New tactic in dengue fight

BY LOH FOON FONG

 

PUTRAJAYA: The Health Ministry is trying outdoor spraying of a ­deltamethrin-based insecticide to kill Aedes mosquitoes in view of the record high number of dengue fever cases recently.

Health Minister Datuk Seri Dr S. Subramaniam said the number – more than 100,000 dengue cases with 215 deaths last year – was not only the highest the country had ever faced, but more dengue patients now had their brain and liver affected by the virus.

“We take the higher number of deaths seriously,” he said at a press conference before the ministry’s post-Cabinet meeting here yesterday.

He said the ministry had started the residual spraying since Feb 11 in four Selangor districts with a high number of dengue cases – Petaling, Hulu Langat, Gombak and Klang.

“The effectiveness of the spray will be assessed over two to three months and if proven to be effective, we will expand the use of the spray to other areas,” he said, giving an assurance that the active ingredient was not harmful to humans.

Currently used to control pests in agriculture and gardens, as well as on pets, deltamethrin is a synthetic compound that gives a broad-­spectrum effect, meaning that most species of mosquitoes and other insects will also be affected.

Dr Subramaniam said the active ingredient was expected to last for three months in the field, and mosquitoes coming into contact with the sprayed surface would die.

He also reiterated the importance of doctors diagnosing dengue early, saying that two companies had agreed to lower the cost of the rapid test kit by 40%.

On the dispensing separation issue, he said more dialogue was needed between the stakeholders before a decision could be made.

“We will not implement anything without consensus from the various parties.

“For now, the current system stays, and there is no need for ­various parties to release statements on a matter that has not been decided,” said Dr Subramaniam, who added that the new Pharmacy Bill was still under review by various quarters, including the Attorney-General’s Chambers.

On Tuesday, discussions were held with the Malaysian Medical Association and Malaysian Medical Council secretariat, with four more sessions with other groups sche­duled for March.

Discussions with other doctor groups will happen on March 4, with consumer groups in the second week, with ministries and government agencies in the third week, and with pharmacy associations and academia in the fourth week.

Dispensing separation is to ensure best care, say pharmacists

The star

BY LOH FOON FONG

PETALING JAYA: Dispensing separation is not about taking away doctors’ rights, but making clear the division of professional responsibilities to ensure best care for patients, the Malaysian Pharma­ceutical Society (MPS) said.

Its community pharmacy chapter chairman Lim Kah Poh said the possibility of undetected prescription errors should not be conveniently brushed aside.

“In dispensing separation, a pharmacist will screen through the prescription to ensure there is no error, and if there is any, he should contact the doctor to clarify,” he said in response to the flurry of comments recently over the matter.

Pharmacists are hoping that the “doctors diagnose, pharmacists dispense” system would be accepted by all by April 1.

Doctors are protesting the move while consumer bodies said the decision of where to get medicines should be left to patients.

On Feb 17, Health Minister Datuk Seri Dr S. Subramaniam said dialogue was still ongoing and no decision has been made by the ministry.

On patients’ willingness to pay higher medicine prices at clinics, Lim said patients should be aware that pharmaceutical companies do attempt to influence doctors to promote one product over another, sometimes to the extent of disregarding safety, efficacy and/or price.

Lim, who is also in MPS’ task force against inducement of health professionals, also asked why some health professionals preferred to prescribe pricier “branded or innovator drugs” over generic versions.

“The healthcare system should be designed to safeguard the health of the people,” he said, though admitting that inducement could also apply to pharmacists, thus underscoring the need for policing in this area as well.

Community pharmacist Gan Ber Zin said doctors only attended a one-year lecture on pharmacology in their five-year medicine course.

Pharmacists, on the other hand, were trained from formulation drugs to monitoring side-effects, and would screen every dispensed drug for possible interaction with other drugs, food and other substances.

“There is no justification to delay the implementation of the prescribing and dispensing functions for doctors and pharmacists,” he said.

According to Gan, such separation was already in place in the public sector, while private hospitals were working towards the same.

“Why are private sector pharmacists in community pharmacy practice not treated the same?”.

