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This article first appeared in the Mar/Apr 2010 print issue of PA TIMES.
Azharul Islam Khan, Shakeel Mahmood
In late July 2007, Bangladesh experienced atypical torrential rains causing widespread flooding, affecting about 50 percent of its administrative districts. Floods are typically associated with contamination of surface water and the piped water system in cities; they are usually followed by outbreaks of waterborne diseases, particularly diarrheal diseases, and increased prevalence of vector borne diseases. Floods displace people from their homes and force them to take refuge in overcrowded camps, facilitating the transmission of many infectious and contagious agents, including diarrheal diseases, measles, acute respiratory infection (ARI), and scabies.
Because of poverty, malnutrition is common, which may lead to compromised immunity with higher risks of infectious diseases, including cholera.
Mohakhali Cholera Hospital
In Bangladesh, both public and private healthcare facilities can provide appropriate treatment to diarrhoeal patients. However, all year round and particularly during outbreaks of diarrhea, a disproportionately higher number of patients visit the Dhaka Hospital, popularly known as ‘Mohakhali Cholera Hospital.’
Patient visits to the Dhaka Hospital average around 110,000 per year, with pre-monsoon (April-May) and post-monsoon (August-September) peaks. The 2007 epidemic was unusual, since an exceptionally higher number of patients visited Dhaka Hospital during July-September 2007, which provided care and treatment to a record highest number of 1,045 patients on a single day since its establishment in 1962.
The Dhaka Hospital has maintained a Diarrheal Disease Surveillance System (DDSS) since 1979, which monitors sociodemographic, economic, nutritional and illness characteristics in a systematic 2 percent sample of all patients. The DDSS also determines the etiology of diarrhea and antimicrobial susceptibility of major bacterial pathogens. DDSS data, during the study period, showed that over 70 percent of patients aged over five years and 35 percent of under-five children presented with severe dehydration.
Epidemics of diarrheal diseases in emergency settings may be associated with relatively higher case-fatality rates, which is illustrated in Goma in the recent past, where inappropriate management, slow intravenous rehydration, and delay in treatment were believed to have been responsible for very high case-fatality among cholera patients. In 2007, a huge influx of patients at the Dhaka Hospital during the flood-related diarrheal outbreaks placed a heavy burden on the Hospital’s resources, requiring additional manpower, excessive amount of intravenous (I.V.) and oral rehydration fluids, and antimicrobials. Despite these odds, no diarrheal patients without any co-morbidity died.
With an annual patient visitation rate of around 110,000, inclusive of diarrhea outbreaks, average daily patient visits vary between 250 and 300. An outbreak is defined as the time when the daily patient visits reach or exceed 350 on 3 consecutive days, and also when 20 percent or higher proportion of them have culture-proven cholera. From the DDSS database, 451 patients were identified as eligible for stratified analyses by age group: children aged less than five years and patients aged five years and older.
Despite the high burden, Dhaka Hospital could keep the mortality rate remarkably low; in fact, none of the patients with diarrhea alone, irrespective of their severity, died; those who died had other co-morbidities as the primary cause of death. Severe dehydration is the leading cause of death from diarrheal diseases, and rapid rehydration, using appropriate intravenous fluids, as advocated by WHO , is the key to prevent deaths. It reduces vomiting by correcting metabolic acidosis, leading to promotion of ORT and normal food intake, and facilitating early recovery. Based on the high proportion of patients hospitalized with severe dehydration and cholera and assuming that at least 30 percent of them would have died in the absence of efficient management, we estimate that the hospital saved 13,000 lives during this period.
50 Years of ICDDR,B
The success of the Dhaka Hospital relates to several factors. First, this is a specialized diarrheal diseases hospital in existence for 50 years. It is supported by highly knowledgeable and skilled clinicians and researchers, nurses, health workers, and auxiliary staff with unparallel experience. The Hospital experiences outbreak situations annually and, due to seasonal variations, it can anticipate such events, although timings and magnitudes may vary each year.
The Hospital practices evidence-based treatment protocols and essentially follows the WHO guidelines with minor modifications in assessing dehydration and in reducing inter-individual variations for quick identification of patients requiring intravenous rehydration. This method also called ‘Dhaka Method’ has been used for WHO-sponsored, multi-country studies in cholera. In 2009, Dhaka Hospital turned into a paperless patient management information system which is totally a new concept globally.
Modifications were made in the patient registration system, which itself take a couple of minutes. Following this, trained experienced nurses triage patients taking into account a brief medical history and a quick assessment focusing on dehydration status and presence of complications or co-morbidities. However, a delay of minutes could be critical for the survival of patients with hypovolemic shock. Recognizing these factors, the hospital waived both registration fees and triaging, to directly put patients on emergency beds which initiated immediate resuscitation with concomitant assessment and a deferred registration after stabilization of the patient’s condition.
The use of ‘cholera cots’ (modified camp cots with a central hole), regularly used at the ICDDR,B’s hospitals is a low-tech but high output device, which ensured efficient fluid balance, hygienic disposal of diarrheal stool, and kept the extremely busy hospital clean and almost smell-free.
The hospital routinely emphasizes oral rehydration with its many advantages, including its ability to save intravenous fluids, and building confidence among patients. The main limitation of ORS, however, is that it neither reduces stool volume nor dirahea duration, two factors that are considered important for its acceptance by caretakers. We prefer rice-based ORS (R-ORS) for patients older than 6 months as R-ORS has been proven to be beneficial in cholera because it is associated with significantly less purging both in terms of duration and volume and it is equally effective in diarrhea due to other causes.
The concentrations of the salts (sodium, and potassium) and bases are the same in the rice-based and glucose-based formulations. R-ORS may induce early recovery of patients, facilitating early discharge, which is essential in managing an excessive number of patients without turning away any. ICDDR,B has an in-house kitchen catering rice-based ORS.
While ICDDR,B achieved a historic milestone, available government infrastructure remained heavily underutilized. The policies that resulted in the successful management of one of the worst diarrhea outbreaks may well be recommended for replication in both public and private sectors offering health services for tackling similar situations in the future. Facilities in Bangladesh and agencies that respond to outbreaks of diarrheal disease globally should consider adopting the collapsible cholera cot, protocolized diarrheal-management practices, and prior planning and responsive management, including hands-on training of potential staff, for such emergency situations.
Azharul Islam Khan is the head of short stay unit, Dhaka Hospital, ICDDR,B. Email: [email protected]
ASPA?member Shakeel Mahmood is working at ICDDR,B as coordinator, monitoring and evaluation framework (MEF). Email: [email protected]