Dr Niyaf's Online Clinic

Haveeru Online reports that the Indonesian who was recently screened for Swine Flu has now been confirmed as a case of H1N1. This is the first confirmed case of Swine Flu in the Maldives, although the patient is not a Maldivian. The story so far, one that is very poorly covered by the media in terms of specifics, raise several concerns. I just hope that the authorities would be less secretive and more transparent in providing information and advise to the public so that we may indeed all work together to prevent a catastrophe.

This is not fear mongering! I am just disappointed, with the way the media is reporting this story. The media, as always acts as a mouth piece which simply relays the information dished out by the authorities. There is hardly any analysis. I just hope it changes, as soon.

The story so far has me wondering about many things:

This is the first case of Influenza A detected in the screening program!

I believe we have had Influenza spreading among Maldivians for quite sometime now. I do not mean Swine Flu, please don’t confuse all Flu to be Swine Flu. I suspect the reason why we have not previously detected Influenza A in Maldives is because we have only been screening a minority; only those with symptoms who had recently traveled.Patients who are diagnosed as Flu Like Illness who have not traveled (or have had direct contact with travelers) have not been screened. The screening kits have, I have been explicitly told, reserved for cases identified for screening by Port Health, not by Clinicians in the Hospitals. Had the screening net been wider, we could have found Influenza A much earlier; but perhaps used up all our screening test kids in the process.

When this “index case” was still in the Influenza Like Illness stage (suspected Flu A stage) was the case and contacts managed appropriately?

We do have a National Pandemic Preparedness Plan that is to be used in handling this very kind of situation. If a case is suspected, then the case and its close contacts must be segregated to prevent further spread of infection. This is important because, should the suspected case become confirmed, both the case and contacts could be responsible for further dissemination of the infection if left in the community.For lack of information, I wonder if this was the way we acted. It sure would be very satisfying to know that it indeed was.

We heard that the case was transfered to Male’ (and to Hulhumale’ Isolation Unit) from Coco Palm for further testing for Influenza A.

I wonder how the case was indeed transfered! Was it by flight? If it was by flight; were there other common passengers on the same flight? If there were; were they informed that their fellow passenger was a suspected Influenza A case? And, if there were other passengers; how are they being managed after sharing the same atmosphere for the duration of the flight?

They are contacts, aren’t they?

If indeed the worst of our fears is true; about the contacts that is, the other fear is already realized, then does the handling raise legal issues about endangerment of lives?

There are so many unanswered question that without actually knowing about the way the case was actually handled we wouldn’t be able to take the story in further. I just hope the media would play its role in making the information available and making the situation clear. The media could ensure that the authorities do their jobs effectively in protecting the health of the nation.

Beyond the story itself. 

I wonder why clinicians in Maldives are still not adequately sensitized about the National Pandemic Preparedness Plan and their role in the entire process. I recall being called to just one meeting; I attended too. I quite clearly remember requesting the chair of the meeting to educate the clinicians as to what the plan was all about and to identify what the role of each of us was. That, to my knowledge, has not happened so far. And here we are talking about the arrival of Swine Flu to our shores.

Having a plan is of no use if the people who are to execute it are not made aware of the plan itself and the role each has to play! 

I just hope this post creates some awareness among journalists in Maldives to ask the necessary questions.

(Source: blog.niyaf.com)

Lessons not learned?

Maldives has seen 4 major industrial strikes in recent years. The Taxi drivers strike, teachers strike, the tourism workers strike and now a “strike” by doctors at IGMH. All four have, in my personal opinion, not gone down well with the majority of the public. At the very least, that is the impression one gets from the publics’ response. The fact that the state-controlled media aggressively portrayed the striking fraction as inhumane and selfish, in all four cases, didn’t help either.

It is my understanding and belief, that calling for and going on strike is not the problem. It is the method of the strike and the way the strikers and the media “sell” the cause and effect of the strike. Most strikes that disrupt services, no matter how small the impact, would face resistance and hence has the potential to be disliked by the public. Perhaps, this was one of the reasons for the apparent poor acceptance of the doctors Sick-Leave-Strike!

Could a different method be more acceptable?

I wrote earlier, at another forum, on how I’d prefer to “strike”, at least during the initial phase. Industrial action is within our rights too. I think in Maldives, at this stage of realization of our rights, we’d do better, in terms of results, with a more visual strike than industrial action. That is my opinion. I had discussed using the “lunch break” for demonstrating. It shouldn’t halt services at IGMH because people taking part would be on their official break! The striking staff could stand along the sea wall just to the west of IGMH with banners and posters. These could display reasons for demonstrating and their demands. Perhaps slogans could be used too. Media could be invited to cover the daily Lunch-Break Strikes. The protest for the day must be wrapped-up before the lunch break ends to allow staff to return to work. A form of visual demonstration could be continued beyond the lunch-break using arm bands or badges. If these strike fail to achieve results or at least a constructive dialog then further steps could be considered. Then, for the greater good of the profession and ultimately that of the health of the people too, an industrial action would be necessary.

The medical service providers, including those of us at IGMH, have had unnecessary and unacceptable stress and inconveniences added to the frustrations of a grossly inadequate and under-resourced medical care provision system for years and years. Any time something good happens and the expectations and hopes for a better health care system gives us hope for the future, someone comes along to kill those dreams. The frustrations build and finally the last straw breaks the camels back!

Why strike? Is pay the only issue?

I can understand, one may say because I am an “insider”, why the doctors at IGMH went on the Sick-Leave-Strike. There are several reasons for a strike or a show of disapproval and displeasure. Salary is an issue, an important one too, but it is certainly not the sole one, as some politicians and Commissions would like the public to believe. That was just bad politics adding insult to injury.

Pay is an issue because, in addition to our work being one which is in itself humanitarian, it is work and a means of earning a living too. There will be people who disagree with me, and that is perfectly fine with me, but it is not wrong to ask for a pay increment when your official work hour has increased by 2 hours per day too! Fine, we are faced with financial and fiscal challenges and one may need to revise pay scales to suit the financial capacity of the government. But then, why would the authorities call the changes to pay; a “pay increment”? Just for the technical truth in it? How is it that they then justify  the political elite being allowed to continue to draw salaries that truly burden the national budget even during this same financial hardship? How dare the MPs attempt to discredit us on national TV when they have voted for themselves a pay rise? Then again, is there any reason why we should expect anything less from them?
Questioning a doctors humanity.

