Zika outbreak: are we affected?

The Zika virus outbreak in Brazil has been associated with a significant rise in the number of babies born with microcephaly and neurological disorders, and has been declared a "Global Emergency" by the World Health Organization.

Let’s talk about Zika!

Zika Virus outside Africa.  Zika virus infection presents with acute onset of fever, maculopapular rash, arthralgia and conjunctivitis.  It is an Aedes mosquito-borne flavivirus  that was first discovered in 1947 in the Zika Forest of Uganda, infecting a rhesus monkey. Its serum was inoculated into mice.  Zika virus was isolated from mouse brains.  Zika was isolated from humans in Nigeria during studies conducted in 1968 and during 1971-1975.  From 1951 through 1981, serologic evidence of human ZIKV infection was reported from other African countries such as Uganda, Tanzania, Egypt, Central African Republic, Sierra Leone and Gabon, and in parts of Asia including India, Malaysia, Philippines, Thailand, Vietnam and Indonesia.

Zika Virus Infection in the Philippines.  In an active surveillance for acute febrile illness initiated in Cebu City, Philippines, in 2012, there was a report of a 15-year old boy who reported a subjective fever.  ZIKV RNA was detected in his serum sample.  The boy recovered fully by 3 weeks. Most infections are asymptomatic, and symptomatic disease generally is mild.

Between 2012-2014, the Pacific experienced a high burden of mosquito-borne disease due to concurrent epidemics of dengue, chikungunya and Zika virus infections.  Data from the French Polynesia documented a concomitant epidemic of 73 cases of Guillain-Barre syndrome and other neurologic conditions.  

Zika Virus Transmission from French Polynesia to Brazil.  There are some theories on the introduction of ZIKV to Brazil from the French Polynesia: during a World Cup soccer competition in 2014, or during the Va'a World Spirit Championship canoe race in Rio de Janeiro in 2014.   In May 2015, Zika spreads through local transmission in Brazil.  Following the spread of the Zika virus in Brazil, there has been a marked reported increase in the number of infants born with microcephaly. Until more is known, pregnant women should consider postponing travel to any area with ongoing Zika virus transmission.  Health authorities recommend that pregnant women take meticulous precautions to avoid mosquito bites and even to delay pregnancy.

LINK BETWEEN ZIKA AND MICROCEPHALY

Carlos Brito (2015) explained it well in his article Zika Virus:  New Chapter in the History of Medicine:

The increase in cases of microcephaly could be associated to Zika virus infection based on the following clinical-epidemiological aspectsand in the different diagnosis:

• the outbreak of many cases in a short space of time, occuring simultaneously in different cities and states characterizes a disease with high attack rates and rapid dispersion, a phenomenon associated with disease transmitted by arthropods;
• besides microcephaly, image exams presented some common characteristics such as: periventricular and cortical microcalcifications, vernix cerebellar hypoplasia and in some cases lisencephaly compatible with the pattern of congenital infections;
• diseases associated to TORCH, because of the transmission pattern, are not associated with large outbreaks; 
• the investigation in prenatal and perinatal were negative for TORCH infections;
• most of the mothers (70%) reported compatible features of Zika disease in the first trimester of pregnancy, the period in which the Zika V outbreak occured in the region.

Identification of zika virus in the amniotic fluid samples, brain tissue and placental tissues strengthen the link between Zika virus and microcephaly.

Alerts from the Brazil Ministry of Health, European Centre for Disease Prevention and Control, and the CDC concerning the possible association of microcephaly with the recent outbreak of Zika virus infection.  Several reports were posted as MMWR Early Release on the MMWR website, including interim guidelines on pregnant women, on infants with congential Zika virus infection, on healthcare providers caring for pregnant women and women of reproductive age, on prevention of sexual transmission.

Preventive measures would involve prevention of transmission.  Zika virus infection has been known to be transmitted through mosquito bites, through sexual transmission (proven by cases in Tahiti and USA) and through blood transfusion of blood infected with the Zika virus.

Let's talk about Zika now!  ...and do something about it!

