H1N1 – We should all be involved

The unpredictability of the H1N1 virus makes it imperative that all individuals play their part to control the transmission of the disease. 

THE only predictable feature about the influenza virus is its unpredictability. The virus mutates often. Minor mutations (antigenic drift) are frequent and cause repeated outbreaks. Major mutations (antigenic shift) are rare and are due to re-assortment of genetic material from different viral sub-types. When they occur pandemics result, causing many deaths. 

Where during previous influenza pandemics, it took more than six months to spread globally, it took less than six weeks in the current one. This was facilitated to a large extent by international travel. 

The first case was reported in Malaysia on May 15, 2009. Initially, the cases were imported ones, but the infection soon spread locally and the number of local infections overtook the imported ones from mid-July onwards. The spread was rapid and the first death was reported on July 23, 2009. There have been 69 deaths as of August 24, 2009, comprising four from July 23 to 31, 11 from August 1 to 7, 41 from August 8 to 14, and 12 from August 15 to 21. 

Pandemic (H1N1-2009) 

It is particularly worrying that medical advice has been ignored by some of those infected who are managedwith home quarantine. This behaviour will inevitably result in the spread of the infection, particularly whenpublic places are visited by persons who are still infectious.

The virus contains unique gene segments from four different viruses from swine, bird (avian), and human viruses. Since it is a new virus that has appeared in humans, no one will have immunity to it and everyone is at risk of getting the infection.  

The symptoms of infection are similar to that of seasonal influenza. They include high fever (more than 38 degrees Centigrade) and one or more respiratory symptoms like cough, sore throat, running nose, muscle aches (myalgia), and sometimes breathlessness. There may be one or more of following, viz: close contact with a person diagnosed as probable or confirmed case of pandemic (H1N1-2009) or recent travel to an area or country reporting cases of confirmed pandemic (H1N1-2009). 

As there is now community spread of the virus, it is likely that more and more of the seasonal influenza will be caused by the pandemic (H1N1-2009) virus strain. 

The vast majority of those infected will recover within a week or so. The likelihood of a worsening of the infection or of complications is increased in individuals with risk factors. 

The World Health Organization (WHO) has categorised the severity of the pandemic (H1N1-2009) as moderate. This means that most people recover from infection without the need for medical care and the incidence of severe illness is similar to that seen during local ordinary seasonal influenza outbreaks, although higher levels have occurred in some local areas and institutions. 

Knowledge about the pandemic (H1N1-2009) has increased since it was first reported in Mexico in April 2009. However, the knowledge is still incomplete. Guidelines and advice on its management will continue to be updated in the light of new knowledge about this novel infection. 


The public’s response has ranged from complacency to panic, with more of the latter coming to the fore after the death reports started coming in. It is particularly worrying that medical advice has been ignored by some of those infected who are managed with home quarantine. This behaviour will inevitably result in the spread of the infection, particularly when public places are visited by persons who are still infectious.  

The Health Ministry was initially criticised for over-reaction. This has been replaced with criticism that it is not doing enough to stop the rapid spread of the virus. 

Many healthcare facilities are swarmed by the “worried well”. Doctors in outpatient clinics and the accident and emergency units of the Health Ministry’s facilities have to attend to between 120 and 150 patients in an eight hour session. Laboratories have difficulty coping with the demand for pandemic (H1N1-2009) tests. It used to take six to eight hours to get the results of tests for A (H1N1), but now it takes about a week or so! 

Private healthcare facilities have difficulty getting access to antiviral medicines. A similar situation exists with laboratory test kits. This has lead to unpleasant experiences for everyone involved.  

Pointing fingers are becoming the norm. The fingers are pointed at everyone, particularly the Health Ministry, the Government, healthcare facilities, doctors, nurses, etc.  

This brings to mind a saying learnt in my childhood – when a finger is pointed at someone, there are four fingers pointed at your own self. 

There is positive news for a small segment of the population, but negative news for the vast majority. There is an increase in the number of advertisements on healthcare products, especially antiseptics in the print and electronic media, together with advertisements on courses on the prevention of the pandemic (H1N1-2009). The prices of masks have increased by up to ten-fold in some outlets. Some private sector doctors report that the price of original antiviral medicines is less than that of generics. They also report that payment terms have changed from cash on delivery to cash on ordering the antiviral medicines. Even then, there is a time lag before the medicines are delivered. 

Although the Health Ministry has emphasised on personal hygiene, respiratory etiquette, social distancing, improving general health, and staying at home when sick in the print and electronic media since WHO’s declaration of the pandemic, the degree of compliance or non-compliance is unknown. 

In short, there is no shortage of misperception, confusion, anxiety, fear and even panic. This is reflected in calls, some by doctors, for an emergency curfew. However, there is no suggestion how long the curfew should last – one week, 10 days, two weeks or longer? What about repeat curfews? As the virus is already in the community, would a curfew stop its spread?  

There is reference to Mexico’s curfew in April. But it must be remembered that at that time no one knew what was happening. All that was known then was that many people with influenza like symptoms were dying. The situation is different today - there is knowledge, although incomplete, about the pandemic (H1N1-2009) infection. The actual number of pandemic (H1N1-2009) infections in Malaysia, although alarming to some, is still manageable. 

There are about 17 deaths from road traffic accidents daily. Should there be a curfew to reduce the number of such deaths? In short, the case for an emergency curfew has not been made out at this point in time. 


The case fatality rate (CFR) is the proportion of people with a disease who will die. The CFR for pandemic (H1N1-2009) infection has become clearer since the initial reports from Mexico that cited a high case-fatality rate (i.e. in excess of 5%, which is higher than the Spanish flu of 1918). As more information became available, this rate has dropped to the current CFR estimate of 0.1% to 0.4%.  

