optometry.naija: National Health Insurance Scheme (NHIS), Universal...

optometry.naija: National Health Insurance Scheme (NHIS), Universal...: The National Health Bill 2014 referred to a:  "health care personnel" as health care providers and health workers;  "hea...

National Health Insurance Scheme (NHIS), Universal health coverage and the Nigerian Optometrist. Part 4.

The National Health Bill 2014 referred to a:

 "health care personnel" as health care providers and health workers;

 "health care provider" as a person providing health services under Act of Law;

[Section 64(c)]

 Laws of the Federation (1989) Chap. 09, No. 34 established the regulatory framework of the Optometrists in Nigeria, the ODORBN (Optometrist and Dispensing Opticians Board of Nigeria). This Act of Law automatically qualifies the Optometrist as a "health care provider" as posited above.

It is therefore important to note the inclusiveness of the Optometrist in the Health system of Nigeria.

In Part 2 of this blog, I pointed out this:

The National Health Insurance Scheme Operational Guidelines (2012) identifies the Optometrist thus:

2.2.13.1 Possession of Doctor of Optometry degree, or equivalent qualification recognized by optometrist and dispensing optician registration board of Nigeria (ODORBN)
2.2.13.2 Registration with ODORBN
2.2.13.3 Possession of current license to practice issued by ODORBN.

In pursuant to a proper representation and inclusiveness of Optometry in the health system of Nigeria it is very important to identify with these:

(4) The National Council shall have powers to regulate its proceedings.
(5)(1) The National Council which shall be the highest policy making body in Nigeria on matters relating to health, shall-

(c) ensure the delivery of basic health services to the people of Nigeria and prioritize other health services that may be provided within available resources;

[ National Health Bill 2014]

Basic health is defined as

 "basic minimum package" which means the set of health services as may be prescribed from time to time by the Minister after consultation with the National Council on Health; [Section 64]

The National Health Insurance Scheme is funded under the National Health Bill 2014 for:

"provision of basic minimum package of health services to citizens, in eligible primary/or secondary health care facilities" [Section 11(3)(a)]

And,

(5)(3) The National Council shall be advised by the Technical Committee established in terms of this Bill.

The " Technical Committee" means the committee formed by section 6;[Section 64]


The Technical Committee shall comprise - (Amongst others)

one representative each of all statutory health regulatory agencies or councils; 

[Section 6(2)(h)]

ODORBN is the statutory health regulatory body of the Nigerian Optometrists by law and is automatically a member of the Technical Committee based on the provision of Section 6(2)(h). It therefore behoves of us to consolidate our view points and stress our agendas using this channel.
ODORBN, with the blessing of the NOA, is expected and literally compelled to assume the responsibility of proper representation of the profession in relevant health issues like the NHIS, national health policy etc.

 It is a good head-start by Dr Damien Echendu's NOA (Nigerian Optometric Association) presidency to have inaugurated the Political Action Committee (PAC) with an instruction to explore NHIS and other relevant issues. I hope the recommendations they (PAC) came up with will be appropriately looked into with the view of forming opinions to be discussed at the Technical Committee meetings. Another laudable and bold step is the town-hall meeting that was organized recently in Owerri, first of its kind since 1968! This type of town-hall meeting should be held in all 36 states of the country and in Abuja periodically to hear our version of the Optometry story and act as a melting pot in our quest for growth and development!

 Finally, on the 24th of December, Dr.Anene Chukwuemeka, the secretary of the PAC, released some recommendations by the committee. I will only highlight one of those recommendations, to wit,

"We also recommend that a letter be written to all relevant parastatals and agencies associated with health and more especially ocular health such as National health insurance scheme, National primary health care development agency etc. This is necessary and will open up channels of communication between the association and these agencies which will be utilized when the need arises."

I will add that we should seek legislative interpretations of the relevant laws guiding the operation of NHIS in Nigeria with a view to appreciating the role of the Nigerian Optometrist as an Eye care service provider, nay, as an independent primary eyecare provider.

It will be laudable and appreciated if the newly appointed ODORBN registrar, Prof. Mrs Uzodike, and The NOA President, Dr Damien Echendu, will become allies for the common good of the profession especially as it pertains to National Health Insurance Scheme in Nigeria. For  starters, we need to have eye clinics that meet the minimum requirements on the NHIS operational guidelines for Optometry (See Section 2.7.9. of the 2012 NHIS Operational Guidelines) and become registered as a Primary care Provider under the NHIS.

This is the first line to "... open up channels of communication..." between the Optometrists, the Health Maintenance Organizations (HMO) and the citizenry.
The ODORBN should be responsible for "advising" The National Council of Health in Nigeria. They should play that role, as well as their traditional "dues" collecting role and other responsibilities as contained in the Act of Law that brought it to existence. On the other hand, the NOA should play the advocacy role, it should even lobby to ensure that ODORBN is heard at the technical committee meetings! NOA should seek the invocation of existing legislative premises that support our collective aspirations and even encourage review of our existing "scope" of participation in health care practice in Nigeria in a bid to align with the goals of the NHIS.
With the burden of blindness and visual handicap astronomical among the poor, the NHIS will surely ameliorate the sufferings of the masses and help in facilitating the objectives of vision 2020.