A doctors work should be professional, capable, caring and humane. Drawing a salary or getting paid for providing a service does not make it any less humane! I’d be happy if doctors participate in Free-Medical care. Many of us do that too in our own capacity. Go on, make health care free for the people. We’d be happy too. It is disgusting and hurting to think that people look at us as money hungry and inhumane. That is so far from the truth. 

Perhaps ensuring alternative striking methods wouldn’t have caused these false accusations. Again, I wonder if it is fair to expect anything different from those opportunistic politicians either way. Nonetheless, industrial action that results in service disruptions could have allowed for bad politics taking advantage of the situation.

What is the real pay change?

Just for the record, I have been told, that my take-home pay has not decreased during this pay scale revision. It is exactly the same Rufiyaa for Rufiyaa as it was before. All my allowances were canceled, according to my employers, but my basic salary was increased to adjust for that. So despite the significant increase in official work hours (lets not even talk about the actual time some of us spend at the hospital) we would have to be content that our salary is not going to be reduced. To think that it could have been worse, I am just about content.

Unfortunately though, I am told, some of my colleagues didn’t fare as well. They will actually be taking home a significantly less salary than earlier. Some of them having to be “thankful” for a reduction of only a few thousand! That too when the purchasing power of the Rufiyaa is falling due to various reasons. It would put a different perspective to the situation if one accepts that the changes in economic condition would affect everyone, doctors included, and not just the government.

I’d like to add here that it is not only doctors or nurses who are affected by these pay changes. There are probably others in other fields of work too. My thoughts are with them as well. It is not fair for them either. I’d encourage them to make their voices heard too.

Giving more time to mismanagement.

During the recent presidential election campaign, while campaigning for DRP, we heard the then Health minister, Ilyas Ibrahim, say that it was a failure of the administration at IGMH that was the primary cause for the institutions failures. Many of us had literally gone blue in the face saying the same thing, repeatedly, to the authorities without them heeding a word of it. The only action they were ready to take was to try to silence the very people who tried to convey the truth. 

Members of the current ruling party, MDP, both before and after the election continue to say that the administration at IGMH is a failure. Is it then not surprising that the very elements that they have so openly labeled as utter failures are now either in the same posts (may I mention with a better pay) or at similar or higher posts within the ministry. All that, when the public continue to suffer the inadequacies and failures of the health system and its institutions. 

We anxiously wait to see what the 3 month deadline for an A-Z change at IGMH would actually bring about! I wonder too, what is the rationale for allowing the decay to continue for another 3 months while we wait for that all-fixing change?

Is the publics mistrust of the health sector justified?

Truth be told, the attitude and lack of professionalism among the service providers including doctors has not helped either. There is no smoke without fire and there must be reasons why the public mistrust health care workers! We hear again and again of few doctors speaking rudely to patients, doctors who fail to see patients under their care (even when patient is in ICU), doctors failing to provide reasonable explanations and information to their patients, etc. These are some of the reasons for the mistrust but there will be many other that one could list, should one attempt to make an all inclusive record. Having said that, it is also true that there are several doctors who are truly professional, caring and capable in their work. The few bad apples certainly are spoiling the whole basket. It would take much effort to bring out the kind, caring and professional face of this profession to the forefront. That is a challenge we must meet. 

But meeting that challenge is increasingly being made impossible both by the actions of the politicians and Commissions who continue to attempt to undermine the profession and the health sector as a whole. Inciting the public, to further mistrust the service providers, on state media is likely to make the gaps even wider. Their short-sightedness may make them popular for a while, but it threatens to suffocate the health sector even further. Why would they care? They could easily afford, especially with the benefit of their healthier pay, to travel abroad for medical care. We suffer. Our patients suffer!

Do we have appropriate infrastructure?

It is no secret that quality medical services require certain infrastructure, including human infrastructure. Medical equipment at IGMH and many other health institutions are at best; basic and historically poorly maintained. Once in a while the media highlights non-functioning of certain essential equipment and brings it to the publics notice. CT scans, ultrasound scan machines, Xray machines  and ECHO machines: out of order, blood culture services discontinued for months and ventilators waiting for spares happens far too frequently. The lack of back-up systems has on several occasions compromised the institutions ability to provide even essential care! Quality of care is an even bigger challenge in this situation. The brunt of all this is usually borne by the clinical workers. Add to that the lack of several important drugs despite repeated requests at various forums. Even with those that are supposed to be available, supply is a major concern. We have had instances when Male’ ran out of Paracetamol, Augmentin, Penicillin and ceftazidime, just to name a few!

Personnel development and training opportunities has over the years been on the decline. Seats for MBBS and specialization supported by government funds (or donor aid) has decreased. Cheaper opportunities are invariably preferred over quality. It is an expensive field, we accept. A bit of investment to quality is nonetheless essential. Private funding has tried to fill that gap in past few years. Thankfully such arrangements have helped and we are very thankful to the parties who have sponsored many of us. It is not only about training doctors though. Providing health care requires a team: doctors, nurses, lab technicians and several others. Training opportunities for the support services too, is far from adequate. For instance, medical equipment need maintenance to keep them in proper working order. The lack of appropriately trained Biotechnicians at IGMH is one reason for the poor maintenance of vital medical equipment. Add to that the lack of support and spare parts and the system could literally grind to a halt.

So there are reasons for unhappiness. That list isn’t an all inclusive list either. Perhaps some of us should sit together and make that all inclusive list soon.

What about next time?

I’d like to hope that there will be no need for a next time. It is not something we’d hope to see in a democracy that functions along the lines of fairness, equity and transparency. We are happier working than staying away from it. Whether one believes or not, we take great pride in the work we do, at the same time being humble in accepting our human limitations. 

