepal in a few days time - to set the goal of 2020 for elimination.
Maldives with our high coverage of measles vaccines should be ready to push for elimination should the target be set. Much would need to be done to ensure that vaccine uptake is sustained at the currently high levels to make the effort fruitful. Our biggest challenge would be to address the emerging issue of vaccine refusal in the Maldives.

I hope to be involved in a meeting to address this very issue in the very near future.

Response & Discussion:

Jaa wrote [5 Sep 2009, 3:41 AM]
Interesting. And, I didn’t know refusal to vaccination was a emerging issue in the Maldives! Would be interesting to hear your opinion on the social impacts if this trend were to continue…

Dr Abdulla Niyaf wrote [25 Sep 2009, 2:26 PM]:
It is a worrying development. One that has been increasing over the past few year. We (my colleagues and I) currently encounter one case roughly every month where parents refuse to vaccinate their kids. There are 2 groups among them; one who refuse based purely on perceived religious beliefs while others quote internet-based “scientific” publications as reasons to refuse vaccinations; although I find the majority within the latter group to be “morphologically” similar to the previous group.

Vaccination does not offer a fail proof 100% protection from an illness! A smaller number of kids who get vaccinated may not build within themselves the immune response in strength adequate enough (seroconversion) to protect against future infections. However, a larger significant number do. It is this high number of post-vaccination seroconversion rate that is in effect protecting those who are not seroconverted following vaccination AND even those who are not vaccinated at all; from catching the illness. The protected kids act as barriers against spread of infection within the community; a concept called Herd Immunity.

In the event that a critical number of kids either fail to get vaccinated or fail to develop seroconversion following vaccination, the level of community protection offered by Herd Immunity (for that particular illness) may be too small to stop transmission of illness. That is to say: the chance of an infected kid coming in contact with an unprotected kid (who is likely to get infected) is increased, allowing the disease to spread within a community! That is the concern.

We, in Maldives, take pride in the significant gains made in the improved child and infant health indicators like low Infant Mortality Rate. It is arguable that a significant contribution to this achievement was made by the success in controlling vaccine preventable illnesses like Polio, Diptheria, Tetanus, Pertusis, Measles and Mumps. Such control allowed a significant reduction of disease associated mortality and morbidity. That in turn made it possible for us to concentrate on other aspects of infant and young child health. 

A consultation process with those on the other side of the great divide could help identify the exact reasons for vaccine refusal and address them.

(Source: blog.niyaf.com)

Times are uncertain. But the outcome of leaving the biggest state-run hospital in its current state is just about anybody’s guess. 

Those who now hold the responsibility of running IGMH seem to be all too happy to let someone else shoulder the burden. Attempting to revive the ailing institution, one could deduce from their eagerness to sell, would, to them, amount to political suicide. To sell the idea of selling IGMH, they are showing the truly terrible condition it is in and by allowing the decay to rot the institution to its core they’d like people to smell the stench till everyone gives in to the idea. It does reek even now.

On the other side of the political divide are those who would love to see the institution crumble to dust so that they may lay all blame on their opponents; again for political gain. So it would seem that IGMH has it’s fate sealed. After all, it is a win-win situation for both parties.

The dotted line has apparently been prepared already. It only needs that fateful stroke of a pen. That is where we are at now. At least that’s what we are being told. It is either Corporatization or Public-Private Partnership.

Corporatization is a nice way of saying that it would be sold to a private company to run as a business. Privatization is apparently too easy to digest so we go by a word that many can’t even chew. We are resigned to the statement that if we are unable to manage it by ourselves; we may as well get someone else to manage it and make it viable. Now, wouldn’t that be nice and easy!

I have to admit. I am pretty disappointed that it has come to this. But we all saw it coming. Years of neglect, not just since last November, has got all of us in this situation for which many of us can’t see another option. There are other options but there is hardly any trust left.

Then there is this remote possibility that “we” would not lose control altogether. The Public-Private Partnership where the ownership is with the state but managed by a private party as a business venture. A bit like what has been happening all along, but now with the legal blessing. I wonder if the money skimmed to private accounts would be legal in that situation! Just a thought.

I am yet to be convinced that either of the plans have been studied well enough from a public service point-of-view to throw all fears away and take the plunge. The water looks scary and dark from where I stand.

