Category: Health Blogs

Addressing the Concerns of a Pregnant Patient with Hepatitis B

12/10/20

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

COVID-19: Higher Risk for Smokers and Vapers

12/10/20

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 Times has 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.

Women’s Aid Organization (WAO): Stop Domestic Violence

11/10/20

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)

Battling Loneliness

02/02/20

While there is no data on elderly Malaysians living alone, it is reported that in Britain and the United States, one in three people older than 65 live alone. They suffer from loneliness due to a solitary lifestyle, lack of close family relationships, and age-related health conditions

Loneliness among the elderly is identified as a major public health issue. It can increase the risk of high blood pressure, a weakened immune system, depression, heart attack, heart disease, stroke and dementia. Those who suffer from loneliness are also at risk of premature death.

KPJ Ampang Puteri Specialist Hospital senior consultant psychiatrist Dr Azhar Zain says as people age, their social situation changes and this is one of the reasons why they feel lonely. The situation intensifies especially after retirement and they feel they are getting old and are not needed.

He explains: “When they are no longer working, they will lose touch with their friends from the office. If they live alone, it can make the situation worse as they will feel lost, unless they do something to keep busy.

“The situation can make them angry and irritable. It is also likely that they will ignore or avoid family members and neighbours, which makes them lonelier.”

LACK OF COMMUNICATION

Although living alone is identified as the main cause of loneliness, researchers at the University Of California, San Francisco, found that two-thirds of the 1,600 elderly in their study, who said they were lonely, were married or living with a partner.

Dr Azhar says the changes in family dynamics may be one of the reasons. For instance, even though parents stay with their children in the same house, they may have limited communication. He says as children and grandchildren are busy, most of the time the old folk are at home with the maid.

“Years ago, children had more time as they would be home by 6pm. Now the world has changed and so have family dynamics. In a situation where a parent has to stay with the children after the spouse passes on, it is more difficult for him/her to adapt as he/she is no longer independent. Without someone to talk to, he/she can suffer from loneliness,” he says.

“Some elderly couples may communicate with each other through their children or grandchildren, so when they are alone, they don’t know how to talk to each other. This can lead to loneliness for both of them.”

Dr Azhar says the nature of their personality can also make some people more prone to loneliness. They isolate themselves despite the social support network. They may find it hard to face being old. They feel people don’t understand them or regret that there are things they can’t do anymore.

“People think a person is not lonely if he or she is never alone. But some people can feel lonely even when there are people around them. It is hard for the elderly to talk about their feelings, so it is important for those around them to notice any change in their behaviour,” he says, adding that loneliness is more common among women. This leads to a higher risk of depression, especially when they are going through menopause. In addition, women do not have social support, as most of the time they are either at work or at home.

“In our culture, women don’t go out to meet friends, unlike men. Their interaction with friends is at the office and once they are home, it is only with the children. As women go through the menopause stage, depression is one of the symptoms and it can get worse with loneliness.

“Due to depression, women may suffer from pseudo dementia and experience memory loss, become confused or are unable to focus. But it does not mean they have dementia or Alzheimer’s disease. When they complain that they can’t sleep, can’t eat, misplace and forget things, these may be linked to depression,” he says.

“Some patients do not want to say they are depressed. Doctors must know what to look for as there are tests that can be done to determine if the person is depressed or suffering from dementia.”

As a support system for the elderly is lacking in the country, Dr Azhar, who is an advisor to the Malaysian Healthy Ageing Society, says it is important that they take steps to overcome loneliness.

“We can treat the symptoms but it is more important for them to take steps to overcome their situation. The elderly need to modify their way of thinking. They have to find things to do, such as joining a group to meet people and make friends or getting a new hobby,” he advises.

“Keep in touch with family and friends. Ask children or grandchildren to teach them new technology so that they will not be left out. “If they live in nursing homes, make sure they are engaged in activities every day.

Don’t leave them on their own; family members must visit them often and regularly.”

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Category: Health Blogs

Addressing the Concerns of a Pregnant Patient with Hepatitis B

COVID-19: Higher Risk for Smokers and Vapers

Women’s Aid Organization (WAO): Stop Domestic Violence

Battling Loneliness