Strikes don’t always work. They sometimes make things even worse than they were before. Perhaps, if forced with the necessity,  a re-think of the method, a more thought-out, better planned and less disruptive strike could be more effective and acceptable with the public. Or would any strike be acceptable? Ever? Certainly not for the party in power. The public, though, maybe more receptive if they could be engaged and better informed.

Here is wishing that there’d be no need for any of it.

Responses and Discussions:
 

Sayed: A VERY GOOD article!!! I completely agree with you about how the strike could be carried out.

Pary: very true. hope this would be resolved and the poltician’s like Afeef would have more sense in themselves and be genuine to tackle the real issues instead of blaming and threatening doctors and nurses

Musaid: Well said! However, I still doubt about the effectiveness of any “Protest/Strike” against the NOW government. Same as before indeed. Having involved in the Healthcare field before, I completely agree with you about the situation of our Healthcare profession as per today. I pity the fact that still patients await for longer hours just to carryout a simple procedure otherwise could’ve taken a while, if properly handled.

To those who claim the inhumanity of Medical Professionals. If you are claiming such with evident proof, I should say you speak aloud. But if you are just showing your anger and frustration just because a doctor was unable to treat your illness or prevent your relatives/friends death, you should re-think of what you’re saying. Life and death isn’t on their hands neither could they guarantee of your well being the next moment. All that they could do is to help you when you’re sick and treat you the best they could. They dedicate themselves, they sweat, they work for longer hours than they actually should even with the “INADEQUATE” equipments/drugs. Why? Just to claim you a better tomorrow. Shouldn’t you appreciate them? Shouldn’t you atleast turn to them and say a “Thank You” with a smile on your face? They’re humans too. Who knows, may be a word of appreciation could help them provide their care, even better.

Anyhow, all I hope is a better future. For both the care providers and those who recieve the care. May Allah shine our way and guide us to the right path.

(Source: blog.niyaf.com)

Yesterday was a half day at work for us, WHO Fellows at AIIMS, and we took the opportunity of an afternoon off to go to Delhi’s favourite hangout: Select City Mall at Sarket. It is a nice place with a young Delhi crowd hanging around and having fun. After checking out the few electronic shops (my favourite part of any Mall) I ended up at the food court.

I was just near the end of my Shredded Lamb Sizzler when out of the corner of my eyes I noticed, to my surprise, familiar faces at the table just next to mine. There sitting and having Kebab were Minister Aminath Jameel and her team from the health ministry of Maldives. A small world, huh? I went over, and over pleasantries found out that they were in Delhi to meet the Indian health minister. I impulsively asked Dr Yasir, a member of that team, if it was regarding IGMH. What I gathered from the conversation was that IGMH-foreign-management wasn’t a done deal yet and that their visit was related to a number of issues. 

It was good to hear that they were trying to improve the health sector in the Maldives. They were trying to do what they believed was the right thing to do. I do not agree that giving IGMH to foreign management is the only solution though. But right now, I’d be willing to consider that option as an alternative to the utter mismanagement at IGMH! It is too painful to see our people suffering the effects of an inadequate and grossly mismanaged health care institutions. Certainly, a well performing health institution is far better than one that doesn’t. It hurts to think that by bringing in a foreign management we are proclaiming our incapacity to manage such institutions ourselves. I would like to think that we do have people who could truly manage an institution of this size and importance among our own people! Then again; the handful of individuals who, over the years, were given the opportunity and responsibility of managing IGMH did not do anything worth much praise. Perhaps, one would argue, there are others who are more capable.

One way or the other, IGMH, and possibly other health institutions in Maldives, must change to meet the medical care needs of our people. Years of neglect and failure must now be addressed. It most certainly won’t be easy. Difficult decisions may need to me made. I, as a practicing clinician and a Maldivian citizen hope that the changes happen quickly and more importantly deliver results that meet our peoples needs.

(Source: blog.niyaf.com)

This is my personal opinion and it is independent of any official IGMH position. And for the record: the system has since changed back to the old system.

 
I read a news article on Haveeru Online. It presented an interview with an official from IGMH regarding a change to the OPD appointment system starting from 1st February 2009. The change, apparently made after discussions with relevant staff (I was, sadly,  considered irrelevant), was to stop doctor specific appointments. That is; you would no longer be able to get an appointment for a specific doctor by name. Instead patients will be provided the next available appointment slot for the related department dealing with the kind of illness. It could be for any doctor of that department.

I certainly would have voiced my concern had I been included in the group of relevant staff. Perhaps the fact that I am away from IGMH, on official leave, was the reason my opinion was not sought.

I believe the new system is not in the best interest of the patients. It is likely to force many patients to turn to private clinics to be able to consult the doctor of their choice. It is no wonder that many common people are speculating this as the intended reason for the change. 

Why do I believe that not allowing doctor specific appointments is against the best interest of the patient?

Diagnosis may not be possible in a single consultation.

I agree that a large number of patients who present to hospital suffer from relatively minor ailments that are relatively easy to diagnose. Perhaps some of them could be diagnosed in a single OPD visit and treatment advised.  In some of those cases a follow-up may not be needed.

However, a significant number of patients have illnesses that require more than a single visit for diagnosis and institution of the required treatment. Some of them may need to have investigations done to help establish diagnosis. Others may need follow-up after a few days of instituting therapy to assess the response so that therapy could be modified where response is not as desired.

In these situations having to see a different doctor at each visit could be frustrating for the patients. Each doctor may need to start from the very beginning, repeating many of the things already done by the other doctor at the previous visit; like repeat of history.

Having the opportunity to consult the same doctor with the reports or after initiation of therapy is therefore better for the patient and the doctor.

Continuity of care for Chronic illnesses.

Some illnesses have a long course, even with treatment. Some may have recurrent episodes of illnesses while others maybe lifelong. In these situations continuity of care is absolutely vital for proper care.
The system being proposed prevents this kind of continuity of care. It opens up the possibility of unnecessary alterations to treatment and therefore prolonging the ailment. 

Not all doctors within a department have the same capacity.

