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H1N1 – the testing confusion

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I think there are mixed signals about testing coming out from the MOH especially when there were earlier media reports about the Health Minister encouraging doctors to use the “rapid test”. The Star reported

As the death toll from Influenza A (H1N1) rose to 38, the Government green-lighted the use of rapid test kits for private clinics and hospitals to conduct flu checks on the public.
Health Minister Datuk Seri Liow Tiong Lai said private healthcare providers can use these kits to help cope with the large number of patients wanting to be checked, and for faster detection and containment of the pandemic.
“Use of rapid test kits was discouraged in the private sector earlier when the H1N1 outbreak was still small and mostly imported.
“Now that it has reached the community level, it’s important to detect it fast and treat it quickly,” he said after checking Serdang Hospital’s service centre for patients with flu-like symptoms.

I don’t know who advises the Health Minister but can someone please tell him that the usefulness of the rapid test kit depends more on the sensitivity (the ability to pick up) and the specificity (the ability to exclude false positives) of the test. While some manufacturers make claims of 90% sensitivity, the CDC in fact has shown that the sensitivity of the current tests are low, about 50-60% (see our previous post Rapid Diagnostic Tests for H1N1 Have Low Overall Sensitivity)
Dr Steven Chow spoke up on this matter on the problem of apparently confusing instructions from the MOH.

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.

Dr Chow also pointed that rapid test kits, which increased the cost of care were not specific or sensitive enough for diagnostic use.

It is really up to the doctor treating the patient with ILI to decide whether or not to use a rapid test kit for Influenza but in my opinion, unless the patient demands it, it really only adds mostly to the cost of treatment and a 50-60% sensitivity test is clinically useless. A much more accurate PCR test on the other hand is also more expensive, has a slower turn-around time and is less readily available.

So what is the best option? In a pandemic, the majority of patients with ILI are likely to have H1N1 and it is not unreasonable to treat them as presumptive H1N1 according to the MOH Guidelines. This does not mean automatic prescription of antivirals, but only in more severe illness and those with co-morbidities/high risk factors.

So the message is, there is no need to demand your GP to do a rapid H1N1 test for it adds little value to the decision to treat or not in the out patient setting. A negative test does not rule out H1N1 40% of the time since the rapid test is going to pick up only 50-60% of the cases according to the CDC. It will also add another RM100 or so to the bill so you ask yourself, is it worth it?
I hope GPs won’t be so unfortunate like Tru-Asian who had this encounter with a particularly unreasonable relative:

I, myself have not been spared the misfortune of blame, even by my regular patients. Not only that, 2 nights ago, a lady who claimed to be the wife of a 60 year old man, stormed into my consultation room demanding to know why I had given her husband, who is a known hypertensive and had high fever and URTI sypmtoms antiviral treatment without doing any test to confirm H1N1. I told her since we are now in pandemic, all influenza like illnesses will be presumed to be H1N1, and this is also the directive from the Health Ministry. Not happy with my explanation and not giving me a chance to clarify further, she continued to reprimand me and to my surprise, snatched the patient record card right in front of me. I was injured in my effort to prevent her from running away with the card (with the help of another accomplice) and this matter has now come under investigation by the police.

Such idiotic behaviour partly stems from confusion after reading newspaper reports and the Minister’s press statements but this obnoxious relative is to be mostly responsible her behaviour and not listening to the doctor’s explanation. Such confusion and malicious behaviour could be avoided if the MOH had a 24 hour hotline (currently they only have an 8am – 5:30 pm hotline 03 -8881 0200 03 -8881 0300).

from the Malaysian Medical Resources

H1N1 – the testing confusion

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