The Malaysian Medical Association answers common H1N1 questions

The Malaysian Medical Association answers common H1N1 questions

KUALA LUMPUR, Aug 21 – As the total number of people infected with A(H1N1), and the death toll from it, soars, so too does the level of concern among the general public.

People have questions to which they want answers.Here, the Malaysian Medical Association tries to answer some of the most common queries.

1. How is MMA helping in this pandemic? Some doctors and the public have lamented that it does not appear to have done enough.

The MMA is a professional body, which represents the largest number of doctors in the country, but we are also responsible in the face of any health crisis or threat to the country and our citizens.

Right from the outset, the MMA has been invited as an important dialogue partner in the National Influenza Pandemic Task Force, the Inter-Ministerial Influenza Pandemic Committee, and even the National Emergency Council pertaining to this A(H1N1) crisis.

In fact, our participation started even before this, while the MOH was planning for the much-feared but still remote H5N1 bird flu possible pandemic a few years ago.

Our views and input have been welcomed by health ministry officials, as we grapple with a clearly novel and previously unknown health threat. Clearly we are participating in every possible way to lend our expertise and strength of diverse knowledge to this national crisis.

When a country and its population are hit by a pandemic disease, in this case A (H1N1), everyone has to work together as a team and not individually to combat the disease.

The main ‘leader’ is of course the Ministry of Health but the rest of us have to join forces with them to come up with a contingency plan.

It is becoming increasingly clear that this is no easy task, and translating policies down to proper and appropriate practical responses and ground-level implementation can be challenging, and would be less than clockwork precision.

The MMA cannot work alone on this. We do not have the regulatory clout nor the logistical machinery to enforce decisions, which have been formulated by the Ministry of Health, as our member doctors are distributed far and wide across differing terrains and locales.

However, we have been disseminating our information to all our doctor members the best way we can, so that collectively we can help ameliorate the more serious consequences of this pandemic.

We are working closely with Association of Private Hospitals, the Academy of Family Physicians, and the Federation of Private Medical Practitioner Associations of Malaysia, to ensure that we are up to mark in offering alternative health care sites in the private sector to help treat this disease in as uniform a manner as possible, i.e. in private clinics and private hospitals, and have been doing this from the beginning.

Our private practitioner clinics are already working fulltime with the constraints of not being able to carry out confirmatory testing for the A(H1N1) flu, and also the very limited access to the antiviral drugs which were previously stockpiled by the MOH.

It is only now that we are able to purchase in (still) limited amounts the antiviral medicines for possible use in complicated H1N1 flu. Many clinics in more remote areas are still finding great difficulties in getting supply of such in-demand specific medicines.

Thus there is growing frustration and some sense of hopelessness and worry that we cannot act better and more promptly for our very ill patients.

We have already informed our members that they should be very prudent in using these drugs, because we do not wish to dish antiviral medicine out to just anyone who demand it, which could encourage waste and possible future development of resistant viral types.

GPs have also been giving out seasonal flu vaccines to those with higher risk of contracting the bug, although this does not necessarily help to protect against this new strain of A(H1N1). Higher risk patients may benefit from this prevention exercise.

Thus it is fair to say that the MOH and government cannot go solo in this, and private doctors have already been mobilised to help fight this disease.

Logistic problems remain which undermines the best that doctors can do or respond most rapidly.

2. There is a perception that private doctors are not adequately engaged in the management of this A(H1N1) influenza pandemic. Are private doctors willing to pitch in if the situation gets out of control?

This is not true. Most of our doctors are actively engaged in looking after many flu-like illness patients, but find many constraints due to lack of access to specific treatment modalities.

The lack of available and reliable testing and difficulty in confirming such illness as being due to this A(H1N1) flu compounds the situation, when many patients demand to know for sure. Doctors are thus left quite alone to firefight angry and worried patients with very few resources or reassurances or specific therapies.

