Dr Niyaf's Online Clinic

Life without bone marrow transplant.

Fri, 27 May 2011 02:24:00 -0400

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.

"If you have a child with Autism please call 7529901 (Zila) and book an appointment to consult a..."

Sun, 27 Feb 2011 10:33:07 -0500

“If you have a child with Autism please call 7529901 (Zila) and book an appointment to consult a visiting specialist on 13th March 2011”

- Autism Society of Maldives

Gone Tumblr!

Sun, 28 Nov 2010 06:11:21 -0500

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.

Outbreak Alert: Diarrhoeal Disease

Thu, 27 May 2010 00:00:00 -0400

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.

Outbreak Alert: Hand Foot & Mouth Disease

Tue, 09 Mar 2010 00:00:00 -0500

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.

H1 N1 Vaccine Information

Tue, 02 Feb 2010 00:00:00 -0500

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

Dengue: Follow-up

Thu, 05 Nov 2009 00:00:00 -0500

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.

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

Sun, 25 Oct 2009 00:00:00 -0400

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.

WHO: Guiding Principles on Complementary Feeding (Weaning foods)

Tue, 13 Oct 2009 00:00:00 -0400

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?

Fri, 04 Sep 2009 00:00:00 -0400

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.

Corporatisation

Thu, 13 Aug 2009 00:00:00 -0400

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!

Proposing changes to the On-Call duty at IGMH.

Sat, 08 Aug 2009 00:00:00 -0400

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.

First case of Swine Flu in Maldives

Sat, 25 Jul 2009 00:00:00 -0400

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.

Accepting the strike but not the method?

Tue, 03 Mar 2009 00:00:00 -0500

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.

Running into the Maldivian Health Minister at a food court in Delhi.

Tue, 24 Feb 2009 00:00:00 -0500

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.

Why I believe the new appointment system at IGMH is not in the patients best interest

Sun, 01 Feb 2009 00:00:00 -0500

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.

Bronchiolitis

Thu, 13 Nov 2008 00:00:00 -0500

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.

Diarrhea Again!

Wed, 12 Nov 2008 00:00:00 -0500

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.

Children visiting the sick at the hospitals

Sat, 08 Nov 2008 00:00:00 -0500

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!

Another emerging Enteroviral illness in Male?

Mon, 03 Nov 2008 00:00:00 -0500

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.