As dengue cases leap skywards in another full blown epidemic, health officials across the country are left struggling against heavy odds as they try to treat the torrent of patients showing symptoms of a disease that could become fatal if not detected and treated early. A survey by the Sunday Observer found most hospitals treating dengue patients overloaded to the hilt. Beds in many wards were shared by at least two patients and sometimes three, while others slept under beds, or in long chains of bodies sleeping on available hospital corridors.
Even the Infectious Diseases Hospital (IDH), the premier hospital for communicable diseases in the country, has not escaped the problems posed by the runaway disease.
“We are coping with difficulty,” IDH Hospital Senior Consultant Physician Dr Ananda Wijewickrama confessed. “The lack of space and severe staff shortage poses a huge problem as we have to cater to patients with all sorts of infectious diseases, on a daily basis. Now, with the dengue epidemic, we have to cope with an additional surge of patients. In fact, from last month, the majority of our patients are those with suspected dengue symptoms”, he told the Sunday Observer. In 2014, the hospital’s Out Patients Department (OPD) was visited by 153,450 patients. Now, two years on, Dr Wijewickrama estimates the number could easily have reached the 200,000 mark, with the spike in communicable diseases which have now overtaken non communicable diseases in the country.
“We set up a separate ward for dengue patients five years ago in anticipation of a future outbreak as the number of dengue cases were mounting every year. But, even that was not enough for so many patients. So we are grateful to the Army for constructing a new ward for dengue patients as an emergency measure, on the instructions of the President,” he said.
Built in a record time of just eight days, the solidly fully furnished hospital with 40 beds opened Thursday, February 2.
Yet, even this addition may not be enough if the epidemic progresses, Dr Wijewickrama thinks. “We have been promised another Dengue ward with sixty beds. It is already under construction and may take around six months to complete”.
Manpower
While the hospital has enough doctors, drugs, and other facilities, apart a bed shortage, it is woefully lacking in adequate manpower. “We don’t have enough nurses with proper training for our wards. At present, we are working with trainee nurses awaiting appointments. We need at least 25-30 more trained nurses. Being a hospital which caters to patients from all parts of the country, filling this vacuum, especially, in providing emergency care for dengue patients, should be given priority,” he said.
However, there could be more than a glimmer of hope for the 130 year old colonial hospital when the second dengue ward comes up. ‘It will also have an attached Dengue Training Center, which will be used not only to train our own personnel, but even those from other hospitals.
We plan to make it a World Health Organization (WHO) Collaborative Center for Dengue.” he said, brimming with ideas to achieve that ambitious goal. He said, conducting training programs for staff members was not something new to the hospital which already had a track record for excellent ongoing training programs, in the past. However, establishing a center specializing in dengue will take it to a new level, he believes.
We asked if there had been any cases of in-ward cross infections due to the added intake of dengue patients. ‘This hospital has been built and planned for infectious diseases and is thus well ventilated, reducing infection spread. We also do frequent fogging and cleaning of our premises”, he pointed out.
Diagnosis
Questioned on how patients were being diagnosed for dengue, and if the Rapid Test diagnosis was being used for dengue patients, he replied in the negative. “It is not 100% sensitive. If it is positive, it is dengue. But, even when a patient tests negative, it still could be dengue as the test only ‘catches’ 85% of patients and misses 15% who also have dengue, but have tested negative.”
So, how are dengue patients diagnosed?
“With suggestive symptoms and a full blood count. The full blood count is what’s most important. The normal level is 150,000-400,000 generally. In dengue patients when the platelet count goes down it doesn’t affect the patient. But it can have other complications. So, when it is low (below 130,000) we admit them and look for possible complications, and monitor them.”
Asked if the same procedure was adopted in other state hospitals as well for dengue patients, he said, standardized tests for dengue were the same in all hospitals - whatever part of the island they were located.
He cautioned patients having symptoms of dengue to refrain from taking non steroid anti inflammatory drugs such as ibuferon and diclofenac as they could suppress the actual symptoms and delay treatment. “Only take paracetamol and avoid aspirin. And, no home treatments. Unfortunately, some doctors tend to prescribe some of these tablets to them. Patients must ask the physician what the drugs given to them are when it comes to dengue treatment”, he said.
Negombo Base Hospital
We next contacted Senior President, Sri Lanka College of Paediatricians and Senior Consultant Paediatrician, Negombo Base Hospital, Dr Lak Kumar Fernando.
It was under his direction that the hospital’s Centre for the Clinical Management of Dengue and Dengue Haemorrhagic Fever (CCMDDHF) was set up in July 2013. To date, it has successfully treated over 5,000 dengue patients inside the 17 bedded unit, while over 4-5 times the number have been receiving treatment in the medical and children’s wards, in relatively less severe cases. Of those treated inside the hospital, over 4,000 cases have been Dengue Hemorrhagic Fever (DHF). Dr Fernando said, there had been only six deaths so far of adults and elderly patients, but no deaths among children and adolescents, from the time it was set up. Construction of the centre, following guidelines from the WHO, incidentally, was on the instructions of the then Health Minister, President Maithripala Sirisena.
