Sunday, August 23, 2009

H1N1 Hoax: When not to take Tamiflu

On August 14, Lim Kit Siang questioned Liow Tiong Lai why Malaysia’s A (H1N1) death rate is four times the global case fatality rate. In his response, Liow Tiong Lai said Malaysia had requested the WHO to send three epidemiologists to look into the H1N1 deaths, especially why some patients developed pneumonia so fast and died in a short period.
The government's expert, Dr Christopher Lee, consultant physician and head of infectious diseases at Sungai Buloh Hospital, then retorted that the death toll is not remarkly high especially when one considers the World Health Organisation estimation that 15-20 cases go unreported for every case of A (H1N1) confirmed.

If we based on the statistic provide by Kit Siang which did not consider the World Health Organisation estimation that 15-20 cases go unreported for every case of A (H1N1) confirmed, our death toll is still petty high compare to other nations.

CountryDeathsTotal Confirmed CasesMortality rate(%)
Hong Kong46,4170.0623
Indonesia3812 (11 Aug)0.3695
Philippines83,207 (30 July)0.2495
Singapore103,071 (11 July)0.3256
Thailand978,877 (2 Aug)1.092
New Zealand142,984 (11 Aug)0.469

Even if we go by the argument of the of the government's expert, you should realised that there is no death toll from those unreported cases of which majority of the patients were treated by private clinics without using Tamiflu. One should remember that the national stockpile of Tamiflu is controlled by the Ministry of Health, which was not readily available to private clinics before August 15. It is also a well known fact that private clinics are hesitant to stock up on the A (H1N1) anti-viral drug, Tamiflu, due to its high cost and inconsistent guidelines from the Health Ministry.

On August 14,Health Minister Datuk Seri Liow Tiong Lai directed all public and private hospitals to administer immediate treatment to patients with flu-like symptoms and with high fever that persisted for more than 48 hours.

This led to the complaint by private clinics as reported in the Star:
Saturday, 15 August 2009 08:08am

Clinics not keen on stocking up Tamiflu
by Shaun Ho & Chew Wan Ying

PETALING JAYA: Private clinics are hesitant to stock up on the A (H1N1) anti-viral drug, Tamiflu, due to its high cost and inconsistent guidelines from the Health Ministry.

According to a survey carried out by The Star among 12 private clinics here, eight did not have the supply and did not intend to place orders with suppliers.

“The Government is inconsistent in giving guidelines regarding the prescription of drugs,” said a doctor in Jalan Bangsar in Kuala Lumpur.

Yesterday, Health Minister Datuk Seri Liow Tiong Lai directed all public and private hospitals to administer immediate treatment to patients with flu-like symptoms and with high fever that persisted for more than 48 hours.

Prescription should be made based on the doctor’s discretion and on a case-by-case basis, said the doctor who did not want to be named.

“If we indeed follow the latest guidelines, the supply will run out soon. It will be harder for us to restock, as there is a limited supply nationwide,” he said.

Most of the nation’s supply had been taken up by government hospitals, said another private medical practitioner in Cheras who wished to remain anonymous.

“The Government is not releasing sufficient quantities of the drug to private hospitals. We are left on our own to source for the drugs.

“On the ground, there is no supply at all for private clinics,” he said.

He added that the Government should focus on preventive measures rather than the cure, as the virus can build up resistance to the drug over time.

“The Government is not making people, especially school and college students, wear masks,” he said.

Another doctor from Bukit Sentosa said that maintaining the standard of hygiene was more important.

He said he had observed a shortage while sourcing the drug for his clinic.

“I have not seen genuine Tamiflu made by Roche in Malaysia. What we have are generic drugs,” he said, adding that he was not adhering strictly to the ministry’s guidelines.

“I only prescribe to confirmed cases.”

Some cited the drug’s high price, ranging between RM140 and RM220 for 10 tablets, as a leading factor in deterring them from purchasing it.

“The loss would be too high to bear if nobody buys the drug,” said Dr Raman Nathan of Klinik Sentosa at Taman Putra Ampang.

One should also realised that our national stockpile of Tamiflu has been expired since August 8, but the shelf life of the Tamiflu has been extended by two years following the recommendation of Swiss drug maker Roche. This is the first time in modern medicine history where an expired drug has been given shelf life extension. A drug that led to adverse effect causing deaths during treatment has been given extension because the whole world has no ideas what to do with H1N1.
The lack of available and reliable testing and difficulty in confirming such illness as being due to this A(H1N1) flu compounds the situation, when many patients demand to know for sure. Doctors are thus left quite alone to firefight angry and worried patients with very few resources or reassurances or specific therapies. - (Source: The MMA answers common H1N1 questions By Dr David KL Quek, President MMA)
Doctors are reported to be confused by the MOH's guidelines.

