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HealthUpdate

So what is Chikungunya fever? Chikungunya fever is a viral disease transmitted to humans by the bite of infected mosquitoes. The Chikungunya virus was first isolated from a patient in Tanzania in 1953, and has since been identified repeatedly in Africa and many areas of Asia.

What type of illness does the Chikungunya virus cause? The illness is characterised by fever, headache, fatigue, nausea, vomiting, muscle pain, rash and joint pain. The term Chikungunya is Swahili for ‘that which bends up’.The incubation period (time from infection to illness) is usually 3 to 7 days. The illness typically lasts a few days to a couple of weeks. The symptoms are very similar to that of dengue fever; however some patients with Chikungunya fever experience fatigue and severe joint pains that last for several weeks. Fortunately unlike dengue, no cases of haemorrhagic (bleeding) shock syndrome have been reported in Chikungunya fever. There have also not been any reported deaths or long-term complications related to the illness. A person

who has previously been infected will be immune to the disease and not get re-infected in future.

How is Chikungunya fever treated? There is currently no medication to treat the condition, or vaccine to prevent it. However like many viral illnesses, Chikungunya fever is a self-limiting condition and treatment is directed at relieving symptoms. Rest, fluids, and medications like paracetamol (or acetaminophen) and ibuprofen will help relieve fever and aching. Infected persons should be protected from further mosquito exposure (stay indoors and under a mosquito net during the first few days of illness) so that they cannot contribute to the transmission cycle.

How can one prevent becoming infected with the Chikungunya virus? The best way to avoid Chikungunya infection is to prevent mosquito bites. Prevention tips include:• Getting rid of mosquito breeding sites by emptying standing water from flower pots or buckets. Change the water in pet dishes

regularly. Keep children’s wading pools empty and on their sides when not in use.• Using insect repellent containing DEET on exposed skin when outdoors, especially during the day. • Wearing long sleeves and pants, ideally having treated clothes with permethrin or another repellent. Half of the reported cases were imported, with infection having occurred outside of Singapore. There have been reports of outbreaks around the region such as India, Indonesia, and parts of Malaysia. Persons travelling overseas are advised to seek prompt medical treatment if they are unwell and have symptoms of Chikungunya fever.

Chikungunya, which is endemic in Africa and the Indian subcontinent, was unknown here until 2008, when Singapore had its first locally transmitted case. A major outbreak followed, with 690 people coming down with it that year and another 343 the following year. Last year (2013) witnessed an outbreak of about 900 cases and to date, 143 cases have been reported this year.

Chikungunya Fever

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Dr June Tan Sheren

MBBS (Singapore), M Med (Family Med)

(Singapore).A graduate of the National University of Singapore in 1997, Dr Tan is a Family Physician with special interests in chronic disease management, women’s health, paediatrics, and musculoskeletal conditions. She earned her Masters degree in Family Medicine in 2002, and has served as a senior family physician in a local primary care institution.

Dr June Tan Sheren Returns to CamdenCongratulations to Dr June Tan who gave birth to a gorgeous little girl named Jade Evelyn on May 23, 2013. Dr Tan is now back working part-time at our Camden clinic and looking forward to seeing her regular and new patients.

Caring For Cambodia Update

Zostavax is a vaccine used to prevent the occurrence of shingles.

Shingles is an infection of the nerve and area supplied by that nerve. It is caused by the herpes varicella-zoster virus, which also causes chicken pox. You will only get shingles if you have previously been infected with chicken pox.

The symptoms of shingles are skin rash, blisters and pain in the area of the skin that the nerve supplies. The pain may continue even after the skin blisters and rash have healed (post-herpetic neuralgia), sometime for months or even longer. Most people will feel unwell for several days before the rash appears.

Shingles can occur at any age, but it is more common in people over the age of 50. The symptoms also tend to be more severe with age. It is thought that stress and conditions that affect the immune system can activate the shingles infection.

Shingles can be passed on as chicken pox to infants and chicken pox might have significant clinical implications for pregnant women who have never had chicken pox.

Zostavaxcan also be used if you have had shingles before, as it can prevent future episodes. If you do develop shingles despite the vaccination, the condition may be milder and may last for a shorter time than usual. In clinical trials, Zostavax has been shown to reduce the risk of shingles by 51% and the risk of post-herpetic neuralgia by 67%. It is licensed for use in people over the age of 50 years.