Time management for healthcare workers

Time management for healthcare workers

Instant culture.  Today's culture is filled with technological innovations that make processes faster and make communication easier.  Food is now instant - processed to be prepared simply by adding hot water, coffee three-in-one, ready to eat home-cooked meals packaged in tetra packs or cans, fast food restaurants have replaced bed and breakfast facilities.  What used to take a whole day of doing laundry from soaping, scrubbing, rinsing, bleaching and starching, hanging and drying is now completed in one hour by a washing machine and drier.  This frees up women to pursue more loftier goals and careers.

Instant communications.  Unfortunately, with this "instant" culture, even our relationships become instant as well.  Interactions become superficial.  People often run off to do a gazillion things with so limited time.  What happened to the time that machines like washing machines saved for us?  We need to create new machines that make other work for us in an instant.

From the time when Morse code and telegraphs were the main means of communication, we went on to telephone lines and cellphones until now we have wireless web-based communication, complete with video conferencing.  Social media enables communities to interact globally at real time. It is now easier for overseas Filipino workers to communicate with their loved ones in the Philippines.

Does anybody send handwritten letters through the post office anymore?

How does this instant culture and technology impact the way we interact with each other?  A lot of material on social media show families and friends sitting at a table with noses stuck up in front of their mobile phones looking through social media.  This defeats the purpose of bringing loved ones close together when we can't even sit down and talk face to face.

Healthcare workers.  How do handheld mobile phones with internet access and social media apps affect how healthcare workers interact with patients in the clinics, in the wards and in the treatment rooms?  During the last tweetchat about barriers to physician-patient communication, time management was one of the identified barriers.  Healthcare workers are always on the run, always in a hurry, with no time to sit and really listen to patients.  I googled and found that there are a number of materials online that give tips on time management for physicians.

So how come with all the technological advance that make processes faster, and improve communication, time management is still a barrier to efficient interaction with patients?

What activities consume the time of healthcare workers?

How would healthcare workers more efficiently manage their time?

How can technology help healthcare workers manage their time more efficiently to provide more time for patient interaction?

Impact of social media on children, adolescents and families

The harsh realities of Filipino children today include the risk of being exposed to cyberpornography and even cyberbullying.  This leads to low self-esteem that leads to dependency, which when left unaddressed make them vulnerable to sexual abuse, teenage pregnancy, illicit drug use, HIV infection and a gamut of other problems.

The advances of technology these days allow commerce to be done online with far-reaching audiences and social markets. 

Unfortunately, children in the third world countries such as the Philippines, are being exploited through this same technology.  Webcam sex tourism is a newly coined term describing how pedophiles and sex offenders virtually rape children in their own homes. 

Sweetie is a virtual 10 year old Filipina girl created by the Terre des Hommes Netherlands to trap pedophiles around the globe.

Research shows that there are 750,000 predators online at any one time.  Groups enjoin Filipinos to sign petitions to government to deliver a strong statement against Filipino children being victimized through webcam sex tourism.

A number of researches have been done to study the effect of internet use, social networking and social media on children.  Over 60% of 13-17 year olds have at least one profile on a social networking site, many spending more than 2 hours per day on social networking sites.  Majority of teenagers have cell phones.  Some use them for social media and instant messaging, and half of the population use them for texting. 

Parents are the primary protectors of their children.  They should become aware of the nature of social media sites, and provide regulation and guidance to their children when navigating the internet. 

"There are frequent online expressions of offline behaviours such as bullying, clique forming, and sexual experimentation that have introduced problems such as cyberbullying, privacy issues and sexting.”
“Cyberbullying is a potent form of strain that may be related to involvement in school problems and delinquent behaviour offline.”

Studies in the US have linked problematic internet usage with moderate to severe depression.

Looking on the bright side, although there is still a lot that the Philippine government needs to learn to be able to enforce laws and policies that protect children’s rights online, efforts have been taken to create special bodies to address these issues.  In the Central Visayas, the head of the Interagency Council against Trafficking (IACAT-7 VAWC) Senior Prosecutor Fernando Gubalane, announced that we’ve counted 16 convictions for trafficking in persons for 2015.  Many of these cases involved victims who were minors.