Long Live Optometry in Nigeria.
Long Live the Federal Republic of Nigeria.

National Health Insurance Scheme (NHIS), Universal health coverage and the Nigerian Optometrist Part 3.

To achieve the goals of Universal Health Coverage, WHO posited the following as prerequisite requirements. I will discuss them in the light of existing legislation and our contemporary premise in health care service delivery in Nigeria.

1) A strong, efficient, well-run health system.

Roemer (1991) defined a health system as“the combination of resources, organization,financing and management that culminate in the delivery of health services to the population.”{1}


An efficient health system should be able to provide comprehensive health services to its recipients including primary health care services on a properly "balanced":

a) Resources: These include hospital equipments, consumables, personnel, hospital buildings, and other hardware used in the hospitals etc.
b) Financing: The cost of hospital resources, cost of health care providers, cost of training health personnel, salaries, allowances, cost of oversight, and other financial transactions in the organization and management of the health system etc.
c) Organization: Policy making, regulations, gate-keeping healthcare finance, distribution and maintenance of hospital resources, Health care providers, Health management Organizations, Ministry of health etc
d) Management: Managing hospital resources, managing information, managing organization etc

2) A system for financing health services: Financing of health care services is known to influence efficiency in health service provision. Health services are financed either through government budgetary allocations, through taxation, through payroll contributions, through voluntary contributions to have a pool of health fund. Health services can be financed by "fee-for-service" (or out-of-pocket) method.
The goal of universal health coverage is to remove "out-of-pocket" method as a form of financing health services.

Health care funding systems have various effects on cost of running health care services, equity and access to health care services and patient’s choice and power. World Health Organization (WHO) 2000 report on ranking of national health system performance done in 1997 put Nigeria in 187th position out of 191 member countries. Nigeria needs a health care funding system that can sustain and improve health care service delivery to the whole population irrespective of patients’ financial status. {2}


The 2014 National Health Bill captures the Nigerian method of financing health service thus:

 [Section 11. Establishment of Basic Health Care Provision Fund.].

(1) There is hereby created a Fund to be known as Basic Health Care Provision Fund.
 
(2) The Basic Health Care Provision Fund shall be financed from-
(a) Federal Government Annual Grant of not less than one per cent of its Consolidated Revenue Fund.
(b) grants by international donor partners; and
(c) funds from any other source.

The Nigerian health care funding system is still evolving despite the numerous challenges facing the system. Amongst the challenges are shortage of manpower, poor implementation of good programs, poor funding and lack of political will on the part of government (Kumar, 2007).

3) Access to essential medicines and technologies: Access to essential medications involves the production, distribution and consumption of "medicines" prescribed by a healthcare expert for either curative and/or diagnostic purposes without hitches. The success of  universal health coverage is predicated on how easy prescribed "medicines" can reach an ill individual for consumption. NHB (National Health Bill 2014) captures the importance of access to essential "medicine" thus:

[Section 11. (3)]
 (b) 20 percent of the fund shall be used to provide essential drugs, vaccines and consumables for eligible primary health care facilities.

Section 39. Part IV [National Drugs Formulary and Essential Drugs List and Safety of Drugs and Food Supply].

 (1) There shall be a compendium of drugs approved for use in health facilities throughout the Federation- (in this Bill referred to as the "Essential Drugs List") which shall be under the periodic review of the National Drugs Formulary, and Essential Drugs List Review Committee.
(2) Indigenous and local manufacture and production of as many items in the formulary as practicable shall be encouraged.

Section 2.[Functions of the Federal Ministry of Health]
 (1)The Federal Ministry of Health shall-

 (I) promote availability of good quality, safe and affordable essential drugs, medical commodities, hygienic food and water; and
(m) issue guidelines and ensure the continuous monitoring, analysis and good use of drugs and poisons including medicines and medical devices.

  
Technological advancement has helped in improving diagnosis and saving lives in the health care system. For an efficient health coverage, access to new live-saving technologies should be a norm. Health technology is defined as the application of organized knowledge and skills in the form of devices, medicines, vaccines, procedures and systems developed to solve a health problem and improve quality of life (WHO).


4)  A sufficient capacity of well-trained, motivated health workers:
As diseases keep evolving, new ways to tackle them are accessed by training of health personnel periodically. Well trained health care capacity improves medical science and health care delivery. Motivation in the area of their remunerations, allowances and promotion as at when due will not only foster diligence in service deliver by health care personnel, it improves productivity and efficiency.

The National Health Bill 2014 provides for "Human Resources" development in Section 3 (d) :

 10 per cent of the fund shall be used for the development of Human Resources for Primary Health Care;

The National Council is obligated to:

 the provision of appropriately trained staff at all levels of the national health system to meet the population's health care needs; {3}

Section 43 (a-h) of the National Health Bill 2014 further throws more light on the need to have a well trained staff and on motivation of health workers in Nigeria.