Still, private doctors are already currently working very hard with the Ministry to curb this disease, so naturally they will do their part, under such unusual stresses.

There has been good cooperation from all private doctors as far as the MMA is concerned. Clearly, there had been some confusion in the earlier phase of this outbreak, which was due to rapidly changing scenarios and policies. All of us are learning as we face this unprecedented disease on the run…

Some of our doctors and their clinic staff have even become infected by this flu, but thankfully so far we have not received any news of more serious consequences such as death. So private doctors are also exposed to this threat but continue to look after their patients, including very many people with flu-like illness.

Our private hospitals are already looking after some seriously ill patients, including some requiring intensive care or mechanical ventilation–so yes, we have been prepared and are aggressively managing this pandemic. We note that thus far, our flu patients have emerged well after their ordeal, at least those who have come to us in the main urban areas.

It is possible that smaller private medical centres may not be adequately staffed or equipped to handle more seriously ill respiratory failure patients, but this is also the similar situation in some smaller district hospitals of the public sector. Furthermore, some of these gravely ill patients would not survive despite the most aggressive treatment strategies, under any circumstances.

3. What are the current/potential problems doctors might be facing in combating the spread of the swine flu?

It would be good if every doctor keeps a constant and 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 medical professionalism during this trying period, which is expected to run into at least one to two years.  Importantly, they must assiduously look out for lung complications, quickly identify high-risk profiles and refer these patients promptly for further more specialised care.

Easier access to antiviral drugs and their responsible use and monitoring would help allay public fears of delayed treatment, but this should be tampered with care and not with over-exuberance to dish out to one and all. There is genuine fear that the precious antiviral drug might be used indiscriminately, just for prevention – this would be a very bad move, which could 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 patents and frequent travelers to have the seasonal flu vaccination is a useful adjunct to help stem the usual problems from other flu types.

Health insurances agencies not willing to reimburse hospital care costs for Pandemic Flu

We are facing some problems with health insurance companies, however. This is especially the case in private hospitals, where many insurance companies are refusing to reimburse for the treatment because it appears that in the contract for medical insurance, pandemic illness is excluded. Thus we have lots of problems from ill patients having to find alternative sources of funding!

We strongly urge the insurers to be more magnanimous and empathetic and help out more under such crises. Corporate social responsibility should not be limited to only green or conservation issues – human lives and humane compassion should clearly be a greater mandate!

It is good that Etiqa Health insurance has come forward to state publicly that the H1N1 flu is a reimbursable illness. We urge other health insurers to follow suit. Otherwise, our hands are tied somewhat in helping to deliver the best care possible.

4. Is the government’s current logistical capacity able to handle this outbreak or worse a second/third wave of the flu as predicted?

It is difficult to say at this time. Although we certainly hope that this second or third wave would not take place. It is almost a certainty that the community spread of the A(H1N1) flu in Malaysia would escalate, and more and more Malaysians will come down with this flu.

However, the MMA wishes to reiterate that most of these infections would be quite mild and require only symptomatic treatment, bed rest and close watch at home. Only a minority (perhaps 2-5 per cent) may require hospital care or more.

If these very severe complications occur in a staggered manner then, we can cope with the problem. But if a huge unprecedented outbreak of very severe complications does take place, this can easily overwhelm the system. But contingency plans of converting general wards to intensive care capacities, or even field hospitals, have been made.

There are also more structured plans to increase the country’s intensive care bed capacity to at least twice the current number available now (which is around 300 beds only!) However, training sufficient staff and specialists to handle such expert care may require more time and expert guidance.

5. Have there been problems translating policy to ground-level implementation?

MMA’s concern is that although we have had some very detailed and stringent policies and directives in place, there may be logistical gaps in translating down these expected high levels or standards of care, horizontally.

We expect that there might be some variation in the care quality, appropriateness or speed of care delivery at more peripheral healthcare facilities, but this should be kept to a minimum when everyone has a chance to learn very fast and acquire the skills more quickly.

