CHILD (5-YEAR OLD) - DEATH AT DR. JEETOO HOSPITAL DUE TO MALARIA
The Leader of the Opposition (Dr. N. Ramgoolam) (By Private Notice) asked the Minister of Health & Quality of Life whether, following the recent death of a minor at Dr. Jeetoo Hospital due to malaria, he will state –
(a) the circumstances which led to the diagnosis and the treatment given;
(b) whether the source of the infection has been established;
(c) whether any case of malaria has been reported recently, and
(d) the measures which have been taken to prevent the spread of the infection.
Mr A. Jugnauth: Mr Speaker, Sir, the information asked for with regard to the recent death of a 5 year old girl at Dr. Jeetoo Hospital on 09 April 2004, due to malaria is as follows -
With regard to part (a), the child was admitted at Dr. Jeetoo Hospital on 02 April 2004, referred by a private paediatrician with a provisional diagnosis of acute hepatitis. There was a history of fever for the past 3 days with generalised weakness and a yellowish coloured urine. There was no history of foreign travel. On examination, the child was afebrile with severe pallor and pain over the liver and spleen. Blood analysis showed anaemia and sufficient evidence to point to a diagnosis of a blood disorder. The child was transfused with two units of packed cells and four units of platelets. The child was also started on antibiotics. It was decided to perform a bone marrow examination on 03 April. The result of the bone marrow examination was normal. During that same period, the patient started to have regular peaks of high temperature, which led the paediatrician to ordering a test for malaria parasites. This was done on 08 April and a positive diagnosis of malaria (plasmodium falciparum) was made. The Preventive Health Section of the Ministry of Health & Quality of Life was informed immediately and treatment was started with quinine dihydrochloride in line with WHO Protocol for the treatment of malaria. Unfortunately, the child developed cerebral symptoms in the form of generalised fits in the morning of 09 April. The child passed away at 7.55 p.m. on that evening despite all treatment given.
With regard to part (b), an epidemiological investigation has been carried out to identify the source of infection. In Mauritius, the last case of indigenous (local) falciparum malaria was reported in 1967. However, in 1988, some cases, secondary to an imported case, were reported. Since 1990, an average of about 50 imported cases are reported annually in Mauritius. A few secondary cases are also reported, but since 1989 none of them has been of the falciparum type.
It was on 09 March 2004 that a case of falciparum malaria in a one- year old girl from Comoros Islands was reported. The patient came to Mauritius for investigation for abdominal pain. She attended the Chisty Shifa Clinic.
Blood was taken from the child in the clinic and falciparum malaria was diagnosed by the central laboratory of the Ministry. Appropriate treatment was given by the public health officers of my Ministry. The child was attending the private clinic from 03 to 08 April for medical investigation. The child stayed with her parents in Vallée Pitot. Our public health inspectors have taken blood from the parents and the close relatives at Vallée Pitot. They were all negative. A fever survey and larviciding were carried out in the region and no case was detected from blood samples collected. The child left Mauritius for Comoros Islands on 15 March 2004. We believe that this Comoros infant could be the most probable source of infection, in view of the proximity of the clinic with the residence of the deceased.
It is the standard practice for malaria surveillance that public health officers note the names and addresses of all incoming passengers from malarious countries at Port and Airport for follow-up and surveillance procedures.
As regards part (c), a second case of falciparum malaria was diagnosed in a 10-year old girl, admitted on 30 March 2004 with a history of fever, loss of appetite and dry cough for one week. She had previously been seen by a general practitioner in the private sector. The child gave no history of foreign travel. She resides at about 150 metres from the residence of the deceased child. Investigation on the child pointed to a diagnosis of pneumonia and she was started on antibiotics. On 01 April, blood analysis pointed to a possible blood disorder, which prompted the treating doctor to do a bone marrow examination on 05 April. The bone marrow examination was inconclusive and test for malaria was ordered. The diagnosis of falciparum malaria was made and treatment was started immediately. The patient is responding very well to the treatment and her condition is improving.
A third malaria case of a 67 year old man was diagnosed following a mass blood examination carried out on 09 April in the vicinity of the residence of the deceased child. The patient was well without symptoms and treatment was started in view of his positive smear for falciparum malaria. He resides some 20 metres from the residence of the deceased child. As the 2 other patients, this third one too has not travelled to malarious countries nor has he received any visit from foreigners coming therefrom.