Some doctors within a department may be better dealing with certain specific types of illnesses than others. This is recognized among doctors within a department as well. It sometimes happens that we refer patients between each other because of this reason. 
Some doctors may have had extra training in specific areas, in addition to the specialty training of the department. We have some specialists who have acquired extra skills and knowledge specific to a sub-specialty field. For instance a physician may have extra skills in treating Diabetes or Kidney diseases. In such cases, being able to refer patients or guide them to one of these people, where the need exists is likely to be more rewarding to the patient. This wouldn’t be possible with the new system at IGMH.

In addition to these, there are various other reasons why a patient may choose to or prefer to consult a specific doctor; like past experiences with a doctor could prompt a patient to either prefer a specific doctor or not.

I believe that the system needs to change to allow for an opportunity to allow patients to seek consultation with a doctor of their choice. I would support having some OPDs where patients are able to get appointment by a walk-in system. Such OPDs as OAPC (Open Appointment Pediatric Clinic) and Walk-In OPD at the internal medicine department were doing this even before. Perhaps they need to be managed better to improve its value to the public.

I urge the IGMH administration to reconsider the changes and come up with a system that indeed is in the patients best interest.

Responses and Discussions:

•  Yasiph wrote:
  1st para: you said you were sadly considered irrelevant
  2nd para: you happen to know why your opinion was not sought.
  Why make a fuss out of it?
  
  Isn’t there just anyone except you who feel this isn’t right! Where’s MMA?
  
  IGMH never had a system that is in the patient’s best interest! Why now, or ever!

• Anonymous wrote:
  I hate this change in IGMH, I have a 3 yr old who is an asthmatic patient, since birth i have been consulting him to one specific doc of my choice. 
  Now cause of this change i wont be able to consult him to the same doc unless i go to a private clinic and spend more money, It seems like now v dont have the right to consult our kids and us to docs of our choice…. Where is human rights?>……..is this the changes that maldivians need, what to do all the poor ppl r suffering …. pls ppl reconsider this matter pls
  
  
• Niyaf wrote:
  Yasif,
  
  Even while I am away I continue to provide my opinion to the admin at IGMH. It is up to them to decide if it is useful or not. But I make it a point to contribute to the best I can my views. I do not want you or anyone to believe that my opinion is more important than those of others, but it is definitely not less important either!
  
  At IGMH we have internal email, which sadly isn’t being used for communication such as seeking opinion from staff regarding issues. It should be. 
  In the 2nd paragraph I am trying to think from their perspective (see I have used the word Perhaps) to see if I can explain why.
  
  I fuss about it because poor decisions are being made and the public is being misinformed that this was done after discussion with everyone! More than that, I am totally fussed about it because, patients stand to lose if this new system is allowed to continue in its current form.
  
  I am pretty sure that other people too have opinions. But over the past many years people had become afraid to voice their concerns due to inevitable reprisals. That fear is still there. The way things are turning out against those who voice their opinions, even today, one may say that the fear remains. Perhaps a legacy of yester-years.
  
  I am not sure what MMA is doing about it. I am away from Male’ for quite sometime now. I hope they are doing something too. They must. We must. I think even the public must. These issues are far too important not to speak about.
  
  Why now? It is not only now. I guess you know a bit more history to say why now to mean: why am I bothered only now! I have been speaking out before, do now and will continue to do so. But again, why now (collectively for everyone) has a reason too: when plans are being set in motion that would almost definitely make things worse more people would come out and speak.
  
  I’d also like to hope that with the new government we should make it a habit for us to speak up and for them to realise that they must hear us and heed us as well. This is an opportunity to get the public to be more assertive and I’d like to at least try than to sulk 30 or so years later!

• Augmentin wrote:
  Dear Dr Niyaf
  1.In Maldives the health systems provide a lot of choice to the patients in selecting their doctors. It may not be sustainable over the long term. Instituations like IGMH has to undergo a tough love approach to implement systems that optimizes patients consultations and care. 
  2.The MOHF should start a GP system where everybody will have a family doctor in opartnership with the private clinics
  3.regarding continiuty of care it is hightime departments in IGMH start using STGs so everybody is on the same page.

• faisal wrote:
  There are several problems with the new system, ranging from the basic right of a patient to choose his doctor to issues of confidentiality and privacy. Why this got the OK to be implemented in the first place raises questions of credibility and capability of the current administration’s health care policies. As a doctor I strongly oppose this.
  
  
• drhameed wrote:
  Since when did the doctors at IGMH consider patients. Its always your self intrest first then the patients. The reason that IGMH is so hated by the general population is the internal politics of its maldivian doctors.After studying on public funding your lot don’t seem too eager to serve the public yet you squeeze every penny out of people who don’t have any other way. The roster now being planned i see has a Doc as the head trying to divert the benefits of peoples illnesses to your clinics. I don’t know you but this is my view in general of doctors who serve at IGMH. /thanks

• Niyaf wrote:
  Hi drhameed (I have a feeling that, that is not your real name. I maybe wrng though),
  
  I cannot speak for all doctors at IGMH. But I think it is very unfair to put all doctors in that one basket. I can assure you that there are many doctors who are kind, caring and very committed to their profession. Some work terribly hard to try to do what is right. Unfortunately, what is right for some is almost alway wrong in another persons perception.
  
  Most public service institutes in the country need to re-invent themselves as service-providers. IGMH is perhaps one institution that needs to do the greatest work.
  
  I understand that there are reasons why you and many others have these opinions regarding IGMH and Maldivian doctors working there. I hope you’ll accept that there are people who try to do the ethical and right thing too. They don’t succeed much often though. It is disheartening for them. But they continue to try nonetheless.
  
  I don’t have an answer for every problem that IGMH has. But I think we can start off by listening to the workers and those we are serving; the public. I understand that we probably will never be able to satisfy everyone. Simply because the needs and views of people are so diverse. Perhaps more transparency in decision making, increased involvement of real stakeholders in that process and improved public relation (not just having a “complain here” counter) could help a great deal.
  