Last December 1 and 2, 2015, the Ako Para Sa Bata (I am for the Child) International Conference at Marco Polo Hotel in Cebu showcased best practices in advocacies to protect the Filipino child.  Nearly 1,000 delegates from government agencies, academe and non-government organizations were in attendance.  

Mulat Pinoy shared that youth advocates are given an opportunity to become journalistic writers on burning issues, and that children are given a chance to air the views in a creative way that makes a positive impact on children’s involvement in social media.  They believe that young people can learn to use social media for good.  As youth reporters, they are able to communicate with people and friends from far-away places.  The internet becomes a good source of information.  Social media creates opportunities for growth and development and with proper coordination they can achieve a lot.  This also allows transmitting youth messages to a broader audience.

The Role of Social Media in Child Participation Rights

THE ROLE OF SOCIAL MEDIA IN CHILD PARTICIPATION RIGHTS

November has been declared as National Children's Month!  The Passage of Repulic Act No. 10661, a consolidation of House Bill 1641 and Senate Bill 332, declared November of every year as National Children's Month.  It was approved by President Benigno S. Aquino III on May 29, 2015.

1. The rights.  

In 1989, governments worldwide adopted the United Nations Convention on the Rights of the Child, also known as the CRC or UNCRC.  This convention has changed the way children are treated - as human beings with a distinct set of rights.  UNICEF has published a child-friendly summary of these rights.  Article 12 reads that "Every child has the right to have a say in all matters affecting them, and to have their views taken seriously". 

In Cebu, The Share A Child Movement Inc has worked with child rights advocates on room-to-room campaigns in schools to spread awareness on the right of the child.  There are many other child-centered NGOs in the Philippines, advocating not only for child rights protection but also for child involvement in governance.

2. The real situation.  

There are a lot of stories from news articles that abound regarding violations of the inherent rights of the child. There are reports about children videotaped performing indecent acts. Some articles discuss facts on human trafficking in the Philippines.  There have been success stories about Cebu bar owners convicted for qualified trafficking of minors for sex. However, sexual abuse has moved to a different environment, as sex offenders are now online engaged in webcam sex tourism.  Sweetie, is a 10-year old virtual Filipina girl who posed on video chatrooms to entrap pedophiles and sex predators across the globe. This kind of crime "requires a new way of policing". 

Child trafficking is real in the Philippines. Many crimes go unreported because victims lack information on human trafficking, crimes are concealed by victims and violators, or families of victims accept the situation as normal.

3.  Prevention is key.  

The Church also participates in National Children's Month.  This year’s National Children’s Month focuses on child participation rights, with the theme “Bata, Kasali ka, Ikaw ay Mahalaga!" (Child, you are included, you are precious!) It aims to highlight the right of the children to express their views, to be heard, and to actively participate in matters that affect them.

4.  How do children actively participate in matters that affect them?

The major events and activities for National Children's Month Celebration include zumbata, discussion on violence against children, story books for children and talent showcase of children.

For the government, the theme for this year is “Komunidad at Pamahalaan Magkaisa, ang-aabuso sa Bata, Wakasan Na!” (Community and Government unite to end child abuse!) which highlights protection from all forms of violence, abuse, neglect, exploitation and discrimination and to encourage stakeholders to promote as well as advocate protection of children at the family, schools, community, institution, organization and other settings.

Share you own ideas on how to promote children's rights and prevent child abuse. 


In what ways can children be involved in decision-making on matters that affect them?
What challenges that hinder children from claiming their rights?
What is the role of social media in promoting child participation rights?

Public Health Policy versus Individual Patient Rights: Addressing the Philippine HIV Epidemic

According to the Department of Health (DOH) National Epidemiology Center (NEC) AIDS Registry, one Filipino is newly diagnosed with human immunodeficiency virus (HIV) infection every hour.

I was chatting face to face with Dr. Ted Herbosa and Dr. Narciso Tapia last week, and a sort of debate on how we should address the growing HIV epidemic lead me to re-thinking my perception of the problem, and to explore the different possible strategies to address the problem. One view is that of a public health policymaker, where the welfare of the public is of foremost concern.  In an epidemic, what needs to be done to control an infection is identification of cases and contact tracing.  In the Philippines, we have a number of HIV advocates whose priority is the protection of individual patient rights to privacy and confidentiality, lobbying for laws to improve counselling and testing, HIV risk reduction and stigma reduction and improvement of access to health service delivery and support.  Do these hinder control and elimination of the HIV infection in our country?

