The Flu

A month has passed since all of us, specially in the health sector had a hectic time battling the flu outbreak that happened in March. A time with a lot of public panic, mixed information, social media controversy and all that went with such a situation.

At this time I thought to reflect on the efforts that we (ADK Hospital) put into to try and contribute the control of the outbreak. Though the data and actions described are very much as it was implemented by the Hospital, my own views and interpretations are included to bring the perspectives of my thinking.

Surveillance

Surveillance is an integral part of any healthcare system. All healthcare institutions are required to report certain notifiable diseases to the HPA as part of the mandatory reporting requirements and hence data flow is always there. In this instance of the flu, some individuals in social media and also some news agencies stared mention an increase in the speed of flu, H1N1 specifically and there has been deaths associated with it. Even in non outbreak situations, such diseases will have some  patients whose severity of condition will be different and the outcomes are different. Also important to note is that even best health systems may not always be able to prevent an outbreak from happening, yet, perhaps could manage such events more effectively and efficiently depending on the available resources and know how.

In case of the recent flu outbreak, as can be seen from the graph below, the number of people who sought treatment for flu-like illnesses started to increase from the first week of February. The numbers continued to be higher and by mid March the numbers reached a peak and then reduced. By end of March the numbers came down to and the whole of April normal levels were maintained. For ease of reference I have marked the important dates on the figure and also coded it into three zones of green (normal), yellow (higher) and red (alert level 3 period).

Flu clinic

Immediately after the HPA’s declaration of outbreak response level 3 on 13 March 2017, we decided to set up a flu clinic and also as quickly as possible to locate it to place outside the hospital. The first day of the clinic, we started is outside at the open area of the hospital. Though some may think that this is not a very ideal way to establish a clinic, I took this form a learning experience at Singapore General Hospital during the SARS outbreak. They did an initial screening for temperature and other vitals at the SGH lobby and provided protective masks for those with symptoms before they entered the hospital proper. Perhaps no harm in attempting to get something like that done ourselves. However, unfortunately the weather wasn’t too kind on us. We moved the clinic to H. Sosunge, thanks to Maldives National University, who very kindly agreed to share the premise for the cause.

There were few things we made sure that happened in the flu clinic.

  1. We made sure that every single person who came to the clinic seeking care were attended to whether a local or expatriate, and that a series of steps followed in the care. Initial registration by an administrative staff, screening of the vitals by nurses, consultation with a doctor and basic medications given on the spot, all free of charge. In order to ensure that we had to close up the hospital’s main general OPD for the entire duration of the clinic in order to relieve staff. We conducted the flu clinic from 14-22 March 2017 before winding it down and streamlining it into the normal hospital operations.
  2. Continuously monitor the care seeking behavior of people during this time. This was done to keep us alert to the fact whether we should further increase the efforts or whether we needed alternate strategies. During this time, a concern for us was that we are only seeing people who come to the clinic, but what about those who may not be able to come. Some maybe hard to reach! This is where we decided to undertake a mobile clinic. We decided to go to the people, let people access to us near their homes, and even in some cases the flu clinic staff went to the homes of the sick to ensure we covered a good reach. I have to also highlight the readiness of the Maldives Red Crescent society. They did a wonderful job doing the door to door data collection for sick people so that we can reach and provide care.
  3. Making sure we published data in some way for public to know what we have been doing. In this regard we made an effort to publish the flu clinic’s work every day just after the completion of the clinic. We thought that this would be a good way to keep the information flowing and also to encourage people who may want to interact to do so too. We did this through social media mainly on Twitter and Facebook platforms. Above is the last set of flu clinic data we published before closure.

After 9 days of continuous efforts, we saw that the number of people who came to seek care at the flu clinic started to drop and hence based on this trend, we closed the flu clinic and returned back to the hospital and streamlined the services into our normal routine.

Awareness creation

Making people aware goes hand in hand with any services we provide. Specially in an outbreak situation, it is important to intensify the awareness work. Though the national authorities were doing a good share of awareness messages, we decided that it is only right that we chip in as well. Our team made awareness material on signs and symptoms of the flu, prevention matters, detailed awareness flyers related to vaccination. Eventually we did static flyers and animated videos as a contribution to include HPA and MRC as partners so that it became a collective effort.

This is an area we have a lot of room for improvement. Perhaps one aspect of service that we will have to uptake in future and device continuous process to create awareness generally.

Vaccination

Vaccination was the topic of interest. So much of criticism on the healthcare system for it did not have good stocks or general availability of influenza vaccine. I agree and rightly so. Influenza vaccines were a controlled vaccine, at least up until this flu outbreak and were only given to those going to Umrah and Hajj and in some cases those who were specifically prescribed to be vaccinated, by a doctor. The outbreak lead to finding ways of quickly finding stock and making it available, which eventually happened. I hope and believe that, from now on influenza vaccine will be readily available in the market. As I know almost all importers are now given license to import and store the vaccine.

