H1N1 update: Sunday Star-How Mexico licked the flu...

How Mexico licked the flu

Sunday Star: August 16, 2009

BY PAUL GABRIEL

Football matches were played to empty stadiums, no more than six people were allowed into an elevator, and press conferences were held in the open air. These were some of the strict measures taken to contain the influenza A (H1N1) in Mexico City, shares Mexico’s Deputy Foreign Minister Lourdes Aranda.

SINCE Mexico reported its first cases of the H1N1 flu virus to the World Health Organisation (WHO) on April 23, the virus has spread with unprecedented speed to 170 countries and territories worldwide, with 177,450 confirmed cases.

It was later that day that Canadian public health authorities announced that the Mexican virus was the H1N1 “swine flu” virus.

Health authorities around the world went on an alert as WHO disclosed that several hundred cases of “swine flu” were reported in Mexico, with Mexican authorities speaking for the first time of an epidemic.

Mexican President Felipe Calderon declared an emergency and ordered the closure of schools, nurseries, universities, theatres and museums until further notice in Mexico City, the world’s most populous city with 24 million inhabitants, to stop the spread of the disease.

The emergency gave the president powers to order quarantines and suspend public events. Football matches in the soccer-crazed nation were played to empty stadiums.

Aranda: ‘I think what is important is that we will learn from this experience and we are open about it.’

For those who had to go out, wearing mouth masks were a must as “swine flu” fear gripped the capital city.

“The Mexican way of life came to an abrupt halt. Imagine, in a colourful and bustling city, people had to stay home for days. And the president led by example,’’ Mexico’s Deputy Foreign Minister Lourdes Aranda tells Sunday Star in an interview.

“It was exemplary how the people came together and supported the effort. The health of Mexicans was a cause we defended with unity,’’ adds Aranda, who held discussions with Wisma Putra on Wednesday.

In the days leading to the state of emergency imposed, at least 20 deaths from the virus had been confirmed in Mexico, with 68 other deaths attributed to the virus.

While the deputy minister says that the worst is over for her country as far as the A (H1N1) threat is concerned, the latest news is that officials in Mexico’s Chiapas state postponed classes for over 1 million students in an effort to avoid a resurgence of the flu.

Aranda contends that there is no evidence that the outbreak actually started in her country.

“We must also find out where the outbreak began, it was not in Mexico. We (Mexico) believe that it started in the US but we don’t know which region,’’ she says.

Q: The world, including Malaysia, is facing a deadly H1N1 pandemic since it emerged in Mexico in April. How did you face the crisis?

A: It’s really incredible, now that we’ve had some months to reflect on it. We reacted with discipline. President Calderon was criticised by some sectors because he basically shut down the economy to stop the spread of the virus. It was a complete standstill in Mexico City with schools and offices closed. Only the police who were involved in duty during the emergency were allowed to go out with all precautions in place. And there was a very specific protocol to follow to take the elevator, and for washing our hands. Not more than six people were allowed in an elevator. Press conferences about the epidemic were held out in the open.

We already had a very good plan with the United States and Canada for an emergency situation but that was more for a terrorist or anthrax attack. In the beginning, nobody knew what it was except that it was a new virus. We didn’t know where it originated. We thought it was very deadly; later we found out that it was very infectious but not so deadly once we knew how to treat it. It was dangerous because Mexicans have this habit of not going to the doctor. So, many people with flu did not see a doctor. By the time they got to the hospital, they were really sick.

Q: All schools, nurseries, public and private institutions were closed in the capital?

A: Yes, that’s correct. Only emergency services could operate. There were no cinemas, no bars, no parties. The president came on TV and told the people to stay home. He meant everyone – rich or poor; imagine, in 24 million-people Mexico City. The Mexican way of life came to a halt; people sitting at home without going to cinemas or to church. The capital city is ruled by the Opposition, but they worked hand-in-hand with President Calderon.

It was about 10pm when the president was told that it was a new virus, after the Canadians confirmed it (on April 23). The moment he knew that, he went on TV and addressed the people. He ordered schools (in Mexico City) to be closed immediately. It was a Thursday of the Holy Week (preceding Easter Sunday) and it was going to be a long weekend.

