Minister's Dialogue with Private Medical Doctors help clear the air...

Thursday's meeting (28 August 2009) with the Minister of Health, Dato' Sri Liow Tiong Lai and the Director General of Health Tan Sri Mohd Ismail Merican, was certainly a high point in timely dialogue between two seemingly disparate and separate sectors of the health service for Malaysia, particularly in the context of the current outbreak of the A(H1N1) influenza.

Among the many doctors (>60) who attended were several enthusiastic representatives from the MMA, PPSMMA, FPMPAM, PCDOM, APHM, AFPM, as well as several other interested medical practitioners from the Klang Valley, and even as far away as from Penang. It underscores the importance of such a meeting to help demystify the approach to the swine flu which has taken Malaysia by storm.

More importantly, the meeting was rather civil and accommodating with both sides cautiously trying to understand some of the undercurrents of unease which has permeated the relationship, especially whenever some untoward event related to the H1N1 occurs. The most recent recriminations took place when a woman teacher died after some supposedly possible delay in her treatment, when she had come down with the flu.

The difficulty in obtaining the antiviral drug (oseltamivir) was once again highlighted, and the restrictions in its use, were exposed, although in theory, the algorithm for managing the flu patient had been disseminated. Clinical judgement regarding moderate or severe symptoms and signs are not as clearcut as many would like to have believed.

The epidemiology of the Flu thus far was given by Dato' Dr Abdul Hassan, Director of Communicable Diseases, MOH. Dr Chris Lee gave a quick but comprehensive summary of the management guidelines as agreed to by the MOH and its task force and experts.

Clarifications were sought, with the plea by most private medical practitioners to further simplify the management of referring patients with suspected more serious complications to hospital sooner. Examples of patients being given the round around when referred for further action at various hospitals were given, which demonstrated that on the ground, practical issues still dominate the actual situation about whether the individual patient gets the treatment without too much delay. Some bureaucratic hiccups still take place, which may make the patient and doctor experiences very frustrating.

There was a further plea by the FPMPAM president, that there should not be too much finger-pointing at the private sector doctors, every time something bad or untoward occurs, because this is felt to undermine the credibility and morale of private doctors, who very often are not really to blame, and where circumstances and actual issues are the bugbears which create an environment of miscommunication and confusion.

However, in the light of the wide community spread of this H1N1 flu, there was a pledge on both sides to work harder to address these problematic areas, and ensure smoother and perhaps more constructive management of very ill patients.

Because, the MOH did not have a system in place to monitor or survey the usual flu like illness, in the country, it was felt that this makes it very hard to know if this current flu outbreak was really out of the ordinary, or perhaps just a little more virulent for some. Thus, it was agreed that GPs will assist the MOH by completing daily update notifications of all ILI, to help us maintain a closer surveillance and scrutiny of the situation on the ground.

Closer collaboration with the district MOH offices was also urged, with the plea for the MOH to circulate to all neighboring doctors any current or changed protocols so that GPs can be alerted to these more timely and accurately--the district MOH offices were felt to be the best community area to disseminate these updates.

Current changes will be notified at the MOH special H1N1 wbsite, and all doctors are urged to keep themselves apprised of changes or modifications regularly.

It was further announced that a National A(H1N1) Pandemic Influenza Conference 2009 would be organised very soon on 12 September 2009 at the Renaissance Hotel KL. This will be jointly organised by the MMA, the MOH and FPMPAM.

NST Online Doctors now have clearer picture

NST Online Doctors now have clearer picture

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NST 2009/08/29

KUALA LUMPUR: Private doctors now have a clearer picture on how to deal with people having influenza-like symptoms.

This followed a dialogue cum briefing by Health Minister Datuk Seri Liow Tiong Lai and Director-General of Health Tan Sri Dr Ismail Merican on Thursday.

Malaysian Medical Association president Dr David Quek said the session gave them a wider view of what was expected of them in terms of managing and treating patients with influenza-like illness (ILI).

He said although doctors were doing their best to treat patients and refer those suspected of having influenza A (H1NI) to hospital, they were in a dilemma as there were no proper guidelines initially from the ministry and the World Health Organisation.

However, after four months of closely monitoring and analysing the situation, the ministry came out with its clinical guidelines on who should be treated with anti-viral drugs and also recently by the WHO.

Dr Quek said although there were policies, directives and guidelines on the handling of the H1N1 pandemic, interpretation was a problem.

He said no one, including WHO, knows much about the new virus and everyone is doing their best to handle the situation.

"There may have been slip-ups earlier in the management of cases but now doctors are clearer as to what is expected of them although we would much prefer that we be given a free hand in managing the cases."

He said the district and state health departments should explain clearly to private doctors and hospitals in their areas of the clinical guidelines.

The Federation of Private Medical Practitioners' Association of Malaysia president Dr Steven Chow said they had asked all doctors to submit the daily information on ILI cases to the ministry and said the ministry should make anti-virals affordable.

Meanwhile, Dr Ismail said another 391 people have contracted the H1N1 virus while death toll remains at 71.

52% of HK health workers don't want H1N1 vaccine

HK health workers baulk at H1N1 vaccine

Some Hong Kong health workers are refusing H1N1 vaccine shots for fear of unknown side-effects. — Reuters pic

HONG KONG, Aug 26 — Just over half of health workers surveyed in Hong Kong do not want to be vaccinated against the H1N1 virus because of fears of side effects and doubts about its effectiveness.

The study results, published in the British Medical Journal today, echo the findings from a survey of 1,500 nurses in Britain where 30 per cent said they would refuse new vaccines against the H1N1 swine flu for safety reasons.

