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A(H1N1): Still under control

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.

Picture of a stethoscope
(Pic by Barky /
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:
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
Malaysian Medical Association

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One Response to “A(H1N1): Still under control”

  1. megabigBLUR says:

    I would really like to know which labs in the country actually have the capacity to do qRT-PCR or sequencing to confirm cases of swine flu. IMHO H1N1 is a very poor label for this pandemic virus because many strains of typical human flu are H1N1 (haemagluttinin type 1, neuraminidase type 1) and the ordinary serological tests cannot distinguish between them and this strain. It’s like telling the police you were hit by a red car – superficial and not very specific. Is it possible that some labs that don’t have the high-tech machines are just running serological tests and labelling all H1N1 isolates as pandemic flu?

    Going by rough figures, about 2 million people around the world die of flu each year. If the deaths were distributed evenly among nations (I know they’re not, but I did say “rough figures”) this works out to 7,000-8,000 Malaysians dying of flu annually. People aren’t aware of this because we just don’t normally pay attention to flu or pneumonia deaths. Sorry to the families of the deceased, but why are we freaking out about 60-something [deaths]?

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