Some parents were upset, asking what they were going to do with the children at home. When the situation did not improve over the long weekend, the schools were ordered to remain closed for the full week.

Q: Did the president himself go to work? Where did you operate from?

A: The president did not go to office. We did have meetings but they were held outdoors because it is harder for the virus to thrive outdoors. About 10% of the staff at the Foreign Ministry were allowed to work. I went in wearing a mouth mask or I wouldn’t be allowed to enter. Everything inside (buildings) was kept clean, including the elevators. We didn’t kiss or shake hands with anyone. The Health Minister held meetings with the press twice daily as sharing information was vital.

It was complicated because we are a Federal Republic, so not all governments complied as quickly by giving the exact number (of those affected by the virus). In the end, everyone, even the Opposition, put their faith on the central government. Our discipline was amazing. It was a great, positive attitude from the population for everyone’s well-being. There was no paranoia.

Q: All Mexicans were united? Nobody opposed the measures?

A: At the start, there were those who opposed the president’s measures, as business was being affected. And during Cabinet meetings, some ministers disagreed with the president. But President Calderon told them he was not going to take any chances. He kept the schools closed. He wanted this as there was no other way to stop the spread of the virus among children. Mexico is a very polarised society with lots of political parties and opposition towards President Calderon. But everybody supported him on this. The authorities even closed down Congress. The president has no power to do this on his own.

Q: How long did it take for Mexico to contain the virus?

A: It was about a month to a month-and-a-half. I think what Mexico did was very responsible in terms of global health. We took the blow economically but it was the best thing to do. We didn’t hide anything, right from the first case that was detected.

Now we are recovering, and tourism is getting back to normal levels again. We had some cases of discrimination (against Mexican travellers), but not as many as we expected. At this stage, the Mexican Ambassador to Malaysia Jorge Alberto Lozoya interjects: “Malaysia was wonderful. The reaction of both the people and the Government was excellent. We even had the support of the Malaysian government to mobilise (Mexicans) who were stranded in Singapore and Cambodia.”

Q: Was the supply of medicine adequate? How many million doses of anti-viral were distributed to Mexicans?

A: The anti-viral Tamiflu was effective when it was administered to patients on time. We do not have the capacity to develop our own vaccine but we have very good doctors. We only gave the anti-viral to those who were sick and not to everybody, because supply would easily run out otherwise.

Q: Malaysia is now facing the brunt of the A (H1N1) virus. What was Mexico’s strong prevention strategy?

A: We had to be very responsible. All those who were down with the virus were immediately isolated. We followed a very strict protocol, even in our homes. Every time we touched anything, we washed our hands. We used our arms to cover our mouths when we sneezed. We even used our elbows to press the lift buttons. During meetings, we will observe each other and if anyone put their fingers close to their face, we would alert them! I don’t know if it is the same here, but in Mexico, those who died were very young people. It was very strange. We still don’t know why.

There must be a study done to find out. We must also find out where the outbreak began; it was not in Mexico. We (Mexico) believe that it started in the US but we don’t know which region.

Q: According to the official information, the new virus was first reported in Veracruz, Mexico, on April 11. Are you disputing that?

A: It didn’t start in Mexico. They say it is an Asian virus which has been confined several times but there is no point going on about this. What is true is that it didn’t start in the place they said it did. Do you know how many people cross the (US-Mexico) border daily? There is no point in blaming as right now, the virus is everywhere. Even WHO has stopped counting (the number of cases).

Q: The European media even referred to the influenza as “Mexican flu”. How did you counter that?

A: There were about two or three countries, Germany and the Netherlands included. France was trying to suspend flights (to Mexico) but it didn’t happen. Our Ambassador explained the issue to the European Union. Argentina, Peru and Cuba also tried to suspend air links with us. Ignorance is terrible. In some of these countries, they were reacting to domestic issues. In Cuba, the problem was the health system was going down and they told us they couldn’t take the risk. Most of these countries later apologised.

Q: There was this proposal to close the US-Mexico border.