The vaccine however, is not recommended for treatment of active shingles or post-herpetic neuralgia. It is also not used to prevent chicken pox infection as there is a separate vaccination (Varicella vaccination).

Zostavax is a vaccination we are able to provide at IMC but, this is a vaccination that will be ordered in only after it has been prescribed. It often will be available within a week.

Zostavax

Pneumococcus is a bacterium that can cause diseases such as pneumonia, meningitis and blood infections. You should consider having a pneumococcal vaccine if you are aged over 65 years or have certain diseases of the lung, heart, kidney, liver, and nervous system as you are at increased risk of developing a pneumococcal infection.Anyone can get pneumococcal disease, but people at higher risk include:• People 65 years and older• Very young children• People with certain health problems (e.g. diabetes, heart disease)• People with a weakened immune system (e.g. HIV, people with no spleen)• Smokers• Adults with asthmaThe vaccine does not contain live organisms and so cannot cause any of the diseases against which it protects. The vaccine stimulates your body to make antibodies to protect you from illness should you become infected. The vaccine protects against most types of pneumococcal bacteria and is normally given just once to provide lifelong protection.

Pneumococcal immunisation usually causes no side effects, although mild soreness and a lump at the injection site sometimes occur. A mild fever may develop for a day or so. These side-effects are usually minor and soon resolve. You should not receive the pneumococcal immunisation if you have had a severe reaction to a previous dose of pneumococcal vaccine.

A dose of vaccine may be delayed if you have a fever, although there is no reason to delay if you or your child has a minor infection, such as a cough, cold or sniffles.

The vaccine may be given to pregnant women when the need for protection is required without delay. It is safe to have if you are breast-feeding.

Pneumococcal Vaccination for Adults

Dr Foong Tsin UinMMBS (London)

MRCGP (UK) Dip PractDerm (Cardiff)

Dr. Foong graduated from Royal Free Hospital (UK 2000) and is a member of the Royal College of General Practitioners (UK 2005). Special interest in Dermatology. Dipl. in Practical Dermatology from Cardiff University in 2012 and in Women and Children’s medicine. She has worked in General Practice for over 10 years, was a Partner in a Family Practice in Swiss Cottage, London and spent a decade serving in an inner city Drug and Alcohol Rehabilitation Centre and considerable time training in Palliative Care.

Dr Michael Rodger

MBBS (Western Australia)

A graduate from the University of Liverpool (UK) in 2001, Dr Rodger completed a fellowship of the Royal College of General Practitioners (UK) in 2005. He has worked in General Practice in London and South East England in a variety of settings, including family practices and the coporate sector. His interests include family medicine, diabetes, travel medicine and minor surgical procedures.

Is your child’s body covered in red spots after a virus, or are blisters appearing? Rashes in toddlers can be pretty sudden and alarming. A rash is a reaction of the skin and can be caused by many things: an infection, an allergy, or the heat outside in the tropics. The good news is that most rashes are not dangerous and will fade in time on their own or with a little help from a doctor.To find out more about the rash you might be dealing with, check the list below.

Post ViralA red rash from head to toe after a fever or cold virus. The rash is harmless, causes no symptoms (at most a bit of itching), and is seen as your child is recovering from a virus. It usually starts on the head or chest and can spread in a day over the entire body. It usually goes away after 2-3 days and does not need treatment. Typically this type of rash disappears if you stretch the skin.

PetechiaeDark spots from head to toe after a fever or cold virus. This rash also usually has no symptoms and occurs after a common cold virus. It can rarely be dangerous, and if these spots appear (they are tiny bruises in the skin), you need to call your doctor, especially if any spots appear inside the mouth. The big difference between this rash and a post-viral rash is that the spots do not disappear if you stretch the skin.

Hand-foot-and-mouthRed spots or blisters on the hands, feet, and buttocks. It’s a very common virus in Singapore, usually starting with a mild fever. The next day the fever is gone and a red rash and possibly blisters appear on the hands, feet, and often the buttocks. The rash needs no treatment. The only worry is due to the sores in the mouth – if severe they

can be painful. The good news is most toddlers have a mild course and don’t have too much pain (little babies are more vulnerable). The only treatment is a pain medicine like a paracetamol or ibuprofen.

