During this stressful pandemic times, it is understandable that people are getting alarmed and confused. There is also a sense of helplessness as we see the death toll continues to rise (71 dead in Malaysia as of today). And of course, it is human nature to apportion blame to certain quarters especially the Health Ministry and healthcare workers.
I, myself have not been spared the misfortune of blame, even by my regular patients. Not only that, 2 nights ago, a lady who claimed to be the wife of a 60 year old man, stormed into my consultation room demanding to know why I had given her husband, who is a known hypertensive and had high fever and URTI sypmtoms antiviral treatment without doing any test to confirm H1N1. I told her since we are now in pandemic, all influenza like illnesses will be presumed to be H1N1, and this is also the directive from the Health Ministry. Not happy with my explanation and not giving me a chance to clarify further, she continued to reprimand me and to my surprise, snatched the patient record card right in front of me. I was injured in my effort to prevent her from running away with the card (with the help of another accomplice) and this matter has now come under investigation by the police.
The clinic does stock up antiviral for H1N1 as with other clinics around the nation who had partipitated in the program. The cost of treatment has now come down to RM80 (previously it was RM180) for clinics which is in the list Just key in the area code in the box, and you will find the list of clinics in your locality.
The article below is another example of blame apportioned to a private doctor before further investigation.
Tuesday August 25, 2009
Results show teacher died from A(H1N1)
By MAZWIN NIK ANIS, IAN YEE, TheStar
PUTRAJAYA: The primary cause of death for the SMK USJ 12 teacher who died on Aug 19 was Influenza A(H1N1), said Health Minister Datuk Seri Liow Tiong Lai.
The 38-year-old only received the right treatment when she came to Kuala Lumpur Hospital six days after a private clinic tested her positive for the disease.
Liow said the teacher, who was in the high-risk group as she was obese, had sought treatment from a clinic on Aug 13 after suffering from fever and cough for two days.
Although she tested positive for Influenza A, the doctor only gave her symptomatic treatment and not anti-viral medication.
On Aug 18, she sought treatment at a private hospital after experiencing breathing difficulties and cyanosis and was referred to Kuala Lumpur Hospital where she was given anti-viral treatment immediately.
However, the woman died on Aug 19 due to pneumonia. The next day, results from the victim’s throat swab confirmed she had Influenza A(H1N1). The teacher’s death bring the total number of A(H1N1) fatalities to 69.
The following article quoting Dr Steven Chow, confirms my treatment stand that we should presume all influenza-like illnesses as H1N1, and the rapid test kit is not sensitive enough to detect the virus in many cases.
Sunday August 23, 2009
Doctors confused by many ministry guidelines
By LESTER KONG, TheStar
PETALING JAYA: Some private medical practitioners are confused by the Health Ministry’s guidelines on how to treat patients with influenza-like illnesses (ILI).
Federation of Private Medical Practitioners Associations Malaysia president Dr Steven Chow said the many guidelines that were issued were often conflicting.
For example, Dr Chow said general physicians (GPs) had been asked at one point to send all cases to the nearest hospital for testing; and when the hospitals could not cope, they were asked to send only selected cases.
He added when deaths were first reported, private doctors were blamed for late diagnosis and referrals to government hospitals.
“When dengue was not controlled, they were blamed and then the A(H1N1) came.
“This does not help the doctors on the ground. It is a nightmare for our GPs,” he said in an e-mail interview.
He added that private sector GPs also faced a shortage of anti-viral drugs to treat the virus.
“The main stockpile is with the Government and we are not aware of the type prescribed by the Minis-try.”
However, Dr Chow reminded that the A(H1N1) strain was resistant to existing antiviral drugs.
“Antiviral drugs are not the magic bullet for stopping or controlling this pandemic. There has been too much hype on the usefulness of these medications,” he said.
Dr Chow also pointed that rapid test kits, which increased the cost of care were not specific or sensitive enough for diagnostic use.
On Health Minister Datuk Seri Liow Tiong Lai’s directive to private healthcare providers to raise the level of suspicion on the virus, Dr Chow said the Federation had advised members to treat all ILI as A(H1N1).
He said the federation was ready to work with the Ministry to fight the virus and take pre-emptive measures to decrease future fatalities.
Thursday, August 27, 2009
Tuesday, August 18, 2009
H1N1 - An observation from ground zero
My first full length H1N1 journal.
