Another review of the H1N1 scene

Today, the date toll for H1N1 rises to 32. Many people are asking me whether the disease is becoming more serious since the mortality rate seems to have gone up.

At the first look, yes, the apparent rate has gone up, since there are now 32 deaths and thousand plus CONFIRMED cases. But the actual rate is much lower than that.

Many of the flu cases now are H1N1 and majority are very mild, so they do not get picked up, since government is only doing the confirmatory tests on more serious cases like those down with pneumonia, and those in the high risks groups.  So the actual cases of H1N1 is much much higher than the thousand over cases reported.

This is unlike initially during the containment phase. During that time, most cases coming back from overseas with H1N1 were detected and quarantined , whether mild or serious.  And most contacts were traced and those contacts with H1N1 were also detected. SO the pick up rate was much higher. However, not all cases were detected, otherwise the disease would not have spread, since many of those coming back with H1N1 virus from overseas had no symptoms at all when they went throught the check point at the airports, but only developed symptoms after one or 2 days… Many did not get picked up. Still, the pick up rate was much higher than now, when most of the flu cases are actually H1N2 but did not get tested because they are not serious enough.. The government facilities cannot simply coped with the huge numbers of patients turning up in governemnt clinics.

So nobody knows how many actual H1N1 cases were there. But based on what was told to me by a government doctor, a sampling test among flu patients detected 5 H1N1 out of 6 cases with flu. That is why SIngapore has said that if you are having symptoms of flu like cough and runnign nose now, chances are you are having the H1N1 flu.

My estimate based on the number of sick people in schools , classes and so on, the actual number may have reached hundred of thousands.

I have predicted, during the initial outbreak of H1N1 overseas, that although this flu is mild and like seasonal flu, the ABSOLUTE number of people dying will be high since this flu spreads very easily.

Let us presume that the mortality rate is 0.4% (the actual rate is much lower since there are many milder cases not detected, but let us assume it to be 0.4%) .  Which means that for every 100 million actual H1N1 cases, there will be 400,000 deaths. 

Most of those who died, based on the experience so far, are those in the high risk group: those with co-morbid diesases such as heart failure, kidney failure, cancers , those who are pregnant, those very old and very young, those with chronic lung problems such as asthma, HIV cases, those on immunosupressive drugs like transplant patients. Another group is the obese people. Obesity is defined as having a BMI of more than 30. From the experience so far, obese people seem to be at high risk of developing pneumonia, and the postulation is that obese people tend to hypoventilate, meaning their beathing is slower and more shallow.

So while most of us will get a mild flu if ever we get H1N1, the onus is on us not to spread it to those in the high risk groups. If you are down with flu, stay at home and isolate yourself from those in the high risk groups..If you need to go out, wear a mask and wear it properly. I have seen so many people wearing masks covering their mouths only without covering their nostrils, which defeat the purpose of wearing mask.

All of us need to practise good personal hygiene. Wash our hands properly before touching ourselves, or our loved ones, or before eating. Wash our hands after touching handrails of escalators, stairs, supermarket trolley handles; for that matter, wash our hands after we touch any surfaces in public places before touching ourselves or our loved ones.

We need to have good sleep (see my earlier posts), adequate exercise, balanced diet and plenty of fluid intake to boost up our immune system.

The government  should have done more to educate Malaysians on proper etiquette when they are having flu, even mild ones. You may have a mild flu when you get H1N1, but the same virus can be DEADLY if spread to someone who is in the high risk groups. Look at it this way:  For everyone who died, there must be someone who have inadvertently killed him by spreading the virus to him.

I have seen people coughing and sneezing directly into the faces of someone else, some their loved ones. They have no qualm to pass on the virus. So we need to educate Malaysians not to do that. If they need to cough or sneeze, cover their mouths and nostrils with tissues or at least with their hands , and dispose off the tissue properly and wash their hands immediately. SOme Malaysians have this couldn’t care less type of attitude: So-what-if-I-spread-to-you, you-die-and-not-I-die type of attitude .. Luckily not all malaysians are like that.

