Thursday August 6, 2009
by Dr David KL Quek
1) Can we distinguish between regular and H1N1 flu, without a lab test?
No, the flu is the flu, but there are variations in presentation. Some symptoms such as cough, runny nose, fever, body aches, fatigue, vomiting, diarrhoea occur more or less in every flu patient, but may present differently by different people. Some infected people have very mild symptoms, some in between, and a small minority, probably less than 10 per cent, have severe features including the dangerous pneumonia.
However, from sentinel testing and surveillance by the Ministry of Health the last few weeks have shown that almost 95 per cent of all flu-like illness are now caused by the H1N1 virus. Earlier some months ago, seasonal flu variants caused by the B and other A virus were the main causes, the bug causing most flu these few days is the A(H1N1). This appears to be the case also in neighbouring countries, meaning that the new virus is causing more havoc and symptomatic illness than previous types of flu (which are still in the community).
Because almost every flu-like illness (influenza-like illness or ILI) is due to H1N1, the MOH is now recommending that no testing to confirm this H1N1 will now be offered.
Treat as if this is H1N1 for ILI — symptom relief for mild symptoms (paracetamol, hydration, cough medicines, etc) and self-quarantine, social distancing, be alert for complications.
Most (70 per cent) do not need any anti-viral medications such as Tamiflu or Relenza. Only severe cases need to be referred to hospital for further treatment.
2) How should doctors decide if a person be given further specific treatment for H1N1?
If after 2-3 days, fever and cough symptoms do not improve, a recheck with the doctor is recommended, especially if there are features of difficulty breathing, severe weakness and giddiness, or, if the following risk factors are present:
1. obesity (fatter patients seem to have poorer outcome and more complications)
2. those with underlying diabetes, heart disease
3. those with asthma, or chronic lung disease
4. pregnant women
5. those with reduced immunity, cancer patients, etc
6. those with obvious pneumonia features
3) Many anxious people with flu-like symptoms want to be tested or treated for suspected H1N1, but are kept waiting or sent home, without being tested. Is this practice right?
There is no right or wrong practice as this outbreak is extensive and is stretching our resources to the limit. This is also the case not just here in Malaysia, but also elsewhere around the entire world!
The recommendation is now not to spend too much time and effort trying to get tested at designated hospitals or clinics — there is probably no need to do so. I have been informed that as many as 1,000 patients queue anxiously at Sungai Buloh Hospital for testing, due to fear of the H1N1 flu.
So the message must be made clear: Most flu illness do not require confirmatory testing, and are mild and self-limiting. More than 90 per cent will get better on their own, with symptomatic treatment — just watch out for possible complications, and risk factors as mentioned above.
Our resources are limited especially for testing. This is not just for Malaysia, but globally as well. The global demand for test kits and reagents for the H1N1 (PCR) is overextended and are rationed due to this extreme demand.
Some 200 million test kits have been deployed worldwide, but this supply is critically short because of excessive demand, so most countries have to ration testing to confirm only the worst cases, so as to monitor the pandemic better.
4) Are doctors confused as to what to do in this outbreak, especially when they do not have ready access to confirmatory lab tests?
Not really. Earlier on there was some confusion as to what to do next and who to test or who to refer for further testing and admission. Now the rules are clearer.
There is no need to do any testing to confirm the H1N1 virus for any ILI — just assume that this is the case in the majority of cases. Treat symptomatically when symptoms are mild, reassure the patients and ensure that these infected patients practice good personal hygiene, impose self-quarantine and social distancing, wear masks if their coughing or sneezing become troublesome, and keep a watchful eye on whether the infection is getting better or worse.
If there is difficulty breathing and gross weakness, then patients should quickly present themselves for admission. Understandably this phase of worsening is not always clear or easily understood by everyone... But there is not much more that we can do — otherwise we will be admitting too many patients and this will totally overwhelm our health services.
But prudent caution would help to determine which seriously ill patients need more attention and more intensive care. Unfortunately however, there will be that odd patient who will progress unusually quickly and collapse even before anything can be planned — hopefully these will be few and far between.