But because some flu patients appear to deteriorate so fast, we have to heighten our vigilance and react more urgently to try and save more lives. But even in most developed countries in the west, some people would continue to succumb to this illness (some 300,000 to 500,000 flu patients die yearly, especially during winter of seasonal flu, around the world).

How can we do this better? It is very difficult. However, we urge everyone to be very alert and pay exceptional attention to this pandemic and its development. Doctors both from public and private healthcare sectors must be kept in the loop of information, continuous training and preparedness, so that they can deliver the medical care at the optimum level to help reduce complications and deaths.

6. Should all doctors advise their patients to self-quarantine if they display symptoms?

Yes, this is the message that we have been advocating; it is best for all doctors to advise their patients to self-quarantine if they display flu-like symptoms.  This is the first and basic step in curbing the spread of the disease.

Last week, I remember informing a young coughing patient who came to my heart clinic, that she should probably come back later when she was better, because her complaint was not serious.

But she was incensed, and was upset when I told her to undergo self-quarantine for at least one week. She flatly refused although I was willing to give her an MC for the week.

My concern is that my other heart patients might contract the ailment due to her less-than-prudent action, and then their conditions may compound to a higher risk for complications!

We have to encourage everyone to be more socially responsible. Wear a mask, and don’t touch it too often, if you need to go out, or even to visit your doctor when you think you have possible flu-like illness.

Wash your hands frequently or use hand sanitisers to reduce the contamination chances to others. Avoid shaking hands, perhaps practice the Japanese bow to acknowledge each other!

However, we should also not be too panicky. Be vigilant, be cautious, be socially responsible, and think of others too.

7. How are private doctors/clinics kept informed about how to deal with A(H1N1) patients? (Some clinics claim they don’t receive anything from the MOH, while others admit to receiving some guidelines. This is very inconsistent). Is MMA doing anything to ensure that all doctors get the same information?

We have sent out MOH bulletins through our website, but not directly to each clinic or medical practitioner. Logistically, sending paper bulletins on a nearly daily basis is too cumbersome and costly, and likely to be not very helpful as these become obsolete so quickly. Members have also received clearer more defined updates in our monthly MMA News (Berita MMA), but these are usually not timely enough.

We urge members and doctors to check with the Internet for more up-to-date news and modifications in guidelines to managing this pandemic.

Thus, there are no standardised bulletins as mentioned above.  However, on the part of the MMA, we have been posting circulars, guidelines, important notices, etc to our doctors via our website – http://www.mma.org.my. There is also the official MOH site for the H1N1 flu, http://www.h1n1.moh.gov.my.

We have also informed our members to log-in to my personal blogsite for updates: http://myhealth-matters.blogspot.com/ Some of our other members have also been writing articles on the disease in our monthly newsletter – Berita MMA.

Besides, there is extensive coverage in the electronic and print media about the disease and its evolving status, daily.

We urge everyone to be more proactive and impress upon himself or herself, to look into more relevant information by themselves in the world wide web.

This pandemic situation is so fluid that one has to be keeping pace actively to remain engaged and up-to-date.

8. Would the MMA describe the current A(H1N1) Pandemic as “out of control”?

At this juncture, the MMA does not believe that the situation is out of control and that we need any health curfew. The Minister of Health yesterday announced that the government would only consider declaring a health curfew if the mortality rate due to Influenza A (H1N1) outbreak goes above 0.4 per cent.  According to their calculations, currently, the country’s mortality rate is between 0.1 per cent and 0.4 per cent.

Some have suggested that we shut down the country by imposing a nationwide health emergency lock down. But this is quite futile, as the disease is already in place within the community. Also, how long should this go on, one week, ten days, or longer?

