Friday, August 14, 2009


I am going to deviate off my cardiac posting today, to talk about the AH1N1 crisis. Is there a crisis? What is happening now is getting crazier.

How does a senior clinician, albeit a cardiologist, see it?.

The whole situation began in Feb when news came out the the had been a " flu " outbreak in Mexico. The Mexican, did us all a severe injustice ( how to blame them, their healthcare system is probably worse than ours ), by not containing the infection in Mexico. Before you know it, the virus is all over the world. That is probably mistake number 1. The horse has bolted and left the stable. How to catch the wind?

Then WHO, who was monitoring the situation declared a pandemic sometime in June, when the infection seemed to have spread to 3 continents. This was a very liberal definition of a pandemic, without assessing the severity and also the virus strain. There are many of us who suspect that WHO was heavily pushed by drug makers. This is mistake number 2. Looks like the WHO is not beyond reproach. Now you have the whole world in some sort of a panic

Back home in Malaysia, we reacted and follow the flawed WHO advisory ( we did not think for ourselves ) by instituting measures that make people not want to come forward for treatment. We threaten to throat swab everyone, and quarantine them for seven days. This just drove everyone underground. This is mistake number 3. As a result, we now do not know the real incidence and pattern of disease and spread. Not getting the private GPs involved, and in fact blaming them for this that and the other, did not help. Now we have a situation whereby, our basic data collection is severely flawed.

Now we hear of more and more deaths, as if this infection is very deadly, when it is not. Just for statistical purpose, we are suppose to have about 2,000 reported, positive cases of AH1N1. Any epidermiologist ( specialist in the study of disease patterns ) will tell you that for every case reported, there are probably 20x the number unreported, especially in a disease as infective as AH1N1. If you apply that rule of the thumb, there should be about 40,000 people ( including boys and girls out there ) who have AH1N1. It is true that when the MOH surveillance system sampled the cases with throat swabs, they were all H1N1 ( so far ). There were no mutant strains at this point in time. Death is something that no one can hide. In our language, death is a hard endpoint. There were to date, 51 deaths, giving us a mortality of 0.1% ( if you agree that we have about 40,000 cases as predicted ) , still too high for a seasonal " flu" mortality, but not a deadly disease " panic provoking " situation. Mistake number 4 would be to make it sound like a deadly virus is going around the country. Which is not true. In fact, many of the deaths were not well documented, so one wonders whether it was like a post 9/11 situation, where all catastrophe was blamed on "al-qeeda ". All deaths now, with a throat swab positive done post-mortem, is labelled as a AH1N1 death. We have urged the Minister to set up a task force to examine all deaths and try and give us some real numbers.

There is a prevailing consencus ( following the WHO line ), of pushing the use of " oseltamivir " ( the generic name of the branded Tamiflu ), as if it is the magic cure. That is simply not true. If fact, in Feb, 2009 the CDC of USA released a document saying that about 100% of the H1N1 in their population was " oseltamivir resistant ". What is even worse is that Roche, the maker of Tamiflu, is holding out on their supply of Tamiflu. The conspiracy theory people feel that they are keeping it for the US winter that is ahead of us. This has forced our government to buy hurriedly prepared generic " oseltamivir ", who's quality and BE studies are not even available. We could be getting nothing better then " flour pills " . This is mistake number 5. Oseltamivir is not a magic bullet to cure AH1N1. At best, it may reduce the disease period and reduce suffering. At worse, it may not work and give patient a false sense of security. Some of the anti-virals have known side effects.

Many guidelines have been dished out to health professionals and to the public as to what to do. Many are not well thought of. Patients are told to keep good personal hygeine. That is correct and probably the best advice. To get all patients with fever 38oC for 2 days admitted is crazy. There will not be enough beds to house them, be it in public or private hospitals. Most of the patients with AH1N1 survive. Some ( especially in the high risk group ) surcumb to secondary bacterial pneumonia. Giving patients in the high risk group antibiotics early may be a worth while strategy. To get all patients with " flu " symptoms tested with the rapid test, is useless. In an epidermic, treat all as if they have AH1N1, and detect complications early and treat it as necessary. To be, announcing that we have oseltamivir when we do not have enough stock, is a joke. Now you have built up expectation, and cannot deliver. And when you deliver, it is generic drugs, which have not undergone stringent safety and efficacy testing.

What then can be done?
Well the authorities have to calm down and begin to play down this crisis. Encourage good hygeine and allow patients to care for themselves at home. GPs should be advised to treat all with " Flu " symptoms as AH1N1, and start antibiotics early. Those who suffer compliactions ( high fever, with cough and breathlessness ) should go to hospital immediately for hospitalisation. That allow the hospitals to function more efficiently. It is important to note that the death rates of AH1N1 at the big public hospitals like the Sungei Buloh Hospital is low ( one to be exact ) although they deal with complicated ones. Most of the deaths have occurred in peripherals hospitals where the care may not have been so good. In fact, many of us see this AH1N1 crisis as a stress test for the acute healthcare delivery system of Malaysia, and so far, the system seem to have failed. With a system like this, it may be wiser to ride out the crisis and treat the complicated ones, and not to hype the issues and blame this and the other. Let us gather data and learn more about this " flu " so that in future we will be smarter. For the moment, this crisis is still on, but let us not panic. Let us all prepared for a surge in number of cases with the Hari Raya holidays infront of us. With people movement and travelling, there will be an increase. Let us be prepared, take precaution and keep good hygeine.

For sure, this AH1N1 crisis will pass ( and we hope soon ), but the authorities must learn their lesson. And the best people to end the crisis are the people, by taking care of themselves and avoid infection ( if possible ) Besides avoiding infection, it is also important to keep our body healthy to increase their body resistance. This is what should have been emphasize at the beginning. Maybe some deaths could have been avoided.

1 comment:

sorindian said...

i scan thru your blogs. as a general public, i find it very informative and well presented. logical and scientific yet simple. thanks a alot for the info. keep this up.