A: It was just what one (US) Senator proposed. We didn’t really have a problem with the US and Canada. In fact, we detected what kind of virus it was first. It also helped to find where the deficiency was in our (Mexican) health system. What is important is that we talk about these issues openly, and not hide anything.

There is no way in such an inter-dependent world anything is going to be kept from each other, good or bad. As the crisis has shown, the solution is not going to be found individually. What Mexico is trying to be is a responsible actor on the world stage. And that’s part of the reason why I have travelled here.

Q: So there are only a few isolated cases of A(H1N1) cases in Mexico now?

A: Very few, in the southern part. When I left Mexico, we didn’t have any recent deaths. Our total number of cases is nothing compared to the US or UK. I think what is important is that we will learn from this experience and we are open about it. We have to understand that we live in a global world, when something happens to a country as far away as Mexico, it can affect another.

Q: What more did Mexico derive from its experience dealing with this new, highly contagious virus which is killing humans?

A: We had a very active diplomacy explaining to the world how we were dealing with the crisis. And we sent our scientists and doctors to Spain, France and WHO. We also convened a High-Level Meeting on Learned Lessons from the Influenza A (H1N1) in Cancun in July. An initiative of the Government of Mexico, it was attended by Health Ministers from 40 countries. The objective of the meeting was to analyse the international response to the epidemic. The conference decided that there was a need to review how WHO decreed whether it was a pandemic or not, and that international co-operation was one of the most efficient tools to attend to this kind of disease.

Q: You’ve been in and out of airports. How did you find the screening of passengers for the flu virus at the KLIA?

A: I don’t think what happens in the airport is that important. It is disseminating information and creating awareness. People have to be responsible. If you feel sick, don’t get into a plane. But if you’re healthy there is no reason not to travel. In Mexico, the flu is not an issue anymore. We know that when winter comes, we will have to be more careful. But it is no longer an issue now. We are just dealing with the downturn in tourism. We are investing in a Visit Mexico campaign. There are new promotional packages, for example to Cancun. Prices are really good (smiles). Things are getting back to normal.

Q: Lastly, how did Mexico mitigate the impact on its economy?

A: As you know, we are the 13th largest economy in the world. We took the blow economically and things were complicated but now things are returning to normal. We’ve had a lot of investments from the private sector and the government to get things back on track.

People were not eating pork because it was associated with swine flu at the start. Mexicans are big eaters of pork. Now consumption is back to normal. We are large exporters of pork to Japan and Korea and our exports are back to normal.

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

US CDC: Flu.gov

Community Strategy for Pandemic Influenza Mitigation

Goals of Community Mitigation





















Effect of R0 on Hypothetical Epidemic Curves






















Projected Mortality* of a Modern Influenza Pandemic Compared with That of 20th Century Pandemics (1918, 1957, 1968)




Pandemic Severity Categories As Determined by Differences in Case Fatality Ratio






















Pandemic Severity Index





























Pandemic Severity Index by Epidemiologic Characteristics























Summary of the Community Mitigation Strategy by Pandemic Severity

H1N1 Flu: US Report--Futile exercise in Mitigation?

It is depressing to note that the US of A has just indicated that it is no longer able to contain the H1N1 flu, and that mitigation has failed, as the flu sweeps through every community, until closure of schools or offices are futile efforts...

Latest counts by WHO of H1N1 numbers are 162,230 confirmed cases and 1,154 deaths, i.e. a case fatality rate of 0.71%, underlining the fact that only more seriously ill patients are tested and confirmed thus inflating the death rate figures.

WHO also estimates that some one-third of the world's population will be exposed to this novel flu virus, thereby infecting some 2 BILLION people worldwide!

Specific A(H1N1) flu vaccines are expected only in Dec 2009, but would require 2 doses, and can only help a limited number of people, even those in the front lines who are now exposed without safety or surety of escaping infection...

H1N1 can no longer be contained

WASHINGTON, Aug 6 — Closing schools, stopping large gatherings and other such measures are unlikely to do much to prevent the spread of the H1N1 swine flu pandemic, a team of experts predicted yesterday.