  Some amount of internal rivalry and politics is probably helpful (I could be wrong but that is my current belief). But that has to remain within healthy limits.
  About private practice; I do private practice too. And I know some of my patients whose parents would prefer to see me in the clinic rather than IGMH. Some prefer it because of convenience. Other prefer because they get to spend more time with me at the clinic than they’d be able to at IGMH. This happens because at the clinic I limit the number of patients I see over a 3 hour period to 12. That is 15 minutes per patient. In the same amount of time at IGMH, the admin wants me to see 20 patients (maybe even more). It is a difficult balance between quality and quantity; both are important but for me quality is what I am not willing to compromise on.
  
  Going to clinic is not only about making more money. The extra income is useful and I don’t say that I don’t make money from working at a clinic. But it is also an exertion for me. It is time I could otherwise spend with my wife and kids. It give me an opportunity to practice OPD medicine with less time constraints and pressure (That I think makes my patients happier and they then get more return for their expenditure). So, it is not all about money. Not for me anyway.
   
  I just hope that we could have more services at IGMH and other health care outlets that are to the likings of our people. I wish that those people who hold the authority positions in the ministry and the institutions would heed the opinions of the people.

(Source: blog.niyaf.com)

What is bronchiolitis?

This is a viral illness of the respiratory tract that usually afflicts children of less than 2 years of age. It is characterized by an increased effort of breathing and wheezing following an uppers respiratory tract infection.

What are the symptoms and signs of Bronchiolitis?

Affected children would have a prodromal illness with runny nose and cough for a few days. The illness will be much like a common cold at this stage. Few children may have fever and malaise at this stage. The illness then progresses to involve the lower respiratory tract. This stage is characterized by increasing severity of cough, increased work of breathing and respiratory distress and wheezing.

Is bronchiolitis a severe illness?

In its classical form it may be a very severe illness requiring hospitalization and varying degrees of respiratory support. In the very young, severe illness may result in fatalities. The illness may be particularly severe in those children with congenital heart disease or those with prematurity related lung disease.

What causes Bronchiolitis?

Bronchiolitis is a viral infection. The most commonly identified virus is RSV (Respiratory Syncytial Virus). In western countries where the illness has been studied, there are reports of over 90% of all cases being caused by RSV. Other viruses identified are Influenza, para-influenza and adenoviruses.

Is bronchiolitis seasonal?

In countries with the four seasons, bronchiolitis is predominantly seen in winter. In countries like Maldives an increased number of cases maybe expected during the rainy season.

What is the treatment of Bronchiolitis?

Much work has gone into finding the best treatment for Bronchiolitis at research institutes around the world. In essence what has been agreed upon among the scientific community is that the illness has no specific treatment that acts as a cure. As is the case with most viral infections of the respiratory tract; Bronchiolitis is also best managed with supportive therapy.  Antibiotics have no role in the management and should not be used routinely. No specific antiviral agent has been identified as particularly useful.

Supportive therapy includes use of humidified Oxygen for inhalation, maintaining fluid balance (including use of intravenous fluids where indicated) and monitoring for signs of respiratory insufficiency.

Bronchodilator therapy is used at many centers, initially as a trial and sometimes in the very severely ill children. The most commonly used bronchodilator is salbutamol (ventolin) as nebulisation or inhalers.

Steroids have no routine role and its use in Bronchiolitis is under review at many centers.

I have observed a sudden increase in the number of children presenting with an acute Diarrheal disease over the past couple of weeks. I am also aware of an increase in the number of children with Diarrhea requiring hospitalized care during the same period.
It may be too early to say if this is the beginning of another Diarrheal epidemic in Male’, however, I would like to take this opportunity to advice the public to make an extra effort to improve personal and food hygiene to help avert an outbreak.

Ensuring improved personal hygiene, especially among children, people who care for children and those involved in preparation of food both at home and at public food outlets will be an important measure in breaking the transmission cycle of viral and bacterial causes of diarrhea. 

Safety of drinking water needs to be ensured. At home, this is best done by using boiled and or filtered water. Water is commonly found to be the media of transmission of viral and bacterial Diarrheal diseases. Commercial producers and distributors of drinking water in Male’ must ensure that the safety standards in processing, packaging and supplying is followed.

Imropved hygiene at all times during preparation and handling of food is very important. Hotels, cafe’s and restaurants must ensure extra measures of food safety are in place at all times, but in particular during periods when a food or water borne infection is spreading. Consuming well cooked food in their fresh state is another important step. Raw vegetables and fruits, if to be consumed, must be cleaned thoroughly.

In the event a child gets Diarrhea, the mainstay of treatment is maintaining adequate hydration by replacing fluid losses by using Oral Rehydration solutions. In small infants it is particularly important to ensure adequate hydration, as they are most likely to become dehydrated quickly.

I would recommend that all children who develop diarrhea be shown to a doctor for assessment. This would also make it possible for improved reporting and surveillance of emerging epidemics.

During the visiting hours at IGMH, we see several kids going in and coming out of hospital wards, visiting members of their  family and friends who are admitted for treatment. Their numbers are not small. I presume, based on personal observations that the numbers are high enough to be very concerned about potential pubic health implications of the practice.

Hospitals harbor a multitude of micro-organisms that have the potential to cause deadly infections. A significant number of patients across the world, are known to acquire very severe forms of bacterial infections during their stay in hospitals. Unfortunately, a very high proportion of them have suffered grave consequences as a result of such infections.

The pathogenic  organisms (those with the potential to cause illness) are found everywhere within the hospitals. The walls, furniture, floor, files, folders, door handles, curtains, TV remotes or almost every other object within the walls of the hospital probably carry enough pathogens to propagate an illness. Most hospitals regularly run bacterial detection tests on swabs taken from such surfaces to study the nature of organisms that are residents of the environment. IGMH, and I presume ADK, too run such tests from time to time. Such tests invariably detect disease causing bacteria. While it is true that, based on such reports, various disinfection measures are implemented to try to cleanse the area, it is also true that despite the best efforts, these pathogens persist.

It is to this pathogen laden environment that many of our children are exposed to when they visit the sick at the hospital! Children, more so than healthy adults, are likely to acquire infections from this environment, or from the child or adult whom they are visiting. 

I still remember, a few years back, IGMH used to restrict entry to hospital wards of young children to visit the sick! However, today I do not see such a restriction in practice. Several children, including some very young infants will be seen entering the wards as visitor, most with their parents.

