The Virtual Doctors During a Pandemic

We have not published any Cases from the Field over the last couple of months. The Medical Team has been busy working on Educational Materials for our Forum. The plan is to produce a weekly series of Case-based problems for our Clinical Officers; covering scenarios that we have managed with them. We were aiming to launch this programme at the beginning of April; but suddenly everything changed. We have put this to the side for the time being to concentrate all our efforts on COVID-19 preparedness. 

At the time of writing there have been just 45 cases of confirmed COVID-19 in Zambia.  But there is a great fear of what may happen as the numbers rise. The majority of cases to date have been in Lusaka, the capital city, and all were managed in designated isolation facilities with active contact tracing. 

We surveyed over 100 of the clinics that we support to assess their ability to respond to COVID-19. We are now exploring how we can work with the Ministry of Health to mount a rapid response to some of the practical challenges they are facing.  And instead of our planned Educational Programme we have put together a series of resources for our Clinical Officers about COVID-19.  We aim to keep these updated as the situation evolves.

In the meantime, we are grateful to our Volunteers in the UK who continue to swiftly manage case queries from the Clinical Officers despite the enormous pressures on their NHS roles during this time. It is so important that we maintain our service.  Malaria, TB and HIV will continue to pose huge challenges in Zambia and diarrhoeal disease and malnutrition will still take young lives. We will work with our Clinical Officers to make sure that, as well as responding to the COVID-19 pandemic, all presenting conditions are managed optimally to maintain the health of the population both during and after the crisis.

MALARIA

At the end of March, we received a referral about a 38-year old gentleman who had presented with headache and fever.  He was unwell with a high temperature, fast heart rate and low blood pressure. The Clinical Officer described how he looked ill and restless. He had assessed him for signs of brain infection, but reassuringly could not find any features of meningitis on examination.

There are few laboratory tests available in the Clinics, but most should have access to HIV, Tb and malaria testing. The Clinical Officers will routinely test for malaria in patients presenting with an unexplained fever. At most facilities this will involve a finger prick test; the blood sample is automatically analysed with a rapid testing kit, giving a very quick answer. 

The test confirmed that the patient had malaria and the Clinical Officer commenced him on the appropriate therapy given through a drip. The COs see many cases of malaria and are often very competent at managing this infection, but nevertheless he was worried about this patient and sought further advice.

The Volunteer was able to discuss ongoing management with him. They were both concerned about the patient’s blood pressure. The Volunteer made recommendations about the type, rate and route of fluid to give to treat this problem. He explained clearly why this would work well in this scenario and described how the CO could continue to monitor the patient’s fluid requirements. The Virtual Doctor’s assistance was key in helping to improve the clinical course of the patient and prevent further deterioration.

On admission the Clinical Officer had started antibiotics in case there was a bacterial infection as well as the malaria making the patient so unwell. The Volunteer talked the Clinical Officer through points to gather from the history and examination to give clues as to the source of another infection. Together they judged that the safest thing for the meantime was to continue the antibiotics and keep the patient under close review.

The Volunteer described how the fever caused by malaria would not respond immediately to therapy. But he also reminded the Clinical Officer of some of the complications of malaria to be vigilant for; such as difficulty breathing and increasing drowsiness, which would indicate a need to escalate therapy. Again he encouraged the CO to reassess the patient regularly on the observation ward to monitor his progress.

REFLECTION ON THE CASE

Malaria is a life-threatening parasitic disease transmitted by mosquitoes. There are over 200 million cases of malaria every year. Although it is treatable, the annual worldwide mortality is still over 400,000. Over 60% of these deaths occur in children under the age of 5. More than 90% of the world’s malaria cases, and deaths, are in Africa.

Around 16 million people are at risk of malaria in Zambia. The disease burden has decreased following impressive control efforts in the past decade. But the disease is still a major public health challenge and remains endemic across all ten provinces. The country’s Strategic Malaria plan aims to eliminate the disease from Zambia. This will require ongoing coordinated efforts optimizing vector control and case management, community wide health education programmes and robust investigation and reporting systems.

Malaria presents with fever, as in our case above.  This is a non specific symptom characteristic of many infections and therefore in endemic areas a high index of suspicion is required to ensure that malaria is always considered as a possible diagnosis. 

COVID-19 also has fever as one of its major presenting criteria. But there is no known cure. It is easy to imagine, how many potentially treatable conditions, like malaria, might get overlooked in the midst of a crisis, whilst our focus is elsewhere. The Zambian National guidelines for COVID-19 stress that testing for malaria, as well as HIV and TB, in all suspected cases of coronavirus is really important to ensure that these treatable conditions are not missed. The Virtual Doctors have highlighted this to the Clinical Officers as they prepare to encounter cases of COVID-19. But it will not be easy. It is a new disease. We are all learning together.

One of the strengths of our service is that we support the Clinical Officers deal with all patients, whatever their presenting problem; we are not selective by disease, age or gender. Our response to this unprecedented situation aims not just to deal with the immediate threat of COVID-19 but also all the other health needs of our patients in Zambia both now and in the future.