The hospital is said to be the only centre in the world that provides all treatment facilities for dengue and Dengue Hemorrhagic Fever under one roof for patients of all ages. According to sources of the dengue cases that occurred this year, one in 10 patients were treated at the Negombo Base Hospital.
Asked what kind of problems the hospital faced following the surge in dengue patients, Dr Fernando said, “We have a problem about insufficient number of beds. There are only 17 beds in our High Dependency Ward where the blood pressure and cardiac status of each patient can be monitored continuously as each bed is equipped with a multi para monitor. However, in the past three weeks, we have had over 100 patients a day.
As beds are in severe shortage, we are now forced to admit only the most serious patients.” He said, apart from the dengue ward, the other wards were also full. The two paediatric wards have a total of 60 beds, while the two medical wards also have a total of 120 beds.
During the past few weeks, there were as much as 150 dengue patients in the four wards, in addition to the 17 inside CCMDDHF. However, due to the lack of space and beds in our wards, at times two dengue patients had to share one bed in the wards.
In addition to bed shortage, the hospital also has a problem of inadequate manpower to deal with the present crisis. “We need between three to four trained nurses and at least four more doctors to the unit”, he said.
Lab tests
We also asked for his comments on the very recent decision by the Health Minister to ban all state hospitals ordering patients to get their blood tested by the private sector, saying a special circular had already been sent to all health directors informing them of the new procedure.
The new rule came into effect on January 1 this year. According to the Minister, the Health Ministry had supplied auto analysers to state hospitals and the ban was already in place at the Colombo National Hospital. An auto analyser machine costs Rs 15 million, and funds had been allocated for this purpose from the health budget, the Minister is reported to have said. Each machine can produce 16 blood reports per 30 seconds.
He said, “Whatever claims are made regarding the availability of lab tests, it is still not possible to do all the tests in a state hospital.
“Frankly”, he concluded, “I think, the labs in the state sector and their staff in our country are not ready, and have not got the correct attitude to help the Minister’s very good decision to save poor people’s money spent to do tests at private labs.
There is a lot of waste and malpractice in the laboratory set up, and providing an auto analyzer alone cannot cure these. They also need the mindset,” he said. More thought should be given to this important issue before implementing it, though overall the intention is very good. For some tests the cost the government incurs is more than the cost of the test in the private sector”.
Kalubowila Hospital
We next contacted the Kalubowila Hospital, the second largest Teaching Hospital in Colombo. Hospital Director Dr Asela Gunewardene also admitted that his hospital faced similar problems. “Our biggest problems now are, overcrowding, bed shortage and lack of adequate staff. Last month alone we treated nearly 700 patients. The majority were dengue patients”.
The hospital which had three dengue related deaths - two last year and one in January, is taking no chances of similar tragic outcomes occurring this year.
“We have begun fogging operations and we’re distributing protective mosquito liquid vapourises. All our staff attend ongoing educational programs following the WHO guidelines on personal hygiene and protection, wearing masks, etc. So far there have been no cases of internal transmission of the disease,” Dr Gunewardene said.
Separate Dengue ward
Asked if they had a separate Dengue ward he said, “Not at present. But, from next week a new High Dependency Unit will be opened”. However, adding more beds to the six wards the hospital has is not the answer, he noted. “While the number of people needing admission is more than the number of beds we have, there is no space to accommodate more beds. Each of our wards has 40 beds. So the 240 beds in our six wards are a tight fit”.
So, was there an alternate solution to squeeze in more patients?
“Yes. We have already drawn up a plan. It includes setting up more High Dependency Units and medical units,” he said. He added that he had noted an emerging trend of more adult patients now attending the clinics and urged all those with fever for over 2 days to immediately seek medical advice and avoid home treatments, take paracetamol only, and stay home and rest…
We also contacted Chief Public Health Inspector, Negombo Municipal Council, E.G. Somasiri who said, more cases of dengue had been reported at Dalupotha, Kochchikade, Negombo.
He said, a month ago a young mother had died of dengue because she had been nursing the rest of her family who had been down with the flu and neglected herself. “By the time she was admitted it was too late.
This is not an isolated incident. Anyone who has symptoms of dengue must immediately see a doctor”, he stressed.
He said, a separate team from the Municipality was now doing home visits. “If a dengue patient was confirmed in a certain area, we send out the PHI and others nearest the affected area to spray within 200- 300 metres distance outside the site.
We also do wall spraying”. He said, they now used the electronic website available in every MOH area which can convey immediately information regarding a dengue patient so that an intervention team can be sent immediately to the site.
CCMDDHF