Outbreaks, Health News Reporting, The Internet and Miscommunication:

What Lessons Can We Learn...

Dr David Quek


"The public is poorly served by the coverage of medical science in the general press. Scientists and physicians blame the press, claiming that journalists are careless in their reporting, subject to competitive pressures, and ignorant of the scientific process. Journalists accuse the medical community of limiting access to information and erecting barriers to the public dissemination of medical research." So say Drs Miriam Shuchman and Michael Wilkes in an introduction to their article "Medical Scientists and Health News Reporting: A Case of Miscommunication" in the recent Annals of Internal Medicine (15 June 1997).

The recent (ongoing?) viral outbreak which gripped the Malaysian public and medical fraternity's attention, in a menacing claw-hold of terror and insecurity, must be the classic example of such miscommunication, misinformation and ignorant rumour-mongering.

The deserted nurseries, kindergartens, schools, hotels, swimming pools, even fast-food stalls in urban areas of Sarawak, are still reeling from the onslaught of the ailment which has claimed 31 young lives, often with such devastating swiftness and wanton fortuity, that many people are understandably terrified, confused, and even angry. An exhaustive feeling of helplessness and watchful fatalism has permeated some households, whilst many wealthier others have elected to run-away from it all, by sending their children abroad or even to the Peninsula. This unwelcomed saga is fortunately nearing its end, and hopefully it will serve as a valuable albeit painful lesson for everyone concerned.

Over the past few weeks, the Berita MMA has been bombarded with many queries and suggestions by many doctors and lay persons alike with access to the internet. Many are truly concerned that the situation is far from satisfactory and that many uncertainties still remain. Many are disturbed that the clinical information made available thus far had been sketchy and insufficiently detailed to help them make an accurate assessment and understanding of what has been going on.

Perhaps, the Health Ministry and immediate hospitals involved could have been more forthcoming in providing accurate and comprehensive clinical notes to make the information more digestible for doctors in particular. This can help allay the scare-mongering among the public, which doctors cannot deflect because of lack of certain knowledge. But having said this, under such trying circumstances, the Health Ministry has done commendably well, in disseminating useful knowledge about hand-foot-and-mouth (HFM) disease, and its possibly related virulent partner, be it coxsackie or enterovirus or even both. Importantly, preventive measures have been quickly highlighted and enforced, which could have accounted for the tailing-off of the outbreak in the recent one to two weeks.

The earlier sensationalistic reporting in the media, did not help, but only serve to fan more fear and irrational behaviour. However, thankfully, more recent reports have been more objective and responsible. While the internet and cyberspace has been awashed with innumerable suggestions and innuendoes about how the outbreak should be managed and how the fatal illness can be treated or contained, many do not withstand close scrutiny, and are without scientific basis or proven usefulness.

Certain centres of excellence from the USA, i.e. the University of Nebraska Department of Virus Research and the Centre for Disease Control, have been particularly helpful in their dispassionate appraisal and recommendations which have assisted the Sarawak Health Services and Health Ministry, enormously. However, one must remember that the internet is one global complexity where information largess is unfiltered and oftentimes incomprehensibly contradictory and confusing. Pet cures and panaceas with unproven anecdotal stories abound, and cannot be seriously taken or adopted.

In reading the reports made available to some doctors (via the internet), the medical and nursing staff of the hospitals in Sarawak have done tremendously well in their assessment and management of this fulminant disorder. This is especially so, when they have been working under such an oppressive and publicly-visible atmosphere. However, there is some truth in that to some extent, medical management of the condition was mainly supportive, and public health measures, largely preventive. In this regard, the public should understand that this is usually the only method of therapy for most viral disorders, anyway. There is unfortunately no magic bullet or vaccine for most of such viral infections, at least for a huge majority.

In admitting that the "coxsackie virus is very hard to identify", the Minister of Health has rightly shifted the focus to preventive and damage-control measures which are now bearing fruits. It did not quite matter that the causative agent has not yet been identified definitively. However, one newspaper has unfairly described this scenario as "still groping in the dark".

There is no doubt that HFM disease and the "fatal myocarditis syndrome" are extraordinary and complicated. For the uninitiated public and possibly even the press, this may seem like procrastinating, and even suggested hints of a cover-up. However, as medical scientists are well-aware of, there can be no doubt as to the extremely complex, tedious but meticulous laboratory techniques which have to be performed before one can be sure about the identity of the causal agent or agents.