They said pandemic closely resembles the pandemic of H2N2 influenza in 1957 when it quickly became apparent that there was little officials could do to stop it.

“Efforts to mitigate it were futile,” Brooke Courtney Center for Biosecurity at the University of Pittsburgh Medical Centre said in a telephone interview.

Federal officials are expected to announce their recommendations for school closures tomorrow. Local school districts and states usually make the decision to close schools, but they look to the federal government for advice.

At the height of the epidemic in May, more than 700 schools closed in the United States, according to the Department of Education.

In Mexico, where the pandemic started, officials closed government offices and schools for around two weeks in April and May, and encouraged businesses to close.

H1N1 is still circulating and, just as influenza did in 1957, it is dominating the mixture of viruses in the southern hemisphere’s flu season going on now.

In its latest update last week the World Health Organisation reported 162,230 confirmed cases and 1,154 deaths. But flu experts said this probably reflected only a fraction of the true count as not every patient can be diagnosed with a lab test.

Experts expect the flu will pick up activity in the northern hemisphere’s autumn and the WHO predicted one third of the world’s population — two billion people — will eventually be infected.

TOO WIDESPREAD

Governments are taking different approaches to slowing the spread of the virus. Last month, British experts on the spread of disease said closing schools at the first sign of a new pandemic might delay the worst so health officials can prepare, but cannot prevent the spread of the disease.

Writing in the journal Biosecurity and Bioterrorism, Courtney, Dr. DA Henderson and colleagues said it appears that the new H1N1 is now too widespread to try to stop.

“In 1957 it was decided pretty early on that efforts to quarantine or isolate people would not be effective,” Courtney said.

As happened this year, the virus first appeared in the northern hemisphere’s spring. It worsened in the fall. “The opening of schools in September appeared to be a major factor in initiating community epidemics,” the researchers wrote.

“Schools were not closed for the purpose of trying to control the spread of disease. They were closed because too many teachers or administrators or students were out,” Courtney said.

In 1957, 25 per cent of the US population became ill. Global health experts estimate two million people died.

“What we saw was that the federal government took very practical steps to deal with the expected pandemic in the fall in 1957,” Courtney said. “They understood that, yes, it was expected that there would be a lot of people who got sick.”

In 1957 it took months to make a vaccine and then it was not very effective, the researchers found.

Drug companies have started making vaccine against H1N1 swine flu. But the recommended population of 160 million people, including healthcare workers and pregnant women, cannot be fully immunised until December, experts estimate. Two doses are needed for full protection.

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.

--------------ooooooooooooooo00000000000000ooooooooooo---------------------

H1N1 Flu Guidelines: Is it Non-Compliance or Confusion?

PUTRAJAYA, July 30 - Doctors who fail to comply with the guidelines from the Health Ministry to detect the Influenza A (H1N1) infection much earlier will be called up by the Health Ministry for an explanation so that the problem would not recur.

The Director-General of Health Services, Tan Sri Dr Mohd Ismail Merican said the investigation was not meant to penalise the doctors concerned but to understand why they did not comply with the guidelines.

For this purpose, he said the Director of the Disease Control Division, Datuk Dr Hasan Abdul Rahman would instruct a team to question the doctors concerned to get further information on the medical examinations carried out.

“If there are doctors who still don't adhere to the guidelines issued by the ministry, we will call up the doctors concerned, ask them whether they understand (the guidelines issued).

“Some of them may not understand, so I will call them. Like in the case of the patient who died within 24 hours (first death of H1N1), he saw the doctor and after one hour, he died.

“So I want to find out from the doctor, did he examine the patient? And if so, why is it not recorded in the outpatient department (OPD) card? How can a patient collapse just like that?“ he said.

Dr Mohd Ismail said all doctors must also have their own computers with internet facilities to ensure that they kept abreast with current developments on the infection, particularly directives issued by the ministry on the matter.

“I was told that some doctors don't even own a computer, so please buy a computer, hook on to the internet and visit our (ministry's) website so that they will be up to date in the management of their patients, and it is not just for H1N1, it is for continual professional development (CPD).

