Sunday, December 20, 2009

Workplace Accident: Amputation of Right Thumb

2 weeks ago, a worker came with Amputation of his Right Thumb at the base, alleged accidentally cut by a machine saw. This is a workplace accident and needs further investigation to find out the root cause as well as needs to be notified to DOSH by the employer.
For the worker, it will be the worst experience, he will grieve for the loss of his right thumb, worst still he is the right handed person. He appealed to the ortho. surgeon to rejoin his right thumb back. Yes, the surgeon tried but the difficult thing is- it occured at the joint line of his right thumb, the outcome would not be that successful in term of function and might be failed.
The impact of this loss incident is a trauma and a crisis experience in his life. He will in grief for a certain duration of time. While his thumb is badly injured, his mind is traumatised by the incident. What will his employer do to help him?

Wednesday, December 16, 2009



Today, at 2:30 pm I attended 2nd Fire Drill exercise conducted by Independent Oil Terminal Management (IOTM) at their LPG Terminal at Senari Port. The exercise took 1 hour with participation from Jabatan Bomba Dan Penyelamat and Kuching Port Authority. As a whole, the exercise has improved compare with last year exercise. Congratulation to IOTM!

Tuesday, December 15, 2009


Today (15 December,2009) I was invited by SHECOM of Pusat Makmal Bahan-Bahan (PMB), JKR at Tabuan Jaya Kuching to give a talk on Stress Management at 9:30 a.m.
My talk was entitled Occupational & Psychological Stress. My presentation is divided into two part : 1) Understand Stress 2) Basic Management of Stress.
I focused on 2 components of stress situation which is vital to understand in order to manage STRESS effectively. First component is the STRESSOR or source of stress. The first step in stress management is to identify the STRESSOR and decide whether it can be eliminate, modify or cannot at all. If the source can be eliminated and modified, it will make it easy to manage the stress. In some situation, the source cannot be changed at all for example loss event (death).So we have to be rational to accept it as a FACT in life. In this case, the strategy is to concentrate on the way you cope (response) with the situation. The approach will be individual and organizational.
Although the talk has a small crowd but during Q&A session, there were a lot of questions asked by the participants.

NIOSH : Best OSH Practice Seminar

On 14 December, 2009 I presented one topic entitled : Hazards & Risk @ Workplace : Identification, Prevention and Rectification at Merdeka Palace, Kuching. I shared the concept of HRA (Health Risk Assessment) that was practiced by SHELL as one good practice in handling health hazards at workplace. According to NIOSH Kuching, the total number of participants were 70 with many registered at last minute.

Friday, December 11, 2009


On the 8 December, 2009 I have a privilege to give a health talk on occupational hazard to the workers of Brooke DockYard, Kuching. The topic of my health talk is on Noise at workplace. Around 20 workers were attending the talk. Few questions were asked by the participants.

Thursday, November 26, 2009

ASSAR SENARI: Healthy workforce Health Screening Program

The first batch of ASSARSENARI GROUP's workforce participated in 'Healthy Workforce Healthg Screening Program' on 4 November, 2009. 20 staff including CEO, COO, Legal Adviser, Human Resource executives etc. attended the program.
The objectives of this program are:
1.To identify the baseline health status of the workforce
2.To identify the workforce who has risk factors for NCD occurrence
3.To identify the workers who has established NCD and also CD
4.To design a future plan for monitoring schedule of the workers health status
5.To assess the needs of health promotion to maintain the healthy life status of the worker

The program use WHO STEPS questionnaire to achieve the above objectives. The program will check each of the worker on the 8 modifiable risk factors for the Non Communicable Diseases.
The 8 Modifiable risk factors are:
1. Smoking
2. Alcohol Consumption
3.Unhealthy Diet
4. Physical Inactivity
5. Obesity
6. High Blood Pressure
7. High Sugar Level
8. High lipid levels
Second batch of the participants will attend their health screening session on 7 December 2009


SHELL TIMUR SDN BHD, Kuching Installation, launched their HSSE Week 2009 from 3 to 6 November, 2009 recently. The HSSE week was officially opened by SHELL Malaysia Chairman, Dato' Saw Choo Boon. The Theme for this year HSSE Week was "Do The Right Things : Life Saving Rules". I was invited to give health talk on ' FATIGUE MANAGEMENT'. Jabatan Keselamatan Jalan Raya (JKJR) Sarawak also provided exhibition on Road Safety Awareness and Pengangkutan Mekar Tiasa (PMT), one of SHELL's haulier exhibited their activities and new vehicle for petrol transportation.

Tuesday, October 20, 2009

Preparing Workplace for Pandemic H1N1

Although Pandemic H1N1 is in its cool phase atleast in the news, but we need to prepare for the 2nd wave of infection which is much expected.
ILO has produce a Guidance and Action Manual that can be adopted by any organisation for the above purpose.