For the hospital staff involved in this crisis, the rapidity and fulminant nature of any fatal illness can be quite frustrating and it is oftentimes very difficult to have complete access to all details of history, or physical examination. The luxury of immediate access to clinical tests, investigations or even therapy is often also not possible, due to the nature of the disease itself. So we salute all the health workers who have worked tirelessly in trying to bring an end to this sad saga.

Notwithstanding this however, some important questions remained to be resolved pertaining to this outbreak.

Are we really dealing with the Coxsackie virus or another agent or agents? Might some of these deaths be unrelated deaths from other sporadic infections which occasionally becomes fatal, but which had in the enthusiasm of the ongoing drama, got inextricably lumped together with the true epidemic?

Is the Enterovirus 71 strain the true and decisively-incriminated culprit involved in this serial killing of young helpless children ranging from 6 months to 6 years old? Is the ongoing flare-up of the endemic hand-foot-and-mouth disease (HFM) related to the fatal ones which had features to suggest severe myocardial involvement, and failure, i.e. acute fulminant myocarditis? Are the deaths truly "myocarditis" or due to end-stage cardiopulmonary-circulatory collapse and failure?

Might this severe form of viral outbreak be the result of a mutant strain, which had become more virulent? In October 1995, one such mutation was described by Zheng ZM and others (J Med Virol 1995 Oct;47(2):161-167), when they identified a strain known as EV71H which carried a neuro-virulent genomic RNA variation in the 5'-noncoding region, compared with the common EV71 BrCr genome. They suggested that this could account for the polio-like virulence in the USA, Australia, and Eastern Europe, and the milder self-limiting HFM disease seen in Singapore, China and Japan, i.e. accounting for the two concomitant clinical syndromes. Could this be a possible scenario for the outbreak seen here in Malaysia?

We understand that the Sarawak Health Department and Ministry of Health is organising an Outbreak Seminar for participating physicians and health officials on the 22 July 1997, to try and scrutinize and collate all data available. We certainly wish them well and Godspeed. Hopefully soon, all the issues can be resolved and the epidemic pronounced truly over.

One stark reminder remains, which is: that public and personal hygiene among Malaysians must be elevated to another higher plain of consistency. Only then can such an outbreak be prevented from rearing its ugly head in the future. Everyone of us must take that initiative and promote a cleaner and more hygienic lifestyle and environment. Over the past 2 months or so, Malaysians have learnt that something which is invisible to the naked eye (like the coxsackie or enterovirus) can be extremely dangerous. We have all become more knowledgeable about this virus as never before.

What about the endemic and now resurgent dengue virus? Isn't it time to try and eradicate this scourge, and take severe measures to bring this about? As of the middle of this year, the dengue infection rate (>10,000 reported cases) has more than doubled (~200%) that of last year's! Surely we must now try and embark on a Dengue Eradication Programme, which has been stridently advocated by the MMA and the editorial board on several occasions in the past few years. The time to act is now.

We are glad that of late, the Housing & Local Authority Ministry together with the public health authorities have been actively cracking down on breeding grounds of the ubiquitous Aedes mosquito. This should not just be a placatory gesture, and should be enforced rigorously for all time as an ongoing programme, with the ultimate goal to totally eradicate the Dengue virus or Aedes mosquito. While it is true that the Aedes mosquito is endemic to Malaysia, there is no reason why it cannot be totally wiped out, if sufficient tenacity to the programme is instituted and enforced. Certain swampy areas in the USA, which were breeding grounds for mosquitoes and malaria in the seventeenth century, have now all been eradicated. Now only sporadic and imported cases of such disease occur, and rarely at that.

Therefore, our complacency should not be allowed to work against us, especially in our relentless pursuit of the good life. We should not succumb to our widespread tendency of "tidak-apa" disregard for public cleanliness, disposable wastes, hygiene and environment.

We can choose to eat only at clean stalls, and boycott dirty ones. We can practise healthy lifestyle such as eating better by watching fat, sugar or salt overload in our food, quit smoking as a society, exercise more regularly, and even keep our public toilets spotless (the shame and bane of our foreign tourists)!

We can ensure that our houses, compounds and those of our workplaces are free from breeding hot-spots for flies, cockroaches, rats, mosquitoes, etc. We have to learn to be better, cleaner, healthier, and more caring Malaysians. The Media can play an ongoing role to try and promote such a lifestyle, and continue to expose those which are found to be wanting.

/July 97

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