Fighting to break the dengue cycle

the star
BY LOH FOON FONG

ANYONE walking into a hospital in an urban area these days is likely to be swarmed by dengue or suspected dengue patients.

Last year, an astronomical 108,698 dengue cases with 215 deaths were reported to the Health Ministry, more than double the figure in 2013. That’s close to 300 cases a day and four deaths per week.

Dengue infection has become one of the leading causes of hospital admission among adults and also a major cause of illness and deaths, according to “A Review of Dengue Research” published in the Medical Journal of Malaysia, Vol 69 Supplement A, August 2014.

The numbers are not getting any better this year. As of Feb 7, a total of 15,039 dengue cases have been reported this year with 44 deaths. That’s close to 400 cases a day and at least one death every day. During the same period last year, there were 9,453 cases with 17 deaths.

In fact, Health director-general Datuk Seri Dr Noor Hisham Abdullah said that there is a substantially higher percentage of patients who show symptoms of severe dengue.

“These could mean dengue with plasma leaking from the blood vessels, bleeding and dengue with severe involvement of organs such as the liver, brain, heart and kidneys,” he said.

Crowded ward: Patients with dengue fever being treated at Tengku Ampuan Rahimah Hospital in Klang.

There has also been an increase in dengue patients with underlying medical conditions who come in with uncommon symptoms and suffer more throughout the course of the disease, he said.

He said the severity of a particular infection was not solely dependent on the dengue strain’s virulence, but also on the interplay between the micro-organism and the patient’s immune system.

“That is why patients tend to develop life-threatening diseases only after the virus is cleared from the blood,” he said.

Dr Noor Hisham said recurrent dengue infections, possibly within a short interval, make a patient more prone to a severe form of the infection.

“It is as yet uncertain whether the increase in severe dengue cases is solely due to this particular reason,” he said.

Due to these concerns, the Ministry has told doctors to start looking for other dengue symptoms, rather than just fever and rashes, before they are considered for admission.

The symptoms are lethargy, vomiting, diarrhoea and abdominal pains.

Direct message: A sign placed in SS 22, Petaling Jaya, warning people against dumping rubbish.

Patient profile

Dr Noor Hisham said that among the 215 dengue patients who died last year, the average duration from onset of fever to hospital admission was four days, and the average duration of hospital stay from admission to death was another four days.

He said those who died mostly came from districts with a high number of dengue cases such as Petaling (9.6%), Hulu Langat (8.5%), Gombak (7.4%), Johor Baru (7.4%), Kinta (7.4%), Kota Baru (5.9%) and Klang (4.8%).

Of the number, 55% of the dengue deaths involved Malays, 22.3% Chinese, 13% Indians, 5.1% foreigners and 3.7% others.

More than half – 58.6% – were aged between 15 and 50, while 30.7% were aged above 50 years and 10.7% were below 14.

Of the cases, 53% were females and 47% males.

About one in every four (23%) patients who died of dengue had other illnesses such as diabetes, hypertension, heart disease, renal failure and risk factors such as obesity, pregnancy and old age.

Dr Noor Hisham said the Ministry took all dengue deaths seriously.

Yes, we need to change Malaysian attitudes towards cleanliness. — Datuk Seri Dr Noor Hisham Abdullah

“Every death is discussed at multiple levels and every management decision is scrutinised, including the diagnostic tests done and the reporting of the case to the public health authorities,” he said.

Asked if dengue serotype and other viral cross-infections could happen in the hospital ward leading to patients’ severe conditions or deaths, he said it was theoretically possible but that there had been no evidence to suggest that this was happening in Malaysia.

“If there were cross-infections between patients in hospitals or among people living near hospitals, then the majority of people with dengue would be from these groups but so far, that has not been the case,” he said.

Most hospitals where dengue is common have taken steps to create specialised wards to cater to the increasing load of patients as well as to streamline human resources, investigations and monitoring of these patients, he said.

“The ministry’s hospital authorities regularly patrol their grounds to ensure they are free of mosquitoes,” he added.

World Health Organisation Representative to Malaysia, Brunei and Singapore, Dr Graham Harrison, said Malaysia already had a good level of expertise in the clinical management of dengue and had taken many steps to ensure that there is effective identification and treatment of people with dengue.

