Wednesday, August 12, 2009

10 Questions Regarding H1N1

AUG 6 — Dr. David KL Quek wrote:

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

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

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

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

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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