Haitian Child

Haitian Child

Friday, March 11, 2016

Zika Virus Infection

During my recent trip to Haiti I was bitten by a mosquito that carried Zika virus and I developed clinical symptoms.

On the day after Christmas I woke up with a generalized rash. The rash was on my chest, back, arms, and legs. There was no rash on my face, palms, or soles. The rash consisted of small flat irregular-shaped spots less than 5 mm in diameter. My skin felt a bit itchy.The whites of my eyes were red (conjunctivitis). I had a headache and felt a somewhat achy generally. I otherwise felt well and I worked that day and the next.

The rash and the red eyes lasted about a week. I measured my temperature every night for the first 3 or 4 nights and the highest I recorded was 37.8 degrees.

I did not have a sore throat, runny nose, or cough. I did not have specific pains in my large or small joints.

During the day before the rash developed (Christmas) I had two watery poops and after the second liquid poop I decided to take Cipro just in case this might be the start of a bacterial gastroenteritis. My poops stayed fine thereafter. I have never taken Cipro before and when the rash developed the next day I wondered if perhaps this might be an allergic reaction to the antibiotic.

The rash and the other symptoms slowly resolved over about a week and during this time I decided the rash was either a viral infection or an allergic reaction to the Cipro.

After I returned home I had blood, urine and poop tests done, and I had a TB skin test. I routinely get checked out when I return from working abroad. My sedimentation rate test (ESR) was elevated and this suggested inflammation somewhere in the body. This test does not imply a specific infection or disease. The other tests were normal.

By the time the lab results were available the rash and other symptoms had long resolved but I was keen to track down the cause. By this time Zika was in the news and my reading from the Center for Disease Control suggested this was a likely cause for the symptoms. I had another blood test to look for Zika virus and for other viruses that might cause the symptoms. These tests take time. In early March I was notified that my Zika virus IgM studies were positive. IgM is an antibody protein that increases after a recent infection with the virus. This test implies my symptoms were due to Zika virus.

I had done my very best to avoid insect bites in Haiti. I set up a mosquito net and I routinely slept under the canopy every night. I was careful to tuck the net in around the bed. The mosquito that transmits Zika virus usually feeds (bites) during the daytime. I left for work at dawn and was usually back in the dormitory at nightfall. I wore long pants, shoes with socks, and a t-shirt. My arms, neck and face were therefore exposed during the daytime. I did not see mosquitoes in the hospital but I did see a few in the dormitory. I do not recollect a bite.

Even though I saw very few mosquitoes, and even though I took good precautions, I was still bitten and infected with Zika virus. Based on this, my sense is that infection with Zika Virus is likely inevitable for travellers to endemic areas. If the virus is proved to cause congenital malformations, this is indeed a serious public health problem for pregnant women.

Zika Virus was first discovered in 1947 and until recently was only reported in tropical Africa, Southeast Asia, and the Pacific Islands. In May 2015 the Pan American Health Organization (PAHO) confirmed the first case of Zika virus in Brazil and on February 1, 2016 the World Health Organization (WHO) declared Zika virus to be a public health emergency of international concern. 

Sunday, December 27, 2015

My Mother's Stories

My mother's family was very poor. Her Icelandic mother did not speak English and her Scottish father did not always have work. When I was a little boy, my Mom often told me stories that I could not believe. I could not fathom the poverty she described. My Dad had a very good job and we were certainly not poor and there was no poverty I could see in Calgary. However, my Mom was one of seven children who were born during the years from World War One through the Great Depression. They did not have enough money for anything. There was no money for food, for shoes, for schoolbooks, or for medical care. Mom told me they often survived on bread, fat drippings, and salt. She left school to work after grade seven. One memorable story is that after my Mom cut her thumb seriously with a knife, her mother was obliged to take her to the doctor to have the thumb sewn back together. As my Mom describes the situation, her mother alternately cried and screamed in Icelandic all the way to the doctor because the family could not afford to pay the medical fees. Because of the accident the family did not eat for a few days.

My mother has been in my thoughts a lot during this trip to Haiti. The families in Haiti are likely even poorer than my mother's family, but maybe not. Many children in Haiti cannot afford school and this reminds me that my mother's education was cut short. When I purchased three pairs of shoes for my interpreter I thought of my Mom without shoes as a little girl in Vancouver. Many remark that there is a circle of life. This can mean many things. I think there are many circles, and in a strong sense, this trip helped me to complete a circle started with my mother's stories. 

Saturday, December 26, 2015

The Little Girl and I Both Exhaled

For the last week I have cared for a 2.5 year-old girl with pneumonia. She had only mild respiratory distress on admission. Pneumonia is one of the most common diagnoses on the paediatric ward. Most of these children respond well to an antibiotic, hydration, oxygen, a drug to open up the lungs, time, and the resilience of the human body.