Heat RashSmall, clear or red bumps, often around the neck or where clothes are tight – likely to be heat rash as the warm tropical air can cause clogged skin pores. It rarely causes problems beyond a mild itching, and tends to come and go. Treatment is simple – wear loose-fitting clothing and the rash will clear up on its own within a few days. Drying powders can help, but creams and ointments may make the rash worse by clogging more pores.

Chicken PoxVery itchy blisters spreading rapidly a day after a fever. A virus causes it, and the spots can take as much as two weeks to heal. Some spots can permanently scar, especially if scratched. There are no effective medicines other than anti-itch lotions like Calamol. Though it usually causes no serious problems, it can be prevented or made very mild by the chicken pox vaccine.

ImpetigoRed, itchy patches of open skin, often draining a yellowish fluid. It’s a bacterial skin infection and can spread rapidly, usually after scratching an itchy sore. Early on, it can be treated with antibiotic ointment, but if it’s spreading it usually takes antibiotics by mouth.

EczemaRed, itchy, rough, usually in patches. In toddlers it usually has no obvious cause, but food allergies and viral infections can cause it to flare. Moisturizers can resolve mild eczema, but if it is more severe, see your doctor for a proper diagnosis and medication to ease the symptoms.

Water wartsSmall fleshy wart-like spots, often under the arms or on the chest, it is likely to be molluscumcontagiosum. Also called “water warts,” it’s caused by a harmless virus. It does not cause any problems if left alone, and it will go away without treatment (though it may take 6 or more months). It can be easily treated if it spreads, or if it gets irritated (usually if it’s scratched at).

Rashes in Toddlers

Dr Leo HamiltonMD (Alabama)

Board Cert (Paediatrics)A graduate of the University of Alabama School of Medicine in 2000, Dr Hamilton continued training in Paediatrics and became Board Certified in Paediatrics in 2003. Dr Hamilton continued his studies as a fellow in Paediatric Hematology/Oncology at St. Jude Children’s Hospital in Knoxville, Tennessee graduating in 2006. He has worked as Attending Physician in East Tennessee Children’s Hospital, a General Paediatrician at the University of Tennessee Medical Center and the primary caregiver of Paediatrics at a Paediatric Clinic in Oak Ridge. His interests include psychiatric and behavioral issues in children and adolescents.

Direct Billing UpdateOur cashless Direct Billing Department takes the hassle out of doing your own claims – we liaise directly with the Insurance companies, and try to settle all invoices as quickly as we can.

Our Insurance Direct Billing Department is always on the lookout for new companies to represent. Please let reception know if we do not have representation with your insurance company, and we can approach that company to see if they are interested in a Direct Billing agreement.

Urinary tract infections (UTIs) are common in childhood. It is estimated that up to 8% of girls and 1-2% of boys will have had at least one UTI by age 10 years and UTIs remain the most common cause of serious bacterial infection in the less than 3 month-old infants. Bacteria invading the tract causes a urinary tract infection. E.Coli is the most common bacteria to cause infection is E.Coli, accounting for approximately 80% of infections.

The urinary tract comprises the kidneys, the ureters (the tubes connecting the kidneys to the bladder), the bladder and the urethra. Symptoms vary dependent on where the infection is within the urinary tract and the age of the child. Infection of the upper urinary tract (kidneys and ureters) is known as pyelonephritis and usually presents with fever amongst other things, whereas infection of the lower urinary tract (cystitis) does not commonly present with fever.

It is often easiest to divide UTIs into age groups when discussing background, treatment and presenting symptoms. The first group is the under 2 year olds (non-toilet trained children) and the second is the toilet trained child above 2 years old.

Symptoms

CausesIn younger children and infants, a UTI may be related to an abnormality in the child’s urinary tract and therefore further investigations may be required. Your paediatrician or GP may suggest an ultrasound looking for this and then further testing depending on the results.

In older children that have never had UTIs before they were toilet trained, these abnormalities are less common. In this group, UTIs are more common in girls than boys and can be due to toilet hygiene practices, holding on and not urinating frequently or associated with constipation.

Collecting a specimenThe best way to collect a urine specimen is to collect midstream urine in a toilet trained child or a “clean catch” urine in a smaller child/infant. This can be very challenging, particularly in small girls. If this is not possible, your doctor may talk to you about collecting urine by placing a small plastic tube (catheter) into their bladder to collect a specimen. Collecting urine in a clean bag attached to your child’s skin is another way of collecting urine. This can be a good screening test but due to high contamination rates, it is not generally accepted as the most accurate way to collect urine.