With regard to part (d), following notification of the two cases in the late afternoon of 08 April 2004, the following measures were taken -
(i) Larviciding has been carried out in the affected area as from the next day of notification of the cases, that is, from 09 April. It is an ongoing activity.
(ii) A survey of fever cases in the neighbourhood where malaria cases were reported, was carried out on 09 April 2004. 47 blood specimens were taken, from which the third malaria case was detected.
(iii) A mass blood survey was carried out in the affected area of Port Louis as from 11 April 2004. A total of 621 specimens have been collected as at 12 April 2004. Examinations of these blood samples were negative for malaria.
(iv) House to house visits of premises in the region to identify mosquito breeding places were carried out and notices were served in some cases for the abatement of nuisances.
(v) All mosquito breeding grounds in the region are being treated with insecticide to eliminate mosquito larvae.
(vi) The spraying of houses is being carried out in the region. As at 12 April, 103 houses have been sprayed. This spraying operation is ongoing and is expected to be over by the end of this week.
(vii) Spraying of Dr. Jeetoo hospital started on 12 April and is expected to be completed today.
(viii) The school attended by the two patients at Dr. Jeetoo Hospital, namely the Labourdonnais Government school, is being sprayed today.
(ix) A mosquito survey is being carried out in the region where cases were reported.
Mr Speaker, Sir, I must point out that communicable disease surveillance is an ongoing process. This includes the following -
· screening of passengers, at Port and Airport, irrespective of port of embarkation. Names and addresses of those coming from malarious countries are noted and sent to health offices nearest to the place of residence of passengers. They are visited by surveillance officers and blood samples are taken from them to exclude malaria;
· examination of blood specimen at the Malaria Laboratory at Candos to exclude malaria. This laboratory operates on a 24 hour basis, and
· routine assessment of mosquito density and behaviour is being carried out by the Medical Entomology Division of my Ministry. The Laboratory also carries out this activity whenever malaria cases are detected. Mosquito surveys include night catch of mosquitoes.
Moreover, the Communicable Disease Control Unit of my Ministry -
· monitors all anti-malaria activities being carried out in the periphery to ensure consistency in the type of activities being carried out;
· publishes and circulates a monthly Malaria bulletin to doctors in the public and private sector;
· carries out health education in schools on vector borne diseases with emphasis on eliminating the breeding grounds of vectors of these diseases, and
· ensures that all malaria cases are followed up.
Mr Speaker, Sir, taking this opportunity, I am making an appeal to the public -
(i) to eliminate potential breeding grounds of mosquitoes namely, water on flat roof tops (dalles) and on their premises, particularly during heavy rainfalls;
(ii) for people travelling to malarious countries to take antimalarial prophylaxis tablets which are freely available at the International Vaccination Centre of the Ministry of Health & Quality of Life, and
(iii) for incoming passengers from malarious countries to cooperate with the health authorities in providing a blood sample for malaria examination and to report to any health office in cases of fever.
Dr. Ramgoolam: Mr Speaker, Sir, can I ask the hon. Minister whether he can confirm that the child had been to Dr. Jeetoo Hospital twice and was given panadol for persistent high fever?
Mr A. Jugnauth: Mr Speaker, Sir, I have not been informed that she went twice and was given panadol. I am saying exactly what I have been informed by the doctors.
Dr. Ramgoolam: Maybe the information that the Minister has is correct, I am not sure. I heard him say that when the child was admitted, she was found to be passing black urine…
Mr A. Jugnauth: Yellow urine.
Dr. Ramgoolam: Ok. It is not easy for the doctor and he could have missed the diagnosis, I am not saying that at all because malaria is not on the priority list probably. But once this yellow urine was there, did they not ask for specific investigation for malaria then?
Mr A. Jugnauth: Sir, if the hon. Leader of the Opposition says it is difficult for the doctor, is it easy for the Minister to say whether the doctor has rightly diagnosed or not? Whether the child was passing yellow urine or whatever, it is difficult for me to say whether the doctor has given the right treatment or not.
Dr. Ramgoolam: When was the diagnosis of malaria actually made?
Mr A. Jugnauth: On 08 April as I have just mentioned.