“Find out what are the things that you need to do, be aware of things like guidelines about tamiflu, about wearing mask, about treating patients, everything is there. There is no excuse for people to say they do not know anything,” he said.

Dr Mohd Ismail said this when asked about the action to be taken against doctors who failed to adhere to the guidelines on examining Influenza A (H1N1) as stipulated by the Meeting of the Technical Committee on the Influenza A

(H1N1) yesterday. The guidelines which, among other things, stated that all severe cases of pneumonia for which a throat swab was required to be taken for Influenza A

(H1N1) tests and antiviral treatment given, were issued because there were doctors who failed to detect the ailment in the four fatal cases of Influenza A (H1N1) recorded earlier.

Asked whether the investigation was carried out in the four fatal cases earlier, Dr Mohd Ismail said so far the doctors concerned were only given reminders, and further action would depend on the subsequent developments.

He also said doctors could not refuse to see patients with influenza like illness (ILI) on their second visit, and the patients could actually insist on being tested for Influenza A (H1N1) on their second visit, if they had not recovered from their flu.

When asked about a case in Hospital Kuala Lumpur (HKL), where a patient suffering from asthma and suspected to be infected with H1N1 was asked to go home and rest instead, Dr Mohd Ismail said he would bring the matter up with HKL. - Bernama

--------------oooooo00000ooooo--------------

The MalaysianInsider has published this on 31 July 2009: H1N1 Measures: Confusion rather than Non-compliance

Malaysiakini too has published a version (31 July 2009) as Flu measures: Confusion rather than non-compliance

The news media appear to have started the blame game. More journalists are angling around the idea that because the H1N1 flu is fast spreading in the community and more and more people are reportedly succumbing to the infection, then there must be someone to blame, some agency which is at fault.

Perhaps the Health Ministry has not done enough, despite its earlier promise of containment and now mitigation. How is it that when we are now in mitigation phase, there are more people dying, comes the indignant cry of disbelief and alarm?

Sadly this is the myopic vision and misunderstanding of most people in this country. The Health Ministry and the Malaysian Medical Association (MMA) have been proactively warning of this possible scenario right from the outset of this pandemic.

But then many detractors (some tourism officials, air carriers, doctors even) have pooh-poohed our contingency plans as being too alarmist, too exaggerated, pointless even. They have been spreading counter messages that some of us have overstated the H1N1 flu threat, blowing things out of proportion, in our initial reaction to this 'benign' flu!

But I think we need not apologise for what our public health measures had been--these steps had been carefully put together according to well-thought out protocols accepted by health authorities, worldwide. It is precisely because these measures were put in place, that I think we managed to slow the unstoppable entry of this influenza into the country.

Believe it or not, our earlier stringent containment measures—which displeased many agencies, appear to have stemmed the more rapid spread of the H1N1 bug, until we are now closer to the more definitive vaccine, currently under tests.

We've also learnt from the mistakes, the resultant serious complications, the better management strategies of other countries with a runaway pandemic, such as Mexico, the United States, United Kingdom and Australia! It is our hope that we can now truly mitigate the final spread of this virus, decrease its lethality.

Perhaps, we may have a much greater chance to use the soon to be ready vaccine to help decrease the severity of this influenza, which has yet to show its potential true colors of devastation, yet to be played out...

Even among within some of our own physician communities, there have been suggestions to just let this pandemic loose into the community so that we can rapidly reach some form of spontaneous equilibrium, some herd cross-immunity, sooner.

The problem is no one wants to talk about the expected consequences of any outbreak, no matter how 'mild' or how 'generally benign' such pandemics appear to be at first glance.

Have we really considered the likely fatalities which must necessarily accompany this outbreak? Who should cope with explaining or even looking after the rising number of deaths and the very critically ill?

Now when the fatalities begin to ring in, we are suddenly sensitised to the rude truth that this H1N1 flu can kill. More disturbingly, the deaths so far have been unpredictable, the victims were not necessarily the most ill or immune-compromised to begin with, except for some comorbid features... obesity being one of them. And, these are relatively young people, who normally should not succumb to common cold/flu ailments...