TreatmentIn young infants and very unwell children with high fever, it may be necessary to treat a UTI in hospital with intravenous antibiotics initially until the infections is under control and the fever is settling. After this time, children can finish with oral antibiotics.

In older infants (more than 6 months) and children, successful treatment is often achieved using oral antibiotics for between 4 to 7 days depending on the severity of the child’s infection.

PreventionIn older children, looking at possible underlying contributing factors can help prevent recurrence• Wiping from front to back for girls is very important • Sitting on the toilet comfortably to allow full emptying of the bladder for girls• Good water intake throughout the day• Regular toileting and encouraging a child to not “hold on”• Reducing irritants such as bubble baths and sitting in wet swimmers• Treating any underlying constipation

In younger children, sometimes low dose regular antibiotics are used to prevent recurrent infection in those with underlying urinary tract abnormalities. Circumcision in boys has also been shown to decrease recurrence but these management decisions are always made on an individual basis and should be discussed with your child’s primary physician.

Urinary Tract Infections in Kids

Dr Samantha IzzardMBBS (Sydney) FRACP (Aust).

Dr Samantha Izzard is a Sydney University graduate (2000) and Fellow of the Royal Australasian College of Physicians (Paediatric & Child Health Division). She completed her first 2 years internship and residency at Royal Prince Alfred Hospital and Paediatric training at the Children’s Hospital at Westmead, Sydney. Since 2011 she has worked as a consultant Paediatrician at The Children’s Hospital in addition to running her own private practice. Interests include infant feeding and nutrition, breastfeeding, eating disorders and weight management.

Infants and younger children:Often non-specific•Fever•Irritability•Vomiting•Poor feeding•Occasionally offensive smelling urine

Older children (toilet trained):More likely to be more specific to the urinary tract•Offensive smelling urine•Burning and stinging when passing urine (dysuria)•Going to the toilet frequently•Feeling the sudden urge to urinate (urgency)•Wetting themselves or wetting the bed (if previously dry at night)•Fevers and loin pain if infection has spread to the kidneys

There are many different tactics for quitting smoking, but the one common ground is the desire and motivation to quit. Without this you will likely fail. To determine the best tactic for you, you need to be aware of your options for quitting and be prepared for the challenges of trying to quit. You will need to address the addiction, as well as the habits and routines that go with smoking. It is important to set a quit date and tell family and friends the date you plan to quit. The date should be within two to four weeks of making the decision. This allows time to prepare a plan but not so long that you lose motivation and change your mind.

For most people smoking is ingrained as a daily ritual. One of the best things you can do while preparing a plan, is to identify the things that make you want to smoke, such as specific situations, activities, feelings and people. Avoiding these triggers is not always possible, however you can prepare a plan to help you cope with cravings when faced with these triggers. The psychological cravings are often harder to deal with and last much longer then the physical cravings.

Once you stop smoking you will experience a number of withdrawal symptoms. These usually begin quickly and peak about 2 to 3 days later. They can last from a few days to several weeks and differ from person to person. As unpleasant as these withdrawal symptoms may be, it is important to remember they are only temporary. Nicotine replacement

therapy or non-nicotine medications can help you deal with these cravings. Talk to your doctor about these medications and whether they are right for you.

Remember most people try to quit smoking several times before they are successful, so don’t give up if it doesn’t work the first time. Learn from your failed attempts and where you slipped up, and factor this into the plan for the next attempt. It takes a strong commitment over a long time to be successful. You may wish there was a magic pill to make it easy and painless, but there is no such thing.

Quitting Smoking

Dr Hamilton is now available for evaluating and admitting children and adolescents at Thompson Medical Centre and the Parkway Hospitals (Mount Elizabeth, Gleneagles, Mt Elizabeth Novena, and Parkway East). This includes attending newborn deliveries and providing routine newborn care.

Both Dr Natalie Epton and Dr Hamilton will be sharing responsibility for emergency and inpatient care for their patients, with coverage alternating weekly. These services are also available for any patients who see Dr. Samantha Izzard and want an International Paediatric Clinic (IPC) physician involved in their care.

The individual paediatricians will still provide newborn deliveries and neonatal care upon request, and these are not routinely shared.

Please do not hesitate to call IPC or discuss this with your doctor if you have any questions.