A more important note is that all doctors and nursing personnel should be very aware that they too have to take precautions, and employ barrier contact practices, if there are patients with cough and cold during this period of H1N1 outbreak, which is expected to last a year or two. Carelessness can result in the physician or nurse or nurse-aide becoming infected!
5) Are there sufficient guidelines from the Ministry of Health to address this situation?
I think there are sufficient guidelines from the MOH. Although some politicians have blamed the MOH and the minister for being inept at handling this pandemic — in truth this is not the case.
It is useful to remember that this is an entirely new or novel virus, which no one previously had encountered before — thus its infectivity and contagiousness is quite high and almost no one is immune to this virus.
Perhaps, there will come a time when all the resources from both public and private sectors can be put to more efficient use. Some logistic problems will invariably occur, because human beings differ in their capacity to understand or follow directives, whatever the source or authority.
Also patient demands have been extraordinarily high and at times very difficult to meet — every patient necessarily feels that his flu is potentially the worst possible type and therefore requires the most stringent measures and testing...
Doctors are also unsure as to the seriousness or severity of this new ailment — and we are only now beginning to understand this better — so our less than reassuring style when encountering this new H1N1 flu is sometimes detected by an equally anxious patient and/or their relatives.
But there is only so much that we can do under such a pressure cooker of an outbreak which is spreading like wildfire! But nevertheless we should not panic, and remember that most (more than 90 per cent) of infected people will recover with very little after-effects. Possibly only one in 10 patients develop more serious problems which necessitate hospitalisation.
6) Is limiting H1N1 testing only to those who have been admitted to hospital justifiable?
I have explained the worldwide shortage of such testing kits and reagents. Also it is near impossible to test everyone, the world over. Besides, knowing now that almost all the flu-like illness in the country is due to H1N1 makes it a moot point to want to test for this, especially when most are mild.
The rationale for testing only those who need hospitalisation is to ensure that we are dealing with the true virus, and also help to isolate possible changes or mutations to this viral strain. The MOH is also constantly doing sentinel surveillance (random spot-testing at various sites around the country to determine more accurately the various virus types and spread that are causing ILI).
7) Are we short of anti-virul drugs (Tamiflu, Relenza)? Should I take Tamiflu?
These antiviral drugs were available to most doctors during the earlier scare of the bird flu virus, but now are severely restricted, although some orders are still entertained from individual doctors, clinics or hospitals. Remember that these have been block-booked by more than 167 countries which have been shown to have been penetrated by the H1N1 flu bug.
Our MOH has actually stockpiled some two million doses of the Tamiflu or its generic form. In the last inter-ministerial pandemic influenza task force meeting, this stockpile will be bumped up to 5.5 million doses to cover some possible 20 per cent of the population.
Right now there is no shortage in the country. It is just that it is not readily available on demand for anyone just yet. The MOH is still of the opinion that this antiviral drug be used prudently and would like to register every patient given this drug.
The private sector on the other hand would like to have a looser control over the use of this drug — but we acknowledge that we should be meticulously prudent in its use. There is a genuine fear that resistant strains to this drug may develop with indiscriminate and unnecessary use — then we will all be in trouble with a drug-resistant H1N1 virus run amok!
Drug-resistant strains have been detected in Mexico, border-towns in the US, Vietnam, Britain, Australia even. So we have to be vigilant and closely monitor the situation. Right now, the very limited usage of Tamiflu gives us good reason to be optimistic.
However, because of some unusual patterns of seemingly well people dying or having very critical infections, some people and doctors are wondering if these new strains have already reached our shores... or have we been too late in instituting proper treatment...?
The rising number of deaths to 14 now is quite worrisome, but our health authorities are watching this development very closely and are also checking the virus strain to see if this has mutated. We can only hope that this is not the case, for now.
8) What are some of the problems faced by doctors in dealing with the H1N1 problem?
It would be good if every medical practitioner keeps a close tab on the H1N1 pandemic, and remain fully aware of the developments and changes, which are evolving daily. Every doctor has to be learning on the trot, so to speak, to keep up with the progress of this outbreak and its management, so that we can serve our patients better.