However, he said one challenge was people’s own understanding of the need to get early medical assessment, which could lead to more severe complications that can be harder to treat.

“Unfortunately, the clinical presentation of dengue may mimic symptoms of upper respiratory tract infection, and someone who has these symptoms may not identify the need to see a healthcare provider quickly or may not be concerned with completing the follow-up steps as recommended by their doctors,” he said.

Precautionary measure: Trolley beds on standby in Hospital Kuala Lumpur in the event that all dengue beds in the special ward are filled up.

Rethinking strategies

WHO Collaborating Centre for Arbovirus Reference and Research director Prof Dr Sazaly Abu Bakar said that Malaysians have been doing the same thing for the last 30 years and it is time to adopt new approaches.

With new concerns that more people are suffering from more severe dengue and dying from it, he said, attention should be directed to preventing deaths.

He also expressed concern over transmission of the virus when Aedes mosquitoes bite patients who are asymptomatic or have mild symptoms.

“It may be mild in this person but if the virus load is high, the person could become the source of infection in others which may not necessarily be mild,” he said.

He said the ministry has all the data and it is a matter of what they do with the data to bring down the numbers.

Dr Sazaly said people could continue getting rid of dengue breeding spots but it would still not make a difference as long as infected humans do not prevent themselves from being bitten by mosquitoes.

In a letter to The Star, a retired public health specialist had pointed out that Aedes mosquitoes by themselves do not transmit dengue but get the virus from humans and transmit it to others.

He said that the public health advisory should be given to every person diagnosed or suspected of having dengue to break the cycle of infection by protecting oneself from being bitten by mosquitoes with protective clothing and limiting outdoor mobility, as well as destroying adult mosquitoes in and around the house with insecticide sprays.

Patients or family members should check in and around the house to find and destroy Aedes or potential Aedes breeding places, while neighbours must be informed as mosquitoes have a flight range of at least 200m, he said.

Asymptomatic patients pose challenge in controlling infection

Dr Noor Hisham (pic) also said that as in most other infections, one in four patients carry the dengue virus without exhibiting any symptoms or any serious symptoms.

“This is one of the main reasons why it can be very difficult for public health authorities to control the disease despite dengue being a strict notifiable disease,” he said.

Asked if the ministry needed to change its approaches to tackle the rising number of cases, Dr Noor Hisham said the principal approach in dengue control worldwide is breeding source reduction.

Fogging and other methods of spraying insecticide are temporary measures. Dengue control is highly dependent on the destruction of Aedes breeding, which is within the control of the public, he said.

However, as long as Malaysians continue their bad habits of littering, illegal dumping of garbage, apathy on breeding within their own homes, not bothering about community work and poor environmental cleanliness, and construction sites continue to ignore guidelines, they are fighting a losing battle.

“Yes, we need to change Malaysian attitudes towards cleanliness,” he said.

“Our researchers must also think out of the box to find more tools to fight Aedes and the dengue virus,” he added.

Dr Harrison said that dengue was a very difficult problem to eliminate.

“Until an effective and affordable vaccine is readily available, dengue is likely to persist as a an ongoing health problem, with some exacerbations in the numbers of cases from time to time.”

It is important for the community to understand that they must be engaged with dengue control because officers from the local government and health departments can only do so much, he said.

“Individuals must take responsibility for regularly checking around their homes and workplaces to ensure that there are no potential mosquito breeding places, and if there are ways to take action – either to drain the water away or use appropriate chemicals or biological methods to stop further mosquito breeding,” he said.

This is not a one-off activity but requires regular attention to remove rubbish and inspect possible places where water may be collecting and to take further action, he said.

While the relevant authorities carry out their checks and impose penalties, perhaps it is time for all resident associations to be galvanised into getting residents to take turns and work together to do clean-ups in their own area on a regular basis.

Medical practitioners: Listen to patients’ views

the star
BY LOH FOON FONG

PETALING JAYA: The Medical Practitioners Coalition Association of Malaysia wants the current system where private general practitioners can dispense medicine to be maintained for patients' convenience.

Its president Dr Jim Loi said that patients’ views should be heard on this.

