More Flu Cases in Singapore

The first case of novel influenza A(H1N1) virus infection to be identified in Singapore arrived in the early hours of 26^th May. The SMU student had flown in from New York, slipped past the thermal scanners although she had already developed symptoms onboard the flight, but sought medical attention in the later part of the morning. An alert general practitioner had her transferred to the Communicable Diseases Center (CDC), where laboratory testing confirmed that she was infected with the novel influenza virus in the early hours of 27^th May.

Within 36 hours, we have three further cases unrelated to the first, all of whom have come from different parts of the United States. All four patients are being treated at CDC, with none reported as having serious infections. In other words, they would not ordinarily have been hospitalized, except for the unfortunate circumstance of being infected with this new influenza virus. It is understood that their close contacts are also being quarantined (albeit not in the hospital), and have been provided (likely) oseltamivir prophylaxis to prevent the development of overt disease.

On the backdrop of a pandemic with confirmed cases in 58 countries, the importation of this number of cases is not unusual. There will likely be more in the coming weeks. What is unusual is the length of time it had taken for the first case to appear on our shores, given the recent identification of cases in surrounding countries, and Changi Airport’s status as a major aviation hub for the region.

An analysis of the news reports suggests that our Ministry of Health (MOH) is trying to contain the spread of disease at this point. By giving antiviral prophylaxis to all contacts of the initial cases, it is hoped that they will not develop the disease and transmit it to others. One might ask, given the mild nature of this influenza to date – could these contacts not just have been quarantined, rather than risk the additional potential adverse effects of oseltamivir? These are relatively rare, but some – especially the controversial neuropsychiatric effects (fiercely contested by Roche investigators, with a nebulous warning by the FDA) – are nontrivial. The experts at MOH must have performed their calculations and either projected that quarantine alone would be insufficient for containment, or that the benefits of antiviral prophylaxis outweighed the risks/costs.

Some – including the National Neuroscience Institute director – have argued that containment is ultimately futile, and that we should allow the first wave of the virus to run its course in Singapore to develop herd immunity. This strategy is based in particular on the 1918-1999 pandemic, where the first wave was relatively mild (albeit with higher mortality than seasonal flu), whereas a more virulent mutated form returned 4 months later. Survivors of the first wave were not infected by the far more deadly ‘second wave’ virus. This strategy was rebutted by MOH’s Director of Medical Services, who was opposed to subjecting the population to unnecessary and unknown risks.

Will there be a ‘second wave’ and will it be more deadly than the first? The answer to the first question is ‘probably – and there might well be more than two waves’, while the second question is harder to answer with any degree of confidence. Dr Mark Miller and his colleagues from the Fogarty International Center of the National Institutes of Health, USA, wrote a concise and informative article on previous influenza pandemics that is well worth a read. The short summary of most experts’ viewpoints seems to be this: there is a lot of knowledge on historical 20^th century influenza pandemics but we still have no idea how this one is going to play out because each pandemic had been different in significant ways. Sometimes a little extra knowledge (and therefore the knowledge that little is certain) can be paralyzing. Sobering to consider 2-5 years of elevated DORSCON-Flu alerts though.

Will we be able to stop the virus from entering and transmitting in the local community? Probably not in the long run, although even a delay – as well as attempts at diminishing transmission with social interventions should community spread occur – will be beneficial. There might (or might not) be a widely available vaccine in the next year. There might (or might not) be a more virulent ‘second wave’ influenza virus. But whereas our medical services are generally first-rate, the current undersupply is unlikely to be alleviated in the next couple of years. An increased utilization (or reduction) of health services because of influenza in the short term may lead to critical compromises that we can ill afford.

We Knew This Would Happen

Article from ChannelNewsAsia

Now let's hope Prof. Lee Wei Ling's recommendation about herd immunity will bear fruit.

At least we haven't escalated to DORSCON Orange yet again.

I, for one, am hoping to avoid those yellow impermeable gowns for as long as possible.
The perspiration's one thing, but the incessant swishing noise with the slightest movement can induce psychosis.

