Finding Swine on the Famished Road

Diarrhea and vector-borne illnesses be damned. I come to Kenya and I get slammed hard by that wretched little bugger, the flu.

It didn’t matter that the multiple vaccinations I had received a month ago rendered my immune system excited and inflamed and ready to fight not only Yellow Fever and Typhoid, but also Meningococcus, even though I was unlikely to travel anywhere near the Meningococcal Belt. (Our beloved travel medicine clinic doc can be very convincing- though I did put my foot down to the rabies vaccine. Even though I had been considering going for a run or two out here, I was willing to take my chances with the stray dogs.)

Two weeks later I also received the seasonal flu vaccine. The novel H1N1 vaccine came out just a couple of days before I left, but- and don’t hate me for saying this- I was suffering from vaccine-fatigue. And honestly, I am neither pregnant nor immunocompromised in any way, so why bother? I mean does the vaccine really reduce nasal carriage and risk of transmission, or is only risk of acquisition?

I have been taking my Mefloquine religiously, and put on 40% Deet on occasion, usually when lady Anopheles and friends decide to have a party in our house every once in a while.

I put out my hand sanitzer on the folding table every day, and use it in between patients religiously. One sweet elderly patient saw the bottle on the desk and motioned towards me, a nonverbal request asking if she could take some. She looked at the bottle closely, shrugged her shoulders and proceeded to take a palm full and rub it all over her body as though it were cologne.

Pride comes before a fall. I can count on one hand the number of times I have gotten sick while traveling and during residency.

In spite it all, the flu hit me. Hard. And of course it hit me hardest on our trip to Masai Mara Game Reserve. Dave and I thought carefully about the one “indulgence” we were going to allow ourselves and in the end it was a toss up between a game drive and a flight to Mombasa on the other side of the country. In the end we were glad to have spent the money on this very touristy adventure.

But for most of the trip I felt like the emaciated cows on the savannah whose hardened faces would stare emptily at me while chewing endlessly on dry cud. The Masai were even trying to graze their cattle within the confines of the national park because the land is just so dry.

I did manage to enjoy our game drives regardless. We saw 4 of the 5 big five- lions, elephants, rhinoceros and water buffalo. Our lovely driver-guide took us within inches of some of these intimidating creatures, including a close up of two mating lions. They were lazily lounging on the grass, yawning in synchrony, their majestic bodies stretched out long and large. And then, without any verbal cues, they rose together, and began their play. It was amazing.

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I went to work the next morning in spite of my better judgment. My original plan was to not do any direct patient care and focus on some chart reviews and perhaps leave a bit early. Such was not the case. We were short several clinical officers and the chart pile was sky high. By the end of the day, I was hypoglycemic and febrile again and Dave had to rescue me. He put his foot down and gave away a couple of my charts to the other clinical officers.

So I previously extolled the evidence-based protocol driven system that I have found here, but of course it is far from perfect. The evidence for cotrimoxazole in all patients with HIV (regardless of CD4 count) is fairly convincing, especially in children, though in certain studies there is some suggestion of waning efficacy after a period of time, likely due to non-adherence and increased resistance.

The issue of adherence is fascinating in and of itself. Though we have a decent selection of ARVs (AZT, 3TC, d4T, NVP, Lopinavir/r, and apparently even Tenofovir), our limited stock makes it crucial that patients commit to adherence. So they have to undergo a three-week counseling session before they start, and if they fail the counseling sessions then they are just plain out of luck. The guidelines are fairly strict with respect to CD4 count and WHO staging- I have even seen a clinical officer defer placing a patient on ARVs with a CD4 of 260, as 250 is the cutoff. In the States we also use the rate of decline as another marker, in addition to increasing the cutoff to 350. I did convince this clinical officer to have the patient come back in another month to recheck the CD4, as I was convinced that it would eventually meet her criteria.

Ah lists and protocols. Protocols and lists. Peter Pronovost would be having a field day out here.

The issue of whom to test for malaria is also rather tricky for me. In an otherwise healthy population, those who would be at risk for developing clinical malaria are children, pregnant women and those from non-endemic areas. Of course HIV confers an increased risk for complications, but the extent of these complications depends on whether the malaria in the area is “stable” or “unstable.” I have met several patients who presented with complicated malaria- which makes me suspect that the malaria prevalence waxes and wanes, perhaps with the different seasons. Yes, even in equatorial Africa there are seasons.

To smear or not to smear? This is what I have been asking myself for the last couple of days. Clinically, everything I am experiencing- myalgias, rhinorrhea, a nasty cough, low grade fevers and rigors- all smell of influenza.

But after all, I am currently in Africa.

Thoughts?