Inpatient Care — Dr Leo Hamilton Southern Hemisphere Influenza Vaccine

The influenza vaccine will be available at the end of May. The strains contained in this vaccine are as follows:•A/California/7/2009(H1N1)•A/Victoria/361/2011(H3N2)•B/Massachusetts/02/2012Please be aware that the manufactures of the flu vaccine make limited quantities per season. Therefore as experienced last year, stocks can run out overnight depending on the status of influenza and media reports.Hence it would be wise to obtain the flu vaccine while stocks are available.

Dr Kaye McMullen

MBBS (Western Australia)

A graduate from The University of Western Australia in 2007, Dr McMullan spent her time in Western Australia in Tertiary Hospitals gaining a variety of experience, including Emergency Medicine, ICU, Respiratory Medicine, Palliative Care and Women’s Health. Prior to moving to Singapore she spent 2 years working in Paediatrics and attained a Diploma of Child Health at Princess Margaret Hospital for Children. She moved to Singapore in 2011 and has been working in general practice since. Her special interests include paediatrics, women’s health and respiratory medicine.

Why did you choose Family Medicine? Being able to help someone ‘from cradle to grave’ was appealing. There is always advice you can give to someone about something.

Also, it is one speciality that I know will allow me to manage a decent work/life balance.

What is the kindest thing a patient has ever said to you or done for you?Apart from the gifts of chocolate and wine we often get at Christmas (I also once got a hand-knitted scarf and an umbrella – it rains a lot in the UK!), the kindest thing I appreciate from patients is when they return over and over again because they trust and like you as a doctor.

What aspect of Family medicine interests you most?Getting to know a patient and their family. Over time, you get to know the person well and possibly members of their family. It is like putting a jigsaw together.Also I like the breadth of medicine in Family Medicine – ‘Jack of all trades’ is a term sometimes used.

What do you like to do when you are not working?I have 3 children – Fiona 7, Angus 5 and Marcus aged 10 months. They take up virtually ALL my time outside work.Otherwise I swim to relax and I’m always planning the next holiday!

What book are you currently reading? ‘Lean In’ by Sheryl Sandberg – COO of Facebook. It is a book encouraging women to put themselves forward at work and pursue their goals. I try to constantly remind myself, as it is very easy to lose sight of one’s own ambitions when managing the children.

Where did you spend your last vacation?We were in Fiji & Sydney over Christmas. My husband is based in Sydney for the year so we had some time in sun soaked Fiji and watched the iconic New Year’s fireworks over Sydney’s Harbour Bridge. We made the kids stay up as we didn’t know when we would next be back.

Snapshot of Our New IMC Family Physician: Dr Foong Tsin Uin

Camden Clinic | 1 Orchard Boulevard, Camden Medical Centre #14-06 | 6733 4440

Jelita Clinic | 293 Holland Road, Jelita Cold Storage #02-04 | 6465 4440

Paediatric Clinic | 1 Orchard Boulevard, Camden Medical Centre #11-06 | 6887 4440

www.imc-healthcare.com

IMC and CFC continue to build on their already strong relationship. IMC staff have assisted in a total of 3 First Aid training courses in CFC schools. These courses are run for high school students, teachers and school administrators and have been very successful.

Our staff continue to participate in regular health screening trips and in November 2013 we saw a further 489 children who were screened, bringing the total to 5354 children from CFC schools screened to date.

Part of our commitment to CFC is the ongoing support of professional staff development. In this regard, the CFC school nurse recently visited Singapore and IMC and was able to liaise with staff about current health issues and health policy development.

IMC staff continues to generously support CFC’s Calender for Caring and is currently collecting toiletries for CFC for the next delivery.

Caring For Cambodia Update

Sassy Mama is an online community for parents – www.sassymama.com.sg. It is the ultimate site for mothers in Singapore – covering fun things to do with kids as well as where to eat, shop, play in the Lion City and more.

On an annual basis they conduct a survey called the Sassy Mama Awards asking their 10,000 plus mama readers over the course of 2 weeks to nominate their favourite local businesses covering over 22 categories such as restaurants, spas, stylists, healthcare providers and more. With nearly 1000 votes, mamas were free to nominate whomever they wished and this year International Medical Clinic won the “Favourite Family Health Clinic” within the Health section. Thank you to all those readers who voted for us!

IMC Receives Award