So we all need to do our part. The death toll is going to rise, but we need not panic. FOr most of us it will be a mild flu, but do be vigilant and practise proper etiquette and good personal hygiene  so as not to spread the virus around. I stress again:  It may be mild to you, but it can be DEADLy for those in the high risk groups, and that can include your own loved ones.

 

Read my earlier article on H1N1:

Do not be unduly worried

Revisiting the H1N1 scene

44 Comments (+add yours?)

  1. Dr Hsu
    Aug 11, 2009 @ 16:13:56

    Recently, I saw a case of DM (diabetes mellitus)having cough for more than 2 months. Xrays showed pneumonia and blood sugar was very high. She is a diabetic being followed up in a semigovernment institution.

    I told her that her pneumonia is because of her Diabetes not under controlled. She argued that she is taking medicine. But I tried to explain to her that taking medicine does not equate to having good control of her diabetes. You can be on treatment but your sugar can still be sky high if there is no effort to watch the diet.

    This is typical of many diabetic patients. If diabetes is not controlled, they are prone to infections, (and of course other complications as well, chief of which is kidney failure, eyes problems).

    Since diabetic constitute a high proportion of population now, I hope this meassage will help them realise the importance of watching their diet and controlling thier diabetes.

    Like

  2. A true Malaysian
    Aug 11, 2009 @ 16:38:08

    Dr. Hsu,

    Malaysians have the habit of spitting around. I think this should be stopped as well.

    Again, thanks for this timely message,😀

    Like

  3. petestop
    Aug 11, 2009 @ 18:10:45

    Doc Hsu,

    Few month ago, my regular GP says he has H1N1 flu shot and showed me the package, which indeed says that it is H1N1 flu shot.

    Being the kiasi that I am and the fact that I travel
    often, I naturally paid up to get the shot.

    Do you think this is useful, or it is for another strain that is totally useless against this H1N1/09
    strain ?

    Also those who contracted it before, would they be immuned ?

    Like

  4. Justin Choo
    Aug 12, 2009 @ 00:00:57

    Thanks Dr Hsu. I took the liberty to forward email your post to all my contacts .

    Like

  5. romerz
    Aug 12, 2009 @ 01:50:32

    On Sunday, I went to the PC Fair at PISA in Penang and was alarmed at the crowd. It was shoulder-to-shoulder crowd and I was just thinking statistically, there must have at least been one or two amongst the many thousands there who may had come in contact with H1N1.

    I felt uneasy and wanted to leave (after being bumped around a bit) as I’m in daily contact with my mother who has health issues but could not leave as the fair was designed with traffic flow in one direction (one entry and one exit point).

    What I’m trying to say here is I thought it was irresponsible of the organizers given the present H1N1 situation not to anticipate the crowd and design the fair as such, not to mention the fire hazard potential.

    Whilst H1N1 may not be as lethal as it is made out to be by our sensationalist MSM, I believe the authorities should impose far greater control over large gatherings of people in confined spaces given the present H1N1 climate.

    At least we have the option to leave if we breach our comfort zones. Alas, our authorities are more prone to knee-jerk reactions than forward thinking.

    Like

  6. klm
    Aug 12, 2009 @ 09:32:29

    Dr. Hsu. The current H1N1 fatality rate is 1.7%. This is 4 times higher than the 0.4% reference that you use. Maybe, this with reference only to confirmed H1N1 cases. But again, the statistical fatality rate is also with known flu cases.

    I still think the govt medical authorities are not in control of the situation. When the shit hit the ceiling, they will still say the situation is critical but under control.

    Like

  7. Dr Hsu
    Aug 12, 2009 @ 10:25:46

    petestop
    its good to take the jab but that is for seasonal flu. The H1N1 the pack refered to is not the same H1n1 of this flu. That H1N1 flu was for 2007 & 8 strains.

    Research has shown that those who have taken this seasonal H1N1 flu jab has no antibody against the present H1N1.

    But if you have taken the seasonal flu jab, and still you are down with flu, then chances are your flu is the Present H1N1 flu.. This is why WHO has advocated people to take the seasonal H1N1 flu shots, not to prevent the new H1N1 but to aid in self realisation and early treatment of Tamiflu tablets, beside preventing from the normal seasonal flu which can be as deadly or even more so aginst those in the high risk groups.

