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