To make matters worse, there appears to be more confusion on the ground. Guidelines and press releases are fine, but so far have been difficult to implement on the practical side, not necessarily due to not trying hard enough.

Reports from the mass media have been skewed differently by disparate interests, without giving the entire picture, but only highlighting preferred slants quite dependent upon the journalists covering the news, or even their editorialising staff.

Sadly, we do need all the mainstream and alternate media to play a more accurate and comprehensive role in educating and informing our citizens, not to play the blame game, nor second-guessing our hardpressed Health Ministry's personnel and facilities, or worse to apportion blame of inadequacy on the private sector, which has of late become the convenient 'whipping boy' of the media.

The dedicated H1N1 website (http://h1n1.moh.gov.my) by the MOH is not sufficiently updated and spot-on contemporary, being at least one to 2 weeks behind, except for the daily numbers and DG update. Unfortunately the website is entirely in Bahasa Malaysia, and this may discourage some people from accessing this site...

And again, how many of our citizens bother to check with these information on a compulsive manner, daily, to keep themselves totally abreast of the most current information?

Realities of the ground however, are proving to be tricky and frustrating. With the high alert mental state among some of our citizens, there has been growing exasperation for some people (including some foreigners, visitors) when trying to seek treatment and confirmation on what appears to be influenza-like illness (ILI).

Directives from the MOH are not entirely clear, and although on paper these may look good. The interpretation of what constitutes serious symptoms always pose a dilemma and a bone of contention with many a presenting patient, who demand to know for sure, to be tested and be confirmed (or dismissed), and treated appropriately, quickly.

There has been crescendoing demands for the Tamiflu antiviral drugs, which are now under strict control and distribution by the MOH. To be fair, this rationing is to prevent indiscriminate use and the possible creation of resistant strains of the H1N1 flu bug.

As of now, 21 major private hospitals have been supplied the Tamiflu antiviral drug to help look after the expected rise in H1N1 infections. Whether this stringent control is practical or simply too bureaucratic remains to be seen.

Conflicting media calls, purportedly attributed to the DG of Health, do not help the already pandemonic situation... At a press conference, a patient demanded to know why she could not be tested earlier despite having symptoms for a few days, when she had been sent away each time, by an MOH facility in KL, which prompted the DG of Health to reassure her that she should be examined and then tested. This was reported by The Star as “Docs cannot refuse requests for swabs to be taken”.

At my hospital there have angry demands for testing for the H1N1 virus: an irate expatriate father demanded to have the testing for his child who had been having mild fever for a few days, but with no other features of high risk. Because the protocol demands that the Emergency department doctor teleconsult with a MOH officer before submitting or sending a throat swab, this was not understood, especially when the MOH officer did not agree with the need for the swab or testing!

Thus, this artificial stumbling block is yet another area of gap for public-doctor misunderstanding. It is therefore, not simply a question of compliance, the ground rules are fluid and are not black or white!

This pre-approval necessity for H1N1 virus testing is making it very hard for doctors out there who are facing daily demands from worried ILI patients to be tested. Almost invariably there will be those who feel that their illness is more serious than what some of us doctors would feel otherwise, even after full examination/reassurance—so what do we do then?

In the early phases, can this ailment be so readily distinguishable from other more benign colds and other URTIs? Are we expected to be spot-on diagnosticians who must get this correct every time? Would our patients and the MOH officials understand this difficulty?

Or should we expand our testing facilities much more widely until this can be performed on demand by anyone, anytime? Would this be too expensive and would we really have sufficient test kits to answer to this need? Is this really necessary and shouldn't our citizens be made more aware of this, so that they do not panic and demand unnecessarily?

In fact, although in our frustration, the media and some of our officials may wish to find someone at fault, it is more likely that there are real logistic problems on the ground, rather than non-compliance on the part of some doctors, clinics, or even hospitals—be they private or public institutions!

We must strive to iron out some of these glitches, these inconsistencies, and perhaps, where posible, allow every health facility (public or private) to carry out such heavy demands for testing, treatment, since almost every interested physician and major medical facility have already been empowered to now treat the more seriously complicated H1N1 patient.