Dr. Ramgoolam: The hon. Minister said that these two children and the third person that he mentions have never travelled abroad and that the last case of endigenous malaria - if I heard him right - was in 1967 and the last case of falciparum plasmodium was in 1989. Are we saying therefore that there are now new endogenous cases?
Mr A. Jugnauth: Although it is not conclusively found out that it was the Comoros child who brought in this type of malaria, it was the link that has been made between the type of malaria the girl died of and that case of the Comoros child.
Dr. Ramgoolam: I am making a difference between exogenous and endogenous cases. For the first time, since 1967 we have actually endogenous cases in Mauritius, whether it is true, whether it was from the Comoros person or not, it is endogenous cases, that is what I want to point out.
Mr A. Jugnauth: I am told that this cannot be because this is a secondary case. This is what the doctors are telling me; it is a secondary case and, therefore, it cannot be an endogenous case.
Dr. Ramgoolam: I do not know whether that is the right answer, but I will not quarrel with it. The fact is be it secondary, it is becoming an endogenous case. We have got three cases where people have not travelled abroad. Is that correct?
Mr A. Jugnauth: I have already stated that there is no history of them having travelled abroad. I have said it in my answer.
Dr. Ramgoolam: The Minister is therefore saying that these are endogenous cases. Endogenous means that it is from people who have not travelled abroad. That is what I am saying.
Mr A. Jugnauth: This is the interpretation of the hon. Leader of the Opposition. From what I have been informed, it is not so. I have been told that the secondary cases are classified as introductory by the World Health Organisation.
Dr. Ramgoolam: So, why did the Minister say that in 1967 there was the last endogenous case. Can I ask him that?
Mr A. Jugnauth: I was informed.
Dr. Ramgoolam: Can the Minister tell me what he means by endogenous case?
Mr A. Jugnauth: I am not here to explain to the hon. Leader of the Opposition what endogenous means. If he wants to go and carry out….
Dr. Ramgoolam: I am not asking the Minister to explain to me; it is for the public. He has himself said that in 1967 there was a last endogenous case. So, what does he understand by endogenous case? That's why I am asking him as he has used the expression himself.
Mr A. Jugnauth: Mr Speaker, Sir, I am not here to explain medical terms or other things to the Leader of the Opposition. He can draw his own conclusion.
Dr. Ramgoolam: I have already drawn my conclusion. But is the Minister aware that the maternal grandmother of that child has also passed away during the same time? Does he know the cause of death?
Mr A. Jugnauth: I do not have information about the maternal grandmother. If she died of malaria, most probably it would have been included. I have explained to this House about the three cases, that is, the child who died, the 67 year old man and the 9 or 12 year old girl who was a friend of the deceased.
Dr. Ramgoolam: I did not say that she died of malaria. I asked whether we could know the cause of death because it is at the same time. Mr Speaker, Sir, we can see already that there are lapses here. We have had the tragic death of a child. The diagnosis has been made since 08 April. Can I ask the Minister why his Ministry has not launched a national awareness campaign to ask people to take certain precautionary measures?
Mr A. Jugnauth: Mr Speaker, Sir, I have said it is an ongoing process and I was supposed to make a statement today in Parliament. And as there is no outbreak as such, we do not want to panic the Mauritian society when we are taking the necessary measures; and it is ongoing, as I said. Not only because we have found a malarious case in our country that these measures are taken. It is an ongoing process. This is on since a long time. And, therefore, I do not think we should go and create panic in this society saying well there is…
Listen! Mr Speaker, Sir, in the circumstances we have taken all the necessary measures; and, as I said, the measures taken are ongoing and we have taken additional measures as well. In this particular case, we have gone house to house and insecticides have been sprayed. We have checked all the families, and I have given the information to the effect that the people who have been examined are free from malaria.
Dr. Ramgoolam: It is not a question of panic, Mr Speaker, Sir. It is the duty of Government to take precautions. We have had three cases already with one tragic death. We have a responsibility towards the people as well. We have to make sure that they take certain precautionary measures. They could have been informed of certain things. The Minister himself has just said that we should make sure that water is not accumulated on the dalle, etc. A lot of other things have to be done. They should be told also that when patients, especially children, have persistent fevers and jaundice, they should be taken to hospital. It is these kinds of things that we want the Minister to do and not to say that he is not going to panic the people and that, therefore, he won't say anything.