And please don't cancel my conference leave...

Does This Apply To Singapore?

Interesting Article from Time magazine


A rather similar piece was published almost 10 years ago - I remember because I quoted it in a write-up I did for a local medical newsletter. Funny how things haven't changed much all this time.

Whether it applies to the local context, it would depend a lot on the department you're in. High-risk postings include surgical ones ( general, orthopaedic ), maybe even certain medical rotations ( my time as a house and medical officer in internal medicine was hellish ), or any place that is famous for bad night calls and minimal post-calls.

Some of you may not be aware that the National University Hospital recently started a shift system for ward teams ( I'm told medical departments have come on board ). So instead of working 8-5 and staying overnight when you're on-call, everyone does 12-hour shifts ( something like 8am to 8pm then 8pm-8am, correct me if I'm wrong because I don't work there ) at fixed stretches, followed by another stretch of days off.

I'm told hospitals in Australia and the United Kingdom also utilize the same system. Reason it hasn't made it to Singapore may have something to do with our manpower shortage and resistance to change by the powers-that-be.

Commenting from an ER physician's perspective, I think shift hours for all doctors is the best way to go. Why deprive them,of sleep and put patients at unnecessary risk? Certainly, other factors may come into play where medical errors are concerned, but it's been proven that sleep-deprived doctors' cognitive and motor skills are equivalent to those intoxicated with alcohol.

Would you want someone like that taking care of you in the middle of the night, especially if you require an emergency procedure?

Anyway, it remains to be seen whether Singapore's healthcare system will undergo any major revamping in the near future.

Just some food for thought.

p.s. A book recommendation - How Doctors Think, by Jerome Groopman.

Further thoughts on the novel influenza A(H1N1) outbreak

Depending on how you choose to calculate, we are currently approximately two months into the global H1N1 epidemic now. The WHO has put up an interactive map showing the timeline of cases (it is about 2 days behind time), whereas the unknown authors of Wikipedia have depicted this timeline – based on WHO reports – as a graph (it is about 1 day behind time). The figures are sobering – there are now in excess of 12,000 confirmed cases and 90 deaths. That is about 50% more cases than the entire SARS outbreak but slightly less than 12% of the deaths. And there are no signs that the epidemic has peaked yet. The main silver lining (if you choose to see it that way) is that the official figures of infected cases are almost certainly a gross underestimate, so the case fatality rate(CFR) is actually far lower than 0.7%.

There have been several publications on the clinical features of this new influenza, the latest being the WHO weekly epidemiological record (pdf format) on 22nd May 2009. The new disease looks, in essence, like the old influenza, except that a significant proportion of severe and fatal cases have occurred among young and healthy adults. Adults with underlying medical conditions, in particular chronic heart or lung diseases, appear to be more at risk for severe disease. Much has been said about the increased proportion of cases with gastrointestinal (mainly diarrhea and/or vomiting) symptoms, but at 25% or less, this is just a statistic for those looking for a way to make the diagnosis clinically.

The country that appears to be the worst hit outside the WHO North America (comprising USA, Mexico and Canada) region is surprisingly Japan, one of the cleanest countries in the world. Although the first cases were only confirmed on 8th May (imported from either Canada or Detroit, USA where the three cases transited), the figure has jumped to 338 cases as of today – the 4th highest worldwide. It is unclear if the Japanese are just better at detecting and confirming H1N1 cases than most other countries at this point in time, although that would not be unexpected.

Dr Margaret Chan, Director-General of the WHO, has so far resisted (or conceivably also been pressured to avoid) raising the global pandemic alert to Phase 6 – the ultimate level. The problem with the global alert definitions, which is clear on hindsight, is that disease severity (i.e. virulence of the virus) is not included as a factor for up- or downgrading the alerts. This is also the issue for Singapore’s DORSCON-flu alert system, which is largely based on the WHO system anyway. To date, all recorded influenza pandemics have had CFR’s that have exceeded 0.1%, and the H5N1 avian influenza virus – until March 2009 the most likely candidate virus for a pandemic – has an eye-popping CFR of more than 67%. So what do you do when a novel pandemic influenza virus comes along that has a CFR that is not much (if at all) above that of seasonal influenza? You can imagine the quandary facing world experts and health leaders:

• You cannot outright say that the global pandemic alert system (or your country’s alert system) is flawed.