Section 2. (1) The Federal Ministry of Health shall-

 (d) promote adherence to norms and standards for the training of human resources for health;

What is the way forward then? How would we remain relevant in realization of our objectives in providing comprehensive eye care examination, provision of necessary medications, glasses, treatments and surgery, necessary ocular rehabilitation for those with severe visual handicap through the National Health Insurance Scheme?
It is my opinion that Optometry in Nigeria should evolve away from the shadow of mediocrity in the Nigerian Health care sector and grow some teeth by pursuing autonomy of our profession.
By the way, Nigerian Optometric Association (NOA) defined the Nigerian Optometrist thus:

Optometrists are independent primary eye care providers who examine, diagnose, treat and manage diseases and disorders of the visual system, the eye and associated structures; as well as diagnose related systemic conditions.

 The emphasis here is on "independence". I have the hunch that the future of our dear profession lies in our independence and our ability to curve out for ourselves a niche and truly bring eye care to the people that really need it.
The last part of this elaborate discussion will be deliberated on subsequently...
To be continued!

National Health Insurance Scheme (NHIS), Universal health coverage and the Nigerian Optometrist Part 2.

On the 31st of August 2014, a Political Action Committee (PAC) was inaugurated by the NOA President Dr Damien Echendu. The chairman of the committee, Dr. Joe Owie, was to perform the following functions, among other things:

Ensure that optometrists are included in National health insurance scheme (NHIS) 
Ensure that National Health Insurance Scheme (NHIS) Act is amended to include optometry as Primary Care Provider (PCP).

 COST in health care- eye care inclusive- is the much needed impetus driving Optometry to explore the National Health Insurance Scheme (NHIS) option. In a sequel blog, I rhetorically raised the following questions:

1) How does eye health care service benefit from NHIS scheme in Nigeria?

The Nigerian NHIS established in 1999 by act 35 of the Federal Government of Nigeria has the overall goal of enhancing access to quality and affordable health care to all Nigerian citizens. The eye care system, a microcosm of health care service, would actualize the goal of quality  and affordability service in it's practice by keying into the NHIS till.

2) Of what effect is the National Health Bill of 2014 to the rising cost of eye care services in Nigeria today? How will NHIS affect the direct and indirect cost of visual impairment and  blindness in the country?

To ameliorate the sufferings of the average Nigerian citizen on the burden of astronomical rise in cost of health care services, the Basic Health Care Provision Fund was introduced into the Nigerian Health care system. (National Health Bill[ Section 11 (1). 2014]).

 The purpose of this fund is elaborated in subsection (3) and summarized such:

(a) 50% of the fund will be used to provide basic minimum package of health services to eligible citizens.
(b) 20% of the fund will be used to provide essential drugs, vaccines and consumables for eligible primary health care facilities.
(c) 15% of the fund goes for maintenance of facilities, equipments and transportation for primary health care facilities.
(d) 10% of the fund goes for Human Resources development.
(e) 5% of the fund will go to Emergency Medical Treatment.

3) Legislatively, can the eye care business be said to have a good representation in the National Health Insurance Scheme?

The National Health Insurance Scheme Operational Guidelines (2012) identifies the Optometrist thus:

2.2.13.1 Possession of Doctor of Optometry degree, or equivalent qualification recognized by optometrist and dispensing optician registration board of Nigeria (ODORBN)
2.2.13.2 Registration with ODORBN
2.2.13.3 Possession of current license to practice issued by ODORBN.

Remember this? [laws of the Federation (1989) Chap. 09, No. 34. Part VI. {29}]

 “Optometry” means a health-care profession specializing in the art and science of
vision care and whose scope of practice includes—

(a) eye examinations to determine refractive errors and other departures
from the optimally healthy and visually efficient eye;
(b) correction of refractive errors using spectacles, contact lenses, low
vision aids and other devices;
(c) correction of errors of binocularity by means of vision training
(orthoptics);
(d) diagnosis and management of minor ocular infections which do not
pose a threat to the integrity of the ocular or visual system; and
(e) ocular first aid;

 NHIS Operational Guidelines (2012) [Section  1.1.3.1.x] highlights our Primary health Care functions thus:

 Treatment of minor eye ailments including:

* Conjunctivitis.

* Simple contusion, abrasions, foreign bodies etc.

* Other illnesses as may be listed from time to time by the NHIS.

 NHIS Operational Guidelines (2012) [Section 1.1.3.2.xvi.]  highlights our Secondary Health Care functions thus:

* Refraction, including provision of low priced spectacles and excluding contact lenses,

*All Ophthalmological cases that cannot be handled at the primary level except those requiring tertiary care or on the exclusion list.

NHIS Operational Guidelines (2012) [Section 1.1.3.3.vi.] highlights our Tertiary Health Care functions thus:

*All Ophthalmological cases that cannot be handled at the primary and secondary levels of care except those on the exclusion list.

It is obvious that Optometry is not only represented in the operational guidelines of the National Health Insurance Scheme (NHIS), clauses in the guidelines predicate the legislative nuances that we (Nigerian Optometrists) fail to explore. I always remain of the opinion that we should focus on the real substance than to shadowbox mirages or ask irrelevant questions.