Previously described as “low and slow”, the HIV epidemic in the Philippines has now been described as “fast and furious” - and we need to do something about it!

Question 1. What public health policies do we currently have to address the HIV Epidemic in the Philippines?  In the Philippines we have the AIDS law, formally known as the Republic Act 8504, The Philippine AIDS Prevention and Control Act of 1998.

On HIV testing, the AIDS law requires that the patient to be tested for HIV give informed consent, and that this is voluntary and cannot lawfully be mandatory.  In simple terms, nobody can be forced to undergo HIV testing.

“SEC. 15. Consent as a Requisite for HIV Testing – No compulsory HIV testing shall be allowed. However, the State shall encourage voluntary testing for individuals with a high risk for contracting HIV; Provided, That written informed consent must first be obtained. Such consent shall be obtained from the person concerned if he/she is of legal age or from the parents or legal guardian in the case of a minor or a mentally incapacitated individual.”

Medical practitioners and healthcare professionals are bound to maintain confidentiality on the identity and status of persons with HIV.  This therefore prohibits the healthcare professional from disclosing to anyone (even the patient’s sexual partner) the HIV status of the patient.

“SEC. 30. Medical Confidentiality - All health professionals, medical instructors, workers, employers, recruitment agencies, insurance companies, data encoders, and other custodians of any medical record, file, data, or test results are directed to strictly observe confidentiality in the handling of all medical information, particularly the identity and status of persons with HIV.

Although healthcare professionals themselves cannot disclose the HIV status of their HIV-positive patient, the law encourages contact tracing, provided it is the patient who decides to disclose to his/her partner:

“Section 29.  Contact Tracing.  HIV/AIDS contact tracing and all other related health intelligence activities may be pursued by the Department of Health: Provided, That these do not run counter to the general purpose of this Act.”

Section 34 of Republic Act 8504 on Disclosure to Sexual Partners reads:

“Any person with HIV is obliged to disclose his/her HIV status and health condition to his/her spouse or sexual partner at the earliest opportune time.”

The DOH issued  Administrative Order 2009-0016 on Policies and Guidelines on Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV).  Under Article VI Section 4 of this administrative order on Components of PMTCT on HIV Counseling and Testing, it reads:

“all partners of women infected with HIV shall be offered HIV counselling and testing.”

Question 2: How does one get HIV in the first place?

1. First, through unprotected penetrative sexual intercourse: commercial sex workers with low rates of condom use; increasing rates of casual sex among young adolescents (e.g. call center agents)

2. Transfusion of HIV-infected blood through IV drug use or blood transfusion:  The incidence of HIV infection through needle sharing in 2010 was relatively fewer in comparison to some Asian countries. A cited reason for this is the small population of people who inject drugs (PWID) in the country (Farr & Wilson, 2010), but recently an explosive rise in HIV was noted among injection drug users in Cebu.

3. From HIV-infected mother to her unborn child.  Anti-retroviral prophylaxis is a mainstay for preventing mother to child transmission.  However, there may be merits for Plan B+ also known as test-and-treat regardless of CD4 count and WHO stage of HIV infection.

Question 3: Why is there stigma and discrimination among people living with HIV?

The risk factors for acquiring HIV infection stem from high risk behaviors that are still considered taboo, such as promiscuity, casual sex or having multiple sexual partners increase the risk for acquiring HIV.  Males who have sex with males have an increased risk of HIV transmission.  Commercial sex work involves having sexual intercourse with individuals of unknown HIV status, most with low condom use. Illegal drug use is a crime punishable by law, hence re-use of needles possibly infected with HIV predispose IV drug users in acquiring the infection.

Question 4: What would be the implications of allowing HIV-positive patients confidentiality of their status which prohibits effective contact tracing?

