A two-year-old child passed away in Miri Hospital, Sarawak, from diphtheria in March 2018. An investigation by the Ministry of Health (MOH) Malaysia revealed that the parents chose to not have her immunised against diphtheria due to concerns about the halal nature of vaccine.
According to the MOH, there were 32 cases of diphtheria – including seven deaths – reported throughout the country last year. Out of those cases, 75% were unvaccinated, most of them children.
Health Director-General Datuk Dr Noor Hisham Abdullah advised that children should be administered with the ‘five-in-one’ injection at two, three and five months, including a booster at 18 months.
Vaccines are Halal
The technical committee chairman of vaccine advocacy programme Immunise4Life, Datuk Dr Zulkifli Ismail, said the anti-vaccine sentiment has created confusion and distrust towards vaccination. “There is nothing in Islam or any other religion that says you cannot give vaccinations to children. The only reason we are seeing diphtheria cases is not because vaccine has failed, but because parents do not want their children to take the vaccine.”
The MOH urged Muslim parents to not doubt the halal status of vaccines.
The National Fatwa Council has also issued a statement that vaccines provided by the government are all halal. Health Deputy Minister Datuk Seri Dr Hilmi Yahaya advised Muslim parents to trust the data provided by experts instead of false information circulated on social media.
“In Malaysia, there is only one vaccine which contains porcine DNA – the rotavirus vaccine. The government does not buy this vaccine. It is only available in private clinics to treat severe diarrhoea,” he added.
Dr Zulkifli encouraged the use of reliable resources to retrieve information on immunisation, such as Immunise4Life website (www.ifl.my) and MYVaksinBaby app.
Doctors in Singapore are on alert regarding herb-drug interactions following an incident last year, when a 58-year old woman died after surgical removal of a benign brain tumour.
The woman failed to inform doctors that she took cordyceps, a herbal medication, a week before her operation. This was believed to have led to extensive bleeding in her brain.
Patients need to understand that herbal medications are not completely safe, and that these preparations, when taken with other drugs, can alter the way that the drug is processed and excreted by the body, enhance a drug’s side effects, or block the intended therapeutic effect of the drug.
It is important that patients consult first with a physician before taking any herbal supplements, or inform their physician if they are taking herbal preparations if they are prescribed with medications.
Below are some of the most common herbs used as supplements, together with some of their known interactions with drugs:
1. Black Cohosh Black cohosh is often used for menopausal disorders. It could be toxic to the liver and could have an increased toxic effect to liver when used together with other drugs that can also cause liver toxicity. Drugs that depend on the liver for their excretion may accumulate and lead to toxicity when used with black cohosh.
2. Coenzyme Q10 Coenzyme Q10 protects the heart from damage from cancer medications. The use of coenzyme Q10 with warfarin decreases its blood thinning effects and may increase the risk for a blood clot.
3. Echinacea Echinacea is used to enhance the body’s immune system and helps in the management of the common cold. Echinacea affects the metabolism of drugs by the CYP450 system. This could lead to complicated drug interactions, enhancement of side effects and reduction of the drug’s therapeutic effects. It can also slow down the metabolism of caffeine which can lead to insomnia, jitteriness and headache.
4. St. John’s Wort supplements Supplements containing St. John’s Wort are commonly used to treat symptoms of depression. This should not be used concomitantly with other antidepressants, migraine medications, dextromethorphan, warfarin, birth control pills, and certain antiretroviral medications due to seriousness of drug interactions.
5. Ginseng Ginseng is commonly used to improve the body’s resistance and vitality. There are four known types of ginseng, namely American, Korean, Siberian and Brazillian. Of these, American ginseng is known to decrease the effects of warfarin and should not be used together with other anticoagulants, though this cannot be conclusively said for the other three types. Ginseng also has an effect in blood pressure and blood sugar medications.
6. Ginkgo biloba Gingkgo biloba is used to enhance memory, and in improving symptoms of Alzheimer’s and Parkinson’s diseases. It can decrease effects of certain HIV medications, and alter the actions of drugs metabolized by the liver.
Hepatitis B is a silent infection which is often taken lightly and under-diagnosed and can be transmitted through infected blood and body fluids, as well as from mothers to babies during pregnancy and delivery. Dr Nurhazinat bt Mohd Yunus, Consultant Obstetrician and Gynaecologist, shares some important points about hepatitis B in pregnancy.
Questions
1. What are the most common concerns for pregnant patients regarding hepatitis B?
Patients are usually concerned about three things – their baby, their partner and lastly themselves.
Firstly, they are concerned whether their baby will be ok, and whether the virus will cause abnormalities to their baby. We need to reassure these patients that although their baby can be infected with the virus, it will not cause any abnormalities. There are viruses that are known to cause foetal abnormalities such as chicken pox, but not HBV.