1. But you will still need to somehow tweak the system such that it will be more flexible to deal with viruses of different virulence and transmissibility.

• You cannot tell the different countries to stand down, since it will:

1. Insult the countries (especially Mexico) that have put in great public efforts at tremendous costs to stem the epidemic.
2. Make you look like a fool if history repeats and a more virulent “second wave” follows the first.

• You also do not want to overplay the threat of the pandemic, since it will quickly lead to media and public exhaustion, and you still need to conserve resources for the anticipated “second wave” of the virus.
  

Some have questioned if Singapore – especially its hospitals – has over-reacted in the early phase of the H1N1 epidemic. After all, we swiftly escalated to Orange, created great inconvenience for both healthcare staff and patients/relatives, and doubtlessly used up lots of masks and other protective equipment needlessly. Millions of dollars have been spent and the morbidity cost for patients (in terms of elective operations and clinic follow-ups postponed) has yet to be tabulated. And to date, we have not had a single case of H1N1 in the country. The answer for this writer is naturally, yes. But the benefits of this “over-reaction” have far outweighed its costs, such that this writer feels that it is actually better for us in the long term that we had reacted in this manner.

Singapore has organized several “preparedness” exercises (you can read about a couple of them at this UN website) involving the hospitals in the past. For most of us in the healthcare profession, these have tended to be more farcical than useful – more to reassure the community at large rather than anything else. You almost always knew when (to the hour) and how the simulated patient was going to appear in your hospital. The exercises were also by nature short-lived (it is almost impossible to justify a sustained test of the healthcare system). Thanks to the H1N1 pandemic, we have had a real systems test, highlighting virtually all the issues that had previously been undetected or glossed over (such as sustainability of response). Our responses have previously been based on a SARS-like scenario – all these assumptions have now been challenged and will probably change for a more flexible set of responses. One might argue that all these should have been worked out beforehand, but it is virtually impossible to identify all the fine details and tease out the fault lines in a simulation. “No plans survive first contact with the enemy”, but even “real” anticipated contact has served us well. This does not excuse all the inconveniences and delays/morbidity faced by the patients, but we are far better prepared to deal with any pandemic influenza virus now than before 28th April, and this will surely make a difference when H1N1 or some other virus finally appears in our community.

Points To Ponder

Excerpts from How To Prepare For A Pandemic
- from Time magazine's May 18 2009 issue


"A virulent flu pandemic...would cause health-care systems to crash like an overloaded website. Professor Richard Coker of the London School of Hygiene and Tropical Medicine has spent the past five years examining the preparedness of various countries for a pandemic. He says even developed countries do not have enough hospital beds, staff and equipment to handle the expected surge during a worldwide outbreak."

"...while countries in...Southeast Asia...have detailed preparedness plans for flu that adhere to WHO guidelines, says Coker, the question is, "When it comes down to it, can you actually implement your strategy? Do you have the resources? And if you do have the resources, can you allocate them properly? And the answer we're finding tends to be no."

"But there are international models the U.S. can follow. Hong Kong... has 2 million courses of Tamiflu, three times the city's population.
... Holiday camps on the fringes of the city have been set up to serve as isolation wards, and the city has invested in epidemiology labs and more hospital beds. "Hong Kong really is the international gold standard when it comes to dealing with infectious disease." "

"As a result of jet travel and international trade, a new pathogen managed to seed itself in more than 20 countries in less than 2 weeks."