Monday, October 19, 2009

AOEMM SEMINAR : Influenza A H1N1 Pandemic

Just back from KL via Flight AK 5218 landed at 9:50 pm, delayed almost 20 minutes due to some technical problem. Impressed with safety measures done in the flight with the pilot went out discussed the technical problem with the engineer. After clearance and given green light to fly by the engineer, the pilot announced the good news to the passenger.
I went to KL on Sunday night to attend today Seminar on Influenza A H1n1 Pandemic: Pragmatic Approaches for the workplace organised by Academy of Occupational & Envrionmental Medicine, Malaysia (AOEMM) at Grand Dorsett Subang Hotel.
The seminar started with the Keynote address on Situation Report on Influenza A H1N1/09 in Malaysia - What to expect in time to come by Dr Sirajuddin Hashim, Sr. Principal Assistant Director Diseases Control Division, Ministry of Health.
7 Lectures were delivered by expert as follows:
1. Mitigation Phase : Actions taken by MOH and Role of Private Medical Services Provider by Dr Priya Ragunath from MOH.
2. Clinical Presentation and Management of Influenza A H1n1 : The Malaysian Experience by Dr Suresh Kumar, Consultant Infectioius Disease Physician, Sungai Buloh Hospital
3. Health Care Wokers - The Appropriate Protective Measures in the Healthcare Facility by Ms Josephine Xavier, Sime Darby Medical Centre
4. Influenza Pandemic: ILO Training Material on Workplace Action by Dr Zalina from DOSH
5. Recommended Preventive Actions to be taken in the workplace - the Role of Employers & Employees by Dr Abed onn, Medical Director GE
6. Business Continutiy Plan : What Works by Dr Khatijah Jumangat from Infineon Technologies
7. Risk Perception and Risk Communication during the Current H1N1 Pandemic by Prof. Dr KG Rampal of UKM
I will post some new informations from each of the lectures later....

Thursday, October 15, 2009


This past few weeks I am really busy analysing audiometric results of employees from 2 of our corporate clients. Analysing the audiometric results is very time consuming and painful especially if you dont have the previous result in hand. Lucky for me as I have created the audiometry surveillance database for me to keep the data of my clients so that I can compare their current audiometric results with the previous one. This is important especially if we want to determine the occurence of standard threshold shift (STS).
After the analysis done, the reports need to be revealed to the workers as well as their employer. Advising the employer on the important of implementing the Hearing Conservation Program is very important. Nonetheless, educating the employee on the risk of noise to their hearing and the important of wearing Hearing Protective devices is very challenging.
Generally, the findings will be classified into 3 categories:
1. Normal Hearing
2. Hearing Impairment
3. Noise Induced Hearing loss (hearing loss at high frequency 3 Khz - 6 Khz or typical 4 Khz notching).
The category 2 & 3, need to be notified to DOSH. Here is the problem start to emerge, some employers look scary and try to argue about the findings.
My advice to them will be:
Implement the Comprehensive Hearing Conservation Program and DOSH will be pleased with your effort.
Note: The above picture was captured from my humble database created using Filemaker Pro

Monday, September 21, 2009


During my hariraya visit to my grand uncle's house yesterday, from his neighbour's house suddenly blasted a long chain of fire crackers with a very loud unwanted sound. Of course it causes NOISE - one form of physical hazards. In my experience, the intensity of that noise must be between 90 to 105 dB (based on this field study).
The firecrackers' noise lasted for more than 5 minutes. I managed to record it at its last part(about 24 seconds duration). My ears feel discomfort although I was sitting in my granduncle's house about 20 feet away and it also annoyed our conversation.
I supposed, it not only can cause 'temporary standard shift (TTS)' to my hearing but also can cause physical injury. I hope this 'hariraya' celebration will not end up with tragic otherwise
it will loss its meaning.


Sunday, September 20, 2009


Alhamdulillah, hari ini kita menyambut kedatangan syawal, hari kita kembali semula kepada fitrah setelah menjalani tarbiyah terhadap nafsu sepanjang bulan Ramadhan al-Mubarak. Pemergian Ramadhan tentu menyedihkan kita setelah tekun menjalani ibadah puasa selama sebulan, semuga ibadah puasa kita mendapat keberkatan dan diterima Allah Taala. Ketibaan Syawal tentu disambut dengan penuh kesyukuran, berbekal dengan tarbiyah madrasah Ramadhan diharap kita dapat meningkat nafsu kita ke tingkat mutmainnah.
Begitulah sunnah kehidupan ini, kita perlu sentiasa memperbaiki diri dan prestasi agar ilmu dan amal kita meningkat.

Tuesday, September 15, 2009

Prevention is Better Than Cure

Medical adage, "Prevention is Better Than Cure", is one of the health principle we should practice in our daily life. Health Prevention refers to any activity we do that prevent the health from harm. The fact is Prevention is cheaper than Treatment cannot be disputed.
Prevention Mode of Action can be classified into 3 stages:
1. Primary Prevention
2. Secondary Prevention
3. Tertiary Prevention

Primary Prevention:
In primary prevention stage, the main activities are to prevent disease or injury from occuring. Primary Prevention can be done at individual and community level. The focus of activity in primary prevention stage can be directed at host in order to increase his resistance to the agent, for instance by giving immunisations, stop smoking et cetera. Primary prevention activity also can be directed on the environment such as reduce the condition favorable to the vector of the agent such as in biological hazards (example:Fogging to destroy aedes mosquito inorder to prevent Dengue disease). The acitivities in primary prevention do not depend on the doctors alone. Health Protection and Health Promotion are the two tools widely used in primary prevention.
In Health Protection, the main aim is to eliminate the agent and also any predisposing factors that can cause the disease. Hierarchy of Control is included in this Health Protection tool. Health Promotion is another tool that not only give the health education to the individu but also empower them to take care and responsible of their own health.

Secondary Prevention:
In Secondary Prevention the main aims is to detect the disease early and manage it as early as possible to prevent its complication. Detection of disease can be made through health screening, health and medical surveillance. In our current contact of handling influenza A H1N1 infection both home quarantine and mitigation phase are belong to this stage of prevention.