    The spanish flu of 1918 which killed 40 million (estimate only) was also a H1N1 flu virus…

    Like

  8. Dr Hsu
    Aug 12, 2009 @ 10:54:35

    klm
    refer to my post when the experts have no expertise……

    Loss of excellence is everywhere….

    In 2003, I thought we handled the SARS outbreak very well. This time, we have tried too much in containing this virus, which is an impossible task for flu, But SARs did not spread as easily as this one and the mortality rate is much much higher.

    As for the 1,7% rate, since the denominator does not reflect the actual no. of cases, this rate is not an accurate reflection of actual situation. The rate for seasonal flu is 1%, but even in seasonal flu, the actual rate is much lower, since mild cases are not picked up. In other words, the denominator is not a true reflection of actual cases there are…

    In AUstralia, even though Melbourne is dubbed the H1N1 flu capital of the world, there is no panic there, people go around their daily lives, only with good hygienic practise and good flu etiqutte, and serious cases were well handled, since their priority was on early detection and treatment and not like us, our priority was trying to contain the flu, which I ahve said is an impossible task. They build up their herd immunity fast, and the flu is getting less seriuos there now.

    Like

  9. CYC
    Aug 12, 2009 @ 11:10:00

    Dr Hsu,

    Don’t you think the health ministry should help education ministry and others to establish a firm mechanism to determine when a school should be closed or other wise. there is so much confusion now.

    Secondly, how come there is no proper planning of what to be done to contain the pandemic at each stage just like trigger system that compel the ministry concern to institute appropriate counter measures. This is a standard practice in other countries as evidence during the SARS pandemic.

    Thirdly, why is it so difficult for the ministry to announce and publish the list of hospitals where suspected H1N1 patients can seek treatment or have their symptom checked properly rather than having the minister acting as advertisement personality in radio station.

    It simply shows that our government agencies has no proper training and lack of proper system to deal with abnormal situation. What KPIs are we measuring against, Dr KTK?

    People are dying and the government is behaving as an amateur and slow in instituting effective measures to contain the spread of the pandemic. Liow Tiong Lai is definitely performing LIKE A CHILD ACTOR compare to his two predecessors.

    Like

  10. Dr Hsu
    Aug 12, 2009 @ 11:21:30

    CYC,
    I tend to agree with your view that it could have been handled much better.

    The SARs outbreak was handled very well. Those who were in the forefront, eg. my wife who was the deputy director of HKL then and many of the other directors, had all retired….

    The 2 Chua s were considered to be the better Ministers of Health. in 2003, Chua CM was the Minister. He was a fast learner and was able to grasp the important concepts in health and prevention. Chua SL, the dvd actor, was considered the best Minister, and from 2004 to 2008, the ministry was very well run… Now this one is more political more than anything else… And in health, you cannot politicise any issues since it is a matter of life and death.

    Like

  11. klm
    Aug 12, 2009 @ 12:06:10

    Dr Hsu. Can I conclude that the authorities do not really know how many H1NI cases are there in the country. They only know the cases tested.

    You now what. I hope the current Minister will get infected with a virulent H1NI virus. One with his name on it.

    Like

  12. Justin Choo
    Aug 12, 2009 @ 14:44:33

    Dr Hsu,

    I heard from the “USJ Forum” that Klang Hospital is stretched over the limit:
    http://www.usj.com.my/bulletin/upload/showthread.php?t=27617

    By the way what is the standard treatment for this? Do we have suffient stock. Do the private clinics like yours have them?

    (Can you please read my email to you?)

    Like

  13. Dr Hsu
    Aug 12, 2009 @ 16:34:22

    Justin,
    most cases require only symptomatic treatment, meaning take some panadol and rest, since most cases of flu are mild ones.

    In the case of high risk patients, the doctor may start them on tamiflu on the first symptoms of flu, even without confirmatory tests.

    Most clinics should have tamiflu… the only problem is tamiflu tablts is very expensive, and a course of tamiflu now can cost you RM 150, since one tablet is about 15 RM.. This is beisdes the consultation. If you add on consultation and maybe some cough drops, expect the bills to go up to Rm170-180… It is very expensive for a common person .