 For instance, is it more important to request that frames are put on the exclusion list of NHIS than to explore areas our profession appropriately fits into the Nigerian version of universal health coverage?

To be continued...

National Health Insurance Scheme (NHIS), Universal health coverage and the Nigerian Optometrist Part 1.

The world health organization (WHO) define Health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Health care is known as one of man's fundamental needs. The cost of health care has been on the rise for decades now owing to increasing population, increased life expectancy, rise in cost of hospital equipments amongst other things. Skyrocketing cost of healthcare, the effect it has on families and communities brought about the concept of universal health care.

Eye care, a microcosm of the health care concept, comprises the primary eye care, the secondary eye care and tertiary eye care systems. The eye health care concept is fundamental to a healthy eye and by extension to a healthy body.

 WHO (2012) estimates there are approximately 314 million people around the world whose vision is impaired, due either to eye diseases or uncorrected refractive errors. Of this number, 45 million people are blind and over 110 million in need of low vision aid.

The direct and indirect cost of visual impairments and blindness to the society and especially to the individual runs into hundreds of million dollars. The direct cost is measurable via cost of performing eye surgery, cost of having a comprehensive eye examination, the dearth of eye care professionals and eye care structures etc. Indirect cost is measurable by measuring the activity of daily living quotient. 

Universal health care, sometimes referred to as universal health coverage, universal coverage, or universal care, is a health care system which provides health care and financial protection to all its citizens. universal health care system incorporates the primary health care system that focuses mainly on prevention, early detection and planned management of diseases or illnesses.
The concept of secondary health care, which includes active use of medication to manage diseases, illness and or injuries, the use of surgery to remove, replace or amend tissues or organs. And tertiary health care system, this health care system is focused on rehabilitative care e.g. low vision care etc.

Historically, Germany is credited as the first country to start up a universal health coverage for its citizens as early as 1883! As at 2009, we had about 58 countries with one form of Universal health care or another. {1}
 Nigeria is eager to achieve Universal Healthcare Care. Since its launch in 1999, the National Health Insurance Scheme (NHIS) has been the major initiative to expand health insurance in Nigeria. However, as of mid-2012, NHIS still covered only about 3 percent of the population (5 million individuals). {2}

There are four models of health care systems as put forward by Physicians for a National Health Program (PNHP), Chicago (2010). {3}

 I will discuss them briefly:

a) The Beveridge Model: In this system, health care is provided and financed by the government through tax revenues of the government. This is known as the single payer model of health care system. This means that the government determines what type of health care services is been provided for the individual, what the doctors will charge and the individual is not expected to pay for his health care services! The government acts as both the regulator of funds and regulator of health services provided. This model is named after the author, William Beveridge.
Countries practicing such model include Britain, Cuba, Spain, most of Scandinavia, New Zealand and Hong-Kong.

b) The Bismarck Model: This model of health care system is regulated by government, financed through payroll deductions from employees and employers of labour known as health insurance fund. It is often a no-profit insurance scheme and it is aimed at providing health care coverage for everyone. This is a multi-payer system of health system and named after the Prussian Chancellor Otto Von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. Countries that practice this model include Germany, France, Belgium, Japan, Netherlands, the USA( though it practices a variant kind!) and to an extent Latin America.

c) National Health Insurance (NHI) Model: This model adopts the Beveridge and Bismarck systems of health care provision. Government-run insurance scheme are paid into by the citizens and the government on its own provides fund via taxation  to fund the NHI model. Government regulations control how the health fund is used both in private and public health care facilities. Countries that practice this system include Taiwan, Canada and Nigeria.

d) Out-of-Pocket Model: This model requires payment from the pocket when the patient goes to see a doctor. This is common in many rural areas in Africa, Asia etc were health care facilities are either moribund or health care facilities  are not readily in place.

Majority of Nigerians and Africans practices the out-of-pocket model till date, the remaining minority especially those working in state, federal civil services and those working in banks, multinational companies etc are covered under the NHI Model and/or the Bismarck Model of health care!

No doubt that health insurance scheme is cost effective, but enormous challenges abound as to the effective implementation of this scheme in the country partly as a result of inadequate legislation, corruption and outright distrust of the portfolio handlers, the government. These are some hitches that frustrate the effective take-off of the scheme in Nigeria since it was made law in 1990 . The 2014 National Health Bill passed by President Goodluck Jonathan last year can be said to have put to rest a lot of the challenges raised above. We are looking forward to a more participatory health insurance scheme in the country when the policies in the bill are implemented from the second quarter of 2015.

How does eye health care service benefit from NHIS scheme in Nigeria? Of what effect is the National Health Bill of 2014 to the rising cost of eye care services in Nigeria today? How will NHIS bill affect the direct and indirect cost of visual impairment and to blindness in the country? How do the eye care professionals key into National health insurance scheme? Legislatively, can the eye care business be said to have a better representation in the 2014 National Health Bill 2014? I will discuss the questions raised above above in a subsequent blog while analyzing them in the light of WHO's requirements for achieving Universal health care goals, they include:

1) A strong, efficient, well-run health system.
2)  A system for financing health services.
3)  Access to essential medicines and technologies.
4)  A sufficient capacity of well-trained, motivated health workers.