Logging in to the Internet regularly for more updated information will certainly help, instead of lamenting that not enough is being disseminated via the media thus far... Every doctor has to be more proactive and practice more responsible and cautious medicine during this trying period which is expected to run into at least one to two years. Importantly, look out for lung complications, and the above stated higher risk profiles, and refer these patients quickly for further care.
Easier access to antiviral drugs and their responsible use and monitoring would help allay public fears of delay in treatment, but this should be tempered with care and not over-exuberance to dish out to one and all, the precious antiviral drug, just for prevention — this may be a very bad move which can inadvertently create a worse outcome of drug-resistant bugs.
However, in the light of the very quick deterioration of some young patients who have died, it might be prudent to use antiviral treatment earlier and more aggressively.
We look forward to the specific H1N1 vaccine, when it does come our way, probably towards the end of the year. In the meantime, encouraging those in the front-line, heart or lung patients and frequent travellers to have the seasonal flu vaccination is a useful adjunct to help stem the usual problems from other flu types.
9) Are we doing everything that should or needs to be done?
Yes, if you check what other nations are doing, we are doing relatively well. We are not overstating the dangers and we have been quite transparent on the possibilities of this pandemic. Earlier, many agencies and even the public and doctors have accused us of exaggerating the pandemic, and our response was dismissed as being too much, even over the top! Unfortunately, it was only when some deaths occur that many are now decrying that we have done too little!
Also if you are quite honest about it, just compare with the countries globally, and you will notice that no one health or government authority has got this right, spot on.
We are all learning about this novel flu pandemic, and each country's response is coloured by its past experiences. In Hong Kong, China, Vietnam, Singapore and Malaysia we have had the SARS outbreak, so we are necessarily more paranoid! Also here the experience is that flu does not usually cause death in our community, unlike the west where seasonal flu kills some hundreds of thousands every year!
So the fear factor for this H1N1 flu is not nearly as great in the West, although it is slowly sinking in that its contagiousness and infectivity is far greater, and fears of its reassortment to a more virulent mutant form are growing, into the so-called second and/or third wave of this pandemic, but we will not know until a year or so down the line.
10) Is the public in general doing enough to help in controlling the outbreak?
I think the public is now reasonably well-informed as to this H1N1 pandemic. Perhaps, they are too well-informed, that they have a fearful approach to this virus. But the proper thing is not too over-react and to panic, although I know this does sound easier said than done.
It is almost a certainty that this flu will spread within the community — in schools, universities, academies, factories, work places, offices, etc. WHO has projected that possibly some 20-30 per cent of the population worldwide will become infected by this novel flu bug, after studying various models of spread of past infections — the huge and very rapid spread worldwide is mainly due to air travel. While older flu pandemics took six months to extend to so many countries, this H1N1 flu did so in less than six weeks!
In the worst-case scenarios of course, this outbreak will be alarming — hospitalisations may be required for 100,000 up to 500,000 Malaysians, with perhaps as many as 5,000 to 27,000 infected patients (depending on the case fatality rate or either 0.1 to 0.5 per cent) succumbing to this illness.
But because we have been monitoring closely and containing the outbreak thus far, with heightened awareness and greater social responsibility, it is possible to ameliorate the infectivity, spread and fatality that will unfortunately accompany this pandemic... Just how successful we will be in limiting these adverse outcomes remains to be seen, but we can be hopeful.
How can the public help? First learn and acquire good personal hygiene. If sick, please be responsible and stay at home, even in your own room where possible, wear a face mask (a cheap three-ply surgical mask will do, because large droplet spread is the main danger). Do not go out, practice what is now known as social distancing (about three metres from anyone), and be socially responsible, don't go to public places and infect others — for young people this would be hard, but absolutely necessary — the spread is most rampant in this age group between 16 and 25 years.
When the illness does not go away after a few days or when you are deteriorating, get to the nearest hospital. Most importantly, be very aware and responsible!
Finally, keep abreast of all new developments, because these are evolving all the time. With keen awareness, prudent care, early detection and social responsibility, correct and prompt use of antiviral and other support medical care, and later mass specific vaccination, we can overcome this novel H1N1 flu! But it will take time, patience, public cooperation, much concerted effort and consume great resources.
Dr David KL Quek is president the Malaysian Medical Association.
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