Every now and then, we do come across clusters of cases of Herpangina or Hand Foot and Mouth Disease in Maldives.

Herpangina Ulcer in the mouth. (Picture shared by a parent).

What is it?
It is an acute viral illness in children that causes sudden onset high-grade fever and appearance of painful blisters and/or ulcers over the palate and back of throat. It occurs most frequently in children younger than age 5 but can affect bigger kids too.
It is quite similar to Hand Foot and Mouth Disease (HFMD), in which, in addition to the fever and oral ulcers, there are vesicular rash on hands, (elbows), feet, (around the knees, over thighs and buttocks).

What causes it?
It is caused by a virus. The most commonly identified viruses are Coxsackie A (A16, A6), Coxsackie B, Enterovirus (A71) and Echovirus.

How do you get it?
It’s highly contagious and is spread by droplets and via contact with droplet contaminated surfaces. An uninfected child gets the illness when respiratory droplets from an infected child are inhaled. Respiratory droplets are formed during coughing, sneezing and during speech. The virus also gets transmitted when spit or sputum contaminated objects (Eg: Toys) are handled by an uninfected child. Stool contamination (feco-oral) of food and drinking water has also been documented as a transmission mode.

Can we prevent it?
Good hand hygiene; with frequent sanitizer use or hand washing, transmission may be restricted. Also, isolating and keeping affected kids away from others, can limit transmission opportunities.

What are it’s signs and symptoms?
After an incubation period of 3 to 6 days druing which the newly infected child remains well, the illness begins with sudden onset moderate to high-grade fever ranging from 38° to 41° C. Painful swallowing, sore throat, drooling, headache, loss of appetite and generalized un-wellness are common. Small children may become fussy or irritable.

Oral lesions are often present starting day 1-2 of illness and could be used by healthcare workers to identify the illness during an outbreak. They are generally 3 to 7 mm in diameter and surrounded by a narrow zone of redness.

How do you diagnose it?
Diagnosis is clinical, from the symptoms and signs. Blood tests are not required.

Home care:
Hydration and symptomatic treatment are important. Lets the child take plenty of fluids. It may help child to tolerate the fluid better, if it is not warm. Acidic fluids such as citrus juices may sting and cause discomfort.

Paracetamol can be used for fever. Oral pain relieving gels may help transiently reduce severe pain.

As this is a contagious disease, where possible, affected kids can be kept separate from those unaffected.

How long does it take to recover?
Fever usually subsides after 2-5 days. The lesions usually resolve in 1 week without any treatment.

Similar to Hand Foot and Mouth Disease, some nail changes have been seen few weeks after recovery. They recover without treatment.

Monkeypox Virus

Quick Information Sheet for Healthcare Workers

19 May 2022

ALERT: Multiple cases of Monkeypox reported from USA & Europe!

A. General Info

  1. The first description of Monkeypox was reported in 1958 among monkeys kept for research purposes.
  2. The first known human infection with Monkeypox was in 1970 in Democratic Republic of Congo.
  3. Monkeypox is a rare disease caused by Monkeypox virus. The virus belongs to Orthopoxvirus genus of Poxviridae family. The same genus as the viruses for both smallpox and cowpox infection. 
  4. Majority of outbreaks and infections have been reported from African countries; primarily DRC.
  5. From time to time, cases have been reported outside Africa linked to international travel and transport of animals.
  6. Last year DRC reported more than 6000 cases while Nigeria reported 3000 cases.
  7. African rodents and non-human primates have been known to harbor the virus and are thought to be the source for human transmission. Specific primary natural reservoir is yet unknown.
  8. The recent cases described from Europe and USA are linked to international travel from African countries. Cases have been described from July 2021 and November 2021 by US CDC.
  9. The current alert is related to pockets of outbreaks in multiple countries; USA, UK, Spain, Portugal, etc.
  10. Person-to-person transmission is uncommon. However, among the cases in UK, a number of cases have no known travel history to Africa, thus raising concern about undetected community spread. 
  11. There are reports of possible transmission from a primary case to a HCW in one setting.

B. Transmission

  1. Transmission occurs when a person comes in contact with the virus from an animal, human or contaminated materials.
  2. The virus enters body via broken skin, respiratory system and other mucus membranes.
  3. Animal-to-human transmission is documented from bites, scratches, raw-meat (contaminated) handling, direct/indirect contact with body/lesion fluids.
  4. Human-to-human transmission is thought to be primarily via respiratory droplets. However, in the recent outbreak, a newer mechanism, is suspected to be at play; sexual transmission. One cluster is identified among individuals who self-identify as gay (male to male) or bisexual. Investigators report that this could signify sexual transmission or just the close contact associated with the sexual act.

C. Incubation Period

  1. Incubation period is usually 7-14 days but can range from 5-21 days.

D. Signs and Symptoms

  1. Prodrome begins with:
  • Fever
  • Headache
  • Muscle aches
  • Backache
  • Swollen lymph nodes
  • Chills
  • Exhaustion

The typical rash often develops after 1-3 days (sometimes longer) from onset of fever. The skin lesions typically follow stages before falling off.

  • Enanthem (tongue/mouth)
  • Macules 1-2 days
  • Papules 1-2 days
  • Vesicles 1-2 days
  • Pustules 5-7 days
  • Scabs 7-14 days

Rash typically begins on face/ mouth, but could appear anywhere on the body. In recent series, genital lesion have been frequently described.  

  1. The illness usually lasts 2-4  weeks.
  2. Historically 1 out 10 infected cases died from complications associated with it. However, in the recent out-break, case fatality, so far, is lower at <1%.
  3. Complications of monkeypox include secondary infections, sepsis, bronchopneumonia, encephalitis, infection of the cornea with ensuing loss of vision. 

