Wednesday, June 17, 2009

ALL Suspected Dengue Infections must be Notified and sent to Public hospitals

The NST's Front page final warning to doctors to act on dengue cases or face compound fines of RM5,000, supposedly issued by the Minister of Health, must jolt the medical profession into some form of action, sadly because it is out of fear of repercussions and frustration, rather than common sense.

Although the MMA understands that the dengue situation is a grave public health concern, and the Ministry of Health is at wits' end to try and contain this seemingly unstoppable scourge, this confrontational approach is neither helpful nor conducive to collaborative efforts to curb this epidemic which has been endemic in our shores for some 30 odd years, at last count.

We understand the frustration of seeming haplessness with regards to the periodic flare-ups of this potentially lethal disease. We understand that more can and must be done, but this should be made in concert with all authorities to eradicate the origins of the Aedes aegypti or albopictus breeding grounds.

Knee jerk reactive foggings and punishing of domestic or commercial owners of breeding grounds for this pesky mosquito, can only be stop-gap measures, which soon passes attention once the threat is temporarily removed. We need more concentrated and more consistent tactics to ensure that such eradication measures are maintained for the longer term—our rakyat and our officials must learn to understand their importance.

But to single out private medical practitioners as "stubbornly" refusing to alert authorities to these dengue cases, is to conveniently pass the buck and shift the blame, to a moving target which must be the current punching bag for some of the officials advising the Health Minister.

This is at best trying to placate the ghosts of incompetent policies or logistic failures on the part of authorities, to deflect the real situation at hand—that our local authorities, our public health overseeing officials, our housing (construction) ministry have failed to mandate enough measures to fully eradicate every possible mosquito breeding ground. In the same press statement, we understand that at last some of these measures are now being seriously contemplated.

We have earlier discussed why it is not so simple to diagnose or to treat this dengue illness. Like most viral infections, early presentations of the disease are nonspecific, vague and similar. Of course, there are different competencies at how good some of our doctors might be at diagnosing correctly the dengue disease, but this is not to say that we are all systematically deficient in notifying or recognising it.

Patient and physician reluctance to what appears as simple viral fever management from blunderbuss testing of all fevers is understandable, but to label the private doctors as consistently recalcitrant and therefore culpable for the spread of this ongoing epidemic is mischievous and totally uncalled for. Not only is this impractical and costly, it will also overwhelm the system, and only elevate the cost of a simple medical outpatient consult. Of course all doctors must be wary and alert as to dengue; we very nearly all are.

However, more often than not, we use our better judgement to practice as cautious doctors, we use our acumen to define our diagnosis more accurately rather than to alarm the patient or their relatives. So we sometimes do the cheaper full blood counts to check on the white cell count, platelet count and monitor these when patients are agreeable.

For most other viral infections, we cannot be simply ordering blood tests, because these are not only expensive but also require in most instances serial blood tests for antibody responses, which take time and money; which not every private-paying patient is willing to fork out, at every doctor-patient encounter.

Interestingly too, in most instances, most viral infections are self-limiting and healing takes place when the patient's own immunity overwhelms the virus, but most infections even if serious, still warrant the very similar supportive therapies only, without any real direct specific cure!

Thus, to demand that we raise the ante to apply this to all and sundry, as well as to notify suspected cases is perhaps too strong a call to make. Nevertheless, since this is the option demanded by the Ministry of Health, and its resounding ultimatum, then as medical doctors, we will comply.

Therefore, the MMA calls on all medical doctors to urgently notify every case of possible (suspected) dengue infection to the Ministry of Health, and refer all fevers of suspicious origins to the public hospitals for evaluation, testing and confirmation, so that the authorities can be alerted earlier. More importantly, so that they would not be blamed for negligence in reporting and notifying, and fined RM5000!

We wish the Ministry of Health good luck and god speed in tackling this epidemic. Doctors should report ALL cases by sending the completed prescribed form Appendix 3: Borang Health 1 Rev 2001, available at, by fax and registered post to the nearest District Health Office.

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