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.

Influenza A (H1N1): Revised Guidelines from India (14 Aug 2009)

Thanks to good friend Dr Muruga Vadivale, Medical Director of Sanofi-aventis India, we have the latest guidelines from the Indian Ministry of Health and Family welfare.

Dr Muruga has been known as Cyberdoc, where he has been updating various health items particularly communicable diseases in his very comprehensive website:VADSCORNER. Check it out! Truly a treasure-trove!

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Influenza A (H1N1): Revised Guidelines released by Ministry of Health & Family Welfare - India (14 Aug 2009)

In order to prevent and contain outbreak of Influenza-A H1N1 virus for screening, testing and isolation following guidelines are to be followed:

At first all individuals seeking consultations for flu like symptoms should be screened at healthcare facilities both Government and private or examined by a doctor and these will be categorized as under:

Category- A :

• Patients with mild fever plus cough / sore throat with or without body ache, headache, diarrhoea and vomiting will be categorised as Category-A. They do not require Oseltamivir and should be treated for the symptoms mentioned above.The patients should be monitored for their progress and reassessed at 24 to 48 hours by the doctor.

• No testing of the patient for H1N1 is required.

• Patients should confine themselves at home and avoid mixing up with public and high risk members in the family.

Category-B:

1. In addition to all the signs and symptoms mentioned under Category-A, if the patient has high grade fever and severe sore throat, may require home isolation and Oseltamivir;

2. In addition to all the signs and symptoms mentioned under Category-A, individuals having one or more of the following high risk conditions shall be treated with Oseltamivir:

   • Children less than 5 years old;

   • Pregnant women;

   • Persons aged 65 years or older;

   • Patients with lung diseases, heart disease, liver disease, kidney disease, blood disorders, diabetes, neurological disorders, cancer and HIV/AIDS;

   • Patients on long term cortisone therapy.

• No tests for H1N1 is required for Category-B (1) and (2).

• All patients of Category-B (1) and (2) should confine themselves at home and avoid mixing with public and high risk members in the family.

Category-C

In addition to the above signs and symptoms of Category-A and B, if the patient has one or more of the following:

• Breathlessness, chest pain, drowsiness, fall in blood pressure, sputum mixed with blood, bluish discolouration of nails;

• Irritability among small children, refusal to accept feed;

• Worsening of underlying chronic conditions.

All these patients mentioned above in Category-C require testing, immediate hospitalization and treatment.

Source: http://mohfw-h1n1.nic.in/

Australian community’s attitude towards H1N1 flu pandemic

Pandemic (H1N1) 2009

The community’s attitude towards swine flu and pandemic influenza

Abstract

Objective: To ascertain the beliefs, perceived risks and initial attitudes of the Australian community towards the influenza pandemic declared by the World Health Organization in response to the emergence of an A(H1N1) influenza subtype.

Design, setting and participants:
Cross-sectional survey of Sydney residents during WHO Phase 5 of pandemic (H1N1) 2009. Members of the public were approached in shopping and pedestrian malls in seven areas of Sydney between 2 May and 29 May 2009 to undertake the survey. The survey was also made available by email.

Main outcome measures:













Perceived personal risk and seriousness of the disease, opinion on the government and health authorities’ response, feelings about quarantine and infection control methods, and potential compliance with antiviral prophylaxis.

Results:

• Of 620 respondents, 596 (96%) were aware of pandemic (H1N1) 2009,
  
• but 44% (273/620) felt they did not have enough information about the situation.
  
• More than a third (38%; 235/620) ranked their risk of catching influenza during a pandemic as low.
  
• When asked how they felt pandemic influenza would affect their health if they were infected, only a third (33%; 206/620) said “very seriously”.
  
• Just over half of the respondents (58%; 360/620) believed the pandemic would be over within a year.
  
• Respondents rated quarantine and vaccination with a pandemic vaccine as more effective than hand hygiene for the prevention of pandemic influenza.

Conclusions:

Emphasising the efficacy of recommended actions (such as hand hygiene), risks from the disease and the possible duration of the outbreak may help to promote compliance with official advice.

A(H1N1) virus continues to spread worldwide, more deaths reported

A(H1N1) virus continues to spread worldwide, more deaths reported

BEIJING, Aug 15 — The death toll from the A(H1N1) flu pandemic continues to rise as the new virus persists in its advance around the world, health officials say.

The European Center for Disease Prevention and Control said in its daily situation report on Wednesday that 873 new A(H1N1) flu cases were reported in the European Union and European Free Trade Association countries. The number of cases there now totals 35,025, according to a report by China’s Xinhua new agency.

