We feel that We have to address the most serious issue at hand. Today the most important priority should be given to the H1N1 influenza and how we go about dealing with this. Below is an article from Malaysiakini.com.
The number of reported H1N1 cases could be higher than what is estimated, claimed a virologist from the United Kingdom who urged the Malaysian government to adopt his country’s surveillance system.
Dr John McCauley from the National Institute for Medical Research UK said though it takes time to set up the system, the government should adopt the UK’s “influenza sentinel surveillance programme” to monitor the situation.
“Reported cases of infection are bound to increase but what I am unsure of is whether current figures given are accurate. There can be yet more undetected cases.
“There might be some kind of systematic underestimation of the number of cases. If it is always mild, you can always underestimate the cases you have got,” said McCauley (above).
He explained that under those circumstances some people might not get vaccinated on time. For the vaccination to be effective it has to be administered as soon as the symptoms appear.
Fire brigade approach
He spoke to reporters after delivering a keynote address entitled Pandemic H1N1 – Background and Update at the Kuala Lumpur Convention Centre yesterday.
He said as those below the age of 24, are more susceptible to greater impact from the illness. However, he said, there may a slight degree of immunity for those born before 1957.
He also said that the drugs should only be used in serious cases, this especially so for those not in good health and, pregnant women.
“At the pandemic stage, what you really want the drugs for is to control serious complications arising from the infection,” he said.
Meanwhile, Institute of Bioscience deputy director Prof Dr Abdul Rahman Omar who was also present urged the government to adopt a proper disease control approach.
“We should not practise the ‘fire brigade’ approach but have active surveillance in more places,” he said.
Currently, 51 patients confirmed with the virus, are being warded, with 29 others admitted to intensive care units.
Of the 29, 16 are in the high-risk group with 12 suffering from chronic diseases.
Khoo Kay Peng
I read that Muhyiddin predicted PR may not last more than 2 years. Mahathir expected the PR to lose Selangor. A number of leaders from BN component parties are expecting the nascent coalition to crumble anytime soon. Leaders such as Khairy Jamaluddin are busy courting the Pan-Islamic Party (PAS) to join UMNO to unite the Malays.
What motivated their prediction? There were bickering in Kedah, Penang and Selangor. Over what? Pig’s abattoir, banning of beer in muslim majority areas, Kampung Buah Pala and other menial issues. Most of them opined that PAS and DAP cannot coexist due to their vast ideological difference.
For BN’s own survival, it is even more dangerous for the leaders NOT to acknowledge that their coalition faces even more daunting challenges e.g. lost of credibility, the death of Teoh Beng Hock in custody, racist media propaganda against non-Malays, Kampung Buah Pala, PKFZ, leadership crisis in almost all BN component parties, abuse of state machinery and public institutions, Perak power grab, corruption etc.
Many of these issues and controversies may not encourage the voters to support the BN coalition.
If the PR has two more years, how long does BN have?
Din Merican’s blog
THE AUNG SAN SUU KYI VERDICT: ASEAN MUST
Parti Keadilan Rakyat (KEADILAN) condemns the guilty verdict and harsh prison sentence handed down by the Burmese court yesterday in the case against Aung San Suu Kyi and her colleagues, Khin Khin Win and Win Ma Ma.
While the guilty verdict was fully expected, it is nevertheless deeply disappointing, especially as the case had offered a precious opportunity for the military junta to gracefully make some significant steps towards change.
Instead, the junta continues to violate human rights and poses as a threat to regional peace and security (the military regime is suspected of secretly exploring nuclear capabilities).
The court decision came as the grand finale of a carefully orchestrated charade, with political manipulation being unconvincingly dressed up as a judicial process. The junta leaders evidently felt the heat of international outrage to the point that they immediately announced that her 3-year hard labour prison sentence was commuted to 18 months under house arrest.
Despite their reduction of the sentence, we believe the Burmese military regime acted with malicious intent.Their main aim has always been to ensure that Aung San Suu Kyi would not be able to play a role in next year’s general election, and they have not budged an inch on this.
The connection of this case to the elections was further underlined by the government’s justification of her continued detention, saying that true supporters of democracy do not want them to be marred by riots and unrest. It should be remembered that there are still thousands of political opponents languishing in prison, and it is safe to assume that they will remain there for the same purpose.
The world is again outraged, but it is ASEAN which stands to lose in real terms, being guilty by association. Thus, ASEAN must take firm and prompt action to bring their recalcitrant member into line, especially with the human rights principles stated in the ASEAN Charter – a major step which could improve the current poor standing of ASEAN nations in the world.
If ASEAN still wants to save the face of the junta’s leaders, they could do this by initiating a renewed communal effort towards enhancing standards of democracy and human rights in Burma.
WAN AZIZAH WAN ISMAIL
Parti Keadilan Rakyat
THE MALAYSIAN INSIDER
Villagers protesting the impending demolition of Kampung Buah Pala battle with riot police of the Federal Reserve Unit after heavy machinery was sent to the site today.
PENANG, Aug 13 — The controversial demolition of Kampung Buah Pala has been postponed to Sept 1, after a tense standoff today between villagers, the land owners and police.
George Town OCPD Azam Abd Hamid said today an agreement had been reached with all parties to postpone the court-ordered demolition.
Bulldozers were sent in this morning into the village to demolish the houses whose residents refused to move out of the disputed piece of land.
Police had earlier cordoned off the village as the deadline for the residents to move out ended today.