What about the economic implications and the day-to-day running of the country and businesses? Also what happens when another surge appears again? Do we need to have repeated cycles of national curfew? Therefore, it makes no practical sense to even consider this seriously at this time, the actual numbers while alarming to some, are still manageable.

9. So why do the growing numbers seem to imply that we are getting more and more infections, with what appears as a disproportionate number of deaths?

There is no clear or adequate answer to this. I do not believe that the MOH is to blame for the forthright transparency, which it has been practicing right from the outset of this outbreak. We have released all the data almost daily in full view of our public. In fact earlier on, it should be remembered that the MOH was accused of being too alarmist and even guilty of scaremongering, driving away businesses and tourists!

There is organisational acknowledgement that our viral testing may have been less than adequate, and there have been long queues and frustrations from many worried iflu-like patients. Some had also been sent home, where no tests were offered, and therefore felt abandoned and treated less than expected.

Thus, there were/are many ill flu patients in the community, where no confirmatory tests had been performed. This gross under-reporting would therefore to add to the lower numbers of laboratory-proved or confirmed A(H1N1) flu, reported.

The WHO has estimated that for every confirmed case, there are at least another 20 patients who would have been infected. This means that most of these are not serious enough to be counted – many would have had mild or even no symptoms. Thus, in this context, the actual numbers with this pandemic flu would have been grossly underestimated.

So, it is unfair to state that the MOH is manipulating the numbers to justify the growing death rate, which we have already predicted would happen simply based on the attack rate of this very contagious flu.

We must inform the public that this pandemic will continue for at least another year or two, with the intensity likely to become less serious and less feared with time, unless the dreaded second wave of reassortment into a more virulent form of the H1N1 virus takes place.

There is no indication that this second wave has taken place yet, even in Mexico, USA or UK or Australia.

Although Mexico has declared that its worst is over, it is probably more a local nationalistic perception than the actual truth–there are still reports of continuing flu-like illness being reported, but like most authorities the Mexican government has taken the position of not confirming the actual attack rate any more. This less than rigorous case reporting is mainly done to allay irrational public fears.

A recent report (Seeking lessons in swine flu fight, 10 August, 2009, NY Times) by a visiting American expert noted that in the Mexican/Latin American situation, the flu characteristics might have become less typical, with many not developing fever in as many as 30-50%, but that some of these still go on to develop more serious lung complications.

Dr Wenzel, a former president of the International Society for Infectious Diseases, said he had observed a broad spectrum of illness from human swine influenza: people who experienced few or no symptoms to those who rapidly developed complications and died. Thus, like anywhere else, this flu will continue to exert its toll, but perhaps in a less alarming manner, once the public overcomes the initial fear and alarm…

Also the complication rates appear to have plateaued and most health authorities have learnt to cope with this, and the expected number of deaths. The scenario in Malaysia is probably still evolving with the peak still to come, but I would predict that the mortality rate would become less frightening as we cope with the complications better.

Even in the USA, the number of A(H1N1) flu is estimated to be in the millions as of now, but most are really quite mild disease and therefore not so scary. More worrisome in the northern hemisphere would be the winter months when this flu might exert its more serious effects, yet.

In Malaysia, it is possible that many more Malaysians have come into contact with this flu and are suffering very mildly from this, and most have got better without much concern. It is those few who seem to get complications so quickly that makes us so afraid, may be too afraid.

But, like most communicable diseases, we will overcome this outbreak in time, but we need to be patient, vigilant, be socially responsible and work together.

There is little to be gained from scapegoating anyone, be they the governmental machinery, the MOH, doctors or our politicians. We would all be better served by refraining from too many knee-jerk, alarmist or partisan responses.

The MMA is organising an urgent National A(H1N1) Pandemic Influenza Conference on Sept 12 2009, to help disseminate and share more scientific and practical up-to-date information about this novel influenza. The mass media will be invited to participate and help learn and educate our citizens more about this dreaded outbreak.

Malaysian Insider

By Dr David KL Quek, President MMA

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