Of the 69 deaths as at 24 August, 70% were due to co-morbid causes which included pregnancy, diabetes, obesity, asthma, other chronic conditions and children with syndromes. 

There have been claims that the number infected and the CFR in Malaysia are high, giving rise to anxiety and even panic. The tables provide a perspective on the numbers that the reader should consider in addressing this question.  

It can be seen from the tables that the case fatality rate is not as near that of panic proportions as has been made out by certain quarters. However, every death is regrettable and should be investigated to enable better management of future patients. 

Analyses of the causes of deaths associated with pandemic (H1N1-2009) infection in Malaysia have yet to be published. There are several questions that need to be answered, and they include: 

·Were the deaths due to viral pneumonia or were they due to superimposed bacterial pneumonia? 

·Were the deaths due to worsening of co-morbid conditions?  

·Were the pandemic (H1N1-2009) infections an incidental finding? 

·Was the care provided optimal? 

Country comparisons have been made but they are fraught with difficulties. The saying that apples must be compared with apples and oranges with oranges, and not apples with oranges also holds true in healthcare.  

For example, the health profile, healthcare development and access to healthcare of Malaysia differ from other countries. The risk factors for pandemic (H1N1-2009) also differ, e.g. 11.6% and 14.9% of Malaysians above the ages of 18 years and 30 years respectively are diabetic; 29% are overweight and 14% obese (National Morbidity Survey 2006); and 400,000 to 450,000 Malaysians give birth annually.  

Going forward 

It would be useful for everyone to reflect on the current situation. No one can control the air we breathe nor human behaviour, so the community spread of pandemic (H1N1-2009) will continue. However, it can be contained through the collective efforts of everyone. There is no place for turf mentalities to come in the way of containment and mitigation efforts. 

Policies and guidelines have to be evidenced-based, reflective of conditions on the ground, and are implementable. Although the Malaysian healthcare system comprises the public, private and voluntary sectors, the virus does not recognise such distinctions. Enhanced co-ordination and co-operation between the various sectors, and an obliteration of the gap between policy and implementation, are crucial for significant impacts to be made in disease control.  

Regular sharing, updating, and dissemination of knowledge gained are vital.  

Doctors, nurses and other healthcare professionals have a particular responsibility to keep abreast of the information and guidelines about the disease which will be updated from time to time in the light of newer knowledge.  

The basics of risk communication have to be remembered when health messages are put out. The messages are usually judged in the first place by whether their source is a trusted one. The responses to messages depend not only on the content but also on the manner in which it is delivered, particularly the emotional tone.  

The public require succinct messages, which should include: 

·Comply with the Health Ministry’s messages as it will go a long way to combating the pandemic (H1N1-2009) and other infections. They include washing hands, covering coughs and sneezes, keeping a distance from someone who is coughing or sneezing, recognising danger signs and seeking prompt care, staying at home when ill, providing the ill a separate space at home, and assigning a single caregiver to an ill person; 

·Consult your regular doctor without delay if there are influenza-like symptoms; 

·With continuing community spread, the likelihood that the seasonal influenza is due to pandemic (H1N1-2009) will increase.  

·If you have got an infection, rapid tests for pandemic (H1N1-2009) will not change the course of the infection. Neither will it change the management as its sensitivity ranges from 40% to 69%. (Centre for Disease Control. MMWR: Evaluation of Rapid Influenza Diagnostic Tests for Detection of Novel Influenza A (H1N1) Virus, August 7, 2009/58(30);826-829); 

·Healthy individuals are likely to recover within a week without any problems 

·Adhere to the doctor’s advice and the medicines prescribed 

·Remain at home and keep your doctor informed of your progress daily 

·The doctor will refer you to the nearest Health Ministry designated hospital for close monitoring if there are risk factors, i.e. children below five years; those below 19 years who are on long-term aspirin medication; pregnancy; chronic respiratory, cardiovascular, metabolic (especially diabetes), renal, liver, neurological or neuromuscular diseases; deficient immunity (e.g. cancer, HIV/AIDS), obesity, and any other condition that prejudices a person’s breathing (respiratory) function 

·Since progression to more severe disease can be very rapid, medical attention should be sought immediately whenever any of the following signs appear in anyone with confirmed or suspected pandemic (H1N1-2009) infection, i.e. shortness of breath, either during physical activity or while resting; difficulty in breathing; turning blue; bloody or coloured sputum; chest pain; altered mental status; high fever that persists beyond three days; and low blood pressure 

·The danger signs in children include rapid or difficult breathing, lack of alertness, difficulty in waking up, and little or no desire to play. 

·Guidelines just published by WHO do not recommend antiviral medicines for healthy individuals who have mild to moderate uncomplicated pandemic (H1N1-2009) infection as the body will deal with the infection just like any other infection. (WHO Guidelines for Pharmacological Management of Pandemic (H1N1) 2009 Influenza and other Influenza Viruses; August 20, 2009); 

·Avoid listening to and spreading rumours.  

Like other flu viruses, the pandemic (H1N1-2009) strain will change. New mutations may be harmless but the possibility also exists that the virus will become more infectious and lethal thereby affecting the infectivity and case fatality rate. It will take time for the full picture to emerge. 

Until then, there is need for vigilance; not complacency, panic, or irresponsible behaviour. Everyone has to play their part in the efforts to combat the disease. Individual efforts may not be significant by themselves but the collective contributions will have a significant impact. The understanding and active participation of the public is crucial to combating this new disease. 


> Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. The views expressed are those of the writer and readers are advised to always consult expert advice before undertaking any changes to their lifestyles. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information. 

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