“With the reported low level of willingness to accept pre-pandemic vaccination in this study, future work on intervention to increase vaccination uptake is warranted,” wrote the researchers, led by Paul Chan, a microbiology professor at the Chinese University of Hong Kong.

“A campaign to encourage vaccination among healthcare workers should be introduced,” they added.

The South China Morning Post, citing the local health department, reported on August 17 the number of swine flu cases had risen to 7,071.

The study consisted of two surveys involving 2,255 doctors, nurses and other health workers in public hospitals in Hong Kong.

The first, conducted between January and March 2009 when the World Health Organisation’s flu pandemic alert was at phase 3, showed just over 28 per cent of respondents said they would be willing to be vaccinated against the H5N1 bird flu virus.

The second, undertaken in May 2009 when the WHO raised its alert level to 5 because of swine flu, found only 47.9 per cent of those surveyed would be vaccinated against H1N1.

“The most common reason for refusal was ‘worry about side effects’ and other reasons included ‘query on the efficacy of the vaccine’, ‘not yet the right time to be vaccinated’ and ‘simply did not want the vaccine’,” the researchers wrote.

Those who said they would opt for swine flu vaccination tended to be young, had had the seasonal flu vaccine in 2008-2009 and feared they were vulnerable to H1N1.

Malik Peiris, microbiology professor at the University of Hong Kong, who is not connected with the study, said the surveys gave an insight into public perception, but he warned such views could alter rapidly.

“In Hong Kong, if you have one death in a healthcare worker, you will have a change in perception,” he said.

“Protection of oneself is important and particularly when it comes to healthcare workers who are more (at risk) than the general public because they come into contact with sick people.”

Robert Dingwall, director of the Institute for Science and Society at University of Nottingham, cautioned against taking the findings too seriously. He was not linked to the study.

“Real decisions will be made in a future context where health professionals have better information about the safety of the vaccine and opportunities to reflect on their responsibilities towards their patients and the functioning of major social institutions,” he said. — Reuters

Malaysiakini: Prognosis: Flu to last for a year, mostly mild

Prognosis: Flu to last for a year, mostly mild

Aug 22, 09 3:30pm

Malaysian Medical Association (MMA) president Dr David Quek estimates that the current H1N1 pandemic plaguing the world is expected to run for another year or two.

Quek, however was quick to say that the majority of cases would be mild and it was those in the high risk group that needed to be cautious.

Speaking to Malaysiakini, he said "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."

Doctors, he said have to be acutely aware that the initial symptoms could deteriorate into something more serious.

"Doctors must assiduously look out for lung complications, quickly identify high-risk profiles and refer these patients promptly for further more specialised care."

When asked if the medical profession's governing body was not doing enough, the MMA president said "Most of our doctors are actively engaged in looking after many flu-like illness patients. But they find many constraints due to lack of access to specific treatment modalities."

He said that the lack of available and reliable testing and difficulty in confirming such illness as A(H1N1) flu compounds the situation.

Many patients demand to know for sure if they have the flu but the doctors are thus left quite alone to fire fight angry and worried patients with very few resources or reassurances or specific therapies.

He said that it was the Ministry of Health, (MOH) that takes the lead in such matters but it needed the cooperation of all sectors to handle this situation.

While the MOH comes out with the guidelines and policies, implementing it on the ground required all parties to come together.

"The main 'leader' is of course the Ministry of Health (MOH) 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," he said.

Keeping abreast critical

Quek also advised doctors in the private sector to keep themselves updated and not just depend on official handouts as these may be late filtering down to the ground.

"It would be good if every doctor keeps a constant and close tab on the H1N1 pandemic and remains 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.

He said that "logging 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."

Doctors he said "must assiduously look out for lung complications, quickly identify high-risk profiles and refer these patients promptly for more specialised care.

Quek called for an easier access to antiviral drugs and their responsible use and monitoring to help allay public fears of delayed treatment.

But, he warned that this should be tampered with care and not with over-exuberance "in dishing 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," Quek said.

Self-qurantine and common sense

He said that 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.

While there is no specific H1N1 vaccine as such, he expects one to be available by the end of the year.

"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", he said.

In a wide ranging interview, Quek said that most of the affected cases would be mild ones and strongly advised those exhibiting flu symptoms to self-quarantine to help curb the spread of the disease.

As a cardiologist, he said that he had a patient who came to see him and was coughing. When he asked her to take a weeks's quarantine, she was reluctant despite him giving her a medical certificate.

"I informed 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 self-quarantine for at least one week. She flatly refused although I was willing to give her MC (medical certificate) for the week."

The patient, he said, was actually exposing the others who were in the high risk group with heart ailments.

Quek concluded by said that the people should join forces with the authorities and medical personal to help in curbing the current pandemic by looking out for the tell-tale signs in both themselves and their loved ones.

Taking proper and commons sense measures, could go a long way, he says, in helping curb the H1N1 spread.

Below is the full text of a question-and-answer session with Malaysian Medical Association president David Quek, who has been keeping a close eye on the H1N1 pandemic.

Nutgraph Version: A(H1N1): Still under control

A(H1N1): Still under control

21 Aug 09 : 5.55PM

By Dr David KL Quek
editor@thenutgraph.com

WHAT are the current and potential problems doctors might be facing in combating the spread of the swine flu?

It would be good if every doctor kept a constant and close tab on the H1N1 pandemic, and remained fully aware of the developments and changes, which are evolving daily. Logging on to the internet regularly for more updated information would certainly help.

(Pic by Barky / sxc.hu)

Every doctor has to be more proactive and practise more responsible and cautious medical professionalism during this trying period, which is expected to go on for 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 specialised care.