Tertiary Prevention:
Tertiary Prevention are activities which promote rehabilitation, restoration and maintenance of maximum function after the disease and its complications have stabilised. The activities are directed at host and also environment.

Host-Agent-Environment Paradigm

Before we explore 'Health Prevention Concept' further, it is important at this juncture to understand another paradigm called 'Host-Agent-Environment' which contributes to ill health condition. In this paradigm, the Host, Agent and Environment interact with each other to form a condition that favors ill health or disease to occur. The Host is the person who has or at risk of specific disease. The Agent is the organism or direct cause of the disease. In occupational health we called its health hazards categorised as Biological, Chemical, Ergonomics, Physical and Psychological (BCEPP). The Environment includes the external factors which influence the host or his susceptibility to the agent and also the vector which transmits or carries the agent from the environment to the host. This paradigm explains the causation and transmission of many diseases. The combination of factors in these 3 premises in effects form a contagion of theories of disease causation.
The factors in the host which contributes to his susceptibility to the disease are age, gender, genetic, occupation, lifestyle, education etc. The agent's factors which contribute in disease susceptibility in the host are biological, type, characteristics etc. The factors in the environment are the economic, social condition,climate etc. This 'Host-Agent-Environment' complex interaction only can cause disease with Allah Willing.

Sunday, September 13, 2009

Occupational Health explored

In my last posting, I concluded that WHO's definition of health can be accepted as an ideal goals that everybody should achieve. The state of complete physical, mental, spiritual and social well being is the state of being in equalibrium. But in reality, health is a continuous responding process of adjustment of the four mentioned human dimensions to the demands of everyday life. These demands arise as a result of the interaction between ourselves with others and our environment. In simple word, we live in the interactive ecology system. So, to preserve our health in the state of complete well being, we cannot act alone. We need a balance interactive of this ecosystem so that it is always in equilibrium states or state of well being. So the responsiblilty to preserve health is beyond individual; it also involves the active role of the family, society and environment. In the nutshell,we need a maintenance of health preservation effort at individual level and also a health protective and promoting system at the family, society and environment level.
The understanding of this concept of health is very important especially when we want to explore occupational health (and also public health). Occupational health is the specific subset of the public health which focus its prevention activity by protecting and promoting health at workplace. The 'workplace' is the domain of occupational heath function. In the 'worker-workplace' ecosystem, workplace is the society and environment components. Since the worker is part of the population, the population as whole and a family as a specific origin of the worker also play a vital role in maintenance the state of well being of the worker.
Workers who come from families of the society in the population, brought with them their health state, belief and behavior to their workplace. At workplace they form an interactive mini ecosystem with the workplace and its environment. This mini ecosystem is a subset of a big ecosystem in the family, society and the population.
In preserving the workers' health, all the components of this mini ecosystem as well as the entire ecocystem have their roles to play. These roles must be integrated.
So the health prevention is an integrated functions which involved the worker, the workplace (the management,peer workers) and the environment (organisation, job task, building ec cetera.).
Health Prevention can be simply defined as stopping or eliminating the factors that can disturb the equilibrium of health. It involved protection and promotion of health at workplace. This is the main 2Ps activities of occupational health.
Health Prevention can be divided into three stages or phases.
1. Primary Prevention 2. Secondary Prevention 3. Tertiary Prevention
to be continued.....

Understand Health & Occupational Health

The soul of occupational health is prevention; its functions are to protect and promote the health of people at workplace. The key words here are Prevention, Health and Workforce(people at workplace). Let us understand the definition so that we don't have confused understanding.
According to WHO, HEALTH is defined as a state of complete physical, mental and social well being AND not merely the absence of disease or infirmity. Health is multidimensional. In this definition, WHO focuses on 3 specific dimensions of health namely Physical, Mental and Social.
However, in this posting I would like to add another dimension called spiritual to this definition. So now, our definition of health is " a state of complete Physical, Mental, Spiritual and Social well being". In this new definition, it is better to differentiate between mental health and spiritual health.
Mental health is a state of emotional and psychological well being in which an individual is able to use his or her cognitive and emotional capabilities to function in the society and meet ordinary demands of everyday life.
Spiritual health on the other hand is individual ability to differentiate between Right or Wrong and resolve to lead a more righteous life, free of stratagems, deception, dishonesty and selfishness.
To perceive health as a state at all is too idealistic. However, it is the ideal goal that everyone should achieve. In real fact, health is a process of continous adjustment to the changing demands of life. posting : Understand Prevention...stay tune

Thursday, September 10, 2009


Last week, I asked my ordinary grass cutter came to do his job at my house compound. He knows the hazards of his job and he voluntarily used all the necessary Personal Protective Devices(PPD/PPE) according to his own standard. (Cover his face&head, using google, using long sleeve and using PCK safety boot). His self-compliance without even knowing the existence of OSHA 1994 is very much appreciated.
When come to safety, our inner self is fully aware to protect ourself from dangers. However, a lot of the time we see people totally ignorance about their safety especially on the road and at their workplace. They do unsafe acts and create unsafe conditions (the two culprits of accident) and it becomes their routine or behavior. Their mindset already corrupted by false satisfaction they get from the non accident consequences they get from their actions and conditions. This false satisfaction is like 'atomic bomb waiting to explode'. The vital question is : Can we change their practices or behaviour?
Definitely........ we need to change their mindset first....changing their mindset means changing their perception or to be accurate change their 'world view'. We only can change their 'world view' by giving them 'knowledge' (ilmu) using simple language that they can understand. By changing their mindset, only then they will change their behavior. In another word, we are talking about 'Behavior Based safety'. We have to use a lot of approaches including religion approach. In religion there are a lot of safety values we can practice.