We started vaccination on the 15th of March and it was only to a controlled group as per the directive published by the national authorities. We kept to the same guideline. However, we did provide vaccination for people who came with a prescription. This we believed would ensure that those who may be out of the controlled criteria, but may genuinely need might not get access. However, we observed that this was not necessarily the case. More and more people got the prescriptions. Many people called me complaining that doctors at ADK Hospital did not give the prescription on their request. Well, of course we have specific instructions that prescriptions should only be made available to those who fall into a higher risk category and not just for perfectly healthy people, at least till the national guidelines changed. I personally talked to some patients who came with prescriptions, from everywhere and anywhere. Some patients told me that they got the prescription by paying a doctor MVR300.00 or sometimes MVR500.00 (I cannot confirm how true that it, but that’s just what people said). Many prescriptions had statements such as “parent want to vaccinate the child”, “issued on patient request” etc. Well, so much for the prescriptions. Eventually, we decided to open generally. We had our own differences of opinion on this and some very heated discussions too. But then, we had to do that, and some of us believed that is the way to go. By end of April, some 10,980 influenza vaccinations were provided from the hospital.

The queue

On 26 March 2017 it was chaos. Just chaos. A long queue started way before the vaccination time and by 1:00pm the queue was all the way up to the Henveiru grounds. This was an underestimation, I agree from our side. I had to make decisions quickly. Well, I decided to release the tokens before the vaccination time that was still two hours away. I couldn’t bear to keep the people waiting like that for that long on the road in a never ending queue. After al we can only release also certain number of tokens for the day, and knowing that there was more people in the queue than the amount of tokens we can issue, it only made sense to release the tokens too. No point keeping people just because we set a time. Well this wasn’t a solution at all. The next day, the queue was that long by 9:00am. But we were a little bit more prepared to monitor the situation. It was early morning around 6:00 am I was informed of the forming queue. Well the vaccination starts at 3:00pm. People though took on the word we put to them previous day that we will not be content to make them waiting in queue for long long hours. So by 9:00 am we released the tokens for the day.

Next day, by 3:30am the queue started. Now that means if we waited to release the tokens at the time of vaccination at 3:00pm, that’ll be a waiting queue for 12 hours. We released the tokens at 6:00am. We did stick to this time to release tokens till we winded down the exercise few more days later. The dilemma here was when people started to demand a time for release of tokens. Our aim was to start releasing tokens just at the time of starting vaccination so people do not have to come two times, one to take the token and two to get vaccination. For some reason, this happened automatically when queues that long formed. What we realised was, if we say that we will release tokens at 3:00pm, the queue is there 6 hours before, full and even more. People simply refused to go even if we told then that this is the end of the queue. Well, an experience to learn from, perhaps we should learn more on the behaviour of people in such situations as well. I did get a lot of good feedback from the people who queued up, good load of all sorts of criticism and some harsh remarks and shouts at my face too. I was there everyday managing the chaos. There was one night that people in the queue continuously called my phone since 3:30am. Different people from different numbers. Saying that they were there, to come and release the tokens. Well that’s the type of work that we have to do eh! All I get out of this whole exercise is how patient people were, how cooperative most people were, and above all many people thanked us personally and the very few who just gave a pat on the shoulder. That’s enough, more than enough satisfaction from doing the work. I still keep reflecting on that, trying to learn, figure out ways in which we could perhaps do it better.

Burden of the flu

Well I’ll just refrain from writing too long on this topic, but I feel that in order to complete this post, it is appropriate to present this in some way. I will just add the infographic published at the ADK Hospital website for information here. You may click on the image for a larger version.

Volunteers

It will not be just to complete this post without saying something about volunteers here. In fact we did not make any formal call for volunteers. It came from a conversation I have with our Director of Nursing. She came to me saying that the flu control measures we are undertaking is making our staff a bit stretched and asked me what solutions we could use to somehow address it. Just as we were brainstorming, I told her to see if she can get a few nurses who may not be working at the time, but willing to help out temporarily to give some relief to our staff. In the meantime we can also ask other staff members to see if they have friends or family who can come for short period to help out if they are willing to do so.

In a short period of time after that conversation, a Viber message the Nursing Director posted on a group belonging to nurses went viral. It was shared in many viper groups and eventually went on to newspaper headlines that we were looking for volunteers to assist in the flu control efforts. All for the good. I call it beautiful. Specially because volunteers did approach us. Phone calls, SMS, Facebook messages all came from people who wanted to volunteer. We did have to politely decline since we didn’t require so many. The lesson though is that people have big hearts. They are kind and willing to help out. A good sign. I do appreciate the work of all those volunteers, their willingness and enthusiasm was something to acknowledge and applaud. Thank you all.

The staff

I have never doubted the commitment of our staff. And they passed with flying colours in what they showed and how they worked. I sensed that everyone took pride in what they did. Despite the heavy load and long hours everyone managed a smile at the end of the day. They kept questioning what more they could do? They were always ready for the next call. “Let’s do it” became the motto, it was all action. As a person who works with them day in and day out, I cannot be any more proud of them. Kudos to the hard work and showing that we can count on each other. Just keep it up.

____________

By end of March, the number of people who sought care with flu-like symptoms reduced and we kept a continuous tap on the trend. It went down below the average and stayed slightly lower than that of January before the increase in cases. A good sign and perhaps a result of good work done buy everyone involved. What I’ve written here is based only on the work we did and data is also from ADK Hospital. What is written is an account of our efforts and in no circumstance undermines the great and noble effort of the entire health sector. We cannot compare the work everyone did, but of course compliment the work.

Every emergency, outbreak or abnormal situation that we face gives us an opportunity to learn. And this outbreak also is no different. In hindsight, I can say there are many things that can be improved. As for us, we could improve our own surveillance mechanisms and be proactive in our actions. Play a bigger and better role in public health perhaps? maybe at the least publication of information on disease and trends so that we are more proactive.

Learning is continuous …

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