Mr A. Jugnauth: I have stated in my answer that those people who are feverish should report to the hospital immediately.
All the measures that the hon. Leader of the Opposition has mentioned are taken. As I said, it is ongoing. We do not wait for a malarious case to be reported for us to take action. I am telling this House that all these measures are taken on a routine basis.
Dr. Ramgoolam: His own colleague, Minister Bhagwan who was acting as Minister of Health then, said on 09 June 2001 - and I must give credit to him - that if not monitored closely, this situation may lead to the spread of the disease in the local population and that we have got the problem of imported malaria. He said that in 2001; and he said that he was worried and that we should not rest on our laurels, we should make sure that we do not allow this to continue. Now, we have had three cases. The Minister himself has said that the last endogenous case was in 1967; he himself said that the last case of falciparum was in 1989. We have got three cases of falciparum. I do not know whether the Minister realises because mosquitoes spread like anything.
The hon. Prime Minister is as if getting annoyed. Maybe he should preside a committee instead of presiding committees on rats and corbeaux and all these things! He should preside a committee to get rid of mosquitoes. That is what he should be doing.
Mr Speaker: Order!
Mr A. Jugnauth: Mr Speaker, Sir, the hon. Leader of the Opposition himself said it can spread. Of course, malaria is a communicable disease and, therefore, the problem is that it is going to spread. And this is the reason why we are taking additional measures.
Dr. Ramgoolam: I ask the Minister again. Will he launch a nationwide campaign to make people, at least, aware of the symptoms and what they should do, minimum things that they can do instead of just now trying to say it in Parliament?
Mr A. Jugnauth: I will say again, Mr Speaker, Sir, that this is an ongoing process. We don't wait for a malarious case to be reported to the hospital or elsewhere. On several occasions, I have said that it is ongoing. My colleague, hon. Bhagwan, was right; and this is the reason why we say that there are ongoing measures and precautions that are being taken. Not because we have been declared malaria free that we are not taking any precaution. We have got a Communicable Disease Unit that monitors the situation at all times in this country, Mr Speaker, Sir; and I repeat that it is not only when there is a malarious case that we take measures, but it is an ongoing process.
Mr Hurnam: How often does the Health Monitoring Committee report on its progress?
Mr A. Jugnauth: Well, I have said that there is a monthly bulletin that comes out.
Mr Hurnam: Can this be communicated to the hon. Leader of the Opposition?
Dr. Beebeejaun: This is a very valuable proposition, because none of us doctors here has ever received any communication from any Communicable Disease Unit regarding malaria. So, I would ask the Minister to make sure, as the hon. Member has said, that we do receive these communications. We have not received any. Can the Minister make sure that we do receive these bulletins? The Minister has read what has been communicated to him; and we have asked this question: have they attended the hospital service before the date of admission? And the Minister said that it is not in his notes. Has he taken the trouble of asking his officers whether prior to the admission, this child who died, has attended casualty and, if so, on how many occasions and with what result? The officers are here. They could inform him.
Mr A. Jugnauth: The officers are here, but the doctor who treated the child is not here. If the information is available, I will gladly give it to the hon. Member. According to our records, she has not attended casualty earlier.
Dr. Beebeejaun: I take it, Mr Speaker, Sir, that there has been an in-depth investigation in this very sad case. In-depth investigation means going to the home of the family of the deceased and finding out what has been going on there. If they had done it, they would have seen that the grandmother had died a few days before, that this child had attended hospital on more than one occasion. So, it seems that there has been no attempt to look at this case properly.
The Prime Minister: Mr Speaker, Sir, on a point of order. Again statements are being made instead of questions being asked. Two very serious statements have been made. Can we get from the Member that he guarantees to these information? Otherwise he should put the question.
Dr. Beebeejaun: I guarantee this information and I stand to lose my seat and remove myself from this House if this information is incorrect.
Mr A. Jugnauth: Sir, as I said, I have been informed of all these facts. I also stated in my main reply that the child was referred by a paediatrician of the private sector. I do not know whether before that she went to hospital for other reasons or not. I do not know.
Why don't you shut up, hon. Dulloo? Stupid! Shame!
Mr Speaker: Hon. Dulloo!
Mr A. Jugnauth: I have a report from the hospital. The child - I won't mention the name - is five years old. She was admitted to Paediatric ward of the above-mentioned hospital on 02 April 2004 referred by a private paediatrician for suspicion of hépatite aigue.