Thursday, August 27, 2009


Tonite, one gentleman in his late twenties, came to our A&E Dept. with the above problem. He is suffering from this problem more than one year. He was previously treated in government hospital. On further questions, he claimed that he was a heavy chronic smoker and just quit recently. He came to A&E because he could not stand the pain on his fingers and toes. Some of his fingers and toes were already lost. At a glance, I diagnosed him as having Buerger's Disease. Detail about Buerger's Disease you can read here and also here.
When I asked him what is his occupation, he replied, "I was working at the Chemical Production Company. Now I already quit". I dont know whether his occupation has some relationship with his illness or not. I need to do some literature review on this subject. However, as far as my clinical knowledge on Buerger's Disease,I am sure it is related to heavy tobacco smoking. With this posting, I urge all of my fellow visitors of this blog who are smokers, please QUIT SMOKING. It is better now than later.

Personal Hygiene

Personal Hygiene is one of the preventive & control measures advocated and endorsed by WHO in fighting the spreading of infections including H1N1.
Personal hygiene which includes a practice of washing your hands frequently is one of the most practical and easiest control measures in occupational health. However, due to bad habit and 'syndrome of short cut' we always omit washing our hands particularly before eating. In many industries especially in food and healthcare industry, washing our hand is a good and compulsory practice for the benefit of our own health, patient and food's safety.
For devoted muslim, personal hygiene is a routine practice because at least 5 times per day they practice it via the act of taking 'wuduk' (ablution) before they perform the 5 prayers. In wuduk practice, not only you wash your hands but almost all part of your body : mouth, ear, face and feet. So let practice Personal Hygiene in our daily life. Prevention is better than Cure

Wednesday, August 26, 2009

No indication, No test

Yesterday, one gentleman came to our A&E during my duty time and requested from my nurse to do a test for H1N1. The nurse asked him, did he has fever, cough or flu (the common symptoms of H1N1 illness). He replied, "No". So my nurse told him that there is no need to do the test because there is no indication. He insisted to have a test and said he is willing to pay. At last, the nurse asked him to see me.
I explained to him that : 1. He has no indication for the test 2. The test which is available at our hospital is a rapid test, it takes about 30 minutes to get the result but its specificity and sensitivity is only around 80%. Meaning that it only can say you have infection caused by Influenza A or B or both BUT cannot confirm it is H1N1. If the test is positive for Influenza A, the chances to have H1N1 infections is high. BUT due to reason no 1, I turned down his request although he is willing to pay. The issue is not that he can afford to pay BUT there is no clinical indication. This is not a good clinical practice. During my medical student time, my Professor of Medicine always told us the purpose of doing investigations in clinical practice. The professor named it as 3C - To Confirm the diagnosis, To find the Cause and To monitor the Complications. So doing the test for this gentleman is not fulfilling the purpose of 3Cs as he has no symptom. And it is not cost effective also.

Sunday, August 23, 2009


BIOLOGICAL HAZARDS is one of the 5 categories of Health Hazards (The other 4 are: Chemical, Ergonomics, Physical & Psychosocial).
Biological hazard is any living organism that can cause harm to our health such as virus ( e.g. H1N1 which cause Influenza A H1N1 infections at the moment), bacteria (e.g. Mycobacterium tubercule which cause Tuberculosis) et cetera.
One thing we should remember of Biological hazards is it has no threshold exposure value or in another word it has no PEL value as for chemical hazards. At any value, biological hazards can cause disease, this especially true for H1N1 virus of which everybody does not have antibody. Generally to control the infection of biological hazards, we must break the infection chain.
We can divide infection by biological hazards into three types (depends on their mode of transmission) : 1. blood-borne infection (transmit through blood e.g. Hepatitis B which causes hepatitis), 2. oral-fecal infection (transmit via mouth & stool e.g. Salmonella which causes Typhoid) and 3. air-borne infection (transmitted via air e.g. TB which causes Tuberculosis).
For Influenza A H1N1 infection, it is caused by the droplet which contains the virus from the cough and sneeze of the infected person. The droplet can be transmitted via direct cough to the contact person through the air if another person stays within one meter distance. This social distance of one meter is including the 'breathing zone'. Besides that the person who cough out the virus can transmit it via his hand if he cough directly on his hand.
This is the reasons why the authority advise us to practise personal hygiene, respiratory hygiene or cough etiquette, stay more than one meter distance from the person who has cough or other symptoms of H1N1.
These control measures are the basic things we need to practice during this pandemic time. If you have the symptoms: practise personal hygiene - wash you hand with soap, if you have cough make sure you practise cough etiquette - when you cough or sneeze, cover your mouth or nose with a tissue paper then throw it into the dust bin and if possible dont attend any gathering or the crowd. However, if unavoidable, please use face mask. In another word, quarantine youself at home. Practicing this control measures is every one responsibility. At this point of time, we need to be VIGILANCE but do not PANIC.