    That is why if you have flu and the fever is not very high, most docotrs will only give you symptomatic treatment and you should recover within 3-4 days..

    Unless fever persists, or if a person develops difficulty in breathing, he may have to go for further check to rule out pneumonia, and if there is then tamiflu can be started….. But if you are not in the high risk groups, and you rest well if you have flu, you should recover… Chances are (from statistics and experience so far) you should not get pneumonia…

    One reason why tamiflu should not be used indiscriminately is the risk of develop drug resistance to tamiflu. If resistance occure, then it will be difficult to treat if ever complications like pneumonia arises.

    Like

  14. kl_boy
    Aug 12, 2009 @ 17:10:01

    Dear Sir,

    Just asking your medical opinion, for students going to UK for studies, is it advisable to get the H1N1 vaccine injection before leaving ? I am currently considering this as winter will set in the coming months.
    Thanks.

    Like

  15. Dr Hsu
    Aug 12, 2009 @ 22:11:01

    I think it is good for anyone going to temperate countries to get the seasonal flu jabs.

    It will protect you against seasonal flu which can be even more deadly than the present flu. The jab itself protect against a few strains of flu.
    If you dont have the jab, chances are you may get the few flu which may each incapacitate you for a few days.

    Like

  16. Meng
    Aug 12, 2009 @ 23:12:59

    Dr Hsu

    Are there any statistic or Data on death, critical serious, mild and reported cases of this flu eg,

    By Race, Age group, High Density Urban, Semi Rural, Rural…etc

    This should provide an indication where and whereabout these cases are surfacing..Public health should target those areas and go to the ground to educate them.

    The Adun/parties service centers in that specific area should also team up with public health to help in dissemination of info.

    Like

  17. Meng
    Aug 12, 2009 @ 23:15:14

    Could you believe it a clown said masturbation can cause H!NI. sheeesh confused.

    Like

  18. klm
    Aug 13, 2009 @ 09:44:43

    No wonder the country is in such a mess. The Utusan reporter in Karpal Singh’s sedition case did not know what the phrase ultra vires meant and thought it was an insult to the royalty.

    Maybe he should checked into the General Hospital. The doctors there might treat him as H1NI virus infected. These Utusan reporter and the GH doctors wont know the difference between H1N1 virus and ultra vires.

    Like

  19. J
    Aug 13, 2009 @ 13:21:27

    Thank you Dr Hsu for sharing your expertise and knowledge.

    Like

  20. robertchai
    Aug 13, 2009 @ 21:21:31

    MOH need to be proactive and make fast decision to save lives. We cannot be complacent and take a “tidak apa” attitude to handle this urgent issue.

    Like

  21. Enna
    Aug 15, 2009 @ 11:18:33

    Dear Dr. Hsu,
    Thanks you for your informative website. I would really appreciate your opinion on tamiflu and children. The are now websites which state that tamiflu only reduces the symptoms by one day and can cause adverse reactions on children like respiratory failure, dehydration and suicidal tendencies. What recourse do parents have then, if they do not want their children to take tamiflu?

    Like

  22. Dr Hsu
    Aug 15, 2009 @ 12:07:41

    every drug has side effects. On the whole, tamiflu is quite safe and millions have taken it since it is used to treat seasonal flu overseas every year.

    It does have some side effects. Some may feel nausea and giddy, some may experience confusion … but on the whole side effects are rare .

    I dont advocate taking tamiflu just because some one is having mild flu symptoms. When the temperature is not high, and there is no difficulty to breathe, we should just treat the flu symptomatically. Unless those who are in the high risk group, there is a case to start tamiflu early.

    Misuse of tamiflu is causing resistance in flu virus in some instances. There are also reported cases of resistance in H1 N1 virus overseas.

    Like

  23. Dr Hsu
    Aug 15, 2009 @ 12:54:11

    I was pleasantly surprised when I went to 1utama. The management has placed spirits hadn rub dispensers at every floor in the new wing.

    Other shooping centres should follow this example, since those who have touched escalator handrails and so on can use the spirits rub to clean themselves.

    I have mentioned that in my estimates there are now hundred of thousands of cases, even though the official figures is around 2000.