Every few months, Male’ has seen one or more epidemics of infectious diseases, especially among children. Among many other factors, I expect, if studies are conducted, the practice of taking children to hospital to visit the sick, would be a significant contributor to the spread of illnesses in Male’.

Having to take kids to the hospital to seek care when they are sick and unwell is important, but taking them to such an infection prone environment without a clear need for them to be there is irresponsible. While hospitals need to work on improving cleanliness, hygiene and infection safety within their premises for both patients and hospital visitors, we as parent, must too prevent our kids from being exposed to nasty hospital acquired or in-hospital transmitted infections.

I would urge parents to be aware of the potential dangers of this unhealthy practices and put a stop to them in the future. I also urge hospital administrations to review their policies and the implementation of the policies on children visiting the sick at their hospital.

Responses & Discussions:

• Anonymous wrote:
  This practice has got to be curbed again. Notices should be put up and the rules should be strictly enforced.
  Health authorities should take note of this issue.
• Simon wrote:
  This is very true. Most people falsely believe that hospitals, being the establishments that help cure the sick, are inherently safe havens from diseases.
  
  Hospitals should warn visitors and I think implement policies that proactively discourage visits from adults accompanying kids.
• andhu wrote:
  i always wondered why people do not carry out awareness programs about such issues, i don’t think half the population can identify the risks of certain life style leading to a steep decline in health , smoking, drugs are more commonly advertised with their medical side effects, why not about diabetes? heart illnesses and why on earth is the only STI people are scared of are HIV and AIDs when other STIs are also of importance…
• Niyaf wrote:
  Andhu, that is a very valid observation. Public awareness is very poor and the awareness campaigns that are conducted don’t reach the masses. 
   
  The responsible government agencies need to review campaign strategies and come up with better targeted, further reaching and more effective programs. An honest dissection and scrutiny of the current public health awareness programs and the reasons they are not as effective as we need them to be would be greatly helpful. 
  It would also help if the public are more information and awareness seeking!

Since returning to work last Thursday, I have seen a few kids with what appears to be an Enteroviral illness. Enteroviral infections have the potential to cause epidemics. Epidemiological surveillance is therefore  important in keeping tract of further cases to see if this illness could lead to an outbreak. I have reported the cases that I have seen for the benefit of  surveillance and I urge other clinicians to do the same.

Over 5 kids were brought to my practice having moderately high grade fever for about 2-3 days. When examined they were all found to have oral mucosal lesions (ulcers or vesicles) over their hard and soft palate. The lesions were clinically very similar to those seen in both HFMD (Hand Foot and Mouth Disease) and Herpangina. Both of these are Enteroviral illnesses that have sporadically appeared in Maldives every now and then. A couple of these cases that I saw also had red, papular rash on their palms and soles. 

Enteroviral illnesses are spread from person to person through respiratory droplets (minute droplets of saliva or secretions expelled during coughing, sneezing or even talking), feco-oral (via food or utensils contaminated with human waste due to poor hygiene) and via formite (illness carried on surface of inanimate objects soiled with secretions or saliva). Improved hygiene in day to day living and especially in caring for a sick child is of utmost importance in breaking the transmission route.

These illnesses are nonetheless mostly self-limiting, requiring no specific treatment. They do however cause significant discomfort during the illness itself.

If you suspect your kid has a similar illness, please do have him or her shown.

The news of young infants dying as a result of illnesses cause by consumption of Melamine tainted-milk in China has been making the international news headlines for the past week or so. Two infants have reportedly died so far and reports suggest that more that 13000 infants in China, have been affected. The true extent and implications of this crisis may not be clear for many months to come. The numbers are expected to rise in the coming weeks to months.

The Chinese CCTV has thus far reported that 69 different milk products manufactured by over 22 separate manufacturers had been withdrawn from shelves in China for concern of contamination. One milk brand in particular, Sanlu, has been at the center of the scandal with reports of the contamination being non-accidental.

In Maldives, the news has caused some concerned parents and reporters from some media outlets, to ask questions about the safety of the milk products available in the country. Thankfully, the infant formula available in the Maldives are packaged outside of China. However, the exact sourcing of the milk used in manufacturing is not always clear.

• A press release from Dutch Lady Malaysia, to which I was alerted by a friendly journalist, raises concern about Dutch Lady milk products packaged in Singapore; one of the countries from which Maldives imports the widely used Dutch Lady milk range. It is reported that Dutch Lady Singapore has had to recall and remove from shopping shelves some of their products for fear of Melamine contamination. The milk used in their manufacturing was allegedly imported from China. How safe the Dutch Lady milk products available in Maldives needs therefore to be ascertained.
• Nestle’, whose infant formula products (Lactogen, NAN, etc.) are widely being used in Maldives has issued statements on their website declaring their products free from melamine contamination. The Swiss company, who had been cited by IBFAN on several previous occasions for allegedly violating the International Code of Marketing of Breast milk Substitutes, appears keen to alleviate fears among its many consumers in relation to this emerging public health nightmare.
• Mead Johnson Nutritionals, another infants milk manufacturer whose products (Enfalac, 0-Lac, EnfaGrow, etc) are used in Maldives was also quick to declare that none of their products had milk sourced from China and further that their products were free from Melamine contamination.

I was asked today, by a Minivan News journalist, by phone, if I had heard of any affected infants in Maldives. I have personally not seen any suspicious cases and I have not been told by any of my colleagues of any suspicious cases that they had seen themselves thus far. In fact, apart from a 3 year old girl in Hong Kong, no child from outside of mainland China has been reported to be affected.

Public health authorities in several countries, including Singapore, Malaysia and Brunei (just to name a few from the region) have reportedly placed extra security measures on sourcing of milk and milk products from China. While such measures from these  countries, from whom we import milk products, are likely to directly benefit us too, I would like to see some efforts being made by our authorities (like DPH, MFDA and Min. of Health) and importers of potentially suspicious products to alleviate the concerns being raised by our public. I urge them to please make it absolutely certain that those products available in Maldives are safe from Melamine contamination!