Easier access to antiviral drugs and responsible use and monitoring would help allay public fears of delayed treatment, but this should be with care. There is genuine fear that the precious antiviral drug might be used indiscriminately for prevention; this could inadvertently create the worse outcome of drug-resistant bugs.

However, in light of the very quick deterioration and death of some young patients, 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

We are facing some problems with health insurance companies. This is especially the case in private hospitals, where many insurance companies are refusing to reimburse for the treatment because it appears that pandemic illness is excluded from the contract for medical insurance. Hence, it is good that Etiqa health insurance has come forward to state publicly that the H1N1 flu is a reimbursable illness.

Is the government's current logistics capable of handling this outbreak, or a second or third wave of the flu as predicted?

It is difficult to say at this time. We certainly hope that this second or third wave will not take place. It is almost a certainty that the community spread of the A(H1N1) flu in Malaysia will 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, bedrest and close watch at home. Only a minority (perhaps 2% to 5%) 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 takes place, this can easily overwhelm the system. That said, contingency plans of equipping general wards with intensive care capacities, or even field hospitals, have been made.

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

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 most basic step in curbing the spread of the disease.

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 health minister 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%. According to their calculations, currently, the country's mortality rate is between 0.1% and 0.4%.

Some have suggested that we shut down the country by imposing a nationwide health emergency lockdown. But this is quite futile as the disease is already in place within the community.

Microscopic view of influenza virus particles (Pic by Dr FA
Murphy, Centers for Disease Control and Prevention; source:
ah1n1.com)

How long should a shutdown go on for? One week, 10 days, or longer? What about the economic implications and the day-to-day running of the country and businesses? What happens when another surge appears? Do we need to have repeated cycles of national curfew?

It makes no practical sense to even consider this at this time. The actual numbers, while alarming to some, are still manageable.

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 Health Ministry is to blame for the forthright transparency, which it has been practising right from the outset.

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 patients, some of whom were sent home with no tests offered. Thus, there were and are many flu patients in the community who have not had confirmatory tests performed. This under-reporting would add to the lower numbers of laboratory-proven or confirmed A(H1N1) flu infections.

The World Health Organisation 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. In this context, the actual numbers would have been grossly underestimated.

So it is unfair to state that the Health Ministry 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 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, UK or Australia.

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.

It is possible that many more Malaysians in the country have come into contact with this flu and are suffering very mildly from it. Most would have got better without much concern. It is those few who seem to get complications so quickly that make us afraid.

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

Dr David KL Quek
President
Malaysian Medical Association

A(H1N1): "No need to panic" says FPMPAM

A(H1N1): "No need to panic"

20 Aug 09 : 2.47PM

By Dr Ng Swee Choon
editor@thenutgraph.com

THERE has been much alarm over the rising number of cases and the fatality rate of the A(H1N1) virus, and rightly so, because the A(H1N1) is infectious.

Unfortunately, 67 have already died in Malaysia. But if you were to be objective, 67 deaths, out of a possible 70,000 to 80,000 cases, amounts to a death rate of 0.08%. This is still a bit higher than the usual seasonal flu death rate of 0.04%, but surely not anywhere near panic-inducing proportions.

But while alarm and widespread panic is unnecessary, there exists the pressing need to restrategise and implement mechanisms and Standard Operating Procedures (SOP) for the prevention of secondary bacterial pneumonia.

A closer look at the deaths reveal that 80% were A(H1N1)-associated, or were incidentally found to have contracted the virus, the virus by no means causing the death.

We can call this A(H1N1)-associated death or death with incidental A(H1N1) infection. So, if the certification of death is proper, it may be that only 15 deaths were actually due to A(H1N1), giving a fatality rate of 0.02%.

The flu itself is usually a mild disease in the majority of cases. From all available clinical epidemiological evidence, the bulk of patients dying in flu pandemics are from secondary bacterial pneumonias. This has been shown to be the case in all flu epidemics and pandemics.

This is why we need to consolidate measures that are already in place. This should include a national level SOP whereby all affected patients with secondary bacterial pneumonias would be immediately triaged for intensive tertiary level care.

Indeed, we should all be vigilant, because there is an infectious disease in our midst. Good personal hygiene is crucial, now and at all times, even after this crisis. If you are not well, as always, seek medical advice.

But there is certainly no need to panic and there is no national emergency here.

There is already too much misinformation and misperception of the situation out in the lay media without having to distract the public with the hype about a national emergency.

Dr Ng Swee Choon
Member, Medical Affairs Committee
Federation of Private Medical Practitioners' Associations Malaysia

H1N1: Health curfew 'a last resort'

Health curfew 'a last resort'

2009/08/18

Annie Freeda Cruez and Shuhada Elis

H1N1 situation 'manageable', people advised to play their part in preventing the disease from spreading.

KUALA LUMPUR: “No” to health curfew.

Both the National Security Council and the Health Ministry said the situation in the country was manageable, with the influenza A (H1N1) mortality rate at only 0.007 per cent.

National Security Council director-general Datuk Mohamed Thajudeen Abdul Wahab told the New Straits Times that declaring a curfew would be the last resort, where the situation had reached the worst case scenario.

“We are far from that level,” he said.

On Monday, Health Minister Datuk Seri Liow Tiong Lai said the H1N1 outbreak was a “national health emergency” and the government would consider a curfew should the mortality rate rise above 0.4 per cent.

Thajudeen said several agencies, including the council, were working closely with the Health Ministry to monitor the situation.

“We have been having regular meetings with the ministry, some
times more than once a week,” he said.

He added that the government needed cooperation from the public
to curb the spread of the virus and asked those who were sick to quarantine themselves.