Saturday, August 22, 2009


Alhamdulillah, kita dilanjutkan usia untuk menemui kedatangan Ramadhan tahun ini dan akan mula berpuasa. Semuga ibadah puasa akan mentarbiyahkan diri kita untuk dapat mengawal hawa nafsu yang selalu mendorong kita bertindak sewenang-wenang. Semuga tarbiyah ini akan membentuk diri kita menjadi orang yang sobarin dan solehin. Semuga kedatangan Ramadhan ini juga akan meningkatkan kesihatan dan keselamatan kita serta persekitaran kita, Insyaallah.

Saturday, August 08, 2009

Compulsory Reading: Dr David Quek's posting on H1N1: 10 FAQs

I copied & pasted below, a very good information on H1N1 posted by Dr David Quek, President of Malaysian Medical Association. Please visit his blog at:

H1N1 Flu: What's Current, Some Dos & Don'ts...

Here are some Queries from the Press that I have collated and answered:

A(H1N1) Flu: Updates on 10 FAQs

by Dr David KL Quek
President MMA.

1) Can we distinguish between regular and H1N1 flu, without a lab test?

No, the flu is the flu, but there are variations in presentation. Some symptoms such as cough, runny nose, fever, body aches, fatigue, vomiting, diarrhoea occur more or less in every flu patient, but may present differently by different people. Some infected people have very mild symptoms, some in between, and a small minority, probably less than 10%, have severe features including the dangerous pneumonia.

However, from sentinel testing and surveillance by the Ministry of Health the last few weeks have shown that almost 95% of all flu-like illness are now caused by the H1N1 virus. Earlier some months ago, seasonal flu variants caused by the B and other A virus were the main causes, the bug causing most flu these few days is the A(H1N1). This appears to be the case also in neighbouring countries, meaning that the new virus is causing more havoc and symptomatic illness than previous types of flu (which are still in the community).

Because almost every flu-like illness (influenza-like illness or ILI) is due to H1N1, the MOH is now recommending that no testing to confirm this H1N1 will now be offered.

Treat as if this is H1N1 for ILI—symptom relief for mild symptoms (paracetamol, hydration, cough medicines, etc) and self-quarantine, social distancing, be alert for complications.

Most (~70%) do not need any anti-viral medications such as Tamiflu or Relenza. Only severe cases need to be referred to hospital for further treatment.

2) How should doctors decide if a person be given further specific treatment for H1N1?

If after 2-3 days, fever and cough symptoms do not improve, a recheck with the doctor is recommended, especially if there are features of difficulty breathing, severe weakness and giddiness, or, if the following risk factors are present:
  1. obesity (fatter patients seem to have poorer outcome and more complications)
  2. those with underlying diabetes, heart disease
  3. those with asthma, or chronic lung disease
  4. pregnant women
  5. those with reduced immunity, cancer patients, etc
  6. those with obvious pneumonia features

3) Many anxious people with flu-like symptoms want to be tested or treated for suspected H1N1, but are kept waiting or sent home, without being tested. Is this practice right?

There is no right or wrong practice as this outbreak is extensive and is stretching our resources to the limit. This is also the case not just here in Malaysia, but also elsewhere around the entire world!

The recommendation is now not to spend too much time and effort trying to get tested at designated hospitals or clinics—there is probably no need to do so. I have been informed that as many as 1000 patients queue anxiously at Sg Buloh hospital for testing, due to fear of the H1N1 flu.

So the message must be made clear: Most flu illness do not require confirmatory testing, and are mild and self-limiting. More than 90 percent will get better on their own, with symptomatic treatment—just watch out for possible complications, and risk factors as mentioned above.

Our resources are limited especially for testing. This is not just for Malaysia, but globally as well. The global demand for test kits and reagents for the H1N1 (PCR) is overextended and thus these tests are rationed due to this extreme demand.

Some 200 million test kits have been deployed worldwide, but this supply is critically short because of excessive demand, so most countries have to ration testing to confirm only the worst cases, so as to monitor the pandemic better.

4) Are doctors confused as to what to do in this outbreak, especially when they do not have ready access to confirmatory lab tests?

Not really. Earlier on there was some confusion as to what to do next and who to test or who to refer for further testing and admission. Now the rules are clearer.

There is no need to do any testing to confirm the H1N1 virus for any ILI—just assume that this is the case in the majority of cases. Treat symptomatically when symptoms are mild, reassure the patients and ensure that these infected patients practice good personal hygiene, impose self-quarantine and social distancing, wear masks if their coughing or sneezing become troublesome, and keep a watchful eye on whether the infection is getting better or worse.

If there is difficulty breathing and gross weakness, then patients should quickly present themselves for admission. Understandably this phase of worsening is not always clear or easily understood by everyone... But there is not much more that we can do—otherwise we will be admitting too many patients and this will totally overwhelm our health services.

But prudent caution would help to determine which seriously ill patients need more attention and more intensive care. Unfortunately however, there will be that odd patient who will progress unusually quickly and collapse even before anything can be planned—hopefully these will be few and far between.

A more important note, is that all doctors and nursing personnel should be very aware that they too have to take precautions, and employ barrier contact practices, if there are patients with cough and cold during this period of H1N1 outbreak, which is expected to last a year or two. Carelessness can result in the physician or nurse or nurse-aide becoming infected!

5) Are there sufficient guidelines from the Ministry of Health to address this situation?

I think there are sufficient guidelines from the MOH. Although some politicians have blamed the MOH and the Minister for being inept at handling this pandemic—in truth this is not the case.