Perhaps the free media has a role to play in ensuring that the interest of the public and the safety of a vulnerable population are protected. The authorities may be prompted to ensure mechanisms are in place and functioning to prevent the tainted milk from reaching our shores. 

Let us stay safe. Take care.

Updates:

• Niyaf wrote:
  The death count has increased to 4. Reportedly, another 150 or so kids are in a serious condition. The total number of kids who have been affected has jumped to more than 60,000.
  
  Locally, MFDA has finally issued warnings and certain milk products and dairy containing products have been ordered to be removed from shelves. No Melamine contamination has been dcumented in Maldives, but products with milk sourced from China have been banned.
  
  I just hope that a system of reporting potentially affected kids is established soon. Surveilance is vital.
  
  
• Niyaf wrote:
  Unilever has recalled Lipton milk tea from shops in Hong Kong after they find traces of melamine in it. The milk used was sourced from China.
  
  Erlier Cadbury Hong Kong also recalled chocolate candies from Hong Kong after they too were found to be contaminated with melamine. Some of these products were reportedly exported far beyond the borders of China including Australia!
  
  White Rabbit milk candy, manufactured in China, is another product that was found to have unacceptable levels of melamine. It has been recalled.

Both IGMH laboratory and ADK laboratory has had to stop doing blood culture tests for out-patients for the past one week! Three of my own patients, for whom I had requested Blood Culture tests (among other tests) were refused service at both the laboratories during the past 3 days.

Blood Culture is an essential investigation in the work-up of patients suspected of having infectious diseases of bacterial origin. When reliably done, it helps a clinician narrow down antibiotic therapy to mono therapy in an evidence based manner with the knowledge that a specific antibiotic was, in vivo, able to cure the infection. This investigation is therefore, invaluable and essential in identifying specific type of infection and the choice antibiotic therapy for that infection.

I have been told that the test had been discontinued because both laboratories had run out of stock of blood culture bottles, the special bottle used to collect the blood sample for the test! This too, as the recent antibiotic shortage suggested, is evidence of poor stock keeping at both the institutes.

As a practicing pediatrician, not having this vital investigation available, I fear that rational use of antibiotic therapy would be further challenged and proper, directed antibiotic therapy made impossible in most cases with serious bacterial infections.

I am told that concerned authorities have been alerted and efforts are underway to procure new stocks of the bottles. Equally important, I would like to stress to those responsible, is to ensure that adequate stocks are maintained at all times to ensure that this and other vital laboratory services are not discontinued in the future. Failure to do so will, as is the case at present, compromise medical treatment offered to all patients.

Responses & Discussions:

• Issei T wrote:
  If this is what we have to expect from an ISO certified lab, we didn’t need that certification.
  
  
• Nabba wrote:
  Issei T,i gues u cnt say lab is responsible fo discontinuin of B c/s. dis is a big misunderstandin dat som tests r discontinued cuz of lab, actualy it is not so.. 
  d supplyin department n store is responsible fo it.. Yeah, it is realy sad dat dese types of important test r somtyms blocked due t various reasons…hope t geta permanent solution fo dis… anywayz its gud t knw dat nw b c/s test can be done frm IGMH lab.
  
  
• Niyaf wrote:
  Nabba, the lab has to take some resposibility for this. I agree that stock keeping is not controlled by the lab. However, it is a lab service that gets discontinued as a result. I believe that the stock keeping should be computerised so that at any given time a stock status report is available as a snapshot. Potential stock depletion alarms should automatically be generated and authorities or responsible staff alerted to this.
  
  Such procedures already do exist at many businesses even in Maldives
  
  
• nadu wrote:
  sept 7 antibiotics are out of stock
  sept 12 blood cultures are temporarily discontinued.
  what next patient died because he couldnt not get antibiotics or patient misdiagnosed due to lack of some tests
  
  
• Niyaf wrote:
  Issei T, I do believe the Lab has only a small role t play in the procurement of sample bottles, I may be wrong though.
  
  It is the responsibility of the procurement department and to some extent stock keeping process that has failed.
  
  Whatever it is, it is completely unacceptable.
  
  Nadu, it is deeply worrying. This is not the first time this has happened and it is unlikely to be the last time; should we continue to go about bussiness as is now.
  
  It is no secret, we do have a lot of work to do to get us out of our sorry state. I just hope that things do not go as wrong, as that in scenario you suggested, before we realise what we are getting ourselves into.
  
  
• Niyaf wrote:
  The bottles have arrived and the discontinued services have been resumed.
  
  I hope that lessons were learnt as a result of the week long service discontinuation.
  
  Would this or other similar events happen? I think, sadly, it is only a matter of time!
  
  
• Anonymous wrote:
  Niyaf that’s the reality, we are a poor country, things like this can happen, after all I am not sure you guys are so concern about your patients. You all wants always to criticize and make noise and get attention.
  
  
• Niyaf wrote:
  We may be a poor country, but that is no excuse for mismanagement. I am concerned about my patients welfare, whether you believe it or not. Making these issue public is important in rapidly addressing the problems. The attention therefore helps my patients (and what is good for my patients is indeed good for me).
  
  Thank you for your thoughts.

Pharmacies around Male’ have run out of three commonly used injectible antibiotics! Ampiclox (a combination of Ampicillin and Cloxacillin) has not been available for a few days and today caretakers are struggling to find both Augmentin and Cefuroxime for their loved ones at pharmacies in Male’. 

This is not the first time this has happened. This time around, however, the number of people affected could well be more than on previous occasions. At least that is the impression I got at work today. STO, the largest importer and distributor of pharmaceutical products in Maldives, is the local reseller of all three products. What is more alarming is that there is fear that a fourth drug, Ceftazidime, also an antibiotic, could be declared out of stock in the coming days.

The situation has caused several kids (I am not personally aware of adults cases) to have their antibiotic therapies changed in the past few days, some who were apparently responding well to the empirical treatment. I have had a difficult time today, explaining to parents of a few of those kids affected as to why the treatment had to be changed.