Health director-general Tan Sri Dr Ismail Merican, appearing on a
NSTLive session at Balai Berita yesterday, said the ministry would not advise the government to impose a health curfew just yet.

He said a health curfew would not stop the virus from spreading.

“You impose a curfew for one or two weeks, what do you do after
that? Continue with the curfew or stop it? Let’s say you stop it but do you think the virus will just go away?

“The virus is not going to go away, it is going to stay for a long time.”

Dr Ismail said a health curfew would not improve the situation.

“Rather than impose a health curfew, it will be better if all Malaysians played their part in delaying the spread of the disease while the ministry concentrated on giving treatment.”

He felt strongly that there was a lot more that the ministry could do, through the cooperation of the public, corporate bodies, business enterprises and others, to delay the spread of the disease.

Dr Ismail said Malaysians should go on with their normal life but strictly adhere to personal hygiene, such as washing their hands with soap and water and using hand sanitiser, to avoid being infected.

"Please wear your face mask if you are sick. By doing so, you will protect others from being infected," he said, adding that Malaysians could demand for a national health emergency or health curfew.

But he warned that if they were not disciplined enough, then all the measures put in place would not help in containing the H1N1.

Malaysian Medical Association president Dr David K.L. Quek concurred with the decision, saying that the World Health Organisation and the Centers for Disease Control and Prevention in the United States had never mentioned a curfew.

He said Mexico, which announced a one-week curfew in May to contain the virus, only did so because they did not know what they were facing as the virus was then new.

Yesterday, the Health Ministry recorded three more deaths, raising the death toll to 67 with 4,501 confirmed cases.

Dr Ismail said 276 H1N1 patients were being treated in hospitals nationwide and that 36 were in intensive care units. Of those in the ICUs, 21 are in the high-risk category and suffering from various complications due to their illnesses.

Health DG says doctors must assume all flu cases to be H1N1

Health DG says doctors must assume all flu cases to be H1N1














Live videocast of the interview...

NST Online Private doctors, staff also hit by H1N1

NST Online Private doctors, staff also hit by H1N1















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Managing schools during the current pandemic (H1N1) 2009

Managing schools during the current pandemic (H1N1) 2009 – Reactive and proactive school closures in Europe (European Centre for Disease Prevention & Control, ECDC)

Proactive school closures, that is, closing schools ahead of a pandemic arriving in an area, is a public health measure that has been commonly suggested for mitigating the impact of pandemics. It has been suggested that they could help because children are considered to be more infectious and susceptible to seasonal influenza than adults and can therefore be important vectors of transmission. Similarly, the high contact rates among children in schools favour transmission.[1,2] This is an area that is addressed with other public health measures in the ECDC ‘Menu’ on Public Health Measures.

Here it is important to distinguish between proactive closures of schools (which means closing schools just as, or even before, they are affected by a pandemic) and reactive closures, which occur simply because many students or staff are sick and the schools cannot function for a while (Table 1).

It was hoped by some that closing schools proactively during a pandemic may break some chains of transmission and so reduce the total number of cases. This would, to some extent, slow the epidemic, giving a little more time for final preparations and vaccine development and production, as well as reducing the incidence of cases at the peak of the epidemic. The latter effect in particular, would limit both the stress on healthcare systems and peak absenteeism in the general population.

However, though some health benefits can be expected, there is still considerable debate about if, when and how, proactive school closure policy should be implemented.[3]

There is no consensus on the scale of the benefits to be expected but the most recent scientific review addressing the general issue, conducted by a European group of authors from the UK, France, Sweden and ECDC, concluded that proactive school closures could indeed be beneficial in the ways described above, but only if the children do not simply mix elsewhere outside the schools.[4]

Any benefits, however substantial, must be weighed against the potential high economic and social costs of proactively closing schools.[3,4] Particularly critical may be the negative impact of unplanned school closures on key health workers since, for example, many doctors and nurses are also parents with dependent children.[4]

There are also many important operational issues related to school closures which, though not insuperable, need careful preparation. It is also important to remember the many educational and social functions that schools deliver which would be lost, especially by prolonged closures (Table 2).

The current pandemic (H1N1) 2009 is proving especially challenging when considering school closures. The heterogeneous and unpredictable distribution of outbreaks and the mild nature of the illness in most people means that, by the time it becomes clear that the infection is in a school, it is too late for a proactive closure.

For example, the Centers for Disease Control and Prevention (CDC) in North America, has moved away from recommending that authorities consider proactive closures. The CDC is also emphasising the importance of local flexibility and local decisions.[2,5]

Within Europe there are different traditions with regard to school closures, and schools and school systems are often administratively complex bodies not necessarily under a single national authority. Communication of the policies to the public presents particular challenges in a European context where some countries (or even regions within a country) may close schools proactively, others perhaps only reactively and some not close them at all. In their paper published in The Lancet, the authors point out that historical experience shows that some schools close during pandemics just because of high levels of illness-related absenteeism. That has been the experience to date in North America.[4,6] It therefore seems sensible for countries and schools to at least have plans for reactive closures.

Table 1: Definitions and types of school closure

School closure: Closing a school and sending all the children and staff home.
Class dismissal: A school remains open with administrative staff but most children stay home.
Reactive closure: Closing a school when many children and/or staff are experiencing illness.
Proactive closure: School closure or class dismissal before significant transmission among the school children occurs.