The European Union Health Security Committee has agreed on a coordinated EU approach to A(H1N1) flu regarding school closures and monitoring of travellers.

The French government has prepared to close schools on a case-by-case basis if the A(H1N1) flu becomes a nationwide pandemic, Education Minister Luc Chatel said on Wednesday.

France so far has recorded around 1,000 A(H1N1) flu cases and one death.

The government fears that the spread of the virus could accelerate when the new school year starts this fall.

In Greece, the A(H1N1) flu cases totalled 1,424 as of Wednesday, including 422 additional cases confirmed during the past week.

Finland on Wednesday confirmed the second case of the flu in its Defence Forces, according to a statement released by the military.

In Latin America, where the flu began in April, more deaths have been reported in the past two weeks.

Mexico has registered 17 more deaths over the past two weeks, raising the total death toll there to 163, Health Minister Jose Angel Cordova said Thursday.

He also said the government is ready to apply the first A(H1N1) flu vaccines to cope with the virus.

Brazil remains the country with the third largest number of A(H1N1) deaths, after the United States and Argentina. It registered three more deaths from A(H1N1) flu Thursday, raising the death toll to 277.

The Brazilian Health Ministry has decided to postpone polio immunizations scheduled for Aug 22, fearing that crowding in hospitals could lead to more flu infections.

Meanwhile, Chile confirmed a total of 105 A(H1N1) deaths on Thursday while the number in Argentina stood at 386 on Wednesday.

Nicaragua on Wednesday confirmed its first A(H1N1) influenza death, a 30-year-old woman, the Health Ministry said.

The disease also was spreading to high officials in Latin America.

Costa Rican President Oscar Arias is being quarantined at home and is in stable condition after testing positive for the A(H1N1) virus, official sources said Wednesday.

Ecuadorian Policy Minister Ricardo Patino was also diagnosed with the flu, the Health Ministry reported Thursday. He is now being treated with anti-viral medicine at home.

In the northern hemisphere, the A(H1N1) virus continued to spread across the hard hit United States.

The death toll from the A(H1N1) flu by Wednesday had reached 104 in California, the most populous state in the country, with 1,057 people hospitalised, the California Department of Public Health said.

Meanwhile, the state of Lousiana, one of the few states that had reported no deaths or few confirmed cases of the flu virus, confirmed on Thursday its first death from the disease.

The deadly virus has also hit Middle Eastern countries. Israel registered its eighth victim of the pandemic on Wednesday, according to the Health Ministry.

Saudi Arabia confirmed two new deaths from the flu Thursday, bringing the total death toll there to 11. The Palestinians have confirmed only one death so far.

In Africa, the situation is more delicate given widespread poverty and diseases such as HIV and tuberculosis that make people more vulnerable to the virus.

The South African government has launched an intensive information campaign to help people cope with the pandemic, Health Minister Aaron Motsoaledi said Thursday.

He also said the country so far had 1,910 confirmed cases of A(H1N1) flu and three deaths.

The pace of the virus has not eased in Asia, either.

Malaysia reported on Thursday seven more deaths from A(H1N1) flu, bringing the total number of deaths there to 51.

On Tuesday, Thailand’s Public Health Ministry announced 16 more A(H1N1) – related deaths, raising the country’s death toll to 97.

The flu has so far killed 22 people in Bangkok, 10 in Singapore, and two in Vietnam.

On the other side of the Pacific, Jim Bishop, Australia’s chief medical officer, said Thursday that the number of A(H1N1)-related deaths in his country has reached 102.

He said 449 people are hospitalized with the flu across the country, 109 of them in intensive care.

Even the small island nation of Tuvalu has not escaped the pandemic. Its first six cases of influenza A(H1N1) were confirmed Thursday, Radio Tuvalu reported.

The flu has caused 1,462 deaths worldwide since it was first detected in April, the World Health Organisation (WHO) said Tuesday. – Bernama

H1N1 Flu: Singapore's Infections Soar...

The Straits Times of Singapore reports on July 30, that "the H1N1 flu bug is spreading like wildfire, more than doubling the number of people down with influenza."

Polyclinic attendances for upper respiratory tract infections have shot past epidemic levels — pegged at 16,665 cases a week — for the first time in more than three years.

Polyclinic attendances are a yardstick for the number of infectious diseases, as these clinics treat about 20 per cent of patients with acute ailments; national figure would be about five times that.

Two weeks ago, URTIs passed the epidemic threshold, with 18,705 cases. Last week these reached 22,880 cases.