"H1N1 wasn't a true test of our mettle but a warning shot. "We should look at this as a wake-up call, not one more snooze alarm." "

Libel Laws and Blogging Against Quackery

I have been following the libel suit filed by the British Chiropractic Association (BCA) against science author Simon Singh with some interest as alternative medicine is a subject I frequently blog on, and as Singapore's libel laws are descended from the British Common Law.

So far the case has gone in favour of the BCA; the decision hinged on the judge's interpretation of the word 'bogus', which will require Singh to prove (as libel cases involve a reverse burden of proof) intention of the part of chiropractors to deceive, something which is notoriously difficult to do in a court of law. If Singh decides to appeal, his legal team will have their work cut out for them. His decision is eagerly awaited by many in the legal, medical and scientific circles as this case is seen as a test case on freedom of speech and the right to criticise alternative medicine - if Singh loses, this may set a precedent for the use of libel suits as a means to silence legitimate criticism of people professing abilities to heal which they do not in fact possess; in other words, it may soon become too dangerous to call a quack a quack.

Can such a fate befall a blogger in Singapore who criticises the lack of evidence behind the promotion of alternative medicine?

Under Singapore's defamation law (Penal Code Chapter XII), it is indeed possible for a person to defame "a company, or an association or a collection of persons as such". In other words, if in blogging about "X-therapy" (to make up a term for an unspecified alternative medicine to avoid a defamation suit, you understand...) a blogger is deemed to have 'defamed' its practitioners in general, a suit may be brought against him by a body of "X-therapy" practitioners.

This creates a potentially dangerous situation for the blogger writing in his personal capacity, as defending a libel suit can be costly, while an association of practitioners may be better able to afford the cost of hiring lawyers.

As a practising doctor, I have come to accept that one cannot ensure that one will never be the target of a malpractice suit - it comes with the territory - but one may reduce one's chances of having a suit brought against oneself and to reduce the chances of that suit being successful. Are there measures then which our blogger can adopt to reduce his own risks then?

The wording of the defamation law itself perhaps gives us some guidelines on how to avoid some of the pitfalls.

Specifically, Explanation 4. in Section 499 states that "[n]o imputation is said to harm a person’s reputation, unless that imputation directly or indirectly, in the estimation of others, lowers the moral or intellectual character of that person, or lowers the character of that person in respect of his calling".

In other words, it may be safe if the blogger examines only the evidence behind the form of alternative medicine being discussed, without making any statement on the character of its practitioners. (I confess that I find this hard to do as I personally consider someone who knowingly promotes a form of therapy he or she knows to not be backed by evidence to be at the very least intellectually sloppy, and at the very worst blatantly dishonest.)

However, the law also provides an exception in the First Exception. in Section 499, which states that:

It is not defamation to impute anything which is true concerning any person, if it is for the public good that the imputation should be made or published. Whether or not it is for the public good is a question of fact.

This allows the defendant to invoke truth and public interest as defence, but as mentioned earlier, the onus is on the defendant to provide the proof in this case, and the difficulty of proving intent in a court of law remains. This provision then perhaps allows our blogger to write that "X-therapy has not been shown to have any efficacy in the treatment of this condition, and promotion of its use by this population by its practitioners has resulted in these specific mortality and morbidity" but not "X-therapy has not been shown to have any efficacy in the treatment of this condition, and by promoting its use its practitioners are knowingly causing these specific mortality and morbidity in this population".

+++

I am not a lawyer or a student of law, and in the absence of a local test case it remains to be seen if the observations I have made above are accurate and correct, or if a blogger can indeed avoid a lawsuit by taking my advice.

In the meantime, I continue to keep an eye on the BCA suit.

Singapore's 3rd Medical School Cometh

So after some ballyhooing - including a few Forum Page letters - the headlines today confirm plans for yet another med school, to be run by NTU.

Aside from the glaring fact that MOH failed to foresee this so-called doctor shortage years in advance - I belong to a generation that suffered the consequences of massive restrictions on the NUS cohort size and number of overseas med schools recognized by MOH back in the day - it remains to be seen whether this venture will reap long-term benefits.