    Say, in a class, if normally at any one time, only 2 or 3 students are absent due to sickness, and now suddenly there are 10-20 absentees, it can be concluded that the additional absentees probably are suffering from a novel bug, in this case, H1N1.. Past one week, I have seen so many school schildren, and the teachers are telling me that in some classes, almost one third is absent due to flu like symptoms.. even though officially none was tested for H1N1 since most cases are mild, it can be concluded that most of these flu are H1N1 related..

    BUt all recovered…

    So most children do not need tamiflu which can shorten the flu duration may be by one or 2 days… Only when the child is considered high risk, say juvenile diabetes, asthma case, heart lesions (congenital heart problems), then tamiflu can be started within the first 48 hours, when it is most effective…As i have mentioned above, one rare side effects, especially in children , is confusion, and they can be so confused that there are reports of self injuries… so if a child needs to be started on tamflu, the parents please keep an eye on them…

    Like

  24. Enna
    Aug 16, 2009 @ 17:32:24

    Thanks so much for your reply. I live in Penang and really do not know if I should continue sending my children to school since it is almost the school holidays. My son says many of his classmates are staying home but this could be due to self quarantine rather then sickness. Definitely more than 10 absentees! I really wish our DPM would disclose the flu hotspots and let parents decide if they should keep their children home. It is really frustrating not knowing and listening to rumours everyday. So what if tourism is affected for a couple of months? We should be informed instead of being treated like imbeciles..”better not to let you know because you will let your guard down….”

    Like

  25. J
    Aug 16, 2009 @ 18:00:25

    Dear Dr Hsu

    I agreee with Enna, that that the govt should inform about where clusters are occuring so that we can make informed choice about whether to go there.

    Today, DPM said “if A (H1N1) cases were reported in Kuantan, it was not right to restrict people from travelling there.” Nobody has said anything about restricting movement! DPM said it himself. All we are asking is for transparent and truthful reporting. Really, is it so hard to get som truth from out govt?

    And yes, there is only 1 more week of school to go, there should be someone smart enough to suggest closing schools early.

    Like

  26. Justin Choo
    Aug 19, 2009 @ 11:29:19

    Dr Hsu,

    What do you think about this article?

    http://margeemar.blogspot.com/2009/08/ah1n1-bnumno-sending-malaysians-to.html

    Frightening.??!!

    Like

  27. J
    Aug 19, 2009 @ 14:12:13

    Dear Dr Hsu and all forummers

    MoH does not even bother to respond to email enquiries to them. Which speaks volumes as to their effiiciency.

    When will the govt take H1N1 seriously??

    Like

  28. karenleehs
    Aug 20, 2009 @ 22:16:37

    Can i seek some clarification? For a person who is on the high risk group, would you recommend pneumococcal vaccination?

    Those who had H1N1 and recovered, what sort of medication were given?

    Did they take the usual medication for cough and running nose like
    1) anti histamine eg Polaramine or Loratadine or Zyrtec?
    2) bronchiodilator eg salbutamol (Ventolin) or combivent, inhale or oral?
    3) something for the phelgm eg Rhinithiol or mucosolvent?
    4) steroid for the inflammation of the lung eg prednisolone or seretide?

    (these are the usual medication i have to give my 5 year old child when he has bronchitis….)

    It’s important to know what are the care they have taken after they got infected so that we know what to do…..

    What about those that died? Did they know the medication required to take?

    Thanks for your feedback…..

    Like

  29. karenleehs
    Aug 20, 2009 @ 22:17:33

    Can i seek some clarification? For a person who is on the high risk group, would you recommend pneumococcal vaccination?

    Those who had H1N1 and recovered, what sort of medication were given?

    Did they take the usual medication for cough and running nose like
    1) anti histamine eg Polaramine or Loratadine or Zyrtec?
    2) bronchiodilator eg salbutamol (Ventolin) or combivent, inhale or oral?
    3) something for the phelgm eg Rhinithiol or mucosolvent?
    4) steroid for the inflammation of the lung eg prednisolone or seretide?

    (these are the usual medication i have to give my 5 year old child when he has bronchitis….)

    It’s important to know what are the care they have taken after they got infected so that we know what to do…..

    What about those that died? Did they know the medication required to take?