Table 2: Operational questions concerning school closure to be considered during pandemic (H1N1) 2009

• The need for local sensitivity in timing in larger countries as the pandemic spreads; even if proactive school closures are considered desirable, it will not be necessary for all schools to close in all parts of a country at once, despite the communication and administrative advantages of doing so.
• What should be the trigger for proactive closures? Some suggested triggers are:
  • The first case/outbreak involving the pandemic strain confirmed in a child or teacher.
  • Outbreaks in neighbouring/nearby schools.
• What should be the trigger for re-opening? Low levels of transmission in surrounding community?
• What should be the recommended length of time of closure?
• How to sustain teaching and learning over prolonged periods of closure, especially for pupils approaching examinations.
• How to maintain contact between the schools and families and teachers; the advantages of ‘class dismissal’ over ‘school closures’.
• Anticipate group childcare arrangements so that any healthcare benefits are not undermined; consider organised approaches to alternative childcare.
• How to sustain vital social functions of some schools, especially with regard to disadvantaged and vulnerable families.
• Consider the major complexities of school systems that comprise state schools, independent schools, faith-based schools and the fact that decisions on school closures are often a matter for local not central government, i.e. some European countries find it much harder than others to have command and control relations with schools.
• Consider the potential loss of earning of parents who have to take time off work.
• Establish agreements between sectors (such as education and health) so that one does not undermine the other.
• Consider the communication issues inherent in explaining different policies in neighbouring countries or even adjoining administrations.

• Consider early warning mechanisms so that adjoining administrations are aware of imminent decisions.
• Should Tertiary (Higher) Education and pre-school care be included?

References

1. Glass RJ, Glass LM, Beyeler WE, Min HJ. Targeted social distancing design for pandemic influenza. Emerging Infectious Diseases 2006;12(11):1671-1681.
2. CDC United States Department of Health and Human Services and Centers for Disease Prevention and Control. Interim pre-pandemic planning guidance: Community strategy for pandemic influenza Mitigation in the United States. Dec 2006
3. Inglesby TV, Nuzzo JB, O'Toole T, Henderson DA. Disease mitigation measures in the control of pandemic influenza. Biosecur Bioterror 2006;4(4):366-75
4. Cauchemez S, Ferguson NM, Wachtel C, Tegnell A, Saour G, Duncan B, et al. Closure of schools during an influenza pandemic. Lancet Infect Dis 2009; 9: 473–81.
5. CDC Update on School (K – 12) and Child Care Programs: Interim CDC Guidance in Response to Human Infections with the Novel Influenza A (H1N1) Virus
6. Weisfuse I. Presentation to ECDC on Outbreak of Influenza A(H1N1)v in New York

H1N1 update: EU health authorities agree on common approach

EU health authorities agree on common approach to H1N1 flu

BRUSSELS, Aug 13 — The European Union (EU) Health Security Committee has agreed on a coordinated EU approach to the Influenza A/H1N1, the European Commission said Thursday.

China's Xinhua news agency reported that the committee has adopted two policy statements on public health measures, which set out a common approach on what kind of school closures may be most appropriate to protect public health, and how to balance freedom of movement and public health protection for travellers with flu symptoms.

The European Commission, the executive body of the EU, proposed the statements as part of the broader strategic planning for coordinated efforts in the EU in fighting the A/H1N1 flu.

In the statement on school closures, the committee says there is no need to enact preemptive mass school closures at present.

Decisions on school closures are the sole responsibility of each EU member state based on the epidemiological situation in each country, it says.

In the statement concerning travel, the committee provides a set of options on what to do in a situation where a traveller falls ill before or during travel, adding that the overriding public health recommendation to symptomatic individuals remains to delay travel and stay at home.

However, this public health recommendation should not lead to restriction of movement at the EU borders and travel restrictions between EU member states, it says.

The EU Health Security Committee, established in 2001, was given the responsibility to exchange information on health-related threats and to share information and experience on preparedness and response plans and crisis management strategies.

The committee is chaired by the European Commission and consists of officials from EU member states. – Bernama

H1N1 opinion: Whose fault is it that leads to the high mortality?

Whose fault is it that leads to the high mortality?

By LIM SUE GOAN, My Sin Chew, Opinion, 2009-08-13 14:13

The influenza A (H1N1) mortality rate in Malaysia is close to 2% instead of the 0.1% to 0.4% as estimated by the Health Ministry. It reflects an unusual phenomenon. Without finding out the crux of the problem, assuming that 5 million of people are infected, probably 100,000 of them will die, instead of 5,000 to 28,000 as estimated by the World Health Organization (WHO).

If we compare to other countries, we can see the inadequacy of prevention and control in Malaysia. Vietnam reported 1211 confirmed cases with one death and the mortality rate of 0.08%. While Hong Kong reported 5991 confirmed cases with four deaths and the mortality rate of 0.067%. Australia reported 27,663 confirmed cases with 95 deaths and the mortality rate of 0.34%. Even Singapore that found death cases earlier than Malaysia, reported only nine deaths.

The Health Ministry believed that the domestic confirmed cases are far lesser than the announced amount, and said it should be multiply by 20 to get the correct data. But if we compare it to other countries calculated based on the announced confirmed cases, their rates are still lower than ours.

"Many people complaint that government hospitals have been reacting too slow to the influenza..."

Why was our death toll increased to 44 people within three weeks after the first death case reported on 22 July? And why are we having over 200 new cases each day, causing the epidemic to fall out of control?

Such a high mortality rate might be caused by a variation of the virus, weak immune system of Malaysians, poor public health system and ability to deal with an emergency. The former two causes have very low probability. If there is a variation or a new virus, the Health Ministry would have recognized it through the autopsy reports. And no matter how weak is the Malaysians immune system, it would not have killed six to eight people every day. The key should be the public health system and the mobility of medical personnel.