Secondly, it involves their partner. Sometimes, patients do not know that they have hepatitis, so when they are found to be positive, a lot of questions arise. Have they always been a carrier? Did they get it from their side of the family, through blood transfusion, or from their husband? The list goes on. If their husband is tested negative, part of the management involves counselling the couple to use condom, get vaccinated, inform them about the possible risk of getting infected, and so on. We will try to find the cause and have them alert their family members as well. It is well worth to get their whole family screened and vaccinated.
The third concern revolves around the patients themselves and their future. Can they get pregnant again? Will they get sick in the future? Do they need to limit the number of children to bear? There are no straight answers to this as we need to check the patients’ viral load and liver function to see how aggressive the infection is.
2. Can patients with hepatitis B breastfeed their babies?
Most disease control committees have declared that there are no issues for mothers with hepatitis B to breastfeed. Of course, the risk is still there and there is no 100% guarantee that breast milk-transmitted infection will not occur. Most doctors recommend breastfeeding but there are also doctors who disagree. They feel that there is no point in exposing a baby to the smallest risk of contracting an infection and recommend feeding by formula milk instead, especially in well-developed countries where they have good infant formulas with low contamination rate. In the end, we can only counsel patients and provide the information, but patients will have to make the decision themselves.
3. What about antivirals? Are they safe to use during pregnancy and breastfeeding?
There are a few types of antivirals that are deemed relatively safe to use during pregnancy and breastfeeding. Usually pregnant women with hepatitis will be jointly managed by medical and obstetrics and gynaecology specialists. Most of the time, attending physicians will decide if their patients need to be on antivirals as they will continue to manage these patients even after delivery. These patients need more care, so their viral load and liver function must be closely monitored.
4. How can babies be protected if their mother has hepatitis? Is there any special care for babies who are infected?
Malaysia has a national vaccination programme where hepatitis B vaccination is given at birth. As such, the younger generation is better protected against the disease.
If a mother is tested positive for HBV infection, her baby will be given the vaccine and Hepatitis B immune globulin (HBIG), which is effective in preventing the development of the virus. If the vaccine is given together with the HBIG within 12 hours, it will reduce the rate of contracting the virus by 90%.
These babies will then undergo paediatrics follow-up and more tests will be done to confirm their hepatitis B status. Sometimes the infection will clear off, and sometimes the initial blood drawn for testing is actually the mother’s blood. There are a lot of possibilities but it is certain that these babies will need special care and probably lifelong follow-up. 5. How can doctors reassure patients regarding their disease?
If patients are pregnant and have hepatitis B, remind them that they can live a normal life with a normal life expectancy. They can still have as many children as they want, and we as doctors will not limit their childbirth choices just because they have hepatitis B. In between pregnancies, they need to undergo check-ups to assess if they are healthy, if their liver is ok, or if they need any medications. Even if all is well, remind them that they still need to continue their follow-ups for long-term monitoring.
Dr. Nor Anisa Hanan, 11 Jul 2018 Consultant Obstetrician and Gynaecologist Tropicana Medical Centre
When someone’s lungs are exposed to flu or other infections the adverse effects of smoking or vaping are much more serious than among people who do not smoke or vape.
Smoking makes COVID worse if you get it and smoking — and vaping — increase the risk of being infected and developing COVID-19.
As of April 28, 2020 there were 19 peer reviewed papers that had data on smoking and COVID disease progression, 17 from China, 1 from Korea, and 1 from the US. Our peer reviewed meta-analysis of these 19 papers found that smoking was associated with more than a doubling of odds of disease progression in people who had already developed COVID.
There have been several reports, mostly in non-peer reviewed preprints, reporting lower levels of COVID-19 infections among smokers than nonsmokers. This is a surprising finding because, based on what we know about the effects of smoking and vaping on immune function of the respiratory system, one would expect that smoking and vaping would increase risks of COVID infection. A big problem with all the studies to date has been that they have been based on people who were tested, rather than samples drawn from the population as a whole. Because of limited availability of tests in many places, the resulting samples are biased toward people who may already have symptoms.
On August 11, 2020, Shivani Mathur Gaiha and Bonnie Halpern-Felsher from Stanford and Jing Cheng from UCSF addressed this problem in a study that used a population-based sample of youth and young adults, “Association between youth smoking, electronic cigarette use and Coronavirus Disease 2019. Among young people (ages 13-24) COVID-19 diagnosis was five times more likely among ever-users of e-cigarettes only, seven times more likely among ever-dual-users, and 6.8 times more likely among past 30-day dual-users.
These findings are particularly important as the case mix of people getting COVID is moving to younger people, perhaps reflecting increased exposures due to reduced social distancing and a lack of understanding about factors exacerbating COVID-related risk in this age group.
Why?