It is useful to remember that this is an entirely new or novel virus, which no one previously had encountered before—thus its infectivity and contagiousness is quite high and almost no one is immune to this virus.

Perhaps, there will come a time when all the resources from both public and private sectors can be put to more efficient use. Some logistic problems will invariably occur, because human beings differ in their capacity to understand or follow directives, whatever the source or authority.

Also patient demands have been extraordinarily high and at times very difficult to meet—every patient necessarily feels that his flu is potentially the worst possible type and therefore requires the most stringent measures and testing...

Doctors are also unsure as to the seriousness or severity of this new ailment—and we are only now beginning to understand this better—so our less than reassuring style when encountering this new H1N1 flu is sometimes detected by an equally anxious patient and/or their relatives.

But there is only so much that we can do under such a pressure cooker of an outbreak which is spreading like wildfire!
But nevertheless we should not panic, and remember that most >90% of infected people will recover with very little after effects. Possibly only one in ten patients develop more serious problems which necessitate hospitalisation.

6) Is limiting H1N1 testing only to those who have been admitted to hospital justifiable?

I have explained the worldwide shortage of such testing kits and reagents. Also it is near impossible to test everyone, the world over. Besides, knowing now that almost all the flu-like illness in the country is due to H1N1 makes it a moot point to want to test for this, especially when most are mild.

The rationale for testing only those who need hospitalisation is to ensure that we are dealing with the true virus, and also help to isolate possible changes or mutations to this viral strain. The MOH is also constantly doing sentinel surveillance (random spot-testing at various sites around the country to determine more accurately the various virus types and spread that are causing ILI)

7) Are we short of anti-virul drugs (Tamiflu, Relenza)? Should I take Tamiflu?

These antiviral drugs were available to most doctors during the earlier scare of the bird flu virus, but now are severely restricted, although some orders are still entertained from individual doctors, clinics or hospitals. Remember that these have been block-booked by more than 167 countries who have been shown to have been penetrated by the H1N1 flu bug.

Our MOH has actually stockpiled some 2 million doses of the Tamiflu or its generic form. In the last inter-ministerial Pandemic Influenza task force meeting, this stockpile will be bumped up to 5.5 million doses to cover some possible 20% of the population.

Right now there is no shortage in the country. It is just that it is not readily available on demand for anyone just yet. The MOH is still of the opinion that this antiviral drug be used prudently and would like to register every patient given this drug.

The private sector on the other hand would like to have a looser control over the use of this drug—but we acknowledge that we should be meticulously prudent in its use. There is a genuine fear that resistant strains to this drug may develop with indiscriminate and unnecessary use—then we will all be in trouble with a drug-resistant H1N1 virus run amok!

Drug-resistant strains have been detected in Mexico, border-towns in USA, Vietnam, UK, Australia even. So we have to be vigilant and closely monitor the situation. Right now, the very limited usage of Tamiflu gives us good reason to be optimistic.

However, because of some unusual patterns of seemingly well people dying or having very critical infections, some people and doctors are wondering if these new strains have already reached our shores...
or have we been too late in instituting proper treatment...?

The rising number of deaths to 14 now, is quite worrisome, but our health authorities are watching this development very closely and are also checking the virus strain to see if this has mutated. We can only hope that this is not the case, for now.

8) What are some of the problems faced by doctors in dealing with the H1N1 problem?

It would be good if every medical practitioner keeps a close tab on the H1N1 pandemic, and remain fully aware of the developments and changes, which are evolving daily. Every doctor has to be learning on the trot, so to speak, to keep up with the progress of this outbreak and its management, so that we can serve our patients better.

Logging-in to the internet regularly, for more updated information will certainly help, instead of lamenting that not enough is being disseminated via the media thus far... Every doctor has to be more proactive and practice more responsible and cautious medicine during this trying period which is expected to run into at least 1 to 2 years. Importantly look out for lung complications, and the above stated higher risk profiles, and refer these patients quickly for further care.

Easier access to antiviral drugs and their responsible use and monitoring would help allay public fears of delay in treatment, but this should be tempered with care and not over-exuberance to dish out to one and all, the precious antiviral drug,
just for prevention—this may be a very bad move which can inadvertently create a worse outcome of drug-resistant bugs.

However, in the light of the very quick deterioration of some young patients who have died, it might be prudent to use antiviral treatment earlier and more aggressively.

We look forward to the specific H1N1 vaccine, when it does come our way, probably towards the end of the year. In the meantime, encouraging those in the front-line, heart or lung patients and frequent travellers to have the seasonal flu vaccination is a useful adjunct to help stem the usual problems from other flu types.

9) Are we doing everything that should or needs to be done?

Yes, if you check what other nations are doing, we are doing relatively well. We are not overstating the dangers and we have been quite transparent on the possibilities of this pandemic. Earlier, many agencies and even the public and doctors have accused us of exaggerating the pandemic, and our response was dismissed as being too much, even over the top! Unfortunately, it was only when some deaths occur that many are now decrying that we have done too little!

Also if you are quite honest about it, just compare with the countries globally, and you will notice that no one health or government authority has got this right, spot on.

We are all learning about this novel flu pandemic, and each country's response is coloured by its past experiences. In Hong Kong, China, Vietnam, Singapore and Malaysia we have had the SARS outbreak, so we are necessarily more paranoid! Also here the experience is that flu does not usually cause death in our community, unlike the west where seasonal flu kills some hundreds of thousands every year!