For the past week or so, the patient load in most clinics has increased tremendously due to the dreaded flu. You may want to know how I go about managing my patients with suspected H1N1 when this country is having such an alarmingly higher than average morbidity and mortality rate compared to the rest of the world. The first thing I would ask myself is, if one of my own family members were to come down with it, how do I treat the illness?
The most important thing to do is to look for deteriorating signs and symptoms as per guideline that I have posted earlier link. Next, the doctor needs to screen for those high risk category groups namely the very young, the very old, pregnant women (more predisposed to respiratory distress and also due to the fact that you are dealing with 2 lives here), obesity, co-morbid chronic medical conditions which may range from diabetes, heart failure to cancer, immunosuppressed conditions, congenital heart disease, kidney failure etc, co-existing lung conditions in particular asthma, smokers' lung otherwise known as COAD, tuberculosis etc. The doctor must always have a high index of suspicion for worsening clinical state for these groups as they may deteriorate quite rapidly if not monitored closely. They are the ones who would benefit most from antiviral treatment, esp. if given within 48 hrs from the onset of any symptom (and not only fever), though it is still beneficial if given outside that period depending on individual clinical status.
There are 2 other new indications for antivirals, released by MOH which is quite controversial though the public have not realised it. One is high grade fever for more than 48 hrs (which is too general for an indication anyways), and the other being a positive rapid influenza diagnostic test (RIDT). If we think about it, we will know that many forms of viral high fever esp the still dreaded but a little sidelined dengue fever could last for more than 2 days for most of the cases. Dengue fever can actually mimic many forms of fever though the predominant symptom is that of a bone breaking pain which is also found in novel A (H1N1) patients to a certain extent together with high grade fever.
As for RIDT, it becomes less useful once the pandemic sets in as most flu cases would be H1N1 anyways. Further more, as I've blogged on it earlier link, the sensitivity rate is as noted by US CDC is quite low, thereby giving false sense of security for those with H1N1. Of course, there are now many marketing agencies selling RIDT kits telling us their sensitivity rate is almost 100%, but these have yet to be verified in scientific studies as in CDC. Furthermore, they are expensive. However, I won't be surprised if many clinics are already performing such tests in 'compliance' with patients' demands.
What's the reason for the high morbidity and mortality rate in our country? I'm sure this must be a burning question in the hearts of many responsible Malaysian citizen. Is there a co-infection with other respiratory viruses? Why do I feel sadness tinged with embarassment? Are we such an unhealthy nation on the whole because we consume too much nasi lemak and fried food, or is this is part of the globesity trend facing effluent societies? Before you start poking fun at your seemingly obese friends, I suggest you do a measurement of your own waistline because abdominal obesity is considered more dangerous to the heart, compared to generalised obesity. In other words, if you have a choice to become an apple or a pear, you would be better off as an apple.
The other question is, how efficient are the doctors in starting antiviral treatment early? I dont want to point a finger at the govt hospital staff because they have been heavily criticised already by the 'court of public opinion' and because these poor souls are already working beyond their limits. However, I need to point to the fact that many a horror story given by my GP colleagues lately when they referred very ill distressed suspected H1N1 patients, only to be turned away from getting that magical antiviral elixir.
Why do private doctors refer patients to hospitals though they could easily administer the antivirals themselves? (I do stock both forms of antivirals, oseltamivir and zanamivir, though I cannot promise they won't run dry) Well, here's the reality check for the top officials in MOH – for the simple reason that most cannot afford it, or they may be able to afford it for one person, but imagine if you have a few family members down and require the antivirals. (this can easily happen given the fact that H1N1 is a very infectious virus) The other reality check is we may be running low on original stock. When the govt says to give Tamiflu, do they actually mean those generic 'proudly-made-in-Malaysia-but-still-shockingly-expensive' ones because the original oseltamivir (Tamiflu) is definitely unavailable to order as far as I know unless you are getting those with extended expiry dates. I would like to know how stringent has any testing being done on the effectiveness of our own brand of antivirals in the past. What about the safety profile? How's the recovery rate of those in ICU treated with the generic compared to original?
So again what's the reason for the high mortality rate? If we join the dots carefully, we will arrive at the answer sooner or later. Of course, politicians will try to mix things up. Declare national curfew if the mortality rate touches 0.4%. Where do they based the figures from – what about unconfirmed lab cases? Have they factored in the millions of foreign workers, whether legal or illegal? If someone is found to have influenza-like illness and not wearing masks, they want to impose a RM10,000 fine.