E. Diagnosis

  1. Clinical diagnosis is possible when contact history, signs and symptoms match.
  2. Laboratory diagnosis could be possible with tests done on lesion fluid:
  • Virus isolation
  • PCR
  • Histopathology with virus identification.

Sample collections have to be with strict PPE, as the fluid itself is infectious. In our context, at present time, laboratory diagnosis and confirmation is limited/not possible.

F. Treatment

  1. There is currently no specific proven, safe treatment. Antiviral drugs and Vaccinia immune globulin (VIG) have been used with variable success.
  2. Treatment is symptomatic and supportive care.

G. Prevention

  1. Infection can be prevented by avoiding (taking protective precautions during essential) contact with symptomatic humans and animals that could harbor the virus (rodents and other dead or sick animals) particularly in localities with known transmission.
  2. Standard infection control practices and barrier nursing can help prevent nosocomial spread in healthcare settings.
  3. Practice contact and respiratory isolation of suspected/known cases. Use contact and respiratory droplet precautions in isolation settings.
  4. Contact precautions in healthcare settings: hand hygiene, disposable gowns, gloves when handling, surface disinfection (bedding, etc), linen decontamination, safe body fluid disposal, etc.
  5. Droplet precautions in healthcare settings: suitable PPE including mask, goggles/shields, etc.
  6. Vaccines are available. Approved by US FDA. Smallpox vaccine work against Monkeypox. Limited global stockpiles are available for smallpox vaccine. US ACIP is evaluating the vaccine for protection of people at risk due to occupational exposures.
  • ACAM2000: A replication-competent vaccinia virus vaccine. It is a sub-cutaneous, single dose vaccine delivered via multiple puncture technique.
  • Aventis Pasteur Smallpox Vaccine (APSV): Also a replication-competent vaccinia virus vaccine. Replacement for ACAM2000. It is also a sub-cutaneous, single dose vaccine delivered via multiple puncture technique.
  • Jynneos, Imavamune, Imvanex: Replication-deficient attenuated live virus vaccine. It is used as a subcutaneous 2 dose, 4 weeks apart shot. If previously vaccinated against Smallpox, a single dose is sufficient. 


  • WHO
  • CDC, USA.
  • Various news outlets

Mosquitoes everywhere!

Original post 18 April 2008

[Comment: Turn the clock to May 2022 & it’s no different!]

This is probably the topic that I have written most often about in recent times. Yet again, I am compelled to write about mosquitoes and their potential to cause ill health in this country.

After the recent rainfall, as expected, there is a definite increase in the number of mosquitoes buzzing around and biting us to spread illnesses such as Dengue Fever. This is a huge concern for health care workers like myself. I am in no doubt that this concern is shared by many others. We all know how deadly an illness Dengue can be in its severe form.

I was at work (at IGMH) the other day when I couldn’t help but complain about the number of times I was bitten by mosquitoes while seeing patients in OPD. I get terrible reactions to mosquito bites; with very rapid appearance of a severe Urticarial rash. A dozen or so mosquitoes were in a feeding frenzy within that single room. I along with the patients who had come to see me were at the mercy of these air-borne pests.

I realize that the whole of Male’, and probably the rest of the country, is experiencing a resurgence of the mosquito menace. But, for the mosquitoes to be present in such large numbers in the one place where they could readily feed on people with mosquito borne illnesses (such as Dengue) is a serious concern. These hospital premises are fast becoming the prime location where Aedes mosquitoes are spreading the Dengue virus.

Where the mosquitoes are coming from, I am not so sure. But the fact that they are indeed there is as certain as these really itchy wheals on my arms. It is a very likely possibility that some of these mosquitoes are coming from outside of IGMH, probably from the several construction sites around the hospital. However, I suspect that a significant number of them are born and bred within the hospital premises! 

There are so many water logged areas within the hospital premises, not least the roofing and the roof drainage system. The terraces are also water-logged for several days after the rain ceases. It probably is my ignorance, but I really don’t see anyone putting in an effort to clear up the potential breeding areas within the hospital.

It is quite probable that any such effort restricted to the hospital alone would be, on its own, of no significant impact to the mosquito population. Nonetheless, I believe that such an effort is needed as soon as possible. IGMH could begin the work and urge the community and other responsible bodies to revive the mosquito control program.

I don’t see any logic in waiting for the mosquito menace to cause an epidemic, as happens every year, before we launch a preventive health campaign. If we wait even a bit longer, the epidemic may soon begin. Or has it already!

Testing times again!!

Original post 19 Jan 2007

[Comments: Dejavu. May 2022]

To say that we are going through a rough patch would be an under statement. There was no smooth patch before…..and there is no sight of any of it in the near future either. It seems that in recent months all we did was manage one crisis after another.

One major illness on top of another has increased our patient population to an extent that is clearly well beyond the current capacity of public health care provision. As one of my colleagues suggested; we are indeed dealing with a “mass casualty”! And as with any mass casualty…..this current situation is taking its toll.

Post-Tsunami-Male’ is bursting at its sides. The congestion is virtually fueling the spread of one epidemic after another. Our public health care system is being tested way beyond its capabilities. It is evident that even at full capacity we would fall well short of the current health care needs.

These are testing times for all of us. The institution is struggling to manage its physical and service infrastructure in the crowded wards and waiting areas, the health care providers are being tested for their physical, mental and emotional endurance and the patients….well their patience, health and well being.

Where we are at now, we probably have never been before. And it is too painful to think of what would happen if things were to get worse than the current “things gone horribly wrong” situation.