Doctors confused by many ministry guidelines

PETALING JAYA: Some private medical practitioners are confused by the Health Ministry’s guidelines on how to treat patients with influenza-like illnesses (ILI).Federation of Private Medical Practitioners Associations Malaysia president Dr Steven Chow said the many guidelines that were issued were often conflicting.For example, Dr Chow said general physicians (GPs) had been asked at one point to send all cases to the nearest hospital for testing; and when the hospitals could not cope, they were asked to send only selected cases. He added when deaths were first reported, private doctors were blamed for late diagnosis and referrals to government hospitals.“When dengue was not controlled, they were blamed and then the A(H1N1) came.“This does not help the doctors on the ground. It is a nightmare for our GPs,” he said in an e-mail interview.He added that private sector GPs also faced a shortage of anti-viral drugs to treat the virus.“The main stockpile is with the Government and we are not aware of the type prescribed by the Minis-try.”However, Dr Chow reminded that the A(H1N1) strain was resistant to existing antiviral drugs.“Antiviral drugs are not the magic bullet for stopping or controlling this pandemic. There has been too much hype on the usefulness of these medications,” he said.Dr Chow also pointed that rapid test kits, which increased the cost of care were not specific or sensitive enough for diagnostic use.On Health Minister Datuk Seri Liow Tiong Lai’s directive to private healthcare providers to raise the level of suspicion on the virus, Dr Chow said the Federation had advised members to treat all ILI as A(H1N1).He said the federation was ready to work with the Ministry to fight the virus and take pre-emptive measures to decrease future fatalities.Meanwhile, in Bukit Mertajam, IAN MCINTYRE reported patients refused treatment for flu symptoms at hospitals or clinics should inform the Penang state government.The public can e-mail their complaints and views to state health, environment and caring society committee chairman Phee Boon Poh face masks, there should be amply supply in the market following the Federal Government’s move to make it a controlled item, said Phee before accompanying Chief Minister Lim Guan Eng on a house-to-house campaign at the Permatang Pasir by-election here yesterday.He said a large consignment of masks were expected to arrive in Penang soon from Taiwan.

Before the first H1n1 related death was reported on July 23, Malaysia was quite proud about it's ability to contain the H1N1 flu pandemic even with reported cases amounting to over 900.

On July 9, Health Minister Datuk Seri Liow Tiong Lai announced that Malaysia has moved from containment to mitigation of the Influenza A(H1N1). The WHO representative for Malaysia, Singapore and Brunei, Dr Han Theru, said it was the right time for Malaysia to move to the mitigation stage as it needed to focus more on how to reduce the damage to patients and society as more local cases were detected.

Since then the pressure for the government to release the national stockpile of Tamiflu has been mounting. With the MOH decided to go all out to treat suspected H1N1 patients with Tamiflu, suddenly the death toll is out of control with more and more deaths reported.

Mistakes committed by our medical profession on the H1N1 are as follows:
1) Forget that the Tamiflu is designed for avain flu not swine flu. Bird == Pig ? May be at the Bak Kua stall of Wo Lai Yeh, bird and pig seem to be looked alike ;->(
2) Wrong diagnostic kits being used for testing H1N1. If you can't diagnostic, forget about treatment! Shame on you, doctors!
3) Ignoring that there are more than 1 strains of flu circulating in the country
4) Ignoring the fact that the A(H1N1) strain was resistant to existing antiviral drugs.
5) Allowing the salesman of antiviral drugs to lead the nose of doctors in treating influenza like illness
6) Inconsistent and often self-contradicting guidelines from MOH on H1N1 testing and treatment
7) Never learn from the 2005 Avian flu hysteria, and continue to play up the media hype on H1N1
8) Ignoring the Tamiflu's adverse effect on patients of previous H5N1 outbreak before deciding to treat all influenza like illness with Tamiflu
9) Working hand in hand with WHO to lie about the shelf life of Tamiflu, which is confirmed by Roche to be 3 years, now become 5 years and with option of local authorities to extend it for another 2 years
10) Desperate attempt by MOH to dispose off the expired Tamiflu which original stockpiled in anticipation of an avian flu pandemic that never happened.

So in the event, if you end up in the hospital with suspected H1N1, how are you going to make a decision on whether to take Tamiflu or not.
If you have any of the following syndromes, please politely decline the offer of Tamiflu to aviod adverse event- Death caused by viral pneumonia:
1) No aversion to cold, fever with yellowish tongue fur
2) Sweating on your head and torso with fever still persisting or if you suffered from Hyperhidrosis
3) Diabetes with excessive thirst, extreme hunger, unusual weight loss and increased fatigue
4) Dengue fever
5) Smelly yellow nasal discharge
6) Sore throat
7) Aversion to fever
8) Parkinson desease
9) Sleeping Disorder
10) Chronic Renal Failure
11) Hypertensive heart desease
12) Inflammatory Cardiomyopathy
13) Bacterial pneumonia

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