So the fear factor for this H1N1 flu is not nearly as great in the west, although it is slowly sinking in that its contagiousness and infectivity is far greater, and fears of its reassortment to a more virulent mutant form is growing, into the so-called second and/or third wave of this pandemic, but we will not know until a year or so down the line.

10) Is the public in general doing enough to help in controlling the outbreak?

I think the public is now reasonably well-informed as to this H1N1 pandemic. Perhaps, they are too well-informed, that they have a fearful approach to this virus. But the proper thing is not too over-react and to panic, although I know this does sound easier said than done.

It is almost a certainty that this flu will spread within the community—in schools, universities, academies, factories, work places, offices, etc. WHO has projected that possibly some 20 to 30% of the population worldwide will become infected by this novel flu bug, after studying various models of spread of past infections—the huge and very rapid spread worldwide is mainly due to air-travel. While older flu pandemics took 6 months to extend to so many countries, this H1N1 flu did so in less than 6 weeks!

In the worst case scenarios of course, this outbreak will be alarming—hospitalisations may be required for 100,000 up to 500,000 Malaysians, with perhaps as many as 5000 to 27000 infected patients (depending on the case fatality rate or either 0.1 to 0.5%) succumbing to this illness.

But because we have been monitoring closely and containing the outbreak thus far, with heightened awareness and greater social responsibility, it is possible to ameliorate the infectivity, spread and fatality that will unfortunately accompany this pandemic... Just how successful we will be in limiting these adverse outcomes remains to be seen, but we can be hopeful.

How can the public help? First learn and acquire good personal hygiene. If sick, please be responsible and stay at home, even in your own room where possible, wear a face mask (a cheap 3-ply surgical mask will do, because large droplet spread is the main danger). Do not go out, practice what is now known as social distancing (about 3 metres from anyone), and be socially responsible, don't go to public places and infect others—for young people this would be hard, but absolutely necessary—the spread is most rampant in this age group between 16 to 25 years.

When the illness does not go away after a few days or when you are deteriorating, get to the nearest hospital. Most importantly, be very aware and responsible!

Finally, keep abreast of all new developments, because these are evolving all the time. With keen awareness, prudent care, early detection and social responsibility, correct and prompt use of antiviral and other support medical care, and later mass specific vaccination, we can overcome this novel H1N1 flu! But it will take time, patience, public cooperation, much concerted effort and consume great resources.

Monday, August 03, 2009

7th Malaysia H1N1 victim is First Sarawak Victim

The death toll of H1N1 infection in Malaysia was increased to 7 where 24 year old pregnant lady became its 7th victim, who was admitted in ICU of Miri Hospital. Detail news, please click here.

Wednesday, July 29, 2009


Today I presented a paper on Total Health Promotion: Smoking Issue at workplace at the seminar on Global Strategy On OSH, organised by NIOSH SARAWAK. About 70 participants, majority are SHO, attended this seminar at Merdeka Palace Hotel Kuching. In my presentation, I explained why smoking at workplace matters and how Total Health Promotion can be used to tackle the issue of smoking at workplace. Anybody want a copy of my presentation, kindly email me at The file is in pdf format with 3.3 MB size.


On 28 July 2009, I attended a dialog session with DOSH Sarawak. About 40 OHDs from the whole state of Sarawak attended the session which was held at Bilik Gerakan, Tingkat 9, Bangunan Tuanku Iskandar, Simpang Tiga, Kuching.
Dr. Faridah Amin, Deputy Director, Occupational Health Section of DOSH Putra Jaya presented 2 papers on NADOOPOD Regulation 2006, Latest statistics of Occupational Diseases & USECHH4, 5i & 5ii Forms. En. Yurisman, Pen. Pemeriksa Kilang & Jentera, DOSH Putra Jaya presented a paper on "Panduan Permohonan Kelulusan Pusat Ujian Audiometrik (PUA)", Dr Jack Wong SY, from OHU, Sarawak Health Department presented on Management of H1N1 Pandemic and Dr. Nik of SOCSO KL, presented on Noise Induced Hearing Loss (NIHL). I am the last speaker, sharing my personal experience as OHD.
This session is very informative especially for the OHD as well as for DOSH, who get a lot of feedback on the problems faced by them in carrying out their duty as OHD. The session was officially closed by Pengarah DOSH Sarawak, Ir. Hj Dasuki Mohd Heak.

Wednesday, June 10, 2009

Alcohol & Drug Free Workplace Part 3

Alcohol & Drug Free Workplace Program must starts with a good policy statement. The policy which shows the full commitment of the top management on the program as well as allocation of a budget to run the program. The policy also clearly determines when to do the urine drug screens (UDSs)- randomly as well as when there is an incident/accident occured or other indications such as 'tell tale ' signs amongst the worker. 'Tell tale' signs such as odd behaviour like in the case mentioned in my previous posting. Possible other 'tell tale' signs such as frequent sickness absence, poor health ec cetera. After confirmation of the urine result, the policy must clear in the 'action to be taken' whether to send the worker for rehabilitation or disciplinary actions. If the worker voluntarily come forward for the test, the policy must clear enough not to punish the worker.
Beside the policy, the procedures to perform the test and how to randomly pick up the worker for the test must crystal clear , cannot just do a selective random check up only.
The lab. where the test done must have a high quality standard with recognition by an international body such as NATA. The appointed person who collects the urine and the doctor who interpretes the result must have a proper training in this field of specialisation. In Malaysia, SOEM-MMA regularly conduct a MRO course for doctors.