    Like

  30. Dr Hsu
    Aug 20, 2009 @ 22:46:49

    karenleehs

    pneumonia can be caused by many pathogens, and pneumococcus is only one of the causes of pneumonia. Vaccination against pneumococall pneumonia does not protect that person from other forms of pneumonia, like viral pneumonia, or other types of bacteria pneumonia.

    Those who died of pneumonia in influenza cases mostly from viral pneumonia .

    Most of the H1N1 cases will recover whether they take medicine or not. Medicine sych as cold and cough medicine including antihistaminies are symptomatic treatment, and they do not alter the course of the infection. They treat the symptoms and make the symptoms more tolerable. Like panadol will bring down fever so you dont feel so much of bodyaches , cold medication to dry up your nose, or cough medicines to make your cough easily and bring up the phlegm easier.

    Brochodilators such as ventolin adn bricanyl will help those who have asthma, since they dilate the airways and make breathing easier. As we know, breathing enable oxygen to be attached to our red cells which circulate our body and broing oxygen to cellular levels, so that our cells can have oxygen to function. So by making the airway dilate, these medicines help asthma patients to take in oxygen better.

    As for steroids, it should not be used indiscriminately since steriods will weaken our immune system..

    Most of those who died in Malaysia ot elsewhere died because of comorbid conditions, such as weakened immune system, like those cases listed in the text above. For these groups, earlier administration of tamiflu might have helped them…

    ……….

    Pathogens are organism that cause diseases. They can be bacteria or viruses or fungi (plueral of fungus). Antibiotic kills bacteria but have not effects on viruses. For viruses, you need to use anti viral. Certain antibiotics will act against certain bacteria only and similarly certain antiviral acts aginst specific viruses. For example, penicillin is an antibiotic and accts against streptococcus bacteria but have no effect on pseudomonas bacteria. Antiviral such as tamiflu acts against influenza viruses but have no effect on herpes virus. Acyclovir, another antiviral, acts against herpes and chicken pox virus but have no effect on influenza viruses.

    Influenza is virus and anti biotics have no effects on them. But on certain occasions, doctors may give antibiotics even when they know it wil not work against the virus, to prevent secondary bacteria infections. For examples, in influenza cases, the virus may weaken the person and that person may develop a bacteria infections and bacterial pneumonia, especially in those who are old and bed ridden, so docotrs may give antibiotics as a prophylaxis to prevent a secondary bacteria infection even though the antibiotic will have no effects on the virus.

    Like

  31. karenleehs
    Aug 21, 2009 @ 01:06:42

    Thanks for the prompt response, Dr. Hsu.

    A couple more questions,

    Assuming hypothetical cases……..

    1)A five year old patient, with history of bronchitis (more than six times a year), comes to you with dry cough, (coughing for the past 1 1/2 days), no fever, slight redness in the throat, still physically active….. what would the treatment you recommend?

    2)Same patient but at different stages of his cough, phelgmy, chesty, wheezing, no fever, vomited the night before, physically still active…… what would then the treatment you recommend?

    3) Same patient but at another different stage, he has been on a course of antibiotic already (say, Augmentin), still coughing and wheezing, slight fever, physically tired, vomiting, loss of appetite….. what would be the treatment?

    The reason i ask these is to find out at what stage should we consider sending that patient to the hospital.

    In the event my son contracted h1N1, i would like to know at which point i should consider sending him to the hospital?

    I know the hospitals are now understaffed , overworked, and i thought the best care is still the mother’s care (with pediatrician’s prescription) at the initial stage of H1N1. Having home care at initial stage, i could at least ensure he is given nutrients, vit C and D, fluids etc……

    Thanks again for your feedback.

    Like

  32. karenleehs
    Aug 21, 2009 @ 01:14:15

    Dr. Hsu…..