The residents had earlier refused to take up the developers’ offer of double-storey houses to move out.
Scores of residents and members of non-governmental organisations sat in the rain to form a human barricade to prevent the heavy machinery from destroying their homes.
Police presence was heavy and some villagers claimed that the police were resorting to “violence” to disperse them.
There was much shouting and pushing throughout the morning, with villagers, representatives of NGOs and political parties trying to prevent demolition work from starting.
Kampung Buah Pala residents have argued that they are victims of a land scam perpetrated by the previous Barisan Nasional (BN) administration.
The DAP-led Pakatan Rakyat (PR) state government had negotiated an offer from the developer of double-storey terrace houses in return for the villagers moving out.
But this was rejected by a majority of the villagers.
Last week Penang Chief Minister Lim Guan Eng said his administration would wash their hands of the controversy since the offer had been rejected.
The land owners, who want to build apartments on the land, had won a court case against the villagers to have them evicted.
But the villagers, backed by Hindraf leaders who claimed the village of cowherds was an Indian heritage, wanted the state government to sign over the land to them.
The original settlers of the village had been workers in a British-owned plantation. When the planters left the original settlers were allowed to live on the land based on a trust administered by the colonial administration.
After independence the land was converted to temporary occupational licence (TOL) status as the new Penang state government in 1957 was unwilling to act as trustees.
During Tan Sri Dr Koh Tsu Koon’s administration, the land, which belonged to the state, was sold.
Hindraf and MIC leaders have attempted to turn the issue into a racial dispute, but the issue has not gained much traction, and public sympathy appears to have swung against the villagers after they rejected the offer of double-storey houses.
THE MALAYSIAN INSIDER
AUG 13 – The influenza A (H1N1) mortality rate in Malaysia is close to 2 per cent instead of the 0.1 to 0.4 per cent 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 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 1,211 confirmed cases with one death and the mortality rate of 0.08 per cent. Hong Kong reported 5,991 confirmed cases with four deaths and the mortality rate of 0.067 per cent. Australia reported 27,663 confirmed cases with 95 deaths and the mortality rate of 0.34 per cent.
Even Singapore, which reported deaths earlier than Malaysia, has recorded only nine deaths.
The Health Ministry believed that the domestic confirmed cases are far less than the announced figure, 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.
Why has our death toll shot up to 44 people within three weeks after the first death case reported on July22 ?
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 recognised 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. – mysinchew.com
So, what is the issue here? Is the issue Islam? Is the issue about eradicating sin? Is the issue about not allowing vice in Malay neighbourhoods? Is Umno outraged that beer is being sold in ‘Malay’ Shah Alam? What is really the issue?
Raja Petra Kamarudin
There is a controversy sweeping Selangor state. Well, actually there are many controversies sweeping the state. But this particular controversy I am talking about involves the matter of the confiscation of beer.
As explained by the EXCO Member in charge of local government, Ronnie Liu, the confiscation was a mistake, an error of judgment of sorts, and the beer was ultimately returned to the owner the same day with an apology attached.
Furthermore, explained Ronnie, you need a licence to sell liquor. But beer does not come under the classification of liquor. So you do not need a licence to sell beer and therefore the government can’t confiscate beer even if the premises that is selling it does not have a liquor licence. This is not the law that Pakatan Rakyat made. This is the law that the Barisan Nasional government made.
But Umno is not about to allow the matter to end there. They want to organise a protest demonstration and they demand that PAS join them in this demonstration as proof that the Islamic party is committed to its Islamic agenda. Basically, Umno wants to pressure the Pakatan Rakyat state government into reversing its policy on ‘allowing’ beer to be sold in Selangor and it wants PAS to unite with Umno in propagating this stand.
The impression being created is that Umno is opposed to beer being sold in Selangor. But only today is it opposed to the sale of beer. For 51 years, when Selangor was under Umno, it was not opposed to the sale of beer. It is only opposed to the sale of beer now that it no longer rules the state.
Hasan Ali, the man behind the secret talks with Umno soon after the 8 March 2008 general election, has of course jumped onto the bandwagon in ‘defence’ of Islam. He wants Selangor to ban the sale of liquor and beer in the state, or at least in Malay-majority neighbourhoods or townships like Shah Alam.
That is all well and fine. I am certainly in support of eradicating immoral activities. And I will support not only Muslims but also Jews, Christians, Hindus, Buddhists and whatnot to see this happen.
But this is not what is behind the brouhaha. The issue is not about eradicating vice. It is about trying to embarrass the Pakatan Rakyat state government and in the same process create a rift between PAS and its other partners, DAP and PKR.
First of all, how would we define Malay-majority townships? What percentage of the population would have to be Malay before it is classified as Malay-majority neighbourhoods or townships? Malays make up about 51% of the population of Selangor. So would that particular neighbourhood or township have to have at least a 90% population to be classified as Malay-majority? Or is 70% a more realistic percentage since it would be almost impossible to find a township with a 90% Malay-majority population?
TO READ MORE : http://mt.m2day.org/2008/content/view/25592/84/
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:
- obesity (fatter patients seem to have poorer outcome and more complications)
- those with underlying diabetes, heart disease
- those with asthma, or chronic lung disease
- pregnant women
- those with reduced immunity, cancer patients, etc
- 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 1,000 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 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 10 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 one to two 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.
DAVID KL QUEK is president of the Malaysian Medical Association (MMA).