Smoking is associated with increased development of acute respiratory distress syndrome (ARDS) in people with a risk factor like severe infection, non-pulmonary sepsis (blood infection), or blunt trauma. People who have any cotinine (a metabolite of nicotine) in their bodies – even at the low levels associated with secondhand smoke – have substantially increased risk of acute respiratory failure from ARDS.
The recent excellent summary of the evidence on the pulmonary effects of e-cigarettes reported multiple ways that e-cigarettes impair lungs’ ability to fight off infections:
Effects on immunity
Reporting of respiratory symptoms by e-cigarette users suggests increased susceptibility to and/or delayed recovery from respiratory infections. A study of 30 healthy non-smokers exposed to e-cigarette aerosol found decreased cough sensitivity. If human ciliary dysfunction is also negatively affected, as suggested by animal and cellular studies, the combination of reduced coughing and impaired mucociliary clearance may predispose users to increased rates of pneumonia. Exposure to e-cigarettes may also broadly suppress important capacities of the innate immune system. Nasal scrape biopsies from non-smokers, smokers, and vapers showed extensive immunosuppression at the gene level with e-cigarette use. Healthy non-smokers were exposed to e-cigarette aerosol, and bronchoalveolar lavage was obtained to study alveolar macrophages. The expression of more than 60 genes was altered in e-cigarette users’ alveolar macrophages two hours after just 20 puffs, including genes involved in inflammation. Neutrophil extracellular trap (NET) formation, or NETosis, is a mode of innate defense whereby neutrophils lyse DNA and release it into the extracellular environment to help to immobilize bacteria, a process that can also injure the lung. Neutrophils from chronic vapers have been found to have a greater propensity for NET formation than those from cigarette smokers or non-smokers. Given that e-cigarettes may also impair neutrophil phagocytosis, these data suggest that neutrophil function may be impaired in e-cigarette users. [emphasis added]
Studies in animals reinforce and help explain these human effects:
Two weeks of exposure to e-cigarette aerosol in mice decreased survival and increased pathogen load following inoculation with either Streptococcus pneumoniae or influenza A, two leading causes of pneumonia in humans. Furthermore, the aerosol exposure may lead to enhanced upper airway colonization with pathogens and to virulent changes in pathogen phenotype, as shown with Staphylococcus aureus. Thus, although more studies are needed, the animal data suggesting that vaping leads to an increased susceptibility to infection would seem to correlate with the population level data in young adult humans, whereby vapers have increased rates of symptoms of chronic bronchitis. [emphasis added]
A meta-analysis of the relationship between smoking and influenza found that smokers were more likely to be hospialized and admitted to the ICU.
The WHO has also concluded that, ” smokers are more likely to develop severe disease with COVID-19, compared to non-smokers” and provides a nice discussion of how smoking increases risk of COVID-19 by increasing the risk of heart, lung, and other diseases.
Dr. Nora Volkow, director of the National Institute on Drug Abuse, posted an article on her blog “COVID-19: Potential Implications for Individuals with Substance Use Disorders,” that stared off by saying
As people across the U.S. and the rest of the world contend with coronavirus disease 2019 (COVID-19), the research community should be alert to the possibility that it could hit some populations with substance use disorders (SUDs) particularly hard. Because it attacks the lungs, the coronavirus that causes COVID-19 could be an especially serious threat to those who smoke tobacco or marijuana or who vape.
She goes on to address other drug use and how COVID-19 could interact with them, including noting that
Vaping, like smoking, may also harm lung health. Whether it can lead to COPD is still unknown, but emerging evidence suggests that exposure to aerosols from e-cigarettes harms the cells of the lung and diminishes the ability to respond to infection. In one NIH-supported study, for instance, influenza virus-infected mice exposed to these aerosols had enhanced tissue damage and inflammation.
In addition, an article in Scientific American, “Smoking or Vaping May Increase the Risk of a Severe Coronavirus Infection,” summarizes how smoking and vaping affect the lungs and the immune system that is consistent with the view that using these products increases the risk of infection and worse outcomes. CNN also has a good story, “How smoking, vaping and drug use might increase risks from Covid-19.” KQED/NPR reports on a young man who developed COVID that may have been aggrevated by his vaping. Fortunately, he recovered and has now stopped vaping.
The New York Timeshas a good story reporting that the Massachusetts AG put out an advisory urging people to stop smoking and vaping and pointed to resources to quit.
CDC, FDA, the Surgeon General, state health departments and everyone (including comedians, such as John Oliver who spent his whole show on the issue last weekend) working to educate the public on how to lower risk of serious complications from covid-19 should add stopping smoking, vaping, and avoiding secondhand exposure to their list of important preventive measures.
This would also be a good time for cities, states private employers and even individual families to strengthen their smokefree laws and policies – including e-cigarettes — to protect nonsmokers from the effects of secondhand smoke and aerosol on their lungs and to create an environment that will help smokers quit.