For example, he said: “What am I to do if a feverish elderly woman comes to my clinic and I have to tell her that I can’t give medicine after examining her because of this dispensing separation and she has to go to the nearest pharmacy, which is one or two kilometers away?"

The Star reported yesterday that pharmacists had hoped that the dispensing separationwould come into effect on April 1 when patients could no longer get their medicine from private clinics but obtain it from pharmacies, if the Health Ministry accepts the proposed “doctors diagnose, pharmacists dispense system”.

While the system may cause some inconvenience to patients, pharmacists said it would help lower the prices of medicine and give doctors access to many more drugs to prescribe.

However, Dr Loi said the system might add to the patient’s cost and time.

Malaysia, he said, should not be compared to the dispensing separation system adopted in Britain or the United States.

“We have no current economic status that allows insurance to cover medical bills, such as the National Health Insurance scheme in Britain, to support that,” he said.

Asked about the benefit of the new system that aims to restrict abuse of drugs by consumers, Dr Loi said that if it was enforced properly, it would be good for everyone.

However, there was no guarantee that pharmacists would not prescribe medicine without a doctor's prescription under the new system, which he said was rampant even with the current system due to the lack of enforcement.

He said major pharmacies had stopped selling medicine without a doctor's prescription in recent years only because they wanted to show good behaviour before the dispensing separation is implemented.

Dr Loi said that “it was important for doctors to be given the right to prescribe as well because they understand patients better”.

He said when a pharmacist did not have a doctor's prescribed drug in stock, he might suggest another drug to replace it and this could pose a problem if they change the prescription.

Well-maintained communities register highest dengue infections

the star
BY LOH FOON FONG

Published: Monday February 2, 2015 MYT 12:00:00 AM
Updated: Monday February 2, 2015 MYT 11:57:15 AM

Well-maintained communities register highest dengue infections

BY LOH FOON FONG

Dengue hotspots: Larvae was found in a small puddle of water on a garbage bag in an alley in Damansara Utama SS22.

 

Anti-dengue PSA

PETALING JAYA: The iDengue website, which tracks dengue hotspots nationwide, showed that even a well-maintained urban community such as SS22 here is among the top in the list of hotspots with 116 infections from June last year until Jan 24 this year.

At first glance, the area looked clean but its security committee member Michael Yea, 61, pointed out the plastic bottles and bags, and disposable polystyrene food containers filled with larvae hidden under bushes beside several houses.

Old tyres, dustbins filled with rain water, a house full of junk and containers and vacant houses were also identified as potential mosquito breeding spots.

“People are still generally not bothered and this is happening in many other neighbourhoods.

“If only each family can take care of their own backyard, this could reduce the number of infections,” he said.

Other top hotspots were Shah Alam Seksyen 7 Commercial Centre A with 214 cases in the last 158 days of outbreak (from Aug 20 to Jan 24) and Seksyen 7 (Flat A) with 90 cases in the last 172 days of outbreak (June 8 to Jan 24).

Larvae was found in empty plastic containers.

 

Hulu Langat 3/A-R Seksyen 3 Bandar Sri Putra had 71 cases in the last 136 days of outbreak (Sept 11 to Jan 24) and Gombak Kg Simpang 3 had 47 cases in the last 117 days of outbreak (Sept 30 to Jan 24).

On Wednesday, the Health Ministry said there were 8,502 dengue cases (Jan 1 to 24) nationwide compared with 5,141 cases in the same period last year.

It said 80% of dengue cases happened in home surroundings.

Yea, a retiree, said local councils must be more efficient as well.

He pointed to uncleared construction materials, garbage bags at the side of drains that had puddles of water and drains that were almost 70% filled with silt.

“Who is responsible for these?” he asked.

He also said the recently installed MBPJ dustbins at the playground were welcomed but without holes at the bottom of the bins to allow rain water to flow out, they could turn into mosquito breeding sites.

Those living in crowded neighbourhoods admitted keeping their community clean was a challenge.

Unemployed single mother Azian Abu Bakar, 30, who lived in a squatter area in Taman Datuk Seno in Sentul, Kuala Lumpur, said she was not aware of any garbage collection service in her area.

“Most people living in my area burn their garbage as a way of disposal,” she said.

