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Medical Thursday Doors Zambia

Thursday Doors at School

Zambia’s National Immunisation Schedule is very similar to that in the UK. After three injections in infancy against tetanus, there is a booster at school entry and another for school leavers. This isn’t so good for children who don’t go to school, but you have to cut corners sometimes. And children who have to repeat their first year may end up getting an additional jab.

We have been doing the fourth and fifth tetanus (with a small dose of diphtheria) in the local schools over the past few weeks. My job here is to help, support and assist, not to take over the programme. We sometimes end up running out of vaccine or syringes, bringing the wrong kind of syringes (BCG syringes are just 0.05ml, the other vaccines need 0.5ml syringes), forgetting to inform the school that we are coming or have had to alter the date. But we got the job done. I don’t know the precise figures, but we vaccinated about a thousand school children.

Door on its side

Here is a door in a classroom in Mfuwe. It may have been taken off its hinges, or it might have been pushed off by the scrum of schoolchildren crashing through the doorway. So this satisfies inclusion of this post in Thursday Doors.

The health inspector in charge of the programme has not been trained in vaccinations. I asked the nurse in charge of the clinic if it was ok for me to train the health inspector and he said he thought it was a good idea. Now in mass vaccination campaigns, speed is of the essence. You don’t take your time slowly inserting the needle, pulling back, injecting, then looking around for a cotton wool ball to place over the injection site.

It took some time for the health inspector to gain confidence, but after a couple of schools, he was able to inject at speed.

Drawing up the vaccine

Now some of you may have seen a clip on YouTube of a paediatrician playing with a baby before he vaccinates them. This looks marvellous and the doctor is to be congratulated. However, he isn’t trying to vaccinate 200 children in school without their parents being there to comfort and support them. This calls for military-like precision. You line ’em up and jab them.

We had a gang of young men and women who volunteered to help with the school campaign. They did some health education while I was injecting. They helped fill the syringes, recorded the children’s names and wrote out vaccination cards. One young lady’s help was invaluable when dealing with youngsters. They would fling their arms around her thighs, she would cover their eyes so they couldn’t see the needle, she would distract them by asking them questions and she made sure their left upper arm was immobilised.

Last week, there was a thunderstorm brewing and I started vaccinating as the rain started. Lightning flashes at the same time as injections was a double whammy for the children. My assistant was brilliant in this situation.

Ouch!

Sometimes the children would not feel the vaccination, other times they would jerk when the needle entered their skin. On a few occasions, this led to the needle going in deeper and hitting bone. Older girls could become hysterical and if we didn’t deal with this properly, it could become infectious, with all the students panicking.

Lining up for vaccination

We hadn’t reckoned on schools having a two shift system, with some pupils coming in the morning, and the remainder coming in the afternoon. I would return to the clinic, see patients about whom the nurse wanted my opinion, then return to the school.

Health education

We need to give the students a booster in a month’s time. The nurse in charge of the clinic felt that the students should come to us for their boosters, but this would overload the clinic with the risk of students being unwilling to wait and leaving before they had had their jabs. I suggested that we go back to the schools and do the vaccinating there instead. We all agreed that this was a great idea.

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Bangladesh Medical

Diseases which should never happen

Before today, 11th November 2017, the only person I knew who had diphtheria was my Aunty June, who had contracted the disease in 1935.¹

“Have you seen the woman with the white throat?” Dr Nadim asked me.

P1320703At first, I didn’t click. What did he mean by a white throat? Was he describing vitiligo on the front of her neck? It was a shock when I saw the patient. There was a thick, greyish membrane on the right side of the back of her pharynx, inside the mouth. Her neck was diffusely swollen, known in the trade as a “bull neck”. She looked uncomfortable and couldn’t swallow without pain. It was just like it is described in textbooks – but diphtheria is so rare nowadays that it only merits a brief entry in the Oxford Handbook of Clinical Medicine. There is nothing else which causes this appearance. (See my previous blog post about diphtheria for more information)


In our other isolation room, we have three children with tetanus. Two have neonatal tetanus, a disease which has been virtually eliminated from the world by vaccinating women in the antenatal period. I have seen seven Rohingya patients suffering from tetanus in the two months I have been working here in Kutupalong.


Some diseases are so feared that we may not speak their name. Cholera has become “severe acute watery diarrhoea”. Poliomyelitis is “acute flaccid paralysis”. The Bangladesh Health Ministry has organised vaccination campaigns in the refugee camp to prevent both these diseases, but not before one boy contracted “acute flaccid paralysis” which could have been wild-type polio. We admitted him to the ward for observation, but his symptoms did not progress, and we discharged him after a week.


The only letter I have ever written to The Times newspaper was to criticise Nigella Lawson’s view on measles vaccination, which she felt was too risky given that measles was not “a serious disease”. I wrote that measles could be lethal. I recall admitting twenty children suffering from measles to a hospital ward on a single day in 1980 in Southern Sudan; by the next morning, only twelve were still alive. Nigella didn’t reply.

Here we have a measles isolation tent. Six months ago, Cyclone Mora blew the tent onto the roof of the hospital laboratory. It was retrieved and fixed more securely to the ground. When I visited the tent last month, it was hotter than Hades.

The mothers were complaining that there were no fans in this furnace of a ward. The children looked irritable and ill, lying on mats on the floor. I checked them for dangerous complications of measles and we said we would get one of the logisticians to bring a power cable into the tent to run a standing fan.

The following day, the mothers were delighted at the cooling breeze from the fan. I was less than delighted with the increase in numbers of ill children.

P1320829
The waiting area where we assess children with measles to determine whether they are so unwell that they need admission to the tent. Note the logo on the tee shirt of the man wearing a blue checked lunghi.

 

A week later, the mothers were angry again. The fan had stopped running. I saw that the plug had come out of the socket, perhaps when moving the fan to make room for another mattress. I moved the fan closer and replaced the plug. The fan remained dead. The mothers looked downhearted.

I couldn’t give up and lose face, so I tried twiddling the switch governing the speed of the fan. Still no good. Then I tried a bit of “percussive therapy” – I bashed it and the fan spun into life. A cheer went up (mainly from me). Everyone was happy. The spotty children were all doing extremely well and would soon be discharged.

The logistics team have now fixed up a massive awning over the top of the tent to provide some insulation from the hot sun. The patients find it much more bearable now.

P1320769
Measles tent with protective bamboo roof/shade 

 

The misery caused by all these diseases could have been prevented by routine immunisation. This has been so successful that many parents (like Nigella) in developed countries have become rather blasé about having their children protected. Sadly, many Rohingya in Myanmar have not had the luxury of that choice; they had no access to vaccination. The consequences of this are plain to see in the hospital.

 

 

¹ My father and his siblings were quarantined at home, issued with a bottle of “Thymo-Cresol” disinfectant and not allowed to go to school. Crucially, this impacted on his performance in the grammar school entry examination, the Eleven Plus. He said,” With this period of isolation, all my dreams of becoming Prime Minister came to an end.”