Normally in Singapore, polyclinics see ~ 13,340 patients a week who have coughs, colds, the flu or flare-ups of chronic illnesses like asthma.

Nationwide, the number is usually 20% of the 75,000 patients that clinics see in total in any week. In July 2009, such infections accounted for more than a quarter of all cases. It is not known how many of these were caused by Influenza A (H1N1).

A Health Ministry spokesman said that most H1N1 flu patients have only mild illness and do not need antiviral medicine, such as Tamiflu; the vast majority need only conventional medicine to treat their symptoms, e.g. fever medicines, and plenty of rest.

The large increase is attributed the wider sustained community spread of H1N1 — with no immunity to the new strain, it is spreading quickly. Estimates are that more than one in two people with influenza have the H1N1 virus.

So far, 5 people in Singapore have died of it. Worldwide, there have been more than 800 deaths.

Singapore's Health Ministry spokesman said numbers are expected to stay high for another week or two as the epidemic peaks, and urged the public to seek medical treatment promptly if they are unwell and to continue exercising social responsibility.

H1N1 Flu: Onwards to Mitigation Phase...

Cumulative A(H1N1) flu cases topped 671 on 11 July 2009: 485 imported and 186 local transmissions. Thus far we've been lucky, there has been no deaths reported in Malaysia. Most of our patients have recovered completely, as detailed by the D-G of Health in NST: Influenza A (H1N1): Nearly all patients fully recovered.

Yet worldwide, the positively-tested H1N1 cases have exceeded 100,000. The WHO reports that some 105,304 cases (an increase of 1,374 cases overnight) with 463 deaths from 143 countries, have now been identified. Although not universally known, the fatality rate has maintained at a remarkably consistent 0.44% or 1 in 227, hardly changed from a month ago.

In the United Kingdom worries are now surfacing as more deaths (up to 14 as of 10 July 2009) from this supposedly benign form of flu have been reported. With 9700 reported cases now in the UK, some 335 people are still hospitalised with some 43 being in critical care. Thus, there are people who fall seriously ill, especially when they also have underlying health problems. With the fall or autumn approaching, there is fear that worse is yet to come.

At the G8 meeting in Italy, US president Barack Obama urged that Americans ramp up preparedness against the A(H1N1) influenza, warning that the virus could return with a vengeance in the fall, that "the potential for a significant outbreak in the fall is looming." He added that "we want to make sure that we are not promoting panic, but we are promting vigilance and preparedness" (AFP, July 10, 2009).

Specific vaccination would be the way to go, but the vaccine only recently developed, is yet to be fully tested for efficacy, but most health authorities believe that this would be the most effective and safe way to combat this community spread of the virus.

In a CrossTalk interview with the NST "Don't sensationalise H1N1 stories", I continue to maintain that we should remain at full vigilance and preparedness, and that what we have been doing thus far, is not alarmist but necessary under the current state of infection of the A(H1N1).

As we progress from containment to mitigation phase, we must urge every citizen to remain calm but responsible so that they can help prevent even greater local spread of the infection. Personal hygiene and even voluntary social distancing is still the prudent approach even if these are inconvenient or costly from a personal or even national perspective.

But we must observe our civic responsibilities and duty if we are to face this pandemic together and come out of this with as little scathing consequences as possible. Unfortunately, the full extent of this influenza outbreak is unlikely to abate anytime soon, with most authorities believing that it would be at least a year or two before this infection makes any meaningful decline to levels of normalcy...

Sunday Star 12 July 2009, highlights a comprehensive and balanced review by Dr Milton Lum (What is an appropriate response?) on the H1N1 pandemic and the difficulties involved in making the appropriate response to this virus in Malaysia.

Clearly no one will have the correct response and there will be detractors that we are either doing too much, or not enough. The uncertainties associated with this pandemic unfortunately have not abated, and might never be known until this pandemic blows over in the next few years... then, and only then will we be enlightened, in hindsight!

What then would the final human toll be? How would Malaysians have fared, and will there be recriminations of having done too little too late, to stem the more unwelcome outcomes? Or, would we then be accused to having alarmingly propagated another Y2K-like non-event?

I think most of us would have preferred that perhaps, we had been judiciously overcautious and that we had mitigated more deaths than would have had taken place otherwise. We'd preferred the inconvenience, the stringent preparedness, until the true benignity or malevolence of this H1N1 pandemic had blown over, even if these measures had cost us a little more, in terms of resources, personal space, and even hard-pressed financial outlay!

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H1N1: Contagion escalates, but caution still advocated...