    Found this and thought it might be of use for H1N1

    http://www.cdc.gov/h1n1flu/guidance/ppsv_h1n1.htm

    Like

  33. Enna
    Aug 21, 2009 @ 11:33:09

    Karen, I thought of giving my children the pneumococcal vaccines too since most websites say they prevent 30% of the pneumonia cases.( Non-viral) Thanks for all the questions. I’ve been trying to put them to words but couldn’t! I broughtmy coughing, phlegmy, slightly feverish 3 y.o. to the ped but he told me not to worry. Those that have H1N1 have very high fever, very lethargic and look half dead. Errr…by then, by the time they look half-dead…would’t it be too late? That’s why they end up dead!!I’ve been tring to look for a time line for the symptoms of H1N1 but can’t seem to find anything on the net.

    Like

  34. Trackback: we could have done better « Dr Hsu ' s Forum
  35. Dr Hsu
    Aug 21, 2009 @ 13:26:15

    karen,
    if the child is just having dry cough, give a cough syrup and then just monitor him.
    If wheezing develops after the first stage, you need to use an inhaler and start him on bronchodilaotrs like ventolin syrup, and medicine for phlegm like bromhexine. If there is no fever, there is really no need to start on antibiotics.

    If after a few days , he devloped a fever, the best thing to do is to bring him to see a doctor to check his lungs , whether there is any chance of pneumonia (in children, broncho peunomia can develop).

    If the fever subsided, and then high fever flare up again, then this time you may want to have an xray of his lungs( on the advice of his doctor of course), since there is a chance that he may get pneumonia.

    As for breathlessness, watch his rib cages. When you see his rib cages are being pulled in for each breathe, he is having difficulty to breath .

    Enna,
    it is good to get the pnuemococcal vaccine for your child. But the vaccine does not quaranttee your child would not get a pneumonia if ever he has a flu, since he can still get viral pneumonia (which can be deadly), or other types of bacteria pneumonia like streptococcal, pseudomonas, hemophilus etc etc.

    There is a good website at Mayo clinic on pneumonia. But medicine is not like computer operating system,which you can learn from website. A website can tell you all about the disease, but you need experience to tell whether symptoms developed are serious or not, so the best thing is still to consult your family doctor on the severity of the illness.

    mayo clinic on pneumonia http://www.mayoclinic.com/health/pneumonia/DS00135/DSECTION=causes

    Merck manual on pneumonia listed strptococcus to be the leading cause of all pneumonia http://www.merck.com/mmpe/sec05/ch052/ch052a.html?qt=pneumonia&alt=sh

    Like

  36. karenleehs
    Aug 21, 2009 @ 15:09:14

    Dr Hsu, I can’t thank you enough for the clear and direct advice you gave on the different stages of illness.

    I work very closely with my pediatrician regarding my son’s situation and for the past one year, we do not need to administer any antibiotics because prompt medical attention and treatment has always been given at the first sight of flu……

    Previously, he needed to have two weeks medication before his condition cleared….

    Fortunately, as he gets older, his immune system as well as perhaps his airways and other tracts have grown larger, he needs about 2-3 days to recover……

    We travel with his medication ie antihistamine, inhaler etc. He gets rashes whenever he gets insect bites no matter how small the insect is……

    Now with two doctors giving immediately advice, i can safely say i am well prepared mentally to handle AH1N1 (hopefully).

    Unfortunately, many malaysians are in a lost as to what to do when their child gets the fever, running nose, cough etc……… They will visit a doctor, after not recovering for a few days, change another doctor etc……

    In H1N1 situation like this, it will make matters worse if the parents are unsure of what to do, signs to look for, medication to be given etc….

    Do you mind if i pass your advice to others including writing to the press? I will not be quoting anyone doctors in particular but will just make reference to ‘my family doctor’?

    I would like to make my experience with my son as a hypothetical case so that other parents with similiar symptom and condition can relate to the situation and act accordingly without panic?

    Thanks so much again for your feed back……

    Like

  37. Dr Hsu
    Aug 21, 2009 @ 16:37:49

    karen, by all means pass my advice to your friends..

    Not many doctors blog,and out of those doctors who blog, not many comment on illnesses.SO I deem it as my duty to offer advice to whoever needs it.

    Like

  38. karenleehs
    Aug 22, 2009 @ 06:35:42

    God bless you for your kindness, Dr. Hsu……

    Got some more questions. As i have pretty much establish what are the signs and steps i need to take in this H1N1 situation….ie right up to hospitalisation, i would like to further find out what happens next.