Whether we like medical prophecy or not, it's predicted that we have to live an altered lifestyle for at least another year or so. Everyone is going to be affected one way or another. Ignorance is stupidity, and the first thing to do when you are down with flu, even if its a mild one, and even before you see a doctor, is to please practice social distancing, pay attention to hand hygiene and get a 3-ply face mask because you are definitely going to spread this around and cause more distress to a lot of people.
So, in conclusion, I wont give antiviral to my family member unless there is a clear indication. I hope every doctor with the power to prescribe wont just give it to any Tom, Dick and Harry if you really love humanity, and if you really are serious about stemming the tide of resistance which may happen sooner than you think. Don't let greed come in the way at this time when we should be working together.
An update on influenza A (H1N1) by Dr David Quek can be found here
For the past week or so, the patient load in most clinics has increased tremendously due to the dreaded flu. You may want to know how I go about managing my patients with suspected H1N1 when this country is having such an alarmingly higher than average morbidity and mortality rate compared to the rest of the world. The first thing I would ask myself is, if one of my own family members were to come down with it, how do I treat the illness?
The most important thing to do is to look for deteriorating signs and symptoms as per guideline that I have posted earlier link. Next, the doctor needs to screen for those high risk category groups namely the very young, the very old, pregnant women (more predisposed to respiratory distress and also due to the fact that you are dealing with 2 lives here), obesity, co-morbid chronic medical conditions which may range from diabetes, heart failure to cancer, immunosuppressed conditions, congenital heart disease, kidney failure etc, co-existing lung conditions in particular asthma, smokers' lung otherwise known as COAD, tuberculosis etc. The doctor must always have a high index of suspicion for worsening clinical state for these groups as they may deteriorate quite rapidly if not monitored closely. They are the ones who would benefit most from antiviral treatment, esp. if given within 48 hrs from the onset of any symptom (and not only fever), though it is still beneficial if given outside that period depending on individual clinical status.
There are 2 other new indications for antivirals, released by MOH which is quite controversial though the public have not realised it. One is high grade fever for more than 48 hrs (which is too general for an indication anyways), and the other being a positive rapid influenza diagnostic test (RIDT). If we think about it, we will know that many forms of viral high fever esp the still dreaded but a little sidelined dengue fever could last for more than 2 days for most of the cases. Dengue fever can actually mimic many forms of fever though the predominant symptom is that of a bone breaking pain which is also found in novel A (H1N1) patients to a certain extent together with high grade fever.
As for RIDT, it becomes less useful once the pandemic sets in as most flu cases would be H1N1 anyways. Further more, as I've blogged on it earlier link, the sensitivity rate is as noted by US CDC is quite low, thereby giving false sense of security for those with H1N1. Of course, there are now many marketing agencies selling RIDT kits telling us their sensitivity rate is almost 100%, but these have yet to be verified in scientific studies as in CDC. Furthermore, they are expensive. However, I won't be surprised if many clinics are already performing such tests in 'compliance' with patients' demands.
What's the reason for the high morbidity and mortality rate in our country? I'm sure this must be a burning question in the hearts of many responsible Malaysian citizen. Is there a co-infection with other respiratory viruses? Why do I feel sadness tinged with embarassment? Are we such an unhealthy nation on the whole because we consume too much nasi lemak and fried food, or is this is part of the globesity trend facing effluent societies? Before you start poking fun at your seemingly obese friends, I suggest you do a measurement of your own waistline because abdominal obesity is considered more dangerous to the heart, compared to generalised obesity. In other words, if you have a choice to become an apple or a pear, you would be better off as an apple.
The other question is, how efficient are the doctors in starting antiviral treatment early? I dont want to point a finger at the govt hospital staff because they have been heavily criticised already by the 'court of public opinion' and because these poor souls are already working beyond their limits. However, I need to point to the fact that many a horror story given by my GP colleagues lately when they referred very ill distressed suspected H1N1 patients, only to be turned away from getting that magical antiviral elixir.
Why do private doctors refer patients to hospitals though they could easily administer the antivirals themselves? (I do stock both forms of antivirals, oseltamivir and zanamivir, though I cannot promise they won't run dry) Well, here's the reality check for the top officials in MOH – for the simple reason that most cannot afford it, or they may be able to afford it for one person, but imagine if you have a few family members down and require the antivirals. (this can easily happen given the fact that H1N1 is a very infectious virus) The other reality check is we may be running low on original stock. When the govt says to give Tamiflu, do they actually mean those generic 'proudly-made-in-Malaysia-but-still-shockingly-expensive' ones because the original oseltamivir (Tamiflu) is definitely unavailable to order as far as I know unless you are getting those with extended expiry dates. I would like to know how stringent has any testing being done on the effectiveness of our own brand of antivirals in the past. What about the safety profile? How's the recovery rate of those in ICU treated with the generic compared to original?