Mr Dulloo: The child had been admitted…
Mr Speaker: Order! This question has been put several times by the Leader of the Opposition and by hon. Beebeejaun and the Minister has said that he is not aware whether the girl patient attended hospital prior to admission.
Order! Order, please! I am not going to allow further questions.
Hon. Beebeejaun, can you please keep quiet? Hon. Boolell!
Dr. Boolell: I am related to the girl.
Mr Speaker: Can the hon. Member take his seat?
Order! Hon. Boolell, please! I am warning you. If you behave like this - this is not a market fair, this is Parliament.
This is Parliament. Can you please keep quiet? You can't address the House from a sitting position, please. I have had a lot of patience with hon. Boolell and hon. David.
Mr Dulloo: Mr Speaker, Sir, we have got complacent and sometimes provocative replies. The hon. Minister has surely got an attaché de presse paid by public funds. It has been reported…
I am asking the hon. Minister whether he has taken cognizance of the fact that it has been widely reported that this child, prior to 02 April, has been admitted to hospital…
Mr Speaker: I am not allowing this question. Can the hon. Member take his seat?
Order! I have just given a ruling. Can the hon. Member take his seat? Hon. Beebeejaun, please! No cross-talking! I just gave a ruling that this question has been asked by the hon. Leader of the Opposition, by hon. Beebeejaun and the Minister has given a reply. He said "no". We are not going to lose the time of the House by allowing you to put the same question again.
Mr Dulloo: I am trying to help by giving a source of information. Never mind! To help the country, to help our people! I am asking the hon. Minister whether for the past few weeks, the whole history of that child has been inquired into before he reports to the House of the situation prevailing there, and also of that particular case resulting in death.
Mr A. Jugnauth: Mr Speaker, Sir, our doctors have been talking live on the radio about this issue during the weekend, explaining….
Listen fool! They were explaining all these to the public….
Dr. Boolell: On a point of order! Is the hon. Minister allowed to call a Member of the Opposition a fool?
Dr. David: He is the biggest fool!
Dr. Boolell: Exactement! He is the biggest fool!
The hon. Minister cannot treat Members with contempt!
Mr Speaker: Order, please! Hon. Dr. Boolell, please!
Dr. Boolell: (Interruptions)
Mr Speaker: If you continue like this, you will have to go outside.
As I said, this is not a market place. There are rules and procedures to be observed. You have to put questions according to procedures and you have to go by the procedures, which have been adopted in this House.
Dr. Ramgoolam: Mr Speaker, Sir, why do you look at the Opposition every time? When the other side is interrupting, you don't say anything. We want to have a ruling on this.
Mr Speaker: Order! Hon. Leader of the Opposition, are you casting aspersion on the Chair? Are you making an insinuation that the Chair is protecting one side to the expense of the other?
Dr. Ramgoolam: This is the perception that we are getting, Mr Speaker, Sir.
Mr Speaker: This is not what I am doing. The hon. Leader of the Opposition may have whatever perception he wants to have. I am trying to apply the rules. From the Opposition side, I called to order hon. Dr. Boolell, hon. Dr. David hon. Dr. Beebeejaun, because they were addressing the House from a sitting position. I called the other side also to order.
Mr Dulloo: Mr Speaker, Sir, we have just heard that since independence, it is for the first time that we are getting such a malarial attack….
The Prime Minister: On a point of order, Mr Speaker, this is not at all what was said.
Mr Dulloo: But since independence, this is the first time! Prior to independence, there has never been any case of falciparum infection. It is an endogenous case. Others were imported, this one is indigenous. May I ask the hon. Minister whether he is aware that this particular area, a depressed area, a poor area of Tranquebar, commonly known as Bangladesh and there has been…
Mr Speaker: Put your question, please.
Mr Dulloo: I am asking him about the area.
Mr Speaker: Hon. Dulloo, I am asking you to put questions, not to make a speech.
Mr Dulloo: I am referring to the place. I would like to know whether the hon. Minister is aware that this place at Tranquebar…
Mr Speaker: Please resume your seat, hon. Dulloo! We know the place. This has been given in the reply of the hon. Minister. If everybody rises and starts giving details, we won't finish; we have only half and hour for the PNQ.