Azian’s son Adam Hakim, 13, was warded at the Hospital Kuala Lumpur (HKL) on Jan 25.

Bangladeshi construction worker Dulal Farez, 31, who lived with seven other workers, said they tried their best to keep their place clean and his employers had also cleaned up the construction site following his infection.

“I don’t know where exactly I contracted dengue fever because none of my housemates or colleagues had dengue,” he said.

Drastic actions needed to reduce dengue cases

PETALING JAYA: The persistently high number of dengue cases in the past year are unlikely to go down unless drastic actions are taken.

Deputy Health director-general (public health) Datuk Lokman Hakim Sulaiman saidgotong-royong efforts on many occasions were poorly received by the public and were mainly participated by government agencies and staff.

Deputy Health director-general (medical) Datuk Dr S. Jeyaindran said the ministry had held dengue awareness and gotong-royong sessions but many residents had literally closed their doors at them when they arrived at their doorsteps.

While noting that conducive environment for mosquito breeding such as rain, hot and humid temperature, and serotype switch could aggravate the situation, there were many things the public could do to reduce the spread of infection and deaths.

Dr Lokman said the average Aedes breeding index remained high above threshold level of 1% throughout the year (ranging from 0.9% to 1.9%, while in some hotspot areas as high as 8%).

Mosquito breeding incidents were highest in empty lots (14.6%) and parks/recreational areas (8.0%) in 2014, he said.

“Littering is still a big problem in Malaysia with plastic bags, polystyrene cups and boxes which collect water found in public places,” said Dr Lokman.

Factory and construction sites were the next most common breeding places, with 6.3% and 5.8% respectively.

Asked if Malaysia should be more aggressive in enforcing the law like Singapore, he said Singapore’s Gross Domestic Product (GDP) was huge for a small country and they had 800 enforcement officers to inspect a country less than the size of Klang Valley while Malaysia had similar number of officers to cover the whole country.

Nevertheless, Dr Lokman pointed out that last year, more than five million premises were inspected and more than RM7mil in compounds had been issued but the mosquito breeding problem remained.

Don’t blame us for not detecting dengue in patients earlier, say docs

thestar
BY LOH FOON FONG

PETALING JAYA: General practitioners (GPs) have objected to the view that they usually missed dengue detection on patients’ early visits, saying that the dengue rapid test should be carried out only when symptoms were suspicious.

“Even when we confirm dengue on day one, if blood pressure, platelet level and everything else is normal and we send the patient to a government hospital, they will turn away the patient,” Medical Practitioners Coalition Association of Malaysia president Dr Jim Loi said.

GPs, he said, would normally do the test on patients’ second visit.

Based on past incidents, he said patients referred to government hospitals after they were diagnosed for dengue on the second visit had been turned away when their vital readings were normal.

On Wednesday, Health Minister Datuk Seri Dr S. Subramaniam urged GPs to stock up on dengue rapid test kits as 99% of them missed the diagnosis on the first visits.

However, Dr Loi noted that cost was also a deterrent factor for many patients.

The normal rapid test cost RM30 to RM40 (NS1 antigen test) while the combo rapid test kit (IgG and IgM) cost RM80, not including consultation and medicine, he said.

“If symptoms persist after two days, we would advise them either to return to us to check for dengue or go straight to the hospital.”

He said early detection had no bearing on patient mortality as it would depend on how patients were managed as the disease progresses.

Malaysian Medical Association president Dr Krishna Kumar also said patients were not screened during early visits because it was not economically viable to do so.

“Currently, we don’t think it is necessary to do the test on the first day of fever but we tell the patients to return after two days if fever persists,” he said.

He noted that patients could miss the diagnosis if they hopped from one doctor to another.

The Federation of Private Medical Practitioners’ Associations president Dr Steven Chow said commercially available test kits could not confirm the diagnosis of dengue in the early stages of the disease.

“What is most important is a high index of suspicion for all cases and the proper use of the test at the appropriate time,” he said.

He said the decision was best left to the attending doctor to advise on adequate fluid consumption, monitor the patient regularly for danger signs and to refer problematic cases with potential complications to hospitals for further management.

“This has been the standard operating procedure recommended by the Health Ministry,” he said.