Are there enforceable policies that can  require HIV-positive patients to change their behavior to reduce risk of transmitting the HIV infection? Counsellors and medical practitioners need to appeal to their sense of justice and benevolence.  Not allowing doctors to trace the contacts of their HIV-positive patients prevents them from advising these contacts to get tested and treated.

For instance, pregnancy is an evidence of unprotected penetrative sexual intercourse.  Many of these patients referred to us have not disclosed to the father of their child that they are HIV-positive.  The harm posed to the possibly HIV-negative sexual partner is evident since a woman can only get pregnant through unprotected penetrative sexual intercourse.  However, they fear that in disclosing to their partners, they would be thrown out on the streets with nobody to support them throughout their pregnancy.

• One such patient kept asking “kung iwanan niya ako, pano kami kakain? Saan kami titira ng mga anak ko? Saan ako kukuha ng pang-gastos ng CS ko? Paano ako bibili ng gatas ng anak ko? Anong trabaho ang pwede ko gawin eh hindi naman ako nakatapos ng pag-aaral…” (if he leaves me, how will we eat? Where will we live? Where will we get budget for my caesarean delivery? How will I buy milk formula for my baby? What work can I find when I did not finish school?)

• One HIV patient admitted that she was liberated when it came to sex, and that’s how she got infected. We were trying to convince her to disclose her HIV status to her current partner so that he could be tested as well.  She answered “bakit, sila ba naawa sa akin nung hinawahan nila ako ng HIV?” (why, did they have pity on me when they infected me with HIV?)

Non-disclosure of HIV-positive status puts people at risk for getting HIV infection.  You prevent the natural ability of the public to protect itself from acquiring the HIV infection.

Question 5: What about moves to provide needle exchange programs, condom use and pre-exposure prophylaxis?

The common view about these interventions are that these are band-aide therapies, with the risk of reinforcing high risk behaviors like IV drug use and sexual intercourse among patients already positive with HIV instead of addressing the root cause of the problem, which is drug addiction and high risk sexual behaviors.

Needle Exchange Program.  The NEP, properly understood and operated, does not contradict the goal of treatment. Research has shown that NEPs, aside from being preventive to HIV transmission, is also an effective conduit to treatment programs and other health services (Geffray, Schiray, Fabre, & Guilhem, 2002).

Pre-exposure Prophylaxis.  Just like diabetics say “I can eat cake and icecream, anyway there’s medicine to reduce my blood sugar…”  Pre-exposure prophylaxis does not address risk reduction, but allows HIV-positive patients to continue having risky sexual behaviors, after all, “there is medication for my partner anyway…”

Privilege should come with responsibility.  If HIV advocates demand that they be protected by law and afforded privacy and confidentiality regarding their status so that they can continue to be productive and self-sufficient working citizens, then they should be required to at least 1) get appropriate treatment that they need, 2) inform their own contacts to get those people tested and treated as well.

What needs to be done?  Support should be provided for these patients to be able to openly disclose their status 1) to their sexual partners on whom they are fully dependent financially, emotionally and spiritually and 2) to drug addicts to be rehabilitated to prevent addictive IV drug use which predisposes to HIV transmission from use of infected needles and syringes 3) increase awareness and acceptance of HIV counselling and testing, especially among high risk groups.

Children-centered DRRM

                        Role of Technology in Children-centered Disaster Risk Reduction Management

This week, I attended a meeting with a group of NGOs involved in child rights advocacy in Cebu to talk about children and their role in disaster risk reduction management (DRRM).

In 2005 UNICEF committed to the Hyogo Framework for Action with five priority areas.  UNICEF’s DRR goals include: (1) DRR for children and women is a national and local priority, (2) different risks faced by girls, boys and women are identified and addressed, (3) safer and more resilient conditions for girls, boys and women, and (4) strengthened humanitarian preparedness, response and recovery through capacity development.  UNICEF stresses that children have an inalienable right to participate in decisions that ultimately affect them.

The scholars and child rights advocates of The Share A Child Movement Inc go room to room campaigning for children to know and protect their rights.  Imagine what they can accomplish advocating for disaster preparedness, risk reduction and mitigating climate change.