To be continued...

Ebola Virus Disease (EVD) and what Nigerian Optometrist should know...

In that moment you thought that Human Immunodeficiency Virus (HIV) is ravaging  people all over the world in an pandemic scale, Ebola Virus Disease (EVD) suddenly props up dealing mortal blows at its victims, creating an epidemic!

What is EVD?

EVD, formerly called Ebola hemorrhagic fever,  is a severe and often fatal virus infection in humans and primates. It is a form of hemorrhagic fever caused by genus Ebolavirus, a member of  Filoviridae family according to a WHO publication.

Filoviridae is a family of single-stranded RNA viruses that infect vertebrates, that have a pleomorphic usually bacilliform or filamentous shape with a helical nucleocapsid and a lipoprotein envelope with glycoprotein projections, and that include the Ebola viruses and the Margburg virus.{1}

Viral hemorrhagic fever (VHF) is an acute febrile syndrome characterized by systemic involvement, which includes generalized bleeding and severe infections.{2}

 According to a world health organization (WHO) publication, the genus Ebolavirus comprises 5 distinct species:

• Bundibugyo ebolavirus (BDBV)
• Zaire ebolavirus (EBOV)
• Reston ebolavirus (RESTV)
• Sudan ebolavirus (SUDV)
• Taï Forest ebolavirus (TAFV).

 BDBV, EBOV, and SUDV have been associated with large EVD outbreaks in Africa, whereas RESTV and TAFV have not. The RESTV species, found in Philippines and the People’s Republic of China, can infect humans, but no illness or death in humans from this species has been reported to date. {3}

 EBOV has a mortality rate of between (77-100)%;  SUDV has a mortality rate of between (53-65)%; and the Margburg virus has a mortality rate of between (20-50)% .{4}

BDBV has a mortality rate of between (34-47)%. {5}

What we need to know:

Biomedical science first encountered the virus family Filoviridae when Margburg virus appeared in 1967 in Margburg, Germany. {6}
According to a world health organization publication, Ebola first appeared in 1976 in 2 simultaneous outbreaks, in Nzara, Sudan, and in Yambuku, Democratic Republic of Congo. The latter was in a village situated near the Ebola River, from which the disease takes its name.
between 1976, when it was first seen in Africa, till date EVD had affected people within some African regions:{4}
In 1976, Sudan had 285 reported cases with 53% mortality rate.

In 1976, Congo Democratic Republic (formerly Zaire) reported 318 cases with 88% mortality rate.

1977, CDR, reported one case with 100% mortality rate.

In 1979, Sudan had 34 cases with 65% mortality rate.

1994, Gabon recorded 44 cases with 64% mortality rate.
Same year, Ivory Coast had one reported case with 0% mortality rate.

CDR had another major outbreak with a reported case of 315 and 77% mortality rate in 1995!

In 1996, 37 cases were reported in Gabon with 57% mortality rate.

In 1997, 60 cases were reported in Gabon with 75% mortality rate.

In 2000, Uganda had a reported case of 425 with 53% mortality rate!

In 2001, it was Gabon again with 65 cases and 82% mortality rate reported. 

2002, CDR, cases reported were 8 with 83% mortality rate. 2003, CDR, cases reported was 143 with 90% mortality rate. Same year, CDR reported another 42 cases with 69% mortality rate.

EVD is not a death sentence, but a highly contagious disease due to the virulent nature of the causative agent.

Re-emergence
The re-emergence of the Ebola outbreak started in a village in Guinea with a total number of 543 suspects and confirmed cases of EVD, including 396 laboratory confirmed and 394 deaths since it re-emerged this year it then spread to Liberia (834 suspects and confirmed EVD cases, including 200 laboratory confirmations and 466 deaths) and Sierra Leone (WHO reported a cumulative total of 848 suspects and confirmed cases, including 775 laboratory confirmed cases and 365 deaths) according to a Centre for Disease control and prevention (CDC), 2014 Ebola outbreak in West Africa: Ebola Hemorrhagic fever, highlight.

Patrick Sawyer, a U.S citizen,  became the first known victim of Ebola to die in Nigeria. As at the last count, the country has recorded 4 deaths including that of Patrick Sawyer. A Doctor, who attended to late Patrick Sawyer, was released from a quarantine of 10 persons after she  spontaneously recovered. There are 177 direct and indirect contacts to late Mr Sawyer being observated in Lagos and 21 in Enugu state.

Transmission
Ebola is extremely contagious, it transmitted by contact with blood, feces or body fluids from an infected person or by direct contact with the virus, as in a laboratory. People can be exposed to Ebola virus from direct contact with the blood or secretions of an infected person.

This is why the virus has often been spread through the families and friends of infected persons: in the course of feeding, holding, or otherwise caring for them, family members, health workers who "treat" the victims and friends would come into close contact with such secretions. People can also be exposed to Ebola virus through contact with objects, such as needles, that have been contaminated with infected secretions.