Monday, June 08, 2009

Alcohol & Drug Free Workplace Part 2

The worker’s blood test result (which is quiet comprehensive -Full Blood count, Kidney function,Liver function ec cetera) are all normal. The urine drug screens (UDSs) showed the following results:
Cannabinoids & Opiates Class were Negative & Coccaine/Metabolite was not detected. AMPHETAMINE was detected.
The other UDSs for Barbiturate Class and Benzodiazipine class will be performed in Australia together with confirmation test (GCMS) for the positive drugs.
Exactly one week later, the urine confirmation test (GCMS) done in Australia was ready and shows the following result:
UDSs (EMIT) for Benzodiazepine Class was detected.
Urine GCMS analysis identified both Ephedrine and Pseudoephedrine and 7-1 amino-Clonazepam.
I consulted Prof. Dr Aishah Latiff of DOPING Centre USM Penang (one of resource persons during the MRO course in 2005) for advised. She agreed with me that the Test for Amphetamine is NEGATIVE and Benzodiazipine Class is POSITIVE.
This official result will be revealed to the management of the company. I called the worker for the last time to inform him about the official results.He denied taking any drug from benzodiazepine class. He sworn for only taking cough syrup. He strongly persuaded me to help him. Based on my strong ethical and religion belief I cannot act wrongly and I have to reveal the TRUTH. BUT I advised him to quit the job before his employer dismissed him. The rest of the story are history.
There are few lessons we can learned from this incidence. The most important lesson is to have a proper well designed policy and program for handling alcohol and drug abused case at your workplace.
I will discuss on the elements of proper Alcohol & Drug-Free Workplace in my next posting.
For this posting I want to discuss few terminologies which are commonly used in handling drug abused case.
1. Chain of Custody (COC) : the procedures used to document handling of urine specimen from the time donor gives it to the COLLECTOR until it is destroyed.
2. Collector is a person specially trained to collect the urine
3. Medical Review Officer (MRO) is a doctor with special training in interpreting and handling drug testing. This position is only available in US.
4. Urine drug Screens(UDSs) : the lab. test designed to detect the drug in the urine. It is of 2 types : Screening test normally using immunoassay such as enzyme multiplied immunoassay technique(EMIT) and confirmation test using Gas chromatography-mass spectrometry (GC-MS).
5. POSITIVE RESULT : Screening and Confirmatory are Positive
6. NEGATIVE RESULT: Screening or/and Confirmatory is Negative
7. FALSE POSITIVE or EXCUSE POSITIVE : Screening and Confirmatory are positive but with legal/ authorised drug used
For the start, you can use Code of Practice on Prevention and Eradication of Drug, Alcohol and Substance abuse in the workplace, 2005 for reference (you can download a copy from DOSH website by clicking here)

Sunday, June 07, 2009

Alcohol & Drug Free Workplace Part I

Last Friday, my friend who is a HR personnel from one company called my handphone to consult about urine testing for drug abused. Instead of just telling the name of the lab. I decided to give brief explanation on how important to have a proper Alcohol & Drug Free Workplace policy or/and program. I recalled handling one drug abused case in early 2008. Here is the story:
“Doc, can you please check the urine of one of my worker to rule out drug abused?”, asked a supervisor who walked into the clinic , during my relief duty at one of an in-house clinic in January 2008. I quickly asked back ,“Why?, why drug test?”.
Then the HR personnel of the company came in and interrupted, “ He is suspected of drug abused because he has odd behaviour lately. Just now, he switched off the machine unncessarily, causing interuption in our production.” “OK,OK! I said....Let me handle the case properly”. Then the mentioned worker came in with another personnel. I told the personnel that I will perform full medical checkup with general blood screening test including the urine test for drugs. They agreed and left the clinic.
I asked the nurse in-charge about the Alcohol & Drug-Free Workplace Policy. The nurse looked puzzle about the policy. I explained to her what I learned from The First Medical Review Officer (MRO) Course organised by SOEM-MMA in November, 2005. She understood.
I instructed the nurse to collect the urine and also to maintain a chain of custody (COC) when sending the urine to the private lab. The nurse called the security department and one of the guard came and went to the toilet with the worker to get his urine specimen. I sent his urine for a battery of tests for drug-abused and his blood for screening test to assess his baseline health. I did a full physical examinations to find out any signs of drug-abused.
The next morning, the nurse informed me that the urine test was positive for Amphetamines. I asked the nurse to instruct the lab. to do the confirmation test . The private lab. sent the urine specimen to their HQ in Australia to do the confirmation test. "The result will be only available in one week", informed the lab. personnel.
Meanwhile, I take detail history from the worker including questions about the latest medication he took which can cause False Positive screening test result for amphetamine. There are some agents contributing to positive (False Positive) result by immunoassay screening test such as ephedrine,pseudoephedrine which is the common ingredients of flu and cough medicine. He told me he took syrup sedilix prescibed by one of a panel clinic a night before. I asked him to bring the cough syrup bottle for my reference(See photo above- the bottle box he handed to me). I called the clinic and the doctor confirmed his prescription on the cough syrup.
Sedilix-DM Linctus contained Dextromethorphan,Promethazine,Psudoephedrine and parabens. As mentioned earlier, this cough syrup contained Pseudoephedrine which can cause False Positive for amphetamine.
So, I reserved my judgment as False Positive or Excused Positive urine test at this junction.