A2D’s work on inclusive DRR with UNICEF brought them to Haiyan affected areas in North Cebu where they capacitated the children with trainings, seminars and workshops.  The very first DRR youth camp in northern Cebu was conducted last May 2015. The community also participated during the Earth Hour for the very first time.

Save the Children is lobbying to support the passage of the ‘Children’s Emergency Relief & Protection Act’ House Bill 5285 and Senate Bills 2446, 2448, 2466, 2487, 2502 & 2718, which aims to increase protection for the child during emergencies when the child is most vulnerable.

Even the Cebu Provincial government seeks to support child-centered DRRM with capacity-building activities empowering children.

Many NGOs recognize the children as valuable advocates for rights.  They can be valuable advocates in caring for the environment and for the protection of vulnerable populations such as pregnant women and children, the disabled and handicapped, and the elderly as well.  They have the capacity to identify hazards and risks in their schools, homes and communities.  During times of disaster and calamities, they can be easily mobilized as leaders to ensure early evacuation as needed and proper coordination with authorities for rescue.

Children are more and more into technology and social media. How can we direct this positive energy to get the vulnerable population involved in protecting themselves and others during natural disasters and calamities so that the death toll during events like Yolanda would be brought to a minimum.

As the former Senator Nino Aquino once said “the Filipino is worth dying for…” let us hope that during times of natural disasters and calamities, we are prepared enough to be able to say “the Filipino is worth living for…”

BEDSIDE MANNERS OF E.R. DOCTORS

BEDSIDE MANNERS OF E.R. DOCTORS 

Tonight's #HealthXPH tweetchat topic drew its inspiration from an article published in MindanaoTimes which went viral on facebook because the journalist lambasted resident doctors for being fake doctors, simply because of their lack of bedside manners.

Dr. Tony Leachon reminds us to be always on our toes.  Patients nowadays don't trust as easily as before.  Doctors need to earn their patient's trust, and good bedside manners, showing empathy and and expressing compassion are ways to build rapport, alleviate anxiety, give comfort and earn patient's trust.

With patients becoming empowered, they turn to social media with their negative healthcare experiences.  This is a two-edged sword as it could destroy a healthcare professional's reputation or it could provide much needed feedback for healthcare providers to step up their performance.   This was out topic during the #HealthXPH tweetchat last week (July 18, 2015).  This reminds doctors to be vigilant on how they treat their patients regardless of whatever they are going through at that moment in time.

Emma Wilkinson offers tips on how to improve your bedside manner: 
#1 Focus.
#2 Really Listen.
#3 Ensure Privacy.
#4 Be Observant.
#5 Strike the Right Pose.
#6 Don't Judge.
#7 Use Open Questions.
#8 Offer Reassurance.
#9 Choose Words Carefully.
#10 Stay in Control.

Dr. Edgar Lerma shared this article where Leonard Feldman of Johns Hopkins University School of Medicine pointed out that basic things make a difference in patient outcomes. Etiquette-based communication include: introducing oneself, explaining one's role in the patient's care, touching the patient, asking open-ended questions such as "How are you feeling today?" and sitting down with the patient.  Maybe I should see if my own residents and interns also fail to do these things, because we don't do these during our grand bedside rounds.  Learning something new everyday, this should also be a reminder to me, to extend compassion to our patients while teaching our students  the science of medicine, we should not forget the art of medicine as well.

My take is on how we were trained in Basic Life Support (BLS), that the very first step would always to tap the patient on the should and ask "hey hey hey are you okay?" - this written and memorized script shows that the priority is ascertaining first of all if the patient is stable enough to respond, and second, to determine how the patient is doing.  In all patient encounters, simply asking a patient whether he or she is okay focuses on the patient and expresses the healthcare provider's concern over the patient's welfare.  At the emergency room where the situation is quite chaotic, simple supportive touches, attentive focused listening and sincere reassurance that everything will be done for the patient are enough to alleviate anxiety and comfort.

And now, the next project for me is to learn about Storify from Marie Ennis-Conner @JBBC like she did for our latest tweetchat.  Thanks for sharing!  Join our next #HealthXPH tweetchat Saturday 9PM Mla / 9AM EST!


Dr Helen V. Madamba, working on my bedside manners