We have to make the handling of this pandemic easier and less bureaucratic... If the WHO projection is to be believed, it will become even more devastating once the spread escalates to unimaginable proportions!

At a recent briefing to the National Influenza Pandemic Task Force meeting (29 July 2009), Dato' Dr Tee Ah Sian, Director of communicable diseases of WHO, painted a possible scenario for the Malaysian H1N1 pandemic. While I do not wish to be alarmist, it is good to at least recognise the least impact scenario which has been projected.

For our 27.7 million population, if simply 20% are at risk and exposed, then some 5.5 million people will contract the H1N1 flu. Based on other serious influenza statistics, if 2% to 9% require hospitalisation then, some 110,000 to 500,000, respectively, would need hospital care.

From these numbers, if we estimate the case fatality rate to be from 0.1% to 0.5%, then some 5,500 to 28,000 of infected patients would die, respectively. In the latest updates of the most seriously ill patients identified and confirmed infections, the global case fatality rate has risen from the 0.4% to 0.66%...

So, the hardnosed reality is that it is more than likely that the worse is yet to come. We can only hope that this is the worst case scenario!

In the meantime, let's keep cool heads, and work together. We must maintain, even heighten our sense of vigilance, so as not to miss out the more serious complications and the more potentially at risk people, so that we can help reduce the death rate.

This pandemic is expected to linger on for at least a year or two, before it burns itself out, by hopefully mutating into a more benign form, indistinguishable from the seasonal flu bugs; or because it is finally controlled to near-eradication by specific vaccines.

But there is that possibility that it may also mutate by reassortment into a far more lethal form, that much feared second or third wave, which would then demolish all our efforts achieved thus far!

Of course, if this does not pan out, then hooray for us! We'd have survived the wiser, slightly poorer, bruised, but alive and healthy! A "Y2K-like non-event" would be a most welcome projection, if and when this does come to pass!

But, we are not anywhere near out of the woods as yet. So let's be vigilantly proactive, while remaining socially responsible.

The Health Ministry can only help put in place some instruments to help mitigate and systematically monitor the spread, but it cannot ensure our own personal health safety on this H1N1 outbreak.

Only we as individuals and groups, can. We will all have to do our part.

----------------------oooooooo00000000ooooooo---------------------------

H1N1 Flu: Is it time to move from Containment to Mitigation Mode?

H1N1 Flu escalates in Singapore with more local transmission.

A(H1N1) spreads in Singapore

A Star newspaper report puts the growing scale of this pandemic on a thought-provoking spin with the modification of public health policy now in place in Singapore.

Another 26 new cases of Influenza A(H1N1) was confirmed on Monday: 17 local cases and 9 cases with travel history, bringing the total number of confirmed cases to 168.

"In a statement Tuesday, its Health Ministry said it appeared that community spread had gathered momentum with more cases from local transmission reported."

Thus, the Singapore Health Ministry was readying local polyclinics and hundreds of general practitioners to treat suspected cases, and has incorporated these clinics to help to manage patients with influenza-like illness as the government moved from containment into mitigation mode.

Perhaps in Malaysia we may sooner than later move towards this community approach of reducing the impact by allowing more local resources to handle the outbreak and hope for it to peter out sooner once community or herd immunity gathers momentum.

Otherwise, it is becoming extremely likely that a lot of hard-earned resources and expenses would have to be expended, with the futility that the H1N1 flu is set to dominate anyway...

This appears to have been the approach of countries such as UK, Australia, New Zealand, the USA and lately even Japan. Of course places such as Thailand and Philippines are not equipped to really contain the outbreak and hence their operations are at best leaky and porous anyway.

Perhaps it is time to give the seasonal flu vaccine to all front-liners and their dependents, and then allow greater distribution of the antiviral therapies once confirmation is made by any medical practitioner, with the proviso that home quarantine be imposed and some semblance of civic duty reinforced by government media pronouncements and directives.

Employers, agencies and schools must exercise cautionary discretion to assist in mitigating these spread and hope for the pandemic to blow over.

But then again I am no expert as to how to really forecast this unprecedented new disease...

--------------------oooooooooooo00000000000000oooooooooooo--------------------------