The fruit bats of the Pteropodidae family particularly species of the genera Hypsignathus monstrosus, Epomops franqueti and Myonycteris torquata, are considered possible natural hosts for EVD.
Other carriers of this virus are the green monkeys, great Apes, gorillas and even dead or wounded animals. Any contact with those affected animals likely leads to transmission to a human host!

This virus has been isolated from dead bodies, hence people are advised to handle dead bodies suspected to be victims of EVD with care.

Treatment
Currently, there is no proven cure for Ebola.Victims are treated with supportive therapy with the hope that they will recover, though Zmapp and the controversial Nano Silver has been trending recently. Zmapp was administered to two American "Doctors" infected with EVD and another Spanish priest. The later did not survive though.

Nano Silver is promoted by Dr Rimi for its "strong" anti-pathogenic effect at the cellular level but in some quarters, this cocktail's efficacy has been questioned.{7}

Meanwhile, the best way not to be infected with EVD is not contacting it. The research continues though.


Symptoms
The early symptoms of the virus are said to mimic the symptoms of malaria or flu at first. They include high fever, headache, muscle aches, stomach pain, and diarrhea. 

There may also be sore throat, hiccups, and red and itchy eyes ( allergic conjunctivitis, tangelesias, sub-conjunctival hemorrhage, conjunctival hyperemia). A study in Kikwit, CDR, after a 1995 major outbreak infecting 103 people with 84 deaths and only 19 survivors, conjunctivitis was reported in 42% of those that died and 47% of those that survived. Further more, it was noted that 3 of the early onset manifestation that appears to be more suggestive EVD include: bilateral conjunctival injection, maculopapular rash and sore throat with odynophagia (pains on trying to swallow), and always associated with fever [temp: >37.5*C] as the most common symptoms (93% of the time there is fever!).

"Am therefore of the opinion to handle patients with acute red eyes and presented with sudden onset of fever with utmost care! I advice we refer such to a general practitioner to rule out EVD."

The symptoms that tend to follow include vomiting and rash and bleeding problems with bloody nose (epistaxis), spitting up blood from the lungs (hemoptysis) and vomiting it up from the stomach (hematemesis), chest pains and bloody eyes (conjunctival hemorrhages). 

“Hemorrhaging symptoms" begin 4 – 5 days after onset, which includes hemorrhagic conjunctivitis, pharyngitis, bleeding gums, oral/lip ulceration, hematemesis, melena, hematuria, epistaxis, and vaginal bleeding,” reports the Pathogen Safety Data Sheet from the Public Health Agency of Canada. {8}

In its late stages, Your bloodstream starts to fill with small blood clots, which slows the blood. Some of these clots stick to blood vessels' sides. (This is called pavementing, because the clots resemble a mosaic).
These clots are very dangerous; they clog up capillaries, which shuts off blood supply various parts of the body, such as the kidneys, lungs, intestines, liver, brain, and throughout the skin. Your skin starts to get these little red dots all over it, which are hemorrhages under the skin (petechiae). It attacks connective tissues that hold your organs together, destroys collagen, and liquefies the under layers of the skin. White blisters appear alongside the red dots (called a maculopapular rash, and looks like tapioca pudding). Rips easily occur in the skin, and hemorrhagic blood spills out. The rash develops into bruises, and the skin becomes pulpy and soft. Your connective face tissues are destroyed, and your face takes on hollow, mask-like look. 

Your eyes also turn bright red, and may be fixed in one position (optometrists take note). Your gums, mouth linings, and salivary glands start hemorrhaging. The surface of the tongue turns bright red, and dissolves. The lining of your throat also dissolves. Then the black vomit starts... Your heart starts bleeding in itself, and blood starts to fill the chest cavity. Blood clots in the brain kill brain cells, which is known as sludging of the brain. The linings of the eyeballs may fill with blood, and you could go blind. You may even weep blood. 

You could possibly have a hemispherical stroke, in which parts of your body may become paralyzed, or could be fatal.

Since your organs are clogged with coagulated blood, the blood that you bleed does not clog, the red blood cells having been destroyed, those organs/tissues die while you are still alive... The liver turns yellow, bulges, and may start to dissolve. The kidneys may fail, the spleen hardens, and the intestines fill with blood. If the victim is pregnant, she will abort her baby, which is filled with Ebola virus particles and has red eyes.

EVD destroys the brain thoroughly, and you would probably have epileptic convulsions, or grand Mal-seizures. The entire body violently shakes. If you don't die from a stroke or organ failure, then you will have to suffer from "crash and bleed".... like you might see depicted in some horror zombie flick! You hemorrhage through almost every opening of your body. Your body, already damaged from shock, heated by fever, and slowly being destroyed tissue by tissue, quickly "crashes" from blood loss.  After the body is clinically dead, body tissues (skin, organs, etc.) liquefy, and the fluids are filled with Ebola virus particles.{4}

In general, it takes about 2-21 days (average incubation period) for symptoms to become visible.

According to reports, people who have the virus aren’t contagious until symptoms become visible.

What do we need to do?