Hong Kong, Japan and Australia no longer take the quarantine measures, but they are still having a low mortality rate because of their sound public health systems in which their medical personnel treat the high-risk patients first.

Many people complaint that government hospitals have been reacting too slow to the influenza, including spending a lot of time waiting for tests and long testing time. Many patients might have missed the golden time for treatment during the waiting period and died.

In addition, during the early stage, the government treated the epidemic with neglect, low efficiency and it did not see it as a serious infectious disease. If the government has held a large-scale awareness and hygiene campaign, including stopping assemblies, the epidemic would not have lost control.

The people lost the sense of crisis because the government did not propagate it through the media at that time as they took into account the impact of it on the national economy, especially on tourism.

Such a serious epidemic has tested Prime Minister Datuk Seri Najib Tun Razak’s governing philosophy of “people first, performance now”. The government must take urgent measures and emergency means, including having early school holiday and a general mobilisation of medical resources, to prevent the spread of the influenza. Any hesitation will further push up the death toll. (By LIM SUE GOAN/Translated by SOONG PHUI JEE/Sin Chew Daily)

( The opinions expressed by the writer do not necessarily reflect those of MySinchew ) MySinchew 2009.08.13

A/H1N1 update: AntiViral drugs Offer 'Small Benefits' to Kids with Mild Seasonal Flu

Physician's First watch: 11 August, 2009; by David G. Fairchild, MD, MPH, Editor-in-Chief

Oseltamivir and Zanamivir Offer 'Small Benefits' to Kids with Mild Seasonal Flu

In treating seasonal flu, oseltamivir and zanamivir (marketed, respectively, as Tamiflu and Relenza) offer "small benefit" to young children, a BMJ meta-analysis finds. One of the authors is being widely quoted as saying that use of the drugs in mild flu is "inappropriate."

Analysts looked at randomized trials using the neuraminidase inhibitors either for treatment or postexposure prophylaxis of seasonal influenza. (The authors say there isn't enough information on which to base an analysis of the drugs in novel H1N1 flu.)

In studies comprising some 2600 children aged 12 or under:

• symptoms resolved about a day earlier with treatment;
• therapy did not lessen asthma exacerbations;
• the drugs conferred about an 8% reduction in risk when used as prophylaxis;
• oseltamivir increased the risk for vomiting.

The authors warn that it's "difficult to know the extent to which these findings can be generalized" to children with novel H1N1 disease.

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Full BMJ Paper:

Published 10 August 2009, doi:10.1136/bmj.b3172
Cite this as: BMJ 2009;339:b3172

Neuraminidase inhibitors for treatment and prophylaxis of influenza in children: systematic review and meta-analysis of randomised controlled trials

Matthew Shun-Shin, academic foundation year 2 doctor¹, Matthew Thompson, senior clinical scientist², Carl Heneghan, clinical lecturer², Rafael Perera, university lecturer in medical statistics², Anthony Harnden, university lecturer in general practice², David Mant, professor of general practice²

¹ Kadoorie Centre, John Radcliffe Hospital, Headington, Oxford OX3 9DU, ² Oxford University Department of Primary Health Care, Rosemary Rue Building, Headington, Oxford OX3 7LF

Correspondence to: M Thompson matthew.thompson@dphpc.ox.ac.uk

Abstract

Abstract
Introduction
Methods
Results
Discussion
References

Objective To assess the effects of the neuraminidase inhibitors oseltamivir and zanamivir in treatment of children with seasonal influenza and prevention of transmission to children in households.

Design Systematic review and meta-analysis of data from published and unpublished randomised controlled trials.

Data sources Medline and Embase to June 2009, trial registries, and manufacturers and authors of relevant studies.

Review methods Eligible studies were randomised controlled trials of neuraminidase inhibitors in children aged 12 in the community (that is, not admitted to hospital) with confirmed or clinically suspected influenza. Primary outcome measures were time to resolution of illness and incidence of influenza in children living in households with index cases of influenza.

Results We identified four randomised trials of treatment of influenza (two with oseltamivir, two with zanamivir) involving 1766 children (1243 with confirmed influenza, of whom 55-69% had influenza A), and three randomised trials for postexposure prophylaxis (one with oseltamivir, two with zanamivir) involving 863 children; none of these trials tested efficacy with the current pandemic strain.

• Treatment trials showed reductions in median time to resolution of symptoms or return to normal activities, or both, of 0.5-1.5 days, which were significant in only two trials.
  
• A 10 day course of postexposure prophylaxis with zanamivir or oseltamivir resulted in an 8% (95% confidence interval 5% to 12%) decrease in the incidence of symptomatic influenza.
  
• Based on only one trial, oseltamivir did not reduce asthma exacerbations or improve peak flow in children with asthma.
• Treatment was not associated with reduction in overall use of antibiotics (risk difference –0.30, –0.13 to 0.01).
• Zanamivir was well tolerated, but oseltamivir was associated with an increased risk of vomiting (0.05, 0.02 to 0.09, number needed to harm=20).

Antiviral drug use in confirmed influenza









Incidence of confirmed symptomatic influenza in
paediatric contacts of index cases with clinical influenza












Conclusions

• Neuraminidase inhibitors provide a small benefit by shortening the duration of illness in children with seasonal influenza and reducing household transmission.
  
• They have little effect on asthma exacerbations or the use of antibiotics.
  
• Their effects on the incidence of serious complications, and on the current A/H1N1 influenza strain remain to be determined.

Implications for seasonal and pandemic influenza

• For children with seasonal influenza neuraminidase inhibitors seem to have a small effect in terms of reducing duration ofillness of between 0.5 and 1.5 days.
  