We as clinicians are, at the very least, partly responsible for this problem. This judgement of mine may be challenged by some of my colleagues, but I strongly believe that these and other antibiotics have been irrationaly prescribed, more so during the past few months. I am sure, if willing, STO could release figures to show that these drugs were sold in larger numbers in the past few months than usual. It is my personal observation, as a practicing clinician, that they were indeed prescribed more frequently than usual these past few months. This is perhaps a result of the recent epidemic of viral ARI in the capital. Needless to say, viral ARI does not need to be treated with antibiotics, unless complicated by a secondary bacterial infection or strong suspicion of the same happening is raised.

I was told today, by a pharmacist at STO, that they do not have either drug (Augmentin or Cefuroxime) in stock and that he could not predict when it would be available again. This is tragic. It does not mean the end of the world, but still, it is an unacceptable situation, to say the least.

I would like to urge all those responsible to ensure that this does not recur anytime in the future. This certainly does compromise the medical treatment offered to our patients and as such every effort should be made to ensure that we do not face the same situation again, ever. 

Lets hope that someone with an administrative authority, who could ensure that remedial action is taken promptly reads this post.

Responses & Discussions:

• Mixhar wrote:
  Excellent Post!
  This issue is more common in the islands, and very common medicines go out of stock for quite a long time!
  
  
• Niyaf wrote:
  That is right. It is an everyday event in the isands, even those with regional hospitals.
  I wonder what such shortages would do to the new insurance scheme, in which not all medicines are covered.
  
  
• ppc bid management tool wrote:
  I don’t have to wonder why those antibiotics run out. This is an old issue and until now this problem still exists.

It is probably a bit too early to start celebrating the proposed launching of another health insurance scheme in the Maldives. The last time this happened, the scheme did not survive long enough. Nevertheless, in these times of desperation, as the proverbial saying goes, we are indeed willing to make an effort to clutch at even a straw.

Some information on the new NSPA (National Social Protection Agency) insurance scheme is available on their website: www.nspa.gov.mv

I was aware of the new scheme being drawn up but have not had any formal information on the scheme provided to. As a practicing Pediatrician, I believe that all medical practitioners must be provided with sufficient information regarding how the scheme works and what medical care are covered under the scheme. It is my belief, not based on any official information, but an expectation based on common sense, that the administrators of the scheme would ensure that detailed information is provided to health-care providers on their role within the program.

Out of curiosity, I browsed through the “covered” medicine list provided on the  agency website. I expected it and was not surprised to find that the list did not include some commonly prescribed medicines. I hope the agency, like other such agencies across the world, would form a scientific body that would evaluate additional medicines (and treatments) for suitability and eligibility in being included in the covered list.

The list of treatments currently not covered by the scheme is also very long. Some of these treatments, after further evaluation of need, cost-effectiveness and effectiveness (among other things), may need to be included in the scheme in the future.

Lets hope, for the sake of the many thousand needy Maldivians, that the scheme lives long enough itself and helps Maldivians live healthier and longer.

Responses & Discussions:

Yasiph wrote:
Do you think the current information at nspa.gov.mv is lacking? if yes, could you provide me with what (as a visitor who happens to be a doctor) feel is missing so tht I could ask nspa to include them. btw, i happen to be the webmaster 

Niyaf wrote:
I think there is a lot of information on the site, but I mustsay that the information is not packaged very well. For instance the information on what an NSPA insured person needs to do when medical care is required is presented within a large PDF file. I assure you that packaging such information within a file of that size will make it virtually inaccesible.

I am also concerned about the lack of English on the site. As you’d be aware of, a large number of health-care providers are expatriates. Having the information (apart from the PDF file, which itself is linked via a dhivehi link) only in dhivehi would be a barrier.

I would also like the site to provide information on what a private service provider would need to do to join the scheme as a provider! What are the criteria by which a center is recognised as eligible to be a Provider?

I am sure you are already looking at ways in which the aesthetics and presentation of information on the site could be improved. I think a FAQ, links to seperately identifiable information (such as information for clients, doctors…..etc) may be useful on the home page (say in a menu)………….. Multiple search options maybe enabled to serach the site for eligibility (whether registered - as already present  on the site but not on the home page), whether a certain treatment is covered or not………identify and name a complaints handling officer (with contact info and procedure for contact or complaint) on the site too.

As I have said in the main post, it would be a good idea to present the scheme and its mechanisms to the Providers so that problems could be avoided. The prescription system would need to be changed too……the current system does not provide extra copies as the scheme says we must.

On the essential drug list (or covered drug list): it would be worth having an easily searchable drug list either on the website or as a downloadable application that providers could then install on their office computers.

That was just a quick brainstorming session…….I am sure we could come up with more ideas if we could get more heads together and appropriate time  given.

Good luck with the site management.

Faisal wrote:
I had a brief look through the information provided and the first thing that struck me was, much like you mentioned, whether any doctors were informed or consulted regarding this scheme. Such a program requires consultation with the people who will be providing the service. Can a doctor prescribe expensive treatment because it is ‘free’ for the patient? Can everyone get a CT scan? In some places where the treatment and investigations are free ( like in some regional hospitals), doctors aren’t too limiting in the list of investigations requested. Some doctors who would have limited their diagnostic tools because of the expenses to the patient might not see it as much of a constraint now. 

This raises the question as to where the money will come from. The scheme earmarks a total of Mrf 100,000 for each insured person annually. That it a lot of money, and requires justification when the money will come from the public’s pocket. Should a 70 year old with chronic renal failure and a not so good prognosis have equal claim to the 60 instance of dialysis mentioned? 
There are issues of patient confidentiality as well when the NSPA requires the copies of the medical records for the claim procedure. And in one documents its mentioned that the original prescription should be kept with the pharmacist. At a time when there are no provisions made to ensure patient confidentiality, this will raise serious issues. 
it is interesting to note that treatment for psychiatric problems in not covered in the scheme when more than half the patients visiting the OPD have some form of symptom related to psychiatry. 

These were few things that caught my attention and I am curious as to what position MMA has on the scheme

Niyaf wrote:
I too wonder what the medical association thinks about the scheme!
This looks to me like a very hastily “copied” system of insurance. I guess the authors didn’t want to copy everything from the “certain” overseas scheme that they evaluated.