Every patient that reports for eye check should be requested to have his or her body temperature checked among other parameters like the blood pressure, weight, pulse etc. Anyone with fever and sudden conjunctival hyperemia should be watched and preferably accessed by a general practitioner.

In absence of a general practitioner, the person's full blood count (FBC) is requested cos it often gives clue to EVD. The first line of defense in our body, the macrophages, neutrophils, monocytes etc are highly suppressed in hemorrhagic fever.

EVD is not airborne, though it has been isolated borne on aerosol suspended in the air!{9} . 

It is highly advised that we should wear a nose/mouth mask while performing direct ophthalmoscopic examination, hand-held Goldman applanation tonometry or even Schiotz type of tonometer! The air puff tonometry should be the more appropriate in this type of scenario.

EVD is a contact disease. The virus can be transmitted when it comes in direct or indirect contact with a new host. It is therefore advised to ensure we wear re-useable gloves that can be disinfected immediately after attending to a patient. Always wash your hands with disinfectant soap after attending to a patient. Our trial lens frame or the phoropter head should be disinfected with methylated spirit after seeing every patient. When contact equipments are used in the clinic, the least you can do is to disinfect it with methylated spirit.

Do not send home someone you suspect of any of the above symptoms. Let the fever component be of particular interest, others like conjunctivitis and the acute onset of this fever be very suggestive for further action.

The Public Health Agency of Canada explains that virus can survive in liquid or dried material for a number of days. Infectivity is found to be stable at room temperature or at 4 C for several days, and indefinitely stable at -70 C. There is need therefore to disinfect our door knobs, in the clinic and at home. 

A message to Optometrists:
What could be faulted as the pathophysiology of conjunctival hyperemia often associated with proven cases of  EVD? Does conjunctival involvement predict survival or death in those with EVD? Can ocular involvement and fever be consistent enough for EVD diagnosis? 

There is certainly much work to be done, researches to be carried out, bearing in mind that most survivors of EVD end up with chronic ocular complication. As the window of the body to the world, can't some unknown be revealed of this deadly virus since our country is not fully equipped to identify this deadly virus.

It is important as primary eye care professional to develop visual"clues" that may be very helpful... This writeup is retrospective because there has not been any active research work to this end. The onus of proof lies with us.
 

EVD is a national emergency situation, we should stay prepared and be ready to help in containing this virus and learning more about it.

Ebola is real, a real manace to humanity. We should confront it with ferocity it deserves...

Dr Victor Ezebuiroh.


{1} (http://www.merriam-webster.com/medical/filoviridae)

{2} (Peter B. Jarhling, PhD*; Aileen M. Marty, MD†; and THOMAS W. Geisbert, PhD: Viral Hemorrhagic fevers. Medical aspects of biological warfare Chapter 13; p272)

{3} (http://www.who.int/mediacentre/factsheets/fs103/en/)

{4} http://www.tpida.org/files/Filoviridae.pdf)

{5} http://en.m.wikipedia.org/wiki/Bundibugyo_virus]. 

{6} Martin GA, Siegert R, eds. Marburg virus disease. Berlin: Springer Verlag, 1971.)

{7} http://drrimatruthreports.com/dtra-confirma-ebola-nano-study/)

{8} (http://www.phac-aspc.gc.ca/lab-bio/res/psds-)

{9} Peters and LeDuc. Ebola: The virus and the disease. The Journal of Infectious diseases 1999; 179(Suppl1): xi.]

A holistic metric based analysis of Optometric practice especially in private practice!

"Although optometrists are taught the quantitative science of optics and spend most of their workday taking measurements of visual acuity, most do not invest much time to measure the state of their business. More often they form intuitive impressions about business issues. Then they make decisions without a solid, metrics-based understanding of their actual situation and without any quantitative norms against which to compare their performance."
[Key Metrics: Assessing Optometric Practice performance, 2011 Edition (Introduction).]

The Management & Business Academy™ (MBA) is a metrics-based approach to optometric practice management. Since 2005, MBA has gathered comprehensive information on the characteristics and financial performance of over 1,800 private optometric practices in the U.S. There is this popular narrative, "Whatever you measure improves." This is the primary call to action that presupposes introduction of measurement in growing Optometric practice.
With the heavy reliance of eye care health sector on private practicing optometrist in Nigeria, I decided to point out those metrics with the intention of providing insights as to how to grow our practices, because it is said: "Where the money goes, so goes the authority."- and the power too!

Tagged Total Practice Productivity Metrics, it discusses the overall productivity of a practice and empirically analyze them:

1)Gross Revenue per Exam:  This is defined as the gross revenue per every comprehensive eye examination at any given time. This metric is singled out as, "...perhaps the single most useful measure of practice productivity..."
It is influenced by the internal processes of your practice and can be improved by the actions of the practitioner.
If H represents the gross revenue receipts in a given time frame, X(0,1,2,3,4...) representing comprehensive eye examinations carried out on a patient in the same given time frame... (0,1,2,3,4...) represents what constitutes a "comprehensive" eye examination and the internal processes of practice! The later identified in numerals has the tendency of influencing gross revenue earned and highlighted in note below

Hence, H/X (0,1,2,3,4...)................................................................. (i)
= Gross Revenue per Exam!