• There is currently no evidence to single out special treatment for children with asthma.
  
• It is difficult to know the extent to which these findings can be generalised to children in the current A/H1N1 pandemic.
  
• At present, most cases in children have been mild, but recommendations in several countries encourage treatment of children with suspected or confirmed A/H1N1 flu.
  
• While morbidity and mortality in the current pandemic remain low, a more conservative strategy might be considered prudent, given the limited data, side effects such as vomiting, and the potential for developing resistant strains of influenza.
  
• Use of neuraminidase inhibitors to limit the spread of influenza is a key component of containment strategies.
  
• The evidence of magnitude of this effect (at least for seasonal influenza) is now clear: 13 people need to be treated to prevent one additional case.
  
• In a prolonged pandemic, however, those most likely to be treated (such as healthcare professionals) might require multiple courses as the number of contacts escalates.

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H1N1 Flu CDC Guidelines: School Responses...

CDC Guidance for State and Local Public Health Officials and School Administrators for School (K-12) Responses to Influenza during the 2009-2010 School Year

Physician First Watch Summary (by David G. Fairchild, MD, MPH, Editor-in-Chief):

If H1N1 severity is the same as during the spring outbreak, the CDC advises that:

• ill students and staff should remain at home for 24 hours after they are free of fever (without use of fever-lowering drugs);
• those who are sick at school should be separated from others until they can be sent home.

If the virus shows increased severity compared with the spring outbreak:

• students and staff should be screened on arrival at school and sent home if ill;
• people at high risk for complications or with ill household members should stay home;
• sick people should stay home for at least 7 days, even if they become asymptomatic.

This document provides guidance to help decrease the spread of flu among students and school staff during the 2009-2010 school year. This document expands upon earlier school guidance documents by providing a menu of tools that school and health officials can choose from based on conditions in their area.

It recommends actions to take this school year and suggests strategies to use if CDC finds that the flu starts causing more severe disease. The guidance also provides a checklist for making decisions at the local level.

Detailed information on the reasons for these strategies and suggestions on how to use them is included in the Technical Report.

Based on the severity of 2009 H1N1 flu-related illness thus far, this guidance also recommends that students and staff with influenza-like illness remain home until 24 hours after resolution of fever without the use of fever-reducing medications.

For the purpose of this guidance, “schools” will refer to both public and private institutions providing grades K-12 education to children and adolescents in group settings. The guidance applies to such schools in their entirety, even if they provide services for younger or older students. Guidance for child care settings and institutions of higher education will be addressed in separate documents.

The guidance is designed to decrease exposure to regular seasonal flu and 2009 H1N1 flu while limiting the disruption of day-to-day activities and the vital learning that goes on in schools. CDC will continue to monitor the situation and update the current guidance as more information is obtained on 2009 H1N1.

• About 55 million students and 7 million staff attend the more than 130,000 public and private schools in the United States each day.
  

• By implementing these recommendations, schools and health officials can help protect one-fifth of the country’s population from flu.
  

• Collaboration is essential: CDC, the U.S. Department of Education, state and local public health and education agencies, schools, students, staff, families, businesses, and communities all have active roles to play.

The decision to dismiss students should be made locally and should balance the goal of reducing the number of people who become seriously ill or die from influenza with the goal of minimizing social disruption and safety risks to children sometimes associated with school dismissal.

Based on the experience and knowledge gained in jurisdictions that had large outbreaks in spring 2009, the potential benefits of preemptively dismissing students from school are often outweighed by negative consequences, including students being left home alone, health workers missing shifts when they must stay home with their children, students missing meals, and interruption of students’ education.

Still, although the situation in fall 2009 is unpredictable, more communities may be affected, reflecting wider transmission. The overall impact of 2009 H1N1 should be greater than in the spring, and school dismissals may be warranted, depending on the disease burden and other conditions. (See the Technical Report for discussion of the kinds of circumstances that might warrant preemptive school dismissals.)

Recommended school responses for the 2009-2010 school year

Under conditions with similar severity as in spring 2009

• Stay home when sick: Those with flu-like illness should stay home for at least 24 hours after they no longer have a fever, or signs of a fever, without the use of fever-reducing medicines. They should stay home even if they are using antiviral drugs. (For more information, visit http://www.cdc.gov/h1n1flu/guidance/exclusion.htm.)
• Separate ill students and staff: Students and staff who appear to have flu-like illness should be sent to a room separate from others until they can be sent home. CDC recommends that they wear a surgical mask, if possible, and that those who care for ill students and staff wear protective gear such as a mask.
• Hand hygiene and respiratory etiquette: The new recommendations emphasize the importance of the basic foundations of influenza prevention: stay home when sick, wash hands frequently with soap and water when possible, and cover noses and mouths with a tissue when coughing or sneezing (or a shirt sleeve or elbow if no tissue is available).
• Routine cleaning: School staff should routinely clean areas that students and staff touch often with the cleaners they typically use. Special cleaning with bleach and other non-detergent-based cleaners is not necessary.
• Early treatment of high-risk students and staff: People at high risk for influenza complications who become ill with influenza-like illness should speak with their health care provider as soon as possible. Early treatment with antiviral medications is very important for people at high risk because it can prevent hospitalizations and deaths. People at high risk include those who are pregnant, have asthma or diabetes, have compromised immune systems, or have neuromuscular diseases.
• Consideration of selective school dismissal: Although there are not many schools where all or most students are at high risk (for example, schools for medically fragile children or for pregnant students) a community might decide to dismiss such a school to better protect these high-risk students.

Under conditions of increased severity compared with spring 2009

CDC may recommend additional measures to help protect students and staff if global and national assessments indicate that influenza is causing more severe disease.