"Benefits" can be viewed in 2 ways:

1) From the MOH perspective:

a) Do whatever is necessary to generate the required doctor:patient ratio ( never mind that a large proportion of these doctors is in private practice and may or may not "specialize" in aesthetics ).
b) Secure "big names" as collaborators.
c) Emphasize research - which, if you think about it, doesn't equate full-time clinical work, which again contributes to manpower shortage.
d) And now, emphasize medical technology ( effect on manpower still unknown ).


2) From an actual practising physician's perspective:

a) Produce doctors who can actually function.
b) Produce doctors who will stay on in the public service instead of running away the first chance they get.
c) Ensure that the additional manpower is managed efficiently, i.e. distribute junior doctors ( house and medical officers ) among departments which are dangerously understaffed ( e.g. polyclinics, A&E, selected medical and surgical rotations ).


That said, a recent conversation with an MO who left our department during the changeover last week resulted in the following excerpt:

Me: So, how's X posting?

MO: Very boring. Nothing to do after 10am.

Me: Hah? I thought it's supposed to be very busy?

MO: No leh. But my HO is sooooo slow. I end up having to help her do all the changes - and we have only 5 patients!

Me: Oh my goodness!

MO: Ya, she was supposed to call a specialist for a blue letter referral today, and hadn't done it by 2pm when I asked her about it, so I did the calling instead. Sigh.

Me: That's damn sad, man.


I still remember my HO days, when patient lists hit 50 on bad days, and you could NEVER count on your MO to help you do anything ( culture was different back then ).

Wonder what all those med school internship programmes are for, and what kind of graduates we're churning out.

Sad, but true.

Thoughts on the novel influenza A(H1N1) outbreak

It has been almost two months since Mexican health officials detected a surge in cases of influenza-like illness (ILI) in Mexico city, heralding the start of our first global influenza A pandemic of the 21st century. Just to be clear, it is not officially a pandemic yet. For that, the World Health Organization (WHO) will have to acknowledge that at least one other country outside the “North America region” (to which USA, Canada and Mexico belong) is seeing sustained community transmission of the novel influenza A(H1N1) virus. But a quick glance at the map of H1N1 confirmed cases (reproduced below) provided by WHO will demonstrate the incredible spread of the virus within just a couple of months.



Three important interlinked questions that have not been definitively answered are:
1. How serious is an infection by the novel virus?
2. What will be the course of the pandemic?
3. What should we do about the pandemic?
We will try to touch on the first question today.

Many people hypnotized by the WHO “scorecard” will conclude that, as of 15th May 2009, the case fatality rate (CFR) of this virus is 0.3% (corresponding to 65 deaths in 7,520 confirmed cases) – a rate higher than any previously documented pandemic except for the Spanish flu of 1918-1919. Others argue that these figures are misleading – confirmed cases only represent a small fraction of the actual number of H1N1 cases. Dr Daniel Jernigan, deputy director of US Centers for Disease Control and Prevention (CDC)’s influenza division, had expressed his opinion in a news conference yesterday that the number of confirmed cases reported to US CDC was a gross underestimate – perhaps by more than a factor of 10. This would put the CFR of influenza A(H1N1) virus more in the league of seasonal rather than pandemic influenza. Not that this is a figure to be sneezed at, of course – more people are projected to die from causes related to influenza in Singapore each year than from the combined mortality of all the diseases listed on our ministry’s weekly infectious disease bulletin.

The scenario painted by Dr Jernigan also makes more sense from the epidemiological viewpoint. There is just no way that “merely” 6,000 or so cases in Mexico and US can result in the export of so many cases so quickly to so many countries in the rest of the world.

But there are disturbing possibilities that lie ahead that we will try to address in future posts. Namely, the chance that a second wave of the pandemic virus will result in more severe disease and higher mortality; and the chance that this new virus will re-assort with current existing influenza viruses, resulting in a “monster hybrid” that will either be resistant to tamiflu, or will have the virulence of avian influenza (whose CFR shockingly exceeds 60% to date), or both.