Thursday, July 14, 2011

A meningitis post by Dr. Clarke

8 July, 2011

This was a “meningitis” day. About 2.5 months ago we started having a series of cases of meningitis, or at least what we called meningitis based on our most educated guess. We diagnosed a case, then Across in Adol diagnosed three cases, then we had several more. At the Ministry of Health meeting in April we told of our findings and we also heard from Yirol that they had made definitive diagnosis of N. Meningococcus meningitis in three cases. We had 6 by that stage. In 2007 N. Meningococcus caused an epidemic across Sudan that left thousands dead, including some very close to the Akot family. The conventional wisdom is that the epidemics come every three to four years. I felt we were on the cusp of another epidemic. Our case number eventually rose to 15, but we have not had another case in several weeks, making it look to me like an aborted epidemic.

As evidence of a possible epidemic increased, I sent word out for prayer and for intervention. I think we got a good deal of both. God turned back the pestilence He sent against Israel at the pleading of David (II Sam 24), and I believe and will continue to believe that God spared us this epidemic because of the prayers on our behalf. Two specific things I asked for as the epidemic loomed were the Meningococcal vaccine and a counting chamber so that we could make a definite diagnosis of meningitis. A recent team from St. James Church in Richmond got us both, and today we used them both. We had a child come in obtunded with backwards (opisthotonic) posturing. He had a large spleen and was test (+) for malaria, but he had not responded as well as we would have liked by last night, so Elijah started him on Ceftriaxone. I felt this was a good time to get a more definitive diagnosis. The father agreed to a lumbar puncture (spinal tap), so I did it. I have done many, but not for several years, and my holder was inexperienced, and the child was 5 years old, so I sedated with ketamine. The procedure went well and there were no cells, so we could feel good about stopping the Ceftriaxone and continuing the Quinine.

Almost immediately after that, I traveled to Atiaba with Mary Agum to vaccinate the Hope and Resurrection School against Meningococcus. Though we were leaving after the time I told Marcelina to expect us, I tried to think through all the things we would need. I got the vaccine and the diluent. We have a cold box for transporting the vaccines and I got that. I got the syringes for giving the vaccine and the cotton soaked in methylated spirits to clean the skin before administration. But once we got there, we realized two important items I had forgotten: larger syringes to mix the vaccine and a sharps container for the used syringes and needles. We got around the first by opening the vaccine bottles with a knife and pouring the diluent into the powdered vaccine.

The day actually went well with no real problems, but a few surprises. The biggest surprise to me was the amount of fear the injections caused, even among the boys. I have spoken about the bang, the state of nirvana or disassociation that these young boys go into as the one who administers the cuts walks around the circle sharpening his blade and looking for any signs of fear. I could never go through that ritual, and there was a time in my life when I hated shots about like these men did, but I was surprised at not only their fear, but also the fact that they were not embarrassed to show the fear in front of the girls. At that stage of my life I still was not fond of needles, but I would have more successfully hidden my fears if there were female classmates around. Several times I joked that I would have to get Mary Agum wielding the knife and killing any who showed fear. Strange, but they did not seem to enjoy the joke as much as I did. Overall it went well. Because of the unrest in the area, many of the students were not there. I have not decided if we will offer a make-up day for those students. I was pleased, however, when members of the community of Atiaba were asking if we were going to offer the vaccine to them. I told them our basic strategy is to get the schools in the area first, then open it up to the people in Akot, and then Atiaba would probably be our next stop. They were pleased with that approach.

As a child of South Carolina, I have always sympathized with governors faced with making the call for forced evacuation of the coast as a hurricane approaches. There will always be those who criticize you, particularly if you call for an evacuation and the storm is not as severe as predicted. That is how I have felt with this “epidemic.” I am glad to be wrong. I do not want hundreds dying. Fortunately, the vaccine is good. Everyone who receives it should be protected for the next 10 years or so, and possibly for life. What if there is never another epidemic? Well, it would be a great blessing to Africa if those epidemics quit, but there is nothing to give us that kind of confidence. If what I have been told is true, that the epidemics occur only during the dry season, then the onset of the rains may have ended or greatly diminished the epidemic. If that is the case, there is a good chance the epidemic may reappear when the rains cease. So it may well be that what we have had was some advanced warnings of troubles to come, and so vaccinating the school aged children is still doing is good, even if not so pressingly urgent as I once thought.

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