The initial x-ray on the little girl showed pneumonia in her right lung and the pattern implied a bacteria rather than a virus. She was admitted by the Head of Paediatrics and treated with the usual first line antibiotic available at the hospital. On the third day she got worse and notwithstanding a change to the usual second line antibiotic, she continued to get worse. On the fifth day I was very concerned and shared my concern with the person in charge of the ward. She looked very tired and "toxic," the way critically ill children look. My sense at that time was that she might have a collection of infected pus (empyema, lung abscess) in her lung. Until an abscess is drained, even the correct antibiotic will not work. I repeated the x-ray and to my eyes the image suggested that a collection of pus was likely. The x-ray images at this hospital are not as good as in Canada and the technician was not able to accomplish the views I requested to localize the pus. Since I am not a lung x-ray expert, I could not be sure. Still, I thought this was the likely diagnosis. I talked this over with the head physician but she did not agree. She recommended another antibiotic change. The third and even a fourth antibiotic did not make any difference. I repeated the x-ray on the sixth day and this time, the head physician agreed with my diagnosis. I found the surgeon and made sure he saw her early in the morning. He asked for another x-ray (no idea why) and I made sure this happened early in the day. Once the x-ray was done I found the surgeon and took him to see the x-ray. I have learned to be persistent to insure that anything urgent is done. If I had not personally "driven the system," the x-ray might not have been done until later in the day, by then the surgeon would have finished his holiday rounds and gone home, and an entire and perhaps critical day might have passed. My persistence paid off and the surgeon agreed to operate the same day. I attended in the OR. The surgeon placed a chest tube and drained some bloody pus. My relief to witness the pus drain out of her lung was a Christmas present, both for the little girl and for me. Back on the ward, for the first time in a week, I could hear air entering her right lung.

Friday, December 25, 2015

Christmas Day

The Mellon family is an ongoing legend in Deschappelles. Everyone has a Mellon story and they are all positive. The original Dr. and Mrs. Mellon had compassion, a vision, and the financial resources to make things happen. Their descendants continue to encourage the original vision. I do not know anything about the current financial support but I imagine the annual cost to support the hospital is considerable. Kudus to the Mellon family. Well done!

Hรดpital Albert Schweitzer shows signs of age as everything does over time but there are ongoing renovations and refurbishing of the various facilities. Today I saw men preparing the hospital entrance for new paint. The climate is harsh. The salt water rusts the metal. The sun and the humidity degrade the wood.

When built, the hospital must have looked like a palace to the citizens. You can feel the grandeur of this place. For the time, the facilities were likely "state of the art." Notwithstanding the daily press of illness through the doors, the facility still functions very well.

The grounds are well landscaped. I read that Haiti had no trees because the people cut them down for fuel. Not so here. The trees and shrubs have been well tended and nurtured. The poor and the sick at least look out over the verdant lushness of their native land. The flowers and the music are the happy things about Haiti.

One of the overwhelming aspects of this trip has been my isolation as literally the only white face in a sea of poor and sick black faces. My previous trips to Haiti were with teams of white physicians, nurses, and other medical personnel who worked alongside the Haitian personnel. I expected to see white faces here. This was intimidating at the start but feels much less so now as I end my stay.

The eleven consecutive days I have worked on in the hospital has been just enough for me to figure out how this works, or doesn't work. The nurses and physicians have been very patient with me. Thank goodness for the interpreters.

Thursday, December 24, 2015

Christmas Eve

The hospital feels deserted. The hallways are empty of stretchers. There are empty beds in the wards.

Disease does not take time off for any holiday but the inpatient census goes down over Christmas all over the Christian world. The walking wounded return home to their families.

I did my share and discharged three children this morning. The three infants were all improved and ready to go even if this were not Christmas Eve. Some of the children live a long distance away and there is no efficient transportation. Sending a sick child home prematurely might be a disaster.

The mother of the sickest child that I follow, a 2.5 year-old girl with very serious pneumonia, told me her husband is coming and they want to take the child home. This is her right, but I suggested she should keep her in the hospital. Today, for the first time, her fever is down and a blood test showed modest improvement. She is still very weak. Apart from treating children with cystic fibrosis, I do not recollect a sicker child with pneumonia. I am happy her temperature is down but the x-ray shows that her right lung is not contributing much at all to her breathing. She needs oxygen. She cannot tolerate oral feedings. She is on three intravenous antibiotics. If the parents stop the oxygen and antibiotics, I do not think she will survive long. The Mom is very discouraged. She has been in the hospital a week. The little girl is modestly malnourished. She was sick but looked better during the first two days in hospital and then she got much worse. The antibiotics were changed twice and the last change seems to have made a difference. Over the last 36 or so hours she has started to slowly improve. I hope they don't take her home.

Since the clinic is closed today I went with Renold, my interpreter, to the market. I asked if I could purchase something for his three children. He picked out three pairs of shoes, which don't look like much, but Renold was very happy about this gift. His wife died from hypertension seven years ago and his mother has also passed on. His 80 year-old father was formerly a cook for the hospital and he still lives with them.