The California Department of Public Health has information on smoking, vaping and COVID here, as does the California Smokers’ Helpline. Trinity Health is also urging people to stop smoking to protect against COVID-19. FDA has said that vaping and smoking could increased COVID risks. CDC lists smoking as one of the risk factors for COVID-19 because smoking depresses immune function.
UCSF has added smoking and vaping nicotine and cannabis to COVID-19 triage protocol. Doing so will both improve patient care and, over the longer term, provide important information needed to quantfy how smoking and vaping impact COVID risks.
A study by the World Health Organization (WHO) in 2013 revealed that almost 40% of all murdered women were killed by their intimate partners, and 42% of women who have experienced physical or sexual violence at the hands of a partner had suffered some form of visible injuries. MIMS Today met with Tan Heang-Lee, the Communications Officer of Women’s Aid Organization (WAO), to talk about the organization and how healthcare professionals (HCPs) play an important role in identifying domestic violence
Questions
1. Could you share with us the type of services provided by WAO?
We are a local organization that has been operating for about 35 years. We provide services related to gender-based violence, which includes domestic violence, sexual assault, rape, abuse of migrant domestic worker, trafficking, etc. We are the largest service provider for domestic violence survivors in Malaysia.
Domestic violence covers the entire spectrum of violence, comprising physical, emotional, psychological, sexual and even financial abuse. There’s social isolation and our clients usually have been forced to sever ties with family and friends, and they are completely alone. Our social workers assist clients to access the services provided by various government agencies, such as the police, hospitals, welfare department, the courts, etc. Apart from that, our social workers provide emotional and psychosocial support and educate our clients about their rights.
In terms of advocacy, we strive to improve law and policies, and their implementation and enforcement. We also work to shift the public’s mindset and behaviour towards recognizing women’s rights.
2. How do you liaise with government agencies?
We work very closely with the police,hospitals and welfare department. The One Stop Crisis Centre (OSCC) is located at the emergency departments of government hospitals, and it is where survivors of gender-based violence can obtain comprehensive services. When facing difficulties, survivors of domestic violence can lodge a police report there and get the necessary medical attention and support.
Hospitals are actually the first place that many women go to following domestic violence. It makes sense because hospitals feel like a safe place. Doctors and nurses are generally very friendly, they genuinely care and patients trust them.
3. What would be a typical scenario that you deal with?
I don’t think there really is a typical scenario. However, when survivors interact with a healthcare professional, it’s common for survivors to not disclose that they are being abused. If they are injured, they may say that they had fallen, but their injury does not match that of a fall and the perpetrator is usually reluctant to be separated from the victim.
If an injured woman comes in with a potential perpetrator, there’s a dynamic there and doctors need to be attentive. If doctors suspect something amiss behind an injury, they should try to ask if the woman would like to talk to them in private, or they could ask the suspected perpetrator to leave the room for a while.
4. Where do these survivors of domestic violence go after they are discharged from the hospital?
We do have a safe-house, a temporary shelter at a secure location for survivors of gender-based violence. Apart from providing the much-needed necessities, we also have empowerment programmes such as creative writing classes to help our clients express and process their emotions by having them write about their feelings. We also try to conduct programmes to enhance their skills so that they will slowly become more confident and independent as time goes by. These programmes include workshops on job interview skills, financial literacy, economic empowerment, and so on.
Generally, our clients can stay up to 3 months but it really depends on the case. A majority of our clients stay for a few weeks to clear their minds and calm themselves after their initial traumatic experience. We also have a Child Care Centre, so domestic violence survivors can obtain child care as they begin to rebuild their lives and get back on their feet.
5. What is the most important thing that healthcare professionals should know about domestic violence?
Firstly, it’s recognizing the dynamics of domestic violence. As mentioned earlier, domestic violence covers the whole spectrum of abuse. As such, when a doctor suspects that something is not right, try to talk to the patient in private or note down their concern in a medical report for proper documentation. Domestic violence is usually a cycle, so being attentive is important. A study by WHO in 2013 revealed that almost 40% of all murdered women were killed by their intimate partners.
Even when there is no physical abuse, survivors of domestic violence could be facing other forms of abuse, such as being stalked, receiving threats, or being isolated socially. Healthcare professionals thus need to be alert. If a patient is experiencing domestic violence, healthcare professionals can share with patients the WAO Hotline number: 03 7956 3488 and the WAO SMS/WhatsApp line: 018 988 8058.
The One Stop Crisis Centre also has guidelines on how to handle domestic violence cases. The OSCC guidelines are readily available online and in hospitals.
Tan Heang-Lee, 27 Jun 2018 Communications Officer Women’s Aid Organization (WAO)