    As in what are we to expect when we send our child to the hospital at the stage where he is suspected to have developed pneumonia?

    Like

  39. Dr Hsu
    Aug 22, 2009 @ 09:55:19

    If a child is admitted, the first thing is to take a Xray to see whether there is pneumonia and the extent and severity of it ( i refer to a child that is still conscious and breathing and not one already in coma, in the latter case, emergency procedure would have precedence over all investigations, such as putting in an airway and put the child on respirator, and drip).

    After the xray, if there is pneumonia, the doctor would take a culture to determine the cause (type of pathogens) of the pneumonia. In the meantime, while waiting for the culture results (it will take a few days for organism to grow), if this is a confirmed case of H1N1 (either by thorat swab or PCR tests), the doctor would start the child immediately on antiviral such as tamiflu.

    In the meantime, supportive measures such as oxygen will be given to help the child breathe better if the child is breathless. Bronchodilators will be given for those with wheezing.

    A drip will be set up even if the child is not in immediate danger. A drip is a lifeline, and it serves as a lifeline for iv drugs in case emergency develops and lifesaving iv drugs can be administered immediately via drip if the child suddenly go into emergency. ( if a drip is not already set up, the doctor will waste precious time to find veins to set up drips in case of emergency, and every minute in an emergency counts.

    Depending on the culture results, if the pneumonia is due to secondary bacteria infections, antibiotics will be given following the culture results.

    Most cases will recover, like the majority warded in hospitals all over the world-most recover.

    So far, despite lab/research findings saying that this virus is more virulent than expected , this virus still have a mortality rate of less than 1% (actual rate is lower since majority of cases go undected and the denominator is actually bigger ), similar and even less than that of seasonal flu. The danger is , it may mutate, it may recombine with existing flu viruses and change into a new and more deadly ones. The worst case scenerio that every healthcare worker worries about is that it may combine with bird flu virus and emerge as a virus that can spread as easily as the present epidemic and as deadly as the bird flu…

    The race is now on to see whether vaccines for this H1N1 can be made available BEFORE the onset of the winter season in Northern Hemisphere, when seasonal flu will be in season again. The combination of the various viruses inside our body may facilitate mutation and recombination of viral materials, and a deadly virus can emerge.

    That is why in certain medical circles, there is a form of thinking (not that I advocate this) that it is OK to catch this virus now since it is mild, and have some form of immunity so that when the virus turns more virulent, we have at least some form of resistance, and we won’t get an illness more serious than otherwise. Just like those who are over 50 and 60s , they get only a mild disease even if they catch H1N1 because they already have certain form of immunity

    Like

  40. karenleehs
    Aug 22, 2009 @ 17:29:01

    I have heard parents in UK went around organising H1N1 parties just like chicken pox parties….. trying to get infected first to build immunity……

    I believe that better information on initial care and contstant monitoring, knowledge on what to be expected during hospitalisation etc needed to be made easily available to the public.

    That way, the hospitals will not be swarmed by patients with managable stages of the flu…. leaving only those who need intensive care to be monitored in the wards….

    The last few days, more medical experts are making their views and advice known in the papers, thank good for that, at least we are hearing from the experts and not the politicians…

    Is it against a doctor’s ethics to write to the press the information like the one you have given us??

    It is really informative and more people will benefit from this…….

    Thanks once again……

    Like

  41. Boon
    Aug 25, 2009 @ 14:00:24

    Other than going to hospital to check for H1N1, do you know any clinic in USJ, Sunway, Puchong areas that provide checking for H1N1?

    Like

  42. Angela
    Jan 14, 2011 @ 21:21:41

    Can acyclovir hide H1N1 symptoms???

    Like

  43. Dr Hsu
    Jan 15, 2011 @ 15:04:30

    Angela

    acyclovir is an anti viral used for herpes and chicken pox infection. It has no effects on flu viruses and so it cannot hide the symptoms.

    Like

  44. att systems
    Apr 09, 2013 @ 04:41:17

    Hi there! This is my first comment here so I just wanted to give a quick shout
    out and say I genuinely enjoy reading through your blog posts.
    Can you recommend any other blogs/websites/forums that
    go over the same topics? Thank you!

    Like

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