Then again; I could change where I stand. Listening to one of the chief architects of Operation: Bin the Junk say “our way or the highway” was probably a divine a sign for us. Perhaps the highway would be a good place to stand. Another thought. And in one day. I must be on a roll today!

(Source: blog.niyaf.com)

The current situation: 

 All clinical and allied departments at IGMH have at least one person on an On-Call duty at all times. The current role of this person is to attend to hospital if called for urgent work that needs his or her expertise. As a Pediatrician, I would therefore be called in - on my On-Call day - to attend to emergencies or urgent situations that the in-house Pediatric Medical Officer decides requires my expertise. I could therefore, open to interpretation, stay at home expecting to be called in only when a situation requires my presence.

The problem: 

In few clinical areas, and perhaps in some allied fields too, the need to call in the On-Call doctor or technician is an infrequent event. This maybe true for fields like Dermatology (skin specialist) and Clinical Pathology. However, for many clinical speciality fields, like Internal Medicine, Pediatrics, Obstetrics, Surgery; just to mention a few, the need to call in the On-Call specialist maybe more frequent and more importantly Urgent! 

Just consider these situations.

•  If a woman needs to have her baby delivered urgently by C-Section, say for Fetal Distress (which suggests that fetal well being is being compromised), an Obstetrician and a Pediatrician needs to be available on the spot almost immediately.
• If a newborn baby, who prior to being born had not shown any sign of fetal compromise, does not initiate breathing spontaneously or even following the initial steps of care; a Pediatricians presence could mean the difference between survival and death.
• If an adult patient in ICU has a Cardiac Arrest; the presence of an Anaesthetists and/or a Physician could help manage the situation promptly and with expertise the situation demands!

Some may argue that in these situations the first emergency care could be provided by the in-house junior level Medical Officers until the Specialist could arrive at the site. Perhaps, considering the clinical expertise demonstrated by few of the junior Medical Officer, this may be valid in some situations, but from experience I find that the situation is not always that. Others may, on the other hand, argue that even if the specialist was available certain situations may not be reversed. Very true. There is a limit to what anyone can humanly do and some clinical condition are not reversed or correct even with best of efforts. BUT the best effort must be put in! 

What I propose: 

I believe it is only right for an On-Call person to be available around the clock, within the hospital premises to respond urgently to those situations that demand prompt attention. 

Factor to consider in implementing this proposal:

• Willingness: First there must be willingness from those in the clinical fields and more importantly those in the administrative posts to get these changes to materialise. A strong political will would most definitely help too. Unfortunately a few individuals are quite comfortable with the way things work at present and this increased time at work would be challenged. I have little doubt that it would be.
• Facilities: At present, even if a doctor wishes to be in hospital for the duration of his On-Call duty, there is hardly any place to be in. While not immediately needed at the bedside or to attend an emergency it would be beneficial, to have a staff lounge or rest facility (toilets, shower facilities etc), within the hospital premises, where the duty doctor could stay. Then when the need arises the emergency could be promptly attended to.
• Pay issues: The current CSC practice of capping the overtime means that this extra time spent within the hospital would not be included in overtime payment. Being On-Call is a high demand, stressful duty for even the best of clinicians despite their decidedly calm appearance and confident aura. It would be much satisfying if the On-Call duties are rewarded with an extra allowance; especially if - as I propose - they have to stay in hospital for the duration of the duty.
• Meals: Many employees in other fields of work, where the working hours are long, get meal or food allowances. It would be appropriate to have such allowances especially for those who are On-Call.
• Length of On-Call: Being On-Call for 24 hour continuously is very challenging and could at times make a person physically and mentally exhausted to the extent of affecting his mental and physical capacity to perform effectively. It might therefore make the On-Call doctor or technician more productive in performance if the On-Call shift is shorter.

 Do I really think this is possible? 

I not only think it is possible, I think it is essential. Absolutely. However, I do foresee a great deal of opposition to this proposal, especially from some clinicians. At least initially. The inertia is expected. Change is always a challenge. But good change, one that benefits the purpose of our profession, whether difficult or not, must happen. Getting the rest of the work environment to be supportive of this change is however absolutely essential to make this work.

PS: This was one of the issues which a Group of Concerned Doctors proposed to the senior level management few years ago and proposed yet again in a more recent meeting.

(Source: blog.niyaf.com)