Note:
a) Number of eye tests carried out.
b) Types of high end user frames on display.
c) Products on display such a medications, contact lenses, surgical practices, low vision care etc
d) Turn-over of patients
e) New patient flow
f) Size of practice etc
Influences the "Gross Revenue per Exam" metric.


2) Exams per OD hour: This is defined as, "The number of complete eye exams performed during each hour an optometrist works." It is an empirical reproduction of revenue generated per OD hour. The key variables impacting this metric are size of the patient base, recall effectiveness, extent of delegation of testing tasks to staff, exam process efficiency and appointment scheduling efficiency.

If X(0,1,2,3,4,...) represents the comprehensive eye examination on an individual patient, Hx represents the optometrist's work rate in an hour, therefore,

Exams per OD Hour would be stated empirically thus:

X(0,1,2,3,4...)/Hx.................................................................... (ii)

Apart from adding a new OD, the main way solo OD practices can grow is to increase patient traffic per hour! The primary determinant of this metrics is efficiency of the OD in the clinic measured per hour!

3) Gross Revenue per Staff Hour (non-OD Staff): This metric is a ratio of the total revenue gained in a specific period of time divided by the total number of non-lab/non-OD staff hours worked during the same period.
This metric is a measure of how efficiently patients are managed administratively in a given OD clinic. It also determines how under-staffed an OD clinic is and triggers hiring of more non-OD staff or firing as the case maybe!

Lets take H as the gross revenue receipts in a given period of time.
Let Ns represent the non-lab/non-OD staff hours worked in a given period of time.

The Gross Revenue per Staff Hour can hence be mathematically represented thus:

H/Ns................................................................... (iii)

Note: Gross Revenue per Staff Hour is dependent on the following factors:
a) Number of staff members
b) Exams performed per hour
c) Gross revenue generated per exam
d) Patient traffic.

4) Gross Revenue per OD Hour: This is a ratio of the gross revenue in a given OD hour. It is a measure of how productive an OD uses his time in generating revenue in a given time measured per hour. It also correlates with the productivity of the staff members on how they efficiently attend to patients administratively! This metric correlates strongly with the clinical efficiency of the OD measured in hour! It is strongly suggestive of how successful the clinical practice is.
Other parameters that correlate with this metric include:

i) Revenue per OD hour
ii) Practice size
iii) Practice growth
iv) Improved OD time utilization.

If the Gross Revenue generated, often indicated by the gross revenue receipt generated in a given period of time, is H,

Let the OD hour be indicated by Ohr;

Therefore, Gross Revenue per OD hour can be mathematically represented thus:

H/Ohr...................................................................... (iv)

5) Complete Exams per 100 Active Patients: This is a metric that indicates the recall rate success of patients. A patient is said to be active if he had completed at least one circle of complete eye examination in a particular OD clinic within a given period. One circle of complete eye examination includes at least on recall examination. That being said, it should be noted that this metric is not dependent of the size of the clinic. The following factors can influence the recall rate, viz.
a) Recurrent ocular conditions like Vernal conjunctivitis especially in Children, Dry eye syndrome in adults etc
b) Chronic conditions like ocular manifestations of Diabetes, Hypertension etc...
c) Glass prescriptions for pediatric patients and for binocular anomalies etc.

It is noted that the average recall rate of active patients is about 28 months especially in OD clinics with more than 70% revenue generated from glasses especially for presbyopes! Hence, an OD clinic with 50 exams per 100 Active Patient is said to have an above average successful recall rate!

6) Annual Gross Revenue per Active Patient: This is the ratio of the Gross Revenue generated in an annum in relation to every active patient seen within the same period. It measures the recall rate and revenue per exam.

7) Gross Revenue per Square Foot of the Office Space: It represents how efficient clinic space is fully utilized and translated into revenue recouped either traffic of patients and multiple examinations carried out simultaneously in a clinic space to improve the OD hour, thereby increasing the gross revenue earning. It is weakly correlated to increase in practice size. It is a particular relevant consideration when ODs plan to expand their practice size... Like introducing Slit Lamp Bi-microscope, Automated central visual field analyzers, lens fitting lab etc. Again, when an OD clinic is moving to a new location, this metric helps in determining space size of new location.

The metrics described above have helped developed OD clinical practice in the USA especially for private practicing Optometrists. Subsequently, this blog will discuss each metric in details such that local contents will be developed. Because my primary interest is to synergize these growth concepts with what is obtainable in our country such that efficiency in practice could be achieved.

Finally, I want to say a big thank you to the developers of Management & Business Academy™ (MBA), Practice Advancement Associates (PAA), a unit of Jobson Medical information. To reach PAA, contact Al Greco at agreco@jobson.com.
Hope you enjoyed this piece.
Long Live Optometry in Nigeria!
Long Live Nigeria!
Dr Ezebuiroh Victor Okwudiri.
(This is strictly a free blog with no financial obligation anywhere!)