Part of this article appeared in The Star 01 July 2009 as Caution can Save Lives and in Malaysiakini as Better Safe than Sorry on 30 June 2009.

Last Wednesday 24 June 2009, I attended the National Influenza Pandemic Task Force meeting chaired by the DG of Health, Tan Sri Dr Ismail Merican.

There remains fear that the H1N1 flu infection will continue to spread in the country, with most being imported cases, but with a steadily growing person to person spread becoming a reality. The plan is to try and contain and limit the contagion to as few people as possible and thus perhaps shield Malaysians from the worst aspects of this pandemic's potential lethality and socioeconomic perils.

As of June 26, the latest WHO statistics show that of 59,814 reported cases there have been 263 deaths — a mortality rate of 0.44%.

This is in contrast to two other high-profile global health threats of recent years. Avian Flu (influenza A(H5N1) had 433 reported cases and 262 deaths; while SARS (Severe Acute Respiratory Syndrome) had 8,096 reported cases and 774 deaths; thus their mortality rates are much higher at 61% and 9.6% respectively.

(Contrast this with our resurgent dengue fever; in the first half of this year, there were 23,057 dengue cases and 57 related deaths in Malaysia, i.e. 1 death in 404 cases or a case fatality of 0.25%.)

Not Really Much Ado about Nothing
Although some skeptics had brought up concerns that perhaps the response to this current pandemic is overblown or exaggerated, and that socio-economic implications remain still unrealised; the MOH and the DG pointed out correctly that while this may turn out to be true in the longer term, we just can't simply sit by and let this pandemic go without careful monitoring.

One very important and poignant point raised by the DG is that, if and when this pandemic turns out to be truly benign, then it's well and good. But consider the converse, if this flu became more lethal and many Malaysians then die, what then? Will the culpability for this potential disaster be equally shared for blame and recriminations? Indeed, will anyone then wish to take the rap, the responsibility?

In neighbouring Thailand, as of today, two among the hundreds infected have died, so this is not so benign after all. In the USA, CDC spokesperson, respiratory director Dr Ann Shuchart has stated that perhaps as many as 1 million Americans may have been infected with the H1N1 virus.

U.S. Passes Million Swine Flu Cases, Officials Say

Of the 27,717 laboratory-confirmed cases, about 3,000 Americans have been hospitalized, (their median age was quite young, just 19) and 127 have died; i.e. an in-hospital case fatality rate of 1 in 23, or 4.2%. Those who have died had a higher median age of 37 years, and when looked at in this way the actual in-hospital case fatality rate is around 2%.

But if we were to consider that the true number is perhaps just half as estimated, then 127 out of 500,000 exposed, is about as benign as the usual seasonal flu... Even if we considered just lab-confirmed cases, the case fatality rate would have been 0.45% or 1 in 218, very consistent with global figures.

Still, Malaysians are known to be very quick at pointing fingers and apportioning blame and vindictive censure. Many very vocal citizens are frequently irrationally strident and unforgiving, expecting that no authority or government can do any wrong!

Already there have been mutterings that we have not done enough. A recent letter No wonder A (H1N1) cases are on the rise stated that Singapore's surveillance methods are better and more visible, just because that person and their friends were not screened when crossing over the 2nd Tuas Link into Johor Bahru when returning. Yet they fail to note that the tiny nation state has already more than twice the number of cases of H1N1 infections than Malaysia, with even greater numbers of local transmission! Sadly, it's that inherent color of bias that our neighbour down south is always perceptibly better, whatever the raw unvarnished truth!

Hence, Malaysian health authorities have very limited options. Rigorous vigilance, close monitoring and being overly cautious might be the more prudent approach—yes, perhaps, this might cost us a bit of time, energy, resources and money in the beginning, but in the long term this would have been worth it—every life saved, is and should always be a correct public health measure! The question that begs to be answered is, at what cost?

It is true that many countries are loosening their surveillance programmes and are moving towards mitigation measures, which will help preserve resources and perhaps offer a more realistic approach to the pandemic.

Of course, everyone hopes that this flu will peter out after the initial wave of snuffles and fever subsides, if or when it does. But much remains to be seen, the unknowable remains as unpredictable as ever, and the possible future scenarios range from the most optimistically benign to the most catastrophic!

In the meantime, we can only help by assisting the MOH to respect and abide by the continually updated measures that are being rolled out on a day-to-day basis. At the very least, we can help by mitigating against the careless spread of this quite contagious virus, by scrupulous hygiene measures, and where necessary, by applying strict self-quarantine, if and when, anyone of us, might be possibly infected. Let's do our civic duty and be responsible and good citizens!