Mr Dulloo: But, Mr Speaker, Sir, the hon. Minister is not answering to questions, which are put to him. We are asking him whether he is aware that in this locality there has been a high incidence of contagious disease, especially gastro-enteritis. There is also a problem of drainage there. We would like to know whether he is liasing with the competent authorities, especially the Municipality of Port Louis, because of the high rain recently, to ensure that there is a proper drainage system in the area because this is causing a lot of diseases. Cases of typhoid have also been reported there.
Mr A. Jugnauth: Mr Speaker, Sir, we don't pick and choose places. The measures, as I have said, are ongoing for the whole country. We don't pick and choose, Mr Speaker. The same measures are adopted throughout the country by the Surveillance Unit.
Dr. Beebeejaun: If I may. In the survey that is being carried out from house to house in the neighbourhood, has there been a report made of sewage leaking on the abandoned ground next to the family's place?
Mr A. Jugnauth: Mr Speaker, Sir, I don't have that information.
Dr. Chady: Normally, the examining doctor should take the history of a patient. May we know whether the hon. Minister did inquire as to whether that doctor has taken the history of the patient? The past medical history should have been in the file if that was so. If it is not in the file, then the doctor should be taken to task.
Mr A. Jugnauth: Mr Speaker, Sir, as the hon. Member has said, I presume that the doctor should have done his work as it should be. Now, whether we can go and check and make it public, I don't know. We'll have to check. If this is so, I have no objection at all to find out whether he has done what hon. Dr. Chady has asked and publicise it. I am not saying that we are going to do it, but we'll check whether this is in order to see what examination was carried out by the treating doctor and whether this can be publicised.
Dr. Beebeejaun: Once this one-year old child from Comoros Island was diagnosed as suffering from malaria, were the hospital's doctors and the medical profession working in Port Louis informed? Was alarm raised that a case of malaria was discovered and so to be careful? Were any such things done?
Mr A. Jugnauth: As I have just said, it was discovered in the laboratory of the Ministry of Health and it was the doctors from Dr. Jeetoo Hospital who treated the child. Cases of malaria are mostly treated in the public sector. The private sector does not have the necessary know-how and equipment to treat cases of malaria in this country. And, as I said, it was the doctors from Dr. Jeetoo Hospital who treated that one-year old child.
Mr Speaker: We have one more minute left before we move to Prime Minister's questions.
Dr. Boolell: Mr Speaker, Sir, if preventive measures were taken and there were proper inter-ministerial co-ordination in respect of cleaning of drains, cleaning of canals, epidemiological study, surveillance, why is it then that this child has got this disease? The Minister said that there has been no contact with somebody coming from overseas. As the hon. Leader of the Opposition has pointed out, this is an endogenous case. Mauritius prided itself from the fact that we have eradicated malaria in this country and there has been a relapse of cases of malaria, Mr Speaker, Sir.
Mr A. Jugnauth: Mr Speaker, Sir, the second part of the statement, if I may say so, of the hon. Member is correct. WHO has declared Mauritius as a malaria-free country. Mr Speaker, Sir, canal or whatever, everything is being cleaned. Other Ministries are assuming their responsibilities in this Government. All that I am saying is there might be a link of this falciparum malaria case the one-year old child from Comoros.
Dr. Ramgoolam: Since the hon. Minister has said that the child was treated with quinine, may we know whether he has made sure that we have enough stock of resistant drugs to malaria? Because some of the drugs are not working with cases of malaria.
Mr A. Jugnauth: I am being informed that we have sufficient drugs. We have the WHO protocol which is adhered to whenever there is a case of malaria. Stocks of drugs are available.
Dr. Ramgoolam: May we know what are these drugs?
Mr A. Jugnauth: Mr Speaker, Sir, quinine is one. There is also Artemeter Fansidar. These are the medicines.
Mr Speaker: Before proceeding with the questions addressed to the hon. Prime Minister, I have to announce some changes to the questions. I have been advised that Parliamentary Question B/172 will be replied by the hon. Prime Minister whereas Parliamentary Questions B/162 and B/171 will be answered by the hon. Minister of Public Infrastructure and the Minister of Civil Service Affairs respectively at the end of questions, time permitting.
I have also been advised that Parliamentary Questions B/167 and B/196 have been withdrawn.