In addition, local health and education officials may elect to implement some of these additional measures. Except for school dismissals, these strategies have not been scientifically tested.

But CDC wants communities to have tools to use that may be the right measures for their community and circumstances.

• Active screening: Schools should check students and staff for fever and other symptoms of flu when they get to school in the morning, separate those who are ill, and send them home as soon as possible. Throughout the day, staff should be vigilant in identifying students and other staff who appear ill.
• High-risk students and staff members stay home: People at high-risk of flu complications should talk to their doctor about staying home from school when a lot of flu is circulating in the community. Schools should plan now for ways to continue educating students who stay home through instructional phone calls, homework packets, internet lessons, and other approaches.
• Students with ill household members stay home: Students who have an ill household member should stay home for five days from the day the first household member got sick. This is the time period they are most likely to get sick themselves.
• Increase distance between people at schools: CDC encourages schools to try innovative ways of separating students. These can be as simple as moving desks farther apart or canceling classes that bring together children from different classrooms.
• Extend the period for ill persons to stay home: If influenza severity increases, people with flu-like illness should stay home for at least 7 days, even if they have no more symptoms. If people are still sick, they should stay home until 24 hours after they have no symptoms.

• School dismissals: School and health officials should work closely to balance the risks of flu in their community with the disruption dismissals will cause in both education and the wider community. The length of time schools should be dismissed will vary depending on the type of dismissal as well as the severity and extent of illness. Schools that dismiss students should do so for five to seven calendar days and should reassess whether or not to resume classes after that period. Schools that dismiss students should remain open to teachers and staff so they can continue to provide instruction through other means.

  Reactive dismissals might be appropriate when schools are not able to maintain normal functioning for example, when a significant number and proportion of students have documented fever while at school despite recommendations to keep ill children home.

  Preemptive dismissals can be used proactively to decrease the spread of flu. CDC may recommend preemptive school dismissals if the flu starts to cause severe disease in a significantly larger proportion of those affected.

Deciding on a course of action

CDC and its partners will continuously look for changes in the severity of influenza-like illness and will share what is learned with state and local agencies. However, states and local communities can expect to see a lot of differences in disease burden across the country.

Every state and community has to balance a variety of objectives to determine their best course of action to help decrease the spread of influenza.

Decision-makers should explicitly identify and communicate their objectives which might be one or more of the following:

• (a) protecting overall public health by reducing community transmission;
  

• (b) reducing transmission in students and school staff; and
  

• (c) protecting people with high-risk conditions.

Some strategies can have negative consequences in addition to their potential benefits. In the particular case of school dismissals, decision-makers also must consider and balance additional factors:

• (a) how to ensure students continue to learn;
  

• (2) how to provide an emotionally and physically safe place for students; and

• (3) how to reduce demands on local health care services.

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In the CDC technical report the details are very similar to what we have been advocating:

If influenza severity increases, school-aged children who live with people with influenza-like illness should remain home for 5 days from the day the first household member got sick. This is the time period they are most likely to get sick themselves.

• The greatest risk of transmission is during the first 5 days of illness of the first ill household member (about 90%), with the largest transmission risk by Day 1 of this person’s illness (about 40%).

• Keeping all the children in the household at home during this time period may also keep the flu virus from being spread to others outside the home.

• If a household member develops an acute respiratory illness during this time, the recommendations for exclusion of persons with influenza-like illness should be implemented.

• The five-day period does not need to start again for other well children in the household.

Increase social distances within the school environment

If influenza severity increases, schools should explore innovative methods for increasing social distances within the school environment. The goal should be to keep distance between people at most times or to cluster students in small, consistent groups. This is not a simple or easy strategy for most schools. Implementing any of the following options would require considerable flexibility and willingness to change among students, staff, and families. Some possible options to increase the amount of space between students or to keep consistent groups of students include:

• rotate teachers between classrooms while keeping the same group of students in one classroom (in middle and high school);
• cancel classes that bring students together from multiple classrooms (in elementary school);
• postpone class trips that bring students together from multiple classrooms or schools in large, densely-packed groups;
• hold classes outdoors;
• discourage use of school buses and public transit;
• divide classes into smaller groups;
• move desks farther apart; and
• move classes to larger spaces, when available, to allow more space between students.

Extended exclusion period

• If influenza severity increases, individuals with influenza-like illness should remain at home for at least 7 days, even if symptoms resolve sooner.

• Individuals who are still sick 7 days after they become ill should continue to stay home until at least 24 hours after symptoms have resolved.

H1N1 Flu: What's Current, Some Dos & Don'ts...

Here are some Queries from the Press that I have collated and answered:

A(H1N1) Flu: Updates on 10 FAQs

by Dr David KL Quek
President MMA.

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%, have severe features including the dangerous pneumonia.

However, from sentinel testing and surveillance by the Ministry of Health the last few weeks have shown that almost 95% 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%) 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 1000 patients queue anxiously at Sg 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 percent will get better on their own, with symptomatic treatment—just watch out for possible complications, and risk factors as mentioned above.

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 thus these tests 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 virus.

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 relatives.

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 >90% of infected people will recover with very little after effects. Possibly only one in ten 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 who have been shown to have been penetrated by the H1N1 flu bug.

Our MOH has actually stockpiled some 2 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% 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 USA, Vietnam, UK, 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 1 to 2 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 is 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 to 30% 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 6 months to extend to so many countries, this H1N1 flu did so in less than 6 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 5000 to 27000 infected patients (depending on the case fatality rate or either 0.1 to 0.5%) 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 3-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 3 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 to 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.

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