Fears of ‘second wave’ bug may be exaggerated

JUNE 27 — A new strain of the pandemic virus was identified in Shanghai in the middle of this month.

This, however, was reported by the media in mainland China only. The virus isolated from a 22-year-old Shanghai woman shows a significant mutation called E627K in the PB2 gene, one of the novel strain’s eight genes.

(A recent MIT study shows that without the PB2 gene, human viruses spread mainly by contact. Acquisition of the avian PB2 gene, however, enables them to transmit by air, which is why the pandemic strain is spreading so rapidly now.)

Before E627K appeared in the PB2 gene, PB2 was simply that which the pandemic strain had acquired from bird viruses. When E627K appeared, however, it meant that the PB2 gene was humanised or better adapted to people.

These genomic details can be confirmed on two free Internet databases. The expert who first noticed the E627K mutation in the Shanghai isolate noted that, in 1997, the H5N1 bird flu virus seen in Hong Kong which was very virulent in lab mice also carried E627K.

Dr Henry Niman of Pittsburgh-based Recombinomics, a private consultancy, told The Straits Times that, in 2003, the H7N7 bird flu virus that killed a veterinarian in the Netherlands had E627K as well.

Most importantly, the world’s only sample of the 1918 pandemic virus ever isolated from a patient also has E627K. This victim had been buried in Alaska (in permafrost) in November 1918 when the bug was killing people ferociously.

The Shanghai sample also shows another significant mutation, D701N, which is thought to augment E627K’s ability to infect humans. Does this Shanghai strain, which the United States authorities have now noted with little fanfare, presage a lethal second wave later this year?

It seems ominous. East Asia is ground zero for all flu virus mutations, a fact confirmed last month by two genomic studies. From Asia, mutated flu viruses are then spread by humans via air travel to both hemispheres. So E627K being detected in Shanghai first looks bad.

However, other experts remain sceptical: Whether the bug already had E627K in the spring and summer of 1918 when far fewer deaths were noted is not known. This is because there isn’t a single patient sample from that spring or summer to compare with the sole autumnal one available. Thus, one cannot conclude that it was E627K that turned the bug ferocious.

All that can be deduced is that E627K is associated with, not causal of, virulence. Likewise, E627K was also only associated with but not proven to cause the virulence in the 2003 Dutch case or the 1997 Hong Kong sample.

Until E627K is widely detected in a lethal second or third wave of the current pandemic, its relationship to virulence remains conjectural. More generally, the 1918 pandemic per se offers no genomic evidence that it was mutations after a mild spring or summer outbreak that caused the bug to turn ferocious.

Say, mutations were not responsible. What then might have caused the virulence in 1918? Perhaps, the poor nutritional status of all during wartime was crucial. At any rate, with no antibiotics available in that time period as yet, most deaths in 1918 were caused by untreated bacterial pneumonias in people already laid low by the flu. There were probably lots of pneumonia-causing bacteria like pneumococci, staphylococci or Haemophilus circulating in the poor hygiene.

Then there were also killers like tuberculosis, cholera and typhoid as well as other non-flu respiratory viruses which might have presented with flu-like illness but remained undiagnosed.

Some scientists now speculate that the use of high doses of aspirin advocated then might have been responsible too. Aspirin can cause Reye’s syndrome – a situation in which there is potentially fatal brain and liver swelling in children with viral infections. While aspirin is therefore avoided in childhood fevers nowadays, there are many aspirin derivatives.

In Mexico, such derivatives as diclofenac, mefenamic acid and ibuprofen are easily available. Not knowing that these are related to aspirin, parents tend to use them for fevers in children when paracetamol (branded Panadol here) fails to work. These may potentially have the same harmful effects. Did this cause Mexico’s high kill rates this year?

Here is an even more radical idea. Perhaps the bug never turned ferocious in the autumn of 1918 at all. Some experts are now arguing that, without lab confirmation of cause of death, the estimated number of deaths attributed to flu in late 1918 is imprecise. (The virus was first identified only in 1933.)

In fact, the idea of a “lethal second wave” came from a Journal of Infectious Diseases study published in January last year. However, this is merely one study using highly imprecise data from 1918 in but one city, Copenhagen. Amazingly, these experts say, this study alone has given rise to concerns about a lethal second wave, which may be less relevant today.

There are now antivirals and ventilators to treat bad flu cases; antibiotics for bacterial pneumonias; flu vaccines and personal protective equipment to prevent infection; better nutrition and sanitation; and, the public is better informed too.

The future may not be so bleak, after all. (Andy Ho – Straits Times, Singapore)