So again what's the reason for the high mortality rate? If we join the dots carefully, we will arrive at the answer sooner or later. Of course, politicians will try to mix things up. Declare national curfew if the mortality rate touches 0.4%. Where do they based the figures from – what about unconfirmed lab cases? Have they factored in the millions of foreign workers, whether legal or illegal? If someone is found to have influenza-like illness and not wearing masks, they want to impose a RM10,000 fine.
Whether we like medical prophecy or not, it's predicted that we have to live an altered lifestyle for at least another year or so. Everyone is going to be affected one way or another. Ignorance is stupidity, and the first thing to do when you are down with flu, even if its a mild one, and even before you see a doctor, is to please practice social distancing, pay attention to hand hygiene and get a 3-ply face mask because you are definitely going to spread this around and cause more distress to a lot of people.
So, in conclusion, I wont give antiviral to my family member unless there is a clear indication. I hope every doctor with the power to prescribe wont just give it to any Tom, Dick and Harry if you really love humanity, and if you really are serious about stemming the tide of resistance which may happen sooner than you think. Don't let greed come in the way at this time when we should be working together.
An update on influenza A (H1N1) by Dr David Quek can be found here
Friday, August 14, 2009
Miracle of Love
Model Reference: Xi Zhang from Texas, USA. Used with her permission.
This is created out of spontaneity. It may look to be symbolic of the merging of self into Love. A transfiguration, a sort of creative force, a 'miracle' of love so to speak.
Yes, love is truly magical. But it is not easy for the beholders to interpret what the artist is trying to convey. Most of the time it is based on their own belief system and how they see the world.
For me, I do not now have any grand idea of what love should be. I do not see myself as only an artist but also an imperfect human being, and I seek only to communicate what I see. This is not part of my life story, but it can be anyone's story.
I see love as a shade lower than what most will interpret as flowing from the 'Creator of the Universe', and its flow as an extension of the soul. For me, love exists only between human beings, but nothing more than that. It cannot be measured, it cannot be weighed and it is certainly indescribable. Maybe you know better than me on this, I'm sure. But one thing I do know is there exists a strong but real chemistry between 2 persons, and that's all there is....but its good enough for me.
Its true that my thinking has evolved over the past 3 years, but people do need to change for the better.
Peace
The Unstoppable Flu
I'm a little skeptical about the use of Rapid Influenza Diagnostic Test (RIDT) for detecting novel influenza A (H1N1), despite it being strongly advocated by the Health Ministry, probably as one of their desperate measures to contain the unstoppable pandemic, apart from liberalising the use of antivirals which hopefully does not get out of hand.
The above table (click to enlarge), sourced from CDC Atlanta, USA showed the latest finding that among the three commercially available RIDT kit, the overall sensitivity was low (40%--69%) among all specimens tested and declined substantially as virus levels decreased. Only QuickVue did quite well with detection rate of 69%, compared to using the more accurate rRT-PCR which is only available in certain labs in this country, notably Institute of Medical Research (IMR) but then they only run them on very ill patients who are admitted for complications of influenza.
According to CDC, a negative RIDT result should NOT be interpreted as indicating the absence of infection, especially since the sensitivity declines as the viral levels decreases.
More updates to come.
Reference source: CDC Atlanta via Malaysian Medical Resources
The above table (click to enlarge), sourced from CDC Atlanta, USA showed the latest finding that among the three commercially available RIDT kit, the overall sensitivity was low (40%--69%) among all specimens tested and declined substantially as virus levels decreased. Only QuickVue did quite well with detection rate of 69%, compared to using the more accurate rRT-PCR which is only available in certain labs in this country, notably Institute of Medical Research (IMR) but then they only run them on very ill patients who are admitted for complications of influenza.
According to CDC, a negative RIDT result should NOT be interpreted as indicating the absence of infection, especially since the sensitivity declines as the viral levels decreases.
More updates to come.
Reference source: CDC Atlanta via Malaysian Medical Resources
Wednesday, August 05, 2009
Contemplation
International model: Audrey Lai from San Francisco, USA
Photographer credit: Delmott Patrice from France - used with permission
My first painting on traditional Chinese costume.
100% painted - no paintover
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