Dr Niyaf's Online Clinic

Outbreak Alert: Diarrhoeal Disease

2010-05-27T10:56:00Z

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.

PS:

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.

Previously:

Diarrhoea again [Nov 2008]

Housefly invasion: is a diarrhoeal epidemic imminent [Jun 2008]

Outbreak Alert: Hand Foot and Mouth Disease

2010-03-09T17:17:00Z

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.

H1N1 vaccine information.

2010-02-02T06:50:00Z

Here is an information sheet published by CDC on H1N1 vaccine. It is in PDF form.

http://bit.ly/3QmCcd

Moving my private practice to Eve Clinic for Women & Children

2009-12-22T10:00:00Z

I have decided to call time on my private practice at Lifeline Multispecialty Clinics and move to Eve Clinic for Women & Children when I return to work after my annual leave in January 2010.

Eve Clinic for Women & Children, located near Nalahiya Hotel, will be opening its doors in January 2010. I hope to be able to start work from the first day of operations.

I would like to thank the management, administrative team and all staff at Lifeline for helping my practice during the past few years. I enjoyed my time at Lifeline and would like to wish all the best to Lifeline Multispecialty Clinics.

Dr Abdulla Niyaf

Dengue: Follow-up

2009-11-05T08:31:00Z

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 Crescent society 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.

We are in to Dengue Season 2009 and the signs of things to come are not good.

2009-10-25T05:43:00Z

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.

WHO: Guiding Principles on Complementary Feeding (Weaning foods)

2009-10-13T18:25:00Z

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.

Eliminating measles by 2020?

2009-09-04T10:17:00Z

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.

I will be out of Maldives for 5 days.

2009-08-22T17:59:00Z

Hello everyone.

I will be traveling to Delhi on an official visit from 24th to 28th August to participate in a WHO conference on Measles eradication campaign. During this period I may take more than the usual time to respond to questions you post on this blog. I am sure you will understand.

Will write about the meeting when I return.

Take care,

Niyaf

Corporatization!

2009-08-13T08:10:00Z

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!